Hospital Visit

Reading Hospital Visit Pricing Data

The 16 procedure codes grouped under Hospital Visit share a common clinical taxonomy in the CMS Medicare Physician & Other Practitioners dataset. Across this category, the average Medicare payment is $166.87 — the figure Medicare actually reimburses providers for the allowed amount after geographic and specialty adjustments. Inpatient hospital visits for evaluation and management Each CPT/HCPCS code in the table above carries its own fee schedule value determined by CMS's Resource-Based Relative Value Scale (RBRVS), which weights physician work, practice expense, and professional liability.

Billed charges — the "Billed" column — often run several multiples above Medicare allowed amounts. This is expected under US chargemaster pricing practices: providers list a gross rate, then accept negotiated write-offs from Medicare, Medicaid, and commercial insurers under participation agreements. A high markup ratio does not necessarily indicate overcharging, because almost no payer pays the full billed charge. However, uninsured and out-of-network patients can be exposed to amounts closer to the billed rate, which is why federal rules now require providers to publish cash and negotiated prices through the Hospital Price Transparency initiative.

Volume matters when interpreting category-level data. Procedures with millions of annual services — evaluation visits, common diagnostic work — reflect stable, well-benchmarked pricing. Lower-volume codes may show wider variation across providers and settings because small sample sizes produce less stable averages. When comparing specific procedures, drill into the individual procedure page for state-level breakdowns, provider counts, and commercial pricing estimates derived from RAND 2024 research. This page presents CMS reference data for educational use; it does not constitute medical, legal, or financial advice.