Physicians’ Services Fee Schedule - 2014 - Maryland

1 Physicians Services Fee Schedule - 2014 2014 Maryland Medical Assistance FS-1 Physicians Services Fee Schedule - 2014 Overview Introduction This Fee Schedule includes the current CPT codes and their maximum reimbursement that the Physicians Services program pays for each procedure. To clarify and assist providers in using and navigating this Fee Schedule , it also contains information on the limitations on its use, abbreviations in the Schedule , and electronic format information. All rates are based upon the Medicare Part-B Fee Schedule . In This Chapter This chapter contains: TOPIC PAGE Limitations of the Fee Schedule FS-1 Abbreviations Used in the Fee Schedule FS-2 Electronic Formats FS-3 Special Note FS-3 Addendum (April 1, 2013) FS-3 Fee Schedule FS-4 Limitations of the Fee Schedule All reimbursement rates and additional documentation requirements only apply to professional Services when recipients have coverage under fee-for-service.

2 Recipients with Managed Care Organization (MCO) coverage through the HealthChoice program may have different requirements. This fee Schedule does not contain reimbursement rates for any HCPCS Level-II codes (beginning with Alpha characters A through W) outside of the digital mammography codes (G0202, G0204, and G0206) and other replacement codes (G0453 and G0455). There is no separate fee Schedule for J-codes. All providers must bill J-codes their exact acquisition costs, NOT usual and customary charges or average wholesale price (AWP). There are separate fee schedules for Durable Medical Equipment (DME), Durable Medical Supplies (DMS), and Oxygen providers, as well as laboratory and pathology codes in the 80000 series. These schedules are available online at: Physicians Services Fee Schedule - 2014 2014 Maryland Medical Assistance FS-2 Limitations (cont.) This fee Schedule does not contain any CPT Category II (Performance Measurement) or CPT Category III (Emerging Technology & Procedures).

3 The Program does not reimburse providers for these procedures. Abbreviations Used in the Fee Schedule The following abbreviations are used in the fee Schedule : Abbreviation Details NFAC Non-Facility Fee. The Non-Facility Fee is the fee Schedule amount for Services rendered in an office, home, or school setting. For many procedures, the Non-Facility and Facility rates are identical. Certain procedures may have higher non-facility rates compared to facility rates to accommodate overhead and indirect expenses providers incur by operating their own facility. FAC Facility Fee. The Facility Fee is the fee Schedule amount for Services rendered in a hospital (inpatient or outpatient), psychiatric hospital (inpatient or outpatient), nursing facility or skilled nursing facility. 26 Modifier 26. The Modifier -26 Fee is the amount for only the professional component of a procedure, where applicable.

4 TC Modifier TC. The Modifier -TC Fee is the amount for only the technical component of a procedure, where applicable. NOTE The NOTE column is used to designate whether a code requires additional documentation, and may contain one of four abbreviations, listed below. The documentation for each of these forms may be found at: A Abortion Form Required. Certain Services require the Certification for Abortion Form (DHMH 521) to be completed and kept in the patient s Medical Record. H Hysterectomy Form Required. Certain Services require the Document for Hysterectomy Form (DHMH 2990) to be completed and kept in the patient s Medical Record. Physicians Services Fee Schedule - 2014 2014 Maryland Medical Assistance FS-3 Abbreviations (cont.) S Sterilization Form Required. Certain Services require the Sterilization Consent Form (DHMH 2989) to be completed and kept in the patient s Medical Record. P Prior Authorization Required.

5 Certain Services require prior authorization. Requests for preauthorization are made in writing and must document that the Services are medically necessary. INVOICE / REPORT Rates with INVOICE / REPORT require additional documentation in order to be priced. Documentation may include (but is not limited to) medical notes, surgery notes, or invoices from manufacturer or wholesaler. N/A Rates with N/A are not considered an appropriate service for the designated Place of Service. Electronic Formats The fee Schedule is available in both PDF and Excel (.xls) versions for your convenience. The reimbursement rates between these two versions should be identical; if there are discrepancies, please use the PDF version as the official rate. To conveniently locate a specific code, please use the Find search functions on your computer (On Windows: CTRL + F. On Mac: CMD + F). Special Note Please use G0453 in place of 95941, and G0455 in place of 44705.

6 The rates for both of these replacement codes in this Fee Schedule . Physicians Services Fee Schedule - 2014 2014 Code Note NFAC FAC 26 TC Code Note NFAC FAC 26 TC Maryland Medical Assistance FS-4 00100 00102 00103 00104 00120 00124 00126 00140 00142 00144 00145 00147 00148 00160 00162 00164 00170 00172 00174 00176 00190 00192 00210 00211 00212 00214 00215 00216 00218 00220 00222 00300 00320 00322 00326 00350 00352 00400 00402 00404 00406 00410 00450 00452 00454 00470 00472 00474 00500 00520 00522 00524

7 00528 00529 00530 00532 00534 00537 00539 00540 00541 00542 00546 00548 00550 00560 00561 00562 00563 00566 00567 00580 00600 00604 00620 00622 00625 00626 00630 00632 00634 00635 00640 00670 00700 00702 00730 00740 00750 00752 00754 00756 00770 00790 00792 00794 Physicians Services Fee Schedule - 2014 2014 Code Note NFAC FAC 26 TC Code Note NFAC FAC 26 TC Maryland Medical Assistance FS-5 00796 00797 00800 00802 P 00810 00820 00830 00832 00834 00836 00840 00842 00844 00846 H 00848 00851 S 00860 00862 00864 00865 00866 00868 00870 00872 00873 00880 00882 00902 00904 00906 00908 00910 00912 00914 00916 00918 00920 00921 S 00922 00924 00926 00928 00930 00932 00934 00936 00938 00940 00942 00944 H 00948 00950 00952 01112 01120 01130 01140 01150 01160 01170 01173 01180 01190 01200 01202 01210 01212 01214 01215 01220 01230 01232 01234 01250

8 01260 01270 01272 01274 01320 01340 01360 01380 01382 01390 01392 01400 01402 01404 01420 01430 01432 01440 01442 01444 01462 01464 Physicians Services Fee Schedule - 2014 2014 Code Note NFAC FAC 26 TC Code Note NFAC FAC 26 TC Maryland Medical Assistance FS-6 01470 01472 01474 01480 01482 01484 01486 01490 01500 01502 01520 01522 01610 01620 01622 01630 01634 01636 01638 01650 01652 01654 01656 01670 01680 01682 01710 01712 01714 01716 01730 01732 01740 01742 01744 01756 01758 01760 01770 01772 01780 01782 01810 01820 01829 01830 01832 01840 01842 01844 01850 01852 01860 01916 01920 01922 01924 01925 01926 01930 01931 01932 01933 01935 01936 01951 01952 01953 01958 01960 01961 01962 H 01963 H 01965 01966 A 01967 01968 01969 H 01990 01991 01992 01996 01999 REPORT REPORT REPORT 10021 10022 10030 10040 10060 10061 10080 10081 10120 10121 10140 10160 10180

9 Physicians Services Fee Schedule - 2014 2014 Code Note NFAC FAC 26 TC Code Note NFAC FAC 26 TC Maryland Medical Assistance FS-7 11000 11001 11004 11005 11006 11008 11010 11011 11012 11042 11043 11044 11045 11046 11047 11055 11056 11057 11100 11101 11200 11201 11300 11301 11302 11303 11305 11306 11307 11308 11310 11311 11312 11313 11400 11401 11402 11403 11404 11406 11420 11421 11422 11423 11424 11426 11440 11441 11442 11443 11444 11446 11450 11451 11462 11463 11470 11471 11600 11601 11602 11603 11604 11606 11620 11621 11622 11623 11624 11626 11640 11641 11642 11643 11644 11646 11719 11720 11721 11730 11732 11740 11750 11752 11755 11760 11762 11765 11770 11771 11772 11900 11901 11920 11921 11922 Physicians Services Fee Schedule - 2014 2014 Code Note NFAC FAC 26 TC Code Note NFAC FAC 26 TC Maryland Medical Assistance FS-8 11950 11951 11952 11954 11960 11970 11971 11976

10 11980 11981 11982 11983 12001 12002 12004 12005 12006 12007 12011 12013 12014 12015 12016 12017 12018 12020 12021 12031 12032 12034 12035 12036 12037 12041 12042 12044 12045 12046 12047 12051 12052 12053 12054 12055 12056 12057 13100 13101 13102 13120 13121 13122 13131 13132 13133 13151 13152 13153 13160 14000 14001 14020 14021 14040 14041 14060 14061 14301 14302 14350 15002 15003 15004 15005 15040 15050 15100 15101 15110 15111 15115 15116 15120 15121 15130 15131 15135 15136 15150 15151 15152 15155 15156 15157 15200 15201 Physicians Services Fee Schedule - 2014 2014 Code Note NFAC FAC 26 TC Code Note NFAC FAC 26 TC Maryland Medical Assistance FS-9 15220 15221 15240 15241 15260 15261 15271 15272 15273 15274 15275 15276 15277 15278 15570 15572 15574 15576 15600 15610 15620 15630 15650 15731 15732 15734 15736 15738 15740 15750 15756