114.3 CMR 40.00 — Rates for services under MGL c.152, Workers' Compensation Act

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114.3 CMR 40.00: RATES FOR SERVICES UNDER M.G.L. c. 152, WORKERS’ COMPENSATION ACT Section 40.01: General Provisions 40.02: General Definitions 40.03: Service and Rate Coverage Provisions 40.04: Provisions Affecting Eligible Providers 40.05: Policies for Individual Service Types 40.06: Fees 40.07: Appendices 40.08: Severability

114.3 CMR 40.00 Rates for services under MGL c.152, Workers' Compensation Act

40.01 General Provisions

40.01: General Provisions (1) Scope, Purpose and Effective Date. 114.3 CMR 40.00 governs the payment rates effective April 1, 2009 for purchasers of health care services under M.G.L. c. 152, the Workers’ Compensation Act. Payment rates for services provided by hospitals are set forth in 114.1 CMR 41.00. Program policies relating to medical necessity and clinical appropriateness are determined pursuant to M.G.L. c. 152 and 452 CMR 6.00. (2) Coverage. The payment rates set forth in 114.3 CMR 40.06 are full payment for services provided under M.G.L. c. 152, § 13, including any related administrative or overhead costs. The insurer, employer and health care service provider may agree upon a different payment rate for any service set forth in the fee schedule in 114.3 CMR 40.00. No employee may be held liable for the payment for health care services determined compensable under M.G.L. c. 152, § 13. (3) Administrative Bulletins. The Division may issue administrative bulletins to clarify substantive provisions of 114.3 CMR 40.00, or to publish procedure code updates and corrections. For coding updates and correction, the bulletin will list: (a) new code numbers for existing codes, with the corresponding cross references between existing and new codes numbers; (b) deleted codes for which there are no corresponding new codes; and (c) codes for entirely new services that require pricing. The Division will designate these codes to be paid by individual consideration under 114.3 CMR 40.04(3) until appropriate rates are developed. (4) Rate Updates for Services Covered by Other Regulations. The Division will post rate amendments for services governed by other regulations on its website. (5) Disclaimer for Authorization of Services. 114.3 CMR 40.00 is not authorization for or approval of services for which rates are determined pursuant to 114.3 CMR 40.00. (6) Authority. 114.3 CMR 40.00 is adopted pursuant to M.G.L. c. 118G and M.G.L. c. 152, § 13.

40.02 General Definitions

40.02: General Definitions (1) Meaning of Terms. Terms used in 114.3 CMR 40.00 will have the meanings set forth in

40.02 Adjusted Acquisition Cost. The price paid to a supplier by an Eligible Provider for durable

114.3 CMR 40.02: Adjusted Acquisition Cost. The price paid to a supplier by an Eligible Provider for durable medical equipment, medical/surgical supplies, customized equipment, oxygen and respiratory therapy equipment. The adjusted acquisition cost shall not exceed the manufacturer's current catalogue price. Administrative Costs. A provider's costs for administration, including but not limited to facility costs overhead and other costs of doing business, are included in the rates set forth in this fee schedule, unless stated otherwise.

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40.02 continued

40.02: continued At Invoice Cost (AI). The price paid by the provider net of any manufacturer discounts received. Documentation of AI cost must be supplied to purchaser for payment upon request however submission of the request to the provider must be made within ten days of the initial billing date, will not affect the payment timeframe dictated by DIA regulations and will be limited to items where the provider's cost exceeds $500.00. The provider is responsible for maintaining documentation of the cost for any items costing less than $500.00 for a minimum of three years from the date of the original bill to the carrier. Centers for Medicare and Medicaid Services (CMS). A division of the U.S. Department of Health and Human Services (HHS) that oversees and publishes rules and guidelines of the Medicare and Medicaid programs. Consultation. A service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source. A physician consultant may initiate diagnostic and/or therapeutic services. The written or verbal request for a consultation may be made by a physician or other appropriate source and must be documented in the patient's medical record. The consultant's opinion and any services that were ordered or performed must also be documented in the patient's medical record and communicated by written report to the requesting physician or other appropriate source. A consultation initiated by a patient and/or family, and not requested by a physician, is not reported using the consultation codes but may be reported using the appropriate office visit codes. Any procedure that can be identified with a specific CPT code performed on or subsequent to the date of the initial consultation should be reported separately. If, subsequent to the completion of a consultation, the consultant assumes responsibility for management of a portion or all of the patient's condition(s), the appropriate Evaluation and Management services code for the service should be reported. CPT Codes. 114.3 CMR 40.00 uses Codes from the Physicians' Current Procedural Terminology (CPT)© system developed and maintained by the American Medical Association. All CPT codes are copyrighted by the American Medical Association. All procedures and codes set forth under 114.3 CMR 40.00 conform to CPT 2008 codes and descriptors and the principles for their use, as set forth in the Physicians' Current Procedural Terminology, 2008, and any later updates. These CPT publications contain the complete and most current listings of CPT descriptive terms and numeric identifying codes and modifiers for reporting medical services and procedures. Department of Industrial Accidents (DIA). A department of the Commonwealth of Massachusetts Executive Office of Labor and Workforce Development that oversees the Workers’ Compensation system pursuant to M.G.L. c. 152 and other applicable laws and waivers. Department of Public Health (DPH). A department of the Commonwealth of Massachusetts established under M.G.L. c.17, § 1 that oversees and licenses healthcare facility standards and operations and administers public health programs for all Massachusetts residents. Description. An explanation of the medical procedure or item assigned to the code. This may include certain stipulations relevant to Massachusetts under M.G.L. c. 152. Division. The Division of Health Care Finance and Policy established under M.G.L. c. 118G. Durable Medical Equipment (DME). Prosthetic devices, implantable devices, replacement parts (external or internal), accessories and supplies for the DME and other devices identified as DMEPOS by CMS. Implantable devices not listed with a fee in 114.3 CMR 40.06(6) and not included as a portion of the ambulatory surgery fee will be paid at invoice (A.I.) cost net of any manufacturer discounts received by the provider plus a mark up of 20% not to exceed $200.00.

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40.02 continued

40.02: continued Eligible Provider. A provider as defined in 114.3 CMR 40.05, that also meets such conditions of participation as have been or may be adopted by a Governmental Unit or purchaser under M.G.L. c. 152. Out-of-state providers must meet the comparable conditions of licensure and participation required by the state in which they practice. Established Patient. A person who has received professional services from the physician or another physician of the same specialty in the same group practice within the past three years. Under 114.3 CMR 40.00, Established Patient will be applied to a single work related injury or episode of illness. Fee. The payment value for the medical procedure or item set forth in 114.3 CMR 40.06 and identified by a Code. Fees may be listed as Professional Component Fee (PC Fee), Technical Component Fee (TC Fee) and Global Fee (GL Fee) when a professional, technical or global fee applies. Single payment rates are listed as "Fees". See definitions of (GL), (PC) and (TC). Global Fee (GL). The Global Fee is the sum of the PC Fee and TC Fee. See definitions of (PC) and (TC) below. Governmental Unit. The Commonwealth, any division, department, agency, board or commission of the Commonwealth, and any political subdivision of the Commonwealth. HCPCS National Codes. Level II coding system of alpha-numeric codes published by the Centers for Medicare and Medicaid Services (CMS) to supplement CPT codes for medical services and supplies. All D codes are copyrighted by the American Dental Association. Services and items set forth under 114.3 CMR 40.00 utilize HCPCS 2008 codes and descriptors. Instrumental Activities of Daily Living (IADLs). Activities related to personal care of a patient such as meal preparation and clean-up, household services, laundry, shopping, housekeeping, transportation to a medical provider, or assistance with the care and maintenance of adaptive devices. Liquid Oxygen Systems. Oxygen and oxygen equipment as DME includes the system for furnishing it, the vessels that store it, the tubing, and administration sets that allow the safe delivery of oxygen in the home, and the oxygen contents. Medical and Surgical Supplies. Medical and treatment products that: (a) are produced primarily and routinely to fulfill a medical or surgical purpose; (b) are used in the treatment of a specific medical condition; (c) are non-reusable and disposable. Modifiers. A two digit (numeric or alpha) sequence that alters the description of a delivered service or supply. 114.3 CMR 40.07(1): Appendix A lists a limited number of the common modifiers and certain reimbursement provisions associated with their use. However, providers, suppliers and carriers may utilize any appropriate current CPT Level I and HCPCS Level II National Modifiers as necessary. Non-standard Prescription Options. New mobility systems including devices that: (a) provide their user with a substantially greater range of motion than are usually required of the standard device; or (b) require substantially greater service or time than are usually provided for the standard device. Orthotic Device. A mechanical device designed to support or correct any defect of form or function of the human body, and generally known as a "brace" or "orthosis" but not including dental braces or breast prostheses.

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40.02: continued Oxygen Delivery Systems. A comprehensive oxygen service that includes, but is not limited to: the gaseous/liquid oxygen, oxygen generating device and related delivery systems container or cylinder, manifold systems whenever high volume oxygen is used, stand, cart, walker/stroller, supply reservoir, contents indicator, regulator with flow gage, humidifcation devices, cannulas, masks, and special oxygen administration device, tubing and refill adapter. Professional Component (PC). Certain procedures are a combination of a physician, or professional component and a technical component. When the modifier "-26" is added to an appropriate code a PC allowable amount will be paid. Prosthesis. An artificial device used to replace a missing body part, such as a limb, tooth, eye, or heart valve. Prosthetic Device. Any substitute or ancillary equipment or component part used in a prosthesis for replacement or modification purposes. Rehabilitation Technology Specialist (RTS). A professional with expertise in assistive and rehabilitation technology, including wheeled mobility, seating and alternative positioning, ambulating assistance, environmental control and related activities who meets such conditions of participation as may be adopted by a Governmental Unit to work directly with consumers in the provision of wheeled mobility systems in the service delivery process. Respiratory Therapy Devices and Supplies. Devices and necessary ancillary equipment prescribed by a physician for the care and treatment of pulmonary illnesses that meet such standards as may be required by federal or state Governmental Units. Respiratory Therapy Devices may include the complete device and related delivery system accessories such as, regulator with flow gauge, humidification and heating units, filters, cannulas, masks, and special administration device tubing and adapters. Seating, Positioning, Mobility Systems and Related Accessories. Any device including its components, accessories and modifications, that has been prescribed, designed and constructed to meet the individual custom needs of a patient. This equipment will be provided by an eligible DME provider who employs a Rehabilitation Technology Specialist (RTS). The equipment must fulfill a medical purpose and be generally not useful in the absence of illness or injury, withstand repeated use over an extended period of time, be appropriate for home use, and meet professionally recognized standards of quality. Special Report. A service that is rarely provided, unusual, variable, or new may require an explanation to determine the medical appropriateness of the service. These services are generally reported as "unlisted services or procedures" and designated by digits '99' after the first three beginning code numbers. Pertinent information should include, but not be limited to, 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. Additional items that can be included are: complexity of symptoms, final diagnosis, pertinent physical findings, diagnostic and therapeutic procedures, concurrent problems, and follow-up care. Technical Component (TC): The TC component reflects the technical portion of the procedure code. When the technical component is provided by a health care provider other than the one providing the professional component, the health care provider bills for the technical component by adding Modifier "-TC" to the applicable code. The TC rate is payment for the facility's cost of rent, equipment, utilities, supplies, administrative and technical salaries and benefits, and all other overhead expenses. Transcutaneous Electrical Nerve Stimulator (TENS). A TENS unit must be distinguished from other electrical stimulators that directly stimulate muscles and/or motor nerves, eg, neuromuscular stimulators.

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40.02 continued

40.02: continued Unlisted Procedure or Service. A service or procedure may be provided that is not listed in Regulation 114.3 CMR 40.06. When reporting such a service, the appropriate "Unlisted Procedure" code may be used to indicate the service. A "Special Report" may be required when billing codes for unlisted procedures. Used Equipment. Any item that has been previously purchased or rented, including equipment that was: (a) used by a patient for a trial period; (b) used by the supplier as a demonstrator; or (c) rented by a patient who now wants to buy it. Usual and Customary Charge. The lowest fee charged to the general public by an Eligible Provider specified by 114.3 CMR 40.05: Usual and Customary Charge, which fee is in effect at the time that such service is performed or equipment is sold or rented.

40.03 Service and Rate Coverage Provisions

40.03: Service and Rate Coverage Provisions (1) Services and Rates Covered by 114.3 CMR 40.00. Payment rates for the following health care service are governed by the provisions of 114.3 CMR 40.00. These services are: (a) Acupuncture Services - 114.3 CMR 40.05(1) (b) Anesthesia Services - 114.3 CMR 40.05(2) (c) Chiropractic Services - 114.3 CMR 40.05(3) (d) Clinical Laboratory Services - 114.3 CMR 40.05(4) (e) Dental Services - 114.3 CMR 40.05(5) (f) Durable Medical Equipment - 114.3 CMR 40.05(6) (g) Freestanding Diagnostic Facilities - 114.3 CMR 40.05(7) (h) Freestanding Ambulatory Surgical Centers - 114.3 CMR 40.05(8) (i) Homemaker Services - 114.3 CMR 40.05(9) (j) Medicine - 114.3 CMR 40.05(10) (k) Psychology Services - 114.3 CMR 40.05(11) (l) Radiology - 114.3 CMR 40.05(12) (m) Restorative Services - 114.3 CMR 40.05(13) (n) Surgery - 114.3 CMR 40.05(14) (2) Services and Rates Covered by Other Regulations. Payment rates for the following health care services are governed by other regulations promulgated by the Division. These services are: (a) Abortion and Sterilization - 114.3 CMR 13.00 (b) Adult Day Health - 114.3 CMR 10.00 (c) Ambulance Services - 114.3 CMR 27.00 (d) Chronic Maintenance Dialysis and Home Dialysis Supplies - 114.3 CMR 37.00 (e) Community Health Center Services - 114.3 CMR 4.00 (f) Hearing Aid Dispensers - 114.3 CMR 23.00 (g) Home Health Services, including Private Duty Nursing - 114.3 CMR 50.00 (h) Hospice Services - 114.3 CMR 43.00 (i) Independent Living Services (Personal Care Attendant) - 114.3 CMR 9.00 (j) Mental Health Services provided in Community Health Centers and Mental Health Centers - 114.3 CMR 6.00 (k) Nursing Facility Services - 114.2 CMR 6.00; rates for individual facilities posted on Division website (l) Outpatient Tuberculosis Control Services - 114.3 CMR 8.00 (m) Prescribed Drugs - 114.3 CMR 31.00 (n) Psychiatric Day Treatment - 114.3 CMR 7.00 (o) Resident Care Facilities (Rest Homes) -114.2 CMR 4.00; rates for individual facilities posted on Division's website (p) Substance Abuse Treatment Services - 114.3 CMR 46.00 (q) Vision Care and Ophthalmic Materials - 114.3 CMR 15.00

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40.03 continued

40.03: continued (3) Other Service Providers. If a treatment measure performed by practitioners of alternative or complementary care, such as massage therapy, is authorized under 452 CMR 6.00, the insurer, the employer and the health care service provider must agree upon the appropriate method of billing for treatment and the payment rate for such services.

40.04 Provisions Affecting Eligible Providers

40.04: Provisions Affecting Eligible Providers (1) Facility Rate. If a procedure other than those listed in 114.3 CMR 40.06 with a PC and TC fee is performed at a site other than the provider's office and is also properly billed by another health care provider, each provider will be reimbursed at 50% of the listed fee. (2) Out-of-state Providers. An insurer may pay out-of-state provider for services at the payment rates set forth in 114.3 CMR 40.00. (3) Individual Consideration (I.C.). Services that are authorized but for which there are no established rates are designated as I.C. items. The purchaser under M.G.L. c. 152 will determine an appropriate payment rate. Unless otherwise provided in 114.3 CMR 40.05, the payment will be determined in accordance with all of the applicable following standards and criteria: (a) The amount of time required to perform the procedure, (b) The degree of skill required to perform the procedure, (c) The severity or complexity of the patient's disease, disorder or disability, (d) The policies, procedures and practices of other third party insurers, (e) A copy of the current invoice from the supplier for items if the provider cost exceeds $500.00. The provider is responsible for maintaining invoices for any items that cost less than $500.00 for a minimum of three years from the date of the original bill to the carrier. (4) Utilization Standard. The DIA Healthcare Services Board publishes treatment guidelines pertaining to work place injury and illness that define appropriate care deemed medically necessary. All services provided under the Workers’ Compensation Act must be delivered within the scope of these guidelines.

40.05 Policies for Individual Service Types

40.05: Policies for Individual Service Types (1) Acupuncture. (a) Eligible Providers. An Eligible Provider is any person licensed by the Board of Registration in Acupuncture under M.G.L. c. 112, §§ 148 through 162, to practice acupuncture. (b) Acupuncture Services. Acupuncture is the insertion of needles through the skin at certain points on the body in an attempt to relieve pain or improve bodily function. Services include examinations, Evaluation and Management services (E/M), acupuncture treatments and supportive services. The acupuncture treatment codes include a patient assessment. Additional E/M services may be reported separately using the modifier '-25', if the patient's condition requires a significant separately identifiable E/M service, above and beyond the usual pre-service and post-service work associated with the procedure. (c) Fees. Payment rates for acupuncture services are set forth in 114.3 CMR 40.06(1). (d) Modalities and Supportive Procedures. A charge may be assessed for modalities only in conjunction with an acupuncture treatment performed during the course of the same visit. (e) Nutritional Supplements. The payment rate for nutritional supplements is the invoice cost, plus a handling fee of $3.00. (2) Anesthesia Services. (a) Eligible Providers. An Eligible Provider is:

a licensed medical doctor or licensed osteopath, other than an intern or resident, authorized by the Board of Registration in Medicine in accordance with the provisions of M.G.L. c. 112; or

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40.05: continued 2. a certified registered nurse anesthetist (CRNA) licensed and subject to the rules and requirements in accordance with the provisions of M.G.L. c. 112 and 244 CMR 4.00 to practice as a CRNA. The CRNA is limited to those procedures within the scope of CRNA services and subject to the rules of physician relationship for reimbursement defined by the Commonwealth's Nurse Practice Act, M.G.L. c. 112, §§ 74 through 81. The CRNA is an employee of the eligible physician provider and not salaried by the health care facility. Availability by telephone is not direct supervision; however, the physician need not be in the room where the services are being performed. (b) Anesthesia Services. Services include, but are not limited to, general, regional, supplementation to local anesthesia, or other supportive services for optimal anesthesia care to the patient. These services include anesthesia care during the procedure, the administration of fluids and/or blood and the usual monitoring services, (eg, ECG, temperature, blood pressure, oximetry, capnography, and mass spectrometry). These services do not include preoperative and postoperative services or pain management services that may be billable separately. Unusual forms of monitoring beyond the basic anesthesia service (eg, intra-arterial, central venous, and Swan-Ganz catheters) are not included and are reimbursed separately based on the appropriate medical or surgical fee schedule. (c) Fees. The payment rates for anesthesia services are set forth in 114.3 CMR 40.05(2)(g) for use with base units set forth in 114.3 CMR 40.06(2). Fees for supplies and materials provided by the physician (eg, sterile trays, drugs) over and above those usually included with the office visit or other services rendered may be listed separately using code 99070. (d) Payments for Qualified CRNAs. Payment rates are established using the appropriate 2 digit modifier listed in 114.3 CMR 40.07: Appendix A to denote services rendered by a non-physician provider. Payments to employers billing for eligible CRNA services as specified in 114.3 CMR 40.05(2)(a)2. are:

50% of the fees specified in 114.3 CMR 40.05(2)(c) for CRNA services with medical direction of 2, 3 or 4 concurrent procedures by a physician, or
100% of the allowable fee specified in 114.3 CMR 40.05(2)(c) for CRNA services with medical direction of one CRNA or without direction by a physician. (e) Time Reporting. Anesthesia time begins when the anesthesiologist begins to prepare the patient for the induction of anesthesia in the operating suite (or its equivalent area) and ends when the anesthesiologist is no longer in personal attendance, i.e., when the patient is placed in postoperative supervision. (f) Qualifying Circumstances. If anesthesia services are provided under particularly difficult circumstances, based on factors such as extraordinary condition of the patient, notable operative conditions, and/or unusual risk factors, CPT codes 99100 to 99140 may be listed as additional procedure codes as follows: Qualifying Circumstances in CPT Description Unit Value 99100 99116 99135 99140 Anesthesia for a patient of extreme age, under one year old and 70 years of age or older Anesthesia complicated by utilization of total body hypothermia Anesthesia complicated by utilization of controlled hypotension Anesthesia complicated by emergency conditions (an emergency is defined as existing when delay in treatment of the patient would lead to a significant increase in the threat to life or body part.) 1 5 5 2 (g) Determining Payment for Anesthesia Services. Providers must use anesthesia codes and report time in minutes to ensure proper payment. Payments are determined by adding base units, time units and modifying units (if any) and multiplying this sum by a rate per unit. Each time unit equals 15 minutes. Partial time units should be reported rounded to one decimal place. PAYMENT EQUALS : (TIME UNITS + BASE UNITS + MODIFYING UNITS) TIMES $39.00 (Rate per UNIT)

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40.05: continued (h) Special Coding Situations.

Multiple Procedures. When multiple surgical procedures are performed during a single anesthetic administration, providers must report only the anesthesia procedure with the highest unit value. The provider must report time as the combined total for all procedures performed.
Anesthesia Modifiers. Physical status and common CPT modifiers used in conjunction with anesthesia codes are set forth in 114.3 CMR 40.07(1): Appendix A.
Postoperative Pain Management. Postoperative pain management is payable as an additional procedure. (3) Chiropractic Services. (a) Eligible Providers. An Eligible Provider is an individual licensed by the Board of Registration of Chiropractors in accordance with the provisions of M.G.L. c. 112. (b) Chiropractic Services. Chiropractic Services include examinations, Evaluation and Management services (E/M), Chiropractic Manipulative Treatment (CMT), therapeutic (supportive) procedures and modalities. The chiropractic manipulative treatment codes include a pre-manipulation patient assessment. Additional E/M services may be reported separately using the modifier '-25' if the patient's condition requires a significant separately identifiable E/M service, above and beyond the usual pre-service and post-service work associated with the procedure. When an extraspinal manipulation (code 98943) is performed in conjunction with CMT codes 98940 through 98942, the Multiple Procedure modifier -51 must be added to code 98943 indicating payment at 50% of the allowable fee set forth in 114.3 CMR 40.06. (c) Fees. Payment rates for chiropractic services are set forth in 114.3 CMR 40.06(3). (d) Modalities and Supportive Procedures. A charge may be assessed for modalities (97012-97039) only in conjunction with a chiropractic treatment performed over the course of treatment of the patient. Service provisions pertaining to physical medicine are set forth in 114.3 CMR 40.05(13) and rates of payment for supportive procedures are listed in 114.3 CMR 40.06(12). No charge will be allowed for application of hot and cold packs (CPT code 97010). (e) Durable Medical Equipment, Prosthetics/Orthotics, and Supplies (DMEPOS). Payment rates for durable medical equipment, prosthetic/orthotics and supplies are set forth in 114.3 CMR 40.06(6) and subject to the provisions and guidelines set forth in 114.3 CMR 40.05(6). (f) Nutritional Supplements. The payment rate for nutritional supplements is the invoice cost, plus a handling fee of $3.00. (g) Radiology. Payment rates for radiological services are set forth in 114.3 CMR 40.06(7) subject to the provisions and guidelines set forth in 114.3 CMR 40.05(12). (4) Clinical Laboratory Services. (a) Eligible Providers. An Eligible Provider is an independent licensed clinical diagnostic laboratory, a diagnostic laboratory in a physician's office or a hospital laboratory. Payment for clinical laboratory tests subject to 114.3 CMR 40.06(4) applies to the person or entity that performs or supervises the performance of the tests. (b) Clinical Laboratory Services. Clinical Laboratory Services include microbiological, chemical, hematological, biophysical, cytological, immunohematological, or pathological examinations performed in a laboratory on materials derived from the human body to provide information for the diagnosis, prevention, or treatment of a disease or assessment of a medical condition. (c) Fees. Payment rates for clinical laboratory services are set forth in 114.3 CMR 40.06(4). Payment Rates for physician laboratory services, i.e., anatomic and surgical pathology are set forth in 114.3 CMR 40.06(8).

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40.05 continued

40.05: continued (d) Items Over and Above Usual Service. If the physician's administration of supplies and drugs includes items over and above the usual service rendered (eg, sterile trays, drugs, supplies and materials), the provider may list these separately using code 99070. To report physician attendance and monitoring during the test, providers must use the appropriate evaluation and management code, including the prolonged physician care codes if appropriate. Prolonged physician care codes are not separately reported when evocative/ suppression testing involves prolonged descriptors where reference is made to a particular analyte (eg, Cortisol (82533 x 2) where the "x 2" refers to the number of times the test for that particular analyte is performed). (e) Pricing of Automated Tests. The payment for automated tests is based on the total number of actual tests whether billed individually or as part of a panel. For example, if three automated tests are performed on one blood draw from a patient, the total fee allowed for these tests will be $9.29, the pricing equivalent for three tests. (5) Dental Services. (a) Eligible Providers. An Eligible Provider is:

a dentist registered by the Board of Registration in Dentistry in accordance with the provisions of M.G.L. c. 112; or
an authorized governmental, nonprofit or charitably incorporated dental clinic not involved with teaching dental students; or
an authorized dental clinic that wholly or partially derives support from Title V Funds under the Social Security Act; or
a teaching dental clinic operated by dental education institutions. (b) Dental Services. Dental services include, but are not limited to, diagnostic, consultative and evaluative oral examinations, X-rays, preventive, restorative, endodontic, periodontic, prosthodontic, surgical, exodontic and orthodontic procedures and appliances. (c) Fees. Payment rates for dental services are set forth in 114.3 CMR 40.06(5). (d) Surgery. Payment rates for surgical dental services are set forth in 114.3 CMR 40.06(8) and subject to the provisions and guidelines set forth in 114.3 CMR 40.05(14). (e) Codes and Descriptions. All codes and descriptions are copyrighted by the American Dental Association's Current Dental Terminology, (CDT-4). (6) Durable Medical Equipment, Prosthetics/Orthotics, and Supplies (DMEPOS). (a) Eligible Providers. An Eligible Provider is:
any person, partnership, corporation, or other entity authorized by the Commonwealth of Massachusetts to engage in the business of furnishing Durable Medical Equipment (DME), Medical and surgical supplies, Customized equipment, Oxygen or respiratory therapy equipment, Mobility systems, Intravenous and enteral therapy equipment, and/or related supplies and services;
a provider authorized under 114.3 CMR 40.05 to provide equipment or supplies relative to his or her specialty in an office setting;
an eligible prosthesis provider certified by the American Board for Certification in Prosthetics and Orthotics (P&O) with experience and knowledge of upper and lower extremity prostheses, cosmetic restoration and devices for traumatic or congenital deformities, their design, fabrication and fitting; or
any person, partnership, corporation or other entity authorized by the Commonwealth of Massachusetts to engage in the business of furnishing orthotic devices. At the discretion of the purchasing agency, a provider of certain orthotic devices may be a certified orthotist who has experience in and knowledge of upper and lower extremity bracing, torso, and spinal bracing, devices for congenital deformities, their design, fabrication and fitting. (b) Exclusions. 114.3 CMR 40.00 does not govern the payment rates for the following services:
Respiratory therapy services rendered by a qualified respiratory therapist;
Oxygen provided to a nursing home that is reimbursed under the per diem rate for such nursing home;
Services for inpatients at a facility licensed as an acute or chronic hospital.

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40.05 continued

40.05: continued (c) General Provisions.

Coverage. 114.3 CMR 40.05 governs the payment rates for the following situations:
1. the purchase or rental of durable medical equipment;
2. the purchase or rental of medical/surgical supplies;
3. the purchase or rental of prescribed oxygen delivery systems and respiratory
therapy equipment and related supplies; d. the purchase or rental of seating, positioning, mobility systems and related accessories; e. the purchase or rental of intravenous and enteral supplies, equipment and services; and f. the repair of the listed types of equipment in 114.3 CMR 40.05(6)(c)1.a. through e.
Pre-authorization. Insurers and other payers under 114.3 CMR 40.00 may require pre-authorization, recertification and/or other requirements documenting medical necessity for equipment and related supplies and services under 114.3 CMR 40.05(6). In most cases, the physician's prescription for the equipment and other medical information available are sufficient to establish that the equipment is necessary and suitable in the treatment of the illness or injury. Providers should determine if there are documentation and coverage requirements associated with a prescription for durable medical supplies prior to dispensing. (d) Fees. Payment rates for DMEPOS, are set forth in 114.3 CMR 40.06(6). (e) Payment Methodology. DME fee schedules are calculated for the following DME payment classes:
Inexpensive and Other Routinely Purchased Items (IN). These items have a purchase price of $150 or less, or are generally purchased 75% of the time or more, or are accessories used in conjunction with certain nebulizers, aspirators, and ventilators. These items can be purchased new or used and can be rented; however, total payments cannot exceed the purchase new fee for the item.
Frequently Serviced Items (FS). These items require frequent and substantial servicing. These items can be rented as long as they are medically necessary.
Oxygen and Oxygen Equipment. Payment for oxygen and oxygen equipment is made on a monthly basis. One bundled monthly payment amount is made for all covered stationary equipment, stationary and portable contents, and all accessories used in conjunction with the oxygen equipment. A monthly payment is made for oxygen contents only. An additional monthly payment may be made for portable oxygen.
Other Covered Items. Supplies necessary for the effective use of the DME.
Capped Rental Items (CR). Items that do not fall under any other DME payment category, generally expensive items that are routinely rented. Items designated as "capped rental" in the code description are rented for a maximum period of 15 months or until the rental fees paid equal the purchase price, at which point the provider stops billing. The provider may bill for repairs as needed to maintain proper working condition th of the equipment for the patient's use after the 15 month. The methodology for payment of items on a capped rental basis is as follows:
1. for the first three months of rental, 10% of the new purchase fee;
2. for months four through 15, 75% of the monthly fee for months one through
three; c. if provided equipment is used for less than one month, the payment will be prorated. The payment is determined by dividing the monthly rental fee by the number of days in the applicable month, and multiplying the daily rate by the number of rental days. For purchase of capped rental items, the purchase price may not exceed the sum of the capped rental methodology applied for ten months.
Unlisted Items. Items that are not listed but may be prescribed as medically necessary for the treatment of illness or injury or to improve patient function are payable using the Medicare fee for the locality in which the item is prescribed. If no Medicare fee is available then the item shall be paid under the reimbursement policies for individually considered (I.C.) items in accordance with 114.3 CMR 40.05(6). In this case a code not listed in 114.3 CMR 40.06(6) should be assigned an unlisted service or procedure code such as A9900 (Miscellaneous DME supply, accessory, and/or service component of another HCPCS code) or E1399 (Durable Medical Equipment, miscellaneous.) Customized items that are deemed medically necessary are payable at individual consideration (I.C.).

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40.05 continued

40.05: continued (f) Individual Consideration (I.C.). The payment for individually considered items is the lower of:

The Eligible Provider's usual and customary charge to the general public; or
The adjusted acquisition cost to the Eligible Provider plus a markup not to exceed:
1. 30% for inexpensive and routinely purchased items; or
2. 40% for frequently serviced items, customized equipment, prosthetics and
orthotics; or c. as priced in 114.3 CMR 40.06(6) (g) Labor Rate for Repair Services.
Payments for labor costs for repair code E1340 to an Eligible Provider for items that require additional service, intensive time or procedures, or that require repair, may be billed at the rate of $21.00 per 15 minutes.
Payments for labor costs for orthotic repair code L4205 and prosthetic repair code L7520 to an Eligible Provider for items that require additional service, intensive time or procedures, or that require repair, may be billed at the rate of $21.00 per 15 minutes. (7) Freestanding Diagnostic Facilities. (a) Eligible Provider. An Eligible Provider is a licensed freestanding diagnostic imaging facility or hospital. (b) Fees. Payment rates for freestanding diagnostic facilities and imaging technical components are set forth in 114.3 CMR 40.06(7). (c) General Rate Guidelines.
The TC payment for CAT and MRI procedures that specify "with contrast" include payment for contrast media.
The TC rate for nuclear medicine does not include the radionuclide used in connection with the procedure. These substances are separately billed under codes A4641 and A4642 for diagnostic procedures and are paid on an I.C. basis depending on the substance used. (8) Freestanding Ambulatory Surgical Centers. (a) Eligible Provider. An Eligible Provider is a DPH licensed freestanding ambulatory surgical center (FASC) or hospital outpatient surgical center. (b) FASC Services. FASC Services are procedures that CMS recognizes as safe to perform in an ambulatory setting without requiring hospital facilities as of January 1, 2008. (c) Fees. Payment rates are based upon Medicare rates for Massachusetts effective January 1, 2008. The fees are listed in 114.3 CMR 40.06(8). For procedures that are deemed safe to perform in the ambulatory setting subsequent to January 1, 2008, the Medicare fee for Massachusetts should be used for services provided under 114.3 CMR 40.00. (d) Global Surgical Procedures Facility Coverage. The fee covers services and the normal range of care required before and after surgery that are included in the Medicare fee. (e) Services not included in the global facility rate. Services required in conjunction with the surgical procedure that are not included in the Medicare fee should be reimbursed at their respective CPT/HCPCS rates. (f) Implanted DME, implanted prosthetic devices, replacement parts (External or Internal), accessories and supplies for the implanted DME. Payment for items not included in the Medicare ASC fee but listed in 114.3 CMR 40.06(6) includes the associated fees. Otherwise payment for the items is the invoice cost as specified in 114.3 CMR 40.02. No separate payment shall be made for implanted devices that are included in the Medicare ASC fee. Fees do not include medically appropriate observation stays in hospitals which are established under 114.1 CMR 41.00. (g) Modifiers. See 114.3 CMR 40.07(1): Appendix A for a list of Level 1 CPT modifiers. (9) Homemaker Services. (a) Eligible Provider. An Eligible Provider is an individual, partnership or corporation that employs homemakers. (b) Homemaker Services. Homemaker Services are services that comply with the Homemaker Standards issued by the Executive Office of Elder Affairs to assist a client with IADL.

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40.05 continued

40.05: continued (c) Fees. The payment rate for homemaker services is set forth in 114.3 CMR 40.06(9). (10) Medicine. (a) Eligible Providers. Eligible Providers include:

a physician or osteopath other than an intern, resident, or house officer licensed by the Board of Registration in Medicine in accordance with the provisions of M.G.L. c. 112. A licensed Physician Assistant (PA) authorized by the Board of Registration for Physician Assistants in accordance with the provisions of M.G.L. c. 112, may not bill separately for services rendered.
a licensed, registered podiatrist other than an intern, resident, or house officer authorized by the Board of Registration in Medicine or the Board of Registration in Podiatry in accordance with the provisions of M.G.L. c. 112, whose eligibility is limited to those procedures within the scope of his/her licensure.
a licensed registered nurse authorized by the Board of Registration in Nursing in accordance with the provisions of M.G.L. c. 112 to practice as a Nurse Practitioner (NP), limited to those procedures within the scope of NP services and subject to the rules of physician relationship for reimbursement defined by the Commonwealth's Nurse Practice Act, M.G.L. c. 112, §§ 74 through 81. (b) Fees. Payment rates for medicine services are set forth in 114.3 CMR 40.06(10). (c) Payments for Qualified NPs and PAs. Payment to employers billing for eligible NPs and PAs as specified in 114.3 CMR 40.05(10)(a)3. is 85% of the fees set forth in 114.3 CMR 40.06. Providers must use the appropriate 2-digit modifier listed in 114.3 CMR 40.07: Appendix A to denote services rendered by a non-physician provider. (d) Allowable Fees - Medical Services.
Office Visits. The office visit fees apply only when the Eligible Provider customarily bills for services rendered.
Drugs, Medications, Supplies and Laboratory Specimen Collections. Supplies and materials used in preparation for or as part of a procedure (eg, bandages, laboratory kits, syringes or disposable gloves) are not reimbursed separately, but included in the office visit rate. In addition, no supplemental charge will be submitted nor payment allowed for routine specimen collection in a physician's office and preparation for clinical laboratory analysis (and activities related thereto), eg, venipuncture, urine, fecal and sputum sample collection, culturing, swabbing and scraping for removal of tissues.
Payments for Other Services. Where applicable, payment for drugs, medicines, supplies, and related materials dispensed to patients are governed by provisions of other Division regulations applicable to the service provided, and may not exceed the physician's usual and customary fee. If there is no appropriate code for the supplies or materials provided by the physician over and above those usually included with the office visit, the service should be billed under code (99070).
Medication and Injections. Medication and injectables not available free of charge from the Department of Public Health may be billed under the appropriate J Code at A.I. cost net of any manufacturer discounts received by the provider. See 114.3 CMR

40.07(4) Appendix D for a list of J codes. If the code is not available, use an unlisted

40.07(4): Appendix D for a list of J codes. If the code is not available, use an unlisted procedures category (such as code 90749 for immunizations or code 99070 under miscellaneous services). Immunization injections are usually given in conjunction with a medical service. When an immunization is the only service performed, a minimal service (such as codes 90471, 90472 or 96400) may be listed in addition to the injection; an office visit should not be separately billed. Immunization procedures include the supply of materials. 5. Physical Medicine. Service provisions pertaining to physical and restorative medicine are set forth in 114.3 CMR 40.05(13) and codes and fees for physical medicine procedures are listed in 114.3 CMR 40.06(12). (11) Psychology. (a) Eligible Providers. An Eligible Provider is:

a psychologist licensed by the Massachusetts Board of Registration of Psychologists in accordance with the provisions of M.G.L. c. 112; or

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40.05 continued

40.05: continued 2. a social worker (LICSW) licensed by the Massachusetts Board of Registration of Social Work in accordance with the provisions of M.G.L. c. 112. Psychiatric Services provided by a licensed physician are set in accordance with 114.3 CMR 40.05(10). (b) Psychological Services. Psychological Services include:

diagnostic services, which are evaluative interviews to determine a client's emotional and psychological disability for the purpose of developing a treatment plan;
individual therapy, which is a meeting between an Eligible Provider and the client to help to ameliorate problems, conflicts and disturbances;
group therapy, which is a treatment session conducted by an Eligible Provider for the application of psychotherapeutic or counseling techniques to a group of people each of whom manifests an emotional problem or disturbance. Groups are usually five people but are limited to a maximum of ten clients.
psychological testing, which is performed with the use of standard test instruments to evaluate aspects of a client's functioning, aptitudes and educational ability, cognitive processes, emotional conflicts and type and degree of psychopathology. All fees for psychological tests cover the complete cost of interviewing, testing, scoring, interpreting and writing reports of test outcomes. (c) Fees. Payment rates for psychological services are set forth in 114.3 CMR 40.06(11). (12) Radiology. (a) Eligible Providers. Eligible Providers include:
a physician or osteopath other than an intern, resident, or house officer licensed by the Board of Registration in Medicine in accordance with the provisions of M.G.L. c. 112.
a podiatrist other than an intern, resident, or house officer licensed by the Board of Registration in Medicine or the Board of Registration in Podiatry in accordance with the provisions of M.G.L. c. 112, whose eligibility is limited to those procedures specified by the purchaser of the services.
an oral and/or maxillofacial surgeon licensed by the Board of Registration in Dentistry in accordance with the provisions of M.G.L. c. 112.
a chiropractor licensed by the Board of Registration of Chiropractors under and meeting the requirements of M.G.L. c. 112, §§ 89 through 97, whose eligibility is limited to those procedures within the scope and limitations of chiropractic medicine services. (b) Radiological Services. Services include all diagnostic and therapeutic imaging. Most radiological services are comprised of a professional component and a technical component. The professional component is the physician's interpretation of the procedure, and the technical component is the equipment, supplies and technician's services used to perform the procedure. Fees and requirements for certain technical component services are set forth in the regulatory section entitled Freestanding Diagnostic Services. (c) Fees. Rates of payment for radiological services are set forth in 114.3 CMR 40.06(7). (d) Contrast Media. Complete procedures, interventional radiological procedures or diagnostic studies involving injection of contrast media include all usual pre-injection and post-injection services, eg, necessary local anesthesia, placement of needle catheter, injection of contrast media, supervision of the study, and interpretation of the results. Providers must determine whether the use of ionic or non-ionic contrast media is appropriate for the individual patient. (13) Rehabilitation Clinic Services, Audiological Services, Restorative Services. (a) Eligible Providers. Eligible Providers include:
a physical therapist (PT) currently licensed by the Board of Allied Health Professionals;
an occupational therapist (OT) currently licensed by the Board of Allied Health Professionals;
a speech therapist (ST) currently licensed by the Board of Speech and Language Pathology and Audiology;
an audiologist currently licensed by the Board of Speech and Language Pathology and Audiology;

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40.05 continued

40.05: continued 5. a freestanding clinic licensed by DPH providing rehabilitative services; 6. a hospital outpatient clinic licensed by the Department of Public Health and not subject to provisions of 114.1 CMR 41.00; 7. any speech and hearing center (proprietorship, partnership or corporation) that provides authorized speech or language services by a qualified speech pathologist that does not bill separately from such facility for professional services rendered; or 8. a chiropractor whose eligibility as it pertains to 114.3 CMR 40.05(13) is limited to modalities and therapeutic procedures. (b) Rehabilitation, Restorative, Speech/Language Pathology and Audiological Services.

Rehabilitation services are comprehensive services deemed appropriate to the needs of an injured person, in a program designed to achieve objectives of improved health and welfare with the realization of optimal physical, social and vocational potential.
Restorative services are PT, OT, or ST services for the purpose of maximum reduction of physical and/or speech disability and restoration of optimal functional levels.
Speech/Language Pathology services include the evaluation and treatment of communicative disorders with regard to the functions of articulation (including aphasia and dysarthria, language, voice and fluency.)
Audiological services include testing related to the determination of hearing loss, evaluation of hearing aids, the prescription of hearing aid devices, and aural rehabilitation which includes lip-reading and auditory training. Complete audiological evaluation includes a routine audiological evaluation plus site of Lesion Testing (Impedance Testing and/or Recruitment Testing) as needed or recommended by a physician. (c) Fees. Payment rates for restorative services are set forth in 114.3 CMR 40.06(12). (d) Functional Capacity Assessments. To report a functional capacity assessment (or Key functional assessment), providers must use CPT code 97750 that may be billed up to a maximum of nine units per session. (e) Work Hardening and Work Conditioning. Work Hardening and Work Conditioning are goal-oriented therapies designed to prepare injured workers for their return to work. Providers must use CPT codes 97545 and 97456 to report these services. 97456 must be used in conjunction with 97545. (f) Visits. The number of visits and duration of treatment are the subject of DIA treatment guidelines for various injuries. Providers should seek prior approval for treatment regimens that deviate from these guidelines. (g) Therapeutic Procedures. Pre-approval should be obtained if a provider believes that more than two therapeutic procedures should be performed at a session. The number of units allowed per session is limited only by medical necessity. (h) Modalities. A charge may be assessed for supportive services (CPT codes 97012 through 97039) only in conjunction with a procedure performed during the course of the same visit. Pre-approval should be obtained if a provider believes that more than three modalities should be performed in a given session. The number of units allowed per session is limited only by medical necessity. When determining the correct units allowed, round partial units to one decimal place. No fee will be paid for the application of hot and cold packs (CPT code 97010). (i) Durable Medical Equipment, Prosthetics/Orthotics, and Supplies (DMEPOS). Rates of payment for durable medical equipment, prosthetic/orthotics and supplies are listed in 114.3 CMR 40.06(6) and subject to the provisions and guidelines in 114.3 CMR 40.05(6). (14) Surgery. (a) Eligible Providers. An Eligible Provider is:
a physician or osteopath other than an intern, resident, or house officer licensed by the Board of Registration in Medicine in accordance with the provisions of M.G.L. c. 112. A physician assistant (PA) licensed by the Board of Registration for Physician Assistants in accordance with the provisions of M.G.L. c. 112 may not bill separately for services rendered;
a podiatrist other than an intern, resident, or house officer licensed by the Board of Registration in Medicine in accordance with the provisions of M.G.L. c. 112, whose eligibility is limited to those procedures specified by the purchaser of the services;

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40.05 continued

40.05: continued 3. a registered nurse licensed by the Board of Registration in Nursing in accordance with the provisions of M.G.L. c. 112 to practice as a nurse practitioner (NP), limited to those procedures within the scope of NP services and subject to the rules of physician relationship for reimbursement defined by the Commonwealth's Nurse Practice Act, M.G.L. c. 112, §§ 74 through 81; or 4. a dentist licensed by the Board of Registration in Dentistry in accordance with the provisions of M.G.L. c. 112. (b) Payment for Surgical Procedures Includes:

the immediate preoperative care performed on the same day as surgery, completion of hospital records and initiation of the treatment program;
local anesthesia, such as infiltration, metacarpal/digital or topical anesthesia,
the surgical procedure;
supplies and materials usually included in the office visit or procedure;
normal, uncomplicated postoperative care performed on the same day as surgery at the facility.
up to two normal post operative follow up visits when indicated by an "I" in the fee schedule. (c) First Assistants. Non-physician providers who act as first assistants during surgical procedures must be identified by adding the modifier -81, Minimum Assistant Surgeon, to the usual procedure number and will be reimbursed at 15% of the fee stipulated in 114.3 CMR 40.06(16)(f). The non-physician must be an employee of the eligible physician provider and not salaried by a facility. (d) Fees. Rates of payment for surgical services are set forth in 114.3 CMR 40.06(8). (e) Payments for Qualified NP's and PA's. Payment to employers billing for eligible NPs and PAs as specified in 114.3 CMR 40.06(16)(a)3 is 85% of the fees set forth in 114.3 CMR 40.06. Providers must use the appropriate two-digit modifier listed in 114.3 CMR 40.07: Appendix A to denote services rendered by a non-physician provider. (f) Modifiers. See 114.3 CMR 40.07(1): Appendix A for a list of Level 1 CPT modifiers. (g) Add-on Codes. 114.3 CMR 40.07(2): Appendix B lists procedures that are commonly carried out in addition to the primary procedure performed and must never be reported as stand-alone codes. These codes are exempt from the multiple procedure modifier '51'.

40.06 Fees

40.06: Fees (1) Acupuncture. Code Fee 40.06(1) Acupuncture Description 97039 9.53 Unlisted modality (specify type and time if constant attendance)

97124 18.73 Therapeutic procedure, one or more areas, each 15 minutes; massage, including effleurage,

AMBULATORY CARE

40.06: continued Code Fee Nu Fee Ue Fee RR L6925 7,617.30 L6930 6,388.01 L6935 7,437.03 L6940 8,153.41 L6945 9,280.46 L6950 8,572.50 L6955 10,378.59 L6960 11,439.98 L6965 13,422.59 L6970 14,367.62 L6975 16,193.97 L7007 3,114.32

40.06: continued Code Global PC 77423 227.59 77427 187.58 77431 98.10 77432 409.28 77435 683.04 77470 409.01 105.96 77499 I.C. I.C. 77520 I.C. 77522 I.C. 77523 I.C. 77525 I.C. 77600 378.05 78.68 77605 616.68 103.77 77610 555.26 75.45 77615 786.40 104.57 77620 388.09 80.43 77750 349.94 249.81 77761 369.08 189.97 77762 511.05 289.95 77763 718.00 434.48 77776 420.48 232.93 77777 608.18 378.35 77778 869.35 567.59 77781 656.36 64.88 77782 876.75 107.15 77783 1,201.32 169.35 77784 1,777.12 264.62 77789 106.68 58.21 77790 90.88 53.00 77799 I.C. I.C. 78000 74.87 9.55 78001 96.43 13.32 78003 82.41 16.63 TC 40.06(7) - Radiologic Service Description (con’t) High energy neutron radiation treatment delivery; one or more isocenter(s) with coplanar or non-coplanar geometry with blocking and/or wedge, and/or compensator(s) Radiation treatment management, five treatments Radiation therapy management with complete course of therapy consisting of one or two fractions only Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of one session) Stereotactic body radiation therapy, treatment management, per treatment course, to one or more lesions, including image guidance, entire course not to exceed five fractions 303.06 Special treatment procedure (eg, total body irradiation, hemibody radiation, per oral, endocavitary or intraoperative cone irradiation) I.C. Unlisted procedure, therapeutic radiology treatment management Proton treatment delivery; simple, without compensation Proton treatment delivery; simple, with compensation Proton treatment delivery; intermediate Proton treatment delivery; complex 299.38 Hyperthermia, externally generated; superficial (ie, heating to a depth of 4 cm or less) 512.90 Hyperthermia, externally generated; deep (ie, heating to depths greater than 4 cm) 479.81 Hyperthermia generated by interstitial probe(s); five or fewer interstitial applicators 681.83 Hyperthermia generated by interstitial probe(s); more than five interstitial applicators 307.66 Hyperthermia generated by intracavitary probe(s) 100.14 Infusion or instillation of radioelement solution (includes three months follow-up care) 179.10 Intracavitary radiation source application; simple 221.11 Intracavitary radiation source application; intermediate 283.52 Intracavitary radiation source application; complex 187.55 Interstitial radiation source application; simple 229.83 Interstitial radiation source application; intermediate 301.75 Interstitial radiation source application; complex 591.48 Remote afterloading high intensity brachytherapy; one

four source positions or catheters 769.60 Remote afterloading high intensity brachytherapy; five - eight source positions or catheters 1,031.96 Remote afterloading high intensity brachytherapy; nine-12 source positions or catheters 1,512.50 Remote afterloading high intensity brachytherapy; over 12 source positions or catheters 48.47 Surface application of radiation source 37.88 Supervision, handling, loading of radiation source I.C. Unlisted procedure, clinical brachytherapy 65.32 Thyroid uptake; single determination 83.11 Thyroid uptake; multiple determinations 65.78 Thyroid uptake; stimulation, suppression or discharge (not including initial uptake studies)

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40.06 continued

40.06: continued Code ASC Incl GL Fee PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee 23221 1,234.43 Radical resection of bone tumor, proximal humerus; with autograft (includes obtaining graft) 23222 1,657.63 Radical resection of bone tumor, proximal humerus; with prosthetic replacement 23330 388.12 233.06 Removal of foreign body, shoulder; subcutaneous 23331 943.36 585.38 Removal of foreign body, shoulder; deep (eg, Neer hemiarthroplasty removal) 23332 876.56 Removal of foreign body, shoulder; complicated (eg, total shoulder) 23350 178.63 Injection procedure for shoulder arthrography or enhanced CT/MRI shoulder arthrography 23395 1,920.92 1,266.78 Muscle transfer, any type, shoulder or upper arm; single 23397 3,549.34 1,131.50 Muscle transfer, any type, shoulder or upper arm; multiple 23400 1,304.45 966.25 Scapulopexy (eg, Sprengels deformity or for paralysis) 23405 1,304.45 626.79 Tenotomy, shoulder area; single tendon 23406 1,304.45 779.71 Tenotomy, shoulder area; multiple tendons through same incision 23410 1,920.92 892.11 Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; acute 23412 1,920.92 I 2,271.64 Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; chronic 23415 1,920.92 732.20 Coracoacromial ligament release, with or without acromioplasty 23420 1,920.92 I 2,118.74 Reconstruction of complete shoulder (rotator) cuff avulsion, chronic (includes acromioplasty) 23430 1,920.92 737.74 Tenodesis of long tendon of biceps 23440 1,920.92 760.51 Resection or transplantation of long tendon of biceps 23450 3,549.34 948.68 Capsulorrhaphy, anterior; Putti-Platt procedure or Magnuson type operation 23455 3,549.34 1,008.99 Capsulorrhaphy, anterior; with labral repair (eg, Bankart procedure) 23460 3,549.34 1,092.71 Capsulorrhaphy, anterior, any type; with bone block 23462 1,920.92 1,067.17 Capsulorrhaphy, anterior, any type; with coracoid process transfer 23465 3,549.34 1,110.71 Capsulorrhaphy, glenohumeral joint, posterior, with or without bone block 23466 1,920.92 1,097.00 Capsulorrhaphy, glenohumeral joint, any type multi-directional instability 23470 1,210.72 Arthroplasty, glenohumeral joint; hemiarthroplasty 23472 1,488.46 Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (eg, total shoulder)) 23480 1,920.92 818.43 Osteotomy, clavicle, with or without internal fixation; 23485 3,549.34 957.53 Osteotomy, clavicle, with or without internal fixation; with bone graft for nonunion or malunion (includes obtaining graft and/or necessary fixation) 23490 1,920.92 810.94 Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; clavicle 23491 3,549.34 1,013.09 Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; proximal humerus 23500 79.02 208.75 Closed treatment of clavicular fracture; without manipulation

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AMBULATORY CARE

40.06 Code

40.06: Code 23505 23515 23520 23525 23530 23532 23540 23545 23550 23552 continued ASC Incl Rate 79.02 2,646.58 79.02 79.02 1,837.10 1,169.01 79.02 79.02 1,837.10 1,837.10 GL Fee 339.76 214.99 339.32 214.04 306.58 23570 23575 79.02 79.02 222.12 376.53 23585 23600 23605 2,646.58 79.02 79.02 315.20 459.43 23615 2,646.58 23616 2,646.58 23620 23625 23630 23650 23655 23660 79.02 79.02 2,646.58 79.02 659.86 1,837.10 257.54 372.19 288.92 370.58 PC TC

Fee Fee

675.82 546.28 616.42 567.19 653.34 898.46 851.31 1,298.12 715.01 574.46 40.06(8) - Surgical Services Description (con’t) Closed treatment of clavicular fracture; with manipulation Open treatment of clavicular fracture, includes internal fixation, when performed Closed treatment of sternoclavicular dislocation; without manipulation Closed treatment of sternoclavicular dislocation; with manipulation Open treatment of sternoclavicular dislocation, acute or chronic; Open treatment of sternoclavicular dislocation, acute or chronic; with fascial graft (includes obtaining graft) Closed treatment of acromioclavicular dislocation; without manipulation Closed treatment of acromioclavicular dislocation; with manipulation Open treatment of acromioclavicular dislocation, acute or chronic; Open treatment of acromioclavicular dislocation, acute or chronic; with fascial graft (includes obtaining graft) Closed treatment of scapular fracture; without manipulation Closed treatment of scapular fracture; with manipulation, with or without skeletal traction (with or without shoulder joint involvement) Open treatment of scapular fracture (body, glenoid or acromion) with or without internal fixation Closed treatment of proximal humeral (surgical or anatomical neck) fracture; without manipulation Closed treatment of proximal humeral (surgical or anatomical neck) fracture; with manipulation, with or without skeletal traction Open treatment of proximal humeral (surgical or anatomical neck) fracture, includes internal fixation, when performed, includes repair of tuberosity(s), when performed; Open treatment of proximal humeral (surgical or anatomical neck) fracture, includes internal fixation, when performed, includes repair of tuberosity(s), when performed; with proximal humeral prosthetic replacement Closed treatment of greater humeral tuberosity fracture; without manipulation Closed treatment of greater humeral tuberosity fracture; with manipulation Open treatment of greater humeral tuberosity fracture, includes internal fixation, when performed Closed treatment of shoulder dislocation, with manipulation; without anesthesia Closed treatment of shoulder dislocation, with manipulation; requiring anesthesia Open treatment of acute shoulder dislocation

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AMBULATORY CARE

40.06 continued

40.06: continued Code ASC Incl GL Fee PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee 23665 79.02 410.57 Closed treatment of shoulder dislocation, with fracture of greater humeral tuberosity, with manipulation 23670 2,646.58 794.27 Open treatment of shoulder dislocation, with fracture of greater humeral tuberosity, includes internal fixation, when performed 23675 79.02 537.83 Closed treatment of shoulder dislocation, with surgical or anatomical neck fracture, with manipulation 23680 1,837.10 872.32 Open treatment of shoulder dislocation, with surgical or anatomical neck fracture, includes internal fixation, when performed 23700 659.86 193.81 Manipulation under anesthesia, shoulder joint, including application of fixation apparatus (dislocation excluded) 23800 3,549.34 1,012.60 Arthrodesis, glenohumeral joint; 23802 1,920.92 1,194.11 Arthrodesis, glenohumeral joint; with autogenous graft (includes obtaining graft) 23900 1,307.47 Interthoracoscapular amputation (forequarter) 23920 1,062.30 Disarticulation of shoulder; 23921 672.37 443.68 Disarticulation of shoulder; secondary closure or scar revision 23929 I.C. Unlisted procedure, shoulder 23930 818.67 374.01 Incision and drainage, upper arm or elbow area; deep abscess or hematoma 23931 818.67 306.78 Incision and drainage, upper arm or elbow area; bursa 23935 950.47 499.17 Incision, deep, with opening of bone cortex (eg, for osteomyelitis or bone abscess), humerus or elbow 24000 1,304.45 467.42 Arthrotomy, elbow, including exploration, drainage, or removal of foreign body 24006 1,304.45 703.90 Arthrotomy of the elbow, with capsular excision for capsular release (separate procedure) 24065 135.32 246.18 Biopsy, soft tissue of upper arm or elbow area; superficial 24066 719.48 599.87 Biopsy, soft tissue of upper arm or elbow area; deep (subfascial or intramuscular) 24075 719.48 486.62 Excision, tumor, soft tissue of upper arm or elbow area; subcutaneous 24076 943.36 462.88 Excision, tumor, soft tissue of upper arm or elbow area; deep (subfascial or intramuscular) 24077 943.36 795.87 Radical resection of tumor (eg, malignant neoplasm), soft tissue of upper arm or elbow area 24100 950.47 393.89 Arthrotomy, elbow; with synovial biopsy only 24101 1,304.45 494.91 Arthrotomy, elbow; with joint exploration, with or without biopsy, with or without removal of loose or foreign body 24102 1,304.45 609.95 Arthrotomy, elbow; with synovectomy 24105 950.47 337.37 Excision, olecranon bursa 24110 950.47 576.61 Excision or curettage of bone cyst or benign tumor, humerus; 24115 1,304.45 657.37 Excision or curettage of bone cyst or benign tumor, humerus; with autograft (includes obtaining graft) 24116 1,304.45 860.94 Excision or curettage of bone cyst or benign tumor, humerus; with allograft

114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY

40.06: continued Code ASC Incl GL Fee PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee 25320 1,920.92 960.23 Capsulorrhaphy or reconstruction, wrist, open (eg, capsulodesis, ligament repair, tendon transfer or graft) (includes synovectomy, capsulotomy and open reduction) for carpal instability 25332 1,604.48 837.85 Arthroplasty, wrist, with or without interposition, with or without external or internal fixation 25335 1,920.92 968.23 Centralization of wrist on ulna (eg, radial club hand) 25337 1,920.92 892.69 Reconstruction for stabilization of unstable distal ulna or distal radioulnar joint, secondary by soft tissue stabilization (eg, tendon transfer, tendon graft or weave, or tenodesis) with or without open reduction of distal radioulnar joint 25350 3,549.34 818.13 Osteotomy, radius; distal third 25355 1,920.92 899.17 Osteotomy, radius; middle or proximal third 25360 1,304.45 799.62 Osteotomy; ulna 25365 1,304.45 1,049.41 Osteotomy; radius AND ulna 25370 1,920.92 1,121.91 Multiple osteotomies, with realignment on intramedullary rod (Sofield type procedure); radius OR ulna 25375 1,920.92 1,096.65 Multiple osteotomies, with realignment on intramedullary rod (Sofield type procedure); radius AND ulna 25390 1,304.45 909.18 Osteoplasty, radius OR ulna; shortening 25391 1,920.92 1,130.20 Osteoplasty, radius OR ulna; lengthening with autograft 25392 1,304.45 1,128.86 Osteoplasty, radius AND ulna; shortening (excluding 64876) 25393 1,920.92 1,268.72 Osteoplasty, radius AND ulna; lengthening with autograft 25394 735.73 759.00 Osteoplasty, carpal bone, shortening 25400 3,549.34 952.79 Repair of nonunion or malunion, radius OR ulna; without graft (eg, compression technique) 25405 3,549.34 1,180.98 Repair of nonunion or malunion, radius OR ulna; with autograft (includes obtaining graft) 25415 3,549.34 1,114.46 Repair of nonunion or malunion, radius AND ulna; without graft (eg, compression technique) 25420 3,549.34 1,304.67 Repair of nonunion or malunion, radius AND ulna; with autograft (includes obtaining graft) 25425 1,920.92 1,213.97 Repair of defect with autograft; radius OR ulna 25426 1,920.92 1,226.15 Repair of defect with autograft; radius AND ulna 25430 1,175.77 695.76 Insertion of vascular pedicle into carpal bone (eg, Hori procedure) 25431 1,175.77 782.39 Repair of nonunion of carpal bone (excluding carpal scaphoid (navicular)) (includes obtaining graft and necessary fixation), each bone 25440 3,549.34 784.54 Repair of nonunion, scaphoid carpal (navicular) bone, with or without radial styloidectomy (includes obtaining graft and necessary fixation) 25441 5,461.16 928.34 Arthroplasty with prosthetic replacement; distal radius 25442 5,461.16 798.18 Arthroplasty with prosthetic replacement; distal ulna 25443 2,274.08 768.48 Arthroplasty with prosthetic replacement; scaphoid carpal (navicular) 25444 2,274.08 815.96 Arthroplasty with prosthetic replacement; lunate 25445 2,274.08 718.00 Arthroplasty with prosthetic replacement; trapezium

114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY

AMBULATORY CARE

40.06 Code

40.06: Code 25446 25447 25449 25450 25455 25490 25491 25492 continued ASC Incl Rate 5,461.16 1,604.48 1,604.48 1,920.92 1,920.92 1,920.92 1,920.92 1,920.92 GL Fee PC TC Fee Fee 1,164.70 802.78 1,023.86 634.98 763.33 838.62 879.69 1,035.97 25500 25505 25515 25520 79.02 79.02 1,837.10 79.02 254.53 492.85 538.24 663.47 25525 1,837.10 818.81 25526 1,837.10 1,019.35 25530 25535 25545 25560 25565 25574 79.02 79.02 1,837.10 79.02 79.02 2,646.58 250.22 471.41 258.33 513.27 631.39 647.94 25575 2,646.58 879.18 40.06(8) - Surgical Services Description (con’t) Arthroplasty with prosthetic replacement; distal radius and partial or entire carpus (total wrist) Arthroplasty, interposition, intercarpal or carpometacarpal joints Revision of arthroplasty, including removal of implant, wrist joint Epiphyseal arrest by epiphysiodesis or stapling; distal radius OR ulna Epiphyseal arrest by epiphysiodesis or stapling; distal radius AND ulna Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; radius Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; ulna Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; radius AND ulna Closed treatment of radial shaft fracture; without manipulation Closed treatment of radial shaft fracture; with manipulation Open treatment of radial shaft fracture, includes internal fixation, when performed Closed treatment of radial shaft fracture and closed treatment of dislocation of distal radioulnar joint (Galeazzi fracture/dislocation) Open treatment of radial shaft fracture, includes internal fixation, when performed, and closed treatment of distal radioulnar joint dislocation (Galeazzi fracture/ dislocation), includes percutaneous skeletal fixation, when performed Open treatment of radial shaft fracture, includes internal fixation, when performed, and open treatment of distal radioulnar joint dislocation (Galeazzi fracture/ dislocation), includes internal fixation, when performed, includes repair of triangular fibrocartilage complex Closed treatment of ulnar shaft fracture; without manipulation Closed treatment of ulnar shaft fracture; with manipulation Open treatment of ulnar shaft fracture, includes internal fixation, when performed Closed treatment of radial and ulnar shaft fractures; without manipulation Closed treatment of radial and ulnar shaft fractures; with manipulation Open treatment of radial AND ulnar shaft fractures, with internal fixation, when performed; of radius OR ulna Open treatment of radial AND ulnar shaft fractures, with internal fixation, when performed; of radius AND ulna

114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY

AMBULATORY CARE

40.06 Code

40.06: Code 25600 continued ASC Incl Rate 79.02 GL Fee 283.48 25605 79.02 594.16 25606 25607 25608 1,169.01 2,646.58 2,646.58 25609 2,646.58 25622 25624 25628 25630 79.02 79.02 1,837.10 79.02 292.05 455.31 296.60 25635 79.02 429.34 25645 25650 25651 25652 25660 25670 25671 25675 25676 25680 25685 25690 25695 25800 1,837.10 79.02 1,169.01 1,837.10 79.02 1,169.01 1,169.01 79.02 1,169.01 79.02 1,169.01 79.02 1,169.01 3,549.34 307.81 390.69 419.65 440.86 455.32 PC TC

Fee Fee

674.73 691.41 784.97 998.07 703.61 566.33 464.58 609.55 605.87 515.02 628.42 720.23 627.85 752.71 40.06(8) - Surgical Services Description (con’t) Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; without manipulation Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; with manipulation Percutaneous skeletal fixation of distal radial fracture or epiphyseal separation Open treatment of distal radial extra-articular fracture or epiphyseal separation, with internal fixation Open treatment of distal radial intra-articular fracture or epiphyseal separation; with internal fixation of 2 fragments Open treatment of distal radial intra-articular fracture or epiphyseal separation; with internal fixation of 3 or more fragments Closed treatment of carpal scaphoid (navicular) fracture; without manipulation Closed treatment of carpal scaphoid (navicular) fracture; with manipulation Open treatment of carpal scaphoid (navicular) fracture, includes internal fixation, when performed Closed treatment of carpal bone fracture (excluding carpal scaphoid (navicular)); without manipulation, each bone Closed treatment of carpal bone fracture (excluding carpal scaphoid (navicular)); with manipulation, each bone Open treatment of carpal bone fracture (other than carpal scaphoid (navicular)), each bone Closed treatment of ulnar styloid fracture Percutaneous skeletal fixation of ulnar styloid fracture Open treatment of ulnar styloid fracture Closed treatment of radiocarpal or intercarpal dislocation, one or more bones, with manipulation Open treatment of radiocarpal or intercarpal dislocation, one or more bones Percutaneous skeletal fixation of distal radioulnar dislocation Closed treatment of distal radioulnar dislocation with manipulation Open treatment of distal radioulnar dislocation, acute or chronic Closed treatment of trans-scaphoperilunar type of fracture dislocation, with manipulation Open treatment of trans-scaphoperilunar type of fracture dislocation Closed treatment of lunate dislocation, with manipulation Open treatment of lunate dislocation Arthrodesis, wrist; complete, without bone graft (includes radiocarpal and/or intercarpal and/or carpometacarpal joints)

114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY

AMBULATORY CARE

40.06 continued

40.06: continued Code ASC Incl GL Fee PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee 25805 1,920.92 862.84 Arthrodesis, wrist; with sliding graft 25810 3,549.34 864.87 Arthrodesis, wrist; with iliac or other autograft (includes obtaining graft) 25820 735.73 621.51 Arthrodesis, wrist; limited, without bone graft (eg, intercarpal or radiocarpal) 25825 3,549.34 756.93 Arthrodesis, wrist; with autograft (includes obtaining graft) 25830 3,549.34 986.80 Arthrodesis, distal radioulnar joint with segmental resection of ulna, with or without bone graft (eg, Sauve-Kapandji procedure) 25900 806.59 Amputation, forearm, through radius and ulna; 25905 788.64 Amputation, forearm, through radius and ulna; open, circular (guillotine) 25907 950.47 709.10 Amputation, forearm, through radius and ulna; secondary closure or scar revision 25909 785.80 Amputation, forearm, through radius and ulna; re-amputation 25915 1,253.66 Krukenberg procedure 25920 677.35 Disarticulation through wrist; 25922 950.47 598.02 Disarticulation through wrist; secondary closure or scar revision 25924 663.87 Disarticulation through wrist; re-amputation 25927 812.78 Transmetacarpal amputation; 25929 672.37 563.00 Transmetacarpal amputation; secondary closure or scar revision 25931 950.47 760.90 Transmetacarpal amputation; re-amputation 25999 I.C. Unlisted procedure, forearm or wrist 26010 62.85 280.05 Drainage of finger abscess; simple 26011 516.57 432.40 Drainage of finger abscess; complicated (eg, felon) 26020 735.73 424.01 Drainage of tendon sheath, digit and/or palm, each 26025 735.73 413.63 Drainage of palmar bursa; single, bursa 26030 735.73 484.61 Drainage of palmar bursa; multiple bursa 26034 735.73 526.65 Incision, bone cortex, hand or finger (eg, osteomyelitis or bone abscess) 26035 735.73 792.64 Decompression fingers and/or hand, injection injury (eg, grease gun) 26037 561.29 Decompressive fasciotomy, hand (excludes 26035) 26040 1,175.77 307.58 Fasciotomy, palmar (eg, Dupuytren's contracture); percutaneous 26045 1,175.77 462.33 Fasciotomy, palmar (eg, Dupuytren's contracture); open, partial 26055 735.73 653.85 Tendon sheath incision (eg, for trigger finger) 26060 735.73 261.77 Tenotomy, percutaneous, single, each digit 26070 735.73 289.49 Arthrotomy, with exploration, drainage, or removal of loose or foreign body; carpometacarpal joint 26075 735.73 311.44 Arthrotomy, with exploration, drainage, or removal of loose or foreign body; metacarpophalangeal joint, each 26080 735.73 379.92 Arthrotomy, with exploration, drainage, or removal of loose or foreign body; interphalangeal joint, each 26100 735.73 322.37 Arthrotomy with biopsy; carpometacarpal joint, each 26105 735.73 327.99 Arthrotomy with biopsy; metacarpophalangeal joint, each 26110 735.73 314.07 Arthrotomy with biopsy; interphalangeal joint, each

114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY

AMBULATORY CARE

40.06 continued

40.06: continued Code ASC Incl GL Fee PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee 26115 943.36 679.47 Excision, tumor or vascular malformation, soft tissue of hand or finger; subcutaneous 26116 943.36 477.24 Excision, tumor or vascular malformation, soft tissue of hand or finger; deep (subfascial or intramuscular) 26117 943.36 637.25 Radical resection of tumor (eg, malignant neoplasm), soft tissue of hand or finger 26121 1,175.77 591.78 Fasciectomy, palm only, with or without Z-plasty, other local tissue rearrangement, or skin grafting (includes obtaining graft) 26123 1,175.77 798.89 Fasciectomy, partial palmar with release of single digit including proximal interphalangeal joint, with or without Z-plasty, other local tissue rearrangement, or skin grafting (includes obtaining graft); 26125 735.73 277.46 Fasciectomy, partial palmar with release of single digit including proximal interphalangeal joint, with or without Z-plasty, other local tissue rearrangement, or skin grafting (includes obtaining graft); each additional digit (List separately in addition to code for primary procedure) 26130 735.73 450.94 Synovectomy, carpometacarpal joint 26135 1,175.77 546.55 Synovectomy, metacarpophalangeal joint including intrinsic release and extensor hood reconstruction, each digit 26140 735.73 498.51 Synovectomy, proximal interphalangeal joint, including extensor reconstruction, each interphalangeal joint 26145 735.73 505.59 Sy novectom y , t en d o n s h ea t h , radical (tenosynovectomy), flexor tendon, palm and/or finger, each tendon 26160 735.73 625.78 Excision of lesion of tendon sheath or joint capsule (eg, cyst, mucous cyst, or ganglion), hand or finger 26170 735.73 399.74 Excision of tendon, palm, flexor or extensor, single, each tendon 26180 735.73 435.19 Excision of tendon, finger, flexor or extensor, each tendon 26185 735.73 511.17 Sesamoidectomy, thumb or finger (separate procedure) 26200 735.73 444.51 Excision or curettage of bone cyst or benign tumor of metacarpal; 26205 1,175.77 596.17 Excision or curettage of bone cyst or benign tumor of metacarpal; with autograft (includes obtaining graft) 26210 735.73 435.39 Excision or curettage of bone cyst or benign tumor of proximal, middle, or distal phalanx of finger; 26215 735.73 546.79 Excision or curettage of bone cyst or benign tumor of proximal, middle, or distal phalanx of finger; with autograft (includes obtaining graft) 26230 735.73 498.04 Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis); metacarpal 26235 735.73 489.16 Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis); proximal or middle phalanx of finger 26236 735.73 435.47 Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis); distal phalanx of finger 26250 735.73 571.75 Radical resection, metacarpal (eg, tumor);

114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY

AMBULATORY CARE

40.06 continued

40.06: continued Code ASC Incl GL Fee PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee 26255 1,175.77 894.12 Radical resection, metacarpal (eg, tumor); with autograft (includes obtaining graft) 26260 735.73 540.69 Radical resection, proximal or middle phalanx of finger (eg, tumor); 26261 735.73 647.90 Radical resection, proximal or middle phalanx of finger (eg, tumor); with autograft (includes obtaining graft) 26262 735.73 453.66 Radical resection, distal phalanx of finger (eg, tumor) 26320 719.48 341.35 Removal of implant from finger or hand 26340 79.02 319.32 Manipulation, finger joint, under anesthesia, each joint 26350 1,175.77 791.14 Repair or advancement, flexor tendon, not in zone 2 digital flexor tendon sheath (eg, no man's land); primary or secondary without free graft, each tendon 26352 1,175.77 883.96 Repair or advancement, flexor tendon, not in zone 2 digital flexor tendon sheath (eg, no man's land); secondary with free graft (includes obtaining graft), each tendon 26356 1,175.77 1,123.96 Repair or advancement, flexor tendon, in zone 2 digital flexor tendon sheath (eg, no man's land); primary, without free graft, each tendon 26357 1,175.77 933.57 Repair or advancement, flexor tendon, in zone 2 digital flexor tendon sheath (eg, no man's land); secondary, without free graft, each tendon 26358 1,175.77 991.81 Repair or advancement, flexor tendon, in zone 2 digital flexor tendon sheath (eg, no man's land); secondary, with free graft (includes obtaining graft), each tendon 26370 1,175.77 844.98 Repair or advancement of profundus tendon, with intact superficialis tendon; primary, each tendon 26372 1,175.77 968.72 Repair or advancement of profundus tendon, with intact superficialis tendon; secondary with free graft (includes obtaining graft), each tendon 26373 1,175.77 923.34 Repair or advancement of profundus tendon, with intact superficialis tendon; secondary without free graft, each tendon 26390 1,175.77 877.65 Excision flexor tendon, with implantation of synthetic rod for delayed tendon graft, hand or finger, each rod 26392 1,175.77 1,043.56 Removal of synthetic rod and insertion of flexor tendon graft, hand or finger (includes obtaining graft), each rod 26410 735.73 632.29 Repair, extensor tendon, hand, primary or secondary; without free graft, each tendon 26412 1,175.77 750.58 Repair, extensor tendon, hand, primary or secondary; with free graft (includes obtaining graft), each tendon 26415 1,175.77 759.43 Excision of extensor tendon, with implantation of synthetic rod for delayed tendon graft, hand or finger, each rod 26416 1,175.77 890.50 Removal of synthetic rod and insertion of extensor tendon graft (includes obtaining graft), hand or finger, each rod 26418 735.73 639.25 Repair, extensor tendon, finger, primary or secondary; without free graft, each tendon 26420 1,175.77 781.71 Repair, extensor tendon, finger, primary or secondary; with free graft (includes obtaining graft) each tendon

114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY

AMBULATORY CARE

40.06 continued

40.06: continued Code ASC Rate Incl GL Fee 26426 1,175.77 26428 1,175.77 26432 735.73 550.77 26433 735.73 589.09 26434 1,175.77 26437 26440 26442 735.73 735.73 1,175.77 673.45 700.52 26445 735.73 660.39 26449 1,175.77 26450 26455 26460 26471 26474 26476 735.73 735.73 735.73 735.73 735.73 735.73 432.49 429.33 418.14 662.25 643.74 623.75 26477 735.73 631.15 26478 735.73 678.59 26479 735.73 669.78 26480 1,175.77 26483 1,175.77 26485 1,175.77 26489 1,175.77 26490 1,175.77 26492 1,175.77 26494 26496 26497 1,175.77 1,175.77 1,175.77 26498 1,175.77 26499 1,175.77 PC TC

Fee Fee

661.20 813.78 686.17 999.66 847.23 830.29 915.59 885.70 897.34 825.67 912.60 841.32 898.47 903.49 1,184.35 853.47 40.06(8) - Surgical Services Description (con’t) Repair of extensor tendon, central slip, secondary (eg, boutonniere deformity); using local tissue(s), including lateral band(s), each finger Repair of extensor tendon, central slip, secondary (eg, boutonniere deformity); with free graft (includes obtaining graft), each finger Closed treatment of distal extensor tendon insertion, with or without percutaneous pinning (eg, mallet finger) Repair of extensor tendon, distal insertion, primary or secondary; without graft (eg, mallet finger) Repair of extensor tendon, distal insertion, primary or secondary; with free graft (includes obtaining graft) Realignment of extensor tendon, hand, each tendon Tenolysis, flexor tendon; palm OR finger, each tendon Tenolysis, flexor tendon; palm AND finger, each tendon Tenolysis, extensor tendon, hand OR finger, each tendon Tenolysis, complex, extensor tendon, finger, including forearm, each tendon Tenotomy, flexor, palm, open, each tendon Tenotomy, flexor, finger, open, each tendon Tenotomy, extensor, hand or finger, open, each tendon Tenodesis; of proximal interphalangeal joint, each joint Tenodesis; of distal joint, each joint Lengthening of tendon, extensor, hand or finger, each tendon Shortening of tendon, extensor, hand or finger, each tendon Lengthening of tendon, flexor, hand or finger, each tendon Shortening of tendon, flexor, hand or finger, each tendon Transfer or transplant of tendon, carpometacarpal area or dorsum of hand; without free graft, each tendon Transfer or transplant of tendon, carpometacarpal area or dorsum of hand; with free tendon graft (includes obtaining graft), each tendon Transfer or transplant of tendon, palmar; without free tendon graft, each tendon Transfer or transplant of tendon, palmar; with free tendon graft (includes obtaining graft), each tendon Opponensplasty; superficialis tendon transfer type, each tendon Opponensplasty; tendon transfer with graft (includes obtaining graft), each tendon Opponensplasty; hypothenar muscle transfer Opponensplasty; other methods Transfer of tendon to restore intrinsic function; ring and small finger Transfer of tendon to restore intrinsic function; all four fingers Correction claw finger, other methods

114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY

AMBULATORY CARE

40.06 continued

40.06: continued Code ASC Incl Rate 26500 735.73 26502 1,175.77 26508 735.73 26510 1,175.77 26516 1,175.77 26517 1,175.77 26518 1,175.77 26520 735.73 26525 735.73 26530 1,604.48 26531 2,274.08 26535 1,604.48 26536 2,274.08 26540 735.73 26541 1,175.77 26542 735.73 26545 1,175.77 26546 1,175.77 26548 1,175.77 26550 1,175.77 26551 26553 26554 26555 1,175.77 26556 26560 735.73 26561 1,175.77 26562 1,175.77 26565 1,175.77 26567 1,175.77 GL Fee 674.39 684.94 731.25 734.87 710.16 729.92 3,028.34 2,861.22 3,908.67 2,947.95 589.69 PC TC 40.06(8) - Surgical Services Description (con’t) Fee Fee Reconstruction of tendon pulley, each tendon; with local tissues (separate procedure) 748.27 Reconstruction of tendon pulley, each tendon; with tendon or fascial graft (includes obtaining graft) (separate procedure) Release of thenar muscle(s) (eg, thumb contracture) 647.93 Cross intrinsic transfer, each tendon 752.31 Capsulodesis, metacarpophalangeal joint; single digit 866.46 Capsulodesis, metacarpophalangeal joint; two digits 867.47 Capsulodesis, metacarpophalangeal joint; three or four digits Capsulectomy or capsulotomy; metacarpophalangeal joint, each joint Capsulectomy or capsulotomy; interphalangeal joint, each joint 528.02 Arthroplasty, metacarpophalangeal joint; each joint 613.96 Arthroplasty, metacarpophalangeal joint; with prosthetic implant, each joint 382.67 Arthroplasty, interphalangeal joint; each joint 683.62 Arthroplasty, interphalangeal joint; with prosthetic implant, each joint Repair of collateral ligament, metacarpophalangeal or interphalangeal joint 853.35 Re c o n s t r u c t i o n , c o l l a t e r a l l ig a me nt, metacarpophalangeal joint, single; with tendon or fascial graft (includes obtaining graft) Re c on str uc tio n, c oll ate ral lig a me nt, metacarpophalangeal joint, single; with local tissue (eg, adductor advancement) 744.22 Reconstruction, collateral ligament, interphalangeal joint, single, including graft, each joint 1,012.10 Repair non-union, metacarpal or phalanx (includes obtaining bone graft with or without external or internal fixation) 811.01 Repair and reconstruction, finger, volar plate, interphalangeal joint 1,548.85 Pollicization of a digit Transfer, toe-to-hand with microvascular anastomosis; great toe wrap-around with bone graft Transfer, toe-to-hand with microvascular anastomosis; other than great toe, single Transfer, toe-to-hand with microvascular anastomosis; other than great toe, double 1,394.07 Transfer, finger to another position without microvascular anastomosis Transfer, free toe joint, with microvascular anastomosis Repair of syndactyly (web finger) each web space; with skin flaps 921.44 Repair of syndactyly (web finger) each web space; with skin flaps and grafts 1,223.61 Repair of syndactyly (web finger) each web space; complex (eg, involving bone, nails) 726.11 Osteotomy; metacarpal, each 728.20 Osteotomy; phalanx of finger, each

114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY

AMBULATORY CARE

40.06 continued

40.06: continued Code ASC Rate Incl GL Fee 26568 26580 26587 1,175.77 735.73 735.73 1,272.96 932.92 26590 26591 26593 26596 735.73 1,175.77 735.73 735.73 1,322.43 642.96 726.42 26600 79.02 265.35 26605 79.02 313.23 26607 79.02 467.29 26608 26615 26641 1,169.01 1,837.10 79.02 346.52 26645 79.02 397.78 26650 1,169.01 26665 1,837.10 26670 79.02 320.74 26675 79.02 431.07 26676 1,169.01 26685 1,169.01 26686 26700 2,646.58 79.02 300.67 26705 79.02 397.21 26706 79.02 427.02 26715 26720 1,169.01 79.02 188.59 PC TC

Fee Fee

958.66 491.60 475.98 522.23 471.88 590.41 500.63 547.53 611.08 526.96

40.06: continued Code ASC Rate Incl GL Fee 27727 27730 27732 27734 27740 27742 1,304.45 1,304.45 1,304.45 1,304.45 1,920.92 1,021.63 27745 27750 3,549.34 79.02 336.76 27752 79.02 530.23 27756 27758 1,169.01 1,837.10 27759 2,646.58 27760 79.02 326.10 27762 79.02 479.49 27766 27767 1,837.10 79.02 260.97 27768 79.02 392.32 27769 27780 1,837.10 79.02 290.19 27781 79.02 413.39 27784 27786 1,837.10 79.02 309.22 27788 79.02 420.92 27792 27808 1,837.10 79.02 324.87 PC TC

Fee Fee

581.19 415.86 624.95 708.58 645.94 755.71 566.57 880.82 997.49 614.56 664.75 668.12 682.77

114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY

AMBULATORY CARE

40.06 continued

40.06: continued Code ASC Rate Incl GL Fee 28312 930.79 470.98 28313 930.79 483.70 28315 28320 28322 930.79 1,978.29 1,978.29 453.03 28340 28341 930.79 930.79 600.17 681.54 28344 28345 930.79 930.79 442.29 546.21 28360 28400 79.02 957.08 247.39 28405 79.02 393.07 28406 1,169.01 28415 2,646.58 28420 1,837.10 28430 79.02 232.41 28435 28436 79.02 1,169.01 315.17 28445 1,837.10 28446 1,978.29 28450 79.02 213.98 28455 79.02 285.52 28456 1,169.01 28465 1,837.10 28470 79.02 213.18 28475 79.02 263.26 28476 1,169.01 28485 1,837.10 28490 75.39 136.79 PC TC

Fee Fee

644.06 760.64 537.61 1,166.71 1,208.49 432.81 1,080.13 1,147.79 288.43 612.88 348.35 527.06 40.06(8) - Surgical Services Description (con’t) Osteotomy, shortening, angular or rotational correction; other phalanges, any toe Reconstruction, angular deformity of toe, soft tissue procedures only (eg, overlapping second toe, fifth toe, curly toes) Sesamoidectomy, first toe (separate procedure) Repair, nonunion or malunion; tarsal bones Repair, nonunion or malunion; metatarsal, with or without bone graft (includes obtaining graft) Reconstruction, toe, macrodactyly; soft tissue resection Reconstruction, toe, macrodactyly; requiring bone resection Reconstruction, toe(s); polydactyly Reconstruction, toe(s); syndactyly, with or without skin graft(s), each web Reconstruction, cleft foot Closed treatment of calcaneal fracture; without manipulation Closed treatment of calcaneal fracture; with manipulation Percutaneous skeletal fixation of calcaneal fracture, with manipulation Open treatment of calcaneal fracture, includes internal fixation, when performed; Open treatment of calcaneal fracture, includes internal fixation, when performed; with primary iliac or other autogenous bone graft (includes obtaining graft) Closed treatment of talus fracture; without manipulation Closed treatment of talus fracture; with manipulation Percutaneous skeletal fixation of talus fracture, with manipulation Open treatment of talus fracture, includes internal fixation, when performed Open osteochondral autograft, talus (includes obtaining graft[s]) Treatment of tarsal bone fracture (except talus and calcaneus); without manipulation, each Treatment of tarsal bone fracture (except talus and calcaneus); with manipulation, each Percutaneous skeletal fixation of tarsal bone fracture (except talus and calcaneus), with manipulation, each Open treatment of tarsal bone fracture (except talus and calcaneus), includes internal fixation, when performed, each Closed treatment of metatarsal fracture; without manipulation, each Closed treatment of metatarsal fracture; with manipulation, each Percutaneous skeletal fixation of metatarsal fracture, with manipulation, each Open treatment of metatarsal fracture, includes internal fixation, when performed, each Closed treatment of fracture great toe, phalanx or phalanges; without manipulation

114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY

AMBULATORY CARE

40.06 continued

40.06: continued Code ASC Incl GL Fee Rate 33220 1,071.63 33222 672.37 381.57 33223 672.37 453.25 33224 16,765.50 33225 16,765.50 33226 1,071.63 33233 1,071.63 33234 1,071.63 33235 1,071.63 33236 800.28 33237 880.75 33238 956.76 33240 22,075.11 33241 1,071.63 33243 1,378.09 33244 924.29 33249 26,786.01 33250 1,480.30 33251 1,612.27 PC TC

Fee Fee

40.06: continued Code ASC Incl GL Fee PC TC Rate Fee Fee 35013 1,282.99 35021 1,251.74 35022 1,440.17 35045 1,003.10 35081 1,770.01 35082 2,240.92 35091 1,903.70 35092 2,666.78 35102 1,920.58 35103 2,313.44 35111 1,434.34

35112 1,737.13

40.06: Code 44238 44300 44310 44312 44314 44316 44320 44322 continued ASC Incl Rate 903.02 GL Fee I.C. 768.09 958.30 544.97 926.58 1,273.24 1,093.26 902.03 PC Fee TC Fee 44340 44345 44346 44360 903.02 425.84 552.79 959.13 1,071.98 153.96 44361 425.84 169.19 44363 425.84 201.36 44364 425.84 215.08 44365 425.84 191.55 44366 425.84 254.18 44369 425.84 258.23 44370 1,116.37 279.12 40.06(8) - Surgical Services Description (con’t) Unlisted laparoscopy procedure, intestine (except

rectum)

Placement, enterostomy or cecostomy, tube open (eg,

for feeding or decompression) (separate procedure)

Ileostomy or jejunostomy, non-tube

Revision of ileostomy; simple (release of superficial

scar) (separate procedure)

Revision of ileostomy; complicated (reconstruction

in-depth) (separate procedure)

Continent ileostomy (Kock procedure) (separate

procedure)

Colostomy or skin level cecostomy;

Colostomy or skin level cecostomy; with multiple

biopsies (eg, for congenital megacolon) (separate

procedure)

Revision of colostomy; simple (release of superficial

scar) (separate procedure)

Revision of colostomy; complicated (reconstruction

in-depth) (separate procedure)

Revision of colostomy; with repair of paracolostomy

hernia (separate procedure)

Small intestinal endoscopy, enteroscopy beyond

second portion of duodenum, not including ileum;

diagnostic, with or without collection of specimen(s)

by brushing or washing (separate procedure)

Small intestinal endoscopy, enteroscopy beyond

second portion of duodenum, not including ileum;

with biopsy, single or multiple

Small intestinal endoscopy, enteroscopy beyond

second portion of duodenum, not including ileum;

with removal of foreign body

Small intestinal endoscopy, enteroscopy beyond

second portion of duodenum, not including ileum;

with removal of tumor(s), polyp(s), or other lesion(s)

by snare technique

Small intestinal endoscopy, enteroscopy beyond

second portion of duodenum, not including ileum;

with removal of tumor(s), polyp(s), or other lesion(s)

by hot biopsy forceps or bipolar cautery

Small intestinal endoscopy, enteroscopy beyond

second portion of duodenum, not including ileum;

with control of bleeding (eg, injection, bipolar

cautery, unipolar cautery, laser, heater probe, stapler,

plasma coagulator)

Small intestinal endoscopy, enteroscopy beyond

second portion of duodenum, not including ileum;

with ablation of tumor(s), polyp(s), or other lesion(s)

not amenable to removal by hot biopsy forceps,

bipolar cautery or snare technique

Small intestinal endoscopy, enteroscopy beyond

second portion of duodenum, not including ileum;

with transendoscopic stent placement (includes

AMBULATORY CARE

40.06 continued

40.06: continued Code ASC Incl GL Fee PC TC Rate Fee Fee 63001 1,154.56 63003 1,165.17 63005 1,110.10 63011 1,037.78 63012 1,133.46 63015 1,395.33 63016 1,424.77 63017 1,173.00 63020 1,109.66 63030 I 2,974.28 63035 195.21 63040 1,348.03

40.06(8) - Surgical Services Description (con’t) Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; cervical Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; thoracic Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; lumbar, except for spondylolisthesis Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; sacral Laminectomy with removal of abnormal facets and/or pars inter-articularis with decompression of cauda equina and nerve roots for spondylolisthesis, lumbar (Gill type procedure) Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral segments; cervical Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral segments; thoracic Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral segments; lumbar Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; one interspace, cervical Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; one interspace, lumbar (including open or endoscopically-assisted approach) Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; each additional interspace, cervical or lumbar (List separately in addition to code for primary procedure) Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; cervical

114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY

AMBULATORY CARE

40.06 continued

40.06: continued Code ASC Incl GL Fee PC TC Rate Fee Fee 63042 1,268.02 63043 I.C. 63044 I.C. 63045 63046 63047 63048 I 1,204.42 1,151.06 3,399.04 208.64 63050 63051 1,431.55 1,617.79 63055 1,547.36

63056 1,436.03

114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY

AMBULATORY CARE

40.06 continued

40.06: continued Code ASC Incl GL Fee PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee 65730 1,675.35 1,095.79 Keratoplasty (corneal transplant); penetrating (except in aphakia) 65750 1,675.35 1,108.61 Keratoplasty (corneal transplant); penetrating (in aphakia) 65755 1,675.35 1,102.26 Keratoplasty (corneal transplant); penetrating (in pseudophakia) 65760 I.C. Keratomileusis 65765 I.C. Keratophakia 65767 I.C. Epikeratoplasty 65770 3,789.74 1,260.93 Keratoprosthesis 65771 I.C. Radial keratotomy 65772 722.66 414.53 Corneal relaxing incision for correction of surgically induced astigmatism 65775 722.66 497.31 Corneal wedge resection for correction of surgically induced astigmatism 65780 1,675.35 811.63 Ocular surface reconstruction; amniotic membrane transplantation 65781 1,675.35 1,203.64 Ocular surface reconstruction; limbal stem cell allograft (eg, cadaveric or living donor) 65782 1,675.35 1,041.25 Ocular surface reconstruction; limbal conjunctival autograft (includes obtaining graft) 65800 722.66 141.56 Paracentesis of anterior chamber of eye (separate procedure); with diagnostic aspiration of aqueous 65805 722.66 157.21 Paracentesis of anterior chamber of eye (separate procedure); with therapeutic release of aqueous 65810 1,035.68 416.20 Paracentesis of anterior chamber of eye (separate procedure); with removal of vitreous and/or discission of anterior hyaloid membrane, with or without air injection 65815 1,035.68 619.64 Paracentesis of anterior chamber of eye (separate procedure); with removal of blood, with or without irrigation and/or air injection 65820 228.66 690.83 Goniotomy 65850 1,035.68 762.06 Trabeculotomy ab externo 65855 143.05 318.36 Trabeculoplasty by laser surgery, one or more sessions (defined treatment series) 65860 133.86 294.95 Severing adhesions of anterior segment, laser technique (separate procedure) 65865 722.66 439.15 Severing adhesions of anterior segment of eye, incisional technique (with or without injection of air or liquid) (separate procedure); goniosynechiae 65870 1,035.68 534.39 Severing adhesions of anterior segment of eye, incisional technique (with or without injection of air or liquid) (separate procedure); anterior synechiae, except goniosynechiae 65875 1,035.68 566.76 Severing adhesions of anterior segment of eye, incisional technique (with or without injection of air or liquid) (separate procedure); posterior synechiae 65880 722.66 596.11 Severing adhesions of anterior segment of eye, incisional technique (with or without injection of air or liquid) (separate procedure); corneovitreal adhesions 65900 722.66 875.73 Removal of epithelial downgrowth, anterior chamber of eye

114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY

AMBULATORY CARE

40.06 continued

40.06: continued Code ASC Rate Incl GL Fee 65920 1,035.68 65930 66020 1,035.68 722.66 184.87 66030 228.66 166.21 66130 66150 1,035.68 1,035.68 66155 1,035.68 66160 1,035.68 66165 1,035.68 66170 1,035.68 66172 1,035.68 66180 1,774.58 66185 66220 66225 66250 1,774.58 1,662.75 1,774.58 722.66 727.18 66500 228.66 330.89 66505 228.66 361.04 66600 1,035.68 66605 1,035.68 66625 228.66 390.74 66630 1,035.68 66635 1,035.68 66680 66682 1,035.68 1,035.68 66700 66710 722.66 722.66 410.56 404.28 66711 722.66 565.55 66720 66740 722.66 1,035.68 430.57 PC TC

Fee Fee

704.78 582.41 670.12 780.68 777.46 878.53 764.38 1,062.72 1,332.37 1,039.12 663.09 646.78 827.20 729.84 949.06 506.24 510.70 459.11 559.96 401.05

40.06(8) - Surgical Services Description (con’t) Removal of implanted material, anterior segment of eye Removal of blood clot, anterior segment of eye Injection, anterior chamber of eye (separate procedure); air or liquid Injection, anterior chamber of eye (separate procedure); medication Excision of lesion, sclera Fistulization of sclera for glaucoma; trephination with iridectomy Fistulization of sclera for glaucoma; thermocauterization with iridectomy Fistulization of sclera for glaucoma; sclerectomy with punch or scissors, with iridectomy Fistulization of sclera for glaucoma; iridencleisis or iridotasis Fistulization of sclera for glaucoma; trabeculectomy ab externo in absence of previous surgery Fistulization of sclera for glaucoma; trabeculectomy ab externo with scarring from previous ocular surgery or trauma (includes injection of antifibrotic agents) Aqueous shunt to extraocular reservoir (eg, Molteno, Schocket, Denver-Krupin) Revision of aqueous shunt to extraocular reservoir Repair of scleral staphyloma; without graft Repair of scleral staphyloma; with graft Revision or repair of operative wound of anterior segment, any type, early or late, major or minor procedure Iridotomy by stab incision (separate procedure); except transfixion Iridotomy by stab incision (separate procedure); with transfixion as for iris bombe Iridectomy, with corneoscleral or corneal section; for removal of lesion Iridectomy, with corneoscleral or corneal section; with cyclectomy Iridectomy, with corneoscleral or corneal section; peripheral for glaucoma (separate procedure) Iridectomy, with corneoscleral or corneal section; sector for glaucoma (separate procedure) Iridectomy, with corneoscleral or corneal section; optical (separate procedure) Repair of iris, ciliary body (as for iridodialysis) Suture of iris, ciliary body (separate procedure) with retrieval of suture through small incision (eg, McCannel suture) Ciliary body destruction; diathermy Ciliary body destruction; cyclophotocoagulation, transscleral Ciliary body destruction; cyclophotocoagulation, endoscopic Ciliary body destruction; cryotherapy Ciliary body destruction; cyclodialysis

114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY

AMBULATORY CARE

40.06 Code

40.06: Code 66761 66762 continued ASC Incl Rate 194.90 197.48 GL Fee 416.68 433.78 66770 66820 213.29 228.66 479.39 380.14 66821 232.38 298.92 66825 66830 1,035.68 228.66 633.84 66840 66850 666.62 1,282.70 621.16 66852 66920 66930 66940 66982 1,282.70 1,282.70 1,282.70 666.62 1,066.48 695.11 66983 66984 1,066.48 1,066.48 66985 1,066.48 66986 66990 66999 1,066.48 81.73 I.C. PC TC

Fee Fee

40.06: continued Code ASC Rate Incl GL Fee 68100 68110 68115 68130 68135 68200 68320 102.96 131.64 837.04 722.66 62.52 18.02 837.04 177.53 229.05 321.90 531.06 144.45 39.88 698.38 68325 1,086.26 68326 1,086.26 68328 1,086.26 68330 1,035.68 68335 1,086.26 68340 837.04 534.25 68360 68362 1,035.68 1,035.68 68371 68399 68400 68420 722.66 129.69 198.21 384.94 I.C. 298.29 330.60 68440 68500 61.41 1,086.26 111.14 68505 1,086.26 68510 68520 68525 68530 837.04 1,086.26 837.04 253.00 452.55 240.36 447.83 68540 68550 1,086.26 1,086.26 68700 68705 68720 1,086.26 129.69 1,086.26 239.72 68745 1,086.26 68750 1,086.26 68760 97.37 203.29 68761 68770 75.39 837.04 143.27 492.45 PC TC

Fee Fee

591.91 575.14 646.84 586.98 575.89 511.92 582.85 886.18 890.82 624.39 834.41 1,015.56 537.05 686.34 688.30 711.20 40.06(8) - Surgical Services Description (con’t) Biopsy of conjunctiva Excision of lesion, conjunctiva; up to 1 cm Excision of lesion, conjunctiva; over 1 cm Excision of lesion, conjunctiva; with adjacent sclera Destruction of lesion, conjunctiva Subconjunctival injection Conjunctivoplasty; with conjunctival graft or extensive rearrangement Conjunctivoplasty; with buccal mucous membrane graft (includes obtaining graft) Conjunctivoplasty, reconstruction cul-de-sac; with conjunctival graft or extensive rearrangement Conjunctivoplasty, reconstruction cul-de-sac; with buccal mucous membrane graft (includes obtaining graft) Repair of symblepharon; conjunctivoplasty, without graft Repair of symblepharon; with free graft conjunctiva or buccal mucous membrane (includes obtaining graft) Repair of symblepharon; division of symblepharon, with or without insertion of conformer or contact lens Conjunctival flap; bridge or partial (separate procedure) Conjunctival flap; total (such as Gunderson thin flap or purse string flap) Harvesting conjunctival allograft, living donor Unlisted procedure, conjunctiva Incision, drainage of lacrimal gland Incision, drainage of lacrimal sac (dacryocystotomy or dacryocystostomy) Snip incision of lacrimal punctum Excision of lacrimal gland (dacryoadenectomy), except for tumor; total Excision of lacrimal gland (dacryoadenectomy), except for tumor; partial Biopsy of lacrimal gland Excision of lacrimal sac (dacryocystectomy) Biopsy of lacrimal sac Removal of foreign body or dacryolith, lacrimal passages Excision of lacrimal gland tumor; frontal approach Excision of lacrimal gland tumor; involving osteotomy Plastic repair of canaliculi Correction of everted punctum, cautery Dacryocystorhinostomy (fistulization of lacrimal sac to nasal cavity) Conjunctivorhinostomy (fistulization of conjunctiva to nasal cavity); without tube Conjunctivorhinostomy (fistulization of conjunctiva to nasal cavity); with insertion of tube or stent Closure of the lacrimal punctum; by thermocauterization, ligation, or laser surgery Closure of the lacrimal punctum; by plug, each Closure of lacrimal fistula (separate procedure)

114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY

AMBULATORY CARE

40.06 continued

40.06: continued Code ASC Incl GL Fee PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee 68801 38.86 119.89 Dilation of lacrimal punctum, with or without irrigation 68810 97.37 255.27 Probing of nasolacrimal duct, with or without irrigation; 68811 837.04 189.98 Probing of nasolacrimal duct, with or without irrigation; requiring general anesthesia 68815 837.04 453.11 Probing of nasolacrimal duct, with or without irrigation; with insertion of tube or stent 68816 468.12 694.08 Probing of nasolacrimal duct, with or without irrigation; with transluminal balloon catheter dilation 68840 57.00 116.50 Probing of lacrimal canaliculi, with or without irrigation 68850 65.34 Injection of contrast medium for dacryocystography 68899 I.C. Unlisted procedure, lacrimal system 69000 62.85 186.35 Drainage external ear, abscess or hematoma; simple 69005 108.85 214.06 Drainage external ear, abscess or hematoma; complicated 69020 62.85 240.77 Drainage external auditory canal, abscess 69100 65.45 110.49 Biopsy external ear 69105 91.57 145.73 Biopsy external auditory canal 69110 719.48 463.01 Excision external ear; partial, simple repair 69120 1,071.47 416.28 Excision external ear; complete amputation 69140 1,071.47 903.99 Excision exostosis(es), external auditory canal 69145 719.48 391.81 Excision soft tissue lesion, external auditory canal 69150 332.81 1,069.75 Radical excision external auditory canal lesion; without neck dissection 69155 1,686.59 Radical excision external auditory canal lesion; with neck dissection 69200 28.19 132.57 Removal foreign body from external auditory canal; without general anesthesia 69205 943.36 103.81 Removal foreign body from external auditory canal; with general anesthesia 69210 22.06 49.94 Removal impacted cerumen (separate procedure), one or both ears 69220 35.44 143.67 Debridement, mastoidectomy cavity, simple (eg, routine cleaning) 69222 143.79 232.05 Debridement, mastoidectomy cavity, complex (eg, with anesthesia or more than routine cleaning) 69310 1,782.06 1,127.78 Reconstruction of external auditory canal (meatoplasty) (eg, for stenosis due to injury, infection) (separate procedure) 69399 I.C. Unlisted procedure, external ear 69400 91.57 145.05 Eustachian tube inflation, transnasal; with catheterization 69401 50.74 86.53 Eustachian tube inflation, transnasal; without catheterization 69405 131.64 261.55 Eustachian tube catheterization, transtympanic 69420 111.73 198.52 Myringotomy including aspiration and/or eustachian tube inflation 69421 729.71 156.76 Myringotomy including aspiration and/or eustachian tube inflation requiring general anesthesia 69424 83.10 135.14 Ventilating tube removal requiring general anesthesia 69433 117.68 204.23 Tympanostomy (requiring insertion of ventilating tube), local or topical anesthesia 69436 729.71 169.96 Tympanostomy (requiring insertion of ventilating tube), general anesthesia 69440 1,071.47 690.41 Middle ear exploration through postauricular or ear canal incision

114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY

AMBULATORY CARE

40.06 continued

40.06: continued Code ASC Rate Incl GL Fee PC Fee TC Fee 69450 69501 69502 69505 69511 69530 69535 69540 69550 69552 69554 69601 69602 69603 69604 69605 69610 1,782.06 1,782.06 1,071.47 1,782.06 1,782.06 1,782.06 140.47 1,782.06 1,782.06 1,782.06 1,782.06 1,782.06 1,782.06 1,782.06 1,782.06 192.33 2,712.65 2,557.82 403.57 542.42 740.16 975.75 1,244.79 1,274.67 1,688.16 220.48 1,074.71 1,614.72 1,053.12 1,098.43 1,316.26 1,124.32 1,604.86 69620 69631 1,071.47 1,782.06 724.43 886.36 69632 1,782.06 1,085.37 69633 1,782.06 1,046.94 69635 1,782.06 1,250.39 69636 1,782.06 1,422.40 69637 1,782.06 1,414.67 69641 1,782.06 1,048.68 40.06(8) - Surgical Services Description (con’t) Tympanolysis, transcanal Transmastoid antrotomy (simple mastoidectomy) Mastoidectomy; complete Mastoidectomy; modified radical Mastoidectomy; radical Petrous apicectomy including radical mastoidectomy Resection temporal bone, external approach Excision aural polyp Excision aural glomus tumor; transcanal Excision aural glomus tumor; transmastoid Excision aural glomus tumor; extended (extratemporal) Revision mastoidectomy; resulting in complete mastoidectomy Revision mastoidectomy; resulting in modified radical mastoidectomy Revision mastoidectomy; resulting in radical mastoidectomy Revision mastoidectomy; resulting in tympanoplasty Revision mastoidectomy; with apicectomy Tympanic membrane repair, with or without site preparation of perforation for closure, with or without patch Myringoplasty (surgery confined to drumhead and donor area) Tympanoplasty without mastoidectomy (including canalplasty, atticotomy and/or middle ear surgery), initial or revision; without ossicular chain reconstruction Tympanoplasty without mastoidectomy (including canalplasty, atticotomy and/or middle ear surgery), initial or revision; with ossicular chain reconstruction (eg, postfenestration) Tympanoplasty without mastoidectomy (including canalplasty, atticotomy and/or middle ear surgery), initial or revision; with ossicular chain reconstruction and synthetic prosthesis (eg, partial ossicular replacement prosthesis (PORP), total ossicular replacement prosthesis (TORP)) Tympanoplasty with antrotomy or mastoidotomy (including canalplasty, atticotomy, middle ear surgery, and/or tympanic membrane repair); without ossicular chain reconstruction Tympanoplasty with antrotomy or mastoidotomy (including canalplasty, atticotomy, middle ear surgery, and/or tympanic membrane repair); with ossicular chain reconstruction Tympanoplasty with antrotomy or mastoidotomy (including canalplasty, atticotomy, middle ear surgery, and/or tympanic membrane repair); with ossicular chain reconstruction and synthetic prosthesis (eg, partial ossicular replacement prosthesis (PORP), total Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); without ossicular chain reconstruction

114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY

AMBULATORY CARE

40.06 continued

40.06: continued Code ASC Incl GL Fee PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee 69642 1,782.06 1,350.89 Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); with ossicular chain reconstruction 69643 1,782.06 1,232.09 Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); with intact or reconstructed wall, without ossicular chain reconstruction 69644 1,782.06 1,525.80 Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); with intact or reconstructed canal wall, with ossicular chain reconstruction 69645 1,782.06 1,494.88 Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); radical or complete, without ossicular chain reconstruction 69646 1,782.06 1,584.45 Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); radical or complete, with ossicular chain reconstruction 69650 1,071.47 802.76 Stapes mobilization 69660 1,782.06 935.85 Stapedectomy or stapedotomy with reestablishment of ossicular continuity, with or without use of foreign material; 69661 1,782.06 1,226.07 Stapedectomy or stapedotomy with reestablishment of ossicular continuity, with or without use of foreign material; with footplate drill out 69662 1,782.06 1,170.69 Revision of stapedectomy or stapedotomy 69666 1,782.06 813.50 Repair oval window fistula 69667 1,782.06 815.22 Repair round window fistula 69670 1,782.06 953.02 Mastoid obliteration (separate procedure) 69676 1,782.06 843.41 Tympanic neurectomy 69700 1,782.06 715.66 Closure postauricular fistula, mastoid (separate procedure) 69710 I.C. Implantation or replacement of electromagnetic bone conduction hearing device in temporal bone 69711 1,782.06 871.74 Removal or repair of electromagnetic bone conduction hearing device in temporal bone 69714 1,782.06 1,085.38 Implantation, osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; without mastoidectomy 69715 1,782.06 1,339.39 Implantation, osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; with mastoidectomy 69717 1,782.06 1,157.52 Replacement (including removal of existing device), osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; without mastoidectomy 69718 1,782.06 1,407.91 Replacement (including removal of existing device), osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; with mastoidectomy 69720 1,782.06 1,189.52 Decompression facial nerve, intratemporal; lateral to geniculate ganglion 69725 1,889.00 Decompression facial nerve, intratemporal; including medial to geniculate ganglion

114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY

AMBULATORY CARE

40.06 continued

40.06: continued Code ASC Incl Rate 69740 1,782.06 69745 1,782.06 69799 69801 1,782.06 69802 1,782.06 69805 1,782.06 69806 1,782.06 69820 1,782.06 69840 1,782.06 69905 1,782.06 69910 1,782.06 69915 1,782.06 69930 25,420.43 69949 69950 69955 69960 69970 69979 69990 88000 88005 88007 88020 88025 88027 88036 88037 88040 88045 88099 88300 GL Fee I.C. I.C. 1,828.97 2,011.27 1,937.08 2,157.75 I.C. 215.24 I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. 26.81 PC TC Fee Fee 1,166.32 1,185.04 754.22 1,045.89 1,054.61 950.87 876.41 941.26 923.19 1,028.43 1,544.64 1,283.32 4.41 22.39

40.06(8) - Surgical Services Description (con’t) Suture facial nerve, intratemporal, with or without graft or decompression; lateral to geniculate ganglion Suture facial nerve, intratemporal, with or without graft or decompression; including medial to geniculate ganglion Unlisted procedure, middle ear Labyrinthotomy, with or without cryosurgery including other nonexcisional destructive procedures or perfusion of vestibuloactive drugs (single or multiple perfusions); transcanal Labyrinthotomy, with or without cryosurgery including other nonexcisional destructive procedures or perfusion of vestibuloactive drugs (single or multiple perfusions); with mastoidectomy Endolymphatic sac operation; without shunt Endolymphatic sac operation; with shunt Fenestration semicircular canal Revision fenestration operation Labyrinthectomy; transcanal Labyrinthectomy; with mastoidectomy Vestibular nerve section, translabyrinthine approach Cochlear device implantation, with or without mastoidectomy Unlisted procedure, inner ear Vestibular nerve section, transcranial approach Total facial nerve decompression and/or repair (may include graft) Decompression internal auditory canal Removal of tumor, temporal bone Unlisted procedure, temporal bone, middle fossa approach Microsurgical techniques, requiring use of operating microscope (List separately in addition to code for primary procedure) Necropsy (autopsy), gross examination only; without CNS Necropsy (autopsy), gross examination only; with brain Necropsy (autopsy), gross examination only; with brain and spinal cord Necropsy (autopsy), gross and microscopic; without CNS Necropsy (autopsy), gross and microscopic; with brain Necropsy (autopsy), gross and microscopic; with brain and spinal cord Necropsy (autopsy), limited, gross and/or microscopic; regional Necropsy (autopsy), limited, gross and/or microscopic; single organ Necropsy (autopsy); forensic examination Necropsy (autopsy); coroner's call Unlisted necropsy (autopsy) procedure Level I - Surgical pathology, gross examination only

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40.06 continued

40.06: continued Code ASC Rate Incl GL Fee PC Fee TC Fee 40.06(8) - Surgical Services Description (con’t) 88302 58.73 7.04 51.69 Level II - Surgical pathology, gross and microscopic examination Appendix, incidental Fallopian tube, sterilization Fingers/toes, amputation, traumatic Foreskin, newborn Hernia sac, any location Hydrocele sac Nerve Skin, plastic repair Sympathetic ganglion Testis, castration Vaginal mucosa, incidental Vas deferens, sterilization 88304 72.39 11.03 61.36 Level III - Surgical pathology, gross and microscopic examination Abortion, induced Abscess Aneurysm arterial/ventricular Anus, tag Appendix, other than incidental Artery, atheromatous plaque Bartholin's gland cyst Bone fragment(s), other than pathologic fracture Bursa/synovial cyst Carpal tunnel tissue Cartilage, shavings Cholesteatoma Colon, colostomy stoma Conjunctiva - biopsy/pterygium Cornea Diverticulum - esophagus/small intestine Dupuytren's contracture tissue Femoral head, other than fracture 88305 118.38 38.47 79.91 Fissure/fistula Foreskin, other than newborn Gallbladder Ganglion cyst Hematoma Hemorrhoids Hydatid of Morgagni Intervertebral disc Joint, loose body Meniscus Mucocele, salivary Neuroma Morton's/traumatic Pilonidal cyst/sinus Polyps, inflammatory -nasal/sinusoidal Skin - cyst/tag/debridement Soft tissue, debridement Soft tissue, lipoma Spermatocele Tendon/tendon sheath Testicular appendage Thrombus or embolus Tonsil and/or adenoids Varicocele Vas deferens, other than sterilization Vein, varicosity Level IV - Surgical pathology, gross and microscopic examination Abortion - spontaneous/missed Artery, biopsy Bone marrow, biopsy Bone exostosis Brain/meninges, other than for tumor resection Breast, biopsy, not requiring microscopic evaluation of surgical margins Breast, reduction mammoplasty Bronchus, biopsy Cell block, any source Cervix, biopsy Colon, biopsy Duodenum, biopsy Endocervix, curettings/biopsy Endometrium, curettings/biopsy Esophagus, biopsy Extremity, amputation, traumatic Fallopian tube, biopsy Fallopian tube, ectopic pregnancy Femoral head, fracture Fingers/toes, amputation, non-traumatic Gingiva/oral mucosa, biopsy Heart valve Joint, resection Kidney, biopsy Larynx, biopsy Leiomyoma(s), uterine myomectomy

without uterus Lip, biopsy/wedge resection Lung, transbronchial biopsy Lymph node, biopsy Muscle, bio p s y N a s a l m u c os a , b iop sy Nasopharynx/oropharynx, biopsy Nerve, biopsy Odontogenic/dental cyst Omentum, biopsy Ovary with or without tube, non-neoplastic Ovary, biopsy/wedge resection Parathyroid gland Peritoneum, biopsy Pituitary tumor Placenta, other than third trimester Pleura/pericardium - biopsy/tissue Polyp, cervical/endometrial Polyp, colorectal Polyp, stomach/smallintestineProstate,needlebiopsy

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40.06 continued

40.06: continued Code ASC Incl GL Fee PC Rate Fee 88307 232.33 82.78

40.06: continued Code GL Fee PC Fee TC Fee 40.06(10) - Medical Service Description (continued) 99377 67.59 Physician supervision of a hospice patient (patient not present) requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans, review of subsequent reports of patient status, review of related laboratory and other studies, communication (includiing telephone calls) for purposes of assessment of care decisions with health care professional(s), family member(s), surrogate decision maker(s) (e.g., 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 123.30 Physician supervision of a hospice patient (patient not present) requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans, review of subsequent reports of patient status, review of related laboratory and other studies, communication (includiing telephone calls) for purposes of assessment of care decisions with health care professional(s), family member(s), surrogate decision maker(s) (e.g., 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 99379 67.29 Physician supervision of a nursing facility patient (patient not present) requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans, review of subsequent reports of patient status, review of related laboratory and other studies, communication (includiing telephone calls) for purposes of assessment of care decisions with health care professional(s), family member(s), surrogate decision maker(s) (e.g., 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 99380 100.91 Physician supervision of a nursing facility patient (patient not present) requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans, review of subsequent reports of patient status, review of related laboratory and other studies, communication (includiing telephone calls) for purposes of assessment of care decisions with health care professional(s), family member(s), surrogate decision maker(s) (e.g., 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 99441 13.28 Telephone evaluation and management service provided by a physician to an established patient, parent, or guardian not originating from a related E/M service provided within the previous seven days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; five

ten minutes of medical discussion

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40.07 Appendices

40.07: Appendices APPENDIX DESCRIPTION A CPT and HCPCS Modifiers.Add the appropriate Level 1 CPT modifier to the five digit code or identify the modifier by use of a separate code by adding 099 before the 2 digit number e.g. 09950, 09951.This table includes only common modifiers, any valid modifier may be used if it is appropriate to the situation. B Add-On Codes - Procedures that are commonly carried out in addition to the primary procedure performed and must never be reported as stand-alone codes.These codes are exempt from the multiple modifier '51' as are all codes that specify that they should be listed in addition to the main procedure. C Separate Procedures - Procedures that are stand alone codes.These codes are exempt from the multiple modifier '51'. D Drugs Administered Other Than Oral Method - List of drugs and biologicals that can be injected either subcutaneously, intramuscularly, or intravenously reimbursed at invoice cost. APPENDIX A - Level I and Level II Common Modifiers This appendix lists the modifiers that are most commonly used in treating injured workers.The absence of a modifier from this appendix does not preclude its use in the appropriate situation. (a) Anesthesia Modifiers.

Physical Status Modifiers.Physical status modifying units will be reimbursed if the patient is ranked in one of the following three categories.Physical status is included in CPT to distinguish various levels of complexity of provided.Example: 00100-P3 the anesthesia service Physical Status Modifiers Description Modifying Unit Value P3 P4 P5 A patient with severe systemic disease. A patient with severe systemic disease that is a constant threat to life. A moribund patient who is not expected to survive without the operation. 1 2 3
CPT and HCPCS Modifiers for Anesthesia Services.Add the appropriate Level 1 CPT modifier or HCPCS Level II modifier to the five digit code or identify the modifier by use of a separate code by adding 099 before the 2 digit number e.g. 09950, 09951. Level 1 CPT Modifier Description 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 the modifier '-23' to the procedure code of the basic service. 47Anesthesia by Surgeon Regional or general anesthesia provided by the surgeon may be reported by adding the modifier '-47' to the basic service.(This does not include local anesthesia.)Note: Modifier '-47' or 09947 would not be used as a modifier for the anesthesia procedures.

AS Assistant at Surgery Physician assistant, nurse practitioner or clinical nurse specialist services for assistant at surgery. SA Nurse Practitioner Nurse practitioner rendering service in collaboration with a physician.This indicates reduced payment. -SM Second Option Second surgical opinion. -SN Third Option Third surgical opinion. Appendix B - Add-On Codes Summary of CPT Add-On Codes for CPT 2008.Add on codes are identified in the CPT book with a "+".The CPT book is the final authority on the identification of add-on codes. CODE

01953 15221 20937 26125

15176 20931 22848 33924

15201 20936 22851 33961

01968 15241 20938 26861

01969 15261 20985 26863

11001 15301 20986 27358

11008 15321 20987 27692

11101 15331 22103 31620

11201 15336 22116 31632

11732 15341 22208 31633

11922 15361 22216 31637

13102 15366 22226 32501

13122 15401 22328 33141

13133 15421 22522 33225

13153 15431 22525 33257

15003 15787 22527 33258

15005 15847 22534 33259

15101 16036 22585 33508

15111 17003 22614 33517

15116 17312 22632 33518

15121 17314 22840 33519

15131 17315 22841 33521

15136 19001 22842 33522

15151 19126 22843 33523

15152 19291 22844 33530

15156 19295 22845 33572

15157 19297 22846 33768

15171 20930 22847 33884

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34806

34808

34813

34826

35306

35390

35400

35500

35572

35600

35681

35682

35683

35685

35686

35697

35700

36218

36248

36476

36479

37185

37186

37206

37208

37250

37251

38102

38746

38747

43635

44015

44121

44128

44139

44203

44213

44701

44955

47001

47550

48400

49326

49435

49568

49905

51797

56606

57267

58110

58611

59525

60512

61316

61517

61609

61610

61611

61612

61641

61642

61795

61864

61868

62148

62160

63035

63043

63044

63048

63057

63066

63076

63078

63082

63086

63088

63091

63103

63295

63308

64472

64476

64480

64484

64623

64627

64727

64778

64783

64787

64832

64837

64859

64872

64874

64876

64901

64902

66990

67225

67320

67331

67332

67334

67335

67340

69990

74301

75774

75946

75964

75968

75993

75996

76125

76802

76810

76812

76814

76937

77001

77051

77052

78020

78478

78480

78496

78730

83901

87187

87904

88155

88185

88311

88312

88313

88314

90466

90468

90472

90474

90761

90766

90767

90768

90770

90771

90775

90776

92547

92608

92627

92973

92974

92978

92979

92981

92984

92996

92998

93320

93321

93325

93571

93572

93609

93613

93621

93622

93623

93662

94645

95873

95874

95920

95962

95967

95973

95975

96411

96415

96417

96423

96570

96571

97546

97811

97814

99100

99116

99135

99140

99145

99150

99290

99292

99354

99355

99356

99357

99358

99359

99602

99607

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APPENDIX C-- Codes Exempt from Modifier -51 Summary of CPT Separate Procedure Codes Exempt from Modifier 51 for CPT 2008.This list is not exhaustive.The CPT book identifies all codes exempt from modifier 51 and is the final authority on the matter. CODE 17004 93539 93602 93631 20974 93540 93603 94610 20975 93544 93610 95900 31500 93545 93612 95903 36620 93555 93615 95904 44500 93556 93616 99143 61107 93600 93618 99144 93503 Appendix D: Drugs Administered Other Than Oral Method CODE J0476 J0770 J1270 J0120 J0480 J0780 J1300 J0128 J0500 J0795 J1320 J0129 J0515 J0800 J1325 J0130 J0520 J0835 J1325 J0132 J0530 J0850 J1327 J0133 J0540 J0878 J1330 J0150 J0550 J0881 J1335 J0152 J0560 J0882 J1364 J0170 J0570 J0885 J1380 J0180 J0580 J0886 J1390 J0190 J0583 J0894 J1410 J0200 J0585 J0895 J1430 J0205 J0587 J0900 J1435 J0207 J0592 J0945 J1436 J0210 J0594 J0970 J1438 J0215 J0595 J1000 J1440 J0220 J0600 J1020 J1441 J0256 J0610 J1030 J1450 J0270 J0620 J1040 J1451 J0275 J0630 J1051 J1452 J0278 J0636 J1055 J1455 J0280 J0637 J1056 J1457 J0282 J0640 J1060 J1457 J0285 J0670 J1070 J1460 J0287 J0690 J1080 J1470 J0288 J0692 J1094 J1480 J0289 J0694 J1100 J1490 J0290 J0696 J1110 J1500 J0295 J0697 J1120 J1510 J0300 J0698 J1160 J1520 J0330 J0702 J1162 J1530 J0348 J0704 J1165 J1540 J0350 J0706 J1170 J1550 J0360 J0710 J1180 J1560 J0364 J0713 J1190 J1561 J0365 J0715 J1200 J1562 J0380 J0720 J1205 J1565 J0390 J0725 J1212 J1566 J0395 J0735 J1230 J1568 J0400 J0740 J1240 J1569 J0456 J0743 J1245 J1570 J0460 J0744 J1250 J1571 J0470 J0745 J1260 J1572 J0475 J0760 J1265 J1573

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J1580 J1590 J1595 J1600 J1610 J1620 J1626 J1630 J1631 J1640 J1642 J1644 J1645 J1650 J1652 J1655 J1670 J1700 J1710 J1720 J1730 J1740 J1742 J1743 J1745 J1751 J1752 J1756 J1785 J1790 J1800 J1810 J1815 J1817 J1825 J1830 J1835 J1840 J1850 J1885 J1890 J1931 J1940 J1945 J1950 J1955 J1956 J1960 J1980 J1990 J2001 J2010 J2020 J2060 J2150 J2170 J2175 J2180 J2185 J2210 J2248 J2250 J2260 J2270 J2271 J2275 J2278 J2280 J2300 J2310 J2315 J2320 J2321 J2322 J2325 J2353 J2354 J2355 J2357 J2360 J2370 J2400 J2405 J2410 J2425 J2430 J2440 J2460 J2469 J2501 J2503 J2504 J2505 J2510 J2513 J2515 J2540 J2543 J2545 J2550 J2560 J2590 J2597 J2650 J2670 J2675 J2680 J2690 J2700 J2710 J2720 J2724 J2725 J2730 J2760 J2765 J2770 J2778 J2780 J2783 J2788 J2790 J2791 J2792 J2795 J2800 J2805 J2810 J2820 J2850 J2910 J2916 J2920 J2930 J2940 J2941 J2950 J2993 J2995 J2997 J3000 J3010 J3030 J3070 J3100 J3105 J3110 J3120 J3130 J3140 J3150 J3230 J3240 J3243 J3246 J3250 J3260 J3265 J3280 J3285 J3301 J3302 J3303 J3305 J3310 J3315 J3320 J3350 J3355 J3360 J3364 J3365 J3370 J3395 J3396 J3400 J3410 J3411 J3415 J3420 J3430 J3465 J3470 J3472 J3473 J3475 J3480 J3485 J3486 J3487 J3488 J3490 J3520 J3530 J3535 J3570 J3590 J7030 J7040 J7042 J7050 J7060 J7070 J7100 J7110 J7120 J7130 J7187 J7189 J7190 J7191 J7192 J7193 J7194 J7195 J7197 J7198 J7199 J7300 J7302 J7303 J7304 J7306 J7307 J7308 J7310 J7311 J7321 J7322 J7323 J7324 J7330 J7340 J7341 J7342 J7343 J7344 J7346 J7347 J7348 J7349 J7500 J7501 J7502 J7504 J7505 J7506 J7507 J7509 J7510 J7511 J7513

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J7515 J8520 J9212 J7516 J8521 J9213 J7517 J8530 J9214 J7518 J8540 J9215 J7520 J8560 J9216 J7525 J8565 J9217 J7599 J8597 J9218 J7602 J8600 J9219 J7603 J8610 J9225 J7604 J8650 J9226 J7605 J8700 J9230 J7607 J9000 J9245 J7608 J9001 J9250 J7609 J9010 J9260 J7610 J9015 J9261 J7615 J9017 J9263 J7620 J9020 J9264 J7622 J9025 J9265 J7624 J9027 J9266 J7626 J9031 J9268 J7627 J9035 J9270 J7629 J9040 J9280 J7631 J9041 J9290 J7632 J9045 J9291 J7633 J9050 J9293 J7634 J9055 J9300 J7635 J9060 J9303 J7636 J9062 J9305 J7637 J9065 J9310 J7638 J9070 J9320 J7639 J9080 J9340 J7640 J9090 J9350 J7641 J9091 J9355 J7642 J9092 J9357 J7643 J9093 J9360 J7644 J9094 J9370 J7645 J9095 J9375 J7647 J9096 J9380 J7648 J9097 J9390 J7649 J9098 J9395 J7650 J9100 J9600 J7658 J9110 J7659 J9120 J7660 J9130 J7667 J9140 J7668 J9150 J7669 J9151 J7670 J9160 J7674 J9165 J7676 J9170 J7680 J9175 J7681 J9178 J7682 J9181 J7683 J9182 J7684 J9185 J7685 J9190 J7699 J9200 J7799 J9201 J8498 J9202 J8499 J9206 J8501 J9208 J8510 J9209 J8515 J9211

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40.08 Severability

40.08: Severability The provisions of 114.3 CMR 40.00 are severable. If any provision of 114.3 CMR 40.00 or the application of such provision to Eligible Providers of services or any circumstances should be held invalid or unconstitutional, such determination shall not be construed to affect the validity or constitutionality of any other provision of 114.3 CMR 40.00 or the application of any other provision. REGULATORY AUTHORITY 114.3 CMR 40.00: M.G.L. c. 118G and c. 152.

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