Code Short Descriptor Status APC Relative Weight ACH Fee CAH Fee ASC Fee

545 Pages·2015·7.77 MB·English

Outpatient Facility Maine Workers' Compensation Board Appendix IV
Medical Fee Schedule
Relative
Code Short Descriptor Status APC Weight ACH Fee CAH Fee ASC Fee
0001F Heart failure composite E $0.00 $0.00 $0.00
0001M Infectious dis hcv 6 assays E $0.00 $0.00 $0.00
0002M Liver dis 10 assays w/ash E $0.00 $0.00 $0.00
0003M Liver dis 10 assays w/nash E $0.00 $0.00 $0.00
0004M Scoliosis dna alys E $0.00 $0.00 $0.00
0005F Osteoarthritis composite E $0.00 $0.00 $0.00
0006M Onc hep gene risk classifier E $0.00 $0.00 $0.00
0007M Onc gastro 51 gene nomogram E $0.00 $0.00 $0.00
0008M Onc breast risk score E $0.00 $0.00 $0.00
00100 Anesth salivary gland N $0.00 $0.00 $0.00
00102 Anesth repair of cleft lip N $0.00 $0.00 $0.00
00103 Anesth blepharoplasty N $0.00 $0.00 $0.00
00104 Anesth electroshock N $0.00 $0.00 $0.00
00120 Anesth ear surgery N $0.00 $0.00 $0.00
00124 Anesth ear exam N $0.00 $0.00 $0.00
00126 Anesth tympanotomy N $0.00 $0.00 $0.00
0012F Cap bacterial assess E $0.00 $0.00 $0.00
00140 Anesth procedures on eye N $0.00 $0.00 $0.00
00142 Anesth lens surgery N $0.00 $0.00 $0.00
00144 Anesth corneal transplant N $0.00 $0.00 $0.00
00145 Anesth vitreoretinal surg N $0.00 $0.00 $0.00
00147 Anesth iridectomy N $0.00 $0.00 $0.00
00148 Anesth eye exam N $0.00 $0.00 $0.00
0014F Comp preop assess cat surg E $0.00 $0.00 $0.00
0015F Melan follow-up complete E $0.00 $0.00 $0.00
00160 Anesth nose/sinus surgery N $0.00 $0.00 $0.00
00162 Anesth nose/sinus surgery N $0.00 $0.00 $0.00
00164 Anesth biopsy of nose N $0.00 $0.00 $0.00
00170 Anesth procedure on mouth N $0.00 $0.00 $0.00
00172 Anesth cleft palate repair N $0.00 $0.00 $0.00
00174 Anesth pharyngeal surgery N $0.00 $0.00 $0.00
00176 Anesth pharyngeal surgery C $0.00 $0.00 $0.00
00190 Anesth face/skull bone surg N $0.00 $0.00 $0.00
00192 Anesth facial bone surgery C $0.00 $0.00 $0.00
0019T Extracorp shock wv tx ms nos A $0.00 $0.00 $0.00
00210 Anesth cranial surg nos N $0.00 $0.00 $0.00
00211 Anesth cran surg hemotoma C $0.00 $0.00 $0.00
00212 Anesth skull drainage N $0.00 $0.00 $0.00
00214 Anesth skull drainage C $0.00 $0.00 $0.00
00215 Anesth skull repair/fract C $0.00 $0.00 $0.00
00216 Anesth head vessel surgery N $0.00 $0.00 $0.00
00218 Anesth special head surgery N $0.00 $0.00 $0.00
00220 Anesth intrcrn nerve N $0.00 $0.00 $0.00
00222 Anesth head nerve surgery N $0.00 $0.00 $0.00
00300 Anesth head/neck/ptrunk N $0.00 $0.00 $0.00
00320 Anesth neck organ 1yr/> N $0.00 $0.00 $0.00
00322 Anesth biopsy of thyroid N $0.00 $0.00 $0.00
00326 Anesth larynx/trach < 1 yr N $0.00 $0.00 $0.00
00350 Anesth neck vessel surgery N $0.00 $0.00 $0.00
00352 Anesth neck vessel surgery N $0.00 $0.00 $0.00
00400 Anesth skin ext/per/atrunk N $0.00 $0.00 $0.00
00402 Anesth surgery of breast N $0.00 $0.00 $0.00
CPT Codes, Copyright 2014, American Medical Association 1
Outpatient Facility Maine Workers' Compensation Board Appendix IV
Medical Fee Schedule
Relative
Code Short Descriptor Status APC Weight ACH Fee CAH Fee ASC Fee
00404 Anesth surgery of breast N $0.00 $0.00 $0.00
00406 Anesth surgery of breast N $0.00 $0.00 $0.00
00410 Anesth correct heart rhythm N $0.00 $0.00 $0.00
0042T Ct perfusion w/contrast cbf N $0.00 $0.00 $0.00
00450 Anesth surgery of shoulder N $0.00 $0.00 $0.00
00454 Anesth collar bone biopsy N $0.00 $0.00 $0.00
00470 Anesth removal of rib N $0.00 $0.00 $0.00
00472 Anesth chest wall repair N $0.00 $0.00 $0.00
00474 Anesth surgery of rib C $0.00 $0.00 $0.00
00500 Anesth esophageal surgery N $0.00 $0.00 $0.00
0051T Implant total heart system C $0.00 $0.00 $0.00
00520 Anesth chest procedure N $0.00 $0.00 $0.00
00522 Anesth chest lining biopsy N $0.00 $0.00 $0.00
00524 Anesth chest drainage C $0.00 $0.00 $0.00
00528 Anes mediascpy & dx thorscpy N $0.00 $0.00 $0.00
00529 Anes medscpy&thorscpy 1 lung N $0.00 $0.00 $0.00
0052T Replace thrc unit hrt syst C $0.00 $0.00 $0.00
00530 Anesth pacemaker insertion N $0.00 $0.00 $0.00
00532 Anesth vascular access N $0.00 $0.00 $0.00
00534 Anesth cardioverter/defib N $0.00 $0.00 $0.00
00537 Anesth cardiac electrophys N $0.00 $0.00 $0.00
00539 Anesth trach-bronch reconst N $0.00 $0.00 $0.00
0053T Replace implantable hrt syst C $0.00 $0.00 $0.00
00540 Anesth chest surgery C $0.00 $0.00 $0.00
00541 Anesth one lung ventilation N $0.00 $0.00 $0.00
00542 Anesthesia removal pleura C $0.00 $0.00 $0.00
00546 Anesth lung chest wall surg C $0.00 $0.00 $0.00
00548 Anesth trachea bronchi surg N $0.00 $0.00 $0.00
0054T Bone srgry cmptr fluor image N $0.00 $0.00 $0.00
00550 Anesth sternal debridement N $0.00 $0.00 $0.00
0055T Bone srgry cmptr ct/mri imag N $0.00 $0.00 $0.00
00560 Anesth heart surg w/o pump C $0.00 $0.00 $0.00
00561 Anesth heart surg <1 yr C $0.00 $0.00 $0.00
00562 Anesth hrt surg w/pmp age 1+ C $0.00 $0.00 $0.00
00563 Anesth heart surg w/arrest N $0.00 $0.00 $0.00
00566 Anesth cabg w/o pump N $0.00 $0.00 $0.00
00567 Anesth cabg w/pump C $0.00 $0.00 $0.00
00580 Anesth heart/lung transplnt C $0.00 $0.00 $0.00
0058T Cryopreservation ovary tiss Q1 0433 2.4765 $355.60 $412.34 $194.48
00600 Anesth spine cord surgery N $0.00 $0.00 $0.00
00604 Anesth sitting procedure C $0.00 $0.00 $0.00
00620 Anesth spine cord surgery N $0.00 $0.00 $0.00
00625 Anes spine tranthor w/o vent N $0.00 $0.00 $0.00
00626 Anes spine transthor w/vent N $0.00 $0.00 $0.00
00630 Anesth spine cord surgery N $0.00 $0.00 $0.00
00632 Anesth removal of nerves C $0.00 $0.00 $0.00
00635 Anesth lumbar puncture N $0.00 $0.00 $0.00
00640 Anesth spine manipulation N $0.00 $0.00 $0.00
00670 Anesth spine cord surgery C $0.00 $0.00 $0.00
00700 Anesth abdominal wall surg N $0.00 $0.00 $0.00
00702 Anesth for liver biopsy N $0.00 $0.00 $0.00
0071T Us leiomyomata ablate <200 S 0066 25.6592 $3,684.40 $4,272.26 $2,015.02
CPT Codes, Copyright 2014, American Medical Association 2
Outpatient Facility Maine Workers' Compensation Board Appendix IV
Medical Fee Schedule
Relative
Code Short Descriptor Status APC Weight ACH Fee CAH Fee ASC Fee
0072T Us leiomyomata ablate >200 S 0066 25.6592 $3,684.40 $4,272.26 $2,015.02
00730 Anesth abdominal wall surg N $0.00 $0.00 $0.00
00740 Anesth upper gi visualize N $0.00 $0.00 $0.00
00750 Anesth repair of hernia N $0.00 $0.00 $0.00
00752 Anesth repair of hernia N $0.00 $0.00 $0.00
00754 Anesth repair of hernia N $0.00 $0.00 $0.00
00756 Anesth repair of hernia N $0.00 $0.00 $0.00
0075T Perq stent/chest vert art C $0.00 $0.00 $0.00
0076T S&i stent/chest vert art C $0.00 $0.00 $0.00
00770 Anesth blood vessel repair N $0.00 $0.00 $0.00
00790 Anesth surg upper abdomen N $0.00 $0.00 $0.00
00792 Anesth hemorr/excise liver C $0.00 $0.00 $0.00
00794 Anesth pancreas removal C $0.00 $0.00 $0.00
00796 Anesth for liver transplant C $0.00 $0.00 $0.00
00797 Anesth surgery for obesity N $0.00 $0.00 $0.00
00800 Anesth abdominal wall surg N $0.00 $0.00 $0.00
00802 Anesth fat layer removal C $0.00 $0.00 $0.00
00810 Anesth low intestine scope N $0.00 $0.00 $0.00
00820 Anesth abdominal wall surg N $0.00 $0.00 $0.00
00830 Anesth repair of hernia N $0.00 $0.00 $0.00
00832 Anesth repair of hernia N $0.00 $0.00 $0.00
00834 Anesth hernia repair < 1 yr N $0.00 $0.00 $0.00
00836 Anesth hernia repair preemie N $0.00 $0.00 $0.00
00840 Anesth surg lower abdomen N $0.00 $0.00 $0.00
00842 Anesth amniocentesis N $0.00 $0.00 $0.00
00844 Anesth pelvis surgery C $0.00 $0.00 $0.00
00846 Anesth hysterectomy C $0.00 $0.00 $0.00
00848 Anesth pelvic organ surg C $0.00 $0.00 $0.00
00851 Anesth tubal ligation N $0.00 $0.00 $0.00
0085T Breath test heart reject E $0.00 $0.00 $0.00
00860 Anesth surgery of abdomen N $0.00 $0.00 $0.00
00862 Anesth kidney/ureter surg N $0.00 $0.00 $0.00
00864 Anesth removal of bladder C $0.00 $0.00 $0.00
00865 Anesth removal of prostate C $0.00 $0.00 $0.00
00866 Anesth removal of adrenal C $0.00 $0.00 $0.00
00868 Anesth kidney transplant C $0.00 $0.00 $0.00
00870 Anesth bladder stone surg N $0.00 $0.00 $0.00
00872 Anesth kidney stone destruct N $0.00 $0.00 $0.00
00873 Anesth kidney stone destruct N $0.00 $0.00 $0.00
00880 Anesth abdomen vessel surg N $0.00 $0.00 $0.00
00882 Anesth major vein ligation C $0.00 $0.00 $0.00
00902 Anesth anorectal surgery N $0.00 $0.00 $0.00
00904 Anesth perineal surgery C $0.00 $0.00 $0.00
00906 Anesth removal of vulva N $0.00 $0.00 $0.00
00908 Anesth removal of prostate C $0.00 $0.00 $0.00
00910 Anesth bladder surgery N $0.00 $0.00 $0.00
00912 Anesth bladder tumor surg N $0.00 $0.00 $0.00
00914 Anesth removal of prostate N $0.00 $0.00 $0.00
00916 Anesth bleeding control N $0.00 $0.00 $0.00
00918 Anesth stone removal N $0.00 $0.00 $0.00
00920 Anesth genitalia surgery N $0.00 $0.00 $0.00
00921 Anesth vasectomy N $0.00 $0.00 $0.00
CPT Codes, Copyright 2014, American Medical Association 3
Outpatient Facility Maine Workers' Compensation Board Appendix IV
Medical Fee Schedule
Relative
Code Short Descriptor Status APC Weight ACH Fee CAH Fee ASC Fee
00922 Anesth sperm duct surgery N $0.00 $0.00 $0.00
00924 Anesth testis exploration N $0.00 $0.00 $0.00
00926 Anesth removal of testis N $0.00 $0.00 $0.00
00928 Anesth removal of testis N $0.00 $0.00 $0.00
00930 Anesth testis suspension N $0.00 $0.00 $0.00
00932 Anesth amputation of penis C $0.00 $0.00 $0.00
00934 Anesth penis nodes removal C $0.00 $0.00 $0.00
00936 Anesth penis nodes removal C $0.00 $0.00 $0.00
00938 Anesth insert penis device N $0.00 $0.00 $0.00
00940 Anesth vaginal procedures N $0.00 $0.00 $0.00
00942 Anesth surg on vag/urethral N $0.00 $0.00 $0.00
00944 Anesth vaginal hysterectomy C $0.00 $0.00 $0.00
00948 Anesth repair of cervix N $0.00 $0.00 $0.00
00950 Anesth vaginal endoscopy N $0.00 $0.00 $0.00
00952 Anesth hysteroscope/graph N $0.00 $0.00 $0.00
0095T Rmvl artific disc addl crvcl C $0.00 $0.00 $0.00
0098T Rev artific disc addl C $0.00 $0.00 $0.00
0099T Implant corneal ring T 0233 23.6288 $3,392.86 $3,934.20 $1,855.57
0100T Prosth retina receive&gen T 0673 42.0983 $6,044.89 $7,009.37 $3,305.98
0101T Extracorp shockwv tx hi enrg T 0050 35.0819 $5,037.41 $5,841.14 $2,754.98
0102T Extracorp shockwv tx anesth T 0050 35.0819 $5,037.41 $5,841.14 $2,754.98
0103T Holotranscobalamin A $0.00 $0.00 $0.00
0106T Touch quant sensory test Q1 0340 0.7061 $101.39 $117.57 $55.45
0107T Vibrate quant sensory test Q1 0340 0.7061 $101.39 $117.57 $55.45
0108T Cool quant sensory test Q1 0420 1.7762 $255.04 $295.74 $139.48
0109T Heat quant sensory test Q1 0340 0.7061 $101.39 $117.57 $55.45
0110T Nos quant sensory test Q1 0340 0.7061 $101.39 $117.57 $55.45
01112 Anesth bone aspirate/bx N $0.00 $0.00 $0.00
0111T Rbc membranes fatty acids A $0.00 $0.00 $0.00
01120 Anesth pelvis surgery N $0.00 $0.00 $0.00
01130 Anesth body cast procedure N $0.00 $0.00 $0.00
01140 Anesth amputation at pelvis C $0.00 $0.00 $0.00
01150 Anesth pelvic tumor surgery C $0.00 $0.00 $0.00
01160 Anesth pelvis procedure N $0.00 $0.00 $0.00
01170 Anesth pelvis surgery N $0.00 $0.00 $0.00
01173 Anesth fx repair pelvis N $0.00 $0.00 $0.00
01180 Anesth pelvis nerve removal N $0.00 $0.00 $0.00
01190 Anesth pelvis nerve removal N $0.00 $0.00 $0.00
01200 Anesth hip joint procedure N $0.00 $0.00 $0.00
01202 Anesth arthroscopy of hip N $0.00 $0.00 $0.00
01210 Anesth hip joint surgery N $0.00 $0.00 $0.00
01212 Anesth hip disarticulation C $0.00 $0.00 $0.00
01214 Anesth hip arthroplasty C $0.00 $0.00 $0.00
01215 Anesth revise hip repair N $0.00 $0.00 $0.00
01220 Anesth procedure on femur N $0.00 $0.00 $0.00
01230 Anesth surgery of femur N $0.00 $0.00 $0.00
01232 Anesth amputation of femur C $0.00 $0.00 $0.00
01234 Anesth radical femur surg C $0.00 $0.00 $0.00
0123T Scleral fistulization T 0233 23.6288 $3,392.86 $3,934.20 $1,855.57
01250 Anesth upper leg surgery N $0.00 $0.00 $0.00
01260 Anesth upper leg veins surg N $0.00 $0.00 $0.00
0126T Chd risk imt study Q1 0340 0.7061 $101.39 $117.57 $55.45
CPT Codes, Copyright 2014, American Medical Association 4
Outpatient Facility Maine Workers' Compensation Board Appendix IV
Medical Fee Schedule
Relative
Code Short Descriptor Status APC Weight ACH Fee CAH Fee ASC Fee
01270 Anesth thigh arteries surg N $0.00 $0.00 $0.00
01272 Anesth femoral artery surg C $0.00 $0.00 $0.00
01274 Anesth femoral embolectomy C $0.00 $0.00 $0.00
01320 Anesth knee area surgery N $0.00 $0.00 $0.00
01340 Anesth knee area procedure N $0.00 $0.00 $0.00
01360 Anesth knee area surgery N $0.00 $0.00 $0.00
01380 Anesth knee joint procedure N $0.00 $0.00 $0.00
01382 Anesth dx knee arthroscopy N $0.00 $0.00 $0.00
01390 Anesth knee area procedure N $0.00 $0.00 $0.00
01392 Anesth knee area surgery N $0.00 $0.00 $0.00
01400 Anesth knee joint surgery N $0.00 $0.00 $0.00
01402 Anesth knee arthroplasty C $0.00 $0.00 $0.00
01404 Anesth amputation at knee C $0.00 $0.00 $0.00
01420 Anesth knee joint casting N $0.00 $0.00 $0.00
01430 Anesth knee veins surgery N $0.00 $0.00 $0.00
01432 Anesth knee vessel surg N $0.00 $0.00 $0.00
01440 Anesth knee arteries surg N $0.00 $0.00 $0.00
01442 Anesth knee artery surg C $0.00 $0.00 $0.00
01444 Anesth knee artery repair C $0.00 $0.00 $0.00
01462 Anesth lower leg procedure N $0.00 $0.00 $0.00
01464 Anesth ankle/ft arthroscopy N $0.00 $0.00 $0.00
01470 Anesth lower leg surgery N $0.00 $0.00 $0.00
01472 Anesth achilles tendon surg N $0.00 $0.00 $0.00
01474 Anesth lower leg surgery N $0.00 $0.00 $0.00
01480 Anesth lower leg bone surg N $0.00 $0.00 $0.00
01482 Anesth radical leg surgery N $0.00 $0.00 $0.00
01484 Anesth lower leg revision N $0.00 $0.00 $0.00
01486 Anesth ankle replacement C $0.00 $0.00 $0.00
01490 Anesth lower leg casting N $0.00 $0.00 $0.00
01500 Anesth leg arteries surg N $0.00 $0.00 $0.00
01502 Anesth lwr leg embolectomy C $0.00 $0.00 $0.00
01520 Anesth lower leg vein surg N $0.00 $0.00 $0.00
01522 Anesth lower leg vein surg N $0.00 $0.00 $0.00
0159T Cad breast mri N $0.00 $0.00 $0.00
01610 Anesth surgery of shoulder N $0.00 $0.00 $0.00
01620 Anesth shoulder procedure N $0.00 $0.00 $0.00
01622 Anes dx shoulder arthroscopy N $0.00 $0.00 $0.00
01630 Anesth surgery of shoulder N $0.00 $0.00 $0.00
01634 Anesth shoulder joint amput C $0.00 $0.00 $0.00
01636 Anesth forequarter amput C $0.00 $0.00 $0.00
01638 Anesth shoulder replacement C $0.00 $0.00 $0.00
0163T Lumb artif diskectomy addl C $0.00 $0.00 $0.00
0164T Remove lumb artif disc addl C $0.00 $0.00 $0.00
01650 Anesth shoulder artery surg N $0.00 $0.00 $0.00
01652 Anesth shoulder vessel surg C $0.00 $0.00 $0.00
01654 Anesth shoulder vessel surg C $0.00 $0.00 $0.00
01656 Anesth arm-leg vessel surg C $0.00 $0.00 $0.00
0165T Revise lumb artif disc addl C $0.00 $0.00 $0.00
01670 Anesth shoulder vein surg N $0.00 $0.00 $0.00
01680 Anesth shoulder casting N $0.00 $0.00 $0.00
01682 Anesth airplane cast N $0.00 $0.00 $0.00
0169T Place stereo cath brain C $0.00 $0.00 $0.00
CPT Codes, Copyright 2014, American Medical Association 5
Outpatient Facility Maine Workers' Compensation Board Appendix IV
Medical Fee Schedule
Relative
Code Short Descriptor Status APC Weight ACH Fee CAH Fee ASC Fee
01710 Anesth elbow area surgery N $0.00 $0.00 $0.00
01712 Anesth uppr arm tendon surg N $0.00 $0.00 $0.00
01714 Anesth uppr arm tendon surg N $0.00 $0.00 $0.00
01716 Anesth biceps tendon repair N $0.00 $0.00 $0.00
0171T Lumbar spine proces distract J1 0425 137.8399 $19,792.43 $22,950.34 $10,824.57
0172T Lumbar spine process addl N $0.00 $0.00 $0.00
01730 Anesth uppr arm procedure N $0.00 $0.00 $0.00
01732 Anesth dx elbow arthroscopy N $0.00 $0.00 $0.00
01740 Anesth upper arm surgery N $0.00 $0.00 $0.00
01742 Anesth humerus surgery N $0.00 $0.00 $0.00
01744 Anesth humerus repair N $0.00 $0.00 $0.00
0174T Cad cxr with interp N $0.00 $0.00 $0.00
01756 Anesth radical humerus surg C $0.00 $0.00 $0.00
01758 Anesth humeral lesion surg N $0.00 $0.00 $0.00
0175T Cad cxr remote N $0.00 $0.00 $0.00
01760 Anesth elbow replacement N $0.00 $0.00 $0.00
01770 Anesth uppr arm artery surg N $0.00 $0.00 $0.00
01772 Anesth uppr arm embolectomy N $0.00 $0.00 $0.00
01780 Anesth upper arm vein surg N $0.00 $0.00 $0.00
01782 Anesth uppr arm vein repair N $0.00 $0.00 $0.00
0178T 64 lead ecg w/i&r B $0.00 $0.00 $0.00
0179T 64 lead ecg w/tracing S 0100 3.2093 $460.82 $534.35 $252.03
0180T 64 lead ecg w/i&r only B $0.00 $0.00 $0.00
01810 Anesth lower arm surgery N $0.00 $0.00 $0.00
01820 Anesth lower arm procedure N $0.00 $0.00 $0.00
01829 Anesth dx wrist arthroscopy N $0.00 $0.00 $0.00
0182T Hdr elect brachytherapy S 0313 9.8375 $1,412.57 $1,637.94 $772.54
01830 Anesth lower arm surgery N $0.00 $0.00 $0.00
01832 Anesth wrist replacement N $0.00 $0.00 $0.00
01840 Anesth lwr arm artery surg N $0.00 $0.00 $0.00
01842 Anesth lwr arm embolectomy N $0.00 $0.00 $0.00
01844 Anesth vascular shunt surg N $0.00 $0.00 $0.00
0184T Exc rectal tumor endoscopic T 0150 35.0675 $5,035.34 $5,838.74 $2,753.85
01850 Anesth lower arm vein surg N $0.00 $0.00 $0.00
01852 Anesth lwr arm vein repair N $0.00 $0.00 $0.00
01860 Anesth lower arm casting N $0.00 $0.00 $0.00
0188T Videoconf crit care 74 min M $0.00 $0.00 $0.00
0189T Videoconf crit care addl 30 M $0.00 $0.00 $0.00
0190T Place intraoc radiation src N $0.00 $0.00 $0.00
01916 Anesth dx arteriography N $0.00 $0.00 $0.00
0191T Insert ant segment drain int T 0673 42.0983 $6,044.89 $7,009.37 $3,305.98
01920 Anesth catheterize heart N $0.00 $0.00 $0.00
01922 Anesth cat or mri scan N $0.00 $0.00 $0.00
01924 Anes ther interven rad artrl N $0.00 $0.00 $0.00
01925 Anes ther interven rad card N $0.00 $0.00 $0.00
01926 Anes tx interv rad hrt/cran N $0.00 $0.00 $0.00
01930 Anes ther interven rad vein N $0.00 $0.00 $0.00
01931 Anes ther interven rad tips N $0.00 $0.00 $0.00
01932 Anes tx interv rad th vein N $0.00 $0.00 $0.00
01933 Anes tx interv rad cran vein N $0.00 $0.00 $0.00
01935 Anesth perc img dx sp proc N $0.00 $0.00 $0.00
01936 Anesth perc img tx sp proc N $0.00 $0.00 $0.00
CPT Codes, Copyright 2014, American Medical Association 6
Outpatient Facility Maine Workers' Compensation Board Appendix IV
Medical Fee Schedule
Relative
Code Short Descriptor Status APC Weight ACH Fee CAH Fee ASC Fee
01951 Anesth burn less 4 percent N $0.00 $0.00 $0.00
01952 Anesth burn 4-9 percent N $0.00 $0.00 $0.00
01953 Anesth burn each 9 percent N $0.00 $0.00 $0.00
01958 Anesth antepartum manipul N $0.00 $0.00 $0.00
0195T Prescrl fuse w/o instr l5/s1 C $0.00 $0.00 $0.00
01960 Anesth vaginal delivery N $0.00 $0.00 $0.00
01961 Anesth cs delivery N $0.00 $0.00 $0.00
01962 Anesth emer hysterectomy N $0.00 $0.00 $0.00
01963 Anesth cs hysterectomy N $0.00 $0.00 $0.00
01965 Anesth inc/missed ab proc N $0.00 $0.00 $0.00
01966 Anesth induced ab procedure N $0.00 $0.00 $0.00
01967 Anesth/analg vag delivery N $0.00 $0.00 $0.00
01968 Anes/analg cs deliver add-on N $0.00 $0.00 $0.00
01969 Anesth/analg cs hyst add-on N $0.00 $0.00 $0.00
0196T Prescrl fuse w/o instr l4/l5 C $0.00 $0.00 $0.00
0198T Ocular blood flow measure Q1 0698 1.3596 $195.22 $226.37 $106.77
01990 Support for organ donor C $0.00 $0.00 $0.00
01991 Anesth nerve block/inj N $0.00 $0.00 $0.00
01992 Anesth n block/inj prone N $0.00 $0.00 $0.00
01996 Hosp manage cont drug admin N $0.00 $0.00 $0.00
01999 Unlisted anesth procedure N $0.00 $0.00 $0.00
0200T Perq sacral augmt unilat inj T 0050 35.0819 $5,037.41 $5,841.14 $2,754.98
0201T Perq sacral augmt bilat inj T 0050 35.0819 $5,037.41 $5,841.14 $2,754.98
0202T Post vert arthrplst 1 lumbar C $0.00 $0.00 $0.00
0205T Inirs each vessel add-on N $0.00 $0.00 $0.00
0206T Cptr dbs alys car elec dta Q1 0420 1.7762 $255.04 $295.74 $139.48
0207T Clear eyelid gland w/heat Q1 0230 0.7019 $100.79 $116.87 $55.12
0208T Audiometry air only Q1 0364 0.5841 $83.87 $97.25 $45.87
0209T Audiometry air & bone Q1 0364 0.5841 $83.87 $97.25 $45.87
0210T Speech audiometry threshold Q1 0364 0.5841 $83.87 $97.25 $45.87
0211T Speech audiom thresh & recog Q1 0364 0.5841 $83.87 $97.25 $45.87
0212T Compre audiometry evaluation Q1 0365 1.5902 $228.34 $264.77 $124.88
0213T Njx paravert w/us cer/thor T 0207 9.0607 $1,301.03 $1,508.61 $711.54
0214T Njx paravert w/us cer/thor N $0.00 $0.00 $0.00
0215T Njx paravert w/us cer/thor N $0.00 $0.00 $0.00
0216T Njx paravert w/us lumb/sac T 0207 9.0607 $1,301.03 $1,508.61 $711.54
0217T Njx paravert w/us lumb/sac N $0.00 $0.00 $0.00
0218T Njx paravert w/us lumb/sac N $0.00 $0.00 $0.00
0219T Plmt post facet implt cerv C $0.00 $0.00 $0.00
0220T Plmt post facet implt thor C $0.00 $0.00 $0.00
0221T Plmt post facet implt lumb T 0050 35.0819 $5,037.41 $5,841.14 $2,754.98
0222T Plmt post facet implt addl N $0.00 $0.00 $0.00
0223T Acoustic ecg w/i&r Q1 0099 1.0579 $151.90 $176.14 $83.08
0224T Acoustic ecg 1+ analysis Q1 0690 0.4739 $68.05 $78.90 $37.22
0225T Acoustic ecg analy & reprog Q1 0690 0.4739 $68.05 $78.90 $37.22
0228T Njx tfrml eprl w/us cer/thor T 0207 9.0607 $1,301.03 $1,508.61 $711.54
0229T Njx tfrml eprl w/us cer/thor N $0.00 $0.00 $0.00
0230T Njx tfrml eprl w/us lumb/sac T 0207 9.0607 $1,301.03 $1,508.61 $711.54
0231T Njx tfrml eprl w/us lumb/sac N $0.00 $0.00 $0.00
0232T Njx platelet plasma Q1 0420 1.7762 $255.04 $295.74 $139.48
0233T Skin glycation spectroscopy A $0.00 $0.00 $0.00
0234T Trluml perip athrc renal art J1 0229 129.8028 $18,638.38 $21,612.17 $10,193.41
CPT Codes, Copyright 2014, American Medical Association 7
Outpatient Facility Maine Workers' Compensation Board Appendix IV
Medical Fee Schedule
Relative
Code Short Descriptor Status APC Weight ACH Fee CAH Fee ASC Fee
0235T Trluml perip athrc visceral C $0.00 $0.00 $0.00
0236T Trluml perip athrc abd aorta J1 0229 129.8028 $18,638.38 $21,612.17 $10,193.41
0237T Trluml perip athrc brchiocph J1 0229 129.8028 $18,638.38 $21,612.17 $10,193.41
0238T Trluml perip athrc iliac art J1 0319 200.1597 $28,740.93 $33,326.59 $15,718.54
0240T Esoph motility 3d topography S 0361 4.4320 $636.39 $737.93 $348.04
0241T Esoph motility w/stim/perf N $0.00 $0.00 $0.00
0243T Intm msr bronchodil wheeze Q1 0077 2.2195 $318.70 $369.55 $174.30
0244T Cont msr bronchodil wheeze S 0369 3.1934 $458.54 $531.70 $250.78
0249T Ligation hemorrhoid w/us T 0150 35.0675 $5,035.34 $5,838.74 $2,753.85
0253T Insert aqueous drain device T 0673 42.0983 $6,044.89 $7,009.37 $3,305.98
0254T Evasc rpr iliac art bifur C $0.00 $0.00 $0.00
0255T Evasc rpr iliac art bifr s&i C $0.00 $0.00 $0.00
0262T Impltj pulm vlv evasc appr C $0.00 $0.00 $0.00
0263T Im b1 mrw cel ther cmpl S 0112 38.3671 $5,509.13 $6,388.12 $3,012.97
0264T Im b1 mrw cel ther xcl hrvst S 0112 38.3671 $5,509.13 $6,388.12 $3,012.97
0265T Im b1 mrw cel ther hrvst onl S 0112 38.3671 $5,509.13 $6,388.12 $3,012.97
0266T Implt/rpl crtd sns dev total C $0.00 $0.00 $0.00
0267T Implt/rpl crtd sns dev lead T 0688 28.7006 $4,121.12 $4,778.65 $2,253.86
0268T Implt/rpl crtd sns dev gen J1 0039 230.6235 $33,115.23 $38,398.81 $18,110.86
0269T Rev/remvl crtd sns dev total Q2 0221 39.7387 $5,706.08 $6,616.49 $3,120.68
0270T Rev/remvl crtd sns dev lead Q2 0688 28.7006 $4,121.12 $4,778.65 $2,253.86
0271T Rev/remvl crtd sns dev gen Q2 0688 28.7006 $4,121.12 $4,778.65 $2,253.86
0272T Interrogate crtd sns dev S 0218 2.1417 $307.53 $356.59 $168.19
0273T Interrogate crtd sns w/pgrmg S 0218 2.1417 $307.53 $356.59 $168.19
0274T Perq lamot/lam crv/thrc T 0208 55.4537 $7,962.60 $9,233.04 $4,354.78
0275T Perq lamot/lam lumbar T 0208 55.4537 $7,962.60 $9,233.04 $4,354.78
0278T Tempr Q1 0215 1.2804 $183.85 $213.19 $100.55
0281T Laa closure w/implant C $0.00 $0.00 $0.00
0282T Periph field stimul trial J1 0061 71.3285 $10,242.06 $11,876.20 $5,601.43
0283T Periph field stimul perm J1 0318 352.7212 $50,647.24 $58,728.08 $27,699.20
0284T Periph field stimul revise Q2 0688 28.7006 $4,121.12 $4,778.65 $2,253.86
0285T Periph field stimul analys S 0216 3.6766 $527.92 $612.15 $288.72
0286T Near ifr spectrsc of wounds N $0.00 $0.00 $0.00
0287T Near ifr guide of vasc site N $0.00 $0.00 $0.00
0288T Anoscopy w/rf delivery T 0150 35.0675 $5,035.34 $5,838.74 $2,753.85
0289T Laser inc for pkp/lkp donor N $0.00 $0.00 $0.00
0290T Laser inc for pkp/lkp recip N $0.00 $0.00 $0.00
0291T Iv oct for proc init vessel N $0.00 $0.00 $0.00
0292T Iv oct for proc addl vessel N $0.00 $0.00 $0.00
0293T Ins lt atrl press monitor C $0.00 $0.00 $0.00
0294T Ins lt atrl mont pres lead C $0.00 $0.00 $0.00
0295T Ext ecg complete M $0.00 $0.00 $0.00
0296T Ext ecg recording Q1 0099 1.0579 $151.90 $176.14 $83.08
0297T Ext ecg scan w/report Q1 0099 1.0579 $151.90 $176.14 $83.08
0298T Ext ecg review and interp M $0.00 $0.00 $0.00
0299T Esw wound healing init wound T 0326 2.9651 $425.76 $493.69 $232.85
0300T Esw wound healing addl wound N $0.00 $0.00 $0.00
0301T Mw therapy for breast tumor S 0066 25.6592 $3,684.40 $4,272.26 $2,015.02
0302T Icar ischm mntrng sys compl J1 0089 127.9907 $18,378.18 $21,310.45 $10,051.11
0303T Icar ischm mntrng sys eltrd J1 0090 88.2442 $12,670.98 $14,692.66 $6,929.82
0304T Icar ischm mntrng sys device J1 0090 88.2442 $12,670.98 $14,692.66 $6,929.82
0305T Icar ischm mntrng prgrm eval Q1 0690 0.4739 $68.05 $78.90 $37.22
CPT Codes, Copyright 2014, American Medical Association 8
Outpatient Facility Maine Workers' Compensation Board Appendix IV
Medical Fee Schedule
Relative
Code Short Descriptor Status APC Weight ACH Fee CAH Fee ASC Fee
0306T Icar ischm mntr interr eval Q1 0690 0.4739 $68.05 $78.90 $37.22
0307T Rmvl icar ischm mntrng dvce Q2 0105 31.6455 $4,543.98 $5,268.98 $2,485.12
0308T Insj ocular telescope prosth J1 0351 311.2228 $44,688.48 $51,818.60 $24,440.33
0309T Prescrl fuse w/ instr l4/l5 C $0.00 $0.00 $0.00
0310T Motor function mapping ntms S 0218 2.1417 $307.53 $356.59 $168.19
0311T Cal & alys cntrl artl press Q1 0099 1.0579 $151.90 $176.14 $83.08
0312T Laps impltj nstim vagus C $0.00 $0.00 $0.00
0313T Laps rmvl nstim array vagus T 0688 28.7006 $4,121.12 $4,778.65 $2,253.86
0314T Laps rmvl vgl arry&pls gen Q2 0688 28.7006 $4,121.12 $4,778.65 $2,253.86
0315T Rmvl vagus nerve pls gen Q2 0688 28.7006 $4,121.12 $4,778.65 $2,253.86
0316T Replc vagus nerve pls gen J1 0039 230.6235 $33,115.23 $38,398.81 $18,110.86
0317T Elec alys vagus nrv pls gen Q1 0690 0.4739 $68.05 $78.90 $37.22
0329T Mntr io press 24hrs/> uni/bi E $0.00 $0.00 $0.00
0330T Tear film img uni/bi w/i&r Q1 0230 0.7019 $100.79 $116.87 $55.12
0331T Heart symp image plnr S 0377 15.3768 $2,207.95 $2,560.24 $1,207.54
0332T Heart symp image plnr spect S 0377 15.3768 $2,207.95 $2,560.24 $1,207.54
0333T Visual ep acuity screen auto E $0.00 $0.00 $0.00
0335T Extraosseous joint stblztion T 0062 27.5390 $3,954.33 $4,585.24 $2,162.64
0336T Lap ablat uterine fibroids T 0174 108.7985 $15,622.38 $18,114.95 $8,543.95
0337T Endothel fxnassmnt non-invas S 0097 1.5196 $218.20 $253.01 $119.33
0338T Trnscth renal symp denrv unl S 0279 34.5196 $4,956.67 $5,747.51 $2,710.82
0339T Trnscth renal symp denrv bil S 0279 34.5196 $4,956.67 $5,747.51 $2,710.82
0340T Ablate pulm tumors + extnsn T 0423 55.2208 $7,929.15 $9,194.26 $4,336.49
0341T Quant pupillometry w/ rprt N $0.00 $0.00 $0.00
0342T Thxp apheresis w/hdl delip S 0112 38.3671 $5,509.13 $6,388.12 $3,012.97
0345T Transcath mtral vlve repair C $0.00 $0.00 $0.00
0346T Ultrasound elastography N $0.00 $0.00 $0.00
0347T Ins bone device for rsa Q1 0420 1.7762 $255.04 $295.74 $139.48
0348T Rsa spine exam Q1 0261 1.2810 $183.94 $213.29 $100.60
0349T Rsa upper extr exam Q1 0261 1.2810 $183.94 $213.29 $100.60
0350T Rsa lower extr exam Q1 0261 1.2810 $183.94 $213.29 $100.60
0351T Intraop oct brst/node spec N $0.00 $0.00 $0.00
0352T Oct brst/node i&r per spec B $0.00 $0.00 $0.00
0353T Intraop oct breast cavity N $0.00 $0.00 $0.00
0354T Oct breast surg cavity i&r B $0.00 $0.00 $0.00
0355T Gi tract capsule endoscopy T 0142 11.4924 $1,650.19 $1,913.48 $902.50
0356T Insrt drug device for iop S 0698 1.3596 $195.22 $226.37 $106.77
0357T Cryopreservation oocyte(s) Q1 0433 2.4765 $355.60 $412.34 $194.48
0358T Bia whole body Q1 0340 0.7061 $101.39 $117.57 $55.45
0359T Behavioral id assessment V 0632 1.4327 $205.72 $238.54 $112.51
0360T Observ behav assessment V 0632 1.4327 $205.72 $238.54 $112.51
0361T Observ behav assess addl N $0.00 $0.00 $0.00
0362T Expose behav assessment V 0632 1.4327 $205.72 $238.54 $112.51
0363T Expose behav assess addl N $0.00 $0.00 $0.00
0364T Adaptive behavior treatment S 0322 1.2065 $173.24 $200.88 $94.75
0365T Adaptive behavior tx addl N $0.00 $0.00 $0.00
0366T Group behavior treatment S 0325 0.8905 $127.87 $148.27 $69.93
0367T Group behav treatment addl N $0.00 $0.00 $0.00
0368T Behavior treatment modified S 0322 1.2065 $173.24 $200.88 $94.75
0369T Behav treatment modify addl N $0.00 $0.00 $0.00
0370T Fam behav treatment guidance S 0324 1.6717 $240.04 $278.34 $131.28
0371T Mult fam behav treat guide S 0324 1.6717 $240.04 $278.34 $131.28
CPT Codes, Copyright 2014, American Medical Association 9
Outpatient Facility Maine Workers' Compensation Board Appendix IV
Medical Fee Schedule
Relative
Code Short Descriptor Status APC Weight ACH Fee CAH Fee ASC Fee
0372T Social skills training group S 0325 0.8905 $127.87 $148.27 $69.93
0373T Exposure behavior treatment S 0323 1.5574 $223.63 $259.31 $122.30
0374T Expose behav treatment addl N $0.00 $0.00 $0.00
0375T Total disc arthrp ant appr C $0.00 $0.00 $0.00
0376T Insert ant segment drain int N $0.00 $0.00 $0.00
0377T Anoscpy inj agent for incont T 0150 35.0675 $5,035.34 $5,838.74 $2,753.85
0378T Visual field assmnt rev/rprt B $0.00 $0.00 $0.00
0379T Vis field assmnt tech suppt Q1 0230 0.7019 $100.79 $116.87 $55.12
0380T Comp animat ret imag series Q1 0230 0.7019 $100.79 $116.87 $55.12
0381T Ext h rate epi sz 14 days M $0.00 $0.00 $0.00
0382T Ext h rate sz 14 day ri only M $0.00 $0.00 $0.00
0383T Ext h rate sz up to 30 days M $0.00 $0.00 $0.00
0384T Ex h rate sz 30 day ri only M $0.00 $0.00 $0.00
0385T Ex h rate for sz ovr 30 day M $0.00 $0.00 $0.00
0386T Ex h rate sz 30+ day ri only M $0.00 $0.00 $0.00
0387T Leadless c pm ins/rpl ventr J1 0319 200.1597 $28,740.93 $33,326.59 $15,718.54
0388T Leadless c pm remove ventr T 0622 30.1495 $4,329.17 $5,019.89 $2,367.64
0389T Prog eval inper leadls pm Q1 0690 0.4739 $68.05 $78.90 $37.22
0390T Periproc eval inper ledls pm N $0.00 $0.00 $0.00
0391T Intergt eval inper leadls pm Q1 0690 0.4739 $68.05 $78.90 $37.22
0500F Initial prenatal care visit E $0.00 $0.00 $0.00
0501F Prenatal flow sheet E $0.00 $0.00 $0.00
0502F Subsequent prenatal care E $0.00 $0.00 $0.00
0503F Postpartum care visit E $0.00 $0.00 $0.00
0505F Hemodialysis plan docd E $0.00 $0.00 $0.00
0507F Periton dialysis plan docd E $0.00 $0.00 $0.00
0509F Urine incon plan docd M $0.00 $0.00 $0.00
0513F Elev bp plan of care docd M $0.00 $0.00 $0.00
0514F Care plan hgb docd esa pt E $0.00 $0.00 $0.00
0516F Anemia plan of care docd E $0.00 $0.00 $0.00
0517F Glaucoma plan of care docd M $0.00 $0.00 $0.00
0518F Fall plan of care docd M $0.00 $0.00 $0.00
0519F Pland chemo docd b/4 txmnt E $0.00 $0.00 $0.00
0520F Rad dos limts b/4 3d rad M $0.00 $0.00 $0.00
0521F Plan of care 4 pain docd M $0.00 $0.00 $0.00
0525F Initial visit for episode E $0.00 $0.00 $0.00
0526F Subs visit for episode M $0.00 $0.00 $0.00
0528F Rcmnd flw-up 10 yrs docd M $0.00 $0.00 $0.00
0529F Intrvl 3/>yr pts clnscp docd M $0.00 $0.00 $0.00
0535F Dyspnea mngmnt plan docd E $0.00 $0.00 $0.00
0540F Gluco mngmnt plan docd M $0.00 $0.00 $0.00
0545F Follow up care plan mdd docd E $0.00 $0.00 $0.00
0550F Cytopath report nongyn spcmn E $0.00 $0.00 $0.00
0551F Cytopath report non routine E $0.00 $0.00 $0.00
0555F Symptom mgmnt plan care docd E $0.00 $0.00 $0.00
0556F Plan care lipid control docd E $0.00 $0.00 $0.00
0557F Plan caremng angnl symptdocd M $0.00 $0.00 $0.00
0575F Hiv rna plan care docd E $0.00 $0.00 $0.00
0580F Multidisciplinary care plan E $0.00 $0.00 $0.00
0581F Pt trnsfrd from anesth to cc E $0.00 $0.00 $0.00
0582F No trnsfr from anesth to cc E $0.00 $0.00 $0.00
0583F Transfer care checklist used E $0.00 $0.00 $0.00
CPT Codes, Copyright 2014, American Medical Association 10