Miss. Admin. Code tit. 20 | Miss. Admin. Code Title 20 — Labor

MISSISSIPPI DEPARTMENT OF EMPLOYMENT SECURITY MISSISSIPPI DEPARTMENT OF EMPLOYMENT SECURITY

Part 101 Regulations of the Mississippi Department of Employment Security

20 Miss. Admin. Code Pt. 101, R. 309.03 Rule 309.03

Temporary Agencies 310.00 Refusal of Work Disqualification 311.00 New Benefit Year 312.00 School Employee Designated Vacation or Holiday 313.00 Total Unemployment Definition 314.00 Claim Week 315.00 Change of Address

316.00 Employers’ responsibility to furnish separation information 317.00 Employers required to report Labor Disputes 318.00 Payment of Benefits to Interstate Claimants 318.01 Definitions 318.02 Registration for work 318.03 Benefit Rights for Interstate Claimants 318.04 Claims for Benefits 318.05 Determination of Claims 318.06 Appellate Procedure

318.07 Extension of Interstate Benefit payments to include claims taken in and for Canada 319.00 Benefits – Deceased Claimants 320.00 Seasonal Industry 321.00 Charging and Non-Charging of Benefits 322.00 Vacation and Holiday Pay Benefit Payment Control Regulations

20 Miss. Admin. Code Pt. 101, R. 400.00 Rule 400.00

Overpayments Generally 401.00 Reporting Earnings While Filing for Benefits

402.00 Criteria for determining Fraud and Non-Fraudulent Overpayment 403.00 Collection of Overpayment 404.00 Disqualification Period Assessed for Fraud 405.00 Interest Accrual 406.00 Prosecution of Fraudulent Overpayments Legal Regulations 500 Contribution Regulations 600 600.00 First Contribution Payment 600.01 Payment of Contribution 600.02 Transmittal of Contributions Payments 600.03 Overpayment of Contributions 601.00 Wages Defined 601.01 Exclusions 601.02 Items Included 601.03 Private Unemployment Benefit Plans

601.04 Reduction of Commissions, Sales Cancelled in Later Years

20 Miss. Admin. Code Pt. 101, R. 601.05 Rule 601.05

Bonuses in the Form of Securities 601.06 Sales Contest Prize Awards 601.07 Gifts 601.08 Gifts to Spouse of Deceased Employee

601.09 Spouse Employed by Corporation Wholly or Principally Owned by Other Spouse

601.10 Spouse Employed by Partnership in which the Other Spouse is Partner 601.11 Trustees in Bankruptcy – Compensation Paid to

601.12 Payments Made to Labor Union Representatives for Lost Wages

601.13 “idle Time” Payments under Minimum Number of Hours Guarantee 601.14 Tips 601.15 Remuneration Covering Salary and Expenses 601.16 Training Courses 601.17 Use of Employer’s Car by Employee

601.18 Payments to Employees Absent on Account of Sickness 601.19 Cash Value of Certain Remunerations 602.00 Employer 602.01 Demonstrators

602.02 Employers Disposing of Business Assets thereof, Ceasing Business, Etc.

602.03 For Profit Corporation owned by Non-Profit Charitable Organization

602.04 Payroll Records of Predecessor “Employer” Modified Rate of Contribution for Successor

602.05 Successors to Reimbursable Employers who Become Tax Paying (contributory) Employers by Requirements of the Law

602.06 Reimbursable employers Who Elect to Become Tax Paying (Contributory) 602.07 Predecessor Employers Who Resume Employment 602.08 Status by Voluntary Election 603.00 Employment 603.01 Service in Usual Trade or Business

603.02 Services Excluded from the Definition of Employment (Generally) 603.03 Officers and Members of Crew 603.04 Family Services

603.05 Religious, Charitable, Scientific, Literary, and Educational Exemptions 603.06 Aliens, Non-Residents and Minors 603.07 Newspaper and Magazine Distributor

20 Miss. Admin. Code Pt. 101, R. 603.08 Rule 603.08

Temporary, Casual and Training Period Workers 603.09 Pieceworkers 603.10 Non-resident Employers 603.11 Services Performed for the United States 603.12 Dredges

603.13 Concessionaires on Vessels on Navigable Water of the United States

603.14 Book Publishing Establishment Owned and Operated by Religious Organizations 603.15 Privately Owned Hospitals 603.16 Privately Owned Colleges 603.17 Newspaper Correspondents 603.18 Newspaper Carrier 603.19 Traveling Salesperson

603.20 Agents of Magazine Publishing and Distributing Companies

603.21 Officers of Parent Corporation Serving Subsidiary Corporation 603.22 Voluntary Coverage of Exempted Employments 603.23 Beneficiaries Employed by Administrator

603.24 Trustees and Estate-Fiduciaries, Receivers, Trustee, Trustees in Bankruptcy, Administrators of Estates, Guardians and Liquidators of Banks

603.25 Banks Acting as Trustee, Receivers, Administrator, or Guardian 603.26 Real Estate Agents Managing Real Estate for Owner 603.27 Self-Employed Fishermen 604.00 Records 604.01 Reporting 604.02 Reports of Subsidiary Employing Units 605.00 Determining the Number of Employees 606.00 Computation of Employer Tax Rates 607.00 Political Subdivisions Surety Bond 608.00 Reimbursing Employer Payment Liability 609.00 Funding Options 610.00 Temporary Help Firm 611.00 Power of Attorney 612.00 Tax Appeal Regulation 613.00 Contractors and Sub-contractors must be reported

614.00 Establishment of Employer Contribution Rate During Pendency of Appeal on Liability Questions FINANCIAL REGULATIONS

20 Miss. Admin. Code Pt. 101, R. 700.00 Combining Securities

EMPLOYMENT SERVICES 800

20 Miss. Admin. Code Pt. 101, R. 800.00 Mississippi First Initiative

20 Miss. Admin. Code Pt. 101, R. 800.01 Responsibility of State and Local Government

20 Miss. Admin. Code Pt. 101, R. 800.02 Contractor Responsibilities

20 Miss. Admin. Code Pt. 101, R. 800.03 Role of the MDES WIN Job Center

20 Miss. Admin. Code Pt. 101, R. 800.04 Reporting Requirement

TITLE 20 LABOR

Chapter 200 BENEFIT APPEAL REGULATIONS

20 Miss. Admin. Code Pt. 101, R. 200.0 Rule 200.0

Administrative Law Judge Defined (A) For purposes of the Law, a referee shall be an Administrative Law Judge (ALJ) as used throughout the following Regulations. (B) Pursuant to and as provided by the Employment Security Act, appealed claims shall be heard and decided by an ALJ. (C) Pursuant to and as provided by the Law, appeals of ALJ’s decisions shall be heard and decided by the Board of Review. 200.01 Filing an Appeal (A) Time for Filing: Pursuant to Sections 71-5-517 and 71-5-519 of the Law, an interested party must file an appeal for an initial or amended determination within fourteen (14) days of the date the determination was mailed to the last known address or delivered electronically to the email address on record. If the last day to appeal falls on a Saturday, Sunday, or other legal holiday, or day in which the Agency is closed for business, then the time allowed to appeal shall run until the end of the next business day. (B) Method of Filing: Appeals shall be filed using methods and procedures the Agency has established. Those methods prescribed by the Agency and new methods that may develop with technological advances and specifically include the following: (1) delivery by the United States Postal Services to the address provided on the determination or decision being appealed; (2) faxing to the number provided in the determination or decision being appealed; (3) in-person at any WIN Job Center; (4) electronically at the address provided in the determination or decision being appealed; or (5) telephonically by calling the number provided on the determination or decision being appealed. 200.02 Scheduling of Hearings before the Appeals Department (A) Telephone Hearings: Filed appeals will be set for a hearing to be conducted using a telephone conferencing system, unless a request for a Video Conference or In-person Hearing is made and the Department determines it necessary.

(1) In-person Factors: Factors that will be considered prior to granting a request for a Video Conference or In-person Hearing include, but are not limited to, the timeliness of the request, the location of the hearing if held in-person, cost factors for the Agency and the parties, the number of witnesses and/or exhibits to be introduced, credibility issues, sense related issues (i.e. visual appearance), interpreter issues, and any clear and present safety concerns. (2) Scheduling of a Hearing: Within fifteen (15) days of the receipt of an appeal (barring extraordinary circumstances) the Appeals Department of the Agency (the “Appeals Department”), shall schedule the appeal for a hearing before an ALJ. At least seven (7) days prior to the scheduled hearing date, a Notice of Hearing shall be sent by regular mail or electronically to the parties interested in the determination being appealed. (3) Contents of the Notice of Hearing: (a) A statement of the legal authority and jurisdiction under which the proceeding is being conducted; (b) A reference to the applicable statutes and rules; (c) A statement of the issues to be decided; (d) A statement of the time (and if in person the place) of the hearing; (e) A phone number that the parties must call the day before and leave their phone contact number for the time of the hearing. (B) Consolidation: If the Agency determines that a number of appeals cases are similar in facts and circumstances, the Agency has the discretion to consolidate the cases. The Agency shall advise the parties to select from their members an individual to act as representative for their side (a claimants’ representative and an employers’ representative). (C) Exhibits: A party desiring to offer exhibits as evidence shall provide copies to the Appeals Department and the opposing party which must be post marked, faxed, hand-delivered, or sent by electronic delivery, no less than three (3) days prior to the hearing unless approval for a later date is requested and granted for good cause. (1) Information submitted to the Agency is not part of the appeals record unless discussed at the hearing and entered in the record. See Section 200.04 (D), Page 11 of these regulations for more on exhibits, evidence, and the record. (D) Continuances: A request for a continuance must be made no later than three (3) days prior to the scheduled date of the hearing. A request for a continuance must include reasons that constitute good cause for granting the continuance. The need to attend to other business does not constitute

good cause. A request for continuance does not grant a stay of the scheduled hearing. The Appeals Department must affirmatively grant the request or the hearing remains as scheduled. In determining whether there is good cause to grant a continuance, the following factors will be considered: (1) The amount of time between the receipt of the Notice of Hearing and the request for continuance; (2) What actions the party requesting the continuance has taken to attend the hearing; (3) Whether the request for continuance is due to illness or incapacity; (4) Whether granting the continuance would result in a decision being issued over thirty (30) days after the appeal was filed; and (5) To the extent the reason is the unavailability of counsel and whether there are other attorneys in the firm that may represent the requesting party. 200.03 Disqualification Duties; Reports; Conflicts of Interest: (A) An Administrative Law Judge (ALJ) or Board of Review Member (Board Member) may not participate in the hearing of an appeal in which they have an interest. Challenges to the interest of an ALJ or Board Member who refuses to recuse themselves may be heard and decided by the Chairman of the Board of Review. (B) Whenever an ALJ is disqualified or it becomes impracticable for the ALJ to continue the hearing, another ALJ may continue with the hearing. If it is shown that substantial prejudice to any party will result, the new ALJ shall start the hearing over with a blank record. Whenever a Board Member is disqualified or it becomes impracticable for the Board Member to continue the hearing review, the remaining Board Members may continue with the review. If it is shown that substantial prejudice to any party will result, the remaining Board of Review members shall disregard prior discussions and start the hearing review over. (C) Ex parte Communications: An ex parte communication is an off-the- record communication between a presiding ALJ or Board Member and one party to the appeal without the other party’s presence. This practice is generally not acceptable. Further, the ALJ and the Board of Review shall maintain independent decision making from one another. (1) In any adjudicatory proceeding, no Board Member or ALJ authorized to take final action or to make findings of fact and conclusions of law shall communicate directly or indirectly in connection with any issue of fact, law, or procedure, with any party or other persons legally interested in the proceeding, except with proper notice and opportunity for all parties to participate. (2) This subsection does not prohibit Board Members from:

(a) Communicating in any respect with other Board Members; or (b) Having the aid and advice of their own staff, counsel or consultants retained by the Board of Review who have not participated and will not participate in the Board of Review proceeding in an advocate capacity. (3) This subsection does not prohibit any ALJ from: (a) Communicating in any respect with other members of the Appeals Department; or (b) Having the aid or advice of those members of her own staff, counsel or consultants retained by the Appeals Department who have not participated and will not participate in the Appeals Department proceeding in an advocate capacity. 200.04 Conduct of Hearings (A) The ALJ’s duties are to: (1) preside over and control the hearing; (2) maintain the official timepiece of the hearing; (3) administer oaths and affirmations; (4) rule on the admissibility of evidence; (5) set the time and place for continued hearings; (6) when warranted, fix the time for filing evidence, briefs, and other written submissions; and (7) take other actions authorized by the Law and these Regulations. (B) Every interested party shall have the right to present evidence and arguments on all relevant and noticed issues during the course of a hearing. This shall be done through the opportunity to testify, call and question witnesses, question or cross examine the other party and their witnesses that testify, present exhibits, and object to the other party’s exhibits. (C) The parties to an appeal, with the consent of the ALJ, may stipulate to facts involved in writing or on the record. The ALJ may decide the appeal on the basis of the stipulated facts or, in their discretion, may proceed with a hearing and take such further evidence as they deem necessary to determine the facts and proper decision. (D) Evidence (Testimony and Exhibits): (1) Hearsay evidence may be admitted and weighed accordingly. Generally, evidence will only be admitted and/or given weight if: a. it meets a hearsay exception, or

b. is from a source normally considered reliable, or c. is corroborated by other witnesses, or d. the ALJ otherwise determines that, in his or her opinion, the hearsay may be relied upon considering all of the facts and circumstances. (2) All testimony shall be under oath. The ALJ shall administer an oath to all witnesses before they testify in a proceeding. (3) Exhibits to be offered into evidence at the hearing must be submitted as described in 200.02 (D) above. A party or witness must explain what the exhibits are, and then must request the exhibits be entered as evidence. Prior to entering exhibits into the record as evidence, the ALJ will give the other party an opportunity to object to the admission. The ALJ will then decide whether or not to enter the exhibits in as evidence. (4) Parties should submit all relevant documents prior to the hearing date in accordance with 200.02(D). Further, parties should bring individuals with first–hand knowledge of facts and events regarding the issues to the hearing as witnesses. (5) When the decision is made, the ALJ will consider only the evidence entered into the record during the hearing, or evidence from which judicial notice is taken. (6) The ALJ and the Board of Review may take judicial notice of evidence, including Agency generated documents and forms, which shall then become record evidence. Judicial notice for purposes of these regulations is defined as: (a) that which is commonly known or accepted; (b) that which is accepted as an authority on a matter especially of a scientific or technical nature; (c) that which is generated by a Court, Agency or other government body; or (d) that which is the best evidence available to prove or disprove a fact in the case; and (e) such evidence is admissible without being formerly explained and offered by a party. (7) Facts entered through judicial notice will be indicated as such in the record and/or the decision. (8) If an appeal is made to the Board of Review, only testimony and exhibits entered into evidence at the hearing, or otherwise submitted by the ALJ with the appeal, will be included in the appeals record forwarded to the Board of Review. Only the record transcript and exhibits before the Board of Review will be submitted to the Courts, including additional evidence, exhibits, and testimony taken by the Board. (E) Sequestration of Witnesses.

All witnesses present, not including any interested party or their designated representative, who has not yet testified in the proceeding before the Board of Review or Appeals Department, may be sequestered at the request of a party or the discretion of the ALJ or Board of Review. Witnesses who have testified, but who may be recalled to testify further may also be sequestered at the request of any party or upon the initiative of the Board of Review or the ALJ. (F) Subpoenas. (1) Subpoenas to compel the attendance of witnesses and the production of records for a hearing of an appeal may be issued by a member of the Board of Review or by the ALJ before whom the hearing is scheduled. A subpoena will only be issued if a request showing the necessity for the issuance of the subpoena is made in writing and the ALJ or Board of Review deems it necessary. (2) Witnesses subpoenaed for hearings before an ALJ or the Board of Review shall be paid a daily witness fee amount, as well as a mileage per diem for in-person hearings according to the rates provided in Section 25-3-41 of the Law. (3) No witness fee shall be allowed a witness who does not appear at the hearing when called or who is disqualified from testifying. No witness fees or mileage will be paid unless the ALJ or the Chairman of the Board of Review before whom the witness was called to testify certifies the attendance of the witness and the amount of witness fee to which she is entitled. One copy of such witness certificate shall be given to the witness, one transmitted to the Agency, and one copy preserved in the file of the case. (G) Record: A record shall be kept of the proceedings, which shall include the following: (1) All applications, pleadings, motions, preliminary and interlocutory rulings, and orders; (2) Evidence received or considered; (3) A statement of facts officially noticed; (4) Offers of proof, objections, and rulings thereon; and (5) Proposed findings and exceptions, if any; (6) The decision of the Board of Review and the Appeals Department The record does not include documents submitted to the Agency prior to an appeal being filed that are not either resubmitted after the appeal is filed or discussed during the hearing. (H) Other recordings: In order to assure the confidentiality of hearings before an ALJ, no party or participant at a hearing shall be permitted to record such hearing by any means, and the recording made by the ALJ

shall be the official record of the proceeding. This prohibition is pursuant to the provisions of Sections 71-5-127 and 71-5-525 of the Law. (J) Dismissal Due To Behavior. In the event any party or party's representative during a hearing conducts themselves in a manner determined by the ALJ to be disrespectful, and who, after having been warned once to stop, fails to stop, shall be dismissed from the hearing. If, in the ALJ’s opinion, justice requires that the party be granted a continuance to obtain another representative, then it shall be granted. 200.05 Disposition without full hearing (A) The Board of Review or the Appeals Department may make informal disposition of any adjudicatory proceeding by default when the appealing party or the party with the burden of proof fails to appear at the scheduled hearing. A party shall be deemed to have failed to timely appear at a hearing when the party fails to appear as provided in the notice of hearing, including calling an Appeals Department telephone number or providing in advance a telephone number as required by the notice of hearing, or by failing to be present at the telephone number provided by the party for ten (10) or more minutes past the scheduled start time of the hearing. (B) Any such default may be set-aside by the Board of Review or Appeals Department for good cause shown. The procedure for good cause hearings is as follows: (1) No later than fourteen (14) days after the date of the postal or electronic mailing of the decision, upon written request setting forth the reasons for failing to appear, the Appeals Department may provide a good cause hearing to a party that failed to appear at the hearing. If the Appeals Department determines that good cause exists, it will conduct a hearing on the underlying substantive issues. Similarly, upon written request setting forth the reasons for failing to appear at a hearing, the Board of Review may provide a good cause hearing to the appealing party. A hearing on the underlying substantive issues shall be conducted only if the Board of Review determines that good cause exists. (2) If it is decided that a party did not have good cause for nonappearance, no evidence will be taken on the substantive issues, and the decision previously made will remain unaffected and in force. 200.06 Decisions (A) Every decision of the Board of Review and Appeals Department shall be in writing and shall include findings of fact sufficient to inform the parties of the basis for the conclusions of law and the decision. Findings of fact must be supported by substantial evidence in the record. (B) A copy of the decision shall be promptly mailed via U.S. Mail or electronically to each party to the proceeding and their representative of

record. Written notice of the party's rights to appeal to the Board of Review or the courts, and the time within which such action must be taken, shall be given to each party with the decision. (C) The following statement shall appear on the ALJ’s decision: "If an appeal is taken to the Board of Review, such appeal will be considered on the record previously made, and no hearing before the Board will be scheduled." (D) The Board of Review shall maintain a record of the vote of each member of the Board of Review with respect to the Board of Review decision. If a decision of the Board of Review is not unanimous, the decision of the majority shall control. The minority may file a dissent from such decision setting forth the reasons why it fails to agree with the majority.

History

Source: Miss. Code Ann. §§ 71-5-115 & 71-5-117 (Rev. 2004).

20 Miss. Admin. Code Pt. 101, R. 201.00 Rule 201.00

Appeals Pending Before Administrative Law Judge and Removed to Board of Review (A) The Chairman of the Board of Review may remove to the Board of Review the proceedings on any claim pending before an ALJ. (B) Any appeal removed to the Board of Review shall be presented, heard, and decided by the Board of Review in the manner prescribed by the Law and in the preceding and following Regulations.

History

Source: Miss. Code Ann. §§ 71-5-115 & 71-5-117 (Rev. 2004).

20 Miss. Admin. Code Pt. 101, R. 202.00 Rule 202.00

Appeals From Decisions Of Administrative Law Judges To The Board Of Review Any interested party to a decision of an ALJ, adversely affected by the decision, shall have the right to appeal to the Board of Review. 202.01 Method of Review (A) The Board of Review may affirm, modify, reverse, or set aside any ALJ decision based on the record previously made by the ALJ. All appeals to the Board of Review shall be heard upon the evidence in the record previously made. The Board of Review, at its discretion, may also consider written arguments or briefs filed by any of the parties. (B) The Board of Review, in its discretion, may remand any claim that is before it to an ALJ for the taking of such additional evidence as the Board of Review may deem necessary. Such testimony shall be taken by the ALJ in the manner prescribed for the conduct of hearings on appeal before the ALJ. Upon the completion of the taking of evidence by an ALJ, pursuant to the direction of the Board of Review, the record of such evidence shall be returned to the Board of Review for a decision. Alternatively, the ALJ may be instructed to issue a decision and in that case, a right of appeal to the Board of Review shall be provided to the parties.

20 Miss. Admin. Code Pt. 101, R. 202.02 Rule 202.02

Appeals by Board of Review of its Own Motion (A) Within fourteen (14) days following a decision issued by an ALJ, and in the absence of filing of a notice of appeal by any of the parties, the Board of Review, on its own motion, may order the parties to appear before it for a hearing on the claim or any issue involved. (B) Such hearing shall be held only after ten (10) days prior notice to the parties, and shall be heard in the manner prescribed for the hearing of appeals from the decision of the ALJ. 202.03 Board of Review Decision Any decision of the Board of Review shall become final ten (10) days after the regular U.S. Mail mailing date or electronic transmittal date of the notification. No request by any party for reconsideration by the Board of its decision, made by a standard review of an ALJ’s hearing record, shall be considered by the Board. However, in any case in which the Board of Review conducts a hearing and receives additional evidence, testimony, or hears argument on the issues, any party not present or represented at such a hearing may, not later than ten (10) days after the date of notification of the Board's decision, file with the Board a written request to set aside such decision and reopen the case for further hearings. Such request shall state the reasons for the party's failure to appear and if the Board of Review determines that the party has made a showing of good cause for his or her failure to appear, it shall reschedule the case for further hearing and its final decision. 202.04 Appeals to Courts Within ten (10) days after the decision of the Board of Review has become final (see 202.4), any party who is aggrieved thereby may appeal an action in the Circuit Court of the County in which they reside against the Agency for a review of such decision. The Agency is also authorized to appeal decisions of the Board of Review involving questions of interpretation of the Law. The Agency will provide notice to the parties to the decision, and such an appeal shall not have the effect of denying benefits to any claimant who has been awarded benefits by virtue of the decision of the Board of Review from which the appeal is taken.

History

Source: Miss. Code Ann. §§ 71-5-115 & 71-5-117 (Rev. 2004).

20 Miss. Admin. Code Pt. 101, R. 203.00 Rule 203.00

Requests to Supply Information from the Records of the Department of Employment Security Requests for information from the records of the Agency by a party to an appeal, or their representative, shall be complied with to the extent necessary for the proper disposition of the claim, in accordance with Section 71-5-127 of the :Law, All such requests shall state the nature of the information desired. Such compliance may include the furnishing of a copy of the record on appeal to a party, which will generally be a recorded copy of the hearing.

History

Source: Miss. Code Ann. §§ 71-5-115 & 71-5-117 (Rev. 2004).

20 Miss. Admin. Code Pt. 101, R. 204.00 Rule 204.00

Representation before Administrative Law Judges and Board of Review (A) Any individual may represent themselves, or have a duly authorized representative or counsel in any evidentiary hearing before an ALJ or the Board of Review. Any partnership may be represented by any of its members or its duly authorized representative. Any corporation or association may be represented by an officer or its duly authorized representative. (B) All fees for representation that are charged to claimants must be approved by the ALJ or the Board of Review, as the case may be, for representation in hearings before them. No fee shall be allowed unless request for such fee shall have been filed with the ALJ or the Board of Review, as the case may be, prior to the adjournment of the hearing. (C) As authorized in Section 71-5-537 of the Law, the Board of Review hereby approves, subject to the provisions of subsection (4) below, the following charges for representing claimants by persons entitled to charge for such representation by the laws of this State: (1) For representation in proceedings before an ALJ, not to exceed eighty (80%) per centum of the claimant's weekly benefit amount or thirty dollars ($30.00), whichever is greater. (2) For representation in proceedings before the Board of Review, not to exceed one hundred twenty (120%) per centum of the claimant's weekly benefits amount or fifty dollars ($ 50.00) whichever is greater. (3) For representation in proceedings in the Circuit Court or the Supreme Court, such fee as may be approved by the Court. (4) In any case in which the claimant and his or her counsel believe the fee as approved in subsection (1) or (2) above for representation in proceedings before the ALJ or the Board of Review is insufficient, the amount of the fee may be appealed by giving notice in writing to the ALJ or the Board of Review at the hearing and filing within ten (10) days. A sworn statement, signed by the claimant and the counsel, of the facts upon which they base their contention must be presented. The Board of Review will render its final decision on any such appeal on the amount of fee at its next regular meeting after receipt of the sworn statement. In appeals on the amount of fee for representation in proceedings before the ALJ, the Board of Review may request a statement from the ALJ on the reasonableness of the fee being requested. (5) An appeal on the amount of fee for representation of a claimant shall be entirely separate and apart from and shall have no bearings whatsoever upon the appeal proceedings on the merits of the pertinent claim, decisions, or appeals.

(6) If a party is represented by more than one duly authorized representative at a hearing, only one of them may participate in the hearing.

History

Source: Miss. Code Ann. §§ 71-5-115 & 71-5-117 (Rev. 2004).

20 Miss. Admin. Code Pt. 101, R. 205.00 Rule 205.00

Waiver of Notice and Entry of Appearance Interested parties to whom a notice of any hearing on appeal is required by these Regulations to be given, whether before an ALJ or the Board of Review, may, prior to or at such hearing, waive the requirement of such notice and enter their appearance at such hearing for all purposes. Such waiver and entry of appearance is evidenced by a statement in writing to that effect, or a statement duly recorded, which is made part of the record of the hearing.

History

Source: Miss. Code Ann. §§ 71-5-115 & 71-5-117 (Rev. 2004).

20 Miss. Admin. Code Pt. 101, R. 206.00 Rule 206.00

Records of Decisions of Administrative Law Judges and Board of Review to be Kept (A) All decisions of any ALJ and of the Board of Review shall be listed in a minute book and /or electronic file provided for such purpose. Decisions of any ALJ shall be signed by the individual rendering the same, and decisions of the Board of Review shall be signed as “The Board of Review.” The minute book or electronic file shall be kept by the Chairman of the Board of Review. (B) Copies of all decisions of the ALJ and the Board of Review shall be kept on file, via either paper file or electronic file, at the Agency in Jackson, Mississippi. Such decisions shall be open for inspection, without in any manner without revealing the names of any of the parties or witnesses involved. The said decisions shall be numbered, codified, or identified by the Board of Review, or its authorized representative, and in such manner as it shall determine. (C) For purposes of these regulations, "parties in interest", "interested parties", and "parties interested" shall mean, unless otherwise indicated, the claimant, the Agency, the Claims Examiner whose determination has been appealed, and the claimant's last employer, and any other person whose interests may be proximately affected.

History

Source: Miss. Code Ann. §§ 71-5-115 & 71-5-117 (Rev. 2004).

20 Miss. Admin. Code Pt. 101, R. 207.00 Rule 207.00

Precedent Decision (A) The Board of Review, by unanimous vote, may designate all or part of a decision as a precedent decision if it contains a significant legal or policy determination of general application that is likely to recur. (B) A legal or policy determination is significant if it establishes a rule of law or policy, resolves an unsettled area of law or overrules, modifies, refines, clarifies, or explains a prior precedent decision.

(C) A legal or policy determination is of general application if the facts are sufficiently common to give guidance to future cases, clearly illuminate the legal or policy determination, and are significant to the parties, the public, the taxpayers, or the operation of the Agency. (D) A precedent decision shall be clearly identified as such and published in such a manner as to make it available for public use. Information identifying any party shall be removed prior to the publications. (E) The Board shall maintain an index of significant legal and policy determinations made in precedent decisions.

History

Source: Miss. Code Ann. §§ 71-5-115 & 71-5-117 (Rev. 2004).

20 Miss. Admin. Code Pt. 101, R. 208.00 Rule 208.00

Responsibility of Parties to Notify the Appeals Department of Address Change (A) It is the responsibility of each party to an appeal before the ALJ or the Board of Review to notify the Appeals Department of any change of name or address. If any party to an appeal has reason to believe that it will be difficult to receive mail or email at the address or email address provided to the Appeals Department, the party shall make the necessary arrangements to insure timely receipt of all correspondence from the Agency. (B) In any instance where a party alleges failure to receive timely notice of a hearing, or of a decision from the ALJ or Board of Review, it shall be the burden of such party to prove compliance with subsection (A) above.

History

Source: Miss. Code Ann. §§ 71-5-115 & 71-5-117 (Rev. 2004).

20 Miss. Admin. Code Pt. 101, R. 209.00 Rule 209.00

Notices from the Appeals Department Any notice of hearing, decision, or continuance properly named, addressed, and mailed or electronically delivered by the Appeals Department and Board of Review to any interested party, and not returned by the U.S. Postal Service or as undeliverable through email, shall create a rebuttable presumption of proper delivery and receipt of such notice or decision.

History

Source: Miss. Code Ann. §§ 71-5-115 & 71-5-117 (Rev. 2004).

Chapter 300 BENEFIT REGULATIONS 300.00 Filing Initial, Additional and Reopened Claims The effective date of an initial claim will be the Sunday preceding the date on which the individual files a claim for benefits by any method provided by the Agency. If the claim is filed on a Sunday, then the claim will be effective on the Sunday it is filed. If the Agency determines that an individual filed their initial claim at the first available opportunity, the effective date of the claim will be the Sunday prior to the date they became unemployed.

20 Miss. Admin. Code Pt. 101, R. 301.00 Rule 301.00

Reconsideration of Initial Determination An initial determination may for good cause be reconsidered if the request is filed within fourteen (14) days from the date such notification was mailed or electronically delivered to an individual’s last known address or email address. The Agency has the discretionary authority to consider untimely filed requests made under this regulation if it can be shown there are compelling circumstances which justify a reconsideration such as fraud, misconception of facts or any other reason the Agency deems compelling.

History

Source: Miss. Code Ann. §§ 71-5-115 & 71-5-117 (Rev. 2004).

20 Miss. Admin. Code Pt. 101, R. 302.00 Rule 302.00

Filing Mass Lay-off Initial Claims Initial claims for benefits for individuals may be filed in groups for a layoff from the same employer for the same time period of unemployment. The effective date of the claims will be determined by the Agency based on the first day of unemployment, provided the person files in the specified manner, at a designated time, date, and place agreed on by the employer and the Agency.

History

Source: Miss. Code Ann. §§ 71-5-115 & 71-5-117 (Rev. 2004).

20 Miss. Admin. Code Pt. 101, R. 303.00 Rule 303.00

Filing Weekly Certifications for Benefits A claim for waiting period credit or benefits must be filed by the Friday following the week being claimed, using methods prescribed by the Agency. An exception to this rule can be considered if the individual files their claim within fourteen (14) days of the week being filed, provided no availability issue exists. If an individual is in a claim series and makes no attempt to file a continued claim for three (3) or more consecutive weeks, no claim for benefits will be allowed until the claim is reopened. A reopened claim is an additional claim without interim employment with a new effective date. The effective date of the reopened claim will be the Sunday prior to the date in which the individual attempted to file another claim.

The Agency will have the authority to deny benefits or waiting period credit for any week which is not properly filed within set guidelines.

History

Source: Miss. Code Ann. §§ 71-5-115 & 71-5-117 (Rev. 2004).

20 Miss. Admin. Code Pt. 101, R. 304.00 Rule 304.00

Reporting Requirements Individuals must report to the Agency as directed. Such reporting may be in person or by other methods established by the Agency. Failure to report may result in a denial of benefits.

History

Source: Miss. Code Ann. §§ 71-5-115 & 71-5-117 (Rev. 2004).

20 Miss. Admin. Code Pt. 101, R. 305.00 Eligibility for Unemployment Benefits

An individual must follow the requirements in Mississippi Code Annotated Section 71-5-511 to be eligible for unemployment benefits and to maintain their ongoing eligibility.

20 Miss. Admin. Code Pt. 101, R. 305.01 Rule 305.01

Registering for Work In order to receive unemployment benefits an individual must be registered for work through the Agency unless they fall within one the following categories of workers: 1. Temporary layoff of less than four (4) weeks; 2. In Agency approved training; 3. Unemployed due to a Labor Dispute; and/or 4. Individuals who have a specific return to work date.

20 Miss. Admin. Code Pt. 101, R. 305.02 Work Search

In accordance with Mississippi Code Annotated Section 71-5-11, individuals must make an active search for full-time (35 hours or more) work in order to receive unemployment insurance benefits. The Agency defines “actively seeking work” as follows:

The individual must register for employment services as prescribed by MDES. 2. The individual must engage in an active weekly search for full-time work and include an appropriate number of employer contacts as prescribed by MDES and make contact with at least three (3) employers each week. At least one (1) employer contact must include the submission of an application for employment. Additionally, the work applied for must be appropriate in light of the labor market and the individual’s skills and capabilities. An “application for employment” is defined as any completed application or resume submitted to an employer that may reasonable be expected to have an opening for for suitable work, either in-person, via mail, or via electronic communication; or any telephonic or in-person interview with an employer that may reasonably expected to have an opening for suitable work. 3. The individual must maintain and provide a record of his/her work search including the name, address and phone number of the employer contacted, if contacted via electronic

means, the website, email address or fax number of the employer, the name of the individual contacted, method of contact, and date of contact. 4. The individual cannot report the same employer contact until three (3) weeks after it was first reported to MDES, unless the employer contact is part of a progressive hiring process.

If an individual fails to comply with any of the above stated requirements, the individual shall be disqualified from receiving unemployment benefits for the week or weeks in which the violation or violations occurred. The agency may impose more stringent penalties in situations in which an individual is shown to be a habitual violator of the requirements contained in this regulation.

Acceptable employer contacts may include, but are not limited to: a. Making a self-referral for job openings via the MDES Online Employment Services System. b. Visiting a local WIN Job Center for staff-assisted job referrals and making employer contacts based on those referrals. c. Completing a job application with employers who may reasonably be expected to have openings for suitable work. The job application may be submitted in person, online, by fax or in any other manner directed by the employer and appropriate for the type of work the individual is seeking. d. Mailing a job application and/or resume as instructed by a job notice. e. Making in-person visits with employers that may reasonably be expected to have openings for suitable work. f. Interviewing with potential employers in person, by telephone or in any other manner directed by the employer and appropriate for the type of work the individual is seeking. g. Attending a job fair and submitting an application or providing a resume to employers in attendance. The work search requirements for certain individuals may be waived by the Agency for the following reasons: job attached (as defined by the Agency), Jury Duty, Approved Training, and Approved Self-Employment Assistance Program, individuals who are members in good standing of a union that maintains a nondiscriminatory hiring hall, as that term is defined by the Landrum- Griffin Act, and who maintain contact with and use the placement services of the hiring hall. The Agency may also waive this requirement due to other extenuating circumstances as determined by the Agency.

20 Miss. Admin. Code Pt. 101, R. 305.03 Able and Available

Individuals must be able to work and available for work to be eligible for unemployment benefits with respect to any week. If the Department finds that an individual may not be able to work and available for work due to a medical condition, illness or disability, that individual will be required to provide the Department certification from a physician, medical facility, medical practice, physician assistant, or nurse practitioner that includes the following:

Whether the individual was advised to leave work;
Whether the individual is released to return to their usual work, and if so, the date of release; 3. If the individual is not released to return to their usual work, an explanation of their restrictions.

After the certification is received, the Department will investigate to determine whether the individual is able to work and available for work. If the Department finds that the individual is not able to work and available for work, an appealable decision outlining the Department’s decision will be sent to the individual. If the individual fails to return the medical certificate within time period prescribed by the Department, the Department has the discretion to disallow benefits to the individual for failure to return the requested information.

History

Source: Miss. Code Ann. §§ 71-5-115 & 71-5-117 (Rev. 2004).

20 Miss. Admin. Code Pt. 101, R. 306.00 Rule 306.00

Lifting Disqualification Some disqualifications require that an individual return to work and earn eight times the Weekly Benefit Amount (8XWBA) in covered employment. The WBA of the benefit year in which the separation occurred must be used to remove this disqualification.

History

Source: Miss. Code Ann. §§ 71-5-115 & 71-5-117 (Rev. 2004).

20 Miss. Admin. Code Pt. 101, R. 307.00 Rule 307.00

Approved Training An individual is considered to be in approved training if they are participating in training which will enhance their chances of obtaining employment. Usually, the individual is referred to such training through the Agency. However, if the training is self-funded, and is identical to the training to which applicants are normally referred, they will be considered to be in approved training.

History

Source: Miss. Code Ann. §§ 71-5-115 & 71-5-117 (Rev. 2004).

20 Miss. Admin. Code Pt. 101, R. 308.00 Misconduct Defined

A. For purposes of Mississippi Code Section 71-5-513, misconduct shall be defined as including but not limited to:

The failure to obey orders, rules or instructions, or failure to discharge the duties for which an individual was employed; a. An individual shall be found guilty of employee misconduct for the violation of an employer rule only under the following conditions: i. the employee knew or should have known of the rule; ii. the rule was lawful and reasonably related to the job environment and performance; and iii the rule is fairly and consistently enforced.
A substantial disregard of the employer’s interests or of the employee’s duties and obligations to the employer; 3. Conduct which shows intentional disregard – or if not intentional disregard, utter indifference – of an employer’s interests as is found in deliberate violations or disregard of standards of behavior which the employer has the right to expect of the employee; or 4. Carelessness or negligence of such degree or recurrence as to demonstrate wrongful intent.

However, mere inefficiency, unsatisfactory conduct, failure to perform as the result of inability or incapacity, a good faith error in judgment or discretion, or conduct mandated by a religious belief or the law is not misconduct. Conduct mandated by the law does not include court ordered conduct resulting from claimant’s illegal activity; this may be considered misconduct

History

Source: Miss. Code Ann. §§ 71-5-115 & 71-5-117 (Rev. 2004).

20 Miss. Admin. Code Pt. 101, R. 309.00 Good Cause Defined

If the employment conditions or circumstances leading to claimant’s voluntary separation from employment are such that an ordinary prudent employee would leave their employment, the claimant has demonstrated good cause, for the purpose of Mississippi Code Annotated Section 71-5-513. Additionally, claimant must show that after exploring alternatives to quitting, and after making reasonable efforts to preserve their employment, an ordinary prudent person would be compelled to voluntarily quit their employment.

20 Miss. Admin. Code Pt. 101, R. 309.01 Domestic Violence Exception

An individual is disqualified for leaving employment for marital, filial, or domestic circumstances. However, the claim may be allowed if sufficient evidence shows that continuing in the employment would be a detriment to the welfare of the claimant, or the claimant’s under-aged dependents, due to domestic violence.

20 Miss. Admin. Code Pt. 101, R. 309.02 Military Exception

An individual is disqualified for leaving employment for marital, filial, or domestic circumstances, however, leaving an employer to accompany a spouse who is on active duty, and has been reassigned from one military assignment to another shall be deemed to be for good cause; provided, however, that a rated employer’s account shall not be charged for benefits paid. Reimbursing employers are not entitled to an non-charge under the law.

20 Miss. Admin. Code Pt. 101, R. 309.03 Temporary Agencies

The Agency will have sole discretion to determine if a temporary employer or employee has met the requirements of Section 71-5-511(l) of the Law. In making its determination, the Agency may consider the following factors: (1) the policy of the temporary agency; (2) the reasonableness of the policy; (3) the actions of the temporary agency; and (4) the actions of the temporary employee. Upon the completion of an assignment, if the temporary employee contacts the temporary employer and is given a new job assignment, the Agency may examine the suitability of the new assignment under Section 71-5-513 (A)(3)(a) of the Law.

History

Source: Miss. Code Ann. §§ 71-5-115 & 71-5-117 (Rev. 2004).

20 Miss. Admin. Code Pt. 101, R. 310.00 Rule 310.00

Refusal of Work Disqualification An individual is disqualified for the week in which the failure to accept work occurred, and for not more than twelve (12) weeks immediately following such week, as determined by the Agency according to the circumstances in each case. The Agency has the discretion of issuing varying lengths of disqualification. However, a disqualification for refusing an offer of suitable work should not exceed the length of the available suitable work.

History

Source: Miss. Code Ann. §§ 71-5-115 & 71-5-117 (Rev. 2004).

20 Miss. Admin. Code Pt. 101, R. 311.00 Rule 311.00

New Benefit Year Requalification Provision An individual who established one (1) benefit year, and received benefits, is not eligible for benefits in the second benefit year unless they have returned to work and earned eight (8) times their previous weekly benefit amount (WBA). These wages must be in covered employment and must be earned after the effective date of the prior benefit year.

History

Source: Miss. Code Ann. §§ 71-5-115 & 71-5-117 (Rev. 2004).

20 Miss. Admin. Code Pt. 101, R. 312.00 Rule 312.00

School Employee Designated Vacation or Holiday School employees who are off work for a designated vacation period, such as Christmas holiday or spring break are subject to denial under Section 71-5-511(k) of the Law which provides for denial of benefits during a designated holiday or vacation period. However, if claims are filed by school employees between academic years or terms, such as summer break, they must be adjudicated under Section 71-5-511(h) of the Law.

History

Source: Miss. Code Ann. §§ 71-5-115 & 71-5-117 (Rev. 2004).

20 Miss. Admin. Code Pt. 101, R. 313.00 Rule 313.00

Total Unemployment Definition An individual is considered totally unemployed during any week in which they perform no services and in which no wages are payable to him or her. They are

considered part totally unemployed if wages are less than their weekly benefit amount plus forty dollars ($40.00) or if they work less than full time. Employment less than thirty-five (35) hours per week will not be considered full time, unless industry standards are considered. Such consideration will be at the discretion of the Agency.

History

Source: Miss. Code Ann. §§ 71-5-115 & 71-5-117 (Rev. 2004).

20 Miss. Admin. Code Pt. 101, R. 314.00 Rule 314.00

Claim Week An individual’s week of total or part-total unemployment shall consist of a calendar week (Sunday through Saturday). If any part of a week falls within a benefit year, the entire week is considered to be in that benefit year.

History

Source: Miss. Code Ann. §§ 71-5-115 & 71-5-117 (Rev. 2004).

20 Miss. Admin. Code Pt. 101, R. 315.00 Rule 315.00

Change of Address Each claimant or employer must notify the Agency immediately of any change in their address.

History

Source: Miss. Code Ann. §§ 71-5-115 & 71-5-117 (Rev. 2004).

20 Miss. Admin. Code Pt. 101, R. 316.00 Rule 316.00

Employers’ responsibility to furnish separation information Upon request of the Agency, each employer or employing unit shall furnish to the Agency information concerning any worker separated from their work with such employer or employing unit, including: (1) the last day on which such worker was employed; (2) the reason for their separation from work; and (3) such other matters as may be requested. Such information shall be furnished to the Agency within the specified time. It will be presumed that employers who fail to furnish such information within the time required have admitted that the individual claiming benefits is not subject to disqualification.

History

Source: Miss. Code Ann. §§ 71-5-115 & 71-5-117 (Rev. 2004).

20 Miss. Admin. Code Pt. 101, R. 317.00 Rule 317.00

Employers Required to Report Labor Disputes An employer is required to notify the Agency of cases of unemployment due to a strike, lockout. or other labor dispute. This may be through the WIN Job Center nearest to their place of business or to the state office of the Agency. The notification by employer should include the circumstances surrounding the dispute, including the number of workers affected and a list of workers ordinarily attached to the business or the establishment where such unemployment exists.

History

Source: Miss. Code Ann. §§ 71-5-115 & 71-5-117 (Rev. 2004).

20 Miss. Admin. Code Pt. 101, R. 318.00 Rule 318.00

Payment of Benefits to Interstate Claimants Regulations 318.01 through 318.07 shall govern the Agency in its administrative cooperation with other states adopting similar regulations for the payment of benefits to interstate claimants. 318.01 Definitions As used in this Regulation, unless the context clearly requires otherwise: (A) Interstate Benefit Payment Plan means the plan approved by the Interstate Conference of Employment Security Agencies under which benefits shall be payable to unemployed individuals absent from the state (or states) in which benefit credits have been accumulated. (B) Interstate claimant means an individual who claims benefits under the unemployment insurance law of one or more liable states, through the facilities of an agent state. The term "interstate claimant" shall not include any individual who customarily commutes from a residence in an agent state to work in a liable state unless the Agency finds that this exclusion would create undue hardship on such claimant in specified areas. (C) State includes the District of Columbia, Puerto Rico, and the Virgin Islands. (D) Agent State means any state in which an individual files a claim for benefits from another state. (E) Liable State means any state against which an individual files a claim for benefits through another state. (F) Benefits mean the compensation payable to an individual, with respect to their unemployment under the unemployment insurance law of any state. (G) Week of Unemployment includes any week of unemployment as defined in the Law of the liable state from which benefits with respect to such week are claimed. 318.02 Registration for work (A) Each interstate claimant shall be registered for work, through any public employment office in the agent state as required by the Law, regulations, and procedures of the agent state. Such registration shall be accepted as meeting the registration requirements of the liable state provided Mississippi is the liable state and such requirements are not contrary to the provisions of the Mississippi Employment Security Law. (B) Each agent state shall duly report to the liable state, whether each interstate claimant meets the registration requirements of the agent state. 318.03 Benefit Rights for Interstate Claimants If a claimant files a claim against a state, and it is determined by such state that the claimant has available benefit credits in such state, then claims shall be filed only against such state as long as benefit credits are available in that state.

Thereafter, the claimant may file claims against any other state in which there are available benefit credits. For the purposes of this regulation, benefit credits shall be deemed to be unavailable whenever benefits have been exhausted, terminated, or postponed for an indefinite period or for the entire period in which benefits would otherwise be payable, or whenever benefits are affected by the application of a seasonal restriction. 318.04 Claims for Benefits (A) Claims for benefits or waiting period shall be filed by interstate claimants on uniform interstate claim forms and in accordance with uniform procedures developed pursuant to the Interstate Benefit Payment Plan. Claims shall be filed in accordance with the reporting period used by the agent state. Any adjustments required to fit the reporting period used by the liable state shall be made by the liable state on the basis of consecutive claims filed. (B) Claims shall be filed in accordance with agent state regulations for intrastate claims by established agency methods. (1) With respect to claims for weeks of unemployment in which an individual was not working for his regular employer, the liable state shall, under circumstances which it considers good cause, accept a continued claim filed up to one (1) week, or one (1) reporting period, late. If a claimant files more than one (1) reporting period late, an initial claim must be used to begin a claim series and no continued claim for a past period shall be accepted. (2) With respect to weeks of unemployment during which an individual is attached to his regular employer, the liable state shall accept any claim which is filed within the time limit applicable to such claims under the law of the agent state, provided the same is not inconsistent with the provisions of the Mississippi Employment Security Law. 318.05 Determination of Claims (A) The agent state shall, in connection with each claim filed by an interstate claimant, ascertain and report to the liable state such facts relating to the claimant's availability for work and eligibility for benefits as are readily determined in and by the agent state. (B) The agent state's responsibility and authority in connection with the determination of interstate claims shall be limited to investigation and reporting of relevant facts. The agent state shall not refuse to take an interstate claim.

20 Miss. Admin. Code Pt. 101, R. 318.06 Rule 318.06

Appellate Procedure (A) The agent state shall afford all reasonable cooperation in the taking of evidence and the holding of hearings in connection with appealed interstate benefit claims. (B) With respect to the time limits imposed by the law of the liable state upon the filing of an appeal in connection with a disputed benefit claim, an appeal made by an interstate claimant shall be deemed to have been made and communicated to the liable state on the date when it is received by any qualified officer of the agent state. 318.07 Extension of interstate benefit payments to include claims taken in and for Canada. As part of the interstate agreement, the regulations regarding interstate claims shall apply to claims taken in and for Canada.

History

Source: Miss. Code Ann. §§ 71-5-115 & 71-5-117 (Rev. 2004).

20 Miss. Admin. Code Pt. 101, R. 319.00 Rule 319.00

Benefits – Deceased Claimants In order to provide for the payment of benefits in cases where the claimant has filed a valid claim and has died before receiving payment, the Agency adopts the following regulations: (A) Wholly or partially paid benefits due at the time of the claimant’s death will be paid to the duly qualified administrator or executor of the estate of the deceased claimant. If an administrator or executor is not appointed, the benefits will be paid to the claimant’s heir or heirs at law as determined by the laws of descent and distribution in the State of Mississippi, and supported by appropriate affidavit. (B) Any benefit checks that have not been cashed that were issued directly to the deceased claimant shall be returned to the Agency for cancellation before any funds shall be paid in lieu of such check. (C) Any claim for benefits due a deceased claimant by any person as herein provided must be filed with the Agency within ninety (90) days following the death of the claimant; provided, however, the Executive Director, may extend said period. (D) It is the responsibility of the person claiming payment of benefits due a deceased claimant to request payment of such benefits, and must provide an affidavit setting forth facts upon which the claim is based. (E) Payments due a deceased claimant that are made by electronic processes will only be issued to the individual requesting said benefits under the guidelines established by the banking industry.

History

Source: Miss. Code Ann. §§ 71-5-115 & 71-5-117 (Rev. 2004).

20 Miss. Admin. Code Pt. 101, R. 320.00 Seasonal Industry (A) Definitions:

(1) Seasonal industry is (a) that group of employers classified as “cotton gins” under the four-digit Industrial Classification Code based on the Standard Industrial Classification Manual. If an employer with a different classification has a cotton ginning operation, the Agency will assign such unit a sub- classification for cotton gins. (b) that group of employers who employ vendors, concessionaires, and people working at jobs providing services at professional baseball stadiums. (2) Seasonal employment is employment in a seasonal industry within the seasonal operating period, as determined by the Agency. (3) Seasonal wages are wages paid in seasonal employment as above defined. (4) Seasonal benefits are benefits based on seasonal wages as above defined. (5) Non-seasonal employment is employment for which wages paid in such employment carry no seasonal restrictions. This employment may consist of : (a) Employment in the seasonal industry for which wages are paid outside the seasonal operating period (employment in the seasonal industry and in no other part of an employer’s operations). (b) Employment in any other covered employment as defined in the Law. (6) Non-seasonal wages are wages paid in non-seasonal employment as defined above. (7) Non-seasonal benefits are benefits based on non-seasonal wages as defined above. (B) The seasonal operating period, as determined by the Department: (1) for the cotton ginning industry, shall be from September 1 through December 31 of each year. (2) for the professional baseball industry, as defined in A(1)(b), above shall be from April 1 through September 15 of each year. (C) Employer quarterly reports- Each employer in the cotton ginning industry shall keep separate accounts of wages paid to employees so that the following separate quarterly reports may be made to the Department if appropriate. (1) Wages paid in the cotton ginning industry inside the seasonal operating period.

(2) Wages paid in the cotton ginning industry outside the seasonal operating period. (3) Wages paid in any other covered employment.

(D) Professional Baseball Industry Report – Each employer in the professional baseball industry, as defined in A(1)(b) above, shall, within fourteen (14) days from the mailing date or date of electronic delivery of the Notice to Employer of Claim Filed and Request for Information (Form UI-21A) submit to the Agency information as to the type of service performed by the individual, and the period of employment, in order for the Agency to properly administer the seasonal provision of the Law.

(E) (1) Payment of benefits to Seasonal Workers. The weekly benefit amount and the maximum benefit amount of any claimant who is a seasonal worker shall be calculated in the usual manner as prescribed by the Law. Seasonal benefit rights shall be used in payment of such worker’s benefits only when the benefits accrue during weeks of unemployment within the seasonal operating period as defined above. Any week which begins within the seasonal operating period shall be deemed to be within the seasonal operating period. (2) The calculation of a benefit determination for individuals with seasonal cotton ginning wages shall include the amount of “seasonal” benefits which may be payable only for weeks of unemployment occurring within the seasonal operating period, and the amount of benefits based on wages with no seasonal restrictions, if any. Benefits with no seasonal restrictions shall be payable to cotton gin workers for a week of unemployment during the season only if their seasonal benefits have previously been exhausted. Seasonal benefits and benefits with no seasonal restrictions may be payable for weeks of unemployment occurring during the seasonal operating period. Benefits with no seasonal restrictions shall be payable to a seasonal worker for weeks of unemployment occurring outside such period, but shall be based only on wages earned in employment with no seasonal restrictions. (3) Benefits paid to a seasonal worker and a non-seasonal worker shall be charged to an employer’s experience rating in the usual manner as prescribed by Law.

History

Source: Miss. Code Ann. §§ 71-5-115 & 71-5-117 (Rev. 2004).

20 Miss. Admin. Code Pt. 101, R. 321.00 Charging and Non-Charging of Benefits

(A) Benefits paid to a claimant will be charged or non-charged as set forth in

Section 71-5-355(2) (b)(ii) the Law.

(B) An employer shall be eligible for non-charging as provided in (A) above only when they have furnished the Agency with notice regarding the separation from work or refusal to accept an offer of suitable work, whichever is applicable, in the manner and within the time required, by one of the following methods:

(1) The employer has, within ten (10) days from the mailing date or date of electronic delivery of Notice to Employer of Claim Filed and Request for Information (Form UI-21A) to submit to the Agency a written statement showing the date and detailed reason for the separation or the date and details with respect to the refusal of an offer of suitable employment from such employer, whichever is applicable, identifying the individual involved by name and Social Security account number. Failure to furnish such information within the time required will result in the employer being denied eligibility for the relief of charges as provided in the referenced section of the Law.

(2) The employer has ten (10) days from the date of the refusal of an offer of suitable employment to notify the Agency in writing of such refusal, giving the date and details with respect thereto.

(C) When an employer has furnished the Agency with notice regarding the separation from work or refusal to accept an offer of suitable work, within the time and in the manner prescribed, a decision regarding the chargeability to the employer’s experience rating record will be issued. This determination will be final unless the employer files an appeal within fourteen (14) days from the regular mailing date or electronic mailing date or notification of the decision.

The appeal will be heard in accordance with Section 71-5-519 of the Law. After affording all interested parties an opportunity for a fair hearing, a decision will be issued to affirm, modify or reverse the determination. That decision will become final unless within fourteen (14) days after the mailing or notification of such decision an appeal is filed to the Board of Review.

Any decision of the Board of Review will become final ten (10) days after the date of mailing or notification of that decision. Any party may secure judicial review in accordance with Section 71-5-531 of the Law by commencing action in the circuit court. The circuit court to which action should be pursued is that of the county in which the plaintiff resides, or the county in which the action occurred.

History

Source: Miss. Code Ann. §§ 71-5-115 & 71-5-117 (Rev. 2004).

20 Miss. Admin. Code Pt. 101, R. 322.00 Rule 322.00

Vacation and Holiday Pay The legislative definition of unemployment specifies that an individual shall be deemed "unemployed" in any week during which they perform no services, and with respect to which no wages are payable to him or her. Vacation and holiday

wages flow from services rendered prior to being laid off temporarily or released from employment, and are earned prior to such action. Vacation and holiday pay shall not be deducted from unemployment insurance benefits to which an individual is otherwise entitled.

History

Source: Miss. Code Ann. §§ 71-5-115 & 71-5-117 (Rev. 2004).

20 Miss. Admin. Code Pt. 101, R. 401.00 Rule 401.00

Reporting Earnings While Filing for Benefits For purposes of determining entitlement to benefits, an individual must report wages as defined by the Law payable to him or her in any week, regardless of whether compensation has been received.

History

Source: Miss. Code Ann. §§ 71-5-115 & 71-5-117 (Rev. 2004).

20 Miss. Admin. Code Pt. 101, R. 402.00 Rule 402.00

Criteria for Determining Overpayments (Fraud and Non- Fraud) An overpayment of benefits occurs when a person receives benefits under this chapter while any conditions for the receipt of benefits imposed by this chapter were not fulfilled in his/her case, while the claimant was disqualified from receiving benefits, or when the claimant receives benefits and is later found to be disqualified or ineligible due to any reason. Reasons for disqualification and ineligibility may include but are not limited to a re-determination or reversal by the Agency or the courts of a previous decision to award the claimant benefits or failure by the claimant to properly report his/her earnings during the week earned when filing a weekly certification.

For purposes of determining unreported earnings, the Agency will consider the claim week to be Sunday through Saturday. The Agency will not consider holiday pay, vacation pay, severance pay, bonus pay, jury duty, reserve components (week-end drill), unit training assembly (summer camp), loans, cash

advances and retroactive wages in the computation of unreported earnings overpayments.

Any person determined to have received an overpayment of benefits for any reason may be liable to the Agency for the repayment of those benefits. The Agency shall also determine whether the overpayment was received by the claimant through fraud committed by the claimant and assess appropriate penalties under such circumstances.

For the purpose of determining fraud, the Agency will consider that (1) a person received benefits, (2) at a time when he/she was ineligible, (3) by reason of a nondisclosure or misrepresentation of a material fact, (4) made by that person or another, and/or (5) had the willful intent to commit fraud or had knowledge of the omitted or misrepresented fact. Fraud may be implied or presumed from the circumstances, such as but not be limited to, failure to report earnings on weekly claims forms, or falsification of any documents. This inference may be overcome by the introduction of contrary evidence. Fraud shall include, but not be limited to the claimant’s actual falsification of any documents which will include but not be limited to certification or proof of earnings and doctor’s statements.

If the claimant does not report his earnings correctly, but does report at least fifty percent (50%) of his earnings for a particular week, the week would be considered non-fraudulent with a non-fraud overpayment established.

History

Source: Miss. Code Ann. §§ 71-5-115 & 71-5-117 (Rev. 2004).

20 Miss. Admin. Code Pt. 101, R. 403.00 Rule 403.00

Collection of Overpayments Pursuant to the authority granted to the Agency by Section 71-5-19(4) of the Law, the Agency shall have the authority or discretion to pursue repayment and collection of overpayments that occurred due to any reason, including overpayments that result from a re-determination by the Agency, or that occur as the result of an appeal within the Agency or to the courts, and irrespective of whether said overpayment resulted from fraud, non-disclosure, or misrepresentation by the claimant. The Agency shall have the authority to pursue collection of all overpayments, including overpayments that result from a re- determination or reversal from an appeal, by the methods or manner as provided in Sections 71-5-363 through 71-5-383 of the Law, for the collection of past-due contributions, also authorized by Section 71-5-19 of the Law. Methods of collection shall include, but not be limited to, cash repayment, offset of future benefits, filing liens, warrants, or suit, garnishment, and interception of state income tax refunds.

Any such judgment, lien or warrant against a person for collection of an overpayment shall be in the form of a seven (7) year renewable lien. Unless action is brought thereon prior to expiration of the lien, the Agency must refile the notice of the lien prior to its expiration at the end of seven (7) years. There shall be no limit upon the number of times the Agency may refile notices of liens for

collection of overpayments. The Agency will participate in the Interstate Reciprocal Overpayment Recovery Arrangement, which will include withholding benefits in order to assist other states in collecting overpayments.

Overpayments must be liquidated in accordance with specific program restrictions before future benefits can be paid to the individual.

History

Source: Miss. Code Ann. §§ 71-5-115 & 71-5-117 (Rev. 2004).

20 Miss. Admin. Code Pt. 101, R. 404.00 Disqualification Period Assessed For Fraud

The Agency has the authority to assess disqualifications for a period up to 52 weeks, according to the circumstances of each case. Under this authority the Agency shall impose the following penalties under the stated conditions:

For the first fraudulent overpayment received by a claimant a six week disqualification is established for each week up to a total of four such weeks. For five or more fraudulent weeks a fifty-two (52) week disqualification is assessed.
For the second or greater fraudulent overpayment received by a claimant within three years of the establishment date of a previous fraudulent overpayment, a twelve week disqualification is established for each week up to a total of four such weeks. For five or more fraudulent weeks a fifty-two (52) week disqualification is assessed.

The disqualification period shall start no later than the week during which the initial determination of such fraudulent overpayment is made.

History

Source: Miss. Code Ann. §§ 71-5-115 & 71-5-117 (Rev. 2004).

20 Miss. Admin. Code Pt. 101, R. 405.00 Rule 405.00

Interest Accrual Interest accrues at the rate of one per centum (1%) per month on the unpaid principal balance beginning with the month following the month in which the overpayment is established.

History

Source: Miss. Code Ann. §§ 71-5-115 & 71-5-117 (Rev. 2004).

20 Miss. Admin. Code Pt. 101, R. 406.00 Rule 406.00

Prosecution of Fraudulent Overpayments The Agency has the authority to prosecute overpayments due to fraud as defined in Subsection 402.00 above and Section 71-5-19(4) of the Law.

History

Source: Miss. Code Ann. §§ 71-5-115 & 71-5-117 (Rev. 2004).

Chapter 600 CONTRIBUTIONS

20 Miss. Admin. Code Pt. 101, R. 600.00 Rule 600.00

First Contribution Payment The first contribution payment of an employer who is newly liable for contribution in any year will become due and be payable on or before the last day of the month immediately following the calendar quarter the individual or employing unit became a liable employer.

20 Miss. Admin. Code Pt. 101, R. 600.01 Rule 600.01

Payment of Contribution (A) Each quarterly contribution payment shall be based upon wages paid for employment in all pay periods (weekly, biweekly, monthly, semimonthly) ending within the quarter. (B) The first contribution payment of an employer who becomes newly liable for contributions in any year because of employment performed for such employer within such a year shall include contributions with respect to all wages paid for employment from the first day of the calendar year. Such wages shall be reported in the calendar quarter in which the wages were paid and contributions shall be paid for the quarter in which the wages were paid. (C) The first contribution payment of an employer who becomes newly liable for contributions by any of the three following methods is due for the quarter in which the wages were paid. Employers establish liability by: (1) Acquiring the business of an employer; (2) Employer and/or employer’s predecessor(s) who employed one or more workers, acquiring the business of an employing unit whose employment record together with his or her own employment record totals one or more employees on one or more days in each of twenty (20) weeks of the current or last calendar year, regardless of whether the workers were the same person or different in each of the different weeks; and/or (3) Affiliation with one or more other employing units whose employment record together with his or her employment record totals one or more employees on one or more days in each of twenty (20) weeks of the current or last calendar year. (D) Contributions shall be due for all wages paid that are subject to this chapter in the calendar year if contributions are due on any part of the wages paid in the calendar year. (E) With respect to employment, the measure of the contribution is the total amount of wages paid by an employer during each calendar quarter.

History

Source: Miss. Code Ann. §§ 71-5-115 & 71-5-117 (Rev. 2004).

20 Miss. Admin. Code Pt. 101, R. 600.02 Transmittal of Contributions Payments

Payment of contributions sent through the United States mail shall be deemed to have been made as of the date shown by the postmark thereon. All other payments of contributions shall be considered to have been made on date received by the Agency.

History

Source: Miss. Code Ann. §§ 71-5-115 & 71-5-117 (Rev. 2004).

20 Miss. Admin. Code Pt. 101, R. 600.03 Rule 600.03

Overpayment of Contributions Overpayment of contributions by an employer for one period may be credited on subsequent contributions due.

History

Source: Miss. Code Ann. §§ 71-5-115 & 71-5-117 (Rev. 2004).

20 Miss. Admin. Code Pt. 101, R. 601.00 Rule 601.00

Wages Defined (A) Definition “Wages” means all remuneration for personal services, including commissions and bonuses, and the value of all remuneration in any medium other than cash. The name by which such remuneration is designated is immaterial. Thus, salaries, commissions on sales or on insurance premiums, fees, and bonuses are wages within the meaning of the Law if they are, in fact, remuneration or compensation for services not excluded by the Law. The basis upon which the remuneration is payable or paid, the amount of remuneration, and the time of payment are immaterial in determining whether the remuneration constitutes “wages”. Thus it may be paid or payable on the basis of piecework or a percentage of profits; and it may be paid or payable hourly, daily, weekly, monthly, or annually. Facilities or privileges (such as entertainment, cafeterias, restaurants, medical services, so-called “courtesy” discounts on purchases), furnished or offered by an employer to his employees, generally are not considered as remuneration for services if such facilities or privileges are offered or furnished by the employer merely as a convenience to the employee or as a means of promoting the health, good will, contentment, or efficiency of his employees.

(B) Definition of Wages for Tax Purposes Wages paid in any calendar quarter shall include wages actually or constructively paid for all pay periods ending within the quarter and wages paid during the quarter for services performed in prior quarters or prior years. Wages constructively paid means payments credited to the account of, or set apart for, the wage earner so that they may be drawn upon by him or her at any time although not then actually reduced to possession.

20 Miss. Admin. Code Pt. 101, R. 601.01 Rule 601.01

Exclusions Certain exclusions apply as directed by Section 71-5-11 of the Law, however, the plan or system established by an employer need not provide for payments on account of all of the specified items, but such plan or system may provide for any one or more of such items.

It is immaterial for purposes of this exclusion whether the amount or possibility of such benefit payments is taken into consideration in fixing the amount of an employee’s remuneration or whether such payments are required, expressly or implied, by the contract of service. 601.02 Items Included The total wages paid by an employer to his or her employees with respect to employment during any calendar year, or any pay period thereof, shall include items actually or constructively paid during that calendar year, or any part thereof. (A) Items actually paid shall include: (1) Cash; and (2) The fair market value, at the time of payment, of all items other than money. Wages are constructively paid when they are credited to the account of or set apart for an employee so that they may be drawn upon by him or her at any time although not then actually reduced to possession. (B) Items actually or constructively paid shall include: (1) Cash; and (2) The fair value, at the time of actual or constructive payment, or all items other than money. (3) Vacation allowances - Payment to an employee’s so-called vacation allowances constitute wages. (4) Traveling and other expenses - Amounts paid to traveling salespersons or other employees as allowances or reimbursements for traveling or other expenses incurred in the business of the employer constitute wages only to the extent of the excess of such amounts over such expenses actually incurred and accounted for by the employee. (5) Premium on life insurance - Generally, premiums paid by an employer on a policy of life insurance covering the life of an employee constitute wages if the employer is not a beneficiary under the policy. However, premiums paid by an employer on policies of group life insurance covering the lives of his or her employees are not wages, if the employee has no option to take the amount of premiums instead of accepting the insurance and has no equity in the policy (such as the right of assignment or the right to surrender value on termination of his employment). (6) Deductions - Amounts deducted from the remuneration of an employee by an employer constitute wages paid to the employee at the time of such deduction. It is immaterial that the Law, or any Act of Congress or the law of any state, requires or permits such

deduction and the payment of the amount thereof to the United States, a state, or any political subdivision thereof. (7) Payments by employers into stock bonus or profit-sharing funds - Payments made by an employer into a stock bonus or profit- sharing fund constitute wages if such payments inure to the exclusive benefit of the employee and may be withdrawn by the employee at any time or upon resignation or dismissal, or if the contract of employment requires such payment as part of the compensation. Whether or not under other circumstances such payments constitute wages depends upon the particular facts of each case. (8) Hiring of individual with his or her equipment - Only remuneration employment is the basis of contributions. Equipment is only rented and its rental value should not be included in the basis for contributions, provided it is accounted for separately. Contributions should be based on the remuneration for services only. In the case of hiring an individual and his or her equipment, such as a truck driver who owns his or her truck, the employer may differentiate between the fair value of the wages and the rental value of the equipment and pay contributions only on the wages. (9) Pensioned employees-Retirement Pay - Contributions are based only on wages of employees arising out of the performance of service. Employees who have been pensioned or retired by an employer and who perform no service for such former employer are pensioned or retired employees and the remuneration or compensations received by them as pension or retirement pay is not considered wages and should not be included in the payroll upon which contributions are based. However, if a pensioned or retired employee receives any compensation or remuneration distinct from such pensions or retirement pay for any employment, whether occasional, temporary or permanent, such pensioned or retired employee is covered by the Law and his or her earnings must be included in the payroll upon which contributions are based. C. For all political subdivisions that elect to make contributions under the provisions of either Section 71-5-559 (2)(j), or Section 71-5-357 (b)(iv), the Law provides that the rates specified in those sections, i.e., two percent (2%) and five tenths percent (.5%) respectively, shall be applied to the first seven thousand dollars ($7,000) of remuneration paid to each employee in the calendar year, from and after January 1, 1983. 601.03 Private Unemployment Benefit Plans Employees covered by private unemployment benefit plans are not thereby excluded from the requirement to be reported and their wages taxed as all other employees described in the Law.

20 Miss. Admin. Code Pt. 101, R. 601.04 Rule 601.04

Reduction of Commissions, Sales Cancelled in Later Years Commission on sales made in one calendar year constitutes wages with respect to employment during the calendar year. When a sale made in one calendar year is cancelled in a subsequent calendar year and the commission is deducted from the earnings of the salesperson during the calendar year in which the sale is cancelled, such a reduction in commission is a reduction of the wages of the salesperson for the calendar year in which the services were performed and not for the year in which the sale is cancelled. 601.05 Bonuses in the Form of Securities Bonuses in the form of securities are wages and contributions are payable on the fair market value of such securities at the time of transfer. 601.06 Sales Contest Prize Awards The cash or fair market value of prizes awarded to salespersons as winners of contests conducted by their employer for the purpose of stimulating the sales of certain products constitute wages upon which contributions are required, and shall be included in the total amount of wages paid, as additional compensation or remuneration, in computing contribution liability. 601.07 Gifts Gifts from employers to employees, such as Christmas gifts, directly or indirectly based upon or related to services rendered, constitute wages upon which contributions are payable. 601.08 Gift to Spouse of Deceased Employee An amount paid to the widow or widower of a deceased employee in excess of the compensation earned by the decedent in the course of his or her employment and for which the widow or widower renders no services does not constitute wages. 601.09 Spouse Employed by Corporation Wholly or Principally Owned by Other Spouse Services performed by the spouse of the sole or principal stockholder of a corporation are not exempt since the corporation and its stockholders are entirely separate and distinct legal entities. 601.10 Spouse Employed by Partnership in Which the Other Spouse Is Partner Although the Law excludes from its operation services performed by a spouse in the employ of the other spouse, the exclusion does not apply to the services performed by a spouse of a member of a partnership in the employ of such partnership, since the partnership is a legal entity separate and distinct from the individuals who comprise it. 601.11 Trustees in Bankruptcy-Compensation Paid To Compensation paid to trustees in bankruptcy is not subject to the contribution liability imposed under the Law. 601.12 Payments Made to Labor Union Representatives for Lost Wages

Payments made to labor union representatives for lost wages will not be considered wages for unemployment insurance purposes provided the individual is not otherwise employed by the labor union. 601.13 “Idle Time” Payments under Minimum Number of Hours Guarantee Payments made to an employee for “idle time” by a company which guarantees to its employees a minimum number of hours of employment per week and makes payments to them for “idle time” when they do not render services for the minimum number of hours, constitutes wages with respect to employment and the total of such remuneration should be included in the computation of wages for the purpose of determining the amount of contributions. 601.14 Tips Tips accounted for by an employee to his or her employer are wages on which contributions are payable. 601.15 Remuneration Covering Salary and Expenses Where an employee, such as a salesperson, is paid an amount to cover salary and expenses incurred in the employer’s business, the amount constituting wages subject to contribution liability is the total amount paid minus the expenses actually incurred by the salesperson in the employer’s business and is accounted for as such by him or her. It is, therefore, necessary for the salesperson to maintain such records as will enable accountability to the employer for the amount of expenses actually incurred, and the employer must keep such records as will show the portions of the total amount paid to the salesperson which represent, respectively, expenses and remuneration for services. 601.16 Training Courses Expenses for employees’ training courses, paid by the employer, do not constitute wages on which contributions are payable. 601.17 Use of Employer’s Car by Employee Where an employee keeps a car belonging to his or her employer and at times uses same for his or her own personal use, such use of the car does not constitute wages or remuneration. 601.18 Payments to Employees Absent on Account of Sickness Where an employee is absent on account of sickness and he or she is kept on the payroll and wages are paid to him or her, such wages must be reported and contributions paid thereon. 601.19 Cash Value of Certain Remunerations If board, lodging, or any other payment in kind, considered as payment for services performed by an employee, is in addition to (rather than a deduction from) monetary wages, or wholly comprises an employee’s wages, the Agency may determine the cash value of such board and lodging in individual cases for the purpose of computing contributions due under the Law. The cash value for

such board and lodging furnished an employee as agreed upon shall be deemed the value of such board and lodging.

History

Source: Miss. Code Ann. §§ 71-5-115 & 71-5-117 (Rev. 2004).

20 Miss. Admin. Code Pt. 101, R. 602.00 Rule 602.00

Employer (A) Proprietors A proprietor of a business is not considered an employee even though a salary may be paid for services performed. (B) Partners Partners are not considered employees of the partnership, and the income of partners from the business whether recorded as salary or drawings, is considered a distribution of profits, and not wages. (C) Officers of Corporations Corporate officers, who perform services for wages or under any contract of hire, written or oral, expressed or implied, are employees. (D) Directors of Corporations A director of a corporation, who performs no service for the corporation except as director in the usual and ordinary sense of the term, is not an employee and the compensation paid as a director is not subject to contributions. A director, who performs services for the corporation other than as a director, is an employee, and the compensation paid him therefore is subject to contributions. 602.01 Demonstrators A demonstrator, who is placed by a manufacturer in department and specialty stores to aid in the sale of the specialized products of such a manufacturer, and who is engaged by the manufacturer, who are paid directly or indirectly by the manufacturer, and who work under the direction which may be delegated to the retailer, is an employee of the manufacturer. If the retailer, not acting as an agent for the manufacturer, engaged a demonstrator and the demonstrator works under the direction of the retailer and receives the salary directly from the retailer, the retailer is the employer. If the wages are paid in part by the manufacturer and in part by the retailer, the demonstrator is an employee of both manufacturer and retailer and each is required to pay contributions on that part of the salary that he pays. 602.02 Employers Disposing of Business Assets Thereof, Ceasing Business, Etc. Every employer who shall sell, convey, or otherwise dispose of his or her business or any part of the assets of the business, or who shall cease business for any reason, whether voluntary by being in bankruptcy, or otherwise, shall no less than thirty (30) days prior to such sale or conveyance of business, report such fact in writing to the Agency, stating the name, address and telephone number of the person, firm or corporation, or other entity to whom such business or all of any part of the assets thereof shall have been conveyed. In cases of bankruptcy,

receivership, or similar situations, such employer shall report the name address and telephone number of the trustee, receiver, or other official placed in charge of the business. 602.03 For Profit Corporation Owned by Non-Profit Charitable Organization Services performed in the employ of a corporation operated as a business enterprise but wholly owned by a non-profit charitable organization are not exempt under the Law. Such organizations are separate legal entities and must be considered separately. 602.04 Payroll Records of Predecessor “Employer” Modified Rate of Contribution for Successor In determining “modified” rates of contributions, under Section 71-5-355 of the Law, for an employer who succeeds, or has succeeded, or acquires, or has acquired the organization, trade, separate establishment ( provided separate payroll records have been kept and maintained for such separate establishment by the predecessor and are clearly identifiable and segregable), or business, or substantially all the assets thereof, or another, the payroll records of the predecessor may be used only if such predecessor was an “employer” as defined and subject to the Law at the time of such acquisition. The term “separate establishment,” as used herein, means a distinct and separate portion of the business. 602.05 Successors to Reimbursable Employer Who Become Tax Paying (contributory) Employers by Requirements of the Law When a successor employer becomes a contributory employer (pursuant to requirements defined by the Law) by acquiring the business of a reimbursing employer, then such successor shall be considered a newly subject employer, within the meaning of Section 71-5-353 of the Law. 602.06 Reimbursable Employers Who Elect to Become Tax Paying (Contributory) When an employer elects to change from reimbursing status to contributory status, the employer shall be considered a newly subject employer, within the meaning of Section 71-5-353 of the Law. 602.07 Predecessor Employers Who Resume Employment In any case in which the account of an employer is terminated (inactivated) by the Agency because the employer sold the business and the experience was transferred to the successor, and the predecessor resumes employment, he or she shall be considered a newly subject employer, within the meaning of Section 71- 3-353 of the Law. 602.08 Status by Voluntary Election An employing unit not otherwise subject to the Law that elects voluntarily to become subject thereto must furnish the Agency detailed data sufficient in the opinion of the Agency to warrant approval of such election.

History

Source: Miss. Code Ann. §§ 71-5-115 & 71-5-117 (Rev. 2004).

20 Miss. Admin. Code Pt. 101, R. 603.00 Rule 603.00

Employment (A) Independent Contractors The Law provides that the relationship of employer and employee shall be determined in accordance with the principles of the common law governing the relation of master and servant. Generally, the relationship exists when the person for whom services are performed has the right to control and direct the individual who performs the services, not only as to the result to be accomplished by the work but also as to the details and means by which the result is accomplished. That is, an employee is subject to the will and control of the employer not only as to what shall be done, but how it shall be done. In this connection, it is not necessary that the employer actually direct or control the manner in which the services are performed; it is sufficient if he or she has the right to do so. The right to discharge is also an important factor indicating that the person possessing that right is an employer Other factors characteristic of an employer are the furnishing of tools and the furnishing of a place to work to the individual who performs the service. In general, if an individual is subject to the control or direction of another merely as to the result to be accomplished by the work and not as to the means and methods for accomplishing the result, he or she is an independent contractor, not an employee. If the relationship of employer and employees exists, the designation or description of the relationship by the parties as anything other than that of employer and employee is immaterial. Thus, if two (2) individuals in fact stand in relation of employer and employee to each other, it is of no consequence that the employee is designated as a partner, co-adventurer, agent, or independent contractor. The measurement, method, or designation of compensation is also immaterial, if the relationship of employer and employee in fact exists. Generally, physicians, lawyers, dentists, veterinarians, contractors, sub- contractors, public stenographers, auctioneers, and others who follow an independent trade, business, or profession, in which they offer their services to the public, are independent contractors and not employees. Whether or not persons performing services, directly or indirectly, for an employing unit are employees depends upon the particular facts in each case. No single test is conclusive and every employing unit claiming the existence of a relationship other than that of employer-employee shall make application to the Agency for determination of its status. They shall furnish to the Agency a full and complete statement of all facts concerning its relationship with the person claimed to be an independent contractor, together with a copy of the contract existing between them. All persons performing services for any employing unit shall be deemed employees unless and until this rule shall have been complied with and their status shall have been otherwise determined by the Agency after a decision has been made by the Agency relative to the employer-employee relationship, and the business has been notified by mail or electronically. The business has the right within ten (10) days from the transmittal date of this decision to protest the

decision and request a hearing before the Agency, as provided in Section 71-5- 355(2)(b)(ix) of the Law. (B) Employed Individuals The words “employ”, “employer”, and “employee”, as used herein, are to be taken in their ordinary meaning. An employer, however, may be an individual, a corporation, partnership, a limited liability company, trust, estate, association, joint-stock company, insurance company, or corporation, or other recognized business organization, whether domestic or foreign, syndicate group, or entity. An employer may be a person acting in a fiduciary capacity or on behalf of another, such as a guardian, committee, trustee, executor or administrator, trustees in bankruptcy, receiver, assignee, for the benefit of creditors, or conservator. An individual is in the employment or employ of another within the meaning of the Law if he performs a service, including service in interstate commerce, for such other, for wages or under any contract of hire, written or oral, expressed, or implied. The relationship between the individual who performs such service and the person for whom such service is rendered must be the legal relationship of employer and employee. The Law makes no distinction between classes or grades of employees. Thus, superintendents, managers, and other superior employees are employees within the meaning of the Law.

Whether the relationship of employer and employee exists, will in questionable cases be determined upon examination of the particular facts of each case. 603.01 Service in Usual Trade or Business An employing unit which contracts with or has under it any contractor or sub- contractor for any employment which it claims is not part of its usual trade, occupation, profession, or business shall submit to the Agency a complete, detailed written statement of facts in support of such claim. No such claim shall be recognized until and unless the Agency is satisfied of its validity and correctness. 603.02 Services Excluded from the Definition of Employment (Generally) (A) To constitute “employment” within the meaning of the Law the services performed by the employee must be performed, in whole or in part, primarily or incidentally, within the State of Mississippi; or if performed elsewhere, must be incidental to service in the United States for a Mississippi based employer. To the extent that an employee performs services wholly or outside of the State of Mississippi for the person who employs him or her, he or she is not in “employment” within the meaning of the Law unless such services are incidental to service in this state, or unless such services are performed outside the United States for a Mississippi based employer. Furthermore, the employee’s remuneration for services that he or she performs wholly outside the State of Mississippi, and that are in no way

incidental to services in this state, is excluded from the computation of wages upon which his or her employer’s contribution is based, except that wages paid by a Mississippi based employer for services performed outside the United States must be included in the computation of wages upon which the employer’s computation is based. However, if any services are performed by the employee within the State of Mississippi, such services, unless specifically excluded by the Law, constitute “employment.” In such cases the employee is counted for the purpose for determining whether the person who employs him or her is an “employer,” within the meaning of the Law and his wages on account of such employment are included in the computation of wages for the purpose of determining the amount of the employer’s contribution. The place where the contract for services is entered into and the citizenship or residence of the employee or of the person who employs him or her is immaterial. Thus, the employee and the person who employs him or her may be citizens and residents of a foreign country or a foreign state and the contract for the services may be entered into in a foreign country or foreign state, and yet, if the employee under such contract actually performs services within the State of Mississippi, there is an “employment” within the meaning of the Law, and the person who has employed such individual may be an “employer” within the meaning of the Law. (B) Even though the services of the employee are performed within the State of Mississippi, if they are in a class which is excluded by the Law, they are excluded for the following purposes: (1) In determining whether a person employs a sufficient number of individuals to be an employer subject to contribution; or (2) In computing the employer’s total wages with respect to employment during the calendar year. The exclusion is attached to the services performed by the employee and not to the employee as an individual; and the exclusion applies only for the period during which the individual is rendering services in an excluded class.

20 Miss. Admin. Code Pt. 101, R. 603.03 Rule 603.03

Officers and Members of Crews The expression “navigable waters within, or within and without the United States” means such waters are navigable in fact and which by themselves or in connection with other waters form a continuous channel for commerce with foreign countries or among the states. The word “vessel: includes every description of watercraft or other contrivance, used as a means of transportation on water. It does not include any type of aircraft.

The expression “officers and members of the crew” includes the master or officer in charge of the vessel, however designated, and every individual subject to his or her authority serving on board and contributing in any way to the operation and welfare of the vessel. The expression extends, for example, to services rendered by the master, mates, pilots, pursers, surgeons, stewards, engineers, firemen, cooks, clerks, carpenters, deck hands, porters, and chambermaids and by seal hunters and fishermen on sealing and fishing vessels. 603.04 Family Services Under Section 71-5-11 J (15) (d) of the Law, certain services are excluded because of the existence of family relationship between the employee and the person for whom he or she performs the services. The exclusions are as follows: (A) services performed by a husband for his wife, or by a wife for her husband; (B) services performed by a father or mother for a son or daughter, or for a partnership composed of sons and/or daughters only; or (C) services performed by a son or daughter under twenty-one (21) years of age for the father or mother, or for a partnership composed of the father and mother only. (D) The term “child” shall mean and include adopted or stepchild. Under (A) and (B) above, the exclusion is conditioned solely upon the relationship of the employer to the employee. Under (C), in addition to the relationship of parent and child, there is a further requirement that the child shall be under the age of twenty-one (21) and the exclusion continues only during the time that such child is under the age of twenty-one (21). The exclusions do not extend to services performed by an employee for a corporation or other entity except such family partnerships as are set forth in (B) and (C) above. 603.05 Religious, Charitable, Scientific, Literary, and Educational Exemption Any organization claiming an exemption under Section 71-5-11 J (4) of the Law must provide a copy of Internal Revenue Service documents that show exemption under Section 501 (c) (3) of the Internal Revenue Code. 603.06 Aliens, Non-Residents and Minors Aliens, non-residents, and minors are employees if they are performing any service for an employer within the State of Mississippi and come within the definition of employee and employment. 603.07 Newspaper and Magazine Distributor A newspaper distributor who owns his own truck, hires or discharges his or her own employees or helpers, distributes newspapers or magazines in his own territory, and keeps track of his or her own records as to sales and collections, with all sales to such distributor by the publisher and all magazines or newspapers

returned within certain limited period being credited to the distributor, who receives no salary, wages or other remuneration from the publisher, no record being kept on where the distributor disposes of the magazines or newspapers which are taken by him or her, is not an employee of the publisher for the reason that the distributor’s remuneration for his or her services or activities in distribution of magazines or newspapers is derived solely from the resale of magazines or newspapers to customers. 603.08 Temporary, Casual and Training Period Workers The length of employment of an individual employee, however short, and the amount of remuneration paid to him or her, however small, does not affect the employer’s liability to pay contributions. Contributions are required to be paid on wages of temporary employees as well as on wages of permanent employees. The term “casual labor” exempted under Section 71-5-11 J (15) (c) of the Law includes labor, which is occasional, incidental, and irregular. The expression “not in the usual course of the employing unit’s trade or business” includes labor that does not promote or advance the trade or business of the employing unit. 603.09 Pieceworkers Persons who are paid on the basis of the amount of work accomplished are employees, especially where they are subject to the direction or control of the employer. 603.10 Non-resident Employers Non-resident employers may be subject to Mississippi Law and the employer’s citizenship or residence is immaterial. 603.11 Services Performed for the United States Service performed in the employ of the United States or of an instrumentality wholly owned by the United States is excluded. The exemption of federal instrumentalities is restricted to those instrumentalities: (A) wholly owned by the United States; and/or (B) exempt from the Law by virtue of some federal statutory provision. 603.12 Dredges Services are exempt that are performed on dredges used for navigation and transportation in carrying on the work of deepening and removing obstructions from channels and harbors which are navigable waters of the United States are exempt. 603.13 Concessionaires on Vessels on Navigable Water of the United States Services performed in the employ of concessionaires on vessels on the navigable waters of the United States are not exempt under the Law. 603.14 Book Publishing Establishment Owned and Operated by Religious Organizations

Services performed in the employ of a book publishing establishment owned by a church or convention or association of churches, or that is owned by an organization that is operated primarily for religious purposes, or that is operated, supervised, controlled, or principally supported by a church or convention or association of churches primarily for religious purposes, no part of the net earnings of which inures to the benefit of any private shareholder or individual, are exempt from the Law. 603.15 Privately Owned Hospitals Services performed in the employ of privately owned hospitals are not exempt under the Law. If they are organized and operated exclusively for charitable purposes and no part of the net earnings inures to the benefit of any private shareholder or individual, they come under the “four (4) or more in twenty (20) weeks” provision of Section 7-1-5-11 J (4) of the Law. 603.16 Privately Owned Colleges Services performed in the employ of privately owned institutions of higher learning are not exempt, but if the institution is a non-profit organization it is not a covered employer unless it employs four (4) or more employees for some day in each of twenty (20) different weeks in the current or preceding calendar year. 603.17 Newspaper Correspondents Newspaper correspondents who contribute items subject to acceptance for publication by the newspaper at a stipulated remuneration per item or per inch for news items accepted and published, but who are not employed full time and whose time and effort are not subject to the control of the newspaper, are not employees of the newspaper under the Law. 603.18 Newspaper Carrier Section 71-5-11 J (15) (m) of the Law, exempts services performed by a person under the age of eighteen (18) in making street sales of newspapers and in making house-to-house delivery of newspapers or shopping news, including handbills and other similar types of advertising material. This exemption does not apply to the handling of newspapers and advertising material prior to the time they are turned over for subsequent delivery or distribution. 603.19 Traveling Salesperson The Law covers individuals performing services for another as salespersons and remunerated on a commission basis and contributions are required on their commissions. Section 71-5-11 J (2) of the Law specifically covers certain agent- drivers and commission-drivers and certain traveling or city salespersons. 603.20 Agents of Magazine Publishing and Distributing Companies Salespersons and collectors for publishing companies engaged in selling magazines and other publications of such company and collecting for same on a commission basis are employees of the company. 603.21 Officers of Parent Corporation Serving Subsidiary Corporation

Officers of a parent corporation serving as officers of a subsidiary corporation, whether they receive remuneration as such or not, are to be included and counted as employees for the purpose of determining whether such subsidiary corporation employs a sufficient number of employees to be subject to the payment of contributions. 603.22 Voluntary Coverage of Exempted Employments An employer may, under certain circumstances, waive his or her exemption and voluntarily become subject to the Law, thereby covering and entitling to benefits his or her employees who would otherwise be exempt. 603.23 Beneficiaries Employed by Administrator Beneficiaries of an estate employed by the administrator of the estate in the operation of the business previously conducted by the decedent are employees of the estate. 603.24 Trustees and Estate-Fiduciaries, Receivers, Trustee, Trustees in Bankruptcy, Administrators of Estates, Guardians and Liquidators of Banks Trusts or estates managed and conducted by a fiduciary, such as a receiver, trustee, trustee in bankruptcy, administrator of an estate, guardian, or liquidator of a bank, are held generally to the employer of persons employed to render and rendering services in connection with the trust, estate, or bank. This construction is applicable not only to strict trusts but also to corporations and estates whose affairs are being administered or liquidated by trustees in bankruptcy and state and federal estates should be filed by the fiduciary. The fiduciary, whether receiver, trustee, trustee in bankruptcy, administrator of an estate, guardian, or liquidator of a bank, is not himself or herself considered an employee of the trust or estate. 603.25 Banks Acting as Trustee, Receiver, Administrator, or Guardian Where a bank acts in the capacity of trustee, receiver, administrator, or guardian and employs persons to render services for the corporation in receivership or the estate being administered, paying such persons out of the funds of such trust or estate, the services performed by such persons are not exempt. The trust, company in receivership, or estate, as the case may be, is the employer. Returns and reports must be made in the name of the trust, company in receivership, or estate, by the bank in its fiduciary capacity. 603.26 Real Estate Agents Managing Real Estate for Owner Where a real estate agent or company manages improved real estate for the owner thereof under an agency contract and in accordance with such contract and as agent of the owner, employs, supervises, directs, controls, and discharges building managers, janitors, maids, and other help, but is not responsible for the payment of their wages except from the funds of the owner in its possession that are deposited in a special account un-comingled with the company’s fund, the owner of the real estate, and not the real estate agent or company, who is an independent person, is the employer of such individuals.

20 Miss. Admin. Code Pt. 101, R. 603.27 Rule 603.27

Self-Employed Fishermen Certain fishermen who work on a fishing boat are considered self-employed. A fisherman is considered self-employed if he meets all of the following: 1. The amount received is based on a share of the catch or a share of the proceeds from the sale of the catch; 2. The share received depends on the amount of the catch: 3. He receives his share from a boat (or from each boat in the case of a fishing operation involving more than one boat) with an operating crew that is normally made up of fewer than ten (10) individuals. This requirement is considered to be met if the average number of crew members on the trips the boat made during the last four (4) calendar quarters was less than ten (10); 4. Any money received other than for a share of the catch or a share of the proceeds from the sale of the catch is less than one hundred dollars ($100.00) per trip, paid only if there is some minimum catch and paid solely for additional duties (such as services performed as mate, engineer, or cook).

History

Source: Miss. Code Ann. §§ 71-5-115 & 71-5-117 (Rev. 2004).

20 Miss. Admin. Code Pt. 101, R. 604.00 Rule 604.00

Records (A) Each employing unit shall keep a true, accurate and complete record which shall show: (1) all disbursements by items; (2) the amount of each disbursement; (3) to whom each disbursement is made; (4) for what each disbursement is made; and (5) the number of employees on that day in each week in which it employed the highest number. (B) For each individual worker and each pay period the records shall show: (1) employee’s Social Security account number; (2) employee’s name; (3) employee’s place of employment within the state; (4) period covered by each payment; (5) number of hours worked for each pay period; (6) employee’s wages for employment under this act, showing separately (a) cash wages and

(b) the cash value of any other remuneration; (7) any special payments for services other than those rendered exclusively in a given quarter such as annual bonuses, gifts, prizes, etc., showing separately (a) cash payments and (b) any other remuneration and the nature of said payment; and (8) number of hours worked and wages payable in each week (except for workers paid on a salary or fixed stipend). 604.01 Reporting (A) Each employer shall report to the Agency at the time of paying each contribution upon a form or any type of media, and in such a format as prescribed by the Agency, all information concerning the number of employees, total wages paid and total other remuneration paid, if any, for employment for each pay period covered by the contribution, together with such other information as may be prescribed on the report forms or requested by the Agency. He or she shall also furnish quarterly, when and as directed and upon such forms or format as the Agency may prescribe, a report showing for each of his employees during the quarter: (1) Social Security Account Number; (2) employee name; (3) wages paid for employment; (4) amount of other compensation paid for employment, during the quarter; and (5) such other information as may be prescribed on the report forms or requested by the Agency.

20 Miss. Admin. Code Pt. 101, R. 604.02 Rule 604.02

Reports of Subsidiary Employing Units Any employing unit that owns or controls another separate employing unit within this State may, with the approval of the Agency, designate such separate employing unit as its agent or attorney for the purpose of keeping records and making reports or contributions with respect to employment performed for such separate employing unit. Such designation, however, shall not subrogate the primary liability of the controlling employing unit.

History

Source: Miss. Code Ann. §§ 71-5-115 & 71-5-117 (Rev. 2004).

20 Miss. Admin. Code Pt. 101, R. 605.00 Rule 605.00

Determining the Number of Employees One or more individuals must be employed on any days within the weeks used to calculate the number of employees. The days used to calculate the number of employees does not need to be consecutive. It is not necessary that the individuals so employed be the same individuals; they may be different

individuals on each such calendar day. It is also not necessary that the one or more individuals be employed at the same moment of time or for any particular length of time or on any particular basis of compensation. It is sufficient that one or more individuals be employed during the twenty-four (24) hours of a calendar day, regardless of the period of service during that day or the basis of compensation.

In determining whether a person employs a sufficient number of individuals to be an employer subject to the contribution, no individual is counted unless he is engaged in the performance, in whole or in part, primarily, or incidentally, within the State of Mississippi, of services not excluded by Section 71-5-11 (J) of the Law; or is engaged in the performance elsewhere of services which are incidental to such services in this state, and which are not excluded by Section 71-5-11 (J). Any individuals who perform services outside the United States for a Mississippi based employer are counted.

History

Source: Miss. Code Ann. §§ 71-5-115 & 71-5-117 (Rev. 2004).

20 Miss. Admin. Code Pt. 101, R. 606.00 Rule 606.00

Computation of Employer Tax Rates All components of the general experience rate and the employers individual experience rate involving the accumulation of data shall be computed for each rate year independent of previous computations. The Agency will utilize the Cost Rate Criterion (CRC) computations provided by the Unemployment Insurance Service of the U.S. Department of Labor Employment and Training Administration for each period, ending with the CRC computation for December 2001. Computations of CRC for periods subsequent to December 2001 will be made by the Agency from data accumulated through the Agency’s reporting processes. Under no circumstances will the Agency computations specified in this regulation in any manner change or affect the general experience rating of any period prior to the computation for the 2004 calendar year. This regulation will be effective with the computation of the 2004 annual rates and for all subsequent years.

History

Source: Miss. Code Ann. §§ 71-5-115 & 71-5-117 (Rev. 2004).

20 Miss. Admin. Code Pt. 101, R. 607.00 Rule 607.00

Political Subdivision Surety Bond Reimbursing Political Subdivisions may execute a Surety Bond in lieu of establishing a revolving fund as provided in Section 71-5-3559(2)(f) of the Law. The bond shall be executed annually, and shall be for less than two percent (2%) of the covered wages paid during the next preceding year. This bond shall be submitted to the Agency for approval. Failure to submit an approved renewal bond in the allotted time will automatically place the political subdivision under the revolving fund requirement of the Law. Any Surety Bond approved under this regulation shall remain effective according to its terms regardless of the

continuation of a contractual relationship between the Political Subdivision and any company providing unemployment insurance services to it.

History

Source: Miss. Code Ann. §§ 71-5-115 & 71-5-117 (Rev. 2004).

20 Miss. Admin. Code Pt. 101, R. 608.00 Rule 608.00

Reimbursing Employer Payment Liability Reimbursing employers who elect to become contributory, whether political subdivisions or non-profit employers defined by the Law, are liable for reimbursements which may accrue, until such time as wages paid by such employer as a reimbursing employer are no longer in the base period of a claim or in the case of extended benefits, the parent claim.

History

Source: Miss. Code Ann. §§ 71-5-115 & 71-5-117 (Rev. 2004).

20 Miss. Admin. Code Pt. 101, R. 609.00 Rule 609.00

Funding Options Any political subdivision rated at two percent (2%), reimbursing, or rated at five tenths of one percent (.5%) and reimbursing, may elect to change its funding option from reimbursing to rate paying in accordance with Section 71-5-359 of the Law provided the requested information is delivered to the Agency on or before December 1 of the year immediately prior to January 1 of the year for which the election is made. The election will be in effect and in force for no less than two (2) calendar years and the first election shall be made effective the first day of employment and subsequent elections will be made effective January 1 of the year. In the event an employer does not make an election within thirty (30) days of registration, the employer will become a reimbursable employer but will be allowed to make an election for the next calendar year provided the election is received by the Agency as described.

Any IRS 501(C)(3) exempt nonprofit organization that is paying contributions or reimbursing under the authority of the Law may elect to change its funding option by filing a written notice of election with the Agency not later than thirty (30) days prior to the election. Such election shall not be terminable by the organization for that and the next tax year. Any nonprofit organization which makes an election in accordance with 71-5-357(a)(i) of the Law will continue to be liable for contributions unless it files with the Agency a written termination notice not later than thirty (30) days immediately following the date of determination of such subjectivity. In the event the non-profit employer chooses to give up its right to be a reimbursing employer, such employer must give written notification to the Agency no later than November 30 of the year preceding the year for which it will again become liable for contributions. Any reimbursements that accrue following such election will continue to be the responsibility of the non-profit employer.

History

Source: Miss. Code Ann. §§ 71-5-115 & 71-5-117 (Rev. 2004).

20 Miss. Admin. Code Pt. 101, R. 610.00 Rule 610.00

Temporary Help Firm A temporary help firm is any individual or organization who recruits and hires its own employees and provides those employees to other individuals or

organizations to perform some service, to support or supplement the existing workforce in special situations such as employee absences, temporary skill shortages, seasonal workloads and special assignments and projects, with the expectation that the worker’s position will be terminated upon the completion of the specified task or function. A temporary help firm is presumed to be the employer for unemployment insurance purposes of a temporary employee assigned to a client for up to one (1) year of continuous service with that client from the last day of the first quarter in which the worker was assigned, irrespective of the number of hours the temporary employee works at the client’s place of business. Continuous service means service to the same client with less than thirty (30) consecutive days break in service. After a temporary employee has completed one (1) year of continuous service with the same client, the relationship of employer and employee shall be determined in accordance with the principles of a common law governing the relation of master and servant and a temporary help firm may be required to demonstrate that it is an employer consistent with such principles. Provided however that any temporary help firm will be considered prima facia in compliance with this regulation if at least ninety percent (90%) of the total number of individuals working for the temporary help firm on any day has been assigned to all clients for a period not exceeding twelve (12) months from the last day of the first calendar quarter in which the worker was assigned.

History

Source: Miss. Code Ann. §§ 71-5-115 & 71-5-117 (Rev. 2004).

20 Miss. Admin. Code Pt. 101, R. 611.00 Rule 611.00

Power of Attorney Any individual or organization providing representation to any employer or claimant, in any unemployment issues in the absence of the client, must provide a power of attorney signed by the entity they will represent. A power of attorney is not required if the individual is a Certified Public Accountant who is a member of the AICPA, or an attorney who is a member of the Mississippi Bar Association or another Bar Association of equal status in another state or jurisdiction of the United States of America; or an Enrolled Agent who is a federally-authorized tax practitioner and is a member of the National Association of Enrolled Agents.

History

Source: Miss. Code Ann. §§ 71-5-115 & 71-5-117 (Rev. 2004).

20 Miss. Admin. Code Pt. 101, R. 612.00 Rule 612.00

Tax Appeal Regulation 1. Any employer who appeals a determination or redetermination of his or her unemployment tax liability, hereinafter called tax protest, shall have such tax protest heard by a hearing officer designated for that purpose by the Agency. 2. Any tax protest filed by an employer under the provisions of Section 71-5- 355 of the Law shall be promptly forwarded to the MDES Appeals Department for processing purposes. 3. The ALJ who has been assigned the tax protest shall notify the employer of the scheduling of a hearing thereon, and a notice shall be mailed or

electronically delivered to the employer not later than fourteen (14) days prior to the date set for the hearing. 4. Prior to the hearing, the ALJ shall obtain from the Contributions and Status Department of the Agency the complete file pertaining to the employer filing the protest, as well as any claim file appertaining thereto, in order that he or she may prepare for the hearing. The complete files shall be made available to the employer at the hearing so that they may have an opportunity to review same at the time. The files shall be made a part of the record that is made at the hearing. 5. The Agency shall have the discretion to set the time and place of the hearing, and shall designate whether the hearing will be in-person or by telephone. 6. The employer may be represented at the hearing by an attorney or any other representative he or she has authorized. 7. Any testimony received shall be under oath, and the hearing shall be recorded by the ALJ, but need not be transcribed unless there is a further appeal. 8. The rules of evidence shall be relaxed. 9. The ALJ, upon a showing of the necessity, may issue subpoenas at the request of either party, or may subpoena any individual, including a claimant and any records maintained by either party or their agents which the ALJ believes may contain information relevant to the tax protest being heard. 10. The ALJ, at his or her discretion, may elect to continue a hearing for the purpose of securing testimony of a witness or for other purposes. 11. The hearing may be postponed or adjourned for good cause, within the discretion of the ALJ. If, at any time prior to an appeal to the Circuit Court of the First Judicial District of Hinds County, Mississippi, as provided by the Law, it should appear to the ALJ that the record should be perfected or completed, then a hearing may be reopened or reconvened for that purpose. 12. As soon as reasonably possible after the hearing has been concluded the ALJ shall issue his or her written decision, which shall in concise form state the findings of fact, and the conclusions based on such findings. The decision shall be mailed or electronically delivered to the employer and delivered to the Contributions and Status Department of the Agency. 13. There shall appear in bold face type upon the transmittal letter the following language: THIS DECISION SHALL BECOME FINAL UNLESS WITHIN TEN (10) DAYS AFTER DATE OF MAILING OR ELECTRONIC DELIVERY HEREOF THERE SHALL BE AN APPEAL TO THE MDES BOARD OF REVIEW.

An appeal to the Board of Review may be taken by either the employer or by the Contributions and Status Department of the Agency. 15. Upon an appeal to the Board of Review, there may be oral argument, or briefs filed, within the discretion of the Agency.

History

Source: Miss. Code Ann. §§ 71-5-115 & 71-5-117 (Rev. 2004).

20 Miss. Admin. Code Pt. 101, R. 613.00 Rule 613.00

Contractors and Sub-contractors Must be Reported Whenever and as an employing unit contracts with or has under it any contractor or sub-contractor for any employment which is part of its usual trade, occupation, profession, or business, such employing unit may be required to furnish in writing to the Agency: (A) name and address of each such contractor or sub-contractor; (B) date of commencement of the work under such contract; (C) place or places at which the work is to be performed; (D) whether such contractor of sub-contractor is registered as an employer under the Employment Security Law; and (E) if registered, the registration number of the employing unit.

History

Source: Miss. Code Ann. §§ 71-5-115 & 71-5-117 (Rev. 2004).

20 Miss. Admin. Code Pt. 101, R. 614.00 Rule 614.00

Establishment of Employer Contribution Rate during Pendency of Appeal on Liability Questions During the period an appeal is pending the agency will take no collection action regarding taxes. First and final notices, as required by sections 71-5-365 and 71-5-367, will be issued and transmitted to the employer and wage information (workers’ names, social security numbers and payments to workers) will be required by the Department. Wage information will consist of any payments the Department has determined to be wages paid by the employer even though the appeal is still active. Payment of taxes will be required once liability has been determined, and no further appeal rights exist under the Mississippi Employment Security Law.

History

Source: Miss. Code Ann. §§ 71-5-115 & 71-5-117 (Rev. 2004).

Chapter 800 EMPLOYMENT SERVICES

20 Miss. Admin. Code Pt. 101, R. 800.00 Mississippi First Initiative (Senate Bill 2662)

The Mississippi Jobs First Bill (SB NO. 2622 of the 2012 Legislative Session and any future corresponding citation in the Mississippi Code of 1972) requires contractors that are awarded bids for public works projects that utilize funds received by State or Local governmental entities resulting from a federally declared disaster or a spill of national significance to register and list job opportunities with the Mississippi Department of Employment Security (MDES). This initiative will ensure that Mississippians have an opportunity to apply for jobs created by a disaster.

NOTE: The following rules (800.01-800.04) concerning the Mississippi Jobs First Bill pertain only to contracts executed after the law went into effect on May 1, 2012. All contracts existing before the effective date are not subject to these provisions.

20 Miss. Admin. Code Pt. 101, R. 800.01 Responsibility of State and Local Government

(A) It is the responsibility of state and local government entities soliciting bids for public works projects that utilize funding resulting from a federally declared disaster or spill of national significance to ensure that all contractors submit, with their bid, a completed employment plan which shall include the following information: the type of jobs involved in the project; the skill level of the jobs involved in the project; wage information on the jobs involved in the project; the number of vacant positions that the contractor needs to fill; how the contractor will recruit low wage and unemployed individuals for job vacancies; other information that may be required by MDES; and proof of registration with MDES for taxation in accordance with provisions of Title 71.

(B) When a contractor’s bid is accepted, the state or local government entity shall enter into an agreement with the contractor that requires the contractor to only hire personnel referred from MDES for a period of ten (10) days from when the contract is awarded.

20 Miss. Admin. Code Pt. 101, R. 800.02 Contractor Responsibilities

(A) Contractors that are awarded bids for public works projects that utilize funds received by State and Local Governmental entities resulting from a federally declared disaster or spill of national significance must submit an employment plan that includes the following information: the type of jobs involved in the project; the skill level of the jobs involved in the project; wage information on the jobs involved in the project; the number of vacant positions that the contractor needs to fill; how the contractor will recruit

low wage and unemployed individuals for job vacancies; other information that may be required by MDES; and proof of registration with MDES for taxation in accordance with provisions of Title 71 with their bid to the entity requesting the solicitation of services.

(B) When a contractors bid is accepted, the contractor shall enter into an agreement with the entity that accepted the bid that requires the contractor to only hire personnel referred from MDES for a period of ten (10) days from when the contract is awarded. Contractors must place a job order with MDES to receive a list of qualified individuals. The contractor is required to review the applicants submitted by MDES before hiring individuals who were not referred.

MDES shall define the ten (10) days as follows: The time period for the ten (10) days shall begin to run on the first day the job order is opened with MDES. The ten (10) days shall be considered working days and weekends and official state holidays shall not be counted. If the tenth (10th) day shall fall on a weekend or holiday, then the following Monday or the next day that MDES is open for business shall be deemed the tenth (10th) day.

The ten (10) day rule shall apply to any entity charged with hiring personnel under the awarded contract. For example, if the contractor enlists a temporary agency to hire employees for the project, the ten (10) day rule shall apply to the temporary agency, or any subcontractor the contractor may utilize for the project.

NOTE: The contractor is not prohibited from hiring MDES referrals during the ten (10) day time period and may hire employees referred by MDES immediately.

(C) The contractor is required to register his/her business online in the Workforce Investment Network Global System (WINGS) by visiting Wings.mdes.ms.gov. The following information is needed to register:

(1) Register in the Workforce Investment Network Global Systems (WINGS) and create a username and password;

(2) Employer Federal ID #;

(3) Company Name;

(4) Company (Corporate) Physical address if applicable;

(5) Company (Corporate) Mailing address for E-Verify notices (if applicable);

(6) Company telephone number and fax number; and

(7) Company contact name, title, phone number and email address.

(D) In order to create a job order the contractor must provide the WIN Job Center or Call Center Representative with the following information (Call Center information and a complete list of WIN Job Centers can be found on MDES’s website: www.mdes.ms.gov):

(1) Job title

(2) Job physical location (Worksite)

(3) Number of openings

(4) Job description

(5) Job qualifications (level of education, months of experience, driver’s license if required)

(6) Duration of the position (less than 3 days, 4 to 150 days, more than 150 days)

(7) Temporary, permanent position or seasonal position

(8) Full time or Part time

(9) Number of hours to work per week

(10) Days to work and shifts

(11) Referral instructions (how the applicant will apply)

(12) Job Order contact person if different from the Contractor registration contact.

20 Miss. Admin. Code Pt. 101, R. 800.03 Role of the MDES WIN Job Center

MDES will designate sites to assist contractors according to location of the federally declared disaster. After the job order(s) have been finalized and opened for recruitment, the MDES WIN Job Centers will begin the process of referring qualified applicants to the contractor to consider for the vacant positions.

20 Miss. Admin. Code Pt. 101, R. 800.04 Reporting Requirement

In accordance with the act, MDES will provide the Mississippi Legislature with an annual report ending June 30, 2013, and will follow each year thereafter. MDES will develop procedures to track and report relevant information received from contractors. The annual report will detail data received from contractors that were awarded contracts under this act throughout the year.

STATE WORKFORCE INVESTMENT BOARD STATE WORKFORCE INVESTMENT BOARD

Part 201 Mississippi Works Fund Rules & Regulations

20 Miss. Admin. Code Pt. 201 Mississippi Works Fund Rules & Regulations

Title 20: Labor

Part 201: Mississippi Works Fund Rules & Regulations Part 201 Chapter 1: Statutory Authority Rule 1.1: Statutory Authority. The Mississippi Works Fund was created through Mississippi Works Funds created in Mississippi Code Annotated § 71-5-353.

The rules for the Mississippi Works Fund (MS Works Fund) are promulgated in accordance with Senate Bill 2723, Regular Legislative Session 2022, which empowers and requires the Office of Workforce Development (AccelerateMS) to create rules and implement performance metrics for the MS Works Fund to determine added value to the local and state economy.

Source: Miss. Code Ann. §71-5-353 and §37-153-7 Rule 1.2: Rules Committee. The Rules Committee shall consist of State Workforce Development Board members: A. The Executive Director of the Mississippi Development Authority;

B. The Executive Director of the Mississippi Department of Employment Security;

C. The Executive Director of the Mississippi Community College Board;

D. The Chair of the Mississippi Association of Community and Junior Colleges;

E. The Chair of the State Workforce Development Board;

F. A representative from the workforce areas selected by the Mississippi Association of Workforce Areas, Inc.;

G. A business representative currently serving on the board, selected by the Chairman of the State Workforce Development Board; and

H. Two (2) legislators, who shall serve in a nonvoting capacity, one (1) of whom shall be appointed by the Lieutenant Governor from the membership of the Mississippi Senate and one (1) of whom shall be appointed by the Speaker of the House of Representatives from the membership of the Mississippi House of Representatives. Source: Miss. Code Ann. §71-5-353 §37-153-7 Part 201 Chapter 2: MS Works Fund Projects

Rule 2.1: Introduction. The MS Works Fund is a legislatively authorized program administered by

AccelerateMS that is tasked with providing funding to address immediate training needs of eligible Mississippi employers and support for related economic development activities throughout the state. Funds allocated by the executive director shall only be utilized for the training of unemployed or underemployed persons, for immediate training needs for the net new jobs created by an employer, for the retention of jobs, to create a work-ready applicant pool of Mississippians with credentials and/or postsecondary education in accordance with the state’s Workforce Investment and Opportunity Act plan, or for the support of local economic and community development activities related to workforce development in the state. Of the funds deposited annually, Job Creation Projects will be prioritized. Remaining funds will be used at the discretion of AccelerateMS.

MS Works funding may be utilized by AccelerateMS for three types of projects:

Job Creation Projects
Workforce Retention and Reskilling Projects
Local Workforce Delivery Coordination and Outreach

Source: Miss. Code Ann. §71-5-353

Rule 2.2: Applications. External applications are accepted year-round, as training needs are identified or as new initiatives are created if funds are available. Needs are presented to AccelerateMS through a pre-application process. Once needs are deemed eligible, AccelerateMS will invite a full application. Eligible Applicants must apply through AccelerateMS by submitting an application package related to the initiative.

Requirements include, but are not limited to:

Applicant Information
Benefitting Business Information (if applicable)

Consent to Release Employment Data (UI Wage Record)
1. Project Description
2. Project Budget
Stipend Cost
Course Cost
Registration Costs
Internship costs
1. Detailed Training Plan
2. Vendor Training and/or Third-Party Training Costs
3. Detailed Job and Wage Information

Source: Miss. Code Ann. §71-5-353

Rule 2.3: MS Works Eligible Applicants. The Eligible Applicant will apply on behalf of a Benefitting Business/and or Training Provider to receive training funds, or to receive funds directly in order to provide training. Eligible Applicants will be determined at the discretion of AccelerateMS once activity driving training needs have been presented.

Eligible applicants include, but are not limited to:

Community and junior colleges
State institutions of higher learning
The Local Planning and Development District,
Non-Profits in partnership the Local Planning and Development District, community and

junior college, or state institution of higher learning.

E. Secondary schools in partnership the Local Planning and Development District,

community and junior college, or state institution of higher learning.

Rule 2.4: Training Providers. AccelerateMS, in collaboration with Mississippi Public Community Colleges, Local Planning and Development Districts, and state institutions of higher learning partners shall be the primary entities to facilitate the training associated with each of the project types. Other providers are eligible to provide training services based on the training plan approved by AccelerateMS.

Source: Miss. Code Ann. §71-5-353

Rule 2.5: Project Descriptions.

A. Job Creation Projects primarily address economic development projects, which must result in net new full-time jobs or meet retention requirements, as defined by the Mississippi Development Authority, or at the discretion of AccelerateMS. These projects must be tied to a defined training plan with an eligible benefiting business. A full-time job is defined as averaging a minimum of 35 hours per week. B. Workforce Retention and Reskilling Projects primarily address:

The critical training needs of eligible Benefitting Business(es); or
The critical skills necessary for existing employees for the retention of jobs to improve productivity, and support competitiveness; or
Skills needed in a work-ready applicant pool of Mississippians to fill high growth, in-demand jobs, and/or aligning with AccelerateMS priority sectors and occupations.
Local Workforce Delivery Coordination and Outreach allow AccelerateMS to utilize funding for regional coordination and outreach of workforce planning and delivery or training needs.

Source: Miss. Code Ann. §71-5-353

Rule 2.6: MS Works Eligible Projects. Eligible projects must address the critical training needs of eligible Benefitting Businesses or provide training needed to fill high growth, in-demand jobs, and/or aligned with AccelerateMS priority sectors and occupations. Funding must be used to train employees in skills necessary for the operation of the business, or to support subsidized on- the-job training for net new full-time jobs created, or reskill existing full-time employees to enhance competitiveness, or to train unemployed or underemployed individuals. M S W o r k s grants should be used in conjunction with existing training funds through coordination with the

state’s Workforce Innovation and Opportunity Act, Mississippi Workforce Enhancement Training funds, and other funding to maximize resources.

A. Eligible Benefitting Businesses should align with high-growth target industry sectors, as identified by the Mississippi Development Authority (MDA), or AccelerateMS priority sectors and occupations. The Benefiting Business shall create or enhance at least 10 net, full-time, permanent jobs, and the strong employee retention is essential. AccelerateMS will not commit funds towards training for any job that is known to be short-term (a year or less, nor will future funds be committed toward training for a Benefitting Business that has a poor history of job retention; B. Eligible Training Activities: • Training targeting significantly underemployed individuals’ or current employees in skills necessary for the operation of the business or to enhance competitiveness; • Training aimed at targeting unemployed individuals, to build a work-ready applicant pool that supports employer and industry demand. • Funding may also be used by AccelerateMS to coordinate local workforce delivery and outreach or planning to meet needs of economic development activity. C. Equipment purchases for private sector businesses to be purchased by or for an approved public entity and owned by the approved public entity may be approved.

Source: Miss. Code Ann. §71-5-353

Rule 2.7: MS Works Eligible Benefitting Businesses. A Benefitting Business must fall into one of the following two categories:

A. Existing: For-profit businesses that have been in operation in Mississippi for a minimum of one year prior to the application date, are expanding the number of net new full-time employees at the Mississippi location or need to train existing full- time employees in skills necessary for the retention of jobs. Entities must be current on all federal and state tax obligations, not experienced a layoff in the previous 120 days, and are financially viable to be eligible to apply. B. New: For-profit businesses that have been recruited to the state by MDA or in consultation with MDA. Entities must be current on all federal and state tax obligations and are financially viable to be eligible to apply.

Source: Miss. Code Ann. §71-5-353

Rule 2.8: Allowable Use of Funds. MS Works Funds may only be utilized for the training of unemployed or underemployed persons, for immediate training needs for the net new jobs created by an employer, for the retention of jobs, to create a work-ready applicant pool of Mississippians with credentials and/or postsecondary education in accordance with the state’s Workforce Investment and Opportunity Act plan, or for the support of local economic and community development activities related to workforce development in the state. Requirements

for Use of Funds:

A. Project cycles run for a maximum of 36 months, beginning with the date of the first hire or, in the case of retention or reskilling projects, the application date. After 36 months, the project must be closed, unless an extension is granted. AccelerateMS may recommend a longer performance period for a project at the time AccelerateMS is making a commitment to a project. B. MS Works Funds should be used as part of an overall workforce training funding plan that maximizes the value of workforce funds available from other sources, including but not limited to local, state, or federal sources. Applicants must disclose state or federal funds sought or awarded for workforce training. C. MS Works Fund grants shall be available for, but not limited to, high growth industry sectors as designated by MDA, and/or AccelerateMS priority sectors and occupations; D. Applicants may request administrative cost recovery and AccelerateMS may approve on a case-by-case basis. Administrative costs will be capped at two percent (2%) but may be negotiated up to a maximum of five percent (5%) based on the justifiable costs associated with each project. E. Priority for training shall be given to improving the skills of unemployed and underemployed individuals. AccelerateMS will take wage rates into consideration when making a determination on the amount of grant funds made available to the Benefitting Business. Higher wage rates are a factor in Mississippi’s recruitment of industries and as such will be a factor in the determination of how MS Works Funds are allocated. F. Local workforce delivery coordination and outreach may only be initiated by AccelerateMS based on specific needs of the office. G. Allowable training activities:

These funds shall place a special emphasis and priority on skill enhancement and related assessments such as nationally recognized credentials and certifications.
Non-production training wages should only make up a portion of the overall training plan. Reimbursable wages must not include benefits and may be reimbursed at a maximum of 50%.
Personnel contracted to implement or teach courses, workshops, and/or seminars must have a contract on file with the partnering entity performing the activities.
Costs associated with apprenticeships or internships.
Vendor Training /Train the Trainer expenses to include tuition or registration fees, and eligible travel expenses.
Cost associated with the development and delivery of customized training.
Training in operational strategies to improve efficiency of business operations connected to an expansion is allowed.
MS Works grants may be used for Lean Manufacturing training, only to match the contribution to the cost of such training made by the company or group of companies.
Educational training including, but not limited to: workplace literacy, basic skills, soft skills, and English as a second language may be included as a portion of the training plan.

Registration fees of participants enrolling in training
Participants stipends are to be utilized for unemployed Mississippians for training programs with a documented regional need. Training programs must have documented employer partners committed to interviewing trainees for current, available jobs.
Similar expenses may be approved by AccelerateMS on a case-by-case basis.

Source: Miss. Code Ann. §71-5-353

Rule 2.9: MS Works Unallowable Use of Funds. The following activities are specifically prohibited for funding from MS Works Funds when applying for funds or having an active grant with AccelerateMS:

A. Paying training costs of a company that:

relocates the company’s worksite from one community in Mississippi to another; or
Has experienced a layoff or plant closure in Mississippi within the past 120 days. B. MS Works Fund grants may not be used to provide the following:
Training for gaming enterprises, the cannabis industry, retail facilities similar businesses. C. Meals/snacks during a training for participants.

Source: Miss. Code Ann. §71-5-353

Rule 2.10: Application Process. The Eligible Applicant must submit electronic copies of the application in the format adopted by AccelerateMS. The application must be complete, with all information supplied. A. The application must clearly describe the training to be delivered, state the training objectives, and describe how the funds will be used to meet the objectives; B. The application must document that the training is needed and include other resources that are available to meet the need; C. A customized training plan must be submitted that, when applicable, is aligned with the state plan. This plan should be submitted in the AccelerateMS prescribed format and include, at a minimum:

Training description and objectives
Curriculum
Instructor and/or training provider
Training hours
Number of individuals to be trained
Budget
Anticipated wage escalation for reskilled employees D. Other information as requested by AccelerateMS.

Source: Miss. Code Ann. §71-5-353

Rule 2.11: MS Works Subgrant Agreement. Upon approval of the application by AccelerateMS, Applicant must enter into a sub grant agreement with AccelerateMS to facilitate training related to the project activity.

Source: Miss. Code Ann. §71-5-353

Rule 2.12: MS Works Disbursement and Reimbursement of Funds. All funds deposited into the Mississippi Department of Employment Security (MDES) MS Works Fund shall be disbursed exclusively by the Executive Director of the MDES, in accordance with the rules and regulations promulgated by AccelerateMS. The MDES, upon approval by AccelerateMS, will make all disbursements to the Applicant.

Reimbursement requests must be submitted quarterly, but no more frequently than every thirty (30) days.

Source: Miss. Code Ann. §71-5-353

Rule 2.13: WRP UNALLOWABLE USE OF FUNDS. In no case shall MS Works Funds be used to supplant workforce funds available from any other source, including but not limited to local, state, or federal sources that are available for workforce training and development.

Funds approved for WRP may not be used to pay training costs for a company that relocates the company’s worksite from one community in Mississippi to another.

Trainee wages are not allowable expenditures. In addition, the purchase of proprietary or production equipment is not an allowable expenditure.

MS Works Fund grants may not be used to provide the following:

A. Proprietary management training packages such as: VitalEdu, AchieveGlobal, Plexus, Zig Ziglar, Phi Theta Kappa Leadership, Stephen Covey and similar packages;

B. Training to a gaming enterprise; and

C. Training for service sector businesses. Source: Miss. Code Ann. §71-5-353 Rule 2.14: WRP APPLICATION PROCESS. The applicable Training Provider, in partnership with a Benefitting Business if applicable, must submit electronic copies of the application according to the appropriate format.

A. The application must be complete, with all information supplied;

B. The application must clearly describe the training to be delivered, state the training objectives, and describe how the funds will be used to meet the objectives;

C. The application must document that the training is needed and that other resources are not available to meet the need; and

D. Any additional criteria required by MDA. Source: Miss. Code Ann. §71-5-353 Rule 2.15: WRP SUB GRANT AGREEMENT. Upon approval of the application by the MDA, Training Providers must enter into a sub grant agreement with the MDA to facilitate training related to the WRP activity. Source: Miss. Code Ann. §71-5-353 Rule 2.16: WRP DISBURSEMENT AND REIMBURSEMENT. All funds deposited into the Mississippi Department of Employment Security (MDES) MS Works Fund shall be disbursed exclusively by the Executive Director of the Mississippi Department of Employment Security, in accordance with the rules and regulations promulgated by the State Workforce Development Board Rules Committee. The MDES upon approval by the MDA will make disbursements.

The Training Provider will be reimbursed upon completion of a participant’s training. Reimbursement requests may be submitted no more frequently than on a monthly basis. Source: Miss. Code Ann. §71-5-353 Part 201 Chapter 3: Performance Metrics

AccelerateMS has created performance metrics for the MS Works Fund to determine the added value to the local and state economy and the contribution to the future growth of the state economy.

Rule 3.1: Required Performance Metrics for MS Works Projects. The State Longitudinal Data System (SLDS) will be used to calculate performance. Performance metrics for projects will at a minimum include:

Projects Awarded
Jobs Created
Jobs Retained
Wages / Personal Income
Certificates or Credentials Awarded (geo-located)
Other Training Funds Leveraged
Training Enrollments
Training Completion
Entered Employment
Wages Earned

The Applicant will be required to input data associated with each MS Works activity using appropriate mechanisms to incorporate that data into SLDS.

Source: Miss. Code Ann. §71-5-353

Rule 3.2: REQUIRED PERFORMANCE METRICS FOR WORK READY POJECTS. The State Longitudinal Data System (SLDS) will be used to calculate performance. Performance metrics for Work Ready Projects will at a minimum include:

A. Training Enrollments

B. Training Completion

C. National Career Readiness Certificates and other Job Preparedness Certifications Granted (geo-located)

D. Entered Employment

E. Wages Earned

The Training Providers will be required to input data associated with each JCP and WRP activity using appropriate mechanisms to incorporate that data into SLDS. Source: Miss. Code Ann. §71-5-353 Part 201 Chapter 4: Reconciliation and Reporting

Rule 4.1: Reconciliation of Performance and Financial Measures. The SLDS will be used to generate annual performance reports. Specific reporting requirements will be included in sub grant agreements between AccelerateMS and the Applicant which will describe the process for collecting, transmitting, validating, and reporting data in compliance with SLDS Governing Board rules and regulations on training expenditures and participant results.

For training delivered by training providers, AccelerateMS is responsible for the review and validation of all financial information. NSPARC, partner, supports AccelerateMS by validating all demographic data submitted by training providers. Once both demographic and financial validations are complete, AccelerateMS will submit the finalized data to SLDS. AccelerateMS rely on training providers to collect accurate data and submit all required information by the established deadlines.

Source: Miss. Code Ann. §71-5-353

Rule 4.2: Required Reports. The MDES in conjunction with AccelerateMS will generate quarterly and annual financial reports by project and in the aggregate. Financial reports will include:

Collections
Expenditures
Obligations
Plan versus Actual

A report on the performance of the fund shall be made to the Governor, Lieutenant Governor, and Speaker of the House of Representatives quarterly and annually, throughout the life of the fund.

Source: Miss. Code Ann. §71-5-353 Rule 4.3: Reporting Schedule. Quarterly financial reports will be submitted via GranTraks, which shows the allocation for the grant, expenditures, and balance of the grant for review and approval to AccelerateMS and to be available for the State Workforce Investment Board (SWIB) 45 days after the end of each quarter. Annual financial reports will be submitted to AccelerateMS and the SWIB 45 days after the end of the calendar year.

Source: Miss. Code Ann. §71-5-353

WORKERS COMPENSATION COMMISSION WORKERS COMPENSATION COMMISSION

Part 1 Rules of the Mississippi Workers' Compensation Commission

Chapter 2 Procedural Rules

20 Miss. Admin. Code Pt. 1, R. 106.06 Rule 106.06

There shall be no interruption of a participant who has been given the floor by the presiding officer, except that the presiding officer may in his or her discretion interrupt or end the partisan’s time where the orderly conduct of the proceeding so requires. Conduct of Oral Proceeding Presiding Officer 107.01 The presiding officer shall have authority to conduct the proceeding in his or her discretion for the orderly conduct of the proceeding. The presiding officer shall (i) call proceeding to order; (ii) give a brief synopsis of the proposed rule, a statement of the statutory authority for the proposed rule, and the reasons provided by the Agency for the proposed rule; (ii) call on those individuals who have contacted the Agency about speaking on or against the proposed rule; (iii) allow for rebuttal statements following all participants’ comments; (iv) adjourn the proceeding. Questions 107.02 The presiding officer, where time permits and to facilitate the exchange of information, may open the floor to questions or general discussion. The presiding officer may question participants and permit the questioning of participants by other participants about any matter relating to that rulemaking proceeding, including any prior written submissions made by those participants in that proceeding; but no participant shall be required to answer any question. Physical and Documentary Submissions 107.03 Physical and Documentary Submissions. Submissions presented by participants in an oral proceeding shall be submitted to the presiding officer. Such submissions become the property of the Commission, part of the rulemaking record, and are subject to the Commission’s public records request procedure. Recording 107.04 The Commission may record oral proceedings by stenographic or electronic means.

This Rule shall be in force and effect on and after January 18, 2018.

History

Source: Miss. Code Ann. § 71-3-85.

Part 2 Mississippi Workers' Compensation Medical Fee Schedule

20 Miss. Admin. Code Pt. 2, R. 10 Rule 10

CPT Copyright 2024 American Medical Association. All rights reserved. D. The practice of medicine is deemed to occur in the location of the injured worker. Therefore, only physicians and OQHPs holding a valid Mississippi license are allowed to practice telemedicine in Mississippi. However, a valid Mississippi license is not required where the evaluation, treatment, and/or medicine to be rendered by a physician or OQHP outside of Mississippi is requested by a physician or OQHP duly licensed to practice medicine in Mississippi, and the physician or OQHP who has requested such evaluation, treatment and/or medical opinion has already established a doctor/patient relationship with the injured worker to be evaluated and/or treated. E. Telemedicine services must include an examination of the injured worker that meets the applicable standards of care, a discussion with the injured worker, a diagnosis, and maintenance of a complete medical record. F. Documentation requirements, including work status, are the same as for face-to-face services and shall include the locations of the rendering provider and the injured worker at the time of service. G. Services eligible to be provided by telemedicine are marked with a star (★) in the rate tables. H. Services that are performed via telemedicine should be billed with Modifier 93, Synchronous Telemedicine Service Rendered Via Telephone or Other Real-Time Interactive Audio-Only Telecommunications System or modifier 95, Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System and place of service (POS) code 02 or 10. I. For services that may be provided face-to-face or via telemedicine, the maximum allowable reimbursement is the same as if the services were provided in-person, except as elsewhere indicated in these rules. XIII. PHARMACEUTICAL REIMBURSEMENT In the event that the MWCC implements a drug formulary, the Formulary and any subsequent Pharmacy Fee Schedule will govern. XIV. DRUG SCREENING (MCA §71-3-121) Only one (1) drug screen or drug test result shall be eligible for reimbursement for each drug test conducted on the same injured worker on the same day, unless the initial screening results are deemed by the prescribing provider to be inconsistent or inherently unreliable. In that event, a confirmation screening may be ordered by the prescribing provider and paid for by the payer. In addition, treatment may not be discontinued based on the results of a drug test absent a confirmation test, which shall be reimbursed in addition to the initial screening test. Merely duplicate screenings or tests which are rerun to confirm initial results are not otherwise eligible for reimbursement. XV. MILEAGE REIMBURSEMENT (MCA §71-3-15; MISS. WORK COMP. COM. GENERAL RULE 1.14) The payer shall reimburse each injured worker for all travel to obtain medical treatment which is being obtained under the provisions of the Mississippi Workers’ Compensation Law, including travel to a pharmacy to obtain medication or supplies necessary for treatment of a compensable injury, regardless of the number of miles traveled. There is no minimum distance of travel required for reimbursement, and reimbursement shall be made for each mile of round-trip travel necessitated by the compensable injury, at the rate adopted by the MWCC and in effect at the time of the travel. Only reasonable and necessary miles traveled are subject to reimbursement. XVI. SALES TAX All amounts in the Mississippi Workers’ Compensation Fee Schedule include any sales tax/shipping charges, etc. Therefore, no additional amount is reimbursed for these items. XVII. INJURED WORKER’S RIGHT TO HEARING Nothing provided in this Fee Schedule shall estop or prevent the injured worker from obtaining legal counsel and/or seeking relief in the form of a request to compel medical treatment before an Administrative Judge. XVIII. TIME In this Fee Schedule, when calculating any time period of seven (7) days or less, only business days are counted. When calculating any time period of more than seven (7) days, all calendar days are counted. Any time period which ends on a weekend, holiday or other day when the Commission is closed, is automatically extended to the first following day which is not a weekend, holiday or other day when the Commission is closed. XIX. INVESTIGATIONAL PROCEDURES Services that are experimental, investigational or for performance measurement, including but not limited to CPT Category II and Category III codes, are not reimbursable for this Fee Schedule, except Category III codes specifically listed.

CPT Copyright 2024 American Medical Association. All rights reserved. 11 BILLING AND REIMBURSEMENT RULES I. GENERAL PROVISIONS A. Maximum Allowable Reimbursement (MAR). Unless the payer and provider have a separate fee contract which provides for a different level of reimbursement, the maximum allowable reimbursement for health care services shall be the lesser of (a) the provider’s total billed charge, or (b) the maximum specific fee established by the Fee Schedule. Items or services or procedures which do not have a maximum allowable reimbursement established by this Fee Schedule shall be reimbursed at the usual and customary fee as defined in this Fee Schedule, and in such cases, the maximum allowable reimbursement shall be the lesser of (1) the provider’s total billed charge, or (2) the usual and customary fee as defined by this Fee Schedule. If this Fee Schedule does not establish a maximum allowable reimbursement for a particular service or procedure, and a usual and customary rate cannot be determined because the FH ® Benchmarks products do not contain a fee for same, then the maximum allowable reimbursement shall be equal to the national Medicare allowance plus thirty percent (30%). In the absence of an established Medicare value, and assuming none of the above provisions apply, the maximum allowable reimbursement shall be eighty percent (80%) of the provider’s total billed charge. New codes may be assigned values and posted on the MWCC website annually, or as needed. B. Separate Fee Contract. An employer/payer may enter into a separate contractual agreement with a medical provider regarding reimbursement for services provided under the provisions of the Mississippi Workers’ Compensation Law, and if an employer/payer has such a contractual agreement with a provider designed to reduce the cost of workers’ compensation health care services, the contractual agreement shall control as to the amount of reimbursement and shall not be subject to the maximum allowable reimbursement otherwise established by the Fee Schedule. However, all other rules, guidelines and policies as provided in this Fee Schedule shall apply and shall be considered to be automatically incorporated into such agreement. 1. Repricing Agreements. Payers and providers may voluntarily enter into repricing agreements designed to contain the cost of workers’ compensation health care after the medical care or service has been provided, and in such case, the reimbursement voluntarily agreed to by the parties shall control to the exclusion of the Fee Schedule. However, the time spent by the payer and provider attempting to negotiate a post-care repricing agreement does not extend the time elsewhere provided in this Fee Schedule for billing claims, paying claims, requesting correction of an incorrect payment, requesting reconsideration, seeking dispute resolution, or reviewing and responding to requests for correction or reconsideration or dispute resolution. In addition, applicable interest and penalties related to late billing and/or late payment shall continue to accrue as otherwise provided. Efforts to negotiate a post-care repricing agreement do not justify late billing or payment, and either party may seek further relief in accordance with the rules provided herein should billing or payment not be made within the time otherwise due under these rules. No party shall be obligated to negotiate or enter into a repricing agreement of any kind whatsoever. Repricing agreements must include language that specifically includes medical services provided to workers’ compensation claimants. No party, in attempting to negotiate a repricing or other post treatment price reduction agreement, shall state or imply that consent to such an agreement is mandatory, or that the failure to enter into any such agreement may result in audit, delay of payment, or other adverse consequence. If the MWCC determines that any party, or other person in privity therewith, has made such false or misleading statements in an effort to coerce another party’s consent to a repricing or other price reduction agreement outside the Fee Schedule, the MWCC may refer the matter to the appropriate authorities to consider whether such conduct warrants criminal prosecution under §71-3-69 of the Workers’ Compensation Law. This statute declares that any false or misleading statement or representation made for the purpose of wrongfully withholding any benefit or payment otherwise due under the terms of the Workers’ Compensation Law shall be considered a felony. In addition, the MWCC may levy a civil penalty in an amount not to exceed ten thousand dollars ($10,000.00) if it finds that payment of a just claim has been delayed without reasonable grounds, as provided in §71-3-59(2) of the Workers’ Compensation Law. C. Billing Forms. Billing for provider services shall be standardized and submitted on the following forms: Providers must bill outpatient professional services on the most recently authorized paper form, CMS- 1500, or electronic version, 837p, regardless of the site of service. Health care facilities must bill on the most recently authorized uniform billing form. The electronic version, 837i, or the paper form UB-04 (CMS-1450) is required. Billing must be submitted using the most current paper or electronic forms which are authorized by CMS. D. Identification Number. All professional reimbursement submissions by Covered Health Care Providers as defined under CMS rules must include the National Provider Identifier (NPI) field so as to enable the specific identification of individual providers without the need for other unique provider identification numbers. Providers are required to obtain an NPI within the dates specified by CMS in its implementation rules.

Billing and Reimbursement Rules Mississippi Workers’ Compensation Medical Fee Schedule

20 Miss. Admin. Code Pt. 2, R. 12 Rule 12

CPT Copyright 2024 American Medical Association. All rights reserved. E. Provider Specialty. The rules and maximum allowable reimbursement in the Mississippi Workers’ Compensation Medical Fee Schedule do not address physician or other qualified health care professional (OQHP) specialization within a specialty. Payment is not based on the fact that a physician or OQHP has elected to treat injured workers with a particular/specific problem. Reimbursement to qualified physicians or OQHPs is the same amount regardless of specialty. F. “No Show” Appointments. When an appointment is made for a physician or OQHP visit by the employer or payer, and the injured worker does not show up or call, the provider is entitled to payment at the rate allowed for a minimal office visit. Procedure code 99202 or 99211 may be billed. When the appointment is for a functional capacity evaluation (FCE) the physician or OQHP is entitled to payment at the applicable rate for procedure codes 99202, 99211, 97161, or 97165. G. “After Hours” and Other Adjunct Service Codes. When an office service occurs after a provider’s normal business hours, procedure code 99050 may be billed. Other adjunct service codes (99051– 99060) may be billed as appropriate. Typically, only a single adjunct service code is reported per encounter. However, there may be circumstances in which reporting multiple adjunct codes per patient encounter may be appropriate. H. Portable Services. When procedures are performed using portable equipment, bill the appropriate procedure code. The charge for the procedure includes the cost of the portable equipment. I. Injections. • Reimbursement for injections includes charges for the administration of the drug and the cost of the supplies to administer the drug. Medications are charged separately using the appropriate HCPCS J-code. • The description must include the name of the medication, strength, and dose injected. • When multiple drugs are administered from the same syringe, reimbursement will be for a single injection. • Reimbursement for anesthetic agents such as Xylocaine and Carbocaine, when used for infiltration, is included in the reimbursement for the procedure performed and will not be separately reimbursed. • Reimbursement for intra-articular and intra- bursal injection medications (steroids and anesthetic agents) may be separately billed. The description must include the name of the medication, strength, and volume given. J. Supplies. Use CPT ® code 99070 or specific HCPCS codes to report supplies over and above those usually included with the office visit or service rendered. Do not bill for supplies that are currently included in surgical packages, such as gauze, sponges, and Steri-Strips ® . Supplies and materials provided by the physician or OQHP over and above those usually included with the office visit (drugs, splints, sutures, etc.) may be charged separately and reimbursed at a reasonable rate. II. INSTRUCTIONS TO PROVIDERS A. All bills for service must be coded with the appropriate CPT, CDT, HCPCS or state-specific code. B. The medical provider must file the appropriate billing form and necessary documentation within twenty (20) days of rendering services on a newly diagnosed work-related injury or illness. Subsequent billings must be submitted at least every thirty (30) days, or within thirty (30) days of each treatment or visit, whichever last occurs, with the appropriate medical records to substantiate the medical necessity for continued services. Late billings will be subject to discounts, not to exceed one and one-half percent (1.5%) per month of the bill or part thereof which was not timely billed, from the date the billing or part thereof is first due until received by the payer. Any bill or part thereof not submitted to the payer within sixty (60) days after the due date under this rule shall be subject to an additional one-time only discount penalty equal to ten percent (10%) of the total bill or part thereof. Any bill for services rendered which is not submitted to the payer within one (1) year after the date of service, or date of discharge for inpatient care, will not be eligible or considered for reimbursement under this Fee Schedule, unless otherwise ordered by the MWCC or its Cost Containment Division. C. When services were rendered by another qualified health care professional and billed under the physician’s National Provider Identifier (NPI), the billing physician must sign the medical record. When the physician bills the E/M services, the physician must personally document that the physician performed the service or was physically present during the critical or key portions of the service furnished by the qualified health care professional, and the physician’s participation in the management of the injured worker. D. Fees in excess of the maximum allowable reimbursement (MAR) must not be billed to the injured worker, employer, or payer. The provider cannot collect any non-allowed amount (MCA §71-3- 15(3) (Rev. 2000)). E. If it is medically necessary to exceed the Fee Schedule limitations and/or exclusions, substantiating documentation must be submitted by the provider to the payer with the claim form. F. If a provider believes an incorrect payment was made for services rendered, or disagrees for any reason with the payment and explanation of review tendered by the payer, then the provider may request reconsideration pursuant to the rules set forth herein. G. If, after the resolution of a reconsideration request or a formal dispute resolution request, or otherwise, the provider is determined to owe a refund to the payer, the amount refunded shall bear interest at the rate of one and one-half percent (1.5%) per month from the date the refunded amount was first received by the provider, until refunded to the payer.

Mississippi Workers’ Compensation Medical Fee Schedule Billing and Reimbursement Rules

CPT Copyright 2024 American Medical Association. All rights reserved. 13 III. INSTRUCTIONS TO PAYERS A. An employer’s/payer’s payment shall reflect any adjustments in the bill made through the employer’s/payer’s bill review program. The employer/payer must provide an explanation of review (EOR) to a health care provider whenever reimbursement differs from the amount billed by the provider. This must be done individually for each bill. B. In a case where documentation does not indicate the service was performed, the charge for the service may be denied. The EOR must clearly and specifically indicate the reason for the denial. C. (1) When a billed service is documented, but the code selected by the provider is not, in the payer’s/reviewer’s estimation, the most accurate code available to describe the service, the reviewer must not deny payment, but shall reimburse based on the revised code. The EOR must clearly and specifically detail the reason(s) for recoding the service or otherwise altering the claim. No claim shall be recoded or otherwise revised or altered without the payer having actually reviewed the medical records associated with the claim which document the service(s) provided. (2) As an alternative to recoding or altering a claim, the payer may treat the matter under rule E.(1) and E.(2) below by paying any undisputed portion of the bill, and notifying the provider by EOR that the remaining parts of the bill are denied or disputed. (3) Recoding cannot be used solely for cost containment. Recoding may only be used for the correction of miscoded services. Whenever there is any dispute concerning coding, the provider must be notified immediately and given the opportunity to furnish additional information, although nothing herein suspends the time periods for making payment or giving notice of dispute. Any recoding or so-called “downcoding,” which is found by the MWCC or its Cost Containment Division to be solely for the purpose of cost containment, will subject the party engaging in such conduct to additional penalties as allowed by law. D. Properly submitted bills must be paid within thirty (30) days of receipt by the payer. Properly submitted bills not fully paid within thirty (30) days of receipt by the payer shall automatically include interest on the unpaid balance at the rate of one and one-half percent (1.5%) per month from the due date of any unpaid remaining balance until such time as the claim is fully paid and satisfied. Properly submitted bills not fully paid within sixty (60) days of receipt will be subject to an additional one-time only penalty equal to ten percent (10%) of the unpaid remaining balance, including interest as herein provided. E. (1) When an employer/payer disputes or otherwise adjusts a bill or portion thereof, the employer/payer shall pay the undisputed or unadjusted portion of the bill within thirty (30) days of receipt of the bill. Failure to pay the undisputed portion when due shall subject the payer to interest and penalty as above provided on the undisputed portion of the bill. If the dispute is ultimately resolved in the provider’s favor, interest and penalty on the disputed amounts will apply from the original due date of the bill until paid. (2) When a payer disputes a bill or portion thereof, the payer shall notify the provider within thirty (30) days of the receipt of the bill of the reasons for disputing the bill or portion thereof, and shall notify the provider of its right to provide additional information and to request reconsideration of the payer’s action. The payer shall set forth the clear and specific reasons for disputing a bill or portion thereof on the EOR, and shall provide additional documentation if necessary to provide an adequate explanation of the dispute. F. Reimbursement determinations shall be based on medical necessity of services to either establish a diagnosis or treat an injury/illness. Thus, where service is provided in good faith reliance on authorization given by the employer or payer, reimbursement shall not be dependent on the outcome of medically necessary diagnostic services or treatment. IV. FACILITY FEE RULES A. Please refer to the Pain Management section for the state-specific facility reimbursement rules to be used for outpatient pain management procedures. B. Please refer to the Inpatient Hospital and Outpatient Facility Payment Schedule and Rules section for the state-specific facility reimbursement rules to be used for ambulatory surgery center (ASC) procedures and hospital-based outpatient departments. C. Where there is an identifiable professional and technical component to a procedure, the portion considered to be the maximum allowable for the technical component is listed in the TC MAR column. Outpatient facilities are paid based on the TC MAR when there is one. If there is no TC MAR, and the service is payable in an outpatient setting, there will be an APC MAR which should be used. Procedures with a $0.00 in the TC MAR column or where the TC MAR column is blank are considered one hundred percent (100%) professional. See Modifier and Code Rules for additional information. D. Implantables. An implantable is an item that is implanted into the body for the purpose of permanent placement, and remains in the body as a fixture. Absorbable items, temporary items, or other items used to help place the implant, are not within the definition of “implantable” and are not reimbursed as such. Implantables are included in the applicable MS-DRG reimbursement for inpatient treatment, and, therefore, the provider of inpatient services is not required to furnish the payer with an invoice for implantables. For implantables used in the outpatient setting, reimbursement is likewise included in the APC MAR paid to the facility. No separate billing or payment for implants shall be made in either the inpatient or outpatient setting. V. EXPLANATION OF REVIEW (EOR) A. Payers must provide an explanation of review (EOR) to health care providers for each bill (and each

Billing and Reimbursement Rules Mississippi Workers’ Compensation Medical Fee Schedule

20 Miss. Admin. Code Pt. 2, R. 14 Rule 14

CPT Copyright 2024 American Medical Association. All rights reserved. reconsideration) whenever the payer’s reimbursement differs from the amount billed by the provider, or when an original claim is altered or adjusted by the payer. The EOR must be provided within thirty (30) days of receipt of the bill, and must accompany any payment that is being made. B. A payer may use the listed EOR codes and descriptors or may develop codes of their own to explain why a provider’s charge has been reduced or disallowed, or why a claim has been altered or adjusted in some other way. In all cases, the payer must clearly and specifically detail the reasons for adjusting or altering a bill, including references to the applicable provisions of the Fee Schedule or CPT book, or other source(s) used as the basis for the EOR. Should the EOR include an alteration in the codes submitted on the original claim, it must be based on a review of the medical records documenting the service. C. The EOR must contain appropriate identifying information to enable the provider to relate a specific reimbursement to the applicable injured worker, the procedure billed, and the date of service. D. Acceptable EORs may include manually produced or computerized forms that contain the EOR codes, written explanations, and the appropriate identifying information. E. The following EOR codes may be used by the payer to explain to the provider why a procedure or service is not reimbursed as billed, provided clear and specific detail is included, along with references to the applicable provisions of the Fee Schedule or CPT book, or other source(s) used as the basis for the EOR: 001 These services are not reimbursable under the Workers’ Compensation Law for the following reason(s): [Provide specific reason(s) why services are not reimbursable under the Workers’ Compensation Law] 002 Charges exceed maximum allowable reimbursement [Specify] 003 Charge is included in the basic surgical allowance [Specify] 004 Surgical assistant is not routinely allowed for this procedure. Documentation of medical necessity required [Specify] 005 This procedure is included in the basic allowance of another procedure [Specify the other procedure] 006 This procedure is not appropriate to the diagnosis [Specify] 007 This procedure is not within the scope of the license of the billing provider [Specify] 008 Equipment or services are not prescribed by a physician [Specify] 009 This service exceeds reimbursement limitations [Specify] 010 This service is not reimbursable unless billed by a physician [Specify] 011 Incorrect billing form [Specify] 012 Incorrect or incomplete identification number of billing provider [Specify] 013 Medical report required for payment [Specify] 014 Documentation does not justify level of service billed [Specify] 015 Place of service is inconsistent with procedure billed [Specify] 016 Invalid procedure code [Specify] 017 Prior authorization was not obtained [Specify] VI. REQUEST FOR RECONSIDERATION A. When, after examination of the explanation of review (EOR) and other documentation, a health care provider is dissatisfied with a payer’s payment or dispute of a bill for medical services, reconsideration may be requested by the provider. Any other matter in dispute between the provider and payer may be subject to reconsideration as herein provided at the request of either party, including, but not limited to, a request by the payer for refund of an alleged over-payment. Alleged over-payments should be addressed through the dispute resolution process, if necessary, and not by way of unilateral recoupment initiated by the payer on subsequent billings. B. A provider or payer must make a written request for reconsideration within sixty (60) days from the receipt of the initial explanation of review (EOR) or other written documentation evidencing the basis for the dispute. A request for reconsideration must be accompanied by a copy of the bill in question, the payers’ explanation of review (EOR), and/or any additional documentation to support the request for reconsideration. C. The payer or provider, upon receipt of a request for reconsideration, must review and re-evaluate the original bill and accompanying documentation, and, must notify the requesting party sixty (60) days thereafter of the results of the reconsideration. The response must adequately explain the reason(s) for the decision, and cite the specific basis upon which the final determination was made. If the payer finds the provider’s request for reconsideration is meritorious, and that additional payment(s) should be made, or if the provider finds the payer’s request for refund or other payment is meritorious, the additional payment should be made within the above thirty (30) day period. Any additional payment(s) made in response to a provider’s or payer’s request for reconsideration shall include interest from the original due date of the bill or payment, and an additional ten percent (10%) penalty if applicable. D. If the dispute is not resolved within the above time after a proper request for reconsideration has been served by the provider or payer, then either party may request further review by the MWCC pursuant to the Dispute Resolution Rules set forth hereafter. E. Failure to seek reconsideration within the time above provided shall bar and prohibit any further reconsideration or review of the bill or other issue in question unless, for good cause shown, the MWCC or its representative extends the time for seeking reconsideration or review under these rules. In no event shall the time for seeking reconsideration hereunder be extended by more than an additional sixty (60) days, and any such request for additional

Mississippi Workers’ Compensation Medical Fee Schedule Billing and Reimbursement Rules

CPT Copyright 2024 American Medical Association. All rights reserved. 15 time in which to seek reconsideration or further review must be made in writing to the MWCC within the initial sixty (60) day period set forth in paragraph B above. F. Requests by either provider or payer for refunds, or for additional payment, or other requests related to the billing or payment of a claim, must be sought in accordance with the specific rules set forth herein. No retrospective audits or dispute requests shall be allowed beyond one year from the date of service for seeking reconsideration and/or review.

20 Miss. Admin. Code Pt. 2, R. 16 Rule 16

CPT Copyright 2024 American Medical Association. All rights reserved. 17 MEDICAL RECORDS RULES I. MEDICAL RECORDS A. The medical record, which documents the injured worker’s course of treatment, is the responsibility of the provider and is the basis for determining medical necessity and for substantiating the service(s) rendered; therefore, failure to submit necessary or adequate documentation to support the services rendered may result in the services being disallowed. B. A medical provider may not charge any fee for completing a medical report or form required by the MWCC which is part of the required supporting documentation which accompanies a request for payment. The supporting documentation that is required to substantiate the medical treatment is included in the fee for service and does not warrant a separate fee as it is incidental to providing medical care. CPT ® code 99080 is appropriate for billing special reports beyond those required by this Fee Schedule and requested by the payer or their representatives. C. Medical records must be legible and include, as applicable: 1. Initial office visit notes which document time, medical decision making, assessment and plan appropriate to the level of service indicated by the presenting injury/illness or treatment of the ongoing injury/illness; 2. Progress notes which reflect injured worker complaints, objective findings, assessment of the problem, and plan of care or treatment; 3. Copies of lab, imaging, or other diagnostic tests that reflect current progress of the injured worker and/or response to therapy or treatment; 4. Physical therapy/occupational therapy progress notes that reflect the injured worker’s response to treatment/therapy; 5. Operative reports, consultation notes with report, and/or dictated report; and 6. Impairment rating (projected and actual) and anticipated maximum medical improvement (MMI) date. D. A plan of care should be included in the medical record and should address, as applicable, the following: 1. The disability; 2. Degree of restoration anticipated; 3. Measurable goals; 4. Specific therapies to be used; 5. Frequency and duration of treatments to be provided; 6. Anticipated return to work date; and 7. Projected impairment. E. Health care providers must submit copies of records and reports to payers upon request. Providers can facilitate the timely processing of claims and payment for services by submitting appropriate documentation to the payer when requested. Only those records for a specific date of injury are considered non-privileged as it relates to a workers’ compensation injury. The employer/payer is not privileged to non-work-related medical information. F. Providers must submit documentation for the following when applicable: 1. The initial office visit; 2. A progress report if still treating after thirty (30) days; 3. Evaluation for therapy services/treatment (P.T., O.T., C.M.T., O.M.T.); 4. A progress report every thirty (30) days for therapy services/treatment (P.T., O.T., C.M.T., O.M.T.); 5. An operative report or office note (if done in the office) for a surgical procedure; 6. A consultation; 7. The anesthesia record for anesthesia services; 8. A functional capacity or work hardening evaluation; 9. When billing “By Report” (BR), a description of the service is required; this description should include an adequate definition or description of the nature, extent, and need for the procedure and the time, effort, and equipment necessary to provide the service; 10. Whenever a modifier is used to describe an unusual circumstance; and 11. Whenever the procedure code descriptors include a written report. G. Hospitals and other inpatient facilities must submit required documentation with the appropriate billing forms for applicable services as follows: 1. Admission history and physical; 2. Discharge summary; 3. Operative reports; 4. Pathology reports; 5. Radiology reports; 6. Consultations; 7. Other dictated reports; and 8. Emergency room records.

Medical Records Rules Mississippi Workers’ Compensation Medical Fee Schedule

20 Miss. Admin. Code Pt. 2, R. 18 Rule 18

CPT Copyright 2024 American Medical Association. All rights reserved. II. COPIES OF RECORDS A. Outpatient Records. The payer may request additional records or reports from the provider concerning service or treatment provided to an injured worker. These additional records and reports will be reimbursed as follows: $20.00 for first 20 pages; $1.00 per page for pages 21-100; and $0.50 per page for everything thereafter This applies to copies of microfiche and other electronic media or storage systems. As provided by MCA §11-1-52(1) (Supp. 2006), as amended, the provider may add ten percent (10%) of the total charge to cover the cost of postage and handling, and may charge an additional fifteen dollars ($15.00) for retrieving records stored off the premises where the provider’s facility or office is located. B. Inpatient Records. The payer may request additional records or reports from a facility concerning inpatient service or treatment provided to an injured worker. Such reports or records requested by the payer will be reimbursed as follows: $20.00 for first 20 pages; $1.00 per page for pages 21-100; and $0.50 per page for everything thereafter This applies to copies of microfiche and other electronic media or storage systems. There is a maximum reimbursement allowance of one hundred dollars ($100.00) for a particular inpatient medical record, exclusive of postage, handling and retrieval charges as set forth below. This is per admission. As provided by MCA §11-1-52(1) (Supp. 2006), as amended, the provider may add ten percent (10%) of the total charge to cover the cost of postage and handling, and may charge an additional fifteen dollars ($15.00) for retrieving records stored off the premises where the provider’s facility or office is located. C. Copies of records requested by the injured worker and/or the injured worker’s attorney or legal representative will be reimbursed by the requesting party according to the provisions of this section on additional reports and records. D. Documentation submitted by the provider which has not been specifically requested will not be subject to reimbursement. E. Health care providers may charge up to ten dollars ($10.00) per image for copying x-rays or for providing copies of x-rays via electronic or other magnetic media. (Copies of film do not have to be returned to the provider.) F. Payers, their representatives, and other parties requesting records and reports must be specific in their requests so as not to place undue demands on provider time for copying records. G. Providers should respond promptly (within fourteen (14) working days) to requests for additional records and reports. H. Records requested by the MWCC will be furnished by the provider without charge to the MWCC. I. Any additional reimbursement, including copy service vendors, other than specifically set forth above, is not required, and providers or their vendors will not be paid any additional amounts. III. HEALTH INSURANCE PORTABILITY & ACCOUNTABILITY ACT (HIPAA) AND WORKERS’ COMPENSATION HIPAA makes important exceptions concerning the disclosure of protected health information (PHI) for workers’ compensation purposes. The United States Department of Health and Human Services, through its Office for Civil Rights, enforces the HIPAA Law and maintains an informative website with information on HIPAA and its application to workers’ compensation claims. For additional information, refer to the MWCC website (mwcc.ms.gov), or consult an attorney and/or the HIPAA resource site maintained by the U. S. Department of Health and Human Services (http://hhs.gov/ocr/privacy/).

CPT Copyright 2024 American Medical Association. All rights reserved. 19 DISPUTE RESOLUTION RULES I. GENERAL PROVISIONS A. Unresolved disputes over the amount charged for services rendered under the provisions of the Fee Schedule or over the amount of reimbursement for services rendered under the Fee Schedule may be appealed to and resolved by the MWCC. Regardless of the date of service, all changes to the dispute resolution procedures found in this edition of this section of the Fee Schedule shall be applied retroactively to all Requests for Resolution of Dispute or other documents filed on or after the effective date of this Fee Schedule. B. Reconsideration must be sought by the provider or payer prior to a Request for Resolution of Dispute being sent to the MWCC. The providers request to the carrier for reconsideration of an adjusted and/or disputed bill shall include a statement on their letterhead providing in detail the reasons for disagreement and the exact amount owed. This provides the payer and provider an opportunity to resolve most concerns in a timely manner. C. All communication between parties in dispute will be handled by the MWCC, Cost Containment Division. In addition, there will be no communication between the parties in dispute and any Peer Reviewer who might be called upon to assist the MWCC in the resolution of a dispute. D. In the absence of any agreement between the parties submitted to the MWCC in writing, Requests for Resolution of Dispute shall not be ruled upon in claims for which the compensability of the underlying injury is currently disputed or denied by the payer. In the event the parties submit such an agreement, it shall be subject to the review and approval of the Cost Containment Division, and such agreement shall be recognized or denied in the sole discretion of the Cost Containment Division and/or the MWCC. Otherwise, Cost Containment Decisions for Requests for Resolution of Dispute may be held in abeyance pending a final adjudication and/or admission of compensability by the payer for the underlying injury in the dispute. II. FORMS AND DOCUMENTATION A. Valid requests for resolution of a dispute must be submitted on the “Request for Resolution of Dispute” form (see the form at the end of this section or https://www.mwcc.ms.gov/pdf/Request_Resolution %20of%20Dispute.pdf along with the following: 1. Copies of the original and resubmitted bills in dispute that include dates of service, procedure codes, charges for services rendered and any payment received, and an explanation of any unusual services or circumstances; 2. Information on the provider’s letterhead stating and detailing the reason for the dispute request; 3. All EORs including the specific reimbursement; 4. Supporting documentation and correspondence; 5. Specific information regarding contact with the payer; and 6. Any other information deemed relevant by the applicant for dispute resolution. B. A Request for Resolution of Dispute can be submitted via email to: costcontainment@mwcc.ms.gov Or by CERTIFIED MAIL to: Mississippi Workers’ Compensation Commission Cost Containment Division 1428 Lakeland Drive P.O. Box 5300 Jackson, MS 39296-5300

C. A party, whether payer, provider, or injured worker, shall certify that a copy of the Request for Resolution of Dispute and/or the Response to such Request, and any supporting documentation, being filed with the MWCC has been provided to the other interested parties or their representatives by email or CERTIFIED MAIL simultaneously with the filing to the MWCC. This requirement shall also apply when a party files a request seeking review of a dispute by the MWCC. III. TIME FOR FILING A Request for Resolution of Dispute must be filed with the MWCC within sixty (60) days following the payer’s or provider’s response to a request for reconsideration of any matter in dispute, or, in cases where the payer or provider fails to respond to a request for reconsideration, within sixty (60) days of the expiration of the time in which said response should have been provided. Failure to file a Request for Resolution of Dispute within this time shall bar any further action on the disputed issue(s) unless, for good cause shown, the MWCC Cost Containment Division or its designee extends the time for filing said request. In no event will a Request for Resolution of Dispute be considered by the Cost Containment Division if submitted more than one (1) year after the date of service unless for good cause. The decision to extend the time for filing a Request for Resolution of Dispute based on “good cause” shall be entirely at the discretion of the MWCC Cost Containment Division or its designee. Mere neglect will not constitute “good cause.” IV. PROCEDURE BY COST CONTAINMENT DIVISION A. Requests for dispute resolution will be reviewed and decided by the Cost Containment Division of the MWCC after all required and requested information has been received. Additional time may be required to accommodate a Peer Review. The payer and/or provider may be contacted by telephone or other means for additional information if necessary; however, both parties to a dispute may submit in

Dispute Resolution Rules Mississippi Workers’ Compensation Medical Fee Schedule

20 Miss. Admin. Code Pt. 2, R. 20 Rule 20

CPT Copyright 2021 2024 American Medical Association. All rights reserved. writing any information or argument they deem relevant to the issue in dispute, if not already submitted with the request for dispute resolution, and this information shall be considered by the Cost Containment Division when rendering a decision. Any written information or argument submitted for consideration by a party to a dispute, without a request from the MWCC, must be received by the Cost Containment Division within twenty-three (23) days after filing the Request for Resolution of Dispute in order to merit consideration. Unlike the Request for Resolution of Dispute Form, there is no specific prescribed form for a response to such request. B. Every effort should be made by the parties to resolve disputes between themselves by telephone or in writing even after the filing of a Request for Resolution of Dispute. The payer and provider may be requested to attend an informal hearing conducted by a MWCC representative. Failure to appear at an informal hearing may result in dismissal of the Request for Resolution of Dispute. However, no formal hearing or oral argument shall be allowed unless requested by the Cost Containment Division and/or the MWCC. Otherwise, Requests for Resolution of Dispute shall be heard and considered solely on the record provided by the parties in the documentation they have submitted to the Cost Containment Division and any arguments they have made therein, without any oral argument or formal hearing. C. Following review of all documentation submitted for dispute resolution and/or following contact with the payer and/or provider for additional information and/or negotiation, the Cost Containment Division shall render an administrative decision on the request for dispute resolution and forward it to the involved parties. D. Cases involving medical care determination may be referred for peer review, but only on request of the MWCC. The peer review consultant will render an opinion and submit same to the MWCC representative within the time set by the Cost Containment Division. The MWCC representative will notify the parties in dispute if a Peer Review has been requested, and of the peer review consultant’s determination. V. MWCC REVIEW OF A DISPUTE A. Any party aggrieved by the decision of the Cost Containment Division shall have twenty (20) days from the date of said decision to request review by the MWCC. Failure to file a written request for review with the MWCC within this twenty (20) day period shall bar any further review or action with regard to the issue(s) presented. A decision of the Cost Containment Division that is not timely appealed shall constitute a final decision of the Full MWCC, with all findings and determinations of the Cost Containment Division or its designee, including the award of penalties, interest, and attorney’s fees and/or expenses, to be considered as having been awarded by the Full MWCC itself, including any penalty under Mississippi Code Annotated Section 71-3-59. No extension of time within which to file for MWCC review of a dispute under these Rules shall be allowed. In the event a request for review is not filed with the MWCC within twenty (20) days, the parties to the dispute shall have fourteen (14) days thereafter in which to comply with the final decision of the Cost Containment Division. A party to a dispute may, when a written request for review has not been timely filed with the MWCC, seek enforcement of payment of that decision pursuant to the terms and time period set forth in Mississippi Code Annotated Section 71-3-49. A Final Decision of the Cost Containment Division and/or the MWCC shall be considered sufficient to allow the payer and/or provider to pursue any and all remedies available to it for enforcement of payment in default pursuant to Mississippi Code Annotated Section 71-3-49. No further action to enforce payment shall be made by the MWCC, nor shall any other document be issued regarding the dispute unless the MWCC finds the issuance of such document to be necessary. The payer and/or provider shall be solely responsible for calculating the interest and penalty owed to it pursuant to the terms of the Fee Schedule, and any dispute regarding enforcement of payment in default and/or the amount of interest or penalty due shall be determined by the Court wherein the payer or provider has sought enforcement pursuant to Mississippi Code Annotated. Section 71-3-49. The same procedure for enforcement above shall also be applicable to all final decisions of the MWCC in the event the decision of the Cost Containment Division was timely appealed in an official letter to the MWCC commissioners and a final decision of the MWCC has been issued. B. The request for review by the MWCC shall be filed with the Cost Containment Division of the Mississippi Workers’ Compensation Commission, shall be in writing, and shall state the grounds on which the requesting party relies. All documentation submitted to and considered by the Cost Containment Division, including the Request for Resolution of Dispute form, along with a copy of the decision of the Cost Containment Division, shall be attached to the request for review which is filed with the MWCC. The party seeking relief hereunder shall certify that a copy of the request for review and any supporting documentation being filed with the MWCC has been provided to the other interested parties or their representatives by CERTIFIED MAIL or email simultaneously with the filing to the MWCC. Unlike the Request for Resolution of Dispute Form, there is no specific prescribed form for a Request for MWCC Review. C. The MWCC shall review the issue(s) solely on the basis of the documentation submitted to the Cost Containment Division. No additional documentation not presented to and considered by the Cost Containment Division shall be considered by the MWCC on review, unless specifically requested by the MWCC, and no hearing or oral argument shall be allowed, unless specifically requested by the MWCC. D. The MWCC shall consider the request for review and issue a decision.

Mississippi Workers’ Compensation Medical Fee Schedule Dispute Resolution Rules

CPT Copyright 2024 American Medical Association. All rights reserved. 21 E. Following the decision of the MWCC, or following the conclusion of the dispute resolution process at any stage without an appeal to the MWCC, no further audit, adjustment, refund, review, consideration, reconsideration or appeal with respect to the claim in question by the MWCC may be sought by either party. F. The costs incurred in seeking MWCC review, or in seeking compliance with an Administrative Decision rendered by the Cost Containment Division or its designee, including reasonable attorney fees, if any, may be assessed to the party who requested review if that party’s position is not sustained by the MWCC and to the party who has failed to comply with a prior decision if compliance therewith is ordered by the MWCC. Otherwise, each party shall bear their own costs, including attorney’s fees. G. If the Cost Containment Division or its designee and/or the MWCC determines that a dispute is based on or arises from a billing error, a payment adjustment or error, including but not limited to improper bundling of service codes, unbundling, downcoding, code shifting, or other action by either party to the dispute, or if the MWCC determines that a provider or payer has unreasonably refused to comply with the Workers’ Compensation Law, the Rules of the MWCC, including this Fee Schedule, or with any decision of the MWCC or its representatives, and that this causes proceedings with respect to the billing and/or payment for covered medical services to be instituted or continued or delayed without reasonable grounds, then the MWCC may require the responsible party or parties, and/or the attorney advising such party or parties, to pay the reasonable expenses, including attorney’s fees, if any, to the opposing party; and, in addition, the MWCC may levy against the responsible party or parties a civil penalty not to exceed the sum of ten thousand dollars ($10,000.00), payable to the MWCC, as provided in §71-3-59(2) of the Workers’ Compensation Law. The award of costs and penalties as herein provided shall be in addition to interest and penalty charges which may apply under other provisions of this Fee Schedule.

20 Miss. Admin. Code Pt. 2, R. 22 Rule 22

AUTHORIZATION/PRE-CERTIFICATION RULES Certain medical services associated with the provision of medical treatment covered under the Workers’ Compensation Law and subject to the Fee Schedule may be subject to prior authorization/pre-certification at the discretion of the payer. “Pre-certification” refers to a system for reviewing proposed medical services to make sure that such procedures are medically necessary and represent the most efficient and appropriate use of medical resources given the nature of the injury to the injured worker and the process of his or her recovery, and that such services are properly and timely reimbursed. These rules are set forth to encourage efficient and timely communication between payers and providers (including agents of either) in order to make sure that medically necessary services are provided and timely reimbursed, and to curtail the use of unnecessary or unreasonable treatment. The provisions herein set forth regarding pre-certification are in addition to the requirements of Mississippi Code Annotated (MCA) §41- 83-1 et seq. (Rev. 2005), as amended, and any regulations adopted pursuant thereto by the State Department of Health, the State Board of Medical Licensure, or the regulatory agency as defined for the practitioner rendering the service. In the event of conflict between this Fee Schedule and the above statutes, and any implementing regulations adopted by the Health Department or Board of Medical Licensure, the provisions in this Fee Schedule or other applicable rules of the MWCC shall control. A payer may provide for pre-certification by using personnel or units in-house, by contracting with a third- party utilization review agent properly licensed by the MS Department of Health, or by contracting with a Nurse Case Manager or similar person to monitor the care being provided in person working with the injured worker and provider. An injured worker and/or his or her attorney and any case manager assigned by the payer shall strive to cooperate with one another for the purpose of ensuring the injured worker receives all of the medically necessary care needed for the treatment of the injury and the process of recovery. A payer also may exercise their statutory right to an Employer Medical Evaluation (EME) as provided for in MCA §71-3-15(1) (Rev. 2000) in conjunction with, or in lieu of, ongoing prior authorization/pre-certification. NO DECISION OR DETERMINATION ADVERSE TO AN INJURED WORKER OR HEALTH CARE PROVIDER WHICH MAY RESULT IN THE DENIAL OF PAYMENT, OR IN THE DENIAL OF PRE-CERTIFICATION FOR TREATMENT IN THIS STATE, SHALL BE MADE WITHOUT THE PRIOR EVALUATION AND CONCURRENCE IN THE ADVERSE DETERMINATION BY A PHYSICIAN CURRENTLY LICENSED TO PRACTICE MEDICINE IN THE STATE OF MISSISSIPPI, AND PROPERLY TRAINED IN THE SAME SPECIALTY OR SUB-SPECIALTY AS THE REQUESTING PROVIDER WHO IS SEEKING APPROVAL FOR TREATMENT OR SERVICES. THIS ADVERSE DETERMINATION MUST BE PROVIDED WITHIN TWO (2) BUSINESS DAYS EITHER BY EMAIL, FACSIMILE OR TELEPHONE FOLLOWED BY A WRITTEN NOTIFICATION VIA U.S. MAIL OR COMMERCIAL MAIL DELIVERY SERVICE WITHIN ONE (1) BUSINESS DAY THEREAFTER, TO THE REQUESTING PROVIDER. ANY SUCH ADVERSE DETERMINATION MUST INCLUDE WRITTEN DOCUMENTATION CONTAINING THE SPECIFIC EVALUATION, FINDINGS AND CONCURRENCE OF THE MISSISSIPPI LICENSED PHYSICIAN TRAINED IN THE RELEVANT SPECIALTY OR SUB-SPECIALTY, AND MUST REFERENCE ANY SPECIFIC PROVISIONS OF THE MISSISSIPPI WORKERS’ COMPENSATION MEDICAL FEE SCHEDULE IN EFFECT ON THE DATE OF ADVERSE DETERMINATION WHICH ALLEGEDLY JUSTIFIES THE ADVERSE DETERMINATION. ANY ADVERSE DETERMINATION WHICH DOES NOT COMPLY WITH THIS PROVISION SHALL HAVE NO FORCE OR EFFECT AND SHALL NOT PREVENT THE PROVIDER FROM PROCEEDING WITH THE PROPOSED TREATMENT AND ULTIMATELY BEING REIMBURSED AS THOUGH THE PROPOSED TREATMENT OR SERVICE HAD BEEN TIMELY APPROVED IN ADVANCE. IF A PAYER ELECTS TO SEEK AN EME IN LIEU OF PRIOR AUTHORIZATION/PRE-CERTIFICATION, THE INJURED WORKER AND THE PROVIDER MUST BE NOTIFIED OF THIS ELECTION WITHIN THE SAME TWO (2) DAY PERIOD APPLICABLE TO ADVERSE DETERMINATIONS STATED ABOVE. I. SERVICES THAT MAY REQUIRE PRE- CERTIFICATION The following medical procedures may require pre- certification by the payer. The payer may waive pre- certification or, at its discretion, require review by a utilization review agent. If a utilization review agent is not used, the review must be based on evidence-based practice standards. Any adverse determination must have concurrence of a physician of the same specialty or sub- specialty and licensed to practice in Mississippi. If the payer requires review by a utilization review agent and receives an adverse determination, the payer may override the decision and authorize the series(s). A. Elective admissions to inpatient facilities of any type; B. Elective surgical procedures, inpatient and outpatient; C. Physical medicine treatments after 15 visits and/or 30 days post-operatively; D. Rental or purchase of supplies or equipment, including items billed with HCPCS code E1399, over the amount of four hundred dollars ($400.00) per item or per month for rental; E. Rental or purchase of transcutaneous electrical nerve stimulation (TENS) or neurostimulator devices; F. Home health services; G. Pain clinic/therapy programs, including interdisciplinary pain rehabilitation programs; H. External spinal stimulators; I. Pain control programs;

Authorization/Pre-Certification Rules Mississippi Workers’ Compensation Medical Fee Schedule

20 Miss. Admin. Code Pt. 2, R. 24 Rule 24

CPT Copyright 2024 American Medical Association. All rights reserved. J. Work hardening programs, functional capacity testing, ISO kinetic testing; K. Orthotics or prosthetics if over four hundred dollars ($400.00) per item; L. Psychological testing/counseling/treatment; M. Substance abuse program; N. Weight reduction program; O. Any non-emergency medical service outside the State of Mississippi; P. Repeat MRI, repeat CT scan, repeat EMG/NCS, and repeat myelogram (more than once per injury and/or more than one post-operatively); and Q. Massage therapy, acupuncture and biofeedback. II. DEFINITIONS For the purpose of this Fee Schedule the following activities have been defined: Authorization. An authorization is an approval of medical services by a carrier/payer/employer, usually prior to service being rendered. Case Management. The clinical and administrative process in which timely, individualized, and cost-effective medical rehabilitation services are implemented, coordinated, and evaluated, by a nurse, other case manager, or other utilization reviewer employed by the payer, on an ongoing basis for patients who have sustained an injury or illness. Use of case management is optional in Mississippi. Use CPT codes 99366, 99367, or 99368 for a conference with workers’ compensation medical case manager/claims manager. Clinical Peer. A health professional that holds an unrestricted medical or equivalent license and is qualified to practice in the same or similar specialty as would typically manage the medical condition, procedures, or treatment under review. Generally, as a peer in a similar specialty, the individual must be in the same profession (i.e., the same licensure category as the ordering provider). Clinical Rationale. A statement or other documentation that taken together provides additional clarification of the clinical basis for a non-certification determination. The clinical rationale should relate the non-certification determination to the injured worker’s condition or treatment plan, and must include a detailed basis for denial or non-certification of the proposed treatment so as to give the provider or injured worker a sufficient basis for a decision to pursue an appeal. Clinical rationale must include specific reference to any applicable provisions of the Mississippi Workers’ Compensation Medical Fee Schedule which allegedly support the determination of the reviewer, or a statement attesting to the fact that no such provision(s) exists in the Fee Schedule. Concurrent Review. Certification or Authorization review conducted during a worker’s hospital stay or course of treatment, sometimes called continued stay review. Discharge Planning. The process of assessing an injured worker’s need for medically appropriate treatment after hospitalization including plans for an appropriate and timely discharge. Expedited Appeal. An expedited appeal is a request to reconsider a prior determination not to certify imminent or ongoing services, an admission, an extension of stay, or other medical services of an emergency, imminent, or ongoing nature. An expedited appeal is to be completed within 72 hours of receipt. First Level Clinical Review. Review conducted by a registered nurse, nurse case manager, or other appropriate licensed or certified health professional. First level clinical review staff may approve requests for admissions, procedures, and services that meet the standard of medical necessity as defined elsewhere in the Fee Schedule, but must refer requests that do not meet this medical necessity standard, in their opinion, to second level clinical peer reviewers for approval or denial. Notification. Correspondence transmitted by mail, telephone, facsimile, email, and/or other reliable electronic means. Peer Review. A review of any issue related to a claim as requested by another party. (Not usually requested by the provider.) Pre-certification. The review and assessment of proposed medical treatment or services before they occur to determine if such treatment or services meet the definition of medical necessity as set forth elsewhere in this Fee Schedule. The appropriateness of the site or level of care is assessed along with the duration and timing of the proposed services. Provider. A licensed health care facility, program, agency, or health professional that delivers health care services. Retrospective Review. Authorization review conducted after services have been provided to the injured worker. Second Level Clinical Review. Peer review conducted by appropriate clinical peers when the First Level Clinical Reviewer is unable to determine whether a request for an admission, procedure, or service satisfies the standard of medical necessity as defined elsewhere in this Fee Schedule. A decision to deny, or not certify, proposed treatment or services, must be supported by the express written evaluation, findings and concurrence of a physician licensed to practice medicine in the State of Mississippi and properly trained in the same specialty as the requesting provider. Standard Appeal. A request by or on behalf of the injured worker or provider to reconsider a prior decision by the payer or its utilization review agent to deny proposed medical treatment or service, including but not limited to, a determination not to certify an admission, extension of stay, or other health care service. Third Level Clinical Review. Medical necessity review conducted by appropriate clinical peers who were not involved in the first or second level review when a decision not to certify a requested admission, procedure, or service has been appealed. The third level peer reviewer must be in the same or like specialty as the requesting provider. A decision to deny, or not certify, proposed treatment or services, must be supported by the express written evaluation, findings and concurrence

Mississippi Workers’ Compensation Medical Fee Schedule Authorization/Pre-Certification Rules

CPT Copyright 2024 American Medical Association. All rights reserved. 25 of a physician licensed to practice medicine in the State of Mississippi and properly trained in the same specialty as the requesting provider. Utilization Reviewer. An entity, organization, or representative/person performing prior authorization/pre-certification activities or services on behalf of an employer, payer or third-party claims administrator. Variance. A deviation from a specific standard. III. STANDARDS Payers, providers and their utilization review organizations or programs or agents are required to meet the following standards: A. The payer’s utilization reviewer or agent must comply with the licensing and certification requirements of MCA §41-83-1 et seq. (Rev. 2005), as amended, and any regulations adopted pursuant thereto by the State Department of Health or the State Board of Medical Licensure, and shall have utilization review personnel, agents or representatives who are properly qualified, trained, supervised, and supported by explicit clinical review criteria and review procedures. In no event shall proposed treatment or services be denied except in accordance with the express provisions stated elsewhere in these Rules and in accordance with MCA §41-83-31 (Rev. 2009). B. The first level review is performed if the claims adjuster or manager has not already approved the treatment in question, and is performed by individuals who are health care professionals, who possess a current and valid professional license, and who have been trained in the principles and procedures of utilization review. C. The first level reviewers are required to be supported by a doctor of medicine who has an unrestricted license to practice medicine, and in cases where treatment is being denied or withheld by a utilization reviewer, this determination must be supported in writing by a physician licensed in Mississippi and trained in the relevant specialty or sub-specialty, as previously set forth in these Rules. D. The second and third level review is performed by clinical peers who hold a current, unrestricted Mississippi license to practice in the same or like specialty as the treating physician whose recommendation is under review, and are oriented in the principles and procedures of utilization review. The second level review shall be conducted for all cases where a clinical determination to certify has not already been made by the payer or payer’s agent, and the determination of medical necessity cannot be made by first level clinical reviewers. Second and third level clinical reviewers shall be available within one (1) business day by telephone or other electronic means to discuss the determination with the attending physicians or other ordering providers. In the event more information is required before a determination can be rendered by a second or third level reviewer, the attending/ordering provider must be notified immediately of the delay and given a specific time frame for determination, and a specific explanation of the additional information needed. A requesting provider shall not be required to participate in further discussions where the payer or its agents have unilaterally scheduled such a conference. Further, a request for treatment or service may not be denied solely on grounds the requesting provider fails to participate in a conference which has been unilaterally scheduled by the payer or their agent. Follow-up conferences must be arranged by joint agreement. E. The payer’s utilization reviewer shall maintain all licensing applications, certificates, and other supporting information, including any and all reports, data, studies, etc., along with written policies and procedures for the effective management of its prior authorization/pre-certification activities, which shall be made available to the provider, or the Commission, upon request. F. The payer maintains the responsibility for the oversight of the delegated functions if the payer delegates prior authorization/pre-certification responsibility to a vendor. The vendor or organization to which the function is being delegated must be currently certified by the Mississippi Board of Health, Division of Licensure and Certification to perform utilization management in the State of Mississippi. A copy of the license or certification held by the utilization review agent shall be furnished to the provider, or to the Commission, upon request. The payer who has another entity perform prior authorization/pre-certification functions or activities on its behalf maintains full responsibility for compliance with the rules. G. The payer’s utilization reviewer shall maintain a telephone review service that provides access to its review staff at a toll-free number from at least 9:00 a.m. to 5:00 p.m. CT each normal business day. There should be an established procedure for receiving or redirecting calls after hours or receiving faxed or electronic requests. Reviews should be conducted during hospitals’ and health professionals’ reasonable and normal business hours. H. The payer’s utilization reviewer shall collect only the information necessary to certify the admission procedure or treatment, length of stay, frequency, and duration of services. The utilization reviewer should have a process to share all clinical and demographic information on individual workers among its various clinical and administrative departments to avoid duplicate requests to providers. I. Providers must submit a request to the payer using the MWCC Request for Authorization/Pre- certification. (A copy of this form is provided at the end of this section.) IV. PROCEDURES FOR REVIEW DETERMINATIONS The following procedures are required for effective review determination. A. Initial review determinations must be made within two (2) business days of receipt of the attending or ordering physician’s or OQHP’s records and other necessary information on a proposed non-emergency

Authorization/Pre-Certification Rules Mississippi Workers’ Compensation Medical Fee Schedule

20 Miss. Admin. Code Pt. 2, R. 26 Rule 26

CPT Copyright 2024 American Medical Association. All rights reserved. admission or service requiring a review determination. Receipt of necessary information may necessitate a discussion with the attending or ordering physician or OQHP and may involve a completed second level clinical review. In the case of determinations made by a specialist conducting a second level clinical review as defined under the Authorization/Pre-certification Rules of the Fee Schedule, the two (2) day period begins to run upon the payer’s receipt of a completed second opinion review from the second level clinical reviewer. Second level clinical review is not an Employer’s Medical Evaluation (EME). In an EME, the injured worker is examined. In contrast, a second level clinical review as defined under the Fee Schedule does not include an in-person examination of the injured worker. An EME conducted in lieu of pre- certification is governed by other provisions of the Authorization/Pre-certification Rules of the Fee Schedule, Miss. Code Ann. Section 71-3-15, and Miss. Work. Comp. Com. General Rule 1.9. In cases where an EME is conducted in lieu of pre- certification, the payer must notify the provider and the injured worker of its election to obtain an EME within the same two (2) day period applicable to initial review determinations that begins once the payer has received the necessary information. However, in that instance, collection of the necessary information will not include the opinion of a second level clinical reviewer because no second level clinical reviewer will be used. Rather, the EME is elected in lieu of any further pre-certification. The Mississippi Workers’ Compensation Commission Request for authorization/pre-certification of Medical Treatment form may be used to request prior authorization/pre-certification. B. When an initial determination is made to certify, notification shall be provided promptly, at least within one (1) business day or before the service is scheduled, whichever first occurs, either by telephone or by written or electronic notification to the provider or facility rendering the service. If an initial determination to certify is provided by telephone, a written notification of the determination shall be provided within two (2) business days thereafter. The written notification shall include the number of days approved, the new total number of days or services approved, and the date of admission or onset of services. C. When a determination is made not to certify, notification to the attending or ordering provider or facility must be provided by email, fax or telephone within one (1) business day followed by a written notification via U.S. mail or commercial mail delivery service within one (1) business day thereafter. The written notification must include the principal reason/clinical rationale for the determination not to certify, including specific reference to any provision of this Fee Schedule relied upon by the reviewer, and instructions for initiating an appeal and/or reconsideration request. D. The payer or its review agent shall inform the attending or ordering physician or OQHP of their right to initiate an expedited appeal in cases involving emergency or imminent care or admission, or a standard appeal, as the case may permit, of a determination not to certify, and the procedure to do so. 1. Expedited appeal—Review of an expedited appeal must be completed within 72 hours of receipt. When an initial determination not to certify a health care service is made prior to or during an ongoing service requiring imminent or expedited review, and the attending or ordering physician or other qualified health care professional believes that the determination warrants immediate appeal, the attending or ordering physician or OQHP shall have an opportunity to appeal that determination over the telephone or by email or facsimile on an expedited basis within one (1) business day. a. Each private review agent shall provide for prompt and expeditious access to its consulting physician(s) or OQHP(s) for such appeals. b. Both providers of care and private review agents should attempt to share the maximum information by phone, fax, or otherwise to resolve the expedited appeal (sometimes called a reconsideration request) satisfactorily. c. Expedited appeals, which do not resolve a difference of opinion, may be resubmitted through the standard appeal process, or submitted directly to the Commission’s Medical Cost Containment Division as a Request for Resolution of Dispute. A disagreement warranting expedited review or reconsideration does not have to be resubmitted to the payer or utilization review agent through the standard appeal process unless the requesting provider so wishes. 2. Standard appeal—A standard appeal will be considered as a request for reconsideration, and notification of the appeal decision given to the provider, not later than twenty (20) calendar days after receiving the required documentation for the appeal. a. An attending or ordering physician or OQHP who has been unsuccessful in an attempt to reverse a determination not to certify treatment or services must be provided the clinical rationale for the determination along with the notification of the appeal decision. 3. Retrospective review—For retrospective review, the review determination shall be based on the medical information available to the attending or ordering provider at the time the medical care was provided, and on any other relevant information regardless of whether the information was available to or considered by the provider at the time the care or service was provided. A request for review and approval of services already provided must be handled by the payer or its utilization reviewer in the same manner as any other request for approval of services is handled.

Mississippi Workers’ Compensation Medical Fee Schedule Authorization/Pre-Certification Rules

CPT Copyright 2024 American Medical Association. All rights reserved. 27 a. When there is retrospective determination not to certify an admission, stay, or other service, the attending physician or other ordering provider and hospital or facility shall receive written notification, or notification by facsimile or email, within twenty (20) calendar days after receiving the request for retrospective review and all necessary and supporting documentation. b. Notification should include the principal reasons for the determination and a statement of the procedure for standard appeal if the determination is adverse to the injured worker. 4. Emergency admissions or surgical procedures— Emergency admissions or surgical procedures must be reported to the payer by the end of the next business day. Retrospective review activities will be performed following emergency admissions, and a continued stay review may be initiated. a. If a licensed physician or OQHP certifies in writing to the payer or its agent or representative within seventy-two (72) hours of an admission that the injured worker admitted was in need of emergency admission to hospital care, such shall constitute a prima facie case for the medical necessity of the admission. An admission qualifies as an emergency admission if it results from a sudden onset of illness or injury which is manifested by acute symptoms of sufficient severity that the failure to admit to hospital care could reasonably result in (1) serious impairment of bodily function(s), (2) serious or permanent dysfunction of any bodily organ or part or system, (3) permanently placing the person’s health in jeopardy, or (4) other serious medical consequence. b. To overcome a prima facie case for emergency admission as established above, the utilization reviewer must demonstrate by clear and convincing evidence that the injured worker was not in need of an emergency admission. E. Failure of the provider to provide necessary information for review, after being specifically requested to do so by the payer or its review agent in detail, may result in denial of certification and/or reimbursement. F. When a payer and provider have completed the prior authorization/pre-certification appeals process and cannot agree on a resolution to a dispute, either party, or the injured worker, can appeal to the Cost Containment Division of the Mississippi Workers’ Compensation Commission, and should submit this request on the Request for Dispute Resolution Form adopted by the Commission. A Request for Resolution of an authorization/pre-certification dispute should be filed with the Commission within twenty (20) calendar days following the conclusion of the underlying appeal process provided by the payer or its utilization reviewer. The Commission shall consider and decide a Request for Resolution of an authorization/pre-certification dispute in accordance with the Dispute Resolution Rules provided elsewhere in this Fee Schedule. G. Failure of a payer or its utilization review agent to timely notify the provider of a decision whether to certify or approve an admission, procedure, service or other treatment shall be deemed to constitute approval by the payer of the requested treatment, and shall obligate the payer to reimburse the provider in accordance with other applicable provisions of this Fee Schedule should the provider elect to proceed with the proposed treatment or service. Timely notification means notification by email, fax or telephone, followed by written notification via U.S. mail or commercial mail delivery service, to the provider, within the applicable time periods set forth in these authorization/pre- certification Rules. H. Upon request of the provider, or the Commission, a payer and/or the review agent must furnish a copy of the license or certification obtained from the State Department of Health, along with all supporting documentation, reports, data, studies, etc., which authorizes the reviewer to engage in authorization/pre-certification activities in the State of Mississippi. The Commission may, likewise, obtain this information unilaterally from the Mississippi Department of Health pursuant to an agreement with that Agency. I. Upon a finding by the Commission or an Administrative Judge that a payer, and/or their review agent, has unreasonably delayed a claim without reasonable grounds within the meaning of §71-3-59 of the Workers’ Compensation Law, penalties pursuant to MCA §71-3-59 (Rev. 2000) may be assessed against the payer. Any payer electing to obtain an Employer Medical Evaluation (EME) pursuant to MCA §71-3-15(1) must do so without unreasonable delay. With respect to an EME sought after the filing of a motion to compel medical treatment by an injured worker, failure by the payer to obtain and submit the EME report to the injured worker and the Commission within 45 days of the injured worker’s filing of a motion to compel may be deemed an unreasonable delay. Counsel for both parties may agree to extend the forty-five-day (45-day) limitation, or the Administrative Judge may extend the forty-five-day (45-day) limitation at his or her discretion. The forty-five-day (45-day) limitation does not apply to experts selected by the agreement of both parties to render a second opinion. If an Administrative Judge or the Commission finds that a payer has demonstrated unreasonable delay in seeking or obtaining an EME, regardless of whether a motion to compel medical treatment has been filed, such a finding may result in the imposition of penalties and/or attorney’s fees or expenses pursuant to MCA §71-3-59 and/or waiver of the payer’s right to an EME. J. Nothing provided herein shall estop or prevent the injured worker from obtaining legal counsel and/or seeking relief in the form of a request to compel medical treatment before an Administrative Judge.

20 Miss. Admin. Code Pt. 2, R. 28 Rule 28

CPT Copyright 2024 American Medical Association. All rights reserved. 29 MODIFIER AND CODE RULES This section of the Mississippi Workers’ Compensation Medical Fee Schedule includes a complete listing of appropriate modifiers for use with CPT ® and HCPCS codes. A. Modifiers must be used by providers to identify procedures or services that are modified due to specific circumstances. B. When modifier 22 is used to report an increased service, a report explaining the medical necessity of the situation must be submitted with the claim to the payer. It is not appropriate to use modifier 22 for routine billing. When appropriate, the Mississippi Workers’ Compensation Medical Fee Schedule reimbursement for modifier 22 is one hundred twenty percent (120%) of the maximum reimbursement allowance. C. The use of modifiers does not imply or guarantee that a provider will receive reimbursement as billed. Reimbursement for a modified service or procedure is based on documentation of medical necessity and determined on a case-by-case basis. D. Modifiers allow health care providers to indicate that a service was altered in some way from the stated description without actually changing the definition of the service. I. MODIFIERS FOR CPT CODES Modifiers augment CPT codes to more accurately describe the circumstances of services provided. When applicable, the circumstances should be identified by a modifier code: a two-digit number placed after the usual procedure code, separated by a hyphen. If more than one modifier is needed, place the multiple modifiers code 99 after the procedure code to indicate that two or more modifiers will follow. 22 Increased Procedural Services When the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. Documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient’s condition, physical and mental effort required). Note: This modifier should not be appended to an E/M service. Mississippi note: A report explaining the medical necessity of the situation must be submitted with the claim to the payer. By definition, this modifier would be used in unusual circumstances only and is not appropriate to use for billing of routine procedures. Use of this modifier does not guarantee additional reimbursement. When appropriate, the Fee Schedule reimbursement for modifier 22 is one hundred twenty percent (120%) of the maximum allowable reimbursement.

20 Miss. Admin. Code Pt. 2, R. 23 Rule 23

Unusual Anesthesia Occasionally, a procedure, which usually requires either no anesthesia or local anesthesia, because of unusual circumstances must be done under general anesthesia. This circumstance may be reported by adding modifier 23 to the procedure code of the basic service. 24 Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period The physician or other qualified health care professional may need to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure. This circumstance may be reported by adding modifier 24 to the appropriate level of E/M service. 25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (See Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier 57. For significant, separately identifiable non-E/M services, see modifier 59. 26 Professional Component Certain procedures are a combination of a physician or other qualified health care professional component and a technical component. When the physician or other qualified health care professional component is reported separately, the service may be identified by adding modifier 26 to the usual procedure number. Mississippi note: The professional component maximum allowable reimbursement is listed in the PC MAR column of the Fee Schedule.

Modifier and Code Rules Mississippi Workers’ Compensation Medical Fee Schedule

20 Miss. Admin. Code Pt. 2, R. 30 Rule 30

CPT Copyright 2024 American Medical Association. All rights reserved. TC Technical Component (HCPCS Modifier) Certain procedures are a combination of a professional component and a technical component. When the technical component is reported separately, the service may be identified by adding modifier TC to the usual procedure number. Technical component charges are institutional charges and not billed separately by physicians or other qualified health care professionals. Mississippi note: The technical component maximum allowable reimbursement is listed in the TC MAR column of the Fee Schedule. Outpatient facilities are paid based on the TC MAR when there is one. If there is no TC amount, and the service is payable in an outpatient setting, there will be an APC MAR which should be used. 32 Mandated Services Services related to mandated consultation and/or related services (eg, third-party payer, governmental, legislative or regulatory requirement) may be identified by adding modifier 32 to the basic procedure. 47 Anesthesia by Surgeon Regional or general anesthesia provided by the surgeon may be reported by adding modifier 47 to the basic service. (This does not include local anesthesia.) Note: Modifier 47 would not be used as a modifier for the anesthesia procedures. Mississippi note: Reimbursement is made for base units only for anesthesia codes 00100-01999. 50 Bilateral Procedure Unless otherwise identified in the listings, bilateral procedures that are performed at the same session should be identified by adding modifier 50 to the appropriate 5 digit code. Note: This modifier should not be appended to designated “add-on” codes (see Appendix D). Mississippi note: This modifier is reimbursed at fifty percent (50%) of the maximum allowable reimbursement, unless the procedure is included in the Pain Management section, where this modifier is reimbursed at twenty-five percent (25%) of the maximum allowable reimbursement. 51 Multiple Procedures When multiple procedures, other than E/M Services, Physical Medicine and Rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. The additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). Note: This modifier should not be appended to designated “add- on” codes (see Appendix D). Mississippi note: This modifier should not be appended to designated “modifier 51 exempt” codes as specified in the Fee Schedule. Services with modifier 51 are reimbursed at fifty percent (50%) of the maximum allowable reimbursement, unless the procedure is included in the Pain Management section, where this modifier is reimbursed at twenty- five percent (25%) of the maximum allowable reimbursement. 52 Reduced Services Under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. Under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. This provides a means of reporting reduced services without disturbing the identification of the basic service. Note: For hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for ASC hospital outpatient use). 53 Discontinued Procedure Under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. This circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. Note: This modifier is not used to report the elective cancellation of a procedure prior to the patient’s anesthesia induction and/or surgical preparation in the operating suite. For outpatient hospital/ ambulatory surgery center (ASC) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for ASC hospital outpatient use). 54 Surgical Care Only When 1 physician or other qualified health care professional performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services may be identified by adding modifier 54 to the usual procedure number. Mississippi note: The maximum allowable reimbursement for this modifier is eighty percent (80%) of the total value of the surgery. 55 Postoperative Management Only When 1 physician or other qualified health care professional performed the postoperative management and another performed the surgical procedure, the postoperative component may be identified by adding modifier 55 to the usual procedure number. Mississippi note: The maximum allowable reimbursement for this modifier is twenty percent (20%) of the total value of the surgery.

Mississippi Workers’ Compensation Medical Fee Schedule Modifier and Code Rules

CPT Copyright 2024 American Medical Association. All rights reserved. 31 56 Preoperative Management Only When 1 physician or other qualified health care professional performed the preoperative care and evaluation and another performed the surgical procedure, the preoperative component may be identified by adding modifier 56 to the usual procedure number. 57 Decision for Surgery An evaluation and management service that resulted in the initial decision to perform the surgery may be identified by adding modifier 57 to the appropriate level of E/M service.

20 Miss. Admin. Code Pt. 2, R. 58 Rule 58

Staged or Related Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period It may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. This circumstance may be reported by adding modifier 58 to the staged or related procedure. Note: For treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. 59 Distinct Procedural Service Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25. 62 Two Surgeons When 2 surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. Each surgeon should report the co-surgery once using the same procedure code. If additional procedure(s) (including add-on procedure[s]) are performed during the same surgical session, separate code(s) may also be reported with modifier 62 added. Note: If a co- surgeon acts as an assistant in the performance of additional procedure(s), other than those reported with the modifier 62, during the same surgical session, those services may be reported using separate procedure code(s) with modifier 80 or modifier 82 added, as appropriate. Mississippi note: This modifier is reimbursed at one hundred fifty percent (150%) of the maximum allowable reimbursement divided equally between the two co-surgeons. 66 Surgical Team Under some circumstances, highly complex procedures (requiring the concomitant services of several physicians or other qualified health care professionals, often of different specialties, plus other highly skilled, specially trained personnel, various types of complex equipment) are carried out under the “surgical team” concept. Such circumstances may be identified by each participating individual with the addition of modifier 66 to the basic procedure number used for reporting services. 76 Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional It may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. This circumstance may be reported by adding modifier 76 to the repeated procedure or service. Note: This modifier should not be appended to an E/M service. 77 Repeat Procedure by Another Physician or Other Qualified Health Care Professional It may be necessary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service. This circumstance may be reported by adding modifier 77 to the repeated procedure or service. Note: This modifier should not be appended to an E/M service. 78 Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period It may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). When this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (For repeat procedures, see modifier 76.)

Modifier and Code Rules Mississippi Workers’ Compensation Medical Fee Schedule

20 Miss. Admin. Code Pt. 2, R. 32 Rule 32

CPT Copyright 2024 American Medical Association. All rights reserved. 79 Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period The individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. This circumstance may be reported by using modifier 79. (For repeat procedures on the same day, see modifier 76.) 80 Assistant Surgeon Surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). Mississippi note: Reimbursement is twenty percent (20%) of the maximum allowable reimbursement. 81 Minimum Assistant Surgeon Minimum surgical assistant services are identified by adding modifier 81 to the usual procedure number. Mississippi note: Reimbursement is ten percent (10%) of the maximum allowable reimbursement. 82 Assistant Surgeon (when qualified resident surgeon not available) The unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). 90 Reference (Outside) Laboratory When laboratory procedures are performed by a party other than the treating or reporting physician or other qualified health care professional, the procedure may be identified by adding modifier 90 to the usual procedure number. 91 Repeat Clinical Diagnostic Laboratory Test In the course of treatment of the patient, it may be necessary to repeat the same laboratory test on the same day to obtain subsequent (multiple) test results. Under these circumstances, the laboratory test performed can be identified by its usual procedure number and the addition of modifier 91. Note: This modifier may not be used when tests are rerun to confirm initial results; due to testing problems with specimens or equipment; or for any other reason when a normal, one-time, reportable result is all that is required. This modifier may not be used when other code(s) describe a series of test results (eg, glucose tolerance tests, evocative/suppression testing). This modifier may only be used for laboratory test(s) performed more than once on the same day on the same patient. 92 Alternative Laboratory Platform Testing When laboratory testing is being performed using a kit or transportable instrument that wholly or in part consists of a single use, disposable analytical chamber, the service may be identified by adding modifier 92 to the usual laboratory procedure code (HIV testing 86701–86703, and 87389). The test does not require permanent dedicated space, hence by its design may be hand carried or transported to the vicinity of the patient for immediate testing at that site, although location of the testing is not in itself determinative of the use of this modifier. 93 Synchronous Telemedicine Service Rendered Via Telephone or Other Real- Time Interactive Audio-Only Telecommunications System Synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified health care professional and a patient who is located away at a distant site from the physician or other qualified health care professional. The totality of the communication of information exchanged between the physician or other qualified health care professional and the patient during the course of the synchronous telemedicine service must be of an amount and nature that is sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction. 95 Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System Synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified health care professional and a patient who is located at a distant site from the physician or other qualified health care professional. The totality of the communication of information exchanged between the physician or other qualified health care professional and the patient during the course of the synchronous telemedicine service must be of an amount and nature that would be sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction. Modifier 95 may only be appended to the services listed in Appendix P. Appendix P is the list of CPT codes for services that are typically performed face-to-face, but may be rendered via a real-time (synchronous) interactive audio and video telecommunications system.

Mississippi note: Append Modifiers 93 and 95 to codes indicated with the telemedicine icon in this Fee Schedule. These modifiers are used to identify when services are provided using audio-only telemedicine (modifier 93) or audio-visual telemedicine (modifier 95). 99 Multiple Modifiers Under certain circumstances 2 or more modifiers may be necessary to completely delineate a service. In such situations, modifier 99 should be added to the basic procedure and other applicable modifiers may be listed as part of the description of the service. AA Anesthesia Services Performed Personally by Anesthesiologist (HCPCS Modifier) Report modifier AA when the anesthesia services are personally performed by an anesthesiologist.

Mississippi Workers’ Compensation Medical Fee Schedule Modifier and Code Rules

CPT Copyright 2024 American Medical Association. All rights reserved. 33 AD Medical Supervision by a Physician: More Than Four Concurrent Anesthesia Procedures (HCPCS Modifier) Report modifier AD when the anesthesiologist supervises more than four concurrent anesthesia procedures. AS Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist Services for Assistant at Surgery (HCPCS Modifier) Assistant at surgery services provided by another qualified individual (e.g., physician assistant, nurse practitioner, clinical nurse specialist, registered nurse first assistant) and not another physician are identified by adding modifier AS to the listed applicable surgical procedures. Modifier AS may be appended to any code identified as appropriate for surgical assistance in this Fee Schedule. Mississippi note: Modifier AS reimbursement is ten percent (10%) of the maximum allowable reimbursement. For assistant at surgery services provided by a physician, see modifiers 80, 81, and 82. M1 Nurse Practitioner (Mississippi Modifier) This modifier should be added to the appropriate CPT code to indicate that the services were rendered or provided by a nurse practitioner. M2 Physician Assistant (Mississippi Modifier) This modifier should be added to the appropriate CPT code to indicate that the services were rendered or provided by a physician assistant. M3 Physical or Occupational Therapist Assistant (Mississippi Modifier) This modifier should be added to the appropriate CPT code to indicate that the services were rendered or provided by either a physical therapist assistant or an occupational therapist assistant. M4 CARF Accredited (Mississippi Modifier) This modifier should be used in conjunction with CPT code 97799 to indicate chronic pain treatment being administered by a CARF accredited provider as part of a pre-approved interdisciplinary pain rehabilitation program. M5 Chronic Pain Treatment (Mississippi Modifier) This modifier should be used only in conjunction with CPT code 97799 to indicate chronic pain treatment administered as part of a pre-approved interdisciplinary pain rehabilitation program. M6 Psychologist, Social Worker, Licensed Professional Counselor (Mental Health Counselor) (Mississippi Modifier) This modifier should be added to the appropriate CPT code to indicate that the services were rendered or provided by a psychologist, social worker or licensed professional counselor. QK Medical Direction of 2, 3, or 4 Concurrent Anesthesia Procedures (HCPCS Modifier) Report modifier QK when the anesthesiologist supervises 2, 3, or 4 concurrent anesthesia procedures involving qualified individuals. QX CRNA Service with Medical Direction by a Physician Regional or general anesthesia provided by a CRNA with medical direction by a physician may be reported by adding modifier QX. QY Medical Direction of One Certified Registered Nurse Anesthetist (CRNA) by an Anesthesiologist (HCPCS Modifier) Report modifier QY when the anesthesiologist supervises one qualified certified registered nurse anesthetist. QZ CRNA Service Without Medical Direction by a Physician Report modifier QZ with an appropriate CPT code when all anesthesia services are performed by a CRNA. Mississippi note: Modifier QZ reimbursement is eighty percent (80%) of the maximum allowable reimbursement. II. MODIFIERS APPROVED FOR AMBULATORY SURGERY CENTER (ASC) AND HOSPITAL OUTPATIENT USE This section contains a list of modifiers used with ambulatory surgery center and hospital-based outpatient services. 25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (See Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier 57. For significant, separately identifiable non-E/M services, see modifier 59.

Modifier and Code Rules Mississippi Workers’ Compensation Medical Fee Schedule

20 Miss. Admin. Code Pt. 2, R. 34 Rule 34

CPT Copyright 2024 American Medical Association. All rights reserved. 27 Multiple Outpatient Hospital E/M Encounters on the Same Date For hospital outpatient reporting purposes, utilization of hospital resources related to separate and distinct E/M encounters performed in multiple outpatient hospital settings on the same date may be reported by adding modifier 27 to each appropriate level outpatient and/or emergency department E/M code(s). This modifier provides a means of reporting circumstances involving evaluation and management services provided by physician(s) in more than one (multiple) outpatient hospital setting(s) (eg, hospital emergency department, clinic). Note: This modifier is not to be used for physician reporting of multiple E/M services performed by the same physician on the same date. For physician reporting of all outpatient evaluation and management services provided by the same physician on the same date and performed in multiple outpatient setting(s) (eg, hospital emergency department, clinic), see Evaluation and Management, Emergency Department, or Preventive Medicine Services codes. 50 Bilateral Procedure Unless otherwise identified in the listings, bilateral procedures that are performed at the same session should be identified by adding modifier 50 to the appropriate 5 digit code. Note: This modifier should not be appended to designated “add-on” codes (see Appendix D). Mississippi note: This modifier is reimbursed at fifty percent (50%) of the maximum allowable reimbursement, unless the procedure is included in the Pain Management section, where this modifier is reimbursed at twenty-five percent (25%) of the maximum allowable reimbursement. 52 Reduced Services Under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. Under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. This provides a means of reporting reduced services without disturbing the identification of the basic service. Note: For hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for ASC hospital outpatient use). 58 Staged or Related Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period It may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. This circumstance may be reported by adding modifier 58 to the staged or related procedure. Note: For treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. 59 Distinct Procedural Service Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25. 73 Discontinued Out-Patient Hospital/Ambulatory Surgery Center (ASC) Procedure Prior to the Administration of Anesthesia Due to extenuating circumstances or those that threaten the well being of the patient, the physician may cancel a surgical or diagnostic procedure subsequent to the patient’s surgical preparation (including sedation when provided, and being taken to the room where the procedure is to be performed), but prior to the administration of anesthesia (local, regional block(s) or general). Under these circumstances, the intended service that is prepared for but cancelled can be reported by its usual procedure number and the addition of modifier 73. Note: The elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. For physician reporting of a discontinued procedure, see modifier 53.

Mississippi Workers’ Compensation Medical Fee Schedule Modifier and Code Rules

CPT Copyright 2024 American Medical Association. All rights reserved. 35 74 Discontinued Out-Patient Hospital/Ambulatory Surgery Center (ASC) Procedure After Administration of Anesthesia Due to extenuating circumstances or those that threaten the well being of the patient, the physician may terminate a surgical or diagnostic procedure after the administration of anesthesia (local, regional block(s), general) or after the procedure was started (incision made, intubation started, scope inserted, etc). Under these circumstances, the procedure started but terminated can be reported by its usual procedure number and the addition of modifier 74. Note: The elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. For physician reporting of a discontinued procedure, see modifier 53. 76 Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional It may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. This circumstance may be reported by adding modifier 76 to the repeated procedure or service. Note: This modifier should not be appended to an E/M service. 77 Repeat Procedure by Another Physician or Other Qualified Health Care Professional It may be necessary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service. This circumstance may be reported by adding modifier 77 to the repeated procedure or service. Note: This modifier should not be appended to an E/M service. 78 Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period It may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). When this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (For repeat procedures, see modifier 76.) 79 Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period The individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. This circumstance may be reported by using modifier 79. (For repeat procedures on the same day, see modifier 76.) 91 Repeat Clinical Diagnostic Laboratory Test In the course of treatment of the patient, it may be necessary to repeat the same laboratory test on the same day to obtain subsequent (multiple) test results. Under these circumstances, the laboratory test performed can be identified by its usual procedure number and the addition of modifier 91. Note: This modifier may not be used when tests are rerun to confirm initial results; due to testing problems with specimens or equipment; or for any other reason when a normal, one-time, reportable result is all that is required. This modifier may not be used when other code(s) describe a series of test results (eg, glucose tolerance tests, evocative/ suppression testing). This modifier may only be used for laboratory test(s) performed more than once on the same day on the same patient. III. MODIFIERS FOR HCPCS CODES This section contains a list of modifiers that are commonly used with HCPCS DME codes. AU Item Furnished in Conjunction with a Urological, Ostomy, or Tracheostomy Supply AV Item Furnished in Conjunction with a Prosthetic Device, Prosthetic, or Orthotic AW Item Furnished in Conjunction with a Surgical Dressing KC Replacement of Special Power Wheelchair Interface NU New Equipment RR Rental (use the RR modifier when DME is to be rented) Mississippi note: Listed amount is the per month allowance, except codes, E0935 and E0936, which are per-day allowances. UE Used Durable Medical Equipment Mississippi note: Used to report the purchase of used durable medical equipment. IV. PROCEDURE CODE EXCEPTIONS A. Unlisted Procedure Codes. If a procedure is performed that is not listed in the Fee Schedule, the provider must bill with the appropriate “Unlisted Procedure” code and submit a narrative report to the payer explaining why it was medically necessary to use an unlisted procedure code. CPT contains codes for unlisted procedures. Use these codes only when there is no procedure code that accurately describes the service rendered. A report is required as these services are reimbursed by report (see below). B. By Report (BR) Codes. By report (BR) codes are used by payers to determine the reimbursement for

Modifier and Code Rules Mississippi Workers’ Compensation Medical Fee Schedule

20 Miss. Admin. Code Pt. 2, R. 36 Rule 36

CPT Copyright 2024 American Medical Association. All rights reserved. a service or procedure performed by the provider that does not have an established maximum allowable reimbursement (MAR) amount. For more information please see the Definitions section. C. Category II Codes. This Fee Schedule does not include Category II codes. Category II codes are supplemental tracking codes that can be used for performance measurements. These codes describe clinical components that are typically included and reimbursed in other services such as evaluation and management (E/M) or laboratory services. These codes do not have an associated fee. D. Category III Codes. This Fee Schedule does not generally include Category III codes published in CPT 2025. If a provider bills a Category III code that is not included in this Fee Schedule, payment may be denied. E. Add-On Codes. CPT identifies procedures that are always performed in addition to the primary procedure and designates them with a + symbol. Add-on codes are never reported for stand-alone services but are reported secondarily in addition to the primary procedure. Specific language is used to identify add-on procedures such as “each additional” or “(List separately in addition to primary procedure).” The same physician or other qualified health care professional that performed the primary service/procedure must perform the add-on service/procedure. Add-on codes describe additional intra-service work associated with the primary service/procedure (e.g., additional digit(s), lesions(s), neurorrhaphy(s), vertebral segment(s), tendon(s), joint(s)). Add-on codes are always performed in addition to the primary service/procedure, and must never be reported as a stand-alone code. All add-on codes found in the CPT book are exempt from the multiple procedure concept (see modifier 51 definition in this section). Add-on codes are reimbursed at one hundred percent (100%) of the maximum allowable reimbursement or the provider’s charge, whichever is less. Refer to the most current version of CPT for a complete list of add-on codes. F. Codes Exempt From Modifier 51. This symbol  denotes procedure codes that are exempt from the use of modifier 51 and are not designated as add-on procedures/services as defined in CPT. Modifier 51 exempt services and procedures can be found in Appendix E of CPT 2025. Codes exempt from modifier 51 are reimbursed at one hundred percent (100%) of the maximum allowable reimbursement or the provider’s charge, whichever is less.

CPT Copyright 2024 American Medical Association. All rights reserved. 37 PHARMACY RULES I. SCOPE This section provides specific rules for the dispensing of and payment for medications and other pharmacy services prescribed to treat work-related injury/illness under the terms of the Workers’ Compensation Law. II. DEFINITIONS A. Medications are defined as drugs prescribed by a licensed health care provider and include name brand and generic drugs as well as patented or over- the-counter drugs, compound drugs and physician- dispensed or repackaged drugs. B. Average Wholesale Price (AWP) means Average Wholesale Price based on data obtained from manufacturers. Under this Fee Schedule, drugs should be reimbursed according to the AWP based on the most current edition of the RED BOOK in effect at the time the medication is dispensed. Pharmacy bills should be submitted using the NCPDP Workers’ Compensation/Property and Casualty Claim Form or the equivalent NCPDP electronic format. Additional information can be obtained here: https://ncpdp.org/Universal-Claim-Forms. Nothing shall prohibit parties from using an agreed upon billing form or format. III. RULES In the event that the MWCC implements a drug formulary, the Formulary and any subsequent Pharmacy Fee Schedule will govern and supersede the rules in this Fee Schedule where they conflict. A. Generic Equivalent Drug Products. Unless otherwise specified by the ordering physician or other qualified health care professional, all prescriptions will be filled under the generic name. When the physician or OQHP writes “brand medically necessary” on the prescription, the pharmacist will fill the order with the brand name. When taking telephone orders, the pharmacist will assume the generic is to be used unless “brand medically necessary” is specifically ordered by the treating physician or OQHP. Without exception, the treating physician or OQHP has the authority to order a brand name medication if he/she feels the brand name drug is substantially more effective. B. A payer or provider shall not prohibit or limit any injured worker from selecting a pharmacy or pharmacist of his/her choice, and may not require any injured worker to purchase pharmacy services, including prescription drugs, exclusively through a mail-order pharmacy or program, or to obtain medication dispensed by the physician or in the physician’s office, provided the pharmacy or pharmacist selected by the injured worker has agreed to be bound by the terms of the Workers’ Compensation Law and this Fee Schedule with regard to the provision of services and the billing and payment therefor. C. Dietary supplements, including but not limited to minerals, vitamins, and amino acids are not reimbursable unless a specific compensable dietary deficiency has been clinically established as related to the work injury. D. Not more than one dispensing fee shall be paid per drug within a thirty (30) day period. E. Providers should refer to the Mississippi Workers’ Compensation Commission Guidelines for the Prescription of Opiates for rules relating to opiate prescriptions. The guidelines are available on the MWCC website at https://mwcc.ms.gov/pdf/mwccGuidlinesFor ThePrescriptionOfOpiates.pdf IV. REIMBURSEMENT A. Reimbursement for pharmaceuticals ordered for the treatment of work-related injury/illness is as follows: 1. Brand/Trade Name Medications: Average Wholesale Price (AWP) minus 10% plus a five- dollar ($5.00) dispensing fee. 2. Generic Medications: Average Wholesale Price (AWP) minus 15% plus a five-dollar ($5.00) dispensing fee. 3. Over-the-counter (OTC) medications are reimbursed at usual and customary rates, and are not subject to a dispensing fee. 4. Dispensing fees are payable only if the prescription is filled under the direct supervision of a registered pharmacist. If a physician dispenses medications from his/her office, a dispensing fee is not allowed. 5. Physician-dispensed Medications: Physician dispensing is limited to an initial supply not greater than 10 (ten) days per medication, per dispensing physician, in the physician’s office at the point of care. Reimbursement for brand and generic medications shall not exceed the lowest cost generic equivalent. Reimbursement limits apply regardless of tax ID. B. Supplies and equipment used in conjunction with medication administration should be billed with the appropriate HCPCS codes and shall be reimbursed according to the Fee Schedule. Supplies and equipment not listed in the Fee Schedule will be reimbursed at the usual and customary rate. C. Mail-order pharmaceutical services are subject to the rules and reimbursement limitations of this Fee Schedule when supplying medications to Mississippi Workers’ Compensation claimants. Shipping for mail-

Pharmacy Rules Mississippi Workers’ Compensation Medical Fee Schedule

20 Miss. Admin. Code Pt. 2, R. 38 Rule 38

CPT Copyright 2024 American Medical Association. All rights reserved. order pharmaceutical services is not separately reimbursed. D. A 503B compounding pharmacy is an FDA-registered outsourcing facility that can manufacture large batches of compounded medications for distribution to healthcare facilities, including office-use medications administered directly in a healthcare provider’s office. These medications are often billed at higher prices than retail pharmacies or non-bulk prices. Reimbursement for medications provided in a physician’s office to an injured worker obtained from a 503B pharmacy will be required to follow the reimbursement indicated in this Fee Schedule. V. REPACKAGED MEDICATION If the only submitted National Drug Code (NDC) for the drug product as dispensed is a repackaged drug NDC, the drug will not be reimbursed. For repackaged drugs, providers shall submit both the NDC of the repackaged drug dispensed and the NDC of the original manufacturer to receive properly calculated reimbursement. Submission and placement of both NDCs shall be in accordance with the specifications of the billing form/format being used. VI. COMPOUNDED TOPICAL MEDICATIONS AND TOPICAL PATCHES A. Compound Topical Medications: A compound medication is any customized formulation of medication prepared by a compounding pharmacist that is not commercially available and which requires a prescription. All compounded medications shall be billed by listing each individual component ingredient and each compound ingredient’s NDC as assigned by the original manufacturer. Ingredients lacking an NDC will not be reimbursed. The entity compounding two or more products or Active Pharmaceutical Ingredients (APIs) together must bill the products as individual line items identified by their original AWP and calculating the charge for each component ingredient separately based on its AWP. Payment shall be based on the sum of the AWP fee for each ingredient, plus a single dispensing fee of five dollars ($5.00). Supplies used in compounding the products or APIs are considered integral to the final medication product and are not reimbursed separately. Prior authorization and medical documentation are required for any amount over eighty dollars ($80.00). B. Compounded Topical Medications Reimbursement: Regardless of how many ingredients or what type, compounded topical medications cannot be reimbursed higher than the Level III fee. The 30-day MAR shall be prorated down to the prescribed and dispensed amount given to the injured worker. Automatic refills are not allowed. All compounded topical medications shall be billed and reimbursed corresponding to the applicable level as follows:

Level I - $40.00 per 30-day supply. Any anti- inflammatory medication or any local anesthetic —single agent.
Level II - $60.00 per 30-day supply. Any anti- inflammatory agent or agents in combination with any local anesthetic agent or agents.
Level III - $80.00 per 30-day supply. Any agent(s) other than anti-inflammatory or local anesthetic agents, either alone, or in combination with other anti-inflammatory or local anesthetic agents.

The NCPDP file format will be used in all billing and the NDC number for each medication used in the compounded topical medication will be billed.

C. Topical Patches: Topical patches will be reimbursed the billed charge up to a maximum of sixty dollars ($60.00) for a 30-day supply, prorated if a lesser amount is provided.

CPT Copyright 2024 American Medical Association. All rights reserved. 39 OTHER QUALIFIED HEALTH CARE PROFESSIONAL RULES I. ANY QUALIFIED HEALTH CARE PROFESSIONAL Any qualified health care professional who is licensed in Mississippi, practices within state guidelines, and is listed within this Fee Schedule as an authorized provider is reimbursed for services based on this Fee Schedule. II. NURSE PRACTITIONER A. Mississippi-specific Modifier M1 should be appended to the appropriate CPT ® code when billing services rendered by the nurse practitioner. The nurse practitioner must use his/her unique identifier to bill for all services. Nurse practitioners must comply with the requirements for a National Provider Identifier (NPI) as specified in the Billing and Reimbursement Rules of this Fee Schedule. B. The nurse practitioner is reimbursed at eighty-five percent (85%) of the maximum allowable for the procedure. C. There is only one fee allowed for each CPT code. It is the decision of the physician or the nurse practitioner as to who will bill for a service when both have shared in the provision of the service. Incorrect billing of the service may cause a delay or improper payment by the payer. The medical doctor (MD) must be on-site on the date of service and provide additional documentation and review of services in order for physician reimbursement to be applied. III. PHYSICIAN ASSISTANT A. Mississippi-specific modifier M2 should be appended to the appropriate CPT code(s) when billing services rendered by the physician assistant.

B. The physician assistant is reimbursed at eighty-five percent (85%) of the maximum allowable for the procedure. C. There is only one fee allowed for each CPT code. It is the decision of the physician or the physician assistant as to who will bill for a service when both have shared in the provision of the service. Incorrect billing of the service may cause a delay or improper payment by the payer. The medical doctor (MD) must be on-site on the date of service and provide additional documentation and review of services in order for physician reimbursement to be applied. IV. PHYSICAL THERAPIST ASSISTANT OR OCCUPATIONAL THERAPIST ASSISTANT A. Mississippi-specific modifier M3 should be appended to the appropriate CPT code(s) when billing services rendered by a physical therapist assistant or an occupational therapist assistant. B. The physical therapist assistant or occupational therapist assistant is reimbursed at eighty-five percent (85%) of the maximum allowable for the procedure. V. PSYCHOLOGY A. Mississippi-specific modifier M6 should be appended to the appropriate CPT code (s) when a provider other than a psychiatrist provides psychology services.

B. The reimbursement amount is eighty-five percent (85%) of the maximum allowable reimbursement. This applies to psychologists, social workers, licensed professional counselors, etc.

CPT Copyright 2024 American Medical Association. All rights reserved. 41 HOME HEALTH I. SCOPE This section of the Fee Schedule pertains to home health, nursing, respite care, personal care, hospice and parenteral/enteral/home infusion services provided to injured workers who have a work-related injury/illness or condition. A. The determination that the injury/illness or condition is work related must be made by the payer and services must be medically necessary. B. All services must have prior authorization by the payer. C. A description of needed nursing or other attendant care must accompany the request for authorization. II. REIMBURSEMENT A. If a payer and provider have a mutually agreed upon contractual arrangement governing the payment for services to injured workers, the payer shall reimburse under the contractual agreement and not according to the Fee Schedule. B. In the absence of a mutually agreed upon contractual arrangement governing payment for services, reimbursement shall be made as in other cases (see Billing and Reimbursement Rules) in an amount equal to billed charges, or the maximum allowable reimbursement (MAR), whichever is less. Billing for home health services is appropriate using the applicable billing form for other institutional providers or facilities. C. A visit made simultaneously by two or more workers from a home health agency to provide a single covered service for which one supervises or instructs the other shall be counted as one visit. D. A visit is defined as time up to and including the first two hours. E. The maximum allowable reimbursement (MAR) listed herein are inclusive of mileage and other incidental travel expenses, unless otherwise agreed to by the payer and provider. F. The rates set forth in this section of the Fee Schedule apply to all hours worked. No additional reimbursement is allowed for overtime hours, unless otherwise agreed to by the parties in a separate fee contract.

III. RATES A. The following MAR and codes apply to services provided by or through a home health agency: Service MAR Per Visit Billing Code RN Skilled Nursing $140.00 S9123 LPN Skilled Nursing $115.00 S9124 Physical Therapy $135.00 S9131 Speech and Language Therapy $135.00 S9128 Occupational Therapy $135.00 S9129 Medical Social Services $135.00 S9127 Home Health Aide $60.00 S9122 Note: The descriptions of these codes have been modified for this Fee Schedule. Please see the HCPCS section. For services that exceed two (2) hours, reimbursement for time in excess of the first two (2) hours shall be pro-rated and based on an hourly rate equal to fifty percent (50%) of the above visit fee. For home health services rendered in two (2) hours or less, reimbursement shall be made for a visit as above provided. B. The following Private Duty Maximum Allowable Rates shall apply: Skilled Nursing Care – R.N. $50.00 per hour Skilled Nursing Care – L.P.N. $40.00 per hour Certified Nurse Assistant $22.00 per hour Personal Care Attendant $17.00 per hour C. Any reimbursement to persons not working under a professional license, such as a spouse or relative, will be at the rate of ten dollars ($10.00) per hour unless otherwise negotiated by the payer and caregiver or provider. D. Professional providers not assigned a MAR for home health services and who have not negotiated their rates with the payer prior to provision of home health care, shall be reimbursed at the usual and customary rate, or the total billed charge, whichever is less. E. Respite Care is reimbursed at a rate of $20.00 per hour.

Home Health Mississippi Workers’ Compensation

20 Miss. Admin. Code Pt. 2, R. 42 Rule 42

CPT Copyright 2024 American Medical Association. All rights reserved. IV. PARENTERAL/ENTERAL/HOME INFUSION THERAPY IN THE HOME SETTING A. The MAR for this therapy provided in the home setting is a per diem amount and includes necessary supplies for the safe and effective administration of the prescribed therapy. Supplies include set(s), needles, syringes, saline, tubing, dressing kits, saline, heparin, alcohol pads, start kits, catheters, adapters, tape, gauges, pump, poles, and other supplies. B. Per diem amounts are as follows: Parenteral therapy/home infusion (with or without antibiotics) Daily – $174.90 Twice a day – $201.40 Three times a day – $227.90 Four times a day – $280.90 Five or more times a day – $355.10 Total Parenteral Nutrition (TPN): 1-1.6 Liters per day – $296.80 1.7-2.4 Liters per day – $371.00 More than 2.4 liters per day – $408.10 Lipids: 10% – $79.50 20% – $100.70 Enteral Therapy: $25.44 Medications for Parenteral/Enteral Therapy are reimbursed at AWP. V. HOSPICE A. Hospice reimbursement is a per diem amount that is all inclusive for services provided. B. Daily per diem amounts are as follows: Routine Home Care – $384.78 Continuous Home Rate – $1,995.56 Inpatient Care – $1,486.36

CPT Copyright 2024 American Medical Association. All rights reserved. 43 EVALUATION AND MANAGEMENT This section contains rules and codes used to report evaluation and management (E/M) services. Rules and Guidelines follow the CPT ® guidelines that are current on the date that the evaluation and management service was provided. Note: Rules used by all physicians or other qualified health care professionals in reporting their services are presented in the General Rules section. See the Modifier and Code Rules section for detailed information on modifiers. I. DEFINITIONS AND RULES Definitions and rules pertaining to E/M services are as follows: A. DOCUMENTATION MUST BE PATIENT SPECIFIC, PERTAIN DIRECTLY TO THE CURRENT VISIT AND SUPPORT THE EVALUATION AND MANAGEMENT SERVICES PROVIDED FOR THE INJURED WORKER. INFORMATION COPIED DIRECTLY FROM PRIOR RECORDS WITHOUT CHANGE IS NOT CONSIDERED CURRENT NOR COUNTED. B. Consultations. CPT defines a consultation as a type of evaluation and management service provided at the request of another physician, other qualified health care professional or appropriate source to either recommend care for a specific condition or problem or to determine whether to accept responsibility for ongoing management of the injured worker’s entire care or for the care of a specific condition or problem. (This includes referrals for a second opinion.) Consultations are reimbursable only to physicians or other qualified health care professionals with the appropriate specialty for the services provided. In order to qualify as a consultation, the following criteria must be met: • The verbal or written request for a consult must be documented in the injured worker’s medical record; • The consultant’s opinion and any services ordered or performed must be documented by the consultant in the injured worker’s medical record; and • The consultant must provide a written report to the requesting physician, other qualified health care professional, or other appropriate source. A payer/employer may request a second opinion examination or evaluation for the purpose of evaluating temporary or permanent disability or medical treatment being rendered, as provided in MCA §71-3-15(1) (Rev. 2000). This examination is considered a confirmatory consultation. The confirmatory consultation is billed using the appropriate level and site-specific consultation codes 99242–99245 for office or other outpatient consultations and 99252–99255 for inpatient consultations, with modifier 32 appended to indicate a mandated service.

If subsequent to the completion of a consultation the consultant assumes responsibility for management of a portion or all of the injured worker’s condition(s), the appropriate evaluation and management services code for the site of service should be reported. In the hospital or nursing facility setting, the consultant should use the appropriate inpatient consultation code for the initial encounter and then subsequent hospital or nursing facility care codes. In the office setting, the consultant should use the appropriate office or other outpatient consultation codes and then the established patient office or other outpatient services codes. Evaluation and management consultation services will continue to be reported with CPT codes 99242– 99245 for outpatient consultation services and codes 99252–99255 for inpatient consultation services. The rules regarding the definition, documentation, and reporting of consultation services as contained in CPT will apply unless superseded by these rules. Consultation services will be reimbursed at the lesser of the Fee Schedule maximum allowable reimbursement (MAR) or the billed amount. C. Referral. Subject to the definition of “consultation” provided in this Fee Schedule, a referral is the transfer of the total or specific care of an injured worker from one physician or other qualified health care professional to another and does not constitute a consultation. (Initial evaluations and subsequent services are designated as listed in the Evaluation and Management section). D. New and Established Patient Service. Several code subcategories in the Evaluation and Management section are based on the injured worker’s status as new or established. The new versus established patient guidelines also clarify the situation in which a physician or other qualified health care professional is on call or covering for another physician or OQHP. In this instance, classify the injured worker’s encounter the same as if it were for the physician or OQHP who is unavailable. • New Patient. A new patient is one who has not received any professional services from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, for this same injury or within the past three years. • Established Patient. An established patient is a patient who has been treated for the same injury by any physician or other qualified health care professional of the exact same specialty and subspecialty, who belongs to the same group practice within the past three years.

Evaluation and Management Mississippi Workers’ Compensation Medical Fee Schedule

20 Miss. Admin. Code Pt. 2, R. 44 Rule 44

CPT 2024 American Medical Association. All Rights Reserved. E. Medical Decision Making An Evaluation and Management code-level may be selected by Medical Decision Making (MDM) or time. When MDM is used there are three elements to determine: • The number and complexity of problem(s) that are addressed during the encounter. • The amount and/or complexity of data to be reviewed and analyzed. • The risk of complication and/or morbidity or mortality of patient management. A detailed explanation of each element can be found in CPT.

F. Time. The inclusion of time in the definitions of levels of E/M services is to assist physicians or other qualified health care professionals in selecting the most appropriate level of E/M service. Time may be used to select the appropriate code level for all E/M service codes (with the exception of 99211).

Different categories of services use time differently. It is important to review the instructions for each category.

Time is not a descriptive component for the emergency department levels of E/M services because emergency department services are typically provided on a variable intensity basis, often involving multiple encounters with several patients over an extended period. Therefore, it is often difficult for physicians or other qualified health care professionals to provide accurate estimates of the time spent face-to-face with the injured worker.

Time may be used to select a code level in office or other outpatient services whether or not counseling and/or coordination of care dominates the service.

When time is used for reporting E/M service codes, the time defined in the service descriptors is used for selecting the appropriate level of service. For office or other outpatient services, if the physician’s or other qualified health care professional’s time is spent in the supervision of clinical staff who perform the services of the encounter, use 99211.

A shared or split visit is defined as a visit in which a physician and other qualified health care professional(s) jointly provide the work related to the visit. When time is being used to select the appropriate level of service for which time-based reporting of shared or split visits is allowed, the time personally spent by the physician and other qualified health care professional(s) assessing and managing the patient on the date of the encounter is summed to define total time. When medical decision making (MDM) is used to select E/M code-level, the appropriate E/M code is reported by the physician or other qualified health care professional who created or approved the patient’s management plan for the number and complexity of problems addressed during the service and is taking responsibility for the patient risks of morbidity or mortality integral to the management plan. When time is used to select the E/M code-level, the physician or other qualified health care professional who spent the majority of the time performing the service would report the service.

When prolonged time occurs, the appropriate prolonged services code may be reported. The appropriate time should be documented in the medical record when it is used as the basis for code selection. The physician or other qualified health care professional can report prolonged service codes 99417 or 99418 when an E/M service is billed based on time and the total time associated with the highest level of service has been exceeded. Code 99417 is reported with code 99205 or 99215. Code 99418 is reported with 99223, 99233, 99236, 99255, or 99310.

Total time includes both the face-to-face with the patient and/or family/caregiver and non-face-to-face time personally spent by the physician and/or other qualified health care professional(s) on the day of the encounter regardless of whether the provider is at the inpatient unit or in the outpatient office (includes time in activities that require the physician or other qualified health care professional and does not include time in activities normally performed by clinical staff. Time should not be counted for the performance of services separately reported.

Physician/other qualified health care professional time includes the following activities, when performed:

a. Preparing to see the patient (e.g., review of tests) b. Obtaining and/or reviewing separately obtained history c. Performing a medically appropriate examination and/or evaluation d. Counseling and educating the patient/family/caregiver e. Ordering medications, tests, or procedures f. Referring and communicating with other health care professionals (when not separately reported) g. Documenting clinical information in the electronic or other health record h. Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver i. Care coordination (not separately reported)

Mississippi Workers’ Compensation Medical Fee Schedule Evaluation and Management

CPT Copyright 2024 American Medical Association. All rights reserved. 45 G. Interpretation of Diagnostic Studies in the Emergency Department 1. Only one fee for the interpretation of an image or EKG procedure will be reimbursed per procedure. 2. The payer is to provide reimbursement to the provider that directly contributed to the diagnosis and treatment of the individual injured worker. 3. It is necessary to provide a signed report in order to bill the professional component of a diagnostic procedure. The payer may require the report before payment is rendered. 4. If more than one bill is received, physician specialty should not be the deciding factor in determining which physician or OQHP to reimburse. Example: In many emergency departments (EDs), an emergency room (ER) physician orders the imaging on a particular patient. If the ER physician interprets the imaging making a notation as to the findings in the chart and then treats the patient according to these radiological findings, the ER physician should be paid for the interpretation and report. There may be a radiologist on staff at the particular facility with quality control responsibilities at that particular facility. However, the fact that the radiologist reads all imaging taken in the ED for quality control purposes is not sufficient to command a separate or additional reimbursement from the payer.

A review alone of an imaging or EKG does not meet the conditions for separate payment of a service, as it is already included in the ED visit. II. GENERAL GUIDELINES The E/M section is divided into broad categories such as office visits, hospital visits, and consultations. Most of the categories are further divided into two or more subcategories of E/M services. Keep the following in mind when coding each service setting: A. A patient is considered an outpatient at a health care facility until formal inpatient admission occurs. B. All physicians or OQHPs use codes 99281–99285 for reporting emergency department services, regardless of hospital-based or non-hospital-based status. C. Admission to a hospital or nursing facility includes E/M services provided elsewhere on the same day. D. When the patient is admitted to the hospital as an inpatient or to observation status in the course of an encounter in another site of service (eg, hospital emergency department, office, nursing facility), the services in the initial site may be separately reported. Modifier 25 may be added to the other evaluation and management service to indicate a significant, separately identifiable service by the same physician or other qualified health care professional was performed on the same date. E. Not more than one hospital visit per day shall be payable except when documentation describe the medical necessity of more than one visit by a particular physician or other qualified health care professional. Hospital visit codes shall be combined into the single code that best describes the service rendered. F. Only one provider is reimbursed for a patient visit, except where wound care evaluation is provided in an established wound care center. III. OFFICE OR OTHER OUTPATIENT SERVICES (99202–99215) Use the Office or Other Outpatient Services codes to report Evaluation and Management services provided in the office or in an outpatient or other ambulatory facility. A patient is considered an outpatient until inpatient admission to a health care facility occurs. IV. TELEMEDICINE SERVICES CPT codes 98000-98007 report audio-video and 98008- 98015 audio-only telemedicine services by the health care provider. The services are further defined by new and established patients. Medical decision making or time determines the level of service. The guidelines indicate these services must be performed on a separate date of service from other E/M services.

CPT code 98016 is reported for an audio-only virtual check-in initiated by an established patient. The intent of the service is to evaluate the patient to see if a more extensive visit may be warranted. When the check-in leads to another E/M service on the same date, and if time is used to select the level of that service, the time provided for code 98016 may be added to the time of the E/M service. V. HOSPITAL INPATIENT OR OBSERVATION SERVICES (99221-99236) CPT codes 99221-99236 report E/M services provided to patients designated as “inpatient or observation status” in a hospital. It is not necessary that the patient be located in an observation area designated by the hospital. VI. HOSPITAL INPATIENT OR OBSERVATION CARE DISCHARGE SERVICES (99238-99239) A. CPT codes 99238 and 99239 are used only if discharge from hospital inpatient or observation status occurs on a date other than the initial date of inpatient admission or observation. The code includes final examination of the patient, discussion of the hospital stay, instructions for continuing care, and preparation of discharge records. B. If a patient is admitted to and subsequently discharged from hospital inpatient or observation status on the same date, see codes 99234–99236 as appropriate.

Evaluation and Management Mississippi Workers’ Compensation Medical Fee Schedule

20 Miss. Admin. Code Pt. 2, R. 46 Rule 46

CPT 2024 American Medical Association. All Rights Reserved. VII. EMERGENCY DEPARTMENT SERVICES (99281– 99285) Emergency department (ED) service codes do not differentiate between new and established patients and are used by hospital-based and non-hospital-based physicians or other qualified health care professionals. An emergency department is defined as “an organized hospital-based facility for the provision of unscheduled episodic services to patients who present for immediate medical attention. The facility must be available 24 hours a day.” This guideline indicates that care provided in the ED setting for convenience should not be coded as an ED service. Also note that more than one ED service can be reported per calendar day if medically necessary. Codes 99281–99285 are used to report services provided in a medical emergency. If, however, the physician or other qualified health care professional sees the injured worker in the emergency room out of convenience for either the injured worker or the physician or other qualified health care professional, the appropriate office visit code should be reported (99202–99215) and reimbursement will be made accordingly. Code 99281 may be performed by clinical staff and under the supervision of a physician or other qualified health care professional. VIII. CRITICAL CARE SERVICES (99291–99292) Critical care is the direct delivery by a physician or other qualified health care professional(s) of medical care for a critically ill or critically injured patient. A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life- threatening deterioration in the patient’s condition. Critical care involves high complexity decision making to assess, manipulate, and support vital system function(s) to treat single or multiple vital organ system failure and/or to prevent further life-threatening deterioration of the patient’s condition. Examples of vital organ system failure include, but are not limited to: central nervous system failure, circulatory failure, shock, renal, hepatic, metabolic, and/or respiratory failure. Although critical care typically requires interpretation of multiple physiologic parameters and/or application of advanced technology(s), critical care may be provided in life- threatening situations when these elements are not present. Critical care may be provided on multiple days, even if no changes are made in the treatment rendered to the injured worker, provided that the injured worker’s condition continues to require the level of physician or other qualified health care professional attention described above. Providing medical care to a critically ill, injured, or postoperative injured worker qualifies as a critical care service only if both the illness or injury and the treatment being provided meet the above requirements. Critical care is usually, but not always, given in a critical care area, such as the coronary care unit, intensive care unit, pediatric intensive care unit, respiratory care unit, or the emergency care facility. Services for an injured worker who is not critically ill but happens to be in a critical care unit are reported using other appropriate E/M codes. Critical care and other E/M services may be provided to the same injured worker on the same date by the same individual. The following services are included in reporting critical care when performed during the critical period by the physician or other qualified health care professional(s) providing critical care: the interpretation of cardiac output measurements (93598), chest imaging (71045, 71046), pulse oximetry (94760, 94761, 94762), blood gases, and collection and interpretation of physiologic data (eg, ECGs, blood pressures, hematologic data); gastric intubation (43752, 43753); temporary transcutaneous pacing (92953); ventilatory management (94002–94004, 94660, 94662); and vascular access procedures (36000, 36410, 36415, 36591, 36600). Any services performed which are not included in this listing should be reported separately. Facilities may report the above services separately. The critical care codes 99291 and 99292 are used to report the total duration of time spent in provision of critical care services to a critically ill or critically injured patient, even if the time spent providing care on that date is not continuous. For any given period of time spent providing critical care services, the individual must devote his or her full attention to the patient and, therefore, cannot provide services to any other patient during the same period of time. IX. NURSING FACILITY SERVICES (99304–99318) Codes 99304–99318 are used to report evaluation and management services to patients in nursing facilities (skilled nursing facilities (SNFs)) or intermediate care facilities (ICFs). These codes should also be used to report evaluation and management services provided to a patient in a psychiatric residential treatment center (a facility or a distinct part of a facility for psychiatric care, which provides a 24-hour therapeutically planned and professionally staffed group living and learning environment). If procedures such as medical psychotherapy are provided in addition to evaluation and management services, these should be reported in addition to the evaluation and management services provided.

X. HOME SERVICES (99341–99350) Services and care provided in a private residence are coded from this subcategory. They also are used to report evaluation and management services in an assisted living facility, group home, custodial care facility, and residential substance abuse treatment facility. XI. PROLONGED SERVICES (99358–99359, 99415– 99418) Codes 99358–99359 are used when a physician or other qualified health care professional provides prolonged service for patient management where face-to-face services have or will occur on another date of service. Codes 99415–99416 are used when a physician or other qualified health care professional provides prolonged service involving direct patient contact that is provided

Mississippi Workers’ Compensation Medical Fee Schedule Evaluation and Management

CPT Copyright 2024 American Medical Association. All rights reserved. 47 beyond the usual service in either an office or outpatient setting. Codes 99417-99418 are used to report prolonged services performed by a physician or other qualified health care professional prolonged services when they are provided on the same date of service as an E/M service. The E/M service must be reported based on time and the total time associated with the highest level of service has been exceeded. Code 99417 is reported with code 99205, 99215 99245, 99345, 99350, or 99483. Code 99418 is reported with 99223, 99233, 99236, 99255, 99306, or 99310. XII. PHYSICIAN STANDBY SERVICES (99360) Code 99360 is used to report physician or other qualified health care professional standby service that is requested by another individual and that involves prolonged attendance without direct (face-to-face) patient contact. Care or services may not be provided to other patients during this period. This code is not used to report time spent proctoring another individual. It is also not used if the period of standby ends with the performance of a procedure subject to a “surgical” package by the individual who was on standby. XIII. CASE MANAGEMENT SERVICES (99366– 99368) Case management is a process in which a physician or other qualified health care professional is responsible for direct care of a patient, and, additionally, for coordinating, managing access to, initiating, and/or supervising other health care services needed by the patient.

Use code 99368, Medical team conference with interdisciplinary team of health care professionals, patient and/or family not present, 30 minutes or more; participation by nonphysician qualified health care professional, to report a conference with a workers’ compensation medical case manager/claims manager. XIV. CARE PLAN OVERSIGHT SERVICES (99374– 99380) Care plan oversight services are reported separately from codes for office/outpatient, hospital, home, nursing facility, domiciliary, or non-face-to-face services. The complexity and the approximate time of the care plan oversight services provided within a thirty (30) day period determine code selection. Only one individual may report care plan oversight services for a given period of time, to reflect the sole or predominant supervisory role with a particular patient. These codes should not be used for supervision of patients in nursing facilities or under the care of home health agencies unless they require recurrent supervision of therapy. XV. NON-FACE-TO-FACE SERVICES (99441– 99449, 99451-99454, 99091, 99457-99458, 98975-98981) These codes are used to report non-face-to-face evaluation and management services using the telephone or internet resources and for remote physiologic monitoring and treatment management services. XVI. SPECIAL EVALUATION AND MANAGEMENT SERVICES (99450 and 99455–99456) These codes are used to report evaluations performed to establish baseline information prior to life or disability insurance certificates being issued. XVII. CARE MANAGEMENT SERVICES (99424–99427, 99437–99439, 99487–99491) Care management services are management and support services provided by clinical staff, under the direction of or provided personally by a physician or other qualified health care professional to an injured worker residing at home or in a domiciliary, rest home, or assisted living facility. Services include establishing, implementing, revising, or monitoring the care plan, coordinating the care of other professionals and agencies, and educating the injured worker or caregiver about the injured worker’s condition, care plan, and prognosis. There are three general categories of care management: chronic care management (99437, 99439, 99490, 99491), complex chronic care management (99487, 99489), and principal care management (99424, 99425, 99426, 99427). The physician or other qualified health care professional provides or oversees the management and/or coordination of services, as needed, for all medical conditions, psychosocial needs, and activities of daily living. XVIII. PSYCHIATRIC COLLABORATIVE CARE MANAGEMENT (99492–99494) Psychiatric collaborative care services are provided under the direction of a treating physician or other qualified health care professional. These include the services of the treating physician or other qualified health care professional, the behavioral health care manager and the psychiatric consultant. Patients typically have behavioral health signs and/or symptoms or a newly diagnosed behavioral health condition, may need help in engaging in treatment, have not responded to standard care delivered in a non-psychiatric setting, or require further assessment and engagement, prior to consideration of referral to a psychiatric care setting. XIX. TRANSITIONAL CARE MANAGEMENT (99495–99496) Transitional care management services are for a new or established patient whose medical and/or psychosocial problems require moderate or high complexity medical decision making during transitions in care from an inpatient hospital setting, partial hospital or observation status in a hospital, or skilled nursing facility/nursing facility to the patient’s community setting.

Evaluation and Management Mississippi Workers’ Compensation Medical Fee Schedule

20 Miss. Admin. Code Pt. 2, R. 48 Rule 48

CPT 2024 American Medical Association. All Rights Reserved. XX. ADVANCE CARE PLANNING (99497–99498) These face-to-face services between a physician or other qualified health care professional and a patient, family member, or surrogate involving counseling and discussing advance directives with or without completing relevant legal forms. XXI. OTHER EVALUATION AND MANAGEMENT SERVICES (99499) This is an unlisted code to report E/M services not specifically defined in CPT.

Evaluation and Management Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 98000-98016, 99091, 99202-99499 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine CPT Copyright 2024 American Medical Association. All rights reserved. 49

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  ★ 98000 Synchronous audio-video visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded. 80.85 XXX N  ★ 98001 Synchronous audio-video visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded. 133.35 XXX N  ★ 98002 Synchronous audio-video visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded. 212.63 XXX N  ★ 98003 Synchronous audio-video visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high medical decision making. When using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded. 281.93 XXX N  ★ 98004 Synchronous audio-video visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 10 minutes must be met or exceeded. 62.48 XXX N  ★ 98005 Synchronous audio-video visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded. 109.20 XXX N  ★ 98006 Synchronous audio-video visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded. 161.18 XXX N  ★ 98007 Synchronous audio-video visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded. 213.68 XXX N  ★ 98008 Synchronous audio-only visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination, straightforward medical decision making, and more than 10 minutes of medical discussion. When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded. 76.65 XXX N  ★ 98009 Synchronous audio-only visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination, low medical decision making, and more than 10 minutes of medical discussion. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded. 127.05 XXX N  ★ 98010 Synchronous audio-only visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination, moderate medical decision making, and more than 10 minutes of medical discussion. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded. 197.93 XXX N

Evaluation and Management Mississippi Workers’ Compensation Medical Fee Schedule 98000-98016, 99091, 99202-99499 Effective June 1, 2026 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 50 CPT 2024 American Medical Association. All Rights Reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  ★ 98011 Synchronous audio-only visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination, high medical decision making, and more than 10 minutes of medical discussion. When using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded. 257.25 XXX N  ★ 98012 Synchronous audio-only visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination, straightforward medical decision making, and more than 10 minutes of medical discussion. When using total time on the date of the encounter for code selection, 10 minutes must be exceeded. 57.23 XXX N  ★ 98013 Synchronous audio-only visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination, low medical decision making, and more than 10 minutes of medical discussion. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded. 99.75 XXX N  ★ 98014 Synchronous audio-only visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination, moderate medical decision making, and more than 10 minutes of medical discussion. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded. 145.95 XXX N  ★ 98015 Synchronous audio-only visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination, high medical decision making, and more than 10 minutes of medical discussion. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded. 212.10 XXX N  ★ 98016 Brief communication technology-based service (eg, virtual check- in) by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related evaluation and management service provided within the previous 7 days nor leading to an evaluation and management service or procedure within the next 24 hours or soonest available appointment, 5-10 minutes of medical discussion 25.73 XXX N  99091 Collection and interpretation of physiologic data (eg, ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified health care professional, qualified by education, training, licensure/regulation (when applicable) requiring a minimum of 30 minutes of time, each 30 days 85.58 XXX N  99202 Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded. 112.35 XXX N  99203 Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded. 172.73 XXX N

Mississippi Workers’ Compensation Medical Fee Schedule Evaluation and Management June 1, 2026 98000-98016, 99091, 99202-99499 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine CPT Copyright 2024 American Medical Association. All rights reserved. 51

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  99204 Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded. 257.25 XXX N  99205 Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded. 340.20 XXX N  99211 Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician or other qualified health care professional 35.70 XXX N  99212 Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 10 minutes must be met or exceeded. 87.15 XXX N  99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded. 139.65 XXX N  99214 Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded. 196.88 XXX N  99215 Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded. 277.73 XXX N  ★ 99221 Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded. 152.78 XXX N  ★ 99222 Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 55 minutes must be met or exceeded. 205.28 XXX N  ★ 99223 Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 75 minutes must be met or exceeded. 300.83 XXX N  ★ 99231 Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded. 58.80 XXX N

Evaluation and Management Mississippi Workers’ Compensation Medical Fee Schedule 98000-98016, 99091, 99202-99499 Effective June 1, 2026 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 52 CPT 2024 American Medical Association. All Rights Reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  ★ 99232 Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 35 minutes must be met or exceeded. 108.15 XXX N  ★ 99233 Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 50 minutes must be met or exceeded. 155.40 XXX N  ★ 99234 Hospital inpatient or observation care, for the evaluation and management of a patient including admission and discharge on the same date, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded. 197.93 XXX N  ★ 99235 Hospital inpatient or observation care, for the evaluation and management of a patient including admission and discharge on the same date, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 70 minutes must be met or exceeded. 250.95 XXX N  ★ 99236 Hospital inpatient or observation care, for the evaluation and management of a patient including admission and discharge on the same date, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 85 minutes must be met or exceeded. 321.30 XXX N  ★ 99238 Hospital inpatient or observation discharge day management; 30 minutes or less on the date of the encounter 109.20 XXX N  ★ 99239 Hospital inpatient or observation discharge day management; more than 30 minutes on the date of the encounter 159.60 XXX N  ★ 99242 Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded. 133.88 XXX N 152.48  ★ 99243 Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded. 184.28 XXX N 153.30  ★ 99244 Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded. 274.58 XXX N 224.65  ★ 99245 Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 55 minutes must be met or exceeded. 334.95 XXX N 246.78  ★ 99252 Inpatient or observation consultation for a new or established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When 111.83 XXX N

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR using total time on the date of the encounter for code selection, 35 minutes must be met or exceeded.  ★ 99253 Inpatient or observation consultation for a new or established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded. 173.78 XXX N 280.36  ★ 99254 Inpatient or observation consultation for a new or established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded. 250.43 XXX N  ★ 99255 Inpatient or observation consultation for a new or established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 80 minutes must be met or exceeded. 302.93 XXX N  ★ 99281 Emergency department visit for the evaluation and management of a patient that may not require the presence of a physician or other qualified health care professional 33.60 XXX N 105.19  ★ 99282 Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward medical decision making 65.10 XXX N 190.49  ★ 99283 Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and low level of medical decision making 110.78 XXX N 335.62  ★ 99284 Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making 186.90 XXX N 527.56  ★ 99285 Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making 271.43 XXX N 757.24  99288 Physician or other qualified health care professional direction of emergency medical systems (EMS) emergency care, advanced life support BR XXX N  ★ 99291 Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes 428.40 XXX N 1080.25  ★ 99292 Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service) 186.90 ZZZ N  ★ 99304 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded. 134.93 XXX N  ★ 99305 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 35 minutes must be met or exceeded. 194.78 XXX N  ★ 99306 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 50 minutes must be met or exceeded. 249.90 XXX N

Evaluation and Management Mississippi Workers’ Compensation Medical Fee Schedule 98000-98016, 99091, 99202-99499 Effective June 1, 2026 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 54 CPT 2024 American Medical Association. All Rights Reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  ★ 99307 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 10 minutes must be met or exceeded. 66.15 XXX N  ★ 99308 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded. 104.48 XXX N  ★ 99309 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded. 137.55 XXX N  ★ 99310 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded. 202.65 XXX N  ★ 99315 Nursing facility discharge management; 30 minutes or less total time on the date of the encounter 109.73 XXX N  ★ 99316 Nursing facility discharge management; more than 30 minutes total time on the date of the encounter 156.98 XXX N  ★ 99341 Home or residence visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded. 81.90 XXX N  ★ 99342 Home or residence visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded. 116.55 XXX N  ★ 99344 Home or residence visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded. 273.00 XXX N  ★ 99345 Home or residence visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 75 minutes must be met or exceeded. 330.75 XXX N  ★ 99347 Home or residence visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded. 82.95 XXX N  ★ 99348 Home or residence visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded. 126.00 XXX N

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  ★ 99349 Home or residence visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded. 194.25 XXX N  ★ 99350 Home or residence visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded. 269.33 XXX N  99358 Prolonged evaluation and management service before and/or after direct patient care; first hour 168.00 XXX N  99359 Prolonged evaluation and management service before and/or after direct patient care; each additional 30 minutes (List separately in addition to code for prolonged service) 81.90 ZZZ N  99360 Standby service, requiring prolonged attendance, each 30 minutes (eg, operative standby, standby for frozen section, for cesarean/high risk delivery, for monitoring EEG) 92.40 XXX N  99366 Medical team conference with interdisciplinary team of health care professionals, face-to-face with patient and/or family, 30 minutes or more, participation by nonphysician qualified health care professional 65.63 XXX N  99367 Medical team conference with interdisciplinary team of health care professionals, patient and/or family not present, 30 minutes or more; participation by physician 85.05 XXX N  99368 Medical team conference with interdisciplinary team of health care professionals, patient and/or family not present, 30 minutes or more; participation by nonphysician qualified health care professional 56.18 XXX N  99374 Supervision of a patient under care of home health agency (patient not present) in home, domiciliary or equivalent environment (eg, Alzheimer's facility) requiring complex and multidisciplinary care modalities involving regular development and/or revision of care plans by that individual, review of subsequent reports of patient status, review of related laboratory and other studies, communication (including telephone calls) for purposes of assessment or care decisions with health care professional(s), family member(s), surrogate decision maker(s) (eg, legal guardian) and/or key caregiver(s) involved in patient's care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 15-29 minutes 105.53 XXX N  99375 Supervision of a patient under care of home health agency (patient not present) in home, domiciliary or equivalent environment (eg, Alzheimer's facility) requiring complex and multidisciplinary care modalities involving regular development and/or revision of care plans by that individual, review of subsequent reports of patient status, review of related laboratory and other studies, communication (including telephone calls) for purposes of assessment or care decisions with health care professional(s), family member(s), surrogate decision maker(s) (eg, legal guardian) and/or key caregiver(s) involved in patient's care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 30 minutes or more 156.98 XXX N  99377 Supervision of a hospice patient (patient not present) requiring complex and multidisciplinary care modalities involving regular development and/or revision of care plans by that individual, review of subsequent reports of patient status, review of related laboratory and other studies, communication (including telephone 105.53 XXX N

Evaluation and Management Mississippi Workers’ Compensation Medical Fee Schedule 98000-98016, 99091, 99202-99499 Effective June 1, 2026 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 56 CPT 2024 American Medical Association. All Rights Reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR calls) for purposes of assessment or care decisions with health care professional(s), family member(s), surrogate decision maker(s) (eg, legal guardian) and/or key caregiver(s) involved in patient's care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 15-29 minutes  99378 Supervision of a hospice patient (patient not present) requiring complex and multidisciplinary care modalities involving regular development and/or revision of care plans by that individual, review of subsequent reports of patient status, review of related laboratory and other studies, communication (including telephone calls) for purposes of assessment or care decisions with health care professional(s), family member(s), surrogate decision maker(s) (eg, legal guardian) and/or key caregiver(s) involved in patient's care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 30 minutes or more 156.98 XXX N  99379 Supervision of a nursing facility patient (patient not present) requiring complex and multidisciplinary care modalities involving regular development and/or revision of care plans by that individual, review of subsequent reports of patient status, review of related laboratory and other studies, communication (including telephone calls) for purposes of assessment or care decisions with health care professional(s), family member(s), surrogate decision maker(s) (eg, legal guardian) and/or key caregiver(s) involved in patient's care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 15-29 minutes 105.53 XXX N  99380 Supervision of a nursing facility patient (patient not present) requiring complex and multidisciplinary care modalities involving regular development and/or revision of care plans by that individual, review of subsequent reports of patient status, review of related laboratory and other studies, communication (including telephone calls) for purposes of assessment or care decisions with health care professional(s), family member(s), surrogate decision maker(s) (eg, legal guardian) and/or key caregiver(s) involved in patient's care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 30 minutes or more 156.98 XXX N  99381 Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; infant (age younger than 1 year) 168.53 XXX N 132.34  99382 Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; early childhood (age 1 through 4 years) 175.88 XXX N 144.97  99383 Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; late childhood (age 5 through 11 years) 182.70 XXX N 129.35

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  99384 Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; adolescent (age 12 through 17 years) 207.90 XXX N 162.11  99385 Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 18-39 years 201.60 XXX N 164.42  99386 Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 40-64 years 233.10 XXX N 163.36  99387 Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 65 years and older 252.00 XXX N 149.15  99391 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; infant (age younger than 1 year) 152.25 XXX N 115.91  99392 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; early childhood (age 1 through 4 years) 161.70 XXX N 113.55  99393 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; late childhood (age 5 through 11 years) 161.18 XXX N 120.28  99394 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; adolescent (age 12 through 17 years) 176.40 XXX N 126.82  99395 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 18-39 years 180.08 XXX N 128.86  99396 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 40-64 years 193.73 XXX N 139.06

Evaluation and Management Mississippi Workers’ Compensation Medical Fee Schedule 98000-98016, 99091, 99202-99499 Effective June 1, 2026 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 58 CPT 2024 American Medical Association. All Rights Reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  99397 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 65 years and older 208.43 XXX N 122.02  99401 Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 15 minutes 59.85 XXX N 101.02  99402 Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 30 minutes 99.23 XXX N 115.72  99403 Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 45 minutes 134.93 XXX N 129.28  99404 Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 60 minutes 173.78 XXX N 140.65  ★ 99406 Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes 23.63 XXX N 38.11  ★ 99407 Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes 43.58 XXX N 38.11  ★ 99408 Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes 54.60 XXX N 68.16  ★ 99409 Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; greater than 30 minutes 105.00 XXX N 127.70  99411 Preventive medicine counseling and/or risk factor reduction intervention(s) provided to individuals in a group setting (separate procedure); approximately 30 minutes 32.03 XXX N 78.68  99412 Preventive medicine counseling and/or risk factor reduction intervention(s) provided to individuals in a group setting (separate procedure); approximately 60 minutes 39.38 XXX N 68.50  99415 Prolonged clinical staff service (the service beyond the highest time in the range of total time of the service) during an evaluation and management service in the office or outpatient setting, direct patient contact with physician supervision; first hour (List separately in addition to code for outpatient Evaluation and Management service) 15.75 ZZZ N  99416 Prolonged clinical staff service (the service beyond the highest time in the range of total time of the service) during an evaluation and management service in the office or outpatient setting, direct patient contact with physician supervision; each additional 30 minutes (List separately in addition to code for prolonged service) 8.93 ZZZ N  ★ 99417 Prolonged outpatient evaluation and management service(s) time with or without direct patient contact beyond the required time of the primary service when the primary service level has been selected using total time, each 15 minutes of total time (List separately in addition to the code of the outpatient Evaluation and Management service) 48.83 ZZZ N  ★ 99418 Prolonged inpatient or observation evaluation and management service(s) time with or without direct patient contact beyond the required time of the primary service when the primary service level has been selected using total time, each 15 minutes of total time 60.90 ZZZ N

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR (List separately in addition to the code of the inpatient and observation Evaluation and Management service)  99421 Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes 23.10 XXX N  99422 Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 11-20 minutes 45.15 XXX N  99423 Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes 73.50 XXX N  99424 Principal care management services, for a single high-risk disease, with the following required elements: one complex chronic condition expected to last at least 3 months, and that places the patient at significant risk of hospitalization, acute exacerbation/decompensation, functional decline, or death, the condition requires development, monitoring, or revision of disease- specific care plan, the condition requires frequent adjustments in the medication regimen and/or the management of the condition is unusually complex due to comorbidities, ongoing communication and care coordination between relevant practitioners furnishing care; first 30 minutes provided personally by a physician or other qualified health care professional, per calendar month. 126.53 XXX N  99425 Principal care management services, for a single high-risk disease, with the following required elements: one complex chronic condition expected to last at least 3 months, and that places the patient at significant risk of hospitalization, acute exacerbation/decompensation, functional decline, or death, the condition requires development, monitoring, or revision of disease- specific care plan, the condition requires frequent adjustments in the medication regimen and/or the management of the condition is unusually complex due to comorbidities, ongoing communication and care coordination between relevant practitioners furnishing care; each additional 30 minutes provided personally by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure) 91.35 ZZZ N  99426 Principal care management services, for a single high-risk disease, with the following required elements: one complex chronic condition expected to last at least 3 months, and that places the patient at significant risk of hospitalization, acute exacerbation/decompensation, functional decline, or death, the condition requires development, monitoring, or revision of disease- specific care plan, the condition requires frequent adjustments in the medication regimen and/or the management of the condition is unusually complex due to comorbidities, ongoing communication and care coordination between relevant practitioners furnishing care; first 30 minutes of clinical staff time directed by physician or other qualified health care professional, per calendar month. 96.08 XXX N 108.52  99429 Unlisted preventive medicine service BR XXX N 31.89  99437 Chronic care management services with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, chronic conditions that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline, comprehensive care plan established, implemented, revised, or monitored; each additional 30 minutes by a physician or other qualified health care professional per calendar month (List separately in addition to code for primary procedure) 92.93 ZZZ N  99439 Chronic care management services with the following required elements: multiple (two or more) chronic conditions expected to 73.50 ZZZ N

Evaluation and Management Mississippi Workers’ Compensation Medical Fee Schedule 98000-98016, 99091, 99202-99499 Effective June 1, 2026 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 60 CPT 2024 American Medical Association. All Rights Reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR last at least 12 months, or until the death of the patient, chronic conditions that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline, comprehensive care plan established, implemented, revised, or monitored; each additional 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure)  99446 Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician or other qualified health care professional, including a verbal and written report to the patient's treating/requesting physician or other qualified health care professional; 5-10 minutes of medical consultative discussion and review 28.35 XXX N  99447 Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician or other qualified health care professional, including a verbal and written report to the patient's treating/requesting physician or other qualified health care professional; 11-20 minutes of medical consultative discussion and review 55.65 XXX N  99448 Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician or other qualified health care professional, including a verbal and written report to the patient's treating/requesting physician or other qualified health care professional; 21-30 minutes of medical consultative discussion and review 83.48 XXX N  99449 Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician or other qualified health care professional, including a verbal and written report to the patient's treating/requesting physician or other qualified health care professional; 31 minutes or more of medical consultative discussion and review 111.83 XXX N  99450 Basic life and/or disability examination that includes: Measurement of height, weight, and blood pressure; Completion of a medical history following a life insurance pro forma; Collection of blood sample and/or urinalysis complying with "chain of custody" protocols; and Completion of necessary documentation/ certificates. 21.53 XXX N  99451 Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician or other qualified health care professional, including a written report to the patient's treating/requesting physician or other qualified health care professional, 5 minutes or more of medical consultative time 55.13 XXX N  99452 Interprofessional telephone/Internet/electronic health record referral service(s) provided by a treating/requesting physician or other qualified health care professional, 30 minutes 56.18 XXX N  99453 Remote monitoring of physiologic parameter(s) (eg, weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education on use of equipment 28.88 XXX N 172.32  99454 Remote monitoring of physiologic parameter(s) (eg, weight, blood pressure, pulse oximetry, respiratory flow rate), initial; device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days 84.53 XXX N 54.00

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  99455 Work related or medical disability examination by the treating physician that includes: Completion of a medical history commensurate with the patient's condition; Performance of an examination commensurate with the patient's condition; Formulation of a diagnosis, assessment of capabilities and stability, and calculation of impairment; Development of future medical treatment plan; and Completion of necessary documentation/certificates and report. See Rules

XXX N  99456 Work related or medical disability examination by other than the treating physician that includes: Completion of a medical history commensurate with the patient's condition; Performance of an examination commensurate with the patient's condition; Formulation of a diagnosis, assessment of capabilities and stability, and calculation of impairment; Development of future medical treatment plan; and Completion of necessary documentation/certificates and report. Negotiated XXX N  99457 Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; first 20 minutes 76.13 XXX N  99458 Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; each additional 20 minutes (List separately in addition to code for primary procedure) 61.95 ZZZ N  99459 Pelvic examination (List separately in addition to code for primary procedure) 35.70 ZZZ N  99460 Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infant 144.38 XXX N 172.32  99461 Initial care, per day, for evaluation and management of normal newborn infant seen in other than hospital or birthing center 141.75 XXX N  99462 Subsequent hospital care, per day, for evaluation and management of normal newborn 64.05 XXX N  99463 Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infant admitted and discharged on the same date 166.43 XXX N 172.32  99464 Attendance at delivery (when requested by the delivering physician or other qualified health care professional) and initial stabilization of newborn 113.40 XXX N  99465 Delivery/birthing room resuscitation, provision of positive pressure ventilation and/or chest compressions in the presence of acute inadequate ventilation and/or cardiac output 221.03 XXX N 814.70  99466 Critical care face-to-face services, during an interfacility transport of critically ill or critically injured pediatric patient, 24 months of age or younger; first 30-74 minutes of hands-on care during transport 360.68 XXX N  99467 Critical care face-to-face services, during an interfacility transport of critically ill or critically injured pediatric patient, 24 months of age or younger; each additional 30 minutes (List separately in addition to code for primary service) 181.65 ZZZ N  ★ 99468 Initial inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or younger 1391.25 XXX N  ★ 99469 Subsequent inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or younger 602.70 XXX N

Evaluation and Management Mississippi Workers’ Compensation Medical Fee Schedule 98000-98016, 99091, 99202-99499 Effective June 1, 2026 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 62 CPT 2024 American Medical Association. All Rights Reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  ★ 99471 Initial inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 29 days through 24 months of age 1204.35 XXX N  ★ 99472 Subsequent inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 29 days through 24 months of age 614.25 XXX N  ★ 99473 Self-measured blood pressure using a device validated for clinical accuracy; patient education/training and device calibration 17.85 XXX N 35.83  99474 Self-measured blood pressure using a device validated for clinical accuracy; separate self-measurements of two readings one minute apart, twice daily over a 30-day period (minimum of 12 readings), collection of data reported by the patient and/or caregiver to the physician or other qualified health care professional, with report of average systolic and diastolic pressures and subsequent communication of a treatment plan to the patient 23.10 XXX N  ★ 99475 Initial inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 2 through 5 years of age 865.73 XXX N  ★ 99476 Subsequent inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 2 through 5 years of age 519.23 XXX N  ★ 99477 Initial hospital care, per day, for the evaluation and management of the neonate, 28 days of age or younger, who requires intensive observation, frequent interventions, and other intensive care services 526.58 XXX N  ★ 99478 Subsequent intensive care, per day, for the evaluation and management of the recovering very low birth weight infant (present body weight less than 1500 grams) 207.90 XXX N  ★ 99479 Subsequent intensive care, per day, for the evaluation and management of the recovering low birth weight infant (present body weight of 1500-2500 grams) 189.53 XXX N  ★ 99480 Subsequent intensive care, per day, for the evaluation and management of the recovering infant (present body weight of 2501-5000 grams) 181.65 XXX N  ★ 99483 Assessment of and care planning for a patient with cognitive impairment, requiring an independent historian, in the office or other outpatient, home or domiciliary or rest home, with all of the following required elements: Cognition-focused evaluation including a pertinent history and examination, Medical decision making of moderate or high complexity, Functional assessment (eg, basic and instrumental activities of daily living), including decision-making capacity, Use of standardized instruments for staging of dementia (eg, functional assessment staging test [FAST], clinical dementia rating [CDR]), Medication reconciliation and review for high-risk medications, Evaluation for neuropsychiatric and behavioral symptoms, including depression, including use of standardized screening instrument(s), Evaluation of safety (eg, home), including motor vehicle operation, Identification of caregiver(s), caregiver knowledge, caregiver needs, social supports, and the willingness of caregiver to take on caregiving tasks, Development, updating or revision, or review of an Advance Care Plan, Creation of a written care plan, including initial plans to address any neuropsychiatric symptoms, neuro- cognitive symptoms, functional limitations, and referral to community resources as needed (eg, rehabilitation services, adult day programs, support groups) shared with the patient and/or caregiver with initial education and support. Typically, 60 minutes of total time is spent on the date of the encounter. 429.45 XXX N 108.52  99484 Care management services for behavioral health conditions, at least 20 minutes of clinical staff time, directed by a physician or 67.73 XXX N 38.11

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR other qualified health care professional, per calendar month, with the following required elements: initial assessment or follow-up monitoring, including the use of applicable validated rating scales, behavioral health care planning in relation to behavioral/psychiatric health problems, including revision for patients who are not progressing or whose status changes, facilitating and coordinating treatment such as psychotherapy, pharmacotherapy, counseling and/or psychiatric consultation, and continuity of care with a designated member of the care team.  99485 Supervision by a control physician of interfacility transport care of the critically ill or critically injured pediatric patient, 24 months of age or younger, includes two-way communication with transport team before transport, at the referring facility and during the transport, including data interpretation and report; first 30 minutes 114.98 XXX N  99486 Supervision by a control physician of interfacility transport care of the critically ill or critically injured pediatric patient, 24 months of age or younger, includes two-way communication with transport team before transport, at the referring facility and during the transport, including data interpretation and report; each additional 30 minutes (List separately in addition to code for primary procedure) 100.28 XXX N  99487 Complex chronic care management services with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, chronic conditions that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline, comprehensive care plan established, implemented, revised, or monitored, moderate or high complexity medical decision making; first 60 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month. 203.70 XXX N 194.04  99489 Complex chronic care management services with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, chronic conditions that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline, comprehensive care plan established, implemented, revised, or monitored, moderate or high complexity medical decision making; each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure) 107.10 ZZZ N  99490 Chronic care management services with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, chronic conditions that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline, comprehensive care plan established, implemented, revised, or monitored; first 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month. 97.13 XXX N 108.52  99491 Chronic care management services with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, chronic conditions that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline, comprehensive care plan established, implemented, revised, or monitored; first 30 minutes provided personally by a physician or other qualified health care professional, per calendar month. 130.73 XXX N

Evaluation and Management Mississippi Workers’ Compensation Medical Fee Schedule 98000-98016, 99091, 99202-99499 Effective June 1, 2026 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 64 CPT 2024 American Medical Association. All Rights Reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  99492 Initial psychiatric collaborative care management, first 70 minutes in the first calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional, with the following required elements: outreach to and engagement in treatment of a patient directed by the treating physician or other qualified health care professional, initial assessment of the patient, including administration of validated rating scales, with the development of an individualized treatment plan, review by the psychiatric consultant with modifications of the plan if recommended, entering patient in a registry and tracking patient follow-up and progress using the registry, with appropriate documentation, and participation in weekly caseload consultation with the psychiatric consultant, and provision of brief interventions using evidence-based techniques such as behavioral activation, motivational interviewing, and other focused treatment strategies. 233.10 XXX N 108.52  99493 Subsequent psychiatric collaborative care management, first 60 minutes in a subsequent month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional, with the following required elements: tracking patient follow-up and progress using the registry, with appropriate documentation, participation in weekly caseload consultation with the psychiatric consultant, ongoing collaboration with and coordination of the patient's mental health care with the treating physician or other qualified health care professional and any other treating mental health providers, additional review of progress and recommendations for changes in treatment, as indicated, including medications, based on recommendations provided by the psychiatric consultant, provision of brief interventions using evidence-based techniques such as behavioral activation, motivational interviewing, and other focused treatment strategies, monitoring of patient outcomes using validated rating scales, and relapse prevention planning with patients as they achieve remission of symptoms and/or other treatment goals and are prepared for discharge from active treatment. 225.75 XXX N 108.52  99494 Initial or subsequent psychiatric collaborative care management, each additional 30 minutes in a calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional (List separately in addition to code for primary procedure) 96.60 ZZZ N  ★ 99495 Transitional care management services with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge At least moderate level of medical decision making during the service period Face-to-face visit, within 14 calendar days of discharge 317.10 XXX N 172.32  ★ 99496 Transitional care management services with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge High level of medical decision making during the service period Face-to-face visit, within 7 calendar days of discharge 427.35 XXX N 172.32  ★ 99497 Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate 129.68 XXX N 108.52

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  ★ 99498 Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; each additional 30 minutes (List separately in addition to code for primary procedure) 112.35 ZZZ N  99499 Unlisted evaluation and management service BR XXX N

20 Miss. Admin. Code Pt. 2, R. 66 Rule 66

Relative Value Guide © 2024 American Society of Anesthesiologists. All rights reserved. 67 CPT Copyright 2024 American Medical Association. All rights reserved. ANESTHESIA Note: Rules used by all physicians or other qualified health care professionals (OQHP) in reporting their services are presented in the General Rules section. See the Modifier and Code Rules section for detailed information on modifiers. I. INTRODUCTION The 2025 American Society of Anesthesiologists’ (ASA) Relative Value Guide ® is recognized as an appropriate assessment of current relative values for specific anesthesiology procedures. It is the basis for the assigned base units for CPT ® codes in the Anesthesia section of the Fee Schedule. The conversion factor for anesthesia services has been designated at $75.00 per unit. Total anesthesia value is defined in the following formula: (Base units + time units + modifying units) x conversion factor = reimbursement II. BASE UNITS Base units are listed for most procedures. This value is determined by the complexity of the service and includes all usual anesthesia services except the time actively spent in anesthesia care and the modifying factors. The base units include preoperative and postoperative visits, the administration of fluids and/or blood incident to the anesthesia care, and interpretation of non-invasive monitoring (ECG, temperature, blood pressure, oximetry, and other usual monitoring procedures). The basic anesthesia unit includes the routine follow-up care and observation (including recovery room observation and monitoring). When multiple surgical procedures are performed during the same period of anesthesia, only the highest base unit allowance of the various surgical procedures will be used. III. TIME UNITS Anesthesia time begins when the anesthesiologist starts the preparation of the injured worker for anesthesia in the preoperative area, the operating room or a similar area, and ends when the injured worker is placed under postoperative care, such as transfer to the recovery room. The anesthesia time units will be calculated in 15-minute intervals, or portions thereof, equaling one (1) time unit. No additional time units are allowed for recovery room time and monitoring.

IV. SPECIAL CIRCUMSTANCES A. Physical Status Modifiers. Physical status modifiers are represented by the initial letter P followed by a single digit from one (1) to six (6) defined below: Status Description Base Units P1 A normal healthy patient 0 P2 A patient with mild systemic disease

P3 A patient with severe systemic disease

P4 A patient with severe systemic disease that is a constant threat to life

P5 A moribund patient who is not expected to survive without the operation

P6 A patient declared brain-dead whose organs are being removed for donor purposes

These six levels are consistent with the American Society of Anesthesiologists’ (ASA) ranking of patient physical status. Physical status is included in CPT to distinguish between various levels of complexity of the anesthesia service provided. Documentation submitted with the billing must include the indicators that justify physical status for P3, P4, and P5. B. Qualifying Circumstances 1. Many anesthesia services are provided under particularly difficult circumstances, depending on factors such as extraordinary condition of patient, notable operative condition, and/or unusual risk factors. These procedures would not be reported alone but would be reported as additional procedure numbers qualifying an anesthesia procedure or service. CPT Code Description Units 99100 Anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure)

20 Miss. Admin. Code Pt. 2, R. 99116 Rule 99116

Anesthesia complicated by utilization of total body hypothermia (List separately in addition to code for primary anesthesia procedure)

Anesthesia Mississippi Workers’ Compensation Medical Fee Schedule

20 Miss. Admin. Code Pt. 2, R. 68 Rule 68

Relative Value Guide © 2024 American Society of Anesthesiologists. All rights reserved. CPT © 2024 American Medical Association. All Rights Reserved. CPT Code Description Units 99135 Anesthesia complicated by utilization of controlled hypotension (List separately in addition to code for primary anesthesia procedure) Mississippi note: Documentation must include maintaining BP at 100 or less for one hour or more.

20 Miss. Admin. Code Pt. 2, R. 99140 Rule 99140

Anesthesia complicated by emergency conditions (specify) (List separately in addition to code for primary anesthesia procedure)

Payers must utilize their medical consultants when there is a question regarding modifiers and/or special circumstances for anesthesia charges. V. MONITORED ANESTHESIA CARE Monitored anesthesia care occurs when the attending or ordering physician or OQHP requests that an anesthesiologist be present during a procedure. This may be to ensure compliance with accepted procedures of the facility. Monitored anesthesia care includes pre- anesthesia exam and evaluation of the injured worker. The anesthesiologist must participate or provide medical direction for the plan of care. The anesthesiologist, resident, or nurse anesthetist must be in continuous physical presence and provide diagnosis and treatment of emergencies. This will also include non-invasive monitoring of cardiocirculatory and respiratory systems with administration of oxygen and/or intravenous administration of medications. Reimbursement will be the same as if general anesthesia had been administered (time units + base units). VI. REIMBURSEMENT FOR ANESTHESIA SERVICES A. Criteria for Reimbursement. Anesthesia services may be billed for any one of the three following circumstances: 1. An anesthesiologist provides total and individual anesthesia service. 2. An anesthesiologist directs a Certified Registered Nurse Anesthetist (CRNA). 3. Anesthesia provided by a CRNA working independent of an anesthesiologist’s supervision is covered under the following conditions: a. The service falls within the CRNA’s scope of practice and scope of license as defined by law. b. The service is supervised by a licensed health care provider who has prescriptive authority in accordance with the clinical privileges individually granted by the hospital or other health care organization.

B. Reimbursement 1. The maximum allowable reimbursement (MAR) for anesthesia is calculated by adding the base unit value, the number of time units, any applicable modifier and/or unusual circumstances units, and multiplying the sum by a dollar amount (conversion factor) allowed per unit. 2. Reimbursement includes the usual pre- and postoperative visits, the care by the anesthesiologist during surgery, the administration of fluids and/or blood, and the usual monitoring services. Unusual forms of monitoring, such as central venous, intra- arterial, and Swan-Ganz monitoring, may be reimbursed separately. 3. When an unlisted service or procedure is provided, the value should be substantiated with a report. Unlisted services are identified in this Fee Schedule as by report (BR). 4. When it is necessary to have a second anesthesiologist, the necessity should be substantiated by report. The second anesthesiologist will be reimbursed by report. 5. Payment for covered anesthesia services is as follows: a. When the anesthesiologist provides an anesthesia service directly, payment will be made in accordance with the Billing and Reimbursement Rules of this Fee Schedule. b. When an anesthesiologist provides medical direction to the CRNA providing the anesthesia service, then the reimbursement will be divided between the two providers (anesthesiologist and CRNA) at fifty percent (50%). c. When the CRNA provides the anesthesia service directly, then payment will be the lesser of the billed charge or eighty percent (80%) of the maximum allowable listed in the Fee Schedule for that procedure. 6. Anesthesiologists or CRNAs must bill their services with the appropriate modifiers to indicate which one provided the service. Bills NOT properly coded may cause a delay or error in reimbursement by the payer. Application of the appropriate modifier to the bill for service is the responsibility of the provider, regardless of the place of service. For detailed information on anesthesia modifiers, refer to the Modifier and Code Rules section.

Mississippi Workers’ Compensation Medical Fee Schedule Anesthesia 00100-01999, 99100-99140 Effective June 1, 2026 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine Relative Value Guide © 2024 American Society of Anesthesiologists. All rights reserved. 69 CPT Copyright 2024 American Medical Association. All rights reserved.

CODE DESCRIPTION BASE UNIT  00100 ANESTHESIA SALIVARY GLANDS WITH BIOPSY 5.00  00102 ANESTHESIA CLEFT LIP INVOLVING PLASTIC REPAIR 6.00  00103 ANESTHESIA EYELID RECONSTRUCTIVE PROCEDURE 5.00  00104 ANESTHESIA ELECTROCONVULSIVE THERAPY 4.00  00120 ANESTHESIA EXTERNAL MIDDLE & INNER EAR W/BX NOS 5.00  00124 ANES EXTERNAL MIDDLE & INNER EAR W/BX OTOSCOPY 4.00  00126 ANES XTRNL MID & INNER EAR W/BX TYMPANOTOMY 4.00  00140 ANESTHESIA EYE NOT OTHERWISE SPECIFIED 5.00  00142 ANESTHESIA EYE LENS SURGERY 4.00  00144 ANESTHESIA EYE CORNEAL TRANSPLANT 6.00  00145 ANESTHESIA EYE VITREORETINAL SURGERY 6.00  00147 ANESTHESIA EYE IRIDECTOMY 4.00  00148 ANESTHESIA EYE OPHTHALMOSCOPY 4.00  00160 ANESTHESIA NOSE & ACCESSORY SINUSES NOS 5.00  00162 ANES NOSE & ACCESSORY SINUSES RADICAL SURGERY 7.00  00164 ANES NOSE & ACCESSORY SINUSES BIOPSY SOFT TISSUE 4.00  00170 ANESTHESIA INTRAORAL WITH BIOPSY NOS 5.00  00172 ANES INTRAORAL W/BIOPSY REPAIR CLEFT PALATE 6.00  00174 ANES INTRAORAL W/BX EXC RETROPHARYNGEAL TUMOR 6.00  00176 ANESTHESIA INTRAORAL W/BIOPSY RADICAL SURGERY 7.00  00190 ANESTHESIA FACIAL BONES OR SKULL NOS 5.00  00192 ANES FACIAL BONES/SKULL RAD SURG W/PROGNATHISM 7.00  00210 ANESTHESIA INTRACRANIAL PROCEDURE NOS 11.00  00211 ANES INTRACRANIAL CRANIOTOMY/CRANIECTOMY HMTMA 10.00  00212 ANESTHESIA INTRACRANIAL PROCEDURE SUBDURAL TAPS 5.00  00214 ANES INTRACRANIAL BURR HOLES W/VENTRICULOGRAPHY 9.00  00215 ANES INTRACRANIAL/ELEVATION DEPRSD SKULL FX XDRL 9.00  00216 ANESTHESIA INTRACRANIAL VASCULAR PROCEDURE 15.00  00218 ANES INTRACRANIAL PROCEDURE IN SITTING POSITION 13.00  00220 ANES INTRACRANIAL CEREBROSPINAL FLUID SHUNTING 10.00  00222 ANES INTRACRANIAL ELECTROCOAGULATION ICRA NERVE 6.00  00300 ANES INTEG MUSC & NRV HEAD NECK&POSTERIOR TRUNK 5.00  00320 ANES ESOPH THYRD LARYNX TRACH & LYMPH NECK 1YR 6.00  00322 ANES ESOPH THYRD LARX TRACH & LYMPH NCK BX THYRD 3.00  00326 ANESTHESIA LARYNX & TRACHEA CHILDREN <1 YEAR 7.00  00350 ANESTHESIA MAJOR VESSELS NECK NOS 10.00  00352 ANESTHESIA MAJOR VESSELS NECK SIMPLE LIGATION 5.00  00400 ANES INTEG EXTREMITIES ANT TRUNK & PERINEUM NOS 3.00  00402 ANESTHESIA RECONSTRUCTION BREAST 5.00  00404 ANESTHESIA RADICAL/MODIFIED RADICAL BREAST 5.00  00406 ANES RADICAL/MODIFIED RADICAL BREAST W/NODES 13.00  00410 ANES INTEG SYS ELEC CONVERSION ARRHYTHMIAS 4.00  00450 ANESTHESIA CLAVICLE AND SCAPULA NOS 5.00  00454 ANESTHESIA CLAVICLE & SCAPULA BIOPSY CLAVICLE 3.00  00470 ANESTHESIA PARTIAL RIB RESECTION NOS 6.00  00472 ANESTHESIA PARTIAL RIB RESECTION THORACOPLASTY 10.00  00474 ANESTHESIA PARTIAL RIB RESECTION RADICAL 13.00  00500 ANESTHESIA ESOPHAGUS 15.00

Anesthesia Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 00100-01999, 99100-99140

Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 70 Relative Value Guide © 2024 American Society of Anesthesiologists. All rights reserved. CPT Copyright 2024 American Medical Association. All rights reserved.

CODE DESCRIPTION BASE UNIT  00520 ANESTHESIA CLOSED CHEST W/BRONCHOSCOPY NOS 6.00  00522 ANESTHESIA CLOSED CHEST NEEDLE BIOPSY PLEURA 4.00  00524 ANESTHESIA CLOSED CHEST PNEUMOCENTESIS 4.00  00528 ANES MEDIASTINOSCOPY&THORACSCOPY W/O 1 LUNG VNTJ 8.00  00529 ANES MEDIASTINOSCOPY&THORACOSCOPY W/1 LUNG VNT 11.00  00530 ANES PERMANENT TRANSVENOUS PACEMAKER INSERTION 4.00  00532 ANESTHESIA ACCESS CENTRAL VENOUS CIRCULATION 4.00  00534 ANES TRANSVENOUS INSJ/REPLACEMENT PACING CVDFB 7.00  00537 ANES CARDIAC ELECTROPHYSIOL STDY W/RF ABLATION 10.00  00539 ANESTHESIA TRACHEOBRONCHIAL RECONSTRUCTION 18.00  00540 ANES THORACOTOMY & THORACOSCOPY NOS 12.00  00541 ANES THORACOTOMY & THORACOSCOPY W/1 LUNG VNTJ 15.00  00542 ANES THORACOTOMY & THORACOSCOPY DECORTICATION 15.00  00546 ANES THORACOTOMY & THORACOSCOPY PULMONARY RESC 15.00  00548 ANES THORACOTOMY &THORACSCOPY TRACHEA & BRONCHI 17.00  00550 ANESTHESIA FOR STERNAL DEBRIDEMENT 10.00  00560 ANES HRT PERICARDIAL SAC& GRT VESLS W/O PMP OXT 15.00  00561 ANES HRT PERICARD SAC&GREAT VSLS W/PMP OXTJ <1YR 25.00  00562 ANES HRT PERICRD SAC&GRT VSLS W/PMP OXTJ >1MO PO 20.00  00563 ANES HRT PRCRD SAC & GREAT VSL W/PUMP OXTJ HYPTH 25.00  00566 ANES DIRECT CABG W/O PUMP OXYGENATOR 25.00  00567 ANES DIRECT CABG W/PUMP OXYGENATOR 18.00  00580 ANES HEART TRANSPLANT/HEART/LUNG TRANSPLANT 20.00  00600 ANESTHESIA CERVICAL SPINE & CORD NOS 10.00  00604 ANES CERVICAL SPINE & CORD W/PATIENT SITTING 13.00  00620 ANESTHESIA THORACIC SPINE & CORD NOS 10.00  00625 ANES THRC SPINE & CORD ANT APPR W/O 1 LUNG VENTJ 13.00  00626 ANES THORACIC SPINE & CORD ANT APPR W/1 LNG VENT 15.00  00630 ANESTHESIA LUMBAR REGION NOS 8.00  00632 ANESTHESIA LUMBAR REGION LUMBAR SYMPATHECTOMY 7.00  00635 ANES DIAGNOSTIC/THERAPEUTIC LUMBAR PUNCTURE 4.00  00640 ANES MANIPULATE SPINE/CLSD CRV THORC/LUMBR SPINE 3.00  00670 ANESTHESIA EXTENSIVE SPINE & SPINAL CORD 13.00  00700 ANESTHESIA UPPER ANTERIOR ABDOMINAL WALL NOS 4.00  00702 ANES UPR ANT ABDL WALL PERCUTANEOUS LIVER BX 4.00  00730 ANESTHESIA UPPER POSTERIOR ABDOMINAL WALL 5.00  00731 ANESTHESIA UPPER GI ENDOSCOPIC PX NOS 5.00  00732 ANESTHESIA UPPER GI ENDOSCOPIC PX ERCP 6.00  00750 ANESTHESIA HERNIA REPAIR UPPER ABDOMEN NOS 4.00  00752 ANES HRNA RPR UPR ABD LMBR&VENTRAL HERNIA&/DEHSN 6.00  00754 ANES HERNIA REPAIR UPPER ABDOMEN OMPHALOCELE 7.00  00756 ANES HRNA REPAIR UPR ABD TABDL RPR DIPHRG HRNA 7.00  00770 ANESTHESIA ALL PX MAJOR ABDOMINAL BLOOD VESSELS 15.00  00790 ANES INTRAPERITONEAL UPPER ABDOMEN W/LAPS NOS 7.00  00792 ANES IPER UPR ABD PRTL HPCT MGMT LIVER HMRRG 13.00  00794 ANES IPER UPR ABD PARTIAL/TOTAL PANCREATECTOMY 8.00  00796 ANES IPER UPR ABD LIVER TRANSPLANT 30.00  00797 ANES IPER UPR ABD GASTRIC RSTCV PX MO 11.00

Mississippi Workers’ Compensation Medical Fee Schedule Anesthesia 00100-01999, 99100-99140 Effective June 1, 2026 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine Relative Value Guide © 2024 American Society of Anesthesiologists. All rights reserved. 71 CPT Copyright 2024 American Medical Association. All rights reserved.

CODE DESCRIPTION BASE UNIT  00800 ANESTHESIA LOWER ANTERIOR ABDOMINAL WALL NOS 4.00  00802 ANES LOWER ANT ABDOMINAL WALL PANNICULECTOMY 5.00  00811 ANESTHESIA LOWER INTST ENDOSCOPIC PX NOS 4.00  00812 ANESTHESIA LOWER INTST ENDOSCOPIC PX SCR COLSC 3.00  00813 ANESTHESIA COMBINED UPPER&LOWER GI ENDOSCOPIC PX 5.00  00820 ANESTHESIA LOWER POSTERIOR ABDOMINAL WALL 5.00  00830 ANESTHESIA HERNIA REPAIR LOWER ABDOMEN NOS 4.00  00832 ANES LWR ABD VENTRAL & INCISIONAL HERNIA REPAIR 6.00  00834 ANES HERNIA REPAIR LOWER ABDOMEN NOS & 1YR AGE 5.00  00836 ANES HRNA RPR LWR ABD NOS INFTS <37WK BRTH/50WK 6.00  00840 ANESTHESIA INTRAPERITONEAL LOWER ABD W/LAPS NOS 6.00  00842 ANES IPER LOWER ABDOMEN W/LAPS AMNIOCENTESIS 4.00  00844 ANES IPER LOWER ABD W/LAPS ABDOMINOPRNL RESCJ 7.00  00846 ANES IPER LOWER ABD W/LAPS RAD HYSTERECTOMY 8.00  00848 ANES IPER LOWER ABD W/LAPS PELVIC EXENTERATION 8.00  00851 ANES IPER LWR ABD W/LAPS TUBAL LIGATION/TRANSECT 6.00  00860 ANES EXTRAPERITONEAL LWR ABD W/URINARY TRACT NOS 6.00  00862 ANES XTRPRTL LOWER ABD UR TRACT RENAL DON NFRCT 7.00  00864 ANES XTRPRTL LWER ABD W/URINARY TRACT TOT CYSTEC 8.00  00865 ANES XTRPRTL LWR ABD W/URINARY TRACT RAD PRSTECT 7.00  00866 ANES XTRPRTL LOWER ABD W/URIN TRACT ADRENLECTOMY 10.00  00868 ANES XTRPRTL LWR ABD W/URIN TRACT RENAL TRANSPL 10.00  00870 ANES XTRPRTL LWR ABD W/URIN TRACT CSTOLITHOTOMY 5.00  00872 ANES LITHOTRP XTRCORP SHOCK WAVE W/WATER BATH 7.00  00873 ANES LITHOTRP XTRCORP SHOCK WAVE W/O WATER BATH 5.00  00880 ANESTHESIA MAJOR LOWER ABDOMINAL VESSELS NOS 15.00  00882 ANES MAJOR LOWER ABDOMINAL VESSELS IVC LIGATION 10.00  00902 ANESTHESIA ANORECTAL PROCEDURE 5.00  00904 ANESTHESIA RADICAL PERINEAL PROCEDURE 7.00  00906 ANESTHESIA VULVECTOMY 4.00  00908 ANESTHESIA PERINEAL PROSTATECTOMY 6.00  00910 ANES TRANSURETHRAL W/URETHROCYSTOSCOPY NOS 3.00  00912 ANES TRANSURETHRAL RESECTION OF BLADDER TUMOR 5.00  00914 ANESTHESIA TRANSURETHRAL RESECTION OF PROSTATE 5.00  00916 ANES TRURL POST-TRURL RESECTION BLEEDING 5.00  00918 ANES TRURL FRAGMNTJ MANJ&/RMVL URETERAL CALCULUS 5.00  00920 ANESTHESIA MALE GENITALIA INCL OPEN URETHRAL PX 3.00  00921 ANES VASECTOMY UNI/BI INCL OPEN URETHRAL PX 3.00  00922 ANES SEMINAL VESICLES INCL OPEN URETHRAL PX 6.00  00924 ANES UNDSCND TESTIS UNI/BI INCL OPEN URTL PX 4.00  00926 ANES RAD ORCHIECTOMY INGUN INCL OPEN URTL PX 4.00  00928 ANES RAD ORCHIECTOMY ABDOMINAL INCL OPN URTL 6.00  00930 ANES ORCHIOPEXY UNI/BI INCL OPEN URETHRAL PX 4.00  00932 ANES COMPLETE AMPUTATION PENIS INCL OPEN URTL 4.00  00934 ANES RAD AMP PENIS W/BI INGUINAL LYMPH NODE RMVL 6.00  00936 ANES RAD AMP PENIS W/BI INGUNL&ILIAC LYMPH RMOVL 8.00  00938 ANES INSJ PENILE PROSTH PRNL INCL OPEN URTL 4.00  00940 ANESTHESIA VAGINAL PROCEDURE W/BIOPSY NOS 3.00

Anesthesia Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 00100-01999, 99100-99140

Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 72 Relative Value Guide © 2024 American Society of Anesthesiologists. All rights reserved. CPT Copyright 2024 American Medical Association. All rights reserved.

CODE DESCRIPTION BASE UNIT  00942 ANES COLPTMY VAGNC COLPRPHY INCL BX W/OPN URTL 4.00  00944 ANESTHESIA VAGINAL HYSTERECTOMY INCL BIOPSY 6.00  00948 ANESTHESIA CERVICAL CERCLAGE INCLUDING BIOPSY 4.00  00950 ANESTHESIA CULDOSCOPY INCLUDING BIOPSY 5.00  00952 ANES HYSTEROSCOPY&/HYSTEROSALPINGOGRAPHY W/BX 4.00  01112 ANES BONE MARROW ASPIR&/BX ANT/PST ILIAC CREST 5.00  01120 ANESTHESIA ON BONY PELVIS 6.00  01130 ANESTHESIA BODY CAST APPLICATION OR REVISION 3.00  01140 ANESTHESIA INTERPELVI ABDOMINAL AMPUTATION 15.00  01150 ANES RADICAL TUMOR PELVIS XCP HINDQUARTER AMP 10.00  01160 ANES CLOSED SYMPHYSIS PUBIS/SACROILIAC JOINT 4.00  01170 ANES OPEN SYMPHYSIS PUBIS/SACROILIAC JOINT 8.00  01173 ANES OPN RPR DISRPJ PELVIS/COLUMN FX ACETABULUM 12.00  01200 ANESTHESIA CLOSED HIP JOINT PROCEDURE 4.00  01202 ANESTHESIA ARTHROSCOPIC HIP JOINT PROCEDURE 4.00  01210 ANESTHESIA OPEN HIP JOINT PROCEDURE NOS 6.00  01212 ANESTHESIA OPEN HIP JOINT DISARTICULATION 10.00  01214 ANESTHESIA OPEN TOTAL HIP ARTHROPLASTY 8.00  01215 ANESTHESIA OPEN REVISION TOTAL HIP ARTHROPLASTY 10.00  01220 ANESTHESIA CLOSED PROCEDURES UPPER 2/3 FEMUR 4.00  01230 ANESTHESIA OPEN PROCEDURES UPPER 2/3 FEMUR NOS 6.00  01232 ANESTHESIA UPPER 2/3 FEMUR AMPUTATION 5.00  01234 ANES UPPER 2/3 FEMUR RADICAL RESCECTION 8.00  01250 ANES NERVE MUSC TENDON FASCIA & BURSAE UPPER LEG 4.00  01260 ANES VEINS OF UPPER LEG INCLUDING EXPLORATION 3.00  01270 ANESTHESIA ARTERIES UPPER LEG INCL BYPASS GRAFT 8.00  01272 ANES ART UPPER LEG W/BYPASS GRAFT FEM ART LIG 4.00  01274 ANES UPPER LEG W/BYPASS GRFT FEM ART EMBOLECTOMY 6.00  01320 ANES NERVE MUSC TENDON FASCIA&BURSA KNEE&/POPLT 4.00  01340 ANESTHESIA CLOSED PROCEDURES LOWER 1/3 FEMUR 4.00  01360 ANESTHESIA OPEN PROCEDURES LOWER 1/3 FEMUR 5.00  01380 ANESTHESIA CLOSED PROCEDURES KNEE JOINT 3.00  01382 ANESTH DIAGNOSTIC ARTHROSCOPIC PROC KNEE JOINT 3.00  01390 ANES CLOSED PROC UPPER END TIBIA FIBULA/PATELLA 3.00  01392 ANES OPEN PROC UPPER ENDS TIBIA FIBULA&/PATELLA 4.00  01400 ANES OPEN/SURG ARTHROSCOPIC PROC KNEE JOINT NOS 4.00  01402 ANESTH OPEN/SURG ARTHRS TOTAL KNEE ARTHROPLASTY 7.00  01404 ANESTH OPEN/SURG ARTHRS KNEE DISARTICULATION 5.00  01420 ANES CAST APPLICATION REMOVAL/REPAIR KNEE JOINT 3.00  01430 ANESTHESIA VEINS KNEE & POPLITEAL AREA NOS 3.00  01432 ANES KNEE & POPLITEAL ARTERY VEIN FISTULA NOS 6.00  01440 ANES ARTERIES OF KNEE & POPLITEAL AREA NOS 8.00  01442 ANES ART KNEE POPLITEAL TEAEC W/WO PATCH GRAFT 8.00  01444 ANES ART KNEE POPLITEAL EXC&GRF/RPR OCCLS/ARYS 8.00  01462 ANESTHESIA CLOSED PROC LOWER LEG ANKLE & FOOT 3.00  01464 ANESTHESIA ARTHROSCOPIC PROCEDURE ANKLE & FOOT 3.00  01470 ANES NRV/MUS/TND/FASC LOWER LEG/ANKLE/FOOT NOS 3.00  01472 ANES RPR RUPTURED ACHILLES TENDON W/WO GRAFT 5.00

Mississippi Workers’ Compensation Medical Fee Schedule Anesthesia 00100-01999, 99100-99140 Effective June 1, 2026 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine Relative Value Guide © 2024 American Society of Anesthesiologists. All rights reserved. 73 CPT Copyright 2024 American Medical Association. All rights reserved.

CODE DESCRIPTION BASE UNIT  01474 ANESTHESIA GASTROCNEMIUS RECESSION 5.00  01480 ANES OPEN PROC BONES LOWER LEG/ANKLE/FOOT NOS 3.00  01482 ANES RADICAL RESECJ INCL BELOW KNEE AMPUTATION 4.00  01484 ANES OPEN OSTEOTOMY/OSTEOPLASTY TIBIA&/FIBULA 4.00  01486 ANESTHESIA OPEN TOTAL ANKLE REPLACEMENT 7.00  01490 ANES LOWER LEG CAST APPLICATION REMOVAL/REPAIR 3.00  01500 ANESTHESIA ARTERIES LOWER LEG W/BYPASS GRAFT NOS 8.00  01502 ANES ART LOWER LEG W/BYP GRAFT EMBLC DIR/W/CATH 6.00  01520 ANESTHESIA VEINS OF LOWER LEG NOS 3.00  01522 ANES VEINS LOWER LEG VENOUS THRMBC DIR/W/CATH 5.00  01610 ANES NRV MUSC TNDN FSCIA BURSA SHOULDER & AXILLA 5.00  01620 ANES CLOSED HUMRL H/N STRNCLAV JOINT& SHO JOINT 4.00  01622 ANES DIAG ARTHROSCOPIC SHOULDER JOINT PROC NOS 4.00  01630 ANES ARTHRS HUMERAL H/N STRNCLAV & SHOULDER NOS 5.00  01634 ANESTHESIA ARTHROSCOPIC SHOULDER DISARTICULATION 9.00  01636 ANES ARTHRS INTERTHORACOSCAPULAR AMPUTATION 15.00  01638 ANES ARTHROSCOPIC TOTAL SHOULDER REPLACEMENT 10.00  01650 ANESTHESIA ARTERIES SHOULDER & AXILLA NOS 6.00  01652 ANESTHESIA AXILLARY-BRACHIAL ANEURYSM 10.00  01654 ANES ARTERIES SHOULDER & AXILLA BYPASS GRAFT 8.00  01656 ANESTHESIA AXILLARY-FEMORAL BYPASS GRAFT 10.00  01670 ANESTHESIA VEINS SHOULDER & AXILLA 4.00  01680 ANES SHOULDER CAST APPL REMOVAL/REPAIR NOS 3.00  01710 ANES NRV MUSC TDN FSCA&BRS UPR ARM/ELBOW NOS 3.00  01712 ANESTHESIA OPEN TENOTOMY ELBOW TO SHOULDER 5.00  01714 ANESTHESIA TENOPLASTY ELBOW TO SHOULDER 5.00  01716 ANESTHESIA BICEPS TENODESIS RUPTURE LONG TENDON 5.00  01730 ANESTHESIA CLOSED PROCEDURES HUMERUS & ELBOW 3.00  01732 ANESTHESIA ELBOW JOINT DIAGNOSTIC ARTHROSCOPIC 3.00  01740 ANES OPEN/SURG ARTHROSCOPIC ELBOW PROC NOS 4.00  01742 ANESTHESIA OPEN/SURG ARTHRS OSTEOTOMY HUMERUS 5.00  01744 ANES OPEN/SURG ARTHRS REPRS NON/MALUNION HUMERUS 5.00  01756 ANESTHESIA OPEN/SURG ARTHRS RADICAL PROC ELBOW 6.00  01758 ANESTH OPEN/SURG ARTHRS EXC CYST/TUMOR HUMERUS 5.00  01760 ANESTH OPEN/SURG ARTHRS TOTAL ELBOW REPLACEMENT 7.00  01770 ANESTHESIA ARTERIES UPPER ARM & ELBOW NOS 6.00  01772 ANESTHESIA ARTERIES UPPER ARM&ELBOW EMBOLECTOM 6.00  01780 ANESTHESIA VEINS UPPER ARM & ELBOW NOS 3.00  01782 ANESTHESIA VEINS UPPER ARM & ELBOW PHLEBORRHAPHY 4.00  01810 ANES NERVE MUSCLE TDN FASCIA&BURSA FOREARM WRIST 3.00  01820 ANES RADIUS ULNA WRIST/HAND BONES CLOSED PX 3.00  01829 ANESTHESIA DIAGNOSTIC ARTHROSCOPIC PROC WRIST 3.00  01830 ANES ARTHRS/ENDSCPY DSTL RADIUS ULNA/WRIST/HAND 3.00  01832 ANESTHESIA ARTHRS/ENDOSCPIC TOTAL WRIST REPLCMT 6.00  01840 ANESTHESIA ARTERIES FOREARM WRIST & HAND NOS 6.00  01842 ANES ARTERIES FOREARM WRIST & HAND EMBOLECTOMY 6.00  01844 ANESTHESIA VASCULAR SHUNT/SHUNT REVISION 6.00  01850 ANESTHESIA VEINS FOREARM WRIST & HAND NOS 3.00

Anesthesia Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 00100-01999, 99100-99140

Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 74 Relative Value Guide © 2024 American Society of Anesthesiologists. All rights reserved. CPT Copyright 2024 American Medical Association. All rights reserved.

CODE DESCRIPTION BASE UNIT  01852 ANES VEINS FOREARM WRIST & HAND PHLEBORRHAPHY 4.00  01860 ANES FOREARM WRIST/HAND CAST APPL RMVL/REPAIR 3.00  01916 ANESTHESIA DIAGNOSTIC ARTERIOGRAPHY/VENOGRAPH 5.00  01920 ANES C-CATHJ W/C ANGIOGRAPHY & VENTRICULOGRAPHY 7.00  01922 ANES NON-INVASIVE IMAGING/RADIATION THERAPY 7.00  01924 ANESTHESIA THER IVNTL RADIOLOGICAL ARTERIAL 5.00  01925 ANESTHESIA CAROTID/CORONARY THER IVNTL RAD 7.00  01926 ANES ICRA ICAR/AORTIC THER IVNTL RAD ARTL 8.00  01930 ANES VENOUS/LYMPHATIC NOS THER IVNTL RAD NOS 5.00  01931 ANESTHESIA INTRAHEPATIC/PORTAL THER IVNTL RAD 7.00  01932 ANESTHESIA INTRATHORACIC/JUGULAR THER IVNTL RAD 6.00  01933 ANES INTRACRANIAL THER IVNTL RAD VENS/LYMPHTC 7.00  01937 ANES PERQ IMG NJX DRG/ASPIR PX SPI/SP CRV/THRC 4.00  01938 ANES PERQ IMG NJX DRG/ASPIR PX SPI/SP LMBR/SAC 4.00  01939 ANES PERQ IMG DSTRJ PX NULYT AGT SPI/SP CRV/THRC 4.00  01940 ANES PERQ IMG DSTRJ PX NULYT AGT SPI/SP LMBR/SAC 4.00  01941 ANES PERQ IMG NEUROMD/NTRVRT PX SPI/SP CRV/THRC 5.00  01942 ANES PERQ IMG NEUROMD/NTRVRT PX SPI/SP LMBR/SAC 5.00  01951 ANES 2&3 DGR BURN EXC/DBRDMT W/WO GRFG <4 % TBSA 3.00  01952 ANES 2&3 DGR BURN EXC/DBRDMT W/WO GRFG 4-9 % TBSA 5.00   01953 ANES 2&3 DGR BURN EXC/DBRDMT W/WO GRFG EA 9% TBSA 1.00  01958 ANESTHESIA EXTERNAL CEPHALIC VERSION 5.00  01960 ANESTHESIA VAGINAL DELIVERY ONLY 5.00  01961 ANESTHESIA CESAREAN DELIVERY ONLY 7.00  01962 ANES URGENT HYSTERECTOMY FOLLOWING DELIVERY 8.00  01963 ANESTHESIA C HYST W/O ANY LABOR ANALG/ANES CARE 8.00  01965 ANESTHESIA INCOMPLETE/MISSED ABORTION PROCEDURES 4.00  01966 ANESTHESIA INDUCED ABORTION PROCEDURES 4.00  01967 NEURAXIAL LABOR ANALG/ANES PLND VAGINAL DELIVERY 5.00   01968 ANES CESARN DLVR FLWG NEURAXIAL LABOR ANALG/ANES 2.00   01969 ANES CESARN HYST FLWG NEURAXIAL LABOR ANALG/ANES 5.00  01990 PHYSIOL SUPPORT HARVEST ORGAN FROM BRAIN-DEAD PT 7.00  01991 ANES DX/THER NRV BLK/NJX OTH/THN PRONE POS 3.00  01992 ANES DX/THER NERVE BLOCK/INJECTION PRONE POS 5.00  01996 DAILY HOSP MGMT EDRL/SARACH CONT DRUG ADMN 3.00  01999 UNLISTED ANESTHESIA PROCEDURE BR   99100 ANESTHESIA EXTREME AGE PATIENT UNDER <1 YR&>70 1.00   99116 ANES COMP BY UTILIZATION TOTAL BODY HYPOTHERMIA 5.00   99135 ANES COMP UTILIZATION CONTROLLED HYPOTENSION 5.00   99140 ANES COMP BY EMERGENCY CONDITIONS SPECIFY 2.00

CPT Copyright 2024 American Medical Association. All rights reserved. 75 PAIN MANAGEMENT Note: Rules used by all physicians or other qualified health care professionals (OQHP) in reporting their services are presented in the General Rules section. See the Modifier and Code Rules section for detailed information on modifiers. I. SCOPE A. In addition to the General Rules, this section provides specific rules and guidelines for Pain Management services.

B. This Fee Schedule sets rates of payment for hospitals, physicians and OQHPs. It does not determine medical necessity, or the clinical appropriateness of procedures and services rendered. Guidance included herein is intended to reflect the medically accepted standard of care. II. INTRODUCTION A. Treatment should reflect indications recognized by established medical practice that are adequately supported by the relevant medical literature. B. Providers must demonstrate the effectiveness of previously provided treatment in order to repeat or continue it. This includes the use of pain diagrams, functional outcome scales, and numerical pain scores where appropriate. C. Payers and utilization review professionals must approve or deny treatment based on this section of the Fee Schedule. If there is a conflict between the Fee Schedule and external guidelines, the Fee Schedule will apply. D. When denying care, the specific section of this Fee Schedule must be cited as the basis for denial. All denials must provide the rationale or the treatment will be approved. E. When Modifier 50, bilateral procedure, is used with pain management procedures listed in this section, reimbursement shall be twenty-five percent (25%) of the amount listed in the rate tables for the second or contralateral side. III. REIMBURSEMENT FOR PAIN MANAGEMENT SERVICES A. Use of Fluoroscopy. Fluoroscopic guidance, CPT ®

codes 77002 and 77003, is not separately reimbursable when fluoroscopy is bundled and included in the amount for the primary surgical service per NCCI edits. All procedures performed fluoroscopically must have stored hard copy or digital images showing final needle placement in at least two (2) views (typically posterior/anterior and lateral or oblique) demonstrating final needle placement and depth AND disbursement of contrast (when not contraindicated). These images are to be available upon request by payers, or reimbursement may be denied. B. Reimbursement for Injection/Destruction Procedures 1. Facet injections and medial branch blocks are reimbursed at a maximum of two (2) total anatomic joint levels. Additional level or bilateral modifiers may be used to allow up to a maximum of one (1) additional service levels for facet or medial branch blocks in the cervical/thoracic (64491 and 64492) or lumbar (64494 and 64495) for a maximum of two (2) procedure levels reimbursed per treatment session or day. These procedures are unilateral by definition. Bilateral modifiers may be used when nerves or joints are treated bilaterally. 2. Therapeutic and diagnostic peripheral nerve blocks (64450/64445 & 64400-64474) for pain management other than surgical or post- operative pain control should be limited to two (2) per year. Exceptions for a third therapeutic injection require documentation of clear progressive and durable relief. A maximum of 3 therapeutic peripheral nerve blocks may be performed per year. 3. Nerve destructive procedures are reimbursed for a maximum of two (2) anatomical levels. 4. Reimbursement for injection/destruction procedure codes is made on the basis of joint levels, not nerves treated (e.g., destruction by neurolytic agent of the L4–L5 facets counts as one (1) level/nerve and must be billed as 64635 (first level/nerve)). There are two nerves supplying each joint but reimbursement is based upon joint(s) treated, not the nerves treated. This applies to CPT codes 64635, 64636 (lumbar), and 64633, 64634 (cervical/thoracic). These procedures are unilateral by definition. Bilateral modifiers may be used when nerves are treated bilaterally. 5. A maximum of two (2) levels of transforaminal epidural steroid injections or one level bilaterally are reimbursable for a given date of service. This applies to codes 64479, 64480, 64483, and 64484. 6. A maximum of one (1) interlaminar epidural steroid injection is reimbursable for a given date of service. This applies to codes 62320 and 62322. 7. If an injured worker with bilateral pain receives only unilateral treatment on a given date of service, any similar procedures (same CPT codes) performed on the contralateral side within ninety (90) days of the initial procedure will be subject to reimbursement reductions related to modifiers for bilateral treatment on the same date of service. For example, if a person undergoes a right sided medial branch block(s) or neurotomy(ies) on a given date of service, any similar procedure(s) on the left side will be subject to the reductions in reimbursement related to use of the bilateral

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CPT Copyright 2024 American Medical Association. All Rights Reserved. modifier if this treatment is provided within ninety (90) days of the date of service of the right sided procedures. This applies to professional and facility reimbursement. C. Multiple Procedure Reimbursement. Only one (1) type of pain management procedure is reimbursable on a given date of service, unless otherwise approved by the payer. This does not include multiple level injections or bilateral procedures of the same type, with appropriate modifiers. “Type” is defined as any procedure code involving an anatomically different structure (e.g., spinal nerve, facet joint, sacroiliac joint, trigger point, etc.). Joints and nerves in different anatomical regions (cervical/thoracic, lumbar/sacral) are considered to be different “types” and are limited to one (1) procedure per given day. Additional level or bilateral injections of a single procedure in the same area are not considered different “types,” and for the purpose of this Fee Schedule, are considered to be the same “type.” However, the multiple level restrictions, as detailed herein, still apply. Diagnostic injections of more than one type in the same anatomic area on the same date of service will not be reimbursed without prior authorization. Reimbursement of the multiple procedure modifier (51) is twenty-five percent (25%) of the base amount for the second or additional procedure for procedures listed in the Pain Management section. D. Repeat epidural injections would typically occur two to four (2-4) weeks after the initial treatment, contingent upon some degree of continuing radiating pain. Repeat injections performed within twelve (12) days of the previous epidural injection will not be reimbursed. E. Sacroiliac injection/arthrography (CPT code 27096) may only be used once per six (6) month period. F. CPT codes 62324-62327 includes needle placement, catheter infusion, and subsequent injections. Code 62324-62327 should be used for multiple solutions injected by way of the same catheter, or multiple bolus injections during the initial procedure. The epidural needle or catheter placement is inherent to the procedure, and, therefore, no additional charge for needle or catheter placement is allowed. G. Pain management procedures which are included in this section of the Fee Schedule must be performed by a licensed physician holding either an M.D. or D.O. degree. Pain management procedures performed by any other person, such as a Certified Registered Nurse Anesthetist (CRNA) or Nurse Practitioner (NP) are not eligible for reimbursement. H. The following procedures must be performed fluoroscopically in order to qualify for reimbursement: 1. Facet injections (64490–64495). 2. Sacroiliac (SI) injections (27096). 3. Transforaminal epidural steroid injections (64479, 64480, 64483, 64484). 4. Cervical translaminar/interlaminar epidural injections (62321). I. Cervical/thoracic discography (CPT code 62291 injection cervical/thoracic disc) and radiology supervision and interpretation (CPT code 72285) will not be reimbursed. J. Any analgesia/sedation used in the performance of the procedures in this section is considered integral to the procedure, and will not be separately reimbursed. This applies whether or not the person administering the analgesia/sedation is the physician who is performing the pain management injection. Administration of analgesia/sedation by a different person from the physician performing the injection, including an RN, PA, CRNA, or MD/DO, does not allow for separate billing of analgesia/sedation. If an injured worker is unable to cooperate during routine needle placement, despite judicious use of sedation for anxiety, elective interventional pain management (IPM) procedures should be terminated due to patient safety concerns. Sedating or anesthetizing a patient into a plane of deep sedation or anesthesia, rendering them unconversant or unable to experience or communicate unusual or excessive pain puts the injured worker at increased risk for elective IPM procedures. K. Detailed anatomical descriptions of the procedures performed must accompany the bill for service in order to qualify for reimbursement. These descriptions must include landmarks used in determining needle positioning, needles used (size, length), and the type and quantity of each drug injected. Unless there is a contraindication to contrast media (e.g., documented allergy) it is expected that the quantity of contrast injection AND a written description of the contrast spread pattern be included in the procedure report. Generic descriptions such as “the procedure was performed in the usual fashion,” “the needle was placed on (next to, by, etc.) the nerve/joint/target,” “the needle was placed in the correct anatomical location,” or similar wording, which was templated or otherwise lacking an actual detailed anatomical description of needle placement or contrast pattern (where appropriate), is inadequate and cause for denial of payment. Templates for standard needle placement are acceptable, but any deviation from the usual technique must be explained in the procedure note. Contrast injection patterns should not be templated. Tolerance to the procedure, and side effects or lack thereof should be included in this documentation. L. Radiographic Codes in Pain Management. Codes 72020–72220 which apply to radiographic examination of the spine are not reimbursed when performed with the pain management procedures in this section. M. When a joint injection is performed at the end of a surgical procedure for pain control, reimbursement is allowed according to the Multiple Procedure rule. This rule applies to professional and facility reimbursement. N. Refill of Pain Pumps 1. CPT code 95990 applies to refilling and maintenance of an implantable pump or reservoir for drug delivery spinal (intrathecal, epidural) or brain (intraventricular). This service is

Mississippi Workers’ Compensation Medical Fee Schedule Pain Management

CPT Copyright 2024 American Medical Association. All Rights Reserved. 77 reimbursed at the specified MAR listed in the Medicine section of the Fee Schedule. 2. Evaluation and Management Services. Refilling and maintenance of implantable pump or reservoir for pain management drug delivery is a global service. A separate evaluation and management service is not paid unless significant additional or other cognitive services are provided and documented. To report a significant, separately identifiable evaluation and management service, append modifier 25 to the appropriate evaluation and management code. Documentation is required and payment will be allowed if supported by the documentation. 3. Drugs used in the refill of the pain pump shall be reimbursed in accordance with the Pharmacy Rules contained in the Pharmacy Rules section of this Fee Schedule. 4. Compounding Fee. If the drugs used in the refill of the pain pump must be compounded, the compounding service shall be reimbursed at $157.44 per individual refill. Report the compounding service with code S9430, Pharmacy compounding and dispensing services. 5. Non-FDA-approved drugs for intrathecal use will not be reimbursed. IV. DIAGNOSTIC INJECTIONS AND PROCEDURES A. Radiofrequency Medial Branch Neurotomy/Facet Rhizotomy. This procedure may be reimbursed not to exceed two (2) contiguous spinal joint levels (three nerves) during the same session/ procedure. If there has been improvement with a prior successful radiofrequency (RF) denervation, then a minimum time of six (6) months of relief should elapse since the prior RF denervation treatment and the injured worker should experience enough improvement to return to work in order to qualify for a repeat procedure. No more than two (2) RF denervations may be reimbursed in the first twelve (12) months and one (1) per year thereafter. Pulsed radiofrequency therapies are not a covered service for any indication. V. THERAPEUTIC SERVICES A. Modalities. In the pain management setting, no more than two (2) modalities and/or procedures may be used on a date of service (e.g., heat/cold, ultrasound, diathermy, iontophoresis, TENS, electrical stimulation, muscle stimulation, etc.). Multiple modalities should be performed sequentially. Only one (1) modality can be reported for concurrently performed procedures.

B. Intradiscal Therapies. Intradiscal therapies for purported discogenic pain are considered investigational and are not reimbursable under the Fee Schedule. These therapies include injections of steroid, biologics, PRP, stem cell or notochordal cell- derived matrix, or any other biologic therapy. Disc or disc nerve ablative procedures or disc sealant therapies are not reimbursable under the Fee Schedule. VI. GENERAL RULES A. Reimbursement will be limited to three (3) epidural pain injections in a twelve (12) month period unless the payer provides prior authorization for more than three (3) such injections. Separate billing for the drug injected will not be reimbursed. B. Investigational Procedures. Refer to the General Rules section. C. Sacroiliac (SI) Joint. Therapeutic and diagnostic sacroiliac joint injections require the use of image guidance. Injections performed without imaging guidance should be billed, and will be reimbursed, as a trigger point injection. CPT code 27096 should not be separately billed when a physician provides routine sacroiliac injections. This code is to be used only with imaging confirmation of intra-articular needle positioning. Image guidance (fluoroscopy or CT) and any injection of contrast are inclusive components of 27096.

CPT code 27096 has a bilateral surgery indicator of "1." Thus, it is considered a "unilateral" procedure: • When injecting a sacroiliac joint bilaterally, file with modifier 50. • When injecting a sacroiliac joint unilaterally, file the appropriate anatomic modifier LT or RT. • Only one (1) unit of service should be submitted for a unilateral sacroiliac injection or one (1) unit of service with a 50 bilateral modifier for bilateral injections. VII. PAIN MANAGEMENT CRITERIA A. All Interventional Pain Management (IPM) procedures must be billed with the appropriate CPT codes and modifiers (where applicable) using accepted ICD-10-CM codes as the indications for the procedures. Providers must use acceptable codes in order to initiate or maintain treatment. Failure to do so is cause for denial of treatment until the proper appropriate codes are submitted. Payers and Utilization Reviewers must reference this Fee Schedule to deny requested treatment. Failure to cite the specific section of the IPM portion of the Mississippi Workers’ Compensation Medical Fee Schedule will result in automatic adjudication for the provider without appeal. “Specific” refers to citing the actual section, and appropriate subsections directly from the Fee Schedule. Failure to have the Fee Schedule available during the review would make such citation unachievable, resulting in automatic adjudication for the provider. External guidelines may not be used to deny IPM care requested in accordance with the Fee Schedule. B. Injection/Destruction Procedures Multiple Epidural Injections in a Single Treatment Day/Session. Reimbursement is limited to one epidural injection in a single treatment day/session, unless appropriate documentation is entered into the medical record of a medical condition for which

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CPT Copyright 2024 American Medical Association. All Rights Reserved. multiple injections would be appropriate. These conditions include: 1. Disc pathology (e.g., protrusion) at one level with a dermatomal pain distribution of an adjacent level (e.g., disc affects the traversing nerve root, such as an L4/5 disc herniation affecting the traversing L5 nerve root). 2. Multiple dermatomal nerve root involvement. 3. Bilateral radicular pain. C. Intrathecal Drug Delivery. This method of delivery requires prior authorization. Specific brands of infusion systems have been FDA approved for the following: chronic intraspinal (epidural and intrathecal) infusion of preservative-free morphine sulfate sterile solution in the treatment of chronic intractable pain, chronic infusion of preservative-free ziconotide sterile solution for the management of severe chronic pain, and chronic intrathecal infusion of baclofen for the management of severe spasticity. 1. Description: This mode of therapy delivers small doses of medications directly into the cerebrospinal fluid. 2. Complications: Intrathecal delivery is associated with significant complications, such as infection, catheter disconnects, CSF leak, arachnoiditis, pump failure, nerve injury, and paralysis. Typical adverse events reported with opioids (i.e., respiratory depression, tolerance, and dependence), or spinal catheter-tip granulomas that might arise during intrathecal morphine or hydromorphone treatment have not currently been recorded for ziconotide. 3. Indications: Clinical studies are conflicting, regarding long-term, effective pain relief in patients with non-malignant pain. Due to the complication rate for long-term use of intrathecal drug delivery systems for chronic pain, it may be considered only in very rare occasions when dystonia and spasticity are dominant features or when pain is not able to be managed using any other non-operative treatment. This treatment must be prior authorized and have the recommendation of at least one physician experienced in chronic pain management in consultation with the primary treating physician. The procedure should be performed by physicians with documented experience. This small eligible sub-group of patients must meet all of the following indications: a. A diagnosis of a specific physical condition known to be chronically painful has been made on the basis of objective findings; b. All reasonable surgical and non-surgical treatment has been exhausted including failure of conservative therapy including active and/or passive therapy, medication management, or therapeutic injections; c. Pre-trial psychiatric or psychological evaluation has been performed (as for SCS) and has demonstrated motivation and long- term commitment without issues of secondary gain. Significant personality disorders must be taken into account when considering an injured worker for spinal cord stimulation and other major procedures; d. There is no evidence of current addictive behavior. (Tolerance and dependence to opioid analgesics are not addictive behaviors and do not preclude implantation); and e. A successful trial of continuous infusion by a percutaneous spinal infusion pump for a minimum of twenty-four (24) hours. A screening test is considered successful if the injured worker (a) experiences a fifty percent (50%) decrease in pain, which may be confirmed by VAS, and (b) demonstrates objective functional gains or decreased utilization of pain medications. Functional gains should be evaluated by an occupational therapist and/or physical therapist prior to and before discontinuation of the trial. 4. Contraindications: Infection and body size insufficient to support the size and weight of the implanted device. Injured workers with other implanted programmable devices should be given these pumps with caution since interference between devices may cause unintended changes in infusion rates.

D. Diagnostic Injections and Procedures 1. Valid diagnostic injections require an appropriately alert patient capable of adequately determining the amount or level of pain relieved or produced by the procedure. This requires judicious use of sedatives in the performance of such procedures. Additional analgesic medications such as intravenous narcotics are to be avoided during the procedure and evaluation phase of testing, as these medications can affect the validity of such diagnostic tests. The results of the tests and drugs used during the injection or procedure must be part of the medical records, and available for review by the payer. Failure to document the injured worker’s response to a diagnostic procedure or injection, and the level of alertness following the procedure or injection, could result in denial of reimbursement. Affected diagnostic procedures include but are not limited to discography and medial branch blocks, diagnostic sacroiliac injections and selective nerve root blocks (billed with epidural codes). 2. Diagnostic injections with local anesthetics require documentation of analgesic response through any validated pain measurement test or scale (e.g., numerical pain scale, visual analogue scale) according to the following recommendations. Measurement is to be performed in the treatment facility after the

Mississippi Workers’ Compensation Medical Fee Schedule Pain Management

CPT Copyright 2024 American Medical Association. All Rights Reserved. 79 procedure during the time that there would be an expected analgesic response at 30- and 60- minutes post injection, prior to discharge and documented for use by the provider and for review by the payer. Pain scores should be documented as produced by the same test that was used to provoke the pain prior to the intervention. Typically, this involves range of motion (flexion, extension, rotation) of the involved area for joint injections or reduction of pain with appropriate sensory loss for diagnostic nerve blocks. Failure to provide such scores upon request can/will result in loss of reimbursement. Subsequent pain scores are to be documented at least hourly for two (2) additional hours after the procedure. If the injured worker’s pre-procedure pain was determined by provocative exam tests or maneuvers, these should be repeated during the evaluation period following the procedure, to differentiate analgesia related to the procedure from positional analgesia (pain improvement), such as, that which may be provided by lying in a recovery bed. 3. Other injections with both therapeutic and potentially diagnostic benefit, such as selective nerve root, peripheral nerve blocks, sympathetic blocks or therapeutic facet injections, would ideally be performed with minimal sedation and avoidance of intravenous narcotics. However, as these injections also have potential therapeutic benefit, this is not a requirement for reimbursement. However, if there is an intended diagnostic component, measurement and documentation of pain levels after the procedure are required for at least the anticipated duration of the local anesthetic used. Failure to provide such documentation of anesthetic or analgesic effect invalidates the diagnostic component of the injection.

E. Epidural Injections 1. This Fee Schedule does not recognize a “series” of epidural injections, regardless of number. A trial of epidural injections is permitted provided there is appropriate documentation of a recognized indication for this procedure. Only a single injection can be approved unless there is documentation of analgesic response consistent with response to the injection. Further injections require a positive analgesic response to be repeated. For the first injection, the initial analgesic response may be temporary but cannot be attributed solely to a local anesthetic effect or intra-procedural sedation (i.e., relief for the first few hours after injection). Additionally, to repeat an epidural injection, continued radiating pain is required, rather than just residual axial (back/neck) pain. After the second injection, a residual and progressive analgesic benefit is necessary to perform a third injection. Documentation of an injured worker’s positive response will be required to continue epidural treatment. If there is no documented residual pain relief after two (2) injections, no further epidural injections will be reimbursed. 2. Treatment of only one spine region may be reimbursed per session (date of service). Only two total levels per session are allowed for CPT codes 64479, 64483 and 64484 (two unilateral or two bilateral levels). CPT code 64480 should be reported in conjunction with CPT code 64479 and CPT code 64484 should be reported in conjunction with CPT code 64483. CPT codes 62321 and 62323 may only be reported for one level per session. 3. No more than three (3) epidural injection sessions (CPT codes 62321, 62323, 64479, 64480, 64483 of 64484) may be reported per anatomic region in a rolling 12-month period regardless of the number of levels involved. a. Repeat injections (up to two (2) additional injections, for a total of three (3) per twelve (12) month period), however, do NOT require prior authorization as long as the appropriate responses are properly documented. b. Utilization management or review decisions should not be based solely on the application of clinical guidelines, but must include review of clinical information submitted by the provider and represent an individualized determination based on the injured worker’s current condition and the concept of medical necessity predicated on objective or appropriate subjective improvements in the injured worker’s clinical status.

Interlaminar epidural injections are seldom used for diagnostic purposes because the generalized regional spread of local anesthetic with spinal injection makes it impractical if not impossible to selectively block a specific nerve. 5. To be reimbursed, both cervical and interlaminar epidural steroid injections must be performed fluoroscopically, typically with contrast injection, unless there is a documented contrast allergy. Epidural blood patches do not require fluoroscopic guidance, though this is preferred. The specific cause of radiating pain may not always be obvious on imaging, such as MRI, CT or x-rays. Therefore, the indications for a trial of epidural steroid injections are based on the injured worker's clinical presentation, not imaging. All nerve root pain or radiating pain is not caused by damage (nerve or axon loss) to the nerve or dorsal root ganglion. When there is only inflammation or irritation of the nerve, there may be radiating pain in the absence of physical exam findings of nerve damage such as altered or absent motor, sensory, or reflex function. Actual nerve damage is not treated by steroid injections, as steroids do not accelerate the process of new nerve tissue (axon) regeneration. Therefore, demonstrable weakness, reflex changes and sensory loss are not necessary as an indication

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CPT Copyright 2024 American Medical Association. All Rights Reserved. for a trial of epidural steroids. Similarly, EMG/NCV testing demonstrating nerve or axon loss is not necessary as an indication for a trial of epidural steroid injections. A trial of epidural steroids injections may be indicated when there is radiating pain (extremity or buttock) with or without co-existing back pain. 6. Initiation and Continuation of Epidural Injections. Prior authorization by the payer is required before initiating a trial of epidural injections. It is NOT necessary to obtain prior authorization to repeat an injection as long as a positive analgesic response (pain improvement or functional improvement) to the previous injection is reported. Repeat trials of epidural injections may be considered for reimbursement after one (1) year if the preceding trial provided several months of demonstrable benefit. In order to be considered effective, this benefit must include greater than thirty percent (30%) improvement in pain scores, AND documentation of either 1) significant reduction of daily narcotic consumption, defined as a sustained reduction (several months) of at least thirty percent (30%) of the daily narcotic use prior to initiation of the trial of epidural injections, or 2) ability to work for a sustained period of time (several months) at least at sedentary work level or the work level as determined by a valid Functional Capacity Evaluation (FCE) or as determined with an appropriate physical examination by a qualified specialist. No injured worker can be considered for a repeat trial of epidural steroid injections, if after the preceding trial (in a similar anatomical area) they are unable to reduce narcotic consumption to less than 100 mg morphine equivalent per day. If, after an initial trial of epidural injections, it is suspected that there is a new nerve injury involving a different anatomical nerve, a trial of epidural injections may be indicated independent of the response to the initial trial of epidural injections. However, as this would represent a separate nerve injury, causation would have to be established prior to initiation of further treatment related to a work injury.

Documentation Requirements for Epidural Injections. All documentation must be maintained in the injured worker’s medical record and be made available to the payer upon request. a. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or OQHP responsible for and providing the care to the injured worker. b. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed. c. The procedural report should clearly document the indications and medical necessity for the blocks along with the pre and post percent (%) pain relief achieved immediately post-injection. d. Films that adequately document (minimum of two views) final needle position and contrast flow should be retained and made available upon request. e. The injured worker’s medical record should include, but is not limited to: • The assessment of the injured worker by the performing provider as it relates to the complaint of the injured worker for that visit. • Relevant medical history. • Results of pertinent tests/procedures. • Signed and dated office visit record/operative report. • Documentation to support the medical necessity of the procedures(s).

F. Facet Injections. Intra-articular joint injections (cervical, thoracic, lumbar), which can have both diagnostic and therapeutic indications, should always be considered primarily therapeutic. Reimbursement for facet injections is limited to four (4) dates of service with a maximum of two (2) therapeutic and two (2) diagnostic injections for the initial twelve (12) month period of treatment per anatomical region. This allows for a total of four (4) dates of service, regardless of the number of levels treated, which levels are treated, or which side (left or right or bilateral) is treated, in the same anatomical region. To qualify for reimbursement for a repeat intra-articular facet injection, there must be a documented reduction of at least 50% in the treated spine pain for a minimum duration of two months. If treatment for facet-related pain continues past twelve (12) months, further injections are limited to a total of two (2) dates of service per twelve (12) month period. Facet injections in different anatomical areas are not subject to these limits, as each anatomical area would be subject to its own separate limit. Nerve-destructive procedures (e.g. radiofrequency facet nerve neurotomy, codes 64633, 64634, 64635, 64636) are not considered additional therapeutic procedures for the purpose of this Fee Schedule. A “different anatomical area” refers to the lumbar, thoracic, and cervical areas. Injections within the lumbar spine, for example, are considered to be within the same anatomical area regardless of the actual lumbar joint/nerve level, or which side (right or left), is treated, and all limits would apply in this anatomical area. In order to be a “successful” (“positive”) diagnostic facet procedure (either intra-articular or medial

Mississippi Workers’ Compensation Medical Fee Schedule Pain Management

CPT Copyright 2024 American Medical Association. All Rights Reserved. 81 branch block(s)), the injured worker must experience at least seventy-five percent (75%) relief of the index pain (pain being treated by the procedure). Additionally, this index pain must be at least fifty percent (50%) of the injured worker’s total pain. Cervical, upper/lower thoracic or lumbar nerves facet nerve (medial branch ablation will be reimbursed once per seven (7) month period. Repeat (medial branch) ablation is contingent upon documentation of at least six (6) months’ measurable (greater than thirty percent (30%) improvement in pain scores), and documentation of either 1) reduction of daily narcotic consumption of at least thirty percent (30%) from the daily use noted prior to the procedure, or 2) ability to work at least at a light duty work level or work level as determined by a valid Functional Capacity Evaluation (FCE) or as determined with a physical exam by a qualified specialist. No injured worker will be considered for a repeat neuroablative procedure (e.g., neurotomy) if after the preceding neuroablative procedure (at similar anatomical levels) they are unable to reduce narcotic consumption to less than 100 mg morphine equivalent per day. A repeat therapeutic facet joint injection (cervical, thoracic, or lumbar; codes 64490–64495) will be considered for reimbursement if there is documentation of a significant analgesic response that persists for at least six (6) months. This relief must be at least fifty percent (50%) of the pain in the specific anatomical area targeted by the injection, and must allow the injured worker to return or continue to work at least at a light duty capacity (if the reason for being off work or at restricted work capacity was related to the injured worker’s back or neck pain). G. Trigger Point Injections. Trigger point (also called myofascial or myoneural) injections are reimbursed as one (1) procedure regardless of the number of injection sites. Multiple injections, and multiple regions will be reimbursed as one procedure. Report CPT 20552 for injection(s) single or multiple trigger point(s), one or two muscles, or 20553, injection(s), single or multiple trigger point(s), three or more muscles. Only one of these procedure codes will be reimbursed per date of service. The goal of a trigger point injection is to treat the cause of pain, not just the symptoms. With this intent, in order to be repeated in the same muscle group, there must be at least a fifty percent (50%) persistent benefit from the previous injection. For injured workers not in therapy, trigger point injections can be performed monthly, as long as there is a documented fifty percent (50%) residual benefit, and progressive relief (pain intensity and duration of relief) with the preceding injection. After six months, if similar pain persists, the injured worker should be re-evaluated regarding the etiology of the complaint, and the available treatment options reconsidered. The payer may consider payment for additional trigger point injections upon review. H. Soft Tissue Injections. “Myofascial,” “myoneural,” and “trigger point injections” are synonymous and are to be reimbursed with code 20552 or 20553. Modifiers for additional injections are not allowed with these codes. Reimbursement will be made for 20552 or 20553, but not both, on the same date. CPT codes 20550 and 20551 are used for injections of tendon origins and are not to be used for “myofascial, myoneural or trigger point” injections. Code 20612 is used for the aspirations/injection of a ganglion cyst and not for “myofascial, myoneural, or trigger point” injections. I. Sacroiliac (SI) Joint. Sacroiliac joint injections (code 27096) require documentation of at least an eight (8) week durable analgesic benefit of at least fifty percent (50%) pain relief in the anatomical area being targeted by the injection. A maximum of two (2) therapeutic sacroiliac joint injections can be reimbursed per twelve (12) month period per joint injected, and not including the contralateral joint (i.e., right or left sided joint) when bilateral sacroiliac joint pain is suspected. J. Lumbar Discography. Lumbar provocative discography is used for evaluation for disc pathology in persons with persistent, severe low back pain (LBP) and abnormal interspaces on magnetic resonance imaging (MRI), where other diagnostic tests have failed to reveal clear confirmation of a suspected disc as the source of pain, and surgical intervention is being considered for suspected disc pain, not radiculopathy. Lumbar provocative discography is not covered for all other indications. Functional anesthetic discography (involving injection of anesthetic directly into the disc) is not covered. K. Botulinum Toxin. Botulinum toxin is not indicated for the relief of musculoskeletal pain, and its use as such is not covered by the Fee Schedule. With prior authorization, an exception can be made when treatment is indicated for limb spasticity or other indications. L. Implantation of Spinal Cord Stimulators. 1. The following criteria must be met for consideration of reimbursement for spinal cord stimulators. a. Injured worker has a medical condition for which spinal cord stimulation (SCS) is a recognized and accepted form of treatment. Current indications are limited to cervical or lumbar radiculopathy with radiating pain involving the appropriate dermatome, typically involving an extremity. b. Injured worker received a trial stimulation that includes a minimum seven (7) day home trial with the temporary stimulating electrode. c. During the trial stimulation, the injured worker reported functional improvement, decreased use of medications, and at least fifty percent (50%) pain reduction during the last four (4) days of the stimulation trial. d. Psychological screening is used to determine if the injured worker is free from: i. Substance abuse issues; ii. Untreated psychiatric conditions;

Pain Management Mississippi Workers’ Compensation Medical Fee Schedule

20 Miss. Admin. Code Pt. 2, R. 82 Rule 82

CPT Copyright 2024 American Medical Association. All Rights Reserved. iii. Major psychiatric illness that could impair the injured worker’s ability to respond appropriately to the trial stimulation; and iv. Opioid medications should be weaned, preferably completely prior to a trial of stimulation to determine if the injured worker is responding to the stimulator trial. Injured workers unable to wean to less than 50 MME (morphine milligram equivalent) on a daily basis are not eligible to receive a trial of spinal cord stimulation. e. Neurostimulation i. Description: Spinal cord stimulation devices are FDA approved as an aid in the management of chronic intractable pain of the trunk and/or limbs, including unilateral and bilateral pain associated with the following: failed back surgery syndrome, intractable low back pain and leg pain. There is limited evidence that supports its use for spinal axial pain. SCS may be effective in injured workers with CRPS I who have not achieved relief with oral medications, rehabilitation therapy, or therapeutic nerve blocks, and in whom the pain has persisted for longer than six (6) months. Surgical procedures involving a laminotomy for lead placement are to be performed by a surgeon, usually with a neurosurgical or spinal background. ii. Surgical Indications: Patients with established CRPS I or a failed spinal surgery with persistent functionally limiting radicular pain greater than axial pain who have failed conservative therapy including active and/or passive therapy, pre-stimulator trial psychiatric evaluation and treatment, medication management, and therapeutic injections. SCS is not reimbursed for patients with the major limiting factor of persistent axial spine pain. Type 2 CRPS (aka “causalgia”) with a demonstrable nerve injury that is causing pain lacks sufficient evidence of efficacy with SCS and is not a covered indication. SCS may be indicated in a subset of patients who have a clear neuropathic radicular pain (radiculitis). The extremity pain must account for at least fifty percent (50%) or greater of the overall back and leg pain experienced by the injured worker and involve a radicular etiology and pattern. Prior authorization is required. Patients with severe psychiatric disorders, and issues of secondary gain are not candidates for the procedure. iii. A comprehensive psychiatric or psychological evaluation is provided prior to the stimulator trial. This evaluation includes a standardized detailed personality inventory with validity scales (such as MMPI-2, MMPI- 2-RF, or PAI) pain inventory with validity measures (for example, BHI 2, MBMD); clinical interview and complete review of the medical records. Before proceeding to a spinal stimulator trial, the evaluation should find the following: • No indication of falsifying information, or of invalid response on testing; • No primary psychiatric risk factors or “red flags” (e.g., psychosis, active suicidality, severe depression, addiction, factitious disorder or somatic symptom disorder). (Note that tolerance and dependence to opioid analgesics are not addictive behaviors and do not preclude implantation); • A level of secondary risk factors or “yellow flags” (e.g., moderate depression, job dissatisfaction),) judged to be below the threshold for compromising the injured worker’s ability to benefit from neurostimulation; • The injured worker is cognitively capable of understanding and operating the neurostimulation control device; • The injured worker is cognitively capable of understanding and appreciating the risks and benefits of the procedure; and • The injured worker has demonstrated a history of motivation in and adherence to prescribed treatments. iv. The psychologist or psychiatrist performing these evaluations is not an employee of the physician performing the implantation. This evaluation must be completed, with favorable findings, before the screening trial is scheduled. Significant personality disorders must be taken into account when considering an injured worker for spinal cord stimulation and other major procedures. v. All reasonable surgical and non-surgical treatment has been exhausted. vi. The topography of pain and its underlying pathophysiology are amenable to stimulation coverage (the entire painful extremity area has been covered). vii. Successful neurostimulation screening test: For a spinal cord neurostimulation screening test, a temporary lead is implanted at the level of pain and attached to an external source to validate therapy effectiveness. A screening test is considered successful if the injured worker meets both of the following criteria:

Mississippi Workers’ Compensation Medical Fee Schedule Pain Management

CPT Copyright 2024 American Medical Association. All Rights Reserved. 83 • Experiences a fifty percent (50%) decrease in radicular or CRPS pain, which may be confirmed by visual analogue scale (VAS) or Numerical Rating Scale (NRS). • Demonstrates objective functional gains or decreased utilization of pain medications. It is expected that there will be an attempt to wean opioid pain medications at least partially prior to the stimulation trial to determine if there was additional pain relief that could be attributed to the stimulator trial. Ideally, the patient should be weaned off opioid medications prior to the implantation trial. The patient must not be currently taking greater than 50 morphine milligram equivalent (MME) in order to proceed with the trial of the stimulation. Objective, measurable, functional gains should be evaluated by an occupational therapist and/or physical therapist and the primary treating physician prior to and before discontinuation of the trial. M. Topical Drug Delivery 1. Description: Topical medications, such as lidocaine and capsaicin, may be an alternative treatment for neuropathic disorders and is an acceptable form of treatment in selected patients. 2. Indications: Neuropathic pain for most agents. Episodic use of NSAIDs and salicylates for joint pain. Patient selection must be rigorous to select those patients with the highest probability of compliance. Many patients do not tolerate the side effects for some medication or the need for frequent application. 3. Dosing and Time to Therapeutic Effect: All topical agents should be prescribed with strict instructions for application and maximum number of applications per day to obtain the desired benefit and avoid potential toxicity. There is no evidence that topical agents are more or less effective than oral medications. For most patients, the effects of long-term use are unknown and thus may be better used episodically. 4. Side Effects: Localized skin reactions may occur, depending on the medication agent used vs. Topical Agents. 5. Topical Agents: a. Capsaicin. Formulations of capsaicin have been FDA approved for management of pain associated with post-herpetic neuralgia. Capsaicin offers a safe and effective alternative to systemic NSAID therapy. There is also good evidence that a high dose (8%) capsaicin patch applied for 60 minutes can decrease post herpetic neuralgic pain for three (3) months. b. Ketamine and Tricyclics. Topical medications, such as the combination of ketamine and amitriptyline have been proposed as an alternative treatment for neuropathic disorders including CRPS. However, neither tricyclic nor ketamine topicals are FDA approved for topical use in neuropathic pain. Continued use of these agents beyond the initial prescription requires documentation of effectiveness, including functional improvement, and/or decreased use of other medications, particularly decreased use of opiates or other habituating medications. c. Lidocaine. Formulations of lidocaine (patch form) have been FDA approved for pain associated with post-herpetic neuralgia. d. Topical Salicylates and Non-salicylates. These have been shown to be effective in relieving pain in acute musculoskeletal conditions and single joint osteoarthritis. Topical salicylate and non-salicylates achieve tissue levels that are potentially therapeutic, at least with regard to Cyclooxygenase (COX) inhibition. There is good evidence that diclofenac gel reduces pain and improves function in mild-to- moderate hand osteoarthritis. Diclofenac gel has been FDA approved for acute pain due to minor strains, pains, and contusions; and for relief of pain due to osteoarthritis of the joints amenable to topical treatment, such as those of the knees and hands. e. Other Compounded Topical Agents. At the time this guideline was written, no studies identified evidence for the effectiveness of compounded topical agents other than those recommended above. Therefore, other compounded topical agents are not recommended. 6. Prior authorization is required for all agents that have not been recommended above. Continued use requires documentation of effectiveness including functional improvement and/or decrease in other medications.

N. Use of Opioids or Other Controlled Substances for Management of Chronic (Non-Terminal) Pain. Optimal, effective treatment for chronic pain may require the use of opioids or other controlled substances. The proper and effective use of opioids or other controlled substances has been specifically addressed by the Mississippi Board of Medical Licensure. Unless otherwise directed by the MWCC, reimbursement for prescriptions for opioids or other controlled substances used for the management or treatment of chronic, non-terminal pain should not be provided under this Fee Schedule unless treatment is sufficiently documented and complies with the Rules and Regulations, as promulgated by the Mississippi State Board of Medical Licensure and supplemented by the MWCC accordingly. In addition to the specific Rules and Regulations promulgated by the Mississippi State Board of Medical Licensure, the payer may, as in other cases, obtain a second opinion from an appropriate and qualified physician to determine the appropriateness

Pain Management Mississippi Workers’ Compensation Medical Fee Schedule

20 Miss. Admin. Code Pt. 2, R. 84 Rule 84

CPT Copyright 2024 American Medical Association. All Rights Reserved. of the treatment being rendered, including but not limited to the appropriateness of the continuing use of opioids or other controlled substances for treatment of the injured worker’s chronic pain. However, any such second opinion shall not be used as the basis for abrupt withdrawal of medication or payment thereof. Nothing in this paragraph shall prohibit a physician from administering narcotic drugs to an injured worker for the purpose of relieving acute withdrawal symptoms when necessary while arrangements are being made for referral or discontinuance of treatment, and the payer shall provide reimbursement in accordance with this Fee Schedule, as follows: not more than one (1) day’s medication may be administered to the injured worker or for the injured worker’s use at one time. Such emergency treatment may be carried out for not more than three (3) days. Discontinuance of treatment or reimbursement of prescriptions based on a second opinion obtained hereunder shall be subject to review by the MWCC pursuant to the Dispute Resolution Rules set forth in the Dispute Resolution Rules section in this Fee Schedule.

See the MWCC website for Guidelines for the Prescription of Opiates at https://www.mwcc.ms.gov/pdf/mwccGuidlinesForTh ePrescriptionOfOpiates.pdf

O. Other Medications. The recently approved non- opioid pain reliever Journavx (suzetrigine) is indicated only for acute non-neuropathic pain, such as after an acute injury or with acute post-operative pain management. Use beyond two (2) weeks is not reimbursed. There is no indication for the use of suzetrigine for the management of chronic pain. Doses greater than 50mg BID have not been sufficiently studied and are not reimbursable.

Mississippi Workers’ Compensation Medical Fee Schedule Pain Management Effective June 1, 2026 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine CPT Copyright 2024 American Medical Association. All Rights Reserved. 85

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  01996 DAILY HOSP MGMT EDRL/SARACH CONT DRUG ADMN see page 74 XXX N  20526 INJECTION THERAPEUTIC CARPAL TUNNEL 292.80 000 N 378.90  20550 INJECTION 1 TENDON SHEATH/LIGAMENT APONEUROSIS 204.00 000 N 378.90  20551 INJECTION SINGLE TENDON ORIGIN/INSERTION 206.40 000 N 378.90  20552 INJECTION SINGLE/MLT TRIGGER POINT 1/2 MUSCLES 190.80 000 N 378.90  20553 INJECTION SINGLE/MLT TRIGGER POINT 3/> MUSCLES 219.60 000 N 378.90  20600 ARTHROCENTESIS ASPIR&/INJ SMALL JT/BURSA W/O US 188.40 000 N 378.90  20604 ARTHROCNT ASPIR&/INJ SMALL JT/BURSAW/US REC RPRT 289.80 000 N 378.90  20605 ARTHROCENTESIS ASPIR&/INJ INTERM JT/BURS W/O US 194.40 000 N 378.90  20606 ARTHROCENTESIS ASPIR&/INJ INTERM JT/BURS W/US 316.80 000 N 920.90  20610 ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/O US 230.40 000 N 378.90  20611 ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/US 354.00 000 N 378.90  20612 ASPIRATION&/INJECTION GANGLION CYST ANY LOCATJ 228.00 000 N 378.90  27096 INJECT SI JOINT ARTHRGRPHY&/ANES/STEROID W/IMA 582.00 000 N  62263 PRQ LYSIS EPIDURAL ADHESIONS MULT SESS 2/> DAYS 937.20 010 N 920.90  62264 PRQ LYSIS EPIDURAL ADHESIONS MULT SESSIONS 1 DAY 937.20 010 N 920.90  62270 DIAGNOSTIC LUMBAR SPINAL PUNCTURE 506.40 000 N 920.90  62272 THERAPEUTIC SPINAL PUNCTURE DRAINAGE CSF 668.40 000 N 920.90  62273 INJECTION EPIDURAL BLOOD/CLOT PATCH 601.20 000 N 920.90  62280 INJX/INFUSION NEUROLYTIC SUBSTANCE SUBARACHNOID 1182.00 010 N 1193.84  62281 INJX/INFUS NEUROLYT SUBST EPIDURAL CERV/THORACIC 853.20 010 N 1193.84  62282 INJX/INFUS NEUROLYT SBST EPIDURAL LUMBAR/SACRAL 1162.80 010 N 1193.84  62290 INJECTION PX DISCOGRAPHY EACH LEVEL LUMBAR 1154.40 000 N  62291 INJECTION PX DISCOGRPHY EA LVL CERVICAL/THORACIC 0.00 000 N  J1 62350 IMPLTJ REVJ/RPSG ITHCL/EDRL CATH PMP W/O LAM 1412.40 010 N 10435.06  62355 RMVL PREVIOUSLY IMPLTED ITHCL/EDRL CATH 968.40 010 N 2546.50  J1 62360 IMPLTJ/RPLCMT ITHCL/EDRL DRUG NFS SUBQ RSVR 1153.20 010 N 28524.69  J1 62361 IMPLTJ/RPLCMT FS NON-PRGRBL PUMP 1551.60 010 N 28339.33  J1 62362 IMPLTJ/RPLCMT ITHCL/EDRL DRUG NFS PRGRBL PUMP 1366.80 010 N 28361.08  62365 RMVL SUBQ RSVR/PUMP INTRATHECAL/EPIDURAL INFUS 1052.40 010 N 8270.01  62367 ELECT ANLYS IMPLT ITHCL/EDRL PMP W/O REPRG/REFIL 136.80 XXX N 395.98  62368 ELECT ANALYS IMPLT ITHCL/EDRL PUMP W/REPRGRMG 188.40 XXX N 395.98  62369 ELECT ANLYS IMPLT ITHCL/EDRL PMP W/REPRG&REFIL 400.80 XXX N 395.98  62370 ELEC ANLYS IMPLT ITHCL/EDRL PMP W/REPR PHYS/QHP 416.40 XXX N 395.98  J1 63650 PRQ IMPLTJ NSTIM ELECTRODE ARRAY EPIDURAL 1077.15 010 N 11073.07  63661 RMVL SPINAL NSTIM ELTRD PRQ ARRAY INCL FLUOR 2101.20 010 Y 2316.70  J1 63662 RMVL SPINAL NSTIM ELTRD PLATE/PADDLE INCL FLUOR 2928.00 090 Y 4089.32  J1 63663 REVJ INCL RPLCMT NSTIM ELTRD PRQ RA INCL FLUOR 2812.80 010 Y 10355.35  J1 63664 REVJ INCL RPLCMT NSTIM ELTRD PLT/PDLE INCL FLUOR 3034.80 090 Y 29514.29  J1 63685 INSJ/RPLCMT SPI NPGR DIR/INDUXIVE COUPLING 1248.00 010 Y 43809.69  J1 63688 REVJ/RMVL IMPLANTED SPINAL NEUROSTIM GENERATOR 1287.60 010 N 4089.32  64400 INJECTION AA&/STRD TRIGEMINAL NERVE EACH BRANCH 465.60 000 N 378.90  64405 INJECTION AA&/STRD GREATER OCCIPITAL NERVE 284.40 000 N 378.90  64408 INJECTION AA&/STRD VAGUS NERVE 402.00 000 N 378.90  64415 INJECTION AA&/STRD BRACHIAL PLEXUS W/IMG GDN 405.60 000 N 1193.84  64416 INJECTION AA&/STRD BRACH PLEX CONT NFS CATH IMG 273.60 000 N 1193.84  64417 INJECTION AA&/STRD AXILLARY NERVE W/IMG GDN 501.60 000 N 1193.84  64418 INJECTION AA&/STRD SUPRASCAPULAR NERVE 325.20 000 N 920.90  64420 INJECTION AA&/STRD INTERCOSTAL NRV SINGLE LVL 378.00 000 N 920.90

Pain Management Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 86 CPT Copyright 2024 American Medical Association. All Rights Reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR 

20 Miss. Admin. Code Pt. 2, R. 64421 Rule 64421

INJECTION AA&/STRD INTERCOSTAL NRV EA ADDL LVL 535.20 ZZZ N 1193.84  64425 INJECTION AA&/STRD ILIOINGUINAL IH NERVES 471.60 000 N 920.90  64430 INJECTION AA&/STRD PUDENDAL NERVE 496.80 000 N 1193.84  64435 INJECTION AA&/STRD PARACERVICAL NERVE 480.00 000 N 920.90  64445 INJECTION AA&/STRD SCIATIC NERVE W/IMG GDN 466.80 000 N 920.90  64446 INJECTION AA&/STRD SCIATIC NRV CONT NFS CATH IMG 273.60 000 N 1193.84  64447 INJECTION AA&/STRD FEMORAL NERVE W/IMG GDN 415.20 000 N 920.90  64448 INJECTION AA&/STRD FEM NRV CONT NFS CATH IMG GDN 246.00 000 N 1193.84  64449 INJECTION AA&/STRD LUMBAR PLEXUS CONT NFS CATH 292.80 000 N 1193.84  64450 INJECTION AA&/STRD OTHER PERIPHERAL NERVE/BRANCH 271.20 000 N 920.90  64455 NJX AA&/STRD PLANTAR COMMON DIGITAL NERVES 176.40 000 N 378.90  64461 PVB THORACIC SINGLE INJECTION SITE W/IMG GID 487.20 000 N 920.90 

20 Miss. Admin. Code Pt. 2, R. 64462 Rule 64462

PVB THORACIC SECOND & ADDL INJ SITE W/IMG GID 264.00 ZZZ N  64463 PVB THORACIC CONT CATHETER INFUSION W/IMG GID 707.94 000 N 920.90  64479 NJX AA&/STRD TFRML EPI CERVICAL/THORACIC 1 LEVEL 834.00 000 N 1086.07 

20 Miss. Admin. Code Pt. 2, R. 64480 Rule 64480

NJX AA&/STRD TFRML EPI CERVICAL/THORACIC EA ADDL 410.40 ZZZ N  64483 NJX AA&/STRD TFRML EPI LUMBAR/SACRAL 1 LEVEL 772.80 000 N 1086.07 

20 Miss. Admin. Code Pt. 2, R. 64484 Rule 64484

NJX AA&/STRD TFRML EPI LUMBAR/SACRAL EA ADDL 334.80 ZZZ N  64486 TAP BLOCK UNILATERAL BY INJECTION(S) 374.40 000 N  64487 TAP BLOCK UNILATERAL BY CONTINUOUS INFUSION(S) 538.80 000 N  64488 TAP BLOCK BILATERAL BY INJECTION(S) 459.60 000 N  64489 TAP BLOCK BILATERAL BY CONTINUOUS INFUSION(S) 798.00 000 N  64490 NJX DX/THER AGT PVRT FACET JT CRV/THRC 1 LEVEL 684.00 000 Y 1193.84 

20 Miss. Admin. Code Pt. 2, R. 64491 NJX DX/THER AGT PVRT FACET JT CRV/THRC 2ND LEVEL 344.40 ZZZ Y 

20 Miss. Admin. Code Pt. 2, R. 64492 Rule 64492

NJX DX/THER AGT PVRT FACET JT CRV/THRC 3+ LEVEL 345.60 ZZZ Y  64493 NJX DX/THER AGT PVRT FACET JT LMBR/SAC 1 LEVEL 626.40 000 Y 1193.84 

20 Miss. Admin. Code Pt. 2, R. 64494 NJX DX/THER AGT PVRT FACET JT LMBR/SAC 2ND LEVEL 324.00 ZZZ Y 

20 Miss. Admin. Code Pt. 2, R. 64495 Rule 64495

NJX DX/THER AGT PVRT FACET JT LMBR/SAC 3+ LEVEL 322.80 ZZZ Y  64505 INJECTION ANES AGENT SPHENOPALATINE GANGLION 403.20 000 N 351.42  64510 NJX ANES STELLATE GANGLION CRV SYMPATHETIC 521.64 000 N 1193.84  64517 INJECTION ANES SUPERIOR HYPOGASTRIC PLEXUS 691.20 000 N 1193.84  64520 INJECTION ANES LMBR/THRC PARAVERTBRL SYMPATHETIC 793.50 000 N 1193.84  64530 INJX ANES CELIAC PLEXUS W/WO RADIOLOGIC MONITRNG 790.74 000 N 1193.84  64600 DSTRJ TRIGEMINAL NRV SUPRAORB INFRAORB BRANCH 1671.60 010 N 1193.84  J1 64605 DSTRJ NEUROLYTIC TRIGEMINAL NRV 2/3 DIV BRANCH 2307.60 010 N 3577.39  J1 64610 DSTRJ NEURLYTIC TRIGEM NRV 2/3 DIV RADIO MONITOR 2882.40 010 N 3569.59  64620 DSTRJ NEUROLYTIC AGENT INTERCOSTAL NERVE 744.00 010 N 1193.84  64630 DSTRJ NEUROLYTIC AGENT PUDENDAL NERVE 931.20 010 N 1193.84  64632 DSTRJ NEUROLYTIC PLANTAR COMMON DIGITAL NERVE 319.20 010 N 378.90  J1 64633 DSTR NROLYTC AGNT PARVERTEB FCT SNGL CRVCL/THORA 1426.80 010 N 3259.45 

20 Miss. Admin. Code Pt. 2, R. 64634 Rule 64634

DSTR NROLYTC AGNT PARVERTEB FCT ADDL CRVCL/THORA 640.80 ZZZ N  J1 64635 DSTR NROLYTC AGNT PARVERTEB FCT SNGL LMBR/SACRAL 1411.20 010 N 3259.45 

20 Miss. Admin. Code Pt. 2, R. 64636 Rule 64636

DSTR NROLYTC AGNT PARVERTEB FCT ADDL LMBR/SACRAL 582.00 ZZZ N  64640 DSTRJ NEUROLYTIC AGENT OTHER PERIPHERAL NERVE 463.20 010 N 1086.07  64680 DSTRJ NEUROLYTIC W/WO RAD MONITOR CELIAC PLEXUS 1251.66 010 N 1193.84  64681 DSTRJ NULYT W/WORAD MNTR SUPRIOR HYPOGSTR PLEXUS 1971.60 010 N 1193.84  72285 DISKOGRAPY CERVICAL/THORACIC RS&I 0.00 0.00 0.00 XXX N

 72295 DISKOGRAPY LUMBAR RS&I 211.77 78.11 133.66 XXX N

 76942 US GUIDANCE NEEDLE PLACEMENT IMG S&I 109.22 57.79 51.43 XXX N

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR 

20 Miss. Admin. Code Pt. 2, R. 77002 Rule 77002

FLUOROSCOPIC GUIDANCE NEEDLE PLACEMENT ADD ON 208.85 50.80 158.05 ZZZ N 

20 Miss. Admin. Code Pt. 2, R. 77003 Rule 77003

FLUOR NEEDLE/CATH SPINE/PARASPINAL DX/THER ADDON 200.66 54.61 146.05 ZZZ N  95990 REFILL&MAINTENANCE PUMP DRUG DLVR SPINAL/BRAIN 158.71 XXX N 462.41  95991 RFL&MAIN IMPLT PMP/RSVR DLVR SPI/BRN PHY/QHP 194.70 XXX N 378.90

20 Miss. Admin. Code Pt. 2, R. 88 Rule 88

CPT Copyright 2024 American Medical Association. All rights reserved. 89 SURGERY Note: Rules used by all physicians or other qualified health care professionals (OQHP) in reporting their services are presented in the General Rules section. See the Modifier and Code Rules section for detailed information on modifiers. I.GENERAL GUIDELINES A. Global Reimbursement. The reimbursement allowances for surgical procedures are based on a global reimbursement concept that covers performing the basic service and the normal range of care required after surgery. The State of Mississippi follows the surgical package definition from CPT ®

B. Normal, Uncomplicated Follow-Up (FU) Care. Normal, uncomplicated follow-up (FU) care for the time periods indicated in the follow-up days (FUD) column for each procedure code. The number in that column establishes the days during which no additional reimbursement is allowed for the usual care provided following surgery, absent complications or unusual circumstances. The maximum allowable reimbursement (MAR) covers all normal postoperative care, including the removal of sutures by the surgeon or associate. Follow-up days are specified by procedure. Follow-up days listed are for 0, 10, or 90 days and are listed in the Fee Schedule as 000, 010, or 090. Follow-up days may also be listed as: MMM indicating that services are for uncomplicated maternity care; XXX indicating that the global surgery concept does not apply; YYY indicating that the follow-up period is to be set by the payer (used primarily with BR procedures); or ZZZ indicating that the code is related to another service and is treated in the global period of the other procedure (used primarily with add-on and exempt from modifier 51 codes). The day of surgery is day one when counting follow- up days. Hospital discharge day management is considered to be normal, uncomplicated follow-up care. C. Follow-up for Diagnostic Procedures. When a procedure is done for diagnostic purposes, the follow-up does not include care of the condition itself, only recovery/recovery care for the procedure itself. D. Follow-up Care for Therapeutic Surgical Procedures. When a procedure is therapeutic in nature, the follow-up care includes routine post-op care and recovery. Any care needed for complications, care needed that is not part of routine post-op recovery, or any care that is not due to the procedure itself, may warrant additional charges. E. Separate Procedures. Separate procedures are commonly carried out as an integral part of another procedure. They should not be billed in conjunction with the related procedure. These procedures may be billed when performed independently by adding modifier 59 to the specific “separate procedure” code. F. Additional Surgical Procedure(s). When an additional surgical procedure(s) is carried out within the listed period of follow-up care for a previous surgery, the follow-up periods will continue concurrently to their normal terminations. G. Microsurgery, Operating Microscope, and Use of Code 69990. The surgical microscope is employed when the surgical services are performed using the techniques of microsurgery. Code 69990 should be reported (without modifier 51 appended) in addition to the code for the primary procedure performed. Do not use 69990 for visualization with magnifying loupes or corrected vision. Do not report 69990 in addition to procedures where use of the operating microscope is an inclusive component (15756–15758, 15842, 19364,19368, 20955–20962, 20969–20973, 22551, 22552, 22856–22861, 26551–26554, 26556, 31526, 31531, 31536, 31541, 31545, 31546, 31561, 31571, 43116, 43180, 43496, 46601, 46607, 49906, 61548, 63075–63078, 64727, 64820–64823, 64912, 64913, 65091–68850). For purposes of clarification, if microsurgery technique is employed and the primary procedure code is not contained in the list above, it is appropriate to report 69990 with the primary procedure performed and reimbursement is required for such services. (For example, code 63030 is not included in the list therefore, it is appropriate for providers to report 69990 along with 63030 to describe microsurgical technique.) Reimbursement for 69990 is required provided operative documentation affirms microsurgical technique and not just visualization with magnifying loupes or corrected vision. H. Unique Techniques. A surgeon is not entitled to an extra fee for a unique technique. It is inappropriate to use modifier 22 unless the procedure is significantly more difficult than indicated by the description of the code. I. Surgical Destruction. Surgical destruction is part of a surgical procedure, and different methods of destruction (e.g., laser surgery) are not ordinarily listed separately unless the technique substantially alters the standard management of a problem or condition. Exceptions under special circumstances are provided for by separate code numbers. J. Incidental Procedure(s). An additional charge for an incidental procedure (e.g., incidental appendectomy, incidental scar excisions, puncture of ovarian cysts, simple lysis of adhesions, simple

Surgery Mississippi Workers’ Compensation Medical Fee Schedule

20 Miss. Admin. Code Pt. 2, R. 90 Rule 90

CPT Copyright 2024 American Medical Association. All rights reserved. repair of hiatal hernia, etc.) is not customary and does not warrant additional reimbursement. K. Endoscopic Procedures. When multiple endoscopic procedures are performed by the same practitioner at a single encounter, the major procedure is reimbursed at one hundred percent (100%). If a secondary procedure is performed through the same opening/orifice, fifty percent (50%) is allowable as a multiple procedure. However, diagnostic procedures during the same session and entry site are incidental to the major procedure. L. Biopsy Procedures. A biopsy of the skin and another surgical procedure performed on the same lesion on the same day must be billed as one procedure. M. Repair of Nerves, Blood Vessels, and Tendons with Wound Repairs. The repair of nerves, blood vessels, and tendons is usually reported under the appropriate system. Normal wound repair is considered part of the nerve, blood vessel and/or tendon repair. Additional reimbursement for wound repair is only warranted if it is a complex wound, and modifier 59 should be used to identify such. N. Suture Removal. Billing for suture removal by the operating surgeon is not appropriate as this is considered part of the global fee. O. Joint Manipulation Under Anesthesia. There is no payment for manipulation of a joint under anesthesia when it is preceded or followed by a surgical procedure on that same day by that surgeon. However, when manipulation of a joint is the scheduled procedure and it indicates additional procedures are necessary and appropriate, the lesser of the billed amount or fifty percent (50%) of the MAR for manipulation may be allowed. P. Supplies and Materials. Supplies and materials provided by the physician or OQHP (e.g., sterile trays/drugs) over and above those usually included with the office visit may be listed separately using CPT code 99070 or specific HCPCS codes. Supplies (except those related to splint/casting) are not separately billable on the same date of service as the procedure (i.e., anti-embolism stockings and compression garments). Q. Aspirations and Injections Puncture of a cavity or joint for aspiration followed by injection of a therapeutic agent is one procedure and should be billed as such. When joint injections/trigger point injections are performed, ultrasound and/or Doppler guidance is considered integral to the procedure and will not be separately reimbursed. When a joint injection is performed at the end of a surgical procedure for pain control, whether done by the surgeon or by the anesthesiologist, reimbursement is allowed according to the Multiple Procedure Billing rule. This rule applies to facility reimbursement as well as provider reimbursement. R. Platelet Rich Plasma (PRP) Injections The maximum allowable reimbursement for PRP injections, billed with CPT code 0232T, applies to all body parts and includes imaging guidance, harvesting and preparation, as well as the injection, kits and supplies. S. Surgical Assistant 1. Physician Surgical Assistant — For the purpose of reimbursement, a physician who assists at surgery is reimbursed as a surgical assistant. Assistant surgeons should use modifier 80 and are allowed the lesser of the billed amount or twenty percent (20%) of the maximum allowable reimbursement (MAR) for the procedure(s). 2. Registered Nurse Surgical Assistant or Physician Assistant a. A physician assistant, or registered nurse who has completed an approved first assistant training course, may be allowed a fee when assisting a surgeon in the operating room (O.R.). b. The MAR for the physician assistant or the registered nurse first assistant (RNFA) is ten percent (10%) of the surgeon’s fee for the procedure(s) performed. c. Under no circumstances will a fee be allowed for an assistant surgeon and a physician assistant or RNFA at the same surgical encounter. d. Registered nurses on staff in the O.R. of a hospital, clinic, or outpatient surgery center do not qualify for reimbursement as an RNFA. e. CPT codes with modifier AS or modifier 81 should be used to bill for physician assistant or RNFA services on a CMS-1500 form or electronic claim and should be submitted with the charge for the surgeon’s services. 3. The Fee Schedule includes a column indicating which procedures are approved for assistant services with Y (yes) or N (no). If a surgical procedure is approved/pre-certified for a code with a Y in the “Assist Surg” column, the assistant is implied and does not require separate prior authorization/pre-certification for reimbursement. T. Operative Reports. An operative report must be submitted to the payer before reimbursement can be made for the surgeon’s or assistant surgeon’s services. The report should document the use and specific role(s) of assistants providing services. U. Needle Procedures. Needle procedures (lumbar puncture, thoracentesis, jugular or femoral taps, etc.) should be billed in addition to the medical care on the same day. V. Therapeutic Procedures. Therapeutic procedures (injecting into cavities, nerve blocks, etc.) (CPT codes 20526–20611, 64400–64484) may be billed in addition to the medical care for a new patient. (Use appropriate level of service plus injection.) In follow-up cases for additional therapeutic injections and/or aspirations, an office visit is only indicated if it is necessary to re-evaluate the injured worker. In this case, report the evaluation and

Mississippi Workers’ Compensation Medical Fee Schedule Surgery

CPT Copyright 2024 American Medical Association. All rights reserved. 91 management service and append modifier 25, significant, separately identifiable evaluation and management services. Documentation supporting the office visit charge must be submitted with the bill to the payer. Reimbursement for therapeutic injections will be made according to the multiple procedure rules. Trigger point injection is considered one procedure and reimbursed as such regardless of the number of injection sites. Two codes are available for reporting trigger point injections. Use 20552 for injection(s) of single or multiple trigger point(s) in one or two muscles or 20553 when three or more muscles are involved. W. Post-Operative Nerve Blocks. Post-operative nerve blocks are reimbursable when medically necessary. X. Anesthesia by Surgeon. In certain circumstances it may be appropriate for the attending surgeon to provide regional or general anesthesia. Anesthesia by the surgeon is considered to be more than local or digital anesthesia. Identify this service by adding modifier 47 to the surgical code. Only base anesthesia units are allowed. See the Anesthesia section. Y. Therapeutic/Diagnostic Injections. Injections are considered incidental to the procedure when performed with a related invasive procedure. Z. Intervertebral Biomechanical Device(s). CPT codes 22853, 22854 and 22859 describe the insertion of an intervertebral biomechanical device into an intervertebral disc space or vertebral body defect. These codes are reported per level; each code captures insertion of both devices with integral anterior instrumentation for device anchoring and devices without integral anterior instrumentation for device anchoring, regardless of approach (anterior, posterior, lateral). Coding is based on the location of the device insertion and whether interbody arthrodesis is being performed. AA. Intraoperative Neurophysiologic Monitoring (e.g., SSEP, MEP, BAEP, TES, DEP, VEP) Reimbursement for intraoperative neurophysiologic monitoring will not be allowed in the following cases, unless pre-certification is obtained from the payer prior to the services. 1. Neuromuscular junction testing of each nerve during intraoperative monitoring; 2. Intraoperative monitoring during peripheral nerve entrapment releases, such as carpal release, ulnar nerve transposition at the elbow, and tarsal tunnel release; 3. During decompression of cervical nerve roots without myelopathy; 4. During placement of cervical instrumentation absent evidence of myelopathy; 5. During lumbar discectomy for radiculopathy; or 6. During lumbar decompression for treatment of stenosis without the need for instrumentation. II. MULTIPLE PROCEDURES A. Multiple Procedure Reimbursement Rule. Multiple procedures performed during the same operative session at the same operative site are reimbursed as follows: • One hundred percent (100%) of the MAR for the primary procedure • Fifty percent (50%) of the MAR for the second and subsequent procedures B. Bilateral Procedure Reimbursement Rule. Bilateral procedures are identical procedures (i.e., use the same CPT code) performed on the same anatomic site but on opposite sides of the body. Furthermore, each procedure should be performed through its own separate incision to qualify as bilateral. For example, open reductions of bilateral fractures of the mandible treated through a common incision would not qualify under the definition of bilateral and would be reimbursed according to the multiple procedure rule. Medicare’s accepted method of billing bilateral services is to list the procedure once and add modifier 50. Mississippi is adopting this same policy. Refer to the example below: 69300 50 Otoplasty, protruding ear, with or without size reduction Place a “2” in the UNITS column of the CMS-1500 claim form so that payers are aware that two procedures were performed. List the charge as one hundred fifty percent (150%) of the normal charge. Reimbursement shall be at one hundred fifty percent (150%) of the amount allowed for a unilateral procedure(s). For example, if the allowable for a unilateral surgery is one hundred dollars ($100.00) and it is performed bilaterally, reimbursement shall be one hundred fifty dollars ($150.00). However, if the procedure description states “bilateral,” reimbursement shall be as listed in the Fee Schedule since the fee was calculated for provision of the procedure bilaterally. C. Multiple Procedures—Different Areas Rule. When multiple surgical procedures are performed in different areas of the body during the same operative sessions and the procedures are unrelated (e.g., abdominal hernia repair and a knee arthroscopy), the multiple procedure reimbursement rule will apply independently to each area. Modifier 51 must be added. D. Multiple Procedure Billing Rules 1. The primary procedure, which is defined as the procedure with the highest RVU, must be billed with the applicable CPT code. 2. The second or lesser or additional procedure(s) must be billed by adding modifier 51 to the codes, unless the procedure(s) is exempt from modifier 51 or qualifies as an add-on code. III. REPAIR OF WOUNDS A. Wound classifications of simple, intermediate, or complex are expected to be consistent with current CPT descriptions/definitions/guidelines. B. Reporting 1. The use of appropriate codes should be consistent with the current CPT guidelines.

Surgery Mississippi Workers’ Compensation Medical Fee Schedule

20 Miss. Admin. Code Pt. 2, R. 92 Rule 92

CPT Copyright 2024 American Medical Association. All rights reserved. 2. Wound exploration codes should not be billed with codes that specifically describe a repair to major structure or major vessel. The specific repair code supersedes the use of a wound exploration code. IV. MUSCULOSKELETAL SYSTEM A. Casting and Strapping. This applies to severe muscle sprains or strains that require casting or strapping. 1. Initial (new patient) treatment for soft tissue injuries must be billed under the appropriate office visit code. 2. When a cast or strapping is applied during an initial visit, supplies and materials (e.g., stockinet, plaster, fiberglass, ace bandages) may be itemized and billed separately using the appropriate HCPCS code. 3. When initial casting and/or strapping is applied for the first time during an established patient visit, reimbursement may be made for the itemized supplies and materials in addition to the appropriate established patient visit. 4. Replacement casts or strapping provided during a follow-up visit (established patient) include reimbursement for the replacement service as well as the removal of casts, splints, or strapping. Follow-up visit charges may be reimbursed in addition to replacement casting and strapping only when additional significantly identifiable medical services are provided. Office notes should substantiate medical necessity of the visit. Cast supplies may be billed using the appropriate HCPCS code and reimbursed separately. B. Fracture Care 1. Fracture care is a global service. It includes the examination, restoration or stabilization of the fracture, application of the first cast, and cast removal. Casting material is not considered part of the global package and may be reimbursed separately. It is inappropriate to bill an office visit since the reason for the encounter is for fracture care. However, if the injured worker requires surgical intervention, additional reimbursement can be made for the appropriate E/M code to properly evaluate the injured worker for surgery. Use modifier 57 with the E/M code. 2. Reimbursement for fracture care includes the application and removal of the first cast or traction device only. Replacement casting during the period of follow-up care is reimbursed separately. 3. The phrase “with manipulation” describes reduction of a fracture. 4. Re-reduction of a fracture performed by the primary physician or OQHP may be identified by the addition of modifier 76 to the usual procedure code to indicate “repeat procedure” by the same physician or OQHP. 5. The term “complicated” appears in some musculoskeletal code descriptions. It implies an infection occurred or the surgery took longer than usual. Be sure the medical record documentation supports the “complicated” descriptor to justify reimbursement. C. Bone, Cartilage, and Fascia Grafts 1. Reimbursement for obtaining autogenous bone, cartilage or fascia grafts, or other tissue through separate incisions is made only when the graft is not described as part of the basic procedure. 2. Tissue obtained from a cadaver for grafting must be billed using code 99070 and accompanied by a report. D. Arthroscopy Note: Diagnostic arthroscopy is considered to be included in a surgical arthroscopy. Only in the most unusual case is an increased fee justified because of increased complexity of the intra- articular surgery performed. 1. Diagnostic arthroscopy will be reimbursed at fifty percent (50%) when followed by open surgery. 2. Diagnostic arthroscopy is not billed when followed by arthroscopic surgery. 3. If there are only minor findings that do not confirm a significant preoperative diagnosis, the procedure should be billed as a diagnostic arthroscopy. E. Arthrodesis Procedures. CPT has clarified when it is appropriate to code a discectomy in addition to an arthrodesis, by adding the statement “including minimal discectomy” to prepare interspace is in the code description for anterior interbody technique. If the disk is removed for decompression of the spinal cord, the decompression should be coded and reimbursed separately. F. External Spinal Stimulators Post Fusion 1. Pre-certification is required for use of the external spinal stimulator. 2. The following criteria are established for the medically accepted standard of care when determining applicability for the use of an external spinal stimulator. However, the medical necessity should be determined on a case-by-case basis. a. Injured worker has had a previously failed spinal fusion; and/or b. Injured worker is scheduled for revision or repair of pseudoarthrosis; and/or c. The injured worker smokes greater than a pack of cigarettes per day and is scheduled for spinal fusion. 3. The external spinal stimulator is not approved by MWCC for use in primary spinal fusions. 4. When medical necessity is established based on the above criteria, the external spinal

Mississippi Workers’ Compensation Medical Fee Schedule Surgery

CPT Copyright 2024 American Medical Association. All rights reserved. 93 stimulator will be reimbursed according to the MAR in the Fee Schedule. G. Carpal Tunnel Release. The following intraoperative services are included in the global service package for carpal tunnel release and should not be reported separately and do not warrant additional reimbursement: • Surgical approach; • Isolation of neurovascular structures; • Video imaging; • Stimulation of nerves for identification; • Application of dressing, splint, or cast; • Tenolysis of flexor tendons; • Flexor tenosynovectomy; • Excision of lipoma of carpal canal; • Exploration of incidental release of ulnar nerve; • Division of transverse carpal ligament; • Use of endoscopic equipment; • Placement and removal of surgical drains or suction device; and • Closure of wound. V. BURNS, LOCAL TREATMENT A. Degree of Burns 1. Code 16000 must be used when billing for treatment of first degree burns when no more than local treatment of burned surfaces is required. 2. Codes 16020–16030 must be used when billing for treatment of partial-thickness burns only. 3. Codes 16035-16036 must be used when billing an escharotomy for treatment of a burn. 4. The claim form must be accompanied by a report substantiating the services performed. 5. Major debridement of foreign bodies, grease, epidermis, or necrotic tissue may be billed separately under codes 11000–11001. Modifier 51 does not apply. B. Percentage of Total Body Surface (TBS) Area. The following definitions apply to codes 16020–16030: 1. “Small” means a burn that encompasses five percent (5%) of TBS area or less. 2. “Medium” means a burn that encompasses five percent to ten percent (5%–10%) of TBS or that involves the whole face, or a whole extremity. 3. “Large” means a burn that encompasses greater than ten percent (10%) TBS area. C. Reimbursement 1. To identify accurately the proper procedure code and substantiate the descriptor for billing, the exact percentage of the body surface involved and the degree of the burn must be specified on the claim form submitted or by attaching a special report. Claims submitted without this specification will be returned to the physician or OQHP for this additional information. 2. Hospital visits, emergency room visits, or critical care visits provided by the same physician or OQHP on the same day as the application of burn dressings will be reimbursed as a single procedure at the highest level of service. VI. NERVE BLOCKS A. Diagnostic or Therapeutic 1. Please refer to the Pain Management section for guidelines and reimbursement of therapeutic nerve blocks. 2. Medications such as steroids, pain medication, etc., may be separately billed using the appropriate HCPCS code. a. The name of the medication(s), dosage, and volume must be identified. b. Medication will be reimbursed according to fees listed in the HCPCS section. If not listed in HCPCS, reimbursement will be according to the Pharmacy Rules section of this Fee Schedule. B. Anesthetic. When a nerve block for anesthesia is provided by the operating room surgeon, the procedure codes listed in the Anesthesia section must be used.

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 94 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   0232T NJX PLTLT PLASMA W/IMG HARVEST/PREPARATION 495.47 XXX N 393.60   10004 FINE NEEDLE ASPIRATION BX W/O IMG GDN EA ADDL 181.20 ZZZ N   10005 FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION 493.20 XXX N 902.47   10006 FINE NEEDLE ASPIRATION BX W/US GDN EA ADDL 213.60 ZZZ N   10007 FINE NEEDLE ASPIRATION BX W/FLUOR GDN 1ST LESION 1082.40 XXX N 902.47   10008 FINE NEEDLE ASPIRATION BX W/FLUOR GDN EA ADDL 590.40 ZZZ N   10009 FINE NEEDLE ASPIRATION BX W/CT GDN 1ST LESION 1628.40 XXX N 902.47   10010 FINE NEEDLE ASPIRATION BX W/CT GDN EA ADDL 957.60 ZZZ N   10011 FINE NEEDLE ASPIRATION BX W/MR GDN 1ST LESION 652.80 XXX N 902.47   10012 FINE NEEDLE ASPIRATION BX W/MR GDN EA ADDL 85.20 ZZZ N   10021 FINE NEEDLE ASPIRATION BX W/O IMG GDN 1ST LESION 362.40 XXX N 501.26   10030 IMG-GUIDED FLU COLLJ DRG CATH SOFT TISS PERQ 2245.26 000 N 902.47   10035 PLMT SFT TISS LOCLZJ DEV PERQ 1ST LESION 1640.40 000 N 902.47   10036 PLMT SFT TISS LOCLZJ DEV PERQ EACH ADDL LESION 1414.80 ZZZ N   10040 ACNE SURGERY 414.00 010 N 260.43   10060 INCISION & DRAINAGE ABSCESS SIMPLE/SINGLE 442.80 010 N 260.43   10061 INCISION & DRAINAGE ABSCESS COMPLICATED/MULTIPLE 758.40 010 N 501.26   10080 INCISION & DRAINAGE PILONIDAL CYST SIMPLE 721.74 010 N 902.47   10081 INCISION & DRAINAGE PILONIDAL CYST COMPLICATED 1081.92 010 N 902.47   10120 INCISION & REMOVAL FOREIGN BODY SUBQ TISS SIMPLE 535.20 010 N 501.26  J1 10121 INCISION & REMOVAL FOREIGN BODY SUBQ TISS COMP 946.80 010 N 2873.34  J1 10140 I&D HEMATOMA SEROMA/FLUID COLLECTION 608.40 010 N 2865.65   10160 PUNCTURE ASPIRATION ABSCESS HEMATOMA BULLA/CYST 460.80 010 N 501.26  J1 10180 INCISION & DRAINAGE COMPLEX PO WOUND INFECTION 945.60 010 N 4823.49   11000 DBRDMT EXTENSV ECZMT/INFCT SKIN UP 10% BDY SURF 207.60 000 N 759.54   11001 DBRDMT EXTNSVE ECZMT/INFCT SKN EA ADDL 10% 85.56 ZZZ N   11004 DBRDMT SKN SBQ T/M/F NECRO INFCTJ XTRNL GENT&PER 2014.80 000 N 1733.00   11005 DBRDMT SKN SUBQ T/M/F NECRO INFCTJ ABDL WALL 2752.80 000 N 3196.96   11006 DBRDMT SKN SUBQ T/M/F NECRO INFCTJ GENT PER&ABDL 2484.00 000 N   11008 RMVL PROSTC MATRL/MESH ABDL WALL FOR INFECTION 970.80 ZZZ N 1711.63   11010 DBRDMT W/RMVL FM FX&/DISLC SKIN&SUBQ TISSUS 1658.40 010 N 902.47   11011 DBRDMT W/RMVL FM FX&/DISLC SKN SUBQ T/M/F MUSC 1831.20 000 N 902.47  J1 11012 DBRDMT FX&/DISLC SUBQ T/M/F BONE 2374.80 000 N 4826.27   11042 DEBRIDEMENT SUBCUTANEOUS TISSUE 1ST 20 SQ CM/< 464.40 000 N 501.26   11043 DEBRIDEMENT MUSCLE &/FASCIA 1ST 20 SQ CM/< 830.40 000 N 759.54  J1 11044 DEBRIDEMENT BONE 1ST 20 SQ CM/< 1102.80 000 N 2868.52   11045 DEBRIDEMENT SUBCUTANEOUS TISSUE EA ADDL 20 SQ CM 145.20 ZZZ N   11046 DEBRIDEMENT MUSCLE &/FASCIA EA ADDL 20 SQ CM 261.60 ZZZ N   11047 DEBRIDEMENT BONE EACH ADDITIONAL 20 SQ CM 428.40 ZZZ N   11055 PARING/CUTTING BENIGN HYPERKERATOTIC LESION 1 219.42 000 N 260.43   11056 PARING/CUTTING BENIGN HYPERKERATOTIC LESION 2-4 262.20 000 N 260.43   11057 PARING/CUTTING BENIGN HYPERKERATOTIC LESION >4 291.18 000 N 260.43   11102 TANGENTIAL BIOPSY SKIN SINGLE LESION 366.00 000 N 260.43   11103 TANGENTIAL BIOPSY SKIN EA SEP/ADDITIONAL LESION 182.40 ZZZ N   11104 PUNCH BIOPSY SKIN SINGLE LESION 454.80 000 N 501.26   11105 PUNCH BIOPSY SKIN EA SEP/ADDITIONAL LESION 212.40 ZZZ N

Mississippi Workers’ Compensation Medical Fee Schedule Surgery 0232T, 10004-69990 Effective June 1, 2026 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine CPT Copyright 2024 American Medical Association. All rights reserved. 95

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   11106 INCISIONAL BIOPSY SKIN SINGLE LESION 562.80 000 N 759.54   11107 INCISIONAL BIOPSY SKIN EA SEP/ADDITIONAL LESION 256.80 ZZZ N   11200 RMVL SKIN TAGS MLT FIBRQ TAGS ANY UP TO&INC 15 320.40 010 N 260.43   11201 RMVL SKIN TAGS MLT FIBRQ TAGS ANY EA ADDL 10 64.80 ZZZ N   11300 SHAVING SKIN LESION 1 TRUNK/ARM/LEG DIAM 0.5CM/< 367.20 000 N 501.26   11301 SHVG SKIN LESION 1 TRUNK/ARM/LEG DIAM 0.6-1.0 CM 439.20 000 N 260.43   11302 SHVG SKN LESION 1 TRUNK/ARM/LEG DIAM 1.1-2.0 CM 496.80 000 N 260.43   11303 SHVG SKIN LESION 1 TRUNK/ARM/LEG DIAM >2.0 CM 547.20 000 N 501.26   11305 SHAVING SKIN LESION 1 S/N/H/F/G DIAM 0.5 CM/< 385.20 000 N 260.43   11306 SHAVING SKIN LESION 1 S/N/H/F/G DIAM 0.6-1.0 CM 441.60 000 N 260.43   11307 SHAVING SKIN LESION 1 S/N/H/F/G DIAM 1.1-2.0 CM 505.20 000 N 260.43   11308 SHAVING SKIN LESION 1 S/N/H/F/G DIAM >2.0 CM 535.20 000 N 501.26   11310 SHAVING SKIN LESION 1 F/E/E/N/L/M DIAM 0.5 CM/< 418.80 000 N 260.43   11311 SHVG SKIN LESION 1 F/E/E/N/L/M DIAM 0.6-1.0 CM 493.20 000 N 260.43   11312 SHVG SKIN LESION 1 F/E/E/N/L/M DIAM 1.1-2.0 CM 558.00 000 N 501.26   11313 SHAVING SKIN LESION 1 F/E/E/N/L/M DIAM >2.0 CM 651.60 000 N 501.26   11400 EXC B9 LESION MRGN XCP SK TG T/A/L 0.5 CM/< 458.40 010 N 902.47   11401 EXC B9 LESION MRGN XCP SK TG T/A/L 0.6-1.0 CM 560.40 010 N 501.26   11402 EXC B9 LESION MRGN XCP SK TG T/A/L 1.1-2.0 CM 616.80 010 N 902.47   11403 EXC B9 LESION MRGN XCP SK TG T/A/L 2.1-3.0 CM 706.80 010 N 902.47  J1 11404 EXC B9 LESION MRGN XCP SK TG T/A/L 3.1-4.0 CM 804.00 010 N 2873.48  J1 11406 EXC B9 LESION MRGN XCP SK TG T/A/L >4.0 CM 1141.20 010 N 2872.62  J1 11420 EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 0.5 CM/< 457.20 010 N 2873.77   11421 EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 0.6-1.0CM 572.40 010 N 902.47  J1 11422 EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 1.1-2.0CM 642.00 010 N 2873.41  J1 11423 EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 2.1-3.0CM 732.00 010 N 2873.48  J1 11424 EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 3.1-4.0CM 838.80 010 N 2870.53  J1 11426 EXC B9 LESION MRGN XCP SK TG S/N/H/F/G > 4.0CM 1190.40 010 N 4838.50   11440 EXC B9 LESION MRGN XCP SK TG F/E/E/N/L/M 0.5CM/< 513.60 010 N 902.47   11441 EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 0.6-1.0CM 624.00 010 N 902.47   11442 EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 1.1-2.0CM 691.20 010 N 902.47  J1 11443 EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 2.1-3.0CM 814.80 010 N 2873.70  J1 11444 EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 3.1-4.0CM 1012.80 010 N 2872.69  J1 11446 EXC B9 LESION MRGN XCP SK TG F/E/E/N/L/M > 4.0CM 1377.60 010 N 4841.77  J1 11450 EXCISION HIDRADENITIS AXILLARY SMPL/INTRM RPR 1552.50 090 N 4842.38  J1 11451 EXCISION HIDRADENITIS AXILLARY COMPLEX REPAIR 1908.00 090 N 4838.38  J1 11462 EXCISION HIDRADENITIS INGUINAL SMPL/INTRM RPR 1512.48 090 N 4840.44  J1 11463 EXCISION HIDRADENITIS INGUINAL COMPLEX REPAIR 1940.40 090 N 4831.24  J1 11470 EXCISION H/P/P/U SIMPLE/INTERMEDIATE REPAIR 1648.80 090 N 4842.38  J1 11471 EXCISION H/P/P/U COMPLEX REPAIR 1972.80 090 N 4827.85   11600 EXCISION MAL LESION TRUNK/ARM/LEG 0.5 CM/< 709.20 010 N 902.47   11601 EXCISION MAL LESION TRUNK/ARM/LEG 0.6-1.0 CM 817.20 010 N 902.47   11602 EXCISION MAL LESION TRUNK/ARM/LEG 1.1-2.0 CM 871.20 010 N 501.26   11603 EXCISION MAL LESION TRUNK/ARM/LEG 2.1-3.0 CM 991.20 010 N 902.47   11604 EXCISION MAL LESION TRUNK/ARM/LEG 3.1-4.0 CM 1105.20 010 N 902.47  J1 11606 EXCISION MALIGNANT LESION TRUNK/ARM/LEG > 4.0 CM 1593.60 010 N 2871.97  J1 11620 EXCISION MALIGNANT LESION S/N/H/F/G 0.5 CM/< 711.60 010 N 2869.17

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 96 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   11621 EXCISION MALIGNANT LESION S/N/H/F/G 0.6-1.0 CM 819.60 010 N 902.47   11622 EXCISION MALIGNANT LESION S/N/H/F/G 1.1-2.0 CM 900.00 010 N 902.47  J1 11623 EXCISION MALIGNANT LESION S/N/H/F/G 2.1-3.0 CM 1054.80 010 N 2871.54  J1 11624 EXCISION MALIGNANT LESION S/N/H/F/G 3.1-4.0 CM 1201.20 010 N 2871.68  J1 11626 EXCISION MALIGNANT LESION S/N/H/F/G >4.0 CM 1452.00 010 N 4837.29   11640 EXCISION MALIGNANT LESION F/E/E/N/L 0.5 CM/< 728.40 010 N 902.47   11641 EXCISION MALIGNANT LESION F/E/E/N/L 0.6-1.0 CM 844.80 010 N 902.47   11642 EXCISION MALIGNANT LESION F/E/E/N/L 1.1-2.0 CM 955.20 010 N 902.47  J1 11643 EXCISION MALIGNANT LESION F/E/E/N/L 2.1-3.0 CM 1122.00 010 N 2873.70  J1 11644 EXCISION MALIGNANT LESION F/E/E/N/L 3.1-4.0 CM 1383.60 010 N 2872.83  J1 11646 EXCISION MALIGNANT LESION F/E/E/N/L >4.0 CM 1800.00 010 N 4840.92   11719 TRIMMING NONDYSTROPHIC NAILS ANY NUMBER 49.20 000 N 80.73   11720 DEBRIDEMENT NAIL ANY METHOD 1-5 115.20 000 N 80.73   11721 DEBRIDEMENT NAIL ANY METHOD 6/> 156.00 000 N 80.73   11730 AVULSION NAIL PLATE PARTIAL/COMPLETE SIMPLE 1 411.60 000 N 260.43   11732 AVULSION NAIL PLATE PARTIAL/COMP SIMPLE EA ADDL 120.00 ZZZ N   11740 EVACUATION SUBUNGUAL HEMATOMA 201.48 000 N 163.53   11750 EXCISION NAIL MATRIX PERMANENT REMOVAL 571.20 010 N 501.26   11755 BIOPSY NAIL UNIT SEPARATE PROCEDURE 440.40 000 N 902.47   11760 REPAIR NAIL BED 675.60 010 N 759.54   11762 RECONSTRUCTION NAIL BED W/GRAFT 1039.20 010 N 2483.95   11765 WEDGE EXCISION SKIN NAIL FOLD 594.00 010 N 501.26  J1 11770 EXCISION PILONIDAL CYST/SINUS SIMPLE 1117.80 010 N 4833.78  J1 11771 EXCISION PILONIDAL CYST/SINUS EXTENSIVE 2282.40 090 N 4837.65  J1 11772 EXCISION PILONIDAL CYST/SINUS COMPLICATED 2773.80 090 N 4833.54   11900 INJECTION INTRALESIONAL UP TO & INCLUD 7 LESIONS 201.60 000 N 260.43   11901 INJECTION INTRALESIONAL >7 LESIONS 250.80 000 N 260.43   11920 TATTOOING INCL MICROPIGMENTATION 6.0 CM/< 696.00 000 N 759.54   11921 TATTOOING INCL MICROPIGMENTATION 6.1-20.0 CM 792.00 000 N 759.54   11922 TATTOOING INCL MICROPIGMENTATION EA 20.0 CM 213.60 ZZZ N   11950 SUBCUTANEOUS INJECTION FILLING MATERIAL 1 CC/< 269.10 000 N 260.43   11951 SUBCUTANEOUS INJECTION FILLING MATRL 1.1-5.0 CC 381.60 000 N 759.54   11952 SUBCUTANEOUS INJECTION FILLING MATRL 5.1-10.0CC 510.00 000 N 759.54   11954 SUBCUTANEOUS INJECTION FILLING MATRL >10.0 CC 561.60 000 N 759.54   11960 INSERTION TISSUE EXPANDER INCL SBSQ XPNSJ 3602.40 090 N 5106.63  J1 11970 REPLACEMENT TISSUE EXPANDER W/PERMANENT IMPLANT 2096.40 090 N 11790.73   11971 REMOVAL TISSUE EXPANDER W/O INSERTION IMPLANT 1865.76 090 N 3438.60   11976 REMOVAL IMPLANTABLE CONTRACEPTIVE CAPSULES 514.80 000 N 902.47   11980 SUBCUTANEOUS HORMONE PELLET IMPLANTATION 328.80 000 N 393.60   11981 INSERTION DRUG DELIVERY IMPLANT 486.00 000 N 163.53   11982 REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT 538.80 000 N 393.60   11983 RMVL W/RINSJ NON-BIODEGRADABLE DRUG DLVR IMPLT 787.20 000 N 393.60   12001 SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/< 336.00 000 N 260.43   12002 SMPL REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.6-7.5CM 404.40 000 N 260.43   12004 SIMPLE RPR SCALP/NECK/AX/GENIT/TRUNK 7.6-12.5CM 469.20 000 N 260.43   12005 SMPL RPR SCALP/NECK/AX/GENIT/TRUNK 12.6-20.0CM 633.60 000 N 501.26   12006 SMPL RPR SCALP/NECK/AX/GENIT/TRUNK 20.1-30.0CM 740.40 000 N 501.26

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   12007 SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK >30.0CM 832.80 000 N 260.43   12011 SIMPLE REPAIR F/E/E/N/L/M 2.5CM/< 402.00 000 N 260.43   12013 SIMPLE REPAIR F/E/E/N/L/M 2.6CM-5.0 CM 418.80 000 N 260.43   12014 SIMPLE REPAIR F/E/E/N/L/M 5.1CM-7.5 CM 513.60 000 N 260.43   12015 SIMPLE REPAIR F/E/E/N/L/M 7.6CM-12.5 CM 615.60 000 N 260.43   12016 SIMPLE REPAIR F/E/E/N/L/M 12.6CM-20.0 CM 787.20 000 N 501.26   12017 SIMPLE REPAIR F/E/E/N/L/M 20.1CM-30.0 CM 541.20 000 N 501.26   12018 SIMPLE REPAIR F/E/E/N/L/M >30.0 CM 614.40 000 Y 260.43   12020 TX SUPERFICIAL WOUND DEHISCENCE SIMPLE CLOSURE 1077.60 010 N 759.54   12021 TX SUPERFICIAL WOUND DEHISCENCE W/PACKING 633.60 010 N 501.26   12031 REPAIR INTERMEDIATE S/A/T/E 2.5 CM/< 948.00 010 N 501.26   12032 REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM 1083.60 010 N 501.26   12034 REPAIR INTERMEDIATE S/A/T/E 7.6-12.5 CM 1200.00 010 N 501.26   12035 REPAIR INTERMEDIATE S/A/T/E 12.6-20.0CM 1398.00 010 N 501.26   12036 REPAIR INTERMEDIATE S/A/T/E 20.1-30.0 CM 1558.80 010 N 759.54   12037 REPAIR INTERMEDIATE S/A/T/E >30.0 CM 1740.00 010 N 2483.95   12041 REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.5CM/< 951.60 010 N 501.26   12042 REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.6-7.5 CM 1112.40 010 N 501.26   12044 REPAIR INTERMEDIATE N/H/F/XTRNL GENT 7.6-12.5CM 1366.80 010 N 759.54   12045 REPAIR INTERMEDIATE N/H/F/XTRNL GENT 12.6-20 CM 1464.00 010 N 759.54   12046 RPR INTERMEDIATE N/H/F/XTRNL GENT 20.1-30.0 CM 1813.20 010 N 759.54   12047 REPAIR INTERMEDIATE N/H/F/XTRNL GENT >30.0 CM 1982.40 010 Y 2483.95   12051 REPAIR INTERMEDIATE F/E/E/N/L&/MUC 2.5 CM/< 1020.00 010 N 501.26   12052 REPAIR INTERMEDIATE F/E/E/N/L&/MUC 2.6-5.0 CM 1131.60 010 N 501.26   12053 REPAIR INTERMEDIATE F/E/E/N/L&/MUC 5.1-7.5 CM 1308.00 010 N 501.26   12054 REPAIR INTERMEDIATE F/E/E/N/L&/MUC 7.6-12.5 CM 1387.20 010 N 501.26   12055 REPAIR INTERMEDIATE F/E/E/N/L&/MUC 12.6-20.0CM 1813.20 010 N 501.26   12056 REPAIR INTERMEDIATE F/E/E/N/L&/MUC 20.1-30.0CM 2084.40 010 N 501.26   12057 REPAIR INTERMEDIATE F/E/E/N/L&/MUC >30.0 CM 2200.80 010 Y 501.26   13100 REPAIR COMPLEX TRUNK 1.1-2.5 CM 1224.00 010 N 759.54   13101 REPAIR COMPLEX TRUNK 2.6-7.5 CM 1428.00 010 N 759.54   13102 REPAIR COMPLEX TRUNK EACH ADDITIONAL 5 CM/< 418.80 ZZZ N   13120 REPAIR COMPLEX SCALP/ARM/LEG 1.1-2.5 CM 1276.80 010 N 759.54   13121 REPAIR COMPLEX SCALP/ARM/LEG 2.6-7.5 CM 1525.20 010 N 759.54   13122 REPAIR COMPLEX SCALP/ARM/LEG EA ADDL 5 CM/< 453.60 ZZZ N   13131 REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 1.1-2.5 CM 1390.80 010 N 501.26   13132 REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6-7.5 CM 1688.40 010 N 759.54   13133 REPAIR COMPLEX F/C/C/M/N/AX/G/H/F EA ADDL 5 CM/< 607.20 ZZZ N   13151 REPAIR COMPLEX EYELID/NOSE/EAR/LIP 1.1-2.5 CM 1515.60 010 N 759.54   13152 REPAIR COMPLEX EYELID/NOSE/EAR/LIP 2.6-7.5 CM 1778.40 010 N 759.54   13153 REPAIR COMPLX EYELID/NOSE/EAR/LIP EA ADDL 5 CM/< 660.00 ZZZ N   13160 SECONDARY CLOSURE SURG WOUND/DEHSN XTNSV/COMP 2827.20 090 N 2483.95   14000 ADJACENT TISSUE TRANSFER/REARGMT TRUNK 10 SQCM/< 2258.40 090 N 2483.95   14001 ADJNT TIS TRANSFR/REARRANGE TRUNK 10.1-30.0 SQCM 2876.40 090 N 2483.95   14020 ADJT TIS TRNSFR/REARGMT SCALP/ARM/LEG 10 SQ CM/< 2486.40 090 N 2483.95   14021 ADJT/REARRGMT SCALP/ARM/LEG 10.1-30.0 SQ CM 3062.40 090 N 2483.95   14040 ADJT TIS TRNS/REARGMT F/C/C/M/N/A/G/H/F 10SQCM/< 2680.80 090 N 2483.95

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 98 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   14041 ADJT/REARGMT F/C/C/M/N/AX/G/H/F 10.1-30.0 SQ CM 3249.60 090 N 2483.95   14060 ADJT TIS TRNSFR/REARRGMT E/N/E/L DFCT 10 SQ CM/< 2709.60 090 N 2483.95   14061 ADJT TIS REARGMT EYE/NOSE/EAR/LIP 10.1-30.0 SQCM 3500.40 090 N 2483.95   14301 ADJNT TIS TRNSFR/REARGMT ANY AREA 30.1-60 SQ CM 3852.00 090 Y 5106.63   14302 ADJT TIS TRNSFR/REARGMT DEFEC EA ADDL 30 SQCM 760.80 ZZZ Y   14350 FILLETED FINGER/TOE FLAP W/PREPJ RECIPIENT SITE 2401.20 090 N 2483.95   15002 PREP SITE TRUNK/ARM/LEG 1ST 100 SQ CM/1PCT 1248.00 000 N 2483.95   15003 PREP SITE TRUNK/ARM/LEG ADDL 100 SQ CM/1PCT 253.20 ZZZ N   15004 PREP SITE F/S/N/H/F/G/M/D GT 1ST 100 SQ CM/1PCT 1417.20 000 N 759.54   15005 PREP SITE F/S/N/H/F/G/M/D GT ADDL 100 SQ CM/1PCT 422.40 ZZZ N   15011 HRV SKIN FOR SKIN CELL SSP AGRFT 1ST 25 SQ CM/< BR 000 N 2597.51   15012 HRV SKIN FOR SKIN CELL SSP AGRFT EA ADDL 25 SQCM BR ZZZ N   15013 PREPARATION SKIN CELL SSP AGRFT 1ST 25 SQ CM/< BR XXX N 10295.71   15014 PREPARATION SKIN CELL SSP AGRFT EA ADDL 25 SQ CM BR ZZZ N   15015 APPL SKIN CELL SSP AGRFT T/A/L 1ST 480 SQ CM/< BR 090 N 2597.51   15016 APPL SKIN CELL SSP AGRFT T/A/L EA ADDL 480 SQ CM BR ZZZ N   15017 APPL SKN CLL SSP AGRFT F/S/N/H/F/G/M/DGT 1ST 480 BR 090 N 2597.51   15018 APPL SKN CLL SSP AGRFT F/S/N/H/F/G/M/DGT EA ADDL BR ZZZ N   15040 HARVEST SKIN TISSUE CLTR SKIN AGRFT 100 CM/< 951.60 000 N 2483.95   15050 PINCH GRAFT 1/MLT SM ULCER TIP/OTH AR UP TO 2 CM 2131.20 090 N 759.54   15100 SPLT AGRFT T/A/L 1ST 100 SQCM/</1% BDY INFT/CHLD 3109.20 090 N 2483.95   15101 SPLT AGRFT T/A/L EA ADD 100 SQCM/EA 1% INFT/CHLD 678.00 ZZZ N   15110 EPIDRM AGRFT T/A/L 1ST 100 SQCM/</1% INFT/CHLD 2968.80 090 N 2483.95   15111 EPDRM AGRFT T/A/L EA ADD 100 SQCM/EA 1%INFT/CHLD 402.00 ZZZ N   15115 EPIDERMAL AGRFT F/S/N/H/F/G/M/DGT 1ST 100 SQCM/< 2865.60 090 N 2483.95   15116 EPIDERMAL AGRFT F/S/N/H/F/G/M/DGT EA 100 SQCM 579.60 ZZZ N   15120 SPLT AGRFT F/S/N/H/F/G/M/DGT 1ST 100 SQCM/</1% 3009.60 090 N 5106.63   15121 SPLT AGRFT F/S/N/H/F/G/M/DGT EA 100 SQCM/EA 1% 760.80 ZZZ N   15130 DERMAL AGRFT T/A/L 1ST 100 SQCM/</1%INFT/CHLD 2584.80 090 N 2483.95   15131 DERMAL AGRFT T/A/L EA ADD 100 SQCM/1% INFT/CHLD 344.40 ZZZ N   15135 DERMAL AUTOGRAFT F/S/N/H/F/G/M/DGT 1ST 100 SQCM 3123.60 090 N 5106.63   15136 DERMAL AGRFT F/S/N/H/F/G/M/DGT EA 100 SQCM/EA 1% 340.80 ZZZ N   15150 TISS CLTR SKIN AUTOGRAFT T/A/L 1ST 25 SQ CM/< 2548.80 090 N 2483.95   15151 TISS CLTR SKIN AUTOGRAFT T/A/L ADDL 1-75 SQCM 424.80 ZZZ N   15152 TISS CLTR SKIN AGRFT T/A/L EA ADD 100 SQCM/EA 1% 522.00 ZZZ N   15155 TIS CLTR SKN AGRFT F/S/N/H/F/G/M/DGT 1ST 25SQCM/ 2836.80 090 N 5106.63   15156 TIS CLTR SKN AGRFT F/S/N/H/F/G/M/DGT AD 1-75SQCM 571.20 ZZZ N   15157 TIS CLTR SKN AGRFT F/S/N/H/F/G/M/DGT EACH ADDL 633.60 ZZZ N   15200 FTH/GFT FREE W/DIRECT CLOSURE TRUNK 20 SQ CM/< 2984.40 090 N 2483.95   15201 FTH/GFT FR W/DIR CLSR TRUNK EA ADDL 20 SQ CM 505.20 ZZZ N   15220 FTH/GFT FREE W/DIRECT CLOSURE S/A/L 20 SQ CM/< 2725.20 090 N 2483.95   15221 FTH/GFT FR W/DIR CLSR S/A/L EA ADDL 20 SQ CM 470.40 ZZZ N   15240 FTH/GFT FR DIR CLSR F/C/C/M/N/AX/G/H/F 20SQCM/< 3286.80 090 N 2483.95   15241 FTH/GFT FR W/DIR CLSR F/C/C/M/N/AX/G/H/F EA ADDL 626.40 ZZZ N   15260 FTH/GFT FREE W/DIRECT CLOSURE N/E/E/L 20 SQ CM/< 3520.80 090 N 2483.95   15261 FTH/GFT FREE W/DIR CLSR N/E/E/L EA ADDL 20 SQ CM 735.60 ZZZ N   15271 APP SKN SUB GRFT T/A/L AREA/100SQ CM /<1ST 25 554.40 000 N 2483.95

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   15272 APP SKN SUB GRFT T/A/L AREA/100SQ CM EA ADL 25SC 91.20 ZZZ N   15273 APP SKN SUBGRFT T/A/L AREA/100SQ CM 1ST 100SQ CM 1136.40 000 N 5106.63   15274 APP SKN SUB GRFT T/A/L AREA>=100SCM ADL 100SQCM 296.70 ZZZ N   15275 SUB GRFT F/S/N/H/F/G/M/D <100SQ CM 1ST 25 SQ CM 570.00 000 N 2483.95   15276 SUB GRFT F/S/N/H/F/G/M/D<100SQ CM EA ADDL25SQ CM 117.60 ZZZ N   15277 SUB GRFT F/S/N/H/F/G/M/D >= 100SCM 1ST 100SQ CM 1246.80 000 N 2483.95   15278 SUB GRFT F/S/N/H/F/G/M/D >= 100SCM ADL 100SQ CM 348.00 ZZZ N   15570 FRMJ DIRECT/TUBED PEDICLE W/WO TRANSFER TRUNK 3249.60 090 N 2483.95   15572 FRMJ DIRECT/TUBE PEDICLE W/WO TR SCALP ARMS/LEGS 3111.60 090 N 5106.63   15574 FRMJ DIR/TUBE PEDCL W/WOTR FH/CH/CH/M/N/AX/G/H/F 3132.00 090 N 2483.95   15576 FRMJ DIRECT/TUBED PEDICLE W/WOTR E/N/E/L/NTRORAL 2784.00 090 N 2483.95   15600 DELAY FLAP/SECTIONING FLAP TRUNK 1209.60 090 N 5106.63   15610 DELAY FLAP/SECTIONING FLAP SCALP ARMS/LEGS 1310.40 090 N 2483.95   15620 DELAY FLAP/SECTIONING FLAP F/C/C/N/AX/G/H/F 1594.80 090 N 2483.95   15630 DELAY FLAP/SCTJ FLAP EYELIDS NOSE EARS/LIPS 1641.60 090 N 2483.95   15650 TRANSFER ANY PEDICLE FLAP ANY LOCATION 1820.40 090 N 2483.95   15730 MIDFACE FLAP W/PRESERVATION OF VASCULAR PEDICLES 5239.20 090 N 5106.63   15731 FOREHEAD FLAP W/PRESERVATION VASCULAR PEDICLE 3988.80 090 N 5106.63   15733 MUSC MYOQ/FSCQ FLAP HEAD&NECK W/NAMED VASC PEDCL 3649.20 090 N 5106.63   15734 MUSC MYOCUTANEOUS/FASCIOCUTANEOUS FLAP TRUNK 5341.20 090 Y 5106.63   15736 MUSC MYOCUTANEOUS/FASCIOCUTANEOUS FLAP UXTR 4314.00 090 N 2483.95   15738 MUSC MYOCUTANEOUS/FASCIOCUTANEOUS FLAP LXTR 4522.80 090 Y 5106.63   15740 FLAP ISLAND PEDICLE ANATOMIC NAMED AXIAL ARTERY 3570.00 090 N 2483.95   15750 FLAP NEUROVASCULAR PEDICLE 3301.20 090 Y 5106.63   15756 FREE MUSCLE/MYOCUTANEOUS FLAP W/MVASC ANAST 8106.00 090 Y   15757 FREE SKIN FLAP W/MICROVASCULAR ANASTOMOSIS 8060.40 090 Y 706.54   15758 FREE FASCIAL FLAP W/MICROVASCULAR ANASTOMOSIS 8049.60 090 Y   15760 GRAFT COMPOSITE W/PRIMARY CLOSURE DONOR AREA 2994.00 090 N 2483.95   15769 GRAFTING OF AUTOLOGOUS SOFT TISS BY DIRECT EXC 1698.00 090 N 5106.63   15770 GRAFT DERMA-FAT-FASCIA 2374.80 090 Y 5106.63   15771 GRAFTING OF AUTOLOGOUS FAT BY LIPO 50 CC OR LESS 2096.40 090 N 5106.63   15772 GRAFTING OF AUTOLOGOUS FAT BY LIPO EA ADDL 50 CC 672.00 ZZZ N   15773 GRAFTING OF AUTOLOGOUS FAT BY LIPO 25 CC OR LESS 2146.80 090 N 2483.95   15774 GRAFTING OF AUTOLOGOUS FAT BY LIPO EA ADDL 25 CC 658.80 ZZZ N   15775 PUNCH GRAFT HAIR TRANSPLANT 1-15 PUNCH GRAFTS 1206.12 000 N 501.26   15776 PUNCH GRAFT HAIR TRANSPLANT >15 PUNCH GRAFTS 1734.66 000 N 501.26   15777 IMPLNT BIO IMPLNT FOR SOFT TISSUE REINFORCEMENT 760.80 ZZZ N   15778 IMPL ABSRB MESH/PRSTH DLYD CLSR DFCT INFCTJ/TRMA 1372.80 000 Y  J1 15780 DERMABRASION TOTAL FACE 3139.20 090 N 4823.97   15781 DERMABRASION SEGMENTAL FACE 1927.20 090 N 902.47  J1 15782 DERMABRASION REGIONAL OTHER THAN FACE 1963.20 090 N 4823.97   15783 DERMABRASION SUPERFICIAL ANY SITE 1634.40 090 N 501.26   15786 ABRASION 1 LESION 837.60 010 N 260.43   15787 ABRASION EACH ADDITIONAL 4 LESIONS OR LESS 152.40 ZZZ N   15788 CHEMICAL PEEL FACIAL EPIDERMAL 1530.00 090 N 501.26   15789 CHEMICAL PEEL FACIAL DERMAL 1890.00 090 N 759.54   15792 CHEMICAL PEEL NONFACIAL EPIDERMAL 1416.00 090 N 759.54

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 100 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   15793 CHEMICAL PEEL NONFACIAL DERMAL 1689.60 090 N 501.26   15820 BLEPHAROPLASTY LOWER EYELID 2038.80 090 N 2483.95   15821 BLEPHAROPLASTY LOWER EYELID W/HERNIATED FAT PAD 2193.60 090 N 2483.95   15822 BLEPHAROPLASTY UPPER EYELID 1640.40 090 N 2483.95   15823 BLEPHAROPLASTY UPPER EYELID W/EXCESSIVE SKIN 2192.40 090 N 2483.95   15824 RHYTIDECTOMY FOREHEAD 4180.02 000 N 2483.95   15825 RHYTIDECTOMY NECK W/PLATYSMAL TIGHTENING 6904.80 000 N 5106.63   15826 RHYTIDECTOMY GLABELLAR FROWN LINES 2306.06 000 N 5106.63   15828 RHYTIDECTOMY CHEEK CHIN & NECK 10657.20 000 N 5106.63   15829 RHYTIDECTOMY SMAS FLAP 7737.66 000 N 5106.63  J1 15830 EXC EXCSV SKN ABD INFRAUMBILICAL PANNICULECTOMY 4159.20 090 Y 11258.42  J1 15832 EXCISION EXCESSIVE SKIN & SUBQ TISSUE THIGH 3254.40 090 Y 4838.62  J1 15833 EXCISION EXCESSIVE SKIN & SUBQ TISSUE LEG 3108.00 090 N 4826.76  J1 15834 EXCISION EXCESSIVE SKIN & SUBQ TISSUE HIP 3165.60 090 N 4843.10  J1 15835 EXCISION EXCESSIVE SKIN & SUBQ TISSUE BUTTOCK 3297.60 090 N 4823.97  J1 15836 EXCISION EXCESSIVE SKIN & SUBQ TISSUE ARM 2824.80 090 N 4829.91  J1 15837 EXC EXCESSIVE SKIN &SUBQ TISSUE FOREARM/HAND 3082.80 090 N 4802.54  J1 15838 EXC EXCSV SKIN & SUBQ TISSUE SUBMENTAL FAT PAD 2300.40 090 N 4838.38  J1 15839 EXCISION EXCESSIVE SKIN & SUBQ TISSUE OTHER AREA 3177.60 090 N 4830.87   15840 GRAFT FACIAL NERVE PARALYSIS FREE FASCIAL GRAFT 3602.40 090 N 5106.63   15841 GRAFT FACIAL NERVE PARALYSIS FREE MUSCLE GRAFT 6308.40 090 Y 5106.63   15842 GRF FACIAL NRV PALYSS FR MUSCLE FLAP MICROSURG 9561.60 090 Y 2483.95   15845 GRF FACIAL NERVE PARALYSIS REGIONAL MUSCLE TR 3760.80 090 Y 5106.63   15847 EXCISION EXCESSIVE SKIN & SUBQ TISSUE ABDOMEN 2739.60 YYY Y   15851 REMOVAL SUTURES/STAPLES REQUIRING ANESTHESIA 384.00 000 N 2483.95   15852 DRESSING CHANGE UNDER ANESTHESIA 165.60 000 N 759.54   15853 REMOVAL SUTURES/STAPLES NOT REQUIRING ANESTHESIA 40.80 ZZZ N   15854 REMOVAL SUTURES&STAPLES NOT REQUIRING ANESTHESIA 57.60 ZZZ N   15860 IV INJECTION TEST VASCULAR FLOW FLAP/GRAFT 376.80 000 N 393.60   15876 SUCTION ASSISTED LIPECTOMY HEAD & NECK 3015.60 000 N 5106.63   15877 SUCTION ASSISTED LIPECTOMY TRUNK 4603.20 000 N 5106.63   15878 SUCTION ASSISTED LIPECTOMY UPPER EXTREMITY BR 000 N 2483.95   15879 SUCTION ASSISTED LIPECTOMY LOWER EXTREMITY 5754.00 000 N 5106.63  J1 15920 EXC COCCYGEAL PR ULC W/COCCYGECTOMY W/PRIM SUTR 2287.20 090 N 4843.10   15922 EXC COCCYGEAL PR ULC W/COCCYGECTOMY W/FLAP CLSR 2833.20 090 Y 5106.63  J1 15931 EXCISION SACRAL PRESSURE ULCER W/PRIMARY SUTURE 2500.80 090 N 4834.51  J1 15933 EXC SACRAL PRESSURE ULC W/PRIM SUTR W/OSTECTOMY 3112.80 090 N 4843.10   15934 EXCISION SACRAL PRESSURE ULCER W/SKIN FLAP CLSR 3381.60 090 N 5106.63   15935 EXC SACRAL PR ULCER W/SKN FLAP CLSR W/OSTECTOMY 4105.20 090 Y 5106.63   15936 EXC SAC PR ULC PREPJ MUSC/MYOQ FLAP/SKN GRF CLSR 3225.60 090 N 2483.95   15937 EXC SAC PR ULC PREPJ MUSC/MYOQ FLAP/SKN GRF OSTC 3727.20 090 N 2483.95  J1 15940 EXC ISCHIAL PRESSURE ULCER W/PRIMARY SUTURE 2504.40 090 N 4843.10  J1 15941 EXC ISCHIAL PR ULC W/PRIM SUTR W/OSTC ISCHIECT 3320.40 090 N 4837.78   15944 EXC ISCHIAL PRESSURE ULCER W/SKIN FLAP CLOSURE 3319.20 090 N 5106.63   15945 EXC ISCHIAL PR ULC W/SKN FLAP CLSR W/OSTECTOMY 3621.60 090 N 2483.95   15946 EXC ISCHIAL PR ULCER W/OSTC MUSC/MYOQ FLAP/SKIN 5763.60 090 N 2483.95  J1 15950 EXC TROCHANTERIC PRESSURE ULCER W/PRIMARY SUTR 2263.20 090 N 2873.91

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 15951 EXC TRCHNTRIC PR ULCER W/PRIM SUTR W/OSTECTOMY 3199.20 090 N 4843.10   15952 EXC TROCHANTERIC PR ULCER W/SKIN FLAP CLOSURE 3253.20 090 Y 2483.95   15953 EXC TRCHNTRIC PR ULC W/SKN FLAP CLSR W/OSTECTOMY 3586.80 090 N 5106.63   15956 EXC TROCHANTERIC PR ULCER MUSC/MYOQ FLAP/SKIN 4174.80 090 N 2483.95   15958 EXC TRCHNTRIC PR ULC MUSC/MYOQ FLAP/SKIN W/OSTC 4243.20 090 N 5106.63   15999 UNLISTED PROCEDURE EXCISION PRESSURE ULCER BR YYY N 902.47   16000 INITIAL TX 1ST DEGREE BURN LOCAL TX 270.00 000 N 260.43   16020 DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ SMALL 301.20 000 N 260.43   16025 DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ MEDIUM 561.60 000 N 260.43   16030 DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ LARGE 704.40 000 N 501.26   16035 ESCHAROTOMY FIRST INCISION 678.00 000 N 501.26   16036 ESCHAROTOMY EACH ADDITIONAL INCISION 283.20 ZZZ N   17000 DESTRUCTION PREMALIGNANT LESION 1ST 238.80 010 N 260.43   17003 DESTRUCTION PREMALIGNANT LESION 2-14 EA 22.08 ZZZ N   17004 DESTRUCTION PREMALIGNANT LESION 15/> 594.78 010 N 501.26   17106 DESTRUCTION CUTANEOUS VASC PROLIFERATIVE <10CM 1210.80 090 N 501.26   17107 DSTRJ CUTANEOUS VASCULAR LESIONS 10.0-50.0 SQ CM 1578.00 090 N 759.54   17108 DSTRJ CUTANEOUS VASCULAR LESIONS >50.0 SQ CM 2227.20 090 N 2483.95   17110 DESTRUCTION BENIGN LESIONS UP TO 14 404.40 010 N 260.43   17111 DESTRUCTION BENIGN LESIONS 15/> 472.80 010 N 260.43   17250 CHEMICAL CAUTERIZATION OF GRANULATION TISSUE 318.78 000 N 260.43   17260 DESTRUCTION MALIGNANT LESION T/A/L 0.5 CM/< 355.20 010 N 260.43   17261 DESTRUCTION MAL LESION TRUNK/ARM/LEG 0.6-1.0 CM 525.60 010 N 260.43   17262 DESTRUCTION MAL LESION TRUNK/ARM/LEG 1.1-2.0CM 636.00 010 N 260.43   17263 DESTRUCTION MAL LESION TRUNK/ARM/LEG 2.1-3.0CM 687.60 010 N 260.43   17264 DESTRUCTION MAL LESION TRUNK/ARM/LEG 3.1-4.0CM 735.60 010 N 501.26   17266 DESTRUCTION MAL LESION TRUNK/ARM/LEG > 4.0 CM 836.40 010 N 501.26   17270 DESTRUCTION MALIGNANT LESION S/N/H/F/G 0.5 CM/< 528.00 010 N 260.43   17271 DESTRUCTION MALIGNANT LESION S/N/H/F/G 0.6-1.0CM 589.20 010 N 260.43   17272 DESTRUCTION MALIGNANT LESION S/N/H/F/G 1.1-2.0CM 672.00 010 N 260.43   17273 DESTRUCTION MALIGNANT LESION S/N/H/F/G 2.1-3.0CM 742.80 010 N 501.26   17274 DESTRUCTION MALIGNANT LESION S/N/H/F/G 3.1-4.0CM 867.60 010 N 501.26   17276 DSTRJ MAL LESION S/N/H/F/G LESION DIAM > 4.0 CM 1009.20 010 N 501.26   17280 DESTRUCTION MALIGNANT LESION F/E/E/N/L/M 0.5CM/< 496.80 010 N 260.43   17281 DESTRUCTION MAL LESION F/E/E/N/L/M 0.6-1.0CM 639.60 010 N 501.26   17282 DESTRUCTION MAL LESION F/E/E/N/L/M 1.1-2.0CM 730.80 010 N 501.26   17283 DESTRUCTION MAL LESION F/E/E/N/L/M 2.1-3.0CM 860.40 010 N 501.26   17284 DESTRUCTION MAL LESION F/E/E/N/L/M 3.1-4.0CM 980.40 010 N 759.54   17286 DESTRUCTION MAL LESION F/E/E/N/L/M >4.0 CM 1254.00 010 N 759.54   17311 MOHS MICROGRAPHIC H/N/H/F/G 1ST STAGE 5 BLOCKS 2384.40 000 N 759.54   17312 MOHS MICROGRAPHIC H/N/H/F/G EACH ADDL STAGE 1453.20 ZZZ N   17313 MOHS TRUNK/ARM/LEG 1ST STAGE 5 BLOCKS 2240.40 000 N 759.54   17314 MOHS TRUNK/ARM/LEG EA STAGE AFTER 1ST STAGE 1390.80 ZZZ N   17315 MOHS TRUNK/ARM/LEG EA ADDL BLOCK ANY STAGE 272.40 ZZZ N   17340 CRYOTHERAPY CO2 SLUSH LIQUID N2 ACNE 184.80 010 N 49.09   17360 CHEMICAL EXFOLIATION ACNE 433.20 010 N 260.43   17380 ELECTROLYSIS EPILATION EACH 30 MINUTES 153.60 000 N 759.54

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 102 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   17999 UNLISTED PX SKIN MUC MEMBRANE & SUBQ TISSUE BR YYY N 260.43   19000 PUNCTURE ASPIRATION CYST OF BREAST 374.40 000 N 902.47   19001 PUNCTURE ASPIRATION CYST BREAST EACH ADDL CYST 94.80 ZZZ N  J1 19020 MASTOTOMY W/EXPLORATION/DRAINAGE ABSCESS DEEP 1700.40 090 N 2871.76   19030 INJECTION PX ONLY MAMMARY DUCTOGRAM/GALACTOGRAM 592.80 000 N  J1 19081 BX BREAST W/DEVICE 1ST LESION STEREOTACTIC GUID 2210.40 000 N 2829.00   19082 BX BREAST W/DEVICE ADDL LESION STEREOTACT GUID 1803.60 ZZZ N  J1 19083 BX BREAST W/DEVICE 1ST LESION ULTRASOUND GUID 2164.80 000 N 2818.59   19084 BX BREAST W/DEVICE ADDL LESION ULTRASOUND GUID 1738.80 ZZZ N  J1 19085 BX BREAST W/DEVICE 1ST LESION MAGNETIC RES GUID 3286.80 000 N 2826.27   19086 BX BREAST W/DEVICE ADDL LESION MAGNET RES GUID 2636.40 ZZZ N  J1 19100 BX BREAST NEEDLE CORE W/O IMAGING GUIDANCE SPX 558.00 000 N 2850.42  J1 19101 BIOPSY BREAST OPEN INCISIONAL 1200.00 010 N 6430.17  J1 19105 ABLTJ CRYOSURGICAL W/US GID EA FIBROADENOMA 9660.00 000 N 5709.06  J1 19110 NIPPLE EXPLORATION 1766.40 090 N 6447.42  J1 19112 EXCISION LACTIFEROUS DUCT FISTULA 1676.40 090 N 6450.00  J1 19120 EXC CYST/ABERRANT BREAST TISSUE OPEN 1/> LESION 1864.80 090 N 6443.87  J1 19125 EXC BREAST LES PREOP PLMT RAD MARKER OPEN 1 LES 2056.80 090 N 6438.55   19126 EXC BRST LES PREOP PLMT RAD MARKER OPN EA ADDL 572.40 ZZZ N   19281 PERQ DEVICE PLACEMENT BREAST LOC 1ST LES W/GDNCE 860.40 000 N 902.47   19282 PERQ DEVICE PLACEMT BREAST LOC EA LESION W/GDNCE 613.20 ZZZ N   19283 PERQ BREAST LOC DEVICE PLACEMT 1ST STRTCTC GDNCE 938.40 000 N 902.47   19284 PERQ BREAST LOC DEVICE PLACEMT EA LESION STRTCTC 704.40 ZZZ N   19285 PERQ BREAST LOC DEVICE PLACEMT 1ST LESIO US IMAG 1654.80 000 N 902.47   19286 PERQ BREAST LOC DEVICE PLACEMT EACH LES US IMAGE 1429.20 ZZZ N   19287 PERQ BREAST LOC DEVICE PLACEMT 1ST LESIO MR GUID 2796.00 000 N 902.47   19288 PERQ BREAST LOC DEVICE PLACEMT ADD LESIO MR GUID 2239.20 ZZZ N   19294 PREPJ TUMOR CAVITY IORT W/PARTIAL MASTECTOMY 586.80 ZZZ N  J1 19296 PLMT EXPANDABLE CATH BRST FOLLOWING PRTL MAST 14070.00 000 N 16327.80   19297 PLMT EXPANDABLE CATH BRST CONCURRENT PRTL MAST 334.80 ZZZ N  J1 19298 PLMT RADTHX BRACHYTX BRST FOLLOWING PRTL MAST 3388.80 000 N 10690.10  J1 19300 MASTECTOMY FOR GYNECOMASTIA 2108.40 090 N 6439.04  J1 19301 MASTECTOMY PARTIAL 2368.80 090 N 6426.94  J1 19302 MASTECTOMY PARTIAL W/AXILLARY LYMPHADENECTOMY 3253.20 090 Y 11253.33  J1 19303 MASTECTOMY SIMPLE COMPLETE 3433.20 090 Y 11278.20   19305 MAST RAD W/PECTORAL MUSCLES AXILLARY LYMPH NODES 4116.00 090 Y 5293.95   19306 MAST RAD W/PECTORAL MUSC AX INT MAM LYMPH NODES 4389.60 090 Y  J1 19307 MAST MODF RAD W/AX LYMPH NOD W/WO PECT/ALIS MIN 4234.80 090 Y 11276.22  J1 19316 MASTOPEXY 2811.60 090 Y 11185.23  J1 19318 BREAST REDUCTION 3879.60 090 Y 11275.38  J1 19325 BREAST AUGMENTATION WITH IMPLANT 2215.20 090 N 16996.66   19328 REMOVAL INTACT BREAST IMPLANT 1968.00 090 N 4579.50   19330 RMVL RUPTURED BREAST IMPLANT W/IMPLANT CONTENTS 2295.60 090 N 4579.50  J1 19340 INSERTION BREAST IMPLANT SAME DAY OF MASTECTOMY 3432.00 090 N 10544.84  J1 19342 INSJ/RPLCMT BREAST IMPLANT SEP DAY MASTECTOMY 3183.60 090 N 16870.99  J1 19350 NIPPLE/AREOLA RECONSTRUCTION 2958.00 090 N 6430.97  J1 19355 CORRECTION INVERTED NIPPLES 2694.00 090 N 6450.00

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 19357 TISSUE EXPANDER PLACEMENT BREAST RECONSTRUCTION 5179.20 090 Y 28094.55   19361 BREAST RECONSTRUCTION W/LATISSIMUS DORSI FLAP 5527.20 090 Y 5107.44   19364 BREAST RECONSTRUCTION W/FREE FLAP 9656.40 090 Y 3110.51   19367 BREAST RECONSTRUCTION SINGLE PEDICLED TRAM FLAP 6280.80 090 Y   19368 BREAST RECONSTRUCTION 1PEDICLED TRAM FLAP ANAST 7705.20 090 Y   19369 BREAST RECONSTRUCTION BIPEDICLED TRAM FLAP 7159.20 090 Y  J1 19370 REVISION PERI-IMPLANT CAPSULE BREAST 2382.00 090 N 6220.87  J1 19371 PERI-IMPLANT CAPSULECTOMY BREAST COMPLETE 2707.20 090 N 6413.08  J1 19380 REVISION OF RECONSTRUCTED BREAST 2864.40 090 N 10971.58  J1 19396 PREPARATION MOULAGE CUSTOM BREAST IMPLANT 994.80 000 N 6433.07  J1 19499 UNLISTED PROCEDURE BREAST BR YYY N 6266.66   20100 EXPLORATION PENETRATING WOUND SPX NECK 2146.80 010 Y 655.90   20101 EXPLORATION PENETRATING WOUND SPX CHEST 1788.48 010 N 2483.95   20102 EXPL PENETRATING WOUND SPX ABDOMEN/FLANK/BACK 1937.52 010 N 2483.95  J1 20103 EXPLORATION PENETRATING WOUND SPX EXTREMITY 2034.00 010 N 902.47  J1 20150 EXCISION EPIPHYSEAL BAR 3568.80 090 Y 5710.81  J1 20200 BIOPSY MUSCLE SUPERFICIAL 796.80 000 N 2872.69  J1 20205 BIOPSY MUSCLE DEEP 1104.00 000 N 4841.77  J1 20206 BIOPSY MUSCLE PERCUTANEOUS NEEDLE 828.00 000 N 2871.90  J1 20220 BIOPSY BONE TROCAR/NEEDLE SUPERFICIAL 661.02 000 N 2857.96  J1 20225 BIOPSY BONE TROCAR/NEEDLE DEEP 1765.20 000 N 2855.09  J1 20240 BIOPSY BONE OPEN SUPERFICIAL 517.20 000 N 4816.59  J1 20245 BIOPSY BONE OPEN DEEP 1226.40 000 N 4804.96  J1 20250 BIOPSY VERTEBRAL BODY OPEN THORACIC 1380.00 010 N 5649.06  J1 20251 BIOPSY VERTEBRAL BODY OPEN LUMBAR/CERVICAL 1504.80 010 Y 12575.32  J1 20500 INJECTION SINUS TRACT THERAPEUTIC SEPARATE PROC 426.42 010 N 2622.65   20501 INJECTION SINUS TRACT DIAGNOSTIC 499.56 000 N  J1 20520 REMOVAL FOREIGN BODY MUSCLE/TENDON SHEATH SIMPLE 780.00 010 N 2873.55  J1 20525 RMVL FOREIGN BODY MUSCLE/TENDON SHEATH DEEP/COMP 1681.20 010 N 4830.63   20526 INJECTION THERAPEUTIC CARPAL TUNNEL 292.80 000 N 378.90   20527 INJECTION ENZYME PALMAR FASCIAL CORD 309.60 000 N 378.90   20550 INJECTION 1 TENDON SHEATH/LIGAMENT APONEUROSIS 204.00 000 N 378.90   20551 INJECTION SINGLE TENDON ORIGIN/INSERTION 206.40 000 N 378.90   20552 INJECTION SINGLE/MLT TRIGGER POINT 1/2 MUSCLES 190.80 000 N 378.90   20553 INJECTION SINGLE/MLT TRIGGER POINT 3/> MUSCLES 219.60 000 N 378.90  J1 20555 PLACEMENT NEEDLES MUSCLE SUBSEQUENT RADIOELEMENT 1168.80 000 N 5707.92   20560 NEEDLE INSERTION W/O INJECTION 1 OR 2 MUSCLES 93.60 XXX N 35.83   20561 NEEDLE INSERTION W/O INJECTION 3 OR MORE MUSCLES 133.20 XXX N 35.83   20600 ARTHROCENTESIS ASPIR&/INJ SMALL JT/BURSA W/O US 188.40 000 N 378.90   20604 ARTHROCNT ASPIR&/INJ SMALL JT/BURSAW/US REC RPRT 289.80 000 N 378.90   20605 ARTHROCENTESIS ASPIR&/INJ INTERM JT/BURS W/O US 194.40 000 N 378.90   20606 ARTHROCENTESIS ASPIR&/INJ INTERM JT/BURS W/US 316.80 000 N 920.90   20610 ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/O US 230.40 000 N 378.90   20611 ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/US 354.00 000 N 378.90   20612 ASPIRATION&/INJECTION GANGLION CYST ANY LOCATJ 228.00 000 N 378.90   20615 ASPIRATION & INJECTION TREATMENT BONE CYST 900.00 010 N 902.47  J1 20650 INSERTION WIRE/PIN W/APPL SKELETAL TRACTION SPX 795.60 010 N 5533.95

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 104 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   20660 APPL CRANIAL TONG/STRTCTC FRAME W/REMOVAL SPX 854.40 000 N 2019.96   20661 APPLICATION HALO CRANIAL INCLUDING REMOVAL 1821.60 090 N 4107.04  J1 20662 APPLICATION HALO PELVIC INCLUDING REMOVAL 1856.40 090 N 2842.96  J1 20663 APPLICATION HALO FEMORAL INCLUDING REMOVAL 1710.00 090 N 5710.81   20664 APPL HALO CRANIAL 6/> PINS THIN SKULL OSTEOLOGY 3156.00 090 N 4107.04   20665 REMOVAL TONGS/HALO APPLIED BY ANOTHER INDIVIDUAL 410.40 010 N 393.60   20670 REMOVAL IMPLANT SUPERFICIAL SEPARATE PROCEDURE 1297.20 010 N 2040.53   20680 REMOVAL IMPLANT DEEP 2157.60 090 N 3438.60  J1 20690 APPLICATION UNIPLANE EXTERNAL FIXATION SYSTEM 2121.60 090 N 11613.53  J1 20692 APPLICATION MULTIPLANE EXTERNAL FIXATION SYSTEM 3975.60 090 Y 22543.88  J1 20693 ADJUSTMENT/REVJ XTRNL FIXATION SYSTEM REQ ANES 1575.60 090 N 12071.24   20694 REMOVAL EXTERNAL FIXATION SYSTEM UNDER ANES 1534.80 090 N 2019.96  J1 20696 APP MLTPLN UNI XTRNL FIX STRTCTC ADJMT 1ST&SUBSQ 4200.00 090 Y 28289.87   J1 20697 APP MLTPLN UNI XTRNL FIX STRTCTC ADJMT EXCHANGE 7069.20 BR 6780.00 000 Y   20700 MANUAL PREP AND INSERTION DEEP DRUG DELIVERY DEV 301.20 ZZZ N   20701 REMOVAL DEEP DRUG DELIVERY DEVICE 229.20 ZZZ N   20702 MANUAL PREP&INSJ INTRAMEDULLARY DRUG DLVR DEVICE 507.60 ZZZ N   20703 REMOVAL INTRAMEDULLARY DRUG DELIVERY DEVICE 369.60 ZZZ N   20704 MANUAL PREP&INSJ I-ARTIC DRUG DELIVERY DEVICE 536.40 ZZZ N   20705 REMOVAL INTRA-ARTICULAR DRUG DELIVERY DEVICE 439.20 ZZZ N  J1* 20802 REPLANTATION ARM COMPLETE AMPUTATION 9729.60 090 Y 27818.41  J1* 20805 REPLANTATION FOREARM COMPLETE AMPUTATION 11562.00 090 Y 27818.41  J1* 20808 REPLANTATION HAND COMPLETE AMPUTATION 13956.00 090 Y 27818.41  J1* 20816 RPLJ DGT EXCEPT THMB MTCARPHLNGL JT COMPL AMP 7285.20 090 Y 12031.89  J1 20822 RPLJ DGT EXCLUDING THMB SUBLIMIS TDN COMPL AMP 6291.60 090 Y 2800.57  J1* 20824 RPLJ THMB CARP/MTCRPL JT MP JT COMPL AMPUTATION 7298.40 090 Y 12031.89  J1* 20827 RPLJ THUMB DISTAL TIP MP JOINT COMPL AMPUTATION 6457.20 090 Y 12031.89  J1* 20838 REPLANTATION FOOT COMPLETE AMPUTATION 9885.60 090 Y 27818.41  J1 20900 BONE GRAFT ANY DONOR AREA MINOR/SMALL 1414.80 000 Y 11817.59  J1 20902 BONE GRAFT ANY DONOR AREA MAJOR/LARGE 984.00 000 Y 11926.34   20910 CARTILAGE GRAFT COSTOCHONDRAL 1690.80 090 N 759.54   20912 CARTILAGE GRAFT NASAL SEPTUM 1711.20 090 N 5106.63   20920 FASCIA LATA GRAFT BY STRIPPER 1413.60 090 N 2483.95   20922 FASCIA LATA GRAFT INCISION & AREA EXPOSURE 2148.00 090 Y 2483.95  J1 20924 TENDON GRAFT FROM A DISTANCE 1798.80 090 Y 12254.83   20930 ALLOGRAFT FOR SPINE SURGERY ONLY MORSELIZED 920.40 XXX N   20931 ALLOGRAFT FOR SPINE SURGERY ONLY STRUCTURAL 391.20 ZZZ N   20932 OSTEOARTICULAR ALLOGRAFT W/ARTICULAR SURF & BONE 2674.80 ZZZ Y   20933 HEMICORTICAL INTERCALARY ALLOGRAFT PARTIAL 2456.40 ZZZ Y   20934 INTERCALARY ALLOGRAFT COMPLETE 2672.40 ZZZ Y   20936 AUTOGRAFT SPINE SURGERY LOCAL FROM SAME INCISION 1150.80 XXX N   20937 AUTOGRAFT SPINE SURGERY MORSELIZED SEP INCISION 590.40 ZZZ Y   20938 AUTOGRAFT SPINE SURGERY BICORT/TRICORT SEP INC 651.60 ZZZ Y   20939 BONE MARROW ASPIRATION BONE GRFG SPI SURG ONLY 246.00 ZZZ N   20950 MNTR INTERSTITIAL FLUID PRESSURE CMPRT SYNDROME 963.60 000 N 902.47  J1* 20955 BONE GRAFT MICROVASCULAR ANASTOMOSIS FIBULA 8732.40 090 Y 12031.89  J1* 20956 BONE GRAFT MICROVASCULAR ANAST ILIAC CREST 9363.60 090 Y 12031.89

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1* 20957 BONE GRAFT MICROVASCULAR ANAST METATARSAL 9748.80 090 Y 12031.89  J1* 20962 BONE GRF W/MVASC ANAST OTH/THN ILIAC CREST/METAR 9442.80 090 Y 12031.89  J1* 20969 FREE OSTQ FLAP W/MVASC ANAST METAR/GREAT TOE 9603.60 090 Y 12031.89  J1* 20970 FREE OSTQ FLAP W/MVASC ANASTOMOSIS ILIAC CREST 10094.40 090 Y 12031.89  J1 20972 FREE OSTQ FLAP W/MVASC ANASTOMOSIS METATARSAL 10064.40 090 Y 11715.24  J1 20973 FR OSTQ FLAP W/MVASC ANAST GRT TOE W/WEB SPACE 10635.60 090 Y 12031.89  

20 Miss. Admin. Code Pt. 2, R. 20974 ELECTRICAL STIMULATION BONE HEALING NONINVASIVE 288.00 000 N  

20 Miss. Admin. Code Pt. 2, R. 20975 Rule 20975

ELECTRICAL STIMULATION BONE HEALING INVASIVE 621.60 000 Y   20979 LOW INTENSITY US STIMJ BONE HEALING NONINVASIVE 196.80 000 N 35.83  J1 20982 ABLATION BONE TUMOR RF PERQ W/IMG GDN WHEN DONE 13216.80 000 N 12277.86  J1 20983 ABLATJ BONE TUMOR CRYO PERQ W/IMG GDN WHEN PRFMD 19648.80 000 N 11846.70   20985 CPTR-ASST SURGICAL NAVIGATION IMAGE-LESS 513.60 ZZZ N   20999 UNLISTED PROCEDURE MUSCSKELETAL SYSTEM GENERAL BR YYY N 298.91  J1 21010 ARTHROTOMY TEMPOROMANDIBULAR JOINT 2638.80 090 N 5587.96  J1 21011 EXCISION TUMOR SOFT TISS FACE/SCALP SUBQ <2CM 1341.60 090 Y 2873.70  J1 21012 EXCISION TUMOR SOFT TISS FACE/SCALP SUBQ 2 CM/> 1208.40 090 Y 2872.76  J1 21013 EXC TUMOR SOFT TISS FACE&SCALP SUBFASCIAL <2CM 1922.40 090 Y 2872.55  J1 21014 EXC TUMOR SOFT TISS FACE&SCALP SUBFASCIAL 2 CM/> 1855.20 090 Y 4839.23  J1 21015 RAD RESECTION TUMOR SOFT TISS FACE/SCALP < 2CM 2484.00 090 N 4838.26  J1 21016 RAD RESECTION TUMOR SOFT TISS FACE/SCALP 2 CM/> 3579.60 090 Y 4831.96  J1 21025 EXCISION BONE MANDIBLE 2984.40 090 N 10289.33  J1 21026 EXCISION FACIAL BONE 2042.40 090 N 10381.01  J1 21029 REMOVAL CONTOURING BENIGN TUMOR FACIAL BONE 2722.80 090 N 5560.58  J1 21030 EXC BENIGN TUMOR/CYST MAXL/ZYGOMA ENCL & CURTG 1755.60 090 N 10250.37  J1 21031 EXCISION TORUS MANDIBULARIS 1374.00 090 N 5584.19  J1 21032 EXCISION MAXILLARY TORUS PALATINUS 1365.60 090 N 5582.10  J1 21034 EXCISION MALIGNANT TUMOR MAXILLA/ZYGOMA 4626.00 090 Y 10318.94  J1 21040 EXCISION BENIGN TUMOR/CYST MANDIBLE ENCL & CURT 1768.80 090 N 5539.07  J1 21044 EXCISION MALIGNANT TUMOR MANDIBLE 3068.40 090 Y 10284.40  J1* 21045 EXCISION MALIGNANT TUMOR MANDIBLE RADICAL 4251.60 090 Y 10272.97  J1 21046 EXC BENIGN TUMOR/CYST MNDBL INTRA-ORAL OSTEOT 3788.40 090 N 10250.12  J1 21047 EXC B9 TUM/CST MNDBL XTR-ORAL OSTEOT&PRTL MNDB 4522.80 090 Y 10263.36  J1 21048 EXC BENIGN TUMOR/CYST MAXL INTRA-ORAL OSTEOT 3848.40 090 N 10064.42  J1 21049 EXC B9 TUM/CST MAXL XTR-ORAL OSTEOT&PRTL MAXLC 4328.40 090 Y 10270.11  J1 21050 CONDYLECTOMY TEMPOROMANDIBULAR JOINT SPX 3110.40 090 N 10227.78  J1 21060 MENISCECTOMY PRTL/COMPL TEMPOROMANDIBULAR JT SPX 2829.60 090 Y 10382.05  J1 21070 CORONOIDECTOMY SEPARATE PROCEDURE 2198.40 090 N 10316.86  J1 21073 MANIPULATION TMJ THERAPEUTIC REQUIRE ANESTHESIA 1340.40 090 N 2763.08  J1 21076 IMPRESSION&PREPARATION SURGICAL OBTURATOR PROSTH 3312.00 010 N 2763.08  J1 21077 IMPRESSION & PREPARATION ORBITAL PROSTHESIS 8256.00 090 N 10388.54  J1 21079 IMPRESSION&PREPARATION INTERIM OBTURATOR PROSTH 5599.20 090 N 5587.96  J1 21080 IMPRESSION & PREPJ DEFINITIVE OBTURATOR PROSTH 6327.60 090 N 5587.96  J1 21081 IMPRESSION & PREPJ MANDIBULAR RESECTION PROSTH 5823.60 090 N 10388.54  J1 21082 IMPRESSION & PREPJ PALATAL AUGMENTATION PROSTH 5439.60 090 N 5587.96  J1 21083 IMPRESSION & PREPARATION PALATAL LIFT PROSTHESIS 5186.40 090 N 5587.96  J1 21084 IMPRESSION & PREPARATION SPEECH AID PROSTHESIS 5938.80 090 N 5587.96   21085 IMPRESSION & PREPARATION ORAL SURGICAL SPLINT 2526.00 010 N 306.82

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 106 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 21086 IMPRESSION & PREPARATION AURICULAR PROSTHESIS 6132.00 090 N 5381.07  J1 21087 IMPRESSION & PREPARATION NASAL PROSTHESIS 6132.00 090 N 10388.54  J1 21088 IMPRESSION & PREPARATION FACIAL PROSTHESIS 5984.40 090 N 5587.96   21089 UNLISTED MAXILLOFACIAL PROSTHETIC PROCEDURE BR YYY N 306.82  J1 21100 APPL HALO APPLIANCE MAXILLOFACIAL FIXATION SPX 2386.80 090 N 10272.97   21110 APPL INTERDENTAL FIXATION DEVICE NON-FX/DISLC 3134.40 090 N 1961.79   21116 INJECTION TEMPOROMANDIBULAR JOINT ARTHROGRAPHY 701.04 000 N  J1 21120 GENIOPLASTY AUGMENTATION 2384.40 090 N 10215.57  J1 21121 GENIOPLASTY SLIDING OSTEOTOMY SINGLE PIECE 2514.00 090 Y 5564.91  J1 21122 GENIOPLASTY SLIDING OSTEOTOMIES 2/> 2685.60 090 Y 10272.97  J1 21123 GENIOP SLIDING AGMNTJ W/NTRPSTJ BONE GRAFTS 3134.40 090 Y 5564.91  J1 21125 AGMNTJ MNDBLR BODY/ANGLE PROSTHETIC MATERIAL 9932.40 090 Y 9722.90  J1 21127 AGMNTJ MNDBLR BDY/ANGL W/BONE GRF ONLAY/NTRPSTJ 14836.80 090 Y 10046.50  J1 21137 REDUCTION FOREHEAD CONTOURING ONLY 2665.20 090 Y 5576.51  J1 21138 RDCTJ FHD CNTRG & PROSTHETIC MATRL/BONE GRAFT 3246.00 090 Y 10272.97  J1 21139 RDCTJ FHD CNTRG & SETBACK ANT FRONTAL SINUS WALL 3885.60 090 Y 9746.53  J1 21141 RCNSTJ MIDFACE LEFORT I 1 PIECE W/O BONE GRAFT 4735.20 090 Y 10272.97  J1 21142 RCNSTJ MIDFACE LEFORT I 2 PIECES W/O BONE GRAFT 4867.20 090 Y 10272.97  J1 21143 RCNSTJ MIDFACE LEFORT I 3/> PIECE W/O BONE GRAFT 5078.40 090 Y 10272.97  J1* 21145 RCNSTJ MIDFACE LEFORT I 1 PIECE W/BONE GRAFTS 5548.80 090 Y 10272.97  J1* 21146 RCNSTJ MIDFACE LEFORT I 2 PIECES W/BONE GRAFTS 5769.60 090 Y 10272.97  J1* 21147 RCNSTJ MIDFACE LEFORT I 3/> PIECE W/BONE GRAFTS 6100.80 090 Y 10272.97  J1 21150 RCNSTJ MIDFACE LEFORT II ANTERIOR INTRUSION 5838.00 090 Y 10272.97  J1* 21151 RCNSTJ MIDFACE LEFORT II W/BONE GRAFTS 6422.40 090 Y 10272.97  J1* 21154 RCNSTJ MIDFACE LEFORT III W/O LEFORT I 6910.80 090 Y 10272.97  J1* 21155 RCNSTJ MIDFACE LEFORT III W/LEFORT I 7663.20 090 Y 10272.97  J1* 21159 RCNSTJ MIDFACE LEFORT III W/FHD W/O LEFORT I 9182.40 090 Y 10272.97  J1* 21160 RCNSTJ MIDFACE LEFORT III W/FHD W/LEFORT I 9957.60 090 Y 10272.97  J1 21172 RCNSTJ SUPERIOR-LATERAL ORBITAL RIM & LOWER FHD 7573.20 090 Y 10126.23  J1 21175 RCNSTJ BIFRONTAL SUPERIOR-LAT ORB RIMS & LWR FHD 7858.80 090 Y 10272.97  J1* 21179 RCNSTJ FOREHEAD &/ SUPRAORB RIMS W/ALGRF/PROSTC 5403.60 090 Y 10272.97  J1* 21180 RCNSTJ FOREHEAD &/ SUPRAORBITAL RIMS W/AUTOGRAFT 6034.80 090 Y 10272.97  J1 21181 RCNSTJ CONTOURING BENIGN TUMOR CRNL BONES XTRC 2631.60 090 N 10387.24  J1* 21182 RCNSTJ ORBIT/FHD/NASETHMD EXCBONE TUM GRF<40SQCM 7507.20 090 Y 10272.97  J1* 21183 RCNSTJ ORBIT/FHD/NASETHMD EXC BONE GRF>40 <80 8167.20 090 Y 10272.97  J1* 21184 RCNSTJ ORBIT/FHD/NASETHMD EXC BONE TUM GRF>80SQ 8784.00 090 Y 10272.97  J1* 21188 RCNSTJ MDFC OTH/THN LEFORT OSTEOT & BONE GRAFTS 5767.20 090 Y 10272.97  J1 21193 RCNSTJ MNDBLR RAMI HRZNTL/VER/C/L OSTEOT W/O GRF 4413.60 090 Y 9854.31  J1 21194 RCNSTJ MNDBLR RAMI HRZNTL/VER/C/L OSTEOT W/GRAFT 5086.80 090 Y 10272.97  J1 21195 RCNSTJ MNDBLR RAMI&/BODY SGTL SPLT W/O INT RGD 4921.20 090 Y 9076.47  J1 21196 RCNSTJ MNDBLR RAMI&/BDY SGTL SPLT W/INT RGD FI 5091.60 090 Y 10272.97  J1 21198 OSTEOTOMY MANDIBLE SEGMENTAL 3969.60 090 Y 9878.98  J1 21199 OSTEOTOMY MANDIBLE SGMTL W/GENIOGLOSSUS ADVMNT 3714.00 090 Y 9572.00  J1 21206 OSTEOTOMY MAXILLA SEGMENTAL 4096.80 090 Y 10388.54  J1 21208 OSTEOPLASTY FACIAL BONES AUGMENTATION 5990.40 090 N 9849.90  J1 21209 OSTEOPLASTY FACIAL BONES REDUCTION 3090.00 090 Y 10309.33  J1 21210 GRAFT BONE NASAL/MAXILLARY/MALAR AREAS 7233.60 090 N 9738.48

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 21215 GRAFT BONE MANDIBLE 15130.80 090 N 9692.77  J1 21230 GRAFT RIB CRTLG AUTOGENOUS FACE/CHIN/NOSE/EAR 2666.40 090 N 10251.93  J1 21235 GRAFT EAR CRTLG AUTOGENOUS NOSE/EAR 2607.60 090 N 10368.28  J1 21240 ARTHRP TEMPOROMANDIBULAR JOINT W/WO AUTOGRAFT 3858.00 090 Y 10326.21  J1 21242 ARTHROPLASTY TEMPOROMANDIBULAR JT W/ALLOGRAFT 3590.40 090 Y 10155.32  J1 21243 ARTHRP TMPRMAND JOINT W/PROSTHETIC REPLACEMENT 5870.40 090 Y 28596.19  J1 21244 RCNSTJ MNDBL XTRORAL W/TRANSOSTEAL BONE PLATE 3602.40 090 Y 9315.41  J1 21245 RCNSTJ MNDBL/MAXL SUBPRIOSTEAL IMPLANT PARTIAL 4196.40 090 Y 9494.61  J1 21246 RCNSTJ MNDBL/MAXL SUBPRIOSTEAL IMPLANT COMPLETE 3052.80 090 Y 10151.94  J1* 21247 RCNSTJ MNDBLR CONDYLE W/BONE CARTLG AUTOGRAFTS 5644.80 090 Y 10272.97  J1 21248 RCNSTJ MANDIBLE/MAXL ENDOSTEAL IMPLANT PARTIAL 3733.20 090 N 10035.33  J1 21249 RCNSTJ MANDIBLE/MAXL ENDOSTEAL IMPLANT COMPLETE 5388.00 090 N 9859.25  J1 21255 RCNSTJ ZYGMTC ARCH/GLENOID FOSSA W/BONE CARTLG 4881.60 090 Y 10272.97  J1 21256 RECONSTRUCTION ORBIT W/OSTEOTOMIES & BONE GRAFTS 4395.60 090 Y 9543.18  J1 21260 PERIORBITAL OSTEOTOMIES BONE GRAFTS EXTRACRANIAL 4886.40 090 Y 10272.97  J1 21261 PERIORBITAL OSTEOTOMIES W/BONE GRAFTS ICRA & XTR 8637.60 090 Y 10272.97  J1 21263 PERIORBITAL OSTEOTOMIES W/BONE GRAFTS W/FOREHEAD 7993.20 090 Y 10272.97  J1 21267 ORBITAL REPOSITIONING W/BONE GRAFTS EXTRACRANIAL 5710.80 090 Y 8921.42  J1* 21268 ORBITAL REPOSITIONING W/BONE GRAFTS ICRA & XTRC 7160.40 090 Y 10272.97  J1 21270 MALAR AUGMENTATION PROSTHETIC MATERIAL 3600.00 090 Y 9828.34  J1 21275 SECONDARY REVISION ORBITOCRANIOFACIAL RCNSTJ 3006.00 090 Y 10176.36  J1 21280 MEDIAL CANTHOPEXY SEPARATE PROCEDURE 2058.00 090 N 5526.08  J1 21282 LATERAL CANTHOPEXY 1401.60 090 N 5569.24  J1 21295 REDUCTION MASSETER MUSCLE & BONE EXTRAORAL 690.00 090 N 2746.02  J1 21296 REDUCTION MASSETER MUSCLE & BONE INTRAORAL 1450.80 090 N 5564.91   21299 UNLISTED CRANIOFACIAL & MAXILLOFACIAL PROCEDURE BR YYY N 306.82  J1 21315 CLOSED TX NASAL BONE FX W/MNPJ W/O STABILIZATION 940.80 000 N 2758.66  J1 21320 CLOSED TX NASAL BONE FX W/MNPJ W/STABILIZATION 867.60 000 N 5584.75  J1 21325 OPEN TREATMENT NASAL FRACTURE UNCOMPLICATED 1606.80 090 N 5554.43  J1 21330 OPEN TX NASAL FX COMP W/INT&/XTRNL SKELETAL FI 1940.40 090 N 10205.18  J1 21335 OPEN TX NASAL FX W/CONCOMITANT OPTX FXD SEPTUM 2554.80 090 N 5529.57  J1 21336 OPEN TX NASAL SEPTAL FRACTURE W/WO STABILIZATION 2306.40 090 N 5780.80  J1 21337 CLOSED TX NASAL SEPTAL FRACT W/WO STABILIZATION 1504.80 090 N 5583.77  J1 21338 OPEN TX NASOETHMOID FX W/O EXTERNAL FIXATION 2410.80 090 N 9487.34  J1 21339 OPEN TX NASOETHMOID FX W/EXTERNAL FIXATION 2722.80 090 Y 9645.24  J1 21340 PERCUTANEOUS TX NASOETHMOID COMPLEX FRACTURE 2671.20 090 N 5564.91  J1* 21343 OPEN TX DEPRESSED FRONTAL SINUS FRACTURE 3882.00 090 Y 10272.97  J1* 21344 OPEN TX COMPLICATED FRONTAL SINUS FRACTURE 4971.60 090 Y 10272.97  J1 21345 CLOSED TX NASOMAXILLARY COMPLEX FRACTURE 2856.00 090 N 2746.02  J1 21346 OPTX NASOMAX CPLX FX LEFT II TYPE W/WIRG & FXJ 3670.80 090 N 9731.21  J1 21347 OPTX NASOMAX CPLX FX LEFT II TYPE REQ MLT OPN 3724.80 090 Y 10272.97  J1* 21348 OPTX NASOMAX CPLX FX LEFT II TYPE W/BONE GRAFT 3883.20 090 Y 10272.97  J1 21355 PERCUTANEOUS TX MALAR AREA FRACTURE 1593.60 010 N 5587.96  J1 21356 OPEN TX DEPRESSED ZYGOMATIC ARCH FRACTURE 1947.60 010 N 10282.32  J1 21360 OPEN TX DEPRESSED MALAR FRACTURE 1856.40 090 Y 9692.51  J1 21365 OPEN TX COMP FX MALAR W/INTERNAL FX&MULT SURG 3841.20 090 Y 9536.94  J1 21366 OPEN TX COMP FRACTURE MALAR AREA W/BONE GRAFT 4533.60 090 Y 10272.97

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 108 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 21385 OPEN TX ORBITAL FLOOR BLOWOUT FX TRANSANTRAL 2613.60 090 Y 9839.77  J1 21386 OPEN TX ORBITAL FLOOR BLOWOUT FX PERIORBITAL 2457.60 090 Y 9728.87  J1 21387 OPEN TX ORBITAL FLOOR BLOWOUT FX COMBINED APPR 2726.40 090 Y 9758.74  J1 21390 OPTX ORB FLOOR BLWT FX PRI/BITAL APPR W/ALLPLSTC 2844.00 090 Y 9706.79  J1 21395 OPTX ORB FLOOR BLWT FX PRI/BITAL APPR W/BONE GRF 3589.20 090 Y 10388.54   21400 CLSD TX FX ORBIT EXCEPT BLOWOUT W/O MANIPULATION 752.40 090 N 655.90  J1 21401 CLOSED TX FX ORBIT EXCEPT BLOWOUT W/MANIPULATION 1826.40 090 Y 2645.03  J1 21406 OPEN TX FX ORBIT EXCEPT BLOWOUT W/O IMPLANT 2078.40 090 Y 9754.32  J1 21407 OPEN TX FX ORBIT EXCEPT BLOWOUT W/IMPLANT 2274.00 090 Y 9772.76  J1 21408 OPEN TX FX ORBIT EXCEPT BLOWOUT W/BONE GRAFT 3210.00 090 Y 10225.18  J1 21421 CLOSED TX PALATAL/MAXILLARY FX W/FIXATION/SPLINT 2439.60 090 N 5564.21  J1 21422 OPEN TREATMENT PALATAL/MAXILLARY FRACTURE 2276.40 090 Y 10272.97  J1* 21423 OPEN TX PALATAL/MAXILLARY FX COMP MULTIPLE APPR 2847.60 090 Y 10272.97  J1* 21431 CLOSED TX CRANIOFACIAL SEPARATION 2491.20 090 Y 10272.97  J1* 21432 OPEN TX CRANIOFACIAL SEP W/WIRING&/INT FIXJ 2570.40 090 Y 10272.97  J1* 21433 OPEN TX CRANIOFACIAL SEP COMPLICATED MLT APPR 6157.20 090 Y 10272.97  J1* 21435 OPEN TX CRANIOFACIAL SEP COMP W/INT&/XTRNL FIX 4994.40 090 Y 10272.97  J1* 21436 OPTX CRNFCL SEP LFT III TYP COMP INT FIXJ W/BONE 7222.80 090 Y 10272.97  J1 21440 CLTX MANDIBULAR/MAXILLARY ALVEOLAR RIDGE FX SPX 2391.54 090 N 5552.34  J1 21445 OPTX MANDIBULAR/MAXILLARY ALVEOLAR RIDGE FX SPX 2899.20 090 Y 10218.69   21450 CLOSED TX MANDIBULAR FRACTURE W/O MANIPULATION 2146.80 090 N 655.90  J1 21451 CLOSED TX MANDIBULAR FRACTURE W/MANIPULATION 2784.00 090 N 2703.88  J1 21452 PERCUTANEOUS TX MANDIBULAR FX W/EXTERNAL FIXJ 2645.46 090 N 9543.95  J1 21453 CLOSED TX MANDIBULAR FX W/INTERDENTAL FIXATION 3811.56 090 N 9911.71  J1 21454 OPEN TX MANDIBULAR FX W/EXTERNAL FIXATION 1882.80 090 N 9203.99  J1 21461 OPEN TX MANDIBULAR FX W/O INTERDENTAL FIXATION 7132.80 090 N 9437.21  J1 21462 OPEN TX MANDIBULAR FX W/INTERDENTAL FIXATION 7604.40 090 Y 9341.38  J1 21465 OPEN TREATMENT MANDIBULAR CONDYLAR FRACTURE 3104.40 090 Y 9535.38  J1 21470 OPTX COMP MANDIBULAR FX MLT APPR W/INT FIXATION 4144.80 090 Y 9382.41   21480 CLOSED TX TEMPOROMANDIBULAR DISLOCATION 1ST/SBSQ 423.66 000 N 298.91  J1 21485 CLOSED TX TEMPOROMANDIBULAR DISLC COMP 1ST/SBSQ 3283.02 090 N 2748.02  J1 21490 OPEN TREATMENT TEMPOROMANDIBULAR DISLOCATION 3067.20 090 Y 5295.29  J1 21497 INTERDENTAL WIRING OTHER THAN FRACTURE 2568.00 090 N 2752.72   21499 UNLISTED MUSCULOSKELETAL PROCEDURE HEAD BR YYY N 306.82  J1 21501 I&D DEEP ABSC/HMTMA SOFT TISSUE NECK/THORAX 1749.60 090 N 4828.69  J1 21502 I&D DP ABSC/HMTMA SFT TIS NCK/THRX PRTL RIB OSTC 1819.20 090 Y 5710.81  J1* 21510 INCISION DEEP OPENING BONE CORTEX THORAX 1621.20 090 N 12031.89  J1 21550 BIOPSY SOFT TISSUE NECK/THORAX 962.40 010 N 2870.89  J1 21552 EXC TUMOR SOFT TIS NECK/ANT THORAX SUBQ 3 CM/> 1599.60 090 Y 4841.65  J1 21554 EXC TUMOR SOFT TISSUE NECK/THORAX SUBFASC 5 CM/> 2610.00 090 Y 4838.99  J1 21555 EXC TUMOR SOFT TISSUE NECK/ANT THORAX SUBQ <3CM 1569.60 090 N 2872.40  J1 21556 EXC TUMOR SOFT TISS NECK/THORAX SUBFASCIAL <5CM 1896.00 090 N 4836.93  J1 21557 RAD RESECT TUMOR SOFT TISS NECK/ANT THORAX <5CM 3399.60 090 Y 4841.17  J1 21558 RAD RESECT TUMOR SOFT TISS NECK/ANT THORAX 5CM/> 4780.80 090 Y 4836.81  J1 21600 EXCISION RIB PARTIAL 1999.20 090 Y 12651.77  J1 21601 EXCISION CHEST WALL TUMOR INCLUDING RIBS 4105.20 090 Y 4823.97  J1* 21602 EXCISION CH WAL TUM W/RIB W/O MEDSTNL LYMPHADEC 5527.20 090 Y 12031.89

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1* 21603 EXCISION CH WAL TUM W/RIB W/MEDSTNL LYMPHADEC 6007.20 090 Y 12031.89  J1 21610 COSTOTRANSVERSECTOMY SEPARATE PROCEDURE 4300.80 090 Y 5784.56  J1* 21615 EXCISION 1ST &/CERVICAL RIB 2187.60 090 Y 12031.89  J1* 21616 EXCISION 1ST &/CERVICAL RIB W/SYMPATHECTOMY 2535.60 090 Y 12031.89  J1* 21620 OSTECTOMY STERNUM PARTIAL 1806.00 090 Y 12031.89  J1* 21627 STERNAL DEBRIDEMENT 1936.80 090 Y 12031.89  J1* 21630 RADICAL RESECTION STERNUM 4664.40 090 Y 12031.89  J1 21685 HYOID MYOTOMY & SUSPENSION 3501.60 090 Y 9664.72  J1 21700 DIVISION SCALENUS ANTICUS W/O RESCJ CERVICAL RIB 1266.00 090 Y 12728.21  J1* 21705 DIVISION SCALENUS ANTICUS RESECTION CERVICAL RIB 1896.00 090 Y 12031.89  J1 21720 DIVISION STERNOCLEIDOMASTOID OPEN W/O CAST 1896.00 090 Y 5784.56   21725 DIVISION STERNOCLEIDOMASTOID OPEN W/CAST 1938.00 090 Y 902.47  J1* 21740 REPAIR PECTUS EXCAVATUM/CARINATUM OPEN 3640.80 090 Y 12031.89  J1 21742 REPAIR PECTUS EXCAVATM/CARINATM MINLY W/O THRSC 7274.40 090 Y 5773.72  J1 21743 REPAIR PECTUS EXCAVATM/CARINATM MINLY W/THRSC 10012.80 090 Y 5710.81  J1* 21750 CLOSE MEDIAN STERNOTOMY SEP W/WO DEBRIDEMENT SPX 2407.20 090 Y 12031.89  J1 21811 OPEN TX RIB FX W/FIXJ THORACOSCOPIC VIS 1-3 RIBS 2107.20 000 Y 11321.50  J1 21812 OPEN TX RIB FX W/FIXJ THORACOSCOPIC VIS 4-6 RIBS 2554.80 000 Y 10534.98  J1 21813 OPEN TX RIB FX W/FIXJ THORACOSCOPIC VIS 7+ RIBS 3501.60 000 Y 2469.48   21820 CLOSED TREATMENT STERNUM FRACTURE 534.00 090 N 298.91  J1* 21825 OPEN TX STERNUM FRACTURE W/WO SKELETAL FIXATION 1963.20 090 Y 12031.89   21899 UNLISTED PROCEDURE NECK/THORAX BR YYY N 306.82  J1 21920 BIOPSY SOFT TISSUE BACK/FLANK SUPERFICIAL 931.20 010 N 2872.26  J1 21925 BIOPSY SOFT TISSUE BACK/FLANK DEEP 1779.60 090 N 2871.90  J1 21930 EXCISION TUMOR SOFT TISSUE BACK/FLANK SUBQ <3CM 1814.40 090 N 2873.70  J1 21931 EXCISION TUMOR SOFT TIS BACK/FLANK SUBQ 3 CM/> 1682.40 090 Y 2872.76  J1 21932 EXC TUMOR SOFT TISS BACK/FLANK SUBFASCIAL <5CM 2372.40 090 Y 4842.62  J1 21933 EXC TUMOR SOFT TISS BACK/FLANK SUBFASCIAL 5 CM/> 2643.60 090 Y 4836.69  J1 21935 RAD RESECTION TUMOR SOFT TISSUE BACK/FLANK <5CM 3657.60 090 N 4840.20  J1 21936 RAD RESECTION TUMOR SOFT TISSUE BACK/FLANK 5CM/> 5038.80 090 Y 4840.20  J1* 22010 I&D DEEP ABSCESS PST SPINE CRV THRC/CERVICOTHR 3454.80 090 N 12031.89  J1* 22015 I&D DEEP ABSCESS PST SPINE LUMBAR SAC/LUMBOSAC 3391.20 090 N 12031.89  J1 22100 PRTL EXC PST VRT INTRNSC B1Y LES 1 VRT SGM CRV 3082.80 090 Y 12735.25  J1 22101 PRTL EXC PST VRT INTRNSC B1Y LES 1 VRT SGM THRC 3063.60 090 Y 12788.67  J1 22102 PRTL EXC PST VRT INTRNSC B1Y LES 1 VRT SGM LMBR 2817.60 090 Y 12759.24   22103 PRTL EXC PST VRT INTRNSC B1Y LES 1 VRT SGM EA 492.00 ZZZ Y  J1* 22110 PRTL EXC VRT BDY B1Y LES W/O SPI CORD 1 SGM CRV 3762.00 090 Y 12031.89  J1* 22112 PRTL EXC VRT BDY B1Y LES W/O SPI CORD 1 SGM THRC 4050.00 090 Y 12031.89  J1* 22114 PRTL EXC VRT BDY B1Y LES W/O SPI CORD 1 SGM LMBR 4050.00 090 Y 12031.89   22116 PRTL EXC VRT BDY B1Y LES W/O SPI CORD 1 SGM EA 501.60 ZZZ Y  J1* 22206 OSTEOTOMY SPINE POSTERIOR 3 COLUMN THORACIC 8708.40 090 Y 12031.89  J1* 22207 OSTEOTOMY SPINE POSTERIOR 3 COLUMN LUMBAR 8523.60 090 Y 12031.89   22208 OSTEOTOMY SPINE POSTERIOR 3 COLUMN EA ADDL SGM 2088.00 ZZZ Y  J1* 22210 OSTEOTOMY SPINE PST/PSTLAT APPR 1 VRT SGM CRV 6364.80 090 Y 12031.89  J1* 22212 OSTEOTOMY SPINE PST/PSTLAT APPR 1 VRT SGM THRC 5379.60 090 Y 12031.89  J1* 22214 OSTEOTOMY SPINE PST/PSTLAT APPR 1 VRT SGM LMBR 5380.80 090 Y 12031.89   22216 OSTEOT SPI PST/PSTLAT APPR 1 VRT SGM EA VRT SGM 1284.00 ZZZ Y

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 110 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1* 22220 OSTEOTOMY SPINE W/DSC ANT APPR 1 VRT SGM CRV 5768.40 090 Y 12031.89  J1* 22222 OSTEOTOMY SPINE W/DSC ANT APPR 1 VRT SGM THRC 6270.00 090 Y 12031.89  J1* 22224 OSTEOTOMY SPINE W/DSC ANT APPR 1 VRT SGM LUMBAR 5650.80 090 Y 12031.89   22226 OSTEOTOMY SPINE W/DSC ANT APPR 1 VRT SGM EA ADDL 1274.40 ZZZ Y   22310 CLTX VRT BDY FX W/O MANJ REQ&W/CSTING/BRACING 1111.20 090 N 298.91  J1 22315 CLTX VRT FX&/DISLC CSTING/BRACING MANJ/TRCJ 3144.00 090 N 5744.50  J1* 22318 OPTX&/RDCTJ ODNTD FX&/DISLC ANT FIXJ W/O GRAFT 5862.00 090 Y 22251.08  J1* 22319 OPTX&/RDCTJ ODNTD FX&/DISLC ANT W/INT FIXJ 6534.00 090 Y 22251.08  J1* 22325 OPTX&/RDCTJ VRT FX&/DISLC PST 1 VRT SGM LM 5236.80 090 Y 22251.08  J1* 22326 OPTX&/RDCTJ VRT FX&/DISLC PST 1 VRT SGM CR 5377.20 090 Y 22251.08  J1* 22327 OPTX&/RDCTJ VRT FX&/DISLC PST 1 VRT SGM TH 5454.00 090 Y 22251.08   22328 OPTX&/RDCTJ VRT FX&/DISLC PST 1 VRT SGM EA 993.60 ZZZ Y  J1 22505 MANIPULATION SPINE REQUIRING ANESTHESIA 459.60 010 N 2845.02  J1 22510 PERQ VERTEBROPLASTY UNI/BI INJX CERVICOTHORACIC 6736.80 010 N 5532.93  J1 22511 PERQ VERTEBROPLASTY UNI/BI INJECTION LUMBOSACRAL 6726.00 010 N 5528.16   22512 VERTEBROPLASTY EACH ADDL CERVICOTHOR/LUMBOSACRAL 3072.00 ZZZ N  J1 22513 PERQ VERT AGMNTJ CAVITY CRTJ UNI/BI CANNULATION 23466.00 010 N 12126.25  J1 22514 PERQ VERT AGMNTJ CAVITY CRTJ UNI/BI CANNULJ LMBR 23390.40 010 N 12113.46   22515 PERQ VERT AGMNTJ CAVITY CRTJ UNI/BI CANNULJ EACH 13578.00 ZZZ N   22526 PERQ INTRDSCL ELECTROTHRM ANNULOPLASTY 1 LEVEL 0.00 010 N   22527 PERQ INTRDSCL ELECTROTHRM ANNULOPLASTY ADDL LVL 0.00 ZZZ N  J1* 22532 ARTHRODESIS LATERAL EXTRACAVITARY THORACIC 6421.20 090 Y 27818.41  J1* 22533 ARTHRODESIS LATERAL EXTRACAVITARY LUMBAR 5887.20 090 Y 37500.00   22534 ARTHRODESIS LAT EXTRACAVITARY EA ADDL THRC/LMBR 1270.80 ZZZ Y  J1* 22548 ARTHRD ANT TRANSORL/XTRORAL C1-C2 W/WO EXC ODNTD 7000.80 090 Y 27818.41  J1 22551 ARTHRD ANT INTERBODY DECOMPRESS CERVICAL BELW C2 6060.00 090 Y 22322.87   22552 ARTHRD ANT INTERDY CERVCL BELW C2 EA ADDL NTRSPC 1402.80 ZZZ Y  J1 22554 ARTHRD ANT INTERBODY MIN DSC CRV BELOW C2 4485.60 090 Y 22427.39  J1* 22556 ARTHRD ANT INTERBODY MIN DSC THORACIC 5929.20 090 Y 27818.41  J1* 22558 ARTHRD ANT INTERBODY MIN DSC LUMBAR 5440.80 090 Y 27818.41   22585 ARTHRD ANT NTRBD MIN DSC EA ADDL INTERSPACE 1152.00 ZZZ Y 2220.82  J1* 22586 ARTHRODESIS PRESACRAL NTRBDY DSC W/INSTRMJ L5-S1 7243.20 090 Y 27818.41  J1* 22590 ARTHRODESIS POSTERIOR CRANIOCERVICAL 5653.20 090 Y 27818.41  J1* 22595 ARTHRODESIS POSTERIOR ATLAS-AXIS C1-C2 5403.60 090 Y 27818.41  J1* 22600 ARTHRD PST/PSTLAT TQ 1NTRSPC CRV BELW C2 SEGMENT 4632.00 090 Y 27818.41  J1* 22610 ARTHRODESIS POSTERIOR/PSTLAT TQ 1NTRSPC THORACIC 4551.60 090 Y 27818.41  J1 22612 ARTHRODESIS POSTERIOR/PSTLAT TQ 1NTRSPC LUMBAR 5647.20 090 Y 22473.99   22614 ARTHRODESIS PST/PSTLAT TQ 1NTRSPC EA ADDL NTRSPC 1383.60 ZZZ Y  J1 22630 ARTHRODESIS POSTERIOR INTERBODY 1 NTRSPC LUMBAR 5635.20 090 Y 28867.83   22632 ARTHRODESIS POSTERIOR INTERBODY 1 NTRSPC EA ADDL 1135.20 ZZZ Y 2239.48  J1 22633 ARTHRODESIS COMBINED TQ 1NTRSPC LUMBAR 6586.80 090 Y 37500.00   22634 ARTHRODESIS CMBN TQ 1NTRSPC EACH ADDITIONAL 1756.80 ZZZ Y  J1* 22800 ARTHRODESIS POSTERIOR SPINAL DFRM <6 VRT SGM 4834.80 090 Y 27818.41  J1* 22802 ARTHRODESIS POSTERIOR SPINAL DFRM 7-12 VRT SGM 7526.40 090 Y 27818.41  J1* 22804 ARTHRODESIS POSTERIOR SPINAL DFRM 13+ VRT SGM 8634.00 090 Y 27818.41  J1* 22808 ARTHRODESIS ANTERIOR SPINAL DFRM 2-3 VRT SGM 6500.40 090 Y 27818.41  J1* 22810 ARTHRODESIS ANTERIOR SPINAL DFRM 4-7 VRT SGM 7233.60 090 Y 27818.41

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1* 22812 ARTHRODESIS ANTERIOR SPINAL DFRM 8+ VRT SGM 7814.40 090 Y 27818.41  J1* 22818 KYPHECTOMY SINGLE OR TWO SEGMENTS 7634.40 090 Y 27818.41  J1* 22819 KYPHECTOMY 3 OR MORE SEGMENTS 8787.60 090 Y 27818.41  J1* 22830 EXPLORATION SPINAL FUSION 2931.60 090 Y 22251.08   22836 ANT THORACIC VRT BODY TETHERING <7 VRT SEGMENTS 6163.20 090 N   22837 ANT THORACIC VRT BODY TETHERING 8+ VRT SEGMENTS 6788.40 090 N   22838 REVJ RPLCMT/RMVL THORACIC VRT BODY TETHERING 6878.40 090 N   22840 POSTERIOR NON-SEGMENTAL INSTRUMENTATION 2685.60 ZZZ Y 2449.65   22841 INTERNAL SPINAL FIXATION WIRING SPINOUS PROCESS 3068.40 XXX N   22842 POSTERIOR SEGMENTAL INSTRUMENTATION 3-6 VRT SEG 2700.00 ZZZ Y 2647.48   22843 POSTERIOR SEGMENTAL INSTRUMENTATION 7-12 VRT SEG 2887.20 ZZZ Y   22844 POSTERIOR SEGMENTAL INSTRUMENTATION 13/> VRT SE 3482.40 ZZZ Y   22845 ANTERIOR INSTRUMENTATION 2-3 VERTEBRAL SEGMENTS 2575.20 ZZZ Y 2281.43   22846 ANTERIOR INSTRUMENTATION 4-7 VERTEBRAL SEGMENTS 2677.20 ZZZ Y 1683.01   22847 ANTERIOR INSTRUMENTATION 8/> VERTEBRAL SEGMENTS 2833.20 ZZZ Y   22848 PELVIC FIXATION OTHER THAN SACRUM 1272.00 ZZZ Y  J1* 22849 REINSERTION SPINAL FIXATION DEVICE 4654.80 090 Y 27818.41  J1* 22850 REMOVAL POSTERIOR NONSEGMENTAL INSTRUMENTATION 2629.20 090 Y 22251.08  J1* 22852 REMOVAL POSTERIOR SEGMENTAL INSTRUMENTATION 2524.80 090 Y 22251.08   22853 INSJ BIOMCHN DEV INTERVERTEBRAL DSC SPC W/ARTHRD 913.20 ZZZ Y   22854 INSJ BIOMCHN DEV VRT CORPECTOMY DEFECT W/ARTHRD 1185.60 ZZZ Y  J1* 22855 REMOVAL ANTERIOR INSTRUMENTATION 3949.20 090 Y 22251.08  J1 22856 TOTAL DISC ARTHRP ANT SINGLE INTERSPACE CERVICAL 5803.20 090 Y 28514.45  J1* 22857 TOTAL DISC ARTHRP ANT SINGLE INTERSPACE LUMBAR 6272.40 090 Y 27818.41   22858 TOTAL DISC ARTHRP ANT 2ND LEVEL CERVICAL 1791.60 ZZZ Y 3460.25   22859 INSJ BIOMCHN DEV NTRVRT DISC SPACE W/O ARTHRD 1178.40 ZZZ Y   22860 TOTAL DISC ARTHRP ANT SECOND INTERSPACE LUMBAR 1485.60 ZZZ Y  J1* 22861 REVJ W/RPLCMT TOT DISC ARTHRP ANT 1 NTRSPC CRV 8253.60 090 Y 27818.41  J1* 22862 REVJ W/RPLCMT TOT DISC ARTHRP ANT 1 NTRSPC LMBR 7581.72 090 Y 27818.41  J1* 22864 RMVL TOT DISC ARTHRP ANT 1 INTERSPACE CERVICAL 7370.40 090 Y 22251.08  J1* 22865 RMVL TOT DISC ARTHRP ANT 1 INTERSPACE LUMBAR 7780.44 090 Y 22251.08  J1 22867 INSJ STABLJ DEV W/DCMPRN LUMBAR SINGLE LEVEL 3828.00 090 Y 28088.40   22868 INSJ STABLJ DEV W/DCMPRN LUMBAR SECOND LEVEL 861.60 ZZZ Y  J1 22869 INSJ STABLJ DEV W/O DCMPRN LUMBAR SINGLE LEVEL 1590.00 090 Y 20423.80   22870 INSJ STABLJ DEV W/O DCMPRN LUMBAR SECOND LEVEL 434.40 ZZZ Y   22899 UNLISTED PROCEDURE SPINE 0.00 YYY Y 298.91  J1 22900 EXC TUMOR SOFT TISSUE ABDL WALL SUBFASCIAL <5CM 2023.20 090 Y 4838.26  J1 22901 EXC TUMOR SOFT TISSUE ABDL WALL SUBFASCIAL 5CM/> 2392.80 090 Y 4836.69  J1 22902 EXC TUMOR SOFT TISSUE ABDOMINAL WALL SUBQ <3CM 1712.40 090 Y 2873.41  J1 22903 EXC TUMOR SOFT TISSUE ABDOMINAL WALL SUBQ 3 CM/> 1578.00 090 Y 4840.20  J1 22904 RAD RESECTION TUMOR SOFT TISSUE ABDL WALL <5CM 3764.40 090 Y 4821.07  J1 22905 RAD RESECTION TUMOR SOFT TISSUE ABDL WALL 5 CM/> 4734.00 090 Y 4796.25   22999 UNLISTED PX ABDOMEN MUSCULOSKELETAL SYSTEM BR YYY N 298.91  J1 23000 REMOVAL SUBDELTOID CALCAREOUS DEPOSITS OPEN 2077.20 090 Y 4843.10  J1 23020 CAPSULAR CONTRACTURE RELEASE 2466.00 090 Y 5766.63  J1 23030 I&D SHOULDER DEEP ABSCESS/HEMATOMA 1598.40 010 N 4820.58  J1 23031 I&D SHOULDER INFECTED BURSA 1536.00 010 N 4842.25

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 112 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 23035 INCISION BONE CORTEX SHOULDER AREA 2442.00 090 Y 2736.34  J1 23040 ARTHROTOMY GLENOHUMERAL JT EXPL/DRG/RMVL FB 2571.60 090 Y 5718.62  J1 23044 ARTHRT ACROMCLAV STRNCLAV JT EXPL/DRG/RMVL FB 2028.00 090 N 5712.26  J1 23065 BIOPSY SOFT TISSUE SHOULDER SUPERFICIAL 812.40 010 N 2870.46  J1 23066 BIOPSY SOFT TISSUE SHOULDER DEEP 2032.80 090 N 4818.04  J1 23071 EXCISION TUMOR SOFT TISSUE SHOULDER SUBQ 3 CM/> 1504.80 090 Y 2872.90  J1 23073 EXC TUMOR SOFT TISSUE SHOULDER SUBFASCIAL 5 CM/> 2490.00 090 Y 4839.95  J1 23075 EXCISION TUMOR SOFT TISSUE SHOULDER SUBQ <3CM 1882.80 090 N 2864.86  J1 23076 EXC TUMOR SOFT TISS SHOULDER SUBFASC <5CM 1944.00 090 N 4841.89  J1 23077 RAD RESECTION TUMOR SOFT TISSUE SHOULDER <5CM 4033.20 090 Y 4843.10  J1 23078 RAD RESECTION TUMOR SOFT TISSUE SHOULDER 5 CM/> 5095.20 090 Y 4835.35  J1 23100 ARTHROTOMY GLENOHUMERAL JOINT W/BIOPSY 1814.40 090 Y 5784.56  J1 23101 ARTHRT ACROMCLAV/STRNCLAV JT W/BX&/EXC CRTLG 1639.20 090 N 5784.56  J1 23105 ARTHRT GLENOHUMRL JT W/SYNOVECTOMY W/WO BIOPSY 2289.60 090 Y 12227.00  J1 23106 ARTHRT GLENOHUMRL JT STRNCLAV JT W/SYNVCT W/WOBX 1801.20 090 N 5710.81  J1 23107 ARTHRT GLENOHMRL JT W/JT EXPL W/WO RMVL LOOSE/FB 2362.80 090 Y 12577.56  J1 23120 CLAVICULECTOMY PARTIAL 2101.20 090 Y 5773.28  J1 23125 CLAVICULECTOMY TOTAL 2539.20 090 Y 5784.56  J1 23130 ACROMIOPLASTY/ACROMIONECTOMY PRTL +-LIGAMENT RLS 2217.60 090 N 5763.30  J1 23140 EXC/CURTG BONE CYST/BENIGN TUMOR CLAV/SCAPULA 1989.60 090 N 5779.65  J1 23145 EXC/CURTG BONE CST/B9 TUM CLAV/SCAPULA W/AGRFT 2491.20 090 Y 5710.81  J1 23146 EXC/CURTG BONE CST/B9 TUM CLAV/SCAPULA W/ALGRFT 2232.00 090 N 12506.87  J1 23150 EXC/CURTG BONE CYST/BENIGN TUMOR PROX HUMERUS 2368.80 090 Y 5730.04  J1 23155 EXC/CURTG BONE CYST/BENIGN TUM PROX HUM W/AGRFT 2851.20 090 Y 12031.89  J1 23156 EXC/CURTG BONE CYST/BENIGN TUM PROX HUM W/ALGRFT 2428.80 090 Y 11616.09  J1 23170 SEQUESTRECTOMY CLAVICLE 2022.00 090 N 5784.56  J1 23172 SEQUESTRECTOMY SCAPULA 2042.40 090 Y 5710.81  J1 23174 SEQUESTRECTOMY HUMERAL HEAD SURGERY NECK 2731.20 090 Y 12031.89  J1 23180 PARTIAL EXCISION BONE CLAVICLE 2382.00 090 N 12674.16  J1 23182 PARTIAL EXCISION BONE SCAPULA 2404.80 090 Y 12794.10  J1 23184 PARTIAL EXCISION BONE PROXIMAL HUMERUS 2641.20 090 Y 12648.25  J1 23190 OSTECTOMY SCAPULA PARTIAL 2060.40 090 Y 5782.68  J1 23195 RESECTION HUMERAL HEAD 2652.00 090 Y 12648.57  J1* 23200 RADICAL RESECTION TUMOR CLAVICLE 5344.80 090 Y 12031.89  J1* 23210 RADICAL RESECTION TUMOR SCAPULA 6270.00 090 Y 12031.89  J1* 23220 RADICAL RESECTION BONE TUMOR PROXIMAL HUMERUS 6882.00 090 Y 12031.89  J1 23330 REMOVAL FOREIGN BODY SHOULDER SUBCUTANEOUS 1088.40 010 N 902.47  J1 23333 REMOVAL SHOULDER FOREIGN BODY DEEP SUBFASCIAL/IM 1690.80 090 N 4843.10  J1 23334 PROSTHESIS REMOVAL HUMERAL/GLENOID COMPONENT 3776.40 090 N 4808.11  J1* 23335 PROSTHESIS REMOVAL HUMERAL AND GLENOID COMPONENT 4503.60 090 N 4823.97   23350 INJECTION SHOULDER ARTHROGRAPHY/ CT/MRI ARTHG 547.86 000 N  J1 23395 MUSCLE TRANSFER SHOULDER/UPPER ARM SINGLE 4548.00 090 Y 11985.52  J1 23397 MUSCLE TRANSFER SHOULDER/UPPER ARM MULTIPLE 4048.80 090 Y 12460.18  J1 23400 SCAPULOPEXY 3469.20 090 Y 12794.10  J1 23405 TENOTOMY SHOULDER AREA 1 TENDON 2212.80 090 Y 12694.31  J1 23406 TENOTOMY SHOULDER MULTIPLE THRU SAME INCISION 2664.00 090 Y 12260.91  J1 23410 OPEN REPAIR OF ROTATOR CUFF ACUTE 2925.60 090 Y 12002.79

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 23412 OPEN REPAIR OF ROTATOR CUFF CHRONIC 3039.60 090 Y 12080.19  J1 23415 CORACOACROMIAL LIGAMENT RELEAS W/WOACROMIOPLASTY 2498.40 090 N 12489.28  J1 23420 RECONSTRUCTION ROTATOR CUFF AVULSION CHRONIC 3474.00 090 Y 11946.17  J1 23430 TENODESIS LONG TENDON BICEPS 2659.20 090 Y 12105.14  J1 23440 RESECTION/TRANSPLANTATION LONG TENDON BICEPS 2702.40 090 Y 12152.48  J1 23450 CAPSULORRHAPHY ANTERIOR PUTTI-PLATT/MAGNUSON 3375.60 090 Y 11490.06  J1 23455 CAPSULORRHAPHY ANTERIOR W/LABRAL REPAIR 3538.80 090 Y 11826.55  J1 23460 CAPSULORRHAPHY ANTERIOR WITH BONE BLOCK 3886.80 090 Y 11392.83  J1 23462 CAPSULORRHAPHY ANTERIOR W/CORACOID PROCESS TR 3802.80 090 Y 12209.09  J1 23465 CAPSULORRHAPHY GLENOHUMERAL JT PST W/WO BONE BLK 3987.60 090 Y 12005.35  J1 23466 CAPSULORRHAPHY GLENOHUMRL JT MULTI-DIRIONAL INS 3990.00 090 Y 12015.26  J1 23470 ARTHROPLASTY GLENOHUMRL JT HEMIARTHROPLASTY 4266.00 090 Y 21927.44  J1 23472 ARTHROPLASTY GLENOHUMERAL JOINT TOTAL SHOULDER 5139.60 090 Y 21387.82  J1 23473 REVIS SHOULDER ARTHRPLSTY HUMERAL/GLENOID COMPNT 5726.40 090 Y 22387.72  J1* 23474 REVIS SHOULDER ARTHRPLSTY HUMERAL&GLENOID COMPNT 6178.80 090 Y 22251.08  J1 23480 OSTEOTOMY CLAVICLE W/WO INTERNAL FIXATION 2929.20 090 N 12242.68  J1 23485 OSTEOTOMY CLAV W/WO INT FIXJ W/BONE GRF NON/MAL 3388.80 090 Y 22557.73  J1 23490 PROPH TX W/WO METHYLMETHACRYLATE CLAVICLE 3072.00 090 Y 11589.22  J1 23491 PROPH TX W/WO METHYLMETHACRYLATE PROX HUMERUS 3622.80 090 Y 23046.98   23500 CLSD TX CLAVICULAR FRACTURE W/O MANIPULATION 802.80 090 N 298.91  J1 23505 CLSD TX CLAVICULAR FRACTURE W/MANIPULATION 1299.60 090 N 2833.78  J1 23515 OPEN TX CLAVICULAR FRACTURE INTERNAL FIXATION 2571.60 090 Y 11593.06  J1 23520 CLSD TX STERNOCLAVICULAR DISLC W/O MANIPULATION 870.00 090 N 2845.02   23525 CLOSED TX STERNOCLAVICULAR DISLC W/MANIPULATION 1429.20 090 N 298.91  J1 23530 OPEN TX STERNOCLAVICULAR DISLC ACUTE/CHRONIC 2064.00 090 Y 12289.70  J1 23532 OPTX STRNCLAV DISLC ACUTE/CHRONIC W/FASCIAL GRF 2242.80 090 Y 11586.34   23540 CLSD TX ACROMIOCLAVICULAR DISLC W/O MANIPULATION 862.80 090 N 298.91   23545 CLSD TX ACROMIOCLAVICULAR DISLC W/MANIPULATION 1269.60 090 N 298.91  J1 23550 OPEN TX ACROMIOCLAVICULAR DISLC ACUTE/CHRONIC 2048.40 090 Y 11760.02  J1 23552 OPTX ACROMCLAV DISLC ACUTE/CHRONIC W/FASCIAL GRF 2340.00 090 Y 11610.33   23570 CLOSED TX SCAPULAR FRACTURE W/O MANIPULATION 848.40 090 N 298.91  J1 23575 CLTX SCAPULAR FX W/MNPJ W/WO SKELETAL TRACTION 1483.20 090 N 2845.02  J1 23585 OPEN TX SCAPULAR FX W/INT FIXATION WHEN PFRMD 3488.40 090 Y 11732.51   23600 CLTX PROXIMAL HUMERAL FRACTURE W/O MANIPULATION 1204.80 090 N 298.91  J1 23605 CLTX PROX HUMRL FX W/MNPJ W/WO SKELETAL TRACJ 1694.40 090 N 2825.68  J1 23615 OPTX PROX HUMERAL FX W/INT FIXJ RPR TUBEROSITY 3151.20 090 Y 22440.62  J1 23616 OPTX PROX HUMRL FX W/INT FIXJ RPR TUBRST RPLCMT 4392.00 090 Y 28882.69   23620 CLTX GREATER HUMERAL TUBEROSITY FX W/O MNPJ 979.20 090 N 298.91  J1 23625 CLTX GREATER HUMRL TUBEROSITY FX W/MANIPULATION 1388.40 090 N 2838.41  J1 23630 OPTX GREATER HUMERAL TUBEROSITY FX W/INT FIXJ 2779.20 090 Y 11812.16   23650 CLSD TX SHOULDER DISLC W/MANIPULATION W/O ANES 1180.80 090 N 298.91  J1 23655 CLSD TX SHOULDER DISLC W/MANIPULATION REQ ANES 1472.40 090 N 2844.52  J1 23660 OPEN TX ACUTE SHOULDER DISLOCATION 2091.60 090 Y 12363.90  J1 23665 CLTX SHOULDER DISLC W/FX HUMERAL TUBRST W/MNPJ 1564.80 090 N 2844.95  J1 23670 OPTX SHO DISLC W/FX GR HUMERAL TUBRST INT FIXJ 3098.40 090 Y 11902.99  J1 23675 CLTX SHOULDER DISLC W/SURG/ANTMCL NECK FX W/MNPJ 1986.00 090 N 2845.02  J1 23680 OPTX SHO DISLC W/SURG/ANTMCL NECK FX INT FIXJ 3306.00 090 Y 22512.40

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 114 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 23700 MNPJ W/ANES SHOULDER JT APPL FIXATION APPARATUS 699.60 010 N 2842.89  J1 23800 ARTHRODESIS GLENOHUMERAL JOINT 3660.00 090 Y 11785.29  J1 23802 ARTHRODESIS GLENOHUMERAL JT W/AUTOGENOUS GRAFT 4562.40 090 Y 23225.18  J1* 23900 INTERTHORACOSCAPULAR AMPUTATION 4923.60 090 Y 22251.08  J1* 23920 DISARTICULATION SHOULDER 3996.00 090 Y 22251.08   23921 DISRTCJ SHOULDER SECONDARY CLSR/SCAR REVISION 1686.00 090 N 2483.95   23929 UNLISTED PROCEDURE SHOULDER BR YYY Y 298.91  J1 23930 I&D UPPER ARM/ELBOW DEEP ABSCESS/HEMATOMA 1309.20 010 N 4835.60  J1 23931 INCISION&DRAINAGE UPPER ARM/ELBOW BURSA 1099.20 010 N 2872.19  J1 23935 INC DEEP W/OPENING BONE CORTEX HUMERUS/ELBOW 1825.20 090 N 5739.01  J1 24000 ARTHRT ELBOW W/EXPLORATION DRAINAGE/REMOVAL FB 1695.60 090 N 5715.58  J1 24006 ARTHRT ELBOW CAPSULAR EXCISION CAPSULAR RLS SPX 2545.20 090 Y 5745.23  J1 24065 BIOPSY SOFT TISSUE UPPER ARM/ELBOW SUPERFICIAL 940.80 010 N 2872.47  J1 24066 BIOPSY SOFT TISSUE UPPER ARM/ELBOW AREA DEEP 2236.80 090 N 4831.84  J1 24071 EXC TUMOR SOFT TISSUE UPPER ARM/ELBOW SUBQ 3CM/> 1453.20 090 Y 4841.17  J1 24073 EXC TUMOR SOFT TISS UPPER ARM/ELBW SUBFASC 5CM/> 2475.60 090 Y 4838.02  J1 24075 EXC TUMOR SOFT TISS UPPER ARM/ELBOW SUBQ <3CM 1942.80 090 N 2873.34  J1 24076 EXC TUMOR SOFT TISS UPR ARM/ELBOW SUBFASC <5CM 1950.00 090 N 4840.08  J1 24077 RAD RESCJ TUMOR SOFT TISS UPPER ARM/ELBOW <5CM 3681.60 090 N 4842.25  J1 24079 RAD RESCJ TUMOR SOFT TISS UPPER ARM/ELBOW 5CM+ 4714.80 090 Y 4841.29  J1 24100 ARTHROTOMY ELBOW W/SYNOVIAL BIOPSY ONLY 1506.00 090 Y 5784.56  J1 24101 ARTHRT ELBOW W/JT EXPL W/WOBX W/O RMVL LOOSE/FB 1806.00 090 Y 5730.91  J1 24102 ARTHROTOMY ELBOW W/SYNOVECTOMY 2215.20 090 Y 5717.46  J1 24105 EXCISION OLECRANON BURSA 1290.00 090 N 5781.24  J1 24110 EXCISION/CURTG BONE CYST/BENIGN TUMOR HUMERUS 2114.40 090 N 5779.21  J1 24115 EXC/CURTG BONE CYST/BENIGN TUMOR HUMERUS W/AGRFT 2636.40 090 Y 12431.07  J1 24116 EXC/CURTG BONE CYST/BENIGN TUM HUMERUS W/ALGRFT 3070.80 090 Y 11773.77  J1 24120 EXC/CURTG BONE CYST/BENIGN TUMOR H/N RDS/OLECRN 1909.20 090 N 5778.05  J1 24125 EXC/CURTG BONE CST/B9 TUM H/N RDS/OLECRN W/AGRFT 2232.00 090 Y 5710.81  J1 24126 EXC/CURTG BONE CST/B9 TUM H/N RDS/OLECRN W/ALGRT 2330.40 090 Y 11195.48  J1 24130 EXCISION RADIAL HEAD 1826.40 090 N 5759.40  J1 24134 SEQUESTRECTOMY SHAFT/DISTAL HUMERUS 2672.40 090 Y 12531.82  J1 24136 SEQUESTRECTOMY RADIAL HEAD OR NECK 2265.60 090 N 5710.81  J1 24138 SEQUESTRECTOMY OLECRANON PROCESS 2461.20 090 Y 12794.10  J1 24140 PARTIAL EXCISION BONE HUMERUS 2515.20 090 Y 5742.62  J1 24145 PARTIAL EXCISION BONE RADIAL HEAD/NECK 2131.20 090 N 12794.10  J1 24147 PARTIAL EXCISION BONE OLECRANON PROCESS 2251.20 090 N 5771.26  J1 24149 RAD RESCJ CAPSL TISS&HTRTPC B1 ELBW CONTRCT RLS 4191.60 090 Y 12728.21  J1 24150 RADICAL RESECTION TUMOR SHAFT/DISTAL HUMERUS 5487.60 090 Y 12554.85  J1 24152 RADICAL RESECTION TUMOR RADIAL HEAD/NECK 4772.40 090 Y 12794.10  J1 24155 RESECTION ELBOW JOINT ARTHRECTOMY 3042.00 090 Y 5784.56   24160 PROSTHESIS REMOVAL HUMERAL AND ULNAR COMPONENTS 4448.40 090 N 4107.04   24164 PROSTHESIS REMOVAL RADIAL HEAD 2588.40 090 N 4107.04  J1 24200 RMVL FOREIGN BODY UPPER ARM/ELBOW SUBCUTANEOUS 790.80 010 N 2872.76  J1 24201 REMOVAL FOREIGN BODY UPPER ARM/ELBOW DEEP 1977.60 090 N 4841.04   24220 INJECTION PROCEDURE FOR ELBOW ARTHROGRAPHY 649.98 000 N  J1 24300 MANIPULATION ELBOW UNDER ANESTHESIA 1562.40 090 N 2845.02

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 24301 MUSCLE/TENDON TRANSFER UPPER ARM/ELBOW SINGLE 2680.80 090 Y 12569.57  J1 24305 TENDON LENGTHENING UPPER ARM/ELBOW EA TENDON 2072.40 090 N 5726.57  J1 24310 TENOTOMY OPEN ELBOW TO SHOULDER EACH TENDON 1706.40 090 N 5699.10  J1 24320 TENOPLASTY ELBOW TO SHOULDER SINGLE 2787.60 090 Y 12031.89  J1 24330 FLEXOR-PLASTY ELBOW 2568.00 090 Y 11975.60  J1 24331 FLEXOR-PLASTY ELBOW W/EXTENSOR ADVANCEMENT 2806.80 090 Y 12031.89  J1 24332 TENOLYSIS TRICEPS 2204.40 090 N 5784.56  J1 24340 TENODESIS BICEPS TENDON ELBOW SEPARATE PROCEDURE 2214.00 090 Y 12155.04  J1 24341 REPAIR TENDON/MUSCLE UPPER ARM/ELBOW EA TDN/MUSC 2658.00 090 Y 12165.59  J1 24342 RINSJ RPTD BICEPS/TRICEPS TDN DSTL W/WO TDN GRF 2768.40 090 Y 12075.07  J1 24343 REPAIR LATERAL COLLATERAL LIGAMENT ELBOW 2552.40 090 Y 5453.97  J1 24344 RCNSTJ LAT COLTRL LIGM ELBOW W/TENDON GRAFT 3898.80 090 Y 11733.47  J1 24345 REPAIR MEDIAL COLLATERAL LIGAMENT ELBOW 2540.40 090 Y 11945.85  J1 24346 RCNSTJ MEDIAL COLTRL LIGM ELBW W/TDN GRF 3934.80 090 Y 23371.26  J1 24357 TENOTOMY ELBOW LATERAL/MEDIAL PERCUTANEOUS 1500.00 090 N 5728.89  J1 24358 TNOT ELBOW LATERAL/MEDIAL DEBRIDE OPEN 1894.80 090 N 5754.48  J1 24359 TNOT ELBOW LATERAL/MEDIAL DEBRIDE OPEN TDN RPR 2367.60 090 N 5632.43  J1 24360 ARTHROPLASTY ELBOW W/MEMBRANE 3224.40 090 Y 11379.08  J1 24361 ARTHROPLASTY ELBOW W/DISTAL HUMRL PROSTC RPLCMT 3595.20 090 Y 27883.64  J1 24362 ARTHRP ELBOW W/IMPLT&FSCA LATA LIGAMENT RCNSTJ 3782.40 090 Y 21365.15  J1 24363 ARTHRP ELBOW W/DISTAL HUM&PROX UR PROSTC RPLCM 5138.40 090 Y 28156.11  J1 24365 ARTHROPLASTY RADIAL HEAD 2296.80 090 Y 22251.09  J1 24366 ARTHROPLASTY RADIAL HEAD W/IMPLANT 2436.00 090 Y 21695.09  J1 24370 REVIS ELBOW ARTHRPLSTY HUMERAL/ULNA COMPNT 5460.00 090 Y 22402.21  J1 24371 REVIS ELBOW ARTHRPLSTY HUMERAL&ULNA COMPNT 6272.40 090 Y 29190.67  J1 24400 OSTEOTOMY HUMERUS W/WO INTERNAL FIXATION 2947.20 090 Y 12041.17  J1 24410 MLT OSTEOT W/RELIGNMT IMED ROD HUMERAL SHAFT 3771.60 090 Y 22251.08  J1 24420 OSTEOPLASTY HUMERUS 3820.80 090 Y 11725.48  J1 24430 REPAIR NON/MALUNION HUMERUS W/O GRAFT 3756.00 090 Y 22614.40  J1 24435 REPAIR NON/MALUNION HUMERUS W/ILIAC/OTH AGRFT 3847.20 090 Y 22579.77  J1 24470 HEMIEPIPHYSEAL ARREST 2407.20 090 Y 5710.81  J1 24495 DECOMPRESSION FASCT F/ARM W/BRACH ART EXPL 2907.60 090 N 12782.59  J1 24498 PROPH TX W/WO METHYLMETHACRYLATE HUMERAL SHAFT 3092.40 090 Y 22954.42   24500 CLSD TX HUMERAL SHAFT FRACTURE W/O MANIPULATION 1306.80 090 N 298.91  J1 24505 CLTX HUMERAL SHFT FX W/MANJ W/WO SKELETAL TRACJ 1816.80 090 N 2843.03  J1 24515 OPTX HUMERAL SHFT FX W/PLATE/SCREWS W/WOCERCLAGE 3145.20 090 Y 22885.79  J1 24516 TX HUMRAL SHAFT FX W/INSJ IMED IMPLT W/W CERCLGE 3066.00 090 Y 22729.00   24530 CLTX SPRCNDYLR/TRANSCNDYLR HUMERAL FX W/WO MANJ 1380.00 090 N 298.91  J1 24535 CLTX SPRCNDYLR/TRANSCNDYLR HUMERAL FX W/MANJ 2224.80 090 N 2845.02  J1 24538 PRQ SKEL FIXJ SPRCNDYLR/TRANSCNDYLR HUMERAL FX 2836.80 090 N 12458.58  J1 24545 OPEN TX HUMERAL SUPRACONDYLAR FRACTURE W/O XTN 3309.60 090 Y 22499.17  J1 24546 OPEN TX HUMERAL SUPRACONDYLAR FRACTURE W/XTN 3692.40 090 Y 29306.26   24560 CLTX HUMERAL EPICONDYLAR FX MEDIAL/LAT W/O MANJ 1203.60 090 N 298.91  J1 24565 CLTX HUMERAL EPICONDYLAR FX MEDIAL/LAT W/MANJ 1950.00 090 N 2845.02  J1 24566 PRQ SKEL FIXJ HUMRL EPCNDYLR FX MEDIAL/LAT MANJ 2577.60 090 N 2842.96  J1 24575 OPEN TX HUMERAL EPICONDYLAR FRACTURE 2616.00 090 Y 22892.09   24576 CLTX HUMERAL CONDYLAR FX MEDIAL/LAT W/O MANJ 1269.60 090 N 298.91

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 116 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 24577 CLTX HUMERAL CONDYLAR FX MEDIAL/LATERAL W/MANJ 2005.20 090 N 2845.02  J1 24579 OPEN TREATMENT HUMERAL CONDYLAR FRACTURE 2973.60 090 Y 22986.53  J1 24582 PRQ SKEL FIXJ HUMRL CNDYLR FX MEDIAL/LAT W/MANJ 2918.40 090 N 12666.16  J1 24586 OPTX PERIARTICULAR FRACTURE &/DISLOCATION ELBO 3870.00 090 Y 22678.00  J1 24587 OPTX PRIARTICULAR FX&/DISLC ELBW W/IMPLT ARTHR 3879.60 090 Y 22093.04   24600 TREATMENT CLOSED ELBOW DISLOCATION W/O ANES 1352.40 090 N 298.91  J1 24605 TREATMENT CLOSED ELBOW DISLOCATION REQ ANES 1719.60 090 N 2844.81  J1 24615 OPEN TX ACUTE/CHRONIC ELBOW DISLOCATION 2550.00 090 Y 11773.45  J1 24620 CLOSED TX MONTEGGIA FX DISLOCATION ELBOW W/MANJ 2024.40 090 N 2845.02  J1 24635 OPEN TX MONTEGGIA FRACTURE DISLOCATION ELBOW 2412.00 090 Y 11713.64   24640 CLTX RDL HEAD SUBLXTJ CHLD NURSEMAID ELBW W/MANJ 373.20 010 N 298.91   24650 CLOSED TX RADIAL HEAD/NECK FX W/O MANIPULATION 951.60 090 N 298.91  J1 24655 CLOSED TX RADIAL HEAD/NECK FX W/MANIPULATION 1614.00 090 N 2843.32  J1 24665 OPEN TX RADIAL HEAD/NECK FRACTURE 2353.20 090 Y 11831.99  J1 24666 OPEN TX RADIAL HEAD/NECK FRACTURE PROSTHETIC 2614.80 090 Y 21556.57   24670 CLOSED TX ULNAR FRACTURE PROXIMAL END W/O MANJ 1058.40 090 N 298.91  J1 24675 CLOSED TX ULNAR FRACTURE PROXIMAL END W/MANJ 1676.40 090 N 2838.62  J1 24685 OPEN TREATMENT ULNAR FRACTURE PROXIMAL END 2337.60 090 Y 11752.98  J1 24800 ARTHRODESIS ELBOW JOINT LOCAL 2977.20 090 Y 11452.32  J1 24802 ARTHRODESIS ELBOW JOINT W/AUTOGENOUS GRAFT 3577.20 090 Y 22593.62  J1* 24900 AMPUTATION ARM THRU HUMERUS W/PRIMARY CLOSURE 2637.60 090 Y 22251.08  J1* 24920 AMPUTATION ARM THRU HUMERUS OPEN CIRCULAR 2619.60 090 Y 22251.08  J1 24925 AMP ARM THRU HUMERUS SECONDARY CLSR/SCAR REVJ 2038.80 090 Y 5784.56  J1* 24930 AMPUTATION ARM THRU HUMERUS RE-AMPUTATION 2764.80 090 Y 12031.89  J1* 24931 AMPUTATION ARM THRU HUMERUS W/IMPLANT 3320.40 090 Y 22251.08  J1 24935 STUMP ELONGATION UPPER EXTREMITY 4378.80 090 N 12031.89  J1* 24940 CINEPLASTY UPPER EXTREMITY COMPLETE PROCEDURE 3307.89 090 Y 22251.08   24999 UNLISTED PROCEDURE HUMERUS/ELBOW BR YYY N 298.91  J1 25000 INCISION EXTENSOR TENDON SHEATH WRIST 1236.00 090 N 2844.10  J1 25001 INCISION FLEXOR TENDON SHEATH WRIST 1240.80 090 N 5740.31  J1 25020 DCMPRN FASCT F/ARM&WRST FLXR/XTNSR W/O DBRDMT 2267.34 090 N 2844.67  J1 25023 DCMPRN FASCT F/ARM&/WRST FLXR/XTNSR W/DBRDMT 4392.54 090 N 5784.56  J1 25024 DCMPRN FASCT F/ARM&/WRST FLXR&XTNSR W/O DB 2793.60 090 N 5784.56  J1 25025 DCMPRN FASCT F/ARM&/WRST FLXR&XTNSR DBRDMT 4198.80 090 N 2842.96  J1 25028 I&D FOREARM&/WRIST DEEP ABSCESS/HEMATOMA 2087.94 090 N 5772.56  J1 25031 INCISION & DRAINAGE FOREARM&/WRIST BURSA 1323.60 090 N 2845.02  J1 25035 INCISION DEEP BONE CORTEX FOREARM&/WRIST 2096.40 090 N 12774.91  J1 25040 ARTHRT RDCRPL/MIDCARPL JT W/EXPL DRG/RMVL FB 2000.40 090 N 5784.56  J1 25065 BIOPSY SOFT TISSUE FOREARM&/WRIST SUPERFICIAL 926.40 010 N 2858.18  J1 25066 BIOPSY SOFT TISSUE FOREARM&/WRIST DEEP 1310.40 090 N 4840.56  J1 25071 EXC TUMOR SOFT TISS FOREARM AND/WRIST SUBQ 3CM/> 1516.80 090 Y 2871.11  J1 25073 EXC TUMOR SFT TISS FOREARM&/WRIST SUBFASC 3CM/> 1911.60 090 Y 4838.38  J1 25075 EXC TUMOR SOFT TISSUE FOREARM &/WRIST SUBQ <3CM 1891.20 090 N 2872.98  J1 25076 EXC TUMOR SOFT TISS FOREARM&/WRIST SUBFASC <3CM 1848.00 090 N 2868.23  J1 25077 RAD RESECT TUMOR SOFT TISS FOREARM&/WRIST <3 CM 3178.80 090 N 4843.10  J1 25078 RAD RESCJ TUM SOFT TISSUE FOREARM&/WRIST 3 CM/> 4141.20 090 Y 4833.66  J1 25085 CAPSULOTOMY WRIST 1605.60 090 Y 5732.50

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 25100 ARTHROTOMY WRIST JOINT WITH BIOPSY 1258.80 090 N 5782.10  J1 25101 ARTHRT WRST W/JT EXPL W/WO BX W/WO RMVL LOOSE/FB 1453.20 090 N 5767.50  J1 25105 ARTHROTOMY WRIST JOINT WITH SYNOVECTOMY 1742.40 090 N 5754.92  J1 25107 ARTHROTOMY DSTL RADIOULNAR JOINT RPR CARTILAGE 2204.40 090 Y 5672.34  J1 25109 EXC TENDON FOREARM&/WRIST FLEXOR/EXTENSOR EA 1915.20 090 N 5753.04  J1 25110 EXCISION LESION TENDON SHEATH FOREARM&/WRIST 1244.40 090 N 2842.32  J1 25111 EXCISION GANGLION WRIST DORSAL/VOLAR PRIMARY 1161.60 090 N 2843.81  J1 25112 EXCISION GANGLION WRIST DORSAL/VOLAR RECURRENT 1398.00 090 N 2842.32  J1 25115 RAD EXC BURSA SYNVA WRST/F/ARM TDN SHTHS FLXRS 2692.80 090 N 2835.78  J1 25116 RAD EXC BURSA SYNVA WRST/F/ARM TDN SHTHS XTNSRS 2154.00 090 N 5772.41  J1 25118 SYNOVECTOMY EXTENSOR TENDON SHTH WRIST 1 CMPRT 1371.60 090 N 2845.02  J1 25119 SYNVCT XTNSR TDN SHTH WRST 1 RESCJ DSTL ULNA 1802.40 090 Y 5755.93  J1 25120 EXCISION/CURETTAGE CYST/TUMOR RADIUS/ULNA 1796.40 090 N 5737.13  J1 25125 EXC/CURTG CYST/TUMOR RADIUS/ULNA W/AUTOGRAFT 2133.60 090 N 2845.02  J1 25126 EXC/CURTG CYST/TUMOR RADIUS/ULNA W/ALLOGRAFT 2149.20 090 Y 5519.05  J1 25130 EXCISION/CURETTAGE CYST/TUMOR CARPAL BONES 1616.40 090 N 5721.51  J1 25135 EXC/CURTG CYST/TUMOR CARPAL BONES W/AUTOGRAFT 2010.00 090 Y 12429.15  J1 25136 EXC/CURTG CYST/TUMOR CARPAL BONES W/ALLOGRAFT 1788.00 090 Y 11989.99  J1 25145 SEQUESTRECTOMY FOREARM &/WRIST 1869.60 090 Y 5715.58  J1 25150 PARTIAL EXCISION BONE ULNA 2032.80 090 N 5735.39  J1 25151 PARTIAL EXCISION BONE RADIUS 2091.60 090 Y 5750.43  J1 25170 RADICAL RESECTION TUMOR RADIUS OR ULNA 5218.80 090 Y 12794.10  J1 25210 CARPECTOMY 1 BONE 1761.60 090 N 5696.93  J1 25215 CARPECTOMY ALL BONES PROXIMAL ROW 2211.60 090 Y 5666.41  J1 25230 RADICAL STYLOIDECTOMY SEPARATE PROCEDURE 1550.40 090 N 5740.60  J1 25240 EXCISION DISTAL ULNA PARTIAL/COMPLETE 1538.40 090 N 5743.20   25246 INJECTION WRIST ARTHROGRAPHY 673.44 000 N  J1 25248 EXPL W/REMOVAL DEEP FOREIGN BODY FOREARM/WRIST 1506.00 090 N 2843.46   25250 REMOVAL WRIST PROSTHESIS SEPARATE PROCEDURE 1916.40 090 Y 2019.96   25251 REMOVAL WRIST PROSTH COMPLICATED W/TOTAL WRIST 2572.80 090 Y 4107.04  J1 25259 MANIPULATION WRIST UNDER ANESTHESIA 1544.40 090 N 2844.81  J1 25260 RPR TDN/MUSC FLXR F/ARM&/WRST PRIM 1 EA TDN/MU 2269.20 090 N 5747.83  J1 25263 RPR TDN/MUSC FLXR F/ARM&/WRIST SEC 1 EA TDN/MUS 2272.80 090 Y 12667.12  J1 25265 RPR TDN/MUSC FLXR F/ARM&/WRISTSEC FR GRF EA 2680.80 090 Y 5784.56  J1 25270 RPR TDN/MUSC XTNSR F/ARM&/WRIST PRIM 1 EA TDN 1768.80 090 N 5734.67  J1 25272 RPR TDN/MUSC XTNSR F/ARM&/WRIST SEC 1 EA TDN/MU 2007.60 090 N 5724.11  J1 25274 RPR TDN/MUSC XTNSR F/ARM&/WRST SEC FR GRF EA TDN 2374.80 090 N 5635.32  J1 25275 RPR TENDON SHEATH EXTENSOR F/ARM&/WRIST W/GRAFT 2401.20 090 N 5666.70  J1 25280 LNGTH/SHRT FLXR/XTNSR TDN F/ARM&/WRIST 1 EA TDN 2026.80 090 N 5724.55  J1 25290 TNOT FLXR/XTNSR TENDON FOREARM&/WRIST 1 EA 1562.40 090 N 5741.32  J1 25295 TNOLS FLXR/XTNSR TENDON FOREARM&/WRIST 1 EA 1886.40 090 N 5752.60  J1 25300 TENODESIS WRIST FLEXORS FINGERS 2470.80 090 Y 5770.97  J1 25301 TENODESIS WRIST EXTENSORS FINGERS 2296.80 090 Y 5784.13  J1 25310 TDN TRNSPLJ/TR FLXR/XTNSR F/ARM&/WRST 1 EA TDN 2216.40 090 Y 5754.19  J1 25312 TDN TRNSPLJ/TR FLXR/XTNSR F/ARM&/WRST 1/TDN GR 2554.80 090 Y 5674.80  J1 25315 FLEXOR ORIGIN SLIDE FOREARM &/WRIST 2751.60 090 Y 12644.09  J1 25316 FLEXOR ORIGIN SLIDE F/ARM&/WRST TENDON TRANSFE 3272.40 090 Y 12535.66

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 118 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 25320 CAPSL-RHPHY/RCNSTJ WRST OPN CARPL INS 3505.20 090 Y 12085.31  J1 25332 ARTHRP WRST W/WO INTERPOS W/WO XTRNL/INT FIXJ 3012.00 090 Y 5462.07  J1 25335 CENTRALIZATION OF WRIST ON ULNA 3374.40 090 Y 5628.23  J1 25337 RCNSTJ STABLJ DSTL U/DSTL JT 2 SOFT TISS STABLJ 3154.80 090 N 12115.06  J1 25350 OSTEOTOMY RADIUS DISTAL THIRD 2409.60 090 Y 11418.74  J1 25355 OSTEOTOMY RADIUS MIDDLE/PROXIMAL THIRD 2736.00 090 Y 5710.81  J1 25360 OSTEOTOMY ULNA 2343.60 090 Y 11951.61  J1 25365 OSTEOTOMY RADIUS & ULNA 3276.00 090 Y 23162.84  J1 25370 MLT OSTEOTOMIES W/RELIGNMT IMED ROD RADIUS/ULNA 3613.20 090 Y 5710.81  J1 25375 MLT OSTEOTOMIES W/RELIGNMT IMED ROD RADIUS&ULNA 3406.80 090 Y 5710.81  J1 25390 OSTEOPLASTY RADIUS/ULNA SHORTENING 2743.20 090 Y 11659.27  J1 25391 OSTEOPLASTY RADIUS/ULNA LENGTHENING W/AUTOGRAFT 3555.60 090 Y 22229.68  J1 25392 OSTEOPLASTY RADIUS & ULNA SHORTENING 3616.80 090 Y 12063.24  J1 25393 OSTEOPLASTY RADIUS&ULNA LENGTHENING W/AUTOGRAF 4024.80 090 Y 11757.46  J1 25394 OSTEOPLASTY CARPAL BONE SHORTENING 2803.20 090 Y 5532.36  J1 25400 RPR NONUNION/MALUNION RADIUS/ULNA W/O AUTOGRAFT 2863.20 090 Y 11510.53  J1 25405 RPR NONUNION/MALUNION RADIUS/ULNA W/AUTOGRAFT 3697.20 090 Y 11539.00  J1 25415 RPR NONUNION/MALUNION RADIUS&ULNA W/O AUTOGRAF 3457.20 090 Y 11370.76  J1 25420 RPR NONUNION/MALUNION RADIUS&ULNA W/AUTOGRAFT 4155.60 090 Y 11340.69  J1 25425 REPAIR DEFECT W/AUTOGRAFT RADIUS/ULNA 3442.80 090 Y 12395.25  J1 25426 REPAIR DEFECT W/AUTOGRAFT RADIUS&ULNA 4002.00 090 Y 5249.35  J1 25430 INSERTION VASCULAR PEDICLE CARPAL BONE 2616.00 090 N 5773.57  J1 25431 REPAIR NONUNION CARPAL BONE EACH BONE 2814.00 090 Y 11997.35  J1 25440 RPR NONUNION SCAPHOID CARPAL B1 W/WO RDL STYLODC 2738.40 090 Y 12163.67  J1 25441 ARTHROPLASTY W/PROSTHETIC RPLCMT DISTAL RADIUS 3349.20 090 Y 21904.77  J1 25442 ARTHROPLASTY W/PROSTHETIC RPLCMT DISTAL ULNA 2888.40 090 Y 27895.20  J1 25443 ARTHROPLASTY W/PROSTHETIC RPLCMT SCAPHOID CARPAL 2806.80 090 Y 11379.71  J1 25444 ARTHROPLASTY W/PROSTHETIC REPLACEMENT LUNATE 2956.80 090 Y 21162.40  J1 25445 ARTHROPLASTY W/PROSTHETIC REPLACEMENT TRAPEZIUM 2566.80 090 N 11345.17  J1 25446 ARTHRP W/PROSTC RPLCMT DSTL RDS&PRTL/ENTIR CARPS 4161.60 090 Y 27536.03  J1 25447 ARTHRP INTERCARPAL/CARP/MTCRPL JT INTERPOSITION 2961.60 090 Y 5586.73  J1 25448 ARTHRP INTERCARPAL/CARP/MTCRPL JT SUSPENSION 3256.80 090 Y 6387.66  J1 25449 REVJ ARTHRP W/REMOVAL IMPLANT WRIST JOINT 3679.20 090 Y 11651.27  J1 25450 EPIPHYSL ARRST EPIPHYSIOD/STAPLING DSTL RDS/ULNA 2214.00 090 N 5710.81  J1 25455 EPIPHYSL ARRST EPIPHYSIOD/STAPLING DSTL RDS&ULNA 2616.00 090 N 5710.81  J1 25490 PROPH TX W/WO METHYLMETHACRYLATE RADIUS 2571.60 090 Y 11945.85  J1 25491 PROPH TX W/WO METHYLMETHACRYLATE ULNA 2643.60 090 Y 22799.52  J1 25492 PROPH TX W/WO METHYLMETHACRYLATE RADIUS&ULNA 3238.80 090 Y 5677.84   25500 CLOSED TX RADIAL SHAFT FRACTURE W/O MANIPULATION 1028.40 090 N 298.91  J1 25505 CLOSED TX RADIAL SHAFT FRACTURE W/MANIPULATION 1821.60 090 N 2845.02  J1 25515 OPEN TREATMENT RADIAL SHAFT FRACTURE W/INT FIXJ 2394.00 090 Y 11685.81  J1 25520 CLTX RDL SHFT FX&CLTX DISLC DSTL RAD/ULN JT 2079.60 090 N 2845.02  J1 25525 OPTX RDL SHAFT FX&CLTX DSTL RAD/ULN JT DISLC 2814.00 090 Y 11762.90  J1 25526 OPTX RDL SHAFT FX&OPTX DSTL RAD/ULN JT DISLC 3412.80 090 Y 11688.05   25530 CLOSED TX ULNAR SHAFT FRACTURE W/O MANIPULATION 951.60 090 N 298.91   25535 CLOSED TX ULNAR SHAFT FRACTURE W/MANIPULATION 1788.00 090 N 298.91  J1 25545 OPEN TREATMENT ULNAR SHAFT FRACTURE W/INT FIXJ 2234.40 090 Y 11805.76

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   25560 CLOSED TX RADIAL&ULNAR SHAFT FRACTURES W/O MNPJ 1048.80 090 N 298.91  J1 25565 CLOSED TX RADIAL&ULNAR SHAFT FRACTURES W/MNPJ 1874.40 090 N 2843.74  J1 25574 OPTX RADIAL&ULNAR SHFT FX W/INT FIXJ RADIUS/ULNA 2412.00 090 Y 11540.28  J1 25575 OPTX RADIAL&ULNAR SHFT FX W/INT FIXJ RADIUS&ULNA 3225.60 090 Y 11612.57   25600 CLTX DSTL RADIAL FX/EPIPHYSL SEP W/O MNPJ 1222.80 090 N 298.91  J1 25605 CLTX DSTL RDL FX/EPIPHYSL SEP W/MNPJ 1947.60 090 N 2844.60  J1 25606 PERQ SKEL FIXJ DISTAL RADIAL FX/EPIPHYSL SEP 2389.20 090 N 5698.81  J1 25607 OPTX DSTL RDL X-ARTIC FX/EPIPHYSL SEPARATION 2637.60 090 Y 11394.75  J1 25608 OPTX DSTL RADL I-ARTIC FX/EPIPHYSL SEP 2 FRAG 2952.00 090 Y 11405.94  J1 25609 OPTX DSTL RADL I-ARTIC FX/EPIPHYSL SEP 3+ FRAG 3746.40 090 Y 11377.16   25622 CLOSED TX CARPAL SCAPHOID FRACTURE W/O MNPJ 1111.20 090 N 298.91  J1 25624 CLOSED TX CARPAL SCAPHOID FRACTURE W/MNPJ 1772.40 090 N 2817.00  J1 25628 OPEN TX CARPAL SCAPHOID NAVICULAR FX W/INT FIXJ 2571.60 090 Y 12165.59   25630 CLTX CARPAL BONE FX W/O MNPJ EACH BONE 1104.00 090 N 298.91  J1 25635 CLTX CARPAL BONE FX W/MNPJ EACH BONE 1682.40 090 N 2845.02  J1 25645 OPEN TX CARPAL BONE FRACTURE OTH/THN SCAPHOID EA 2049.60 090 Y 5589.04   25650 CLOSED TREATMENT ULNAR STYLOID FRACTURE 1194.00 090 N 298.91  J1 25651 PERQ SKELETAL FIXATION ULNAR STYLOID FRACTURE 1752.00 090 N 5779.65  J1 25652 OPEN TREATMENT ULNAR STYLOID FRACTURE 2228.40 090 N 11818.23   25660 CLTX RDCRPL/INTERCARPL DISLC 1/> BONES W/MNPJ 1615.20 090 N 298.91  J1 25670 OPEN TX RADIOCARPAL/INTERCARPAL DISLC 1/> BONES 2180.40 090 Y 11575.14  J1 25671 PERQ SKELETAL FIXJ DISTAL RADIOULNAR DISLOCATION 1899.60 090 N 5779.36   25675 CLOSED TX DISTAL RADIOULNAR DISLOCATION W/MNPJ 1622.40 090 N 298.91  J1 25676 OPEN TX DISTAL RADIOULNAR DISLC ACUTE/CHRONIC 2257.20 090 Y 12545.58   25680 CLTX TRANS-SCAPHOPRILUNAR TYP FX DISLC W/MNPJ 1906.80 090 N 298.91  J1 25685 OPEN TX TRANS-SCAPHOPERILUNAR FRACTURE DISLC 2629.20 090 Y 11980.08  J1 25690 CLOSED TX LUNATE DISLOCATION W/MANIPULATION 1768.80 090 N 2845.02  J1 25695 OPEN TREATMENT LUNATE DISLOCATION 2274.00 090 Y 12289.06  J1 25800 ARTHRODESIS WRIST COMPLETE W/O BONE GRAFT 2612.40 090 Y 11420.34  J1 25805 ARTHRODESIS WRIST W/SLIDING GRAFT 3028.80 090 Y 11433.13  J1 25810 ARTHRODESIS WRIST W/ILIAC/OTHER AUTOGRAFT 3079.20 090 Y 22560.25  J1 25820 ARTHRODESIS WRIST LIMITED W/O BONE GRAFT 2331.60 090 Y 11613.85  J1 25825 ARTHRODESIS WRIST WITH AUTOGRAFT 2842.80 090 Y 11617.05  J1 25830 ARTHRD DSTL RAD/ULN JT SGMTL RSCJ ULNA W/WO BONE 3730.80 090 Y 11879.32  J1* 25900 AMPUTATION FOREARM THROUGH RADIUS & ULNA 2558.40 090 N 22251.08  J1* 25905 AMP FOREARM THRU RADIUS & ULNA OPEN CIRCULAR 2512.80 090 Y 22251.08  J1 25907 AMP F/ARM THRU RADIUS&ULNA SEC CLOSURE/SCAR RE 2202.00 090 Y 5784.56  J1 25909 AMP FOREARM THRU RADIUS&ULNA RE-AMPUTATION 2455.20 090 Y 12763.40  J1* 25915 KRUKENBERG PROCEDURE 4154.40 090 Y 12031.89  J1* 25920 DISARTICULATION THROUGH WRIST 2626.80 090 N 12031.89  J1 25922 DISARTICULATION THRU WRIST SEC CLOSURE/SCAR REVJ 2329.20 090 Y 2842.96  J1* 25924 DISARTICULATION THRU WRIST RE-AMPUTATION 2568.00 090 Y 12031.89  J1* 25927 TRANSMETACARPAL AMPUTATION 3132.00 090 N 5710.81   25929 TRANSMETACARPAL AMPUTATION SEC CLOSURE/SCAR REVJ 2148.00 090 Y 2483.95  J1 25931 TRANSMETACARPAL AMPUTATION RE-AMPUTATION 2904.00 090 N 5767.50   25999 UNLISTED PROCEDURE FOREARM/WRIST BR YYY N 298.91   26010 DRAINAGE FINGER ABSCESS SIMPLE 1068.12 010 N 260.43

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 120 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 26011 DRAINAGE FINGER ABSCESS COMPLICATED 1585.62 010 N 2873.55  J1 26020 DRAINAGE TENDON SHEATH DIGIT&/PALM EACH 1722.24 090 N 5782.97  J1 26025 DRAINAGE OF PALMAR BURSA SINGLE BURSA 1507.20 090 N 5784.56  J1 26030 DRAINAGE OF PALMAR BURSA MULTIPLE BURSA 1755.60 090 N 5784.56  J1 26034 INCISION BONE CORTEX HAND/FINGER 1975.20 090 N 2808.46  J1 26035 DECOMPRESSION FINGERS&/HAND INJECTION INJURY 3073.20 090 N 5784.56  J1 26037 DECOMPRESSIVE FASCIOTOMY HAND 2002.80 090 N 5783.84  J1 26040 FASCIOTOMY PALMAR PERCUTANEOUS 1131.60 090 N 2845.02  J1 26045 FASCIOTOMY PALMAR OPEN PARTIAL 1692.00 090 N 5782.25  J1 26055 TENDON SHEATH INCISION 2154.00 090 N 2844.52  J1 26060 TENOTOMY PERCUTANEOUS SINGLE EACH DIGIT 919.20 090 N 2843.24  J1 26070 ARTHRT EXPL DRG/RMVL LOOSE/FB CARP/MTCRPL JT 1149.60 090 N 2839.55  J1 26075 ARTHRT EXPL DRG/RMVL LOOSE/FB MTCARPHLNGL JT EA 1210.80 090 N 5772.27  J1 26080 ARTHRT EXPL DRG/RMVL LOOSE/FB IPHAL JT EA 1429.20 090 N 2843.96  J1 26100 ARTHROTOMY BIOPSY CARP/MTCRPL JOINT EACH 1219.20 090 N 5727.58  J1 26105 ARTHROTOMY BIOPSY MTCARPHLNGL JOINT EACH 1227.60 090 N 5783.41  J1 26110 ARTHROTOMY BIOPSY INTERPHALANGEAL JOINT EACH 1167.60 090 N 2842.25  J1 26111 EX TUM/VASC MALF SFT TISS HAND/FNGR SUBQ 1.5CM/> 1482.00 090 Y 2872.62  J1 26113 EX TUM/VASC MAL SFT TIS HAND/FNGR SUBFSC 1.5CM/> 1948.80 090 Y 2870.61  J1 26115 EXC TUM/VASC MAL SFT TISS HAND/FNGR SUBQ <1.5CM 1988.40 090 N 2871.68  J1 26116 EXC TUM/VAS MAL SFT TIS HAND/FNGR SUBFASC<1.5CM 1873.20 090 N 2871.18  J1 26117 RAD RESECT TUMOR SOFT TISSUE HAND/FINGER <3CM 2630.40 090 N 4829.42  J1 26118 RAD RESCJ TUM SOFT TISSUE HAND/FINGER 3 CM/> 3758.40 090 Y 4843.10  J1 26121 FASCT PALM W/WO Z-PLASTY TISSUE REARGMT/SKN GRFT 2142.00 090 N 5779.21  J1 26123 FASCT PRTL PALMAR 1 DGT PROX IPHAL JT W/WO RPR 2983.20 090 N 5777.77   26125 FASCT PRTL PALMR ADDL DGT PROX IPHAL JT W/WO RPR 951.60 ZZZ N  J1 26130 SYNOVECTOMY CARPOMETACARPAL JOINT 1684.80 090 N 5666.85  J1 26135 SYNVCT MTCARPHLNGL JT W/INTRNSC RLS&XTNSR HOOD 1984.80 090 N 5736.98  J1 26140 SYNVCT PROX IPHAL JT W/XTNSR RCNSTJ EA IPHAL JT 1818.00 090 N 2840.40  J1 26145 SYNVCT TDN SHTH RAD FLXR TDN PALM&/FNGR EA TDN 1845.60 090 N 2843.32  J1 26160 EXC LESION TDN SHTH/JT CAPSL HAND/FNGR 2240.40 090 N 2843.60  J1 26170 EXCISION TENDON PALM FLEXOR/EXTENSOR SINGLE EACH 1462.80 090 N 2845.02  J1 26180 EXCISION TENDON FINGER FLEXOR/EXTENSOR EACH 1608.00 090 N 2845.02  J1 26185 SESAMOIDECTOMY THUMB/FINGER SEPARATE PROCEDURE 1993.20 090 Y 2828.95  J1 26200 EXCISION/CURETTAGE CYST/TUMOR METACARPAL 1608.00 090 N 2824.61  J1 26205 EXC/CURETTAGE CYST/TUMOR METACARPAL W/AUTOGRAFT 2172.00 090 N 12794.10  J1 26210 EXCISION/CURETTAGE CYST/TUMOR PHALANX FINGER 1600.80 090 N 2841.54  J1 26215 EXC/CURETTAGE CYST/TUMOR PHALANX FINGER W/AGRAFT 2034.00 090 N 5600.76  J1 26230 PARTIAL EXCISION BONE METACARPAL 1789.20 090 N 5769.52  J1 26235 PARTIAL EXCISION PROXIMAL/MIDDLE PHALANX FINGER 1760.40 090 N 2840.33  J1 26236 PARTIAL EXCISION DISTAL PHALANX FINGER 1582.80 090 N 2840.75  J1 26250 RADICAL RESECTION TUMOR METACARPAL 3789.60 090 N 5676.54  J1 26260 RAD RESECTION TUMOR PROX/MIDDLE PHALANX FINGER 2842.80 090 Y 5731.34  J1 26262 RADICAL RESECTION TUMOR DISTAL PHALANX FINGER 2251.20 090 Y 2845.02   26320 REMOVAL IMPLANT FROM FINGER/HAND 1255.20 090 N 2040.53  J1 26340 MANIPULATION FINGER JOINT UNDER ANES EACH JOINT 1263.60 090 N 2845.02   26341 MANIPLATN PALAR FASCIAL CRD POST INJ SINGLE CORD 400.20 010 N 298.91

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 26350 RPR/ADVMNT FLXR TDN N/Z/2 W/O FR GRAFT EA TENDON 2720.40 090 N 5727.87  J1 26352 RPR/ADVMNT FLXR TDN N/Z/2 W/FR GRAFT EA TENDON 3030.00 090 Y 12449.62  J1 26356 RPR/ADVMNT FLXR TDN ZONE 2 W/O FR GRFT EA TENDON 2842.80 090 N 5725.70  J1 26357 RPR/ADVMNT FLXR TDN ZONE 2 W/O FR GRFT EA TENDON 3190.80 090 Y 5746.53  J1 26358 RPR/ADVMNT FLXR TDN ZONE 2 W/FR GRAFT EA TENDON 3523.20 090 Y 12590.68  J1 26370 RPR/ADVMNT TDN W/NTC SUPFCIS TDN PRIM EA TDN 2860.80 090 N 5716.45  J1 26372 RPR/ADVMNT TDN W/NTC SUPFCIS TDN W/FREE GRAFT EA 3334.80 090 Y 12594.83  J1 26373 RPR/ADVMNT TDN W/NTC SUPFCIS TDN W/O FREE GRF EA 3211.20 090 Y 5502.42  J1 26390 EXC FLXR TDN W/IMPLTJ SYNTH ROD DLYD TDN GRF H/F 3189.60 090 Y 11752.66  J1 26392 RMVL SYNTH ROD & INSJ FLXR TDN GRF H/F EA ROD 3643.20 090 Y 12660.72  J1 26410 REPAIR EXTENSOR TENDON HAND W/O GRAFT EACH 2191.44 090 N 2836.70  J1 26412 REPAIR EXTENSOR TENDON HAND W/GRAFT EACH 2612.40 090 N 5695.62  J1 26415 EXC XTNSR TDN W/IMPLTJ SYNTH ROD DLYD GRF H/F EA 3100.80 090 N 5692.59  J1 26416 RMVL SYNTH ROD & INSJ XTNSR TDN GRF H/F EA ROD 3350.40 090 N 5651.52  J1 26418 REPAIR EXTENSOR TENDON FINGER W/O GRAFT EACH 2242.50 090 N 2834.71  J1 26420 REPAIR EXTENSOR TENDON FINGER W/GRAFT EACH 2712.00 090 Y 5662.94  J1 26426 RPR XTNSR TDN CNTRL SLIP TISS W/LAT BAND EA FNGR 1802.40 090 N 5672.49  J1 26428 RPR XTNSR TDN CNTRL SLIP SEC W/FR GRFT EA FINGER 2904.00 090 N 5710.95  J1 26432 CLTX DSTL XTNSR TDN INSJ W/WO PERCUTAN PINNING 1930.62 090 N 2838.41  J1 26433 REPAIR EXTENSOR TENDON DISTAL INSERTION W/O GRF 2053.44 090 N 5670.03  J1 26434 REPAIR EXTENSOR TENDON DISTAL INSERTION W/GRAFT 2517.12 090 Y 5488.39  J1 26437 REALIGNMENT EXTENSOR TENDON HAND EACH TENDON 2424.66 090 N 5768.94  J1 26440 TENOLYSIS FLEXOR TENDON PALM/FINGER EACH TENDON 2378.40 090 N 2834.35  J1 26442 TENOLYSIS FLEXOR TENDON PALM&FINGER EACH TENDO 3580.80 090 N 5738.86  J1 26445 TENOLYSIS EXTENSOR TENDON HAND/FINGER EACH 2223.60 090 N 5754.19  J1 26449 TENOLYSIS CPLX XTNSR TENDON FINGER W/FOREARM EA 2487.60 090 N 5575.60  J1 26450 TENOTOMY FLEXOR PALM OPEN EACH TENDON 1581.48 090 N 5777.48  J1 26455 TENOTOMY FLEXOR FINGER OPEN EACH TENDON 1567.68 090 N 2844.88  J1 26460 TENOTOMY EXTENSOR HAND/FINGER OPEN EACH TENDON 1534.56 090 N 2817.14  J1 26471 TENODESIS PROXIMAL INTERPHALANGEAL JOINT EACH 2395.68 090 N 5621.73  J1 26474 TENODESIS DISTAL JOINT EACH 2340.48 090 Y 2834.35  J1 26476 LENGTHENING TENDON EXTENSOR HAND/FINGER EACH 2311.50 090 N 5601.77  J1 26477 SHORTENING TENDON EXTENSOR HAND/FINGER EACH 2257.68 090 N 5606.54  J1 26478 LENGTHENING TENDON FLEXOR HAND/FINGER EACH 2403.96 090 N 5776.03  J1 26479 SHORTENING TENDON FLEXOR HAND/FINGER EACH 2431.56 090 Y 5784.56  J1 26480 TR/TRNSPL TDN CARP/MTCRPL HAND W/O FR GRF EA TDN 2858.40 090 N 5761.28  J1 26483 TENDON TRANSFER TRANSPLANT CARP/MTCRPL GRAFT 3163.20 090 Y 5774.01  J1 26485 TRANSFER/TRANSPLANT TENDON PALMAR W/O GRAFT EACH 3034.80 090 Y 5668.00  J1 26489 TRANSFER/TRANSPLANT TENDON PALMAR W/GRAFT EACH 3511.20 090 N 5698.08  J1 26490 OPPONENSPLASTY SUPFCIS TDN TR TYP EA TDN 3051.60 090 N 5715.87  J1 26492 OPPONENSPLASTY TDN TR W/GRF EA TDN 3367.20 090 Y 5681.31  J1 26494 OPPONENSPLASTY HYPOTHENAR MUSC TR 3062.40 090 Y 5784.56  J1 26496 OPPONENSPLASTY OTHER METHODS 3292.80 090 N 5742.05  J1 26497 TR TDN RESTORE INTRNSC FUNCJ RING&SM FNGR 3289.20 090 Y 5757.09  J1 26498 TR TDN RESTORE INTRNSC FUNCJ ALL 4 FNGRS 4268.40 090 Y 5784.56  J1 26499 CORRECTION CLAW FINGER OTHER METHODS 3165.60 090 Y 5544.21  J1 26500 RCNSTJ TENDON PULLEY EACH W/LOCAL TISSUES SPX 2409.48 090 N 12704.86

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 122 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 26502 RCNSTJ TDN PULLEY EA TDN W/TDN/FSCAL GRF SPX 2754.00 090 Y 5628.09  J1 26508 RELEASE THENAR MUSCLE 2453.64 090 N 5714.42  J1 26510 CROSS INTRINSIC TRANSFER EACH TENDON 2311.50 090 N 5723.82  J1 26516 CAPSULODESIS MTCARPHLNGL JOINT SINGLE DIGIT 2704.80 090 N 5450.65  J1 26517 CAPSULODESIS MTCARPHLNGL JOINT 2 DIGITS 3148.80 090 Y 5549.42  J1 26518 CAPSULODESIS MTCARPHLNGL JOINT 3/4 DIGITS 3190.80 090 Y 11563.63  J1 26520 CAPSULECTOMY/CAPSULOTOMY MTCARPHLNGL JOINT EACH 2492.40 090 N 5758.97  J1 26525 CAPSULECTOMY/CAPSULOTOMY IPHAL JOINT EACH 2500.80 090 N 2839.90  J1 26530 ARTHROPLASTY METACARPOPHALANGEAL JOINT EACH 1936.80 090 Y 11736.99  J1 26531 ARTHRP MTCARPHLNGL JT W/PROSTC IMPLT EA JT 2256.00 090 Y 11411.38  J1 26535 ARTHROPLASTY INTERPHALANGEAL JOINT EACH 1562.40 090 N 5480.15  J1 26536 ARTHROPLASTY INTERPHALANGEAL JT W/PROSTHETIC EA 2726.40 090 N 11502.86  J1 26540 RPR COLTRL LIGM MTCARPHLNGL/IPHAL JT 2546.40 090 N 5458.46  J1 26541 RCNSTJ COLTRL LIGM MTCARPHLNGL 1 W/TDN/FSCAL GRF 3025.20 090 Y 5395.41  J1 26542 RCNSTJ COLTRL LIGM MTCARPHLNGL 1 W/LOCAL TISS 2628.00 090 N 5443.56  J1 26545 RCNSTJ COLTRL LIGM IPHAL JT 1 W/GRF EA JT 2659.20 090 N 5501.55  J1 26546 RPR NON-UNION MTCRPL/PHALANX 3740.40 090 Y 11980.72  J1 26548 RPR & RCNSTJ FINGER VOLAR PLATE INTERPHALANGEAL 2899.20 090 N 5567.21  J1 26550 POLLICIZATION DIGIT 5962.80 090 Y 5784.56  J1* 26551 TR TOE-TO-HAND W/MVASC ANAST GRT TOE WRP/ARND 11784.00 090 Y 12031.89  J1* 26553 TR TOE-TO-HAND W/MVASC ANAST OTH/THN GRT TOE 1 11704.80 090 Y 12031.89  J1* 26554 TR TOE-TO-HAND W/MVASC ANAST OTH/THN GRT TOE 2 13616.40 090 Y 12031.89  J1 26555 TR FNGR AXH POS W/O MVASC ANAST 5018.40 090 Y 12135.85  J1* 26556 TRANSFER FREE TOE JOINT W/MVASC ANASTOMOSIS 12169.20 090 Y 12031.89  J1 26560 REPAIR SYNDACTYLY EACH SPACE W/SKIN FLAPS 2278.38 090 Y 2845.02  J1 26561 REPAIR SYNDACTYLY EACH SPACE W/SKIN FLAPS&GRAFT 3565.20 090 Y 5585.43  J1 26562 REPAIR SYNDACTYLY EACH SPACE COMPLEX 4960.80 090 Y 5710.81  J1 26565 OSTEOTOMY METACARPAL EACH 2611.20 090 Y 5465.54  J1 26567 OSTEOTOMY PHALANX FINGER EACH 2618.40 090 N 5626.50  J1 26568 OSTEOPLASTY LENGTHENING METACARPAL/PHALANX 3392.40 090 Y 11702.13  J1 26580 REPAIR CLEFT HAND 5546.40 090 Y 5784.56  J1 26587 RCNSTJ POLYDACTYLOUS DIGIT SOFT TISSUE & BONE 3724.80 090 Y 5784.56  J1 26590 REPAIR MACRODACTYLIA EACH DIGIT 5164.80 090 Y 2845.02  J1 26591 REPAIR INTRINSIC MUSCLES HAND EACH MUSCLE 1705.68 090 N 5784.56  J1 26593 RELEASE INTRINSIC MUSCLES HAND EACH MUSCLE 2334.96 090 N 5754.05  J1 26596 EXC CONSTRICTING RING FNGR W/MLT Z-PLASTIES 2960.40 090 Y 5784.56   26600 CLTX METACARPAL FX W/O MANIPULATION EACH BONE 1087.20 090 N 298.91   26605 CLTX METACARPAL FX W/MANIPULATION EACH BONE 1197.60 090 N 298.91  J1 26607 CLTX METACARPAL FX W/MANJ W/XTRNL FIXJ EA BONE 1842.00 090 N 5471.47  J1 26608 PRQ SKELETAL FIXJ METACARPAL FX EACH BONE 1730.40 090 N 5748.26  J1 26615 OPEN TX METACARPAL FRACTURE SINGLE EA BONE 2058.00 090 N 5474.94   26641 CLTX CARPO/METACARPAL DISLOCATION THUMB W/MANJ 1482.12 090 N 298.91  J1 26645 CLTX CARPO/METACARPAL FX DISLC THUMB W/MANJ 1567.20 090 N 2845.02  J1 26650 PRQ SKELETAL FIX CARPO/METACARPAL FX DISLC THUMB 1729.20 090 N 5720.64  J1 26665 OPEN TX CARPOMETACARPAL FRACTURE DISLOCATE THUMB 2229.60 090 N 5570.97   26670 CLTX CARPO/METACARPL DISLC THMB MANJ EA W/O ANES 1263.60 090 N 298.91  J1 26675 CLTX CARPO/MTCRPL DISLC THUMB MANJ EA JT W/ANES 1669.20 090 N 2838.34

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 26676 PRQ SKEL FIXJ CARPO/MTCRPL DISLC THMB MANJ EA JT 1827.60 090 N 5764.61  J1 26685 OPEN TX CARPOMETACARPAL DISLOCATE NOT THUMB 2061.60 090 N 5631.27  J1 26686 OPTX CARP/MTCRPL DISLC THMB CPLX MLT/DLYD RDCTJ 2234.40 090 Y 5522.38   26700 CLTX METACARPOPHALANGEAL DISLC W/MANJ W/O ANES 1222.80 090 N 298.91  J1 26705 CLTX METACARPOPHALANGEAL DISLC W/MANJ W/ANES 1530.00 090 N 2844.81  J1 26706 PRQ SKEL FIXJ METACARPOPHALANGEAL DISLC W/MANJ 1604.40 090 N 5718.04  J1 26715 OPEN TREATMENT METACARPOPHALANGEAL DISLOCATION 2050.80 090 N 5748.26   26720 CLTX PHLNGL FX PROX/MIDDLE PX/F/T W/O MANJ EA 722.40 090 N 298.91   26725 CLTX PHLNGL FX PROX/MIDDLE PX/F/T W/MANJ EA 1236.00 090 N 298.91  J1 26727 PRQ SKEL FIXJ PHLNGL SHFT FX PROX/MIDDLE PX/F/T 1702.80 090 N 5757.95  J1 26735 OPEN TX PHALANGEAL SHAFT FRACTURE PROX/MIDDLE EA 2126.40 090 N 5574.44   26740 CLTX ARTCLR FX INVG MTCRPHLNGL/IPHAL JT W/O MANJ 840.00 090 N 298.91  J1 26742 CLTX ARTCLR FX INVG MTCARPHLNGL/IPHAL JT W/MANJ 1352.40 090 N 2843.67  J1 26746 OPEN TX ARTICULAR FRACTURE MCP/IP JOINT EA 2650.80 090 N 5667.28   26750 CLTX DSTL PHLNGL FX FNGR/THMB W/O MANJ EA 675.60 090 N 298.91   26755 CLTX DSTL PHLNGL FX FNGR/THMB W/MANJ EA 1156.80 090 N 298.91  J1 26756 PRQ SKEL FIXJ DSTL PHLNGL FX FNGR/THMB EA 1527.60 090 N 5760.85  J1 26765 OPEN TX DISTAL PHALANGEAL FRACTURE EACH 1797.60 090 N 5749.13   26770 CLTX IPHAL JT DISLC W/MANJ W/O ANES 1032.00 090 N 298.91   26775 CLTX IPHAL JT DISLC W/MANJ REQ ANES 1418.40 090 N 349.86  J1 26776 PRQ SKEL FIXJ IPHAL JT DISLC W/MANJ 1618.80 090 N 5774.87  J1 26785 OPEN TX INTERPHALANGEAL JOINT DISLOCATION 1954.80 090 N 5754.48  J1 26820 FUSION OPPOSITION THUMB W/AUTOGENOUS GRAFT 3019.20 090 Y 11603.93  J1 26841 ARTHRD CARPO/METACARPAL JT THUMB W/WO INT FIXJ 2809.20 090 N 11946.17  J1 26842 ARTHRD CRP/MTACRPL JT THMB W/WO INT FIXJ W/AGRFT 3026.40 090 Y 11969.84  J1 26843 ARTHRD CARP/MTCRPL JT DGT OTHER THAN THUMB EACH 2852.40 090 Y 11532.92  J1 26844 ARTHRD CARP/MTCRPL JT DGT OTH/THN THMB W/AGRFT 3128.40 090 Y 11746.91  J1 26850 ARTHRODESIS METACARPOPHALANGEAL JT W/WO INT FIXJ 2671.20 090 N 12077.31  J1 26852 ARTHRODESIS MTCRPL JT W/WO INT FIXJ W/AUTOGRAFT 3019.20 090 Y 11996.71  J1 26860 ARTHRODESIS INTERPHALANGEAL JT W/WO INT FIXJ 2195.58 090 N 5536.55   26861 ARTHRODESIS IPHAL JT W/WO INT FIXJ EA IPHAL JT 360.00 ZZZ N  J1 26862 ARTHRODESIS IPHAL JT W/WO INT FIXJ W/AUTOGRAFT 2782.80 090 Y 5532.64   26863 ARTHRODESIS IPHAL JT W/WO INT FIXJ W/AGRFT EA JT 802.80 ZZZ Y  J1 26910 AMP MTCRPL W/FINGER/THUMB W/WO INTEROSS TRANSFER 2767.20 090 N 5771.84  J1 26951 AMP F/TH 1/2 JT/PHALANX W/NEURECT W/DIR CLSR 2540.40 090 N 5781.67  J1 26952 AMP F/TH 1/2 JT/PHALANX W/NEURECT LOCAL FLAP 2486.40 090 N 5779.50   26989 UNLISTED PROCEDURE HANDS/FINGERS BR YYY N 298.91  J1 26990 I&D PELVIS/HIP JT AREA DEEP ABSCESS/HEMATOMA 2452.80 090 N 5760.70  J1 26991 I&D PELVIS/HIP JOINT AREA INFECTED BURSA 2544.00 090 N 2839.05  J1* 26992 INCISION BONE CORTEX PELVIS&/HIP JOINT 3608.40 090 N 12031.89  J1 27000 TENOTOMY ADDUCTOR HIP PERCUTANEOUS SPX 1435.20 090 N 2835.78  J1 27001 TENOTOMY ADDUCTOR HIP OPEN 1934.40 090 Y 5622.31  J1 27003 TX ADDUXOR SUBQ OPN W/OBTURATOR NEURECTOMY 2145.60 090 Y 12031.89  J1* 27005 TENOTOMY HIP FLEXOR OPEN SEPARATE PROCEDURE 2582.40 090 Y 12031.89  J1 27006 TENOTOMY ABDUCTORS&/EXTENSOR HIP OPEN SPX 2554.80 090 Y 5705.31  J1* 27025 FASCIOTOMY HIP/THIGH ANY TYPE 3290.40 090 N 12031.89  J1 27027 DECOMPRESSION FASCIOTOMY PELVIC COMPARTMENT UNI 3154.80 090 N 12514.87

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 124 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1* 27030 ARTHROTOMY HIP W/DRAINAGE 3339.60 090 Y 12031.89  J1 27033 ARTHROTOMY HIP EXPLORATION/REMOVAL FOREIGN BODY 3463.20 090 Y 12581.72  J1 27035 DNRVTJ HIP JT INTRAPEL/XTRPEL INTRA-ARTCLR BRNCH 4068.00 090 Y 5763.16  J1* 27036 CAPSLCTOMY/CAPSUL HIP W/RLS HIP FLXR MUSC 3628.80 090 Y 12031.89  J1 27040 BIOPSY SOFT TISSUE PELVIS&HIP AREA SUPERFICIAL 1222.80 010 N 2873.55  J1 27041 BIOPSY SOFT TISSUE PELVIS&HIP DEEP/SUBFSCAL/IM 2529.60 090 N 2872.69  J1 27043 EXCISION TUMOR SOFT TISSUE PELVIS&HIP SUBQ 3CM/> 1678.80 090 N 4840.80  J1 27045 EXC TUMOR SOFT TISSUE PELVIS & HIP SUBFASC 5CM/> 2622.00 090 Y 4840.44  J1 27047 EXC TUMOR SOFT TISSUE PELVIS & HIP SUBQ <3CM 1792.80 090 N 4837.90  J1 27048 EXC TUMOR SOFT TISSUE PELVIS & HIP SUBFASC <5CM 2178.00 090 Y 4827.36  J1 27049 RAD RESECT TUMOR SOFT TISSUE PELVIS & HIP <5 CM 4798.80 090 Y 4841.17  J1 27050 ARTHROTOMY W/BIOPSY SACROILIAC JOINT 1453.20 090 N 2845.02  J1 27052 ARTHROTOMY W/BIOPSY HIP JOINT 2067.60 090 Y 2768.63  J1* 27054 ARTHROTOMY W/SYNOVECTOMY HIP JOINT 2457.60 090 Y 5710.81  J1 27057 DCMPRN FASCIOTOMY PELVIC CMPRT DBRDMT MUSCLE UNI 3596.40 090 N 2845.02  J1 27059 RAD RESECTION TUMOR SOFT TISS PELVIS&HIP 5 CM/> 6436.80 090 Y 4840.20  J1 27060 EXCISION ISCHIAL BURSA 1668.00 090 N 12691.75  J1 27062 EXCISION TROCHANTERIC BURSA/CALCIFICATION 1630.80 090 N 5604.37  J1 27065 EXCISION BONE CYST/BNIGN TUMOR SUPERFICIAL 1882.80 090 Y 12696.55  J1 27066 EXCISION BONE CYST/BENIGN TUMOR DEEP 2910.00 090 Y 5736.26  J1 27067 EXC B1 CST/B9 TUM W/AGRFT REQ SEP INC 3690.00 090 Y 12794.10  J1* 27070 PARTIAL EXCISION SUPERFICIAL PELVIS 3184.80 090 Y 12031.89  J1* 27071 PARTIAL EXCISION DEEP PELVIS 3492.00 090 Y 12031.89  J1* 27075 RAD RESCT TUMOR WING OF ILIUM 1 PUBIC/ISCHIAL 7388.40 090 Y 12031.89  J1* 27076 RAD RESCT TUMOR ILIUM ACETABULUM BOTH PUBIC 8929.20 090 Y 12031.89  J1* 27077 RADICAL RESCTION TUMOR INNOMINATE BONE TOTAL 9958.80 090 Y 22251.08  J1* 27078 RAD RESCT TUMOR ISCHIAL TUBEROSITY&GRT TRCHNTR 7285.20 090 Y 22251.08  J1 27080 COCCYGECTOMY PRIMARY 1831.20 090 Y 5781.81  J1 27086 RMVL FOREIGN BODY PELVIS/HIP SUBCUTANEOUS TISS 1125.60 010 N 4842.74  J1 27087 REMOVAL FOREIGN BODY PELVIS/HIP DEEP 2197.20 090 Y 5778.05  J1* 27090 REMOVAL HIP PROSTHESIS SEPARATE PROCEDURE 2964.00 090 Y 4823.97  J1* 27091 RMVL HIP PROSTH COMP W/TOT HIP PROSTH MMA 5658.00 090 Y 4823.97   27093 INJECTION HIP ARTHROGRAPHY W/O ANESTHESIA 789.36 000 N   27095 INJECTION HIP ARTHROGRAPHY W/ANESTHESIA 1051.56 000 N   27096 INJECT SI JOINT ARTHRGRPHY&/ANES/STEROID W/IMA 582.00 000 N  J1 27097 RELEASE/RECESSION HAMSTRING PROXIMAL 2446.80 090 Y 5729.18  J1 27098 TRANSFER ADDUCTOR ISCHIUM 2488.80 090 Y 5672.34  J1 27100 TR XTRNL OBLQ MUSC TRCHNTR W/FSCAL/TDN XTN GRF 2965.20 090 Y 11918.03  J1 27105 TR PARASPI MUSC HIP FASC/TDN XTN GRF 3109.20 090 Y 5710.81  J1 27110 TRANSFER ILIOPSOAS GREATER TROCHANTER FEMUR 3464.40 090 Y 11657.35  J1 27111 TRANSFER ILIOPSOAS FEMORAL NECK 3225.60 090 Y 5710.81  J1* 27120 ACETABULOPLASTY 4620.00 090 Y 22251.08  J1* 27122 ACETABULOPLASTY RESECTION FEMORAL HEAD 3931.20 090 Y 22251.08  J1* 27125 HEMIARTHROPLASTY HIP PARTIAL 4024.80 090 Y 22251.08  J1 27130 ARTHRP ACETBLR/PROX FEM PROSTC AGRFT/ALGRFT 4690.80 090 Y 22103.12  J1* 27132 CONV PREV HIP TOT HIP ARTHRP W/WO AGRFT/ALGRFT 5931.60 090 Y 22251.08  J1* 27134 REVJ TOT HIP ARTHRP BTH W/WO AGRFT/ALGRFT 6758.40 090 Y 22251.08

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1* 27137 REVJ TOT HIP ARTHRP ACTBLR W/WO AGRFT/ALGRFT 5203.20 090 Y 22251.08  J1* 27138 REVJ TOT HIP ARTHRP FEM ONLY W/WO ALGRFT 5408.40 090 Y 22251.08  J1* 27140 OSTEOTOMY&TRANSFER GREATER TROCHANTER SPX 3187.20 090 Y 22251.08  J1* 27146 OSTEOTOMY ILIAC ACETABULAR/INNOMINATE BONE 4554.00 090 Y 12031.89  J1* 27147 OSTEOTOMY ILIAC ACETABULAR/INNOMINATE HIP RDCTJ 5197.20 090 Y 12031.89  J1* 27151 OSTEOTOMY ILIAC ACETABULAR/INNOMINATE FEM OSTEOT 5616.00 090 Y 12031.89  J1* 27156 OSTEOT ILIAC ACTBLR/INNOMINATE BONE OSTEOT RDCTJ 6050.40 090 Y 12031.89  J1* 27158 OSTEOTOMY PELVIS BILATERAL 4975.20 090 Y 12031.89  J1* 27161 OSTEOTOMY FEMORAL NECK SEPARATE PROCEDURE 4344.00 090 Y 12031.89  J1* 27165 OSTEOT INTERTRCHNTRIC/SUBTRCHNTRIC W/INT/XTRNL 4903.20 090 Y 12031.89  J1* 27170 B1 GRF FEM H/N INTERTRCHNTRIC/SUBTRCHNTRIC AREA 4147.20 090 Y 12031.89  J1* 27175 TX SLP FEMORAL EPIPHYSIS TRCJ W/O REDUCTION 2379.60 090 N 12031.89  J1* 27176 TX SLP FEM EPIPHYSIS SINGLE/MULTIPL PINNING SITU 3290.40 090 Y 22251.08  J1* 27177 OPTX SLP FEM EPIPHYSIS SINGLE/MULT PIN/BONE GRFT 3973.20 090 Y 12031.89  J1* 27178 OPTX SLP FEM EPIPHYSIS CLSD MANJ SINGL/MLTPL PIN 3290.40 090 Y 12031.89  J1 27179 OPTX SLP FEM EPIPHYSIS OSTPL FEM NCK HEYMAN PX 3492.00 090 Y 12031.89  J1* 27181 OPTX SLP FEM EPIPHYSIS OSTEOT&INT FIXJ 3985.20 090 Y 12031.89  J1* 27185 EPIPHYSL ARRST EPIPHYSIOD/STAPLING TRCHNTR FEMUR 2568.00 090 N 12031.89  J1* 27187 PROPH TX N/P/PLTWR W/WO MMA FEM NCK & PROX FEMUR 3554.40 090 Y 12031.89   27197 CLSD TX PELVIC RING FX W/O MANIPULATION 478.80 000 N 298.91   27198 CLSD TX PELVIC RING FX W/MANIPULATION W/ANES 1135.20 000 N 298.91   27200 CLOSED TREATMENT COCCYGEAL FRACTURE 676.80 090 N 298.91  J1 27202 OPEN TREATMENT COCCYGEAL FRACTURE 1885.20 090 Y 5710.81   27215 OPTX ILIAC TUBRST AVLS/WING FX FIXJ IF PRFRMD 2160.00 090 N   27216 PERQ SKELETAL FIXATION PST PELVIC BONE FX&/DIS 3206.40 090 N   27217 OPTX ANT PELVIC BONE FX&/DISLC INT FIXJ IF PFR 3008.40 090 N 5927.33   27218 OPTX POST PEL BONE FX&/DISLC INT FIXJ IF PFRMD 4155.60 090 N   27220 CLTX ACETABULUM HIP/SOCKT FX W/O MANJ 1837.20 090 N 298.91  J1* 27222 CLTX ACETABULM HIP/SOCKT FX MANJ W/WO SKEL TRACJ 3510.00 090 N 420.93  J1* 27226 OPTX PST/ANT ACTBLR WALL FX W/INT FIXJ 3757.20 090 Y 12031.89  J1* 27227 OPTX ACTBLR FX INVG ANT/PST 1 COLUMN/FX W/INT 5859.60 090 Y 12031.89  J1* 27228 OPTX ACTBLR FX INVG ANT&POST 2 COLUMNS FX W/INT 6660.00 090 Y 12031.89   27230 CLTX FEM FX PROX END NCK W/O MANJ 1748.40 090 N 298.91  J1* 27232 CLTX FEM FX PROX END NCK W/MANJ W/WO SKEL TRACJ 2634.00 090 N 2842.96  J1 27235 PRQ SKEL FIXJ FEMORAL FX PROX END NECK 3235.20 090 N 11964.72  J1* 27236 OPTX FEM FX PROX END NCK INT FIXJ/PROSTC RPLCMT 4244.40 090 Y 12031.89  J1 27238 CLTX INTER/PERI/SUBTROCHANTERIC FEM FX W/O MANJ 1677.60 090 N 2809.96  J1* 27240 CLTX INTR/PERI/SBTRCHNTC FEMORAL FX W/MANJ 3420.00 090 N 2842.96  J1* 27244 TX INTER/PR/SUBTRCHNTRIC FEMORAL FX SCREW IMPLT 4365.60 090 Y 12031.89  J1* 27245 TX INTER/PR/SUBTRCHNTRIC FEM FX IMED IMPLTSCREW 4362.00 090 Y 12031.89   27246 CLTX GREATER TROCHANTERIC FX W/O MANJ 1405.20 090 N 298.91  J1* 27248 OPEN TREATMENT GREATER TROCHANTERIC FRACTURE 2664.00 090 Y 12031.89   27250 CLTX HIP DISLOCATION TRAUMATIC W/O ANESTHESIA 639.60 000 N 298.91  J1 27252 CLTX HIP DISLOCATION TRAUMATIC REQ ANESTHESIA 2697.60 090 N 2844.24  J1* 27253 OPTX HIP DISLOCATION TRAUMATIC W/O INTERNAL FIXJ 3354.00 090 Y 5710.81  J1* 27254 OPTX HIP DISLC TRAUMTC W/ACTBLR WALL&FEM HEAD 4525.20 090 Y 5710.81   27256 TX SPONTAN HIP DISLC ABDCT SPLNT/TRCJ W/O ANES 1098.00 010 N 298.91

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 126 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 27257 TX SPON HIP DISLC ABDCT SPLNT/TRCJ W/MANJ ANES 1282.80 010 N 2845.02  J1* 27258 OPTX SPON HIP DISLC RPLCMT FEM HEAD ACTBLM 3960.00 090 Y 5710.81  J1* 27259 OPTX SPON HIP DISLC RPLCMT FEM HEAD ACTBLM SHRT 5480.40 090 Y 5710.81   27265 CLTX POST HIP ARTHRP DISLC W/O ANES 1473.60 090 N 298.91  J1 27266 CLTX POST HIP ARTHRP DISLC REQ ANES 2095.20 090 N 2844.31  J1 27267 CLOSED TX FEMORAL FRACTURE PROX HEAD W/O MANJ 1581.60 090 Y 5650.36  J1* 27268 CLOSED TX FEMORAL FRACTURE PROX HEAD W/MANJ 1950.00 090 Y 5710.81  J1* 27269 OPEN TX FEMORAL FRACTURE PROXIMAL END HEAD 4408.80 090 Y 2842.96  J1 27275 MANIPULATION HIP JOINT GENERAL ANESTHESIA 652.80 010 N 2844.95  J1 27278 ARTHRD SI JT PRQ W/PLMT IARTIC IMPLT WO TFXJ DEV 43746.00 090 N 32757.47  J1 27279 ARTHRODESIS SI JOINT PERCUTANEOUS/MIN INVASIVE 2758.62 090 Y 27215.67  J1* 27280 ARTHRODESIS SI JT OPN W/OBTAINING B1 GRF INSTRMJ 4851.60 090 Y 27818.41  J1* 27282 ARTHRODESIS SYMPHYSIS PUBIS W/OBTAINING GRAFT 3070.80 090 Y 22251.08  J1* 27284 ARTHRODESIS HIP JOINT W/OBTAINING GRAFT 5695.20 090 Y 27818.41  J1* 27286 ARTHRD HIP JT W/OBTG GRF W/SUBTRCHNTRIC OSTEOT 5832.00 090 Y 27818.41  J1* 27290 INTERPELVIABDOMINAL AMPUTATION 5774.40 090 Y 27818.41  J1* 27295 DISARTICULATION HIP 4494.00 090 Y 27818.41   27299 UNLISTED PROCEDURE PELVIS/HIP JOINT BR YYY Y 298.91  J1 27301 I&D DEEP ABSC BURSA/HEMATOMA THIGH/KNEE REGION 2422.80 090 N 4820.82  J1* 27303 INC DEEP W/OPNG BONE CORTEX FEMUR/KNEE 2283.60 090 Y 12031.89  J1 27305 FASCIOTOMY ILIOTIBIAL OPEN 1731.60 090 Y 5727.30  J1 27306 TENOTOMY PRQ ADDUCTOR/HAMSTRING 1 TENDON SPX 1207.20 090 Y 5718.33  J1 27307 TENOTOMY PRQ ADDUCTOR/HAMSTRING MULTIPLE TENDON 1657.20 090 N 5427.37  J1 27310 ARTHRT KNE W/EXPL DRG/RMVL FB 2616.00 090 Y 5733.08  J1 27323 BIOPSY SOFT TISSUE THIGH/KNEE AREA SUPERFICIAL 982.80 010 N 2871.47  J1 27324 BIOPSY SOFT TISSUE THIGH/KNEE AREA DEEP 1455.60 090 N 4841.53  J1 27325 NEURECTOMY HAMSTRING MUSCLE 2024.40 090 Y 3586.62  J1 27326 NEURECTOMY POPLITEAL 1874.40 090 Y 3586.62  J1 27327 EXCISION TUMOR SOFT TISSUE THIGH/KNEE SUBQ <3CM 1827.60 090 N 2873.12  J1 27328 EXC TUMOR SOFT TISSUE THIGH/KNEE SUBFASC <5CM 2224.80 090 N 4841.65  J1 27329 RAD RESECT TUMOR SOFT TISSUE THIGH/KNEE <5CM 3710.40 090 Y 4842.62  J1 27330 ARTHROTOMY KNEE W/SYNOVIAL BIOPSY ONLY 1514.40 090 N 5727.30  J1 27331 ARTHRT KNE W/JT EXPL BX/RMVL LOOSE/FB 1706.40 090 Y 5758.82  J1 27332 ARTHRT W/EXC SEMILUNAR CRTLG KNEE MEDIAL/LAT 2310.00 090 Y 5693.17  J1 27333 ARTHRT W/EXC SEMILUNAR CRTLG KNEE MEDIAL&LAT 2109.60 090 Y 5705.46  J1 27334 ARTHROTOMY W/SYNOVECTOMY KNEE ANTERIOR/POSTERIOR 2452.80 090 Y 5668.58  J1 27335 ARTHRT W/SYNVCT KNE ANT&POST W/POP AREA 2737.20 090 Y 12288.74  J1 27337 EXCISON TUMOR SOFT TISSUE THIGH/KNEE SUBQ 3 CM/> 1502.40 090 Y 4841.65  J1 27339 EXC TUMOR SOFT TISSUE THIGH/KNEE SUBFASC 5 CM/> 2697.60 090 Y 4835.11  J1 27340 EXCISION PREPATELLAR BURSA 1345.20 090 N 5771.55  J1 27345 EXCISION SYNOVIAL CYST POPLITEAL SPACE 1741.20 090 Y 5749.86  J1 27347 EXCISION LESION MENISCUS/CAPSULE KNEE 1884.00 090 Y 5755.50  J1 27350 PATELLECTOMY/HEMIPATELLECTOMY 2342.40 090 Y 12649.85  J1 27355 EXCISION/CURETTAGE CYST/TUMOR FEMUR 2179.20 090 Y 5720.50  J1 27356 EXCISION/CURETTAGE CYST/TUMOR FEMUR W/ALLOGRAFT 2644.80 090 Y 23096.73  J1 27357 EXCISION/CURETTAGE CYST/TUMOR FEMUR W/AUTOGRAFT 2929.20 090 Y 11573.55   27358 EXCISION/CURETTAGE CYST/TUMOR FEMUR INT FIXATION 973.20 ZZZ Y

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 27360 PRTL EXC BONE FEMUR PROX TIBIA&/FIBULA 3246.00 090 Y 5691.86  J1 27364 RAD RESECTION TUMOR SOFT TIS THIGH/KNEE 5 CM/> 5558.40 090 Y 4838.02  J1* 27365 RADICAL RESECTION TUMOR FEMOR OR KNEE 7280.40 090 Y 12031.89   27369 NJX PX CNTRST KNE ARTHG CNTRST ENHNCD CT/MRI KNE 560.28 000 N  J1 27372 REMOVAL FOREIGN BODY DEEP THIGH/KNEE 2142.00 090 N 4840.56  J1 27380 SUTURE INFRAPATELLAR TENDON PRIMARY 2242.80 090 Y 12459.54  J1 27381 SUTR INFRAPATELLAR TDN 2 RCNSTJ W/FSCAL/TDN GRF 2948.40 090 Y 11833.59  J1 27385 SUTURE QUADRICEPS/HAMSTRING RUPTURE PRIMARY 2185.20 090 Y 12461.46  J1 27386 SUTR QUADRICEPS/HAMSTRING MUSC RPT RCNSTJ 3079.20 090 Y 12068.68  J1 27390 TENOTOMY OPEN HAMSTRING KNEE HIP SINGLE TENDON 1610.40 090 Y 5567.21  J1 27391 TENOTOMY OPN HAMSTRING KNEE HIP MULTIPLE 1 LEG 1992.00 090 N 5705.75  J1 27392 TENOTOMY OPEN HAMSTRING KNEE HIP MULTIPLE BI 2550.00 090 Y 5784.56  J1 27393 LENGTHENING HAMSTRING TENDON SINGLE 1798.80 090 Y 12794.10  J1 27394 LENGTHENING HAMSTRING TENDON MULTIPLE 1 LEG 2343.60 090 Y 12031.89  J1 27395 LENGTHENING HAMSTRING TENDON MULTIPLE BILATERAL 3147.60 090 Y 5784.56  J1 27396 TRANSPLANT/TRANSFER THIGH XTNSR TO FLXR 1 TENDON 2214.00 090 Y 12419.88  J1 27397 TRANSPLANT/TRANSFER THIGH XTNSR TO FLXR MULT TDN 3262.80 090 Y 12031.89  J1 27400 TRANSFER TENDON/MUSCLE HAMSTRINGS FEMUR 2490.00 090 Y 12558.69  J1 27403 ARTHROTOMY W/MENISCUS REPAIR KNEE 2307.60 090 Y 11613.85  J1 27405 RPR PRIMARY TORN LIGM&/CAPSULE KNEE COLLATERAL 2421.60 090 Y 12333.83  J1 27407 REPAIR PRIMARY TORN LIGM&/CAPSULE KNEE CRUCIAT 2848.80 090 Y 11671.42  J1 27409 RPR 1 TORN LIGM&/CAPSL KNE COLTRL&CRUCIATE 3451.20 090 Y 12092.67  J1 27412 AUTOLOGOUS CHONDROCYTE IMPLANTATION KNEE 5853.60 090 Y 11027.24  J1 27415 OSTEOCHONDRAL ALLOGRAFT KNEE OPEN 4879.20 090 Y 21575.46  J1 27416 OSTEOCHONDRAL AUTOGRAFT KNEE OPEN MOSAICPLASTY 3494.40 090 N 12269.86  J1 27418 ANTERIOR TIBIAL TUBERCLEPLASTY 2968.80 090 Y 12434.91  J1 27420 RCNSTJ DISLOCATING PATELLA 2653.20 090 Y 12456.66  J1 27422 RCNSTJ DISLC PATELLA W/XTNSR RELIGNMT&/MUSC RL 2654.40 090 Y 12444.82  J1 27424 RCNSTJ DISLC PATELLA W/PATELLECTOMY 2677.20 090 Y 12614.67  J1 27425 LATERAL RETINACULAR RELEASE OPEN 1626.00 090 N 5697.79  J1 27427 LIGAMENTOUS RECONSTRUCTION KNEE EXTRA-ARTICULAR 2540.40 090 Y 11665.98  J1 27428 LIGAMENTOUS RECONSTRUCTION KNEE INTRA-ARTICULAR 3980.40 090 Y 23035.65  J1 27429 LIGMOUS RCNSTJ AGMNTJ KNE INTRA-ARTICULAR XTR 4479.60 090 Y 22487.84  J1 27430 QUADRICEPSPLASTY 2654.40 090 Y 12394.29  J1 27435 CAPSULOTOMY POSTERIOR CAPSULAR RELEASE KNEE 2874.00 090 Y 5747.11  J1 27437 ARTHROPLASTY PATELLA W/O PROSTHESIS 2361.60 090 N 12045.97  J1 27438 ARTHROPLASTY PATELLA W/PROSTHESIS 2997.60 090 Y 22778.12  J1 27440 ARTHROPLASTY KNEE TIBIAL PLATEAU 2848.80 090 Y 22519.95  J1 27441 ARTHRP KNEE TIBIAL PLATEAU DBRDMT&PRTL SYNVCT 2941.20 090 Y 22666.67  J1 27442 ARTHROPLASTY FEM CONDYLES/TIBIAL PLATEAU KNEE 3106.80 090 Y 22247.31  J1 27443 ARTHRP FEM CONDYLES/TIBL PLATU KNE DBRDMT&PRTL 2913.60 090 Y 22366.32  J1* 27445 ARTHROPLASTY KNEE HINGE PROSTHESIS 4461.60 090 Y 22251.08  J1 27446 ARTHRP KNEE CONDYLE&PLATEAU MEDIAL/LAT CMPRT 4101.60 090 Y 22286.35  J1 27447 ARTHRP KNE CONDYLE&PLATU MEDIAL&LAT COMPARTMENTS 4688.40 090 Y 22183.71  J1* 27448 OSTEOTOMY FEMUR SHAFT/SUPRACONDYLAR W/O FIXATION 2889.60 090 Y 12031.89  J1* 27450 OSTEOTOMY FEMUR SHAFT/SUPRACONDYLAR W/FIXATION 3607.20 090 Y 12031.89  J1* 27454 OSTEOT MLT W/RELIGNMT IMED ROD FEM SHFT 4598.40 090 Y 12031.89

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 128 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1* 27455 OSTEOT PROX TIBIA FIB EXC/OSTEOT BEFORE EPIPHYSL 3435.60 090 Y 12031.89  J1* 27457 OSTEOT PROX TIBIA FIB EXC/OSTEOT AFTER EPIPHYSL 3426.00 090 Y 12031.89  J1* 27465 OSTEOPLASTY FEMUR SHORTENING EXCLUDING 64876 4438.80 090 Y 12031.89  J1* 27466 OSTEOPLASTY FEMUR LENGTHENING 4216.80 090 Y 12031.89  J1* 27468 OSTPL FEMUR CMBN LNGTH&SHRT W/FEMORAL SGM TRNSFR 4770.00 090 Y 12031.89  J1* 27470 RPR NON/MAL FEMUR DSTL H/N W/O GRF 4197.60 090 Y 12031.89  J1* 27472 RPR NON/MAL FEMUR DSTL H/N W/ILIAC/AUTOG BONE 4495.20 090 Y 12031.89  J1 27475 ARREST EPIPHYSEAL DISTAL FEMUR 2374.80 090 N 12031.89  J1 27477 ARREST EPIPHYSEAL TIBIA & FIBULA PROXIMAL 2623.20 090 N 11166.05  J1 27479 ARRST EPIPHYSL CMBN DSTL FEMUR PROX TIBFIB 3276.00 090 Y 12031.89  J1 27485 ARRST HEMIEPIPHYSL DSTL FEMUR/PROX TIBIA/FIBULA 2403.60 090 N 12138.09  J1* 27486 REVJ TOTAL KNEE ARTHRP W/WO ALGRFT 1 COMPONENT 4987.20 090 Y 22251.08  J1* 27487 REVJ TOT KNEE ARTHRP FEM&ENTIRE TIBIAL COMPONE 6222.00 090 Y 22251.08  J1* 27488 RMVL PROSTH TOT KNEE PROSTH MMA W/WO INSJ SPACER 4267.20 090 Y 12031.89  J1* 27495 PROPH TX N/P/PLTWR W/WO METHYLMETHACRYLATE FEMUR 4023.60 090 Y 12031.89  J1 27496 DECOMPRESSION FASCIOTOMY THIGH&/KNEE 1 COMPONENT 1964.40 090 N 5710.81  J1 27497 DCMPRN FASCT THIGH&/KNEE DBRDMT MUSCLE&/NERVE 2078.40 090 N 5710.81  J1 27498 DCMPRN FASCIOTOMY THIGH&/KNEE MLT COMPARTMENTS 2350.80 090 Y 2845.02  J1 27499 DCMPRN FASCT THIGH&/KNEE MLT DBRDMT NV MUSC&NRVE 2508.00 090 Y 12031.89   27500 CLOSED TX FEMORAL SHAFT FX W/O MANIPULATION 1873.20 090 N 298.91   27501 CLTX SPRCNDYLR/TRNSCNDYLR FEM FX W/O MANJ 1820.40 090 N 298.91  J1 27502 CLTX FEM SHFT FX W/MANJ W/WO SKIN/SKELETAL TRACJ 2712.00 090 N 2815.22  J1 27503 CLTX SPRCNDYLR/TRNSCNDYLR FEM FX W/MANJ 2853.60 090 N 2792.82  J1* 27506 OPTX FEM SHFT FX W/INSJ IMED IMPLT W/WO SCREW 4754.40 090 Y 12031.89  J1* 27507 OPTX FEM SHFT FX W/PLATE/SCREWS W/WO CERCLAGE 3446.40 090 Y 12031.89   27508 CLTX FEM FX DSTL END MEDIAL/LAT CONDYLE W/O MANJ 1890.00 090 N 298.91  J1 27509 PRQ SKELETAL FIXJ FEMORAL FX DISTAL END 2433.60 090 N 11314.78  J1 27510 CLTX FEM FX DSTL END MEDIAL/LAT CONDYLE W/MANJ 2426.40 090 N 2845.02  J1* 27511 OPEN TX FEMORAL SUPRACONDYLAR FRACTURE W/O XTN 3544.80 090 Y 12031.89  J1* 27513 OPEN TX FEMORAL SUPRACONDYLAR FRACTURE W/XTN 4398.00 090 Y 12031.89  J1* 27514 OPEN TX FEMORAL FRACTURE DISTAL MED/LAT CONDYLE 3441.60 090 Y 12031.89   27516 CLTX DISTAL FEMORAL EPIPHYSL SEPARATION W/O MANJ 1864.80 090 N 298.91  J1 27517 CLTX DSTL FEM EPIPHYSL SEP W/MANJ W/WO SKIN/SKEL 2464.80 090 N 2845.02  J1* 27519 OPEN TX DISTAL FEMORAL EPIPHYSEAL SEPARATION 3175.20 090 Y 12031.89   27520 CLOSED TX PATELLAR FRACTURE W/O MANIPULATION 1176.00 090 N 298.91  J1 27524 OPTX PATLLR FX W/INT FIXJ/PATLLC&SOFT TISS RPR 2691.60 090 Y 12344.07   27530 CLTX TIBIAL FX PROXIMAL W/O MANIPULATION 1113.60 090 N 298.91  J1 27532 CLTX TIBIAL FX PROXIMAL W/WO MANJ W/SKEL TRACJ 2227.20 090 N 5647.61  J1* 27535 OPEN TX TIBIAL FRACTURE PROXIMAL UNICONDYLAR 3195.60 090 Y 12031.89  J1* 27536 OPTX TIBIAL FX PROX BICONDYLAR W/WO INT FIXJ 4221.60 090 Y 12031.89   27538 CLTX INTERCONDYLAR SPI&/TUBRST FX KNE W/WO MAN 1754.40 090 N 298.91  J1* 27540 OPEN TX INTERCONDYLAR SPINE/TUBRST FRACTURE KNEE 2905.20 090 Y 12031.89   27550 CLOSED TX KNEE DISLOCATION W/O ANESTHESIA 1855.20 090 N 298.91  J1 27552 CLOSED TX KNEE DISLOCATION W/ANESTHESIA 2271.60 090 N 2844.38  J1* 27556 OPEN TX KNEE DISLOCATION W/O LIGAMENTOUS REPAIR 3124.80 090 Y 12031.89  J1* 27557 OPEN TX KNEE DISLOCATION W/LIGAMENTOUS REPAIR 3723.60 090 Y 12031.89  J1* 27558 OPEN TX KNEE DISLOCATION W/REPAIR/RECONSTRUCTION 4232.40 090 Y 12031.89

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   27560 CLOSED TX PATELLAR DISLOCATION W/O ANESTHESIA 1332.00 090 N 298.91   27562 CLOSED TX PATELLAR DISLOCATION W/ANESTHESIA 1760.40 090 N 298.91  J1 27566 OPTX PATELLAR DISLC W/WO PRTL/TOT PATELLECTOMY 3184.80 090 Y 12571.49  J1 27570 MANIPULATION KNEE JOINT UNDER GENERAL ANESTHESIA 544.80 010 N 2843.46  J1* 27580 ARTHRODESIS KNEE ANY TECHNIQUE 5263.20 090 Y 22251.08  J1* 27590 AMPUTATION THIGH THROUGH FEMUR ANY LEVEL 2805.60 090 Y 27818.41  J1* 27591 AMP THI THRU FEMUR LVL IMMT FITG TQ W/1ST CST 3438.00 090 Y 27818.41  J1* 27592 AMPUTATION THIGH THRU FEMUR OPEN CIRCULAR 2389.20 090 Y 27818.41  J1 27594 AMP THIGH THRU FEMUR SEC CLOSURE/SCAR REVISION 1813.20 090 N 5763.88  J1* 27596 AMPUTATION THIGH THROUGH FEMUR RE-AMPUTATION 2547.60 090 N 12031.89  J1* 27598 DISARTICULATION KNEE 2498.40 090 Y 22251.08   27599 UNLISTED PROCEDURE FEMUR/KNEE BR YYY Y 298.91  J1 27600 DCMPRN FASCT LEG ANT&/LAT COMPARTMENTS ONLY 1442.40 090 N 5755.78  J1 27601 DCMPRN FASCT LEG POST COMPARTMENT ONLY 1598.40 090 N 5782.39  J1 27602 DCMPRN FASCT LEG ANT&/LAT&PST CMPRT 1711.20 090 Y 5577.76  J1 27603 INCISION & DRAINAGE LEG/ANKLE ABSCESS/HEMATOMA 1912.80 090 N 4814.29  J1 27604 INCISION & DRAINAGE LEG/ANKLE INFECTED BURSA 1638.00 090 N 5784.56  J1 27605 TENOTOMY PRQ ACHILLES TENDON SPX LOCAL ANES 1186.80 010 N 2807.40  J1 27606 TENOTOMY PRQ ACHILLES TENDON SPX GENERAL ANES 969.60 010 N 5716.88  J1 27607 INCISION LEG/ANKLE 2125.20 090 N 5673.93  J1 27610 ARTHROTOMY ANKLE W/EXPL DRAINAGE/REMOVAL FB 2310.00 090 N 5743.64  J1 27612 ARTHRT PST CAPSUL RLS ANKLE W/WO ACHLL TDN LNGTH 1988.40 090 Y 5706.62  J1 27613 BIOPSY SOFT TISSUE LEG/ANKLE AREA SUPERFICIAL 906.00 010 N 2873.34  J1 27614 BIOPSY SOFT TISSUE LEG/ANKLE AREA DEEP 2089.20 090 N 4843.10  J1 27615 RAD RESECTION TUMOR SOFT TISSUE LEG/ANKLE <5CM 3642.00 090 N 4785.83  J1 27616 RAD RESECTION TUMOR SOFT TISSUE LEG/ANKLE 5 CM/> 4515.60 090 N 4824.82  J1 27618 EXC TUMOR SOFT TISSUE LEG/ANKLE SUBQ <3CM 1771.20 090 N 2865.00  J1 27619 EXC TUMOR SOFT TISSUE LEG/ANKLE SUBFASCIAL <5CM 1642.80 090 N 4835.35  J1 27620 ARTHRT ANKLE W/EXPL W/WO BX W/WO RMVL LOOSE/FB 1605.60 090 Y 5719.63  J1 27625 ARTHROTOMY W/SYNOVECTOMY ANKLE 2044.80 090 Y 5616.81  J1 27626 ARTHROTOMY W/SYNOVECTOMY ANKLE TENOSYNOVECTOMY 2143.20 090 Y 5692.73  J1 27630 EXCISION LESION TENDON SHEATH/CAPSULE LEG&/ANK 1941.60 090 N 5762.73  J1 27632 EXCISION TUMOR SOFT TISSUE LEG/ANKLE SUBQ 3 CM/> 1473.60 090 Y 4829.42  J1 27634 EXC TUMOR SOFT TISSUE LEG/ANKLE SUBFASC 5 CM/> 2408.40 090 Y 4842.38  J1 27635 EXCISION/CURETTAGE BONE CYST/TUMOR TIBIA/FIBULA 2066.40 090 N 5732.36  J1 27637 EXC/CURETTAGE CYST/TUMOR TIBIA/FIBULA W/AGRAFT 2620.80 090 Y 11588.58  J1 27638 EXC/CURETTAGE CYST/TUMOR TIBIA/FIBULA W/ALGRAFT 2674.80 090 Y 11669.18  J1 27640 PARTIAL EXCISION BONE TIBIA 2964.00 090 N 5694.61  J1 27641 PARTIAL EXCISION BONE FIBULA 2322.00 090 N 5730.33  J1* 27645 RADICAL RESECTION OF TUMOR TIBIA 6270.00 090 Y 12031.89  J1* 27646 RADICAL RESECTION TUMOR BONE FIBULA 5449.20 090 Y 12031.89  J1 27647 RADICAL RESECTION OF TUMOR TALUS OR CALCANEUS 3520.80 090 Y 5784.56   27648 INJECTION ANKLE ARTHROGRAPHY 720.36 000 N  J1 27650 REPAIR PRIMARY OPEN/PRQ RUPTURED ACHILLES TENDON 2346.00 090 Y 11943.61  J1 27652 RPR PRIMARY OPEN/PRQ RUPTURED ACHILLES W/GRAFT 2341.20 090 N 11553.39  J1 27654 REPAIR SECONDARY ACHILLES TENDON W/WO GRAFT 2535.60 090 Y 11771.85  J1 27656 REPAIR FASCIAL DEFECT LEG 2186.40 090 Y 5334.67

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 130 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 27658 REPAIR FLEXOR TENDON LEG PRIMARY W/O GRAFT EACH 1311.60 090 Y 5600.90  J1 27659 RPR FLEXOR TENDON LEG SECONDARY W/O GRAFT EACH 1671.60 090 Y 12081.79  J1 27664 RPR EXTENSOR TENDON LEG PRIMARY W/O GRAFT EACH 1300.80 090 N 12409.32  J1 27665 RPR EXTENSOR TENDON LEG SECONDRY W/WO GRAFT EACH 1504.80 090 Y 11882.84  J1 27675 RPR DISLOC PERONEAL TENDON W/O FIBULAR OSTEOTOMY 1749.60 090 Y 5563.01  J1 27676 REPAIR DISLOCATING PERONEAL TENDON W/FIB OSTEOT 2166.00 090 Y 12517.11  J1 27680 TENOLYSIS FLXR/XTNSR TENDON LEG&/ANKLE 1 EACH 1488.00 090 N 5590.20  J1 27681 TNOLS FLXR/XTNSR TDN LEG&/ANKLE MLT TDN 1893.60 090 N 5577.33  J1 27685 LNGTH/SHRT TENDON LEG/ANKLE 1 TENDON SPX 2342.40 090 Y 5673.64  J1 27686 LNGTH/SHRT TDN LEG/ANKLE MLT TDN SAME INC EA 1894.80 090 N 5706.62  J1 27687 GASTROCNEMIUS RECESSION 1614.00 090 Y 5731.78  J1 27690 TR/TRNSPL 1 TDN W/MUSC REDIRION/REROUTING SUPFC 2280.00 090 Y 12154.72  J1 27691 TR/TRNSPL 1 TDN W/MUSC REDIRION/REROUTING DP 2649.60 090 Y 12217.09   27692 TR/TRNSPL 1 TDN W/MUSC REDIRION/REROUTING EA TDN 362.40 ZZZ Y  J1 27695 RPR PRIMARY DISRUPTED LIGAMENT ANKLE COLLATERAL 1707.60 090 N 11860.13  J1 27696 RPR PRIM DISRUPTED LIGM ANKLE BTH COLTRL LIGMS 1951.20 090 N 11804.48  J1 27698 REPAIR SECONDARY DISRUPTED LIGAMENT ANKLE COLTRL 2266.80 090 Y 11902.35  J1 27700 ARTHROPLASTY ANKLE 2178.00 090 Y 11533.56  J1 27702 ARTHROPLASTY ANKLE W/IMPLANT 3426.00 090 Y 21037.72  J1* 27703 ARTHROPLASTY ANKLE REVISION TOTAL ANKLE 3940.80 090 Y 22251.08   27704 REMOVAL ANKLE IMPLANT 2035.20 090 N 4107.04  J1 27705 OSTEOTOMY TIBIA 2706.00 090 Y 11673.34  J1 27707 OSTEOTOMY FIBULA 1442.40 090 N 5522.67  J1 27709 OSTEOTOMY TIBIA & FIBULA 4065.60 090 Y 22669.18  J1* 27712 OSTEOTOMY MULTIPLE W/RELIGNMT INTRAMEDULLARY ROD 3922.80 090 Y 22251.08  J1* 27715 OSTEOPLASTY TIBIA&FIBULA LENGTHENING/SHORTENING 3823.20 090 Y 22251.08  J1 27720 REPAIR NONUNION/MALUNION TIBIA W/O GRAFT 3118.80 090 Y 11532.28  J1 27722 REPAIR NONUNION/MALUNION TIBIA W/SLIDING GRAFT 3193.20 090 Y 10934.80  J1* 27724 RPR NON/MAL TIBIA W/ILIAC/OTH AGRFT 4459.20 090 Y 12031.89  J1* 27725 RPR NON/MAL TIBIA SYNOSTOSIS W/FIBULA ANY METH 4322.40 090 Y 12031.89  J1 27726 REPAIR FIBULA NONUNION/MALUNION W/INT FIXATION 3415.20 090 N 11581.22  J1* 27727 REPAIR CONGENITAL PSEUDARTHROSIS TIBIA 3700.80 090 Y 12031.89  J1 27730 ARREST EPIPHYSEAL OPEN DISTAL TIBIA 2108.40 090 N 5784.56  J1 27732 ARREST EPIPHYSEAL OPEN DISTAL FIBULA 1624.80 090 N 5710.81  J1 27734 ARREST EPIPHYSEAL OPEN DISTAL TIBIA&FIBULA 2354.40 090 N 5710.81  J1 27740 ARREST EPIPHYSEAL ANY METHOD TIBIA & FIBULA 2532.00 090 Y 5710.81  J1 27742 ARRST EPIPHYSL ANY METH TIBFIB&DSTL FEMUR 2774.40 090 Y 5710.81  J1 27745 PROPH TX N/P/PLTWR W/WO METHYLMETHACRYLATE TIBIA 2703.60 090 Y 11731.23   27750 CLTX TIBIAL SHAFT FX W/O MANIPULATION 1254.00 090 N 298.91  J1 27752 CLTX TIBIAL SHAFT FX W/MANJ W/WO SKEL TRACJ 1927.20 090 N 2843.74  J1 27756 PRQ SKELETAL FIXATION TIBIAL SHAFT FRACTURE 2074.80 090 Y 11559.47  J1 27758 OPTX TIBIAL SHFT FX W/PLATE/SCREWS W/WO CERCLAGE 3198.00 090 Y 22618.18  J1 27759 TX TIBL SHFT FX IMED IMPLT W/WO SCREWS&/CERCLA 3553.20 090 Y 22990.94   27760 CLTX MEDIAL MALLEOLUS FX W/O MANIPULATION 1200.00 090 N 298.91  J1 27762 CLTX MEDIAL MALLS FX W/MANJ W/WO SKN/SKEL TRACJ 1738.80 090 N 2837.20  J1 27766 OPEN TREATMENT MEDIAL MALLEOLUS FRACTURE 2161.20 090 N 12130.41   27767 CLOSED TREATMENT PST MALLEOLUS FRACTURE W/O MANJ 1054.80 090 N 298.91

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 27768 CLOSED TREATMENT PST MALLEOLUS FRACTURE W/MANJ 1608.00 090 N 2800.43  J1 27769 OPEN TREATMENT POSTERIOR MALLEOLUS FRACTURE 2601.60 090 N 11810.56   27780 CLTX PROX FIBULA/SHFT FX W/O MANJ 1119.60 090 N 298.91  J1 27781 CLTX PROX FIBULA/SHFT FX W/MANJ 1572.00 090 N 2840.33  J1 27784 OPEN TREATMENT PROXIMAL FIBULA/SHAFT FRACTURE 2526.00 090 N 11689.97   27786 CLTX DSTL FIBULAR FX LAT MALLS W/O MANJ 1135.20 090 N 298.91   27788 CLTX DSTL FIBULAR FX LAT MALLS W/MANJ 1532.40 090 N 298.91  J1 27792 OPEN TX DISTAL FIBULAR FRACTURE LAT MALLEOLUS 2305.20 090 N 11687.09   27808 CLOSED TX BIMALLEOLAR ANKLE FRACTURE W/O MANJ 1212.00 090 N 298.91  J1 27810 CLOSED TX BIMALLEOLAR ANKLE FRACTURE W/MANJ 1700.40 090 N 2843.53  J1 27814 OPEN TREATMENT BIMALLEOLAR ANKLE FRACTURE 2728.80 090 Y 11689.97   27816 CLTX TRIMALLEOLAR ANKLE FX W/O MANIPULATION 1195.20 090 N 298.91  J1 27818 CLTX TRIMALLEOLAR ANKLE FX W/MANIPULATION 1761.60 090 N 2843.67  J1 27822 OPEN TX TRIMALLEOLAR ANKLE FX W/O FIXJ PST LIP 3140.40 090 Y 11691.25  J1 27823 OPEN TX TRIMALLEOLAR ANKLE FX W/FIXJ PST LIP 3526.80 090 Y 11746.91   27824 CLTX FX W8 BRG ARTCLR PRTN DSTL TIBIA W/O MANJ 1146.00 090 N 298.91  J1 27825 CLTX FX W8 BRG ARTCLR PRTN DSTL TIB W/SKEL TRACJ 1951.20 090 N 2800.14  J1 27826 OPEN TREATMENT FRACTURE DISTAL TIBIA FIBULA 3063.60 090 Y 11661.50  J1 27827 OPEN TREATMENT FRACTURE DISTAL TIBIA ONLY 4009.20 090 Y 22752.93  J1 27828 OPEN TREATMENT FRACTURE DISTAL TIBIA & FIBULA 4753.20 090 Y 22610.00  J1 27829 OPEN TX DISTAL TIBIOFIBULAR JOINT DISRUPTION 2539.20 090 Y 11726.75   27830 CLTX PROX TIBFIB JT DISLC W/O ANES 1411.20 090 N 298.91  J1 27831 CLTX PROX TIBFIB JT DISLC REQ ANES 1472.40 090 N 5784.56  J1 27832 OPEN TX PROX TIBFIB JOINT DISLOCATE EXC PROX FIB 2704.80 090 Y 11692.85   27840 CLOSED TX ANKLE DISLOCATION W/O ANESTHESIA 1375.20 090 N 298.91  J1 27842 CLTX ANKLE DISLC REQ ANES W/WO PRQ SKEL FIXJ 1780.80 090 N 2822.26  J1 27846 OPTX ANKLE DISLOCATION W/O REPAIR/INTERNAL FIXJ 2581.20 090 Y 12505.60  J1 27848 OPTX ANKLE DISLOCATION W/REPAIR/INT/XTRNL FIXJ 2820.00 090 Y 11745.95  J1 27860 MANIPULATION ANKLE UNDER GENERAL ANESTHESIA 590.40 010 N 5557.81  J1 27870 ARTHRODESIS ANKLE OPEN 3597.60 090 Y 22116.34  J1 27871 ARTHRODESIS TIBIOFIBULAR JOINT PROXIMAL/DISTAL 2462.40 090 Y 22387.09  J1* 27880 AMPUTATION LEG THROUGH TIBIA&FIBULA 3206.40 090 Y 27818.41  J1* 27881 AMP LEG THRU TIBFIB W/IMMT FITG TQ W/1ST CST 3044.40 090 Y 12031.89  J1* 27882 AMPUTATION LEG THRU TIBIA&FIBULA OPEN CIRCULAR 2110.80 090 N 12031.89  J1 27884 AMP LEG THRU TIBIA&FIBULA SEC CLOSURE/SCAR REV 2060.40 090 N 5769.09  J1* 27886 AMP LEG THRU TIBIA&FIBULA RE-AMPUTATION 2318.40 090 N 12031.89  J1* 27888 AMP ANKLE-MALLI TIBFIB W/PLSTC CLSR&RESCJ NRV 2311.20 090 Y 22251.08  J1 27889 ANKLE DISARTICULATION 2266.80 090 N 12794.10  J1 27892 DCMPRN FASCT LEG ANT&/LAT W/DBRDMT MUSC&/NERVE 1912.80 090 N 5678.27  J1 27893 DCMPRN FASCT LEG PST W/DBRDMT MUSC&/NRV 2194.80 090 N 12794.10  J1 27894 DCMPRN FASCT LEG ANT&/LAT&PST W/DBRDMT MUS 2919.60 090 Y 5710.81   27899 UNLISTED PROCEDURE LEG/ANKLE BR YYY N 298.91  J1 28001 INCISION&DRAINAGE BURSA FOOT 963.60 000 N 2865.79  J1 28002 I&D BELOW FASCIA FOOT 1 BURSAL SPACE 1534.80 000 N 2815.65  J1 28003 I&D BELOW FASCIA FOOT MULTIPLE AREAS 2416.80 000 N 5730.77  J1 28005 INCISION BONE CORTEX FOOT 2024.40 090 N 5660.34  J1 28008 FASCIOTOMY FOOT&/TOE 1520.40 090 N 5726.57

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 132 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 28010 TENOTOMY PERCUTANEOUS TOE SINGLE TENDON 822.00 090 N 2844.24  J1 28011 TENOTOMY PERCUTANEOUS TOE MULTIPLE TENDON 1110.00 090 N 2844.88  J1 28020 ARTHRT W/EXPL DRG/RMVL LOOSE/FB NTRTRSL/TARS JT 1962.00 090 N 5665.83  J1 28022 ARTHRT W/EXPL DRG/RMVL LOOSE/FB MTTARPHLNGL JT 1729.20 090 N 5704.45  J1 28024 ARTHRT W/EXPL DRG/RMVL LOOSE/FB IPHAL JT 1616.40 090 N 2817.50  J1 28035 RELEASE TARSAL TUNNEL 1862.40 090 N 3491.76  J1 28039 EXCISION TUMOR SOFT TIS FOOT/TOE SUBQ 1.5 CM/> 1744.80 090 Y 4817.68  J1 28041 EXC TUMOR SOFT TISSUE FOOT/TOE SUBFASC 1.5 CM/> 1590.00 090 N 4814.29  J1 28043 EXCISION TUMOR SOFT TISSUE FOOT/TOE SUBQ <1.5CM 1378.80 090 N 2863.28  J1 28045 EXC TUMOR SOFT TISSUE FOOT/TOE SUBFASC <1.5CM 1707.60 090 N 4842.62  J1 28046 RAD RESECTION TUMOR SOFT TISSUE FOOT/TOE <3CM 2515.20 090 N 4746.72  J1 28047 RAD RESECTION TUMOR SOFT TISSUE FOOT/TOE 3 CM/> 3652.80 090 Y 4841.89  J1 28050 ARTHRT W/BX INTERTARSAL/TARSOMETATARSAL JOINT 1472.40 090 N 5750.58  J1 28052 ARTHRTOMY W/BX METATARSOPHALANGEAL JOINT 1536.00 090 N 5669.45  J1 28054 ARTHRTOMY W/BX INTERPHALANGEAL JOINT 1300.80 090 N 5738.86  J1 28055 NEURECTOMY INTRINSIC MUSCULATURE OF FOOT 1347.60 090 N 3545.65  J1 28060 FASCIECTOMY PLANTAR FASCIA PARTIAL SPX 1848.00 090 N 5693.74  J1 28062 FASCIECTOMY PLANTAR FASCIA RADICAL SPX 2024.40 090 N 5599.17  J1 28070 SYNVCT INTERTARSAL/TARSOMETATARSAL JT EA SPX 1856.40 090 N 12740.69  J1 28072 SYNOVECTOMY METATARSOPHALANGEAL JOINT EACH 1743.60 090 N 5588.03  J1 28080 EXCISION INTERDIGITAL MORTON NEUROMA SINGLE EACH 1887.60 090 N 2833.22  J1 28086 SYNOVECTOMY TENDON SHEATH FOOT FLEXOR 1910.40 090 Y 5671.47  J1 28088 SYNOVECTOMY TENDON SHEATH FOOT EXTENSOR 1618.80 090 N 5784.56  J1 28090 EXC LESION TENDON SHEATH/CAPSULE W/SYNVCT FOOT 1647.60 090 N 2833.50  J1 28092 EXC LESION TENDON SHEATH/CAPSULE W/SYNVCT TOE EA 1484.40 090 N 2835.92  J1 28100 EXCISION/CURETTAGE CYST/TUMOR TALUS/CALCANEUS 2188.80 090 Y 5692.44  J1 28102 EXC/CURTG CST/B9 TUM TALUS/CLCNS W/ILIAC/AGRFT 2186.40 090 Y 11669.82  J1 28103 EXC/CURETTAGE CYST/TUMOR TALUS/CALCANEUS ALGRFT 1366.80 090 Y 11393.79  J1 28104 EXC/CURTG BONE CYST/B9 TUMORTARSAL/METATARSAL 1860.00 090 Y 5735.97  J1 28106 EXC/CURTG CST/B9 TUM TARSAL/METAR W/ILIAC/AGRFT 1501.20 090 Y 11978.16  J1 28107 EXC/CURTG CST/B9 TUM TARSAL/METAR W/ALGRFT 1785.60 090 Y 11494.22  J1 28108 EXC/CURTG CST/B9 TUM PHALANGES FOOT 1539.60 090 N 2831.51  J1 28110 OSTECTOMY PRTL 5TH METAR HEAD SPX 1630.80 090 N 5720.35  J1 28111 OSTECTOMY COMPLETE 1ST METATARSAL HEAD 1707.60 090 N 5699.53  J1 28112 OSTECTOMY COMPLETE OTHER METATARSAL HEAD 2/3/4 1716.00 090 N 5723.97  J1 28113 OSTECTOMY COMPLETE 5TH METATARSAL HEAD 2070.00 090 N 5755.06  J1 28114 OSTC COMPL ALL METAR HEADS W/PRTL PROX PHALANGC 3784.80 090 Y 5665.98  J1 28116 OSTECTOMY TARSAL COALITION 2742.00 090 N 5721.66  J1 28118 OSTECTOMY CALCANEUS 2143.20 090 Y 5472.77  J1 28119 OSTECTOMY CALCANEUS SPUR W/WO PLNTAR FASCIAL RLS 1866.00 090 N 5625.05  J1 28120 PARTIAL EXCISION BONE TALUS/CALCANEUS 2394.00 090 N 5671.62  J1 28122 PRTL EXC B1 TARSAL/METAR B1 XCP TALUS/CALCANEUS 2094.00 090 Y 5723.54  J1 28124 PARTICAL EXCISION BONE PHALANX TOE 1686.00 090 N 5760.12  J1 28126 RESECTION PARTIAL/COMPLETE PHALANGEAL BASE EACH 1380.00 090 N 5748.12  J1 28130 TALECTOMY ASTRAGALECTOMY 2203.20 090 Y 12115.70  J1 28140 METATARSECTOMY 2052.00 090 N 5712.69  J1 28150 PHALANGECTOMY TOE EACH TOE 1478.40 090 N 5747.11

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 28153 RESECTION CONDYLE DISTAL END PHALANX EACH TOE 1444.80 090 N 5758.24  J1 28160 HEMIPHALANGECTOMY/INTERPHALANGEAL JOINT EXC TOE 1459.20 090 N 5747.98  J1 28171 RAD RESCJ TUMOR TARSAL EXCEPT TALUS/CALCANEUS 3936.00 090 Y 5767.64  J1 28173 RADICAL RESECTION TUMOR METATARSAL 2557.20 090 N 5679.14  J1 28175 RADICAL RESECTION TUMOR PHALANX OR TOE 1648.80 090 N 2845.02   28190 REMOVAL FOREIGN BODY FOOT SUBCUTANEOUS 882.00 010 N 902.47  J1 28192 REMOVAL FOREIGN BODY FOOT DEEP 1633.20 090 N 2870.53  J1 28193 REMOVAL FOREIGN BODY FOOT COMPLICATED 1850.40 090 N 2868.02  J1 28200 RPR TDN FLXR FOOT 1/2 W/O FREE GRAFG EACH TENDON 1764.00 090 N 5570.24  J1 28202 RPR TENDON FLXR FOOT SEC W/FREE GRAFT EA TENDON 2109.60 090 Y 11910.99  J1 28208 REPAIR TENDON EXTENSOR FOOT 1/2 EACH TENDON 1716.00 090 N 5513.56  J1 28210 RPR TENDON XTNSR FOOT SEC W/FREE GRAFT EA TENDON 2078.40 090 Y 11761.94  J1 28220 TENOLYSIS FLEXOR FOOT SINGLE TENDON 1596.00 090 N 2731.08  J1 28222 TENOLYSIS FLEXOR FOOT MULTIPLE TENDONS 1846.80 090 N 5783.41  J1 28225 TENOLYSIS EXTENSOR FOOT SINGLE TENDON 1472.40 090 N 5658.89  J1 28226 TENOLYSIS EXTENSOR FOOT MULTIPLE TENDON 2212.80 090 N 5686.51  J1 28230 TX OPN TENDON FLEXOR FOOT SINGLE/MULT TENDON SPX 1533.60 090 N 2823.19  J1 28232 TX OPEN TENDON FLEXOR TOE 1 TENDON SPX 1342.80 090 N 2844.45  J1 28234 TENOTOMY OPEN EXTENSOR FOOT/TOE EACH TENDON 1447.20 090 N 2814.37  J1 28238 RCNSTJ PST TIBL TDN W/EXC ACCESSORY TARSL NAVCLR 2380.80 090 Y 12200.78  J1 28240 TENOTOMY LENGTHENING/RLS ABDUCTOR HALLUCIS MUSC 1584.00 090 N 5595.26  J1 28250 DIVISION PLANTAR FASCIA & MUSCLE SPX 2060.40 090 Y 5783.41  J1 28260 CAPSULOTOMY MIDFOOT MEDIAL RELEASE ONLY SPX 2521.20 090 Y 5710.81  J1 28261 CAPSULOTOMY MIDFOOT W/TENDON LENGTHENING 4097.22 090 N 2845.02  J1 28262 CAPSUL MIDFOOT W/PST TALOTIBL CAPSUL&TDN LNGTH 4974.00 090 Y 12763.08  J1 28264 CAPSULOTOMY MIDTARSAL 3492.00 090 Y 2845.02  J1 28270 CAPSUL MTTARPHLNGL JT W/WO TENORRHAPHY EA JT SPX 1725.60 090 N 5575.16  J1 28272 CAPSULOTOMY IPHAL JOINT EACH JOINT SPX 1360.80 090 N 2845.02  J1 28280 SYNDACTYLIZATION TOES 1813.20 090 N 5717.90  J1 28285 CORRECTION HAMMERTOE 1903.20 090 N 5597.87  J1 28286 CORRECTION COCK-UP 5TH TOE W/PLASTIC CLOSURE 1566.00 090 N 5783.12  J1 28288 OSTC PRTL EXOSTC/CONDYLC METAR HEAD 2144.40 090 N 5736.84  J1 28289 HALLUX RIGIDUS W/CHEILECTOMY 1ST MP JT W/O IMPLT 2527.20 090 Y 5699.10  J1 28291 HALLUX RIGIDUS W/CHEILECTOMY 1ST MP JT W/IMPLT 2521.20 090 Y 11193.24  J1 28292 CORRJ HLX VLGS BNCTY SESMDC RESCJ PROX PHLX BASE 2564.40 090 Y 5664.53  J1 28295 CORRJ HLX VLGS BNCTY SESMDC PROX METAR OSTEOT 3808.80 090 Y 5444.86  J1 28296 CORRJ HLX VLGS BNCTY SESMDC DSTL METAR OSTEOT 3165.60 090 Y 5529.46  J1 28297 CORRJ HLX VLGS BNCTY SESMDC JOINT ARTHRODESIS 3698.40 090 Y 11268.41  J1 28298 CORRJ HLX VLGS BNCTY SESMDC PROX PHLX OSTEOT 2961.60 090 Y 11816.63  J1 28299 CORRJ HLX VLGS BNCTY SESMDC W/DOUBLE OSTEOTOMY 3585.60 090 Y 11761.62  J1 28300 OSTEOTOMY CALCANEUS W/WO INTERNAL FIXATION 2307.60 090 Y 11648.39  J1 28302 OSTEOTOMY TALUS 2558.40 090 Y 11560.11  J1 28304 OSTEOTOMY TARSAL BONES OTH/THN CALCANEUS/TALUS 2938.80 090 Y 12065.80  J1 28305 OSTEOT TARSAL OTH/THN CALCANEUS/TALUS W/AGRFT 2406.00 090 Y 11169.25  J1 28306 OSTEOT W/WO LNGTH SHRT/CORRJ 1ST METAR 2150.40 090 Y 11839.34  J1 28307 OSTEOT W/WO LNGTH SHRT/CORRJ METAR XCP 1ST TOE 2565.42 090 N 11989.03  J1 28308 OSTEOT W/WO LNGTH SHRT/CORRJ METAR XCP 1ST EA 2023.20 090 Y 5539.88

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 134 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 28309 OSTEOT W/WO LNGTH SHRT/ANGULAR CORRJ METAR MLT 3162.00 090 N 11770.57  J1 28310 OSTEOT SHRT CORRJ PROX PHALANX 1ST TOE 1933.20 090 N 11885.72  J1 28312 OSTEOT SHRT CORRJ OTH PHALANGES ANY TOE 1839.60 090 N 5662.80  J1 28313 RCNSTJ ANGULAR DFRM TOE SOFT TISS PX ONLY 1873.20 090 N 5540.74  J1 28315 SESAMOIDECTOMY FIRST TOE SPX 1705.20 090 N 5747.11  J1 28320 REPAIR NONUNION/MALUNION TARSAL BONES 2164.80 090 Y 22513.03  J1 28322 RPR NON/MALUNION METARSAL W/WO BONE GRAFT 2790.00 090 Y 11541.24  J1 28340 RCNSTJ TOE MACRODACTYLY SOFT TISSUE RESECTION 2004.00 090 N 5710.81  J1 28341 RCNSTJ TOE MACRODACTYLY REQUIRING BONE RESECTION 2322.00 090 N 5710.81  J1 28344 RECONSTRUCTION TOE POLYDACTYLY 1482.00 090 N 5784.56  J1 28345 RCNSTJ TOE SYNDACTYLY W/WO SKIN GRAFT EACH WEB 1814.40 090 N 2845.02  J1 28360 RECONSTRUCTION CLEFT FOOT 3916.80 090 Y 12031.89   28400 CLOSED TX CALCANEAL FRACTURE W/O MANIPULATION 886.80 090 N 298.91   28405 CLOSED TX CALCANEAL FRACTURE W/MANIPULATION 1394.40 090 N 298.91  J1 28406 PRQ SKELETAL FIXJ CALCANEAL FRACTURE W/MANJ 2022.00 090 N 12160.47  J1 28415 OPEN TREATMENT CALCANEAL FRACTURE 4014.00 090 Y 11573.55  J1 28420 OPEN TREATMENT CALCANEAL FRACTURE W BONE GRAFT 4638.00 090 Y 22716.41   28430 CLOSED TX TALUS FRACTURE W/O MANIPULATION 862.80 090 N 298.91  J1 28435 CLOSED TX TALUS FRACTURE W/MANIPULATION 1329.60 090 N 2845.02  J1 28436 PRQ SKELETAL FIXATION TALUS FRACTURE W/MANJ 1786.80 090 N 11800.32  J1 28445 OPEN TREATMENT TALUS FRACTURE 3633.60 090 Y 11644.23  J1 28446 OPEN OSTEOCHONDRAL AUTOGRAFT TALUS 4358.40 090 Y 11507.02   28450 TX TARSAL BONE FX XCP TALUS&CALCN W/O MANJ 757.20 090 N 298.91  J1 28455 TX TARSAL BONE FX XCP TALUS&CALCN W/MANJ 1039.20 090 N 2845.02  J1 28456 PRQ SKEL FIXJ TARSL FX XCP TALUS&CALCNS W/MANJ 1276.50 090 N 11602.33  J1 28465 OPEN TX TARSAL FRACTURE XCP TALUS & CALCANEUS EA 2266.80 090 N 11546.68   28470 CLOSED TX METATARSAL FRACTURE W/O MANIPULATION 781.20 090 N 298.91   28475 CLTX METAR FX W/MANJ 912.00 090 N 298.91  J1 28476 PRQ SKEL FIXJ METAR FX W/MANJ 1394.40 090 N 5530.62  J1 28485 OPEN TREATMENT METATARSAL FRACTURE EACH 1998.00 090 N 11687.09   28490 CLTX FX GRT TOE PHLX/PHLG W/O MANJ 504.00 090 N 298.91   28495 CLTX FX GRT TOE PHLX/PHLG W/MANJ 637.20 090 N 298.91  J1 28496 PRQ SKEL FIXJ FX GRT TOE PHLX/PHLG W/MANJ 1608.00 090 N 5729.46  J1 28505 OPEN TX FRACTURE GREAT TOE/PHALANX/PHALANGES 2346.00 090 N 5599.89   28510 CLTX FX PHLX/PHLG OTH/THN GRT TOE W/O MANJ 427.20 090 N 298.91   28515 CLTX FX PHLX/PHLG OTH/THN GRT TOE W/MANJ 582.00 090 N 298.91  J1 28525 OPEN TX FRACTURE PHALANX/PHALANGES NOT GREAT TOE 2023.20 090 N 5639.08   28530 CLOSED TREATMENT SESAMOID FRACTURE 403.20 090 N 298.91  J1 28531 OPEN TX SESAMOID FRACTURE W/WO INTERNAL FIXATION 1182.00 090 N 12744.21   28540 CLTX TARSAL DISLC OTH/THN TALOTARSAL W/O ANES 693.60 090 N 298.91  J1 28545 CLTX TARSAL DISLC OTH/THN TALOTARSAL W/ANES 1111.20 090 N 5710.81  J1 28546 PRQ SKEL FIXJ TARSL DISLC XCP TALOTARSAL W/MANJ 2109.60 090 N 2842.96  J1 28555 OPEN TREATMENT TARSAL BONE DISLOCATION 3062.40 090 Y 11472.47   28570 CLOSED TX TALOTARSAL JOINT DISLC W/O ANES 841.20 090 N 298.91  J1 28575 CLOSED TX TALOTARSAL JOINT DISLOCATION W/ANES 1359.60 090 N 5784.56  J1 28576 PRQ SKEL FIXJ TALOTARSAL JT DISLC W/MANJ 1375.20 090 N 12442.58  J1 28585 OPEN TREATMENT TALOTARSAL JOINT DISLOCATION 3142.80 090 Y 11415.86

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   28600 CLOSED TX TARSOMETATARSAL DISLOCATION W/O ANES 771.60 090 N 298.91   28605 CLOSED TX TARSOMETATARSAL DISLOCATION W/ANES 1227.60 090 N 298.91  J1 28606 PRQ SKEL FIXJ TARS JT DISLC W/MANJ 1354.80 090 N 5588.03  J1 28615 OPEN TREATMENT TARSOMETATARSAL JOINT DISLOCATION 2946.00 090 Y 11536.12   28630 CLTX METATARSOPHLNGL JT DISLC W/O ANES 546.00 010 N 298.91  J1 28635 CLTX METATARSOPHLNGL JT DISLC REQ ANES 618.00 010 N 2844.52  J1 28636 PRQ SKEL FIXJ METATARSOPHLNGL JT DISLC W/MANJ 1118.40 010 N 5476.25  J1 28645 OPEN TX METATARSOPHALANGEAL JOINT DISLOCATION 2308.80 090 N 5538.00   28660 CLTX INTERPHALANGEAL JOINT DISLOCATION W/O ANES 438.00 010 N 298.91   28665 CLTX INTERPHALANGEAL JOINT DISLOCATION REQ ANES 534.00 010 N 349.86  J1 28666 PRQ SKEL FIXJ INTERPHALANGEAL JOINT DISLC W/MANJ 625.14 010 N 5750.43  J1 28675 OPEN TREATMENT INTERPHALANGEAL JOINT DISLOCATION 2050.80 090 N 5688.97  J1 28705 ARTHRODESIS PANTALAR 4339.20 090 Y 28322.89  J1 28715 ARTHRODESIS TRIPLE 3340.80 090 Y 21827.95  J1 28725 ARTHRODESIS SUBTALAR 2761.20 090 Y 22358.13  J1 28730 ARTHRD MIDTARSL/TARSOMETATARSAL MULT/TRANSVRS 2599.20 090 Y 21896.59  J1 28735 ARTHRD MIDTARSL/TARS MLT/TRANSVRS W/OSTEOT 2776.80 090 Y 21780.73  J1 28737 ARTHRD W/TDN LNGTH&ADVMNT TARSL NVCLR-CUNEIFOR 2433.60 090 Y 21894.07  J1 28740 ARTHRODESIS MIDTARSOMETATARSAL SINGLE JOINT 2944.80 090 Y 11199.32  J1 28750 ARTHRODESIS GREAT TOE METATARSOPHALANGEAL JOINT 2791.20 090 N 11358.92  J1 28755 ARTHRODESIS GREAT TOE INTERPHALANGEAL JOINT 1802.40 090 N 11931.78  J1 28760 ARTHRD W/XTNSR HALLUCIS LONGUS TR 1ST METAR NCK 2745.60 090 Y 11810.56  J1* 28800 AMPUTATION FOOT MIDTARSAL 1873.20 090 Y 5710.81  J1 28805 AMPUTATION FOOT TRANSMETARSAL 2514.00 090 N 5750.14  J1 28810 AMPUTATION METATARSAL W/TOE SINGLE 1504.80 090 N 5757.66  J1 28820 AMPUTATION TOE METATARSOPHALANGEAL JOINT 1941.60 000 N 5767.35  J1 28825 AMPUTATION TOE INTERPHALANGEAL JOINT 1858.80 000 N 5770.68  J1 28890 ESWT HI NRG PHYS/QHP W/US GDN INVG PLNTAR FASCIA 1118.40 090 N 2838.91   28899 UNLISTED PROCEDURE FOOT/TOES BR YYY N 298.91   29000 APPLICATION HALO TYPE BODY CAST 1238.40 000 N 349.86   29010 APPLICATION RISSER JACKET LOCALIZER BODY ONLY 954.00 000 N 349.86   29015 APPLICATION RISSER JACKET LOCALIZER BODY W/HEAD 1027.20 000 N 349.86   29035 APPLICATION BODY CAST SHOULDER HIPS 896.40 000 N 349.86   29040 APPLICATION BODY CAST SHOULDER HIPS HEAD MINERVA 1022.40 000 N 349.86   29044 APPLICATION BODY CAST SHOULDER HIPS W/ONE THIGH 1002.00 000 N 204.89   29046 APPLICATION BODY CAST SHOULDER HIPS BOTH THIGHS 1100.40 000 N 349.86   29049 APPLICATION CAST FIGURE-OF-8 349.20 000 N 349.86   29055 APPLICATION CAST SHOULDER SPICA 780.00 000 N 349.86   29058 APPLICATION CAST PLASTER VELPEAU 433.20 000 N 349.86   29065 APPLICATION CAST SHOULDER HAND LONG ARM 339.60 000 N 349.86   29075 APPLICATION CAST ELBOW FINGER SHORT ARM 304.80 000 N 349.86   29085 APPLICATION CAST HAND & LOWER FOREARM GAUNTLET 336.00 000 N 204.89   29086 APPLICATION CAST FINGER 268.80 000 N 204.89   29105 APPLICATION LONG ARM SPLINT SHOULDER HAND 286.80 000 N 204.89   29125 APPLICATION SHORT ARM SPLINT FOREARM-HAND STATIC 230.40 000 N 163.53   29126 APPLICATION SHORT ARM SPLINT DYNAMIC 271.20 000 N 163.53   29130 APPLICATION FINGER SPLINT STATIC 145.20 000 N 163.53

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 136 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   29131 APPLICATION FINGER SPLINT DYNAMIC 186.00 000 N 80.73   29200 STRAPPING THORAX 117.60 000 N 204.89   29240 STRAPPING SHOULDER 106.80 000 N 163.53   29260 STRAPPING ELBOW/WRIST 105.60 000 N 80.73   29280 STRAPPING HAND/FINGER 104.40 000 N 80.73   29305 APPLICATION HIP SPICA CAST 1 LEG 865.20 000 N 349.86   29325 APPL HIP SPICA CAST ONE&ONE-HALF SPICA/BOTH LEGS 956.40 000 N 349.86   29345 APPLICATION LONG LEG CAST THIGH-TOE 476.40 000 N 349.86   29355 APPLICATION LONG LEG CAST WALKER/AMBULATORY TYPE 499.20 000 N 349.86   29358 APPLICATION LONG LEG CAST BRACE 561.60 000 N 349.86   29365 APPLICATION CYLINDER CAST THIGH ANKLE 432.00 000 N 349.86   29405 APPLICATION SHORT LEG CAST BELOW KNEE-TOE 279.60 000 N 349.86   29425 APPLICATION SHORT LEG CAST WALKING/AMBULATORY 264.00 000 N 349.86   29435 APPLICATION PATELLAR TENDON BEARING CAST 402.00 000 N 349.86   29440 ADDING WALKER PREVIOUSLY APPLIED CAST 148.80 000 N 204.89   29445 APPLICATION RIGID TOTAL CONTACT LEG CAST 452.40 000 N 349.86   29450 APPL CLUBFOOT CAST MOLDING/MANJ LONG/SHORT LEG 513.60 000 N 204.89   29505 APPLICATION LONG LEG SPLINT THIGH ANKLE/TOES 306.00 000 N 204.89   29515 APPLICATION SHORT LEG SPLINT CALF FOOT 249.60 000 N 204.89   29520 STRAPPING HIP 124.80 000 N 163.53   29530 STRAPPING KNEE 106.80 000 N 163.53   29540 STRAPPING ANKLE &/FOOT 98.40 000 N 204.89   29550 STRAPPING TOES 67.20 000 N 80.73   29580 STRAPPING UNNA BOOT 228.00 000 N 204.89   29581 APPL MLTLAYR COMPRES LEG BELOW KNEE W/ANKLE FOOT 319.20 000 N 204.89   29584 APPL MLTLAYR COMPRES SYS UPARM LWARM HAND&FING 295.20 000 N 204.89   29700 REMOVAL/BIVALVING GAUNTLET BOOT/BODY CAST 218.40 000 N 349.86   29705 REMOVAL/BIVALVING FULL ARM/FULL LEG CAST 222.00 000 N 349.86   29710 RMVL/BIVALV SHO/HIP SPICA MINERVA/RISSER JACKET 428.40 000 N 349.86   29720 REPAIR SPICA BODY CAST/JACKET 296.40 000 N 204.89   29730 WINDOWING CAST 224.40 000 N 204.89   29740 WEDGING CAST EXCEPT CLUBFOOT CASTS 348.00 000 N 349.86   29750 WEDGING CLUBFOOT CAST 375.60 000 N 349.86   29799 UNLISTED PROCEDURE CASTING/STRAPPING BR YYY N 204.89  J1 29800 ARTHRS TEMPOROMANDIBULR JT DX W/WO SYNVAL BX SPX 1894.80 090 N 5782.68  J1 29804 ARTHROSCOPY TEMPOROMANDIBULAR JOINT SURGICAL 2211.60 090 Y 5781.09  J1 29805 DIAGNOSTIC ARTHROSCOPY SHOULDER +- SYNOVIAL BX 1675.20 090 N 5741.90  J1 29806 SURGICAL ARTHROSCOPY SHOULDER CAPSULORRHAPHY 3772.80 090 N 11931.46  J1 29807 SURGICAL ARTHROSCOPY SHOULDER REPAIR SLAP LESION 3680.40 090 N 12141.92  J1 29819 SURGICAL ARTHROSCOPY SHOULDER REMOVAL LOOSE/FB 2097.60 090 N 5762.58  J1 29820 SURGICAL ARTHROSCOPY SHOULDER PRTL SYNOVECTOMY 1917.60 090 Y 12722.78  J1 29821 SURGICAL ARTHROSCOPY SHOULDER COMPL SYNOVECTOMY 2125.20 090 Y 5780.66  J1 29822 SURGICAL ARTHROSCOPY SHOULDER LMTD DBRDMT 1/2 1962.00 090 Y 5754.34  J1 29823 SURGICAL ARTHROSCOPY SHOULDER XTNSV DBRDMT 3+ 2133.60 090 Y 5747.11  J1 29824 SURGICAL ARTHROSCOPY SHOULDER DSTL CLAVICULC 2418.00 090 Y 5754.19  J1 29825 SURGICAL ARTHROSCOPY SHOULDER W/LSS&RESCJ ADS 2097.60 090 Y 5767.50   29826 SURGICAL ARTHROSCOPY SHO W/CORACOACRM LIGM RLS 612.00 ZZZ Y

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 29827 SURGICAL ARTHROSCOPY SHOULDER W/ROTATOR CUFF RPR 3805.20 090 Y 11938.50  J1 29828 SURGICAL ARTHROSCOPY SHOULDER BICEPS TENODESIS 3266.40 090 Y 12451.22  J1 29830 ARTHROSCOPY ELBOW DIAG W/WO SYNOVIAL BIOPSY SPX 1624.80 090 N 5784.56  J1 29834 ARTHROSCOPY ELBOW SURGICAL W/REMOVAL LOOSE/FB 1759.20 090 Y 5777.62  J1 29835 ARTHROSCOPY ELBOW SURGICAL SYNOVECTOMY PARTIAL 1822.80 090 Y 5772.56  J1 29836 ARTHROSCOPY ELBOW SURGICAL SYNOVECTOMY COMPLETE 2091.60 090 Y 12780.99  J1 29837 ARTHROSCOPY ELBOW SURGICAL DEBRIDEMENT LIMITED 1892.40 090 Y 5774.01  J1 29838 ARTHROSCOPY ELBOW SURGICAL DEBRIDEMENT EXTENSIVE 2120.40 090 N 5777.91  J1 29840 ARTHROSCOPY WRIST DIAG W/WO SYNOVIAL BIOPSY SPX 1610.40 090 N 5784.56  J1 29843 ARTHROSCOPY WRIST INFECTION LAVAGE&DRAINAGE 1740.00 090 Y 5710.81  J1 29844 ARTHROSCOPY WRIST SURGICAL SYNOVECTOMY PARTIAL 1783.20 090 Y 5701.12  J1 29845 ARTHROSCOPY WRIST SURGICAL SYNOVECTOMY COMPLETE 2090.40 090 Y 5773.43  J1 29846 ARTHRS WRST EXC&/RPR TRIANG FIBROCART&/JOINT 1864.80 090 N 5762.29  J1 29847 ARTHROSCOPY WRIST SURG INT FIXJ FX/INSTABILITY 1945.20 090 Y 12196.94  J1 29848 NDSC WRST SURG W/RLS TRANSVRS CARPL LIGM 1824.00 090 N 2841.96  J1 29850 ARTHROSCOPY AID TX SPINE&/FX KNEE W/O FIXJ 2227.20 090 N 2834.50  J1 29851 ARTHROSCOPY AID TX SPINE&/FX KNEE W/FIXJ 3309.60 090 Y 2817.07  J1 29855 ARTHRS AID TIBIAL FRACTURE PROXIMAL UNICONDYLAR 2786.40 090 Y 11077.77  J1 29856 ARTHRS AID TIBIAL FX PROX UNICONDYLAR BICONDYLAR 3535.20 090 Y 21940.66  J1 29860 ARTHROSCOPY HIP DIAGNOSTIC W/WO SYNOVIAL BYP SPX 2293.20 090 Y 12634.50  J1 29861 ARTHROSCOPY HIP SURGICAL W/REMOVAL LOOSE/FB 2560.80 090 Y 12560.29  J1 29862 ARTHRS HIP DEBRIDEMENT/SHAVING ARTICULAR CRTLG 2905.20 090 Y 12585.88  J1 29863 ARTHROSCOPY HIP SURGICAL W/SYNOVECTOMY 2894.40 090 Y 5696.35  J1 29866 ARTHROSCOPY KNEE OSTEOCHONDRAL AGRFT MOSAICPLAST 3747.60 090 N 12338.63  J1 29867 ARTHROSCOPY KNEE OSTEOCHONDRAL ALLOGRAFT 4548.00 090 N 22499.80  J1 29868 ARTHROSCOPY KNEE MENISCAL TRNSPLJ MED/LAT 5928.00 090 N 11651.91  J1 29870 ARTHROSCOPY KNEE DIAGNOSTIC W/WO SYNOVIAL BX SPX 1981.20 090 N 5658.46  J1 29871 ARTHROSCOPY KNEE INFECTION LAVAGE & DRAINAGE 1838.40 090 N 5765.33  J1 29873 ARTHROSCOPY KNEE LATERAL RELEASE 1922.40 090 N 5763.02  J1 29874 ARTHROSCOPY KNEE REMOVAL LOOSE/FOREIGN BODY 1915.20 090 N 5766.77  J1 29875 ARTHROSCOPY KNEE SYNOVECTOMY LIMITED SPX 1773.60 090 N 5770.53  J1 29876 ARTHROSCOPY KNEE SYNOVECTOMY 2/>COMPARTMENTS 2331.60 090 N 5770.10  J1 29877 ARTHRS KNEE DEBRIDEMENT/SHAVING ARTCLR CRTLG 2218.80 090 N 5766.34  J1 29879 ARTHRS KNEE ABRASION ARTHRP/MLT DRLG/MICROFX 2360.40 090 N 5761.14  J1 29880 ARTHRS KNEE W/MENISCECTOMY MED&LAT W/SHAVING 2007.60 090 N 5773.28  J1 29881 ARTHRS KNE SURG W/MENISCECTOMY MED/LAT W/SHVG 1934.40 090 N 5773.28  J1 29882 ARTHROSCOPY KNEE W/MENISCUS RPR MEDIAL/LATERAL 2456.40 090 N 5535.97  J1 29883 ARTHROSCOPY KNEE W/MENISCUS RPR MEDIAL&LATERAL 2996.40 090 N 5680.87  J1 29884 ARTHROSCOPY KNEE W/LYSIS ADHESIONS W/WO MANJ SPX 2206.80 090 Y 5771.55  J1 29885 ARTHRS KNEE DRILL OSTEOCHONDRITIS DISSECANS GRFG 2698.80 090 Y 11451.68  J1 29886 ARTHRS KNEE DRILLING OSTEOCHOND DISSECANS LESION 2270.40 090 N 5685.36  J1 29887 ARTHRS KNEE DRLG OSTEOCHOND DISSECANS INT FIXJ 2686.80 090 Y 12706.46  J1 29888 ARTHRS AIDED ANT CRUCIATE LIGM RPR/AGMNTJ/RCNSTJ 3478.80 090 Y 11571.31  J1 29889 ARTHRS AIDED PST CRUCIATE LIGM RPR/AGMNTJ/RCNSTJ 4357.20 090 Y 22590.48  J1 29891 ARTHRS ANKLE EXC OSTCHNDRL DFCT W/DRLG DFCT 2384.40 090 Y 5654.99  J1 29892 ARTHRS AID RPR LES/TALAR DOME FX/TIBL PLAFOND FX 2262.00 090 Y 11941.06  J1 29893 ENDOSCOPIC PLANTAR FASCIOTOMY 2366.40 090 N 5731.78

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 138 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 29894 ARTHROSCOPY ANKLE W/REMOVAL LOOSE/FOREIGN BODY 1795.20 090 Y 5755.50  J1 29895 ARTHROSCOPY ANKLE SURGICAL SYNOVECTOMY PARTIAL 1664.40 090 Y 5707.48  J1 29897 ARTHROSCOPY ANKLE SURGICAL DEBRIDEMENT LIMITED 1750.80 090 Y 5686.37  J1 29898 ARTHROSCOPY ANKLE SURGICAL DEBRIDEMENT EXTENSIVE 1995.60 090 Y 5709.65  J1 29899 ARTHROSCOPY ANKLE SURGICAL W/ANKLE ARTHRODESIS 3613.20 090 Y 11713.96  J1 29900 ARTHROSCOPY METACARPOPHALANGEAL SYNOVIAL BIOPSY 1800.00 090 N 5784.56  J1 29901 ARTHRS METACARPOPHALANGEAL JOINT DEBRIDEMENT 1932.00 090 N 5757.81  J1 29902 ARTHRS MTCARPHLNGL JT W/RDCTJ UR COLTRL LIGM 2048.40 090 N 2842.96  J1 29904 ARTHRS SUBTALAR JOINT REMOVE LOOSE/FOREIGN BODY 2280.00 090 Y 5784.56  J1 29905 ARTHROSCOPY SUBTALAR JOINT WITH SYNOVECTOMY 1809.60 090 Y 11952.25  J1 29906 ARTHROSCOPY SUBTALAR JOINT WITH DEBRIDEMENT 2340.00 090 Y 5718.91  J1 29907 ARTHROSCOPY SUBTALAR JOINT SUBTALAR ARTHRODESIS 3126.00 090 Y 22955.05  J1 29914 ARTHROSCOPY HIP W/FEMOROPLASTY 3553.20 090 Y 12414.44  J1 29915 ARTHROSCOPY HIP W/ACETABULOPLASTY 3656.40 090 Y 12362.62  J1 29916 ARTHROSCOPY HIP W/LABRAL REPAIR 3632.40 090 Y 12158.24   29999 UNLISTED PROCEDURE ARTHROSCOPY BR YYY N 298.91   30000 DRAINAGE ABSCESS/HEMATOMA NASAL INT APPROACH 942.54 010 N 306.82   30020 DRAINAGE ABSCESS/HEMATOMA NASAL SEPTUM 952.20 010 N 655.90  J1 30100 BIOPSY INTRANASAL 512.40 000 N 2762.18  J1 30110 EXCISION NASAL POLYP SIMPLE 898.80 010 N 2763.08  J1 30115 EXCISION NASAL POLYP EXTENSIVE 1692.00 090 N 5544.10  J1 30117 EXCISION/DESTRUCTION INTRANASAL LESION INT APPR 3539.70 090 N 5565.19  J1 30118 EXCISION/DESTRUCTION INTRANASAL LESION XTRNL 2860.80 090 N 5571.48  J1 30120 EXCISION/SURGICAL PLANING SKIN NOSE RHINOPHYMA 1818.00 090 N 5569.52  J1 30124 EXCISION DERMOID CYST NOSE SIMPLE SUBCUTANEOUS 1090.80 090 N 2763.08  J1 30125 EXC DERMOID CYST NOSE COMPLEX UNDER BONE/CRTLG 2367.60 090 Y 10388.54  J1 30130 EXCISION INFERIOR TURBINATE PARTIAL/COMPLETE 1513.20 090 N 5560.86  J1 30140 SUBMUCOUS RESCJ INFERIOR TURBINATE PRTL/COMPL 1065.60 000 N 5524.68  J1 30150 RHINECTOMY PARTIAL 2900.40 090 N 10368.54  J1 30160 RHINECTOMY TOTAL 2941.20 090 Y 10357.38   30200 INJECTION TURBINATE THERAPEUTIC 398.40 000 N 655.90  J1 30210 DISPLACEMENT THERAPY PROETZ TYPE 543.60 010 N 2746.02  J1 30220 INSERTION NASAL SEPTAL PROSTHESIS BUTTON 1112.40 010 N 2734.76   30300 REMOVAL FOREIGN BODY INTRANASAL OFFICE PROCEDURE 725.88 010 N 163.53  J1 30310 REMOVAL FOREIGN BODY INTRANASAL GENERAL ANES 752.40 010 N 5578.32  J1 30320 RMVL FOREIGN BODY INTRANASAL LATERAL RHINOTOMY 1767.60 090 N 2763.08  J1 30400 RHINP PRIM LAT&ALAR CRTLGS&/ELVTN NASAL TI 4275.24 090 N 10338.68  J1 30410 RHINP PRIM COMPLETE XTRNL PARTS 4937.64 090 Y 10364.65  J1 30420 RHINOPLASTY PRIMARY W/MAJOR SEPTAL REPAIR 5253.60 090 N 10311.93  J1 30430 RHINOPLASTY SECONDARY MINOR REVISION 3759.12 090 Y 10260.24  J1 30435 RHINOPLASTY SECONDARY INTERMEDIATE REVISION 4663.02 090 Y 10247.78  J1 30450 RHINOPLASTY SECONDARY MAJOR REVISION 6197.58 090 Y 10242.06  J1 30460 RHINP DFRM W/COLUM LNGTH TIP ONLY 2982.00 090 Y 10272.97  J1 30462 RHINP DFRM COLUM LNGTH TIP SEPTUM OSTEOT 5748.00 090 Y 9864.44  J1 30465 REPAIR NASAL VESTIBULAR STENOSIS 3709.20 090 N 9983.39  J1 30468 RPR NSL VLV COLLAPSE SUBQ/SBMCSL LAT WALL IMPLT 9540.00 000 N 9402.15  J1 30469 RPR NSL VLV COLLAPSE LW NRG SUBQ/SBMCSL RMDLG 9064.80 000 N 9851.69

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 30520 SEPTOPLASTY/SUBMUCOUS RESECJ W/WO CARTILAGE GRF 2437.20 090 N 5558.07  J1 30540 REPAIR CHOANAL ATRESIA INTRANASAL 2674.80 090 Y 10095.59  J1 30545 REPAIR CHOANAL ATRESIA TRANSPALATINE 3630.00 090 Y 10388.54   30560 LYSIS INTRANASAL SYNECHIA 1098.48 010 N 655.90  J1 30580 REPAIR FISTULA OROMAXILLARY 2199.60 090 N 10266.48  J1 30600 REPAIR FISTULA ORONASAL 1944.00 090 N 10307.77  J1 30620 SEPTAL/OTHER INTRANASAL DERMATOPLASTY 2455.20 090 N 10355.56  J1 30630 REPAIR NASAL SEPTAL PERFORATIONS 2424.00 090 N 5469.08  J1 30801 ABLTJ SOFT TIS INFERIOR TURBINATES UNI/BI SUPFC 795.60 010 N 2755.76  J1 30802 ABLTJ SOF TISS INF TURBS UNI/BI SUPFC INTRAMURAL 1006.80 010 N 2747.82   30901 CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE 539.58 000 N 163.53   30903 CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX 850.08 000 N 163.53   30905 CTRL NSL HEMRRG PST NASAL PACKS&/CAUTERY 1ST 1279.20 000 N 163.53   30906 CTRL NSL HEMRRG PST NASAL PACKS&/CAUTERY SUBSQ 1342.80 000 N 306.82  J1 30915 LIGATION ARTERIES ETHMOIDAL 2170.80 090 N 5842.29  J1 30920 LIGATION ARTERIES INT MAXILLARY TRANSANTRAL 3147.60 090 N 5845.95  J1 30930 FRACTURE NASAL INFERIOR TURBINATE THERAPEUTIC 417.60 010 N 5494.64   30999 UNLISTED PROCEDURE NOSE BR YYY N 306.82   31000 LAVAGE CANNULATION MAXILLARY SINUS 662.40 010 N 306.82  J1 31002 LAVAGE CANNULATION SPHENOID SINUS 698.40 010 N 2472.75  J1 31020 SINUSOTOMY MAXILLARY ANTROTOMY INTRANASAL 1654.80 090 N 5530.69  J1 31030 SINUSOTOMY MAXILLARY RAD W/O RMVL ANTROCH POLYPS 2296.80 090 N 10252.45  J1 31032 SINUSOT MAX ANTRT RAD W/RMVL ANTROCH POLYPS 2134.80 090 N 10296.08  J1 31040 PTERYGOMAXILLARY FOSSA SURGERY ANY APPROACH 2905.20 090 N 10244.66  J1 31050 SINUSOTOMY SPHENOID W/WO BIOPSY 1872.00 090 N 10309.85  J1 31051 SINUSOT SPHENOID W/MUCOSAL STRIPPING/RMVL POLYP 2515.20 090 N 10199.73  J1 31070 SINUSOTOMY FRONTAL EXTERNAL SIMPLE 1724.40 090 N 9853.53  J1 31075 SINUSOTOMY FRONTAL TRANSORBITAL UNILATERAL 2994.00 090 Y 10202.85  J1 31080 SINUSOTOMY FRNT OBLITERATIVE W/O FLAP BROW INC 3938.40 090 Y 10388.54  J1 31081 SINUSOT FRNT OBLIT W/O OSTPL FLAP CORONAL INC 4215.60 090 Y 10028.58  J1 31084 SINUSOT FRNT OBLIT W/OSTPL FLAP BROW INC 4364.40 090 Y 9701.86  J1 31085 SINUSOT FRNT OBLIT W/OSTPL FLAP CORONAL INC 4495.20 090 Y 9519.28  J1 31086 SINUSOT FRNT NONOBLIT W/OSTPL FLAP BROW INC 4248.00 090 Y 9777.44  J1 31087 SINUSOT FRNT NONOBLIT W/OSTPL FLAP CORONAL INC 4033.20 090 Y 10387.24  J1 31090 SINUSOT UNI 3/> PARANSL SINUSES 4026.00 090 N 10088.31  J1 31200 ETHMOIDECTOMY INTRANASAL ANTERIOR 2247.60 090 N 10301.28  J1 31201 ETHMOIDECTOMY INTRANASAL TOTAL 2886.00 090 N 2763.08  J1 31205 ETHMOIDECTOMY EXTRANASAL TOTAL 3358.80 090 Y 5587.96   31225 MAXILLECTOMY W/O ORBITAL EXENTERATION 6439.20 090 Y   31230 MAXILLECTOMY W/ORBITAL EXENTERATION 7168.80 090 Y   31231 NASAL ENDOSCOPY DIAGNOSTIC UNI/BI SPX 682.80 000 N 238.73   31233 NASAL/SINUS ENDOSCOPY DX MAXILLARY SINUSOSCOPY 988.80 000 N 545.11  J1 31235 NASAL/SINUS ENDOSCOPY DX SPHENOID SINUSOSCOPY 1122.00 000 N 3056.00  J1 31237 NASAL/SINUS NDSC SURG W/BX POLYPC/DBRDMT SPX 915.60 000 N 3054.02  J1 31238 NASAL/SINUS NDSC SURG W/CONTROL NASAL HEMORRHAGE 894.00 000 N 3053.18  J1 31239 NASAL/SINUS NDSC SURG W/DACRYOCYSTORHINOSTOMY 2146.80 010 N 6254.72  J1 31240 NASAL/SINUS NDSC SURG W/CONCHA BULLOSA RESECTION 558.00 000 N 3032.09

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 140 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 31241 NASAL/SINUS NDSC SURG W/LIG SPHENOPALATINE ART 1566.00 000 N 3044.85  J1 31242 NASAL/SINUS NDSC DSTRJ RF ABLATION PST NSL NRV 9009.60 000 N 10293.67  J1 31243 NASAL/SINUS NDSC DSTRJ CRYOABLATION PST NSL NRV 8745.60 000 N 10171.35  J1 31253 NASAL/SINUS NDSC TOT W/FRNT SINS EXPL TISS RMVL 1765.20 000 N 11360.88  J1 31254 NASAL/SINUS NDSC W/PARTIAL ETHMOIDECTOMY 1581.60 000 N 11703.75  J1 31255 NASAL/SINUS NDSC W/TOTAL ETHOIDECTOMY 1143.60 000 N 11624.65  J1 31256 NASAL/SINUS ENDOSCOPY W/MAXILLARY ANTROSTOMY 632.40 000 N 6232.57  J1 31257 NASAL/SINUS NDSC TOTAL WITH SPHENOIDOTOMY 1570.80 000 N 11435.22  J1 31259 NASAL/SINUS NDSC TOT W/SPHENDT W/SPHEN TISS RMVL 1663.20 000 N 11566.36  J1 31267 NSL/SINUS NDSC MAX ANTROST W/RMVL TISS MAX SINUS 934.80 000 N 11713.56  J1 31276 NASAL/SINUS NDSC W/RMVL TISS FROM FRONTAL SINUS 1332.00 000 N 11373.96  J1 31287 NASAL/SINUS ENDOSCOPY W/SPHENOIDOTOMY 710.40 000 N 11683.23  J1 31288 NSL/SINUS NDSC SPHENDT RMVL TISS SPHENOID SINUS 826.80 000 N 11696.02   31290 NASAL/SINUS NDSC RPR CEREBRSP FLUID LEAK ETHMOID 4076.40 010 N 1481.24   31291 NASAL/SINUS NDSC RPR CEREBSP FLUID LEAK SPHENOID 4287.60 010 N  J1 31292 NASAL/SINUS NDSC SURG MEDIAL/INF ORB WALL DCMPRN 3544.80 010 N 11838.76  J1 31293 NASAL/SINUS NDSC SURG MEDIAL&INF ORB WALL DCMPRN 3829.20 010 N 11876.53  J1 31294 NASAL/SINUS NDSC SURG W/OPTIC NERVE DCMPRN 4372.80 010 N 11885.45  J1 31295 NASAL/SINUS NDSC SURG W/DILATION MAXILLARY SINUS 6675.60 000 Y 11157.77  J1 31296 NASAL/SINUS NDSC SURG W/DILATION FRONTAL SINUS 6763.20 000 Y 11042.09  J1 31297 NASAL/SINUS NDSC SURG W/DILATION SPHENOID SINUS 6627.60 000 N 11130.41  J1 31298 NASAL/SINUS NDSC SURG W/DILATION FRNT&SPHN SINUS 12793.20 000 N 11009.68   31299 UNLISTED PROCEDURE ACCESSORY SINUSES BR YYY N 306.82  J1 31300 LARYNGOTOMY W/RMVL TUMOR/LARYNGOCELE CORDECTOMY 4482.00 090 Y 5585.03   31360 LARYNGECTOMY TOTAL W/O RADICAL NECK DISSECTION 7332.00 090 Y   31365 LARYNGECTOMY TOTAL W/RADICAL NECK DISSECTION 9034.80 090 Y   31367 LARYNGECTOMY STOT SUPRAGLOTTIC W/O RAD NECK DSJ 7770.00 090 Y   31368 LARYNGECTOMY STOT SUPRAGLOTTIC W/RAD NCK DSJ 8596.80 090 Y   31370 PARTIAL LARYNGECTOMY HEMILARYGECTOMY HORIZONTAL 7303.20 090 Y   31375 PARTIAL LARYNGECTOMY HEMILARYNG LATEROVERTICAL 6940.80 090 Y   31380 PARTIAL LARYNGECTOMY HEMILARYNG ANTEROVERTICAL 6843.60 090 Y   31382 PARTIAL LARYNG HEMILARYNG ANTERO-LATERO-VERTICAL 7495.20 090 Y   31390 PHARYNGOLARYNGECTOMY W/RAD NECK DSJ W/O RCNSTJ 9984.00 090 Y   31395 PHARYNGOLARYNGECTOMY W/RAD NECK DSJ W/RCNSTJ 10491.60 090 Y  J1 31400 ARYTENOIDECTOMY/ARYTENOIDOPEXY XTRNL APPROACH 3628.80 090 Y 10190.64  J1 31420 EPIGLOTTIDECTOMY 2972.40 090 Y 10174.54   31500 INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE 498.00 000 N 306.82   31502 TRACHEOTOMY TUBE CHANGE PRIOR TO FISTULA TRACT 123.60 000 N 306.82   31505 LARYNGOSCOPY INDIRECT DIAGNOSTIC SPX 327.60 000 N 238.73  J1 31510 LARYNGOSCOPY INDIRECT W/BIOPSY 769.20 000 N 6327.16   31511 LARYNGOSCOPY INDIRECT W/REMOVAL FOREIGN BODY 760.80 000 N 238.73  J1 31512 LARYNGOSCOPY INDIRECT W/REMOVAL LESION 772.80 000 N 6299.16   31513 LARYNGOSCOPY INDIRECT W/VOCAL CORD INJECTION 458.40 000 N 545.11   31515 LARYNGOSCOPY W/WO TRACHEOSCOPY ASPIRATION 769.20 000 N 545.11   31520 LARYNGOSCOPY W/WO TRACHEOSCOPY DX NEWBORN 546.00 000 N 545.11  J1 31525 LARYNGOSCOPY W/WO TRACHEOSCOPY DX EXCEPT NEWBORN 896.40 000 N 3052.49  J1 31526 LARYNGOSCOPY W/WO TRACHEOSCOPY W/MICRO/TELESCOPE 550.80 000 N 3048.90

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 31527 LARYNGOSCOPY W/WO TRACHEOSCOPY INSERT OBTURATOR 682.80 000 N 6041.02  J1 31528 LARYNGOSCOPY W/WO TRACHEOSCOPY W/DILATION IN 504.00 000 N 6107.14  J1 31529 LARYNGOSCOPY W/WO TRACHEOSCOPY DILATION SUBSQ 566.40 000 N 6115.04  J1 31530 LARYNGOSCOPY W/FOREIGN BODY REMOVAL 700.80 000 N 3054.93  J1 31531 LARYNGOSCOPY FOREIGN BODY RMVL MICRO/TELESCOPE 741.60 000 N 6284.61  J1 31535 LARYNGOSCOPY DIRECT OPERATIVE W/BIOPSY 662.40 000 N 6324.00  J1 31536 LARYNGOSCOPY W/BIOPSY MICROSCOPE/TELESCOPE 739.20 000 N 6324.00  J1 31540 LARYNGOSCOPY EXC TUM&/STRIPPING CORDS/EPIGLOTT 849.60 000 N 6319.57  J1 31541 LARGSC EXC TUM&/STRPG CORDS/EPIGL MCRSCP/TLSCP 924.00 000 N 6314.82  J1 31545 LARGSC MICRO/TELESCOPE RMVL LES VOCAL CORD FLAP 1270.80 000 N 6313.08  J1 31546 LARGSC MICRO/TELESCOPE RMVL LES VOCAL CORD GRAFT 1928.40 000 N 11887.23  J1 31551 LARYNGOPLASTY LARYNGEAL STEN W/O STENT < 12 YRS 5509.20 090 N 10272.97  J1 31552 LARYNGOPLASTY LARYNGEAL STEN W/O STENT 12 YRS > 5323.20 090 N 9921.84  J1 31553 LARYNGOPLASTY LARYNGEAL STEN W/STENT < 12 YRS 6031.20 090 N 10272.97  J1 31554 LARYNGOPLASTY LARYNGEAL STEN W/STENT 12 YRS > 6034.80 090 N 10254.53  J1 31560 LARYNGOSCOPY DIRECT OPERATIVE W/ARYTENOIDECTOMY 1096.80 000 N 11773.04  J1 31561 LARGSC ARYTENOIDECTOMY MICROSCOPE/TELESCOPE 1201.20 000 N 11771.25  J1 31570 LARYNGOSCOPE INJECTION VOCAL CORD THERAPEUTIC 1225.20 000 N 6013.65  J1 31571 LARGSC W/NJX VOCAL CORD THER W/MICRO/TELESCOPE 873.60 000 N 6023.62  J1 31572 LARYNGOSCOPY FLEXIBLE ABLATJ DESTJ LESION(S) UNI 1918.80 000 N 6320.36  J1 31573 LARYNGOSCOPY FLEXIBLE THERAPEUTIC INJECTION UNI 1029.60 000 N 3031.40  J1 31574 LARYNGOSCOPY FLEXIBLE W/INJECTION AGMNTJ UNI 3499.20 000 N 2951.26   31575 LARYNGOSCOPY FLEXIBLE DIAGNOSTIC 456.78 000 N 238.73  J1 31576 LARYNGOSCOPY FLEXIBLE W/BIOPSY(IES) 964.80 000 N 3054.78   31577 LARYNGOSCOPY FLX RMVL FOREIGN BODY(S) 988.80 000 N 545.11  J1 31578 LARYNGOSCOPY FLEXIBLE RMVL LESION(S) NON-LASER 1099.20 000 N 6309.60   31579 LARYNGOSCOPY FLX/RGD TELESCOPIC W/STROBOSCOPY 709.20 000 N 545.11  J1 31580 LARYNGOPLASTY LARYN WEB W/KEEL STENT INSERTION 4615.20 090 N 10265.44  J1 31584 LARYNGOPLASTY W/OPEN REDUCTION FRACTURE W/TRACHS 5080.80 090 N 9764.71  J1 31587 LARYNGOPLASTY CRICOID SPLIT W/O GRAFT PLACEMENT 4320.00 090 N 10158.96  J1 31590 LARYNGEAL REINNERVATION NEUROMUSCULAR PEDICLE 3321.60 090 Y 10223.36  J1 31591 LARYNGOPLASTY MEDIALIZATION UNLIATERAL 3939.60 090 N 10090.39  J1 31592 CRICOTRACHEAL RESECTION 6184.80 090 N 9835.35   31599 UNLISTED PROCEDURE LARYNX BR YYY N 306.82  J1 31600 TRACHEOSTOMY PLANNED SEPARATE PROCEDURE 1082.40 000 N 5562.82  J1 31601 TRACHEOSTOMY PLANNED UNDER 2 YEARS SPX 1584.00 000 Y 10272.97  J1 31603 TRACHEOSTOMY EMERGENCY PROCEDURE TRANSTRACHEAL 1135.20 000 N 2757.90   31605 TRACHEOSTOMY EMERGENCY CRICOTHYROID MEMBRANE 1178.40 000 N 306.82  J1 31610 TRACHEOSTOMY FENESTRATION W/SKIN FLAPS 3440.40 090 N 10109.87  J1 31611 CONSTJ TRACHEOESOPHAGEAL FSTL&INSJ SP PROSTH 1926.00 090 Y 5506.66  J1 31612 TRACHEAL PNXR PERQ W/TRANSTRACHEAL ASPIR&/NJX 329.82 000 N 5453.99  J1 31613 TRACHEOSTOMA REVJ SMPL W/O FLAP ROTATION 1534.80 090 N 5548.85  J1 31614 TRACHEOSTOMA REVJ CPLX W/FLAP ROTATION 2556.00 090 N 10363.35   31615 TRACHEOBRONCHOSCOPY THRU EST TRACHEOSTOMY INC 619.20 000 N 655.90  J1 31622 BRNCHSC INCL FLUOR GDNCE DX W/CELL WASHG SPX 889.20 000 N 3052.79  J1 31623 BRNCHSC BRUSHING/PROTECTED BRUSHINGS 999.60 000 N 3053.56  J1 31624 BRNCHSC W/BRNCL ALVEOLAR LAVAGE 921.60 000 N 3054.86

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 142 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 31625 BRONCHOSCOPY BRONCHIAL/ENDOBRNCL BX 1+ SITES 1278.00 000 N 3053.40  J1 31626 BRONCHOSCOPY W/PLMT FIDUCIAL MARKERS SINGLE/MULT 2941.20 000 N 11558.93   31627 BRONCHOSCOPY W/CPTR-ASST IMAGE-GUIDED NAVIGATION 4538.40 ZZZ N  J1 31628 BRONCHOSCOPY W/TRANSBRONCHIAL LUNG BX 1 LOBE 1357.20 000 N 6317.04  J1 31629 BRONCHOSCOPY NEEDLE BX TRACHEA MAIN STEM&/BRON 1665.60 000 N 6304.38  J1 31630 BRNCHSC W/TRACHEAL/BRONCHIAL DILAT/CLSD RDCTJ FX 694.80 000 N 6142.88  J1 31631 BRONCHOSCOPY W/PLACEMENT TRACHEAL STENT 793.20 000 N 11020.68   31632 BRONCHOSCOPY W/TRANSBRONCHIAL LUNG BX EACH LOBE 230.40 ZZZ N   31633 BRONCHOSCOPY W/TRANSBRONCL NDL ASPIR BX EA LOBE 285.60 ZZZ N  J1 31634 BRONCHOSCOPY BALLOON OCCLUSION 5928.00 000 Y 11573.20  J1 31635 BRONCHOSCOPY W/REMOVAL FOREIGN BODY 1056.00 000 N 3048.13  J1 31636 BRNCHSC W/PLACEMENT BRNCL STENT 1ST BRONCHUS 762.00 000 N 10566.59   31637 BRONCHOSCOPY EACH MAJOR BRONCHUS STENTED 270.00 ZZZ N  J1 31638 BRNCHSC REVJ TRACHEAL/BRNCL STENT INS PREV SESS 866.40 000 N 11519.68  J1 31640 BRONCHOSCOPY W/EXCISION TUMOR 872.40 000 N 6297.74  J1 31641 BRNCHSC W/DSTRJ TUM RELIEF STENOSIS OTH/THN EXC 896.40 000 N 6279.87  J1 31643 BRNCHSC W/PLMT CATH INTRCV RADIOELMNT APPL 614.40 000 N 3016.35  J1 31645 BRONCHOSCOPY W/THER ASPIR TRACHBRNCL TREE 1ST 984.00 000 N 3052.87   31646 BRONCHOSCOPY W/THER ASPIR TRACHBRNCL TREE SBSQ 496.80 000 N 545.11  J1 31647 BRNCHSC OCCLUSION&INSERT BRONCH VALVE INIT LOBE 732.00 000 N 10601.39  J1 31648 BRNCHSC REMOVAL BRONCHIAL VALVE INITIAL 696.00 000 N 6305.97   31649 BRNCHSC REMOVAL BRONCHIAL VALVE EA ADDL 235.20 ZZZ N 2169.76   31651 BRNCHSC OCCLUSION&INSERT BRONCH VALVE ADDL LOBE 266.40 ZZZ N  J1 31652 BRNCHSC EBUS GUIDED SAMPL 1/2 NODE STATION/STRUX 3783.96 000 N 6316.09  J1 31653 BRNCHSC EBUS GUIDED SAMPL 3/> NODE STATION/STRUX 3964.74 000 N 6318.62   31654 BRNSCHSC TNDSC EBUS DX/TX INTERVENTION PERPH LES 435.60 ZZZ N  J1 31660 BRONCHOSCOPIC THERMOPLASTY ONE LOBE 688.80 000 N 10219.85  J1 31661 BRONCHOSCOPIC THERMOPLASTY 2/> LOBES 722.40 000 N 10237.70   31717 CATHETERIZATION W/BRONCHIAL BRUSH BIOPSY 1062.00 000 N 545.11   31720 CATHETER ASPIRATION NASOTRACHEAL SPX 197.34 000 N 272.60   31725 CATH ASPIR TRACHEOBRNCL FIBERSCOPE BEDSIDE SPX 278.40 000 N  J1 31730 TTRACH INTRO NDL WIRE DIL/STENT/TUBE O2 THER 4108.80 000 N 2995.19  J1 31750 TRACHEOPLASTY CERVICAL 4884.00 090 Y 10253.23  J1 31755 TRACHEOPLASTY TRACHEOPHARYNGEAL FSTLJ EA STAGE 6231.60 090 Y 10388.54   31760 TRACHEOPLASTY INTRATHORACIC 4855.20 090 Y   31766 CARINAL RECONSTRUCTION 6259.20 090 Y   31770 BRONCHOPLASTY GRAFT REPAIR 4682.40 090 Y   31775 BRONCHOPLASTY EXCISION STENOSIS & ANASTOMOSIS 4933.20 090 Y   31780 EXCISION TRACHEAL STENOSIS&ANASTOMOSIS CERVICA 4189.20 090 Y   31781 EXC TRACHEAL STENOSIS&ANAST CERVICOTHORACIC 5097.60 090 Y  J1 31785 EXCISION TRACHEAL TUMOR/CARCINOMA CERVICAL 3816.00 090 Y 10339.20   31786 EXCISION TRACHEAL TUMOR/CARCINOMA THORACIC 5085.60 090 Y   31800 SUTURE TRACHEAL WOUND/INJURY CERVICAL 2553.60 090 N   31805 SUTURE TRACHEAL WOUND/INJURY INTRATHORACIC 2895.60 090 Y  J1 31820 SURG CLSR TRACHEOSTOMY/FISTULA W/O PLASTIC RPR 1602.00 090 N 5585.45  J1 31825 SURG CLSR TRACHEOSTOMY/FISTULA W/PLASTIC RPR 2194.80 090 N 5582.10  J1 31830 REVISION TRACHEOSTOMY SCAR 1760.88 090 N 5584.47

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   31899 UNLISTED PROCEDURE TRACHEA BRONCHI BR YYY N 238.73   32035 THORACOSTOMY W/RIB RESECTION EMPYEMA 2606.40 090 Y   32036 THORACOSTOMY OPEN FLAP DRAINAGE EMPYEMA 2806.80 090 Y   32096 THORACTOMY W/DX BX LUNG INFILTRATE UNILATERAL 2822.40 090 Y   32097 THORACTOMY W/DX BX LUNG NODULE/MASS UNILATERAL 2828.40 090 Y   32098 THORACOTOMY W/BIOPSY OF PLEURA 2679.60 090 Y   32100 THORACOTOMY WITH EXPLORATION 2860.80 090 Y   32110 THORCOM CTRL TRAUMTC HEMRRG&/RPR LNG TEAR 5206.80 090 Y   32120 THORACOTOMY POSTOPERATIVE COMPLICATIONS 3084.00 090 Y   32124 THORACOTOMY OPN INTRAPLEURAL PNEUMONOLYSIS 3271.20 090 Y   32140 THORCOM W/REMOVAL OF CYST 3496.80 090 Y   32141 THORACOTOMY W/RESECTION BULLAE 5365.20 090 Y   32150 THORCOM W/RMVL INTRAPLEURAL FB/FIBRIN DEP 3571.20 090 Y   32151 THORCOM W/RMVL IPUL FB 3547.20 090 Y   32160 THORACOTOMY W/CARDIAC MASSAGE 2815.20 090 Y 2820.51   32200 PNEUMONOSTOMY W/OPEN DRAINAGE ABSCESS/CYST 4024.80 090 Y   32215 PLEURAL SCARIFICATION REPEAT PNEUMOTHORAX 2823.60 090 Y   32220 DECORTICATION PULMONARY TOTAL SEPARATE PROCEDURE 5638.80 090 Y   32225 DECORTICATION PULMONARY PARTIAL SEPARATE PROC 3526.80 090 Y   32310 PLEURECTOMY PARIETAL SEPARATE PROCEDURE 3249.60 090 Y   32320 DECORTICATION & PARIETAL PLEURECTOMY 5666.40 090 Y  J1 32400 BIOPSY PLEURA PERCUTANEOUS NEEDLE 597.60 000 N 2869.82  J1 32408 CORE NEEDLE BX LUNG/MEDIASTINUM PERQ W/IMG 3182.40 000 N 2852.43   32440 REMOVAL OF LUNG PNEUMONECTOMY 5542.80 090 Y   32442 REMOVAL LUNG PNEUMONECTOMY RESXN SGMNT TRACHEA 10748.40 090 Y   32445 REMOVAL LUNG PNEUMONECTOMY EXTRAPLEURAL 12421.20 090 Y   32480 RMVL LUNG OTHER THAN PNEUMONECTOMY 1 LOBE LOBECT 5226.00 090 Y   32482 RMVL LUNG OTHER THAN PNEUMONECT 2 LOBES BILOBEC 5592.00 090 Y   32484 RMVL LUNG OTHER THAN PNEUMONECT 1 SEGMENTECTOMY 5061.60 090 Y   32486 RMVL LUNG XCP TOT PNEUMONECTOMY SLEEVE LOBECTOMY 8240.40 090 Y   32488 RMVL LUNG OTHER/THAN PNUMEC COMPLETION PNUMEC 8420.40 090 Y   32491 RMVL LUNG OTH/THN PNUMEC RESXN-PLCTJ EMPHY LUNG 5194.80 090 Y   32501 RESCJ&BRONCHOPLASTY PFRMD TM LOBEC/SGMECTOMY 852.00 ZZZ Y   32503 RESCJ APICAL LUNG TUMOR W/O CHEST WALL RCNSTJ 6324.00 090 Y   32504 RESCJ APICAL LUNG TUMOR W/CHEST WALL RCNSTJ 7202.40 090 Y   32505 THORACOTOMY W/THERAPEUTIC WEDGE RESEXN INITIAL 3289.20 090 Y   32506 THORACOTOMY W/THERAP WEDGE RESEXN ADDL IPSILATRL 550.80 ZZZ Y   32507 THORACOTOMY W/DX WEDGE RESEXN & ANTOM LUNG RESE 550.80 ZZZ Y   32540 EXTRAPLEURAL ENUCLEATION EMPYEMA EMPYEMECTOMY 6094.80 090 Y  J1 32550 INSERTION INDWELLING TUNNELED PLEURAL CATHETER 2938.02 000 N 6078.56  J1 32551 TUBE THORACOSTOMY INCLUDES WATER SEAL 553.20 000 N 2853.15   32552 RMVL NDWELLG TUNNELED PLEURAL CATHETER W/CUFF 650.40 010 N 783.90   32553 PLMT NTRSTL DEV RADJ THX GID PRQ INTRATHRC 1/MLT 1870.80 000 Y 1831.33   32554 THORACENTESIS NEEDLE/CATH PLEURA W/O IMAGING 829.38 000 N 783.90   32555 THORACENTESIS NEEDLE/CATH PLEURA W/IMAGING 1159.20 000 N 783.90  J1 32556 PERQ DRAINAGE PLEURA INSERT CATH W/O IMAGING 2402.58 000 N 3244.05  J1 32557 PERQ DRAINAGE PLEURA INSERT CATH W/IMAGING 2214.90 000 N 2753.84

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 144 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   32560 INSTLJ VIA CHEST TUBE/CATH AGENT FOR PLEURODESIS 950.40 000 N 783.90   32561 INSTLJ VIA CH TUBE/CATH AGENT FBRNLYSIS 1ST DAY 337.20 000 Y 783.90   32562 INSTLJ CH TUBE/CATH AGENT FBRNLYSIS SBSQ DAY 298.80 000 Y 783.90  J1 32601 THORSC DX LUNGS/PERICAR/MED/PLEURAL SPACE W/O BX 1083.60 000 N 10224.54  J1 32604 THORACOSCOPY DX PERICARDIAL SAC W/BIOPSY SPX 1683.60 000 N 10335.38  J1 32606 THORACOSCOPY DX MEDIASTINAL SPACE W/BIOPSY SPX 1624.80 000 N 10293.52  J1 32607 THORACOSCOPY W/DX BX OF LUNG INFILTRATE UNILATRL 1082.40 000 N 10218.08  J1 32608 THORACOSCOPY W/DX BX OF LUNG NODULES UNILATRL 1332.00 000 N 10262.78  J1 32609 THORACOSCOPY WITH BIOPSYIES OF PLEURA 900.00 000 N 10155.81   32650 THORACOSCOPY W/PLEURODESIS 2359.20 090 Y   32651 THORACOSCOPY W/PARTIAL PULMONARY DECORTICATION 3865.20 090 Y   32652 THRSC TOT PULM DCRTCTJ INTRAPLEURAL PNEUMONOLSS 5859.60 090 Y   32653 THORACOSCOPY RMVL INTRAPLEURAL FB/FIBRIN DEPOSIT 3740.40 090 Y   32654 THORACOSCOPY CONTROL TRAUMATIC HEMORRHAGE 4107.60 090 Y   32655 THORACOSCOPY W/RESECTION BULLAE W/WO PLEURAL PX 3375.60 090 Y   32656 THORACOSCOPY W/PARIETAL PLEURECTOMY 2841.60 090 Y   32658 THORACOSCOPY W/RMVL CLOT/FB FROM PERICARDIAL SAC 2524.80 090 Y   32659 THRSC CRTJ PRCRD WINDOW/PRTL RESCJ PRCRD SAC 2586.00 090 Y   32661 THORACOSCOPY W/EXC PERICARDIAL CYST TUMOR/MASS 2821.20 090 Y   32662 THORACOSCOPY W/EXC MEDIASTINAL CYST TUMOR/MASS 3153.60 090 Y   32663 THORACOSCOPY W/LOBECTOMY SINGLE LOBE 4930.80 090 Y   32664 THORACOSCOPY W/THORACIC SYMPATHECTOMY 2994.00 090 Y 6001.43   32665 THORACOSCOPY W/ESOPHAGOMYOTOMY HELLER TYPE 4340.40 090 Y   32666 THORACOSCOPY W/THERA WEDGE RESEXN INITIAL UNILAT 3072.00 090 Y 4923.02   32667 THORACOSCOPY W/THERA WEDGE RESEXN ADDL IPSILATRL 552.00 ZZZ Y 2724.03   32668 THORACOSCOPY W/DX WEDGE RESEXN ANATO LUNG RESEXN 553.20 ZZZ Y   32669 THORACOSCOPY W/SEGMENTECTOMY 4731.60 090 Y   32670 THORACOSCOPY W/BILOBECTOMY 5653.20 090 Y   32671 THORACOSCOPY W/PNEUMONECTOMY 6240.00 090 Y   32672 THORACOSCOPY W/RESEXN-PLICAJ EMPHYSEMA LUNG UNIL 5353.20 090 Y   32673 THORACOSCOPY RESEXN THYMUS UNI/BILATERAL 4284.00 090 Y   32674 THORCOSCPY W/MEDIASTINL & REGIONL LYMPHDENECTOMY 756.00 ZZZ Y   32701 THORAX STEREOTACTIC RADIATION TARGET W/TX COURSE 750.00 750.00 BR XXX N   32800 REPAIR LUNG HERNIA THROUGH CHEST WALL 3337.20 090 Y   32810 CLSR CH WALL FLWG OPN FLAP DRG EMPYEMA 3182.40 090 Y   32815 OPEN CLOSURE MAJOR BRONCHIAL FISTULA 9871.20 090 Y   32820 MAJOR RECONSTRUCTION CHEST WALL POSTTRAUMATIC 4699.20 090 Y   32850 DONOR PNEUMONECTOMY FROM CADAVER DONOR 6495.66 XXX N   32851 LUNG TRANSPLANT 1 W/O CARDIOPULMONARY BYPASS 11515.20 090 Y   32852 LUNG TRANSPLANT 1 W/CARDIOPULMONARY BYPASS 12482.40 090 Y   32853 LUNG TRANSPLANT 2 W/O CARDIOPULMONARY BYPASS 16082.40 090 Y   32854 LUNG TRANSPLANT 2 W/CARDIOPULMONARY BYPASS 17048.40 090 Y   32855 BKBENCH PREPJ CADAVER DONOR LUNG ALLOGRAFT UNI 2667.60 XXX Y   32856 BKBENCH PREPJ CADAVER DONOR LUNG ALLOGRAFT BI 3105.60 XXX Y   32900 RESECTION RIBS EXTRAPLEURAL ALL STAGES 4995.60 090 Y   32905 THORACOPLASTY SCHEDE TYPE/EXTRAPLEURAL 4704.00 090 Y   32906 THORACOP SCHEDE TYP/XTRPLEURAL CLSR BRNCPLR FSTL 5803.20 090 Y

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   32940 PNEUMONOLYSIS XTRPRIOSTEAL W/FILLING/PACKING PX 4348.80 090 Y   32960 PNEUMOTHORAX THER INTRAPLEURAL INJECTION AIR 447.60 000 N 783.90  J1 32994 ABLATION THER 1+ PULM TUMORS PERQ CRYOABLATION 19141.20 000 Y 9444.73   32997 TOTAL LUNG LAVAGE UNILATERAL 1194.00 000 N  J1 32998 ABLATION THER 1+ PULM TUMORS PERQ RADIOFREQUENCY 12074.40 000 Y 9995.87   32999 UNLISTED PROCEDURE LUNGS & PLEURA BR YYY N 783.90  J1 33016 PERICARDIOCENTESIS W/IMG GUIDANCE WHEN PERFORMED 828.00 000 N 2753.55   33017 PERQ PRCRD DRG 6YR+ W/O CONGENITAL CAR ANOMALY 866.40 000 N   33018 PERQ PRCRD DRG 0-5YR/ANY AGE W/CGEN CAR ANOMALY 1023.60 000 N   33019 PERQ PERICARDIAL DRG W/INSJ NDWELLG CATH W/CT 757.20 000 N   33020 PERICARDIOTOMY REMOVAL CLOT/FOREIGN BODY PRIMARY 3045.60 090 Y   33025 CRTJ PERICARDIAL WINDOW/PRTL RESECJ W/DRG/BX 2762.40 090 Y   33030 PRICARDIECTOMY STOT/COMPL W/O CARDPULM BYPASS 7050.00 090 Y   33031 PRICARDIECTOMY STOT/COMPL W/CARDPULM BYPASS 8713.20 090 Y   33050 RESECTION PERICARDIAL CYST/TUMOR 3549.60 090 Y   33120 EXC INTRACARDIAC TUMOR RESCJ CARDIOPULMONARY BYP 7365.60 090 Y   33130 RESECTION EXTERNAL CARDIAC TUMOR 4819.20 090 Y   33140 TRANSMYOCARDIAL LASER REVASCULAR THORACOTOMY SPX 5487.60 090 Y   33141 TRANSMYOCRD LASER REVSC PFRMD TM OTH OPN CAR PX 463.20 ZZZ Y   33202 INSERTION EPICARDIAL ELECTRODE OPEN 2721.60 090 N   33203 INSERTION EPICARDIAL ELECTRODE ENDOSCOPIC 2851.20 090 N  J1 33206 INS NEW/RPLCMT PRM PACEMAKR W/TRANS ELTRD ATRIAL 1620.00 090 N 18108.60  J1 33207 INS NEW/RPLC PRM PACEMAKER W/TRANSV ELTRD VENTR 1700.40 090 N 18078.33  J1 33208 INS NEW/RPLCMT PRM PM W/TRANSV ELTRD ATRIAL&VENT 1844.40 090 N 17899.93  J1 33210 INSJ/RPLCMT TEMP TRANSVNS 1CHMBR ELTRD/PM CATH 571.20 000 N 15967.74  J1 33211 INSJ/RPLCMT TEMP TRANSVNS 2CHMBR PACG ELTRDS SPX 597.60 000 N 15287.40  J1 33212 INS PM PLS GEN W/EXIST SINGLE LEAD 1147.20 090 N 14209.19  J1 33213 INS PACEMAKER PULSE GEN ONLY W/EXIST DUAL LEADS 1196.40 090 N 17876.57  J1 33214 UPG PACEMAKER SYS CONVERT 1CHMBR SYS 2CHMBR SYS 1702.80 090 N 18036.39  J1 33215 RPSG PREV IMPLTED PM/DFB R ATR/R VENTR ELECTRODE 1100.40 090 N 5662.05  J1 33216 INSJ 1 TRANSVNS ELTRD PERM PACEMAKER/IMPLTBL DFB 1323.60 090 N 15119.92  J1 33217 INSJ 2 TRANSVNS ELTRD PERM PACEMAKER/IMPLTBL DFB 1311.60 090 N 14521.66   33218 RPR 1 TRANSVNS ELTRD PRM PM/PACING IMPLNTBL DFB 1384.80 090 N 4993.88   33220 RPR 2 TRANSVNS ELECTRODES PRM PM/IMPLANTABLE DFB 1359.60 090 N 4993.88  J1 33221 INS PACEMAKER PULSE GEN ONLY W/EXIST MULT LEADS 1284.00 090 N 31844.61   33222 RELOCATION OF SKIN POCKET FOR PACEMAKER 1219.20 090 N 2483.95   33223 RELOCATE SKIN POCKET IMPLANTABLE DEFIBRILLATOR 1458.00 090 N 2483.95  J1 33224 INSJ ELTRD CAR VEN SYS ATTCH PREV PM/DFB PLS GEN 1820.40 000 N 18396.38   33225 INSJ ELTRD CAR VEN SYS TM INSJ DFB/PM PLS GEN 1653.60 ZZZ N  J1 33226 RPSG PREV IMPLTED CAR VEN SYS L VENTR ELTRD 1744.80 000 N 5417.78  J1 33227 REMVL PERM PM PLSE GEN W/REPL PLSE GEN SNGL LEAD 1207.20 090 N 14165.03  J1 33228 REMVL PERM PM PLS GEN W/REPL PLSE GEN 2 LEAD SYS 1263.60 090 N 17993.91  J1 33229 REMVL PERM PM PLS GEN W/REPL PLSE GEN MULT LEAD 1334.40 090 N 31807.52  J1 33230 INSJ IMPLNTBL DEFIB PULSE GEN W/EXIST DUAL LEADS 1366.80 090 N 38382.00  J1 33231 INSJ IMPLNTBL DEFIB PULSE GEN W/EXIST MULTILEADS 1419.60 090 N 55436.47   33233 REMOVAL PERMANENT PACEMAKER PULSE GENERATOR ONLY 831.60 090 N 11831.97   33234 RMVL TRANSVNS PM ELTRD 1 LEAD SYS ATR/VENTR 1724.40 090 N 4993.88

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 146 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   33235 RMVL TRANSVNS PM ELTRD DUAL LEAD SYS 2266.80 090 N 4993.88   33236 RMVL PRM EPICAR PM&ELTRDS THORCOM 1 LEAD SYS 2772.00 090 N   33237 RMVL PRM EPICAR PM&ELTRDS THORCOM DUAL LEAD SY 2973.60 090 N   33238 RMVL PRM TRANSVENOUS ELECTRODE THORACOTOMY 3354.00 090 N  J1 33240 INSJ IMPLNTBL DEFIB PULSE GEN W/1 EXISTING LD 1304.40 090 N 38188.88   33241 REMOVAL IMPLANTABLE DEFIB PULSE GENERATOR ONLY 766.80 090 N 4993.88   33243 RMVL 1/DUAL CHAMBER DEFIB ELECTRODE BY THORACOM 4849.20 090 Y   33244 RMVL1/DUAL CHMBR IMPLTBL DFB ELTRD TRANSVNS XTRJ 3081.60 090 N 4993.88  J1 33249 INSJ/RPLCMT PERM DFB W/TRNSVNS LDS 1/DUAL CHMBR 3256.80 090 N 54587.73   33250 ABLATION ARRHYTHMOGENIC FOCI/PATHWAY W/O BYPASS 5133.60 090 Y   33251 ABLATION ARRHYTHMOGENIC FOCI/PATHWAY W/BYPASS 5732.40 090 Y   33254 ABLATION & RECONSTRUCTION ATRIA LIMITED 4802.40 090 Y   33255 ABLATION & RCNSTJ ATRIA EXTNSV W/O BYPASS 5732.40 090 Y   33256 ABLATION & RCNSTJ ATRIA EXTNSV W/BYPASS 6792.00 090 Y   33257 ATRIA ABLATE & RCNSTJ W/OTHER PROCEDURE LIMITE 2052.00 ZZZ Y   33258 ATRIA ABLTJ & RCNSTJ W/OTHER PX EXTENSIV W/O BYP 2292.00 ZZZ Y   33259 ATRIA ABLTJ & RCNSTJ W/OTHER PX EXTEN W/BYPASS 2983.20 ZZZ Y   33261 OPRATIVE ABLTJ VENTR ARRHYTHMOGENIC FOC W/BYPASS 5680.80 090 Y  J1 33262 RMVL IMPLTBL DFB PLSE GEN W/REPL PLSE GEN 1 LEAD 1329.60 090 N 38573.94  J1 33263 RMVL IMPLTBL DFB PLSE GEN W/RPLCMT PLSE GEN 2 LD 1382.40 090 N 38360.80  J1 33264 RMVL IMPLTBL DFB PLS GEN W/RPLCMT PLS GEN MLT LD 1440.00 090 N 54470.32   33265 NDSC ABLATION & RCNSTJ ATRIA LIMITED W/O BYPAS 4797.60 090 Y   33266 NDSC ABLATION & RCNSTJ ATRIA EXTEN W/O BYPASS 6484.80 090 Y   33267 EXCLUSION LEFT ATRIAL APPENDAGE OPEN ANY METHOD 3692.40 090 Y   33268 EXCLUSION LAA OPEN TM STRNT/THRCM ANY METHOD 460.80 ZZZ Y   33269 EXCLUSION L ATR APPENDAGE THORACOSCOPIC ANY METH 2920.80 090 Y  J1 33270 INS/RPLCMNT PERM SUBQ IMPLTBL DFB W/SUBQ ELTRD 2001.60 090 N 54290.84  J1 33271 INSJ OF SUBQ IMPLANTABLE DEFIBRILLATOR ELECTRODE 1605.60 090 N 14002.13   33272 RMVL OF SUBQ IMPLANTABLE DEFIBRILLATOR ELECTRODE 1234.80 090 N 4993.88   33273 REPOS PREVIOUSLY IMPLANTED SUBQ IMPLANTABLE DFB 1416.00 090 N 4993.88  J1 33274 TCAT INSJ/RPL PERM LEADLESS PACEMAKER RV W/IMG 1711.20 090 N 27414.00  J1 33275 TCAT REMOVAL PERM LEADLESS PM RIGHT VENTR W/IMG 1812.00 090 N 4604.72   33276 INSERTION PHRENIC NERVE STIMULATOR SYSTEM 2046.00 090 N 63900.71   33277 INSJ PHRENIC NRV STIMULATOR TRANSVNS SENSING LD 1070.40 ZZZ N  J1 33278 REMOVAL PHRENIC NERVE STIMULATOR SYSTEM 2036.40 090 N 6355.26  J1 33279 RMVL PHRNC NRV STIMULATOR TRANSVNS STIMJ/SNSG LD 1231.20 090 N 5872.56  J1 33280 RMVL PHRENIC NRV STIMULATOR PULSE GENERATOR ONLY 740.40 090 N 6355.26  J1 33281 REPOSITIONING PHRENIC NRV STIMULATOR TRANSVNS LD 1330.80 090 N 6355.26  J1 33285 INSERTION SUBQ CARDIAC RHYTHM MONITOR W/PRGRMG 17528.40 000 N 13582.18   33286 REMOVAL SUBCUTANEOUS CARDIAC RHYTHM MONITOR 478.80 000 N 902.47  J1 33287 RMVL&RPLCMT PHRENIC NRV STIMULATOR PLS GENERATOR 1372.80 090 N 48356.43  J1 33288 RMVL&RPLCMT PHRNC NRV STIM TRNSVNS STIMJ/SNSG LD 1809.60 090 N 20712.20  J1 33289 TCAT IMPL WRLS P-ART PRS SNR L-T HEMODYN MNTR 1179.60 000 N 46835.51   33300 REPAIR CARDIAC WOUND W/O BYPASS 8600.40 090 Y   33305 REPAIR CARDIAC WOUND W/CARDIOPULMONARY BYPASS 14378.40 090 Y   33310 CARDIOT EXPL W/RMVL FB ATR/VENTR THRMB W/O BYP 4126.80 090 Y   33315 CARDIOT EXPL RMVL FB ATR/VENTR THRMB CARD BYP 6754.80 090 Y

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   33320 SUTR RPR AORTA/GRT VSL W/O SHUNT/CARD BYP 3721.20 090 Y   33321 SUTR RPR AORTA/GREAT VESSEL W/SHUNT BYPASS 4194.00 090 Y   33322 SUTURE REPAIR AORTA/GREAT VESSEL W/BYPASS 4900.80 090 Y   33330 INSJ GRAFT AORTA/GREAT VESSEL W/O SHUNT/BYPASS 5023.20 090 Y   33335 INSJ GRAFT AORTA/GREAT VESSEL W/BYPASS 6584.40 090 Y   33340 PERQ CLSR TCAT L ATR APNDGE W/ENDOCARDIAL IMPLNT 2775.60 000 N   33361 REPLACE AORTIC VALVE PERQ FEMORAL ARTRY APPROACH 4737.60 000 N   33362 REPLACE AORTIC VALVE OPENFEMORAL ARTERY APPROACH 5172.00 000 N   33363 REPLACE AORTIC VALVE OPEN AXILLRY ARTRY APPROACH 5356.80 000 N   33364 REPLACE AORTIC VALVE OPEN ILIAC ARTERY APPROACH 5536.80 000 N   33365 REPLACE AORTIC VALVE OPEN TRANSAORTIC APPROACH 6219.60 000 N   33366 TRANSCATHETER TRANSAPICAL REPLACEMT AORTIC VALVE 6723.60 000 N   33367 REPLACE AORTIC VALVE W/BYP PRQ ART/VENOUS APPRCH 2194.80 ZZZ N   33368 REPLACE AORTIC VALVE W/BYP OPEN ART/VENOUS APRCH 2608.80 ZZZ N   33369 REPLACE AORTA VALVE W/BYP CNTRL ART/VENOUS APRCH 3441.60 ZZZ N   33370 TRANSCATHETER PLACEMENT&SBSQ REMOVAL CEPD PERQ 468.00 ZZZ N   33390 VALVULOPLASTY AORTIC VALVE OPEN CARD BYP SIMPLE 6789.60 090 Y   33391 VALVULOPLASTY AORTIC VALVE OPEN CARD BYP COMPLEX 8072.40 090 Y   33404 CONSTRUCTION APICAL-AORTIC CONDUIT 6163.20 090 Y   33405 RPLCMT PROST AORTIC VALVE OPEN XCP HOMOGRF/STENT 7993.20 090 Y   33406 RPLCMT AORTIC VALVE OPN ALLOGRAFT VALVE FREEHAND 10117.20 090 Y   33410 RPLCMT AORTIC VALVE OPN W/STENTLESS TISSUE VALVE 8941.20 090 Y   33411 RPLCMT AORTIC VALVE ANNULUS ENLGMENT NONC SINUS 11802.00 090 Y   33412 REPLACEMENT AORTIC VALVE KONNO PROCEDURE 11076.00 090 Y   33413 REPLACEMENT AORTIC&PULMON VALVES ROSS PROCEDUR 11348.40 090 Y   33414 RPR VENTR O/F TRC OBSTRCJ PATCH ENLGMENT O/F TRC 7554.00 090 Y   33415 RESECTION/INCISION SUBVALVULAR TISSUE 7140.00 090 Y   33416 VENTRICULOMYOTOMY-MYECTOMY 7122.00 090 Y   33417 AORTOPLASTY SUPRAVALVULAR STENOSIS 5876.40 090 Y   33418 TCAT MITRAL VALVE REPAIR INITIAL PROSTHESIS 6339.60 090 Y   33419 TCAT MITRAL VALVE REPAIR ADDL PROSTHESIS 1492.80 ZZZ Y   33420 VALVOTOMY MITRAL VALVE CLOSED HEART 5115.60 090 N   33422 VALVOTOMY MITRAL VALVE OPEN HEART W/BYPASS 5864.40 090 Y   33425 VALVULOPLASTY MITRAL VALVE W/CARDIAC BYPASS 9612.00 090 Y   33426 VLVP MITRAL VALVE W/CARD BYP W/PROSTC RING 8382.00 090 Y   33427 VLVP MITRAL VALVE W/BYPASS RAD RCNSTJ W/WO RING 8578.80 090 Y   33430 REPLACEMENT MITRAL VALVE W/CARDIOPULMONARY BYP 9862.80 090 Y   33440 RPLCMT AORTIC VALVE BY TLCJ AUTOL PULM VALVE 11984.40 090 Y   33460 VALVECTOMY TRICUSPID VALVE W/CARDIOPULMONARY BYP 8448.00 090 Y   33463 VALVULOPLASTY TRICUSPID VALVE W/O RING INSERTION 10804.80 090 Y   33464 VALVULOPLASTY TRICUSPID VALVE W/RING INSERTION 8577.60 090 Y   33465 REPLACEMENT TRICUSPID VALVE W/CARD BYPASS 9686.40 090 Y   33468 TRICUSPID VALVE RPSG&PLCTJ EBSTEIN ANOMALY 8616.00 090 Y   33474 VALVOTOMY PULMONARY VALVE OPEN HEART W/BYPASS 7670.40 090 Y   33475 REPLACEMENT PULMONARY VALVE 8170.80 090 Y   33476 R VENTRIC RESCJ INFUND STEN W/WO COMMISSUROTOMY 5368.80 090 Y   33477 TCAT PULMONARY VALVE IMPLANTATION PRQ APPROACH 4773.60 000 N

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 148 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   33478 OUTFLOW TRACT AGMNTJ W/WO COMMISSUR/INFUND RESCJ 5545.20 090 Y   33496 RPR NON-STRUCT PROSTC VALVE DYSFUNCTION W/BYPASS 5870.40 090 Y   33500 RPR CORONARY AV/ARTERIOCAR CHMBR FSTL W/BYPASS 5503.20 090 Y   33501 RPR CORONARY AV/ARTERIOCAR CHMBR FSTL W/O BYPASS 3939.60 090 Y   33502 RPR ANOM CORONARY ART PULM ART ORIGIN LIGATION 4508.40 090 Y   33503 RPR ANOM CORONARY ARTERY PULM ART ORIGIN GRAFT 4682.40 090 N   33504 RPR ANOM CORONARY ART PULM ART ORIGIN GRF W/BYP 5172.00 090 Y   33505 RPR ANOM CORON ART W/CONSTJ INTRAPULM ART TUNNEL 7244.40 090 Y   33506 RPR ANOM CORONARY ART FROM PULM ART TO AORTA 7216.80 090 Y   33507 RPR ANOM AORTIC ORIGIN CORONARY ART UNROOF/TLCJ 6055.20 090 Y   33508 NDSC SURG W/VIDEO-ASSISTED HARVEST VEIN CABG 57.60 ZZZ Y  

20 Miss. Admin. Code Pt. 2, R. 33509 Rule 33509

ENDOSCOPIC HARVEST UXTR ARTERY 1 SEGMENT CAB PX 608.40 ZZZ Y   33510 CORONARY ARTERY BYPASS 1 CORONARY VENOUS GRAFT 6813.60 090 Y   33511 CORONARY ARTERY BYPASS 2 CORONARY VENOUS GRAFTS 7479.60 090 Y   33512 CORONARY ARTERY BYPASS 3 CORONARY VENOUS GRAFTS 8528.40 090 Y   33513 CORONARY ARTERY BYPASS 4 CORONARY VENOUS GRAFTS 8732.40 090 Y   33514 CORONARY ARTERY BYPASS 5 CORONARY VENOUS GRAFTS 9188.40 090 Y   33516 CORONARY ARTERY BYPASS 6/+ CORONARY VENOUS GRAFT 9514.80 090 Y   33517 CORONARY ARTERY BYP W/VEIN & ARTERY GRAFT 1 VEIN 660.00 ZZZ Y   33518 CORONARY ARTERY BYP W/VEIN & ARTERY GRAFT 2 VEIN 1443.60 ZZZ Y   33519 CORONARY ARTERY BYP W/VEIN & ARTERY GRAFT 3 VEIN 1912.80 ZZZ Y   33521 CORONARY ARTERY BYP W/VEIN & ARTERY GRAFT 4 VEIN 2293.20 ZZZ Y   33522 CORONARY ARTERY BYP W/VEIN & ARTERY GRAFT 5 VEIN 2574.00 ZZZ Y   33523 CORONARY ARTERY BYP W/VEIN &ARTERY GRAFT 6 VEIN 2912.40 ZZZ Y   33530 ROPRTJ CAB/VALVE PX > 1 MO AFTER ORIGINAL OPERJ 1844.40 ZZZ Y   33533 CABG W/ARTERIAL GRAFT SINGLE ARTERIAL GRAFT 6592.80 090 Y   33534 CABG W/ARTERIAL GRAFT TWO ARTERIAL GRAFTS 7738.80 090 Y   33535 CABG W/ARTERIAL GRAFT THREE ARTERIAL GRAFTS 8614.80 090 Y   33536 CABG W/ARTERIAL GRAFT FOUR/>ARTERIAL GRAFTS 9278.40 090 Y   33542 MYOCARDIAL RESECTION 9210.00 090 Y   33545 RPR POSTINFRCJ VENTRICULAR SEPTAL DEFECT 10801.20 090 Y   33548 SURG VENTRICULAR RSTRJ PX W/PROSTC PATCH PFRMD 10459.20 090 Y   33572 CORONARY ENDARTERCOMY OPEN ANY METHOD 808.80 ZZZ Y   33600 CLOSURE ATRIOVENTRICULAR VALVE SUTURE/PATCH 6055.20 090 Y   33602 CLOSURE SEMILUNAR VALVE AORTIC/PULM SUTURE/PATCH 5878.80 090 Y   33606 ANAST PULMONARY ART AORTA DAMUS-KAYE-STANSEL PX 6264.00 090 Y   33608 RPR CAR ANOMAL XCP PULM ATRESIA VENTR SEPTL DFCT 6342.00 090 Y   33610 RPR CAR ANOMAL SURG ENLGMENT VENTR SEPTL DFCT 6255.60 090 Y   33611 RPR 2 OUTLET R VNTRC W/INTRAVENTR TUNNEL RPR 6860.40 090 Y   33612 RPR 2 OUTLET R VNTRC RPR R VENTR O/F TRC OBSTRCJ 7041.60 090 Y   33615 RPR CAR ANOMAL CLSR SEPTL DFCT SMPL FONTAN PX 7034.40 090 Y   33617 RPR COMPLEX CARDIAC ANOMALY MODIFIED FONTAN PX 7615.20 090 Y   33619 RPR 1 VNTRC W/O/F OBSTRCJ&AORTIC ARCH HYPOPLAS 9674.40 090 Y   33620 APPLICATION RIGHT & LEFT PULMONARY ARTERY BAND 5799.60 090 Y   33621 TRANSTHORACIC CATHETER INSERTION FOR STENT PLMT 3276.00 090 Y   33622 RECONSTRUCTION COMPLEX CARDIAC ANOMALY 12054.00 090 Y   33641 RPR ATRIAL SEPTAL DFCT SECUNDUM W/BYP W/WO PATCH 5767.20 090 Y

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   33645 DIR/PTCH CLS SINUS VENOSUS W/WO ANOM PUL VEN DRG 6093.60 090 Y   33647 RPR ATRIAL & VENTRIC SEPTAL DFCT DIR/PATCH CLS 6391.20 090 Y   33660 RPR INCPLT/PRTL AV CANAL W/WO AV VALVE RPR 6176.40 090 Y   33665 RPR INTRM/TRANSJ AV CANAL W/WO AV VALVE RPR 6728.40 090 Y   33670 RPR COMPL AV CANAL W/WO PROSTC VALVE 6933.60 090 Y   33675 CLOSURE MULTIPLE VENTRICULAR SEPTAL DEFECTS 6931.20 090 Y   33676 CLOSURE MULTIPLE VSD W/RESECTION 7114.80 090 Y   33677 CLOSURE MULTIPLE VSD W/REMOVAL ARTERY BAND 7388.40 090 Y   33681 CLSR 1 VENTRICULAR SEPTAL DEFECT W/WO PATCH 6498.00 090 Y   33684 CLSR VSD W/WO PATCH W/PULM VLVT/INFUND RESCJ 6640.80 090 Y   33688 CLSR 1 VSD W/WO PATCH W/RMVL P-ART BAND 6622.80 090 Y   33690 BANDING PULMONARY ARTERY 4239.60 090 Y   33692 COMPL RPR TETRALOGY FALLOT W/O PULM ATRESIA 6877.20 090 Y   33694 COMPL RPR TOF W/O PULM ATRESIA W/TANULR PATCH 6860.40 090 Y   33697 COMPLETE REPAIR TOF W/PULMONARY ATRESIA 7225.20 090 Y   33702 RPR SINUS VALSALVA FISTULA 5452.80 090 Y   33710 RPR SINUS VALSALVA FISTULA W/RPR V-SEPTAL DEFECT 7214.40 090 Y   33720 RPR SINUS VALSALVA ANEURYSM 5457.60 090 Y   33724 REPAIR ISOLATED PARTIAL PULM VENOUS RETURN 5412.00 090 Y   33726 REPAIR PULMONARY VENOUS STENOSIS 7144.80 090 Y   33730 COMPLETE RPR ANOMALOUS PULMONARY VENOUS RETURN 7063.20 090 Y   33732 RPR COR TRIATM/SUPVALVR RING RESCJ L ATRIAL MEMB 5809.20 090 Y   33735 ATRIAL SEPTECTOMY/SEPTOSTOMY CLOSED HEART 4576.80 090 Y   33736 ATRIAL SEPTECTOMY/SEPTOSTOMY OPEN HEART W/BYPASS 4965.60 090 Y   33741 TAS CONGENITAL CARDIAC ANOMALIES ANY METHOD 2653.20 000 Y   33745 TIS CRTJ ST CONGENITAL CARDIAC ANOMAL 1ST SHUNT 3788.40 000 Y   33746 TIS CRTJ ST CONGENITAL CARDIAC ANOMAL EA ADDL 1514.40 ZZZ Y   33750 SHUNT SUBCLAVIAN TO PULMONARY ARTERY 4455.60 090 Y   33755 SHUNT ASCENDING AORTA TO PULMONARY ARTERY 4648.80 090 Y   33762 SHUNT DESCENDING AORTA TO PULMONARY ARTERY 4522.80 090 Y   33764 SHUNT CENTRAL W/PROSTHETIC GRAFT 4648.80 090 Y   33766 SHUNT SUPERIOR VENA CAVA TO PULMONARY ART 1 LUNG 4699.20 090 Y   33767 SHUNT SUPERIOR VENA CAVA TO PULM ARTERY BTH LNGS 5017.20 090 Y   33768 ANASTOMOSIS CAVOPULMARY SEC SUPRIOR VENA CAVA 1461.60 ZZZ Y   33770 RPR TGA W/VSD&SUBPULM STEN W/O SURG ENLGMNT VSD 7438.80 090 Y   33771 RPR TGA W/VSD&SUBPULM STEN W/SURG ENLGMNT VSD 7652.40 090 Y   33774 RPR TGA ATRIAL BAFFLE PX W/CARDIOPULMONARY BYP 6340.80 090 Y   33775 RPR TGA ATRIAL BAFFLE PX CARD BYP RMVL PULM BAND 6532.80 090 Y   33776 RPR TGA ATRIAL BAFFLE PX CARD BYP W/CLOSURE VSD 6906.00 090 Y   33777 RPR TGA ATR BAFFLE PX CARD BYP RPR SBPULM OBSTRC 6663.60 090 Y   33778 RPR TGA AORTIC PULMONARY ARTERY RECONSTRUCTION 8270.40 090 Y   33779 RPR TGA AORTIC PULM ART RCNSTJ W/RMVL PULM BAND 8169.60 090 Y   33780 RPR TGA AORTIC PULM ART RCNSTJ W/CLOSURE VSD 8322.00 090 Y   33781 RPR TGA AORTIC P-ART RCNSTJ RPR SBPULMC OBSTRCJ 8124.00 090 Y   33782 A-ROOT TLCJ VSD PULM STNS RPR W/O C OST RIMPLTJ 11340.00 090 Y   33783 A-ROOT TLCJ VSD PULM STNS RPR W/RIMPLTJ C OSTIA 12250.80 090 Y   33786 TOTAL REPAIR TRUNCUS ARTERIOSUS 8011.20 090 Y

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 150 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   33788 REIMPLANTATION ANOMALOUS PULMONARY ARTERY 5403.60 090 Y   33800 AORTIC SUSPENSION TRACHEAL DECOMPRESSION SPX 3475.20 090 Y   33802 DIVISION ABERRANT VESSEL VASCULAR RING 3831.60 090 Y   33803 DIVISION ABERRANT VESSEL W/REANASTOMOSIS 4064.40 090 Y   33814 OBLTRJ AORTOPULMONARY SEPTAL DFCT W/CARD BYPASS 5373.60 090 Y   33820 REPAIR PATENT DUCTUS ARTERIOSUS BY LIGATION 3411.60 090 Y   33822 REPAIR PDA BY DIVISION YOUNGER THAN 18 YRS 3600.00 090 Y   33824 REPAIR PDA BY DIVISION 18 YEARS & OLDER 4167.60 090 Y   33840 EXCISION COA W/WO PDA W/DIRECT ANASTOMOSIS 4375.20 090 Y   33845 EXCISION COARCTATION AORTA W/WO PDA W/GRAFT 4708.80 090 Y   33851 EXC COA W/WO PDA RPR L SUBCLA ART/PROSTC 4491.60 090 Y   33852 RPR HYPOPLASTIC A-ARCH W/AUTOG/PROSTC W/O BYPASS 4938.00 090 Y   33853 RPR HYPOPLASTIC A-ARCH W/AUTOG/PROSTC W/BYPASS 6458.40 090 Y   33858 AS-AORT GRF W/CARD BYP F/AORTIC DISSECTION 11938.80 090 Y   33859 AS-AORT GRF W/CARD BYP F/AORTIC DS OTH/THN DSJ 8580.00 090 Y   33863 AS-AORT GRF W/CARD BYP & AORTIC ROOT RPLCMT 11065.20 090 Y   33864 ASCENDING AORTA GRF VALVE SPARE ROOT REMODEL 11322.00 090 Y   33866 AORTIC HEMIARCH GRAFT W/ISOL & CTRL ARCH VESSELS 3582.00 ZZZ N   33871 TRANSVRS A-ARCH GRF W/CARD BYP PRFD HYPOTHERMIA 11458.80 090 Y   33875 DESCENDING THORACIC AORTA GRAFT W/WO BYPASS 9585.60 090 Y   33877 RPR THORACOABDOMINAL AORTIC ANEURYS W/WO BYPASS 12709.20 090 Y   33880 EVASC RPR DTA COVERAGE ART ORIGIN 1ST ENDOPROSTH 6294.00 090 Y   33881 EVASC RPR DTA EXP COVERAGE W/O ART ORIGIN 5395.20 090 Y   33883 PLMT PROX XTN PROSTH EVASC RPR DTA 1ST XTN 3909.60 090 Y   33884 PLMT PROX XTN PROSTH EVASC RPR DTA EA PROX XTN 1386.00 ZZZ Y   33886 PLMT DSTL XTN PROSTH DLYD AFTER EVASC RPR DTA 3387.60 090 Y   33889 OPN SUBCLA CRTD ART TRPOS NCK INC ULAT 2790.00 000 Y   33891 BYP GRF W/DESCENDING THORACIC AORTA RPR NECK INC 3381.60 000 Y   33894 EVASC ST RPR COARCJ THRC/AA ACRS MAJ SIDE BRNCH 3417.60 000 N   33895 EVASC ST RPR COARCJ THRC/AA XCRSG MAJ SIDE BRNCH 2719.20 000 N   33897 PERQ TRANSLUMINAL ANGIOPLASTY NATIVE/RECR COA 2024.40 000 N  J1 33900 PERQ P-ART REVSC ST 1ST NML NATIVE CONNJ UNI 2054.40 000 N 19585.25  J1 33901 PERQ P-ART REVSC ST 1ST NML NATIVE CONNJ BI 2700.00 000 N 19585.25  J1 33902 PERQ P-ART REVSC ST 1ST ABNOR CONNJ UNILATERAL 2608.80 000 N 31692.67  J1 33903 PERQ P-ART REVSC ST 1ST ABNORMAL CONNJ BILATERAL 3074.40 000 N 19585.25   33904 PERQ P-ART REVSC ST EA ADDL VSL/SEP LES NM/ABNL 1032.00 ZZZ N   33910 PULMONARY ARTERY EMBOLECTOMY W/CARD BYPASS 9259.20 090 Y   33915 PULMONARY ARTERY EMBOLECTOMY W/O CARD BYPASS 4855.20 090 Y   33916 PULMONARY ENDARTERCOMY W/WO EMBOLECTOMY W/BYPASS 14780.40 090 Y   33917 RPR PULMONARY ART STENOSIS RCNSTJ W/PATCH/GRAFT 5142.00 090 Y   33920 RPR PULMONARY ATRESIA W/CONSTJ/RPLCMT CONDUIT 6375.60 090 Y   33922 TRANSECTION PULMONARY ARTERY W/CARD BYPASS 4900.80 090 Y   33924 LIG&TKDN SYSIC-TO-PULM ART SHUNT W/CGEN HEART 1000.80 ZZZ Y   33925 RPR P-ART ARBORIZJ ANOMAL UNIFCLIZJ W/O BYPASS 6038.40 090 Y   33926 RPR P-ART ARBORIZJ ANOMAL UNIFCLIZJ W/BYPASS 8490.00 090 Y   33927 IMPLTJ TOTAL RPLCMT HEART SYS W/RCP CARDIECTOMY 8949.60 XXX Y   33928 REMOVAL & RPLCMT TOTAL RPLCMT HEART SYS BR XXX Y

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   33929 REMOVAL TOTAL RPLCMT HEART SYS FOR HEART TRNSPL BR ZZZ Y   33930 DONOR CARDIECTOMY-PNEUMONECTOMY BR XXX N   33933 BKBENCH PREPJ CADAVER DONOR HEART/LUNG ALLOGRAFT 1676.40 XXX Y   33935 HEART-LUNG TRNSPL W/RECIPIENT CARDIECTOMY-PNUMEC 17353.20 090 Y   33940 DONOR CARDIECTOMY BR XXX N   33944 BKBENCH PREPJ CADAVER DONOR HEART ALLOGRAFT 1938.00 XXX Y   33945 HEART TRANSPLANT W/WO RECIPIENT CARDIECTOMY 17098.80 090 Y   33946 ECMO/ECLS INITIATION VENO-VENOUS 1089.60 XXX N   33947 ECMO/ECLS INITIATION VENO-ARTERIAL 1204.80 XXX N   33948 ECMO/ECLS DAILY MANAGEMENT EACH DAY VENO-VENOUS 837.60 XXX N   33949 ECMO/ECLS DAILY MANAGEMENT EA DAY VENO-ARTERIAL 812.40 XXX N   33951 ECMO/ECLS INSJ OF PRPH CANNULA BIRTH-5 YRS PERQ 1489.20 000 N   33952 ECMO/ECLS INSJ OF PRPH CANNULA 6 YRS&OLDER PERQ 1503.60 000 N   33953 ECMO/ECLS INSJ OF PRPH CANNULA BIRTH-5 YRS OPEN 1665.60 000 N   33954 ECMO/ECLS INSJ OF PRPH CANNULA 6 YRS&OLDER OPEN 1678.80 000 N   33955 ECMO/ECLS INSJ OF CENTRAL CANNULA BIRTH-5 YRS 2911.20 000 N   33956 ECMO/ECLS INSJ OF CENTRAL CANNULA 6 YRS & OLDER 2932.80 000 N   33957 ECMO/ECLS REPOS PERIPH CANNULA PERQ BIRTH-5 YRS 649.20 000 N   33958 ECMO/ECLS REPOS PERPH CANNULA PRQ 6 YRS & OLDER 649.20 000 N   33959 ECMO/ECLS REPOS PERPH CANNULA OPEN BIRTH-5 YRS 822.00 000 N   33962 ECMO/ECLS REPOS PERPH CANNULA OPEN 6 YRS & OLDER 822.00 000 N   33963 ECMO/ECLS REPOS CENTRAL PERPH CANNULA BIRTH-5YRS 1642.80 000 N   33964 ECMO/ECLS ECLS REPOS CENTRAL CNULA 6YRS & OLDER 1732.80 000 N   33965 ECMO/ECLS RMVL OF PERPH CANNULA PERQ BIRTH-5 YRS 649.20 000 N   33966 ECMO/ECLS RMVL OF PRPH CANNULA PRQ 6 YRS & OLDER 830.40 000 N   33967 INSERTION INTRA-AORTIC BALLOON ASSIST DEV PERQ 910.80 000 N 2371.93   33968 REMOVAL INTRA-AORTIC BALLOON ASSIST DEVICE PRQ 117.60 000 N   33969 ECMO/ECLS RMVL OF PERPH CANNULA OPEN BIRTH-5 YRS 957.60 000 N   33970 INSJ INTRA-AORT BALO ASSIST DEV VIA FEM ART OPEN 1245.60 000 Y   33971 RMVL I-AORT BALO ASST DEV W/RPR FEM ART W/WO GRF 2499.60 090 N   33973 INSJ I-AORT BALO ASSIST DEV VIA ASCENDING AORTA 1803.60 000 Y   33974 RMVL ASCENDING-AORTA BALO DEV W/RPR ASCEND-AORTA 3145.20 090 N   33975 INSJ VENTRIC ASSIST DEV XTRCORP SINGLE VENTRICLE 4573.20 XXX Y   33976 INSJ VENTRIC ASSIST DEV XTRCORP BIVENTRICULAR 5568.00 XXX Y   33977 REMOVAL VENTR ASSIST DEVICE XTRCORP 1 VENTRICLE 3934.80 XXX Y   33978 REMOVAL VENTR ASSIST DEVICE XTRCORP BIVENTR 4675.20 XXX Y   33979 INSJ VENTR ASSIST DEV IMPLTABLE ICORP 1 VNTRC 6829.20 XXX Y   33980 RMVL VENTR ASSIST DEV IMPLTABLE ICORP 1 VNTRC 6247.20 XXX Y   33981 RPLCMT XTRCORP VAD 1/BIVENTR PUMP 1/EA PUMP 2918.40 XXX Y   33982 PLCMT VAD PMP IMPLTBL ICORP 1 VENTR W/O BYPASS 6858.00 XXX Y   33983 RPLCMT VAD PMP IMPLTBL ICORP 1 VNTR W/BYPASS 8103.60 XXX Y   33984 ECMO/ECLS RMVL PRPH CANNULA OPEN 6 YRS & OLDER 997.20 000 N   33985 ECMO/ECLS REMOVAL OF CENTRAL CANNULA BIRTH-5 YRS 1803.60 000 N   33986 ECMO/ECLS RMVL OF CENTRAL CANNULA 6 YRS & OLDER 1838.40 000 N   33987 ARTERY EXPOS/GRAFT ARTERY PERFUSION ECMO/ECLS 733.20 ZZZ N   33988 INSERT LEFT HEART VENT BY THORACIC INC ECMO/ECLS 2730.00 000 N   33989 RMVL LEFT HEART VENT BY THORACIC INCIS ECMO/ECLS 1732.80 000 N

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 152 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   33990 INSJ PERQ VAD W/RS&I L HRT ARTERIAL ACCESS ONLY 1488.00 000 Y 5211.37   33991 INSJ PERQ VAD W/RS&I L HRT ARTERIAL&VEN ACCESS 2182.80 000 Y   33992 REMOVAL PERQ LEFT HRT VAD ARTL/ARTL&VEN SEP INSJ 696.00 000 Y   33993 REPOSITIONING PERQ R/L VAD W/IMG GDN SEP INSJ 610.80 000 Y   33995 INSJ PERQ VAD W/RS&I R HEART VENOUS ACCESS ONLY 1270.80 000 Y   33997 REMOVAL PERQ R HEART VAD VENOUS CANNULA SEP INSJ 565.20 000 Y   33999 UNLISTED PROCEDURE CARDIAC SURGERY BR YYY Y 783.90   34001 EMBLC/THRMBC CATH CRTD SUBCLA/INNOMINATE ART 3344.40 090 Y   34051 EMBLC/THRMBC INNOMINATE SUBCLAVIAN ARTERY 3510.00 090 Y  J1 34101 EMBLC/THRMBC AX BRACH INNOMINATE SUBCLA ART 2104.80 090 Y 9607.30  J1 34111 EMBLC/THRMBC W/WO CATH RADIAL/ULNAR ART ARM INC 2115.60 090 Y 9589.28   34151 EMBLC/THRMBC RNL CELIAC MESENTRY AORTO-ILIAC ART 4897.20 090 Y  J1 34201 EMBLC/THRMBC FEMORAL POPLITEAL AORTO-ILIAC ART 3600.00 090 Y 9304.37  J1 34203 EMBLC/THRMBC POPLITEAL-TIBIO-PRONEAL ART LEG INC 3340.80 090 Y 9290.00   34401 THRMBC DIR/W/CATH VENA CAVA ILIAC VEIN ABDL INC 5227.20 090 Y  J1 34421 THRMBC DIR/W/CATH V/C ILIAC FEMPOP VEIN LEG INC 2560.80 090 Y 5578.58   34451 THRMBC DIR/W/CATH V/C ILIAC FEMPOP VEIN ABDL&LEG 5048.40 090 Y   34471 THRMBC DIR/W/CATH SUBCLAVIAN VEIN NECK INC 3796.80 090 N 783.90  J1 34490 THRMBC DIR/W/CATH AXILL&SUBCLAVIAN VEIN ARM IN 2298.00 090 N 5823.87  J1 34501 VALVULOPLASTY FEMORAL VEIN 3145.20 090 Y 9347.71   34502 RECONSTRUCTION VENA CAVA ANY METHOD 5430.00 090 Y  J1 34510 VENOUS VALVE TRANSPOSITION ANY VEIN DONOR 3592.80 090 Y 9598.53  J1 34520 CROSS-OVER VEIN GRAFT VENOUS SYSTEM 3480.00 090 Y 9193.33  J1 34530 SAPHENOPOPLITEAL VEIN ANASTOMOSIS 3315.60 090 Y 5578.58   34701 EVASC RPR DPLMNT AORTO-AORTIC NDGFT 4362.00 090 Y   34702 EVASC RPR DPLMNT AORTO-AORTIC NDGFT RPT 6498.00 090 Y   34703 EVASC RPR DPLMNT AORTO-UN-ILIAC NDGFT 4843.20 090 Y   34704 EVASC RPR DPLMNT AORTO-UN-ILIAC NDGFT RPT 8071.20 090 Y   34705 EVASC RPR DPLMNT AORTO-BI-ILIAC NDGFT 5368.80 090 Y   34706 EVASC RPR DPLMNT AORTO-BI-ILIAC NDGFT RPT 8025.60 090 Y   34707 EVASC RPR DPLMNT ILIO-ILIAC NDGFT 4068.00 090 Y   34708 EVASC RPR DPLMNT ILIO-ILIAC NDGFT RPT 6493.20 090 Y   34709 PLACEMENT XTN PROSTH FOR ENDOVASCULAR RPR 1131.60 ZZZ Y   34710 DLYD PLACEMENT XTN PROSTH FOR EVASC RPR 1ST VSL 2796.00 090 Y   34711 DLYD PLACEMENT XTN PROSTH FOR EVASC RPR EA ADDL 1039.20 ZZZ Y   34712 TRANSCATHETER DLVR ENHNCD FIXATION DEVICES RS&I 2382.00 090 Y   34713 PERQ ACCESS & CLOSURE FEM ART FOR DELIVERY NDGFT 447.60 ZZZ Y   34714 OPN FEM ART EXPOS W/CNDT CRTJ DLVR EVASC PROSTH 945.60 ZZZ Y   34715 OPN AX/SUBCLA ART EXPOS DLVR EVASC PROSTH UNI 1054.80 ZZZ Y   34716 OPN AXILLARY/SUBCLAVIAN ART EXPOS W/CNDT CRTJ 1304.40 ZZZ Y   34717 EVASC RPR ILIAC ART TM OF A-ILIAC ART NDGFT UNI 1562.40 ZZZ Y   34718 EVASC RPR ILIAC ART N/A A-ILIAC ART NDGFT UNI 4342.80 090 Y   34808 EVASC PLACEMENT ILIAC ARTERY OCCLUSION DEVICE 733.20 ZZZ Y   34812 OPN FEM ART EXPOS DLVR EVASC PROSTH UNI 723.60 ZZZ Y   34813 PLMT FEM-FEM PROSTC GRF EVASC AORTIC ARYSM RPR 829.20 ZZZ Y   34820 OPN ILIAC ART EXPOS PROSTH/ILIAC OCCLS EVASC UNI 1210.80 ZZZ Y   34830 OPN RPR ARYSM RPR ARTL TRAUMA TUBE PROSTH 6193.20 090 Y

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   34831 OPN RPR ARYSM RPR ARTL TRMA AORTOBIILIAC PROSTH 6766.80 090 Y   34832 OPN RPR ARYSM RPR ARTL TRMA AORTO-BIFEM PROSTH 6658.80 090 Y   34833 OPN ILIAC ART EXPOS CRTJ PROSTH EST CARD BYP 1406.40 ZZZ Y   34834 OPN BRACHIAL ARTERY EXPOS DLVR EVASC PROSTH UNI 453.60 ZZZ Y   34839 PLNNING PT SPEC FENEST VISCERAL AORTIC GRAFT BR YYY N   34841 ENDOVASC VISCER AORTA REPAIR FENEST 1 ENDOGRAFT 6850.80 YYY Y   34842 ENDOVASC VISCER AORTA REPAIR FENEST 2 ENDOGRAFT BR YYY Y   34843 ENDOVASC VISCER AORTA REPAIR FENEST 3 ENDOGRAFT BR YYY Y   34844 ENDOVASC VISCER AORTA REPR FENEST 4+ ENDOGRAFT 11479.20 YYY Y   34845 VISCER AND INFRARENAL ABDOM AORTA 1 PROSTHESIS 8288.40 YYY Y   34846 VISCER AND INFRARENAL ABDOM AORTA 2 PROSTHESIS 9472.80 YYY Y   34847 VISCER AND INFRARENAL ABDOM AORTA 3 PROSTHESIS 16011.60 YYY Y   34848 VISCER AND INFRARENAL ABDOM AORTA 4+ PROSTHESIS 27577.20 YYY Y   35001 DIR RPR ANEURYSM CAROTID-SUBCLAVIAN ARTERY 3966.00 090 Y   35002 DIR RPR RUPTD ANEURYSM CAROTID-SUBCLAVIAN ARTERY 4002.00 090 Y   35005 DIR RPR ANEURYSM VERTEBRAL ARTERY 3507.60 090 Y  J1 35011 DIR RPR ANEURYSM AXIL-BRACHIAL ARM INCISION 3559.20 090 Y 9609.98   35013 DIR RPR RUPTD ANEURYSM AXIL-BRACHIAL ARM INCIS 4448.40 090 Y   35021 DIR RPR ANEURYSM INNOMINATE/SUBCLAVIAN ARTERY 4448.40 090 Y   35022 DIR RPR RUPTD ANEURYSM INNOMINATE/SUBCLAVIAN 5089.20 090 Y  J1 35045 DIR RPR RUPTD ANEURYSM RADIAL/ULNAR ARTERY 3433.20 090 Y 9691.80   35081 DIR RPR ANEURYSM ABDOMINAL AORTA 6082.80 090 Y   35082 DIR RPR RUPTD ANEURYSM ABDOMINAL AORTA 7626.00 090 Y   35091 DIR RPR ANEURYSM ABDOM AORTA W/VISCERAL VESSELS 6289.20 090 Y   35092 DIR RPR RUPTD ANEURSM ABDOM AORTA W/VISCERA VSLS 9162.00 090 Y   35102 DIR RPR ANEURYSM ABDOM AORTA W/ILIAC VESSELS 6597.60 090 Y   35103 DIR RPR RUPTD ANEURYSM ABDOM AORTA W/ILIAC VSLS 7798.80 090 Y   35111 DIR RPR ANEURYSM SPLENIC ARTERY 4671.60 090 Y   35112 DIR RPR RUPTD ANEURYSM SPLENIC ARTERY 5740.80 090 Y   35121 DIR RPR ANEURYSM HEPATIC/CELIAC/RENAL/MESENTERIC 5796.00 090 Y   35122 DIR RPR RUPTD ANEURSM HEPATIC/CELIAC/RENAL/MESEN 6642.00 090 Y   35131 DIR RPR ANEURYSM & GRAFT ILIAC ARTERY 4826.40 090 Y   35132 DIR RPR RUPTD ANEURYSM & GRAFT ILIAC ARTERY 5740.80 090 Y   35141 DIR RPR ANEURYSM & GRAFT COMMON FEMORAL ARTERY 3860.40 090 Y   35142 DIR RPR RUPTD ANEURYSM & GRF COMMON FEMORAL ART 4654.80 090 Y   35151 DIR RPR ANEURYSM & GRAFT POPLITEAL ARTERY 4352.40 090 Y   35152 DIR RPR RUPTD ANEURYSM & GRF POPLITEAL ARTERY 4911.60 090 Y  J1 35180 REPAIR CONGENITAL AV FISTULA HEAD & NECK 3052.80 090 Y 2872.32   35182 REPAIR CONGENITAL AV FISTULA THORAX & ABDOMEN 6313.20 090 Y  J1 35184 REPAIR CONGENITAL AV FISTULA EXTREMITIES 3394.80 090 Y 5807.06  J1 35188 RPR ACQUIRED/TRAUMATIC AV FISTULA HEAD & NECK 4572.00 090 Y 9491.15   35189 RPR ACQUIRED/TRAUMATIC AV FISTULA THORAX&ABDOMEN 5302.80 090 Y  J1 35190 RPR ACQUIRED/TRAUMATIC AV FISTULA EXTREMITIES 2706.00 090 Y 9587.82  J1 35201 REPAIR BLOOD VESSEL DIRECT NECK 3321.60 090 Y 9588.06  J1 35206 REPAIR BLOOD VESSEL DIRECT UPPER EXTREMITY 2767.20 090 Y 5824.17  J1 35207 REPAIR BLOOD VESSEL DIRECT HAND FINGER 2682.00 090 N 5790.11   35211 RPR BLOOD VESSEL DIRECT INTRATHORACIC W/BYPASS 4924.80 090 Y

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 154 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   35216 RPR BLOOD VESSEL DIRECT INTRATHORACIC W/O BYPASS 7366.80 090 Y   35221 REPAIR BLOOD VESSEL DIRECT INTRA-ABDOMINAL 5212.80 090 Y   35226 REPAIR BLOOD VESSEL DIRECT LOWER EXTREMITY 2935.20 090 Y 902.47  J1 35231 REPAIR BLOOD VESSEL W/VEIN GRAFT NECK 4396.80 090 Y 5847.26  J1 35236 REPAIR BLOOD VESSEL W/VEIN GRAFT UPPER EXTREMITY 3529.20 090 Y 9630.43   35241 RPR BLOOD VESSEL VEIN GRAFT INTRATHORACIC W/BYP 5066.40 090 Y   35246 RPR BLOOD VESSEL VEIN GRF INTRATHORACIC W/O BYP 5512.80 090 Y   35251 REPAIR BLOOD VESSEL VEIN GRAFT INTRA-ABDOMINAL 6126.00 090 Y  J1 35256 REPAIR BLOOD VESSEL VEIN GRAFT LOWER EXTREMITY 3583.20 090 Y 9686.93  J1 35261 REPAIR BLOOD VESSEL W/GRAFT OTHER/THAN VEIN NECK 3447.60 090 Y 5578.58  J1 35266 RPR BLOOD VSL GRF OTH/THN VEIN UPPER EXTREMITY 3044.40 090 Y 9467.77   35271 RPR BLOOD VSL GRF OTH/THN VEIN INTRATHRC W/BYP 4876.80 090 Y   35276 RPR BLOOD VSL GRF OTH/THN VEIN INTRATHRC W/O BYP 5145.60 090 Y   35281 RPR BLVSL W/GRFT OTHER/THAN VEIN INTRA-ABDOMINAL 5713.20 090 Y  J1 35286 RPR BLVSL W/GRF OTHER/THAN VEIN LOWER EXTREMITY 3288.00 090 Y 9443.90   35301 TEAEC W/PATCH GRF CAROTID VERTB SUBCLAV NECK INC 3978.00 090 Y 7174.27   35302 TEAEC W/GRAFT SUPERFICIAL FEMORAL ARTERY 3945.60 090 Y   35303 TEAEC W/GRAFT POPLITEAL ARTERY 4340.40 090 Y   35304 TEAEC W/GRAFT TIBIOPERONEAL TRUNK ARTERY 4484.40 090 Y   35305 TEAEC W/GRAFT TIBIAL/PERONEAL ART 1ST VESSEL 4314.00 090 Y   35306 TEAEC W/GRAFT EA ADDL TIBIAL/PERONEAL ART 1563.60 ZZZ Y   35311 TEAEC W/WO PATCH GRF SUBCLAV INNOM THORACIC INC 5484.00 090 Y  J1 35321 TEAEC W/WO PATCH GRF AXILLARY-BRACHIAL 3145.20 090 Y 9592.45   35331 TEAEC W/WO PATCH GRAFT ABDOMINAL AORTA 5103.60 090 Y   35341 TEAEC W/WO PATCH GRAFT MESENTERIC CELIAC/RENAL 4872.00 090 Y   35351 TEAEC W/WO PATCH GRAFT ILIAC 4531.20 090 Y   35355 TEAEC W/WO PATCH GRAFT ILIOFEMORAL 3621.60 090 Y   35361 TEAEC W/WO PATCH GRAFT COMBINED AORTOILIAC 5348.40 090 Y   35363 TEAEC W/WO PATCH GRAFT COMBINED AORTOILIOFEMORAL 5707.20 090 Y   35371 TEAEC W/WO PATCH GRAFT COMMON FEMORAL 2870.40 090 Y  J1* 35372 TEAEC W/WO PATCH GRAFT DEEP PROFUNDA FEMORAL 3427.20 090 Y 9347.71   35390 ROPRTJ CRTD TEAEC > 1 MO AFTER ORIGINAL OPRATIO 556.80 ZZZ Y   35400 ANGIOSCOPY NON-CORONARY VESSEL/GRAFTS THER IVNTJ 519.60 ZZZ N   35500 HARVEST UXTR VEIN 1 SGM LOWER EXTREMITY/CABG PX 1117.20 ZZZ Y   35501 BYPASS W/VEIN COMMON-IPSILATERAL CAROTID 5200.80 090 Y   35506 BYPASS W/VEIN CAROTID-SUBCLV/SUBCLAVIAN CAROTID 4477.20 090 Y   35508 BYPASS W/VEIN CAROTID-VERTEBRAL 4664.40 090 Y   35509 BYPASS W/VEIN CAROTID-CONTRALATERAL CAROTID 4962.00 090 Y   35510 BYPASS W/VEIN CAROTID-BRACHIAL 4321.20 090 Y   35511 BYPASS W/VEIN SUBCLAVIAN-SUBCLAVIAN 3937.20 090 Y   35512 BYPASS W/VEIN SUBCLAVIAN-BRACHIAL 4234.80 090 Y   35515 BYPASS W/VEIN SUBCLAVIAN-VERTEBRAL 4664.40 090 Y   35516 BYPASS W/VEIN SUBCLAVIAN-AXILLARY 4287.60 090 Y   35518 BYPASS W/VEIN AXILLARY-AXILLARY 4012.80 090 Y   35521 BYPASS W/VEIN AXILLARY-FEMORAL 4317.60 090 Y   35522 BYPASS W/VEIN AXILLARY-BRACHIAL 4196.40 090 Y   35523 BYPASS W/VEIN BRACHIAL-ULNAR/-RADIAL 4510.80 090 Y

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   35525 BYPASS W/VEIN BRACHIAL-BRACHIAL 3988.80 090 Y   35526 BYPASS W/VEIN AORTOSUBCLAV/CAROTID/INNOMINATE 6099.60 090 Y   35531 BYPASS W/VEIN AORTOCELIAC/AORTOMESENTERIC 6850.80 090 Y   35533 BYPASS W/VEIN AXILLARY-FEMORAL-FEMORAL 5295.60 090 Y   35535 BYPASS W/VEIN HEPATORENAL 6685.20 090 Y   35536 BYPASS W/VEIN SPLENORENAL 5940.00 090 Y   35537 BYPASS W/VEIN AORTOILIAC 7320.00 090 Y   35538 BYPASS W/VEIN AORTOBI-ILIAC 8202.00 090 Y   35539 BYPASS W/VEIN AORTOFEMORAL 7698.00 090 Y   35540 BYPASS W/VEIN AORTOBIFEMORAL 8580.00 090 N   35556 BYPASS W/VEIN FEMORAL-POPLITEAL 4914.00 090 Y   35558 BYPASS W/VEIN FEMORAL-FEMORAL 4334.40 090 Y   35560 BYPASS W/VEIN AORTORENAL 5991.60 090 Y   35563 BYPASS W/VEIN ILIOILIAC 4652.40 090 Y   35565 BYPASS W/VEIN ILIOFEMORAL 4610.40 090 Y   35566 BYP FEM-ANT TIBL PST TIBL PRONEAL ART/OTH DSTL 5860.80 090 Y   35570 BYP TIBL-TIBL/PRONEAL-TIBL/TIBL/PRONEAL TRK-TIBL 5247.60 090 Y   35571 BYP W/VEIN POP-TIBL-PRONEAL ART/OTH DSTL VSL 4662.00 090 Y   35572 HARVEST FEMPOP VEIN 1 SGM VASC RCNSTJ PX 1207.20 ZZZ Y   35583 IN-SITU VEIN BYPASS FEMORAL-POPLITEAL 5062.80 090 Y   35585 IN-SITU FEM-ANT TIBL PST TIBL/PRONEAL ART 5872.80 090 Y   35587 IN-SITU VEIN BYP POP-TIBL PRONEAL 4761.60 090 Y  

20 Miss. Admin. Code Pt. 2, R. 35600 Rule 35600

OPEN HARVEST UPPER EXTREMITY ART 1 SEGMENT CAB 891.60 ZZZ Y   35601 BYP OTH/THN VEIN COMMON-IPSILATERAL CAROTID 4933.20 090 Y   35606 BYP OTH/THN VEIN CAROTID-SUBCLAVIAN 4120.80 090 Y   35612 BYP OTH/THN VEIN SUBCLAVIAN-SUBCLAVIAN 3675.60 090 Y   35616 BYP OTH/THN VEIN SUBCLAVIAN-AXILLARY 3870.00 090 Y   35621 BYP OTH/THN VEIN AXILLARY-FEMORAL 3861.60 090 Y   35623 BYP OTH/THN VEIN AXILLARY-POPLITEAL/-TIBIAL 4621.20 090 Y   35626 BYPASS NOT VEIN AORTOSUBCLA/CAROTID/INNOMINATE 5625.60 090 Y   35631 BYP OTH/THN VEIN AORTOCELIAC AORTOMSN AORTORNL 6493.20 090 Y   35632 BYPASS GRAFT W/OTHER THAN VEIN ILIO-CELIAC 6348.00 090 Y   35633 BYPASS GRAFT W/OTHER THAN VEIN ILIO-MESENTERIC 6962.40 090 Y   35634 BYPASS GRAFT W/OTHER THAN VEIN ILIORENAL 6212.40 090 Y   35636 BYP OTH/THN VEIN SPLENORENAL 5605.20 090 Y   35637 BYP OTH/THN VEIN AORTOILIAC 5827.20 090 Y   35638 BYP OTH/THN VEIN AORTOBI-ILIAC 6110.40 090 Y   35642 BYP OTH/THN VEIN CAROTID-VERTEBRAL 3476.40 090 Y   35645 BYP OTH/THN VEIN SUBCLAVIAN-VERTEBRAL 3332.40 090 Y   35646 BYP OTH/THN VEIN AORTOBIFEMORAL 6002.40 090 Y   35647 BYP OTH/THN VEIN AORTOFEMORAL 5449.20 090 Y   35650 BYP OTH/THN VEIN AXILLARY-AXILLARY 3765.60 090 Y   35654 BYP OTH/THN VEIN AXILLARY-FEMORAL-FEMORAL 4804.80 090 Y   35656 BYP OTH/THN VEIN FEMORAL-POPLITEAL 3786.00 090 Y   35661 BYP OTH/THN VEIN FEMORAL-FEMORAL 3814.80 090 Y   35663 BYP OTH/THN VEIN ILIOILIAC 4282.80 090 Y   35665 BYP OTH/THN VEIN ILIOFEMORAL 4120.80 090 Y

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 156 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   35666 BYP OTH/THN VEIN FEM-ANT TIBL PST TIBL/PRONEAL 4540.80 090 Y   35671 BYP OTH/THN VEIN POPLITEAL-TIBIAL/-PERONEAL ART 4004.40 090 Y   35681 BYPASS COMPOSITE GRAFT PROSTHETIC & VEIN 280.80 ZZZ Y   35682 BYP AUTOG COMPOSIT 2 SEG VEINS FROM 2 LOCATIONS 1240.80 ZZZ N   35683 BYP AUTOG COMPOSIT 3/> SEG FROM 2/> LOCATION 1437.60 ZZZ N   35685 PLMT VEIN PATCH/CUFF DSTL ANAST BYP CONDUIT 694.80 ZZZ Y   35686 CRTJ DSTL ARVEN FSTL LXTR BYP SURG NON-HEMO 566.40 ZZZ Y   35691 TRPOS&/RIMPLTJ VERTEBRAL CAROTID ART 3330.00 090 Y   35693 TRPOS&/RIMPLTJ VERTEBRAL SUBCLAVIAN ART 2940.00 090 Y   35694 TRPOS&/RIMPLTJ SUBCLAVIAN CAROTID ART 3477.60 090 Y   35695 TRPOS&/RIMPLTJ CAROTID SUBCLAVIAN ART 3608.40 090 Y   35697 RIMPLTJ VISC ART INFRARNL AORTIC PROSTH EA ART 516.00 ZZZ Y   35700 ROPRTJ > 1 MO AFTER ORIGINAL OPRATION 532.80 ZZZ Y   35701 EXPLORATION N/FLWD SURG NECK ARTERY 1968.00 090 Y   35702 EXPLORATION N/FLWD SURG UPPER EXTREMITY ARTERY 1437.60 090 Y   35703 EXPLORATION N/FLWD SURG LOWER EXTREMITY ARTERY 1478.40 090 Y  J1* 35800 EXPL PO HEMRRG THROMBOSIS/INFCTJ NCK 2581.20 090 Y 9347.71   35820 EXPL PO HEMRRG THROMBOSIS/INFCTJ CH 7084.80 090 Y   35840 EXPL PO HEMRRG THROMBOSIS/INFCTJ ABD 4290.00 090 Y 4200.55  J1 35860 EXPL PO HEMRRG THROMBOSIS/INFCTJ XTR 2960.40 090 Y 5803.55   35870 RPR GRF-ENTERIC FSTL 4388.40 090 Y  J1 35875 THRMBC ARTL/VEN GRF OTH/THN HEMO GRF/FSTL 2092.80 090 N 9473.86  J1 35876 THRMBC ARTL/VEN GRF XCP HEMO GRF/FSTL W/REVJ GRF 3322.80 090 Y 9399.10  J1 35879 REVJ LXTR ARTL BYP OPN VEIN PATCH ANGIOP 3246.00 090 Y 9379.37  J1 35881 REVJ LXTR ARTL BYP OPN W/SGMTL VEIN INTERPOS 3596.40 090 Y 9727.60  J1 35883 REVJ FEM ANAST BPG GRN OPN W/NONAUTOG PATCH GRF 4228.80 090 Y 9445.61  J1 35884 REVJ FEM ANAST BPG GRN OPN W/AUTOG VN PATCH GRF 4356.00 090 Y 9551.54   35901 EXCISION INFECTED NECK GRAFT 1677.60 090 Y  J1 35903 EXCISION INFECTED GRAFT EXTREMITY 2001.60 090 Y 5831.18   35905 EXCISION INFECTED GRAFT THORAX 5907.60 090 Y   35907 EXCISION INFECTED GRAFT ABDOMEN 6706.80 090 Y   36000 INTRODUCTION NEEDLE/INTRACATHETER VEIN 106.26 XXX N   36002 INJECTION PX PRQ TX EXTREMITY PSEUDOANEURYSM 538.80 000 N 783.90   36005 NJX PX XTR VNGRPH W/INTRO NDL/INTRACATH 1051.20 000 N   36010 INTRO CATHETER SUPERIOR/INFERIOR VENA CAVA 1970.64 XXX N   36011 SLCTV CATH PLMT VEN SYS 1ST ORDER BRANCH 3030.00 XXX N   36012 SLCTV CATH PLMT VEN SYS 2ND ORDER/> SLCTV BRANC 3099.60 XXX N   36013 INTRO CATHETER RIGHT HEART/MAIN PULMONARY ARTERY 2900.40 XXX N   36014 SLCTV CATHETER PLMT LEFT/RIGHT PULMONARY ARTERY 2938.80 XXX N   36015 SLCTV CATH PLMT SEGMENTAL/SUBSEGMENTAL PULM ART 3174.00 XXX N   36100 INTRO NEEDLE/INTRACATH CAROTID/VERTEBRAL ARTERY 2013.60 XXX N   36140 INTRO OF NEEDLE OR INTRACATHETER UPR/LXTR ARTERY 1756.74 XXX N   36160 INTRO NEEDLE/INTRACATH AORTIC TRANSLUMBAR 2016.18 XXX N   36200 INTRODUCTION CATHETER AORTA 2211.60 000 N   36215 SLCTV CATHJ EA 1ST ORD THRC/BRCH/CPHLC BRNCH 3832.80 000 N   36216 SLCTV CATHJ 1ST 2ND ORD THRC/BRCH/CPHLC BRNCH 3940.80 000 N   36217 SLCTV CATHJ 3RD+ ORD SLCTV THRC/BRCH/CPHLC BRNCH 6526.80 000 N

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   36218 SLCTV CATHJ EA 2ND+ ORD THRC/BRCH/CPHLC BRNCH 826.80 ZZZ N   36221 NONSLCTV CATH THOR AORTA ANGIO INTR/XTRCRANL ART 3684.00 000 N 4151.55   36222 SLCTV CATH CAROTID/INNOM ART ANGIO XTRCRANL ART 4447.20 000 N 4151.55   36223 SLCTV CATH CAROTID/INNOM ART ANGIO INTRCRANL ART 5886.00 000 N 6915.76   36224 SLCTV CATH INTRNL CAROTID ART ANGIO INTRCRNL ART 7384.80 000 N 6915.76   36225 SLCTV CATH SUBCLAVIAN ART ANGIO VERTEBRAL ARTERY 5587.20 000 N 4151.55   36226 SLCTV CATH VERTEBRAL ART ANGIO VERTEBRAL ARTERY 7120.80 000 N 6915.76   36227 SLCTV CATH XTRNL CAROTID ANGIO XTRNL CAROTD CIRC 867.60 ZZZ N   36228 SLCTV CATH INTRCRNL BRNCH ANGIO INTRL CAROT/VERT 4590.00 ZZZ N   36245 SLCTV CATHJ EA 1ST ORD ABDL PEL/LXTR ART BRNCH 4614.00 XXX N   36246 SLCTV CATHJ 2ND ORDER ABDL PEL/LXTR ART BRNCH 3093.60 000 N   36247 SLCTV CATHJ 3RD+ ORD SLCTV ABDL PEL/LXTR BRNCH 5290.80 000 N   36248 SLCTV CATHJ EA 2ND+ ORD ABDL PEL/LXTR ART BRNCH 493.20 ZZZ N   36251 SLCTV CATH 1STORD W/WO ART PUNCT/FLUORO/S&I UN 4784.40 000 N 4151.55   36252 SLCTV CATH 1STORD W/WO ART PUNCT/FLUOR/S&I BIL 5157.60 000 N 4151.55   36253 SUPSLCTV CATH 2ND+ORD RENAL&ACCESSORY ARTERY/S&I 7512.00 000 N 6915.76   36254 SUPSLCTV CATH 2ND+ORD RENAL&ACCESSORY ARTERY/S&I 7396.80 000 N 4151.55  J1 36260 INSJ IMPLANTABLE INTRA-ARTERIAL INFUSION PUM 2352.00 090 N 9723.46   36261 REVJ IMPLANTED INTRA-ARTERIAL INFUSION PUMP 1474.80 090 Y 4993.88   36262 REMOVAL IMPLANTED INTRA-ARTERIAL INFUSION PUMP 1125.60 090 N 4993.88   36299 UNLISTED PROCEDURE VASCULAR INJECTION BR YYY N   36400 VNPNXR <3 YEARS PHY/QHP SKILL FEMORAL/JUGULAR VN 97.20 XXX N   36405 VNPNXR <3 YEARS PHYS/QHP SKILL SCALP VEIN 84.00 XXX N   36406 VNPNXR <3 YEARS PHYS/QHP SKILL OTHER VEIN 61.20 XXX N   36410 VNPNXR 3 YEARS/> PHYS/QHP SKILL DX/THER PURPOSES 62.40 XXX N   36415 COLLECTION VENOUS BLOOD VENIPUNCTURE 10.40 XXX N   36416 COLLECTION CAPILLARY BLOOD SPECIMEN 22.80 XXX N   36420 VENIPUNCTURE CUTDOWN YOUNGER THAN AGE 1 YR 166.80 XXX N 163.53   36425 VENIPUNCTURE CUTDOWN AGE 1 YR/> 141.60 XXX N 393.60   36430 TRANSFUSION BLOOD/BLOOD COMPONENTS 135.60 XXX N 575.63   36440 PUSH TRANSFUSION BLOOD 2 YR OR YOUNGER 178.80 XXX N 575.63   36450 BLOOD EXCHANGE TRANSFUSION NEWBORN 603.60 XXX N 575.63   36455 BLOOD EXCHANGE TRANSFUSION OTHER THAN NEWBORN 442.80 XXX N 575.63   36456 PRTL EXCHANGE TRANSFUSE BLOOD/PLSM/CRYST NEWBORN 363.60 XXX N 575.63   36460 TRANSFUSION INTRAUTERINE FETAL 1216.80 XXX Y 575.63   36465 NJX NONCMPND SCLEROSANT SINGLE INCMPTNT VEIN 5236.80 000 N 2483.95   36466 NJX NONCMPND SCLEROSANT MULTIPLE INCMPTNT VEINS 5504.40 000 N 2483.95   36468 INJECTIONS SCLEROSANT FOR SPIDER VEINS LIM/TRNK 460.80 000 N 501.26   36470 INJECTION SCLEROSANT SINGLE INCMPTNT VEIN 412.80 000 N 501.26   36471 INJECTION SCLEROSANT MULTIPLE INCMPTNT VEINS 717.60 000 N 501.26  J1 36473 ENDOVEN ABLTJ INCMPTNT VEIN MCHNCHEM 1ST VEIN 4968.00 000 N 5707.22   36474 ENDOVEN ABLTJ INCMPTNT VEIN MCHNCHEM SBSQ VEINS 944.40 ZZZ N  J1 36475 ENDOVEN ABLTJ INCMPTNT VEIN XTR RF 1ST VEIN 4872.00 000 N 5526.69   36476 ENDOVEN ABLTJ INCMPTNT VEIN XTR RF 2ND+ VEINS 1042.80 ZZZ N  J1 36478 ENDOVEN ABLTJ INCMPTNT VEIN XTR LASER 1ST VEIN 3852.00 000 N 5735.58   36479 ENDOVEN ABLTJ INCMPTNT VEIN XTR LASER 2ND+ VEINS 1093.20 ZZZ N   36481 PRQ PORTAL VEIN CATHETERIZATION ANY METHOD 6652.80 000 N

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 158 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 36482 ENDOVEN ABLTI THER CHEM ADHESIVE 1ST VEIN 6958.80 000 N 9399.58   36483 ENDOVEN ABLTI THER CHEM ADHESIVE SBSQ VEIN 511.20 ZZZ N   36500 VEN CATHJ SLCTV ORGAN BLD SAMPLING 637.20 000 N   36510 CATHJ UMBILICAL VEIN DX/THER NB 303.60 000 N   36511 THERAPEUTIC APHERESIS WHITE BLOOD CELLS 382.80 000 N 1978.09   36512 THERAPEUTIC APHERESIS RED BLOOD CELLS 374.40 000 N 1978.09   36513 THERAPEUTIC APHERESIS PLATELETS 379.20 000 N 575.63   36514 THERAPEUTIC APHERESIS PLASMA PHERESIS 2460.00 000 N 1978.09   36516 THER APHERESIS W/EXTRACORPOREAL IMMUNOADSORPTION 6752.40 000 N 5865.25   36522 PHOTOPHERESIS EXTRACORPOREAL 7346.40 000 N 5865.25  J1 36555 INSJ NON-TUNNELED CENTRAL VENOUS CATH AGE < 5 Y 688.80 000 N 5747.57  J1 36556 INSJ NON-TUNNELED CENTRAL VENOUS CATH AGE 5 YR/> 780.00 000 N 5777.68  J1 36557 INSERT TUNNELED CVC W/O SUBQ PORT/PMP AGE <5 YR 4010.28 010 N 9285.13  J1 36558 INSJ TUNNELED CVC W/O SUBQ PORT/PMP AGE 5 YR/> 2994.60 010 N 5522.74  J1 36560 INSJ TUNNELED CTR VAD W/SUBQ PORT UNDER 5 YR 4639.20 010 N 5608.55  J1 36561 INSJ TUNNELED CTR VAD W/SUBQ PORT AGE 5 YR/> 3678.00 010 N 5519.38  J1 36563 INSJ TUNNELED CTR VAD W/SUBQ PUMP 4186.80 010 N 9162.89  J1 36565 INSJ TUN VAD REQ 2 CATH 2 SITS W/O SUBQ PORT/PMP 3063.60 010 N 5560.45  J1 36566 INSJ TUN VAD REQ 2 CATH 2 SITS W/SUBQ PORT 16292.40 010 N 9295.12  J1 36568 INSERTION PICC W/O IMG GDN < 5 YR 320.40 000 N 2771.07  J1 36569 INSERTION PICC W/O IMG GDN 5 YR/> 328.80 000 N 2757.14  J1 36570 INSJ PRPH CTR VAD W/SUBQ PORT UNDER 5 YR 5494.80 010 N 5674.91  J1 36571 INSJ PRPH CTR VAD W/SUBQ PORT AGE 5 YR/> 4782.00 010 N 5552.56   36572 INSERTION PICC W/RS&I < 5 YR 1428.00 000 N 783.90  J1 36573 INSERTION PICC W/RS&I 5 YR/> 1423.20 000 N 2732.51   36575 RPR TUN/NON-TUN CTR VAD CATH W/O SUBQ PORT/PMP 550.80 000 N 783.90  J1 36576 RPR CTR VAD W/SUBQ PORT/PMP CTR/PRPH INSJ SIT 1274.40 010 N 2839.22  J1 36578 RPLCMT CATH CTR VAD SUBQ PORT/PMP 1610.40 010 N 5496.72  J1 36580 RPLCMT COMPL NON-TUN CVC W/O SUBQ PORT/PMP 735.60 000 N 2651.58  J1 36581 RPLCMT COMPL TUN CVC W/O SUBQ PORT/PMP 2913.60 010 N 5418.95  J1 36582 RPLCMT COMPL TUN CTR VAD W/SUBQ PORT 3402.00 010 N 5484.00  J1 36583 RPLCMT COMPL TUN CTR VAD W/SUBQ PMP 4323.60 010 N 9016.78  J1 36584 COMPLETE REPLACEMENT PICC RS&I 1220.40 000 N 2701.42  J1 36585 RPLCMT COMPL PRPH CTR VAD W/SUBQ PORT 4210.38 010 N 5543.64   36589 RMVL TUN CVC W/O SUBQ PORT/PMP 594.00 010 N 783.90   36590 RMVL TUN CTR VAD W/SUBQ PORT/PMP CTR/PRPH INSJ 805.20 010 N 2039.35   36591 COLLECT BLOOD FROM IMPLANT VENOUS ACCESS DEVICE 94.80 BR 94.80 XXX N   36592 COLLECT BLOOD FROM CATHETER VENOUS NOS 105.60 BR 105.60 XXX N   36593 DECLOT BY THROMBOLYTIC AGENT IMPLANT DEVICE/CATH 116.40 BR 116.40 XXX N  J1 36595 MCHNL RMVL PRICATH OBSTR CV DEV VIA VEN ACCESS 2205.60 000 N 5395.71  J1 36596 MCHNL RMVL INTRAL OBSTR CV DEV THRU DEV LUMEN 428.40 000 N 2758.94  J1 36597 RPSG PREVIOUSLY PLACED CVC UNDER FLUOR GDNCE 442.80 000 N 2757.00   36598 CNTRST NJX RAD EVAL CTR VAD FLUOR IMG&REPRT 442.80 000 N 296.68   36600 ARTERIAL PUNCTURE WITHDRAWAL BLOOD DX 104.40 XXX N 163.53   36620 ARTL CATHJ/CANNULJ MNTR/TRANSFUSION SPX PRQ 154.80 000 N   36625 ARTL CATHJ/CANNULJ MNTR/TRANSFUSION SPX CUTDOWN 372.00 000 N  J1 36640 ARTL CATHJ PROLNG NFS THER CHEMOTX CUTDOWN 405.60 000 N 5813.06

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   36660 CATHETERIZATION UMBILICAL NEWBORN ART DX/THERAPY 241.20 000 N   36680 PLACEMENT NEEDLE INTRAOSSEOUS INFUSION 208.80 000 N 393.60  J1 36800 INSJ CANNULA HEMO OTH PURPOSE SPX VEIN VEIN 428.40 000 N 9448.29  J1 36810 INSJ CANNULA HEMO OTH PURPOSE SPX ARVEN XTRNL 741.60 000 N 5627.11  J1 36815 INSJ CANNULA HEMO OTH SPX ARVEN XTRNL REVJ/CLSR 475.20 000 N 9622.64  J1 36818 ARVEN ANAST OPN UPR ARM CEPHALIC VEIN TRPOS 2431.20 090 Y 9702.76  J1 36819 ARVEN ANAST OPN UPR ARM BASILIC VEIN TRPOS 2577.60 090 Y 9688.63  J1 36820 ARVEN ANAST OPN F/ARM VEIN TRPOS 2550.00 090 Y 9646.26  J1 36821 ARTERIOVENOUS ANASTOMOSIS OPEN DIRECT 2336.40 090 Y 5815.98   36823 INSJ CNULA ISLTD XC-CIRCJ REG CHEMOTX XTR RMVL 5020.80 090 N  J1 36825 CRTJ ARVEN FSTL XCP DIR ARVEN ANAST AUTOG GRF 2800.80 090 Y 9365.01  J1 36830 CRTJ ARVEN FSTL XCP DIR ARVEN ANAST NONAUTOG GRF 2352.00 090 Y 9091.05  J1 36831 THRMBC OPN ARVEN FSTL W/O REVJ DIAL GRF 2169.60 090 Y 9264.68  J1 36832 REVJ OPN ARVEN FSTL W/O THRMBC DIAL GRF 2666.40 090 Y 9492.36  J1 36833 REVJ OPN ARVEN FSTL W/THRMBC DIAL GRF 2851.20 090 Y 9207.21  J1 36835 INSERTION THOMAS SHUNT SEPARATE PROCEDURE 1716.00 090 N 5124.69  J1 36836 PERQ AV FISTULA CREATION UXTR SINGLE ACCESS 25219.20 000 Y 30893.06  J1 36837 PERQ AV FISTULA CREATION UXTR SEP ACCESS SITES 35892.00 000 Y 29938.84  J1 36838 DSTL REVSC&INTERVAL LIG UXTR HEMO ACCESS 4023.60 090 Y 9457.78  J1 36860 XTRNL CANNULA DECLTNG SPX W/O BALO CATH 860.40 000 N 2782.28  J1 36861 XTRNL CANNULA DECLTNG SPX W/BALO CATH 492.00 000 N 9089.35  J1 36901 INTRO CATH DIALYSIS CIRCUIT DX ANGRPH FLUOR S&I 2529.54 000 N 2765.76  J1 36902 INTRO CATH DIALYSIS CIRCUIT W/TRLUML BALO ANGIOP 4489.20 000 N 9488.26  J1 36903 INTRO CATH DIALYSIS CIRCUIT W/TCAT PLMT IV STENT 18265.20 000 N 17873.37  J1 36904 PERQ THRMBC/NFS DIALYSIS CIRCUIT IMG DX ANGRPH 6703.20 000 N 9377.66  J1 36905 PERQ THRMBC/NFS DIAL CIRCUIT TRLUML BALO ANGIOP 8499.60 000 N 19052.07  J1 36906 PERQ THRMBC/NFS DIAL CIRCUIT TCAT PLMT IV STENT 22387.20 000 N 28751.61   36907 TRLUML BALO ANGIOP CTR DIALYSIS SEG W/IMG S&I 2451.60 ZZZ N   36908 STENT PLMT CENTRAL DIAYLSIS SEG PFRMD DIAL CIR 8162.40 ZZZ N   36909 DIALYIS CIRCUIT VASC EMBOLI OCCLS EVASC IMG S&I 7245.60 ZZZ N   37140 VENOUS ANASTOMOSIS OPEN PORTOCAVAL 8293.20 090 N   37145 VENOUS ANASTOMOSIS OPEN RENOPORTAL 7694.40 090 Y   37160 VENOUS ANASTOMOSIS OPEN CAVAL-MESENTERIC 7900.80 090 Y   37180 VENOUS ANASTOMOSIS OPEN SPLENORENAL PROXIMAL 7591.20 090 Y   37181 VENOUS ANASTOMOSIS OPEN SPLENORENAL DISTAL 8293.20 090 Y  J1* 37182 INSJ TRANSVNS INTRAHEPATC PORTOSYSIC SHUNT 2854.80 000 N 18519.65  J1 37183 REVJ TRANSVNS INTRHPTC PORTOSYSTEMIC SHNT (TIPS) 21978.00 000 N 9224.28  J1 37184 PRIM PRQ TRLUML MCHNL THRMBC N-COR N-ICRA 1ST 7228.80 000 N 18359.11   37185 PRIM PRQ TRLUML MCHNL THRMBC N-COR N-ICRA SBSQ 2227.20 ZZZ N   37186 SEC PRQ TRLUML THRMBC N-CORONARY N-INTRACRANIAL 4495.20 ZZZ N  J1 37187 PRQ TRANSLUMINAL MECHANICAL THROMBECTOMY VEIN 6667.20 000 N 18320.64  J1 37188 PRQ TRLUML MCHNL THRMBC VEIN REPEAT TX 5607.60 000 N 5578.58  J1 37191 INS INTRVAS VC FILTR W/WO VAS ACS VSL SELXN RS&I 8394.00 000 N 8754.03  J1 37192 REPSNG INTRVAS VC FILTR W/WO ACS VSL SELXN RS&I 4742.40 000 N 5349.51  J1 37193 RTRVL INTRVAS VC FILTR W/WO ACS VSL SELXN RS&I 5551.20 000 N 5466.02   37195 THROMBOLYSIS CEREBRAL IV INFUSION 2464.80 XXX N 462.41  J1 37197 PRQ TRANSCATHETER RTRVL INTRVAS FB WITH IMAGING 5806.80 000 N 5494.53

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 160 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 37200 TRANSCATHETER BIOPSY 756.00 000 N 9404.70  J1 37211 THROMBOLYSIS ARTERIAL INFUSION ICRA RS&I INIT TX 1350.00 000 N 9135.13  J1 37212 THROMBOLYSIS VENOUS INFUSION W/IMAGING INIT TX 1177.20 000 N 5692.75  J1 37213 THROMBOLYSIS ART/VENOUS INFSN W/IMAGE SUBSQ TX 811.20 000 N 5638.37  J1 37214 CESSATION THROMBOLYTIC THER W/CATHETER REMOVAL 428.40 000 N 5468.65   37215 TCAT IV STENT CRV CRTD ART EMBOLIC PROTECJ 3505.20 090 N 5458.26   37216 TCAT IV STENT CRV CRTD ART W/O EMBOLIC PROTECJ 3514.80 090 N   37217 TCATH STENT PLACEMT RETROGRAD CAROTID/INNOMINATE 3800.40 090 N   37218 TCATH STENT PLACEMT ANTEGRADE CAROTID/INNOMINATE 2874.00 090 N  J1 37220 REVASCULARIZATION ILIAC ARTERY ANGIOP 1ST VSL 10051.20 000 N 9398.67  J1 37221 REVSC OPN/PRQ ILIAC ART W/STNT PLMT & ANGIOPLSTY 14264.40 000 N 18458.62   37222 REVASCULARIZATION ILIAC ART ANGIOP EA IPSI VSL 2716.80 ZZZ N   37223 REVSC OPN/PRQ ILIAC ART W/STNT & ANGIOP IPSILATL 7513.20 ZZZ N  J1 37224 REVSC OPN/PRG FEM/POP W/ANGIOPLASTY UNI 12081.60 000 N 9172.15  J1 37225 REVSC OPN/PRQ FEM/POP W/ATHRC/ANGIOP SM VSL 41434.80 000 N 17686.15  J1 37226 REVSC OPN/PRQ FEM/POP W/STNT/ANGIOP SM VSL 35938.80 000 N 18043.15  J1 37227 REVSC OPN/PRQ FEM/POP W/STNT/ATHRC/ANGIOP SM VSL 53388.00 000 N 28258.72  J1 37228 REVSC OPN/PRQ TIB/PERO W/ANGIOPLASTY UNI 17512.80 000 N 18825.36  J1 37229 REVSC OPN/PRQ TIB/PERO W/ATHRC/ANGIOP SM VSL 41457.60 000 N 28913.99  J1 37230 REVSC OPN/PRQ TIB/PERO W/STNT/ANGIOP SM VSL 35295.60 000 N 29183.81  J1 37231 REVSC OPN/PRQ TIB/PERO W/STNT/ATHR/ANGIOP SM VSL 50712.00 000 N 28711.43   37232 REVSC OPN/PRQ TIB/PERO W/ANGIOPLASTY UNI EA VSL 3735.60 ZZZ N   37233 REVSC OPN/PRQ TIB/PERO W/ATHRC/ANGIOP UNI EA VSL 4551.60 ZZZ N   37234 REVSC OPN/PRQ TIB/PERO W/STNT/ANGIOP UNI EA VSL 13593.60 ZZZ N   37235 REVSC OPN/PRQ TIB/PERO W/STNT/ATHR/ANGIOP EA VSL 14548.80 ZZZ N  J1 37236 OPEN/PERQ PLACEMENT INTRAVASCULAR STENT INITIAL 12194.40 000 N 18554.53   37237 OPEN/PERQ PLACEMENT INTRAVASCULAR STENT EA ADDL 7240.80 ZZZ N  J1 37238 OPEN/PERQ PLACEMENT INTRAVASCULAR STENT SAME 1ST 12903.60 000 N 18297.05   37239 OPEN/PERQ PLACEMENT INTRAVASC STENT SAME EA ADDL 6378.00 ZZZ N  J1 37241 VASCULAR EMBOLIZATION OR OCCLUSION VENOUS RS&I 17526.00 000 N 18975.13  J1 37242 VASCULAR EMBOLIZATION OR OCCLUSION ARTERIAL RS&I 26794.80 000 N 18472.47  J1 37243 VASCULAR EMBOLIZE/OCCLUDE ORGAN TUMOR INFARCT 32834.40 000 N 19399.83  J1 37244 VASCULAR EMBOLIZATION OR OCCLUSION HEMORRHAGE 24673.20 000 N 18828.95  J1 37246 TRLML BALO ANGIOP OPEN/PERQ IMG S&I 1ST ART 7113.60 000 N 9438.66   37247 TRLML BALO ANGIOP OPEN/PERQ IMG S&I EA ADDL ART 2710.80 ZZZ N  J1 37248 TRLML BALO ANGIOP OPEN/PERQ W/IMG S&I 1ST VEIN 5085.60 000 N 9493.83   37249 TRLML BALO ANGIOP OPEN/PERQ W/IMG S&I ADDL VEIN 2012.40 ZZZ N   37252 INTRAVASCULAR US NONCORONARY RS&I INTIAL VESSEL 4293.60 ZZZ N   37253 INTRAVASCULAR US NONCORONARY RS&I ADDL VESSEL 672.00 ZZZ N  J1 37500 VASC ENDOSCOPY SURG W/LIG PERFORATOR VEINS SPX 2223.60 090 N 9734.41   37501 UNLISTED VASCULAR ENDOSCOPY PROCEDURE BR YYY N 783.90  J1 37565 LIGATION INTERNAL JUGULAR VEIN 2583.60 090 N 5711.02  J1 37600 LIGATION EXTERNAL CAROTID ARTERY 2607.60 090 Y 5847.26  J1 37605 LIGATION INTERNAL/COMMON CAROTID ARTERY 2598.00 090 Y 5847.26  J1 37606 LIG INT/COMMON CAROTID ART W/GRADUAL OCCLUSION 2601.60 090 Y 5578.58  J1 37607 LIG/BANDING ANGIOACCESS ARTERIOVENOUS FISTULA 1322.40 090 N 5807.06  J1 37609 LIGATION/BIOPSY TEMPORAL ARTERY 1131.60 010 N 2872.76

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 37615 LIGATION MAJOR ARTERY NECK 1911.60 090 Y 5843.75   37616 LIGATION MAJOR ARTERY CHEST 3902.40 090 Y  J1* 37617 LIGATION MAJOR ARTERY ABDOMEN 4663.20 090 Y 5578.58   37618 LIGATION MAJOR ARTERY EXTREMITY 1384.80 090 Y 2810.17  J1 37619 LIGATION OF INFERIOR VENA CAVA 6169.20 090 Y 9036.75  J1 37650 LIGATION OF FEMORAL VEIN 1622.40 090 N 5847.26   37660 LIGATION OF COMMON ILIAC VEIN 4699.20 090 Y  J1 37700 LIG&DIV LONG SAPH VEIN SAPHFEM JUNCT/INTERRUPJ 868.80 090 N 5812.62  J1 37718 LIG DIV & STRIPPING SHORT SAPHENOUS VEIN 1494.00 090 N 5836.45  J1 37722 LIG DIV&STRPG LONG SAPH SAPHFEM JUNCT KNE/BELW 1654.80 090 N 5818.46  J1 37735 LIG&DIV&COMPL STRPG LONG/SHRT SAPHENOUS VN W/EXC 2052.00 090 N 5765.69  J1 37760 LIG PRFRATR VEINS SUBF RAD W/SKN GRAFT OPN 1 LEG 2169.60 090 N 5766.13  J1 37761 LIG PRFRATR VEIN SUBFSCAL OPEN INCL US GID 1 LEG 1894.80 090 Y 5828.70  J1 37765 STAB PHLEBT VARICOSE VEINS 1 XTR 10-20 STAB INCS 2222.40 010 N 5821.53  J1 37766 STAB PHLEBT VARICOSE VEINS 1 XTR > 20 INCS 2641.20 010 N 5826.94  J1 37780 LIGJ & DIV SHORT SAPH VEIN SAPHENOPOP JUNCT SPX 831.60 090 N 5840.83  J1 37785 LIGJ DIVJ &/EXCJ VARICOSE VEIN CLUSTER 1 LEG 1278.00 090 N 5830.89   37788 PENILE REVASCULARIZATION ARTERY W/WO VEIN GRAFT 4425.60 090 Y  J1 37790 PENILE VENOUS OCCLUSIVE PROCEDURE 1704.00 090 N 6175.83   37799 UNLISTED PROCEDURE VASCULAR SURGERY BR YYY N 783.90   38100 SPLENECTOMY TOTAL SEPARATE PROCEDURE 4110.00 090 Y   38101 SPLENECTOMY PARTIAL SEPARATE PROCEDURE 4168.80 090 Y   38102 SPLENC TOT EN BLOC EXTNSV DS CONJUNCT W/OTH PX 926.40 ZZZ Y   38115 RPR RPTD SPLEEN SPLENORRHAPHY W/WO PRTL SPLENECT 4623.60 090 Y  J1 38120 LAPAROSCOPIC SURGICAL SPLENECTOMY 3781.20 090 Y 18136.98  J1 38129 UNLISTED LAPAROSCOPY PROCEDURE SPLEEN BR YYY Y 10309.03   38200 INJECTION PROCEDURE SPLENOPORTOGRAPY 460.80 000 N   38204 MGMT RCP HEMATOP PROGENITOR CELL DONOR &ACQUISJ 363.60 XXX N   38205 BLD-DRV HEMATOP PROGEN CELL HRVG TRNSPLJ ALGNC 301.20 000 N   38206 BLD-DRV HEMATOP PROGEN CELL HRVG TRNSPLJ AUTOL 297.60 000 N 1978.09   38207 TRNSPL PREPJ HEMATOP PROGEN CELLS CRYOPRSRV STOR 162.00 XXX N 575.63   38208 TRNSPL PREP HEMATOP PROGEN THAW PREV HRV PER DNR 103.20 XXX N 575.63   38209 TRNSP PREP HMATOP PROG THAW PREV HRV WSH PER DNR 43.20 XXX N 575.63   38210 TRNSPL PREPJ HEMATOP PROGEN DEPLJ IN HRV T-CELL 288.00 XXX N 575.63   38211 TRNSPL PREPJ HEMATOP PROGEN TUM CELL DEPLJ 259.20 XXX N 575.63   38212 TRNSPL PREPJ HEMATOP PROGEN RED BLD CELL RMVL 171.60 XXX N 575.63   38213 TRNSPL PREPJ HEMATOP PROGEN PLTLT DEPLJ 43.20 XXX N 575.63   38214 TRNSPL PREPJ HEMATOP PROGEN PLSM VOL DEPLJ 147.60 XXX N 575.63   38215 TRNSPL PREPJ HEMATOP PROGEN CONCENTRATION PLSM 171.60 XXX N 575.63  J1 38220 DIAGNOSTIC BONE MARROW ASPIRATIONS 565.20 XXX N 2870.03  J1 38221 DIAGNOSTIC BONE MARROW BIOPSIES 579.60 XXX N 2862.13  J1 38222 DIAGNOSTIC BONE MARROW BIOPSIES & ASPIRATIONS 627.60 XXX N 4827.60   38225 CAR-T THERAPY HRVG BLD-DRV T LYMPHCYT PR DAY 348.00 XXX N   38226 CAR-T THERAPY PREPJ BLD-DRV T LYMPHCYT F/TRNS 140.40 XXX N   38227 CAR-T THERAPY RECEIPT & PREPJ CAR-T CELLS F/ADMN 141.60 XXX N   38228 CAR-T THERAPY AUTOL CAR-T CELL ADMINISTRATION 1039.20 XXX N 471.00   38230 BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC 720.00 000 N 1978.09

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 162 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   38232 BONE MARROW HARVEST TRANSPLANTATION AUTOLOGOUS 697.20 000 N 5865.25  J1 38240 TRNSPLJ ALLOGENEIC HEMATOPOIETIC CELLS PER DONOR 853.20 XXX N 82053.96   38241 TRNSPLJ AUTOLOGOUS HEMATOPOIETIC CELLS PER DONOR 628.80 XXX N 1978.09   38242 ALLOGENEIC LYMPHOCYTE INFUSIONS 444.00 000 N 1978.09   38243 TRNSPLJ HEMATOPOIETIC CELL BOOST 432.00 000 N 1978.09  J1 38300 DRG LYMPH NODE ABSC/LYMPHADENITIS SMPL 1237.20 010 N 4812.11  J1 38305 DRG LYMPH NODE ABSC/LYMPHADENITIS EXTNSV 1772.40 090 N 4843.10  J1 38308 LYMPHANGIOTOMY/OTH OPRATIONS LYMPHATIC CHANNELS 1654.80 090 Y 6440.97   38380 SUTR&/LIG THORACIC DUCT CERVICAL APPROACH 2025.60 090 Y   38381 SUTR&/LIG THORACIC DUCT THORACIC APPROACH 2839.20 090 Y   38382 SUTR&/LIG THORACIC DUCT ABDOMINAL APPROACH 2432.40 090 Y  J1 38500 BX/EXC LYMPH NODE OPEN SUPERFICIAL 1215.60 010 N 6437.91  J1 38505 BX/EXC LYMPH NODE NEEDLE SUPERFICIAL 491.28 000 N 2866.80  J1 38510 BX/EXC LYMPH NODE OPEN DEEP CERVICAL NODE 1899.60 010 N 6439.36  J1 38520 BX/EXC LYMPH NODE OPN DP CRV NODE W/EXC FAT PAD 1663.20 090 N 6435.97  J1 38525 BX/EXC LYMPH NODE OPEN DEEP AXILLARY NODE 1578.00 090 N 6441.46  J1 38530 BX/EXC LYMPH NODE OPEN INT MAMMARY NODE 2002.80 090 Y 6438.23  J1 38531 OPEN BIOPSY/EXCISION INGUINOFEMORAL NODES 1594.80 090 N 6440.17  J1 38542 DISSECTION DEEP JUGULAR NODE 1861.20 090 Y 10331.25  J1 38550 EXC CSTIC HYGROMA AX/CRV W/O DP NEUROVASC DSJ 1878.00 090 N 6450.00  J1 38555 EXC CSTIC HYGROMA AX/CRV W/DP NEUROVASC DSJ 3680.40 090 Y 11279.05  J1* 38562 LMTD LMPHADEC STAGING SPX PEL&PARA-AORTIC 2509.20 090 Y 17741.74   38564 LMTD LMPHADEC STAGING SPX RPR AORTIC&/SPLENIC 2517.60 090 Y  J1 38570 LAPS SURG RETROPERITONEAL LYMPH NODE BX 1/MLT 1828.80 010 Y 10301.79  J1 38571 LAPS SURG BILATERAL TOTAL PELVIC LMPHADECTOMY 2330.40 010 Y 18149.71  J1 38572 LAPS BI TOT PEL LMPHADEC & PRI-AORTIC LYMPH BX 1 3213.60 010 Y 18148.80  J1 38573 LAPS W/BI TOT PEL LMPHADEC & OMNTC LYMPH BX 4153.20 010 Y 18156.54  J1 38589 UNLISTED LAPAROSCOPY PX LYMPHATIC SYSTEM BR YYY Y 10275.95  J1 38700 SUPRAHYOID LYMPHADENECTOMY 2868.00 090 Y 11288.09  J1 38720 CERVICAL LYMPHADENECTOMY 4761.60 090 Y 18162.28   38724 CERVICAL LYMPHADEC MODIFIED RADICAL NECK DSJ 5145.60 090 Y 5777.46  J1 38740 AXILLARY LYMPHADENECTOMY SUPERFICIAL 2509.20 090 Y 10322.98  J1 38745 AXILLARY LYMPHADENECTOMY COMPLETE 3153.60 090 Y 10310.06   38746 THORCOM THRC W/MEDSTNL & REGIONAL LMPHADEC 756.00 ZZZ Y   38747 ABDL LMPHADEC REG CELIAC GSTR PORTAL PRIPNCRTC 946.80 ZZZ Y  J1 38760 INGUINOFEM LMPHADEC SUPFC W/CLOQUETS NODE SPX 2978.40 090 Y 11283.29   38765 INGUINOFEM LMPHADEC SUPFC W/PEL LMPHADEC 4658.40 090 Y   38770 PEL LMPHADEC W/XTRNL ILIAC HYPOGSTR&OBTURATOR 2839.20 090 Y   38780 RPR TABDL LMPHADEC EXTNSV W/PEL AORTIC&RNL 3681.60 090 Y   38790 INJECTION PROCEDURE LYMPHANGIOGRAPHY 286.80 000 N   38792 INJ RADIOACTIVE TRACER FOR ID OF SENTINEL NODE 295.20 000 N 546.69   38794 CANNULATION THORACIC DUCT 1030.80 090 N   38900 INTRAOP SENTINEL LYMPH NODE ID W/DYE INJECTION 489.60 ZZZ Y   38999 UNLISTED PROCEDURE HEMIC OR LYMPHATIC SYSTEM BR YYY N 575.63   39000 MEDIAST W/EXPL DRG RMVL FB/BX CRV APPR 1772.40 090 Y 3690.91   39010 MEDIAST W/EXPL DRG RMVL FB/BX TTHRC APPR 2787.60 090 Y 3199.30   39200 RESECTION OF MEDIASTINAL CYST 3073.20 090 Y

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   39220 RESECTION MEDIASTINAL TUMOR 4004.40 090 Y  J1 39401 MEDIASTINOSCOPY INCLUDES MEDIASTINAL MASS BIOPSY 1086.00 000 N 10311.35  J1 39402 MEDIASTINOSCOPY WITH LYMPH NODE BIOPSY/IES 1418.40 000 N 10311.35   39499 UNLISTED PROCEDURE MEDIASTINUM BR YYY Y   39501 REPAIR LACERATION DIAPHRAGM ANY APPROACH 3044.40 090 Y   39503 RPR NEONATAL DIPHRG HERNIA W/WO CHEST TUBE INSJ 20854.80 090 Y   39540 RPR DIPHRG HRNA OTH/THN NEONATAL TRAUMTC AQT 3075.60 090 Y   39541 RPR DIPHRG HRNA OTH/THN NEONATAL TRAUMTC CHRNC 3350.40 090 Y   39545 IMBRICATION DIAPHRAGM EVENTRATION 3176.40 090 Y   39560 RESCJ DIAPHRAGM W/SIMPLE REPAIR 2845.20 090 Y   39561 RESCJ DIAPHRAGM W/COMPLEX REPAIR 4423.20 090 Y   39599 UNLISTED PROCEDURE DIAPHRAGM BR YYY Y 5906.61   40490 BIOPSY OF LIP 438.00 000 N 306.82  J1 40500 VERMILIONECTOMY LIP SHV W/MUCOSAL ADVMNT 1881.60 090 N 5587.96  J1 40510 EXC LIP TRANSVRS WEDGE EXC W/PRIM CLSR 1760.40 090 N 5585.45  J1 40520 EXC LIP V-EXC W/PRIM DIR LINR CLSR 1806.00 090 N 5586.01  J1 40525 EXC LIP FULL THKNS RCNSTJ W/LOCAL FLAP 1959.60 090 N 5586.84  J1 40527 EXC LIP FULL THKNS RCNSTJ W/CROSS LIP FLAP 2228.40 090 N 10388.54  J1 40530 RESCJ LIP > ONE-FOURTH W/O RCNSTJ 2007.60 090 N 5587.82   40650 REPAIR LIP FULL THICKNESS VERMILION ONLY 1729.20 090 N 655.90   40652 REPAIR LIP FULL THICKNESS <HALF VERTICAL HEIGHT 1852.80 090 N 655.90  J1 40654 RPR LIP FTH OVER ONE-HALF VERT HEIGHT/COMPLEX 2088.00 090 N 2763.08  J1 40700 PLSTC RPR CL LIP/NSL DFRM PRIM PRTL/COMPL UNI 3573.60 090 N 10383.35  J1 40701 PLSTC RPR CL LIP/NSL DFRM PRIM BI 1 STG PX 4220.40 090 Y 10272.97  J1 40702 PLSTC RPR CL LIP/NSL DFRM PRIM BI 1 2 STGS 3543.60 090 Y 10272.97  J1 40720 PLSTC RPR CL LIP/NSL DFRM SEC RECRTJ DFCT & RECL 3637.20 090 N 5475.92  J1 40761 PLSTC RPR CL LIP/NSL DFRM W/CROSS LIP PEDCL FLAP 3826.80 090 N 10388.54   40799 UNLISTED PROCEDURE LIPS BR YYY Y 306.82   40800 DRG ABSC CST HMTMA VESTIBULE MOUTH SMPL 733.20 010 N 902.47   40801 DRG ABSC CST HMTMA VESTIBULE MOUTH COMP 1063.20 010 N 655.90   40804 RMVL EMBEDDED FB VESTIBULE MOUTH SMPL 673.20 010 N 1173.47   40805 RMVL EMBEDDED FB VESTIBULE MOUTH COMP 1069.20 010 N 655.90   40806 INCISION LABIAL FRENUM FRENOTOMY 357.60 000 N 655.90   40808 BIOPSY VESTIBULE MOUTH 644.40 010 N 655.90  J1 40810 EXC LES MUCOSA & SBMCSL VESTIBULE MOUTH W/O RPR 780.00 010 N 5583.91  J1 40812 EXC LESION MUCOSA & SBMCSL VESTIBULE SMPL RPR 1027.20 010 N 2761.01  J1 40814 EXC LESION MUCOSA & SBMCSL VESTIBULE CPLX RPR 1338.00 090 N 5572.60  J1 40816 EXC LESION MUCOSA&SBMCSL VESTIBULE CPLX EXC MUSC 1435.20 090 N 5578.18   40818 EXC MUCOSA VESTIBULE MOUTH AS DON GRF 1317.60 090 N 655.90  J1 40819 EXC FRENUM LABIAL/BUCCAL 1086.00 090 N 2734.62  J1 40820 DSTRJ LES/SCAR VESTIBULE MOUTH PHYSICAL METHS 948.00 010 N 5587.82   40830 CLOSURE LACERATION VESTIBULE MOUTH 2.5 CM/< 933.60 010 N 306.82   40831 CLOSURE LACERATION VESTIBULE MOUTH > 2.5 CM/CPL 1194.00 010 N 655.90  J1 40840 VESTIBULOPLASTY ANTERIOR 3102.00 090 Y 10291.93  J1 40842 VESTIBULOPLASTY POSTERIOR UNILATERAL 3146.40 090 N 10341.53  J1 40843 VESTIBULOPLASTY POSTERIOR BILATERAL 4156.56 090 Y 10366.99  J1 40844 VESTIBULOPLASTY ENTIRE ARCH 5374.80 090 Y 10388.54

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 164 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 40845 VESTIBULOPLASTY CPLX W/RIDGE XTN MUSC RPSG 5311.20 090 N 10356.34   40899 UNLISTED PROCEDURE VESTIBULE MOUTH BR YYY N 306.82   41000 INTRAORAL I&D TONGUE/FLOOR LINGUAL 558.00 010 N 655.90   41005 INTRAORAL I&D TONGUE/FLOOR SUBLNGL SUPFC 774.00 010 N 306.82  J1 41006 INTRAORAL I&D TONGUE/FLOOR SUBLNGL DP SPRMLHYD 1297.20 090 N 2763.08  J1 41007 INTRAORAL I&D TONGUE/FLOOR SUBMENTAL SPACE 1201.20 090 N 2763.08  J1 41008 INTRAORAL I&D TONGUE/FLOOR SUBMNDBLR SPACE 1395.60 090 N 5587.96   41009 INTRAORAL I&D TONGUE/FLOOR MASTICATOR SPACE 1509.60 090 N 655.90  J1 41010 INCISION LINGUAL FRENUM FRENOTOMY 790.80 010 N 2762.94   41015 XTRORAL I&D ABSC CST/HMTMA FLOOR MOUTH SUBLNGL 1447.20 090 N 655.90  J1 41016 XTRORAL I&D ABSC CST/HMTMA FLOOR MOUTH SUBMENT 1692.00 090 N 10380.75  J1 41017 XTRORAL I&D ABSC CST/HMTMA FLOOR MOUTH SUBMNDB 1668.00 090 N 5587.26  J1 41018 XTRORAL I&D FLOOR MASTICATOR SPACE 1868.40 090 N 2763.08  J1 41019 PLACEMENT NEEDLE HEAD/NECK RADIOELEMENT APPLICAT 1704.00 000 N 10207.26   41100 BIOPSY TONGUE ANTERIOR TWO-THIRDS 675.60 010 N 655.90  J1 41105 BIOPSY TONGUE POSTERIOR ONE-THIRD 674.40 010 N 5586.29  J1 41108 BIOPSY FLOOR MOUTH 603.06 010 N 2873.91  J1 41110 EXCISION LESION TONGUE W/O CLOSURE 829.20 010 N 5577.76  J1 41112 EXC LESION TONGUE W/CLSR ANTERIOR TWO-THIRDS 1216.80 090 N 5587.54  J1 41113 EXC LESION TONGUE W/CLSR POSTERIOR ONE-THIRD 1309.20 090 N 5585.73  J1 41114 EXC LESION TONGUE W/CLSR W/LOCAL TONGUE FLAP 2174.40 090 N 5587.82  J1 41115 EXCISION LINGUAL FRENUM FRENECTOMY 948.00 010 N 2763.08  J1 41116 EXCISION LESION FLOOR MOUTH 1206.00 090 N 5581.82  J1 41120 GLOSSECTOMY <ONE-HALF TONGUE 3813.60 090 Y 10373.74   41130 GLOSSECTOMY HEMIGLOSSECTOMY 4692.00 090 Y 5103.31   41135 GLOSSECTOMY PRTL W/UNI RADICAL NECK DSJ 7695.60 090 Y   41140 GLSSC COMPL/TOT W/WOTRACHS W/O RAD NECK DSJ 7780.80 090 Y   41145 GLSSC COMPL/TOT W/WO TRACHS W/UNI RAD NECK DSJ 9806.40 090 Y   41150 GLSSC COMPOSIT W/RESCJ FLOOR & MANDIBULAR RESCJ 7824.00 090 Y   41153 GLSSC COMPOSIT RESCJ FLOOR SUPRAHYOID NCK DSJ 8510.40 090 Y   41155 GLSSC COMPOSIT RESCJ FLR MNDBLR RESCJ & RAD NECK 10639.20 090 Y   41250 RPR LAC 2.5 CM/< MOUTH&/ANT TWO-THIRDS TONG 1023.60 010 N 393.60   41251 RPR LAC 2.5 CM/< PST ONE-THIRD TONGUE 1126.80 010 N 306.82   41252 RPR LAC TONGUE FLOOR MOUTH > 2.6 CM/CPLX 1183.20 010 N 306.82  J1 41510 SUTURE TONGUE LIP MICROGNATHIA 1635.60 090 N 5564.91  J1 41512 TONGUE BASE SUSPENSION PERMANENT SUTURE TQ 2398.80 090 N 9548.37  J1 41520 FRENOPLASTY SURG REVJ FRENUM EG W/Z-PLASTY 1317.60 090 N 5587.96  J1 41530 SUBMUCOSAL ABLTJ TONGUE RF 1/> SITES PR SESSION 3403.20 000 N 5574.13   41599 UNLISTED PROCEDURE TONGUE FLOOR MOUTH BR YYY N 306.82   41800 DRG ABSC CST HMTMA FROM DENTOALVEOLAR STRUXS 1052.40 010 N 163.53  J1 41805 RMVL EMBEDDED FB FROM DENTALVLR STRUXS SOFT TISS 1132.80 010 N 2763.08  J1 41806 RMVL EMBEDDED FB FROM DENTOALVEOLAR STRUXS BONE 1489.20 010 N 2763.08  J1 41820 GINGIVECTOMY EXC GINGIVA EACH QUADRANT 2724.00 000 N 5587.96  J1 41821 OPRCULECTOMY EXC PRICORONAL TISSUE 422.40 000 N 2746.02  J1 41822 EXC FIBROUS TUBEROSITIES DENTOALVEOLAR STRUXS 1127.46 010 N 2763.08  J1 41823 EXC OSS TUBEROSITIES DENTOALVEOLAR STRUXS 1740.18 090 N 10165.71  J1 41825 EXC LESION/TUMOR DENTOALVEOLAR STRUX W/O RPR 790.80 010 N 5579.44

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 41826 EXC LESION/TUMOR DENTOALVEOLAR STRUX W/SMPL RPR 1095.60 010 N 5576.65  J1 41827 EXC LESION/TUMOR DENTALVEOLAR STRUX W/CMPLX RPR 1561.20 090 N 10214.27  J1 41828 EXC HYPRPLSTC ALVEOLAR MUCOSA EA QUADRANT SPEC 1244.76 010 N 2763.08  J1 41830 ALVEOLECTOMY W/CURTG OSTEITIS/SEQUESTRECTOMY 1575.96 010 N 5554.30  J1 41850 DESTRUCTION LESION DENTOALVEOLAR STRUCTURES 672.00 000 N 2763.08  J1 41870 PERIODONTAL MUCOSAL GRAFTING 1342.80 000 N 2746.02  J1 41872 GINGIVOPLASTY EACH QUADRANT SPECIFY 1546.98 090 N 5587.96  J1 41874 ALVEOLOPLASTY EACH QUADRANT SPECIFY 1387.20 090 N 5582.93   41899 UNLISTED PROCEDURE DENTOALVEOLAR STRUCTURES BR YYY N 306.82   42000 DRAINAGE ABSCESS PALATE UVULA 579.60 010 N 306.82  J1 42100 BIOPSY PALATE UVULA 528.00 010 N 2763.01  J1 42104 EXC LESION PALATE UVULA W/O CLOSURE 778.80 010 N 5586.01  J1 42106 EXC LESION PALATE UVULA W/SMPL PRIM CLOSURE 934.80 010 N 5585.17  J1 42107 EXC LESION PALATE UVULA W/LOCAL FLAP CLOSURE 1648.80 090 N 10388.54  J1 42120 RESCJ PALATE/EXTENSIVE RESCJ LESION 3602.40 090 Y 10381.01  J1 42140 UVULECTOMY EXCISION UVULA 1058.46 090 N 5587.12  J1 42145 PALATOPHARYNGOPLASTY 2450.40 090 N 10333.74  J1 42160 DSTRJ LESION PALATE/UVULA THERMAL CRYO/CHEM 838.80 010 N 5579.72   42180 REPAIR LACERATION PALATE <2 CM 920.40 010 N 655.90  J1 42182 REPAIR LACERATION PALATE >2 CM/COMPLEX 1190.40 010 N 10353.22  J1 42200 PALATOP CL PALATE SOFT&/HARD PALATE ONLY 3300.00 090 Y 9987.03  J1 42205 PALATOPLASTY W/CLSR ALVEOLAR RIDGE SOFT TISSUE 3434.40 090 Y 5554.43  J1 42210 PALATOP CLSR ALVEOLAR RIDGE GRF ALVEOLAR RIDGE 3835.20 090 Y 9157.76  J1 42215 PALATOPLASTY CLEFT PALATE MAJOR REVJ 2502.00 090 Y 10337.12  J1 42220 PALATOPLASTY CLEFT PALATE SEC LNGTH PX 2060.40 090 Y 10388.54  J1 42225 PALATOP CL PALATE ATTACHMENT PHARYNGEAL FLAP 3528.00 090 Y 10049.62  J1 42226 LENGTHENING PALATE & PHARYNGEAL FLAP 3242.40 090 Y 10388.54  J1 42227 LENGTHENING PALATE W/ISLAND FLAP 3021.60 090 Y 10372.18  J1 42235 REPAIR ANTERIOR PALATE W/VOMER FLAP 2658.00 090 Y 10388.54  J1 42260 REPAIR NASOLABIAL FISTULA 3078.00 090 Y 9899.24   42280 MAXILLARY IMPRESJ PALATAL PROSTHESIS 637.20 010 N 655.90  J1 42281 INSJ PIN-RETAINED PALATAL PROSTHESIS 810.00 010 N 10271.93   42299 UNLISTED PROCEDURE PALATE UVULA BR YYY Y 306.82  J1 42300 DRAINAGE ABSCESS PAROTID SIMPLE 774.00 010 N 2763.08  J1 42305 DRAINAGE ABSCESS PAROTID COMPLICATED 1514.40 090 N 5578.60   42310 DRG ABSC SUBMAXILLARY/SUBLINGUAL INTRAORAL 615.60 010 N 655.90   42320 DRAINAGE ABSCESS SUBMAXILLARY INTRAORAL 942.00 010 N 655.90  J1 42330 SIALOT SUBMNDBLR SUBLNGL/PRTD UNCOMP INTRAORAL 836.40 010 N 5580.70  J1 42335 SIALOLITHOTOMY SUBMNDBLR SUBMAX COMP INTRAORAL 1537.32 090 N 5571.34  J1 42340 SIALOLITHOTOMY PRTD XTRORAL/COMP INTRAORAL 1907.16 090 N 5574.97   42400 BIOPSY SALIVARY GLAND NEEDLE 354.00 000 N 902.47  J1 42405 BIOPSY SALIVARY GLAND INCISIONAL 1084.80 010 N 2761.63  J1 42408 EXC SUBLINGUAL SALIVARY CYST RANULA 1962.00 090 N 5579.72  J1 42409 MARSUPIALIZATION SUBLNGL SALIVARY CST RANULA 1378.62 090 Y 5583.91  J1 42410 EXC PRTD TUM/PRTD GLND LAT LOBE W/O NRV DSJ 2239.20 090 Y 10379.45  J1 42415 EXC PRTD TUM/PRTD GLND LAT DSJ&PRSRV FACIAL NR 3756.00 090 Y 10371.40  J1 42420 EXC PRTD TUM/PRTD GLND TOT DSJ&PRSRV FACIAL NR 4209.60 090 Y 10363.35

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 166 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 42425 EXCISION PAROTID TUMOR/GLAND TOTAL EN BLOC RMVL 2977.20 090 Y 10360.75   42426 EXC PRTD TUM/PRTD GLND TOT W/UNI RAD NCK DSJ 4789.20 090 Y 5900.16  J1 42440 EXCISION SUBMANDIBULAR SUBMAXILLARY GLAND 1476.00 090 Y 10375.82  J1 42450 EXISION OF SUBLINGUAL GLAND 1694.40 090 N 10370.88  J1 42500 PLSTC RPR SALIVARY DUX SIALODOCHOPLASTY PRIM 1614.00 090 N 10310.11  J1 42505 PLSTC RPR SALIVARY DUX SIALODOCHOPLASTY SEC/COMP 2059.20 090 N 10303.88  J1 42507 PAROTID DUCT DIVERSION BILATERAL WILKE PX 1767.60 090 Y 10388.54  J1 42509 PAROTID DUCT DVRJ BI W/EXC BOTH SUBMNDBLR GLANDS 2919.60 090 N 10272.97  J1 42510 PAROTID DUCT DVRJ BILATERAL WITH LIG BOTH DUCTS 2169.60 090 Y 5564.91   42550 INJECTION PROCEDURE SIALOGRAPHY 572.40 000 N  J1 42600 CLOSURE SALIVARY FISTULA 1952.70 090 N 5570.78  J1 42650 DILATION SALIVARY DUCT 277.20 000 N 2748.78   42660 DILAT&CATHJ SALIVARY DUCT W/WO INJECTION 433.20 000 N 655.90  J1 42665 LIGATION SALIVARY DUCT INTRAORAL 1299.96 090 N 5564.91   42699 UNLISTED PX SALIVARY GLANDS/DUCTS BR YYY Y 306.82   42700 I&D ABSCESS PERITONSILLAR 691.20 010 N 306.82  J1 42720 I&D ABSC RTRPHRNGL/PARAPHARYNGEAL INTRAORAL 1603.20 010 N 5587.12  J1 42725 I&D ABSC RTRPHRNGL/PARAPHARYNGEAL XTRNL APPR 2836.80 090 Y 10388.54  J1 42800 BIOPSY OROPHARYNX 567.60 010 N 2762.74  J1 42804 BIOPSY NASOPHARYNX VISIBLE LESION SIMPLE 777.60 010 N 5584.61  J1 42806 BX NASOPHARYNX SURVEY UNKNOWN PRIMARY LESION 864.00 010 N 5573.85  J1 42808 EXCISION/DESTRUCTION LESION PHARYNX ANY METHOD 829.20 010 N 5573.01   42809 REMOVAL FOREIGN BODY PHARYNX 729.60 010 N 393.60  J1 42810 EXC BRANCHIAL CLEFT CYST CONFINED SKN&SUBQ TIS 1395.60 090 Y 5577.76  J1 42815 EXC BRANCHIAL CLEFT CYST BELOW SUBQ TISS&/PHRYNX 1926.00 090 Y 10377.89  J1 42820 TONSILLECTOMY & ADENOIDECTOMY <AGE 12 1033.20 090 N 10377.89  J1 42821 TONSILLECTOMY & ADENOIDECTOMY AGE 12/> 1078.80 090 N 5583.91  J1 42825 TONSILLECTOMY PRIMARY/SECONDARY <AGE 12 952.80 090 N 10272.97  J1 42826 TONSILLECTOMY PRIMARY/SECONDARY AGE 12/> 907.20 090 N 5582.51  J1 42830 ADENOIDECTOMY PRIMARY <AGE 12 753.60 090 N 5568.13  J1 42831 ADENOIDECTOMY PRIMARY AGE 12/> 818.40 090 N 5534.88  J1 42835 ADENOIDECTOMY SECONDARY<AGE 12 700.80 090 N 5587.96  J1 42836 ADENOIDECTOMY SECONDARY AGE 12/> 866.40 090 N 5571.48  J1 42842 RADICAL RESECTION TONSIL W/O CLOSURE 3619.20 090 N 10358.94  J1 42844 RADICAL RESCJ TONSIL CLOSURE W/LOCAL FLAP 4909.20 090 Y 10388.54   42845 RADICAL RESCJ TONSIL CLOSURE W/OTHER FLAP 7860.00 090 Y  J1 42860 EXCISION TONSIL TAGS 685.20 090 N 5587.96  J1 42870 EXC/DSTRJ LINGUAL TONSIL ANY METHOD SPX 2121.60 090 N 10370.10  J1 42890 LIMITED PHARYNGECTOMY 5066.40 090 Y 10373.48  J1 42892 RESCJ LAT PHRNGL WALL/PYRIFORM SINUS DIR CLSR 6679.20 090 Y 10361.79   42894 RESCJ PHRNGL WALL CLSR W/FLP OR FLP W/MVASC ANAS 8427.60 090 Y  J1 42900 SUTURE PHARYNX WOUND/INJURY 1176.00 010 N 2213.92  J1 42950 PHARYNGOPLASTY PLSTC/RCNSTV OPRATION PHARYNX 2866.80 090 Y 10170.12   42953 PHARYNGOESOPHAGEAL REPAIR 3433.20 090 Y  J1 42955 PHARYNGOSTOMY FSTLJ PHARYNX XTRNL FEEDING 2724.00 090 Y 2746.02   42960 CONTROL OROPHARYNGEAL HEMORRHAGE SIMPLE 579.60 010 N 655.90   42961 CTRL OROPHARYNGEAL HEMORRHAGE COMP REQ HOSPITJ 1491.60 090 Y 2330.61

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 42962 CTRL OROPHARYNGEAL HEMORRHAGE W/SEC SURG IVNTJ 1832.40 090 N 5584.61   42970 CTRL NASOPHARYNGEAL HEMRRG SMPL W/PST NSL PACKS 1465.20 090 N 306.82   42971 CTRL NASOPHARYNGEAL HEMRRG COMP REQ HOSPIZATION 1614.00 090 Y  J1 42972 CTRL NASOPHARYNGEAL HEMORRHAGE W/SEC SURG IVNTJ 1802.40 090 Y 5587.96  J1 42975 DISE DYN EVAL SLEEP DISORDERED BREATHING FLX DX 398.40 000 N 238.73   42999 UNLISTED PROCEDURE PHARYNX ADENOIDS/TONSILS BR YYY N 306.82  J1 43020 ESOPHAGOTOMY CERVICAL APPR W/RMVL FB 2030.40 090 Y 2763.08  J1 43030 CRICOPHARYNGEAL MYOTOMY 1860.00 090 Y 10310.11   43045 ESOPHAGOTOMY THORACIC APPR W/RMVL FB 4615.20 090 Y   43100 EXC LESION ESOPHOGUS W/PRIM RPR CERVICAL APPR 2258.40 090 Y   43101 EXC LESION ESOPHAGUS W/PRIM RPR THRC/ABDL APPR 3566.40 090 Y   43107 TOT ESOPHAGECTOMY W/O THORCOM W/WO PYLOROPLASTY 10512.00 090 Y   43108 TOT ESOPHG W/O THORCOM COLON NTRPSTJ/INT RCNSTJ 15663.60 090 Y   43112 TOTAL ESOPHAGECTOMY W/THORCOM W/WO PYLORPLASTY 12250.80 090 Y   43113 TOT ESOPHG W/THORCOM W/COLON NTRPSTJ/INT RCNSTJ 15306.00 090 Y   43116 PRTL ESOPHAGECTOMY CERVICAL W/FREE INTSTINAL GRF 17512.80 090 Y   43117 PRTL ESOPHECT DSTL W/WO PROX GASTRECT/PYLORPLSTY 11491.20 090 Y   43118 PRTL ESOPH DSTL W/WO PROX GASTRC W/COLON NTRPSTJ 12777.60 090 Y   43121 PRTL ESOPHAGEC W/WO PROX GASTREC/PYLOROPLASTY 10074.00 090 Y   43122 PRTL ESOPHG THORACOABD W/WO PROXGASTREC/PYLOROPL 9060.00 090 Y   43123 PRTL ESPHG THORACOABDL/ABDL APPR NTRPSTJ/RCNSTJ 15867.60 090 Y   43124 TOT/PRTL ESPHG W/O RCNSTJ W/CRV ESOPHAGOSTOMY 13418.40 090 Y  J1 43130 DIVERTICULECTOMY HYPOPHARYNX/ESOPH CRV APPR 2823.60 090 Y 10373.22   43135 DIVERTICULECTOMY HYPOPHARYNX/ESOPH THRC APPR 5192.40 090 Y  J1 43180 ESOPHAGOSCP RIG TRANSORAL HYPOPHARYNX CRV ESOPH 1940.40 090 N 10353.74  J1 43191 ESOPHAGOSCOPY RIGID TRANSORAL DIAGNOSTIC BRUSH 546.00 000 N 3313.14  J1 43192 ESOPHAGOSCOPY RIGID TRANSORAL INJ SUBMUCOSAL 597.60 000 N 3310.57  J1 43193 ESOPHAGOSCOPY RIGID TRANSORAL WITH BIOPSY 596.40 000 N 3316.46  J1 43194 ESOPHAGOSCOPY RIG TRANSORAL REMOVAL FOREIGN BODY 681.60 000 N 3316.21  J1 43195 ESOPHAGOSCOPY RIGID TRANSORAL BALLOON DILATION 649.20 000 N 6040.53  J1 43196 ESOPHAGOSCOPY RIG TRANSORAL GUIDE WIRE DILATION 687.60 000 N 6211.91   43197 ESOPHAGOSCOPY FLEXIBLE TRANSNASAL DIAGNOSTIC 696.00 000 N 1173.47   43198 ESOPHAGOSCOPY FLEXIBLE TRANSNASAL WITH BIOPSY 768.00 000 N 1173.47   43200 ESOPHAGOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC 897.00 000 N 1173.47  J1 43201 ESOPHAGOSCOPY FLEXIBLE TRANSORAL W SUBMUCOUS INJ 903.90 000 N 3302.53  J1 43202 ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY 1264.08 000 N 3308.25  J1 43204 ESOPHAGOSCOPY FLEX TRANSORAL INJECTION VARICES 475.20 000 N 3239.41  J1 43205 ESPHGOSCOPY FLEX W/BAND LIGATION ESOPHGL VARICES 495.60 000 N 3308.08  J1 43206 ESOPHAGOSCOPY TRANSORAL W/OPTICAL ENDOMICROSCOPY 1083.30 000 N 3239.41  J1 43210 EGD PARTIAL/COMPL ESOPHAGOGASTRIC FUNDOPLASTY 1521.60 000 N 16991.28  J1 43211 ESOPHAGOSCOPY FLEXIBLE TRANSORAL MUCOSAL RESEXN 824.40 000 N 3309.00  J1 43212 ESOPHAGOSCOPY TRANSORAL STENT PLACEMENT 666.00 000 N 8814.76  J1 43213 ESOPHAGOSCOPY RETROGRADE DILATE BALLOON/OTHER 4636.80 000 N 3287.76  J1 43214 ESOPHAGOSCOPY DILATE ESOPHAGUS BALLOON 30 MM 678.00 000 N 3230.20  J1 43215 ESOPHAGOSCOPY FLEXIBLE REMOVAL FOREIGN BODY 1456.80 000 N 3305.68  J1 43216 ESPHAGOSCOPY FLEX LESION REMOVAL HOT BX FORCEPS 1466.94 000 N 3317.62  J1 43217 ESOPHAGOSCOPY FLEXIB LESION REMOVAL TUMOR SNARE 1538.70 000 N 3315.71

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 168 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 43220 ESOPHAGOSCOPY FLEX BALLOON DILAT <30 MM DIAM 3549.60 000 N 3139.47  J1 43226 ESOPHAGOSCOPY FLEXIBLE GUIDE WIRE DILATION 1323.42 000 N 3270.43  J1 43227 ESOPHAGOSCOPY FLEXIBLE W/BLEEDING CONTROL 2218.80 000 N 3317.62  J1 43229 ESOPHAGOSCOPY FLEX TRANSORAL LESION ABLATION 2634.42 000 N 5790.60  J1 43231 ESOPHAGOSCOPY FLEXIBLE TRANSORAL ULTRASOUND EXAM 1174.80 000 N 3309.25  J1 43232 ESOPHAGOSCOPY INTRA/TRANSMURAL NEEDLE ASPIRAT/BX 1426.80 000 N 3310.24  J1 43233 EGD ESOPHAGUS BALLOON DILATION 30 MM OR LARGER 807.60 000 N 3184.25   43235 ESOPHAGOGASTRODUODENOSCOPY TRANSORAL DIAGNOSTIC 1050.18 000 N 1173.47   43236 ESOPHAGOGASTRODUODENOSCOPY SUBMUCOSAL INJECTION 1381.38 000 N 1173.47  J1 43237 ESOPHAGOGASTRODUODENOSCOPY US SCOPE W/ADJ STRXRS 687.60 000 N 3310.16  J1 43238 EGD INTRMURAL US NEEDLE ASPIRATE/BIOPSY ESOPHAGS 817.20 000 N 3308.08   43239 EGD TRANSORAL BIOPSY SINGLE/MULTIPLE 1395.60 000 N 1173.47  J1 43240 EGD TRANSORAL TRANSMURAL DRAINAGE PSEUDOCYST 1380.00 000 N 8701.92  J1 43241 EGD INTRALUMINAL TUBE/CATHETER INSERTION 500.40 000 N 3286.69  J1 43242 EGD INTRMURAL NEEDLE ASPIR/BIOP ALTERED ANATOMY 922.80 000 N 3308.17  J1 43243 EGD INJECTION SCLEROSIS ESOPHGL/GASTRIC VARICES 832.80 000 N 3294.57  J1 43244 EGD BAND LIGATION ESOPHGEAL/GASTRIC VARICES 860.40 000 N 3301.12  J1 43245 EGD DILATION GASTRIC/DUODENAL STRICTURE 2220.00 000 N 3164.93  J1 43246 EGD PERCUTANEOUS PLACEMENT GASTROSTOMY TUBE 704.40 000 N 3292.74   43247 EGD FLEXIBLE FOREIGN BODY REMOVAL 1410.00 000 N 1173.47   43248 EGD INSERT GUIDE WIRE DILATOR PASSAGE ESOPHAGUS 1451.76 000 N 1173.47  J1 43249 EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM 4093.20 000 N 3175.46  J1 43250 EGD FLEX REMOVAL LESION(S) BY HOT BIOPSY FORCEPS 1628.40 000 N 3312.23  J1 43251 EGD REMOVAL TUMOR POLYP/OTHER LESION SNARE TECH 1799.52 000 N 3293.49  J1 43252 EGD FLEX TRANSORAL W/OPTICAL ENDOMICROSCOPY 1236.48 000 N 6110.46  J1 43253 EGD US GUIDED TRANSMURAL INJXN/FIDUCIAL MARKER 924.00 000 N 3288.01  J1 43254 EGD TRANSORAL ENDOSCOPIC MUCOSAL RESECTION 950.40 000 N 3282.21  J1 43255 EGD TRANSORAL CONTROL BLEEDING ANY METHOD 2337.60 000 N 3296.14  J1 43257 EGD DELIVER THERMAL ENERGY SPHNCTR/CARDIA GERD 820.80 000 N 6089.61  J1 43259 EDG US EXAM SURGICAL ALTER STOM DUODENUM/JEJUNUM 794.40 000 N 3310.07  J1 43260 ERCP DX COLLECTION SPECIMEN BRUSHING/WASHING 1134.00 000 N 6060.91  J1 43261 ERCP W/BIOPSY SINGLE/MULTIPLE 1190.40 000 N 6079.42  J1 43262 ERCP W/SPHINCTEROTOMY/PAPILLOTOMY 1255.20 000 N 6066.24  J1 43263 ERCP W/PRESSURE MEASUREMENT SPHINCTER OF ODDI 1256.40 000 N 6160.63  J1 43264 ERCP REMOVE CALCULI/DEBRIS BILIARY/PANCREAS DUCT 1279.20 000 N 6064.52  J1 43265 ERCP DESTRUCTION/LITHOTRIPSY CALCULI ANY METHOD 1522.80 000 N 9850.64  J1 43266 EGD ENDOSCOPIC STENT PLACEMENT W/WIRE& DILATION 766.80 000 N 8777.49  J1 43270 EGD ABLATE TUMOR POLYP/LESION W/DILATION& WIRE 2711.70 000 N 3113.92   43273 ENDOSCOPIC PAPILLA CANNULATION BILE/PANCREATIC 418.80 ZZZ N  J1 43274 ERCP STENT PLACEMENT BILIARY/PANCREATIC DUCT 1627.20 000 N 9569.95  J1 43275 ERCP REMOVE FOREIGN BODY/STENT BILIARY/PANC DUCT 1324.80 000 N 6101.84  J1 43276 ERCP BILIARY/PANC DUCT STENT EXCHANGE W/DIL&WIRE 1694.40 000 N 9519.06  J1 43277 ERCP BALLOON DILATE BILIARY/PANC DUCT/AMPULLA EA 1330.80 000 N 6007.13  J1 43278 ERCP TUMOR/POLYP/LESION ABLATION W/DILATION&WIRE 1521.60 000 N 6062.32   43279 LAPS ESOPHAGOMYOTOMY W/FUNDOPLASTY IF PERFORMED 4586.40 090 Y 8011.55  J1 43280 LAPS SURG ESOPG/GSTR FUNDOPLASTY 3858.00 090 Y 17964.60  J1 43281 LAPS RPR PARAESPHGL HRNA INCL FUNDPLSTY W/O MESH 5498.40 090 Y 17848.17

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 43282 LAPS RPR PARAESPHGL HRNA INCL FUNDPLSTY W/MESH 6181.20 090 Y 17356.96   43283 LAPS ESOPHAGEAL LENGTHENING ADDL 561.60 ZZZ Y 2662.66  J1 43284 LAPS ESOPHGL SPHNCTR AGMNTJ PLMT DEV CRRPL 2338.80 090 Y 15840.58   43285 REMOVAL ESOPHAGEAL SPHINCTER AGMNTJ DEVICE 2408.40 090 Y 7338.12   43286 ESOPHAGECTOMY TOTAL NEAR TOTAL W/LAPS MOBLJ 11258.40 090 Y   43287 ESOPHAGECTOMY DISTAL 2/3 W/LAPAROSCOPIC MOBLJ 12552.00 090 Y   43288 ESOPHAGECTOMY TOTAL NEAR TOTAL W/THRSC MOBLJ 13225.20 090 Y  J1 43289 UNLISTED LAPAROSCOPY PROCEDURE ESOPHAGUS BR YYY Y 10209.29  J1 43290 EGD FLX TRNSORL W/DPLMNT NTRGSTR BARIATRIC BALO 9697.20 000 N 3483.18   43291 EGD FLX TRNSORL W/RMVL NTRGSTR BARIATRIC BALO 1663.20 000 N 1172.22   43300 ESPHGP CRV APPR W/O RPR TRACHEOESOPHGL FSTL 2222.40 090 Y   43305 ESPHGP CRV APPR W/RPR TRACHEOESOPHGL FSTL 3884.40 090 Y   43310 ESPHGP THRC APPR W/O RPR TRACHEOESOPHGL FSTL 5239.20 090 Y   43312 ESPHGP THRC APPR W/RPR TRACHEOESOPHGL FSTL 5602.80 090 Y   43313 ESPHGP CGEN DFCT THRC APPR W/O RPR FSTL 10363.20 090 Y   43314 ESPHGP CGEN DFCT THRC APPR W/RPR FSTL 11122.80 090 Y   43320 EGST W/WO VAGOTOMY&PYLOROPLASTY TABDL/TTHRC AP 5006.40 090 Y   43325 ESOPG/GSTR FUNDOPLASTY W/FUNDIC PATCH 4870.80 090 Y   43327 ESOPG/GSTR FUNDOPLASTY W/LAPAROTOMY 2932.80 090 Y   43328 ESOPG/GSTR FUNDOPLASTY W/THORACOTOMY 3974.40 090 Y   43330 ESOPHAGOMYOTOMY HELLER TYPE ABDOMINAL APPROACH 4790.40 090 Y   43331 ESOPHAGOMYOTOMY HELLER TYPE THORACIC APPROACH 4737.60 090 Y   43332 RPR PARAESOPH HIATAL HERNIA W/LAPT W/O MESH 4107.60 090 Y 4806.24   43333 LAPT RPR PARAESOPH HIATAL HERNIA W/MESH 4485.60 090 Y   43334 RPR PARAESOPH HIATAL HERNIA W/THORCOM W/O MESH 4405.20 090 Y   43335 RPR PARAESOPH HIATAL HERNIA W/THORCOM W/MESH 4713.60 090 Y   43336 RPR PARAESOPH HIATAL HERNIA THORCOABDOM W/O MESH 5258.40 090 Y   43337 RPR PARAESOPH HIATAL HERNIA THORCOABDOM W/MESH 5458.80 090 Y   43338 ESOPHAGUS LENGTHENING 405.60 ZZZ Y   43340 ESOPHAGOJEJUNOSTOMY W/O TOT GSTRCT ABDL APPR 4945.20 090 Y   43341 ESOPHAGOJEJUNOSTOMY W/O TOT GSTRCT THRC APPR 4953.60 090 Y   43351 ESOPHAGOSTOMY FSTLJ ESOPH XTRNL THRC APPR 4669.20 090 Y   43352 ESOPHAGOSTOMY FSTLJ ESOPH XTRNL CRV APPR 3778.80 090 Y   43360 GI RCNSTJ PREV ESPHG/EXCLUSION W/STOMACH 7940.40 090 Y   43361 GI RCNSTJ PREV ESPHG/EXCLUSION W/COLON SM INT 9637.20 090 Y   43400 LIGATION DIRECT ESOPHAGEAL VARICES 5455.20 090 Y   43405 LIG/STAPLING G-ESOP JUNCT PRE-ESOPHGL PRF8J 5158.80 090 Y   43410 SUTR ESOPHGL WND/INJ CRV APPR 3654.00 090 Y   43415 SUTR ESOPHGL WND/INJ TTHRC/TABDL APPR 9044.40 090 Y  J1 43420 CLSR ESOPHAGOSTOMY/FSTL CRV APPR 3608.40 090 N 5579.16   43425 CLSR ESOPHAGOSTOMY/FSTL TTHRC/TABDL APPR 5100.00 090 Y   43450 DILATION ESOPH UNGUIDED SOUND/BOUGIE 1/MULT PASS 648.60 000 N 1173.47  J1 43453 DILATION ESOPHAGUS GUIDE WIRE 3054.00 000 N 3287.68   43460 ESOPG/GSTR TAMPONADE W/BALO SENGSTAKEN TYPE 746.40 000 N   43496 FREE JEJUNUM TRSF W/MICROVASC ANASTOMOSIS BR 090 Y  J1 43497 TRANSORAL LOWER ESOPHAGEAL MYOTOMY 2808.00 090 N 5785.74   43499 UNLISTED PROCEDURE ESOPHAGUS BR YYY N 1173.47

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 170 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   43500 GASTROTOMY W/EXPLORATION/FOREIGN BODY REMOVAL 2818.80 090 Y   43501 GASTROTOMY W/SUTURE REPAIR BLEEDING ULCER 4834.80 090 Y   43502 GASTROTOMY W/SUTR RPR PRE-ESOPG/GASTRIC LAC 5468.40 090 Y   43510 GSTRT W/ESOPHGL DILAT&INSJ PRM INTRAL TUBE 3409.20 090 Y 1173.47   43520 PYLOROMYOTOMY CUTTING PYLORIC MUSC 2478.00 090 Y 4478.92   43605 BIOPSY STOMACH LAPAROTOMY 3001.20 090 Y   43610 EXC LOCAL ULCER/BENIGN TUMOR STOMACH 3506.40 090 Y 5636.32   43611 EXC LOCAL MALIGNANT TUMOR STOMACH 4369.20 090 Y   43620 GSTRCT TOT W/ESOPHAGOENTEROSTOMY 7098.00 090 Y   43621 GSTRCT TOT W/ROUX-EN-Y RCNSTJ 8112.00 090 Y   43622 GSTRCT TOT W/FRMJ INTSTINAL POUCH ANY TYPE 8265.60 090 Y   43631 GSTRCT PRTL DSTL W/GASTRODUODENOSTOMY 5185.20 090 Y   43632 GSTRCT PRTL DSTL W/GASTROJEJUNOSTOMY 7262.40 090 Y   43633 GSTRCT PRTL DSTL W/ROUX-EN-Y RCNSTJ 6866.40 090 Y   43634 GSTRCT PRTL DSTL W/FRMJ INTSTINAL POUCH 7603.20 090 Y   43635 VAGOTOMY PFRMD W/PRTL DSTL GSTRCT 399.60 ZZZ Y   43640 VGTMY W/PYLORPLSTY W/WO GASTROST TRUNCAL/SLCTV 4273.20 090 Y   43641 VGTMY W/PYLOROPLASTY W/WO GASTROST PARIETAL CELL 4322.40 090 Y   43644 LAPS GSTR RSTCV PX W/BYP ROUX-EN-Y LIMB <150 CM 6216.00 090 Y 7460.30   43645 LAPS GSTR RSTCV PX W/BYP&SM INT RCNSTJ 6574.80 090 Y  J1 43647 LAPS IMPLTJ/RPLCMT GASTRIC NSTIM ELTRD ANTRUM 3054.00 YYY Y 19401.75  J1 43648 LAPS REVISION/RMVL GASTRIC NSTIM ELTRD ANTRUM 2061.72 YYY Y 10066.92  J1 43651 LAPS SURG TRNSXJ VAGUS NRV TRUNCAL 2358.00 090 Y 10304.12  J1 43652 LAPS SURG TRNSXJ VAGUS NRV SLCTV/HILY SLCTV 2748.00 090 Y 10194.30  J1 43653 LAPS SURG GASTROSTOMY W/O CONSTJ GSTR TUBE SPX 2077.20 090 Y 10233.32  J1 43659 UNLISTED LAPAROSCOPY PROCEDURE STOMACH BR YYY Y 10259.68   43752 NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE 141.60 000 N 393.60   43753 GASTRIC INTUBATJ & ASPIRAJ W/PHYS SKILL/LAVAGE 78.00 000 Y 383.81   43754 GASTRIC INTUBAT DX W/ASPIRATION SINGLE SPECIMEN 637.56 000 Y 383.81   43755 GASTRIC INTUBATION DX & ASPIRATJ MULTIPLE SPEC 611.34 000 Y 202.48   43756 DUODENAL INTUBAT W/IMAG GUIDED SINGLE SPECIMEN 899.76 000 Y 1173.47   43757 DUODENAL INTUBAT W/IMAG GUIDED MULTIPLE SPECIMEN 1253.04 000 Y 1173.47   43761 REPOS NASO/ORO GASTRIC FEEDING TUBE THRU DUO 442.80 000 N 385.91   43762 PERQ REPLACEMENT GTUBE NOT REQ REVJ GSTRST TRC 841.20 000 N 385.91   43763 PERQ REPLACEMENT GTUBE REQ REVJ GSTRST TRC 1269.60 000 N 385.91  J1 43770 LAPS GASTRIC RESTRICTIVE PROCEDURE PLACE DEVICE 4047.60 090 Y 16086.64   43771 LAPS GASTRIC RESTRICTIVE PX REVISION DEVICE 4590.00 090 Y 4134.59  J1 43772 LAPS GASTRIC RESTRICTIVE PX REMOVE DEVICE 3406.80 090 Y 6248.44  J1 43773 LAPS GASTRIC RESTRICTIVE PX REMOVE&RPLCMT DEVICE 4590.00 090 Y 9961.24  J1 43774 LAPS GASTRIC RESTRICTIVE PX REMOVE DEVICE & PORT 3445.20 090 Y 6255.65   43775 LAPS GSTRC RSTRICTIV PX LONGITUDINAL GASTRECTOMY 3963.60 090 Y 5691.67   43800 PYLOROPLASTY 3336.00 090 Y   43810 GASTRODUODENOSTOMY 3646.80 090 Y   43820 GASTROJEJUNOSTOMY W/O VAGOTOMY 4809.60 090 Y   43825 GASTROJEJUNOSTOMY W/VAGOTOMY ANY TYPE 4702.80 090 Y  J1 43830 GASTROSTOMY OPEN W/O CONSTJ GASTRIC TUBE SPX 2523.60 090 Y 3309.74   43831 GASTROSTOMY OPEN NEONATAL FOR FEEDING 2200.80 090 Y 1173.47

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   43832 GASTROSTOMY OPEN W/CONSTJ GASTRIC TUBE 3740.40 090 Y  J1* 43840 GASTRORRHAPHY SUTR PRF8 DUOL/GSTR ULCER WND/INJ 4866.00 090 Y 9534.48   43842 GASTRIC RSTCV W/O BYP VERTICAL-BANDED GASTROPLY 4150.80 090 N   43843 GSTR RSTCV W/O BYP OTH/THN VER-BANDED GSTP 4608.00 090 Y   43845 GASTRIC RSTCV W/PRTL GASTRECTOMY 50-100 CM 6994.80 090 Y   43846 GASTRIC RSTCV W/BYP W/SHORT LIMB 150 CM/< 5922.00 090 Y   43847 GASTRIC RSTCV W/BYP W/SM INT RCNSTJ LIMIT ABSRPJ 6482.40 090 Y   43848 REVISION OPEN GASTRIC RESTRICTIVE PX NOT DEVICE 6906.00 090 Y   43860 REVJ GSTR/JJ ANAST W/RCNSTJ W/O VGTMY 5853.60 090 Y   43865 REVJ GSTR/JJ ANAST W/RCNSTJ W/VGTMY 6124.80 090 Y  J1 43870 CLOSURE GASTROSTOMY SURG 2545.20 090 Y 6239.97   43880 CLOSURE GASTROCOLIC FISTULA 5722.80 090 Y   43881 IMPLTJ/RPLCMT GASTRIC NSTIM ELTRDE ANTRUM OPEN 2671.68 YYY Y   43882 REVISION/RMVL GASTRIC NSTIM ELTRDE ANTRUM OPEN 2710.80 YYY Y   43886 GSTR RSTCV PX OPN REVJ SUBQ PORT COMPONENT ONLY 1324.80 090 Y 5106.63   43887 GSTR RSTCV PX OPN RMVL SUBQ PORT COMPONENT ONLY 1191.60 090 Y 2483.95   43888 GSTR RSTCV OPN RMVL & RPLCMT SUBQ PORT 1676.40 090 Y 5106.63   43999 UNLISTED PROCEDURE STOMACH BR YYY N 1173.47   44005 ENTEROLSS FRING INTSTINAL ADHESION SPX 3906.00 090 Y 3846.75   44010 DUODENOTOMY EXPLORATION/BX/FOREIGN BODY REMOVAL 3054.00 090 Y   44015 TUBE/NEEDLE CATH JEJUNOSTOMY ANY METHOD 504.00 ZZZ Y   44020 ENTEROTOMY SM INT OTH/THN DUO EXPL BX/FB RMVL 3492.00 090 Y   44021 ENTEROTOMY SM INT OTH/THN DUO DCMPRN 3474.00 090 Y   44025 COLOTOMY EXPLORATION/BIOPSY/FOREIGN BODY REMOVAL 3507.60 090 Y   44050 RDCTJ VOLVULUS INTUSSUSCEPTION INT HRNA LAPT 3350.40 090 Y 2970.22   44055 CORRJ MALROTATION BANDS&/RDCTJ VOLVULUS 5317.20 090 Y   44100 BX INTESTINE CAPSULE TUBE PRORAL 1/> SPECIMENS 376.80 000 N 1173.47   44110 EXC 1/> SMALL/LARGE LESIONS INTESTINE ENTEROTOM 3021.60 090 Y 3787.96   44111 EXC 1/> SM/LG LESIONS INTESTNE MULT ENTEROTOMIE 3494.40 090 Y   44120 ENTRC RESCJ SMALL INTESTINE 1 RESCJ & ANAST 4363.20 090 Y 4472.97   44121 ENTERECTOMY RESCJ SMALL INTESTINE EA RESCJ & ANA 854.40 ZZZ Y   44125 ENTERECTOMY RESCJ SMALL INTESTINE W/ENTEROSTOMY 4198.80 090 Y   44126 ENTRC RESCJ ATRESIA RESCJ & ANAST W/O TAPRING 8833.20 090 Y   44127 ENTRC RESCJ ATRESIA RESCJ & ANAST SGM W/TAPRING 10200.00 090 Y   44128 ENTRC RESCJ ATRESIA EA RESCJ & ANASTOMOSIS 864.00 ZZZ Y   44130 ENTEROENTEROST ANAST INT W/WO CUTAN NTRSTM SPX 4699.20 090 Y   44132 DONOR ENTERECTOMY OPEN CADAVER DONOR BR XXX N   44133 DONOR ENTERECTOMY OPEN LIVING DONOR BR XXX N   44135 INTESTINAL ALLOTRANSPLANTATION CADAVER DONOR BR XXX N   44136 INTESTINAL ALLOTRANSPLANTATION LIVING DONOR BR XXX N   44137 RMVL TRNSPLED INTESTINAL ALLOGRAFT COMPL BR XXX Y   44139 MOBLJ SPLENIC FLXR PFRMD CONJUNCT W/PRTL COLCT 428.40 ZZZ Y   44140 COLECTOMY PARTIAL W/ANASTOMOSIS 4791.60 090 Y 3405.32   44141 COLECTOMY PRTL W/SKIN LEVEL CECOST/COLOSTOMY 6484.80 090 Y   44143 COLECTOMY PRTL W/END COLOSTOMY & CLSR DSTL SGMT 5910.00 090 Y   44144 COLECTOMY PRTL W/COLOST/ILEOST & MUCOFISTULA 6285.60 090 Y   44145 COLECTOMY PRTL W/COLOPROCTOSTOMY 5866.80 090 Y

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 172 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   44146 COLECTOMY PRTL W/COLOPROCTOSTOMY & COLOSTOMY 7471.20 090 Y   44147 COLECTOMY PRTL ABDOMINAL & TRANSANAL APPROACH 6874.80 090 Y   44150 COLCT TOT ABDL W/O PRCTECT W/ILEOST/ILEOPXTS 6604.80 090 Y   44151 COLCT TOT ABDL W/O PRCTECT W/CONTINENT ILEOST 7710.00 090 Y   44155 COLECTOMY TOT ABDL W/PROCTECTOMY W/ILEOSTOMY 7351.20 090 Y   44156 COLECTOMY TOT ABDL W/PROCTECTOMY W/CONTNT ILEOST 8246.40 090 Y   44157 COLECTOMY TOT ABD W/PROCTECTOMY ILEOANAL ANAST 7830.00 090 Y   44158 COLCT TTL ABD W/PRCTECT ILEOANAL ANAST & RSVR 8023.20 090 Y   44160 COLECTOMY PRTL W/RMVL TERMINAL ILEUM & ILEOCOLOS 4429.20 090 Y  J1 44180 LAPAROSCOPY ENTEROLYSIS SEPARATE PROCEDURE 3291.60 090 Y 10289.91  J1 44186 LAPAROSCOPY SURGICAL JEJUNOSTOMY 2336.40 090 Y 10281.64   44187 LAPAROSCOPY SURG ILEOSTOMY/JEJUNOSTOMY NON-TUBE 3889.20 090 Y   44188 LAPAROSCOPY SURG COLOSTOMY/SKN LVL CECOSTOMY 4335.60 090 Y   44202 LAPS ENTERECT RESCJ 1 SMALL INTEST RESCJ & ANA 4950.00 090 Y 4060.32   44203 LAPAROSCOPY SMALL INTESTINE RESCJ & ANASTOMOSIS 853.20 ZZZ Y   44204 LAPAROSCOPY COLECTOMY PARTIAL W/ANASTOMOSIS 5466.00 090 Y 4640.81   44205 LAPS COLECTOMY PRTL W/RMVL TERMINAL ILEUM 4746.00 090 Y 4705.49   44206 LAPS COLECTOMY PRTL W/END CLST & CLSR DSTL SGM 6198.00 090 Y   44207 LAPS COLECTOMY PRTL W/COLOPXTSTMY LW ANAST 6426.00 090 Y   44208 LAPS COLECTMY PRTL W/COLOPXTSTMY LW ANAST W/CLST 6993.60 090 Y   44210 LAPS COLECTOMY TOT W/O PRCTECT W/ILEOST/ILEOPXTS 6267.60 090 Y   44211 LAPS COLCT TTL ABD W/PRCTECT ILEOANAL ANASTOMSIS 7554.00 090 Y   44212 LAPS COLECTOMY ABDL W/PROCTECTOMY W/ILEOSTOMY 7171.20 090 Y   44213 LAPS MOBLJ SPLENIC FLXR PFRMD W/PRTL COLECTOMY 662.40 ZZZ Y   44227 LAPS CLSR NTRSTM LG/SM INT W/RESCJ & ANASTOMOSIS 5907.60 090 Y  J1 44238 UNLISTED LAPAROSCOPY PX INTESTINE XCP RECTUM BR YYY Y 10306.70  J1* 44300 PLACEMENT ENTEROSTOMY/CECOSTOMY TUBE OPEN 3013.20 090 Y 3239.41   44310 ILEOSTOMY/JEJUNOSTOMY NON-TUBE 3703.20 090 Y   44312 REVJ ILEOSTOMY SIMPLE RLS SUPERFICIAL SCAR SPX 2133.60 090 N 5106.63   44314 REVJ ILEOSTOMY COMPLIC RCNSTJ IN-DEPTH SPX 3578.40 090 Y 5106.63   44316 CONTINENT ILEOSTOMY KOCK PROCEDURE SPX 5070.00 090 Y   44320 COLOSTOMY/SKIN LEVEL CECOSTOMY 4280.40 090 Y   44322 COLOSTOMY/SKN LVL CECOSTOMY W/MULT BXS SPX 3627.60 090 Y   44340 REVJ COLOSTOMY SMPL RLS SUPFC SCAR SPX 2238.00 090 N 5106.63  J1* 44345 REVJ COLOSTOMY COMP RCNSTJ IN-DEPTH SPX 3740.40 090 Y 6307.96  J1* 44346 REVJ COLOSTOMY W/RPR PARACLST HERNIA SPX 4210.80 090 Y 6307.96  J1 44360 ENDOSCOPY UPPER SMALL INTESTINE 504.00 000 N 3305.93  J1 44361 ENDOSCOPY UPPER SMALL INTESTINE W/BIOPSY 558.00 000 N 3309.49  J1 44363 ENTEROSCOPY > 2ND PRTN W/RMVL FOREIGN BODY 674.40 000 N 3286.93  J1 44364 ENTEROSCOPY > 2ND PRTN W/RMVL LESION SNARE 718.80 000 N 3292.66  J1 44365 ENTEROSCOPY > 2ND PRTN W/RMVL LESION CAUTERY 638.40 000 N 3297.63  J1 44366 ENTEROSCOPY > 2ND PRTN W/CONTROL BLEEDING 842.40 000 N 3306.92  J1 44369 ENTEROSCOPY > 2ND PRTN ABLTJ LESION 862.80 000 N 3297.47  J1 44370 ENTEROSCOPY > 2ND PRTN TNDSC STENT PLMT 936.00 000 N 8636.63  J1 44372 ENTEROSCOPY > 2ND PRTN W/PLMT PRQ TUBE 842.40 000 N 3276.82  J1 44373 ENTEROSCOPY > 2ND PRTN CONV GSTRST TUBE 674.40 000 N 3261.97  J1 44376 ENTEROSC >2ND PRTN W/ILEUM W/WO COLLJ SPEC SPX 999.60 000 N 3309.08

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 44377 ENTEROSC >2ND PRTN W/ILEUM W/BX SINGLE/MULTIPLE 1052.40 000 N 3305.02  J1 44378 ENTEROSCOPY > 2ND PRTN ILEUM CONTROL BLEEDING 1353.60 000 N 3294.32  J1 44379 ENTEROSCOPY > 2ND PRTN W/ILEUM W/STENT PLMT 1438.80 000 N 10281.70   44380 ILEOSCOPY THRU STOMA DX W/COLLJ SPEC WHEN PRFMD 685.86 000 N 1173.47  J1 44381 ILEOSCOPY STOMA W/BALLOON DILATION 3651.60 000 N 3166.75   44382 ILEOSCOPY STOMA W/BX SINGLE/MULTIPLE 1076.40 000 N 1173.47  J1 44384 ILEOSCOPY STOMA W/PLMT OF ENDOSCOPIC STENT 542.40 000 N 6008.23   44385 NDSC EVAL INTSTINAL POUCH DX W/COLLJ SPEC SPX 772.80 000 N 1150.88   44386 NDSC EVAL INTSTINAL POUCH W/BX SINGLE/MULTIPLE 1153.68 000 N 1150.88   44388 COLONOSCOPY STOMA DX INCLUDING COLLJ SPEC SPX 1153.20 000 N 1150.88   44389 COLONOSCOPY STOMA W/BIOPSY SINGLE/MULTIPLE 1515.60 000 N 1503.87   44390 COLONOSCOPY STOMA W/RMVL FOREIGN BODY 1476.00 000 N 1150.88   44391 COLONOSCOPY STOMA CONTROL BLEEDING 2372.40 000 N 1503.87   44392 COLONOSCOPY STOMA RMVL LES BY HOT BIOPSY FORCEPS 1408.80 000 N 1503.87   44394 COLONOSCOPY STOMA W/RMVL TUM POLYP/OTH LES SNARE 1606.80 000 N 1503.87   44401 COLONOSCOPY STOMA ABLATION LESION 10347.60 000 N 1503.87  J1 44402 COLONOSCOPY STOMA W/ENDOSCOPIC STENT PLCMT 919.20 000 N 8342.57   44403 COLONOSCOPY STOMA W/ENDOSCOPIC MUCOSAL RESCJ 1066.80 000 N 1503.87   44404 COLONOSCOPY STOMA W/SUBMUCOSAL INJECTION 1490.40 000 N 1503.87   44405 COLONOSCOPY STOMA W/BALLOON DILATION 2064.00 000 N 1503.87   44406 COLONOSCOPY STOMA W/ENDOSCOPIC ULTRASOUND EXAM 807.60 000 N 1503.87   44407 COLONOSCOPY STOMA W/US GID NDL ASPIR/BX 969.60 000 N 1503.87   44408 COLONOSCOPY THROUGH STOMA WITH DECOMPRESSION 814.80 000 N 1150.88  

20 Miss. Admin. Code Pt. 2, R. 44500 Rule 44500

INTRODUCTION LONG GI TUBE SEPARATE PROCEDURE 68.40 000 N 1173.47  J1* 44602 ENTERORRHAPHY SINGLE PERFORATION 5022.00 090 Y 6068.75   44603 ENTERORRHAPHY MULTIPLE PERFORATIONS 5755.20 090 Y   44604 SUTR LG INTESTINE 1/MULT PERFORAT W/O COLOSTOMY 3758.40 090 Y 3780.33   44605 SUTR LG INTESTINE 1/MULT PERFORAT W/COLOSTOMY 4635.60 090 Y   44615 INTSTINAL STRICTUROPLASTY W/WO DILAT OBSTRCJ 3825.60 090 Y   44620 CLOSURE ENTEROSTOMY LG/SMALL INTESTINE 3078.00 090 Y 3541.55   44625 CLSR NTRSTM LG/SM RESCJ & ANAST OTH/THN CLRCT 3591.60 090 Y   44626 CLSR NTRSTM LG/SM RESCJ & COLORECTAL ANASTOMOSIS 5677.20 090 Y   44640 CLOSURE INTESTINAL CUTANEOUS FISTULA 4976.40 090 Y   44650 CLSR ENTEROENTERIC/ENTEROCOLIC FSTL 5134.80 090 Y   44660 CLSR ENTEROVES FSTL W/O INTSTINAL/BLADDER RESCJ 4717.20 090 Y   44661 CLSR ENTEROVES FSTL W/INTESTINE&/BLADDER RESCJ 5488.80 090 Y   44680 INTESTINAL PLICATION SEPARATE PROCEDURE 3861.60 090 Y   44700 EXCLUSION SM INT FROM PELVIS MESH/PROSTH/TISS 3540.00 090 Y   44701 INTRAOPERATIVE COLONIC LAVAGE 603.60 ZZZ Y   44705 PREPARE FECAL MICROBIOTA FOR INSTILLATION 391.20 XXX N   44715 BKBENCH PREP CADAVER/LIVING DONOR INTESTINE 2790.00 XXX Y   44720 BKBENCH RCNSTJ INT ALGRFT VEN ANAST EA 975.60 XXX Y   44721 BKBENCH RCNSTJ INT ALGRFT ARTL ANAST EA 1364.40 XXX Y   44799 UNLISTED PROCEDURE SMALL INTESTINE BR YYY N 1173.47   44800 EXC MECKEL'S DIVERTICULUM/OMPHALOMESENTERIC DUCT 2758.80 090 Y 2874.55   44820 EXCISION LESION MESENTERY SEPARATE PROCEDURE 3056.40 090 Y   44850 SUTURE MESENTERY SEPARATE PROCEDURE 2688.00 090 Y

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 174 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   44899 UNLISTED PX MECKEL'S DIVERTICULUM & MESENTERY BR YYY Y   44900 INCISION AND DRAINAGE APPENDICEAL ABSCESS OPEN 2818.80 090 Y  J1 44950 APPENDECTOMY 2301.60 090 Y 6487.82   44955 APPENDEC INDICATED PURPOSE OTH MAJOR PX NOT SPX 295.20 ZZZ Y   44960 APPENDEC RPTD APPENDIX ABSC/PRITONITIS 3148.80 090 Y 4251.71  J1 44970 LAPAROSCOPIC APPENDECTOMY 2161.20 090 Y 10304.12  J1 44979 UNLISTED LAPAROSCOPY PROCEDURE APPENDIX BR YYY Y 10247.27   45000 TRANSRECTAL DRAINAGE OF PELVIC ABSCESS 1528.80 090 N 1503.87   45005 I&D SUBMUCOSAL ABSCESS RECTUM 1123.32 010 N 1503.87  J1 45020 I&D DP SUPRALEVATOR PELVIRCT/RETRORCT ABSC 2050.80 090 N 4988.83  J1 45100 BX ANORECTAL WALL ANAL APPROACH 1076.40 090 N 4988.21  J1 45108 ANORECTAL MYOMECTOMY 1342.80 090 N 4990.08   45110 PRCTECT COMPL CMBN ABDOMINOPRNL W/CLST 6463.20 090 Y   45111 PRCTECT PRTL RESCJ RECTUM TABDL APPR 3870.00 090 Y   45112 PRCTECT CMBN ABDOMINOPRNL PULL-THRU PX 6542.40 090 Y   45113 PRCTECT PRTL W/MUCOSEC ILEOANAL ANAST RSVR 6577.20 090 Y   45114 PRCTECT PRTL W/ANAST ABDL & TRANSSAC APPROACH 6505.20 090 Y   45116 PRCTECT PRTL W/ANAST TRANSSAC APPR ONLY 5438.40 090 Y   45119 PRCTECT CMBN PULL-THRU W/RSVR W/NTRSTM 6714.00 090 Y   45120 PRCTECT COMPL W/PULL-THRU PX & ANASTOMOSIS 5733.60 090 Y   45121 PRCTECT COMPL W/STOT/TOT COLCT W/MLT BXS 6259.20 090 Y   45123 PRCTECT PRTL W/O ANAST PRNL APPR 3955.20 090 Y   45126 PELVIC EXENTERATION COLORECTAL MALIGNANCY 9693.60 090 Y   45130 EXC RCT PROCIDENTIA W/ANAST PERINEAL APPROACH 3834.00 090 Y   45135 EXC RCT PROCIDENTIA W/ANAST ABDL & PRNL APPROACH 4567.20 090 Y   45136 EXC ILEOANAL RSVR W/ILEOSTOMY 6405.60 090 Y   45150 DIVISION STRICTURE RECTUM 1521.60 090 N 1503.87  J1 45160 EXC RCT TUM PROCTOTOMY TRANSSAC/TRANSCOCCYGEAL 3680.40 090 Y 4910.74  J1 45171 EXC RCT TUM NOT INCL MUSCULARIS PROPRIA 2215.20 090 Y 4986.34  J1 45172 EXC RCT TUM INCL MUSCULARIS PROPRIA 2947.20 090 Y 4984.22  J1 45190 DESTRUCTION RECTAL TUMOR TRANSANAL APPROACH 2527.20 090 N 4988.83   45300 PROCTOSGMDSC RGD DX W/WO COLLJ SPEC BR/WA SPX 466.80 000 N 1150.88   45303 PROCTOSGMDSC RIGID W/DILATION 3565.20 000 N 1503.87   45305 PROCTOSGMDSC RIGID W/BX SINGLE/MULTIPLE 604.44 000 N 1503.87  J1 45307 PROCTOSGMDSC RIGID W/RMVL FOREIGN BODY 694.14 000 N 4990.08  J1 45308 PROCTOSGMDSC RIGID RMVL 1 LESION CAUTERY 680.34 000 N 4990.08   45309 PROCTOSGMDSC RIGID RMVL 1 LESION SNARE TQ 705.18 000 N 1503.87   45315 PROCTOSGMDSC RIGID RMVL MULT TUMOR CAUTERY/SNARE 774.18 000 N 1503.87   45317 PROCTOSGMDSC RIGID CONTROL BLEEDING 761.76 000 N 1503.87  J1 45320 PROCTOSGMDSC RIGID ABLATION LESION 754.86 000 N 4990.08  J1 45321 PROCTOSGMDSC RIGID DCMPRN VOLVULUS 367.20 000 N 4964.13  J1 45327 PROCTOSGMDSC RIGID TNDSC STENT PLMT 415.20 000 N 9509.29   45330 SIGMOIDOSCOPY FLX DX W/COLLJ SPEC BR/WA IF PFRMD 673.44 000 N 1150.88   45331 SIGMOIDOSCOPY FLX W/BIOPSY SINGLE/MULTIPLE 1048.80 000 N 1150.88   45332 SIGMOIDOSCOPY FLX W/RMVL FOREIGN BODY 1015.68 000 N 1503.87   45333 SIGMOIDOSCOPY FLX W/RMVL TUMOR BY HOT BX FORCEPS 1196.46 000 N 1150.88   45334 SIGMOIDOSCOPY FLX CONTROL BLEEDING 1844.40 000 N 1503.87

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   45335 SGMDSC FLX DIRED SBMCSL NJX ANY SBST 986.70 000 N 1150.88   45337 SGMDSC FLX W/DCMPRN W/PLMT DCMPRN TUBE 404.40 000 N 1150.88   45338 SGMDSC FLX RMVL TUM POLYP/OTH LES SNARE TQ 1088.82 000 N 1503.87   45340 SIGMOIDOSCOPY FLX TNDSC BALO DILAT 1717.20 000 N 1503.87   45341 SIGMOIDOSCOPY FLX NDSC US XM 435.60 000 N 1150.88   45342 SIGMOIDOSCOPY FLX TNDSC US GID NDL ASPIR/BX 595.20 000 N 1503.87   45346 SIGMOIDOSCOPY FLX ABLATION TUMOR POLYP/OTH LES 9885.60 000 N 1503.87  J1 45347 SIGMOIDOSCOPY FLX PLACEMENT OF ENDOSCOPIC STENT 542.40 000 N 8635.60  J1 45349 SGMDSC FLX WITH ENDOSCOPIC MUCOSAL RESECTION 696.00 000 N 4947.67   45350 SIGMOIDOSCOPY FLX WITH WITH BAND LIGATION(S) 2263.20 000 N 1503.87   45378 COLONOSCOPY FLX DX W/COLLJ SPEC WHEN PFRMD 1238.40 000 N 1150.88   45379 COLONOSCOPY FLX W/REMOVAL OF FOREIGN BODY(S) 1590.00 000 N 1503.87   45380 COLONOSCOPY W/BIOPSY SINGLE/MULTIPLE 1596.00 000 N 1503.87   45381 COLSC FLX WITH DIRECTED SUBMUCOSAL NJX ANY SBST 1589.76 000 N 1503.87   45382 COLSC FLEXIBLE W/CONTROL BLEEDING ANY METHOD 2470.80 000 N 1503.87   45384 COLSC FLX W/REMOVAL LESION BY HOT BX FORCEPS 1796.40 000 N 1503.87   45385 COLSC FLX W/RMVL OF TUMOR POLYP LESION SNARE TQ 1659.60 000 N 1503.87   45386 COLSC FLEXIBLE W/TRANSENDOSCOPIC BALLOON DILAT 2268.00 000 N 1503.87   45388 COLONOSCOPY FLX ABLATION TUMOR POLYP/OTHER LES 10424.40 000 N 1503.87  J1 45389 COLONOSCOPY FLX WITH ENDOSCOPIC STENT PLACEMENT 1018.80 000 N 8694.21  J1 45390 COLONOSCOPY FLX W/ENDOSCOPIC MUCOSAL RESECTION 1168.80 000 N 4927.33   45391 COLSC FLX W/NDSC US XM RCTM ET AL LMTD&ADJ STRUX 906.00 000 N 1503.87   45392 COLSC FLX W/US GUID NDL ASPIR/BX W/US RCTM ET AL 1069.20 000 N 1503.87   45393 COLONOSCOPY FLEXIBLE WITH DECOMPRESSION 889.20 000 N 1503.87   45395 LAPS PROCTECTOMY ABDOMINOPERINEAL W/COLOSTOMY 6922.80 090 Y   45397 LAPS PROCTECTOMY COMBINED PULL-THRU W/RESERVOIR 7520.40 090 Y   45398 COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S) 2880.06 000 N 1503.87   45399 UNLISTED PROCEDURE COLON BR YYY N 1150.88   45400 LAPAROSCOPY PROCTOPEXY PROLAPSE 4011.60 090 Y 5603.62   45402 LAPAROSCOPY PROCTOPEXY PROLAPSE SIGMOID RESCJ 5361.60 090 Y  J1 45499 UNLISTED LAPAROSCOPY PROCEDURE RECTUM BR YYY Y 10276.73  J1 45500 PROCTOPLASTY STENOSIS 2055.60 090 N 4990.08  J1 45505 PROCTOPLASTY PROLAPSE MUCOUS MEMBRANE 2154.00 090 N 4984.47   45520 PERIRECTAL INJ SCLEROSING SOLUTION PROLAPSE 590.40 000 N 1150.88   45540 PROCTOPEXY ABDOMINAL APPROACH 3741.60 090 Y  J1 45541 PROCTOPEXY PERINEAL APPROACH 3367.20 090 Y 4985.09   45550 PROCTOPEXY W/SIGMOID RESCJ ABDL APPR 5174.40 090 Y  J1 45560 REPAIR RECTOCELE SEPARATE PROCEDURE 2457.60 090 Y 4939.56   45562 EXPL RPR & PRESACRAL DRG RECTAL INJURY 4070.40 090 Y   45563 EXPL RPR & PRESACRAL DRG RECTAL INJ W/COLOSTOMY 5956.80 090 Y   45800 CLOSURE RECTOVESICAL FISTULA 4567.20 090 Y   45805 CLSR RECTOVESICAL FISTULA W/COLOSTOMY 5277.60 090 Y   45820 CLOSURE RECTOURETHRAL FISTULA 4579.20 090 Y   45825 CLOSURE RECTOURETHRAL FISTULA W/COLOSTOMY 5528.40 090 Y   45900 RDCTJ PROCIDENTIA UNDER ANES SEPARATE PROCEDURE 763.20 010 N 1150.88   45905 DILAT ANAL SPHNCTR SPX UNDER ANES OTH/THN LOCAL 602.40 010 N 1503.87   45910 DILAT RCT STRIX SPX UNDER ANES OTH/THN LOCAL 688.80 010 N 1503.87

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 176 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   45915 RMVL FECAL IMPACTION/FB SPX UNDER ANES 1281.60 010 N 1503.87  J1 45990 ANRCT XM SURG REQ ANES GENERAL SPI/EDRL DX 372.00 000 N 4983.72   45999 UNLISTED PROCEDURE RECTUM BR YYY N 1150.88  J1 46020 PLACEMENT SETON 960.00 000 N 4987.96   46030 REMOVAL ANAL SETON OTHER MARKER 557.52 000 N 1503.87   46040 I&D ISCHIORECTAL&/PERIRECTAL ABSCESS SPX 2014.80 090 N 1503.87  J1 46045 I&D INTRAMURAL IM/ABSC TRANSANAL ANES 1579.20 090 N 4989.08   46050 I&D PERIANAL ABSCESS SUPERFICIAL 825.24 010 N 1150.88  J1 46060 I&D ISCHIORCT/INTRAMURAL ABSC W/WO SETON 1742.40 090 N 4985.47  J1 46070 INCISION ANAL SEPTUM INFANT 984.00 090 N 4964.13  J1 46080 SPHINCTEROTOMY ANAL DIVISION SPHINCTER SPX 1022.58 010 N 4987.84   46083 INCISION THROMBOSED HEMORRHOID EXTERNAL 723.12 010 N 385.91  J1 46200 FISSURECTOMY INCL SPHINCTEROTOMY WHEN PERFORMED 1720.80 090 N 4988.83   46220 EXCISION SINGLE EXTERNAL PAPILLA OR TAG ANUS 858.36 010 N 1503.87   46221 HEMORRHOIDECTOMY INTERNAL RUBBER BAND LIGATIONS 1033.20 010 N 1150.88  J1 46230 EXCISION MULTIPLE EXTERNAL PAPILLAE/TAGS ANUS 1119.18 010 N 4989.58  J1 46250 HEMORRHOIDECTOMY XTRNL 2/> COLUMN/GROUP 1740.00 090 N 4985.47  J1 46255 HEMORRHOIDECTOMY NTRNL & XTRNL 1 COLUMN/GROUP 1893.60 090 N 4987.59  J1 46257 HEMORRHOID NTRNL & XTRNL 1 COLUMN W/FISSURECTO 1485.60 090 N 4990.08  J1 46258 HRHC 1 COL/GRP W/FSTULECTMY INCL FSSRECTOMY 1732.80 090 N 4965.26  J1 46260 HEMORRHOIDECTOMY INT & XTRNL 2/> COLUMN/GRO 1732.80 090 N 4987.09  J1 46261 HRHC NTRNL & XTRNL 2/> COLUMN/GROUP W/FISSU 1893.60 090 N 4987.34  J1 46262 HRHC 2/> COL/GRP W/FSTULECTMY INCL FSSRECTMY 2116.80 090 N 4984.22  J1 46270 SURG TX ANAL FISTULA SUBQ 1942.80 090 N 4986.09  J1 46275 SURG TX ANAL FISTULA INTERSPHINCTERIC 2046.00 090 N 4987.46  J1 46280 TX ANAL FSTL TRANS/SUPRA/XTRASPHNCTRC INCL SETON 1722.00 090 N 4981.23  J1 46285 SURG TX ANAL FISTULA 2ND STAGE 2035.20 090 N 4987.71  J1 46288 CLSR ANAL FSTL W/RCT ADVMNT FLAP 1994.40 090 N 4947.42   46320 EXC THROMBOSED HEMORRHOID XTRNL 749.34 010 N 1503.87   46500 INJECTION SCLEROSING SOLUTION HEMORRHOIDS 1135.74 010 N 1150.88   46505 CHEMODENERVATION INTERNAL ANAL SPHINCTER 1140.00 010 N 1503.87   46600 ANOSCOPY DX W/COLLJ SPEC BR/WA SPX WHEN PRFRMD 375.36 000 N 163.53   46601 ANOSCOPY DX W/HRA &CHEM AGNTS ENHANCEMENT 547.20 000 N 163.53   46604 ANOSCOPY W/DILATION 2512.80 000 N 1503.87   46606 ANOSCOPY W/BX SINGLE/MULTIPLE 950.82 000 N 1503.87   46607 ANOSCOPY DX W/HRA &CHEM AGNTS ENHANCEMENT W/BX 763.20 000 N 1503.87   46608 ANOSCOPY W/RMVL FOREIGN BODY 1001.88 000 N 1150.88  J1 46610 ANOSCOPY W/RMVL LESION CAUTERY 950.82 000 N 4989.58   46611 ANOSC RMVL 1 TUM POLYP/OTH LES SNARE TQ 749.34 000 N 1150.88  J1 46612 ANOSC RMVL MULT TUMORS CAUTERY/SNARE 1156.44 000 N 4985.09   46614 ANOSCOPY CONTROL BLEEDING 547.86 000 N 1503.87  J1 46615 ANOSCOPY ABLATION LESION 598.92 000 N 4988.71  J1 46700 ANOPLASTY PLASTIC OPERATION STRICTURE ADULT 2342.40 090 N 4989.71   46705 ANOPLASTY PLASTIC OPERATION STRICTURE INFANT 2062.80 090 Y  J1 46706 REPAIR ANAL FISTULA W/FIBRIN GLUE 642.00 010 N 4972.24  J1 46707 REPAIR ANORECTAL FISTULA PLUG 1821.60 090 N 4609.59   46710 RPR ILEOANAL POUCH FSTL/POUCH ADVMNT TPRNL APPR 3994.80 090 Y

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   46712 RPR ILEOANAL POUCH FSTL/POUCH ADVMNT CMBN APPR 7962.00 090 Y   46715 RPR LW IMPERFORATE ANUS W/ANOPRNL FSTL CUT-BK 2008.80 090 Y   46716 RPR LW IMPERFORATE ANUS W/TRPOS FISTULA 4432.80 090 Y   46730 RPR HI IMPRF ANUS W/O FSTL PRNL/SACROPRNL APPR 7126.80 090 Y   46735 RPR HI IMPRF ANUS W/O FISTULA CMBN APPR 8198.40 090 Y   46740 RPR HI IMPRF ANUS W/FSTL PRNL/SACROPRNL APPR 7773.60 090 Y   46742 RPR HI IMPRF ANUS W/FSTL TABDL & SACROPRNL 8978.40 090 Y   46744 RPR CLOACAL ANOMALY SACROPERINEAL 12656.40 090 Y   46746 RPR CLOACAL ANOMALY CMBN ABDL&SACROPRNL 13941.60 090 Y   46748 RPR CLOACAL ANOMALY CMBN ABDL & SACROPRNL W/GRF 15105.60 090 Y  J1 46750 SPHNCTROP ANAL INCONTINENCE/PROLAPSE ADULT 2673.60 090 Y 4989.96   46751 SPHNCTROP ANAL INCONTINENCE/PROLAPSE CHLD 2415.60 090 Y  J1 46753 GRAFT THIERSCH RCT INCONTINENCE &/PROLAPSE 2236.80 090 N 4969.37  J1 46754 RMVL THIERSCH WIRE/SUTURE ANAL CANAL 1245.60 010 N 4990.08  J1 46760 SPHINCTEROPLASTY ANAL MUSCLE TRANSPLANT 3903.60 090 Y 4964.13  J1 46761 SPHNCTROP ANAL LEVATOR MUSC IMBRCJ 3259.20 090 Y 4791.35   46900 DSTRJ LESION ANUS SIMPLE CHEMICAL 856.80 010 N 501.26   46910 DSTRJ LESION ANUS SMPL ELTRDSICCATION 960.00 010 N 2483.95   46916 DSTRJ LESION ANUS SIMPLE CRYOSURGERY 938.40 010 N 260.43  J1 46917 DSTRJ LESION ANUS SIMPLE LASER SURG 1586.40 010 N 4989.58  J1 46922 DSTRJ LESION ANUS SIMPLE SURG EXCISION 1104.00 010 N 4987.84  J1 46924 DSTRJ LESION ANUS EXTENSIVE 2002.80 010 N 4989.08   46930 DESTRUCTION INTERNAL HEMORRHOID THERMAL ENERGY 787.20 090 N 1503.87  J1 46940 CURTG/CAUT ANAL FISSURE W/DILAT SPHNCTR SPX 1ST 937.02 010 N 4989.71   46942 CURTG/CAUT ANAL FISSURE W/DILAT SPHNCTR SPX SBSQ 894.24 010 N 1150.88  J1 46945 INT HRHC BY LIGATION SINGLE HROID W/O IMG GDN 1219.20 090 N 4985.59  J1 46946 INT HRHC BY LIGATION 2+ HROID W/O IMG GDN 1265.46 090 N 4984.84  J1 46947 HEMORRHOIDOPEXY STAPLING 1392.00 090 N 4985.47  J1 46948 INT HRHC TRANSANAL HROID DARTLZJ 2+ W/US GDN 1604.40 090 N 4964.13   46999 UNLISTED PROCEDURE ANUS BR YYY N 1150.88  J1 47000 BIOPSY LIVER NEEDLE PERCUTANEOUS 1102.80 000 N 2870.39   47001 BX LVR NDL DONE PURPOSE TM OTH MAJOR PX 367.20 ZZZ N   47010 HEPATOTOMY OPEN DRAINAGE ABSCESS/CYST 1/2 STAGES 4351.20 090 Y   47015 LAPT W/ASPIR &/NJX HEPATC PARASITIC CYST/ABSCESS 4186.80 090 Y   47100 BIOPSY LIVER WEDGE 3046.80 090 Y 2798.34   47120 HEPATECTOMY RESCJ PARTIAL LOBECTOMY 8335.20 090 Y 5344.30   47122 HEPATECTOMY RESCJ TRISEGMENTECTOMY 12252.00 090 Y   47125 HEPATECTOMY RESCJ TOTAL LEFT LOBECTOMY 10977.60 090 Y   47130 HEPATECTOMY RESCJ TOTAL RIGHT LOBECTOMY 11776.80 090 Y   47133 DONOR HEPATECTOMY CADAVER DONOR 19334.40 XXX N   47135 LVR ALTRNSPLJ ORTHOTOPIC PRTL/WHL DON ANY AGE 19197.60 090 Y   47140 DONOR HEPATECTOMY LIVING DONOR SEG II & III 12744.00 090 Y   47141 DONOR HEPATECTOMY LIVING DONOR SEG II III & IV 15234.00 090 Y   47142 DONOR HEPATECTOMY LIVING DONOR SEG V VI VII &VI 16741.20 090 Y   47143 BKBENCH PREP CADAVER DONOR 2956.80 XXX Y   47144 BKBENCH PREPJ CADAVER WHOLE LIVER GRF I&IV VII 4603.20 090 Y   47145 BKBENCH PREPJ CADAVER DONOR WHL LVR GRF I&V VI 2557.20 XXX Y

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 178 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   47146 BKBENCH RCNSTJ LVR GRF VENOUS ANAST EA 1166.40 XXX Y   47147 BKBENCH RCNSTJ LVR GRF ARTL ANAST EA 1354.80 XXX Y   47300 MARSUPIALIZATION CST/ABSC LVR 4062.00 090 Y   47350 MGMT LVR HEMRRG SMPL SUTR LVR WND/INJ 4897.20 090 Y   47360 MGMT LVR HEMRRG CPLX SUTR WND/INJ 6722.40 090 Y   47361 MGMT LVR HEMRRG EXPL WND DBRDMT COAGJ/SUTR 10761.60 090 Y   47362 MGMT LVR HEMRRG RE-EXPL WND RMVL PACKING 5107.20 090 Y  J1 47370 LAPS SURG ABLTJ 1/> LVR TUM RF 4477.20 090 Y 17900.93  J1 47371 LAPS SURG ABLTJ 1 > LVR TUM CRYOSURG 4515.60 090 Y 18185.19  J1 47379 UNLISTED LAPAROSCOPIC PROCEDURE LIVER BR YYY Y 10291.97   47380 ABLTJ OPN 1/> LVR TUM RF 5169.60 090 Y   47381 ABLTJ OPN 1/> LVR TUM CRYOSURG 5308.80 090 Y  J1 47382 ABLTJ 1/> LVR TUM PRQ RF 15680.40 010 N 9871.58  J1 47383 ABLATION 1/> LIVER TUMOR PERQ CRYOABLATION 23541.60 010 N 9077.05   47399 UNLISTED PROCEDURE LIVER BR YYY N 902.47   47400 HEPATCOTOMY/HEPATCOSTOMY W/EXPL DRG/RMVL ST1 7707.60 090 Y   47420 CHOLEDOCHOT/OST W/O SPHNCTROTOMY/SPHNCTROP 4778.40 090 Y 6173.68   47425 CHOLEDOCHOT/OST W/SPHNCTROTOMY/SPHNCTROP 4909.20 090 Y   47460 TRANSDUOL SPHINCTEROT/PLASTY W/WO RMVL CALCULUS 4562.40 090 Y   47480 CHOLECSTOT/CHOLECSTOST W/EXPL DRG/RMVL ST1 SPX 3138.00 090 Y  J1 47490 CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT 1170.00 010 N 6276.61   47531 NJX CHOLANGIO PRQ W/IMG GID RS&I EXISTING ACCESS 1364.82 000 N 4614.08   47532 NJX CHOLANGIO PRQ W/IMG GID RS&I NEW ACCESS 3118.80 000 N 4614.08  J1 47533 PRQ PLMT BILIARY DRG CATH W/IMG GID RS&I EXTERNL 4336.80 000 N 6246.72  J1 47534 PRQ PLMT BILIARY DRG CATH W/IMG GID RS&I INT-EXT 4927.20 000 N 6205.94  J1 47535 CONV EXT BIL DRG CATH TO INT-EXT BIL DRG CATH 3414.00 000 N 6123.89  J1 47536 EXCHANGE BILIARY DRG CATHETER PRQ W/IMG GID RS&I 2368.80 000 N 6245.90   47537 REMOVAL BILIARY DRG CATHETER REQ FLUOR GID RS&I 1588.38 000 N 1173.47  J1 47538 PLMT BILE DUCT STENT PRQ EXISTING ACCESS 14616.00 000 N 9076.27  J1 47539 PLMT BILE DUCT STENT PRQ NEW ACCESS W/O SEP CATH 16210.80 000 N 9570.05  J1 47540 PLMT BILE DUCT STENT PRQ NEW ACCESS W/SEP CATH 16488.00 000 N 9295.90  J1 47541 PLMT ACCESS THRU BILIARY TREE INTO SMALL BWL NEW 4290.00 000 N 6196.51   47542 BALLOON DILAT BILIARY DUCT/AMPULLA PRQ EACH DUCT 1844.40 ZZZ N   47543 ENDOLUMINAL BX BILIARY TREE PRQ ANY METH 1/MLT 1605.60 ZZZ N   47544 REMOVAL BILIARY DUCT &/GLBLDR CALCULI PERQ RS&I 3513.60 ZZZ N   47550 BILIARY NDSC INTRAOPERATIVE 585.60 ZZZ Y  J1 47552 BILIARY ENDO PRQ T-TUBE DX W/COLLECT SPEC BRUSH 1081.20 000 N 6341.27  J1 47553 BILIARY NDSC PRQ T-TUBE W/BX SINGLE/MULTIPLE 1069.20 000 N 6365.48  J1 47554 BILIARY ENDOSCOPY PRQ VIA T-TUBE W/RMVL CALCULUS 1832.40 000 N 10188.88  J1 47555 BILIARY NDSC PRQ T-TUBE W/DIL DUCT W/O STENT 1146.00 000 N 6100.66  J1 47556 BILIARY NDSC PRQ T-TUBE DILAT STRIX W/STENT 1299.60 000 N 9333.63  J1 47562 LAPAROSCOPY SURG CHOLECYSTECTOMY 2371.20 090 Y 10317.55  J1 47563 LAPS SURG CHOLECYSTECTOMY W/CHOLANGIOGRAPHY 2580.00 090 Y 10307.74  J1 47564 LAPS SURG CHOLECSTC W/EXPL COMMON DUCT 4003.20 090 Y 10259.16   47570 LAPAROSCOPY SURG CHOLECYSTOENETEROSTOMY 2787.60 090 Y  J1 47579 UNLISTED LAPAROSCOPY PROCEDURE BILIARY TRACT BR YYY Y 10308.77   47600 CHOLECYSTECTOMY 3831.60 090 Y 6062.86

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   47605 CHOLECYSTECTOMY W/CHOLANGIOGRAPHY 4044.00 090 Y 5202.83   47610 CHOLECYSTECTOMY W/EXPLORATION COMMON DUCT 4497.60 090 Y   47612 CHOLECYSTECTOMY EXPL DUCT CHOLEDOCHOENTEROSTOMY 4572.00 090 Y   47620 CHOLECSTC EXPL DUX SPHNCTROTOMY/SPHNCTROP 4934.40 090 Y   47700 EXPL CONGENITAL ATRESIA BILE DUCTS 3814.80 090 Y   47701 PORTOENETEROSTOMY 6235.20 090 N   47711 EXC BILE DUX TUM W/WO PRIM RPR XTRHEPATC 5574.00 090 Y   47712 EXC BILE DUX TUM W/WO PRIM RPR INTRAHEPATC 7156.80 090 Y   47715 EXCISION CHOLEDOCHAL CYST 4779.60 090 Y   47720 CHOLECYSTOENTEROSTOMY DIRECT 4154.40 090 Y   47721 CHOLECYSTOENTEROSTOMY W/GASTROENTEROSTOMY 4867.20 090 Y   47740 CHOLECYSTOENTEROSTOMY ROUX-EN-Y 4720.80 090 Y   47741 CHOLECSTONTRSTM ROUX-EN-Y W/GASTRONTRSTM 5301.60 090 Y   47760 ANAST XTRHEPATC BILIARY DUCTS & GI TRACT 8042.40 090 Y   47765 ANAST INTRAHEPATC DUCTS & GI TRACT 10849.20 090 Y   47780 ANAST ROUX-EN-Y XTRHEPATC BILIARY DUCTS & GI 8829.60 090 Y   47785 ANAST ROUX-EN-Y INTRAHEPATC BILIARY DUCTS & GI 11509.20 090 Y   47800 RCNSTJ PLSTC BILIARY DUCTS W/END-TO-END ANAST 5499.60 090 Y   47801 PLACEMENT CHOLEDOCHAL STENT 4012.80 090 Y   47900 SUTURE EXTRAHEPATIC BILE DUCT PRE-EXIST INJURY 4892.40 090 Y   47999 UNLISTED PROCEDURE BILIARY TRACT BR YYY N 1173.47   48000 PLACE DRAIN PERIPANCREATIC ACUTE PANCREATITIS 6745.20 090 Y   48001 PLACE DRAIN PERIPANCREATIC W/CHOLECYSTOSTOMY 8256.00 090 Y   48020 REMOVAL PANCREATIC CALCULUS 4237.20 090 Y   48100 BIOPSY PANCREAS OPEN 3146.40 090 Y  J1 48102 BIOPSY PANCREA PERCUTANEOUS NEEDLE 1884.00 010 N 2872.26   48105 RESECJ/DBRDMT PANCREAS NECROTIZING PANCREATITIS 10137.60 090 Y   48120 EXCISION LESION PANCREAS 3950.40 090 Y   48140 PNCRTECT DSTL STOT W/O PNCRTCOJEJUNOSTOMY 5588.40 090 Y   48145 PNCRTECT DSTL STOT W/PNCRTCOJEJUNOSTOMY 5853.60 090 Y   48146 PNCRTECT DSTL NR-TOT W/PRSRV DUO CHLD-TYP PX 6769.20 090 Y   48148 EXCISION AMPULLA VATER 4490.40 090 Y   48150 PNCRTECT PROX STOT W/PANCREATOJEJUNOSTOMY 11115.60 090 Y   48152 PNCRTECT WHIPPLE W/O PANCREATOJEJUNOSTOMY 10350.00 090 Y   48153 PNCRTECT W/PANCREATOJEJUNOSTOMY 11095.20 090 Y   48154 PNCRTECT PROX STOT W/O PANCREATOJEJUNOSTOMY 10395.60 090 Y   48155 PANCREATECTOMY TOTAL 6516.00 090 Y   48160 PANCREATECTOMY W/TRNSPLJ PANCREAS/ISLET CELLS 21482.40 XXX N   48400 INJECTION INTRAOPERATIVE PANCREATOGRAPHY 381.60 ZZZ N   48500 MARSUPIALIZATION PANCREATIC CYST 4136.40 090 Y   48510 EXTERNAL DRAINAGE PSEUDOCYST OF PANCREAS OPEN 3944.40 090 Y   48520 INT ANAST PANCREATIC CYST GI TRACT DIRECT 3952.80 090 Y   48540 INT ANAST PANCREATIC CYST GI TRACT ROUX-EN-Y 4690.80 090 Y   48545 PANCREATORRHAPHY INJURY 4830.00 090 Y   48547 DUOL EXCLUSION W/GASTROJEJUNOSTOMY PNCRTC INJ 6420.00 090 Y   48548 PANCREATICOJEJUNOSTOMY SIDE-TO-SIDE ANAST 5992.80 090 Y   48550 DONOR PANCREATECTOMY DUODENAL SGM TRANSPLANT BR XXX N

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 180 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   48551 BKBENCH PREPJ CADAVER DONOR PANCREAS ALLOGRAFT 2762.40 XXX Y   48552 BKBENCH RCNSTJ CDVR PNCRS ALGRFT VEN ANAST EA 838.80 XXX Y   48554 TRANSPLANTATION PANCREATIC ALLOGRAFT 9303.60 090 Y   48556 RMVL TRANSPLANTED PANCREATIC ALLOGRAFT 4604.40 090 Y   48999 UNLISTED PROCEDURE PANCREAS BR YYY Y 902.47   49000 EXPLORATORY LAPAROTOMY CELIOTOMY W/WO BIOPSY SPX 2750.40 090 Y 3847.85   49002 REOPENING RECENT LAPAROTOMY 3727.20 090 Y  J1* 49010 EXPL RETROPERITONEUM W/WO BX SPX 3295.20 090 Y 6307.96   49013 PREPERITONEAL PEL PACK F/HEMRRG ASSOC PEL TRMA 1628.40 000 N   49014 REEXPL PEL WND W/RMVL PREPERITONEAL PEL PACKING 1352.40 000 N   49020 DRAINAGE PERITON ABSCESS/LOCAL PERITONITIS OPEN 5694.00 090 Y 2127.66   49040 DRAINAGE SUBDIAPHRAGMATIC/SUBPHREN ABSCESS OPEN 3604.80 090 Y   49060 DRAINAGE OF RETROPERITONEAL ABSCESS OPEN 3922.80 090 N   49062 DRG XTRAPERITONEAL LYMPHOCELE PERITON CAVITY OPN 2755.20 090 Y   49082 ABDOM PARACENTESIS DX/THER W/O IMAGING GUIDANCE 777.60 000 N 1173.47   49083 ABDOM PARACENTESIS DX/THER W/IMAGING GUIDANCE 1076.40 000 N 1173.47   49084 PERITONEAL LAVAGE W/WO IMAGING GUIDANCE 379.20 000 N 1173.47  J1 49180 BX ABDL/RETROPERITONEAL MASS PRQ NEEDLE 626.40 000 N 2871.18  J1 49185 SCLEROTHERAPY FLUID COLLECTION PRQ W/IMG GID 4178.64 000 N 902.47   49186 OPEN EXC/DSTRJ INTRA-ABDL TUMOR/CST 5 CM OR LESS 4740.00 090 Y   49187 OPEN EXC/DSTRJ INTRA-ABDL TUMOR/CST 5.1-10 CM 6057.60 090 Y   49188 OPEN EXC/DSTRJ INTRA-ABDL TUMOR/CST 10.1-20 CM 7238.40 090 Y   49189 OPEN EXC/DSTRJ INTRA-ABDL TUMOR/CST 20.1-30 CM 8420.40 090 Y   49190 OPEN EXC/DSTRJ INTRA-ABDL TUMOR/CYST >30 CM 10380.00 090 Y   49215 EXC PRESAC/SACROCOCCYGEAL TUMOR 7884.00 090 Y  J1 49250 UMBILECTOMY OMPHALECTOMY EXC UMBILICUS SPX 2124.00 090 N 6472.87  J1* 49255 OMNTC EPIPLOECTOMY RESCJ OMENTUM SPX 2823.60 090 Y 6307.96  J1 49320 LAPS ABD PRTM&OMENTUM DX W/WO SPEC BR/WA SPX 1174.80 010 Y 10267.43  J1 49321 LAPAROSCOPY SURG W/BX SINGLE/MULTIPLE 1231.20 010 Y 10291.72  J1 49322 LAPS SURG W/ASPIR CAVITY/CYST SINGLE/MULTIPLE 1341.60 010 Y 10311.61  J1 49323 LAPS SURG W/DRG LYMPHOCELE PRTL CAVITY 2265.60 090 Y 10301.53  J1 49324 LAPS INSERTION TUNNELED INTRAPERITONEAL CATHETER 1388.40 010 Y 10140.04  J1 49325 LAPS W/REVISION INTRAPERITONEAL CATHETER 1483.20 010 Y 10273.37   49326 LAPAROSCOPY W/OMENTOPEXY 673.20 ZZZ Y   49327 LAPS W/INSERTION NTRSTL DEV W/IMG GUID 1/MLT 464.40 ZZZ Y  J1 49329 UNLISTED LAPAROSCOPY PX ABD PERTONEUM & OMENTUM BR YYY Y 10275.95   49400 INJECTION AIR/CONTRAST PERITONEAL CAVITY SPX 542.34 000 N  J1 49402 REMOVAL PERITONEAL FOREIGN BODY FROM CAVITY 3052.80 090 N 6484.73  J1 49405 IMAGE-GUIDE FLUID COLLXN DRAINAGE CATH VISC PERQ 3289.20 000 N 2805.22  J1 49406 IMG-GUIDE FLUID COLLXN DRAINAG CATH PERITON PERQ 3288.00 000 N 2793.65  J1 49407 IMAGE FLUID COLLXN DRAINAG CATH TRANSREC/VAGINAL 2681.34 000 N 2828.00   49411 INTERSTITIAL DEV PLMT RADIATION THERAPY 1/MLT 1749.60 000 N 1831.33   49412 PLACEMENT INTRSTL DEV OPN W/IMG GUID 1/MLT 294.00 ZZZ N  J1 49418 INSJ INTRAPERITONEAL CATHETER W/IMG GUID 4334.40 000 N 6070.60  J1 49419 INSERTION TUNNEL INTRAPERITONEAL CATH SUBQ PORT 1532.40 090 N 9311.43  J1 49421 INSERTION TUNNEL INTRAPERITONEAL CATH DIAL OPEN 806.40 000 N 6368.08   49422 REMOVAL TUNNELED INTRAPERITONEAL CATHETER 788.40 000 N 4151.55

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 49423 EXCHNG ABSC/CST DRG CATH RAD GID SPX 2215.20 000 N 3195.87   49424 CNTRST NJX ASSMT ABSC/CST VIA DRG CATH/TUBE SPX 600.30 000 N   49425 INSERTION PERITONEAL-VENOUS SHUNT 2502.00 090 Y  J1 49426 REVIS PERITONEAL-VENOUS SHUNT 2409.60 090 N 6328.60   49427 INJECT EVALUATE PREVIOUS PERITONEAL-VENOUS SHUNT 158.40 000 N   49428 LIGATION PERITONEAL-VENOUS SHUNT 1544.40 010 N   49429 RMVL PERITONEAL-VENOUS SHUNT 1640.40 010 N 4151.55   49435 INSJ SUBQ EXTENSION INTRAPERITONEAL CATHETER 423.60 ZZZ Y  J1 49436 DELAYED CREATION EXIT SITE EMBEDDED CATHETER 674.40 010 Y 3299.71  J1 49440 INSERT GASTROSTOMY TUBE PERCUTANEOUS 3238.80 010 N 3214.03  J1 49441 INSERT DUODENOSTOMY/JEJUNOSTOMY TUBE PERQ 3675.60 010 N 3189.65   49442 INSERT CECOSTOMY/OTHER COLONIC TUBE PERCUTANEOUS 3058.80 010 N 1503.87  J1 49446 CONVERT GASTROSTOMY-GASTRO-JEJUNOSTOMY TUBE PERQ 3114.00 000 N 3161.36   49450 REPLACE GASTROSTOMY/CECOSTOMY TUBE PERCUTANEOUS 2256.00 000 N 1173.47   49451 REPLACE DUODENOSTOMY/JEJUNOSTOMY TUBE PERQ 2454.00 000 N 1173.47   49452 REPLACEMENT GASTRO-JEJUNOSTOMY TUBE PERCUTANEOUS 3019.20 000 N 1173.47   49460 OBSTRUCTIVE MATERIAL REMOVAL FROM GI TUBE 2496.00 000 N 1173.47   49465 CONTRAST INJECTION PERQ RADIOLOGIC EVAL GI TUBE 537.60 000 N 333.70  J1 49491 RPR 1ST INGUN HRNA PRETERM INFT RDC 2870.40 090 Y 10194.30  J1 49492 RPR 1ST INGUN HRNA PRETERM INFT INCARCERATED 3448.80 090 Y 6345.17  J1 49495 RPR 1ST INGUN HRNA FULL TERM INFT <6 MO RDC 1467.60 090 Y 6307.96  J1 49496 RPR 1ST INGUN HRNA FULL TERM INFT <6 MO INCARCER 2214.00 090 Y 6361.74  J1 49500 RPR 1ST INGUN HRNA AGE 6 MO-5 YRS REDUCIBLE 1494.00 090 Y 6498.70  J1 49501 RPR 1ST INGUN HRNA AGE 6 MO-5 YRS INCARCERATED 2181.60 090 Y 6433.55  J1 49505 RPR 1ST INGUN HRNA AGE 5 YRS/> REDUCIBLE 1879.20 090 Y 6348.74  J1 49507 RPR 1ST INGUN HRNA AGE 5 YRS/> INCARCERATED 2109.60 090 Y 6361.09  J1 49520 RPR RECRT INGUINAL HERNIA ANY AGE REDUCIBLE 2276.40 090 Y 6357.03  J1 49521 RPR RECRT INGUN HERNIA ANY AGE INCARCERATED 2571.60 090 Y 6361.90  J1 49525 RPR INGUN HERNIA SLIDING ANY AGE 2061.60 090 Y 6364.34  J1 49540 REPAIR LUMBAR HERNIA 2428.80 090 Y 10003.36  J1 49550 RPR 1ST FEM HRNA ANY AGE REDUCIBLE 2071.20 090 Y 6357.36  J1 49553 RPR 1ST FEM HERNIA ANY AGE INCARCERATED 2274.00 090 Y 6374.41  J1 49555 RPR RECRT FEM HERNIA REDUCIBLE 2175.60 090 Y 6327.79  J1 49557 RPR RECRT FEM HRNA INCARCERATED 2601.60 090 Y 6397.97  J1 49591 RPR AA HERNIA 1ST < 3 CM REDUCIBLE 1224.00 000 Y 6884.10  J1 49592 RPR AA HERNIA 1ST < 3 CM NCRC8/STRANGULATED 1702.80 000 Y 10291.39  J1 49593 RPR AA HERNIA 1ST 3-10 CM REDUCIBLE 2050.80 000 Y 6884.10  J1 49594 RPR AA HERNIA 1ST 3-10 CM NCRC8/STRANGULATED 2670.00 000 Y 10291.39  J1 49595 RPR AA HERNIA 1ST > 10 CM REDUCIBLE 2756.40 000 Y 6884.10   49596 RPR AA HERNIA 1ST > 10 CM NCRC8/STRANGULATED 3660.00 000 Y  J1 49600 RPR SMALL OMPHALOCELE W/PRIMARY CLOSURE 2644.80 090 Y 6307.96   49605 RPR LG OMPHALOCELE/GASTROSCHISIS W/WO PROSTH 17569.20 090 Y   49606 RPR LG OMPHALOCELE/GASTROSCHISIS RMVL PROSTH 4072.80 090 Y   49610 RPR OMPHALOCELE GROSS TYP OPRATION 1ST STG 2497.20 090 Y   49611 RPR OMPHALOCELE GROSS TYP OPRATION 2ND STG 2199.60 090 Y  J1 49613 RPR AA HERNIA RECR < 3 CM REDUCIBLE 1508.40 000 Y 6884.10  J1 49614 RPR AA HERNIA RECR < 3 CM NCRC8/STRANGULATED 2046.00 000 Y 10291.39

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 182 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 49615 RPR AA HERNIA RECR 3-10 CM REDUCIBLE 2288.40 000 Y 6884.10   49616 RPR AA HERNIA RECR 3-10 CM NCRC8/STRANGULATED 3073.20 000 Y   49617 RPR AA HERNIA RECR > 10 CM REDUCIBLE 3165.60 000 Y   49618 RPR AA HERNIA RECR > 10 CM NCRC8/STRANGULATED 4435.20 000 Y   49621 RPR PARASTOMAL HERNIA 1ST/RECR REDUCIBLE 2653.20 000 Y   49622 RPR PARASTOMAL HRNA 1ST/RECR NCRC8/STRANGULATED 3273.60 000 Y   49623 RMVL NONINFCT MESH/PROSTH AA/PARASTOMAL HRNA RPR 705.60 ZZZ Y  J1 49650 LAPAROSCOPY SURG RPR INITIAL INGUINAL HERNIA 1554.00 090 Y 10023.00  J1 49651 LAPS SURG RPR RECURRENT INGUINAL HERNIA 2029.20 090 Y 10033.33  J1 49659 UNLISTED LAPS PX HRNAP HERNIORRHAPHY HERNIOTOMY BR YYY Y 10046.77   49900 SEC ABDOMINAL WALL SUTURE EVISCERATION/DEHSN 2940.00 090 Y 3090.54   49904 OMENTAL FLAP EXTRA-ABDOMINAL 4944.00 090 N   49905 OMENTAL FLAP INTRA-ABDOMINAL 1250.40 ZZZ Y   49906 FREE OMENTAL FLAP W/MICROVASCULAR ANAST 4737.54 090 N   49999 UNLISTED PROCEDURE ABDOMEN PERITONEUM & OMENTUM BR YYY N 1173.47   50010 RENAL EXPLORATION NOT NECESSITATING OTH SPEC PX 2546.40 090 Y  J1 50020 DRAINAGE PERIRENAL/RENAL ABSCESS OPEN 3561.60 090 N 3651.45   50040 NEPHROSTOMY NEPHROTOMY W/DRAINAGE 3244.80 090 N 2723.43   50045 NEPHROTOMY W/EXPLORATION 3270.00 090 Y   50060 NEPHROLITHOTOMY REMOVAL CALCULUS 3990.00 090 Y 5511.19   50065 NEPHROLITHOTOMY SECONDARY SURG OPERJ CALCULUS 4230.00 090 Y 5034.37   50070 NEPHROLITHOTOMY COMP CGEN KDN ABNORMALITY 4149.60 090 Y   50075 NEPHROLITHOTOMY RMVL LARGE STAGHORN CALCULUS 5098.80 090 Y  J1 50080 PERQ NL/PL LITHOTRP SIMPLE UP TO 2 CM 1 LOCATION 3043.20 090 N 16359.08  J1 50081 PERQ NL/PL LITHOTRP COMPLEX >2 CM MLT LOCATIONS 4476.00 090 Y 16341.38   50100 TRNSXJ/REPOSITIONING ABERRANT RENAL VESSELS SPX 3882.00 090 Y   50120 PYELOTOMY W/EXPLORATION 3327.60 090 Y   50125 PYELOTOMY W/DRAINAGE PYELOSTOMY 3446.40 090 Y   50130 PYELOTOMY WITH REMOVAL CALCULUS 3618.00 090 Y  J1 50200 RENAL BIOPSY PRQ TROCAR/NEEDLE 1911.60 000 N 2869.46   50205 RENAL BIOPSY SURG EXPOSURE KIDNEY 2691.60 090 Y   50220 NEPHRECTOMY W/PRTL URETERECTOMY W/OPEN RIB RESCJ 3711.60 090 Y 5822.54   50225 NEPHRECTOMY W/PRTL URETERECT OPN RIB RESCJ COMPL 4222.80 090 Y   50230 NEPHRECTOMY W/PRTL URETERECT OPEN RIB RESCJ RAD 4488.00 090 Y   50234 NEPHRECTOMY W/TOT URETERECT&BLDR CUFF SAME INC 4575.60 090 Y   50236 NEPHRECTOMY TOT URETEREC&BLDR CUFF SEPAR INCISN 5133.60 090 Y   50240 NEPHRECTOMY PARTIAL 4650.00 090 Y   50250 OPEN ABLATION 1/>RENAL MASS LESION CRYOSURGICAL 4263.60 090 Y   50280 EXCISION/UNROOFING CYST KIDNEY 3375.60 090 Y   50290 EXCISION PERINEPHRIC CYST 3153.60 090 Y   50300 DONOR NEPHRECTOMY CADAVER DONOR UNI/BILATERAL BR XXX N   50320 DONOR NEPHRECTOMY OPEN LIVING DONOR 5428.80 090 Y   50323 BKBENCH PREPJ CADAVER DONOR RENAL ALLOGRAFT 1826.40 XXX Y   50325 BKBENCH PREPJ LIVING RENAL DONOR ALLOGRAFT 1826.40 XXX Y   50327 BKBENCH RCNSTJ RENAL ALGRFT VENOUS ANAST EA 769.20 XXX Y   50328 BKBENCH RCNSTJ RENAL ALLOGRAFT ARTERIAL ANAST EA 674.40 XXX Y   50329 BKBENCH RCNSTJ ALGRFT URETERAL ANAST EA 638.40 XXX Y

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   50340 RECIPIENT NEPHRECTOMY SEPARATE PROCEDURE 3429.60 090 Y   50360 RENAL ALTRNSPLJ IMPLTJ GRF W/O RCP NEPHRECTOMY 8665.20 090 Y   50365 RENAL ALTRNSPLJ IMPLTJ GRF W/RCP NEPHRECTOMY 10335.60 090 Y   50370 REMOVAL OF TRANSPLANTED RENAL ALLOGRAFT 4338.00 090 Y   50380 RENAL AUTOTRANSPLANTATION REIMPLANTATION KIDNEY 7281.60 090 Y  J1 50382 RMVL & RPLCMT INTLY DWELLING URETERAL STENT PRQ 3762.00 000 N 3441.61   50384 REMOVAL INDWELLING URETERAL STENT PRQ 3195.60 000 N 2596.68  J1 50385 REMOVE & REPLACE INDWELL URETERAL STENT TRURTHRL 3753.60 000 N 3504.43   50386 REMOVE INT DWELL URETERAL STENT TRANSURETHRAL 2770.80 000 N 2596.68  J1 50387 RMVL & RPLCMT XTRNL ACCESSIBLE NEPHROURTRL CATH 2023.08 000 N 3438.32   50389 RMVL NFROS TUBE REQ FLUORO GUIDANCE 1309.62 000 N 834.34   50390 ASPIR &/NJX RENAL CYST/PELVIS NEEDLE PRQ 333.60 000 N 902.47   50391 INSTLJ THER AGENT RENAL PELVIS&/URETER VIA TUB 442.80 000 N 385.91  J1 50396 MANOMETRIC STDS THRU TUBE/NDWELLG URTRL CATH 405.60 000 N 834.34   50400 PYELOPLASTY SIMPLE 4047.60 090 Y   50405 PYELOPLASTY COMPLICATED 4881.60 090 Y 3351.20   50430 NJX PX ANTEGRDE NFROSGRM &/URTRGRM NEW ACCESS 2005.14 000 N 834.34   50431 NJX PX ANTEGRDE NFROSGRM &/URTRGRM EXSTNG ACESS 832.14 000 N 834.34  J1 50432 PLMT NEPHROSTOMY CATH PRQ NEW ACCESS RS&I 3245.76 000 N 3500.04  J1 50433 PLMT NEPHROURETERAL CATH PRQ NEW ACCESS RS&I 4188.00 000 N 5924.94  J1 50434 CONVERT NEPHROSTOMY CATH TO NEPHROURTRL CATH PRQ 3368.40 000 N 3402.11  J1 50435 EXCHANGE NEPHROSTOMY CATHETER PRQ W/IMG GID RS&I 2018.94 000 N 3456.15  J1 50436 PERQ DILATION XST TRC ENDOUROLOGIC PX W/IMG 524.40 000 N 5970.00  J1 50437 PERQ DILATION XST TRC NEW ACCESS RENAL COLTJ SYS 874.80 000 N 6018.05   50500 NEPHRORRHAPHY SUTURE KIDNEY WOUND/INJURY 4478.40 090 Y   50520 CLOSURE NEPHROCUTANEOUS/PYELOCUTANEOUS FISTULA 4159.20 090 Y   50525 CLSR NEPHROVISCERAL FISTULA W/VISC RPR ABDL APPR 5274.00 090 Y   50526 CLSR NEPHROVISCERAL FISTULA W/VISC RPR THRC APPR 5646.00 090 Y   50540 SYMPHYSIOTOMY HORSESHOE KDN W/WO PLOP UNI/BI 4015.20 090 Y  J1 50541 LAPAROSCOPY SURG ABLATION RENAL CYSTS 3213.60 090 Y 10299.21  J1 50542 LAPS ABLTJ RENAL MASS LESION W/INTRAOP US 4089.60 090 Y 17175.03  J1 50543 LAPAROSCOPY SURG PARTIAL NEPHRECTOMY 5218.80 090 Y 18097.41  J1 50544 LAPAROSCOPY SURG PYELOPLASTY 4348.80 090 Y 18034.64   50545 LAPAROSCOPY RADICAL NEPHRECTOMY 4672.80 090 Y 12879.74   50546 LAPAROSCOPY NEPHRECTOMY W/PARTIAL URETERECT 4221.60 090 Y 7779.26   50547 LAPAROSCOPY DONOR NEPHRECTOMY LIVING DONOR 5758.80 090 Y   50548 LAPAROSCOPY NEPHRECTOMY W/TOTAL URETERECTOMY 4699.20 090 Y  J1 50549 UNLISTED LAPAROSCOPY PROCEDURE RENAL BR YYY Y 10269.49  J1 50551 RENAL ENDOSCOPY NEPHROSTOMY W/WO IRRIGATION 1272.00 000 N 8789.64  J1 50553 RENAL NDSC NEPHROST W/URETERAL CATH W/WO DILA 1363.20 000 N 8729.94  J1 50555 RENAL NDSC NEPHROS/PYELOSTOMY BIOPSY 1450.80 000 N 16410.92  J1 50557 RENAL NDSC NEPHROS/PYELOSTOMY FULG&/INC W/WO BI 1476.00 000 N 16551.25  J1 50561 RENAL NDSC NEPHROS/PYELOSTOMY RMVL FB/CALCULUS 1672.80 000 N 8799.10  J1 50562 RENAL NDSC NEPHROS/PYELOSTOMY RESCJ TUMOR 2017.20 090 Y 16382.68  J1 50570 RENAL NDSC NEPHROTOMY W/WO IRRIGATION 1707.60 000 N 6090.74  J1 50572 RNL NDSC NFROT W/URTRL CATHJ W/WO DILAT URETER 1848.00 000 N 834.34  J1 50574 RENAL NDSC NEPHROTOMY W/BIOPSY 1965.60 000 N 6194.99

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 184 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 50575 RNL NDSC NFROT/PLOT W/ENDOPYELOTOMY 2481.60 000 N 8710.34  J1 50576 RNL NDSC NFROT FULGURATION &/INCISION W/WO BX 1960.80 000 N 8557.14  J1 50580 RNL NDSC NFROT/PLOT W/RMVL FB/CALCULUS 2110.80 000 N 8692.99  J1 50590 LITHOTRIPSY XTRCORP SHOCK WAVE 2638.80 090 N 6260.77  J1 50592 ABLTJ 1/> RENAL TUMOR PRQ UNI RADIOFREQUENCY 11086.80 010 N 9889.67  J1 50593 ABLATION RENAL TUMOR UNILATERAL PERQ CRYOTHERAPY 15058.80 010 Y 15997.04   50600 URTROTOMY W/EXPL/DRG SEPARATE PROCEDURE 3285.60 090 Y

  50605 URETEROTOMY INSERTION INDWELLING STENT ALL TYPES 3576.00 090 Y   50606 ENDOLUMINAL BX URTR &/RNL PELVIS NONENDOSCOPIC 2256.00 ZZZ N   50610 URTROLITHOTOMY UPPER ONE-THIRD URETER 3308.40 090 Y   50620 URTROLITHOTOMY MIDDLE ONE-THIRD URETER 3164.40 090 Y   50630 URTROLITHOTOMY LOWER ONE-THIRD URETER 3128.40 090 Y   50650 URETRECECTOMY W/BLADDER CUFF SEPARATE PROCEDURE 3644.40 090 Y   50660 URETERECTOMY TOT ECTOPIC URETER CMBN APPR 4002.00 090 Y   50684 INJ PX URETEROGRAPHY/URETEROPYLOGRAPHY CATH 427.80 000 N   50686 MANOMETRIC STDS THRU URTROST/NDWELLG URTRL CATH 508.80 000 N 202.48  J1 50688 CHNG URTROST TUBE/XTRNLLY ACCESSIBLE STENT ILEAL 270.00 010 N 3470.14   50690 NJX VISUALIZATION ILEAL CONDUIT&/URETEROPYELOG 396.06 000 N  J1 50693 PLMT URTRL STENT PRQ PRE-EXISTING NFROS TRACT 3690.00 000 N 5879.26  J1 50694 PLMT URTRL STNT PRQ NEW ACESS W/O SEP NFROS CATH 4128.00 000 N 5920.23  J1 50695 PLMT URTRL STENT PRQ NEW ACCESS W/SEP NFROS CATH 4959.60 000 N 5856.18   50700 URETEROPLASTY PLASTIC OPERATION URETER 3247.20 090 Y   50705 URETERAL EMBOLIZATION/OCCLUSION W/IMG GID RS&I 6877.20 ZZZ N   50706 BALLOON DILAT URETERAL STRICTURE W/IMG GID RS&I 3289.20 ZZZ N   50715 URETEROLYSIS W/WORPSG URETER RETROPERIT FIBROSIS 4255.20 090 Y 3289.28   50722 URETEROLYSIS FOR OVARIAN VEIN SYNDROME 3625.20 090 Y   50725 URTROLSS RETROCAVAL URTR W/REANAST 3856.80 090 Y  J1 50727 REVJ URINARY-CUTANEOUS ANASTAMOSIS 1804.80 090 Y 6263.60   50728 REVJ UR-CUTAN ANAST RPR FSCAL DFCT & HERNIA 2587.20 090 Y   50740 URETEROPYELOSTOMY ANAST URETER RENAL PELVIS 4390.80 090 Y   50750 URETEROCALYCOSTOMY ANAST URETER RENAL CALYX 4035.60 090 Y   50760 URETEROURETEROSTOMY 4008.00 090 Y   50770 TRANSURETEROURETEROSTOMY ANAST URETER CLAT URTR 4035.60 090 Y   50780 URETERONEOCYSTOSTOMY ANAST 1 URETER BLADDER 3902.40 090 Y 6610.44   50782 URETERONEOCYSTOSTOMY ANAST DUPLICATE URETER BLDR 3764.40 090 Y   50783 URETERONEOCYSTOSTOMY W/URETERAL TAILORING 3946.80 090 Y   50785 URTRONEOCSTOST W/VESICO-PSOAS HITCH/BLDR FLAP 4254.00 090 Y   50800 URETEROENTEROSTOMY ANAST URETER INTESTINE 3242.40 090 Y   50810 URETEROSIGMOIDOSTOMY W/SIGMOID BLADDER & COLOSTO 5041.20 090 Y   50815 URETEROCOLON CONDUIT INTESTINE ANASTOMOSIS 4291.20 090 Y   50820 URETEROILEAL CONDUIT W/INTESTINE ANASTOMOSIS 4598.40 090 Y   50825 CONTINENT DVRJ W/INT ANAST ANY SGM SM&/LG INTSTN 5769.60 090 Y   50830 URINARY UNIDIVERSION 6300.00 090 Y   50840 RPLCMT ALL/PART URETER INTESTINE SGM W/ANAST 4312.80 090 Y   50845 CUTANANEOUS APPENDICO-VESICOSTOMY 4396.80 090 Y   50860 URETEROSTOMY TRANSPLANTATION URETER SKIN 3314.40 090 Y   50900 URETERORRHAPHY SUTURE URETER SEPARATE PROCEDURE 2959.20 090 Y

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   50920 CLOSURE URETEROCUTANEOUS FISTULA 3091.20 090 Y   50930 CLOSURE URETEROCUTANEOUS FISTULA W/VISC RPR 3855.60 090 Y   50940 DELIGATION URETER 3114.00 090 Y  J1 50945 LAPAROSCOPY URTROLITHOTOMY 3403.20 090 Y 10160.20  J1 50947 LAPS URTRONEOCSTOST W/CSTSC&URTRL STENT PLMT 4849.20 090 Y 10227.38  J1 50948 LAPS URTRONEOCSTOST W/O CSTSC&URTRL STENT PLMT 4464.00 090 Y 18034.64  J1 50949 UNLISTED LAPAROSCOPY PROCEDURE URETER BR YYY Y 10265.10  J1 50951 URETERAL ENDOSCOPY VIA URETEROSTOMY 1333.20 000 N 6176.78  J1 50953 URETERAL ENDOSCOPY VIA URETEROST W/WO DIL URETER 1410.00 000 N 6069.70  J1 50955 URETERAL ENDOSCOPY VIA URETEROSTOMY W/BIOPSY 1502.40 000 N 8813.30  J1 50957 URETERAL ENDOSCOPY W/DEST&/INC W/WO BIOPSY 1515.60 000 N 8846.87  J1 50961 URETERAL ENDOSCOPY VIA URETEROST W/RMVL FB/STONE 1371.60 000 N 8798.43  J1 50970 URETERAL ENDOSCOPY VIA URETEROTOMY W/O IMAGING 1290.00 000 N 6157.46  J1 50972 NDSC URETEROTOMY URTRL CATHJ W/WO DILAT URETER 1246.80 000 N 6136.58  J1 50974 URETERAL ENDOSCOPY VIA URETEROT W/O IMAGING W/BX 1644.00 000 N 8753.82  J1 50976 URETERAL ENDOSC VIA URETEROT W/DEST&/INC W/WO BX 1621.20 000 N 8857.68  J1 50980 NDSC URETEROTOMY RMVL FB/CALCULUS 1239.60 000 N 8677.22  J1 51020 CYSTOTOMY/CYSTOSTOMY FULG&/INSJ RADACT MATRL 1656.00 090 Y 6276.00  J1 51040 CYSTOSTOMY CYSTOTOMY W/DRAINAGE 1026.00 090 Y 3632.80  J1 51045 CYSTOTOMY W/INSJ URETERAL CATH/STENT SPX 1794.00 090 Y 3627.86  J1 51050 CYSTOLITHOTOMY CYSTOTOMY W/RMVL CALCULUS 1658.40 090 Y 8964.25  J1 51060 TRANSVESICAL URETROLITHOTOMY 2049.60 090 Y 3599.42  J1 51065 CYSTOTOMY W/CALCULUS BASKET XTRJ&/FRAGMENTATIO 2041.20 090 N 6205.66  J1 51080 DRG PRIVESICAL/PREVESICAL SPACE ABSC 1437.60 090 Y 4636.30   51100 ASPIRATION BLADDER NEEDLE 253.92 000 N 385.91   51101 ASPIRATION BLADDER TROCAR/INTRACATHETER 523.02 000 N 1334.25  J1 51102 ASPIRATION BLADDER INSERT SUPRAPUBIC CATHETER 867.60 000 N 3589.28  J1 51500 EXC URACHAL CYST/SINUS W/WO UMBILICAL HERNIA RPR 2241.60 090 Y 10288.10  J1 51520 CYSTOTOMY SIMPLE EXCISION VESICAL NECK 2095.20 090 Y 6280.08   51525 CYSTOTOMY EXCISE BLADDER DIVERTICULUM 1/MULTIPLE 3015.60 090 Y   51530 CYSTOTOMY EXCISION BLADDER TUMOR 2706.00 090 Y  J1 51535 CYSTOTOMY EXCISE/INCISE/REPAIR URETEROCELE 2737.20 090 Y 6257.79   51550 CYSTECTOMY PARTIAL SIMPLE 3385.20 090 Y   51555 CYSTECTOMY PARTIAL COMPLICATED 4426.80 090 Y   51565 CSTC PRTL W/RIMPLTJ URTR IN BLDR URTRONEOCSTOST 4515.60 090 Y   51570 CYSTECTOMY COMPLETE SEPARATE PROCEDURE 5149.20 090 Y   51575 CYSTECTOMY W/BI PELVIC LYMPHADENECTOMY 6373.20 090 Y   51580 CYSTECTOMY W/URETEROSIGMOIDOSTOMY W/NODES 6633.60 090 Y   51585 CYSTECTOMY W/URETEROSIGMOID BI PELV LYMPH NODES 7381.20 090 Y   51590 CSTC COMPL W/URTROILEAL CONDUIT/BLDR W/INT ANAST 6759.60 090 Y   51595 CSTC COMPL W/CONDUIT/SIGMOID BLDR PEL LMPHADEC 7644.00 090 Y   51596 CSTC COMPL W/CONTINENT DVRJ OPN NEOBLDR 8234.40 090 Y   51597 PELVIC EXENTERATION COMPLETE MALIGNANCY 8043.60 090 Y   51600 NJX CSTOGRAPY/VOIDING URETHROCSTOGRAPY 768.66 000 N   51605 NJX & PLACEMENT CHAIN CONTRAST&/URETHROCSTOGRAPY 135.60 000 N   51610 NJX RETROGRADE URETHROCSTOGRAPY 442.98 000 N   51700 BLDR IRRIGATION SMPL LAVAGE &/INSTLJ 274.80 000 N 385.91

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 186 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   51701 INSJ NON-NDWELLG BLADDER CATHETER 159.60 000 N 163.53   51702 INSJ TEMP NDWELLG BLADDER CATHETER SIMPLE 222.00 000 N 163.53   51703 INSJ TEMP NDWELLG BLADDER CATHETER COMPLICATED 521.64 000 N 202.48   51705 CHANGE CYSTOSTOMY TUBE SIMPLE 345.60 000 N 385.91  J1 51710 CHANGE CYSTOSTOMY TUBE COMPLICATED 487.20 000 N 834.34  J1 51715 NDSC NJX IMPLT MATRL URT&/BLDR NCK 1251.66 000 N 5708.28  J1 51720 BLADDER INSTILLATION ANTICARCINOGENIC AGENT 310.80 000 N 385.91   51721 INSJ TRURL ABLTJ TRNSDCR DLVR THRM US PRST8 TISS 1950.00 000 N   51725 SIMPLE CYSTOMETROGRAM 785.22 264.00 521.22 000 N   51726 BLADDER PRESSURE MEASUREMENT DURING FILLING 1093.20 295.20 798.00 000 N  J1 51727 COMPLEX CYSTOMETROGRAM URETHRAL PRESS PROFILE 1295.82 369.60 926.22 000 N  J1 51728 COMPLEX CYSTOMETROGRAM VOIDING PRESSURE STUDIES 1317.90 362.40 955.50 000 N  J1 51729 COMPLX CYSTOMETRO W/VOID PRESS & URETHRAL PROFIL 1405.20 439.20 966.00 000 N   51736 SIMPLE UROFLOMETRY 48.00 28.80 19.20 XXX N   51741 COMPLEX UROFLOMETRY 49.20 30.00 19.20 XXX N   51784 EMG STDS ANAL/URTL SPHNCTR OTH/THN NDL 231.60 130.80 100.80 XXX N   51785 NDL EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ 1265.46 327.60 937.86 XXX N   51792 STIMULUS EVOKED RESPONSE 906.66 190.80 715.86 000 N   51797 VOID PRESSURE STUDIES INTRAABDOMINAL 545.10 139.20 405.90 ZZZ N   51798 MEAS POST-VOIDING RESIDUAL URINE&/BLADDER CAP 43.20 BR 37.20 XXX N   51800 CSTOPLASTY/CSTOURTP PLSTC ANY 3646.80 090 Y   51820 CSTOURTP W/UNI/BI URTRONEOCSTOST 3804.00 090 Y  J1* 51840 ANT VESICOURETHROPEXY/URETHROPEXY SMPL 2468.40 090 Y 8656.16   51841 ANT VESICOURETHROPEXY/URETHROPEXY COMP 2848.80 090 Y  J1 51845 ABDOMINO-VAG VESICAL NCK SSP W/WO NDSC CTRL 2049.60 090 Y 9006.98  J1 51860 CYSTORRHAPHY SUTR BLDR WND INJ/RPT SIMPLE 2636.40 090 Y 8861.51   51865 CYSTORRHAPHY SUTR BLDR WND INJ/RPT COMPLICATED 3162.00 090 Y  J1 51880 CLOSURE CYSTOSTOMY SEPARATE PROCEDURE 1640.40 090 Y 6232.82   51900 CLSR VESICOVAGINAL FISTUL AABDL APPROACH 2892.00 090 Y   51920 CLOSURE VESICOUTERINE FISTULA 2680.80 090 Y   51925 CLSR VESICOUTERINE FISTULA W/HYSTERECTOMY 3859.20 090 Y   51940 CLOSURE EXSTROPHY BLADDER 5743.20 090 Y   51960 ENTEROCYSTOPLASTY W/INTESTINAL ANASTOMOSIS 4849.20 090 Y   51980 CUTANEOUS VESICOSTOMY 2506.80 090 Y  J1 51990 LAPAROSCOPY URETHRAL SUSPENSION STRESS INCONT 2619.60 090 Y 10006.98  J1 51992 LAPAROSCOPY SLING OPERATION STRESS INCONT 2958.00 090 Y 9481.68  J1 51999 UNLISTED LAPAROSCOPY PROCEDURE BLADDER BR YYY N 10266.65  J1 52000 CYSTOURETHROSCOPY 743.82 000 N 834.34  J1 52001 CYSTO W/IRRIG & EVAC MULTPLE OBSTRUCTING CLOTS 1562.16 000 N 6254.49  J1 52005 CYSTOURETHROSCOPY W/URETERAL CATHETERIZATION 1105.20 000 N 3627.31  J1 52007 CYSTO W/URTRL CATHJ BRUSH BX URTR&/RENAL PELVIS 1651.20 000 N 6165.00  J1 52010 CYSTO W/EJACULATORY DUCT CATHETERIZATION 1389.60 000 N 834.34  J1 52204 CYSTOURETHROSCOPY WITH BIOPSY 1383.60 000 N 3648.43  J1 52214 CYSTO W/DESTRUCTION OF LESIONS 2760.00 000 N 6260.93  J1 52224 CYSTO W/REMOVAL OF LESIONS SMALL 2883.60 000 N 6267.37  J1 52234 CYSTO W/REMOVAL OF TUMORS SMALL 855.60 000 N 6259.52  J1 52235 CYSTOURETHROSCOPY W/DEST &/RMVL MED BLADDER TUM 1002.00 000 N 6255.43

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 52240 CYSTOURETHROSCOPY W/DEST &/RMVL TUMOR LARGE 1363.20 000 N 8972.36  J1 52250 CYSTOURETHROSCOPY INSJ RADIOACT SBST W/WOBX/FULG 832.80 000 N 6250.25  J1 52260 CYSTOURETHROSCOPY W/DIL BLADDER GENERAL ANESTH 734.40 000 N 3651.73  J1 52265 CYSTOURETHROSCOPY W/DIL BLADDER LOCAL ANESTHESIA 1366.80 000 N 3648.98  J1 52270 CYSTOURETHROSCOPY W/INTERNAL URETHROTOMY FEMALE 1505.58 000 N 3653.92  J1 52275 CYSTOURETHROSCOPY W/INTERNAL URETHROTOMY MALE 1970.40 000 N 3628.68  J1 52276 CYSTOURETHROSCOPY W/INTERNAL URETHROTOMY 919.20 000 N 3626.58  J1 52277 CYSTOURETHROSCOPY W/RESECJ EXTERNAL SPHINCTER 1123.20 000 N 6229.37  J1 52281 CYSTO CALIBRATION DILAT URTL STRIX/STENOSIS 1177.14 000 N 3624.75  J1 52282 CYSTOURETHROSCOPY INSERTION PERM URETHRAL STENT 1171.20 000 N 6025.11  J1 52283 CYSTOURETHROSCOPY W/STEROID INJECTION STRICTURE 1197.84 000 N 3640.30  J1 52284 CYSTO W/DILAT RX BALO CATH URTL STRIX/STEN MALE 9633.60 000 N 9596.89  J1 52285 CYSTOURETHROSCOPY TX FEMALE URETHRAL SYNDROME 1195.08 000 N 834.34  J1 52287 CYSTOURETHROSCOPY INJ CHEMODENERVATION BLADDER 1331.70 000 N 3650.63  J1 52290 CYSTOURETHROSCOPY W/URETERAL MEATOTOMY UNI/BI 848.40 000 N 3631.70  J1 52300 CYSTO W/RESCJ/FULG ORTHOPIC URETEROCELE UNI/BI 972.00 000 N 6246.17  J1 52301 CYSTO W/RESECJ ECTOPIC URETEROCELE UNI/BI 1006.80 000 N 6238.01  J1 52305 CYSTO INC/RESCJ ORIFICE BLDR DIVERTICULUM 1/MLT 967.20 000 N 8944.19  J1 52310 CYSTO W/SIMPLE REMOVAL STONE & STENT 1059.84 000 N 3649.71  J1 52315 CYSTO W/COMPLEX REMOVAL STONE & STENT 1692.00 000 N 3639.66  J1 52317 LITHOLAPAXY SMPL/SM <2.5 CM 3241.20 000 N 6232.35  J1 52318 LITHOLAPAXY COMP/LG > 2.5 CM 1645.20 000 N 6243.34  J1 52320 CYSTOURETHROSCOPY W/RMVL URETERAL CALCULUS 856.80 000 N 6145.37  J1 52325 CYSTO FRAGMENTATION URETERAL STONE 1112.40 000 N 8797.08  J1 52327 CYSTO W/SUBURTRIC NJX IMPLT MATRL 916.80 000 N 7893.20  J1 52330 CYSTO MANJ W/O RMVL URETERAL STONE 2133.48 000 N 6106.12  J1 52332 CYSTO W/INSERT URETERAL STENT 1623.60 000 N 6070.96  J1 52334 CYSTO INSJ URTRL GD WIRE PRQ NFROS RTRGR 636.00 000 N 6100.16  J1 52341 CYSTO W/TX URETERAL STRICTURE 986.40 000 N 6160.29  J1 52342 CYSTO W/TX URETEROPELVIC JUNCTION STRICTURE 1074.00 000 N 5994.81  J1 52343 CYSTO W/TX INTRA-RENAL STRICTURE 1195.20 000 N 6040.81  J1 52344 CYSTO W/URTROSCOPY W/TX URETERAL STRICTURE 1285.20 000 N 6037.04  J1 52345 CYSTO W/URTROSCOPY W/TX URTROPEL JUNCT STRIX 1370.40 000 N 6043.64  J1 52346 CYSTO W/URTROSCOPY W/TX INTRA-RENAL STRICTURE 1550.40 000 N 8727.69  J1 52351 CYSTO W/URTROSCOPY&/PYELOSCOPY DX 1051.20 000 N 6194.99  J1 52352 CYSTO W/URETEROSCOPY W/RMVL/MANJ STONES 1231.20 000 N 6127.32  J1 52353 CYSTO W/URETEROSCOPY W/LITHOTRIPSY 1363.20 000 N 8889.67  J1 52354 CYSTO/PYELOSCOPY BX&/FULGURATION PELIVC LESION 1449.60 000 N 8807.67  J1 52355 CYSTO/PYELOSCOPY RESCJ PELVIC TUMOR 1623.60 000 N 8821.86  J1 52356 CYSTO/URETERO W/LITHOTRIPSY &INDWELL STENT INSRT 1446.00 000 N 8780.86  J1 52400 CYSTO INC FULG/RESCJ URTL VALVES/FOLDS 1671.60 090 N 6271.92  J1 52402 CSTO W/TRURL RESCJ/INC EJACULATORY DUXS 927.60 000 N 6240.83   52441 CYSTO INSERTION TRANSPROSTATIC IMPLANT SINGLE 4710.00 000 N   52442 CYSTO INSERTION TRANSPROSTATIC IMPLANT EA ADDL 3255.60 ZZZ N  J1 52450 TRANSURETHRAL INCISION PROSTATE 1666.80 090 N 6252.92  J1 52500 TRANSURETHRAL RESECTION BLADDER NECK 1726.80 090 N 6246.17  J1 52601 TRURL ELECTROSURG RESCJ PROSTATE BLEED COMPLETE 2554.80 090 N 8991.73

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 188 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 52630 TRURL RESCJ RESIDUAL/REGROWTH OBSTR PRSTATE TISS 1423.20 090 N 8987.23  J1 52640 TRURL RESCJ POSTOP BLADDER NECK CONTRACTURE 1129.20 090 N 6245.54  J1 52647 LASER COAGULATION OF PROSTATE FOR URINE FLOW 5709.60 090 N 8977.31  J1 52648 LASER VAPORIZATION OF PROSTATE FOR URINE FLOW 5887.20 090 N 8981.59  J1 52649 LASER ENUCLEATION PROSTATE W/MORCELLATION 2898.00 090 N 8962.89  J1 52700 TRURL DRAINAGE PROSTATIC ABSCESS 1554.00 090 N 6274.59  J1 53000 URTT/URTS XTRNL SPX PENDULOUS URETHRA 520.80 010 N 3652.73  J1 53010 URETHROTOMY/URETHROSTOMY XT SPX PERINEAL URETHRA 1044.00 090 N 8973.26  J1 53020 MEATOTOMY CUTTING MEATUS SPX EXCEPT INFANT 337.20 000 N 3650.81  J1 53025 MEATOTOMY CUTTING MEATUS SPX INFANT 236.40 000 N 3599.42  J1 53040 DRAINAGE DEEP PERIURETHRAL ABSCESS 1378.80 090 N 6248.21  J1 53060 DRG OF SKENE'S GLAND ABSCESS OR CYST 670.80 010 N 3657.30  J1 53080 DRG PERINEAL URINARY XTRVASATION UNCOMP SPX 1480.80 090 N 834.34  J1 53085 DRG PERINEAL URINARY XTRVASATION COMPLIC 2282.40 090 Y 3599.42  J1 53200 BIOPSY URETHRA 556.80 000 N 3646.60  J1 53210 URETHRECTOMY TOT W/CYSTOST FEMALE 2727.60 090 Y 6267.99  J1 53215 URETHRECTOMY TOT W/CYSTOST MALE 3254.40 090 Y 9003.00  J1 53220 EXC/FULGURATION CARCINOMA URETHRA 1587.60 090 N 6269.56  J1 53230 EXC URETHRAL DIVERTICULUM SPX FEMALE 2149.20 090 Y 8979.57  J1 53235 EXC URETHRAL DIVERTICULUM SPX MALE 2228.40 090 Y 8989.48  J1 53240 MARSUPIALIZATION URTL DIVERTICULUM MALE/FEMALE 1496.40 090 N 6175.83  J1 53250 EXCISION OF BULBOURETHRAL GLAND 1393.20 090 N 6280.08  J1 53260 EXC/FULGURATION URETHRAL POLYP DSTL URETHRA 733.20 010 N 6272.70  J1 53265 EXC/FULGURATION URETHRAL CARUNCLE 812.40 010 N 3654.65  J1 53270 EXCISION OR FULGURATION SKENES GLANDS 747.60 010 N 6280.08  J1 53275 EXCISION/FULGURATION URETHRAL PROLAPSE 927.60 010 N 6274.74  J1 53400 URETHROPLASTY 1ST STG FISTULA/DIVERTICULUM/STRIX 2808.00 090 Y 8964.25  J1 53405 URETHROPLASTY 2ND STAGE W/URINARY DIVERSION 3062.40 090 Y 8996.24  J1 53410 URETHROPLASTY 1 STG RECNST MALE ANTERIOR URETHRA 3439.20 090 Y 8966.72   53415 URTP TRANSPUBIC/PRNL 1 STG RCNSTJ/RPR URT 3961.20 090 Y 7751.27  J1 53420 URTP 2-STG RCNSTJ/RPR PROSTAT/URETHRA 1ST STAGE 2952.00 090 N 8991.96  J1 53425 URTP 2-STG RCNSTJ/RPR PROSTAT/URETHRA 2ND STAGE 3284.40 090 Y 8965.82  J1 53430 URETHROPLASTY RCNSTJ FEMALE URETHRA 3423.60 090 Y 8928.65  J1 53431 URTP W/TUBULARIZATION POST URT&/LWR BLDR 4036.80 090 Y 8988.35  J1 53440 SLING OPRATION CORRJ MALE URINARY INCONTINENCE 2643.60 090 Y 19691.67  J1 53442 RMVL/REVJ SLING MALE URINARY INCONTINENCE 2758.80 090 Y 8381.86  J1 53444 INSERTION TANDEM CUFF 2785.20 090 Y 31466.73  J1 53445 INSJ INFLATABLE URETHRAL/BLADDER NECK SPHINCTER 2656.80 090 Y 30614.29   53446 REMVL INFLATABLE URETHRAL/BLADDER NECK SPHINCTER 2260.80 090 Y 6398.36  J1 53447 RMVL & RPLCMT NFLTL URETHRAL/BLADDER NECK SPHINC 2833.20 090 Y 30824.13   53448 RMVL & RPLCMT NFLTBL NCK SPHNCTR THRU INFCT FLD 4472.40 090 Y  J1 53449 RPR NFLTBL URETHRAL/BLADDER NECK SPHINCTER 2156.40 090 Y 8398.53  J1 53450 URETHROMEATOPLASTY W/MUCOSAL ADVANCEMENT 1440.00 090 N 6254.02  J1 53451 PERIURETHRAL TPRNL ADJTBL BALO CNTNC DEV BI INSJ BR 010 N 19062.36  J1 53452 PERIURETHRL TPRNL ADJTBL BALO CNTNC DEV UNI INSJ BR 010 N 7335.14  J1 53453 PERIURETHRAL TPRNL ADJTBL BALO CNTNC DEV RMVL EA BR 000 N 6175.83   53454 PERIURETHRAL TPRNL ADJTBL BALO CNTNC DEV ADJMT 610.80 000 N 385.91

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 53460 URETHROMEATOPLASTY W/PRTL EXC DSTL URTL SGM 1611.60 090 N 6264.54  J1 53500 URETHROLSS TRVG SEC OPN W/CSTO 2640.00 090 Y 6239.10  J1 53502 URETHRORRHAPHY SUTR URETHRAL WOUND/INJ FEMALE 1710.00 090 N 6267.52  J1 53505 URETHRORRHAPHY SUTR URETHRAL WOUND/INJ PENILE 1708.80 090 Y 8901.84  J1 53510 URETHRORRHAPHY SUTR URETHRAL WOUND/INJ PERINEAL 2223.60 090 Y 9003.90  J1 53515 URTORR SUTR URETHRAL WND/INJ PROSTATOMEMBRANOUS 2792.40 090 Y 9011.78  J1 53520 CLSR URETHROSTOMY/URETHROQ FSTL MALE SPX 1963.20 090 N 8960.19   53600 DILAT URETHRAL STRIX DILATOR MALE 1ST 313.20 000 N 385.91   53601 DILAT URETHRAL STRIX DILATOR MALE SBSQ 300.00 000 N 163.53  J1 53605 DILAT URETHRAL STRIX/VESICAL NCK DILAT MALE ANES 224.40 000 N 6212.57  J1 53620 DILAT URETHRAL STRIX FILIFORM & FOLLWR MALE 1ST 523.02 000 N 834.34   53621 DILAT URETHRAL STRIX FILIFORM & FOLLWR MALE SBSQ 491.28 000 N 385.91   53660 DILAT FEMALE URETHRA W/SUPPOSITORY&/INSTLJ INI 267.60 000 N 202.48   53661 DILAT FEMALE URT W/SUPPOSITORY&/INSTLJ SBSQ 262.80 000 N 163.53  J1 53665 DILAT FEMALE URETHRA GENERAL/CNDJ SPINAL ANES 134.40 000 N 3648.98  J1 53850 TRURL DSTRJ PRSTATE TISS MICROWAVE THERMOTH 5449.20 090 N 6279.61  J1 53852 TRURL DSTRJ PRSTATE TISS RF THERMOTH 5276.40 090 N 6271.29  J1 53854 TRURL DSTRJ PRST8 TISS RF WV THERMOTHERAPY 6246.00 090 N 6270.98  J1 53855 INSERT TEMP PROSTATIC URETH STENT W/MEASUREMENT 2613.60 000 N 3600.52  J1 53860 TRURL RF FEMALE BLADDER NECK STRS URIN INCONT 7275.36 090 N 3599.42  J1 53865 CYSTO INSJ TEMP DEV ISCHMC RMDLG BLDR NECK&PRST8 10557.60 000 N 17514.28   53866 CATHJ RMVL TEMP DEV ISCHMC RMDLG BLDR NECK&PRST8 507.60 000 N 345.36   53899 UNLISTED PROCEDURE URINARY SYSTEM BR YYY N 385.91  J1 54000 SLITTING PREPUCE DORSAL/LATERAL SPX NEWBORN 582.00 010 N 5978.17  J1 54001 SLITTING PREPUCE DORSAL/LAT SPX XCP NEWBORN 704.40 010 N 3651.91  J1 54015 I&D PENIS DEEP 1070.40 010 N 2873.98   54050 DSTRJ LESION PENIS SIMPLE CHEMICAL 502.80 010 N 501.26   54055 DSTRJ LESION PENIS SIMPLE ELECTRODESICCATION 481.20 010 N 2483.95   54056 DSTRJ LESION PENIS SIMPLE CRYOSURGERY 505.20 010 N 260.43   54057 DSTRJ LESION PENIS SIMPLE LASER 501.60 010 N 2483.95   54060 DSTRJ LESION PENIS SIMPLE SURG EXCISION 697.20 010 N 2483.95   54065 DSTRJ LESION PENIS EXTENSIVE 786.00 010 N 2483.95  J1 54100 BIOPSY PENIS SEPARATE PROCEDURE 722.40 000 N 2873.26  J1 54105 BIOPSY PENIS DEEP STRUCTURES 979.20 010 N 4840.08  J1 54110 EXCISION OF PENILE PLAQUE 2205.60 090 Y 6146.47  J1 54111 EXC PENILE PLAQUE GRAFT &/5 CM LENGTH 2803.20 090 Y 8555.11  J1 54112 EXC PENILE PLAQUE GRAFT > 5 CM LENGTH 3286.80 090 Y 16021.08  J1 54115 REMOVAL FOREIGN BODY DEEP PENILE TISSUE 1612.80 090 Y 4780.87  J1 54120 AMPUTATION PENIS PARTIAL 2223.60 090 Y 6272.39   54125 AMPUTATION PENIS COMPLETE 2883.60 090 Y   54130 AMPUTATION PENIS RADW/BI INGUINOFEMORAL LMPHADE 4183.20 090 Y   54135 AMPUTATION PENIS RADICAL W/LYMPH NODES 5288.40 090 Y  J1 54150 CIRCUMCISION W/CLAMP/OTH DEV W/BLOCK 530.40 000 N 3656.30  J1 54160 CIRCUMCISION NEONATE 783.60 010 N 834.34  J1 54161 CIRCUMCISION AGE >28 DAYS 693.60 010 N 3656.11  J1 54162 LYSIS/EXCISION PENILE POSTCIRCUMCISION ADHESIONS 916.80 010 N 3656.66  J1 54163 REPAIR INCOMPLETE CIRCUMCISION 766.80 010 N 3646.51

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 190 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 54164 FRENULOTOMY PENIS 681.60 010 N 3657.12   54200 INJECTION PROCEDURE FOR PEYRONIE DISEASE 408.00 010 N 385.91  J1 54205 INJECTION PX PEYRONIE DS W/SURG EXPOSURE PLAQUE 1872.00 090 Y 9011.78   54220 IRRIGATION CORPORA CAVERNOSA PRIAPISM 782.40 000 N 385.91   54230 INJECTION PROCEDURE FOR CORPORA CAVERNOSOGRAPY 374.40 000 N   54231 DYNAMIC CAVERNOSOMETRY NJX VASOACTIVE DRUGS 501.60 000 N 385.91   54235 INJECTION CORPORA CAVERNOSA PHARMACOLOGIC AGENT 309.60 000 N 385.91   54240 PENILE PLETHYSMOGRAPHY 373.20 231.60 141.60 000 N   54250 NOCTURNAL PENILE TUMESCENCE &/RIGIDITY TEST 429.60 379.20 50.40 000 N  J1 54300 PENIS STRAIGHTENING CHORDEE 2275.20 090 Y 6279.30  J1 54304 PENIS CORRJ CHORDEE/1ST STAGE HYPOSPADIAS RPR 2628.00 090 Y 6278.67  J1 54308 URETHROPLASTY 2ND STAGE HYPOSPADIAS RPR <3 CM 2516.40 090 Y 8867.37  J1 54312 URETHROPLASTY 2ND STAGE HYPOSPADIAS RPR > 3 CM 2871.60 090 Y 6280.08  J1 54316 URETHROPLASTY 2ND STAGE HYPOSPADIAS RPR SKIN GRF 3490.80 090 Y 8867.37  J1 54318 URETHROPLASTY 3RD STG HYPOSPADIAS RPR RLS PENIS 2499.60 090 Y 6175.83  J1 54322 1 STG DSTL HYPOSPADIAS RPR W/SMPL MEATAL ADVMNT 2743.20 090 Y 6222.46  J1 54324 1 STG DSTL HYPOSPADIAS RPR W/URTP SKIN FLAPS 3396.00 090 Y 6158.72  J1 54326 1 STG DSTL HYPOSPADIAS RPR URTP SKN FLAPS 3304.80 090 Y 6278.51  J1 54328 1 STAGE DSTL HYPOSPADIAS RPR W/EXTENSIVE DSJ 3285.60 090 Y 5613.77  J1 54332 1 STAGE PROX PENILE/PENOSCROTAL HYPOSPADIAS RPR 3543.60 090 Y 6234.71  J1 54336 1 STG PERINEAL HYPOSPADIAS RPR W/GRF&/FLAP 4165.20 090 Y 6175.83  J1 54340 RPR HYPOSPADIAS COMPLCTJS CLSR INC/EXC SIMPLE 2004.00 090 Y 6280.08  J1 54344 RPR HYPOSPADIAS COMPLCTJS MOBLJ FLAPS & URTP 3314.40 090 Y 9011.78  J1 54348 RPR HYPOSPADIAS COMPLCTJS DSJ & URTP FLAP/GRF 3543.60 090 Y 8867.37  J1 54352 REVISION PRIOR HYPOSPADIAS REPAIR DSJ&EXC RCNSTJ 4954.80 090 Y 9011.78  J1 54360 PLASTIC RPR PENIS CORRECT ANGULATION 2533.20 090 Y 6255.43  J1 54380 PLASTIC RPR PENIS EPISPADIAS DSTL SPHNCTR 2806.80 090 Y 3657.30  J1 54385 PLASTIC PENIS EPISPADIAS DSTL SPHNCTR W/INCONT 3268.80 090 Y 3657.30   54390 PLASTIC RPR PENIS EPISPADIAS W/EXSTROPHY BLADDER 4352.40 090 Y  J1 54400 INSJ PENILE PROSTHESIS NON-INFLATABLE SEMI-RIGID 1873.20 090 N 19522.17  J1 54401 INSJ PENILE PROSTHESOS INFLATABLE SELF-CONTAINED 2332.80 090 N 30809.21  J1 54405 INSJ MULTI-COMPONENT INFLATABLE PENILE PROSTH 2838.00 090 Y 30671.18   54406 RMVL INFLATABLE PENILE PROSTH W/O RPLCMT PROSTH 2569.20 090 Y 4458.86  J1 54408 RPR COMPONENT INFLATABLE PENILE PROSTHESIS 2778.00 090 Y 8546.55  J1 54410 RMVL & RPLCMT INFLATABLE PENILE PROSTH SAME SESS 3031.20 090 Y 31015.33  J1 54411 RMVL & RPLCMT NFLTBL PENILE PROSTH INFECTED FIEL 3610.80 090 Y 31158.02   54415 RMVL NON-NFLTBL/NFLTBL PENILE PROSTH W/O RPLCMT 1869.60 090 Y 4458.86  J1 54416 RMVL & RPLCMT NON-NFLTBL/NFLTBL PENILE PROSTHESI 2520.00 090 Y 30964.03  J1 54417 RMVL & RPLCMT PENILE PROSTHESIS INFECTED FIELD 3156.00 090 Y 19712.79  J1 54420 CORPORA CAVERNOSA-SAPHENOUS VEIN SHUNT UNI/BI 2469.60 090 Y 6277.41   54430 CORPORA CAVERNOSA-CORPUS SPONGIOSUM SHUNT UNI/BI 2246.40 090 Y 3620.27  J1 54435 CORPORA CAVERNOSA-GLANS PENIS FSTLJ PRIAPISM 1455.60 090 N 6278.36  J1 54437 REPAIR OF TRAUMATIC CORPOREAL TEAR(S) 2382.00 090 Y 6278.20  J1 54440 PLASTIC OPERATION PENIS INJURY 3268.80 090 Y 6278.20   54450 FORESKN MANJ W/LSS PREPUTIAL ADS&STRETCHING 238.80 000 N 385.91  J1 54500 BIOPSY TESTIS NEEDLE SEPARATE PROCEDURE 260.40 000 N 4837.17  J1 54505 BIOPSY TESTIS INCISIONAL SEPARATE PROCEDURE 735.60 010 N 6279.30

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 54512 EXC XTRPARENCHYMAL LESION TESTIS 1888.80 090 N 6280.08  J1 54520 ORCHIECTOMY SIMPLE SCROTAL/INGUINAL APPROACH 1156.80 090 N 6261.71  J1 54522 ORCHIECTOMY PARTIAL 2066.40 090 Y 6260.46  J1 54530 ORCHIECTOMY RADICAL TUMOR INGUINAL APPROACH 1789.20 090 Y 6484.57  J1 54535 ORCHIECTOMY RADICAL TUMOR W/ABDOMINAL EXPL 2612.40 090 Y 6280.08  J1 54550 EXPL UNDESCENDED TSTIS INGUN/SCROTAL AREA 1729.20 090 Y 6498.70  J1 54560 EXPL UNDESCENDED TESTIS W/ABDOMINAL EXPL 2414.40 090 Y 3599.42  J1 54600 RDCTJ TORSION TSTIS W/WO FIXJ CLAT TESTIS 1592.40 090 N 6279.61  J1 54620 FIXATION CONTRALATERAL TESTIS SEPARATE PROCEDURE 1047.60 010 N 6280.08  J1 54640 ORCHIOPEXY INGUINAL OR SCROTAL APPROACH 1660.80 090 N 6491.72  J1 54650 ORCHIOPEXY ABDL APPROACH INTRA-ABDOMINAL TESTIS 2502.00 090 Y 6498.70  J1 54660 INSJ TESTICULAR PROSTH SEPARATE PROCEDURE 1261.20 090 N 7870.44  J1 54670 SUTURE/REPAIR TESTICULAR INJURY 1440.00 090 N 6280.08  J1 54680 TRANSPLANTATION TESTIS TO THIGH 2767.20 090 Y 6175.83  J1 54690 LAPAROSCOPY SURGICAL ORCHIECTOMY 2304.00 090 Y 10327.63  J1 54692 LAPAROSCOPY ORCHIOPEXY INTRA-ABDOMINAL TESTIS 2654.40 090 N 10194.30  J1 54699 UNLISTED LAPAROSCOPY PROCEDURE TESTIS BR YYY Y 10194.30  J1 54700 I&D EPIDIDYMIS TSTIS&/SCROTAL SPACE 750.00 010 N 3656.75  J1 54800 BIOPSY EPIDIDYMIS NEEDLE 436.80 000 N 2852.43  J1 54830 EXCISION LOCAL LESION EPIDIDYMIS 1312.80 090 N 6278.98  J1 54840 EXCISION SPERMATOCELE W/WO EPIDIDYMECTOMY 1135.20 090 N 3656.66  J1 54860 EPIDIDYMECTOMY UNILATERAL 1476.00 090 N 6273.65  J1 54861 EPIDIDYMECTOMY BILATERAL 2000.40 090 N 6280.08  J1 54865 EXPLORATION EPIDIDYMIS W/WO BIOPSY 1266.00 090 N 6280.08  J1 54900 EPIDIDYMOVASOSTOMY ANAST EPIDIDYMIS UNI 2811.60 090 N 3599.42  J1 54901 EPIDIDYMOVASOSTOMY ANAST EPIDIDYMIS BI 3712.80 090 N 6260.14   55000 PNXR ASPIR HYDROCELE TUNICA VAGIS W/WO NJX MED 429.60 000 N 902.47  J1 55040 EXCISION HYDROCELE UNILATERAL 1194.00 090 N 6495.94  J1 55041 EXCISION HYDROCELE BILATERAL 1803.60 090 N 6495.29  J1 55060 RPR TUNICA VAGINALIS HYDROCELE BOTTLE TYPE 1339.20 090 N 6279.14  J1 55100 DRAINAGE SCROTAL WALL ABSCESS 824.40 010 N 2872.69  J1 55110 SCROTAL EXPLORATION 1371.60 090 N 6274.74  J1 55120 REMOVAL FOREIGN BODY SCROTUM 1249.20 090 N 3657.30  J1 55150 RESECTION SCROTUM 1744.80 090 Y 6264.07  J1 55175 SCROTOPLASTY SIMPLE 1286.40 090 N 6242.25  J1 55180 SCROTOPLASTY COMPLICATED 2437.20 090 N 9000.97  J1 55200 VASOTOMY CANNULIZATION W/WO VAS INC UNI/BI SPX 1455.60 090 N 6280.08  J1 55250 VASECTOMY UNI/BI SPX W/POSTOP SEMEN EXAMS 1279.20 090 N 3656.57   55300 VASOTOMY VASOGRAMS UNI/BI 650.40 000 N  J1 55400 VASOVASOSTOMY VASOVASORRHAPHY 1756.80 090 Y 6275.37  J1 55500 EXC HYDROCELE SPRMATIC CORD UNI SPX 1392.00 090 N 6277.57  J1 55520 EXC LESION SPERMATIC CORD SEPARATE PROCEDURE 1644.00 090 Y 6256.53  J1 55530 EXC VARICOCELE/LIGATION SPERMATIC VEINS SPX 1245.60 090 N 6279.30  J1 55535 EXC VARICOCELE/LIGATION SPERMATIC VEINS ABDL 1516.80 090 Y 6497.08  J1 55540 EXC VARICOCELE/LIGATION VEINS W/HERNIA RPR 1993.20 090 N 6374.41  J1 55550 LAPS LIGATION SPERMATIC VEINS VARICOCELE 1513.20 090 Y 10335.38  J1 55559 UNLISTED LAPROSCOPY PROCEDURE SPERMATIC CORD BR YYY Y 10185.26

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 192 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 55600 VESICULOTOMY 1486.80 090 N 3599.42   55605 VESICULOTOMY COMPLICATED 1843.20 090 N   55650 VESICULECTOMY ANY APPROACH 2526.00 090 Y  J1 55680 EXCISION MULLERIAN DUCT CYST 1222.80 090 N 6175.83  J1 55700 PROSTATE NEEDLE BIOPSY ANY APPROACH 866.40 000 N 3656.39  J1 55705 BIOPSY PROSTATE INCISIONAL ANY APPROACH 932.40 010 N 6278.51  J1 55706 BX PROSTATE STRTCTC SATURATION SAMPLING IMG GID 1321.20 010 Y 6268.15  J1 55720 PROSTATOTOMY EXTERNAL DRG ABSCESS SIMPLE 1592.40 090 Y 6244.60  J1 55725 PROSTATOTOMY EXTERNAL DRG ABSCESS COMPLICATED 2094.00 090 Y 6175.83   55801 PROSTATECTOMY PERINEAL SUBTOTAL 3838.80 090 Y   55810 PROSTATECTOMY PERINEAL RADICAL 4579.20 090 Y   55812 PROSTATECTOMY PERINEAL RADICAL W/LYMPH NODE BX 5628.00 090 Y   55815 PROSTATECTOMY PERINEAL RAD W/BI PELVIC LYMPH EXC 6162.00 090 Y   55821 PROSTATECTOMY SUPRAPUBIC SUBTOTAL 1/2 STAGES 3061.20 090 Y   55831 PROSTATECTOMY RETROPUBIC SUBTOTAL 3316.80 090 Y   55840 PROSTATECTOMY RETROPUBIC W/WO NERVE SPARING 4096.80 090 Y   55842 PROSTECT RETROPUBIC RAD W/WO NRV SPAR W/LYMPH BX 4098.00 090 Y   55845 PROSTECT RETROPUB RAD W/WO NRV SPAR & BI PLV LYM 4765.20 090 Y 6456.71  J1 55860 EXPOS PROSTATE ANY APPROACH INSJ RADIOACT SUBST 3068.40 090 N 8903.42   55862 EXPOS PROSTATE INSJ RADIOACT SBST W/LYMPH BX 3838.80 090 Y   55865 EXPOS PROSTATE INSJ RADIOAC SBST W/BI PELV LYMPH 4677.60 090 Y  J1 55866 LAPS SURG PRST8ECT RPBIC RAD W/NRV SPARING ROBOT 5044.80 090 Y 18117.88  J1 55867 LAPS SURG PRST8ECT SMPL STOT ROBOTIC ASSISTANCE 3706.80 090 Y 17748.86   55870 ELECTROEJACULATION 619.20 000 N 919.41  J1 55873 CRYOSURGICAL ABLATION PROSTATE W/US & MONITORI 21358.80 090 N 14820.40  J1 55874 TRANSPERINEAL PLMT BIODEGRADABLE MATRL 1/MLT NJX 11836.80 000 N 6398.36  J1 55875 TRANSPERINEAL PLMT NDL/CATHS PROSTATE RADJ INSJ 2722.80 090 N 8679.92   55876 PLMT INTERSTITIAL DEV RADIAT TX PROSTATE 1/MULT 537.60 000 N 1831.33  J1 55880 TRANSRECTAL ABLTJ MAL PRST8 TISSUE HIFU W/US 3440.40 090 N 8867.37   55881 ABLATION TRANSURETHRAL PRST8 TISSUE W/THERMAL US 31566.00 000 N  J1 55882 ABLT TRURL PRST8 TIS THRM US INS TRURL US TRNSDC 32665.20 000 N 21746.71   55899 UNLISTED PROCEDURE MALE GENITAL SYSTEM BR YYY N 385.91  J1 55920 PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL 1605.60 000 N 8836.75  J1 55970 INTERSEX SURG MALE FEMALE BR YYY N 9006.98  J1 55980 INTERSEX SURG FEMALE MALE BR YYY N 6280.08   56405 I&D VULVA/PERINEAL ABSCESS 448.50 010 N 409.02   56420 I&D OF BARTHOLINS GLAND ABSCESS 532.68 010 N 247.07  J1 56440 MARSUPIALIZATION BARTHOLINS GLAND CYST 642.00 010 N 5358.99  J1 56441 LYSIS LABIAL ADHESIONS 597.54 010 N 5356.04  J1 56442 HYMENOTOMY SIMPLE INCISION 165.60 000 N 5359.12   56501 DESTRUCTION LESIONS VULVA SIMPLE 565.80 010 N 2483.95   56515 DESTRUCTION LESIONS VULVA EXTENSIVE 927.36 010 N 2483.95   56605 BIOPSY VULVA/PERINEUM 1 LESION SPX 335.34 000 N 919.41   56606 BIOPSY VULVA/PERINEUM EACH ADDL LESION 136.80 ZZZ N  J1 56620 VULVECTOMY SIMPLE PARTIAL 2101.20 090 Y 5356.31  J1 56625 VULVECTOMY SIMPLE COMPLETE 2390.40 090 Y 5354.30  J1* 56630 VULVECTOMY RADICAL PARTIAL 3430.80 090 Y 8656.16

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   56631 VULVECTOMY RAD PRTL UNI INGUINOFEM LMPHADECTOMY 4224.00 090 Y   56632 VULVECTOMY RAD PRTL BI INGUINOFEM LMPHADECTOMY 5119.20 090 Y   56633 VULVECTOMY RADICAL COMPLETE 4386.00 090 Y   56634 VULVECTOMY RAD COMPL UNI INGUINOFEM LYMPHADEC 4609.20 090 Y   56637 VULVECTOMY RAD COMPL BI INGUINOFEM LYMPHADEC 5397.60 090 Y   56640 VLVCTMY RAD COMPL INGUINOFEM ILIAC&PEL LYMPHADEC 5437.20 090 Y  J1 56700 PARTIAL HYMENECTOMY OR REVISION HYMENAL RING 728.40 010 Y 5358.59  J1 56740 EXCISION BARTHOLINS GLAND OR CYST 1132.80 010 N 5353.76  J1 56800 PLASTIC REPAIR INTROITUS 903.60 010 Y 5354.70  J1 56805 CLITOROPLASTY INTERSEX STATE 4172.40 090 Y 5359.12  J1 56810 PERINEOPLASTY RPR PERINEUM NONOBSTETRICAL SPX 972.00 010 Y 5336.35   56820 COLPOSCOPY VULVA 448.80 000 N 247.07   56821 COLPOSCOPY VULVA W/BIOPSY 601.20 000 N 409.02  J1 57000 COLPOTOMY W/EXPLORATION 724.80 010 N 5341.71  J1 57010 COLPOTOMY W/DRAINAGE PELVIC ABSCESS 1640.40 090 N 5359.12  J1 57020 COLPOCENTESIS SEPARATE PROCEDURE 382.26 000 N 8932.00  J1 57022 I&D VAGINAL HEMATOMA OBSTETRICAL/POSTPARTUM 650.40 010 N 4823.97  J1 57023 I&D VAGINAL HEMATOMA NON-OBSTETRICAL 1146.00 010 N 4827.85  J1 57061 DESTRUCTION VAGINAL LESIONS SIMPLE 485.76 010 N 5358.18  J1 57065 DESTRUCTION VAGINAL LESIONS EXTENSIVE 811.44 010 N 5356.04   57100 BIOPSY VAGINAL MUCOSA SIMPLE 364.32 000 N 919.41  J1 57105 BIOPSY VAGINAL MUCOSA EXTENSIVE 578.22 010 N 5358.72  J1 57106 VAGINECTOMY PARTIAL REMOVAL VAGINAL WALL 1928.40 090 Y 5346.53  J1 57107 VAGNC PRTL RMVL VAG WALL W/RMVL PARAVAGINAL TISS 5193.60 090 Y 5343.31  J1 57109 VAGNC PRTL RMVL VAG WALL W/BI TOT PEL LYMPHADEC 6158.40 090 Y 5339.16   57110 VAGINECTOMY COMPLETE REMOVAL VAGINAL WALL 3231.60 090 Y   57111 VAGNC COMPL RMVL VAG WAL W/RMVL PARAVAGINAL TISS 6158.40 090 Y  J1 57120 COLPOCLEISIS LE FORT TYPE 1900.80 090 Y 8977.48  J1 57130 EXCISION VAGINAL SEPTUM 734.16 010 Y 5359.12  J1 57135 EXCISION VAGINAL CYST/TUMOR 800.40 010 N 5353.09   57150 IRRIGATION VAGINA&/APPL MEDICAMENT TX DISEASE 190.44 000 N 80.73  J1 57155 INSERTION UTERINE TANDEM&/VAGINAL OVOIDS 1394.40 000 N 8991.67   57156 INSERTION VAGINAL RADIATION DEVICE 807.60 000 N 409.02   57160 FIT&INSJ PESSARY/OTH INTRAVAGINAL SUPPORT DEVI 247.02 000 N 247.07   57170 DIAPHRAGM/CERVICAL CAP FITTING W/INSTRUCTIONS 255.30 000 N 247.07   57180 INTRO ANY HEMOSTATIC AGENT/PACK VAG HEMRRG SPX 603.06 010 N 247.07  J1 57200 COLPORRHAPHY SUTURE INJURY VAGINA 1194.00 090 Y 5352.42  J1 57210 COLPOPERINEORRHAPHY SUTURE INJ VAGINA&/PERINEU 1414.80 090 Y 5352.83  J1 57220 PLASTIC URETHRAL SPHINCTER VAGINAL APPROACH 1245.60 090 Y 8989.19  J1 57230 PLASTIC REPAIR URETHROCELE 1503.60 090 Y 5359.12  J1 57240 ANTERIOR COLPORRAPHY RPR CYSTOCELE W/CYSTO 2190.00 090 Y 8852.06  J1 57250 POST COLPORRHAPHY RECTOCELE W/WO PERINEORRHAPHY 2204.40 090 Y 8912.18  J1 57260 CMBND ANTERPOST COLPORRAPHY W/CYSTO 2782.80 090 Y 8916.91  J1 57265 CMBND ANTERPOST COLPORRAPHY W/CYSTO W/NTRCL RPR 3115.20 090 Y 8695.34   57267 INSJ MESH/PROSTH PELVIC FLOOR DEFECT EACH SITE 886.80 ZZZ Y  J1 57268 REPAIR ENTEROCELE VAGINAL APPROACH SPX 1815.60 090 Y 8859.94   57270 REPAIR ENTEROCELE ABDOMINAL APPROACH SPX 2907.60 090 Y 2933.94

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 194 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   57280 COLPOPEXY ABDOMINAL APPROACH 3447.60 090 Y 4040.76  J1 57282 COLPOPEXY VAGINAL EXTRAPERITONEAL APPROACH 2009.28 090 Y 13066.00  J1 57283 COLPOPEXY VAGINAL INTRAPERITONEAL APPROACH 2497.20 090 Y 13507.65  J1 57284 PARAVAGINAL DEFECT REPAIR OPEN ABDOMINAL APPR 2973.60 090 Y 8941.23  J1 57285 PARAVAGINAL DEFECT REPAIR VAGINAL APPROACH 2476.80 090 Y 13133.95   57287 RMVL/REVJ SLING STRESS INCONTINENCE 2656.80 090 Y 3804.98  J1 57288 SLING OPERATION STRESS INCONTINENCE 2649.60 090 Y 8270.89  J1 57289 PEREYRA PX W/ANTERIOR COLPORRHAPHY 2846.40 090 Y 13750.31  J1 57291 CONSTRUCTION ARTIFICIAL VAGINA W/O GRAFT 1970.40 090 Y 9006.98  J1 57292 CONSTRUCTION ARTIFICIAL VAGINA W/GRAFT 2964.00 090 Y 8473.32  J1 57295 REVJ/RMVL PROSTHETIC VAGINAL GRAFT VAGINAL APP 1795.20 090 Y 5321.34   57296 REVJ W/RMVL PROSTHETIC VAGINAL GRAFT ABDML APPR 3426.00 090 Y  J1 57300 CLSR RECTOVAGINAL FISTULA VAGINAL/TRANSANAL APPR 2202.00 090 Y 5320.94   57305 CLSR RECTOVAGINAL FISTULA ABDOMINAL APPROACH 3541.20 090 Y   57307 CLSR RECTOVAG FSTL ABDL APPR W/CONCOMITANT CLST 3860.40 090 Y   57308 CLSR RECTOVAG FSTL TPRNL PRNL BDY RCNSTJ 2358.00 090 Y  J1 57310 CLOSURE URETHROVAGINAL FISTULA 1750.80 090 Y 13719.46   57311 CLSR URETHROVAG FSTL W/BULBOCAVERNOSUS TRNSPL 1971.60 090 Y  J1 57320 CLOSURE VESICOVAGINAL FISTULA VAGINAL APPROACH 2024.40 090 Y 8955.64  J1 57330 CLSR VESICOVAG FSTL TRANSVESICAL&VAG APPR 2715.60 090 Y 13830.04  J1 57335 VAGINOPLASTY INTERSEX STATE 4213.20 090 Y 8581.63  J1 57400 DILATION VAGINA W/ANESTHESIA OTHER THAN LOCAL 463.20 000 N 5323.22  J1 57410 PELVIC EXAMINATION W/ANESTHESIA OTHER THAN LOCAL 373.20 000 N 5354.97  J1 57415 REMOVAL IMPACTED VAG FB SPX W/ANES OTH/THN LOCAL 628.80 010 N 5357.25   57420 COLPOSCOPY ENTIRE VAGINA W/CERVIX IF PRESENT 472.80 000 N 409.02   57421 COLPOSCOPY ENTIRE VAGINA W/VAGINA/CERVIX BX 636.00 000 N 919.41  J1 57423 PARAVAGINAL DEFECT REPAIR LAPAROSCOPIC APPROACH 3314.40 090 Y 17562.99  J1 57425 LAPAROSCOPY COLPOPEXY SUSPENSION VAGINAL APEX 3470.40 090 Y 17454.29  J1 57426 REVISION PROSTHETIC VAGINAL GRAFT LAPAROSCOPIC 3114.00 090 Y 13705.59   57452 COLPOSCOPY CERVIX UPPER/ADJACENT VAGINA 448.50 000 N 247.07   57454 COLPOSCOPY CERVIX BX CERVIX & ENDOCRV CURRETAGE 608.40 000 N 409.02   57455 COLPOSCOPY CERVIX UPPR/ADJCNT VAGINA W/CERVIX BX 579.60 000 N 409.02   57456 COLPOSCOPY CERVIX ENDOCERVICAL CURETTAGE 544.80 000 N 409.02  J1 57460 COLPOSCOPY CERVIX VAG LOOP ELTRD BX CERVIX 1145.40 000 N 5358.72  J1 57461 COLPOSCOPY CERVIX VAG ELTRD CONIZATION CERVIX 1281.60 000 N 5359.12   57465 COMPUTER-AIDED MAPG CERVIX UTERI DRG COLPOSCOPY 192.00 ZZZ N   57500 BIOPSY CERVIX SINGLE/MULT/EXCISION OF LESION SPX 524.40 000 N 919.41   57505 ENDOCERVICAL CURETTAGE NOT DONE AS PART OF D&C 440.22 010 N 919.41  J1 57510 CAUTERY CERVIX ELECTRO/THERMAL 538.20 010 N 5359.12   57511 CAUTERY CERVIX CRYOCAUTERY INITIAL/REPEAT 611.34 010 N 409.02  J1 57513 CAUTERY CERVIX LASER ABLATION 636.18 010 N 5359.12  J1 57520 CONIZATION CERVIX W/WO D&C RPR KNIFE/LASER 1264.08 090 N 5356.71  J1 57522 CONIZATION CERVIX W/WO D&C RPR ELTRD EXC 1075.02 090 N 5356.71  J1 57530 TRACHELECTOMY CERVICECTOMY AMP CERVIX SPX 1340.40 090 Y 8996.17   57531 RAD TRACHELECTOMY W/BI PEL LMPHADEC 6516.00 090 Y   57540 EXCISION CERVICAL STUMP ABDOMINAL APPROACH 2833.20 090 Y   57545 EXC CERVICAL STUMP ABDL APPR W/PELVIC FLOOR RPR 2984.40 090 Y

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 57550 EXCISION CERVICAL STUMP VAGINAL APPROACH 1549.20 090 Y 9006.98  J1 57555 EXC CRV STUMP VAG APPR W/ANT &/POST REPAIR 2218.80 090 Y 8439.09  J1 57556 EXC CRV STUMP VAG APPR W/RPR NTRCL 2107.20 090 Y 8656.16  J1 57558 DILATION & CURETTAGE CERVICAL STUMP 524.40 010 N 5359.12  J1 57700 CERCLAGE UTERINE CERVIX NONOBSTETRICAL 1259.94 090 N 5359.12  J1 57720 TRACHELORRHAPHY PLSTC RPR UTERINE CERVIX VAG 1203.60 090 Y 5359.12  J1 57800 DILATION CERVICAL CANAL INSTRUMENTAL SPX 255.30 000 N 5344.79   58100 ENDOMETRIAL BX W/WO ENDOCERVIX BX W/O DILAT SPX 364.32 000 N 247.07   58110 ENDOMETRIAL BX CONJUNCT W/COLPOSCOPY 177.60 ZZZ N  J1 58120 DILATION & CURETTAGE DX&/THER NONOBSTETRIC 1057.08 010 N 5352.56   58140 MYOMECTOMY 1-4 MYOMAS W/250 GM/< ABDOMINAL APPR 3339.60 090 Y 5793.03  J1 58145 MYOMECTOMY 1-4 MYOMAS 250 GM/< VAGINAL APPR 2037.60 090 Y 5341.44   58146 MYOMECTOMY 5/> MYOMAS &/>250 GM ABDOMINA 4128.00 090 Y 5513.00   58150 TOTAL ABDOMINAL HYSTERECT W/WO RMVL TUBE OVARY 3607.20 090 Y 6767.21   58152 TOT ABD HYST W/WO RMVL TUBE OVARY W/COLPURETHRXY 4419.60 090 Y   58180 SUPRACERVICAL ABDL HYSTER W/WO RMVL TUBE OVARY 3421.20 090 Y 5701.75   58200 TOT ABD HYST W/PARAORTIC & PELVIC LYMPH NODE SAM 4790.40 090 Y   58210 RAD ABDL HYSTERECTOMY W/BI PELVIC LMPHADENECTOMY 6481.20 090 Y 8625.30   58240 PEL EXNTJ GYNECOLOGIC MAL 10465.20 090 Y  J1 58260 VAGINAL HYSTERECTOMY UTERUS 250 GM/< 3000.00 090 Y 8962.85  J1 58262 VAG HYST 250 GM/< W/RMVL TUBE&/OVARY 3313.20 090 Y 8970.05  J1 58263 VAG HYST 250 GM/< W/RMVL TUBE OVARY W/RPR NTRCL 3550.80 090 Y 8907.46   58267 VAG HYST 250 GM/< W/COLPO-URTCSTOPEXY 3826.80 090 Y 3035.88  J1 58270 VAGINAL HYSTERECTOMY 250 GM/< W/RPR ENTEROCELE 3202.80 090 Y 8946.41   58275 VAGINAL HYSTERECTOMY W/TOT/PRTL VAGINECTOMY 3535.20 090 Y   58280 VAG HYSTER W/TOT/PRTL VAGINECT W/RPR ENTEROCELE 3789.60 090 Y   58285 VAGINAL HYSTERECTOMY RADICAL SCHAUTA OPERATION 5059.20 090 Y 6043.05  J1 58290 VAGINAL HYSTERECTOMY UTERUS > 250 GM 4113.60 090 Y 13813.40  J1 58291 VAG HYST > 250 GM RMVL TUBE&/OVARY 4444.80 090 Y 8867.15  J1 58292 VAG HYST > 250 GM RMVL TUBE&/OVARY W/RPR ENTRCLE 4683.60 090 Y 13446.98  J1 58294 VAGINAL HYSTERECTOMY >250 GM RPR ENTEROCELE 4351.20 090 Y 8885.39   58300 INSERTION INTRAUTERINE DEVICE IUD 314.64 XXX N 1397.51   58301 REMOVAL INTRAUTERINE DEVICE IUD 372.60 000 N 409.02   58321 ARTIFICIAL INSEMINATION INTRA-CERVICAL 290.40 000 N 409.02   58322 ARTIFICIAL INSEMINATION INTRA-UTERINE 326.40 000 N 247.07   58323 SPERM WASHING ARTIFICIAL INSEMINATION 52.80 000 N 247.07   58340 CATH & SALINE/CONTRAST SONOHYSTER/HYSTEROSALPI 616.86 000 N  J1 58345 TRANSCERV FALLOPIAN TUBE CATH W/WO HYSTOSALPING 1035.60 010 Y 5202.23  J1 58346 INSERTION HEYMAN CAPSULES CLINICAL BRACHYTHERAPY 1747.20 090 N 8997.07  J1 58350 CHROMOTUBATION OVIDUCT W/MATERIALS 423.66 010 N 9006.98  J1 58353 ENDOMETRIAL ABLTJ THERMAL W/O HYSTEROSCOPIC GUID 3484.80 010 N 8943.48  J1 58356 ENDOMETRIAL CRYOABLATION W/US & ENDOMETRIAL CR 6259.20 010 Y 9006.98   58400 UTERINE SUSPENSION W/WO SHORTENING LIGAMENTS SPX 1660.80 090 Y 3288.11   58410 UTERINE SUSP W/WO SHORT LIGAMNTS W/SYMPATHECTOMY 2919.60 090 Y   58520 HYSTERORRHAPHY REPAIR RUPT UTERUS NONOBSTETRICAL 2860.80 090 Y 2750.04   58540 HYSTEROPLASTY RPR UTERINE ANOMALY 3282.00 090 Y 3565.77  J1 58541 LAPAROSCOPY SUPRACERVICAL HYSTERECTOMY 250 GM/< 2606.40 090 Y 10122.22

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 196 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 58542 LAPS SUPRACRV HYSTERECT 250 GM/< RMVL TUBE/OVAR 2970.00 090 Y 17713.54  J1 58543 LAPS SUPRACERVICAL HYSTERECTOMY >250 3014.40 090 Y 18033.28  J1 58544 LAPS SUPRACRV HYSTEREC >250 G RMVL TUBE/OVARY 3236.40 090 Y 18008.26  J1 58545 LAPS MYOMECTOMY EXC 1-4 MYOMAS 250 GM/< 3216.00 090 Y 10299.21  J1 58546 LAPS MYOMECTOMY EXC 5/> MYOMAS >250 GRAMS 3974.40 090 Y 18112.87   58548 LAPS W/RAD HYST W/BILAT LMPHADEC RMVL TUBE/OVARY 6694.80 090 Y 10681.92  J1 58550 LAPS VAGINAL HYSTERECTOMY UTERUS 250 GM/< 3146.40 090 Y 10218.33  J1 58552 LAPS W/VAG HYSTERECT 250 GM/&RMVL TUBE&/OVARIES 3495.60 090 Y 18034.64  J1 58553 LAPS W/VAGINAL HYSTERECTOMY > 250 GRAMS 3996.00 090 Y 18192.92  J1 58554 LAPS VAGINAL HYSTERECT > 250 GM RMVL TUBE&/OVAR 4650.00 090 Y 18127.88  J1 58555 HYSTEROSCOPY DIAGNOSTIC SEPARATE PROCEDURE 1159.20 000 N 5342.51  J1 58558 HYSTEROSCOPY BX ENDOMETRIUM&/POLYPC W/WO D&C 4988.40 000 N 5333.67  J1 58559 HYSTEROSCOPY LYSIS INTRAUTERINE ADHESIONS 1008.00 000 N 8972.31  J1 58560 HYSTEROSCOPY DIV/RESCJ INTRAUTERINE SEPTUM 1107.60 000 Y 8868.05  J1 58561 HYSTEROSCOPY REMOVAL LEIOMYOMATA 1266.00 000 N 8900.70  J1 58562 HYSTEROSCOPY REMOVAL IMPACTED FOREIGN BODY 1433.82 000 N 5322.55  J1 58563 HYSTEROSCOPY ENDOMETRIAL ABLATION 6928.98 000 N 8924.79  J1 58565 HYSTEROSCOPY BI TUBE OCCLUSION W/PERM IMPLNTS 6224.40 090 N 7718.76  J1 58570 LAPAROSCOPY W TOTAL HYSTERECTOMY UTERUS 250 GM/< 2875.20 090 Y 18120.15  J1 58571 LAPS TOTAL HYSTERECT 250 GM/< W/RMVL TUBE/OVARY 3238.80 090 Y 18120.61  J1 58572 LAPAROSCOPY TOTAL HYSTERECTOMY UTERUS >250 GM 3696.00 090 Y 18136.52  J1 58573 LAPAROSCOPY TOT HYSTERECTOMY >250 G W/TUBE/OVAR 4338.00 090 Y 18133.80   58575 LAPS TOT HYSTERECTOMY RESJ MALIGNANCY W/OMNTC 6884.40 090 Y  J1 58578 UNLISTED LAPAROSCOPY PROCEDURE UTERUS BR YYY Y 10220.66   58579 UNLISTED HYSTEROSCOPY PROCEDURE UTERUS BR YYY Y 247.07  J1 58580 TRANSCERVICAL ABLATION UTERINE FIBROID RF 11170.80 010 N 13282.47  J1 58600 LIG/TRNSXJ FLP TUBE ABDL/VAG APPR UNI/BI 1326.00 090 Y 5359.12   58605 LIG/TRNSXJ FLP TUBE ABDL/VAG POSTPARTUM SPX 1209.60 090 Y   58611 LIG/TRNSXJ FALOPIAN TUBE CESAREAN DEL/ABDML SURG 268.80 ZZZ Y 1280.72  J1 58615 OCCLUSION FLP TUBE DEV VAG/SUPRAPUBIC APPR 910.80 010 Y 5313.30  J1 58660 LAPAROSCOPY W/LYSIS OF ADHESIONS 2436.00 090 Y 10296.62  J1 58661 LAPAROSCOPY W/RMVL ADNEXAL STRUCTURES 2325.60 010 Y 10315.23  J1 58662 LAPS FULG/EXC OVARY VISCERA/PERITONEAL SURFACE 2538.00 090 Y 10298.18  J1 58670 LAPAROSCOPY FULGURATION OVIDUCTS 1330.80 090 N 10304.12  J1 58671 LAPAROSCOPY W/PLMT OCCLUSION DEVICE OVIDUCTS 1328.40 090 N 10227.12  J1 58672 LAPAROSCOPY FIMBRIOPLASTY 2613.60 090 Y 10194.30  J1 58673 LAPAROSCOPY SALPINGOSTOMY 2832.00 090 Y 10292.75  J1 58674 LAPS ABLTJ UTERINE FIBROIDS W/INTRAOP US GDN 2905.20 090 Y 17339.22  J1 58679 UNLISTED LAPAROSCOPY PROCEDURE OVIDUCT OVARY BR YYY Y 10315.49   58700 SALPINGECTOMY COMPLETE/PARTIAL UNI/BI SPX 2864.40 090 Y 3881.60   58720 SALPINGO-OOPHORECTOMY COMPL/PRTL UNI/BI SPX 2708.40 090 Y 4291.40   58740 LYSIS OF ADHESIONS SALPINX/OVARY 3220.80 090 Y 2175.74   58750 TUBOTUBAL ANASTATOMOSIS 3256.80 090 Y 6572.58   58752 TUBOUTERINE IMPLANTATION 3248.40 090 Y   58760 FIMBRIOPLASTY 2938.80 090 Y  J1 58770 SALPINGOSTOMY 3085.20 090 Y 5339.16  J1 58800 DRAINAGE OVARIAN CYST UNI/BI SPX VAGINAL APPR 1288.92 090 N 5169.68

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 58805 DRAINAGE OVARIAN CYST UNI/BI SPX ABDOMINAL 1536.00 090 Y 5335.94  J1 58820 DRAINAGE OVARIAN ABSCESS VAGINAL APPR OPEN 1219.20 090 Y 5339.16   58822 DRAINAGE OVARIAN ABSCESS ABDOMINAL APPROACH 2560.80 090 Y   58825 TRANSPOSITION OVARY 2542.80 090 Y 4742.37  J1 58900 BIOPSY OVARY UNI/BI SEPARATE PROCEDURE 1568.40 090 Y 5359.12  J1 58920 WEDGE RESCJ/BISCTJ OVARY UNI/BI 2559.60 090 Y 13866.44  J1 58925 OVARIAN CYSTECTOMY UNI/BI 2746.80 090 Y 8988.74   58940 OOPHORECTOMY PARTIAL/TOTAL UNI/BI 1993.20 090 Y 4326.18   58943 OOPHORECTOMY PRTL/TOT UNI/BI OVARIAN MALIGNANCY 4166.40 090 Y   58950 RESCJ OVARIAN/TUBAL/PERITONEAL MALIGNANCY W/BSO 4111.20 090 Y   58951 RESCJ PRIM PRTL MAL W/BSO & OMNTC TAH & LMPHAD 5132.40 090 Y   58952 RESCJ PRIM PRTL MAL W/BSO & OMNTC RAD DEBULKING 5860.80 090 Y   58953 BSO W/OMENTECTOMY TAH&RAD DEBULKING DISSECTION 7112.40 090 Y   58954 BSO W/OMENTECTOMY TAH DEBULKING W/LMPHADECTOMY 7695.60 090 Y   58956 BSO W/TOT OMENTECTOMY & HYSTERECTOMY MALIGNANC 4832.40 090 Y   58958 RESCJ RECR OVR TBL PP UTR MAL OMNTC PEL LMPHADEC 6148.80 090 Y   58960 LAPT STG/RESTG OVARIAN TUBAL/PRIM MAL 2ND LOOK 3546.00 090 Y   58970 FOLLICLE PUNCTURE OOCYTE RETRIEVAL ANY METHOD 862.80 000 N 919.41   58974 EMBRYO TRANSFER INTRAUTERINE 1534.80 000 Y 919.41   58976 GAMETE ZYGOTE/EMBRYO FALLOPIAN TRANSFER ANY METH 922.80 000 Y 409.02   58999 UNLISTED PX FEMALE GENITAL SYSTEM NONOBSTETRICAL BR YYY N 247.07   59000 AMNIOCENTESIS DIAGNOSIC 423.60 000 N 919.41   59001 AMNIOCENTESIS THER AMNIOTIC FLUID RDCTJ US GUID 630.00 000 N 409.02   59012 CORDOCENTESIS INTRAUTERINE 710.40 000 N 409.02   59015 CHORIONIC VILLUS SAMPLING 554.40 000 N 919.41   59020 FETAL CONTRACTION STRESS TEST 249.60 130.80 118.80 000 N   59025 FETAL NONSTRESS TEST 170.40 102.00 68.40 000 N   59030 FETAL SCALP BLOOD SAMPLING 397.20 000 N 409.02   59050 FETAL MONITORING LABOR PHYS WRITTEN REPORT 177.60 XXX N   59051 FETAL MONITR LABOR PHYS WRTTN REPRT INTERPJ ONLY 147.60 XXX N   59070 TRANSABDOMINAL AMNIOINFUSION W/ULTRSND GUIDANCE 1420.80 000 Y 409.02   59072 FETAL UMBILICAL CORD OCCLUSION W/ULTRSND GUIDNCE 1842.00 000 N 409.02   59074 FETAL FLUID DRAINAGE W/ULTRASOUND GUIDANCE 1362.00 000 Y 409.02   59076 FETAL SHUNT PLACEMENT W/ULTRASOUND GUIDANCE 1842.00 000 Y 409.02  J1 59100 HYSTEROTOMY ABDOMINAL 3058.80 090 Y 8656.16   59120 TX ECTOPIC PREGNANCY ABDOMINAL/VAGINAL APPR 2919.60 090 Y 4256.11   59121 TX ECTOPIC PREGNANCY W/O SALPING&/OOPHORECTOMY 2922.00 090 Y 3654.86   59130 TX ECTOPIC PREGNANCY ABDL PREGNANCY 3387.60 090 N   59136 TX ECTOPIC PREGNANCY NTRSTL PRTL RESCJ UTER 3216.00 090 Y   59140 TX ECTOPIC PREGNANCY CERVICAL W/EVACUATION 1497.60 090 Y  J1 59150 LAPS TX ECTOPIC PREG W/O SALPING&/OOPHORECTOMY 2834.40 090 Y 10307.22  J1 59151 LAPS TX ECTOPIC PREG W/SALPING&/OOPHORECTOMY 2772.00 090 Y 10314.45  J1 59160 CURETTAGE POSTPARTUM 856.98 010 N 5354.03   59200 INSERTION CERVICAL DILATOR SEPARATE PROCEDURE 307.74 000 N 409.02  J1 59300 EPISIOTOMY/VAG RPR OTH/THN ATTENDING 796.26 000 N 5359.12  J1 59320 CERCLAGE CERVIX PREGNANCY VAGINAL 536.40 000 N 5358.59   59325 CERCLAGE CERVIX PREGNANCY ABDOMINAL 850.80 000 N 5505.96

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 198 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   59350 HYSTERORRHAPHY RUPTURED UTERUS 985.20 000 Y   59400 OB CARE ANTEPARTUM VAG DLVR & POSTPARTUM 8339.34 MMM N  J1 59409 VAGINAL DELIVERY ONLY 2847.60 MMM N 5359.12   59410 VAGINAL DELIVERY ONLY W/POSTPARTUM CARE 3765.60 MMM N  J1 59412 EXTERNAL CEPHALIC VERSION W/WO TOCOLYSIS 363.60 MMM N 5359.12  J1 59414 DELIVERY PLACENTA SEPARATE PROCEDURE 319.20 MMM N 5359.12   59425 ANTEPARTUM CARE ONLY 4-6 VISITS 1818.84 MMM N   59426 ANTEPARTUM CARE ONLY 7/> VISITS 3245.76 MMM N   59430 POSTPARTUM CARE ONLY SEPARATE PROCEDURE 768.66 MMM N   59510 OB ANTEPARTUM CARE CESAREAN DLVR & POSTPARTUM 9246.00 MMM N   59514 CESAREAN DELIVERY ONLY 3219.60 MMM Y 2555.80   59515 CESAREAN DELIVERY ONLY W/POSTPARTUM CARE 4639.20 MMM N   59525 STOT/TOT HYSTERECTOMY AFTER CESAREAN DELIVERY 1706.40 ZZZ Y   59610 ROUTINE OB CARE VAG DLVRY & POSTPARTUM CARE VB 8750.58 MMM N  J1 59612 VAGINAL DELIVERY AFTER CESAREAN DELIVERY 3214.80 MMM N 5359.12   59614 VAGINAL DELIVERY & POSTPARTUM CARE VBAC 4066.80 MMM N   59618 ROUTINE OBSTETRICAL CARE ATTEMPTED VBAC 9367.44 MMM N   59620 CESAREAN DELIVERY ATTEMPTED VBAC 3328.80 MMM Y   59622 CESAREAN DLVRY & POSTPARTUM CARE ATTEMPTED VBA 4812.00 MMM N  J1 59812 TX INCOMPLETE ABORTION ANY TRIMESTER SURGICAL 1293.06 090 N 5350.55  J1 59820 TX MISSED ABORTION FIRST TRIMESTER SURGICAL 1551.12 090 N 5358.59  J1 59821 TX MISSED ABORTION SECOND TRIMESTER SURGICAL 1552.50 090 N 5358.32   59830 TX SEPTIC ABORTION SURGICAL 1664.40 090 N  J1 59840 INDUCED ABORTION DILATION AND CURETTAGE 897.00 010 N 5355.64  J1 59841 INDUCED ABORTION DILATION & EVACUATION 1537.20 010 N 5345.19   59850 INDUCED ABORTION 1/> AMNIOTIC INJX W/D&C/EVACJ 1398.00 090 N   59851 INDUCE ABORT 1/> AMNIOT NJXS DLVR FETUS D&C 1515.24 090 N   59852 INDUCE ABORT 1/> AMNIOT NJXS DLVR FETUS HYSTOTM 2074.14 090 N   59855 INDUCED ABORT 1/> VAG SUPPOSITORIES DLVR FETUS 1518.00 090 N 1776.83   59856 INDUCED ABORT 1/> VAG SUPP DLVR FETUS D&C &/EVAC 1776.00 090 N   59857 INDUCED ABORT 1/> VAG SUPPOS DLVR FETUS HYSTOT 2072.40 090 N   59866 MULTIFETAL PREGNANCY REDUCTION 842.40 000 Y 409.02  J1 59870 UTERINE EVACUATION & CURETTAGE HYDATIDIFORM MOLE 1926.00 090 Y 5359.12   59871 REMOVAL CERCLAGE SUTURE UNDER ANESTHESIA 468.00 000 N 3804.98   59897 UNLISTED FETAL INVASIVE PX W/ULTRASOUND BR YYY N 247.07  J1 59898 UNLISTED LAPAROSCOPY PX MATERNITY CARE&DELIVERY BR YYY Y 10194.30   59899 UNLISTED PROCEDURE MATERNITY CARE & DELIVERY BR YYY Y 247.07  J1 60000 I&D THYROGLOSSAL DUCT CYST INFECTED 658.80 010 N 2746.02   60100 BIOPSY THYROID PERCUTANEOUS CORE NEEDLE 388.80 000 N 902.47  J1 60200 EXC CYST/ADENOMA THYROID/TRANSECTION ISTHMUS 2383.20 090 Y 10314.71  J1 60210 PRTL THYROID LOBECTOMY UNI W/WO ISTHMUSECTOMY 2523.60 090 Y 10316.78  J1 60212 PRTL THYROID LOBEC UNI W/CONTRATLAT STOT LOBEC 3686.40 090 Y 10302.31  J1 60220 TOTAL THYROID LOBECTOMY UNI W/WO ISTHMUSECTOMY 2520.00 090 Y 10315.23  J1 60225 TOTAL THYROID LOBEC UNI W/CONTRALAT STOT LOBEC 3342.00 090 Y 10312.64  J1 60240 THYROIDECTOMY TOTAL/COMPLETE 3272.40 090 Y 10319.36  J1 60252 THYROIDECTOMY TOTAL/SUBTOTAL LMTD NECK DISSECT 4708.80 090 Y 10374.00   60254 THYROIDECTOMY TOTAL/SUBTOTAL RAD NECK DISSECT 5936.40 090 Y 8763.30

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 60260 THYROIDECTOMY RMVL REMAINING TISS FLWG PRTL RMVL 3877.20 090 Y 10368.28   60270 THYROIDECT W/SUBSTERNAL SPLIT/TRANSTHORACIC 4848.00 090 Y 6320.67  J1 60271 THYROIDECTOMY SUBSTERNAL CERVICAL APPROACH 3757.20 090 Y 10374.26  J1 60280 EXCISION THYROGLOSSAL DUCT CYST/SINUS 1618.80 090 Y 10326.60  J1 60281 EXCISION THYROGLOSSAL DUCT CYST/SINUS RECURRENT 2119.20 090 Y 10335.38   60300 ASPIRATION AND/OR INJECTION THYROID CYST 392.40 000 N 902.47  J1 60500 PARATHYROIDECTOMY/EXPLORATION PARATHYROIDS 3460.80 090 Y 10376.08  J1 60502 PARATHYROIDECTOMY/EXPLOR PARATHYROIDS RE-EXPLOR 4640.40 090 Y 10381.79   60505 PARATHYRDEC/EXPL PARATHYR MEDSTNL STERNAL/TTHRC 4995.60 090 Y 6858.64   60512 PARATHYROID AUTOTRANSPLANTATION ADD-ON 855.60 ZZZ Y  J1 60520 THYMECTOMY PRTL/TOT TRANSCERVICAL APPR SPX 3751.20 090 Y 10381.01   60521 THYMECTOMY PRTL/TOT W/O RAD MEDSTNL DSJ SPX 3969.60 090 Y   60522 THYMECTOMY PRTL/TOT RAD MEDSTNL DSJ SPX 4832.40 090 Y   60540 ADRENALECTOMY W/EXPL W/WO BX ABDL/LMBR/DRSAL SPX 3819.60 090 Y   60545 ADRENALECTOMY EXPL W/EXC RETROPERTINEAL TUMOR 4431.60 090 Y   60600 EXC CAROTID BODY TUMOR W/O EXC CAROTID ARTERY 4814.40 090 Y   60605 EXC CAROTID BODY TUMOR W EXC CAROTID ARTERY 5820.00 090 Y   60650 LAPAROSCOPY ADRENALECTOMY PRTL/COMPL TABDL 4226.40 090 Y 9305.85  J1 60659 UNLISTED LAPAROSCOPY PROCEDURE ENDOCRINE SYSTEM BR YYY Y 10331.25  J1 60660 ABLTJ 1/+THYROID NODULE 1 LOBE/ISTHMUS PERQ RF 8870.40 000 N 3210.59   60661 ABLTJ 1/+THYR NDUL ADDL LOBE PERQ RADIOFREQUENCY 1438.80 ZZZ N  J1 60699 UNLISTED PROCEDURE ENDOCRINE SYSTEM BR YYY Y 10226.09   61000 SUBDURAL TAP FONTANELLE/SUTUR INFANT UNI/BI INIT 400.80 000 N 920.90   61001 SUBDURAL TAP FONTANELLE/SUTUR INFANT UNI/BI SBSQ 381.60 000 N 920.90   61020 VENTRICULAR PUNCTURE PREVIOUS BURR HOLE W/O NJX 375.60 000 N 1193.84   61026 VENTRICULAR PUNCTURE PREVIOUS BURR HOLE W/INJ 378.00 000 N 920.90   61050 CISTERNAL/LATERAL C1-C2 PUNCTURE W/O INJ SPX 294.00 000 N 378.90   61055 CISTERNAL/LATERAL C1-C2 PUNCTURE W/INJECTION 434.40 000 N 378.90   61070 PUNCTURE SHUNT TUBE/RESERVOIR ASPIRATION/INJ PX 200.40 000 N 920.90   61105 TWIST DRILL HOLE SUBDURAL/VENTRICULAR PUNCTURE 1657.20 090 N  

20 Miss. Admin. Code Pt. 2, R. 61107 Rule 61107

TWIST DRILL HOLE IMPLT VENTRICULAR CATH/DEVICE 1106.40 000 N   61108 TWIST DRILL HOLE EVAC&/DRG SUBDURAL HEMATOMA 3232.80 090 N   61120 BURR HOLE FOR VENTRICULAR PUNCTURE 2685.60 090 N   61140 BURR HOLE/TREPHINE W/BX BRAIN/INTRACRNIAL LESION 4540.80 090 Y   61150 BURR HOLE/TREPHINE W/DRG BRAIN ABSCESS/CYST 4821.60 090 N   61151 BURR HOLE/TREPHINE W/SBSQ TAPPING ICRA ABSC/CYST 3553.20 090 N   61154 BURR HOLE W/EVAC&/DRG HEMATOMA EXTRADURAL/SDRL 4564.80 090 Y   61156 BURR HOLE W/ASPIR HEMATOMA/CYST INTRACEREBRAL 4435.20 090 Y   61210 BURR HOLE IMPLANT VENTRICULAR CATH/OTHER DEVICE 1303.20 000 N 5822.26  J1 61215 INSJ SUBQ RSVR PUMP/CONT INFUSION SYS VENTR CATH 1840.80 090 N 11318.85   61250 BURR HOLE/TREPHINE STTL EXPL N/FLWD OTH SURG 3108.00 090 Y   61253 BURR HOLE/TREPHINE INFRATENTORIAL UNI/BI 3553.20 090 Y   61304 CRANIECTOMY/CRANIOTOMY EXPL SUPRATENTORIAL 5858.40 090 Y   61305 CRANIECTOMY/CRANIOTOMY EXPL INFRATENTORIAL 7155.60 090 Y   61312 CRNEC/CRNOT HMTMA SUPRATENTORIAL XDRL/SUBDURAL 7378.80 090 Y   61313 CRNEC/CRNOT HMTMA SUPRATENTORIAL INTRACEREBRAL 7074.00 090 Y   61314 CRNEC/CRNOT HMTMA INFRATENTORIAL XDRL/SDRL 6530.40 090 Y

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 200 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   61315 CRNEC/CRNOT HMTMA INFRATENTORIAL INTRACEREBELLAR 7359.60 090 Y   61316 INCISION&SUBCUTANEOUS PLMT CRANIAL BONE GRAFT 312.00 ZZZ N   61320 CRNEC/CRNOT DRG INTRACRANIAL ABSC SUPRATENTORIAL 6750.00 090 Y   61321 CRNEC/CRNOT DRG INTRACRANIAL ABSC INFRATENTORIAL 7576.80 090 Y   61322 CRNEC/CRNOT DCMPRV W/WO DURAPLASTY W/O LOBECTOMY 8488.80 090 Y   61323 CRNEC/CRNOT W/WO DURAPLASTY WITH LOBECTOMY 8503.20 090 Y  J1 61330 DECOMPRESSION ORBIT ONLY TRANSCRANIAL APPROACH 6402.00 090 Y 5577.49   61333 EXPL ORBIT TRANSCRANIAL APPROACH W/RMVL LESION 7186.80 090 Y   61340 SUBTEMPORAL CRANIAL DECOMPRESSION 5140.80 090 Y   61343 CRNEC SUBOCCIPITAL CRV LAM DCMPRN MEDULLA & CORD 7830.00 090 Y   61345 OTHER CRANIAL DECOMPRESSION POSTERIOR FOSSA 7285.20 090 Y   61450 CRNEC STPL SCTJ COMPRESSION/DCMPRN GANGLION 6846.00 090 Y   61458 CRNEC SOPL EXPLORATION/DECOMPRESSION CRANIAL NRV 7184.40 090 Y   61460 CRANIECTOMY SUBOCCIPITAL SECTION 1/> CRANIAL NRV 7513.20 090 Y   61500 CRANIECTOMY W/EXCISION TUMOR/OTH BONE LESION SKL 4645.20 090 Y   61501 CRANIECTOMY FOR OSTEOMYELITIS 4026.00 090 Y   61510 CRNEC TREPH BONE FLAP CRNOT EXC BRAIN TUMOR STTL 7848.00 090 Y   61512 CRNEC TREPH BONE FLAP CRNOT EXC MENINGIOMA STTL 9098.40 090 Y   61514 CRNEC TREPH BONE FLAP CRNOT EXC BRAIN ABSC STTL 6830.40 090 Y   61516 CRNEC TREPH BONE FLAP CRNOT EXC/FENEST CYST STTL 6670.80 090 Y   61517 IMPLTJ BRAIN INTRACAVITARY CHEMOTHERAPY AGENT 310.80 ZZZ N   61518 CRNEC EXC BRAIN TUMOR INFRATENTORIAL/POST FOSSA 9867.60 090 Y   61519 CRNEC EXC TUM INFRATENTOR/POST FOSSA MENINGIOMA 10458.00 090 Y   61520 CRNEC TUM INFRATTL/POSTFOSSA CRBLOPNT ANGLE TUM 13302.00 090 Y   61521 CRNEC TUM INFRATTL/PFOSSA MIDLINE TUM BASE SKULL 11286.00 090 Y   61522 CRNEC INFRATNTORIAL/POST FOSSA EXC BRAIN ABSCESS 7803.60 090 Y   61524 CRNEC INFRATNTOR/POSTFOSSA EXC/FENESTRATION CYST 7434.00 090 Y   61526 CRNEC TRANSTEMPOR EXC CEREBELLOPONTINE ANGLE TUM 11918.40 090 N   61530 CRNEC EXC CEREBELLOPNTIN ANGLE TUM MID/POSTFOSSA 10934.40 090 N   61531 SUBDURAL IMPLTJ ELECTRODES SEIZURE MONITORING 4380.00 090 Y   61533 CRANIOT SUBDURAL IMPLT ELCTRD SEIZURE MONITORING 5452.80 090 Y   61534 CRANIOT EPILEPTOGENIC FOC W/O ELECTRCORTICOGRPHY 5899.20 090 Y   61535 CRANIOT RMVL EPID/SUBDURL ELCTRD W/O EXC TIS SPX 3596.40 090 Y   61536 CRANIOT EPILEPTOGENIC FOCUS W/ELECTROCORTCOGRPHY 9182.40 090 Y   61537 CRANIOT TEMPORAL LOBE W/O ELECTROCORTICOGRAPHY 8752.80 090 Y   61538 CRANIOT LOBEC TEMPORAL LOBE W/ELECTROCORTCOGRPHY 9470.40 090 Y   61539 CRANIOT LOBECTOMY OTH/THN TEMPORAL LOBE W/ECOG 8415.60 090 Y   61540 CRANIOT LOBECTOMY OTH/THN TEMPORAL LOBE W/O ECOG 7760.40 090 Y   61541 CRANIOTOMY TRANSECTION CORPUS CALLOSUM 7666.80 090 Y   61543 CRANIOTOMY PARTIAL/SUBTOTAL HEMISPHERECTOMY 7750.80 090 Y   61544 CRANIOTOMY EXCISION/COAGULATION CHOROID PLEXUS 6769.20 090 Y   61545 CRANIOTOMY EXCISION CRANIOPHARYNGIOMA 11347.20 090 Y   61546 CRANIOT HYPOPHYSEC/EXC PITUITARY TUMOR ICRL APPR 8226.00 090 Y   61548 HYPOPHYSEC/EXC PITUITARY TUM TRANSNASAL/SEPTAL 5599.20 090 Y   61550 CRANIECTOMY CRANIOSYNOSTOSIS 1 CRANIAL SUTURE 4279.20 090 Y   61552 CRANIECT CRANIOSYNOSTOSIS MULT CRANIAL SUTURES 5317.20 090 Y   61556 CRANIEC CRANIOSYNOSTOSIS FRONT/PARIET BONE FLAP 6100.80 090 Y

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   61557 CRANIECTOMY CRANIOSYNOSTOSIS BIFRONTAL BONE FLAP 6022.80 090 Y   61558 XTN CRANIECT MULTIPLE SUTURE CRANIOSYNOSTOSIS 6717.60 090 Y   61559 XTN CRNEC MLT SUTR CRANIOSYNOSTOSIS W/BONE GRAFT 8556.00 090 Y   61563 EXC BENIGN TUM CRANIAL BONE W/O OPTIC NRV DCMPRN 7074.00 090 Y   61564 EXC BENIGN TUM CRANIAL BONE W/OPTIC NRV DCMPRN 8580.00 090 Y   61566 CRANIOTOMY SELECTIVE AMYGDALOHIPPOCAMPECTOMY 7989.60 090 Y   61567 CRANIOTOMY MULTIPLE SUBPIAL TRANSECTIONS W/ECOG 9097.20 090 Y   61570 CRANIECTOMY/CRANIOTOMY EXC FOREIGN BODY BRAIN 6679.20 090 Y   61571 CRANIECTOMY/CRANIOTOMY TX PENETRATNG WOUND BRAIN 7106.40 090 Y   61575 TRNSRAL SKULL BSE/BR STEM/CORD BX/DCOMPR/EXC LES 8924.40 090 Y   61576 TRNSRL SKUL BSE/BR STM/CORD BX/DCMP/ SPLT TONGUE 14932.80 090 Y   61580 CRANIOFACIAL ANT CRANIAL FOSSA W/O ORBITAL EXNTJ 8948.40 090 N   61581 CRANIOFACIAL ANT CRANIAL FOSSA W/ORBITAL EXNTJ 10184.40 090 N   61582 CRANFCL ANT CRANIAL FOSSA UNI/BI CRANIOT/OSTEOT 10846.80 090 Y   61583 CRANFCL ANT CRANIAL FOSSA UNI/BIFRNTL ELEV LOBE 10461.60 090 Y   61584 ORBITOCRANIAL ANT CRANIAL FOSSA W/O ORBIT EXNTJ 10339.20 090 Y   61585 ORBITOCRANIAL ANT CRANIAL FOSSA W/ORBITAL EXNTJ 11800.80 090 Y   61586 BICORONAL TRANSZYGMTC&/LEFORT I W/O BONE GRFT 9168.00 090 Y   61590 INFRATEMPORAL MID CRANIAL FOSSA W/WO DISARTICLTN 10862.40 090 Y   61591 INFRATEMPO MID CRANIAL FOSSA W/WO DCOMPR&/MOBI 10914.00 090 Y   61592 ORBITOCRNL APPR MID CRANIAL FOSSA TEMPORAL LOBE 11355.60 090 Y   61595 TRANSTEMP APPR POST CRAN FOSSA DCOMPR SINUS/NRV 8588.40 090 N   61596 TRANSCOCHLR POST CRNL FOSSA W/WO MOBIL NRV/ART 8698.80 090 Y   61597 TRNSCONDLR POST CRNL FOSSA DCOMPR ART W/WO MOBIL 10664.40 090 Y   61598 TRANSPTRSAL POST CRNL FOSSA CLIVUS/FORAMN MAGNUM 10263.60 090 Y   61600 RESCJ/EXC LES BASE ANT CRANIAL FOSSA EXTRADURAL 7647.60 090 Y   61601 RESCJ/EXC LES BASE ANT CRNL FOSSA INDRL W/WO GRF 8737.20 090 Y   61605 RESCJ/EXC LES INFRATEMPOR FOSSA SPACE APEX XDRL 7753.20 090 Y   61606 RESCJ/EXC LES ITPRL FOSSA SPACE APEX IDRL W/RPR 10430.40 090 Y   61607 RESCJ/EXC LES PARASELLAR SINUS CLIVUS/MSB XDRL 9517.20 090 Y   61608 RESCJ/EXC LES PARASELLAR SINUS CLIVUS/MSB IDRL 11712.00 090 Y   61611 TRNSXJ/LIG CAROTID ARTERY PETROUS CANAL W/O RPR 1665.60 ZZZ Y   61613 OBLTRJ CAROTID ARYSM ARTVEN CAROTID FISTULA DSJ 11782.80 090 Y   61615 RESCJ/EXC LES BASE POST CRNL FOSSA JUG FRMN XDRL 10128.00 090 Y   61616 RESCJ/EXC LES BASE PCF FORAMEN VRT BODIES IDRL 11943.60 090 Y   61618 SECONDARY RPR DURA CSF LEAK FREE TISSUE GRAFT 4594.80 090 Y   61619 SEC RPR DURA CSF LEAK LOCAL/REGIONALIZED FLAP 5055.60 090 Y  J1 61623 EVASC TEMP BALLOON ARTL OCCLUSION HEAD/NECK 2034.00 000 N 18788.43  J1* 61624 TCAT PERMANENT OCCLUSION/EMBOLIZATION PRQ CNS 4072.80 000 N 28649.09  J1 61626 TCAT PERMANT OCCLUSION/EMBOLIZATION PRQ NON-CNS 3146.40 000 N 18594.03   61630 BALLOON ANGIOPLASTY INTRACRANIAL PERCUTANEOUS 4876.80 XXX Y   61635 TCAT PLMT IV STENT ICRA W/BALO ANGIOP IF PFRMD 5143.20 XXX Y   61640 BALLOON DILAT INTRACRANIAL VASOSPASM PRQ INITIAL 1681.20 000 N   61641 PERQ BALO DILA IC VSPSM EA VSL SM VASC TER 590.40 ZZZ N   61642 PERQ BALO DILA IC VSPSM EA VSL DIFF VASC TER 1180.80 ZZZ N   61645 PERQ ART TRLUML M-THROMBEC &/NFS INTRACRANIAL 2960.40 000 N   61650 EVASC INTRACRANIAL PROLNG ADMN RX AGENT ART 1ST 2028.00 000 N

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 202 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   61651 EVASC INTRACRANIAL PROLNG ADMN RX AGENT ART ADDL 854.40 ZZZ N   61680 INTRACRANIAL ARVEN MALFRMJ SUPRATENTRL SMPL 8060.40 090 Y   61682 INTRACRANIAL ARVEN MALFRMJ SUPRATENTRL CMPL 14820.00 090 Y   61684 INTRACRANIAL ARVEN MALFRMJ INFRATENTRL SMPL 10119.60 090 Y   61686 INTRACRANIAL ARVEN MALFRMJ INFRATENTRL CMPL 16371.60 090 Y   61690 INTRACRANIAL ARVEN MALFRMJ DURAL SMPL 7771.20 090 Y   61692 INTRACRANIAL ARVEN MALFRMJ DURAL CMPL 13057.20 090 Y   61697 COMPLX INTRACRANIAL ARYSM CAROTID CIRCULATION 15056.40 090 Y   61698 CPLX INTRACRANIAL ARYSM VERTEBROBASILAR CRCJ 16801.20 090 Y   61700 SIMPLE INTRACRANIAL ARYSM CAROTID CIRCULATION 12094.80 090 Y   61702 SIMPLE INTRACRANIAL ARYSM VERTEBROBASILAR CRCJ 14286.00 090 Y   61703 ICRA CRV APPL OCCLUDING CLAMP CRV CRTD ART 4857.60 090 Y   61705 ARYSM VASC MALFRMJ/CRTD-OCCLUSION CRTD ART 9271.20 090 Y   61708 ARYSM VASC MALFRMJ/ICRA ELECTROTHROMBOSIS 9068.40 090 Y   61710 ARYSM VASC MALFRMJ IA EMBOLIZATION 7647.60 090 N   61711 ANAST ARTL EXTRACRANIAL-INTRACRANIAL ARTERIES 9150.00 090 Y  J1 61715 MRGFUS STEREOTACTIC ABLATION TARGET INTRACRANIAL 4376.40 000 N 24919.42  J1 61720 CRTJ LES STRTCTC BURR GLOBUS PALLIDUS/THALAMUS 4546.80 090 N 11465.03   61735 CRTJ LES STRTCTC BURR SUBCORTICAL STRUX OTH/THN 5702.40 090 N   61736 LITT LES ICR SINGLE TRAJECTORY 1 SIMPLE LESION 3206.40 000 N   61737 LITT LES ICR MLT TRAJECTORIES MLT/CPLX LESIONS 3819.60 000 N   61750 STEREOTACTIC BX ASPIR/EXC BURR INTRACRANIAL LES 5034.00 090 N   61751 STRTCTC BX ASPIR/EXC BURR ICRA LESION W/CT&I/MR 4953.60 090 N 7361.77   61760 STRTCTC IMPLTJ ELTRD CEREBRUM SEIZURE MONITORING 5668.80 090 N  J1 61770 STRTCTC LOCLZJ INSJ CATH/PRB PLMT RADJ SRC 5792.40 090 N 10833.13   61781 STRTCTC CPTR ASSTD PX CRANIAL INTRADURAL 832.80 ZZZ N   61782 STRTCTC CPTR ASSTD PX EXTRADURAL CRANIAL 609.60 ZZZ N   61783 STEREOTACTIC COMPUTER ASSISTED PX SPINAL 822.00 ZZZ N  J1 61790 CREATE LESION STRTCTC PRQ NEUROLYTIC GASSERIAN 3164.40 090 N 3573.44  J1 61791 CREATE LES STRTCTC PRQ NEUROLYTIC TRIGEMINAL TRC 4032.00 090 N 3577.21   61796 STEREOTACTIC RADIOSURGERY 1 SIMPLE CRANIAL LES 3636.00 090 Y   61797 STRTCTC RADIOSURGERY EA ADDL CRANIAL LES SIMPLE 777.60 ZZZ Y   61798 STEREOTACTIC RADIOSURGERY 1 COMPLEX CRANIAL LES 4924.80 090 Y   61799 STRTCTC RADIOSURGERY EA ADDL CRANIAL LES COMPLEX 1077.60 ZZZ Y   61800 APPL STRTCTC HEADFRAME STEREOTACTIC RADIOSURGERY 542.40 ZZZ Y   61850 TWIST/BURR HOLE IMPLTJ NSTIM ELTRD CORTICAL 3529.20 090 Y   61860 CRNEC/CRX IMPLTJ NSTIM ELTRD CERE CORTICAL 5584.80 090 Y   61863 STRTCTC IMPLTJ NSTIM ELTRD W/O RECORD 1ST ARRAY 5376.00 090 Y   61864 STRTCTC IMPLTJ NSTIM ELTRD W/O RECORD EA ARRAY 1003.20 ZZZ Y   61867 STRTCTC IMPLTJ NSTIM ELTRD W/RECORD 1ST ARRAY 8121.60 090 Y   61868 STRTCTC IMPLTJ NSTIM ELTRD W/RECORD EA ARRAY 1767.60 ZZZ Y  J1 61880 REVJ/RMVL INTRACRANIAL NEUROSTIMULATOR ELTRDS 2100.00 090 Y 6436.35  J1 61885 INSJ/RPLCMT CRANIAL NEUROSTIM PULSE GENERATOR 1881.60 090 N 32813.88  J1 61886 INSJ/RPLCMT CRANIAL NEUROSTIM GENER 2/> ELTRDS 3130.80 090 N 47280.84  J1 61888 REVJ/RMVL NEUROSTIMULATOR PULSE GENERATOR 1428.00 010 N 19782.42   61889 INSERTION SKULL-MNTD CRANIAL NSTIM PG/RECEIVER 4550.40 090 N  J1 61891 REVJ/RPLCMT SKULL-MNTD CRANIAL NSTIM PG/RECEIVER 2158.80 090 N 38451.68

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 61892 REMOVAL SKULL-MNTD CRANIAL NSTIM PG/RCVR W/CRNOP 2978.40 090 N 6078.78  J1 62000 ELEVATION DEPRESSED SKULL FX SIMPLE EXTRADURAL 3702.00 090 N 5447.70   62005 ELVTN DEPRS SKL FX COMPOUND/COMMIND XDRL 4549.20 090 Y   62010 ELVTN DEPRS SKL FX W/RPR DURA&/DBRDMT BRN 5498.40 090 Y   62100 CRX RPR DURAL/CSF LEAK RHINORRHEA/OTORRHEA 5623.20 090 Y 4155.46   62115 RDCTJ CRANIOMEGALIC SKULL W/O GRAFT/CRANIOPLASTY 6024.00 090 Y   62117 RDCTJ CRANIOMEGALIC CRANIO&RECNSTJ W/WO GRAFT 7012.80 090 Y   62120 RPR ENCEPHALOCELE SKULL VAULT W/CRANIOPLASTY 7471.20 090 Y   62121 CRANIOTOMY FOR ENCEPHALOCELE REPAIR SKULL BASE 5604.00 090 Y   62140 CRANIOPLASTY SKULL DEFECT <5 CM DIAMETER 3638.40 090 Y 4078.67   62141 CRANIOPLASTY SKULL DEFECT >5 CM DIAMETER 4072.80 090 Y   62142 RMVL BONE FLAP/PROSTHETIC PLATE SKULL 3192.00 090 Y 4338.91   62143 RPLCMT BONE FLAP/PROSTHETIC PLATE SKULL 3738.00 090 Y   62145 CRANIOPLASTY SKULL DEFECT REPARATIVE BRAIN SURG 5011.20 090 Y   62146 CRANIOPLASTY W/AUTOGRAFT <5 CM DIAMETER 4470.00 090 Y   62147 CRANIOPLASTY W/AUTOGRAFT > 5 CM DIAMETER 5088.00 090 Y   62148 INCISE&RETRIEVAL SUBQ CRANIOPLASTY BONE GRAFT 447.60 ZZZ N   62160 NUNDSC ICRA PLMT/RPLCMT VENTR CATH SHUNT SYS 673.20 ZZZ N   62161 NUNDSC ICRA DSJ ADS FENESTRATION SEPTUM CSTS 5421.60 090 Y   62162 NUNDSC ICRA FENESTEXC CYST W/VENTRIC CATH DRG 6741.60 090 Y   62164 NEUROENDOSCOPY ICRA W/RETRIEVAL FOREIGN BODY 7474.80 090 Y   62165 NUNDSC ICRA EXC PITUITRY TUM TRNSNSL/SPHENOID 5400.00 090 N   62180 VENTRICULOCISTERNOSTOMY 5709.60 090 Y   62190 CRTJ SHUNT SARACH/SDRL-ATR-JUG-AUR 3330.00 090 N   62192 CRTJ SHUNT SARACH/SDRL-PRTL-PLEURAL OTH 3530.40 090 Y  J1 62194 RPLCMT/IRRG SUBARACHNOID/SUBDURAL CATHETER 1768.80 010 N 3586.62   62200 VENTRICULOCISTERNOSTOMY 3RD VENTRICLE 4920.00 090 Y   62201 VENTRICULOCISTERNOSTOMY 3RD VNTRC NEURONDSC 4332.00 090 N   62220 CRTJ SHUNT VENTRICULO-ATR-JUG-AUR 3513.60 090 Y   62223 CRTJ SHUNT VENTRICULO-PERITNEAL-PLEURAL TERMINUS 3720.00 090 Y 5735.41  J1 62225 RPLCMT/IRRIGATION VENTRICULAR CATHETER 1911.60 090 N 10794.40  J1 62230 RPLCMT/REVJ CSF SHUNT VALVE/CATH SHUNT SYS 3013.20 090 Y 10928.35   62252 REPRGRMG PROGRAMMABLE CEREBROSPINAL SHUNT 292.80 162.00 130.80 XXX N   62256 RMVL COMPL CSF SHUNT SYSTEM W/O RPLCMT SHUNT 2182.80 090 Y   62258 RMVL COMPLETE CSF SHUNT SYSTEM W/RPLCMT SHUNT 3982.80 090 Y   62263 PRQ LYSIS EPIDURAL ADHESIONS MULT SESS 2/> DAYS 937.20 010 N 920.90   62264 PRQ LYSIS EPIDURAL ADHESIONS MULT SESSIONS 1 DAY 937.20 010 N 920.90   62267 PRQ ASPIR PULPOSUS/INTERVERTEBRAL DISC/PVRT TISS 966.00 000 N 902.47   62268 PERCUTANEOUS ASPIRATION SPINAL CORD CYST/SYRINX 900.00 000 N 1193.84  J1 62269 BIOPSY SPINAL CORD PERCUTANEOUS NEEDLE 919.20 000 N 2863.64   62270 DIAGNOSTIC LUMBAR SPINAL PUNCTURE 506.40 000 N 920.90   62272 THERAPEUTIC SPINAL PUNCTURE DRAINAGE CSF 668.40 000 N 920.90   62273 INJECTION EPIDURAL BLOOD/CLOT PATCH 601.20 000 N 920.90   62280 INJX/INFUSION NEUROLYTIC SUBSTANCE SUBARACHNOID 1182.00 010 N 1193.84   62281 INJX/INFUS NEUROLYT SUBST EPIDURAL CERV/THORACIC 853.20 010 N 1193.84   62282 INJX/INFUS NEUROLYT SBST EPIDURAL LUMBAR/SACRAL 1162.80 010 N 1193.84   62284 INJECTION PROCEDURE MYELOGRAPHY/CT LUMBAR 699.60 000 N

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 204 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 62287 DCMPRN PX PERQ NUCLEUS PULPOSUS 1/MLT LVL LUMBAR 2035.20 090 N 3429.35   62290 INJECTION PX DISCOGRAPHY EACH LEVEL LUMBAR 1154.40 000 N   62291 INJECTION PX DISCOGRPHY EA LVL CERVICAL/THORACIC 0.00 000 N  J1 62292 INJECTION PX CHEMONUCLEOLYSIS 1/MLT LUMBAR 2035.20 090 N 3563.31   62294 NJX ARTERIAL OCCLUSION ARVEN MALFRMJ SPINAL 3403.20 090 N 1193.84   62302 MYELOGRAPHY VIA LUMBAR INJECTION RS&I CERVICAL 940.80 000 N 1037.55   62303 MYELOGRAPHY VIA LUMBAR INJECTION RS&I THORACIC 957.60 000 N 1037.55   62304 MYELOGRAPHY VIA LUMBAR INJECT RS&I LUMBOSACRAL 930.00 000 N 1037.55   62305 MYELOGRAPHY VIA LUMBAR INJECTION RS&I 2+ REGIONS 1014.00 000 N 1037.55   62320 NJX DX/THER SBST INTRLMNR CRV/THRC W/O IMG GDN 589.20 000 N 920.90   62321 NJX DX/THER SBST INTRLMNR CRV/THRC W/IMG GDN 950.40 000 N 920.90   62322 NJX DX/THER SBST INTRLMNR LMBR/SAC W/O IMG GDN 523.20 000 N 920.90   62323 NJX DX/THER SBST INTRLMNR LMBR/SAC W/IMG GDN 937.20 000 N 920.90   62324 NJX DX/THER SBST INTRLMNR CRV/THRC W/O IMG GDN 494.40 000 N 1193.84   62325 NJX DX/THER SBST INTRLMNR CRV/THRC W/IMG GDN 920.40 000 N 1193.84   62326 NJX DX/THER SBST INTRLMNR LMBR/SAC W/O IMG GDN 513.60 000 N 1193.84   62327 NJX DX/THER SBST INTRLMNR LMBR/SAC W/IMG GDN 923.22 000 N 1193.84   62328 DIAGNOSTIC LUMBAR SPINAL PUNCTURE W/FLUOR OR CT 872.40 000 N 920.90   62329 THERAPEUTIC SPINAL PNXR DRAINAGE CSF W/FLUOR/CT 1105.20 000 N 920.90  J1 62350 IMPLTJ REVJ/RPSG ITHCL/EDRL CATH PMP W/O LAM 1412.40 010 N 10435.06  J1 62351 IMPLTJ REVJ/RPSG ITHCL/EDRL CATH W/LAM 3249.60 090 Y 12124.33   62355 RMVL PREVIOUSLY IMPLTED ITHCL/EDRL CATH 968.40 010 N 2546.50  J1 62360 IMPLTJ/RPLCMT ITHCL/EDRL DRUG NFS SUBQ RSVR 1153.20 010 N 28524.69  J1 62361 IMPLTJ/RPLCMT FS NON-PRGRBL PUMP 1551.60 010 N 28339.33  J1 62362 IMPLTJ/RPLCMT ITHCL/EDRL DRUG NFS PRGRBL PUMP 1366.80 010 N 28361.08   62365 RMVL SUBQ RSVR/PUMP INTRATHECAL/EPIDURAL INFUS 1052.40 010 N 8270.01   62367 ELECT ANLYS IMPLT ITHCL/EDRL PMP W/O REPRG/REFIL 136.80 XXX N 395.98   62368 ELECT ANALYS IMPLT ITHCL/EDRL PUMP W/REPRGRMG 188.40 XXX N 395.98   62369 ELECT ANLYS IMPLT ITHCL/EDRL PMP W/REPRG&REFIL 400.80 XXX N 395.98   62370 ELEC ANLYS IMPLT ITHCL/EDRL PMP W/REPR PHYS/QHP 416.40 XXX N 395.98  J1 62380 NDSC DCMPRN SPINAL CORD 1 W/LAMOT NTRSPC LUMBAR 10444.80 090 Y 12768.83  J1 63001 LAM W/O FACETEC FORAMOT/DSC 1/2 VRT SGM CRV 4402.80 090 Y 12709.02  J1 63003 LAMINECTOMY W/O FFD 1/2 VERT SEG THORACIC 4401.60 090 Y 12589.40  J1 63005 LAMINECTOMY W/O FFD 1/2 VERT SEG LUMBAR 4273.20 090 Y 12631.94  J1 63011 LAMINECTOMY W/O FFD 1/2 VERT SEG SACRAL 3906.00 090 Y 12727.89  J1 63012 LAMINECTOMY W/RMVL ABNORMAL FACETS LUMBAR 4263.60 090 Y 12614.03  J1 63015 LAMINECTOMY W/O FFD > 2 VERT SEG CERVICAL 5276.40 090 Y 12729.81  J1 63016 LAMINECTOMY W/O FFD > 2 VERT SEG THORACIC 5438.40 090 Y 12769.15  J1 63017 LAMINECTOMY W/O FFD > 2 VERT SEG LUMBAR 4506.00 090 Y 12701.98  J1 63020 LAMNOTMY INCL W/DCMPRSN NRV ROOT 1 INTRSPC CERVC 4134.00 090 Y 12696.87  J1 63030 LAMNOTMY INCL W/DCMPRSN NRV ROOT 1 INTRSPC LUMBR 3480.00 090 Y 12735.25   63035 LAMNOTMY W/DCMPRSN NRV EACH ADDL CRVCL/LMBR 676.80 ZZZ Y  J1 63040 LAMOT PRTL FFD EXC DISC REEXPL 1 NTRSPC CERVICAL 4924.80 090 Y 12786.11  J1 63042 LAMOT PRTL FFD EXC DISC REEXPL 1 NTRSPC LUMBAR 4612.80 090 Y 12725.33   63043 LAMOT PRTL FFD EXC DISC REEXPL 1 NTRSPC EA CRV 3528.66 ZZZ Y   63044 LAMOT W/PRTL FFD HRNA8 REEXPL 1 NTRSPC EA LMBR 2677.20 ZZZ Y  J1 63045 LAM FACETECTOMY & FORAMOTOMY 1 VRT SGM CERVICAL 4593.60 090 Y 12734.29

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 63046 LAM FACETECTOMY & FORAMOTOMY 1 VRT SGM THORACIC 4377.60 090 Y 12718.62  J1 63047 LAM FACETECTOMY & FORAMOTOMY 1 VRT SGM LUMBAR 3940.80 090 Y 12721.82   63048 LAM FACETECTOMY&FORAMOT 1 VRT SGM EA ADDL SGM 745.20 ZZZ Y   63050 LAMOP CERVICAL W/DCMPRN SPI CORD 2/> VERT SEG 5278.80 090 Y   63051 LAMOPLASTY CERVICAL DCMPRN CORD 2/> SEG RCNSTJ 6042.00 090 Y   63052 LAM FACETEC/FORAMOT DRG ARTHRD LUMBAR 1 VRT SGM 914.40 ZZZ Y   63053 LAM FACETEC/FORAMOT DRG ARTHRD LMBR EA ADDL SGM 684.00 ZZZ Y  J1 63055 TRANSPEDICULAR DCMPRN SPINAL CORD 1 SEG THORACIC 5791.20 090 Y 12749.96  J1 63056 TRANSPEDICULAR DCMPRN SPINAL CORD 1 SEG LUMBAR 5318.40 090 Y 12748.04   63057 TRANSPEDICULAR DCMPRN 1 SEG EA THORACIC/LUMBAR 1136.40 ZZZ Y  J1 63064 COSTOVERTEBRAL DCMPRN SPINAL CORD THORACIC 1 SEG 6338.40 090 Y 12794.10   63066 COSTOVERTEBRAL DCMPRN SPINE CORD THORACIC EA SEG 727.20 ZZZ Y  J1 63075 DISCECTOMY ANT DCMPRN CORD CERVICAL 1 NTRSPC 4844.40 090 Y 11798.40   63076 DISCECTOMY ANT DCMPRN CORD CERVICAL EA NTRSPC 864.00 ZZZ Y   63077 DISCECTOMY ANT DCMPRN CORD THORACIC 1 NTRSPC 5349.60 090 Y   63078 DISCECTOMY ANT DCMPRN CORD THORACIC EA NTRSPC 732.00 ZZZ Y   63081 VERTEBRAL CORPECTOMY ANT DCMPRN CERVICAL 1 SEG 6260.40 090 Y 2173.27   63082 VERTEBRAL CORPECTOMY DCMPRN CERVICAL EA SEG 937.20 ZZZ Y 1435.98   63085 VERTEBRAL CORPECTOMY DCMPRN CORD THORACIC 1 SEG 6860.40 090 Y   63086 VERTEBRAL CORPECTOMY DCMPRN CORD THORACIC EA SEG 674.40 ZZZ Y   63087 VCRPEC THORACOLMBR DCMPRN LWR THRC/LMBR 1 SEG 8554.80 090 Y   63088 VCRPEC THORACOLMBR DCMPRN LWR THRC/LMBR EA SEG 907.20 ZZZ Y   63090 VCRPEC TRANSPRTL/RPR DCMPRN THRC LMBR/SAC 1 SEG 6967.20 090 Y   63091 VCRPEC TRANSPRTL/RPR DCMPRN THRC LMBR/SAC EA SEG 627.60 ZZZ Y   63101 VERTEB CORPECT LAT XTRCAVITARY DCMPRN THRC 1 SEG 8278.80 090 Y   63102 VERTEB CORPECT LAT XTRCAVITARY DCMPRN LMBR 1 SEG 8066.40 090 Y   63103 VCRPEC LAT XTRCAVITARY DCMPRN THRC/LMBR EA SEG 1039.20 ZZZ Y   63170 LAM W/MYELOTOMY CERVICAL/THORACIC/THORACOLUMBAR 5694.00 090 Y   63172 LAM W/DRG INTRMEDULLARY CYST/SYRINX SUBARACHNOID 5046.00 090 Y   63173 LAM W/DRG INTRMEDULRY CYST/SYRINX PRTL/PLEURAL 6163.20 090 Y   63185 LAMINECTOMY W/RHIZOTOMY 1/2 SEGMENTS 4048.80 090 Y   63190 LAMINECTOMY W/RHIZOTOMY > 2 SEGMENTS 4412.40 090 Y   63191 LAMINECTOMY W/SECTION SPINAL ACCESSORY NERVE 4938.00 090 Y   63197 LAM W/CORDOTOMY SCTJ SPINOTHALAMIC TRC 1STG THRC 6110.40 090 Y   63200 LAMINECTOMY RELEASE TETHERED SPINAL CORD LUMBAR 5412.00 090 Y   63250 LAM EXC/OCCLUSION AVM SPINAL CORD CERVICAL 10555.20 090 Y   63251 LAM EXC/OCCLUSION AVM SPINAL CORD THORACIC 10790.40 090 Y   63252 LAM EXC/OCCLUSION AVM SPI CORD THORACOLUMBAR 10788.00 090 Y  J1 63265 LAM EXC/EVAC ISPI LES OTH/THN NEO XDRL CERVICAL 5954.40 090 Y 12741.33  J1 63266 LAM EXC/EVAC ISPI LES OTH/THN NEO XDRL THORACIC 6140.40 090 Y 12305.37  J1 63267 LAM EXC/EVAC ISPI LESION OTH/THN NEO XDRL LUMBAR 4898.40 090 Y 12712.86  J1 63268 LAM EXC/EVAC ISPI LES OTH/THN NEO XDRL SACRAL 5065.20 090 Y 12761.48   63270 LAM EXC ISPI LES OTH/THN NEO IDRL CERVICAL 7416.00 090 Y   63271 LAM EXC ISPI LES OTH/THN NEO IDRL THORACIC 7388.40 090 Y   63272 LAM EXC ISPI LES OTH/THN NEO IDRL LUMBAR 6680.40 090 Y 10394.02   63273 LAM EXC ISPI LES OTH/THN NEO IDRL SACRAL 6670.80 090 Y   63275 LAMINECTOMY BX/EXC ISPI NEO XDRL CERVICAL 6453.60 090 Y

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 206 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   63276 LAMINECTOMY BX/EXC ISPI NEO XDRL THORACIC 6381.60 090 Y   63277 LAMINECTOMY BX/EXC ISPI NEO XDRL LUMBAR 5565.60 090 Y   63278 LAMINECTOMY BX/EXC ISPI NEO XDRL SACRAL 5700.00 090 Y   63280 LAM BX/EXC ISPI NEO IDRL XMED CERVICAL 7560.00 090 Y   63281 LAM BX/EXC ISPI NEO IDRL XMED THORACIC 7482.00 090 Y   63282 LAM BX/EXC ISPI NEO IDRL XMED LUMBAR 7063.20 090 Y 7744.75   63283 LAM BX/EXC ISPI NEO IDRL SACRAL 6795.60 090 Y   63285 LAM BX/EXC ISPI NEO IDRL IMED CERVICAL 9318.00 090 Y   63286 LAM BX/EXC ISPI NEO IDRL IMED THORACIC 9188.40 090 Y   63287 LAM BX/EXC ISPI NEO IDRL IMED THORACOLMBR 9770.40 090 Y   63290 LAM BX/EXC ISPI NEO XDRL-IDRL LES ANY LVL 9934.80 090 Y   63295 OSTPL RCNSTJ DORSAL SPI ELMNTS FLWG ISPI PX 1171.20 ZZZ Y   63300 VCRPEC LES 1 SGM XDRL CERVICAL 6464.40 090 Y   63301 VCRPEC LES 1 SGM XDRL THORACIC TTHRC 7869.60 090 Y   63302 VCRPEC LES 1 SEG XDRL THRC THORACOLMBR 7776.00 090 Y   63303 VCRPEC LES 1 SEG XDRL LMBR/SAC TRANSPRTL/RPR 8253.60 090 Y   63304 VERTEBRAL CORPECTOMY EXC LES 1 SEG IDRL CERVICAL 8378.40 090 Y   63305 VERTEBRAL CORPECTOMY LES 1 SEG IDRL THRC TTHRC 8912.40 090 Y   63306 VERTEBRL CORPECT LES 1 SEG IDRL THRC THORACOLMBR 8757.60 090 Y   63307 VCRPEC LES 1 SEG IDRL LMBR/SAC TRANSPRTL/RPR 8580.00 090 Y   63308 VERTEBRAL CORPECTOMY EXC INDRL LES EACH SEG 1135.20 ZZZ Y  J1 63600 CREATION LES SPINAL CORD STEREOTACTIC METHOD PRQ 3908.40 090 N 3586.62  J1 63610 STRTCTC STIMJ SPI CORD PRQ SPX N/FLWD OTH SURG 2058.00 000 N 3148.97   63620 STEREOTACTIC RADIOSURGERY 1 SPINAL LESION 4012.80 090 Y   63621 STEREOTACTIC RADIOSURGERY EA ADDL SPINAL LESION 897.60 ZZZ Y  J1 63650 PRQ IMPLTJ NSTIM ELECTRODE ARRAY EPIDURAL 1077.15 010 N 11073.07  J1 63655 LAM IMPLTJ NSTIM ELTRDS PLATE/PADDLE EDRL 2989.20 090 Y 34734.70   63661 RMVL SPINAL NSTIM ELTRD PRQ ARRAY INCL FLUOR 2101.20 010 Y 2316.70  J1 63662 RMVL SPINAL NSTIM ELTRD PLATE/PADDLE INCL FLUOR 2928.00 090 Y 4089.32  J1 63663 REVJ INCL RPLCMT NSTIM ELTRD PRQ RA INCL FLUOR 2812.80 010 Y 10355.35  J1 63664 REVJ INCL RPLCMT NSTIM ELTRD PLT/PDLE INCL FLUOR 3034.80 090 Y 29514.29  J1 63685 INSJ/RPLCMT SPINAL NPG/RCVR POCKET CRTJ&CONNJ 1248.00 010 Y 43809.69  J1 63688 REVJ/RMVL IMPL SPI NPG/RCVR DTCH CONNJ ELTRD RA 1287.60 010 N 4089.32   63700 REPAIR MENINGOCELE < 5 CM DIAMETER 4694.40 090 Y   63702 REPAIR MENINGOCELE > 5 CM DIAMETER 5130.00 090 Y   63704 REPAIR MYELOMENINGOCELE < 5 CM DIAMETER 5964.00 090 Y   63706 REPAIR MYELOMENINGOCELE > 5 CM DIAMETER 6616.80 090 Y   63707 RPR DURAL/CEREBROSPINAL FLUID LEAK X REQ LAM 3346.80 090 Y 4810.43   63709 RPR DURAL/CSF LEAK/PSEUDOMENINGOCELE W/LAM 3985.20 090 Y 4741.19   63710 DURAL GRAFT SPINAL 3870.00 090 Y 2988.69   63740 CRTJ SHUNT LMBR SARACH-PRTL-PLEURAL/OTH W/LAM 3530.40 090 Y  J1 63741 CRTJ SHUNT LMBR SARACH-PRTL-PLEURAL PRQ X LAM 2424.00 090 Y 10557.08  J1 63744 RPLCMT IRRIGATION/REVJ LUMBOSARACH SHUNT 2473.20 090 Y 10472.92   63746 RMVL ENTIRE LUMBOSARACH SHUNT SYS W/O RPLCMT 2190.00 090 N 2546.50   64400 INJECTION AA&/STRD TRIGEMINAL NERVE EACH BRANCH 465.60 000 N 378.90   64405 INJECTION AA&/STRD GREATER OCCIPITAL NERVE 284.40 000 N 378.90   64408 INJECTION AA&/STRD VAGUS NERVE 402.00 000 N 378.90

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   64415 INJECTION AA&/STRD BRACHIAL PLEXUS W/IMG GDN 405.60 000 N 1193.84   64416 INJECTION AA&/STRD BRACH PLEX CONT NFS CATH IMG 273.60 000 N 1193.84   64417 INJECTION AA&/STRD AXILLARY NERVE W/IMG GDN 501.60 000 N 1193.84   64418 INJECTION AA&/STRD SUPRASCAPULAR NERVE 325.20 000 N 920.90   64420 INJECTION AA&/STRD INTERCOSTAL NRV SINGLE LVL 378.00 000 N 920.90   64421 INJECTION AA&/STRD INTERCOSTAL NRV EA ADDL LVL 535.20 ZZZ N 1193.84   64425 INJECTION AA&/STRD ILIOINGUINAL IH NERVES 471.60 000 N 920.90   64430 INJECTION AA&/STRD PUDENDAL NERVE 496.80 000 N 1193.84   64435 INJECTION AA&/STRD PARACERVICAL NERVE 480.00 000 N 920.90   64445 INJECTION AA&/STRD SCIATIC NERVE W/IMG GDN 466.80 000 N 920.90   64446 INJECTION AA&/STRD SCIATIC NRV CONT NFS CATH IMG 273.60 000 N 1193.84   64447 INJECTION AA&/STRD FEMORAL NERVE W/IMG GDN 415.20 000 N 920.90   64448 INJECTION AA&/STRD FEM NRV CONT NFS CATH IMG GDN 246.00 000 N 1193.84   64449 INJECTION AA&/STRD LUMBAR PLEXUS CONT NFS CATH 292.80 000 N 1193.84   64450 INJECTION AA&/STRD OTHER PERIPHERAL NERVE/BRANCH 271.20 000 N 920.90   64451 INJECTION AA&/STRD NERVES NRVTG SI JOINT W/IMG 831.60 000 N 920.90   64454 INJECTION AA&/STRD GENICULAR NRV BRANCHES W/IMG 808.80 000 N 920.90   64455 NJX AA&/STRD PLANTAR COMMON DIGITAL NERVES 176.40 000 N 378.90   64461 PVB THORACIC SINGLE INJECTION SITE W/IMG GID 487.20 000 N 920.90   64462 PVB THORACIC SECOND & ADDL INJ SITE W/IMG GID 264.00 ZZZ N   64463 PVB THORACIC CONT CATHETER INFUSION W/IMG GID 707.94 000 N 920.90   64466 THORACIC FASCIAL PLANE BLOCK UNI INJECTION 445.20 000 N   64467 THORACIC FASCIAL PLANE BLOCK UNI CONT INFUSION 823.20 000 N   64468 THORACIC FASCIAL PLANE BLOCK BI INJECTION 513.60 000 N   64469 THORACIC FASCIAL PLANE BLOCK BI CONT INFUSION 1256.40 000 N   64473 LOWER XTR FASCIAL PLANE BLOCK UNI INJECTION 420.00 000 N   64474 LOWER XTR FASCIAL PLANE BLOCK UNI CONT INFUSION 813.60 000 N   64479 NJX AA&/STRD TFRML EPI CERVICAL/THORACIC 1 LEVEL 834.00 000 N 1086.07   64480 NJX AA&/STRD TFRML EPI CERVICAL/THORACIC EA ADDL 410.40 ZZZ N   64483 NJX AA&/STRD TFRML EPI LUMBAR/SACRAL 1 LEVEL 772.80 000 N 1086.07   64484 NJX AA&/STRD TFRML EPI LUMBAR/SACRAL EA ADDL 334.80 ZZZ N   64486 TAP BLOCK UNILATERAL BY INJECTION(S) 374.40 000 N   64487 TAP BLOCK UNILATERAL BY CONTINUOUS INFUSION(S) 538.80 000 N   64488 TAP BLOCK BILATERAL BY INJECTION(S) 459.60 000 N   64489 TAP BLOCK BILATERAL BY CONTINUOUS INFUSION(S) 798.00 000 N   64490 NJX DX/THER AGT PVRT FACET JT CRV/THRC 1 LEVEL 684.00 000 Y 1193.84   64491 NJX DX/THER AGT PVRT FACET JT CRV/THRC 2ND LEVEL 344.40 ZZZ Y   64492 NJX DX/THER AGT PVRT FACET JT CRV/THRC 3+ LEVEL 345.60 ZZZ Y   64493 NJX DX/THER AGT PVRT FACET JT LMBR/SAC 1 LEVEL 626.40 000 Y 1193.84   64494 NJX DX/THER AGT PVRT FACET JT LMBR/SAC 2ND LEVEL 324.00 ZZZ Y   64495 NJX DX/THER AGT PVRT FACET JT LMBR/SAC 3+ LEVEL 322.80 ZZZ Y   64505 INJECTION ANES AGENT SPHENOPALATINE GANGLION 403.20 000 N 351.42   64510 NJX ANES STELLATE GANGLION CRV SYMPATHETIC 521.64 000 N 1193.84   64517 INJECTION ANES SUPERIOR HYPOGASTRIC PLEXUS 691.20 000 N 1193.84   64520 INJECTION ANES LMBR/THRC PARAVERTBRL SYMPATHETIC 793.50 000 N 1193.84   64530 INJX ANES CELIAC PLEXUS W/WO RADIOLOGIC MONITRNG 790.74 000 N 1193.84  J1 64553 PRQ IMPLTJ NEUROSTIMULATOR ELTRD CRANIAL NERVE 6735.78 010 N 19149.69

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 208 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 64555 PRQ IMPLTJ NEUROSTIMULATOR ELTRD PERIPHERAL NRV 6114.78 010 N 10576.67  J1 64561 PRQ IMPLTJ NEUROSTIM ELTRD SACRAL NRVE W/IMAGING 2708.40 010 N 11022.08   64566 POST TIB NEUROSTIMULATION PRQ NEEDLE ELECTRODE 434.40 000 N 378.90  J1 64568 OPEN IMPLANTATION CRANIAL NERVE NEA & PULSE GEN 2211.60 090 N 47243.26  J1 64569 REVISION/REPLMT NEUROSTIMLATOR ELTRD CRANIAL NRV 2743.20 090 N 18380.87   64570 REMOVAL CRNL NRV NSTIM ELTRDS & PULSE GENERATO 2629.20 090 N 8270.01  J1 64575 OPEN IMPLANTATION NEA PERIPHERAL NERVE 1152.00 090 N 19447.68  J1 64580 OPEN IMPLANTATION NEA NEUROMUSCULAR 1128.00 090 Y 34197.25  J1 64581 OPEN IMPLANTATION NEA SACRAL NERVE 2318.40 090 N 10604.37  J1 64582 OPEN IMPLTJ HPGLSL NRV NSTIM RA PG&RESPIR SENSOR 3078.00 090 N 47243.26  J1 64583 REVJ/RPLCMT HPGLSL NERVE NSTIM RA PG&RESPIR SNR 2799.60 090 N 21186.84   64584 REMOVAL HYPOGLOSSAL NERVE NSTIM RA PG&RESPIR SNR 2359.20 090 N 8270.01  J1 64585 REVJ/RMVL PERPH NEUROSTIMULATOR ELECTRODE ARRAY 879.60 010 N 6477.84  J1 64590 INS/RPLC PERPH SAC/GSTRC NPG/RCVR PCKT CRTJ&CONN 948.00 010 N 33116.07  J1 64595 REV/RMV PRPH SAC/GSTRC NPG/RCV DTCH CONN ELTR RA 835.20 010 N 6362.91  J1 64596 INSJ/RPLCMT PERQ ELTRD RA PN W/INT NSTIM 1ST RA BR 010 N 23944.07   64597 INSJ/RPLCMT PERQ ELTRD RA PN INT NSTIM EA ADD RA BR ZZZ N  J1 64598 REVISION/REMOVAL NSTIM ELTRD ARRAY PN INT NSTIM BR 010 N 6355.26   64600 DSTRJ TRIGEMINAL NRV SUPRAORB INFRAORB BRANCH 1671.60 010 N 1193.84  J1 64605 DSTRJ NEUROLYTIC TRIGEMINAL NRV 2/3 DIV BRANCH 2307.60 010 N 3577.39  J1 64610 DSTRJ NEURLYTIC TRIGEM NRV 2/3 DIV RADIO MONITOR 2882.40 010 N 3569.59   64611 CHEMODENERV PAROTID&SUBMANDIBL SALIVARY GLNDS 460.80 010 N 378.90   64612 CHEMODNRVTJ MUSC MUSC INNERVATED FACIAL NRV UNIL 483.60 010 N 378.90   64615 CHEMODERVATE FACIAL/TRIGEM/CERV MUSC MIGRAINE 550.80 010 N 378.90   64616 CHEMODENERVATION MUSCLE NECK UNILAT FOR DYSTONIA 492.00 010 N 378.90   64617 CHEMODENERVATION MUSCLE LARYNX UNILAT W/EMG 580.80 010 N 378.90   64620 DSTRJ NEUROLYTIC AGENT INTERCOSTAL NERVE 744.00 010 N 1193.84  J1 64624 DESTRUCTION NEUROLYTIC AGT GENICULAR NERVE W/IMG 1418.40 010 N 3581.96  J1 64625 RADIOFREQUENCY ABLTJ NRV NRVTG SI JT W/IMG GDN 1718.40 010 N 3581.96  J1 64628 THERMAL DSTRJ INTRAOSSEOUS BVN 1ST 2 LMBR/SAC 1629.60 010 N 21594.35   64629 THERMAL DSTRJ INTRAOSSEOUS BVN EA ADDL LMBR/SAC 763.20 ZZZ N   64630 DSTRJ NEUROLYTIC AGENT PUDENDAL NERVE 931.20 010 N 1193.84   64632 DSTRJ NEUROLYTIC PLANTAR COMMON DIGITAL NERVE 319.20 010 N 378.90  J1 64633 DSTR NROLYTC AGNT PARVERTEB FCT SNGL CRVCL/THORA 1426.80 010 N 3259.45   64634 DSTR NROLYTC AGNT PARVERTEB FCT ADDL CRVCL/THORA 640.80 ZZZ N  J1 64635 DSTR NROLYTC AGNT PARVERTEB FCT SNGL LMBR/SACRAL 1411.20 010 N 3259.45   64636 DSTR NROLYTC AGNT PARVERTEB FCT ADDL LMBR/SACRAL 582.00 ZZZ N   64640 DSTRJ NEUROLYTIC AGENT OTHER PERIPHERAL NERVE 463.20 010 N 1086.07   64642 CHEMODENERVATION ONE EXTREMITY 1-4 MUSCLE 542.40 000 N 920.90   64643 CHEMODENERVATION 1 EXTREMITY EA ADDL 1-4 MUSCLE 333.60 ZZZ N   64644 CHEMODENERVATION 1 EXTREMITY 5 OR MORE MUSCLES 637.20 000 N 920.90   64645 CHEMODENERVATION 1 EXTREMITY EA ADDL 5/> MUSCLES 433.20 ZZZ N   64646 CHEMODENERVATION OF TRUNK MUSCLE 1-5 MUSCLES 565.20 000 N 920.90   64647 CHEMODENERVATION OF TRUNK 6 OR MORE MUSCLES 648.00 000 N 920.90   64650 CHEMODENERVATION ECCRINE GLANDS BOTH AXILLAE 310.50 000 N 378.90   64653 CHEMODENERVATION ECCRINE GLANDS OTH AREA PER DAY 379.20 000 N 378.90   64680 DSTRJ NEUROLYTIC W/WO RAD MONITOR CELIAC PLEXUS 1251.66 010 N 1193.84

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   64681 DSTRJ NULYT W/WORAD MNTR SUPRIOR HYPOGSTR PLEXUS 1971.60 010 N 1193.84  J1 64702 NEUROPLASTY DIGITAL 1/BOTH SAME DIGIT 1816.80 090 N 3542.78  J1 64704 NEUROPLASTY NERVE HAND/FOOT 1149.60 090 Y 3462.53  J1 64708 NEURP MAJOR PRPH NRV ARM/LEG OPN OTH/THN SPEC 1791.60 090 Y 3547.62  J1 64712 NEURP MAJOR PRPH NRV OPN ARM/LEG SCIATIC NRV 2122.80 090 Y 3511.93  J1 64713 NEURP MAJOR PRPH NRV OPN ARM/LEG BRACH PLEXUS 2816.40 090 Y 3489.34  J1 64714 NEURP MAJOR PRPH NRV OPN ARM/LEG LMBR PLEXUS 2695.20 090 Y 3558.38  J1 64716 NEUROPLASTY &/TRANSPOSITION CRANIAL NERVE 1822.80 090 Y 3454.28  J1 64718 NEUROPLASTY &/TRANSPOSITION ULNAR NERVE ELBOW 2143.20 090 N 3578.28  J1 64719 NEUROPLASTY &/TRANSPOSITION ULNAR NERVE WRIST 1454.40 090 N 3575.50  J1 64721 NEUROPLASTY &/TRANSPOS MEDIAN NRV CARPAL TUNNE 1586.40 090 N 3583.04  J1 64722 DECOMPRESSION UNSPECIFIED NERVE 1284.00 090 Y 3539.10  J1 64726 DECOMPRESSION PLANTAR DIGITAL NERVE 951.60 090 N 3535.33   64727 INTERNAL NEUROLYSIS REQ OPERATING MICROSCOPE 637.20 ZZZ N  J1 64732 TRANSECTION/AVULSION SUPRAORBITAL NERVE 1621.20 090 Y 3586.62  J1 64734 TRANSECTION/AVULSION INFRAORBITAL NERVE 1832.40 090 N 3563.22  J1 64736 TRANSECTION/AVULSION MENTAL NERVE 1287.60 090 Y 3449.70  J1 64738 TRANSECTION/AVULSION INF ALVEOLAR NRV W/OSTEO 1604.40 090 Y 3537.13  J1 64740 TRANSECTION/AVULSION LINGUAL NERVE 1681.20 090 Y 3581.96  J1 64742 TRANSECTION/AVULSION FACIAL NRV DIFFERENT/CMPL 1726.80 090 Y 3562.50  J1 64744 TRANSECTION/AVULSION GREATER OCCIPITAL NERVE 1807.20 090 N 3524.39  J1 64746 TRANSECTION/AVULSION PHRENIC NERVE 1540.80 090 Y 3586.62   64755 TRANSECTION/AVULSION VAGUS NERVES 3307.20 090 Y   64760 TRANSECTION/AVULSION VAGUS NERVE ABDOMINAL 1873.20 090 Y  J1 64763 TRNSXJ/AVLSN OBTURAT NRV XPELV W/WO TENOTOMY 1852.80 090 Y 3586.62  J1 64766 TRNSXJ/AVLSN OBTURAT NRV INPELV W/WO TENOTOMY 2286.00 090 Y 3586.62  J1 64771 TRANSECTION/AVULSION OTH CRANIAL NRV XDRL 2059.20 090 Y 3441.19  J1 64772 TRANSECTION/AVULSION OTH SPINAL NRV XDRL 2000.40 090 Y 3570.75  J1 64774 EXC NEUROMA CUTAN NRV SURGLY IDENTIFIABLE 1486.80 090 N 3569.86  J1 64776 EXC NEUROMA DIGITAL NERVE 1 OR BOTH SAME DIGIT 1399.20 090 N 3562.77   64778 EXCISION NEUROMA DIGITAL NRV EA ADDL DIGIT 638.40 ZZZ N  J1 64782 EXC NEUROMA HAND/FOOT XCP DIGITAL NERVE 1618.80 090 N 3525.20   64783 EXC NEUROMA HAND/FOOT EA NRV XCP SM DGT 763.20 ZZZ N  J1 64784 EXC NEUROMA MAJOR PERIPHERAL NRV XCP SCIATIC 2589.60 090 N 3551.20  J1 64786 EXCISION NEUROMA SCIATIC NERVE 3609.60 090 Y 11533.17   64787 IMPLANTATION NERVE END BONE/MUSCLE 841.20 ZZZ N  J1 64788 EXC NEUROFIBROMA/NEUROLEMMOMA CUTAN NRV 1444.80 090 N 3578.91  J1 64790 EXC NEUROFIBROMA/NEUROLEMMOMA MAJOR PRPH NRV 2985.60 090 N 3575.06  J1 64792 EXC NEUROFIBROMA/NEUROLEMMOMA EXTNSV 3798.00 090 Y 11615.00  J1 64795 BIOPSY NERVE 676.80 000 N 3564.83  J1 64802 SYMPATHECTOMY CERVICAL 3025.20 090 Y 3581.96  J1 64804 SYMPATHECTOMY CERVICOTHORACIC 4264.80 090 Y 3581.96   64809 SYMPATHECTOMY THORACOLUMBAR 3895.20 090 Y   64818 SYMPATHECTOMY LUMBAR 2772.00 090 Y  J1 64820 SYMPATHECTOMY DIGITAL ARTERIES EACH DIGIT 2588.40 090 N 3586.62  J1 64821 SYMPATHECTOMY RADIAL ARTERY 2458.80 090 N 5784.13  J1 64822 SYMPATHECTOMY ULNAR ARTERY 2493.60 090 N 5784.56

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 210 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 64823 SYMPATHECTOMY SUPERFICIAL PALMAR ARCH 2822.40 090 N 5773.72  J1 64831 SUTURE DIGITAL NERVE HAND/FOOT 1 NERVE 2467.20 090 N 3457.86   64832 SUTR DIGITAL NRV HAND/FOOT EA DGTAL NRV 1172.40 ZZZ N  J1 64834 SUTURE 1 NERVE HAND/FOOT COMMON SENSORY NERVE 2634.00 090 N 11320.01  J1 64835 SUTURE 1 NERVE MEDIAN MOTOR THENAR 2907.60 090 Y 11189.27  J1 64836 SUTURE 1 NERVE ULNAR MOTOR 2907.60 090 Y 11371.56   64837 SUTURE EACH ADDITIONAL NERVE HAND/FOOT 1285.20 ZZZ Y  J1 64840 SUTURE POSTERIOR TIBIAL NERVE 3426.00 090 Y 11647.90  J1 64856 SUTR PRPH NRV ARM/LEG XCP SCIATIC W/TRPOS 3591.60 090 N 11176.16  J1 64857 SUTR PRPH NRV ARM/LEG XCP SCIATIC W/O TRPOS 3747.60 090 Y 11304.29  J1 64858 SUTURE SCIATIC NERVE 4177.20 090 Y 2871.81   64859 SUTURE EACH ADDITIONAL PERIPHERAL NERVE 874.80 ZZZ Y  J1 64861 SUTURE BRACHIAL PLEXUS 5434.80 090 Y 3581.96  J1 64862 SUTURE LUMBAR PLEXUS 4875.60 090 Y 10833.13  J1 64864 SUTURE FACIAL NERVE EXTRACRANIAL 3034.80 090 Y 11521.52  J1 64865 SUTURE FACIAL NERVE INFRATEMPORAL W/WO GRAFT 3870.00 090 Y 11629.27   64866 ANASTOMOSIS FACIAL-SPINAL ACCESSORY 4440.00 090 Y   64868 ANASTOMOSIS FACIAL HYPOGLOSSAL 3552.00 090 Y   64872 SUTURE NERVE REQ SECONDARY/DELAYED SUTURE 408.00 ZZZ Y   64874 SUTURE NERVE REQ XTNSV MOBIL/TRPOS NERVE 612.00 ZZZ Y   64876 SUTURE NERVE REQ SHORTENING BONE EXTREMITY 692.40 ZZZ Y  J1 64885 NERVE GRAFT HEAD/NECK < 4 CM 3909.60 090 Y 10937.38  J1 64886 NERVE GRAFT HEAD/NECK >4 CM 4549.20 090 Y 10357.02  J1 64890 NERVE GRAFT 1 STRAND HAND/FOOT <4 CM 3838.80 090 Y 10366.92  J1 64891 NERVE GRAFT 1 STRAND HAND/FOOT >4 CM 4080.00 090 Y 9777.54  J1 64892 NERVE GRAFT 1 STRAND ARM/LEG <4 CM 3733.20 090 Y 11020.66  J1 64893 NERVE GRAFT 1 STRAND ARM/LEG >4 CM 3980.40 090 Y 11647.90  J1 64895 NERVE GRAFT MLT STRANDS HAND/FOOT <4 CM 4707.60 090 Y 11647.90  J1 64896 NERVE GRAFT MLT STRANDS HAND/FOOT > 4 CM 5071.20 090 Y 11063.76  J1 64897 NERVE GRAFT MLT STRANDS ARM/LEG <4 CM 4496.40 090 Y 11420.48  J1 64898 NERVE GRAFT MLT STRANDS ARM/LEG >4 CM 4864.80 090 Y 11140.05   64901 NERVE GRAFT EACH NERVE 1 STRAND 2097.60 ZZZ Y   64902 NERVE GRAFT EACH NERVE MULTIPLE STRANDS 2428.80 ZZZ Y  J1 64905 NERVE PEDICLE TRANSFER FIRST STAGE 3573.60 090 Y 11433.00  J1 64907 NERVE PEDICAL TRANSFER SECOND STAGE 4616.40 090 Y 10833.13  J1 64910 NERVE REPAIR W/CONDUIT EACH NERVE 2746.80 090 Y 10311.01  J1 64911 NERVE REPAIR W/AUTOGENOUS VEIN GRAFT EA NERVE 3643.20 090 Y 11105.11  J1 64912 NERVE REPAIR W/NERVE ALLOGRAFT FIRST STRAND 3080.16 090 Y 10168.91   64913 NERVE REPAIR W/NERVE ALLOGRAFT EA ADDL STRAND 619.20 ZZZ Y   64999 UNLISTED PROCEDURE NERVOUS SYSTEM BR YYY N 378.90  J1 65091 EVISCERATION OCULAR CONTENTS W/O IMPLANT 2539.20 090 N 6672.15  J1 65093 EVISCERATION OCULAR CONTENTS W/IMPLANT 2512.98 090 N 6561.74  J1 65101 ENUCLEATION OF EYE W/O IMPLANT 2949.06 090 N 6724.32  J1 65103 ENUCLEATION EYE IMPLT MUSC X ATTACHED IMPLT 3070.50 090 N 6540.13  J1 65105 ENUCLEATION EYE IMPLT MUSC ATTACHED IMPLT 3379.62 090 Y 6449.12  J1 65110 EXENTERATION ORBIT REMVL ORBITAL CONTENTS ONLY 4668.00 090 Y 6748.80  J1 65112 EXENTERATION ORBIT RMVL ORBIT CONTENTS & BONE 5337.60 090 Y 6753.36

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 65114 EXNTJ ORBIT RMVL ORB CNTS W/MUSC/MYOQ FLAP 5571.60 090 Y 6602.76  J1 65125 MODIFICAJ OC IMPLT W/PLMT/RPLCMT PEGS SPX 1620.00 090 N 4005.35  J1 65130 INSJ OC IMPLT SEC AFTER EVSC SCLL SHELL 2921.46 090 N 6565.79  J1 65135 INSJ OC IMPLT AFTER ENCL MUSC X ATTACHED 2962.86 090 N 6631.80  J1 65140 INSJ OC IMPLT AFTER ENCL MUSC ATTACHED 3218.16 090 N 6359.14  J1 65150 REINSERTION OCULAR IMPLT W/WO CONJUNCTIVAL GRAFT 2318.40 090 N 6548.90  J1 65155 REINSERTION OCULAR IMPLT RNFCMT &/ ATTACH MUSCLE 3367.20 090 N 6537.59  J1 65175 REMOVAL OCULAR IMPLANT 2628.90 090 N 6716.89   65205 REMOVAL FB EYE CONJUNCTIVAL SUPERFICIAL 157.20 000 N 163.53   65210 RMVL FB XTRNL EYE EMBED SCJNCL/SCLERAL NONPERFOR 192.00 000 N 393.60   65220 RMVL FB XTRNL EYE CORNEAL W/O SLIT LAMP 212.40 000 N 393.60   65222 RMVL FB XTRNL EYE CORNEAL W/SLIT LAMP 237.60 000 N 163.53  J1 65235 RMVL FB INTRAOCULAR ANT CHAMBER EYE/LENS 2550.00 090 N 4241.62  J1 65260 RMVL FB IO FROM POST SEG MAG XTRJ ANT/POST ROUTE 3429.60 090 Y 4241.72  J1 65265 RMVL FB IO FROM POST SEG NONMAGNETIC XTRJ 3860.40 090 Y 4222.00  J1 65270 RPR LAC CJNC W/WO NONPERFOR LAC SCLERA DIR CLSR 1018.80 010 N 4081.37  J1 65272 RPR LAC CJNC MOBLJ& REARGMT W/O HOSPITALIZATION 1874.40 090 N 4087.40   65273 RPR LAC CJNC MOBLJ & REARGMT W/HOSPIZATION 1322.40 090 N  J1 65275 RPR LAC CORNEA NONPERFOR W/WO RMVL FOREIGN BODY 2073.60 090 N 6751.00  J1 65280 RPR LAC CORNEA&/SCLERA PERFOR X INVG UVEAL TIS 2331.60 090 N 7962.79  J1 65285 RPR LAC CORN&/SCLRA PERF W/REPOS/RESCJ UVEAL T 3843.60 090 N 7988.18  J1 65286 RPR LAC APPL TISSUE GLUE WOUND CORNEA&/SCLERA 2473.20 090 N 4240.98  J1 65290 RPR WND EXTRAOCULAR MUSCLE TENDON&/TENON CAPSU 1704.00 090 N 6753.36   65400 EXCISION LESION CORNEA XCP PTERYGIUM 2426.40 090 N 1174.43  J1 65410 BIOPSY CORNEA 501.60 000 N 4080.15  J1 65420 EXCISION/TRANSPOSITION PTERYGIUM W/O GRAFT 1912.80 090 N 4061.04  J1 65426 EXCISION/TRANSPOSITION PTERYGIUM W/GRAFG 2372.40 090 N 3947.00   65430 CORNEA SCRAPING DIAGNOSTIC SMEAR &/CULTURE 402.00 000 N 393.60   65435 RMVL CORNEAL EPITHELIUM W/WO CHEMOCAUTERIZATION 288.00 000 N 1174.43  J1 65436 RMVL CORNEAL EPITHELIUM W/APPL CHELATING AGENT 1350.00 090 N 4059.91   65450 DSTRJ LESION CRYOTHER PHOTO/THERMOCAUTZATION 1143.60 090 N 379.37  J1 65600 MULTIPLE PUNCTURES ANTERIOR CORNEA 1544.40 090 N 4070.13  J1 65710 KERATOPLASTY ANTERIOR LAMELLAR 3986.40 090 Y 7731.81  J1 65730 KERATOPLASTY PENTRG EXCEPT APHAKIA/PSEUDOPHAKIA 4369.20 090 Y 7783.20  J1 65750 KERATOPLASTY PENETRAING APHAKIA 4404.00 090 Y 7758.61  J1 65755 KERATOPLASTY PENETRATING PSEUDOPHAKIA 4383.60 090 Y 7816.80  J1 65756 KERATOPLASTY ENDOTHELIAL 4087.20 090 Y 7741.21   65757 BACKBENCH PREPJ CORNEAL ENDOTHELIAL ALLOGRAFT 871.20 ZZZ N   65760 KERATOMILEUSIS 4296.00 XXX N   65765 KERATOPHAKIA 4278.87 XXX N   65767 EPIKERATOPLASTY 3983.94 XXX N  J1 65770 KERATOPROSTHESIS 4897.20 090 Y 13137.07   65771 RADIAL KERATOTOMY 731.50 XXX N 1294.43   65772 CRNL RELAXING INC CORRJ INDUCED ASTIGMATISM 1598.40 090 N 1174.43  J1 65775 CRNL WEDGE RESCJ CORRJ INDUCED ASTIGMATISM 2005.20 090 N 4087.40   65778 PLACE AMNIOTIC MEMBRA OCULAR SURFACE W/O SUTURES 4898.40 000 N 1174.43   65779 PLACE AMNIOTIC MEMBRANE OCULAR SURFACE SUTURED 4245.60 000 N 4794.89

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 212 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 65780 OCULAR SURFACE RECONSTRUCTION AMNIOTIC MEMBRANE 2324.40 090 N 6253.11  J1 65781 OCULAR SURFACE RECONSTRUCTION LIMBAL ALLOGRAFT 4605.60 090 Y 7295.65  J1 65782 OCCULAR SURFACE RECONSTRUCTION LIMBAL AUTOGRAFT 3976.80 090 N 6588.24  J1 65785 IMPLANTATION INTRASTROMAL CORNEAL RING SEGMENTS 8347.20 090 N 7782.40  J1 65800 PARACENTSIS ANT CHAMB EYE ASPIR AQUEOUS SPX 416.40 000 N 4239.71  J1 65810 PARACENTSIS ANT CHAM RMVL VITREOUS W/WO AIR INJX 1610.40 090 N 4217.44  J1 65815 PARACEN ANT CHAM RMVL BLOOD W/WO IRRIG&/AIR IN 2271.60 090 N 4234.94  J1 65820 GONIOTOMY 2906.40 090 N 7790.60  J1 65850 TRABECULOTOMY AB EXTERNO 2940.00 090 N 4110.97   65855 TRABECULOPLASTY BY LASER SURGERY 861.60 010 N 729.85   65860 SEVERING ADHESIONS ANTERIOR SEGMENT LASER SPX 1076.40 090 N 729.85  J1 65865 SEVERING ADS ANT SEG INCAL TQ SPX GONIOSYNECHIAE 1666.80 090 N 4142.25  J1 65870 SEVERING ADS ANT SEG INCAL SPX ANT SYNECHIAE 2073.60 090 N 4199.31  J1 65875 SEVERING ADS ANT SEG INCAL SPX POST SYNECHIAE 2210.40 090 N 4155.09  J1 65880 SEVERING ADS ANT SEG INCAL SPX CORNEOVITREAL 2323.20 090 N 7999.18  J1 65900 RMVL EPITHELIAL DOWNGROWTH ANT CHAMBER EYE 3465.60 090 Y 4241.72  J1 65920 RMVL IMPLANTED MATERIAL ANTERIO SEGMENT EYE 2757.60 090 N 4219.45  J1 65930 RMVL BLOOD CLOT ANTERIOR SEGMENT EYE 2238.00 090 N 4231.12  J1 66020 INJX ANTERIOR CHAMBER EYE AIR/LIQUID SPX 697.20 010 N 4227.62  J1 66030 INJX ANTERIOR CHAMBER EYE MEDICATION SPX 630.00 010 N 4239.60  J1 66130 EXCISION LESION SCLERA 2491.20 090 N 3945.88  J1 66150 FSTLJ SCLERA GLAUCOMA TREPHIN W/IRIDECTOMY 3051.60 090 N 7666.61  J1 66155 FSTLJ SCLERA GLAUCOMA THERMOCAUT IRRIDEC 3050.40 090 N 7494.83  J1 66160 FSTLJ SCLERA SCLERECTOMY PUNCH/SCISSORS IRIDECT 3430.80 090 N 4218.39  J1 66170 FSTLJ SCLERA GLAUCOMA TRABECULECT AB EXTERNO 3800.40 090 Y 4189.44  J1 66172 FSTLJ SCLERA GLC TRBEC AB EXTERNO SCARRING 4149.60 090 Y 4216.27  J1 66174 TRLUML DILAT AQUEOUS O/F CAN WO RETENTION DEV/ST 3232.80 090 Y 7632.42  J1 66175 TRLUML DILAT AQUEOUS O/F CAN W/RETENTION DEV/ST 3386.40 090 Y 7433.64  J1 66179 AQUEOUS SHUNT EXTRAOCULAR RESERVOIR W/O GRAFT 3756.00 090 Y 7343.65  J1 66180 AQUEOUS SHUNT EXTRAOC EQUAT PLATE RSVR W/GRAFT 3958.80 090 Y 7303.65  J1 66183 INSERT ANTER DRAINAGE DEV W/O EXTRAOC RESERVOIR 3577.20 090 Y 7013.48  J1 66184 REVJ SHUNT EXTRAOCULAR RESERVOIR W/O GRAFT 2751.60 090 Y 4197.71  J1 66185 REVJ AQUEOUS SHUNT EXTRAOCULAR RESERVOIR W/GRAFT 2958.00 090 Y 4084.78  J1 66225 REPAIR SCLERAL STAPHYLOMA W/GRAFT 3254.40 090 N 7405.04  J1 66250 REVJ/RPR OPRATIVE WOUND ANTERIOR SEGMENT 2664.00 090 N 4067.58  J1 66500 IRIDOTOMY STAB INC SPX XCP TRANSFIXION 1393.20 090 N 4241.72  J1 66505 IRIDOTOMY STAB INC SPX TRANSFIXION 1514.40 090 N 4241.72  J1 66600 IRDEC CRNLSCLRL/CRNL SCTJ RMVL LES 3192.00 090 N 7980.58  J1 66605 IRDEC CRNLSCLRL/CRNL SCTJ CYCLECTOMY 3812.40 090 N 4241.72  J1 66625 IRDEC CRNLSCLRL/CRNL SCTJ PRPH GLC SPX 1489.20 090 N 4215.53  J1 66630 IRDEC CRNLSCLRL/CRNL SCTJ SECTOR GLC SPX 1968.00 090 N 4108.00  J1 66635 IRDEC CRNLSCLRL/CRNL SCTJ OPTICAL SPX 1987.20 090 N 4224.33  J1 66680 REPAIR IRIS CILIARY BODY 1818.00 090 N 4212.03  J1 66682 SUTURE IRIS CILIARY BODY SPX RETRIEVAL SUTURE 2521.20 090 N 4230.27  J1 66683 IMPLTJ IRIS PROSTHESIS W/SUTR FIXJ&RPR/RMVL IRIS 2778.00 090 N 26926.25  J1 66700 CILIARY BODY DESTRUCTION DIATHERMY 1581.60 090 N 4241.72  J1 66710 CILIARY BODY DSTRJ CYCLOPHOTOCOAG TRANSSCERAL 1550.40 090 N 4084.44

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 66711 ECP CILIARY BODY DSTRJ W/O RMVL CRYSTALLINE LENS 2193.60 090 N 4233.35  J1 66720 CILIARY BODY DESTRUCTION CRYOTHERAPY 1632.00 090 N 4087.40  J1 66740 CILIARY BODY DESTRUCTION CYCLODIALYSIS 1537.20 090 N 4087.40   66761 IRIDOTOMY/IRRIDECTOMY LASER SURG PER SESSION 1052.40 010 N 729.85   66762 IRIDOPLASTY PHOTOCOAGULATION 1/> SESSIONS 1669.20 090 N 729.85   66770 DSTRJ CYST/LESION IRIS/CILIARY BODY 1849.20 090 N 729.85  J1 66820 DISCISSION SECONDARY MEMBRANOUS CATARACT 1581.48 090 N 4235.04   66821 POST-CATARACT LASER SURGERY 1170.00 090 N 729.85  J1 66825 REPOSITIONING IO LENS PROSTHESIS REQ INC SPX 2941.20 090 N 4224.97  J1 66830 RMVL SEC MEMBRANOUS CTRC CORNEO-SCLL SCTJ 2464.80 090 N 4240.77  J1 66840 RMVL LENS MATERIAL ASPIR TQ 1/> STAGES 2407.20 090 N 4237.69  J1 66850 RMVL LENS MATERIAL PHACOFRAGMENTATION ASPIR 2734.80 090 N 4174.60  J1 66852 RMVL LENS MATERIAL PARS PLANA W/WO VITRECTOMY 2913.60 090 N 7964.39  J1 66920 RMVL LENS MATERIAL INTRACAPSULAR 2598.00 090 N 4227.30  J1 66930 REMOVAL LENS MATRL INTRACAPSULAR DISLOCATED LENS 2978.40 090 N 7931.19  J1 66940 REMOVAL LENS MATERIAL EXTRACAPSULAR 2725.20 090 N 4229.85  J1 66982 XCAPSL CTRC RMVL INSJ IO LENS PROSTH CPLX WO ECP 2707.20 090 N 4108.96  J1 66983 ICAPSULAR CATARACT XTRJ INSJ IO LENS PRSTH 1 STG 2530.80 090 N 4135.26  J1 66984 XCAPSL CTRC RMVL INSJ IO LENS PROSTH W/O ECP 2179.20 090 N 4105.35  J1 66985 INSJ IO LENS PROSTHESIS NOT W/CONCURRENT RMVL 2672.40 090 N 4150.10  J1 66986 EXCHANGE INTRAOCULAR LENS 3136.80 090 N 4151.69  J1 66987 XCAPSL CTRC RMVL INSJ IO LENS PROSTH CPLX W/ECP 4371.60 090 N 7749.01  J1 66988 XCAPSL CTRC RMVL INSJ IO LENS PROSTH W/ECP 3914.40 090 N 7784.80  J1 66989 XCAPSL CTRC RMVL INSJ IO LENS PRSTH CPLX INSJ 1+ 2970.00 090 N 6035.71   66990 USE OPHTHALMIC ENDOSCOPE 307.20 ZZZ N  J1 66991 XCAPSL CTRC RMVL INSJ IO LENS PROSTH INSJ 1+ 2370.00 090 N 6035.71  J1 66999 UNLISTED PROCEDURE ANTERIOR SEGMENT EYE BR YYY N 4133.88  J1 67005 RMVL VITREOUS ANT APPR PARTIAL REMOVAL 1646.40 090 N 4173.11  J1 67010 RMVL VITREOUS ANT APPR SUBTOT RMVL MECH VITRECT 1886.40 090 N 4187.22  J1 67015 ASPIRATION/RELEASE VITREOUS SUBRETINAL/CHOROIDAL 2116.80 090 N 4236.10  J1 67025 INJ SUBSTITUTE PARS PLANA/LIMBL W/WO ASPIR SPX 2604.00 090 N 4219.56  J1 67027 IMPLTJ INTRAVITREAL DRUG DLVR SYS RMVL VTS 2942.40 090 Y 33940.25   67028 INTRAVITREAL NJX PHARMACOLOGIC AGT SPX 396.00 000 N 462.41  J1 67030 DISCISSION VITREOUS STRANS PARS PLANA APPROACH 1948.80 090 N 4231.54   67031 SEVERING VITREOUS STRANS LASER 1/> STAGES 1364.40 090 N 729.85  J1 67036 VITRECTOMY MECHANICAL PARS PLANA 3111.60 090 Y 7960.79  J1 67039 VITRECTOMY MCHNL PARS PLNA FOCAL ENDOLASER PC 3326.40 090 Y 7961.39  J1 67040 VTRECTOMY MCHNL PARS PLNA ENDOLASER PANRTA PC 3591.60 090 Y 7976.58  J1 67041 VITRECTOMY PARS PLANA REMOVE PRERETINAL MEMBRANE 3963.60 090 Y 7980.98  J1 67042 VITRECTOMY PARS PLANA REMOVE INT MEMB RETINA 3963.60 090 Y 7978.18  J1 67043 VITRECTOMY PARS PLANA REMOVE SUBRETINAL MEMBRANE 4179.60 090 Y 7957.19  J1 67101 RPR RETINAL DTCHMNT DRG SUBRETINAL FLUID CRTX 1168.80 010 N 4193.05   67105 RPR RETINAL DTCHMNT DRG SUBRETINAL FLUID PC 1033.20 010 N 729.85  J1 67107 REPAIR RETINAL DETACHMENT SCLERAL BUCKLING 3897.60 090 Y 7947.59  J1 67108 RPR RETINAL DTCHMNT W/VITRECTOMY ANY METH 4125.60 090 Y 7934.79  J1 67110 RPR RETINAL DTCHMNT INJECTION AIR/OTHER GAS 3115.20 090 N 4234.41  J1 67113 RPR COMPLEX RETINA DETACH VITRECT &MEMBRANE PEEL 4611.60 090 Y 7896.59

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 214 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 67115 RELEASE ENCIRCLING MATERIAL POSTERIOR SEGMENT 1728.00 090 N 7999.18  J1 67120 RMVL IMPLNT MATL POSTERIOR SEGMENT EXTRAOCULAR 2360.40 090 N 4226.77  J1 67121 RMVL IMPLT MATRL POSTERIOR SEGMENT INTRAOCULAR 3134.40 090 Y 4234.51   67141 PROPH RETINAL DTCHMNT W/O DRG CRTX DIATHERMY 1790.40 010 N 379.37   67145 PROPH RETINAL DTCHMNT W/O DRG PHOTOCOAGULATION 1802.40 010 N 729.85   67208 DSTRJ LOCLZD LESION RETINA 1/> SESS CRTX DTHRM 2100.00 090 N 379.37   67210 DSTRJ LOCLZD LESION RETINA 1/> SESS PC 1798.80 090 N 729.85  J1 67218 DSTRJ LESION RETINA 1/> SESS RADJ IMPLTJ 4846.80 090 N 6680.09   67220 DSTRJ LESION CHOROID PC 1/> SESS 1852.80 090 N 729.85   67221 DSTRJ LESION CHOROID PHOTODYNAMIC THERAPY 968.40 000 N 729.85   67225 DSTRJ LESION CHOROID PDT 2ND EYE 1 SESSION 102.00 ZZZ N  J1 67227 DESTRUCTION RETINOPATHY CRYOTHERAPY DIATHERMY 1029.60 010 N 6745.43   67228 TREATMENT EXTENSIVE RETINOPATHY PHOTOCOAGULATION 1184.40 010 N 729.85   67229 EXTENSIVE RETINOPATHY 1/> SESS PRETERM INFANT 4018.80 090 N 729.85  J1 67250 SCLERAL REINFORCEMENT SPX W/O GRAFT 3120.18 090 N 4027.32  J1 67255 SCLERAL REINFORCEMENT SPX W/GRAFT 2394.00 090 Y 3995.28  J1 67299 UNLISTED PROCEDURE POSTERIOR SEGMENT BR YYY N 4208.96  J1 67311 STRABISMUS RECESSION/RESCJ 1 HRZNTL MUSC 2035.20 090 N 4086.69  J1 67312 STRABISMUS RECESSION/RESCJ 2 HRZNTL MUSC 2427.60 090 N 6751.84  J1 67314 STRABISMUS RECESSION/RESCJ 1 VER MUSC 2292.00 090 N 4087.20  J1 67316 STRABISMUS RECESSION/RESCJ 2/MORE VER MUSC 2728.80 090 N 4083.93  J1 67318 STRABISMUS ANY SUPERIOR OBLIQUE MUSCLE 2395.20 090 N 4071.56   67320 TRANSPOSITION PROCEDURE EXTRAOCULAR MUSC 1100.40 ZZZ N   67331 STRABISMUS PREVIOUS EYE X INVOLVE EO MUSC 1044.00 ZZZ N   67332 STRABISMUS SCARRING EO MUSC/RSTCV MYOPATHY 1132.80 ZZZ N   67334 STRABISMUS POST FIXJ SUTR TQ W/WO MUSC RECESSION 1030.80 ZZZ N   67335 PLACEMENT ADJUSTABLE SUTURE STRABISMUS 580.98 ZZZ N   67340 STRABISMUS EXPL&/RPR DETACHED EXTROCULAR MUSC 1222.80 ZZZ Y  J1 67343 RLS XTNSV SCAR TISS W/O DETACHING EO MUSC SPX 2330.40 090 N 4057.05   67345 CHEMODENERVATION EXTRAOCULAR MUSCLE 852.00 010 N 379.37  J1 67346 BIOPSY EXTRAOCULAR MUSCLE 660.00 000 N 6753.36   67399 UNLISTED PROCEDURE EXTRAOCULAR MUSCLE BR YYY Y 379.37  J1 67400 ORBITOTOMY W/O BONE FLAP EXPL W/WO BIOPSY 3680.40 090 N 6735.30  J1 67405 ORBITOTOMY W/O BONE FLAP EXPL W/DRAINAGE ONLY 3154.68 090 N 4079.64  J1 67412 ORBITOTOMY W/O BONE FLAP W/REMOVAL LESION 3405.84 090 N 4084.75  J1 67413 ORBITOTOMY W/O BONE FLAP W/RMVL FOREIGN BODY 3408.60 090 Y 4070.24  J1 67414 ORBITOTOMY W/O BONE FLAP W/RMVL BONE DCMPRN 5194.80 090 Y 6721.45  J1 67415 FINE NEEDLE ASPIRATION ORBITAL CONTENTS 356.40 000 N 4038.25  J1 67420 ORBITOTOMY BONE FLAP/WINDOW LAT RMVL LESION 6164.40 090 Y 6697.14  J1 67430 ORBITOTOMY BONE FLAP/WINDOW LATERAL RMVL FB 4917.60 090 Y 6753.36  J1 67440 ORBITOTOMY BONE FLAP/WINDOW LATERAL W/DRG 4774.80 090 Y 6643.45  J1 67445 ORBITOTOMY BONE FLAP/WINDOW LAT RMVL BONE DCMPRN 5406.00 090 Y 6743.40  J1 67450 ORBITOTOMY BONE FLAP/WINDOW LAT EXPL W/WO BX 4940.40 090 Y 6734.79   67500 RETROBULBAR INJECTION MEDICATION SPX 266.40 000 N 379.37   67505 RETROBULBAR INJECTION ALCOHOL 303.60 000 N 379.37   67515 INJECTION MEDICATION/OTHER SUBST TENON CAPSULE 268.80 000 N 379.37   67516 SUPRACHOROIDAL SPACE NJX PHARMACOLOGIC AGENT 429.60 000 N 458.21

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 67550 ORBITAL IMPLANT INSERTION 3839.16 090 N 6397.80  J1 67560 ORBITAL IMPLANT REMOVAL/REVISION 3933.60 090 N 6600.91  J1 67570 OPTIC NERVE DECOMPRESSION 4685.10 090 Y 6726.52   67599 UNLISTED PROCEDURE ORBIT BR YYY Y 379.37   67700 BLEPHAROTOMY DRAINAGE ABSCESS EYELID 1028.40 010 N 379.37   67710 SEVERING TARSORRHAPHY 878.40 010 N 1174.43  J1 67715 CANTHOTOMY SEPARATE PROCEDURE 954.00 010 N 4076.57   67800 EXCISION CHALAZION SINGLE 451.20 010 N 379.37   67801 EXCISION CHALAZION MULTIPLE SAME LID 570.00 010 N 1174.43   67805 EXCISION CHALAZION MULTIPLE DIFFERENT LIDS 712.80 010 N 379.37  J1 67808 EXC CHALAZION ANES REQ HOSPIZATION SINGLE/MULT 1276.80 090 N 4087.40   67810 INCISIONAL BIOPSY EYELID SKIN W/LID MARGIN 666.00 000 N 379.37   67820 CORRECTION TRICHIASIS EPILATION FORCEPS ONLY 111.60 000 N 163.53   67825 CORRECTION TRICHIASIS EPILATION OTH/THAN FORCEPS 476.40 010 N 379.37   67830 CORRECTION TRICHIASIS INCCISION LID MARGIN 967.20 010 N 1174.43  J1 67835 CORRJ TRICHIASIS INC LID MRGN W/FR MUC MEMB GRF 1531.20 090 N 4058.69   67840 EXC LESION EYELID W/O CLSR/W/SIMPLE DIR CLOSURE 1006.80 010 N 1174.43   67850 DESTRUCTION LESION LID MARGIN < 1 CM 769.20 010 N 1174.43   67875 TEMPORARY CLOSURE EYELIDS SUTURE 651.60 000 N 1174.43  J1 67880 CONSTJ INTERMARGIN ADHES/TARSORRH/CANTHORRHAPY 1651.20 090 N 4073.40  J1 67882 CONSTJ INTERMARGIN ADHES/TARSOR/CANTHOR W/TRPOS 2013.60 090 N 4071.16  J1 67900 REPAIR BROW PTOSIS 2294.40 090 N 4076.16  J1 67901 RPR BLEPHAROPTOSIS FRONTALIS MUSC SUTR/OTH MATRL 2821.20 090 N 4065.23  J1 67902 RPR BLEPHAROPT FRONTALIS MUSC AUTOL FASCAL SLING 2524.80 090 N 6710.65  J1 67903 RPR BLEPHAROPTOSIS LEVATOR RESCJ/ADVMNT INTERNAL 2132.40 090 N 4085.46  J1 67904 RPR BLEPHAROPTOSIS LEVATOR RESCJ/ADVMNT XTRNL 2613.60 090 N 4086.59  J1 67906 RPR BLEPHAROPTOSIS SUPERIOR RECTUS FASCIAL SLING 1753.20 090 N 6667.76  J1 67908 RPR BLPOS CONJUNCTIVO-TARSO-MUSC-LEVATOR RESCJ 1916.40 090 N 4086.79  J1 67909 REDUCTION OVERCORRECTION PTOSIS 1944.00 090 N 4087.40  J1 67911 CORRECTION LID RETRACTION 1940.40 090 N 4029.77  J1 67912 CORRJ LAGOPHTHALMOS IMPLTJ UPR EYELID LID LOAD 3259.20 090 N 3900.91  J1 67914 REPAIR ECTROPION SUTURE 1742.40 090 N 4084.34  J1 67915 REPAIR ECTROPION THERMOCAUTERIZATION 1132.80 090 N 4087.40  J1 67916 REPAIR ECTROPION EXCISION TARSAL WEDGE 2172.00 090 N 4082.19  J1 67917 REPAIR ECTROPION EXTENSIVE 2218.80 090 N 4083.72  J1 67921 REPAIR ENTROPION SUTURE 1705.20 090 N 4086.18  J1 67922 REPAIR ENTROPION THERMOCAUTERIZATION 1096.80 090 N 4087.40  J1 67923 REPAIR ENTROPION EXCISION TARSAL WEDGE 2170.80 090 N 4085.97  J1 67924 REPAIR ENTROPION EXTENSIVE 2310.00 090 N 4084.75  J1 67930 SUTR WND EYELID/MARGIN/TARSUS/CONJUNC PRTL THICK 1314.00 010 N 4087.40  J1 67935 SUTR WND EYELID/MARGIN/TARSUS/CONJUNC FULL THICK 2118.00 090 N 4086.38   67938 REMOVAL EMBEDDED FOREIGN BODY EYELID 984.00 010 N 379.37  J1 67950 CANTHOPLASTY 2070.00 090 N 4067.78  J1 67961 EXCISION & REPAIR EYELID < ONE-FOURTH LID MARGIN 2076.00 090 N 4083.83  J1 67966 EXCISION & REPAIR EYELID ONE-FOURTH LID MARGIN 2738.40 090 N 4086.38  J1 67971 RCNSTJ EYELID FULL THICKNESS <TWO-THIRDS 1 STG 2498.40 090 N 4079.02  J1 67973 RCNSTJ EYELID FULL THICKNESS LOWER EYELID 1 STG 3207.60 090 Y 4076.06

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 216 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 67974 RCNSTJ EYELID FULL THICKNESS UPPER EYELID 1 STG 3200.40 090 Y 6728.71  J1 67975 RCNSTJ EYELID FULL THICKNESS SECOND STAGE 2365.20 090 N 4061.65   67999 UNLISTED PROCEDURE EYELIDS BR YYY N 379.37   68020 INCISION CONJUNCTIVA DRAINAGE OF CYST 424.80 010 N 1174.43   68040 EXPRESSION CONJUNCTIVAL FOLLICLES 217.20 000 N 379.37  J1 68100 BIOPSY CONJUNCTIVA 645.60 000 N 4061.86  J1 68110 EXCISION LESION CONJUNCTIVA <1 CM 840.00 010 N 4029.16  J1 68115 EXCISION LESION CONJUNCTIVA > 1 CM 1191.60 010 N 3997.28  J1 68130 EXCISION LESION CONJUNCTIVA ADJACENT SCLERA 1957.20 090 N 3972.96  J1 68135 DESTRUCTION LESION CONJUNCTIVA 547.20 010 N 4037.33   68200 SUBCONJUNCTIVAL INJECTION 146.40 000 N 393.60  J1 68320 CONJUNCTIVOPLASTY W/GRF/XTNSV REARRANGEMENT 2632.80 090 N 4046.63  J1 68325 CONJUNCTIVOPLASTY W/BUCCAL MUC MEMB GRAFT 2272.80 090 N 6631.80  J1 68326 CJP RCNSTJ CUL-DE-SAC BUCCAL GRF/XTNSV REARRGMT 2232.00 090 N 6662.70  J1 68328 CONJUNCTPL CUL-DE-SAC W/BUCCAL MUC MEMB GRAFT 2450.40 090 N 4027.93  J1 68330 RPR SYMBLEPHARON CONJUNCTIVOPLASTY W/O GRAFT 2204.40 090 N 4189.44  J1 68335 RPR SYMBLEPHARON FR GRF CJNC/BUCCAL MUC MEMB 2238.00 090 N 6502.48  J1 68340 RPR & DIV SYMBLEPHARON W/WO CONFORM/CONTACT LE 2150.40 090 N 3993.19  J1 68360 CONJUNCTIVAL FLAP BRIDGE/PARTIAL SPX 1921.20 090 N 6682.28  J1 68362 CONJUNCTIVAL FLAP TOTAL 2268.00 090 N 4021.08  J1 68371 HARVESTING CONJUNCIVAL ALLOGRAPHY LIVING DONOR 1432.80 010 N 4036.00   68399 UNLISTED PROCEDURE CONJUNCTIVA BR YYY N 379.37   68400 INCISION&DRAINAGE LACRIMAL GLAND 1064.40 010 N 1174.43  J1 68420 INCISION&DRAINAGE LACRIMAL SAC 1192.80 010 N 4082.50   68440 SNIP INCISION LACRIMAL PUNCTUM 364.80 010 N 379.37  J1 68500 EXCISION LACRIMAL GLAND XCPT TUMOR TOTAL 3735.60 090 N 6753.36  J1 68505 EXCISION LACRIMAL GLAND XCPT TUMOR PRTL 3718.80 090 N 6745.43  J1 68510 BIOPSY LACRIMAL GLAND 1606.80 000 N 4087.40  J1 68520 EXCISION LACRIMAL SAC 2595.60 090 N 6721.96  J1 68525 BIOPSY LACRIMAL SAC 902.40 000 N 4064.10   68530 RMVL FB/DACRYOLITH LACRIMAL PASSAGES 1546.80 010 N 379.37  J1 68540 EXC LACRIMAL GLAND TUMOR FRONTAL APPROACH 3452.40 090 N 4087.40  J1 68550 EXC LACRIMAL GLAND TUMOR W/OSTEOTOMY 4302.00 090 N 6753.36  J1 68700 PLASTIC REPAIR CANALICULI 2090.40 090 N 4060.02   68705 CORRECTION EVERTED PUNCTUM CAUTERY 938.40 010 N 379.37  J1 68720 DACRYOCSTORHINOSTOMY 2847.60 090 Y 6716.89  J1 68745 CONJUNCTIVORHINOSTOMY W/O TUBE 2860.80 090 Y 6737.15  J1 68750 CONJUNCTIVORHINOSTOMY INSJ TUBE/STENT 3028.80 090 Y 6655.78   68760 CLSR LACRIMAL PUNCTUM THERMOCAUT LIG/LASER 784.80 010 N 379.37   68761 CLSR LACRIMAL PUNCTUM PLUG EACH 520.80 010 N 379.37  J1 68770 CLOSURE LACRIMAL FISTULA SPX 2175.60 090 N 4087.40   68801 DILATION LACRIMAL PUNCTUM W/WO IRRGATION 339.60 010 N 393.60   68810 PROBE NASOLACRIMAL DUCT W/WO IRRIGATION 568.80 010 N 379.37  J1 68811 PROBE NASOLACRIMAL DUCT W/WO IRRIG REQ GEN ANES 465.60 010 N 4079.02  J1 68815 PROBE NASOLACRIMAL DUCT W/WO IRRG INSJ TUBE/STNT 1346.40 010 N 4025.89  J1 68816 PROBE NASOLACRIMAL DUCT WITH CATHETER DILATION 2829.00 010 N 4009.54   68840 PROBE LACRIMAL CANALICULI W/WO IRRIGATION 468.00 010 N 379.37

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  

20 Miss. Admin. Code Pt. 2, R. 68841 Rule 68841

INSJ RX ELUTING IMPLT PUNCTAL DILAT LAC CANAL EA 133.20 000 N 462.41   68850 INJECTION CONTRAST MEDIUM DACRYOCYSTOGRAPY 214.80 000 N   68899 UNLISTED PROCEDURE LACRIMAL SYSTEM BR YYY N 379.37   69000 DRAINAGE EXTERNAL EAR ABSCESS/HEMATOMA SIMPLE 672.00 010 N 902.47  J1 69005 DRAINAGE EXTERNAL EAR ABSCESS/HEMATOMA COMP 788.40 010 N 2873.98   69020 DRAINAGE EXTERNAL AUDITORY CANAL ABSCESS 849.60 010 N 902.47   69090 EAR PIERCING 92.40 XXX N   69100 BIOPSY EXTERNAL EAR 345.60 000 N 306.82  J1 69105 BIOPSY EXTERNAL AUDITORY CANAL 526.80 000 N 2761.63  J1 69110 EXCISION EXTERNAL EAR PARTIAL SIMPLE REPAIR 1699.20 090 N 4839.23  J1 69120 EXCISION EXTERNAL EAR COMPLETE AMPUTATION 1404.00 090 N 10388.02  J1 69140 EXCISION EXOSTOSIS EXTERNAL AUDITORY CANAL 3271.20 090 N 10344.39  J1 69145 EXCISION SOFT TIS LESION EXTERNAL AUDITORY CANAL 1491.60 090 N 4840.68  J1 69150 RAD EXC XTRNL AUDITORY CANAL LES W/O NCK DSJ 3628.80 090 N 10386.21   69155 RAD EXC XTRNL AUDITORY CANAL LES NCK DSJ 5816.40 090 Y   69200 RMVL FB XTRNL AUDITORY CANAL W/O ANES 285.60 000 N 163.53  J1 69205 RMVL FB XTRNL AUDITORY CANAL ANES 338.40 010 N 2868.67   69209 REMOVAL IMPACTED CERUMEN IRRIGATION/LVG UNILAT 54.00 000 N 80.73   69210 REMOVAL IMPACTED CERUMEN INSTRUMENTATION UNILAT 168.00 000 N 80.73   69220 DEBRIDEMENT MASTOIDECTOMY CAVITY SIMPLE 274.80 000 N 260.43   69222 DEBRIDEMENT MASTOIDECTOMY CAVITY CMPLX 780.00 010 N 655.90  J1 69300 OTOPLASTY PROTRUDING EAR W/WO SIZE RDCTJ 2326.80 YYY N 5587.68  J1 69310 RECONSTRUCTION EXTERNAL AUDITORY CANAL SPX 4052.40 090 N 10335.82  J1 69320 RCNSTJ XTRNL AUD CANAL CONGENITAL ATRESIA 1 STG 5637.60 090 Y 10303.62   69399 UNLISTED PROCEDURE EXTERNAL EAR BR YYY N 306.82   69420 MYRINGOTOMY ASPIR&/EUSTACHIAN TUBE NFLTJ 686.40 010 N 306.82  J1 69421 MYRINGOTOMY ASPIR&/EUSTACHIAN TUBE NFLTJ ANES 540.00 010 N 5463.49   69424 VENTILATING TUBE RMVL REQUIRING GENERAL ANES 465.60 000 N 3967.45   69433 TYMPANOSTOMY LOCAL/TOPICAL ANESTHESIA 724.80 010 N 655.90  J1 69436 TYMPANOSTOMY GENERAL ANESTHESIA 566.40 010 N 2732.21  J1 69440 MIDDLE EAR EXPL THRU POSTAUR/EAR CANAL INC 2491.20 090 N 5566.45  J1 69450 TYMPANOLYSIS TRANSCANAL 1981.20 090 N 5572.04  J1 69501 TRANSMASTOID ANTROTOMY 2553.60 090 N 10314.26  J1 69502 MASTOIDECTOMY COMPLETE 3385.20 090 N 10249.08  J1 69505 MASTOIDECTOMY MODIFIED RADICAL 4441.20 090 N 10369.84  J1 69511 MASTOIDECTOMY RADICAL 4543.20 090 N 10315.04  J1 69530 PETROUS APICECTOMY RADICAL MASTOIDECTOMY 6039.60 090 Y 10317.38   69535 RESCJ TEMPORAL BONE EXTERNAL APPROACH 9562.80 090 N  J1 69540 EXCISION AURAL POLYP 765.60 010 N 2762.74  J1 69550 EXCISION AURAL GLOMUS TUMOR TRANSCANAL 3844.80 090 Y 10336.34  J1 69552 EXCISION AURAL GLOMUS TUMOR TRANSMASTOID 5716.80 090 Y 10349.85   69554 EXCISION AURAL GLOMUS TUMOR EXTENDED 9067.20 090 Y  J1 69601 REVJ MASTOIDECTOMY RSLTG COMPL MASTOIDECTOMY 3660.00 090 N 10357.12  J1 69602 REVJ MASTOIDECTOMY RSLTG MODF RAD MSTDC 3916.80 090 N 10322.58  J1 69603 REVJ MASTOIDECTOMY RSLTG RAD MASTOIDECTOMY 4639.20 090 N 10366.47  J1 69604 REVJ MASTOIDECTOMY RSLTG TYMPANOPLASTY 4000.80 090 N 10290.63  J1 69610 TYMPANIC MEMB RPR W/WO PREPJ PERFOR PATCH 1371.60 010 N 2748.71  J1 69620 MYRINGOPLASTY 2684.40 090 N 5550.94

Surgery Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 0232T, 10004-69990 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 218 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  J1 69631 TYMPANOPLASTY W/O MASTOIDECT W/O OSSICLE RECNSTJ 3205.20 090 N 10319.20  J1 69632 TYMPNOPLSTY W/O MSTDC 1ST/REVJ W/OSICLE RECNSTJ 3910.80 090 N 10169.86  J1 69633 TYMPANOPLASTY W/O MASTOIDEC 1ST/REVJ PROSTH TORP 3787.20 090 N 10075.07  J1 69635 TYMPP ANTRT/MASTOID W/O OSSICULAR CHAIN RECNSTJ 4581.60 090 N 10346.73  J1 69636 TYMPP ANTRT/MASTOID W/OSSICULAR CHAIN RECNSTJ 5089.20 090 N 10213.76  J1 69637 TMPP ANTRT/MASTOIDOTOMY PROSTHESIS TORP 5190.00 090 N 10051.69  J1 69641 TMPP MASTOIDECTOMY W/O OSSICULAR CHAIN RECNSTJ 3753.60 090 N 10332.44  J1 69642 TMPP MASTOIDECTOMY W/OSSICULAR CHAIN RECNSTJ 4815.60 090 N 10234.01  J1 69643 TMPP MASTOIDECT NTC/RCNSTED WALL W/O OCR 4406.40 090 N 10322.58  J1 69644 TMPP MASTOIDECT NTC/RCNSTED CANAL WALL OCR 5437.20 090 N 10215.57  J1 69645 TYMPANOPLASTY MASTOIDECTOMY RAD/COMPL W/O OCR 5350.80

20 Miss. Admin. Code Pt. 2, R. 090 Rule 090

N 10326.73  J1 69646 TYMPANOPLASTY MASTOIDECTOMY RAD/COMPL W/OCR 5662.80 090 N 10215.83  J1 69650 STAPES MOBILIZATION 2893.20 090 N 5566.45  J1 69660 STAPEDECTOMY/STAPEDOTOMY 3324.00 090 N 10133.76  J1 69661 STAPEDECTOMY/STAPEDOTOMY W/FOOTPLATE DRILL OUT 4320.00 090 N 10177.66  J1 69662 REVISION STAPEDECTOMY/STAPEDOTOMY 4156.80 090 N 10107.27  J1 69666 REPAIR OVAL WINDOW FISTULA 2908.80 090 N 5574.83  J1 69667 REPAIR ROUND WINDOW FISTULA 2910.00 090 N 5586.84  J1 69670 MASTOID OBLITERATION SEPARATE PROCEDURE 3405.60 090 Y 10267.52  J1 69676 TYMPANIC NEURECTOMY 3006.00 090 N 5548.71  J1 69700 CLOSURE POSTAURICULAR FISTULA MASTOID SPX 2391.60 090 N 2763.08  J1 69705 SURG NASOPHARYNGOSCOPY DILAT EUSTACHIAN TUBE UNI 10201.20 000 N 9276.71  J1 69706 SURG NASOPHARYNGOSCOPY DILAT EUSTACHIAN TUBE BI 10530.00 000 N 9276.71   69710 IMPLTJ/RPLCMT EMGNT BONE CNDJ DEV TEMPORAL BONE 3990.00 XXX N 3952.42  J1 69711 RMVL/RPR EMGNT BONE CNDJ DEV TEMPORAL BONE 3014.40 090 Y 5458.32  J1 69714 IMPL OI IMPLT SKULL PERQ ATTACHMENT ESP 3656.40 090 N 21148.54  J1 69716 IMPL OI IMPLT SKULL MAG TC ATTACHMENT ESP<100 2157.60 090 N 23234.62  J1 69717 RPLCMT OI IMPLT SKULL PERQ ATTACHMENT ESP 3831.60 090 N 10851.96  J1 69719 RPLCMT OI IMPLT SKULL MAG TC ATTACHMENT ESP<100 2157.60 090 N 23234.62  J1 69720 DCMPRN FACIAL NRV INTRATEMPORAL LAT GANGLION 4267.20 090 N 10388.54  J1 69725 DCMPRN NRV INTRATEMPORAL MEDIAL GENICULATE 6679.20 090 Y 10388.54  J1 69726 REMOVAL ENTIRE OI IMPLT SKL PERQ ATTACHMENT ESP 1468.80 090 N 5710.81  J1 69727 REMOVAL ENTIRE OI IMPLT SKL MAG TC ATTCH ESP<100 1680.00 090 N 5710.81  J1 69728 RMVL ENTIRE OI IMPLT SKL MAG TC ATTCH ESP>=100 2137.20 090 N 5869.38  J1 69729 IMPL OI IMPLT SKULL MAG TC ATTACHMENT ESP>=100 2420.40 090 N 24073.71  J1 69730 RPLCMT OI IMPLT SKULL MAG TC ATTACHMENT ESP>=100 2476.80 090 N 24073.71  J1 69740 SUTR NRV ITPRL W/WO GRF/DCMPRN LAT GENICULATE 4158.00 090 Y 10272.97  J1 69745 SUTR NRV ITPRL W/WO GRF/DCMPRN MEDIAL GENICULATE 4434.00 090 Y 10272.97   69799 UNLISTED PROCEDURE MIDDLE EAR BR YYY N 306.82  J1 69801 LABYRINTHOTOMY TRANSCANAL 804.54 000 N 2762.81  J1 69805 ENDOLYMPHATIC SAC W/O SHUNT 3679.20 090 Y 10330.63  J1 69806 ENDOLYMPHATIC SAC SHUNT 3307.20 090 N 10247.52  J1 69905 LABYRINTHECTOMY TRANSCANAL 3306.00 090 N 10349.85  J1 69910 LABYRINTHECTOMY W/MASTOIDECTOMY 3552.00 090 N 10335.04  J1 69915 VESTIBULAR NRV SECTION TRANSLABYRINTHINE APPR 5370.00 090 Y 5564.91  J1 69930 COCHLEAR DEVICE IMPLANTATION W/WO MASTOIDECTOMY 4354.80 090 N 56091.84   69949 UNLISTED PROCEDURE INNER EAR BR YYY N 306.82   69950 VESTIBULAR NRV SECTION TRANSCRANIAL APPROACH 6216.00 090 Y

 J1 69955 TOTAL FACIAL NERVE DECOMPRESSION &/REPAIR 7023.60 090 Y 10382.31  J1 69960 DECOMPRESSION INTERNAL AUDITORY CANAL 6720.00 090 Y 10028.32  J1 69970 REMOVAL TUMOR TEMPORAL BONE 7592.40 090 Y 10371.14   69979 UNLISTED PROCEDURE TEMPORAL BONE MIDDLE FOSSA BR YYY N 306.82   69990 MICROSURG TQS REQ USE OPERATING MICROSCOPE 768.00 ZZZ Y

CPT Copyright 2024 American Medical Association. All rights reserved. 219 RADIOLOGY I. SCOPE The following guidelines apply to radiology services provided in offices, clinics, and under some circumstances in hospital imaging departments. This section also contains guidelines that include nuclear medicine and diagnostic ultrasound.

Note: Rules used by all physicians or other qualified health care professionals (OQHP) in reporting their services are presented in the General Rules section. See the Modifier and Code Rules section for detailed information on modifiers. II. GUIDELINES A. Total Fee. A total fee includes both the professional component for the radiologist and the technical component needed to accomplish the procedure. Explanations of the professional component and the technical component are listed below. The values as listed in the MAR column represent the total reimbursement. B. Professional Component. The professional component represents the reimbursement allowance of the professional radiological services of the physician or OQHP and is identified by the use of modifier 26. This includes examination of the injured worker when indicated, performance or supervision of the procedure, interpretation and written report of the examination, and consultation with the referring physician or OQHP. In the majority of hospital radiology departments, the radiologist submits a separate statement to the injured worker for professional services rendered, which are listed as the professional component. Values in the PC MAR column are intended for the services of a radiologist for the professional component only and do not include any other charges. To identify a charge for a professional component only, use the five-digit code followed by modifier 26. C. Technical Component. The technical component includes charges made by the institution or clinic to cover the services of technologists and other staff members, the film, contrast media, chemicals and other materials, and the use of the space and facilities of the imaging department. To identify a charge for a technical component only, use the five- digit code followed by HCPCS modifier TC. The technical component amount is listed in the TC MAR column of the Fee Schedule. Outpatient facilities are paid based on the TC MAR when there is one. If there is no TC amount, and the service is payable in an outpatient setting, there will be an APC MAR which should be used D. Review of X-rays. Billing code 76140 is not appropriate in the following circumstances because review of the x-rays is inherent to the evaluation and management code: • The physician or OQHP, during the course of an office visit or consultation, reviews an x-ray made elsewhere; • The treating or consulting physician or OQHP reviews x-rays at an emergency room or hospital visit; • CPT ® code 76140, Consultation on x-ray examination made elsewhere, written report, will only be paid when there is a documented need for the service and when performed by a radiologist or physician or OQHP certified to perform radiological services; This provision is for payment of a second interpretation under unusual circumstances such as a questionable finding for which the physician or OQHP performing the initial interpretation requests the expertise of another physician or OQHP (i.e., expertise of a radiologist). CPT code 76140 is to be used when a second opinion is required for a radiological procedure.

E. Additional Imaging. No payment shall be made for additional imaging when recent images are available except when supported by adequate information regarding the need to take new images. The use of photographic or digital media and/or imaging is not reported separately, but is considered to be a component of the basic procedure and shall not merit any additional payment. F. Comparison Imaging. Comparison imaging is reimbursable when appropriate. Any repeat comparison image requires prior authorization and will not be reimbursed without prior authorization. G. Contrast Material 1. Complete procedures, interventional radiological procedures, or diagnostic studies involving injection of contrast media include all usual pre- injection and post-injection services (e.g., necessary local anesthesia, placement of needle catheter, injection of contrast media, supervision of the study, and interpretation of results). 2. Low osmolar contrast material and paramagnetic contrast materials should only be billed when not included in the descriptor of the procedure. When appropriately billed, the contrast media is reimbursed according to the lesser of the billed charges or MAR listed in the HCPCS section of the Fee Schedule. Supplies are considered incidental to the administration of the contrast and are not separately reimbursable. 3. When contrast can be administered orally (upper G.I.) or rectally (barium enema), the administration of contrast is included as part of the procedure and not separately reimbursed. 4. When an intravenous line is placed simply for access in the event of a problem with a procedure or for administration of contrast, it is considered part of the procedure and is not separately reimbursed.

Radiology Mississippi Workers’ Compensation Medical Fee Schedule

20 Miss. Admin. Code Pt. 2, R. 220 Rule 220

CPT Copyright 2024 American Medical Association. All rights reserved. H. Urologic Procedures. In the case of urologic procedures (e.g., CPT codes 74400–74485), insertion of a urethral catheter is part of the procedure and is not separately billed. I. Vertebral Motion Analysis (VMA). Vertebral Motion Analysis, generally done on the cervical and lumbar spine, is typically billed with CPT code 76496, unlisted fluoroscopic procedure (e.g., diagnostic, interventional). There is no specific CPT code for this radiological test. For the cervical spine, pay the combination of 76000 and 72052. For the lumbar spine, pay the combination of 76000 and 72110. J. Separate or Multiple Procedures 1. When multiple procedures are performed on the same day or at the same session, it is appropriate to designate them by separate entries. Surgical procedures performed in conjunction with a radiology procedure will be subject to the rules and regulations of the Surgery section. 2. When images of multiple sections of a body area are billed separately, the total reimbursement must not exceed the maximum reimbursement allowance of the complete body area. K. Outpatient CT Scans and MRI Imaging. CT scans and MRI imaging, when performed on an outpatient basis, are subject to the Fee Schedule, regardless of site of service. L. Unlisted Service or Procedure. When reporting a service or procedure that is not listed in this Fee Schedule, use the appropriate unlisted procedure code. The bill must be accompanied by a Special Report as described below. If a HCPCS or CPT code has been established subsequent to the release of this Fee Schedule, include the code(s) with the Special Report. M. Special Report. Any test/service that is not provided routinely or is an unlisted service or procedure should be reported with the appropriate unlisted service or procedure code designating the service and the billing for that test/service should include a description of the procedure, the process used, and a full report of the findings. Additional information provided should include an acceptable definition or description of the extent and nature of the procedure, as well as information regarding the need for the procedure. Also essential are data regarding the equipment necessary to perform the service, as well as the time and effort required. Special reports to justify the necessity of a service do not warrant a separate fee. N. By Report (BR). “BR” in the MAR column indicates services that are too new, unusual, or variable in the nature of their performance to permit the assignment of a definable fee. Such services should be substantiated by documentation submitted with the bill. Sufficient information should be included to permit proper identification and a sound evaluation. For more information, please see Definitions in the Introduction. O. Radiology Supervision and Interpretation Procedures. There are times when a single physician or OQHP may perform the procedure and supervise the imaging and interpretation. On other occasions, one physician or OQHP may perform the procedure, and the imaging supervision with interpretation may be performed by another physician or OQHP. The appropriate radiology codes are to be used for supervision and interpretation of the imaging. The appropriate surgical codes are to be used for the procedure, including necessary local anesthesia, placement of needle or catheters, injection of contrast media, etc. The surgical codes are subject to the rules and regulations of the Surgery section, and the radiology codes are subject to this section of radiology rules and regulations. P. Written Report(s). A written report, signed by the interpreting physician or OQHP should be considered an integral part of a radiological procedure or interpretation and must be submitted with the billing. Q. Facility Fee. Outpatient facilities are paid based on the TC MAR when there is one. If there is no TC amount, and the service is payable in an outpatient setting, there will be an APC MAR which should be used.

Mississippi Workers’ Compensation Medical Fee Schedule Radiology 70010-79999 Effective June 1, 2026 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine CPT Copyright 2024 American Medical Association. All rights reserved. 221

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   70010 MYELOGRAPY POST FOSSA RS&I 109.86 XXX N 534.05   70015 CISTERNOGRAPHY POSITIVE CONTRAST RS&I 317.66 107.95 209.71 XXX N   70030 RADIOLOGIC EXAMINATION EYE DETECT FOREIGN BODY 60.62 16.51 44.11 XXX N   70100 RADIOLOGIC EXAMINATION MANDIPLE PRTL <4 VIEWS 70.84 16.51 54.33 XXX N   70110 RADIOLOG EXAM MANDIBLE COMPL MINIMUM 4 VIEWS 82.52 22.86 59.66 XXX N   70120 RADIOLOGIC EXAM MASTOIDS < 3 VIEWS PER SIDE 70.84 16.51 54.33 XXX N   70130 RADEX MASTOIDS COMPL MINIMUM 3 VIEWS PR SIDE 117.58 31.12 86.46 XXX N   70134 RADEX INTERNAL AUDITORY MEATI COMPLETE 110.27 32.39 77.88 XXX N   70140 RADEX FACIAL BONES < 3 VIEWS 60.96 18.42 42.54 XXX N   70150 RADEX FACIAL BONES COMPLETE MINIMUM 3 VIEWS 89.83 24.13 65.70 XXX N   70160 RADEX NASAL BONES COMPLETE MINIMUM 3 VIEWS 70.84 15.88 54.96 XXX N   70170 DACRYOCSTOGRAPY NASOLACRIMAL DUCT RS&I 93.98 27.31 66.67 XXX N   70190 RADEX OPTIC FORAMINA 72.39 20.32 52.07 XXX N   70200 RADEX ORBITS COMPLETE MINIMUM 4 VIEWS 90.55 25.40 65.15 XXX N   70210 RADEX SINUSES PARANASAL <3 VIEWS 61.60 15.88 45.72 XXX N   70220 RADEX SINUSES PARANASAL COMPL MINIMUM 3 VIEWS 71.76 22.86 48.90 XXX N   70240 RADIOLOGIC EXAMINATION SELLA TURCICA 62.87 17.78 45.09 XXX N   70250 RADIOLOGIC EXAMINATION SKULL 4< VIEWS 67.95 22.86 45.09 XXX N   70260 RADIOLOGIC EXAM SKULL COMPLETE MINIMUM 4 VIEWS 85.09 31.75 53.34 XXX N   70300 RADIOLOGIC EXAMINATION TEETH 1 VIEW 25.40 10.16 15.24 XXX N   70310 RADIOLOGIC EXAM TEETH PRTL EXAM < FULL MOUTH 72.39 14.61 57.78 XXX N   70320 RADIOLOGIC EXAM TEETH COMPLETE FULL MOUTH 103.51 22.23 81.28 XXX N   70328 RADEX TEMPOROMANDBLE JT OPN & CLSD MOUTH UNILAT 65.00 16.51 48.49 XXX N   70330 RADEX TEMPOROMANDBLE JT OPN & CLSD MOUTH BILAT 101.51 22.23 79.28 XXX N   70332 TEMPOROMANDBLE JT ARTHROGRAPHY RS&I 157.01 49.53 107.48 XXX N   70336 MRI TEMPOROMANDIBULAR JOINT 562.61 132.72 429.89 XXX N   70350 CEPHALOGRAM ORTHODONTIC 33.66 17.78 15.88 XXX N   70355 ORTHOPANTOGRAM 35.56 19.69 15.87 XXX N   70360 RADIOLOGIC EXAMINATION NECK SOFT TISSUE 59.69 16.51 43.18 XXX N   70370 RADEX PHARYNX/LARX W/FLUOR&/MAGNIFICATION TQ 165.77 27.94 137.83 XXX N   70371 CPLX DYNAMIC PHARYNGEAL&SP EVAL C/V REC 198.76 76.84 121.92 XXX N   70380 RADIOLOGIC EXAMINATION SALIVARY GLAND CALCULUS 69.38 15.24 54.14 XXX N   70390 SIALOGRAPHY RS&I 211.77 34.29 177.48 XXX N   70450 CT HEAD/BRAIN W/O CONTRAST MATERIAL 207.65 76.84 130.81 XXX N   70460 CT HEAD/BRAIN W/CONTRAST MATERIAL 292.74 102.87 189.87 XXX N   70470 CT HEAD/BRAIN W/O & W/CONTRAST MATERIAL 343.54 114.94 228.60 XXX N   70480 CT ORBIT SELLA/POST FOSSA/EAR W/O CONTRAST MATRL 415.93 115.57 300.36 XXX N   70481 CT ORBIT SELLA/POST FOSSA/EAR W/CONTRAST MATRL 492.76 125.10 367.66 XXX N   70482 CT ORBIT SELLA/POST FOSSA/EAR W/O & W/CONTR MATR 536.58 130.81 405.77 XXX N   70486 CT MAXILLOFACIAL W/O CONTRAST MATERIAL 251.46 77.47 173.99 XXX N   70487 CT MAXILLOFACIAL W/CONTRAST MATERIAL 299.72 101.60 198.12 XXX N   70488 CT MAXILLOFACIAL W/O & W/CONTRAST MATERIAL 366.40 114.94 251.46 XXX N   70490 CT SOFT TISSUE NECK W/O CONTRAST MATERIAL 295.91 115.57 180.34 XXX N   70491 CT SOFT TISSUE NECK W/CONTRAST MATERIAL 365.13 125.10 240.03 XXX N   70492 CT SOFT TISSUE NECK W/O & W/CONTRAST MATERIAL 439.42 146.05 293.37 XXX N   70496 CT ANGIOGRAPHY HEAD W/CONTRAST/NONCONTRAST 544.83 158.12 386.71 XXX N

Radiology Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 70010-79999 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 222 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   70498 CT ANGIOGRAPHY NECK W/CONTRAST/NONCONTRAST 544.20 158.12 386.08 XXX N   70540 MRI ORBIT FACE &/NECK W/O CONTRAST 474.98 121.92 353.06 XXX N   70542 MRI ORBIT FACE & NECK W/CONTRAST MATERIAL 564.52 146.69 417.83 XXX N   70543 MRI ORBIT FACE & NECK W/O & W/CONTRAST MATRL 709.30 193.04 516.26 XXX N   70544 MRA HEAD W/O CONTRST MATERIAL 497.84 108.59 389.25 XXX N   70545 MRA HEAD W/CONTRAST MATERIAL 494.03 108.59 385.44 XXX N   70546 MRA HEAD W/O & W/CONTRAST MATERIAL 730.25 133.35 596.90 XXX N   70547 MRA NECK W/O CONTRST MATERIAL 499.75 108.59 391.16 XXX N   70548 MRA NECK W/CONTRAST MATERIAL 549.91 135.89 414.02 XXX N   70549 MRA NECK W/O &W/CONTRAST MATERIAL 763.27 162.56 600.71 XXX N   70551 MRI BRAIN BRAIN STEM W/O CONTRAST MATERIAL 405.13 133.99 271.14 XXX N   70552 MRI BRAIN BRAIN STEM W/CONTRAST MATERIAL 562.61 161.29 401.32 XXX N   70553 MRI BRAIN BRAIN STEM W/O W/CONTRAST MATERIAL 663.58 206.38 457.20 XXX N   70554 MRI BRAIN FUNCTIONAL W/O PHYSICIAN ADMNISTRATION 787.40 190.50 596.90 XXX N   70555 MRI BRAIN FUNCTIONAL W/PHYSICIAN ADMNISTRATION 1337.31 227.33 1109.98 XXX N   70557 MRI BRAIN OPEN INTRACRANIAL PX W/O CONTRAST MATL 2562.81 296.55 2266.26 XXX N   70558 MRI BRAIN OPEN INTRACRANIAL PX W/CONTRAST MATL 2821.66 314.33 2507.33 XXX N   70559 MRI BRAIN OPEN INTRACRANIAL PX W/O & W/CONTRAST 2846.05 296.55 2549.50 XXX N   71045 RADIOLOGIC EXAM CHEST SINGLE VIEW 48.90 16.51 32.39 XXX N   71046 RADIOLOGIC EXAM CHEST 2 VIEWS 63.50 19.69 43.81 XXX N   71047 RADIOLOGIC EXAM CHEST 3 VIEWS 80.01 25.40 54.61 XXX N   71048 RADIOLOGIC EXAM CHEST 4+ VIEWS 87.63 29.21 58.42 XXX N   71100 RADEX RIBS UNILATERAL 2 VIEWS 69.85 20.32 49.53 XXX N   71101 RADEX RIBS UNI W/POSTEROANT CH MINIMUM 3 VIEWS 80.01 24.77 55.24 XXX N   71110 RADEX RIBS BILATERAL 3 VIEWS 83.19 26.67 56.52 XXX N   71111 RADEX RIBS BI W/POSTEROANT CH MINIMUM 4 VIEWS 99.70 29.85 69.85 XXX N   71120 RADEX STERNUM MINIMUM 2 VIEWS 64.14 18.42 45.72 XXX N   71130 RADEX STERNOCLAVICULAR JT/JTS MINIMUM 3 VIEWS 76.68 19.69 56.99 XXX N   71250 DIAGNOSTIC COMPUTED TOMOGRAPHY THORAX W/O CNTRST 283.85 105.41 178.44 XXX N   71260 DIAGNOSTIC COMPUTED TOMOGRAPHY THORAX W/CONTRAST 351.16 112.40 238.76 XXX N   71270 DIAGNOSTIC COMPUTED TOMOGRAPHY THORAX C-/C+ 416.56 125.10 291.46 XXX N   71271 COMPUTED TOMOGRAPHY THORAX LW DOSE LNG CA SCR C- 269.88 96.52 173.36 XXX N   71275 CT ANGIOGRAPHY CHEST W/CONTRAST/NONCONTRAST 556.26 164.47 391.79 XXX N   71550 MRI CHEST W/O CONTRAST MATERIAL 724.54 131.45 593.09 XXX N   71551 MRI CHEST W/CONTRAST MATERIAL 802.01 156.21 645.80 XXX N   71552 MRI CHEST W/O & W/CONTRAST MATERIAL 1012.83 203.84 808.99 XXX N   71555 MRA CHEST W/O & W/CONTRAST MATERIAL 700.41 161.29 539.12 XXX N   72020 RADEX SPINE 1 VIEW SPECIFY LEVEL 46.36 14.61 31.75 XXX N   72040 RADEX SPINE CERVICAL 2 OR 3 VIEWS 74.93 20.32 54.61 XXX N   72050 RADEX SPINE CERVICAL 4 OR 5 VIEWS 100.97 28.58 72.39 XXX N   72052 RADEX SPINE CERVICAL 6 OR MORE VIEWS 117.48 33.02 84.46 XXX N   72070 RADEX SPINE THORACIC 2 VIEWS 62.23 20.32 41.91 XXX N   72072 RADEX SPINE THORACIC 3 VIEWS 74.30 20.32 53.98 XXX N   72074 RADEX SPINE THORACIC MINIMUM 4 VIEWS 81.79 22.23 59.56 XXX N   72080 RADEX SPINE THORACOLUMBAR JUNCTION MIN 2 VIEWS 66.04 20.32 45.72 XXX N   72081 RADEX ENTIR THRC LMBR CRV SAC SPI W/SKULL 1 VW 80.65 24.77 55.88 XXX N

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   72082 RADEX ENTIR THRC LMBR CRV SAC SPI W/SKULL 2/3 VW 133.35 29.21 104.14 XXX N   72083 RADEX ENTIR THRC LMBR CRV SAC SPI W/SKULL 4/5 VW 149.23 33.02 116.21 XXX N   72084 RADEX ENTIR THRC LMBR CRV SAC SPI W/SKULL 6/> VW 184.02 38.10 145.92 XXX N   72100 RADEX SPINE LUMBOSACRAL 2/3 VIEWS 75.22 20.32 54.90 XXX N   72110 RADEX SPINE LUMBOSACRAL MINIMUM 4 VIEWS 97.16 28.58 68.58 XXX N   72114 RADEX SPINE LUMBSCRL COMPL W/BENDING VIEWS MIN 6 117.48 29.85 87.63 XXX N   72120 RADEX SPINE LUMBOSACRAL ONLY BENDING 2/3 VIEWS 77.47 20.32 57.15 XXX N   72125 CT CERVICAL SPINE W/O CONTRAST MATERIAL 328.93 96.52 232.41 XXX N   72126 CT CERVICAL SPINE W/CONTRAST MATERIAL 406.40 110.49 295.91 XXX N   72127 CT CERVICAL SPINE W/O &W/CONTRAST MATERIAL 481.33 114.30 367.03 XXX N   72128 CT THORACIC SPINE W/O CONTRAST MATERIAL 322.58 90.81 231.77 XXX N   72129 CT THORACIC SPINE W/CONTRAST MATERIAL 408.94 110.49 298.45 XXX N   72130 CT THORACIC SPINE W/O & W/CONTRAST MATERIAL 481.97 114.30 367.67 XXX N   72131 CT LUMBAR SPINE W/O CONTRAST MATERIAL 321.31 90.81 230.50 XXX N   72132 CT LUMBAR SPINE W/CONTRAST MATERIAL 407.04 110.49 296.55 XXX N   72133 CT LUMBAR SPINE W/O & W/CONTRAST MATERIAL 480.06 114.94 365.12 XXX N   72141 MRI SPINAL CANAL CERVICAL W/O CONTRAST MATRL 394.97 134.62 260.35 XXX N   72142 MRI SPINAL CANAL CERVICAL W/CONTRAST MATRL 573.41 161.93 411.48 XXX N   72146 MRI SPINAL CANAL THORACIC W/O CONTRAST MATRL 395.61 134.62 260.99 XXX N   72147 MRI SPINAL CANAL THORACIC W/CONTRAST MATRL 570.23 161.29 408.94 XXX N   72148 MRI SPINAL CANAL LUMBAR W/O CONTRAST MATERIAL 395.61 134.62 260.99 XXX N   72149 MRI SPINAL CANAL LUMBAR W/CONTRAST MATERIAL 566.42 161.93 404.49 XXX N   72156 MRI SPINAL CANAL CERVICAL W/O & W/CONTR MATRL 668.02 206.38 461.64 XXX N   72157 MRI SPINAL CANAL THORACIC W/O & W/CONTR MATRL 669.93 206.38 463.55 XXX N   72158 MRI SPINAL CANAL LUMBAR W/O & W/CONTR MATRL 666.75 206.38 460.37 XXX N   72159 MRA SPINAL CANAL W/WO CONTRAST MATERIAL 725.81 162.56 563.25 XXX N   72170 RADIOLOGIC EXAMINATION PELVIS 1/2 VIEWS 59.06 15.88 43.18 XXX N   72190 RADIOLOGIC EXAM PELVIS COMPL MINIMUM 3 VIEWS 80.01 22.64 57.37 XXX N   72191 CT ANGIOGRAPHY PELVIS W/CONTRAST/NONCONTRAST 607.70 162.56 445.14 XXX N   72192 CT PELVIS W/O CONTRAST MATERIAL 261.62 98.43 163.19 XXX N   72193 CT PELVIS W/CONTRAST MATERIAL 461.65 105.41 356.24 XXX N   72194 CT PELVIS W/O & W/CONTRAST MATERIAL 509.27 109.86 399.41 XXX N   72195 MRI PELVIS W/O CONTRAST MATERIAL 483.87 132.08 351.79 XXX N   72196 MRI PELVIS W/CONTRAST MATERIAL 565.15 156.85 408.30 XXX N   72197 MRI PELVIS W/O & W/CONTRAST MATERIAL 713.74 198.76 514.98 XXX N   72198 MRA PELVIS W/WO CONTRAST MATERIAL 704.22 160.66 543.56 XXX N   72200 RADIOLOGIC EXAMINATION SACROILIAC JNTS <3 VIEWS 62.23 15.88 46.35 XXX N   72202 RADIOLOGIC EXAM SACROILIAC JOINTS 3/MORE VIEWS 71.56 19.72 51.84 XXX N   72220 RADEX SACRUM & COCCYX MINIMUM 2 VIEWS 61.60 15.88 45.72 XXX N   72240 MYELOGRAPHY CERVICAL RS&I 214.69 82.55 132.14 XXX N   72255 MYELOGRAPHY THORACIC RS&I 218.35 85.73 132.62 XXX N   72265 MYELOGRAPY LUMBOSACRAL RS&I 200.82 74.30 126.52 XXX N   72270 MYELOGRAPY 2/MORE REGIONS RS&I 278.96 125.10 153.86 XXX N   72285 DISKOGRAPY CERVICAL/THORACIC RS&I 0.00 0.00 0.00 XXX N   72295 DISKOGRAPY LUMBAR RS&I 211.77 78.11 133.66 XXX N   73000 RADEX CLAVICLE COMPLETE 59.88 15.24 44.64 XXX N   73010 RADEX SCAPULA COMPLETE 57.15 16.51 40.64 XXX N

Radiology Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 70010-79999 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 224 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   73020 RADEX SHOULDER 1 VIEW 42.55 14.61 27.94 XXX N   73030 RADEX SHOULDER COMPLETE MINIMUM 2 VIEWS 62.08 17.15 44.93 XXX N   73040 RADEX SHOULDER ARTHROGRAPHY RS&I 227.84 50.80 177.04 XXX N   73050 RADEX A-C JOINTS BI W/WO WEIGHTED DISTRCJ 66.68 19.05 47.63 XXX N   73060 RADEX HUMERUS MINIMUM 2 VIEWS 60.33 15.24 45.09 XXX N   73070 RADEX ELBOW 2 VIEWS 55.25 15.24 40.01 XXX N   73080 RADEX ELBOW COMPLETE MINIMUM 3 VIEWS 61.34 15.88 45.46 XXX N   73085 RADEX ELBOW ARTHROGRAPHY RS&I 216.54 52.07 164.47 XXX N   73090 RADEX FOREARM 2 VIEWS 55.25 15.24 40.01 XXX N   73092 RADEX UPPER EXTREMITY INFANT MINIMUM 2 VIEWS 59.16 14.61 44.55 XXX N   73100 RADEX WRIST 2 VIEWS 64.14 15.24 48.90 XXX N   73110 RADEX WRIST COMPLETE MINIMUM 3 VIEWS 75.22 15.88 59.34 XXX N   73115 RADEX WRIST ARTHROGRAPHY RS&I 243.18 51.44 191.74 XXX N   73120 RADEX HAND 2 VIEWS 59.06 15.24 43.82 XXX N   73130 RADEX HAND MINIMUM 3 VIEWS 68.64 15.88 52.76 XXX N   73140 RADEX FINGR MINIMUM 2 VIEWS 69.38 12.70 56.68 XXX N   73200 CT UPPER EXTREMITY W/O CONTRAST MATERIAL 322.58 90.81 231.77 XXX N   73201 CT UPPER EXTREMITY W/CONTRAST MATERIAL 399.42 105.41 294.01 XXX N   73202 CT UPPER EXTREMITY W/O & W/CONTRAST MATERIAL 501.02 110.49 390.53 XXX N   73206 CT ANGIOGRAPHY UPPER EXTREMITY 592.46 161.93 430.53 XXX N   73218 MRI UPPER EXTREMITY OTH THAN JT W/O CONTR MATRL 642.62 122.56 520.06 XXX N   73219 MRI UPPER EXTREMITY OTH THAN JT W/CONTR MATRL 705.49 146.69 558.80 XXX N   73220 MRI UPPER EXTREM OTHER THAN JT W/O & W/CONTRAS 873.13 193.68 679.45 XXX N   73221 MRI ANY JT UPPER EXTREMITY W/O CONTRAST MATRL 417.20 123.19 294.01 XXX N   73222 MRI ANY JT UPPER EXTREMITY W/CONTRAST MATRL 664.85 147.32 517.53 XXX N   73223 MRI ANY JT UPPER EXTREMITY W/O & W/CONTR MATRL 824.87 194.31 630.56 XXX N   73225 MRA UPPER EXTREMITY W/WO CONTRAST MATERIAL 695.33 155.58 539.75 XXX N   73501 RADEX HIP UNILATERAL WITH PELVIS 1 VIEW 61.60 17.15 44.45 XXX N   73502 RADEX HIP UNILATERAL WITH PELVIS 2-3 VIEWS 88.37 20.32 68.05 XXX N   73503 RADEX HIP UNILATERAL WITH PELVIS MINIMUM 4 VIEWS 110.27 25.40 84.87 XXX N   73521 RADEX HIPS BILATERAL WITH PELVIS 2 VIEWS 78.11 20.32 57.79 XXX N   73522 RADEX HIPS BILATERAL WITH PELVIS 3-4 VIEWS 101.60 27.31 74.29 XXX N   73523 RADEX HIPS BILATERAL WITH PELVIS MINIMUM 5 VIEWS 116.21 29.21 87.00 XXX N   73525 RADEX HIP ARTHROGRAPHY RS&I 232.22 53.34 178.88 XXX N   73551 RADIOLOGIC EXAMINATION FEMUR 1 VIEW 55.25 15.24 40.01 XXX N   73552 RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS 66.68 16.51 50.17 XXX N   73560 RADIOLOGIC EXAMINATION KNEE 1/2 VIEWS 64.77 15.24 49.53 XXX N   73562 RADIOLOGIC EXAMINATION KNEE 3 VIEWS 76.68 17.15 59.53 XXX N   73564 RADIOLOGIC EXAM KNEE COMPLETE 4/MORE VIEWS 85.45 20.32 65.13 XXX N   73565 RADIOLOGIC EXAM BOTH KNEES STANDING ANTEROPOST 76.68 15.88 60.80 XXX N   73580 RADIOLOGIC EXAM KNEE ARTHROGRAPHY RS&I 262.17 53.34 208.83 XXX N   73590 RADIOLOGIC EXAMINATION TIBIA & FIBULA 2 VIEWS 59.69 14.61 45.08 XXX N   73592 RADEX LOWER EXTREMITY INFANT MINIMUM 2 VIEWS 59.16 14.61 44.55 XXX N   73600 RADIOLOGIC EXAMINATION ANKLE 2 VIEWS 60.96 15.24 45.72 XXX N   73610 RADEX ANKLE COMPLETE MINIMUM 3 VIEWS 68.64 15.88 52.76 XXX N   73615 RADEX ANKLE ARTHROGRAPHY RS&I 243.90 52.71 191.19 XXX N   73620 RADIOLOGIC EXAMINATION FOOT 2 VIEWS 53.34 13.97 39.37 XXX N

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   73630 RADEX FOOT COMPLETE MINIMUM 3 VIEWS 64.26 15.24 49.02 XXX N   73650 RADEX CALCANEUS MINIMUM 2 VIEWS 54.61 14.61 40.00 XXX N   73660 RADEX TOE MINIMUM 2 VIEWS 55.25 12.07 43.18 XXX N   73700 CT LOWER EXTREMITY W/O CONTRAST MATERIAL 321.31 90.81 230.50 XXX N   73701 CT LOWER EXTREMITY W/CONTRAST MATERIAL 403.86 105.41 298.45 XXX N   73702 CT LOWER EXTREMITY W/O & W/CONTRAST MATRL 488.95 109.86 379.09 XXX N   73706 CT ANGIOGRAPHY LOWER EXTREMITY 642.62 170.18 472.44 XXX N   73718 MRI LOWER EXTREM OTH/THN JT W/O CONTR MATRL 469.27 121.92 347.35 XXX N   73719 MRI LOWER EXTREM OTH/THN JT W/CONTRAST MATRL 554.99 146.69 408.30 XXX N   73720 MRI LOWER EXTREM OTH/THN JT W/O & W/CONTR MATR 711.84 193.68 518.16 XXX N   73721 MRI ANY JT LOWER EXTREM W/O CONTRAST MATRL 417.20 123.19 294.01 XXX N   73722 MRI ANY JT LOWER EXTREM W/CONTRAST MATERIAL 668.02 147.32 520.70 XXX N   73723 MRI ANY JT LOWER EXTREM W/O & W/CONTRAST MATRL 822.96 193.68 629.28 XXX N   73725 MRA LOWER EXTREMITY W/WO CONTRAST MATERIAL 704.85 161.93 542.92 XXX N   74018 RADIOLOGIC EXAM ABDOMEN 1 VIEW 57.15 16.51 40.64 XXX N   74019 RADIOLOGIC EXAM ABDOMEN 2 VIEWS 69.85 20.96 48.89 XXX N   74021 RADIOLOGIC EXAM ABDOMEN 3+ VIEWS 81.92 24.77 57.15 XXX N   74022 RADIOLOGIC EXAM COMPLETE ACUTE ABDOMEN SERIES 94.62 29.21 65.41 XXX N   74150 CT ABDOMEN W/O CONTRAST MATERIAL 269.88 107.95 161.93 XXX N   74160 CT ABDOMEN W/CONTRAST MATERIAL 471.17 114.94 356.23 XXX N   74170 CT ABDOMEN W/O CONTRAST FLWD BY CONTRAST MATRL 527.69 126.37 401.32 XXX N   74174 CTA ABD&PLVS W/CNTRST & IMG POSTPROCESSING 757.56 196.85 560.71 XXX N   74175 CTA ABDOMEN W/CONTRAST&IMG POSTPROCESSING 608.33 163.20 445.13 XXX N   74176 CT ABDOMEN & PELVIS W/O CONTRAST MATERIAL 359.41 157.48 201.93 XXX N   74177 CT ABDOMEN & PELVIS W/CONTRAST MATERIAL 611.51 165.10 446.41 XXX N   74178 CT ABD&PLV W/O CNTRST 1/BTH FLWD CNTRST 1/BTH 684.53 180.98 503.55 XXX N   74181 MRI ABDOMEN W/O CONTRAST MATERIAL 436.88 132.08 304.80 XXX N   74182 MRI ABDOMEN W/CONTRAST MATERIAL 641.99 156.85 485.14 XXX N   74183 MRI ABDOMEN W/O CONTRAST FLWD BY W/CONTRAST 714.38 198.76 515.62 XXX N   74185 MRA ABDOMEN W/WO CONTRAST MATERIAL 706.76 161.29 545.47 XXX N   74190 PERITONEOGRAM RS&I 113.84 41.91 71.93 XXX N   74210 RADIOLOGIC EXAM PHRNX&/CRV ESOPH CONTRAST STUDY 181.84 53.34 128.50 XXX N   74220 RADIOLOGIC EXAM ESOPHAGUS SINGLE CONTRAST STUDY 191.14 60.96 130.18 XXX N   74221 RADIOLOGIC EXAM ESOPHAGUS DOUBLE CONTRAST STUDY 215.27 62.87 152.40 XXX N   74230 RADIOLOGIC EXAM SWALLOW FUNCTION CONTRAST STUDY 247.65 48.26 199.39 XXX N   74235 RMVL FB ESOPHAGEAL W/USE BALLOON CATH RS&I 342.88 107.95 234.93 XXX N   74240 RADIOLOGIC EXAM UPR GI TRC SINGLE CONTRAST STUDY 239.40 71.76 167.64 XXX N   74246 RADIOLOGIC EXAM UPR GI TRC DOUBLE CONTRAST STUDY 273.05 71.56 201.49 XXX N   74248 RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY 161.29 62.87 98.42 ZZZ N   74250 RADIOLOGIC EXAM SMALL INT SINGLE CONTRAST STUDY 232.22 48.93 183.29 XXX N   74251 RADIOLOGIC EXAM SMALL INT DOUBLE CONTRAST STUDY 772.16 71.56 700.60 XXX N   74261 CT COLONOGRPHY DX IMAGE POSTPROCESS W/O CONTRAST 862.33 217.17 645.16 XXX N   74262 CT COLONOGRPHY DX IMAGE POSTPROCESS W/CONTRAST 968.38 226.06 742.32 XXX N   74263 CT COLONOGRAPHY SCREENING IMAGE POSTPROCESSING 1352.55 207.01 1145.54 XXX N

Radiology Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 70010-79999 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 226 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   74270 RADIOLOGIC EXAM COLON SINGLE CONTRAST STUDY 300.36 71.56 228.80 XXX N   74280 RADIOLOGIC EXAM COLON DOUBLE CONTRAST STUDY 433.07 102.97 330.10 XXX N   74283 THERAPEUTIC ENEMA RDCTJ INTUSSUSCEPTION/OBSTRCJ 482.70 187.96 294.74 XXX N   74290 CHOLECYSTOGRAPHY ORAL CONTRST 157.01 29.21 127.80 XXX N   74300 CHOLANGIOGRAPHY&/PANCREATOGRAPHY NTRAOP RS&I 109.86 33.02 76.84 XXX N   74301 CHOLANGIO&/PANCREATOGRAPHY ADDL SET INTRAOP RS 58.28 19.05 39.23 ZZZ N   74328 ENDOSCOPIC CATHJ BILIARY DUCTAL SYSTEM RS&I 228.36 64.14 164.22 XXX N   74329 ENDOSCOPIC CATHJ PANCREATIC DUCTAL SYS RS&I 197.20 64.14 133.06 XXX N   74330 CMBN NDSC CATHJ BILIARY&PNCRTC DUCTAL SYS RS&I 303.53 81.92 221.61 XXX N   74340 INTRO LONG GI TUBE W/MULT FLUORO & IMAGES RS&I 208.71 48.90 159.81 XXX N   74355 PERCUTANEOUS PLACEMENT ENTEROCLYSIS TUBE RS&I 275.81 68.58 207.23 XXX N   74360 INTRALUMINAL DILATION STRICTURES&/OBSTRCJS RS&I 225.66 50.80 174.86 XXX N   74363 PRQ TRANSHEPATC DILAT BILIARY DUCT STRICTRE RS&I 236.50 78.11 158.39 XXX N   74400 UROGRAPHY IV W/WO KUB W/WO TOMOGRAPHY 245.36 44.45 200.91 XXX N   74410 UROGRAPHY INFUSION DRIP &/BOLUS TECHNIQUE 249.02 43.82 205.20 XXX N   74415 UROGRAPHY NFS DRIP &/BOLUS W/NEPHROTOMOGRAPHY 297.22 44.45 252.77 XXX N   74420 UROGRAPHY RETROGRADE WITH/WO KUB 145.42 46.36 99.06 XXX N   74425 ANTEGRADE UROGRAPHY RADIOLOGICAL SUPVJ & INTERPJ 135.10 36.51 98.59 XXX N   74430 CYSTOGRAPHY MINIMUM 3 VIEWS RS&I 76.84 29.21 47.63 XXX N   74440 VASOGRAPY VESICULOGRAPY/EPIDIDYMOGRAPY RS&I 178.18 33.02 145.16 XXX N   74445 CORPORA CAVERNOSOGRAPY RS&I 174.63 99.70 74.93 XXX N   74450 URETHROCYSTOGRAPHY RETROGRADE RS&I 129.54 29.85 99.69 XXX N   74455 URETHROCYSTOGRAPHY VOIDING RS&I 186.22 29.85 156.37 XXX N   74470 RADEX RENAL CYST STUDY TRANSLUMBAR RS&I 140.95 47.63 93.32 XXX N   74485 DILATION URETERS/URETHRA RS&I 220.54 72.39 148.15 XXX N   74712 FETAL MRI W/PLACNTL MATRNL PLVC IMG SING/1ST GES 861.06 271.15 589.91 XXX N   74713 FETAL MRI W/PLACNTL MATRNL PLVC IMG EA ADDL GES 419.10 168.28 250.82 ZZZ N   74740 HYSTEROSALPINGOGRAPHY RS&I 169.42 34.29 135.13 XXX N   74742 TRANSCERVICAL CATHJ FALLOPIAN TUBE RS&I 162.64 55.88 106.76 XXX N   74775 PERINEOGRAM 193.21 56.52 136.69 XXX N   75557 CARDIAC MRI MORPHOLOGY & FUNCTION W/O CONTRAST 581.66 208.92 372.74 XXX N   75559 CARDIAC MRI W/O CONTRAST W/STRESS IMAGING 810.90 258.45 552.45 XXX N   75561 CARDIAC MRI W/WO CONTRAST & FURTHER SEQ 763.91 230.51 533.40 XXX N   75563 CARDIAC MRI W/W/O CONTRAST W/STRESS 905.51 264.16 641.35 XXX N   75565 CARDIAC MRI FOR VELOCITY FLOW MAPPING 95.89 22.23 73.66 ZZZ N   75571 CT HEART NO CONTRAST QUANT EVAL CORONRY CALCIUM 194.31 52.07 142.24 XXX N   75572 CT HEART CONTRAST EVAL CARDIAC STRUCTURE&MORPH 477.52 156.85 320.67 XXX N   75573 CT HEART C+ CARDIAC STRUX&MORPH CGEN HRT DS 646.43 227.97 418.46 XXX N   75574 CTA HRT CORNRY ART/BYPASS GRFTS CONTRST 3D POST 701.04 213.36 487.68 XXX N   75580 N-INVAS EST C FFR AUGMNT SW ALYS CTA I&R PHY/QHP 1722.12 66.04 1656.08 XXX N   75600 AORTOGRAPHY THORACIC W/O SERIALOGRAPHY RS&I 359.41 45.09 314.32 XXX N   75605 AORTOGRAPHY THORACIC SERIALOGRAPHY RS&I 240.03 100.33 139.70 XXX N   75625 AORTOGRAPHY ABDOMINAL SERIALOGRAPHY RS&I 242.57 115.38 127.19 XXX N   75630 AORTOGRAPHY ABDL BI ILIOFEM LOW EXTREM CATH RS&I 300.36 176.53 123.83 XXX N   75635 CTA ABDL AORTA&BI ILIOFEM W/CONTRAST&POSTP 809.63 214.00 595.63 XXX N

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   75705 ANGIOGRAPHY SPINAL SELECTIVE RS&I 461.01 215.27 245.74 XXX N   75710 ANGIOGRAPHY EXTREMITY UNILATERAL RS&I 300.36 155.58 144.78 XXX N   75716 ANGIOGRAPHY EXTREMITY BILATERAL RS&I 320.04 173.36 146.68 XXX N   75726 ANGIOGRAPHY VISCERAL SLCTV/SUPRASLCTV RS&I 297.94 113.92 184.02 XXX N   J1 75731 ANGIOGRAPHY ADRENAL UNILATERAL SLCTV RS&I 300.36 103.51 196.85 XXX N   75733 ANGIOGRAPHY ADRENAL BILATERAL SLCTV RS&I 323.22 114.94 208.28 XXX N   75736 ANGIOGRAPHY PELVIC SLCTV/SUPRASLCTV RS&I 278.13 99.06 179.07 XXX N   75741 ANGIOGRAPHY PULMONARY UNILATERAL SLCTV RS&I 262.26 114.30 147.96 XXX N   75743 ANGIOGRAPHY PULMONARY BILATERAL SLCTV RS&I 294.64 144.78 149.86 XXX N   J1 75746 ANGRPH PULMONARY NONSLCTV CATH/VEN NJX RS&I 264.16 100.33 163.83 XXX N   75756 ANGIOGRAPHY INTERNAL MAMMARY RS&I 304.17 102.87 201.30 XXX N   75774 ANGRPH SLCTV EA VSL STUDIED AFTER BASIC XM RS&I 170.15 35.79 134.37 ZZZ N   75801 LYMPHANGIOGRAPHY EXTREMITY ONLY UNILATERAL RS&I 474.35 80.65 393.70 XXX N   J1 75803 LYMPHANGIOGRAPHY EXTREMITY ONLY BILATERAL RS&I 514.33 106.68 407.65 XXX N   J1 75805 LYMPHANGIOGRAPHY PELVIC/ABDOMINAL UNILAT RS&I 490.86 73.66 417.20 XXX N   75807 LYMPHANGIOGRAPHY PELVIC/ABDOMINAL BILATERAL RS&I 569.21 101.60 467.61 XXX N   75809 SHUNTOGRAM INDWELLING NONVASCULAR SHUNT RS&I 170.82 43.18 127.64 XXX N   J1 75810 SPLENOPORTOGRAPY RS&I 1010.36 89.54 920.82 XXX N   75820 VENOGRAPHY EXTREMITY UNILATERAL RS&I 209.55 72.30 137.25 XXX N   J1 75822 VENOGRAPHY EXTREMITY BILATERAL RS&I 253.37 107.35 146.02 XXX N   75825 VENOGRAPHY CAVAL INFERIOR SERIALOGRAPHY RS&I 233.68 100.33 133.35 XXX N   75827 VENOGRAPHY CAVAL SUPERIOR SERIALOGRAPHY RS&I 242.57 101.60 140.97 XXX N   75831 VENOGRAPHY RENAL UNILATERAL SELECTIVE RS&I 243.84 99.06 144.78 XXX N   75833 VENOGRAPHY RENAL BILATERAL SELECTIVE RS&I 288.93 131.45 157.48 XXX N   75840 VENOGRAPHY ADRENAL UNILATERAL SELECTIVE RS&I 259.08 103.51 155.57 XXX N   75842 VENOGRAPHY ADRENAL BILATERAL SELECTIVE RS&I 314.33 135.26 179.07 XXX N   75860 VENOGRAPHY VENOUS SINUS/JUGULAR CATH RS&I 253.37 101.60 151.77 XXX N   J1 75870 VENOGRAPHY SUPERIOR SAGITTAL SINUS RS&I 336.55 116.21 220.34 XXX N   75872 VENOGRAPHY EPIDURAL RS&I 259.08 103.51 155.57 XXX N   75880 VENOGRAPHY ORBITAL RS&I 218.44 63.50 154.94 XXX N   75885 PRQ TRANSHEPATC PORTOGRAPY HEMODYN EVAL RS&I 272.42 121.92 150.50 XXX N   J1 75887 PRQ TRANSHEPATC PORTOGRAPY W/O HEMODYN EVL INTRP 273.69 122.56 151.13 XXX N   75889 HEPATC VNGRPH WDG/FR HEMODYN EVAL RS&I 249.56 98.43 151.13 XXX N   75891 HEPATC VNGRPH WDG/FR W/O HEMODYN EVAL RS&I 252.73 99.70 153.03 XXX N   75893 VENOUS SAMPLING THRU CATH W/WO ANGIOGRAPHY RS& 210.82 48.90 161.92 XXX N   75894 TRANSCATHETER EMBOLIZATION ANY METH RS&I 1877.70 131.45 1746.25 XXX N   J1 75898 ANGRPH CATH F-UP STD TCAT OTHER THAN THROMBYLSIS 248.29 166.37 81.92 XXX N   75901 MECHANICAL RMVL PERICATHETER OBSTR MATRL RS&I 410.40 43.18 367.22 XXX N   75902 MECHANICAL RMVL INTRALUMINAL OBSTR MATRL RS&I 162.12 34.93 127.19 XXX N   75956 EVASC RPR DESCND THORCIC AORTA SUBCLAV ORIG RS&I 624.84 624.84 BR XXX N   75957 EVASC RPR DESCND THORCIC AORTA CELIAC ORIG RS&I 535.31 535.31 BR XXX N   75958 PLMT PROX XTN PRSTH EVASC DESC THORAC AORTA RS&I 355.60 355.60 BR XXX N   75959 PLMT DSTL XTN PRSTH EVASC DESC THORAC AORTA RS&I 312.42 312.42 BR XXX N   75970 TRANSCATHETER BIOPSY RS&I 796.93 71.76 725.17 XXX N

Radiology Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 70010-79999 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 228 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   75984 CHANGE PRQ TUBE/DRAINAGE CATH W CONTRAST RS&I 184.79 70.49 114.30 XXX N   75989 RADIOLOGICAL GUIDANCE PRQ DRG W/PLMT CATH RS&I 217.17 104.78 112.39 XXX N   76000 FLUOROSCOPY UP TO 1 HOUR PHYSICIAN/QHP TIME 84.46 28.58 55.88 XXX N   76010 RADEX FROM NOSE RECTUM FOREIGN BODY 1 VIEW CHLD 56.24 16.51 39.73 XXX N   76014 MR SAFETY IMPLANT&/FB ASSMT CLIN STAF 1ST 15 MIN 20.96 XXX N 34.78   76015 MR SAFETY IMPLANT&/FB ASSMT CLIN STAFF EA ADD 30 100.97 ZZZ N   76016 MR SAFETY DETERMINATION PHYSICIAN/OTHER QHP 139.70 53.34 86.36 XXX N  

20 Miss. Admin. Code Pt. 2, R. 76017 Rule 76017

MR SAFETY MED PHYSICS XM CUSTOMIZATION PLNG&MNTR 431.17 67.95 363.22 XXX N  

20 Miss. Admin. Code Pt. 2, R. 76018 Rule 76018

MR SAFETY IMPLT ELECTRONICS PREPJ SUPVJ PHYS/QHP 219.08 66.68 152.40 XXX N  

20 Miss. Admin. Code Pt. 2, R. 76019 Rule 76019

MR SAFETY IMPLANT POS&/IMMOBLJ SUPVJ PHYS/QHP 285.75 52.71 233.04 XXX N   76080 RADEX ABSCESS/FISTULA/SINUS TRACT RS&I 114.94 46.99 67.95 XXX N   76098 RADIOLOGICAL EXAMINATION SURGICAL SPECIMEN 34.33 16.80 17.53 XXX N   76100 RADEX 1 PLNE BODY SECTION OTH/THN W/UROGRAPY 170.82 56.52 114.30 XXX N   76120 CINERADIOGRAPY/VIDRADIOGRAPY XCPT WHERE SPEC 209.59 36.20 173.39 XXX N   76125 CINERADIOGRAPY/VIDRADIOGRAPY ROUTINE EXAMINATION 81.92 25.40 56.52 ZZZ N   76140 CONSLTJ X-RAY XM MADE ELSEWHERE WRTTN REPRT 62.23 XXX N 74.38   76145 MEDICAL PHYSICS DOSE EVAL RADIATION EXPOS W/RPRT 1528.45 XXX N 491.11   76376 3D RENDERING W/INTERP & POSTPROCESS SUPERVISION 43.18 17.78 25.40 XXX N   76377 3D RENDERING W/INTERP&POSTPROC DIFF WORK STATION 135.89 71.76 64.13 XXX N   76380 CT LIMITED/LOCALIZED FOLLOW UP STUDY 260.35 87.63 172.72 XXX N   76390 MRI SPECTROSCOPY 781.69 127.64 654.05 XXX N   76391 MAGNETIC RESONANCE ELASTOGRAPHY 422.91 100.33 322.58 XXX N   76496 UNLISTED FLUOROSCOPIC PROCEDURE BR BR BR XXX N   76497 UNLISTED COMPUTED TOMOGRAPHY PROCEDURE BR BR BR XXX N   76498 UNLISTED MAGNETIC RESONANCE PROCEDURE BR BR BR XXX N   76499 UNLISTED DIAGNOSTIC RADIOGRAPHIC PROCEDURE BR BR BR XXX N   76506 ECHOENCEPHALOGRAPHY REAL TIME IMAGING 220.35 57.79 162.56 XXX N   76510 OPHTHALMIC US DX B-SCAN&QUAN A-SCAN SM PT ENCTR 200.03 104.78 95.25 XXX N   76511 OPHTHALMIC US DX QUANTITATIVE A-SCAN ONLY 122.56 65.41 57.15 XXX N   76512 OPHTHALMIC US DX B-SCAN W/WO NON-QUAN A-SCAN 109.86 62.87 46.99 XXX N   76513 DX OPHTHALMIC US ANT SEGMENT IMMERSION UNI/BI 176.53 64.77 111.76 XXX N   76514 OPHTHALMIC US DX CORNEAL PACHYMETRY UNI/BI 22.86 14.61 8.25 XXX N   76516 OPHTHALMIC BIOMETRY US ECHOGRAPY A-SCAN 97.16 41.28 55.88 XXX N   76519 OPH BMTRY US ECHOGRAPY A-SCAN IO LENS PWR CAL 125.73 56.52 69.21 XXX N   76529 OPHTHALMIC ULTRASONIC FOREIGN BODY LOCALIZATION 161.29 59.69 101.60 XXX N   76536 US SOFT TISSUE HEAD & NECK REAL TIME IMGE DOCM 214.00 51.44 162.56 XXX N   76604 US CHEST REAL TIME W/IMAGE DOCUMENTATION 159.39 52.07 107.32 XXX N   76641 US BREAST UNI REAL TIME WITH IMAGE COMPLETE 196.85 66.04 130.81 XXX N   76642 US BREAST UNI REAL TIME WITH IMAGE LIMITED 161.29 61.60 99.69 XXX N   76700 US ABDOMINAL REAL TIME W/IMAGE DOCUMENTATION 224.16 73.03 151.13 XXX N   76705 US ABDOMINAL REAL TIME W/IMAGE LIMITED 167.64 53.34 114.30 XXX N   76706 US ABDOMINAL AORTA REAL TIME SCREEN STUDY AAA 203.84 49.53 154.31 XXX N   76770 US RETROPERITONEAL REAL TIME W/IMAGE COMPLETE 207.65 66.68 140.97 XXX N   76775 US RETROPERITONEAL REAL TIME W/IMAGE LIMITED 109.86 52.07 57.79 XXX N   76776 US TRNSPLNT KIDNEY REAL TIME W/IMAGE DOCMTN 285.12 68.58 216.54 XXX N   76800 ULTRASOUND SPINAL CANAL & CONTENTS 278.13 111.13 167.00 XXX N

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   76801 US PREGNANT UTERUS 14 WK TRANSABDL 1/1ST GESTAT 223.52 90.17 133.35 XXX N   76802 US PREG UTERUS 14 WK TRANSABDL EACH GESTATION 115.57 76.20 39.37 ZZZ N   76805 US PREG UTERUS AFTER 1ST TRIMEST 1/1ST GESTATION 257.18 90.81 166.37 XXX N   76810 US PREG UTERUS > 1ST TRIMESTER ABDL EA GESTATIO 167.01 90.81 76.20 ZZZ N   76811 US PREG UTERUS W/DETAIL FETAL ANAT 1ST GESTATION 329.57 175.90 153.67 XXX N   76812 US PREG UTERUS DETAIL FETAL ANAT EXAM EA GESTAT 367.03 166.37 200.66 ZZZ N   76813 US FETAL NUCHAL TRANSLUCENCY 1ST GESTATION 224.16 109.86 114.30 XXX N   76814 US FETAL NUCHAL TRANSLUCENCY EA ADDL GESTATION 144.15 92.71 51.44 XXX N   76815 US PREGNANT UTERUS LIMITED 1/> FETUSES 154.94 59.06 95.88 XXX N   76816 US PREG UTERUS REAL TIME F/U TRNSABDL PER FETUS 208.92 78.74 130.18 XXX N   76817 US PREG UTERUS REAL TIME W/IMAGE DCMTN TRANSVAG 177.17 68.58 108.59 XXX N   76818 FETAL BIOPHYSICAL PROFILE NON-STRESS TESTING 218.44 97.79 120.65 XXX N   76819 FETAL BIOPHYSICAL PROFILE W/O NON-STRESS TESTING 160.02 71.12 88.90 XXX N   76820 DOPPLER VELOCIMETRY FETAL UMBILICAL ARTERY 85.73 46.36 39.37 XXX N   76821 DOPPLER VELOCIMETRY FETAL MIDDLE CEREBRAL ART 168.28 65.41 102.87 XXX N   76825 ECHO FETAL CARDIOVASC W/WO M-MODE RECORDING 502.92 151.13 351.79 XXX N   76826 ECHO FETAL CARDIOVASC W/WO M-MODE REPEAT STD 302.90 74.93 227.97 XXX N   76827 DOPPLER ECHO FETAL SPECTRAL DISPLAY COMPLETE 133.99 52.07 81.92 XXX N   76828 DOPPLER ECHO FETAL PULS SPECTRAL F/U/REPEAT 95.89 51.44 44.45 XXX N   76830 US TRANSVAGINAL 229.24 62.87 166.37 XXX N   76831 SALINE INFUS SONOHYSTEROGRAPHY W/COLOR DOPPLER 222.89 66.04 156.85 XXX N   76856 US PELVIC NONOBSTETRIC REAL-TIME IMAGE COMPLETE 202.57 62.23 140.34 XXX N   76857 US PELVIC NONOBSTETRIC IMAGE DCMTN LIMITED/F/U 90.17 45.09 45.08 XXX N   76870 US SCROTUM & CONTENTS 193.04 57.79 135.25 XXX N   76872 US TRANSRECTAL 264.35 60.33 204.02 XXX N   76873 US TRANSRCT PRSTATE VOL BRACHYTX PLNNING SPX 328.93 141.61 187.32 XXX N   76881 US COMPL JOINT R-T W/IMAGE DOCUMENTATION 159.39 57.15 102.24 XXX N   76882 US LMTD JT/FCL EVAL NONVASC XTR STRUX R-T W/IMG 106.05 44.45 61.60 XXX N   76883 US NRV&ACC STRUX 1 XTR COMPRE W/IMG PR EXTREMITY 136.53 108.59 27.94 XXX N   76885 US INFT HIPS R-T IMG DYNAMIC REQ PHYS/QHP MANJ 262.89 67.31 195.58 XXX N   76886 US INFT HIPS R-T IMG LMTD STATIC PHYS/QHP MANJ 192.41 56.52 135.89 XXX N   76932 US ENDOMYOCARDIAL BIOPSY RS&I 180.34 66.68 113.66 YYY N   76936 US CMPRN RPR ARTL PSEUDOARYSM/ARVEN FSTL 497.84 176.53 321.31 XXX N   76937 US VASC ACCESS SITS VSL PATENCY NDL ENTRY 70.10 26.04 44.06 ZZZ N   76940 US &MNTR PARENCHYMAL TISSUE ABLATION 300.36 186.06 114.30 YYY N   76941 US INTRAUTERINE FTL TFUJ/CORDOCNTS IMG S&I 231.78 125.10 106.68 XXX N   76942 US GUIDANCE NEEDLE PLACEMENT IMG S&I 109.22 57.79 51.43 XXX N   76945 US GUIDANCE CHORIONIC VILLUS SAMPLING IMG S&I 174.63 62.87 111.76 XXX N   76946 US GUIDANCE AMNIOCENTESIS IMG S&I 60.33 34.93 25.40 XXX N   76948 US GUIDANCE ASPIRATION OVA IMG S&I 151.77 62.87 88.90 XXX N   76965 US GUIDANCE INTERSTITIAL RADIOELMENT APPLICATION 173.36 123.83 49.53 XXX N   76975 GI ENDOSCOPIC US S&I 197.25 76.20 121.05 XXX N   76977 US BONE DENSITY MEAS & INTERP PERIPH ANY METHO 13.34 5.08 8.26 XXX N   76978 ULTRASOUND TRGT DYNAMIC MICROBUBBLE 1ST LESION 582.93 146.05 436.88 XXX N   76979 ULTRASOUND TRGT DYNAMIC MICROBUBBLE EA ADDL LES 395.61 76.84 318.77 ZZZ N   76981 ULTRASOUND ELASTOGRAPHY PARENCHYMA 198.76 53.98 144.78 XXX N

Radiology Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 70010-79999 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 230 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   76982 ULTRASOUND ELASTOGRAPHY FIRST TARGET LESION 179.07 53.98 125.09 XXX N   76983 ULTRASOUND ELASTOGRAPHY EA ADDL TAGET LESION 116.21 45.72 70.49 ZZZ N   76984 DX INTRAOPERATIVE THORACIC AORTA ULTRASOUND BR 58.42 BR XXX N   76987 DX NTRAOP EPICAR CAR US CHD PLMT&MNP TRNSDCR I&R BR 178.44 BR XXX N   76988 DX NTRAOP EPCAR CAR US CHD PLMT MNPJ&IMG ACQUISJ BR 113.67 BR XXX N   76989 DX INTRAOP EPICAR CARDIAC US CHD I&R ONLY BR 66.68 BR XXX N   76998 ULTRASONIC GUIDANCE INTRAOPERATIVE 114.94 114.94 BR XXX N   76999 UNLISTED US PROCEDURE BR BR BR XXX N   77001 FLUORO CENTRAL VENOUS ACCESS DEV PLACEMENT 186.22 34.29 151.93 ZZZ N   77002 FLUOROSCOPIC GUIDANCE NEEDLE PLACEMENT ADD ON 208.85 50.80 158.05 ZZZ N   77003 FLUOR NEEDLE/CATH SPINE/PARASPINAL DX/THER ADDON 200.66 54.61 146.05 ZZZ N   77011 CT GUIDANCE STEREOTACTIC LOCALIZATION 429.26 114.94 314.32 XXX N   77012 CT GUIDANCE NEEDLE PLACEMENT 271.15 133.35 137.80 XXX N   77013 CT GUIDANCE &MONITORING VISC TISS ABLATION 963.30 346.71 616.59 XXX N   77014 CT GUIDANCE RADIATION THERAPY FLDS PLACEMENT 227.33 83.19 144.14 XXX N   77021 MRI GUIDANCE NEEDLE PLACEMENT RS&I 853.44 132.08 721.36 XXX N   77022 MRI GUIDANCE FOR PARENCHYMAL TISSUE ABLATION 1259.84 390.53 869.31 XXX N   77046 MRI BREAST WITHOUT CONTRAST MATERIAL UNILATERAL 445.77 130.81 314.96 XXX N   77047 MRI BREAST WITHOUT CONTRAST MATERIAL BILATERAL 457.84 144.78 313.06 XXX N   77048 MRI BREAST W/OUT&WITH CONTRAST W/CAD UNILATERAL 708.03 189.23 518.80 XXX N   77049 MRI BREAST WITHOUT&WITH CONTRAST W/CAD BILATERAL 723.27 207.01 516.26 XXX N   77053 MAMMARY DUCTOGRAM OR GALACTOGRAM SINGLE 102.87 32.39 70.48 XXX N   77054 MAMMARY DUCTOGRAM OR GALACTOGRAM MULTIPLE 134.62 41.28 93.34 XXX N   77061 DIGITAL BREAST TOMOSYNTHESIS UNILATERAL 108.08 67.09 40.99 XXX N   77062 DIGITAL BREAST TOMOSYNTHESIS BILATERAL 117.58 84.03 33.55 XXX N   77063 SCREENING DIGITAL BREAST TOMOSYNTHESIS BI 99.06 54.61 44.45 ZZZ N   77065 DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI 239.40 73.66 165.74 XXX N   77066 DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ BI 302.90 90.81 212.09 XXX N   77067 SCREENING MAMMOGRAPHY BI 2-VIEW BREAST INC CAD 243.84 68.58 175.26 XXX N   77071 MANUAL APPL STRESS PHYS/QHP JOINT RADIOGRAPHY 104.43 XXX N 117.31   77072 BONE AGE STUDIES 49.53 17.15 32.38 XXX N   77073 BONE LENGTH STUDIES 77.41 26.04 51.37 XXX N   77074 RADIOLOGIC EXAMINATION OSSEOUS SURVEY LIMITED 123.83 41.28 82.55 XXX N   77075 RADIOLOGIC EXAMINATION OSSEOUS SURVEY COMPLETE 189.23 50.17 139.06 XXX N   77076 RADIOLOGIC EXAMINATION OSSEOUS SURVEY INFANT 203.20 63.50 139.70 XXX N   77077 JOINT SURVEY SINGLE VIEW 2 OR MORE JOINTS 79.60 31.12 48.48 XXX N   77078 CT BONE MINERL DENSITY STUDY 1/> SITS AXIAL SKE 205.74 22.23 183.51 XXX N   77080 DXA BONE DENSITY STUDY 1/> SITES AXIAL SKEL 71.76 17.78 53.98 XXX N   77081 DXA BONE DENSITY STUDY 1/>SITES APPENDICLR SKEL 59.69 18.42 41.27 XXX N   77084 MRI BONE MARROW BLOOD SUPPLY 680.72 145.42 535.30 XXX N   77085 DXA BONE DENSITY STD 1/> AXL SKEL W/VRT FX ASSMT 97.79 27.31 70.48 XXX N   77086 VERTEBRAL FRACTURE ASSESSMENT VIA DXA 62.87 15.24 47.63 XXX N   77089 TBS DXA/OTHER IMG CALCULATION W/I&R FX RISK 76.20 XXX N   77090 TBS TECHL PREP&TRANSMIS DATA ALYS PFRMD ELSEWHR 4.45 XXX N 117.31

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   77091 TBS TECHNICAL CALCULATION ONLY 52.71 XXX N 117.31   77092 TBS INTERPRETATION & REPORT FX RISK BY OTHER QHP 19.05 XXX N   77261 THERAPEUTIC RADIOLOGY TX PLANNING SIMPLE 132.08 XXX N   77262 THERAPEUTIC RADIOLOGY TX PLANNING INTERMEDIATE 200.03 XXX N   77263 THERAPEUTIC RADIOLOGY TX PLANNING COMPLEX 312.42 XXX N   77280 THER RAD SIMULAJ-AIDED FIELD SETTING SIMPLE 505.46 70.49 434.97 XXX N   77285 THER RAD SIMULAJ-AIDED FIELD SETTING INTERMED 835.66 105.41 730.25 XXX N   77290 THER RAD SIMULAJ-AIDED FIELD SETTING COMPLEX 916.31 153.04 763.27 XXX N   77293 RESPIRATORY MOTION MANAGEMENT SIMULATION 829.31 195.58 633.73 ZZZ N   77295 3-D RADIOTHERAPY PLAN DOSE-VOLUME HISTOGRAMS 885.83 417.83 468.00 XXX N   77299 UNLISTED PX THER RADIOLOGY CLINICAL TX PLANNING BR BR BR XXX N   77300 BASIC RADIATION DOSIMETRY CALCULATION 121.29 60.33 60.96 XXX N   77301 NTSTY MODUL RADTHX PLN DOSE-VOL HISTOS 3495.68 776.61 2719.07 XXX N   77306 TELETHX ISODOSE PLN SMPL W/DOSIMETRY CALCULATION 271.78 135.89 135.89 XXX N   77307 TELETHX ISODOSE PLN CPLX W/BASIC DOSIMETRY 528.32 281.94 246.38 XXX N   77316 BRACHYTX ISODOSE PLN SMPL W/DOSIMETRY CAL 422.08 135.89 286.19 XXX N   77317 BRACHYTX ISODOSE PLN INTERMED W/DOSIMETRY CAL 552.81 179.07 373.74 XXX N   77318 BRACHYTX ISODOSE PLN CPLX W/DOSIMETRY CAL 794.51 281.94 512.57 XXX N   77321 SPEC TELETHX PORT PLN PARTS HEMIBDY TOT BDY 173.99 92.71 81.28 XXX N   77331 SPEC DOSIM ONLY PRESCRIBED TREATING PHYS 120.02 85.09 34.93 XXX N   77332 TX DEVICES DESIGN & CONSTRUCTION SIMPLE 94.62 44.45 50.17 XXX N   77333 TX DEVICES DESIGN & CONSTRUCTION INTERMEDIATE 226.38 73.66 152.72 XXX N   77334 TX DEVICES DESIGN & CONSTRUCTION COMPLEX 231.14 111.76 119.38 XXX N   77336 CONTINUING MEDICAL PHYSICS CONSLTJ PR WK 154.31 XXX N 184.02   77338 MLC IMRT DESIGN & CONSTRUCTION PER IMRT PLAN 899.16 417.83 481.33 XXX N   77370 SPEC MEDICAL RADJ PHYSICS CONSLTJ 245.75 XXX N 184.02   J1 77371 RADIATION DELIVERY STEREOTACTIC CRANIAL COBALT 4603.12 XXX N 15885.17   J1 77372 RADIATION DELIVERY STEREOTACTIC CRANIAL LINEAR 1920.24 XXX N 15885.57   77373 STEREOTACTIC BODY RADIATION TREATMENT DELIVERY 2324.74 XXX N 2515.22   77385 INTENSITY MODULATED RADIATION TX DLVR SIMPLE 1090.99 XXX N 786.85   77386 INTENSITY MODULATED RADIATION TX DLVR COMPLEX 1323.98 XXX N 786.85   77387 GUIDANCE FOR LOCLZJ TARGET VOL FOR RADJ TX DLVR 176.53 XXX N   77399 UNLISTD PX MED RADJ PHYSIC DOSIM&TX DEV&SPEC SVC BR BR BR XXX N

  77401 RADIATION TX DELIVERY SUPERFICIAL&/ORTHO VOLTAGE 51.12 XXX N 173.72   77402 RADIATION TREATMENT DELIVERY >=1 MEV SIMPLE 204.47 XXX N 173.72   77407 RADIATION TX DELIVERY >=1 MEV INTERMEDIATE 260.35 XXX N 350.56   77412 RADIATION TREATMENT DELIVERY >=1 MEV COMPLEX 321.31 XXX N 350.56   77417 THERAPEUTIC RADIOLOGY PORT IMAGE(S) 23.37 XXX N   77423 HIGH ENERGY NEUTRON RADJ TX DLVR 1/> ISOCENTER 184.32 XXX N 786.85   J1 77424 INTRAOP RADIAJ TX DELIVER XRAY SINGLE TX SESSION BR XXX N 15632.58   J1 77425 INTRAOP RADIAJ TX DELIVER ELECTRONS SNGL TX SESS BR XXX N 15867.69   ★

20 Miss. Admin. Code Pt. 2, R. 77427 Rule 77427

RADIATION TREATMENT MANAGEMENT 5 TREATMENTS 353.70 XXX N   77431 RADIATION THERAPY MGMT 1/2 FRACTIONS ONLY 198.12 XXX N   77432 STERETCTC RADIATION TX MANAGEMENT CRANIAL LESION 789.31 XXX N   77435 STEREOTACTIC BODY RADIATION MANAGEMENT 1190.63 XXX N   77469 INTRAOPERATIVE RADIATION TREATMENT MANAGEMENT 590.55 XXX N

Radiology Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 70010-79999 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 232 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   77470 SPECIAL TREATMENT PROCEDURE 252.73 198.76 53.97 XXX N   77499 UNLISTED PROCEDURE THERAPEUTIC RADIOLOGY TX MGMT BR BR BR XXX N   77520 PROTON TX DELIVERY SIMPLE W/O COMPENSATION 1973.14 XXX N 786.85   77522 PROTON TX DELIVERY SIMPLE W/COMPENSATION BR XXX N 1875.99   77523 PROTON TX DELIVERY INTERMEDIATE BR XXX N 1875.99   77525 PROTON TX DELIVERY COMPLEX 3926.84 XXX N 1875.99   77600 HYPERTHERMIA EXTERNALLY GENERATED SUPERFICIAL 931.80 130.81 800.99 XXX N   77605 HYPERTHERMIA EXTERNALLY GENERATED DEEP 1610.21 189.23 1420.98 XXX N   77610 HYPERTHERMIA INTERSTITIAL PROBE 5/< APPLICATORS 1311.91 127.64 1184.27 XXX N   77615 HYPERTHERMIA INTERSTIAL PROBE>5 APPLICATORS 2043.43 179.71 1863.72 XXX N   77620 HYPERTHERMIA GENERATED BY INTRACAVITARY PROBES 1071.28 157.48 913.80 XXX N   77750 NFS/INSTLJ RADIOELMNT SLN 3 MO FOLLOW-UP CARE 726.44 487.68 238.76 090 N   77761 INTRACAVITARY RADIATION SOURCE APPLIC SIMPLE 769.62 374.02 395.60 090 N   77762 INTRACAVITARY RADIATION SOURCE APPLIC INTERMED 1010.92 560.71 450.21 090 N   77763 INTRACAVITARY RADIATION SOURCE APPLIC COMPLEX 1423.04 842.65 580.39 090 N   77767 HDR RDNCL SKN SURF BRACHYTX LES <2CM/1 CHAN 462.92 102.24 360.68 XXX N   77768 HDR RDNCL SK SRF BRCHYTX LES >2CM&2CHAN/MLT LES 675.01 136.53 538.48 XXX N   77770 HDR RDNCL NTRSTL/INTRCAV BRACHYTX 1 CHANNEL 645.80 190.50 455.30 XXX N   77771 HDR RDNCL NTRSTL/INTRCAV BRACHYTX 2-12 CHANNEL 1110.62 368.30 742.32 XXX N   77772 HDR RDNCL NTRSTL/INTRCAV BRACHYTX >12 CHANNELS 1651.64 520.70 1130.94 XXX N   77778 INTERSTITIAL RADIATION SOURCE APPLIC COMPLEX 1678.31 852.17 826.14 000 N   77789 SURFACE APPLIC LOW DOSE RATE RADIONUCLIDE SOURCE 247.65 111.76 135.89 000 N   77790 SUPERVISION HANDLING LOADING RADIATION SOURCE 29.85 XXX N   77799 UNLISTED PROCEDURE CLINICAL BRACHYTHERAPY BR BR BR XXX N   78012 THYROID UPTAKE SINGLE/MULTIPLE QUANT MEASUREMENT 151.77 17.15 134.62 XXX N   78013 THYROID IMAGING WITH VASCULAR FLOW 351.79 33.02 318.77 XXX N   78014 THYROID UPTAKE W/BLOOD FLOW SNGLE/MULT QUAN MEAS 441.33 44.45 396.88 XXX N   78015 THYROID CARCINOMA METASTASES IMG LMTD AREA 413.39 60.33 353.06 XXX N   78016 THYROID CARCINOMA METASTASES IMG ADDL STUDY 515.62 61.60 454.02 XXX N   78018 THYROID CARCINOMA METASTASES IMG WHOLE BODY 573.41 74.30 499.11 XXX N   78020 THYROID CARCINOMA METASTASES UPTAKE 153.04 50.17 102.87 ZZZ N   78070 PARATHYROID PLANAR IMAGING 546.74 70.49 476.25 XXX N   78071 PARATHYROID PLANAR IMAGING W/WO SUBTRACTION 652.15 106.05 546.10 XXX N   78072 PARATHYROID IMAGING W/TOMOGRAPHIC SPECT & CT 791.21 139.07 652.14 XXX N   78075 ADRENAL IMAGING CORTEX &/MEDULLA 825.50 67.31 758.19 XXX N   78099 UNLISTED ENDOCRINE PX DX NUCLEAR MEDICINE BR BR BR XXX N   78102 BONE MARROW IMAGING LIMITED AREA 310.52 47.63 262.89 XXX N   78103 BONE MARROW IMAGING MULTIPLE AREAS 398.15 63.50 334.65 XXX N   78104 BONE MARROW IMAGING WHOLE BODY 454.03 69.85 384.18 XXX N   78110 PLASMA VOL RADIOPHARM VOL DILUTION SPX 1 SAMPLE 131.45 14.61 116.84 XXX N   78111 PLASMA VOL RADIOPHARM VOL DILUTE SPX MULT SMPLES 139.70 17.15 122.55 XXX N   78120 RED CELL VOLUME DETERMINATION SPX 1 SAMPLING 134.62 17.78 116.84 XXX N   78121 RED CELL VOLUME DETERMINATION SPX MULT SAMPLINGS 147.32 24.77 122.55 XXX N   78122 WHOLE BLOOD VOLUME DETERMINATION 183.52 38.10 145.42 XXX N

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   78130 RED CELL SURVIVAL STUDY 235.59 46.36 189.23 XXX N   78140 LABELED RBC SEQUESTRATION DIFFERNTL ORGAN/TISSUE 208.92 46.36 162.56 XXX N   78185 SPLEEN IMAGING ONLY W/WO VASCULAR FLOW 310.52 30.48 280.04 XXX N   78191 PLATELET SURVIVAL STUDY 235.59 46.36 189.23 XXX N   78195 LYMPHATICS & LYMPH NODES IMAGING 652.15 106.05 546.10 XXX N   78199 UNLISTED HEMATOP RET/ENDO&LYMPHATIC DX NUC MED BR BR BR XXX N   78201 LIVER IMAGING STATIC ONLY 348.62 38.10 310.52 XXX N   78202 LIVER IMAGING W/VASCULAR FLOW 380.37 43.82 336.55 XXX N   78215 LIVER & SPLEEN IMAGING STATIC ONLY 356.24 43.82 312.42 XXX N   78216 LIVER & SPLEEN IMAGING W/VASCULAR FLOW 241.30 49.53 191.77 XXX N   78226 HEPATOBILIARY SYST IMAGING INCLUDING GALLBLADDER 604.52 66.04 538.48 XXX N   78227 HEPATOBIL SYST IMAG INC GB W/PHARMA INTERVENJ 817.25 80.65 736.60 XXX N   78230 SALIVARY GLAND IMAGING 319.41 41.28 278.13 XXX N   78231 SALIVARY GLAND IMAGING SERIAL IMAGES 198.12 39.37 158.75 XXX N   78232 SALIVARY GLAND FUNCTION STUDY 194.95 35.56 159.39 XXX N   78258 ESOPHAGEAL MOTILITY 400.69 64.77 335.92 XXX N   78261 GASTRIC MUCOSA IMAGING 370.21 52.07 318.14 XXX N   78262 GASTROESOPHAGEAL REFLUX STUDY 441.96 61.60 380.36 XXX N   78264 GASTRIC EMPTYING IMAGING STUDY 612.78 69.85 542.93 XXX N   78265 GASTRIC EMPTYNG IMAG STD W/SM BWL TRANSIT 727.08 87.00 640.08 XXX N   78266 GSTRC EMPTNG IMAG STD W/SM BWL COL TRNST MLT DAY 862.33 95.89 766.44 XXX N   78267 UREA BREATH TEST C-14 ISOTOPIC ACQUISJ ANALYSIS 20.29 XXX N   78268 UREA BREATH TEST C-14 ISOTOPIC ANALYSIS 173.24 XXX N   78278 ACUTE GASTROINTESTINAL BLOOD LOSS IMAGING 638.81 88.27 550.54 XXX N   78282 GASTROINTESTINAL PROTEIN LOSS 146.37 29.21 117.16 XXX N   78290 INTESTINE IMAGING 605.16 60.33 544.83 XXX N   78291 PERITONEAL-VENOUS SHUNT PATENCY TEST 471.81 78.74 393.07 XXX N   78299 UNLISTED GASTROINTESTINAL PX DX NUCLEAR MEDICINE BR BR BR XXX N

  78300 BONE &/JOINT IMAGING LIMITED AREA 421.01 55.88 365.13 XXX N   78305 BONE &/JOINT IMAGING MULTIPLE AREAS 513.08 74.30 438.78 XXX N   78306 BONE &/JOINT IMAGING WHOLE BODY 553.09 76.20 476.89 XXX N   78315 BONE &/JOINT IMAGING 3 PHASE STUDY 633.73 90.17 543.56 XXX N   78350 BONE DENSITY 1/> SITES 1 PHOTON ABSORPTIOMETRY 59.06 20.32 38.74 XXX N   78351 BONE DENSTY 1/> SITES DUAL PHOTON ABSORPTIOMETR 27.94 XXX N   78399 UNLISTED MUSCULOSKELETAL PX DX NUCLEAR MEDICINE BR BR BR XXX N   78414 CARD-VASC HEMODYNAM W/WO PHARM/EXER 1/MLT DETERM 142.30 40.01 102.29 XXX N   78428 CARDIAC SHUNT DETECTION 339.73 68.58 271.15 XXX N   78429 MYOCRD IMG PET METAB EVAL SINGLE STUDY CNCRNT CT 2001.52 148.59 1852.93 XXX N   78430 MYOCRD IMG PET PRFUJ 1STD REST/STRESS CNCRNT CT 1903.73 141.61 1762.12 XXX N   78431 MYOCRD IMG PET PRFUJ MLT STD RST&STRS CNCRNT CT 2235.20 165.10 2070.10 XXX N   78432 MYOCRD IMG PET PRFUJ W/METAB DUAL RADIOTRACER BR 174.63 BR XXX N   78433 MYOCRD IMG PET PRFUJ W/METAB 2RTRACER CNCRNT CT 3016.89 192.41 2824.48 XXX N   78434 AQMBF PET REST AND PHARMACOLOGIC STRESS 179.71 54.61 125.10 ZZZ N   78445 NONCARDIAC VASCULAR FLOW IMAGING 379.10 46.36 332.74 XXX N   78451 MYOCARDIAL SPECT SINGLE STUDY AT REST OR STRESS 620.40 121.29 499.11 XXX N

Radiology Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 70010-79999 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 234 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   78452 MYOCARDIAL SPECT MULTIPLE STUDIES 863.60 142.88 720.72 XXX N   78453 MYOCARDIAL PERFUSION PLANAR 1 STUDY REST/STRESS 557.53 89.54 467.99 XXX N   78454 MYOCARDIAL PERFUSION PLANAR MULTIPLE STUDIES 797.56 120.02 677.54 XXX N   78456 ACUTE VENOUS THROMBOSIS IMAGING PEPTIDE 567.06 88.27 478.79 XXX N   78457 VENOUS THROMBOSIS IMAGING VENOGRAM UNILATERAL 350.52 70.49 280.03 XXX N   78458 VENOUS THROMBOSIS IMAGING VENOGRAM BILATERAL 375.92 81.28 294.64 XXX N   78459 MYOCRD IMG PET METAB EVAL SINGLE STUDY 800.96 136.53 664.43 XXX N   78466 MYOCARDIAL IMAGING INFARCT AVID PLANAR QUAL/QUAN 360.05 63.50 296.55 XXX N   78468 MYOCRD IMG INFARCT AVID PLNR EJEC FXJ 1ST PS TQ 373.38 71.12 302.26 XXX N   78469 MYOCRD INFARCT AVID PLNR TOMOG SPECT W/WO QUANTJ 412.75 81.92 330.83 XXX N   78472 CARD BLOOD POOL GATED PLANAR 1 STUDY REST/STRESS 418.47 87.00 331.47 XXX N   78473 CARD BL POOL GATED MLT STDY WAL MOTN EJECT FRACT 528.32 128.27 400.05 XXX N   78481 CARD BL POOL PLANAR 1 STDY WAL MOTN EJECT FRACT 321.95 87.00 234.95 XXX N   78483 CARD BL POOL PLNR MLT STDY WAL MOTN EJECT FRACT 438.79 129.54 309.25 XXX N   78491 MYOCRD IMG PET PRFUJ SINGLE STUDY REST/STRESS 859.92 132.08 727.84 XXX N   78492 MYOCRD IMG PET PRFUJ MULTIPLE STUDY REST&STRESS 1076.09 161.93 914.16 XXX N   78494 CARD BL POOL GATED SPECT REST WAL MOTN EJCT FRCT 414.02 104.78 309.24 XXX N   78496 CARD BL POOL GATED 1 STDY REST RT VENT EJCT FRCT 80.01 44.45 35.56 ZZZ N   78499 UNLISTED CARDIOVASCULAR PX DX NUCLEAR MEDICINE BR BR BR XXX N   78579 PULMONARY VENTILATION IMAGING 340.36 43.18 297.18 XXX N   78580 PULMONARY PERFUSION IMAGING PARTICULATE 436.25 66.04 370.21 XXX N   78582 PULMONARY VENTILATION & PERFUSION IMAGING 612.14 95.25 516.89 XXX N   78597 QUANT DIFFERENTIAL PULM PERFUSION W/WO IMAGING 367.67 64.14 303.53 XXX N   78598 QUANT DIFF PULM PRFUSION & VENTLAJ W/WO IMAGIN 558.80 74.30 484.50 XXX N   78599 UNLISTED RESPIRATORY PX DX NUCLEAR MEDICINE BR BR BR XXX N   78600 BRAIN IMAGING <4 STATIC VIEWS 337.82 40.01 297.81 XXX N   78601 BRAIN IMAGING <4 STATIC VIEWS W/VASCULAR FLOW 396.88 45.72 351.16 XXX N   78605 BRAIN IMAGING MINIMUM 4 STATIC VIEWS 364.49 48.26 316.23 XXX N   78606 BRAIN IMAGING MIN 4 STATIC VIEWS W VASCULAR FLOW 603.25 56.52 546.73 XXX N   78608 BRAIN IMAGING PET METABOLIC EVALUATION 1151.97 129.54 1022.43 XXX N   78609 BRAIN IMAGING PET PERFUSION EVALUATION 137.16 137.16 BR XXX N   78610 BRAIN IMAGING VASCULAR FLOW ONLY 320.04 27.31 292.73 XXX N   78630 CEREBROSPINAL FLUID FLOW W/O MATL CISTERNOGRAPHY 618.49 60.96 557.53 XXX N   78635 CEREBROSPINAL FLUID FLOW W/O MATL VENTRICLGRAPHY 620.40 55.88 564.52 XXX N   78645 CEREBROSPINAL FLUID FLOW W/O MATL SHUNT EVALTJ 595.00 50.17 544.83 XXX N   78650 CEREBROSPINAL FLUID LEAK DETECTION&LOCALIZATIO 501.02 46.36 454.66 XXX N   78660 RADIOPHARMACEUTICAL DACRYOCYSTOGRAPHY 335.28 47.63 287.65 XXX N   78699 UNLISTED NERVOUS SYSTEM PX DX NUCLEAR MEDICINE BR BR BR XXX N   78700 KIDNEY IMAGING MORPHOLOGY 312.42 39.37 273.05 XXX N   78701 KIDNEY IMAGING MORPHOOGY W/VASCULAR FLOW 398.15 43.82 354.33 XXX N   78707 KIDNEY IMG MORPHOLOGY VASCULAR FLOW 1 W/O RX 424.82 83.82 341.00 XXX N   78708 KIDNEY IMG MORPHOLOGY VASCULAR FLOW 1 W/RX 328.93 106.68 222.25 XXX N   78709 KIDNEY IMG MORPHOLOGY VASCULAR FLOW MULTIPLE 673.10 123.19 549.91 XXX N   78725 KIDNEY FUNCJ STUDY NON-IMG RADIOISOTOPIC STUDY 211.46 33.02 178.44 XXX N

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   78730 URINARY BLADDER RESIDUAL STUDY 140.97 14.61 126.36 ZZZ N   78740 URETERAL REFLUX STUDY RP VOIDING CYSTOGRAM 399.42 49.53 349.89 XXX N   78761 TESTICULAR IMAGING WITH VASCULAR FLOW 386.08 64.14 321.94 XXX N   78799 UNLISTED GENITOURINARY PX DX NUCLEAR MEDICINE BR BR BR XXX N   78800 RP LOCLZJ TUM PLNR 1 AREA SINGLE DAY IMAGING 409.68 60.96 348.72 XXX N   78801 RP LOCLZJ TUM PLNR 2+AREA 1+D IMG/1 AREA IMG>2+D 495.30 71.12 424.18 XXX N   78802 RP LOCLZJ TUM PLNR WHOLE BODY SINGLE DAY IMAGING 589.92 74.93 514.99 XXX N   78803 RP LOCLZJ TUM SPECT 1 AREA/ACQUISJ 1 DAY IMG 689.61 93.98 595.63 XXX N   78804 RP LOCLZJ TUM PLNR WHOLE BODY 2+ DAYS IMAGING 1174.75 93.98 1080.77 XXX N   78808 NJX RP LOCLZJ NON-IMG PROBE STUDY INTRAVENOUS 75.57 XXX N 546.69   78811 PET IMAGING LIMITED AREA CHEST HEAD/NECK 1242.10 135.89 1106.21 XXX N   78812 PET IMAGING SKULL BASE TO MID-THIGH 1507.74 167.64 1340.10 XXX N   78813 PET IMAGING WHOLE BODY 1575.50 172.72 1402.78 XXX N   78814 PET IMAGING CT FOR ATTENUATION LIMITED AREA 1739.49 191.77 1547.72 XXX N   78815 PET IMAGING CT ATTENUATION SKULL BASE MID-THIGH 1919.74 214.63 1705.11 XXX N   78816 PET IMAGING FOR CT ATTENUATION WHOLE BODY 1936.68 217.17 1719.51 XXX N   78830 RP LOCLZJ TUM SPECT W/CT 1 AREA/ACQUISJ 1DAY IMG 870.59 127.00 743.59 XXX N   78831 RP LOCLZJ TUM SPECT 2 AREA/SEP ACQUISJ IMG 1269.37 156.85 1112.52 XXX N   78832 RP LOCLZJ TUM SPECT CT 2AREA/SEP ACQUISJ IMG 1652.27 182.25 1470.02 XXX N   78835 RADIOPHARMACEUTICAL QUANTIFICATION MEAS 1 AREA 179.71 40.01 139.70 ZZZ N   78999 UNLISTED MISCELLANEOUS PX DX NUCLEAR MEDICINE BR BR BR XXX N   79005 RP THERAPY ORAL ADMINISTRATION 254.00 158.75 95.25 XXX N   79101 RP THERAPY INTRAVENOUS ADMINISTRATION 274.96 176.53 98.43 XXX N   79200 RP THERAPY INRACAVITARY ADMINISTRATION 251.46 149.86 101.60 XXX N   79300 RP THERAPY INTERSTITIAL RADIOACTIVE COLLOID ADMN 255.47 121.29 134.18 XXX N   79403 RP THER RADIOLBLD MONOCLONAL ANTIBODY IV INFUS 345.44 197.49 147.95 XXX N   79440 RP THERAPY INTRA-ARTICULAR ADMINISTRATION 226.70 149.86 76.84 XXX N   79445 RP THERAPY INTRA-ARTERIAL PARTICULATE ADMN 376.56 207.01 169.55 XXX N   79999 RP THERAPY UNLISTED PROCEDURE BR BR BR XXX N

CPT Copyright 2024 American Medical Association. All rights reserved. 237 PATHOLOGY AND LABORATORY Note: Rules used by all physicians or other qualified health care professionals (OQHP) in reporting their services are presented in the General Rules section. See the Modifier and Code Rules section for detailed information on modifiers. I. GUIDELINES A. Pathology Services. Pathology and Laboratory services are provided for evaluating the nature of disease or a change in body tissue and organs due to injury and/or caused by a disease. B. Separate or Multiple Procedures. When multiple procedures are performed on the same date or at the same session, it is appropriate to designate them by separate entries. C. Unlisted Service or Procedures. When reporting a service or procedure that is not listed in this Fee Schedule, use the appropriate unlisted procedure code. The bill must be accompanied by a Special Report as described below. If a HCPCS or CPT ® code has been established subsequent to the release of this Fee Schedule, include the code(s) with the Special Report. D. Special Report. Any test/service that is not provided routinely or is an unlisted service or procedure should be reported with the appropriate unlisted service or procedure code designating the service and the billing for that test/service should include a description of the procedure, the process used and a full report of the findings. Special reports to justify the necessity of a service do not warrant a separate fee. E. By Report (BR). “BR” in the MAR column indicates services that are too new, unusual, or variable in the nature of their performance to permit the assignment of a definable fee. Such services should be substantiated by documentation submitted with the bill. Sufficient information should be included to permit proper identification and a sound evaluation. For more information, please see Definitions in the Introduction. F. Facility Fee. Outpatient facilities are paid based on the TC MAR when there is one. If there is no TC amount, and the service is payable in an outpatient setting, there will be an APC MAR which should be used. II. GENERAL INFORMATION AND INSTRUCTIONS A. Panel Tests. The billing for panel tests must include documentation listing the tests in the panel. When billing for panel tests (80047–80081), use the code number corresponding to the appropriate panel test. These tests will not be reimbursed separately. The panel components do not preclude the performance of other tests not listed in the panel. If other laboratory tests are performed in conjunction with a particular panel, the additional tests may be reported separately in addition to the panel. B. Handling and Collection Process 1. In collecting a specimen, the cost for collection is covered by the technical component when the lab test is conducted at that site. No separate collection or handling fee for this purpose will be reimbursed. 2. When a specimen must be sent to a reference laboratory, the cost of specimen collection is covered in a collection fee. This charge is only allowed when a reference laboratory is used, and modifier 90 must be used. C. Global, Professional, and Technical Components. Some procedures in the Pathology and Laboratory section are considered global fees (MAR) and do not qualify for a separate technical (TC) or professional (PC/26) component. Procedures that do qualify for separate components have separate Fee Schedule amounts for modifiers 26 and TC. Outpatient facilities are paid based on the TC MAR when there is one. If there is no TC amount, and the service is payable in an outpatient setting, there will be an APC MAR which should be used. Whereas these guidelines are written to be all- inclusive, there are instances when the reviewer must make an informed decision regarding the PC/TC reimbursements. Request for PC reimbursement will only be considered if: • The physician or OQHP performs the procedure or reviews the results; and • A written report, not a computer-generated report, is submitted with the request for payment. D. Occupational Blood Exposure Testing/Treatment 1. Work related Blood Exposures should minimally meet the appropriate CDC Guidelines for Management of Occupational Blood Exposures. 2. The CDC Guidelines are updated at intervals and the most current guidelines should be used. 3. Current information can be obtained at www.cdc.gov. E. Drug Screens 1. Post-Accident Drug Screens should comply with MCA §71-7-1 and other state and federal regulations with which the employer must comply. Reimbursement will either be made by the payer/carrier or the employer. Post-accident drug screens shall be billed with CPT 80305. Reimbursement shall not be dependent on the outcome of the testing results. 2. Other drug screens: a. Drug testing relies on a structure of “screening” (also known as presumptive testing), followed by “confirmation” testing to confirm the results of the screening tests

Pathology and Laboratory Mississippi Workers’ Compensation Medical Fee Schedule

20 Miss. Admin. Code Pt. 2, R. 238 Rule 238

CPT Copyright 2024 American Medical Association. All rights reserved. and quantitative or “definitive” testing that identifies the presence of specific drugs and quantities. Presumptive testing indicates the presence or absence of a drug or drug classes. Results are commonly reported as “positive” or “negative” and do not indicate the level of drug present. Definitive drug testing is most often used to evaluate presumptive drug test results and identify specific drugs and concentrations of drugs and their associated metabolites. b. A definitive drug test is reimbursable if: • A definitive concentration of a drug must be identified to guide treatment, or • A specific drug in a large family of drugs (e.g., benzodiazepines, barbiturates, and opiates) must be identified to guide treatment, or • A false result must be ruled out for a presumptive drug test that is inconsistent with a member's self- report, presentation, medical history, or current prescriptions, or • A specific substance or metabolite that is inadequately detected by presumptive drug testing (direct-to- definitive testing) must be identified. c. Only one (1) drug screen or drug test result shall be eligible for reimbursement for each drug test conducted on the same injured worker on the same day, unless the initial screening results are deemed by the prescribing provider to be inconsistent or inherently unreliable. In that event, a confirmation screening may be ordered by the prescribing provider and paid for by the payer. In addition, treatment may not be discontinued based on the results of a drug test absent a confirmation test, which shall be reimbursed in addition to the initial screening test. Merely duplicate screenings or tests which are rerun to confirm initial results are not otherwise eligible for reimbursement. d. Presumptive drug testing should be billed with CPT codes 80305, 80306 or 80307, based on the methodology used to perform the test. Each code represents all drugs and drug classes performed by the respective methodology per date of service. • CPT code 80305 is used to report procedures in which the results are read by direct optical observation. The results are visually read. Examples of these procedures are dipsticks, cups, cards and cartridges. Report 80305 once, regardless of the number of direct observation drug class procedures performed or results on any date of service. CPT 80305 - Drug tests(s), presumptive, any number of drug classes, any number of devices or procedures; capable of being read by direct optical observation only (e.g., utilizing immunoassay [dipsticks, cups, cards, or cartridges]), includes sample validation when performed, per date of service. • Code 80306 is used to report procedures when an instrument is used to assist in determining the result of a direct optical observation methodology. Examples of these procedures are dipsticks, cards, and cartridges inserted into an instrument that determines the final result of an optical observation methodology. Report 80306 once, regardless of the number of drug class procedures or results on any date of service. CPT 80306 - Drug tests(s), presumptive, any number of drug classes, any number of devices or procedures; capable of being read by instrument-assisted direct optical observation (e.g., utilizing immunoassay [e.g., dipsticks, cups, cards, or cartridges]), includes sample validation when performed, per date of service. • Code 80307 is used to report any number of devices or procedures by instrumented chemistry analyzers. There are many different instrumented methodologies available to perform presumptive drug assays, including immunoassay, chromatography, and mass spectrometry, either with or without chromatography. Report 80307 once, regardless of the number of drug class procedures or results on any date of service. CPT 80307 - Drug tests(s), presumptive, any number of drug classes, any number of devices or procedures capable of being read by instrument chemistry analyzers (e.g., utilizing immunoassay [e.g., EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (e.g., GC, HPLC), and mass spectrometry either with or without chromatography, (e.g., DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC- MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service. e. Definitive drug testing should be billed with HCPCS G codes G0480-G0483 or G0659. Only one of the five HCPCS Level II G codes for definitive testing shall be billed per injured worker, per day. The number of definitive drug classes tested, including metabolites if performed, shall determine the appropriate definitive testing HCPCS G code to bill. • G0480 - Drug test(s), definitive, utilizing (1) drug identification methods

Mississippi Workers’ Compensation Medical Fee Schedule Pathology and Laboratory

CPT Copyright 2024 American Medical Association. All rights reserved. 239 able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 1-7 drug class(es), including metabolite(s) if performed. • G0481 - Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 8-14 drug class(es), including metabolite(s) if performed. • G0482 - Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed. • G0483 - Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed. • G0659 - Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem), excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase), performed without method or drug- specific calibration, without matrix- matched quality control material, or without use of stable isotope or other universally recognized internal standard(s) for each drug, drug metabolite or drug class per specimen; qualitative or quantitative, all sources, includes specimen validity testing, per day, any number of drug classes 3. Testing validity is considered part of the screen and is not separately reimbursed. 4. Reimbursement shall not be dependent on the outcome of the test results. F. Pharmacogenomic Testing 1. Pharmacogenomic (or pharmacogenetic) tests are those germline tests performed to predict or assess an injured worker’s response to therapy as well as the risk of toxicity from drug treatment. 2. Testing may be performed prior to treatment in order to determine if the injured worker has genetic variants that could affect drug response and/or increase the risk for adverse drug reactions. Testing may also be performed during treatment to assess whether an injured worker is having

Pathology and Laboratory Mississippi Workers’ Compensation Medical Fee Schedule

20 Miss. Admin. Code Pt. 2, R. 240 Rule 240

CPT Copyright 2024 American Medical Association. All rights reserved. an adequate response or investigate the cause of an unexpected or adverse reaction. 3. Pharmacogenomic tests may be indicated when ALL of the following conditions are met: a. The injured worker is currently taking or considering treatment with a drug potentially affected by a known mutation that can be detected by a corresponding test. b. Technical and clinical validity: The test must be accurate, sensitive, and specific, based on sufficient, quality scientific evidence to support the claims of the test. c. Clinical utility: Health care providers can use the test results to guide changes in drug therapy management that will improve injured worker outcomes. d. Reasonable use: The usefulness of the test is not significantly offset by negative factors, such as expense, clinical risk, or social, or ethical challenges. 4. Testing for purposes of medication usage will be approved when the following criteria are met: a. Testing is being performed in a CLIA- certified laboratory, AND b. Testing of the requested gene has not previously been performed, AND c. A medication’s FDA label requires results from the genetic test to effectively or safely use the therapy in question, AND d. Health care providers can use the test results to directly impact medical care for the injured worker e. Testing is covered for the medications listed on the FDA Table of Pharmacogenetic Associations (https://www.fda.gov/medical- devices/precision-medicine/table- pharmacogenetic-associations) if criteria 4a-d are met. 5. Testing will be covered only for the number of genes or tests necessary to establish drug response. When available and cost- efficient, a tiered approach to testing, with reflex to more detailed testing and/or different genes, is recommended. For pharmacogenomic tests that look for changes in germline DNA (i.e., not tumor DNA or viral DNA), testing will be allowed once per lifetime per gene for an injured worker. 6. Pharmacogenomic panels, regardless of how they are billed, are considered investigational and/or experimental and, therefore, are not eligible for reimbursement. 7. Payment for pharmacogenomic testing is limited to a maximum reimbursement of five hundred dollars ($500.00) per claim regardless of the number of medications tested.

Mississippi Workers’ Compensation Medical Fee Schedule Pathology and Laboratory 80047-89398, G0480-G0483, G0659 Effective June 1, 2026 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine CPT Copyright 2024 American Medical Association. All rights reserved. 241

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  80047 BASIC METABOLIC PANEL CALCIUM IONIZED 23.61 XXX N  80048 BASIC METABOLIC PANEL CALCIUM TOTAL 15.52 XXX N  80050 GENERAL HEALTH PANEL 264.18 XXX N 237.41  80051 ELECTROLYTE PANEL 12.86 XXX N  80053 COMPREHENSIVE METABOLIC PANEL 19.38 XXX N  80055 OBSTETRIC PANEL 87.70 XXX N 222.88  80061 LIPID PANEL 24.57 XXX N  80069 RENAL FUNCTION PANEL 15.93 XXX N  80074 ACUTE HEPATITIS PANEL 87.39 XXX N  80076 HEPATIC FUNCTION PANEL 14.99 XXX N  80081 OBSTETRIC PANEL INCLUDES HIV TESTING 137.33 XXX N  80143 DRUG ASSAY ACETAMINOPHEN 32.05 XXX N  80145 DRUG ASSAY ADALIMUMAB 66.32 XXX N  80150 DRUG SCREEN QUANTITATIVE AMIKACIN 27.65 XXX N  80151 DRUG ASSAY AMIODARONE 32.05 XXX N  80155 DRUG ASSAY CAFFEINE 66.32 XXX N  80156 DRUG ASSAY CARBAMAZEPINE TOTAL 26.71 XXX N  80157 DRUG ASSAY CARBAMAZEPINE FREE 24.32 XXX N  80158 DRUG ASSAY CYCLOSPORINE 33.12 XXX N  80159 DRUG ASSAY CLOZAPINE 34.64 XXX N  80161 DRUG ASSAY CARBAMAZEPINE -10,11-EPOXIDE 32.05 XXX N  80162 DRUG SCREEN QUANTITATIVE DIGOXIN TOTAL 24.35 XXX N  80163 DRUG SCREEN QUANTITATIVE DIGOXIN FREE 24.35 XXX N  80164 DRUG ASSAY VALPROIC DIPROPYLACETIC ACID TOTAL 24.85 XXX N  80165 DRUG SCREEN QUANT DIPROPYLACETIC ACID FREE 24.85 XXX N  80167 DRUG ASSAY FELBAMATE 32.05 XXX N  80168 DRUG SCREEN QUANTITATIVE ETHOSUXIMIDE 29.97 XXX N  80169 DRUG ASSAY EVEROLIMUS 25.19 XXX N  80170 DRUG SCREEN QUANTITATIVE GENTAMICIN 30.05 XXX N  80171 DRUG SCREEN QUANTITATIVE GABAPENTIN 37.26 XXX N  80173 DRUG SCREEN QUANTITATIVE HALOPRIDOL 27.13 XXX N  80175 DRUG SCREEN QUANTITATIVE LAMOTRIGINE 24.32 XXX N  80176 DRUG SCREEN QUANTITATIVE LIDOCAINE 26.94 XXX N  80177 DRUG SCREEN QUANTITATIVE LEVETIRACETAM 24.32 XXX N  80178 DRUG SCREEN QUANTITATIVE LITHIUM 12.13 XXX N  80179 DRUG ASSAY SALICYLATE 32.05 XXX N  80180 DRUG SCREEN QUANTITATIVE MYCOPHENOLATE 33.12 XXX N  80181 DRUG ASSAY FLECAINIDE 32.05 XXX N  80183 DRUG SCREEN QUANTITATIVE OXCARBAZEPINE 24.32 XXX N  80184 DRUG SCREEN QUANTITATIVE PHENOBARBITAL 26.31 XXX N  80185 DRUG SCREEN QUANTITATIVE PHENYTOIN TOTAL 24.32 XXX N  80186 DRUG SCREEN QUANTITATIVE PHENYTOIN FREE 25.24 XXX N  80187 DRUG ASSAY POSACONAZOLE 46.61 XXX N  80188 DRUG SCREEN QUANTITATIVE PRIMIDONE 30.44 XXX N  80189 DRUG ASSAY ITRACONAZOLE 46.61 XXX N  80190 DRUG SCREEN QUANTITATIVE PROCAINAMIDE 103.16 XXX N  80192 DRUG SCREEN QUANTITATIVE PROCAINAMIDE METABOLITE 30.72 XXX N

Pathology and Laboratory Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 80047-89398, G0480-G0483, G0659 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 242 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  80193 DRUG ASSAY LEFLUNOMIDE 66.32 XXX N  80194 DRUG SCREEN QUANTITATIVE QUINIDINE 26.78 XXX N  80195 DRUG SCREEN QUANTITATIVE SIROLIMUS 25.19 XXX N  80197 DRUG SCREEN QUANTITATIVE TACROLIMUS 25.19 XXX N  80198 DRUG SCREEN QUANTITATIVE THEOPHYLLINE 25.94 XXX N  80199 DRUG SCREEN QUANTITATIVE TIAGABINE 46.61 XXX N  80200 DRUG SCREEN QUANTITATIVE TOBRAMYCIN 29.59 XXX N  80201 DRUG SCREEN QUANTITATIVE TOPIRAMATE 21.86 XXX N  80202 DRUG SCREEN QUANTITATIVE VANCOMYCIN 24.85 XXX N  80203 DRUG SCREEN QUANTITATIVE ZONISAMIDE 24.32 XXX N  80204 DRUG ASSAY METHOTREXATE 66.32 XXX N  80210 DRUG ASSAY RUFINAMIDE 46.61 XXX N  80220 DRUG ASSAY HYDROXYCHLOROQUINE 32.05 XXX N  80230 DRUG ASSAY INFLIXIMAB 66.32 XXX N  80235 DRUG ASSAY LACOSAMIDE 46.61 XXX N  80280 DRUG ASSAY VEDOLIZUMAB 66.32 XXX N  80285 DRUG ASSAY VORICONAZOLE 46.61 XXX N  80299 QUANTITATION DRUG NOT ELSEWHERE SPECIFIED 32.05 XXX N  80305 DRUG TEST PRSMV READ DIRECT OPTICAL OBS PR DATE 21.66 XXX N  80306 DRUG TST PRSMV READ INSTRMNT ASSTD DIR OPT OBS 29.47 XXX N  80307 DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE 106.84 XXX N  80320 DRUG SCREEN QUANTITATIVE ALCOHOLS 0.00 XXX N  80321 DRUG SCREEN QUANT ALCOHOLS BIOMARKERS 1 OR 2 0.00 XXX N  80322 DRUG SCREEN QUANT ALCOHOLS BIOMARKERS 3 OR MORE 0.00 XXX N  80323 ALKALOIDS NOT OTHERWISE SPECIFIED 0.00 XXX N  80324 DRUG SCREEN QUANT AMPHETAMINES 1 OR 2 0.00 XXX N  80325 DRUG SCREEN QUANT AMPHETAMINES 3 OR 4 0.00 XXX N  80326 DRUG SCREEN QUANT AMPHETAMINES 5 OR MORE 0.00 XXX N  80327 DRUG SCREEN QUANT ANABOLIC STEROID 1 OR 2 0.00 XXX N  80328 DRUG SCREEN QUANT ANABOLIC STEROID 3 OR MORE 0.00 XXX N  80329 DRUG SCREEN ANALGESICS NON-OPIOID 1 OR 2 0.00 XXX N  80330 DRUG SCREEN ANALGESICS NON-OPIOID 3-5 0.00 XXX N  80331 DRUG SCREEN ANALGESICS NON-OPIOID 6 OR MORE 0.00 XXX N  80332 ANTIDEPRESSANTS SEROTONERGIC CLASS 1 OR 2 0.00 XXX N  80333 ANTIDEPRESSANTS SEROTONERGIC CLASS 3-5 0.00 XXX N  80334 ANTIDEPRESSANTS SEROTONERGIC CLASS 6 OR MORE 0.00 XXX N  80335 ANTIDEPRESSANTS TRICYCLIC OTHER CYCLICALS 1 OR 2 0.00 XXX N  80336 ANTIDEPRESSANTS TRICYCLIC OTHER CYCLICALS 3-5 0.00 XXX N  80337 ANTIDEPRESSANTS TRICYCLIC OTHER CYCLICALS 6/MORE 0.00 XXX N  80338 ANTIDEPRESSANTS NOT OTHERWISE SPECIFIED 0.00 XXX N  80339 ANTIEPILEPTICS NOT OTHERWISE SPECIFIED 1-3 0.00 XXX N  80340 ANTIEPILEPTICS NOT OTHERWISE SPECIFIED 4-6 0.00 XXX N  80341 ANTIEPILEPTICS NOT OTHERWISE SPECIFIED 7/MORE 0.00 XXX N  80342 ANTIPSYCHOTICS NOT OTHERWISE SPECIFIED 1-3 0.00 XXX N  80343 ANTIPSYCHOTICS NOT OTHERWISE SPECIFIED 4-6 0.00 XXX N  80344 ANTIPSYCHOTICS NOT OTHERWISE SPECIFIED 7/MORE 0.00 XXX N  80345 DRUG SCREENING BARBITURATES 0.00 XXX N

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  80346 DRUG SCREENING BENZODIAZEPINES 1-12 0.00 XXX N  80347 DRUG SCREENING BENZODIAZEPINES 13 OR MORE 0.00 XXX N  80348 DRUG SCREENING BUPRENORPHINE 0.00 XXX N  80349 DRUG SCREENING CANNABINOIDS NATURAL 0.00 XXX N  80350 DRUG SCREENING CANNABINOIDS SYNTHETIC 1-3 0.00 XXX N  80351 DRUG SCREENING CANNABINOIDS SYNTHETIC 4-6 0.00 XXX N  80352 DRUG SCREENING CANNABINOIDS SYNTHETIC 7/MORE 0.00 XXX N  80353 DRUG SCREENING COCAINE 0.00 XXX N  80354 DRUG SCREENING FENTANYL 0.00 XXX N  80355 DRUG SCREENING GABAPENTIN NON-BLOOD 0.00 XXX N  80356 DRUG SCREENING HEROIN METABOLITE 0.00 XXX N  80357 DRUG SCREENING KETAMINE AND NORKETAMINE 0.00 XXX N  80358 DRUG SCREENING METHADONE 0.00 XXX N  80359 DRUG SCREENING METHYLENEDIOXYAMPHETAMINES 0.00 XXX N  80360 DRUG SCREENING METHYLPHENIDATE 0.00 XXX N  80361 DRUG SCREENING OPIATES 1 OR MORE 0.00 XXX N  80362 DRUG SCREENING OPIOIDS AND OPIATE ANALOGS 1 OR 2 0.00 XXX N  80363 DRUG SCREENING OPIOIDS AND OPIATE ANALOGS 3 OR 4 0.00 XXX N  80364 DRUG SCREENING OPIOIDS & OPIATE ANALOGS 5/MORE 0.00 XXX N  80365 DRUG SCREENING OXYCODONE 0.00 XXX N  80366 DRUG SCREENING PREGABALIN 0.00 XXX N  80367 DRUG SCREENING PROPOXYPHENE 0.00 XXX N  80368 DRUG SCREENING SEDATIVE HYPNOTICS 0.00 XXX N  80369 DRUG SCREENING SKELETAL MUSCLE RELAXANTS 1 OR 2 0.00 XXX N  80370 DRUG SCREENING SKEL MUSCLE RELAXANTS 3 OR MORE 0.00 XXX N  80371 DRUG SCREENING STIMULANTS SYNTHETIC 0.00 XXX N  80372 DRUG SCREENING TAPENTADOL 0.00 XXX N  80373 DRUG SCREENING TRAMADOL 0.00 XXX N  80374 DRUG SCREEN STEREOISOMER ANALYSIS 1 DRUG CLASS 0.00 XXX N  80375 DRUG/SUBSTANCE DEFINITIVE QUAL/QUANT NOS 1-3 0.00 XXX N  80376 DRUG/SUBSTANCE DEFINITIVE QUAL/QUANT NOS 4-6 0.00 XXX N  80377 DRUG/SUBSTANCE DEFINITIVE QUAL/QUANT NOS 7/MORE 0.00 XXX N  80400 ACTH STIMULATION PANEL ADRENAL INSUFFICIENCY 59.83 XXX N  80402 ACTH STIMULATION PANEL 21 HYDROXYLASE DEFICIENCY 159.52 XXX N  80406 ACTH STIMJ PANEL 3 BETA-HYDROXYDEHYD DEFNCY 143.55 XXX N  80408 ALDOSTERONE SUPPRESSION EVALUATION PANEL 230.21 XXX N  80410 CALCITONIN STIMULATION PANEL 147.45 XXX N  80412 CORTICOTROPIC RELEASING HORM STIMJ PANEL 1378.26 XXX N  80414 CHORNC GONAD STIMJ PANEL TESTOSTERONE RESPONSE 94.72 XXX N  80415 CHORNC GONAD STIMJ PNL TOTAL ESTRADIOL RESPONSE 102.51 XXX N  80416 RENAL VEIN RENIN STIMULATION PANEL 359.89 XXX N  80417 PERIPHERAL VEIN RENIN STIMULATION PANEL 80.70 XXX N  80418 COMBINED RAPID ANT PITUITARY EVALUATION PANEL 1062.97 XXX N  80420 DEXMETHASONE SUPPRESSION PANEL 48 HR 278.33 XXX N  80422 GLUCOSE TOLERANCE PANEL INSULINOMA 84.51 XXX N  80424 GLUCOSE TOLERANCE PANEL PHEOCHROMOCYTOMA 92.64 XXX N  80426 GONADOTROPIN RELEASING HORMONE STIMJ PANEL 272.25 XXX N

Pathology and Laboratory Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 80047-89398, G0480-G0483, G0659 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 244 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  80428 GROWTH HORMONE STIMULATION PANEL 122.37 XXX N  80430 GROWTH HORMONE SUPRJ PANEL GLUCOSE ADMN 222.36 XXX N  80432 INSULIN-INDUCED C-PEPTIDE SUPRESSION PANEL 284.74 XXX N  80434 INSULIN TOLERANCE PANEL ACTH INSUFFICIENCY 490.06 XXX N  80435 INSULIN TOLERANCE PANEL GROWTH HORM DEFNCY 188.96 XXX N  80436 METYRAPONE PANEL 167.23 XXX N  80438 THYROTROPIN RELEASING HORMONE STMLJ PANEL 1 HR 92.47 XXX N  80439 THYROTROPIN RELEASING HORMONE STMLJ PANEL 2 HR 123.30 XXX N  80503 PATHOLOGY CLINICAL CONSULTATION SF MDM 5-20 MIN 45.82 XXX N 72.07  80504 PATHOLOGY CLINICAL CONSULTATION MOD MDM 21-40MIN 91.63 XXX N 216.29  80505 PATHOLOGY CLINICAL CONSULTATION HI MDM 41-60 MIN 166.01 XXX N 216.29  80506 PATHOLOGY CLINICAL CONSLTJ PROLNG SVC EA ADDL 30 74.38 ZZZ N  81000 URINLS DIP STICK/TABLET REAGNT NON-AUTO MICRSCPY 6.91 XXX N  81001 URNLS DIP STICK/TABLET REAGENT AUTO MICROSCOPY 5.81 XXX N  81002 URNLS DIP STICK/TABLET RGNT NON-AUTO W/O MICRSCP 5.98 XXX N  81003 URNLS DIP STICK/TABLET RGNT AUTO W/O MICROSCOPY 4.11 XXX N  81005 URINALYSIS QUAL/SEMIQUANT EXCEPT IMMUNOASSAYS 3.98 XXX N  81007 URINALYSIS BACTERIURIA SCR XCPT CULTURE/DIPSTICK 51.55 XXX N  81015 URINALYSIS MICROSCOPIC ONLY 5.60 XXX N  81020 URINALYSIS 2/3 GLASS TEST 8.08 XXX N  81025 URINE PREGNANCY TEST VISUAL COLOR CMPRSN METHS 14.80 XXX N  81050 VOLUME MEASUREMENT TIMED COLLECTION EACH 6.26 XXX N  81099 UNLISTED URINALYSIS PROCEDURE BR XXX N  81105 HPA-1 GENOTYPING GENE ANALYSIS COMMON VARIANT 224.20 XXX N  81106 HPA-2 GENOTYPING GENE ANALYSIS COMMON VARIANT 224.20 XXX N  81107 HPA-3 GENOTYPING GENE ANALYSIS COMMON VARIANT 224.20 XXX N  81108 HPA-4 GENOTYPING GENE ANALYSIS COMMON VARIANT 224.20 XXX N  81109 HPA-5 GENOTYPING GENE ANALYSIS COMMON VARIANT 224.20 XXX N  81110 HPA-6 GENOTYPING GENE ANALYSIS COMMON VARIANT 224.20 XXX N  81111 HPA-9 GENOTYPING GENE ANALYSIS COMMON VARIANT 224.20 XXX N  81112 HPA-15 GENOTYPING GENE ANALYSIS COMMON VARIANT 224.20 XXX N  81120 IDH1 COMMON VARIANTS 332.26 XXX N  81121 IDH2 COMMON VARIANTS 508.57 XXX N  81161 DMD DUPLICATION/DELETION ANALYSIS 479.70 XXX N  81162 BRCA1 BRCA2 GENE ALYS FULL SEQ FULL DUP/DEL ALYS 3347.60 XXX N  81163 BRCA1 BRCA2 GENE ANALYSIS FULL SEQUENCE ANALYSIS 804.65 XXX N  81164 BRCA1 BRCA2 GENE ANALYSIS FULL DUP/DEL ANALYSIS 1004.49 XXX N  81165 BRCA1 GENE ANALYSIS FULL SEQUENCE ANALYSIS 486.37 XXX N  81166 BRCA1 GENE ANALYSIS FULL DUP/DEL ANALYSIS 518.12 XXX N  81167 BRCA2 GENE ANALYSIS FULL DUP/DEL ANALYSIS 486.37 XXX N  81168 CCND1/IGH TRANSLOCATION ALYS MAJOR BP QUAL&QUAN 356.44 XXX N  81170 ABL1 GENE ANALYSIS KINASE DOMAIN VARIANTS 515.80 XXX N  81171 AFF2 GENE ANALYSIS EVAL DETECT ABNORMAL ALLELES 235.55 XXX N  81172 AFF2 GENE ANALYSIS CHARACTERIZATION OF ALLELES 472.53 XXX N  81173 AR GENE ANALYSIS FULL GENE SEQUENCE 518.12 XXX N  81174 AR GENE ANALYSIS KNOWN FAMILIAL VARIANT 318.42 XXX N  81175 ASXL1 GENE ANALYSIS FULL GENE SEQUENCE 1163.14 XXX N

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  81176 ASXL1 GENE ANALYSIS TARGETED SEQ ANALYSIS 443.74 XXX N  81177 ATN1 GENE ANALYSIS EVAL DETECT ABNORMAL ALLELES 235.55 XXX N  81178 ATXN1 GENE ANALYSIS EVAL DETECT ABNORMAL ALLELES 235.55 XXX N  81179 ATXN2 GENE ANALYSIS EVAL DETECT ABNORMAL ALLELES 235.55 XXX N  81180 ATXN3 GENE ANALYSIS EVAL DETECT ABNORMAL ALLELES 235.55 XXX N  81181 ATXN7 GENE ANALYSIS EVAL DETECT ABNORMAL ALLELES 235.55 XXX N  81182 ATXN8OS GENE ANALYSIS EVAL DETECT ABNOR ALLELES 235.55 XXX N  81183 ATXN10 GENE ANALYSIS EVAL DETC ABNORMAL ALLELES 235.55 XXX N  81184 CACNA1A GENE ANALYSIS EVAL DETECT ABNOR ALLELES 235.55 XXX N  81185 CACNA1A GENE ANALYSIS FULL GENE SEQUENCE 1455.03 XXX N  81186 CACNA1A GENE ANALYSIS KNOWN FAMILIAL VARIANT 318.42 XXX N  81187 CNBP GENE ANALYSIS EVAL DETECT ABNORMAL ALLELES 235.55 XXX N  81188 CSTB GENE ANALYSIS EVAL DETECT ABNORMAL ALLELES 235.55 XXX N  81189 CSTB GENE ANALYSIS FULL GENE SEQUENCE 472.53 XXX N  81190 CSTB GENE ANALYSIS KNOWN FAMILIAL VARIANTS 318.42 XXX N  81191 NTRK1 TRANSLOCATION ANALYSIS 356.44 XXX N  81192 NTRK2 TRANSLOCATION ANALYSIS 356.44 XXX N  81193 NTRK3 TRANSLOCATION ANALYSIS 356.44 XXX N  81194 NTRK TRANSLOCATION ANALYSIS 891.10 XXX N  81195 CYTOG GEN-WIDE ALYS HEM MAL STRUX VRNT&CNV OGM 2324.21 XXX N  81200 ASPA GENE ANALYSIS COMMON VARIANTS 81.24 XXX N  81201 APC GENE ANALYSIS FULL GENE SEQUENCE 1341.09 XXX N  81202 APC GENE ANALYSIS KNOWN FAMILIAL VARIANTS 481.42 XXX N  81203 APC GENE ANALYSIS DUPLICATION/DELETION VARIANTS 343.87 XXX N  81204 AR GENE ANALYSIS CHARACTERIZATION OF ALLELES 235.55 XXX N  81205 BCKDHB GENE ANALYSIS COMMON VARIANTS 163.32 XXX N  81206 BCR/ABL1 MAJOR BREAKPNT QUALITATIVE/QUANTITATIVE 300.78 XXX N  81207 BCR/ABL1 MINOR BREAKPNT QUALITATIVE/QUANTITATIVE 265.69 XXX N  81208 BCR/ABL1 OTHER BREAKPNT QUALITATIVE/QUANTITATIVE 369.01 XXX N  81209 BLM GENE ANALYSIS 2281DEL6INS7 VARIANT 67.59 XXX N  81210 BRAF GENE ANALYSIS V600 VARIANT(S) 301.57 XXX N  81212 BRCA1 BRCA 2 GEN ALYS 185DELAG 5385INSC 6174DELT 756.51 XXX N  81215 BRCA1 GENE ANALYSIS KNOWN FAMILIAL VARIANT 645.18 XXX N  81216 BRCA2 GENE ANALYSIS FULL SEQUENCE ANALYSIS 318.29 XXX N  81217 BRCA2 GENE ANALYSIS KNOWN FAMILIAL VARIANT 645.18 XXX N  81218 CEBPA GENE ANALYSIS FULL GENE SEQUENCE 443.74 XXX N  81219 CALR GENE ANALYSIS COMMON VARIANTS IN EXON 9 223.11 XXX N  81220 CFTR GENE ANALYSIS COMMON VARIANTS 956.99 XXX N  81221 CFTR GENE ANALYSIS KNOWN FAMILIAL VARIANTS 167.15 XXX N  81222 CFTR GENE ANALYSIS DUPLICATION/DELETION VARIANTS 748.04 XXX N  81223 CFTR GENE ANALYSIS FULL GENE SEQUENCE 857.95 XXX N  81224 CFTR GENE ANALYSIS INTRON 8 POLY-T ANALYSIS 290.14 XXX N  81225 CYP2C19 GENE ANALYSIS COMMON VARIANTS 500.95 XXX N  81226 CYP2D6 GENE ANALYSIS COMMON VARIANTS 775.27 XXX N  81227 CYP2C9 GENE ANALYSIS COMMON VARIANTS 300.56 XXX N  81228 CYTOG ALYS CHRMOML ABNOR COPY NUMBER VRNT CGH 1547.41 XXX N

Pathology and Laboratory Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 80047-89398, G0480-G0483, G0659 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 246 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  81229 CYTOG ALYS CHRMOML ABNOR CPY NUMBER&SNP VRNT CGH 1994.44 XXX N  81230 CYP3A4 GENE ANALYSIS COMMON VARIANTS 300.56 XXX N  81231 CYP3A5 GENE ANALYSIS COMMON VARIANTS 300.56 XXX N  81232 DPYD GENE ANALYSIS COMMON VARIANTS 300.56 XXX N  81233 BTK GENE ANALYSIS COMMON VARIANTS 301.57 XXX N  81234 DMPK GENE ANALYSIS EVAL DETECT ABNORMAL ALLELES 235.55 XXX N  81235 EGFR GENE ANALYSIS COMMON VARIANTS 558.07 XXX N  81236 EZH2 GENE ANALYSIS FULL GENE SEQUENCE 486.37 XXX N  81237 EZH2 GENE ANALYSIS COMMON VARIANTS 301.57 XXX N  81238 F9 FULL GENE SEQUENCE 1031.61 XXX N  81239 DMPK GENE ANALYSIS CHARACTERIZATION OF ALLELES 472.53 XXX N  81240 F2 GENE ANALYSIS 20210G >A VARIANT 112.94 XXX N  81241 F5 COAGULATION FACTOR V ANAL LEIDEN VARIANT 126.15 XXX N  81242 FANCC GENE ANALYSIS COMMON VARIANT 62.96 XXX N  81243 FMR1 GENE ALYS EVAL TO DETECT ABNORMAL ALLELES 98.07 XXX N  81244 FMR1 GENE ANALYSIS CHARACTERIZATION OF ALLELES 77.18 XXX N  81245 FLT3 GENE ANALYSIS INTERNAL TANDEM DUP VARIANTS 284.57 XXX N  81246 FLT3 GENE ANLYS TYROSINE KINASE DOMAIN VARIANTS 142.71 XXX N  81247 G6PD GENE ANALYSIS COMMON VARIANTS 300.56 XXX N  81248 G6PD GENE ANALYSIS KNOWN FAMILIAL VARIANTS 645.18 XXX N  81249 G6PD GENE ANALYSIS FULL GENE SEQUENCE 1031.61 XXX N  81250 G6PC GENE ANALYSIS COMMON VARIANTS 100.56 XXX N  81251 GBA GLUCOSIDASE/BETA/ACID ANAL COMM VARIANTS 81.24 XXX N  81252 GJB2 GENE ANALYSIS FULL GENE SEQUENCE 173.86 XXX N  81253 GJB2 GENE ANALYSIS KNOWN FAMILIAL VARIANTS 105.77 XXX N  81254 GJB6 GENE ANALYSIS COMMON VARIANTS 60.18 XXX N  81255 HEXA GENE ANALYSIS COMMON VARIANTS 88.46 XXX N  81256 HFE HEMOCHROMATOSIS GENE ANAL COMMON VARIANTS 119.89 XXX N  81257 HBA1/HBA2 GENE ANALYSIS COMMON DELETIONS/VARIANT 175.82 XXX N  81258 HBA1/HBA2 GENE ANALYSIS KNOWN FAMILIAL VARIANT 645.18 XXX N  81259 HBA1/HBA2 GENE ANALYSIS FULL GENE SEQUENCE 1031.61 XXX N  81260 IKBKAP GENE ANALYSIS COMMON VARIANTS 67.59 XXX N  81261 IGH@ REARRANGE ABNORMAL CLONAL POP AMPLIFIED 363.20 XXX N  81262 IGH@ REARRANGE ABNORMAL CLONAL POP DIRECT PROBE 117.86 XXX N  81263 IGH@ VARIABLE REGION SOMATIC MUTATION ANALYSIS 540.27 XXX N  81264 IGK@ GENE REARRANGE DETECT ABNORMAL CLONAL POP 296.98 XXX N  81265 COMPARATIVE ANAL STR MARKERS PATIENT&COMP SPEC 400.73 XXX N  81266 COMPARATIVE ANAL STR MARKERS EA ADDL SPECIMEN 524.07 XXX N  81267 CHIMERISM W/COMP TO BASELINE W/O CELL SELECTION 380.57 XXX N  81268 CHIMERISM W/COMP TO BASELINE W/CELL SELECTION EA 478.39 XXX N  81269 HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS 348.00 XXX N  81270 JAK2 GENE ANALYSIS P.VAL617PHE VARIANT 168.15 XXX N  81271 HTT GENE ANALYSIS DETECT ABNORMAL ALLELES 235.55 XXX N  81272 KIT GENE ANALYSIS TARGETED SEQUENCE ANALYSIS 566.54 XXX N  81273 KIT GENE ANALYSIS D816 VARIANT(S) 214.69 XXX N  81274 HTT GENE ANALYSIS CHARACTERIZATION ALLELES 472.53 XXX N

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  81275 KRAS GENE ANALYSIS VARIANTS IN EXON 2 332.26 XXX N  81276 KRAS GENE ANALYSIS ADDITIONAL VARIANT(S) 332.26 XXX N  81277 CYTOGENOMIC NEOPLASIA MICROARRAY ANALYSIS 1994.44 XXX N  81278 IGH@/BCL2 TLCJ ALYS MBR & MCR BP QUAL/QUAN 356.44 XXX N  81279 JAK2 TARGETED SEQUENCE ANALYSIS 318.42 XXX N  81283 IFNL3 GENE ANALYSIS RS12979860 VARIANT 126.15 XXX N  81284 FXN GENE ANALYSIS EVAL DETECT ABNORMAL ALLELES 235.55 XXX N  81285 FXN GENE ANALYSIS CHARACTERIZATION ALLELES 472.53 XXX N  81286 FXN GENE ANALYSIS FULL GENE SEQUENCE 472.53 XXX N  81287 MGMT GENE PROMOTER METHYLATION ANALYSIS 214.30 XXX N  81288 MLH1 GENE ANALYSIS PROMOTER METHYLATION ANALYSIS 330.66 XXX N  81289 FXN GENE ANALYSIS KNOWN FAMILIAL VARIANTS 318.42 XXX N  81290 MCOLN1 MUCOLIPIN1 GENE ANALYSIS COMMON VARIANTS 67.59 XXX N  81291 MTHFR GENE ANALYSIS COMMON VARIANTS 112.34 XXX N  81292 MLH1 GENE ANALYSIS FULL SEQUENCE ANALYSIS 1161.25 XXX N  81293 MLH1 GENE ANALYSIS KNOWN FAMILIAL VARIANTS 569.10 XXX N  81294 MLH1 GENE ANALYSIS DUPLICATION/DELETION VARIANTS 348.00 XXX N  81295 MSH2 GENE ANALYSIS FULL SEQUENCE ANALYSIS 656.27 XXX N  81296 MSH2 GENE ANALYSIS KNOWN FAMILIAL VARIANTS 580.67 XXX N  81297 MSH2 GENE ANALYSIS DUPLICATION/DELETION VARIANTS 366.74 XXX N  81298 MSH6 GENE ANALYSIS FULL SEQUENCE ANALYSIS 1103.56 XXX N  81299 MSH6 GENE ANALYSIS KNOWN FAMILIAL VARIANTS 529.56 XXX N  81300 MSH6 GENE ANALYSIS DUPLICATION/DELETION VARIA 409.20 XXX N  81301 MICROSATELLITE INSTAB ANAL MISMATCH REPAIR DEF 599.29 XXX N  81302 MECP2 GENE ANALYSIS FULL SEQUENCE 907.59 XXX N  81303 MECP2 GENE ANALYSIS KNOWN FAMILIAL VARIANT 206.32 XXX N  81304 MECP2 GENE ANALYSIS DUPLICATION/DELETION VARIANT 257.90 XXX N  81305 MYD88 GENE ANALYSIS P.LEU265 (L265P) VARIANT 301.57 XXX N  81306 NUDT15 GENE ANALYSIS COMMON VARIANTS 500.95 XXX N  81307 PALB2 GENE ANALYSIS FULL GENE SEQUENCE 1163.14 XXX N  81308 PALB2 GENE ANALYSIS KNOWN FAMILIAL VARIANT 518.12 XXX N  81309 PIK3CA GENE ANALYSIS TARGETED SEQUENCE ANALYSIS 472.53 XXX N  81310 NPM1 NUCLEOPHOSMIN GENE ANAL EXON 12 VARIANTS 423.85 XXX N  81311 NRAS GENE ANALYSIS VARIANTS IN EXON 2&3 508.57 XXX N  81312 PABPN1 GENE ANALYSIS EVAL DETC ABNORMAL ALLELES 235.55 XXX N  81313 PCA3/KLK3 PROSTATE SPECIFIC ANTIGEN RATIO 438.52 XXX N  81314 PDGFRA GENE ANALYS TARGETED SEQUENCE ANALYS 566.54 XXX N  81315 PML/RARALPHA COMMON BREAKPOINTS QUAL/QUANT 380.30 XXX N  81316 PML/RARALPHA SINGLE BREAKPOINT QUAL/QUAN 380.30 XXX N  81317 PMS2 GENE ANALYSIS FULL SEQUENCE 1163.14 XXX N  81318 PMS2 GENE ANALYSIS KNOWN FAMILIAL VARIANTS 569.10 XXX N  81319 PMS2 GENE ANALYSIS DUPLICATION/DELETION VARIANTS 349.89 XXX N  81320 PLCG2 GENE ANALYSIS COMMON VARIANTS 500.95 XXX N  81321 PTEN GENE ANALYSIS FULL SEQUENCE ANALYSIS 1031.61 XXX N  81322 PTEN GENE ANALYSIS KNOWN FAMILIAL VARIANT 80.12 XXX N  81323 PTEN GENE ANALYSIS DUPLICATION/DELETION VARIANT 515.80 XXX N  81324 PMP22 GENE ANAL DUPLICATION/DELETION ANALYSIS 1303.88 XXX N

Pathology and Laboratory Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 80047-89398, G0480-G0483, G0659 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 248 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  81325 PMP22 GENE ANALYSIS FULL SEQUENCE ANALYSIS 1323.17 XXX N  81326 PMP22 GENE ANALYSIS KNOWN FAMILIAL VARIANT 80.12 XXX N  81327 SEPT9 GENE PROMOTER METHYLATION ANALYSIS 330.11 XXX N  81328 SLCO1B1 GENE ANALYSIS COMMON VARIANTS 300.56 XXX N  81329 SMN1 GENE ANALYSIS DOSAGE/DELET ALYS W/SMN2 ALYS 235.55 XXX N  81330 SMPD1 GENE ANALYSIS COMMON VARIANTS 80.81 XXX N  81331 SNRPN/UBE3A METHYLATION ANALYSIS 87.81 XXX N  81332 SERPINA1 GENE ANALYSIS COMMON VARIANTS 80.07 XXX N  81333 TGFBI GENE ANALYSIS COMMON VARIANTS 235.55 XXX N  81334 RUNX1 GENE ANALYSIS TARGETED SEQUENCE ANALYSIS 566.54 XXX N  81335 TPMT GENE ANALAYSIS COMMON VARIANTS 300.56 XXX N  81336 SMN1 GENE ANALYSIS FULL GENE SEQUENCE 518.12 XXX N  81337 SMN1 GENE ANALYSIS KNOWN FAMILIAL SEQ VARIANTS 318.42 XXX N  81338 MPL GENE ANALYSIS COMMON VARIANTS 258.47 XXX N  81339 MPL GENE ANALYSIS SEQUENCE ANALYSIS EXON 10 318.42 XXX N  81340 TRB@ REARRANGEMENT ANAL AMPLIFICATION METHOD 383.24 XXX N  81341 TRB@ REARRANGEMENT ANAL DIRECT PROBE METHODOLOGY 90.97 XXX N  81342 TRG@ GENE REARRANGEMENT ANALYSIS 369.62 XXX N  81343 PPP2R2B GENE ANALYSIS EVAL DETC ABNORMAL ALLELES 235.55 XXX N  81344 TBP GENE ANALYSIS EVAL DETECT ABNORMAL ALLELES 235.55 XXX N  81345 TERT GENE ANALYSIS TARGETED SEQUENCE ANALYSIS 318.42 XXX N  81346 TYMS GENE ANALYSIS COMMON VARIANTS 300.56 XXX N  81347 SF3B1 GENE ANALYSIS COMMON VARIANTS 332.26 XXX N  81348 SRSF2 GENE ANALYSIS COMMON VARIANTS 301.57 XXX N  81349 CYTOG ALYS CHRMOML ABNOR LOW-PASS SEQ ALYS 2203.56 XXX N  81350 UGT1A1 GENE ANALYSIS COMMON VARIANTS 402.33 XXX N  81351 TP53 GENE ANALYSIS FULL GENE SEQUENCE 1103.56 XXX N  81352 TP53 GENE ANALYSIS TARGETED SEQUENCE ANALYSIS 566.54 XXX N  81353 TP53 GENE ANALYSIS KNOWN FAMILIAL VARIANT 529.56 XXX N  81355 VKORC1 GENE ANALYSIS COMMON VARIANT(S) 151.65 XXX N  81357 U2AF1 GENE ANALYSIS COMMON VARIANTS 332.26 XXX N  81360 ZRSR2 GENE ANALYSIS COMMON VARIANT(S) 332.26 XXX N  81361 HBB COMMON VARIANTS 300.56 XXX N  81362 HBB KNOWN FAMILIAL VARIANTS 645.18 XXX N  81363 HBB DUPLICATION/DELETION VARIANTS 348.00 XXX N  81364 HBB FULL GENE SEQUENCE 558.07 XXX N  81370 HLA CLASS I&II LOW HLA-A -B -C -DRB1/3/4/5&DQB 737.66 XXX N  81371 HLA I&LI LOW RESOLUTION HLA-A -B&-DRB1 695.51 XXX N  81372 HLA CLASS I TYPING LOW RESOLUTION COMPLETE 693.91 XXX N  81373 HLA CLASS I TYPING LOW RESOLUTION ONE LOCUS EACH 219.10 XXX N  81374 HLA I LOW RESOLUTION ONE ANTIGEN EQUIVALENT EACH 133.45 XXX N  81375 HLA II LOW RESOLUTION HLA-DRB1/3/4/5 AND -DQB1 404.94 XXX N  81376 HLA CLASS II TYPING LOW RESOLUTION ONE LOCUS EA 224.20 XXX N  81377 HLA II LOW RESOLUTION ONE ANTIGEN EQUIVALENT EA 168.42 XXX N  81378 HLA I&II HIGH RESOLUTION HLA-A -B -C AND -DRB1 633.91 XXX N  81379 HLA CLASS I TYPING HIGH RESOLUTION COMPLETE 615.24 XXX N

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  81380 HLA CLASS I TYPING HIGH RESOLUTION ONE LOCUS EA 325.14 XXX N  81381 HLA I TYPING HIGH RESOLUTION 1 ALLELE/ALLELE GRP 292.12 XXX N  81382 HLA CLASS II TYPING HIGH RESOLUTION ONE LOCUS EA 226.88 XXX N  81383 HLA II HIGH RESOLUTION 1 ALLELE/ALLELE GROUP 200.20 XXX N  81400 MOLECULAR PATHOLOGY PROCEDURE LEVEL 1 109.97 XXX N  81401 MOLECULAR PATHOLOGY PROCEDURE LEVEL 2 235.55 XXX N  81402 MOLECULAR PATHOLOGY PROCEDURE LEVEL 3 258.47 XXX N  81403 MOLECULAR PATHOLOGY PROCEDURE LEVEL 4 318.42 XXX N  81404 MOLECULAR PATHOLOGY PROCEDURE LEVEL 5 472.53 XXX N  81405 MOLECULAR PATHOLOGY PROCEDURE LEVEL 6 518.12 XXX N  81406 MOLECULAR PATHOLOGY PROCEDURE LEVEL 7 486.37 XXX N  81407 MOLECULAR PATHOLOGY PROCEDURE LEVEL 8 1455.03 XXX N  81408 MOLECULAR PATHOLOGY PROCEDURE LEVEL 9 3438.69 XXX N  81410 AORTIC DYSFUNCTION/DILATION GENOMIC SEQ ANALYSIS 866.55 XXX N  81411 AORTIC DYSFUNCTION/DILATION DUP/DEL ANALYSIS 2321.44 XXX N  81412 ASHKENAZI JEWISH ASSOC DSRDRS GEN SEQ ANAL 9 GEN 4209.92 XXX N  81413 CAR ION CHNNLPATH GENOMIC SEQ ALYS INC 10 GNS 1072.96 XXX N  81414 CAR ION CHNNLPATH DUP/DEL GN ALYS PANEL 2 GENES 1072.96 XXX N  81415 EXOME SEQUENCE ANALYSIS 8218.47 XXX N  81416 EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME 20632.14 XXX N  81417 EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ 550.19 XXX N  81418 RX METAB GENOMIC SEQ ALYS PANEL AT LEAST 6 GENES 1686.93 XXX N  81419 EPILEPSY GENOMIC SEQUENCE ANALYSIS PANEL 4209.92 XXX N  81420 FETAL CHROMOSOMAL ANEUPLOIDY GENOMIC SEQ ANALYS 1305.07 XXX N  81422 FETAL CHROMOSOMAL MICRODELTJ GENOMIC SEQ ANALYS 1305.07 XXX N  81425 GENOME SEQUENCE ANALYSIS 8650.37 XXX N   81426 GENOME SEQUENCE ANALYSIS EACH COMPARATOR GENOME 4659.34 XXX N  81427 GENOME RE-EVALUATION OF PREC OBTAINED GENOME SEQ 4019.23 XXX N  81430 HEARING LOSS GENOMIC SEQUENCE ANALYSIS 60 GENES 2793.94 XXX N  81431 HEARING LOSS DUP/DEL ANALYSIS 1168.42 XXX N  81432 HEREDITARY BRST CA-RLATD DO GEN SEQ ALYS 5+ GEN 1245.67 XXX N  81434 HEREDITARY RTA DO GEN SEQ ALYS AT LEAST 15 GEN 1028.01 XXX N  81435 HEREDITARY COLON CA-RELATED DO GEN SEQ ALYS 5+ 1072.96 XXX N  81437 HERED NEUROEND TUM-RELATED DO GEN SEQ ALYS 5+ 805.19 XXX N  81439 HEREDITARY CARDIOMYOPATHY GEN SEQ ANALYS 5 GEN 1072.96 XXX N  81440 NUCLEAR MITOCHONDRIAL 100 GENE GENOMIC SEQ 5715.10 XXX N  81441 IBMFS SEQUENCE ANALYSIS PANEL AT LEAST 30 GENES 4299.24 XXX N  81442 NOONAN SPECTRUM DISORDERS GEN SEQ ANALYS 12 GEN 3685.59 XXX N  81443 GENETIC TESTING FOR SEVERE INHERITED CONDITIONS 4209.92 XXX N  81445 SOLID ORGAN NEOPLASM GSAP 5-50 DNA/DNA&RNA ALYS 1028.01 XXX N  81448 HEREDITARY PERIPHERAL NEUROPATHY GEN SEQ PNL 1072.96 XXX N  81449 SOLID ORGAN NEOPLASM GSAP 5-50 RNA ANALYSIS 1049.83 XXX N  81450 HEMATOLYMPHOID NEO/DO GSAP 5-50DNA/DNA&RNA ALYS 1305.89 XXX N  81451 HEMATOLYMPHOID NEO/DO GSAP 5-50 RNA ANALYSIS 1333.60 XXX N  81455 SO/HEMATOLYMPHOID NEO/DO 51/>GSAP DNA/DNA&RNA 5019.80 XXX N  81456 SO/HEMATOLYMPHOID NEO/DO 51/>RNA ANALYSIS 5126.31 XXX N

Pathology and Laboratory Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 80047-89398, G0480-G0483, G0659 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 250 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  81457 SO NEO GSAP DNA ALYS MICROSATELLITE INSTABILITY 1649.75 XXX N  81458 SO NEO GSAP DNA ALY CPY NMBR&MICROSATELLITE INS 1924.72

XXX N  81459 SO NEO GSAP DNA ALYS/DNA&RNA CPY NMBR MCRSTL INS 5499.15 XXX N  81460 WHOLE MITOCHONDRIAL GENOME 2212.80 XXX N  81462 SO NEO GSAP CLL FR DNA/DNA&RNA CPY NMBR&REARGMT 2199.68 XXX N  81463 SO NEO GSAP CLL FR DNA ALYS CPY NMBR&MCRSTL INS 2474.64 XXX N  81464 SO NEO GSAP CL FR DNA/DNA&RNA CPY NMBR MCRST INS 6049.07 XXX N  81465 WHOLE MITOCHONDRIAL GENOME ANALYSIS PANEL 1609.31 XXX N  81470 X-LINKED INTELLECTUAL DBLT GENOMIC SEQ ANALYS 1571.48 XXX N  81471 X-LINKED INTELLECTUAL DBLT DUP/DEL GENE ANALYS 1571.48 XXX N  81479 UNLISTED MOLECULAR PATHOLOGY PROCEDURE BR XXX N  81490 AUTOIMMUNE RHEUMATOID ARTHRITIS ALYS 12 BMRK 1445.37 XXX N  81493 COR ART DISEASE MRNA GENE EXPRESSION 23 GENES 1805.31 XXX N  81500 ONCO (OVARIAN) BIOCHEMICAL ASSAY TWO PROTEINS 447.89 XXX N  81503 ONCO (OVARIAN) BIOCHEMICAL ASSAY FIVE PROTEINS 1542.25 XXX N 665.95  81504 ONCOLOGY TISSUE OF ORIGIN SIMILAR SCOR ALGORITHM 894.06 XXX N  81506 ENDOCRINOLOGY BIOCHEMICAL ASSAY SEVEN ANAL 123.28 XXX N  81507 FETAL ANEUPLOIDY 21 18 13 SEQ ANALY TRISOM RISK 1366.88 XXX N  81508 FETAL CONGENITAL ABNOR ASSAY TWO PROTEINS 93.36 XXX N 144.80  81509 FETAL CONGENITAL ABNOR ASSAY 3 PROTEINS 2557.30 XXX N  81510 FETAL CONGENITAL ABNOR ASSAY THREE ANAL 95.49 XXX N 205.61  81511 FETAL CONGENITAL ABNOR ASSAY FOUR ANAL 263.92 XXX N 180.05  81512 FETAL CONGENITAL ABNOR ASSAY FIVE ANAL 119.53 XXX N 270.36  81513 NFCT DS BACTERAL VAGINOSIS RNA VAGINAL-FLUID ALG 245.23 XXX N  81514 NFCT DS BCT VAGINOSIS&VAGINITIS DNA VAG FLU ALG 452.17 XXX N  81515 NFCT DS BV&VAGINITIS RTPCR AMP DNA MARKERS 483.76 XXX N  81517 LIVER DS ALYS 3 BIOMARKERS IA SRM PROGNOSTIC ALG 320.16 XXX N  81518 ONCOLOGY BREAST MRNA GENE EXPRESSION 11 GENES 6659.02 XXX N  81519 ONCOLOGY BREAST MRNA GENE EXPRESSION 21 GENES 6659.02 XXX N  81520 ONC BREAST MRNA GENE XPRSN PRFL HYBRD 58 GENES 4604.79 XXX N  81521 ONC BREAST MRNA MICRORA GENE XPRSN PRFL 70 GENES 6659.02 XXX N  81522 ONCOLOGY BREAST MRNA GENE XPRSN PRFL 12 GENES 6659.02 XXX N  81523 ONC BRST MRNA NEXT GNRJ SEQ GEN XPRSN 70 CNT&31 6659.02 XXX N  81525 ONCOLOGY COLON MRNA GENE EXPRESSION 12 GENES 5357.48 XXX N  81528 ONCOLOGY COLORECTAL SCREENING QUAN 10 DNA MARKRS 874.92 XXX N  81529 ONC CUTAN MLNMA MRNA GENE XPRS PRFL 31 GENES ALG 12367.25 XXX N  81535 ONCOLOGY GYNE LIVE TUM CELL CLTR&CHEMO RESP 1ST 996.29 XXX N   81536 ONCOLOGY GYNE LIVE TUM CELL CLTR&CHEMO RESP ADD 305.29 XXX N  81538 ONCOLOGY LUNG MS 8-PROTEIN SIGNATURE 4936.24 XXX N  81539 ONCOLOGY PROSTATE BIOCHEMICAL ASSAY 4 PROTEINS 1306.70 XXX N  81540 ONCOLOGY TUM UNKNOWN ORIGIN MRNA 92 GENES 6447.54 XXX N  81541 ONC PRST8 MRNA GENE XPRSN PRFL RT-PCR 46 GENES 6659.02 XXX N  81542 ONC PRST8 MRNA MICRORA GENE XPRSN PRFL 22 GENES 6659.02 XXX N  81546 ONC THYR MRNA 10,196 GENES FINE NDL ASPIRATE ALG 6189.64 XXX N  81551 ONC PRST8 PRMTR METHYLATION PRFL R-T PCR 3 GENES 3490.27 XXX N  81552 ONC UVEAL MLNMA MRNA GENE XPRSN PRFL 15 GENES 13369.63 XXX N

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  81554 PULM DS IPF MRNA 190 GENE TRANSBRONCHIAL BX ALG 9456.40 XXX N  81558 TRNSPLJ REJ KDN MRNA GENE XPRSN PRFLG QPCR 139 5959.84 XXX N  81560 TRNSPLJ PED LVR&BWL MES CD154+T CLL WHL PRPH BLD 1178.60 XXX N  81595 CARDIOLOGY HRT TRNSPL MRNA GENE EXPRESS 20 GENES 5570.68 XXX N  81596 NFCT DS CHRNC HCV 6 BIOCHEM ASSAY SRM ALG LVR 124.12 XXX N  81599 UNLISTED MULTIANALYTE ASSAY ALGORITHMIC ANALYSIS BR XXX N 322.29  82009 KETONE BODYS QUALITATIVE 8.29 XXX N  82010 KETONE BODYS QUANTITATIVE 14.99 XXX N  82013 ASSAY OF ACETYLCHOLINESTERASE 21.13 XXX N  82016 ACYLCARNITINES QUALITATIVE EACH SPECIMEN 28.35 XXX N  82017 ACYLCARNITINES QUANTIATIVE EACH SPECIMEN 30.94 XXX N  82024 ADRENOCORTICOTROPIC HORMONE ACTH 70.84 XXX N  82030 ADENOSINE 5-MONOPHOSPHATE CYCLIC 47.33 XXX N  82040 ALBUMIN SERUM PLASMA/WHOLE BLOOD 9.08 XXX N  82042 OTHER SOURCE ALBUMIN QUANTITATIVE EACH SPECIMEN 13.38 XXX N  82043 URINE ALBUMIN QUANTITATIVE 10.60 XXX N  82044 URINE ALBUMIN SEMIQUANTITATIVE 10.71 XXX N  82045 ALBUMIN ISCHEMIA MODIFIED 62.26 XXX N  82075 ASSAY OF ALCOHOL (ETHANOL) BREATH 51.58 XXX N  82077 ASSAY OF ALCOHOL (ETHANOL) SPEC XCP UR&BREATH IA 29.69 XXX N  82085 ASSAY OF ALDOLASE 17.81 XXX N  82088 ASSAY OF ALDOSTERONE 74.76 XXX N  82103 ALPHA-1-ANTITRYPSIN TOTAL 24.65 XXX N  82104 ALPHA-1-ANTITRYPSIN PHENOTYPE 26.53 XXX N  82105 ALPHA-FETOPROTEIN SERUM 30.77 XXX N  82106 ALPHA-FETOPROTEIN AMNIOTIC FLUID 30.77 XXX N  82107 AFP-L3 FRACTION ISOFORM & TOTAL AFP W/RATIO 118.16 XXX N  82108 ASSAY OF ALUMINUM 46.74 XXX N  82120 AMINES VAGINAL FLUID QUALITATIVE 10.30 XXX N  82127 AMINO ACIDS 1 QUALITATIVE EACH SPECIMEN 25.44 XXX N  82128 AMINO ACIDS MULTIPLE QUALITATIVE EACH SPECIMEN 25.44 XXX N  82131 AMINO ACIDS 1 QUANTITATIVE EACH SPECIMEN 39.51 XXX N  82135 AMINOLEVULINIC ACID DELTA 30.18 XXX N  82136 AMINO ACIDS 2-5 AMINO ACIDS QUANTITATIVE EA SPEC 33.72 XXX N  82139 AMINO ACIDS 6/> AMINO ACIDS QUANTITATIVE EA SPE 30.94 XXX N  82140 ASSAY OF AMMONIA 26.73 XXX N  82143 AMNIOTIC FLU SCAN 16.08 XXX N  82150 ASSAY OF AMYLASE 11.89 XXX N  82154 ANDROSTANEDIOL GLUCURONIDE 52.90 XXX N  82157 ANDROSTENEDIONE 53.71 XXX N  82160 ANDROSTERONE 45.86 XXX N  82163 ANGIOTENSIN II 37.64 XXX N  82164 ANGIOTENSIN I-CONVERTING ENZYME 26.78 XXX N  82166 ASSAY OF ANTI-MULLERIAN HORMONE 70.18 XXX N  82172 APOLIPOPROTEIN EACH 36.26 XXX N  82175 ASSAY OF ARSENIC 34.80 XXX N  82180 ASSAY OF ASCORBIC ACID BLOOD 18.13 XXX N

Pathology and Laboratory Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 80047-89398, G0480-G0483, G0659 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 252 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  82190 ATOMIC ABSRPJ SPECTROSCOPY EA ANALYTE 27.34 XXX N  82232 BETA-2 MICROGLOBULIN 29.67 XXX N  82233 BETA-AMYLOID 1-40 (ABETA 40) BR XXX N  82234 BETA-AMYLOID 1-42 (ABETA 42) BR XXX N  82239 BILE ACIDS TOTAL 31.42 XXX N  82240 BILE ACIDS CHOLYLGLYCINE 48.75 XXX N  82247 BILIRUBIN TOTAL 9.20 XXX N  82248 BILIRUBIN DIRECT 9.20 XXX N  82252 BILIRUBIN FECES QUALITATIVE 8.35 XXX N  82261 BIOTINIDASE EACH SPECIMEN 30.94 XXX N  82270 BLOOD OCCULT PEROXIDASE ACTV QUAL FECES 1 DETER 7.53 XXX N  82271 BLOOD OCCULT PEROXIDASE ACTV QUAL OTHER SOURCES 9.15 XXX N  82272 BLOOD OCCULT PEROXIDASE ACTV QUAL FECES 1-3 SPEC 7.27 XXX N  82274 BLOOD OCCULT FECAL HGB DETER IA QUAL FECES 1-3 29.17 XXX N  82286 BRADYKININ 9.46 XXX N  82300 CADMIUM 42.46 XXX N  82306 25 HYDROXY INCLUDES FRACTIONS IF PERFORMED 54.30 XXX N  82308 CALCITONIN 49.15 XXX N  82310 CALCIUM TOTAL 9.46 XXX N  82330 CALCIUM IONIZED 25.09 XXX N  82331 CALCIUM AFTER CALCIUM INFUSION TEST 22.94 XXX N  82340 CALCIUM URINE QUANTITATIVE TIMED SPECIMEN 11.06 XXX N  82355 CALCULUS QUALITATIVE ANALYSIS 21.23 XXX N  82360 CALCULUS QUANTITATIVE CHEMICAL 23.61 XXX N  82365 CALCULUS INFRARED SPECTROSCOPY 23.66 XXX N  82370 CALCULUS XRAY DIFFRACTION 22.98 XXX N  82373 CARBOHYDRATE DEFICIENT TRANSFERRIN 33.12 XXX N  82374 CARBON DIOXIDE BICARBONATE 8.96 XXX N  82375 CARBOXYHEMOGLOBIN QUANTITATIVE 22.60 XXX N  82376 CARBOXYHEMOGLOBIN QUALITATIVE 24.19 XXX N  82378 CARCINOEMBRYONIC ANTIGEN CEA 34.79 XXX N  82379 CARNITINE QUANTITATIVE EACH SPECIMEN 30.94 XXX N  82380 CAROTENE 16.92 XXX N  82382 CATECHOLAMINES TOTAL URINE 46.94 XXX N  82383 CATECHOLAMINES BLOOD 50.00 XXX N  82384 CATECHOLAMINES FRACTIONATED 46.33 XXX N  82387 CATHEPSIN-D 33.12 XXX N  82390 CERULOPLASMIN 19.70 XXX N  82397 CHEMILUMINESCENT ASSAY 25.90 XXX N  82415 CHLORAMPHENICOL 23.25 XXX N  82435 CHLORIDE BLD 8.44 XXX N  82436 CHLORIDE URINE 9.89 XXX N  82438 CHLORIDE OTHER SOURCE 8.96 XXX N  82441 CHLORINATED HYDROCARBONS SCREEN 11.01 XXX N  82465 CHOLESTEROL SERUM/WHOLE BLOOD TOTAL 7.99 XXX N  82480 CHOLINESTERASE SERUM 14.45 XXX N  82482 CHOLINESTERASE RBC 16.87 XXX N

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  82485 CHONDROITIN B SULFATE QUANTITATIVE 37.89 XXX N  82495 ASSAY OF CHROMIUM 37.20 XXX N  82507 ASSAY OF CITRATE 51.00 XXX N  82523 COLLAGEN CROSS LINKS ANY METHOD 34.27 XXX N  82525 ASSAY OF COPPER 22.77 XXX N  82528 CORTICOSTERONE 41.31 XXX N  82530 CORTISOL FREE 30.66 XXX N  82533 CORTISOL TOTAL 29.90 XXX N  82540 ASSAY OF CREATINE 8.50 XXX N  82542 COL-CHR/MS NONDRUG ANALYTE NES QUAL/QUAN EA SPEC 41.42 XXX N  82550 CREATINE KINASE TOTAL 11.94 XXX N  82552 CREATINE KINASE ISOENZYMES 24.57 XXX N  82553 CREATINE KINASE MB FRACTION ONLY 21.18 XXX N  82554 CREATINE KINASE ISOFORMS 21.78 XXX N  82565 CREATININE BLOOD 9.39 XXX N  82570 CREATININE OTHER SOURCE 9.49 XXX N  82575 CREATININE CLEARANCE 17.35 XXX N  82585 ASSAY OF CRYOFIBRN 24.31 XXX N  82595 CRYOGLOBULIN QUALITATIVE/SEMI-QUANTITATIVE 11.85 XXX N  82600 ASSAY OF CYANIDE 35.58 XXX N  82607 CYANOCOBALAMIN VITAMIN B-12 27.65 XXX N  82608 CYANOCOBALAMIN VIT B-12 UNSAT BINDING CAPACITY 26.27 XXX N  82610 CYSTATIN C 31.84 XXX N  82615 CSTINE&HOMOCSTINE URINE QUALITATIVE 16.42 XXX N  82626 DEHYDROEPIANDROSTERONE 46.36 XXX N  82627 DEHYDROEPIANDROSTERONE-SULFATE 40.80 XXX N  82633 DESOXYCORTICOSTERONE 11- 56.84 XXX N  82634 DEOXYCORTISOL 11- 53.71 XXX N  82638 ASSAY OF DIBUCAINE NUMBER 22.47 XXX N  82642 DIHYDROTESTOSTERONE (DHT) 53.71 XXX N  82652 1 25 DIHYDROXY INCLUDES FRACTIONS IF PERFORMED 70.63 XXX N  82653 ELASTASE PANCREATIC FECAL QUANTITATIVE 39.49 XXX N  82656 ELASTASE PANCREATIC FECAL QUAL/SEMI-QUANTITATIVE 21.15 XXX N  82657 NZYM ACTIV BLD CELLS/TISS NONRADACT SUBSTRATE EA 38.12 XXX N  82658 NZYM ACTV BLOOD CELLS/TISS RADACT SUBSTRATE EA 75.70 XXX N  82664 ELCTROPHORETIC TECHNIQUE NOT ELSEWHERE SPECIFIED 105.74 XXX N  82668 ASSAY OF ERYTHROPOIETIN 34.47 XXX N  82670 ASSAY OF TOTAL ESTRADIOL 51.25 XXX N  82671 ASSAY OF ESTROGENS FRACTIONATED 59.25 XXX N  82672 ASSAY OF ESTROGENS TOTAL 39.81 XXX N  82677 ASSAY OF ESTRIOL 44.36 XXX N  82679 ASSAY OF ESTRONE 45.78 XXX N  82681 ASSAY OF DIRECT MEASUREMENT FREE ESTRADIOL 48.04 XXX N  82693 ASSAY OF ETHYLENE GLYCOL 27.34 XXX N  82696 ASSAY OF ETIOCHOLANOLONE 45.12 XXX N  82705 FAT/LIPIDS FECES QUALITATIVE 9.34 XXX N  82710 FAT/LIPIDS FECES QUANTITATIVE 30.82 XXX N

Pathology and Laboratory Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 80047-89398, G0480-G0483, G0659 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 254 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  82715 FAT DIFFIAL FECES QUANTITATIVE 39.49 XXX N  82725 FATTY ACIDS NONESTERIFIED 32.27 XXX N  82726 VERY LONG CHAIN FATTY ACIDS 33.96 XXX N  82728 ASSAY OF FERRITIN 25.01 XXX N  82731 FTL FIBRONECTIN CERVICOVAG SECRETIONS SEMI-QUAN 118.16 XXX N  82735 ASSAY OF FLUORIDE 34.01 XXX N  82746 ASSAY OF FOLIC ACID SERUM 26.98 XXX N  82747 ASSAY OF FOLIC ACID RBC 31.78 XXX N  82757 ASSAY OF FRUCTOSE SEMEN 31.80 XXX N  82759 ASSAY OF GALACTOKINASE RBC 39.41 XXX N  82760 ASSAY OF GALACTOSE 20.54 XXX N  82775 GALACTOSE-1-PHOSPHATE URIDYL TRANSFERASE QUAN 38.65 XXX N  82776 GALACTOSE-1-PHOSPHATE URIDYL TRANSFERASE SCREEN 20.19 XXX N  82777 GALECTIN-3 76.08 XXX N  82784 ASSAY OF GAMMAGLOBULIN IGA IGD IGG IGM EACH 17.07 XXX N  82785 ASSAY OF GAMMAGLOBULIN IGE 30.20 XXX N  82787 GAMMAGLOBULIN IMMUNOGLOBULIN SUBCLASSES 14.71 XXX N  82800 GASES BLOOD PH ONLY 18.91 XXX N  82803 BLOOD GASES ANY COMBINATION PH PCO2 PO2 CO2 HCO3 44.82 XXX N  82805 GASES BLOOD PH DIRECT MEAS XCPT PULSE OXIMITRY 135.43 XXX N  82810 GASES BLOOD O2 SATURATION ONLY DIRECT MEAS 16.80 XXX N  82820 HGB-O2 AFFINITY PO2 50% SATURATION OXYGEN 22.94 XXX N  82930 GASTRIC ACID ANALYIS W/PH EACH SPECIMEN 11.54 XXX N  82938 GASTRIN AFTER SECRETIN STIMULATION 32.46 XXX N  82941 ASSAY OF GASTRIN 32.34 XXX N  82943 ASSAY OF GLUCAGON 26.22 XXX N  82945 GLUCOSE BODY FLUID OTHER THAN BLOOD 7.21 XXX N  82946 GLUCOSE TOLERANCE TEST 30.55 XXX N  82947 GLUCOSE QUANTITATIVE BLOOD XCPT REAGENT STRIP 7.21 XXX N  82948 GLUCOSE BLOOD REAGENT STRIP 8.67 XXX N  82950 GLUCOSE POST GLUCOSE DOSE 8.70 XXX N  82951 GLUCOSE TOLERANCE TEST GTT 3 SPECIMENS 23.61 XXX N  

20 Miss. Admin. Code Pt. 2, R. 82952 Rule 82952

GLUCOSE TOLERANCE EA ADDL BEYOND 3 SPECIMENS 7.20 XXX N  82955 GLUC-6-PHOSPHATE DEHYDROGENASE QUANTITATIVE 17.78 XXX N  82960 GLUC-6-PHOSPHATE DEHYDROGENASE SCREEN 11.09 XXX N  82962 GLUC BLD GLUC MNTR DEV CLEARED FDA SPEC HOME USE 5.64 XXX N  82963 ASSAY OF GLUCOSIDASE BETA 39.41 XXX N  82965 ASSAY OF GLUTAMATE DEHYDROGENASE 22.61 XXX N  82977 ASSAY OF GLUTAMYLTRASE GAMMA 13.21 XXX N  82978 ASSAY OF GLUTATHIONE 26.56 XXX N  82979 ASSAY OF GLUTATHIONE REDUCTASE RBC 17.32 XXX N  82985 ASSAY OF GLYCATED PROTEIN 28.82 XXX N  83001 GONADOTROPIN FOLLICLE STIMULATING HORMONE 34.09 XXX N  83002 GONADOTROPIN LUTEINIZING HORMONE 33.96 XXX N  83003 ASSAY OF GROWTH HORMONE HUMAN 30.58 XXX N  83006 GROWTH STIMULATION EXPRESSED GENE 2 129.98 XXX N  83009 HPYLORI BLOOD ANAL UREASE ACT NON-RADACT ISOTOPE 123.56 XXX N

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  83010 ASSAY OF HAPTOGLOBIN QUANTITATIVE 23.06 XXX N  83012 ASSAY OF HAPTOGLOBIN PHENOTYPES 46.23 XXX N  83013 HPYLORI BREATH ANAL UREASE ACT NON-RADACT ISTOPE 123.56 XXX N  83014 HPYLORI DRUG ADMINISTRATION 14.41 XXX N  83015 HEAVY METAL QUALITATIVE ANY ANALYTES 36.00 XXX N  83018 HEAVY METAL QUANTIATIVE EACH NES 40.30 XXX N  83020 HEMOGLOBIN FRACTJ/QUANTJ ELECTROPHORESIS 54.55 31.54 23.01 XXX N  83021 HEMOGLOBIN FRACTJ/QUANTJ CHROMOTOGRAPHY 33.12 XXX N  83026 HEMOGLOBIN COPPER SULFATE METHOD NON-AUTOMATED 6.89 XXX N  83030 HEMOGLOBIN F FETAL CHEMICAL 18.47 XXX N  83033 HEMOGLOBIN F FETAL QUALITATIVE 13.75 XXX N  83036 HEMOGLOBIN GLYCOSYLATED A1C 17.81 XXX N  83037 HGB GLYCOSYLATED A1C DEVICE CLEARED FDA HOME USE 17.81 XXX N  83045 HEMOGLOBIN METHEMOGLOBIN QUALITATIVE 11.16 XXX N  83050 HEMOGLOBIN METHEMOGLOBIN QUANTITATIVE 14.10 XXX N  83051 HEMOGLOBIN PLASMA 13.41 XXX N  83060 HEMOGLOBIN SULFHEMOGLOBIN QUANTITATIVE 15.17 XXX N  83065 HEMOGLOBIN THERMOLABILE 15.47 XXX N  83068 HEMOGLOBIN UNSTABLE SCREEN 16.28 XXX N  83069 HEMOGLOBIN URINE 7.25 XXX N  83070 ASSAY OF HEMOSIDERIN QUALITATIVE 8.70 XXX N  83080 ASSAY OF B-HEXOSAMINIDASE EACH ASSAY 30.94 XXX N  83088 ASSAY OF HISTAMINE 54.17 XXX N  83090 ASSAY OF HOMOCYSTEINE 30.94 XXX N  83150 ASSAY OF HOMOVANILLIC ACID 38.53 XXX N  83491 ASSAY OF HYDROXYCORTICOSTEROIDS 17 32.14 XXX N  83497 ASSAY OF HYDROXYINDOLACETIC ACID 5-HIAA 23.66 XXX N  83498 ASSAY OF HYDROXYPROGESTERONE 17-D 49.84 XXX N  83500 ASSAY OF FREE HYDROXYPROLINE 41.56 XXX N  83505 ASSAY OF TOTAL HYDROXYPROLINE 44.59 XXX N  83516 IMMUNOASSAY ANALYTE QUAL/SEMIQUAN MULTIPLE STEP 21.15 XXX N  83518 IMMUNOASSAY ANALYTE QUAL/SEMIQUAL SINGLE STEP 16.57 XXX N  83519 IMMUNOASSAY ANALYTE QUANT RADIOIMMUNOASSAY 31.64 XXX N  83520 IMMUNOASSAY ANALYTE QUANTITATIVE NOS 29.69 XXX N  83521 IMMUNOGLOBULIN LIGHT CHAINS FREE EACH 29.69 XXX N  83525 ASSAY OF INSULIN TOTAL 20.97 XXX N  83527 ASSAY OF INSULIN FREE 23.76 XXX N  83528 ASSAY OF INTRINSIC FACTOR 34.08 XXX N  83529 ASSAY OF INTERLEUKIN-6 (IL-6) 29.69 XXX N  83540 ASSAY OF IRON 11.87 XXX N  83550 IRON BINDING CAPACITY 16.03 XXX N  83570 ISOCITRIC DEHYDROGENASE 16.23 XXX N  83582 ASSAY OF KETOGENIC STEROIDS FRACTIONATION 26.60 XXX N  83586 ASSAY OF KETOSTEROIDS 17- TOTAL 23.48 XXX N  83593 KETOSTEROIDS 17- FRACTIONATION 49.00 XXX N  83605 ASSAY OF LACTATE 19.89 XXX N  83615 LACTATE DEHYDROGENASE LDH 11.08 XXX N

Pathology and Laboratory Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 80047-89398, G0480-G0483, G0659 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 256 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  83625 LACTATE DEHYDROGENASE ISOENZYMES SEP&QUAN 23.48 XXX N  83630 LACTOFERRIN FECAL QUALITATIVE 36.01 XXX N  83631 LACTOFERRIN FECAL QUANTITATIVE 36.01 XXX N  83632 LACTOGEN HPL HUMAN CHORIONIC SOMATOMAMMOTROPIN 37.10 XXX N  83633 LACTOSE URINE QUALITATIVE 19.34 XXX N  83655 ASSAY OF LEAD 22.21 XXX N  83661 FETAL LUNG MATURITY LECITHIN SPHINGOMYELIN RATIO 40.33 XXX N  83662 FETAL LUNG MATURITY FOAM STABILITY TEST 34.69 XXX N  83663 FETAL LUNG MATURITY FLUORESCENCE POLARIZATION 34.69 XXX N  83664 FETAL LUNG MATURITY LAMELLAR BODY DENSITY 34.69 XXX N  83670 LEUCINE AMINOPEPTIDASE LAP 16.87 XXX N  83690 ASSAY OF LIPASE 12.63 XXX N  83695 LIPOPROTEIN (A) 24.62 XXX N  83698 LIPOPROTEIN-ASSOCIATED PHOSPHOLIPASE A2 79.62 XXX N  83700 LIPOPROTEIN BLOOD ELECTROPHORECTIC SEP&QUAN 20.65 XXX N  83701 LIPOPROTEIN BLOOD HIGH RESOLTJ&QUANTJ SUBCLASS 58.22 XXX N  83704 LIPOPROTEIN BLOOD QUAN NUMBERS & SUBCLASSES 58.78 XXX N  83718 LIPOPROTEIN DIR MEAS HIGH DENSITY CHOLESTEROL 15.02 XXX N  83719 LIPOPROTEIN DIRECT MEASUREMENT VLDL CHOLESTEROL 21.92 XXX N  83721 LIPOPROTEIN DIRECT MEASUREMENT LDL CHOLESTEROL 18.05 XXX N  83722 DIR MEAS LIPOPROTEIN SMALL DENSE LDL CHOLESTEROL 58.78 XXX N  83727 LUTEINIZING RELEASING FACTOR 31.53 XXX N  83735 ASSAY OF MAGNESIUM 12.28 XXX N  83775 ASSAY OF MALATE DEHYDROGENASE 13.52 XXX N  83785 ASSAY OF MANGANESE 45.82 XXX N  83789 MASS SPECT&TANDEM MASS SPECT NONDRG ANAL NES EA 41.45 XXX N  83825 ASSAY OF MERCURY QUANTITATIVE 29.82 XXX N  83835 METANEPHRINES 31.07 XXX N  83857 METHEMALBUMIN 19.70 XXX N  83861 MICROFLUIDIC ANALYSIS TEAR OSMOLARITY 38.65 XXX N  83864 MUCOPOLYSACCHARIDES ACID QUANTITATIVE 49.00 XXX N  83872 MUCIN SYNOVIAL FLUID ROPES TEST 10.75 XXX N  83873 MYELIN BASIC PROTEIN CEREBROSPINAL FLUID 31.57 XXX N  83874 MYOGLOBIN 23.69 XXX N  83876 MYELOPEROXIDASE MPO 87.45 XXX N  83880 NATRIURETIC PEPTIDE 67.50 XXX N  83883 ASSAY OF NEPHELOMETRY EACH ANALYTE NES 24.95 XXX N  83884 ASSAY NEUROFILAMENT LIGHT CHAIN BR XXX N  83885 ASSAY OF NICKEL 44.96 XXX N  83915 ASSAY OF NUCLEOTIDASE 5'- 20.46 XXX N  83916 OLIGOCLONAL IMMUNE 47.09 XXX N  83918 ORGANIC ACIDS TOTAL QUANTITATIVE EACH SPECIMEN 40.58 XXX N  83919 ORGANIC ACIDS QUALITATIVE EACH SPECIMEN 30.18 XXX N  83921 ORGANIC ACID 1 QUANTITATIVE 36.47 XXX N  83930 ASSAY OF OSMOLALITY BLOOD 12.13 XXX N  83935 ASSAY OF OSMOLALITY URINE 12.50 XXX N  83937 ASSAY OF OSTEOCALCIN 54.75 XXX N

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  83945 ASSAY OF OXALATE 24.84 XXX N  83950 ONCOPROTEIN HER-2/NEU 118.16 XXX N  83951 ONCOPROTEIN DES-GAMMA-CARBOXY-PROTHROMBIN DCP 118.16 XXX N  83970 ASSAY OF PARATHORMONE 75.71 XXX N  83986 PH BODY FLUID NOT ELSEWHERE SPECIFIED 6.57 XXX N  83987 PH EXHALED BREATH CONDENSATE 6.57 XXX N  83992 ASSAY OF PHENCYCLIDINE 76.76 XXX N  83993 ASSAY OF CALPROTECTIN FECAL 36.01 XXX N  84030 ASSAY OF PHENYLALANINE BLOOD 10.09 XXX N  84035 ASSAY OF PHENYLKETONES QUALITATIVE 6.84 XXX N  84060 ASSAY OF PHOSPHATASE ACID TOTAL 13.55 XXX N  84066 ASSAY OF PHOSPHATASE ACID PROSTATIC 17.72 XXX N  84075 ASSAY OF PHOSPHATASE ALKALINE 9.49 XXX N  84078 ASSAY OF PHOSPHATASE ALKALINE HEAT STABLE 14.20 XXX N  84080 ASSAY OF PHOSPHATASE ALKALINE ISOENZYMES 27.13 XXX N  84081 PHOSPHATIDYLGLYCEROL 30.30 XXX N  84085 PHOSPHOGLUCONATE 6-DEHYD RBC 17.32 XXX N  84087 ASSAY OF PHOSPHOHEXOSE ISOMERASE 18.94 XXX N  84100 ASSAY OF PHOSPHORUS INORGANIC 8.70 XXX N  84105 ASSAY OF PHOSPHORUS INORGANIC URINE 9.94 XXX N  84106 PORPHOBILINOGEN URINE QUALITATIVE 10.01 XXX N  84110 ASSAY OF PORPHOBILINOGEN URINE QUANTITATIVE 15.49 XXX N  84112 EVAL C/V AMNIOTIC FLUID PROTEIN QUAL EA SPECIMEN 168.68 XXX N  84119 PORPHYRINS URINE QUALITATAIVE 22.97 XXX N  84120 PORPHYRINS URINE QUANTITATION & FRACTIONATION 26.99 XXX N  84126 PORPHYRINS FECES QUANTITATIVE 67.24 XXX N  84132 POTASSIUM SERUM PLASMA/WHOLE BLOOD 8.44 XXX N  84133 POTASSIUM URINE 8.13 XXX N  84134 PREALBUMIN 26.76 XXX N  84135 PREGNANEDIOL 36.57 XXX N  84138 PREGNANETRIOL 36.19 XXX N  84140 PREGNENOLONE 37.92 XXX N  84143 17-HYDROXYPREGNENOLONE 41.84 XXX N  84144 ASSAY OF PROGESTERONE 38.27 XXX N  84145 PROCALCITONIN (PCT) 49.15 XXX N  84146 ASSAY OF PROLACTIN 35.55 XXX N  84150 ASSAY OF PROSTAGLNDIN EACH 71.82 XXX N  84152 ASSAY OF PROSTATE SPECIFIC ANTIGEN COMPLEXED 33.75 XXX N  84153 ASSAY OF PROSTATE SPECIFIC ANTIGEN TOTAL 33.75 XXX N  84154 ASSAY OF PROSTATE SPECIFIC ANTIGEN FREE 33.75 XXX N  84155 PROTEIN XCPT REFRACTOMETRY SERUM PLASMA/WHL BLD 6.72 XXX N  84156 PROTEIN TOTAL XCPT REFRACTOMETRY URINE 6.72 XXX N  84157 PROTEIN TOTAL XCPT REFRACTOMETRY OTH SRC 6.88 XXX N  84160 PROTEIN TOTAL REFRACTOMETRY ANY SRC 9.65 XXX N  84163 PREGNANCY-ASSOCIATED PLASMA PROTEIN-A 27.62 XXX N  84165 PROTEIN ELECTROPHORETIC FRACTJ&QUANTJ SERUM 50.64 31.54 19.10 XXX N  84166 PROTEIN ELECTROP FXJ&QUAN OTH FLUS CONCENTRATI 63.65 31.54 32.11 XXX N

Pathology and Laboratory Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 80047-89398, G0480-G0483, G0659 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 258 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  84181 PROTEIN WESTRN BLOT I&R BLOOD/OTHER FLUID 62.18 31.54 30.64 XXX N  84182 PROTEIN WESTRN BLOT BLOOD/OTH FLU IMMUNOLOGICAL 81.76 31.54 50.22 XXX N  84202 PROTOPORPHYRIN RBC QUANTITATIVE 26.32 XXX N  84203 PROTOPORPHYRIN RBC SCREEN 16.75 XXX N  84206 ASSAY OF PROINSULIN 45.89 XXX N  84207 ASSAY OF PYRIDOXAL PHOSPHATE 51.54 XXX N  84210 ASSAY OF PYRUVATE 24.90 XXX N  84220 ASSAY OF PYRUVATE KINASE 17.32 XXX N  84228 ASSAY OF QUININE 21.35 XXX N  84233 ASSAY OF RECEPTOR ASSAY ESTROGEN 151.10 XXX N  84234 ASSAY OF RECEPTOR ASSAY PROGESTERONE 119.02 XXX N  84235 RECEPTOR ASSAY ENDOCRINE OTH/THN ESTRGN/PROGST 122.47 XXX N  84238 RECEPTOR ASSAY NON-ENDOCRINE SPECIFY RECEPTOR 67.08 XXX N  84244 ASSAY OF RENIN 40.35 XXX N  84252 ASSAY OF RIBOFLAVIN-VITAMIN B-2 37.13 XXX N  84255 ASSAY OF SELENIUM 46.84 XXX N  84260 ASSAY OF SEROTONIN 56.84 XXX N  84270 ASSAY OF SEX HORMONE BINDING GLOBULIN 39.87 XXX N  84275 ASSAY OF SIALIC ACID 24.65 XXX N  84285 ASSAY OF SILICA 43.34 XXX N  84295 SODIUM SERUM PLASMA OR WHOLE BLOOD 8.83 XXX N  84300 ASSAY OF URINE SODIUM 8.92 XXX N  84302 ASSAY OF SODIUM OTHER SOURCE 8.92 XXX N  84305 ASSAY OF SOMATOMEDIN 39.01 XXX N  84307 ASSAY OF SOMATOSTATIN 33.53 XXX N  84311 SPECTROPHOTOMETRY ANALYT NOT ELSEWHERE SPECIFIED 13.93 XXX N  84315 SPECIFIC GRAVITY EXCEPT URINE 5.64 XXX N  84375 SUGARS CHROMATOGRAPHIC TLC/PAPER CHROMATOGRAPHY 67.05 XXX N  84376 SUGARS MONO DI&OLIGOS 1 QUALITATAIVE EACH SPEC 10.09 XXX N  84377 SUGARS MONO DI&OLIGOS MLT QUALITATIVE EACH SPE 10.09 XXX N  84378 SUGARS MONO DI&OLIGOS 1 QUANTITATIVE EACH SPEC 21.15 XXX N  84379 SUGARS MONO DI&OLIGOS MLT QUANTITATIVE EA SPEC 21.15 XXX N  84392 ASSAY OF SULFATE URINE 9.44 XXX N  84393 TAU PHOSPHORYLATED EACH BR XXX N  84394 TOTAL TAU (TTAU) BR XXX N  84402 ASSAY OF TESTOSTERONE FREE 46.72 XXX N  84403 ASSAY OF TESTOSTERONE TOTAL 47.35 XXX N  84410 ASSAY BIOVLBL TESTOSTERONE DIRECT MEASUREMENT 94.07 XXX N  84425 ASSAY OF THIAMINE-VITAMIN B-1 38.95 XXX N  84430 ASSAY OF THIOCYANATE 21.35 XXX N  84431 THROMBOXANE METABOLITE W/WO THROMBOXANE URINE 60.37 XXX N  84432 ASSAY OF THYROGLOBULIN 29.45 XXX N  84433 ASSAY THIOPURINE S-METHYLTRANSFERASE 38.93 XXX N  84436 ASSAY OF THYROXINE TOTAL 12.60 XXX N  84437 ASSAY OF THYROXINE REQUIRING ELUTION 11.85 XXX N  84439 ASSAY OF FREE THYROXINE 16.54 XXX N

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  84442 ASSAY OF THYROXINE BINDING GLOBULIN 27.13 XXX N  84443 ASSAY OF THYROID STIMULATING HORMONE TSH 30.82 XXX N  84445 THYROID STIMULATING IMMUNE GLOBULINS TSI 93.30 XXX N  84446 ASSAY OF TOCOPHEROL ALPHA VITAMIN E 26.00 XXX N  84449 ASSAY OF TRANSCORTIN CORTISOL BINDING GLOBULIN 33.02 XXX N  84450 TRANSFERASE ASPARTATE AMINO AST SGOT 9.49 XXX N  84460 TRANSFERASE ALANINE AMINO ALT SGPT 9.72 XXX N  84466 ASSAY OF L7383TRANSFERRIN 23.41 XXX N  84478 ASSAY OF TRIGLYCERIDES 10.53 XXX N  84479 THYROID HORM UPTK/THYROID HORMONE BINDING RATIO 11.85 XXX N  84480 ASSAY OF TRIIODOTHYRONINE T3 TOTAL TT3 26.00 XXX N  84481 ASSAY OF TRIIODOTHYRONINE T3 FREE 31.07 XXX N  84482 TRIIODOTHYRONINE T3 REVERSE 28.91 XXX N  84484 ASSAY OF TROPONIN QUANTITATIVE 21.44 XXX N  84485 ASSAY OF TRYPSIN DUODENAL FLUID 13.21 XXX N  84488 ASSAY OF TRYPSIN FECES QUALITATIVE 13.39 XXX N  84490 TRYPSIN FECES QUANTITATIVE 24-HR COLLECTION 17.07 XXX N  84510 ASSAY OF TYROSINE 19.09 XXX N  84512 ASSAY OF TROPONIN QUALITATIVE 17.35 XXX N  84520 ASSAY OF UREA NITROGEN QUANTITATIVE 7.25 XXX N  84525 ASSAY OF UREA NITROGEN SEMIQUANTITATIVE 8.82 XXX N  84540 ASSAY OF UREA NITROGEN URINE 9.56 XXX N  84545 UREA NITROGEN CLEARANCE 12.38 XXX N  84550 ASSAY OF BLOOD/URIC ACID 8.29 XXX N  84560 ASSAY OF URIC ACID OTHER SOURCE 8.73 XXX N  84577 ASSAY OF UROBILINOGEN FECES QUANTITATIVE 30.82 XXX N  84578 ASSAY OF UROBILINOGEN URINE QUALITATIVE 7.69 XXX N  84580 UROBILINOGEN URINE QUANTITATIVE TIMED SPECIMEN 16.42 XXX N  84583 ASSAY OF UROBILINOGEN URINE SEMIQUANTITATIVE 10.40 XXX N  84585 ASSAY OF VANILLYLMANDELIC ACID URINE 28.43 XXX N  84586 ASSAY OF VASOACTIVE INTESTINAL PEPTIDE 64.82 XXX N  84588 ASSAY OF VASOPRESSIN ANTI-DIURETIC HORMONE 62.26 XXX N  84590 ASSAY OF VITAMIN A 21.30 XXX N  84591 ASSAY OF VITAMIN NOT OTHERWISE SPECIFIED 29.33 XXX N  84597 ASSAY OF VITAMIN K 25.16 XXX N  84600 ASSAY OF VOLATILES 29.50 XXX N  84620 XYLOSE ABSORPTION TEST BLOOD &/URINE 22.20 XXX N  84630 ASSAY OF ZINC 20.88 XXX N  84681 ASSAY OF C-PEPTIDE 38.19 XXX N  84702 GONADOTROPIN CHORIONIC QUANTITATIVE 27.62 XXX N  84703 GONADOTROPIN CHORIONIC QUALITATIVE 13.80 XXX N  84704 GONADOTROPIN CHORIONIC HCG FREE BETA CHAIN 27.62 XXX N  84830 OVULATION TEST VISUAL COLOR COMPARISON HLH 21.84 XXX N  84999 UNLISTED CHEMISTRY PROCEDURE BR XXX N  85002 BLEEDING TIME TEST 8.29 XXX N  85004 BLOOD COUNT AUTOMATED DIFFERENTIAL WBC COUNT 11.85 XXX N

Pathology and Laboratory Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 80047-89398, G0480-G0483, G0659 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 260 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  85007 BLOOD COUNT SMEAR MCRSCP W/MNL DIFRNTL WBC COUNT 6.53 XXX N  85008 BLD COUNT SMEAR MCRSCP W/O MNL DIFRNTL WBC COUNT 6.31 XXX N  85009 BLOOD COUNT MANUAL DIFRNTL WBC COUNT BUFFY COAT 8.72 XXX N  85013 BLOOD COUNT SPUN MICROHEMATOCRIT 12.04 XXX N  85014 BLOOD COUNT HEMATOCRIT 4.34 XXX N  85018 BLOOD COUNT HEMOGLOBIN 4.34 XXX N  85025 BLOOD COUNT COMPLETE AUTO&AUTO DIFRNTL WBC 14.25 XXX N  85027 BLOOD COUNT COMPLETE AUTOMATED 11.85 XXX N  85032 BLOOD COUNT MANUAL CELL COUNT EACH 7.91 XXX N  85041 BLOOD COUNT RED BLOOD CELL AUTOMATED 5.53 XXX N  85044 BLOOD COUNT RETICULOCYTE MANUAL 7.91 XXX N  85045 BLOOD COUNT RETICULOCYTE AUTOMATED 7.33 XXX N  85046 BLOOD COUNT RETICULOCYTES AUTO 1/> CELL MEAS 10.22 XXX N  85048 BLOOD COUNT LEUKOCYTE WBC AUTOMATED 4.66 XXX N  85049 BLOOD COUNT PLATELET AUTOMATED 8.21 XXX N  85055 RETICULATED PLATELET ASSAY 61.45 XXX N  85060 BLOOD SMEAR PERIPHERAL INTERP PHYS W/WRIT REPORT 42.25 XXX N  85097 BONE MARROW SMEAR INTERPRETATION 125.55 XXX N 950.39  85130 CHROMOGENIC SUBSTRATE ASSAY 21.81 XXX N  85170 BLOOD CLOT RETRACTION 28.03 XXX N  85175 CLOT LYSIS TIME WHOLE BLOOD DILUTION 35.02 XXX N  85210 CLOTTING FACTOR II PROTHROMBIN SPECIFIC 23.82 XXX N  85220 CLOTTING FACTOR V ACG/PROACCELERIN LABILE FACTOR 32.38 XXX N  85230 CLOTTING FACTOR VII PROCONVERTIN STABLE FACTOR 32.84 XXX N  85240 CLOTTING FACTOR VIII AHG 1 STAGE 32.84 XXX N  85244 CLOTTING FACTOR VIII RELATED ANTIGEN 37.46 XXX N  85245 CLOTTING FACTOR VIII VW FACTOR RISTOCETIN COFACT 42.08 XXX N  85246 CLOTTING FACTOR VIII VW FACTOR ANTIGEN 42.08 XXX N  85247 CLOTTING FACTOR VIII MULTIMETRIC ANALYSIS 42.08 XXX N  85250 CLOTTING FACTOR IX PTC/CHRISTMAS 34.93 XXX N  85260 CLOTTING FACTOR X STUART-PROWER 32.84 XXX N  85270 CLOTTING FACTOR XI PTA 32.84 XXX N  85280 CLOTTING FACTOR XII HAGEMAN 35.50 XXX N  85290 CLOTTING FACTOR XIII FIBRIN STABILIZING 29.97 XXX N  85291 CLOTTING FACTOR XIII FIBRN STABILIZ SCREEN SOLUB 16.31 XXX N  85292 CLOTTING PREKALLIKREIN ASSAY FLETCHER FACT ASSAY 34.74 XXX N  85293 CLOTTING HI MOLEC WEIGHT KININOGEN ASSAY 34.74 XXX N  85300 CLOTTING INHIBITORS ANTITHROMBIN III ACTIVITY 21.74 XXX N  85301 CLOTTING INHIBITRS ANTITHROMBN III ANTIGEN ASSAY 19.83 XXX N  85302 CLOTTING INHIBITORS PROTEIN C ANTIGEN 22.04 XXX N  85303 CLOTTING INHIBITORS PROTEIN C ACTIVITY 25.38 XXX N  85305 CLOTTING INHIBITORS PROTEIN S TOTAL 21.30 XXX N  85306 CLOTTING INHIBITORS PROTEIN S FREE 28.12 XXX N  85307 ACTIVATED PROTEIN C APC RESISTANCE ASSAY 28.12 XXX N  85335 FACTOR INHIBITOR TEST 23.61 XXX N  85337 THROMBOMODULIN 29.69 XXX N

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  85345 COAGULATION TIME LEE AND WHITE 8.06 XXX N  85347 COAGULATION TIME ACTIVATED 7.81 XXX N  85348 COAGULATION TIME OTHER METHODS 7.72 XXX N  85360 EUGLOBULIN LYSIS 15.42 XXX N  85362 FIBRIN DGRADJ SPLT PRODUXS AGGLUJ SLIDE SEMIQUAN 12.63 XXX N  85366 FIBRIN DGRADJ SPLT PRODUXS PARACOAGJ 138.34 XXX N  85370 FIBRIN DGRADJ SPLT PRODUCTS QUANTITATIVE 21.37 XXX N  85378 FIBRIN DGRADJ PRODUCTS D-DIMER QUAL/SEMIQUAN 16.71 XXX N  85379 FIBRIN DGRADJ PRODUCTS D-DIMER QUANTITATIVE 18.67 XXX N  85380 FIBRIN DGRADJ PRODUCTS D-DIMER ULTRASENSITIVE 18.67 XXX N  85384 FIBRINOGEN ACTIVITY 16.71 XXX N  85385 FIBRINOGEN ANTIGEN 24.86 XXX N  85390 FIBRINOLYSINS/COAGULOPATHY SCREEN INTERP&REPOR 90.88 64.26 26.62 XXX N  85396 COAGJ/FBRNLYS ASSAY WHOLE BLOOD ADDITIVE PER DAY 34.51 XXX N  85397 COAGJ&FIBRINOLYSIS FUNCTIONAL ACTV NOS EA ANAL 53.06 XXX N  85400 FIBRINOLYTIC FACTORS & INHIBITORS PLASMIN 14.13 XXX N  85410 FBRNLYC FACTORS&INHIBITORS ALPHA-2 ANTIPLASMIN 14.13 XXX N  85415 FBRNLYC FACTORS&INHIBITORS PLSMNG ACTIVATOR 31.53 XXX N  85420 FBRNLYC FACTORS&INHIBITRS PLSMNG XCPT AGIC ASS 11.99 XXX N  85421 FBRNLYC FACTORS&INHIBITORS PLSMNG AGIC ASSAY 18.69 XXX N  85441 HEINZ BODIES DIRECT 7.71 XXX N  85445 HEINZ BODIES INDUCED ACETYL PHENYLHYDRAZINE 12.50 XXX N  85460 HGB/RBCS FETAL FETOMATERNAL HEMRRG DIFRNTL LYSIS 14.18 XXX N  85461 HGB/RBCS FETAL FETOMATERNAL HEMRRG ROSETTE 16.09 XXX N  85475 HEMOLYSIN ACID 16.28 XXX N  85520 HEPARIN ASSAY 24.02 XXX N  85525 HEPARIN NEUTRALIZATION 21.71 XXX N  85530 HEPARIN-PROTAMINE TOLERANCE TST 24.02 XXX N  85536 IRON STAIN PERIPHERAL BLOOD 11.85 XXX N  85540 WBC ALKALINE PHOSPHATASE COUNT 15.78 XXX N  85547 MECHANICAL FRAGILITY RBC 15.78 XXX N  85549 MURAMIDASE 34.39 XXX N  85555 OSMOTIC FRAGILITY RBC UNINCUBATED 12.84 XXX N  85557 OSMOTIC FRAGILITY RBC INCUBATED 24.50 XXX N  85576 PLATELET AGGREGATION IN VITRO EACH AGENT 74.37 31.54 42.83 XXX N  85597 PHOSPHOLIPID NEUTRALIZATION PLATELET 32.97 XXX N  85598 PHOSPHOLIPID NEUTRALIZATION HEXAGONAL 32.97 XXX N  85610 PROTHROMBIN TIME 7.38 XXX N  85611 PROTHROMBIN TIME SUBSTITUTION PLASMA FRCTJ EACH 7.23 XXX N  85612 RUSSELL VIPER VENON TIME UNDILUTED 30.07 XXX N  85613 RUSSELL VIPER VENOM TIME DILUTED 17.57 XXX N  85635 REPTILASE TEST 18.06 XXX N  85651 SEDIMENTATION RATE RBC NON-AUTOMATED 7.34 XXX N  85652 SEDIMENTATION RATE RBC AUTOMATED 4.95 XXX N  85660 SICKLING RBC REDUCTION 10.10 XXX N  85670 THROMBIN TIME PLASMA 10.58 XXX N  85675 THROMBIN TIME TITER 12.56 XXX N

Pathology and Laboratory Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 80047-89398, G0480-G0483, G0659 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 262 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  85705 THROMBOPLASTIN INHIBITION TISSUE 17.67 XXX N  85730 THROMBOPLASTIN TIME PARTIAL PLASMA/WHOLE BLOOD 11.01 XXX N  85732 THROMBOPLASTIN TIME PRTL SUBSTIT PLASMA FRCTJ EA 11.85 XXX N  85810 VISCOSITY 21.41 XXX N  85999 UNLISTED HEMATOLOGY & COAGULATION PROCEDURE BR XXX N  86000 AGGLUTININS FEBRILE EACH ANTIGEN 12.81 XXX N  86001 ALLERGEN SPECIFIC IGG QUAN/SEMIQUAN EA ALLERGEN 13.45 XXX N  86003 ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH 9.58 XXX N  86005 ALLERGEN SPEC IGE QUAL MULTIALLERGEN SCREEN 14.61 XXX N  86008 ALLERGEN SPEC IGE RECOMBINANT/PURIFIED COMPNT EA 32.90 XXX N  86015 ACTIN SMOOTH MUSCLE ANTIBODY EACH 19.82 XXX N  86021 ANTIBODY IDENTIFICATION LEUKOCYTE ANTIBODIES 27.62 XXX N  86022 ANTIBODY IDENTIFICATION PLATELET ANTIBODIES 33.70 XXX N  86023 ANTIBODY IDENTIFICATION PLATELET IMMUNOGL ASSAY 22.85 XXX N  86036 ANTINEUTROPHIL CYTOPLASMIC ANTB SCREEN EA ANTB 20.72 XXX N  86037 ANTINEUTROPHIL CYTOPLASMIC ANTB TITER EA ANTB 20.72 XXX N  86038 ANTINUCLEAR ANTIBODIES ANA 22.17 XXX N  86039 ANTINUCLEAR ANTIBODIES ANA TITER 20.47 XXX N  86041 ACETYLCHOLINE RECEPTOR BINDING ANTIBODY 33.43 XXX N  86042 ACETYLCHOLINE RECEPTOR BLOCKING ANTIBODY 33.43 XXX N  86043 ACETYLCHOLINE RECEPTOR MODULATING ANTIBODY 21.90 XXX N  86051 AQUAPORIN-4 ANTIBODY ELISA 19.82 XXX N  86052 AQUAPORIN-4 ANTIBODY CELL-BASED IMFLUOR ASSAY EA 20.72 XXX N  86053 AQUAPORIN-4 ANTIBODY FLOW CYTOMETRY EACH 20.72 XXX N  86060 ANTISTREPTOLYSIN O TITER 13.39 XXX N  86063 ANTISTREPTOLYSIN O SCREEN 10.58 XXX N  86077 BLD BANK PHYS SVCS DIFFC CROSS MATCH&/EVAL REP 93.42 XXX N 35.83  86078 BLD BANK PHYS SVCS INVSTGJ TFUJ RXN REPRT 93.42 XXX N 216.29  86079 BLD BANK PHYS SVCS AUTHJ DEVIJ STANDARD REPRT 92.82 XXX N 72.07  86140 C-REACTIVE PROTEIN 9.49 XXX N  86141 C-REACTIVE PROTEIN HIGH SENSITIVITY 23.76 XXX N  86146 BETA 2 GLYCOPROTEIN I ANTIBODY EACH 46.69 XXX N  86147 CARDIOLIPIN ANTIBODY EACH IG CLASS 46.69 XXX N  86148 ANTI-PHOSPHATIDYLSERINE ANTIBODY 29.47 XXX N  86152 CELL ENUMERATION IMMUNE SELECTJ & ID FLUID SPEC 450.72 XXX N  86153 CELL ENUMERATION IMMUNE SELECTJ & ID PHYS INTERP 0.00 59.50 BR XXX N  86155 CHEMOTAXIS ASSAY SPECIFY METHOD 29.32 XXX N  86156 COLD AGGLUTININ SCREEN 13.88 XXX N  86157 COLD AGGLUTININ TITER 14.79 XXX N  86160 COMPLEMENT ANTIGEN EACH COMPONENT 22.01 XXX N  86161 COMPLEMENT FUNCTIONAL ACTIVITY EACH COMPONENT 22.01 XXX N  86162 COMPLEMENT TOTAL HEMOLYTIC 37.28 XXX N  86171 COMPLEMENT FIXATION TESTS EACH ANTIGEN 18.36 XXX N  86200 CYCLIC CITRULLINATED PEPTIDE ANTIBODY 23.76 XXX N  86215 DEOXYRIBONUCLEASE ANTIBODY 24.30 XXX N  86225 DNA ANTIBODY NATIVE/DOUBLE STRANDED 25.21 XXX N  86226 DNA ANTIBODY SINGLE STRANDED 22.21 XXX N

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  86231 ENDOMYSIAL ANTIBODY EACH IMMUNOGLOBULIN CLASS 20.79 XXX N  86235 EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY ANY METHOD 32.90 XXX N  86255 FLUORESCENT NONNFCT AGT ANTB SCREEN EA ANTIBODY 53.05 31.54 21.51 XXX N  86256 FLUORESCENT NONNFCT AGT ANTB TITER EA ANTIBODY 53.05 31.54 21.51 XXX N  86258 GLIADIN ANTIBODY EACH IMMUNOGLOBULIN CLASS 19.82 XXX N  86277 GROWTH HORMONE HUMAN ANTIBODY 28.88 XXX N  86280 HEMAGGLUTINATION INHIBITION TEST HAI 15.02 XXX N  86294 IMMUNOASSAY TUMOR ANTIGEN QUAL/SEMIQUANTITATIVE 43.96 XXX N  86300 IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 15-3 38.19 XXX N  86301 IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 19-9 38.19 XXX N  86304 IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 125 38.19 XXX N  86305 HUMAN EPIDIDYMIS PROTEIN 4 (HE4) 38.19 XXX N  86308 HETEROPHILE ANTIBODIES SCREEN 9.49 XXX N  86309 HETEROPHILE ANTIBODIES TITER 11.85 XXX N  86310 HETEROPHILE ANTIBODIES TITER AFTER ABSORPTION 13.52 XXX N  86316 IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE 38.19 XXX N  86317 IMMUNOASSAY INFECTIOUS AGENT ANTIBODY QUAN NOS 27.49 XXX N  86318 IA INFECTIOUS AGT ANTIBODY QUAL/SEMIQ 1STEP METH 31.10 XXX N  86320 IMMUNOELECTROPHORESIS SERUM 82.98 31.54 51.44 XXX N  86325 IMMUNOELECTROPHORESIS OTHER FLUIDS CONCENTRATION 71.97 31.54 40.43 XXX N  86328 IA INFECTIOUS AGT ANTIBODY SARS-COV-2 COVID-19 77.85 XXX N  86329 IMMUNODIFFUSION NOT ELSEWHERE SPECIFIED 25.77 XXX N  86331 IMMUNODIFFUSION GEL DIFFUSION QUAL EA AG/ANTBDY 21.97 XXX N  86332 IMMUNE COMPLEX ASSAY 44.71 XXX N  86334 IMMUNOFIXJ ELECTROPHORESIS SERUM 71.93 31.54 40.39 XXX N  86335 IMMUNOFIXJ ELECTROPHORESIS OTHER FLUIDS 84.78 31.54 53.24 XXX N  86336 INHIBIN A 28.60 XXX N  86337 INSULIN ANTIBODIES 39.28 XXX N  86340 INTRINSIC FACTOR ANTIBODIES 27.65 XXX N  86341 ISLET CELL ANTIBODY 40.52 XXX N  86343 LEUKOCYTE HISTAMINE RELEASE TEST LHR 22.85 XXX N  86344 LEUKOCYTE PHAGOCYTOSIS 17.86 XXX N  86352 CELLULAR FUNCTION ASSAY STIMUL&DETECT BIOMARKE 249.23 XXX N  86353 LYMPHOCYTE TR MITOGEN/AG INDUCED BLASTOGENESIS 89.93 XXX N  86355 B CELLS TOTAL COUNT 69.21 XXX N  86356 MONONUCLEAR CELL ANTIGEN QUANTITATIVE NOS EA 49.12 XXX N  86357 NATURAL KILLER CELLS TOTAL COUNT 69.21 XXX N  86359 T CELLS TOTAL COUNT 69.21 XXX N  86360 T CELLS ABSOLUTE CD4&CD8 COUNT RATIO 86.18 XXX N  86361 T CELLS ABSOLUTE CD4 COUNT 49.12 XXX N  86362 MOG-IGG1 ANTIBODY CELL-BASED IMFLUOR ASSAY EACH 20.72 XXX N  86363 MOG-IGG1 ANTIBODY FLOW CYTOMETRY EACH 20.72 XXX N  86364 TISSUE TRANSGLUTAMINASE EA IMMUNOGLOBULIN CLASS 19.82 XXX N  86366 MUSCLE-SPECIFIC KINASE ANTIBODY 33.43 XXX N  86367 STEM CELLS TOTAL COUNT 133.73 XXX N  86376 MICROSOMAL ANTIBODIES EACH 26.70 XXX N

Pathology and Laboratory Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 80047-89398, G0480-G0483, G0659 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 264 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  86381 MITOCHONDRIAL ANTIBODY EACH 43.76 XXX N  86382 NEUTRALIZATION TEST VIRAL 31.02 XXX N  86384 NITROBLUE TETRAZOLIUM DYE TEST NTD 23.40 XXX N  86386 NUCLEAR MATRIX PROTEIN 22 NMP22 QUALITATIVE 37.45 XXX N  86403 PARTICLE AGGLUTINATION SCREEN EACH ANTIBODY 19.84 XXX N  86406 PARTICLE AGGLUTINATION TITER EACH ANTIBODY 19.51 XXX N  86408 NEUTRALIZING ANTIBODY SARS-COV-2 SCREEN 105.91 XXX N  86409 NEUTRALIZING ANTIBODY SARS-COV-2 TITER 415.31 XXX N  86413 SEV AQT RESPIR SYND CORONAVIRUS 2 ANTIBODY QUAN 141.02 XXX N  86430 RHEUMATOID FACTOR QUALITATIVE 10.56 XXX N  86431 RHEUMATOID FACTOR QUANTITATIVE 10.40 XXX N  86480 TB CELL MEDIATED ANTIGN RESPNSE GAMMA INTERFERON 113.70 XXX N  86481 TB ANTIGEN RESPONSE GAMMA INTERFERON T-CELL SUSP 171.93 XXX N  86485 SKIN TEST CANDIDA 49.96 XXX N 35.83  86486 SKIN TEST UNLISTED ANTIGEN EACH BR XXX N 35.83  86510 SKIN TEST HISTOPLASMOSIS 13.01 XXX N 80.73  86580 SKIN TEST TUBERCULOSIS INTRADERMAL 16.42 XXX N 35.83  86581 STRPTCS PNEUM ANTIBODY IGG SEROTYPES MLT IA QUAN BR XXX N  86590 STREPTOKINASE ANTIBODY 21.77 XXX N  86592 SYPHILIS TEST NON-TREPONEMAL ANTIBODY QUAL 7.84 XXX N  86593 SYPHILIS TEST QUANTITATIVE 8.07 XXX N  86596 VOLTAGE-GATED CALCIUM CHANNEL ANTIBODY EACH 31.64 XXX N  86602 ANTIBODY ACTINOMYCES 18.67 XXX N  86603 ANTIBODY ADENOVIRUS 23.61 XXX N  86606 ANTIBODY ASPERGILLUS 27.62 XXX N  86609 ANTIBODY BACTERIUM NOT ELSEWHERE SPECIFIED 23.63 XXX N  86611 ANTIBODY BARTONELLA 18.67 XXX N  86612 ANTIBODY BLASTOMYCES 23.68 XXX N  86615 ANTIBODY BORDETELLA 24.19 XXX N  86617 ANTIBODY BORRELIA BURGDORFERI CONFIRMATORY TST 28.41 XXX N  86618 ANTIBODY BORRELIA BURGDORFERI LYME DISEASE 31.24 XXX N  86619 ANTIBODY BORRELIA RELAPSING FEVER 24.53 XXX N  86622 ANTIBODY BRUCELLA 16.38 XXX N  86625 ANTIBODY CAMPYLOBACTER 24.07 XXX N  86628 ANTIBODY CANDIDA 22.02 XXX N  86631 ANTIBODY CHLAMYDIA 21.69 XXX N  86632 ANTIBODY CHLAMYDIA IGM 23.26 XXX N  86635 ANTIBODY COCCIDIOIDES 21.05 XXX N  86638 ANTIBODY COXIELLA BURNETII Q FEVER 22.24 XXX N  86641 ANTIBODY CRYPTOCOCCUS 26.43 XXX N  86644 ANTIBODY CYTOMEGALOVIRUS CMV 26.40 XXX N  86645 ANTIBODY CYTOMEGALOVIRUS CMV IGM 30.91 XXX N  86648 ANTIBODY DIPHTHERIA 27.90 XXX N  86651 ANTIBODY ENCEPHALITIS CALIFORNIA LA CROSSE 24.19 XXX N  86652 ANTIBODY ENCEPHALITIS EASTERN EQUINE 24.19 XXX N  86653 ANTIBODY ENCEPHALITIS ST. LOUIS 24.19 XXX N  86654 ANTIBODY ENCEPHALITIS WESTRN EQUINE 24.19 XXX N

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  86658 ANTIBODY ENTEROVIRUS 23.89 XXX N  86663 ANTIBODY EPSTEIN-BARR EB VIRUS EARLY ANTIGEN EA 24.07 XXX N  86664 ANTIBODY EPSTEIN-BARR EB VIRUS NUCLEAR AG EBNA 28.05 XXX N  86665 ANTIBODY EPSTEIN-BARR EB VIRUS VIRAL CAPSID VCA 33.28 XXX N  86666 ANTIBODY EHRLICHIA 18.67 XXX N  86668 ANTIBODY FRANCISELLA TULARENSIS 24.35 XXX N  86671 ANTIBODY FUNGUS NOT ELSEWHERE SPECIFIED 22.49 XXX N  86674 ANTIBODY GIARDIA LAMBLIA 26.99 XXX N  86677 ANTIBODY HELICOBACTER PYLORI 28.97 XXX N  86682 ANTIBODY HELMINTH NOT ELSEWHERE SPECIFIED 23.86 XXX N  86684 ANTIBODY HAEMOPHILUS INFLUENZA 29.06 XXX N  86687 ANTIBODY HTLV-I 15.63 XXX N  86688 ANTIBODY HTLV-II 25.69 XXX N  86689 ANTIBODY HTLV/HIV ANTIBODY CONFIRMATORY TEST 35.51 XXX N  86692 ANTIBODY HEP DELTA AGENT 31.48 XXX N  86694 ANTIBODY HERPES SMPLX NON-SPECIFIC TYPE TEST 26.40 XXX N  86695 ANTIBODY HERPES SMPLX TYPE 1 24.19 XXX N  86696 ANTIBODY HERPES SMPLX TYPE 2 35.51 XXX N  86698 ANTIBODY HISTOPLASMA 23.71 XXX N  86701 ANTIBODY HIV-1 16.30 XXX N  86702 ANTIBODY HIV-2 24.80 XXX N  86703 ANTIBODY HIV-1&HIV-2 SINGLE RESULT 25.14 XXX N  86704 HEPATITIS B CORE ANTIBODY HBCAB TOTAL 22.11 XXX N  86705 HEPATITIS B CORE ANTIBODY HBCAB IGM ANTIBODY 21.59 XXX N  86706 HEPATITIS B SURF ANTIBODY HBSAB 19.70 XXX N  86707 HEPATITIS BE ANTIBODY HBEAB 21.22 XXX N  86708 HEPATITIS A ANTIBODY HAAB 22.72 XXX N  86709 HEPATITIS ANTIBODY HAAB IGM ANTIBODY 20.65 XXX N  86710 ANTIBODY INFLUENZA VIRUS 24.86 XXX N  86711 ANTIBODY JOHN CUNNINGHAM VIRUS 29.04 XXX N  86713 ANTIBODY LEGIONELLA 28.07 XXX N  86717 ANTIBODY LEISHMANIA 22.47 XXX N  86720 ANTIBODY LEPTOSPIRA 27.85 XXX N  86723 ANTIBODY LISTERIA MONOCYTOGENES 24.19 XXX N  86727 ANTIBODY LYMPHOCYTIC CHORIOMENINGITIS 23.61 XXX N  86732 ANTIBODY MUCORMYCOSIS 25.79 XXX N  86735 ANTIBODY MUMPS 23.94 XXX N  86738 ANTIBODY MYCOPLSM 24.29 XXX N  86741 ANTIBODY NEISSERIA MENINGITIDIS 24.19 XXX N  86744 ANTIBODY NOCARDIA 27.49 XXX N  86747 ANTIBODY PARVOVIRUS 27.57 XXX N  86750 ANTIBODY PLASMODIUM MALARIA 24.19 XXX N  86753 ANTIBODY PROTOZOA NES 22.72 XXX N  86756 ANTIBODY RESPIRATORY SYNCTIAL VIRUS 27.32 XXX N  86757 ANTIBODY RICKETTSIA 35.51 XXX N  86759 ANTIBODY ROTAVIRUS 31.34 XXX N  86762 ANTIBODY RUBELLA 26.40 XXX N

Pathology and Laboratory Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 80047-89398, G0480-G0483, G0659 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 266 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  86765 ANTIBODY RUBEOLA 23.63 XXX N  86768 ANTIBODY SALMONELLA 24.19 XXX N  86769 ANTB SEVERE AQT RESPIR SYND SARS-COV-2 COVID-19 72.44 XXX N  86771 ANTIBODY SHIGELLA 42.09 XXX N  86774 ANTIBODY TETANUS 27.14 XXX N  86777 ANTIBODY TOXOPLASMA 26.40 XXX N  86778 ANTIBODY TOXOPLASMA IGM 26.43 XXX N  86780 ANTIBODY TREPONEMA PALLIDUM 24.29 XXX N  86784 ANTIBODY TRICHINELLA 23.05 XXX N  86787 ANTIBODY VARICELLA-ZOSTER 23.63 XXX N  86788 ANTIBODY WEST NILE VIRUS IGM 30.91 XXX N  86789 ANTIBODY WEST NILE VIRUS 26.40 XXX N  86790 ANTIBODY VIRUS NOT ELSEWHERE SPECIFIFED 23.63 XXX N  86793 ANTIBODY YERSINIA 24.19 XXX N  86794 ZIKA VIRUS IGM ANTIBODY 30.91 XXX N  86800 THYROGLOBULIN ANTIBODY 29.17 XXX N  86803 HEPATITIS C ANTIBODY 26.17 XXX N  86804 HEPATITIS C ANTIBODY CONFIRMATORY TEST 28.41 XXX N  86805 LYMPHOCYTOTOXICITY ASSAY VIS CROSSMATCH TITRATJ 325.83 XXX N  86806 LMPHOCYTOTOXICITY ASSAY VIS CROSSMTCH W/O TITRAT 87.30 XXX N  86807 SERUM SCREENING % REACTIVE ANTIBODY STANDRD METH 135.23 XXX N  86808 SERUM SCREENING % REACTIVE ANTIBODY QUICK METH 54.45 XXX N  86812 HLA TYPING A/B/C SINGLE ANTIGEN 47.33 XXX N  86813 HLA TYPING A/B/C MULTIPLE ANTIGENS 106.39 XXX N  86816 HLA TYPING DR/DQ SINGLE ANTIGEN 51.87 XXX N  86817 HLA TYPING DR/DQ MULTIPLE ANTIGENS 182.49 XXX N  86821 HLA TYPING LYMPHOCYTE CULTURE MIXED 67.06 XXX N  86825 HLA CROSSMATCH NONCYTOTOXIC 1ST SERUM/DILUTION 188.25 XXX N  

20 Miss. Admin. Code Pt. 2, R. 86826 Rule 86826

HLA CROSSMATCH NONCYTOTOXIC ADDL SERUM/DILUTION 62.81 XXX N  86828 ANTIBODY HLA CLASS I & CLASS II ANTIGENS QUAL 110.36 XXX N  86829 ANTIBODY HLA CLASS I OR CLASS II ANTIGENS QUAL 110.36 XXX N  86830 ANTIBODY HLA CLASS I PHENOTYPE PANEL QUALITATIVE 164.23 XXX N  86831 ANTIBODY HLA CLASS II PHENOTYPE PANEL QUAL 140.78 XXX N  86832 ANTIBODY HLA CLASS I HIGH DEFINITION PANEL QUAL 556.64 XXX N  86833 ANTIBODY HLA CLASS II HIGH DEFINITION PANEL QUAL 560.16 XXX N  86834 ANTIBODY HLA CLASS I SEMIQUANTITATIVE PANEL 655.92 XXX N  86835 ANTIBODY HLA CLASS II SEMIQUANTITATIVE PANEL 592.46 XXX N  86849 UNLISTED IMMUNOLOGY BR XXX N  86850 ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE 16.80 XXX N 72.07  86860 ANTIBODY ELUTION RBC EACH ELUTION 125.90 XXX N 216.29  86870 ANTIBODY ID RBC ANTIBODIES EA PANEL EA SERUM TQ 148.16 XXX N 422.38  86880 ANTIHUMAN GLOBULIN DIRECT EACH ANTISERUM 9.89 XXX N 80.73  86885 ANTIHUMAN GLOBULIN INDIR QUAL EA REAGENT CELL 10.50 XXX N 216.29  86886 ANTIHUMAN GLOBULIN INDIRECT EACH ANTIBODY TITER 9.49 XXX N 216.29  86890 AUTOL BLD/COMPONENT COLLJ STORAGE PREDEPOSITED 248.12 XXX N 216.29  86891 AUTOL BLD/COMPONENT COLLJ STORAGE SALVAGE 877.90 XXX N 950.39  86900 BLOOD TYPING SEROLOGIC ABO 5.48 XXX N 163.53

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  86901 BLOOD TYPING SEROLOGIC RH (D) 5.48 XXX N 49.09  86902 BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EACH 10.92 XXX N 422.38  86904 BLOOD TYPING ANTIGEN SCREEN PATIENT SERUM/UNIT 28.09 XXX N 49.09  86905 BLOOD TYPING RBC ANTIGENS OTH/THN ABO/RH D EACH 7.02 XXX N 422.38  86906 BLOOD TYPING SEROLOGIC RH PHENOTYPING COMPLETE 14.21 XXX N 49.09  86910 BLOOD TYPING PATERNITY PR INDIV ABO RH&MN 44.44 XXX N  86911 BLOOD TYPING PATERNITY INDIV ADDL ANTIGEN SYS 38.10 XXX N  86920 COMPATIBILITY EACH UNIT IMMEDIATE SPIN TECHNIQUE 54.06 XXX N 216.29  86921 COMPATIBILITY EACH UNIT INCUBATION 47.01 XXX N 216.29  86922 COMPATIBILITY EACH UNIT ANTIGLOBULIN 86.22 XXX N 216.29  86923 COMPATIBILITY EACH UNIT ELECTRONIC 106.51 XXX N 216.29  86927 FRESH FROZEN PLASMA THAWING EACH UNIT 24.40 XXX N 216.29  86930 FROZEN BLOOD EACH UNIT FREEZING 200.64 XXX N 422.38  86931 FROZEN BLOOD EACH UNIT THAWING 150.49 XXX N 422.38  86932 FROZEN BLOOD EACH UNIT FREEZING & THAWING 170.81 XXX N 49.09  86940 HEMOLYSINS&AGGLUTININS AUTO SCREEN EACH 15.08 XXX N  86941 HEMOLYSINS&AGGLUTININS INCUBATED 22.21 XXX N  86945 IRRADIATION BLOOD PRODUCT EACH UNIT 2112.85 XXX N 49.09  86950 LEUKOCYTE TRANSFUSION 122.79 XXX N 216.29  86960 VOLUME REDUCTION BLOOD/BLOOD PRODUCT EACH UNIT 43.79 XXX N 216.29  86965 POOLING PLATELETS/OTHER BLOOD PRODUCTS 351.03 XXX N 216.29  86970 PRETX RBC ANTIBODY INCUBAT W/CHEM AGNTS/DRUGS EA 153.96 XXX N 49.09  86971 PRETX RBC ANTIBODY INCUBAT W/ENZYMES EACH 63.67 XXX N 422.38  86972 PRETX RBC ANTIBODY INCUBAT W/DENSITY GRAD SEP 674.73 XXX N 216.29  86975 PRETX SERUM RBC ANTIBODY INCUBATION DRUGS EACH 98.40 XXX N 393.60  86976 PRETX SERUM RBC ANTIBODY IDENTIFICATION DILUTION 65.69 XXX N 35.83  86977 PRETX SERUM RBC ANTB ID INCUBATION INHIBITORS EA 60.32 XXX N 216.29  86978 PRETX SERUM RBC ANTIBODY ID DIFFIAL EACH ABSRPJ 142.32 XXX N 49.09  86985 SPLITTING BLOOD/BLOOD PRODUCTS EACH UNIT 112.46 XXX N 216.29  86999 UNLISTED TRANSFUSION MEDICINE PROCEDURE BR XXX N 35.83  87003 ANIMAL INOCULATION SMALL ANIMAL W/OBS&DSJ 30.89 XXX N  87015 CONCENTRATION INFECTIOUS AGENTS 12.25 XXX N  87040 CULTURE BACTERIAL BLOOD AEROBIC W/ID ISOLATES 18.94 XXX N  87045 CUL BACT STOOL AEROBIC ISOL SALMONELLA&SHIGELL 17.32 XXX N  87046 CUL BACT STOOL AEROBIC ADDL PATHOGENS&ID EA 17.32 XXX N  87070 CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL 15.80 XXX N  87071 CUL BACT QUAN AEROBIC ISOL XCPT UR BLOOD/STOOL 17.32 XXX N  87073 CUL BACT QUAN ANAERC ISOL XCPT UR BLOOD/STOOL 17.32 XXX N  87075 CULTURE BACTERIAL ANY SOURCE ANAEROBIC ISO&ID 17.37 XXX N  87076 CUL BACT ANAEROBIC ADDL METHS DEFINITIVE EA ISOL 14.81 XXX N  87077 CUL BACT AEROBIC ADDL METHS DEFINITIVE EA ISOL 14.81 XXX N  87081 CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ 12.15 XXX N  87084 CUL PRSMPTV PTHGNC ORGANISMS SCR DNS CHART 46.54 XXX N  87086 CULTURE BACTERIAL QUANTTATIVE COLONY COUNT URINE 14.81 XXX N  87088 CULTURE BCT ISOL&PRSMPTV ID ISOLATE EA URINE 14.84 XXX N  87101 CUL FNGI MOLD/YEAST PRSMPTV ID SKN HAIR/NAIL 14.13 XXX N  87102 CULTURE FNGI MOLD/YEAST PRSMPTV OTH XCPT BLOOD 15.42 XXX N

Pathology and Laboratory Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 80047-89398, G0480-G0483, G0659 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 268 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  87103 CULTURE FNGI MOLD/YEAST ISOL PRSMPTV ISOL BLOOD 35.18 XXX N  87106 CULTURE FUNGI DEFINITIVE ID EACH ORGANISM YEAST 18.94 XXX N  87107 CULTURE FUNGI DEFINITIVE ID EACH ORGANISM MOLD 18.94 XXX N  87109 CULTURE MYCOPLASMA ANY SOURCE 28.23 XXX N  87110 CULTURE CHLAMYDIA ANY SOURCE 35.94 XXX N  87116 CULTURE TUBERCLE/OTH ACID-FAST BACILLI ANY ISOL 19.81 XXX N  87118 CULTURE MYCOBACTERIAL DEFINITIVE ID EA ISOL 25.12 XXX N  87140 CULTURE TYPING IMMUNOFLUORESCENT EACH ANTISERUM 10.22 XXX N  87143 CULTURE TYPING GAS/HIGH PRES LIQ CHROMATOGRAPHY 22.98 XXX N  87147 CULTURE TYPING IMMUNOLOGIC OTH/THN IMMUNOFLUORES 9.49 XXX N  87149 CULTURE TYPING NUCLEIC ACID PROBE DIR EA ORGANSM 36.78 XXX N  87150 CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM 64.37 XXX N  87152 CULTURE TYPING IDENTIFJ PULSE FIELD GEL TYPING 13.31 XXX N  87153 CULTYP NUCLEIC ACID SEQUENCING METH EA ISOLATE 211.61 XXX N  87154 CULTURE TYPING ID BLD PTHGN&RESIST TYPING 6+TRGT 374.92 XXX N  87158 CULTURE TYPING OTHER METHODS 13.31 XXX N  87164 DARK FIELD EXAM ANY SOURCE W/SPECIMEN COLLECTION 53.62 33.92 19.70 XXX N  87166 DARK FIELD EXAM ANY SOURCE W/O COLLECTION 20.74 XXX N  87168 MACROSCOPIC EXAMINATION ARTHROPOD 7.84 XXX N  87169 MACROSCOPIC EXAMINATION PARASITE 7.84 XXX N  87172 PINWORM EXAMINATION 7.84 XXX N  87176 HOMOGENIZATION TISSUE CULTURE 10.80 XXX N  87177 OVA&PARASITES DIRECT SMEARS CONCENTRATION & ID 16.33 XXX N  87181 SUSCEPTBILTY STDY ANTIMICRBIAL AGNT AGAR DILUTJ 8.70 XXX N  87184 SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD 12.86 XXX N  87185 SUSCEPTIBILITY STUDY ANTIMICROBIAL ENZYME DETCJ 8.70 XXX N  87186 SUSCEPTIBLTY STDY ANTIMICRBIAL MICRO/AGAR DILUTJ 15.87 XXX N  

20 Miss. Admin. Code Pt. 2, R. 87187 Rule 87187

SUSCEPTIBLTY STDY ANTMCRB MICRO/AGAR DILUTJ EA 69.07 XXX N  87188 SC STD ANTMCRB AGT MACROBROTH DIL METH EA AGT 12.18 XXX N  87190 SUSCEPTIBLTY STDY ANTMCRB MYCOBACT PROPORJ MTHD 12.57 XXX N  87197 SERUM BACTERICIDAL TITER 27.55 XXX N  87205 SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL 7.84 XXX N  87206 SMR PRIM SRC FLUORESCENT&/AFS BCT FNGI PARASIT 9.89 XXX N  87207 SMR PRIM SRC SPEC STAIN BODIES/PARASITS 41.94 31.54 10.40 XXX N  87209 SMR PRIM SRC CPLX SPEC STAIN OVA&PARASITS 32.97 XXX N  87210 SMR PRIM SRC WET MOUNT NFCT AGT 10.01 XXX N  87220 TISS KOH SLIDE SAMPS SKN/HR/NLS FNGI/ECTOPARASIT 7.84 XXX N  87230 TOXIN/ANTITOXIN ASSAY TISSUE CULTURE 36.21 XXX N  87250 VIRUS INOCULATION EGGS/SM ANIMAL OBS&DSJ 35.88 XXX N  87252 VIRUS TISS CUL INOCULATION CYTOPATHIC EFFECT 47.83 XXX N  87253 VIRUS TISSUE CULTURE ADDL STDY/ID EACH ISOLATE 37.06 XXX N  87254 VIRUS CENTRIFUGE ENHNCD ID IMFLUOR STAIN EA 35.88 XXX N  87255 VIRUS ID NON-IMMUNOLOGIC OTH/THN CYTOPATHIC 62.11 XXX N  87260 IAADI ADENOVIRUS 24.81 XXX N  87265 IAADI BORDETELLA PRTUSSIS/PARAPRTUSSIS 21.99 XXX N  87267 IAADI ENTEROVIRUS DIRECT FLUORESCENT ANTIBODY 23.07 XXX N

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  87269 IAADI GIARDIA 23.40 XXX N  87270 IAADI CHLAMYDIA TRACHOMATIS 21.99 XXX N  87271 IAADI CYTOMEGALOVIRUS DIR FLUORESCENT ANTIBODY 23.07 XXX N  87272 IAADI CRYPTOSPORIDIUM 21.99 XXX N  87273 IAADI HERPES SMPLX VIRUS TYPE 2 21.99 XXX N  87274 IAADI HERPES SMPLX VIRUS TYPE 1 21.99 XXX N  87275 IAADI INFLUENZA B VIRUS 21.99 XXX N  87276 IAADI INFFLUENZA A VIRUS 27.63 XXX N  87278 IAADI LEGIONELLA PNEUMOPHILA 26.82 XXX N  87279 IAADI PARAINFLUENZA VIRUS EACH TYPE 28.25 XXX N  87280 IAADI RESPIRATORY SYNCTIAL VIRUS 23.07 XXX N  87281 IAADI PNEUMOCUSTIS CARINII 21.99 XXX N  87283 IAADI RUBEOLA 104.54 XXX N  87285 IAADI TREPONEMA PALLIDUM 21.99 XXX N  87290 IAADI VARICELLA ZOSTER VIRUS 23.07 XXX N  87299 IAADI NOT OTHERWISE SPECIFIED EACH ORGANISM 27.68 XXX N  87300 IAADI POLYV MLT ORGANISMS EA POLYV ANTISERUM 21.99 XXX N  87301 IAAD IA ADENOVIRUS ENTERIC TYP 40/41 21.99 XXX N  87305 IAAD IA ASPERGILLUS 21.99 XXX N  87320 IAAD IA CHLAMYDIA TRACHOMATIS 25.79 XXX N  87324 IAAD IA CLOSTRIDIUM DIFFICILE TOXIN 21.99 XXX N  87327 IAAD IA CRYPTOCOCCUS NEOFORMANS 23.07 XXX N  87328 IAAD IA CRYPTOSPORIDIUM 23.76 XXX N  87329 IAAD IA GIARDIA 21.99 XXX N  87332 IAAD IA CYTOMEGALOVIRUS 21.99 XXX N  87335 IAAD IA ESCHERICHIA COLI 0157 21.99 XXX N  87336 IAAD IA ENTAMOEBA HISTOLYTICA DISPAR GRP 27.51 XXX N  87337 IAAD IA ENTAMOEBA HISTOLYTICA GRP 21.99 XXX N  87338 IAAD IA HPYLORI STOOL 26.38 XXX N  87339 IAAD IA HPYLORI 27.51 XXX N  87340 IAAD IA HEPATITIS B SURFACE ANTIGEN 18.95 XXX N  87341 IAAD IA HEPATITIS B SURFACE AG NEUTRALIZATION 18.95 XXX N  87350 IAAD IA HEPATITIS BE ANTIGEN 21.15 XXX N  87380 IAAD IA HEPATITIS DELTA ANTIGEN 31.57 XXX N  87385 IAAD IA HISTOPLASM CAPSULATUM 22.78 XXX N  87389 IAAD IA HIV-1 AG W/HIV-1 & HIV-2 ANTBDY SINGLE 44.16 XXX N  87390 IAAD IA HIV-1 41.37 XXX N  87391 IAAD IA HIV-2 37.65 XXX N  87400 IAAD IA INFLUENZA A/B EACH 24.29 XXX N  87420 IAAD IA RESPIRATORY SYNCTIAL VIRUS 23.92 XXX N  87425 IAAD IA ROTAVIRUS 21.99 XXX N  87426 IAAD IA SEVERE AQT RESPIR SYND CORONAVIRUS 141.02 XXX N  87427 IAAD IA SHIGA-LIKE TOXIN 21.99 XXX N  87428 IAAD IA SARSCOV & INFLUENZA VIRUS TYPES A&B 53.20 XXX N  87430 IAAD IA STREPTOCOCCUS GROUP A 28.90 XXX N  87449 IAAD IA NOT OTHERWISE SPECIFIED EACH ORGANISM 21.99 XXX N  87451 IAAD IA POLYV MLT ORGANISMS EA POLYV ANTISERUM 18.07 XXX N

Pathology and Laboratory Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 80047-89398, G0480-G0483, G0659 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 270 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  87467 HEPATITIS B SURFACE ANTIGEN QUANTITATIVE 26.43 XXX N  87468 IADNA ANAPLASMA PHAGOCYTOPHILUM AMPLIFED PRB TQ 61.61 XXX N  87469 IADNA BABESIA MICROTI AMPLIFIED PROBE TECHNIQUE 61.61 XXX N  87471 IADNA BARTONELLA AMPLIFIED PROBE TECHNIQUE 64.37 XXX N  87472 IADNA BARTONELLA HENSELAE&QUINTANA QUANTJ 78.59 XXX N  87475 IADNA BORRELIA BURGDORFERI DIRECT PROBE TQ 36.78 XXX N  87476 IADNA BORRELIA BURGDORFERI AMPLIFIED PROBE TQ 64.37 XXX N  87478 IADNA BORRELIA MIYAMOTOI AMPLIFIED PRB TECHNIQUE 61.61 XXX N  87480 IADNA CANDIDA SPECIES DIRECT PROBE TQ 36.78 XXX N  87481 IADNA CANDIDA SPECIES AMPLIFIED PROBE TQ 64.37 XXX N  87482 IADNA CANDIDA SPECIES QUANTIFICATION 95.84 XXX N  87483 CNS DNA/RNA AMP PROBE MULTIPLE SUBTYPES 12-25 764.55 XXX N  87484 IADNA EHRLICHIA CHAFFEENSIS AMPLIFIED PROBE TQ 61.61 XXX N  87485 IADNA CHLAMYDIA PNEUMONIAE DIRECT PROBE TQ 36.78 XXX N  87486 IADNA CHLAMYDIA PNEUMONIAE AMPLIFIED PROBE TQ 64.37 XXX N  87487 IADNA CHLAMYDIA PNEUMONIAE QUANTIFICATION 78.59 XXX N  87490 IADNA CHLAMYDIA TRACHOMATIS DIRECT PROBE TQ 39.12 XXX N  87491 IADNA CHLAMYDIA TRACHOMATIS AMPLIFIED PROBE TQ 64.37 XXX N  87492 IADNA CHLAMYDIA TRACHOMATIS QUANTIFICATION 91.93 XXX N  87493 INF AGENT DET NUCLEIC ACID CLOSTRIDIUM AMP PROBE 64.37 XXX N  87495 IADNA CYTOMEGALOVIRUS DIRECT PROBE TQ 51.63 XXX N  87496 IADNA CYTOMEGALOVIRUS AMPLIFIED PROBE TQ 64.37 XXX N  87497 IADNA CYTOMEGALOVIRUS QUANTIFICATION 78.59 XXX N  87498 IADNA ENTEROVIRUS AMPLIF PROBE & REVRSE TRNSCRIP 64.37 XXX N  87500 INFECTIOUS AGENT DNA/RNA VANCOMYCIN RESISTANCE 64.37 XXX N  87501 INFECTIOUS AGENT DNA/RNA INFLUENZA EA TYPE 94.14 XXX N  87502 INFECTIOUS AGENT DNA/RNA INFLUENZA 1ST 2 TYPES 164.71 XXX N  

20 Miss. Admin. Code Pt. 2, R. 87503 Rule 87503

NFCT AGENT DNA/RNA INFLUENZA >2 TYPES EA ADDL 50.24 XXX N  87505 NFCT AGENT DNA/RNA GASTROINTESTINAL PATHOGEN 235.33 XXX N  87506 IADNA-DNA/RNA GI PTHGN MULTIPLEX PROBE TQ 6-11 452.17 XXX N  87507 IADNA-DNA/RNA GI PTHGN MULTIPLEX PROBE TQ 12-25 764.55 XXX N  87510 IADNA GARDNERELLA VAGINALIS DIRECT PROBE TQ 36.78 XXX N  87511 IADNA GARDNERELLA VAGINALIS AMPLIFIED PROBE TQ 64.37 XXX N  87512 IADNA GARDNERELLA VAGINALIS QUANTIFICATION 76.61 XXX N  87513 IADNA H PYLORI CLARITHROMYCIN RESIST AMP PRB TQ 64.55 XXX N  87516 IADNA HEPATITIS B VIRUS AMPLIFIED PROBE TQ 64.37 XXX N  87517 IADNA HEPATITIS B VIRUS QUANTIFICATION 78.59 XXX N  87520 IADNA HEPATITIS C DIRECT PROBE TECHNIQUE 53.68 XXX N  87521 IADNA HEPATITIS C AMPLIFIED PROBE&REVRSE TRANSCR 64.37 XXX N  87522 IADNA HEPATITIS C QUANT & REVERSE TRANSCRIPTION 78.59 XXX N  87523 IADNA HEPATITIS D DELTA QUAN W/REV TRANSCRIPTION 77.85 XXX N  87525 IADNA HEPATITIS G DIRECT PROBE TECHNIQUE 51.24 XXX N  87526 IADNA HEPATITIS G AMPLIFIED PROBE TECHNIQUE 67.50 XXX N  87527 IADNA HEPATITIS G QUANTIFICATION 76.61 XXX N  87528 IADNA HERPES SIMPLX VIRUS DIRECT PROBE TQ 36.78 XXX N  87529 IADNA HERPES SOMPLX VIRUS AMPLIFIED PROBE TQ 64.37 XXX N  87530 IADNA HERPES SOMPLX VIRUS QUANTIFICATION 78.59 XXX N

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  87531 IADNA HERPES VIRUS-6 DIRECT PROBE TQ 99.72 XXX N  87532 IADNA HERPES VIRUS-6 AMPLIFIED PROBE TQ 64.37 XXX N  87533 IADNA HERPES VIRUS-6 QUANTIFICATION 76.61 XXX N  87534 IADNA HIV-1 DIRECT PROBE TECHNIQUE 37.69 XXX N  87535 IADNA HIV-1 AMPLIFIED PROBE & REVERSE TRANSCRPJ 64.37 XXX N  87536 IADNA HIV-1 QUANT & REVERSE TRANSCRIPTION 156.10 XXX N  87537 IADNA HIV-2 DIRECT PROBE TECHNIQUE 37.69 XXX N  87538 IADNA HIV-2 AMPLIFIED PROBE & REVERSE TRANSCRIPJ 64.37 XXX N  87539 IADNA HIV-2 QUANT & REVERSE TRANSCRIPTION 100.79 XXX N  87540 IADNA LEGIONELLA PNEUMOPHILA DIRECT PROBE TQ 36.78 XXX N  87541 IADNA LEGIONELLA PNEUMOPHILA AMPLIFIED PROBE TQ 64.37 XXX N  87542 IADNA LEGIONELLA PNEUMOPHILA QUANTIFICATION 76.61 XXX N  87550 IADNA MYCOBACTERIA SPECIES DIRECT PROBE TQ 36.78 XXX N  87551 IADNA MYCOBACTERIA SPECIES AMPLIFIED PROBE TQ 82.94 XXX N  87552 IADNA MYCOBACTERIA SPECIES QUANTIFICATION 78.59 XXX N  87555 IADNA MYCOBACTERIA TUBERCULOSIS DIR PRB 46.22 XXX N  87556 IADNA MYCOBACTERIA TUBERCULOSIS AMP PRB 71.66 XXX N  87557 IADNA MYCOBACTERIA TUBERCULOSIS QUANTIFICATION 78.59 XXX N  87560 IADNA MYCOBACTERIA AVIUM-INTRACLRE DIR PRB 46.92 XXX N  87561 IADNA MYCOBACTERIA AVIUM-INTRACLRE AMP PRB 64.37 XXX N  87562 IADNA MYCOBACTERIA AVIUM-INTRACELLULARE QUANT 78.59 XXX N  87563 IADNA MYCOPLASMA GENITALIUM AMPLIFIED PROBE TECH 60.33 XXX N  87564 IADNA MTB RIFAMPIN RESISTANCE AMP PRB TQ 141.22 XXX N  87580 IADNA MYCOPLSM PNEUMONIAE DIRECT PROBE TQ 36.78 XXX N  87581 IADNA MYCOPLSM PNEUMONIAE AMPLIFIED PROBE TQ 64.37 XXX N  87582 IADNA MYCOPLSM PNEUMONIAE QUANTIFICATION 520.31 XXX N  87590 IADNA NEISSERIA GONORRHOEAE DIRECT PROBE TQ 46.22 XXX N  87591 IADNA NEISSERIA GONORRHOEAE AMPLIFIED PROBE TQ 64.37 XXX N  87592 IADNA NEISSERIA GONORRHOEAE QUANTIFICATION 78.59 XXX N  87593 IADNA ORTHOPOXVIRUS AMPLIFIED PROBE TECHNIQUE EA 94.38 XXX N  87594 IADNA PNEUMOCYSTIS JIROVECII AMPLIFIED PROBE TQ 64.55 XXX N  87623 IADNA HUMAN PAPILLOMAVIRUS LOW-RISK TYPES 64.37 XXX N  87624 IADNA HUMAN PAPILLOMAVIRUS HI-RSK TYP POOLD RSLT 64.37 XXX N  87625 IADNA HUMAN PAPILLOMAVIRUS TYPES 16 & 18 ONLY 69.72 XXX N  87626 IADNA HPV SEP RPRT HI-RSK TYP&HI-RSK POOLD RSLTS 129.13 XXX N  87631 IADNA RESPIRATRY PROBE & REV TRNSCR 3-5 TARGETS 245.23 XXX N  87632 IADNA RESPIRATRY PROBE & REV TRNSCR 6-11 TARGETS 391.51 XXX N  87633 IADNA RESPIRATRY PROBE & REV TRNSCR 12-25 TARGET 764.55 XXX N  87634 IADNA DNA/RNA RSV AMPLIFIED PROBE TECHNIQUE 128.76 XXX N  87635 IADNA SARS-COV-2 COVID-19 AMPLIFIED PROBE TQ 88.22 XXX N  87636 IADNA SARSCOV2& INF A&B MULT AMPLIFIED PROBE TQ 245.23 XXX N  87637 IADNA SARSCOV2 & INF A&B & RSV MULT AMP PROBE TQ 245.23 XXX N  87640 IADNA S AUREUS AMPLIFIED PROBE TQ 64.37 XXX N  87641 IADNA S AUREUS METHICILLIN RESIST AMP PROBE TQ 64.37 XXX N  87650 IADNA STREPTOCOCCUS GROUP A DIRECT PROBE TQ 36.78 XXX N  87651 IADNA STREPTOCOCCUS GROUP A AMPLIFIED PROBE TQ 64.37 XXX N  87652 IADNA STREPTOCOCCUS GROUP A QUANTIFICATION 76.61 XXX N

Pathology and Laboratory Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 80047-89398, G0480-G0483, G0659 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 272 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  87653 IADNA STREPTOCOCCUS GROUP B AMPLIFIED PROBE TQ 64.37 XXX N  87660 IADNA TRICHOMONAS VAGINALIS DIRECT PROBE TQ 36.78 XXX N  87661 IADNA TRICHOMONAS VAGINALIS AMPLIFIED PROBE TECH 64.37 XXX N  87662 IADNA DNA/RNA ZIKA VIRUS AMPLIFIED PROBE TQ 94.14 XXX N  87797 IADNA NOS DIRECT PROBE TQ EACH ORGANISM 51.63 XXX N  87798 IADNA NOS AMPLIFIED PROBE TQ EACH ORGANISM 64.37 XXX N  87799 IADNA NOS QUANTIFICATION EACH ORGANISM 78.59 XXX N  87800 IADNA MULTIPLE ORGANISMS DIRECT PROBE TQ 75.08 XXX N  87801 IADNA MULTIPLE ORGANISMS AMPLIFIED PROBE TQ 128.76 XXX N  87802 IAADIADOO STREPTOCOCCUS GROUP B 21.99 XXX N  87803 IAADIADOO CLOSTRIDIUM DIFFICILE TOXIN A 27.51 XXX N  87804 IAADIADOO INFLUENZA 28.46 XXX N  87806 IAADIADOO HIV1 ANTIGEN W/HIV1 & HIV2 ANTIBODIES 56.34 XXX N  87807 IAADIADOO RESPIRATORY SYNCTIAL VIRUS 22.52 XXX N  87808 IAADIADOO TRICHOMONAS VAGINALIS 26.29 XXX N  87809 IAADIADOO ADENOVIRUS 37.41 XXX N  87810 IAADIADOO CHLAMYDIA TRACHOMATIS 60.68 XXX N  87811 IAADIADOO SEVERE AQT RESPIR SYND CORONAVIRUS 141.02 XXX N  87850 IAADIADOO NEISSERIA GONORRHOEAE 42.23 XXX N  87880 IAADIADOO STREPTOCOCCUS GROUP A 28.42 XXX N  87899 IAADIADOO NOT OTHERWISE SPECIFIED 27.63 XXX N  87900 NFCT AGT DRUG SUSCEPT PHENOTYPE PREDICTION 239.11 XXX N  87901 NFCT AGT GNOTYP ALYS NUCLE ACD HIV1 REV TRNSCRPT 472.26 XXX N  87902 NFCT AGENT GENOTYPE ALYS NUCLEIC ACD HEP C VIRUS 472.26 XXX N  87903 NFCT PHEXYP RESIST TISS CUL HIV FIRST 1-10 DRUGS 896.40 XXX N   87904 NFCT PHEXYP RESIST TISS CUL HIV EA ADDL DRUG 47.83 XXX N  87905 INFECTIOUS AGENT ENZYMATIC ACTV OTH/THN VIRUS 22.42 XXX N  87906 NFCT AGT GNOTYP ALYS NUCLE ACD HIV1 OTHER REGION 236.14 XXX N  87910 NFCT AGT GENOTYPE ALYS NUCLEIC ACID CMV 472.26 XXX N  87912 NFCT AGENT GENOTYPE ALYS NUCLEIC ACD HEP B VIRUS 472.26 XXX N  87913 NFCT AGENT GENOTYPE ALYS NUCLEIC ACID SARSCOV2 452.04 XXX N  87999 UNLISTED MICROBIOLOGY PROCEDURE BR XXX N  88000 NECROPSY GROSS EXAMINATION ONLY W/O CNS 412.71 XXX N  88005 NECROPSY GROSS EXAMINATION W/BRAIN 481.29 XXX N  88007 NECROPSY GROSS EXAMINATION W/BRAIN&SPINAL CORD 504.15 XXX N  88012 NECROPSY GROSS EXAMINATION INFANT W/BRAIN 412.71 XXX N  88014 NECROPSY GROSS EXAM STILLBORN/NEWBORN W/BRAIN 378.43 XXX N  88016 NECROPSY GROSS EXAM MACERATED STILLBORN 527.01 XXX N  88020 NECROPSY GROSS & MICROSCOPIC W/O CNS 710.51 XXX N  88025 NECROPSY GROSS & MICROSCOPIC W/BRAIN 667.59 XXX N  88027 NECROPSY GROSS&MCRSCP BRAIN & SPINAL CORD 733.37 XXX N  88028 NECROPSY GROSS & MICROSCOPIC INFANT W/BRAIN 412.71 XXX N  88029 NECROPSY GROSS&MCRSCP STILLBORN/NEWBORN BRAIN 412.71 XXX N  88036 NECROPSY LIMITED GROSS&/MCRSCP REGIONAL 206.37 XXX N  88037 NECROPSY LIMITD GROSS&/MCRSCP SINGLE ORGAN 183.50 XXX N  88040 NECROPSY FORENSIC EXAMINATION 1146.09 XXX N  88045 NECROPSY CORONER CALL 114.93 XXX N

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  88099 UNLISTED NECROPSY (AUTOPSY) PROCEDURE BR XXX N  88104 CYTP FLU WASHGS/BRUSHINGS XCPT C/V SMRS INTERPJ 117.81 48.79 69.02 XXX N  88106 CYTP FLU BR/WA XCPT C/V FILTER METH ONLY INTERPJ 117.22 33.32 83.90 XXX N  88108 CYTP CONCENTRATION SMEARS & INTERPRETATION 112.46 38.68 73.78 XXX N  88112 CYTP SLCTV CELL ENHANCEMENT INTERPJ XCPT C/V 116.03 48.20 67.83 XXX N  88120 CYTP INSITU HYBRID URINE SPEC 3-5 PROBES EA MNL 1084.09 99.96 984.13 XXX N  88121 CYTP INSITU HYBRID URNE SPEC 3-5 PROBES CPTR EA 806.23 84.49 721.74 XXX N  88125 CYTOPATHOLOGY FORENSIC 47.01 23.80 23.21 XXX N  88130 SEX CHROMATIN IDENTIFICATION BARR BODIES 32.97 XXX N  88140 SEX CHROMATIN IDENTJ PERIPHERAL BLOOD SMEAR 14.66 XXX N  88141 CYTP CERVICAL/VAGINAL REQ INTERP PHYSICIAN 53.55 XXX N  88142 CYTP CERV/VAG AUTO THIN LAYER PREP MNL SCREEN 37.16 XXX N  88143 CYTP C/V FLU AUTO THIN MNL SCR&RESCR PHYS 39.61 XXX N  88147 CYTP SMRS C/V SCR AUTOMATED SYSTEM PHYS SUPV 86.93 XXX N  88148 CYTP SMRS C/V SCR AUTO SYS MNL RESCR PHYS 27.87 XXX N  88150 CYTP SLIDES C/V MNL SCR UNDER PHYS 27.37 XXX N  88152 CYTP SLIDES C/V MNL SCR&CPTR RESCR PHYS 47.52 XXX N  88153 CYTP SLIDES C/V MNL SCR&RESCR PHYS 41.32 XXX N 

 88155 CYTP SLIDES C/V DEFINITIVE HORMONAL EVAL 25.19 XXX N  88160 CYTP SMRS ANY OTH SRC SCR&INTERPJ 124.95 44.63 80.32 XXX N  88161 CYTP SMRS ANY OTH SRC PREPJ SCR&INTERPJ 127.96 43.44 84.52 XXX N  88162 CYTP SMRS ANY OTH SRC EXTND STD > 5 SLIDES 184.75 67.24 117.51 XXX N  88164 CYTP SLIDES CERV/VAG MNL SCRN PHYSICIAN SUPV 27.37 XXX N  88165 CYTP SLIDES C/V MNL SCR&RESCR PHYS SUPV 72.59 XXX N  88166 CYTP SLIDES C/V MNL SCR&CPTR RESCR PHYS SUPV 27.37 XXX N  88167 CYTP SLIDES C/V MNL SCR&CPTR RESCR CELL S&I 27.37 XXX N  88172 CYTP FINE NDL ASPIRATE IMMT CYTOHIST STD DX 1ST 95.20 62.48 32.72 XXX N  88173 CYTP EVAL FINE NEEDLE ASPIRATE INTERP & REPORT 274.30 121.98 152.32 XXX N  88174 CYTP C/V AUTO THIN LYR PREPJ SCR SYS PHYS 43.62 XXX N  88175 CYTP C/V AUTO THIN LYR PREPJ SCR MNL RESCR PHYS 48.60 XXX N 

 88177 CYTP FINE NDL ASPIRATE IMMT CYTOHIST STD EA EVAL 49.98 38.08 11.90 ZZZ N  88182 FLOW CYTOMETRY CELL CYCLE/DNA ANALYSIS 256.45 66.64 189.81 XXX N  88184 FLOW CYTOMETRY CELL SURF MARKER TECHL ONLY 1ST 119.00 XXX N 422.38 

 88185 FLOW CYTOMETRY CELL SURF MARKER TECHL ONLY EA 41.06 ZZZ N  88187 FLOW CYTOMETRY INTERPJ 2-8 MARKERS 64.26 XXX N  88188 FLOW CYTOMETRY INTERPJ 9-15 MARKERS 108.89 XXX N  88189 FLOW CYTOMETRY INTERPRETATION 16/> MARKERS 145.78 XXX N  88199 UNLISTED CYTOPATHOLOGY PROCEDURE BR BR BR XXX N  88230 TISS CUL NON-NEO DISORDERS LYMPHOCYTE 213.70 XXX N  88233 TISS CUL NON-NEO DISORDERS SKN/OTH SOLID TISS BX 258.15 XXX N  88235 TISS CUL NON-NEO DISORDERS AMNIOTIC/CHORNC CELLS 270.15 XXX N  88237 TISS CUL NEO DISORDERS BONE MARROW BLOOD CELLS 247.16 XXX N  88239 TISS CUL NEO DISORDERS SOLID TUMOR 270.61 XXX N  88240 CRYOPRSRV FRZING&STORAGE CELLS EA CELL LINE 22.47 XXX N  88241 THAWING&EXPANSION FROZEN CELLS EACH ALIQUOT 20.79 XXX N  88245 CHRMSM BREAKAGE BASELINE SISTER 20-25 CLL 317.68 XXX N

Pathology and Laboratory Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 80047-89398, G0480-G0483, G0659 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 274 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  88248 CHRMSM BREAKAGE BASELINE BREAKAGE 50-100 CLL 317.68 XXX N  88249 CHRMSM BREAKAGE SYNDS SCORE 100 CLL 317.68 XXX N  88261 CHRMSM COUNT 5 CELL 1KARYOTYPE BANDING 454.49 XXX N  88262 CHRMSM COUNT 15-20 CLL 2KARYOTYP BANDING 228.64 XXX N  88263 CHRMSM COUNT 45 CELL MOSAICISM 2KARYOTYPE 275.70 XXX N  88264 CHRMSM ANALYZE 20-25 CELLS 248.63 XXX N  88267 CHRMSM ALYS AMNIOTIC/VILLUS 15 CELL 1KARYOTYPE 329.78 XXX N  88269 CHRMSM SITU AMNIOTIC CLL 6-12 COLONIES 1KARYOTYP 305.12 XXX N  88271 MOLECULAR CYTOGENETICS DNA PROBE EACH 39.29 XXX N  88272 MOLECULAR CYTOGENETICS CHRMOML ISH 3-5 CELLS 69.98 XXX N  88273 MOLECULAR CYTOGENETICS CHRMOML ISH 10-30 CLL 59.85 XXX N  88274 MOLECULAR CYTOGENETICS INTERPHASE ISH 25-99 CLL 72.87 XXX N  88275 MOLEC CYTG INTERPHASE ISH ANALYZE 100-300 CLL 88.01 XXX N  88280 CHRMSM ANALYSIS ADDL KARYOTYP EACH STUDY 57.55 XXX N  88283 CHRMSM ANALYSIS ADDL SPECIALIZED BANDING 125.84 XXX N  88285 CHRMSM ANALYSIS ADDL CELLS COUNTED EACH STUDY 46.27 XXX N  88289 CHRMSM ANALYSIS ADDL HIGH RESOLUTION STUDY 63.17 XXX N  88291 CYTOGENETICS&MOLEC CYTOGENETICS INTERP&REP 57.72 XXX N  88299 UNLISTED CYTOGENETIC STUDY BR XXX N 72.07  88300 LEVEL I SURG PATHOLOGY GROSS EXAMINATION ONLY 26.78 7.74 19.04 XXX N  88302 LEVEL II SURG PATHOLOGY GROSS&MICROSCOPIC EXAM 55.34 11.90 43.44 XXX N  88304 LEVEL III SURG PATHOLOGY GROSS&MICROSCOPIC EXAM 72.59 19.64 52.95 XXX N  88305 LEVEL IV SURG PATHOLOGY GROSS&MICROSCOPIC EXAM 123.76 65.45 58.31 XXX N  88307 LEVEL V SURG PATHOLOGY GROSS&MICROSCOPIC EXAM 499.80 143.40 356.40 XXX N  88309 LEVEL VI SURG PATHOLOGY GROSS&MICROSCOPIC EXAM 759.22 253.47 505.75 XXX N   88311 DECALCIFICATION PROCEDURE 36.30 21.42 14.88 XXX N  88312 SPECIAL STAIN GROUP 1 MICROORGANISMS I&R 193.65 45.82 147.83 XXX N  88313 SPCL STN 2 I&R EXCPT MICROORG/ENZYME/IMCYT 140.28 20.83 119.45 XXX N 

 88314 SPECIAL STAIN I&R HISTOCHEMICAL W/FROZEN TISSU 172.55 38.68 133.87 XXX N  88319 SPECIAL STAIN I&R GROUP III ENZYME CONSITUENTS 187.48 46.41 141.07 XXX N  88321 CONSLTJ&REPRT REFERRED SLIDES PREPARED ELSEWHERE 169.58 XXX N 49.09  88323 CONSLTJ&REPRT REFERRED MATRL REQUIRING PREPJ SLD 196.35 150.54 45.81 XXX N  88325 CONSLTJ COMPRE RVW RECORD REPRT REFERRED MATRL 304.64 XXX N 216.29  88329 PATHOLOGY CONSULTATION DURING SURGERY 99.96 XXX N 49.09  88331 PATH CONSLTJ SURG 1ST BLK FROZEN SCTJ 1ST SPEC 177.91 108.29 69.62 XXX N 

 88332 PATH CONSLTJ SURG EA ADDL BLK FROZEN SECTION 94.61 53.55 41.06 XXX N  88333 PATH CONSLTJ SURG CYTOLOGIC EXAM INITIAL SITE 162.44 108.29 54.15 XXX N 

 88334 PATH CONSLTJ SURG CYTOLOGIC EXAM EACH ADDL SITE 97.58 66.05 31.53 ZZZ N 

 88341 IMHCHEM/IMCYTCHM EA ADDL SINGLE ANTB STAIN PX 155.89 49.39 106.50 ZZZ N  88342 IMHCHEM/IMCYTCHM 1ST SINGLE ANTB STAIN PROCEDURE 179.10 61.29 117.81 XXX N  88344 IMHCHEM/IMCYTCHM EA MULTIPLEX ANTIBODY STAIN PX 297.50 66.64 230.86 XXX N  88346 IMMUNOFLUORESCENCE PER SPEC 1ST SINGLE ANTB STN 212.81 62.48 150.33 XXX N  88348 ELECTRON MICROSCOPY DIAGNOSTIC 694.52 133.28 561.24 XXX N 

 88350 IMMUNOFLUORESCENCE PR SPEC EA ADD SINGL ANTB STN 149.17 49.98 99.19 ZZZ N  88355 MORPHOMETRIC ANALYSIS SKELETAL MUSCLE 245.74 141.02 104.72 XXX N

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  88356 MORPHOMETRIC ANALYSIS NERVE 428.40 221.94 206.46 XXX N  88358 MORPHOMETRIC ANALYSIS TUMOR 243.36 86.28 157.08 XXX N  88360 M/PHMTRC ALYS TUMOR IMHCHEM EA ANTIBODY MANUAL 214.20 73.19 141.01 XXX N  88361 M/PHMTRC ALYS TUMOR IMHCHEM EA ANTBDY CMPTR ASST 221.34 78.54 142.80 XXX N  88362 NERVE TEASING PREPARATIONS 386.16 191.59 194.57 XXX N  88363 EXAM & SELECT ARCHIVE TISSUE MOLECULAR ANALYSI 39.87 XXX N 35.83 

 88364 IN SITU HYBRIDIZATION EA ADDL PROBE STAIN 240.98 60.10 180.88 ZZZ N  88365 IN SITU HYBRIDIZATION 1ST PROBE STAIN 314.16 75.57 238.59 XXX N  88366 IN SITU HYBRIDIZATION EA MULTIPLEX PROBE STAIN 498.02 107.10 390.92 XXX N  88367 M/PHMTRC ALYS ISH CPTR-ASST TECH 1ST PROBE STAIN 197.54 59.50 138.04 XXX N  88368 M/PHMTRC ALYS IN SITU HYBRIDIZATION EA PROBE MNL 237.41 72.00 165.41 XXX N 

 88369 M/PHMTRC ALYS ISH QUANT/SEMIQ MNL PER SPEC EACH 201.11 55.93 145.18 ZZZ N  88371 PROTEIN ANAL TISSUE WESTERN BLOT W/INTERP&REPO 74.70 33.92 40.78 XXX N  88372 PROTEIN ALYS WSTRN BLOT I&R IMMUNOLOGICAL EA 76.62 31.54 45.08 XXX N 

 88373 M/PHMTRC ALYS ISH QUANT/SEMIQ CPTR PER SPEC EACH 125.55 46.41 79.14 ZZZ N  88374 M/PHMTRC ALYS ISH QUANT/SEMIQ CPTR EACH MULTIPRB 570.61 76.16 494.45 XXX N  88375 OPTICAL ENDOMICROSCOPIC IMAGE INTERP & REPORT 84.49 XXX N  88377 M/PHMTRC ALYS ISH QUANT/SEMIQ MNL EACH MULTIPRB 708.05 110.67 597.38 XXX N  88380 MICRODISSECTION PREP IDENTIFIED TARGET LASER 224.91 94.61 130.30 XXX N  88381 MICRODISSECTION PREP IDENTIFIED TARGET MANUAL 296.96 43.44 253.52 XXX N  88387 MACROSCOPIC XM DSJ&PREPJ TISS NONMCRSCP STD EA 59.50 48.20 11.30 XXX N  88399 UNLISTED SURGICAL PATHOLOGY PROCEDURE BR BR BR XXX N  88720 BILIRUBIN TOTAL TRANSCUTANEOUS 9.20 XXX N  88738 HGB QUANTITATIVE TRANSCUTANEOUS 9.20 XXX N  88740 HEMOGLOBIN QUAN TC PER DAY CARBOXYHEMOGLOBIN 16.11 XXX N  88741 HEMOGLOBIN QUANTITATIVE TC PER DAY METHEMOGLOBIN 16.11 XXX N  88749 UNLISTED IN VIVO LABORTORY SERVICE BR XXX N  89049 CAFFEINE HALOTHANE CONTRACTURE TEST 471.84 XXX N 216.29  89050 CELL COUNT MISCELLANEOUS BODY FLUIDS 8.67 XXX N  89051 CELL COUNT MISC BODY FLUIDS W/DIFFERENTIAL COUNT 10.10 XXX N  89055 LEUKOCYTE ASSMT FECAL QUAL/SEMIQUANTITATIVE 7.84 XXX N  89060 CRYSTAL ID LIGHT MICROSCOPY ALYS TISS/ANY FLUID 44.14 31.54 12.60 XXX N  89125 FAT STAIN FECES URINE/RESPIR SECRETIONS 10.11 XXX N  89160 MEAT FIBERS FECES 8.34 XXX N  89190 NASAL SMEAR EOSINOPHILS 9.96 XXX N  89220 SPUTUM OBTAINING SPEC AEROSOL INDUCED TX SPX 31.48 XXX N 216.29  89230 SWEAT COLLECTION IONTOPHORESIS 4.76 XXX N 72.07  89240 UNLISTED MISCELLANEOUS PATHOLOGY TEST BR XXX N 72.07  89250 CUL OOCYTE/EMBRYO <4 DAYS 2816.73 XXX N 216.29  89251 CUL OOCYTE/EMBRYO < 4 D CO-CULT OCYTE/EMBRY 2545.41 XXX N 216.29  89253 ASSTD EMBRYO HATCHING MICROTQS ANY METH 1097.54 XXX N 216.29  89254 OOCYTE ID FROM FOLLICULAR FLU 1126.93 XXX N 216.29  89255 PREPJ EMBRYO TR 704.48 XXX N 72.07  89257 SPRM ID FROM ASPIR OTH/THN SEMINAL 861.56 XXX N 72.07  89258 CRYOPRSRV EMBRYO 1463.62 XXX N 950.39  89259 CRYOPRSRV SPRM 366.08 XXX N 216.29

Pathology and Laboratory Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 80047-89398, G0480-G0483, G0659 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 276 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR  89260 SPRM ISOL SMPL PREP INSEMINATION/DX SEMEN ALYS 292.86 XXX N 72.07  89261 SPRM ISOL CPLX PREP INSEMINATION/DX SEMEN ALYS 368.90 XXX N 72.07  89264 SPRM ID FROM TSTIS TISS FRSH/CRYOPRSRVD 968.66 XXX N 72.07  89268 INSEMINATION OOCYTES 1170.76 XXX N 216.29  89272 EXTND CUL OOCYTE/EMBRYO 4-7 DAYS 1865.96 XXX N 950.39  89280 ASSTD FERTILIZATION MICROTQ <= 10 OOCYTES 2927.22 XXX N 950.39  89281 ASSTD FERTILIZATION MICROTQ > 10 OOCYTES 2916.69 XXX N 216.29  89290 BX OOCYTE POLR BDY/EMBRY BLST MICROTQ <= 5 EMBRY 2816.73 XXX N 216.29  89291 BX OOCYTE MICROTQ >5 EMBRY 3366.51 XXX N 216.29  89300 SEMEN ALYS PRESENCE&/MOTILITY SPRM HUHNER 16.92 XXX N  89310 SEMEN ALYS MOTILITY&CNT X W/HUHNER TST 15.80 XXX N  89320 SEMEN ANALYSIS VOLUME COUNT MOTILITY DIFFERENT 22.11 XXX N  89321 SEMEN ANALYSIS SPERM PRESENCE&/MOTILITY SPRM 22.11 XXX N  89322 SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA 28.43 XXX N  89325 SPERM ANTIBODIES 19.58 XXX N  89329 SPERM EVALUATION HAMSTER PENETRATION TEST 35.93 XXX N  89330 SPERM EVALUATION CERVICAL MUCOUS PENETRATION 18.14 XXX N  89331 SPERM EVALUATION RETROGRADE EJACULATION URINE 35.93 XXX N  89335 CRYOPRSRV REPRODUCTIVE TISSUE TESTICULAR 512.51 XXX N 72.07  89337 CRYOPRESERVATION MATURE OOCYTE(S) 1756.48 XXX N 216.29  89342 STORAGE PER YEAR EMBRYO 732.15 XXX N 216.29  89343 STORAGE PER YEAR SPERM/SEMEN 340.76 XXX N 216.29  89344 STORAGE PER YR REPRDTVE TISS TSTICULAR/OVARIAN 439.29 XXX N 216.29  89346 STORAGE PER YEAR OOCYTE 512.51 XXX N 422.38  89352 THAWING CRYOPRESERVED EMBRYO 821.10 XXX N 216.29  89353 THAWING CRYOPRESERVED SPERM/SEMEN EACH ALIQUOT 153.96 XXX N 72.07  89354 THAWING CRYOPRESERVED TESTICULAR/OVARIAN 349.86 XXX N 216.29  89356 THAWING CRYOPRESERVED OOCYTES EACH ALIQUOT 765.68 XXX N 216.29  89398 UNLISTED REPRODUCTIVE MEDICINE LAB PROCEDURE BR XXX N 72.07  G0480 DRUG TEST DEF 1-7 CLASSES 196.74 XXX N  G0481 DRUG TEST DEF 8-14 CLASSES 269.23 XXX N  G0482 DRUG TEST DEF 15-21 CLASSES 341.70 XXX N  G0483 DRUG TEST DEF 22+ CLASSES 424.54 XXX N  G0659 DRUG TEST DEF SIMPLE ALL CL 106.84 XXX N

CPT Copyright 2021 2024 American Medical Association. All rights reserved. 277 MEDICINE SERVICES In addition to the general rules, this section applies unique guidelines for medicine specialties. Therapeutic services and rehabilitation guidelines, as well as chiropractic and osteopathic services, are listed in a separate section following Medicine Services. Note: Rules used by all physicians or OQHPs in reporting their services are presented in the General Rules section. See the Modifier and Code Rules section for detailed information on modifiers. I.GUIDELINES A. Unlisted Services or Procedures. When reporting a service or procedure that is not listed in this Fee Schedule, use the appropriate unlisted procedure code. The bill must be accompanied by a Special Report as described below. If a HCPCS or CPT ® code has been established subsequent to the release of this Fee Schedule, include the code(s) with the Special Report. B. Multiple Procedures. When multiple procedures are performed on the same date or at the same session, it is appropriate to designate them by separate entries. C. Separate Procedures. Separate procedures are commonly carried out as an integral component of another procedure. They should not be billed in conjunction with the related procedure. These procedures may be billed when performed independently by adding modifier 59 to the specific “separate procedure” code. D. By Report (BR). “BR” in the MAR column indicates services that are too new, unusual, or variable in the nature of their performance to permit the assignment of a definable fee. Such services should be substantiated by documentation submitted with the bill. Sufficient information should be included to permit proper identification and a sound evaluation. For more information, please see Definitions in the Introduction. E. Special Report. Any test/service that is not provided routinely or is an unlisted service or procedure should be reported with the appropriate unlisted service or procedure code designating the service and the billing for that test/service should include a description of the procedure, the process used, and a full report of the findings. Special reports to justify the necessity of a service do not warrant a separate fee. F. Materials Supplied by Physician or Other Qualified Health Care Professional. Supplies and materials usually included in an office visit are included in the reimbursement for the office visit. Other unusual supplies and materials should be identified with CPT code 99070 or a specific HCPCS code. Reimbursement shall be limited to the lesser of the billed amount, the Fee Schedule MAR or the usual and customary rate for items not listed in this Fee Schedule. G. Audiological Function Tests. The audiometric tests (92551–92597) require the use of calibrated electronic equipment, recording of results and a report with interpretation. Hearing tests (such as whispered voice, tuning fork) that are otorhinolaryngologic evaluation and management services are not reported separately. All services include testing of both ears. Use modifier 52 if a test is applied to one ear instead of two ears. H. Psychological Services 1. Payment for a psychiatric diagnostic interview/ evaluation includes history and mental status determination, development of a treatment plan when necessary and the preparation of a written report that must be submitted with the required billing form. Use of an E/M code with a diagnostic interview/evaluation is not appropriate. 2. Psychotherapy codes are used regardless of place of service. The CPT code most closely matching the length of the session must be billed. 3. When E/M and psychotherapy are performed on the same date of service, use the appropriate psychotherapy with E/M add-on code (90833, 90836, 90838) following the guidelines from CPT and American Psychiatric Association recommendations. 4. A service level adjustment factor is used to determine payment for psychotherapy when a provider other than a psychiatrist provides the service. In those instances, the reimbursement amount for the CPT code is paid at eighty-five percent (85%) of the maximum reimbursement allowance. This applies to psychologists, social workers, licensed professional counselors and other non-physician providers. I. Electromyography (EMG) and Nerve Conduction Studies (NCS). Payment for EMG services includes the initial set of electrodes and all supplies necessary to perform the service. The physician may be paid for a consultation or new patient visit in addition to the EMG performed on the same day, with supporting documentation required as outlined in the Evaluation and Management section. When an EMG is performed on the same day as a follow up visit, payment may be made for the EMG only unless documentation supports the need for a medical service in addition to the EMG. 1. Only a licensed allopathic or osteopathic physician certified in Neurology/Physical Medicine and Rehabilitation (PMR)/ Electrodiagnostic medicine is entitled to reimbursement for performing an electromyogram (EMG) and/or a nerve conduction study (NCS). 2. Reimbursement for automated nerve conduction studies is not allowed under this Fee Schedule.

Medicine Services Mississippi Workers Compensation Medical Fee Schedule

20 Miss. Admin. Code Pt. 2, R. 278 Rule 278

CPT Copyright 2024 American Medical Association. All rights reserved. 3. Referral for an electromyogram and/or a nerve conduction study shall be at the discretion and direction of the physician or OQHP in charge of care, and neither the payer nor the payer’s agent may unilaterally or arbitrarily redirect the injured worker to another provider for these tests. The payer or the payer’s agent may, however, discuss with the physician or OQHP in charge of care, appropriate providers for the conduct of these tests in an effort to reach an agreement with the physician or OQHP in charge as to who will conduct an electromyogram and/or nerve conduction study in any given case. J. Manipulative Services. Chiropractic and Osteopathic manipulative services, which are medicine services, are addressed in the Therapeutic Services section of the Fee Schedule. K. Wound Care. Non-surgical debridement of active wounds should be billed as CPT code 97597, 97598, or 97602.

Mississippi Workers’ Compensation Medical Fee Schedule Medicine Services 90281-96999, 97597-97610, 97802-97804, Effective June 1, 2026 98960-99082, 99151-99199, 99500-99607 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine CPT Copyright 2024 American Medical Association. All rights reserved. 279

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   90281 IMMUNE GLOBULIN IG HUMAN IM USE 70.56 XXX N 79.62   90283 IMMUNE GLOBULIN IGIV HUMAN IV USE 68.44 XXX N 478.87   90284 IMMUNE GLOBULIN HUMAN SUBQ INFUSION 100 MG EA 36.28 XXX N   90287 BOTULINUM ANTITOXIN EQUINE ANY ROUTE 659.26 XXX N 1224.43   90288 BOTULISM IMMUNE GLOBULIN HUMAN INTRAVENOUS USE BR XXX N   90291 CYTOMEGALOVIRUS IMMUNE GLOBULIN HUMAN IV 100.89 XXX N   90296 DIPHTHERIA ANTITOXIN EQUINE ANY ROUTE BR XXX N   90371 HEPATITIS B IMMUNE GLOBULIN HBIG HUMAN IM 225.06 XXX N 192.54   90375 RABIES IMMUNE GLOBULIN RIG HUMAN IM/SUBQ 526.25 XXX N 438.31   90376 RABIES IG HEAT-TREATED HUMAN IM/SUBQ 587.37 XXX N 505.99   90377 RABIES IG HEAT&SOLVENT/DETERGENT HUMAN IM&/SUBQ 409.04 XXX N

  90378 RESPIRATORY SYNCYTIAL VIRUS IG IM 50 MG E 1836.08 XXX N 1683.65   90380 RSV MONOCLONAL ANTB SEASONAL DOSE 0.5ML IM USE 409.46

XXX N   90381 RSV MONOCLONAL ANTB SEASONAL DOSE 1 ML IM USE 415.36 XXX N   90384 RHO(D) IMMUNE GLOBULIN HUMAN FULL-DOSE IM 123.31 XXX N 191.23   90385 RHO(D) IMMUNE GLOBULIN HUMAN MINI-DOSE IM 53.60 XXX N 215.00   90386 RHO(D) IMMUNE GLOBULIN HUMAN IV 118.00 XXX N   90389 TETANUS IMMUNE GLOBULIN TIG HUMAN IM 53.60 XXX N   90393 VACCINIA IMMUNE GLOBULIN HUMAN IM 61.95 XXX N   90396 VARICELLA-ZOSTER IMMUNE GLOBULIN HUMAN IM 146.91 XXX N 2782.96   90399 UNLISTED IMMUNE GLOBULIN BR XXX N   90460 IM ADM THRU 18YR ANY RTE 1ST/ONLY COMPT VAC/TOX 28.91 XXX N   90461 IM ADM THRU 18YR ANY RTE ADDL VAC/TOX COMPT 21.83 ZZZ N   90471 IM ADM PRQ ID SUBQ/IM NJXS 1 VACCINE 28.91 XXX N 89.91   90472 IM ADM PRQ ID SUBQ/IM NJXS EA VACCINE 21.83 ZZZ N   90473 IM ADM INTRANSL/ORAL 1 VACCINE 28.91 XXX N 89.91   90474 IM ADM INTRANSL/ORAL EA VACCINE 21.83 ZZZ N   90476 ADENOVIRUS VACCINE TYPE 4 LIVE ORAL 42.75 XXX N   90477 ADENOVIRUS VACCINE TYPE 7 LIVE FOR ORAL 25.10 XXX N   90480 IMM ADMN SARSCOV2 VACCINE SINGLE DOSE 36.58 XXX N 58.96   90581 ANTHRAX VACCINE SUBCUTANEOUS/IM USE 125.10 XXX N   90584 DENGUE VACC QUAD LIVE 2 DOSE SCHEDULE SUBQ USE BR XXX N   90585 BACILLUS CALMETTE-GUERIN VACC FOR TB LIVE PERQ 229.62 XXX N   90586 BACILLUS CALMETTE-GUERIN VACCINE INTRAVESICAL 241.28 XXX N   90587 DENGUE VACC QUAD LIVE 3 DOSE SCHEDULE SUBQ USE BR XXX N   90589 CHIKUNGUNYA VIRUS VACCINE LIVE FOR IM USE 306.80 XXX N   90593 CHIKUNGUNYA VIRUS VACCINE RECOMBINANT FOR IM USE BR XXX N   90611 SMALLPOX&MONKEYPOX VACC 0.5ML DOS FOR SUBQ USE 68.44 XXX N 0.01   90619 MENACWY-TT CONJ VACC SEROGROUPS ACWY FOR IM USE 135.70 XXX N   90620 MENB-4C RECOMBNT PRTN & OUTER MEMB VESIC VACC IM 168.27 XXX N   90621 MENB-FHBP RECOMBNT LIPOPROTEIN VACC 2/3 DOSE IM 143.16 XXX N   90622 VACCINIA VIRUS VACC LIVE 0.3 ML DOS FOR PERQ USE 56.05 XXX N   90623 MENIGCCAL PNTVLNT MENACWY TT MENB FHBP VACC IM 169.92 XXX N   90624 MENIGCCAL PNTVLNT MENB-4C & MENACWY VACC IM USE BR XXX N   90625 CHOLERA VACCINE ADULT 1 DOSE LIVE FOR ORAL USE 195.88 XXX N   90626 TICK-BORNE ENCEPH VACC INACTIVATED 0.25ML IM USE 270.22 XXX N

Medicine Services Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 90281-96999, 97597-97610, 97802-97804, 98960-99082, 99151-99199, 99500-99607 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 280 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   90627 TICK-BORNE ENCEPH VACC INACTIVATED 0.5ML IM USE 233.05 XXX N   90632 HEPA VACCINE ADULT DOSE FOR INTRAMUSCULAR USE 109.70 XXX N   90633 HEPA VACCINE 2 DOSE SCHEDULE PED/ADOLESC IM USE 44.25 XXX N   90634 HEPA VACCINE 3 DOSE SCHEDULE PED/ADOLESC IM USE 59.59 XXX N 42.86   90636 HEPATITIS A & B VACCINE HEPA-HEPB ADULT IM 106.79 XXX N   90637 VACCINE QIRV MRNA 30 MCG/0.5 ML FOR IM USE 89.68 XXX N   90638 VACCINE QIRV MRNA 60 MCG/0.5 ML FOR IM USE BR XXX N   90644 HIB-MENCY VACC 4 DOSE SCHED 6 WKS-18 MONTHS IM 47.20 XXX N   90647 HIB PRP-OMP VACCINE 3 DOSE SCHEDULE IM USE 37.76 XXX N   90648 HIB PRP-T VACCINE 4 DOSE SCHEDULE IM USE 33.63 XXX N   90649 4VHPV VACCINE 3 DOSE SCHEDULE FOR IM USE 158.12 XXX N   90650 2VHPV VACCINE 3 DOSE SCHEDULE FOR IM USE 158.12 XXX N   90651 9VHPV VACC 2/3 DOSE SCHED IM USE 193.37 XXX N 256.68   90653 IIV ADJUVANTED VACCINE FOR INTRAMUSCULAR USE 89.50 XXX N 80.44   90655 IIV3 VACC PRESRV FREE 0.25 ML DOSAGE IM USE 21.24 XXX N   90656 IIV3 VACC PRESERVATIVE FREE 0.5 ML DOSAGE IM USE 32.37 XXX N   90657 IIV3 VACCINE SPLIT VIRUS 0.25 ML DOSAGE IM USE 21.71 XXX N   90658 IIV3 VACCINE SPLIT VIRUS 0.5 ML DOSAGE IM USE 20.65 XXX N 28.14   90660 LAIV3 VACCINE LIVE FOR INTRANASAL USE 25.10 XXX N   90661 CCIIV3 VACCINE ABX FREE 0.5 ML FOR IM USE 25.37 XXX N   90662 IIV VACCINE PRESERV FREE INCREASED AG CONTENT IM 100.48 XXX N   90664 LAIV VACCINE PANDEMIC FORMULA FOR INTRANASAL USE 39.41 XXX N   90666 INFLUENZA VACCINE PANDEMIC SPLT PRSRV FREE IM 30.68 XXX N   90667 IIV VACCINE PANDEMIC ADJUVANT FOR IM USE 46.02 XXX N   90668 IIV VACCINE PANDEMIC FOR INTRAMUSCULAR USE 31.27 XXX N   90670 PCV13 VACCINE FOR INTRAMUSCULAR USE 386.16 XXX N   90671 PCV15 VACCINE FOR INTRAMUSCULAR USE 419.74 XXX N   90672 LAIV4 VACCINE FOR INTRANASAL USE 21.71 XXX N   90673 RIV3 VACCINE PRESERVATIVE FREE FOR IM USE 31.27 XXX N   90674 CCIIV4 VACCINE PRESERVATIVE FREE 0.5 ML IM USE 45.28 XXX N   90675 RABIES VACCINE INTRAMUSCULAR 545.94 XXX N 485.57   90676 RABIES VACCINE INTRADERMAL 174.05 XXX N 269.27   90677 PCV20 VACCINE FOR INTRAMUSCULAR USE 451.35 XXX N   90678 RSV VACCINE PREF SUBUNIT BIVALENT FOR IM USE BR XXX N   90679 RSV VACC PREF RECOMBINANT ADJUVANTED FOR IM USE 183.49 XXX N   90680 RV5 VACCINE 3 DOSE SCHEDULE LIVE FOR ORAL USE 92.04 XXX N   90681 RV1 VACCINE 2 DOSE SCHEDULE LIVE FOR ORAL USE 120.95 XXX N 166.26   90682 RIV4 VACC RECOMBINANT DNA PRSRV ANTIBIO FREE IM 100.48 XXX N   90683 RSV VACCINE MRNA LIPID NANOPARTICLES FOR IM USE BR XXX N   90684 PCV21 VACCINE FOR INTRAMUSCULAR USE 598.08 XXX N   90685 IIV4 VACC PRSRV FREE 0.25 ML DOS FOR IM USE 36.89 XXX N   90686 IIV4 VACC PRESRV FREE 0.5 ML DOS FOR IM USE 34.99 XXX N   90687 IIV4 VACC SPLIT VIRUS 0.25 ML DOS FOR IM USE 16.97 XXX N   90688 IIV4 VACC SPLIT VIRUS 0.5 ML DOS FOR IM USE 33.59 XXX N   90689 IIV4 VACC INACTIVATED PRSRV FR 0.25ML DOS IM USE 31.27 XXX N   90690 TYPHOID VACCINE LIVE ORAL 61.07 XXX N

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   90691 TYPHOID VACCINE VI CAPSULAR POLYSACCHARIDE IM 114.42 XXX N   90694 AIIV4 VACC INACTIVATED PRSRV FR 0.5ML DOS IM USE 113.25 XXX N   90696 DTAP-IPV VACCINE CHILD 4-6 YRS FOR IM USE 67.85 XXX N   90697 DTAP-IPV-HIB-HEPB VACCINE INTRAMUSCULAR 42.75 XXX N   90698 DTAP-IPV/HIB VACCINE FOR INTRAMUSCULAR USE 97.94 XXX N   90700 DIPHTH TETANUS TOX ACELL PERTUSSIS VACC<7 YR IM 36.58 XXX N   90702 DT VACCINE YOUNGER THAN 7 YRS FOR IM USE 35.96 XXX N   90707 MEASLES MUMPS RUBELLA VIRUS VACCINE LIVE SUBQ 71.24 XXX N   90710 MEASLES MUMPS RUBELLA VARICELLA VACC LIVE SUBQ 182.52 XXX N   90713 POLIOVIRUS VACCINE INACTIVATED SUBQ/IM 37.76 XXX N   90714 TD VACCINE PRSRV FREE 7 YRS OR OLDER FOR IM USE 43.55 XXX N   90715 TDAP VACCINE 7 YRS/> IM 60.88 XXX N   90716 VAR VACCINE LIVE FOR SUBCUTANEOUS USE 114.67 XXX N   90717 YELLOW FEVER VACCINE LIVE SUBQ 157.41 XXX N   90723 DTAP-HEPB-IPV VACCINE INTRAMUSCULAR 92.95 XXX N 95.94   90732 PPSV23 VACCINE 2 YRS OR OLDER FOR SUBQ/IM USE 202.86 XXX N   90733 MPSV4 VACCINE GROUPS ACYW-135 SUBQ USE 120.36 XXX N   90734 MENACWYD/MENACWY-CRM CONJ VACC GRPS ACWY IM USE 124.84 XXX N   90736 ZOSTER VACCINE HZV LIVE FOR SUBCUTANEOUS USE 178.45 XXX N   90738 JAPANESE ENCEPHALITIS VACCINE INACTIVATED IM 241.31 XXX N   90739 HEPB VACCINE ADULT 2/4 DOSE SCHEDULE FOR IM USE 245.86 XXX N 92.40   90740 HEPB VACCINE DIALYSIS/IMMUNSUP PAT 3 DOSE IM 239.97 XXX N   90743 HEPB VACCINE ADOLESCENT 2 DOSE SCHEDULE IM 59.03 XXX N   90744 HEPB VACCINE PED/ADOLESC 3 DOSE SCHEDULE IM 49.03 XXX N   90746 HEPB VACCINE ADULT 3 DOSE SCHEDULE FOR IM USE 119.99 XXX N   90747 HEPB VACCINE DIALYSIS/IMMUNSUP PAT 4 DOSE IM 239.97 XXX N   90748 HIB-HEPB VACCINE FOR INTRAMUSCULAR USE 50.21 XXX N 80.97   90749 UNLISTED VACCINE/TOXOID BR XXX N   90750 HZV ZOSTER VACC RECOMBINANT ADJUVANTED IM NJX 132.31 XXX N   90756 CCIIV4 VACCINE ANTIBIOTIC FREE 0.5 ML DOS IM USE 42.91 XXX N   90758 ZAIRE EBOLAVIRUS VACCINE LIVE FOR IM USE BR XXX N   90759 HEP B VACC 3 AG 10 MCG 3 DOSE SCHED FOR IM USE 134.64 XXX N   ★

20 Miss. Admin. Code Pt. 2, R. 90785 PSYCHOTHERAPY COMPLEX INTERACTIVE 25.37 ZZZ N   ★

20 Miss. Admin. Code Pt. 2, R. 90791 PSYCHIATRIC DIAGNOSTIC EVALUATION 263.94 XXX N 194.04   ★

20 Miss. Admin. Code Pt. 2, R. 90792 Rule 90792

PSYCHIATRIC DIAGNOSTIC EVAL W/MEDICAL SERVICES 296.50 XXX N 194.04   ★

20 Miss. Admin. Code Pt. 2, R. 90832 Rule 90832

PSYCHOTHERAPY W/PATIENT 30 MINUTES 128.92 XXX N 194.04   ★ 90833 PSYCHOTHERAPY W/PATIENT W/E&M SRVCS 30 MIN 121.54 ZZZ N   ★ 90834 PSYCHOTHERAPY W/PATIENT 45 MINUTES 171.66 XXX N 194.04   ★ 90836 PSYCHOTHERAPY W/PATIENT W/E&M SRVCS 45 MIN 153.40 ZZZ N   ★ 90837 PSYCHOTHERAPY W/PATIENT 60 MINUTES 257.24 XXX N 194.04   ★

20 Miss. Admin. Code Pt. 2, R. 90838 PSYCHOTHERAPY W/PATIENT W/E&M SRVCS 60 MIN 201.78 ZZZ N   ★

20 Miss. Admin. Code Pt. 2, R. 90839 PSYCHOTHERAPY FOR CRISIS INITIAL 60 MINUTES 246.03 XXX N 194.04   ★

20 Miss. Admin. Code Pt. 2, R. 90840 PSYCHOTHERAPY FOR CRISIS EACH ADDL 30 MINUTES 122.72 ZZZ N   ★

20 Miss. Admin. Code Pt. 2, R. 90845 PSYCHOANALYSIS 165.79 XXX N 194.04   ★

20 Miss. Admin. Code Pt. 2, R. 90846 FAMILY PSYCHOTHERAPY W/O PATIENT PRESENT 50 MINS 180.54 XXX N 194.04

Medicine Services Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 90281-96999, 97597-97610, 97802-97804, 98960-99082, 99151-99199, 99500-99607 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 282 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   ★

20 Miss. Admin. Code Pt. 2, R. 90847 Rule 90847

FAMILY PSYCHOTHERAPY W/PATIENT PRESENT 50 MINS 187.62 XXX N 194.04   90849 MULTIPLE FAMILY GROUP PSYCHOTHERAPY 69.03 XXX N 194.04   ★ 90853 GROUP PSYCHOTHERAPY 46.61 XXX N 108.52   ★ 90863 PHARMACOLOGIC MANAGEMENT W/PSYCHOTHERAPY 44.25 XXX N 141.24   90865 NARCOSYNTHESIS PSYC DX&THER PURPOSES 287.33 XXX N 194.04   90867 REPET TMS TX INITIAL W/MAP/MOTR THRESHLD/DEL&M 442.38 000 N 383.81   90868 THERAP REPETITIVE TMS TX SUBSEQ DELIVERY & MNG 321.61 000 N 383.81   90869 REPET TMS TX SUBSEQ MOTR THRESHLD W/DELIV & MN 479.70 000 N 383.81   90870 ELECTROCONVULSIVE THERAPY 301.49 000 N 707.91   ★

20 Miss. Admin. Code Pt. 2, R. 90875 Rule 90875

INDIV PSYCHOPHYS BIOFEED TRAIN W/PSYTX 30 MIN 106.20 XXX N   90876 INDIV PSYCHOPHYS BIOFEED TRAIN W/PSYTX 45 MIN 182.90 XXX N   90880 HYPNOTHERAPY 182.90 XXX N 108.52   90882 ENVIRONMENTAL IVNTJ MGMT PURPOSES PSYC PT 37.76 XXX N   90885 PSYCHIATRIC EVAL HOSPITAL RECORDS DX PURPOSES 84.37 XXX N   90887 INTERPJ/EXPLNAJ RESULTS PSYCHIATRIC EXAM FAMILY 149.27 XXX N   90889 PREP REPORT PT PSYCH STATUS AGENCY/PAYER 63.13 XXX N   90899 UNLISTED PSYCHIATRIC SERVICE/PROCEDURE BR XXX N 38.11   ★

20 Miss. Admin. Code Pt. 2, R. 90901 Rule 90901

BIOFEEDBACK TRAINING ANY MODALITY 70.80 000 N   90912 BFB TRAING W/EMG &/MANOMETRY 1ST 15 MIN CNTCT 141.01 000 N   90913 BFB TRAING W/EMG&/MANOMETRY EA ADDL 15 MIN CNTCT 55.46 ZZZ N   90935 HEMODIALYSIS PROCEDURE W/ PHYS/QHP EVALUATION 124.49 000 N 949.85   90937 HEMODIALYSIS PX REPEAT EVAL W/WO REVJ DIALYS RX 178.18 000 N   90940 HEMODIALYSIS ACCESS FLOW STUDY 34.81 XXX N   90945 DIALYSIS OTHER/THAN HEMODIALYSIS 1 PHYS/QHP EVAL 148.09 000 N 527.56   90947 DIALYSIS OTH/THN HEMODIALY REPEAT PHYS/QHP EVALS 214.17 000 N   ★ 90951 ESRD RELATED SVC MONTHLY & <2 YR OLD 4/> VISITS 1806.85 XXX N   ★ 90952 ESRD RELATED SVC MONTHLY <2 YR OLD 2/3 VISITS 1299.52 XXX N   ★ 90953 ESRD RELATED SVC MONTHLY <2 YR OLD 1 VISIT 74.34 XXX N   ★ 90954 ESRD RELATED SVC MONTHLY 2-11 YR OLD 4/> VISITS 1557.84 XXX N   ★

20 Miss. Admin. Code Pt. 2, R. 90955 ESRD RELATED SVC MONTHLY 2-11 YR OLD 2/3 VISITS 877.30 XXX N   ★

20 Miss. Admin. Code Pt. 2, R. 90956 ESRD RELATED SVC MONTHLY 2-11 YR OLD 1 VISIT 602.39 XXX N   ★

20 Miss. Admin. Code Pt. 2, R. 90957 ESRD RELATED SVC MONTHLY 12-19 YR OLD 4/> VISITS 1233.51 XXX N   ★

20 Miss. Admin. Code Pt. 2, R. 90958 ESRD RELATED SVC MONTHLY 12-19 YR OLD 2/3 VISITS 837.27 XXX N   ★

20 Miss. Admin. Code Pt. 2, R. 90959 ESRD RELATED SVC MONTHLY 12-19 YR OLD 1 VISIT 565.81 XXX N   ★

20 Miss. Admin. Code Pt. 2, R. 90960 ESRD RELATED SVC MONTHLY 20&/> YR OLD 4/> VISITS 544.16 XXX N   ★

20 Miss. Admin. Code Pt. 2, R. 90961 ESRD RELATED SVC MONTHLY 20/>YR OLD 2/3 VISITS 457.31 XXX N   ★

20 Miss. Admin. Code Pt. 2, R. 90962 Rule 90962

ESRD RELATED SVC MONTHLY 20&/>YR OLD 1 VISIT 351.05 XXX N   ★ 90963 ESRD SVC HOME DIALYSIS FULL MONTH <2YR OLD 1046.93 XXX N   ★ 90964 ESRD SVC HOME DIALYSIS FULL MONTH 2-11 YR OLD 906.83 XXX N   ★ 90965 ESRD SVC HOME DIALYSIS FULL MONTH 12-19 YR OLD 870.52 XXX N   ★ 90966 ESRD SVC HOME DIALYSIS FULL MONTH 20 YR OLD 455.95 XXX N   ★

20 Miss. Admin. Code Pt. 2, R. 90967 ESRD RELATED SVC <FULL MONTH <2 YR OLD 30.68 XXX N   ★

20 Miss. Admin. Code Pt. 2, R. 90968 ESRD RELATED SVC <FULL MONTH 2-11 YR OLD 30.09 XXX N   ★

20 Miss. Admin. Code Pt. 2, R. 90969 ESRD RELATED SVC <FULL MONTH 12-19 YR OLD 29.18 XXX N   ★

20 Miss. Admin. Code Pt. 2, R. 90970 Rule 90970

ESRD RELATED SVC <FULL MONTH 20/>YR OLD 14.93 XXX N   90989 DIALYSIS TRAINING PATIENT COMPLETED COURSE 536.02 XXX N

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   90993 DIALYSIS TRAINING PATIENT PER TRAINING SESSION 125.08 XXX N   90997 HEMOPERFUSION 153.40 000 N   90999 UNLISTED DIALYSIS PROCEDURE INPATIENT/OUTPATIENT BR XXX N   91010 ESOPHAGEAL MOTILITY STUDY W/INTERP&RPT 365.03 112.69 252.34 000 N   91013 ESOPHAGEAL MOTILITY STD W/I&R STIM/PERFUSION 46.02 15.93 30.09 ZZZ N   91020 GASTRIC MOTILITY MANOMETRIC STUDIES 475.63 126.26 349.37 000 N   91022 DUODENAL MOTILITY MANOMETRIC STUDY 304.44 125.67 178.77 000 N   91030 ESOPHAGUS ACID PERFUSION TEST ESOPHAGITIS 257.83 80.24 177.59 000 N   91034 GASTROESOPHAG REFLX TEST W/CATH PH ELTRD PLCMT 343.38 86.14 257.24 000 N   91035 GASTROESOPHAG REFLX TEST W/TELEMTRY PH ELTRD 847.24 140.42 706.82 000 N   91037 GASTROESOPHAG REFLX TEST W/INTRLUML IMPED ELTRD 303.26 85.55 217.71 000 N   91038 ESOPHGL FUNCJ G-ESOP RFLX IMPD ELTRD PROLNG 749.89 96.17 653.72 000 N   91040 ESOPHGL BALO DISTENSION DX STD W/PROVOCATION 919.37 85.55 833.82 000 N   91065 BREATH HYDROGEN/METHANE TEST 144.52 17.70 126.82 000 N   91110 GI TRC IMG INTRALUMINAL ESOPHAGUS-ILEUM W/I&R 1473.82 217.12 1256.70 XXX N   91111 GI TRACT IMAGING INTRALUMINAL ESOPHAGUS WI&R 1552.41 87.91 1464.50 XXX N   91112 GI TRANSIT & PRES MEAS WIRELESS CAPSULE W/INTERP 2429.71 184.08 2245.63 XXX N   91113 GI TRACT IMAGING INTRALUMINAL COLON I&R 1656.72 209.45 1447.27 XXX N   91117 COLON MOTILITY STDY MIN 6 HR CONT RECORD W/I&R 235.41 000 N 385.91   91120 RECTAL SESATION TONE & COMPLIANCE TEST 877.98 83.78 794.20 XXX N   91122 ANORECTAL MANOMETRY 464.77 152.22 312.55 000 N   91132 ELECTROGASTROGRAPHY DX TRANSCUTANEOUS 461.38 45.43 415.95 XXX N   91133 ELECTROGASTROGRAPHY DX TRANSCUT W/PROVOCTVE TSTG 504.80 57.82 446.98 XXX N   91200 LIVER ELASTOGRAPHY W/O IMAG W/I&R 64.90 23.60 41.30 XXX N   91299 UNLISTED DIAGNOSTIC GASTROENTEROLOGY PROCEDURE BR BR BR XXX N   91304 SARSCOV2 VACC SAPONIN-BSD ADJT 5MCG/0.5ML IM USE 294.65 XXX N   91318 SARSCOV2 VACC 3MCG/0.3ML TRIS-SUCROSE IM USE 118.11 XXX N   91319 SARSCOV2 VACC 10MCG/0.3ML TRIS-SUCROSE IM USE 158.17 XXX N   91320 SARSCOV2 VACC 30MCG/0.3ML TRIS-SUCROSE IM USE 236.22 XXX N   91321 SARSCOV2 VACCINE 25 MCG/0.25 ML FOR IM USE 262.93 XXX N   91322 SARSCOV2 VACCINE 50 MCG/0.5 ML FOR IM USE 262.93 XXX N   ★

20 Miss. Admin. Code Pt. 2, R. 92002 OPH SVCS MEDICAL XM&EVAL INTERMEDIATE NEW PT 149.27 XXX N 172.32   ★

20 Miss. Admin. Code Pt. 2, R. 92004 Rule 92004

OPH SVCS MEDICAL XM&EVAL COMPRE NEW PT 1/> VST 259.01 XXX N 172.32   ★

20 Miss. Admin. Code Pt. 2, R. 92012 OPH SVCS MEDICAL XM&EVAL INTERMEDIATE EST PT 154.58 XXX N 172.32   ★

20 Miss. Admin. Code Pt. 2, R. 92014 Rule 92014

OPH SVCS MEDICAL XM&EVAL COMPRE EST PT 1/>VST 218.89 XXX N 172.32   92015 DETERMINATION REFRACTIVE STATE 34.22 XXX N 45.38   J1 92018 COMPL OPH XM&EVAL GENERAL ANES W/WO MNPJ GLOBE 243.67 XXX N 4087.30   J1 92019 LMTD OPH XM&EVAL GENERAL ANES W/WO MNPJ GLOBE 122.72 XXX N 4087.40   92020 GONIOSCOPY SEPARATE PROCEDURE 48.38 XXX N 163.53   92025 COMPUTERIZED CORNEAL TOPOGRAPHY UNI/BI W/I&R 63.13 33.63 29.50 XXX N   92060 SENSORMOTOR XM W/MLT MEAS OCULAR DEVIJ W/I&R SPX 108.56 63.72 44.84 XXX N   92065 ORTHOPTIC TRAINING PERFORMED BY PHYS/OTHER QHP 91.45 30.09 61.36 XXX N   92066 ORTHOPTIC TRAINING UNDER SUPERVISION OF PHYS/QHP 45.43 XXX N 81.62   92071 FIT CONTACT LENS TX OCULAR SURFACE DISEASE 63.13 XXX N   92072 FITTING CONTACT LENS FOR MGMT OF KERATOCONUS 1ST 220.07 XXX N

Medicine Services Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 90281-96999, 97597-97610, 97802-97804, 98960-99082, 99151-99199, 99500-99607 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 284 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   92081 LIMITED VISUAL FIELD XM UNI/BI I&R 57.23 27.14 30.09 XXX N   92082 INTERMEDIATE VISUAL FIELD XM UNI/BI I&R 80.24 35.99 44.25 XXX N   92083 EXTENDED VISUAL FIELD XM UNI/BI I&R 108.56 46.61 61.95 XXX N   92100 SERIAL TONOMETRY SPX W/MLT MEAS INTRAOCULAR PRS 147.50 XXX N   92132 CPTRIZED OPH DX IMG ANTERIOR SEGMENT UNI/BI 54.28 27.73 26.55 XXX N   92133 CPTRIZED OPH DX IMG PST SEGMENT UNI/BI OPTIC NRV 63.72 37.17 26.55 XXX N   92134 CPTRIZED OPH DX IMG PST SEGMENT UNI/BI RETINA 70.21 43.07 27.14 XXX N   92136 OPH BMTRY PRTL COHER INTRFRMTRY IO LENS PWR CAL 116.82 52.51 64.31 XXX N   92137 CPTRIZD OPH DX IMG PST SGM UNI/BI RTA OCT ANGRPH 103.84 61.36 42.48 XXX N   92145 CORNEA HYSTERESIS DETERMIN IMPULSE STIMJ UNI/BI 28.91 15.93 12.98 XXX N   92201 OPSCPY EXTND RTA DRAWING & SCL DEPRSN I&R UNI/BI 42.48 XXX N 80.73   92202 OPSCPY EXTND OPTIC NRV/MACULA DRAWING I&R UNI/BI 27.14 XXX N 80.73   ★

20 Miss. Admin. Code Pt. 2, R. 92227 Rule 92227

IMG RETINA DETCJ/MNTR DS REM CLIN STAFF UNI/BI 27.14 XXX N 49.09   ★ 92228 IMG RETINA DETCJ/MNTR DS REM PHYS/QHP I&R UNI/BI 57.23 34.81 22.42 XXX N   92229 IMG RETINA DETCJ/MNTR DS POC AUTON A/R UNI/BI 80.24 XXX N 80.73   92230 FLUORESCEIN ANGIOSCOPY INTERPRETATION & REPORT 124.17 XXX N 707.91   92235 FLUORESCEIN ANGRPH W/MULTIFRAME IMG I&R UNI/BI 175.73 72.57 103.16 XXX N   92240 INDOCYANINE-GREEN ANGRPH W/MULTIFRAME I&R UNI/BI 343.97 81.42 262.55 XXX N   92242 FLUORESCEIN&ICG ANGRPH MULTIFRAME IMG I&R UNI/BI 435.42 93.22 342.20 XXX N   92250 FUNDUS PHOTOGRAPHY W/INTERPRETATION & REPORT 84.37 36.58 47.79 XXX N   92260 OPHTHALMODYNAMOMETRY 34.22 XXX N 49.09   92265 NDL OCULOELECTROMYOGRAPHY 1+EO MUSC 1/BOTH EYE 149.27 78.47 70.80 XXX N   92270 ELECTRO-OCULOGRAPY W/INTERPRETATION & REPORT 183.20 72.57 110.63 XXX N   92273 FULL FIELD ELECTRORETINOGRAPHY W/I&R 223.02 62.54 160.48 XXX N   92274 MULTIFOCAL ELECTRORETINOGRAPHY W/I&R 151.04 55.46 95.58 XXX N   92283 COLOR VISION XM EXTENDED ANOMALOSCOPE/EQUIV 93.81 15.34 78.47 XXX N   92284 DX DARK ADAPTATION EXAM INTERPRETATION & REPORT 102.66 21.24 81.42 XXX N

  92285 XTRNL OCULAR PHOTOG W/I&R DOCMT MED PROGRESS 40.12 5.31 34.81 XXX N   92286 ANT SGM IMAGING I&R SPECLR MICROSCOPY&NDTHL ALYS 67.85 37.17 30.68 XXX N   92287 ANT SGM IMAGING W/I&R W/FLUORESCEIN ANGRPH 280.22 78.47 201.75 XXX N   92310 RX&FITG C-LENS SUPVJ CRNL LENS OU XCPT APHK 177.59 XXX N 77.64   92311 RX&FITG CONTACT LENS CORNEAL LENS APHAKIA 1 EYE 184.67 XXX N 393.60   92312 RX&FITG CONTACT LENS CORNEAL LENS APHAKIA OU 214.17 XXX N 163.53   92313 RX&FITG CONTACT LENS CORNEOSCLERAL LENS 174.64 XXX N 163.53   92314 RX&FITG C-LENS TECH CRNL LENS OU XCPT APHAKIA 155.17 XXX N   92315 RX&FITG C-LENS TECH CRNL LENS APHAKIA 1 EYE 143.96 XXX N 163.53   92316 RX&FITG C-LENS TECH CRNL LENS APHAKIA BOTH EYES 177.59 XXX N 163.53   92317 RX&FITG CONTACT LENS TECH CORNEOSCLERAL LENS 151.04 XXX N 49.09   92325 MODIFICAJ CONTACT LENS SPX SUPVJ ADAPTATION 80.24 XXX N 163.53   92326 REPLACEMENT OF CONTACT LENS 68.44 XXX N 80.73   92340 FITTING SPECTACLES XCPT APHAKIA MONOFOCAL 60.18 XXX N   92341 FITTING SPECTACLES XCPT APHAKIA BIFOCAL 68.44 XXX N   92342 FITTING SPECTACLES XCPT APHAKIA MULTIFOCAL 73.16 XXX N   92352 FITTING SPECTACLE PROSTH APHAKIA MONOFOCAL 79.38 XXX N 80.73   92353 FITTING SPECTACLE PROSTH APHAKIA MULTIFOCAL 90.86 XXX N 80.73   92354 FITTING SPECTACLE MNTD LOW VISION AID 1ELMNT SYS 23.01 XXX N 49.09

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   92355 FITTING SPECTACLE MNTD LOW VISION AID CMPND LENS 35.99 XXX N 49.09   92358 PROSTHESIS SERVICE APHAKIA TEMPORARY 18.88 XXX N 80.73   92370 REPAIR&REFITTING SPECTACLES EXCEPT FOR APHAKIA 54.28 XXX N   92371 REPAIR&REFITTING SPECTACLE PROSTH FOR APHAKIA 19.47 XXX N 80.73   92499 UNLISTED OPHTHALMOLOGICAL SERVICE/PROCEDURE BR BR BR XXX N   92502 OTOLARYNGOLOGIC EXAM UNDER GENERAL ANESTHESIA 164.02 000 N 655.90   92504 BINOCULAR MICROSCOPY SEPARATE DX PROCEDURE 50.74 XXX N   ★

20 Miss. Admin. Code Pt. 2, R. 92507 TX SPEECH LANG VOICE COMMJ&/AUD PROC DO INDIV 133.34 XXX N   ★

20 Miss. Admin. Code Pt. 2, R. 92508 Rule 92508

TX SPEECH LANG VOICE COMMJ&/AUD PROC DO GROUP 41.30 XXX N   92511 NASOPHARYNGOSCOPY W/ENDOSCOPE SPX 208.27 000 N 238.73   92512 NASAL FUNCTION STUDIES 108.56 XXX N 383.81   92516 FACIAL NERVE FUNCTION STUDIES 120.95 XXX N 383.81   92517 CERVICAL VEMP TESTING W/I&R 119.18 XXX N 202.48   92518 OCULAR VEMP TESTING W/I&R 112.10 XXX N 202.48   92519 CERVICAL & OCULAR VEMP TESTING W/I&R 185.26 XXX N 383.81   92520 LARYNGEAL FUNCTION STUDIES 143.37 XXX N 163.53   925XX For codes 92521-92526 please see the Therapeutic Services Section

  92531 SPONTANEOUS NYSTAGMUS W/GAZE 25.37 XXX N   92532 POSITIONAL NYSTAGMUS TEST 34.22 XXX N   92533 CALORIC VESTIBULAR TEST EACH IRRIGATION 61.95 XXX N   92534 OPTOKINETIC NYSTAGMUS TEST 53.10 XXX N   92537 CALORIC VESTIBULAR TEST W/REC BI BITHERMAL 71.39 53.69 17.70 XXX N   92538 CALORIC VESTIBULAR TEST W/REC BI MONOTHERMAL 39.53 27.73 11.80 XXX N   92540 VSTBLR FUNCJ NYSTAG FOVL&PERPH STIMJ OSCIL TRK 192.93 134.52 58.41 XXX N   92541 SPONTANEOUS NYSTAGMUS TEST 44.25 35.99 8.26 XXX N   92542 POSITIONAL NYSTAGMUS TEST 50.74 43.07 7.67 XXX N   92544 OPTKINETIC NYSTAG BIDIR/FOVEAL/PERIPH STIM W/REC 31.27 24.78 6.49 XXX N   92545 OSCILLATING TRACKING TEST W/RECORDING 29.50 23.01 6.49 XXX N   92546 SINUSOIDAL VERTICAL AXIS ROTATIONAL TESTING 200.16 25.96 174.20 XXX N   92547 USE VERTICAL ELECTRODES 14.25 ZZZ N   92548 CDP-SOT 6 CONDITIONS W/INTERPRETATION & REPORT 160.48 50.21 110.27 XXX N   92549 CDP-SOT 6 CONDITIONS W/I&R W/MCT & ADT 110.92 76.70 34.22 XXX N   ★

20 Miss. Admin. Code Pt. 2, R. 92550 Rule 92550

TYMPANOMETRY AND REFLEX THRESHOLD MEASUREMENTS 38.94 XXX N 202.48   92551 SCREENING TEST PURE TONE AIR ONLY 20.06 XXX N 54.74   ★

20 Miss. Admin. Code Pt. 2, R. 92552 Rule 92552

PURE TONE AUDIOMETRY AIR ONLY 58.41 XXX N 163.53   ★ 92553 PURE TONE AUDIOMETRY AIR & BONE 70.80 XXX N 202.48   ★ 92555 SPEECH AUDIOMETRY THRESHOLD 44.25 XXX N 49.09   ★ 92556 SPEECH AUDIOMETRY THRESHOLD SPEECH RECOGNIJ 69.62 XXX N 80.73   ★ 92557 COMPRE AUDIOMETRY THRESHOLD EVAL SP RECOGNIJ 65.49 XXX N 202.48   92558 EVOKED OTOACOUSTIC EMISSIONS SCREEN AUTO ANALYS 16.52 XXX N 95.55   92562 LOUDNESS BALANCE BINAURAL/MONAURAL 80.24 XXX N 202.48   ★

20 Miss. Admin. Code Pt. 2, R. 92563 TONE DECAY TEST 55.46 XXX N 49.09   ★

20 Miss. Admin. Code Pt. 2, R. 92565 STENGER TEST PURE TONE 29.18 XXX N 49.09   ★

20 Miss. Admin. Code Pt. 2, R. 92567 TYMPANOMETRY 28.91 XXX N 49.09   ★

20 Miss. Admin. Code Pt. 2, R. 92568 ACOUSTIC REFLEX THRESHOLD 27.14 XXX N 49.09

Medicine Services Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 90281-96999, 97597-97610, 97802-97804, 98960-99082, 99151-99199, 99500-99607 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 286 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   ★

20 Miss. Admin. Code Pt. 2, R. 92570 Rule 92570

ACOUSTIC IMMIT TEST TYMPANOM/ACOUST REFLX/DECAY 57.23 XXX N 202.48   92571 FILTERED SPEECH TEST 49.56 XXX N 49.09   92572 STAGGERED SPONDAIC WORD TEST 71.39 XXX N 202.48   92575 SENSORINEURAL ACUITY LEVEL TEST 121.45 XXX N 49.09   92576 SYNTHETIC SENTENCE IDENTIFICATION TEST 66.08 XXX N 49.09   92577 STENGER TEST SPEECH 26.46 XXX N 707.91   92579 VISUAL REINFORCEMENT AUDIOMETRY 80.24 XXX N 202.48   92582 CONDITIONING PLAY AUDIOMETRY 134.52 XXX N 202.48   92583 SELECT PICTURE AUDIOMETRY 87.91 XXX N 80.73   92584 ELECTROCOCHLEOGRAPHY 141.81 XXX N 202.48   ★

20 Miss. Admin. Code Pt. 2, R. 92587 Rule 92587

DISTORT PRODUCT EVOKED OTOACOUSTIC EMISNS LIMITD 38.35 31.27 7.08 XXX N   ★

20 Miss. Admin. Code Pt. 2, R. 92588 Rule 92588

DISTRT PROD EVOKD OTOACOUSTIC EMSNS COMP/DX EVAL 59.00 49.56 9.44 XXX N   92590 HEARING AID EXAMINATION & SELECTION MONAURAL 89.09 XXX N 116.12   92591 HEARING AID EXAMINATION & SELECTION BINAURAL 94.40 XXX N 145.26   92592 HEARING AID CHECK MONAURAL 37.17 XXX N 52.96   92593 HEARING AID CHECK BINAURAL 53.60 XXX N 84.11   92594 ELECTROACOUS EVAL HEARING AID MONAURAL 37.32 XXX N 43.53   92595 ELECTROACOUS EVAL HEARING AID BINAURAL 63.13 XXX N 96.14   92596 EAR PROTECTOR ATTENUATION MEASUREMENTS 119.18 XXX N 49.09   92597 EVAL&/FITG VOICE PROSTC DEV SUPLMNT ORAL SPEEC 125.67 XXX N   ★

20 Miss. Admin. Code Pt. 2, R. 92601 ANALYSIS COCHLEAR IMPLT PT <7 YR PRGRMG 284.38 XXX N 202.48   ★

20 Miss. Admin. Code Pt. 2, R. 92602 Rule 92602

ANALYSIS COCHLEAR IMPLT PT <7 YR SBSQ REPRGRMG 179.95 XXX N 202.48   ★

20 Miss. Admin. Code Pt. 2, R. 92603 ANALYSIS COCHLEAR IMPLT 7 YR/> PRGRMG 266.09 XXX N 202.48   ★

20 Miss. Admin. Code Pt. 2, R. 92604 Rule 92604

ANALYSIS COCHLEAR IMPLT 7 YR/> SBSQ REPRGRMG 160.48 XXX N 202.48   92605 EVAL RX N-SP-GEN AUGMT ALT COMMUN DEV F2F 1ST HR 161.07 XXX N   92606 THER SVC N-SP-GENRATJ DEV PRGRMG&MODIFICAJ 142.19 XXX N   ★ 92607 RX SP-GENRATJ AUGMNT&COMUNICAJ DEV 1ST HR 217.71 XXX N   ★ 92608 RX SP-GENRATJ AUGMNT&COMUNICAJ DEV EA 30 MIN 86.73 ZZZ N   ★ 92609 THER SP-GENRATJ DEV PRGRMG&MODIFICAJ 181.72 XXX N   ★

20 Miss. Admin. Code Pt. 2, R. 92610 Rule 92610

EVAL ORAL&PHARYNGEAL SWLNG FUNCJ 148.68 XXX N   92611 MOTION FLUOR EVAL SWLNG FUNCJ C/V REC 159.89 XXX N   92612 FLEXIBLE ENDOSCOPIC EVAL SWALLOW C/V REC 338.66 XXX N   92613 FLEXIBLE ENDOSCOPIC EVAL SWALLOW C/V REC I&R 63.13 XXX N   92614 FLEXIBLE ENDOSCOPIC EVAL LARYN SENSORY C/V REC 254.88 XXX N   92615 FLEXIBLE ENDOSCOPIC EVAL LARYN SENS C/V REC I&R 56.64 XXX N   92616 FLEXIBLE NDSC EVAL SWLNG&LARYN SENS C/V REC 377.01 XXX N   92617 FLEXIBLE NDSC EVAL SWLNG&LARYN SENS C/V I&R 70.80 XXX N   92618 EVAL RX N-SP-GEN AUGMT ALT COMMUN DEV ADD 30 MIN 56.64 ZZZ N   92620 EVAL CENTRAL AUDITORY FUNCJ W/REPRT 1ST 60 MIN 158.71 XXX N 202.48   92621 EVAL CENTRAL AUDITORY FUNCJ W/REPRT EA 15 MIN 38.35 ZZZ N   92622 DX ALY PRGRMG&VERIF AUD OI SOUND PROCESSR 1ST 60 139.83 XXX N 211.34   92623 DX ALY PRGRMG&VERIF AUD OI SOUND PROCESSR EA ADL 35.99 ZZZ N   ★

20 Miss. Admin. Code Pt. 2, R. 92625 ASSESSMENT TINNITUS 119.18 XXX N 202.48   ★

20 Miss. Admin. Code Pt. 2, R. 92626 Rule 92626

EVAL AUD FUNCJ CAND/PO SURG IMPLT DEV 1ST HR 153.40 XXX N 202.48   ★

20 Miss. Admin. Code Pt. 2, R. 92627 Rule 92627

EVAL AUD FUNCJ CAND/PO SURG IMPLT DEV EA ADDL 15 37.76 ZZZ N   92630 AUDITORY REHABILITATION PRELINGUAL HEARING LOSS 112.10 XXX N 196.26

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   92633 AUDITORY REHABILITATION POSTLINGUAL HEARING LOSS 84.96 XXX N 220.14   92640 ANALYSIS W/PRGRMG AUD BRAINSTEM IMPLANT PR HR 193.52 XXX N 202.48   92650 AEP SCR AUDITORY POTENTIAL W/STIMULI AUTO ALYS 50.15 XXX N   92651 AEP HEARING STATUS DETER BROADBAND STIMULI I&R 153.99 XXX N 202.48   92652 AEP THRESHOLD ESTIMATION MLT FREQUENCIES I&R 201.78 XXX N 383.81   92653 AEP NEURODIAGNOSTIC INTERPRETATION AND REPORT 149.86 XXX N 383.81   92700 UNLISTED OTORHINOLARYNGOLOGICAL SERVICE/PX BR XXX N 35.83   J1 92920 PRQ TRLUML CORONARY ANGIOPLASTY ONE ART/BRANCH 916.27 000 N 9348.81   92921 PRQ TRLUML CORONARY ANGIOPLASTY ADDL BRANCH 424.21 ZZZ N   J1 92924 PRQ TRLUML CORONARY ANGIO/ATHERECT ONE ART/BRNCH 1092.09 000 N 17816.95   92925 PRQ TRLUML CORONARY ANGIO/ATHEREC ADDL ART/BRNCH 459.02 ZZZ N   J1 92928 PRQ TRLUML CORONARY STENT W/ANGIO ONE ART/BRNCH 1019.52 000 N 18674.56   92929 PRQ TRLUML CORONARY STENT W/ANGIO ADDL ART/BRNCH 516.84 ZZZ N   J1 92933 PRQ TRLUML CORONRY STENT/ATH/ANGIO ONE ART/BRNCH 1143.42 000 N 28322.69   92934 PRQ TRLUML CORONARY STENT/ATH/ANGIO ADDL BRANCH 477.66 ZZZ N   J1 92937 PRQ TRLUML CORONARY BYP GRFT REVASC ONE VESSEL 1018.34 000 N 18723.80   92938 PRQ TRLUML CORONARY BYP GRFT REVASC ADDL VESSEL 497.96 ZZZ N   92941 PRQ TRLUML CORONRY TOT OCCLUS REVASC MI ONE VSL 1145.78 000 N 20366.01   J1 92943 PRQ TRLUML CORONRY CHRONIC OCCLUS REVASC ONE VSL 1145.78 000 N 18330.39   92944 PRQ TRLUML CORONRY CHRNIC OCCLUS REVASC ADDL VSL 500.73 ZZZ N   92950 CARDIOPULMONARY RESUSCITATION 580.56 000 N 383.81   92953 TEMPORARY TRANSCUTANEOUS PACING 1.77 000 N 814.70   92960 CARDIOVERSION ELECTIVE ARRHYTHMIA EXTERNAL 271.40 000 N 814.70   92961 CARDIOVERSION ELECTIVE ARRHYTHMIA INTERNAL SPX 426.57 000 N 814.70   92970 CARDIOASSIST-METH CIRCULATORY ASSIST INTERNAL 328.04 000 N   92971 CARDIOASSIST-METH CIRCULATORY ASSIST EXTERNAL 172.87 000 N 495.26   92972 PERCUTANEOUS TRANSLUMINAL CORONARY LITHOTRIPSY 252.52 ZZZ N   92973 PRQ TRANSLUMINAL CORONARY MECHANICL THROMBECTOMY 305.62 ZZZ N   92974 TCAT PLACEMENT RADJ DLVR DEV SBSQ C IV BRACHYTX 279.07 ZZZ N   92975 THROMBOLYSIS INTRACORONARY NFS SLCTV ANGRPH 651.36 000 N   92977 THROMBOLYSIS CORONARY INTRAVENOUS INFUSION 92.04 XXX N 462.41   92978 ENDOLUMINAL CORONARY IVUS OCT I&R INITIAL VESSEL 470.23 164.61 305.62 ZZZ N   92979 ENDOLUMINAL CORONARY IVUS OCT I&R ADDL VESSEL 284.97 130.98 153.99 ZZZ N   J1 92986 PRQ BALLOON VALVULOPLASTY AORTIC VALVE 2290.97 090 N 9173.92   J1 92987 PRQ BALLOON VALVULOPLASTY MITRAL VALVE 2370.03 090 N 18803.30   J1 92990 PRQ BALLOON VALVULOPLASTY PULMONARY VALVE 1888.00 090 N 19631.67   J1 92997 PRQ TRLUML PULMONARY ART BALLOON ANGIOP 1 VSL 1126.31 000 N 19346.49   92998 PRQ TRLUML PULMONARY ART BALLOON ANGIOP EA VSL 556.96 ZZZ N   93000 ECG ROUTINE ECG W/LEAST 12 LDS W/I&R 28.32 XXX N   93005 ECG ROUTINE ECG W/LEAST 12 LDS TRCG ONLY W/O I&R 14.16 XXX N 80.73   93010 ECG ROUTINE ECG W/LEAST 12 LDS I&R ONLY 14.16 XXX N   93015 CV STRS TST XERS&/OR RX CONT ECG W/SI&R 123.31 XXX N   93016 CV STRS TST XERS&/OR RX CONT ECG W/O I&R 37.17 XXX N   93017 CV STRS TST XERS&/OR RX CONT ECG TRCG ONLY 61.36 XXX N 383.81

Medicine Services Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 90281-96999, 97597-97610, 97802-97804, 98960-99082, 99151-99199, 99500-99607 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 288 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   93018 CV STRS TST XERS&/OR RX CONT ECG I&R ONLY 24.78 XXX N   93024 ERGONOVINE PROVOCATION TST 189.98 95.58 94.40 XXX N   93025 MICROVOLT T-WAVE ASSESS VENTRICULAR ARRHYTHMIAS 249.57 63.72 185.85 XXX N   93040 RHYTHM ECG 1-3 LEADS W/INTERPRETATION & REPORT 21.83 XXX N   93041 RHYTHM ECG 1-3 LEADS TRACING ONLY W/O I&R 10.03 XXX N 80.73   93042 RHYTHM ECG 1-3 LEADS INTERPRETATION & REPRT ON 11.80 XXX N   93050 ART PRESS WAVEFORM ANALYS CENTRAL ART PRESSURE 27.73 14.16 13.57 XXX N   93150 THER ACTIVATION IMPL PHRENIC NRV STIMULATOR SYS 176.41 XXX N 130.97   93151 INTERROG&PRGRMG IMPL PHRENIC NRV STIMULATOR SYS 153.99 XXX N 130.97   93152 INTERROG&PRGRMG IPNSS DURING POLYSOMNOGRAPHY 278.48 XXX N 404.12   93153 INTERROGATION WITHOUT PROGRAMMING IPNSS 91.45 XXX N 130.97   93224 XTRNL ECG REC<48 HRS RECORDING SCAN A/R R&I 148.09 XXX N   93225 XTRNL ECG REC<48 HRS RECORDING 43.07 XXX N 163.53   93226 XTRNL ECG REC<48 HRS SCANNING A/R 66.08 XXX N 163.53   93227 XTRNL ECG REC<48 HRS RVW&INTERPJ PHYS/QHP 44.25 XXX N   ★ 93228 XTRNL MOBILE CV TELEMETRY W/I&REPORT 30 DAYS 44.25 XXX N   ★ 93229 XTRNL MOBILE CV TELEMETRY W/TECHNICAL SUPPORT 1353.61 XXX N 202.48   93241 XTRNL ECG REC>48HR<7D RECORDING SCAN A/R R&I 473.18 XXX N   93242 EXTERNAL ECG REC>48HR<7D RECORDING 24.78 XXX N 80.73   93243 EXTERNAL ECG REC>48HR<7D SCANNING ALYS W/REPORT 628.35 XXX N 163.53   93244 EXTERNAL ECG REC>48HR<7D REVIEW & INTERPRETATION 41.89 XXX N   93245 EXTERNAL ECG REC>7D<15D SCAN ALYS REPORT R&I 441.91 XXX N   93246 EXTERNAL ECG REC>7D<15D RECORDING 24.78 XXX N 80.73   93247 EXTERNAL ECG REC>7D<15D SCANNING ALYS W/REPORT 628.35 XXX N 163.53   93248 EXTERNAL ECG REC>7D<15D REVIEW & INTERPRETATION 46.02 XXX N   93260 PRGRMG DEV EVAL IMPLANTABLE SUBQ LEAD DFB SYSTEM 130.95 73.16 57.79 XXX N   93261 INTERROGATION EVAL F2F IMPLANT SUBQ LEAD DEFIB 120.09 63.72 56.37 XXX N   93264 REMOTE MNTR WIRELESS P-ART PRS SNR UP TO 30 D 86.14 XXX N   ★ 93268 XTRNL PT ACTIV ECG TRANSMIS W/R&I </30 DAYS 336.30 XXX N   ★

20 Miss. Admin. Code Pt. 2, R. 93270 XTRNL PT ACTIVATED ECG RECORD MONITOR 30 DAYS 15.34 XXX N 54.00   ★

20 Miss. Admin. Code Pt. 2, R. 93271 XTRNL PT ACTIVATED ECG REC DWNLD 30 DAYS 278.48 XXX N 145.59   ★

20 Miss. Admin. Code Pt. 2, R. 93272 Rule 93272

XTRNL PT ACTIVTD ECG DWNLD W/R&I </30 DAYS 42.48 XXX N   93278 SIGNAL AVERAGED ELECTROCARDIOGRAPHY W/WO ECG 51.33 21.24 30.09 XXX N   93279 PRGRMG DEV EVAL 1 LEAD PM/LDLS PM 1 CAR CHMBR IP 105.85 54.28 51.57 XXX N   93280 PROGRAM EVAL IMPLANTABLE IN PERSN DUAL LD PACER 124.17 65.49 58.68 XXX N   93281 PROGRAM EVAL IMPLANTABLE IN PRSN MULTI LD PACER 133.66 72.57 61.09 XXX N   93282 PRGRMNG DEV EVAL IMPLANTABLE IN PERSN 1 LD DFB 128.92 72.57 56.35 XXX N   93283 PRGRMG EVAL IMPLANTABLE IN PRSN DUAL LEAD DFB 162.16 97.35 64.81 XXX N   93284 PRGRMG EVAL IMPLANTABLE IN PERSON MULTI LEAD DFB 175.73 105.61 70.12 XXX N   93285 PRGRMG DEV EVAL SCRMS PHYS/QHP IN PERSON 92.95 44.25 48.70 XXX N   93286 PERI-PX DEV EVAL PM/LDLS PM PHYS/QHP IN PERSON 67.17 25.96 41.21 XXX N   93287 PERI-PX DEV EVAL & PROG SING/DUAL/MULTI LEAD DFB 82.78 38.94 43.84 XXX N   93288 INTERROG DEV EVAL PM/LDLS PM PHYS/QHP IN PERSON 84.81 35.99 48.82 XXX N   93289 INTERROG EVAL F2F 1/DUAL/MLT LEADS IMPLTBL DFB 115.35 63.72 51.63 XXX N   93290 INTERROG DEV EVAL ICPMS PHYS/QHP IN PERSON 80.74 36.58 44.16 XXX N   93291 INTERROG DEV EVAL SCRMS PHYS/QHP IN PERSON 72.60 31.27 41.33 XXX N

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   93292 INTERROGATION EVAL IN PERSON WR DEFIBRILLATOR 77.35 35.99 41.36 XXX N   93293 TRANSTELEPHONIC RHYTHM STRIP PACEMAKER EVAL 87.32 25.37 61.95 XXX N   93294 REM INTERROG PM/LDLS PM <90 D PHYS/QHP 51.92 XXX N   93295 INTERROGATION EVAL REMOTE </90 D 1/2/MLT LD DFB 74.34 XXX N   93296 REM INTERROG PM/LDLS PM/IDS <90 D TECH REVIEW 42.48 XXX N 54.00   93297 REM INTERROG ICPMS <30 D PHYS/QHP 45.43

XXX N   93298 REM INTERROG SCRMS <30 D PHYS/QHP 45.43

XXX N   93303 COMPLETE TTHRC ECHO CONGENITAL CARDIAC ANOMALY 394.12 106.79 287.33 XXX N   93304 F-UP/LIMITED TTHRC ECHO CONGENITAL CAR ANOMALY 277.89 62.54 215.35 XXX N   93306 ECHO TTHRC R-T 2D W/WOM-MODE COMPL SPEC&COLR D 349.28 122.72 226.56 XXX N   93307 ECHO TRANSTHORAC R-T 2D W/WO M-MODE REC COMP 244.85 76.11 168.74 XXX N   93308 ECHO TRANSTHORC R-T 2D W/WO M-MODE REC F-UP/LMTD 173.46 43.07 130.39 XXX N   93312 ECHO TRANSESOPHAG R-T 2D W/PRB IMG ACQUISJ I&R 421.26 185.26 236.00 XXX N   93313 ECHO R-T 2D W/PROBE PLACEMENT ONLY 19.47 XXX N 700.74   93314 ECHO TRANSESOPHAG R-T 2D IMG ACQUISJ I&R ONLY 404.74 155.17 249.57 XXX N   93315 ECHO TRANSESOPHAG CONGEN PROBE PLCMT IMGNG I&R 483.80 217.71 266.09 XXX N   93316 ECHO TRANSESOPHAG CONGEN PROBE PLCMT ONLY 46.61 XXX N 700.74   93317 ECHO TRANSESOPHAG IMAGE ACQUISJ INTERP&REPORT 377.77 155.76 222.01 XXX N   93318 ECHO TRANSESOPHAG MONTR CARDIAC PUMP FUNCTJ 416.81 177.00 239.81 XXX N   93319 3D ECHO IMG&PST-PXESSING TEE/TTE CGEN CAR ANOMAL 105.61 ZZZ N   93320 DOPPLER ECHO PULSE WAVE W/SPECTRAL DISPLAY COMPL 90.27 30.68 59.59 ZZZ N   93321 DOPPLER ECHO PULSE WAVE W/SPECTRAL F-UP/LMTD STD 44.84 12.39 32.45 ZZZ N   93325 DOPPLER ECHO COLOR FLOW VELOCITY MAPPING 41.89 5.31 36.58 ZZZ N   93350 ECHO TTHRC R-T 2D W/WO M-MODE COMPLETE REST&ST 331.58 119.77 211.81 XXX N   93351 ECHO TTHRC R-T 2D W/WO M-MODE REST&STRS CONT ECG 411.82 143.96 267.86 XXX N   93352 USE OF ECHO CONTRAST AGENT DURING STRESS ECHO 58.41 ZZZ N   93355 ECHO TEE GUID TCAT ICAR/VESSEL STRUCTURAL INTVN 390.58 XXX N   93356 MYOCRD STRAIN IMG SPECKLE TRCK ASSMT MYOCRD MECH 66.67 ZZZ N   J1 93451 RIGHT HEART CATH O2 SATURATION & CARDIAC OUTPUT 1502.20 225.38 1276.82 000 N   J1 93452 L HRT CATH W/NJX L VENTRICULOGRAPHY IMG S&I 1649.64 408.87 1240.77 000 N   J1 93453 R & L HRT CATH W/NJX L VENTRICULOG IMG S&I 2090.96 547.52 1543.44 000 N   J1 93454 CATH PLACEMENT & NJX CORONARY ART ANGIO IMG S&I 1653.18 413.59 1239.59 000 N   J1 93455 CATH PLMT & NJX CORONARY ART/GRFT ANGIO IMG S&I 1837.85 482.03 1355.82 000 N   J1 93456 CATH PLMT R HRT & ARTS W/NJX & ANGIO IMG S&I 2053.79 537.49 1516.30 000 N   J1 93457 CATH PLMT R HRT/ARTS/GRFTS W/NJX& ANGIO IMG S&I 2240.23 604.16 1636.07 000 N   J1 93458 CATH PLMT L HRT & ARTS W/NJX & ANGIO IMG S&I 1895.08 510.35 1384.73 000 N   J1 93459 CATH PLMT L HRT/ARTS/GRFTS WNJX & ANGIO IMG S&I 2037.86 577.61 1460.25 000 N   J1 93460 R & L HRT CATH WINJX HRT ART& L VENTR IMG 2264.42 646.05 1618.37 000 N   J1 93461 R& L HRT CATH W/INJEC HRT ART/GRFT& L VENT I 2496.29 715.08 1781.21 000 N   93462 LEFT HEART CATH BY TRANSEPTAL PUNCTURE 364.03 ZZZ N   93463 MEDICATION ADMIN & HEMODYNAMIC MEASURMENT 169.92 ZZZ N   93464 PHYSIOLOGIC EXERCISE STUDY & HEMODYNAMIC MEASU 415.36 152.81 262.55 ZZZ N   J1 93503 INSERTION FLOW DIRECTED CATHETER FOR MONITORING 152.22 000 N 2755.85   J1 93505 ENDOMYOCARDIAL BIOPSY 1177.05 391.76 785.29 000 N   93563 NJX DRG CGEN C-CATHJ SLCTV CORONARY ANGRPH S&I 100.30 ZZZ N

Medicine Services Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 90281-96999, 97597-97610, 97802-97804, 98960-99082, 99151-99199, 99500-99607 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 290 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   93564 NJX DRG CGEN C-CATHJ SLCTV OPACIFICATION S&I 105.61 ZZZ N   93565 NJX DRG C-CATHJ SLCTV L VNTRC/R ATRIAL ANGRPHS&I 80.24 ZZZ N   93566 NJX DRG C-CATHJ SLCTV R VNTRC/R ATRIAL ANGRPHS&I 258.42 ZZZ N   93567 NJX DRG C-CATHJ SUPRAVALVULAR AORTOGRAPHY S&I 218.89 ZZZ N   93568 NJX DRG C-CATHJ NSLCTV P-ART ANGIOGRAPHY 234.23 ZZZ N   93569 NJX DRG C-CATHJ SLCTV P-ART ANGIOGRAPHY UNI 65.49 ZZZ N   93571 IV DOP VEL&/OR PRESS C/FLO RSRV MEAS 1ST VSL 377.60 132.16 245.44 ZZZ N   93572 IV DOP VEL&/OR PRESS C/FLO RSRV MEAS ADDL VSL 227.15 106.79 120.36 ZZZ N   93573 NJX DRG C-CATHJ SLCTV P-ART ANGIOGRAPHY BI 109.15 ZZZ N   93574 NJX DRG C-CATHJ SLCTV PULM VEN ANGIOGRAPHY 120.36 ZZZ N   93575 NJX DRG C-CATHJ SLCTV PULM ANGRPH MAPCA CHD EA 161.07 ZZZ N   J1 93580 PRQ TCAT CLSR CGEN INTRATRL COMUNICAJ W/IMPLT 1683.86 000 N 27193.39   J1 93581 PRQ TCAT CLSR CGEN VENTR SEPTAL DFCT W/IMPLT 2293.33 000 N 28593.33   J1 93582 PERCUTAN TRANSCATH CLOSURE PAT DUCT ARTERIOSUS 1147.55 000 N 29285.51   93583 PERCUTANEOUS TRANSCATHETER SEPTAL REDUCTION THER 1281.48 000 N   93584 VENOGRAPHY CHD ANOMALOUS/PERSISTENT SVC NT DRG 102.07 ZZZ N   93585 VENOGRAPHY CHD AZYGOS/HEMIAZYGOS VENOUS SYSTEM 96.17 ZZZ N   93586 VENOGRAPHY CHD CORONARY SINUS 121.54 ZZZ N   93587 VENOGRAPHY CHD VENOVENOUS COLTRL AT/ABOVE HRT 179.36 ZZZ N   93588 VENOGRAPHY CHD VENOVENOUS COLLATERAL BELOW HEART 181.13 ZZZ N   J1 93590 PERQ TRANSCATH CLS PARAVALVR LEAK 1 MITRAL VALVE 1848.47 000 Y 29329.79   J1 93591 PERQ TRANSCATH CLS PARAVALVR LEAK 1 AORTIC VALVE 1526.92 000 N 29927.66   93592 PERQ TRANSCATH CLS PARAVALVR LEAK EACH OCCLS DEV 673.78 ZZZ Y   J1 93593 R HRT CATH CHD W/IMG CATH TRGT ZONE NML NT CONNJ BR 326.27 BR 000 N

  J1 93594 R HRT CATH CHD W/IMG CATH TRGT ZON ABNL NT CONNJ BR 514.48 BR 000 N

  J1 93595 L HRT CATH CHD IMG CATH TRGT ZON NML/ABNL NT CNJ BR 464.33 BR 000 N

  J1 93596 R&L HRT CATH CHD IMG CATH TRGT ZONE NML NT CONNJ 839.57 561.09 278.48 000 N

  J1 93597 R&L HRT CATH CHD IMG CATH TRGT ZON ABNL NT CONNJ 1672.65 749.30 923.35 000 N

  93598 CAR OUTP MEAS DRG CAR CATH EVAL CGEN HRT DEFECT BR 122.72 BR ZZZ N   J1 93600 BUNDLE OF HIS RECORDING 339.25 203.55 135.70 000 N   J1 93602 INTRA-ATRIAL RECORDING 293.39 200.60 92.79 000 N   J1 93603 RIGHT VENTRICULAR RECORDING 318.60 200.60 118.00 000 N   93609 INTRA-VNTR MAPG TACHYCARDIA SITES W/CATH MNPJ 663.75 477.90 185.85 ZZZ N   J1 93610 INTRA-ATRIAL PACING 377.60 283.20 94.40 000 N   J1 93612 INTRAVENTRICULAR PACING 410.32 280.84 129.48 000 N   93613 INTRACARDIAC ELECTROPHYSIOLOGIC 3D MAPPING 512.12 ZZZ N   J1 93615 ESOPHGL REC ATRIAL W/WO VENTRICULAR ELECTROGRAMS 119.00 64.31 54.69 000 N   J1 93616 ESOPHGL REC ATRIAL W/WO VENTR ELECTRGRAMS W/PACG 153.63 100.89 52.74 000 N   J1 93618 INDUCTION ARRHYTHMIA ELECTRICAL PACING 717.76 379.37 338.39 000 N   J1 93619 COMPRE ELECTROPHYSIOLOGIC W/O ARRHYT INDUCTION 1178.82 672.01 506.81 000 N   J1 93620 COMPRE EP EVAL R ATR VNTRC PACG&REC HIS BNDL REC 1714.54 1080.29 634.25 000 N   93621 COMPRE EP EVAL W/L ATRIAL PACG&REC C SINS/L ATR 283.96 200.01 83.95 ZZZ N   93622 COMPRE EP EVAL W/LEFT VENTRICULAR PACING/REC 414.92 296.18 118.74 ZZZ N   93623 PROGRAMMED STIMJ & PACG AFTER IV DRUG INFUSION 385.32 271.99 113.33 ZZZ N

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   J1 93624 ELECTROPHYSIOLOGIC FOLLOW-UP W/PACG&REC W/ARRHYT 532.77 415.36 117.41 000 N   93631 INTRAOP EPICAR& ENDOCAR PACG& MAPG 967.72 683.22 284.50 000 N   93640 EP EVAL 1/2CHMBR PACG CVDFB LEADS 769.95 307.98 461.97 000 N   93641 EP EVAL 1/2CHMB PACG CVDFB LDS TSTG OF PULSE GEN 1013.03 536.90 476.13 000 N   J1 93642 EP EVAL 1/2 CHMB TRANSVNS PAC CVDFB 582.33 440.14 142.19 000 N   93644 EP EVAL SUBQ IMPLANTABLE DEFIBRILLATOR 337.48 247.21 90.27 000 N   J1 93650 ICAR CATHETER ABLATION ATRIOVENTR NODE FUNCTION 1021.88 000 N 11011.16   J1 93653 COMPRE EP EVAL ABLTJ 3D MAPG TX SVT 1444.91 000 N 39718.70   J1 93654 COMPRE EP EVAL ABLTJ 3D MAPG TX VT 1932.84 000 N 38977.96   93655 ICAR CATH ABLATION DISCRETE MECHANISM ARRHYTHMIA 731.60 ZZZ N   J1 93656 COMPRE EP EVAL ABLTJ ATR FIB PULM VEIN ISOLATION 1938.74 000 N 38664.56   93657 ABLATE L/R ATRIAL FIBRIL W/ISOLATED PULM VEIN 730.42 ZZZ N   93660 CARDIOVASCULAR FUNCTION EVAL W/TILT TABLE W/MNTR 276.71 158.71 118.00 000 N   93662 INTRACARD ECHOCARD W/THER/DX IVNTJ INCL IMG S&I 339.99 240.13 99.86 ZZZ N   93668 PERIPHERAL ARTERIAL DISEASE REHAB PER SESSION 29.50 XXX N 80.73   93701 BIOIMPEDANCE-DERIVED PHYSIOLOGIC CV ANALYSIS 47.79 XXX N 163.53   93702 BIS EXTRACELLULAR FLUID ALYS LYMPHEDEMA ASSMNT 242.22 XXX N 202.48   93724 ELECTRONIC ALYS ANTITACHYCARDIA PACEMAKER SYS 495.01 413.59 81.42 000 N   93740 TEMPRATURE GRADIENT STUDY 13.57 XXX N 202.48   93745 1ST SET-UP & PRGRMG PHYS/QHP OF WEARABLE CVDFB 164.50 106.96 57.54 XXX N   ★

20 Miss. Admin. Code Pt. 2, R. 93750 Rule 93750

INTERROGATION VAD IN PRSON W/PHYS/QHP ANALYSIS 93.22 XXX N 145.59   93770 DETERMINATION OF VENOUS PRESSURE 13.57 XXX N   93784 AMBULATORY BP MNTR W/SW 24 HR+ REC SCAN ALYS I&R 89.09 XXX N   93786 AMBULATORY BP MNTR W/SW 24 HR+ RECORDING ONLY 48.97 XXX N 163.53   93788 AMBULATORY BP MNTR W/SW 24 HR+ SCANNING A/R 8.85 XXX N 163.53   93790 AMBULATORY BP MNTR W/SW 24 HR+ REVIEW W/I&R 31.27 XXX N   93792 PT/CAREGIVER TRAING FOR INITIATION HOME INR MNTR 100.42 XXX N   93793 ANTICOAGULANT MGMT FOR PT TAKING WARFARIN 20.06 XXX N   ★

20 Miss. Admin. Code Pt. 2, R. 93797 Rule 93797

PHYS/QHP O/P CARDIAC RHAB W/O CONT ECG MONITOR 28.91 000 N 168.34   ★

20 Miss. Admin. Code Pt. 2, R. 93798 Rule 93798

PHYS/QHP O/P CARDIAC RHAB W/CONT ECG MONITORING 44.84 000 N 168.34   93799 UNLISTED CARDIOVASCULAR SERVICE/PROCEDURE BR BR BR XXX N

  93880 DUPLEX SCAN EXTRACRANIAL ART COMPL BI STUDY 339.84 67.26 272.58 XXX N   93882 DUPLEX SCAN EXTRACRANIAL ART UNI/LMTD STUDY 222.43 42.48 179.95 XXX N   93886 TRANSCRANIAL DOPPLER STDY INTRACRANIAL ART COMPL 477.31 79.65 397.66 XXX N   93888 TRANSCRANIAL DOPPLER STDY INTRACRANIAL ART LMTD 284.38 43.66 240.72 XXX N   93892 TRANSCRANIAL DOPPLER INTRACRAN ART EMBOLI DETECT 556.37 102.07 454.30 XXX N   93893 TCD STD ICR ART VEN-ARTL SHNT DETCJ IV MBUBB NJX 665.61 103.84 561.77 XXX N   93895 CAROTID INTIMA MEDIA & CAROTID ATHEROMA EVAL BI 249.57 BR BR XXX N   93896 VASOREACTIVITY STUDY W/TCD ICR ARTERIES COMPLETE 315.65 71.39 244.26 ZZZ N   93897 EMBOLI DETCJ W/O IV MBUBB NJX TCD ICR ART COMPL 397.07 64.90 332.17 ZZZ N   93898 VEN-ARTL SHNT DETC IV MBUB NJX TCD ICR ART COMPL 415.95 76.11 339.84 ZZZ N   93922 NON-INVAS PHYSIOLOGIC STD EXTREMITY ART 2 LEVEL 144.55 21.24 123.31 XXX N   93923 NON-INVASIVE PHYSIOLOGIC STUDY EXTREMITY 3 LEVLS 226.56 38.35 188.21 XXX N   93924 N-INVAS PHYSIOLOGIC STD LXTR ART COMPL BI 279.66 42.48 237.18 XXX N   93925 DUP-SCAN LXTR ART/ARTL BPGS COMPL BI STUDY 430.11 66.08 364.03 XXX N

Medicine Services Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 90281-96999, 97597-97610, 97802-97804, 98960-99082, 99151-99199, 99500-99607 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 292 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   93926 DUP-SCAN LXTR ART/ARTL BPGS UNI/LMTD STUDY 254.29 40.71 213.58 XXX N   93930 DUP-SCAN UXTR ART/ARTL BPGS COMPL BI STUDY 348.69 66.67 282.02 XXX N   93931 DUP-SCAN UXTR ART/ARTL BPGS UNI/LMTD STUDY 220.66 41.30 179.36 XXX N   93970 DUP-SCAN XTR VEINS COMPLETE BILATERAL STUDY 333.94 58.41 275.53 XXX N   93971 DUP-SCAN XTR VEINS UNILATERAL/LIMITED STUDY 211.81 37.76 174.05 XXX N   93975 DUP-SCAN ARTL FLO ABDL/PEL/SCROT&/RPR ORGN COM 472.00 96.76 375.24 XXX N   93976 DUP-SCAN ARTL FLO ABDL/PEL/SCROT&/RPR ORGN LMT 280.25 66.67 213.58 XXX N   93978 DUP-SCAN AORTA IVC ILIAC VASCL/BPGS COMPLETE 321.55 66.67 254.88 XXX N   93979 DUP-SCAN AORTA IVC ILIAC VASCL/BPGS UNI/LMTD 208.27 41.30 166.97 XXX N   93980 DUP-SCAN ARTL INFL&VEN O/F PEN VSL COMPL 208.27 103.84 104.43 XXX N   93981 DUP-SCAN ARTL INFL&VEN O/F PEN VSL F-UP/LMTD STD 126.85 36.58 90.27 XXX N   93985 DUPLEX SCAN ARTL INFL&VEN O/F HEMO COMPL BI STD 445.45 66.08 379.37 XXX N   93986 DUPLEX SCAN ARTL INFL&VEN O/F HEMO COMPL UNI STD 264.91 41.89 223.02 XXX N   93990 DUPLEX SCAN HEMODIALYSIS ACCESS 261.96 41.30 220.66 XXX N   93998 UNLISTED NONINVASIVE VASCULAR DIAGNOSTIC STUDY BR XXX N 35.83   ★ 94002 VENTILATION ASSIST & MGMT INPATIENT 1ST DAY 159.30 XXX N 706.51   ★ 94003 VENTILATION ASSIST & MGMT INPATIENT EA SBSQ DA 112.10 XXX N 706.51   ★

20 Miss. Admin. Code Pt. 2, R. 94004 VENTILATION ASSIST & MGMT NURSING FAC PR DAY 83.19 XXX N   ★

20 Miss. Admin. Code Pt. 2, R. 94005 Rule 94005

HOME VENTILATOR MGMT CARE OVERSIGHT 30 MIN/> 156.94 XXX N   94010 SPMTRY W/VC EXPIRATORY FLO W/WO MXML VOL VNTJ 59.00 14.16 44.84 XXX N   94011 MEAS SPIROMTRC FORCD EXPIRATORY FLO INFANT&/2 Y 148.09 XXX N 202.48   94012 MEAS SPIRO FRCD EXP FLO PRE&POST BRONCH INF/2YRS 242.49 XXX N 383.81   94013 MEASUREMENT LUNG VOLUMES INFANT/CHILD/2 YRS 33.63 XXX N 707.91   94014 PT-INITIATE SPIROMETRIC RECORDING PHYS/QHP R&I 95.58 XXX N 393.60   94015 PATIENT-INITIATED SPIROMETRIC RECORDING 53.10 XXX N 383.81   94016 PATIENT-INITIATED SPIROMETRIC PHYS/QHP R&I ONLY 42.48 XXX N   94060 BRNCDILAT RSPSE SPMTRY PRE&POST-BRNCDILAT ADMN 99.12 21.83 77.29 XXX N   94070 BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT 107.38 48.38 59.00 XXX N   94150 VITAL CAPACITY TOTAL SEPARATE PROCEDURE 43.07 6.49 36.58 XXX N   94200 MAX BREATHING CAPACITY MAXIMAL VOLUNTARY VENTJ 46.02 9.44 36.58 XXX N   94375 RESPIRATORY FLOW VOLUME LOOP 66.67 24.78 41.89 XXX N   94450 BREATHING RESPONSE TO HYPOXIA 121.54 33.63 87.91 XXX N   94452 HIGH ALTITUDE SIMULATJ TEST W/PHYS INTERP&REPORT 91.45 24.78 66.67 XXX N   94453 HIGH ALTITUDE SIMULATJ W/PHYS I&R W/O2 TITRATION 126.26 32.45 93.81 XXX N  

20 Miss. Admin. Code Pt. 2, R. 94610 Rule 94610

INTRAPULMONARY SURFACTANT ADMINISTJ PHYS/QHP 95.58 XXX N 272.60   94617 XERS TST BRNCSPSM PRE&POST SPMTRY&PLS OX W/ECG 156.94 56.05 100.89 XXX N   94618 PULMONARY STRESS TESTING 57.82 38.35 19.47 XXX N   94619 XERS TST BRNCSPSM PRE&POST SPMTRY&PLS OX WO /ECG 119.77 38.94 80.83 XXX N   94621 CARDIOPULMONARY EXERCISE TESTING 270.22 119.18 151.04 XXX N   ★ 94625 PHYS/QHP SVCS OP PULM REHAB WO CONT OXIMTRY MNTR 112.69 XXX N 80.73   ★ 94626 PHYS/QHP SVCS OP PULM REHAB W/CONT OXIMTRY MNTR 128.03 XXX N 80.73   94640 PRESSURIZED/NONPRESSURIZED INHALATION TREATMENT 30.09 XXX N 272.60   94642 PENTAMIDINE AERSL INHALATION PNEUMOCYSTIS/PROPH 63.78 XXX N 272.60   94644 CONTINUOUS INHALATION TREATMENT 1ST HR 94.99 XXX N 163.53   94645 CONTINUOUS INHALATION TREATMENT EA ADDL HR 27.73 XXX N   94660 CPAP VENTILATION CPAP INITIATION&MGMT 110.92 XXX N 272.60

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   94662 CONTINUOUS NEGATIVE PRESSURE VENTJ INITIAT&MGM 61.95 XXX N 706.51   ★ 94664 DEMO&/EVAL OF PT UTILIZ AERSL GEN/NEB/INHLR/IP 29.50 XXX N 272.60   94667 MANJ CH WALL FACILITATE LNG FUNCJ 1 DEMO&/EVAL 41.89 XXX N 163.53   94668 MANJ CHEST WALL FACILITATE LUNG FUNCTION SUBSQ 61.36 XXX N 163.53   94669 MECHANICAL CHEST WALL OSCILLATION LUNG FUNCTION 53.10 XXX N 272.60   94680 O2 UPTK EXP GAS ANALYSIS REST&XERS DIRECT SIMP 92.63 22.42 70.21 XXX N   94681 O2 UPTK EXP GAS ALYS W/CO2 OUTPUT % O2 XTRC 91.45 17.11 74.34 XXX N   94690 O2 UPTAKE EXP GAS ANALYSIS REST INDIRECT SPX 87.91 6.49 81.42 XXX N   94726 PLETHYSMOGRAPHY LUNG VOLUMES W/WO AIRWAY RESIST 94.99 20.65 74.34 XXX N   94727 GAS DILUT/WASHOUT LUNG VOL W/WO DISTRIB VENT&V 76.11 20.65 55.46 XXX N   94728 AIRWAY RESISTANCE BY OSCILLOMETRY 69.03 21.24 47.79 XXX N   94729 CO DIFFUSING CAPACITY 102.07 15.34 86.73 ZZZ N   94760 NONINVASIVE EAR/PULSE OXIMETRY SINGLE DETER 4.13 XXX N   94761 NONINVASIVE EAR/PULSE OXIMETRY MULTIPLE DETER 7.08 XXX N   94762 NONINVASIVE EAR/PULSE OXIMETRY OVERNIGHT MONITOR 46.02 XXX N 202.48   94772 CIRCADIAN RESPIRATRY PATTERN REC 12-24 HR INFANT 380.64 151.98 228.65 XXX N   94774 PEDIATRIC APNEA MONITOR ATTACHMENT PHYS I&R 565.22 YYY N   94775 PEDIATRIC APNEA MONITOR ATTACHMENT BR YYY N 202.48   94776 PEDIATRIC APNEA MONITOR ANALYSES COMPUTER 308.36 YYY N 202.48   94777 PEDIATRIC APNEA MONITOR PHYS/QHP REVIEW 160.48 YYY N   94780 CAR SEAT/BED TEST INFT THRU 12 MO 60 MIN 89.68 XXX N 49.09   94781 CAR SEAT/BED TEST INFT THRU 12 MO EA ADDL 30 MIN 35.40 ZZZ N   94799 UNLISTED PULMONARY SERVICE/PROCEDURE BR BR BR XXX N   95004 PERCUTANEOUS TESTS W/ALLERGENIC XTR IMMT RXN 7.08 XXX N 1334.25   95012 NITRIC OXIDE EXPIRED GAS DETERMINATION 33.63 XXX N 49.09   95017 ALL TSTG PERQ & IQ W/VENOMS IMMT RXN W/I&R 15.34 XXX N 35.83   95018 ALL TSTG PERQ & IQ W/DRUG/BIOL IMMT RXN W/I&R 35.99 XXX N 49.09   95024 INTRACUTANEOUS TESTS W/ALLERGENIC EXTRACTS 14.75 XXX N 80.73   95027 IQ TSTS SEQL&INCRL W/ALLERGENIC XTRCS AIRBORNE 8.82 XXX N 35.83   95028 IQ TSTS ALLERGENIC XTRCS DLYD TYP RXN W/READING 22.42 XXX N 49.09   95044 PATCH/APPLICATION TESTS SPECIFY NUMBER TESTS 9.44 XXX N 1334.25   95052 PHOTO PATCH TESTS SPECIFY NUMBER TESTS 11.21 XXX N 80.73   95056 PHOTO TESTS 85.55 XXX N 163.53   95060 OPHTHALMIC MUCOUS MEMBRANE TESTS 63.72 XXX N 163.53   95065 DIRECT NASAL MUCOUS MEMBRANE TEST 47.20 XXX N 49.09   95070 INHLJ BRNCL CHALLENGE TSTG W/HISTAMINE/METHACHOL 61.07 XXX N 707.91   95076 INGESTION CHALLENGE TEST INITIAL 120 MINUTES 207.09 XXX N 707.91   95079 INGESTION CHALLENGE TEST EACH ADDL 60 MINUTES 145.73 ZZZ N   95115 PROF SVCS ALLG IMMNTX X W/PRV ALLGIC XTRCS 1 NJX 16.52 XXX N 58.04   95117 PROF SVCS ALLG IMMNTX X W/PRV ALLGIC XTRCS NJXS 20.06 XXX N 58.04   95120 PROF SVCS ALLG IMMNTX W/PRV ALLGIC XTRC 1 NJX 31.27 XXX N   95125 PROF SVCS ALLG IMMNTX W/PRV ALLGIC XTRC 2/> NJX 34.22 XXX N   95130 PROF SVCS ALLG IMMNTX W/PRV XTRC 1 STING INSECT 30.53 XXX N   95131 PROF SVCS ALLG IMMNTX W/PRV XTRC 2 STING INSECT 50.74 XXX N   95132 PROF SVCS ALLG IMMNTX W/PRV XTRC 3 STING INSECT 65.81 XXX N   95133 PROF SVCS ALLG IMMNTX W/PRV XTRC 4 STING INSECT 90.27 XXX N

Medicine Services Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 90281-96999, 97597-97610, 97802-97804, 98960-99082, 99151-99199, 99500-99607 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 294 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   95134 PROF SVCS ALLG IMMNTX W/PRV XTRC 5 STING INSECT 128.03 XXX N   95144 PREPJ& ANTIGEN PRV ALLERGEN IMMUNOTHERAPY 1 DO 27.82 XXX N 58.04   95145 PREPJ& ANTIGEN ALLERGEN IMMUNOTHERAPY 1 INSECT 54.96 XXX N 58.04   95146 PREPJ& ANTIGEN ALLERGEN IMMUNOTHERAPY 2 INSECT 101.78 XXX N 58.04   95147 PREPJ& ANTIGEN ALLERGEN IMMUNOTHERAPY 3 INSECT 105.17 XXX N 89.91   95148 PREPJ& ANTIGEN ALLERGEN IMMUNOTHERAPY 4 INSECT 151.31 XXX N 89.91   95149 PREPJ& ANTIGEN ALLERGEN IMMUNOTHERAPY 5 INSECT 201.51 XXX N 89.91   95165 PREPJ& ALLERGEN IMMUNOTHERAPY 1/MLT ANTIGEN 27.14 XXX N 58.04   95170 PREPJ& ANTIGEN ALLERGEN IMMUNOTHERAPY WHL INSE 20.06 XXX N 58.04   95180 RAPID DESENSITIZATION PROCEDURE EACH HOUR 235.41 XXX N 393.60   95199 UNLISTED ALLERGY/CLINICAL IMMUNOLOGIC SVC/PX BR XXX N 35.83   95249 CONT GLUC MONITORING PATIENT PROVIDED EQUIPMENT 102.07 XXX N 80.73   95250 CONT GLUC MNTR PHYSICIAN/QHP PROVIDED EQUIPMENT 258.42 XXX N 172.32   95251 CONTINUOUS GLUCOSE MONITORING ANALYSIS I&R 60.18 XXX N   95700 EEG CONT REC W/VIDEO BY TECH MIN 8 CHANNELS 477.31 XXX N 383.81   95705 EEG W/O VIDEO BY TECH 2-12 HR UNMONITORED 746.35 XXX N 383.81   95706 EEG W/O VIDEO BY TECH 2-12 HR INTERMITTENT MNTR 315.65 XXX N 383.81   95707 EEG W/O VIDEO BY TECH 2-12HR CONTINUOUS R-T MNTR 1362.31 XXX N 383.81   95708 EEG W/O VID BY TECH EA INCR 12-26HR UNMONITORED 566.40 XXX N 707.91   95709 EEG W/O VID BY TECH EA INCR 12-26 HR INTMT MNTR 1515.12 XXX N 707.91   95710 EEG W/O VID TECH EA INCR 12-26 HR CONT R-T MNTR 766.41 XXX N 707.91   95711 VEEG BY TECH 2-12 HOURS UNMONITORED 883.82 XXX N 383.81   95712 VEEG BY TECH 2-12 HR INTERMITTENT MONITORING 1136.34 XXX N 383.81   95713 VEEG BY TECH 2-12 HR CONTINUOUS R-T MONITORING 919.81 XXX N 707.91   95714 VEEG BY TECH EA INCR 12-26 HR UNMONITORED 757.56 XXX N 707.91   95715 VEEG BY TECH EA INCR 12-26 HR INTERMITTENT MNTR 1893.90 XXX N 707.91   95716 VEEG BY TECH EA INCR 12-26 HR CONT R-T MNTR 3800.19 XXX N 1334.25   95717 EEG PHYS/QHP 2-12 HR WITHOUT VIDEO 175.23 XXX N   95718 EEG PHYS/QHP 2-12 HR WITH VEEG 234.82 XXX N   95719 EEG PHYS/QHP EA INCR>12HR<26HR AFTER 24HR WO VID 271.99 XXX N   95720 EEG PHYS/QHP EA INCR>12HR<26HR AFTER 24HR W/VEEG 361.67 XXX N   95721 EEG COMPLETE STD PHYS/QHP>36 HR<60 HR W/O VIDEO 361.08 XXX N   95722 EEG COMPLETE STD PHYS/QHP>36 HR<60 HR W/VEEG 440.14 XXX N   95723 EEG COMPLETE STD PHYS/QHP>60 HR<84 HR W/O VIDEO 443.68 XXX N   95724 EEG COMPLETE STD PHYS/QHP>60 HR<84 HR W/VEEG 558.73 XXX N   95725 EEG COMPLETE STD PHYS/QHP>84 HR W/O VID 509.76 XXX N   95726 EEG COMPLETE STD PHYS/QHP>84 HR W/VEEG 709.77 XXX N   95782 POLYSOM <6 YRS SLEEP STAGE 4/> ADDL PARAM ATTND 1649.64 215.35 1434.29 XXX N   95783 POLYSOM <6 YRS SLEEP W/CPAP/BILVL VENT 4/> PARAM 1746.99 234.23 1512.76 XXX N   95800 SLP STDY UNATND W/HRT RATE/O2 SAT/RESP/SLP TIME 282.61 70.80 211.81 XXX N   95801 SLP STDY UNATND W/MIN HRT RATE/O2 SAT/RESP ANAL 158.12 70.80 87.32 XXX N   95803 ACTIGRAPHY TESTING RECORDING ANALYSIS I&R 255.47 73.75 181.72 XXX N   95805 MLT SLEEP LATENCY/MAINT OF WAKEFULNESS TSTG 728.06 99.12 628.94 XXX N   95806 SLEEP STD AIRFLOW HRT RATE&O2 SAT EFFORT UNATT 230.10 83.19 146.91 XXX N   95807 SLEEP STD REC VNTJ RESPIR ECG/HRT RATE&O2 ATTN 716.85 103.84 613.01 XXX N   95808 POLYSOM ANY AGE SLEEP STAGE 1-3 ADDL PARAM ATTND 1168.79 151.04 1017.75 XXX N

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   95810 POLYSOM 6/>YRS SLEEP 4/> ADDL PARAM ATTND 1060.23 205.32 854.91 XXX N   95811 POLYSOM 6/>YRS SLEEP W/CPAP 4/> ADDL PARAM ATTND 1106.84 212.99 893.85 XXX N   95812 ELECTROENCEPHALOGRAM EXTEND MONITORING 41-60 MIN 606.52 97.94 508.58 XXX N   95813 EEG EXTENDED MONITORING 61-119 MINUTES 750.48 149.27 601.21 XXX N   95816 ELECTROENCEPHALOGRAM W/REC AWAKE&DROWSY 669.06 97.94 571.12 XXX N   95819 ELECTROENCEPHALOGRAM W/REC AWAKE&ASLEEP 785.29 98.53 686.76 XXX N   95822 ELECTROENCEPHALOGRAM REC COMA/SLEEP ONLY 729.24 98.53 630.71 XXX N   95824 ELECTROENCEPHALOGRAM CERE DEATH EVAL ONLY 172.28 67.26 105.02 XXX N   95829 ELECTROCORTICOGRAM SURGERY SPX 3197.21 572.30 2624.91 XXX N   95830 INSERTION SPHENOIDAL ELECTRODES EEG PHYS/QHP 744.31 XXX N   95836 ECOG IMPLANTED BRAIN NPGT W/REC I&R <30 DAYS 185.26 XXX N 54.00   95851 ROM MEAS&REPRT EA XTR EX HAND/EA TRNK SCTJ SPI 35.99 XXX N   95852 ROM MEAS&REPRT HAND W/WO COMPARISON NORMAL SID 31.27 XXX N   95857 CHOLINESTERASE INHIBITOR CHALLENGE TEST 104.49 XXX N 383.81   95860 NDL EMG 1 XTR W/WO RELATED PARASPINAL AREAS 202.37 87.91 114.46 XXX N   95861 NDL EMG 2 XTR W/WO RELATED PARASPINAL AREAS 289.10 141.01 148.09 XXX N   95863 NDL EMG 3 XTR W/WO RELATED PARASPINAL AREAS 377.60 171.10 206.50 XXX N   95864 NDL EMG 4 XTR W/WO RELATED PARASPINAL AREAS 421.85 182.90 238.95 XXX N   95865 NEEDLE ELECTROMYOGRAPHY LARYNX 269.04 142.78 126.26 XXX N   95866 NEEDLE ELECTROMYOGRAPHY HEMIDIAPHRAGM 230.10 114.46 115.64 XXX N   95867 NEEDLE ELECTROMYOGRAPHY CRANIAL NRV MUSCLE UNI 190.57 71.98 118.59 XXX N   95868 NEEDLE ELECTROMYOGRAPHY CRANIAL NRV MUSCLE BI 252.52 107.97 144.55 XXX N   95869 NEEDLE EMG THRC PARASPI MUSC EXCLUDING T1/T12 175.23 34.22 141.01 XXX N   95870 NEEDLE EMG LMTD STD MUSC 1 XTR/NON-LIMB UNI/BI 152.22 33.63 118.59 XXX N   95872 NEEDLE EMG W/1 FIBER ELECTRODE QUAN MEAS JITTER 370.52 261.96 108.56 XXX N   95873 ELECTRICAL STIMULATION GUID W/CHEMODENERVATION 133.93 33.63 100.30 ZZZ N   95874 NEEDLE EMG GUID W/CHEMODENERVATION 141.01 33.63 107.38 ZZZ N   95875 ISCHEMIC LIMB XERS TST SPEC ACQUISJ METAB 241.31 100.89 140.42 XXX N   95885 NEEDLE EMG EA EXTREMITY W/PARASPINL AREA LIMITED 113.28 31.86 81.42 ZZZ N   95886 NEEDLE EMG EA EXTREMTY W/PARASPINL AREA COMPLETE 175.82 78.47 97.35 ZZZ N   95887 NEEDLE EMG NONEXTREMTY MSCLES W/NERVE CONDUCTION 151.63 64.90 86.73 ZZZ N  

20 Miss. Admin. Code Pt. 2, R. 95905 Rule 95905

MOTOR &/SENS NRV CNDJ PRECONF ELTRD ARRAY LIMB 106.20 4.72 101.48 XXX N   95907 NERVE CONDUCTION STUDIES 1-2 STUDIES 160.48 91.45 69.03 XXX N   95908 NERVE CONDUCTION STUDIES 3-4 STUDIES 207.68 114.46 93.22 XXX N   95909 NERVE CONDUCTION STUDIES 5-6 STUDIES 247.80 137.47 110.33 XXX N   95910 NERVE CONDUCTION STUDIES 7-8 STUDIES 325.09 183.49 141.60 XXX N   95911 NERVE CONDUCTION STUDIES 9-10 STUDIES 390.58 227.74 162.84 XXX N   95912 NERVE CONDUCTION STUDIES 11-12 STUDIES 439.55 271.40 168.15 XXX N   95913 NERVE CONDUCTION STUDIES 13/> STUDIES 508.58 322.14 186.44 XXX N   95919 QUANTITATIVE PUPILLOMETRY PHYS/QHP I&R UNI/BI 27.14 17.11 10.03 XXX N   95921 TSTG ANS FUNCJ CARDIOVAGAL INNERVAJ PARASYMP 155.76 77.29 78.47 XXX N   95922 TSTG ANS FUNCJ VASOMOTOR ADRENERGIC INNERVAJ 177.59 80.83 96.76 XXX N   95923 TESTING AUTONOMIC NERVOUS SYSTEM FUNCTION 221.25 77.29 143.96 XXX N   95924 TSTG ANS FUNCJ PARASYMP&SYMP W/5 MIN PASIVE TILT 263.14 149.86 113.28 XXX N   95925 SHORT-LATENCY SOMATOSENS EP STD UPR LIMBS 253.08 49.56 203.52 XXX N

Medicine Services Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 90281-96999, 97597-97610, 97802-97804, 98960-99082, 99151-99199, 99500-99607 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 296 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   95926 SHORT-LATENCY SOMATOSENS EP STD LWR LIMBS 244.94 47.79 197.15 XXX N   95927 SHORT-LATENCY SOMATOSENS EP STD TRNK/HEAD 253.76 46.02 207.74 XXX N   95928 CTR MOTOR EP STD TRANSCRNL MOTOR STIMJ UPR LIMBS 415.95 136.88 279.07 XXX N   95929 CTR MOTOR EP STD TRANSCRNL MOTOR STIMJ LWR LIMBS 427.75 136.88 290.87 XXX N   95930 VISUAL EP TESTING CNS EXCEPT GLAUCOMA W/I&R 114.46 31.86 82.60 XXX N   95933 ORBICULARIS OCULI REFLX ELECTRODIAGNOSTIC TEST 149.27 54.28 94.99 XXX N   95937 NEUROMUSCULAR JUNCT TSTG EA NRV ANY 1 METH 168.27 59.59 108.68 XXX N   95938 SHORT-LATENCY SOMATOSENS EP STD UPR & LOW LIMB 636.02 78.47 557.55 XXX N   95939 CTR MOTR EP STD TRANSCRNL MOTR STIM UPR&LOW LI 961.11 204.73 756.38 XXX N   95940 IONM 1 ON 1 IN OR W/ATTENDANCE EACH 15 MINUTES 56.05 XXX N   95941 IONM REMOTE/NEARBY/>1 PATIENT IN OR PER HOUR 842.70 XXX N   95954 RX/PHYSICAL EEG ACTIVAJ PHYS/QHP ATTENDANCE 710.36 194.70 515.66 XXX N   95955 EEG NONINTRACRANIAL SURGERY 358.13 92.04 266.09 XXX N   95957 DIGITAL ANALYSIS ELECTROENCEPHALOGRAM 455.48 175.82 279.66 XXX N   95958 WADA ACTIVATION TEST HEMISPHERIC FUNCTION W/EEG 1100.94 392.94 708.00 XXX N   95961 FUNCJAL CORT&SUBCORT MAPG PHYS/QHP ATTND INIT HR 568.17 279.07 289.10 XXX N   95962 FUNCJAL CORT&SUBCORT MAPG PHYS/QHP ATTND ADDL HR 466.69 298.54 168.15 ZZZ N   95965 MAGNETOENCEPHALOGRAPHY SPON BRAIN ACTIVITY 2865.04 716.26 2148.78 XXX N   95966 MAGNETOENCEPHALOGRAPY EVOKED FIELDS 1 MODALITY 1823.10 364.62 1458.48 XXX N   95967 MAGNETOENCEPHALOGRAPY EVOKED FIELDS EACH ADDL 1662.17 319.19 1342.98 ZZZ N   ★

20 Miss. Admin. Code Pt. 2, R. 95970 ELEC ALYS IMPLT NPGT PHYS/QHP W/O PROGRAMMING 33.04 XXX N 163.53   ★

20 Miss. Admin. Code Pt. 2, R. 95971 ELEC ALYS IMPLT NPGT SMPL SP/PN NPGT PRGRMG 84.96 XXX N 145.59   ★

20 Miss. Admin. Code Pt. 2, R. 95972 Rule 95972

ELEC ALYS IMPLT NPGT CPLX SP/PN PRGRMG 97.35 XXX N 145.59   95976 ELEC ALYS IMPLT SMPL CN NPGT PRGRMG 70.21 XXX N 54.00   95977 ELEC ALYS IMPLT CPLX CN NPGT PRGRMG 92.63 XXX N 145.59   95980 ELEC ALYS NSTIM PLS GEN GASTRIC INTRAOP W/PRGRMG 79.06 XXX N   95981 ELEC ALYS NSTIM GEN GASTRIC SBSQ W/O REPRGRMG 65.81 XXX N 163.53   95982 ELEC ALYS NSTIM PLS GEN GASTRIC SBSQ W/REPRGRMG 102.07 XXX N 54.00   ★

20 Miss. Admin. Code Pt. 2, R. 95983 ELEC ALYS IMPLT BRN NPGT PRGRMG 1ST 15 MIN 88.50 XXX N 145.59   ★

20 Miss. Admin. Code Pt. 2, R. 95984 Rule 95984

ELEC ALYS IMPLT BRN NPGT PRGRMG EA ADDL 15 MIN 77.29 ZZZ N   95990 REFILL&MAINTENANCE PUMP DRUG DLVR SPINAL/BRAIN 158.71 XXX N 462.41   95991 RFL&MAIN IMPLT PMP/RSVR DLVR SPI/BRN PHY/QHP 194.70 XXX N 378.90   95992 CANALITH REPOSITIONING PROCEDURE 75.52 XXX N   95999 UNLISTED NEUROLOGICAL/NEUROMUSCULAR DX PX BR XXX N 202.48   96000 COMPRE CPTR MTN ALYS VIDEO TAPING 3D KINEMATICS 160.48 XXX N 707.91   96001 COMPRE CPTR MTN ALYS W/DYN PLNTR PRES MEAS WALKG 215.35 XXX N 1334.25   96002 DYN SURF EMG WALKG/FUNCJAL ACTV 1-12 MUSC 37.76 XXX N 202.48   96004 PHYS/QHP R&I CPTR MTN ALYS WALK/FUNCJL ACTV REPR 192.93 XXX N   96020 TEST SELECT & ADMN FUNCTL BRAIN MAP PHYS/QHP 0.00 275.53 BR XXX N   ★ 96041 MED GENETICS&GENETIC COUNSELING SVCS EACH 30 MIN 91.45 XXX N   ★

20 Miss. Admin. Code Pt. 2, R. 96105 ASSESSMENT APHASIA W/INTERP & REPORT PER HOUR 174.64 XXX N   ★

20 Miss. Admin. Code Pt. 2, R. 96110 Rule 96110

DEVELOPMENTAL SCREEN W/SCORING & DOC STD INSTRM 18.29 XXX N 136.24   ★

20 Miss. Admin. Code Pt. 2, R. 96112 DEVELOPMENTAL TST ADMIN PHYS/QHP 1ST HOUR 225.97 XXX N 383.81   ★

20 Miss. Admin. Code Pt. 2, R. 96113 DEVELOPMENTAL TST ADMIN PHYS/QHP EA ADDL 30 MIN 103.84 ZZZ N   ★

20 Miss. Admin. Code Pt. 2, R. 96116 NEUROBEHAVIORAL STATUS XM PHYS/QHP 1ST HOUR 163.43 XXX N 383.81

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   ★

20 Miss. Admin. Code Pt. 2, R. 96121 Rule 96121

NEUROBEHAVIORAL STATUS XM PHYS/QHP EA ADDL HOUR 136.88 ZZZ N   ★ 96125 STANDARDIZED COGNITIVE PERFORMANCE TESTING 184.08 XXX N   ★ 96127 BEHAV ASSMT W/SCORE & DOCD/STAND INSTRUMENT 8.85 XXX N 49.09   ★ 96130 PSYCHOLOGICAL TST EVAL SVC PHYS/QHP FIRST HOUR 207.09 XXX N 383.81   ★ 96131 PSYCHOLOGICAL TST EVAL SVC PHYS/QHP EA ADDL HOUR 153.99 ZZZ N   ★

20 Miss. Admin. Code Pt. 2, R. 96132 Rule 96132

NEUROPSYCHOLOGICAL TST EVAL PHYS/QHP 1ST HOUR 225.97 XXX N 383.81   ★

20 Miss. Admin. Code Pt. 2, R. 96133 NEUROPSYCHOLOGICAL TST EVAL PHYS/QHP EA ADDL HR 175.23 ZZZ N   ★

20 Miss. Admin. Code Pt. 2, R. 96136 PSYL/NRPSYCL TST PHYS/QHP 2+ TST 1ST 30 MIN 78.47 XXX N 163.53   ★

20 Miss. Admin. Code Pt. 2, R. 96137 PSYCL/NRPSYCL TST PHYS/QHP 2+ TST EA ADDL 30 MIN 72.57 ZZZ N   ★

20 Miss. Admin. Code Pt. 2, R. 96138 PSYCL/NRPSYCL TST TECH 2+ TST 1ST 30 MIN 63.72 XXX N 393.60   ★

20 Miss. Admin. Code Pt. 2, R. 96139 Rule 96139

PSYCL/NRPSYCL TST TECH 2+ TST EA ADDL 30 MIN 63.72 ZZZ N   96146 PSYCL/NRPSYCL TST ELEC PLATFORM AUTO RESULT 3.54 XXX N 35.83   ★

20 Miss. Admin. Code Pt. 2, R. 96156 Rule 96156

HEALTH BEHAVIOR ASSESSMENT/RE-ASSESSMENT 166.38 XXX N 108.52   ★ 96158 HEALTH BEHAVIOR IVNTJ INDIV F2F 1ST 30 MIN 114.46 XXX N 108.52   ★ 96159 HEALTH BEHAVIOR IVNTJ INDIV F2F EA ADDL 15 MIN 38.94 ZZZ N   ★ 96160 PT-FOCUSED HLTH RISK ASSMT SCORE DOC STND INSTRM 5.31 ZZZ N 38.11   ★ 96161 CAREGIVER HLTH RISK ASSMT SCORE DOC STND INSTRM 5.31 ZZZ N 38.11   ★

20 Miss. Admin. Code Pt. 2, R. 96164 HEALTH BEHAVIOR IVNTJ GROUP F2F 1ST 30 MIN 17.11 XXX N 38.11   ★

20 Miss. Admin. Code Pt. 2, R. 96165 HEALTH BEHAVIOR IVNTJ GROUP F2F EA ADDL 15 MIN 7.67 ZZZ N   ★

20 Miss. Admin. Code Pt. 2, R. 96167 Rule 96167

HEALTH BEHAVIOR IVNTJ FAM W/PT F2F 1ST 30 MIN 121.54 XXX N 38.11   ★

20 Miss. Admin. Code Pt. 2, R. 96168 HEALTH BEHAVIOR IVNTJ FAM W/PT F2F EA ADD 15 MIN 43.07 ZZZ N   ★

20 Miss. Admin. Code Pt. 2, R. 96170 HEALTH BEHAVIOR IVNTJ FAM W/O PT F2F 1ST 30 MIN 136.88 XXX N   ★

20 Miss. Admin. Code Pt. 2, R. 96171 HEALTH BEHAVIOR IVNTJ FAM W/O PT F2F EA ADDL 15 49.56 ZZZ N   ★

20 Miss. Admin. Code Pt. 2, R. 96202 MLT FAM GROUP BHV MGMT/MODIFICAJ TRAING 1ST 60 41.30 XXX N   ★

20 Miss. Admin. Code Pt. 2, R. 96203 Rule 96203

MLT FAM GROUP BHV MGMT/MODIFICAJ TRAING EA ADDL 10.62 ZZZ N   96360 IV INFUSION HYDRATION INITIAL 31 MIN-1 HOUR 63.13 XXX N 296.68   96361 IV INFUSION HYDRATION EACH ADDITIONAL HOUR 22.42 ZZZ N 58.04   96365 IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR 119.18 XXX N 296.68   96366 IV INFUSION THERAPY PROPHYLAXIS/DX EA HOUR 36.58 ZZZ N 58.04   96367 IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR 52.51 ZZZ N 89.91   96368 IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS 35.40 ZZZ N   96369 SUBCUTANEOUS INFUSION INITIAL 1 HR W/PUMP SET-UP 276.71 XXX N 296.68   96370 SUBCUTANEOUS INFUSION EACH ADDITIONAL HOUR 26.55 ZZZ N 58.04   96371 SUBQ INFUSION ADDITIONAL PUMP INFUSION SITE 108.56 ZZZ N 89.91   96372 THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM 27.73 XXX N 89.91   96373 THERAPEUTIC PROPHYLACTIC/DX NJX INTRA-ARTERIAL 31.27 XXX N 296.68   96374 THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG 68.44 XXX N 296.68   96375 THERAPEUTIC INJECTION IV PUSH EACH NEW DRUG 27.73 ZZZ N 58.04   96376 THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC 63.72 ZZZ N   96377 APPL ON-BODY INJECTOR FOR TIMED SUBQ INJECTION 33.63 XXX N 58.04   96379 UNLISTED THERAPEUTIC PROPH/DX IV/IA NJX/NFS BR XXX N 58.04   96380 ADMN RSV MONOC ANTB SEASONAL DOS IM CNSL PHY/QHP 40.12 XXX N   96381 ADMN RSV MONOCLONAL ANTB SEASONAL DOSE IM NJX 34.81 XXX N   96401 CHEMOTX ADMN SUBQ/IM NON-HORMONAL ANTI-NEO 132.75 XXX N 89.91   96402 CHEMOTX ADMN SUBQ/IM HORMONAL ANTI-NEO 57.82 XXX N 89.91   96405 CHEMOTHERAPY ADMINISTRATION INTRALESIONAL </7 148.09 000 N 89.91

Medicine Services Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 90281-96999, 97597-97610, 97802-97804, 98960-99082, 99151-99199, 99500-99607 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 298 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   96406 CHEMOTHERAPY ADMINISTRATION INTRALESIONAL >7 234.23 000 N 296.68   96409 CHEMOTX ADMN IV PUSH TQ 1/1ST SBST/DRUG 184.08 XXX N 296.68   96411 CHEMOTX ADMN IV PUSH TQ EA SBST/DRUG 100.30 ZZZ N 89.91   96413 CHEMOTX ADMN IV NFS TQ UP 1 HR 1/1ST SBST/DRUG 238.95 XXX N 462.41   96415 CHEMOTHERAPY ADMN IV INFUSION TQ EA HR 50.74 ZZZ N 89.91   96416 CHEMOTX ADMN TQ INIT PROLNG CHEMOTX NFUS PMP 234.82 XXX N 462.41   96417 CHEMOTX ADMN IV NFS TQ EA SEQL NFS TO 1 HR 116.23 ZZZ N 89.91   96420 CHEMOTHERAPY ADMIN INTRA-ARTERIAL PUSH TQ 188.80 XXX N 462.41   96422 CHEMOTHERAPY ADMIN INTRA-ARTERIAL INFUS <1 HR 287.33 XXX N 296.68   96423 CHEMOTHERAPY ADMN INTRAARTERIAL INFUSION EA HR 132.75 ZZZ N 58.04   96425 CHEMOTX ADMN IA NFS >8 HR PRTBLE IMPLTBL PMP 309.16 XXX N 462.41   96440 CHEMOTX ADMN PLEURAL CAVITY REQ&W/THORACNTS 1397.71 000 N 462.41   96446 CHEMOTX ADMN PERTL CAVITY IMPLANTED PORT/CATH 347.51 XXX N 462.41   96450 CHEMOTX ADMN CNS REQ SPINAL PUNCTURE 302.67 000 N 462.41   96521 REFILLING & MAINTENANCE PORTABLE PUMP 243.67 XXX N 296.68   96522 REFILL&MAINTENANCE PUMP DRUG DLVR SYSTEMIC 213.58 XXX N 296.68   96523 IRRIGAJ IMPLNTD VENOUS ACCESS DRUG DELIVERY SYST 46.61 XXX N 80.73   96542 CHEMOTX NJX SUBARACHND/INTRAVENTR RSVR 1/MULT 231.87 XXX N 296.68   96547 INTRAOPERATIVE HIPEC PX FIRST 60 MINUTES 640.15 ZZZ Y   96548 INTRAOPERATIVE HIPEC PX EACH ADDL 30 MINUTES 293.23 ZZZ Y   96549 UNLISTED CHEMOTHERAPY PROCEDURE BR XXX N 58.04   96567 PDT DSTR PRMLG LES SKN ILLUM/ACTIVJ PER DAY 237.48 XXX N 260.43   96570 PDT NDSC ABL ABNOR TISS VIA ACTIVJ RX 30 MIN 89.09 ZZZ N   96571 PDT NDSC ABL ABNOR TISS VIA ACTIVJ RX A 15 MIN 48.97 ZZZ N   96573 PDT DSTR PRMLG LES SKN ILLUM/ACTIVJ BY PHYS/QHP 386.75 000 N 260.43   96574 DEBRIDEMENT PRMLG HYPERKERATOTIC LES W/PDT 491.91 000 N 260.43   96900 ACTINOTHERAPY ULTRAVIOLET LIGHT 41.39 XXX N 49.09   96902 MCRSCP XM HAIR PLUCK/CLIP FOR CNTS/STRUCT ABNORM 40.12 XXX N   96904 WHOLE BODY INTEGUMENTARY PHOTOGRAPHY 123.49 XXX N   96910 PHOTOCHEMOTX TAR&UVB/PETROLATUM/UVB 206.50 XXX N 80.73   96912 PHOTOCHEMOTX PSORALENS&ULTRAVIOLET A PUVA 177.00 XXX N 80.73   96913 PHOTOCHEMOTHERAPY DERMATOSES 4-8 HRS SUPERVISION 265.29 XXX N 501.26   96920 EXCIMER LASER TX PSORIASIS TOT AREA <250 SQ CM 275.53 000 N 260.43   96921 EXCIMER LASER TX PSORIASIS 250-500 SQ CM 300.90 000 N 260.43   96922 EXCIMER LASER TX PSORIASIS >500 SQ CM 409.46 000 N 501.26   96931 RCM CELULR & SUBCELULR SKN IMGNG IMG ACQ I&R 1ST 301.49 XXX N   96932 RCM CELULR & SUBCELULR SKN IMGNG IMG ACQUISITION 225.38 XXX N 25.85   96933 RCM CELULR & SUBCELULR SKN IMGNG I&R 1ST LES 77.88 XXX N   96934 RCM CELULR & SUBCELULR SKN IMGNG IMG ACQ I&R ADD 185.91 ZZZ N   96935 RCM CELULR & SUBCELULR SKN IMGNG IMG ACQ EA ADDL 85.49 ZZZ N   96936 RCM CELULR & SUBCELULR SKN IMGNG I&R EA ADDL 74.34 ZZZ N   96999 UNLISTED SPECIAL DERMATOLOGICAL SERVICE/PX BR XXX N 260.43   970XX For codes 97010-97546, please see the Therapeutic Services section.

  97597 DEBRIDEMENT OPEN WOUND FIRST 20 SQ CM/< 156.49 000 N 260.43   97598 DEBRIDEMENT OPN WND EA ADDL 20 SQ CM/PRT THEREOF 49.06 ZZZ N

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   97602 RMVL DEVITAL TISS N-SLCTV DBRDMT W/O ANES 1 SESS 56.51 XXX N 260.43   97605 NEGATIVE PRESSURE WOUND THERAPY DME <= 50 SQ CM 73.75 XXX N 260.43   97606 NEGATIVE PRESSURE WOUND THERAPY DME >50 SQ CM 87.32 XXX N 501.26   97607 NEG PRESSURE WOUND THERAPY NON DME <= 50 SQ CM 114.26 XXX N 501.26   97608 NEG PRESSURE WOUND THERAPY NON DME >50 SQ CM 120.47 XXX N 501.26   97610 LOW FREQUENCY NON-THERMAL ULTRASOUND PER DAY 396.82 XXX N 260.43   977XX For codes 97750-97799, please see the Therapeutic Services section.

  ★

20 Miss. Admin. Code Pt. 2, R. 97802 MEDICAL NUTRITION ASSMT&IVNTJ INDIV EACH 15 MI 63.72 XXX N   ★

20 Miss. Admin. Code Pt. 2, R. 97803 MEDICAL NUTRITION RE-ASSMT&IVNTJ INDIV EA 15 M 55.46 XXX N   ★

20 Miss. Admin. Code Pt. 2, R. 97804 Rule 97804

MEDICAL NUTRITION THERAPY GRP2/ INDIV EA 30 MI 29.50 XXX N   9781X For codes 97810-97814, please see the Therapeutic Services section.

 

980XX For codes 98000-98016, please see the Evaluation and Management section

 

989XX For codes 98960-98943, please see the Therapeutic Services section.

  ★

20 Miss. Admin. Code Pt. 2, R. 98960 EDUCATION&TRAINING PT SELF-MGMT NQHP INDIV PT 50.15 XXX N 71.60   ★

20 Miss. Admin. Code Pt. 2, R. 98961 EDUCATION&TRAINING PT SELF-MGMT NQHP 2-4 PTS 23.60 XXX N 41.80   ★

20 Miss. Admin. Code Pt. 2, R. 98962 EDUCATION&TRAINING PT SELF-MGMT NQHP 5-8 PTS 17.70 XXX N 37.20   ★

20 Miss. Admin. Code Pt. 2, R. 98966 TELEPHONE ASSMT&MGMT SVC NQHP EST PT 5-10 MIN 23.01 XXX N   ★

20 Miss. Admin. Code Pt. 2, R. 98967 TELEPHONE ASSMT&MGMT SVC NQHP EST PT 11-20 MIN 44.84 XXX N   ★

20 Miss. Admin. Code Pt. 2, R. 98968 Rule 98968

TELEPHONE ASSMT&MGMT SVC NQHP EST PT 21-30 MIN 66.08 XXX N   98970 NQHP OL DIGITAL ASSMT&MGMT EST PT <7 D 5-10 MIN 20.06 XXX N   98971 NQHP OL DIGITAL ASSMT&MGMT EST PT <7 D 11-20 MIN 35.40 XXX N   98972 NQHP OL DIGITAL ASSMT&MGMT EST PT <7 D 21+ MIN 54.87 XXX N   98975 REMOTE THERAPEUTIC MNTR 1ST SET-UP&PT EDUCAJ EQP 33.04 XXX N 172.32   98976 REM THER MNTR DEV SPLY DATA RESPIR SYS EA 30 D 94.99 XXX N 54.00   98977 REM THER MNTR DEV SPLY DATA MUSCSKEL SYS EA 30 D 94.99 XXX N 54.00   98978 REM THER MNTR DEV SPLY DATA COG BHV THER EA 30 D 69.03 XXX N 49.70   98980 REMOTE THER MNTR TX MGMT PHYS/QHP 1ST 20 MIN 85.55 XXX N   98981 REMOTE THER MNTR TX MGMT PHYS/QHP EA ADDL 20 MIN 69.62 ZZZ N   99000 HANDLG&/OR CONVEY OF SPEC FOR TR OFFICE TO LAB 12.39 XXX N 21.81   99001 HANDLG&/OR CONVEY OF SPEC FOR TR FROM PT TO LAB 20.06 XXX N 25.67   99002 HANDLE/CONVEY/ANY OTH SVC DEVICE FIT PHYS/QHP 15.93 XXX N   99024 POSTOP FOLLOW UP VISIT RELATED TO ORIGINAL PX 50.89 XXX N   99026 HOSPITAL MANDATED CALL SERVICE IN-HOSPITAL EA HR 21.71 XXX N   99027 HOSPITAL MANDATED CALL SVC OUT-OF-HOSPITAL EA HR 25.37 XXX N   99050 SERVICES PROVIDED OFFICE OTH/THN REG SCHED HOURS 31.27 XXX N   99051 SVC PRV OFFICE REG SCHEDD EVN WKEND/HOLIDAY HRS 31.27 XXX N   99053 SERVICES PROVIDED BTW 10 PM&8 AM AT 24-HR FACI 37.76 XXX N   99056 SVC TYPICAL PRV OFFICE PRV OUT OFFICE REQUEST PT 18.88 XXX N   99058 SVC PRV EMER BASIS IN OFFICE DISRUPTING SVCS 46.61 XXX N   99060 SVC PRV EMER OUT OFFICE DISRUPTS OFFICE SVC 157.53 XXX N   99070 SUPPLIES&MATERIALS ABOVE/BEYOND PROV BY PHYS/QHP BR XXX N   99071 EDUCATIONAL SUPPLIES PRV BY THE PHYS AT COST 0.00 XXX N   99072 ADDL SUPL MATRL&STAF TM DRG PHE RES-TR NFCT DS 12.39 XXX N   99075 MEDICAL TESTIMONY BR XXX N

Medicine Services Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 90281-96999, 97597-97610, 97802-97804, 98960-99082, 99151-99199, 99500-99607 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 300 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg APC MAR   99078 PHYS/QHP EDUCATION SVCS RENDERED PTS GRP SETTING 0.00 XXX N   99080 SPEC REPORTS > USUAL MED COMUNICAJ/STAND RPRTG 100.11 XXX N   99082 UNUSUAL TRAVEL BR XXX N   99091 For code 99091, please see the Evaluation and Management section

  991XX For codes 99100-99140, please see the Anesthesia section.  

20 Miss. Admin. Code Pt. 2, R. 99151 MOD SED SAME PHYS/QHP INITIAL 15 MINS <5 YRS 125.08 XXX N  

20 Miss. Admin. Code Pt. 2, R. 99152 Rule 99152

MOD SED SAME PHYS/QHP INITIAL 15 MINS 5/> YRS 89.09 XXX N   99153 MOD SED SAME PHYS/QHP EACH ADDL 15 MINS 18.88 ZZZ N   99155 MOD SED OTHER PHYS/QHP INITIAL 15 MINS <5 YRS 149.86 XXX N   99156 MOD SED OTHER PHYS/QHP INITIAL 15 MINS 5/> YRS 132.16 XXX N   99157 MOD SED OTHER PHYS/QHP EACH ADDL 15 MINS 107.38 ZZZ N   99170 ANOGENITAL XM MAGNIFY CHILD/SUSPECT TRAUMA W IMG 282.61 000 N 247.07   99172 VISUAL FUNCT SCRNG AUTO SEMI-AUTO BI QUAN DETERM 25.96 XXX N 60.05   99173 SCREENING TEST VISUAL ACUITY QUANTITATIVE BILAT 5.31 XXX N 46.35   99174 INSTRUMENT BASED OCULAR SCR BI W/RMT ANAL & RPT 10.03 XXX N   99175 IPECAC/SIMILAR ADMN EMESIS&OBS STOMACH EMPTIED 49.53 XXX N   99177 INSTRUMENT BASED OCULAR SCR BI W/ONSITE ANALYSIS 8.26 XXX N   99183 PHYS/QHP ATTN&SUPVJ HYPRBARIC OXYGEN TX/SESSION 185.26 XXX N   99184 INITIAT SELECTIVE HEAD/BODY HYPOTHERMIA NEONATE 375.24 XXX N   99188 APPLICATION TOPICAL FLUORIDE VARNISH BY PHS/QHP 20.65 XXX N 1319.39   99190 ASSEMBLY&OPERJ PUMP OXYGENATOR/HEAT EXCH EA HR 530.41 XXX N   99191 ASSEMBLY&OPERJ PUMP OXYGENATOR/HEAT EXCH 45 MI 410.05 XXX N   99192 ASSEMBLY&OPERJ PUMP OXYGENATOR/HEAT EXCH 30 MI 271.40 XXX N   99195 PHLEBOTOMY THERAPEUTIC SEPARATE PROCEDURE 177.59 XXX N 163.53   99199 UNLISTED SPECIAL SERVICE PROCEDURE/REPORT BR XXX N   992XX For codes 99201-99499, please see the Evaluation and Management section.

  99500 HOME VISIT PRENATAL MONITORING & ASSESSMENT 74.64 XXX N   99501 HOME VISIT POSTNATAL ASSMT&F-UP CARE 143.84 XXX N   99502 HOME VISIT NEWBORN CARE & ASSESSMENT 114.67 XXX N   99503 HOME VISIT RESPIRATORY THERAPY CARE 75.52 XXX N   99504 HOME VISIT MECHANICAL VENTILATION CARE 160.80 XXX N   99505 HOME VISIT STOMA CARE&MAINT CLST&CSTOST 30.09 XXX N   99506 HOME VISIT INTRAMUSCULAR INJECTIONS 86.17 XXX N   99507 HOME VISIT CARE&MAINT CATH 114.67 XXX N   99509 HOME VISIT ASSISTANCE DAILY LIV&PRSONAL CARE 2.04 XXX N   99510 HOME VISIT INDIV FAM/MARRIAGE COUNSELING 126.26 XXX N   99511 HOME VISIT FECAL IMPACTION MGMT&ENEMA ADMN 75.99 XXX N   99512 HOME VISIT HEMODIALYSIS 488.52 XXX N   99600 UNLISTED HOME VISIT SERVICE/PROCEDURE BR XXX N   99601 HOME NFS/SPECIALTY DRUG ADMN PER VISIT <2 HR 111.95 XXX N   99602 HOME NFS/SPECIALTY DRUG ADMN PR VST<2 HR EA ADDL 71.92 XXX N   99605 MEDICATION THERAPY INITIAL 15 MIN NEW PATIENT 47.20 XXX N 97.48   99606 MEDICATION THERAPY INITIAL 15 MIN ESTABLISHED PT 20.35 XXX N 44.76   99607 MEDICATION THERAPY EACH ADDITIONAL 15 MIN 33.25 XXX N 55.19

CPT Copyright 2021 2024 American Medical Association. All rights reserved. 301 THERAPEUTIC SERVICES All services performed by health care professionals must meet the standards of practice and requirements as established by the applicable state licensing and regulatory agency that governs licensure of the provider in the state of Mississippi. Note: Rules used by all physicians or other qualified health care professionals (OQHP) in reporting their services are presented in the General Rules section. See the Modifier and Code Rules section for detailed information on modifiers. I.SCOPE A. Therapeutic Services. Therapeutic services are an integral part of the healing process for a variety of injured workers. Recognizing this, the Fee Schedule includes codes for physical medicine, modalities, procedures, tests, and measurements in the Therapeutic Services section representing specific therapeutic procedures performed by licensed physicians and other qualified health care professionals including chiropractors, licensed physical therapists, licensed occupational therapists, and speech-language pathologists. B. Selection of Providers. Physical or occupational therapy, including work hardening, functional capacity evaluations, chronic pain programs, or massage therapy shall be provided upon referral from a physician or OQHP. In the absence of specific direction from the treating or prescribing physician or OQHP, the selection of a provider for these services shall be made by the payer in consultation with the treating or prescribing physician or OQHP. No party, in attempting to negotiate a repricing or other post treatment price reduction agreement, shall state or imply that consent to such an agreement is mandatory, or that the failure to enter into any such agreement may result in audit, delay of payment, or other adverse consequence. If the MWCC determines that any party, or other person in privity therewith, has made such false or misleading statements in an effort to coerce another party’s consent to a repricing or other price reduction agreement outside the Fee Schedule, the MWCC may refer the matter to the appropriate authorities to consider whether such conduct warrants criminal prosecution under §71-3-69 of the Workers’ Compensation Law. C. Physical Medicine Assessment 1. An assessment must be performed to determine if an injured worker will benefit from therapeutic services. 2. When a physician or OQHP examines an injured worker and an assessment for therapeutic services is performed, the billing for the office visit includes the therapeutic assessment. 3. Procedure codes 97161–97163 are used for an initial assessment by physical therapists. Code 97164 is used for re-evaluation of an injured worker by physical therapists. Procedure codes 97165–97167 are used for an initial assessment by occupational therapists. Code 97168 is used for re-evaluation of an injured worker by occupational therapists. Procedure codes from 92521–92524 are used for an initial or subsequent assessment by a speech-language pathologist. D. Plan of Care 1. An initial plan of care must be developed and filed with the payer regardless of whether therapy is provided by a physician, OQHP or eligible practicing therapist. The content of the plan of care, at a minimum, should contain: a. The specific therapies to be provided, including the frequency and duration of each; b. The estimated duration of the therapeutic regimen; and c. The potential degree of restoration; and measurable goals (e.g., potential restoration is good, poor, low, guarded). 2. The initial plan of care must be signed by the treating physician or OQHP and submitted to the payer within fourteen (14) days of approval. Physicians or OQHPs are required to sign the plan of care for physical and/or occupational therapy or speech-language pathology. The physician’s or OQHP’s signature indicates approval of the therapy the injured worker is receiving and for the length of time established for the therapy. 3. The physician or OQHP has the responsibility of providing documentation of medical necessity to the payer whenever there are questions regarding the extent of therapy being provided or the appropriateness of the therapy regimen. 4. A plan of care must be updated at least every thirty (30) days and submitted to the payer. 5. Preparation of a care plan for therapy services does not warrant a separate fee. E. Qualifications for Reimbursement 1. The injured worker’s condition must have the potential for restoration of function. 2. The treatment must be ordered by the authorized attending or treating physician or OQHP. 3. The treatment must be specific to the injury and have the potential to improve the injured worker’s condition. 4. The physician, OQHP, or therapist must be on- site during the provision of services or providing the services via telemedicine.

Therapeutic Services Mississippi Workers’ Compensation Medical Fee Schedule

20 Miss. Admin. Code Pt. 2, R. 302 Rule 302

CPT Copyright 2024 American Medical Association. All rights reserved. II. REIMBURSEMENT A. Rules 1. Visits for therapy may not exceed one visit per day without prior authorization from the payer. 2. Therapy exceeding fifteen (15) visits or thirty (30) days, whichever comes first, must have prior authorization from the payer for continuing care. It must meet the following: a. The treatment must be medically necessary. b. Documentation should be made in the injured worker’s medical record indicating that prior authorization was obtained for the continued therapy. 3. Reimbursement is limited to no more than four (4) therapy units concurrently at the same visit. In the event of multiple treatment areas, an additional four (4) therapy units per treatment day may be allowed at the payer’s discretion and with prior authorization. In the event of multiple treatment areas, the second and subsequent areas are subject to the multiple procedure rule. 4. Payment for 97010, which reports application of hot or cold packs, is bundled into payment for other services. Separate reimbursement for hot and cold packs will not be allowed in the treatment of work-related injury/illness. 5. Only one (1) work hardening or work conditioning program is reimbursed per injury. 6. The Physical Therapist Assistant or Occupational Therapist Assistant shall be reimbursed at eighty-five percent (85%) of the maximum allowable for the procedure. Mississippi modifier “M3” should be attached to the appropriate CPT ®

code(s) when billing services rendered by a Physical Therapist Assistant or an Occupational Therapist Assistant. 7. NCCI edits or other bundle/unbundle edits do not apply to the CPT codes in the Therapeutic Services section, other than the stated rules provided in this section. 8. There is no requirement of time in/time out on therapy notes. B. Treatment Areas 1. Spinal areas are recognized as the following five distinct regions: • Cranial; • Cervical; • Thoracic; • Lumbar; and • Sacral. Transitional areas of the spine are not recognized as distinctly different areas (e.g., cervicothoracic, lumbosacral). 2. Pelvis 3. Upper extremity (either left or right) is recognized as the following six distinct regions: • Shoulder; • Upper arm; • Elbow; • Forearm; • Wrist; and • Hand 4. Lower extremity (either left or right) is recognized as the following eight distinct regions: • Hip; • Thigh; • Knee; • Calf; • Ankle; and • Foot 5. Rib cage 6. Anterior trunk C. Tests and Measurements 1. Functional capacity evaluation (FCE) must have prior authorization from the payer before scheduling the tests. D. Fabrication of Orthotics and Prosthetics 1. The applicable procedure code 97760 or 97761 must be billed for the professional services of a physician, OQHP, or therapist to fabricate orthotics or prosthetics. 2. Orthotics, prosthetics, and related supplies used may be billed under the appropriate HCPCS code. The maximum reimbursement allowance is listed in the HCPCS section of the Fee Schedule. For orthotics and supplies not listed in the HCPCS section, use CPT code 99070. Reimbursement may not exceed a twenty percent (20%) mark-up of the provider’s cost and an invoice may be required by the payer before reimbursement is made for items without an allowable amount in the Fee Schedule. E. Re-evaluation of an Established Patient A physician, OQHP, physical therapist, occupational therapist, or speech and language therapist may charge and be reimbursed for a re-evaluation for therapeutic services only if new symptoms present the need for re-examination and evaluation as follows: 1. There is a definitive change in the injured worker’s condition; 2. The injured worker fails to respond to treatment and there is a need to change the treatment plan; and 3. The injured worker has completed the therapy regimen and is ready to receive discharge instructions.

Mississippi Workers’ Compensation Medical Fee Schedule Therapeutic Services

CPT Copyright 2024 American Medical Association. All rights reserved. 303 III. WORK HARDENING RULES A. Work Hardening Program 1. Work hardening is an interdisciplinary, individualized, job or goal-specific program of activity with the goal of returning an injured worker to work. Work hardening programs use real or simulated work tasks and progressively graded conditioning exercises that are based on the injured worker’s measured tolerances. Work hardening provides a transition between acute care and successful return to work and is designed to improve the bio-mechanical, neuromuscular, and cardiovascular functioning of the injured worker. Prior authorization must be based on whether the proposed work hardening program appears reasonably tailored to accomplish the stated goals. a. A work hardening program must, at a minimum, have the following components: • Development of strength and endurance of the injured worker in relation to the return to work goal; • Equipment and methods that quantify and measure strength and conditioning levels, i.e., ergometers, dynamometers, treadmills, measured walking tolerances; • Commercial strength and exercise devices, free weights, and circuit training. Goals for each injured worker are dependent on the demands of their respective jobs; • Simulation of the critical work demands, the tasks, and the environment of the job to which the worker will return. Job simulation tasks that provide for progression in frequency, load, and duration are essential. They must be related to the work goal and include a variety of work stations that offer opportunities to practice work related positions and motions, i.e., clerical, plumbing, electrical; • Education that stresses body mechanics, work pacing, safety and injury prevention, and that promotes worker responsibility and self- management. The education component requires direct therapist and worker interaction; • Assessment of the need for job modifications. Focus on whether the injured worker can return to the stated job goal but only with changes, i.e., added equipment, changes in work position or ergonomics, changes at the work site; • An individualized written plan that identifies observable and measurable goals, the methodology being used to reach these goals, the projected time necessary to accomplish the goal, and the expected outcomes. This plan must be signed by both the provider and the injured worker; • This plan needs to be based on a functional capacity (baseline) evaluation and must be completed within the first two (2) days of the program and compared to the critical demands as stated on the job analysis. A comparative analysis (re-evaluation) is done prior to discharge to determine job readiness; • A reporting system that includes: - Documentation of the initial plan; - Documentation of progress or lack of progress and future goals; - A discharge summary that includes an assessment of the functional capacity level and the achievement of the injured worker’s program goals; and - A record of the injured worker’s daily attendance including number of days and number of hours per day in the program. 2. Criteria for admission: a. The injured worker must have reached a point in his or her recovery where no further active or invasive treatment intervention is being anticipated; b. Physical recovery sufficient to allow participation for a minimum of four (4) hours a day for three to five days a week; c. Injured worker’s current levels of functioning interfere with his/her ability to carry out specific tasks required in the workplace; and d. A defined return to work goal which includes: • A documented specific job to which the injured worker can return, along with a specific job analysis; • A documented agreement of goals between the employer and the injured worker; • Documentation that shows how the injured worker will benefit from the program; and • Facts that show the injured worker is motivated to return to work. An injured worker whose primary limitation is psychological or clouded by significant illness behavior (i.e., significant self- limitation on FCE) is typically not going to be motivated and will not likely benefit. 3. Criteria for discharge from a work hardening program:

Therapeutic Services Mississippi Workers’ Compensation Medical Fee Schedule

20 Miss. Admin. Code Pt. 2, R. 304 Rule 304

CPT Copyright 2024 American Medical Association. All rights reserved. • Completion of the program (the program should take two (2) to four (4) weeks to complete); • The injured worker has reached the goal stated in the plan; or, • The injured worker has not progressed according to the program plan; • The injured worker has not reached interim goals and is not benefiting from the program; or, • Number of absences exceeds those allowed by the program (a maximum of two (2) absences is recommended); • Injured worker does not adhere to the schedule; • The previously identified job is no longer available. B. Work Hardening Billing 1. In all cases, for both voluntary and non- voluntary discharge, payment is for the actual duration of treatment provided. 2. Work hardening should be billed per session as follows: • Up to two (2) hours, use CPT 97545, “work hardening/conditioning; initial 2 hours” • Each additional hour, use CPT 97546, “work hardening/conditioning; each additional hour (list separately in addition to code for primary procedure)” For example, a work hardening session that lasts for four (4) hours should be billed with one (1) unit of CPT 97545 reflecting the first two hours and two (2) units of CPT 97546 for the additional two (2) hours. IV. FUNCTIONAL CAPACITY EVALUATIONS A. The functional capacity evaluation (FCE) is utilized for the following purposes: 1. To determine the highest level of safe functionality and of maximal medical improvement; 2. To provide a pre-vocational baseline of functional capabilities to assist in the vocational rehabilitation process; 3. To objectively set restrictions and guidelines for return to work; 4. To determine whether specific job tasks can be safely performed by modification of technique, equipment, or by further training; 5. To determine whether additional treatment or referral to a work hardening program is indicated; and 6. To assess outcome at the conclusion of a work hardening program. B. General Requirements 1. The FCE may be ordered only by a licensed physician, or may be required by the payer when indicated. 2. The FCE requires prior authorization by the payer. C. FCE Billing The FCE should be billed using code 97750 - Physical performance test or measurement (e.g., musculoskeletal, functional capacity), with written report, each fifteen (15) minutes. Reimbursement of an FCE is limited to a maximum of twenty (20) units. Documentation must include start and stop times for testing. The report is included in the reimbursement for code 97750. V. TENS UNITS A. TENS (transcutaneous electrical nerve stimulation) and use of neurostimulator devices must be provided under the attending or treating physician’s or OQHP’s prescription. B. Prior authorization from the payer is required before purchase or rental arrangements are made for a TENS unit or a neurostimulator device. The payer has sole right of selection of DME supplier for rental or purchase of equipment, supplies, etc. VI. SUPPLIES, EQUIPMENT, ORTHOTICS, AND PROSTHETICS A. Physicians, OQHPs, and therapists must obtain prior authorization from the payer before purchase/rental of supplies, equipment, orthotics, and prosthetics costing more than four hundred dollars ($400.00) per item or per month for rental for workers’ compensation injured workers, including items billed with HCPCS code E1399. When submitting bills, include the appropriate HCPCS code. If there is not an appropriate HCPCS code, use CPT code 99070.

B. For supplies and equipment requiring prior authorization, including items billed with HCPCS code E1399, charges for related supplies, delivery fees or set up fees will not be reimbursed if prior authorization was not obtained.

C. The payer has sole right of selection of supplier. VII. OTHER INSTRUCTIONS A. Charges will not be reimbursed for publications, books, or digital media unless prior authorization of the payer is obtained. B. All charges for services must be clearly itemized by CPT code, and the state professional license number must be on the bill. C. The treating physician or OQHP must approve and sign all physical capability/restriction forms for the work-related injury/illness. This form must be submitted to the payer within fourteen (14) working days of the release to work.

Mississippi Workers’ Compensation Medical Fee Schedule Therapeutic Services

CPT Copyright 2024 American Medical Association. All rights reserved. 305 D. Documentation may be required by the payer to substantiate the necessity for treatment rendered. Documentation to substantiate charges and reports of tests and measurements are included in the fee for the service and do not warrant additional reimbursement. E. When injured workers do not show measurable progress, the payer may request the physician or OQHP discontinue the treatment or provide documentation to substantiate medical necessity. F. When physical medicine therapies are provided to more than one body area, modifier 51 must be added to the procedure code or codes billed for the additional body area and will be reimbursed according to the multiple procedure rule. VIII. BACK SCHOOLS Back schools are not covered services under this Fee Schedule. IX. MASSAGE THERAPY Massage therapy requires prior authorization from the payer before treatment can be rendered. Medical necessity must be established prior to approval. X. CHIROPRACTIC MANIPULATIVE TREATMENT Chiropractic manipulative treatments are allowed for up to fifteen (15) visits or thirty (30) days, whichever first occurs, without any need to seek prior authorization. However, chiropractic manipulative treatments which are proposed beyond the first fifteen (15) visits or thirty (30) days, under any circumstance, must be pre-certified or prior authorized. Like any other service, a spinal manipulation includes pre-evaluation and post-evaluation that would make it inappropriate to bill with an E/M service. However, if the injured worker’s condition has deteriorated or an injury to another site has occurred, reimbursement can be made for an E/M service if documentation substantiates the separate additional service. Modifier 25 is added to an E/M service when a significant, separately identifiable E/M service is provided and documented as medically necessary. XI. CHRONIC PAIN—INTER-DISCIPLINARY PAIN REHABILITATION PROGRAM A. The Inter-Disciplinary Pain Rehabilitation (IDPR) program is based on the bio-psychosocial approach to managing chronic pain and uses both physical medicine treatments as well as psychological treatments and therapy to manage the chronic pain patient. A goal oriented, team approach is used in an effort to reduce pain, improve functioning, and decrease the dependence on the health care system of injured workers with chronic pain. This is an outpatient program. B. Prior authorization/pre-certification is required in order to utilize an interdisciplinary pain rehabilitation program to treat the chronic pain patient. A specific IDPR program plan must be submitted to the payer as part of the prior authorization process. C. The following guidelines shall be used to assist in prior authorization and concurrent review: 1. Persons considered suitable candidates for an inter-disciplinary pain rehabilitation program are those: a. Who are likely to benefit from the program design; b. Whose symptoms are deemed by a pain management provider to constitute chronic pain syndrome; and c. Whose medical, psychological, or other conditions do not prohibit participation in this program. 2. Mental Health Evaluation an initial evaluation to determine the injured worker’s readiness or suitability for this type of treatment may be performed prior to initiation of treatment. This evaluation is not considered part of the IDPR program and shall be billed separately. 3. Due to the nature of intensity of the program, both group and individual therapy may be part of the IDPR program. If the program plan for a particular injured worker includes individual psychotherapy, it shall be billed as part of the program, and not separately. If the program does not include psychotherapy services, such services may be billed separately, if used, subject to applicable prior authorization requirements. 4. Psychological treatments which are part of the IDPR program may be rendered by a psychiatrist, psychologist, licensed professional counselor, or licensed social worker. 5. The IDPR program shall always include a component designed to reduce the injured worker’s dependence on and/or addiction to pain medications. 6. An individual plan of treatment shall be supervised by a medical doctor within a therapeutic environment. Although some time is spent with a doctor on a one-to-one basis, more than fifty percent (50%) of the time may be spent in direct care under the supervision of the physical therapist, occupational therapist, mental health provider, or other licensed member of the IDPR team. 7. Program supervision shall be provided by a medical doctor who is trained and experienced in the treatment of patients with chronic pain syndrome. The program supervisor shall: a. Provide direct, on-site supervision of the daily pain management activities; b. Participate in the initial and final evaluation of the injured worker; c. Write the treatment plan for the injured worker, and write changes to the plan based on the injured worker’s documented response to the treatment and/or based on documented changes in the injured worker’s condition; and

Therapeutic Services Mississippi Workers’ Compensation Medical Fee Schedule

20 Miss. Admin. Code Pt. 2, R. 306 Rule 306

CPT Copyright 2024 American Medical Association. All rights reserved. d. Direct the members of the IDPR team and review the injured worker’s progress on a regular and consistent basis, at least bi- weekly. 8. Participation in an IDPR program requires a minimum attendance of four (4) hours per day during the first week. The program shall not exceed eight (8) hours per day, except that workers who actually have experience working in a job for more than eight (8) hours per day may be allowed to participate for up to ten (10) hours per day, at the discretion of the program supervisor. 9. Daily treatment and injured worker’s response shall be documented and provided to the payer at least every two (2) weeks. 10. Discharge/exit criteria shall include but not be limited to: a. The appropriate use of medications; b. Decreased intensity of subjective pain; c. Increased ability of the injured worker to manage pain; d. Reduced health care use related to the chronic pain; e. Return to work; and/or f. Non-compliance with the program, or failure to obtain meaningful benefit after a reasonable period of time. D. IDPR Billing The IDPR program shall be billed using CPT 97799 - Unlisted physical medicine/rehabilitation service or procedure, and appended with modifier M5 to indicate chronic pain treatment. The total number of hours shall be indicated in the units column of the bill, or in some other conspicuous place on the bill. CARF accredited providers shall also add M4 as an additional modifier. E. Reimbursement Reimbursement shall be as agreed to by the parties, or a maximum of one hundred dollars ($100.00) per hour for CARF accredited providers. Providers without CARF accreditation shall be paid eighty percent (80%) of the maximum reimbursement allowance for CARF accredited providers. Units of less than one hour shall be prorated in fifteen (15) minute increments. A single fifteen (15) minute increment shall be reimbursed if the time is equal to or greater than eight (8) minutes and less than twenty-three (23) minutes.

Mississippi Workers’ Compensation Medical Fee Schedule Therapeutic Services 92507—92526, 95836—95852, 97010—97552, Effective June 1, 2026 97750—97799, 97810—98943, 99070 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine CPT Copyright 2024 American Medical Association. All rights reserved. 307

Code Description MAR PC MAR TC MAR FUD Assist Surg  ★

20 Miss. Admin. Code Pt. 2, R. 92507 TX SPEECH LANG VOICE COMMJ&/AUD PROC DO INDIV 133.34 XXX N  ★

20 Miss. Admin. Code Pt. 2, R. 92508 TX SPEECH LANG VOICE COMMJ&/AUD PROC DO GROUP 41.30 XXX N 

20 Miss. Admin. Code Pt. 2, R. 92520 LARYNGEAL FUNCTION STUDIES 143.37 XXX N  ★

20 Miss. Admin. Code Pt. 2, R. 92521 EVALUATION OF SPEECH FLUENCY (STUTTER CLUTTER) 217.80 XXX N  ★

20 Miss. Admin. Code Pt. 2, R. 92522 EVALUATION OF SPEECH SOUND PRODUCTION ARTICULATE 176.41 XXX N  ★

20 Miss. Admin. Code Pt. 2, R. 92523 EVAL SPEECH SOUND PRODUCT LANGUAGE COMPREHENSION 375.89 XXX N  ★

20 Miss. Admin. Code Pt. 2, R. 92524 BEHAVIORAL & QUALIT ANALYSIS VOICE AND RESONANCE 170.30 XXX N  ★

20 Miss. Admin. Code Pt. 2, R. 92526 TX SWALLOWING DYSFUNCTION&/ORAL FUNCJ FEEDING 148.09 XXX N 

20 Miss. Admin. Code Pt. 2, R. 95836 ECOG IMPLANTED BRAIN NPGT W/REC I&R <30 DAYS 185.26 XXX N 

20 Miss. Admin. Code Pt. 2, R. 95851 ROM MEAS&REPRT EA XTR EX HAND/EA TRNK SCTJ SPI 35.99 XXX N 

20 Miss. Admin. Code Pt. 2, R. 95852 ROM MEAS&REPRT HAND W/WO COMPARISON NORMAL SID 31.27 XXX N 

20 Miss. Admin. Code Pt. 2, R. 97010 APPLICATION MODALITY 1/> AREAS HOT/COLD PACKS 0.00 XXX N 

20 Miss. Admin. Code Pt. 2, R. 97012 APPL MODALITY 1/> AREAS TRACTION MECHANICAL 22.68 XXX N 

20 Miss. Admin. Code Pt. 2, R. 97014 APPL MODALITY 1/> AREAS ELEC STIMJ UNATTENDED 22.68 XXX N 

20 Miss. Admin. Code Pt. 2, R. 97016 APPL MODALITY 1/> AREAS VASOPNEUMATIC DEVICES 19.44 XXX N 

20 Miss. Admin. Code Pt. 2, R. 97018 APPL MODALITY 1/> AREAS PARAFFIN BATH 10.80 XXX N 

20 Miss. Admin. Code Pt. 2, R. 97022 APPLICATION MODALITY 1/> AREAS WHIRLPOOL 27.54 XXX N 

20 Miss. Admin. Code Pt. 2, R. 97024 APPLICATION MODALITY 1/> AREAS DIATHERMY 11.34 XXX N 

20 Miss. Admin. Code Pt. 2, R. 97026 APPLICATION MODALITY 1/> AREAS INFRARED 10.26 XXX N 

20 Miss. Admin. Code Pt. 2, R. 97028 APPL MODALITY 1/> AREAS ULTRAVIOLET 12.96 XXX N 

20 Miss. Admin. Code Pt. 2, R. 97032 APPL MODALITY 1+ AREAS ESTIM EA 15 MIN 23.22 XXX N 

20 Miss. Admin. Code Pt. 2, R. 97033 APPL MODALITY 1+ AREAS IONTOPHORESIS EA 15 MIN 31.86 XXX N 

20 Miss. Admin. Code Pt. 2, R. 97034 APPL MODALITY 1+ AREAS CONTRAST BATHS EA 15 MIN 23.22 XXX N 

20 Miss. Admin. Code Pt. 2, R. 97035 APPL MODALITY 1+ AREAS ULTRASOUND EA 15 MIN 22.68 XXX N 

20 Miss. Admin. Code Pt. 2, R. 97036 APPL MODALITY 1+ AREAS HUBBARD TANK EA 15 MIN 54.54 XXX N 

20 Miss. Admin. Code Pt. 2, R. 97037 APPL MODALITY 1+ AREAS LLLT PO PAIN REDUCTION BR XXX N 

20 Miss. Admin. Code Pt. 2, R. 97039 UNLISTED MODALITY SPEC TYPE&TIME CONSTANT ATTN BR XXX N  ★

20 Miss. Admin. Code Pt. 2, R. 97110 THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES 46.98 XXX N  ★

20 Miss. Admin. Code Pt. 2, R. 97112 THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA 54.54 XXX N 

20 Miss. Admin. Code Pt. 2, R. 97113 THER PX 1/> AREAS EACH 15 MIN AQUA THER W/XERSS 59.40 XXX N  ★

20 Miss. Admin. Code Pt. 2, R. 97116 THER PX 1/> AREAS EA 15 MIN GAIT TRAING W/STAIR 46.98 XXX N 

20 Miss. Admin. Code Pt. 2, R. 97124 THER PX 1/> AREAS EACH 15 MINUTES MASSAGE 47.52 XXX N  ★

20 Miss. Admin. Code Pt. 2, R. 97129 THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES 36.18 XXX N  ★

20 Miss. Admin. Code Pt. 2, R. 97130 THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES 35.10 ZZZ N 

20 Miss. Admin. Code Pt. 2, R. 97139 UNLISTED THERAPEUTIC PROCEDURE SPECIFY BR XXX N 

20 Miss. Admin. Code Pt. 2, R. 97140 MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES 43.20 XXX N  ★

20 Miss. Admin. Code Pt. 2, R. 97150 THERAPEUTIC PROCEDURES GROUP 2/> INDIVIDUALS 28.08 XXX N  ★

20 Miss. Admin. Code Pt. 2, R. 97151 BEHAVIOR ID ASSESSMENT BY PHYS/QHP EA 15 MIN 23.22 XXX N  ★

20 Miss. Admin. Code Pt. 2, R. 97152 BEHAVIOR ID SUPPORT ASSMT BY 1 TECH EA 15 MIN 17.82 XXX N  ★

20 Miss. Admin. Code Pt. 2, R. 97153 ADAPTIVE BEHAVIOR TX BY PROTOCOL TECH EA 15 MIN 14.58 XXX N  ★

20 Miss. Admin. Code Pt. 2, R. 97154 GROUP ADAPTIVE BHV TX BY PROTOCOL TECH EA 15 MIN 12.96 XXX N  ★

20 Miss. Admin. Code Pt. 2, R. 97155 ADAPT BHV TX PRTCL MODIFICAJ PHYS/QHP EA 15 MIN 21.06 XXX N  ★

20 Miss. Admin. Code Pt. 2, R. 97156 FAMILY ADAPT BHV TX GDN PHYS/QHP EA 15 MIN 17.82 XXX N  ★

20 Miss. Admin. Code Pt. 2, R. 97157 MULTIPLE FAM GROUP BHV TX GDN PHYS/QHP EA 15 MIN 17.28 XXX N

Therapeutic Services Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 92507—92523, 95836—95852, 97010—97552, 97750—97799, 97810—98943, 99070 + Add-on Procedure  Modifier 51 Exempt Procedure ★ Telemedicine 308 CPT Copyright 2024 American Medical Association. All rights reserved.

Code Description MAR PC MAR TC MAR FUD Assist Surg  ★

20 Miss. Admin. Code Pt. 2, R. 97158 GRP ADAPT BHV PRTCL MODIFCAJ PHYS/QHP EA 15 MIN 13.50 XXX N  ★

20 Miss. Admin. Code Pt. 2, R. 97161 PHYSICAL THERAPY EVALUATION LOW COMPLEX 20 MINS 149.04 XXX N  ★

20 Miss. Admin. Code Pt. 2, R. 97162 PHYSICAL THERAPY EVALUATION MOD COMPLEX 30 MINS 149.04 XXX N  ★

20 Miss. Admin. Code Pt. 2, R. 97163 PHYSICAL THERAPY EVALUATION HIGH COMPLEX 45 MINS 149.04 XXX N  ★

20 Miss. Admin. Code Pt. 2, R. 97164 PHYSICAL THERAPY RE-EVAL EST PLAN CARE 20 MINS 101.22 XXX N  ★

20 Miss. Admin. Code Pt. 2, R. 97165 OCCUPATIONAL THERAPY EVAL LOW COMPLEX 30 MINS 160.22 XXX N  ★

20 Miss. Admin. Code Pt. 2, R. 97166 OCCUPATIONAL THERAPY EVAL MOD COMPLEX 45 MINS 160.22 XXX N  ★

20 Miss. Admin. Code Pt. 2, R. 97167 OCCUPATIONAL THERAPY EVAL HIGH COMPLEX 60 MINS 160.22 XXX N  ★

20 Miss. Admin. Code Pt. 2, R. 97168 OCCUPATIONAL THER RE-EVAL EST PLAN CARE 30 MINS 109.92 XXX N 

20 Miss. Admin. Code Pt. 2, R. 97169 ATHLETIC TRAINING EVAL LOW COMPLEX 15 MINS 0.00 XXX N 

20 Miss. Admin. Code Pt. 2, R. 97170 ATHLETIC TRAINING EVAL MOD COMPLEX 30 MINS 0.00 XXX N 

20 Miss. Admin. Code Pt. 2, R. 97171 ATHLETIC TRAINING EVAL HIGH COMPLEX 45 MINS 0.00 XXX N 

20 Miss. Admin. Code Pt. 2, R. 97172 ATHLETIC TRAINING RE-EVAL EST PLAN CARE 20 MINS 0.00 XXX N  ★

20 Miss. Admin. Code Pt. 2, R. 97530 THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN 61.02 XXX N 

20 Miss. Admin. Code Pt. 2, R. 97533 SENSORY INTEGRATIVE TECHNIQUES EACH 15 MINUTES 75.14 XXX N  ★

20 Miss. Admin. Code Pt. 2, R. 97535 SELF-CARE/HOME MGMT TRAINING EACH 15 MINUTES 52.38 XXX N  ★

20 Miss. Admin. Code Pt. 2, R. 97537 COMMUNITY/WORK REINTEGRATION TRAING EA 15 MIN 50.76 XXX N  ★

20 Miss. Admin. Code Pt. 2, R. 97542 WHEELCHAIR MGMT EA 15 MIN 50.76 XXX N 

20 Miss. Admin. Code Pt. 2, R. 97545 WORK HARDENING/CONDITIONING 1ST 2 HR 141.48 XXX N 

20 Miss. Admin. Code Pt. 2, R. 97546 WORK HARDENING/CONDITIONING EACH HOUR 66.42 ZZZ N  ★

20 Miss. Admin. Code Pt. 2, R. 97550 CAREGIVER TRAINING STRATEGIES&TQ 1ST 30 MINUTES 85.86 XXX N  ★

20 Miss. Admin. Code Pt. 2, R. 97551 CAREGIVER TRAINING STRATEGIES&TQ EA ADDL 15 MIN 42.66 ZZZ N  ★

20 Miss. Admin. Code Pt. 2, R. 97552 GROUP CAREGIVER TRAINING STRATEGIES & TECHNIQUE 36.18 XXX N  ★

20 Miss. Admin. Code Pt. 2, R. 97750 PHYSICAL PERFORMANCE TEST/MEAS W/REPRT EA 15 MIN 53.46 XXX N  ★

20 Miss. Admin. Code Pt. 2, R. 97755 ASSTV TECHNOL ASSMT DIR CNTCT W/REPRT EA 15 MIN 60.48 XXX N  ★

20 Miss. Admin. Code Pt. 2, R. 97760 ORTHOTICS MGMT & TRAING INITIAL ENCTR EA 15 MINS 77.76 XXX N  ★

20 Miss. Admin. Code Pt. 2, R. 97761 PROSTHETICS TRAINING INITIAL ENCTR EA 15 MINS 66.42 XXX N  ★

20 Miss. Admin. Code Pt. 2, R. 97763 ORTHOTICS/PROSTH MGMT &/TRAING SBSQ ENCTR 15 MIN 86.40 XXX N 

20 Miss. Admin. Code Pt. 2, R. 97799 UNLISTED PHYSICAL MEDICINE/REHAB SERVICE/PX BR XXX N 

20 Miss. Admin. Code Pt. 2, R. 97810 ACUPUNCTURE 1/> NDLS W/O ESTIM 1ST 15 MIN 62.64 XXX N 

20 Miss. Admin. Code Pt. 2, R. 97811 ACUPUNCTURE 1/> NDLS W/O ESTIM EACH ADDL 15 MIN 46.98 ZZZ N 

20 Miss. Admin. Code Pt. 2, R. 97813 ACUPUNCTURE 1/> NDLS W/ESTIM 1ST 15 MIN 70.17 XXX N 

20 Miss. Admin. Code Pt. 2, R. 97814 ACUPUNCTURE 1/> NDLS W/ESTIM EACH ADDL 15 MIN 56.51 ZZZ N 

20 Miss. Admin. Code Pt. 2, R. 98925 OSTEOPATHIC MANIPULATIVE TX 1-2 BODY REGIONS 54.87 000 N 

20 Miss. Admin. Code Pt. 2, R. 98926 OSTEOPATHIC MANIPULATIVE TX 3-4 BODY REGIONS 77.29 000 N 

20 Miss. Admin. Code Pt. 2, R. 98927 OSTEOPATHIC MANIPULATIVE TX 5-6 BODY REGIONS 100.89 000 N 

20 Miss. Admin. Code Pt. 2, R. 98928 OSTEOPATHIC MANIPULATIVE TX 7-8 BODY REGIONS 123.90 000 N 

20 Miss. Admin. Code Pt. 2, R. 98929 OSTEOPATHIC MANIPULATIVE TX 9-10 BODY REGIONS 146.91 000 N 

20 Miss. Admin. Code Pt. 2, R. 98940 CHIROPRACTIC MANIPULATIVE TX SPINAL 1-2 REGIONS 47.79 000 N 

20 Miss. Admin. Code Pt. 2, R. 98941 CHIROPRACTIC MANIPULATIVE TX SPINAL 3-4 REGIONS 68.44 000 N 

20 Miss. Admin. Code Pt. 2, R. 98942 CHIROPRACTIC MANIPULATIVE TX SPINAL 5 REGIONS 89.68 000 N 

20 Miss. Admin. Code Pt. 2, R. 98943 CHIROPRACTIC MANIPLTV TX EXTRASPINAL 1/> REGION 46.02 XXX N 

20 Miss. Admin. Code Pt. 2, R. 99070 SUPPLIES&MATERIALS ABOVE/BEYOND PROV BY PHYS/QHP BR XXX N   

DENTAL I. SCOPE The dental procedure codes included in the 2025 Mississippi Workers’ Compensation Medical Fee Schedule are obtained from the Code on Dental Procedures and Nomenclature (CDT Code) which is published in CDT 2025: Current Dental Terminology, American Dental Association (ADA). All Rights Reserved. CDT codes are five-character codes beginning with “D” and followed by four numeric digits. Billing for dental services should be submitted on the ADA Dental Claim Form. II. GUIDELINES A. Treatments provided for work-related dental injuries not specifically contained in the Fee Schedule should be billed using CDT code D9999 “Unspecified Adjunctive Procedure, By Report.” B. Billing: Dental services should be itemized on the bill by CDT code. C. By Report (BR): “BR” in the MAR column indicates services that are too new, unusual, or variable in the nature of their performance to permit the assignment of a definable fee. Such services should be substantiated by documentation submitted with the bill. Sufficient information should be included to permit proper identification and a sound evaluation. For more information, please see Definitions in the Introduction.

D. Dental Providers: The following dental providers, licensed in the state where they practice, may be paid for dental services: 1. Dentists 2. Oral and maxillofacial surgeons 3. Orthodontists 4. Hospitals 5. Dental clinics Services provided by other dental practitioners, including hygienists and dental assistants, must be billed by the licensed dentist, orthodontist or oral surgeon overseeing these practitioners. E. Laboratory Procedures: Reimbursement for laboratory procedures is included in the maximum allowable reimbursement for the associated dental procedure. F. Modifiers: Dental codes do not contain modifiers.

Dental Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 D0120—D9999

20 Miss. Admin. Code Pt. 2, R. 310 Rule 310

The Code on Dental Procedures and Nomenclature is published in Current Dental Terminology (CDT). Copyright © American Dental Association (ADA). All rights reserved. Fee Data © FAIR Health, Inc. All rights reserved.

Code Description MAR   D0120 PERIODIC ORAL EVALUATION - ESTABLISHED PATIENT 52.00   D0140 LIMITED ORAL EVALUATION - PROBLEM FOCUSED 78.00   D0145 ORAL EVALUATION FOR A PATIENT UNDER THREE YEARS OF AGE AND COUNSELING WITH PRIMARY CAREGIVER 74.75   D0150 COMPREHENSIVE ORAL EVALUATION - NEW OR ESTABLISHED PATIENT 87.00   D0160 DETAILED AND EXTENSIVE ORAL EVALUATION PROBLEM FOCUSED, BY REPORT BR   D0170 RE-EVALUATION - LIMITED, PROBLEM FOCUSED (ESTABLISHED PATIENT; NOT POST-OPERATIVE VISIT) 79.35   D0171 RE-EVALUATION POST-OPERATIVE OFFICE VISIT 64.00   D0180 COMPREHENSIVE PERIODONTAL EVALUATION NEW OR ESTABLISHED PATIENT 109.00   D0190 SCREENING OF A PATIENT 40.00   D0191 ASSESSMENT OF A PATIENT 34.50   D0210 INTRAORAL COMPREHENSIVE SERIES OF RADIOGRAPHIC IMAGES 144.00   D0220 INTRAORAL - PERIAPICAL FIRST RADIOGRAPHIC IMAGE 30.00   D0230 INTRAORAL - PERIAPICAL EACH ADDITIONAL RADIOGRAPHIC IMAGE 25.00   D0240 INTRAORAL - OCCLUSAL RADIOGRAPHIC IMAGE 40.00   D0250 EXTRA-ORAL 2D PROJECTION RADIOGRAPHIC IMAGE CREATED USING A STATIONARY RADIATION SOURCE, AND DETECTOR 49.00   D0251 EXTRA-ORAL POSTERIOR DENTAL RADIOGRAPHIC IMAGE 40.25   D0270 BITEWING - SINGLE RADIOGRAPHIC IMAGE 30.00   D0272 BITEWINGS - TWO RADIOGRAPHIC IMAGES 45.00   D0273 BITEWINGS - THREE RADIOGRAPHIC IMAGES 55.00   D0274 BITEWINGS - FOUR RADIOGRAPHIC IMAGES 65.00   D0277 VERTICAL BITEWINGS - 7 TO 8 RADIOGRAPHIC IMAGES 92.00   D0310 SIALOGRAPHY 446.67   D0320 TEMPOROMANDIBULAR JOINT ARTHROGRAM, INCLUDING INJECTION 789.11   D0321 OTHER TEMPOROMANDIBULAR JOINT RADIOGRAPHIC IMAGES, BY REPORT BR   D0322 TOMOGRAPHIC SURVEY 640.22   D0330 PANORAMIC RADIOGRAPHIC IMAGE 115.00   D0340 2D CEPHALOMETRIC RADIOGRAPHIC IMAGE ACQUISITION, MEASUREMENT AND ANALYSIS 100.00   D0350 2D ORAL/FACIAL PHOTOGRAPHIC IMAGE OBTAINED INTRA-ORALLY OR EXTRA-ORALLY 57.50   D0364 CONE BEAM CT CAPTURE AND INTERPRETATION WITH LIMITED FIELD OF VIEW LESS THAN ONE WHOLE JAW 224.25   D0365 CONE BEAM CT CAPTURE AND INTERPRETATION WITH FIELD OF VIEW OF ONE FULL DENTAL ARCH MANDIBLE 212.75   D0366 CONE BEAM CT CAPTURE AND INTERPRETATION WITH FIELD OF VIEW OF ONE FULL DENTAL ARCH MAXILLA, WITH OR WITHOUT CRANIUM 318.50   D0367 CONE BEAM CT CAPTURE AND INTERPRETATION WITH FIELD OF VIEW OF BOTH JAWS; WITH OR WITHOUT CRANIUM 300.00   D0368 CONE BEAM CT CAPTURE AND INTERPRETATION FOR TMJ SERIES INCLUDING TWO OR MORE EXPOSURES 367.76   D0369 MAXILLOFACIAL MRI CAPTURE AND INTERPRETATION 208.44   D0370 MAXILLOFACIAL ULTRASOUND CAPTURE AND INTERPRETATION 119.11   D0371 SIALOENDOSCOPY CAPTURE AND INTERPRETATION BR   D0372 INTRAORAL TOMOSYNTHESIS COMPREHENSIVE SERIES OF RADIOGRAPHIC IMAGES BR   D0373 INTRAORAL TOMOSYNTHESIS BITEWING RADIOGRAPHIC IMAGE BR   D0374 INTRAORAL TOMOSYNTHESIS PERIAPICAL RADIOGRAPHIC IMAGE BR   D0380 CONE BEAM CT IMAGE CAPTURE WITH LIMITED FIELD OF VIEW LESS THAN ONE WHOLE JAW 97.75   D0381 CONE BEAM CT IMAGE CAPTURE WITH FIELD OF VIEW OF ONE FULL DENTAL ARCH MANDIBLE 207.00   D0382 CONE BEAM CT IMAGE CAPTURE WITH FIELD OF VIEW OF ONE FULL DENTAL ARCH MAXILLA, WITH OR WITHOUT CRANIUM 321.02   D0383 CONE BEAM CT IMAGE CAPTURE WITH FIELD OF VIEW OF BOTH JAWS; WITH OR WITHOUT CRANIUM 230.00

Mississippi Workers’ Compensation Medical Fee Schedule Dental D0120—D9999 Effective June 1, 2026

The Code on Dental Procedures and Nomenclature is published in Current Dental Terminology (CDT). 311 Copyright © American Dental Association (ADA). All rights reserved. Fee Data © FAIR Health, Inc. All rights reserved.

Code Description MAR   D0384 CONE BEAM CT IMAGE CAPTURE FOR TMJ SERIES INCLUDING TWO OR MORE EXPOSURES 372.22   D0385 MAXILLOFACIAL MRI IMAGE CAPTURE 2285.45   D0386 MAXILLOFACIAL ULTRASOUND IMAGE CAPTURE 571.73   D0387 INTRAORAL TOMOSYNTHESIS COMPREHENSIVE SERIES OF RADIOGRAPHIC IMAGES IMAGE CAPTURE ONLY BR   D0388 INTRAORAL TOMOSYNTHESIS BITEWING RADIOGRAPHIC IMAGE IMAGE CAPTURE ONLY BR   D0389 INTRAORAL TOMOSYNTHESIS PERIAPICAL RADIOGRAPHIC IMAGE IMAGE CAPTURE ONLY BR   D0391 INTERPRETATION OF DIAGNOSTIC IMAGE BY A PRACTITIONER NOT ASSOCIATED WITH CAPTURE OF THE IMAGE, INCLUDING REPORT 88.00   D0393 VIRTUAL TREATMENT SIMULATION USING 3D IMAGE VOLUME OR SURFACE SCAN 375.00

  D0394 DIGITAL SUBTRACTION OF TWO OR MORE IMAGES OR IMAGE VOLUMES OF THE SAME MODALITY BR   D0395 FUSION OF TWO OR MORE 3D IMAGE VOLUMES OF ONE OR MORE MODALITIES BR   D0396 3D PRINTING OF A 3D DENTAL SURFACE SCAN BR   D0411 HBA1C IN-OFFICE POINT OF SERVICE TESTING BR   D0412 BLOOD GLUCOSE LEVEL TEST IN-OFFICE USING A GLUCOSE METER BR   D0414 LABORATORY PROCESSING OF MICROBIAL SPECIMEN TO INCLUDE CULTURE AND SENSITIVITY STUDIES, PREPARATION AND TRANSMISSION OF WRITTEN REPORT 59.56   D0415 COLLECTION OF MICROORGANISMS FOR CULTURE AND SENSITIVITY 69.00   D0416 VIRAL CULTURE 64.02   D0417 COLLECTION AND PREPARATION OF SALIVA SAMPLE FOR LABORATORY ANALYSIS 74.75   D0418 ANALYSIS OF SALIVA SAMPLE LABORATORY 69.00   D0419 ASSESSMENT OF SALIVARY FLOW BY MEASUREMENT BR   D0422 COLLECTION AND PREPARATION OF GENETIC SAMPLE MATERIAL FOR LABORATORY ANALYSIS AND REPORT 43.18   D0423 GENETIC TEST FOR SUSCEPTIBILITY TO DISEASES SPECIMEN ANALYSIS BR   D0425 CARIES SUSCEPTIBILITY TESTS 37.22   D0431 ADJUNCTIVE PRE-DIAGNOSTIC TEST THAT AIDS IN DETECTION OF MUCOSAL ABNORMALITIES INCLUDING PREMALIGNANT AND MALIGNANT LESIONS, NOT TO INCLUDE CYTOLOGY OR BIOPSY PROCEDURES 35.65   D0460 PULP VITALITY TESTS 60.00   D0470 DIAGNOSTIC CASTS 106.00   D0472 ACCESSION OF TISSUE, GROSS EXAMINATION, PREPARATION AND TRANSMISSION OF WRITTEN REPORT 81.89   D0473 ACCESSION OF TISSUE, GROSS AND MICROSCOPIC EXAMINATION, PREPARATION AND TRANSMISSION OF WRITTEN REPORT 172.71   D0474 ACCESSION OF TISSUE, GROSS AND MICROSCOPIC EXAMINATION, INCLUDING ASSESSMENT OF SURGICAL MARGINS FOR PRESENCE OF DISEASE, PREPARATION AND TRANSMISSION OF WRITTEN REPORT 193.56   D0475 DECALCIFICATION PROCEDURE 104.22   D0476 SPECIAL STAINS FOR MICROORGANISMS 101.24   D0477 SPECIAL STAINS, NOT FOR MICROORGANISMS 138.47   D0478 IMMUNOHISTOCHEMICAL STAINS 126.56   D0479 TISSUE IN-SITU HYBRIDIZATION, INCLUDING INTERPRETATION 193.56   D0480 ACCESSION OF EXFOLIATIVE CYTOLOGIC SMEARS, MICROSCOPIC EXAMINATION, PREPARATION AND TRANSMISSION OF WRITTEN REPORT 119.11   D0481 ELECTRON MICROSCOPY 446.67   D0482 DIRECT IMMUNOFLUORESCENCE 148.89   D0483 INDIRECT IMMUNOFLUORESCENCE 148.89   D0484 CONSULTATION ON SLIDES PREPARED ELSEWHERE 223.33   D0485 CONSULTATION, INCLUDING PREPARATION OF SLIDES FROM BIOPSY MATERIAL SUPPLIED BY REFERRING SOURCE 308.20   D0486 LABORATORY ACCESSION OF TRANSEPITHELIAL CYTOLOGIC SAMPLE, MICROSCOPIC EXAMINATION, PREPARATION AND TRANSMISSION OF WRITTEN REPORT 142.93   D0502 OTHER ORAL PATHOLOGY PROCEDURES, BY REPORT BR

Dental Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 D0120—D9999

20 Miss. Admin. Code Pt. 2, R. 312 Rule 312

Code Description MAR   D0600 NON-IONIZING DIAGNOSTIC PROCEDURE CAPABLE OF QUANTIFYING, MONITORING, AND RECORDING CHANGES IN STRUCTURE OF ENAMEL, DENTIN, AND CEMENTUM 26.50   D0601 CARIES RISK ASSESSMENT AND DOCUMENTATION, WITH A FINDING OF LOW RISK 10.00   D0602 CARIES RISK ASSESSMENT AND DOCUMENTATION, WITH A FINDING OF MODERATE RISK 82.67   D0603 CARIES RISK ASSESSMENT AND DOCUMENTATION, WITH A FINDING OF HIGH RISK 82.67   D0604 ANTIGEN TESTING FOR A PUBLIC HEALTH RELATED PATHOGEN, INCLUDING CORONAVIRUS 58.07   D0605 ANTIBODY TESTING FOR A PUBLIC HEALTH RELATED PATHOGEN, INCLUDING CORONAVIRUS 43.18   D0606 MOLECULAR TESTING FOR A PUBLIC HEALTH RELATED PATHOGEN, INCLUDING CORONAVIRUS BR   D0701 PANORAMIC RADIOGRAPHIC IMAGE IMAGE CAPTURE ONLY 138.47   D0702 2-D CEPHALOMETRIC RADIOGRAPHIC IMAGE IMAGE CAPTURE ONLY 156.33   D0703 2-D ORAL/FACIAL PHOTOGRAPHIC IMAGE OBTAINED INTRA-ORALLY OR EXTRA-ORALLY IMAGE CAPTURE ONLY 74.44   D0705 EXTRA-ORAL POSTERIOR DENTAL RADIOGRAPHIC IMAGE IMAGE CAPTURE ONLY 52.11   D0706 INTRAORAL OCCLUSAL RADIOGRAPHIC IMAGE IMAGE CAPTURE ONLY 46.16   D0707 INTRAORAL PERIAPICAL RADIOGRAPHIC IMAGE IMAGE CAPTURE ONLY 29.78   D0708 INTRAORAL BITEWING RADIOGRAPHIC IMAGE IMAGE CAPTURE ONLY 29.78   D0709 INTRAORAL COMPREHENSIVE SERIES OF RADIOGRAPHIC IMAGES IMAGE CAPTURE ONLY 169.00   D0801 3D INTRAORAL SURFACE SCAN DIRECT 25.00   D0802 3D DENTAL SURFACE SCAN INDIRECT BR   D0803 3D FACIAL SURFACE SCAN DIRECT 195.00   D0804 3D FACIAL SURFACE SCAN INDIRECT BR   D0999 UNSPECIFIED DIAGNOSTIC PROCEDURE, BY REPORT BR   D1110 PROPHYLAXIS - ADULT 91.00   D1120 PROPHYLAXIS - CHILD 70.00   D1206 TOPICAL APPLICATION OF FLUORIDE VARNISH 48.00   D1208 TOPICAL APPLICATION OF FLUORIDE EXCLUDING VARNISH 37.00   D1301 IMMUNIZATION COUNSELING BR   D1310 NUTRITIONAL COUNSELING FOR CONTROL OF DENTAL DISEASE 72.00   D1320 TOBACCO COUNSELING FOR THE CONTROL AND PREVENTION OF ORAL DISEASE 49.24   D1321 COUNSELING FOR THE CONTROL AND PREVENTION OF ADVERSE ORAL, BEHAVIORAL, AND SYSTEMIC HEALTH EFFECTS ASSOCIATED WITH HIGH-RISK SUBSTANCE USE 62.20   D1330 ORAL HYGIENE INSTRUCTIONS 65.00   D1351 SEALANT - PER TOOTH 58.00   D1353 SEALANT REPAIR PER TOOTH 61.00   D1354 APPLICATION OF CARIES ARRESTING MEDICAMENT PER TOOTH 35.65   D1355 CARIES PREVENTIVE MEDICAMENT APPLICATION PER TOOTH 30.00   D1510 SPACE MAINTAINER - FIXED, UNILATERAL PER QUADRANT 330.00   D1516 SPACE MAINTAINER - FIXED - BILATERAL, MAXILLARY 478.00   D1517 SPACE MAINTAINER - FIXED - BILATERAL, MANDIBULAR 487.53   D1520 SPACE MAINTAINER - REMOVABLE, UNILATERAL - PER QUADRANT 356.34   D1526 SPACE MAINTAINER - REMOVABLE - BILATERAL, MAXILLARY 550.70   D1527 SPACE MAINTAINER - REMOVABLE - BILATERAL, MANDIBULAR 550.70   D1551 RE-CEMENT OR RE-BOND BILATERAL SPACE MAINTAINER - MAXILLARY 69.97   D1552 RE-CEMENT OR RE-BOND BILATERAL SPACE MAINTAINER - MANDIBULAR 69.97   D1553 RE-CEMENT OR RE-BOND UNILATERAL SPACE MAINTAINER - PER QUADRANT 46.65   D1556 REMOVAL OF FIXED UNILATERAL SPACE MAINTAINER - PER QUADRANT 83.50   D1557 REMOVAL OF FIXED BILATERAL SPACE MAINTAINER - MAXILLARY 67.38   D1558 REMOVAL OF FIXED BILATERAL SPACE MAINTAINER - MANDIBULAR 67.38

Mississippi Workers’ Compensation Medical Fee Schedule Dental D0120—D9999 Effective June 1, 2026

The Code on Dental Procedures and Nomenclature is published in Current Dental Terminology (CDT). 313 Copyright © American Dental Association (ADA). All rights reserved. Fee Data © FAIR Health, Inc. All rights reserved.

Code Description MAR   D1575 DISTAL SHOE SPACE MAINTAINER - FIXED, UNILATERAL - PER QUADRANT 356.34   D1701 PFIZER-BIONTECH COVID-19 VACCINE ADMINISTRATION FIRST DOSE BR   D1702 PFIZER-BIONTECH COVID-19 VACCINE ADMINISTRATION SECOND DOSE BR   D1703 MODERNA COVID-19 VACCINE ADMINISTRATION FIRST DOSE BR   D1704 MODERNA COVID-19 VACCINE ADMINISTRATION SECOND DOSE BR   D1708 PFIZER-BIONTECH COVID-19 VACCINE ADMINISTRATION THIRD DOSE BR   D1709 PFIZER-BIONTECH COVID-19 VACCINE ADMINISTRATION BOOSTER DOSE BR   D1710 MODERNA COVID-19 VACCINE ADMINISTRATION THIRD DOSE BR   D1711 MODERNA COVID-19 VACCINE ADMINISTRATION BOOSTER DOSE BR   D1713 PFIZER-BIONTECH COVID-19 VACCINE ADMINISTRATION TRIS-SUCROSE PEDIATRIC FIRST DOSE BR   D1714 PFIZER-BIONTECH COVID-19 VACCINE ADMINISTRATION TRIS-SUCROSE PEDIATRIC SECOND DOSE BR   D1781 VACCINE ADMINISTRATION HUMAN PAPILLOMAVIRUS DOSE 1 BR   D1782 VACCINE ADMINISTRATION HUMAN PAPILLOMAVIRUS DOSE 2 BR   D1783 VACCINE ADMINISTRATION HUMAN PAPILLOMAVIRUS DOSE 3 BR   D1999 UNSPECIFIED PREVENTIVE PROCEDURE, BY REPORT BR   D2140 AMALGAM - ONE SURFACE, PRIMARY OR PERMANENT 145.00   D2150 AMALGAM - TWO SURFACES, PRIMARY OR PERMANENT 175.00   D2160 AMALGAM - THREE SURFACES, PRIMARY OR PERMANENT 214.00   D2161 AMALGAM - FOUR OR MORE SURFACES, PRIMARY OR PERMANENT 245.00   D2330 RESIN-BASED COMPOSITE - ONE SURFACE, ANTERIOR 166.00   D2331 RESIN-BASED COMPOSITE - TWO SURFACES, ANTERIOR 200.00   D2332 RESIN-BASED COMPOSITE - THREE SURFACES, ANTERIOR 241.00   D2335 RESIN-BASED COMPOSITE - FOUR OR MORE SURFACES (ANTERIOR) 298.00   D2390 RESIN-BASED COMPOSITE CROWN, ANTERIOR 396.00   D2391 RESIN-BASED COMPOSITE ONE SURFACE, POSTERIOR 180.00   D2392 RESIN-BASED COMPOSITE - TWO SURFACES, POSTERIOR 230.00   D2393 RESIN-BASED COMPOSITE - THREE SURFACES, POSTERIOR 280.00   D2394 RESIN-BASED COMPOSITE - FOUR OR MORE SURFACES, POSTERIOR 325.00   D2410 GOLD FOIL - ONE SURFACE 323.63   D2420 GOLD FOIL - TWO SURFACES 539.39   D2430 GOLD FOIL - THREE SURFACES 934.93   D2510 INLAY - METALLIC - ONE SURFACE 855.82   D2520 INLAY - METALLIC - TWO SURFACES 970.89   D2530 INLAY - METALLIC - THREE OR MORE SURFACES 1119.04   D2542 ONLAY - METALLIC - TWO SURFACES 1097.47   D2543 ONLAY - METALLIC - THREE SURFACES 1147.81   D2544 ONLAY - METALLIC - FOUR OR MORE SURFACES 1193.84   D2610 INLAY - PORCELAIN/CERAMIC - ONE SURFACE 1006.85   D2620 INLAY - PORCELAIN/CERAMIC - TWO SURFACES 1062.95   D2630 INLAY - PORCELAIN/CERAMIC - THREE OR MORE SURFACES 1131.99   D2642 ONLAY - PORCELAIN/CERAMIC - TWO SURFACES 1100.35   D2643 ONLAY - PORCELAIN/CERAMIC - THREE SURFACES 1140.80   D2644 ONLAY - PORCELAIN/CERAMIC - FOUR OR MORE SURFACES 1092.50   D2650 INLAY - RESIN-BASED COMPOSITE - ONE SURFACE 661.65   D2651 INLAY - RESIN-BASED COMPOSITE - TWO SURFACES 788.22   D2652 INLAY - RESIN-BASED COMPOSITE - THREE OR MORE SURFACES 828.50   D2662 ONLAY - RESIN-BASED COMPOSITE - TWO SURFACES 719.18

Dental Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 D0120—D9999

20 Miss. Admin. Code Pt. 2, R. 314 Rule 314

Code Description MAR   D2663 ONLAY - RESIN-BASED COMPOSITE - THREE SURFACES 845.76   D2664 ONLAY - RESIN-BASED COMPOSITE - FOUR OR MORE SURFACES 906.17   D2710 CROWN - RESIN-BASED COMPOSITE (INDIRECT) 510.62   D2712 CROWN - RESIN-BASED COMPOSITE (INDIRECT) 510.62   D2720 CROWN - RESIN WITH HIGH NOBLE METAL 1258.57   D2721 CROWN - RESIN WITH PREDOMINANTLY BASE METAL 1179.46   D2722 CROWN - RESIN WITH NOBLE METAL 1205.35   D2740 CROWN - PORCELAIN/CERAMIC 1136.00   D2750 CROWN - PORCELAIN FUSED TO HIGH NOBLE METAL 1095.00   D2751 CROWN - PORCELAIN FUSED TO PREDOMINANTLY BASE METAL 1000.00   D2752 CROWN - PORCELAIN FUSED TO NOBLE METAL 1103.00   D2753 CROWN - PORCELAIN FUSED TO TITANIUM AND TITANIUM ALLOYS 1186.65   D2780 CROWN - 3/4 CAST HIGH NOBLE METAL 1222.61   D2781 CROWN - 3/4 CAST PREDOMINANTLY BASE METAL 1150.69   D2782 CROWN - 3/4 CAST NOBLE METAL 299.00   D2783 CROWN - 3/4 PORCELAIN/CERAMIC 1198.00   D2790 CROWN - FULL CAST HIGH NOBLE METAL 1178.00   D2791 CROWN - FULL CAST PREDOMINANTLY BASE METAL 975.00   D2792 CROWN - FULL CAST NOBLE METAL 995.00   D2794 CROWN - TITANIUM AND TITANIUM ALLOYS 1258.57   D2799 INTERIM CROWN FURTHER TREATMENT OR COMPLETION OF DIAGNOSIS NECESSARY PRIOR TO FINAL IMPRESSION 389.00   D2910 RE-CEMENT OR RE-BOND INLAY, ONLAY, VENEER OR PARTIAL COVERAGE RESTORATION 110.00   D2915 RE-CEMENT OR RE-BOND INDIRECTLY FABRICATED OR PREFABRICATED POST AND CORE 125.00   D2920 RE-CEMENT OR RE-BOND CROWN 105.00   D2921 REATTACHMENT OF TOOTH FRAGMENT, INCISAL EDGE OR CUSP 162.02   D2928 PREFABRICATED PORCELAIN/CERAMIC CROWN PERMANENT TOOTH 355.00   D2929 PREFABRICATED PORCELAIN/CERAMIC CROWN PRIMARY TOOTH 500.00   D2930 PREFABRICATED STAINLESS STEEL CROWN - PRIMARY TOOTH 274.00   D2931 PREFABRICATED STAINLESS STEEL CROWN - PERMANENT TOOTH 321.00   D2932 PREFABRICATED RESIN CROWN 370.35   D2933 PREFABRICATED STAINLESS STEEL CROWN WITH RESIN WINDOW 488.00   D2934 PREFABRICATED ESTHETIC COATED STAINLESS STEEL CROWN - PRIMARY TOOTH 311.00   D2940 PLACEMENT OF INTERIM DIRECT RESTORATION 117.00   D2949 RESTORATIVE FOUNDATION FOR AN INDIRECT RESTORATION 109.32   D2950 CORE BUILDUP, INCLUDING ANY PINS WHEN REQUIRED 278.00   D2951 PIN RETENTION - PER TOOTH, IN ADDITION TO RESTORATION 64.00   D2952 POST AND CORE IN ADDITION TO CROWN, INDIRECTLY FABRICATED 413.00   D2953 EACH ADDITIONAL INDIRECTLY FABRICATED POST - SAME TOOTH 215.75   D2954 PREFABRICATED POST AND CORE IN ADDITION TO CROWN 370.00   D2955 POST REMOVAL 175.00   D2956 REMOVAL OF AN INDIRECT RESTORATION ON A NATURAL TOOTH BR   D2957 EACH ADDITIONAL PREFABRICATED POST - SAME TOOTH 156.40   D2960 LABIAL VENEER (RESIN LAMINATE) - DIRECT 575.00   D2961 LABIAL VENEER (RESIN LAMINATE) - INDIRECT 1015.36   D2962 LABIAL VENEER (PORCELAIN LAMINATE) - INDIRECT 1240.00   D2971 ADDITIONAL PROCEDURES TO CUSTOMIZE A CROWN TO FIT UNDER AN EXISTING PARTIAL DENTURE FRAMEWORK 178.00

Mississippi Workers’ Compensation Medical Fee Schedule Dental D0120—D9999 Effective June 1, 2026

The Code on Dental Procedures and Nomenclature is published in Current Dental Terminology (CDT). 315 Copyright © American Dental Association (ADA). All rights reserved. Fee Data © FAIR Health, Inc. All rights reserved.

Code Description MAR   D2975 COPING 46.00   D2976 BAND STABILIZATION PER TOOTH BR   D2980 CROWN REPAIR NECESSITATED BY RESTORATIVE MATERIAL FAILURE 253.00   D2981 INLAY REPAIR NECESSITATED BY RESTORATIVE MATERIAL FAILURE 201.37   D2982 ONLAY REPAIR NECESSITATED BY RESTORATIVE MATERIAL FAILURE 201.37   D2983 VENEER REPAIR NECESSITATED BY RESTORATIVE MATERIAL FAILURE 201.37   D2989 EXCAVATION OF A TOOTH RESULTING IN THE DETERMINATION OF NON-RESTORABILITY BR   D2990 RESIN INFILTRATION OF INCIPIENT SMOOTH SURFACE LESIONS 150.00   D2991 APPLICATION OF HYDROXYAPATITE REGENERATION MEDICAMENT PER TOOTH 59.35   D2999 UNSPECIFIED RESTORATIVE PROCEDURE, BY REPORT BR   D3110 PULP CAP - DIRECT (EXCLUDING FINAL RESTORATION) 75.00   D3120 PULP CAP - INDIRECT (EXCLUDING FINAL RESTORATION) 73.00   D3220 THERAPEUTIC PULPOTOMY (EXCLUDING FINAL RESTORATION) - REMOVAL OF PULP CORONAL TO THE DENTINOCEMENTAL JUNCTION AND APPLICATION OF MEDICAMENT 194.00   D3221 PULPAL DEBRIDEMENT, PRIMARY AND PERMANENT TEETH 207.00   D3222 PARTIAL PULPOTOMY FOR APEXOGENESIS - PERMANENT TOOTH WITH INCOMPLETE ROOT DEVELOPMENT 195.00   D3230 PULPAL THERAPY (RESORBABLE FILLING) - ANTERIOR, PRIMARY TOOTH (EXCLUDING FINAL RESTORATION) 300.00   D3240 PULPAL THERAPY (RESORBABLE FILLING) - POSTERIOR, PRIMARY TOOTH (EXCLUDING FINAL RESTORATION) 260.00   D3310 ENDODONTIC THERAPY, ANTERIOR TOOTH (EXCLUDING FINAL RESTORATION) 850.00   D3320 ENDODONTIC THERAPY, PREMOLAR TOOTH (EXCLUDING FINAL RESTORATION) 975.00   D3330 ENDODONTIC THERAPY, MOLAR TOOTH (EXCLUDING FINAL RESTORATION) 1178.75   D3331 TREATMENT OF ROOT CANAL OBSTRUCTION; NON-SURGICAL ACCESS 225.00   D3332 INCOMPLETE ENDODONTIC THERAPY; INOPERABLE, UNRESTORABLE OR FRACTURED TOOTH 475.00   D3333 INTERNAL ROOT REPAIR OF PERFORATION DEFECTS 273.00   D3346 RETREATMENT OF PREVIOUS ROOT CANAL THERAPY - ANTERIOR 1100.00   D3347 RETREATMENT OF PREVIOUS ROOT CANAL THERAPY - PREMOLAR 1260.00   D3348 RETREATMENT OF PREVIOUS ROOT CANAL THERAPY - MOLAR 1400.00   D3351 APEXIFICATION/RECALCIFICATION INITIAL VISIT (APICAL CLOSURE/CALCIFIC REPAIR OF PERFORATIONS, ROOT RESORPTION, ETC.) 287.50   D3352 APEXIFICATION/RECALCIFICATION INTERIM MEDICATION REPLACEMENT 202.80   D3353 APEXIFICATION/RECALCIFICATION - FINAL VISIT (INCLUDES COMPLETED ROOT CANAL THERAPY - APICAL CLOSURE/CALCIFIC REPAIR OF PERFORATIONS, ROOT RESORPTION, ETC.) 624.00   D3355 PULPAL REGENERATION - INITIAL VISIT 452.40   D3356 PULPAL REGENERATION - INTERIM MEDICATION REPLACEMENT 202.80   D3357 PULPAL REGENERATION - COMPLETION OF TREATMENT BR   D3410 APICOECTOMY - ANTERIOR 960.25   D3421 APICOECTOMY - PREMOLAR (FIRST ROOT) 985.00   D3425 APICOECTOMY - MOLAR (FIRST ROOT) 977.50   D3426 APICOECTOMY (EACH ADDITIONAL ROOT) 382.20   D3428 BONE GRAFT IN CONJUNCTION WITH PERIRADICULAR SURGERY PER TOOTH, SINGLE SITE 1182.48   D3429 BONE GRAFT IN CONJUNCTION WITH PERIRADICULAR SURGERY EACH ADDITIONAL CONTIGUOUS TOOTH IN THE SAME SURGICAL SITE 1127.88   D3430 RETROGRADE FILLING - PER ROOT 262.20   D3431 BIOLOGIC MATERIALS TO AID IN SOFT AND OSSEOUS TISSUE REGENERATION IN CONJUNCTION WITH PERIRADICULAR SURGERY 1388.40   D3432 GUIDED TISSUE REGENERATION, RESORBABLE BARRIER, PER SITE, IN CONJUNCTION WITH PERIRADICULAR SURGERY 1193.40   D3450 ROOT AMPUTATION - PER ROOT 585.00   D3460 ENDODONTIC ENDOSSEOUS IMPLANT 2184.00

Dental Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 D0120—D9999

20 Miss. Admin. Code Pt. 2, R. 316 Rule 316

Code Description MAR   D3470 INTENTIONAL RE-IMPLANTATION (INCLUDING NECESSARY SPLINTING) 1115.40   D3471 SURGICAL REPAIR OF ROOT RESORPTION - ANTERIOR 1388.40   D3472 SURGICAL REPAIR OF ROOT RESORPTION PREMOLAR 1388.40   D3473 SURGICAL REPAIR OF ROOT RESORPTION MOLAR 1388.40   D3501 SURGICAL EXPOSURE OF ROOT SURFACE WITHOUT APICOECTOMY OR REPAIR OF ROOT RESORPTION ANTERIOR 811.20   D3502 SURGICAL EXPOSURE OF ROOT SURFACE WITHOUT APICOECTOMY OR REPAIR OF ROOT RESORPTION PREMOLAR 811.20   D3503 SURGICAL EXPOSURE OF ROOT SURFACE WITHOUT APICOECTOMY OR REPAIR OF ROOT RESORPTION MOLAR 811.20   D3910 SURGICAL PROCEDURE FOR ISOLATION OF TOOTH WITH RUBBER DAM 149.27   D3911 INTRAORIFICE BARRIER 118.56   D3920 HEMISECTION (INCLUDING ANY ROOT REMOVAL), NOT INCLUDING ROOT CANAL THERAPY 444.60   D3921 DECORONATION OR SUBMERGENCE OF AN ERUPTED TOOTH 444.60   D3950 CANAL PREPARATION AND FITTING OF PREFORMED DOWEL OR POST 202.80   D3999 UNSPECIFIED ENDODONTIC PROCEDURE, BY REPORT BR   D4210 GINGIVECTOMY OR GINGIVOPLASTY - FOUR OR MORE CONTIGUOUS TEETH OR TOOTH BOUNDED SPACES PER QUADRANT 950.00   D4211 GINGIVECTOMY OR GINGIVOPLASTY - ONE TO THREE CONTIGUOUS TEETH OR TOOTH BOUNDED SPACES PER QUADRANT 270.00   D4212 GINGIVECTOMY OR GINGIVOPLASTY TO ALLOW ACCESS FOR RESTORATIVE PROCEDURE, PER TOOTH 158.70   D4230 ANATOMICAL CROWN EXPOSURE FOUR OR MORE CONTIGUOUS TEETH OR TOOTH BOUNDED SPACES PER QUADRANT 859.09   D4231 ANATOMICAL CROWN EXPOSURE ONE TO THREE TEETH OR TOOTH BOUNDED SPACES PER QUADRANT 402.50   D4240 GINGIVAL FLAP PROCEDURE, INCLUDING ROOT PLANING - FOUR OR MORE CONTIGUOUS TEETH OR TOOTH BOUNDED SPACES PER QUADRANT 1200.00   D4241 GINGIVAL FLAP PROCEDURE, INCLUDING ROOT PLANING - ONE TO THREE CONTIGUOUS TEETH OR TOOTH BOUNDED SPACES PER QUADRANT 600.00   D4245 APICALLY POSITIONED FLAP 572.73   D4249 CLINICAL CROWN LENGTHENING HARD TISSUE 673.00   D4260 OSSEOUS SURGERY (INCLUDING ELEVATION OF A FULL THICKNESS FLAP AND CLOSURE) FOUR OR MORE CONTIGUOUS TEETH OR TOOTH BOUNDED SPACES PER QUADRANT 1300.00   D4261 OSSEOUS SURGERY (INCLUDING ELEVATION OF A FULL THICKNESS FLAP AND CLOSURE) ONE TO THREE CONTIGUOUS TEETH OR TOOTH BOUNDED SPACES PER QUADRANT 915.00   D4263 BONE REPLACEMENT GRAFT RETAINED NATURAL TOOTH FIRST SITE IN QUADRANT 454.00   D4264 BONE REPLACEMENT GRAFT RETAINED NATURAL TOOTH EACH ADDITIONAL SITE IN QUADRANT 581.90   D4265 BIOLOGIC MATERIALS TO AID IN SOFT AND OSSEOUS TISSUE REGENERATION, PER SITE 397.55   D4266 GUIDED TISSUE REGENERATION, NATURAL TEETH RESORBABLE BARRIER, PER SITE 425.00   D4267 GUIDED TISSUE REGENERATION, NATURAL TEETH NON-RESORBABLE BARRIER, PER SITE 402.50   D4268 SURGICAL REVISION PROCEDURE, PER TOOTH 100.00   D4270 PEDICLE SOFT TISSUE GRAFT PROCEDURE 506.00   D4273 AUTOGENOUS CONNECTIVE TISSUE GRAFT PROCEDURE (INCLUDING DONOR AND RECIPIENT SURGICAL SITES) FIRST TOOTH, IMPLANT, OR EDENTULOUS TOOTH POSITION IN GRAFT 1200.00   D4274 MESIAL/DISTAL WEDGE PROCEDURE, SINGLE TOOTH (WHEN NOT PERFORMED IN CONJUNCTION WITH SURGICAL PROCEDURES IN THE SAME ANATOMICAL AREA) 638.18   D4275 NON-AUTOGENOUS CONNECTIVE TISSUE GRAFT (INCLUDING RECIPIENT SITE AND DONOR MATERIAL) FIRST TOOTH, IMPLANT, OR EDENTULOUS TOOTH POSITION IN GRAFT 1295.00   D4276 COMBINED CONNECTIVE TISSUE AND PEDICLE GRAFT, PER TOOTH 1261.37   D4277 FREE SOFT TISSUE GRAFT PROCEDURE (INCLUDING RECIPIENT AND DONOR SURGICAL SITES) FIRST TOOTH, IMPLANT OR EDENTULOUS TOOTH POSITION IN GRAFT 1014.90   D4278 FREE SOFT TISSUE GRAFT PROCEDURE (INCLUDING RECIPIENT AND DONOR SURGICAL SITES) EACH ADDITIONAL CONTIGUOUS TOOTH, IMPLANT OR EDENTULOUS TOOTH POSITION IN SAME GRAFT SITE 625.00   D4283 AUTOGENOUS CONNECTIVE TISSUE GRAFT PROCEDURE (INCLUDING DONOR AND RECIPIENT SURGICAL SITES) EACH ADDITIONAL CONTIGUOUS TOOTH, IMPLANT OR EDENTULOUS TOOTH POSITION IN SAME GRAFT SITE 806.00

Mississippi Workers’ Compensation Medical Fee Schedule Dental D0120—D9999 Effective June 1, 2026

The Code on Dental Procedures and Nomenclature is published in Current Dental Terminology (CDT). 317 Copyright © American Dental Association (ADA). All rights reserved. Fee Data © FAIR Health, Inc. All rights reserved.

Code Description MAR   D4285 NON-AUTOGENOUS CONNECTIVE TISSUE GRAFT PROCEDURE (INCLUDING RECIPIENT SURGICAL SITE AND DONOR MATERIAL) EACH ADDITIONAL CONTIGUOUS TOOTH, IMPLANT OR EDENTULOUS TOOTH POSITION IN SAME GRAFT SITE 400.00   D4286 REMOVAL OF NON-RESORBABLE BARRIER 168.00   D4322 SPLINT INTRA-CORONAL; NATURAL TEETH OR PROSTHETIC CROWNS 450.00   D4323 SPLINT EXTRA-CORONAL; NATURAL TEETH OR PROSTHETIC CROWNS 409.09   D4341 PERIODONTAL SCALING AND ROOT PLANING - FOUR OR MORE TEETH PER QUADRANT 267.00   D4342 PERIODONTAL SCALING AND ROOT PLANING - ONE TO THREE TEETH PER QUADRANT 192.00   D4346 SCALING IN PRESENCE OF GENERALIZED MODERATE OR SEVERE GINGIVAL INFLAMMATION FULL MOUTH, AFTER ORAL EVALUATION 150.00   D4355 FULL MOUTH DEBRIDEMENT TO ENABLE A COMPREHENSIVE PERIODONTAL EVALUATION AND DIAGNOSIS ON A SUBSEQUENT VISIT 176.00   D4381 LOCALIZED DELIVERY OF ANTIMICROBIAL AGENTS VIA A CONTROLLED RELEASE VEHICLE INTO DISEASED CREVICULAR TISSUE, PER TOOTH 82.69   D4910 PERIODONTAL MAINTENANCE 147.00   D4920 UNSCHEDULED DRESSING CHANGE (BY SOMEONE OTHER THAN TREATING DENTIST OR THEIR STAFF) 115.91   D4921 GINGIVAL IRRIGATION WITH A MEDICINAL AGENT PER QUADRANT 18.02   D4999 UNSPECIFIED PERIODONTAL PROCEDURE, BY REPORT BR   D5110 COMPLETE DENTURE - MAXILLARY 1378.00   D5120 COMPLETE DENTURE - MANDIBULAR 1335.00   D5130 IMMEDIATE DENTURE - MAXILLARY 1600.00   D5140 IMMEDIATE DENTURE - MANDIBULAR 1527.50   D5211 MAXILLARY PARTIAL DENTURE RESIN BASE (INCLUDING, RETENTIVE/CLASPING MATERIALS, RESTS, AND TEETH) 1092.50   D5212 MANDIBULAR PARTIAL DENTURE RESIN BASE (INCLUDING, RETENTIVE/CLASPING MATERIALS, RESTS, AND TEETH) 1200.00   D5213 MAXILLARY PARTIAL DENTURE - CAST METAL FRAMEWORK WITH RESIN DENTURE BASES (INCLUDING RETENTIVE/CLASPING MATERIALS, RESTS AND TEETH) 1600.00   D5214 MANDIBULAR PARTIAL DENTURE - CAST METAL FRAMEWORK WITH RESIN DENTURE BASES (INCLUDING RETENTIVE/CLASPING MATERIALS, RESTS AND TEETH) 1570.99   D5221 IMMEDIATE MAXILLARY PARTIAL DENTURE - RESIN BASE (INCLUDING RETENTIVE/CLASPING MATERIALS, RESTS AND TEETH) 969.00   D5222 IMMEDIATE MANDIBULAR PARTIAL DENTURE - RESIN BASE (INCLUDING RETENTIVE/CLASPING MATERIALS, RESTS AND TEETH) 969.00   D5223 IMMEDIATE MAXILLARY PARTIAL DENTURE - CAST METAL FRAMEWORK WITH RESIN DENTURE BASES (INCLUDING RETENTIVE/CLASPING MATERIALS, RESTS AND TEETH) 1380.00   D5224 IMMEDIATE MANDIBULAR PARTIAL DENTURE - CAST METAL FRAMEWORK WITH RESIN DENTURE BASES (INCLUDING RETENTIVE/CLASPING MATERIALS, RESTS AND TEETH) 1495.00   D5225 MAXILLARY PARTIAL DENTURE - FLEXIBLE BASE (INCLUDING RETENTIVE/CLASPING MATERIALS, RESTS, AND TEETH) 1398.00   D5226 MANDIBULAR PARTIAL DENTURE - FLEXIBLE BASE (INCLUDING RETENTIVE/CLASPING MATERIALS, RESTS, AND TEETH) 1400.00   D5227 IMMEDIATE MAXILLARY PARTIAL DENTURE - FLEXIBLE BASE (INCLUDING ANY CLASPS, RESTS AND TEETH) 1367.05   D5228 IMMEDIATE MANDIBULAR PARTIAL DENTURE - FLEXIBLE BASE (INCLUDING ANY CLASPS, RESTS AND TEETH) 1583.61   D5282 REMOVABLE UNILATERAL PARTIAL DENTURE ONE PIECE CAST METAL (INCLUDING RETENTIVE/CLASPING MATERIALS, RESTS, AND TEETH), MAXILLARY 889.56   D5283 REMOVABLE UNILATERAL PARTIAL DENTURE ONE PIECE CAST METAL (INCLUDING RENTENTIVE/CLASPING MATERIAS, RESTS, AND TEETH), MANDIBULAR 889.56   D5284 REMOVABLE UNILATERAL PARTIAL DENTURE ONE PIECE FLEXIBLE BASE (INCLUDING RETENTIVE/CLASPING MATERIALS, RESTS, AND TEETH) PER QUADRANT 800.00   D5286 REMOVABLE UNILATERAL PARTIAL DENTURE ONE PIECE RESIN (INCLUDING RETENTIVE/CLASPING MATERIALS, RESTS, AND TEETH) PER QUADRANT 729.54   D5410 ADJUST COMPLETE DENTURE - MAXILLARY 93.00   D5411 ADJUST COMPLETE DENTURE - MANDIBULAR 89.00   D5421 ADJUST PARTIAL DENTURE - MAXILLARY 92.00   D5422 ADJUST PARTIAL DENTURE - MANDIBULAR 93.32   D5511 REPAIR BROKEN COMPLETE DENTURE BASE, MANDIBULAR 178.25

Dental Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 D0120—D9999

20 Miss. Admin. Code Pt. 2, R. 318 Rule 318

Code Description MAR   D5512 REPAIR BROKEN COMPLETE DENTURE BASE, MAXILLARY 178.25   D5520 REPLACE MISSING OR BROKEN TEETH COMPLETE DENTURE PER TOOTH 173.00   D5611 REPAIR RESIN PARTIAL DENTURE BASE, MANDIBULAR 210.00   D5612 REPAIR RESIN PARTIAL DENTURE BASE, MAXILLARY 184.00   D5621 REPAIR CAST PARTIAL FRAMEWORK, MANDIBULAR 202.86   D5622 REPAIR CAST PARTIAL FRAMEWORK, MAXILLARY 202.86   D5630 REPAIR OR REPLACE BROKEN RETENTIVE CLASPING MATERIALS PER TOOTH 250.00   D5640 REPLACE MISSING OR BROKEN TEETH PARTIAL DENTURE PER TOOTH 181.00   D5650 ADD TOOTH TO EXISTING PARTIAL DENTURE PER TOOTH 222.00   D5660 ADD CLASP TO EXISTING PARTIAL DENTURE - PER TOOTH 249.00   D5670 REPLACE ALL TEETH AND ACRYLIC ON CAST METAL FRAMEWORK (MAXILLARY) 595.54   D5671 REPLACE ALL TEETH AND ACRYLIC ON CAST METAL FRAMEWORK (MANDIBULAR) 595.54   D5710 REBASE COMPLETE MAXILLARY DENTURE 550.00   D5711 REBASE COMPLETE MANDIBULAR DENTURE 460.00   D5720 REBASE MAXILLARY PARTIAL DENTURE 575.00   D5721 REBASE MANDIBULAR PARTIAL DENTURE 525.00   D5725 REBASE HYBRID PROSTHESIS 602.31   D5730 RELINE COMPLETE MAXILLARY DENTURE (DIRECT) 340.00   D5731 RELINE COMPLETE MANDIBULAR DENTURE (DIRECT) 326.00   D5740 RELINE MAXILLARY PARTIAL DENTURE (DIRECT) 300.00   D5741 RELINE MANDIBULAR PARTIAL DENTURE (DIRECT) 323.00   D5750 RELINE COMPLETE MAXILLARY DENTURE (INDIRECT) 453.00   D5751 RELINE COMPLETE MANDIBULAR DENTURE (INDIRECT) 453.00   D5760 RELINE MAXILLARY PARTIAL DENTURE (INDIRECT) 426.00   D5761 RELINE MANDIBULAR PARTIAL DENTURE (INDIRECT) 435.00   D5765 SOFT LINER FOR COMPLETE OR PARTIAL REMOVABLE DENTURE INDIRECT 453.43   D5810 INTERIM COMPLETE DENTURE (MAXILLARY) 765.00   D5811 INTERIM COMPLETE DENTURE (MANDIBULAR) 771.50   D5820 INTERIM PARTIAL DENTURE (INCLUDING RETENTIVE/CLASPING MATERIALS, RESTS, AND TEETH), MAXILLARY 633.00   D5821 INTERIM PARTIAL DENTURE (INCLUDING RETENTIVE/CLASPING MATERIALS, RESTS, AND TEETH), MANDIBULAR 632.50   D5850 TISSUE CONDITIONING, MAXILLARY 145.00   D5851 TISSUE CONDITIONING, MANDIBULAR 149.50   D5862 PRECISION ATTACHMENT, BY REPORT BR   D5863 OVERDENTURE COMPLETE MAXILLARY NATURAL TOOTH BORNE 1570.07   D5864 OVERDENTURE PARTIAL MAXILLARY NATURAL TOOTH BORNE 2070.87   D5865 OVERDENTURE COMPLETE MANDIBULAR NATURAL TOOTH BORNE 1680.84   D5866 OVERDENTURE PARTIAL MANDIBULAR NATURAL TOOTH BORNE 2152.08   D5867 REPLACEMENT OF REPLACEABLE PART OF SEMI-PRECISION OR PRECISION ATTACHMENT OF NATURAL TOOTH BORNE PROSTHESIS, PER ATTACHMENT 185.52   D5875 MODIFICATION OF REMOVABLE PROSTHESIS FOLLOWING IMPLANT SURGERY 538.00   D5876 ADD METAL SUBSTRUCTURE TO ACRYLIC COMPLETE DENTURE PER ARCH BR   D5899 UNSPECIFIED REMOVABLE PROSTHODONTIC PROCEDURE, BY REPORT BR   D5911 FACIAL MOULAGE (SECTIONAL) 296.71   D5912 FACIAL MOULAGE (COMPLETE) 296.71   D5913 NASAL PROSTHESIS 6248.00   D5914 AURICULAR PROSTHESIS 6248.00

Mississippi Workers’ Compensation Medical Fee Schedule Dental D0120—D9999 Effective June 1, 2026

The Code on Dental Procedures and Nomenclature is published in Current Dental Terminology (CDT). 319 Copyright © American Dental Association (ADA). All rights reserved. Fee Data © FAIR Health, Inc. All rights reserved.

Code Description MAR   D5915 ORBITAL PROSTHESIS 8455.18   D5916 OCULAR PROSTHESIS 2255.21   D5919 FACIAL PROSTHESIS BR   D5922 NASAL SEPTAL PROSTHESIS BR   D5923 OCULAR PROSTHESIS, INTERIM BR   D5924 CRANIAL PROSTHESIS BR   D5925 FACIAL AUGMENTATION IMPLANT PROSTHESIS BR   D5926 NASAL PROSTHESIS, REPLACEMENT BR   D5927 AURICULAR PROSTHESIS, REPLACEMENT BR   D5928 ORBITAL PROSTHESIS, REPLACEMENT BR   D5929 FACIAL PROSTHESIS, REPLACEMENT BR   D5931 OBTURATOR PROSTHESIS, SURGICAL 3364.14   D5932 OBTURATOR PROSTHESIS, DEFINITIVE 6291.75   D5933 OBTURATOR PROSTHESIS, MODIFICATION BR   D5934 MANDIBULAR GUIDANCE PROSTHESIS WITH GUIDE FLANGE 5734.62   D5935 MANDIBULAR GUIDANCE PROSTHESIS WITHOUT GUIDE FLANGE 4989.64   D5936 OBTURATOR PROSTHESIS, INTERIM 5604.41   D5937 TRISMUS APPLIANCE (NOT FOR TMD TREATMENT) 704.42   D5951 FEEDING AID 915.75   D5952 SPEECH AID PROSTHESIS, PEDIATRIC 2973.51   D5953 SPEECH AID PROSTHESIS, ADULT 5647.10   D5954 PALATAL AUGMENTATION PROSTHESIS 5232.99   D5955 PALATAL LIFT PROSTHESIS, DEFINITIVE 4840.22   D5958 PALATAL LIFT PROSTHESIS, INTERIM BR   D5959 PALATAL LIFT PROSTHESIS, MODIFICATION BR   D5960 SPEECH AID PROSTHESIS, MODIFICATION BR   D5982 SURGICAL STENT FOR SOFT TISSUE HEALING 413.00   D5983 RADIATION CARRIER 1067.30   D5984 RADIATION SHIELD 1067.30   D5985 RADIATION CONE LOCATOR 1067.30   D5986 FLUORIDE GEL CARRIER 51.75   D5987 COMMISSURE SPLINT 1600.96   D5988 SURGICAL SPLINT 320.19   D5991 VESICULOBULLOUS DISEASE MEDICAMENT CARRIER 122.74   D5992 ADJUST MAXILLOFACIAL PROSTHETIC APPLIANCE, BY REPORT BR   D5993 MAINTENANCE AND CLEANING OF A MAXILLOFACIAL PROSTHESIS (EXTRA- OR INTRA-ORAL) OTHER THAN REQUIRED ADJUSTMENTS, BY REPORT BR   D5995 PERIODONTAL MEDICAMENT CARRIER WITH PERIPHERAL SEAL LABORATORY PROCESSED MAXILLARY 617.98   D5996 PERIODONTAL MEDICAMENT CARRIER WITH PERIPHERAL SEAL LABORATORY PROCESSED MANDIBULAR 617.98   D5999 UNSPECIFIED MAXILLOFACIAL PROSTHESIS, BY REPORT BR   D6010 SURGICAL PLACEMENT OF IMPLANT BODY: ENDOSTEAL IMPLANT 1989.00   D6011 SURGICAL ACCESS TO AN IMPLANT BODY (SECOND STAGE IMPLANT SURGERY) 201.43   D6012 SURGICAL PLACEMENT OF INTERIM IMPLANT BODY FOR TRANSITIONAL PROSTHESIS: ENDOSTEAL IMPLANT 2440.41   D6013 SURGICAL PLACEMENT OF MINI IMPLANT 1380.00   D6040 SURGICAL PLACEMENT: EPOSTEAL IMPLANT 8887.03   D6050 SURGICAL PLACEMENT: TRANSOSTEAL IMPLANT 5910.02

Dental Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 D0120—D9999

20 Miss. Admin. Code Pt. 2, R. 320 Rule 320

Code Description MAR   D6051 PLACEMENT OF INTERIM IMPLANT ABUTMENT 84.81   D6055 CONNECTING BAR IMPLANT SUPPORTED OR ABUTMENT SUPPORTED 775.85   D6056 PREFABRICATED ABUTMENT INCLUDES MODIFICATION AND PLACEMENT 575.00   D6057 CUSTOM FABRICATED ABUTMENT INCLUDES PLACEMENT 767.00   D6058 ABUTMENT SUPPORTED PORCELAIN/CERAMIC CROWN 1345.00   D6059 ABUTMENT SUPPORTED PORCELAIN FUSED TO METAL CROWN (HIGH NOBLE METAL) 1350.00   D6060 ABUTMENT SUPPORTED PORCELAIN FUSED TO METAL CROWN (PREDOMINANTLY BASE METAL) 1290.00   D6061 ABUTMENT SUPPORTED PORCELAIN FUSED TO METAL CROWN (NOBLE METAL) 1456.00   D6062 ABUTMENT SUPPORTED CAST METAL CROWN (HIGH NOBLE METAL) 1164.95   D6063 ABUTMENT SUPPORTED CAST METAL CROWN (PREDOMINANTLY BASE METAL) 1227.26   D6064 ABUTMENT SUPPORTED CAST METAL CROWN (NOBLE METAL) 1283.68   D6065 IMPLANT SUPPORTED PORCELAIN/CERAMIC CROWN 1560.00   D6066 IMPLANT SUPPORTED CROWN - PORCELAIN FUSED TO HIGH NOBLE ALLOYS 1480.00   D6067 IMPLANT SUPPORTED CROWN - HIGH NOBLE ALLOYS 1382.43   D6068 ABUTMENT SUPPORTED RETAINER FOR PORCELAIN/CERAMIC FPD 1309.00   D6069 ABUTMENT SUPPORTED RETAINER FOR PORCELAIN FUSED TO METAL FPD (HIGH NOBLE METAL) 1106.30   D6070 ABUTMENT SUPPORTED RETAINER FOR PORCELAIN FUSED TO METAL FPD (PREDOMINANTLY BASE METAL) 1236.07   D6071 ABUTMENT SUPPORTED RETAINER FOR PORCELAIN FUSED TO METAL FPD (NOBLE METAL) 1550.00   D6072 ABUTMENT SUPPORTED RETAINER FOR CAST METAL FPD (HIGH NOBLE METAL) 1431.80   D6073 ABUTMENT SUPPORTED RETAINER FOR CAST METAL FPD (PREDOMINANTLY BASE METAL) 1307.66   D6074 ABUTMENT SUPPORTED RETAINER FOR CAST METAL FPD (NOBLE METAL) 1389.48   D6075 IMPLANT SUPPORTED RETAINER FOR CERAMIC FPD 1500.00   D6076 IMPLANT SUPPORTED RETAINER FOR FPD - PORCELAIN FUSED TO HIGH NOBLE ALLOYS 1800.00   D6077 IMPLANT SUPPORTED RETAINER FOR METAL FPD - HIGH NOBLE ALLOYS 1382.43   D6080 IMPLANT MAINTENANCE PROCEDURES WHEN A FULL ARCH FIXED HYBRID PROSTHESIS IS REMOVED AND REINSERTED, INCLUDING CLEANSING OF PROSTHESIS AND ABUTMENTS 158.00   D6081 SCALING AND DEBRIDEMENT OF A SINGLE IMPLANT IN THE PRESENCE OF MUCOSITIS, INCLUDING INFLAMMATION, BLEEDING UPON PROBING AND INCREASED POCKET DEPTHS; INCLUDES CLEANING OF THE IMPLANT SURFACES, WITHOUT FLAP ENTRY AND CLOSURE 63.63   D6082 IMPLANT SUPPORTED CROWN - PORCELAIN FUSED TO PREDOMINANTLY BASE ALLOYS 1424.75   D6083 IMPLANT SUPPORTED CROWN - PORCELAIN FUSED TO NOBLE ALLOYS 1424.75   D6084 IMPLANT SUPPORTED CROWN - PORCELAIN FUSED TO TITANIUM AND TITANIUM ALLOYS 1424.75   D6085 INTERIM IMPLANT CROWN 426.01   D6086 IMPLANT SUPPORTED CROWN - PREDOMINANTLY BASE ALLOYS 1382.43   D6087 IMPLANT SUPPORTED CROWN - NOBLE ALLOYS 1382.43   D6088 IMPLANT SUPPORTED CROWN - TITANIUM AND TITANIUM ALLOYS 1382.43   D6089 ACCESSING AND RETORQUING LOOSE IMPLANT SCREW - PER SCREW 225.00   D6090 REPAIR OF IMPLANT/ABUTMENT SUPPORTED PROSTHESIS 157.00   D6091 REPLACEMENT OF REPLACEABLE PART OF SEMI-PRECISION OR PRECISION ATTACHMENT OF IMPLANT/ABUTMENT SUPPORTED PROSTHESIS, PER ATTACHMENT 95.00   D6092 RE-CEMENT OR RE-BOND IMPLANT/ABUTMENT SUPPORTED CROWN 148.00   D6093 RE-CEMENT OR RE-BOND IMPLANT/ABUTMENT SUPPORTED FIXED PARTIAL DENTURE 179.15   D6094 ABUTMENT SUPPORTED CROWN - TITANIUM AND TITANIUM ALLOYS 1163.78   D6096 REMOVE BROKEN IMPLANT RETAINING SCREW BR   D6097 ABUTMENT SUPPORTED CROWN - PORCELAIN FUSED TO TITANIUM AND TITANIUM ALLOYS 1424.75   D6098 IMPLANT SUPPORTED RETAINER - PORCELAIN FUSED TO PREDOMINANTLY BASE ALLOYS 1386.66   D6099 IMPLANT SUPPORTED RETAINER FOR FPD - PORCELAIN FUSED TO NOBLE ALLOYS 1414.87   D6100 SURGICAL REMOVAL OF IMPLANT BODY 575.00

Mississippi Workers’ Compensation Medical Fee Schedule Dental D0120—D9999 Effective June 1, 2026

The Code on Dental Procedures and Nomenclature is published in Current Dental Terminology (CDT). 321 Copyright © American Dental Association (ADA). All rights reserved. Fee Data © FAIR Health, Inc. All rights reserved.

Code Description MAR   D6101 DEBRIDEMENT OF A PERI-IMPLANT DEFECT OR DEFECTS SURROUNDING A SINGLE IMPLANT, AND SURFACE CLEANING OF THE EXPOSED IMPLANT SURFACES, INCLUDING FLAP ENTRY AND CLOSURE 429.48   D6102 DEBRIDEMENT AND OSSEOUS CONTOURING OF A PERI-IMPLANT DEFECT OR DEFECTS SURROUNDING A SINGLE IMPLANT AND INCLUDES SURFACE CLEANING OF THE EXPOSED IMPLANT SURFACES, INCLUDING FLAP ENTRY AND CLOSURE 575.54   D6103 BONE GRAFT FOR REPAIR OF PERI-IMPLANT DEFECT DOES NOT INCLUDE FLAP ENTRY AND CLOSURE 491.66   D6104 BONE GRAFT AT TIME OF IMPLANT PLACEMENT 420.00   D6105 REMOVAL OF IMPLANT BODY NOT REQUIRING BONE REMOVAL OR FLAP ELEVATION 156.62   D6106 GUIDED TISSUE REGENERATION RESORBABLE BARRIER, PER IMPLANT 502.89   D6107 GUIDED TISSUE REGENERATION NON-RESORBABLE BARRIER, PER IMPLANT 646.58   D6110 IMPLANT /ABUTMENT SUPPORTED REMOVABLE DENTURE FOR EDENTULOUS ARCH MAXILLARY 2993.01   D6111 IMPLANT /ABUTMENT SUPPORTED REMOVABLE DENTURE FOR EDENTULOUS ARCH MANDIBULAR 3000.00   D6112 IMPLANT /ABUTMENT SUPPORTED REMOVABLE DENTURE FOR PARTIALLY EDENTULOUS ARCH MAXILLARY 1976.77   D6113 IMPLANT /ABUTMENT SUPPORTED REMOVABLE DENTURE FOR PARTIALLY EDENTULOUS ARCH MANDIBULAR 1928.34   D6114 IMPLANT /ABUTMENT SUPPORTED FIXED DENTURE FOR EDENTULOUS ARCH MAXILLARY 3461.89   D6115 IMPLANT /ABUTMENT SUPPORTED FIXED DENTURE FOR EDENTULOUS ARCH MANDIBULAR 3461.89   D6116 IMPLANT /ABUTMENT SUPPORTED FIXED DENTURE FOR PARTIALLY EDENTULOUS ARCH MAXILLARY 2589.94   D6117 IMPLANT /ABUTMENT SUPPORTED FIXED DENTURE FOR PARTIALLY EDENTULOUS ARCH MANDIBULAR 2589.94   D6118 IMPLANT/ABUTMENT SUPPORTED INTERIM FIXED DENTURE FOR EDENTULOUS ARCH MANDIBULAR 1756.25   D6119 IMPLANT/ABUTMENT SUPPORTED INTERIM FIXED DENTURE FOR EDENTULOUS ARCH MAXILLARY 1756.25   D6120 IMPLANT SUPPORTED RETAINER PORCELAIN FUSED TO TITANIUM AND TITANIUM ALLOYS 1386.66   D6121 IMPLANT SUPPORTED RETAINER FOR METAL FPD PREDOMINANTLY BASE ALLOYS 1307.66   D6122 IMPLANT SUPPORTED RETAINER FOR METAL FPD NOBLE ALLOYS 1389.48   D6123 IMPLANT SUPPORTED RETAINER FOR METAL FPD TITANIUM AND TITANIUM ALLOYS 1307.66   D6180 IMPLANT MAINTENANCE PROCEDURES WHEN A FULL ARCH FIXED HYBRID PROSTHESIS IS NOT REMOVED, INCLUDING CLEANSING OF PROSTHESIS AND ABUTMENTS BR   D6190 RADIOGRAPHIC/SURGICAL IMPLANT INDEX, BY REPORT BR   D6191 SEMI-PRECISION ABUTMENT PLACEMENT 578.00   D6192 SEMI-PRECISION ATTACHMENT PLACEMENT 200.00   D6193 REPLACEMENT OF AN IMPLANT SCREW BR   D6194 ABUTMENT SUPPORTED RETAINER CROWN FOR FPD TITANIUM AND TITANIUM ALLOYS 1199.04   D6195 ABUTMENT SUPPORTED RETAINER - PORCELAIN FUSED TO TITANIUM AND TITANIUM ALLOYS 1412.05   D6197 REPLACEMENT OF RESTORATIVE MATERIAL USED TO CLOSE AN ACCESS OPENING OF A SCREW- RETAINED IMPLANT SUPPORTED PROSTHESIS, PER IMPLANT 150.87   D6198 REMOVE INTERIM IMPLANT COMPONENT 260.97   D6199 UNSPECIFIED IMPLANT PROCEDURE, BY REPORT BR   D6205 PONTIC - INDIRECT RESIN BASED COMPOSITE 677.13   D6210 PONTIC - CAST HIGH NOBLE METAL 1099.00   D6211 PONTIC - CAST PREDOMINANTLY BASE METAL 970.12   D6212 PONTIC - CAST NOBLE METAL 952.01   D6214 PONTIC - TITANIUM AND TITANIUM ALLOYS 1041.74   D6240 PONTIC - PORCELAIN FUSED TO HIGH NOBLE METAL 1095.00   D6241 PONTIC - PORCELAIN FUSED TO PREDOMINANTLY BASE METAL 982.00   D6242 PONTIC - PORCELAIN FUSED TO NOBLE METAL 1091.00   D6243 PONTIC - PORCELAIN FUSED TO TITANIUM AND TITANIUM ALLOYS 944.07   D6245 PONTIC - PORCELAIN/CERAMIC 1132.00   D6250 PONTIC - RESIN WITH HIGH NOBLE METAL 1094.81   D6251 PONTIC - RESIN WITH PREDOMINANTLY BASE METAL 931.05   D6252 PONTIC - RESIN WITH NOBLE METAL 961.00

Dental Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 D0120—D9999

20 Miss. Admin. Code Pt. 2, R. 322 Rule 322

Code Description MAR   D6253 INTERIM PONTIC - FURTHER TREATMENT OR COMPLETION OF DIAGNOSIS NECESSARY PRIOR TO FINAL IMPRESSION 415.00   D6545 RETAINER - CAST METAL FOR RESIN BONDED FIXED PROSTHESIS 732.00   D6548 RETAINER - PORCELAIN/CERAMIC FOR RESIN BONDED FIXED PROSTHESIS 990.00   D6549 RETAINER RESIN BONDED FIXED PROSTHESIS 336.21   D6600 RETAINER INLAY - PORCELAIN/CERAMIC, TWO SURFACES 852.92   D6601 RETAINER INLAY - PORCELAIN/CERAMIC, THREE OR MORE SURFACES 894.59   D6602 RETAINER INLAY - CAST HIGH NOBLE METAL, TWO SURFACES 911.52   D6603 RETAINER INLAY - CAST HIGH NOBLE METAL, THREE OR MORE SURFACES 1002.67   D6604 RETAINER INLAY - CAST PREDOMINANTLY BASE METAL, TWO SURFACES 893.29   D6605 RETAINER INLAY - CAST PREDOMINANTLY BASE METAL, THREE OR MORE SURFACES 946.68   D6606 RETAINER INLAY - CAST NOBLE METAL, TWO SURFACES 878.96   D6607 RETAINER INLAY - CAST NOBLE METAL, THREE OR MORE SURFACES 975.33   D6608 RETAINER ONLAY - PORCELAIN/CERAMIC, TWO SURFACES 927.15   D6609 RETAINER ONLAY - PORCELAIN/CERAMIC, THREE OR MORE SURFACES 967.51   D6610 RETAINER ONLAY - CAST HIGH NOBLE METAL, TWO SURFACES 983.14   D6611 RETAINER ONLAY - CAST HIGH NOBLE METAL, THREE OR MORE SURFACES 1075.59   D6612 RETAINER ONLAY - CAST PREDOMINANTLY BASE METAL, TWO SURFACES 977.93   D6613 RETAINER ONLAY - CAST PREDOMINANTLY BASE METAL, THREE OR MORE SURFACES 1022.20   D6614 RETAINER ONLAY - CAST NOBLE METAL, TWO SURFACES 957.09   D6615 RETAINER ONLAY - CAST NOBLE METAL, THREE OR MORE SURFACES 994.86   D6624 RETAINER INLAY - TITANIUM 911.52   D6634 RETAINER ONLAY - TITANIUM 957.09   D6710 RETAINER CROWN - INDIRECT RESIN BASED COMPOSITE 132.25   D6720 RETAINER CROWN - RESIN WITH HIGH NOBLE METAL 1099.40   D6721 RETAINER CROWN - RESIN WITH PREDOMINANTLY BASE METAL 1080.80   D6722 RETAINER CROWN - RESIN WITH NOBLE METAL 1302.00   D6740 RETAINER CROWN - PORCELAIN/CERAMIC 1150.00   D6750 RETAINER CROWN - PORCELAIN FUSED TO HIGH NOBLE METAL 1101.00   D6751 RETAINER CROWN - PORCELAIN FUSED TO PREDOMINANTLY BASE METAL 995.00   D6752 RETAINER CROWN - PORCELAIN FUSED TO NOBLE METAL 1076.00   D6753 RETAINER CROWN - PORCELAIN FUSED TO TITANIUM AND TITANIUM ALLOYS 1088.61   D6780 RETAINER CROWN - 3/4 CAST HIGH NOBLE METAL 1100.33   D6781 RETAINER CROWN - 3/4 CAST PREDOMINANTLY BASE METAL 1100.33   D6782 RETAINER CROWN - 3/4 CAST NOBLE METAL 1022.20   D6783 RETAINER CROWN - 3/4 PORCELAIN/CERAMIC 1132.89   D6784 RETAINER CROWN - TITANIUM AND TITANIUM ALLOYS 1100.33   D6790 RETAINER CROWN - FULL CAST HIGH NOBLE METAL 1300.00   D6791 RETAINER CROWN - FULL CAST PREDOMINANTLY BASE METAL 1067.78   D6792 RETAINER CROWN - FULL CAST NOBLE METAL 1044.14   D6793 INTERIM RETAINER CROWN - FURTHER TREATMENT OR COMPLETION OF DIAGNOSIS NECESSARY PRIOR TO FINAL IMPRESSION 478.00   D6794 RETAINER CROWN - TITANIUM AND TITANIUM ALLOYS 1106.84   D6920 CONNECTOR BAR 234.39   D6930 RE-CEMENT OR RE-BOND FIXED PARTIAL DENTURE 155.00   D6940 STRESS BREAKER 309.92   D6950 PRECISION ATTACHMENT 573.00   D6980 FIXED PARTIAL DENTURE REPAIR NECESSITATED BY RESTORATIVE MATERIAL FAILURE 263.98

Mississippi Workers’ Compensation Medical Fee Schedule Dental D0120—D9999 Effective June 1, 2026

The Code on Dental Procedures and Nomenclature is published in Current Dental Terminology (CDT). 323 Copyright © American Dental Association (ADA). All rights reserved. Fee Data © FAIR Health, Inc. All rights reserved.

Code Description MAR   D6985 PEDIATRIC PARTIAL DENTURE, FIXED 520.87   D6999 UNSPECIFIED FIXED PROSTHODONTIC PROCEDURE, BY REPORT BR   D7111 EXTRACTION, CORONAL REMNANTS PRIMARY TOOTH 124.00   D7140 EXTRACTION, ERUPTED TOOTH OR EXPOSED ROOT (ELEVATION AND/OR FORCEPS REMOVAL) 175.00   D7210 EXTRACTION, ERUPTED TOOTH REQUIRING REMOVAL OF BONE AND/OR SECTIONING OF TOOTH, AND INCLUDING ELEVATION OF MUCOPERIOSTEAL FLAP IF INDICATED 278.00   D7220 REMOVAL OF IMPACTED TOOTH - SOFT TISSUE 350.00   D7230 REMOVAL OF IMPACTED TOOTH - PARTIALLY BONY 432.00   D7240 REMOVAL OF IMPACTED TOOTH - COMPLETELY BONY 510.00   D7241 REMOVAL OF IMPACTED TOOTH - COMPLETELY BONY, WITH UNUSUAL SURGICAL COMPLICATIONS 575.00   D7250 REMOVAL OF RESIDUAL TOOTH ROOTS (CUTTING PROCEDURE) 293.25   D7251 CORONECTOMY INTENTIONAL PARTIAL TOOTH REMOVAL, IMPACTED TEETH ONLY 517.50   D7252 PARTIAL EXTRACTION FOR IMMEDIATE IMPLANT PLACEMENT BR   D7259 NERVE DISSECTION BR   D7260 OROANTRAL FISTULA CLOSURE 1861.09   D7261 PRIMARY CLOSURE OF A SINUS PERFORATION 740.00   D7270 TOOTH RE-IMPLANTATION AND/OR STABILIZATION OF ACCIDENTALLY EVULSED OR DISPLACED TOOTH 565.00   D7272 TOOTH TRANSPLANTATION (INCLUDES RE-IMPLANTATION FROM ONE SITE TO ANOTHER AND SPLINTING AND/OR STABILIZATION) 733.95   D7280 EXPOSURE OF AN UNERUPTED TOOTH 638.25   D7282 MOBILIZATION OF ERUPTED OR MALPOSITIONED TOOTH TO AID ERUPTION 230.00   D7283 PLACEMENT OF DEVICE TO FACILITATE ERUPTION OF IMPACTED TOOTH 293.25   D7284 EXCISIONAL BIOPSY OF MINOR SALIVARY GLANDS 946.79   D7285 INCISIONAL BIOPSY OF ORAL TISSUE HARD (BONE, TOOTH) 900.00   D7286 INCISIONAL BIOPSY OF ORAL TISSUE SOFT 417.00   D7287 EXFOLIATIVE CYTOLOGICAL SAMPLE COLLECTION 176.15   D7288 BRUSH BIOPSY - TRANSEPITHELIAL SAMPLE COLLECTION 176.15   D7290 SURGICAL REPOSITIONING OF TEETH 440.37   D7291 TRANSSEPTAL FIBEROTOMY/SUPRA CRESTAL FIBEROTOMY, BY REPORT BR   D7292 PLACEMENT OF TEMPORARY ANCHORAGE DEVICE [SCREW RETAINED PLATE] REQUIRING FLAP 704.59   D7293 PLACEMENT OF TEMPORARY ANCHORAGE DEVICE REQUIRING FLAP 440.37   D7294 PLACEMENT OF TEMPORARY ANCHORAGE DEVICE WITHOUT FLAP 366.97   D7295 HARVEST OF BONE FOR USE IN AUTOGENOUS GRAFTING PROCEDURE BR   D7296 CORTICOTOMY ONE TO THREE TEETH OR TOOTH SPACES, PER QUADRANT BR   D7297 CORTICOTOMY FOUR OR MORE TEETH OR TOOTH SPACES, PER QUADRANT BR   D7298 REMOVAL OF TEMPORARY ANCHORAGE DEVICE [SCREW RETAINED PLATE], REQUIRING FLAP BR   D7299 REMOVAL OF TEMPORARY ANCHORAGE DEVICE, REQUIRING FLAP BR   D7300 REMOVAL OF TEMPORARY ANCHORAGE DEVICE WITHOUT FLAP BR   D7310 ALVEOLOPLASTY IN CONJUNCTION WITH EXTRACTIONS - FOUR OR MORE TEETH OR TOOTH SPACES, PER QUADRANT 253.00   D7311 ALVEOLOPLASTY IN CONJUNCTION WITH EXTRACTIONS - ONE TO THREE TEETH OR TOOTH SPACES, PER QUADRANT 201.25   D7320 ALVEOLOPLASTY NOT IN CONJUNCTION WITH EXTRACTIONS - FOUR OR MORE TEETH OR TOOTH SPACES, PER QUADRANT 423.20   D7321 ALVEOLOPLASTY NOT IN CONJUNCTION WITH EXTRACTIONS - ONE TO THREE TEETH OR TOOTH SPACES, PER QUADRANT 376.05   D7340 VESTIBULOPLASTY - RIDGE EXTENSION (SECONDARY EPITHELIALIZATION) 2018.35   D7350 VESTIBULOPLASTY - RIDGE EXTENSION (INCLUDING SOFT TISSUE GRAFTS, MUSCLE REATTACHMENT, REVISION OF SOFT TISSUE ATTACHMENT AND MANAGEMENT OF HYPERTROPHIED AND HYPERPLASTIC TISSUE) 5871.56   D7410 EXCISION OF BENIGN LESION UP TO 1.25 CM 488.75

Dental Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 D0120—D9999

20 Miss. Admin. Code Pt. 2, R. 324 Rule 324

Code Description MAR   D7411 EXCISION OF BENIGN LESION GREATER THAN 1.25 CM 705.00   D7412 EXCISION OF BENIGN LESION, COMPLICATED 1541.28   D7413 EXCISION OF MALIGNANT LESION UP TO 1.25 CM 1027.52   D7414 EXCISION OF MALIGNANT LESION GREATER THAN 1.25 CM 1541.28   D7415 EXCISION OF MALIGNANT LESION, COMPLICATED 1724.77   D7440 EXCISION OF MALIGNANT TUMOR - LESION DIAMETER UP TO 1.25 CM 1394.50   D7441 EXCISION OF MALIGNANT TUMOR - LESION DIAMETER GREATER THAN 1.25 CM 2055.05   D7450 REMOVAL OF BENIGN ODONTOGENIC CYST OR TUMOR - LESION DIAMETER UP TO 1.25 CM 1060.00   D7451 REMOVAL OF BENIGN ODONTOGENIC CYST OR TUMOR - LESION DIAMETER GREATER THAN 1.25 CM 975.00   D7460 REMOVAL OF BENIGN NONODONTOGENIC CYST OR TUMOR - LESION DIAMETER UP TO 1.25 CM 809.17   D7461 REMOVAL OF BENIGN NONODONTOGENIC CYST OR TUMOR - LESION DIAMETER GREATER THAN 1.25 CM 1203.67   D7465 DESTRUCTION OF LESION(S) BY PHYSICAL OR CHEMICAL METHOD, BY REPORT BR   D7471 REMOVAL OF LATERAL EXOSTOSIS (MAXILLA OR MANDIBLE) 747.50   D7472 REMOVAL OF TORUS PALATINUS 1190.83   D7473 REMOVAL OF TORUS MANDIBULARIS 799.25   D7485 REDUCTION OF OSSEOUS TUBEROSITY 488.75   D7490 RADICAL RESECTION OF MAXILLA OR MANDIBLE 8807.34   D7509 MARSUPIALIZATION OF ODONTOGENIC CYST 486.66   D7510 INCISION AND DRAINAGE OF ABSCESS - INTRAORAL SOFT TISSUE 253.00   D7511 INCISION AND DRAINAGE OF ABSCESS - INTRAORAL SOFT TISSUE - COMPLICATED (INCLUDES DRAINAGE OF MULTIPLE FASCIAL SPACES) 339.25   D7520 INCISION AND DRAINAGE OF ABSCESS - EXTRAORAL SOFT TISSUE 1503.12   D7521 INCISION AND DRAINAGE OF ABSCESS - EXTRAORAL SOFT TISSUE - COMPLICATED (INCLUDES DRAINAGE OF MULTIPLE FASCIAL SPACES) 1651.38   D7530 REMOVAL OF FOREIGN BODY FROM MUCOSA, SKIN, OR SUBCUTANEOUS ALVEOLAR TISSUE 523.00   D7540 REMOVAL OF REACTION PRODUCING FOREIGN BODIES, MUSCULOSKELETAL SYSTEM 575.00   D7550 PARTIAL OSTECTOMY/SEQUESTRECTOMY FOR REMOVAL OF NON-VITAL BONE 1092.50   D7560 MAXILLARY SINUSOTOMY FOR REMOVAL OF TOOTH FRAGMENT OR FOREIGN BODY 2972.48   D7610 MAXILLA - OPEN REDUCTION (TEETH IMMOBILIZED, IF PRESENT) 4807.34   D7620 MAXILLA - CLOSED REDUCTION (TEETH IMMOBILIZED, IF PRESENT) 3605.14   D7630 MANDIBLE - OPEN REDUCTION (TEETH IMMOBILIZED, IF PRESENT) 6250.28   D7640 MANDIBLE - CLOSED REDUCTION (TEETH IMMOBILIZED, IF PRESENT) 3966.24   D7650 MALAR AND/OR ZYGOMATIC ARCH - OPEN REDUCTION 3004.77   D7660 MALAR AND/OR ZYGOMATIC ARCH - CLOSED REDUCTION 1771.74   D7670 ALVEOLUS - CLOSED REDUCTION, MAY INCLUDE STABILIZATION OF TEETH 1382.75   D7671 ALVEOLUS - OPEN REDUCTION, MAY INCLUDE STABILIZATION OF TEETH 2605.50   D7680 FACIAL BONES - COMPLICATED REDUCTION WITH FIXATION AND MULTIPLE SURGICAL APPROACHES 9014.31   D7710 MAXILLA - OPEN REDUCTION 5649.91   D7720 MAXILLA - CLOSED REDUCTION 3966.24   D7730 MANDIBLE - OPEN REDUCTION 8173.21   D7740 MANDIBLE - CLOSED REDUCTION 4044.04   D7750 MALAR AND/OR ZYGOMATIC ARCH - OPEN REDUCTION 5143.49   D7760 MALAR AND/OR ZYGOMATIC ARCH - CLOSED REDUCTION 2063.85   D7770 ALVEOLUS - OPEN REDUCTION STABILIZATION OF TEETH 2796.33   D7771 ALVEOLUS, CLOSED REDUCTION STABILIZATION OF TEETH 2157.80   D7780 FACIAL BONES - COMPLICATED REDUCTION WITH FIXATION AND MULTIPLE APPROACHES 12019.08   D7810 OPEN REDUCTION OF DISLOCATION 5287.34

Mississippi Workers’ Compensation Medical Fee Schedule Dental D0120—D9999 Effective June 1, 2026

The Code on Dental Procedures and Nomenclature is published in Current Dental Terminology (CDT). 325 Copyright © American Dental Association (ADA). All rights reserved. Fee Data © FAIR Health, Inc. All rights reserved.

Code Description MAR   D7820 CLOSED REDUCTION OF DISLOCATION 866.06   D7830 MANIPULATION UNDER ANESTHESIA 496.15   D7840 CONDYLECTOMY 7207.34   D7850 SURGICAL DISCECTOMY, WITH/WITHOUT IMPLANT 6223.85   D7852 DISC REPAIR 7126.61   D7854 SYNOVECTOMY 7354.13   D7856 MYOTOMY 5218.35   D7858 JOINT RECONSTRUCTION 14874.13   D7860 ARTHROTOMY 6339.82   D7865 ARTHROPLASTY 10216.51   D7870 ARTHROCENTESIS 337.61   D7871 NON-ARTHROSCOPIC LYSIS AND LAVAGE 675.23   D7872 ARTHROSCOPY - DIAGNOSIS, WITH OR WITHOUT BIOPSY 3603.67   D7873 ARTHROSCOPY: LAVAGE AND LYSIS OF ADHESIONS 4339.08   D7874 ARTHROSCOPY: DISC REPOSITIONING AND STABILIZATION 6223.85   D7875 ARTHROSCOPY: SYNOVECTOMY 6818.35   D7876 ARTHROSCOPY: DISCECTOMY 7351.19   D7877 ARTHROSCOPY: DEBRIDEMENT 6488.07   D7880 OCCLUSAL ORTHOTIC DEVICE, BY REPORT BR   D7881 OCCLUSAL ORTHOTIC DEVICE ADJUSTMENT 80.92   D7899 UNSPECIFIED TMD THERAPY, BY REPORT BR   D7910 SUTURE OF RECENT SMALL WOUNDS UP TO 5 CM 80.00   D7911 COMPLICATED SUTURE - UP TO 5 CM 1104.52   D7912 COMPLICATED SUTURE - GREATER THAN 5 CM 2163.67   D7920 SKIN GRAFT (IDENTIFY DEFECT COVERED, LOCATION AND TYPE OF GRAFT) 3544.95   D7921 COLLECTION AND APPLICATION OF AUTOLOGOUS BLOOD CONCENTRATE PRODUCT 343.85   D7922 PLACEMENT OF INTRA-SOCKET BIOLOGICAL DRESSING TO AID IN HEMOSTASIS OR CLOT STABILIZATION, PER SITE 46.00   D7939 INDEXING FOR OSTEOTOMY USING DYNAMIC ROBOTIC ASSISTED OR DYNAMIC NAVIGATION BR   D7940 OSTEOPLASTY - FOR ORTHOGNATHIC DEFORMITIES BR   D7941 OSTEOTOMY - MANDIBULAR RAMI 9027.52   D7943 OSTEOTOMY - MANDIBULAR RAMI WITH BONE GRAFT; INCLUDES OBTAINING THE GRAFT 8293.58   D7944 OSTEOTOMY - SEGMENTED OR SUBAPICAL 7390.83   D7945 OSTEOTOMY - BODY OF MANDIBLE 9834.86   D7946 LEFORT I (MAXILLA - TOTAL) 12183.49   D7947 LEFORT I (MAXILLA - SEGMENTED) 10245.87   D7948 LEFORT II OR LEFORT III (OSTEOPLASTY OF FACIAL BONES FOR MIDFACE HYPOPLASIA OR RETRUSION) - WITHOUT BONE GRAFT 13299.08   D7949 LEFORT II OR LEFORT III - WITH BONE GRAFT 17321.10   D7950 OSSEOUS, OSTEOPERIOSTEAL, OR CARTILAGE GRAFT OF THE MANDIBLE OR MAXILLA - AUTOGENOUS OR NONAUTOGENOUS, BY REPORT BR   D7951 SINUS AUGMENTATION WITH BONE OR BONE SUBSTITUTES VIA A LATERAL OPEN APPROACH 1696.23   D7952 SINUS AUGMENTATION VIA A VERTICAL APPROACH 901.12   D7953 BONE REPLACEMENT GRAFT FOR RIDGE PRESERVATION - PER SITE 460.00   D7955 REPAIR OF MAXILLOFACIAL SOFT AND/OR HARD TISSUE DEFECT BR   D7956 GUIDED TISSUE REGENERATION, EDENTULOUS AREA RESORBABLE BARRIER, PER SITE 524.09   D7957 GUIDED TISSUE REGENERATION, EDENTULOUS AREA NON-RESORBABLE BARRIER, PER SITE 673.83   D7961 BUCCAL / LABIAL FRENECTOMY (FRENULECTOMY) 472.00   D7962 LINGUAL FRENECTOMY (FRENULECTOMY) 472.00

Dental Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 D0120—D9999

20 Miss. Admin. Code Pt. 2, R. 326 Rule 326

Code Description MAR   D7963 FRENULOPLASTY 660.55   D7970 EXCISION OF HYPERPLASTIC TISSUE - PER ARCH 226.55   D7971 EXCISION OF PERICORONAL GINGIVA 240.00   D7972 SURGICAL REDUCTION OF FIBROUS TUBEROSITY 350.75   D7979 NON SURGICAL SIALOLITHOTOMY BR   D7980 SURGICAL SIALOLITHOTOMY 332.00   D7981 EXCISION OF SALIVARY GLAND, BY REPORT BR   D7982 SIALODOCHOPLASTY 2187.16   D7983 CLOSURE OF SALIVARY FISTULA 2099.08   D7990 EMERGENCY TRACHEOTOMY 1805.50   D7991 CORONOIDECTOMY 4403.67   D7993 SURGICAL PLACEMENT OF CRANIOFACIAL IMPLANT EXTRA ORAL BR   D7994 SURGICAL PLACEMENT: ZYGOMATIC IMPLANT BR   D7995 SYNTHETIC GRAFT - MANDIBLE OR FACIAL BONES, BY REPORT BR   D7996 IMPLANT-MANDIBLE FOR AUGMENTATION PURPOSES (EXCLUDING ALVEOLAR RIDGE), BY REPORT BR   D7997 APPLIANCE REMOVAL (NOT BY DENTIST WHO PLACED APPLIANCE), INCLUDES REMOVAL OF ARCHBAR 337.61   D7998 INTRAORAL PLACEMENT OF A FIXATION DEVICE NOT IN CONJUNCTION WITH A FRACTURE 1467.89   D7999 UNSPECIFIED ORAL SURGERY PROCEDURE, BY REPORT BR   D9110 PALLIATIVE TREATMENT OF DENTAL PAIN PER VISIT 108.00   D9120 FIXED PARTIAL DENTURE SECTIONING 200.00   D9130 TEMPOROMANDIBULAR JOINT DYSFUNCTION NON-INVASIVE PHYSICAL THERAPIES BR   D9210 LOCAL ANESTHESIA NOT IN CONJUNCTION WITH OPERATIVE OR SURGICAL PROCEDURES 79.00   D9211 REGIONAL BLOCK ANESTHESIA 44.31   D9212 TRIGEMINAL DIVISION BLOCK ANESTHESIA 79.00   D9215 LOCAL ANESTHESIA IN CONJUNCTION WITH OPERATIVE OR SURGICAL PROCEDURES 64.40   D9219 EVALUATION FOR MODERATE SEDATION, DEEP SEDATION OR GENERAL ANESTHESIA 78.92   D9222 ADMINISTRATION OF DEEP SEDATION/GENERAL ANESTHESIA FIRST 15 MINUTE INCREMENT, OR ANY PORTION THEREOF 225.00   D9223 ADMINISTRATION OF DEEP SEDATION/GENERAL ANESTHESIA EACH SUBSEQUENT 15 MINUTE INCREMENT, OR ANY PORTION THEREOF 215.00   D9230 ADMINISTRATION OF NITROUS OXIDE 55.00   D9239 ADMINISTRATION OF MODERATE SEDATION INTRAVENOUS FIRST 15 MINUTE INCREMENT, OR ANY PORTION THEREOF 195.50   D9243 ADMINISTRATION OF MODERATE SEDATION INTRAVENOUS EACH SUBSEQUENT 15 MINUTE INCREMENT, OR ANY PORTION THEREOF 188.00   D9310 CONSULTATION - DIAGNOSTIC SERVICE PROVIDED BY DENTIST OR PHYSICIAN OTHER THAN REQUESTING DENTIST OR PHYSICIAN 115.00   D9311 CONSULTATION WITH A MEDICAL HEALTH CARE PROFESSIONAL 211.76   D9410 HOUSE/EXTENDED CARE FACILITY CALL 253.39   D9420 HOSPITAL OR AMBULATORY SURGICAL CENTER CALL 325.00   D9430 OFFICE VISIT FOR OBSERVATION (DURING REGULARLY SCHEDULED HOURS) - NO OTHER SERVICES PERFORMED 79.51   D9440 OFFICE VISIT - AFTER REGULARLY SCHEDULED HOURS 155.00   D9450 CASE PRESENTATION, SUBSEQUENT TO DETAILED AND EXTENSIVE TREATMENT PLANNING 51.75   D9610 THERAPEUTIC PARENTERAL DRUG, SINGLE ADMINISTRATION 31.80   D9612 THERAPEUTIC PARENTERAL DRUGS, TWO OR MORE ADMINISTRATIONS, DIFFERENT MEDICATIONS 190.83   D9613 INFILTRATION OF SUSTAINED RELEASE THERAPEUTIC DRUG, PER QUADRANT 40.69   D9630 DRUGS OR MEDICAMENTS DISPENSED IN THE OFFICE FOR HOME USE 29.68   D9910 APPLICATION OF DESENSITIZING MEDICAMENT 55.00   D9911 APPLICATION OF DESENSITIZING RESIN FOR CERVICAL AND/OR ROOT SURFACE, PER TOOTH 28.75

Mississippi Workers’ Compensation Medical Fee Schedule Dental D0120—D9999 Effective June 1, 2026

The Code on Dental Procedures and Nomenclature is published in Current Dental Terminology (CDT). 327 Copyright © American Dental Association (ADA). All rights reserved. Fee Data © FAIR Health, Inc. All rights reserved.

Code Description MAR   D9912 PRE-VISIT PATIENT SCREENING 56.34   D9913 ADMINISTRATION OF NEUROMODULATORS BR   D9914 ADMINISTRATION OF DERMAL FILLERS BR   D9920 BEHAVIOR MANAGEMENT, BY REPORT BR   D9930 TREATMENT OF COMPLICATIONS (POST-SURGICAL) - UNUSUAL CIRCUMSTANCES, BY REPORT BR   D9932 CLEANING AND INSPECTION OF REMOVABLE COMPLETE DENTURE, MAXILLARY 113.82   D9933 CLEANING AND INSPECTION OF REMOVABLE COMPLETE DENTURE, MANDIBULAR 119.08   D9934 CLEANING AND INSPECTION OF REMOVABLE PARTIAL DENTURE, MAXILLARY 113.82   D9935 CLEANING AND INSPECTION OF REMOVABLE PARTIAL DENTURE, MANDIBULAR 113.82   D9938 FABRICATION OF A CUSTOM REMOVABLE CLEAR PLASTIC TEMPORARY AESTHETIC APPLIANCE BR   D9939 PLACEMENT OF A CUSTOM REMOVABLE CLEAR PLASTIC TEMPORARY AESTHETIC APPLIANCE BR   D9941 FABRICATION OF ATHLETIC MOUTHGUARD 145.00 D9942 REPAIR AND/OR RELINE OF OCCLUSAL GUARD 90.85 D9943 OCCLUSAL GUARD ADJUSTMENT 91.32 D9944 OCCLUSAL GUARD HARD APPLIANCE, FULL ARCH 441.39 D9945 OCCLUSAL GUARD SOFT APPLIANCE, FULL ARCH 383.82 D9946 OCCLUSAL GUARD HARD APPLIANCE, PARTIAL ARCH 383.82 D9947 CUSTOM SLEEP APNEA APPLIANCE FABRICATION AND PLACEMENT 1411.80 D9948 ADJUSTMENT OF CUSTOM SLEEP APNEA APPLIANCE BR D9949 REPAIR OF CUSTOM SLEEP APNEA APPLIANCE BR D9950 OCCLUSION ANALYSIS - MOUNTED CASE 375.00 D9951 OCCLUSAL ADJUSTMENT - LIMITED 135.00 D9952 OCCLUSAL ADJUSTMENT - COMPLETE 803.00 D9953 RELINE CUSTOM SLEEP APNEA APPLIANCE (INDIRECT) 485.29 D9954 FABRICATION AND DELIVERY OF ORAL APPLIANCE THERAPY (OAT) MORNING REPOSITIONING DEVICE BR D9955 ORAL APPLIANCE THERAPY (OAT) TITRATION VISIT BR D9956 ADMINISTRATION OF HOME SLEEP APNEA TEST BR D9957 SCREENING FOR SLEEP RELATED BREATHING DISORDERS BR D9959 UNSPECIFIED SLEEP APNEA SERVICES PROCEDURE, BY REPORT BR D9961 DUPLICATE/COPY PATIENT'S RECORDS BR D9970 ENAMEL MICROABRASION 156.00 D9971 ODONTOPLASTY - PER TOOTH 115.00 D9972 EXTERNAL BLEACHING - PER ARCH - PERFORMED IN OFFICE 253.00 D9973 EXTERNAL BLEACHING - PER TOOTH 50.00 D9974 INTERNAL BLEACHING - PER TOOTH 277.00 D9975 EXTERNAL BLEACHING FOR HOME APPLICATION, PER ARCH; INCLUDES MATERIALS AND FABRICATION OF CUSTOM TRAYS 99.00 D9985 SALES TAX BR D9986 MISSED APPOINTMENT 50.00 D9987 CANCELLED APPOINTMENT 50.00 D9990 CERTIFIED TRANSLATION OR SIGN-LANGUAGE SERVICES PER VISIT BR D9991 DENTAL CASE MANAGEMENT - ADDRESSING APPOINTMENT COMPLIANCE BARRIERS 49.11 D9992 DENTAL CASE MANAGEMENT - CARE COORDINATION 48.46 D9993 DENTAL CASE MANAGEMENT - MOTIVATIONAL INTERVIEWING 49.11 D9994 DENTAL CASE MANAGEMENT - PATIENT EDUCATION TO IMPROVE ORAL HEALTH LITERACY 67.35 D9995 TELEDENTISTRY SYNCHRONOUS; REAL-TIME ENCOUNTER 211.76 D9996 TELEDENTISTRY ASYNCHRONOUS; INFORMATION STORED AND FORWARDED TO DENTIST FOR SUBSEQUENT REVIEW 215.00

Dental Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 D0120—D9999

20 Miss. Admin. Code Pt. 2, R. 328 Rule 328

Code Description MAR D9997 DENTAL CASE MANAGEMENT - PATIENTS WITH SPECIAL HEALTH CARE NEEDS BR D9999 UNSPECIFIED ADJUNCTIVE PROCEDURE, BY REPORT BR

CPT Copyright 2024 American Medical Association. All rights reserved. 329 INPATIENT HOSPITAL AND OUTPATIENT FACILITY PAYMENT SCHEDULE AND RULES Note: Rules used by physicians and other qualified health care providers (OQHP) in reporting their services are presented in the General Rules section. See the Modifier and Code Rules section for detailed information on modifiers. This section of the Fee Schedule applies to all acute care facilities including long term acute care (LTAC) hospitals. I.INPATIENT AND OUTPATIENT CARE RULES A. Definition. For purposes of this schedule, an injured worker is considered an “inpatient” if formally admitted as an inpatient with the expectation that the injured worker will require hospital care that is expected to span at least two (2) midnights. B. Health care facilities providing services to workers' compensation claimants must meet requirements of the state of Mississippi. C. Billing and Reimbursement Rules for Inpatient Care. 1. Facilities must submit the bill for inpatient services within thirty (30) days after discharge. For those cases involving extended hospitalization, interim bills must be submitted every thirty (30) days. 2. Reimbursement for acute inpatient hospital services shall be the lesser of the amount billed or the MAR for the diagnosis-related group (DRG) as fixed by the rules set forth in this section of the Fee Schedule. 3. Non-covered charges include but are not necessarily limited to: a. Convenience items; b. Charges for services not related to the work-related injury/illness; and c. Services that were not certified by the payer or their representative as medically necessary. 4. When reviewing surgical claims, including for outlier consideration, the following apply: a. Most operative procedures require cardiopulmonary monitoring either by the physician or OQHP performing the procedure or an anesthesiologist/anesthetist. Because these services are integral to the operating room environment, they are considered as part of the operating room (OR) fee and are not separately reimbursed, nor are they included separately in the total charge for outlier consideration: • Cardiac monitors; • Oximetry; • Blood pressure monitor; • Lasers; • Microscopes; • Video equipment; • Set up fees; • Additional OR staff; • Gowns; • Gloves; • Drapes; • Towels; • Mayo stand covers; • On-call or call-back fees; and • After-hours fees. b. Billing for surgery packs as well as individual items in the packs is not allowed and shall not be included in the total charge for outlier consideration. c. A majority of invasive procedures requires availability of vascular and/or airway access; therefore, the work associated with obtaining this access is included in the cost of the service, i.e., anesthesia— airway access is associated with general anesthesia and is included in the anesthesia charges. d. Recovery room and ICU rates include the charge for cardiac monitoring and oximeter. It is assumed the injured worker is placed in these special areas for monitoring and specialized care which is bundled into the special care rate. Call- back fees are not reimbursed for recovery room. e. Separate reimbursement is not allowed for setting up portable equipment at the injured worker’s bedside. f. The following items do not qualify for separate reimbursement regardless of inpatient or outpatient status, and are not included in the total charge for outlier consideration: • Applicators, cotton balls, band-aids; • Syringes; • Aspirin; • Thermometers, blood pressure apparatus; • Water pitchers; • Alcohol preps; and

Facility Payment Schedules and Rules Mississippi Workers’ Compensation Medical Fee Schedule

20 Miss. Admin. Code Pt. 2, R. 330 Rule 330

CPT Copyright 2024 American Medical Association. All rights reserved. • Ice bags. g. Separate reimbursement is not allowed for equipment such as compressive devices, or other equipment used during the operative or immediate postoperative period. D. Implants, Durable Medical Equipment, and Supplies. Generally, durable medical equipment and supplies provided or administered in an inpatient hospital setting are not separately reimbursed since they are included in the reimbursement. Unless otherwise specifically provided herein, implantables used in the inpatient setting are included in the applicable MS-DRG reimbursement for inpatient treatment, and, therefore, the provider of inpatient services is not required to furnish the payer with an invoice for implantables. Implantables used in the outpatient setting, are included in the applicable APC payment for CPT ®

codes with a status indicator of J1. Therefore, the provider of outpatient services is not required to furnish the payer with an invoice for implantables. E. Reimbursement Methodology. The maximum allowable reimbursement (MAR) for inpatient facility services is provided by MS-DRG in this Fee Schedule. As of the effective date of this Fee Schedule, reimbursement is the lesser of the total billed charge or the MS-DRG MAR. This methodology includes inpatient psychiatric admissions and long-term acute care (LTAC). Any MS-DRGs outside of this Fee Schedule shall be reimbursed at seventy-five percent (75%) of charges. The lesser of the billed charges or the MS-DRG MAR represent payment in full, unless the outlier payment is applicable, or unless a contract between the payer and provider governs reimbursement, or unless otherwise specifically stated in this Fee Schedule. 1. MS-DRG MAR is calculated by multiplying the Base Rate times the Relative Weight in effect on the date of discharge for the MS-DRG. 2. The Base Rate for Mississippi is the current National Medicare Base Rate in effect as of the date of discharge, multiplied by two (2). This is posted annually on the MWCC website, Fee Schedule section. 3. Common Medicare add-ons, such as for teaching hospitals (GME), DSH and Capital PPS, will not be allowed, and shall be considered as already included in the enhanced MS-DRG MAR under this Fee Schedule. 4. All implantables shall be included in the applicable MS-DRG reimbursement for inpatient treatment, and shall not be reimbursed separately in addition to the MS-DRG payment. 5. Outlier Payments. To provide additional reimbursement for cases where the MS-DRG payment is deemed inadequate by the MWCC to cover the costs incurred by the facility, the MWCC has established an outlier payment for high-cost cases. The amount eligible for outlier reimbursement is equal to Total Charges minus MS-DRG Payment minus Implantable Charges minus Non-Covered or Non-Qualified Charges (as provided in Part 1.C. above) minus the Outlier Threshold. The Outlier Threshold amount shall be specific to each facility and shall be equal to one-half (1/2) of the Medicare MS-DRG outlier threshold in effect for each facility. Once the annual inpatient hospital MAR are posted on the MWCC website each year, the Medicare threshold and Mississippi hospital outlier thresholds do not change, regardless of any other updates or corrections subsequently posted by CMS. 6. Any amount determined to be eligible for additional outlier reimbursement shall be reimbursed at fifteen percent (15%) above the facility’s cost for the outlier eligible charges. Cost is determined using the facility’s cost-to- charge ratio, as determined by Medicare (CMS), which is in effect at the time of discharge. These cost-to-charge ratios are posted annually on the MWCC website, Fee Schedule section. Outlier payment is figured by multiplying the eligible outlier amount by the cost-to-charge ratio, and then adding fifteen percent (15%) to compute the additional outlier payment due. F. Emergency Room Services. Emergency room facility fees, supplies, and treatment are reimbursed according to the Ambulatory Payment Classification, system, as set forth herein under the heading “Ambulatory Surgery Center/Outpatient Facility Reimbursement.” Laboratory and radiology services are reimbursed at the technical (TC) MAR in the corresponding section of this Fee Schedule. Outpatient facilities are paid based on the TC MAR when there is one. If there is no TC amount, and the service is payable in an outpatient setting, there will be an APC MAR which should be used. Physician or OQHP services are to be billed on an appropriate CMS claim form or electronic submission and paid according to the proper section. G. Observation Services 1. Definition. Observation care is a well-defined set of specific, clinically appropriate services, which include ongoing short-term treatment, assessment, and reassessment before a decision can be made regarding whether the injured worker will require further treatment as a hospital inpatient or if they are able to be discharged from the hospital. Observation services may be ordered for injured workers who present to the emergency department and who then require a significant period of treatment or monitoring in order to make a decision concerning their admission or discharge. In the majority of cases, the decision whether to discharge an injured worker from the hospital following resolution of the reason for the observation care or to admit the injured worker as an inpatient can be made in less than forty-eight (48) hours, usually in less than twenty-four (24) hours.

Mississippi Workers’ Compensation Medical Fee Schedule Facility Payment Schedules and Rules

CPT Copyright 2024 American Medical Association. All rights reserved. 331 2. General Information a. Observation begins when the injured worker monitoring begins and ends when the order for discharge is written or given verbally by the physician or OQHP. b. On rare occasions, an observation stay may be extended to forty-eight (48) hours. In such cases, medical necessity must be established and prior authorization must be provided by the payer. c. Services which are NOT considered necessary for observation are as follows: (1) Services that are not reasonable and necessary for the diagnosis and treatment of the work-related injury, but are provided for convenience of the injured worker, family, or physician or OQHP; (2) Any substitution of an outpatient observation for a medically appropriate inpatient admission; (3) Services ordered as inpatient by the physician or OQHP but billed as outpatient by the facility; (4) Standing orders for observation following outpatient surgery; (5) Test preparation for a surgical procedure; and (6) Continued care of an injured worker who has had a significant procedure as identified with OPPS indicator S or T. d. Observation is not reimbursable for routine preparation furnished prior to an outpatient service or recovery after an outpatient service. Please refer to the criteria for observation services. 3. Billing and Reimbursement a. Observation status is billed at an hourly monitoring rate. The hourly rate is all inclusive with the exception of non- significant ancillary services. b. Observation is billed at the rate of five hundred dollars ($500.00) for the first three (3) hours and eighty dollars ($80.00) per hour thereafter. Laboratory and radiology are reimbursed according to the Fee Schedule payment limits. c. Revenue code 762 is used to bill observation charges. d. Observation services provided to an injured worker who is subsequently admitted as an inpatient should be included on the inpatient claim.

H. Stand-alone Services. When services are provided as an outpatient service, and are not performed as a surgical procedure, medical procedure, or emergency room service, the facility reimbursement equals the technical (TC) MAR in the corresponding section of this Fee Schedule. Outpatient facilities are paid based on the TC MAR when there is one. If there is no TC amount, and the service is payable in an outpatient setting, there will be an APC MAR which should be used.

I. Disputed Medical Charges; Abusive or Unfair Billing 1. Disputes over charges, fees, services, or other issues related to treatment under the terms of the Workers’ Compensation Law shall be resolved in accordance with the Dispute Resolution Rules set forth elsewhere in this Fee Schedule. 2. If the MWCC determines that the charge amount for items substantially and consistently exceeds the facility’s mark-up ratio, or if a facility’s charges for other services or MS-DRGs is substantially and consistently higher than the average charges made for the same services or MS-DRGs by other facilities in the State, then the MWCC may consider this to be an indication of abusive or unfair billing practices, and may order the facility in question to appear and show cause why penalties and other sanctions as allowed by Law should not be imposed on said facility for such abusive billing practices. For purposes of this provision, the mark-up ratio shall be the inverse of the facility’s cost-to- charge ratio. The average charges by facilities for service or MS-DRGs may be determined by reference to the publicly available MedPAR file for Medicare inpatient admissions, with due consideration being given to the differences between the Medicare inpatient population and the workers’ compensation inpatient population. II. INPATIENT REHABILITATION FACILITIES (IRFS) A. Inpatient Rehabilitation Facility Reimbursement Methodology. Reimbursement for inpatient rehabilitation facilities (IRFs) will be based upon the CMS Prospective Payment System (PPS). 1. The Fee Schedule MAR for IRFs will be 1.8 times the CMS IRF PPS Pricer calculation, unless the payer and provider have a separate contract governing the reimbursement of services provided by an IRF, or unless total billed charges are less. 2. The IRF reimbursement due under this Fee Schedule will be calculated using the CMS IRF PPS Pricer calculation in effect on the date of discharge. 3. The CMS IRF Pricer is used only for facilities that have met the CMS qualifications for IRF. 4. Reimbursement for IRFs is not calculated using the MS-DRG methodology. 5. The CMS IRF PPS PC Pricer is available at: https://webpricer.cms.gov/#/pricer/irf

Facility Payment Schedules and Rules Mississippi Workers’ Compensation Medical Fee Schedule

20 Miss. Admin. Code Pt. 2, R. 332 Rule 332

CPT Copyright 2024 American Medical Association. All rights reserved. B. CMS Inpatient Rehabilitation Facility Reimbursement. Medicare regulations define inpatient rehabilitation facilities (IRFs) in the Code of Federal Regulations, Part 412, and subpart B. Medicare payments to IRFs are based on the IRF Prospective Payment System (PPS) under subpart P of part 412. The IRF must be currently accredited by the MWCC on Accreditation of Rehabilitation Facilities (CARF), licensed by the State, and certified by Medicare as an IRF at the time the injured worker is treated. The IRF must possess a Medicare/Medicaid provider number, or CMS Certification Number. The provider number consists of six digits. The first two digits indicate the state, 25 is for Mississippi, and the remaining four digits identify the facility as an IRF. The four-digit suffix must be in the range of 3025– 3099 for rehabilitation facilities, exempt units must have a T in the third position, e.g., 25TXXX. Unless governed by contract between payer and provider, or unless total billed charges are less, the reimbursement for an IRF under this Fee Schedule shall be the IRF PPS calculated rate multiplied by 1.8. Other inpatient MS-DRG or PPS calculations are not appropriate to use for IRF services. The IRF PPS rate is calculated using the formula for the current fiscal year, including outlier. The final calculation is published in the Federal Register, prior to October 1 of each year. IRF reimbursement is based upon the case mix group (CMG) to which the injured worker is assigned and the CMG assigned by the Medicare CMG grouper. The CMG must be reported on the claim with revenue code 0024. This code indicates that this claim is being paid under the PPS and the revenue code can appear on a claim only once. The Federal Register explains the formula for calculating the IRF PPS rate. The rates are calculated on CMG assignment from the combinations of ICD- 10-CM codes with additional factors of labor share, wage index, rural adjustment (if applicable) and low income percentage (LIP) for a final adjusted IRF PPS reimbursement. This calculated IRF PPS reimbursement is multiplied by 1.8 to determine the reimbursement rate. Reimbursement rates are based on the date of discharge, using the Medicare IRF PPS Pricer for the appropriate year, which is available as a free download from: https://www.cms.gov/irf-webpricer. The Medicare Pricer returns the payment rate specific to the facility. C. Neuro Rehabilitation Facilities. Reimbursement for stays in neuro rehabilitation facilities shall be negotiated. III. AMBULATORY SURGERY CENTER/OUTPATIENT FACILITY REIMBURSEMENT A. Reimbursement for all hospital-based outpatient and freestanding ambulatory surgery center services shall be based on the Ambulatory Payment Classification (APC) system as developed by the Centers for Medicare and Medicaid Services (CMS) using the relative weights effective January 2025. B. Reimbursement for implantables used in the outpatient setting is included in the Fee Schedule APC MAR as listed. C. Coding and Billing Rules 1. Facility fees for ambulatory surgery must be billed on the UB-04 form. 2. The CPT/HCPCS code(s) of the procedure(s) performed determines the reimbursement for the facility fee. Report all procedures performed. 3. If a procedure code is assigned a status indicator of J1, then other charges/procedure codes on the bill are considered packaged in the J1 payment and no additional reimbursement is due. If there are multiple codes with status indicator J1 on the bill, only the J1 code with the highest value will be reimbursed. For purposes of this Fee Schedule, certain procedure codes have been assigned a Mississippi state-specific status indicator of J1*. Outpatient Facility and Ambulatory Surgery Center reimbursement for these procedure codes will follow the guidelines set forth for reimbursement of codes with a status indicator of J1. 4. Do not separately reimburse non-implantable orthotic and prosthetic devices when associated with a procedure code that has a status code of J1. Payment is packaged into the allowable for the procedure code. 5. If more than one surgical procedure is furnished in a single operative encounter and none of the codes have a status indicator of J1, the multiple procedure rule applies. The primary procedure is reimbursed at the lesser of the billed charges or one hundred percent (100%) of the MAR. The second and subsequent procedures are reimbursed at the lesser of the billed charges or fifty percent (50%) of the MAR listed in the Fee Schedule. The primary procedure is the procedure with the highest relative weight. 6. Other than the multiple procedure surgical discounts as listed in the previous paragraph and the J1 status indicators described in Section III C. 3., no other Medicare status indicator discounts apply. This means no discounts apply to Medicare’s Q status indicator codes. 7. If the total billed charge for an outpatient surgical encounter is less than the APC MAR, the billed charge is paid to the facility. 8. The payment rate for an APC surgical procedure includes all facility services directly related to

Mississippi Workers’ Compensation Medical Fee Schedule Facility Payment Schedules and Rules

CPT Copyright 2024 American Medical Association. All rights reserved. 333 the procedure performed on the day of surgery. Facility services include: • Nursing and technician services; • Use of the facility; • Drugs, biologicals, surgical dressings, splints, casts and equipment directly related to the provision of the surgical procedure; • Implantables; • Materials for anesthesia; and • Administration, record keeping and housekeeping items and services. 9. Separate payment is not made for the following services that are directly related to the surgery: • Pharmacy; • Medical/surgical supplies; • Sterile supplies; • Laboratory and radiology services with no APC MAR; • Operating room services; • Anesthesia; • Ambulatory surgical care; • Recovery room; and • Treatment or observation room. 10. Pre-op workup services are included in the APC MAR and do not warrant separate reimbursement regardless of the date of service or place of service. Pre-op workup includes: Metabolic Panel, CBC, UA, PT, PTT, EKG, CXR (or any of the components). Note: If a surgical procedure is cancelled after the pre-op has been completed, then the pre-op services should be paid according to this Fee Schedule. 11. The ASC payment rate (APC MAR) is included in the CPT code listing of fees in the Fee Schedule. The column lists the total approved facility fee for that particular CPT code. 12. The facility fees will be paid for medically necessary services only. All ambulatory elective procedures must be pre-certified according to the Fee Schedule. 13. Procedures not assigned a TC MAR or an APC MAR are not reimbursable in an outpatient hospital or ASC setting. Outpatient facilities are paid based on the TC MAR when there is one. If there is no TC amount, and the service is payable in an outpatient setting, there will be an APC MAR which should be used. If a provider receives prior authorization to perform a surgery that does not have an APC MAR listed in the Fee Schedule in an outpatient hospital or ASC, reimbursement shall be according to the lesser of total billed charges or the usual and customary rate. 14. Charges for outpatient surgical codes are all inclusive and are reimbursed in total regardless of the amount billed on that line as long as the total reimbursement does not exceed the total billed charges.

IV. CRITICAL ACCESS HOSPITALS A. A critical access hospital (CAH) is a small, generally geographically remote facility that is certified to provide outpatient and inpatient services. B. A CAH may also be granted “swing bed” approval to provide post-hospital skilled nursing facility level care in its inpatient beds. C. Reimbursement 1. Critical access hospitals are reimbursed at ninety percent (90%) of billed charges for inpatient services. 2. Swing bed services are reimbursed according to the Skilled Nursing Facility rules below. 3. Outpatient services are reimbursed according to the rules in Inpatient Hospital and Outpatient Facility Payment Schedule and Rules. V. SKILLED NURSING FACILITY RULES A. Reimbursement The MAR for medical care provided within the confines of a freestanding skilled nursing facility, a hospital-based skilled nursing facility, or a swing bed facility, shall be four hundred dollars ($400.00) per day. This rate covers and includes all routine and ancillary health care services provided to an injured worker during each day of a covered skilled nursing facility stay. B. Excluded Services The following services are excluded from the daily skilled nursing facility rate, and shall be reimbursed separately and in addition to the above daily rate: • Cardiac catheterization; • Angiography; • Magnetic resonance imaging (MRI) and computerized axial tomography (CT) scans; • Radiation therapy and chemotherapy; • Emergency services, which are defined as an admission or services necessitated by a sudden onset of illness or injury which is manifested by acute symptoms of sufficient severity that the failure to provide services could reasonably result in: - serious impairment of bodily function(s); - serious or permanent dysfunction of any bodily organ or part or system; - permanently placing the person’s health in jeopardy; or - other serious medical consequence. • Outpatient services when provided in a hospital or other free standing outpatient facility separate from the skilled nursing facility;

Facility Payment Schedules and Rules Mississippi Workers’ Compensation Medical Fee Schedule

20 Miss. Admin. Code Pt. 2, R. 334 Rule 334

CPT Copyright 2024 American Medical Association. All rights reserved. • Customized prosthetic services; • Ambulance transportation related to any of the above services; and • Services provided independent of the facility by physicians, and other qualified health care professionals (e.g., NP, PA, CRNA, psychologist). C. Exclusions As in other cases, the above provisions shall not apply to any mutual agreement or contract entered into by the payer and provider which sets forth the terms for the provision of skilled nursing facility services and reimbursement therefor. VI. DRUG AND ALCOHOL TREATMENT A. Any admission for drug and alcohol treatment will be reimbursed by MS-DRG according to the facility inpatient rules. B. Outpatient partial day treatment will be reimbursed at two hundred fifty dollars ($250.00) per diem. C. Outpatient lab and radiology charges will be reimbursed according to the Fee Schedule.

CPT Copyright 2024 American Medical Association. All rights reserved. 335 HCPCS I. DEFINITION HCPCS is an acronym for Healthcare Common Procedure Coding System. It is divided into two subsets. HCPCS Level I codes are CPT ® codes developed and maintained by the AMA. HCPCS Level II codes are developed and maintained by CMS and include codes for procedures, equipment, and supplies not found in CPT. This section of the Fee Schedule contains HCPCS Level II codes. HCPCS Level II codes for Alcohol/Drug Abuse Treatment Services (H0001–H2037) and National Codes for State Medicaid Agencies (T1000–T5999) are not included in the Fee Schedule. Code categories included in this section are as follows:

II. GUIDELINES A. Rental or purchase of supplies or equipment, including items billed with HCPCS code E1399, over the amount of four hundred dollars ($400.00) per item or per month for rental requires prior authorization.

B. Orthotics and prosthetics devices over the amount of four hundred dollars ($400.00) per item require prior authorization.

C. For supplies and equipment requiring prior authorization, including items billed with HCPCS code E1399, charges for related supplies, delivery fees or set up fees will not be reimbursed if prior authorization was not obtained. D. Transportation Services Including Ambulance (A0021–A0999) 1. Transportation service codes include ground and air ambulance, non-emergency transportation (taxi, bus, automobile, wheelchair van), and ancillary transportation-related fees.

Ambulance reimbursement amounts include items and services provided in conjunction with the transport. Such items include but are not limited to oxygen, drugs, extra attendants and EKG testing. 3. Modifiers are required when reporting transportation services. Modifiers are single digits used to identify origin and destination. The first modifier identifies the transport place of origin and the second modifier the destination. Origin and destination modifiers are as follows: D Diagnostic or therapeutic site other than “P” or “H” when these are used as origin codes; E Residential, domiciliary, custodial facility (other than 1819 facility); G Hospital-based ESRD facility; H Hospital; I Site of transfer (e.g., airport or helicopter pad) between modes of ambulance transport; J Free-standing ESRD facility; N Skilled nursing facility (SNF); P Physician’s office; R Residence; S Scene of accident or acute event; and X Intermediate stop at physician’s office on way to hospital (destination code only). Note: Modifier X can only be used as a destination code in the second position of a modifier. 4. Transportation codes can also be found in the S codes. See S0207, S0208, S0209, and S0215. E. Medical and Surgical Supplies (A2001–A8004) 1. These A codes include a wide variety of medical, surgical, and some DME related supplies and services. 2. For rules related to DME supplies, accessories, maintenance, and repair, see H. Durable Medical Equipment below.

Transportation Services Including Ambulance A0021–A0999 Medical/Surgical Supplies A2001–A8004 Other Supplies and Devices, Radiopharmaceuticals, Miscellaneous A9150–A9999 Enteral and Parenteral Therapy B4034–B9999 Outpatient PPS C1052–C9899 Durable Medical Equipment (DME) E0100–E8002 Procedures/Professional Services (Temporary) G0008–G9999 Drugs and Biologicals J0120–J9999 K Codes (Temporary) K0001–K1037 Orthotic Procedures and Devices L0112–L4631 Prosthetic Procedures and Devices L5000–L9900 MIPS Value Pathways, Medical Services, Quality Measures M0001–M1425 Pathology and Laboratory Services P2028–P9615 Q Codes (Temporary) Q0035–Q9998 Diagnostic Radiology Services R0070–R0076 Temporary National Codes (Non- Medicare) S0012–S9999 COVID-19 Testing U0001-U0002 Vision Services V2020–V2799 Hearing Services V5008–V5364

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule

F. Other Supplies and Devices, Radiopharmaceuticals, Miscellaneous (A9150–A9999) 1. These A codes include non-prescription drugs, exercise equipment, radiopharmaceutical diagnostic imaging agents, as well as other miscellaneous supplies. G. Enteral and Parenteral Therapy (B4034–B9999) 1. B codes include supplies, formulae, nutrition solutions and infusion pumps. H. Outpatient PPS (C1052–C9899) 1. C codes include drugs, biologicals, and devices used by hospitals. 2. These codes are only used for facility (technical) services. I. Durable Medical Equipment (DME) (E0100– E8002) 1. E codes include durable medical equipment such as canes, crutches, walkers, commodes, decubitus care, bath and toilet aids, hospital beds, oxygen and related respiratory equipment, monitoring equipment, pacemakers, patient lifts, safety equipment, restraints, traction equipment, fracture frames, wheelchairs, and artificial kidney machines. 2. All durable medical equipment costing more than four hundred dollars ($400.00) per item or per month for rental, including items billed with HCPCS code E1399, must be prior authorized before obtaining the equipment. The payer has the choice of DME supplier for purchase or rental of DME over four hundred dollars ($400.00) per item or per month for rental items. 3. For durable medical equipment and supplies requiring prior authorization, including items billed with HCPCS code E1399, charges for related supplies, delivery fees or set up fees will not be reimbursed if prior authorization was not obtained 4. If an injured/ill worker is receiving DME items for both compensable and non-compensable medical conditions, only those items that apply to the work-related injury should be listed on claims and invoices submitted to the employer. 5. If the rental price for DME exceeds or equals the total purchase price, the employer shall purchase instead of renting equipment. The DME supplier shall make the payer aware of the price options. 6. When rental payments total the purchase price, the equipment is considered purchased and no additional reimbursement is made. 7. The return of rented equipment is the dual responsibility of the injured worker and the DME supplier. The employer is not responsible for additional rental periods solely due to delay in equipment return. 8. For codes E0935 and E0936 the MAR listed is per day. 9. Codes reported with modifier RR are reimbursed at ten (10) percent of the maximum allowed amount when reported with the NU modifier. Codes in the Fee Schedule with only the RR modifier are reimbursed at the listed fee and should not be billed with the NU or UE modifier. J. Procedures/Professional Services (Temporary) (G0008– G9999) 1. G codes identify professional health care procedures and services that would otherwise be reported using CPT codes. 2. Procedures and professional services identified by G codes may have a corresponding CPT code. When both a G code and CPT code describe the same procedure, except for G0480, G0481, G0482, G0483 and G0659, the CPT code is required for reporting purposes. 3. G codes also include procedures and professional services that do not currently have a valid CPT code. In such cases, the applicable G code should be used for reporting purposes. K. Drugs and Biologicals (J0120–J9999) 1. J codes include drugs that ordinarily cannot be self-administered, chemotherapy drugs, immunosuppressive drugs, inhalation solutions, and other miscellaneous drugs and solutions. 2. These codes report only the costs associated with provision of the drug. Administration including injection, infusion, or inhalation is reported separately using the applicable CPT code(s). 3. Additional codes for drugs and biologicals may be found in the Q codes and S codes. L. Temporary Codes (K0001–K1037) 1. K codes are temporary codes used to report durable medical equipment that do not yet have a permanent national code. 2. For rules related to DME supplies, accessories, maintenance, and repair, see G. Durable Medical Equipment above. M. Orthotic Procedures and Devices (L0112– L4631) and Prosthetic Procedures and Devices (L5000–L9900) 1. L codes include orthotic and prosthetic procedures and devices as well as scoliosis equipment, orthopedic shoes, and prosthetic implants. 2. The payer shall only pay for orthotics and prosthetics prescribed by the treating physician or other qualified health care professional (OQHP) for a compensable injury/illness. Prior authorization must be obtained from the payer. 3. For orthotics, prosthetics and supplies that are not listed in the Fee Schedule, use CPT code 99070. Reimbursement may not exceed a twenty percent (20%) mark-up of the provider’s cost and an invoice may be required by the payer before reimbursement is made for items without an allowable amount in the Fee Schedule. N. MIPS Values Pathways (M0001-M0010), Medical Services (M0075-M0301), Quality Measures (M1003-M1425) 1. M codes for medical services include office services, cellular therapy, prolotherapy,

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS CPT Copyright 2024 American Medical Association. All rights reserved. 337 intragastric hypothermia, IV chelation therapy, and fabric wrapping of an abdominal aneurysm. 2. These codes are not reimbursed as they represent services for which the therapeutic efficacy has not been established, the procedure is considered experimental, or the procedure has been replaced with a more effective treatment modality. 3. M codes for MIPS and Quality Measures are not applicable to workers’ compensation. O. Pathology and Laboratory Services (P2028– P9615) 1. P codes include chemistry, toxicology, and microbiology tests, screening Papanicolaou procedures, and various blood products. 2. Blood and blood product codes report the supply of the blood or blood product only. 3. The administration of blood or blood product is reported separately. 4. Code 36430 for transfusion of blood or blood components is reported only once per encounter regardless of the number of units provided. P. Temporary Codes (Q0035–Q9998) 1. Q codes include temporary codes developed for reporting services and supplies that do not have a permanent national HCPCS code or CPT code. Included in this section are codes for: a. Oral anti-emetic drugs; b. Casting supplies; c. Splint supplies; d. Low osmolar contrast; e. High osmolar contrast; f. Skin substitutes; and g. Other supplies/services. 2. Cast supplies and splints should be reported with the appropriate code from Q4001–Q4051. These codes report the cost of the supply only. 3. Cast supplies and splints are reported in addition to the CPT code for fracture management. 4. Cast supplies and splints are reported in addition to CPT codes for application of the cast or splint. 5. Refer to CPT for rules related to reporting fracture management and cast application. Q. Diagnostic Radiology Services (R0070–R0076) 1. R codes are used for the transportation of portable x-ray and/or EKG equipment. These codes are not reimbursable under the Fee Schedule. R. Temporary National Codes (Non-Medicare) (S0012–S9999) 1. Mississippi uses S codes with modified descriptions to report home health services. 2. See J codes for reporting rules related to drugs and biologicals. S. COVID-19 Testing (U0001-U0002) 1. U codes are used for COVID-19 testing. T. Vision Services (V2020–V2799) 1. These V codes include vision-related supplies, including spectacles, lenses, contact lenses, prostheses, intraocular lenses, and miscellaneous lenses. U. Hearing Services (V5008–V5364) 1. These V codes include hearing tests and related supplies and equipment, speech-language pathology screenings, and repair of augmentative communicative systems. V. Facility Fee Outpatient facilities are paid based on the TC MAR when there is one. If there is no TC amount, and the service is payable in an outpatient setting, there will be an APC MAR which should be used.

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G9999, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR A0021 OUTSIDE STATE AMBULANCE SERV 15.26 A0080 NONINTEREST ESCORT IN NON ER 0.59 A0090 INTEREST ESCORT IN NON ER 0.14 A0100 NONEMERGENCY TRANSPORT TAXI 0.62 A0110 NONEMERGENCY TRANSPORT BUS 7.20 A0120 NONER TRANSPORT MINI-BUS 0.75 A0130 NONER TRANSPORT WHEELCH VAN 8.80 A0140 NONEMERGENCY TRANSPORT AIR 6.00 A0160 NONER TRANSPORT CASE WORKER 0.15 A0170 TRANSPORT PARKING FEES/TOLLS 4.80 A0180 NONER TRANSPORT LODGNG RECIP 12.00 A0190 NONER TRANSPORT MEALS RECIP 2.40 A0200 NONER TRANSPORT LODGNG ESCRT 19.20 A0210 NONER TRANSPORT MEALS ESCORT 3.20 A0225 NEONATAL EMERGENCY TRANSPORT 1361.49 A0380 BASIC LIFE SUPPORT MILEAGE 0.49 A0382 BASIC SUPPORT ROUTINE SUPPLS 27.60 A0384 BLS DEFIBRILLATION SUPPLIES 7.62 A0390 ADVANCED LIFE SUPPORT MILEAG 5.20 A0392 ALS DEFIBRILLATION SUPPLIES 19.81 A0394 ALS IV DRUG THERAPY SUPPLIES 24.80 A0396 ALS ESOPHAGEAL INTUB SUPPLS 19.81 A0398 ALS ROUTINE DISPOSBLE SUPPLS 28.80 A0420 AMBULANCE WAITING 1/2 HR 11.60 A0422 AMBULANCE 02 LIFE SUSTAINING 46.00 A0424 EXTRA AMBULANCE ATTENDANT 25.60 A0425 GROUND MILEAGE 8.91 A0426 ALS 1 362.16 A0427 ALS1-EMERGENCY 573.43 A0428 BLS 301.81 A0429 BLS-EMERGENCY 482.88 A0430 FIXED WING AIR TRANSPORT 10277.89 A0431 ROTARY WING AIR TRANSPORT 11827.21 A0432 PI VOLUNTEER AMBULANCE CO 430.79 A0433 ALS 2 829.95 A0434 SPECIALTY CARE TRANSPORT 980.86 A0435 FIXED WING AIR MILEAGE 30.91 A0436 ROTARY WING AIR MILEAGE 82.54 A0888 NONCOVERED AMBULANCE MILEAGE 4.00 A0998 AMBULANCE RESPONSE/TREATMENT 50.80 A0999 UNLISTED AMBULANCE SERVICE BR A2001 INNOVAMATRIX AC, PER SQ CM 955.60 A2002 MIRRAGEN ADV WND MAT PER SQ 375.60 A2003 BIO-CONNEKT WOUND MATRIX BR A2004 XCELLISTEM, 1 MG BR A2005 MICROLYTE MATRIX, PER SQ CM 169.60 A2006 NOVOSORB SYNPATH PER SQ CM BR A2007 RESTRATA, PER SQ CM BR A2008 THERAGENESIS, PER SQ CM BR

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR A2009 SYMPHONY, PER SQ CM BR A2010 APIS, PER SQUARE CENTIMETER BR A2011 SUPRA SDRM, PER SQ CM 219.20 A2012 SUPRATHEL, PER SQ CM BR A2013 INNOVAMATRIX FS, PER SQ CM BR A2014 OMEZA COLLAG PER 100 MG 62.80 A2015 PHOENIX WND MTRX, PER SQ CM 787.20 A2016 PERMEADERM B, PER SQ CM BR A2017 PERMEADERM GLOVE, EACH BR A2018 PERMEADERM C, PER SQ CM BR A2019 KERECIS MARIGEN SHLD SQ CM 370.01 A2020 AC5 WOUND SYSTEM BR A2021 NEOMATRIX PER SQ CM 1205.20 A2022 INNOVABRN/INNOVAMATX XL SQCM 1274.00 A2023 INNOVAMATRIX PD, 1 MG BR A2024 RESOLVE OR XENOPATCH SQ CM BR A2025 MIRO3D PER CUBIC CM 195.5 A2026 RESTRATA MINIMATRIX, 5 MG BR A2027 MATRIDERM PER SQ CM BR A2028 MICROMATRIX FLEX PER MG BR A2029 MIROTRACT MATRIX SHEET BR A2030 MIRO3D FIBERS, PER MG BR A2031 MIRODRY, PER SQ CM BR A2032 MYRIAD MATRIX, PER SQ CM BR A2033 MYRIAD MORCELLS, 4 MG BR A2034 FOUND DRS SOLO, PER SQ CM BR A2035 CORPL P THERAC P ALLAC P MG BR A4100 SKIN SUB FDA CLRD AS DEV NOS BR A4206 1 CC STERILE SYRINGE&NEEDLE 0.62 A4207 2 CC STERILE SYRINGE&NEEDLE 0.80 A4208 3 CC STERILE SYRINGE&NEEDLE 3.20 A4209 5+ CC STERILE SYRINGE&NEEDLE 3.20 A4210 NONNEEDLE INJECTION DEVICE 0.00 A4211 SUPP FOR SELF-ADM INJECTIONS 22.00 A4212 NON CORING NEEDLE OR STYLET 9.20 A4213 20+ CC SYRINGE ONLY 4.00 A4215 STERILE NEEDLE 0.77 A4216 STERILE WATER/SALINE, 10 ML 0.59 A4217 STERILE WATER/SALINE, 500 ML 3.81 A4218 STERILE SALINE OR WATER 0.80 A4220 INFUSION PUMP REFILL KIT 46.00 A4221 SUPP NON-INSULIN INF CATH/WK 27.25 A4222 INFUSION SUPPLIES WITH PUMP 54.24 A4223 INFUSION SUPPLIES W/O PUMP 74.00 A4224 SUPPLY INSULIN INF CATH/WK 27.25 A4225 SUP/EXT INSULIN INF PUMP SYR 3.40 A4226 WEEKLY SUPPLY MAINT CGS PUMP 30.80 A4230 INFUS INSULIN PUMP NON NEEDL 10.00 A4231 INFUSION INSULIN PUMP NEEDLE 6.40

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR A4232 SYRINGE W/NEEDLE INSULIN 3CC 2.80 A4233 NU ALKALIN BATT FOR GLUCOSE MON 0.56 A4234 NU J-CELL BATT FOR GLUCOSE MON 2.60 A4235 NU LITHIUM BATT FOR GLUCOSE MON 1.10 A4236 NU SILVR OXIDE BATT GLUCOSE MON 1.28 A4238 ADJU CGM SUPPLY ALLOWANCE 426.40 A4239 NON-ADJU CGM SUPPLY ALLOW 280.51 A4244 ALCOHOL OR PEROXIDE PER PINT 1.60 A4245 ALCOHOL WIPES PER BOX 5.20 A4246 BETADINE/PHISOHEX SOLUTION 6.00 A4247 BETADINE/IODINE SWABS/WIPES 9.20 A4248 CHLORHEXIDINE ANTISEPT 0.06 A4250 URINE REAGENT STRIPS/TABLETS 16.30 A4252 BLOOD KETONE TEST OR STRIP 8.00 A4253 NU BLOOD GLUCOSE/REAGENT STRIPS 9.15 A4255 GLUCOSE MONITOR PLATFORMS 5.53 A4256 CALIBRATOR SOLUTION/CHIPS 3.72 A4257 REPLACE LENSSHIELD CARTRIDGE 17.17 A4258 LANCET DEVICE EACH 2.33 A4259 LANCETS PER BOX 1.56 A4261 CERVICAL CAP CONTRACEPTIVE 0.00 A4262 TEMPORARY TEAR DUCT PLUG 29.27 A4263 PERMANENT TEAR DUCT PLUG 71.82 A4264 INTRATUBAL OCCLUSION DEVICE 0.00 A4265 PARAFFIN 4.59 A4266 DIAPHRAGM 54.00 A4267 MALE CONDOM 0.50 A4268 FEMALE CONDOM 0.77 A4269 SPERMICIDE 6.80 A4270 DISPOSABLE ENDOSCOPE SHEATH 10.80 A4271 HOME LANCING/TEST CARTRIDGES 36.77 A4280 BRST PRSTHS ADHSV ATTCHMNT 7.19 A4281 REPLACEMENT BREASTPUMP TUBE 12.40 A4282 REPLACEMENT BREASTPUMP ADPT 12.40 A4283 REPLACEMENT BREASTPUMP CAP 2.40 A4284 REPLCMNT BREAST PUMP SHIELD 6.80 A4285 REPLCMNT BREAST PUMP BOTTLE 4.80 A4286 REPLCMNT BREASTPUMP LOK RING 5.20 A4287 DISP COL STO BAG BREAST MIL 0.38 A4290 SACRAL NERVE STIM TEST LEAD 215.60 A4300 CATH IMPL VASC ACCESS PORTAL 18.40 A4301 IMPLANTABLE ACCESS SYST PERC 230.80 A4305 DRUG DELIVERY SYSTEM >=50 ML 85.14 A4306 DRUG DELIVERY SYSTEM <=50 ML 76.62 A4310 INSERT TRAY W/O BAG/CATH 8.83 A4311 CATHETER W/O BAG 2-WAY LATEX 19.93 A4312 CATH W/O BAG 2-WAY SILICONE 24.28 A4313 CATHETER W/BAG 3-WAY 24.93 A4314 CATH W/DRAINAGE 2-WAY LATEX 28.92

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR A4315 CATH W/DRAINAGE 2-WAY SILCNE 35.50 A4316 CATH W/DRAINAGE 3-WAY 38.23 A4320 IRRIGATION TRAY 6.12 A4321 CATH THERAPEUTIC IRRIG AGENT 21.60 A4322 IRRIGATION SYRINGE 4.08 A4326 MALE EXTERNAL CATHETER 14.52 A4327 FEM URINARY COLLECT DEV CUP 60.03 A4328 FEM URINARY COLLECT POUCH 14.05 A4330 STOOL COLLECTION POUCH 8.20 A4331 EXTENSION DRAINAGE TUBING 4.28 A4332 LUBE STERILE PACKET 0.15 A4333 URINARY CATH ANCHOR DEVICE 2.98 A4334 URINARY CATH LEG STRAP 6.62 A4335 INCONTINENCE SUPPLY BR A4336 URETHRAL INSERT 1.94 A4337 INCONTINENT RECTAL INSERT 6.40 A4338 INDWELLING CATHETER LATEX 16.51 A4340 INDWELLING CATHETER SPECIAL 36.31 A4341 IDUC VALVE PAT INST REPL 366.23 A4342 IDUC VALVE SPLY REPL 924.73 A4344 CATH INDW FOLEY 2 WAY SILICN 19.70 A4346 CATH INDW FOLEY 3 WAY 23.35 A4349 DISPOSABLE MALE EXTERNAL CAT 2.71 A4351 STRAIGHT TIP URINE CATHETER 2.26 A4352 COUDE TIP URINARY CATHETER 8.65 A4353 INTERMITTENT URINARY CATH 9.43 A4354 CATH INSERTION TRAY W/BAG 15.88 A4355 BLADDER IRRIGATION TUBING 12.00 A4356 EXT URETH CLMP OR COMPR DVC 56.00 A4357 BEDSIDE DRAINAGE BAG 11.11 A4358 URINARY LEG OR ABDOMEN BAG 7.96 A4360 DISPOSABLE EXT URETHRAL DEV 0.59 A4361 OSTOMY FACE PLATE 24.72 A4362 SOLID SKIN BARRIER 3.97 A4363 OSTOMY CLAMP, REPLACEMENT 2.72 A4364 ADHESIVE, LIQUID OR EQUAL 3.96 A4366 OSTOMY VENT 1.74 A4367 OSTOMY BELT 8.43 A4368 OSTOMY FILTER 0.33 A4369 SKIN BARRIER LIQUID PER OZ 3.27 A4371 SKIN BARRIER POWDER PER OZ 4.91 A4372 SKIN BARRIER SOLID 4X4 EQUIV 5.64 A4373 SKIN BARRIER WITH FLANGE 8.43 A4375 DRAINABLE PLASTIC PCH W FCPL 23.11 A4376 DRAINABLE RUBBER PCH W FCPLT 64.03 A4377 DRAINABLE PLSTIC PCH W/O FP 5.76 A4378 DRAINABLE RUBBER PCH W/O FP 41.38 A4379 URINARY PLASTIC POUCH W FCPL 20.21 A4380 URINARY RUBBER POUCH W FCPLT 50.25

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR A4381 URINARY PLASTIC POUCH W/O FP 6.23 A4382 URINARY HVY PLSTC PCH W/O FP 33.13 A4383 URINARY RUBBER POUCH W/O FP 37.94 A4384 OSTOMY FACEPLT/SILICONE RING 12.94 A4385 OST SKN BARRIER SLD EXT WEAR 6.85 A4387 OST CLSD POUCH W ATT ST BARR 3.03 A4388 DRAINABLE PCH W EX WEAR BARR 5.87 A4389 DRAINABLE PCH W ST WEAR BARR 8.36 A4390 DRAINABLE PCH EX WEAR CONVEX 12.93 A4391 URINARY POUCH W EX WEAR BARR 9.52 A4392 URINARY POUCH W ST WEAR BARR 11.00 A4393 URINE PCH W EX WEAR BAR CONV 12.17 A4394 OSTOMY POUCH LIQ DEODORANT 3.49 A4395 OSTOMY POUCH SOLID DEODORANT 0.06 A4396 PERISTOMAL HERNIA SUPPRT BLT 54.47 A4398 OSTOMY IRRIGATION BAG 18.60 A4399 OSTOMY IRRIG CONE/CATH W BRS 14.52 A4400 OSTOMY IRRIGATION SET 55.90 A4402 LUBRICANT PER OUNCE 1.83 A4404 OSTOMY RING EACH 1.97 A4405 NONPECTIN BASED OSTOMY PASTE 4.60 A4406 PECTIN BASED OSTOMY PASTE 7.70 A4407 EXT WEAR OST SKN BARR <=4SQ" 11.79 A4408 EXT WEAR OST SKN BARR >4SQ" 13.29 A4409 OST SKN BARR CONVEX <=4 SQ I 8.36 A4410 OST SKN BARR EXTND >4 SQ 12.17 A4411 OST SKN BARR EXTND =4SQ 6.85 A4412 OST POUCH DRAIN HIGH OUTPUT 3.64 A4413 2 PC DRAINABLE OST POUCH 7.41 A4414 OST SKNBAR W/O CONV<=4 SQ IN 6.62 A4415 OST SKN BARR W/O CONV >4 SQI 8.06 A4416 OST PCH CLSD W BARRIER/FILTR 3.71 A4417 OST PCH W BAR/BLTINCONV/FLTR 5.02 A4418 OST PCH CLSD W/O BAR W FILTR 2.44 A4419 OST PCH FOR BAR W FLANGE/FLT 2.32 A4420 OST PCH CLSD FOR BAR W LK FL 1.60 A4421 OSTOMY SUPPLY MISC BR A4422 OST POUCH ABSORBENT MATERIAL 0.15 A4423 OST PCH FOR BAR W LK FL/FLTR 2.50 A4424 OST PCH DRAIN W BAR & FILTER 6.40 A4425 OST PCH DRAIN FOR BARRIER FL 4.82 A4426 OST PCH DRAIN 2 PIECE SYSTEM 3.67 A4427 OST PCH DRAIN/BARR LK FLNG/F 3.75 A4428 URINE OST POUCH W FAUCET/TAP 8.78 A4429 URINE OST POUCH W BLTINCONV 11.10 A4430 OST URINE PCH W B/BLTIN CONV 11.46 A4431 OST PCH URINE W BARRIER/TAPV 8.36 A4432 OS PCH URINE W BAR/FANGE/TAP 4.83 A4433 URINE OST PCH BAR W LOCK FLN 4.51

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR A4434 OST PCH URINE W LOCK FLNG/FT 5.06 A4435 1PC OST PCH DRAIN HGH OUTPUT 7.76 A4436 IRR SUPPLY SLEEV REUS PER MO 23.51 A4437 IRR SUPPLY SLEEV DISP PER MO 23.51 A4438 ADHESIVE CLIP EXT ENS CONTR 2.12 A4450 NON-WATERPROOF TAPE 0.12 A4452 WATERPROOF TAPE 0.36 A4453 REC CATH MAN PUMP ENEMA REPL 40.00 A4455 ADHESIVE REMOVER PER OUNCE 1.91 A4456 ADHESIVE REMOVER, WIPES 0.32 A4457 ENEMA TUBE ANY TYPE REPL 401.60 A4458 REUSABLE ENEMA BAG 4.80 A4459 MANUAL PUMP ENEMA, REUSABLE 3768.40 A4461 SURGICL DRESS HOLD NON-REUSE 4.44 A4463 SURGICAL DRESS HOLDER REUSE 17.91 A4465 NON-ELASTIC EXTREMITY BINDER 22.34 A4467 BELT STRAP SLEEV GRMNT COVER 42.56 A4468 EXSUFF BELT INCL ALL SUP ACC BR A4470 GRAVLEE JET WASHER 5.54 A4480 VABRA ASPIRATOR 42.56 A4481 TRACHEOSTOMA FILTER 0.50 A4483 MOISTURE EXCHANGER 4.40 A4490 ABOVE KNEE SURGICAL STOCKING 26.27 A4495 THIGH LENGTH SURG STOCKING 24.00 A4500 BELOW KNEE SURGICAL STOCKING 22.84 A4510 FULL LENGTH SURG STOCKING 81.57 A4520 INCONTINENCE GARMENT ANYTYPE 0.69 A4540 TRANS ELEC NERV PERIPH NERV 721.60 A4541 MONTHLY SUPP USE WITH E0733 43.25 A4542 SUPP EXT UP LIMB TREMOR STIM 554.85 A4543 SUPPLY TRANS ELEC NERVE STIM BR A4544 ELECTRO NERVE STIMULATOR RLS 6.84 A4545 SUPPL ACCESSOR TIBIAL STIM 44.99 A4550 SURGICAL TRAYS 32.63 A4553 NONDISP UNDERPADS, ALL SIZES 8.80 A4554 DISPOSABLE UNDERPADS 0.45 A4555 CA TX E-STIM ELECTR/TRANSDUC 12.40 A4556 ELECTRODES, PAIR 13.89 A4557 LEAD WIRES, PAIR 18.58 A4558 CONDUCTIVE GEL OR PASTE 6.62 A4559 COUPLING GEL OR PASTE 0.13 A4560 NMES DISPOSABLE 192.80 A4561 PESSARY REUSABLE RUB ANYTYPE 27.71 A4562 PESSARY REUSABLE NONRUBBER 68.89 A4563 VAG INSER RECTAL CONTROL SYS 162.35 A4564 PESSARY, DISPOSABLE ANY TYPE BR A4565 SLINGS 10.36 A4566 SHOULD SLING/VEST/ABRESTRAIN 27.60 A4570 SPLINT 37.25

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR A4575 HYPERBARIC O2 CHAMBER DISPS 444.80 A4580 CAST SUPPLIES (PLASTER) 90.45 A4590 SPECIAL CASTING MATERIAL 79.82 A4593 NEUROMOD STI SYS ADJ REHAB BR A4594 NU NEUROMOD ADJ REHAB MOUTHPIE 3337.87 A4595 TENS SUPPL 2 LEAD PER MONTH 25.88 A4596 CES SYSTEM MONTHLY SUPP 44.2 A4600 SLEEVE, INTER LIMB COMP DEV 26.00 A4601 LITH ION NON PROSTH RECHARGE 60.80 A4602 NU REPLACE LITHIUM BATTERY 1.5V 5.02 A4604 NU TUBING WITH HEATING ELEMENT 64.39 A4605 NU TRACH SUCTION CATH CLOSE SYS 22.07 A4606 OXYGEN PROBE USED W OXIMETER 57.20 A4608 TRANSTRACHEAL OXYGEN CATH 67.46 A4611 NU HEAVY DUTY BATTERY 684.87 A4611 RR HEAVY DUTY BATTERY 68.90 A4611 UE HEAVY DUTY BATTERY 513.31 A4612 NU BATTERY CABLES 243.72 A4612 RR BATTERY CABLES 26.57 A4612 UE BATTERY CABLES 197.98 A4613 NU BATTERY CHARGER 576.47 A4613 RR BATTERY CHARGER 39.37 A4613 UE BATTERY CHARGER 293.30 A4614 HAND-HELD PEFR METER 32.01 A4615 CANNULA NASAL 0.98 A4616 TUBING (OXYGEN) PER FOOT 0.08 A4617 MOUTH PIECE 4.17 A4618 NU BREATHING CIRCUITS 10.18 A4618 RR BREATHING CIRCUITS 1.18 A4618 UE BREATHING CIRCUITS 7.63 A4619 NU FACE TENT 2.44 A4620 VARIABLE CONCENTRATION MASK 0.86 A4623 TRACHEOSTOMY INNER CANNULA 7.50 A4624 NU TRACHEAL SUCTION TUBE 3.03 A4625 TRACH CARE KIT FOR NEW TRACH 7.92 A4626 TRACHEOSTOMY CLEANING BRUSH 4.28 A4627 SPACER BAG/RESERVOIR 42.56 A4628 NU OROPHARYNGEAL SUCTION CATH 5.04 A4629 TRACHEOSTOMY CARE KIT 6.26 A4630 NU REPL BAT T.E.N.S. OWN BY PT 8.39 A4633 NU UVL REPLACEMENT BULB 55.23 A4634 REPLACEMENT BULB TH LIGHTBOX BR A4635 NU UNDERARM CRUTCH PAD 6.88 A4635 RR UNDERARM CRUTCH PAD 0.95 A4635 UE UNDERARM CRUTCH PAD 4.59 A4636 NU HANDGRIP FOR CANE ETC 4.63 A4636 RR HANDGRIP FOR CANE ETC 0.47 A4636 UE HANDGRIP FOR CANE ETC 3.42 A4637 NU REPL TIP CANE/CRUTCH/WALKER 2.44

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR A4637 RR REPL TIP CANE/CRUTCH/WALKER 0.29 A4637 UE REPL TIP CANE/CRUTCH/WALKER 1.84 A4638 NU REPL BATT PULSE GEN SYS 0.00 A4638 RR REPL BATT PULSE GEN SYS 0.00 A4638 UE REPL BATT PULSE GEN SYS 0.00 A4639 RR INFRARED HT SYS REPLCMNT PAD 38.67 A4640 NU ALTERNATING PRESSURE PAD 69.75 A4640 RR ALTERNATING PRESSURE PAD 7.04 A4640 UE ALTERNATING PRESSURE PAD 50.81 A4641 RADIOPHARM DX AGENT NOC BR A4642 IN111 SATUMOMAB BR A4648 IMPLANTABLE TISSUE MARKER 164.80 A4649 SURGICAL SUPPLIES BR A4650 IMPLANT RADIATION DOSIMETER 12.80 A4651 CALIBRATED MICROCAP TUBE 6.00 A4652 MICROCAPILLARY TUBE SEALANT 6.00 A4653 PD CATHETER ANCHOR BELT BR A4657 SYRINGE W/WO NEEDLE 0.61 A4660 SPHYG/BP APP W CUFF AND STET 42.84 A4663 DIALYSIS BLOOD PRESSURE CUFF 57.46 A4670 AUTOMATIC BP MONITOR, DIAL 119.46 A4671 DISPOSABLE CYCLER SET 28.80 A4672 DRAINAGE EXT LINE, DIALYSIS 107.60 A4673 EXT LINE W EASY LOCK CONNECT BR A4674 CHEM/ANTISEPT SOLUTION, 8OZ 74.40 A4680 ACTIVATED CARBON FILTER, EA 282.02 A4690 DIALYZER, EACH 200.27 A4706 BICARBONATE CONC SOL PER GAL 38.00 A4707 BICARBONATE CONC POW PER PAC BR A4708 ACETATE CONC SOL PER GALLON 56.40 A4709 ACID CONC SOL PER GALLON 37.20 A4714 TREATED WATER PER GALLON 23.20 A4719 "Y SET" TUBING 7.61 A4720 DIALYSAT SOL FLD VOL > 249CC BR A4721 DIALYSAT SOL FLD VOL > 999CC BR A4722 DIALYS SOL FLD VOL > 1999CC BR A4723 DIALYS SOL FLD VOL > 2999CC 12.40 A4724 DIALYS SOL FLD VOL > 3999CC BR A4725 DIALYS SOL FLD VOL > 4999CC 7.20 A4726 DIALYS SOL FLD VOL > 5999CC 8.00 A4728 DIALYSATE SOLUTION, NON-DEX BR A4730 FISTULA CANNULATION SET, EA BR A4736 TOPICAL ANESTHETIC, PER GRAM 25.20 A4737 INJ ANESTHETIC PER 10 ML BR A4740 SHUNT ACCESSORY BR A4750 ART OR VENOUS BLOOD TUBING 69.17 A4755 COMB ART/VENOUS BLOOD TUBING 84.40 A4760 DIALYSATE SOL TEST KIT, EACH BR A4765 DIALYSATE CONC POW PER PACK BR

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR A4766 DIALYSATE CONC SOL ADD 10 ML 21.60 A4770 BLOOD COLLECTION TUBE/VACUUM 6.00 A4771 SERUM CLOTTING TIME TUBE BR A4772 BLOOD GLUCOSE TEST STRIPS 21.34 A4773 OCCULT BLOOD TEST STRIPS 156.62 A4774 AMMONIA TEST STRIPS BR A4802 PROTAMINE SULFATE PER 50 MG 4.27 A4860 DISPOSABLE CATHETER TIPS 5.20 A4870 PLUMB/ELEC WK HM HEMO EQUIP 738.80 A4890 REPAIR/MAINT CONT HEMO EQUIP 406.40 A4911 DRAIN BAG/BOTTLE 10.00 A4913 MISC DIALYSIS SUPPLIES NOC BR A4918 VENOUS PRESSURE CLAMP 9.20 A4927 NON-STERILE GLOVES 8.72 A4928 SURGICAL MASK 10.40 A4929 TOURNIQUET FOR DIALYSIS, EA 0.42 A4930 STERILE, GLOVES PER PAIR 0.40 A4931 REUSABLE ORAL THERMOMETER 9.61 A4932 REUSABLE RECTAL THERMOMETER 0.00 A5051 POUCH CLSD W BARR ATTACHED 2.77 A5052 CLSD OSTOMY POUCH W/O BARR 2.00 A5053 CLSD OSTOMY POUCH FACEPLATE 1.99 A5054 CLSD OSTOMY POUCH W/FLANGE 2.42 A5055 STOMA CAP 1.76 A5056 1 PC OST POUCH W FILTER 6.29 A5057 1 PC OST POU W BUILT-IN CONV 12.93 A5061 POUCH DRAINABLE W BARRIER AT 4.75 A5062 DRNBLE OSTOMY POUCH W/O BARR 3.00 A5063 DRAIN OSTOMY POUCH W/FLANGE 3.64 A5071 URINARY POUCH W/BARRIER 8.09 A5072 URINARY POUCH W/O BARRIER 4.25 A5073 URINARY POUCH ON BARR W/FLNG 3.64 A5081 STOMA PLUG OR SEAL, ANY TYPE 3.80 A5082 CONTINENT STOMA CATHETER 13.62 A5083 STOMA ABSORPTIVE COVER 0.87 A5093 OSTOMY ACCESSORY CONVEX INSE 2.52 A5102 BEDSIDE DRAIN BTL W/WO TUBE 30.37 A5105 URINARY SUSPENSORY 54.87 A5112 URINARY LEG BAG 46.60 A5113 LATEX LEG STRAP 6.35 A5114 FOAM/FABRIC LEG STRAP 10.24 A5120 SKIN BARRIER, WIPE OR SWAB 0.52 A5121 SOLID SKIN BARRIER 6X6 10.03 A5122 SOLID SKIN BARRIER 8X8 17.28 A5126 DISK/FOAM PAD +OR- ADHESIVE 1.76 A5131 APPLIANCE CLEANER 21.33 A5200 PERCUTANEOUS CATHETER ANCHOR 15.22 A5500 DIAB SHOE FOR DENSITY INSERT 85.58 A5501 DIABETIC CUSTOM MOLDED SHOE 256.66

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR A5503 DIABETIC SHOE W/ROLLER/ROCKR 43.53 A5504 DIABETIC SHOE WITH WEDGE 43.53 A5505 DIAB SHOE W/METATARSAL BAR 43.53 A5506 DIABETIC SHOE W/OFF SET HEEL 43.53 A5507 MODIFICATION DIABETIC SHOE 43.53 A5508 DIABETIC DELUXE SHOE 36.01 A5510 COMPRESSION FORM SHOE INSERT 80.79 A5512 MULTI DEN INSERT DIRECT FORM 34.90 A5513 MULTI DEN INSERT CUSTOM MOLD 52.09 A5514 MULT DEN INSERT DIR CARV/CAM 52.09 A6000 WOUND WARMING WOUND COVER 0.00 A6010 COLLAGEN BASED WOUND FILLER 41.68 A6011 COLLAGEN GEL/PASTE WOUND FIL 3.08 A6021 COLLAGEN DRESSING <=16 SQ IN 28.29 A6022 COLLAGEN DRSG>16<=48 SQ IN 28.29 A6023 COLLAGEN DRESSING >48 SQ IN 256.11 A6024 COLLAGEN DSG WOUND FILLER 8.33 A6025 SILICONE GEL SHEET, EACH 31.60 A6154 WOUND POUCH EACH 19.35 A6196 ALGINATE DRESSING <=16 SQ IN 9.91 A6197 ALGINATE DRSG >16 <=48 SQ IN 22.13 A6198 ALGINATE DRESSING > 48 SQ IN 30.80 A6199 ALGINATE DRSG WOUND FILLER 7.11 A6203 COMPOSITE DRSG <= 16 SQ IN 4.53 A6204 COMPOSITE DRSG >16<=48 SQ IN 8.37 A6205 COMPOSITE DRSG > 48 SQ IN 0.25 A6206 CONTACT LAYER <= 16 SQ IN 14.63 A6207 CONTACT LAYER >16<= 48 SQ IN 9.89 A6208 CONTACT LAYER > 48 SQ IN 62.80 A6209 FOAM DRSG <=16 SQ IN W/O BDR 10.05 A6210 FOAM DRG >16<=48 SQ IN W/O B 26.82 A6211 FOAM DRG > 48 SQ IN W/O BRDR 39.52 A6212 FOAM DRG <=16 SQ IN W/BORDER 13.07 A6213 FOAM DRG >16<=48 SQ IN W/BDR 24.63 A6214 FOAM DRG > 48 SQ IN W/BORDER 13.85 A6215 FOAM DRESSING WOUND FILLER 4.00 A6216 NON-STERILE GAUZE<=16 SQ IN 0.06 A6217 NON-STERILE GAUZE>16<=48 SQ 0.25 A6218 NON-STERILE GAUZE > 48 SQ IN 0.97 A6219 GAUZE <= 16 SQ IN W/BORDER 1.29 A6220 GAUZE >16 <=48 SQ IN W/BORDR 3.49 A6221 GAUZE > 48 SQ IN W/BORDER 5.59 A6222 GAUZE <=16 IN NO W/SAL W/O B 2.87 A6223 GAUZE >16<=48 NO W/SAL W/O B 3.27 A6224 GAUZE > 48 IN NO W/SAL W/O B 4.85 A6228 GAUZE <= 16 SQ IN WATER/SAL 5.32 A6229 GAUZE >16<=48 SQ IN WATR/SAL 4.85 A6230 GAUZE > 48 SQ IN WATER/SALNE 2.08 A6231 HYDROGEL DSG<=16 SQ IN 6.31

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR A6232 HYDROGEL DSG>16<=48 SQ IN 9.24 A6233 HYDROGEL DRESSING >48 SQ IN 25.81 A6234 HYDROCOLLD DRG <=16 W/O BDR 8.81 A6235 HYDROCOLLD DRG >16<=48 W/O B 22.64 A6236 HYDROCOLLD DRG > 48 IN W/O B 36.67 A6237 HYDROCOLLD DRG <=16 IN W/BDR 10.65 A6238 HYDROCOLLD DRG >16<=48 W/BDR 30.68 A6239 HYDROCOLLD DRG > 48 IN W/BDR BR A6240 HYDROCOLLD DRG FILLER PASTE 16.49 A6241 HYDROCOLLOID DRG FILLER DRY 3.47 A6242 HYDROGEL DRG <=16 IN W/O BDR 8.15 A6243 HYDROGEL DRG >16<=48 W/O BDR 16.59 A6244 HYDROGEL DRG >48 IN W/O BDR 52.87 A6245 HYDROGEL DRG <= 16 IN W/BDR 9.79 A6246 HYDROGEL DRG >16<=48 IN W/B 13.37 A6247 HYDROGEL DRG > 48 SQ IN W/B 32.01 A6248 HYDROGEL DRSG GEL FILLER 21.87 A6250 SKIN SEAL PROTECT MOISTURIZR BR A6251 ABSORPT DRG <=16 SQ IN W/O B 2.67 A6252 ABSORPT DRG >16 <=48 W/O BDR 4.38 A6253 ABSORPT DRG > 48 SQ IN W/O B 8.53 A6254 ABSORPT DRG <=16 SQ IN W/BDR 1.61 A6255 ABSORPT DRG >16<=48 IN W/BDR 4.09 A6256 ABSORPT DRG > 48 SQ IN W/BDR 5.20 A6257 TRANSPARENT FILM <= 16 SQ IN 2.07 A6258 TRANSPARENT FILM >16<=48 IN 5.80 A6259 TRANSPARENT FILM > 48 SQ IN 14.72 A6260 WOUND CLEANSER ANY TYPE/SIZE 0.42 A6261 WOUND FILLER GEL/PASTE /OZ 6.12 A6262 WOUND FILLER DRY FORM / GRAM 6.03 A6266 IMPREG GAUZE NO H20/SAL/YARD 2.57 A6402 STERILE GAUZE <= 16 SQ IN 0.15 A6403 STERILE GAUZE>16 <= 48 SQ IN 0.56 A6404 STERILE GAUZE > 48 SQ IN 0.61 A6407 PACKING STRIPS, NON-IMPREG 2.52 A6410 STERILE EYE PAD 0.51 A6411 NON-STERILE EYE PAD 6.00 A6412 OCCLUSIVE EYE PATCH 0.39 A6413 ADHESIVE BANDAGE, FIRST-AID 0.20 A6441 PAD BAND W>=3" <5"/YD 0.92 A6442 CONFORM BAND N/S W<3"/YD 0.21 A6443 CONFORM BAND N/S W>=3"<5"/YD 0.37 A6444 CONFORM BAND N/S W>=5"/YD 0.75 A6445 CONFORM BAND S W <3"/YD 0.43 A6446 CONFORM BAND S W>=3" <5"/YD 0.53 A6447 CONFORM BAND S W >=5"/YD 0.92 A6448 LT COMPRES BAND <3"/YD 1.55 A6449 LT COMPRES BAND >=3" <5"/YD 2.35 A6450 LT COMPRES BAND >=5"/YD 2.35

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR A6451 MOD COMPRES BAND W>=3"<5"/YD 2.35 A6452 HIGH COMPRES BAND W>=3"<5"YD 7.94 A6453 SELF-ADHER BAND W <3"/YD 0.85 A6454 SELF-ADHER BAND W>=3" <5"/YD 1.06 A6455 SELF-ADHER BAND >=5"/YD 1.87 A6456 ZINC PASTE BAND W >=3"<5"/YD 1.69 A6457 TUBULAR DRESSING 1.53 A6460 SYNTHETIC DRSG <= 16 SQ IN BR A6461 SYNTHETIC DRSG >16<=48 SQ IN 4.80 A6501 COMPRES BURNGARMENT BODYSUIT BR A6502 COMPRES BURNGARMENT CHINSTRP 125.60 A6503 COMPRES BURNGARMENT FACEHOOD BR A6504 CMPRSBURNGARMENT GLOVE-WRIST 190.80 A6505 CMPRSBURNGARMENT GLOVE-ELBOW 162.80 A6506 CMPRSBURNGRMNT GLOVE-AXILLA 243.20 A6507 CMPRS BURNGARMENT FOOT-KNEE 131.20 A6508 CMPRS BURNGARMENT FOOT-THIGH 284.00 A6509 COMPRES BURN GARMENT JACKET 351.60 A6510 COMPRES BURN GARMENT LEOTARD BR A6511 COMPRES BURN GARMENT PANTY 326.40 A6512 COMPRES BURN GARMENT, NOC BR A6513 COMPRESS BURN MASK FACE/NECK BR A6515 GRAD COM WRAP W STR FU LE CU BR A6516 GRAD COM WRAP W STRAP FOO CU BR A6517 GRAD COM WRAP W STRAP BN CUS BR A6518 GRAD COM WRAP W STRAP ARM CU BR A6519 GRAD COM GARM NOC NIGHT USE BR A6520 G COM GARMNT GLOVE NGHTTIME 131.49 A6521 G COM GARMNT GLOVE NGHT CUST 521.76 A6522 G COM GARMENT ARM NIGHTTIME 319.52 A6523 G COM GARMENT ARM NGHT CUSTM 758.09 A6524 G COM GARMNT LWR LEG/FT NGHT 398.63 A6525 G COM GARM LWRLEG/FT NGT CUS 804.76 A6526 G COM GARMT FULL LEG/FT NGHT 720.70 A6527 G GARMT FULL LEG/FT NGHT CUS 1325.28 A6528 G COM GARMENT BRA NIGHTTIME 693.00 A6529 G COM GARMT BRA NIGHT CUSTM 1095.05 A6530 COMPRESSION STOCKING BK18-30 52.72 A6531 COMPRESS STKING BK30-40 SURG 64.98 A6532 COMPRESS STKING BK40-50 SURG 91.56 A6533 GC STOCKING THIGHLNGTH 18-30 45.78 A6534 GC STOCKING THIGHLNGTH 30-40 61.04 A6535 GC STOCKING THIGHLNGTH 40+ 97.11 A6536 GC STOCKING FULL LNGTH 18-30 97.11 A6537 GC STOCKING FULL LNGTH 30-40 110.99 A6538 GC STOCKING FULL LNGTH 40+ 152.60 A6539 GC STOCKING WAISTLNGTH 18-30 212.25 A6540 GC STOCKING WAISTLNGTH 30-40 115.14 A6541 GC STOCKING WAISTLNGTH 40+ 155.37

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR A6544 GC STOCKING GARTER BELT 55.49 A6545 GRAD COM NON-ELASTIC BK SURG 127.95 A6549 G COMPRESSION GARMENT 0.00 A6550 NEG PRES WOUND THER DRSG SET 31.82 A6552 GRAD COM STOCKING BK 30-40 60.29 A6553 G COM STCKING BK 30-40 CUSTM 235.41 A6554 GRAD COM STOCKING BK 40+ 82.90 A6555 G COM STCKING BK 40+ CUSTM 235.41 A6556 G COM STCKING THGH18-30 CUST 322.62 A6557 G COM STCKING THGH30-40 CUST 322.62 A6558 G COM STCKING THGH 40+ CUST 332.94 A6559 G STCKNG FULL/CHAP18-30 CUST 1.20 A6560 G STCKNG FULL/CHAP30-40 CUST BR A6561 G STOCKNG FULL/CHAP 40+ CUST BR A6562 G COM STCKNG WAIST18-30 CUST 1055.87 A6563 G COM STCKNG WAIST30-40 CUST 1055.87 A6564 G COM STCKNG WAIST 40+ CUST 1137.40 A6565 GRAD COMP GAUNTLET CUSTOM 182.45 A6566 GRAD COM GARMENT NECK/HEAD 264.91 A6567 G COM GARMENT NECK/HEAD CUST 832.35 A6568 G COM GARMENT TORSO/SHLDR 172.89 A6569 G COM GARMNT TORSO/SHDR CUST 984.50 A6570 GRAD COM GARMENT GENITAL 117.80 A6571 G COM GARMENT GENITAL CUSTM 707.99 A6572 GRAD COM GARMENT TOE CAPS 109.31 A6573 GRAD COM GARMNT TOE CAP CUST 259.38 A6574 CUSTOM GRADIENT SLEEV/GLOV 330.67 A6575 GRADIENT COMP SLEEV/GLOV 107.16 A6576 CUSTOM GRAD COM SLEEVE MED 202.95 A6577 CUSTOM GRAD CM SLEEVE HEAVY 167.97 A6578 GRADIENT COMP SLEEVE 82.72 A6579 CUSTOM GRAD COM GLOVE MED 325.75 A6580 CUSTOM GRAD COM GLOVE HEAVY 323.36 A6581 GRADIENT COMP GLOVE 75.90 A6582 GRADIENT COMP GAUNTLET 50.62 A6583 GRAD COM WRAP W STRAPS BK 166.52 A6584 GRAD COM WRAP W STRAPS BR A6585 GRAD COM WRAP W STRAPS AK 197.16 A6586 GRAD COM WRAP W STRAPS LEG 580.87 A6587 GRAD COM WRAP W STRAPS FOOT 76.09 A6588 GRAD COM WRAP W STRAPS ARM 253.59 A6589 GRAD COM WRAP W STRAPS BRA 100.11 A6590 URINARY CATH DISP SUC PUMP 469.92 A6591 URINARY CATH SUC PUMP 95.46 A6593 GRAD COM ACCESSORY GMT_WRAP BR A6594 G COMP BANDGE LINER LWR EXTR 36.45 A6595 G COMP BANDGE LINER UPR EXTR 35.85 A6596 G COMP BANDGE CONFORM GAUZE 0.19 A6597 G COMP BANDAGE LONG STRETCH 1.62

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR A6598 G COMP BANDAGE MED STRETCH 0.78 A6599 G COMP BANDAGE SHORT STRETCH 1.77 A6600 G COM BANDGE HGH DN FOAM SHT 3.19 A6601 G COM BANDGE HGH DN FOAM PAD 3.59 A6602 G COM BANDGE HGH DN FOAMROLL 5.24 A6603 G COM BANDGE LOW DN FOAMCHNL 2.45 A6604 G COM BANDGE LOW DN FOAM FLT 1.43 A6605 G COM BANDAGE PADDED FOAM 1.64 A6606 G COM BANDAGE PADDED TEXTILE 4.86 A6607 G COM BANDAGE TUB PROTCT LYR 1.30 A6608 G COM BANDAGE TUB PROTCT PAD 5.41 A6609 G COMPRESSION BANDAGING BR A6610 G COM STCKING BK 18-30 CUSTM 235.41 A6611 GRAD COM WRAP W STRAP AK CUS BR A7000 NU DISPOSABLE CANISTER FOR PUMP 11.63 A7001 NU NONDISPOSABLE PUMP CANISTER 39.72 A7002 NU TUBING USED W SUCTION PUMP 4.39 A7003 NU NEBULIZER ADMINISTRATION SET 2.82 A7004 NU DISPOSABLE NEBULIZER SML VOL 1.84 A7005 NU NONDISPOSABLE NEBULIZER SET 25.19 A7006 NU FILTERED NEBULIZER ADMIN SET 11.01 A7007 NU LG VOL NEBULIZER DISPOSABLE 4.98 A7008 NU DISPOSABLE NEBULIZER PREFILL 12.57 A7009 NU NEBULIZER RESERVOIR BOTTLE 55.74 A7010 NU DISPOSABLE CORRUGATED TUBING 23.28 A7012 NU NEBULIZER WATER COLLEC DEVIC 4.33 A7013 NU DISPOSABLE COMPRESSOR FILTER 0.83 A7014 NU COMPRESSOR NONDISPOS FILTER 5.09 A7015 NU AEROSOL MASK USED W NEBULIZE 2.07 A7016 NU NEBULIZER DOME & MOUTHPIECE 9.28 A7017 NU NEBULIZER NOT USED W OXYGEN 164.20 A7017 RR NEBULIZER NOT USED W OXYGEN 16.42 A7017 UE NEBULIZER NOT USED W OXYGEN 123.15 A7018 WATER DISTILLED W/NEBULIZER 0.43 A7020 NU INTERFACE, COUGH STIM DEVICE 19.48 A7021 NU SUPPL AND ACCESS LUNG EXPAN 146.07 A7023 MECH ALLERGEN PARTI BARRIER BR A7025 RR REPLACE CHEST COMPRESS VEST 58.54 A7026 NU REPLACE CHST CMPRSS SYS HOSE 38.69 A7027 NU COMBINATION ORAL/NASAL MASK 202.48 A7028 NU REPL ORAL CUSHION COMBO MASK 54.93 A7029 NU REPL NASAL PILLOW COMB MASK 23.52 A7030 NU CPAP FULL FACE MASK 166.78 A7031 NU REPLACEMENT FACEMASK INTERFA 62.27 A7032 NU REPLACEMENT NASAL CUSHION 35.71 A7033 NU REPLACEMENT NASAL PILLOWS 26.48 A7034 NU NASAL APPLICATION DEVICE 104.12 A7035 NU POS AIRWAY PRESS HEADGEAR 33.20 A7036 NU POS AIRWAY PRESS CHINSTRAP 15.93

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR A7037 NU POS AIRWAY PRESSURE TUBING 31.26 A7038 NU POS AIRWAY PRESSURE FILTER 4.49 A7039 NU FILTER, NON DISPOSABLE W PAP 11.46 A7040 ONE WAY CHEST DRAIN VALVE 54.73 A7041 WATER SEAL DRAIN CONTAINER 102.86 A7044 NU PAP ORAL INTERFACE 123.50 A7045 NU REPL EXHALATION PORT FOR PAP 19.05 A7045 RR REPL EXHALATION PORT FOR PAP 1.90 A7045 UE REPL EXHALATION PORT FOR PAP 14.30 A7046 NU REPL WATER CHAMBER, PAP DEV 19.88 A7047 NU RESP SUCTION ORAL INTERFACE 162.71 A7048 VACUUM DRAIN BOTTLE/TUBE KIT 57.26 A7049 EPAP NASAL VALVE BR A7501 TRACHEOSTOMA VALVE W DIAPHRA 141.33 A7502 REPLACEMENT DIAPHRAGM/FPLATE 67.19 A7503 HMES FILTER HOLDER OR CAP 15.27 A7504 TRACHEOSTOMA HMES FILTER 0.92 A7505 HMES OR TRACH VALVE HOUSING 6.31 A7506 HMES/TRACHVALVE ADHESIVEDISK 0.44 A7507 INTEGRATED FILTER & HOLDER 3.36 A7508 HOUSING & INTEGRATED ADHESIV 3.86 A7509 HEAT & MOISTURE EXCHANGE SYS 1.89 A7520 TRACH/LARYN TUBE NON-CUFFED 63.90 A7521 TRACH/LARYN TUBE CUFFED 63.31 A7522 TRACH/LARYN TUBE STAINLESS 60.78 A7523 TRACHEOSTOMY SHOWER PROTECT 24.80 A7524 TRACHEOSTOMA STENT/STUD/BTTN 104.18 A7525 TRACHEOSTOMY MASK 2.77 A7526 TRACHEOSTOMY TUBE COLLAR 4.57 A7527 TRACH/LARYN TUBE PLUG/STOP 4.82 A8000 NU SOFT PROTECT HELMET PREFAB 206.40 A8000 RR SOFT PROTECT HELMET PREFAB 20.65 A8000 UE SOFT PROTECT HELMET PREFAB 154.83 A8001 NU HARD PROTECT HELMET PREFAB 206.40 A8001 RR HARD PROTECT HELMET PREFAB 20.65 A8001 UE HARD PROTECT HELMET PREFAB 154.83 A8002 NU SOFT PROTECT HELMET CUSTOM BR A8002 RR SOFT PROTECT HELMET CUSTOM BR A8002 UE SOFT PROTECT HELMET CUSTOM BR A8003 NU HARD PROTECT HELMET CUSTOM BR A8003 RR HARD PROTECT HELMET CUSTOM BR A8003 UE HARD PROTECT HELMET CUSTOM BR A8004 NU REPL SOFT INTERFACE, HELMET BR A8004 RR REPL SOFT INTERFACE, HELMET BR A8004 UE REPL SOFT INTERFACE, HELMET BR A9150 MISC/EXPER NON-PRESCRIPT DRU BR A9152 SINGLE VITAMIN NOS 0.18 A9153 MULTI-VITAMIN NOS 29.99 A9154 ARTIFICIAL SALIVA, 1 ML BR

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR A9155 ARTIFICIAL SALIVA BR A9156 ORAL MUCOADHESIVE PER 1 ML BR A9180 LICE TREATMENT, TOPICAL 107.60 A9268 PROGRAMMER ORALLY INGEST CAP BR A9269 PROGRAMABLE INGEST CAPSULE BR A9270 NON-COVERED ITEM OR SERVICE BR A9272 DISP WOUND SUCT, DRSG/ACCESS 1.60 A9273 HOT/COLD BOTLE/CAP/COL/WRAP 4.40 A9274 EXT AMB INSULIN DELIVERY SYS 29.20 A9275 DISP HOME GLUCOSE MONITOR 12.40 A9276 DISPOSABLE SENSOR, CGM SYS 15.20 A9277 EXTERNAL TRANSMITTER, CGM 1085.20 A9278 EXTERNAL RECEIVER, CGM SYS 1039.20 A9279 MONITORING FEATURE/DEVICENOC BR A9280 ALERT DEVICE, NOC BR A9281 REACHING/GRABBING DEVICE 50.80 A9282 WIG ANY TYPE 492.00 A9283 FOOT PRESS OFF LOAD SUPP DEV 22.81 A9284 NON-ELECTRONIC SPIROMETER 15.60 A9285 INVERSION EVERSION COR DEVIC BR A9286 ANY HYGIENIC ITEM, DEVICE 0.34 A9291 PRES DIG COG BEHAV THERA FDA BR A9292 PRES DIG VISUAL THERAPY FDA BR A9293 FERTILITY CYCL TRACKING SOFT 75.20 A9300 EXERCISE EQUIPMENT BR A9500 TC99M SESTAMIBI 208.40 A9501 TECHNETIUM TC-99M TEBOROXIME BR A9502 TC99M TETROFOSMIN 200.40 A9503 TC99M MEDRONATE 48.40 A9504 TC99M APCITIDE BR A9505 TL201 THALLIUM 208.40 A9506 TC-99M GRAPHITE CRUCIBLE BR 466.61 A9507 IN111 CAPROMAB BR A9508 I131 IODOBENGUATE, DX BR A9509 IODINE I-123 SOD IODIDE MIL 495.60 A9510 TC99M DISOFENIN 133.59 A9512 TC99M PERTECHNETATE 25.60 A9513 LUTETIUM LU 177 DOTATAT THER 486.01 389.55 A9515 CHOLINE C-11 5298.10

A9516 IODINE I-123 SOD IODIDE MIC 250.39 A9517 I131 IODIDE CAP, RX 62.41 28.57 A9520 TC99 TILMANOCEPT DIAG 0.5MCI 834.41 A9521 TC99M EXAMETAZIME 1663.60

A9524 I131 SERUM ALBUMIN, DX BR A9526 NITROGEN N-13 AMMONIA 479.60 A9527 IODINE I-125 SODIUM IODIDE BR 57.33 A9528 IODINE I-131 IODIDE CAP, DX 146.49 A9529 I131 IODIDE SOL, DX 1.20 A9530 I131 IODIDE SOL, RX 26.80 18.94

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR A9531 I131 MAX 100UCI 10.80 A9532 I125 SERUM ALBUMIN, DX 270.62 A9536 TC99M DEPREOTIDE BR A9537 TC99M MEBROFENIN 105.20 A9538 TC99M PYROPHOSPHATE 95.99 A9539 TC99M PENTETATE 105.20 A9540 TC99M MAA 250.39 A9541 TC99M SULFUR COLLOID 187.60 A9542 IN111 IBRITUMOMAB, DX BR

A9543 Y90 IBRITUMOMAB, RX BR 84907.27 A9546 CO57/58 16.79 A9547 IN111 OXYQUINOLINE 1094.31

A9548 IN111 PENTETATE 1643.99

A9550 TC99M GLUCEPTATE 183.60 A9551 TC99M SUCCIMER BR A9552 F18 FDG 576.00 A9553 CR51 CHROMATE BR A9554 I125 IOTHALAMATE, DX 813.60 A9555 RB82 RUBIDIUM 667.60 A9556 GA67 GALLIUM 39.22 A9557 TC99M BICISATE BR

A9558 XE133 XENON 10MCI 410.40 A9559 CO57 CYANO BR A9560 TC99M LABELED RBC 208.40 A9561 TC99M OXIDRONATE 83.60 A9562 TC99M MERTIATIDE 1084.80 A9563 P32 NA PHOSPHATE BR 650.84 A9564 P32 CHROMIC PHOSPHATE 199.77 A9566 TC99M FANOLESOMAB BR A9567 TECHNETIUM TC-99M AEROSOL 166.80 A9568 TECHNETIUM TC99M ARCITUMOMAB BR

A9569 TECHNETIUM TC-99M AUTO WBC 2359.60

A9570 INDIUM IN-111 AUTO WBC 6804.40

A9571 INDIUM IN-111 AUTO PLATELET BR A9572 INDIUM IN-111 PENTETREOTIDE 5682.40

A9573 INJ, GADOPICLENOL, 1 ML 5.20 A9574 AIR POLY INTRAUTERINE FOAM 0.09 A9575 INJ GADOTERATE MEGLUMI 0.1ML 0.14 A9576 INJ PROHANCE MULTIPACK 1.82 A9577 INJ MULTIHANCE 2.37 A9578 INJ MULTIHANCE MULTIPACK 2.22 A9579 GAD-BASE MR CONTRAST NOS,1ML 2.09 A9580 SODIUM FLUORIDE F-18 443.20 A9581 GADOXETATE DISODIUM INJ 16.21 A9582 IODINE I-123 IOBENGUANE 7508.80

A9583 GADOFOSVESET TRISODIUM INJ 37.78 A9584 IODINE I-123 IOFLUPANE 4697.20

A9585 GADOBUTROL INJECTION 0.43 A9586 FLORBETAPIR F18 3419.20 4559.62

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR A9587 GALLIUM GA-68 142.80 100.47 A9588 FLUCICLOVINE F-18 529.83 586.43 A9589 INSTI HEXAMINOLEVULINATE HCL 1348.00 A9590 IODINE I-131 IOBENGUANE 1MCI BR 454.57 A9591 FLUOROESTRADIOL F 18 1168.00 915.66 A9592 COPPER CU 64 DOTATATE DIAG 2361.60 1304.30 A9593 GALLIUM GA-68 PSMA-11 UCSF BR 1040.66 A9594 GALLIUM GA-68 PSMA-11, UCLA BR 1018.92 A9595 PIFLU F-18, DIA 1 MILLICURIE 861.20 769.33 A9596 GALLIUM ILLUCCIX 1 MILLICURE 1705.59

A9597 PET, DX, FOR TUMOR ID, NOC 3837.99 A9598 PET DX FOR NON-TUMOR ID, NOC BR A9600 SR89 STRONTIUM 504.54 5644.50 A9601 FLORTAUCIPIR INJ 1 MILLICURI BR

A9602 FLUORODOPA F-18 DIAG PER MCI 1367.60

A9603 INJ, PAFOLACIANINE, 0.1 MG BR A9604 SM 153 LEXIDRONAM 4725.28 24508.99 A9606 RADIUM RA223 DICHLORIDE THER 299.60 211.48 A9607 LUTETIUM LU 177 VIPIVOTIDE 470.00

A9608 FLOTUFOLASTAT F18 DIAG 1 MCI 997.60 898.42 A9609 F18 FDG, 15 MILLICURIES BR A9610 XE129 XENON, DIAGNOSTIC BR A9611 FLURPIRIDAZ F18, DIAG, 1 MCI BR A9615 INJ, PEGULICIANINE, 1 MG BR 53.26 A9697 INJ, MAGTRACE PER STUDY DOSE 867.20

1615.90 A9698 NON-RAD CONTRAST MATERIALNOC BR A9699 RADIOPHARM RX AGENT NOC BR A9700 ECHOCARDIOGRAPHY CONTRAST 199.59 A9800 GALLIUM LOCAMETZ 1 MILLICURI 1192.40

A9900 SUPPLY/ACCESSORY/SERVICE BR A9901 DELIVERY/SET UP/DISPENSING 34.40 A9999 DME SUPPLY OR ACCESSORY, NOS BR B4034 ENTER FEED SUPKIT SYR BY DAY 5.79 B4035 ENTERAL FEED SUPP PUMP PER D 10.68 B4036 ENTERAL FEED SUP KIT GRAV BY 7.69 B4081 ENTERAL NG TUBING W/ STYLET 23.40 B4082 ENTERAL NG TUBING W/O STYLET 17.12 B4083 ENTERAL STOMACH TUBE LEVINE 2.60 B4087 GASTRO/JEJUNO TUBE, STD 39.59 B4088 GASTRO/JEJUNO TUBE, LOW-PRO 42.55 B4100 FOOD THICKENER ORAL 1.29 B4102 EF ADULT FLUIDS AND ELECTRO 3.42 B4103 EF PED FLUID AND ELECTROLYTE 7.03 B4104 ADDITIVE FOR ENTERAL FORMULA 0.94 B4105 ENZYME CARTRIDGE ENTERAL NUT 250.37 B4148 ENTERAL FEED ELASTOMER DAILY 12.97 B4149 EF BLENDERIZED FOODS 1.63 B4150 EF COMPLET W/INTACT NUTRIENT 0.67

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR B4152 EF CALORIE DENSE>/=1.5KCAL 0.55 B4153 EF HYDROLYZED/AMINO ACIDS 1.97 B4154 EF SPEC METABOLIC NONINHERIT 1.19 B4155 EF INCOMPLETE/MODULAR 1.06 B4157 EF SPECIAL METABOLIC INHERIT 5.34 B4158 EF PED COMPLETE INTACT NUT 2.98 B4159 EF PED COMPLETE SOY BASED 2.52 B4160 EF PED CALORIC DENSE>/=0.7KC 1.85 B4161 EF PED HYDROLYZED/AMINO ACID 4.42 B4162 EF PED SPECMETABOLIC INHERIT 8.35 B4164 PARENTERAL 50% DEXTROSE SOLU 23.75 B4168 PARENTERAL SOL AMINO ACID 3. 34.64 B4172 PARENTERAL SOL AMINO ACID 5. 131.78 B4176 PARENTERAL SOL AMINO ACID 7- 67.01 B4178 PARENTERAL SOL AMINO ACID > 80.41 B4180 PARENTERAL SOL CARB > 50% 34.09 B4185 PN SOLN NOS 10 GRAMS LIPIDS 15.70 B4187 OMEGAVEN, 10 GRAMS LIPIDS 15.70 B4189 PARENTERAL SOL AMINO ACID & 248.41 B4193 PARENTERAL SOL 52-73 GM PROT 320.97 B4197 PARENTERAL SOL 74-100 GM PRO 390.79 B4199 PARENTERAL SOL > 100GM PROTE 446.53 B4216 PARENTERAL NUTRITION ADDITIV 10.79 B4220 PARENTERAL SUPPLY KIT PREMIX 11.19 B4222 PARENTERAL SUPPLY KIT HOMEMI 13.81 B4224 PARENTERAL ADMINISTRATION KI 34.94 B5000 PARENTERAL SOL RENAL-AMIROSY 16.62 B5100 PARENTERAL SOLUTION HEPATIC 6.49 B5200 PARENTERAL SOL HEPATIC FREAM 5.57 B9002 NU ENTER NUTR INF PUMP ANY TYPE 1163.16 B9002 RR ENTER NUTR INF PUMP ANY TYPE 113.92 B9002 UE ENTER NUTR INF PUMP ANY TYPE 872.38 B9004 NU PARENTERAL INFUS PUMP PORTAB 3526.09 B9004 RR PARENTERAL INFUS PUMP PORTAB 558.18 B9004 UE PARENTERAL INFUS PUMP PORTAB 2644.55 B9006 NU PARENTERAL INFUS PUMP STATIO 3526.09 B9006 RR PARENTERAL INFUS PUMP STATIO 558.18 B9006 UE PARENTERAL INFUS PUMP STATIO 2644.55 B9998 ENTERAL SUPP NOT OTHERWISE C BR B9999 PARENTERAL SUPP NOT OTHRWS C BR C1052 HEMOSTATIC AGENT, GI, TOPIC BR C1062 INTRAVERTEBRAL FX AUG IMPL BR C1713 ANCHOR/SCREW BN/BN,TIS/BN 0.00 C1714 CATH, TRANS ATHERECTOMY, DIR 0.00 C1715 BRACHYTHERAPY NEEDLE 0.00 C1716 BRACHYTX, NON-STR, GOLD-198 0.00 875.59 C1717 BRACHYTX, NON-STR,HDR IR-192 0.00 485.24 C1719 BRACHYTX, NS, NON-HDRIR-192 0.00 292.26 C1721 AICD, DUAL CHAMBER 0.00

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR C1722 AICD, SINGLE CHAMBER 0.00 C1724 CATH, TRANS ATHEREC,ROTATION 0.00 C1725 CATH, TRANSLUMIN NON-LASER 0.00 C1726 CATH, BAL DIL, NON-VASCULAR 0.00 C1727 CATH, BAL TIS DIS, NON-VAS 0.00 C1728 CATH, BRACHYTX SEED ADM 0.00 C1729 CATH, DRAINAGE 0.00 C1730 CATH, EP, 19 OR FEW ELECT 0.00 C1731 CATH, EP, 20 OR MORE ELEC 0.00 C1732 CATH, EP, DIAG/ABL, 3D/VECT 0.00 C1733 CATH, EP, OTHR THAN COOL-TIP 0.00 C1734 ORTH/DEVIC/DRUG BN/BN,TIS/BN BR C1735 CATH RENAL DENERV RADIOFREQ BR C1736 CATH RENAL DENERV ULTRASND BR C1737 SI&PELVIS FUSN&FIXN DEV BR C1738 POWER ENDO US-GUID BX DEV BR C1739 TISSUE MARKER, DETECTABLE BR C1747 ENDO, SINGLE, URINARY TRACT BR C1748 ENDOSCOPE, SINGLE, UGI BR C1749 ENDO, COLON, RETRO IMAGING 0.00 C1750 CATH, HEMODIALYSIS,LONG-TERM 0.00 C1751 CATH, INF, PER/CENT/MIDLINE 0.00 C1752 CATH,HEMODIALYSIS,SHORT-TERM 0.00 C1753 CATH, INTRAVAS ULTRASOUND 0.00 C1754 CATHETER, INTRADISCAL 0.00 C1755 CATHETER, INTRASPINAL 0.00 C1756 CATH, PACING, TRANSESOPH 0.00 C1757 CATH, THROMBECTOMY/EMBOLECT 0.00 C1758 CATHETER, URETERAL 0.00 C1759 CATH, INTRA ECHOCARDIOGRAPHY 0.00 C1760 CLOSURE DEV, VASC 0.00 C1761 CATH, TRANS INTRA LITHO/CORO BR C1762 CONN TISS, HUMAN(INC FASCIA) 0.00 C1763 CONN TISS, NON-HUMAN 0.00 C1764 EVENT RECORDER, CARDIAC 0.00 C1765 ADHESION BARRIER 0.00 C1766 INTRO/SHEATH,STRBLE,NON-PEEL 0.00 C1767 GENERATOR, NEURO NON-RECHARG 0.00 C1768 GRAFT, VASCULAR 0.00 C1769 GUIDE WIRE 0.00 C1770 IMAGING COIL, MR, INSERTABLE 0.00 C1771 REP DEV, URINARY, W/SLING 0.00 C1772 INFUSION PUMP, PROGRAMMABLE 0.00 C1773 RET DEV, INSERTABLE 0.00 C1776 JOINT DEVICE (IMPLANTABLE) 0.00 C1777 LEAD, AICD, ENDO SINGLE COIL 0.00 C1778 LEAD, NEUROSTIMULATOR 0.00 C1779 LEAD, PMKR, TRANSVENOUS VDD 0.00 C1780 LENS, INTRAOCULAR (NEW TECH) 0.00

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR C1781 MESH (IMPLANTABLE) 0.00 C1782 MORCELLATOR 0.00 C1783 OCULAR IMP, AQUEOUS DRAIN DE 0.00 C1784 OCULAR DEV, INTRAOP, DET RET 0.00 C1785 PMKR, DUAL, RATE-RESP 0.00 C1786 PMKR, SINGLE, RATE-RESP 0.00 C1787 PATIENT PROGR, NEUROSTIM 0.00 C1788 PORT, INDWELLING, IMP 0.00 C1789 PROSTHESIS, BREAST, IMP 0.00 C1813 PROSTHESIS, PENILE, INFLATAB 0.00 C1814 RETINAL TAMP, SILICONE OIL 0.00 C1815 PROS, URINARY SPH, IMP 0.00 C1816 RECEIVER/TRANSMITTER, NEURO 0.00 C1817 SEPTAL DEFECT IMP SYS 0.00 C1818 INTEGRATED KERATOPROSTHESIS 0.00 C1819 TISSUE LOCALIZATION-EXCISION 0.00 C1820 GENERATOR NEURO RECHG BAT SY 0.00 C1821 INTERSPINOUS IMPLANT 0.00 C1822 GEN, NEURO, HF, RECHG BAT BR C1823 GEN, NEURO, TRANS SEN/STIM BR C1824 GENERATOR, CCM, IMPLANT BR C1825 GEN, NEURO, CAROT SINUS BARO BR C1826 GEN, NEURO, CLO LOOP, RECHG BR C1827 GEN, NEURO, IMP LED, EX CNTR BR C1830 POWER BONE MARROW BX NEEDLE 0.00 C1831 PERSONALIZED INTERBODY CAGE BR C1832 AUTO CELL PROCESS SYS BR C1833 CARDIAC MONITOR SYS BR C1839 IRIS PROSTHESIS BR C1840 TELESCOPIC INTRAOCULAR LENS 0.00 C1874 STENT, COATED/COV W/DEL SYS 0.00 C1875 STENT, COATED/COV W/O DEL SY 0.00 C1876 STENT, NON-COA/NON-COV W/DEL 0.00 C1877 STENT, NON-COAT/COV W/O DEL 0.00 C1878 MATRL FOR VOCAL CORD 0.00 C1880 VENA CAVA FILTER 0.00 C1881 DIALYSIS ACCESS SYSTEM 0.00 C1882 AICD, OTHER THAN SING/DUAL 0.00 C1883 ADAPT/EXT, PACING/NEURO LEAD 0.00 C1884 EMBOLIZATION PROTECT SYST 0.00 C1885 CATH, TRANSLUMIN ANGIO LASER 0.00 C1886 CATHETER, ABLATION 0.00 C1887 CATHETER, GUIDING 0.00 C1888 ENDOVAS NON-CARDIAC ABL CATH 0.00 C1889 IMPLANT/INSERT DEVICE, NOC BR C1890 NO DEVICE W/DEV-INTENSIVE PX BR C1891 INFUSION PUMP,NON-PROG, PERM 0.00 C1892 INTRO/SHEATH,FIXED,PEEL-AWAY 0.00 C1893 INTRO/SHEATH, FIXED,NON-PEEL 0.00

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR C1894 INTRO/SHEATH, NON-LASER 0.00 C1895 LEAD, AICD, ENDO DUAL COIL 0.00 C1896 LEAD, AICD, NON SING/DUAL 0.00 C1897 LEAD, NEUROSTIM TEST KIT 0.00 C1898 LEAD, PMKR, OTHER THAN TRANS 0.00 C1899 LEAD, PMKR/AICD COMBINATION 0.00 C1900 LEAD, CORONARY VENOUS 0.00 C1982 CATH, PRESSURE,VALVE-OCCLU BR C2596 PROBE, ROBOTIC, WATER-JET BR C2613 LUNG BX PLUG W/DEL SYS BR C2614 PROBE, PERC LUMB DISC 0.00 C2615 SEALANT, PULMONARY, LIQUID 0.00 C2616 BRACHYTX, NON-STR,YTTRIUM-90 0.00 25223.76 C2617 STENT, NON-COR, TEM W/O DEL 0.00 C2618 PROBE/NEEDLE, CRYO 0.00 C2619 PMKR, DUAL, NON RATE-RESP 0.00 C2620 PMKR, SINGLE, NON RATE-RESP 0.00 C2621 PMKR, OTHER THAN SING/DUAL 0.00 C2622 PROSTHESIS, PENILE, NON-INF 0.00 C2623 CATH, TRANSLUMIN, DRUG-COAT BR C2624 WIRELESS PRESSURE SENSOR BR C2625 STENT, NON-COR, TEM W/DEL SY 0.00 C2626 INFUSION PUMP, NON-PROG,TEMP 0.00 C2627 CATH, SUPRAPUBIC/CYSTOSCOPIC 0.00 C2628 CATHETER, OCCLUSION 0.00 C2629 INTRO/SHEATH, LASER 0.00 C2630 CATH, EP, COOL-TIP 0.00 C2631 REP DEV, URINARY, W/O SLING 0.00 C2634 BRACHYTX, NON-STR, HA, I-125 0.00 214.70 C2635 BRACHYTX, NON-STR, HA, P-103 0.00 64.78 C2636 BRACHY LINEAR, NON-STR,P-103 0.00 74.65 C2637 BRACHY,NON-STR,YTTERBIUM-169 0.00 C2638 BRACHYTX, STRANDED, I-125 0.00 54.23 C2639 BRACHYTX, NON-STRANDED,I-125 0.00 49.44 C2640 BRACHYTX, STRANDED, P-103 0.00 127.22 C2641 BRACHYTX, NON-STRANDED,P-103 0.00 100.75 C2642 BRACHYTX, STRANDED, C-131 0.00 104.19 C2643 BRACHYTX, NON-STRANDED,C-131 0.00 116.48 C2644 BRACHYTX CESIUM-131 CHLORIDE BR 18.86 C2645 BRACHYTX PLANAR, P-103 BR 6.66 C2698 BRACHYTX, STRANDED, NOS 0.00 54.23 C2699 BRACHYTX, NON-STRANDED, NOS 0.00 49.44 C5271 LOW COST SKIN SUBSTITUTE APP BR 759.54 C5272 LOW COST SKIN SUBSTITUTE APP BR C5273 LOW COST SKIN SUBSTITUTE APP BR 2483.95 C5274 LOW COST SKIN SUBSTITUTE APP BR C5275 LOW COST SKIN SUBSTITUTE APP BR 759.54 C5276 LOW COST SKIN SUBSTITUTE APP BR C5277 LOW COST SKIN SUBSTITUTE APP BR 759.54

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR C5278 LOW COST SKIN SUBSTITUTE APP BR C7500 DEB BONE 20 CM2 W/DRUG DEV BR C7501 PERC BX BREAST LESIONS STERO BR C7502 PERC BX BREAST LESIONS MR BR C7503 OPEN EXC CERV NODE(S) W/ ID BR C7504 PERQ CVT&LS INJ VERT BODIES BR C7505 PERQ LS&CVT INJ VERT BODIES BR C7506 FUSION OF FINGER JOINTS BR C7507 PERQ THOR&LUMB VERT AUG BR C7508 PERQ LUMB&THOR VERT AUG BR C7509 DX BRONCH W/ NAVIGATION BR C7510 BRONCH/LAVAG W/ NAVIGATION BR C7511 BRONCH/BPSY(S) W/ NAVIGATION BR C7512 BRONCH/BPSY(S) W/ EBUS BR C7513 CATH/ANGIO DIALCIR W/APLASTY BR C7514 CATH/ANGIO DIAL CIR W/STENTS BR C7515 CATH/ANGIO DIAL CIR W/EMBOL BR C7516 COR ANGIO W/ IVUS OR OCT BR C7517 COR ANGIO W/ILIC/FEM ANGIO BR C7518 COR/GFT ANGIO W/ IVUS OR OCT BR C7519 COR/GFT ANGIO W/ FLOW RESRV BR C7520 COR/GFT ANGIO W/ILIC/FEM ANG BR C7521 R HRT ANGIO W/ IVUS OR OCT BR C7522 R HRT ANGIO W/FLOW RESRV BR C7523 L HRT ANGIO W/ IVUS OR OCT BR C7524 L HRT ANGIO W/FLOW RESRV BR C7525 L HRT GFT ANG W/ IVUS OR OCT BR C7526 L HRT GFT ANG W/FLOW RESRV BR C7527 R&L HRT ANGIO W/ IVUS OR OCT BR C7528 R&L HRT ANGIO W/FLOW RESRV BR C7529 R&L HRT GFT ANG W/FLOW RESRV BR C7530 CATH/APLASTY DIAL CIR W/STNT BR C7531 ANGIO FEM/POP W/ US BR C7532 ANGIO W/ US NON-CORONARY BR C7533 PTCA W/ PLCMT BRACHYTX DEV BR C7534 FEM/POP REVASC W/ARTHR & US BR C7535 FEM/POP REVASC W/STENT & US BR C7537 INSRT ATRIL PM W/L VENT LEAD BR C7538 INSRT VENT PM W/L VENT LEAD BR C7539 INSRT A & V PM W/L VENT LEAD BR C7540 RMV&RPLC PM DUL W/L VNT LEAD BR C7541 ERCP W/ PANCREATOSCOPY BR C7542 ERCP W/BX & PANCREATOSCOPY BR C7543 ERCP W/OTOMY, PANCREATOSCOPY BR C7544 ERCP RMV CALC PANCREATOSCOPY BR C7545 EXCH BIL CATH W/ RMV CALCULI BR C7546 REP NPH/URT CATH W/DIL STRIC BR C7547 CNVRT NEPH CATH W/ DIL STRIC BR C7548 EXCH NEPH CATH W/ DIL STRIC BR

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR C7549 CHGE URTR STENT W/ DIL STRIC BR C7550 CYSTO W/ BX(S) W/ BLUE LIGHT BR C7551 EXC NEUROMA W/ IMPLNT NV END BR C7552 R HRT ART/GRFT ANG HRT FLOW BR C7553 R&I HRT ART/VENT ANG DRG AD BR C7554 CYSTURETH BLU LI CYST FL IMG BR C7555 RMVL THYRD W/AUTOTRAN PARATH BR C7556 BRONCH LAVAGE W/EBUS BR C7557 COR ANGIO/VENT W/FFR BR C7560 ERCP REMOVE FORGN BODY&ENDO BR C7562 R&L HRT ANGIO W/FFR & 3D MAP BR C7563 TRLUML BALLO ANGIOP ALL ART BR C7564 VEIN MECH THROM W/INTRVAS US BR C7565 RPR AA HRN < 3 RDC W/ RMVL BR C7900 HOPD MNTL HLT, 15-29 MIN BR 42.15 C7901 HOPD MNTL HLT, 30-60 MIN BR 107.71 C7902 HOPD MNTL HLT, EA ADDL BR C7903 HOPD MNTL HLT, GRP BR 38.82 C8000 SUPRT DEV, A-V FISTULA, IMP BR C8001 3D ANAT SEG IMAGING PREOP BR 125.03 C8002 PREP SKIN CELL SUSP, AUTOMTD BR 10295.71 J1 C8003 IMP EXTAR KNEE SHCK ABSRB BR 31371.59 C8004 SIM ANG W/PRS CATH RAD EMB BR C8005 PEF BRONCH ABLT 3D NAV EBUS BR C8900 MRA W/CONT, ABD 0.00 534.05 C8901 MRA W/O CONT, ABD 0.00 333.70 C8902 MRA W/O FOL W/CONT, ABD 0.00 534.05 C8903 MRI W/CONT, BREAST, UNI 0.00 259.05 C8905 MRI W/O FOL W/CONT, BRST, UN 0.00 534.05 C8906 MRI W/CONT, BREAST, BI 0.00 534.05 C8908 MRI W/O FOL W/CONT, BREAST, 0.00 534.05 C8909 MRA W/CONT, CHEST 0.00 534.05 C8910 MRA W/O CONT, CHEST 0.00 333.70 C8911 MRA W/O FOL W/CONT, CHEST 0.00 534.05 C8912 MRA W/CONT, LWR EXT 0.00 534.05 C8913 MRA W/O CONT, LWR EXT 0.00 333.70 C8914 MRA W/O FOL W/CONT, LWR EXT 0.00 534.05 C8918 MRA W/CONT, PELVIS 0.00 534.05 C8919 MRA W/O CONT, PELVIS 0.00 333.70 C8920 MRA W/O FOL W/CONT, PELVIS 0.00 534.05 C8921 TTE W OR W/O FOL W/CONT, COM 0.00 1037.55 C8922 TTE W OR W/O FOL W/CONT, F/U 0.00 1037.55 C8923 2D TTE W OR W/O FOL W/CON,CO 0.00 1037.55 C8924 2D TTE W OR W/O FOL W/CON,FU 0.00 534.05 C8925 2D TEE W OR W/O FOL W/CON,IN 0.00 1037.55 C8926 TEE W OR W/O FOL W/CONT,CONG 0.00 1037.55 C8927 TEE W OR W/O FOL W/CONT, MON 0.00 1037.55 C8928 TTE W OR W/O FOL W/CON,STRES 0.00 1037.55 C8929 TTE W OR WO FOL WCON,DOPPLER 0.00 1037.55

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR C8930 TTE W OR W/O CONTR, CONT ECG 0.00 1037.55 C8931 MRA, W/DYE, SPINAL CANAL 0.00 534.05 C8932 MRA, W/O DYE, SPINAL CANAL 0.00 333.70 C8933 MRA, W/O&W/DYE, SPINAL CANAL 0.00 534.05 C8934 MRA, W/DYE, UPPER EXTREMITY 0.00 534.05 C8935 MRA, W/O DYE, UPPER EXTR 0.00 333.70 C8936 MRA, W/O&W/DYE, UPPER EXTR 0.00 534.05 C8937 CAD BREAST MRI BR C8957 PROLONGED IV INF, REQ PUMP 0.00 462.41 C9046 COCAINE HCL NASAL (GOPRELTO) BR 1.85 C9047 INJECTION, CAPLACIZUMAB-YHDP BR 981.83 C9067 GALLIUM GA-68 DOTATOC BR 12.27 C9088 INSTILL, BUPIVAC AND MELOXIC BR

C9089 BUPIVACAINE IMPLANT, 1 MG BR

C9101 INJ, OLICERIDINE 0.1 MG BR

C9143 COCAINE HCL NASAL (NUMBRINO) BR C9144 INJ, BUPIVACAINE (POSIMIR) BR 0.71 C9145 INJ, APONVIE, 1 MG BR 2.67 C9173 INJ, NYPOZI, 1 MCG BR 0.77 C9248 INJ, CLEVIDIPINE BUTYRATE 0.00 4.19 C9250 ARTISS FIBRIN SEALANT 0.00 222.71 C9254 INJECTION, LACOSAMIDE 0.00 C9257 BEVACIZUMAB INJECTION 0.00 2.41 C9285 PATCH, LIDOCAINE/TETRACAINE 0.00 C9293 INJECTION, GLUCARPIDASE 0.00 471.49 C9300 INDIGOTINDISULFONATE, 1 MG BR C9301 OBECABTAGENE CAR POS T BR C9302 INJ ZANIDATAMAB, 2 MG BR C9303 INJ ZOLBETUXIMAB, 1 MG BR C9304 INJ MARSTACIMAB, 0.5 MG BR C9352 NEURAGEN NERVE GUIDE, PER CM 0.00 C9353 NEURAWRAP NERVE PROTECTOR,CM 0.00 C9354 VERITAS COLLAGEN MATRIX, CM2 0.00 C9355 NEUROMATRIX NERVE CUFF, CM 0.00 C9356 TENOGLIDE TENDON PROT, CM2 0.00 C9358 SURGIMEND, FETAL 0.00 C9359 IMPLNT,BON VOID FILLER-PUTTY 0.00 C9360 SURGIMEND, NEONATAL 0.00 C9361 NEUROMEND NERVE WRAP 0.00 C9362 IMPLNT,BON VOID FILLER-STRIP 0.00 C9363 INTEGRA MESHED BIL WOUND MAT 0.00 C9364 PORCINE IMPLANT, PERMACOL 0.00 C9399 UNCLASSIFIED DRUGS OR BIOLOG 0.00 C9460 INJECTION, CANGRELOR 0.00 23.06 C9462 INJECTION, DELAFLOXACIN BR 0.68 C9482 SOTALOL HYDROCHLORIDE IV BR 24.96 C9488 CONIVAPTAN HCL BR 62.04 C9507 COVID-19 CONVALESCENT PLASMA BR

J1 C9600 PERC DRUG-EL COR STENT SING 0.00 18510.42

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR C9601 PERC DRUG-EL COR STENT BRAN 0.00 J1 C9602 PERC D-E COR STENT ATHER S 0.00 28143.91 C9603 PERC D-E COR STENT ATHER BR 0.00 J1 C9604 PERC D-E COR REVASC T CABG S 0.00 18435.53 C9605 PERC D-E COR REVASC T CABG B 0.00 C9606 PERC D-E COR REVASC W AMI S 0.00 22208.02 J1 C9607 PERC D-E COR REVASC CHRO SIN 0.00 28374.36 C9608 PERC D-E COR REVASC CHRO ADD 0.00 C9610 CATH CORONARY DRUG-DELIVERY BR C9725 PLACE ENDORECTAL APP 0.00 1150.88 C9726 RXT BREAST APPL PLACE/REMOV 0.00 J1 C9727 INSERT PALATE IMPLANTS 0.00 2746.02 C9728 PLACE DEVICE/MARKER, NON PRO 0.00 1831.33 C9733 NON-OPHTHALMIC FVA 0.00 534.05 J1 C9734 U/S TRTMT, NOT LEIOMYOMATA 0.00 25186.58 C9738 BLUE LIGHT CYSTO IMAG AGENT BR J1 C9739 CYSTOSCOPY PROSTATIC IMP 1-3 BR 7544.44 J1 C9740 CYSTO IMPL 4 OR MORE BR 13734.34 C9751 MICROWAVE BRONCH, 3D, EBUS BR 5325.71 C9756 FLUORESCENCE LYMPH MAP W/ICG BR J1 C9757 SPINE DEVICE IMPLANT SURGERY BR 23574.01 C9758 BLIND INTERATRIAL SHUNT IDE BR 24850.71 C9759 TRANSCATH INTRAOP MICROINF BR C9760 NON-BLIND INTERATRIAL SHUNT BR 39050.71 J1 C9761 CYSTO, LITHO, VACUUM KIDNEY BR 15551.18 C9762 CARDIAC MRI SEG DYS STRAIN BR 700.74 C9763 CARDIAC MRI SEG DYS STRESS BR 700.74 J1 C9764 REVASC INTRAVASC LITHOTRIPSY BR 18519.65 J1 C9765 REVASC INTRA LITHOTRIP-STENT BR 28271.84 J1 C9766 REVASC INTRA LITHOTRIP-ATHER BR 28649.09 J1 C9767 REVASC LITHOTRIP-STENT-ATHER BR 27942.16 C9768 ENDO US-GUIDE HEP PORTO GRAD BR J1 C9772 REVASC LITHOTRIP TIBI/PERONE BR 18825.87 J1 C9773 REVASC LITHOTR-STENT TIB/PER BR 29183.81 J1 C9774 REVASC LITHOTR-ATHER TIB/PER BR 28913.99 J1 C9775 REVASC LITH-STEN-ATH TIB/PER BR 28711.43 C9776 FLUO BILE DUCT IMAGING W/ICG BR J1 C9777 ESOPHAG MUC INTEG W/ESO EGD BR 5785.74 J1 C9778 COLPOPEXY, MIN/INV, EX-PERIT BR 8308.94 J1 C9779 ESD ENDOSCOPY OR COLONOSCOPY BR 4603.35 C9780 INSERT CV CATH INF & SUP APP BR 11715.71 J1 C9781 ARTHRO/SHOUL SURG; W/SPACER BR

C9782 BLIND MYOCAR TRPL BON MARROW BR

J1 C9783 BLIND COR SINUS REDUCER IMPL BR

J1 C9784 ENDO SLEEVE GASTRO W/TUBE BR 19176.13 J1 C9785 ENDO OUTLET RESTRICT W/TUBE BR 19176.13 C9789 INSTILL PHARM RENAL PELVIS BR 3195.71 C9791 MRI HYPERPOLARIZED XENON129 BR 1775.71 C9792 BLIND/NONBLIND TRANS ATRIAL BR 13845.71

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR C9793 PRE-PLAN 3D MODEL W/CCTA BR 1414.58 J1 C9796 RPR INTST EXCL ANRECT FIST BR 5059.71 J1 C9797 VASC EMB/OCC W/PRS CATH BR 31191.72 C9804 PUMP ELASTOMC NON-OPIOID DEV BR C9806 PUMP PERIST NON-OPIOID DEV BR C9807 NERVE STIM NON-OPIOID DEV BR C9808 CRYO PROBE NON-OPIOID DEV BR C9809 CRYO NEEDLE NON-OPIOID DEV BR C9898 INPNT STAY RADIOLABELED ITEM 0.00 C9899 INPT IMPLANT PROS DEV,NO COV 0.00 E0100 NU CANE ADJUST/FIXED WITH TIP 21.92 E0100 RR CANE ADJUST/FIXED WITH TIP 6.16 E0100 UE CANE ADJUST/FIXED WITH TIP 19.56 E0105 NU CANE ADJUST/FIXED QUAD/3 PRO 60.09 E0105 RR CANE ADJUST/FIXED QUAD/3 PRO 9.22 E0105 UE CANE ADJUST/FIXED QUAD/3 PRO 46.31 E0110 NU CRUTCH FOREARM PAIR 89.98 E0110 RR CRUTCH FOREARM PAIR 16.63 E0110 UE CRUTCH FOREARM PAIR 67.50 E0111 NU CRUTCH FOREARM EACH 55.37 E0111 RR CRUTCH FOREARM EACH 8.76 E0111 UE CRUTCH FOREARM EACH 42.75 E0112 NU CRUTCH UNDERARM PAIR WOOD 45.28 E0112 RR CRUTCH UNDERARM PAIR WOOD 10.34 E0112 UE CRUTCH UNDERARM PAIR WOOD 34.54 E0113 NU CRUTCH UNDERARM EACH WOOD 25.87 E0113 RR CRUTCH UNDERARM EACH WOOD 5.34 E0113 UE CRUTCH UNDERARM EACH WOOD 19.39 E0114 NU CRUTCH UNDERARM PAIR NO WOOD 57.74 E0114 RR CRUTCH UNDERARM PAIR NO WOOD 8.91 E0114 UE CRUTCH UNDERARM PAIR NO WOOD 43.65 E0116 NU CRUTCH UNDERARM EACH NO WOOD 32.20 E0116 RR CRUTCH UNDERARM EACH NO WOOD 5.63 E0116 UE CRUTCH UNDERARM EACH NO WOOD 25.56 E0117 NU UNDERARM SPRINGASSIST CRUTCH 303.28 E0117 RR UNDERARM SPRINGASSIST CRUTCH 23.56 E0117 UE UNDERARM SPRINGASSIST CRUTCH 209.34 E0118 CRUTCH SUBSTITUTE 1206.93 E0130 NU WALKER RIGID ADJUST/FIXED HT 57.70 E0130 RR WALKER RIGID ADJUST/FIXED HT 10.88 E0130 UE WALKER RIGID ADJUST/FIXED HT 45.41 E0135 NU WALKER FOLDING ADJUST/FIXED 63.74 E0135 RR WALKER FOLDING ADJUST/FIXED 10.81 E0135 UE WALKER FOLDING ADJUST/FIXED 48.45 E0140 NU WALKER W TRUNK SUPPORT 365.25 E0140 RR WALKER W TRUNK SUPPORT 35.12 E0140 UE WALKER W TRUNK SUPPORT 293.30 E0141 NU RIGID WHEELED WALKER ADJ/FIX 88.03 E0141 RR RIGID WHEELED WALKER ADJ/FIX 14.53

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR E0141 UE RIGID WHEELED WALKER ADJ/FIX 66.03 E0143 NU WALKER FOLDING WHEELED W/O S 85.01 E0143 RR WALKER FOLDING WHEELED W/O S 12.40 E0143 UE WALKER FOLDING WHEELED W/O S 63.77 E0144 NU ENCLOSED WALKER W REAR SEAT 956.71 E0144 RR ENCLOSED WALKER W REAR SEAT 31.25 E0144 UE ENCLOSED WALKER W REAR SEAT 293.30 E0147 NU WALKER VARIABLE WHEEL RESIST 537.39 E0147 RR WALKER VARIABLE WHEEL RESIST 53.75 E0147 UE WALKER VARIABLE WHEEL RESIST 403.06 E0148 NU HEAVYDUTY WALKER NO WHEELS 114.49 E0148 RR HEAVYDUTY WALKER NO WHEELS 11.46 E0148 UE HEAVYDUTY WALKER NO WHEELS 85.86 E0149 NU HEAVY DUTY WHEELED WALKER 275.31 E0149 RR HEAVY DUTY WHEELED WALKER 18.50 E0149 UE HEAVY DUTY WHEELED WALKER 183.33 E0152 WALKER, BATTERY POWER WHEELS BR E0153 NU FOREARM CRUTCH PLATFORM ATTA 84.90 E0153 RR FOREARM CRUTCH PLATFORM ATTA 8.97 E0153 UE FOREARM CRUTCH PLATFORM ATTA 63.66 E0154 NU WALKER PLATFORM ATTACHMENT 65.30 E0154 RR WALKER PLATFORM ATTACHMENT 7.33 E0154 UE WALKER PLATFORM ATTACHMENT 49.34 E0155 NU WALKER WHEEL ATTACHMENT,PAIR 26.13 E0155 RR WALKER WHEEL ATTACHMENT,PAIR 2.92 E0155 UE WALKER WHEEL ATTACHMENT,PAIR 19.78 E0156 NU WALKER SEAT ATTACHMENT 22.97 E0156 RR WALKER SEAT ATTACHMENT 2.69 E0156 UE WALKER SEAT ATTACHMENT 17.24 E0157 NU WALKER CRUTCH ATTACHMENT 68.92 E0157 RR WALKER CRUTCH ATTACHMENT 7.25 E0157 UE WALKER CRUTCH ATTACHMENT 51.69 E0158 NU WALKER LEG EXTENDERS SET OF4 26.83 E0158 RR WALKER LEG EXTENDERS SET OF4 3.12 E0158 UE WALKER LEG EXTENDERS SET OF4 20.20 E0159 NU BRAKE FOR WHEELED WALKER 17.85 E0159 RR BRAKE FOR WHEELED WALKER 1.82 E0159 UE BRAKE FOR WHEELED WALKER 13.39 E0160 NU SITZ TYPE BATH OR EQUIPMENT 36.81 E0160 RR SITZ TYPE BATH OR EQUIPMENT 3.92 E0160 UE SITZ TYPE BATH OR EQUIPMENT 27.59 E0161 NU SITZ BATH/EQUIPMENT W/FAUCET 30.25 E0161 RR SITZ BATH/EQUIPMENT W/FAUCET 3.61 E0161 UE SITZ BATH/EQUIPMENT W/FAUCET 22.66 E0162 NU SITZ BATH CHAIR 178.26 E0162 RR SITZ BATH CHAIR 18.69 E0162 UE SITZ BATH CHAIR 138.22 E0163 NU COMMODE CHAIR WITH FIXED ARM 91.23 E0163 RR COMMODE CHAIR WITH FIXED ARM 15.73

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR E0163 UE COMMODE CHAIR WITH FIXED ARM 71.91 E0165 NU COMMODE CHAIR WITH DETACHARM 256.99 E0165 RR COMMODE CHAIR WITH DETACHARM 16.70 E0167 NU COMMODE CHAIR PAIL OR PAN 13.57 E0167 RR COMMODE CHAIR PAIL OR PAN 1.36 E0167 UE COMMODE CHAIR PAIL OR PAN 10.19 E0168 NU HEAVYDUTY/WIDE COMMODE CHAIR 159.57 E0168 RR HEAVYDUTY/WIDE COMMODE CHAIR 16.00 E0168 UE HEAVYDUTY/WIDE COMMODE CHAIR 119.67 E0170 RR COMMODE CHAIR ELECTRIC 192.11 E0171 RR COMMODE CHAIR NON-ELECTRIC 35.29 E0172 SEAT LIFT MECHANISM TOILET 0.00 E0175 NU COMMODE CHAIR FOOT REST 81.03 E0175 RR COMMODE CHAIR FOOT REST 8.10 E0175 UE COMMODE CHAIR FOOT REST 59.64 E0181 NU PRESS PAD ALTERNATING W/ PUM 370.73 E0181 RR PRESS PAD ALTERNATING W/ PUM 24.87 E0181 UE PRESS PAD ALTERNATING W/ PUM 256.61 E0182 NU REPLACE PUMP, ALT PRESS PAD 426.34 E0182 RR REPLACE PUMP, ALT PRESS PAD 25.57 E0182 UE REPLACE PUMP, ALT PRESS PAD 322.66 E0183 RR PRESS UNDERLAY ALTER W/PUMP 28.54 E0184 NU DRY PRESSURE MATTRESS 211.55 E0184 RR DRY PRESSURE MATTRESS 24.27 E0184 UE DRY PRESSURE MATTRESS 160.68 E0185 NU GEL PRESSURE MATTRESS PAD 263.69 E0185 RR GEL PRESSURE MATTRESS PAD 33.11 E0185 UE GEL PRESSURE MATTRESS PAD 200.67 E0186 NU AIR PRESSURE MATTRESS 226.07 E0186 RR AIR PRESSURE MATTRESS 21.11 E0186 UE AIR PRESSURE MATTRESS 422.55 E0187 NU WATER PRESSURE MATTRESS 227.94 E0187 RR WATER PRESSURE MATTRESS 24.14 E0187 UE WATER PRESSURE MATTRESS 325.92 E0188 NU SYNTHETIC SHEEPSKIN PAD 30.33 E0188 RR SYNTHETIC SHEEPSKIN PAD 3.32 E0188 UE SYNTHETIC SHEEPSKIN PAD 22.76 E0189 NU LAMBSWOOL SHEEPSKIN PAD 54.04 E0189 RR LAMBSWOOL SHEEPSKIN PAD 5.78 E0189 UE LAMBSWOOL SHEEPSKIN PAD 40.53 E0190 NU POSITIONING CUSHION 79.80 E0190 RR POSITIONING CUSHION 7.43 E0190 UE POSITIONING CUSHION 55.09 E0191 NU PROTECTOR HEEL OR ELBOW 11.75 E0191 RR PROTECTOR HEEL OR ELBOW 1.17 E0191 UE PROTECTOR HEEL OR ELBOW 8.84 E0193 RR POWERED AIR FLOTATION BED 803.79 E0194 NU AIR FLUIDIZED BED 42347.42 E0194 RR AIR FLUIDIZED BED 3981.45

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR E0194 UE AIR FLUIDIZED BED 29331.38 E0196 NU GEL PRESSURE MATTRESS 529.54 E0196 RR GEL PRESSURE MATTRESS 33.78 E0196 UE GEL PRESSURE MATTRESS 176.28 E0197 NU AIR PRESSURE PAD FOR MATTRES 431.14 E0197 RR AIR PRESSURE PAD FOR MATTRES 26.32 E0197 UE AIR PRESSURE PAD FOR MATTRES 262.30 E0198 NU WATER PRESSURE PAD FOR MATTR 248.43 E0198 RR WATER PRESSURE PAD FOR MATTR 23.04 E0198 UE WATER PRESSURE PAD FOR MATTR 310.76 E0199 NU DRY PRESSURE PAD FOR MATTRES 33.34 E0199 RR DRY PRESSURE PAD FOR MATTRES 3.32 E0199 UE DRY PRESSURE PAD FOR MATTRES 25.00 E0200 NU HEAT LAMP WITHOUT STAND 82.44 E0200 RR HEAT LAMP WITHOUT STAND 11.19 E0200 UE HEAT LAMP WITHOUT STAND 61.87 E0201 PENILE CONTRACTUR DEVIC MANU BR E0202 RR PHOTOTHERAPY LIGHT W/ PHOTOM 76.61 E0203 THERAPEUTIC LIGHTBOX TABLETP 290.24 E0205 NU HEAT LAMP WITH STAND 201.81 E0205 RR HEAT LAMP WITH STAND 22.20 E0205 UE HEAT LAMP WITH STAND 151.36 E0210 NU ELECTRIC HEAT PAD STANDARD 34.23 E0210 RR ELECTRIC HEAT PAD STANDARD 3.42 E0210 UE ELECTRIC HEAT PAD STANDARD 25.69 E0215 NU ELECTRIC HEAT PAD MOIST 73.67 E0215 RR ELECTRIC HEAT PAD MOIST 7.71 E0215 UE ELECTRIC HEAT PAD MOIST 55.26 E0217 NU WATER CIRC HEAT PAD W PUMP 604.09 E0217 RR WATER CIRC HEAT PAD W PUMP 58.95 E0217 UE WATER CIRC HEAT PAD W PUMP 453.05 E0218 NU FLUID CIRC COLD PAD W PUMP 1895.41 E0218 RR FLUID CIRC COLD PAD W PUMP 39.61 E0218 UE FLUID CIRC COLD PAD W PUMP 293.81 E0221 INFRARED HEATING PAD SYSTEM 2705.90 E0225 NU HYDROCOLLATOR UNIT 475.48 E0225 RR HYDROCOLLATOR UNIT 46.87 E0225 UE HYDROCOLLATOR UNIT 356.61 E0231 WOUND WARMING DEVICE BR E0232 WARMING CARD FOR NWT BR E0235 NU PARAFFIN BATH UNIT PORTABLE 937.02 E0235 RR PARAFFIN BATH UNIT PORTABLE 21.10 E0235 UE PARAFFIN BATH UNIT PORTABLE 736.77 E0236 NU PUMP FOR WATER CIRCULATING P 4298.82 E0236 RR PUMP FOR WATER CIRCULATING P 54.13 E0236 UE PUMP FOR WATER CIRCULATING P 659.96 E0239 NU HYDROCOLLATOR UNIT PORTABLE 550.34 E0239 RR HYDROCOLLATOR UNIT PORTABLE 55.04 E0239 UE HYDROCOLLATOR UNIT PORTABLE 412.76

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR E0240 NU BATH/SHOWER CHAIR 119.28 E0240 RR BATH/SHOWER CHAIR 13.37 E0240 UE BATH/SHOWER CHAIR 99.16 E0241 BATH TUB WALL RAIL 73.00 E0242 BATH TUB RAIL FLOOR 58.48 E0243 TOILET RAIL 74.19 E0244 TOILET SEAT RAISED 71.28 E0245 TUB STOOL OR BENCH 76.97 E0246 TRANSFER TUB RAIL ATTACHMENT 86.18 E0247 NU TRANS BENCH W/WO COMM OPEN 129.81 E0247 RR TRANS BENCH W/WO COMM OPEN 11.88 E0247 UE TRANS BENCH W/WO COMM OPEN 88.15 E0248 NU HDTRANS BENCH W/WO COMM OPEN 186.01 E0248 RR HDTRANS BENCH W/WO COMM OPEN 17.23 E0248 UE HDTRANS BENCH W/WO COMM OPEN 127.80 E0249 NU PAD WATER CIRCULATING HEAT U 103.58 E0249 RR PAD WATER CIRCULATING HEAT U 11.38 E0249 UE PAD WATER CIRCULATING HEAT U 77.67 E0250 NU HOSP BED FIXED HT W/ MATTRES 1849.69 E0250 RR HOSP BED FIXED HT W/ MATTRES 78.75 E0250 UE HOSP BED FIXED HT W/ MATTRES 1173.27 E0251 NU HOSP BED FIXD HT W/O MATTRES 1852.78 E0251 RR HOSP BED FIXD HT W/O MATTRES 71.61 E0251 UE HOSP BED FIXD HT W/O MATTRES 1099.91 E0255 NU HOSPITAL BED VAR HT W/ MATTR 1606.51 E0255 RR HOSPITAL BED VAR HT W/ MATTR 87.85 E0255 UE HOSPITAL BED VAR HT W/ MATTR 1121.95 E0256 NU HOSPITAL BED VAR HT W/O MATT 905.64 E0256 RR HOSPITAL BED VAR HT W/O MATT 71.52 E0256 UE HOSPITAL BED VAR HT W/O MATT 985.89 E0260 NU HOSP BED SEMI-ELECTR W/ MATT 1852.89 E0260 RR HOSP BED SEMI-ELECTR W/ MATT 109.28 E0260 UE HOSP BED SEMI-ELECTR W/ MATT 1224.59 E0261 NU HOSP BED SEMI-ELECTR W/O MAT 1694.19 E0261 RR HOSP BED SEMI-ELECTR W/O MAT 96.56 E0261 UE HOSP BED SEMI-ELECTR W/O MAT 1026.63 E0265 NU HOSP BED TOTAL ELECTR W/ MAT 2065.00 E0265 RR HOSP BED TOTAL ELECTR W/ MAT 175.49 E0265 UE HOSP BED TOTAL ELECTR W/ MAT 1466.57 E0266 NU HOSP BED TOTAL ELEC W/O MATT 2109.87 E0266 RR HOSP BED TOTAL ELEC W/O MATT 146.94 E0266 UE HOSP BED TOTAL ELEC W/O MATT 1503.26 E0270 NU HOSPITAL BED INSTITUTIONAL T 0.00 E0270 RR HOSPITAL BED INSTITUTIONAL T 0.00 E0270 UE HOSPITAL BED INSTITUTIONAL T 0.00 E0271 NU MATTRESS INNERSPRING 170.57 E0271 RR MATTRESS INNERSPRING 17.44 E0271 UE MATTRESS INNERSPRING 138.05 E0272 NU MATTRESS FOAM RUBBER 171.31

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR E0272 RR MATTRESS FOAM RUBBER 17.54 E0272 UE MATTRESS FOAM RUBBER 128.16 E0273 NU BED BOARD 30.56 E0273 RR BED BOARD 10.00 E0273 UE BED BOARD 74.19 E0274 NU OVER-BED TABLE 426.09 E0274 RR OVER-BED TABLE 55.20 E0274 UE OVER-BED TABLE 411.27 E0275 NU BED PAN STANDARD 17.39 E0275 RR BED PAN STANDARD 1.78 E0275 UE BED PAN STANDARD 13.04 E0276 NU BED PAN FRACTURE 15.04 E0276 RR BED PAN FRACTURE 1.65 E0276 UE BED PAN FRACTURE 11.61 E0277 NU POWERED PRES-REDU AIR MATTRS 7846.78 E0277 RR POWERED PRES-REDU AIR MATTRS 481.53 E0277 UE POWERED PRES-REDU AIR MATTRS 4766.37 E0280 NU BED CRADLE 34.25 E0280 RR BED CRADLE 3.65 E0280 UE BED CRADLE 25.68 E0290 NU HOSP BED FX HT W/O RAILS W/M 838.97 E0290 RR HOSP BED FX HT W/O RAILS W/M 66.26 E0290 UE HOSP BED FX HT W/O RAILS W/M 568.46 E0291 NU HOSP BED FX HT W/O RAIL W/O 635.11 E0291 RR HOSP BED FX HT W/O RAIL W/O 53.10 E0291 UE HOSP BED FX HT W/O RAIL W/O 439.94 E0292 NU HOSP BED VAR HT NO SR W/MATT 772.34 E0292 RR HOSP BED VAR HT NO SR W/MATT 72.24 E0292 UE HOSP BED VAR HT NO SR W/MATT 837.53 E0293 NU HOSP BED VAR HT NO SR NO MAT 657.05 E0293 RR HOSP BED VAR HT NO SR NO MAT 66.79 E0293 UE HOSP BED VAR HT NO SR NO MAT 733.67 E0294 NU HOSP BED SEMI-ELECT W/ MATTR 1429.04 E0294 RR HOSP BED SEMI-ELECT W/ MATTR 93.76 E0294 UE HOSP BED SEMI-ELECT W/ MATTR 989.94 E0295 NU HOSP BED SEMI-ELECT W/O MATT 1146.21 E0295 RR HOSP BED SEMI-ELECT W/O MATT 92.26 E0295 UE HOSP BED SEMI-ELECT W/O MATT 793.78 E0296 NU HOSP BED TOTAL ELECT W/ MATT 1591.83 E0296 RR HOSP BED TOTAL ELECT W/ MATT 133.97 E0296 UE HOSP BED TOTAL ELECT W/ MATT 1393.21 E0297 NU HOSP BED TOTAL ELECT W/O MAT 5006.93 E0297 RR HOSP BED TOTAL ELECT W/O MAT 116.33 E0297 UE HOSP BED TOTAL ELECT W/O MAT 1466.57 E0300 NU ENCLOSED PED CRIB HOSP GRADE 2608.74 E0300 RR ENCLOSED PED CRIB HOSP GRADE 284.22 E0300 UE ENCLOSED PED CRIB HOSP GRADE 2955.01 E0301 NU HD HOSP BED, 350-600 LBS 3177.45 E0301 RR HD HOSP BED, 350-600 LBS 218.86

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR E0301 UE HD HOSP BED, 350-600 LBS 2258.54 E0302 NU EX HD HOSP BED > 600 LBS 21286.79 E0302 RR EX HD HOSP BED > 600 LBS 647.60 E0302 UE EX HD HOSP BED > 600 LBS 12084.49 E0303 NU HOSP BED HVY DTY XTRA WIDE 3473.75 E0303 RR HOSP BED HVY DTY XTRA WIDE 237.65 E0303 UE HOSP BED HVY DTY XTRA WIDE 2419.82 E0304 NU HOSP BED XTRA HVY DTY X WIDE 8938.55 E0304 RR HOSP BED XTRA HVY DTY X WIDE 684.15 E0304 UE HOSP BED XTRA HVY DTY X WIDE 6239.48 E0305 NU RAILS BED SIDE HALF LENGTH 201.21 E0305 RR RAILS BED SIDE HALF LENGTH 15.57 E0305 UE RAILS BED SIDE HALF LENGTH 146.64 E0310 NU RAILS BED SIDE FULL LENGTH 156.60 E0310 RR RAILS BED SIDE FULL LENGTH 17.17 E0310 UE RAILS BED SIDE FULL LENGTH 117.45 E0315 BED ACCESSORY BRD/TBL/SUPPRT 198.53 E0316 NU BED SAFETY ENCLOSURE 4107.67 E0316 RR BED SAFETY ENCLOSURE 217.15 E0316 UE BED SAFETY ENCLOSURE 1775.36 E0325 NU URINAL MALE JUG-TYPE 11.43 E0325 RR URINAL MALE JUG-TYPE 1.31 E0325 UE URINAL MALE JUG-TYPE 8.02 E0326 NU URINAL FEMALE JUG-TYPE 12.03 E0326 RR URINAL FEMALE JUG-TYPE 1.21 E0326 UE URINAL FEMALE JUG-TYPE 9.03 E0328 PED HOSPITAL BED, MANUAL 11447.10 E0329 PED HOSPITAL BED SEMI/ELECT 16092.87 E0350 NU CONTROL UNIT BOWEL SYSTEM BR E0350 RR CONTROL UNIT BOWEL SYSTEM BR E0350 UE CONTROL UNIT BOWEL SYSTEM BR E0352 DISPOSABLE PACK W/BOWEL SYST 62.01 E0370 AIR ELEVATOR FOR HEEL 164.38 E0371 RR NONPOWER MATTRESS OVERLAY 320.51 E0372 RR POWERED AIR MATTRESS OVERLAY 365.46 E0373 RR NONPOWERED PRESSURE MATTRESS 402.52 E0424 RR STATIONARY COMPRESSED GAS 02 151.15 E0425 GAS SYSTEM STATIONARY COMPRE 30.46 E0430 OXYGEN SYSTEM GAS PORTABLE 3.52 E0431 RR PORTABLE GASEOUS 02 75.58 E0433 RR PORTABLE LIQUID OXYGEN SYS 75.58 E0434 RR PORTABLE LIQUID 02 75.58 E0435 OXYGEN SYSTEM LIQUID PORTABL BR E0439 RR STATIONARY LIQUID 02 151.15 E0440 OXYGEN SYSTEM LIQUID STATION 15.87 E0441 STATIONARY O2 CONTENTS, GAS 69.95 E0442 STATIONARY O2 CONTENTS, LIQ 69.95 E0443 PORTABLE 02 CONTENTS, GAS 67.06 E0444 PORTABLE 02 CONTENTS, LIQUID 67.06

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR E0445 OXIMETER NON-INVASIVE 14.76 E0446 TOPICAL OX DELIVER SYS, NOS 14.78 E0447 PORT O2 CONT, LIQ OVER 4 LPM 101.87 E0455 NU OXYGEN TENT EXCL CROUP/PED T 1795.96 E0455 RR OXYGEN TENT EXCL CROUP/PED T BR E0455 UE OXYGEN TENT EXCL CROUP/PED T BR E0457 NU CHEST SHELL 604.00 E0457 RR CHEST SHELL BR E0457 UE CHEST SHELL BR E0459 NU CHEST WRAP 500.27 E0459 RR CHEST WRAP 25.26 E0459 UE CHEST WRAP 189.49 E0462 NU ROCKING BED W/ OR W/O SIDE R 3264.59 E0462 RR ROCKING BED W/ OR W/O SIDE R 356.52 E0462 UE ROCKING BED W/ OR W/O SIDE R 3031.78 E0465 RR HOME VENT INVASIVE INTERFACE 992.63 E0466 RR HOME VENT NON-INVASIVE INTER 992.63 E0467 RR HOME VENT MULTI-FUNCTION 1193.23 E0468 RR HOME VENT DUAL FNCT INCL ALL 1223.34 E0469 RR LUNG EXPANS HIGH OSCIL NEB 1531.47 E0470 NU RAD W/O BACKUP NON-INV INTFC 3229.03 E0470 RR RAD W/O BACKUP NON-INV INTFC 185.02 E0470 UE RAD W/O BACKUP NON-INV INTFC 2199.81 E0471 NU RAD W/BACKUP NON INV INTRFC 7516.14 E0471 RR RAD W/BACKUP NON INV INTRFC 460.88 E0471 UE RAD W/BACKUP NON INV INTRFC 5132.95 E0472 NU RAD W BACKUP INVASIVE INTRFC 6799.63 E0472 RR RAD W BACKUP INVASIVE INTRFC 538.25 E0472 UE RAD W BACKUP INVASIVE INTRFC 4708.94 E0480 NU PERCUSSOR ELECT/PNEUM HOME M 734.18 E0480 RR PERCUSSOR ELECT/PNEUM HOME M 45.70 E0480 UE PERCUSSOR ELECT/PNEUM HOME M 135.15 E0481 INTRPULMNRY PERCUSS VENT SYS BR E0482 RR COUGH STIMULATING DEVICE 471.45 E0483 NU HI FREQ CHEST WALL OSCIL SYS 15763.14 E0483 RR HI FREQ CHEST WALL OSCIL SYS 1300.68 E0483 UE HI FREQ CHEST WALL OSCIL SYS 10999.22 E0484 NU NON-ELEC OSCILLATORY PEP DVC 45.19 E0484 RR NON-ELEC OSCILLATORY PEP DVC 4.52 E0484 UE NON-ELEC OSCILLATORY PEP DVC 33.89 E0485 NU ORAL DEVICE/APPLIANCE PREFAB 212.65 E0485 RR ORAL DEVICE/APPLIANCE PREFAB 19.80 E0485 UE ORAL DEVICE/APPLIANCE PREFAB 146.91 E0486 NU ORAL DEVICE/APPLIANCE CUSFAB 6917.19 E0486 RR ORAL DEVICE/APPLIANCE CUSFAB 643.64 E0486 UE ORAL DEVICE/APPLIANCE CUSFAB 4774.46 E0487 NU ELECTRONIC SPIROMETER 0.00 E0487 RR ELECTRONIC SPIROMETER 0.00 E0487 UE ELECTRONIC SPIROMETER 0.00

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR E0490 RR CONTROL UNIT NM HW REMOTE 103.83 E0491 ORAL DV NM MOUTHPC HW REMOTE 100.88 E0492 CONTROL UNIT NM STIM W PHONE BR E0493 ORAL DV/APP NEUROMUS MOUTHPI BR E0500 NU IPPB ALL TYPES 1829.56 E0500 RR IPPB ALL TYPES 114.15 E0500 UE IPPB ALL TYPES 1371.25 E0530 RR ELECTRONIC POSA TREATMENT 35.54 E0550 NU HUMIDIF EXTENS SUPPLE W IPPB 847.05 E0550 RR HUMIDIF EXTENS SUPPLE W IPPB 61.34 E0550 UE HUMIDIF EXTENS SUPPLE W IPPB 615.96 E0555 NU HUMIDIFIER FOR USE W/ REGULA 6.58 E0555 RR HUMIDIFIER FOR USE W/ REGULA 0.50 E0555 UE HUMIDIFIER FOR USE W/ REGULA 3.68 E0560 NU HUMIDIFIER SUPPLEMENTAL W/ I 179.14 E0560 RR HUMIDIFIER SUPPLEMENTAL W/ I 18.01 E0560 UE HUMIDIFIER SUPPLEMENTAL W/ I 134.34 E0561 NU HUMIDIFIER NONHEATED W PAP 98.38 E0561 RR HUMIDIFIER NONHEATED W PAP 9.83 E0561 UE HUMIDIFIER NONHEATED W PAP 73.78 E0562 NU HUMIDIFIER HEATED USED W PAP 238.99 E0562 RR HUMIDIFIER HEATED USED W PAP 23.89 E0562 UE HUMIDIFIER HEATED USED W PAP 179.24 E0565 NU COMPRESSOR AIR POWER SOURCE 899.94 E0565 RR COMPRESSOR AIR POWER SOURCE 56.01 E0565 UE COMPRESSOR AIR POWER SOURCE 623.28 E0570 NU NEBULIZER WITH COMPRESSION 341.14 E0570 RR NEBULIZER WITH COMPRESSION 13.18 E0570 UE NEBULIZER WITH COMPRESSION 220.02 E0572 NU AEROSOL COMPRESSOR ADJUST PR 360.25 E0572 RR AEROSOL COMPRESSOR ADJUST PR 37.57 E0572 UE AEROSOL COMPRESSOR ADJUST PR 268.84 E0574 NU ULTRASONIC GENERATOR W SVNEB 1373.38 E0574 RR ULTRASONIC GENERATOR W SVNEB 44.34 E0574 UE ULTRASONIC GENERATOR W SVNEB 945.93 E0575 NU NEBULIZER ULTRASONIC 492.13 E0575 RR NEBULIZER ULTRASONIC 106.89 E0575 UE NEBULIZER ULTRASONIC 367.26 E0580 NU NEBULIZER FOR USE W/ REGULAT 140.91 E0580 RR NEBULIZER FOR USE W/ REGULAT 14.10 E0580 UE NEBULIZER FOR USE W/ REGULAT 105.67 E0585 NU NEBULIZER W/ COMPRESSOR & HE 1070.13 E0585 RR NEBULIZER W/ COMPRESSOR & HE 34.60 E0585 UE NEBULIZER W/ COMPRESSOR & HE 637.92 E0600 NU SUCTION PUMP PORTAB HOM MODL 794.14 E0600 RR SUCTION PUMP PORTAB HOM MODL 47.62 E0600 UE SUCTION PUMP PORTAB HOM MODL 549.99 E0601 NU CONT AIRWAY PRESSURE DEVICE 1482.38 E0601 RR CONT AIRWAY PRESSURE DEVICE 76.81

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR E0601 UE CONT AIRWAY PRESSURE DEVICE 989.94 E0602 NU MANUAL BREAST PUMP 36.11 E0602 RR MANUAL BREAST PUMP 3.64 E0602 UE MANUAL BREAST PUMP 27.08 E0603 NU ELECTRIC BREAST PUMP 319.24 E0603 RR ELECTRIC BREAST PUMP 29.71 E0603 UE ELECTRIC BREAST PUMP 220.35 E0604 NU HOSP GRADE ELEC BREAST PUMP 952.62 E0604 RR HOSP GRADE ELEC BREAST PUMP 88.59 E0604 UE HOSP GRADE ELEC BREAST PUMP 659.96 E0605 NU VAPORIZER ROOM TYPE 32.32 E0605 RR VAPORIZER ROOM TYPE 3.74 E0605 UE VAPORIZER ROOM TYPE 26.65 E0606 NU DRAINAGE BOARD POSTURAL 256.97 E0606 RR DRAINAGE BOARD POSTURAL 28.08 E0606 UE DRAINAGE BOARD POSTURAL 303.18 E0607 NU BLOOD GLUCOSE MONITOR HOME 81.75 E0607 RR BLOOD GLUCOSE MONITOR HOME 8.17 E0607 UE BLOOD GLUCOSE MONITOR HOME 61.30 E0610 NU PACEMAKER MONITR AUDIBLE/VIS 290.99 E0610 RR PACEMAKER MONITR AUDIBLE/VIS 30.69 E0610 UE PACEMAKER MONITR AUDIBLE/VIS 218.27 E0615 NU PACEMAKER MONITR DIGITAL/VIS 585.77 E0615 RR PACEMAKER MONITR DIGITAL/VIS 71.57 E0615 UE PACEMAKER MONITR DIGITAL/VIS 439.37 E0616 CARDIAC EVENT RECORDER 7702.04 E0617 RR AUTOMATIC EXT DEFIBRILLATOR 413.00 E0618 RR APNEA MONITOR 343.01 E0619 RR APNEA MONITOR W RECORDER 397.35 E0620 NU CAP BLD SKIN PIERCING LASER 979.21 E0620 RR CAP BLD SKIN PIERCING LASER 106.96 E0620 UE CAP BLD SKIN PIERCING LASER 1136.91 E0621 NU PATIENT LIFT SLING OR SEAT 106.79 E0621 RR PATIENT LIFT SLING OR SEAT 10.46 E0621 UE PATIENT LIFT SLING OR SEAT 80.32 E0625 NU PATIENT LIFT BATHROOM OR TOI 0.00 E0625 RR PATIENT LIFT BATHROOM OR TOI 0.00 E0625 UE PATIENT LIFT BATHROOM OR TOI 0.00 E0627 NU SEAT LIFT MECH, ELECTRIC ANY 353.21 E0627 RR SEAT LIFT MECH, ELECTRIC ANY 35.32 E0627 UE SEAT LIFT MECH, ELECTRIC ANY 264.90 E0629 NU SEAT LIFT MECH, NON-ELECTRIC 351.51 E0629 RR SEAT LIFT MECH, NON-ELECTRIC 35.15 E0629 UE SEAT LIFT MECH, NON-ELECTRIC 263.62 E0630 NU PATIENT LIFT HYDRAULIC 1324.78 E0630 RR PATIENT LIFT HYDRAULIC 86.76 E0630 UE PATIENT LIFT HYDRAULIC 879.98 E0635 NU PATIENT LIFT ELECTRIC 2309.00 E0635 RR PATIENT LIFT ELECTRIC 142.29

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR E0635 UE PATIENT LIFT ELECTRIC 1730.59 E0636 NU PT SUPPORT & POSITIONING SYS 9842.73 E0636 RR PT SUPPORT & POSITIONING SYS 1212.82 E0636 UE PT SUPPORT & POSITIONING SYS 7345.32 E0637 NU COMBINATION SIT TO STAND SYS 4384.85 E0637 RR COMBINATION SIT TO STAND SYS 411.73 E0637 UE COMBINATION SIT TO STAND SYS 3054.18 E0638 NU STANDING FRAME SYS 3462.47 E0638 RR STANDING FRAME SYS 444.31 E0638 UE STANDING FRAME SYS 3295.85 E0639 RR MOVEABLE PATIENT LIFT SYSTEM 136.48 E0640 RR FIXED PATIENT LIFT SYSTEM 136.48 E0641 MULTI-POSITION STND FRAM SYS 7836.79 E0642 DYNAMIC STANDING FRAME 6241.39 E0650 NU PNEUMA COMPRESOR NON-SEGMENT 748.95 E0650 RR PNEUMA COMPRESOR NON-SEGMENT 92.43 E0650 UE PNEUMA COMPRESOR NON-SEGMENT 561.72 E0651 NU PNEUM COMPRESSOR SEGMENTAL 1123.61 E0651 RR PNEUM COMPRESSOR SEGMENTAL 114.79 E0651 UE PNEUM COMPRESSOR SEGMENTAL 842.73 E0652 NU PNEUM COMPRES W/CAL PRESSURE 5513.07 E0652 RR PNEUM COMPRES W/CAL PRESSURE 544.85 E0652 UE PNEUM COMPRES W/CAL PRESSURE 4131.11 E0655 NU PNEUMATIC APPLIANCE HALF ARM 112.24 E0655 RR PNEUMATIC APPLIANCE HALF ARM 13.19 E0655 UE PNEUMATIC APPLIANCE HALF ARM 84.29 E0656 NU SEGMENTAL PNEUMATIC TRUNK 670.49 E0656 RR SEGMENTAL PNEUMATIC TRUNK 70.70 E0656 UE SEGMENTAL PNEUMATIC TRUNK 462.76 E0657 NU SEGMENTAL PNEUMATIC CHEST 868.05 E0657 RR SEGMENTAL PNEUMATIC CHEST 66.41 E0657 UE SEGMENTAL PNEUMATIC CHEST 576.61 E0660 NU PNEUMATIC APPLIANCE FULL LEG 195.45 E0660 RR PNEUMATIC APPLIANCE FULL LEG 19.73 E0660 UE PNEUMATIC APPLIANCE FULL LEG 146.58 E0665 NU PNEUMATIC APPLIANCE FULL ARM 142.47 E0665 RR PNEUMATIC APPLIANCE FULL ARM 14.62 E0665 UE PNEUMATIC APPLIANCE FULL ARM 106.98 E0666 NU PNEUMATIC APPLIANCE HALF LEG 143.61 E0666 RR PNEUMATIC APPLIANCE HALF LEG 14.79 E0666 UE PNEUMATIC APPLIANCE HALF LEG 107.72 E0667 NU SEG PNEUMATIC APPL FULL LEG 336.69 E0667 RR SEG PNEUMATIC APPL FULL LEG 38.02 E0667 UE SEG PNEUMATIC APPL FULL LEG 252.53 E0668 NU SEG PNEUMATIC APPL FULL ARM 459.52 E0668 RR SEG PNEUMATIC APPL FULL ARM 45.35 E0668 UE SEG PNEUMATIC APPL FULL ARM 344.65 E0669 NU SEG PNEUMATIC APPLI HALF LEG 224.28 E0669 RR SEG PNEUMATIC APPLI HALF LEG 22.43

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR E0669 UE SEG PNEUMATIC APPLI HALF LEG 168.23 E0670 NU SEG PNEUM INT LEGS/TRUNK 1355.87 E0670 RR SEG PNEUM INT LEGS/TRUNK 139.94 E0670 UE SEG PNEUM INT LEGS/TRUNK 1016.92 E0671 NU PRESSURE PNEUM APPL FULL LEG 508.16 E0671 RR PRESSURE PNEUM APPL FULL LEG 50.85 E0671 UE PRESSURE PNEUM APPL FULL LEG 381.09 E0672 NU PRESSURE PNEUM APPL FULL ARM 394.82 E0672 RR PRESSURE PNEUM APPL FULL ARM 39.51 E0672 UE PRESSURE PNEUM APPL FULL ARM 296.14 E0673 NU PRESSURE PNEUM APPL HALF LEG 328.08 E0673 RR PRESSURE PNEUM APPL HALF LEG 32.81 E0673 UE PRESSURE PNEUM APPL HALF LEG 246.10 E0675 NU PNEUMATIC COMPRESSION DEVICE 7867.54 E0675 RR PNEUMATIC COMPRESSION DEVICE 470.46 E0675 UE PNEUMATIC COMPRESSION DEVICE 5256.78 E0676 NU INTER LIMB COMPRESS DEV NOS 2826.59 E0676 RR INTER LIMB COMPRESS DEV NOS 284.37 E0676 UE INTER LIMB COMPRESS DEV NOS 2118.52 E0677 RR NON PNEUM SEQ COMP TRUNK 78.85 E0678 RR NON PNEUM SEQ COMP FULL LEG 37.55 E0679 RR NON PNEUM SEQ COMP HALF LEG 25.01 E0680 RR NON PNEUM COMP CONTROL CAL 614.85 E0681 RR NON PNEU COMP CONTROL W/O CA 125.31 E0682 RR NON PNEUM COMPRESS FULL ARM 51.25 E0683 RR NON PNEU PERISTALIC COMP PMP 79.93 E0691 NU UVL PNL 2 SQ FT OR LESS 1099.36 E0691 RR UVL PNL 2 SQ FT OR LESS 109.93 E0691 UE UVL PNL 2 SQ FT OR LESS 824.53 E0692 NU UVL SYS PANEL 4 FT 1380.50 E0692 RR UVL SYS PANEL 4 FT 138.03 E0692 UE UVL SYS PANEL 4 FT 1035.37 E0693 NU UVL SYS PANEL 6 FT 1701.76 E0693 RR UVL SYS PANEL 6 FT 170.18 E0693 UE UVL SYS PANEL 6 FT 1276.32 E0694 NU UVL MD CABINET SYS 6 FT 5416.56 E0694 RR UVL MD CABINET SYS 6 FT 541.65 E0694 UE UVL MD CABINET SYS 6 FT 4062.45 E0700 SAFETY EQUIPMENT BR E0705 NU TRANSFER DEVICE 67.45 E0705 RR TRANSFER DEVICE 6.86 E0705 UE TRANSFER DEVICE 49.38 E0710 RESTRAINTS ANY TYPE 49.24 E0711 UE ENCLOSURE RESTR ROM BR E0715 INTRAVAG PELVIC FLOOR KEGEL BR E0716 SUPP AND ACCES INTRAVAG PELV BR E0720 NU TENS TWO LEAD 263.29 E0720 RR TENS TWO LEAD 48.42 E0720 UE TENS TWO LEAD 359.18

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR E0721 TRANS ELEC STIM AURICULAR BR E0730 NU TENS FOUR LEAD 265.51 E0730 RR TENS FOUR LEAD 64.37 E0730 UE TENS FOUR LEAD 477.45 E0731 NU CONDUCTIVE GARMENT FOR TENS/ 266.34 E0732 RR CES SYSTEM 50.15 E0733 RR TRANS ELEC NERV FOR TRIGEMIN 50.15 E0734 RR EXT UP LIMB TREMOR STIM WRIS 429.24 E0735 RR NON-INVASIVE VAGUS NERV STIM 50.15 E0736 RR TRANSCUT TIBIAL NERV STIMULA 51.36 E0737 TRANSCUT TIBIAL STIM BY APP BR E0738 RR UPPER EXTREMITY REHAB 1999.65 E0739 RR REHAB SYS ACTIVE ASSIST RT 1566.33 E0740 NU NON-IMPLANT PELV FLR E-STIM 733.82 E0740 RR NON-IMPLANT PELV FLR E-STIM 63.97 E0740 UE NON-IMPLANT PELV FLR E-STIM 549.99 E0743 RR EXT LOW EXT NERVE STIMU RLS 237.45 E0744 NU NEUROMUSCULAR STIM FOR SCOLI 2022.09 E0744 RR NEUROMUSCULAR STIM FOR SCOLI 95.23 E0744 UE NEUROMUSCULAR STIM FOR SCOLI 1395.61 E0745 NU NEUROMUSCULAR STIM FOR SHOCK 1266.37 E0745 RR NEUROMUSCULAR STIM FOR SHOCK 93.09 E0745 UE NEUROMUSCULAR STIM FOR SHOCK 894.61 E0746 NU ELECTROMYOGRAPH BIOFEEDBACK 729.62 E0746 RR ELECTROMYOGRAPH BIOFEEDBACK BR E0746 UE ELECTROMYOGRAPH BIOFEEDBACK BR E0747 NU ELEC OSTEOGEN STIM NOT SPINE 4791.05 E0747 RR ELEC OSTEOGEN STIM NOT SPINE 476.08 E0747 UE ELEC OSTEOGEN STIM NOT SPINE 3559.66 E0748 NU ELEC OSTEOGEN STIM SPINAL 4760.02 E0748 RR ELEC OSTEOGEN STIM SPINAL 475.97 E0748 UE ELEC OSTEOGEN STIM SPINAL 3570.02 E0749 RR ELEC OSTEOGEN STIM IMPLANTED 347.90 E0755 ELECTRONIC SALIVARY REFLEX S BR E0760 NU OSTEOGEN ULTRASOUND STIMLTOR 3955.48 E0760 RR OSTEOGEN ULTRASOUND STIMLTOR 395.55 E0760 UE OSTEOGEN ULTRASOUND STIMLTOR 2966.58 E0761 NONTHERM ELECTROMGNTC DEVICE 2151.96 E0762 NU TRANS ELEC JT STIM DEV SYS 1841.11 E0762 RR TRANS ELEC JT STIM DEV SYS 134.53 E0762 UE TRANS ELEC JT STIM DEV SYS 1270.74 E0764 NU FUNCTIONAL NEUROMUSCULARSTIM 1873.52 E0764 RR FUNCTIONAL NEUROMUSCULARSTIM 1353.93 E0764 UE FUNCTIONAL NEUROMUSCULARSTIM 13706.57 E0765 NU NERVE STIMULATOR FOR TX N&V 102.93 E0765 RR NERVE STIMULATOR FOR TX N&V 10.31 E0765 UE NERVE STIMULATOR FOR TX N&V 77.22 E0766 RR ELEC STIM CANCER TREATMENT 14065.72 E0767 INTRABUC AM RF EMF CANCER TX BR

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR E0769 ELECTRIC WOUND TREATMENT DEV BR E0770 NU FUNCTIONAL ELECTRIC STIM NOS 8406.69 E0770 RR FUNCTIONAL ELECTRIC STIM NOS 782.26 E0770 UE FUNCTIONAL ELECTRIC STIM NOS 5802.81 E0776 NU IV POLE 165.15 E0776 RR IV POLE 19.67 E0776 UE IV POLE 122.62 E0779 RR AMB INFUSION PUMP MECHANICAL 18.44 E0780 NU MECH AMB INFUSION PUMP <8HRS 12.69 E0781 RR EXTERNAL AMBULATORY INFUS PU 276.74 E0782 NU NON-PROGRAMBLE INFUSION PUMP 5252.71 E0782 RR NON-PROGRAMBLE INFUSION PUMP 525.29 E0782 UE NON-PROGRAMBLE INFUSION PUMP 3939.53 E0783 NU PROGRAMMABLE INFUSION PUMP 10016.11 E0783 RR PROGRAMMABLE INFUSION PUMP 1001.63 E0783 UE PROGRAMMABLE INFUSION PUMP 7512.12 E0784 NU EXT AMB INFUSN PUMP INSULIN 8407.56 E0784 RR EXT AMB INFUSN PUMP INSULIN 490.95 E0784 UE EXT AMB INFUSN PUMP INSULIN 5802.07 E0785 REPLACEMENT IMPL PUMP CATHET 529.30 E0786 NU IMPLANTABLE PUMP REPLACEMENT 9770.10 E0786 RR IMPLANTABLE PUMP REPLACEMENT 977.00 E0786 UE IMPLANTABLE PUMP REPLACEMENT 7327.58 E0787 NU CGS DOSE ADJ INSULIN INF PMP BR E0787 RR CGS DOSE ADJ INSULIN INF PMP BR E0787 UE CGS DOSE ADJ INSULIN INF PMP BR E0791 NU PARENTERAL INFUSION PUMP STA 3176.35 E0791 RR PARENTERAL INFUSION PUMP STA 319.58 E0791 UE PARENTERAL INFUSION PUMP STA 2199.81 E0830 AMBULATORY TRACTION DEVICE 616.26 E0840 NU TRACT FRAME ATTACH HEADBOARD 89.64 E0840 RR TRACT FRAME ATTACH HEADBOARD 19.98 E0840 UE TRACT FRAME ATTACH HEADBOARD 67.20 E0849 NU CERVICAL PNEUM TRAC EQUIP 789.83 E0849 RR CERVICAL PNEUM TRAC EQUIP 63.05 E0849 UE CERVICAL PNEUM TRAC EQUIP 586.59 E0850 NU TRACTION STAND FREE STANDING 128.52 E0850 RR TRACTION STAND FREE STANDING 17.65 E0850 UE TRACTION STAND FREE STANDING 96.40 E0855 NU CERVICAL TRACTION EQUIPMENT 743.75 E0855 RR CERVICAL TRACTION EQUIPMENT 61.49 E0855 UE CERVICAL TRACTION EQUIPMENT 513.43 E0856 NU CERVIC COLLAR W AIR BLADDERS 739.63 E0856 RR CERVIC COLLAR W AIR BLADDERS 18.83 E0856 UE CERVIC COLLAR W AIR BLADDERS 483.32 E0860 NU TRACT EQUIP CERVICAL TRACT 47.15 E0860 RR TRACT EQUIP CERVICAL TRACT 7.60 E0860 UE TRACT EQUIP CERVICAL TRACT 36.10 E0870 NU TRACT FRAME ATTACH FOOTBOARD 120.96

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR E0870 RR TRACT FRAME ATTACH FOOTBOARD 16.41 E0870 UE TRACT FRAME ATTACH FOOTBOARD 91.12 E0880 NU TRAC STAND FREE STAND EXTREM 130.55 E0880 RR TRAC STAND FREE STAND EXTREM 20.49 E0880 UE TRAC STAND FREE STAND EXTREM 98.81 E0890 NU TRACTION FRAME ATTACH PELVIC 125.21 E0890 RR TRACTION FRAME ATTACH PELVIC 34.14 E0890 UE TRACTION FRAME ATTACH PELVIC 100.87 E0900 NU TRAC STAND FREE STAND PELVIC 133.25 E0900 RR TRAC STAND FREE STAND PELVIC 28.73 E0900 UE TRAC STAND FREE STAND PELVIC 99.97 E0910 NU TRAPEZE BAR ATTACHED TO BED 264.60 E0910 RR TRAPEZE BAR ATTACHED TO BED 15.68 E0910 UE TRAPEZE BAR ATTACHED TO BED 175.07 E0911 RR HD TRAPEZE BAR ATTACH TO BED 50.46 E0912 RR HD TRAPEZE BAR FREE STANDING 107.29 E0920 NU FRACTURE FRAME ATTACHED TO B 516.92 E0920 RR FRACTURE FRAME ATTACHED TO B 48.00 E0920 UE FRACTURE FRAME ATTACHED TO B 606.36 E0930 RR FRACTURE FRAME FREE STANDING 47.50 E0935 RR CONT PAS MOTION EXERCISE DEV 23.66 E0936 RR CPM DEVICE, OTHER THAN KNEE 25.61 E0940 NU TRAPEZE BAR FREE STANDING 370.51 E0940 RR TRAPEZE BAR FREE STANDING 27.67 E0940 UE TRAPEZE BAR FREE STANDING 256.61 E0941 RR GRAVITY ASSISTED TRACTION DE 45.14 E0942 NU CERVICAL HEAD HARNESS/HALTER 20.64 E0942 RR CERVICAL HEAD HARNESS/HALTER 2.45 E0942 UE CERVICAL HEAD HARNESS/HALTER 15.44 E0944 NU PELVIC BELT/HARNESS/BOOT 48.00 E0944 RR PELVIC BELT/HARNESS/BOOT 4.83 E0944 UE PELVIC BELT/HARNESS/BOOT 39.41 E0945 NU BELT/HARNESS EXTREMITY 46.09 E0945 RR BELT/HARNESS EXTREMITY 4.61 E0945 UE BELT/HARNESS EXTREMITY 35.68 E0946 RR FRACTURE FRAME DUAL W CROSS 61.52 E0947 NU FRACTURE FRAME ATTACHMNTS PE 630.67 E0947 RR FRACTURE FRAME ATTACHMNTS PE 65.39 E0947 UE FRACTURE FRAME ATTACHMNTS PE 472.98 E0948 NU FRACTURE FRAME ATTACHMNTS CE 626.48 E0948 RR FRACTURE FRAME ATTACHMNTS CE 63.05 E0948 UE FRACTURE FRAME ATTACHMNTS CE 469.86 E0950 NU TRAY 109.62 E0950 RR TRAY 10.98 E0950 UE TRAY 82.22 E0951 NU LOOP HEEL 17.17 E0951 RR LOOP HEEL 1.75 E0951 UE LOOP HEEL 12.87 E0952 NU TOE LOOP/HOLDER, EACH 20.10

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR E0952 RR TOE LOOP/HOLDER, EACH 2.05 E0952 UE TOE LOOP/HOLDER, EACH 15.08 E0953 NU W/C LATERAL THIGH/KNEE SUP 103.94 E0953 RR W/C LATERAL THIGH/KNEE SUP 10.39 E0953 UE W/C LATERAL THIGH/KNEE SUP 77.96 E0954 NU FOOT BOX, ANY TYPE EACH FOOT 64.33 E0954 RR FOOT BOX, ANY TYPE EACH FOOT 6.51 E0954 UE FOOT BOX, ANY TYPE EACH FOOT 48.23 E0955 NU CUSHIONED HEADREST 271.41 E0955 RR CUSHIONED HEADREST 21.32 E0955 UE CUSHIONED HEADREST 183.63 E0956 NU W/C LATERAL TRUNK/HIP SUPPOR 103.94 E0956 RR W/C LATERAL TRUNK/HIP SUPPOR 10.39 E0956 UE W/C LATERAL TRUNK/HIP SUPPOR 77.96 E0957 NU W/C MEDIAL THIGH SUPPORT 151.33 E0957 RR W/C MEDIAL THIGH SUPPORT 15.14 E0957 UE W/C MEDIAL THIGH SUPPORT 113.50 E0958 NU WHLCHR ATT- CONV 1 ARM DRIVE 635.44 E0958 RR WHLCHR ATT- CONV 1 ARM DRIVE 48.23 E0958 UE WHLCHR ATT- CONV 1 ARM DRIVE 439.94 E0959 NU AMPUTEE ADAPTER 53.10 E0959 RR AMPUTEE ADAPTER 5.32 E0959 UE AMPUTEE ADAPTER 39.86 E0960 NU W/C SHOULDER HARNESS/STRAPS 95.95 E0960 RR W/C SHOULDER HARNESS/STRAPS 9.62 E0960 UE W/C SHOULDER HARNESS/STRAPS 71.97 E0961 NU WHEELCHAIR BRAKE EXTENSION 29.11 E0961 RR WHEELCHAIR BRAKE EXTENSION 3.23 E0961 UE WHEELCHAIR BRAKE EXTENSION 15.44 E0966 NU WHEELCHAIR HEAD REST EXTENSI 74.22 E0966 RR WHEELCHAIR HEAD REST EXTENSI 7.33 E0966 UE WHEELCHAIR HEAD REST EXTENSI 55.66 E0967 NU MAN WC RIM/PROJECTION REP EA 80.35 E0967 RR MAN WC RIM/PROJECTION REP EA 8.05 E0967 UE MAN WC RIM/PROJECTION REP EA 60.25 E0968 NU WHEELCHAIR COMMODE SEAT 200.62 E0968 RR WHEELCHAIR COMMODE SEAT 21.92 E0968 UE WHEELCHAIR COMMODE SEAT 303.18 E0969 NU WHEELCHAIR NARROWING DEVICE 191.62 E0969 RR WHEELCHAIR NARROWING DEVICE 18.97 E0969 UE WHEELCHAIR NARROWING DEVICE 143.73 E0970 NU WHEELCHAIR NO. 2 FOOTPLATES 55.49 E0970 RR WHEELCHAIR NO. 2 FOOTPLATES 50.53 E0970 UE WHEELCHAIR NO. 2 FOOTPLATES 113.69 E0971 NU WHEELCHAIR ANTI-TIPPING DEVI 46.98 E0971 RR WHEELCHAIR ANTI-TIPPING DEVI 5.32 E0971 UE WHEELCHAIR ANTI-TIPPING DEVI 39.84 E0973 NU W/CH ACCESS DET ADJ ARMREST 103.05 E0973 RR W/CH ACCESS DET ADJ ARMREST 9.81

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR E0973 UE W/CH ACCESS DET ADJ ARMREST 77.28 E0974 NU W/CH ACCESS ANTI-ROLLBACK 95.92 E0974 RR W/CH ACCESS ANTI-ROLLBACK 10.17 E0974 UE W/CH ACCESS ANTI-ROLLBACK 72.49 E0978 NU W/C ACC,SAF BELT PELV STRAP 45.02 E0978 RR W/C ACC,SAF BELT PELV STRAP 4.52 E0978 UE W/C ACC,SAF BELT PELV STRAP 33.38 E0980 NU WHEELCHAIR SAFETY VEST 39.86 E0980 RR WHEELCHAIR SAFETY VEST 3.98 E0980 UE WHEELCHAIR SAFETY VEST 29.90 E0981 NU SEAT UPHOLSTERY, REPLACEMENT 45.32 E0981 RR SEAT UPHOLSTERY, REPLACEMENT 4.61 E0981 UE SEAT UPHOLSTERY, REPLACEMENT 34.31 E0982 NU BACK UPHOLSTERY, REPLACEMENT 49.53 E0982 RR BACK UPHOLSTERY, REPLACEMENT 4.95 E0982 UE BACK UPHOLSTERY, REPLACEMENT 37.15 E0983 NU ADD PWR JOYSTICK 9772.82 E0983 RR ADD PWR JOYSTICK 274.55 E0983 UE ADD PWR JOYSTICK 2938.13 E0984 NU ADD PWR TILLER 2140.26 E0984 RR ADD PWR TILLER 233.73 E0984 UE ADD PWR TILLER 1440.09 E0985 NU W/C SEAT LIFT MECHANISM 205.49 E0985 RR W/C SEAT LIFT MECHANISM 24.85 E0985 UE W/C SEAT LIFT MECHANISM 227.39 E0986 NU MAN W/C PUSH-RIM POWR SYSTEM 7590.29 E0986 RR MAN W/C PUSH-RIM POWR SYSTEM 595.12 E0986 UE MAN W/C PUSH-RIM POWR SYSTEM 4888.31 E0988 RR LEVER-ACTIVATED WHEEL DRIVE 366.24 E0990 NU WHEELCHAIR ELEVATING LEG RES 105.26 E0990 RR WHEELCHAIR ELEVATING LEG RES 11.87 E0990 UE WHEELCHAIR ELEVATING LEG RES 82.25 E0992 NU WHEELCHAIR SOLID SEAT INSERT 110.46 E0992 RR WHEELCHAIR SOLID SEAT INSERT 11.31 E0992 UE WHEELCHAIR SOLID SEAT INSERT 86.10 E0994 NU WHEELCHAIR ARM REST 18.33 E0994 RR WHEELCHAIR ARM REST 1.85 E0994 UE WHEELCHAIR ARM REST 13.74 E0995 NU WC CALF REST, PAD REPLACEMNT 29.22 E0995 RR WC CALF REST, PAD REPLACEMNT 2.93 E0995 UE WC CALF REST, PAD REPLACEMNT 21.89 E1002 NU PWR SEAT TILT 7442.08 E1002 RR PWR SEAT TILT 439.61 E1002 UE PWR SEAT TILT 5141.74 E1003 NU PWR SEAT RECLINE 3720.05 E1003 RR PWR SEAT RECLINE 493.27 E1003 UE PWR SEAT RECLINE 3789.73 E1004 NU PWR SEAT RECLINE MECH 5763.40 E1004 RR PWR SEAT RECLINE MECH 544.71

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR E1004 UE PWR SEAT RECLINE MECH 3819.57 E1005 NU PWR SEAT RECLINE PWR 4464.90 E1005 RR PWR SEAT RECLINE PWR 592.50 E1005 UE PWR SEAT RECLINE PWR 3600.24 E1006 NU PWR SEAT COMBO W/O SHEAR 5932.41 E1006 RR PWR SEAT COMBO W/O SHEAR 727.97 E1006 UE PWR SEAT COMBO W/O SHEAR 7017.76 E1007 NU PWR SEAT COMBO W/SHEAR 12765.40 E1007 RR PWR SEAT COMBO W/SHEAR 947.58 E1007 UE PWR SEAT COMBO W/SHEAR 8810.71 E1008 NU PWR SEAT COMBO PWR SHEAR 11355.56 E1008 RR PWR SEAT COMBO PWR SHEAR 958.42 E1008 UE PWR SEAT COMBO PWR SHEAR 8474.30 E1009 NU ADD MECH LEG ELEVATION 0.00 E1009 RR ADD MECH LEG ELEVATION 0.00 E1009 UE ADD MECH LEG ELEVATION 0.00 E1010 NU ADD PWR LEG ELEVATION 2548.59 E1010 RR ADD PWR LEG ELEVATION 127.58 E1010 UE ADD PWR LEG ELEVATION 1759.21 E1011 NU PED WC MODIFY WIDTH ADJUSTM 0.00 E1011 RR PED WC MODIFY WIDTH ADJUSTM 0.00 E1011 UE PED WC MODIFY WIDTH ADJUSTM 0.00 E1012 RR CTR MOUNT PWR ELEV LEG REST 120.61 E1014 NU RECLINING BACK ADD PED W/C 425.52 E1014 RR RECLINING BACK ADD PED W/C 44.69 E1014 UE RECLINING BACK ADD PED W/C 296.76 E1015 NU SHOCK ABSORBER FOR MAN W/C 140.34 E1015 RR SHOCK ABSORBER FOR MAN W/C 14.03 E1015 UE SHOCK ABSORBER FOR MAN W/C 105.25 E1016 NU SHOCK ABSORBER FOR POWER W/C 142.52 E1016 RR SHOCK ABSORBER FOR POWER W/C 14.26 E1016 UE SHOCK ABSORBER FOR POWER W/C 106.89 E1017 NU HD SHCK ABSRBR FOR HD MAN WC 0.00 E1017 RR HD SHCK ABSRBR FOR HD MAN WC 0.00 E1017 UE HD SHCK ABSRBR FOR HD MAN WC 0.00 E1018 NU HD SHCK ABSRBER FOR HD POWWC 0.00 E1018 RR HD SHCK ABSRBER FOR HD POWWC 0.00 E1018 UE HD SHCK ABSRBER FOR HD POWWC 0.00 E1020 NU RESIDUAL LIMB SUPPORT SYSTEM 295.63 E1020 RR RESIDUAL LIMB SUPPORT SYSTEM 25.65 E1020 UE RESIDUAL LIMB SUPPORT SYSTEM 212.61 E1022 WHEELCHR TRANSPORT SECUR BR E1023 WHEELCHR TRANSIT SECUREMENT BR E1028 NU W/C MANUAL SWINGAWAY 279.82 E1028 RR W/C MANUAL SWINGAWAY 21.77 E1028 UE W/C MANUAL SWINGAWAY 192.81 E1029 NU W/C VENT TRAY FIXED 494.90 E1029 RR W/C VENT TRAY FIXED 41.78 E1029 UE W/C VENT TRAY FIXED 368.73

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR E1030 NU W/C VENT TRAY GIMBALED 953.25 E1030 RR W/C VENT TRAY GIMBALED 131.79 E1030 UE W/C VENT TRAY GIMBALED 807.98 E1031 NU ROLLABOUT CHAIR WITH CASTERS 588.07 E1031 RR ROLLABOUT CHAIR WITH CASTERS 50.49 E1031 UE ROLLABOUT CHAIR WITH CASTERS 407.40 E1032 WHEELCHAIR JOYSTICK DRIVE BR E1033 WHEELCHAIR HARDWARE HEADREST BR E1034 WHEELCHAIR TRUNK HIP SUPPORT BR E1035 RR PATIENT TRANSFER SYSTEM <300 709.04 E1036 RR PATIENT TRANSFER SYSTEM >300 1011.72 E1037 NU TRANSPORT CHAIR, PED SIZE 1562.87 E1037 RR TRANSPORT CHAIR, PED SIZE 127.07 E1037 UE TRANSPORT CHAIR, PED SIZE 1061.12 E1038 NU TRANSPORT CHAIR PT WT<=300LB 336.56 E1038 RR TRANSPORT CHAIR PT WT<=300LB 19.33 E1038 UE TRANSPORT CHAIR PT WT<=300LB 265.65 E1039 NU TRANSPORT CHAIR PT WT >300LB 484.37 E1039 RR TRANSPORT CHAIR PT WT >300LB 39.58 E1039 UE TRANSPORT CHAIR PT WT >300LB 337.30 E1050 NU WHELCHR FXD FULL LENGTH ARMS 1219.59 E1050 RR WHELCHR FXD FULL LENGTH ARMS 105.92 E1050 UE WHELCHR FXD FULL LENGTH ARMS 1254.48 E1060 NU WHEELCHAIR DETACHABLE ARMS 3175.91 E1060 RR WHEELCHAIR DETACHABLE ARMS 131.09 E1060 UE WHEELCHAIR DETACHABLE ARMS 1833.23 E1070 NU WHEELCHAIR DETACHABLE FOOT R 3131.18 E1070 RR WHEELCHAIR DETACHABLE FOOT R 113.91 E1070 UE WHEELCHAIR DETACHABLE FOOT R 2168.21 E1083 NU HEMI-WHEELCHAIR FIXED ARMS 2702.73 E1083 RR HEMI-WHEELCHAIR FIXED ARMS 81.88 E1083 UE HEMI-WHEELCHAIR FIXED ARMS 363.81 E1084 NU HEMI-WHEELCHAIR DETACHABLE A 2644.05 E1084 RR HEMI-WHEELCHAIR DETACHABLE A 102.02 E1084 UE HEMI-WHEELCHAIR DETACHABLE A 1211.25 E1085 NU HEMI-WHEELCHAIR FIXED ARMS 355.44 E1085 RR HEMI-WHEELCHAIR FIXED ARMS 31.69 E1085 UE HEMI-WHEELCHAIR FIXED ARMS 370.64 E1086 NU HEMI-WHEELCHAIR DETACHABLE A 2205.40 E1086 RR HEMI-WHEELCHAIR DETACHABLE A 196.85 E1086 UE HEMI-WHEELCHAIR DETACHABLE A 1466.57 E1087 NU WHEELCHAIR LIGHTWT FIXED ARM 1497.22 E1087 RR WHEELCHAIR LIGHTWT FIXED ARM 131.58 E1087 UE WHEELCHAIR LIGHTWT FIXED ARM 1537.96 E1088 NU WHEELCHAIR LIGHTWEIGHT DET A 3913.84 E1088 RR WHEELCHAIR LIGHTWEIGHT DET A 156.79 E1088 UE WHEELCHAIR LIGHTWEIGHT DET A 1466.57 E1089 NU WHEELCHAIR LIGHTWT FIXED ARM 575.67 E1089 RR WHEELCHAIR LIGHTWT FIXED ARM 50.53

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR E1089 UE WHEELCHAIR LIGHTWT FIXED ARM 113.6 E1090 NU WHEELCHAIR LIGHTWEIGHT DET A 3599.42 E1090 RR WHEELCHAIR LIGHTWEIGHT DET A 334.66 E1090 UE WHEELCHAIR LIGHTWEIGHT DET A 2493.19 E1092 NU WHEELCHAIR WIDE W/ LEG RESTS 3474.64 E1092 RR WHEELCHAIR WIDE W/ LEG RESTS 153.88 E1092 UE WHEELCHAIR WIDE W/ LEG RESTS 2346.55 E1093 NU WHEELCHAIR WIDE W/ FOOT REST 4327.98 E1093 RR WHEELCHAIR WIDE W/ FOOT REST 131.92 E1093 UE WHEELCHAIR WIDE W/ FOOT REST 2988.16 E1100 NU WHCHR S-RECL FXD ARM LEG RES 1261.31 E1100 RR WHCHR S-RECL FXD ARM LEG RES 107.94 E1100 UE WHCHR S-RECL FXD ARM LEG RES 1027.75 E1110 NU WHEELCHAIR SEMI-RECL DETACH 1011.95 E1110 RR WHEELCHAIR SEMI-RECL DETACH 105.71 E1110 UE WHEELCHAIR SEMI-RECL DETACH 881.36 E1130 NU WHLCHR STAND FXD ARM FT REST 278.89 E1130 RR WHLCHR STAND FXD ARM FT REST 68.90 E1130 UE WHLCHR STAND FXD ARM FT REST 513.31 E1140 NU WHEELCHAIR STANDARD DETACH A 2034.78 E1140 RR WHEELCHAIR STANDARD DETACH A 64.22 E1140 UE WHEELCHAIR STANDARD DETACH A 478.43 E1150 NU WHEELCHAIR STANDARD W/ LEG R 2122.35 E1150 RR WHEELCHAIR STANDARD W/ LEG R 84.83 E1150 UE WHEELCHAIR STANDARD W/ LEG R 1363.32 E1160 NU WHEELCHAIR FIXED ARMS 1281.28 E1160 RR WHEELCHAIR FIXED ARMS 65.01 E1160 UE WHEELCHAIR FIXED ARMS 887.30 E1161 NU MANUAL ADULT WC W TILTINSPAC 4447.25 E1161 RR MANUAL ADULT WC W TILTINSPAC 289.47 E1161 UE MANUAL ADULT WC W TILTINSPAC 2566.48 E1170 NU WHLCHR AMPU FXD ARM LEG REST 1000.55 E1170 RR WHLCHR AMPU FXD ARM LEG REST 92.89 E1170 UE WHLCHR AMPU FXD ARM LEG REST 1136.91 E1171 NU WHEELCHAIR AMPUTEE W/O LEG R 898.10 E1171 RR WHEELCHAIR AMPUTEE W/O LEG R 83.35 E1171 UE WHEELCHAIR AMPUTEE W/O LEG R 606.36 E1172 NU WHEELCHAIR AMPUTEE DETACH AR 1097.45 E1172 RR WHEELCHAIR AMPUTEE DETACH AR 101.89 E1172 UE WHEELCHAIR AMPUTEE DETACH AR 909.54 E1180 NU WHEELCHAIR AMPUTEE W/ FOOT R 1135.43 E1180 RR WHEELCHAIR AMPUTEE W/ FOOT R 105.38 E1180 UE WHEELCHAIR AMPUTEE W/ FOOT R 1212.72 E1190 NU WHEELCHAIR AMPUTEE W/ LEG RE 1171.71 E1190 RR WHEELCHAIR AMPUTEE W/ LEG RE 121.75 E1190 UE WHEELCHAIR AMPUTEE W/ LEG RE 803.43 E1195 NU WHEELCHAIR AMPUTEE HEAVY DUT 1417.08 E1195 RR WHEELCHAIR AMPUTEE HEAVY DUT 130.64

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR E1195 UE WHEELCHAIR AMPUTEE HEAVY DUT 1237.08 E1200 NU WHEELCHAIR AMPUTEE FIXED ARM 974.94 E1200 RR WHEELCHAIR AMPUTEE FIXED ARM 90.48 E1200 UE WHEELCHAIR AMPUTEE FIXED ARM 795.84 E1220 WHLCHR SPECIAL SIZE/CONSTRC 8270.85 E1221 NU WHEELCHAIR SPEC SIZE W FOOT 532.29 E1221 RR WHEELCHAIR SPEC SIZE W FOOT 58.13 E1221 UE WHEELCHAIR SPEC SIZE W FOOT 378.97 E1222 NU WHEELCHAIR SPEC SIZE W/ LEG 823.75 E1222 RR WHEELCHAIR SPEC SIZE W/ LEG 82.92 E1222 UE WHEELCHAIR SPEC SIZE W/ LEG 733.24 E1223 NU WHEELCHAIR SPEC SIZE W FOOT 635.11 E1223 RR WHEELCHAIR SPEC SIZE W FOOT 90.55 E1223 UE WHEELCHAIR SPEC SIZE W FOOT 440.72 E1224 NU WHEELCHAIR SPEC SIZE W/ LEG 986.26 E1224 RR WHEELCHAIR SPEC SIZE W/ LEG 99.28 E1224 UE WHEELCHAIR SPEC SIZE W/ LEG 961.43 E1225 NU MANUAL SEMI-RECLINING BACK 558.84 E1225 RR MANUAL SEMI-RECLINING BACK 49.61 E1225 UE MANUAL SEMI-RECLINING BACK 418.85 E1226 NU MANUAL FULLY RECLINING BACK 590.04 E1226 RR MANUAL FULLY RECLINING BACK 68.69 E1226 UE MANUAL FULLY RECLINING BACK 500.62 E1227 NU WHEELCHAIR SPEC SZ SPEC HT A 339.50 E1227 RR WHEELCHAIR SPEC SZ SPEC HT A 33.96 E1227 UE WHEELCHAIR SPEC SZ SPEC HT A 254.66 E1228 NU WHEELCHAIR SPEC SZ SPEC HT B 268.12 E1228 RR WHEELCHAIR SPEC SZ SPEC HT B 29.15 E1228 UE WHEELCHAIR SPEC SZ SPEC HT B 216.69 E1229 PEDIATRIC WHEELCHAIR NOS BR E1230 NU POWER OPERATED VEHICLE 2352.09 E1230 RR POWER OPERATED VEHICLE 231.34 E1230 UE POWER OPERATED VEHICLE 1860.23 E1231 NU RIGID PED W/C TILT-IN-SPACE 0.00 E1231 RR RIGID PED W/C TILT-IN-SPACE 0.00 E1231 UE RIGID PED W/C TILT-IN-SPACE 0.00 E1232 NU FOLDING PED WC TILT-IN-SPACE 2952.82 E1232 RR FOLDING PED WC TILT-IN-SPACE 261.65 E1232 UE FOLDING PED WC TILT-IN-SPACE 2203.61 E1233 NU RIG PED WC TLTNSPC W/O SEAT 3924.66 E1233 RR RIG PED WC TLTNSPC W/O SEAT 271.07 E1233 UE RIG PED WC TLTNSPC W/O SEAT 2042.00 E1234 NU FLD PED WC TLTNSPC W/O SEAT 2978.85 E1234 RR FLD PED WC TLTNSPC W/O SEAT 236.00 E1234 UE FLD PED WC TLTNSPC W/O SEAT 1994.26 E1235 NU RIGID PED WC ADJUSTABLE 3291.78 E1235 RR RIGID PED WC ADJUSTABLE 227.26 E1235 UE RIGID PED WC ADJUSTABLE 1759.87 E1236 NU FOLDING PED WC ADJUSTABLE 2166.48

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR E1236 RR FOLDING PED WC ADJUSTABLE 200.49 E1236 UE FOLDING PED WC ADJUSTABLE 1429.41 E1237 NU RGD PED WC ADJSTABL W/O SEAT 3015.82 E1237 RR RGD PED WC ADJSTABL W/O SEAT 202.23 E1237 UE RGD PED WC ADJSTABL W/O SEAT 2250.61 E1238 NU FLD PED WC ADJSTABL W/O SEAT 5170.48 E1238 RR FLD PED WC ADJSTABL W/O SEAT 200.49 E1238 UE FLD PED WC ADJSTABL W/O SEAT 2087.52 E1239 PED POWER WHEELCHAIR NOS BR E1240 NU WHCHR LITWT DET ARM LEG REST 3237.75 E1240 RR WHCHR LITWT DET ARM LEG REST 107.14 E1240 UE WHCHR LITWT DET ARM LEG REST 2242.10 E1250 NU WHEELCHAIR LIGHTWT FIXED ARM 848.17 E1250 RR WHEELCHAIR LIGHTWT FIXED ARM 101.06 E1250 UE WHEELCHAIR LIGHTWT FIXED ARM 702.62 E1260 NU WHEELCHAIR LIGHTWT FOOT REST 2712.96 E1260 RR WHEELCHAIR LIGHTWT FOOT REST 252.23 E1260 UE WHEELCHAIR LIGHTWT FOOT REST 1879.13 E1270 NU WHEELCHAIR LIGHTWEIGHT LEG R 884.44 E1270 RR WHEELCHAIR LIGHTWEIGHT LEG R 82.09 E1270 UE WHEELCHAIR LIGHTWEIGHT LEG R 1152.84 E1280 NU WHCHR H-DUTY DET ARM LEG RES 3640.62 E1280 RR WHCHR H-DUTY DET ARM LEG RES 136.49 E1280 UE WHCHR H-DUTY DET ARM LEG RES 1421.96 E1285 NU WHEELCHAIR HEAVY DUTY FIXED 1277.58 E1285 RR WHEELCHAIR HEAVY DUTY FIXED 150.58 E1285 UE WHEELCHAIR HEAVY DUTY FIXED 1538.63 E1290 NU WHEELCHAIR HVY DUTY DETACH A 583.21 E1290 RR WHEELCHAIR HVY DUTY DETACH A 53.74 E1290 UE WHEELCHAIR HVY DUTY DETACH A 400.33 E1295 NU WHEELCHAIR HEAVY DUTY FIXED 1476.16 E1295 RR WHEELCHAIR HEAVY DUTY FIXED 126.31 E1295 UE WHEELCHAIR HEAVY DUTY FIXED 1480.09 E1296 NU WHEELCHAIR SPECIAL SEAT HEIG 601.50 E1296 RR WHEELCHAIR SPECIAL SEAT HEIG 60.16 E1296 UE WHEELCHAIR SPECIAL SEAT HEIG 451.14 E1297 NU WHEELCHAIR SPECIAL SEAT DEPT 127.98 E1297 RR WHEELCHAIR SPECIAL SEAT DEPT 12.78 E1297 UE WHEELCHAIR SPECIAL SEAT DEPT 95.97 E1298 NU WHEELCHAIR SPEC SEAT DEPTH/W 518.32 E1298 RR WHEELCHAIR SPEC SEAT DEPTH/W 53.03 E1298 UE WHEELCHAIR SPEC SEAT DEPTH/W 388.73 E1300 NU WHIRLPOOL PORTABLE BR E1300 RR WHIRLPOOL PORTABLE BR E1300 UE WHIRLPOOL PORTABLE BR E1301 WHIRLPOOL TUB WALKIN PORTABL BR E1310 NU WHIRLPOOL NON-PORTABLE 2627.21 E1310 RR WHIRLPOOL NON-PORTABLE 224.69 E1310 UE WHIRLPOOL NON-PORTABLE 1970.40

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR E1352 O2 FLOW REG POS INSPIR PRESS 59.05 E1353 NU OXYGEN SUPPLIES REGULATOR 237.95 E1353 RR OXYGEN SUPPLIES REGULATOR 24.58 E1353 UE OXYGEN SUPPLIES REGULATOR 178.34 E1354 WHEELED CART, PORT CYL/CONC 24.60 E1355 NU OXYGEN SUPPLIES STAND/RACK 239.67 E1355 RR OXYGEN SUPPLIES STAND/RACK 14.36 E1355 UE OXYGEN SUPPLIES STAND/RACK 179.63 E1356 BATT PACK/CART, PORT CONC 39.17 E1357 BATTERY CHARGER, PORT CONC 280.52 E1358 DC POWER ADAPTER, PORT CONC 44.79 E1372 NU OXY SUPPL HEATER FOR NEBULIZ 155.85 E1372 RR OXY SUPPL HEATER FOR NEBULIZ 19.43 E1372 UE OXY SUPPL HEATER FOR NEBULIZ 116.06 E1390 NU OXYGEN CONCENTRATOR 3705.89 E1390 RR OXYGEN CONCENTRATOR 151.15 E1390 UE OXYGEN CONCENTRATOR 2493.19 E1391 RR OXYGEN CONCENTRATOR, DUAL 151.15 E1392 RR PORTABLE OXYGEN CONCENTRATOR 75.58 E1399 DURABLE MEDICAL EQUIPMENT MI BR E1405 NU O2/WATER VAPOR ENRICH W/HEAT 3017.66 E1405 RR O2/WATER VAPOR ENRICH W/HEAT 185.75 E1405 UE O2/WATER VAPOR ENRICH W/HEAT 2089.85 E1406 NU O2/WATER VAPOR ENRICH W/O HE 2425.42 E1406 RR O2/WATER VAPOR ENRICH W/O HE 164.33 E1406 UE O2/WATER VAPOR ENRICH W/O HE 1819.08 E1500 CENTRIFUGE BR E1510 NU KIDNEY DIALYSATE DELIVRY SYS 929.65 E1510 RR KIDNEY DIALYSATE DELIVRY SYS 86.46 E1510 UE KIDNEY DIALYSATE DELIVRY SYS 644.12 E1520 NU HEPARIN INFUSION PUMP 0.00 E1520 RR HEPARIN INFUSION PUMP 0.00 E1520 UE HEPARIN INFUSION PUMP 0.00 E1530 NU REPLACEMENT AIR BUBBLE DETEC 0.00 E1530 RR REPLACEMENT AIR BUBBLE DETEC 0.00 E1530 UE REPLACEMENT AIR BUBBLE DETEC 0.00 E1540 NU REPLACEMENT PRESSURE ALARM 0.00 E1540 RR REPLACEMENT PRESSURE ALARM 0.00 E1540 UE REPLACEMENT PRESSURE ALARM 0.00 E1550 NU BATH CONDUCTIVITY METER 0.00 E1550 RR BATH CONDUCTIVITY METER 0.00 E1550 UE BATH CONDUCTIVITY METER 0.00 E1560 NU REPLACE BLOOD LEAK DETECTOR BR E1560 RR REPLACE BLOOD LEAK DETECTOR BR E1560 UE REPLACE BLOOD LEAK DETECTOR BR E1570 NU ADJUSTABLE CHAIR FOR ESRD PT BR E1570 RR ADJUSTABLE CHAIR FOR ESRD PT BR E1570 UE ADJUSTABLE CHAIR FOR ESRD PT BR E1575 NU TRANSDUCER PROTECT/FLD BAR BR

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR E1575 RR TRANSDUCER PROTECT/FLD BAR BR E1575 UE TRANSDUCER PROTECT/FLD BAR BR E1580 NU UNIPUNCTURE CONTROL SYSTEM BR E1580 RR UNIPUNCTURE CONTROL SYSTEM BR E1580 UE UNIPUNCTURE CONTROL SYSTEM BR E1590 NU HEMODIALYSIS MACHINE BR E1590 RR HEMODIALYSIS MACHINE BR E1590 UE HEMODIALYSIS MACHINE BR E1592 AUTO INTERM PERITONEAL DIALY BR E1594 NU CYCLER DIALYSIS MACHINE 8400.62 E1594 RR CYCLER DIALYSIS MACHINE 780.84 E1594 UE CYCLER DIALYSIS MACHINE 5817.28 E1600 DELI/INSTALL CHRG HEMO EQUIP 5334.77 E1610 NU REVERSE OSMOSIS H2O PURI SYS 346.21 E1610 RR REVERSE OSMOSIS H2O PURI SYS 32.21 E1610 UE REVERSE OSMOSIS H2O PURI SYS 239.99 E1615 DEIONIZER H2O PURI SYSTEM BR E1620 REPLACEMENT BLOOD PUMP BR E1625 WATER SOFTENING SYSTEM BR E1629 TABLO FOR DIALYSIS SERVICE BR E1630 RECIPROCATING PERITONEAL DIA BR E1632 WEARABLE ARTIFICIAL KIDNEY BR E1634 PERITONEAL DIALYSIS CLAMP 13.69 E1635 NU COMPACT TRAVEL HEMODIALYZER 0.00 E1635 RR COMPACT TRAVEL HEMODIALYZER 0.00 E1635 UE COMPACT TRAVEL HEMODIALYZER 0.00 E1636 SORBENT CARTRIDGES PER 10 0.00 E1637 HEMOSTATS FOR DIALYSIS, EACH 61.57 E1639 SCALE, EACH 49.22 E1699 DIALYSIS EQUIPMENT NOC BR E1700 NU JAW MOTION REHAB SYSTEM 514.19 E1700 RR JAW MOTION REHAB SYSTEM 42.20 E1700 UE JAW MOTION REHAB SYSTEM 355.98 E1701 REPL CUSHIONS FOR JAW MOTION 11.02 E1702 REPL MEASR SCALES JAW MOTION 23.46 E1800 RR ADJUST ELBOW EXT & FLEX DEV 127.39 E1801 RR SPS ELBOW DEVICE 141.44 E1802 RR ADJST FOREARM PRO/SUP DEVICE 399.83 E1803 RR ADJUST ELBOW EXTENSION DEV 145.49 E1804 RR ADJUST ELBOW FLEXION DEV 145.49 E1805 RR ADJUST WRIST EXT & FLEX DEV 131.39 E1806 RR SPS WRIST DEVICE 116.07 E1807 RR ADJUST WRIST EXTENSION DEV 150.06 E1808 RR ADJUST WRIST FLEXION DEVICE 150.06 E1810 RR ADJUST KNEE EXT & FLEX DEV 129.57 E1811 RR SPS KNEE DEVICE 147.06 E1812 NU KNEE EXT/FLEX W ACT RES CTRL 20646.82 E1812 RR KNEE EXT/FLEX W ACT RES CTRL 105.21 E1812 UE KNEE EXT/FLEX W ACT RES CTRL 1510.57

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR E1813 RR ADJUST KNEE EXTENSION DEVICE 147.97 E1814 RR ADJUST KNEE FLEXION DEVICE 147.97 E1815 RR ADJUST ANKLE EXT & FLEX DEV 131.39 E1816 RR SPS ANKLE DEVICE 149.32 E1818 RR SPS FOREARM DEVICE 152.49 E1820 NU SOFT INTERFACE MATERIAL 100.01 E1820 RR SOFT INTERFACE MATERIAL 9.98 E1820 UE SOFT INTERFACE MATERIAL 75.02 E1821 NU REPLACEMENT INTERFACE SPSD 128.75 E1821 RR REPLACEMENT INTERFACE SPSD 12.84 E1821 UE REPLACEMENT INTERFACE SPSD 96.60 E1822 RR ADJUST ANKLE EXTENSION DEV 150.06 E1823 RR ADJUST ANKLE FLEXION DEVICE 150.06 E1825 RR ADJUST FINGER EXT & FLEX DEV 131.39 E1826 RR ADJUST FINGER EXTENSION DEV 150.06 E1827 RR ADJUST FINGER FLEXION DEVICE 150.06 E1828 RR ADJUST TOE EXTENSION DEVICE 150.06 E1829 RR ADJUST TOE FLEXION DEVICE 150.06 E1830 RR ADJUST TOE EXT & FLEX DEVICE 131.39 E1831 RR STATIC STR TOE DEV EXT/FLEX 80.83 E1832 SPS FINGER DEVICE BR E1840 RR ADJ SHOULDER EXT/FLEX DEVICE 410.36 E1841 RR STATIC STR SHLDR DEV ROM ADJ 554.20 E1902 AAC NON-ELECTRONIC BOARD 0.00 E1905 RR VR CBT THERAPY 646.04 E2000 RR GASTRIC SUCTION PUMP HME MDL 56.81 E2001 RR SUCT PUM EXT MGMT SYS 53.10 E2100 NU BLD GLUCOSE MONITOR W VOICE 786.88 E2100 RR BLD GLUCOSE MONITOR W VOICE 78.71 E2100 UE BLD GLUCOSE MONITOR W VOICE 590.18 E2101 NU BLD GLUCOSE MONITOR W LANCE 230.68 E2101 RR BLD GLUCOSE MONITOR W LANCE 23.07 E2101 UE BLD GLUCOSE MONITOR W LANCE 173.02 E2102 NU ADJU CGM RECEIVER/MONITOR 234.53 E2102 RR ADJU CGM RECEIVER/MONITOR 23.45 E2102 UE ADJU CGM RECEIVER/MONITOR 175.91 E2103 NU NON-ADJU CGM RECEIVER/MON 312.09 E2103 RR NON-ADJU CGM RECEIVER/MON 31.20 E2103 UE NON-ADJU CGM RECEIVER/MON 234.06 E2104 NU GLUCOSE MONITOR W CARTRIDGE 53.45 E2104 RR GLUCOSE MONITOR W CARTRIDGE 5.36 E2104 UE GLUCOSE MONITOR W CARTRIDGE 40.12 E2120 RR PULSE GEN SYS TX ENDOLYMP FL 346.87 E2201 NU MAN W/CH ACC SEAT W>=20"<24" 432.03 E2201 RR MAN W/CH ACC SEAT W>=20"<24" 45.66 E2201 UE MAN W/CH ACC SEAT W>=20"<24" 342.35 E2202 NU SEAT WIDTH 24-27 IN 579.87 E2202 RR SEAT WIDTH 24-27 IN 57.99 E2202 UE SEAT WIDTH 24-27 IN 434.92

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR E2203 NU FRAME DEPTH LESS THAN 22 IN 569.30 E2203 RR FRAME DEPTH LESS THAN 22 IN 58.60 E2203 UE FRAME DEPTH LESS THAN 22 IN 439.53 E2204 NU FRAME DEPTH 22 TO 25 IN 979.77 E2204 RR FRAME DEPTH 22 TO 25 IN 99.53 E2204 UE FRAME DEPTH 22 TO 25 IN 746.36 E2205 NU MANUAL WC ACCESSORY, HANDRIM 39.97 E2205 RR MANUAL WC ACCESSORY, HANDRIM 3.98 E2205 UE MANUAL WC ACCESSORY, HANDRIM 30.00 E2206 NU MAN WC WHL LOCK COMP REPL EA 49.75 E2206 RR MAN WC WHL LOCK COMP REPL EA 4.95 E2206 UE MAN WC WHL LOCK COMP REPL EA 37.32 E2207 NU CRUTCH AND CANE HOLDER 53.03 E2207 RR CRUTCH AND CANE HOLDER 5.32 E2207 UE CRUTCH AND CANE HOLDER 39.79 E2208 NU CYLINDER TANK CARRIER 125.26 E2208 RR CYLINDER TANK CARRIER 12.52 E2208 UE CYLINDER TANK CARRIER 93.95 E2209 NU ARM TROUGH EACH 112.99 E2209 RR ARM TROUGH EACH 11.32 E2209 UE ARM TROUGH EACH 84.76 E2210 NU WHEELCHAIR BEARINGS 6.95 E2210 RR WHEELCHAIR BEARINGS 0.70 E2210 UE WHEELCHAIR BEARINGS 5.23 E2211 NU PNEUMATIC PROPULSION TIRE 42.55 E2211 RR PNEUMATIC PROPULSION TIRE 4.17 E2211 UE PNEUMATIC PROPULSION TIRE 30.48 E2212 NU PNEUMATIC PROP TIRE TUBE 7.18 E2212 RR PNEUMATIC PROP TIRE TUBE 0.77 E2212 UE PNEUMATIC PROP TIRE TUBE 5.40 E2213 NU PNEUMATIC PROP TIRE INSERT 37.22 E2213 RR PNEUMATIC PROP TIRE INSERT 3.74 E2213 UE PNEUMATIC PROP TIRE INSERT 27.89 E2214 NU PNEUMATIC CASTER TIRE EACH 37.43 E2214 RR PNEUMATIC CASTER TIRE EACH 4.11 E2214 UE PNEUMATIC CASTER TIRE EACH 28.06 E2215 NU PNEUMATIC CASTER TIRE TUBE 11.74 E2215 RR PNEUMATIC CASTER TIRE TUBE 1.17 E2215 UE PNEUMATIC CASTER TIRE TUBE 8.80 E2216 NU FOAM FILLED PROPULSION TIRE 49.18 E2216 RR FOAM FILLED PROPULSION TIRE 5.58 E2216 UE FOAM FILLED PROPULSION TIRE 36.88 E2217 NU FOAM FILLED CASTER TIRE EACH 43.52 E2217 RR FOAM FILLED CASTER TIRE EACH 4.92 E2217 UE FOAM FILLED CASTER TIRE EACH 32.64 E2218 NU FOAM PROPULSION TIRE EACH 49.18 E2218 RR FOAM PROPULSION TIRE EACH 5.58 E2218 UE FOAM PROPULSION TIRE EACH 36.88 E2219 NU FOAM CASTER TIRE ANY SIZE EA 43.52

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR E2219 RR FOAM CASTER TIRE ANY SIZE EA 4.92 E2219 UE FOAM CASTER TIRE ANY SIZE EA 32.64 E2220 NU SOLID PROPULS TIRE, REPL, EA 34.91 E2220 RR SOLID PROPULS TIRE, REPL, EA 3.37 E2220 UE SOLID PROPULS TIRE, REPL, EA 26.70 E2221 NU SOLID CASTER TIRE REPL, EACH 31.26 E2221 RR SOLID CASTER TIRE REPL, EACH 3.17 E2221 UE SOLID CASTER TIRE REPL, EACH 23.45 E2222 NU SOLID CASTER INTEG WHL, REPL 25.78 E2222 RR SOLID CASTER INTEG WHL, REPL 2.54 E2222 UE SOLID CASTER INTEG WHL, REPL 19.34 E2224 NU PROPULSION WHL EXCL TIRE REP 108.76 E2224 RR PROPULSION WHL EXCL TIRE REP 10.88 E2224 UE PROPULSION WHL EXCL TIRE REP 81.57 E2225 NU CASTER WHEEL EXCLUDES TIRE 21.28 E2225 RR CASTER WHEEL EXCLUDES TIRE 2.12 E2225 UE CASTER WHEEL EXCLUDES TIRE 15.95 E2226 NU CASTER FORK REPLACEMENT ONLY 46.41 E2226 RR CASTER FORK REPLACEMENT ONLY 4.65 E2226 UE CASTER FORK REPLACEMENT ONLY 34.82 E2227 NU GEAR REDUCTION DRIVE WHEEL 2095.86 E2227 RR GEAR REDUCTION DRIVE WHEEL 228.88 E2227 UE GEAR REDUCTION DRIVE WHEEL 2501.23 E2228 NU MWC ACC, WHEELCHAIR BRAKE 1048.47 E2228 RR MWC ACC, WHEELCHAIR BRAKE 114.53 E2228 UE MWC ACC, WHEELCHAIR BRAKE 726.36 E2230 MANUAL STANDING SYSTEM BR E2231 NU SOLID SEAT SUPPORT BASE 185.05 E2231 RR SOLID SEAT SUPPORT BASE 18.81 E2231 UE SOLID SEAT SUPPORT BASE 140.99 E2291 PLANAR BACK FOR PED SIZE WC 502.57 E2292 PLANAR SEAT FOR PED SIZE WC 514.64 E2293 CONTOUR BACK FOR PED SIZE WC 930.05 E2294 CONTOUR SEAT FOR PED SIZE WC 589.58 E2295 PED DYNAMIC SEATING FRAME 1501.01 E2298 RR PWR SEAT ELEV SYS FOR CRT 206.22 E2301 PWR STANDING 13016.04 E2310 NU ELECTRO CONNECT BTW CONTROL 2016.48 E2310 RR ELECTRO CONNECT BTW CONTROL 127.72 E2310 UE ELECTRO CONNECT BTW CONTROL 1391.95 E2311 NU ELECTRO CONNECT BTW 2 SYS 3760.50 E2311 RR ELECTRO CONNECT BTW 2 SYS 258.22 E2311 UE ELECTRO CONNECT BTW 2 SYS 2595.10 E2312 NU MINI-PROP REMOTE JOYSTICK 3436.17 E2312 RR MINI-PROP REMOTE JOYSTICK 314.67 E2312 UE MINI-PROP REMOTE JOYSTICK 2445.26 E2313 NU PWC HARNESS, EXPAND CONTROL 597.06 E2313 RR PWC HARNESS, EXPAND CONTROL 39.20 E2313 UE PWC HARNESS, EXPAND CONTROL 376.81

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR E2321 NU HAND INTERFACE JOYSTICK 1714.48 E2321 RR HAND INTERFACE JOYSTICK 272.98 E2321 UE HAND INTERFACE JOYSTICK 1265.11 E2322 NU MULT MECH SWITCHES 1181.13 E2322 RR MULT MECH SWITCHES 289.06 E2322 UE MULT MECH SWITCHES 881.44 E2323 NU SPECIAL JOYSTICK HANDLE 77.47 E2323 RR SPECIAL JOYSTICK HANDLE 7.74 E2323 UE SPECIAL JOYSTICK HANDLE 58.09 E2324 NU CHIN CUP INTERFACE 49.56 E2324 RR CHIN CUP INTERFACE 4.93 E2324 UE CHIN CUP INTERFACE 37.17 E2325 NU SIP AND PUFF INTERFACE 1835.88 E2325 RR SIP AND PUFF INTERFACE 151.35 E2325 UE SIP AND PUFF INTERFACE 1371.37 E2326 NU BREATH TUBE KIT 519.70 E2326 RR BREATH TUBE KIT 39.27 E2326 UE BREATH TUBE KIT 387.84 E2327 NU HEAD CONTROL INTERFACE MECH 2213.25 E2327 RR HEAD CONTROL INTERFACE MECH 418.50 E2327 UE HEAD CONTROL INTERFACE MECH 1819.08 E2328 NU HEAD/EXTREMITY CONTROL INTER 6998.19 E2328 RR HEAD/EXTREMITY CONTROL INTER 557.70 E2328 UE HEAD/EXTREMITY CONTROL INTER 5222.53 E2329 NU HEAD CONTROL NONPROPORTIONAL 1496.12 E2329 RR HEAD CONTROL NONPROPORTIONAL 199.74 E2329 UE HEAD CONTROL NONPROPORTIONAL 962.59 E2330 NU HEAD CONTROL PROXIMITY SWITC 5117.94 E2330 RR HEAD CONTROL PROXIMITY SWITC 385.85 E2330 UE HEAD CONTROL PROXIMITY SWITC 3244.42 E2331 ATTENDANT CONTROL 1350.04 E2340 NU W/C WDTH 20-23 IN SEAT FRAME 438.42 E2340 RR W/C WDTH 20-23 IN SEAT FRAME 43.86 E2340 UE W/C WDTH 20-23 IN SEAT FRAME 328.86 E2341 NU W/C WDTH 24-27 IN SEAT FRAME 657.69 E2341 RR W/C WDTH 24-27 IN SEAT FRAME 65.76 E2341 UE W/C WDTH 24-27 IN SEAT FRAME 493.29 E2342 NU W/C DPTH 20-21 IN SEAT FRAME 548.09 E2342 RR W/C DPTH 20-21 IN SEAT FRAME 54.80 E2342 UE W/C DPTH 20-21 IN SEAT FRAME 411.07 E2343 NU W/C DPTH 22-25 IN SEAT FRAME 876.95 E2343 RR W/C DPTH 22-25 IN SEAT FRAME 87.68 E2343 UE W/C DPTH 22-25 IN SEAT FRAME 657.69 E2351 NU ELECTRONIC SGD INTERFACE 790.38 E2351 RR ELECTRONIC SGD INTERFACE 79.04 E2351 UE ELECTRONIC SGD INTERFACE 592.79 E2358 GR 34 NONSEALED LEADACID BR E2359 NU GR34 SEALED LEADACID BATTERY 213.05 E2359 RR GR34 SEALED LEADACID BATTERY 21.30

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR E2359 UE GR34 SEALED LEADACID BATTERY 159.76 E2360 NU 22NF NONSEALED LEADACID 117.44 E2360 RR 22NF NONSEALED LEADACID 11.80 E2360 UE 22NF NONSEALED LEADACID 88.06 E2361 NU 22NF SEALED LEADACID BATTERY 149.03 E2361 RR 22NF SEALED LEADACID BATTERY 14.90 E2361 UE 22NF SEALED LEADACID BATTERY 111.79 E2362 NU GR24 NONSEALED LEADACID 113.12 E2362 RR GR24 NONSEALED LEADACID 11.31 E2362 UE GR24 NONSEALED LEADACID 84.83 E2363 NU GR24 SEALED LEADACID BATTERY 196.14 E2363 RR GR24 SEALED LEADACID BATTERY 19.61 E2363 UE GR24 SEALED LEADACID BATTERY 147.10 E2364 NU U1NONSEALED LEADACID BATTERY 117.44 E2364 RR U1NONSEALED LEADACID BATTERY 11.80 E2364 UE U1NONSEALED LEADACID BATTERY 88.06 E2365 NU U1 SEALED LEADACID BATTERY 118.27 E2365 RR U1 SEALED LEADACID BATTERY 11.81 E2365 UE U1 SEALED LEADACID BATTERY 88.75 E2366 NU BATTERY CHARGER, SINGLE MODE 277.98 E2366 RR BATTERY CHARGER, SINGLE MODE 27.88 E2366 UE BATTERY CHARGER, SINGLE MODE 208.51 E2367 NU BATTERY CHARGER, DUAL MODE 465.01 E2367 RR BATTERY CHARGER, DUAL MODE 46.50 E2367 UE BATTERY CHARGER, DUAL MODE 348.76 E2368 NU PWR WC DRIVEWHEEL MOTOR REPL 704.16 E2368 RR PWR WC DRIVEWHEEL MOTOR REPL 54.46 E2368 UE PWR WC DRIVEWHEEL MOTOR REPL 533.18 E2369 NU PWR WC DRIVEWHEEL GEAR REPL 558.37 E2369 RR PWR WC DRIVEWHEEL GEAR REPL 48.97 E2369 UE PWR WC DRIVEWHEEL GEAR REPL 375.19 E2370 NU PWR WC DR WH MOTOR/GEAR COMB 998.93 E2370 RR PWR WC DR WH MOTOR/GEAR COMB 84.67 E2370 UE PWR WC DR WH MOTOR/GEAR COMB 677.92 E2371 NU GR27 SEALED LEADACID BATTERY 169.68 E2371 RR GR27 SEALED LEADACID BATTERY 16.97 E2371 UE GR27 SEALED LEADACID BATTERY 127.27 E2372 NU GR27 NON-SEALED LEADACID 0.00 E2372 RR GR27 NON-SEALED LEADACID 0.00 E2372 UE GR27 NON-SEALED LEADACID 0.00 E2373 NU HAND/CHIN CTRL SPEC JOYSTICK 1255.85 E2373 RR HAND/CHIN CTRL SPEC JOYSTICK 132.69 E2373 UE HAND/CHIN CTRL SPEC JOYSTICK 866.69 E2374 NU HAND/CHIN CTRL STD JOYSTICK 831.02 E2374 RR HAND/CHIN CTRL STD JOYSTICK 58.55 E2374 UE HAND/CHIN CTRL STD JOYSTICK 563.39 E2375 NU NON-EXPANDABLE CONTROLLER 1002.68 E2375 RR NON-EXPANDABLE CONTROLLER 90.29 E2375 UE NON-EXPANDABLE CONTROLLER 692.20

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR E2376 NU EXPANDABLE CONTROLLER, REPL 1530.58 E2376 RR EXPANDABLE CONTROLLER, REPL 146.37 E2376 UE EXPANDABLE CONTROLLER, REPL 1041.93 E2377 NU EXPANDABLE CONTROLLER, INITL 739.52 E2377 RR EXPANDABLE CONTROLLER, INITL 53.52 E2377 UE EXPANDABLE CONTROLLER, INITL 510.50 E2378 RR PW ACTUATOR REPLACEMENT 62.61 E2381 NU PNEUM DRIVE WHEEL TIRE 80.32 E2381 RR PNEUM DRIVE WHEEL TIRE 8.06 E2381 UE PNEUM DRIVE WHEEL TIRE 60.23 E2382 NU TUBE, PNEUM WHEEL DRIVE TIRE 22.12 E2382 RR TUBE, PNEUM WHEEL DRIVE TIRE 2.21 E2382 UE TUBE, PNEUM WHEEL DRIVE TIRE 16.60 E2383 NU INSERT, PNEUM WHEEL DRIVE 163.62 E2383 RR INSERT, PNEUM WHEEL DRIVE 16.36 E2383 UE INSERT, PNEUM WHEEL DRIVE 122.71 E2384 NU PNEUMATIC CASTER TIRE 85.32 E2384 RR PNEUMATIC CASTER TIRE 8.56 E2384 UE PNEUMATIC CASTER TIRE 64.00 E2385 NU TUBE, PNEUMATIC CASTER TIRE 52.89 E2385 RR TUBE, PNEUMATIC CASTER TIRE 5.30 E2385 UE TUBE, PNEUMATIC CASTER TIRE 39.66 E2386 NU FOAM FILLED DRIVE WHEEL TIRE 158.69 E2386 RR FOAM FILLED DRIVE WHEEL TIRE 15.87 E2386 UE FOAM FILLED DRIVE WHEEL TIRE 119.04 E2387 NU FOAM FILLED CASTER TIRE 71.16 E2387 RR FOAM FILLED CASTER TIRE 7.12 E2387 UE FOAM FILLED CASTER TIRE 53.41 E2388 NU FOAM DRIVE WHEEL TIRE 55.44 E2388 RR FOAM DRIVE WHEEL TIRE 5.55 E2388 UE FOAM DRIVE WHEEL TIRE 41.60 E2389 NU FOAM CASTER TIRE 30.51 E2389 RR FOAM CASTER TIRE 3.06 E2389 UE FOAM CASTER TIRE 22.87 E2390 NU SOLID DRIVE WHEEL TIRE 47.49 E2390 RR SOLID DRIVE WHEEL TIRE 4.75 E2390 UE SOLID DRIVE WHEEL TIRE 35.61 E2391 NU SOLID CASTER TIRE 22.30 E2391 RR SOLID CASTER TIRE 2.24 E2391 UE SOLID CASTER TIRE 16.73 E2392 NU SOLID CASTER TIRE, INTEGRATE 56.81 E2392 RR SOLID CASTER TIRE, INTEGRATE 5.72 E2392 UE SOLID CASTER TIRE, INTEGRATE 42.62 E2394 NU DRIVE WHEEL EXCLUDES TIRE 80.95 E2394 RR DRIVE WHEEL EXCLUDES TIRE 8.11 E2394 UE DRIVE WHEEL EXCLUDES TIRE 60.71 E2395 NU CASTER WHEEL EXCLUDES TIRE 57.52 E2395 RR CASTER WHEEL EXCLUDES TIRE 5.77 E2395 UE CASTER WHEEL EXCLUDES TIRE 43.14

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR E2396 NU CASTER FORK 70.11 E2396 RR CASTER FORK 7.50 E2396 UE CASTER FORK 52.61 E2397 NU PWC ACC, LITH-BASED BATTERY 506.66 E2397 RR PWC ACC, LITH-BASED BATTERY 50.68 E2397 UE PWC ACC, LITH-BASED BATTERY 379.97 E2398 NU WC DYNAMIC POS BACK HARDWARE 160.28 E2398 RR WC DYNAMIC POS BACK HARDWARE 16.03 E2398 UE WC DYNAMIC POS BACK HARDWARE 120.20 E2402 RR NEG PRESS WOUND THERAPY PUMP 1283.74 E2500 NU SGD DIGITIZED PRE-REC <=8MIN 478.42 E2500 RR SGD DIGITIZED PRE-REC <=8MIN 47.85 E2500 UE SGD DIGITIZED PRE-REC <=8MIN 358.81 E2502 NU SGD PREREC MSG >8MIN <=20MIN 1462.96 E2502 RR SGD PREREC MSG >8MIN <=20MIN 146.31 E2502 UE SGD PREREC MSG >8MIN <=20MIN 1097.24 E2504 NU SGD PREREC MSG>20MIN <=40MIN 1929.87 E2504 RR SGD PREREC MSG>20MIN <=40MIN 193.01 E2504 UE SGD PREREC MSG>20MIN <=40MIN 1447.41 E2506 NU SGD PREREC MSG > 40 MIN 2829.74 E2506 RR SGD PREREC MSG > 40 MIN 282.96 E2506 UE SGD PREREC MSG > 40 MIN 2122.26 E2508 NU SGD SPELLING PHYS CONTACT 4375.73 E2508 RR SGD SPELLING PHYS CONTACT 437.57 E2508 UE SGD SPELLING PHYS CONTACT 3281.81 E2510 NU SGD W MULTI METHODS MSG/ACCS 8280.50 E2510 RR SGD W MULTI METHODS MSG/ACCS 828.05 E2510 UE SGD W MULTI METHODS MSG/ACCS 6210.35 E2511 NU SGD SFTWRE PRGRM FOR PC/PDA 41.35 E2511 RR SGD SFTWRE PRGRM FOR PC/PDA 4.16 E2511 UE SGD SFTWRE PRGRM FOR PC/PDA 30.85 E2512 NU SGD ACCESSORY, MOUNTING SYS 1171.28 E2512 RR SGD ACCESSORY, MOUNTING SYS 117.84 E2512 UE SGD ACCESSORY, MOUNTING SYS 874.09 E2513 NU SGD ACCESSORY, EMG SENSOR 4402.94 E2513 RR SGD ACCESSORY, EMG SENSOR 440.31 E2513 UE SGD ACCESSORY, EMG SENSOR 3302.22 E2599 SGD ACCESSORY NOC BR E2601 NU GEN W/C CUSHION WDTH < 22 IN 64.49 E2601 RR GEN W/C CUSHION WDTH < 22 IN 6.46 E2601 UE GEN W/C CUSHION WDTH < 22 IN 48.37 E2602 NU GEN W/C CUSHION WDTH >=22 IN 125.90 E2602 RR GEN W/C CUSHION WDTH >=22 IN 12.60 E2602 UE GEN W/C CUSHION WDTH >=22 IN 94.44 E2603 NU SKIN PROTECT WC CUS WD <22IN 159.83 E2603 RR SKIN PROTECT WC CUS WD <22IN 16.00 E2603 UE SKIN PROTECT WC CUS WD <22IN 119.90 E2604 NU SKIN PROTECT WC CUS WD>=22IN 198.68 E2604 RR SKIN PROTECT WC CUS WD>=22IN 19.87

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR E2604 UE SKIN PROTECT WC CUS WD>=22IN 149.02 E2605 NU POSITION WC CUSH WDTH <22 IN 283.84 E2605 RR POSITION WC CUSH WDTH <22 IN 28.39 E2605 UE POSITION WC CUSH WDTH <22 IN 212.91 E2606 NU POSITION WC CUSH WDTH>=22 IN 443.17 E2606 RR POSITION WC CUSH WDTH>=22 IN 44.32 E2606 UE POSITION WC CUSH WDTH>=22 IN 332.36 E2607 NU SKIN PRO/POS WC CUS WD <22IN 305.64 E2607 RR SKIN PRO/POS WC CUS WD <22IN 30.57 E2607 UE SKIN PRO/POS WC CUS WD <22IN 229.23 E2608 NU SKIN PRO/POS WC CUS WD>=22IN 367.05 E2608 RR SKIN PRO/POS WC CUS WD>=22IN 36.70 E2608 UE SKIN PRO/POS WC CUS WD>=22IN 275.28 E2609 CUSTOM FABRICATE W/C CUSHION 2414.64 E2610 POWERED W/C CUSHION BR E2611 NU GEN USE BACK CUSH WDTH <22IN 329.37 E2611 RR GEN USE BACK CUSH WDTH <22IN 32.93 E2611 UE GEN USE BACK CUSH WDTH <22IN 247.05 E2612 NU GEN USE BACK CUSH WDTH>=22IN 445.56 E2612 RR GEN USE BACK CUSH WDTH>=22IN 44.55 E2612 UE GEN USE BACK CUSH WDTH>=22IN 334.15 E2613 NU POSITION BACK CUSH WD <22IN 414.46 E2613 RR POSITION BACK CUSH WD <22IN 41.45 E2613 UE POSITION BACK CUSH WD <22IN 310.84 E2614 NU POSITION BACK CUSH WD>=22IN 585.22 E2614 RR POSITION BACK CUSH WD>=22IN 58.52 E2614 UE POSITION BACK CUSH WD>=22IN 438.92 E2615 NU POS BACK POST/LAT WDTH <22IN 476.95 E2615 RR POS BACK POST/LAT WDTH <22IN 47.70 E2615 UE POS BACK POST/LAT WDTH <22IN 357.71 E2616 NU POS BACK POST/LAT WDTH>=22IN 641.74 E2616 RR POS BACK POST/LAT WDTH>=22IN 64.17 E2616 UE POS BACK POST/LAT WDTH>=22IN 481.31 E2617 CUSTOM FAB W/C BACK CUSHION 2730.85 E2619 NU REPLACE COVER W/C SEAT CUSH 56.75 E2619 RR REPLACE COVER W/C SEAT CUSH 5.68 E2619 UE REPLACE COVER W/C SEAT CUSH 42.59 E2620 NU WC PLANAR BACK CUSH WD <22IN 577.52 E2620 RR WC PLANAR BACK CUSH WD <22IN 57.76 E2620 UE WC PLANAR BACK CUSH WD <22IN 433.17 E2621 NU WC PLANAR BACK CUSH WD>=22IN 606.07 E2621 RR WC PLANAR BACK CUSH WD>=22IN 60.61 E2621 UE WC PLANAR BACK CUSH WD>=22IN 454.56 E2622 NU ADJ SKIN PRO W/C CUS WD<22IN 363.62 E2622 RR ADJ SKIN PRO W/C CUS WD<22IN 36.37 E2622 UE ADJ SKIN PRO W/C CUS WD<22IN 272.71 E2623 NU ADJ SKIN PRO WC CUS WD>=22IN 461.40 E2623 RR ADJ SKIN PRO WC CUS WD>=22IN 46.15 E2623 UE ADJ SKIN PRO WC CUS WD>=22IN 346.04

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR E2624 NU ADJ SKIN PRO/POS CUS<22IN 367.91 E2624 RR ADJ SKIN PRO/POS CUS<22IN 36.80 E2624 UE ADJ SKIN PRO/POS CUS<22IN 275.94 E2625 NU ADJ SKIN PRO/POS WC CUS>=22 461.04 E2625 RR ADJ SKIN PRO/POS WC CUS>=22 46.10 E2625 UE ADJ SKIN PRO/POS WC CUS>=22 345.78 E2626 NU SEO MOBILE ARM SUP ATT TO WC 759.92 E2626 RR SEO MOBILE ARM SUP ATT TO WC 75.96 E2626 UE SEO MOBILE ARM SUP ATT TO WC 569.86 E2627 NU ARM SUPP ATT TO WC RANCHO TY 1030.68 E2627 RR ARM SUPP ATT TO WC RANCHO TY 103.11 E2627 UE ARM SUPP ATT TO WC RANCHO TY 773.00 E2628 NU MOBILE ARM SUPPORTS RECLININ 913.48 E2628 RR MOBILE ARM SUPPORTS RECLININ 91.33 E2628 UE MOBILE ARM SUPPORTS RECLININ 685.09 E2629 NU FRICTION DAMPENING ARM SUPP 1155.98 E2629 RR FRICTION DAMPENING ARM SUPP 115.59 E2629 UE FRICTION DAMPENING ARM SUPP 866.97 E2630 NU MONOSUSPENSION ARM/HAND SUPP 808.38 E2630 RR MONOSUSPENSION ARM/HAND SUPP 80.83 E2630 UE MONOSUSPENSION ARM/HAND SUPP 606.28 E2631 NU ELEVAT PROXIMAL ARM SUPPORT 274.86 E2631 RR ELEVAT PROXIMAL ARM SUPPORT 27.49 E2631 UE ELEVAT PROXIMAL ARM SUPPORT 206.14 E2632 NU OFFSET/LAT ROCKER ARM W/ELA 188.87 E2632 RR OFFSET/LAT ROCKER ARM W/ELA 18.91 E2632 UE OFFSET/LAT ROCKER ARM W/ELA 141.65 E2633 NU MOBILE ARM SUPPORT SUPINATOR 148.24 E2633 RR MOBILE ARM SUPPORT SUPINATOR 14.84 E2633 UE MOBILE ARM SUPPORT SUPINATOR 111.20 E3000 RR SPEECH VOLUME MODULATION SYS 234.41 E3200 GAIT MOD SYSTM RHYM AUDITORY BR E8000 POSTERIOR GAIT TRAINER 3472.52 E8001 UPRIGHT GAIT TRAINER 4681.21 E8002 ANTERIOR GAIT TRAINER 5077.86 G0008 ADMIN INFLUENZA VIRUS VAC 39.13 58.04 G0009 ADMIN PNEUMOCOCCAL VACCINE 41.11 58.04 G0010 ADMIN HEPATITIS B VACCINE 43.98 58.04 ★ G0011 HIV PREP COUNSEL, MD 15-30M 32.47 G0012 INJECTION OF HIV PREP DRUG 17.67 64.27 ★ G0013 HIV PREP COUNSEL, CLIN STAFF 28.77 120.60 G0017 CRISIS PSYCHOTHERAPY 60M 261.81 G0018 CRISIS PSYCHOTHERAPY ADD 30M 129.87 G0019 COMM HLTH INTG SVS SDOH 60MN 99.46 120.60 G0022 COMM HLTH INTG SVS ADD 30 M 62.06 G0023 PIN SERVICE 60M PER MONTH 99.46 120.60 G0024 PIN SRV ADD 30 MIN PR M 62.06 G0027 SEMEN ANALYSIS 7.95 G0029 NO TOB SCR/CESS INT BR

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR G0030 PT SCR TOB & CESS INT BR G0031 PALL SERV DURING MEAS BR G0032 2+ ANTIPSY SCHIZ BR G0033 2+ BENZO SEIZ BR G0034 PALL SERV DURING MEAS BR G0035 PT ED POS 23 BR G0036 PT/PTN DECLN ASSESS BR G0037 PT NOT ABLE TO PARTICIPATE BR G0038 CLIN PT NO REF BR G0039 PT NO REF, RN SPEC BR G0040 PT PHYS/OCC THERAPY BR G0041 PT/PTN DECLN REFERRAL BR G0042 REF TO THERAPY BR G0043 PT MECH PROS HT VALV BR G0044 PT MITRAL STENOSIS BR G0045 MRS 90 DAYS POST STK BR G0046 NO MRS 90 DAYS POST STK BR G0047 PED BLUNT HD TRAUM BR G0048 PALL SERV DURING MEAS BR G0049 MAIN HEMO IN-CNTR BR G0050 PT W/ LMTED LIFE EXPEC BR G0051 PT HOSPICE MNTH BR G0052 PT PERI DIALYSIS DUR MO BR G0053 ADV RHEUM PT CARE MVP BR G0054 STRK CR PREV POS OUTCME MVP BR G0055 ADV CARE HEART DX MVP BR G0057 BEST PCT PT SAFETY EM MVP BR G0058 IMPRV CARE LE JNT REPR MVP BR G0059 PT SFTY POS EXP W ANETH MVP BR G0060 ALLERGY/IMMUNOLOGY SS BR G0061 ANESTHESIOLOGY SS BR G0062 AUDIOLOGY SS BR G0063 CARDIOLOGY SS BR G0064 CERT NURSE MIDWIFE SS BR G0065 CHIROPRACTIC SS BR G0066 CLINICAL SOCIAL WORK SS BR G0067 DENTISTRY SS BR G0068 ADM IV INFUSION DRUG IN HOME 167.68 G0069 ADM SQ INFUSION DRUG IN HOME 238.25 G0070 ADM OF CHEMO DRUG IN HOME 259.67 G0071 COMM SVCS BY RHC/FQHC 5 MIN 17.95 G0076 CARE MANAG H VST NEW PT 20 M 64.12 G0077 CARE MANAG H VST NEW PT 30 M 91.66 G0078 CARE MANAG H VST NEW PT 45 M 149.60 G0079 CARE MANAG H VST NEW PT 60 M 213.72 G0080 CARE MANAG H VST NEW PT 75 M 258.93 G0081 CARE MAN H V EXT PT 20 MI 64.94 G0082 CARE MAN H V EXT PT 30 M 98.63 G0083 CARE MAN H V EXT PT 45 M 152.07

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR G0084 CARE MAN H V EXT PT 60 M 210.84 G0085 CARE MAN H V EXT PT 75 M 258.93 G0086 CARE MAN HOME CARE PLAN 30 M 91.25 G0087 CARE MAN HOME CARE PLAN 60 M 127.83 G0088 ADM IV DRUG 1ST HOME VISIT 109.32 G0089 ADM SUBQ DRUG 1ST HOME VISIT 51.38 G0090 ADM IV CHEMO 1ST HOME VISIT 183.72 G0101 CA SCREEN;PELVIC/BREAST EXAM 47.67 108.52 G0102 PROSTATE CA SCREENING; DRE 27.95 G0103 PSA SCREENING 22.48 G0104 CA SCREEN;FLEXI SIGMOIDSCOPE 230.66 1150.88 G0105 COLORECTAL SCRN; HI RISK IND 424.16 1150.88 ★ G0108 DIAB MANAGE TRN PER INDIV 66.58 ★ G0109 DIAB MANAGE TRN IND/GROUP 18.91 G0117 GLAUCOMA SCRN HGH RISK DIREC 74.68 35.83 G0118 GLAUCOMA SCRN HGH RISK DIREC 50.96 49.09 G0121 COLON CA SCRN NOT HI RSK IND 424.56 1150.88 G0123 SCREEN CERV/VAG THIN LAYER 24.76 G0124 SCREEN C/V THIN LAYER BY MD 37.00 G0127 TRIM NAIL(S) 28.36 80.73 G0128 CORF SKILLED NURSING SERVICE 10.40 G0129 PHP/IOP OT SERVICE BR G0130 SINGLE ENERGY X-RAY STUDY 43.98 157.89 ★ G0136 ADM OF SOC DTR ASSESS 5-15 M 23.42 38.82 G0137 INTEN OUTPT SVS,MIN 9 PR 7 D BR G0138 IV CIPAGLUCOSIDASE ALFA-ATGA 216.82 923.71 G0140 NAV SRV PEER SUP 60 MIN PR M 99.46 120.60 G0141 SCR C/V CYTO,AUTOSYS AND MD 37.00 G0143 SCR C/V CYTO,THINLAYER,RESCR 29.76 G0144 SCR C/V CYTO,THINLAYER,RESCR 48.37 G0145 SCR C/V CYTO,THINLAYER,RESCR 32.38 G0146 NAV SRV PEER SUP ADD 30 PR M 62.06 G0147 SCR C/V CYTO, AUTOMATED SYS 17.51 G0148 SCR C/V CYTO, AUTOSYS, RESCR 35.13 G0151 HHCP-SERV OF PT,EA 15 MIN See Rules G0152 HHCP-SERV OF OT,EA 15 MIN See Rules G0153 HHCP-SVS OF S/L PATH,EA 15MN See Rules G0155 HHCP-SVS OF CSW,EA 15 MIN See Rules G0156 HHCP-SVS OF AIDE,EA 15 MIN See Rules G0157 HHC PT ASSISTANT EA 15 115.49 G0158 HHC OT ASSISTANT EA 15 115.49 G0159 HHC PT MAINT EA 15 MIN 63.29 G0160 HHC OCCUP THERAPY EA 15 406.07 G0161 HHC SLP EA 15 MIN 1110.94 G0162 HHC RN E&M PLAN SVS, 15 MIN See Rules G0166 EXTRNL COUNTERPULSE, PER TX 132.35 163.53 G0168 WOUND CLOSURE BY ADHESIVE 127.63 G0175 OPPS SERVICE,SCHED TEAM CONF 212.48 527.56 G0176 OPPS/PHP/IOP; ACTIVITY THRPY 64.94

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR G0177 OPPS/PHP/IOP; TRAIN & EDUC 85.49 G0179 MD RECERTIFICATION HHA PT 49.32 G0180 MD CERTIFICATION HHA PATIENT 63.71 G0181 HOME HEALTH CARE SUPERVISION 125.76 G0182 HOSPICE CARE SUPERVISION 127.41 G0183 SOFTWARE MEAS OF CARDIAC VOL BR G0186 DSTRY EYE LESN,FDR VSSL TECH BR 729.85 G0219 PET IMG WHOLBOD MELANO NONCO BR G0235 PET NOT OTHERWISE SPECIFIED BR 546.69 G0237 THERAPEUTIC PROCD STRG ENDUR 12.33 35.83 G0238 OTH RESP PROC, INDIV 12.33 35.83 G0239 OTH RESP PROC, GROUP 15.62 49.09 G0245 INITIAL FOOT EXAM PT LOPS 78.91 172.32 G0246 FOLLOWUP EVAL OF FOOT PT LOP 46.45 172.32 G0247 ROUTINE FOOTCARE PT W LOPS 102.34 260.43 ★ G0248 DEMONSTRATE USE HOME INR MON 83.02 172.32 G0249 PROVIDE INR TEST MATER/EQUIP 83.43 172.32 G0250 MD INR TEST REVIE INTER MGMT 10.69 G0252 PET IMAGING INITIAL DX 92.54 G0255 CURRENT PERCEP THRESHOLD TST 42.74 G0257 UNSCHED DIALYSIS ESRD PT HOS BR 949.85 G0259 INJECT FOR SACROILIAC JOINT 190.30 G0260 INJ FOR SACROILIAC JT ANESTH 586.08 920.90 G0268 REMOVAL OF IMPACTED WAX MD 63.29 G0269 OCCLUSIVE DEVICE IN VEIN ART 322.22 ★ G0270 MNT SUBS TX FOR CHANGE DX 38.63 G0271 GROUP MNT 2 OR MORE 30 MINS 20.55 J1 G0276 PILD/PLACEBO CONTROL CLIN TR 451.28 12671.60 G0277 HBOT, FULL BODY CHAMBER, 30M 146.52 172.96 G0278 ILIAC ART ANGIO,CARDIAC CATH 16.85 G0279 TOMOSYNTHESIS, MAMMO 64.12 G0281 ELEC STIM UNATTEND FOR PRESS 22.68 G0282 ELECT STIM WOUND CARE NOT PD 22.68 64.32 G0283 ELEC STIM OTHER THAN WOUND 22.68 G0288 RECON, CTA FOR SURG PLAN 44.80 G0289 ARTHRO, LOOSE BODY + CHONDRO 103.16 G0293 NON-COV SURG PROC,CLIN TRIAL BR 49.09 G0294 NON-COV PROC, CLINICAL TRIAL BR 49.09 G0295 ELECTROMAGNETIC THERAPY ONC 25.49 ★ G0296 VISIT TO DETERM LDCT ELIG 34.52 108.52 G0299 HHS/HOSPICE OF RN EA 15 MIN 128.23 G0300 HHS/HOSPICE OF LPN EA 15 MIN 60.01 G0302 PRE-OP SERVICE LVRS COMPLETE BR 707.91 G0303 PRE-OP SERVICE LVRS 10-15DOS BR 383.81 G0304 PRE-OP SERVICE LVRS 1-9 DOS BR 707.91 G0305 POST OP SERVICE LVRS MIN 6 BR 707.91 G0306 CBC/DIFFWBC W/O PLATELET 9.49 G0307 CBC WITHOUT PLATELET 7.90 G0310 IMMUNIZE COUNSEL 5-15 MIN BR

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR G0311 IMMUNIZE COUNSEL 16-30 MINS BR G0312 IMMUNIZE COUNS < 21YR 5-15 M BR G0313 IMMUNIZE COUNS < 21YR 6-30 M BR G0314 COUNSEL IMMUNE <21 16-30 M BR G0315 COUNSEL IMMUNE <21 5-15 M BR ★ G0316 PROLONG INPT EVAL ADD15 M 38.63 ★ G0317 PROLONG NURSIN FAC EVAL 15M 38.63 ★ G0318 PROLONG HOME EVAL ADD 15M 37.82 G0320 TWO-WAY AUDIO AND VIDEO HHS 83.55 G0321 AUDIO-ONLY HHS 106.79 G0322 HOME H PHYSIO DATA COLLEC TR 269.80 G0323 CARE MANAGE BEH SVS 20MINS 52.20 42.15 G0327 COLON CA SCRN;BLD-BSD BIOMRK BR G0328 FECAL BLOOD SCRN IMMUNOASSAY 19.86 G0329 ELECTROMAGNTIC TX FOR ULCERS 13.15 J1 G0330 FACILITY SVS DENTAL REHAB 2905.54 2445.85 G0333 DISPENSE FEE INITIAL 30 DAY 48.91 G0337 HOSPICE EVALUATION PREELECTI 85.49 G0339 ROBOT LIN-RADSURG COM, FIRST 9627.67 G0340 ROBT LIN-RADSURG FRACTX 2-5 7264.43 G0341 PERCUTANEOUS ISLET CELLTRANS 2447.92 G0342 LAPAROSCOPY ISLET CELL TRANS 925.99 G0343 LAPAROTOMY ISLET CELL TRANSP 1521.12 G0372 MD SERVICE REQUIRED FOR PMD 10.69 G0378 HOSPITAL OBSERVATION PER HR See Rules G0379 DIRECT REFER HOSPITAL OBSERV See Rules 757.24 G0380 LEV 1 HOSP TYPE B ED VISIT BR 102.44 G0381 LEV 2 HOSP TYPE B ED VISIT 279.59 138.81 G0382 LEV 3 HOSP TYPE B ED VISIT 233.94 262.50 G0383 LEV 4 HOSP TYPE B ED VISIT BR 331.64 G0384 LEV 5 HOSP TYPE B ED VISIT BR 462.17 G0390 TRAUMA RESPONS W/HOSP CRITI 3699.07 1381.57 ★ G0396 ALCOHOL/SUBS INTERV 15-30MN 42.74 38.11 ★ G0397 ALCOHOL/SUBS INTERV >30 MIN 82.20 194.04 G0398 HOME SLEEP TEST/TYPE 2 PORTA 427.43 202.48 G0399 HOME SLEEP TEST/TYPE 3 PORTA 402.78 202.48 G0400 HOME SLEEP TEST/TYPE 4 PORTA 459.90 383.81 G0402 INITIAL PREVENTIVE EXAM 201.39 172.32 G0403 EKG FOR INITIAL PREVENT EXAM 19.73 G0404 EKG TRACING FOR INITIAL PREV 9.86 35.83 G0405 EKG INTERPRET & REPORT PREVE 9.87 ★ G0406 INPT/TELE FOLLOW UP 15 46.03 ★ G0407 INPT/TELE FOLLOW UP 25 84.67 ★ G0408 INPT/TELE FOLLOW UP 35 121.65 G0409 CORF RELATED SERV 15 MINS EA 18.91 ★ G0410 GRP PSYCH PHP/IOP 45-50 195.64 G0411 INTERACTIVE GRP PSYC PHP/IOP 167.10 J1* G0412 OPEN TX ILIAC SPINE UNI/BIL 885.70 12031.89 J1 G0413 PELVIC RING FRACTURE UNI/BIL 1297.53 12187.02

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR J1* G0414 PELVIC RING FX TREAT INT FIX 1223.95 22251.08 J1* G0415 OPEN TX POST PELVIC FXCTURE 1671.13 22251.08 G0416 PROSTATE BIOPSY, ANY MTHD 440.59 422.38 ★ G0420 ED SVC CKD IND PER SESSION 134.81 ★ G0421 ED SVC CKD GRP PER SESSION 32.47 ★ G0422 INTENS CARDIAC REHAB W/EXERC 140.97 168.34 ★ G0423 INTENS CARDIAC REHAB NO EXER 140.97 168.34 ★ G0425 INPT/ED TELECONSULT30 119.60 ★ G0426 INPT/ED TELECONSULT50 160.70 ★ G0427 INPT/ED TELECONSULT70 235.50 G0428 COLLAGEN MENISCUS IMPLANT BR G0429 DERMAL FILLER INJECTION(S) 117.54 2483.95 G0432 EIA HIV-1/HIV-2 SCREEN 21.53 G0433 ELISA HIV-1/HIV-2 SCREEN 20.12 G0435 ORAL HIV-1/HIV-2 SCREEN 14.65 ★ G0438 PPPS, INITIAL VISIT 201.39 ★ G0439 PPPS, SUBSEQ VISIT 155.03 ★ G0442 ANNUAL ALCOHOL SCREEN 15 MIN 22.60 38.11 ★ G0443 BRIEF ALCOHOL MISUSE COUNSEL 31.65 108.52 ★ G0444 DEPRESSION SCREEN ANNUAL 22.20 38.11 ★ G0445 HIGH INTEN BEH COUNS STD 30M 32.87 108.52 ★ G0446 INTENS BEHAVE THER CARDIO DX 31.65 38.11 ★ G0447 BEHAVIOR COUNSEL OBESITY 15M 31.65 108.52 G0448 PLACE PERM PACING CARDIOVERT 1517.00 G0451 DEVLOPMENT TEST INTERPT&REP 12.74 108.52 G0452 MOLECULAR PATHOLOGY INTERPR 85.12 G0453 CONT INTRAOP NEURO MONITOR 39.05 G0454 MD DOCUMENT VISIT BY NPP 10.69 G0455 FECAL MICROBIOTA PREP INSTIL 157.83 1173.47 G0458 LDR PROSTATE BRACHY COMP RAT BR ★ G0459 TELEHEALTH INPT PHARM MGMT 50.14 G0460 AUTOLOG PRP NOT DIAB ULCER BR 2483.95 G0463 HOSPITAL OUTPT CLINIC VISIT 122.48 172.32 G0465 AUTOLOG PRP DIAB WOUND ULCER 0.00

G0466 FQHC VISIT NEW PATIENT 128.65 G0467 FQHC VISIT, ESTAB PT 101.10 G0468 FQHC VISIT, IPPE OR AWV 132.76 G0469 FQHC VISIT, MH NEW PT 143.44 G0470 FQHC VISIT, MH ESTAB PT 105.21 G0471 VEN BLOOD COLL SNF/HHA 5.50 G0472 HEP C SCREEN HIGH RISK/OTHER 50.99 G0473 GROUP BEHAVE COUNS 2-10 15.20 38.11 G0475 HIV COMBINATION ASSAY 26.49 G0476 HPV COMBO ASSAY CA SCREEN 38.60 G0480 DRUG TEST DEF 1-7 CLASSES 196.74 G0481 DRUG TEST DEF 8-14 CLASSES 269.23 G0482 DRUG TEST DEF 15-21 CLASSES 341.70 G0483 DRUG TEST DEF 22+ CLASSES 424.54 G0490 HOME VISIT RN, LPN BY RHC/FQ 85.49

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR G0491 DIALYSIS ACU KIDNEY NO ESRD 138.21 G0492 MD/OTH EVAL ACUT KID NO ESRD BR G0493 RN CARE EA 15 MIN HH/HOSPICE 41.66 G0494 LPN CARE EA 15MIN HH/HOSPICE 8.25 G0495 RN CARE TRAIN/EDU IN HH 64.87 G0496 LPN CARE TRAIN/EDU IN HH 11.95 G0498 CHEMO EXTEND IV INFUS W/PUMP 176.99 462.41 G0499 HEPB SCREEN HIGH RISK INDIV 34.55 G0500 MOD SEDAT ENDO SERVICE >5YRS 68.63 G0501 RESOURCE-INTEN SVC DURING OV 2.44 ★ G0506 COMP ASSES CARE PLAN CCM SVC 74.39 ★ G0508 CRIT CARE TELEHEA CONSULT 60 249.89 ★ G0509 CRIT CARE TELEHEA CONSULT 50 229.33 G0511 CCM/BHI BY RHC/FQHC 20MIN MO 87.91 G0512 COCM BY RHC/FQHC 60 MIN MO 179.61 ★ G0513 PROLONG PREV SVCS, FIRST 30M 78.09 ★ G0514 PROLONG PREV SVCS, ADDL 30M 78.09 G0516 INSERT DRUG DEL IMPLANT, >=4 280.31 393.60 G0517 REMOVE DRUG IMPLANT 302.50 393.60 G0518 REMOVE W INSERT DRUG IMPLANT 528.54 393.60 G0519 NEW PT-CG DYAD DEM LOW CMPLX BR G0520 NEW PT-CG DYAD DEM MOD CMPLX BR G0521 NEW PT-CG DYAD DEM HIG CMPLX BR G0522 MGT NW PT DEMENTIA LOW CMPLX BR G0523 MGT NW PT DEM MOD-HIGH CMPLX BR G0524 EST PT-CG DYAD DEM LOW CMPLX BR G0525 EST PT-CG DYAD DEM MOD CMPLX BR G0526 EST PT-CG DYAD DEM HIG CMPLX BR G0527 MGT EST PT DMENTIA LOW CMPLX BR G0528 MGT EST PT DEM MOD-HI CMPLX BR G0529 IN HOME RESPITE CARE, 4 HR U BR G0530 ADULT DAYCARE CENTER, 8 HR U BR G0531 FCLTY-BASED RESPITE, 24 HR U BR G0532 TAKE HOME SUPP NASAL SPRAY BR G0533 BUPRENORPHONE INJ WEEKLY BR G0534 COORDINATED CARE/OR REFERRAL BR G0535 PT NAVIGAT SVS DIRECT/REF BR G0536 PEER RECOVER SUPPORT SVS BR G0537 RISK ASCVD TST ONCE PR 12 MO 23.23 42.30 G0538 ASCVD RSK MNG CLIN STF PR MO 19.15 131.35 ★ G0539 INITIAL CARE TRAINING 30 M 65.62 ★ G0540 TRAIN FOR CAREGIVER ADD 15 32.19 ★ G0541 NO PT PRSNT TRAIN INITIAL 30 65.62 ★ G0542 NO PT PRSNT TRAIN ADD 15 32.19 ★ G0543 GROUP TRAIN W/O PATIENT 27.72 G0544 POST D/C PHONE FOLLOW UP 77.84 131.35 G0545 INHERENT VISIT TO INPT 54.21 G0546 PHONE/INTERNET EHR ASSESS 21.60 G0547 PHONE/INTERNET SVS 11-20 M 43.61

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR G0548 PHONE/INTER SVS 21-30 M 66.02 G0549 PHONE/INTER FOR TREAT>31M 88.44 G0550 PHONE/INTER FOR DX/TREAT >5M 40.76 G0551 PHN/INTR SVS FR DX TREAT 30M 42.79 G0552 SUPPLY OF DIGITAL DEVICE BR 183.00 G0553 MONTHLY TX FOR DMHT 20MINS 65.21 183.00 G0554 ADD 20 M OF MONTHLY TX 50.14 G0555 REPLACMENT PT ELECTRONIC SYS BR 1444.69 G0556 ADV PRIM CARE MGMT LVL 1 19.15 42.30 G0557 ADV PRIM CARE MGMT LVL 2 61.54 42.30 G0558 ADV PRIM CARE MGMT LVL 3 134.91 131.35 G0559 UNRELAT PRAC FOLLOW UP VISIT 11.00 ★ G0560 SAFETY PLAN INTERVEN 52.16 G0561 TEMP TUBE DELIVERY, UNIL BR G0562 COMPLEX SIMULATION W/PET-CT BR 2769.71 G0563 SBRT W/POSITRON EMISSION DEL BR 5325.71 G0564 365 D IMPLANT GLUCOSE SENSOR BR 4615.71 G0565 REM/INS GLU SNSR 365 DIF SIT BR 4615.71 G0566 3D BN IMG ALGOR DRVD FR MRI BR G0659 DRUG TEST DEF SIMPLE ALL CL 106.84 G0913 IMPROVE VISUAL FUNCT BR G0914 SURVEY NOT COMPLETE BR G0915 NO IMPROVE VISUAL FUNCT BR G0916 SATISFY WITH CARE BR G0917 CARE SURVEY NOT COMPLETE BR G0918 NO SATISFY WITH CARE BR G1001 CDSM EVICORE BR G1002 CDSM MEDCURRENT BR G1003 CDSM MEDICALIS BR G1004 CDSM NDSC BR G1007 CDSM AIM BR G1008 CDSM CRANBERRY PK BR G1010 CDSM STANSON BR G1011 CDSM QUALIFIED NOS BR G1012 CDSM AGILEMD BR G1013 CDSM EVIDENCECARE BR G1014 CDSM INVENIQA BR G1015 CDSM RELIANT BR G1016 CDSM SPEED OF CARE BR G1017 CDSM HEALTHHELP BR G1018 CDSM INFINX BR G1019 CDSM LOGICNETS BR G1020 CDSM CURBSIDE BR G1021 CDSM EHEALTHLINE BR G1022 CDSM INTERMOUNTAIN BR G1023 CDSM PERSIVIA BR G1024 CDSM RADRITE BR G1025 PT MNTH 1 MCP PROV BR G1026 PT HEMO > 3MO BR

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR G1027 PT HEMO < 3MO BR G1028 TAKE HOME SUPPLY 8MG PER 0.1 BR G2000 BLINDED CONV. TX MDD CLIN TR BR 707.91 G2001 POST D/C H VST NEW PT 20 M 64.12 G2002 POST-D/C H VST NEW PT 30 M 91.25 G2003 POST-D/C H VST NEW PT 45 M 148.37 G2004 POST-D/C H VST NEW PT 60 M 213.72 G2005 POST-D/C H VST NEW PT 75 M 258.93 G2006 POST-D/C H VST EXT PT 20 M 64.94 G2007 POST-D/C H VST EXT PT 30 M 98.63 G2008 POST-D/C H VST EXT PT 45 M 152.07 G2009 POST-D/C H VST EXT PT 60 M 210.84 G2010 REMOT IMAGE SUBMIT BY PT 14.38 G2011 ALCOHOL/SUB MISUSE ASSESS 20.14 35.83 G2013 POST-D/C H VST EXT PT 75 M 258.93 G2014 POST-D/C CARE PLAN OVERS 30M 91.25 G2015 POST-D/C CARE PLAN OVERS 60M 127.83 G2020 HI INTEN SERV FOR SIP MODEL BR G2021 HEA CARE PRACT TX IN PLACE 26.71 G2022 BENEF REFUSES SERVICE, MOD BR G2025 DIS SITE TELE SVCS RHC/FQHC 115.49 G2067 MED ASSIST TX METH WK 120.83 G2068 MED ASSIST TX BUPRE ORAL 137.27 G2069 MED ASSIST TX INJECT BR G2073 MED TX NALTREXONE 111.67 G2074 MED ASSIST TX NO DRUG 127.00 G2075 MED TX MEDS NOS BR G2076 INTAKE ACT W/MED EXAM 96.18 G2077 PERIODIC ASSESSMENT 58.78 G2078 TAKE-HOME METH 19.73 G2079 TAKE-HOM BUPRENORPHINE 45.62 G2080 ADD 30 MINS COUNSEL 57.47 G2081 PT 66+ SNP OR LTC POS > 90D BR G2082 VISIT ESKETAMINE 56M OR LESS 956.40 923.71 G2083 VISIT ESKETAMINE, > 56M 1359.58 1349.71 ★ G2086 OFF BASE OPIOID TX 70MIN 472.65 194.04 ★ G2087 OFF BASE OPIOID TX, 60 M 411.41 194.04 ★ G2088 OFF BASE OPIOID TX, ADD30 73.57 G2090 PT 66+ FRAILTY AND MED DEM BR G2091 PT 66+ FRAILTY AND ADV ILL BR G2092 ACE ARB ARNI BR G2093 MED DOC RSN NO ACE ARN ARNI BR G2094 PT RSN NO ACE ARN ARNI BR G2096 NO RSN ACE ARB ARNI BR G2097 DX URI 3D AFTER OTHER DX BR G2098 PT 66+ FRAILTY AND MED DEM BR G2099 PT 66+ FRAILTY AND ADV ILL BR G2100 PT 66+ FRAILTY AND MED DEM BR G2101 PT 66+ FRAILTY AND ADV ILL BR

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR G2105 PT 66+ SNP OR LTC POS > 90D BR G2106 PT 66+ FRAILTY AND MED DEM BR G2107 PT 66+ FRAILTY AND ADV ILL BR G2112 PRED<=5 MG RA GLU <6M BR G2113 PRED>5 MG >6M, NO CHG DA BR G2115 PT 66-80 FRAILTY AND MED DEM BR G2116 PT 66-80 FRAILTY AND ADV ILL BR G2118 PT 81+ FRAILTY BR G2121 PSY DEP ANX AP AND ICD ASSE BR G2122 PSY/DEP/ANX/APANDICD NOASSE BR G2125 PT 81+ FRAILTY BR G2126 PT 66-80 FRAILTY AND ADV ILL BR G2127 PT 66-80 FRAILTY AND MED DEM BR G2128 NO ASPIRIN MED RSN BR G2129 NO BP OUTPT BR G2136 BK PAIN VAS 6-20WK <= 3 BR G2137 BK PAIN VAS 6-20WK > 3 BR G2138 BK PAIN VAS 9-15MO <= 3 BR G2139 BK PAIN VAS 9-15MO > 3 BR G2140 LEG PAIN VAS 6-20WK <= 3 BR G2141 LEG PAIN VAS 6-20WK > 3 BR G2142 FS ODI 9-15MO POSTOP<= 22 BR G2143 FS ODI 9-15MO > 22 BR G2144 FS ODI 6-20WK POSTOP <= 22 BR G2145 FSODI 6-20WK >22 OR CHG 30PT BR G2146 LEG PAIN VAS 9-15MO <= 3 BR G2147 LEG PAIN VAS 9-15MO > 3 BR G2148 MPM USED BR G2149 NO MPM MED RSN BR G2150 NO MPM BR G2151 DX DEGEN NEURO BR G2152 RES CHANGE SC >=0 BR G2167 RES CHANGE SC < 0 BR G2168 SVS BY PT IN HOME HEALTH See Home Health Rules

G2169 SVS BY OT IN HOME HEALTH See Home Health Rules

G2172 TX FOR OPIOID USE DEMO PROJ BR G2173 URI W COMORB 12M OTH DX BR G2174 URI NEW RX ANTIBIOTIC 30D BR G2175 PT COMORB DX 12M OF EPI BR G2176 OUTPT ED OBS W INPT ADMIT BR G2177 BRONCH W RX ANTIBX 30D BR G2178 PT NOT ELIG LOW NEURO EX BR G2179 MED DOC RSN NO LOW EX BR G2180 INELIG FOOTWR EVAL BR G2181 BMI NOT DOC MEDRSN PTREF BR G2182 PT 1ST BIOLOG ANTIRHEUM BR G2183 DOC PT UNABLE COMM BR G2184 NO CAREGIVER BR

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR G2185 CAREGIVER DEM TRAINED BR G2186 PT REF APP RSRCS BR G2187 CLIN IND IMG HD TRAUMA BR G2188 PT 50 YRS W/CLIN IND HD BR G2189 IMG HD ABNML NEURO EXAM BR G2190 IND IMG HD RAD NECK BR G2191 IND IMG HD POS HD ACHE BR G2192 >55 YRS TEMP HD ACHE BR G2193 <6YR NEW ONSET HD ACHE BR G2194 NEW HDACHE PED PT DIS BR G2195 OCCIP HDACHE CHILD BR G2196 SCREEN UNHLTHY ETOH USE BR G2197 SCREEN HLTHY ETOH USE BR G2199 NOT SCRN ETOH NO RSN BR G2200 UNHLTHY ETOH RCVD COUNS BR G2202 NO RSN NO BRIEF COUNS BR G2204 PT 45-85 W/ SCOPE BR G2205 PREG DRNG ADJV TRTMT BR G2206 ADJV TRTMT CHEMO HER2 BR G2207 RSN NO TRTMT CHEM HER2 BR G2208 NO TRTMT CHEMO AND HER2 BR G2209 REFUSED TO PARTICIPATE BR G2210 NO NECK FS PROM NO RSN BR ★ G2211 COMPLEX E/M VISIT ADD ON 30.00 ★ G2212 PROLONG OUTPT/OFFICE VIS 39.45 G2213 INITIAT MED ASSIST TX IN ER 82.20 G2214 INIT/SUB PSYCH CARE M 1ST 30 73.57 108.52 G2215 HOME SUPPLY NASAL NALOXONE 85.49 G2216 HOME SUPPLY INJECT NALOXON BR G2250 REMOT IMG SUB BY PT, NON E/M 14.38 G2251 BRIEF CHKIN, 5-10, NON-E/M 17.26 G2252 BRIEF CHKIN BY MD/QHP, 11-20 33.29 ★ G3002 CHRONIC PAIN MGMT 30 MINS 98.23 ★ G3003 CHRONIC PAIN MGMT ADDL 15M 35.75 G4000 DERMATOLOGY SS BR G4001 DIAGNOSTIC RAD SS BR G4002 EP CARDIO SS BR G4003 EMERGENCY MED SS BR G4004 ENDOCRINOLOGY SS BR G4005 FAMILY MEDICINE SS BR G4006 GASTROENTEROLOGY SS BR G4007 GENERAL SURGERY SS BR G4008 GERIATRICS SS BR G4009 HOSPITALISTS SS BR G4010 INFECTIOUS DISEASE SS BR G4011 INTERNAL MEDICINE SS BR G4012 INTERVENTIONAL RAD SS BR G4013 MNTAL/BEHAV/PSYCH HLTH SS BR G4014 NEPHROLOGY SS BR

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR G4015 NEUROLOGY SS BR G4016 NEUROSURGICAL SS BR G4017 NUTRITION/DIETICIAN SS BR G4018 OB/GYN SS BR G4019 ONCOLOGY/HEMA SS BR G4020 OPHTHALMOLOGY/OPTOMETRY SS BR G4021 ORTHOPEDIC SURGERY SS BR G4022 OTOLARYNGOLOGY SS BR G4023 PATHOLOGY SS BR G4024 PEDIATRICS SS BR G4025 PHYSICAL MEDICINE SS BR G4026 PHYS/OCC THERAPY SS BR G4027 PLASTIC SURGERY SS BR G4028 PODIATRY SS BR G4029 PREVENTIVE MEDICINE SS BR G4030 PULMONOLOGY SS BR G4031 RADIATION ONCOLOGY SS BR G4032 RHEUMATOLOGY SS BR G4033 SKILLED NURSING FACILITY SS BR G4034 SPEECH LANGUAGE PATH SS BR G4035 THORACIC SURGERY SS BR G4036 URGENT CARE SS BR G4037 UROLOGY SS BR G4038 VASCULAR SURGERY SS BR G6001 ECHO GUIDANCE RADIOTHERAPY 217.83 G6002 STEREOSCOPIC X-RAY GUIDANCE 89.19 G6003 RADIATION TREATMENT DELIVERY 178.79 G6004 RADIATION TREATMENT DELIVERY 160.70 G6005 RADIATION TREATMENT DELIVERY 160.70 G6006 RADIATION TREATMENT DELIVERY 160.70 G6007 RADIATION TREATMENT DELIVERY 295.91 G6008 RADIATION TREATMENT DELIVERY 221.12 G6009 RADIATION TREATMENT DELIVERY 220.71 G6010 RADIATION TREATMENT DELIVERY 219.48 G6011 RADIATION TREATMENT DELIVERY 293.04 G6012 RADIATION TREATMENT DELIVERY 292.64 G6013 RADIATION TREATMENT DELIVERY 293.46 G6014 RADIATION TREATMENT DELIVERY 291.81 G6015 RADIATION TX DELIVERY IMRT 445.52 G6016 DELIVERY COMP IMRT 443.88 G6017 INTRAFRACTION TRACK MOTION 130.29 J0120 TETRACYCLIN INJECTION 57.60 J0121 INJ., OMADACYCLINE, 1 MG 4.16 4.73 J0122 INJ., ERAVACYCLINE, 1 MG 1.28 J0129 ABATACEPT INJECTION 53.06 63.22 J0130 ABCIXIMAB INJECTION 1226.69 J0131 INJ, ACETAMINOPHEN (NOS) 3.59 J0132 ACETYLCYSTEINE INJECTION 2.07 J0133 ACYCLOVIR INJECTION 0.09

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR J0134 INJ ACETAMINOPHEN -FRESENIUS 0.17 J0136 INJ, ACETAMINOPHEN (B BRAUN) 0.06 J0137 INJ, ACETAMINOPHEN (HIKMA) 0.06 0.07 J0138 INJ ACETAMINOPH 10MG/IBU 3MG BR J0139 INJ, ADALIMUMAB, 1 MG BR 130.26 J0153 ADENOSINE INJ 1MG 1.16 J0171 ADRENALIN EPINEPHRINE INJECT 0.17 J0172 INJ, ADUCANUMAB-AVWA, 2 MG 7.18 16.86 J0173 INJ, EPINEPHRINE (BELCHER) 2.86 J0174 INJ, LECANEMAB-IRMB, 1 MG 1.62 1.92 J0175 INJ, DONANEMAB-AZBT, 2 MG 4.91 5.81 J0177 INJ, AFLIBERCEPT HD, 1 MG 394.87 467.27 J0178 AFLIBERCEPT INJECTION 1184.37 1300.37 J0179 INJ, BROLUCIZUMAB-DBLL, 1 MG 374.35 442.94 J0180 AGALSIDASE BETA INJECTION 220.14 282.23 J0184 INJ, AMISULPRIDE, 1 MG 18.40 12.89 J0185 INJ., APREPITANT, 1 MG 2.06 2.44 J0190 INJ BIPERIDEN LACTATE/5 MG BR J0200 ALATROFLOXACIN MESYLATE BR J0202 INJECTION, ALEMTUZUMAB 2422.35 3023.39 J0205 ALGLUCERASE INJECTION 39.70 J0206 INJ ALLOPURINOL SODIUM 1 MG 6.66 7.88 J0207 AMIFOSTINE 483.90 1612.68 J0208 INJ, PEDMARK, 100 MG 259.60 136.59 J0209 INJ, SOD THIOSULFATE (HOPE) 2.40 J0210 METHYLDOPATE HCL INJECTION 50.37 J0211 INJ, NITHIODOTE, 3MG / 125MG BR 3.08 J0215 ALEFACEPT 33.30 J0216 INJ, ALFENTANIL HCL, 500MCG BR J0217 INJ VELMANASE ALFA-TYCV 1 MG 528.97 602.08 J0218 INJ OLIPUDASE ALFA-RPCP 1MG 452.36 535.30 J0219 INJ AVAL ALFA-NQPT 4MG 87.22

J0220 ALGLUCOSIDASE ALFA INJECTION 264.70 166.24 J0221 LUMIZYME INJECTION 213.37 257.62 J0222 INJ., PATISIRAN, 0.1 MG 118.76 138.85 J0223 INJ GIVOSIRAN 0.5 MG 129.55 151.47 J0224 INJ. LUMASIRAN, 0.5 MG 381.61 429.22 J0225 INJ, VUTRISIRAN, 1 MG 5901.30 6779.15 J0248 INJ, REMDESIVIR, 1 MG 6.61 7.82 J0256 ALPHA 1 PROTEINASE INHIBITOR 5.55 6.46 J0257 GLASSIA INJECTION 5.93 7.07 J0270 ALPROSTADIL FOR INJECTION 10.59 J0275 ALPROSTADIL URETHRAL SUPPOS BR J0278 AMIKACIN SULFATE INJECTION 1.40 J0280 AMINOPHYLLIN 250 MG INJ 12.33 J0281 INJ AMINOCAPROIC ACID 1 GRAM BR J0282 AMIODARONE HCL 8.50 J0283 INJ, AMIODARONE (NEXTERONE) 3.02 J0285 AMPHOTERICIN B 27.12

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR J0287 AMPHOTERICIN B LIPID COMPLEX 15.73 13.63 J0288 AMPHO B CHOLESTERYL SULFATE 47.69 J0289 AMPHOTERICIN B LIPOSOME INJ 25.25 41.85 J0290 AMPICILLIN 500 MG INJ 1.72 J0291 INJ., PLAZOMICIN, 5 MG 3.76 4.40 J0295 AMPICILLIN SULBACTAM 1.5 GM 2.75 J0300 AMOBARBITAL 125 MG INJ 14.94 177.81 J0330 SUCCINYCHOLINE CHLORIDE INJ 18.79 J0348 ANIDULAFUNGIN INJECTION 0.70 J0349 INJ, REZAFUNGIN, 1 MG 12.50 14.26 J0350 INJECTION ANISTREPLASE 30 U BR J0360 HYDRALAZINE HCL INJECTION 12.68 J0364 APOMORPHINE HYDROCHLORIDE 3.84 J0365 APROTONIN, 10,000 KIU 33.21 J0380 INJ METARAMINOL BITARTRATE 1.28 J0390 CHLOROQUINE INJECTION BR 234.61 J0391 INJ, ARTESUNATE, 1MG BR 67.62 J0395 ARBUTAMINE HCL INJECTION 150.00 J0400 ARIPIPRAZOLE INJECTION 2.12 J0401 INJ, ABILIFY MAINTENA, 1 MG 5.90 8.51 J0402 INJ, ABILIFY ASIMTUFII, 1 MG 7.06 8.35 J0456 AZITHROMYCIN 4.30 J0457 INJECTION, AZTREONAM, 100 MG 3.05 3.61 J0461 ATROPINE SULFATE INJECTION 0.07 J0470 DIMECAPROL INJECTION 53.77 J0475 BACLOFEN 10 MG INJECTION 218.42 257.83 J0476 BACLOFEN INTRATHECAL TRIAL 92.28 J0480 BASILIXIMAB 4178.39 5733.46 J0485 BELATACEPT INJECTION 4.59 5.38 J0490 BELIMUMAB INJECTION 57.59 68.49 J0491 INJ ANIFROLUMAB-FNIA 1MG 19.42

J0500 DICYCLOMINE INJECTION 69.76 J0515 INJ BENZTROPINE MESYLATE 24.55 J0517 INJ., BENRALIZUMAB, 1 MG 202.63 237.76 J0520 BETHANECHOL CHLORIDE INJECT BR J0558 PENG BENZATHINE/PROCAINE INJ 9.15 16.73 J0561 PENICILLIN G BENZATHINE INJ 11.57 21.36 J0565 INJ, BEZLOTOXUMAB, 10 MG 47.84 56.50 J0567 INJ., CERLIPONASE ALFA 1 MG 28123.20 140.94 J0571 BUPRENORPHINE ORAL 1MG 0.62 J0572 BUPREN/NAL UP TO 3MG BUPRENO 10.00 J0573 BUPREN/NAL 3.1 TO 6MG BUPREN 12.40 J0574 BUPREN/NAL 6.1 TO 10MG BUPRE 29.20 J0575 BUPREN/NAL OVER 10MG BUPRENO 21.20 J0577 INJ, BRIXADI, 7 DAYS OR LESS 514.39 608.70 J0578 INJ BRIXADI, MORE THAN 7 DAY 2057.56 2434.77 J0583 BIVALIRUDIN 3.63 J0584 INJECTION, BUROSUMAB-TWZA 1M 481.80 539.81 J0585 INJECTION,ONABOTULINUMTOXINA 7.45 8.79

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR J0586 ABOBOTULINUMTOXINA 10.22 11.80 J0587 INJ, RIMABOTULINUMTOXINB 14.60 17.21 J0588 INCOBOTULINUMTOXIN A 6.07 7.19 J0589 INJ DAXIBOTULINUMTOXINA-LANM 8.40 4.44 J0591 INJ DEOXYCHOLIC ACID, 1 MG BR J0592 BUPRENORPHINE HYDROCHLORIDE 4.15 J0593 INJ., LANADELUMAB-FLYO, 1 MG 246.40 J0594 BUSULFAN INJECTION 40.07 2.06 J0595 BUTORPHANOL TARTRATE 1 MG 3.32 J0596 INJECTION, RUCONEST 37.92 42.63 J0597 C-1 ESTERASE, BERINERT 64.35 81.51 J0598 C-1 ESTERASE, CINRYZE 72.80 83.72 J0599 INJ., HAEGARDA 10 UNITS 3517.20 14.56 J0600 EDETATE CALCIUM DISODIUM INJ 6850.31 8106.20 J0601 SEVELAMER CARBONATE 20 MG BR J0602 SEVELAMER CARBONATE PDR 20MG BR J0603 SEVELAMER HYDROCHLORIDE 20MG BR J0604 CINACALCET, ESRD ON DIALYSIS 3.91 J0605 SUCROFERRIC OXYHYDROXIDE 5MG BR J0606 INJ, ETELCALCETIDE, 0.1 MG 12.70 4.34 J0607 LANTHANUM CARBONATE ORAL 5MG BR J0608 LANTHANUM CARBONATE PWDR 5MG BR J0609 FERRIC CITRATE ORL 3 MG IRON BR J0612 INJ, CALCIUM GLUCONATE, NOS 0.06 0.07 J0613 CALCIUM GLUCON (WG CRITICAL) 0.11 0.13 J0615 CALCIUM ACETATE, ORAL, 23 MG BR J0620 CALCIUM GLYCER & LACT/10 ML 9.21 J0630 CALCITONIN SALMON INJECTION 2677.67 4035.06 J0636 INJ CALCITRIOL PER 0.1 MCG 0.48 J0637 CASPOFUNGIN ACETATE 15.63 15.09 J0638 CANAKINUMAB INJECTION 127.96 164.56 J0640 LEUCOVORIN CALCIUM INJECTION 5.24 J0641 INJ LEVOLEUCOVORIN NOS 0.5MG 1.95 0.18 J0642 INJECTION, KHAPZORY, 0.5 MG 1.75 2.60 J0650 INJ, LEVOTHYROXINE NOS 10MCG 6.47 J0651 INJ, LEVOTHYROXINE, FRESKABI 4.58 5.42 J0652 INJ, LEVOTHYROXINE, HIKMA 6.17 7.30 J0665 INJ, BUPIVACAINE, NOS, 0.5MG 0.01 0.01 J0666 INJ, BUPIVACAINE LIPOSOME 1.74 2.06 J0670 INJ MEPIVACAINE HCL/10 ML 2.74 J0687 INJ CEFAZOLIN (WG CRIT CARE) 1.33 1.58 J0688 INJ CEFAZOLIN SODIUM, HIKMA 1.25 1.42 J0689 INJ CEFAZOLIN SODIUM, BAXTER 1.39 J0690 CEFAZOLIN SODIUM INJECTION 1.08 J0691 INJ LEFAMULIN 1 MG 0.86 1.02 J0692 CEFEPIME HCL FOR INJECTION 3.03 J0694 CEFOXITIN SODIUM INJECTION 5.91 J0695 INJ CEFTOLOZANE TAZOBACTAM 7.68 9.43 J0696 CEFTRIAXONE SODIUM INJECTION 0.94

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR J0697 STERILE CEFUROXIME INJECTION 2.92 J0698 CEFOTAXIME SODIUM INJECTION 28.80 J0699 INJ, CEFIDEROCOL, 10 MG 2.74 2.85 J0701 INJ. CEFEPIME HCL (BAXTER) 6.52 J0702 BETAMETHASONE ACET&SOD PHOSP 7.86 J0703 INJ, CEFEPIME HCL (B BRAUN) 6.07 J0706 CAFFEINE CITRATE INJECTION 1.74 J0710 CEPHAPIRIN SODIUM INJECTION BR J0712 CEFTAROLINE FOSAMIL INJ 3.15 5.07 J0713 INJ CEFTAZIDIME PER 500 MG 2.90 J0714 CEFTAZIDIME AND AVIBACTAM 110.15 131.17 J0715 CEFTIZOXIME SODIUM / 500 MG 16.79 J0716 CENTRUROIDES IMMUNE F(AB) 5591.60 7370.01 J0717 CERTOLIZUMAB PEGOL INJ 1MG 7.81 8.92 J0720 CHLORAMPHENICOL SODIUM INJEC 42.11 J0725 CHORIONIC GONADOTROPIN/1000U 28.07 34.02 J0735 CLONIDINE HYDROCHLORIDE 16.03 J0736 INJ, CLINDAMYCIN PHOSP 300MG 2.28 2.70 J0737 INJ, CLINDAMYCIN (BAXTER) 2.10 2.49 J0739 HIV PREP, INJ, CABOTEGRAVIR 8.27

J0740 CIDOFOVIR INJECTION 699.61 806.45 J0741 INJ, CABOTE RILPIVIR 2MG 3MG 25.26 29.20 J0742 INJ IMIP 4 CILAS 4 RELEB 2MG 2.86 3.28 J0743 CILASTATIN SODIUM INJECTION 6.31 J0744 CIPROFLOXACIN IV 1.32 J0745 INJ CODEINE PHOSPHATE /30 MG 1.28 192.61 J0750 HIV PREP, FTC/TDF 200/300MG 2.18 2.58 J0751 HIV PREP, FTC/TAF 200/25MG 85.55 101.23 J0770 COLISTIMETHATE SODIUM INJ 14.44 J0775 COLLAGENASE, CLOST HIST INJ 53.42 80.37 J0780 PROCHLORPERAZINE INJECTION 15.81 J0791 INJ CRIZANLIZUMAB-TMCA 5MG 150.07 176.25 J0795 CORTICORELIN OVINE TRIFLUTAL 9.89 13.73 J0799 HIV PREP, FDA APPROVED, NOC BR J0801 INJ. ACTHAR GEL TO 40 UNITS 4914.38 5815.35 J0802 INJ. (ANI), UP TO 40 UNITS 4138.90 4755.57 J0834 INJ., COSYNTROPIN, 0.25 MG 53.74 J0840 CROTALIDAE POLY IMMUNE FAB 3126.47 3744.10 J0841 INJ CROTALIDAE IM F(AB')2 EQ 1286.65 1451.88 J0850 CYTOMEGALOVIRUS IMM IV /VIAL 1479.07 2166.15 J0870 INJECTION, IMETELSTAT, 1 MG BR 78.77 J0872 DAPTOMYCIN (XELLIA) UNREFRIG 0.05 0.06 J0873 INJ DAPTOMYCIN (XELLIA) 0.06 0.06 J0874 INJ, DAPTOMYCIN (BAXTER) 0.08 J0875 INJECTION, DALBAVANCIN 17.89 22.56 J0877 INJ, DAPTOMYCIN (HOSPIRA) 0.08 J0878 DAPTOMYCIN INJECTION 0.97 0.63 J0879 DIFELIKEFALIN, ESRD ON DIALY BR

J0881 DARBEPOETIN ALFA, NON-ESRD 5.01 4.39

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR J0882 DARBEPOETIN ALFA, ESRD USE 5.01 4.39 J0883 ARGATROBAN NONESRD USE 1MG BR 1.76 J0884 ARGATROBAN ESRD DIALYSIS 1MG 0.9 1.76 J0885 EPOETIN ALFA, NON-ESRD 14.90 11.67 J0887 EPOETIN BETA ESRD USE 1.94 J0888 EPOETIN BETA NON ESRD 1.94 2.14 J0889 DAPRODUSTAT ORAL 1MG ESRD BR J0890 PEGINESATIDE INJECTION 50.40 J0891 ARGATROBAN NONESRD (ACCORD) 0.68 0.81 J0892 ARGATROBAN DIALYSIS (ACCORD) 0.68 0.81 J0893 INJ, DECITABINE (SUN PHARMA) 1.90 J0894 DECITABINE INJECTION 26.30 4.09 J0895 DEFEROXAMINE MESYLATE INJ 18.13 J0896 INJ LUSPATERCEPT-AAMT 0.25MG 45.53 53.11 J0897 DENOSUMAB INJECTION 21.52 30.12 J0898 ARGATROBAN NONESRD (AUROMED) 2.63 2.98 J0899 ARGATROBAN DIALYSIS, AUROMED 2.63 2.98 J0901 VADADUSTAT ORAL 1MG FOR ESRD BR J0911 INST TAURO 1.35MG/HEP 100U BR 12.30 J0945 BROMPHENIRAMINE MALEATE INJ 4.61 J1000 DEPO-ESTRADIOL CYPIONATE INJ 19.17 J1010 INJ, METHYLPRED ACETATE 1 MG 0.14 0.17 J1050 MEDROXYPROGESTERONE ACETATE 0.49 J1071 INJ TESTOSTERONE CYPIONATE 0.04 J1072 INJ, TESTOSTERONE, AZMIRO BR J1094 INJ DEXAMETHASONE ACETATE 1.84 J1095 INJECTION, DEXAMETHASONE 9% 2.40 1.36 J1096 DEXAMETHA OPTH INSERT 0.1 MG 250.39 190.56 J1097 PHENYLEP KETOROLAC OPTH SOLN 141.60

J1100 DEXAMETHASONE SODIUM PHOS 0.17 J1105 DEXMEDETOMIDINE FILM, 1 MCG BR 1.02 J1110 INJ DIHYDROERGOTAMINE MESYLT 92.70 J1120 ACETAZOLAMID SODIUM INJECTIO 25.88 J1130 INJ DICLOFENAC SODIUM 0.5MG 0.08 J1160 DIGOXIN INJECTION 6.36 J1162 DIGOXIN IMMUNE FAB (OVINE) 3671.01 5862.03 J1165 PHENYTOIN SODIUM INJECTION 0.80 J1171 INJ, HYDROMORPHONE, 0.1 MG 0.11 0.13 J1180 DYPHYLLINE INJECTION BR J1190 DEXRAZOXANE HCL INJECTION 202.54 269.57 J1200 DIPHENHYDRAMINE HCL INJECTIO 0.68 J1201 INJ. CETIRIZINE HCL 0.5MG 18.11 21.71 J1202 MIGLUSTAT ORAL 65 MG BR J1203 INJ, CIPAGLUCOSIDASE, 5 MG 107.26 126.92 J1205 CHLOROTHIAZIDE SODIUM INJ 139.93 J1212 DIMETHYL SULFOXIDE 50% 50 ML 302.19 903.92 J1230 METHADONE INJECTION 14.25 J1240 DIMENHYDRINATE INJECTION 8.36 J1245 DIPYRIDAMOLE INJECTION 1.14

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR J1250 INJ DOBUTAMINE HCL/250 MG 7.62 J1260 DOLASETRON MESYLATE 21.21 J1265 DOPAMINE INJECTION 0.73 J1267 DORIPENEM INJECTION 1.03 J1270 INJECTION, DOXERCALCIFEROL 1.12 J1271 INJ DOXYCYCLINE HYCLATE 1 MG BR J1290 ECALLANTIDE INJECTION 562.15 715.86 J1299 INJ, ECULIZUMAB, 2 MG BR J1300 ECULIZUMAB INJECTION 273.62 325.09 J1301 INJECTION, EDARAVONE, 1 MG 25.19 29.10 J1302 INJ, SUTIMLIMAB-JOME, 10 MG 21.76

J1303 INJ., RAVULIZUMAB-CWVZ 10 MG 268.91 318.97 J1304 INJ TOFERSEN INTRATHEC 1 MG 181.01 214.19 J1305 INJ, EVINACUMAB-DGNB, 5MG 223.57 235.19 J1306 INJECTION, INCLISIRAN, 1 MG 14.74

J1307 INJ, CROVALIMAB-AKKZ, 10 MG BR 760.98 J1308 INJ, FAMOTIDINE, 0.25 MG BR J1320 AMITRIPTYLINE INJECTION 0.34 J1322 ELOSULFASE ALFA, INJECTION 314.77 355.43 J1323 INJ, ELRANATAMAB-BCMM, 1 MG 213.18 252.26 J1324 ENFUVIRTIDE INJECTION 390.81 J1325 EPOPROSTENOL INJECTION 18.92 J1327 EPTIFIBATIDE INJECTION 26.90 3.00 J1330 ERGONOVINE MALEATE INJECTION BR J1335 ERTAPENEM INJECTION 50.29 J1364 ERYTHRO LACTOBIONATE /500 MG 67.23 118.73 J1380 ESTRADIOL VALERATE 10 MG INJ 12.41 J1410 INJ ESTROGEN CONJUGATE 25 MG 317.23 484.93 J1411 INJ, HEMGENIX, PER TX DOSE BR 5268200.00 J1412 INJ ROCTAVIAN ML 2X10^13VC G 8673.61 17051.09 J1413 INJ DELANDISTROGENE MOX ROKL BR 4680320.00 J1414 INJ, BEQVEZ, PER TX DOSE BR 5268200.00 J1426 INJECTION, CASIMERSEN, 10 MG 149.61 236.42 J1427 INJ. VILTOLARSEN 127.61 83.71 J1428 INJ, ETEPLIRSEN, 10 MG 176.93 252.92 J1429 INJ GOLODIRSEN 10 MG 347.60 235.99 J1430 ETHANOLAMINE OLEATE 100 MG 545.00 630.62 J1434 INJ, FOCINVEZ, 1MG 7.61 4.43 J1435 INJECTION ESTRONE PER 1 MG 0.42 J1436 ETIDRONATE DISODIUM INJ BR J1437 INJ. FE DERISOMALTOSE 10 MG 27.64 34.65 J1438 ETANERCEPT INJECTION 6140.60 1122.91 J1439 INJ FERRIC CARBOXYMALTOS 1MG 1.33 1.59 J1440 FECAL MICROBIOTA JSLM 1 ML 75.58 89.43 J1442 INJ FILGRASTIM EXCL BIOSIMIL 1.22 1.39 J1443 INJ FERRIC PYROPHOSPHATE CIT BR J1444 FE PYRO CIT POW 0.1 MG IRON BR J1445 INJ TRIFERIC AVNU 0.1MG IRON BR J1447 INJ TBO FILGRASTIM 1 MICROG 0.93 0.64

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR J1448 INJECTION, TRILACICLIB, 1MG 5.93 7.03 J1449 INJ EFLAPEGRASTIM-XNST 0.1MG 35.62 42.15 J1450 FLUCONAZOLE 5.83 J1451 FOMEPIZOLE, 15 MG 8.97 7.64 J1452 INTRAOCULAR FOMIVIRSEN NA 5.20 J1453 FOSAPREPITANT INJECTION 2.08 3.17 J1454 INJ FOSNETUPITANT, PALONOSET 559.28 715.65 J1455 FOSCARNET SODIUM INJECTION 95.42 101.80 J1456 INJ, FOSAPREPITANT (TEVA) 0.53 0.62 J1457 GALLIUM NITRATE INJECTION 1.71 J1458 GALSULFASE INJECTION 506.18 584.91 J1459 INJ IVIG PRIVIGEN 500 MG 53.14 63.91 J1460 GAMMA GLOBULIN 1 CC INJ 46.46 64.50 J1551 INJ CUTAQUIG 100 MG 14.44 J1552 INJ, ALYGLO, 500 MG 176.27 208.58 J1554 INJ. ASCENIV 578.12 684.11 J1555 INJ CUVITRU, 100 MG 17.96 20.95 J1556 INJ, IMM GLOB BIVIGAM, 500MG 53.98 100.10 J1557 GAMMAPLEX INJECTION 51.83 72.14 J1558 INJ. XEMBIFY, 100 MG 16.28 18.89 J1559 HIZENTRA INJECTION 11.76 16.74 J1560 GAMMA GLOBULIN > 10 CC INJ 464.67 644.95 J1561 GAMUNEX-C/GAMMAKED 52.07 66.04 J1562 VIVAGLOBIN, INJ 12.96 J1566 IMMUNE GLOBULIN, POWDER 48.47 98.82 J1568 OCTAGAM INJECTION 51.27 59.09 J1569 GAMMAGARD LIQUID INJECTION 52.95 66.27 J1570 GANCICLOVIR SODIUM INJECTION 79.94 J1571 HEPAGAM B IM INJECTION 77.52 104.51 J1572 FLEBOGAMMA INJECTION 48.62 50.96 J1573 HEPAGAM B INTRAVENOUS, INJ 75.60 104.51 J1574 INJ, GANCICLOVIR (EXELA) BR J1575 HYQVIA 100MG IMMUNEGLOBULIN 15.05 21.90 J1576 INJ, PANZYGA, 500 MG 79.73 94.34 J1580 GARAMYCIN GENTAMICIN INJ 1.75 J1595 INJECTION GLATIRAMER ACETATE 289.87 200.28 J1596 INJ, GLYCOPYRROLATE, 0.1 MG 0.74 0.82 J1597 INJ GLYCOPYRROLATE, GLYRX-PF BR J1598 INJ GLYCOPYRROLATE FRES KABI 2.42 2.87 J1599 IVIG NON-LYOPHILIZED, NOS 249.20 J1600 GOLD SODIUM THIOMALEATE INJ 39.08 J1602 GOLIMUMAB FOR IV USE 1MG 29.42 22.86 J1610 GLUCAGON HYDROCHLORIDE/1 MG 239.11 236.81 J1611 INJ GLUCAGON HCL, FRESENIUS 194.41 230.05 J1620 GONADORELIN HYDROCH/ 100 MCG 41.60 J1626 GRANISETRON HCL INJECTION 0.52 J1627 INJ, GRANISETRON, XR, 0.1 MG 7.74 9.53 J1628 INJ., GUSELKUMAB, 1 MG 228.01 112.86 J1630 HALOPERIDOL INJECTION 1.84

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR J1631 HALOPERIDOL DECANOATE INJ 24.50 J1632 INJ., BREXANOLONE, 1 MG 83.20 103.60 J1640 HEMIN, 1 MG 30.23 37.81 J1642 INJ HEPARIN SODIUM PER 10 U 0.22 J1643 INJ HEPARIN, PFIZER, 1000U 4.22 J1644 INJ HEPARIN SODIUM PER 1000U 0.29 J1645 DALTEPARIN SODIUM 18.84 J1650 INJ ENOXAPARIN SODIUM 1.38 J1652 FONDAPARINUX SODIUM 3.06 J1655 TINZAPARIN SODIUM INJECTION 4.70 J1670 TETANUS IMMUNE GLOBULIN INJ 559.57 684.55 J1675 HISTRELIN ACETATE 1.28 J1700 HYDROCORTISONE ACETATE INJ 12.40 J1710 HYDROCORTISONE SODIUM PH INJ 8.40 J1720 HYDROCORTISONE SODIUM SUCC I 10.42 J1726 MAKENA, 10 MG 40.00 20.96 J1729 INJ HYDROXYPROGST CAPOAT NOS 1.90 30.59 J1730 DIAZOXIDE INJECTION 129.76 J1738 INJ. MELOXICAM 1 MG 6.80 4.35 J1740 IBANDRONATE SODIUM INJECTION 130.88 83.46 J1741 IBUPROFEN INJECTION 4.40 J1742 IBUTILIDE FUMARATE INJECTION 120.70 449.00 J1743 IDURSULFASE INJECTION 651.38 817.31 J1744 ICATIBANT INJECTION 530.40 284.67 J1745 INFLIXIMAB NOT BIOSIMIL 10MG 96.52 53.79 J1746 INJ., IBALIZUMAB-UIYK, 10 MG 83.71 94.08 J1747 INJ, SPESOLIMAB-SBZO, 1 MG 72.26 85.51 J1748 INJ, ZYMFENTRA, 10 MG 313.48 J1749 INJ, ILOPROST, 0.1 MCG BR J1750 INJ IRON DEXTRAN 16.94 22.48 J1756 IRON SUCROSE INJECTION 0.32 J1786 IMUGLUCERASE INJECTION 52.98 62.44 J1790 DROPERIDOL INJECTION 8.48 J1800 PROPRANOLOL INJECTION 3.70 J1805 INJ, ESMOLOL HCL, 10MG 0.31 0.37 J1806 INJ ESMOLOL HCL WG CRIT CARE 0.54 0.64 J1808 INJ, FOLIC ACID, 0.1 MG BR J1810 DROPERIDOL/FENTANYL INJ 25.20 J1811 FIASP FOR INSULIN PUMP USE 8.16 9.66 J1812 INJ. INSULIN (FIASP) BR J1813 LYUMJEV FOR INSULIN PUMP USE 18.68 22.11 J1814 INJ. INSULIN (LYUMJEV) BR J1815 INSULIN INJECTION 1.10 J1817 INSULIN FOR INSULIN PUMP USE 10.10 J1823 INJ. INEBILIZUMAB-CDON, 1 MG 555.44 656.92 J1826 INTERFERON BETA-1A INJ 1998.70 3257.27 J1830 INTERFERON BETA-1B / .25 MG 349.20 565.16 J1833 INJECTION, ISAVUCONAZONIUM 0.80 1.18 J1835 ITRACONAZOLE INJECTION 23.38

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR J1836 INJ, METRONIDAZOLE, 10 MG 0.02 0.03 J1885 KETOROLAC TROMETHAMINE INJ 0.84

J1890 CEPHALOTHIN SODIUM INJECTION 8.80 J1920 INJ, LABETALOL HCL, 5MG 0.23 0.27 J1921 INJ LABETALOL HCL HIKMA, 5MG 3.07 3.64 J1930 LANREOTIDE INJECTION 66.91 93.98 J1931 LARONIDASE INJECTION 40.89 49.39 J1932 INJ, LANREOTIDE, (CIPLA) 1MG 36.82

J1938 INJ, FUROSEMIDE, 1 MG BR J1939 INJ, BUMETANIDE, 0.5 MG 0.80 0.82 J1940 FUROSEMIDE INJECTION 3.49 J1941 INJ, FUROSCIX, 20 MG 5.21 J1943 INJ., ARISTADA INITIO, 1 MG 3.53 4.26 J1944 ARIPIPRAZOLE LAUROXIL 1 MG 3.50 4.19 J1945 LEPIRUDIN 191.66 J1950 LEUPROLIDE ACETATE /3.75 MG 1290.42 1939.73 J1951 INJ FENSOLVI 0.25 MG 160.15 180.41 J1952 LEUPROLIDE INJ, CAMCEVI, 1MG 67.09

J1953 LEVETIRACETAM INJECTION 0.24 J1954 LEUPROLIDE DEPOT CIPLA 7.5MG 282.34 334.10 J1955 INJ LEVOCARNITINE PER 1 GM 24.22 J1956 LEVOFLOXACIN INJECTION 2.89 J1960 LEVORPHANOL TARTRATE INJ 3.84 J1961 INJ, LENACAPAVIR, 1 MG 26.32 31.14 J1980 HYOSCYAMINE SULFATE INJ 33.87 J1990 CHLORDIAZEPOXIDE INJECTION 26.46 J2002 INJ, LIDOCAINE IN D5W, 1 MG BR 0.00 J2003 INJ, LIDOCAINE HCL, 1 MG 0.69 J2004 INJ, LIDOCAINE W EPINEPHRINE 0.10 J2010 LINCOMYCIN INJECTION 13.54 J2020 LINEZOLID INJECTION 28.64 J2021 INJ, LINEZOLID (HOSPIRA) 19.72 J2060 LORAZEPAM INJECTION 0.92 J2062 LOXAPINE FOR INHALATION 1 MG BR 22.15 J2150 MANNITOL INJECTION 2.23 J2170 MECASERMIN INJECTION 8.97 J2175 MEPERIDINE HYDROCHL /100 MG 6.29 J2180 MEPERIDINE/PROMETHAZINE INJ 71.89 J2182 INJECTION, MEPOLIZUMAB, 1MG 34.93 40.74 J2183 INJ MEROPENEM (WG CRIT CARE) 1.98 2.34 J2184 INJ, MEROPENEM (B. BRAUN) 2.56 J2185 MEROPENEM 1.59 J2186 INJ., MEROPENEM, VABORBACTAM 14.80 2.61 J2210 METHYLERGONOVIN MALEATE INJ 6.83 J2212 METHYLNALTREXONE INJECTION 6.00 J2246 INJ, MICAFUNGIN (BAXTER) BR J2247 INJ, MICAFUNGIN (PAR PHARM) 0.58 J2248 MICAFUNGIN SODIUM INJECTION 1.17 J2249 INJ, REMIMAZOLAM, 1 MG 2.80

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR J2250 INJ MIDAZOLAM HYDROCHLORIDE 0.18 J2251 INJ MIDAZOLAM IN 0.9% NACL 0.37 J2252 INJ MIDAZOLAM IN 0.8% NACL BR J2253 INJ MIDAZOLAM (SEIZALAM) BR J2260 INJ MILRINONE LACTATE / 5 MG 4.03 J2265 MINOCYCLINE HYDROCHLORIDE 3.59 3.04 J2267 INJ, MIRIKIZUMAB-MRKZ, 1 MG 54.47 64.45 J2270 MORPHINE SULFATE INJECTION 1.69 J2272 INJ, MORPHINE (FRESENIUS) 8.94 J2274 INJ MORPHINE PF EPID ITHC 11.90 J2277 INJ, MOTIXAFORTIDE, 0.25 MG 30.26 35.81 J2278 ZICONOTIDE INJECTION 9.97 12.85 J2280 INJ, MOXIFLOXACIN 100 MG 11.60 J2281 INJ MOXIFLOXACIN (FRES KABI) 11.68 J2290 INJ, NAFCILLIN SODIUM, 20 MG BR J2300 INJ NALBUPHINE HYDROCHLORIDE 3.30 J2305 INJ, NITROGLYCERIN, 5 MG 1.55 1.83 J2310 INJ NALOXONE HYDROCHLORIDE 33.81 J2311 INJ, NALOXONE HCL (ZIMHI) 1.80 J2315 NALTREXONE, DEPOT FORM 4.25 5.00 J2320 NANDROLONE DECANOATE 50 MG 55.30 32.65 J2323 NATALIZUMAB INJECTION 23.63 33.02 J2325 NESIRITIDE INJECTION 41.68 112.61 J2326 INJ, NUSINERSEN, 0.1MG 1152.03 1593.62 J2327 INJ RISANKIZUMAB-RZAA 1 MG 18.97 22.45 J2329 INJ UBLITUXIMAB-XIIY, 1 MG 81.19 96.08 J2350 INJECTION, OCRELIZUMAB, 1 MG 72.59 83.65 J2351 INJ OCRELIZUMAB 1MG HYA-OCSQ BR J2353 OCTREOTIDE INJECTION, DEPOT 220.47 293.32 J2354 OCTREOTIDE INJ, NON-DEPOT 1.48 J2355 OPRELVEKIN INJECTION 562.25 246.85 J2356 INJ TEZEPELUMAB-EKKO, 1MG 21.79

J2357 OMALIZUMAB INJECTION 41.63 53.26 J2358 OLANZAPINE LONG-ACTING INJ 3.52 4.15 J2359 INJ. OLANZAPINE, 0.5MG 1.14 1.35 J2360 ORPHENADRINE INJECTION 6.89 J2371 INJ PHENYLEPHRINE HCL 20 MCG 0.79 J2372 INJ, BIORPHEN, 20 MICROGRAMS 0.22 0.26 J2373 INJ, IMMPHENTIV, 20 MCG 0.17 0.20 J2401 CHLOROPROCAINE HCL INJECTION 0.05 J2402 CHLOROPROCAINE (CLOROTEKAL) 0.69 J2403 CHLOROPROCAINE OPHT GEL, 1MG 0.79 1.01 J2404 INJ, NICARDIPINE 0.1 MG 0.10 J2405 ONDANSETRON HCL INJECTION 0.12 J2406 INJECTION, ORITAVANCIN 10 MG 50.72 59.53 J2407 INJECTION, ORITAVANCIN 30.94 34.65 J2410 OXYMORPHONE HCL INJECTION 3.64 J2425 PALIFERMIN INJECTION 22.79 33.98 J2426 INJ, INVEGA SUSTENNA, 1 MG 12.06 17.96

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR J2427 INJ, INVEGA HAFYERA/TRINZA 14.65 17.34 J2428 INJ, ERZOFRI, 1 MG BR J2430 PAMIDRONATE DISODIUM /30 MG 13.98 J2440 PAPAVERIN HCL INJECTION 2.76 J2460 OXYTETRACYCLINE INJECTION 29.60 J2468 INJ, PALONOSETRON (POSFREA) BR 84.83 J2469 PALONOSETRON HCL 25.93 22.50 J2470 INJ PANTOPRAZOLE SODIUM 40MG 25.20 J2471 INJ PANTOPRAZOLE(HIKMA) 40MG 33.20 J2472 INJ, PANTOPRAZOLE SODIUM CHL BR J2501 PARICALCITOL 1.15 J2502 INJ, PASIREOTIDE LONG ACTING 348.00 453.48 J2503 PEGAPTANIB SODIUM INJECTION 1326.86 J2504 PEGADEMASE BOVINE, 25 IU 360.35 553.92 J2506 INJ PEGFILGRAST EX BIO 0.5MG 187.00 258.48 J2507 PEGLOTICASE INJECTION 1893.91 4215.43 J2508 PEGUNIGALSIDASE ALFA-IWXJ 272.15 302.40 J2510 PENICILLIN G PROCAINE INJ 31.29

J2513 PENTASTARCH 10% SOLUTION BR J2515 PENTOBARBITAL SODIUM INJ 50.34 72.69 J2540 PENICILLIN G POTASSIUM INJ 1.15 J2543 PIPERACILLIN/TAZOBACTAM 3.13 J2545 PENTAMIDINE NON-COMP UNIT 145.45 J2547 INJECTION, PERAMIVIR BR 2.39 J2550 PROMETHAZINE HCL INJECTION 2.28 J2560 PHENOBARBITAL SODIUM INJ 40.56 59.98 J2561 INJ, SEZABY, 1 MG BR 0.92 J2562 PLERIXAFOR INJECTION 427.67 543.55 J2590 OXYTOCIN INJECTION 15.90 J2597 INJ DESMOPRESSIN ACETATE 16.33 13.19 J2598 INJ, VASOPRESSIN, 1 UNIT 2.18 2.58 J2599 INJ VASOPRESSIN (AM REG) 1 U 0.55 0.65 J2601 INJ, VASOPRESSIN (BAXTER) 4.36 5.15 J2650 PREDNISOLONE ACETATE INJ 0.83 J2670 TOTAZOLINE HCL INJECTION BR J2675 INJ PROGESTERONE PER 50 MG 1.31 J2679 INJ FLUPHENAZINE HCL 1.25 MG 9.06 10.92 J2680 FLUPHENAZINE DECANOATE 25 MG 26.90 J2690 PROCAINAMIDE HCL INJECTION 64.10

J2700 OXACILLIN SODIUM INJECITON 2.18 J2704 INJ, PROPOFOL, 10 MG 0.15 J2710 NEOSTIGMINE METHYLSLFTE INJ 12.40 J2720 INJ PROTAMINE SULFATE/10 MG 1.62 J2724 PROTEIN C CONCENTRATE 18.28 21.43 J2725 INJ PROTIRELIN PER 250 MCG 54.39 J2730 PRALIDOXIME CHLORIDE INJ 109.70 J2760 PHENTOLAINE MESYLATE INJ 471.22 588.05 J2765 METOCLOPRAMIDE HCL INJECTION 0.98 J2770 QUINUPRISTIN/DALFOPRISTIN 404.96 608.03

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR J2777 INJ, FARICIMAB-SVOA, 0.1MG 42.30

J2778 RANIBIZUMAB INJECTION 468.26 436.22 J2779 INJ, SUSVIMO 0.1 MG 99.88

J2781 INJ, PEGCETACOPLAN, 1MG 181.75 215.07 J2782 INJ AVACINCAPTAD PEGOL 0.1MG 130.44 154.35 J2783 RASBURICASE 322.10 456.77 J2785 REGADENOSON INJECTION 73.78 J2786 INJECTION, RESLIZUMAB, 1MG 11.94 14.38 J2787 RIBOFLAVIN 5'PHOS OPTH<=3ML 3336.40 J2788 RHO D IMMUNE GLOBULIN 50 MCG 29.46 J2790 RHO D IMMUNE GLOBULIN INJ 101.14 J2791 RHOPHYLAC INJECTION 5.77 J2792 RHO(D) IMMUNE GLOBULIN H, SD 28.08 44.76 J2793 RILONACEPT INJECTION 29.42 J2794 INJ RISPERDAL CONSTA, 0.5 MG 10.12 15.68 J2795 ROPIVACAINE HCL INJECTION 0.09 J2797 INJ., ROLAPITANT, 0.5 MG BR 1.41 J2798 INJ., PERSERIS, 0.5 MG 13.10 15.17 J2799 INJ, UZEDY, 1 MG 29.64 35.07 J2800 METHOCARBAMOL INJECTION 52.21 J2801 INJ, RYKINDO, 0.5 MG BR 18.50 J2802 INJ, ROMIPLOSTIM 1 MICROGRAM 12.65 14.97 J2804 INJ, RIFAMPIN, 1 MG BR J2805 SINCALIDE INJECTION 127.91 J2810 INJ THEOPHYLLINE PER 40 MG 0.37 J2820 SARGRAMOSTIM INJECTION 47.61 76.06 J2840 INJ SEBELIPASE ALFA 1 MG 494.12 766.62 J2850 INJ SECRETIN SYNTHETIC HUMAN 45.57 49.39 J2860 INJECTION, SILTUXIMAB 154.19 177.73 J2865 INJ SULFAMETH/TRIM 5 MG/1 MG BR J2910 AUROTHIOGLUCOSE INJECITON 37.60 J2916 NA FERRIC GLUCONATE COMPLEX 3.10 J2919 INJ, METHYLPRED SOD SUCC 5MG 0.32 0.38 J2940 SOMATREM INJECTION 16.79 J2941 SOMATROPIN INJECTION 799.55

J2950 PROMAZINE HCL INJECTION 12.40 J2993 RETEPLASE INJECTION 2744.25 2629.60 J2995 INJ STREPTOKINASE /250000 IU 93.91 J2997 ALTEPLASE RECOMBINANT 102.98 124.49 J2998 INJ PLASMINOGEN TVMH 1MG 67.61

J3000 STREPTOMYCIN INJECTION 16.46 J3010 FENTANYL CITRATE INJECTION 0.68 J3030 SUMATRIPTAN SUCCINATE / 6 MG 101.35 J3031 INJ., FREMANEZUMAB-VFRM 1 MG 4.80 3.28 J3032 INJ. EPTINEZUMAB-JJMR 1 MG 19.70 22.73 J3055 INJ TALQUETAMAB-TGVS 0.25 MG 83.96 99.36 J3060 INJ, TALIGLUCERASE ALFA 10 U 50.03 58.55 J3070 PENTAZOCINE INJECTION 158.76 J3090 INJ TEDIZOLID PHOSPHATE 1.69 2.36

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR J3095 TELAVANCIN INJECTION 7.35 9.09 J3101 TENECTEPLASE INJECTION 130.47 191.16 J3105 TERBUTALINE SULFATE INJ 1.18 J3110 TERIPARATIDE INJECTION 11.11 J3111 INJ. ROMOSOZUMAB-AQQG 1 MG 11.64 13.25 J3121 INJ TESTOSTERO ENANTHATE 1MG 0.06 J3145 TESTOSTERONE UNDECANOATE 1MG 1.98 2.29 J3230 CHLORPROMAZINE HCL INJECTION 26.68 J3240 THYROTROPIN INJECTION 1989.16 2638.42 J3241 INJ. TEPROTUMUMAB-TRBW 10 MG 385.64 448.55 J3243 TIGECYCLINE INJECTION 2.93 2.82 J3244 INJ. TIGECYCLINE (ACCORD) 8.8 J3245 INJ., TILDRAKIZUMAB, 1 MG 166.37 189.70 J3246 TIROFIBAN HCL 10.68 5.13 J3247 INJ SECUKINUMAB INTRAV 1MG 21.26 25.16 J3250 TRIMETHOBENZAMIDE HCL INJ 32.96 J3260 TOBRAMYCIN SULFATE INJECTION 3.24 J3262 TOCILIZUMAB INJECTION 5.55 8.14 J3263 INJ, TORIPALIMAB-TPZI, 1 MG 47.18 55.83 J3265 INJECTION TORSEMIDE 10 MG/ML BR J3280 THIETHYLPERAZINE MALEATE INJ 5.98 J3285 TREPROSTINIL INJECTION 73.96 81.61 J3299 INJ XIPERE 1 MG 58.10

J3300 TRIAMCINOLONE A INJ PRS-FREE 4.68 5.80 J3301 TRIAMCINOLONE ACET INJ NOS 2.18 J3302 TRIAMCINOLONE DIACETATE INJ 1.99 J3303 TRIAMCINOLONE HEXACETONL INJ 9.21 J3304 INJ TRIAMCINOLONE ACE XR 1MG 20.39 25.03 J3305 INJ TRIMETREXATE GLUCORONATE BR J3310 PERPHENAZINE INJECITON 13.20 J3315 TRIPTORELIN PAMOATE 331.96 478.55 J3316 INJ., TRIPTORELIN XR 3.75 MG 2505.60 4355.50 J3320 SPECTINOMYCN DI-HCL INJ BR J3350 UREA INJECTION BR J3355 UROFOLLITROPIN, 75 IU 78.11 J3357 USTEKINUMAB SUB CU INJ, 1 MG 209.63 242.56 J3358 USTEKINUMAB, IV INJECT, 1 MG 14.75 16.50 J3360 DIAZEPAM INJECTION 8.02 J3364 UROKINASE 5000 IU INJECTION BR J3365 UROKINASE 250,000 IU INJ BR J3370 VANCOMYCIN HCL INJECTION 4.67 J3371 INJ, VANCOMYCIN HCL (MYLAN) 7.68 J3372 INJ, VANCOMYCIN HCL (XELLIA) 7.79 J3380 INJ VEDOLIZUMAB IV 1 MG 23.64 30.23 J3385 VELAGLUCERASE ALFA 431.68 510.92 J3392 INJ, EXAGAMGLOGENE AUTOTEM BR 3311440.00 J3393 INJ, BETIBEGLOGENE AUTOTEMCE BR 4214560.00 J3394 INJ, LOVOTIBEGLOGENE AUTOTEM BR 4534060.00 J3396 VERTEPORFIN INJECTION 13.66 15.96

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR J3397 INJ., VESTRONIDASE ALFA-VJBK 221.20 329.33 J3398 INJ LUXTURNA 1 BILLION VEC G 2363.60 4163.44 J3399 INJ ONASE ABEPAR-XIOI TREAT BR

J3400 TRIFLUPROMAZINE HCL INJ BR J3401 VYJUVEK 5X10^9PFU/ML, 0.1 ML 1220.14 3546.81 J3410 HYDROXYZINE HCL INJECTION 3.04 J3411 THIAMINE HCL 100 MG 3.89 J3415 PYRIDOXINE HCL 100 MG 12.38 J3420 VITAMIN B12 INJECTION 3.18 J3424 INJ HYDROXOCOBALAMIN IV 25MG BR 7.36 J3425 HYDROXOCOBALAMIN IM 10MCG 0.01 0.01 J3430 VITAMIN K PHYTONADIONE INJ 3.81 J3465 INJECTION, VORICONAZOLE 4.69 J3470 HYALURONIDASE INJECTION 31.80 J3471 OVINE, UP TO 999 USP UNITS 0.44 J3472 OVINE, 1000 USP UNITS 140.44 J3473 HYALURONIDASE RECOMBINANT 0.43 J3475 INJ MAGNESIUM SULFATE 0.31 J3480 INJ POTASSIUM CHLORIDE 0.20 J3485 ZIDOVUDINE 1.81 J3486 ZIPRASIDONE MESYLATE 18.81 J3489 ZOLEDRONIC ACID 1MG 33.25 J3490 DRUGS UNCLASSIFIED INJECTION BR J3520 EDETATE DISODIUM PER 150 MG 3.71 J3530 NASAL VACCINE INHALATION BR J3535 METERED DOSE INHALER DRUG 3.20 J3570 LAETRILE AMYGDALIN VIT B17 43.19 J3590 UNCLASSIFIED BIOLOGICS BR J3591 ESRD ON DIALYSI DRUG/BIO NOC BR J7030 NORMAL SALINE SOLUTION INFUS 2.60 J7040 NORMAL SALINE SOLUTION INFUS 1.31 J7042 5% DEXTROSE/NORMAL SALINE 0.82 J7050 NORMAL SALINE SOLUTION INFUS 0.63 J7060 5% DEXTROSE/WATER 2.24 J7070 D5W INFUSION 4.48 J7100 DEXTRAN 40 INFUSION 21.18 J7110 DEXTRAN 75 INFUSION 125.20 J7120 RINGERS LACTATE INFUSION 2.53 J7121 5% DEXTROSE IN LAC RINGERS 21.21 J7131 HYPERTONIC SALINE SOL 0.20 J7165 INJ, HUMAN-LANS, PER I.U BR 2.56 J7168 PROTHROMBIN COMPLEX KCENTRA 6.0 2.83 J7169 INJ ANDEXXA, 10 MG BR 409.63 J7170 INJ., EMICIZUMAB-KXWH 0.5 MG 59.88 69.23 J7171 INJ, ADZYNMA, 10 IU 41.48 49.09 J7175 INJ, FACTOR X, (HUMAN), 1IU 10.26 11.64 J7177 INJ., FIBRYGA, 1 MG 1.31 1.61 J7178 INJ HUMAN FIBRINOGEN CON NOS 1.61 1.85 J7179 VONVENDI INJ 1 IU VWF:RCO 24.10 2.61

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR J7180 FACTOR XIII ANTI-HEM FACTOR 10.80 12.98 J7181 FACTOR XIII RECOMB A-SUBUNIT 19.62 22.89 J7182 FACTOR VIII RECOMB NOVOEIGHT 1.75 2.17 J7183 WILATE INJECTION 1.38 1.62 J7185 XYNTHA INJ 1.50 1.80 J7186 ANTIHEMOPHILIC VIII/VWF COMP 1.35 1.60 J7187 HUMATE-P, INJ 1.39 1.79 J7188 FACTOR VIII RECOMB OBIZUR 3.84 4.54 J7189 FACTOR VIIA RECOMB NOVOSEVEN 2.74 3.28 J7190 FACTOR VIII 1.33 1.58 J7191 FACTOR VIII (PORCINE) BR J7192 FACTOR VIII RECOMBINANT NOS 1.63 2.03 J7193 FACTOR IX NON-RECOMBINANT 1.39 1.66 J7194 FACTOR IX COMPLEX 1.69 2.17 J7195 FACTOR IX RECOMBINANT NOS 1.96 2.26 J7196 ANTITHROMBIN RECOMBINANT BR 155.59 J7197 ANTITHROMBIN III INJECTION 4.37 5.04 J7198 ANTI-INHIBITOR 2.65 3.12 J7199 HEMOPHILIA CLOT FACTOR NOC BR J7200 FACTOR IX RECOMBINAN RIXUBIS 1.73 2.06 J7201 FACTOR IX ALPROLIX RECOMB 3.90 4.47 J7202 FACTOR IX IDELVION INJ 5.65 6.55 J7203 FACTOR IX RECOMB GLY REBINYN 5.04 6.06 J7204 INJ RECOMBIN ESPEROCT PER IU 2.52 3.10 J7205 FACTOR VIII FC FUSION RECOMB 2.60 3.01 J7207 FACTOR VIII PEGYLATED RECOMB 2.39 2.75 J7208 INJ. JIVI 1 IU 2.59 3.00 J7209 FACTOR VIII NUWIQ RECOMB 1IU 2.26 1.85 J7210 INJ, AFSTYLA, 1 I.U. 5.13 1.92 J7211 INJ, KOVALTRY, 1 I.U. 2.63 1.75 J7212 FACTOR VIIA RECOMB SEVENFACT 2.36 3.12 J7213 INJ, IXINITY, 1 I.U. 2.18 2.58 J7214 ALTUVIIIO PER FACTOR VIII IU 5.26 6.57 J7294 SEG ACET AND ETH ESTR YEARLY BR J7295 ETH ESTR AND ETON MONTHLY 209.61 J7296 KYLEENA, 19.5 MG 1331.75 J7297 LILETTA, 52 MG 1001.20 J7298 MIRENA, 52 MG 1209.60 J7300 INTRAUT COPPER CONTRACEPTIVE 1001.60 J7301 SKYLA, 13.5 MG 1001.20 J7304 CONTRACEPTIVE HORMONE PATCH 50.00 J7306 LEVONORGESTREL IMPLANT SYS 875.33 J7307 ETONOGESTREL IMPLANT SYSTEM 1118.00 J7308 AMINOLEVULINIC ACID HCL TOP 406.40 555.83 J7309 METHYL AMINOLEVULINATE, TOP 2.80 J7310 GANCICLOVIR LONG ACT IMPLANT 20219.70 J7311 INJ., RETISERT, 0.01 MG 24340.23 460.21 J7312 DEXAMETHASONE INTRA IMPLANT 242.93 284.00 J7313 INJ., ILUVIEN, 0.01 MG 593.03 697.15

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR J7314 INJ., YUTIQ, 0.01 MG 621.77 736.23 J7315 OPHTHALMIC MITOMYCIN 338.79 J7316 INJ, OCRIPLASMIN, 0.125 MG 1340.43 1486.64 J7318 INJ, DUROLANE 1 MG 390.00 25.19 J7320 GENVISC 850, INJ, 1MG 14.81 24.03 J7321 HYALGAN SUPARTZ VISCO-3 DOSE 106.44 120.30 J7322 HYMOVIS INJECTION 1 MG 28.80 44.97 J7323 EUFLEXXA INJ PER DOSE 180.10 192.04 J7324 ORTHOVISC INJ PER DOSE 203.58 209.81 J7325 SYNVISC OR SYNVISC-ONE 15.85 14.81 J7326 GEL-ONE 1013.74 1730.98 J7327 MONOVISC INJ PER DOSE 1129.41 1122.91 J7328 GELSYN-3 INJECTION 0.1 MG 1.54 3.18 J7329 INJ, TRIVISC 1 MG 15.97 27.15 J7330 CULTURED CHONDROCYTES IMPLNT 45256.40 J7331 SYNOJOYNT, INJ., 1 MG 10.68 25.59 J7332 INJ., TRILURON, 1 MG 11.77

J7336 CAPSAICIN 8% PATCH 3.89 4.60 J7340 CARBIDOPA LEVODOPA ENT 100ML 253.80 299.99 J7342 CIPROFLOXACIN OTIC SUSP 6 MG 35.98 42.59 J7345 AMINOLEVULINIC ACID, 10% GEL 1.90 2.26 J7351 INJ BIMATOPROST ITC IMP1MCG 247.68 292.12 J7352 AFAMELANOTIDE IMPLANT, 1 MG 5215.60 4570.84 J7353 ANACAULASE-BCDB 8.8% GEL 1 G BR 80.93 J7354 CANTHARIDIN TOP, APPLICATOR 854.10 1010.69 J7355 INJ TRAVOPROST INTRA IMPL 175.20 279.97 J7402 MOMETASONE SINUS SINUVA 13.12 15.00 J7500 AZATHIOPRINE ORAL 50MG 0.49 J7501 AZATHIOPRINE PARENTERAL 81.96 329.92 J7502 CYCLOSPORINE ORAL 100 MG 4.06 J7503 TACROL ENVARSUS EX REL ORAL 1.87 J7504 LYMPHOCYTE IMMUNE GLOBULIN 1579.32 3344.61 J7505 MONOCLONAL ANTIBODIES 1146.11 J7507 TACROLIMUS IMME REL ORAL 1MG 1.03 J7508 TACROL ASTAGRAF EX REL ORAL 0.54 J7509 METHYLPREDNISOLONE ORAL 0.39 J7510 PREDNISOLONE ORAL PER 5 MG 0.17 J7511 ANTITHYMOCYTE GLOBULN RABBIT 893.19 1190.43 J7512 PREDNISONE IR OR DR ORAL 1MG 0.02 J7513 DACLIZUMAB, PARENTERAL 494.73 J7514 MYCOPHENOL (MYHIBBIN) 100 MG BR J7515 CYCLOSPORINE ORAL 25 MG 1.18 J7516 INJ, CYCLOSPORINE 250MG 59.31 J7517 MYCOPHENOLATE MOFETIL ORAL 1.22 J7518 MYCOPHENOLIC ACID 3.69 J7519 INJ. MYCOPHENOLATE MOFETIL 0.88 1.04 J7520 SIROLIMUS, ORAL 11.68 J7521 TACROLIM GRANULES ORAL SUSP BR J7525 TACROLIMUS INJECTION 228.42 311.93

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR J7527 ORAL EVEROLIMUS 9.05 J7599 IMMUNOSUPPRESSIVE DRUG NOC BR J7601 ENSIFENTRINE INH 3 MG BR J7604 ACETYLCYSTEINE COMP UNIT BR J7605 ARFORMOTEROL NON-COMP UNIT 9.98 J7606 FORMOTEROL FUMARATE, INH 11.36 J7607 LEVALBUTEROL COMP CON 17.20 J7608 ACETYLCYSTEINE NON-COMP UNIT 5.59 J7609 ALBUTEROL COMP UNIT 8.40 J7610 ALBUTEROL COMP CON 8.40 J7611 ALBUTEROL NON-COMP CON 0.16 J7612 LEVALBUTEROL NON-COMP CON 0.34 J7613 ALBUTEROL NON-COMP UNIT 0.06 J7614 LEVALBUTEROL NON-COMP UNIT 0.09 J7615 LEVALBUTEROL COMP UNIT 13.83 J7620 ALBUTEROL IPRATROP NON-COMP 0.18 J7622 BECLOMETHASONE COMP UNIT BR J7624 BETAMETHASONE COMP UNIT 12.40 J7626 BUDESONIDE NON-COMP UNIT 6.42 J7627 BUDESONIDE COMP UNIT 8.48 J7628 BITOLTEROL MESYLATE COMP CON BR J7629 BITOLTEROL MESYLATE COMP UNT BR J7631 CROMOLYN SODIUM NONCOMP UNIT 1.12 J7632 CROMOLYN SODIUM COMP UNIT 0.42 J7633 BUDESONIDE NON-COMP CON 16.00 J7634 BUDESONIDE COMP CON 8.40 J7635 ATROPINE COMP CON 20.00 J7636 ATROPINE COMP UNIT 12.40 J7637 DEXAMETHASONE COMP CON 12.40 J7638 DEXAMETHASONE COMP UNIT 8.40 J7639 DORNASE ALFA NON-COMP UNIT 54.15 J7640 FORMOTEROL COMP UNIT 16.79 J7641 FLUNISOLIDE COMP UNIT 13.23 J7642 GLYCOPYRROLATE COMP CON 28.80 J7643 GLYCOPYRROLATE COMP UNIT 16.79 J7644 IPRATROPIUM BROMIDE NON-COMP 0.25 J7645 IPRATROPIUM BROMIDE COMP 8.40 J7647 ISOETHARINE COMP CON BR J7648 ISOETHARINE NON-COMP CON BR J7649 ISOETHARINE NON-COMP UNIT BR J7650 ISOETHARINE COMP UNIT BR J7657 ISOPROTERENOL COMP CON BR J7658 ISOPROTERENOL NON-COMP CON BR J7659 ISOPROTERENOL NON-COMP UNIT BR J7660 ISOPROTERENOL COMP UNIT BR J7665 MANNITOL FOR INHALER 0.93 J7667 METAPROTERENOL COMP CON BR J7668 METAPROTERENOL NON-COMP CON BR J7669 METAPROTERENOL NON-COMP UNIT BR

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR J7670 METAPROTERENOL COMP UNIT BR J7674 METHACHOLINE CHLORIDE, NEB 0.71 J7676 PENTAMIDINE COMP UNIT DOSE 292.01 J7677 REVEFENACIN INH NON-COM 1MCG 0.23 J7680 TERBUTALINE SULF COMP CON 16.64 J7681 TERBUTALINE SULF COMP UNIT 16.64 J7682 TOBRAMYCIN NON-COMP UNIT 67.17 J7683 TRIAMCINOLONE COMP CON 38.10 J7684 TRIAMCINOLONE COMP UNIT 4.00 J7685 TOBRAMYCIN COMP UNIT 178.21 J7686 TREPROSTINIL, NON-COMP UNIT 703.49 J7699 INHALATION SOLUTION FOR DME BR J7799 NON-INHALATION DRUG FOR DME BR J7999 COMPOUNDED DRUG, NOC BR J8498 ANTIEMETIC RECTAL/SUPP NOS BR J8499 ORAL PRESCRIP DRUG NON CHEMO BR J8501 ORAL APREPITANT 12.32 J8510 ORAL BUSULFAN 15.81

J8515 CABERGOLINE, ORAL 0.25MG 17.93 J8522 CAPECITABINE, ORAL, 50 MG 0.05 0.06 J8530 CYCLOPHOSPHAMIDE ORAL 25 MG 4.44 J8540 ORAL DEXAMETHASONE 0.15 J8541 ORAL, HEMADY, 0.25 MG BR J8560 ETOPOSIDE ORAL 50 MG 91.31 107.22 J8562 ORAL FLUDARABINE PHOSPHATE BR 122.57 J8565 GEFITINIB ORAL 68.29 J8597 ANTIEMETIC DRUG ORAL NOS BR J8600 MELPHALAN ORAL 2 MG 14.36 18.06 J8610 METHOTREXATE ORAL 2.5 MG 1.67 J8611 ORAL METHOTREXATE (JYLAMVO) BR 26.94 J8612 ORAL METHOTREXATE (XATMEP) BR 29.41 J8650 NABILONE ORAL 20.06 J8655 ORAL NETUPITANT, PALONOSETRO 596.80 458.25 J8670 ROLAPITANT, ORAL, 1MG 2.11 2.51 J8700 TEMOZOLOMIDE 4.37 J8705 TOPOTECAN ORAL 125.23 J8999 ORAL PRESCRIPTION DRUG CHEMO BR J9000 DOXORUBICIN HCL INJECTION 3.74 J9015 ALDESLEUKIN INJECTION 4690.40 5389.27 J9017 ARSENIC TRIOXIDE INJECTION 71.58 18.19 J9019 ERWINAZE INJECTION 512.72 606.72 J9020 ASPARAGINASE, NOS 76.84 J9021 INJ, ASPARA, RYLAZE, 0.1 MG 55.84 64.21 J9022 INJ, ATEZOLIZUMAB,10 MG 98.72 113.00 J9023 INJECTION, AVELUMAB, 10 MG 106.06 124.41 J9024 INJ ATEZOLIZUMB 5MG HYA-TQJS BR J9025 AZACITIDINE INJECTION 3.61 1.26 J9026 INJ, TARLATAMAB-DLLE, 1 MG BR 2237.10 J9027 CLOFARABINE INJECTION 167.09 87.54

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR J9028 INJ, NOGAPENDEKIN PMLN, 1MCG 113.84 134.72 J9029 INSTILL ADSTILADRIN, TX DOSE 76082.45 87756.00 J9030 BCG LIVE INTRAVESICAL 1MG 3.40 J9032 INJECTION, BELINOSTAT, 10MG 45.15 61.66 J9033 INJ, BENDAMUSTINE HCL, 1MG 29.69 29.38 J9034 INJ., BENDEKA 1 MG 21.41 27.09 J9035 BEVACIZUMAB INJECTION 85.57 96.36 J9036 INJ. BELRAPZO/BENDAMUSTINE 23.24 32.49 J9037 INJ BELANTAMAB MAFODOT BLMF 52.96 61.47 J9038 INJ AXATILIMAB-CSFR 0.1 MG BR J9039 INJECTION, BLINATUMOMAB 155.78 176.24 J9040 BLEOMYCIN SULFATE INJECTION 28.94 J9041 INJECTION, BORTEZOMIB, 0.1MG 56.48 63.60 J9042 BRENTUXIMAB VEDOTIN INJ 172.85 279.10 J9043 CABAZITAXEL INJECTION 205.19 271.66 J9045 CARBOPLATIN INJECTION 4.39 J9046 INJ, BORTEZOMIB, DR. REDDY'S 13.15 15.56 J9047 INJECTION, CARFILZOMIB, 1 MG 42.90 58.38 J9048 INJ, BORTEZOMIB FRESENIUSKAB 3.22 3.81 J9049 INJ, BORTEZOMIB, HOSPIRA 8.56 10.12 J9050 CARMUSTINE INJECTION 3886.50 1561.74 J9051 INJ, BORTEZOMIB (MAIA) BR J9052 INJ, CARMUSTINE (ACCORD) 22.08 26.13 J9054 INJ BORTEZOMIB BORUZU 0.1 MG BR J9055 CETUXIMAB INJECTION 74.75 96.02 J9056 INJ, VIVIMUSTA, 1 MG 40.14 47.50 J9057 INJ., COPANLISIB, 1 MG 208.79 115.08 J9060 CISPLATIN 10 MG INJECTION 2.15 J9061 INJ, AMIVANTAMAB-VMJW 22.39 25.43 J9063 INJ, ELAHERE, 1 MG 78.85 93.31 J9064 INJ, CABAZITAXEL (SANDOZ) BR J9065 INJ CLADRIBINE PER 1 MG 24.36 21.41 J9071 INJ CYCLOPHOSPHAMD AUROMEDIC 0.84

J9072 INJ CYCLOPHOS AVYXA 5MG 22.40 5.34 J9073 INJ CYCLOPHOSPHAMD (INGENUS) 2.63 3.11 J9074 INJ, CYCLOPHOSPHAMD, SANDOZ 5.22 6.18 J9075 INJ, CYCLOPHOSPHAMIDE, NOS 1.06 1.25 J9076 INJ, CYCLOPHOS (BAXTER) 5MG BR J9098 CYTARABINE LIPOSOME INJ 744.45 945.94 J9100 CYTARABINE HCL 100 MG INJ 1.10 J9118 INJ. CALASPARGASE PEGOL-MKNL 91.84 J9119 INJ., CEMIPLIMAB-RWLC, 1 MG 32.70 39.29 J9120 DACTINOMYCIN INJECTION 1401.60 1191.21 J9130 DACARBAZINE 100 MG INJ 4.81 J9144 DARATUMUMAB, HYALURONIDASE 55.90 63.94 J9145 INJECTION, DARATUMUMAB 10 MG 70.50 81.25 J9150 DAUNORUBICIN INJECTION 36.77 58.56 J9151 DAUNORUBICIN CITRATE INJ 7.58 0.48 J9153 INJ DAUNORUBICIN, CYTARABINE 258.49 294.83

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR J9155 DEGARELIX INJECTION 4.84 5.77 J9161 INJ DENILEUK DIFTI-CXDL 1MCG BR J9165 DIETHYLSTILBESTROL INJECTION BR J9171 DOCETAXEL INJECTION 3.13 2.02 J9172 DOCETAXEL (DOCIVYX), 1 MG 62.65 74.14 J9173 INJ., DURVALUMAB, 10 MG 93.84 109.14 J9175 ELLIOTTS B SOLUTION PER ML 7.73 J9176 INJECTION, ELOTUZUMAB, 1MG 8.34 9.74 J9177 INJ ENFORT VEDO-EJFV 0.25MG 37.63 42.87 J9178 INJ, EPIRUBICIN HCL, 2 MG 1.94 J9179 ERIBULIN MESYLATE INJECTION 145.06 180.96 J9181 ETOPOSIDE INJECTION 0.89 J9185 FLUDARABINE PHOSPHATE INJ 81.40

J9190 FLUOROURACIL INJECTION 2.51 J9196 INJ GEMCITABINE HCL (ACCORD) 10.54 12.47 J9198 INJ. INFUGEM, 100 MG 30.94 35.61 J9200 FLOXURIDINE INJECTION 96.67

J9201 IN GEMCITABINE HCL NOS 200MG 10.53 J9202 GOSERELIN ACETATE IMPLANT 384.32 771.29 J9203 GEMTUZUMAB OZOGAMICIN 0.1 MG 460.79 299.78 J9204 INJ MOGAMULIZUMAB-KPKC, 1 MG 259.50 301.95 J9205 INJ IRINOTECAN LIPOSOME 1 MG 72.17 81.47 J9206 IRINOTECAN INJECTION 5.04 J9207 IXABEPILONE INJECTION 102.06 162.15 J9208 IFOSFAMIDE INJECTION 37.36 J9209 MESNA INJECTION 5.01 J9210 INJ., EMAPALUMAB-LZSG, 1 MG 456.47 514.48 J9211 IDARUBICIN HCL INJECTION 49.52 J9212 INTERFERON ALFACON-1 INJ 8.11 J9213 INTERFERON ALFA-2A INJ 48.62 254.91 J9214 INTERFERON ALFA-2B INJ 33.20 46.49 J9215 INTERFERON ALFA-N3 INJ 21.76 J9216 INTERFERON GAMMA 1-B INJ 382.03 J9217 LEUPROLIDE ACETATE SUSPNSION 305.11 285.04 J9218 LEUPROLIDE ACETATE INJECITON 19.52 J9219 LEUPROLIDE ACETATE IMPLANT BR J9223 INJ. LURBINECTEDIN, 0.1 MG 220.78 255.93 J9225 VANTAS IMPLANT 4177.61 7336.13 J9226 SUPPRELIN LA IMPLANT 33044.64 61688.11 J9227 INJ. ISATUXIMAB-IRFC 10 MG 84.60 98.01 J9228 IPILIMUMAB INJECTION 193.44 228.19 J9229 INJ INOTUZUMAB OZOGAM 0.1 MG 2931.97 3418.22 J9230 MECHLORETHAMINE HCL INJ 309.53 16.67 J9245 INJ MELPHA HYDROCH NOS 50 MG 1937.56 280.39 J9246 INJ., EVOMELA, 1 MG 21.60 25.84 J9247 INJ, MELPHALAN FLUFENAMI 1MG 604.20 706.36 J9248 INJ MELPHALAN (HEPZATO) 1 MG 928.56 1098.80 J9249 INJ, MELPHALAN (APOTEX) 1 MG BR J9255 INJ, METHOTREXATE (ACCORD) 6.80

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR J9260 INJ METHOTREXATE SODIUM 50MG 2.79 J9261 NELARABINE INJECTION 178.91 221.38 J9262 INJ, OMACETAXINE MEP, 0.01MG 4.33 4.69 J9263 OXALIPLATIN 0.46 J9264 PACLITAXEL PROTEIN BOUND 13.94 19.94 J9266 PEGASPARGASE INJECTION 12442.48 30616.69 J9267 PACLITAXEL INJECTION 0.18 J9268 PENTOSTATIN INJECTION 2251.38 2746.92 J9269 INJ. TAGRAXOFUSP-ERZS 10 MCG 371.29 420.80 J9270 PLICAMYCIN (MITHRAMYCIN) INJ 297.20 163.87 J9271 INJ PEMBROLIZUMAB 63.47 74.27 J9272 INJ, DOSTARLIMAB-GXLY, 10 MG 264.52 305.47 J9273 INJ TISOTU VEDOTIN-TFTV, 1MG 187.09 J9274 INJ, TEBENTAFUSP-TEBN, 1 MCG 257.71 J9280 MITOMYCIN INJECTION 129.97 71.94 J9281 MITOMYCIN INSTILLATION 342.43 400.14 J9285 INJ, OLARATUMAB, 10 MG BR 73.94 J9286 INJ GLOFITAMAB GXBM, 2.5 MG 3249.52 3845.26 J9292 INJ, PEMETREXED (AVYXA) 10MG BR J9293 MITOXANTRONE HYDROCHL / 5 MG 38.02 41.75 J9294 INJ PEMETREXED, HOSPIRA 10MG 12.66 14.98 J9295 INJECTION, NECITUMUMAB, 1 MG 6.89 8.15 J9296 INJ PEMETREXED (ACCORD) 10MG 37.20 13.72 J9297 INJ PEMETREXED (SANDOZ) 10MG 1.56 1.85 J9298 INJ NIVOL RELATLIMAB 3MG/1MG 232.63

J9299 INJECTION, NIVOLUMAB 35.24 41.54 J9301 OBINUTUZUMAB INJ 76.90 91.04 J9302 OFATUMUMAB INJECTION 70.18 90.82 J9303 PANITUMUMAB INJECTION 143.62 185.18 J9304 INJ. PEMETREXED, 10 MG 141.20

J9305 INJ. PEMETREXED NOS 10MG 85.79 107.98 J9306 INJECTION, PERTUZUMAB, 1 MG 14.54 19.26 J9307 PRALATREXATE INJECTION 308.04 454.02 J9308 INJECTION, RAMUCIRUMAB 75.04 90.26 J9309 INJ, POLATUZUMAB VEDOTIN 1MG 141.37 161.27 J9311 INJ RITUXIMAB, HYALURONIDASE 45.48 54.26 J9312 INJ., RITUXIMAB, 10 MG 101.00 121.59 J9313 INJ., LUMOXITI, 0.01 MG 28.07 33.21 J9314 INJ PEMETREXED (TEVA) 10MG 8.57 18.87 J9316 PERTUZU, TRASTUZU, 10 MG 84.44 101.74 J9317 SACITUZUMAB GOVITECAN-HZIY 38.44 44.39 J9318 INJ ROMIDEPSIN NON-LYO 0.1MG 27.60

J9319 INJ ROMIDEPSIN LYOPHIL 0.1MG 39.88 47.19 J9320 STREPTOZOCIN INJECTION 419.26 493.99 J9321 INJ EPCORITAMAB-BYSP 0.16 MG 64.56 76.40 J9322 INJ PEMETREXED (BLUEPOINT) 98.00 J9323 INJ PEMETREXED DITROMETHAMIN 7.21 8.53 J9324 INJ, PEMRYDI RTU, 10 MG 98.57 116.64 J9325 INJ TALIMOGENE LAHERPAREPVEC 71.62 81.25

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR J9328 TEMOZOLOMIDE INJECTION 9.36 14.78 J9329 INJ, TISLELIZUMAB-JSGR BR 783.30 J9330 TEMSIROLIMUS INJECTION 76.98 49.35 J9331 INJ SIROLIMUS PROT PART 1 MG 140.94

J9332 INJ EFGARTIGIMOD 2MG 37.84

J9333 INJ RONZANOLIXIZUM-NOLI 1 MG 27.38 31.61 J9334 INJ EFGART-ALFA 2MG HYA-QVFC 39.72 45.78 J9340 THIOTEPA INJECTION 1645.11 433.74 J9345 INJ, RETIFANLIMAB-DLWR, 1 MG 35.80 42.36 J9347 INJ, TREMELIMUMAB-ACTL, 1 MG 163.31 193.25 J9348 INJ. NAXITAMAB-GQGK, 1 MG 770.75 765.21 J9349 INJ., TAFASITAMAB-CXIX 15.56 18.18 J9350 INJ MOSUNETUZUMAB-AXGB, 1 MG 755.57 894.09 J9351 TOPOTECAN INJECTION 2.42 J9352 INJECTION TRABECTEDIN 0.1MG 396.22 461.54 J9353 INJ. MARGETUXIMAB-CMKB, 5 MG 52.84 62.14 J9354 INJ, ADO-TRASTUZUMAB EMT 1MG 40.57 48.49 J9355 INJ TRASTUZUMAB EXCL BIOSIMI 108.12 122.70 J9356 INJ. HERCEPTIN HYLECTA, 10MG 82.48 101.52 J9357 VALRUBICIN INJECTION 1547.69 2038.64 J9358 INJ FAM-TRASTU DERU-NXKI 1MG 30.20 34.93 J9359 INJ LON TESIRIN-LPYL 0.075MG 225.96

J9360 VINBLASTINE SULFATE INJ 4.14 J9361 INJ, EFBEMALENOGRASTIM ALFA- BR J9370 VINCRISTINE SULFATE 1 MG INJ 7.84 J9376 INJ POZELIMAB-BBFG, 1 MG BR J9380 INJ TECLISTAMAB CQYV 0.5 MG 37.02 43.81 J9381 INJ TEPLIZUMAB MZWV 5 MCG 43.51 51.49 J9390 VINORELBINE TARTRATE INJ 13.68 J9393 INJ, FULVESTRANT (TEVA) 18.53 21.92 J9394 INJ, FULVESTRANT (FRESENIUS) 9.42 11.15 J9395 INJECTION, FULVESTRANT 113.04 22.22 J9400 INJ, ZIV-AFLIBERCEPT, 1MG 9.92 10.88 J9600 PORFIMER SODIUM INJECTION 2903.04 31036.02 J9999 CHEMOTHERAPY DRUG BR K0001 NU STANDARD WHEELCHAIR 740.14 K0001 RR STANDARD WHEELCHAIR 37.44 K0001 UE STANDARD WHEELCHAIR 507.46 K0002 NU STND HEMI (LOW SEAT) WHLCHR 961.90 K0002 RR STND HEMI (LOW SEAT) WHLCHR 58.79 K0002 UE STND HEMI (LOW SEAT) WHLCHR 659.96 K0003 NU LIGHTWEIGHT WHEELCHAIR 1186.08 K0003 RR LIGHTWEIGHT WHEELCHAIR 59.73 K0003 UE LIGHTWEIGHT WHEELCHAIR 755.29 K0004 NU HIGH STRENGTH LTWT WHLCHR 1570.95 K0004 RR HIGH STRENGTH LTWT WHLCHR 84.47 K0004 UE HIGH STRENGTH LTWT WHLCHR 1042.30 K0005 NU ULTRALIGHTWEIGHT WHEELCHAIR 2035.67 K0005 RR ULTRALIGHTWEIGHT WHEELCHAIR 203.54

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR K0005 UE ULTRALIGHTWEIGHT WHEELCHAIR 1526.71 K0006 NU HEAVY DUTY WHEELCHAIR 1534.72 K0006 RR HEAVY DUTY WHEELCHAIR 91.25 K0006 UE HEAVY DUTY WHEELCHAIR 1063.22 K0007 NU EXTRA HEAVY DUTY WHEELCHAIR 2117.06 K0007 RR EXTRA HEAVY DUTY WHEELCHAIR 134.99 K0007 UE EXTRA HEAVY DUTY WHEELCHAIR 1466.57 K0008 CSTM MANUAL WHEELCHAIR/BASE BR K0009 RR OTHER MANUAL WHEELCHAIR/BASE 81.86 K0010 NU STND WT FRAME POWER WHLCHR 4772.25 K0010 RR STND WT FRAME POWER WHLCHR 398.69 K0010 UE STND WT FRAME POWER WHLCHR 4547.68

K0011 NU STND WT PWR WHLCHR W CONTROL 6199.17

K0011 RR STND WT PWR WHLCHR W CONTROL 580.21 K0011 UE STND WT PWR WHLCHR W CONTROL 4649.38 K0012 NU LTWT PORTBL POWER WHLCHR 3640.22 K0012 RR LTWT PORTBL POWER WHLCHR 320.61 K0012 UE LTWT PORTBL POWER WHLCHR 2122.25 K0013 CUSTOM POWER WHLCHR BASE 1234.28 K0014 OTHER POWER WHLCHR BASE BR K0015 NU DETACH NON-ADJ HT ARMRST REP 186.21 K0015 RR DETACH NON-ADJ HT ARMRST REP 17.24 K0015 UE DETACH NON-ADJ HT ARMRST REP 110.55 K0017 NU DETACH ADJUST ARMREST BASE 50.10 K0017 RR DETACH ADJUST ARMREST BASE 5.01 K0017 UE DETACH ADJUST ARMREST BASE 37.58 K0018 NU DETACH ADJUST ARMRST UPPER 28.13 K0018 RR DETACH ADJUST ARMRST UPPER 2.81 K0018 UE DETACH ADJUST ARMRST UPPER 21.11 K0019 NU ARM PAD REPL, EACH 16.33 K0019 RR ARM PAD REPL, EACH 1.64 K0019 UE ARM PAD REPL, EACH 12.29 K0020 NU FIXED ADJUST ARMREST PAIR 47.12 K0020 RR FIXED ADJUST ARMREST PAIR 4.72 K0020 UE FIXED ADJUST ARMREST PAIR 35.34 K0037 NU HI MOUNT FLIP-UP FOOTREST EA 41.66 K0037 RR HI MOUNT FLIP-UP FOOTREST EA 3.72 K0037 UE HI MOUNT FLIP-UP FOOTREST EA 31.26 K0038 NU LEG STRAP EACH 24.35 K0038 RR LEG STRAP EACH 2.44 K0038 UE LEG STRAP EACH 18.25 K0039 NU LEG STRAP H STYLE EACH 53.24 K0039 RR LEG STRAP H STYLE EACH 5.34 K0039 UE LEG STRAP H STYLE EACH 39.93 K0040 NU ADJUSTABLE ANGLE FOOTPLATE 70.88 K0040 RR ADJUSTABLE ANGLE FOOTPLATE 7.07 K0040 UE ADJUSTABLE ANGLE FOOTPLATE 53.12 K0041 NU LARGE SIZE FOOTPLATE EACH 51.65 K0041 RR LARGE SIZE FOOTPLATE EACH 5.18 K0041 UE LARGE SIZE FOOTPLATE EACH 38.74

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR K0042 NU STANDARD SIZE FTPLATE REP EA 31.53 K0042 RR STANDARD SIZE FTPLATE REP EA 3.15 K0042 UE STANDARD SIZE FTPLATE REP EA 23.63 K0043 NU FTRST LOWR EXTEN TUBE REP EA 19.68 K0043 RR FTRST LOWR EXTEN TUBE REP EA 1.96 K0043 UE FTRST LOWR EXTEN TUBE REP EA 14.79 K0044 NU FTRST UPR HANGER BRAC REP EA 16.94 K0044 RR FTRST UPR HANGER BRAC REP EA 1.70 K0044 UE FTRST UPR HANGER BRAC REP EA 12.70 K0045 NU FTRST COMPL ASSEMBLY REPL EA 56.75 K0045 RR FTRST COMPL ASSEMBLY REPL EA 5.77 K0045 UE FTRST COMPL ASSEMBLY REPL EA 42.57 K0046 NU ELEV LGRST LWR EXTEN REPL EA 19.75 K0046 RR ELEV LGRST LWR EXTEN REPL EA 1.97 K0046 UE ELEV LGRST LWR EXTEN REPL EA 14.83 K0047 NU ELEV LEGRST UPR HANGR REP EA 73.85 K0047 RR ELEV LEGRST UPR HANGR REP EA 7.40 K0047 UE ELEV LEGRST UPR HANGR REP EA 55.38 K0050 NU RATCHET ASSEMBLY REPLACEMENT 32.64 K0050 RR RATCHET ASSEMBLY REPLACEMENT 3.26 K0050 UE RATCHET ASSEMBLY REPLACEMENT 24.49 K0051 NU CAM REL ASM FT/LEGRST REP EA 52.29 K0051 RR CAM REL ASM FT/LEGRST REP EA 5.25 K0051 UE CAM REL ASM FT/LEGRST REP EA 39.21 K0052 NU SWINGAWAY DETACH FTREST REPL 87.75 K0052 RR SWINGAWAY DETACH FTREST REPL 8.77 K0052 UE SWINGAWAY DETACH FTREST REPL 65.78 K0053 NU ELEVATE FOOTREST ARTICULATE 98.33 K0053 RR ELEVATE FOOTREST ARTICULATE 9.83 K0053 UE ELEVATE FOOTREST ARTICULATE 73.75 K0056 NU SEAT HT <17 OR >=21 LTWT WC 104.72 K0056 RR SEAT HT <17 OR >=21 LTWT WC 10.49 K0056 UE SEAT HT <17 OR >=21 LTWT WC 78.56 K0065 NU SPOKE PROTECTORS 48.93 K0065 RR SPOKE PROTECTORS 4.90 K0065 UE SPOKE PROTECTORS 36.72 K0069 NU RR WHL COMPL SOL TIRE REP EA 110.03 K0069 RR RR WHL COMPL SOL TIRE REP EA 11.46 K0069 UE RR WHL COMPL SOL TIRE REP EA 82.52 K0070 NU RR WHL COMPL PNE TIRE REP EA 246.32 K0070 RR RR WHL COMPL PNE TIRE REP EA 20.18 K0070 UE RR WHL COMPL PNE TIRE REP EA 170.07 K0071 NU FR CSTR COMP PNE TIRE REP EA 120.29 K0071 RR FR CSTR COMP PNE TIRE REP EA 12.03 K0071 UE FR CSTR COMP PNE TIRE REP EA 90.19 K0072 NU FR CSTR SEMI-PNE TIRE REP EA 72.41 K0072 RR FR CSTR SEMI-PNE TIRE REP EA 7.25 K0072 UE FR CSTR SEMI-PNE TIRE REP EA 54.30 K0073 NU CASTER PIN LOCK EACH 38.33

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR K0073 RR CASTER PIN LOCK EACH 3.84 K0073 UE CASTER PIN LOCK EACH 28.74 K0077 NU FR CSTR ASMB SOL TIRE REP EA 64.81 K0077 RR FR CSTR ASMB SOL TIRE REP EA 6.46 K0077 UE FR CSTR ASMB SOL TIRE REP EA 48.58 K0098 NU DRIVE BELT FOR PWC, REPL 26.99 K0098 RR DRIVE BELT FOR PWC, REPL 2.70 K0098 UE DRIVE BELT FOR PWC, REPL 20.23 K0105 NU IV HANGER 109.48 K0105 RR IV HANGER 10.94 K0105 UE IV HANGER 82.11 K0108 W/C COMPONENT-ACCESSORY NOS BR K0195 RR ELEVATING WHLCHAIR LEG RESTS 17.27 K0455 RR PUMP UNINTERRUPTED INFUSION 263.03 K0462 TEMPORARY REPLACEMENT EQPMNT BR K0552 SUP/EXT NON-INS INF PUMP SYR 2.78 K0601 NU REPL BATT SILVER OXIDE 1.5 V 1.21 K0602 NU REPL BATT SILVER OXIDE 3 V 6.87 K0603 NU REPL BATT ALKALINE 1.5 V 0.61 K0604 NU REPL BATT LITHIUM 3.6 V 6.60 K0605 NU REPL BATT LITHIUM 4.5 V 15.81 K0606 RR AED GARMENT W ELEC ANALYSIS 2772.86 K0607 NU REPL BATT FOR AED 217.70 K0607 RR REPL BATT FOR AED 23.74 K0607 UE REPL BATT FOR AED 303.18 K0608 NU REPL GARMENT FOR AED 148.19 K0608 RR REPL GARMENT FOR AED 14.84 K0608 UE REPL GARMENT FOR AED 111.13 K0609 REPL ELECTRODE FOR AED 887.56 K0669 SEAT/BACK CUS NO DMEPDAC VER 261.32 K0672 REMOVABLE SOFT INTERFACE LE 80.95 K0730 NU CTRL DOSE INH DRUG DELIV SYS 1931.52 K0730 RR CTRL DOSE INH DRUG DELIV SYS 189.82 K0730 UE CTRL DOSE INH DRUG DELIV SYS 2273.84 K0733 NU 12-24HR SEALED LEAD ACID 30.74 K0733 RR 12-24HR SEALED LEAD ACID 3.10 K0733 UE 12-24HR SEALED LEAD ACID 23.08 K0738 RR PORTABLE GAS OXYGEN SYSTEM 68.02 K0739 REPAIR/SVC DME NON-OXYGEN EQ 36.18 K0740 REPAIR/SVC OXYGEN EQUIPMENT 19.68 K0743 PORTABLE HOME SUCTION PUMP BR K0744 ABSORP DRG <= 16 SUC PUMP BR K0745 ABSORP DRG >16<=48 SUC PUMP BR K0746 ABSORP DRG >48 SUC PUMP BR K0800 NU POV GROUP 1 STD UP TO 300LBS 1041.43 K0800 RR POV GROUP 1 STD UP TO 300LBS 104.15 K0800 UE POV GROUP 1 STD UP TO 300LBS 781.07 K0801 NU POV GROUP 1 HD 301-450 LBS 1771.68 K0801 RR POV GROUP 1 HD 301-450 LBS 177.16

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR K0801 UE POV GROUP 1 HD 301-450 LBS 1328.76 K0802 NU POV GROUP 1 VHD 451-600 LBS 2162.23 K0802 RR POV GROUP 1 VHD 451-600 LBS 216.22 K0802 UE POV GROUP 1 VHD 451-600 LBS 1621.67 K0806 NU POV GROUP 2 STD UP TO 300LBS 1404.14 K0806 RR POV GROUP 2 STD UP TO 300LBS 140.41 K0806 UE POV GROUP 2 STD UP TO 300LBS 1053.11 K0807 NU POV GROUP 2 HD 301-450 LBS 2152.06 K0807 RR POV GROUP 2 HD 301-450 LBS 215.21 K0807 UE POV GROUP 2 HD 301-450 LBS 1614.05 K0808 NU POV GROUP 2 VHD 451-600 LBS 3328.27 K0808 RR POV GROUP 2 VHD 451-600 LBS 332.83 K0808 UE POV GROUP 2 VHD 451-600 LBS 2496.20 K0812 POWER OPERATED VEHICLE NOC BR K0813 RR PWC GP 1 STD PORT SEAT/BACK 306.37 K0814 RR PWC GP 1 STD PORT CAP CHAIR 359.08 K0815 RR PWC GP 1 STD SEAT/BACK 403.96 K0816 RR PWC GP 1 STD CAP CHAIR 382.19 K0820 RR PWC GP 2 STD PORT SEAT/BACK 321.74 K0821 RR PWC GP 2 STD PORT CAP CHAIR 378.20 K0822 RR PWC GP 2 STD SEAT/BACK 438.06 K0823 RR PWC GP 2 STD CAP CHAIR 429.27 K0824 RR PWC GP 2 HD SEAT/BACK 564.89 K0825 RR PWC GP 2 HD CAP CHAIR 519.58 K0826 RR PWC GP 2 VHD SEAT/BACK 819.06 K0827 RR PWC GP VHD CAP CHAIR 705.18 K0828 RR PWC GP 2 XTRA HD SEAT/BACK 953.75 K0829 RR PWC GP 2 XTRA HD CAP CHAIR 900.68 K0830 PWC GP2 STD SEAT ELEVATE S/B BR K0831 PWC GP2 STD SEAT ELEVATE CAP 9181.95 K0835 RR PWC GP2 STD SING POW OPT S/B 458.90 K0836 RR PWC GP2 STD SING POW OPT CAP 475.93 K0837 RR PWC GP 2 HD SING POW OPT S/B 562.87 K0838 RR PWC GP 2 HD SING POW OPT CAP 501.73 K0839 RR PWC GP2 VHD SING POW OPT S/B 736.07 K0840 RR PWC GP2 XHD SING POW OPT S/B 1121.01 K0841 RR PWC GP2 STD MULT POW OPT S/B 499.10 K0842 RR PWC GP2 STD MULT POW OPT CAP 498.82 K0843 RR PWC GP2 HD MULT POW OPT S/B 597.33 K0848 RR PWC GP 3 STD SEAT/BACK 752.27 K0849 RR PWC GP 3 STD CAP CHAIR 723.26 K0850 RR PWC GP 3 HD SEAT/BACK 872.59 K0851 RR PWC GP 3 HD CAP CHAIR 839.01 K0852 RR PWC GP 3 VHD SEAT/BACK 1008.23 K0853 RR PWC GP 3 VHD CAP CHAIR 1035.71 K0854 RR PWC GP 3 XHD SEAT/BACK 1372.09 K0855 RR PWC GP 3 XHD CAP CHAIR 1296.14 K0856 RR PWC GP3 STD SING POW OPT S/B 807.46 K0857 RR PWC GP3 STD SING POW OPT CAP 823.65

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR K0858 RR PWC GP3 HD SING POW OPT S/B 1001.84 K0859 RR PWC GP3 HD SING POW OPT CAP 955.44 K0860 RR PWC GP3 VHD SING POW OPT S/B 1431.25 K0861 RR PWC GP3 STD MULT POW OPT S/B 808.76 K0862 RR PWC GP3 HD MULT POW OPT S/B 1001.84 K0863 RR PWC GP3 VHD MULT POW OPT S/B 1431.25 K0864 RR PWC GP3 XHD MULT POW OPT S/B 1703.19 K0868 PWC GP 4 STD SEAT/BACK BR K0869 PWC GP 4 STD CAP CHAIR BR K0870 PWC GP 4 HD SEAT/BACK BR K0871 PWC GP 4 VHD SEAT/BACK BR K0877 PWC GP4 STD SING POW OPT S/B BR K0878 PWC GP4 STD SING POW OPT CAP BR K0879 PWC GP4 HD SING POW OPT S/B BR K0880 PWC GP4 VHD SING POW OPT S/B BR K0884 PWC GP4 STD MULT POW OPT S/B 17951.84 K0885 PWC GP4 STD MULT POW OPT CAP BR K0886 PWC GP4 HD MULT POW S/B BR K0890 PWC GP5 PED SING POW OPT S/B 12133.14 K0891 PWC GP5 PED MULT POW OPT S/B BR K0898 POWER WHEELCHAIR NOC BR K0899 POW MOBIL DEV NO DMEPDAC 3808.44 K0900 CSTM DME OTHER THAN WHEELCHR 501.98 K1004 NU LO FREQ US DIATHERMY DEVICE BR K1004 RR LO FREQ US DIATHERMY DEVICE BR K1004 UE LO FREQ US DIATHERMY DEVICE BR K1007 BIL HKAF PC S/D MICRO SENSOR 83895.03 K1027 ORAL DEV WITHOUT FIX MECH 7978.54 K1030 EXT RECHARGE BAT REPLACEMENT BR L0112 CRANIAL CERVICAL ORTHOSIS 1484.62 L0113 CRANIAL CERVICAL TORTICOLLIS 302.50 L0120 CERV FLEX N/ADJ FOAM PRE OTS 29.68 L0130 FLEX THERMOPLASTIC COLLAR MO 214.59 L0140 CERVICAL SEMI-RIGID ADJUSTAB 74.05 L0150 CERV SEMI-RIG ADJ MOLDED CHN 123.48 L0160 CERV SR WIRE OCC/MAN PRE OTS 175.81 L0170 CERVICAL COLLAR MOLDED TO PT 743.99 L0172 CERV COL SR FOAM 2PC PRE OTS 150.85 L0174 CERV SR 2PC THOR EXT PRE OTS 270.99 L0180 CER POST COL OCC/MAN SUP ADJ 368.54 L0190 CERV COLLAR SUPP ADJ CERV BA 554.79 L0200 CERV COL SUPP ADJ BAR & THOR 509.43 L0220 THOR RIB BELT CUSTOM FABRICA 120.82 L0450 TLSO FLEX TRUNK/THOR PRE OTS 187.71 L0452 TLSO FLEX CUSTOM FAB THORACI 384.75 L0454 TLSO TRNK SJ-T9 PRE CST 367.88 L0455 TLSO FLEX TRNK SJ-T9 PRE OTS 346.21 L0456 TLSO FLEX TRNK SJ-SS PRE CST 1054.98 L0457 TLSO FLEX TRNK SJ-SS PRE OTS 992.85

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR L0458 TLSO 2MOD SYMPHIS-XIPHO PRE 946.01 L0460 TLSO 2 SHL SYMPHYS-STERN CST 1064.82 L0462 TLSO 3MOD SACRO-SCAP PRE 1324.44 L0464 TLSO 4MOD SACRO-SCAP PRE 1576.70 L0466 TLSO R FRAM SOFT ANT PRE CST 405.43 L0467 TLSO R FRAM SOFT PRE OTS 381.56 L0468 TLSO RIG FRAM PELVIC PRE CST 508.34 L0469 TLSO RIG FRAM PELVIC PRE OTS 478.39 L0470 TLSO RIGID FRAME PRE SUBCLAV 723.69 L0472 TLSO RIGID FRAME HYPEREX PRE 454.26 L0480 TLSO RIGID PLASTIC CUSTOM FA 1404.69 L0482 TLSO RIGID LINED CUSTOM FAB 1610.30 L0484 TLSO RIGID PLASTIC CUST FAB 1877.57 L0486 TLSO RIGIDLINED CUST FAB TWO 1859.96 L0488 TLSO RIGID LINED PRE ONE PIE 1064.82 L0490 TLSO RIGID PLASTIC PRE ONE 300.05 L0491 TLSO 2 PIECE RIGID SHELL 814.62 L0492 TLSO 3 PIECE RIGID SHELL 527.95 L0621 SIO FLEX PELVIC/SACR PRE OTS 89.02 L0622 SIO FLEX PELVISACRAL CUSTOM 256.48 L0623 SIO RIG PNL PELV/SAC PRE OTS 158.69 L0624 SIO PANEL CUSTOM 123.97 L0625 LO FLEX L1-BELOW L5 PRE OTS 55.02 L0626 LO SAG RIG PNL STAYS PRE CST 82.69 L0627 LO SAG RI AN/POS PNL PRE CST 436.04 L0628 LSO FLEX NO RI STAYS PRE OTS 83.72 L0629 LSO FLEX W/RIGID STAYS CUST 227.20 L0630 LSO R POST PNL SJ-T9 PRE CST 171.76 L0631 LSO SAG R AN/POS PNL PRE CST 1088.93 L0632 LSO SAG RIGID FRAME CUST 1131.91 L0633 LSO SC R POS/LAT PNL PRE CST 304.18 L0634 LSO FLEXION CONTROL CUSTOM 747.97 L0635 LSO SAGIT RIGID PANEL PREFAB 1127.94 L0636 LSO SAGITTAL RIGID PANEL CUS 1664.36 L0637 LSO SC R ANT/POS PNL PRE CST 1444.03 L0638 LSO SAG-CORONAL PANEL CUSTOM 1399.02 L0639 LSO S/C SHELL/PANEL PREFAB 1444.03 L0640 LSO S/C SHELL/PANEL CUSTOM 1109.96 L0641 LO RIG POS PNL L1-L5 PRE OTS 77.82 L0642 LO SAG RI AN/POS PNL PRE OTS 410.36 L0643 LSO SAG CTR RIGI POS PRE OTS 161.65 L0648 LSO SAG R AN/POS PNL PRE OTS 1024.80 L0649 LSO SC R POS/LAT PNL PRE OTS 286.26 L0650 LSO SC R ANT/POS PNL PRE OTS 1358.99 L0651 LSO SAG-CO SHELL PNL PRE OTS 1358.99 L0700 CTLSO A-P-L CONTROL MOLDED 2283.79 L0710 CTLSO A-P-L CONTROL W/ INTER 2492.90 L0720 CTLSO A-P-L CONTROL CUSTOM BR L0810 HALO CERVICAL INTO JCKT VEST 2648.35

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR L0820 HALO CERVICAL INTO BODY JACK 2142.40 L0830 HALO CERV INTO MILWAUKEE TYP 3093.39 L0859 MRI COMPATIBLE SYSTEM 1201.76 L0861 HALO REPL LINER/INTERFACE 228.63 L0970 TLSO CORSET FRONT 112.75 L0972 LSO CORSET FRONT 115.25 L0974 TLSO FULL CORSET 235.49 L0976 LSO FULL CORSET 210.32 L0978 AXILLARY CRUTCH EXTENSION 189.89 L0980 PERONEAL STRAPS PAIR PRE OTS 17.23 L0982 STOCKING SUP GRIPS 4 PRE OTS 18.78 L0984 PROTECT BODY SOCK EA PRE OTS 59.90 L0999 ADD TO SPINAL ORTHOSIS NOS BR L1000 CTLSO MILWAUKE INITIAL MODEL 2002.78 L1001 CTLSO INFANT IMMOBILIZER BR L1005 TENSION BASED SCOLIOSIS ORTH 3395.07 L1006 SCOLIOSIS ORTH SAG/ COR 1283.42 L1010 CTLSO AXILLA SLING 80.65 L1020 KYPHOSIS PAD 110.20 L1025 KYPHOSIS PAD FLOATING 125.25 L1030 LUMBAR BOLSTER PAD 83.67 L1040 LUMBAR OR LUMBAR RIB PAD 100.71 L1050 STERNAL PAD 87.19 L1060 THORACIC PAD 98.35 L1070 TRAPEZIUS SLING 100.57 L1080 OUTRIGGER 69.68 L1085 OUTRIGGER BIL W/ VERT EXTENS 193.58 L1090 LUMBAR SLING 90.42 L1100 RING FLANGE PLASTIC/LEATHER 159.62 L1110 RING FLANGE PLAS/LEATHER MOL 270.36 L1120 COVERS FOR UPRIGHT EACH 43.06 L1200 FURNSH INITIAL ORTHOSIS ONLY 1714.38 L1210 LATERAL THORACIC EXTENSION 258.12 L1220 ANTERIOR THORACIC EXTENSION 218.55 L1230 MILWAUKEE TYPE SUPERSTRUCTUR 560.76 L1240 LUMBAR DEROTATION PAD 96.50 L1250 ANTERIOR ASIS PAD 95.03 L1260 ANTERIOR THORACIC DEROTATION 97.67 L1270 ABDOMINAL PAD 97.55 L1280 RIB GUSSET (ELASTIC) EACH 86.95 L1290 LATERAL TROCHANTERIC PAD 98.57 L1300 BODY JACKET MOLD TO PATIENT 1647.85 L1310 POST-OPERATIVE BODY JACKET 1695.63 L1320 PECTUS CARINATUM ORTHO CUST 2940.44 L1499 SPINAL ORTHOSIS NOS BR L1600 HO FLEX FREJKA W/COV PRE CST 127.12 L1610 HO FREJKA COV ONLY PRE CST 43.31 L1620 HO FLEX PAVLIK HARNS PRE CST 142.61 L1630 ABDUCT CONTROL HIP SEMI-FLEX 170.18

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR L1640 PELV BAND/SPREAD BAR THIGH C 455.19 L1650 HO ABDUCTION HIP ADJUSTABLE 241.40 L1652 HO BI THIGHCUFFS W SPRDR BAR 378.13 L1653 HO ABDUCTION STATIC OTS 431.84 L1660 HO ABDUCTION STATIC PLASTIC 168.82 L1680 PELVIC & HIP CONTROL THIGH C 1387.97 L1681 HO BILATERAL HIP ABDUCTION 2191.52 L1685 POST-OP HIP ABDUCT CUSTOM FA 1464.54 L1686 HO POST-OP HIP ABDUCTION 982.51 L1690 COMBINATION BILATERAL HO 2051.21 L1700 LEG PERTHES ORTH TORONTO TYP 1706.47 L1710 LEGG PERTHES ORTH NEWINGTON 2005.85 L1720 LEGG PERTHES ORTHOSIS TRILAT 1481.72 L1730 LEGG PERTHES ORTH SCOTTISH R 1117.92 L1755 LEGG PERTHES PATTEN BOTTOM T 1627.17 L1810 KO ELASTIC WITH JOINTS 128.42 L1812 KO ELASTIC W/JOINTS PRE OTS 120.86 L1820 KO ELAS W/ CONDYLE PADS & JO 127.91 L1821 KO ELAS W/ CONDYLE PADS OTF 146.07 L1830 KO IMMOB CANVAS LONG PRE OTS 100.69 L1831 KNEE ORTH POS LOCKING JOINT 312.17 L1832 KO ADJ JNT POS R SUP PRE CST 799.66 L1833 KO ADJ JNT POS R SUP PRE OTS 752.57 L1834 KO W/0 JOINT RIGID MOLDED TO 940.80 L1836 KO RIGID W/O JOINTS PRE OTS 133.19 L1840 KO DEROT ANT CRUCIATE CUSTOM 988.94 L1843 KO SINGLE UPRIGHT PRE CST 951.75 L1844 KO W/ADJ JT ROT CNTRL MOLDED 1649.17 L1845 KO DOUBLE UPRIGHT PRE CST 993.54 L1846 KO W ADJ FLEX/EXT ROTAT MOLD 1260.63 L1847 KO DBL UPRIGHT W/AIR PRE CST 610.13 L1848 KO DBL UPRIGHT W/AIR PRE OTS 610.13 L1850 KO SWEDISH TYPE PRE OTS 267.23 L1851 KO SINGLE UPRIGHT PREFAB OTS 895.70 L1852 KO DOUBLE UPRIGHT PREFAB OTS 935.02 L1860 KO SUPRACONDYLAR SOCKET MOLD 1101.33 L1900 AFO SPRNG WIR DRSFLX CALF BD 298.37 L1902 AFO ANKLE GAUNTLET PRE OTS 81.03 L1904 AFO MOLDED ANKLE GAUNTLET 463.88 L1906 AFO MULTILIG ANK SUP PRE OTS 135.57 L1907 AFO SUPRAMALLEOLAR CUSTOM 596.86 L1910 AFO SING BAR CLASP ATTACH SH 263.81 L1920 AFO SING UPRIGHT W/ ADJUST S 344.87 L1930 AFO PLASTIC 233.36 L1932 AFO RIG ANT TIB PREFAB TCF/= 946.56 L1933 AFO RIG ANT TIB TCF/= OTS BR L1940 AFO MOLDED TO PATIENT PLASTI 527.38 L1945 AFO MOLDED PLAS RIG ANT TIB 968.48 L1950 AFO SPIRAL MOLDED TO PT PLAS 734.78

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR L1951 AFO SPIRAL PREFABRICATED 890.84 L1952 AFO SPIRAL PREFAB OTS BR L1960 AFO POS SOLID ANK PLASTIC MO 546.80 L1970 AFO PLASTIC MOLDED W/ANKLE J 808.76 L1971 AFO W/ANKLE JOINT, PREFAB 497.19 L1980 AFO SING SOLID STIRRUP CALF 362.04 L1990 AFO DOUB SOLID STIRRUP CALF 465.17 L2000 KAFO SING FRE STIRR THI/CALF 1000.58 L2005 KAFO SNG/DBL MECHANICAL ACT 4346.62 L2006 KAF SNG/DBL SWG/STN MCPR CUS 88584.64 L2010 KAFO SNG SOLID STIRRUP W/O J 912.12 L2020 KAFO DBL SOLID STIRRUP BAND/ 1151.87 L2030 KAFO DBL SOLID STIRRUP W/O J 999.35 L2034 KAFO PLA SIN UP W/WO K/A CUS 2178.03 L2035 KAFO PLASTIC PEDIATRIC SIZE 183.76 L2036 KAFO PLAS DOUB FREE KNEE MOL 1830.24 L2037 KAFO PLAS SING FREE KNEE MOL 1686.68 L2038 KAFO W/O JOINT MULTI-AXIS AN 1410.41 L2040 HKAFO TORSION BIL ROT STRAPS 180.16 L2050 HKAFO TORSION CABLE HIP PELV 479.77 L2060 HKAFO TORSION BALL BEARING J 615.77 L2070 HKAFO TORSION UNILAT ROT STR 176.89 L2080 HKAFO UNILAT TORSION CABLE 377.25 L2090 HKAFO UNILAT TORSION BALL BR 464.97 L2106 AFO TIB FX CAST PLASTER MOLD 670.73 L2108 AFO TIB FX CAST MOLDED TO PT 1054.01 L2112 AFO TIBIAL FRACTURE SOFT 500.47 L2114 AFO TIB FX SEMI-RIGID 572.59 L2116 AFO TIBIAL FRACTURE RIGID 754.39 L2126 KAFO FEM FX CAST THERMOPLAS 1342.27 L2128 KAFO FEM FX CAST MOLDED TO P 1691.55 L2132 KAFO FEMORAL FX CAST SOFT 795.78 L2134 KAFO FEM FX CAST SEMI-RIGID 954.10 L2136 KAFO FEMORAL FX CAST RIGID 1166.61 L2180 PLAS SHOE INSERT W ANK JOINT 115.53 L2182 DROP LOCK KNEE 90.42 L2184 LIMITED MOTION KNEE JOINT 162.93 L2186 ADJ MOTION KNEE JNT LERMAN T 180.55 L2188 QUADRILATERAL BRIM 393.92 L2190 WAIST BELT 102.31 L2192 PELVIC BAND & BELT THIGH FLA 351.74 L2200 LIMITED ANKLE MOTION EA JNT 46.90 L2210 DORSIFLEXION ASSIST EACH JOI 76.09 L2220 DORSI & PLANTAR FLEX ASS/RES 87.38 L2230 SPLIT FLAT CALIPER STIRR & P 75.69 L2232 ROCKER BOTTOM, CONTACT AFO 102.48 L2240 ROUND CALIPER AND PLATE ATTA 82.51 L2250 FOOT PLATE MOLDED STIRRUP AT 350.52 L2260 REINFORCED SOLID STIRRUP 197.75

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR L2265 LONG TONGUE STIRRUP 116.18 L2270 VARUS/VALGUS STRAP PADDED/LI 52.98 L2275 PLASTIC MOD LOW EXT PAD/LINE 128.91 L2280 MOLDED INNER BOOT 478.88 L2300 ABDUCTION BAR JOINTED ADJUST 270.32 L2310 ABDUCTION BAR-STRAIGHT 121.36 L2320 NON-MOLDED LACER 202.97 L2330 LACER MOLDED TO PATIENT MODE 387.35 L2335 ANTERIOR SWING BAND 227.87 L2340 PRE-TIBIAL SHELL MOLDED TO P 537.71 L2350 PROSTHETIC TYPE SOCKET MOLDE 879.01 L2360 EXTENDED STEEL SHANK 51.04 L2370 PATTEN BOTTOM 253.23 L2375 TORSION ANK & HALF SOLID STI 111.46 L2380 TORSION STRAIGHT KNEE JOINT 121.45 L2385 STRAIGHT KNEE JOINT HEAVY DU 132.13 L2387 ADD LE POLY KNEE CUSTOM KAFO 179.31 L2390 OFFSET KNEE JOINT EACH 107.99 L2395 OFFSET KNEE JOINT HEAVY DUTY 164.87 L2397 SUSPENSION SLEEVE LOWER EXT 115.62 L2405 KNEE JOINT DROP LOCK EA JNT 92.49 L2415 KNEE JOINT CAM LOCK EACH JOI 128.86 L2425 KNEE DISC/DIAL LOCK/ADJ FLEX 152.05 L2430 KNEE JNT RATCHET LOCK EA JNT 152.05 L2492 KNEE LIFT LOOP DROP LOCK RIN 100.59 L2500 THI/GLUT/ISCHIA WGT BEARING 311.21 L2510 TH/WGHT BEAR QUAD-LAT BRIM M 833.23 L2520 TH/WGHT BEAR QUAD-LAT BRIM C 454.45 L2525 TH/WGHT BEAR NAR M-L BRIM MO 1559.13 L2526 TH/WGHT BEAR NAR M-L BRIM CU 840.39 L2530 THIGH/WGHT BEAR LACER NON-MO 231.78 L2540 THIGH/WGHT BEAR LACER MOLDED 417.07 L2550 THIGH/WGHT BEAR HIGH ROLL CU 283.32 L2570 HIP CLEVIS TYPE 2 POSIT JNT 626.49 L2580 PELVIC CONTROL PELVIC SLING 593.88 L2600 HIP CLEVIS/THRUST BEARING FR 202.60 L2610 HIP CLEVIS/THRUST BEARING LO 239.57 L2620 PELVIC CONTROL HIP HEAVY DUT 263.76 L2622 HIP JOINT ADJUSTABLE FLEXION 302.51 L2624 HIP ADJ FLEX EXT ABDUCT CONT 411.26 L2627 PLASTIC MOLD RECIPRO HIP & C 1694.37 L2628 METAL FRAME RECIPRO HIP & CA 1990.34 L2630 PELVIC CONTROL BAND & BELT U 244.28 L2640 PELVIC CONTROL BAND & BELT B 331.51 L2650 PELV & THOR CONTROL GLUTEAL 118.38 L2660 THORACIC CONTROL THORACIC BA 183.86 L2670 THORAC CONT PARASPINAL UPRIG 168.27 L2680 THORAC CONT LAT SUPPORT UPRI 154.37 L2750 PLATING CHROME/NICKEL PR BAR 82.45

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR L2755 CARBON GRAPHITE LAMINATION 138.63 L2760 EXTENSION PER EXTENSION PER 59.94 L2768 ORTHO SIDEBAR DISCONNECT 138.21 L2780 NON-CORROSIVE FINISH 70.90 L2785 DROP LOCK RETAINER EACH 41.68 L2795 KNEE CONTROL FULL KNEECAP 83.82 L2800 KNEE CAP MEDIAL OR LATERAL P 105.23 L2810 KNEE CONTROL CONDYLAR PAD 77.05 L2820 SOFT INTERFACE BELOW KNEE SE 85.67 L2830 SOFT INTERFACE ABOVE KNEE SE 96.33 L2840 TIBIAL LENGTH SOCK FX OR EQU 53.77 L2850 FEMORAL LGTH SOCK FX OR EQUA 61.08 L2861 TORSION MECHANISM KNEE/ANKLE 446.73 L2999 LOWER EXTREMITY ORTHOSIS NOS BR L3000 FT INSERT UCB BERKELEY SHELL 333.22 L3001 FOOT INSERT REMOV MOLDED SPE 140.29 L3002 FOOT INSERT PLASTAZOTE OR EQ 171.31 L3003 FOOT INSERT SILICONE GEL EAC 184.82 L3010 FOOT LONGITUDINAL ARCH SUPPO 184.82 L3020 FOOT LONGITUD/METATARSAL SUP 210.45 L3030 FOOT ARCH SUPPORT REMOV PREM 80.96 L3031 FOOT LAMIN/PREPREG COMPOSITE 129.90 L3040 FT ARCH SUPRT PREMOLD LONGIT 49.92 L3050 FOOT ARCH SUPP PREMOLD METAT 49.92 L3060 FOOT ARCH SUPP LONGITUD/META 78.24 L3070 ARCH SUPRT ATT TO SHO LONGIT 33.73 L3080 ARCH SUPP ATT TO SHOE METATA 33.73 L3090 ARCH SUPP ATT TO SHOE LONG/M 43.18 L3100 HALLUS-VALGUS NT DYN PRE OTS 45.84 L3140 ABDUCTION ROTATION BAR SHOE 94.45 L3150 ABDUCT ROTATION BAR W/O SHOE 86.35 L3160 SHOE STYLED POSITIONING DEV 127.95 L3161 FOOT, ADDUCTUS POSITION, ADJ BR L3170 FOOT PLAS HEEL STABI PRE OTS 53.97 L3201 OXFORD W SUPINAT/PRONAT INF 52.13 L3202 OXFORD W/ SUPINAT/PRONATOR C 58.49 L3203 OXFORD W/ SUPINATOR/PRONATOR 60.02 L3204 HIGHTOP W/ SUPP/PRONATOR INF 57.47 L3206 HIGHTOP W/ SUPP/PRONATOR CHI 63.55 L3207 HIGHTOP W/ SUPP/PRONATOR JUN 74.51 L3208 SURGICAL BOOT EACH INFANT 45.40 L3209 SURGICAL BOOT EACH CHILD 35.51 L3211 SURGICAL BOOT EACH JUNIOR 48.98 L3212 BENESCH BOOT PAIR INFANT 50.37 L3213 BENESCH BOOT PAIR CHILD 66.22 L3214 BENESCH BOOT PAIR JUNIOR 64.88 L3215 ORTHOPEDIC FTWEAR LADIES OXF 101.12 L3216 ORTHOPED LADIES SHOES DPTH I 116.56 L3217 LADIES SHOES HIGHTOP DEPTH I 266.06

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR L3219 ORTHOPEDIC MENS SHOES OXFORD 108.32 L3221 ORTHOPEDIC MENS SHOES DPTH I 134.56 L3222 MENS SHOES HIGHTOP DEPTH INL 170.26 L3224 WOMAN'S SHOE OXFORD BRACE 58.01 L3225 MAN'S SHOE OXFORD BRACE 66.73 L3230 CUSTOM SHOES DEPTH INLAY 184.86 L3250 CUSTOM MOLD SHOE REMOV PROST 367.13 L3251 SHOE MOLDED TO PT SILICONE S 38.84 L3252 SHOE MOLDED PLASTAZOTE CUST 319.33 L3253 SHOE MOLDED PLASTAZOTE CUST 71.96 L3254 ORTH FOOT NON-STNDARD SIZE/W 34.44 L3255 ORTH FOOT NON-STANDARD SIZE/ 17.48 L3257 ORTH FOOT ADD CHARGE SPLIT S 63.85 L3260 AMBULATORY SURGICAL BOOT EAC 42.42 L3265 PLASTAZOTE SANDAL EACH 29.53 L3300 SHO LIFT TAPER TO METATARSAL 55.30 L3310 SHOE LIFT ELEV HEEL/SOLE NEO 86.35 L3320 SHOE LIFT ELEV HEEL/SOLE COR 154.25 L3330 LIFTS ELEVATION METAL EXTENS 600.30 L3332 SHOE LIFTS TAPERED TO ONE-HA 78.24 L3334 SHOE LIFTS ELEVATION HEEL /I 40.47 L3340 SHOE WEDGE SACH 90.41 L3350 SHOE HEEL WEDGE 24.26 L3360 SHOE SOLE WEDGE OUTSIDE SOLE 37.77 L3370 SHOE SOLE WEDGE BETWEEN SOLE 52.62 L3380 SHOE CLUBFOOT WEDGE 52.62 L3390 SHOE OUTFLARE WEDGE 52.62 L3400 SHOE METATARSAL BAR WEDGE RO 43.18 L3410 SHOE METATARSAL BAR BETWEEN 98.50 L3420 FULL SOLE/HEEL WEDGE BTWEEN 57.99 L3430 SHO HEEL COUNT PLAST REINFOR 169.98 L3440 HEEL LEATHER REINFORCED 80.96 L3450 SHOE HEEL SACH CUSHION TYPE 111.94 L3455 SHOE HEEL NEW LEATHER STANDA 43.18 L3460 SHOE HEEL NEW RUBBER STANDAR 36.41 L3465 SHOE HEEL THOMAS WITH WEDGE 62.05 L3470 SHOE HEEL THOMAS EXTEND TO B 66.09 L3480 SHOE HEEL PAD & DEPRESS FOR 66.09 L3485 SHOE HEEL PAD REMOVABLE FOR 35.12 L3500 ORTHO SHOE ADD LEATHER INSOL 31.06 L3510 ORTHOPEDIC SHOE ADD RUB INSL 31.06 L3520 O SHOE ADD FELT W LEATH INSL 33.73 L3530 ORTHO SHOE ADD HALF SOLE 33.73 L3540 ORTHO SHOE ADD FULL SOLE 53.97 L3550 O SHOE ADD STANDARD TOE TAP 9.46 L3560 O SHOE ADD HORSESHOE TOE TAP 24.26 L3570 O SHOE ADD INSTEP EXTENSION 90.41 L3580 O SHOE ADD INSTEP VELCRO CLO 68.80 L3590 O SHOE CONVERT TO SOF COUNTE 56.67

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR L3595 ORTHO SHOE ADD MARCH BAR 44.51 L3600 TRANS SHOE CALIP PLATE EXIST 80.96 L3610 TRANS SHOE CALIPER PLATE NEW 106.56 L3620 TRANS SHOE SOLID STIRRUP EXI 80.96 L3630 TRANS SHOE SOLID STIRRUP NEW 106.56 L3640 SHOE DENNIS BROWNE SPLINT BO 45.84 L3649 ORTHOPEDIC SHOE MODIFICA NOS BR L3650 SO 8 ABD RESTRAINT PRE OTS 57.78 L3660 SO 8 AB RSTR CAN/WEB PRE OTS 99.21 L3670 SO ACRO/CLAV CAN WEB PRE OTS 138.28 L3671 SO CAP DESIGN W/O JNTS CF 869.83 L3674 SO AIRPLANE W/WO JOINT CF 1141.10 L3675 SO VEST CANVAS/WEB PRE OTS 169.41 L3677 SO HARD PLAS STABILI PRE CST 159.55 L3678 SO HARD PLAS STABILI PRE OTS 98.42 L3702 EO W/O JOINTS CF 278.76 L3710 EO ELAS W/METAL JNTS PRE OTS 139.97 L3720 FOREARM/ARM CUFFS FREE MOTIO 698.28 L3730 FOREARM/ARM CUFFS EXT/FLEX A 919.20 L3740 CUFFS ADJ LOCK W/ ACTIVE CON 1033.04 L3760 EO ADJ JT PREFAB CUSTOM FIT 482.76 L3761 EO, ADJ LOCK JOINT PREFAB OT 908.66 L3762 EO RIGID W/O JOINTS PRE OTS 103.82 L3763 EWHO RIGID W/O JNTS CF 766.45 L3764 EWHO W/JOINT(S) CF 764.36 L3765 EWHFO RIGID W/O JNTS CF 1237.83 L3766 EWHFO W/JOINT(S) CF 1310.78 L3806 WHFO W/JOINT(S) CUSTOM FAB 438.50 L3807 WHFO W/O JOINTS PRE CST 241.40 L3808 WHFO, RIGID W/O JOINTS 322.44 L3809 WHFO W/O JOINTS PRE OTS 241.40 L3891 TORSION MECHANISM WRIST/ELBO 221.46 L3900 HINGE EXTENSION/FLEX WRIST/F 1508.06 L3901 HINGE EXT/FLEX WRIST FINGER 1690.94 L3904 WHFO ELECTRIC CUSTOM FITTED 3442.28 L3905 WHO W/NONTORSION JNT(S) CF 957.36 L3906 WHO W/O JOINTS CF 407.24 L3908 WHO COCK-UP NONMOLDE PRE OTS 57.83 L3912 HFO FLEXION GLOVE PRE OTS 92.78 L3913 HFO W/O JOINTS CF 261.47 L3915 WHO NONTORSION JNTS PRE CST 513.17 L3916 WHO NONTORSION JNTS PRE OTS 513.17 L3917 METACARP FX ORTHOSIS PRE CST 101.98 L3918 METACARP FX ORTHOSIS PRE OTS 101.98 L3919 HO W/O JOINTS CF 261.47 L3921 HFO W/JOINT(S) CF 310.06 L3923 HFO WITHOUT JOINTS PRE CST 83.97 L3924 HFO WITHOUT JOINTS PRE OTS 83.97 L3925 FO PIP DIP JNT/SPRNG PRE OTS 50.99

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR L3927 FO PIP DIP NO JT SPR PRE OTS 33.78 L3929 HFO NONTORSION JNTS PRE CST 81.26 L3930 HFO NONTORSION JNTS PRE OTS 81.26 L3931 WHFO NONTORSION JOINT PREFAB 196.60 L3933 FO W/O JOINTS CF 205.97 L3935 FO NONTORSION JOINT CF 213.30 L3956 ADD JOINT UPPER EXT ORTHOSIS 113.48 L3960 SEWHO AIRPLAN DESIG ABDU POS 795.72 L3961 SEWHO CAP DESIGN W/O JNTS CF 1621.92 L3962 SEWHO ERBS PALSEY DESIGN ABD 828.52 L3967 SEWHO AIRPLANE W/O JNTS CF 1914.94 L3971 SEWHO CAP DESIGN W/JNT(S) CF 1817.69 L3973 SEWHO AIRPLANE W/JNT(S) CF 1914.94 L3975 SEWHFO CAP DESIGN W/O JNT CF 1621.92 L3976 SEWHFO AIRPLANE W/O JNTS CF 1621.92 L3977 SEWHFO CAP DESGN W/JNT(S) CF 1817.69 L3978 SEWHFO AIRPLANE W/JNT(S) CF 1914.94 L3980 UP EXT FX ORTHOS HUMERAL NOS 298.43 L3981 UE FX ORTH SHOUL CAP FOREARM 971.70 L3982 UPPER EXT FX ORTHOSIS RAD/UL 368.69 L3984 UPPER EXT FX ORTHOSIS WRIST 393.56 L3995 SOCK FRACTURE OR EQUAL EACH 33.02 L3999 UPPER LIMB ORTHOSIS NOS BR L4000 REPL GIRDLE MILWAUKEE ORTH 1286.90 L4002 REPLACE STRAP, ANY ORTHOSIS 29.53 L4010 REPLACE TRILATERAL SOCKET BR 724.19 L4020 REPLACE QUADLAT SOCKET BRIM 904.57 L4030 REPLACE SOCKET BRIM CUST FIT 498.06 L4040 REPLACE MOLDED THIGH LACER 402.68 L4045 REPLACE NON-MOLDED THIGH LAC 323.60 L4050 REPLACE MOLDED CALF LACER 407.26 L4055 REPLACE NON-MOLDED CALF LACE 263.72 L4060 REPLACE HIGH ROLL CUFF 313.50 L4070 REPLACE PROX & DIST UPRIGHT 299.09 L4080 REPL MET BAND KAFO-AFO PROX 105.45 L4090 REPL MET BAND KAFO-AFO CALF/ 93.33 L4100 REPL LEATH CUFF KAFO PROX TH 105.27 L4110 REPL LEATH CUFF KAFO-AFO CAL 83.66 L4130 REPLACE PRETIBIAL SHELL 575.76 L4205 ORTHO DVC REPAIR PER 15 MIN 35.72 L4210 ORTH DEV REPAIR/REPL MINOR P 63.98 L4350 ANKLE CONTROL ORTHO PRE OTS 103.73 L4360 PNEUMAT WALKING BOOT PRE CST 290.21 L4361 PNEUMA/VAC WALK BOOT PRE OTS 290.21 L4370 PNEUM FULL LEG SPLNT PRE OTS 186.23 L4386 NON-PNEUM WALK BOOT PRE CST 168.17 L4387 NON-PNEUM WALK BOOT PRE OTS 168.17 L4392 REPLACE AFO SOFT INTERFACE 24.98 L4394 REPLACE FOOT DROP SPINT 18.22

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR L4396 STATIC OR DYNAMI AFO PRE CST 178.05 L4397 STATIC OR DYNAMI AFO PRE OTS 178.05 L4398 FOOT DROP SPLINT PRE OTS 81.94 L4631 AFO, WALK BOOT TYPE, CUS FAB 1582.95 L5000 SHO INSERT W ARCH TOE FILLER 556.20 L5010 MOLD SOCKET ANK HGT W/ TOE F 1343.35 L5020 TIBIAL TUBERCLE HGT W/ TOE F 2281.29 L5050 ANK SYMES MOLD SCKT SACH FT 2523.51 L5060 SYMES MET FR LEATH SOCKET AR 2902.80 L5100 MOLDED SOCKET SHIN SACH FOOT 2529.09 L5105 PLAST SOCKET JTS/THGH LACER 3651.03 L5150 MOLD SCKT EXT KNEE SHIN SACH 3690.69 L5160 MOLD SOCKET BENT KNEE SHIN S 4014.29 L5200 KNE SING AXIS FRIC SHIN SACH 3844.25 L5210 NO KNEE/ANKLE JOINTS W/ FT B 2550.27 L5220 NO KNEE JOINT WITH ARTIC ALI 2898.85 L5230 FEM FOCAL DEFIC CONSTANT FRI 3998.08 L5250 HIP CANAD SING AXI CONS FRIC 5453.03 L5270 TILT TABLE LOCKING HIP SING 5428.84 L5280 HEMIPELVECT CANAD SING AXIS 5387.27 L5301 BK MOLD SOCKET SACH FT ENDO 2890.93 L5312 KNEE DISART, SACH FT, ENDO 4138.17 L5321 AK OPEN END SACH 4190.47 L5331 HIP DISART CANADIAN SACH FT 5339.50 L5341 HEMIPELVECTOMY CANADIAN SACH 5558.46 L5400 POSTOP DRESS & 1 CAST CHG BK 1431.25 L5410 POSTOP DSG BK EA ADD CAST CH 439.11 L5420 POSTOP DSG & 1 CAST CHG AK/D 1753.95 L5430 POSTOP DSG AK EA ADD CAST CH 528.87 L5450 POSTOP APP NON-WGT BEAR DSG 430.25 L5460 POSTOP APP NON-WGT BEAR DSG 573.25 L5500 INIT BK PTB PLASTER DIRECT 1349.79 L5505 INIT AK ISCHAL PLSTR DIRECT 1866.82 L5510 PREP BK PTB PLASTER MOLDED 1530.08 L5520 PERP BK PTB THERMOPLS DIRECT 1511.35 L5530 PREP BK PTB THERMOPLS MOLDED 1815.28 L5535 PREP BK PTB OPEN END SOCKET 1782.25 L5540 PREP BK PTB LAMINATED SOCKET 1902.22 L5560 PREP AK ISCHIAL PLAST MOLDED 2042.65 L5570 PREP AK ISCHIAL DIRECT FORM 2123.64 L5580 PREP AK ISCHIAL THERMO MOLD 2479.20 L5585 PREP AK ISCHIAL OPEN END 3051.05 L5590 PREP AK ISCHIAL LAMINATED 2526.47 L5595 HIP DISARTIC SACH THERMOPLS 4463.36 L5600 HIP DISART SACH LAMINAT MOLD 4797.90 L5610 ABOVE KNEE HYDRACADENCE 2175.92 L5611 AK 4 BAR LINK W/FRIC SWING 1693.30 L5613 AK 4 BAR LING W/HYDRAUL SWIG 2647.43 L5614 4-BAR LINK ABOVE KNEE W/SWNG 1793.45

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR L5615 AK 4 BAR LINK HYDL SWG/STANC 6550.59 L5616 AK UNIV MULTIPLEX SYS FRICT 1430.65 L5617 AK/BK SELF-ALIGNING UNIT EA 594.65 L5618 TEST SOCKET SYMES 314.59 L5620 TEST SOCKET BELOW KNEE 292.19 L5622 TEST SOCKET KNEE DISARTICULA 381.01 L5624 TEST SOCKET ABOVE KNEE 382.09 L5626 TEST SOCKET HIP DISARTICULAT 501.09 L5628 TEST SOCKET HEMIPELVECTOMY 535.80 L5629 BELOW KNEE ACRYLIC SOCKET 333.99 L5630 SYME TYP EXPANDABL WALL SCKT 471.67 L5631 AK/KNEE DISARTIC ACRYLIC SOC 461.77 L5632 SYMES TYPE PTB BRIM DESIGN S 257.72 L5634 SYMES TYPE POSTER OPENING SO 319.69 L5636 SYMES TYPE MEDIAL OPENING SO 267.79 L5637 BELOW KNEE TOTAL CONTACT 303.61 L5638 BELOW KNEE LEATHER SOCKET 528.88 L5639 BELOW KNEE WOOD SOCKET 1178.33 L5640 KNEE DISARTICULAT LEATHER SO 672.03 L5642 ABOVE KNEE LEATHER SOCKET 651.15 L5643 HIP FLEX INNER SOCKET EXT FR 1635.78 L5644 ABOVE KNEE WOOD SOCKET 620.75 L5645 BK FLEX INNER SOCKET EXT FRA 838.56 L5646 BELOW KNEE CUSHION SOCKET 575.84 L5647 BELOW KNEE SUCTION SOCKET 836.01 L5648 ABOVE KNEE CUSHION SOCKET 691.93 L5649 ISCH CONTAINMT/NARROW M-L SO 2507.28 L5650 TOT CONTACT AK/KNEE DISART S 513.07 L5651 AK FLEX INNER SOCKET EXT FRA 1262.13 L5652 SUCTION SUSP AK/KNEE DISART 458.20 L5653 KNEE DISART EXPAND WALL SOCK 611.66 L5654 SOCKET INSERT SYMES 348.55 L5655 SOCKET INSERT BELOW KNEE 295.37 L5656 SOCKET INSERT KNEE ARTICULAT 396.24 L5658 SOCKET INSERT ABOVE KNEE 382.13 L5661 MULTI-DUROMETER SYMES 639.57 L5665 MULTI-DUROMETER BELOW KNEE 538.12 L5666 BELOW KNEE CUFF SUSPENSION 73.57 L5668 BK MOLDED DISTAL CUSHION 118.67 L5670 BK MOLDED SUPRACONDYLAR SUSP 285.18 L5671 BK/AK LOCKING MECHANISM 604.34 L5672 BK REMOVABLE MEDIAL BRIM SUS 313.39 L5673 SOCKET INSERT W LOCK MECH 747.30 L5676 BK KNEE JOINTS SINGLE AXIS P 380.85 L5677 BK KNEE JOINTS POLYCENTRIC P 518.19 L5678 BK JOINT COVERS PAIR 41.73 L5679 SOCKET INSERT W/O LOCK MECH 622.72 L5680 BK THIGH LACER NON-MOLDED 348.34 L5681 INTL CUSTM CONG/LATYP INSERT 1398.02

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR L5682 BK THIGH LACER GLUT/ISCHIA M 657.26 L5683 INITIAL CUSTOM SOCKET INSERT 1398.02 L5684 BK FORK STRAP 50.59 L5685 BELOW KNEE SUS/SEAL SLEEVE 136.13 L5686 BK BACK CHECK 53.69 L5688 BK WAIST BELT WEBBING 64.20 L5690 BK WAIST BELT PADDED AND LIN 102.84 L5692 AK PELVIC CONTROL BELT LIGHT 139.65 L5694 AK PELVIC CONTROL BELT PAD/L 190.66 L5695 AK SLEEVE SUSP NEOPRENE/EQUA 176.00 L5696 AK/KNEE DISARTIC PELVIC JOIN 194.45 L5697 AK/KNEE DISARTIC PELVIC BAND 84.37 L5698 AK/KNEE DISARTIC SILESIAN BA 137.96 L5699 SHOULDER HARNESS 248.54 L5700 REPLACE SOCKET BELOW KNEE 3011.24 L5701 REPLACE SOCKET ABOVE KNEE 3616.28 L5702 REPLACE SOCKET HIP 4575.11 L5703 SYMES ANKLE W/O (SACH) FOOT 2367.67 L5704 CUSTOM SHAPE COVER BK 563.34 L5705 CUSTOM SHAPE COVER AK 1006.60 L5706 CUSTOM SHAPE CVR KNEE DISART 986.71 L5707 CUSTOM SHAPE CVR HIP DISART 1300.82 L5710 KNE-SHIN EXO SNG AXI MNL LOC 393.05 L5711 KNEE-SHIN EXO MNL LOCK ULTRA 549.32 L5712 KNEE-SHIN EXO FRICT SWG & ST 460.27 L5714 KNEE-SHIN EXO VARIABLE FRICT 472.77 L5716 KNEE-SHIN EXO MECH STANCE PH 765.98 L5718 KNEE-SHIN EXO FRCT SWG & STA 957.41 L5722 KNEE-SHIN PNEUM SWG FRCT EXO 1011.46 L5724 KNEE-SHIN EXO FLUID SWING PH 1586.36 L5726 KNEE-SHIN EXT JNTS FLD SWG E 1828.24 L5728 KNEE-SHIN FLUID SWG & STANCE 2500.79 L5780 KNEE-SHIN PNEUM/HYDRA PNEUM 1203.27 L5781 LOWER LIMB PROS VACUUM PUMP 4252.48 L5782 HD LOW LIMB PROS VACUUM PUMP 4483.08 L5783 ADD LOW EXT MEC LIMB VOL SYS 3088.30 L5785 EXOSKELETAL BK ULTRALT MATER 676.38 L5790 EXOSKELETAL AK ULTRA-LIGHT M 755.67 L5795 EXOSKEL HIP ULTRA-LIGHT MATE 1504.56 L5810 ENDOSKEL KNEE-SHIN MNL LOCK 511.68 L5811 ENDO KNEE-SHIN MNL LCK ULTRA 766.49 L5812 ENDO KNEE-SHIN FRCT SWG & ST 594.12 L5814 ENDO KNEE-SHIN HYDRAL SWG PH 3947.14 L5816 ENDO KNEE-SHIN POLYC MCH STA 899.19 L5818 ENDO KNEE-SHIN FRCT SWG & ST 1009.27 L5822 ENDO KNEE-SHIN PNEUM SWG FRC 1789.70 L5824 ENDO KNEE-SHIN FLUID SWING P 1611.73 L5826 MINIATURE KNEE JOINT 3319.02 L5827 ENDO KNEE SHIN SINGLE AXIS BR

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR L5828 ENDO KNEE-SHIN FLUID SWG/STA 2967.88 L5830 ENDO KNEE-SHIN PNEUM/SWG PHA 1994.26 L5840 MULTI-AXIAL KNEE/SHIN SYSTEM 3687.39 L5841 ADDITION ENDOSKLETL KNEE-SHI 2814.20 L5845 KNEE-SHIN SYS STANCE FLEXION 1904.98 L5848 KNEE-SHIN SYS HYDRAUL STANCE 1142.84 L5850 ENDO AK/HIP KNEE EXTENS ASSI 134.44 L5855 MECH HIP EXTENSION ASSIST 361.27 L5856 ELEC KNEE-SHIN SWING/STANCE 25513.58 L5857 ELEC KNEE-SHIN SWING ONLY 9053.15 L5858 STANCE PHASE ONLY 19752.48 L5859 KNEE-SHIN PRO FLEX/EXT CONT 15420.61 L5910 ENDO BELOW KNEE ALIGNABLE SY 380.64 L5920 ENDO AK/HIP ALIGNABLE SYSTEM 557.64 L5925 ABOVE KNEE MANUAL LOCK 470.85 L5926 ENDOSKEL POSIT ROTAT UNIT 667.72 L5930 HIGH ACTIVITY KNEE FRAME 3577.29 L5940 ENDO BK ULTRA-LIGHT MATERIAL 527.18 L5950 ENDO AK ULTRA-LIGHT MATERIAL 824.28 L5960 ENDO HIP ULTRA-LIGHT MATERIA 1013.18 L5961 ENDO POLY HIP, PNEU/HYD/ROT 4831.27 L5962 BELOW KNEE FLEX COVER SYSTEM 666.79 L5964 ABOVE KNEE FLEX COVER SYSTEM 984.26 L5966 HIP FLEXIBLE COVER SYSTEM 1254.19 L5968 MULTIAXIAL ANKLE W DORSIFLEX 3862.16 L5969 AK/FT POWER ASST INCL MOTORS BR L5970 FOOT EXTERNAL KEEL SACH FOOT 213.44 L5971 SACH FOOT, REPLACEMENT 213.44 L5972 FLEXIBLE KEEL FOOT 398.70 L5973 ANK-FOOT SYS DORS-PLANT FLEX 18285.26 L5974 FOOT SINGLE AXIS ANKLE/FOOT 244.91 L5975 COMBO ANKLE/FOOT PROSTHESIS 492.74 L5976 ENERGY STORING FOOT 588.57 L5978 FT PROSTH MULTIAXIAL ANKL/FT 306.70 L5979 MULTI-AXIAL ANKLE/FT PROSTH 2398.07 L5980 FLEX FOOT SYSTEM 3896.70 L5981 FLEX-WALK SYS LOW EXT PROSTH 3148.01 L5982 EXOSKELETAL AXIAL ROTATION U 607.58 L5984 ENDOSKELETAL AXIAL ROTATION 598.71 L5985 LWR EXT DYNAMIC PROSTH PYLON 300.11 L5986 MULTI-AXIAL ROTATION UNIT 665.99 L5987 SHANK FT W VERT LOAD PYLON 7645.56 L5988 VERTICAL SHOCK REDUCING PYLO 2123.16 L5990 USER ADJUSTABLE HEEL HEIGHT 1928.15 L5991 LOW PROS EXT OSSEO CONNECTOR 11254.44 L5999 LOWR EXTREMITY PROSTHES NOS BR L6000 PART HAND THUMB REM 1396.42 L6010 PART HAND LITTLE/RING 1553.99 L6020 PART HAND NO FINGERS 1448.84

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR L6026 PART HAND MYO EXCLU TERM DEV 5253.74 L6028 PART HANDFNG ENDOSKEL MOLDED BR L6029 TEST INTERFACE PART HANDFING BR L6030 EXTERNAL FRAME PART HANDFING BR L6031 REP INTERFACE HANDFNG MOLDED BR L6032 PART HANDFNG ULTRALITE TCF/= BR L6033 PART HANDFING ACRYLIC BR L6037 POSTOP DSG CAST CHG HANDFING BR L6050 WRST MLD SCK FLX HNG TRI PAD 1996.45 L6055 WRST MOLD SOCK W/EXP INTERFA 2782.54 L6100 ELB MOLD SOCK FLEX HINGE PAD 2022.71 L6110 ELBOW MOLD SOCK SUSPENSION T 2145.42 L6120 ELBOW MOLD DOUB SPLT SOC STE 2500.19 L6130 ELBOW STUMP ACTIVATED LOCK H 2720.67 L6200 ELBOW MOLD OUTSID LOCK HINGE 2867.14 L6205 ELBOW MOLDED W/ EXPAND INTER 3827.19 L6250 ELBOW INTER LOC ELBOW FORARM 3004.10 L6300 SHLDER DISART INT LOCK ELBOW 3915.54 L6310 SHOULDER PASSIVE RESTOR COMP 3380.90 L6320 SHOULDER PASSIVE RESTOR CAP 1846.90 L6350 THORACIC INTERN LOCK ELBOW 4116.59 L6360 THORACIC PASSIVE RESTOR COMP 3702.22 L6370 THORACIC PASSIVE RESTOR CAP 2215.29 L6380 POSTOP DSG CAST CHG WRST/ELB 1283.71 L6382 POSTOP DSG CAST CHG ELB DIS/ 1931.29 L6384 POSTOP DSG CAST CHG SHLDER/T 2671.73 L6386 POSTOP EA CAST CHG & REALIGN 422.06 L6388 POSTOP APPLICAT RIGID DSG ON 462.03 L6400 BELOW ELBOW PROSTH TISS SHAP 2438.68 L6450 ELB DISART PROSTH TISS SHAP 3258.02 L6500 ABOVE ELBOW PROSTH TISS SHAP 3408.55 L6550 SHLDR DISAR PROSTH TISS SHAP 4097.13 L6570 SCAP THORAC PROSTH TISS SHAP 4599.98 L6580 WRIST/ELBOW BOWDEN CABLE MOL 1756.18 L6582 WRIST/ELBOW BOWDEN CBL DIR F 1590.63 L6584 ELBOW FAIR LEAD CABLE MOLDED 2494.52 L6586 ELBOW FAIR LEAD CABLE DIR FO 2334.46 L6588 SHDR FAIR LEAD CABLE MOLDED 3067.43 L6590 SHDR FAIR LEAD CABLE DIRECT 2913.57 L6600 POLYCENTRIC HINGE PAIR 197.14 L6605 SINGLE PIVOT HINGE PAIR 194.65 L6610 FLEXIBLE METAL HINGE PAIR 186.93 L6611 ADDITIONAL SWITCH, EXT POWER 437.56 L6615 DISCONNECT LOCKING WRIST UNI 201.41 L6616 DISCONNECT INSERT LOCKING WR 74.63 L6620 FLEXION/EXTENSION WRIST UNIT 322.25 L6621 FLEX/EXT WRIST W/WO FRICTION 2430.93 L6623 SPRING-ASS ROT WRST W/ LATCH 898.88 L6624 FLEX/EXT/ROTATION WRIST UNIT 4002.59

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR L6625 ROTATION WRST W/ CABLE LOCK 638.66 L6628 QUICK DISCONN HOOK ADAPTER O 503.47 L6629 LAMINATION COLLAR W/ COUPLIN 153.76 L6630 STAINLESS STEEL ANY WRIST 226.51 L6632 LATEX SUSPENSION SLEEVE EACH 78.67 L6635 LIFT ASSIST FOR ELBOW 185.11 L6637 NUDGE CONTROL ELBOW LOCK 394.82 L6638 ELEC LOCK ON MANUAL PW ELBOW 2657.79 L6640 SHOULDER ABDUCTION JOINT PAI 350.76 L6641 EXCURSION AMPLIFIER PULLEY T 168.60 L6642 EXCURSION AMPLIFIER LEVER TY 228.53 L6645 SHOULDER FLEXION-ABDUCTION J 421.83 L6646 MULTIPO LOCKING SHOULDER JNT 3352.09 L6647 SHOULDER LOCK ACTUATOR 551.85 L6648 EXT PWRD SHLDER LOCK/UNLOCK 3457.18 L6650 SHOULDER UNIVERSAL JOINT 437.96 L6655 STANDARD CONTROL CABLE EXTRA 86.07 L6660 HEAVY DUTY CONTROL CABLE 96.47 L6665 TEFLON OR EQUAL CABLE LINING 48.40 L6670 HOOK TO HAND CABLE ADAPTER 53.52 L6672 HARNESS CHEST/SHLDER SADDLE 212.38 L6675 HARNESS FIGURE OF 8 SING CON 126.22 L6676 HARNESS FIGURE OF 8 DUAL CON 145.90 L6677 UE TRIPLE CONTROL HARNESS 315.32 L6680 TEST SOCK WRIST DISART/BEL E 243.83 L6682 TEST SOCK ELBW DISART/ABOVE 269.59 L6684 TEST SOCKET SHLDR DISART/THO 366.34 L6686 SUCTION SOCKET 827.28 L6687 FRAME TYP SOCKET BEL ELBOW/W 606.21 L6688 FRAME TYP SOCK ABOVE ELB/DIS 602.55 L6689 FRAME TYP SOCKET SHOULDER DI 721.94 L6690 FRAME TYP SOCK INTERSCAP-THO 786.71 L6691 REMOVABLE INSERT EACH 364.11 L6692 SILICONE GEL INSERT OR EQUAL 587.73 L6693 LOCKINGELBOW FOREARM CNTRBAL 3017.28 L6694 ELBOW SOCKET INS USE W/LOCK 747.30 L6695 ELBOW SOCKET INS USE W/O LCK 622.72 L6696 CUS ELBO SKT IN FOR CON/ATYP 1398.02 L6697 CUS ELBO SKT IN NOT CON/ATYP 1398.02 L6698 BELOW/ABOVE ELBOW LOCK MECH 604.34 L6700 UE ADD EXT POWER MYOEL BR L6703 TERM DEV, PASSIVE HAND MITT 382.07 L6704 TERM DEV, SPORT/REC/WORK ATT 615.49 L6706 TERM DEV MECH HOOK VOL OPEN 366.70 L6707 TERM DEV MECH HOOK VOL CLOSE 1351.62 L6708 TERM DEV MECH HAND VOL OPEN 883.60 L6709 TERM DEV MECH HAND VOL CLOSE 1273.29 L6711 PED TERM DEV, HOOK, VOL OPEN 714.53 L6712 PED TERM DEV, HOOK, VOL CLOS 1315.62

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR L6713 PED TERM DEV, HAND, VOL OPEN 1660.39 L6714 PED TERM DEV, HAND, VOL CLOS 1406.40 L6715 TERM DEVICE, MULTI ART DIGIT 3355.44 L6721 HOOK/HAND, HVY DTY, VOL OPEN 2499.70 L6722 HOOK/HAND, HVY DTY, VOL CLOS 2154.91 L6805 TERM DEV MODIFIER WRIST UNIT 357.58 L6810 TERM DEV PRECISION PINCH DEV 202.67 L6880 ELEC HAND IND ART DIGITS 25393.14 L6881 TERM DEV AUTO GRASP FEATURE 4344.98 L6882 MICROPROCESSOR CONTROL UPLMB 3295.93 L6883 REPLC SOCKT BELOW E/W DISA 1667.77 L6884 REPLC SOCKT ABOVE ELBOW DISA 2475.33 L6885 REPLC SOCKT SHLDR DIS/INTERC 3702.22 L6890 PREFAB GLOVE FOR TERM DEVICE 178.76 L6895 CUSTOM GLOVE FOR TERM DEVICE 657.60 L6900 HAND RESTORAT THUMB/1 FINGER 1876.62 L6905 HAND RESTORATION MULTIPLE FI 1865.96 L6910 HAND RESTORATION NO FINGERS 1595.58 L6915 HAND RESTORATION REPLACMNT G 804.47 L6920 WRIST DISARTICUL SWITCH CTRL 7013.91 L6925 WRIST DISART MYOELECTRONIC C 9441.94 L6930 BELOW ELBOW SWITCH CONTROL 7057.41 L6935 BELOW ELBOW MYOELECTRONIC CT 9588.46 L6940 ELBOW DISARTICULATION SWITCH 9220.96 L6945 ELBOW DISART MYOELECTRONIC C 11266.91 L6950 ABOVE ELBOW SWITCH CONTROL 10480.92 L6955 ABOVE ELBOW MYOELECTRONIC CT 12552.33 L6960 SHLDR DISARTIC SWITCH CONTRO 14218.66 L6965 SHLDR DISARTIC MYOELECTRONIC 15164.72 L6970 INTERSCAPULAR-THOR SWITCH CT 15801.89 L6975 INTERSCAP-THOR MYOELECTRONIC 17282.16 L7007 ADULT ELECTRIC HAND 3616.47 L7008 PEDIATRIC ELECTRIC HAND 5691.94 L7009 ADULT ELECTRIC HOOK 3689.94 L7040 PREHENSILE ACTUATOR 2962.88 L7045 PEDIATRIC ELECTRIC HOOK 1698.72 L7170 ELECTRONIC ELBOW HOSMER SWIT 7821.55 L7180 ELECTRONIC ELBOW SEQUENTIAL 34332.27 L7181 ELECTRONIC ELBO SIMULTANEOUS 42584.57 L7185 ELECTRON ELBOW ADOLESCENT SW 7723.89 L7186 ELECTRON ELBOW CHILD SWITCH 9296.45 L7190 ELBOW ADOLESCENT MYOELECTRON 8112.72 L7191 ELBOW CHILD MYOELECTRONIC CT 9714.24 L7259 ELECTRONIC WRIST ROTATOR ANY 3358.82 L7360 SIX VOLT BAT OTTO BOCK/EQ EA 250.78 L7362 BATTERY CHRGR SIX VOLT OTTO 263.32 L7364 TWELVE VOLT BATTERY UTAH/EQU 418.79 L7366 BATTERY CHRGR 12 VOLT UTAH/E 564.12 L7367 REPLACEMNT LITHIUM IONBATTER 413.76

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR L7368 LITHIUM ION BATTERY CHARGER 536.39 L7400 ADD UE PROST BE/WD, ULTLITE 325.75 L7401 ADD UE PROST A/E ULTLITE MAT 364.68 L7402 ADD UE PROST S/D ULTLITE MAT 393.78 L7403 ADD UE PROST B/E ACRYLIC 391.41 L7404 ADD UE PROST A/E ACRYLIC 590.69 L7405 ADD UE PROST S/D ACRYLIC 772.57 L7406 ADD TO UPP EXTR USER ADJ MEC BR L7499 UPPER EXTREMITY PROSTHES NOS BR L7510 PROSTHETIC DEVICE REPAIR REP 123.03 L7520 REPAIR PROSTHESIS PER 15 MIN 53.15 L7600 PROSTHETIC DONNING SLEEVE 114.19 L7700 PROS SOC INSERT GASKET/SEAL 118.61 L7900 MALE VACUUM ERECTION SYSTEM 555.95 L7902 TENSION RING, VAC ERECT DEV BR L8000 MASTECTOMY BRA 46.22 L8001 BREAST PROSTHESIS BRA & FORM 133.30 L8002 BRST PRSTH BRA & BILAT FORM 175.36 L8010 MASTECTOMY SLEEVE 88.30 L8015 EXT BREASTPROSTHESIS GARMENT 63.70 L8020 MASTECTOMY FORM 239.61 L8030 BREAST PROSTHES W/O ADHESIVE 346.58 L8031 BREAST PROSTHESIS W ADHESIVE 346.58 L8032 REUSABLE NIPPLE PROSTHESIS 41.63 L8033 NIPPLE PROSTHESIS CUSTOM, EA BR L8035 CUSTOM BREAST PROSTHESIS 3893.72 L8039 BREAST PROSTHESIS NOS 0.00 L8040 NASAL PROSTHESIS 2568.99 L8041 MIDFACIAL PROSTHESIS 3096.44 L8042 ORBITAL PROSTHESIS 3479.11 L8043 UPPER FACIAL PROSTHESIS 3896.61 L8044 HEMI-FACIAL PROSTHESIS 4314.09 L8045 AURICULAR PROSTHESIS 2701.61 L8046 PARTIAL FACIAL PROSTHESIS 2783.30 L8047 NASAL SEPTAL PROSTHESIS 1426.42 L8048 UNSPEC MAXILLOFACIAL PROSTH BR L8049 REPAIR MAXILLOFACIAL PROSTH BR L8300 TRUSS SINGLE W/ STANDARD PAD 102.36 L8310 TRUSS DOUBLE W/ STANDARD PAD 157.39 L8320 TRUSS ADDITION TO STD PAD WA 68.74 L8330 TRUSS ADD TO STD PAD SCROTAL 68.14 L8400 SHEATH BELOW KNEE 19.93 L8410 SHEATH ABOVE KNEE 22.66 L8415 SHEATH UPPER LIMB 22.53 L8417 PROS SHEATH/SOCK W GEL CUSHN 79.92 L8420 PROSTHETIC SOCK MULTI PLY BK 26.34 L8430 PROSTHETIC SOCK MULTI PLY AK 28.97 L8435 PROS SOCK MULTI PLY UPPER LM 25.99 L8440 SHRINKER BELOW KNEE 55.10

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR L8460 SHRINKER ABOVE KNEE 76.69 L8465 SHRINKER UPPER LIMB 68.35 L8470 PROS SOCK SINGLE PLY BK 7.01 L8480 PROS SOCK SINGLE PLY AK 9.67 L8485 PROS SOCK SINGLE PLY UPPER L 11.69 L8499 UNLISTED MISC PROSTHETIC SER BR L8500 ARTIFICIAL LARYNX 693.60 L8501 TRACHEOSTOMY SPEAKING VALVE 154.03 L8505 ARTIFICIAL LARYNX, ACCESSORY 45.28 L8507 TRACH-ESOPH VOICE PROS PT IN 44.52 L8509 TRACH-ESOPH VOICE PROS MD IN 116.08 L8510 VOICE AMPLIFIER 268.58 L8511 INDWELLING TRACH INSERT 77.30 L8512 GEL CAP FOR TRACH VOICE PROS 2.32 L8513 TRACH PROS CLEANING DEVICE 5.55 L8514 REPL TRACH PUNCTURE DILATOR 100.22 L8515 GEL CAP APP DEVICE FOR TRACH 67.07 L8600 IMPLANT BREAST SILICONE/EQ 656.28 L8603 COLLAGEN IMP URINARY 2.5 ML 460.91 L8604 DEXTRANOMER/HYALURONIC ACID BR L8605 INJ BULKING AGENT ANAL CANAL 761.23 L8606 SYNTHETIC IMPLNT URINARY 1ML 241.94 L8607 INJ VOCAL CORD BULKING AGENT 45.60 L8608 ARG II EXT COM/SUP/ACC MISC BR L8609 ARTIFICIAL CORNEA 6924.66 L8610 OCULAR IMPLANT 673.19 L8612 AQUEOUS SHUNT PROSTHESIS 710.00 L8613 OSSICULAR IMPLANT 317.87 L8614 COCHLEAR DEVICE 20120.61 L8615 COCH IMPLANT HEADSET REPLACE 479.34 L8616 COCH IMPLANT MICROPHONE REPL 111.65 L8617 COCH IMPLANT TRANS COIL REPL 97.55 L8618 COCH IMPLANT TRAN CABLE REPL 27.86 L8619 COCH IMP EXT PROC/CONTR RPLC 8630.98 L8621 REPL ZINC AIR BATTERY 0.65 L8622 REPL ALKALINE BATTERY 0.34 L8623 LITH ION BATT CID,NON-EARLVL 68.74 L8624 LITH ION BATT CID, EAR LEVEL 171.37 L8625 CHARGER COCH IMPL/AOI BATTRY 200.73 L8627 CID EXT SPEECH PROCESS REPL 7316.21 L8628 CID EXT CONTROLLER REPL 1314.80 L8629 CID TRANSMIT COIL AND CABLE 190.29 L8630 METACARPOPHALANGEAL IMPLANT 354.08 L8631 MCP JOINT REPL 2 PC OR MORE 2376.25 L8641 METATARSAL JOINT IMPLANT 384.31 L8642 HALLUX IMPLANT 315.46 L8658 INTERPHALANGEAL JOINT SPACER 329.69 L8659 INTERPHALANGEAL JOINT REPL 2050.86 L8670 VASCULAR GRAFT, SYNTHETIC 585.04

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR L8678 EXT SPLY IMPLT NEUROSTIM 26.29 L8679 IMP NEUROSTI PLS GN ANY TYPE 8868.12 L8680 IMPLT NEUROSTIM ELCTR EACH 837.82 L8681 PT PRGRM FOR IMPLT NEUROSTIM 1200.41 L8682 IMPLT NEUROSTIM RADIOFQ REC 6336.10 L8683 RADIOFQ TRSMTR FOR IMPLT NEU 5577.19 L8684 RADIOF TRSMTR IMPLT SCRL NEU 732.39 L8685 IMPLT NROSTM PLS GEN SNG REC 8420.15 L8686 IMPLT NROSTM PLS GEN SNG NON 13312.28 L8687 IMPLT NROSTM PLS GEN DUA REC 10958.22 L8688 IMPLT NROSTM PLS GEN DUA NON 6992.32 L8689 EXTERNAL RECHARG SYS INTERN 1833.27 L8690 AUD OSSEO DEV, INT/EXT COMP 5055.94 L8691 AOI SND PROC REPL EXCL ACTUA 1830.32 L8692 NON-OSSEOINTEGRATED SND PROC 5994.23 L8693 AUD OSSEO DEV, ABUTMENT 1611.56 L8694 AOI TRANSDUCER/ACTUATOR REPL 1003.72 L8695 EXTERNAL RECHARG SYS EXTERN 17.70 L8696 EXT ANTENNA PHREN NERVE STIM 230.38 L8698 MISC USED WITH TOT ART HEART BR L8699 PROSTHETIC IMPLANT NOS BR L8701 EWH S/D UPRT MICRO SENSOR 34284.44 L8702 EWHF S/D UPRT MICRO SENSOR 70421.05 L8720 EXT LOW EXT SENS PROSTHE MEC BR L8721 RECEPTOR SOLE L8720 REPLACE BR L9900 O&P SUPPLY/ACCESSORY/SERVICE BR M0001 ADVANCING CANCER CARE MVP 0.00 M0002 OPT CARE KIDNEY HLTH MVP 0.00 M0004 QUAL CARE NEUROLOGIC CND MVP 0.00 M0005 VALUE IN PRIMARY CARE MVP 0.00 M0010 EOM MEOS PAYMENT 0.00 M0075 CELLULAR THERAPY 0.00 M0076 PROLOTHERAPY 0.00 M0100 INTRAGASTRIC HYPOTHERMIA 0.00 M0201 PNE FLU HEPB COV HOME ADMIN 0.00 M0220 TIXAGEV AND CILGAV INJ 0.00 M0221 TIXAGEV AND CILGAV INJ HM 0.00 M0222 BEBTELOVIMAB INJECTION 0.00 M0223 BEBTELOVIMAB INJECTION HOME 0.00 M0224 PEMIVIBART INFUSION 0.00 M0240 CASIRI AND IMDEV REPEAT 0.00 M0241 CASIRI AND IMDEV REPEAT HM 0.00 M0243 CASIRIVI AND IMDEVI INJ 0.00 M0244 CASIRIVI AND IMDEVI INJ HM 0.00 M0245 BAMLAN AND ETESEV INFUSION 0.00 M0246 BAMLAN AND ETESEV INFUS HOME 0.00 M0247 SOTROVIMAB INFUSION 0.00 M0248 SOTROVIMAB INF, HOME ADMIN 0.00 M0249 ADM TOCILIZU COVID-19 1ST 0.00

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR M0250 ADM TOCILIZU COVID-19 2ND 0.00 M0300 IV CHELATIONTHERAPY 0.00 M0301 FABRIC WRAPPING OF ANEURYSM 0.00 M1003 TB SCR 12 MO PRI FST BIO DZ 0.00 M1004 DOC MED RSN NO SRN TB 0.00 M1005 TB SCR NO PERF 0.00 M1006 DZ NOT ASES, NO RSN 0.00 M1007 >=50% TOTAL PT OUTPT RA ENCT 0.00 M1008 <50% TOTAL PT OUTPT RA ENCTS 0.00 M1009 DC EOC DOC MED REC 0.00 M1010 DC EOC DOC MED REC 0.00 M1011 DC EOC DOC MED REC 0.00 M1012 DC EOC DOC MED REC 0.00 M1013 DC EOC DOC MED REC 0.00 M1014 DC EPI CARE DOC MEDREC 0.00 M1016 PT DX MEOP OR SUR STERI 0.00 M1018 PT DX HST CR PT SK LG CR SCR 0.00 M1019 ADL PT MJ DEP DS RS 12 PHQ<5 0.00 M1020 ADL PT MJ DEP DS NO RS 12 MO 0.00 M1021 PT UC IN PP 0.00 M1027 IMG HEAD (CT OR MRI) OBTND 0.00 M1028 DOC OF PT PRM HDA DX AND OTR 0.00 M1029 DOC SYSM RSN IMG HD 0.00 M1032 ADT TKNG PHARMTHRY FOR OUD 0.00 M1034 ADT 180 DYS PHARMTHRY OUD 0.00 M1035 ADT PD OUT MAT PR 180 DYS TX 0.00 M1036 ADT NO 180 DYS PHARMTHRY OUD 0.00 M1037 PT DX LUM SP REG CACR 0.00 M1038 PT DX LUM SP REG FRACT 0.00 M1039 PT DX LUM SP REG INF 0.00 M1040 PT DX LUM IDI OR CONG SCOL 0.00 M1041 PT CR FT INF LM OR PT ID SL 0.00 M1043 FS NO ODI 9-15MO 0.00 M1045 FS OKS 9-15MO >= 37 >= 71 0.00 M1046 FS OKS 9-15MO < 37 < 71 0.00 M1049 FS WTH SCR NO ODI PRE AND P 0.00 M1051 PT W/CANCER SCOLIOSIS 0.00 M1052 LG PN NOT MEAS W/ VAS 1YR PO 0.00 M1054 PT UC IN PP 0.00 M1055 ASPIRIN USED 0.00 M1056 PRESC ANTICO MED IN PP 0.00 M1057 ASPIRIN NOT USED, NO RSN 0.00 M1058 PT PRM NURS HM RES IN PP 0.00 M1059 PT NO PRM NURS HM RES IN PP 0.00 M1060 PT DIED IN PP 0.00 M1067 HSPC PT PRV TIME MEAM PER 0.00 M1068 PT NOT AMBULATORY 0.00 M1069 PT SCR FT FALL RSK 0.00 M1070 PT NOT SCRN FUT FALL NO RSN 0.00

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR M1106 START EOC DOC MED REC 0.00 M1107 DOCU DX DEGEN NEURO 0.00 M1108 OC NI PT HOME PROG 0.00 M1109 OC NI PT DC 0.00 M1110 OC NOT P PT SELFDC 0.00 M1111 START EOC DOC MED REC 0.00 M1112 DOCU DX DEGEN NEURO 0.00 M1113 OC NI PT HOME PROG 0.00 M1114 OC NI PT DC 0.00 M1115 OC NI PT SELFDC 0.00 M1116 START EOC DOC MED REC 0.00 M1117 DOCU DX DEGEN NEURO 0.00 M1118 OC NI PT HOME PROG 0.00 M1119 OC NI PT DC 0.00 M1120 OC NI PT SELFDC 0.00 M1121 START EOC DOC MED REC 0.00 M1122 DOCU DX DEGEN NEURO 0.00 M1123 OC NI PT HOME PROG 0.00 M1124 OC NI PT DC 1-2 VIS 0.00 M1125 OC NI PT SELFDC 1-2 VIS 0.00 M1126 START EOC DOC MED REC 0.00 M1127 DOCU DX DEGEN NEURO 0.00 M1128 OC NI PT HOME PROG 0.00 M1129 OC NI PT DC 0.00 M1130 OC NI PT SELFDC 0.00 M1131 DOCU DX DEGEN NEURO 0.00 M1132 OC NI PT HOME PROG 0.00 M1133 OC NI PT DC 0.00 M1134 OC NI PT SELFDC 0.00 M1135 START EOC DOC MED REC 0.00 M1141 FS NO OKS 0.00 M1142 EMERGE CASES 0.00 M1143 NI REHAB MED CHIRO 0.00 M1146 ONGOING CARE NOT IND 0.00 M1147 CARE NOT POSS MED RSN 0.00 M1148 PT SELF DSCHG 0.00 M1149 NO NECK FS PROM INCAP 0.00 P2028 CEPHALIN FLOCULATION TEST BR P2029 CONGO RED BLOOD TEST BR P2031 HAIR ANALYSIS BR P2033 BLOOD THYMOL TURBIDITY BR P2038 BLOOD MUCOPROTEIN 8.11 P3000 SCREEN PAP BY TECH W MD SUPV 17.08 P3001 SCREENING PAP SMEAR BY PHYS 36.01 P7001 CULTURE BACTERIAL URINE 16.58 P9010 WHOLE BLOOD FOR TRANSFUSION 59.27 217.50 P9011 BLOOD SPLIT UNIT 78.11 213.98 P9012 CRYOPRECIPITATE EACH UNIT 49.60 115.77 P9016 RBC LEUKOCYTES REDUCED 274.00 273.19

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR P9017 PLASMA 1 DONOR FRZ W/IN 8 HR 76.80 119.85 P9019 PLATELETS, EACH UNIT BR 103.36 P9020 PLAELET RICH PLASMA UNIT 146.00 289.96 P9021 RED BLOOD CELLS UNIT 291.60 199.55 P9022 WASHED RED BLOOD CELLS UNIT 157.99 550.75 P9023 FROZEN PLASMA, POOLED, SD BR 129.23 P9025 PLASMA CRYO REDU PATH EACH BR 95.25 P9026 CRYO FIB COMP PATH REDU EACH BR 115.77 P9027 RBC O2 CO2 REDUCED BR 691.68 P9031 PLATELETS LEUKOCYTES REDUCED BR 217.36 P9032 PLATELETS, IRRADIATED BR 205.45 P9033 PLATELETS LEUKOREDUCED IRRAD BR 309.08 P9034 PLATELETS, PHERESIS BR 469.74 P9035 PLATELET PHERES LEUKOREDUCED 361.60 705.61 P9036 PLATELET PHERESIS IRRADIATED BR 877.01 P9037 PLATE PHERES LEUKOREDU IRRAD 490.00 895.05 P9038 RBC IRRADIATED BR 245.48 P9039 RBC DEGLYCEROLIZED BR 633.08 P9040 RBC LEUKOREDUCED IRRADIATED 228.80 377.76 P9041 ALBUMIN (HUMAN),5%, 50ML 11.64 14.90 P9043 PLASMA PROTEIN FRACT,5%,50ML 17.93 11.60 P9044 CRYOPRECIPITATEREDUCEDPLASMA 40.80 95.25 P9045 ALBUMIN (HUMAN), 5%, 250 ML 58.20 74.48 P9046 ALBUMIN (HUMAN), 25%, 20 ML 24.00 29.79 P9047 ALBUMIN (HUMAN), 25%, 50ML 57.02 74.48 P9048 PLASMAPROTEIN FRACT,5%,250ML 36.28 232.48 P9050 GRANULOCYTES, PHERESIS UNIT BR 2307.82 P9051 BLOOD, L/R, CMV-NEG BR 307.69 P9052 PLATELETS, HLA-M, L/R, UNIT BR 1167.40 P9053 PLT, PHER, L/R CMV-NEG, IRR BR 648.53 P9054 BLOOD, L/R, FROZ/DEGLY/WASH BR 450.45 P9055 PLT, APH/PHER, L/R, CMV-NEG BR 695.98 P9056 BLOOD, L/R, IRRADIATED BR 223.49 P9057 RBC, FRZ/DEG/WSH, L/R, IRRAD BR 377.81 P9058 RBC, L/R, CMV-NEG, IRRAD 544.00 353.57 P9059 PLASMA, FRZ BETWEEN 8-24HOUR 44.40 103.15 P9060 FR FRZ PLASMA DONOR RETESTED BR 94.36 P9070 PATHOGEN REDUCED PLASMA POOL BR 76.99 P9071 PATHOGEN REDUCED PLASMA SING BR 178.07 P9073 PLATELETS PHERESIS PATH REDU 1084.00 846.50 P9099 BLOOD COMPONENT/PRODUCT NOC BR 11.60 P9100 PATHOGEN TEST FOR PLATELETS BR 80.73 P9603 ONE-WAY ALLOW PRORATED MILES 0.50 P9604 ONE-WAY ALLOW PRORATED TRIP 12.19 P9612 CATHETERIZE FOR URINE SPEC 28.17 P9615 URINE SPECIMEN COLLECT MULT BR Q0035 CARDIOKYMOGRAPHY 22.80 49.09 Q0081 INFUSION THER OTHER THAN CHE 249.60 Q0083 CHEMO BY OTHER THAN INFUSION BR

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR Q0084 CHEMOTHERAPY BY INFUSION 414.28 Q0085 CHEMO BY BOTH INFUSION AND O BR Q0091 OBTAINING SCREEN PAP SMEAR 50.80 35.83 Q0092 SET UP PORT XRAY EQUIPMENT 27.60 Q0111 WET MOUNTS/ W PREPARATIONS 17.51 Q0112 POTASSIUM HYDROXIDE PREPS 6.41 Q0113 PINWORM EXAMINATIONS 5.23 Q0114 FERN TEST 10.71 Q0115 POST-COITAL MUCOUS EXAM 27.50 Q0138 FERUMOXYTOL, NON-ESRD 0.92 1.55 Q0139 FERUMOXYTOL, ESRD USE 0.92 1.42 Q0144 AZITHROMYCIN DIHYDRATE, ORAL 33.16 Q0155 DRONABINOL (SYNDROS) 0.1 MG BR Q0161 CHLORPROMAZINE HCL 5MG ORAL 0.00 Q0162 ONDANSETRON ORAL 0.03 Q0163 DIPHENHYDRAMINE HCL 50MG 0.32 Q0164 PROCHLORPERAZINE MALEATE 5MG 0.06 Q0166 GRANISETRON HCL 1 MG ORAL 1.66 Q0167 DRONABINOL 2.5MG ORAL 1.81 Q0169 PROMETHAZINE HCL 12.5MG ORAL 0.03 Q0173 TRIMETHOBENZAMIDE HCL 250MG 0.86 Q0174 THIETHYLPERAZINE MALEATE10MG 0.86 Q0175 PERPHENAZINE 4MG ORAL 0.86 Q0177 HYDROXYZINE PAMOATE 25MG 2.12 Q0180 DOLASETRON MESYLATE ORAL 130.91 Q0181 UNSPECIFIED ORAL ANTI-EMETIC BR Q0220 TIXAGEV AND CILGAV, 300MG BR Q0221 TIXAGEV AND CILGAV, 600MG BR Q0222 BEBTELOVIMAB 175 MG BR Q0224 INJ, PEMIVIBART, 4500 MG 7241.85 Q0240 CASIRIVI AND IMDEVI 600 MG BR Q0243 CASIRIVIMAB AND IMDEVIMAB BR Q0244 CASIRIVI AND IMDEVI 1200 MG BR Q0245 BAMLANIVIMAB AND ETESEVIMA BR Q0247 SOTROVIMAB BR Q0249 TOCILIZUMAB FOR COVID-19 8.33 Q0477 PWR MODULE PT CABLE LVAD RPL 907.06 Q0478 POWER ADAPTER, COMBO VAD 214.83 Q0479 POWER MODULE COMBO VAD, REP 14008.91 Q0480 DRIVER PNEUMATIC VAD, REP 105293.29 Q0481 MICROPRCSR CU ELEC VAD, REP 16987.87 Q0482 MICROPRCSR CU COMBO VAD, REP 5320.93 Q0483 MONITOR ELEC VAD, REP 21919.76 Q0484 MONITOR ELEC OR COMB VAD REP 4256.76 Q0485 MONITOR CABLE ELEC VAD, REP 410.98 Q0486 MON CABLE ELEC/PNEUM VAD REP 342.05 Q0487 LEADS ANY TYPE VAD, REP ONLY 399.07 Q0488 PWR PACK BASE ELEC VAD, REP BR Q0489 PWR PCK BASE COMBO VAD, REP 19003.24

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR Q0490 EMR PWR SOURCE ELEC VAD, REP 822.00 Q0491 EMR PWR SOURCE COMBO VAD REP 1292.24 Q0492 EMR PWR CBL ELEC VAD, REP 104.14 Q0493 EMR PWR CBL COMBO VAD, REP 296.38 Q0494 EMR HD PMP ELEC/COMBO, REP 250.81 Q0495 CHARGER ELEC/COMBO VAD, REP 4883.40 Q0496 BATTERY ELEC/COMBO VAD, REP 1752.74 Q0497 BAT CLPS ELEC/COMB VAD, REP 547.27 Q0498 HOLSTER ELEC/COMBO VAD, REP 600.49 Q0499 BELT/VEST ELEC/COMBO VAD REP 195.12 Q0500 FILTERS ELEC/COMBO VAD, REP 35.70 Q0501 SHWR COV ELEC/COMBO VAD, REP 597.04 Q0502 MOBILITY CART PNEUM VAD, REP 760.10 Q0503 BATTERY PNEUM VAD REPLACEMNT 1520.23 Q0504 PWR ADPT PNEUM VAD, REP VEH 802.18 Q0506 LITH-ION BATT ELEC/PNEUM VAD 998.55 Q0507 MISC SUP/ACC EXT VAD BR Q0508 MIS SUP/ACC IMP VAD BR Q0509 MIS SUP/AC IMP VAD NOPAY MED BR Q0510 DISPENS FEE IMMUNOSUPRESSIVE 41.60 Q0511 SUP FEE ANTIEM,ANTICA,IMMUNO 20.00 Q0512 PX SUP FEE ANTI-CAN SUB PRES 13.20 Q0513 DISP FEE INHAL DRUGS/30 DAYS 27.60 Q0514 DISP FEE INHAL DRUGS/90 DAYS 55.20 Q0515 SERMORELIN ACETATE INJECTION 1.61 Q0521 SUPPLY FEE HIV PREP FDA APPR BR Q1004 NTIOL CATEGORY 4 BR Q1005 NTIOL CATEGORY 5 BR Q2004 BLADDER CALCULI IRRIG SOL 19.91 Q2009 FOSPHENYTOIN INJ PE 26.38 Q2017 TENIPOSIDE, 50 MG 282.58 3756.91 Q2026 RADIESSE INJECTION 228.80 365.47 Q2028 INJ, SCULPTRA, 0.5MG 2.80 3.54 Q2034 AGRIFLU VACCINE 20.81 Q2035 AFLURIA VACC, 3 YRS & >, IM 16.58 Q2036 FLULAVAL VACC, 3 YRS & >, IM 24.80 Q2037 FLUVIRIN VACC, 3 YRS & >, IM 28.58 Q2038 FLUZONE VACC, 3 YRS & >, IM 28.58 Q2039 INFLUENZA VIRUS VACCINE, NOS 33.20 Q2041 AXICABTAGENE CILOLEUCEL CAR+ 538468.87 584920.72 Q2042 TISAGENLECLEUCEL CAR-POS T 622186.22 609711.97 Q2043 SIPULEUCEL-T AUTO CD54+ 46367.06 74438.64 Q2049 IMPORTED LIPODOX INJ 759.99 441.68 Q2050 DOXORUBICIN INJ 10MG 477.80 284.74 Q2052 HOME IVIG, SERVICES/SUPPLIES 0.00 Q2053 BREXUCABTAGENE CAR POS T 536856.66 581007.20 Q2054 LISOCABTAGENE MARA CAR POS T 568134.57 617583.56 Q2055 IDECABTAGENE VICLEUCEL CAR 581143.67 631431.40 Q2056 CILTACABTAGENE CAR-POS T 606450.17

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR Q2057 AFAMITRESGENE AUTOLEUCEL BR Q3001 BRACHYTHERAPY RADIOELEMENTS 98.01 Q3014 TELEHEALTH FACILITY FEE 26.40 Q3027 INJ BETA INTERFERON IM 1 MCG 53.21 77.87 Q3028 INJ BETA INTERFERON SQ 1 MCG 29.60 Q3031 COLLAGEN SKIN TEST BR Q4001 CAST SUP BODY CAST PLASTER 58.89 Q4002 CAST SUP BODY CAST FIBERGLAS 222.52 Q4003 CAST SUP SHOULDER CAST PLSTR 42.28 Q4004 CAST SUP SHOULDER CAST FBRGL 146.40 Q4005 CAST SUP LONG ARM ADULT PLST 15.60 Q4006 CAST SUP LONG ARM ADULT FBRG 35.13 Q4007 CAST SUP LONG ARM PED PLSTER 7.79 Q4008 CAST SUP LONG ARM PED FBRGLS 17.56 Q4009 CAST SUP SHT ARM ADULT PLSTR 10.42 Q4010 CAST SUP SHT ARM ADULT FBRGL 23.42 Q4011 CAST SUP SHT ARM PED PLASTER 5.19 Q4012 CAST SUP SHT ARM PED FBRGLAS 11.74 Q4013 CAST SUP GAUNTLET PLASTER 18.95 Q4014 CAST SUP GAUNTLET FIBERGLASS 31.96 Q4015 CAST SUP GAUNTLET PED PLSTER 9.49 Q4016 CAST SUP GAUNTLET PED FBRGLS 15.97 Q4017 CAST SUP LNG ARM SPLINT PLST 10.95 Q4018 CAST SUP LNG ARM SPLINT FBRG 17.46 Q4019 CAST SUP LNG ARM SPLNT PED P 5.49 Q4020 CAST SUP LNG ARM SPLNT PED F 8.77 Q4021 CAST SUP SHT ARM SPLINT PLST 8.11 Q4022 CAST SUP SHT ARM SPLINT FBRG 14.63 Q4023 CAST SUP SHT ARM SPLNT PED P 4.08 Q4024 CAST SUP SHT ARM SPLNT PED F 7.33 Q4025 CAST SUP HIP SPICA PLASTER 45.44 Q4026 CAST SUP HIP SPICA FIBERGLAS 141.94 Q4027 CAST SUP HIP SPICA PED PLSTR 22.75 Q4028 CAST SUP HIP SPICA PED FBRGL 71.02 Q4029 CAST SUP LONG LEG PLASTER 34.77 Q4030 CAST SUP LONG LEG FIBERGLASS 91.52 Q4031 CAST SUP LNG LEG PED PLASTER 17.37 Q4032 CAST SUP LNG LEG PED FBRGLS 45.76 Q4033 CAST SUP LNG LEG CYLINDER PL 32.44 Q4034 CAST SUP LNG LEG CYLINDER FB 80.64 Q4035 CAST SUP LNGLEG CYLNDR PED P 16.21 Q4036 CAST SUP LNGLEG CYLNDR PED F 40.35 Q4037 CAST SUP SHRT LEG PLASTER 19.76 Q4038 CAST SUP SHRT LEG FIBERGLASS 49.56 Q4039 CAST SUP SHRT LEG PED PLSTER 9.92 Q4040 CAST SUP SHRT LEG PED FBRGLS 24.77 Q4041 CAST SUP LNG LEG SPLNT PLSTR 24.06 Q4042 CAST SUP LNG LEG SPLNT FBRGL 41.06 Q4043 CAST SUP LNG LEG SPLNT PED P 12.03

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR Q4044 CAST SUP LNG LEG SPLNT PED F 20.56 Q4045 CAST SUP SHT LEG SPLNT PLSTR 13.97 Q4046 CAST SUP SHT LEG SPLNT FBRGL 22.45 Q4047 CAST SUP SHT LEG SPLNT PED P 6.95 Q4048 CAST SUP SHT LEG SPLNT PED F 11.24 Q4049 FINGER SPLINT, STATIC 2.53 Q4050 CAST SUPPLIES UNLISTED BR Q4051 SPLINT SUPPLIES MISC BR Q4074 ILOPROST NON-COMP UNIT DOSE 142.08 Q4081 EPOETIN ALFA, 100 UNITS ESRD 1.37 Q4082 DRUG/BIO NOC PART B DRUG CAP BR Q4100 SKIN SUBSTITUTE, NOS BR Q4101 APLIGRAF 34.56 Q4102 OASIS WOUND MATRIX 12.78 Q4103 OASIS BURN MATRIX 13.73 Q4104 INTEGRA BMWD 35.25 Q4105 INTEGRA DRT OR OMNIGRAFT 140.29 Q4106 DERMAGRAFT 36.38 Q4107 GRAFTJACKET 116.18 Q4108 INTEGRA MATRIX 45.37 Q4110 PRIMATRIX 61.53 Q4111 GAMMAGRAFT 7.91 Q4112 CYMETRA INJECTABLE 262.63 Q4113 GRAFTJACKET XPRESS 262.63 Q4114 INTEGRA FLOWABLE WOUND MATRI 1851.98 Q4115 ALLOSKIN 11.23 Q4116 ALLODERM 38.23 Q4117 HYALOMATRIX 31.60 Q4118 MATRISTEM MICROMATRIX 8.80 Q4121 THERASKIN 47.54 Q4122 DERMACELL, AWM, POROUS SQ CM 61.60 Q4123 ALLOSKIN 26.11 Q4124 OASIS TRI-LAYER WOUND MATRIX 30.80 Q4125 ARTHROFLEX 88.00 Q4126 MEMODERM/DERMA/TRANZ/INTEGUP 386.80 Q4127 TALYMED 43.19 Q4128 FLEXHD/ALLOPATCHHD/SQ CM 63.20 Q4130 STRATTICE TM BR Q4132 GRAFIX CORE, GRAFIXPL CORE 248.80 Q4133 GRAFIX STRAVIX PRIME PL SQCM 149.02 Q4134 HMATRIX BR Q4135 MEDISKIN BR Q4136 EZDERM 61.60 Q4137 AMNIOEXCEL BIODEXCEL 1SQ CM 108.33 Q4138 BIODFENCE DRYFLEX, 1CM 0.00 Q4139 AMNIO OR BIODMATRIX, INJ 1CC 923.60 Q4140 BIODFENCE 1CM 0.00 Q4141 ALLOSKIN AC, 1 CM 0.00 Q4142 XCM BIOLOGIC TISS MATRIX 1CM 50.00

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR Q4143 REPRIZA, 1CM 0.00 Q4145 EPIFIX, INJ, 1MG 15.20 Q4146 TENSIX, 1CM 0.00 Q4147 ARCHITECT ECM PX FX 1 SQ CM 0.00 Q4148 NEOX NEOX RT OR CLARIX CORD 184.80 Q4149 EXCELLAGEN, 0.1 CC 769.60 Q4150 ALLOWRAP DS OR DRY 1 SQ CM 0.00 Q4151 AMNIOBAND, GUARDIAN 1 SQ CM 148.27 Q4152 DERMAPURE 1 SQUARE CM 0.00 Q4153 DERMAVEST, PLURIVEST SQ CM 283.20 Q4154 BIOVANCE 1 SQUARE CM 230.80 Q4155 NEOXFLO OR CLARIXFLO 1 MG 146.00 Q4156 NEOX 100 OR CLARIX 100 0.00 Q4157 REVITALON 1 SQUARE CM 0.00 Q4158 KERECIS OMEGA3, PER SQ CM 67.20 Q4159 AFFINITY1 SQUARE CM 588.60 Q4160 NUSHIELD 1 SQUARE CM 101.57 Q4161 BIO-CONNEKT PER SQUARE CM 123.20 Q4162 WNDEX FLW, BIOSKN FLW, 0.5CC 1354.80 Q4163 WOUNDEX, BIOSKIN, PER SQ CM 99.46 Q4164 HELICOLL, PER SQUARE CM 123.20 Q4165 KERAMATRIX, KERASORB SQ CM 0.00 Q4166 CYTAL, PER SQUARE CENTIMETER 29.37 Q4167 TRUSKIN, PER SQ CENTIMETER BR Q4168 AMNIOBAND, 1 MG 42.80 Q4169 ARTACENT WOUND, PER SQ CM 217.63 Q4170 CYGNUS, PER SQ CM 553.44 Q4171 INTERFYL, 1 MG 97.88 Q4173 PALINGEN OR PALINGEN XPLUS 262.66 Q4174 PALINGEN OR PROMATRX 746.68 Q4175 MIRODERM 75.94 Q4176 NEOPATCH OR THERION, 1 SQ CM 114.00 Q4177 FLOWERAMNIOFLO, 0.1 CC 110.80 Q4178 FLOWERAMNIOPATCH, PER SQ CM 178.97 Q4179 FLOWERDERM, PER SQ CM BR Q4180 REVITA, PER SQ CM 184.80 Q4181 AMNIO WOUND, PER SQUARE CM BR Q4182 TRANSCYTE, PER SQ CENTIMETER BR Q4183 SURGIGRAFT, 1 SQ CM BR Q4184 CELLESTA OR DUO PER SQ CM 686.77 Q4185 CELLESTA FLOWAB AMNION 0.5CC 891.20 Q4186 EPIFIX 1 SQ CM 171.84 Q4187 EPICORD 1 SQ CM 260.77 Q4188 AMNIOARMOR 1 SQ CM 292.40 Q4189 ARTACENT AC, 1 MG BR Q4190 ARTACENT AC 1 SQ CM 259.26 Q4191 RESTORIGIN 1 SQ CM 1117.94 Q4192 RESTORIGIN, 1 CC 1526.80 Q4193 COLL-E-DERM 1 SQ CM BR

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR Q4194 NOVACHOR 1 SQ CM 800.40 Q4195 PURAPLY 1 SQ CM 78.35 181.82 Q4196 PURAPLY AM 1 SQ CM 120.40 181.82 Q4197 PURAPLY XT 1 SQ CM 230.80 Q4198 GENESIS AMNIO MEMBRANE 1SQCM BR Q4199 CYGNUS MATRIX, PER SQ CM 400.17 Q4200 SKIN TE 1 SQ CM 636.00 Q4201 MATRION 1 SQ CM 138.40 Q4202 KEROXX (2.5G/CC), 1CC BR Q4203 DERMA-GIDE, 1 SQ CM 330.20 Q4204 XWRAP 1 SQ CM 246.40 Q4205 MEMBRANE GRAFT OR WRAP SQ CM 215.20 Q4206 FLUID FLOW OR FLUID GF 1 CC 1539.60 Q4208 NOVAFIX PER SQ CM 277.20 Q4209 SURGRAFT PER SQ CM 215.60 Q4211 AMNION BIO OR AXOBIO SQ CM BR Q4212 ALLOGEN, PER CC BR Q4213 ASCENT, 0.5 MG 61.60 Q4214 CELLESTA CORD PER SQ CM BR Q4215 AXOLOTL AMBIENT, CRYO 0.1 MG 308.00 Q4216 ARTACENT CORD PER SQ CM BR Q4217 WOUNDFIX BIOWOUND PLUS XPLUS 317.20 Q4218 SURGICORD PER SQ CM BR Q4219 SURGIGRAFT DUAL PER SQ CM BR Q4220 BELLACELL HD, SUREDERM SQ CM BR Q4221 AMNIOWRAP2 PER SQ CM 461.61 Q4222 PROGENAMATRIX, PER SQ CM 110.80 Q4224 HHF10-P PER SQ CM BR Q4225 AMNIO OR DERMA TL, PER SQ CM 1605.51 Q4226 MYOWN HARV PREP PROC SQ CM 308.00 Q4227 AMNIOCORE PER SQ CM 285.20 Q4229 COGENEX AMNIO MEMB PER SQ CM 573.13 Q4230 COGENEX FLOW AMNION 0.5 CC BR Q4231 CORPLEX P, PER CC 863.60 Q4232 CORPLEX, PER SQ CM 299.60 Q4233 SURFACTOR /NUDYN PER 0.5 CC 4616.80 Q4234 XCELLERATE, PER SQ CM 338.40 Q4235 AMNIOREPAIR OR ALTIPLY SQ CM 104.67 Q4236 CAREPATCH PER SQ CM 954.95 Q4237 CRYO-CORD, PER SQ CM BR Q4238 DERM-MAXX, PER SQ CM 615.60 Q4239 AMNIO-MAXX OR LITE PER SQ CM 584.80 Q4240 CORECYTE TOPICAL ONLY 0.5 CC 277.20 Q4241 POLYCYTE, TOPICAL ONLY 0.5CC BR Q4242 AMNIOCYTE PLUS, PER 0.5 CC BR Q4245 AMNIOTEXT, PER CC BR Q4246 CORETEXT OR PROTEXT, PER CC 1846.80 Q4247 AMNIOTEXT PATCH, PER SQ CM 308.00 Q4248 DERMACYTE AMN MEM ALLO SQ CM 277.20

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR Q4249 AMNIPLY, PER SQ CM 308.00 Q4250 AMNIOAMP-MP PER SQ CM 1150.00 Q4251 VIM, PER SQUARE CENTIMETER BR Q4252 VENDAJE, PER SQUARE CENTIMET 84.67 Q4253 ZENITH AMNIOTIC MEMBRANE PSC 131.37 Q4254 NOVAFIX DL PER SQ CM 507.20 Q4255 REGUARD, TOPICAL USE PER SQ BR Q4256 MLG COMPLET, PER SQ CM 1070.11 Q4257 RELESE, PER SQ CM 536.49 Q4258 ENVERSE, PER SQ CM 80.76 Q4259 CELERA PER SQ CM 1408.81 Q4260 SIGNATURE APATCH, PER SQ CM BR Q4261 TAG, PER SQUARE CENTIMETER BR Q4262 DUAL LAYER IMPAX, PER SQ CM 332.77 Q4263 SURGRAFT TL, PER SQ CM 628.40 Q4264 COCOON MEMBRANE, PER SQ CM 907.60 Q4265 NEOSTIM TL PER SQ CM 2326.17 Q4266 NEOSTIM PER SQ CM 977.81 Q4267 NEOSTIM DL PER SQ CM 961.95 Q4268 SURGRAFT FT PER SQ CM 758.80 Q4269 SURGRAFT XT PER SQ CM BR Q4270 COMPLETE SL PER SQ CM BR Q4271 COMPLETE FT PER SQ CM 1695.77 Q4272 ESANO A, PER SQ CM BR Q4273 ESANO AAA, PER SQ CM BR Q4274 ESANO AC, PER SQ CM 1145.60 Q4275 ESANO ACA, PER SQ CM 1757.20 Q4276 ORION, PER SQ CM 862.80 Q4278 EPIEFFECT, PER SQ CM 580.80 Q4279 VENDAJE AC, PER SQ CM 2623.50 Q4280 XCELL AMNIO MATRIX PER SQ CM 2266.44 Q4281 BARRERA SLOR DL PER SQ CM 1190.40 Q4282 CYGNUS DUAL PER SQ CM 993.61 Q4283 BIOVANCE TRI OR 3L, SQ CM 726.42 Q4284 DERMABIND SL, PER SQ CM BR Q4285 NUDYN DL OR DL MESH PR SQ CM BR Q4286 NUDYN SL OR SLW, PER SQ CM BR Q4287 DERMABIND DL, PER SQ CM BR Q4288 DERMABIND CH, PER SQ CM BR Q4289 REVOSHIELD+ AMNIO, PER SQ CM 2045.45 Q4290 MEMBRANE WRAP HYDR PER SQ CM 1213.20 Q4291 LAMELLAS XT, PER SQ CM BR Q4292 LAMELLAS, PER SQ CM BR Q4293 ACESSO DL, PER SQ CM BR Q4294 AMNIO QUAD-CORE, PER SQ CM 1451.59 Q4295 AMNIO TRI-CORE, PER SQ CM 1279.20 Q4296 REBOUND MATRIX, PER SQ CM BR Q4297 EMERGE MATRIX, PER SQ CM 1966.98 Q4298 AMNICORE PRO, PER SQ CM 2389.65

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR Q4299 AMNICORE PRO+, PER SQ CM 1497.60 Q4300 ACESSO TL, PER SQ CM 2326.17 Q4301 ACTIVATE MATRIX, PER SQ CM 2128.42 Q4302 COMPLETE ACA, PER SQ CM 2209.57 Q4303 COMPLETE AA, PER SQ CM 3754.07 Q4304 GRAFIX PLUS, PER SQ CM 1011.99 Q4305 AMER AM AC TRI-LAY PER SQ CM BR Q4306 AMERIC AMNION AC PER SQ CM BR Q4307 AMERICAN AMNION, PER SQ CM BR Q4308 SANOPELLIS, PER SQ CM BR Q4309 VIA MATRIX, PER SQ CM BR Q4310 PROCENTA, PER 100 MG 2370.48 Q4311 ACESSO, PER SQ CM BR Q4312 ACESSO AC, PER SQ CM BR Q4313 DERMABIND FM, PER SQ CM BR Q4314 REEVA, PER SQ CM BR Q4315 REGENELINK AMNIOTIC MEM ALLO BR Q4316 AMCHOPLAST, PER SQ CM BR Q4317 VITOGRAFT, PER SQ CM BR Q4318 E-GRAFT, PER SQ CM BR Q4319 SANOGRAFT, PER SQ CM BR Q4320 PELLOGRAFT, PER SQ CM BR Q4321 RENOGRAFT, PER SQ CM BR Q4322 CAREGRAFT, PER SQ CM BR Q4323 ALLOPLY, PER SQ CM BR Q4324 AMNIOTX, PER SQ CM BR Q4325 ACAPATCH, PER SQ CM BR Q4326 WOUNDPLUS, PER SQ CM 1256.00 Q4327 DUOAMNION, PER SQ CM BR Q4328 MOST, PER SQ CM BR Q4329 SINGLAY, PER SQ CM BR Q4330 TOTAL, PER SQ CM BR Q4331 AXOLOTL GRAFT, PER SQ CM 1255.20 Q4332 AXOLOTL DUALGRAFT, PER SQ CM 1348.00 Q4333 ARDEOGRAFT, PER SQ CM BR Q4334 AMNIOPLAST 1, PER SQ CM BR Q4335 AMNIOPLAST 2, PER SQ CM BR Q4336 ARTECENT C, PER SQ CM BR Q4337 ARTECENT TRIDENT, PER SQ CM BR Q4338 ARTACENT VELOS, PER SQ CM BR Q4339 ARTACENT VERICLEN, PER SQ CM BR Q4340 SIMPLIGRAFT, PER SQ CM BR Q4341 SIMPLIMAX, PER SQ CM BR Q4342 THERAMEND, PER SQ CM BR Q4343 DERMACYTE AC MATRX PER SQ CM BR Q4344 TRI MEMBRANE WRAP, PER SQ CM BR Q4345 MATRIX HD ALLOGRFT PER SQ CM BR Q4346 SHELTER DM MATRIX PER SQ CM BR Q4347 RAMPART DL MATRIX PER SQ CM BR

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR Q4348 SENTRY SL MATRIX PER SQ CM BR Q4349 MANTLE DL MATRIX PER SQ CM BR Q4350 PALISADE DM MATRIX PER SQ CM BR Q4351 ENCLOSE TL MATRIX, PER SQ CM BR Q4352 OVERLAY SL MATRIX, PER SQ CM BR Q4353 XCEED TL MATRIX PER SQ CM BR Q4354 PALINGEN DUAL-LAYER SQ CM BR Q4355 ABIO XPL ABIO XPL HY P SQ CM BR Q4356 ABIO MEM ABIO HYD PER SQ CM BR Q4357 XWRAP PLUS, PER SQ CM BR Q4358 XWRAP DUAL, PER SQ CM BR Q4359 CHORIPLY, PER SQ CM BR Q4360 AMCHOPLAST FD PER SQ CM BR Q4361 EPIXPRESS, PER SQ CM BR Q4362 CYGNUS DISK, PER SQ CM BR Q4363 AM BUR MEM HYDRO PER SQ CM BR Q4364 AM BUR XP MEM XPL HY P SQ CM BR Q4365 AMNIO BUR DL MEM PER SQ CM BR Q4366 DL AMNIO BUR X-MEM PER SQ CM BR Q4367 AMNIOCORE SL, PER SQ CM BR Q5001 HOSPICE OR HOME HLTH IN HOME See Home Health Rules

Q5002 HOSPICE/HOME HLTH IN ASST LV See Home Health Rules

Q5003 HOSPICE IN LT/NON-SKILLED NF See Home Health Rules

Q5004 HOSPICE IN SNF See Home Health Rules

Q5005 HOSPICE, INPATIENT HOSPITAL See Home Health Rules

Q5006 HOSPICE IN HOSPICE FACILITY See Home Health Rules

Q5007 HOSPICE IN LTCH See Home Health Rules

Q5008 HOSPICE IN INPATIENT PSYCH See Home Health Rules

Q5009 HOSPICE/HOME HLTH, PLACE NOS See Home Health Rules

Q5010 HOSPICE HOME CARE IN HOSPICE See Home Health Rules

Q5101 INJECTION, ZARXIO 1.08 0.44 Q5103 INJECTION, INFLECTRA 36.59 57.61 Q5104 INJECTION, RENFLEXIS 56.38 56.20 Q5105 INJ RETACRIT ESRD ON DIALYSI 0.92 1.71 Q5106 INJ RETACRIT NON-ESRD USE 9.24 11.54 Q5107 INJ MVASI 10 MG 35.46 56.47 Q5108 INJECTION, FULPHILA 181.80 289.88 Q5109 INJECTION, IXIFI, 10 MG BR Q5110 NIVESTYM 0.37 0.48 Q5111 INJECTION, UDENYCA 0.5 MG 189.06 286.98 Q5112 INJ ONTRUZANT 10 MG 75.35 86.78 Q5113 INJ HERZUMA 10 MG 47.26 68.87 Q5114 INJ OGIVRI 10 MG 52.58 79.12 Q5115 INJ TRUXIMA 10 MG 53.17 81.44 Q5116 INJ., TRAZIMERA, 10 MG 50.03 79.22

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR Q5117 INJ., KANJINTI, 10 MG 42.34 67.32 Q5118 INJ., ZIRABEV, 10 MG 46.05 71.84 Q5119 INJ RUXIENCE, 10 MG 48.43 80.05 Q5120 INJ PEGFILGRASTIM-BMEZ 0.5MG 168.66 316.46 Q5121 INJ. AVSOLA, 10 MG 42.52 64.33 Q5122 INJ, NYVEPRIA 239.46 382.18 Q5123 INJ. RIABNI, 10 MG 54.82 91.35 Q5124 INJ. BYOOVIZ, 0.1 MG 186.12 Q5125 INJ, RELEUKO 1 MCG 0.50 Q5126 INJ ALYMSYS 10 MG 64.05 108.16 Q5127 INJ, STIMUFEND, 0.5 MG 361.50 466.67 Q5128 INJ, CIMERLI, 0.1 MG 288.29 372.15 Q5129 INJ, VEGZELMA, 10 MG 79.65 102.82 Q5130 INJ, FYLNETRA, 0.5 MG 222.17 286.80 Q5133 INJ, TOFIDENCE, 1 MG 6.60 8.52 Q5134 INJ, TYRUKO, 1 MG BR Q5135 INJ, TYENNE, 1 MG 4.52 5.84 Q5136 INJ. DENOSUMAB-BBDZ, 1 MG BR Q5137 INJ, WEZLANA, SUB CU, 1 MG BR Q5138 INJ, WEZLANA, IV, 1 MG BR Q5139 INJ, ECULIZUMAB-AEEB, 10 MG BR Q5140 INJ ADALIMUMAB-FKJP, 1 MG BR 123.74 Q5141 INJ ADALIMUMAB-AATY, 1 MG BR 61.87 Q5142 INJ ADALIMUMAB-RYVK, 1 MG BR 14.97 Q5143 INJ ADALIMUMAB-ADBM, 1 MG BR 14.81 Q5144 INJ, IDACIO, 1 MG BR 21.33 Q5145 INJ, ABRILADA, 1 MG BR 181.86 Q5146 INJ, HERCESSI, 10 MG BR Q5147 INJ, AFLIBERCEPT-AYYH, 1 MG BR Q5148 INJ, NYPOSI 1 MCG BR Q5149 INJ, AFLIBERCEPT-ABZV, 1 MG BR Q5150 INJ, AFLIBERCEPT-MRBB, 1 MG BR Q5151 INJ, ECULIZUMAB-AAGH, 2 MG BR Q5152 INJ, ECULIZUMAB-AEEB, 2 MG BR Q9001 CHAPLAIN ASSESSMENT BR Q9002 CHAPLAIN COUNSEL INDIVIDU BR Q9003 CHAPLAIN COUNSEL GROUP BR Q9004 VA WHOLE HEALTH PARTNER SERV BR Q9950 INJ SULF HEXA LIPID MICROSPH 36.61 31.98 Q9951 LOCM >= 400 MG/ML IODINE,1ML 1.60 Q9953 INJ FE-BASED MR CONTRAST,1ML 58.80 Q9954 ORAL MR CONTRAST, 100 ML 18.40 Q9955 INJ PERFLEXANE LIP MICROS,ML 332.40 Q9956 INJ OCTAFLUOROPROPANE MIC,ML 38.65 Q9957 INJ PERFLUTREN LIP MICROS,ML 57.99 Q9958 HOCM <=149 MG/ML IODINE, 1ML 0.09 Q9959 HOCM 150-199MG/ML IODINE,1ML 0.83 Q9960 HOCM 200-249MG/ML IODINE,1ML 0.24 Q9961 HOCM 250-299MG/ML IODINE,1ML 0.25

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR Q9962 HOCM 300-349MG/ML IODINE,1ML 0.83 Q9963 HOCM 350-399MG/ML IODINE,1ML 0.21 Q9964 HOCM>= 400MG/ML IODINE, 1ML BR Q9965 LOCM 100-199MG/ML IODINE,1ML 0.98 Q9966 LOCM 200-299MG/ML IODINE,1ML 0.22 Q9967 LOCM 300-399MG/ML IODINE,1ML 0.14 Q9968 VISUALIZATION ADJUNCT 40.00 11.02 Q9969 NON-HEU TC-99M ADD-ON/DOSE 14.00 14.20 Q9982 FLUTEMETAMOL F18 DIAGNOSTIC 2857.31 Q9983 FLORBETABEN F18 DIAGNOSTIC 2967.93 Q9991 BUPRENORPH XR 100 MG OR LESS 2044.47 2537.58 Q9992 BUPRENORPHINE XR OVER 100 MG 2044.47 2537.58 R0070 TRANSPORT PORTABLE X-RAY 0.00 R0075 TRANSPORT PORT X-RAY MULTIPL 0.00 R0076 TRANSPORT PORTABLE EKG 0.00 S0012 BUTORPHANOL TARTRATE, NASAL 69.70 S0013 ESKETAMINE, NASAL SPRAY 19.10 S0014 TACRINE HYDROCHLORIDE, 10 MG 2.45 S0017 INJECTION, AMINOCAPROIC ACID 46.66 S0021 INJECTION, CEFOPERAZONE SOD BR S0023 INJECTION, CIMETIDINE HYDROC 10.56 S0028 INJECTION, FAMOTIDINE, 20 MG 7.04 S0032 INJECTION, NAFCILLIN SODIUM 87.10 S0034 INJECTION, OFLOXACIN, 400 MG BR S0039 INJECTION, SULFAMETHOXAZOLE 1.15 S0040 INJECTION, TICARCILLIN DISOD 13.04 S0074 INJECTION, CEFOTETAN DISODIU BR S0078 INJECTION, FOSPHENYTOIN SODI 160.21 S0080 INJECTION, PENTAMIDINE ISETH 163.99 S0081 INJECTION, PIPERACILLIN SODI 1.63 S0088 IMATINIB 100 MG 70.29 S0090 SILDENAFIL CITRATE, 25 MG 100.77 S0091 GRANISETRON 1MG 69.99 S0092 HYDROMORPHONE 250 MG 189.25 S0093 MORPHINE 500 MG 4.97 S0104 ZIDOVUDINE, ORAL, 100 MG 1.63 S0106 BUPROPION HCL SR 60 TABLETS 99.47 S0108 MERCAPTOPURINE 50 MG 3.27 S0109 METHADONE ORAL 5MG 0.54 S0117 TRETINOIN TOPICAL 5 G 1.91 S0119 ONDANSETRON 4 MG 24.06 S0122 INJ MENOTROPINS 75 IU 185.84 S0126 INJ FOLLITROPIN ALFA 75 IU 1291.94 S0128 INJ FOLLITROPIN BETA 75 IU 1973.34 S0132 INJ GANIRELIX ACETAT 250 MCG 131.56 S0136 CLOZAPINE, 25 MG 1.23 S0137 DIDANOSINE, 25 MG BR S0138 FINASTERIDE, 5 MG 2.45 S0139 MINOXIDIL, 10 MG 0.82

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR S0140 SAQUINAVIR, 200 MG 1.63 S0142 COLISTIMETHATE INH SOL MG BR S0145 PEG INTERFERON ALFA-2A/180 2441.36 S0148 PEG INTERFERON ALFA-2B/10 BR S0155 EPOPROSTENOL DILUTANT 0.50 S0156 EXEMESTANE, 25 MG 7.75 S0157 BECAPLERMIN GEL 1%, 0.5 GM 15.90 S0160 DEXTROAMPHETAMINE 35.20 S0169 CALCITROL 1.16 S0170 ANASTROZOLE 1 MG 11.44 S0172 CHLORAMBUCIL 2 MG 2.04 S0174 DOLASETRON 50 MG 47.28 S0175 FLUTAMIDE 125 MG 2.04 S0176 HYDROXYUREA 500 MG 1.23 S0177 LEVAMISOLE 50 MG 4.48 S0178 LOMUSTINE 10 MG 23.23 S0179 MEGESTROL 20 MG 0.40 S0182 PROCARBAZINE, ORAL 46.88 S0183 PROCHLORPERAZINE 5 MG 0.40 S0187 TAMOXIFEN 10 MG 2.04 S0189 TESTOSTERONE PELLET 75 MG 150.51 S0190 MIFEPRISTONE, ORAL, 200 MG 132.05 S0191 MISOPROSTOL, ORAL, 200 MCG 7.04 S0194 VITAMIN SUPPL 100 CAPS 25.97 S0197 PRENATAL VITAMINS 30 DAY 8.02 S0199 MED ABORTION INC ALL EX DRUG 794.17 S0201 PARTIAL HOSPITALIZATION SERV 337.69 S0207 PARAMEDICINTERCEP NONHOSPALS 242.96 S0208 PARAMED INTRCEPT NONVOL 226.15 S0209 WC VAN MILEAGE PER MI 1.15 S0215 NONEMERG TRANSP MILEAGE 0.45 S0220 MEDICAL CONFERENCE BY PHYSIC 29.42 S0221 MEDICAL CONFERENCE, 60 MIN 95.12 S0250 COMP GERIATR ASSMT TEAM 132.55 S0255 HOSPICE REFER VISIT NONMD BR S0257 END OF LIFE COUNSELING 49.28 S0260 H&P FOR SURGERY 222.33 S0265 GENETIC COUNSEL 15 MINS 54.24 S0270 HOME STD CASE RATE 30 DAYS 49.28 S0271 HOME HOSPICE CASE 30 DAYS BR S0272 HOME EPISODIC CASE 30 DAYS BR S0273 MD HOME VISIT OUTSIDE CAP BR S0274 NURSE PRACTR VISIT OUTS CAP BR S0280 MEDICAL HOME, INITIAL PLAN 140.19 S0281 MEDICAL HOME, MAINTENANCE 0.79 S0285 CNSLT BEFORE SCREEN COLONOSC 196.54 S0302 COMPLETED EPSDT 13.37 S0310 HOSPITALIST VISIT 97.03 S0311 COMP MGMT CARE COORD ADV ILL 216.97

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR S0315 DISEASE MANAGEMENT PROGRAM 212.01 S0316 FOLLOW-UP/REASSESSMENT 111.16 S0317 DISEASE MGMT PER DIEM 62.64 S0320 RN TELEPHONE CALLS TO DMP BR S0340 LIFESTYLE MOD 1ST STAGE 8.02 S0341 LIFESTYLE MOD 2 OR 3 STAGE BR S0342 LIFESTYLE MOD 4TH STAGE BR S0353 CANCER TREATMENTPLAN INITIAL 244.09 S0354 CANCER TREATMENT PLAN CHANGE 197.49 S0390 ROUT FOOT CARE PER VISIT 71.43 S0395 IMPRESSION CASTING FT 93.97 S0400 GLOBAL ESWL KIDNEY BR S0500 DISPOS CONT LENS 122.24 S0504 SINGL PRSCRP LENS 69.91 S0506 BIFOC PRSCP LENS 155.09 S0508 TRIFOC PRSCRP LENS 140.96 S0510 NON-PRSCRP LENS BR S0512 DAILY CONT LENS 67.61 S0514 COLOR CONT LENS BR S0515 SCLERAL LENS LIQUID BANDAGE 1058.14 S0516 SAFETY FRAMES 84.42 S0518 SUNGLASS FRAMES 113.07 S0580 POLYCARB LENS 23.69 S0581 NONSTND LENS 93.97 S0590 MISC INTEGRAL LENS SERV BR S0592 COMP CONT LENS EVAL 39.73 S0595 NEW LENSES IN PTS OLD FRAME 9.55 S0596 PHAKIC IOL REFRACTIVE ERROR BR S0601 SCREENING PROCTOSCOPY 105.81 S0610 ANNUAL GYNECOLOGICAL EXAMINA 176.87 S0612 ANNUAL GYNECOLOGICAL EXAMINA 135.61 S0613 ANN BREAST EXAM 61.51 S0618 AUDIOMETRY FOR HEARING AID 79.46 S0620 ROUTINE OPHTHALMOLOGICAL EXA 37.06 S0621 ROUTINE OPHTHALMOLOGICAL EXA 37.06 S0622 PHYS EXAM FOR COLLEGE 19.87 S0630 REMOVAL OF SUTURES 77.93 S0800 LASER IN SITU KERATOMILEUSIS 1588.74 S0810 PHOTOREFRACTIVE KERATECTOMY 1587.97 S0812 PHOTOTHERAP KERATECT 1827.10 S1001 DELUXE ITEM BR S1002 CUSTOM ITEM BR S1015 IV TUBING EXTENSION SET 42.02 S1016 NON-PVC INTRAVENOUS ADMINIST 17.57 S1030 GLUC MONITOR PURCHASE BR S1031 GLUC MONITOR RENTAL BR S1034 ART PANCREAS SYSTEM 9358.61 S1035 ART PANCREAS INV DISP SENSOR BR S1036 ART PANCREAS EXT TRANSMITTER 801.05

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR S1037 ART PANCREAS EXT RECEIVER BR S1040 CRANIAL REMOLDING ORTHOSIS 3760.03 S1091 STENT NON-CORONARY PROPEL 1821.75 S2053 TRANSPLANTATION OF SMALL INT BR S2054 TRANSPLANTATION OF MULTIVISC BR S2055 HARVESTING OF DONOR MULTIVIS BR S2060 LOBAR LUNG TRANSPLANTATION BR S2061 DONOR LOBECTOMY (LUNG) BR S2065 SIMULT PANC KIDN TRANS BR S2066 BREAST GAP FLAP RECONST 25420.19 S2067 BREAST "STACKED" DIEP/GAP 50838.85 S2068 BREAST DIEP OR SIEA FLAP 41107.78 S2070 CYSTO LASER TX URETERAL CALC BR S2079 LAP ESOPHAGOMYOTOMY BR S2080 LAUP 505.77 S2083 ADJUSTMENT GASTRIC BAND 289.94 S2095 TRANSCATH EMBOLIZ MICROSPHER 32774.84 S2102 ISLET CELL TISSUE TRANSPLANT BR S2103 ADRENAL TISSUE TRANSPLANT BR S2107 ADOPTIVE IMMUNOTHERAPY BR S2112 KNEE ARTHROSCP HARV 2382.91 S2115 PERIACETABULAR OSTEOTOMY 15884.32 S2117 ARTHROEREISIS, SUBTALAR 2502.10 S2118 TOTAL HIP RESURFACING 9475.13 S2120 LOW DENSITY LIPOPROTEIN(LDL) 9300.18 S2140 CORD BLOOD HARVESTING 238.37 S2142 CORD BLOOD-DERIVED STEM-CELL BR S2150 BMT HARV/TRANSPL 28D PKG BR S2152 SOLID ORGAN TRANSPL PKG BR S2202 ECHOSCLEROTHERAPY BR S2205 MINIMALLY INVASIVE DIRECT CO BR S2206 MINIMALLY INVASIVE DIRECT CO BR S2207 MINIMALLY INVASIVE DIRECT CO BR S2208 MINIMALLY INVASIVE DIRECT CO BR S2209 MINIMALLY INVASIVE DIRECT CO BR S2225 MYRINGOTOMY LASER-ASSIST BR S2230 IMPLANT SEMI-IMP HEAR BR S2235 IMPLANT AUDITORY BRAIN IMP BR S2260 INDUCED ABORTION 17-24 WEEKS 476.74 S2265 INDUCED ABORTION 25-28 WKS BR S2266 INDUCED ABORTION 29-31 WKS BR S2267 INDUCED ABORTION 32 OR MORE BR S2300 ARTHROSCOPY, SHOULDER, SURGI BR S2325 HIP CORE DECOMPRESSION 2780.96 S2340 CHEMODENERVATION OF ABDUCTOR BR S2341 CHEMODENERV ADDUCT VOCAL BR S2342 NASAL ENDOSCOP PO DEBRID 1112.38 S2348 DECOMPRESS DISC RF LUMBAR BR S2350 DISKECTOMY, ANTERIOR, WITH D 4499.96

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR S2351 DISKECTOMY, ANTERIOR, WITH D 3971.66 S2400 FETAL SURG CONGEN HERNIA BR S2401 FETAL SURG URIN TRAC OBSTR BR S2402 FETAL SURG CONG CYST MALF BR S2403 FETAL SURG PULMON SEQUEST BR S2404 FETAL SURG MYELOMENINGO 11310.64 S2405 FETAL SURG SACROCOC TERATOMA BR S2409 FETAL SURG NOC BR S2411 FETOSCOP LASER THER TTTS 7942.93 S2900 ROBOTIC SURGICAL SYSTEM 1309.88 S3000 BILAT DIL RETINAL EXAM BR S3005 EVAL SELF-ASSESS DEPRESSION BR S3600 STAT LAB 22.15 S3601 STAT LAB HOME/NF 17.57 S3620 NEWBORN METABOLIC SCREENING 37.06 S3630 EOSINOPHIL BLOOD COUNT 24.45 S3645 HIV-1 ANTIBODY TESTING OF OR 16.43 S3650 SALIVA TEST, HORMONE LEVEL; 120.72 S3652 SALIVA TEST, HORMONE LEVEL; BR S3655 ANTISPERM ANTIBODIES TEST BR S3708 GASTROINTESTINAL FAT ABSORPT BR S3722 DOSE OPTIMIZATION AUC - 5FU BR S3800 GENETIC TESTING ALS BR S3840 DNA ANALYSIS RET-ONCOGENE BR S3841 GENE TEST RETINOBLASTOMA BR S3842 GENE TEST HIPPEL-LINDAU BR S3844 DNA ANALYSIS DEAFNESS BR S3845 GENE TEST ALPHA-THALASSEMIA BR S3846 GENE TEST BETA-THALASSEMIA BR S3849 GENE TEST NIEMANN-PICK BR S3850 GENE TEST SICKLE CELL BR S3852 DNA ANALYSIS APOE ALZHEIMER BR S3853 GENE TEST MYO MUSCLR DYST BR S3854 GENE PROFILE PANEL BREAST 3522.86 S3861 GENETIC TEST BRUGADA BR S3865 COMP GENET TEST HYP CARDIOMY BR S3866 SPEC GENE TEST HYP CARDIOMY BR S3870 CGH TEST DEVELOPMENTAL DELAY BR S3900 SURFACE EMG 178.78 S3902 BALLISTOCARDIOGRAM BR S3904 MASTERS TWO STEP BR S4005 INTERIM LABOR FACILITY GLOBA 2382.91 S4011 IVF PACKAGE 4156.15 S4013 COMPL GIFT CASE RATE BR S4014 COMPL ZIFT CASE RATE 1636.49 S4015 COMPLETE IVF NOS CASE RATE BR S4016 FROZEN IVF CASE RATE 5574.91 S4017 IVF CANC A STIM CASE RATE 840.40 S4018 F EMB TRNS CANC CASE RATE 937.43

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR S4020 IVF CANC A ASPIR CASE RATE 1454.65 S4021 IVF CANC P ASPIR CASE RATE 6044.39 S4022 ASST OOCYTE FERT CASE RATE 1227.74 S4023 INCOMPL DONOR EGG CASE RATE 10051.18 S4024 AIR POLYMER FOAM PER STUDY BR S4025 DONOR SERV IVF CASE RATE 7946.75 S4026 PROCURE DONOR SPERM 810.22 S4027 STORE PREV FROZ EMBRYOS 25.60 S4028 MICROSURG EPI SPERM ASP 2184.66 S4030 SPERM PROCURE INIT VISIT BR S4031 SPERM PROCURE SUBS VISIT 4169.53 S4035 STIMULATED IUI CASE RATE 1807.24 S4037 CRYO EMBRYO TRANSF CASE RATE 3336.39 S4040 MONIT STORE CRYO EMBRYO 30 D 46.60 S4042 OVULATION MGMT PER CYCLE 397.28 S4981 INSERT LEVONORGESTREL IUS 357.17 S4988 PENILE CONTRACTUR DEVIC MANU BR S4989 CONTRACEPT IUD 716.63 S4990 NICOTINE PATCH LEGEND BR S4991 NICOTINE PATCH NONLEGEND BR S4993 CONTRACEPTIVE PILLS FOR BC 29.42 S4995 SMOKING CESSATION GUM 40.50 S5000 PRESCRIPTION DRUG, GENERIC BR S5001 PRESCRIPTION DRUG,BRAND NAME BR S5010 5% DEXTROSE AND 0.45% SALINE 13.37 S5012 5% DEXTROSE WITH POTASSIUM 14.52 S5013 5%DEXTROSE/0.45%SALINE1000ML 7.26 S5014 D5W/0.45NS W KCL AND MGS04 BR S5035 HIT ROUTINE DEVICE MAINT BR S5036 HIT DEVICE REPAIR BR S5100 ADULT DAYCARE SERVICES 15MIN 1.52 S5101 ADULT DAY CARE PER HALF DAY 51.19 S5102 ADULT DAY CARE PER DIEM 102.00 S5105 CENTERBASED DAY CARE PERDIEM 63.42 S5108 HOMECARE TRAIN PT 15 MIN 9.93 S5109 HOMECARE TRAIN PT SESSION 169.99 S5110 FAMILY HOMECARE TRAINING 15M 8.79 S5111 FAMILY HOMECARE TRAIN/SESSIO 63.42 S5115 NONFAMILY HOMECARE TRAIN/15M 9.16 S5116 NONFAMILY HC TRAIN/SESSION 22.15 S5120 CHORE SERVICES PER 15 MIN 3.06 S5121 CHORE SERVICES PER DIEM 178.01 S5125 ATTENDANT CARE SERVICE /15M 4.21 S5126 ATTENDANT CARE SERVICE /DIEM 105.44 S5130 HOMAKER SERVICE NOS PER 15M BR S5131 HOMEMAKER SERVICE NOS /DIEM BR S5135 ADULT COMPANIONCARE PER 15M 3.43 S5136 ADULT COMPANIONCARE PER DIEM 155.47 S5140 ADULT FOSTER CARE PER DIEM 70.67

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR S5141 ADULT FOSTER CARE PER MONTH BR S5145 CHILD FOSTERCARE TH PER DIEM 62.27 S5146 THER FOSTERCARE CHILD /MONTH BR S5150 UNSKILLED RESPITE CARE /15M See Home Health Rules

S5151 UNSKILLED RESPITECARE /DIEM See Home Health Rules

S5160 EMER RESPONSE SYS INSTAL&TST 23.30 S5161 EMER RSPNS SYS SERV PERMONTH 34.38 S5162 EMER RSPNS SYSTEM PURCHASE 325.46 S5165 HOME MODIFICATIONS PER SERV 3914.73 S5170 HOMEDELIVERED PREPARED MEAL 6.12 S5175 LAUNDRY SERV,EXT,PROF,/ORDER 19.87 S5180 HH RESPIRATORY THRPY IN EVAL 60.73 S5181 HH RESPIRATORY THRPY NOS/DAY BR S5185 MED REMINDER SERV PER MONTH 39.73 S5190 WELLNESS ASSESSMENT BY NONPH 16.81 S5199 PERSONAL CARE ITEM NOS EACH BR S5497 HIT CATH CARE NOC BR S5498 HIT SIMPLE CATH CARE 16.04 S5501 HIT COMPLEX CATH CARE 23.69 S5502 HIT INTERIM CATH CARE 19.87 S5517 HIT DECLOTTING KIT 102.76 S5518 HIT CATH REPAIR KIT 299.11 S5520 HIT PICC INSERT KIT 176.48 S5521 HIT MIDLINE CATH INSERT KIT 221.56 S5522 HIT PICC INSERT NO SUPP 595.54 S5523 HIP MIDLINE CATH INSERT KIT 238.37 S5550 INSULIN RAPID 5 U 11.84 S5551 INSULIN MOST RAPID 5 U 48.89 S5552 INSULIN INTERMED 5 U 16.04 S5553 INSULIN LONG ACTING 5 U 21.39 S5560 INSULIN REUSE PEN 1.5 ML BR S5561 INSULIN REUSE PEN 3 ML BR S5565 INSULIN CARTRIDGE 150 U BR S5566 INSULIN CARTRIDGE 300 U BR S5570 INSULIN DISPOS PEN 1.5 ML BR S5571 INSULIN DISPOS PEN 3 ML BR S8030 TANTALUM RING APPLICATION 501.94 S8035 MAGNETIC SOURCE IMAGING BR S8037 MRCP 448.47 S8040 TOPOGRAPHIC BRAIN MAPPING 516.08 S8042 MRI LOW FIELD BR S8055 US GUIDANCE FETAL REDUCT BR S8080 SCINTIMAMMOGRAPHY BR S8085 FLUORINE-18 FLUORODEOXYGLUCO BR S8092 ELECTRON BEAM COMPUTED TOMOG BR S8096 PORTABLE PEAK FLOW METER 14.52 S8097 ASTHMA KIT BR S8100 SPACER WITHOUT MASK 29.42

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR S8101 SPACER WITH MASK 27.12 S8110 PEAK EXPIRATORY FLOW RATE (P 35.91 S8120 O2 CONTENTS GAS CUBIC FT 1.52 S8121 O2 CONTENTS LIQUID LB 2.30 S8130 INTERFERENTIAL STIM 2 CHAN 2020.78 S8131 INTERFERENTIAL STIM 4 CHAN 43.93 S8185 FLUTTER DEVICE 131.79 S8186 SWIVEL ADAPTOR 12.22 S8189 TRACH SUPPLY NOC BR S8210 MUCUS TRAP 4.21 S8265 HABERMAN FEEDER BR S8270 ENURESIS ALARM 272.36 S8301 INFECT CONTROL SUPPLIES NOS BR S8415 SUPPLIES FOR HOME DELIVERY 294.14 S8420 CUSTOM GRADIENT SLEEV/GLOV 293.76 S8421 READY GRADIENT SLEEV/GLOV 117.66 S8422 CUSTOM GRAD SLEEVE MED 168.08 S8423 CUSTOM GRAD SLEEVE HEAVY 168.84 S8424 READY GRADIENT SLEEVE 56.91 S8425 CUSTOM GRAD GLOVE MED 176.48 S8426 CUSTOM GRAD GLOVE HEAVY 163.88 S8427 READY GRADIENT GLOVE 95.50 S8428 READY GRADIENT GAUNTLET 40.49 S8429 GRADIENT PRESSURE WRAP 144.78 S8430 PADDING FOR COMPRSSN BDG 8.79 S8431 COMPRESSION BANDAGE 8.79 S8450 SPLINT DIGIT 11.46 S8451 SPLINT WRIST OR ANKLE 14.13 S8452 SPLINT ELBOW 19.48 S8460 CAMISOLE POST-MAST 152.03 S8490 100 INSULIN SYRINGES 11.85 S8930 AURICULAR ELECTROSTIMULATION 31.70 S8940 HIPPOTHERAPY PER SESSION 67.61 S8948 LOW-LEVEL LASER TRMT 15 MIN 59.60 S8950 COMPLEX LYMPHEDEMA THERAPY, 71.43 S8990 PT OR MANIP FOR MAINT 39.73 S8999 RESUSCITATION BAG 144.78 S9001 HOME UTERINE MONITOR WITH OR BR S9002 INTRA-VAG MOTION SENS BIOFK 1329.36 S9007 ULTRAFILTRATION MONITOR BR S9024 PARANASAL SINUS ULTRASOUND 145.54 S9025 OMNICARDIOGRAM/CARDIOINTEGRA BR S9034 ESWL FOR GALLSTONES 1898.54 S9055 PROCUREN OR OTHER GROWTH FAC 278.87 S9056 COMA STIMULATION PER DIEM BR S9061 MEDICAL SUPPLIES AND EQUIPME 39.73 S9083 URGENT CARE CENTER GLOBAL 198.64 S9088 SERVICES PROVIDED IN URGENT 59.60 S9090 VERTEBRAL AXIAL DECOMPRESSIO 119.18

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR S9097 HOME VISIT WOUND CARE 198.64 S9098 HOME PHOTOTHERAPY VISIT 635.65 S9110 TELEMONITORING/HOME PER MNTH 33.61 S9117 BACK SCHOOL VISIT 437.00 S9122 HOME HEALTH AIDE OR CERTIFIE 60.00 S9123 NURSING CARE IN HOME RN 140.00 S9124 NURSING CARE, IN THE HOME; B 115.00 S9125 RESPITE CARE, IN THE HOME, P See Home Health Rules

S9126 HOSPICE CARE, IN THE HOME, P See Home Health Rules

S9127 SOCIAL WORK VISIT, IN THE HO 135.00 S9128 SPEECH THERAPY, IN THE HOME, 135.00 S9129 OCCUPATIONAL THERAPY, IN THE 135.00 S9131 PT IN THE HOME PER DIEM 135.00 S9140 DIABETIC MANAGEMENT PROGRAM, 53.10 S9141 DIABETIC MANAGEMENT PROGRAM, 53.10 S9145 INSULIN PUMP INITIATION 119.18 S9150 EVALUATION BY OCULARIST 158.91 S9152 SPEECH THERAPY, RE-EVAL 201.70 S9208 HOME MGMT PRETERM LABOR BR S9209 HOME MGMT PPROM BR S9211 HOME MGMT GEST HYPERTENSION 79.46 S9212 HM POSTPAR HYPER PER DIEM 86.72 S9213 HM PREECLAMP PER DIEM 86.72 S9214 HM GEST DM PER DIEM 206.66 S9325 HIT PAIN MGMT PER DIEM 164.26 S9326 HIT CONT PAIN PER DIEM 370.93 S9327 HIT INT PAIN PER DIEM 158.91 S9328 HIT PAIN IMP PUMP DIEM 95.50 S9329 HIT CHEMO PER DIEM 198.64 S9330 HIT CONT CHEM DIEM 152.03 S9331 HIT INTERMIT CHEMO DIEM 151.66 S9335 HT HEMODIALYSIS DIEM 742.99 S9336 HIT CONT ANTICOAG DIEM 198.64 S9338 HIT IMMUNOTHERAPY DIEM 87.48 S9339 HIT PERITON DIALYSIS DIEM 250.21 S9340 HIT ENTERAL PER DIEM 32.85 S9341 HIT ENTERAL GRAV DIEM 48.51 S9342 HIT ENTERAL PUMP DIEM 47.75 S9343 HIT ENTERAL BOLUS NURS 55.78 S9345 HIT ANTI-HEMOPHIL DIEM 79.46 S9346 HIT ALPHA-1-PROTEINAS DIEM 31.70 S9347 HIT LONGTERM INFUSION DIEM 51.57 S9348 HIT SYMPATHOMIM DIEM 480.94 S9349 HIT TOCOLYSIS DIEM 67.61 S9351 HIT CONT ANTIEMETIC DIEM 198.64 S9353 HIT CONT INSULIN DIEM 158.91 S9355 HIT CHELATION DIEM 244.87 S9357 HIT ENZYME REPLACE DIEM 59.60

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR S9359 HIT ANTI-TNF PER DIEM 198.64 S9361 HIT DIURETIC INFUS DIEM 442.74 S9363 HIT ANTI-SPASMOTIC DIEM 97.79 S9364 HIT TPN TOTAL DIEM 1374.06 S9365 HIT TPN 1 LITER DIEM 306.75 S9366 HIT TPN 2 LITER DIEM 670.41 S9367 HIT TPN 3 LITER DIEM 577.20 S9368 HIT TPN OVER 3L DIEM 436.63 S9370 HT INJ ANTIEMETIC DIEM 171.14 S9372 HT INJ ANTICOAG DIEM 54.63 S9373 HIT HYDRA TOTAL DIEM 428.23 S9374 HIT HYDRA 1 LITER DIEM 103.14 S9375 HIT HYDRA 2 LITER DIEM 79.46 S9376 HIT HYDRA 3 LITER DIEM 142.87 S9377 HIT HYDRA OVER 3L DIEM 93.60 S9379 HIT NOC PER DIEM BR S9381 HIT HIGH RISK/ESCORT BR S9401 ANTICOAG CLINIC PER SESSION 23.69 S9430 PHARMACY COMP/DISP SERV see page 77 S9432 MED FOOD NON INBORN ERR META BR S9433 MEDICAL FOOD ORAL 100% NUTR 17.19 S9434 MOD SOLID FOOD SUPPL 2.67 S9435 MEDICAL FOODS FOR INBORN ERR 15.66 S9436 LAMAZE CLASS 79.46 S9437 CHILDBIRTH REFRESHER CLASS BR S9438 CESAREAN BIRTH CLASS BR S9439 VBAC CLASS BR S9441 ASTHMA EDUCATION 39.73 S9442 BIRTHING CLASS 79.46 S9443 LACTATION CLASS 238.37 S9444 PARENTING CLASS 71.43 S9445 PT EDUCATION NOC INDIVID BR S9446 PT EDUCATION NOC GROUP BR S9447 INFANT SAFETY CLASS 158.91 S9449 WEIGHT MGMT CLASS 46.99 S9451 EXERCISE CLASS 31.70 S9452 NUTRITION CLASS 94.36 S9453 SMOKING CESSATION CLASS 108.11 S9454 STRESS MGMT CLASS 220.79 S9455 DIABETIC MANAGEMENT PROGRAM, BR S9460 DIABETIC MANAGEMENT PROGRAM, 111.16 S9465 DIABETIC MANAGEMENT PROGRAM, 248.30 S9470 NUTRITIONAL COUNSELING, DIET 79.46 S9472 CARDIAC REHABILITATION PROGR 59.60 S9473 PULMONARY REHABILITATION PRO 31.70 S9474 ENTEROSTOMAL THERAPY BY A RE BR S9475 AMBULATORY SETTING SUBSTANCE 2649.17 S9476 VESTIBULAR REHAB PER DIEM 317.82 S9480 INTENSIVE OUTPATIENT PSYCHIA 317.82

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR S9482 FAMILY STABILIZATION 15 MIN 7.26 S9484 CRISIS INTERVENTION PER HOUR 18.72 S9485 CRISIS INTERVENTION MENTAL H 699.06 S9490 HIT CORTICOSTEROID/DIEM 198.64 S9494 HIT ANTIBIOTIC TOTAL DIEM 198.64 S9497 HIT ANTIBIOTIC Q3H DIEM 142.87 S9500 HIT ANTIBIOTIC Q24H DIEM 286.50 S9501 HIT ANTIBIOTIC Q12H DIEM 258.23 S9502 HIT ANTIBIOTIC Q8H DIEM 286.12 S9503 HIT ANTIBIOTIC Q6H DIEM 297.96 S9504 HIT ANTIBIOTIC Q4H DIEM 283.06 S9529 VENIPUNCTURE HOME/SNF 87.48 S9537 HT HEM HORM INJ DIEM 77.16 S9538 HIT BLOOD PRODUCTS DIEM 79.46 S9542 HT INJ NOC PER DIEM BR S9558 HT INJ GROWTH HORM DIEM 53.49 S9559 HIT INJ INTERFERON DIEM BR S9560 HT INJ HORMONE DIEM 293.76 S9562 HT INJ PALIVIZUMAB/AB DIEM 63.42 S9563 HT INJ IMMUNO DIEM BR S9590 HT IRRIGATION DIEM 79.46 S9810 HT PHARM PER HOUR BR S9900 CHRISTIAN SCI PRACT VISIT 238.37 S9901 CHRISTIAN SCI NURSE VISIT BR S9960 AIR AMBULANC NONEMERG FIXED BR S9961 AIR AMBULAN NONEMERG ROTARY BR S9970 HEALTH CLUB MEMBERSHIP YR 108.87 S9975 TRANSPLANT RELATED PER DIEM 36.29 S9976 LODGING PER DIEM BR S9977 MEALS PER DIEM BR S9981 MED RECORD COPY ADMIN 3.06 S9982 MED RECORD COPY PER PAGE 0.30 S9986 NOT MEDICALLY NECESSARY SVC BR S9988 SERV PART OF PHASE I TRIAL BR S9989 SERVICES OUTSIDE US BR S9990 SERVICES PROVIDED AS PART OF BR S9991 SERVICES PROVIDED AS PART OF BR S9992 TRANSPORTATION COSTS TO AND BR S9994 LODGING COSTS (E.G. HOTEL CH BR S9996 MEALS FOR CLINICAL TRIAL PAR BR S9999 SALES TAX 5.73 U0001 2019-NCOV DIAGNOSTIC P 59.22 U0002 COVID-19 LAB TEST NON-CDC 84.59 V2020 VISION SVCS FRAMES PURCHASES 93.18 V2025 EYEGLASSES DELUX FRAMES 132.00 V2100 LENS SPHER SINGLE PLANO 4.00 45.29 V2101 SINGLE VISN SPHERE 4.12-7.00 47.72 V2102 SINGL VISN SPHERE 7.12-20.00 67.68 V2103 SPHEROCYLINDR 4.00D/12-2.00D 39.31

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR V2104 SPHEROCYLINDR 4.00D/2.12-4D 43.55 V2105 SPHEROCYLINDER 4.00D/4.25-6D 53.32 V2106 SPHEROCYLINDER 4.00D/>6.00D 54.11 V2107 SPHEROCYLINDER 4.25D/12-2D 56.87 V2108 SPHEROCYLINDER 4.25D/2.12-4D 55.15 V2109 SPHEROCYLINDER 4.25D/4.25-6D 63.40 V2110 SPHEROCYLINDER 4.25D/OVER 6D 74.00 V2111 SPHEROCYLINDR 7.25D/.25-2.25 65.22 V2112 SPHEROCYLINDR 7.25D/2.25-4D 64.37 V2113 SPHEROCYLINDR 7.25D/4.25-6D 88.91 V2114 SPHEROCYLINDER OVER 12.00D 78.66 V2115 LENS LENTICULAR BIFOCAL 85.51 V2118 LENS ANISEIKONIC SINGLE 84.78 V2121 LENTICULAR LENS, SINGLE 87.53 V2199 LENS SINGLE VISION NOT OTH C BR V2200 LENS SPHER BIFOC PLANO 4.00D 59.27 V2201 LENS SPHERE BIFOCAL 4.12-7.0 64.59 V2202 LENS SPHERE BIFOCAL 7.12-20. 76.02 V2203 LENS SPHCYL BIFOCAL 4.00D/.1 59.80 V2204 LENS SPHCY BIFOCAL 4.00D/2.1 64.83 V2205 LENS SPHCY BIFOCAL 4.00D/4.2 71.14 V2206 LENS SPHCY BIFOCAL 4.00D/OVE 86.61 V2207 LENS SPHCY BIFOCAL 4.25-7D/. 72.29 V2208 LENS SPHCY BIFOCAL 4.25-7/2. 73.18 V2209 LENS SPHCY BIFOCAL 4.25-7/4. 80.49 V2210 LENS SPHCY BIFOCAL 4.25-7/OV 103.57 V2211 LENS SPHCY BIFO 7.25-12/.25- 88.31 V2212 LENS SPHCYL BIFO 7.25-12/2.2 96.10 V2213 LENS SPHCYL BIFO 7.25-12/4.2 98.55 V2214 LENS SPHCYL BIFOCAL OVER 12. 105.62 V2215 LENS LENTICULAR BIFOCAL 114.30 V2218 LENS ANISEIKONIC BIFOCAL 116.94 V2219 LENS BIFOCAL SEG WIDTH OVER 51.47 V2220 LENS BIFOCAL ADD OVER 3.25D 41.75 V2221 LENTICULAR LENS, BIFOCAL 111.53 V2299 LENS BIFOCAL SPECIALITY 98.40 V2300 LENS SPHERE TRIFOCAL 4.00D 76.97 V2301 LENS SPHERE TRIFOCAL 4.12-7. 89.27 V2302 LENS SPHERE TRIFOCAL 7.12-20 97.78 V2303 LENS SPHCY TRIFOCAL 4.0/.12- 81.02 V2304 LENS SPHCY TRIFOCAL 4.0/2.25 84.78 V2305 LENS SPHCY TRIFOCAL 4.0/4.25 103.97 V2306 LENS SPHCYL TRIFOCAL 4.00/>6 96.94 V2307 LENS SPHCY TRIFOCAL 4.25-7/. 96.12 V2308 LENS SPHC TRIFOCAL 4.25-7/2. 102.56 V2309 LENS SPHC TRIFOCAL 4.25-7/4. 119.99 V2310 LENS SPHC TRIFOCAL 4.25-7/>6 131.99 V2311 LENS SPHC TRIFO 7.25-12/.25- 125.71 V2312 LENS SPHC TRIFO 7.25-12/2.25 110.80

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR V2313 LENS SPHC TRIFO 7.25-12/4.25 151.24 V2314 LENS SPHCYL TRIFOCAL OVER 12 165.67 V2315 LENS LENTICULAR TRIFOCAL 183.92 V2318 LENS ANISEIKONIC TRIFOCAL 169.58 V2319 LENS TRIFOCAL SEG WIDTH > 28 57.41 V2320 LENS TRIFOCAL ADD OVER 3.25D 60.57 V2321 LENTICULAR LENS, TRIFOCAL 181.29 V2399 LENS TRIFOCAL SPECIALITY 254.80 V2410 LENS VARIAB ASPHERICITY SING 103.66 V2430 LENS VARIABLE ASPHERICITY BI 134.95 V2499 VARIABLE ASPHERICITY LENS 36.40 V2500 CONTACT LENS PMMA SPHERICAL 93.96 V2501 CNTCT LENS PMMA-TORIC/PRISM 143.13 V2502 CONTACT LENS PMMA BIFOCAL 176.33 V2503 CNTCT LENS PMMA COLOR VISION 168.72 V2510 CNTCT GAS PERMEABLE SPHERICL 128.27 V2511 CNTCT TORIC PRISM BALLAST 184.31 V2512 CNTCT LENS GAS PERMBL BIFOCL 217.78 V2513 CONTACT LENS EXTENDED WEAR 182.83 V2520 CONTACT LENS HYDROPHILIC 120.56 V2521 CNTCT LENS HYDROPHILIC TORIC 209.91 V2522 CNTCT LENS HYDROPHIL BIFOCL 204.28 V2523 CNTCT LENS HYDROPHIL EXTEND 174.09 V2524 CNTCT LENS HYDROPHIL PHOTOCH 101.20 V2525 CL, HYDROPHILIC, DUAL FOCUS BR V2526 CNTCT LENS BLUE VIOLET 78.40 V2530 CONTACT LENS GAS IMPERMEABLE 257.84 V2531 CONTACT LENS GAS PERMEABLE 633.00 V2599 CONTACT LENS/ES OTHER TYPE BR V2600 HAND HELD LOW VISION AIDS 96.40 V2610 SINGLE LENS SPECTACLE MOUNT 27.20 V2615 TELESCOP/OTHR COMPOUND LENS 1023.60 V2623 PLASTIC EYE PROSTH CUSTOM 1037.73 V2624 POLISHING ARTIFICAL EYE 70.38 V2625 ENLARGEMNT OF EYE PROSTHESIS 455.87 V2626 REDUCTION OF EYE PROSTHESIS 289.22 V2627 SCLERAL COVER SHELL 1655.80 V2628 FABRICATION & FITTING 378.58 V2629 PROSTHETIC EYE OTHER TYPE 2066.80 V2630 ANTER CHAMBER INTRAOCUL LENS 137.61 V2631 IRIS SUPPORT INTRAOCLR LENS 137.61 V2632 POST CHMBR INTRAOCULAR LENS 137.61 V2700 BALANCE LENS 50.64 V2702 DELUXE LENS FEATURE 27.99 V2710 GLASS/PLASTIC SLAB OFF PRISM 74.13 V2715 PRISM LENS/ES 13.44 V2718 FRESNELL PRISM PRESS-ON LENS 33.01 V2730 SPECIAL BASE CURVE 24.38 V2744 TINT PHOTOCHROMATIC LENS/ES 25.29

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR V2745 TINT, ANY COLOR/SOLID/GRAD 14.33 V2750 ANTI-REFLECTIVE COATING 29.41 V2755 UV LENS/ES 21.26 V2756 EYE GLASS CASE 4.00 V2760 SCRATCH RESISTANT COATING 18.51 V2761 MIRROR COATING 47.89 V2762 POLARIZATION, ANY LENS 69.70 V2770 OCCLUDER LENS/ES 23.90 V2780 OVERSIZE LENS/ES 19.32 V2781 PROGRESSIVE LENS PER LENS 123.20 V2782 LENS, 1.54-1.65 P/1.60-1.79G 75.25 V2783 LENS, >= 1.66 P/>=1.80 G 84.85 V2784 LENS POLYCARB OR EQUAL 55.18 V2785 CORNEAL TISSUE PROCESSING 1181.20 V2786 OCCUPATIONAL MULTIFOCAL LENS 62.41 V2787 ASTIGMATISM-CORRECT FUNCTION 735.60 V2788 PRESBYOPIA-CORRECT FUNCTION 886.80 V2790 AMNIOTIC MEMBRANE 592.80 V2797 VIS ITEM/SVC IN OTHER CODE 24.80 V2799 MISC VISION ITEM OR SERVICE BR V5008 HEARING SCREENING 57.16 V5010 ASSESSMENT FOR HEARING AID 105.73 V5011 HEARING AID FITTING/CHECKING 190.56 V5014 HEARING AID REPAIR/MODIFYING 162.40 V5020 CONFORMITY EVALUATION 116.40 V5030 BODY-WORN HEARING AID AIR 1468.72 V5040 BODY-WORN HEARING AID BONE 721.88 V5050 HEARING AID MONAURAL IN EAR 1596.10 V5060 BEHIND EAR HEARING AID 2559.19 V5070 GLASSES AIR CONDUCTION 357.28 V5080 GLASSES BONE CONDUCTION 897.67 V5090 HEARING AID DISPENSING FEE 336.59 V5095 IMPLANT MID EAR HEARING PROS BR V5100 BODY-WORN BILAT HEARING AID 1651.63 V5110 HEARING AID DISPENSING FEE 532.01 V5120 BODY-WORN BINAUR HEARING AID 1754.26 V5130 IN EAR BINAURAL HEARING AID 3192.41 V5140 BEHIND EAR BINAUR HEARING AI 4363.17 V5150 GLASSES BINAURAL HEARING AID 1487.17 V5160 DISPENSING FEE BINAURAL 708.80 V5171 HEARING AID MONAURAL ITE 2460.80 V5172 HEARING AID MONAURAL ITC 2581.60 V5181 HEARING AID MONAURAL BTE 1525.19 V5190 HEARING AID MONAURAL GLASSES 1023.17 V5200 DISP FEE CONTRALATERAL MONAU 425.63 V5211 HEARING AID BINAURAL ITE/ITE 3493.20 V5212 HEARING AID BINAURAL ITE/ITC 4429.19 V5213 HEARING AID BINAURAL ITE/BTE 3888.00 V5214 HEARING AID BINAURAL ITC/ITC 3149.60

Mississippi Workers’ Compensation Medical Fee Schedule HCPCS A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364 Effective June 1, 2026

Code Mod Description MAR APC MAR V5215 HEARING AID BINAURAL ITC/BTE 3242.00 V5221 HEARING AID BINAURAL BTE/BTE 3491.61 V5230 HEARING AID BINAURAL GLASSES 1116.22 V5240 DISP FEE CONTRALATERAL BINAU 691.68 V5241 DISPENSING FEE, MONAURAL 344.40 V5242 HEARING AID, MONAURAL, CIC 1771.60 V5243 HEARING AID, MONAURAL, ITC BR V5244 HEARING AID, PROG, MON, CIC 1721.60 V5245 HEARING AID, PROG, MON, ITC BR V5246 HEARING AID, PROG, MON, ITE 1476.39 V5247 HEARING AID, PROG, MON, BTE 1969.60 V5248 HEARING AID, BINAURAL, CIC 3444.80 V5249 HEARING AID, BINAURAL, ITC 18701.20 V5250 HEARING AID, PROG, BIN, CIC 3445.60 V5251 HEARING AID, PROG, BIN, ITC 3039.20 V5252 HEARING AID, PROG, BIN, ITE 3353.20 V5253 HEARING AID, PROG, BIN, BTE 4028.40 V5254 HEARING ID, DIGIT, MON, CIC 2460.40 V5255 HEARING AID, DIGIT, MON, ITC 2126.00 V5256 HEARING AID, DIGIT, MON, ITE 2165.60 V5257 HEARING AID, DIGIT, MON, BTE 2460.80 V5258 HEARING AID, DIGIT, BIN, CIC 3536.80 V5259 HEARING AID, DIGIT, BIN, ITC 3732.39 V5260 HEARING AID, DIGIT, BIN, ITE 4519.20 V5261 HEARING AID, DIGIT, BIN, BTE 5305.20 V5262 HEARING AID, DISP, MONAURAL 1619.20 V5263 HEARING AID, DISP, BINAURAL 3544.80 V5264 EAR MOLD/INSERT 93.60 V5265 EAR MOLD/INSERT, DISP 24.80 V5266 BATTERY FOR HEARING DEVICE 1.20 V5267 HEARING AID SUP/ACCESS/DEV BR V5268 ALD TELEPHONE AMPLIFIER 246.00 V5269 ALERTING DEVICE, ANY TYPE BR V5270 ALD, TV AMPLIFIER, ANY TYPE 344.40 V5271 ALD, TV CAPTION DECODER BR V5272 TDD BR V5273 ALD FOR COCHLEAR IMPLANT BR V5274 ALD UNSPECIFIED BR V5275 EAR IMPRESSION 74.00 V5281 ALD FM/DM SYSTEM, MONAURAL 49.21 V5282 ALD FM/DM SYSTEM BINAURAL 2516.00 V5283 ALD NECK, LOOP IND RECEIVER BR V5284 ALD FM/DM EAR LEVEL RECEIVER 74.00 V5285 ALD FM/DM AUD INPUT RECEIVER 4919.20 V5286 ALD BLU TOOTH FM/DM RECEIVER 4921.20 V5287 ALD FM/DM RECEIVER, NOS BR V5288 ALD FM/DM TRANSMITTER ALD 984.40 V5289 ALD FM/DM ADAPT/BOOT COUPLIN 784.80 V5290 ALD TRANSMITTER MICROPHONE 442.80

HCPCS Mississippi Workers’ Compensation Medical Fee Schedule Effective June 1, 2026 A0021—C9899, E0100—G6017, J0120—S9999, U0001—V5364

Code Mod Description MAR APC MAR V5298 HEARING AID NOC BR V5299 HEARING SERVICE BR V5336 REPAIR COMMUNICATION DEVICE 146.00 V5362 SPEECH SCREENING 112.40 V5363 LANGUAGE SCREENING 108.80 V5364 DYSPHAGIA SCREENING 157.20

INDEX A add-on codes ....................................................... 5,36 advance care planning ............................................. 48 after hours ............................................................. 12 ambulatory payment classification (APC) ........... 3, 6, 332 ambulatory surgery center ................. 3, 13, 30, 33, 332 APC MAR ..................................................... 6, 13, 337 appeal expedited ..................................................... 24, 26 standard ...................................................... 24, 26 appropriate care ....................................................... 3 authorization for treatment ........................... 3, 8, 9, 23 authorized providers .................................................. 6 average wholesale price (AWP) ................................. 37 B back schools ......................................................... 303 billing forms ........................................................... 11 biofeedback ............................................................ 24 burns ..................................................................... 93 by report (BR) .......................................................... 3 C care management services ....................................... 47 care plan oversight services...................................... 47 carpal tunnel release ............................................... 91 case management ............................................. 24, 47 category II codes ................................................ 3, 36 category III codes .......................................... 3, 10, 36 chiropractic................................................................... 278, 305 civil penalty ................................................... 7, 11, 21 clinical guidelines ................................................ 4, 79 clinical rationale ...................................................... 23 clinical review first level............................................................ 24 second level ....................................................... 24 third level .......................................................... 24 CMS-1500 ................................................................ 3 codes exempt from modifier 51 ................................. 36 compound medications ............................................ 38 compounding fee..................................................... 77 concurrent review ............................................ 24, 303 confirmatory consultation ..................................... 7, 43 controverted claim .................................................... 3 copies of records ............................................... 17, 18 critical access hospitals (CAH) ................................. 331 critical care services ................................................. 46 current dental terminology (CDT) ........................ 7, 309 current procedural terminology (CPT) ....................... 3, 7 D definitions............................................................... 24 deposition/witness fees ............................................. 7 diagnosis-related group (DRG) ................................ 329 discharge planning ............................................... 2, 24 downcoding ...................................................... 13, 21 drug screening ................................................ 10, 237 durable medical equipment (DME) ........ 3, 330, 335, 336 E electromyography .................................................. 277 emergency admissions ............................................. 27 emergency department services .....................44, 45, 46 emergency room ........................................ 46, 93, 330 employer medical evaluation (EME) ................. 3, 23, 27 enteral and parenteral therapy .........................335, 336 epidural injections .................................. 76, 77, 79, 80 established patient .................................................. 43 evaluation and management (E/M) ............................ 43 excluded services .................................................. 333 explanation of review (EOR) ................................ 13, 13 F facility fee................................................ 13, 220, 237 federal facilities ........................................................ 8 follow-up days (FUD) ....................................... 4, 6, 89 forms ............................................................... 19, 22 functional capacity evaluations (FCE) ....................... 302 G general guidelines ............................................. 45, 89 global reimbursement .............................................. 89 H healthcare common procedure coding system(HCPCS)335

Index Mississippi Workers’ Compensation Medical Fee Schedule

home health ........................................................... 41 home infusion ......................................................... 42 home services ......................................................... 46 hospice .................................................................. 42 I identification number ............................................... 11 impairment rating ................................................ 7, 17 implantables ............................................ 13, 330, 333 independent medical examination (IME) ................... 4, 8 injections ............................................................... 12 inpatient records ..................................................... 18 inpatient rehabilitation facilities (IRF) ....................... 331 instructions to payers............................................... 13 inter-disciplinary pain rehabilitation ......................... 305 interest and penalty ...................................... 13, 20, 21 interpretation of diagnostic studies in the emergency room ................................................................. 45 investigational procedures .................................. 10, 77 L LPN skilled nursing rates .......................................... 41 long term acute care (LTAC)...............................................329 M mail-order pharmaceutical services ............................ 37 maximum medical improvement ................................. 8 medical necessity ..................................................... 2 medical only case ..................................................... 4 medical records ....................................................... 17 medically accepted standard ...................................... 4 medications ............................................................ 37 mental health evaluation ........................................ 305 microscope ............................................................. 89 mileage .......................................................... 10, 474 mileage reimbursement ............................................. 7 modifier 22 increased procedural services .......................... 29 23 unusual anesthesia ........................................ 29 24 unrelated evaluation and management services . 29 25 significant, separately identifiable evaluation and management service ................................ 29, 34 26 professional component .................................. 29 27 multiple outpatient hospital e/m encounters ...... 34 32 mandated services ......................................... 30 47 anesthesia by surgeon .................................... 30 50 bilateral procedure ................................... 30, 35 51 multiple procedures........................................ 30 52 reduced services ...................................... 30, 35 53 discontinued procedure .................................. 30 54 surgical care only .......................................... 30 55 postoperative management only ..................... 30 56 preoperative management only ....................... 31 57 decision for surgery ....................................... 31 58 staged or related procedure or service ........ 31, 34 59 distinct procedural service ......................... 31, 34 62 two surgeons ................................................ 31 66 surgical team ................................................ 31 73 discontinued out-patient hospital/ambulatory surgery center (asc) {procedure ...................... 34 74 discontinued outpatient hospital/ambulatory surgery center (asc) procedure ....................... 35 76 repeat procedure or service ....................... 31, 35 77 repeat procedure by another physician........ 31, 35 78 unplanned return to the op erating/procedure room....................................................... 31, 35 79 unrelated procedure or service ................... 32, 35 80 assistant surgeon .......................................... 32 81 minimum assistant surgeon ............................ 32 82 assistant surgeon .......................................... 32 90 reference (outside) laboratory ........................ 32 91 repeat clinical diagnostic laboratory test ...... 32, 36 92 alternative laboratory platfor92 alternative laboratory platform testing ............................. 32 93 synchronous telemedicine service rendered via a real-time interacdtive audio and video telecommunications system ............................ 32 95 synchronous telemedicine service .................... 32 99 multiple modifiers ......................................... 33 AA anesthesia services performed personally by anesthesiologist ............................................ 32 AD medical supervision by a physician more than four concurre nt anesthesia procedures .................. 33 AS physician assistant, nurse practitioneror clinical nurse specialist services for assistant at surgery 33 AU item furnished in conjunction with a urological, ostomy, or tracheostomy supply ...................... 35 AV item furnished in conjunction with a prosthetic device, prosthetic, or orthotic ......................... 35 AW item furnished in conjunction with a surgical dressing ....................................................... 35 KC replacement of special power wheelchair interface ................................................................... 35 M1 nurse practitioner ......................................... 33 M2 physician assistant ........................................ 33 M3 physical or occupational therapist assistant ...... 33 M4 CARF accredited ............................................ 33 M5 chronic pain treatment .................................. 33 M6 psychologist, social worker, licensed professional counselor (mental health counselor) ............... 33 NU new equipment ............................................. 35 QK medical direction of 2, 3, or 4 concurrent anesthesia procedures ................................... 33 QX CRNA service with medical direction by a physician ................................................................... 33

Mississippi Workers’ Compensation Medical Fee Schedule Index

QY medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist registered nurse anesthetist ............................ 33 QZ CRNA service without medical direction by a physician ...................................................... 33 RR rental .......................................................... 35 TC technical component ....................................... 30 UE used durable medical equipment ...................... 35 modifier and code rules ............................................ 29 N national correct coding initiative (NCCI) ................... 4, 7 national drug code (NDC) ......................................... 38 national provider identifier (NPI) .................... 11, 12, 39 nerve blocks, ............................................... 75, 79, 90 nerve conduction studies (NCS) .............................. 277 new patient ............................................................ 43 no show appointments ............................................. 12 non-face-to-face services ......................................... 47 non-surgical debridement ....................................... 278 non-work related medical information ........................ 17 notification ............................................................. 24 nurse practitioner .................................................... 39 nursing facility services ............................................ 46 O observation .......................................... 4, 45, 330, 331 occupational therapist assistant .......................... 33, 39 occupational therapy rates ....................................... 41 ODG guidelines ......................................................... 8 office or other outpatient services ............................. 44 operating microscope............................................... 89 orthotics ....................................................... 302, 304 other adjunct service codes ...................................... 12 other evaluation and management services ................ 48 other qualified health care professional (OQHP) .......... 39 out-of-state medical treatment ................................... 8 outpatient records ................................................... 17 P pain control ........................................... 23, 75, 76, 90 pain management ................................................... 75 pain pumps ............................................................ 76 parenteral nutrition ................................................. 42 PC MAR .................................................................... 5 peer group ............................................................... 2 peer review ............................................. 2, 19, 20, 24 pharmacy 503b compounding .............................................. 37 reimbursement.................................................... 37 rules .................................................................. 37 physical therapist (PT) .............................................. 6 physical therapist assistant ....................................... 39 physical therapy rates .............................................. 41 physician assistant (PA) ....................................... 6, 90 physician dispensing ................................................ 37 physician specialty ................................................... 12 physician-dispensed medications ............................... 37 portable service ....................................................... 12 pre-certification ................................................... 9, 23 prior authorization ........................................... 8, 9, 23 private duty rates .................................................... 41 procedure code ........................................................ 5 prolonged services ................................................... 44 prospective payment system (PPS) .......................... 331 prosthetics .....................................................304, 335 provider .................................................................. 1 psychiatric collaborative care management ................. 47 psychological services ............................................ 277 R radiology .............................................................. 219 recoding ................................................................. 13 referral ................................................................... 43 refund to the payer .................................................. 12 registered nurse first assistant (RNFA) ....................... 92 reimbursement .................................................. 11, 41 repackaged medication............................................. 38 repricing ................................................................. 11 request for reconsideration ....................................... 13 request for resolution of dispute ................................ 19 response time .......................................................... 8 retrospective review............................................. 9, 24 return to work ................................................... 9, 303 RN skilled nursing rates ............................................ 41 S sales tax................................................................. 10 second opinion ................................................ 3, 7, 43 selection of providers ......................................... 9, 301 separate fee contract ............................................... 11 skilled nursing facility ....................................... 47, 333 special evaluation and management services .............. 47 speech therapy rates ............................................... 41 supplies ............................................. 12, 90, 277, 304 surgical assistant ..........................................14, 32, 90

Index Mississippi Workers’ Compensation Medical Fee Schedule

T TC MAR ................................................................... 6 technical component ...................................... 6, 13, 29 telemedicine ........................................ 5, 9, 10, 32, 45 therapeutic services ......................................... 77, 301 therapy group and individual .......................................... 305 third level clinical review .......................................... 24 time ....................................................................... 10 topical medications .................................................. 38 topical patches ........................................................ 38 transcutaneous electrical nerve stimulation ............... 304 transitional care management ................................... 47 transportation ....................................................... 335 trigger point injections ............................................. 81 U unlisted procedure code .......................................... 220 unlisted service ..................................................... 220 usual and customary .............. 3, 5, 11, 37, 41, 277, 333 utilization reviewer .................................................. 24 V variance ................................................................ 25 W withhold payment ..................................................... 2 witness fees ............................................................. 2 work hardening ................ 9, 17, 24, 301, 302, 303, 304