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Q4 2026 takes effect Oct 1, 2026. CMS published it early; dates of service before then are priced under the current release — see the current CPT 99254 rate.

CPT 99254

Unable to determine from available CMS sources

99254 · PFS Q4 2026 · Upcoming

Status I is not separately payable under the PFS.

View applicable payment rules
View CMS source and method

CMS published status I (not valid) for CPT 99254 in the Q4 2026 Physician Fee Schedule, with no national PFS amount. These figures take effect for dates of service beginning Oct 1, 2026. Treat the blank amount as unpriced, not as $0.

PFS status evidence

Physician relative value file (Q4 2026) · rvu26d-updated-08-26-2026.zip (PPRRVU2026_Oct_nonQPP.csv row 13,035)
Inspect PFS status evidence
Code
99254
Release
Q4 2026, revision 2
Result
Unable to determine from available CMS sources

Citations

  • Establishes the PFS status (I) and the resulting pathway for this code: unable to determine from available cms sources.

    Physician relative value file (PPRRVU)

    Q4 2026 · revision 2

    Latest revision of this release

    Release period: October 1 – December 31, 2026

    This PFS record alone does not establish a $0 allowance or a coverage determination. Any amount from another schedule needs its own evidence.

    Record details PPRRVU2026_Oct_nonQPP.csv in rvu26d-updated-08-26-2026.zip (row 13,035)
    hcpcs (col 1)
    99254
    modifier (col 2)
    blank
    status_code (col 4)
    I

    SHA-256: 4d0d3f19bd954ffc0f5b8439169d267da023d4f6911f4539bb6e98723cb1a626

    Original source file

Compact facts

Why is there no national PFS amount for 99254?

Its status indicator is I (not valid). Medicare uses a different code to report and pay for this service. Status I is not separately payable under the PFS.

Payment considerations Copy link

The inputs and payment rules that apply to this code. Each link jumps to its detail below.

NCCI same-day edits Applies
Other payment indicators (9)

Facility/non-facility: Not determined, Professional/technical component: Does not apply, Bilateral adjustment: Does not apply, Multiple-procedure reduction: Does not apply, Assistant/co-surgeon treatment: Does not apply, Global surgery: Does not apply, MUE behavior: Not determined, Other fee-schedule routing: Does not apply, Contractor pricing: Does not apply.

Why a 99254 line may not pay separately Copy link

CMS publishes no separately payable amount for 99254 in this release, so reconciling the line means establishing which status governed the date of service rather than chasing a fee-schedule difference.

What to reconcile

  • Confirm the status that governed the date of service before working this line as a short payment—CMS publishes no separately payable fee-schedule amount for it in this release.
  • Check the place of service: CMS publishes no office (non-facility) practice-expense amount for this code, so it prices in a facility setting only.
  • Reprice the line against the release, locality, setting, modifier and participation status that applied to the date of service before treating any difference as an underpayment.

Nearby payment lines

National Q4 2026 amounts at GPCI 1.000. A blank means this schedule does not publish a payable PFS amount.

Code Office Facility
99253 Nearby evaluation and management line in the same release — —
99255 Nearby evaluation and management line in the same release — —
99252 Nearby evaluation and management line in the same release — —
Check an actual payment Model this code in a contract

Sources: CMS Medicare Physician Fee Schedule Relative Value Files; CMS Medicare Physician Fee Schedule Relative Value Files (status indicator field); CMS Practice Expense methodology (cms.gov).

Payment rules

Global period: what 99254's fee already covers Copy link

XXX Does not apply

The global surgery concept does not apply to this code.

Can you bill it with another code? Copy link

Enter a second CPT or HCPCS code billed on the same date of service. We'll check the current NCCI procedure-to-procedure edit between it and 99254.

See every current NCCI pair for 99254 →

Billing together (NCCI edits) Copy link

NCCI Q4 2026

Based on CMS's National Correct Coding Initiative (NCCI). A few examples appear here; use the complete edit page to check a specific pair.

Not separately payable with 99254 on the same date of service—no modifier bypasses the edit (modifier indicator 0)

0469T 0469T denies
36591 36591 denies
36592 36592 denies

Showing 3 of 42.

Separately payable with 99254 only when an NCCI-associated modifier is appropriate and documented (modifier indicator 1)

0335T 99254 denies
0338T 99254 denies
0339T 99254 denies

Showing 3 of 5,843.

Modifier 59 and the X modifiers are not a universal bypass—CMS expects the most specific applicable modifier, and which one that is depends on the pair and the documented circumstances.

Check a paired code or view all 5,885 NCCI pairs →

Common payment questions Copy link

Why would a Medicare claim for 99254 be denied or paid less?

These come from CMS indicators on this page, not general billing advice.

  • Its status indicator is I (not valid)—Medicare uses a different code to report and pay for this service. See status indicators
  • 42 codes form NCCI pairs with 99254 carrying modifier indicator 0—no NCCI-associated modifier bypasses the edit, so billed together on the same date of service, a line of the pair denies. See billing together
  • 5843 codes pair with 99254 under modifier indicator 1—separately payable only when an NCCI-associated modifier (59, or a more specific XE, XS, XP, or XU) is clinically appropriate and the documentation supports a distinct service; without one, a line of the pair denies. See billing together

Payer-specific coverage and documentation rules live outside these files, so a claim that clears every check here can still be denied on other grounds.

History

Rate history by release Copy link

National office (non-facility) amount for 99254 across quarterly releases.

Release Status Office Facility
Q4 2026 takes effect Oct 1, 2026 I — —
Q3 2026 Jul 1, 2026 – Sep 30, 2026 I — —
Q2 2026 Apr 1, 2026 – Jun 30, 2026 I — —
When does this rate change?

CMS publishes a fee schedule release every quarter (January, April, July, October), and each is versioned here. See what changed each release, or get an email when a new release moves rates.

Sources: CMS Medicare Physician Fee Schedule Relative Value Files.

Usage & related

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Source & method

Show sources

This page uses CMS's Medicare Physician Fee Schedule Q4 2026 release (effective October 2026). National baselines use GPCI 1.000 and exclude sequestration. Status and payment instructions determine whether a national amount is established; blank RVUs stay blank. Releases are immutable: historical evidence remains tied to the specified release. Our methodology explains sourcing, parsing, versioning, and how we cross-check claims before they ship.

Physician relative value file (Q4 2026) · rvu26d-updated-08-26-2026.zip (PPRRVU2026_Oct_nonQPP.csv row 13,035)

Use the (i) buttons next to each amount above for the exact row, columns, and math.

Cite this rate

This citation identifies the source release, so its evidence remains reproducible after a newer release lands.

CPT 99254 National PFS baseline: No national PFS rate (Q4 2026; participating; whole service; GPCI 1.000; sequestration excluded). Localis. https://localishealth.com/cpt/99254/2026/D