NOTICES
DEPARTMENT OF PUBLIC WELFARE
Medical Assistance Program Fee Schedule Revisions
[36 Pa.B. 7698]
[Saturday, December 16, 2006]The Department of Public Welfare (Department) announces that it will revise the fees, or a component of the fee, on the Medical Assistance (MA) Program Fee Schedule for select medical, surgical, diagnostic, laboratory, radiological procedure codes and the physician component of select emergency room procedure codes, effective January 2, 2007. In addition, the Department will remove from the MA Program Fee Schedule procedure codes for the treatment of infertility.
Fee Schedule Revisions
The Pennsylvania Medicaid State Plan (State Plan) specifies that maximum fees for services covered under the MA Program are to be determined on the basis of the following: fees may not exceed the Medicare upper limit when applicable; fees must be consistent with efficiency, economy and quality of care and fees must be sufficient to assure the availability of services to recipients.
The Department has determined that MA payment rates for 1573 medical, surgical, diagnostic, laboratory, radiological and the physician component of emergency room physician procedure codes/modifier combinations are above the Medicare-approved amount for the same procedure codes. The Department is adjusting the MA Program Fee Schedule payment rates for these 1573 procedure code/modifier combinations to equal the Medicare-approved amount. Revision of these fees is necessary to comply with the State Plan and to avoid a Federal disallowance.
In reviewing the MA payment rates for these procedure codes, the Department discovered it had transposed the professional and technical component fees for the following procedure code. The Department is correcting this error. In addition, the total fee is being increased to equal the Medicare rate. The new fees are as follows:
Procedure Code Procedure Description Fees 77295 THERAPEUTIC RADIOLOGY SIMULATION-AIDED FIELD SETTING; THREE-DIMENSIONAL $1020.00 (Total Component Fee)
$229.75 (26-Professional Comp)
$790.25 (TC--Technical Comp)The Department is also correcting the assistant surgeon rate (80 modifier) as well as decreasing the total component rate to equal the Medicare rate for the following procedure code, as it has determined that the previous assistant surgeon rate was incorrect. As set forth in 55 Pa.Code § 1150.54(a)(3) (relating to surgical services), the maximum payment to the assistant surgeon will be an amount equal to 20% of the MA maximum allowable payment made to the surgeon.
Procedure Code Procedure Description Fees 21199 OSTEOTOMY, MANDIBLE, SEGMENTAL; WITH GENIOGLOSSUS ADVANCEMENT $ 960.50 (Primary Surgeon File)
$192.10 (80--Assistant Surgeon Fee)The Department has also determined that for the following ten procedure codes, the sum of the professional and technical component rates did not equal the total component rate. The Department has adjusted the rates by decreasing the professional component fee and, in one instance, decreasing the technical component fee. The Department also reduced the total component fee to equal the Medicare rate for these ten procedure codes.
Procedure Code Procedure Description Fees 70320 RADIOLOGIC EXAMINATION, TEETH; COMPLETE, FULL MOUTH $ 35.37 (Total Component Fee)
$ 11.38 (26--Professional Comp)
No Change (TC--Technical Comp)74182 MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITH CONTRAST MATERIAL(S) $ 399.69 (Total Component Fee)
$ 87.49 (26--Professional Comp)
No Change (TC--Technical Comp)76086 MAMMARY DUCTOGRAM OR GALACTOGRAM, SINGLE DUCT, RADIOLOGICAL SUPERVISION AND INTERPRETATION $ 98.34 (Total Component Fee)
$ 18.36 (26--Professional Comp)
No Change (TC--Technical Comp)76088 MAMMARY DUCTOGRAM OR GALACTOGRAM, MULTIPLE DUCTS, RADIOLOGICAL SUPERVISION AND INTERPRETATION $ 133.85 (Total Component Fee)
$ 22.79 (26--Professional Comp)
No Change (TC--Technical Comp)76093 MAGNETIC RESONANCE IMAGING, BREAST, WITHOUT AND/OR WITH CONTRAST MATERIAL(S); UNILATERAL $ 626.11 (Total Component Fee)
$ 82.03 (26--Professional Comp)
No Change (TC--Technical Comp)76094 MAGNETIC RESONANCE IMAGING, BREAST, WITHOUT AND/OR WITH CONTRAST MATERIAL(S); BILATERAL $ 819.98 (Total Component Fee)
$ 82.03 (26--Professional Comp)
No Change (TC--Technical Comp)92544 OPTOKINETIC NYSTAGMUS TEST, BIDIRECTIONAL, FOVEAL OR PERIPHERAL STIMULATION, WITH RECORDING $ 21.57 (Total Component Fee)
$ 14.26 (26--Professional Comp)
No Change (TC--Technical Comp)92545 OSCILLATING TRACKING TEST, WITH RECORDING $ 20.09 (Total Component Fee)
$ 12.78 (26--Professional Comp)
No Change (TC--Technical Comp)92546 SINUSOIDAL VERTICAL AXIS ROTATIONAL TESTING $ 24.00 (Total Component Fee)
$ 15.74 (26--Professional Comp)
No Change (TC--Technical Comp)94450 BREATHING RESPONSE TO HYPOXIA (HYPOXIA RESPONSE CURVE) $ 45.43 (Total Component Fee)
$ 19.87 (26--Professional Comp)
$ 25.56 (TC--Technical Comp)In addition, the Department is end-dating the following procedure codes covering services related to infertility treatment. Section 443.6(f) of the Public Welfare Code (62 P. S. § 443.6(f)), prohibits the Department from paying a provider for any medical services, procedures or drugs related to infertility therapy.
Procedure Code Procedure Description 58752 TUBOUTERINE IMPLANTATION 58770 SALPINGOSTOMY (SALPINGONEOSTOMY) As set forth as follows, the Department will revise the total fee (billed with no modifier) and either the professional component fee (billed with modifier 26), the technical component fee (billed with modifier TC), or the assistant surgeon fee (billed with modifier 80), as applicable, for the following procedure codes:
Procedure Codes with Fees Exceeding 100% Medicare Code Description Assistant Surgeon Fee Revision (Billing with Modifier 80) Professional Component Fee Revision (Billing with Modifier 26) Technical Component Fee Revision (Billing with Modifier TC) Total Fee Revision (Billing with No Modifier) G0108 DIABETES OUTPATIENT SELF-MANAGEMENT TRAINING SERVICES, INDIVIDUAL, PER 30 MINUTES N/A N/A N/A $28.68 G0109 DIABETES SELF-MANAGEMENT TRAINING SERVICES, GROUP SESSION (2 OR MORE), PER 30 MINUTES N/A N/A N/A $16.71 G0202 SCREENING MAMMOGRAPHY, PRODUCING DIRECT DIGITAL IMAGE, BILATERAL, ALL VIEWS N/A $35.31 No Change $98.74 Q0035 CARDIOKYMOGRAPHY N/A $8.80 No Change $20.66 11001 DEBRIDEMENT OF EXTENSIVE ECZEMATOUS OR INFECTED SKIN; EACH ADDITIONAL 10% OF THE BODY SURFACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) N/A N/A N/A $16.35 11101 BIOPSY OF SKIN, SUBCUTANEOUS TISSUE AND/OR MUCOUS MEMBRANE (INCLUDING SIMPLE CLOSURE), UNLESS OTHERWISE LISTED (SEPARATE PROCEDURE); EACH SEPARATE/ADDITIONAL LESION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) N/A N/A N/A $22.64 11201 REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; EACH ADDITIONAL TEN LESIONS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) N/A N/A N/A $15.70 11450 EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, AXILLARY; WITH SIMPLE OR INTERMEDIATE REPAIR N/A N/A N/A $183.24 11451 EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, AXILLARY; WITH COMPLEX REPAIR N/A N/A N/A $252.67 11462 EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, INGUINAL; WITH SIMPLE OR INTERMEDIATE REPAIR N/A N/A N/A $173.95 11463 EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, INGUINAL; WITH COMPLEX REPAIR N/A N/A N/A $257.76 11470 EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, PERIANAL, PERINEAL, OR UMBILICAL; WITH SIMPLE OR INTERMEDIATE REPAIR N/A N/A N/A $212.98 11471 EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, PERIANAL, PERINEAL, OR UMBILICAL; WITH COMPLEX REPAIR N/A N/A N/A $279.15 11970 REPLACEMENT OF TISSUE EXPANDER WITH PERMANENT PROSTHESIS N/A N/A N/A $509.48 15101 SPLIT GRAFT, TRUNK, ARMS, LEGS; EACH ADDITIONAL 100 SQ CM, OR EACH ADDITIONAL ONE PERCENT OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) $22.50 N/A N/A $112.51 15121 SPLIT GRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET AND/OR MULTIPLE DIGITS; EACH ADDITIONAL 100 SQ CM, OR EACH ADDITIONAL ONE PERCENT OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION $35.08 N/A N/A $175.42 15201 FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, TRUNK; EACH ADDITIONAL 20 SQ CM (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) N/A N/A N/A $77.02 15221 FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, SCALP, ARMS AND/OR LEGS; EACH ADDITIONAL 20 SQ CM (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) $13.83 N/A N/A $69.13 15241 FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; EACH ADDITIONAL 20 SQ CM (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) N/A N/A N/A $108.62 15261 FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, NOSE, EARS, EYELIDS AND/OR LIPS; EACH ADDITIONAL 20 SQ CM (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) N/A N/A N/A $138.78 15400 XENOGRAFT, SKIN (DERMAL), FOR TEMPORARY WOUND CLOSURE; TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR LESS, OR ONE PERCENT OF BODY AREA OF INFANTS AND CHILDREN N/A N/A N/A $302.99 15572 FORMATION OF DIRECT OR TUBED PEDICLE, WITH OR WITHOUT TRANSFER; SCALP, ARMS OR LEGS $121.75 N/A N/A $608.75 15576 FORMATION OF DIRECT OR TUBED PEDICLE, WITH OR WITHOUT TRANSFER; EYELIDS, NOSE, EARS, LIPS OR INTRAORAL $118.28 N/A N/A $591.39 15600 DELAY OF FLAP OR SECTIONING OF FLAP (DIVISION AND INSET); AT TRUNK N/A N/A N/A $185.57 15610 DELAY OF FLAP OR SECTIONING OF FLAP (DIVISION AND INSET); AT SCALP, ARMS, OR LEGS N/A N/A N/A $219.65 15786 ABRASION; SINGLE LESION (EG, KERATOSIS, SCAR) N/A N/A N/A $125.41 15787 ABRASION; EACH ADDITIONAL FOUR LESIONS OR LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) N/A N/A N/A $19.20 15820 BLEPHAROPLASTY, LOWER EYELID; N/A N/A N/A $397.76 15821 BLEPHAROPLASTY, LOWER EYELID; WITH EXTENSIVE HERNIATED FAT PAD N/A N/A N/A $426.01 15822 BLEPHAROPLASTY, UPPER EYELID; N/A N/A N/A $333.39 15831 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDING LIPECTOMY); ABDOMEN (ABDOMINOPLASTY) $160.45 N/A N/A $802.25 15936 EXCISION, SACRAL PRESSURE ULCER, IN PREPARATION FOR MUSCLE OR MYOCUTANEOUS FLAP OR SKIN GRAFT CLOSURE; $160.77 N/A N/A $803.85 15937 EXCISION, SACRAL PRESSURE ULCER, IN PREPARATION FOR MUSCLE OR MYOCUTANEOUS FLAP OR SKIN GRAFT CLOSURE; WITH OSTECTOMY $187.48 N/A N/A $937.40 16035 ESCHAROTOMY; INITIAL INCISION N/A N/A N/A $209.80 17003 DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), ALL BENIGN OR PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES) OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; SECOND THROUGH 14 LESIONS, (LIST SEPARATELY IN ADDITION TO CODE FOR FIRST LESION) N/A N/A N/A $8.38 17266 DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), TRUNK, ARMS OR LEGS; LESION DIAMETER OVER 4.0 CM N/A N/A N/A $133.13 17310 CHEMOSURGERY (MOHS MICROGRAPHIC TECHNIQUE), INCLUDING REMOVAL OF ALL GROSS TUMOR, SURGICAL EXCISION OF TISSUE SPECIMENS, MAPPING, COLOR CODING OF SPECIMENS, MICROSCOPIC EXAMINATION OF SPECIMENS BY THE SURGEON, AND COMPLETE HISTOPATHOLOGIC PREPARATION INCLUDING THE FIRST ROUTINE STAIN(EG,HEMATOXYLIN AND EROSIN,TOLUIDINE BLUE); EACH ADDITIONAL SPECIMEN, AFTER THE FIRST FIVE SPECIMENS, FIXED OR FRESH TISSUE, ANY STAGE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) N/A N/A N/A $52.64 19001 PUNCTURE ASPIRATION OF CYST OF BREAST; EACH ADDITIONAL CYST (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) N/A N/A N/A $21.92 19102 BIOPSY OF BREAST; PERCUTANEOUS, NEEDLE CORE, USING IMAGING GUIDANCE N/A N/A N/A $102.63 19126 EXCISION OF BREAST LESION IDENTIFIED BY PREOPERATIVE PLACEMENT OF RADIOLOGICAL MARKER, OPEN; EACH ADDITIONAL LESION SEPARATELY IDENTIFIED BY A PREOPERATIVE RADIOLOGICAL MARKER (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) $31.37 N/A N/A $156.83 19324 MAMMAPLASTY, AUGMENTATION; WITHOUT PROSTHETIC IMPLANT N/A N/A N/A $414.48 19325 MAMMAPLASTY, AUGMENTATION; WITH PROSTHETIC IMPLANT $116.81 N/A N/A $584.04 19340 IMMEDIATE INSERTION OF BREAST PROSTHESIS FOLLOWING MASTOPEXY, MASTECTOMY OR IN RECONSTRUCTION $75.71 N/A N/A $378.54 19380 REVISION OF RECONSTRUCTED BREAST $130.78 N/A N/A $653.89 20100 EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE); NECK $114.20 N/A N/A $571.01 20150 EXCISION OF EPIPHYSEAL BAR, WITH OR WITHOUT AUTOGENOUS SOFT TISSUE GRAFT OBTAINED THROUGH SAME FASCIAL INCISION $164.21 N/A N/A $821.06 20660 APPLICATION OF CRANIAL TONGS, CALIPER OR STEREOTACTIC FRAME, INCLUDING REMOVAL (SEPARATE PROCEDURE) N/A N/A N/A $168.18 20910 CARTILAGE GRAFT; COSTOCHONDRAL N/A N/A N/A $401.44 20912 CARTILAGE GRAFT; NASAL SEPTUM N/A N/A N/A $459.95 20920 FASCIA LATA GRAFT; BY STRIPPER $73.12 N/A N/A $365.61 20924 TENDON GRAFT, FROM A DISTANCE (EG, PALMARIS, TOE EXTENSOR, PLANTARIS) $95.73 N/A N/A $478.65 20926 TISSUE GRAFTS, OTHER (EG, PARATENON, FAT, DERMIS) N/A N/A N/A $398.48 20974 ELECTRICAL STIMULATION TO AID BONE HEALING; NONINVASIVE (NONOPERATIVE) N/A N/A N/A $45.32 21120 GENIOPLASTY; AUGMENTATION (AUTOGRAFT, ALLOGRAFT, PROSTHETIC MATERIAL) $92.30 N/A N/A $461.50 21123 GENIOPLASTY; SLIDING, AUGMENTATION WITH INTERPOSITIONAL BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) $167.03 N/A N/A $835.15 21137 REDUCTION FOREHEAD; CONTOURING ONLY $135.40 N/A N/A $677.02 21138 REDUCTION FOREHEAD; CONTOURING AND APPLICATION OF PROSTHETIC MATERIAL OR BONE GRAFT (INCLUDES OBTAINING AUTOGRAFT) $168.23 N/A N/A $841.16 21209 OSTEOPLASTY, FACIAL BONES; REDUCTION $111.67 N/A N/A $558.33 21242 ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH ALLOGRAFT $187.77 N/A N/A $938.86 21270 MALAR AUGMENTATION, PROSTHETIC MATERIAL N/A N/A N/A $657.44 21275 SECONDARY REVISION OF ORBITOCRANIOFACIAL RECONSTRUCTION $148.85 N/A N/A $744.23 21280 MEDIAL CANTHOPEXY (SEPARATE PROCEDURE) $88.80 N/A N/A $444.02 21282 LATERAL CANTHOPEXY N/A N/A N/A $293.31 21295 REDUCTION OF MASSETER MUSCLE AND BONE (EG, FOR TREATMENT OF BENIGN MASSETERIC HYPERTROPHY); EXTRAORAL APPROACH $29.94 N/A N/A $149.70 21296 REDUCTION OF MASSETER MUSCLE AND BONE (EG, FOR TREATMENT OF BENIGN MASSETERIC HYPERTROPHY); INTRAORAL APPROACH $67.85 N/A N/A $339.25 21386 OPEN TREATMENT OF ORBITAL FLOOR BLOWOUT FRACTURE; PERIORBITAL APPROACH $123.75 N/A N/A $618.75 21387 OPEN TREATMENT OF ORBITAL FLOOR BLOWOUT FRACTURE; COMBINED APPROACH N/A N/A $707.18 21390 OPEN TREATMENT OF ORBITAL FLOOR BLOWOUT FRACTURE; PERIORBITAL APPROACH, WITH ALLOPLASTIC OR OTHER IMPLANT $135.59 N/A N/A $677.95 21400 CLOSED TREATMENT OF FRACTURE OF ORBIT, EXCEPT BLOWOUT; WITHOUT MANIPULATION N/A N/A N/A $121.90 21401 CLOSED TREATMENT OF FRACTURE OF ORBIT, EXCEPT BLOWOUT; WITH MANIPULATION N/A N/A N/A $254.80 21406 OPEN TREATMENT OF FRACTURE OF ORBIT, EXCEPT BLOWOUT; WITHOUT IMPLANT N/A N/A N/A $496.10 21407 OPEN TREATMENT OF FRACTURE OF ORBIT, EXCEPT BLOWOUT; WITH IMPLANT $117.96 N/A N/A $589.81 21454 OPEN TREATMENT OF MANDIBULAR FRACTURE WITH EXTERNAL FIXATION N/A N/A N/A $484.16 21480 CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; INITIAL OR SUBSEQUENT N/A N/A N/A $31.45 21557 RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM), SOFT TISSUE OF NECK OR THORAX $110.54 N/A N/A $552.71 21740 RECONSTRUCTIVE REPAIR OF PECTUS EXCAVATUM OR CARINATUM; OPEN $197.71 N/A N/A $988.57 22103 PARTIAL EXCISION OF POSTERIOR VERTEBRAL COMPONENT (EG, SPINOUS PROCESS, LAMINA OR FACET) FOR INTRINSIC BONY LESION, SINGLE VERTEBRAL SEGMENT; EACH ADDITIONAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) $28.70 N/A N/A $143.48 22116 PARTIAL EXCISION OF VERTEBRAL BODY, FOR INTRINSIC BONY LESION, WITHOUT DECOMPRESSION OF SPINAL CORD OR NERVE ROOT(S), SINGLE VERTEBRAL SEGMENT; EACH ADDITIONAL VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) $28.64 N/A N/A $143.19 22226 OSTEOTOMY OF SPINE, INCLUDING DISKECTOMY, ANTERIOR APPROACH, SINGLE VERTEBRAL SEGMENT; EACH ADDITIONAL VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) $74.78 N/A N/A $373.89 22328 OPEN TREATMENT AND/OR REDUCTION OF VERTEBRAL FRACTURE(S) AND/ OR DISLOCATION(S), POSTERIOR APPROACH, ONE FRACTURED VERTEBRAE OR DISLOCATED SEGMENT; EACH ADDITIONAL FRACTURED VERTEBRAE OR DISLOCATED SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) $56.13 N/A N/A $280.64 22585 ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL DISKECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) $68.62 N/A N/A $343.09 22614 ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE LEVEL; EACH ADDITIONAL VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) $80.14 N/A N/A $400.69 22632 ARTHRODESIS, POSTERIOR INTERBODY TECHNIQUE, INCLUDING LAMINECTOMY AND/OR DISKECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE; EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) $64.91 N/A N/A $324.53 22840 POSTERIOR NONSEGMENTAL INSTRUMENTATION (EG, HARRINGTON ROD TECHNIQUE, PEDICLE FIXATION ACROSS ONE INTERSPACE, ATLANTOAXIAL TRANSARTICULAR SCREW FIXATION, SUBLAMINAR WIRING AT C1, FACET SCREW FIXATION) $156.39 N/A N/A $781.93 22842 POSTERIOR SEGMENTAL INSTRUMENTATION (EG, PEDICLE FIXATION, DUAL RODS WITH MULTIPLE HOOKS AND SUBLAMINAR WIRES); THREE TO SIX VERTEBRAL SEGMENTS $156.51 N/A N/A $782.56 22845 ANTERIOR INSTRUMENTATION; 2 TO 3 VERTEBRAL SEGMENTS $149.55 N/A N/A $747.73 22848 PELVIC FIXATION (ATTACHMENT OF CAUDAL END OF INSTRUMENTATION TO PELVIC BONY STRUCTURES) OTHER THAN SACRUM $74.24 N/A N/A $371.18 23105 ARTHROTOMY; GLENOHUMERAL JOINT, WITH SYNOVECTOMY, WITH OR WITHOUT BIOPSY N/A N/A N/A $598.96 23106 ARTHROTOMY; STERNOCLAVICULAR JOINT, WITH SYNOVECTOMY, WITH OR WITHOUT BIOPSY N/A N/A N/A $451.26 23210 RADICAL RESECTION FOR TUMOR; SCAPULA $168.52 N/A N/A $842.62 23921 DISARTICULATION OF SHOULDER; SECONDARY CLOSURE OR SCAR REVISION N/A N/A N/A $405.50 24100 ARTHROTOMY, ELBOW; WITH SYNOVIAL BIOPSY ONLY N/A N/A N/A $367.27 24152 RADICAL RESECTION FOR TUMOR, RADIAL HEAD OR NECK $138.12 N/A N/A $690.62 24365 ARTHROPLASTY, RADIAL HEAD $121.49 N/A N/A $607.46 24366 ARTHROPLASTY, RADIAL HEAD; WITH IMPLANT $130.10 N/A N/A $650.48 24931 AMPUTATION, ARM THROUGH HUMERUS; WITH IMPLANT $147.05 N/A N/A $735.24 24935 STUMP ELONGATION, UPPER EXTREMITY N/A N/A N/A $928.82 25335 CENTRALIZATION OF WRIST ON ULNA (EG, RADIAL CLUB HAND) N/A N/A N/A $943.22 25574 OPEN TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES, WITH INTERNAL OR EXTERNAL FIXATION; OF RADIUS OR ULNA $109.81 N/A N/A $549.05 26125 FASCIECTOMY, PARTIAL PALMAR WITH RELEASE OF SINGLE DIGIT INCLUDING PROXIMAL INTERPHALANGEAL JOINT, WITH OR WITHOUT Z-PLASTY, OTHER LOCAL TISSUE REARRANGEMENT OR SKIN GRAFTING (INCLUDES OBTAINING GRAFT); EACH ADDITIONAL DIGIT (LIST SEPARATELY IN ADDITION TO PRIMARY PROCEDURE) $55.89 N/A N/A $279.46 26531 ARTHROPLASTY, METACARPOPHALANGEAL JOINT; WITH PROSTHETIC IMPLANT, EACH JOINT $115.84 N/A N/A $579.20 26536 ARTHROPLASTY, INTERPHALANGEAL JOINT; WITH PROSTHETIC IMPLANT, EACH JOINT $120.25 N/A N/A $601.25 26591 REPAIR, INTRINSIC MUSCLES OF HAND, EACH MUSCLE N/A N/A N/A $467.70 26861 ARTHRODESIS, INTERPHALANGEAL JOINT, WITH OR WITHOUT INTERNAL FIXATION; EACH ADDITIONAL INTERPHALANGEAL JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) N/A N/A N/A $105.98 26863 ARTHRODESIS, INTERPHALANGEAL JOINT, WITH OR WITHOUT INTERNAL FIXATION; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT), EACH ADDITIONAL JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) N/A N/A N/A $237.00 27036 CAPSULECTOMY OR CAPSULOTOMY, HIP, WITH OR WITHOUT EXCISION OF HETEROTOPIC BONE, WITH RELEASE OF HIP FLEXOR MUSCLES (IE, GLUTEUS MEDIUS, GLUTEUS MINIMUS, TENSOR FASCIA LATAE, RECTUS FEMORIS, SARTORIUS, ILIOPSOAS) N/A N/A N/A $899.26 27052 ARTHROTOMY, WITH BIOPSY; HIP JOINT N/A N/A N/A $470.39 27054 ARTHROTOMY WITH SYNOVECTOMY, HIP JOINT N/A N/A N/A $619.76 27071 PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION) (EG, OSTEOMYELITIS OR BONE ABSCESS); DEEP (SUBFASCIAL OR INTRAMUSCULAR) $167.83 N/A N/A $839.16 27096 INJECTION PROCEDURE FOR SACROILIAC JOINT, ARTHROGRAPHY AND/ OR ANESTHETIC/STEROID N/A N/A N/A $66.78 27178 OPEN TREATMENT OF SLIPPED FEMORAL EPIPHYSIS; CLOSED MANIPULATION WITH SINGLE OR MULTIPLE PINNING $161.14 N/A N/A $805.68 27334 ARTHROTOMY, WITH SYNOVECTOMY, KNEE; ANTERIOR OR POSTERIOR N/A N/A N/A $629.44 27335 ARTHROTOMY, WITH SYNOVECTOMY, KNEE; ANTERIOR AND POSTERIOR INCLUDING POPLITEAL AREA N/A N/A N/A $713.42 27358 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF FEMUR; WITH INTERNAL FIXATION (LIST IN ADDITION TO CODE FOR PRIMARY PROCEDURE) $58.16 N/A N/A $290.79 27396 TRANSPLANT, HAMSTRING TENDON TO PATELLA; SINGLE TENDON $115.68 N/A N/A $578.39 27425 LATERAL RETINACULAR RELEASE OPEN $82.86 N/A N/A $414.31 27427 LIGAMENTOUS RECONSTRUCTION (AUGMENTATION), KNEE; EXTRA-ARTICULAR $134.29 N/A N/A $671.45 27438 ARTHROPLASTY, PATELLA; WITH PROSTHESIS $155.40 N/A N/A $777.01 27692 TRANSFER OR TRANSPLANT OF SINGLE TENDON (WITH MUSCLE REDIRECTION OR REROUTING); EACH ADDITIONAL TENDON (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) $22.49 N/A N/A $112.43 27700 ARTHROPLASTY, ANKLE; $117.25 N/A N/A $586.24 27742 ARREST, EPIPHYSEAL (EPIPHYSIODESIS), ANY METHOD, COMBINED, PROXIMAL AND DISTAL TIBIA AND FIBULA; AND DISTAL FEMUR $127.00 N/A N/A $635.01 27871 ARTHRODESIS, TIBIOFIBULAR JOINT, PROXIMAL OR DISTAL $131.10 N/A N/A $655.50 28160 HEMIPHALANGECTOMY OR INTERPHALANGEAL JOINT EXCISION, TOE, PROXIMAL END OF PHALANX, EACH N/A N/A N/A $270.50 28456 PERCUTANEOUS SKELETAL FIXATION OF TARSAL BONE FRACTURE (EXCEPT TALUS AND CALCANEUS), WITH MANIPULATION, EACH N/A N/A N/A $257.21 28530 CLOSED TREATMENT OF SESAMOID FRACTURE N/A N/A N/A $93.67 28725 ARTHRODESIS; SUBTALAR $155.68 N/A N/A $778.40 29131 APPLICATION OF FINGER SPLINT; DYNAMIC N/A N/A N/A $29.96 29325 APPLICATION OF HIP SPICA CAST; ONE AND ONE-HALF SPICA OR BOTH LEGS N/A N/A N/A $167.14 29820 ARTHROSCOPY, SHOULDER, SURGICAL; SYNOVECTOMY, PARTIAL $103.63 N/A N/A $518.13 29834 ARTHROSCOPY, ELBOW, SURGICAL; WITH REMOVAL OF LOOSE BODY OR FOREIGN BODY $94.12 N/A N/A $470.58 29835 ARTHROSCOPY, ELBOW, SURGICAL; SYNOVECTOMY, PARTIAL $96.28 N/A N/A $481.40 29837 ARTHROSCOPY, ELBOW, SURGICAL; DEBRIDEMENT, LIMITED $101.31 N/A N/A $506.55 29843 ARTHROSCOPY, WRIST, SURGICAL; FOR INFECTION, LAVAGE AND DRAINAGE $89.66 N/A N/A $448.28 29850 ARTHROSCOPICALLY AIDED TREATMENT OF INTERCONDYLAR SPINE(S) AND/OR TUBEROSITY FRACTURE(S) OF THE KNEE, WITH OR WITHOUT MANIPULATION; WITHOUT INTERNAL OR EXTERNAL FIXATION (INCLUDES ARTHROSCOPY) $104.16 N/A N/A $520.81 29871 ARTHROSCOPY, KNEE, SURGICAL; FOR INFECTION, LAVAGE AND DRAINAGE N/A N/A N/A $484.01 29874 ARTHROSCOPY, KNEE, SURGICAL; FOR REMOVAL OF LOOSE BODY OR FOREIGN BODY (EG, OSTEOCHONDRITIS DISSECANS FRAGMENTATION, CHONDRAL FRAGMENTATION) $101.78 N/A N/A $508.88
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