localis
Calculator

Describe a service in plain words, or type a CPT/HCPCS code.

CPT 99455 Medicare payment status

Restricted / special payment rules

99455 · PFS Q4 2026

No national PFS rate in Q4 2026

Status R: no national PFS amount. The RVUs for this setting are all zero; they do not establish a $0 allowance. Special payment instructions apply.

View applicable payment rules
View CMS source and method

CMS RVU26DOctober 1 – December 31, 2026revision 2

PFS status evidence

Physician relative value file (Q4 2026) · rvu26d-updated-08-26-2026.zip (PPRRVU2026_Oct_nonQPP.csv row 13,122)
Inspect PFS status evidence
Code
99455
Release
Q4 2026, revision 2
Result
Restricted / special payment rules

Citations

  • Shows this code’s PFS status (R). Result: Restricted / special payment rules.

    Physician relative value file (PPRRVU)CMS RVU26DOctober 1 – December 31, 2026revision 2

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

    PPRRVU2026_Oct_nonQPP.csv row 13,122 in rvu26d-updated-08-26-2026.zip

    In the CMS file

    Loading rows 13,120–13,124 of PPRRVU2026_Oct_nonQPP.csv…

    Download rvu26d-updated-08-26-2026.zip from CMS File fingerprint 4d0d3f19bd954ffc0f5b8439169d267da023d4f6911f4539bb6e98723cb1a626

Plain-text summaryReport a problem

CPT 99455 has no published national rate. It carries status R (restricted) in the Q4 2026 release. Special coverage instructions apply, so whether Medicare pays depends on the circumstances of the service. The blank amount means unpriced, not $0.

Why is there no national PFS amount for 99455?

Its status indicator is R (restricted). Special coverage instructions apply, so whether Medicare pays depends on the circumstances of the service. Status R: no national PFS amount. The RVUs for this setting are all zero; they do not establish a $0 allowance. Special payment instructions apply.

Payment considerations Copy link

Here are the inputs and payment rules that apply to this code. Each link takes you to the detail below.

NCCI same-day edits Applies MUE behavior Applies
Other payment indicators (8)
Facility/non-facility: Does not apply, 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, Other fee-schedule routing: Does not apply, Contractor pricing: Does not apply.
Why would a Medicare claim for 99455 be denied or paid less?

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

  • Its status indicator is R (restricted)—Special coverage instructions apply, so whether Medicare pays depends on the circumstances of the service. See status indicators
  • 165 codes form NCCI pairs with 99455 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
  • 154 codes pair with 99455 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
  • More than 1 unit per patient per date of service exceeds 99455's Medically Unlikely Edit (MUE) limit. See billing together
  • Bilateral surgery: no bilateral adjustment. See billing policy
  • Assistant at surgery: restricted without documentation. See billing policy
  • Co-surgeons: not permitted. See billing policy
  • Team surgery: not permitted. See billing policy

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.

Can you bill it with another code? Copy link

Check a pair of codes 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 for the pair.

See every current NCCI pair for 99455 →

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 99455 on the same date of service—no modifier bypasses the edit (modifier indicator 0)

0395T 99455 denies
0469T 0469T denies
36591 36591 denies

Showing 3 of 165.

Separately payable with 99455 only when an NCCI-associated modifier is appropriate and documented (modifier indicator 1)

0362T 0362T denies
0373T 0373T denies
0708T 99455 denies

Showing 3 of 154.

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 319 NCCI pairs →

Medically Unlikely Edit (MUE) limit: 1 unit per patient per date of service.

Payment review for 99455 Copy link

Two published payment rules can change what 99455 allows on a claim: status R coverage instructions and documentation-restricted assistant-at-surgery payment. Each is a legitimate reason for a paid amount to differ from the fee-schedule amount on this page.

What to check

  • Treat the published amount as conditional—status R carries special coverage instructions, so a payable fee-schedule amount does not by itself establish that this line should have paid.
  • Check for documentation on file before appealing an assistant-at-surgery denial: payment on the -80 or -AS line is restricted for this procedure unless medical necessity is established.
  • 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.
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); 42 USC 1395w-4(i)(2) (SSA §1848(i)(2))—Assistants-at-surgery.

How has it changed? Copy link

Rate history by release Copy link

National Office (non-facility) amount for 99455 across quarterly releases.

Release Status Office Facility
Q4 2026 Oct 1, 2026 – present R — —
Q3 2026 Jul 1, 2026 – Sep 30, 2026 R — —
Q2 2026 Apr 1, 2026 – Jun 30, 2026 R — —
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.

Did this answer your question about CPT 99455?

Tell us what you were trying to work out and we'll answer you or build the page that does.

Did this page answer your question?

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. Whether a national amount exists depends on the status and CMS’s payment instructions; blank RVUs are never treated as zero. Past releases are never edited, so these sources stay valid after CMS publishes a newer one. Our methodology explains sourcing, parsing, versioning, and how we cross-check claims before we publish them.

Physician relative value file (Q4 2026) · rvu26d-updated-08-26-2026.zip (PPRRVU2026_Oct_nonQPP.csv row 13,122)

Cite this rate

The citation names the release, so anyone can check it even after CMS publishes a newer one.

CPT 99455 National PFS baseline: No national PFS rate (Q4 2026; participating physician; whole service; GPCI 1.000; sequestration excluded). CMS RVU26D, PPRRVU2026_Oct_nonQPP.csv row 13,122. Localis. https://localishealth.com/cpt/99455/2026/D