ASC Fee Schedule - medicaid.mmis.arkansas.gov

1 ++Region CodeWage Code% of Level III Rock areaWest Memphis and TennesseeTexarkana Rural ArkansasFayetteville and SpringdalePine BluffHot Springs Crawford, Franklin, Sebastian counties AR; LeFlore, Sequoyah counties OK Rural Arkansas (if not specifically listed then use) Benton, Madison, Washington counties AR; McDonald county MO Cleveland, Jefferson, Lincoln countiesASC pricing descriptionARKANSAS medicaid AMBULATORY SURGICAL CENTER FEE SCHEDULEThis fee Schedule does not address the various coverage limitations routinely applied by Arkansas medicaid before final payment is determined ( , beneficiary and provider eligibility, benefit limits, billing instructions, frequency of services, third party liability, age restrictions, prior authorization, co-payments/coinsurance where applicable). Procedure codes and/or fee Schedule amounts listed do not guarantee payment, coverage or amount every effort is made to ensure the accuracy of this information, discrepancies may occur.

2 This fee Schedule may be changed or updated at any time to correct such discrepancies. The reimbursement rates reflected in this fee Schedule are in effect as of the date of this report. The reimbursement rate applied to a claim depends on the claim s date of service because Arkansas medicaid s reimbursement rates are date-of-service effective. This fee Schedule reflects only procedure codes that are currently payable. Any procedure code reflecting a medicaid maximum of $ is manually payment made to an Ambulatory Surgical Center (ASC) for surgical procedures is calculated as the claim is processed for payment. Each county is assigned a County Code based on the regional location. The procedure codes reimbursed each have a base rate used in the calculation. This base rate is reflected in the Arkansas medicaid ASC Fee Schedule . The base rate is equal to 95% of the Medicare rate. The wage index is only applied to half of the base rate. See example below:(Base Rate x Wage Index)($10 x x 50%) = $ Rate =($10 x 50%) = $ = $ medicaid RateFort Smith and OklahomaRegional Location Garland Craighead, Poinsett counties Faulkner, Grant, Lonoke, Perry, Pulaski, Saline counties Crittenden county, TN-MS-AR metro area Miller county AR (Texarkana, AR); Bowie county TX (Texarkana, TX)JonesboroCounty CodeRegionCodeCounty CodeCountyRegionCode0742 Logan71743 Lonoke32744 Madison83745 Marion74846 Miller55747 Mississippi76748 Monroe77749 Montgomery78750 Nevada79751 Newton710752 Ouachita711753 Perry312754 Phillips713955 Pike714756 Poinsett215757 Polk716258 Pope717659 Prairie718460 Pulaski319761 Randolph720762 Saline321763 Scott722764 Searcy723365 Sebastion624666 Sevier725767 Sharp726168 St.

3 Francis727369 Stone728770 Union729771 Van Buren730772 Washington831773 White732774 Woodruff733775 Yell734776 Pulaski (North)735991 State of Louisiana736792 State of Missouri837793 State of Mississippi438794 State of Oklahoma639795 State of Tennessee440996 State of Texas541797 All other States7 Jefferson Johnson Lafayette Lawrence Lincoln Little River Lee Howard Independence Izard Jackson Fulton Garland Grant Greene Hempstead Hot Springs Cross Dallas Desha Drew Faulkner Franklin Cleburne Conway Cleveland Columbia Craighead Crawford Carroll Chicot Clark Clay Benton Boone Bradley Calhoun Ashley Baxter CrittendenCounty Unknown ArkansasProcedure CodeTOSMod 1 Mod 2 Mod 3 Mod 4 Plan CodeMedicaid Maximum Allowed Amount0360G00000000 ZZZ$ $ $ $ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$

4 GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ Date 8/22/17 Please note that Arkansas medicaid will reimburse the lesser of the amount billed or the medicaid maximum. For a full explanation of the procedure codes and modifiers listed here, refer to your Arkansas medicaid provider Type: 2811313 GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000

5 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$ LSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$1, GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$1, GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$1, GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$1, GSG000000 ZZZ$ GSG000000 ZZZ$1, GSG000000 ZZZ$ GSG000000 ZZZ$1, GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$1.

6 GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$2, GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$1, GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$ GSG000000 ZZZ$1, GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$2, GSG000000 ZZZ$3, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$2, GSG000000 ZZZ$1, GSG000000 ZZZ$1.

7 GSG000000 ZZZ$1, GSG000000 ZZZ$2, GSG000000 ZZZ$2, GSG000000 ZZZ$3, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$2, GSG000000 ZZZ$3, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$3, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$2, GSG000000 ZZZ$1, GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$1, GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$1, GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$1, GSG000000 ZZZ$ GSG000000 ZZZ$1, GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$ GSG000000 ZZZ$1, GSG000000 ZZZ$ GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$ GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$2, GSG000000 ZZZ$2, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$1.

8 GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$ GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$ GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$1, GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$ GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$ GSG000000 ZZZ$1, GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$ GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$1.

9 GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$2, GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$3, GSG000000 ZZZ$3, GSG000000 ZZZ$7, GSG000000 ZZZ$3, GSG000000 ZZZ$7, GSG000000 ZZZ$7, GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$1, GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$ GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$3, GSG000000 ZZZ$3, GSG000000 ZZZ$3, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$1, GSG000000 ZZZ$3, GSG000000 ZZZ$3, GSG000000 ZZZ$3, GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$3, GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$2, GSG000000 ZZZ$1, GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$2, GSG000000 ZZZ$2, GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$3.

10 GSG000000 ZZZ$ GSG000000 ZZZ$ GSG000000 ZZZ$3, GSG000000 ZZZ$3, G