Medicare reimbursement reference

CPT 96425: $181

Medicine / E&M. The federally-set baseline for what this code costs when Medicare pays — the standard public-domain reference for self-pay or insured bill review.

Data updated 81 days ago·verified today·Source: CMS Physician Fee Schedule

National average

$181

Per CMS Physician Fee Schedule, effective 2026-01-01. Non-facility national-average. Real Medicare payments adjust by ±15% based on Geographic Practice Cost Index.

No bill yet, just pricing this out? Ask the provider for a written Good Faith Estimate before you schedule — under the No Surprises Act, uninsured and self-pay patients can request one.

What CPT 96425 actually is

Medical service or evaluation-and-management code (CPT 96425). E&M codes describe office, ER, hospital, and consult visits — chosen by the complexity and time of the encounter.

The number above is one piece of context. The other two benchmarks worth knowing:

  • Hospital cash-pay rate

    Federally required to be published by every US hospital under 45 CFR §180.50 (the Hospital Price Transparency rule). The hospital’s own machine-readable file is the authoritative source. Same code; rates vary widely by facility.

  • Insurance-negotiated rate

    Whatever your specific insurance plan and the specific facility have contracted for the same code. Visible on your Explanation of Benefits (EOB) after the claim posts.

  • Medicare allowed amount (this page)

    $181 for code 96425, set in federal law and updated annually by CMS. Used as the floor benchmark in most bill-review work.

Where CPT 96425 commonly shows up on a bill

Common patterns to look at when reviewing this code:

  • 01.A code billed at the global rate when only a partial component was rendered (modifier -26 or -TC may apply).
  • 02.The same code billed multiple times for what appears to be the same encounter.
  • 03.An item billed without supporting documentation in the medical record.

These patterns are documented in CMS billing guidance, the National Correct Coding Initiative (NCCI) edits, and Office of Inspector General audit reports. None of them are accusations about any specific bill or facility — they’re the checks that exist because the patterns themselves exist.

How to check CPT 96425 on your bill

A few quick checks you can run yourself:

  • 01.Pull your itemized bill and find this code. Check the units — a units error quietly multiplies the charge.
  • 02.Look for the same code billed more than once for a single visit.
  • 03.Only have a summary? Request the itemized bill in writing (HIPAA §164.524) so you can see every code.

What hospitals charge for CPT 96425

Distribution across 22 US hospitals reporting this code under federal Hospital Price Transparency rules (45 CFR §180.50). Gross charges shown here are the chargemaster prices — the starting point before insurance discounts or self-pay reductions. Medicare allowed amount: $181.

Hospital gross (median)

$1,166

25th $1,166 · 75th $1,378

Cash / self-pay (median)

$420

What hospitals accept directly

Commercial (median)

$413

Range $101–$1,214

Medicare allowed

$181

Federal-rate floor

Range across all reporting hospitals: $358 to $2,309. That’s a 6× spread for the same procedure code — one of the reasons federal price-transparency rules exist.

Hospitals at the lower end of the distribution

Sorted by published chargemaster price only. Chargemaster is the starting point before insurance discounts or self-pay reductions; the actual amount any specific patient pays depends on case mix, charity-care policy, and insurance contract.

If your bill has this code

See exactly how your charge compares to $181— in just a few minutes.

Upload a photo or PDF of your bill. Our system reads every line, compares each charge to six federal data sources (CMS PFS, NADAC drug benchmarks, federally-required Hospital Price Transparency files, the National Correct Coding Initiative, CMS Hospital Compare quality data, and IRS Publication 78 for charity-care eligibility), and drafts dispute letters for anything worth questioning — with the codes, the math, and the federal-law citations already inside.

  • ✓Line-by-line audit, every charge benchmarked.
  • ✓Up to 5 dispute letters drafted — sign and mail.
  • ✓Charity-care application if your hospital is non-profit.
  • ✓30-day money-back guarantee on single audits.
Check my bill — freeFree preview, no signup. Unlock the full report + letters for $19.97 · 30-day money-back.

Related codes

Codes in the same numerical neighborhood — often appear together on the same bill or get billed in place of each other:

Common questions about CPT 96425

How much does CPT 96425 cost?
Medicare's national-average non-facility allowed amount for CPT 96425 is approximately $181 as of 2026-01-01. Hospital cash-pay rates and commercial-insurance contracted rates for the same code are typically higher; the gap is what most billing reviews focus on.
Why is my CPT 96425 bill higher than $181?
Three common reasons: (1) the rate above is non-facility — bills from inpatient hospital settings can be paid differently, (2) commercial insurance contracts and hospital chargemasters are not bound by Medicare rates and often run several multiples higher, and (3) modifiers on the bill may add or subtract from the base rate. The federally-mandated Hospital Price Transparency file for the facility that billed you is the authoritative source for the cash-pay and insurance-negotiated rates at that specific hospital.
Can I dispute a CPT 96425 charge?
Yes. Federal and state consumer-protection law gives every patient the right to (1) request an itemized statement (HIPAA §164.524), (2) receive a Good Faith Estimate before scheduled service (No Surprises Act, 2022), (3) dispute amounts billed without prior consent or proper notice, and (4) apply for charity care if the facility is a 501(c)(3) non-profit (ACA §501(r)). The benchmark above is one piece of evidence; the hospital's own HPT file is another.
What's the source of this number?
The CMS Physician Fee Schedule (PFS) — published annually by the Centers for Medicare & Medicaid Services and required by 42 USC §1395w-4 to be publicly available. We refresh from CMS quarterly. Last updated: 2026-01-01.

P.S. If you’re holding a bill with code 96425on it right now, the fastest path is to run it through the audit — it takes just a few minutes and shows the exact gap between what was charged and the $181 benchmark above. Start the free audit →

P.P.S. If the bill came from a non-profit hospital, federal law (ACA §501(r)) requires them to offer charity care to patients below specific income thresholds. We auto-check 501(c)(3) status against the IRS Publication 78 database and draft the application letter when applicable.

P.P.P.S. The $181number above is a benchmark, not a verdict. The right question on any specific bill is whether the documentation in your medical record supports the code that was billed — that’s what every bill-review process ultimately comes down to.

Source & methodology

Rate from the CMS Physician Fee Schedule, refreshed quarterly from cms.gov. National-average non-facility allowed amount; real Medicare payment adjusts by ±15% per locality (GPCI). The CMS PFS is in the public domain (17 USC §105). Full data-source register at /data-sources.