CPT 43281: Federal IDR outcomes
Repair of hernia of muscle at esophagus and stomach using an endoscope
In 2025 Q1–Q4, the provider or facility offer prevailed in 82.4% of 391 determined Federal IDR dispute line items for CPT 43281. The median prevailing offer was 17.72x the QPA (25th–75th percentile 1.00x–52.40x; n = 382). The median time to a decision was 28 business days (n = 391).
Determined line items
391
2025 Q1–Q4 · 0 split decisions excluded
Provider win rate
82.4%
n = 391 · 2025 Q1–Q4
Median payment vs QPA
17.72x
middle half 1.00x–52.40x · n = 382 · 2025 Q1–Q4
Median days to decision
28
business days, from dispute initiation · n = 391 · 2025 Q1–Q4
Dollar amounts
Total awarded
$11.4M
sum of prevailing offers · n = 311 · 2025 Q1–Q4
Total QPA
$3.4M
sum of QPAs, same line items · n = 311 · 2025 Q1–Q4
Awarded above QPA
$8.0M
total awarded minus total QPA · n = 311 · 2025 Q1–Q4
Median award per line item
$38,000
mean $36,594 · n = 311 · 2025 Q1–Q4
Median QPA
$1,304
per line item · n = 311 · 2025 Q1–Q4
Award vs QPA, dollar-weighted
3.35x
total awarded ÷ total QPA · n = 311 · 2025 Q1–Q4
Dollar amounts come from the separate CMS “QPA and Offers” file: line items decided for the provider or the plan with a non-suppressed QPA and prevailing offer. That file cannot be joined to the line items above, so its n differs. Awarded = the prevailing (selected) offer; it is not a record of what was paid. State comes from the file’s geographic region; a metro area that spans states counts in each. How the dollar figures work
Dollar amounts by period
| Period | Line items with $ | Total awarded | Total QPA | Above QPA | Median award | Median QPA | Award ×QPA ($-weighted) |
|---|---|---|---|---|---|---|---|
| 2025 Q1–Q4 | 311 | $11.4M | $3.4M | $8.0M | $38,000 | $1,304 | 3.35x |
| 2024 Q3–Q4 | 54 | $757,651 | $71,143 | $686,508 | $11,200 | $928 | 10.65x |
| 2024 Q3–2025 Q4 | 365 | $12.1M | $3.5M | $8.7M | $28,000 | $1,243 | 3.50x |
| 2023 Q1–2024 Q2 | Not available (see methodology). | ||||||
From the CMS QPA and Offers file (see above). Award ×QPA here is total awarded ÷ total QPA, so large claims weigh more than in the per-line median ratio.
By period
| Period | Line items | Win % | Median ×QPA | 25th–75th | Ratio n | Median days |
|---|---|---|---|---|---|---|
| 2025 Q1–Q4 | 391 | 82.4% | 17.72x | 1.00x–52.40x | 382 | 28 |
| 2024 Q1–Q4 | 154 | 84.4% | 10.02x | 5.81x–16.19x | 136 | 47 |
| 2023 Q1–Q4 | Fewer than 30 determined line items; not shown. | |||||
| 2023 Q1–2025 Q4 | 559 | 83.4% | 13.50x | 3.16x–36.60x | 529 | not pooled |
Line items = determined dispute line items (n). Win rate excludes split decisions and includes default decisions. Ratio n = line items reporting a payment-to-QPA ratio. Days are business days as reported by CMS (2023–2024: from IDR entity assignment; 2025: from initiation) and are never pooled.
By state
| State (place of service) | Line items | Win % | Median ×QPA | Ratio n | Median days |
|---|---|---|---|---|---|
| California | 130 | 83.8% | 37.27x † | 129 | 27.5 |
| New Jersey | 84 | 83.3% | 18.29x | 83 | 30 |
| New York | 70 | 90.0% | 16.56x | 67 | 37 |
| Arizona | 61 | 67.2% | 0.80x | 61 | 25 |
| Texas | 31 | 90.3% | – | 27 | 26 |
2025 Q1–Q4 · rows with n ≥ 30 determined line items · sorted by n.
Dollar amounts by state
| State (region) | Line items with $ | Total awarded | Median award | Median QPA | Award ×QPA |
|---|---|---|---|---|---|
| New Jersey | 126 | $3.2M | $17,600 | $605 | 18.59x |
| New York | 126 | $3.2M | $17,600 | $605 | 18.59x |
| Pennsylvania | 126 | $3.2M | $17,600 | $605 | 18.59x |
| California | 116 | $5.9M | $59,250 | $813 | 27.81x |
| Arizona | 44 | $1.5M | $21,405 | $50,000 | 0.53x |
2025 Q1–Q4 · CMS QPA and Offers file · rows with n ≥ 30 line items with dollar amounts · sorted by n · Award ×QPA = total awarded ÷ total QPA.
By specialty
| Specialty group | Line items | Win % | Median ×QPA | Ratio n | Median days |
|---|---|---|---|---|---|
| General and other surgery | 295 | 84.7% | 22.54x † | 286 | 29 |
| Other / unclassified labels | 51 | 74.5% | 0.80x | 51 | 25 |
2025 Q1–Q4 · rows with n ≥ 30 determined line items · sorted by n.
Section: Surgery (10004–69990)
FAQ
What is the Federal IDR provider win rate for CPT 43281?
In 2025 Q1–Q4, the provider or facility offer was selected in 82.4% of 391 determined dispute line items for CPT 43281. Split decisions are excluded from the denominator and default decisions are included. Withdrawn, settled and ineligible disputes are not in the CMS data.
How do Federal IDR payments compare with the QPA for CPT 43281?
In 2025 Q1–Q4, the median prevailing offer was 17.72x the qualifying payment amount (QPA), with a 25th to 75th percentile range of 1.00x to 52.40x (n = 382 line items). This uses the CMS field Prevailing Party Offer as % of QPA, where 1.00x equals the QPA.
How long do Federal IDR decisions take for CPT 43281?
In 2025 Q1–Q4, the median was 28 business days (n = 391 line items), using the CMS field Length of Time to Make Determination (from dispute initiation).