MEDICAL FEE SCHEDULE MAINE WORKERS' COMPENSATION BOARD ... · chapter should refer to the most current CPT® which contains the complete and most current listing of codes and descriptive

MEDICAL FEE SCHEDULE

MAINE WORKERS' COMPENSATION BOARD

90-351

CHAPTER 5

BOARD RULES

WITH APPENDICES I - V

MAINE WORKERS' COMPENSATION BOARD

OFFICE OF MEDICAL/REHABILITATION SERVICES

27 STATE HOUSE STATION

AUGUSTA, MAINE 04333-0027

EFFECTIVE: JANUARY 1, 2020

90-351 WORKERS' COMPENSATION BOARD

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CHAPTER 5 MEDICAL FEES; REIMBURSEMENT LEVELS; REPORTING REQUIREMENTS

The Medical Fee Schedule is available online at http://www.maine.gov/wcb/Departments/omrs/medfeesched.html, or for purchase through Gossamer Press, 259 Main St., Old Town, ME 04468, Tel: (207) 827-9881, Fax: (207) 827-9861.

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 managed care services such as utilization review, case management, and bill review 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 Board has adopted this medical fee schedule which reflects the payment methodology developed by the federal Centers for Medicare and Medicaid Services. The Board has not adopted all components used by the federal Centers for Medicare and Medicaid Services. Therefore, the application of any fee schedule, payment system, claims processing rule, edit or other method of determining the reimbursement level for a service(s) not expressly adopted in this chapter is prohibited.

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.

2. Ambulatory Payment Classification System (APC): Centers for Medicare & Medicaid Services’ list of procedure codes, status indicators, ambulatory payment classifications, and relative weighting factors.

http://www.maine.gov/wcb/Departments/omrs/medfeesched.html


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3. Ambulatory Surgical Center (ASC): A health care facility with an AmbulatorySurgical Clinic/Center Primary Taxonomy in the NPI Registry.

4. Bill: A request by a health care provider that is submitted to an employer/insurerfor payment of medical, surgical and hospital services, nursing, medicines, andmechanical, surgical aids provided for treatment of a work-related injury ordisease.

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 HospitalPrimary Taxonomy in the NPI Registry.

7. Global Days: The number of days of care following a surgical procedure that areincluded in the procedure’s maximum allowable payment but does not includecare 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 careprovider’s license, registration or certification. This paragraph shall not beconstrued as enlarging the scope and/or limitations of practice of any health careprovider.

9. Health Care Records: includes office notes, surgical/operative notes, progressnotes, diagnostic test results and any other information necessary to support theservices rendered.

10. Implantable: An object or device that is made to replace and act as a missingbiological structure that is surgically implanted, embedded, inserted, or otherwiseapplied. 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 thesame 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 ahospital and whose length of stay exceeds 23 hours or is expected to have a lengthof stay exceeding 23 hours, even though it later develops that the patient dies, isdischarged, or is transferred to another facility and does not actually stay in theinstitution for more than 23 hours.

13. Maximum Allowable Payment (MAP): The sum of all fees for medical, surgicaland hospital services, nursing, medicines, and mechanical, surgical aidsestablished by the Board pursuant to this chapter.

14. Modifier: A code adopted by the Centers for Medicare & Medicaid Services thatprovides the means to report or indicate that a service or procedure that has been


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performed has been altered by some specific circumstance but not changed in its definition or code.

15. Outpatient Services: Services provided to a patient who is not admitted for inpatient or residential care (includes observation services).

16. 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.

17. Resource-Based Relative Value Scale (RBRVS): Centers for Medicare & Medicaid Services’ list of procedure codes, modifiers, relative weighting factors, global surgery days, and global surgery package percentages.

18. Severity-Diagnosis Related Group System (MS-DRG): Centers for Medicare & Medicaid Services’ list of Medicare severity diagnosis-related groups, relative weighting factors, and geometric mean length of stay days.

19. Specialty Hospital: A health care facility with a Long-Term Care Hospital, Psychiatric Hospital, or Rehabilitation Hospital Primary Taxonomy in the NPI Registry. Specialty Hospital also includes those distinct parts of a health care facility that are certified by the Centers for Medicare & Medicaid Services as a Long-Term Care Hospital, Psychiatric Hospital, or Rehabilitation Hospital.

20. 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.


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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 employee; 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. Bills for insured employers must be submitted directly to the insurer of record on the date of injury/illness. Health care providers shall attempt to verify the name of the insurer that wrote the workers’ compensation policy for the specific employer on the date of injury/illness prior to the submission of a bill to an insurer.

3. 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.

4. 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).


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2. Changes to bills by employers/insurers are not allowed. 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 or the underlying injury has been controverted or denied.

A. 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 shall pay the undisputed amounts, if any, and file a notice of controversy within 30 days of receipt. A copy of the notice of controversy must be sent to the health care provider from whom the bill originated in accordance with Chapter 3.

B. In cases where the underlying injury has been controverted or denied, a copy of the notice of controversy must be sent to each health care provider that submits or has submitted a request for payment within 30 days of receipt.

C. 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.

3. When there is a dispute whether a request for future 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 within 30 days of receipt of the request. 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.

4. Payment of a medical bill is not an admission by the employer/insurer as to the reasonableness of subsequent medical bills.

5. 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 is a contractual beneficiary of the payment agreement on the date of service.

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.


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D. An employer/insurer that invokes a payment agreement to pay an amount that is different from the maximum allowable payment otherwise available under this chapter shall reference that payment agreement in the employer/insurer’s explanation of payment or benefit.

E. In the event of a dispute as to whether there is a payment agreement that supersedes the maximum allowable payment otherwise payable, the burden is on the party invoking the payment agreement to provide a written contract between the provider and the network within 30 days of a provider’s request. This contract must establish the party’s right to pay an amount different than provided in this chapter. Failure to produce the contract within 30 days of a request will result in the bill being subject to the maximum allowable payment established in this chapter.

6. 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.

7. 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: pay the highest weighted procedure at 100% of the maximum allowable payment under this chapter and all additional procedures at 50% of the maximum allowable payment under this chapter. Add-on codes are not subject to discounting.

-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).

-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.


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-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.

-AS Assistant Surgeon (physician assistant, nurse practitioner, or clinical nurse specialist): 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.

-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.


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-XE Separate Encounter: pay 100% of the maximum allowable payment under this chapter (not subject to multiple procedure discounting).

-XP Separate Practitioner: pay 100% of the maximum allowable payment under this chapter (not subject to multiple procedure discounting).

-XS Separate Structure: pay 100% of the maximum allowable payment under this chapter (not subject to multiple procedure discounting).

-XU Unusual Non-Overlapping Service: pay 100% of the maximum allowable payment under this chapter (not subject to multiple procedure discounting).

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 on the bill using 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. For copies of health care records or other written information, including, but not limited to, billing records furnished in paper form, the maximum fee 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 requesting party. Health care providers shall not require payment prior to responding to the request unless the requesting party has an unpaid balance for previously requested information from the health care provider. In this event, a health care provider may require payment of the past due balance in addition to pre-payment of the current request 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. If the requested information exists in a digital or electronic format, the health care provider shall provide an electronic copy of the requested information, if an electronic copy is requested and it is reasonably possible to provide it. The health care provider may charge reasonable actual costs of staff time to create the electronic information and the costs of necessary supplies, up to a maximum of $150.00. The copying charge must be paid by the requesting party. Health care providers shall not require payment prior to responding to the request unless the requesting party has an unpaid balance for previously requested information from the health care provider. In this event, a health care provider may require payment of the past due balance in addition to pre-payment of the current request 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


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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: $250.00

Each additional 15 minutes: $125.00

3. The maximum fee for attendance at depositions and hearings for the purpose of giving testimony is:

First hour or any fraction thereof: $500.00

Each subsequent 15 minutes: $125.00

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: $400.00

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.


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1.11 MEDICAL INFORMATION

1. A. Pursuant to 39-A M.R.S.A. § 208(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 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.

B. Pursuant to 39-A M.R.S.A. § 208(1), health care providers must, at the written request of the employer/insurer representative, furnish copies of health care records or other written information, including, but not limited to, billing records to the employer/insurer representative and to the employee representative (if none, to the employee) 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 sent to the requestor. C. Pursuant to 39-A M.R.S.A. § 208(1), health care providers must, at the written request of the employee or the employee’s representative, furnish copies of health care records or other written information, including, but not limited to, billing records to the employee or the employee’s representative 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 sent to the requestor.

2. A. Except as provided in subsection 3 of this section, if the employer/insurer or employee representative contends that medical information pre-existing and subsequent to the workplace injury for which claim is being made is relevant to issues in the workers’ compensation case, it shall use Form WCB-220, set forth in Appendix V. Within 14 calendar days the employee or the employee’s authorized representative, as defined in paragraph C of this section, shall sign the release and return it to the requesting party.

B. All parties, including health care providers, shall only use Form WCB-220 set forth in Appendix V. The use of forms other than the ones set forth in Appendix V and/or requiring additional forms is prohibited.

C. For purposes of this section, “authorized representative” has the same definition as set forth in 22 M.R.S.A § 1711-C(1)(A).

D. Health care providers must furnish copies of the health care records within 30 calendar days from receipt of a properly completed Form WCB-220.

E. Form WCB-220 may be revoked using Form WCB-220R.


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3. A. In the event that the employer/insurer or employee representative contends that testing, treatment or counseling records related to psychological matters, HIV/AIDS, substance abuse, or sexually transmitted disease matters are relevant to issues in the workers’ compensation case, it may obtain such specific information as agreed upon by the represented parties. If the represented parties agree, the parties shall use Form WCB-220A, WCB-220B, or WCB-220C, set forth in Appendix V, as appropriate. Within 14 calendar days the employee or the employee’s authorized representative, as defined in paragraph D of this section, shall sign the release and return it to the requesting party.

B. All parties, including health care providers, shall only use Form WCB-220A, WCB-220B, or WCB-220C set forth in Appendix V. The use of forms other than the ones set forth in Appendix V and/or requiring additional forms is prohibited.

C. In all other cases such information shall be requested on written motion to the Administrative Law Judge showing the need for the information. The Administrative Law Judge may authorize the release of this information subject to appropriate terms and conditions as to reasonable protection of confidentiality.

D. For purposes of this section, “authorized representative” has the same definition as set forth in 22 M.R.S.A § 1711-C(1)(A)E. Health care providers must furnish copies of the health care records within 30 calendar days from receipt of a properly completed Form WCB-220A, WCB-220B, or WCB-220C or within 30 calendar days from receipt of an order of an Administrative Law Judge.

F. Form WCB-220A, WCB-220B, or WCB-220C may be revoked using Form WCB-220R.

4. A. If an employee who is being paid pursuant to a compensation payment scheme revokes a medical release using Form WCB-220R, the employer/insurer may file a Motion to Compel with the Administrative Law Judge assigned to the case.

B. The Motion must include, at a minimum:

(i) A copy of the medical release form that was revoked; (ii) The relevant Form WCB-220R; (iii) Proof that the revocation was sent to the relevant health care provider(s); (iv) An explanation of why continued receipt of the medial records is necessary to adjust the employee’s claim; and (v) Notice that the employee has 21 days to respond to the Motion.

C. The employee may reply within 21 days after receipt of the Motion. The reply must explain why continued receipt of the medical records is not necessary to adjust the employee’s claim.


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D. The Administrative Law Judge may grant the Motion to Compel if continued receipt of the medical records is necessary to adjust the employee’s claim.

5. 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.

6. Health care providers must complete the M-1 form set forth in Appendix I in accordance with 39-A M.R.S.A. § 208. The use of a form other than the one set forth in Appendix I is prohibited and may subject the health care provider to penalty under 39-A M.R.S.A. § 360.

7. Pursuant to 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.

8. Fees for copies of medical information are as set forth in § 1.08 of this chapter.

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.


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SECTION 2. PROFESSIONAL SERVICES


1. Pursuant to 39-A M.R.S.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 $60.00.

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 EVALUATION AND MANAGEMENT GUIDELINES

1. Definition of New Patient

A. A new patient is one who has not received any professional services from the health care provider (or another health care provider of the exact same specialty and subspecialty who belongs to the same group practice) within the past three years, or

B. A new patient is one who is being evaluated for a new injury/illness to determine work relatedness/causality, or

C. A new patient is one who is being seen for a new episode of care for an existing injury/illness.

2. Payments for New Patient Visits

Only one new patient visit is reimbursable to a health care provider (or another health care provider of the exact same specialty and subspecialty who belongs to the same group practice) for the same patient relating to the same episode of care.

3. For purposes of this section, “episode of care” includes all the professional services provided by the health care provider (or another health care provider of the exact same specialty and subspecialty who belongs to the same group practice) for the same patient for the same injury/illness from date of initial examination to date of discharge from care.


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2.03 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 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.


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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 the number of minutes of anesthesia time. 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

2.04 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


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of care required before and after surgery. The normal range of post-surgical care is indicated under “Global Days” 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. All post-surgical care services, which are routinely performed by the surgeon or by members of the same group within the same specialty as the surgeon, 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. 5. When two or more surgical procedures are performed at the same session by the

same individual, the highest weighted surgical code is paid at 100% of the fee listed in Appendix II and additional surgical procedures are paid at 50% of the fee listed in Appendix II. Add-on codes are not subject to discounting.

2.05 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.


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2. Fees for durable medical equipment, prosthetics, orthotics, and supplies are as outlined in Appendix II. Invoices need not be requested by the employer/insurer.


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SECTION 3. INPATIENT FACILITY FEES

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 is $11,121.68.

3.03 CRITICAL ACCESS HOSPITALS

The base rate for inpatient services at critical access hospitals is $11,788.98.

3.04 [Reserved]


Pursuant to 39-A M.R.S.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 fees in effect 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 by submitting a copy of the invoice(s) along with the bill. Invoices need not be requested by the employer/insurer. Reimbursement is set at the actual amount paid plus $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.


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3.08 SERVICES INCLUDED

All services provided during an uninterrupted patient encounter leading to an inpatient admission must be included in the inpatient stay. Services do not include costs related to transportation of a patient to obtain medical care. Costs related to transportation are payable separately.

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. Costs related to transportation are payable separately.

3.10 OTHER INPATIENT FACILITY FEES

Inpatient services provided by institutional health care providers other than acute care or critical access 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.


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SECTION 4. OUTPATIENT FACILITY FEES

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 is $150.05.

4.03 CRITICAL ACCESS HOSPITALS

The base rate for outpatient services at critical access hospitals is $174.00.

4.04 AMBULATORY SURGICAL CENTERS

The base rate for surgical services at ambulatory surgical centers is $113.39.


Pursuant to 39-A M.R.S.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 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 additional 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 any 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 calculated at 75% of the provider’s usual and customary charge.\


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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%. If a bill has more than one surgical procedure with a status indicator of J, S or T and one or more of those procedures has less than a $1.01 charge, charges for all status J, S and T lines are summed and the charges are then divided across the J, S and T lines in proportion to their APC payment rate. The new charge amount is used in place of the submitted charge amount in the outlier calculation.

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) by submitting a copy of the invoice(s) along with the bill. Invoices need not be requested by the employer/insurer. 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

Outpatient services include observation in an outpatient status.

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. Costs related to transportation are payable separately.

4.10 OTHER OUTPATIENT FACILITY FEES

Outpatient services provided by institutional health care providers other than acute care or critical access 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.


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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

AMENDED: September 1, 2018 – filing 2018-122 – 136 AMENDED: January 1, 2019 – filing 2018-268


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CHAPTER 5

APPENDIX I


PRACTITIONER’S REPORT (FORM M-1)


- 24 -


- 25 -

GUIDELINES FOR COMPLETING THE M1 FORM

ESTIMATED LENGTH OF TREATMENT: describe in days, weeks, or months TREATMENT PLAN: INCLUDE items like REST, MEDICATION, EXERCISE, or other forms of treatment OFFICE PROCEDURES: INCLUDE Items like CAST, SPLINT, STRAPPING, INJECTIONS, SUTURES, etc. MEDICAL REFERRALS: INCLUDE items like THERAPY, SURGEON, CHIROPRACTIC, etc. MODIFIED WORK: INDICATE RIGHT or LEFT as appropriate; FREQUENCY (Never, Occasional


- 26 -

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 §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


PROFESSIONAL SERVICES

Professional Services - Anesthesia Maine Workers' Compensation BoardMedical Fee Schedule

Appendix II

Code

Anesthesia Base Unit Effective

1-1-2000100 500102 600103 500104 400120 500124 400126 400140 500142 400144 600145 600147 400148 400160 500162 700164 400170 500172 600174 600176 700190 500192 700210 1100211 1000212 500214 900215 900216 1500218 1300220 1000222 600300 500320 600322 300326 700350 1000352 500400 300402 500404 500406 1300410 400450 500452 600454 300470 600472 1000474 1300500 1500520 600522 4

CPT Codes, Copyright, American Medical Association 1


Appendix II

Code


1-1-2000524 400528 800529 1100530 400532 400534 700537 700539 1800540 1200541 1500542 1500546 1500548 1700550 1000560 1500561 2500562 2000563 2500566 2500567 1800580 2000600 1000604 1300620 1000622 1300625 1300626 1500630 800632 700634 1000635 400640 300670 1300700 400702 400730 500731 500732 600750 400752 600754 700756 700770 1500790 700792 1300794 800796 3000797 1100800 400802 500811 4



Appendix II

Code


1-1-2000812 300813 500820 500830 400832 600834 500836 600840 600842 400844 700846 800848 800851 600860 600862 700864 800865 700866 1000868 1000870 500872 700873 500880 1500882 1000902 500904 700906 400908 600910 300912 500914 500916 500918 500920 300921 300922 600924 400926 400928 600930 400932 400934 600936 800938 400940 300942 400944 600948 400950 500952 401112 5



Appendix II

Code


1-1-2001120 601130 301140 1501150 1001160 401170 801173 1201200 401202 401210 601212 1001214 801215 1001220 401230 601232 501234 801250 401260 301270 801272 401274 601320 401340 401360 501380 301382 301390 301392 401400 401402 701404 501420 301430 301432 601440 801442 801444 801462 301464 301470 301472 501474 501480 301482 401484 401486 701490 301500 801502 601520 3



Appendix II

Code


1-1-2001522 501610 501620 401622 401630 501634 901636 1501638 1001650 601652 1001654 801656 1001670 401680 301710 301712 501714 501716 501730 301732 301740 401742 501744 501756 601758 501760 701770 601772 601780 301782 401810 301820 301829 301830 301832 601840 601842 601844 601850 301852 401860 301916 501920 701922 701924 501925 701926 801930 501931 701932 601933 7



Appendix II

Code


1-1-2001935 501936 501951 301952 501953 101958 501960 501961 701962 801963 801964 401965 401966 401967 501968 201969 501990 701991 301992 501995 501996 301999 0


Professional Services - Other Maine Workers' Compensation BoardMedical Fee Schedule

Appendix II

Code Mod

Non-Facility

Total RVUGlobal Days

Pre-Operative

Intra-operative

Post-operative

Professional Fee Effective

1-1-2010004 1.48 ZZZ 0.00 0.00 0.00 $88.8010005 3.67 XXX 0.00 0.00 0.00 $220.2010006 1.70 ZZZ 0.00 0.00 0.00 $102.0010007 8.43 XXX 0.00 0.00 0.00 $505.8010008 4.79 ZZZ 0.00 0.00 0.00 $287.4010009 13.32 XXX 0.00 0.00 0.00 $799.2010010 8.02 ZZZ 0.00 0.00 0.00 $481.2010021 2.80 XXX 0.00 0.00 0.00 $168.0010030 17.53 000 0.00 0.00 0.00 $1,051.8010035 12.84 000 0.00 0.00 0.00 $770.4010036 10.92 ZZZ 0.00 0.00 0.00 $655.2010040 3.11 010 0.10 0.80 0.10 $186.6010060 3.44 010 0.10 0.80 0.10 $206.4010061 5.97 010 0.10 0.80 0.10 $358.2010080 5.99 010 0.10 0.80 0.10 $359.4010081 8.67 010 0.10 0.80 0.10 $520.2010120 4.31 010 0.10 0.80 0.10 $258.6010121 7.76 010 0.10 0.80 0.10 $465.6010140 4.85 010 0.10 0.80 0.10 $291.0010160 3.71 010 0.10 0.80 0.10 $222.6010180 7.30 010 0.10 0.80 0.10 $438.0011000 1.61 000 0.00 0.00 0.00 $96.6011001 0.67 ZZZ 0.00 0.00 0.00 $40.2011004 16.68 000 0.00 0.00 0.00 $1,000.8011005 22.72 000 0.00 0.00 0.00 $1,363.2011006 20.49 000 0.00 0.00 0.00 $1,229.4011008 7.99 ZZZ 0.00 0.00 0.00 $479.4011010 13.56 010 0.10 0.80 0.10 $813.6011011 15.10 000 0.00 0.00 0.00 $906.0011012 19.34 000 0.00 0.00 0.00 $1,160.4011042 3.57 000 0.00 0.00 0.00 $214.2011043 6.64 000 0.00 0.00 0.00 $398.4011044 8.96 000 0.00 0.00 0.00 $537.6011045 1.19 ZZZ 0.00 0.00 0.00 $71.4011046 2.12 ZZZ 0.00 0.00 0.00 $127.2011047 3.53 ZZZ 0.00 0.00 0.00 $211.8011055 1.78 000 0.00 0.00 0.00 $106.8011056 2.10 000 0.00 0.00 0.00 $126.0011057 2.31 000 0.00 0.00 0.00 $138.6011102 2.84 000 0.00 0.00 0.00 $170.4011103 1.51 ZZZ 0.00 0.00 0.00 $90.6011104 3.57 000 0.00 0.00 0.00 $214.2011105 1.72 ZZZ 0.00 0.00 0.00 $103.2011106 4.32 000 0.00 0.00 0.00 $259.2011107 2.04 ZZZ 0.00 0.00 0.00 $122.4011200 2.52 010 0.10 0.80 0.10 $151.2011201 0.53 ZZZ 0.00 0.00 0.00 $31.8011300 2.84 000 0.00 0.00 0.00 $170.4011301 3.45 000 0.00 0.00 0.00 $207.0011302 3.99 000 0.00 0.00 0.00 $239.4011303 4.39 000 0.00 0.00 0.00 $263.40



Appendix II

Code Mod

Non-Facility


Pre-Operative

Intra-operative

Post-operative


1-1-2011305 2.99 000 0.00 0.00 0.00 $179.4011306 3.50 000 0.00 0.00 0.00 $210.0011307 4.09 000 0.00 0.00 0.00 $245.4011308 4.37 000 0.00 0.00 0.00 $262.2011310 3.29 000 0.00 0.00 0.00 $197.4011311 3.90 000 0.00 0.00 0.00 $234.0011312 4.51 000 0.00 0.00 0.00 $270.6011313 5.27 000 0.00 0.00 0.00 $316.2011400 3.57 010 0.10 0.80 0.10 $214.2011401 4.35 010 0.10 0.80 0.10 $261.0011402 4.83 010 0.10 0.80 0.10 $289.8011403 5.58 010 0.10 0.80 0.10 $334.8011404 6.34 010 0.10 0.80 0.10 $380.4011406 9.07 010 0.10 0.80 0.10 $544.2011420 3.60 010 0.10 0.80 0.10 $216.0011421 4.54 010 0.10 0.80 0.10 $272.4011422 5.11 010 0.10 0.80 0.10 $306.6011423 5.81 010 0.10 0.80 0.10 $348.6011424 6.71 010 0.10 0.80 0.10 $402.6011426 9.63 010 0.10 0.80 0.10 $577.8011440 3.97 010 0.10 0.80 0.10 $238.2011441 4.88 010 0.10 0.80 0.10 $292.8011442 5.43 010 0.10 0.80 0.10 $325.8011443 6.45 010 0.10 0.80 0.10 $387.0011444 8.09 010 0.10 0.80 0.10 $485.4011446 11.14 010 0.10 0.80 0.10 $668.4011450 11.67 090 0.10 0.71 0.19 $700.2011451 14.54 090 0.10 0.71 0.19 $872.4011462 11.36 090 0.10 0.71 0.19 $681.6011463 14.79 090 0.10 0.71 0.19 $887.4011470 12.38 090 0.10 0.71 0.19 $742.8011471 15.08 090 0.10 0.71 0.19 $904.8011600 5.61 010 0.10 0.80 0.10 $336.6011601 6.52 010 0.10 0.80 0.10 $391.2011602 7.02 010 0.10 0.80 0.10 $421.2011603 8.00 010 0.10 0.80 0.10 $480.0011604 8.93 010 0.10 0.80 0.10 $535.8011606 12.81 010 0.10 0.80 0.10 $768.6011620 5.64 010 0.10 0.80 0.10 $338.4011621 6.55 010 0.10 0.80 0.10 $393.0011622 7.25 010 0.10 0.80 0.10 $435.0011623 8.52 010 0.10 0.80 0.10 $511.2011624 9.65 010 0.10 0.80 0.10 $579.0011626 11.66 010 0.10 0.80 0.10 $699.6011640 5.77 010 0.10 0.80 0.10 $346.2011641 6.78 010 0.10 0.80 0.10 $406.8011642 7.69 010 0.10 0.80 0.10 $461.4011643 9.06 010 0.10 0.80 0.10 $543.6011644 11.18 010 0.10 0.80 0.10 $670.8011646 14.57 010 0.10 0.80 0.10 $874.2011719 0.40 000 0.00 0.00 0.00 $24.00



Appendix II

Code Mod

Non-Facility


Pre-Operative

Intra-operative

Post-operative


1-1-2011720 0.93 000 0.00 0.00 0.00 $55.8011721 1.29 000 0.00 0.00 0.00 $77.4011730 3.14 000 0.00 0.00 0.00 $188.4011732 0.95 ZZZ 0.00 0.00 0.00 $57.0011740 1.52 000 0.00 0.00 0.00 $91.2011750 4.45 010 0.10 0.80 0.10 $267.0011755 3.47 000 0.00 0.00 0.00 $208.2011760 5.55 010 0.10 0.80 0.10 $333.0011762 8.44 010 0.10 0.80 0.10 $506.4011765 4.80 010 0.10 0.80 0.10 $288.0011770 8.92 010 0.10 0.80 0.10 $535.2011771 17.29 090 0.10 0.71 0.19 $1,037.4011772 20.95 090 0.10 0.71 0.19 $1,257.0011900 1.56 000 0.00 0.00 0.00 $93.6011901 1.97 000 0.00 0.00 0.00 $118.2011920 5.33 000 0.00 0.00 0.00 $319.8011921 6.08 000 0.00 0.00 0.00 $364.8011922 1.71 ZZZ 0.00 0.00 0.00 $102.6011950 2.26 000 0.00 0.00 0.00 $135.6011951 3.07 000 0.00 0.00 0.00 $184.2011952 4.13 000 0.00 0.00 0.00 $247.8011954 4.54 000 0.00 0.00 0.00 $272.4011960 28.11 090 0.10 0.71 0.19 $1,686.6011970 17.62 090 0.10 0.71 0.19 $1,057.2011971 13.77 090 0.10 0.71 0.19 $826.2011976 4.15 000 0.00 0.00 0.00 $249.0011980 2.69 000 0.00 0.00 0.00 $161.4011981 2.96 000 0.00 0.00 0.00 $177.6011982 3.36 000 0.00 0.00 0.00 $201.6011983 4.15 000 0.00 0.00 0.00 $249.0012001 2.58 000 0.00 0.00 0.00 $154.8012002 3.16 000 0.00 0.00 0.00 $189.6012004 3.69 000 0.00 0.00 0.00 $221.4012005 4.88 000 0.00 0.00 0.00 $292.8012006 5.76 000 0.00 0.00 0.00 $345.6012007 6.58 000 0.00 0.00 0.00 $394.8012011 3.15 000 0.00 0.00 0.00 $189.0012013 3.29 000 0.00 0.00 0.00 $197.4012014 4.00 000 0.00 0.00 0.00 $240.0012015 4.84 000 0.00 0.00 0.00 $290.4012016 6.16 000 0.00 0.00 0.00 $369.6012017 4.48 000 0.00 0.00 0.00 $268.8012018 5.08 000 0.00 0.00 0.00 $304.8012020 8.41 010 0.10 0.80 0.10 $504.6012021 4.90 010 0.10 0.80 0.10 $294.0012031 7.17 010 0.10 0.80 0.10 $430.2012032 8.59 010 0.10 0.80 0.10 $515.4012034 9.24 010 0.10 0.80 0.10 $554.4012035 11.03 010 0.10 0.80 0.10 $661.8012036 12.34 010 0.10 0.80 0.10 $740.4012037 14.01 010 0.10 0.80 0.10 $840.60



Appendix II

Code Mod

Non-Facility


Pre-Operative

Intra-operative

Post-operative


1-1-2012041 7.19 010 0.10 0.80 0.10 $431.4012042 8.54 010 0.10 0.80 0.10 $512.4012044 10.60 010 0.10 0.80 0.10 $636.0012045 11.63 010 0.10 0.80 0.10 $697.8012046 14.05 010 0.10 0.80 0.10 $843.0012047 15.43 010 0.10 0.80 0.10 $925.8012051 7.73 010 0.10 0.80 0.10 $463.8012052 8.67 010 0.10 0.80 0.10 $520.2012053 10.16 010 0.10 0.80 0.10 $609.6012054 10.72 010 0.10 0.80 0.10 $643.2012055 13.92 010 0.10 0.80 0.10 $835.2012056 16.34 010 0.10 0.80 0.10 $980.4012057 17.37 010 0.10 0.80 0.10 $1,042.2013100 9.72 010 0.10 0.80 0.10 $583.2013101 11.41 010 0.10 0.80 0.10 $684.6013102 3.43 ZZZ 0.00 0.00 0.00 $205.8013120 10.14 010 0.10 0.80 0.10 $608.4013121 12.24 010 0.10 0.80 0.10 $734.4013122 3.74 ZZZ 0.00 0.00 0.00 $224.4013131 11.11 010 0.10 0.80 0.10 $666.6013132 13.59 010 0.10 0.80 0.10 $815.4013133 4.98 ZZZ 0.00 0.00 0.00 $298.8013151 12.13 010 0.10 0.80 0.10 $727.8013152 14.36 010 0.10 0.80 0.10 $861.6013153 5.45 ZZZ 0.00 0.00 0.00 $327.0013160 22.99 090 0.10 0.71 0.19 $1,379.4014000 17.89 090 0.10 0.71 0.19 $1,073.4014001 22.85 090 0.10 0.71 0.19 $1,371.0014020 19.80 090 0.10 0.71 0.19 $1,188.0014021 24.63 090 0.10 0.71 0.19 $1,477.8014040 21.56 090 0.10 0.71 0.19 $1,293.6014041 26.37 090 0.10 0.71 0.19 $1,582.2014060 21.90 090 0.10 0.71 0.19 $1,314.0014061 28.36 090 0.10 0.71 0.19 $1,701.6014301 30.86 090 0.10 0.71 0.19 $1,851.6014302 6.31 ZZZ 0.00 0.00 0.00 $378.6014350 19.73 090 0.10 0.71 0.19 $1,183.8015002 10.04 000 0.00 0.00 0.00 $602.4015003 2.08 ZZZ 0.00 0.00 0.00 $124.8015004 11.44 000 0.00 0.00 0.00 $686.4015005 3.50 ZZZ 0.00 0.00 0.00 $210.0015040 7.47 000 0.00 0.00 0.00 $448.2015050 16.77 090 0.10 0.71 0.19 $1,006.2015100 24.84 090 0.10 0.71 0.19 $1,490.4015101 5.40 ZZZ 0.00 0.00 0.00 $324.0015110 23.13 090 0.10 0.71 0.19 $1,387.8015111 3.33 ZZZ 0.00 0.00 0.00 $199.8015115 22.84 090 0.10 0.71 0.19 $1,370.4015116 4.81 ZZZ 0.00 0.00 0.00 $288.6015120 24.36 090 0.10 0.71 0.19 $1,461.6015121 6.05 ZZZ 0.00 0.00 0.00 $363.00



Appendix II

Code Mod

Non-Facility


Pre-Operative

Intra-operative

Post-operative


1-1-2015130 20.63 090 0.10 0.71 0.19 $1,237.8015131 2.86 ZZZ 0.00 0.00 0.00 $171.6015135 25.01 090 0.10 0.71 0.19 $1,500.6015136 2.83 ZZZ 0.00 0.00 0.00 $169.8015150 20.30 090 0.10 0.71 0.19 $1,218.0015151 3.47 ZZZ 0.00 0.00 0.00 $208.2015152 4.47 ZZZ 0.00 0.00 0.00 $268.2015155 23.06 090 0.10 0.71 0.19 $1,383.6015156 4.64 ZZZ 0.00 0.00 0.00 $278.4015157 5.19 ZZZ 0.00 0.00 0.00 $311.4015200 23.93 090 0.10 0.71 0.19 $1,435.8015201 4.20 ZZZ 0.00 0.00 0.00 $252.0015220 21.98 090 0.10 0.71 0.19 $1,318.8015221 3.86 ZZZ 0.00 0.00 0.00 $231.6015240 26.53 090 0.10 0.71 0.19 $1,591.8015241 5.18 ZZZ 0.00 0.00 0.00 $310.8015260 28.50 090 0.10 0.71 0.19 $1,710.0015261 5.99 ZZZ 0.00 0.00 0.00 $359.4015271 4.29 000 0.00 0.00 0.00 $257.4015272 0.75 ZZZ 0.00 0.00 0.00 $45.0015273 8.93 000 0.00 0.00 0.00 $535.8015274 2.26 ZZZ 0.00 0.00 0.00 $135.6015275 4.48 000 0.00 0.00 0.00 $268.8015276 0.98 ZZZ 0.00 0.00 0.00 $58.8015277 9.79 000 0.00 0.00 0.00 $587.4015278 2.67 ZZZ 0.00 0.00 0.00 $160.2015570 26.22 090 0.10 0.71 0.19 $1,573.2015572 25.30 090 0.10 0.71 0.19 $1,518.0015574 25.75 090 0.10 0.71 0.19 $1,545.0015576 22.75 090 0.10 0.71 0.19 $1,365.0015600 9.47 090 0.10 0.71 0.19 $568.2015610 10.29 090 0.10 0.71 0.19 $617.4015620 12.60 090 0.10 0.71 0.19 $756.0015630 13.06 090 0.10 0.71 0.19 $783.6015650 14.51 090 0.10 0.71 0.19 $870.6015730 42.95 090 0.10 0.71 0.19 $2,577.0015731 32.09 090 0.10 0.71 0.19 $1,925.4015733 29.94 090 0.10 0.71 0.19 $1,796.4015734 43.61 090 0.10 0.71 0.19 $2,616.6015736 35.30 090 0.10 0.71 0.19 $2,118.0015738 37.43 090 0.10 0.71 0.19 $2,245.8015740 28.62 090 0.10 0.71 0.19 $1,717.2015750 26.41 090 0.10 0.71 0.19 $1,584.6015756 66.02 090 0.10 0.71 0.19 $3,961.2015757 65.62 090 0.10 0.71 0.19 $3,937.2015758 66.04 090 0.10 0.71 0.19 $3,962.4015760 24.14 090 0.10 0.71 0.19 $1,448.4015769 13.86 090 0.10 0.69 0.21 $831.6015770 19.05 090 0.10 0.71 0.19 $1,143.0015771 16.55 090 0.10 0.69 0.21 $993.0015772 5.22 ZZZ 0.00 0.00 0.00 $313.20



Appendix II

Code Mod

Non-Facility


Pre-Operative

Intra-operative

Post-operative


1-1-2015773 16.70 090 0.10 0.69 0.21 $1,002.0015774 5.06 ZZZ 0.00 0.00 0.00 $303.6015775 10.60 000 0.00 0.00 0.00 $636.0015776 14.54 000 0.00 0.00 0.00 $872.4015777 6.25 ZZZ 0.00 0.00 0.00 $375.0015780 25.20 090 0.10 0.71 0.19 $1,512.0015781 15.67 090 0.10 0.71 0.19 $940.2015782 15.35 090 0.10 0.71 0.19 $921.0015783 13.20 090 0.10 0.71 0.19 $792.0015786 6.87 010 0.10 0.80 0.10 $412.2015787 1.15 ZZZ 0.00 0.00 0.00 $69.0015788 12.26 090 0.10 0.71 0.19 $735.6015789 15.38 090 0.10 0.71 0.19 $922.8015792 10.99 090 0.10 0.71 0.19 $659.4015793 13.64 090 0.10 0.71 0.19 $818.4015819 22.96 090 0.10 0.71 0.19 $1,377.6015820 16.23 090 0.10 0.71 0.19 $973.8015821 17.42 090 0.10 0.71 0.19 $1,045.2015822 12.91 090 0.10 0.71 0.19 $774.6015823 17.44 090 0.10 0.71 0.19 $1,046.4015830 33.98 090 0.10 0.71 0.19 $2,038.8015832 26.57 090 0.10 0.71 0.19 $1,594.2015833 25.23 090 0.10 0.71 0.19 $1,513.8015834 25.73 090 0.10 0.71 0.19 $1,543.8015835 26.98 090 0.10 0.71 0.19 $1,618.8015836 21.67 090 0.10 0.71 0.19 $1,300.2015837 24.90 090 0.10 0.71 0.19 $1,494.0015838 18.53 090 0.10 0.71 0.19 $1,111.8015839 25.44 090 0.10 0.71 0.19 $1,526.4015840 28.93 090 0.10 0.71 0.19 $1,735.8015841 51.57 090 0.10 0.71 0.19 $3,094.2015842 78.55 090 0.10 0.71 0.19 $4,713.0015845 28.97 090 0.10 0.71 0.19 $1,738.2015850 2.57 XXX 0.00 0.00 0.00 $154.2015851 2.93 000 0.00 0.00 0.00 $175.8015852 1.34 000 0.00 0.00 0.00 $80.4015860 3.13 000 0.00 0.00 0.00 $187.8015920 18.05 090 0.10 0.71 0.19 $1,083.0015922 22.80 090 0.10 0.71 0.19 $1,368.0015931 20.18 090 0.10 0.71 0.19 $1,210.8015933 24.96 090 0.10 0.71 0.19 $1,497.6015934 27.31 090 0.10 0.71 0.19 $1,638.6015935 33.22 090 0.10 0.71 0.19 $1,993.2015936 26.03 090 0.10 0.71 0.19 $1,561.8015937 30.13 090 0.10 0.71 0.19 $1,807.8015940 20.29 090 0.10 0.71 0.19 $1,217.4015941 26.43 090 0.10 0.71 0.19 $1,585.8015944 26.27 090 0.10 0.71 0.19 $1,576.2015945 29.30 090 0.10 0.71 0.19 $1,758.0015946 47.09 090 0.10 0.71 0.19 $2,825.4015950 17.61 090 0.10 0.71 0.19 $1,056.60



Appendix II

Code Mod

Non-Facility


Pre-Operative

Intra-operative

Post-operative


1-1-2015951 25.70 090 0.10 0.71 0.19 $1,542.0015952 26.31 090 0.10 0.71 0.19 $1,578.6015953 28.96 090 0.10 0.71 0.19 $1,737.6015956 33.75 090 0.10 0.71 0.19 $2,025.0015958 34.08 090 0.10 0.71 0.19 $2,044.8016000 2.09 000 0.00 0.00 0.00 $125.4016020 2.35 000 0.00 0.00 0.00 $141.0016025 4.39 000 0.00 0.00 0.00 $263.4016030 5.54 000 0.00 0.00 0.00 $332.4016035 5.71 000 0.00 0.00 0.00 $342.6016036 2.37 ZZZ 0.00 0.00 0.00 $142.2017000 1.85 010 0.10 0.80 0.10 $111.0017003 0.17 ZZZ 0.00 0.00 0.00 $10.2017004 4.48 010 0.10 0.80 0.10 $268.8017106 9.72 090 0.10 0.71 0.19 $583.2017107 12.73 090 0.10 0.71 0.19 $763.8017108 18.14 090 0.10 0.71 0.19 $1,088.4017110 3.17 010 0.10 0.80 0.10 $190.2017111 3.72 010 0.10 0.80 0.10 $223.2017250 2.42 000 0.00 0.00 0.00 $145.2017260 2.74 010 0.10 0.80 0.10 $164.4017261 4.13 010 0.10 0.80 0.10 $247.8017262 5.01 010 0.10 0.80 0.10 $300.6017263 5.45 010 0.10 0.80 0.10 $327.0017264 5.84 010 0.10 0.80 0.10 $350.4017266 6.66 010 0.10 0.80 0.10 $399.6017270 4.22 010 0.10 0.80 0.10 $253.2017271 4.65 010 0.10 0.80 0.10 $279.0017272 5.32 010 0.10 0.80 0.10 $319.2017273 5.92 010 0.10 0.80 0.10 $355.2017274 6.97 010 0.10 0.80 0.10 $418.2017276 8.07 010 0.10 0.80 0.10 $484.2017280 3.94 010 0.10 0.80 0.10 $236.4017281 5.06 010 0.10 0.80 0.10 $303.6017282 5.82 010 0.10 0.80 0.10 $349.2017283 6.94 010 0.10 0.80 0.10 $416.4017284 7.90 010 0.10 0.80 0.10 $474.0017286 10.18 010 0.10 0.80 0.10 $610.8017311 18.84 000 0.00 0.00 0.00 $1,130.4017312 11.30 ZZZ 0.00 0.00 0.00 $678.0017313 17.66 000 0.00 0.00 0.00 $1,059.6017314 10.80 ZZZ 0.00 0.00 0.00 $648.0017315 2.22 ZZZ 0.00 0.00 0.00 $133.2017340 1.50 010 0.10 0.80 0.10 $90.0017360 3.52 010 0.10 0.80 0.10 $211.2019000 3.11 000 0.00 0.00 0.00 $186.6019001 0.78 ZZZ 0.00 0.00 0.00 $46.8019020 13.54 090 0.10 0.71 0.19 $812.4019030 4.79 000 0.00 0.00 0.00 $287.4019081 17.34 000 0.00 0.00 0.00 $1,040.4019082 13.98 ZZZ 0.00 0.00 0.00 $838.80



Appendix II

Code Mod

Non-Facility


Pre-Operative

Intra-operative

Post-operative


1-1-2019083 17.16 000 0.00 0.00 0.00 $1,029.6019084 13.60 ZZZ 0.00 0.00 0.00 $816.0019085 26.18 000 0.00 0.00 0.00 $1,570.8019086 20.81 ZZZ 0.00 0.00 0.00 $1,248.6019100 4.40 000 0.00 0.00 0.00 $264.0019101 9.62 010 0.10 0.80 0.10 $577.2019105 77.64 000 0.00 0.00 0.00 $4,658.4019110 14.01 090 0.10 0.71 0.19 $840.6019112 13.20 090 0.10 0.71 0.19 $792.0019120 14.52 090 0.10 0.71 0.19 $871.2019125 16.05 090 0.10 0.71 0.19 $963.0019126 4.68 ZZZ 0.00 0.00 0.00 $280.8019281 6.97 000 0.00 0.00 0.00 $418.2019282 4.92 ZZZ 0.00 0.00 0.00 $295.2019283 7.74 000 0.00 0.00 0.00 $464.4019284 5.90 ZZZ 0.00 0.00 0.00 $354.0019285 12.98 000 0.00 0.00 0.00 $778.8019286 11.08 ZZZ 0.00 0.00 0.00 $664.8019287 22.10 000 0.00 0.00 0.00 $1,326.0019288 17.58 ZZZ 0.00 0.00 0.00 $1,054.8019294 4.81 ZZZ 0.00 0.00 0.00 $288.6019296 114.23 000 0.00 0.00 0.00 $6,853.8019297 2.77 ZZZ 0.00 0.00 0.00 $166.2019298 28.47 000 0.00 0.00 0.00 $1,708.2019300 15.83 090 0.10 0.71 0.19 $949.8019301 19.06 090 0.10 0.71 0.19 $1,143.6019302 26.20 090 0.10 0.71 0.19 $1,572.0019303 27.84 090 0.10 0.71 0.19 $1,670.4019305 33.05 090 0.10 0.71 0.19 $1,983.0019306 35.09 090 0.10 0.71 0.19 $2,105.4019307 34.98 090 0.10 0.71 0.19 $2,098.8019316 22.37 090 0.10 0.71 0.19 $1,342.2019318 31.72 090 0.10 0.71 0.19 $1,903.2019324 15.41 090 0.10 0.71 0.19 $924.6019325 18.69 090 0.10 0.71 0.19 $1,121.4019328 14.43 090 0.10 0.71 0.19 $865.8019330 18.31 090 0.10 0.71 0.19 $1,098.6019340 28.58 090 0.10 0.71 0.19 $1,714.8019342 26.78 090 0.10 0.71 0.19 $1,606.8019350 23.82 090 0.10 0.71 0.19 $1,429.2019355 21.76 090 0.10 0.71 0.19 $1,305.6019357 43.37 090 0.10 0.71 0.19 $2,602.2019361 45.46 090 0.10 0.71 0.19 $2,727.6019364 79.72 090 0.10 0.71 0.19 $4,783.2019366 40.38 090 0.10 0.71 0.19 $2,422.8019367 51.50 090 0.10 0.71 0.19 $3,090.0019368 63.54 090 0.10 0.71 0.19 $3,812.4019369 59.01 090 0.10 0.71 0.19 $3,540.6019370 19.91 090 0.10 0.71 0.19 $1,194.6019371 22.76 090 0.10 0.71 0.19 $1,365.6019380 22.47 090 0.10 0.71 0.19 $1,348.20



Appendix II

Code Mod

Non-Facility


Pre-Operative

Intra-operative

Post-operative


1-1-2019396 8.20 000 0.00 0.00 0.00 $492.0020100 17.47 010 0.10 0.80 0.10 $1,048.2020101 13.71 010 0.10 0.80 0.10 $822.6020102 14.74 010 0.10 0.80 0.10 $884.4020103 16.57 010 0.10 0.80 0.10 $994.2020150 29.06 090 0.10 0.69 0.21 $1,743.6020200 6.07 000 0.00 0.00 0.00 $364.2020205 8.47 000 0.00 0.00 0.00 $508.2020206 6.76 000 0.00 0.00 0.00 $405.6020220 7.04 000 0.00 0.00 0.00 $422.4020225 11.92 000 0.00 0.00 0.00 $715.2020240 4.21 000 0.00 0.00 0.00 $252.6020245 10.07 000 0.00 0.00 0.00 $604.2020250 11.38 010 0.10 0.80 0.10 $682.8020251 12.36 010 0.10 0.80 0.10 $741.6020500 3.25 010 0.10 0.80 0.10 $195.0020501 3.91 000 0.00 0.00 0.00 $234.6020520 6.03 010 0.10 0.80 0.10 $361.8020525 13.60 010 0.10 0.80 0.10 $816.0020526 2.25 000 0.00 0.00 0.00 $135.0020527 2.43 000 0.00 0.00 0.00 $145.8020550 1.56 000 0.00 0.00 0.00 $93.6020551 1.60 000 0.00 0.00 0.00 $96.0020552 1.59 000 0.00 0.00 0.00 $95.4020553 1.82 000 0.00 0.00 0.00 $109.2020555 9.48 000 0.00 0.00 0.00 $568.8020560 0.74 XXX 0.00 0.00 0.00 $44.4020561 1.10 XXX 0.00 0.00 0.00 $66.0020600 1.44 000 0.00 0.00 0.00 $86.4020604 2.17 000 0.00 0.00 0.00 $130.2020605 1.49 000 0.00 0.00 0.00 $89.4020606 2.40 000 0.00 0.00 0.00 $144.0020610 1.77 000 0.00 0.00 0.00 $106.2020611 2.68 000 0.00 0.00 0.00 $160.8020612 1.76 000 0.00 0.00 0.00 $105.6020615 7.10 010 0.10 0.80 0.10 $426.0020650 6.08 010 0.10 0.80 0.10 $364.8020660 7.00 000 0.00 0.00 0.00 $420.0020661 14.43 090 0.10 0.69 0.21 $865.8020662 14.80 090 0.10 0.69 0.21 $888.0020663 13.61 090 0.10 0.69 0.21 $816.6020664 25.03 090 0.10 0.69 0.21 $1,501.8020665 3.19 010 0.10 0.80 0.10 $191.4020670 10.53 010 0.10 0.80 0.10 $631.8020680 17.59 090 0.10 0.69 0.21 $1,055.4020690 17.22 090 0.10 0.69 0.21 $1,033.2020692 32.28 090 0.10 0.69 0.21 $1,936.8020693 12.76 090 0.10 0.69 0.21 $765.6020694 12.25 090 0.10 0.69 0.21 $735.0020696 34.33 090 0.10 0.69 0.21 $2,059.8020697 57.81 000 0.00 0.00 0.00 $3,468.60



Appendix II

Code Mod

Non-Facility


Pre-Operative

Intra-operative

Post-operative


1-1-2020700 2.44 ZZZ 0.00 0.00 0.00 $146.4020701 1.82 ZZZ 0.00 0.00 0.00 $109.2020702 4.06 ZZZ 0.00 0.00 0.00 $243.6020703 2.91 ZZZ 0.00 0.00 0.00 $174.6020704 4.23 ZZZ 0.00 0.00 0.00 $253.8020705 3.48 ZZZ 0.00 0.00 0.00 $208.8020802 79.54 090 0.10 0.69 0.21 $4,772.4020805 94.71 090 0.10 0.69 0.21 $5,682.6020808 114.52 090 0.10 0.69 0.21 $6,871.2020816 59.58 090 0.10 0.69 0.21 $3,574.8020822 51.24 090 0.10 0.69 0.21 $3,074.4020824 59.68 090 0.10 0.69 0.21 $3,580.8020827 52.64 090 0.10 0.69 0.21 $3,158.4020838 80.64 090 0.10 0.69 0.21 $4,838.4020900 11.64 000 0.00 0.00 0.00 $698.4020902 8.16 000 0.00 0.00 0.00 $489.6020910 13.50 090 0.10 0.69 0.21 $810.0020912 13.63 090 0.10 0.69 0.21 $817.8020920 11.22 090 0.10 0.69 0.21 $673.2020922 17.06 090 0.10 0.69 0.21 $1,023.6020924 14.60 090 0.10 0.69 0.21 $876.0020931 3.22 ZZZ 0.00 0.00 0.00 $193.2020932 20.63 ZZZ 0.00 0.00 0.00 $1,237.8020933 18.96 ZZZ 0.00 0.00 0.00 $1,137.6020934 20.62 ZZZ 0.00 0.00 0.00 $1,237.2020937 4.85 ZZZ 0.00 0.00 0.00 $291.0020938 5.34 ZZZ 0.00 0.00 0.00 $320.4020939 2.03 ZZZ 0.00 0.00 0.00 $121.8020950 7.43 000 0.00 0.00 0.00 $445.8020955 70.99 090 0.10 0.69 0.21 $4,259.4020956 76.52 090 0.10 0.69 0.21 $4,591.2020957 79.62 090 0.10 0.69 0.21 $4,777.2020962 76.90 090 0.10 0.69 0.21 $4,614.0020969 78.61 090 0.10 0.69 0.21 $4,716.6020970 82.67 090 0.10 0.69 0.21 $4,960.2020972 82.45 090 0.10 0.69 0.21 $4,947.0020973 87.09 090 0.10 0.69 0.21 $5,225.4020974 2.26 000 0.00 0.00 0.00 $135.6020975 5.12 000 0.00 0.00 0.00 $307.2020979 1.53 000 0.00 0.00 0.00 $91.8020982 109.12 000 0.00 0.00 0.00 $6,547.2020983 162.60 000 0.00 0.00 0.00 $9,756.0020985 4.24 ZZZ 0.00 0.00 0.00 $254.4021010 21.49 090 0.10 0.69 0.21 $1,289.4021011 10.35 090 0.10 0.69 0.21 $621.0021012 9.72 090 0.10 0.69 0.21 $583.2021013 15.18 090 0.10 0.69 0.21 $910.8021014 15.00 090 0.10 0.69 0.21 $900.0021015 20.28 090 0.10 0.69 0.21 $1,216.8021016 29.09 090 0.10 0.69 0.21 $1,745.4021025 23.65 090 0.10 0.69 0.21 $1,419.00



Appendix II

Code Mod

Non-Facility


Pre-Operative

Intra-operative

Post-operative


1-1-2021026 16.08 090 0.10 0.69 0.21 $964.8021029 21.85 090 0.10 0.69 0.21 $1,311.0021030 14.07 090 0.10 0.69 0.21 $844.2021031 11.12 090 0.10 0.69 0.21 $667.2021032 11.14 090 0.10 0.69 0.21 $668.4021034 37.23 090 0.10 0.69 0.21 $2,233.8021040 14.18 090 0.10 0.69 0.21 $850.8021044 24.79 090 0.10 0.69 0.21 $1,487.4021045 34.69 090 0.10 0.69 0.21 $2,081.4021046 30.07 090 0.10 0.69 0.21 $1,804.2021047 36.75 090 0.10 0.69 0.21 $2,205.0021048 30.50 090 0.10 0.69 0.21 $1,830.0021049 34.69 090 0.10 0.69 0.21 $2,081.4021050 25.21 090 0.10 0.69 0.21 $1,512.6021060 22.92 090 0.10 0.69 0.21 $1,375.2021070 18.02 090 0.10 0.69 0.21 $1,081.2021073 10.92 090 0.10 0.69 0.21 $655.2021076 25.89 010 0.10 0.80 0.10 $1,553.4021077 64.03 090 0.10 0.69 0.21 $3,841.8021079 43.59 090 0.10 0.69 0.21 $2,615.4021080 49.84 090 0.10 0.69 0.21 $2,990.4021081 45.79 090 0.10 0.69 0.21 $2,747.4021082 42.41 090 0.10 0.69 0.21 $2,544.6021083 40.42 090 0.10 0.69 0.21 $2,425.2021084 46.27 090 0.10 0.69 0.21 $2,776.2021085 20.07 010 0.10 0.80 0.10 $1,204.2021086 47.65 090 0.10 0.69 0.21 $2,859.0021087 47.65 090 0.10 0.69 0.21 $2,859.0021100 18.94 090 0.10 0.69 0.21 $1,136.4021110 23.59 090 0.10 0.69 0.21 $1,415.4021116 5.62 000 0.00 0.00 0.00 $337.2021120 19.22 090 0.10 0.69 0.21 $1,153.2021121 19.44 090 0.10 0.69 0.21 $1,166.4021122 22.14 090 0.10 0.69 0.21 $1,328.4021123 25.16 090 0.10 0.69 0.21 $1,509.6021125 80.89 090 0.10 0.69 0.21 $4,853.4021127 115.15 090 0.10 0.69 0.21 $6,909.0021137 21.75 090 0.10 0.69 0.21 $1,305.0021138 26.57 090 0.10 0.69 0.21 $1,594.2021139 32.08 090 0.10 0.69 0.21 $1,924.8021141 38.46 090 0.10 0.69 0.21 $2,307.6021142 39.53 090 0.10 0.69 0.21 $2,371.8021143 41.06 090 0.10 0.69 0.21 $2,463.6021145 44.93 090 0.10 0.69 0.21 $2,695.8021146 46.89 090 0.10 0.69 0.21 $2,813.4021147 49.42 090 0.10 0.69 0.21 $2,965.2021150 47.30 090 0.10 0.69 0.21 $2,838.0021151 52.08 090 0.10 0.69 0.21 $3,124.8021154 56.04 090 0.10 0.69 0.21 $3,362.4021155 62.20 090 0.10 0.69 0.21 $3,732.0021159 74.59 090 0.10 0.69 0.21 $4,475.40



Appendix II

Code Mod

Non-Facility


Pre-Operative

Intra-operative

Post-operative


1-1-2021160 80.92 090 0.10 0.69 0.21 $4,855.2021172 60.26 090 0.10 0.69 0.21 $3,615.6021175 64.39 090 0.10 0.69 0.21 $3,863.4021179 44.20 090 0.10 0.69 0.21 $2,652.0021180 49.44 090 0.10 0.69 0.21 $2,966.4021181 21.45 090 0.10 0.69 0.21 $1,287.0021182 61.69 090 0.10 0.69 0.21 $3,701.4021183 67.19 090 0.10 0.69 0.21 $4,031.4021184 72.32 090 0.10 0.69 0.21 $4,339.2021188 46.57 090 0.10 0.69 0.21 $2,794.2021193 35.78 090 0.10 0.69 0.21 $2,146.8021194 41.24 090 0.10 0.69 0.21 $2,474.4021195 39.54 090 0.10 0.69 0.21 $2,372.4021196 40.94 090 0.10 0.69 0.21 $2,456.4021198 31.86 090 0.10 0.69 0.21 $1,911.6021199 29.88 090 0.10 0.69 0.21 $1,792.8021206 32.92 090 0.10 0.69 0.21 $1,975.2021208 48.72 090 0.10 0.69 0.21 $2,923.2021209 22.97 090 0.10 0.69 0.21 $1,378.2021210 56.52 090 0.10 0.69 0.21 $3,391.2021215 117.30 090 0.10 0.69 0.21 $7,038.0021230 21.38 090 0.10 0.69 0.21 $1,282.8021235 20.70 090 0.10 0.69 0.21 $1,242.0021240 30.85 090 0.10 0.69 0.21 $1,851.0021242 29.20 090 0.10 0.69 0.21 $1,752.0021243 47.06 090 0.10 0.69 0.21 $2,823.6021244 29.32 090 0.10 0.69 0.21 $1,759.2021245 34.58 090 0.10 0.69 0.21 $2,074.8021246 24.68 090 0.10 0.69 0.21 $1,480.8021247 45.93 090 0.10 0.69 0.21 $2,755.8021248 29.35 090 0.10 0.69 0.21 $1,761.0021249 40.17 090 0.10 0.69 0.21 $2,410.2021255 39.29 090 0.10 0.69 0.21 $2,357.4021256 35.98 090 0.10 0.69 0.21 $2,158.8021260 40.10 090 0.10 0.69 0.21 $2,406.0021261 71.12 090 0.10 0.69 0.21 $4,267.2021263 65.77 090 0.10 0.69 0.21 $3,946.2021267 46.89 090 0.10 0.69 0.21 $2,813.4021268 58.83 090 0.10 0.69 0.21 $3,529.8021270 29.17 090 0.10 0.69 0.21 $1,750.2021275 24.40 090 0.10 0.69 0.21 $1,464.0021280 16.44 090 0.10 0.69 0.21 $986.4021282 11.09 090 0.10 0.69 0.21 $665.4021295 5.39 090 0.10 0.69 0.21 $323.4021296 11.61 090 0.10 0.69 0.21 $696.6021310 3.59 000 0.00 0.00 0.00 $215.4021315 7.80 010 0.10 0.80 0.10 $468.0021320 7.23 010 0.10 0.80 0.10 $433.8021325 12.45 090 0.10 0.69 0.21 $747.0021330 16.01 090 0.10 0.69 0.21 $960.6021335 20.35 090 0.10 0.69 0.21 $1,221.00



Appendix II

Code Mod

Non-Facility


Pre-Operative

Intra-operative

Post-operative


1-1-2021336 18.20 090 0.10 0.69 0.21 $1,092.0021337 11.70 090 0.10 0.69 0.21 $702.0021338 18.74 090 0.10 0.69 0.21 $1,124.4021339 21.30 090 0.10 0.69 0.21 $1,278.0021340 21.33 090 0.10 0.69 0.21 $1,279.8021343 30.70 090 0.10 0.69 0.21 $1,842.0021344 39.67 090 0.10 0.69 0.21 $2,380.2021345 22.37 090 0.10 0.69 0.21 $1,342.2021346 27.40 090 0.10 0.69 0.21 $1,644.0021347 29.07 090 0.10 0.69 0.21 $1,744.2021348 31.07 090 0.10 0.69 0.21 $1,864.2021355 12.26 010 0.10 0.80 0.10 $735.6021356 14.24 010 0.10 0.80 0.10 $854.4021360 14.64 090 0.10 0.69 0.21 $878.4021365 31.64 090 0.10 0.69 0.21 $1,898.4021366 37.03 090 0.10 0.69 0.21 $2,221.8021385 21.58 090 0.10 0.69 0.21 $1,294.8021386 18.73 090 0.10 0.69 0.21 $1,123.8021387 22.53 090 0.10 0.69 0.21 $1,351.8021390 22.97 090 0.10 0.69 0.21 $1,378.2021395 29.33 090 0.10 0.69 0.21 $1,759.8021400 5.77 090 0.10 0.69 0.21 $346.2021401 14.78 090 0.10 0.69 0.21 $886.8021406 16.74 090 0.10 0.69 0.21 $1,004.4021407 18.48 090 0.10 0.69 0.21 $1,108.8021408 26.17 090 0.10 0.69 0.21 $1,570.2021421 19.17 090 0.10 0.69 0.21 $1,150.2021422 18.45 090 0.10 0.69 0.21 $1,107.0021423 22.04 090 0.10 0.69 0.21 $1,322.4021431 19.92 090 0.10 0.69 0.21 $1,195.2021432 20.76 090 0.10 0.69 0.21 $1,245.6021433 50.51 090 0.10 0.69 0.21 $3,030.6021435 40.77 090 0.10 0.69 0.21 $2,446.2021436 59.22 090 0.10 0.69 0.21 $3,553.2021440 17.93 090 0.10 0.69 0.21 $1,075.8021445 22.20 090 0.10 0.69 0.21 $1,332.0021450 16.44 090 0.10 0.69 0.21 $986.4021451 21.55 090 0.10 0.69 0.21 $1,293.0021452 20.12 090 0.10 0.69 0.21 $1,207.2021453 28.71 090 0.10 0.69 0.21 $1,722.6021454 14.65 090 0.10 0.69 0.21 $879.0021461 57.47 090 0.10 0.69 0.21 $3,448.2021462 61.46 090 0.10 0.69 0.21 $3,687.6021465 24.10 090 0.10 0.69 0.21 $1,446.0021470 33.85 090 0.10 0.69 0.21 $2,031.0021480 3.34 000 0.00 0.00 0.00 $200.4021485 25.21 090 0.10 0.69 0.21 $1,512.6021490 23.77 090 0.10 0.69 0.21 $1,426.2021497 19.60 090 0.10 0.69 0.21 $1,176.0021501 13.43 090 0.10 0.69 0.21 $805.8021502 14.61 090 0.10 0.69 0.21 $876.60



Appendix II

Code Mod

Non-Facility


Pre-Operative

Intra-operative

Post-operative


1-1-2021510 12.92 090 0.10 0.69 0.21 $775.2021550 7.50 010 0.10 0.80 0.10 $450.0021552 12.89 090 0.10 0.69 0.21 $773.4021554 21.13 090 0.10 0.69 0.21 $1,267.8021555 12.27 090 0.10 0.69 0.21 $736.2021556 15.22 090 0.10 0.69 0.21 $913.2021557 27.57 090 0.10 0.69 0.21 $1,654.2021558 38.86 090 0.10 0.69 0.21 $2,331.6021600 15.94

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MEDICAL FEE SCHEDULE MAINE WORKERS' COMPENSATION BOARD ... · chapter should refer to the most current CPT® which contains the complete and most current listing of codes and descriptive