2014 REIMBURSEMENT RATE TABLE (Modifiers are to be ...

1 2014 REIMBURSEMENT . RATE TABLE . ( modifiers are to be reported with appropriate CPT codes at the discretion of the Provider or Facility). Fecal Immunochemical Test (FIT). Current Procedural REIMBURSEMENT CPT Code Description Rate Colorectal cancer G0328/ 82274 $ screening by FIT. Screening Office Visits Current Procedural REIMBURSEMENT CPT Code Description Rate New Patient;. history, exam, 99201 straightforward $ decision-making; 10. minutes New Patient;. Consultation, expanded history, 99202 exam, $ straightforward decision-making; 20. minutes Established Patient;. evaluation and management, may 99211 $ not require presence of physician; 5.

2 Minutes Established patient;. consultation, history, exam, 99212 $ straightforward decision-making; 10. minutes Consultation/Referral Visits New Patient;. Consultation, detailed history, exam, 99203 straightforward $ decision-making; 30. minutes Established Patient;. Consultation, expanded history, 99213 exam, $ straightforward decision-making; 15. minutes Colonoscopy Current Procedural Description- NF= Non-facility Facility Surgeon Fee or Ambulatory Facility Fee CPT Code non-facility fee REIMBURSEMENT Ambulatory surgery center Surgery center (FF)-Hospital (Global), FF= facility Rate (NF) surgeon's fee (FS) (ASC).

3 Fee, FS= surgeon fee Diagnostic colonoscopy, flexible, proximal to splenic flexure; with or without collection 45378 $ $ $ $ of specimens by brushing or washing, with or without colon decompression Interrupted diagnostic colonoscopy, flexible, proximal to splenic flexure; with 45378-53*(see Note) or without collection $ $ $ na of specimens by brushing or washing, with or without colon decompression Colonoscopy and 45380 biopsy, single or $ $ $ $ multiple Colonoscopy, with directed submucosal $ $ $ $ injection, any 45381 substance Colonoscopy/with 45382 $ $ $ $ control bleeding Colonoscopy/lesion, polyp(s),tumor removal not amenable 45383 to removal by hot $ $ $ $ biopsy forceps, bipolar cautery or snare Colonoscopy/lesion, polyp(s),tumor 45384 removal with hot $ $ $ $ biopsy forceps or bipolar cautery Colonoscopy/ lesion, polyp(s)

4 ,tumor 45385 removal by snare $ $ $ $ technique Surveillance colonoscopy only: for use with FITWAY. G0105 patients with $ $ $ $ previous abnormal colonoscopies with adenomas or cancer Sigmoidoscopy Current Procedural Reimbursemen Facility Fee CPT Code Description t Rate (NF) (FF) Facility Surgeon Fee (FS). Diagnostic 45330 sigmoidoscopy $ $ $ Pathology Note: -26 modifier=Professional component; TC=Technical component Surgery or surgical staging may be required to provide a histological diagnosis of cancer. All surgery for diagnostic purposes must be approved in advance by the FITWAY MAB. Current Procedural REIMBURSEMENT CPT Code Professsional-26 Technical Description Rate Surgical path, gross 88300 only $ $ $ Surgical path, gross and 88302 microscopic (review $ $ $ level II).

5 Surgical path, gross and 88304 microscopic (review $ $ $ level III). Surgical path, gross and microscopic, colon, 88305 colorectal polyp biopsy $ $ $ (review level VI). Surgical path, gross and microscopic, colon, 88307 segmental resection $ $ $ other than for tumor (review level V). Surgical path, gross and microscopic, colon, segmental 88309 resection for tumor or $ $ $ total resection (review level VI). Immunohist/cyto G0461 $ $ $ 1st stain Immunohist/cyto G0462 $ $ $ 2nd stain Anesthesia NOTE: 1-The use of Propofol will not be reimbursed. 2-If a client fails standard moderate sedation, anesthesia may be used to complete the endoscopic procedure.

6 Documentation should be provided to support the use of anesthesia on a case-by-case basis. Current Procedural REIMBURSEMENT CPT Code Nurse Doctor Description Rate Anesthesia for lower intestinal endoscopy procedures, $ per unit 810 $ $ endoscope [15 min.]. introduced distal to duodenum 810-1 is the base 810-1 $ $ $ amount ( 5 units). 810-6 Base plus one unit $ $ $ Electrocardiogram Electrocardiogram, complete, at least 12. 93000 $ leads w/interp. and report routine ECG w/ 12. leads; tracing only 93005 $ w/o interp. and report routine ECG w/ 12. leads; tracing only 93010 $ with interp. and report rhythm ECG, 1-3.

7 93040 leads; with interp. $ and report rhythm ECG, 1-3. leads; tracing only 93041 $ w/o interp. and report rhythm ECG, 1-3. 93042 leads with interp. $ and report Blood Work Current CPT Code Procedural REIMBURSEMENT Rate Description Comprehensive metabolic panel- must include albumin, total bilirubin, calcium, CO2 (bicarbonate), chloride, creatinine, 80053 glucose, alkaline $ phosphatase, potassium, total protein, sodium, transferase-Alanine amino, transferase- Aspartate amino, urea nitrogen Basic metabolic 80048 panel (calcium, $ total). Blood count, complete CBC, 85025 automated $ differential WBC.

8 Count Blood count, 85027 $ complete CBC. 85610 Prothrombin time $ PTT; plasma or 85730 $ whole blood Version:AL2014.