MEDICAL FEE SCHEDULE MAINE WORKERS' COMPENSATION …

AUGUSTA, MAINE 04333-0027
CHAPTER 5 MEDICAL FEES; REIMBURSEMENT LEVELS; REPORTING REQUIREMENTS
This chapter outlines billing procedures and reimbursement levels for health care providers who treat injured employees. It also describes the dispute resolution process when there is a dispute regarding reimbursement and/or appropriateness of care. Finally, this chapter sets standards for health care reporting.
SECTION 1. GENERAL PROVISIONS
1.01 APPLICATION
1. This chapter is promulgated pursuant to 39-A M.R.S.A. §§ 208 and 209-A. It applies to all medical, surgical and hospital services, nursing, medicines, and mechanical, surgical aids provided for treatment of a claimed work-related injury or disease on or after the effective date of this chapter, regardless of the employee's date of injury or illness. Treatment does not include expenses related to nurse case management services or to examinations performed pursuant to 39-A M.R.S.A. §§ 207 and 312.
1.02 PAYMENT CALCULATION
1. Pursuant to Title 39-A M.R.S.A. §209-A, the medical fee schedule must be consistent with the most current medical coding and billing systems, including the federal Centers for Medicare and Medicaid Services resource-based relative value scale, severity-diagnosis related group system, ambulatory payment classification system and healthcare common procedure coding system; the International Statistical Classification of Diseases and Related Health Problems report issued by the World Health Organization and the current procedural terminology codes used by the American Medical Association.
2. Payment is based on the fees in effect on the date of service.
1.03 DEFINITIONS
1. Acute Care Hospital: A health care facility with a General Acute Care Hospital Primary Taxonomy in the NPI Registry at https://nppes.cms.hhs.gov/NPPES.
2. Ambulatory Payment Classification System (APC): Medicare’s grouping methodology for determining payment for outpatient services. Medicare assigns procedure codes to APC groups which are then given relative weights.
3. Ambulatory Surgical Center (ASC): A health care facility with an Ambulatory Surgical Clinic/Center Primary Taxonomy in the NPI Registry at https://nppes.cms.hhs.gov/NPPES.
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4. Bill: A request by a health care provider that is submitted to an employer/insurer for payment of medical, surgical and hospital services, nursing, medicines, and mechanical, surgical aids provided for treatment of a work-related injury or disease.
5. Board: The Maine Workers' Compensation Board pursuant to 39-A M.R.S.A. §151.
6. Critical Access Hospital: A health care facility with a Critical Access Hospital Primary Taxonomy in the NPI Registry at https://nppes.cms.hhs.gov/NPPES.
7. Follow-up Days (FUD): The number of days of care following a surgical procedure that are included in the procedure’s maximum allowable payment but does not include care for complications, exacerbations, recurrence, or other diseases or injuries.
8. Health Care Provider: An individual, group of individuals, or facility licensed, registered, or certified and practicing within the scope of the health care provider’s license, registration or certification. This paragraph shall not be construed as enlarging the scope and/or limitations of practice of any health care provider.
9. Health Care Records: includes office notes, surgical/operative notes, progress notes, diagnostic test results and any other information necessary to support the services rendered.
10. Implantable: An object or device that is made to replace and act as a missing biological structure that is surgically implanted, embedded, inserted, or otherwise applied. The term also includes any related equipment necessary to operate, program, and recharge the implantable.
11. Incidental Surgery: A surgery which is performed on the same patient, on the same day, by the same health care provider but is not related to the diagnosis.
12. Inpatient Services: Services rendered to a person who is formally admitted to a hospital and whose length of stay exceeds 23 hours.
13. Maximum Allowable Payment (MAP): The sum of all fees for medical, surgical and hospital services, nursing, medicines, and mechanical, surgical aids established by the Board pursuant to this chapter.
14. Medicare Severity-Diagnosis Related Group (MS-DRG): Medicare’s grouping methodology for determining payment for inpatient services. Medicare assigns services to an MS-DRG based on patient demographics, diagnosis codes, and procedure codes which is then given a relative weight.
15. Modifier: A code adopted by the Centers for Medicare & Medicaid Services that provides the means to report or indicate that a service or procedure that has been performed has been altered by some specific circumstance but not changed in its definition or code.
16. Outpatient Services: Services provided to a patient who is not admitted for inpatient or residential care (includes observation services).
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17. Procedure Code: A code adopted by the Centers for Medicare & Medicaid Services that is divided into two principal subsystems, referred to as level I and level II of the Healthcare Common Procedure Coding System (HCPCS). Level I is comprised of Current Procedural Terminology (CPT®), a numeric coding system maintained by the American Medical Association (AMA). Level II is a standardized coding system that is used primarily to identify products, supplies, and services not included in the CPT® codes. The CPT® manual is published by and may be purchased from the AMA, PO Box 930876, Atlanta, GA 31193-0876.
18. Specialty Hospital: A health care facility with a Long Term Care Hospital, Psychiatric Hospital, or Rehabilitation Hospital Primary Taxonomy in the NPI Registry at https://nppes.cms.hhs.gov/NPPES.
19. Usual and Customary Charge: The charge on the price list for the medical, surgical and hospital services, nursing, medicines, and mechanical, surgical aids that is maintained by the health care provider.
1.04 LEGAL DISCLAIMERS
1. This chapter includes data that is proprietary to the AMA, therefore, certain restrictions apply. These restrictions are established by the AMA and are set out below:
A. The five character codes included in this chapter are obtained from the Current Procedural Terminology (CPT®), Copyright by the AMA. CPT® is developed by the AMA as a listing of descriptive terms and five character identifying codes and modifiers for reporting medical services and procedures.
B. The responsibility for the content of this chapter is with the Board and no endorsement by the AMA is intended or should be implied. The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in this chapter.
C. No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT®. Any use of CPT® outside of this chapter should refer to the most current CPT® which contains the complete and most current listing of codes and descriptive terms.
1.05 AUTHORIZATION
1. Nothing in the Act or these rules requires the authorization of medical, surgical and hospital services, nursing, medicines, and mechanical, surgical aids provided pursuant to 39-A M.R.S.A. § 206.
2. An employer/insurer is not permitted to require pre-authorization of medical, surgical and hospital services, nursing, medicines, and mechanical, surgical aids provided pursuant to 39-A M.R.S.A. § 206 as a condition of payment.
1.06 BILLING PROCEDURES
1. Bills must specify the billing entity’s tax identification number, the license number, registration number, certificate number, or National Provider Identifier of the health care provider, the employer, the date of injury/occurrence, the date of service, the work-related injury or disease treated, the appropriate procedure code(s) for the work-related injury or disease treated, and the charges for each procedure code. Bills properly submitted on standardized claim forms prescribed by the Centers for Medicare & Medicaid are sufficient to comply with this requirement. Uncoded bills may be returned for coding.
2. In the event a patient fails to keep a scheduled appointment, health care providers are not to bill for any services that would have been provided nor will there be any reimbursement for such scheduled services.
3. A bill must be accompanied by health care records to substantiate the services rendered. Fees for copies of health care records are outlined below.
1.07 REIMBURSEMENT
1. The injured employee is not liable for payment of any medical, surgical and hospital services, nursing, medicines, and mechanical, surgical aids provided pursuant to 39-A M.R.S.A. § 206. Except as provided by 39-A M.R.S.A. §206(2)(B), health care providers may charge the patient directly only for the treatment of conditions that are unrelated to the compensable injury or disease. See 39-A M.R.S.A. §206(13).
2. An employer/insurer is not liable for charges for medical, surgical and hospital services, nursing, medicines, and mechanical, surgical aids provided pursuant to 39-A M.R.S.A. § 206 in excess of the maximum allowable payment under this chapter.
3. The employer/insurer must pay the health care provider's usual and customary charge or the maximum allowable payment under this chapter, whichever is less, within 30 days of receipt of a properly coded bill unless the bill or previous bills from the same health care provider have been controverted or denied.
4. Changes to bills are not allowed. When there is a dispute whether the provision of medical, surgical and hospital services, nursing, medicines, and mechanical, surgical aids is reasonable and proper under §206 of the Act, the employer/insurer must pay the undisputed amounts, if any, and file a notice of controversy. A copy of the notice of controversy must be sent to the health care provider from whom the bill originated. A health care provider, employee or other interested party is entitled to file a petition for payment of medical and related services for determination of any dispute regarding the provision of medical services.
90-351 WORKERS' COMPENSATION BOARD
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5. When there is a dispute whether a request for medical, surgical and hospital services, nursing, medicines, and mechanical, surgical aids is reasonable and proper under §206 of the Act, the employer/insurer must file a notice of controversy. A copy of the notice of controversy must be sent to the originator of the request. A health care provider, employee, or other interested party is entitled to file a petition for payment of medical and related services for determination of any dispute regarding the request for medical, surgical and hospital services, nursing, medicines, and mechanical, surgical aids.
6. Payment of a medical bill is not an admission by the employer/insurer as to the reasonableness of subsequent medical bills.
7. Nothing in this chapter precludes payment agreements to promote the quality of care and/or the reduction of health care costs.
A. A written payment agreement directly between a health care provider and an employer/insurer supersedes the maximum allowable payment otherwise available under this chapter.
B. A written payment agreement between a health care provider and an entity other than the employer/insurer seeking to invoke its terms supersedes the maximum allowable payment otherwise available under this chapter only if the employer/insurer was a named beneficiary of the payment agreement at the time the health care provider signed the payment agreement.
C. An employee retains the right to select health care providers for the treatment of an injury or disease for which compensation is claimed regardless of any such payment agreement.
8. Payment to out-of-state health care providers who treat injured employees pursuant to 39-A M.R.S.A. § 206 are subject to this chapter.
9. Modifiers which affect reimbursement are as follows:
-22 Increased Procedural Services: pay 150% of the maximum allowable payment under this chapter. -50 Bilateral Procedure: pay 150% of the maximum allowable payment under this chapter for both procedures combined. -51 Multiple Procedures: the total reimbursement for all services is the maximum allowable payment under this chapter for the primary procedure in addition to 50% for the secondary procedure, 25% for the tertiary procedure and 10% for each lesser procedure thereafter. -52 Reduced Services: pay 50% of the maximum allowable payment under this chapter if the procedure was discontinued after 1) the employee was prepared for the procedure and 2) the employee was taken to the room where the procedure was to be performed. Pay 100% of the maximum allowable payment if the procedure was discontinued after 1) the employee received anesthesia or 2) the procedure was started (e.g. scope inserted, intubation started, incision made).
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-53 Discontinued Procedure: pay 25% of the maximum allowable payment under this chapter. -54 Surgical Care Only: pay the intra-operative percentage of the maximum allowable payment under this chapter. -55 Post-operative Management Only: pay the post-operative percentage of the maximum allowable payment under this chapter. -56 Pre-operative Management Only: pay the pre-operative percentage of the maximum allowable payment under this chapter. -59 Distinct Procedural Service: pay 100% of the maximum allowable payment under this chapter (not subject to multiple procedure discounting). -62 Two Surgeons: pay each surgeon 75% of the maximum allowable payment under this chapter. -66 Surgical Team: pay 100% of the maximum allowable payment under this chapter for the surgical procedure and 25% of the maximum allowable payment under this chapter for the surgical procedure for each additional surgeon in the same specialty as the primary surgeon. If the surgeons are of two different specialties, each surgeon must be paid 100% of the maximum allowable payment under this chapter. -73 Discontinued Out-Patient Hospital/Ambulatory Surgery Center (ASC) Procedure Prior to the Administration of Anesthesia: pay 50% of the maximum allowable payment under this chapter. -80 Assistant Surgeon: pay 25% of the maximum allowable payment under this chapter. -81 Minimum Assistant Surgeon: pay 10% of the maximum allowable payment under this chapter. -82 Assistant Surgeon (when qualified resident surgeon not available): pay 25% of the maximum allowable payment under this chapter. -AD Surgical Anesthesia: Physician medically supervised more than 2 to 4 concurrent procedures: pay 50% of the maximum allowable payment under this chapter. -QK Surgical Anesthesia: Physician medically directed 2, 3, or 4 concurrent procedures: pay 50% of the maximum allowable payment under this chapter.
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-QX Surgical Anesthesia: CRNA was medically directed by a physician (2, 3, or 4 concurrent procedures): pay 50% of the maximum allowable payment under this chapter. -QY Surgical Anesthesia: Physician medically directed a CRNA in a single case: pay 50% of the maximum allowable payment under this chapter.
1.08 FEES FOR REPORTS/COPIES
1. Health care providers may charge for completing an initial diagnostic medical report (Form M-1) or other supplemental report. The charge is to be identified by billing CPT® Code 99080.
2. The maximum fee for completing an initial M-1 form or other supplemental report is: Each 10 minutes: $30.00
3. Health care providers may charge for copies of the health care records required to accompany the bill. The charge is to be identified by billing CPT® Code S9981 (units equal total number of pages). The maximum fee for copies is $5 for the first page and 45¢ for each additional page, up to a maximum of $250.00.
4. Health care providers must at the written request of the employer/insurer or the employer/insurer’s representative furnish copies of the health care records to the employer/insurer or the employer/insurer’s representative and to the employee’s representative (if none, to the employee) within 10 business days from receipt of a properly completed Form 220. An itemized invoice must accompany the copies sent to the employer/insurer. The maximum fee for copies is $5 for the first page and 45¢ for each additional page, up to a maximum of $250.00. The copying charge must be paid by the party requesting the records. Health care providers shall not require payment prior to responding to the request. Health care providers shall not charge a fee for postage/ shipping, sales tax, or a fee for researching a request that results in no records.
5. Health care providers must at the written request of the employee or the employee’s representative furnish copies of any written information (may include billing records) pertaining to a claimed workers’ compensation injury or disease regardless of whether the claimed injury or disease is denied by the employer/insurer. Copies must be furnished within 10 business days from receipt of the written request. An itemized invoice must accompany the copies. The maximum fee for copies is $5 for the first page and 45¢ for each additional page, up to a maximum of $250.00. The copying charge must be paid by the party requesting the records. Health care providers shall not require payment prior to responding to the request. Health care providers shall not charge a fee for postage/ shipping, sales tax, or a fee for researching a request that results in no records.
1.09 FEES FOR MEDICAL TESTIMONY
1. Health care providers may charge for preparing to testify at depositions and hearings and for attendance at depositions and hearings for the purpose of giving testimony.
2. The maximum fee for preparing to testify at depositions and hearings is:
First 30 minutes: $180.00 Each additional 15 minutes: $90.00
3. The maximum fee for attendance at depositions and hearings for the purpose of giving testimony is:
First hour or any fraction thereof: $400.00 Each subsequent 15 minutes: $90.00
4. Travel time for attendance at depositions and hearings for the purpose of giving testimony is paid on a portal to portal basis when a deposition or hearing is more than ten miles from the health care provider’s home base. The maximum fee for portal-to-portal travel for the purpose of giving testimony is:
Each 60 minutes: $300.00
5. Health care providers may request advance payment of not more than $400.00 in order to schedule attendance at depositions and hearings. The advance payment will be applied against the total fees for medical testimony (preparation, travel, and attendance).
6. Health care providers will receive a maximum of $350.00 per canceled deposition when the cancellation occurs less than 24 hours prior to the scheduled start of the deposition. Health care providers will receive a maximum of $300.00 per canceled deposition when the cancellation takes place less than 48 but more than 24 hours prior to the scheduled start of the deposition. The party canceling the deposition is responsible for the fee.
1.10 EXPENSES
1. The employer/insurer must pay the employee’s travel-related expenses incurred for treatment (includes travel to the pharmacy) related to the claimed injury in accordance with Board Rules and Regulations Chapter 17.
2. The employer/insurer must pay the employee’s travel-related expenses within 30 days of receipt of a request for reimbursement.
3. The employer/insurer must reimburse the employee’s out-of-pocket costs for medicines and other non-travel-related expenses within 30 days of a request for reimbursement accompanied by receipts.
1.11 MEDICAL INFORMATION
1. Authorization from the employee for release of medical information by health care providers to the employee or the employee’s representative, employer or the employer’s representative, or insurer or insurer’s representative is not required if
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the information pertains to treatment of an injury or disease that is claimed to be compensable under this Act regardless of whether the claimed injury or disease is denied by the employer/insurer.
2. Nothing in the Act or these rules requires any personal or telephonic contact between any health care provider and a representative of the employer/insurer.
3. Health care providers must complete the M-1 form in accordance with Title 39-A M.R.S.A. §208.
4. Pursuant to Title 39-A M.R.S.A. §208, in the event that an employee changes or is referred to a different health care provider or facility, any health care provider or facility having health care records regarding the employee, including x rays, must forward all health care records relating to an injury or disease for which compensation is claimed to the next health care provider. When an employee is scheduled to be treated by a different health care provider or in a different facility, the employee must request to have the records transferred.
1.12 PERMANENT IMPAIRMENT RATINGS
1. Permanent impairment will be determined by the use of the American Medical Association’s Guides to the Evaluation of Permanent Impairment, 4th edition, copyright 1993.
2. Permanent Impairment examinations performed by the employee’s treating health care provider will have a maximum charge of $450.00.
1. Pursuant to Title 39-A §209-A, the medical fee schedule for services rendered by individual health care providers must reflect the methodology underlying the federal Centers for Medicare and Medicaid Services resource-based relative value scale.
2. Fees for anesthesia services are calculated for procedure codes by multiplying the applicable conversion factor times the sum of the base unit (relative value unit (RVU) of the procedure code plus any modifying units) and time unit. The definition of the unit components are as outlined below. The conversion factor for anesthesia services is $50.00.
3. Fees for all other professional services are calculated for procedure codes by multiplying the applicable conversion factor times the non-facility total RVU. The conversion factor for all other professional services is $60.00.
4. Fees for professional services (excluding anesthesia) are as outlined in Appendix II. In the event of a dispute regarding the fee listed in Appendix II, the listed relative weight times the base rate controls.
2.02 ANESTHESIA GUIDELINES
1. Definition of the Unit Components
A. Base Unit: RVU of the five digit anesthesia procedure code (00100-01999) listed in Appendix II plus the unit value of the physical status modifier plus the unit values for any qualifying circumstances.
Physical Status Modifiers. Physical Status modifiers are represented by the initial letter ‘P’ followed by a single digit from 1 to 6 as defined in the following list:
UNIT VALUE
P1: A normal healthy patient 0 P2: A patient with mild systemic disease 0 P3: A patient with severe systemic disease 1 P4: A patient with severe systemic disease that is a constant threat to life 2 P5: A moribund patient who is not expected to survive without the operation 3 P6: A declared brain-dead patient whose organs are being Removed for donor purposes 0
Qualifying Circumstances. More than one qualifying circumstance may be selected. Many anesthesia services are provided under particularly difficult circumstances, depending on factors such as the extraordinary condition of patient, notable operative conditions, and/or unusual risk factors. This section includes a list of important qualifying circumstances that significantly affect the
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character of the anesthesia service provided. These procedures would not be reported alone, but would be reported as additional procedure numbers qualifying as an anesthesia procedure or service.
UNIT VALUE
99100: Anesthesia for patient of extreme age, under one year and over seventy 1 99116: Anesthesia complicated by utilization of total body hypothermia 5 99135: Anesthesia complicated by utilization of controlled hypotension 5 99140: Anesthesia complicated by emergency conditions (an emergency is defined as existing when delay in treatment of the patient would lead to a significant increase in the threat to life or body part) 2
B. Time Unit: Health care providers must bill time units only. One time unit is allowed for each 15 minute time interval, or significant fraction thereof (7.5 minutes or more) of anesthesia time. If anesthesia time extends beyond three hours, one time unit for each 10 minute time interval, or significant fraction thereof (5 minutes or more) is allowed after the first three hours. Documentation of actual anesthesia time is required, such as a copy of the anesthesia record.
2. Calculation Examples
A. In a procedure with a RVU of 3 (no modifiers) requiring one hour of anesthesia time, the total units are determined as follows:
Base Unit 3.0 units Time Unit + 4.0 units Total Units = 7.0 units
B. In a procedure with a RVU of 10, modifying units of 1 and qualifying circumstances of 2, requiring four hours and thirty minutes of anesthesia time, the total units are determined as follows:
Base Unit 13.0 units Time Unit (First three hours) + 12.0 units Time Unit (Subsequent 90 minutes) + 9.0 units
Total Units = 34.0 units
C. In both cases, the maximum allowable payment is determined by multiplying the total units by the conversion factor.
Total Units X Conversion Factor = Maximum Allowable Payment
CONVERSION FACTOR = $50.00
2.03 SURGICAL GUIDELINES
1. For surgical procedures that usually mandate a variety of attendant services, the reimbursement allowances are based on a global reimbursement concept. Global reimbursement covers the performance of the basic service and the normal range of care required before and after surgery. The normal range of post-surgical care is indicated under “FUD” in Appendix II. The maximum allowable payment for a surgical procedure includes all of the following:
A. Any visit that has as its principal function the determination that the surgical procedure is needed.
B. All visits which occur after the need for surgery is determined and are related to or preparatory to the surgery.
C. Surgery.
D. Post-surgical care including removal of sutures.
2. The following four exceptions to the global reimbursement policy may warrant additional reimbursement for services provided before surgery:
A. When a pre-operative visit is the initial visit and prolonged detention or
evaluation is necessary to prepare the patient or to establish the need for a particular type of surgery.
B. When the pre-operative visit is a consultation.
C. When pre-operative services are provided that are usually not part of the preparation for a particular surgical procedure. For example, bronchoscopy prior to chest surgery.
D. When a procedure would normally be performed in the office, but circumstances mandate hospitalization.
3. Additional charges and reimbursement may be warranted for additional services rendered to treat complications, exacerbation, recurrence, or other diseases and injuries. Under such circumstances, additional reimbursement may be requested.
4. An incidental surgery will not be paid under the Workers' Compensation system.
2.04 DURABLE MEDICAL EQUIPMENT, PROSTHETICS, ORTHOTICS, AND SUPPLIES
1. The employer/insurer must pay for all durable medical equipment, prosthetics, orthotics, and supplies that are ordered and approved by the treating health care provider.
2. Fees for durable medical equipment, prosthetics, orthotics, and supplies are as outlined in Appendix II.
3.01 BILLING
Bills for inpatient services must be submitted on a CMS Uniform Billing (UB-04) form. Health care providers are not required to provide the MS-DRG. Inpatient bills without the MS-DRG do not constitute uncoded bills.
3.02 ACUTE CARE HOSPITALS
The base rate for inpatient services at acute care hospitals shall be as follows:
1. On the effective date of this chapter, the base rate shall be $9,021.06.
2. On April 1, 2016, the base rate shall be $9,119.12.
3.03 CRITICAL ACCESS HOSPITALS
The base rate for inpatient services at critical access hospitals shall be as follows:
1. On the effective date of this chapter, the base rate shall be $10,525.95.
3.04 RESERVED 3.05 PAYMENT CALCULATION
Pursuant to Title 39-A §209-A, the medical fee schedule for services rendered by health care facilities must reflect the methodology and categories set forth in the federal Centers for Medicare and Medicaid Services severity-diagnosis related group system for inpatient services. Inpatient fees are calculated by multiplying the base rate times the MS-DRG weight. In the event of a dispute regarding the fee listed in Appendix III, the listed relative weight times the base rate controls. For inpatient services that take place during two different calendar years, payment is calculated based on the discharge date.
3.06 OUTLIER PAYMENTS
The threshold for outlier payments is $75,000.00 plus the fee established in Appendix III. If the outlier threshold is met, the outlier payment is the charges above the threshold multiplied by 75%.
3.07 IMPLANTABLES
Where an implantable exceeds $10,000.00 in cost, an acute care or critical access hospital may seek additional reimbursement. Reimbursement is set at the actual amount paid plus
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$500.00. Handling and freight charges must be included in the hospital's invoiced cost and are not to be reimbursed separately. When a hospital seeks additional reimbursement pursuant to this chapter, the implantable charge is excluded from any calculation for an outlier payment.
3.08 SERVICES INCLUDED
All services provided during an uninterrupted patient encounter leading to an inpatient admittance must be included in the inpatient stay. Services do not include costs related to transportation of a patient to obtain medical care.
3.09 FACILITY TRANSFERS
The following applies to facility transfers when a patient is transferred for continuation of medical treatment between two hospitals:
1. A hospital transferring a patient is paid as follows: The MS-DRG reimbursement amount is divided by the number of days duration listed for the DRG; the resultant per diem amount is then multiplied by two for the first day of stay at the transferring hospital; the per diem amount is multiplied by one for each subsequent day of stay at the transferring hospital; and the amounts for each day of stay at the transferring hospital are totaled. If the result is greater than the MS- DRG reimbursement amount, the transferring hospital is paid the MS-DRG reimbursement amount. Associated outliers and add-ons are then added to the payment.
2. A hospital discharging a patient is paid the full MS-DRG payment plus any appropriate outliers and add-ons.
3. Facility transfers do not include costs related to transportation of a patient to obtain medical care.
3.10 OTHER INPATIENT FACILITY FEES
Inpatient services provided at specialty hospitals must be paid at 75% of the provider’s usual and customary charge.
3.11 PROFESSIONAL SERVICES
Individual health care providers who furnish professional services in an inpatient setting must be reimbursed using the fees set forth in Appendix II. The individual health care provider’s charges are excluded from any calculation of outlier payments.
4.01 BILLING
Bills for hospital outpatient and ambulatory surgical services must be submitted on a UB-04 form. Outpatient hospital facility services performed on the same day for the same patient must be reported on a single UB-04 form.
4.02 ACUTE CARE HOSPITALS
The base rate for outpatient services at acute care hospitals shall be as follows:
1. On the effective date of this chapter, the base rate shall be $120.14.
2. On April 1, 2016, the base rate shall be $131.86.
4.03 CRITICAL ACCESS HOSPITALS
The base rate for outpatient services at critical access hospitals shall be as follows:
4.04 AMBULATORY SURGICAL CENTERS
The base rate for surgical services at ambulatory surgical centers shall be:
Pursuant to Title 39-A §209-A, the medical fee schedule for services rendered by health care facilities must reflect the methodology and categories set forth in the federal Centers for Medicare and Medicaid Services ambulatory payment classification system for outpatient services. Fees for procedure codes are calculated by multiplying the base rate times the APC weight. In the event of a dispute regarding the fee listed in Appendix IV, the listed relative weight times the base rate controls.
1. For procedure codes with no CPT®/HCPCS code or for procedure codes with a status indicator of N, there is no separate payment.
2. If the ACH Fee, CAH Fee or ASC Fee listed in Appendix IV is $0.00 for a procedure code with a status indicator other than N, then payment must be
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calculated at 75% of the health care provider’s usual and customary charge.
3. When two or more procedure codes with a status indicator of T are billed on the same date of service, the highest weighted code is paid at 100% of the fee listed in Appendix IV and subsequent T status code procedures are paid at 50% of the fee listed in Appendix IV. Add-on codes are not subject to discounting.
4. When one or more procedure codes with a status indicator of N are billed without other outpatient services (i.e. non-patient referred specimens or the facility collects the specimen and furnishes only the outpatient labs on a given date of service, etc.), payment must be 75% of the provider’s usual and customary charges.
4.06 OUTLIER PAYMENTS
The threshold for outlier payments is $2,500.00 per procedure code plus the fee listed in Appendix IV. If the outlier threshold is met, the outlier payment is the charges above the threshold multiplied by 75%.
4.07 IMPLANTABLES
Where an implantable exceeds $250.00 in cost, hospitals or ambulatory surgical centers may seek additional reimbursement (regardless of the status indicator). Reimbursement is set at the actual amount paid plus 20% or the actual amount paid plus $500.00, whichever is less. Handling and freight charges must be included in the facility's invoiced cost and are not to be reimbursed separately.
4.08 SERVICES INCLUDED
4.09 TRANSFERS
The following applies to facility transfers when a patient is transferred for continuation of medical treatment between two facilities:
1. A hospital or ambulatory surgical center transferring a patient is paid the maximum allowable payment established in this section.
2. A hospital discharging a patient is paid the full MS-DRG payment plus any appropriate outliers and add-ons per Section 3.
3. Facility transfers do not include costs related to transportation of a patient to obtain medical care.
4.10 OTHER OUTPATIENT FACILITY FEES
Outpatient services provided by institutional health care providers other than hospitals and ambulatory surgical centers (e.g. clinical medical laboratories, free standing outpatient facilities, etc.) must be paid at 75% of the provider’s usual and customary charge.
4.11 PROFESSIONAL SERVICES
Individual health care providers who furnish professional services in an outpatient setting must be reimbursed using the maximum fees set forth in Appendix II. The individual health care provider’s charges are excluded from any calculation of outlier payments.
STATUTORY AUTHORITY: 39-A M.R.S. §§ 152(2) and 209 EFFECTIVE DATE: January 15, 1993 (EMERGENCY) EFFECTIVE DATE OF PERMANENT RULE: April 17, 1993 REPEALED AND REPLACED: April 4, 1994 EFFECTIVE DATE (ELECTRONIC CONVERSION): April 28, 1996 AMENDED: January 1, 1997 - agency asserts § 16 as effective retroactively to April 4, 1994. July 1, 1997 - changed address in § 9 (4), replaced Appendix III. May 1, 1999 - updated CPT® copyright year, replaced Appendices I, II, & III. NON-SUBSTANTIVE CORRECTIONS: October 25, 1999 - minor formatting; date corrections from paper filing in 4.1 - 4.4. AMENDED: July 1, 2001 July 1, 2002 - refiled June 13, 2002 to include some codes missing from the previous filing. September 24, 2002 - filing 2002-349 affecting § 7 sub-§ 2. NON-SUBSTANTIVE CORRECTIONS: January 8, 2003 - character spacing only in §§ 1-19. AMENDED: November 5, 2006 - filing 2006-458
December 11, 2011 – filing 2011 - (repeal Rule and Apps. I-III and replace with new Rule and Apps. I-V) October 1, 2015 – filing 2015-173
EMPLOYER NAME: EMPLOYER MAILING ADDRESS:
INSURER NAME: INSURER MAILING ADDRESS:
CLAIM NUMBER (IF KNOWN): THIRD PARTY ADMIN. NAME (IF APPL.): THIRD PARTY ADMIN. MAILING ADDRESS (IF APPL.):
EMPLOYEE NAME:
XXX-XX-
ICD-9 ICD-10 DIAGNOSIS:_____________________________________________________________________________________________________
IN MY OPINION, THIS DIAGNOSIS IS WORK RELATED NOT WORK RELATED NOT YET IDENTIFIED AS TO CAUSE HAVE DIAGNOSTIC TESTS BEEN PERFORMED? YES NO IF YES, LIST: ________________________________________________________ TREATMENT TO CONTINUE? YES IF YES, DATE TO BE SEEN AGAIN:__________________ NO IF NO, PATIENT AT MMI? YES NO ESTIMATED LENGTH OF TREATMENT ___________________ DAYS WEEKS MONTHS TREATMENT PLAN (CHECK ALL THAT APPLY): REST MEDICATION EXERCISE
MEDICAL REFERRALS: THERAPY (LIST):_________________ SURGERY (LIST):_______________ OTHER(LIST):_________________
OFFICE PROCEDURES: CAST STRAPPING OTHER (LIST): _________________________________________________________ _____________________________________________________________________________________________________________________________ DOES TREATMENT PLAN INCLUDE MEDICATION THAT WOULD PREVENT THE PATIENT FROM DRIVING AND/OR WORKING SAFELY? YES NO
IF YES, LIST MEDICATIONS: _______________________________________________________________________________________________________ WORK CAPACITY: REGULAR DUTY NO WORK CAPACITY IF CHECKED, ESTIMATED DATE OF RETURN : ____________________________
MODIFIED WORK (DESCRIBE RESTRICTIONS BELOW) IF CHECKED, ESTIMATED LENGTH OF RESTRICTIONS? ____________________________ BODY PARTS: RIGHT LEFT UPPER LOWER ACTIVITY/USE OF: NEVER MINIMAL MODERATE NORMAL
HEAD LIFT/CARRY > LBS NECK THORAX WALKING BACK FLANK STANDING SPINE STAIR CLIMBING ABDOMEN SITTING SHOULDER STOOP/BEND HUMERUS KNEEL/CRAWL FOREARM WRIST PUSH/PULL HAND FINGERS VIBRATORY TOOLS PELVIS HIP REPETITIVE ACTIVITIES FEMUR KNEE KEYBOARD USE LEG ANKLE FOOT TOES OTHER_____________
PERMANENT IMPAIRMENT EXPECTED? YES NO IF YES, PERMANENT IMPAIRMENT RATING ______ % OR NOT YET AVAILABLE __________________________________________________________________ __________________________________________________________________________ SIGNATURE OF HEALTH CARE PROVIDER PRINT NAME
ADDRESS _______________________________________ TELEPHONE #___________________________________________
DUTIES OF HEALTH CARE PROVIDERS
Pursuant to 39-A M.R.S.A. §208(2), duties of health care providers are as follows:
• Except for claims for medical benefits only, within 5 business days from the completion of a medical examination or within 5 business days from the date notice of injury is given to the employer, whichever is later, the health care provider treating the employee shall forward to the employer and the employee a diagnostic medical report, on forms prescribed by the board, for the injury for which compensation is being claimed. The report must include the employee's work capacity, likely duration of incapacity, return to work suitability and treatment required. The board may assess penalties up to $500 per violation on health care providers who fail to comply with the 5-day requirement of this subsection.
• If ongoing medical treatment is being provided, every 30 days the employee's health care provider shall forward to the employer and the employee a diagnostic medical report on forms prescribed by the board. An employer may request, at any time, medical information concerning the condition of the employee for which compensation is sought. The health care provider shall respond within 10 business days from receipt of the request.
• A health care provider shall submit to the employer and the employee a final report of treatment within 5 working days of the termination of treatment, except that only an initial report must be submitted if the provider treated the employee on a single occasion.
• Upon the request of the employee and in the event that an employee changes or is referred to a different health care provider or facility, any health care provider or facility having medical records regarding the employee, including x rays, shall forward all medical records relating to an injury or disease for which compensation is claimed to the next health care provider. When an employee is scheduled to be treated by a different health care provider or in a different facility, the employee shall request to have the records transferred.
• A health care provider may not charge the insurer or self-insurer an amount in excess of the fees prescribed in section 209-A for the submission of reports prescribed by this section and for the submission of any additional records.
• An insurer or self-insurer may withhold payment of fees for the submission of any required reports of treatment to any provider who fails to submit the reports on the forms prescribed by the board and within the time limits provided. The insurer or self-insurer is not required to file a notice of controversy under these circumstances, but must notify the provider that payment is being withheld due to the failure to use prescribed forms or to submit the reports in a timely fashion. In the case of dispute, any interested party may petition the board to resolve the dispute.
Other reminders:
• Except for the header information, the remainder of the M-1 form must be completed by the health care provider. This information is vital to the administration of the claim and the employee’s return to work.
• The M-1 form is not submitted to the board.
• Pursuant to Board Rules Chapter 5, a health care provider may charge a fee for completing the initial M-1.
• The attachment of narratives is optional; however, an employer/insurer may request, at any time (for a fee), medical information concerning the condition of the employee for which compensation is sought. The health care provider shall respond within 10 business days from receipt of the request. Pursuant to 39-A M.R.S.A. §208(1) a medical release is not necessary if the information pertains to an injury claimed to be compensable under the Act (whether or not the claim is controverted/denied).
CHAPTER 5
APPENDIX II
Appendix II
CPT Codes, Copyright 2015, American Medical Association 1
Code Base Unit 00100 5 00102 6 00103 5 00104 4 00120 5 00124 4 00126 4 00140 5 00142 4 00144 6 00145 6 00147 4 00148 4 00160 5 00162 7 00164 4 00170 5 00172 6 00174 6 00176 7 00190 5 00192 7 00210 11 00211 10 00212 5 00214 9 00215 9 00216 15 00218 13 00220 10 00222 6 00300 5 00320 6 00322 3 00326 7 00350 10 00352 5 00400 3 00402 5 00404 5 00406 13 00410 4 00450 5 00452 6 00454 3 00470 6 00472 10 00474 13 00500 15 00520 6 00522 4 00524 4 00528 8 00529 11
Professional Services - Anesthesia Maine Workers' Compensation Board Medical Fee Schedule
Appendix II
Code Base Unit 00530 4 00532 4 00534 7 00537 7 00539 18 00540 12 00542 15 00541 15 00546 15 00548 17 00550 10 00560 15 00561 25 00562 20 00563 25 00566 25 00567 18 00580 20 00600 10 00604 13 00620 10 00622 13 00625 13 00626 15 00630 8 00632 7 00634 10 00635 4 00640 3 00670 13 00700 4 00702 4 00730 5 00740 5 00750 4 00752 6 00754 7 00756 7 00770 15 00790 7 00792 13 00794 8 00796 30 00797 11 00800 4 00802 5 00810 5 00820 5 00830 4 00832 6 00834 5 00836 6 00840 6 00842 4
Appendix II
Code Base Unit 00844 7 00846 8 00848 8 00851 6 00860 6 00862 7 00864 8 00865 7 00866 10 00868 10 00870 5 00872 7 00873 5 00880 15 00882 10 00902 5 00904 7 00906 4 00908 6 00910 3 00912 5 00914 5 00916 5 00918 5 00920 3 00921 3 00922 6 00924 4 00926 4 00928 6 00930 4 00932 4 00934 6 00936 8 00938 4 00940 3 00942 4 00944 6 00948 4 00950 5 00952 4 01112 5 01120 6 01130 3 01140 15 01150 10 01160 4 01170 8 01173 12 01180 3 01190 4 01200 4 01202 4 01210 6
Appendix II
Code Base Unit 01212 10 01214 8 01215 10 01220 4 01230 6 01232 5 01234 8 01250 4 01260 3 01270 8 01272 4 01274 6 01320 4 01340 4 01360 5 01380 3 01382 3 01390 3 01392 4 01400 4 01402 7 01404 5 01420 3 01430 3 01432 6 01440 8 01442 8 01444 8 01462 3 01464 3 01470 3 01472 5 01474 5 01480 3 01482 4 01484 4 01486 7 01490 3 01500 8 01502 6 01520 3 01522 5 01610 5 01620 4 01622 4 01630 5 01634 9 01636 15 01638 10 01650 6 01652 10 01654 8 01656 10 01670 4
Appendix II
Code Base Unit 01680 3 01682 4 01710 3 01712 5 01714 5 01716 5 01730 3 01732 3 01740 4 01742 5 01744 5 01756 6 01758 5 01760 7 01770 6 01772 6 01780 3 01782 4 01810 3 01820 3 01829 3 01830 3 01832 6 01840 6 01842 6 01844 6 01850 3 01852 4 01860 3 01916 5 01920 7 01922 7 01924 5 01925 7 01926 8 01930 5 01931 7 01932 6 01933 7 01935 5 01936 5 01951 3 01952 5 01953 1 01958 5 01960 5 01961 7 01962 8 01963 8 01965 4 01966 4 01967 5 01968 2 01969 5
Appendix II
Code Base Unit 01990 7 01991 3 01992 5 01996 3 01999 0
Professional Services - Other Maine Workers' Compensation Board Medical Fee Schedule
Appendix II
Code Mod Non-Facility Total RVU
Global Days
Pre- Operative
Intra- operative
Post- operative Fee
10021 3.50 XXX 0.00 0.00 0.00 $210.00 10022 3.99 XXX 0.00 0.00 0.00 $239.40 10030 22.15 XXX 0.00 0.00 0.00 $1,329.00 10035 15.18 000 0.00 0.00 0.00 $910.80 10036 13.19 ZZZ 0.00 0.00 0.00 $791.40 10040 2.89 010 0.10 0.80 0.10 $173.40 10060 3.32 010 0.10 0.80 0.10 $199.20 10061 5.85 010 0.10 0.80 0.10 $351.00 10080 5.07 010 0.10 0.80 0.10 $304.20 10081 7.60 010 0.10 0.80 0.10 $456.00 10120 4.30 010 0.10 0.80 0.10 $258.00 10121 7.81 010 0.10 0.80 0.10 $468.60 10140 4.61 010 0.10 0.80 0.10 $276.60 10160 3.71 010 0.10 0.80 0.10 $222.60 10180 7.02 010 0.10 0.80 0.10 $421.20 11000 1.55 000 0.00 0.00 0.00 $93.00 11001 0.61 ZZZ 0.00 0.00 0.00 $36.60 11004 16.79 000 0.00 0.00 0.00 $1,007.40 11005 22.74 000 0.00 0.00 0.00 $1,364.40 11006 20.37 000 0.00 0.00 0.00 $1,222.20 11008 8.00 ZZZ 0.00 0.00 0.00 $480.00 11010 14.02 010 0.10 0.80 0.10 $841.20 11011 15.24 000 0.00 0.00 0.00 $914.40 11012 20.46 000 0.00 0.00 0.00 $1,227.60 11042 3.31 000 0.00 0.00 0.00 $198.60 11043 6.49 000 0.00 0.00 0.00 $389.40 11044 8.98 000 0.00 0.00 0.00 $538.80 11045 1.16 ZZZ 0.00 0.00 0.00 $69.60 11046 2.09 ZZZ 0.00 0.00 0.00 $125.40 11047 3.55 ZZZ 0.00 0.00 0.00 $213.00 11055 1.35 000 0.00 0.00 0.00 $81.00 11056 1.65 000 0.00 0.00 0.00 $99.00 11057 1.86 000 0.00 0.00 0.00 $111.60 11100 2.93 000 0.00 0.00 0.00 $175.80 11101 0.93 ZZZ 0.00 0.00 0.00 $55.80 11200 2.49 010 0.10 0.80 0.10 $149.40 11201 0.54 ZZZ 0.00 0.00 0.00 $32.40 11300 2.75 000 0.00 0.00 0.00 $165.00 11301 3.38 000 0.00 0.00 0.00 $202.80 11302 3.99 000 0.00 0.00 0.00 $239.40 11303 4.41 000 0.00 0.00 0.00 $264.60 11305 2.81 000 0.00 0.00 0.00 $168.60 11306 3.45 000 0.00 0.00 0.00 $207.00 11307 4.06 000 0.00 0.00 0.00 $243.60 11308 4.27 000 0.00 0.00 0.00 $256.20 11310 3.22 000 0.00 0.00 0.00 $193.20 11311 3.17 000 0.00 0.00 0.00 $190.20 11312 4.54 000 0.00 0.00 0.00 $272.40 11313 5.27 000 0.00 0.00 0.00 $316.20 11400 3.50 010 0.10 0.80 0.10 $210.00 11401 4.21 010 0.10 0.80 0.10 $252.60 11402 4.69 010 0.10 0.80 0.10 $281.40 11403 5.42 010 0.10 0.80 0.10 $325.20
Appendix II
Global Days
Pre- Operative
Intra- operative
Post- operative Fee
11404 6.17 010 0.10 0.80 0.10 $370.20 11406 8.92 010 0.10 0.80 0.10 $535.20 11420 3.46 010 0.10 0.80 0.10 $207.60 11421 4.43 010 0.10 0.80 0.10 $265.80 11422 4.96 010 0.10 0.80 0.10 $297.60 11423 5.72 010 0.10 0.80 0.10 $343.20 11424 6.62 010 0.10 0.80 0.10 $397.20 11426 9.51 010 0.10 0.80 0.10 $570.60 11440 3.81 010 0.10 0.80 0.10 $228.60 11441 4.75 010 0.10 0.80 0.10 $285.00 11442 5.34 010 0.10 0.80 0.10 $320.40 11443 6.37 010 0.10 0.80 0.10 $382.20 11444 8.00 010 0.10 0.80 0.10 $480.00 11446 11.14 010 0.10 0.80 0.10 $668.40 11450 10.84 090 0.10 0.71 0.19 $650.40 11451 13.87 090 0.10 0.71 0.19 $832.20 11462 10.59 090 0.10 0.71 0.19 $635.40 11463 14.04 090 0.10 0.71 0.19 $842.40 11470 11.78 090 0.10 0.71 0.19 $706.80 11471 14.59 090 0.10 0.71 0.19 $875.40 11600 5.43 010 0.10 0.80 0.10 $325.80 11601 6.46 010 0.10 0.80 0.10 $387.60 11602 7.02 010 0.10 0.80 0.10 $421.20 11603 8.04 010 0.10 0.80 0.10 $482.40 11604 8.95 010 0.10 0.80 0.10 $537.00 11606 12.85 010 0.10 0.80 0.10 $771.00 11620 5.49 010 0.10 0.80 0.10 $329.40 11621 6.51 010 0.10 0.80 0.10 $390.60 11622 7.27 010 0.10 0.80 0.10 $436.20 11623 8.55 010 0.10 0.80 0.10 $513.00 11624 9.64 010 0.10 0.80 0.10 $578.40 11626 11.66 010 0.10 0.80 0.10 $699.60 11640 5.67 010 0.10 0.80 0.10 $340.20 11641 6.74 010 0.10 0.80 0.10 $404.40 11642 7.71 010 0.10 0.80 0.10 $462.60 11643 9.10 010 0.10 0.80 0.10 $546.00 11644 11.25 010 0.10 0.80 0.10 $675.00 11646 14.74 010 0.10 0.80 0.10 $884.40 11719 0.40 000 0.00 0.00 0.00 $24.00 11720 0.91 000 0.00 0.00 0.00 $54.60 11721 1.27 000 0.00 0.00 0.00 $76.20 11730 2.81 000 0.00 0.00 0.00 $168.60 11732 1.01 ZZZ 0.00 0.00 0.00 $60.60 11740 1.41 000 0.00 0.00 0.00 $84.60 11750 5.10 010 0.10 0.80 0.10 $306.00 11752 9.20 010 0.10 0.80 0.10 $552.00 11755 3.78 000 0.00 0.00 0.00 $226.80 11760 5.54 010 0.10 0.80 0.10 $332.40 11762 7.99 010 0.10 0.80 0.10 $479.40 11765 4.74 010 0.10 0.80 0.10 $284.40 11770 7.89 010 0.10 0.80 0.10 $473.40 11771 16.34 090 0.10 0.71 0.19 $980.40 11772 19.81 090 0.10 0.71 0.19 $1,188.60
Appendix II
Global Days
Pre- Operative
Intra- operative
Post- operative Fee
11900 1.57 000 0.00 0.00 0.00 $94.20 11901 1.98 000 0.00 0.00 0.00 $118.80 11920 4.87 000 0.00 0.00 0.00 $292.20 11921 5.68 000 0.00 0.00 0.00 $340.80 11922 1.76 ZZZ 0.00 0.00 0.00 $105.60 11950 2.09 000 0.00 0.00 0.00 $125.40 11951 2.77 000 0.00 0.00 0.00 $166.20 11952 3.72 000 0.00 0.00 0.00 $223.20 11954 4.52 000 0.00 0.00 0.00 $271.20 11960 27.27 090 0.10 0.71 0.19 $1,636.20 11970 17.66 090 0.10 0.71 0.19 $1,059.60 11971 13.49 090 0.10 0.71 0.19 $809.40 11976 4.05 000 0.00 0.00 0.00 $243.00 11980 2.66 000 0.00 0.00 0.00 $159.60 11981 4.00 XXX 0.00 0.00 0.00 $240.00 11982 4.54 XXX 0.00 0.00 0.00 $272.40 11983 6.31 XXX 0.00 0.00 0.00 $378.60 12001 2.52 000 0.00 0.00 0.00 $151.20 12002 3.07 000 0.00 0.00 0.00 $184.20 12004 3.62 000 0.00 0.00 0.00 $217.20 12005 4.57 000 0.00 0.00 0.00 $274.20 12006 5.42 000 0.00 0.00 0.00 $325.20 12007 6.34 000 0.00 0.00 0.00 $380.40 12011 3.09 000 0.00 0.00 0.00 $185.40 12013 3.23 000 0.00 0.00 0.00 $193.80 12014 3.78 000 0.00 0.00 0.00 $226.80 12015 4.58 000 0.00 0.00 0.00 $274.80 12016 5.81 000 0.00 0.00 0.00 $348.60 12017 4.41 000 0.00 0.00 0.00 $264.60 12018 5.00 000 0.00 0.00 0.00 $300.00 12020 8.25 010 0.10 0.80 0.10 $495.00 12021 4.75 010 0.10 0.80 0.10 $285.00 12031 6.72 010 0.10 0.80 0.10 $403.20 12032 8.60 010 0.10 0.80 0.10 $516.00 12034 8.85 010 0.10 0.80 0.10 $531.00 12035 10.88 010 0.10 0.80 0.10 $652.80 12036 12.02 010 0.10 0.80 0.10 $721.20 12037 13.64 010 0.10 0.80 0.10 $818.40 12041 6.72 010 0.10 0.80 0.10 $403.20 12042 8.20 010 0.10 0.80 0.10 $492.00 12044 10.20 010 0.10 0.80 0.10 $612.00 12045 11.45 010 0.10 0.80 0.10 $687.00 12046 13.60 010 0.10 0.80 0.10 $816.00 12047 14.79 010 0.10 0.80 0.10 $887.40 12051 7.34 010 0.10 0.80 0.10 $440.40 12052 8.36 010 0.10 0.80 0.10 $501.60 12053 9.81 010 0.10 0.80 0.10 $588.60 12054 10.25 010 0.10 0.80 0.10 $615.00 12055 13.32 010 0.10 0.80 0.10 $799.20 12056 15.69 010 0.10 0.80 0.10 $941.40 12057 16.09 010 0.10 0.80 0.10 $965.40 13100 9.51 010 0.10 0.80 0.10 $570.60 13101 11.25 010 0.10 0.80 0.10 $675.00
Appendix II
Global Days
Pre- Operative
Intra- operative
Post- operative Fee
13102 3.48 ZZZ 0.00 0.00 0.00 $208.80 13120 9.96 010 0.10 0.80 0.10 $597.60 13121 12.14 010 0.10 0.80 0.10 $728.40 13122 3.80 ZZZ 0.00 0.00 0.00 $228.00 13131 10.96 010 0.10 0.80 0.10 $657.60 13132 13.55 010 0.10 0.80 0.10 $813.00 13133 5.09 ZZZ 0.00 0.00 0.00 $305.40 13151 12.02 010 0.10 0.80 0.10 $721.20 13152 14.44 010 0.10 0.80 0.10 $866.40 13153 5.54 ZZZ 0.00 0.00 0.00 $332.40 13160 23.27 090 0.10 0.71 0.19 $1,396.20 14000 17.80 090 0.10 0.71 0.19 $1,068.00 14001 22.88 090 0.10 0.71 0.19 $1,372.80 14020 19.91 090 0.10 0.71 0.19 $1,194.60 14021 24.90 090 0.10 0.71 0.19 $1,494.00 14040 21.78 090 0.10 0.71 0.19 $1,306.80 14041 26.95 090 0.10 0.71 0.19 $1,617.00 14060 22.21 090 0.10 0.71 0.19 $1,332.60 14061 28.99 090 0.10 0.71 0.19 $1,739.40 14301 30.88 090 0.10 0.71 0.19 $1,852.80 14302 6.42 ZZZ 0.00 0.00 0.00 $385.20 14350 20.01 090 0.10 0.71 0.19 $1,200.60 15002 9.96 000 0.00 0.00 0.00 $597.60 15003 2.17 ZZZ 0.00 0.00 0.00 $130.20 15004 11.48 000 0.00 0.00 0.00 $688.80 15005 3.58 ZZZ 0.00 0.00 0.00 $214.80 15040 7.31 000 0.00 0.00 0.00 $438.60 15050 16.04 090 0.10 0.71 0.19 $962.40 15100 24.64 090 0.10 0.71 0.19 $1,478.40 15101 5.33 ZZZ 0.00 0.00 0.00 $319.80 15110 22.92 090 0.10 0.71 0.19 $1,375.20 15111 3.33 ZZZ 0.00 0.00 0.00 $199.80 15115 23.58 090 0.10 0.71 0.19 $1,414.80 15116 4.40 ZZZ 0.00 0.00 0.00 $264.00 15120 24.44 090 0.10 0.71 0.19 $1,466.40 15121 5.97 ZZZ 0.00 0.00 0.00 $358.20 15130 19.25 090 0.10 0.71 0.19 $1,155.00 15131 2.88 ZZZ 0.00 0.00 0.00 $172.80 15135 24.15 090 0.10 0.71 0.19 $1,449.00 15136 2.74 ZZZ 0.00 0.00 0.00 $164.40 15150 20.00 090 0.10 0.71 0.19 $1,200.00 15151 3.52 ZZZ 0.00 0.00 0.00 $211.20 15152 4.31 ZZZ 0.00 0.00 0.00 $258.60 15155 20.65 090 0.10 0.71 0.19 $1,239.00 15156 4.55 ZZZ 0.00 0.00 0.00 $273.00 15157 5.00 ZZZ 0.00 0.00 0.00 $300.00 15200 23.81 090 0.10 0.71 0.19 $1,428.60 15201 4.24 ZZZ 0.00 0.00 0.00 $254.40 15220 22.06 090 0.10 0.71 0.19 $1,323.60 15221 3.91 ZZZ 0.00 0.00 0.00 $234.60 15240 26.75 090 0.10 0.71 0.19 $1,605.00 15241 5.30 ZZZ 0.00 0.00 0.00 $318.00 15260 28.93 090 0.10 0.71 0.19 $1,735.80
Appendix II
Global Days
Pre- Operative
Intra- operative
Post- operative Fee
15261 6.17 ZZZ 0.00 0.00 0.00 $370.20 15271 4.00 000 0.00 0.00 0.00 $240.00 15272 0.77 ZZZ 0.00 0.00 0.00 $46.20 15273 8.45 000 0.00 0.00 0.00 $507.00 15274 2.04 ZZZ 0.00 0.00 0.00 $122.40 15275 4.23 000 0.00 0.00 0.00 $253.80 15276 0.99 ZZZ 0.00 0.00 0.00 $59.40 15277 9.20 000 0.00 0.00 0.00 $552.00 15278 2.44 ZZZ 0.00 0.00 0.00 $146.40 15570 26.29 090 0.10 0.71 0.19 $1,577.40 15572 25.50 090 0.10 0.71 0.19 $1,530.00 15574 26.21 090 0.10 0.71 0.19 $1,572.60 15576 23.10 090 0.10 0.71 0.19 $1,386.00 15600 9.26 090 0.10 0.71 0.19 $555.60 15610 10.19 090 0.10 0.71 0.19 $611.40 15620 12.61 090 0.10 0.71 0.19 $756.60 15630 13.12 090 0.10 0.71 0.19 $787.20 15650 14.39 090 0.10 0.71 0.19 $863.40 15731 32.41 090 0.10 0.71 0.19 $1,944.60 15732 36.94 090 0.10 0.71 0.19 $2,216.40 15734 43.31 090 0.10 0.71 0.19 $2,598.60 15736 38.13 090 0.10 0.71 0.19 $2,287.80 15738 40.42 090 0.10 0.71 0.19 $2,425.20 15740 29.21 090 0.10 0.71 0.19 $1,752.60 15750 26.63 090 0.10 0.71 0.19 $1,597.80 15756 67.50 090 0.10 0.71 0.19 $4,050.00 15757 66.52 090 0.10 0.71 0.19 $3,991.20 15758 66.62 090 0.10 0.71 0.19 $3,997.20 15760 24.49 090 0.10 0.71 0.19 $1,469.40 15770 19.45 090 0.10 0.71 0.19 $1,167.00 15775 8.56 000 0.00 0.00 0.00 $513.60 15776 14.28 000 0.00 0.00 0.00 $856.80 15777 6.22 ZZZ 0.00 0.00 0.00 $373.20 15780 23.90 090 0.10 0.71 0.19 $1,434.00 15781 15.92 090 0.10 0.71 0.19 $955.20 15782 18.32 090 0.10 0.71 0.19 $1,099.20 15783 13.14 090 0.10 0.71 0.19 $788.40 15786 6.94 010 0.10 0.80 0.10 $416.40 15787 1.39 ZZZ 0.00 0.00 0.00 $83.40 15788 13.11 090 0.10 0.71 0.19 $786.60 15789 15.67 090 0.10 0.71 0.19 $940.20 15792 12.60 090 0.10 0.71 0.19 $756.00 15793 14.03 090 0.10 0.71 0.19 $841.80 15819 21.26 090 0.10 0.71 0.19 $1,275.60 15820 16.01 090 0.10 0.71 0.19 $960.60 15821 17.28 090 0.10 0.71 0.19 $1,036.80 15822 12.67 090 0.10 0.71 0.19 $760.20 15823 17.25 090 0.10 0.71 0.19 $1,035.00 15830 33.99 090 0.10 0.71 0.19 $2,039.40 15832 26.63 090 0.10 0.71 0.19 $1,597.80 15833 24.99 090 0.10 0.71 0.19 $1,499.40 15834 25.78 090 0.10 0.71 0.19 $1,546.80 15835 26.93 090 0.10 0.71 0.19 $1,615.80
Appendix II
Global Days
Pre- Operative
Intra- operative
Post- operative Fee
15836 22.06 090 0.10 0.71 0.19 $1,323.60 15837 23.13 090 0.10 0.71 0.19 $1,387.80 15838 16.51 090 0.10 0.71 0.19 $990.60 15839 25.35 090 0.10 0.71 0.19 $1,521.00 15840 29.17 090 0.10 0.71 0.19 $1,750.20 15841 46.80 090 0.10 0.71 0.19 $2,808.00 15842 76.54 090 0.10 0.71 0.19 $4,592.40 15845 28.86 090 0.10 0.71 0.19 $1,731.60 15850 2.52 XXX 0.00 0.00 0.00 $151.20 15851 2.80 000 0.00 0.00 0.00 $168.00 15852 1.35 000 0.00 0.00 0.00 $81.00 15860 3.21 000 0.00 0.00 0.00 $192.60 15920 17.48 090 0.10 0.71 0.19 $1,048.80 15922 22.65 090 0.10 0.71 0.19 $1,359.00 15931 19.79 090 0.10 0.71 0.19 $1,187.40 15933 24.51 090 0.10 0.71 0.19 $1,470.60 15934 26.79 090 0.10 0.71 0.19 $1,607.40 15935 31.57 090 0.10 0.71 0.19 $1,894.20 15936 25.73 090 0.10 0.71 0.19 $1,543.80 15937 29.91 090 0.10 0.71 0.19 $1,794.60 15940 20.25 090 0.10 0.71 0.19 $1,215.00 15941 25.97 090 0.10 0.71 0.19 $1,558.20 15944 25.58 090 0.10 0.71 0.19 $1,534.80 15945 28.18 090 0.10 0.71 0.19 $1,690.80 15946 47.45 090 0.10 0.71 0.19 $2,847.00 15950 17.03 090 0.10 0.71 0.19 $1,021.80 15951 25.47 090 0.10 0.71 0.19 $1,528.20 15952 25.99 090 0.10 0.71 0.19 $1,559.40 15953 28.84 090 0.10 0.71 0.19 $1,730.40 15956 33.28 090 0.10 0.71 0.19 $1,996.80 15958 33.93 090 0.10 0.71 0.19 $2,035.80 16000 1.95 000 0.00 0.00 0.00 $117.00 16020 2.31 000 0.00 0.00 0.00 $138.60 16025 4.20 000 0.00 0.00 0.00 $252.00 16030 5.29 000 0.00 0.00 0.00 $317.40 16035 5.61 000 0.00 0.00 0.00 $336.60 16036 2.34 ZZZ 0.00 0.00 0.00 $140.40 17000 1.89 010 0.10 0.80 0.10 $113.40 17003 0.16 ZZZ 0.00 0.00 0.00 $9.60 17004 4.26 010 0.10 0.80 0.10 $255.60 17106 9.71 090 0.10 0.71 0.19 $582.60 17107 12.35 090 0.10 0.71 0.19 $741.00 17108 18.21 090 0.10 0.71 0.19 $1,092.60 17110 3.14 010 0.10 0.80 0.10 $188.40 17111 3.72 010 0.10 0.80 0.10 $223.20 17250 2.25 000 0.00 0.00 0.00 $135.00 17260 2.69 010 0.10 0.80 0.10 $161.40 17261 4.07 010 0.10 0.80 0.10 $244.20 17262 4.96 010 0.10 0.80 0.10 $297.60 17263 5.42 010 0.10 0.80 0.10 $325.20 17264 5.82 010 0.10 0.80 0.10 $349.20 17266 6.59 010 0.10 0.80 0.10 $395.40 17270 4.26 010 0.10 0.80 0.10 $255.60
Appendix II
Global Days
Pre- Operative
Intra- operative
Post- operative Fee
17271 4.62 010 0.10 0.80 0.10 $277.20 17272 5.28 010 0.10 0.80 0.10 $316.80 17273 5.89 010 0.10 0.80 0.10 $353.40 17274 6.96 010 0.10 0.80 0.10 $417.60 17276 8.07 010 0.10 0.80 0.10 $484.20 17280 3.99 010 0.10 0.80 0.10 $239.40 17281 5.04 010 0.10 0.80 0.10 $302.40 17282 5.80 010 0.10 0.80 0.10 $348.00 17283 6.94 010 0.10 0.80 0.10 $416.40 17284 7.94 010 0.10 0.80 0.10 $476.40 17286 10.19 010 0.10 0.80 0.10 $611.40 17311 18.80 000 0.00 0.00 0.00 $1,128.00 17312 11.02 ZZZ 0.00 0.00 0.00 $661.20 17313 17.57 000 0.00 0.00 0.00 $1,054.20 17314 10.58 ZZZ 0.00 0.00 0.00 $634.80 17315 2.27 ZZZ 0.00 0.00 0.00 $136.20 17340 1.46 010 0.10 0.80 0.10 $87.60 17360 3.67 010 0.10 0.80 0.10 $220.20 19000 3.21 000 0.00 0.00 0.00 $192.60 19001 0.77 ZZZ 0.00 0.00 0.00 $46.20 19020 13.45 090 0.10 0.71 0.19 $807.00 19030 4.67 000 0.00 0.00 0.00 $280.20 19081 19.67 000 0.00 0.00 0.00 $1,180.20 19082 16.25 ZZZ 0.00 0.00 0.00 $975.00 19083 19.03 000 0.00 0.00 0.00 $1,141.80 19084 15.63 ZZZ 0.00 0.00 0.00 $937.80 19085 29.21 000 0.00 0.00 0.00 $1,752.60 19086 23.13 ZZZ 0.00 0.00 0.00 $1,387.80 19100 4.28 000 0.00 0.00 0.00 $256.80 19101 9.73 010 0.10 0.80 0.10 $583.80 19105 60.59 000 0.00 0.00 0.00 $3,635.40 19110 13.85 090 0.10 0.71 0.19 $831.00 19112 12.98 090 0.10 0.71 0.19 $778.80 19120 14.14 090 0.10 0.71 0.19 $848.40 19125 15.68 090 0.10 0.71 0.19 $940.80 19126 4.70 ZZZ 0.00 0.00 0.00 $282.00 19260 34.84 090 0.10 0.71 0.19 $2,090.40 19271 47.19 090 0.10 0.71 0.19 $2,831.40 19272 51.52 090 0.10 0.71 0.19 $3,091.20 19281 6.78 000 0.00 0.00 0.00 $406.80 19282 4.75 ZZZ 0.00 0.00 0.00 $285.00 19283 7.64 000 0.00 0.00 0.00 $458.40 19284 5.76 ZZZ 0.00 0.00 0.00 $345.60 19285 14.59 000 0.00 0.00 0.00 $875.40 19286 12.81 ZZZ 0.00 0.00 0.00 $768.60 19287 24.39 000 0.00 0.00 0.00 $1,463.40 19288 19.66 ZZZ 0.00 0.00 0.00 $1,179.60 19296 112.31 000 0.00 0.00 0.00 $6,738.60 19297 2.75 ZZZ 0.00 0.00 0.00 $165.00 19298 29.49 000 0.00 0.00 0.00 $1,769.40 19300 14.98 090 0.10 0.71 0.19 $898.80 19301 18.86 090 0.10 0.71 0.19 $1,131.60 19302 25.94 090 0.10 0.71 0.19 $1,556.40
Appendix II
Global Days
Pre- Operative
Intra- operative
Post- operative Fee
19303 29.17 090 0.10 0.71 0.19 $1,750.20 19304 16.53 090 0.10 0.71 0.19 $991.80 19305 32.56 090 0.10 0.71 0.19 $1,953.60 19306 34.62 090 0.10 0.71 0.19 $2,077.20 19307 34.53 090 0.10 0.71 0.19 $2,071.80 19316 22.25 090 0.10 0.71 0.19 $1,335.00 19318 31.97 090 0.10 0.71 0.19 $1,918.20 19324 14.10 090 0.10 0.71 0.19 $846.00 19325 18.56 090 0.10 0.71 0.19 $1,113.60 19328 14.38 090 0.10 0.71 0.19 $862.80 19330 18.40 090 0.10 0.71 0.19 $1,104.00 19340 29.14 090 0.10 0.71 0.19 $1,748.40 19342 26.78 090 0.10 0.71 0.19 $1,606.80 19350 23.78 090 0.10 0.71 0.19 $1,426.80 19355 20.14 090 0.10 0.71 0.19 $1,208.40 19357 43.68 090 0.10 0.71 0.19 $2,620.80 19361 45.69 090 0.10 0.71 0.19 $2,741.40 19364 80.13 090 0.10 0.71 0.19 $4,807.80 19366 40.73 090 0.10 0.71 0.19 $2,443.80 19367 51.95 090 0.10 0.71 0.19 $3,117.00 19368 64.06 090 0.10 0.71 0.19 $3,843.60 19369 59.29 090 0.10 0.71 0.19 $3,557.40 19370 19.92 090 0.10 0.71 0.19 $1,195.20 19371 22.76 090 0.10 0.71 0.19 $1,365.60 19380 22.44 090 0.10 0.71 0.19 $1,346.40 19396 7.97 000 0.00 0.00 0.00 $478.20 20005 8.84 010 0.10 0.80 0.10 $530.40 20100 17.59 010 0.10 0.80 0.10 $1,055.40 20101 12.79 010 0.10 0.80 0.10 $767.40 20102 14.04 010 0.10 0.80 0.10 $842.40 20103 16.73 010 0.10 0.80 0.10 $1,003.80 20150 26.14 090 0.10 0.69 0.21 $1,568.40 20200 5.91 000 0.00 0.00 0.00 $354.60 20205 8.26 000 0.00 0.00 0.00 $495.60 20206 6.70 000 0.00 0.00 0.00 $402.00 20220 4.78 000 0.00 0.00 0.00 $286.80 20225 14.92 000 0.00 0.00 0.00 $895.20 20240 4.48 010 0.10 0.80 0.10 $268.80 20245 14.88 010 0.10 0.80 0.10 $892.80 20250 11.33 010 0.10 0.80 0.10 $679.80 20251 12.23 010 0.10 0.80 0.10 $733.80 20500 2.96 010 0.10 0.80 0.10 $177.60 20501 3.35 000 0.00 0.00 0.00 $201.00 20520 5.80 010 0.10 0.80 0.10 $348.00 20525 13.77 010 0.10 0.80 0.10 $826.20 20526 2.21 000 0.00 0.00 0.00 $132.60 20527 2.42 000 0.00 0.00 0.00 $145.20 20550 1.68 000 0.00 0.00 0.00 $100.80 20551 1.73 000 0.00 0.00 0.00 $103.80 20552 1.57 000 0.00 0.00 0.00 $94.20 20553 1.81 000 0.00 0.00 0.00 $108.60 20555 9.43 000 0.00 0.00 0.00 $565.80 20600 1.36 000 0.00 0.00 0.00 $81.60
Appendix II
Global Days
Pre- Operative
Intra- operative
Post- operative Fee
20604 2.06 000 0.00 0.00 0.00 $123.60 20605 1.43 000 0.00 0.00 0.00 $85.80 20606 2.28 000 0.00 0.00 0.00 $136.80 20610 1.72 000 0.00 0.00 0.00 $103.20 20611 2.61 000 0.00 0.00 0.00 $156.60 20612 1.73 000 0.00 0.00 0.00 $103.80 20615 6.98 010 0.10 0.80 0.10 $418.80 20650 5.96 010 0.10 0.80 0.10 $357.60 20660 7.14 000 0.00 0.00 0.00 $428.40 20661 14.76 090 0.10 0.69 0.21 $885.60 20662 12.39 090 0.10 0.69 0.21 $743.40 20663 13.54 090 0.10 0.69 0.21 $812.40 20664 25.56 090 0.10 0.69 0.21 $1,533.60 20665 3.00 010 0.10 0.80 0.10 $180.00 20670 10.89 010 0.10 0.80 0.10 $653.40 20680 17.75 090 0.10 0.69 0.21 $1,065.00 20690 17.20 090 0.10 0.69 0.21 $1,032.00 20692 32.30 090 0.10 0.69 0.21 $1,938.00 20693 12.80 090 0.10 0.69 0.21 $768.00 20694 12.14 090 0.10 0.69 0.21 $728.40 20696 34.73 090 0.10 0.69 0.21 $2,083.80 20697 56.67 000 0.00 0.00 0.00 $3,400.20 20802 69.36 090 0.10 0.69 0.21 $4,161.60 20805 95.86 090 0.10 0.69 0.21 $5,751.60 20808 116.77 090 0.10 0.69 0.21 $7,006.20 20816 60.04 090 0.10 0.69 0.21 $3,602.40 20822 52.20 090 0.10 0.69 0.21 $3,132.00 20824 59.42 090 0.10 0.69 0.21 $3,565.20 20827 53.00 090 0.10 0.69 0.21 $3,180.00 20838 70.07 090 0.10 0.69 0.21 $4,204.20 20900 11.94 000 0.00 0.00 0.00 $716.40 20902 8.25 000 0.00 0.00 0.00 $495.00 20910 11.82 090 0.10 0.69 0.21 $709.20 20912 13.89 090 0.10 0.69 0.21 $833.40 20920 11.31 090 0.10 0.69 0.21 $678.60 20922 17.98 090 0.10 0.69 0.21 $1,078.80 20924 14.51 090 0.10 0.69 0.21 $870.60 20926 12.24 090 0.10 0.69 0.21 $734.40 20931 3.30 ZZZ 0.00 0.00 0.00 $198.00 20937 4.79 ZZZ 0.00 0.00 0.00 $287.40 20938 5.30 ZZZ 0.00 0.00 0.00 $318.00 20950 7.22 000 0.00 0.00 0.00 $433.20 20955 72.79 090 0.10 0.69 0.21 $4,367.40 20956 77.03 090 0.10 0.69 0.21 $4,621.80 20957 71.07 090 0.10 0.69 0.21 $4,264.20 20962 61.23 090 0.10 0.69 0.21 $3,673.80 20969 80.33 090 0.10 0.69 0.21 $4,819.80 20970 84.92 090 0.10 0.69 0.21 $5,095.20 20972 67.99 090 0.10 0.69 0.21 $4,079.40 20973 76.26 090 0.10 0.69 0.21 $4,575.60 20974 2.19 000 0.00 0.00 0.00 $131.40 20975 5.09 000 0.00 0.00 0.00 $305.40 20979 1.49 000 0.00 0.00 0.00 $89.40
Appendix II
Global Days
Pre- Operative
Intra- operative
Post- operative Fee
20982 85.83 000 0.00 0.00 0.00 $5,149.80 20983 207.53 000 0.00 0.00 0.00 $12,451.80 20985 4.27 ZZZ 0.00 0.00 0.00 $256.20 21010 21.46 090 0.10 0.69 0.21 $1,287.60 21011 10.00 090 0.10 0.69 0.21 $600.00 21012 9.78 090 0.10 0.69 0.21 $586.80 21013 14.94 090 0.10 0.69 0.21 $896.40 21014 15.08 090 0.10 0.69 0.21 $904.80 21015 20.58 090 0.10 0.69 0.21 $1,234.80 21016 29.70 090 0.10 0.69 0.21 $1,782.00 21025 25.97 090 0.10 0.69 0.21 $1,558.20 21026 17.98 090 0.10 0.69 0.21 $1,078.80 21029 22.25 090 0.10 0.69 0.21 $1,335.00 21030 15.10 090 0.10 0.69 0.21 $906.00 21031 11.48 090 0.10 0.69 0.21 $688.80 21032 11.67 090 0.10 0.69 0.21 $700.20 21034 38.13 090 0.10 0.69 0.21 $2,287.80 21040 15.22 090 0.10 0.69 0.21 $913.20 21044 25.47 090 0.10 0.69 0.21 $1,528.20 21045 35.75 090 0.10 0.69 0.21 $2,145.00 21046 32.70 090 0.10 0.69 0.21 $1,962.00 21047 38.57 090 0.10 0.69 0.21 $2,314.20 21048 33.52 090 0.10 0.69 0.21 $2,011.20 21049 35.16 090 0.10 0.69 0.21 $2,109.60 21050 24.46 090 0.10 0.69 0.21 $1,467.60 21060 23.16 090 0.10 0.69 0.21 $1,389.60 21070 17.68 090 0.10 0.69 0.21 $1,060.80 21073 11.23 090 0.10 0.69 0.21 $673.80 21076 29.24 010 0.10 0.80 0.10 $1,754.40 21077 73.31 090 0.10 0.69 0.21 $4,398.60 21079 49.36 090 0.10 0.69 0.21 $2,961.60 21080 55.39 090 0.10 0.69 0.21 $3,323.40 21081 51.15 090 0.10 0.69 0.21 $3,069.00 21082 48.34 090 0.10 0.69 0.21 $2,900.40 21083 46.03 090 0.10 0.69 0.21 $2,761.80 21084 52.95 090 0.10 0.69 0.21 $3,177.00 21085 22.16 010 0.10 0.80 0.10 $1,329.60 21086 54.53 090 0.10 0.69 0.21 $3,271.80 21087 54.44 090 0.10 0.69 0.21 $3,266.40 21100 29.78 090 0.10 0.69 0.21 $1,786.80 21110 23.42 090 0.10 0.69 0.21 $1,405.20 21116 4.16 000 0.00 0.00 0.00 $249.60 21120 19.07 090 0.10 0.69 0.21 $1,144.20 21121 23.63 090 0.10 0.69 0.21 $1,417.80 21122 19.04 090 0.10 0.69 0.21 $1,142.40 21123 27.43 090 0.10 0.69 0.21 $1,645.80 21125 87.87 090 0.10 0.69 0.21 $5,272.20 21127 128.02 090 0.10 0.69 0.21 $7,681.20 21137 22.03 090 0.10 0.69 0.21 $1,321.80 21138 25.76 090 0.10 0.69 0.21 $1,545.60 21139 27.49 090 0.10 0.69 0.21 $1,649.40 21141 39.14 090 0.10 0.69 0.21 $2,348.40 21142 41.09 090 0.10 0.69 0.21 $2,465.40
Appendix II
Global Days
Pre- Operative
Intra- operative
Post- operative Fee
21143 41.29 090 0.10 0.69 0.21 $2,477.40 21145 45.98 090 0.10 0.69 0.21 $2,758.80 21146 44.86 090 0.10 0.69 0.21 $2,691.60 21147 50.99 090 0.10 0.69 0.21 $3,059.40 21150 48.71 090 0.10 0.69 0.21 $2,922.60 21151 59.12 090 0.10 0.69 0.21 $3,547.20 21154 60.72 090 0.10 0.69 0.21 $3,643.20 21155 62.63 090 0.10 0.69 0.21 $3,757.80 21159 72.45 090 0.10 0.69 0.21 $4,347.00 21160 92.94 090 0.10 0.69 0.21 $5,576.40 21172 52.39 090 0.10 0.69 0.21 $3,143.40 21175 62.76 090 0.10 0.69 0.21 $3,765.60 21179 41.96 090 0.10 0.69 0.21 $2,517.60 21180 44.64 090 0.10 0.69 0.21 $2,678.40 21181 21.54 090 0.10 0.69 0.21 $1,292.40 21182 56.16 090 0.10 0.69 0.21 $3,369.60 21183 67.52 090 0.10 0.69 0.21 $4,051.20 21184 61.77 090 0.10 0.69 0.21 $3,706.20 21188 46.84 090 0.10 0.69 0.21 $2,810.40 21193 35.42 090 0.10 0.69 0.21 $2,125.20 21194 41.73 090 0.10 0.69 0.21 $2,503.80 21195 38.92 090 0.10 0.69 0.21 $2,335.20 21196 43.35 090 0.10 0.69 0.21 $2,601.00 21198 34.21 090 0.10 0.69 0.21 $2,052.60 21199 31.25 090 0.10 0.69 0.21 $1,875.00 21206 34.37 090 0.10 0.69 0.21 $2,062.20 21208 54.85 090 0.10 0.69 0.21 $3,291.00 21209 23.44 090 0.10 0.69 0.21 $1,406.40 21210 66.41 090 0.10 0.69 0.21 $3,984.60 21215 118.10 090 0.10 0.69 0.21 $7,086.00 21230 20.61 090 0.10 0.69 0.21 $1,236.60 21235 20.98 090 0.10 0.69 0.21 $1,258.80 21240 32.77 090 0.10 0.69 0.21 $1,966.20 21242 30.04 090 0.10 0.69 0.21 $1,802.40 21243 49.69 090 0.10 0.69 0.21 $2,981.40 21244 31.18 090 0.10 0.69 0.21 $1,870.80 21245 32.05 090 0.10 0.69 0.21 $1,923.00 21246 25.29 090 0.10 0.69 0.21 $1,517.40 21247 45.10 090 0.10 0.69 0.21 $2,706.00 21248 32.36 090 0.10 0.69 0.21 $1,941.60 21249 44.31 090 0.10 0.69 0.21 $2,658.60 21255 40.47 090 0.10 0.69 0.21 $2,428.20 21256 34.77 090 0.10 0.69 0.21 $2,086.20 21260 40.55 090 0.10 0.69 0.21 $2,433.00 21261 60.90 090 0.10 0.69 0.21 $3,654.00 21263 56.26 090 0.10 0.69 0.21 $3,375.60 21267 45.22 090 0.10 0.69 0.21 $2,713.20 21268 50.27 090 0.10 0.69 0.21 $3,016.20 21270 27.69 090 0.10 0.69 0.21 $1,661.40 21275 24.36 090 0.10 0.69 0.21 $1,461.60 21280 16.28 090 0.10 0.69 0.21 $976.80 21282 10.94 090 0.10 0.69 0.21 $656.40 21295 5.17 090 0.10 0.69 0.21 $310.20
Appendix II
Global Days
Pre- Operative
Intra- operative
Post- operative Fee
21296 12.49 090 0.10 0.69 0.21 $749.40 21310 3.75 000 0.00 0.00 0.00 $225.00 21315 7.95 010 0.10 0.80 0.10 $477.00 21320 7.38 010 0.10 0.80 0.10 $442.80 21325 13.72 090 0.10 0.69 0.21 $823.20 21330 16.41 090 0.10 0.69 0.21 $984.60 21335 21.04 090 0.10 0.69 0.21 $1,262.40 21336 18.64 090 0.10 0.69 0.21 $1,118.40 21337 11.65 090 0.10 0.69 0.21 $699.00 21338 20.96 090 0.10 0.69 0.21 $1,257.60 21339 22.25 090 0.10 0.69 0.21 $1,335.00 21340 21.83 090 0.10 0.69 0.21 $1,309.80 21343 35.11 090 0.10 0.69 0.21 $2,106.60 21344 40.36 090 0.10 0.69 0.21 $2,421.60 21345 23.46 090 0.10 0.69 0.21 $1,407.60 21346 26.27 090 0.10 0.69 0.21 $1,576.20 21347 33.18 090 0.10 0.69 0.21 $1,990.80 21348 35.21 090 0.10 0.69 0.21 $2,112.60 21355 12.34 010 0.10 0.80 0.10 $740.40 21356 14.52 010 0.10 0.80 0.10 $871.20 21360 15.63 090 0.10 0.69 0.21 $937.80 21365 32.35 090 0.10 0.69 0.21 $1,941.00 21366 33.41 090 0.10 0.69 0.21 $2,004.60 21385 19.71 090 0.10 0.69 0.21 $1,182.60 21386 20.23 090 0.10 0.69 0.21 $1,213.80 21387 20.59 090 0.10 0.69 0.21 $1,235.40 21390 22.99 090 0.10 0.69 0.21 $1,379.40 21395 29.20 090 0.10 0.69 0.21 $1,752.00 21400 5.53 090 0.10 0.69 0.21 $331.80 21401 12.72 090 0.10 0.69 0.21 $763.20 21406 15.01 090 0.10 0.69 0.21 $900.60 21407 18.71 090 0.10 0.69 0.21 $1,122.60 21408 25.52 090 0.10 0.69 0.21 $1,531.20 21421 21.93 090 0.10 0.69 0.21 $1,315.80 21422 19.61 090 0.10 0.69 0.21 $1,176.60 21423 23.90 090 0.10 0.69 0.21 $1,434.00 21431 21.53 090 0.10 0.69 0.21 $1,291.80 21432 18.98 090 0.10 0.69 0.21 $1,138.80 21433 50.57 090 0.10 0.69 0.21 $3,034.20 21435 36.52 090 0.10 0.69 0.21 $2,191.20 21436 60.69 090 0.10 0.69 0.21 $3,641.40 21440 16.80 090 0.10 0.69 0.21 $1,008.00 21445 22.46 090 0.10 0.69 0.21 $1,347.60 21450 17.83 090 0.10 0.69 0.21 $1,069.80 21451 22.21 090 0.10 0.69 0.21 $1,332.60 21452 17.28 090 0.10 0.69 0.21 $1,036.80 21453 26.66 090 0.10 0.69 0.21 $1,599.60 21454 17.37 090 0.10 0.69 0.21 $1,042.20 21461 62.39 090 0.10 0.69 0.21 $3,743.40 21462 66.11 090 0.10 0.69 0.21 $3,966.60 21465 28.05 090 0.10 0.69 0.21 $1,683.00 21470 35.16 090 0.10 0.69 0.21 $2,109.60 21480 2.84 000 0.00 0.00 0.00 $170.40
Appendix II
Global Days
Pre- Operative
Intra- operative
Post- operative Fee
21485 20.43 090 0.10 0.69 0.21 $1,225.80 21490 26.71 090 0.10 0.69 0.21 $1,602.60 21495 20.42 090 0.10 0.69 0.21 $1,225.20 21497 21.49 090 0.10 0.69 0.21 $1,289.40 21501 13.02 090 0.10 0.69 0.21 $781.20 21502 15.38 090 0.10 0.69 0.21 $922.80 21510 13.01 090 0.10 0.69 0.21 $780.60 21550 7.52 010 0.10 0.80 0.10 $451.20 21552 12.91 090 0.10 0.69 0.21 $774.60 21554 21.18 090 0.10 0.69 0.21 $1,270.80 21555 11.91 090 0.10 0.69 0.21 $714.60 21556 15.34 090 0.10 0.69 0.21 $920.40 21557 27.79 090 0.10 0.69 0.21 $1,667.40 21558 39.11 090 0.10 0.69 0.21 $2,346.60 21600 16.10 090 0.10 0.69 0.21 $966.00 21610 34.88 090 0.10 0.69 0.21 $2,092.80 21615 17.83 090 0.10 0.69 0.21 $1,069.80 21616 21.79 090 0.10 0.69 0.21 $1,307.40 21620 14.58 090 0.10 0.69 0.21 $874.80 21627 15.56 090 0.10 0.69 0.21 $933.60 21630 34.98 090 0.10 0.69 0.21 $2,098.80 21632 35.17 090 0.10 0.69 0.21 $2,110.20 21685 29.05 090 0.10 0.76 0.14 $1,743.00 21700 10.80 090 0.10 0.69 0.21 $648.00 21705 16.01 090 0.10 0.69 0.21 $960.60 21720 13.12 090 0.10 0.69 0.21 $787.20 21725 15.34 090 0.10 0.69 0.21 $920.40 21740 29.73 090 0.10 0.69 0.21 $1,783.80 21750 19.81 090 0.10 0.69 0.21 $1,188.60 21811 17.75 000 0.00 0.00 0.00 $1,065.00 21812 21.29 000 0.00 0.00 0.00 $1,277.40 21813 27.84 000 0.00 0.00 0.00 $1,670.40 21820 4.01 090 0.10 0.69 0.21 $240.60 21825 15.67 090 0.10 0.69 0.21 $940.20 21920 7.36 010 0.10 0.80 0.10 $441.60 21925 12.67 090 0.10 0.69 0.21 $760.20 21930 13.57 090 0.10 0.69 0.21 $814.20 21931 13.59 090 0.10 0.69 0.21 $815.40 21932 19.15 090 0.10 0.69 0.21 $1,149.00 21933 21.33 090 0.10 0.69 0.21 $1,279.80 21935 29.75 090 0.10 0.69 0.21 $1,785.00 21936 40.95 090 0.10 0.69 0.21 $2,457.00 22010 27.73 090 0.10 0.69 0.21 $1,663.80 22015 27.14 090 0.10 0.69 0.21 $1,628.40 22100 25.45 090 0.10 0.69 0.21 $1,527.00 22101 24.81 090 0.10 0.69 0.21 $1,488.60 22102 22.77 090 0.10 0.69 0.21 $1,366.20 22103 4.04 ZZZ 0.00 0.00 0.00 $242.40 22110 30.35 090 0.10 0.69 0.21 $1,821.00 22112 28.72 090 0.10 0.69 0.21 $1,723.20 22114 28.84 090 0.10 0.69 0.21 $1,730.40 22116 4.04 ZZZ 0.00 0.00 0.00 $242.40 22206 70.89 090 0.10 0.69 0.21 $4,253.40
Appendix II
Global Days
Pre- Operative
Intra- operative
Post- operative Fee
22207 69.47 090 0.10 0.69 0.21 $4,168.20 22208 16.53 ZZZ 0.00 0.00 0.00 $991.80 22210 51.85 090 0.10 0.69 0.21 $3,111.00 22212 42.87 090 0.10 0.69 0.21 $2,572.20 22214 42.91 090 0.10 0.69 0.21 $2,574.60 22216 10.39 ZZZ 0.00 0.00 0.00 $623.40 22220 46.37 090 0.10 0.69 0.21 $2,782.20 22222 45.23 090 0.10 0.69 0.21 $2,713.80 22224 45.71 090 0.10 0.69 0.21 $2,742.60 22226 10.33 ZZZ 0.00 0.00 0.00 $619.80 22305 5.49 090 0.10 0.69 0.21 $329.40 22310 8.87 090 0.10 0.69 0.21 $532.20 22315 25.49 090 0.10 0.69 0.21 $1,529.40 22318 47.91 090 0.10 0.69 0.21 $2,874.60 22319 53.54 090 0.10 0.69 0.21 $3,212.40 22325 41.47 090 0.10 0.69 0.21 $2,488.20 22326 43.34 090 0.10 0.69 0.21 $2,600.40 22327 43.73 090 0.10 0.69 0.21 $2,623.80 22328 8.02 ZZZ 0.00 0.00 0.00 $481.20 22505 3.70 010 0.10 0.80 0.10 $222.00 22510 50.35 010 0.10 0.80 0.10 $3,021.00 22511 49.85 010 0.10 0.80 0.10 $2,991.00 22512 27.94 ZZZ 0.00 0.00 0.00 $1,676.40 22513 209.45 010 0.10 0.80 0.10 $12,567.00 22514 209.22 010 0.10 0.80 0.10 $12,553.20 22515 126.77 ZZZ 0.00 0.00 0.00 $7,606.20 22526 67.90 010 0.10 0.80 0.10 $4,074.00 22527 56.34 ZZZ 0.00 0.00 0.00 $3,380.40 22532 51.51 090 0.10 0.69 0.21 $3,090.60 22533 47.83 090 0.10 0.69 0.21 $2,869.80 22534 10.27 ZZZ 0.00 0.00 0.00 $616.20 22548 58.11 090 0.10 0.69 0.21 $3,486.60 22551 49.87 090 0.10 0.69 0.21 $2,992.20 22552 11.35 ZZZ 0.00 0.00 0.00 $681.00 22554 36.26 090 0.10 0.69 0.21 $2,175.60 22556 48.53 090 0.10 0.69 0.21 $2,911.80 22558 44.78 090 0.10 0.69 0.21 $2,686.80 22585 9.44 ZZZ 0.00 0.00 0.00 $566.40 22586 52.58 090 0.10 0.69 0.21 $3,154.80 22590 46.14 090 0.10 0.69 0.21 $2,768.40 22595 44.00 090 0.10 0.69 0.21 $2,640.00 22600 37.46 090 0.10 0.69 0.21 $2,247.60 22610 36.63 090 0.10 0.69 0.21 $2,197.80 22612 46.12 090 0.10 0.69 0.21 $2,767.20 22614 11.20 ZZZ 0.00 0.00 0.00 $672.00 22630 45.51 090 0.10 0.69 0.21 $2,730.60 22632 9.14 ZZZ 0.00 0.00 0.00 $548.40 22633 53.69 090 0.10 0.69 0.21 $3,221.40 22634 14.09 ZZZ 0.00 0.00 0.00 $845.40 22800 39.07 090 0.10 0.69 0.21 $2,344.20 22802 60.86 090 0.10 0.69 0.21 $3,651.60 22804 70.48 090 0.10 0.69 0.21 $4,228.80 22808 53.42 090 0.10 0.69 0.21 $3,205.20
Appendix II
Global Days
Pre- Operative
Intra- operative
Post- operative Fee
22810 58.89 090 0.10 0.69 0.21 $3,533.40 22812 70.67 090 0.10 0.69 0.21 $4,240.20 22818 63.21 090 0.11 0.76 0.13 $3,792.60 22819 81.44 090 0.11 0.76 0.13 $4,886.40 22830 23.49 090 0.10 0.69 0.21 $1,409.40 22840 21.66 ZZZ 0.00 0.00 0.00 $1,299.60 22842 21.76 ZZZ 0.00 0.00 0.00 $1,305.60 22843 23.48 ZZZ 0.00 0.00 0.00 $1,408.80 22844 28.42 ZZZ 0.00 0.00 0.00 $1,705.20 22845 20.78 ZZZ 0.00 0.00 0.00 $1,246.80 22846 21.55 ZZZ 0.00 0.00 0.00 $1,293.00 22847 23.68 ZZZ 0.00 0.00 0.00 $1,420.80 22848 10.34 ZZZ 0.00 0.00 0.00 $620.40 22849 37.68 090 0.10 0.69 0.21 $2,260.80 22850 20.95 090 0.10 0.69 0.21 $1,257.00 22851 11.57 ZZZ 0.00 0.00 0.00 $694.20 22852 20.09 090 0.10 0.69 0.21 $1,205.40 22855 32.02 090 0.10 0.69 0.21 $1,921.20 22856 47.13 090 0.10 0.69 0.21 $2,827.80 22857 57.34 090 0.10 0.69 0.21 $3,440.40 22858 14.76 ZZZ 0.00 0.00 0.00 $885.60 22861 58.36 090 0.10 0.69 0.21 $3,501.60 22862 58.06 090 0.10 0.71 0.19 $3,483.60 22864 60.49 090 0.10 0.69 0.21 $3,629.40 22865 59.64 090 0.10 0.71 0.19 $3,578.40 22900 16.32 090 0.10 0.69 0.21 $979.20 22901 19.22 090 0.10 0.69 0.21 $1,153.20 22902 12.59 090 0.10 0.69 0.21 $755.40 22903 12.69 090 0.10 0.69 0.21 $761.40 22904 30.40 090 0.09 0.81 0.10 $1,824.00 22905 38.54 090 0.09 0.81 0.10 $2,312.40 23000 16.76 090 0.10 0.69 0.21 $1,005.60 23020 19.74 090 0.10 0.69 0.21 $1,184.40 23030 12.68 010 0.10 0.80 0.10 $760.80 23031 12.21 010 0.10 0.80 0.10 $732.60 23035 19.51 090 0.10 0.69 0.21 $1,170.60 23040 20.76 090 0.10 0.69 0.21 $1,245.60 23044 16.36 090 0.10 0.69 0.21 $981.60 23065 6.19 010 0.10 0.80 0.10 $371.40 23066 15.90 090 0.10 0.69 0.21 $954.00 23071 12.12 090 0.10 0.80 0.10 $727.20 23073 20.03 090 0.10 0.69 0.21 $1,201.80 23075 13.39 090 0.10 0.80 0.10 $803.40 23076 15.60 090 0.10 0.69 0.21 $936.00 23077 33.22 090 0.10 0.69 0.21 $1,993.20 23078 41.64 090 0.10 0.69 0.21 $2,498.40 23100 14.37 090 0.10 0.69 0.21 $862.20 23101 13.09 090 0.10 0.69 0.21 $785.40 23105 18.33 090 0.10 0.69 0.21 $1,099.80 23106 14.19 090 0.10 0.69 0.21 $851.40 23107 18.98 090 0.10 0.69 0.21 $1,138.80 23120 16.77 090 0.10 0.69 0.21 $1,006.20 23125 20.49 090 0.10 0.69 0.21 $1,229.40
Appendix II
Global Days
Pre- Operative
Intra- operative
Post- operative Fee
23130 17.60 090 0.10 0.69 0.21 $1,056.00 23140 15.35 090 0.10 0.69 0.21 $921.00 23145 20.08 090 0.10 0.69 0.21 $1,204.80 23146 17.89 090 0.10 0.69 0.21 $1,073.40 23150 18.87 090 0.10 0.69 0.21 $1,132.20 23155 22.93 090 0.10 0.69 0.21 $1,375.80 23156 19.51 090 0.10 0.69 0.21 $1,170.60 23170 16.08 090 0.10 0.69 0.21 $964.80 23172 16.36 090 0.10 0.69 0.21 $981.60 23174 21.66 090 0.10 0.69 0.21 $1,299.60 23180 19.15 090 0.10 0.69 0.21 $1,149.00 23182 18.63 090 0.10 0.69 0.21 $1,117.80 23184 21.19 090 0.10 0.69 0.21 $1,271.40 23190 16.34 090 0.10 0.69 0.21 $980.40 23195 21.76 090 0.10 0.69 0.21 $1,305.60 23200 43.12 090 0.10 0.69 0.21 $2,587.20 23210 51.43 090 0.10 0.69 0.21 $3,085.80 23220 56.16 090 0.10 0.69 0.21 $3,369.60 23330 6.79 010 0.10 0.80 0.10 $407.40 23333 13.09 090 0.10 0.69 0.21 $785.40 23334 31.19 090 0.10 0.69 0.21 $1,871.40 23335 37.11 090 0.10 0.69 0.21 $2,226.60 23350 3.70 000 0.00 0.00 0.00 $222.00 23395 37.04 090 0.10 0.69 0.21 $2,222.40 23397 33.01 090 0.10 0.69 0.21 $1,980.60 23400 28.11 090 0.10 0.69 0.21 $1,686.60 23405 17.95 090 0.10 0.69 0.21 $1,077.00 23406 22.09 090 0.10 0.69 0.21 $1,325.40 23410 23.68 090 0.10 0.69 0.21 $1,420.80 23412 24.53 090 0.10 0.69 0.21 $1,471.80 23415 20.12 090 0.10 0.69 0.21 $1,207.20 23420 27.92 090 0.10 0.69 0.21 $1,675.20 23430 21.44 090 0.10 0.69 0.21 $1,286.40 23440 21.73 090 0.10 0.69 0.21 $1,303.80 23450 27.27 090 0.10 0.69 0.21 $1,636.20 23455 28.84 090 0.10 0.69 0.21 $1,730.40 23460 31.56 090 0.10 0.69 0.21 $1,893.60 23462 30.61 090 0.10 0.69 0.21 $1,836.60 23465 32.00 090 0.10 0.69 0.21 $1,920.00 23466 32.18 090 0.10 0.69 0.21 $1,930.80 23470 34.74 090 0.10 0.69 0.21 $2,084.40 23472 42.03 090 0.10 0.69 0.21 $2,521.80 23473 46.68 090 0.10 0.69 0.21 $2,800.80 23474 50.45 090 0.10 0.69 0.21 $3,027.00 23480 23.74 090 0.10 0.69 0.21 $1,424.40 23485 27.54 090 0.10 0.69 0.21 $1,652.40 23490 24.32 090 0.10 0.69 0.21 $1,459.20 23491 29.30 090 0.10 0.69 0.21 $1,758.00 23500 6.29 090 0.10 0.69 0.21 $377.40 23505 10.15 090 0.10 0.69 0.21 $609.00 23515 20.75 090 0.10 0.69 0.21 $1,245.00 23520 6.41 090 0.10 0.69 0.21 $384.60 23525 10.79 090 0.10 0.69 0.21 $647.40
Appendix II
Global Days
Pre- Operative
Intra- operative
Post- operative Fee
23530 15.85 090 0.10 0.69 0.21 $951.00 23532 17.94 090 0.10 0.69 0.21 $1,076.40 23540 6.49 090 0.10 0.69 0.21 $389.40 23545 9.69 090 0.10 0.69 0.21 $581.40 23550 16.16 090 0.10 0.69 0.21 $969.60 23552 18.85 090 0.10 0.69 0.21 $1,131.00 23570 6.65 090 0.10 0.69 0.21 $399.00 23575 11.45 090 0.10 0.69 0.21 $687.00 23585 28.31 090 0.10 0.69 0.21 $1,698.60 23600 9.37 090 0.10 0.69 0.21 $562.20 23605 13.35 090 0.10 0.69 0.21 $801.00 23615 25.53 090 0.10 0.69 0.21 $1,531.80 23616 35.87 090 0.10 0.69 0.21 $2,152.20 23620 7.71 090 0.10 0.69 0.21 $462.60 23625 10.91 090 0.10 0.69 0.21 $654.60 23630 22.55 090 0.10 0.69 0.21 $1,353.00 23650 8.91 090 0.10 0.69 0.21 $534.60 23655 11.57 090 0.10 0.69 0.21 $694.20 23660 16.72 090 0.10 0.69 0.21 $1,003.20 23665 12.23 090 0.10 0.69 0.21 $733.80 23670 25.25 090 0.10 0.69 0.21 $1,515.00 23675 15.85 090 0.10 0.69 0.21 $951.00 23680 26.79 090 0.10 0.69 0.21 $1,607.40 23700 5.66 010 0.10 0.80 0.10 $339.60 23800 29.69 090 0.10 0.69 0.21 $1,781.40 23802 36.67 090 0.10 0.69 0.21 $2,200.20 23900 40.27 090 0.10 0.69 0.21 $2,416.20 23920 32.54 090 0.10 0.69 0.21 $1,952.40 23921 13.51 090 0.10 0.69 0.21 $810.60 23930 10.10 010 0.10 0.80 0.10 $606.00 23931 8.21 010 0.10 0.80 0.10 $492.60 23935 14.60 090 0.10 0.69 0.21 $876.00 24000 13.75 090 0.10 0.69 0.21 $825.00 24006 20.40 090 0.10 0.69 0.21 $1,224.00 24065 7.32 010 0.10 0.80 0.10 $439.20 24066 17.87 090 0.10 0.69 0.21 $1,072.20 24071 11.72 090 0.10 0.69 0.21 $703.20 24073 20.02 090 0.10 0.69 0.21 $1,201.20 24075 14.06 090 0.10 0.69 0.21 $843.60 24076 15.70 090 0.10 0.69 0.21 $942.00 24077 30.03 090 0.10 0.69 0.21 $1,801.80 24079 38.34 090 0.10 0.69 0.21 $2,300.40 24100 12.06 090 0.10 0.69 0.21 $723.60 24101 14.43 090 0.10 0.69 0.21 $865.80 24102 17.79 090 0.10 0.69 0.21 $1,067.40 24105 10.11 090 0.10 0.69 0.21 $606.60 24110 16.74 090 0.10 0.69 0.21 $1,004.40 24115 21.33 090 0.10 0.69 0.21 $1,279.80 24116 24.94 090 0.10 0.69 0.21 $1,496.40 24120 15.26 090 0.10 0.69 0.21 $915.60 24125 17.69 090 0.10 0.69 0.21 $1,061.40 24126 18.74 090 0.10 0.69 0.21 $1,124.40 24130 14.70 090 0.10 0.69 0.21 $882.00
Appendix II
Global Days
Pre- Operative
Intra- operative
Post- operative Fee
24134 21.57 090 0.10 0.69 0.21 $1,294.20 24136 18.28 090 0.10 0.69 0.21 $1,096.80 24138 19.39 090 0.10 0.69 0.21 $1,163.40 24140 20.22 090 0.10 0.69 0.21 $1,213.20 24145 17.09 090 0.10 0.69 0.21 $1,025.40 24147 17.95 090 0.10 0.69 0.21 $1,077.00 24149 34.01 090 0.10 0.69 0.21 $2,040.60 24150 45.17 090 0.10 0.69 0.21 $2,710.20 24152 38.69 090 0.10 0.69 0.21 $2,321.40 24155 24.40 090 0.10 0.69 0.21 $1,464.00 24160 36.70 090 0.10 0.69 0.21 $2,202.00 24164 21.13 090 0.10 0.69 0.21 $1,267.80 24200 5.90 010 0.10 0.80 0.10 $354.00 24201 15.61 090 0.10 0.69 0.21 $936.60 24220 4.56 000 0.00 0.00 0.00 $273.60 24300 12.02 090 0.10 0.69 0.21 $721.20 24301 21.63 090 0.10 0.69 0.21 $1,297.80 24305 16.68 090 0.10 0.69 0.21 $1,000.80 24310 13.58 090 0.10 0.69 0.21 $814.80 24320 22.59 090 0.10 0.69 0.21 $1,355.40 24330 20.75 090 0.10 0.69 0.21 $1,245.00 24331 22.74 090 0.10 0.69 0.21 $1,364.40 24332 17.64 090 0.10 0.69 0.21 $1,058.40 24340 17.59 090 0.10 0.69 0.21 $1,055.40 24341 21.52

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MEDICAL FEE SCHEDULE MAINE WORKERS' COMPENSATION …