Medical-Visits

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					October 31, 2007

MEDICAL VISIT CODES
FQHC Visit Rate = 100% FQHC rate ($115.33) - maximum of once per day per patient

CODE 99201 99202

99203

DESCRIPTION Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: An expanded problem focused history; An expanded problem focused examination; Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: A detailed history; A detailed examination; Medical decision making of low complexity.

RATE 100% FQHC

PROVIDER TYPE Physician, Physician's Assistant, Nurse Practitioner, Midwife, Optometrist, RN, Osteopath

100% FQHC

Physician, Physician's Assistant, Nurse Practitioner, Midwife, Optometrist, Podiatrist, RN, Osteopath

100% FQHC

Physician, Physician's Assistant, Nurse Practitioner, Midwife, Optometrist, Podiatrist, RN, Osteopath

99204 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity. 100% FQHC 99205 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: A problem focused history; A problem focused examination; Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: An expanded problem focused history; An expanded problem focused examination;

Physician, Physician's Assistant, Nurse Practitioner, Midwife, Optometrist, RN, Osteopath

100% FQHC

Physician, Physician's Assistant, Nurse Practitioner, Midwife, Optometrist, RN, Osteopath

99211

100% FQHC

Physician, Physician's Assistant, Nurse Practitioner, Midwife, Optometrist, Podiatrist, RN, Osteopath

99212

100% FQHC

Physician, Physician's Assistant, Nurse Practitioner, Midwife, Optometrist, Podiatrist, RN, Osteopath

99213

100% FQHC

Physician, Physician's Assistant, Nurse Practitioner, Midwife, Optometrist, Podiatrist, RN, Osteopath

99214

99215

Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. 100% FQHC Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. 100% FQHC

Physician, Physician's Assistant, Nurse Practitioner, Midwife, Optometrist, Podiatrist, RN, Osteopath

Physician, Physician's Assistant, Nurse Practitioner, Midwife, Optometrist, Podiatrist, RN, Osteopath

Medical Visit Codes

October 31, 2007

99218 A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity. Initial observation care, per day, for the evaluation and management of a patient Initial observation care, per day, for the evaluation and management of a patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Initial observation care, per day, for the evaluation and management of a patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: A problem focused interval history; A problem focused examination; Medical decision making that is Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: A detailed interval history; A detailed examination; Medical decision making of high complexity. Hospital discharge day management; 30 minutes or less Hospital discharge day management; more than 30 minutes Office consultation for a new or established patient, which requires these three key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with Office consultation for a new or established patient, which requires these three key components: An expanded problem focused history; An expanded problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of

100% FQHC

Physician, Physician's Assistant, Nurse Practitioner, Podiatrist, Osteopath

99219

100% FQHC

Physician, Physician's Assistant, Nurse Practitioner, Podiatrist, Osteopath

99220

100% FQHC

Physician, Physician's Assistant, Nurse Practitioner, Osteopath

99221

100% FQHC

Physician, Physician's Assistant, Nurse Practitioner, Podiatrist, Osteopath

99222

100% FQHC

Physician, Physician's Assistant, Nurse Practitioner, Podiatrist, Osteopath

99223

100% FQHC

Physician, Physician's Assistant, Nurse Practitioner, Osteopath

99231

100% FQHC

Physician, Physician's Assistant, Nurse Practitioner, Osteopath

99232

100% FQHC

Physician, Physician's Assistant, Nurse Practitioner, Osteopath

99233

99238 99239 99241

100% FQHC 100% FQHC 100% FQHC

Physician, Physician's Assistant, Nurse Practitioner, Osteopath Physician, Physician's Assistant, Nurse Practitioner, Podiatrist, Osteopath Physician, Physician's Assistant, Nurse Practitioner, Podiatrist, Osteopath

100% FQHC

Physician, Physician's Assistant, Nurse Practitioner, Optometrist, Podiatrist, Osteopath

99242

100% FQHC

Physician, Physician's Assistant, Nurse Practitioner, Optometrist, Podiatrist, Osteopath

Medical Visit Codes

October 31, 2007

99243

99244

99245

99251

99252

99253

99254

99255

99381

99382

99383

Office consultation for a new or established patient, which requires these three key components: A detailed history; A detailed examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other providers or Office consultation for a new or established patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with Office consultation for a new or established patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with Inpatient consultation for a new or established patient, which requires these three key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other Inpatient consultation for a new or established patient, which requires these three key components: An expanded problem focused history; An expanded problem focused examination; and Straightforward medical decision making. Counseling and/or Inpatient consultation for a new or established patient, which requires these three key components: A detailed history; A detailed examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other providers Inpatient consultation for a new or established patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with Inpatient consultation for a new or established patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate

100% FQHC

Physician, Physician's Assistant, Nurse Practitioner, Optometrist, Podiatrist, Osteopath

100% FQHC

Physician, Physician's Assistant, Nurse Practitioner, Optometrist, Osteopath

100% FQHC

Physician, Physician's Assistant, Nurse Practitioner, Optometrist, Osteopath

100% FQHC

Physician, Physician's Assistant, Nurse Practitioner, Optometrist, Podiatrist, Osteopath

100% FQHC

Physician, Physician's Assistant, Nurse Practitioner, Podiatrist, Osteopath

100% FQHC

Physician, Physician's Assistant, Nurse Practitioner, Podiatrist, Osteopath

100% FQHC

Physician, Physician's Assistant, Nurse Practitioner, Osteopath

100% FQHC

Physician, Physician's Assistant, Nurse Practitioner, Osteopath

100% FQHC

Physician, Physician's Assistant, Nurse Practitioner, RN, Osteopath

100% FQHC

Physician, Physician's Assistant, Nurse Practitioner, RN, Osteopath

100% FQHC

Physician, Physician's Assistant, Nurse Practitioner, RN, Osteopath

Medical Visit Codes

October 31, 2007

99384

99385

99386

99387

99391

99392

99393

99394

99395

99396

99397

Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate

100% FQHC

Physician, Physician's Assistant, Nurse Practitioner, RN, Osteopath

100% FQHC

Physician, Physician's Assistant, Nurse Practitioner, RN, Osteopath

100% FQHC

Physician, Physician's Assistant, Nurse Practitioner, RN, Osteopath

100% FQHC

Physician, Physician's Assistant, Nurse Practitioner, RN, Osteopath

100% FQHC

Physician, Physician's Assistant, Nurse Practitioner, RN, Osteopath

100% FQHC

Physician, Physician's Assistant, Nurse Practitioner, RN, Osteopath

100% FQHC

Physician, Physician's Assistant, Nurse Practitioner, RN, Osteopath

100% FQHC

Physician, Physician's Assistant, Nurse Practitioner, RN, Osteopath

100% FQHC

Physician, Physician's Assistant, Nurse Practitioner, RN, Osteopath

100% FQHC

Physician, Physician's Assistant, Nurse Practitioner, RN, Osteopath

100% FQHC

Physician, Physician's Assistant, Nurse Practitioner, RN, Osteopath

Medical Visit Codes

October 31, 2007

99431

99433

History and examination of the normal newborn infant, initiation of diagnostic and treatment programs and preparation of hospital records. (This code should also be used for birthing room deliveries.) 100% FQHC Subsequent hospital care, for the evaluation and management of a normal newborn, per day 100% FQHC

Physician, Physician's Assistant, Nurse Practitioner, Midwife, Osteopath Physician, Physician's Assistant, Nurse Practitioner, Midwife, Osteopath

Medical Visit Codes

October 31, 2007

SURGERIES
Note: These are payable and may be included in the PRF statistics only if occurring on a separate day from a Medical Visit. Should be reported on claims data when ever provided including in addition to a medical visit on the same day. CODE 10040 10060 DESCRIPTION Acne surgery (eg, marsupialization, opening or removal of multiple milia, comedones, cysts, pustules) Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple Incision and removal of foreign body, subcutaneous tissues; simple Incision and removal of foreign body, subcutaneous tissues; complicated Puncture aspiration of abscess, hematoma, bulla, or cyst Incision and drainage, complex, postoperative wound infection Debridement; skin, partial thickness Debridement; skin, full thickness Debridement; skin, and subcutaneous tissue Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); single lesion Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); two to four lesions Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed; single lesion Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions Removal of skin tags, multiple fibrocutaneous tags, any area; each additional ten lesions (List separately in addition to code for primary procedure) Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.5 cm or less Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.6 to 1.0 cm Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 1.1 to 2.0 cm RATE 100% FQHC PROVIDER TYPE Physician

100% FQHC

Physician, Podiatrist

10061

10120 10121 10160 10180 11040 11041 11042 11055 11056 11100 11200 11201

100% FQHC 100% FQHC 100% FQHC 100% FQHC 100% FQHC 100% FQHC 100% FQHC 100% FQHC 100% FQHC 100% FQHC 100% FQHC 100% FQHC

Physician, Podiatrist Physician, Podiatrist Physician, Podiatrist Physician, Podiatrist Physician, Podiatrist Physician, Podiatrist Physician, Podiatrist Physician, Podiatrist Physician, Podiatrist Physician, Podiatrist Physician, Podiatrist Physician, Podiatrist

100% FQHC 100% FQHC 100% FQHC 100% FQHC

Physician, Podiatrist Physician Physician Physician

11300 11301 11307

Surgeries

October 31, 2007

11310 11400 11401 11402 11403 11406 11420

Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.5 cm or less Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.5 cm or less Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.6 to 1.0 cm Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 1.1 to 2.0 cm Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 2.1 to 3.0 cm Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter over 4.0 cm Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 0.5 cm or less

100% FQHC 100% FQHC 100% FQHC 100% FQHC 100% FQHC 100% FQHC

Physician Physician Physician Physician Physician Physician

100% FQHC

Physician, Podiatrist

11421 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 0.6 to 1.0 cm 11423 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 2.1 to 3.0 cm Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 0.5 cm or less Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 0.5 cm or less Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 0.6 to 1.0 cm Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 1.1 to 2.0 cm Trimming of nondystrophic nails, any number Debridement of nail(s) by any method(s); one to five Debridement of nail(s) by any method(s); six or more Avulsion of nail plate, partial or complete, simple; single Excision of nail and nail matrix, partial or complete, (eg, ingrown or deformed nail) for permanent removal; Wedge excision of skin of nail fold (eg, for ingrown toenail) Injection, intralesional; up to and including seven lesions Removal, implantable contraceptive capsules Removal with reinsertion, implantable contraceptive capsules 100% FQHC Physician, Podiatrist 100% FQHC Physician, Podiatrist

11440

100% FQHC 100% FQHC 100% FQHC 100% FQHC 100% FQHC 100% FQHC 100% FQHC 100% FQHC 100% FQHC 100% FQHC 100% FQHC 100% FQHC 100% FQHC

Physician Physician Physician Physician Physician, Podiatrist Physician, Podiatrist Physician, Podiatrist Physician, Podiatrist Physician, Podiatrist Physician Physician Physician Physician

11600 11601 11602 11719 11720 11721 11730 11750 11765 11900 11976 11977

Surgeries

October 31, 2007

12001 12002 16000 16020 16025

Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.6 cm to 7.5 cm

100% FQHC 100% FQHC

Physician, Podiatrist Physician, Podiatrist Physician Physician

Initial treatment, first degree burn, when no more than local treatment is required 100% FQHC Dressings and/or debridement of partial-thickness burns, initial or subsequent; small (less than 5% total body surface area) 100% FQHC Dressings and/or debridement of partial-thickness burns, initial or subsequent; medium (eg, whole face or whole extremity, or 5% to 10% total body surface area) 100% FQHC Dressings and/or debridement of partial-thickness burns, initial or subsequent; large (eg, more than one extremity, or greater than 10% total body surface area) 100% FQHC

Physician

16030 Physician

17000 Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses); first lesion Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses); second through 14 lesions, each (List separately in addition to code for first lesion) Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular lesions; up to 14 lesions Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular lesions; 15 or more lesions Puncture aspiration of cyst of breast 100% FQHC Physician, Podiatrist

17003

100% FQHC

Physician, Podiatrist

17110

100% FQHC

Physician, Podiatrist

17111

19000 20550 20551 20552 20600 20605

100% FQHC 100% FQHC

Physician Physician Physician, Podiatrist Physician Physician Physician, Podiatrist

Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar "fascia") 100% FQHC Injection(s); single tendon origin/insertion 100% FQHC Injection(s); single or multiple trigger point(s), one or two muscle(s) 100% FQHC Arthrocentesis, aspiration and/or injection; small joint or bursa (eg, fingers, toes) 100% FQHC Arthrocentesis, aspiration and/or injection; intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa) 100% FQHC Arthrocentesis, aspiration and/or injection; major joint or bursa (eg, shoulder, hip, knee joint, subacromial bursa) 100% FQHC Aspiration and/or injection of ganglion cyst(s) any location 100% FQHC Excision of benign tumor or cyst of mandible, by enucleation and/or curettage 100% FQHC

Physician, Podiatrist Physician Physician, Podiatrist Physician

20610 20612 21040

Surgeries

October 31, 2007

27323 29125 29405 29580 46083 46600 46615

Biopsy, soft tissue of thigh or knee area; superficial Application of short arm splint (forearm to hand); static Application of short leg cast (below knee to toes); Strapping; Unna boot Incision of thrombosed hemorrhoid, external Anoscopy; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) Anoscopy; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique Destruction of lesion(s), anus (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; cryosurgery Laparoscopy, surgical; with biopsy (single or multiple) Cystourethroscopy (separate procedure) Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; chemical Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; cryosurgery Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), extensive (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery) Circumcision, using clamp or other device with regional dorsal penile or ring block Incision and drainage of vulva or perineal abscess Incision and drainage of Bartholin's gland abscess Marsupialization of Bartholin's gland cyst Destruction of lesion(s), vulva; simple (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery) Destruction of lesion(s), vulva; extensive (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery) Biopsy of vulva or perineum (separate procedure); one lesion Biopsy of vulva or perineum (separate procedure); each separate additional lesion (List separately in addition to code for primary procedure) Destruction of vaginal lesion(s); simple (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery) Destruction of vaginal lesion(s); extensive (eg. laser surgery, electrosurgery, cryosurgery, chemosurgery) Biopsy of vaginal mucosa; simple, separate procedure Biopsy of vaginal mucosa; extensive, requiring suture (including cysts) Fitting and insertion of pessary or other intravaginal support device

100% FQHC 100% FQHC 100% FQHC 100% FQHC 100% FQHC 100% FQHC

Physician Physician Physician, Podiatrist Physician, Podiatrist Physician Physician

100% FQHC 100% FQHC 100% FQHC 100% FQHC 100% FQHC 100% FQHC

Physician Physician Physician Physician Physician Physician

46916 49321 52000 54050 54056 54065

100% FQHC 100% FQHC 100% FQHC 100% FQHC 100% FQHC 100% FQHC 100% FQHC 100% FQHC 100% FQHC 100% FQHC 100% FQHC 100% FQHC 100% FQHC 100% FQHC

Physician Physician Physician Physician Physician Physician Physician Physician Physician Physician Physician Physician Physician Physician

54150 56405 56420 56440 56501 56515 56605 56606 57061 57065 57100 57105 57160

Surgeries

October 31, 2007

57170 57420 57452 57454 57455 57456 57460 57500 57505 57510 57511 57520 57522 57800 58100 58300 58301 58600 58611

59025 59050 59051 59200 65205 65220 65222

Diaphragm or cervical cap fitting with instructions Colposcopy of the entire vagina, with cervix if present; Colposcopy of the cervix including upper/adjacent vagina; Colposcopy of the cervix including upper/adjacent vagina; with biopsy(s) of the cervix and endocervical curettage Colposcopy of the cervix including upper/adjacent vagina; with biopsy(s) of the cervix Colposcopy of the cervix including upper/adjacent vagina; with endocervical curettage Colposcopy of the cervix including upper/adjacent vagina; with loop electrode biopsy(s) of the cervix Biopsy, single or multiple, or local excision of lesion, with or without fulguration (separate procedure) Endocervical curettage (not done as part of a dilation and curettage) Cautery of cervix; electro or thermal Cautery of cervix; cryocautery, initial or repeat Conization of cervix, with or without fulguration, with or without dilation and curettage, with or without repair; cold knife or laser Conization of cervix, with or without fulguration, with or without dilation and curettage, with or without repair; loop electrode excision Dilation of cervical canal, instrumental (separate procedure) Endometrial sampling (biopsy) with or without endocervical sampling (biopsy), without cervical dilation, any method (separate procedure) Insertion of intrauterine device (IUD) Removal of intrauterine device (IUD) Ligation or transection of fallopian tube(s), abdominal or vaginal approach, unilateral or bilateral Ligation or transection of fallopian tube(s) when done at the time of cesarean delivery or intra-abdominal surgery (not a separate procedure) (List separately in addition to code for primary procedure) Fetal non-stress test Fetal monitoring during labor by consulting physician (ie, non-attending physician) with written report; supervision and interpretation Fetal monitoring during labor by consulting physician (ie, non-attending physician) with written report; interpretation only Insertion of cervical dilator (eg, laminaria, prostaglandin) (separate procedure) Removal of foreign body, external eye; conjunctival superficial Removal of foreign body, external eye; corneal, without slit lamp Removal of foreign body, external eye; corneal, with slit lamp

100% FQHC 100% FQHC 100% FQHC 100% FQHC 100% FQHC 100% FQHC 100% FQHC 100% FQHC 100% FQHC 100% FQHC 100% FQHC 100% FQHC 100% FQHC 100% FQHC 100% FQHC 100% FQHC 100% FQHC 100% FQHC

Physician Physician Physician Physician Physician Physician Physician Physician Physician Physician Physician Physician Physician Physician Physician Physician Physician Physician

100% FQHC 100% FQHC 100% FQHC 100% FQHC 100% FQHC 100% FQHC 100% FQHC 100% FQHC

Physician Physician Physician Physician Physician Physician Physician Physician

Surgeries

October 31, 2007

66821 Discission of secondary membranous cataract (opacified posterior lens capsule and/or anterior hyaloid); laser surgery (eg, YAG laser) (one or more stages) Correction of trichiasis; epilation, by forceps only Removal foreign body from external auditory canal; without general anesthesia Removal impacted cerumen (separate procedure), one or both ears 100% FQHC 100% FQHC 100% FQHC 100% FQHC Physician, Physician, Physician, Physician

67820 69200 69210

Surgeries

October 31, 2007

Surgeries

October 31, 2007

Surgeries

October 31, 2007

Surgeries

October 31, 2007

Surgeries

October 31, 2007

Surgeries

October 31, 2007

Surgeries

October 31, 2007

URGENT AFTER-HOURS VISIT ADD-ON

CODE 99051

DESCRIPTION Service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service(urgent care after hours and weekends only)

RATE Paid at 114.3 CMR 4.00 (99050)

PROVIDER TYPE Physician, NP, PA, RN

Urgent After-Hours Visit Add-On

October 31, 2007

BEHAVIORAL HEALTH
May be billed in addition to the Medical Visit if servcies occur on the same day CODE 90801 90804 DESCRIPTION Psychiatric diagnostic interview examination Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 20 to 30 minutes face-to-face with the patient; Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 45 to 50 minutes face-to-face with the patient; Family psychotherapy (conjoint psychotherapy) (with patient present)(per 1/2 hour) Multiple Family group psychotherapy Group psychotherapy (other than of a multiple-family group) Pharmacologic management, including prescription, use, and review of medication with no more than minimal medical psychotherapy Environmental intervention for medical management purposes on a psychiatric patient's behalf with agencies, employers, or institutions per1/2 hour) Interpretation or explanation of results of psychiatric, other medical examinations and procedures, or other accumulated data to family or other responsible persons, or advising them how to assist patient(per 1/2 hour) Eligible providers must meet the licensing/certification/supervision provisions of the following regulations: Psychiatrist 130 CMR 429.424(A) Psychologists: 251 CMR 3.00 Licensed Independent Certified Social Worker: 258 CMR 9.03 Licensed Certified Social Worker: 258 CMR 9.04 Licensed Social Worker: 258 CMR 9.05 Licensed Social Work Associate: 258 CMR 9.06 Licensed Mental Health Counselor: 262 CMR 2.00 Psychatric Nurse Mental Health Clincal Specialist: 244 CMR 4.00 Counselor: 130 CMR 429.424(E) Licensed Alcohol and Drug Abuse Counselor I: 105 CMR 168.000 Licensed Alcohol and Drug Abuse Counselor II: 105 CMR 168.000 RATE 100% FQHC PROVIDER TYPE: see qualifications list below

.5(62.5% FQHC)

90806

62.5% FQHC .5(62.5% FQHC) $8.36/pp/30min $8.36/pp/30min

90847 90849 90853 90862

$40.91/15-20min

Clinican must hold license applicable to this service

90882

.5(62.5% FQHC)

90887

.5(62.5% FQHC)

Behavioral Health

October 31, 2007

DENTAL
* Restrictions on frequency and age groups shall follow MassHealth Dental Manual 130 CMR 420.00

CODE D0120 D0150 D0210 D0220 D0230 D0270 D0272 D0274 D0330 D0340 D0350 D0470 D1110 D1120 D1203 D1351 D1510 D1515 D1520 D1525 D1550 D2140 D2150 D2160 D2161 D2330 D2331

DESCRIPTION Periodic oral examination Comprehensive oral evaluation – new or established patient Intraoral – complete series (including bitewings) Intraoral – periapical, first film Intraoral – periapical, each additional film Bitewing - single film Bitewings - two films Bitewings - four films Panoramic film Cephalometric film Oral/facial images Diagnostic casts Prophylaxis - adult Prophylaxis - child Topical application of fluoride (prophylaxis not included) - child Sealant - per tooth Space maintainer - fixed-unilateral Space maintainer - fixed-bilateral Space maintainer - removable-unilateral Space maintainer - removable-bilateral Recementation of space maintainer Amalgam - one surface, primary or permanent Amalgam - two surfaces, primary or permanent Amalgam - three surfaces, primary or permanent Amalgam - four or more surfaces, primary or permanent Resin-based composite - one surface, anterior Resin-based composite - two surfaces, anterior

PROVIDER TYPE Dentist, Hygenist Dentist, Hygenist Dentist, Hygenist Dentist, Hygenist Dentist, Hygenist Dentist, Hygenist Dentist, Hygenist Dentist, Hygenist Dentist, Hygenist Dentist, Hygenist Dentist, Hygenist Dentist, Hygenist Dentist, Hygenist Dentist, Hygenist Dentist, Hygenist Dentist, Hygenist Dentist, Hygenist Dentist, Hygenist Dentist, Hygenist Dentist, Hygenist Dentist, Hygenist Dentist Dentist Dentist Dentist Dentist Dentist

Dental

October 31, 2007

D2332 Resin-based composite - three surfaces, anterior D2335 Resin-based composite - 4 + srfs/ involve incisal angle (anterior) D2390 D2391 D2392 D2393 D2394 D2710 D2751 D2910 D2920 D2930 D2931 D2932 D2951 D2954 D2980 D3310 D3320 D3330 D3410 D3421 D3426 Resin-based composite crown, anterior Resin-based composite – one surface, posterior Resin-based composite – two surfaces, posterior Resin-based composite – three surfaces, posterior Resin-based composite – 4+ surfaces, posterior Crown – resin- based composite (indirect) Crown - porcelain fused to predominantly base metal Recement inlay, onlay, or partial coverage restoration Recement crown Prefabricated stainless steel crown - primary tooth Prefabricated stainless steel crown - permanent tooth Prefabricated resin crown Pin retention - per tooth, in addition to restoration Prefabricated post and core in addition to crown Crown repair, by report Anterior (excluding final restoration) Bicuspid (excluding final restoration) Molar (excluding final restoration) Apicoectomy/periradicular surgery - anterior Apicoectomy/periradicular surgery - bicuspid (first root) Apicoectomy/periradicular surgery (each additional root)

Dentist Dentist Dentist Dentist Dentist Dentist Dentist Dentist Dentist Dentist Dentist Dentist Dentist Dentist Dentist Dentist Dentist Dentist Dentist Dentist Dentist Dentist Dentist Dentist Dentist Dentist Dentist Dentist Dentist Dentist Dentist Dentist Dentist

D4210 Gingivectomy or gingivoplasty – 4+ contiguous teeth or bounded teeth spaces, per quadrant D4341 Periodontal scaling and root planing, 4+ teeth, per quadrant D5110 Complete denture - maxillary D5120 Complete denture - mandibular D5130 Immediate denture - maxillary D5140 Immediate denture - mandibular D5211 Maxillary partial denture - resin base (including any conventional clasps, rests and teeth) D5212 Mandibular partial denture - resin base (including any conventional clasps, rests and teeth) D5510 Repair broken complete denture base D5520 Replace missing or broken teeth - complete denture (each tooth)

Dental

October 31, 2007

Repair resin denture base Repair cast framework Repair or replace broken clasp Replace broken teeth - per tooth Add tooth to existing partial denture Add clasp to existing partial denture Rebase complete maxillary denture Rebase complete mandibular denture Reline complete maxillary denture (laboratory) Reline complete mandibular denture (laboratory) Reline maxillary partial denture (laboratory) Reline mandibular partial denture (laboratory) Pontic - porcelain fused to predominantly base metal Crown - porcelain fused to predominantly base metal Recement fixed partial denture Fixed partial denture repair, by report Unspecified, fixed prosthodontic procedure, by report Extraction, coronal remnants – deciduous tooth Extraction, erupted tooth or exposed root (elevation and/or forceps removal) D7210 Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap& removal of bone and/or section of tooth D7220 D7230 D7240 D7310 D7311 Removal of impacted tooth - soft tissue Removal of impacted tooth - partially bony Removal of impacted tooth - completely bony Alveoloplasty in conjunction with extractions - per quadrant Alveoloplasty in conjunction with extractions – one to three teeth or tooth spaces, per quadrant D7320 Alveoloplasty not in conjunction with extractions - per quadrant

D5610 D5620 D5630 D5640 D5650 D5660 D5710 D5711 D5750 D5751 D5760 D5761 D6241 D6751 D6930 D6980 D6999 D7111 D7140

Dentist Dentist Dentist Dentist Dentist Dentist Dentist Dentist Dentist Dentist Dentist Dentist Dentist Dentist Dentist Dentist Dentist Dentist Dentist Dentist Dentist Dentist Dentist Dentist Dentist

Dentist D7321 Alveoloplasty not in conjunction with extractions – 1-3 teeth or tooth Dentist spaces, per quadrant D7340 Vestibuloplasty - ridge extension (second epithelialization) Dentist Dentist D7410 Excision of benign lesion up to 1.25 cm Dentist D7411 Excision of benign lesion, greater than 1.25cm D7960 Frenulectomy (frenectomy or frenotomy) - separate procedure Dentist D7963 Frenuloplasty Dentist

Dental

October 31, 2007

D7970 D9110 D9220 D9221 D9930

Excision of hyperplastic tissue - per arch Palliative (emergency) treatment of dental pain - minor procedure General anesthesia - first 30 minutes General anesthesia - each additional 15 minutes Treatment of complications (post-surgical) - unusual circumstances, by report D9940 Occlusal guard, by report D9941 Fabrication of athletic mouthguard

Dentist Dentist Dentist Dentist Dentist Dentist Dentist

Dental

October 31, 2007

LAB
CODE DESCRIPTION 80048 Basic metabolic panel This panel must include the following: Calcium (82310) Carbon dioxide (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Potassium (84132) Sodium (84295) Urea nitrogen (BUN) (84520) 80051 Electrolyte panel This panel must include the following: Carbon dioxide (82374) Chloride (82435) Potassium (84132) Sodium (84295) 80053 Comprehensive metabolic panel This panel must include the following: Albumin (82040) Bilirubin, total (82247) Calcium (82310) Carbon dioxide (bicarbonate) (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Phosphatase, alkaline (84075) Potassium 80055 Obstetric panel This panel must include the following: Blood count, complete (CBC), automated and automated differential WBC count (85025 or 85027 and 85004) OR Blood count, complete (CBC), automated (85027) and appropriate manual differential WBC count Paid at Rates in 114.3 CMR 20.00 80061 Lipid panel This panel must include the following: Cholesterol, serum, total (82465) Lipoprotein, direct measurement, high density cholesterol (HDL cholesterol) (83718) Triglycerides (84478) 80069 Renal function panel This panel must include the following: Albumin (82040) Calcium (82310) Carbon dioxide (bicarbonate) (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Phosphorus inorganic (phosphate) (84100) Potassium (84132) Sodium (84295) 80076 Hepatic function panel This panel must include the following: Albumin (82040) Bilirubin, total (82247) Bilirubin, direct (82248) Phosphatase, alkaline (84075) Protein, total (84155) Transferase, alanine amino (ALT) (SGPT) (84460) Transferase, aspartate 80100 Drug screen, qualitative; multiple drug classes chromatographic method, each procedure 80101 Drug screen, qualitative; single drug class method (eg, immunoassay, enzyme assay), each drug class 80156 Carbamazepine; total 80185 Phenytoin; total 81000 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, with microscopy 81001 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, with microscopy 81002 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, without microscopy 81003 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, without microscopy 81005 Urinalysis; qualitative or semiquantitative, except immunoassays 81007 Urinalysis, bacteriuria screen, except by culture or dipstick 81015 Urinalysis; microscopic only 81025 Urine pregnancy test, by visual color comparison methods 82040 Albumin; serum 82043 Albumin; urine, microalbumin, quantitative 82044 Albumin; urine, microalbumin, semiquantitative (eg, reagent strip assay) 82105 Alpha-fetoprotein (AFP); serum Paid at Rates in 114.3 CMR 20.00 RATE Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00

Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00

Lab

October 31, 2007

82120 82150 82247 82270 82272 82274 82310 82374 82435 82465 82550 82565 82570 82670 82728 82947 82948 82950 82951 82952 82955 82960 82977 83001 83002 83021 83036 83051 83550 83615 83655 83718 83840 84075 84132 84146 84152 84153 84155

Amines, vaginal fluid, qualitative Amylase Bilirubin; total Blood, occult, by peroxidase activity (eg, guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (ie, patient was provided three cards or single triple card for consecutive collection) Blood, occult, by peroxidase activity (eg, guaiac), qualitative, feces, single specimen (eg, from digital rectal exam) Blood, occult, by fecal hemoglobin determination by immunoassay, qualitative, feces, 1-3 simultaneous determinations Calcium; total Carbon dioxide (bicarbonate) Chloride; blood Cholesterol, serum or whole blood, total Creatine kinase (CK), (CPK); total Creatinine; blood Creatinine; other source Estradiol Ferritin Glucose; quantitative, blood (except reagent strip) Glucose; blood, reagent strip Glucose; post glucose dose (includes glucose) Glucose; tolerance test (GTT), three specimens (includes glucose) Glucose; tolerance test, each additional beyond three specimens Glucose-6-phosphate dehydrogenase (G6PD); quantitative Glucose-6-phosphate dehydrogenase (G6PD); screen Glutamyltransferase, gamma (GGT) Gonadotropin; follicle stimulating hormone (FSH) Gonadotropin; luteinizing hormone (LH) Hemoglobin fractionation and quantitation; chromatography (eg, A2, S, C, and/or F) Hemoglobin; glycosylated (A1C) Hemoglobin; plasma Iron binding capacity Lactate dehydrogenase (LD), (LDH); Lead Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol) Methadone Phosphatase, alkaline; Potassium; serum Prolactin Prostate specific antigen (PSA); complexed (direct measurement) Prostate specific antigen (PSA); total Protein, total, except by refractometry; serum

Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00

Lab

October 31, 2007

84202 84295 84436 84439 84443 84450 84460 84478 84479 84480 84520 84550 84702 84703 85007 85008 85013 85014 85018 85025 85027 85044 85048 85049 85610 85651 85652 85660 85730 86038 86308 86309 86317 86318 86403 86430 86592 86677 86701 86703

Protoporphyrin, RBC; quantitative Sodium; serum Thyroxine; total Thyroxine; free Thyroid stimulating hormone (TSH) Transferase; aspartate amino (AST) (SGOT) Transferase; alanine amino (ALT) (SGPT) Triglycerides Thyroid hormone (T3 or T4) uptake or thyroid hormone binding ratio (THBR) Triiodothyronine T3; total (TT-3) Urea nitrogen; quantitative Uric acid; blood Gonadotropin, chorionic (hCG); quantitative Gonadotropin, chorionic (hCG); qualitative Blood count; blood smear, microscopic examination with manual differential WBC count Blood count; blood smear, microscopic examination without manual differential WBC count Blood count; spun microhematocrit Blood count; hematocrit (Hct) Blood count; hemoglobin (Hgb) Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC count Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) Blood count; reticulocyte, manual Blood count; leukocyte (WBC), automated Blood count; platelet, automated Prothrombin time; Sedimentation rate, erythrocyte; non-automated Sedimentation rate, erythrocyte; automated Sickling of RBC, reduction Thromboplastin time, partial (PTT); plasma or whole blood Antinuclear antibodies (ANA); Heterophile antibodies; screening Heterophile antibodies; titer Immunoassay for infectious agent antibody, quantitative, not otherwise specified Immunoassay for infectious agent antibody, qualitative or semiquantitative, single step method (eg, reagent strip) Particle agglutination; screen, each antibody Rheumatoid factor; qualitative Syphilis test; qualitative (eg, VDRL, RPR, ART) Antibody; Helicobacter pylori Antibody; HIV-1 Antibody; HIV-1 and HIV-2, single assay

Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00

Lab

October 31, 2007

86704 86706 86762 86885 86900 87070 87075 87077 87081 87084 87086 87088 87101 87110 87176 87184 87205 87210 87220 87250 87320 87340 87400 87449 87490 87590 87797 87804 87880 88142 88150 88164

Hepatitis B core antibody (HBcAb); total Hepatitis B surface antibody (HBsAb) Antibody; rubella Antihuman globulin test; indirect, qualitative, each antiserum Blood typing; ABO Culture, bacterial; any other source except urine, blood or stool, aerobic, with isolation and presumptive identification of isolates Culture, bacterial; any source, except blood, anaerobic with isolation and presumptive identification of isolates Culture, bacterial; aerobic isolate, additional methods required for definitive identification, each isolate Culture, presumptive, pathogenic organisms, screening only; Culture, presumptive, pathogenic organisms, screening only; with colony estimation from density chart Culture, bacterial; quantitative colony count, urine Culture, bacterial; with isolation and presumptive identification of each isolate, urine Culture, fungi (mold or yeast) isolation, with presumptive identification of isolates; skin, hair, or nail Culture, chlamydia, any source Homogenization, tissue, for culture Susceptibility studies, antimicrobial agent; disk method, per plate (12 or fewer agents) Smear, primary source with interpretation; Gram or Giemsa stain for bacteria, fungi, or cell types Smear, primary source with interpretation; wet mount for infectious agents (eg, saline, India ink, KOH preps) Tissue examination by KOH slide of samples from skin, hair, or nails for fungi or ectoparasite ova or mites (eg, scabies) Virus isolation; inoculation of embryonated eggs, or small animal, includes observation and dissection Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; Chlamydia trachomatis Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; hepatitis B surface antigen (HBsAg) Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; Influenza, A or B, each Infectious agent antigen detection by enzyme immunoassay technique qualitative or semiquantitative; multiple step method, not otherwise specified, each organism Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, direct probe technique Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, direct probe technique Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; direct probe technique, each organism Infectious agent antigen detection by immunoassay with direct optical observation; Influenza Infectious agent detection by immunoassay with direct optical observation; Streptococcus, group A Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; manual screening under physician supervision Cytopathology, slides, cervical or vaginal; manual screening under physician supervision Cytopathology, slides, cervical or vaginal (the Bethesda System); manual screening under physician supervision

Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00 Paid at Rates in 114.3 CMR 20.00

Lab

October 31, 2007

RADIOLOGY
CODE 70110 70150 70160 70220 70260 70360 71010 71020 71030 71100 71101 71110 71111 72040 72050 72052 72069 72070 72100 72110 72170 72220 73000 73010 73030 73050 73060 73080 73090 73110 73130 73140 73500 73510 DESCRIPTION Radiologic examination, mandible; complete, minimum of four views Radiologic examination, facial bones; complete, minimum of three views Radiologic examination, nasal bones, complete, minimum of three views Radiologic examination, sinuses, paranasal, complete, minimum of three views Radiologic examination, skull; complete, minimum of four views Radiologic examination; neck, soft tissue Radiologic examination, chest; single view, frontal Radiologic examination, chest, two views, frontal and lateral; Radiologic examination, chest, complete, minimum of four views; Radiologic examination, ribs, unilateral; two views Radiologic examination, ribs, unilateral; including posteroanterior chest, minimum of three views Radiologic examination, ribs, bilateral; three views Radiologic examination, ribs, bilateral; including posteroanterior chest, minimum of four views Radiologic examination, spine, cervical; two or three views Radiologic examination, spine, cervical; minimum of four views Radiologic examination, spine, cervical; complete, including oblique and flexion and/or extension studies Radiologic examination, spine, thoracolumbar, standing (scoliosis) Radiologic examination, spine; thoracic, two views Radiologic examination, spine, lumbosacral; two or three views Radiologic examination, spine, lumbosacral; minimum of four views Radiologic examination, pelvis; one or two views Radiologic examination, sacrum and coccyx, minimum of two views Radiologic examination; clavicle, complete Radiologic examination; scapula, complete Radiologic examination, shoulder; complete, minimum of two views Radiologic examination; acromioclavicular joints, bilateral, with or without weighted distraction Radiologic examination; humerus, minimum of two views Radiologic examination, elbow; complete, minimum of three views Radiologic examination; forearm, two views Radiologic examination, wrist; complete, minimum of three views Radiologic examination, hand; minimum of three views Radiologic examination, finger(s), minimum of two views Radiologic examination, hip, unilateral; one view Radiologic examination, hip, unilateral; complete, minimum of two views RATE Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00

Radiology

October 31, 2007

73540 73550 73560 73562 73564 73590 73610 73630 73650 73660 74000 74020 76519 76536 76645 76700 76805 76815 76830 76856 76870 76880 77051 (76082)

77052 (76083)

77055 (76090) 77056 (76091) 77057 (76092) 77080 (76075) 78305

Radiologic examination, pelvis and hips, infant or child, minimum of two views Radiologic examination, femur, two views Radiologic examination, knee; one or two views Radiologic examination, knee; three views Radiologic examination, knee; complete, four or more views Radiologic examination; tibia and fibula, two views Radiologic examination, ankle; complete, minimum of three views Radiologic examination, foot; complete, minimum of three views Radiologic examination; calcaneus, minimum of two views Radiologic examination; toe(s), minimum of two views Radiologic examination, abdomen; single anteroposterior view Radiologic examination, abdomen; complete, including decubitus and/or erect views Ophthalmic biometry by ultrasound echography, A-scan; with intraocular lens power calculation Ultrasound, soft tissues of head and neck (eg, thyroid, parathyroid, parotid), real time with image documentation Ultrasound, breast(s) (unilateral or bilateral), real time with image documentation Ultrasound, abdominal, real time with image documentation; complete Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester ( or = 14 weeks 0 days), transabdominal approach; single or first gestation Ultrasound, pregnant uterus, real time with image documentation, limited (eg, fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume), one or more fetuses Ultrasound, transvaginal Ultrasound, pelvic (nonobstetric), real time with image documentation; complete Ultrasound, scrotum and contents Ultrasound, extremity, nonvascular, real time with image documentation Computer aided detection (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation, with or without digitization of film radiographic images; diagnostic mammography Computer aided detection (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation, with or without digitization of film radiographic images; screening mammography Mammography; unilateral Mammography; bilateral Screening mammography, bilateral (two view film study of each breast) Dual energy X-ray absorptiometry (DXA), bone density study, one or more sites; axial skeleton (eg, hips, pelvis, spine) Bone and/or joint imaging; multiple areas

Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00

Paid at Rates in 114.3 CMR 18.00

Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00 Paid at Rates in 114.3 CMR 18.00

Radiology

October 31, 2007

VISION
CODE 92002 92004 92012 92014 92015 92020 92060 92081 Visual field examination, unilateral or bilateral, with interpretation and report; limited examination (eg, tangent screen, Autoplot, arc perimeter, or single stimulus level automated test, such as Octopus 3 or 7 equivalent) Visual field examination, unilateral or bilateral, with interpretation and report; intermediate examination (eg, at least 2 isopters on Goldmann perimeter, or semiquantitative, automated suprathreshold screening program, Humphrey suprathreshold automatic Visual field examination, unilateral or bilateral, with interpretation and report; extended examination (eg, Goldmann visual fields with at least 3 isopters plotted and static determination within the central 30°, or quantitative, automated threshold Serial tonometry (separate procedure) with multiple measurements of intraocular pressure over an extended time period with interpretation and report, same day (eg, diurnal curve or medical treatment of acute elevation of intraocular pressure) 100% FQHC (once per patient/day for all services) 100% FQHC (once per patient/day for all services) 100% FQHC (once per patient/day for all services) Physician, Optometrist RATE 100% FQHC (once per patient/day for all services) 100% FQHC (once per patient/day for all services) 100% FQHC (once per patient/day for all services) 100% FQHC (once per patient/day for all services) 100% FQHC (once per Determination of refractive state patient/day for all services) 100% FQHC (once per Gonioscopy (separate procedure) patient/day for all services) Sensorimotor examination with multiple measurements of ocular deviation (eg, restrictive or paretic muscle with 100% FQHC (once per diplopia) with interpretation and report (separate procedure) patient/day for all services) DESCRIPTION Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; intermediate, new patient Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, one or more visits Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, one or more visits PROVIDER TYPE Physician, Optometrist Physician, Optometrist Physician, Optometrist Physician, Optometrist Physician, Optometrist Physician, Optometrist Physician, Optometrist

92082

Physician, Optometrist

92083

Physician, Optometrist

92100

92120 92135 92225

100% FQHC (once per patient/day for all services) 100% FQHC (once per Tonography with interpretation and report, recording indentation tonometer method or perilimbal suction method patient/day for all services) Scanning computerized ophthalmic diagnostic imaging (eg, scanning laser) with interpretation and report, 100% FQHC (once per unilateral patient/day for all services) Ophthalmoscopy, extended, with retinal drawing (eg, for retinal detachment, melanoma), with interpretation and 100% FQHC (once per report; initial patient/day for all services)

Physician, Optometrist Physician, Optometrist Physician, Optometrist Physician, Optometrist

Vision

October 31, 2007

92226 92250 92285 92310

Ophthalmoscopy, extended, with retinal drawing (eg, for retinal detachment, melanoma), with interpretation and 100% FQHC (once per report; subsequent patient/day for all services) 100% FQHC (once per Fundus photography with interpretation and report patient/day for all services) External ocular photography with interpretation and report for documentation of medical progress (eg, close-up 100% FQHC (once per photography, slit lamp photography, goniophotography, stereo-photography) patient/day for all services) Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of 100% FQHC (once per adaptation; corneal lens, both eyes, except for aphakia patient/day for all services)

Physician, Optometrist Physician, Optometrist Physician, Optometrist Physician, Optometrist

92326 Replacement of contact lens 92340 Fitting of spectacles, except for aphakia; monofocal 92340 RP Fitting of spectacles, except for aphakia; monofocal (replacement and repair) (per lens) 92341 Fitting of spectacles, except for aphakia; bifocal 92341 RP Fitting of spectacles, except for aphakia; bi-focal (replacement and repair) (per lens) 92342 Fitting of spectacles, except for aphakia; multifocal, other than bifocal 92342 RP 92370 Fitting of spectacles, except for aphakia; multi-focal other than bi-focal (replacement and repair) (per lens) Repair and refitting spectacles, except for aphakia Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate Physician, Optometrist Physician, Optometrist Physician, Optometrist Physician, Optometrist Physician, Optometrist Physician, Optometrist Physician, Optometrist Paid at 114.3 CMR 15.00 rate Physician, Optometrist

V2020

Frames, purchases

Paid at 114.3 CMR 15.00 rate

Physician, Optometrist

V2100 V2101 V2102

Sphere, single vision, plano to plus or minus 4.00, per lens Sphere, single vision, plus or minus 4.12 to plus or minus 7.00d, per lens Sphere, single vision, plus or minus 7.12 to plus or minus 20.00d, per lens

Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate

Physician, Optometrist Physician, Optometrist Physician, Optometrist

Vision

October 31, 2007

V2103 V2104 V2105 V2106 V2107 V2108 V2109 V2110 V2111 V2112 V2113 V2114 V2115 V2118 V2121

Spherocylinder, single vision, plano to plus or minus 4.00d sphere, 0.12 to 2.00d cylinder, per lens Spherocylinder, single vision, plano to plus or minus 4.00d sphere, 2.12 to 4.00d cylinder, per lens Spherocylinder, single vision, plano to plus or minus 4.00d sphere, 4.25 to 6.00d cylinder, per lens Spherocylinder, single vision, plano to plus or minus 4.00d sphere, over 6.00d cylinder, per lens Spherocylinder, single vision, plus or minus 4.25 to plus or minus 7.00 sphere, 0.12 to 2.00d cylinder, per lens

Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate

Physician, Optometrist Physician, Optometrist Physician, Optometrist Physician, Optometrist Physician, Optometrist Physician, Optometrist Physician, Optometrist Physician, Optometrist Physician, Optometrist Physician, Optometrist Physician, Optometrist Physician, Optometrist Physician, Optometrist Physician, Optometrist Physician, Optometrist

Spherocylinder, single vision, plus or minus 4.25d to plus or minus 7.00d sphere, 2.12 to 4.00d cylinder, per lens Paid at 114.3 CMR 15.00 rate Spherocylinder, single vision, plus or minus 4.25 to plus or minus 7.00d sphere, 4.25 to 6.00d cylinder, per lens Paid at 114.3 CMR 15.00 rate Spherocylinder, single vision, plus or minus 4.25 to 7.00d sphere, over 6.00d cylinder, per lens Paid at 114.3 CMR 15.00 rate

Spherocylinder, single vision, plus or minus 7.25 to plus or minus 12.00d sphere, 0.25 to 2.25d cylinder, per lens Paid at 114.3 CMR 15.00 rate Spherocylinder, single vision, plus or minus 7.25 to plus or minus 12.00d sphere, 2.25d to 4.00d cylinder, per lensPaid at 114.3 CMR 15.00 rate Spherocylinder, single vision, plus or minus 7.25 to plus or minus 12.00d sphere, 4.25 to 6.00d cylinder, per lens Paid at 114.3 CMR 15.00 rate Spherocylinder, single vision, sphere over plus or minus 12.00d, per lens Lenticular (myodisc), per lens, single vision Aniseikonic lens, single vision Lenticular lens, per lens, single Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate

V2200 V2201 V2202

Sphere, bifocal, plano to plus or minus 4.00d, per lens Sphere, bifocal, plus or minus 4.12 to plus or minus 7.00d, per lens Sphere, bifocal, plus or minus 7.12 to plus or minus 20.00d,per lens

Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate

Physician, Optometrist Physician, Optometrist Physician, Optometrist

Vision

October 31, 2007

V2203 V2204 V2205 V2206 V2207 V2208 V2209 V2210 V2211 V2212 V2213 V2214 V2215 V2218 V2219 V2220 V2221

Spherocylinder, bifocal, plano to plus or minus 4.00d sphere, 0.12 to 2.00d cylinder, per lens Spherocylinder, bifocal, plano to plus or minus 4.00d sphere, 2.12 to 4.00d cylinder, per lens Spherocylinder, bifocal, plano to plus or minus 4.00d sphere, 4.12 to 6.00d cylinder, per lens Spherocylinder, bifocal, plano to plus or minus 4.00d sphere, over 6.00d cylinder, per lens Spherocylinder, bifocal, plus or minus 4.25 to plus or minus 7.00d sphere, 0.12 to 2.00d cylinder, per lens Spherocylinder, bifocal, plus or minus 4.25 to plus or minus 7.00d sphere, 2.12 to 4.00d cylinder, per lens Spherocylinder, bifocal, plus or minus 4.25 to plus or minus 7.00d sphere, 4.25 to 6.00d cylinder, per lens Spherocylinder, bifocal, plus or minus 4.25 to plus or minus 7.00d sphere, over 6.00d cylinder, per lens Spherocylinder, bifocal, plus or minus 7.25 to plus or minus 12.00d sphere, 0.25 to 2.25d cylinder, per lens Spherocylinder, bifocal, plus or minus 7.25 to plus or minus 12.00d sphere, 2.25 to 4.00d cylinder, per lens Spherocylinder, bifocal, plus or minus 7.25 to plus or minus 12.00d sphere, 4.25 to 6.00d cylinder, per lens Spherocylinder, bifocal, sphere over plus or minus 12.00d, per lens Lenticular (myodisc), per lens, bifocal Aniseikonic, per lens, bifocal Bifocal seg width over 28mm Bifocal add over 3.25d Lenticular lens, per lens, bifocal

Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate

Physician, Optometrist Physician, Optometrist Physician, Optometrist Physician, Optometrist Physician, Optometrist Physician, Optometrist Physician, Optometrist Physician, Optometrist Physician, Optometrist Physician, Optometrist Physician, Optometrist Physician, Optometrist Physician, Optometrist Physician, Optometrist Physician, Optometrist Physician, Optometrist Physician, Optometrist

V2300

Sphere, trifocal, plano to plus or minus 4.00d, per lens

Paid at 114.3 CMR 15.00 rate

Physician, Optometrist

Vision

October 31, 2007

V2301 V2302 V2303 V2304 V2305 V2306 V2307 V2308 V2309 V2310 V2311 V2312 V2313 V2314 V2315 V2318 V2319 V2320

Sphere, trifocal, plus or minus 4.12 to plus or minus 7.00d per lens Sphere, trifocal, plus or minus 7.12 to plus or minus 20.00, per lens Spherocylinder, trifocal, plano to plus or minus 4.00d sphere, 0.12 to 2.00d cylinder, per lens Spherocylinder, trifocal, plano to plus or minus 4.00d sphere, 2.25 to 4.00d cylinder, per lens Spherocylinder, trifocal, plano to plus or minus 4.00d sphere, 4.25 to 6.00 cylinder, per lens Spherocylinder, trifocal, plano to plus or minus 4.00d sphere, over 6.00d cylinder, per lens Spherocylinder, trifocal, plus or minus 4.25 to plus or minus 7.00d sphere, 0.12 to 2.00d cylinder, per lens Spherocylinder, trifocal, plus or minus 4.25 to plus or minus 7.00d sphere, 2.12 to 4.00d cylinder, per lens Spherocylinder, trifocal, plus or minus 4.25 to plus or minus 7.00d sphere, 4.25 to 6.00d cylinder, per lens Spherocylinder, trifocal, plus or minus 4.25 to plus or minus 7.00d sphere, over 6.00d cylinder per lens Spherocylinder, trifocal, plus or minus 7.25 to plus or minus 12.00d sphere, 0.25 to 2.25d cylinder, per lens Spherocylinder, trifocal, plus or minus 7.25 to plus or minus 12.00d sphere, 2.25 to 4.00d cylinder, per lens Spherocylinder, trifocal, plus or minus 7.25 to plus or minus 12.00d sphere, 4.25 to 6.00d cylinder, per lens Spherocylinder, trifocal, sphere over plus or minus 12.00d, per lens Lenticular, (myodisc), per lens, trifocal Aniseikonic lens, trifocal Trifocal seg width over 28 mm Trifocal add over 3.25d

Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate

Physician, Optometrist Physician, Optometrist Physician, Optometrist Physician, Optometrist Physician, Optometrist Physician, Optometrist Physician, Optometrist Physician, Optometrist Physician, Optometrist Physician, Optometrist Physician, Optometrist Physician, Optometrist Physician, Optometrist Physician, Optometrist Physician, Optometrist Physician, Optometrist Physician, Optometrist Physician, Optometrist

Vision

October 31, 2007

V2321

Lenticular lens, per lens, trifocal

Paid at 114.3 CMR 15.00 rate

Physician, Optometrist

V2410 V2430

Variable asphericity lens, single vision, full field, glass or plastic, per lens Variable asphericity lens, bifocal, full field, glass or plastic, per lens

Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate

Physician, Optometrist Physician, Optometrist

V2500 V2501 V2503 V2510 V2511 V2512 V2520 V2521 V2522

Contact lens, PMMA, spherical, per lens Contact lens, PMMA, toric or prism ballast, per lens Contact lens PMMA, color vision deficiency, per lens Contact lens, gas permeable, spherical, per lens Contact lens, gas permeable, toric, prism ballast, per lens Contact lens, gas permeable, bifocal, per lens Contact lens hydrophilic, spherical, per lens Contact lens hydrophilic, toric, or prism ballast, per lens Contact lens hydrophilic, bifocal, per lens

Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate Paid at 114.3 CMR 15.00 rate

Physician, Optometrist Physician, Optometrist Physician, Optometrist Physician, Optometrist Physician, Optometrist Physician, Optometrist Physician, Optometrist Physician, Optometrist Physician, Optometrist

Vision

October 31, 2007

WELLNESS
CODE 97802 97803 97804 G3076 DESCRIPTION Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes Medical nutrition therapy; re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes Medical nutrition therapy; group (2 or more individual(s)), each 30 minutes RATE Paid at rate in 114.3 CMR 17.00 Paid at rate in 114.3 CMR 17.00 Paid at rate in 114.3 CMR 17.00 PROVIDER TYPE Physician, NP, PA, RN, Registered Dietician Physician, NP, PA, RN, Registered Dietician Physician, NP, PA, RN, Registered Dietician

Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes (at least 30 minutes). (Eligible providers are physician, independent nurse practitioner, and independent nurse midwife.) Paid at 114.3 CMR 17.00 rate Medical nutrition therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition or treatment regimen (including additional hours needed for renal disease), individual, face-to-face with the patient, each 15 minutes Paid at 114.3 CMR 17.00 rate Medical nutrition therapy, reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition, or treatment regimen (including additional hours needed for renal disease), group (2 or more individuals), each 30 minutes Paid at 114.3 CMR 17.00 rate Diabetes outpatient self-management training services, individual, per 30 minutes Diabetes self-management training services, group session (2 or more), per 30 minutes Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 30 minutes Paid at 114.3 CMR 17.00 rate Paid at 114.3 CMR 17.00 rate

Physician, NP, PA, RN, Tobacco Cessation Counselor

G0270

Physician, NP, PA, RN, Registered Dietician

G0271

G0108 G0109 99402

Physician, NP, PA, RN, Registered Dietician Physician, NP, PA, RN, Registered Dietician Physician, NP, PA, RN, Registered Dietician Physician, NP, PA, RN, Registered Dietician

Paid at 114.3 CMR 12.00 rate

Physician, NP, PA, RN, Family Planning Counselor

Tobacco Cessation Counselor: 130 CMR 405.472 Registered Dietician: MassHealth Community Health Center Bulletin 60 - July 2007

Wellness

October 31, 2007

CARDIOLOGY AND PULMONARY
CODE 93005 DESCRIPTION Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report RATE Paid at 114.3 CMR 17.00 rate PROVIDER TYPE X

94060

94150

Included in FQHC rate if performed on Bronchodilation responsiveness, spirometry as in 94010, pre- and same day as med visit; if not, use 114.3 post-bronchodilator administration CMR 17.00 Physician, NP, PA, RN Included in FQHC rate if performed on same day as med visit; if not, use 114.3 Vital capacity, total (separate procedure) CMR 17.00 Physician, NP, PA, RN Included in FQHC rate if performed on same day as med visit; if not, use 114.3 CMR 17.00 Physician, NP, PA, RN Included in FQHC rate if performed on same day as med visit; if not, use 114.3 CMR 17.00 Physician, NP, PA, RN Included in FQHC rate if performed on same day as med visit; if not, use 114.3 CMR 17.00 Physician, NP, PA, RN

94200 Maximum breathing capacity, maximal voluntary ventilation 94370 Determination of airway closing volume, single breath tests Pulmonary stress testing; simple (eg, 6-minute walk test, prolonged exercise test for bronchospasm with pre- and postspirometry and oximetry)

94620

94640 Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes Included in FQHC rate if performed on (eg, with an aerosol generator, nebulizer, metered dose inhaler or same day as med visit; if not, use 114.3 intermittent positive pressure breathing [IPPB] device) CMR 17.00 Physician, NP, PA, RN Included in FQHC rate if performed on Aerosol inhalation of pentamidine for pneumocystis carinii same day as med visit; if not, use 114.3 pneumonia treatment or prophylaxis CMR 17.00 Physician, NP, PA, RN Included in FQHC rate if performed on Demonstration and/or evaluation of patient utilization of an aerosol same day as med visit; if not, use 114.3 generator, nebulizer, metered dose inhaler or IPPB device CMR 17.00 Physician, NP, PA, RN

94642

94664

Cardiology and Pulmonary

October 31, 2007

94760 Noninvasive ear or pulse oximetry for oxygen saturation; single determination 94761 Noninvasive ear or pulse oximetry for oxygen saturation; multiple determinations (eg, during exercise)

Included in FQHC rate if performed on same day as med visit; if not, use 114.3 CMR 17.00 Physician, NP, PA, RN Included in FQHC rate if performed on same day as med visit; if not, use 114.3 CMR 17.00 Physician, NP, PA, RN

Cardiology and Pulmonary

October 31, 2007

OBSTETRIC DELIVERY
CODE 59400 59410 59412 External cephalic version, with or without tocolysis 59425 Antepartum care only; 4-6 visits 59426 59510 59514 Cesarean delivery only; Antepartum care only; 7 or more visits Routine obstetric care including antepartum care, cesarean delivery, and postpartum care DESCRIPTION Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care RATE Pay according to 114.3 CMR 16.00 Pay according to 114.3 CMR 16.00 Pay according to 114.3 CMR 16.00 Pay according to 114.3 CMR 16.00 Pay according to 114.3 CMR 16.00 Pay according to 114.3 CMR 16.00 Pay according to 114.3 CMR 16.00 PROVIDER TYPE Physician, Physician's Assistant, Nurse Practitioner, Midwife Physician, Physician's Assistant, Nurse Practitioner, Midwife Physician, Physician's Assistant, Nurse Practitioner Physician, Physician's Assistant, Nurse Practitioner Physician, Physician's Assistant, Nurse Practitioner Physician, Physician's Assistant, Nurse Practitioner, Midwife Physician, Physician's Assistant, Nurse Practitioner, Midwife

Obstetric Delivery

October 31, 2007

VACCINES, DRUGS, + SUPPLIES
CODE 93965 RATE DESCRIPTION Noninvasive physiologic studies of extremity veins, complete bilateral study (eg, Doppler waveform analysis with responses to compression and other maneuvers, phleborheography, Included in FQHC rate if performed on same day as impedance plethysmography) med visit; if not, use 114.3 CMR 17.00 PROVIDER TYPE

Physician, NP, PA, RN

95115 95117

Professional services for allergen immunotherapy not including provision of allergenic extracts; single injection Professional services for allergen immunotherapy not including provision of allergenic extracts; two or more injections

Included in FQHC rate if performed on same day as med visit; if not, use 114.3 CMR 17.00 Included in FQHC rate if performed on same day as med visit; if not, use 114.3 CMR 17.00

Physician, NP, PA, RN Physician, NP, PA, RN

90471 90472

Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); one vaccine (single or combination vaccine/toxoid) Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure) Immunization administration by intranasal or oral route; one vaccine (single or combination vaccine/toxoid)

Paid at 114.3 CMR 17.00 rate if no medical visit; if there is a medical visit, then part of FQHC payment Physician, NP, PA, RN Paid at 114.3 CMR 17.00 rate if no medical visit; if there is a medical visit, then part of FQHC payment Physician, NP, PA, RN Paid at 114.3 CMR 17.00 rate if no medical visit; if there is a medical visit, then part of FQHC payment Physician, NP, PA, RN

90473

90669 90732 90743 90744 90746

Pneumococcal conjugate vaccine, polyvalent, when administered to children younger than 5 years, for intramuscular use Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, when administered to 2 years or older, for subcutaneous or intramuscular use Hepatitis B vaccine, adolescent (2 dose schedule), for intramuscular use Hepatitis B vaccine, pediatric/adolescent dosage (3 dose schedule), for intramuscular use Hepatitis B vaccine, adult dosage, for intramuscular use

Paid at 114.3 CMR 17.00 rate Paid at 114.3 CMR 17.00 rate Paid at 114.3 CMR 17.00 rate Paid at 114.3 CMR 17.00 rate Paid at 114.3 CMR 17.00 rate

X X X X X

Vaccines, Drugs, + Supplies


				
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Description: Medical-Visits