KY Mediciaid Physician Fee Schedule 2021

1 KY Mediciaid Physician Fee Schedule 2021 Note:2021 Codes in Red; Refer to CPT book for descriptionsR" in PA column indicates Prior Auth is requiredCodes listed as '$ " pay 45% of billed amount not to exceed provider s usual and customary charge for the serviceThe Anesthesia Base Rate is $ Each 15 minute increment=1 time use lab fee Schedule for covered codes not listed below in the 80000-89249 listed on the lab fee Schedule that begin with a P or Q are currently non-covered for physicians* See Billing Instruction manual for rate informationProc CodeProcedure DescriptionPA IndInpat Rate FacilityOutpat Rate NonFacilitTech. Unit ValueNotes00100 ANES FOR PROCEDURES ON SALIVARY GLANDS, INCLUDING BIOPSY ** FOR PROCEDURES INVOLVING PLASTIC REPAIR OF CLEFT LIP ** FOR RECONSTRUCTIVE PROCED OF EYELID ** FOR ELECTROCONVULSIVE THERAPY ** FOR PROC ON EXTERNAL, MIDDLE, AND INNER EAR ,INC BIOPSY ** FOR PROC ON EXTERNAL, MIDDLE, AND INNER EAR,OTOSCOPY ** FOR PROC ON EXTERNAL, MIDDLE, AND INNER EAR, TYMPANOTOMY ** FOR PROC ON EYE; NOT OTHERWISE SPECIFIED ** FOR PROCEDURES ON EYE; LENS SURGERY ** FOR PROCEDURES ON EYE; CORNEAL transplant ** FOR PROCEDURES ON EYE; VITREORETINAL SURGERY ** FOR PROCEDURES ON EYE.

2 IRIDECTOMY ** FOR PROCEDURES ON EYE; OPHTHALMOSCOPY ** FOR PROC ON NOSE AND ACCESS SINUSES; NOT OTHERISE SPEC. ** FOR PROC ON NOSE AND ACCESS SINUSES; RADICAL SURGERY ** Medicaid Physician Fee Schedule 2021* See Billing Instruction manual for rate informationProc CodeProcedure DescriptionPA IndInpat Rate FacilityOutpat Rate NonFacilitTech. Unit ValueNotes00164 ANES FOR PROC ON NOSE AND ACCESS SINUSES; BIOPSY SOFT TISSUE ** FOR INTRAORAL PROC, INCLUDING BIOPSY; NOT OTHERWISE SPEC ** FOR INTRAORAL PROC, INCLUDING BIOPSY; REPAIR OF CLEFT ** FOR INTRAORAL PROC, INCLUDING BIOPSY; EXCISION OF TUMOR ** FOR INTRAORAL PROC, INCLUDING BIOPSY; RADICAL SURGERY ** FOR PROC ON FACIAL BONES OR SKULL; NOT OTHERWISE SPEC ** FOR PROC ON FACIAL BONES OR SKULL; RADICAL SURGERY ** FOR INTRACRANIAL PROCEDURES; NOT OTHERWISE SPECIFIED ** , CRAN SURG, HEMOTOMA** FOR INTRACRANIAL PROCEDURES; SUBDURAL TAPS ** FOR INTRACRANIAL PROCEDURES; BURR HOLES ** FOR INTRACRANIAL PROCEDURES; CRANIOPLASTY ** FOR INTRACRANIAL PROCEDURES.

3 VASCULAR PROCEDURES ** FOR INTRACRANIAL PROCEDURES; PROC IN SITTING POSITION ** FOR INTRACRANIAL PROC; CEREBROSPINAL FLUID SHUNTING ** FOR INTRACRANIAL PROC; ELECTROCOAGULATION OF I C NERVE ** FOR ALL PROC ON THE INTEGUMENTARY SYSTEM, ** FOR ALL PROC ON ESOPHAGUS, THYROID, LARYNX, ETC ** FOR ALL PROC ON ESOPHAGUS, THYROID, AND NEEDLE BIOPSY ** FOR ALL PROC ON THE LARYNX , TRACHEA, LESS THAN 1 YR AGE ** FOR PROC ON MAJOR VESSELS OF NECK; NOT SPEC ** FOR PROC ON MAJOR VESSELS OF NECK; SIMPLE LIGATION ** of 369KY Medicaid Physician Fee Schedule 2021* See Billing Instruction manual for rate informationProc CodeProcedure DescriptionPA IndInpat Rate FacilityOutpat Rate NonFacilitTech. Unit ValueNotes00400 ANES FOR PROC ON THE INTEGUMENTARY SYSTEM ** FOR PROC ON THE INTEGUMENTARY SYSTEM, RECONSTRUCTIVE ** FOR PROC ON THE INTEGUMENTARY SYSTEM, RADICAL BREAST ** FOR PROC ON THE INTEGUMENTARY SYSTEM , AND NODE DIS.

4 ** FOR PROC ON THE INTEGUMENTARY SYSTEM, WITH CONV. ** FOR PROC ON CLAVICLE AND SCAPULA; NOT OTHERWISE SPEC ** FOR PROC ON CLAVICLE AND SCAPULA; BIOPSY OF CLAVICLE ** FOR PARTIAL RIB RESECTION; NOT OTHERWISE SPECIFIED ** FOR PARTIAL RIB RESECTION; THORACOPLASTY (ANY TYPE) ** FOR PARTIAL RIB RESECTION; RADICAL PROCEDURES ** FOR ALL PROCEDURES ON ESOPHAGUS ** FOR CLOSED CHEST PROC; (INCLUDING BRONCHOSCOPY) ** FOR CLOSED CHEST PROC; NEEDLE BIOPSY OF PLEURA ** FOR CLOSED CHEST PROCEDURES; PNEUMOCENTESIS ** FOR CLOSED CHEST PROC; MEDIASTINOSCOPY AND DIAG ** FOR CLOSED CHEST PROC; MEDIAS AND DIAG, LUNG VENT ** FOR PERMANENT TRANSVENOUS PACEMAKER INSERTION ** ACCESS TO CENTRAL VENOUS CIRCULATION ** FOR TRANSVENOUS INSERTION OR REPLACEMENT OF PACING ** FOR CARDIAC ELECTROPHYSIOLOGIC PROCEDURES ** FOR TRACHEOBRONCHIAL RECONSTRUCTION ** FOR THORACOTOMY PROC INV lungs , PLEURA, ETC ** of 369KY Medicaid Physician Fee Schedule 2021* See Billing Instruction manual for rate informationProc CodeProcedure DescriptionPA IndInpat Rate FacilityOutpat Rate NonFacilitTech.

5 Unit ValueNotes00541 ANES FOR THORACOTOMY PROC INV lungs , ETC WITH VENT ** FOR THORACOTOMY PROC, DECORTICATION ** FOR THORACOTOMY PROC, THORACOPLASTY ** FOR THORACOTOMY PROC, INTRA-THORACIC ** FOR STERNAL DEBRIDEMENT ** FOR PROC ON HEART, GREAT VESSELS; W/O OXYGENATOR ** FOR PROC ON HEART, GREAT VESSELS; WITH OXYG, UNDER AGE 1 ** FOR PROC ON HEART, GREAT VESSELS; WITH OXYG, OVER AGE 1 ** FOR PROC HEART, GREAT VESSELS;WITH HCA ** FOR DIRECT COR ARTERY BYPASS GRAFTING WITHOUT PUMP ** , CABG W/PUMP** FOR HEART transplant OR HEART/ lung transplant ** FOR PROC ON CERVICAL SPINE AND CORD; NOT O/W SPEC ** FOR PROC ON CERVICAL SPINE AND CORD;SIT POSITION ** FOR PROC ON THORACIC SPINE AND CORD; NOT OTHERWISE ** FOR PROC ON THORACIC SPINE AND CORD; NOT USING ONE LUNG VENTILATION** FOR PROC ON THORACIC SPINE AND CORD; USING ONE LUNG VENTILATION** FOR PROC IN LUMBAR REGION; NOT OTHERWISE SPECIFIED ** FOR PROC IN LUMBAR REGION; LUMBAR SYMPATHECTOMY ** FOR PROC IN LUMBAR REGION; DIAGNOSTIC OR THERAPEUTIC ** FOR MANIPULATION OF THE SPINE OR FOR CLOSED PROCEDURES ** FOR EXTENSIVE SPINE AND SPINAL CORD PROCEDURES ** of 369KY Medicaid Physician Fee Schedule 2021* See Billing Instruction manual for rate informationProc CodeProcedure DescriptionPA IndInpat Rate FacilityOutpat Rate NonFacilitTech.

6 Unit ValueNotes00700 ANES FOR PROC UPPER ANTERIOR ABDOMINAL WALL ** FOR PROC ON UPPER ANTERIOR ABD WALL; PERC LIVER BIOPSY ** FOR PROC ON UPPER POSTERIOR ABDOMINAL WALL ** UPR GI NDSC PX NOS** Effective 1/1/201800732 ANES UPR GI NDSC PX ERCP** Effective 1/1/201800750 ANES FOR HERNIA REPAIRS IN UPPER ABDOMEN; NOS ** FOR HERNIA REPAIRS IN UPPER ABD; LUMBAR AND VENTRAL ** FOR HERNIA REPAIRS IN UPPER ABDOMEN; OMPHALOCELE ** FOR HERNIA REPAIRS IN UPPER ABDOMEN; TRANSABD REPAIR ** FOR ALL PROC ON MAJOR ABD BLOOD VESSELS ** FOR INTRAPERITONEAL PROC IN UPPER ABD INC LAP ** FOR INTRAPERITONEAL PROC ; HEPATECTOMY ** FOR INTRAPERITONEAL PROC IN UPPER ABD INC WHIPPLE ** FOR INTRAPERITONEAL PROC IN UP ABD INC LIVER TRANS ** FOR INTRAPERITONEAL PROC IN UP ABD INC GASTRIC BYPASS ** FOR PROC ON LOW ANTE ABD WALL; NOS ** FOR PROC ON LOW ANTE ABD WALL; PANNICULECTOMY ** LWR INTST NDSC NOS** Effective 1/1/201800812 ANES LWR INTST SCR COLSC** Effective 1/1/201800813 ANES UPR LWR GI NDSC PX** Effective 1/1/201800820 ANES FOR PROC ON LOWER POSTERIOR ABDOMINAL WALL ** FOR HERNIA REPAIRS IN LOWER ABD; NOS ** FOR HERNIA REPAIRS IN LOWER ABD; VENTRAL AND INCISIONAL ** FOR HERNIA REPAIRS IN THE LOWER ABD;NOS ** FOR HERNIA REPAIRS IN THE LOWER ABD.

7 NOS ** of 369KY Medicaid Physician Fee Schedule 2021* See Billing Instruction manual for rate informationProc CodeProcedure DescriptionPA IndInpat Rate FacilityOutpat Rate NonFacilitTech. Unit ValueNotes00840 ANES FOR INTRAPERITONEAL PROC IN LOWER ABD INC LAP ** FOR AMINOCENTESIS ** FOR ABDOMINOPERINEAL RESECTION ** FOR RADICAL HYSTERECTOMY ** FOR PELVIC EXENTERATION ** FOR TUBAL LIGATION/TRANSECTION ** FOR EXTRAPERITONEAL PROCEDURES LOWER ABD ** FOR RENAL PROCEDURES ** FOR TOTAL CYSTECTOMY ** FOR RADICAL PROSTATECTOMY ** FOR ADRENALECTOMY ** FOR RENAL transplant ** FOR CYSTOLITHOTOMY ** FOR LITHOTRIPSY, EXTRACORPOREAL SHOCK WAVE ** FOR LITHOTRIPSY, EXTRACORPOREAL SHOCK WAVE; W/O WATER ** FOR PROC MAJOR LOWER ABD VESSELS; NOS ** FOR PROC ON MAJOR LOW ABD VESSELS; INFERIOR VENA CAVA ** FOR; ANORECTAL PROCEDURE ** FOR.

8 RADICAL PERINEAL PROCEDURE ** FOR; VULVECTOMY ** FOR; PERINEAL PROSTATECTOMY ** FOR TRANSU PROC INC URETHROCYSTOSCOPY NOS; ** FOR TRANSU PROC INC URETHROCYSTOSCOPY; TUMOR ** FOR TRANSU PROC INC URETHROCYSTOSCOPY; PROSTATE ** FOR TRANSU PROC INC URETHROCYSTOSCOPY;BLEEDING ** FOR TRANSU PROC INC URETHROCYSTOSCOPY; UR CAL ** FOR PROC ON MALE GENITALIA INC OPEN URETHRAL NOS ** of 369KY Medicaid Physician Fee Schedule 2021* See Billing Instruction manual for rate informationProc CodeProcedure DescriptionPA IndInpat Rate FacilityOutpat Rate NonFacilitTech. Unit ValueNotes00921 ANES FOR PROC ON MALE GENITALIA ; VASCETOMY ** PROC ON MALE GENITALIA; SEMINAL VESICLES ** FOR PROC ON MALE GENITALIA INC UNDECENDED TESTIS ** FOR PROC ON MALE GENITALIA ; ORCHIECTOMY, ING ** FOR PROC ON MALE GENITALIA ; ORCHIECTOMY, ABD ** FOR PROC ON MALE GENITALIA ; ORCHIPEXY ** FOR PROC ON MALE GENITALIA ; AMPUTATION OF PENIS ** FOR PROC ON MALE GENITALIA ; ** FOR PROC ON MALE GENITALIA; AMP WITH LYMPHADECTOMY ** FOR PROC ON MALE GENITALIA ; PENIAL PROTHESIS ** FOR VAG PROC INC BIOPSY OF LABIA,VAGINA,NOS ** FOR VAGINAL PROC; COLPOTOMY ETC ** FOR VAG HYSTERECTOMY ** FOR VAG PROC CERVICAL CERLAGE ** FOR VAG PROC INC; CULDOSCOPY ** FOR VAG PROC.

9 HYSTEROSCOPY ** BONE MARROW ASPIRATION AND/OR BIOPSY ** FOR PROCEDURES ON BONY PELVIS ** BODY CAST APPLICATION OR REVISION ** FOR INTERPELVIABDOMINAL (HINDQUARTER) AMPUTATION ** FOR RADICAL PROC FOR TUMOR OF PELVIS; EXCEPT HINDQUAR ** FOR CLOSED PROC INVOLVING SYMPHYSIS PUBIS OR SACR JOINT ** FOR OPEN PROC INVOLVING SYMPHYSIS PUBIS OR SACR JOINT ** FOR OPEN REPAIR OF FRACTURE DISRUPTION OF PELVIS ** FOR OBTURATOR NEURECTOMY; EXTRAPELVIC ** FOR OBTURATOR NEURECTOMY; INTRAPELVIC ** of 369KY Medicaid Physician Fee Schedule 2021* See Billing Instruction manual for rate informationProc CodeProcedure DescriptionPA IndInpat Rate FacilityOutpat Rate NonFacilitTech.

10 Unit ValueNotes01200 ANES FOR ALL CLOSED PROCEDURES INVOLVING HIP JOINT ** FOR ARTHROSCOPIC PROCEDURES HIP JOINT ** FOR OPEN PROCEDURES INVOLVING HIP JOINT; NOS ** FOR OPEN PROC INVOLVING HIP JOINT; HIP DISARTICULATION ** FOR OPEN PROC INVOLVING HIP JOINT; TOTAL HIP ARTHROPLSTY ** FOR OPEN PROC INVOLVING HIP JOINT; REVISION OF TOTAL ** FOR ALL CLOSED PROC INVOLVING UPPER 2/3 OF FEMUR ** FOR OPEN PROC INVOLVING UPPER 2/3 OF FEMUR; NOS ** FOR OPEN PROC INVOLVING UPPER 2/3 OF FEMUR; AMPUTATION ** FOR OPEN PROC INVOLVING UPPER 2/3 OF FEMUR; RADICAL ** FOR ALL PROC ON NERVES, MUSCLES, TENDONS, FASCIA ** FOR ALL PROC I