CPT 99494 Medicare rate and RVUs

Rates by locality Copy link

The national baseline uses GPCI 1.000. These locality-adjusted allowed amounts use each payment locality's own GPCIs. Select a state to see its localities.

Look up your exact locality →

Q4 2026 amounts, computed with each locality's own GPCIs, before the ~2% sequestration cut. A state with more than one payment locality shows a range—its tile is colored by the mean across those localities, which is a shading choice, not an amount anyone is paid.

How this amount is computed Copy link

CPT 99494 has a work RVU of 0.82, a non-facility practice expense RVU of 0.96, a facility practice expense RVU of 0.20 and a malpractice RVU of 0.06—for total non-facility RVUs of 1.84 and total facility RVUs of 1.08 in the Q4 2026 release.

The formula is: (work RVU × work GPCI + PE RVU × PE GPCI + MP RVU × MP GPCI) × conversion factor. National amounts use GPCI = 1.000. To price an RVU figure of your own, use the RVU-to-dollars converter.

Every rate combines three parts: work (the clinician’s time, skill and effort), practice expense (office overhead—higher when the service is done in a doctor’s own office), and malpractice (the share of liability-insurance cost). A blank means CMS publishes no national number for that part. Read it as unknown, never as zero.

Who’s billing it Copy link

Modifier amounts: -26/TC, -50, -80/81/82, -AS, -62, -66 Copy link

National Office (non-facility) amounts for the modifiers this code's indicators support. These are single-line modifiers only. -51 (multiple-procedure reduction) depends on the other codes on the same claim, so it's a claim-level number rather than a per-code one. Use the calculator for a locality-adjusted, sequestration-aware amount.

Not payable with 99494: -26/TC (professional/technical split); -50 (bilateral procedure); -62 (co-surgeons, each); -66 (team surgery).

Each amount applies a standard MPFS percentage (assistant surgeon 16%, non-physician assistant at surgery 13.6%, co-surgeon 62.5%, bilateral 150%) to the national Office (non-facility) amount above. CMS doesn't publish these as a column; Localis derives them, so check them against the current Medicare Claims Processing Manual before relying on them for payment. A row marked If documented carries the ordinary percentage, but this code's CMS indicator allows it only when documentation of medical necessity is submitted. Without that documentation, an unpaid claim is not an underpayment.

CMS RVU26D · October 1 – December 31, 2026 · revision 2 See file rows

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 99494 →

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

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 175 NCCI pairs →

Medically Unlikely Edit (MUE) limit: 4 units per patient per date of service.

Payment review for 99494 Copy link

Three published payment rules can change what 99494 allows on a claim: the office/facility differential, add-on billing 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.

Sources: CMS Medicare Physician Fee Schedule Relative Value Files; CMS Practice Expense methodology (cms.gov); CMS Medicare Claims Processing Manual (Pub. 100-04); 42 USC 1395w-4(i)(2) (SSA §1848(i)(2))—Assistants-at-surgery.

Rate history by release Copy link

National Office (non-facility) amount for 99494 across quarterly releases. -7.7% decrease since Q1 2018 · peak $67.03 in Q1 2019

Why 99494's rate changed Copy link

National baseline (GPCI 1.000) · Office (non-facility) · Before sequestration

99494's national amount fell $5.14 (−7.7%), from $66.60 in Q1 2018 (from Jan 1) to $61.46 in Q4 2026. Changes to the conversion factor, which CMS sets for every code, took $4.80 off. CMS revaluing 99494 itself took $0.34 off: −$0.67 from practice-expense RVUs and +$0.33 from malpractice RVUs. The most recent change came in Q1 2026: +$5.50 (+9.8%), with +$3.01 from practice-expense RVUs, +$1.82 from the conversion factor and +$0.67 from malpractice RVUs.

CMS doesn't publish this split; we derive it from each release's RVUs and conversion factor. We apply the new conversion factor to the earlier RVUs first, then price each RVU change at the new conversion factor. Another order would move a few cents between columns, but every total stays the same.

Contracted rate: % of Medicare Copy link

Commercial contracts are often written as a percentage of Medicare ("115% of Medicare"). Enter yours to see what it means for 99494. A contract benchmarked to the fee schedule applies it to your locality's allowed amount, not the $61.46 national baseline; the calculator finds that amount from your service ZIP.

See how to find your contract's actual percentage.

How often 99494 is billed Copy link

Across Original Medicare in CY2024, 99494 ranked #1,662 of the 7,879 CPT codes billed to Medicare that year, by patients served or total allowed dollars. It repeats: a patient billed for it in 2024 was billed 3.4 times on average that year.

2024 Medicare fee-for-service national totals. They exclude Medicare Advantage, Medicaid and commercial volume, so real-world use runs higher. This is a calendar-year snapshot from the CMS Physician & Other Practitioners dataset, on a different cycle from the Q4 2026 fee schedule above.

How 99494 compares with other codes Copy link

Against every code with a national PFS amount in Q4 2026 · National baseline · Before sequestration

+70.4% Office over facility

99494's Office amount is $25.39 more than its facility amount, because a facility bills its own overhead separately. Of the 7,745 codes priced in both settings, 2,167 have a higher Office amount. 99494's gap is smaller than 54% of theirs; the median gap is +78.1%.

38.9% Highest vs. lowest locality

99494's Office amount is 38.9% higher in its highest-paid payment locality than in its lowest. That spread is narrower than 80% of the 7,716 codes compared; the median spread is 43.6%. How much a code's amount varies by locality depends on its mix of work, practice-expense and malpractice RVUs, since each has its own GPCI.

These comparisons cover every code with a national Physician Fee Schedule amount: status A, R or T, with no blank RVUs. The locality comparison leaves out codes with an OPPS cap, because the cap, not the GPCIs, can set their amount in some localities.

Related codes Copy link

Codes near 99494 in the evaluation and management group, with their national Q4 2026 amounts at GPCI 1.000. A dash means the release publishes no payable PFS amount in that setting.

Localis groups these codes for payment research. The grouping isn't the AMA's code families.