The workers' compensation medical fee schedule for services provided under the Georgia Workers' Compensation Law [2001]

State of Georgia
THE WORKERS' COMPENSATION MEDICAL FEE SCHEDULE FOR SERVICES
PROVIDED UNDER THE GEORGIA WORKERS' COMPENSATION LAW
Effective September 1, 2001
Adopted by: State Board of Workers' Compensation
270 Peachtree Street, NW Atlanta, Georgia 30303-1299
www.ganet.org/sbwc

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE COPYRIGHT INFORMATION
ALL FEE SCHEDULE AMOUNTS ARE COPYRIGHT 2000 STATE OF GEORGIA.
THE PHYSICIAN'S CURRENT PROCEDURAL TERMINOLOGY (CPT) FIVEDIGIT NUMERIC CODES, DESCRIPTIONS, AND TWO-DIGIT NUMERIC MODIFIERS REPRESENTING PHYSICIAN, ANESTHESIOLOGY AND OTHER MEDICAL SERVICES ARE THE 2001 EDITION AS PRODUCED OR COPYRIGHT 2000 BY THE AMERICAN MEDICAL ASSOCIATION.
ALL RIGHTS RESERVED. PRINTED IN THE UNITED STATES OF AMERICA. NO PART OF THIS PUBLICATION MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM OR BY ANY MEANS, ELECTRONIC OR MECHANICAL, INCLUDING PHOTOCOPY, RECORDING, OR STORAGE IN A DATABASE RETRIEVAL SYSTEM, WITHOUT THE PRIOR WRITTEN PERMISSION OF THE PUBLISHER.

Copyright Information

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STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE
DISCLAIMER INFORMATION
AMERICAN MEDICAL ASSOCIATION DISCLAIMER
THE FIVE-DIGIT 2001 NUMERIC CPT CODES INCLUDED IN THE 2001 GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE FOR PHYSICIANS ARE OBTAINED FROM THE PHYSICIANS' CURRENT PROCEDURAL TERMINOLOGY (CPT-4), 2001 EDITION, COPYRIGHT 2000 BY THE AMERICAN MEDICAL ASSOCIATION. THE CPT IS A LISTING OF DESCRIPTIVE TERMS AND NUMERIC IDENTIFYING CODES AND MODIFIERS FOR REPORTING MEDICAL SERVICES AND PROCEDURES PERFORMED BY PHYSICIANS. THIS FEE SCHEDULE ALSO INCLUDES CPT NUMERIC IDENTIFYING CODES AND MODIFIERS FOR REPORTING MEDICAL SERVICES AND PROCEDURES THAT ARE COPYRIGHT 1998 BY THE AMERICAN MEDICAL ASSOCIATION AND USED BY PERMISSION.
NO FEE SCHEDULES, BASIC UNIT VALUES, RELATIVE VALUE GUIDES, CONVERSION FACTORS, OR SCALES ARE INCLUDED IN ANY PART OF THE PHYSICIANS' CURRENT PROCEDURAL TERMINOLOGY (CPT-4), 2001 EDITION AND THE AMERICAN MEDICAL ASSOCIATION DOES NOT RECOMMEND ANY SPECIFIC RELATIVE VALUES, FEES, FEE SCHEDULES, OR RELATED LISTINGS. ANY FEE AMOUNTS OR RELATED LISTINGS ASSIGNED TO THE CPT CODES IN THIS FEE SCHEDULE ARE NOT THOSE OF THE AMERICAN MEDICAL ASSOCIATION AND SUCH ASSIGNMENT SHOULD NOT BE CONSTRUED AS A RECOMMENDATION FOR USE OF THESE RELATIVE VALUES BY THE AMERICAN MEDICAL ASSOCIATION.
STATE OF GEORGIA DISCLAIMER
THIS DOCUMENT ESTABLISHES PROFESSIONAL MEDICAL FEE REIMBURSEMENT AMOUNTS FOR COVERED SERVICES RENDERED TO INJURED EMPLOYEES IN THE STATE OF GEORGIA AND PROVIDES GENERAL GUIDELINES FOR THE APPROPRIATE CODING AND ADMINISTRATION OF WORKERS' MEDICAL CLAIMS. GENERALLY, THE REIMBURSEMENT GUIDELINES ARE IN ACCORDANCE WITH, AND RECOMMENDED ADHERENCE TO, THE COMMERCIAL GUIDELINES ESTABLISHED BY THE AMA ACCORDING TO 2001 CPT CODES. HOWEVER, CERTAIN EXCEPTIONS TO THESE GENERAL RULES ARE PROSCRIBED IN THIS DOCUMENT. PROVIDERS AND PAYORS ARE INSTRUCTED TO ADHERE TO ANY AND ALL SPECIAL RULES THAT FOLLOW.

Table of Contents

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STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

TABLE OF CONTENTS

PAGE

I. BACKGROUND

1

II. EFFECTIVE DATE

4

III. INTRODUCTION TO FEE SCHEDULE

5

IV. GENERAL REIMBURSEMENT REQUIREMENTS

6

V. EVALUATION & MANAGEMENT SERVICES

22

PAYMENT GROUND RULES

22

PAYMENT MODIFIERS BY CATEGORY OF SERVICE

29

SCHEDULE OF FEES

32

VI. ANESTHESIA

35

PAYMENT GROUND RULES

35

PAYMENT MODIFIERS BY CATEGORY OF SERVICE

38

SCHEDULE OF FEES

43

VII. SURGERY

49

PAYMENT GROUND RULES

49

PAYMENT MODIFIERS BY CATEGORY OF SERVICE

57

SCHEDULE OF FEES

62

VIII. DIAGNOSTIC & THERAPEUTIC RADIOLOGY

151

PAYMENT GROUND RULES

151

PAYMENT MODIFIERS BY CATEGORY OF SERVICE

154

SCHEDULE OF FEES

156

IX. PATHOLOGY AND LABORATORY

170

PAYMENT GROUND RULES

170

PAYMENT MODIFIERS BY CATEGORY OF SERVICE

174

SCHEDULE OF FEES

176

X. GENERAL MEDICINE

200

PAYMENT GROUND RULES

200

PAYMENT MODIFIERS BY CATEGORY OF SERVICE

201

SCHEDULE OF FEES

203

Table of Contents

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STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

TABLE OF CONTENTS

PAGE

XI. PHYSICAL MEDICINE

218

PAYMENT GROUND RULES

218

PAYMENT MODIFIERS BY CATEGORY OF SERVICE

221

SCHEDULE OF FEES

224

XII. HOME CARE SERVICES

226

XIII. INPATIENT HOSPITAL PAYMENT SCHEDULE

227

XIV. OUTPATIENT PAYMENT SCHEDULE

233

INDEX

241

Table of Contents

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STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE
SECTION I: BACKGROUND
The State of Georgia 2001 Workers' Compensation Medical Fee Schedule has been prepared to establish maximum fee amounts and uniform payment guidelines for reimbursing medical providers for the treatment of injured employees subject to the authority of the Georgia State Board of Workers' Compensation. This fee schedule completely replaces the previous fee schedule for medical provider's services in the 2000 Georgia Workers' Compensation Medical Fee Schedule. All rules stated herein are pursuant to Official Code of Georgia Annotated (O.C.G.A) 34-9 et seq. Fees are based on usual, customary and reasonable charges.
The fee schedule has been prepared in accordance with the statutes and regulations established by the State of Georgia. In accordance with such statutes and regulations, the fee amounts included herein are deemed to represent usual, customary, and reasonable reimbursement amounts for the specific services rendered.
These rules shall be used by employers, insurance carriers, self-insurers or other payors for the purpose of approving and reimbursing medical charges submitted by physicians or other medical providers for services performed in the treatment of work-related injuries or illnesses.
The fee schedule includes fee amounts for specific medical services and procedures as identified using "CPT" numeric identifying codes and modifiers for reporting medical services and procedures as established by the Physicians' Current Procedural Terminology (CPT-4), 2001 Edition, Copyright by the American Medical Association (AMA). Any use or interpretation CPT4 service descriptions not specifically described herein shall be based on the Physicians' Current Procedural Terminology (CPT-4), 2001 Edition.
This fee schedule has been updated to contain the complete and most current listing of CPT descriptive terms and numeric identifying codes and modifiers for reporting medical services and procedures. All payors and medical providers are required to follow the general rules and requirements for reimbursement established by the AMA unless specifically proscribed differently in this document.
Current Board forms are available on the Board's web site www.ganet.org/sbwc.

Section I: Background

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STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE
SECTION I: BACKGROUND

Format of the Fee Schedule

This fee schedule represents the maximum amount of reimbursement providers may receive for medical or surgical service for the treatment of work-related injuries and illnesses covered under the workers' compensation laws of the State of Georgia. Providers are reimbursed the lesser of billed charges or the fee schedule amount.

The fee schedule document is divided into ten sections in order to provide specific details regarding the different types of rules that determine the amount of reimbursement payable for a specific service and circumstance. Payors should note that the requirements specified in the fee schedule are intended to provide uniform payment policies and procedures in applying usual, customary and reasonable payment. The following sections are included in this fee schedule:

I. II. III. IV. V. VI. VII. VIII. IX. X. XI. XII. XIII. XIV.

Background Effective Date Introduction to Fee Schedule General Reimbursement Requirements Evaluation and Management Services Anesthesia Service Surgery Diagnostic and Therapeutic Radiology Pathology and Laboratory General Medicine Physical Medicine Home Care Services Inpatient Hospital Payment Schedule Outpatient Surgical Payment Schedule

Within each section, you will find definitions and medical terms that explain services provided. Also, in certain sections there is an index of procedures by CPT code identifiers. Use each specific section in addition to general ground rules for clarification of terms and services.

The fee schedule is designed to be an accurate and authoritative source of information about medical coding and reimbursement. Every reasonable effort has been made to verify its accuracy and all information is believed reliable at the time of publication. Absolute accuracy and completeness, however, is neither intended nor guaranteed. The rules and guidelines described herein cannot specifically refer to every payment contingency; the usual, customary, and reasonable fee will govern treatment provided under unusual circumstances.

Section I: Background

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STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE
SECTION I: BACKGROUND
The Georgia State Board of Workers' Compensation reserves the authority to determine applicability of all rules of the fee schedule. Any physician, other medical professional, or other entity having questions regarding applicability to their individual reimbursement as it applies to the fee schedule should direct any such question to the Board or to such other authority as directed by the Board.

Section I: Background

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STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE
SECTION II: EFFECTIVE DATE
These rules shall be applicable to all medical services rendered on or after the effective date of this fee schedule, which shall be September 1, 2001. Any treatment or service rendered on or after the effective date are subject to the payment methodologies and fee reimbursements described herein.

Section II: Effective Date

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SECTION III: INTRODUCTION TO FEE SCHEDULE

The maximum allowable reimbursement (MAR) for CPT codes are generally separable into seven distinct sections based on the category or type of service rendered. Each category of service has separate instructions for application of Ground Rules and modifiers adjustments. The categories of service subject to this fee schedule are:

GENERAL MEDICAL SERVICES CATEGORIES Evaluation & Management Anesthesia Surgery Diagnostic & Therapeutic Radiology Pathology & Laboratory General Medicine Physical Medicine

CPT CODES 99201-99499 00100-01999 10040-69990 70010-79999 80048-89399 90281-99199 97001-98943

The Ground Rules, Modifier Rules, and fee schedule reimbursement for primary or global services are included in Sections V through XI of this fee schedule. As indicated, the maximum allowable reimbursement is subject to modification based on the included specific rules. See Page (iii) Table of Contents for referencing the specific subsections and page numbers.

For each procedure, the fee schedule table includes the following details (if applicable):
Starred Procedure Identifier 5 Digit CPT Code Number CPT Description Maximum Allowable Reimbursement Maximum Reimbursement 26 Professional Component Follow-Up Day Limits

The total maximum allowable reimbursement (MAR) includes the professional component for a procedure and the technical component. Under no circumstances shall the MAR be more than the value of the technical component and the professional component combined for a procedure.

For anesthesia fee amounts, the table includes basic relative values. Anesthesia fees are determined somewhat differently than other services using a relative value and dollar conversion factor basis. See Anesthesia section for an explanation of how anesthesia fee amounts are to be determined.

Section III Introduction to Fee Schedule

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STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION IV:

GENERAL REIMBURSEMENT REQUIREMENTS

This section outlines reimbursement in general. Specific guidelines by service category follow these general guidelines. The following guidelines are intended to provide rules for reimbursement of services provided in the State of Georgia under the workers' compensation law for CPT codes developed by the American Medical Association (AMA) according to AMA guidelines. Specific reimbursement amounts for services by CPT code are located in each section. CPT Code modifiers that might affect reimbursement for specific services are also located in each section. The schedule is divided into sections for structural purposes only.
The reimbursements herein shall be presumed usual, customary, and reasonable according to O.C.G.A. 34-9-205(b). No physician, hospital or medical provider shall bill the employee for authorized medical treatment. If an employee fails to notify a physician, hospital, or medical supplier that he/she is being treated for an injury covered by workers' compensation insurance, such provider of medical services shall not be civilly liable to any person for erroneous billing for such covered treatment if the billing error is corrected by the medical provider upon notice of the same. If a provider's charge is greater than the maximum allowable rate (MAR), the provider must not bill the employee or the employer/insurer for the difference. The fees listed in the fee schedule represent all-inclusive and global fee amounts.
It is important to recognize that the listing of a code number, the service or procedure and the approved fee are not restricted to a specific specialty group. Any procedure or service and fee listed in this book may be used to designate the services rendered by any qualified physician. Such services, however, must be performed within the scope of his/her licensed practice as defined by Georgia law.

Considerations for Reimbursement
There are certain key principles and requirements as described in this section that may apply for determining the appropriate fee reimbursement amount under this fee schedule. These essential principles include:
Medical Service Authorization to Treat Medical Report All Inclusive Fees Separate Procedures Starred Procedures Modifier Services Assistant Surgeons Mid-level Practitioners

Section IV: General Reimbursement Requirements

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SECTION IV:

GENERAL REIMBURSEMENT REQUIREMENTS

The following describes, in general, the principles and requirements that must be met for establishing applicability of this fee schedule.
Medical Service
O.C.G.A. 34-9-201 (b) 1, 2, 3 provide three options for the selection of a physician: 1) the panel of four (six or more effective 1/1/2002) or more physicians; 2) the conformed panel with 10 or more physicians; or 3) a managed care organization certified by the Board. The term "physician" shall include any person licensed to practice a healing art and any remedial treatment and care in the State of Georgia. The fee schedule covers all medical services provided to injured employees by physicians, including the medical services of hospital and clinic-based physicians working on a contract basis.
An employee may make one change from one physician to another physician on the same panel of four or more (six or more effective 1/1/2002) physicians or the conformed panel without prior authorization of the Board. Under the certified managed care program, one change of physician is allowed without going through the Managed Care Organization's 30-day dispute resolution process. Any other changes require agreement of all parties. If the parties have been unsuccessful in agreeing to a change, the party desiring the change may then submit to the Board Form WC-200 (b) requesting that the Board approve the change to another authorized treating physician. Such requests are then reviewed for required Board authorization.
If no workers' compensation physician panel is posted, and the injury is compensable, the employee may see the physician of his/her choice at the expense of the employer/insurer. If an emergency arises and the employer fails to provide the medical or other care as specified by the workers' compensation law, or if other compelling reasons force the employee to seek temporary care, the employee may seek temporary care as may be necessary. The employer/insurer shall pay the reasonable costs of the temporary care if ordered by the Board.
If the employer/insurer deny the workers' compensation claim, the injured employee may see the physician of his/her choice and, if the injury is later determined to be compensable, the employer/insurer shall be responsible for medical expenses related to the injury.

Section IV: General Reimbursement Requirements

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STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION IV:

GENERAL REIMBURSEMENT REQUIREMENTS

Employee's Waiver of Confidentiality
When an employee has submitted a claim for workers' compensation benefits, or is receiving payment of weekly income benefits, or the employer has paid any medical expenses in relation to a workers' compensation claim, that employee shall be deemed to have waived any privilege or confidentiality concerning any communications related to the claim, history, or treatment of injury arising from the incident that the employee has with any physician, including, but not limited to, communications with psychiatrists or psychologists. Notwithstanding any other provision of law to the contrary, when requested by the employer, any physician who has examined, treated, or tested the employee or consulted about the employee shall provide, within a reasonable time and for a reasonable charge, all information and records related to the examination, treatment, testing or consultation concerning the employee. This does not apply when submitting medical bills.

When an employee has submitted a claim for workers' compensation benefits, or is receiving payment of weekly income benefits, or the employer has paid any medical expenses in relation to a claim for workers' compensation benefits, the employee shall provide the employer with a signed release for medical records and information related to the claim, history, or treatment for any mental condition or drug or alcohol abuse. Such release shall designate the provider and shall state that it will expire on the date of the hearing. Refusal by the employee to provide a release can result in a suspension of the payment of income benefits until the employee provides such release.
Authorization to Treat
Preauthorization or precertification for the medical treatment or testing of an injured employee, other than as required by a certified Managed Care Organization, is not required by Chapter 9 of Title 34 of the Official Code of Georgia Annotated (O.C.G.A.), referred to as the Workers' Compensation ACT, as a condition for payment of services rendered. In the event that an authorized treating physician requests preauthorization or precertification for medical treatment or testing of an employee, the procedures provided in Board Rule 205 shall be followed. See page 17 for Board Rule 205.
The Board may require recommendations from a panel of appropriate peers of the physician, hospital or other medical supplier in determining whether fees submitted and necessity of services rendered are reasonable. The recommendations of the panel of appropriate peers shall be evidence of the reasonableness of fees and necessity of services that the Board shall consider in its determination of appropriateness.

Section IV: General Reimbursement Requirements

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STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION IV:

GENERAL REIMBURSEMENT REQUIREMENTS

All-Inclusive Fees
The fee amounts listed in the fee schedule were determined under the principle of "all inclusive services". "All inclusive services" combines certain physician services and procedures, including all necessary care, treatment, and routine supplies and services for reimbursement, into a single principle or global procedure, which reflects the overall level of services or procedures needed for the encounter. The particular services/procedures will be reimbursed using the single global fee amount established by the fee schedule.
For surgical procedures, "all inclusive services" also include all pre-operative and post-operative visits listed in follow-up days (FUD) column, plus examinations necessary for preparing the injured employee for surgery. The follow-up days refers to the time frame during which all services integral to the surgical procedure are covered by a single payment. For diagnostic laboratory testing, the primary or global fee includes both the performance of the test and the interpretation of results provided to the injured employee. No reimbursement for a separate visit allowance would normally be allowed.
There are certain exceptions to the "all inclusive services and fees" provision as indicated by the explanation of "SEPARATE" and "STARRED" services mentioned below. To the extent that other rules or guidance provided along with this fee schedule do not address every exception to this "all inclusive services and fees" principle, insurers, and other payors should be guided by industry standard practices regarding usual, reasonable and customary fees.
Separate Procedures
Some of the listed procedures are commonly carried out as an integral part of a total service and do not warrant a separate identification. If, however, such a procedure is performed independently of, and is not immediately related to, other services, it may be listed as a "separate procedure." Thus, when a procedure that is ordinarily a component of a larger procedure is performed alone for a specific purpose, it may be considered a separate procedure.
Starred (*) Procedures or Items
Some surgical procedures are characterized by indefinite pre- and postoperative services, so the usual "package" concept, (as outlined in the Physicians' Current Procedural Terminology (CPT4), 2001 Edition) for surgical procedures cannot be applied. Starred procedures are identified with an asterisk before the CPT code, e.g. (*). Refer to surgical services for full discussion on starred procedures.

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SECTION IV:

GENERAL REIMBURSEMENT REQUIREMENTS

Modifier Services
A modifier provides the means by which the reporting physician can 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. When applicable, the modifying circumstance should be identified by the addition of the appropriate modifier code, which may be reported in either of two ways. A two-digit number placed after the usual procedure number and separated by a hyphen may report the modifier. The modifier may also be reported by using a separate five-digit code in addition to the procedure code. If more than one modifier is used, place the "multiple modifiers" code -99 immediately after the procedure code. This indicates that one or more additional modifier codes will follow.
Only certain modifiers in each of the categories (anesthesia, surgery, pathology/laboratory, radiology, general medicine, and physical medicine) will be recognized for reimbursement purposes. The acceptable modifiers for each category will be discussed in that section of the fee schedule.
Special Rules and Limitations
Specific circumstances might affect eligibility for reimbursement or amount of reimbursement for specific services. The following listed circumstances could have an effect on eligibility or reimbursement for services.
Materials Supplied by the Health Care Provider
Medical supplies provided by the physician (e.g., sterile trays and drugs) over and above those usually included with the office visit (e.g., band-aids, cotton swabs, etc.) or other services rendered may be listed separately using CPT code 99070. Medical supplies and durable medical equipment are reimbursed at cost times 1.5 plus $4.00. Charges greater than $50 must be accompanied by a copy of the invoice(s) showing the actual cost of the item. Certain procedures include supplies; therefore, CPT code 99070 would not be reported. Custom-made orthotics/prosthetics and rental equipment are exempt from the supplies and equipment reimbursement formula; however, usual, customary, and reasonable charges will apply.
Pharmaceuticals
Both brand name and generic prescription drugs will be reimbursed at the average wholesale price (AWP) x 1.2. A $4.00 fee may be charged by pharmacies and facilities that incur a dispensing fee above the average wholesale price. When the authorized treating physician prescribes pharmaceuticals, the prescription will indicate by stamp or other means that it is for a workers' compensation claim.

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STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION IV:

GENERAL REIMBURSEMENT REQUIREMENTS

Implants/Allografts/Instrumentation
Certain high cost implants such as but not limited to bone grafts and cartilage supplied by vendor companies shall be reimbursed at cost in addition to the reimbursement at the appropriate DRG or ICD-9 level if the vendor invoice for this item is included with facility bill. This additional charge above the DRG or ICD-9 MAR, including reasonable cost, medical necessity, and appropriateness, shall be negotiated in advance with the payor. Instrumentation inserted in surgical procedures is to be reimbursed to the provider at cost when the vendor invoice is included in the facility bill.
Physician Extenders (PE)
The Clinical Nurse Specialist (CNS), Nurse Practitioner (NP), or Physician Assistant (PA), if qualified by training and experience as determined by the supervising physician, may perform medical treatments, diagnostic procedures, or other delegated duties and tasks which are allowable by law, approved by the state licensing board, and which fall within the normal scope of practice of the supervising physician. Reimbursement for the CNS, NP, or PA shall be at 85% of the Fee Schedule MAR or the provider's charge, whichever is less, if the CNS, NP, or PA renders the service under the general supervision of a physician. While the supervising physician is responsible for the overall direction and management of the professional activities of the NP, CNS, or PA, the supervising physician is not required to physically be on site at the time of service. However, if the supervising physician is not physically present with the CNS, NP, or PA, "he or she must be immediately available to the CNS, NP, or PA for consultation purposes by telephone or other effective, reliable means of communication." Medicare Carriers Manual, Coverage and Limitations, section 2156(4)(C). It is the responsibility of the supervising physician to ensure compliance with all ethical and licensing standards and to co-sign all medical notes. Append the appropriate CPT procedure with modifier PE. Physicians may not bill for oversight of these services in addition to an office visit.
Reimbursement of PA, NP, or Registered Nurse First Assistant (RNFA) as a surgical assistant shall be at 10% of the MAR for the CPT code or the practitioner's usual and customary charge, whichever is less, for those procedures that are exempt from the Medicare "5 percent rule". If Medicare's records indicate that a first assistant is used less then 5 percent of the time nationwide for a particular surgical procedure, then the procedure is added to the restricted 5 percent list. The Medicare Correct Coding and Payment Manual published by St. Anthony's Publishing lists the restricted procedures. If circumstances warrant the concurrent services of a surgeon and one of the types of assistants as listed herein and it is medically necessary, those services may be performed by a physician extender (PE) in the place of an assistant surgeon when medically appropriate. In accord with O.C.G.A. 33-24-59.9, the RNFA shall not be on the staff of a hospital or the treating physician. Append the appropriate CPT procedure with the modifier -PE. When an office is billing for both the primary surgeon and the surgical assistant, two lines are used on the HCFA 1500 or UB-92.

Section IV: General Reimbursement Requirements

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STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION IV:

GENERAL REIMBURSEMENT REQUIREMENTS

Interpreter/Translator

In circumstances where an interpreter/translator is required for administering medical treatment to an injured worker and the service is provided over the telephone, CPT code 99371 shall be utilized. If the service is provided face-to-face, then actual charges shall be submitted when filing the claim.

Physical Therapists/Occupational Therapists

Services performed by a physical therapist and/or occupational therapist shall be under the direction of the authorized treating physician detailing the type, frequency, and duration of therapy to be provided. Physical therapists or occupational therapists cannot be reimbursed for office visits. See Physical Medicine for a full discussion of these services.

Physical Medicine Maximum Per Visit and/or Day

No more than four charges will be reimbursed per visit/day regardless of medical necessity. No more than two of the charges can be modality codes (CPT 97010-97039). A unit (15-minutes) is considered one of the four charges. Exemptions to this rule are as follows:

1. An injured worker has been diagnosed with a catastrophic injury O.C.G.A.34-9-200.1 (g).
2. CPT code 97545 work hardening/work conditioning (not to exceed $250.00 per day). 3. CPT code 97750 functional capacity evaluation (not to exceed $600). 4. Fitting and training for custom-made orthotics/prosthetics. 5. By mutual agreement of all parties.

Catastrophic Injury

"Catastrophic injury", in accordance with O.C.G.A. 34-9-200.1 (g), means any injury that is one of the following:

1. Spinal cord injury involving severe paralysis of an arm, a leg, or the trunk; 2. Amputation of an arm, a hand, a foot, or a leg involving the effective loss of use of
that appendage; 3. Severe brain or closed head injury as evidenced by:
A. Severe sensory or motor disturbances; . Severe communications disturbances; C. Severe complex integrated disturbances of cerebral function; D. Severe disturbances of consciousness; E. Severe episodic neurological disorders; or F. Other conditions at least as severe in nature as any condition provided in

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STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION IV:

GENERAL REIMBURSEMENT REQUIREMENTS

subparagraphs (A) through (E) of this paragraph; 4. Second or third degree burns over 25 percent of the body as a whole or third degree
burns to 5 percent or more of the fact or hands; 5. Total or industrial blindness; or 6. Any other injury of a nature and severity that prevents the employee from being able
to perform his or her prior work and any work available in substantial numbers within the national economy for which such employee is otherwise qualified. A decision granting or denying disability income benefits under Title II or supplemental security income benefits under Title XVI of the Social Security Act shall be admissible in evidence and the Board shall give the evidence the consideration and deference due under the circumstances regarding the issue of whether the injury is a catastrophic injury.
Independent Medical Exam (IME)
Employers/insurers have the right to request the injured employee to submit to an independent medical examination (IME), performed by a duly qualified physician or surgeon designated and paid by the employer/insurer. The employer/insurer must notify the employee in writing at least ten (10) days in advance of the time and place of the examination. Advance payment of travel expenses must accompany the notice. Travel beyond the employee's home city shall include the actual cost of meals (up to $30 per day) and lodging. When travel is by private vehicle the rate of mileage shall be .28 cents per mile. The employee shall have the right to have present at such examination any duly qualified physician or surgeon, provided and paid for by the employee.
The employee, after an accepted compensable injury and within 120 days of receipt of any income benefits, shall have the right to one IME performed at a reasonable time and place, within this state or within 50 miles of the employee's residence, by a duly qualified physician or surgeon designated by the employee and paid for by the employer/insurer. The employer or insurer shall be notified in writing in advance. Such examination shall not repeat any diagnostic procedures which have been performed since the date of the employee's injury unless the cost of such diagnostic procedures in excess of $250 are paid for by a party other than the employer or insurer.
Payment for independent medical examinations will be based on time spent in the review of medical records, test reports, a physical examination and a written report regarding the medical condition of the injured employee. Time will be the essential factor in determining reimbursement amount for an IME. The provider shall complete Board Form WC-20 (a) Medical Report or the HCFA-1500 form. Do not use a CPT code when reporting an independent medical exam (IME).
The following hourly rate will establish the maximum allowable reimbursement for this service.

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SECTION IV:

GENERAL REIMBURSEMENT REQUIREMENTS

TIME RATE
$350.00 FIRST HOUR OR PARTS THEREOF $75.00 EACH ADDITIONAL 15 MINUTES
For a no-show at an independent medical examation, reimbursement shall be at $150.00.
Impairment Evaluation
The basis to permanent impairment should be the "Guide to the Evaluation of Permanent Impairment", Fifth Edition, published by the American Medical Association. Permanent partial impairment (PPI) applies to any measurable, objective loss of function of some part of the body after the stage of maximum medical improvement (MMI) has been reached and the condition is stationary. The authorized treating physician shall complete Board Form WC-20 (a) Medical Report or the HCFA-1500 form and submit the form to the employer/insurer when a permanent partial disability rating is determined. If a physical examination is necessary, an evaluation and management code must be used in billing an impairment rating.
Work Hardening/Work Conditioning
These codes can only be used by physician referral and when treatment is initiated and directly supervised by the physician, chiropractor, licensed physical therapist or licensed occupational therapist.
Unlisted (or New) Service or Procedures
A service or procedure may be provided that is not listed in this schedule. When reporting such a service, the appropriate "Unlisted Procedure" code may be used to indicate the service. When reviewing charges for unlisted services or procedures, payors should apply usual, customary and reasonable charges. In compliance with OCGA 34-9-203(a), these usual, customary, and reasonable charges shall be limited to such charges as prevail in the State of Georgia for similar treatment.
By Report
If a procedure is not among those listed in the fee schedule, a reasonable fee must be charged, and may require a special report. A service that is rarely provided, unusual, variable, or new, may require a special report in determining the medical appropriateness of the service. Pertinent information should include:
adequate definition and description of procedure or service required; nature, extent and need (diagnosis and rationale) for the service or procedure;

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time and effort required to perform the service or procedure; skill level necessary for performance of service or procedure; equipment use (if applicable); and other information as needed.
Additional items that may be included are: complexity of symptoms, final diagnosis, pertinent physical findings (such as size, location[s], and number of lesion[s], if appropriate) diagnostic and therapeutic procedures, concurrent problems, and follow-up care. Payment will be determined based upon usual, customary and reasonable charges.
Medical Expense Disputes
Medical expenses shall be limited to the usual, customary and reasonable charges pursuant to O.C.G.A. 34-9-205. Employer/insurers may conform charges according to the fee schedule adopted by the Board and the charges listed in the fee schedule shall be presumed usual, customary, and reasonable and shall be paid within 30 days from the date of receipt of charges. Employer/insurers shall not unilaterally change any CPT-4 code of the provider. All automatically conformed charges according to the fee schedule shall be for the CPT-4 code listed by the provider. In situations where charges have been reduced or payment of a bill denied, the carrier, self-insured employer, or third party administrator shall provide an Explanation of Benefits (EOB) with payment information explaining why the charge has been reduced or disallowed, along with a narrative explanation of each EOB code used. In all claims, any health service provider whose fee is reduced to conform to the fee schedule and who disputes that fee, or any employer/insurer who disputes the CPT-4 code used by the provider for services rendered shall, in the first instance, request peer review of the charges, and may thereafter request a mediation conference by filing Form WC-14 with the Board. For charges not contained in the fee schedule and which are disputed within 30 days as not being usual, customary, and reasonable, the aggrieved party shall follow these procedures:
1. An employer or insurer shall pay when due all charges deemed reasonable, and follow the procedures set forth in subsection (2) for review of only those specified charges that are disputed.
2. For charges not contained in the fee schedule and which are disputed as not being the usual, customary and reasonable charges prevailing in the State of Georgia, the employer, insurer, or physician shall file a request for peer review with a peer review organization authorized by the Board within 30 days of the receipt of charges by the employer/insurer, and shall serve a copy of the request and supporting documentation upon all parties and counsel.
3. The peer review committees approved by the Board are listed below. These committees may be contacted at the following addresses and telephone numbers:

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Dr. Mitchell S. Nudelman Disability Solutions Plus, Inc. 567 Seminole Drive Marietta, GA 30060 (770) 499-0398 FAX (770) 499-8299

Dr. Eric Krohne, Executive Director Georgia Chiropractic Association, Inc. 3772 Pleasantdale Road, Suite 175 Atlanta, GA 30340 (770) 723-1722
Ms. Pat Garner, Executive Director Georgia Psychological Association Suite 525, 1800 Peachtree Street, NW Atlanta, GA 30309 (404) 351-9555

Mr. Marvin Gross, M.S., P.T., Principal Mr. Stuart Platt, M.S.P.T., P.T., Principal Appropriate Utilization Group, LLC 1086 Burton Drive Atlanta, GA 30329 (404) 728-1974

4. If there is no appropriate peer review committee, the party requesting review may request a mediation conference by filing Form WC-14 with the Board. The charges submitted which conform to the fee schedule adopted by the Board shall be prima facie proof of the usual, customary, and reasonable charges for the medical services provided.
5. The employer/insurer shall, within 30 days from the date that a decision regarding the peer review of charges or treatment is issued by a peer review organization, make payment of disputed charges based upon the recommendations, or request a mediation conference. The peer review committee shall serve a copy of its decision upon the employee, if unrepresented, or the employee's attorney. A physician whose fee has been reduced by the peer review committee shall have 30 days from the date that the recommendation is mailed to request a hearing. In case of a mediation conference, the recommendations of the peer review committee shall be evidence of the usual, customary, and reasonable charges.

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6. In cases where the peer review committee recommends that the fee be reduced, the employer/insurer shall pay the physician the fee amount recommended by the peer review committee less the filing costs initially paid by the employer/insurer. In the event the peer review committee recommends the entire fee be disallowed, the employer/insurer may automatically deduct the filing costs for the peer review from future allowable expenses submitted by the physician for treatment or services rendered to the employee arising out of the same injury.
Necessity of Treatment/ Medical Treatment Disputes
Advance authorization for the medical treatment or testing of an injured employee is not required by this Chapter as a condition for payment of services rendered. A Board certified WC/MCO may provide for pre-certification by contract with network providers pursuant to O.C.G.A. 349-201(b)(3).
1. An authorized medical provider may request advance authorization for treatment or testing by completing Sections 1 and 2 of Board Form WC-205 and faxing or emailing same to the insurer/self-insurer. The insurer/self-insurer shall respond by completing Section 3 of the WC-205 within five business days of receipt of this form. The insurer/self-insurer's response shall be by facsimile transmission or email to the requesting authorized medical provider. If the insurer/self-insurer fails to respond to the WC-205 request within the five-day period, the treatment or testing stands pre-approved.
2. In the event the insurer/self-insurer furnish an initial written refusal to authorize the requested treatment or testing within the five business day period, then within 21 days of the initial receipt of the WC-205, the insurer/self-insurer shall either: (a) authorize the requested treatment or testing in writing; or (b) file with the Board a Form WC-3 controverting the treatment or testing, indicating the specific grounds for the controversion.
3. If medical treatment is controverted on the ground that the treatment is not reasonably necessary, the burden of proof shall be on the employer. If the treatment is controverted because the treatment is either not authorized or is unrelated to the compensable injury, the burden of proof shall be upon the employee.

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4. If an employer or insurer utilizes a certified WC/MCO pursuant to O.C.G.A. 34-9201(b)(3), and a dispute arises regarding the treatment/test prescribed by the authorized treating physician and the dispute is not resolved within 30 days as outlined in Rule 208(f), then the employer or insurer has 15 days from notification by the WC/MCO to authorize the treatment/test or controvert the treatment/test. In no event will the employer or insurer using a WC/MCO have more than 45 days from the receipt of the notice of a dispute as set forth in Rule 208(f) to comply with this provision.
5. Where the employer fails to comply with Rule 205(b)(3), the employer/insurer shall pay, in accordance with OCGA 34-9 et seq. for the treatment/test requested.
Appointed Physician
The Board or an Administrative Law Judge may, upon application of either party or upon their own motion, appoint one or more disinterested and duly qualified physicians or surgeons to perform any necessary medical examination of an employee, and to report or testify with respect thereto. The physician or surgeon shall be allowed travel expenses and a reasonable fee, to be paid by either or both parties, as directed by the Board, any Board member, or an Administrative Law Judge.
Physician Testimony/Deposition
Physicians and surgeons may be called upon or may be issued a subpoena, which is a legal instrument of the court requiring any citizen to appear in court as a witness at a specified time, to testify as an expert witness before the Workers' Compensation Board. The expert witness is legally bound to declare his/her knowledge of the case and express medical opinions according to the rules of the court.
Hearings are conducted in an informal manner. Witnesses are sworn and their testimony is recorded. Generally, the parties to the claim offer medical testimony related to the extent of the injury and whether the injured employee is physically able to return to his/her former job duties or is able to accept other more limited employment.
In most instances, testimony of physicians is obtained through deposition. The deposition generally serves to relieve the physician of the necessity of going to court. Physicians and surgeons shall be given two weeks prior notice to giving medical testimony and such testimony shall be scheduled at a mutually agreeable time and place. Charges for medical testimony should be reported using CPT code 99075 and paid within 30 days from receipt of billing.
Payment for a deposition will be based on actual time spent reviewing medical records before giving medical testimony and actual time spent testifying. The following hourly rate will establish the maximum allowable reimbursement for this service:

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TIME RATE $300.00 FIRST HOUR OR PARTS THEREOF $75.00 EACH ADDITIONAL 15 MINUTES
Malpractice Liability
The employer/insurer shall not be liable in damages for malpractice by a physician or surgeon furnished pursuant to the workers' compensation law, but the consequences of any malpractice shall be deemed part of the injury resulting from the accident and the employee shall be compensated for such injury.
Medical Records
The medical provider's medical record is the basis for determining medical necessity and for substantiating the service(s) rendered; therefore, the medical record must be legible and should include the following: office notes, and/or surgical notes, progress notes, operative notes, diagnostic test results, and any other information necessary to support the services rendered. All bills must be submitted using CPT, ICD-9, or DRG codes either on a Board Form WC-20(a), HCFA 1500, or a Uniform Billing 92 (UB-92). These forms must be properly filled out with attached documentation at no charge to the party responsible for payment. Failure to submit supporting documentation and forms required by the Board might jeopardize or delay payment. Medical providers are only required to submit the complete set of documentation once. If documentation is incomplete, the provider is required to submit the missing information. After the complete documentation has been submitted to the payor once, the medical provider can charge for additional copies in accordance with costs defined below.
Services provided pursuant to the Workers' Compensation Act are not confidential from the employer/insurer who, by law, are responsible for payment of medical services. The injured employee, upon request of the employer/insurer, shall furnish copies of all medical records and reports in his/her possession. The employer/insurer shall, upon the request of the injured employee, furnish copies of all medical reports in their possession. Upon failure of either party to furnish medical reports as provided above or when specifically requested by the employee, the physician or other medical provider shall furnish copies of all medical reports and bills in their possession at no expense to the injured employee or to his/her attorney.
Costs for these copies will be charged against the party responsible for payment of medical expenses. Copies for medical records shall be billed at $0.50/per page with a minimum charge of $10.00, sales tax (if applicable), and actual cost for postage to mail the documents. Providers who use a medical records company to make and provide copies of medical records must ensure that neither the injured employee nor his/her attorney is billed for the cost of copies.

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Special medical reports will be billed using CPT code 99080. X-ray copy charges will be billed at $9.50 per copy.
Late Payment
All reasonable charges for medical, surgical, hospital, and pharmacy goods and services shall be payable by the employer or its workers compensation insurer within 30 days from the date that the employer or the insurer receives the charges and reports required by the Board. The employer or insurer shall, within 30 days after receipt of charges for health care goods or services, mail to the provider of such health care goods or services payment of such charges or a letter or other written notice that states the reasons the employer or insurer has for not paying the claim, either in whole or in part, and which also gives the person so notified a written itemization of any documents or other information needed to process the claim or any portion thereof.
The health care goods or services providers failure to include with its submission of charges any reports or other documents required by the Board shall constitute a defense for the employers or insurers failure to pay the submitted charges within 30 days of receipt of the charges. However, if the employer or insurer fails to send the health care goods or services provider the requisite notice indicating a need for further documentation within 30 days of receipt of the charges, the employer and insurer will be deemed to have waived the right to defend a claim for failure to pay such charges in a timely fashion on the grounds that the charges were not appropriately accompanied by required reports. Such waiver shall not extend to any other defense the employer and insurer may have with respect to a claim of untimely payment.
If any charges for health care goods or services are not paid when due, penalties shall be added to such charges and paid at the same time as and in addition to the charges claimed for the health care goods or services. For any payment of charges paid more than 30 days after their due date, but paid within 60 days of such date, there shall be added to such charges an amount equal to 10 percent of the charges. For any payment of charges paid more than 60 days after their due date, but paid within 90 days of such date, there shall be added to such charges an amount equal to 20 percent of the charges. For any charges not paid within 90 days of their due date, in addition to the 20 percent add-on penalty, the employer or insurer shall pay interest on that combined sum in an amount equal to 12 percent per annum from the ninety-first day after the date the charges were due until full payment is made. All such penalties shall be paid to the provider of the health care goods or services. See O.C.G.A. 34-9-203( c).

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The preceding guidelines outline reimbursement in general. Specific rules regarding reimbursement for services rendered by specific category should supplement general guidelines (i.e., evaluation and management, anesthesia, surgery, radiology, pathology and laboratory, general medicine, physical medicine). These specific guidelines are in addition to rules established for the usage of CPT codes by the American Medical Association (AMA). The following section will describe payment in general terms by the category of service provided.
Overview
Sections V through XI of the fee schedule provide specific payment ground rules separately for each of the seven medical service categories. Explanation of the modifiers and the maximum allowable reimbursement is included in each of these sections of the fee schedule.
The payment ground rules are provided in seven separate fee subsections. The ground rules encompass the seven distinct medical service categories. The rules for one service category may include certain principles that apply equally to another service category. Similarly, the ground rules applicable to one category of service apply equally to all professional providers regardless of provider specialty.

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SECTION V:
SUBSECTION A:

EVALUATION & MANAGEMENT (E/M) SERVICES
PAYMENT GROUND RULES FOR E/M CATEGORY

General Guidelines
The E/M section is divided into broad categories such as office visits, hospital visits and consultations. Most of the categories are further divided into two or more subcategories of E/M services. For example, there are two subcategories of office visits (new patient and established patient) and there are two subcategories of hospital visits (initial and subsequent). The subcategories of E/M services are further classified into levels of E/M services that are identified by specific codes. This classification is important because the nature of a physician's work varies by type of service, place of service, and the injured employee's status.
Physicians should include CPT codes for specific performance of diagnostic tests/studies for which specific CPT codes are available. These CPT codes should be reported separately, in addition to the appropriate E/M code.
The basic format of the levels of E/M service is the same for most categories:
First, a unique code number is listed. Second, the place and/or type of service is specified, e.g., office consultation. Third, the content of the service is defined, e.g., comprehensive history and comprehensive
examination. Fourth, the nature of the presenting problem(s) usually associated with a given level is
described. Fifth, the time typically required to provide the service is specified. (A detailed discussion of
time is provided on subsequent pages.
The fee amounts listed in the fee schedule were determined under the principle of "all inclusive services." The principle "all inclusive services" combines certain physician services and procedures including all necessary care, treatment, and routine supplies and services for reimbursement, into a single principle or global procedure, which reflects the overall level of services or procedures needed for the encounter. The particular services/procedures will be reimbursed using the single global fee amount established by the fee schedule.

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EVALUATION & MANAGEMENT (E/M) SERVICES

SUBSECTION A:
Definitions

PAYMENT GROUND RULES FOR E/M CATEGORY

Certain key words and phrases are used throughout the E/M section. The following definitions are intended to reduce the potential for differing interpretations and to increase the consistency of reporting by physicians in differing specialties.

New & Established Patient

A new patient is one who has not received any professional services from a physician or another physician of the same specialty who belongs to the same group practice, within the past three years.

An established patient is one who has received professional services from a physician or another physician of the same specialty who belongs to the same group practice, within the past three years.

On-Call or Substitute Physician

In the instance where a physician is on call for or is covering for the authorized treating physician, the injured employee's encounter will be classified as it would have been by the physician who is not available.

Emergency Situation

No distinction is made between new and established patients in the emergency room. Emergency room services should be reported for any patient (new or established) who presents for treatment in the emergency department.

Concurrent Care

Providing similar service (e.g., hospital visits by more than one physician) to the same injured employee on the same day for treatment of the same illness is concurrent care. When concurrent care is provided, no special reporting is required. Duplicate services, however, (e.g., visit by a physician of the same subspecialty for the same illness which is not a second opinion) will not be reimbursed. The authorized treating physician should coordinate care by all specialists.

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SECTION V:

EVALUATION & MANAGEMENT (E/M) SERVICES

SUBSECTION A:

PAYMENT GROUND RULES FOR E/M CATEGORY

Coordination of Care

When no patient encounter occurs, coordination of care by the authorized treating physician with other health care providers outside normal practice is reported and billed using case management codes (99361-99373). When a patient encounter occurs, any counseling and/or coordination of care with other health care providers as a part of or as a result of the encounter is considered part of the E/M code for that session.

Counseling

Counseling is defined as a discussion with an injured employee and/or family concerning one or
more of the following areas:
Diagnostic results, impressions, and/or recommended diagnostic studies; Prognosis; Risks and benefits of management (treatment) options; Instructions for management (treatment) and/or follow-up; Importance of compliance with chosen management (treatment) options; Risk factor reduction; and Injured employee and family education.

Consultations

Defined by CPT as type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or appropriate source. Consultations are reimbursable only to physicians with the appropriate specialty for the services provided. A consulting physician shall only initiate diagnostic and/or therapeutic services with approval from the authorized treating physician. Following a consultation, if the consulting physician assumes responsibility for management of all or any part of the injured employee's condition(s) in accordance with O.C.G.A. 34-9-200, the injured employee becomes an "established patient" (rather than follow-up consultation) under the care of the consulting physician.

When a second opinion is requested or required regarding the necessity or appropriateness of a recommended medical treatment or surgical procedure by the injured employee or employer/insurer, specific confirmatory (second opinion) codes are used to designate confirmatory medical opinions.

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SECTION V:

EVALUATION & MANAGEMENT (E/M) SERVICES

SUBSECTION A: Referral

PAYMENT GROUND RULES FOR E/M CATEGORY

Transfer of total or specific care of an injured employee from one physician to another physician who is not providing a consultation but rather full care and treatment of an injured employee constitutes a referral. Only the authorized treating physician is authorized to make a referral.

After a referral is made and a consulting physician initiates health care treatments at the request of the authorized treating physician, the consulting physician then becomes a referral physician. The referral physician shall only initiate treatment if approved or recommended by the authorized treating physician. Once a referral physician initiates treatment, communications shall continue between the authorized treating physician and the referral physician.

A referral physician shall not make subsequent referrals to additional physicians. The authorized treating physician is the only physician authorized to coordinate care and referrals of any and all treatments from referral physicians.

Employees may make one change from the authorized treating physician to another physician of his/her choice on the panel without authorization or referral. This constitutes a change of authorized treating physician.

Nature of Presenting Problem

A presenting problem is a disease, condition, illness, injury, symptom, sign, finding, complaint, or other reason for encounter, with or without a diagnosis being established at the time of the encounter. The E/M codes recognize five types of presenting problems that are defined below. The information, however, merely contributes to code selection.
Minimal--A problem that may not require the presence of a physician, but service is provided under the physician's supervision.
Self-limited or Minor--A problem that either runs a definite and prescribed course, is transient in nature and is not likely to permanently alter health status or has a good prognosis with management/compliance.
Low severity--A problem for which the risk of morbidity without treatment is low, there is little to no risk of mortality without treatment, and full recovery without functional impairment is expected.
Moderate severity--A problem for which the risk of morbidity without treatment is moderate, there is moderate risk of mortality without treatment, and the prognosis is uncertain OR there is an increased probability of prolonged functional impairment.
High severity--A problem for which the risk of morbidity without treatment is high to extreme, there is a moderate to high risk of mortality without treatment OR high probability of severe, prolonged functional impairment.

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EVALUATION & MANAGEMENT (E/M) SERVICES

SUBSECTION A:

PAYMENT GROUND RULES FOR E/M CATEGORY

Time

The inclusion of time in the definitions of levels of E/M services is to assist physicians in selecting the most appropriate level of E/M service. It should be recognized that the specific time expressed in the visit code descriptions is an average; therefore, it represents a range of times, which may be higher or lower depending on actual clinical circumstances.

Time is not a descriptive component for the emergency department levels of E/M services because emergency department services are typically provided on a variable intensity basis, often involving multiple encounters with several patients over an extended period. Therefore, it is often difficult for physicians to provide accurate estimates of the time spent face-to-face with the injured employee.

Intra-service time is defined as face-to-face time during office and other outpatient visits and as unit/floor time for hospital and inpatient visits. This distinction is necessary because most of the work of typical office visits takes place during the face-to-face time with the injured employee, while most of the work of typical hospital visits takes place during the time spent on the injured employee's floor or unit.

1. Face-to-face time (office and other outpatient visits and office consultations): For coding purposes, face-to-face time for these services is defined as only that time that the physician spends face-to-face with the injured employee and/or family. This includes the time in which the physician performs such tasks as obtaining a history, performing a physical examination, and counseling the injured employee.

Physicians also spend time doing work before or after the face-to-face time with the injured employee, performing such tasks as reviewing records and tests, arranging for further services, and communicating further with other professionals and the injured employee through written reports and telephone contact. This non- face-to-face time for office services--also called pre- and post-encounter time--is not included in the time component described in the E/M codes; however, it was included in calculating the total work of typical services in physician surveys.

Thus, the face-to-face time associated with the services described by any E/M code is a valid proxy for the total work done before, during, and after the visit.

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SECTION V:

EVALUATION & MANAGEMENT (E/M) SERVICES

SUBSECTION A:

PAYMENT GROUND RULES FOR E/M CATEGORY

2. Unit/floor time (hospital observation services, inpatient hospital care, initial and follow-up

hospital consultations, nursing facility): For reporting purposes, intra-service time for these

services is defined as unit/floor time, which includes the time that the physician is present on

the injured employee's hospital unit and at the bedside rendering services for that injured

employee. This includes the time in which the physician establishes and/or reviews the injured

employee's chart, examines the injured employee, writes notes and communicates with other

professionals and the injured employee's family.

Non-floor time: In the hospital, pre- and post-time includes time spent off the injured employee's floor performing such tasks as reviewing pathology and radiology findings in another part of the hospital. This pre- and post-time is not included in the time component described in these codes; however, it was included in calculating the total work of typical services in physician surveys.

Thus, the unit/floor time associated with the services described by any code is a valid proxy for the total work done before, during, and after the visit.

Emergency Room Services

An emergency room is defined as an organized hospital-based facility for the provision of unscheduled episodic services to patients who require immediate medical attention. The facility must be available 24 hours a day.
Only the Emergency Department (ED) physician, who is responsible for the care of the injured employee in the ED, reports an appropriate level ED Evaluation & Management Service code. If the care of the injured employee is then directly transferred to another physician or if the non-ED physician is the only physician to see the injured employee in the emergency room and that physician elects to evaluate the injured employee while he/she is still in the emergency department, the physician would report that E/M service with the appropriate office or other outpatient service code. If, however, that physician elects to admit the injured employee based on the evaluation performed, only the initial inpatient hospital care code should be reported. Of course, any other procedures performed should be reported in addition, with the modifier 25 appended to the E/M code.
If another physician performs a consultation on a patient, then that physician would submit reimbursement requests using an appropriate office or other outpatient consultation code. Again, if this consultation results in a hospital admission, the initial inpatient hospital care code would be submitted for reimbursement.

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SECTION V:

EVALUATION & MANAGEMENT (E/M) SERVICES

SUBSECTION A: Critical Care

PAYMENT GROUND RULES FOR E/M CATEGORY

Critical care includes the care of critically ill patients in a variety of medical emergencies that require the constant attendance of the physician. Critical care is usually, but not always, given in a critical care area, such as the coronary care unit, intensive care unit, respiratory care unit, or the emergency care facility. Services for an injured employee who is not critically ill but happens to be in a critical care unit are reported using subsequent hospital care codes (99231-99233) or hospital consultation codes (99261-99263) as appropriate. The critical care codes are used to report the total time the physician spends providing constant attention to a critically ill injured employee.

Nursing Facility Services, Domiciliary, Rest Home or Boarding Home, Custodial Care, Home Services, Newborn Services

These services will be reimbursed only if the documented condition is directly related to or is the consequence of the compensable injury.

Broken or Missed Appointments

No fees shall be allowed for broken or missed office visits. Notify the employer/insurer if the injured employee is not following the prescribed course of treatment. The only exception will be for a no-show independent medical examination (IME) with a maximum charge of $150.00.
Unlisted Services

An E/M service may be provided that is not listed in this section of the CPT codes. When reporting such a service, the appropriate unlisted code may be used to indicate the service, identifying it "By Report" as discussed on pages 14 and 50. To report an unlisted evaluation and management service, use CPT code 99499.

Physician Assistants/Extenders

Refer to "General Reimbursement Requirements" for a complete discussion of billing procedures for physician extenders.

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SECTION V:

EVALUATION & MANAGEMENT (E/M) SERVICES

SUBSECTION B:

PAYMENT MODIFIERS FOR E/M CATEGORY

A modifier indicates that a service or procedure performed has been altered by some specific

circumstance but has not changed its definition or code. The modifying circumstance shall be

identified by use of a hyphen and the appropriate modifier following the procedure code. When

two modifiers are applicable to a single code, indicate each modifier, preceded by a hyphen, on

the bill. The modifier may also be reported by using a separate five-digit code in addition to the

procedure code. If more than one modifier is used, place the "Multiple Modifiers" code -99

immediately after the procedure code. This indicates that one or more additional modifier codes

will follow. Only certain modifiers in each of the categories (anesthesia, surgery,

pathology/laboratory, radiology, general medicine, and physical medicine) will be recognized for

reimbursement purposes.

The modifiers listed below may differ from those published by the American Medical Association. Medical providers submitting workers' compensation billing shall use only the modifiers set out in the fee schedule.

The following modifiers will be recognized for reimbursement by the fee schedule for Evaluation and Management (E/M) codes:

-21 Prolonged Evaluation and Management Services: When the face-to-face or floor/unit service(s) provided is prolonged or otherwise greater than that usually required for the highest level of E/M service within a given category, it may be identified by adding modifier (-21) to the E/M code number or using the separate five digit modifier code 09921. A report may also be appropriate.

-22 Unusual Procedural Services: When the service(s) provided is greater than that usually required for the listed procedure, it may be identified by adding modifier (-22) to the usual procedure number or using the separate five digit modifier code 09922. A report may also be appropriate.

-24 Unrelated Evaluation and Management Service by the Same Physician during a Postoperative Period: The physician may need to indicate that an E/M service was performed during a postoperative period for a reason(s) unrelated to the original procedure. This circumstance may be reported by adding the modifier (-24) to the appropriate level of E/M service or using the separate five-digit modifier 09924.

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SECTION V:

EVALUATION & MANAGEMENT (E/M) SERVICES

SUBSECTION B:

PAYMENT MODIFIERS FOR E/M CATEGORY

-25 Significant, Separately Identifiable Evaluation and Management Service by the

Same Physician on the Same Day of a Procedure or Other Service: The physician may

need to indicate that on the day a procedure or service identified by a CPT code was

performed, the patient's condition required a significant, separately identifiable E/M

service above and beyond the other service provided or beyond the usual pre-operative

and post-operative care associated with the procedure that was performed. This

circumstance may be reported by adding the modifier (-25) to the appropriate level of E/M

service or the separate five-digit modifier 09925.

-32 Mandated Services: Services related to mandated consultation and/or related services (e.g., PRO, third party payer) might be identified by adding the modifier (-32) to the basic procedure.

-52 Reduced Services: Under certain circumstances, a service or procedure is partially reduced or eliminated at the physician's election. Under these circumstances, the service provided can be identified by its usual procedure number and the addition of the modifier (-52) signifying that the service is reduced. This provides a means of reporting reduced services without disturbing the identification of the basic service. Modifier code 09952 may be used as an alternative to modifier (-52).

-53 Discontinued Procedure: Due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. This circumstance may be reported by adding the modifier (-53) to the code for the discontinued procedure or by using the separate fivedigit modifier 09953. Note: This modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite.

-57 Decision for Surgery: An E/M service that resulted in the initial decision to perform the surgery may be identified by adding the modifier (-57) to the appropriate level of E/M service.

Section V: Evaluation and Management Services

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STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION V:

EVALUATION & MANAGEMENT (E/M) SERVICES

SUBSECTION B:

PAYMENT MODIFIERS FOR E/M CATEGORY

-59 Distinct Procedural Service: Under certain circumstances, the physician may need to

indicate that a procedure or service was distinct or independent from other services

performed on the same day. Modifier (-59) is used to identify procedures/services that are

not normally reported together, but are appropriate under the circumstances. This may

represent a different session or patient encounter, different procedure or surgery, different

site or organ system, separate incision/excision, separate lesion, or separate injury (or area

of injury in extensive injuries) not ordinarily encountered or performed on the same day

by the same medical provider. However, when another already established modifier is

appropriate it should be used rather than modifier (-59). Only if no more descriptive

modifier is available, and the use of modifier (-59) best explains the circumstances, should

modifier (-59) be used. Modifier code 09959 may be used as an alternative to modifier (-

59).

-PE Physician Assistant, Clinical Nurse Specialist, or Nurse Practitioner: Minimum Physician Assistant, Clinical Nurse Specialist, or Nurse Practitioner services are identified by adding the modifier (-PE) to the usual evaluation and management procedure number. A Physician Assistant must be properly licensed by the Composite Board of Medical Examiners in Georgia and/or licensed or certified in the state where services are provided. A Clinical Nurse Specialist (CNS) or Nurse Practitioner (NP) must be properly licensed by the Georgia Board of Nursing and/or licensed or certified in the state where services are provided.

Section V: Evaluation and Management Services

Page 31

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION V: MAXIMUM ALLOWABLE REIMBURSEMENT

CPT DESCRIPTION

MAR PC/-26 FUD

99201 99202 99203 99204 99205 99211 99212 99213 99214 99215 99217 99218 99219 99220 99221 99222 99223 99231 99232 99233 99234 99235 99236 99238 99239 99241 99242 99243 99244 99245 99251 99252 99253 99254 99255 99261 99262 99263 99271 99272 99273 99274 99275 99281 99282 99283 99284

OFFIC/OUTPT VISIT E&M NEW SELF LIMIT/MINOR 10MIN OFFIC/OUTPT VISIT E&M NEW LOW-MOD SEVERITY 20MIN OFFIC/OUTPT VISIT E&M NEW MODERAT SEVERITY 30MIN OFFIC/OUTPT VISIT E&M NEW MOD-HI SEVERITY 45 MIN OFFIC/OUTPT VISIT E&M NEW MOD-HI SEVERITY 60 MIN OFFIC/OUTPT VISIT E&M ESTAB NO PHYS PRES 5 MIN OFFIC/OUTPT VISIT E&M EST SELF-LIMIT/MINOR 10MIN OFFIC/OUTPT VISIT E&M EST LOW-MOD SEVERITY 15MIN OFFIC/OUTPT VISIT E&M EST MOD-HI SEVERITY 25 MIN OFFIC/OUTPT VISIT E&M ESTAB MOD-HI SEVRTY 40 MIN OBSRV CARE D/C DA MGMT INIT OBSRV CARE-DA E&M LOW SEVERITY INIT OBSRV CARE-DA E&M MODERATE SEVERITY INIT OBSRV CARE-DA E&M HIGH SEVERITY INIT HOSP CARE-DA E&M LOW SEVERITY 30 MIN INIT HOSP CARE-DA E&M MODERATE SEVERITY 50 MIN INIT HOSP CARE-DA E&M HIGH SEVERITY 70 MIN SUBSQT HOSP CARE-DA E&M STABLE/RECOVER 15 MIN SUBSQT HOSP CARE-DA E&M MINOR COMPLIC 25 MIN SUBSQT HOSP CARE-DA E&M SIGNIFIC COMPLIC 35 MIN OBSERV/HOSP SAME DATE OBSERV/HOSP SAME DATE OBSERV/HOSP SAME DATE HOSP D/C DA MGMT; 30 MIN/LESS HOSP D/C DA MGMT; MORE THAN 30 MIN OFFIC CONS NEW/ESTAB SELF LIMIT/MINOR 15 MIN OFFIC CONS NEW/ESTAB LOW SEVERITY 30 MIN OFFIC CONS NEW/ESTAB MODERATE SEVERITY 40 MIN OFFIC CONS NEW/ESTAB MOD-HIGH SEVERITY 60 MIN OFFIC CONS NEW/ESTAB MOD-HIGH SEVERITY 80 MIN INIT INPT CONS NEW/ESTAB SELF LIMIT/MINOR 20 MIN INIT INPT CONS NEW/ESTAB LOW SEVERITY 40 MIN INIT INPT CONS NEW/ESTAB MODERATE SEVERITY 55MIN INIT INPT CONS NEW/ESTAB MOD-HI SEVERITY 80 MIN INIT INPT CONS NEW/ESTAB MOD-HI SEVERITY 110 MIN F/U INPT CONS ESTAB STABLE/RECOVER 10 MIN F/U INPT CONS ESTAB MINOR COMPLIC 20 MIN F/U INPT CONS ESTAB SIGNIF COMPLIC 30 MIN CONFIRM CONS NEW/ESTAB SELF LIMIT/MINOR CONFIRM CONS NEW/ESTAB LOW SEVERITY CONFIRM CONS NEW/ESTAB MODERATE SEVERITY CONFIRM CONS NEW/ESTAB MED DECISION MOD COMPLX CONFIRM CONS NEW/ESTAB MED DECISION HI COMPLX EMER DEPT VISIT E&M SELF LIMITED/MINOR EMER DEPT VISIT E&M LOW-MODERATE SEVERITY EMER DEPT VISIT E&M MODERATE SEVERITY EMER DEPT VISIT E&M HIGH SEVERITY URGENT EVAL

$43

N/A

$54

N/A

$70

N/A

$100

N/A

$134

N/A

$33

N/A

$44

N/A

$55

N/A

$77

N/A

$88

N/A

$77

N/A

$96

N/A

$130

N/A

$163

N/A

$107

N/A

$144

N/A

$176

N/A

$56

N/A

$77

N/A

$113

N/A

$125

N/A

$176

N/A

$212

N/A

$66

N/A

$83

N/A

$79

N/A

$101

N/A

$128

N/A

$168

N/A

$212

N/A

$93

N/A

$120

N/A

$147

N/A

$184

N/A

$232

N/A

$50

N/A

$79

N/A

$114

N/A

$79

N/A

$101

N/A

$128

N/A

$168

N/A

$212

N/A

$56

N/A

$75

N/A

$113

N/A

$169

N/A

Section V: Evaluation and Management Services

Page 32

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION V: MAXIMUM ALLOWABLE REIMBURSEMENT

CPT DESCRIPTION

MAR PC/-26 FUD

99285 99288 99291 99292 99301 99302 99303 99311 99312 99313 99315 99316 99321 99322 99323 99331 99332 99333 99354 99355 99356 99357 99358 99359 99360 99361 99362

EMER DEPT E&M-HIGH SEVERITY IMMED SIGNIF THREAT PHYS DIRECT EMS EMER CARE/ADVANCED LIFE SUPPORT CRITICAL CARE E&M-UNSTABLE PT-CONT ATTND; 1ST HR CRITICAL CARE E&M-UNSTABLE PT; EA ADD 30 MIN E&M N/E ANNUAL NURS FACIL ASSESS STABLE 30 MIN E&M NEW/ESTAB NURS FACIL SIGNIF COMPLIC 40 MIN E&M NEW/ESTAB NURS FACIL ADMIT/READMIT 50 MIN SUBSQT NURS FACIL CARE-DA E&M STABLE 15 MIN SUBSQT NURS FAC CARE-DA E&M MIN0R COMPLIC 25 MIN SUBSQT NURS FAC CARE-DA E&M SIG COMPLIC 35 MIN NURSING FAC DISCHARGE DAY NURSING FAC DISCHARGE DAY DOMICIL/REST HOME VISIT E&M NEW PT LOW SEVERITY DOMICIL/REST HOME VISIT E&M NEW PT MOD SEVERITY DOMICIL/REST HOME VISIT E&M NEW PT HI COMPLX DOMICIL/REST HOME VISIT E&M EST PT STABLE/RECOVR DOMICIL/REST HOME VISIT E&M EST PT MINOR COMPLIC DOMICIL/REST HOME VISIT E&M EST PT SIGNIF COMPLI PROLONG PHYS SERV OFFIC/OTHER OUTPT W/PT; 1ST HR PROLONG PHYS SERV OUTPT W/PT; EA ADD 30 MIN PROLONG PHYS SERV INPT W/PT; 1ST HR PROLONG PHYS SERV INPT W/PT; EA ADD 30 MIN PROLONG E & M BEFORE/AFTER PT CONTACT; 1ST HR PROLONG E & M BEFOR/AFTER PT CONTACT; ADD 30 MIN PHYS STANDBY SERV REQ PROLONG MD ATTEND EA 30 MN MED CONFRNCE PHYS W/TEAM COORDIN PT CARE; 30 MIN MED CONFRNCE PHYS W/TEAM COORDIN PT CARE; 60 MIN

$265

N/A

$258

N/A

$246

N/A

$126

N/A

$57

N/A

$70

N/A

$105

N/A

$40

N/A

$48

N/A

$60

N/A

$71

N/A

$82

N/A

$54

N/A

$78

N/A

$103

N/A

$44

N/A

$54

N/A

$68

N/A

$145

N/A

$72

N/A

$189

N/A

$94

N/A

$138

N/A

$69

N/A

$94

N/A

$79

N/A

$138

N/A

99371 PHONE CALL BY PHYS OR PHONE CALL INTERPRETER PER MINUTE

$3

N/A

99374 HOME HEALTH CARE SUPERVISION

$69

N/A

99375 PHYS SUPERVS PT-HOME HEALTH/HOSPICE; 30-60 MIN

$105

N/A

99377 HOSPICE CARE SUPERVISION

$56

N/A

99378 HOSPICE CARE SUPERVISION

$105

N/A

99379 NURSING FAC CARE SUPERVISION

$56

N/A

99380 NURSING FAC CARE SUPERVISION

$105

N/A

99384 INIT PREVEN MEDS E&M NEW PT; 12-17 YR

$60

N/A

99385 INIT PREVEN MEDS E&M NEW PT; 18-39 YR

$82

N/A

99386 INIT PREVEN MEDS E&M NEW PT; 40-64 YR

$89

N/A

99387 INIT PREVEN MEDS E&M NEW PT; 65/> YR

$101

N/A

99394 PREVEN MEDS E&M ESTAB PT; 12-17 YR

$50

N/A

99395 PREVEN MEDS E&M ESTAB PT; 18-39 YR

$68

N/A

99396 PREVEN MEDS E&M ESTAB PT; 40-64 YR

$74

N/A

99397 PREVEN MEDS E&M ESTAB PT; 65/> YR

$84

N/A

99401 PREVEN MEDS COUNSEL/RISK REDUC (SEP PRO); 15 MIN

$22

N/A

99402 PREVEN MEDS COUNSEL/RISK REDUC (SEP PRO); 30 MIN

$44

N/A

99403 PREVEN MEDS COUNSEL/RISK REDUC (SEP PRO); 45 MIN

$66

N/A

99404 PREVEN MEDS COUNSEL/RISK REDUC (SEP PRO); 60 MIN

$88

N/A

Section V: Evaluation and Management Services

Page 33

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION V: MAXIMUM ALLOWABLE REIMBURSEMENT

CPT DESCRIPTION

MAR PC/-26 FUD

99411 99412 99420 99429 99450 99455 99456 99499

PREVEN MEDS COUNSEL GRP (SEPART PROC); 30 MIN PREVEN MEDS COUNSEL GRP (SEPART PROC); 60 MIN ADMIN/INTERPT HEALTH RISK ASSESSMENT INSTRUM UNLISTED PREVEN MEDS SERV BASIC LIFE &/OR DISABILITY EXAM WORK RELATED/MED DISABILITY EXAM BY TREATING MD WORK RELATED/MED DISABILITY EXAM NOT TREATING MD UNLISTED EVAL & MGMT SERVICES

$31

N/A

$63

N/A

$71

N/A

BR

N/A

$145

N/A

$199

N/A

$229

N/A

BR

N/A

Section V: Evaluation and Management Services

Page 34

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VI:

ANESTHESIA SERVICES

SUBSECTION A:

PAYMENT GROUND RULES FOR ANESTHESIA SERVICES

General Guidelines

Anesthesia care may include, but is not limited to, general, regional, or monitored anesthesia care, supplementation of local anesthesia, or other supportive services in order to afford the injured employee the anesthesia care deemed optimal by the anesthesiologist during any procedure. When anesthesia is provided by the physician performing the primary service, the anesthesia services are included in the primary procedure (HCFA global surgery policy).

Fee schedule amounts for anesthesia services are determined on a different basis than fee determinations for physician services. A relative unit value and dollar conversion factor basis is used. The relative values for anesthesia services are based on values and procedures established by the American Society of Anesthesiologists. A dollar conversion factor has been established for anesthesia services to be multiplied by the total number of units applicable for a particular service. The unit values described in this section reflect the relativity of charges for procedures within this section only.

Anesthesia services may include, but are not limited to, general, regional, supplementation of local anesthesia, or other supportive services in order to afford the injured employee the anesthesia care deemed optimal. Services involving administration of anesthesia are reported by the use of the anesthesia five-digit procedure code and modifier codes.

Anesthesia service reimbursement is determined using relative base unit values for each procedure code, the total time of services provided, physical status modifiers (if any), and a conversion factor. The relative base unit values for anesthesia procedures are specified in the American Society of Anesthesiologists' 1998 (ASA) Relative Value Guide.

Many anesthesia services are provided under particularly difficult circumstances, depending on factors such as extraordinary condition of injured employee, notable operative conditions, or unusual risk factors. Procedure codes 99100, 99116, 99135, and 99140 should be used to define these procedures. These procedures shall not be reported alone, but would be reported as additional procedure codes qualifying as an anesthesia procedure or service. In procedure code 99140 (anesthesia complicated by emergency conditions), emergency is defined as existing when delay in treatment of the injured employee would lead to a significant increase in the threat to life or body part.

Anesthesia Billing Procedures

The total anesthesia value (TAV) for each procedure is defined by adding a basic value, which is related to the complexity of the service, and modifying units (if any), plus time units.

Anesthesia Values

Section VI: Anesthesia Services

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STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VI:

ANESTHESIA SERVICES

SUBSECTION A:

PAYMENT GROUND RULES FOR ANESTHESIA SERVICES

All anesthesia values are determined based on basic unit values for each anesthesia procedure code, the

total time of services provided, physical status modifiers (if any), and the conversion factor as shown

below.

Conversion Factor x TAV = ANESTHESIA FEE or Conversion Factor x (Basic value+time unit value+modifier value) = ANESTHESIA FEE

Base Unit Values

The basic value includes the pre-operative and post-operative visits, the anesthesia care during the duration of the procedure, the administration of fluids and/or blood, including use of cell-saver, and the usual monitoring services (e.g., ECG, temperature, blood pressure, oximetry, capnography, and mass spectrography). Unusual forms of monitoring are not included in the basic units (e.g., intra-arterial, central venous, and Swan-Ganz) and may be coded and billed separately. Documentation of the medical necessity for these types of unusual monitoring is required and shall not be reimbursed separately.

Dollar Conversion Factor

Reimbursement for anesthesia services is based on a dollar conversion unit multiplied by the total anesthesia value (TAV) determined for each service rendered. The conversion factor for anesthesia is $32.00. This amount will be applied to the anesthesia values as described in the fee schedule.

Modifying Units

Use of the 5-digit anesthesia code plus the addition of a physical status modifier must be used to report all anesthesia services. These modifying units may be added to the basic unit values. The initial letter `P' followed represents physical status modifiers by a single digit as defined below:

PHYSICAL STATUS MODIFIERS P1 A normal, healthy patient P2 A patient with mild systemic disease P3 A patient with severe systemic disease P4 A patient w/severe systemic disease, a constant threat to life P5 A moribund patient who is not expected to survive without the operation P6 A declared brain-dead patient whose organs are being removed for donor purposes

UNIT VALUE 0 0 1 2 3 0

Anesthesia services are provided under varied difficult circumstances depending on certain risk factors. Qualifying circumstances that significantly affect the character of the services provided should be reported as additional procedure numbers. These modifying units may be added to the basic unit values.

Section VI: Anesthesia Services

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STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VI:

ANESTHESIA SERVICES

SUBSECTION A:

PAYMENT GROUND RULES FOR ANESTHESIA SERVICES

PHYSICAL STATUS MODIFIERS 99100 Anesthesia for a patient of extreme age, under one year or over seventy 99116 Anesthesia complicated by utilization of total body hypothermia 99135 Anesthesia complicated by utilization of controlled hypertension 99140 Anesthesia complicated by emergency conditions (must be specified)

UNIT VALUE 1 5 5 2

Time Reporting

Anesthesia time begins when the anesthesiologist begins to prepare the injured employee for the induction of anesthesia in the operating room, or in an equivalent area, and ends when the anesthesiologist is no longer in personal attendance (e.g., that is, when the injured employee may be safely placed under post operative supervision). The time value is computed by allowing one unit for each ten (10) minutes of anesthesia time during the duration of the service. In each instance, five minutes or greater is considered a significant portion of a time unit. For anesthesia lasting less than five minutes, only base units without time units will be used to calculate reimbursement by the fee schedule. Acceptable time reporting requires that the hours and minutes of anesthesia be submitted.

Example Anesthesia Fee Calculation

Given a total time of 2 hours for services provided using Anesthesia with a basic unit of three, and no modifiers, the anesthesia fee would be $480.00.

01382 ANESTHESIA FOR ARTHROSCOPIC PROCEDURE OF KNEE JOINT
Dollar Conversion Unit = $32 Basic Value = 3
Time Unit Value = 12 (6 units per hour x 2 hours) Modifier Value = 0
Anesthesia Fee = ($32 x 3 Basic Value) + ($32 x 12 Time Unit Value) + ($32 x 0 Modifier Value) = $480
Second Attending Anesthesiologist
When it is necessary to have a second attending anesthesiologist assist with the preparation and conduct of the anesthesia, these circumstances should be substantiated by Special Report. Such services shall have a basic value of 5.0 units plus time units.

Section VI: Anesthesia Services

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STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VI:

ANESTHESIA SERVICES

SUBSECTION B:

PAYMENT MODIFIERS FOR ANESTHESIA SERVICES

A modifier indicates a service or procedure performed has been altered by some specific

circumstance but has not changed its definition or code. The modifying circumstance shall be

identified by use of a hyphen and the appropriate modifier following the procedure code. When

two modifiers are applicable to a single code, indicate each modifier, preceded by a hyphen, on

the bill. The modifier may also be reported by using a separate five-digit code in addition to the

procedure code. If more than one modifier is used, place the "Multiple Modifiers" code -99

immediately after the procedure code. This indicates that one or more additional modifier codes

will follow. Only certain modifiers in each of the categories (anesthesia, surgery,

pathology/laboratory, radiology, general medicine, and physical medicine) will be recognized for

reimbursement purposes.

The modifiers listed below may differ from those published by the American Medical Association. Medical providers submitting workers' compensation billing shall use only the modifiers set out in the Medical Fee Guideline.

All anesthesia services are reported by use of the anesthesia five-digit procedure code (0010001999) plus the addition of a physical status modifier as outlined below. The added units for each physical status modifier are listed.

Physical Status Modifiers

Six levels of physical status modifiers are consistent with the American Society of Anesthesiologists (ASA) ranking of patient physical status. Physical status is included to distinguish between various levels of complexity of the anesthesia service provided. A listing of physical status modifiers is indicated on the following pages.

Other Modifiers

Other Modifiers (optional): Under certain circumstances, medical services and procedures may need to be further modified. Other modifiers commonly used in anesthesia are :

-22 Unusual Procedural Services: When the service(s) provided is greater than that usually required for the listed procedure, it may be identified by adding modifier (-22) to the usual procedure number or by using the separate five digit modifier code 09922. Payment will be determined based upon special report.

-23 Unusual Anesthesia: Occasionally, a procedure that usually requires either no anesthesia or local anesthesia, because of unusual circumstances must be done under general anesthesia. This circumstance may be reported by adding the modifier (-23) to the procedure code of the basic service or by using the separate five-digit modifier code 09923. Payment will be determined based upon special report.

Section VI: Anesthesia Services

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STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VI:

ANESTHESIA SERVICES

SUBSECTION B:

PAYMENT MODIFIERS FOR ANESTHESIA SERVICES

-42 Concurrent supervision of two Certified Registered Nurse Anesthetists (CRNA) by an Anesthesiologist: Indicated by using this modifier when the Anesthesiologist is directing two concurrent anesthetic procedures. The reimbursement shall be at 90% of the total anesthesia value.

-43 Concurrent supervision of three Certified Registered Nurse Anesthetists (CRNA) by an Anesthesiologist: Indicated by using this modifier when the Anesthesiologist is directing three concurrent anesthetic procedures. The reimbursement shall be at 85% of the total anesthesia value.

-44 Concurrent supervision of four Certified Registered Nurse Anesthetists (CRNA) by an Anesthesiologist: Indicated by using this modifier when the Anesthesiologist is directing four concurrent anesthetic procedures. The reimbursement shall be at 80% of the total anesthesia value.

-47 Anesthesia by Surgeon: Regional or general anesthesia provided by the surgeon may be reported by adding the modifier (-47) to the basic service or by using the separate five digit modifier code 09947. This does not include local anesthesia. Payment will be based on the basic unit value without benefit for time. Payment will not exceed 25% of the total dollar value of the surgery. Note: Modifier (-47) or 09947 would not be used as a modifier for the anesthesia procedures 00100-01999.

-53 Discontinued Procedure: Due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started, but discontinued. This circumstance may be reported by adding the modifier (-53) to the code for the discontinued procedure or by using the separate five-digit modifier 09953. Note: This modifier is not used to report the elective cancellation of a procedure before the patient's anesthesia induction and/or surgical preparation in the operating suite.

Section VI: Anesthesia Services

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STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VI:

ANESTHESIA SERVICES

SUBSECTION B:

PAYMENT MODIFIERS FOR ANESTHESIA SERVICES

-59 Distinct Procedural Service: Under certain circumstances, the medical provider may

need to indicate that a procedure or service was distinct or independent from other

services performed on the same day. Modifier (-59) is used to identify

procedures/services that are not normally reported together, but are appropriate under the

circumstances. This may represent a different session or patient encounter, different

procedure or surgery, different site or organ system, separate incision/excision, separate

lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered

or performed on the same day by the same physician. However, when another already

established modifier is appropriate it should be used rather than modifier (-59). Only if no

more descriptive modifier is available, and the use of modifier (-59) best explains the

circumstances, should modifier (-59) be used. Modifier code 09959 may be used as an

alternative to modifier (-59).

P1 - Physical Status: This modifier is used for a normal, healthy patient. Zero (0) extra bill units shall be added.

P2 - Physical Status: This modifier is used for a patient with a mild systemic disease. Zero (0) extra bill units shall be added.

P3 - Physical Status: This modifier is used for a patient with a severe, systemic disease. One (1) extra bill unit shall be added.

P4 - Physical Status: This modifier is used for a patient with a severe, systemic disease that is a constant threat to life. Two (2) extra bill units shall be added.

P5 - Physical Status: This modifier is used for a patient who is not expected to survive without the operation. Three (3) extra bill units shall be added.

P6 - Physical Status: This modifier is used for a declared brain-dead patient whose organs are being removed for donor purposes. Zero (0) extra bill units shall be added.

Qualifying Circumstances

More than one may be selected.

Many anesthesia services are provided under particularly difficult circumstances, depending on factors such as extraordinary condition of patient, notable operative conditions, and/or unusual risk factors. These procedures would not be reported alone but would be reported as additional procedure numbers qualifying an anesthesia procedure or services.

Section VI: Anesthesia Services

Page 40

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VI:

ANESTHESIA SERVICES

SUBSECTION B:

PAYMENT MODIFIERS FOR ANESTHESIA SERVICES

99140 Anesthesia for patient of extreme age, under one year and over seventy; list separately

in addition to code for primary anesthesia procedure.

99141 Anesthesia complicated by utilization of total body hypothermia; list separately in

addition to code for primary anesthesia procedure.

99142 Anesthesia complicated by utilization of controlled hypertension; list separately in

addition to code for primary anesthesia procedure.

99143 Anesthesia complicated by emergency conditions (specify); list separately in addition

to code for primary anesthesia procedure.

Miscellaneous

Local infiltration, digital block or topical anesthesia administered by the operating surgeon is included in the unit value for the surgical procedure.

If the attending surgeon administers regional anesthesia, the value shall be the "basic" anesthesia value only without added value for time. (See modifier 47).

For diagnostic or therapeutic nerve block, see 62274-62279 and 64400-64680.

Adjunctive services provided during anesthesia and certain other circumstances may warrant an additional charge. Identify by using the appropriate unit value modifier.

For cardio-pulmonary resuscitation (independent procedure), see 92950.

If the surgeon or attending physician administers a local or regional block for anesthesia during a procedure, the bill should indicate with the use of a modifier "NT" for "no time".

In calculating units of time, use 10 minutes per unit. If a medical provider bills for a portion of 10 minutes, round the time up to the next 10 minutes and reimburse one unit for the portion of time.

For diagnostic or therapeutic nerve blocks performed by the surgeon or the anesthesiologist, only one reimbursement per procedure shall be allowed, regardless of the time required. (E.g., see codes 62274-62279, 64400-64530).

Major regional anesthesia administered by the surgeon, such as a spinal epidural or major peripheral nerve block, shall be reimbursed the basic anesthesia value only without benefit for time (e.g., see modifier "-47").

Section VI: Anesthesia Services

Page 41

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VI:

ANESTHESIA SERVICES

SUBSECTION B:

PAYMENT MODIFIERS FOR ANESTHESIA SERVICES

Any procedure around the head, neck or shoulder girdle that requires field avoidance or any

procedure compromising the anesthesia administration (e.g., requiring a position other than supine

or lithotomy) has a minimum basic value of 5.0 units regardless of any lesser basic value assigned

to such procedures. In this case, modifier (-22) is required.

No additional base value shall be reimbursed for anesthesia rendered during additional surgical procedures (other than the primary procedure) performed on the same day during the same operative setting.

Anesthesia reimbursement for multiple procedures is based on the procedure with the highest base value, plus modifying units (if appropriate), plus total time units for all combined surgical procedures.

Section VI: Anesthesia Services

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STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VI:

MAXIMUM ALLOWABLE REIMBURSEMENT

CPT

DESCRIPTION

00100 SALIVARY GLANDS, W/ BX

00102 PLASTIC REPAIR, CLEFT LIP

00103 FOR RECONSTRUCTIVE EYELID

00104 ELECTROCONVULSIVE THERAPY

00120 EAR PROC/BX; NOS

00124 EXT, MIDDLE, & INNER EAR W/ BX; OTOSCOPY

00126 EXT, MIDDLE, & INNER EAR W/ BX; TYMPANOTOMY

00140 EYE; NOS

00142 EYE; LENS SURGERY

00144 EYE; CORNEAL TRANSPLANT

00145 EYE; VITRECTOMY

00147 EYE; IRIDECTOMY

00148 EYE; OPHTHALMOSCOPY

00160 NOSE & ACCESSORY SINUSES; NOS

00162 NOSE & ACCESSORY SINUSES; RADICAL SURGERY

00164 NOSE & ACCESSORY SINUSES; BX, SOFT TISSUE

00170 INTRAORALW/ BX; NOS

00172 INTRAORALW/ BX; REPAIR, CLEFT PALATE

00174 INTRAORALW/ BX; EXCISION, RETROPHARYNGEAL TUMOR

00176 INTRAORALW/ BX; RADICAL SURGERY

00190 FACIAL BONES; NOS

00192 FACIAL BONES; RADICAL SURGERY (W/ PROGNATHISM)

00210 INTRACRANIAL PROC; NOS

00212 INTRACRANIAL PROC; SUBDURAL TAPS

00214 INTRACRANIAL, BURR HOLES, VENTRICULOGRAPHY

00215 INTRACRANIAL PROC; ELEVATION DEPRESSED SKULL FX, EXTRADURAL

00216 INTRACRANIAL PROC; VASCULAR PROC

00218 INTRACRANIAL PROC; PROC IN SITTING POSITION

00220 INTRACRANIAL PROC; SPINAL FLUID SHUNTING PROC

00222 INTRACRANIAL PROC; ELECTROCOAGULATION, INTRACRANIAL NERVE

00300 HEAD, NECK, POST TRUNK INTEGUMENTARY, MUSCLES/NERVES

00320 NECK ORGAN PROC; NOS

00322 THYROID NEEDLE BX

00350 MAJOR VESSELS, NECK; NOS

00352 MAJOR VESSELS, NECK; SIMPLE LIGATION

00400 EXTREMITIES, ANTERIOR TRUNK, PERINEUM, INTEGUMENTARY

00402 BREAST RECONSTRUCTION

00404 RADICAL/MODIFIED BREAST SURGERY

00406 RADICAL/MODIFIED BREAST SURGERY W/ NODE DISSECTION

00410 CARDIOVERSION

00450 CLAVICLE & SCAPULA; NOS

00452 CLAVICLE & SCAPULA; RADICAL SURGERY

00454 CLAVICLE & SCAPULA; BX, CLAVICLE

00470 PARTIAL RIB RESECTION; NOS

BASE UNITS 5 6 5 4 5 4 4 5 6 6 6 6 4 5 7 4 5 6 6 7 5 7 11 5 9 9 15 13 10 6 5 6 3 10 5 3 5 5 13 4 5 6 3 6

Section VI: Anesthesia Services

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STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VI:

MAXIMUM ALLOWABLE REIMBURSEMENT

CPT

DESCRIPTION

00472 PARTIAL RIB RESECTION; THORACOPLASTY, ANY TYPE

00474 PARTIAL RIB RESECTION; RADICAL PROC

00500 ALL ESOPHAGUS

00520 CLOSED CHEST NOS

00522 PLEURA NEEDLE BX

00524 PNEUMOCENTESIS

00528 MEDIASTINOSCOPY, DX THORACOSCOPY

00530 TRANSVENOUS PACEMAKER INSERTION

00532 ACCESS TO CENTRAL VENOUS CIRCULATION

00534 TRANSVENOUS INSRT/REPLC CARDIOVERTER/DEFIB

00540 THORACOTOMY INVOLV LUNGS; NOS

00542 THORACOTOMY INVOLV LUNGS; DECORTIC

00544 THORACOTOMY INVOLV LUNGS; PLEURECTOMY

00546 THORACOTOMY INVOLV LUNGS; W/THORACOPLASTY

00548 THORACOTOMY INVOLV LUNGS; INTHORACIC REPR

00560 HEART, PERICARDIUM SURGERY W/O PUMP

00562 HEART, PERICARDIUM SURGERY W/ PUMP

00580 HEART TRANSPLANT HEART & LUNG TRANSPLANT

00600 CERVICAL SPINE & CORD; NOS

00604 POSTERIOR CERVICAL LAMINECTOMY, SITTING

00620 THORACIC SPINE & CORD; NOS

00622 THORACIC SPINE & CORD; THORACOLUMBAR SYMPATHECTOMY

00630 PROC IN LUMBAR REGION; NOS

00632 PROC IN LUMBAR REGION; LUMBAR SYMPATHECTOMY

00634 PROC IN LUMBAR REGION; CHEMONUCLEOLYSIS

00670 EXTENSIVE SPINE & SPINAL CORD PROC

00700 UPPER ANTERIOR ABDOMINAL WALL; NOS

00702 UPPER ANTERIOR ABDOMINAL WALL; PERCUTANEOUS LIVER BX

00730 UPPER POSTERIOR ABDOMINAL WALL

00740 UPPER GI ENDOSCOPY, PROXIMAL DUODENUM

00750 HERNIA REPAIRS IN UPPER ABDOMEN; NOS

00752 HERNIA REPAIR, LUMBAR & VENTRAL, &/OR WOUND DEHISCENCE

00754 HERNIA REPAIRS IN UPPER ABDOMEN; OMPHALOCELE

00756 HERNIA REPR UP ABD; TRANSABD DIAPHRAGMATIC

00770 ALL MAJOR ABDOMINAL BLOOD VESSELS

00790 INTRAPERITONEALUPPER ABDOMEN, W/ LAPAROSCOPY NOS

00792 W/ LAPAROSCOPY; PARTIAL HEPATECTOMY (W/O LIVER BX)

00794 W/ LAPAROSCOPY; PANCREATECTOMY, PARTIAL/TOTAL

00796 W/ LAPAROSCOPY; LIVER TRANSPLANT, RECIPIENT

00800 LOWER ANTERIOR ABDOMINAL WALL; NOS

00802 LOWER ANTERIOR ABDOMINAL WALL; PANNICULECTOMY

00810 LOWER INTESTINAL ENDOSCOPY, DISTAL DUODENUM

00820 LOWER POSTERIOR ABDOMINAL WALL

00830 HERNIA REPAIRS IN LOWER ABDOMEN; NOS

BASE UNITS 10 13 15 6 4 3 8 4 4 7 13 15 15 15 15 15 20 20 10 13 10 13 8 7 10 13 3 4 5 5 4 6 7 7 15 7 13 8 30 3 5 6 5 4

Section VI: Anesthesia Services

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STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VI:

MAXIMUM ALLOWABLE REIMBURSEMENT

CPT

DESCRIPTION

00832 HERNIA REPAIRS IN LOWER ABDOMEN; VENTRAL & INCISIONAL HERNIAS

00840 INTRAPERITONEALLOWER ABDOMEN, W/ LAPAROSCOPY; NOS

00842 LOWER ABDOMEN, W/ LAPAROSCOPY; AMNIOCENTESIS

00844 LOWER ABDOMEN, W/ LAPAROSCOPY; ABDOMINOPERINEAL RESECTION

00846 LOWER ABDOMEN, W/ LAPAROSCOPY; RADICAL HYSTERECTOMY

00848 LOWER ABDOMEN, W/ LAPAROSCOPY; PELVIC EXTENERATION

00850 LOWER ABDOMEN, W/ LAPAROSCOPY; C-SECTION

00855 LOWER ABDOMEN, W/ LAPAROSCOPY; C-SECTION HYSTERECTOMY

00857 ANESTHESIA/ANALGESIA, NEURAXIAL, LABOR W/ CESAREAN DELIVERY

00860 EXTRAPERITONEALLOWER ABDOMEN, W/ URINARY TRACT; NOS

00862 RENAL PROC/DONOR NEPHRECTOMY

00864 TOTAL CYSTECTOMY

00865 RADICAL PROSTATECTOMY

00866 ADRENALECTOMY

00868 RENAL TRANSPLANT, RECIPIENT

00870 CYSTOLITHOTOMY

00872 LITHOTRIPSY, EXTRACORPOREAL SHOCK WAVE; W/ WATER BATH

00873 LITHOTRIPSY, EXTRACORPOREAL SHOCK WAVE; W/O WATER BATH

00880 MAJOR LOWER ABDOMINAL VESSELS; NOS

00882 MAJOR LOWER ABDOMINAL VESSELS; INFERIOR VENA CAVA LIGATION

00884 MAJOR LOWER ABDOMINAL VESSELS; TRANSVENOUS UMBRELLA INSERTION

00900 PERINEAL INTEGUMENT PROC W/ BX MALE GENITAL SYSTEM; NOS

00902 ANORECTAL PROC W/ ENDOSCOPY &/OR BX

00904 W/ BX MALE GENITAL SYSTEM; RADICAL PERINEAL PROC

00906 VULVECTOMY

00908 PERINEAL PROSTATECTOMY

00910 TRANSURETHRAL PROC (W/ URETHROCYSTOSCOPY); NOS

00912 TRANSURETHRAL RESECTION, BLADDER TUMOR(S)

00914 TRANSURETHRAL RESECTION, PROSTATE

00916 TRANSURETHRAL; POST RESECT BLEEDING

00918 TRANSURETHRAL; W/ FRAGMEN/REMOV CALCU

00920 MALE EXT GENIT; NOS

00922 MALE EXT GENIT; SEMINAL VESICLES

00924 MALE EXT GENIT; UNDESCEND TESTIS UNI/BILAT

00926 MALE EXT GENIT; RADICAL ORCHIECTOMY, ING

00928 MALE EXT GENIT; RADICAL ORCHIECTOMY, ABD

00930 MALE GENIT; ORCHIOPEXY UNI/BILAT

00932 MALE EXT GENIT; COMPLT AMPUTA PENIS

00934 MALE; RAD AMPUT PENIS W/BIL ING LYMPHADENE

00936 MALE; RAD AMP PENIS W/BIL ING & ILIAC LYMP

00938 MALE EXT GENIT; INSRT PENILE PROSTH

00940 VAGINALW/ BX; NOS

00942 VAGINALW/ BX; COLPOTOMY, COLPECTOMY, COLPORRHAPHY

00944 VAGINALW/ BX; VAGINAL HYSTERECTOMY

BASE UNITS 6 6 4 7 8 8 7 8 7 6 7 8 7 10 10 5 7 5 15 10 5 3 5 7 4 6 3 5 5 5 5 3 6 4 4 6 4 4 6 8 4 3 4 6

Section VI: Anesthesia Services

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STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VI:

MAXIMUM ALLOWABLE REIMBURSEMENT

CPT

DESCRIPTION

00946 VAGINALW/ BX; VAGINAL DELIVERY

00948 VAGINALW/ BX; CERVICAL CERCLAGE

00950 VAGINALW/ BX; CULDOSCOPY

00952 VAGINALW/ BX; HYSTEROSCOPY

00955 ANESTHESIA/ANALGESIA, NEURAXIAL, LABOR W/ VAGINAL DELIVER

01120 BONY PELVIS

01130 BODY CAST APPLICATION/REVISION

01140 INTERPELVIABDOMINAL (HINDQUARTER) AMPUTATION

01150 RADICALTUMOR, PELVIS, EXCEPT HINDQUARTER AMPUTATION

01160 CLOSED PROC INVOLVING SYMPHYSIS PUBIS/SACROILIAC JOINT

01170 OPEN PROC INVOLVING SYMPHYSIS PUBIS/SACROILIAC JOINT

01180 OBTURATOR NEURECTOMY; EXTRAPELVIC

01190 OBTURATOR NEURECTOMY; INTRAPELVIC

01200 ALL CLOSED PROC INVOLVING HIP JOINT

01202 ARTHROSCOPICHIP JOINT

01210 OPEN PROC INVOLV HIP JT; NOS

01212 OPEN PROC INVOLV HIP JT; HIP DIASART

01214 OPEN INVOLV HIP JT; TOT HIP REPLAC/REVIS

01220 ALL CLO PROC INVOLV UPPER 2/3 FEMUR

01230 OPEN PROC INVOLV UPPER 2/3 FEMUR; NOS

01232 OPEN PROC INVOLV UPPER 2/3 FEMUR; AMPUTA

01234 OPEN INVOLV UP 2/3 FEMUR; RAD RESECT

01250 ALL NERV/MUSCL/TENDON/FASCIA/BURSAE UP LEG

01260 ALL INVOLV VEINS UP LEG INCL EXPLOR

01270 INVOLV ART UP LEG INCL BYPASS GFT; NOS

01272 INVOLV ART UP LEG INCL GFT; FEM ART LIG

01274 INVOLV ART UP LEG INCL GFT; FEM ART EMBOLE

01320 NERV/MUSCL/TENDON/FASCIA/BURSAE KNEE/POP

01340 ALL CLOSED LOWER ONE THIRD, FEMUR

01360 ALL OPEN LOWER ONE THIRD, FEMUR

01380 ALL CLOSED KNEE JOINT

01382 ARTHROSCOPICKNEE JOINT

01390 ALL CLOSED UPPER ENDS, TIBIA, FIBULA, &/OR PATELLA

01392 ALL OPEN UPPER ENDS, TIBIA, FIBULA, &/OR PATELLA

01400 OPEN KNEE JOINT; NOS

01402 OPEN KNEE JOINT; TOTAL KNEE REPLACEMENT

01404 OPEN KNEE JOINT; DISARTICULATION AT KNEE

01420 ALL CAST APPLICATIONS, REMOVAL/REPAIR INVOLVING KNEE JOINT

01430 VEINS, KNEE & POPLITEAL AREA; NOS

01432 VEINS, KNEE & POPLITEAL AREA; ARTERIOVENOUS FISTULA

01440 ART KNEE & POP AREA; NOS

01442 ART KNEE; POP THROMBOENDART W/WO PATCH GFT

01444 ART KNEE; POP EXC/GFT/REPR OCCLUS/ANEURYSM

01462 ALL CLO PROC LOWER LEG, ANK, & FT

BASE UNITS 5 4 5 4 5 6 3 15 8 4 8 3 4 4 4 6 10 8 4 6 5 8 4 3 8 4 6 4 4 5 3 3 3 4 4 7 5 3 3 6 5 8 8 3

Section VI: Anesthesia Services

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STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VI:

MAXIMUM ALLOWABLE REIMBURSEMENT

CPT

DESCRIPTION

01464 ARTHROSCOPIC PROC ANK JT

01470 NERV/MUSCL/FASCIA LOW LEG/ANK/FT; NOS

01472 NERV/MUSCL LO LEG; REPR ACHILLES W/WO GFT

01474 NERV/MUSCL LO LEG; GASTROCNEMIUS RECESSION

01480 OPEN PROC BONES LOWER LEG, ANK, & FT; NOS

01482 OPEN BONES LO LEG/ANK/FT; RADICAL RESECT

01484 OPEN BONES LO LEG/ANK/FT; OSTEOTMY TIB/FIB

01486 OPEN BONES LO LEG/ANK/FT; TOT ANK REPLAC

01490 LOWER LEG CAST APPLICATION, REMOVAL/REPAIR

01500 ART LOWER LEG, INCL BYPASS GFT; NOS

01502 ART LO LEG W/BYPASS GFT; EMBOLEC DIR/CATH

01520 VEINS LOWER LEG; NOS

01522 VEINS LO LEG; VENOUS THROMBEC DIRECT/CATH

01610 ALL NERV/MUSCL/FASCIA/BURSAE SHOULDER/AXIL

01620 ALL CLO HUMERAL/AC/SHLDR JT

01622 ARTHROSCOPICSHOULDER JOINT

01630 OPENSHOULDER BONE; NOS

01632 OPENSHOULDER BONE; RADICAL RESECTION

01634 OPENSHOULDER BONE; DISARTICULATION

01636 OPENSHOULDER BONE; INTERTHORACOSCAPULAR AMPUTATION

01638 OPENSHOULDER BONE; REPLACEMENT

01650 ARTERIES, SHOULDER & AXILLA; NOS

01652 ARTERIES, SHOULDER & AXILLA; AXILLARY-BRACHIAL ANEURYSM

01654 ARTERIES, SHOULDER & AXILLA; BYPASS GRAFT

01656 ARTERIES, SHOULDER & AXILLA; AXILLARY-FEMORAL BYPASS GRAFT

01670 ALL VEINS, SHOULDER & AXILLA

01680 SHOULDER CAST APPLICATION, REMOVAL/REPAIR; NOS

01682 SHOULDER CAST APPLICATION, REMOVAL/REPAIR; SHOULDER SPICA

01710 NERV/MUSCL/FASCIA/BURSAE UP ARM/ELBOW; NOS

01712 NERV UP ARM/ELB; TENOTOMY ELBOW-SHLDR OPEN

01714 NERV UP ARM/ELBOW; TENOPLASTY ELBOW-SHLDR

01716 NERV UP ARM/ELBOW; TENODESIS RUPT BICEPS

01730 ALL CLOSED HUMERUS & ELBOW

01732 ARTHROSCOPICELBOW JOINT

01740 OPEN HUMERUS & ELBOW; NOS

01742 OPEN HUMERUS & ELBOW; OSTEOTOMY, HUMERUS

01744 OPEN HUMERUS & ELBOW; REPAIR, NONUNION/MALUNION, HUMERUS

01756 OPEN HUMERUS & ELBOW; RADICAL PROC

01758 OPEN HUMERUS & ELBOW; EXCISION, CYST/TUMOR, HUMERUS

01760 OPEN HUMERUS & ELBOW; TOTAL ELBOW REPLACEMENT

01770 ARTERIES, UPPER ARM & ELBOW; NOS

01772 ARTERIES, UPPER ARM & ELBOW; EMBOLECTOMY

01780 VEINS, UPPER ARM & ELBOW; NOS

01782 VEINS, UPPER ARM & ELBOW; PHLEBORRHAPHY

BASE UNITS 3 3 5 5 3 4 4 7 3 8 6 3 5 5 4 4 5 6 9 15 10 6 10 8 10 4 3 4 3 5 5 5 3 3 4 5 5 6 5 7 6 6 3 3

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STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VI:

MAXIMUM ALLOWABLE REIMBURSEMENT

CPT

DESCRIPTION

01784 REPAIR, ARTERIO-VENOUS FISTULA, CONGENITAL/ACQUIRED

01810 NERVES/MUSCLES/TENDONS/FASCIA & BURSAE, LOWER ARM/HAND

01820 ALL CLOSED RADIUS, ULNA, WRIST/HAND BONES

01830 OPEN RADIUS/ULNA/WRIST/HAND BONES; NOS

01832 OPEN RADIUS/ULNA/WRIST/HAND BONES; TOTAL WRIST REPLACEMENT

01840 ARTERIES, FOREARM, WRIST, & HAND; NOS

01842 ARTERIES, FOREARM, WRIST, & HAND; EMBOLECTOMY

01844 VASCULAR SHUNT/SHUNT REVISION, ANY TYPE

01850 VEINS, FOREARM, WRIST, & HAND; NOS

01852 VEINS, FOREARM, WRIST, & HAND; PHLEBORRHAPHY

01860 FOREARM/WRIST/HAND CAST APPLICATION, REMOVAL/REPAIR

01904 INJECTIONPNEUMOENCEPHALOGRAPHY

01906 INJECTIONMYELOGRAPHY; LUMBAR

01908 INJECTIONMYELOGRAPHY; CERVICAL

01910 INJECTIONMYELOGRAPHY; POSTERIOR FOSSA

01912 INJECTIONDISKOGRAPHY; LUMBAR

01914 INJECTIONDISKOGRAPHY; CERVICAL

01916 ARTERIOGRAMS/NEEDLE; CAROTID/VERTEBRAL

01918 ARTERIOGRAMS/NEEDLE; RETROGRAD BRACH/FEM

01920 CARD CATH W/CORONARY ARTERIOGRAPHY & VENTR

01921 ANGIOPLASTY

01922 NON-INVASIVE IMAGING/RADIATION THERAP

01990 PHYSIOLOG SUPPORT HARVEST DONOR ORGAN-BRAIN DEAD

01995 REGIONAL IV ADMIN LOCAL ANES AGENT

01996 DAILY MGMT EPIDURAL OR SUBARACHNOID DRUG ADMIN

BASE UNITS 6 3 3 3 6 6 6 6 3 4 3 7 5 5 9 5 5 5 5 7 7 7 7 5 3

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STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE
SECTION VII: SURGICAL SERVICES
SUBSECTION A: PAYMENT GROUND RULES FOR SURGICAL SERVICES
General Guidelines
Listed values for all surgical procedures include the surgery, local infiltration, digital block or topical anesthesia when used. The normal uncomplicated follow-up care for the period is indicated in days in the column headed "FUD" (Follow-up Days).
All inclusive or global fees for surgical procedures include all necessary services normally performed by the surgeon before, during, and after the surgical procedure. The global reimbursement, as listed, includes the pre-operative care necessary for the specific surgical procedure, completion of hospital records, initiation of treatment, local anesthesia (including local infiltration, digital block, or topical anesthesia), the surgical procedure, and post-operative care that normally follows the specific surgical procedure. When anesthesia is provided by the physician performing the primary service, the anesthesia services are included in the primary procedure (HCFA global surgery policy).
If the pre-operative history and physical is performed by a healthcare provider other than the physician performing the surgery, then it shall be billed using modifier 56.
Included in the global period for surgery are all pre-operative visits beginning with the day before surgery.
The number of consecutive post-operative follow-up days allowed is listed in the column titled FUD adjacent to the MAR column for the specific surgical code. The number of follow-up days allowed is the FUD for the primary procedure.
When an additional surgical procedure is carried out within the listed period of follow-up care for a previous surgery, the follow-up periods shall continue concurrently to their normal termination.
Starred (*) surgical procedures are not subject to the global fee concept after the follow-up days as listed in the MAR section has expired. (See: Starred (*) Procedures).
Listed Surgical Procedures
Surgical procedures include the operation per se, local infiltration, metacarpal/digital block or topical anesthesia when used, and the normal, uncomplicated follow-up care. This concept is referred to as a "package" for surgical procedures. To report a postoperative follow-up visit for documentation purposes only, use 99024. The repair of wounds may be classified as Simple, Intermediate, or Complex:
Simple Repair is used when the wound is superficial; i.e., involving skin and/or subcutaneous tissues, without significant involvement of deeper structures and adhesive strips. List appropriate visit only.

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STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE
SECTION VII: SURGICAL SERVICES
SUBSECTION A: PAYMENT GROUND RULES FOR SURGICAL SERVICES Intermediate Repair includes repair of wounds that, in addition to the above, require layer
closure. Such wounds usually involve deeper layers, such as fascia or muscle, to the extent that at least one of the deeper layers requires separate closure. Complex Repair includes the repair of wounds requiring reconstructive surgery, complicated wound closures, skin grafts, or unusual and time-consuming techniques of repair to obtain the maximum functional and cosmetic result. It may include creation of the defect and necessary preparation for repairs of the debridement and repair of complicated lacerations or avulsions.
Unlisted Service
A surgical service may be provided that is not listed in the surgery section of the CPT codes. When reporting such a service, the appropriate "Unlisted" code may be used to indicate the service, identifying it "By Report" as discussed in the next paragraph. The unlisted services and accompanying codes are listed at the end of the surgery section.
By Report
An unlisted service or one that is unusual, variable, or new may require a special report demonstrating the medical appropriateness of the service. Pertinent information should include an adequate definition or description of the nature, extent, and need for the procedure, and the time, effort, and equipment necessary to provide the service. Additional items that may be included are complexity of symptoms, final diagnosis, pertinent physical findings, diagnostic and therapeutic procedures, concurrent problems, and follow-up care.
Follow-Up Care For Diagnostic Procedures
Follow-up care for these procedures (e.g., endoscopy, arthroscopy, injection procedures for radiography) includes only that care related to recovery from the diagnostic procedure itself. Care of the condition for which the diagnostic procedure was performed or of other conditions is not included and may be listed separately.
Follow-Up Care For Therapeutic Surgical Procedures
This includes only that care which is usually a part of the surgical services. Complications, exacerbations, recurrence or the presence of other diseases or injuries requiring additional services should be reported with the identification of the appropriate procedures.

Section VII: Surgical Services

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STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE
SECTION VII: SURGICAL SERVICES
SUBSECTION A: PAYMENT GROUND RULES FOR SURGICAL SERVICES Surgical Assistants
Certain circumstances may warrant the concurrent services of more than one surgeon. Should the services of an assistant surgeon be medically necessary, adding the modifier -80 to the usual procedure number would identify the services. According to the Board, the total reimbursement for assistant surgeon services is at 20% of the primary surgeon's fee. Other surgical assistants will be reimbursed as defined by the appropriate fee schedule arrangements (see appropriate category of service).
If circumstances warrant the concurrent services of a surgeon and an assistant and it is medically necessary, those services may be performed by a physician extender (PE), in the categories set forth herein, in the place of the assistant surgeon, when medically appropriate. Fees for Registered Nurse First Assistant (RNFA), Nurse Practitioner (NP), or Physician Assistants (PA) if utilized in the place of an assistant surgeon during surgical procedures are to be reimbursed at 10% of the primary surgeon's fee. In accord with O.C.G.A. 33-24-59.9, the RNFA shall not be on the staff of a hospital or the treating physician. Should the services of a RNFA, NP, or PA be medically necessary, add the modifier "-PE" to the usual procedure number to identify the services and list on a separate line from surgeon's fee on the HCFA 1500 or UB-92.
When medically indicated during surgery, if two different specialists are performing separate procedures for treatment of a common problem, each physician shall reduce the fee of their particular procedure by 25% and add modifier 62. Under such circumstances, the modifier shall be added to the procedure number used by each surgeon for reporting his/her services.
Separate Procedure Performed by Assistants
Some of the listed procedures are commonly carried out as an integral part of a total service, and as such do not warrant a separate identification. When, however, such a procedure is performed independently of, and is not immediately related to other services, it may be listed as a "separate procedure." Thus, when a procedure that is ordinarily a component of a larger procedure is performed alone for a specific purpose, it may be considered a separate procedure.
Carticel
The Carticel (cartilage growth process) may be billed by using code 20999. A special report describing the physician's use of carticel must accompany the billing of this code.
Immediate Pre-Operative Visits and Other Services by the Surgeon

Section VII: Surgical Services

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STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE
SECTION VII: SURGICAL SERVICES
SUBSECTION A: PAYMENT GROUND RULES FOR SURGICAL SERVICES Under most circumstances, including ordinary referrals, the immediate pre-operative visit in the hospital or elsewhere necessary to examine the injured employee, complete the hospital records and initiate the treatment program is included in the listed value for the surgical procedure.
Total reimbursement for pre-operative and post-operative components should not exceed that defined by the listed value except under the following circumstances:
A. When the pre-operative visit is the initial visit (e.g., an emergency) and prolonged detention or evaluation is required to prepare the injured employee or to establish the need for and type of surgical procedure.
1. Physicians shall not charge an emergency room visit in addition to a surgery resulting from that visit unless the requirements stipulated in (A) above are met or the surgery is a 99025 procedure.
2. When a physician is called to the emergency room to observe and assume the care of an injured employee under the physician's specialty, an additional consultation charge prior to surgery is not warranted since the hospital work-up is an integral part of the surgical procedure.
B. When the pre-operative visit is a consultation as defined in this schedule, use procedure codes 99241 through 99245.
C. When procedures not usually part of the basic surgical procedure (e.g., bronchoscopy before chest surgery) is provided during the immediate pre-operative period.
D. When a procedure could normally be an office procedure, but under certain circumstances requires hospitalization (e.g., age or condition of injured employee). See modifier code 22.
E. Suture Removal by the same physician or an associate will be included in the charge for the original procedure.
Follow-Up Days
For procedures in the fee schedule designating follow-up days (FUD), the procedure shall include all charges for office and hospital visits during that period. If the length of follow-up care goes beyond the number of follow-up days indicated, the physician would be permitted to charge an evaluation and management code again.

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STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE
SECTION VII: SURGICAL SERVICES
SUBSECTION A: PAYMENT GROUND RULES FOR SURGICAL SERVICES When 0 is listed in the FUD column, services provided the day of the procedure are included in the fee schedule amount. When 10 is listed in the FUD column, services provided the day of and during the 10 day period following the surgical procedure are included in the fee schedule amount. When 90 is listed in the FUD column, services provided the day of and during the 90 day period following the surgical procedure are included in the fee schedule amount.
Bone Grafts
Bone or other tissue grafts obtained from the surgical field warrant an added charge if it is not a part of the procedure description. Plastic and metallic implant or non-autogenous graft materials supplied by the physician are to be valued at the cost to the facility. A vendor invoice must be included with the bill sent to the payor. Notice to the payor shall be given in advance of this added charge for the graft, except in emergency/urgent care procedures.
Fractures
Re-reduction of fractures and/or dislocations that are performed as a separate procedure by the physician may warrant an added charge for this secondary service.
Casting and Strapping
If cast application or strapping is provided as an initial procedure (e.g. first time patient was seen) in which no surgery is performed (e.g. casting of sprained ankle or knee), use the appropriate level of visit in addition to 99070 for supplies. Codes 29000-29799 apply when the cast application or strapping is a replacement procedure used during or after the period of follow-up care. Additional visits are reported only if significant identifiable further services are provided at the time of the cast application or strapping.
Concurrent Services by More than One Physician
Charges for concurrent services of two or more physicians may be warranted under the following circumstances:
A. Medical services are provided by the authorized treating physician who refers the injured employee to another physician (i.e., pre-surgical assessment, etc.).
B. Identifiable medical services provided prior to or during the surgical procedure or in the postoperative period (e.g., diabetic management, operative monitoring of cardiac or brain conditions, management of postoperative electrolyte imbalance, prolonged injured employee or family counseling, psychological support, etc.).

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STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE
SECTION VII: SURGICAL SERVICES
SUBSECTION A: PAYMENT GROUND RULES FOR SURGICAL SERVICES Surgery and Follow-Up Care Provided by Different Physicians
When one physician performs the surgical procedure and another physician provides the follow-up care, the value may be apportioned between the two physicians by agreement and in accordance with medical ethics. (See unit value modifier 54 or 55.)
Surgical Destruction
Surgical destruction is a part of a surgical procedure and different methods of destruction are not ordinarily listed separately unless the technique substantially alters the standard management of a problem or condition. Separate code numbers provide for exceptions under special circumstances.
Starred (*) Procedures or Items
Certain relatively small surgical services involve a readily identifiable surgical procedure but include variable preoperative and postoperative services (e.g., incision and drainage of an abscess, injection of a tendon sheath, manipulation of a joint under anesthesia, dilation of the urethra). Because of the indefinite, pre- and postoperative services the usual "all inclusive" concept for surgical services cannot be applied as outlined in Physicians' Current Terminology (CPT) Guidelines.
Such procedures are identified by a star (*) following the procedure code number. The service as listed includes the surgical procedure only. Associated pre- and postoperative services are not included in the service as listed after the follow-up period (FUD) has expired. Starred procedures will be reimbursed in addition to global surgical fees applying the following rules:
When the starred (*) procedures is carried out at the time of an initial visit (new patient) and this procedure constitutes the major service at that visit, procedure number 99025 is listed instead of the usual initial visit as an additional service.
When the starred (*) procedures is carried out at the time of an initial or other visit involving significant identifiable service (example, removal of a small skin lesion at the time of a comprehensive history and physical examination), the appropriate visit is listed in addition to the starred (*) procedure and its follow-up care.
When the starred (*) procedures are carried out at the time of a follow-up (established patient) visit and this procedure constitutes the major service at that visit, the service visit is usually not added.
When the starred (*) procedure requires hospitalization, an appropriate hospital visit is listed in addition to the starred (*) procedure and its follow-up care.
All postoperative care is added on a service-by-service basis (example, office or hospital visit, cast change) after the follow-up period as listed in the MAR section.

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STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE
SECTION VII: SURGICAL SERVICES
SUBSECTION A: PAYMENT GROUND RULES FOR SURGICAL SERVICES Complications are added on a service-by-service basis (as with all surgical procedures).
Separate Procedure
Certain of the listed procedures are commonly carried out as an integral part of a total service, and, as such, do not warrant a separate charge. When such a service is carried out as a separate procedure, not immediately related to other services, the indicated value (noted by separate procedure) is applicable.
Multiple Surgical Procedures
Where multiple procedures are performed at the same operative site, the primary procedure is billed at 100% and all other procedures are billed at 50% of the listed fee. Bilateral and secondary surgical procedures performed in separate areas will be billed at 100% of the listed fee. Where bilateral surgical procedures are performed through a common incision, the primary will be billed at 100% and the second procedure on the opposite side will be billed at 50% of the primary procedure (example, bilateral spinal procedures).
Multiple Surgeons
When medically indicated during surgery, if two different specialists are performing separate procedures for treatment of a common problem, each physician shall reduce the fee of their particular procedure by 25% and add modifier 62. The modifier shall be added to the procedure number used by each surgeon reporting the service.
Postoperative Period
The immediate postoperative period is the 48 hours immediately following completion of surgery.
Assistant Surgeons
When medically indicated, an assistant surgeon shall be paid at 20% of the total primary surgeon's fee. Fees for Registered Nurse First Assistant (RNFA), Nurse Practitioner (NP) or Physician Assistants (PA), when medically necessary and if utilized, instead of an assistant surgeon during the surgical procedure, are to be reimbursed at 10% of the surgical fee listed using the modifier "PE".

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SECTION VII: SURGICAL SERVICES
SUBSECTION A: PAYMENT GROUND RULES FOR SURGICAL SERVICES
Other
Arthroscopic surgery procedures are included in global fees; therefore, only one fee will be allowed unless special circumstances warrant otherwise. In such cases, operative notes must be sent for review.
Microsurgery is allowed only in the case of surgery on nerves or blood vessels. For those operative surgical procedures requiring the use of the operative microscope (not loupes) the CPT code 69990 shall be used and an additional fee of 25% of the billed procedure will be allowed. In such cases, a special report may be appropriate to document the necessity of the microsurgical approach (CPT codes 64727, 61712, and 64830).
Bilateral procedures require the use of the CPT code for the surgery as well as modifier 50 listed beside the code, which provides for supplemental reimbursement for bilateral surgeries.
No allowance will be made for no shows. Surgical injections delineated as per injection by CPT descriptor and nomenclature warrant
additional reimbursement per injection are subject to the multiple procedure rules within the same body area. All arthrodesis procedures include vertebral graft preparations, such as diskectomy necessary to accomplish the arthrodesis. Incidental procedures, which are not customary will not be reimbursed (e.g., an appendectomy during a cholecystectomy).

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STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE
SECTION VII: SURGICAL SERVICES
SUBSECTION B: PAYMENT MODIFIERS FOR SURGICAL SERVICES A modifier indicates a service or procedure performed has been altered by some specific circumstance but has not changed its definition or code. The modifying circumstance shall be identified by use of a hyphen and the appropriate modifier following the procedure code. When two modifiers are applicable to a single code, indicate each modifier, preceded by a hyphen, on the bill. The modifier may also be reported by using a separate five-digit code in addition to the procedure code. If more than one modifier is used, place the "Multiple Modifiers" code (-99) immediately after the procedure code. This indicates that one or more additional modifier codes will follow. Only certain modifiers in each of the categories (anesthesia, surgery, pathology/laboratory, radiology, general medicine, and physical medicine) will be recognized for reimbursement purposes.
The modifiers listed below may differ from those published by the American Medical Association. Providers submitting workers' compensation billing shall use only the modifiers set out in the Medical Fee Guideline.
The following modifiers will be recognized for reimbursement by the fee schedule for surgical service codes:
-22 Unusual Procedural Services: When the service(s) provided is greater than that usually required for the listed procedure, it may be identified by adding modifier (-22) to the usual procedure number or by using the separate five digit modifier code 09922. A report may also be appropriate.
-25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service: The medical provider may need to indicate that on the day a procedure or service identified by a CPT code was performed, the patient's condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. This circumstance may be reported by adding the modifier (-25) to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery.
-47 Anesthesia by Surgeon: Refer to anesthesia section.
-50 Bilateral Procedure: Bilateral procedures that are performed in the same operative session should be identified by the appropriate five-digit code describing the first procedure. The second (bilateral) procedure is identified either by adding modifier (-50) to the procedure number or by using the separate five-digit modifier code 09950. Unless otherwise indicated, the total reimbursed for the bilateral procedure is 150% of the fee schedule for unilateral surgery.

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STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE
SECTION VII: SURGICAL SERVICES
SUBSECTION B: PAYMENT MODIFIERS FOR SURGICAL SERVICES
-51 Multiple Procedures: When multiple procedures, other than evaluation and management services are performed on the same day or at the same session by the same medical provider, the primary procedure or service may be reported as listed. The additional procedure(s) or service(s) may be identified by appending the modifier (-51) to the additional procedure or service code(s) or by use of the separate five-digit modifier code 09951. This modifier should not be appended to designated "add-on" codes (e.g., 22585, 22614). When each procedure is clearly defined, the following values shall prevail:
100% of the first or major procedure 50% of all additional procedures
-52 Reduced Services: Under certain circumstances, a service or procedure is partially reduced or eliminated at the physician's election. Under these circumstances, the service provided can be identified by its usual procedure number and the addition of the modifier (-52) signifying that the service is reduced. This provides a means of reporting reduced services without disturbing the identification of the basic service. Modifier code 09952 may be used as an alternative to modifier (-52).
-53 Discontinued Procedure: Due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. This circumstance may be reported by adding the modifier (-53) to the code for the discontinued procedure or by using the separate fivedigit modifier 09953. Note: This modifier is not used to report the elective cancellation of a procedure before the patient's anesthesia induction and/or surgical preparation in the operating suite.
-54 Surgical Care Only: When one physician performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services may be identified by adding the modifier (-54) to the usual procedure number or by using the separate five-digit modifier code 09954. See Section V, Surgical Services, Surgery and Follow-Up Care Provided by Different Medical Providers for full discussion of maximum allowable charges for all medical providers.
-55 Postoperative Management Only: When one medical provider performs the postoperative care and evaluation and another physician performs the surgical procedure, the postoperative component may be identified by adding the modifier (-55) to the usual procedure number or by using the separate five-digit modifier code 09955. The maximum reimbursement for this modifier is 20% of the total value of the surgery.

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STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE
SECTION VII: SURGICAL SERVICES
SUBSECTION B: PAYMENT MODIFIERS FOR SURGICAL SERVICES -56 Preoperative Management Only: When one medical provider performs the
preoperative care and evaluation and another medical provider performs the surgical procedure, the preoperative component may be identified by adding the modifier (-56) to the usual procedure number or by using the separate five-digit modifier code 09956. The maximum reimbursement for this modifier is 10% of the total value of the surgery.
-58 Staged Related Procedure or Service by the Same Physician During the Postoperative Period: The medical provider may need to indicate that the performance of a procedure or service during the postoperative period was: a) planned prospectively at the time of the original procedure (staged); b) more extensive than the original procedure; or c) for therapy following a diagnostic surgical procedure. This circumstance may be reported by adding the modifier (-58) to the staged or related procedure, or the separate five-digit modifier 09958 may be used. Note: This modifier is not to be used to report the treatment of a problem that requires a return to the operating room. See modifier (-78).
-59 Distinct Procedural Service: Under certain circumstances, the medical provider may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier (-59) is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same medical provider. However, when another already established modifier is appropriate it should be used rather than modifier (-59). Only if no more descriptive modifier is available, and the use of modifier (-59) best explains the circumstances, should modifier (-59) be used. Modifier code 09959 may be used as an alternative to modifier (-59).
-62 Two Surgeons of Differing Subspecialty: Under certain circumstances, the skills of two surgeons (usually with different skills) may be required in the management of a specific surgical procedure. Under such circumstances, the separate services may be identified by adding the modifier (-62) to the procedure number used by each surgeon for reporting his or her services. The reimbursement amount applicable for each co-surgeon is 75 percent of the surgical CPT code listed in the fee schedule.

Section VII: Surgical Services

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STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE
SECTION VII: SURGICAL SERVICES
SUBSECTION B: PAYMENT MODIFIERS FOR SURGICAL SERVICES -66 Surgical Team: Under some circumstances, highly complex procedures (requiring the
concomitant services of several medical providers, often of different specialties, plus other highly skilled, specialty trained personnel, and various types of complex equipment) are carried out under the "surgical team" concept. Each participating physician may identify such circumstances with the addition of the modifier (-66) to the basic procedure number used for reporting services. Modifier code 09966 may be used as an alternative to modifier (-66).
-76 Repeat Procedure by Same Physician: The medical provider may need to indicate that a procedure or service was repeated after the original service. This circumstance may be reported by adding the modifier (-76) to the repeated service or by using the separate fivedigit modifier code 09976.
-77 Repeat Procedure by Another Physician: The medical provider may need to indicate that a basic procedure performed by another medical providers had to be repeated. This situation may be reported by adding modifier (-77) to the repeated service or by using the separate five-digit modifier code 09977.
-78 Return to the Operating Room for a Related Procedure During the Postoperative Period: The medical provider may need to indicate that another procedure was performed during the postoperative period (first 48 hours after surgery) of the initial procedure. When this subsequent procedure is related to the first, and requires the use of the operating room, it may be reported by adding the modifier (-78) to the related procedure, or by using the separate five-digit modifier 09978. For repeat procedures on the same day, see (-76).
-79 Unrelated Procedure or Service by the Same Physician during the Postoperative Period: The medical provider may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. This circumstance may be reported by using the modifier (-79) or by using the separate fivedigit modifier 09979. For repeat procedures on the same day, see (-76).
-80 Assistant Surgeon: Assistant surgeon is defined to be a medical provider who is capable by background, training, and licensure of performing the surgery on a solo basis. Surgical assistant services may be identified by adding the modifier (-80) to the usual procedure number(s) or by using the separate five digit modifier code 09980. These services are valued at 20% of the listed value.
-81 Minimum Assistant Surgeon: Minimum surgical assistant services are identified by adding the modifier (-81) to the usual procedure number or by use of the separate fivedigit modifier code 09981.

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STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE
SECTION VII: SURGICAL SERVICES
SUBSECTION B: PAYMENT MODIFIERS FOR SURGICAL SERVICES
-PE Physician Assistant or Nurse Practitioner: Minimum Physician Assistant, Registered Nurse First Assistant, or Nurse Practitioner services are identified by adding the modifier (-PE) to the usual procedure number. A Physician Assistant must be properly licensed by the Composite Board of Medical Examiners in Georgia and/or licensed or certified in the state where services are provided. A Nurse Practitioner (NP) must be properly licensed by the Georgia Board of Nursing and/or licensed or certified in the state where services are provided. A Registered Nurse First Assistant (RNFA) must be properly licensed by the Certification Board of Perioperative Nurses and/or licensed or certified in the state where services are provided. In accord with O.C.G.A. 33-24-59.9, the RNFA shall not be on the staff of a hospital or the treating physician
-99 Multiple Modifiers: Under certain circumstances, two or more modifiers may be necessary to completely delineate a service. In such situations, modifier (-99) should be added to the basic procedure, and other applicable modifiers may be listed as part of the description of the service. Modifier code 09999 may be used as an alternative to modifier (-99).

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STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

* 10040 ACNE SURG * 10060 I&D ABSCESS; SIMPL/SNGL
10061 I&D ABSCESS; COMPLIC/MX * 10080 I&D PILONIDAL CYST; SIMPL
10081 I&D PILONIDAL CYST; COMPLIC * 10120 INCS & REMOV FB SUBQ TISS; SIMPL
10121 INCS & REMOV FB SUBQ TISS; COMPLIC * 10140 I&D HEMATOMA/SEROMA/FLUID COLLEC * 10160 PUNCT ASPIRAT ABSCESS/HEMATOMA/BULLA/CYST
10180 I&D COMPLX POSTOP WOUND INFEC * 11000 DEBRID EXTEN ECZEMAT/INFEC SKIN; TO 10% BODY SUR
11001 DEBRID EXTEN ECZEMAT/INFEC SKIN; EA AD 10% SURFA 11010 DEBRID INCL REMOV FOREIGN MAT; SKIN & SUBQ TISS 11011 DEBRID INCL REMOV FOREIGN MAT; SKIN-SUBQ-MUSC 11012 DEBRID INCL REMOV FOREIGN MAT; SKIN-SUBQ-MUSC-BN 11040 DEBRID; SKIN PART THICK 11041 DEBRID; SKIN FULL THICK 11042 DEBRID; SKIN & SUBQ TISS 11043 DEBRID; SKIN-SUBQ TISS-MUSCL 11044 DEBRID; SKIN-SUBQ TISS-MUSCL-BONE 11055 TRIM SKIN LESION 11056 TRIM 2 TO 4 SKIN LESIONS 11057 TRIM OVER 4 SKIN LESIONS 11100 BX SKIN/SUBQ TISS/MUCOUS MEMB (SEP PRO); 1 LES 11101 BX SKIN/SUBQ TISS/MUCOUS MEMB (SEP PRO); EA ADD * 11200 REMOV SKIN TAGS ANY AREA; TO & INCL 15 LES 11201 REMOV SKIN TAGS ANY AREA; EA ADD 10 LES * 11300 SHAVING 1 LES TRUNK/ARMS/LEGS; 0.5CM/LESS 11301 SHAVING 1 LES TRUNK/ARMS/LEGS; 0.6 TO 1.0 CM 11302 SHAVING 1 LES TRUNK/ARMS/LEGS; 1.1 TO 2.0 CM 11303 SHAVING 1 LES TRUNK/ARMS/LEGS; OVER 2.0 CM * 11305 SHAVING 1 LES SCALP/HANDS/FT/GENIT; 0.5 CM/LESS 11306 SHAVING 1 LES SCALP/HANDS/FT/GENIT; 0.6 TO 1.0CM 11307 SHAVING 1 LES SCALP/HANDS/FT/GENIT; 1.1 TO 2.0CM 11308 SHAVING 1 LES SCALP/HANDS/FT/GENIT; OVER 2.0 CM * 11310 SHAVING 1 LES FACE/EARS/NOSE/LIPS; 0.5 CM/LESS 11311 SHAVING 1 LES FACE/EARS/NOSE/LIPS; 0.6 TO 1.0 CM 11312 SHAVING 1 LES FACE/EARS/NOSE/LIPS; 1.1 TO 2.0 CM 11313 SHAVING 1 LES FACE/EARS/NOSE/LIPS; OVER 2.0 CM 11400 EXC BEN LES TRUNK/ARMS/LEGS; 0.5 CM/LESS 11401 EXC BEN LES TRUNK/ARMS/LEGS; 0.6 TO 1.0 CM 11402 EXC BEN LES TRUNK/ARMS/LEGS; 1.1 TO 2.0 CM 11403 EXC BEN LES TRUNK/ARMS/LEGS; 2.1 TO 3.0 CM 11404 EXC BEN LES TRUNK/ARMS/LEGS; 3.1 TO 4.0 CM 11406 EXC BEN LES TRUNK/ARMS/LEGS; OVER 4.0 CM 11420 EXC BEN LES SCALP/HANDS/FT/GENIT; 0.5 CM/LESS

$42

0

$68

0

$210

10

$105

0

$252

10

$71

0

$212

10

$106

0

$57

0

$318

10

$44

0

$36

0

$291

10

$527

10

$631

10

$48

0

$112

0

$196

10

$351

10

$431

10

$36

0

$50

0

$64

0

$71

0

$52

N/A

$61

0

$48

N/A

$57

0

$70

0

$83

0

$104

0

$61

0

$74

0

$87

0

$100

0

$70

0

$83

0

$96

0

$109

0

$83

10

$104

10

$139

10

$178

10

$252

10

$357

10

$91

10

Section VII: Surgical Services

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STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

11421 EXC BEN LES SCALP/HANDS/FT/GENIT; 0.6 TO 1.0 CM 11422 EXC BEN LES SCALP/HANDS/FT/GENIT; 1.1 TO 2.0 CM 11423 EXC BEN LES SCALP/HANDS/FT/GENIT; 2.1 TO 3.0 CM 11424 EXC BEN LES SCALP/HANDS/FT/GENIT; 3.1 TO 4.0 CM 11426 EXC BEN LES SCALP/HANDS/FT/GENIT; OVER 4.0 CM 11440 EXC BEN LES FACE/EARS/NOSE/LIPS; 0.5 CM/LESS 11441 EXC BEN LES FACE/EARS/NOSE/LIPS; 0.6 TO 1.0 CM 11442 EXC BEN LES FACE/EARS/NOSE/LIPS; 1.1 TO 2.0 CM 11443 EXC BEN LES FACE/EARS/NOSE/LIPS; 2.1 TO 3.0 CM 11444 EXC BEN LES FACE/EARS/NOSE/LIPS; 3.1 TO 4.0 CM 11446 EXC BEN LES FACE/EARS/NOSE/LIPS; OVER 4.0 CM 11450 EXC SKIN HIDRADENITIS AX; SIMPL/INTERMED REPR 11451 EXC SKIN HIDRADENITIS AX; W/COMPLX REPR 11462 EXC SKIN HIDRADENITIS ING; W/SIMPL/INTERMED REPR 11463 EXC SKIN HIDRADENITIS ING; W/COMPLEX REPR 11470 EXC SKIN HIDRADENITIS PERIANAL; W/SIMPL/INTERM 11471 EXC SKIN HIDRADENITIS PERIANAL; W/COMPLX REPR 11600 EXC MALIG LES TRUNK/ARMS/LEGS; 0.5 CM/LESS 11601 EXC MALIG LES TRUNK/ARMS/LEGS; 0.6 TO 1.0 CM 11602 EXC MALIG LES TRUNK/ARMS/LEGS; 1.1 TO 2.0 CM 11603 EXC MALIG LES TRUNK/ARMS/LEGS; 2.1 TO 3.0 CM 11604 EXC MALIG LES TRUNK/ARMS/LEGS; 3.1 TO 4.0 CM 11606 EXC MALIG LES TRUNK/ARMS/LEGS; OVER 4.0 CM 11620 EXC MALIG LES SCLP/HANDS/FT/GENIT; 0.5 CM/LESS 11621 EXC MALIG LES SCLP/HANDS/FT/GENIT; 0.6 TO 1.0 CM 11622 EXC MALIG LES SCLP/HANDS/FT/GENIT; 1.1 TO 2.0 CM 11623 EXC MALIG LES SCLP/HANDS/FT/GENIT; 2.1 TO 3.0 CM 11624 EXC MALIG LES SCLP/HANDS/FT/GENIT; 3.1 TO 4.0 CM 11626 EXC MALIG LES SCLP/HANDS/FT/GENIT; OVER 4.0 CM 11640 EXC MALIG LES FACE/EARS/NOSE/LIPS; 0.5 CM/LESS 11641 EXC MALIG LES FACE/EARS/NOSE/LIPS; 0.6 TO 1.0 CM 11642 EXC MALIG LES FACE/EARS/NOSE/LIPS; 1.1 TO 2.0 CM 11643 EXC MALIG LES FACE/EARS/NOSE/LIPS; 2.1 TO 3.0 CM 11644 EXC MALIG LES FACE/EARS/NOSE/LIPS; 3.1 TO 4.0 CM 11646 EXC MALIG LES FACE/EARS/NOSE/LIPS; OVER 4.0 CM 11719 TRIM NAIL(S) 11720 DEBRID NAIL(S) ANY METHD(S); ONE TO FIVE 11721 DEBRID NAIL(S) ANY METHD(S); SIX OR MORE * 11730 AVULSION NAIL PLATE PART/COMPLT SIMPL; SNGL 11732 AVULSION PLATE PART/COMPLT SIMPL; EA ADD NAIL 11740 EVACUATION SUBUNGUAL HEMATOMA 11750 EXC NAIL/MATRIX PART/COMPLT PERM REMOV 11752 EXC NAIL/MATRIX PART/COMPLT PERM; AMPUT DISTAL 11755 BX NAIL UNIT ANY METHD (SEPART PROC) 11760 REPR NAIL BED 11762 RECON NAIL BED W/GFT

$117

10

$148

10

$218

10

$278

10

$383

10

$109

10

$144

10

$191

10

$244

10

$313

10

$448

10

$522

90

$592

90

$452

90

$513

90

$452

90

$513

90

$139

10

$153

10

$202

10

$252

10

$333

10

$486

10

$198

10

$234

10

$279

10

$342

10

$432

10

$540

10

$216

10

$279

10

$351

10

$450

10

$522

10

$648

10

$17

0

$34

0

$50

0

$71

0

$37

N/A

$56

0

$252

10

$354

10

$112

0

$308

10

$448

10

Section VII: Surgical Services

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STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

11765 WEDGE EXC SKIN NAIL FOLD 11770 EXC PILONIDAL CYST/SINUS; SIMPL 11771 EXC PILONIDAL CYST/SINUS; EXTEN 11772 EXC PILONIDAL CYST/SINUS; COMPLIC * 11900 INJ INTRALES; UP TO & INCL 7 LES * 11901 INJ INTRALES; MORE THAN 7 LES 11920 TATTOOING INCL MICROPIGMENTATION; 6.0 SQ CM/LESS 11921 TATTOOING INCL MICROPIGMENTATION; 6.1-20.0 SQ CM 11922 TATTOOING INCL MICROPIGMENTATION; EA ADD 20.0 CM 11950 SUBQ INJ FILLING MAT; 1 CC/LESS 11951 SUBQ INJ FILLING MAT; 1.1 TO 5.0 CC 11952 SUBQ INJ FILLING MAT; 5.1 TO 10.0 CC 11954 SUBQ INJ FILLING MAT; OVER 10.0 CC 11960 INSRT EXPANDER NOT BREAST INCL SUBSQT EXPANSION 11970 REPLAC TISS EXPANDER W/PERM PROSTH 11971 REMOV TISS EXPANDER WO INSRT PROSTH 11975 INSRT IMPLNT CONTRACEPTIVE CAPSULES 11976 REMOV IMPLNT CONTRACEPTIVE CAPSULES 11977 REMOV W/REINSRT IMPLNT CONTRACEPTIVE CAPSULES 11980 IMPLANTATIN, HORMONE PELLET, SUBCUTANEOUS * 12001 SIMPL REPR SCLP/AX/GENIT/TRUNK/EXTREM; 2.5/LESS * 12002 SIMPL REPR SCLP/AX/GENIT/TRUNK/EXTREM; 2.6-7.5CM * 12004 SIMPL REPR SCLP/AX/GENIT/TRUNK/EXTREM; 7.6-12.5 12005 SIMPL REPR SCLP/AX/GENIT/TRUNK/EXTREM; 12.6-20.0 12006 SIMPL REPR SCLP/AX/GENIT/TRUNK/EXTREM; 20.1-30.0 12007 SIMPL REPR SCLP/AX/GENIT/TRUNK/EXTREM; OVER 30.0 * 12011 SIMPL REPR FACE/EARS/NOSE/MUCOUS MEMB; 2.5/LESS * 12013 SIMPL REPR FACE/EARS/NOSE/MUCOUS MEMB; 2.6-5.0 12014 SIMPL REPR FACE/EARS/NOSE/MUCOUS MEMB; 5.1-7.5 12015 SIMPL REPR FACE/EARS/NOSE/MUCOUS MEMB; 7.6-12.5 12016 SIMPL REPR FACE/EARS/NOSE/MUCOUS MEMB; 12.6-20.0 12017 SIMPL REPR FACE/EARS/NOSE/MUCOUS MEMB; 20.1-30.0 12018 SIMPL REPR FACE/EARS/NOSE/MUCOUS MEMB; OVER 30.0 12020 TX SUPERF WOUND DEHISCENCE; SIMPL CLO 12021 TX SUPERF WOUND DEHISCENCE; W/PACKING * 12031 LAYER CLO SCLP/AX/TRUNK/EXTREM; 2.5 CM/LESS * 12032 LAYER CLO SCLP/AX/TRUNK/EXTREM; 2.6 TO 7.5 CM 12034 LAYER CLO SCLP/AX/TRUNK/EXTREM; 7.6 TO 12.5 CM 12035 LAYER CLO SCLP/AX/TRUNK/EXTREM; 12.6 TO 20.0 CM 12036 LAYER CLO SCLP/AX/TRUNK/EXTREM; 20.1 TO 30.0 CM 12037 LAYER CLO SCLP/AX/TRUNK/EXTREM; OVER 30.0 CM * 12041 LAYER CLO NECK/HANDS/FT/GENIT; 2.5 CM/LESS 12042 LAYER CLO NECK/HANDS/FT/GENIT; 2.6 TO 7.5 CM 12044 LAYER CLO NECK/HANDS/FT/GENIT; 7.6 TO 12.5 CM 12045 LAYER CLO NECK/HANDS/FT/GENIT; 12.6 TO 20.0 CM 12046 LAYER CLO NECK/HANDS/FT/GENIT; 20.1 TO 30.0 CM

$168

10

$494

10

$709

90

$797

90

$39

0

$58

0

$385

0

$770

0

$385

N/A

$169

0

$185

0

$200

0

BR

0

$1,181

90

$1,356

90

$262

90

$127

N/A

$127

N/A

$139

N/A

$112

0

$99

10

$125

10

$162

10

$199

10

$241

10

$298

10

$125

10

$152

10

$204

10

$267

10

$329

10

$659

10

$525

10

$214

10

$225

10

$125

10

$168

10

$217

10

$294

10

$380

10

$477

10

$154

10

$193

10

$250

10

$327

10

$424

10

Section VII: Surgical Services

Page 64

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

12047 LAYER CLO NECK/HANDS/FT/GENIT; OVER 30.0 CM * 12051 LAYER CLO FACE/EARS/NOSE/LIPS; 2.5 CM/LESS
12052 LAYER CLO FACE/EARS/NOSE/LIPS; 2.6 TO 5.0 CM 12053 LAYER CLO FACE/EARS/NOSE/LIPS; 5.1 TO 7.5 CM 12054 LAYER CLO FACE/EARS/NOSE/LIPS; 7.6 TO 12.5 CM 12055 LAYER CLO FACE/EARS/NOSE/LIPS; 12.6 TO 20.0 CM 12056 LAYER CLO FACE/EARS/NOSE/LIPS; 20.1 TO 30.0 CM 12057 LAYER CLO FACE/EARS/NOSE/LIPS; OVER 30.0 CM 13100 REPR COMPLX TRUNK; 1.1 CM TO 2.5 CM 13101 REPR COMPLX TRUNK; 2.6 CM TO 7.5 CM 13102 REPAIR, COMPLEX, TRUNK ADD'L 5.0 CM/< 13120 REPR COMPLX SCLP/ARMS/LEGS; 1.1 CM TO 2.5 CM 13121 REPR COMPLX SCLP/ARMS/LEGS; 2.6 CM TO 7.5 CM 13122 REPAIR, COMPLEX, SCALP/ARMS/LEGS, ADD'L 5.0 CM/< 13131 REPR COMPLX FOREHEAD/CHIN/AX/GENIT/FT; 1.1-2.5 13132 REPR COMPLX FOREHEAD/CHIN/AX/GENIT/FT; 2.6-7.5 13133 REPAIR, COMPLEX, ADD'L 5.0 CM/< 13150 REPR COMPLX LIDS/NOSE/EARS/LIPS; 1.0 CM/LESS 13151 REPR COMPLX LIDS/NOSE/EARS/LIPS; 1.1 TO 2.5 CM 13152 REPR COMPLX LIDS/NOSE/EARS/LIPS; 2.6 TO 7.5 CM 13153 REPAIR, COMPLEX, ADD'L 5.0 CM/< 13160 SECNDRY CLO SURG WOUND/DEHISCENCE EXTEN/COMPLIC 14000 ADJACENT TISS TRANSF TRUNK; DEFECT 10 SQ CM/LESS 14001 ADJACENT TISS TRANSF TRUNK; 10.1 TO 30.0 SQ CM 14020 ADJACENT TRANSF SCLP/ARMS/LEGS; 10 SQ CM/LESS 14021 ADJACENT TRANSF SCLP/ARMS/LEGS; 10.1-30.00 SQ CM 14040 ADJACENT TRANSF CHIN/NECK/AX/FT; 10 SQ CM/LESS 14041 ADJACENT TRANSF CHIN/NECK/AX/FT; 10.1-30.0 SQ CM 14060 ADJACENT TRANSF LIDS/NOSE/LIPS; 10 SQ CM/LESS 14061 ADJACENT TRANSF LIDS/NOSE/LIPS; 10.1-30.0 SQ CM 14300 ADJACENT TRANSF MORE THAN 30.0 SQ CM COMPLIC 14350 FILLETED FINGER/TOE FLAP W/PREP RECIPIENT SITE 15000 EXC PREP RECIPIENT SITE PRIOR TO REPR W/SKIN GFT 15001 SKIN GRAFT ADD-ON 15050 PINCH GFT 1/MX TO COVER SMALL AREA UP TO 2 CM 15100 SPLIT GFT TRUNK; 100 SQ CM/LESS-EA 1% BODY CHILD 15101 SPLIT GFT TRUNK; EA AD 100 SQ CM/EA 1% BOD CHILD 15120 SPLIT GFT FACE; 100 SQ CM/LESS-EA 1% BODY CHILD 15121 SPLIT GFT FACE; EA AD 100 SQ CM/EA 1% BODY CHILD 15200 FULL THICK GFT-FREE-TRUNK; 20 SQ CM/LESS 15201 FULL THICK GFT-FREE-TRUNK; EA ADD 20 SQ CM 15220 FULL THICK GFT-FREE-SCLP; 20 SQ CM/LESS 15221 FULL THICK GFT-FREE-SCLP; EA ADD 20 SQ CM 15240 FULL THICK GFT CHIN/NECK/AX/HANDS/FT; 20 SQ CM 15241 FULL THICK GFT CHIN/NECK/AX/HANDS/FT; EA AD 20CM 15260 FULL THICK GFT NOSE/EARS/LIDS/LIPS; 20 SQ CM

$501

10

$193

10

$241

10

$318

10

$414

10

$530

10

$674

10

$671

10

$182

10

$326

10

$107

N/A

$288

10

$441

10

$108

N/A

$336

10

$652

10

$184

N/A

$297

10

$422

10

$825

10

$206

N/A

$576

90

$580

90

$836

90

$741

90

$931

90

$931

90

$1,178

90

$1,178

90

$1,672

90

$1,680

90

$855

90

$350

0

$234

N/A

$484

90

$884

90

$442

N/A

$1,241

90

$621

N/A

$652

90

$326

N/A

$842

90

$421

N/A

$1,073

90

$537

N/A

$1,262

90

Section VII: Surgical Services

Page 65

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

15261 FULL THICK GFT NOSE/EARS/LIDS/LIPS; EA AD 20 CM 15350 APPLIC ALLOGFT SKIN 15351 SKIN HOMOGRAFT ADD-ON 15400 APPLIC XENOGRAFT SKIN 15401 SKIN HETEROGRAFT ADD-ON 15570 FORMATION DIR/TUBED PEDICLE W/WO TRANSF; TRUNK 15572 FORMATION DIR/TUBED PEDICLE W/WO TRANSF; SCLP 15574 FORM DIR PEDICLE W/WO TRANSF; CHEEKS/CHIN/AX/FT 15576 FORM DIR PEDICLE W/WO TRANSF; LIDS/NOSE/EARS/LIP 15600 DELAY FLAP/SECT FLAP; AT TRUNK 15610 DELAY FLAP/SECT FLAP; AT SCLP/ARMS/LEGS 15620 DELAY FLAP/SECT FLAP; FOREHEAD/CHIN/AX/GENIT/FT 15630 DELAY FLAP/SECT; LIDS/NOSE/EARS/LIPS 15650 TRANSF INTERMED ANY PEDICLE FLAP ANY LOCATION 15732 MUSCL MYOCUT/FASCIOCUT FLAP; HEAD & NECK 15734 MUSCL MYOCUT/FASCIOCUT FLAP; TRUNK 15736 MUSCL MYOCUT/FASCIOCUT FLAP; UP EXTREM 15738 MUSCL MYOCUT/FASCIOCUT FLAP; LOWER EXTREM 15740 FLAP; ISLAND PEDICLE 15750 FLAP; NEUROVASCULAR PEDICLE 15756 FREE MUSC FLAP W/WO SKIN GFT W/MICROVASC ANASTOM 15757 FREE SKIN FLAP W/MICROVASC ANASTOM 15758 FREE FASCIAL FLAP W/MICROVASC ANASTOM 15760 GFT; COMPOSITE INCL PRIM CLO DONOR AREA 15770 GFT; DERM-FAT-FASCIA 15840 GFT FACIAL NERV PARALYSIS; FREE FASCIA GFT 15841 GFT FACIAL NERV PARALYSIS; FREE MUSCL GFT 15842 GFT FACE NERV PARALYSIS; MUSCL GFT-MICRO TECH 15845 GFT FACIAL NERV PARALYSIS; REGIONAL MUSCL TRANSF 15850 REMOV SUTURES UNDER ANES SAME SURG 15851 REMOV SUTURES UNDER ANES OTHER SURG 15852 DSG CHANGE UNDER ANES 15860 IV INJ AGENT TO TEST BLD FLOW FLAP/GFT 15876 SUCTION ASSISTED LIPECTOMY; HEAD & NECK 15877 SUCTION ASSISTED LIPECTOMY; TRUNK 15878 SUCTION ASSISTED LIPECTOMY; UPPER EXTREM 15879 SUCTION ASSISTED LIPECTOMY; LOWER EXTREM 15920 EXC COCCYGEAL ULCER W/COCCYGECTOMY; PRIM SUTURE 15922 EXC COCCYGEAL ULCER W/COCCYGECTOMY; FLAP CLO 15931 EXC SACRAL PRESS ULCER W/PRIM SUTURE 15933 EXC SACRAL PRESS ULCER W/PRIM SUTURE; W/OSTECTMY 15934 EXC SACRAL PRESS ULCER W/SKIN FLAP CLO 15935 EXC SACRAL ULCER W/SKIN FLAP CLO; W/OSTECTOMY 15936 EXC SACRAL ULCER W/MUSCL/MYOCUT FLAP CLO 15937 EXC SACRAL ULCER W/MUSCL/MYOCUT FLAP; W/OSTECTMY 15940 EXC ISCHIAL PRESS ULCER W/PRIM SUTURE

$631

N/A

$217

90

$165

N/A

$217

90

$152

N/A

$1,157

90

$1,136

90

$1,347

90

$1,389

90

$526

90

$631

90

$736

90

$867

90

$844

90

$2,430

90

$3,051

90

$2,378

90

$2,378

90

$1,683

90

$1,936

90

$6,022

90

$4,987

90

$5,492

90

$1,305

90

$1,305

90

$2,004

90

$2,277

90

$2,733

90

$2,277

90

$36

N/A

$62

0

$80

0

$182

0

$733

N/A

$1,309

N/A

$733

N/A

$1,309

N/A

$757

90

$1,060

90

$757

90

$985

90

$1,060

90

$1,287

90

$682

90

$833

90

$757

90

Section VII: Surgical Services

Page 66

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

15941 EXC ISCHIAL ULCER W/PRIM SUTURE; W/OSTECTOMY 15944 EXC ISCHIAL PRESS ULCER W/SKIN FLAP CLO 15945 EXC ISCHIAL ULCER W/SKIN FLAP CLO; W/OSTECTOMY 15946 EXC ISCHIAL ULCER W/OSTECT W/MUSCL/MYOCUT FLAP 15950 EXC TROCH PRESS ULCER W/PRIM SUTURE 15951 EXC TROCH ULCER W/PRIM SUTURE; W/OSTECTOMY 15952 EXC TROCH PRESS ULCER W/SKIN FLAP CLO 15953 EXC TROCH ULCER W/SKIN FLAP CLO; W/OSTECTOMY 15956 EXC TROCH ULCER W/MUSCL/MYOCUT FLAP CLO 15958 EXC TROCH ULCER W/MUSCL/MYOCUT FLAP; W/OSTECTOMY 15999 UNLISTED PROC EXC PRESS ULCER 16000 INIT TX 1ST DEGREE BURN WHEN LOCAL TX REQUIRED 16010 DSG &/OR DEBRID INIT/SUBSQT; UNDER ANES SM 16015 DSG/DEBRID INIT/SUBSQT; ANES MED/LG W/MAJ DEBRID * 16020 DSG &/OR DEBRID INIT/SUBSQT; WO ANES OFC/HOSP SM * 16025 DSG &/OR DEBRID INIT/SUBSQT; WO ANES MEDIUM 16030 DSG &/OR DEBRID INIT/SUBSQT; WO ANES LARGE 16035 ESCHAROTOMY * 17000 DESTRCT-ANY METHD-BEN FACE LES W/ANES; 1 LES 17003 DESTROY 2-14 LESIONS 17004 DESTROY 15 & MORE LESIONS 17106 DESTRCT CUT VASCULAR PROLIFERAT LES; < 10 SQ CM 17107 DESTRCT CUT VASCULAR PROLIF LES; 10.0-50.0 SQ CM 17108 DESTRCT CUT VASCULAR PROLIF LES; > 50.0 SQ CM * 17110 DESTRCT WARTS/MOLLUSCUM CONTAG/MILIA TO 15 LES 17111 DESTRUCT LESION, 15 OR MORE * 17250 CHEM CAUT GRANULATION TISS * 17260 DESTRCT MALIG LES TRUNK/ARMS/LEGS; 0.5 CM/LESS 17261 DESTRCT MALIG LES TRUNK/ARMS/LEGS; 0.6-1.0 CM 17262 DESTRCT MALIG LES TRUNK/ARMS/LEGS; 1.1-2.0 CM 17263 DESTRCT MALIG LES TRUNK/ARMS/LEGS; 2.1-3.0 CM 17264 DESTRCT MALIG LES TRUNK/ARMS/LEGS; 3.1-4.0 CM 17266 DESTRCT MALIG LES TRUNK/ARMS/LEGS; OVER 4.0 CM * 17270 DESTRCT MALIG LES SCLP/HANDS/GENIT; 0.5 CM/LESS 17271 DESTRCT MALIG LES SCLP/HANDS/GENIT; 0.6-1.0 CM 17272 DESTRCT MALIG LES SCLP/HANDS/GENIT; 1.1-2.0 CM 17273 DESTRCT MALIG LES SCLP/HANDS/GENIT; 2.1-3.0 CM 17274 DESTRCT MALIG LES SCLP/HANDS/GENIT; 3.1-4.0 CM 17276 DESTRCT MALIG LES SCLP/HANDS/GENIT; OVER 4.0 CM * 17280 DESTRCT MALIG LES FACE/EARS/LIDS; 0.5 CM/LESS 17281 DESTRCT MALIG LES FACE/EARS/LIDS; 0.6-1.0 CM 17282 DESTRCT MALIG LES FACE/EARS/LIDS; 1.1-2.0 CM 17283 DESTRCT MALIG LES FACE/EARS/LIDS; 2.1-3.0 CM 17284 DESTRCT MALIG LES FACE/EARS/LIDS; 3.1-4.0 CM 17286 DESTRCT MALIG LES FACE/EARS/LIDS; OVER 4.0 CM 17304 CHEMOSURG (MOH'S TECH); 1ST STAGE UP TO 5 SPECMN

$985

90

$1,060

90

$1,287

90

$833

90

$757

90

$985

90

$1,060

90

$1,287

90

$682

90

$833

90

BR

N/A

$42

0

$121

0

$303

0

$45

0

$83

0

$151

0

$379

90

$50

10

$13

N/A

$214

10

$269

90

$505

90

$757

90

$51

10

$73

10

$42

0

$84

10

$114

10

$139

10

$156

10

$173

10

$215

10

$101

10

$126

10

$151

10

$181

10

$198

10

$223

10

$122

10

$147

10

$173

10

$198

10

$223

10

$248

10

$496

0

Section VII: Surgical Services

Page 67

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

17305 CHEMOSURG (MOH'S TECH); 2ND STAGE UP TO 5 SPECMN 17306 CHEMOSURG (MOH'S TECH); 3RD STAGE UP TO 5 SPECMN 17307 CHEMOSURG (MOH'S TECH); ADD STAGE TO 5 SPEC EA 17310 CHEMOSURG (MOH'S TECH); > 5 SPECMN ANY STAGE * 17340 CRYOTHERAPY-ACNE * 17360 CHEM EXFOLIATION ACNE * 17380 ELECTROLYSIS EPILATION EA 1/2 HR 17999 UNLISTED PROC SKIN/MUCOS MEMBRN/SUBQ TISS * 20000 INCS SOFT TISS ABSCESS; SUPERF 20005 INCS SOFT TISS ABSCESS; DEEP/COMPLIC 20100 EXPLOR PENETRATING WOUND (SEPART PROC); NECK 20101 EXPLOR PENETRATING WOUND (SEPART PROC); CHEST 20102 EXPLOR PENETRAT WOUND (SEP PROC); ABD/FLANK/BACK 20103 EXPLOR PENETRATING WOUND (SEPART PROC); EXTREM 20150 EXC EPIPHYSEAL BAR W/WO AUTOG GFT THRU SAME INCS 20200 BX MUSCL; SUPERF 20205 BX MUSCL; DEEP * 20206 BX MUSCL PERCUT NEEDLE 20220 BX BONE TROCAR/NEEDLE; SUPERF 20225 BX BONE TROCAR/NEEDLE; DEEP 20240 BX EXC; SUPERF 20245 BX EXC; DEEP 20250 BX VERTEBRAL BODY OPEN; THORACIC 20251 BX VERTEBRAL BODY OPEN; LUMBAR/CERV * 20500 INJ SINUS TRACT; THERAP (SEPART PROC) * 20501 INJ SINUS TRACT; DX * 20520 REMOV FB MUSCL/TENDON SHEATH; SIMPL 20525 REMOV FB MUSCL/TENDON SHEATH; DEEP/COMPLIC * 20550 INJ TENDON SHEATH/LIG/TRIGGER PT/GANGLION CYST * 20600 ARTHROCENTESIS/ASPIR/INJ; SM JT/BURSA/CYST * 20605 ARTHROCENTESIS/ASPIR/INJ; INTERMED JT/BURSA/CYST * 20610 ARTHROCENTESIS/ASPIR/INJ; MAJOR JT/BURSA 20615 ASPIRAT & INJ TX BONE CYST * 20650 INSRT WIRE W/APPLIC TRACT W/REMOV (SEPART PROC) 20660 APPLIC CRAN TONGS/CALIPER W/REMOV (SEPART PROC) 20661 APPLIC HALO INCL REMOV; CRANIAL 20662 APPLIC HALO INCL REMOV; PELVIC 20663 APPLIC HALO INCL REMOV; FEMORAL 20664 HALO BRACE APPLICATION * 20665 REMOV TONGS/HALO APPLIC BY ANOTHER PHYS * 20670 REMOV IMPLNT; SUPERF (SEPART PROC) 20680 REMOV IMPLNT; DEEP 20690 APPLIC UNIPLANE-UNILAT-EXT FIXA SYST 20692 APPLIC MULTIPLANE-UNILAT-EXT FIXA SYST 20693 ADJUSTMENT/REVIS EXT FIXA SYST REQUIRING ANES 20694 REMOV UNDER ANES EXT FIXA SYST

$296

0

$296

0

$296

0

BR

0

$38

10

$38

10

$52

N/A

BR

N/A

$76

10

$378

10

$937

10

$1,277

10

$1,107

10

$989

10

$1,230

90

$208

0

$322

0

$132

0

$151

0

$369

0

$312

10

$530

10

$1,325

10

$1,325

10

$57

10

$76

0

$142

10

$416

10

$57

0

$52

0

$57

0

$66

0

$227

10

$189

10

$511

0

$653

90

$435

90

$435

90

$1,091

90

$76

10

$161

10

$473

90

$643

90

$899

90

$473

90

$360

90

Section VII: Surgical Services

Page 68

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

20802 REPLANTATION ARM; COMPLT AMPUTA 20805 REPLANTATION FOREARM; COMPLT AMPUTA 20808 REPLANTATION HAND; COMPLT AMPUTA 20816 REPLANTATION DIGIT (INCL MCP JT); COMPLT AMPUTA 20822 REPLANTATION DIGIT (DISTAL TIP); COMPLT AMPUTA 20824 REPLANTATION THUMB (CM JT-MP JT); COMPLT AMPUTA 20827 REPLANTATION THUMB (DISTAL TIP); COMPLT AMPUTA 20838 REPLANTATION FT; COMPLT AMPUTA 20900 BONE GFT ANY DONOR AREA; MINOR/SM 20902 BONE GFT ANY DONOR AREA; MAJOR/LARGE 20910 CARTILAGE GFT; COSTOCHONDRAL 20912 CARTILAGE GFT; NASAL SEPTUM 20920 FASCIA LATA GFT; BY STRIPPER 20922 FASCIA LATA GFT; INCS & AREA EXPOSURE COMPLX 20924 TENDON GFT FROM A DISTANCE 20926 TISS GFT OTHER 20930 ALLOGFT SPINE SURG ONLY; MORSELIZED 20931 ALLOGFT SPINE SURG ONLY; STRUCTURAL 20936 AUTOGFT SPINE SURG ONLY; LOCAL THRU SAME INCIS 20937 AUTOGFT SPINE SURG ONLY; MORSELIZED 20938 AUTOGFT SPINE SURG ONLY; STRUCTUR/BI-TRICORTICAL 20950 MONITOR INTERSTITIAL PRESS-DETECT MUSCL COMPARTM 20955 BONE GFT W/MICROVASCULAR ANASTOM; FIBULA 20956 BONE GFT W/MICROVASC ANASTOM; ILIAC CREST 20957 BONE GFT W/MICROVASC ANASTOM; METATARSAL 20962 BONE GFT W/MICROVAS ANAST; NOT FIB/ILIAC/METATAR 20969 FREE OSTEOCUT FLAP; NOT ILIAC/METATARS/GR TOE 20970 FREE OSTEOCUT FLAP W/MICROVASC ANASTOM; ILIAC 20972 FREE OSTEOCUT FLAP W/MICROVASC ANASTOM; METATARS 20973 FREE OSTEOCUT FLAP W/MICROVASC ANASTOM; GRT TOE 20974 ELEC STIM TO AID BONE HEALING; NONINVASIVE 20975 ELEC STIM TO AID BONE HEALING; INVASIVE 20979 ULTRASOUND TO AID BONE HEALING 20999 UNLISTED PROC MS SYST GEN 21010 ARTHROTOMY TEMPOROMANDIBULAR JT 21015 RADICAL RESECT TUMOR SOFT TISS FACE/SCLP 21025 EXC BONE; MANDIB 21026 EXC BONE; FACIAL BONE 21029 REMOV BY CONTOURING BEN TUMOR FACIAL BONE 21030 EXC BEN TUMOR/CYST FACE BONE OTHER THAN MANDIB 21031 EXC TORUS MANDIBULARIS 21032 EXC MAXIL TORUS PALATINUS 21034 EXC MALIG TUMOR FACIAL BONE OTHER THAN MANDIB 21040 EXC BEN CYST/TUMOR MANDIB; SIMPL 21041 EXC BEN CYST/TUMOR MANDIB; COMPLX 21044 EXC MALIG TUMOR MANDIB

$11,686

90

$11,686

90

$10,787

90

$5,034

90

$3,596

90

$5,753

90

$4,944

90

$11,686

90

$360

90

$719

90

$530

90

$624

90

$416

90

$568

90

$397

90

$378

90

$218

N/A

$265

N/A

$331

N/A

$577

N/A

$719

N/A

$132

0

$2,129

90

$2,129

90

$2,129

90

$2,129

90

$2,839

90

$2,839

90

$2,839

90

$3,023

90

$473

0

$757

0

$40

0

BR

N/A

$2,173

90

$1,292

90

$1,442

90

$1,545

90

$1,730

90

$968

90

$362

90

$515

90

$1,710

90

$474

90

$948

90

$1,710

90

Section VII: Surgical Services

Page 69

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

21045 EXC MALIG TUMOR MANDIB; RADICAL RESECT 21050 CONDYLECTOMY TEMPOROMANDIBULAR JT (SEPART PROC) 21060 MENISCECTOMY PART/COMPLT TMJ (SEPART PROC) 21070 CORONOIDECTOMY (SEPART PROC) 21076 IMPRESSION & CUSTOM PREP; SURG OBTUR PROSTH 21077 IMPRESSION & CUSTOM PREP; ORBIT PROSTH 21079 IMPRESS & CUST PREP; INTERIM OBTURATOR PROSTH 21080 IMPRESS & CUST PREP; DEFINITIVE OBTURATOR PROSTH 21081 IMPRESS & CUST PREP; MANDIB RESECT PROSTH 21082 IMPRESS & CUST PREP; PALATAL AUGMEN PROSTH 21083 IMPRESS & CUST PREP; PALATAL LIFT PROSTH 21084 IMPRESS & CUST PREP; SPEECH AID PROSTH 21085 IMPRESS & CUST PREP; ORAL SURG SPLINT 21086 IMPRESS & CUST PREP; AURICULAR PROSTH 21087 IMPRESS & CUST PREP; NASAL PROSTH 21088 IMPRESS & CUST PREP; FACIAL PROSTH 21089 UNLISTED MAXILLOFACIAL PROSTH PROC * 21100 APPLIC HALO-MAXILLOFAC INCL REMOV (SEPART PROC) 21110 APPLIC INTERDENTAL DEVICE-NOT FX DISLOC W/REMOV 21116 INJ PROC TEMPOROMANDIBULAR JT ARTHROGRAPHY 21120 GENIOPLASTY; AUGMEN 21121 GENIOPLASTY; SLIDING OSTEOTOMY SNGL PIECE 21122 GENIOPLASTY; SLIDING OSTEOTOMIES 2/MORE 21123 GENIOPLASTY; SLIDING AUGMEN W/INTERPOSIT GFT 21125 AUGMEN MANDIB BODY/ANGLE; PROSTH MAT 21127 AUGMEN MANDIB BODY/ANGLE; W/BONE GFT ONLAY 21137 REDUCTION FOREHEAD; CONTOURING ONLY 21138 REDUCT FOREHEAD; CONTOUR/APPLIC PROSTH/BONE GFT 21139 REDUCT FOREHEAD; SETBACK ANT FRONTAL SINUS WALL 21141 RECON MIDFACE LEFORT I; 1 PIECE WO BONE GFT 21142 RECON MIDFACE LEFORT I; 2 PIECE WO BONE GFT 21143 RECON MIDFACE LEFORT I; 3/MORE PIECE WO BONE GFT 21145 RECON MIDFACE LEFORT I; 1 PIECE REQ BONE GFT 21146 RECON MIDFACE LEFORT I; 2 PIECES REQ BONE GFT 21147 RECON MIDFACE LEFORT I; 3/MORE PIECES REQ GFT 21150 RECON MIDFACE LEFORT II; ANT INTRUSION 21151 RECON MIDFACE LEFORT II; ANY DIRECT REQ BONE GFT 21154 RECON MIDFACE LEFORT III REQ GFT; WO LEFORT I 21155 RECON MIDFACE LEFORT III REQ GFT; W/LEFORT I 21159 RECON MIDFACE FOREHEAD ADVANC W/GFT; WO LEFORT I 21160 RECON MIDFACE FOREHEAD ADVANC W/GFT; W/LEFORT I 21172 RECON SUP-LAT ORBITAL RIM/LO FOREHEAD W/WO GFTS 21175 RECON BIFRONTAL ORBIT RIMS/LO FOREHEAD W/WO GFTS 21179 RECON MAJORITY FOREHEAD/SUPRAORBITAL RIMS; W/GFT 21180 RECON MAJ FOREHEAD/SUPRAORBIT RIMS; W/AUTOGFT 21181 RECON CONTOUR BEN TUMOR CRANIAL BONE EXTRACRANI

$3,090

90

$2,472

90

$2,781

90

$2,039

90

$1,586

10

$3,986

90

$2,642

90

$2,966

90

$2,704

90

$2,467

90

$2,281

90

$2,662

90

$1,061

10

$2,946

90

$2,946

90

$724

90

BR

90

$263

90

$618

90

$117

0

$1,463

90

$1,792

90

$2,369

90

$2,637

90

$1,627

90

$2,266

90

$2,081

90

$2,596

90

$3,110

90

$3,862

90

$4,058

90

$4,202

90

$4,233

90

$4,429

90

$4,635

90

$5,026

90

$5,644

90

$6,077

90

$7,004

90

$8,549

90

$9,929

90

$3,790

90

$5,974

90

$4,944

90

$5,562

90

$1,957

90

Section VII: Surgical Services

Page 70

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

21182 RECON ORBIT-EXC BONE TUM; BONE GFT < 40 CM2 21183 RECON ORBIT-EXC TUM; BONE GFT > 40 BUT < 80 CM2 21184 RECON ORBIT-EXC BONE TUM; BONE GFT > 80 CM2 21188 RECON MIDFACE OSTEOTOMIES & BONE GFT 21193 RECON MANDIB RAMI OSTEOTOMY; WO BONE GFT 21194 RECON MANDIB RAMI OSTEOTOMY; W/BONE GFT 21195 RECON MANDIB RAMI/BODY SAGIT SPLIT; WO INT FIXA 21196 RECON MANDIB RAMI/BODY SAGIT SPLIT; W/INT FIXA 21198 OSTEOTOMY MANDIB SEGMT 21206 OSTEOTOMY MAXIL SEGMT 21208 OSTEOPLASTY FACIAL BONES; AUGMEN 21209 OSTEOPLASTY FACIAL BONES; REDUCTION 21210 GFT BONE; NASAL/MAXIL/MALAR AREAS 21215 GFT BONE; MANDIB 21230 GFT; RIB CARTILAGE AUTOGEN-FACE/CHIN/NOSE/EAR 21235 GFT; EAR CARTILAGE AUTOGEN NOSE/EAR 21240 ARTHROPLASTY TEMPOROMANDIBULAR JT W/WO AUTOGFT 21242 ARTHROPLASTY TEMPOROMANDIBULAR JT W/ALLOGFT 21243 ARTHROPLASTY TMJ W/PROSTH JT REPLAC 21244 RECON MANDIB EXTRAORAL W/TRANSOSTEAL BONE PLATE 21245 RECON MANDIB/MAXIL SUBPERIOSTEAL IMPLNT; PART 21246 RECON MANDIB/MAXIL SUBPERIOSTEAL IMPLNT; COMPL 21247 RECON MANDIB CONDYLE W/BONE & CARTILAGE AUTOGFT 21248 RECON MANDIB/MAXIL ENDOSTEAL IMPLNT; PART 21249 RECON MANDIB/MAXIL ENDOSTEAL IMPLNT; COMPLT 21255 RECON ZYGOMATIC ARCH/GLENOID FOSSA W/BONE-CARTIL 21256 RECON ORBIT W/OSTEOTOMIES & W/BONE GFT 21260 PERIORBIT OSTEOTOM-HYPERTELORISM W/GFT; EXTRACRA 21261 PERIORBIT OSTEOTOMIES W/BONE GFT; INTRA-EXTRACRA 21263 PERIORBIT OSTEOTOMIES W/BONE GFT; W/FORHD ADVANC 21267 ORBIT REPOSIT OSTEOT-UNILAT W/GFTS; EXTRACRANIAL 21268 ORBIT REPOSIT-UNILAT W/GFTS; INTRA-EXTRACRANIAL 21270 MALAR AUGMEN PROSTH MAT 21275 SECNDRY REVIS ORBITOCRANIOFACIAL RECON 21280 MEDIAL CANTHOPEXY (SEPART PROC) 21282 LAT CANTHOPEXY 21295 REDUCT MASSETER MUSCL/BONE; EXTRAORAL 21296 REDUCT MASSETER MUSCL/BONE; INTRAORAL 21299 UNLISTED CRANIOFACIAL & MAXILLOFACIAL PROC 21300 CLO TX SKULL FX WO OR 21310 CLO TX NASAL BONE FX WO MANIP * 21315 CLO TX NASAL BONE FX; WO STABILIZATION 21320 CLO TX NASAL BONE FX; W/STABILIZATION 21325 OPEN TX NASAL FX; UNCOMP 21330 OPEN TX NASAL FX; COMPLIC-W/INT-EXT SKELETAL FIX 21335 OPEN TX NASAL FX; W/CONCOMTANT OPEN TX FX SEPTUM

$6,056

90

$6,633

90

$7,189

90

$4,779

90

$4,625

90

$5,309

90

$4,511

90

$4,887

90

$2,266

90

$3,378

90

$1,751

90

$1,339

90

$2,307

90

$2,163

90

$2,348

90

$1,586

90

$3,502

90

$3,502

90

$5,047

90

$2,884

90

$3,708

90

$4,099

90

$4,017

90

$3,193

90

$4,120

90

$3,399

90

$4,532

90

$4,614

90

$5,768

90

$7,622

90

$7,416

90

$9,064

90

$1,854

90

$4,532

90

$1,566

90

$1,236

90

$2,493

90

$2,039

90

BR

N/A

$266

0

$166

0

$266

10

$432

10

$681

90

$1,146

90

$1,793

90

Section VII: Surgical Services

Page 71

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

21336 OPEN TX NASAL SEPTAL FX W/WO STABILIZATION 21337 CLO TX NASAL SEPTAL FX W/WO STABILIZATION 21338 OPEN TX NASOETHMOID FX; WO EXT FIXA 21339 OPEN TX NASOETHMOID FX; W/EXT FIXA 21340 PERCUT TX NASOETHMOID FX W/FIXA W/REPR NASOLACRL 21343 OPEN TX DEPRESSED FRONTAL SINUS FX 21344 OPEN TX COMPLIC FRONTAL SINUS FX VIA CORONAL 21345 CLO TX NASOMAXIL FX W/INTERDENTAL FIXA/SPLINT 21346 OPEN TX NASOMAXIL FX; W/WIRING &/OR LOCAL FIXA 21347 OPEN TX NASOMAXIL FX; REQ MX OPEN APPROACHES 21348 OPEN TX NASOMAXILLARY COMPLX FX; W/BONE GFT * 21355 PERCUT TX FX MALAR AREA INCL ZYGOMATIC W/MANIP 21356 OPEN TX DEPRESSED ZYGOMATIC ARCH FX 21360 OPEN TX DEPRESS MALAR FX INCL ZYGOMATIC ARCH 21365 OPEN TX FX MALAR AREA; W/INT FIX & MX APPROACH 21366 OPEN TX COMPLIC FX MALAR AREA INCL ZYGOMAT ARCH 21385 OPEN TX ORBIT 'BLOWOUT' FX; TRANSANTRAL APPROACH 21386 OPEN TX ORBITAL 'BLOWOUT' FX; PERIORBIT APPROACH 21387 OPEN TX ORBIT FLOOR 'BLOWOUT' FX; COMBO APPROACH 21390 OPEN TX ORBITAL 'BLOWOUT' FX; PERIORBIT W/IMPLNT 21395 OPEN TX ORBITAL 'BLOWOUT' FX; PERIORB W/BONE GFT 21400 CLO TX FX ORBITAL EX 'BLOWOUT'; WO MANIP 21401 CLO TX FX ORBITAL EX 'BLOWOUT'; W/MANIP 21406 OPEN TX FX ORBITAL EX 'BLOWOUT'; WO IMPLNT 21407 OPEN TX FX ORBITAL EX 'BLOWOUT' W/IMPLNT 21408 OPEN TX FX ORBITAL EX 'BLOWOUT'; W/BONE GFT 21421 CLO TX PALATAL/MAXIL FX W/INTERDENTAL WIRE FIXA 21422 OPEN TX PALATAL/MAXIL FX 21423 OPEN TX PALATAL/MAXIL FX; COMPLIC-MX APPROACHES 21431 CLO TX CRANIOFAC SEPART USING INTERDENT WIRE FIX 21432 OPEN TX CRANIOFAC SEPART; W/WIRE &/OR INT FIXA 21433 OPEN TX CRANIOFAC SEPART; COMPLIC-MX SURG APPRCH 21435 OPEN TX CRANIOFAC SEPART; COMPLIC W/INT-EXT FIXA 21436 OPEN TX CRANIOFAC SEPART; COMPLIC W/FIXA W/GFT 21440 CLO TX MANDIB/MAXIL ALVEOLAR RIDGE FX (SEP PRO) 21445 OPEN TX MANDIB/MAXIL ALVEOLAR RIDGE FX (SEP PRO) 21450 CLO TX MANDIB FX; WO MANIP 21451 CLO TX MANDIB FX; W/MANIP 21452 PERCUT TX MANDIB FX W/EXT FIXA 21453 CLO TX MANDIB FX W/INTERDENTAL FIXA 21454 OPEN TX MANDIB FX W/EXT FIXA 21461 OPEN TX MANDIB FX; WO INTERDENTAL FIXA 21462 OPEN TX MANDIB FX; W/INTERDENTAL FIXA 21465 OPEN TX MANDIB CONDYLAR FX 21470 OPEN TX MANDIB FX-MX APPROACH W/INT FIXA/SPLINTS 21480 CLO TX TEMPOROMANDIBULAR DISLOC; INIT/SUBSQT

$731

90

$465

90

$1,162

90

$1,278

90

$1,677

90

$1,594

90

$2,441

90

$1,561

90

$1,992

90

$2,374

90

$2,391

90

$465

10

$830

10

$1,129

90

$1,826

90

$2,241

90

$1,129

90

$1,395

90

$1,926

90

$1,594

90

$1,959

90

$232

90

$398

90

$1,162

90

$1,461

90

$1,660

90

$996

90

$1,328

90

$1,527

90

$1,096

90

$1,561

90

$2,490

90

$2,839

90

$3,321

90

$548

90

$648

90

$996

90

$1,096

90

$1,278

90

$1,096

90

$1,378

90

$1,461

90

$1,727

90

$1,992

90

$2,258

90

$166

0

Section VII: Surgical Services

Page 72

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

21485 CLO TX TM DISLOC; COMPLIC INIT/SUBSQT 21490 OPEN TX TEMPOROMANDIBULAR DISLOC 21493 CLO TX HYOID FX; WO MANIP 21494 CLO TX HYOID FX; W/MANIP 21495 OPEN TX HYOID FX 21497 INTERDENTAL WIRING-CONDITION OTHER THAN FX 21499 UNLISTED MS PROC HEAD 21501 I&D DEEP ABSCESS/HEMATOMA SOFT TISS NECK/THORAX 21502 I&D DEEP ABSCESS SOFT TISS NECK; W/PART RIB OSTE 21510 INCS DEEP W/OPENING BONE CORTEX THORAX 21550 BX SOFT TISS NECK/THORAX 21555 EXC TUMOR SOFT TISS NECK/THORAX; SUBQ 21556 EXC TUMOR SOFT TISS NECK; DEEP/SUBFACIAL/IM 21557 RADICAL RESECT TUMOR SOFT TISS NECK/THORAX 21600 EXC RIB PART 21610 COSTOTRANSVERSECTOMY (SEPART PROC) 21615 EXC 1ST &/OR CERV RIB; 21616 EXC 1ST &/OR CERV RIB; W/SYMPATHECTOMY 21620 OSTECTOMY STERNUM PART 21627 STERNAL DEBRID 21630 RADICAL RESECT STERNUM; 21632 RAD RESECT STERNUM; W/MEDIASTINAL LYMPHADENECTMY 21700 DIVISION SCALENUS ANTICUS; WO RESECT CERV RIB 21705 DIVISION SCALENUS ANTICUS; W/RESECT CERV RIB 21720 DIVIS STERNOCLEIDOMASTOID-TORTICOLLIS; WO CAST 21725 DIVIS STERNOCLEIDOMASTOID-TORTICOLLIS; W/CAST 21740 RECON REPR PECTUS EXCAVATUM/CARINATUM 21750 CLO STERNOTOMY SEPART W/WO DEBRID (SEPART PROC) 21800 CLO TX RIB FX UNCOMP EA 21805 OPEN TX RIB FX WO FIXA EA 21810 TX RIB FX REQUIRING EXT FIXA 21820 CLO TX STERNUM FX 21825 OPEN TX STERNUM FX W/WO SKELETAL FIXA 21899 UNLISTED PROC NECK/THORAX 21920 BX SOFT TISS BACK/FLANK; SUPERF 21925 BX SOFT TISS BACK/FLANK; DEEP 21930 EXC TUMOR SOFT TISS BACK/FLANK 21935 RADICAL RESECT TUMOR SOFT TISS BACK/FLANK 22100 PART EXC POST VERTEB COMPON-1 SEGMT; CERV 22101 PART EXC POST VERTEB COMPON-1 SEGMT; THOR 22102 PART EXC POST VERTEB COMPON-1 SEGMT; LUMB 22103 PART EXC POST VERTEB COMPON; EA ADD SEGMT 22110 PART EXC VERTEB BODY WO DECOMP-1 SEGMT; CERV 22112 PART EXC VERTEB BODY WO DECOMP-1 SEGMT; THOR 22114 PART EXC VERTEB BODY WO DECOMP-1 SEGMT; LUMB 22116 PART EXC VERTEB BODY; EA ADD VERTEB SEGMT

$365

90

$1,461

90

$133

90

$299

90

$1,112

90

$398

90

BR

N/A

$480

90

$576

90

$576

90

$192

10

$375

90

$672

90

$2,459

90

$768

90

$1,345

90

$1,748

90

$1,921

90

$1,556

90

$1,633

90

$2,401

90

$3,554

90

$1,133

90

$1,364

90

$912

90

$1,028

90

$2,401

90

$1,153

90

$106

90

$960

90

$2,401

90

$240

90

$960

90

BR

N/A

$130

10

$461

90

$730

90

$1,633

90

$864

90

$864

90

$864

90

$259

N/A

$1,153

90

$1,153

90

$1,153

90

$346

N/A

Section VII: Surgical Services

Page 73

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

22210 OSTEOT SPINE-POST/POSTLAT APPROACH-1 SEGMT; CERV 22212 OSTEOT SPINE-POST/POSTLAT APPROACH-1 SEGMT; THOR 22214 OSTEOT SPINE-POST/POSTLAT APPROACH-1 SEGMT; LUMB 22216 OSTEOT SPINE-POST/POSTLAT APPROACH; EA ADD SEGMT 22220 OSTEOT SPINE W/DISKECT-ANT APPRCH-1 SEGMT; CERV 22222 OSTEOT SPINE W/DISKECT-ANT APPRCH-1 SEGMT; THOR 22224 OSTEOT SPINE W/DISKECT-ANT APPRCH-1 SEGMT; LUMB 22226 OSTEOT SPINE W/DISKECT-ANT APPROCH; EA ADD SEGMT 22305 CLO TX VERTEBRAL PROCESS FX 22310 CLO TX VERTEB BODY FX WO MANIP-W/CAST/BRACE 22315 CLO TX VERT FX/DISLOC W/CAST/BRACE-BY MANIP/TRAC 22318 OPEN TREATMT, ODONTOID FX, W/O GRAFTING 22319 OPEN TREATMT, ODONTOID FX, W/ GRAFTING 22325 OPEN TX VERT FX/DISLOC-VIA POST-1 SEGMT; LUMB 22326 OPEN TX VERT FX/DISLOC-VIA POST-1 SEGMT; CERV 22327 OPEN TX VERT FX/DISLOC-VIA POST-1 SEGMT; THOR 22328 OPEN TX VERT FX/DISLOC VIA POST; EA ADD VERT/SEG 22505 MANIP SPINE REQUIRING ANES ANY REGION 22548 ARTHRODESIS-ANT-C1 C2, W/WO EXC ODONTOID PROCESS 22554 ARTHRODESIS-ANT W/MINI DISKECT; CERV BELOW C2 22556 ARTHRODESIS-ANT INTERBODY W/MINI DISKECT; THOR 22558 ARTHRODESIS-ANT INTERBODY W/MINI DISKECT; LUMB 22585 ARTHRODESIS-ANT-W/MINI DISKECT; EA ADD INTRSPACE 22590 ARTHRODESIS-POST TECH, CRANIOCERV 22595 ARTHRODESIS-POST TECH, ATLAS-AXIS 22600 ARTHRODESIS-POST/POSTLAT-1 LEVEL; CERV BELOW C2 22610 ARTHRODESIS-POST/POSTLAT-1 LEVEL; THOR 22612 ARTHRODESIS-POST/POSTLAT-1 LEVEL; LUMB 22614 ARTHRODESIS-POST/POSTLAT TECH; EA ADD VERT SEGMT 22630 ARTHRODESIS-POST INTERBODY-1 INTERSPACE; LUMB 22632 ARTHRODESIS-POST INTERBODY; EA ADD INTERSPACE 22800 ARTHRODESIS-POST-W/WO CAST; 6/LESS VERTEB SEGMT 22802 ARTHRODESIS-POST-W/WO CAST; 7 TO 12 VERTEB SEGMT 22804 ARTHRODESIS-POST-W/WO CAST; 13/MORE VERTEB SEGMT 22808 ARTHRODESIS-ANT-W/WO CAST; 2 TO 3 VERTEB SEGMT 22810 ARTHRODESIS-ANT-W/WO CAST; 4 TO 7 VERTEB SEGMT 22812 ARTHRODESIS-ANT-W/WO CAST; 8/MORE VERTEB SEGMT 22818 KYPHECTOMY, 1-2 SEGMENTS 22819 KYPHECTOMY, 3 & MORE SEGMENT 22830 EXPLOR SPINAL FUSION 22840 POST NON-SEGMT INSTRUM 22841 INT SPINAL FIX BY WIRING SPINOUS PROCESSES 22842 POST SEGMT INSTRUM; 3 TO 6 VERTEB SEGMT 22843 POST SEGMT INSTRUM; 7 TO 12 VERTEB SEGMT 22844 POST SEGMT INSTRUM; 13/MORE VERTEB SEGMT 22845 ANT INSTRUM; 2 TO 3 VERTEB SEGMT

$3,400

90

$3,304

90

$3,362

90

$1,009

N/A

$3,592

90

$3,496

90

$3,554

90

$1,066

N/A

$250

90

$528

90

$768

90

$3,245

90

$3,667

90

$2,209

90

$2,401

90

$2,305

90

$692

N/A

$221

10

$3,088

90

$2,984

90

$3,298

90

$2,984

90

$895

N/A

$3,402

90

$3,465

90

$2,984

90

$2,774

90

$2,701

90

$900

N/A

$2,724

90

$869

N/A

$3,612

90

$4,334

90

$5,203

90

$3,476

90

$4,188

90

$4,858

90

$5,416

90

$6,243

90

$3,350

90

$2,167

N/A

$602

N/A

$2,408

N/A

$2,649

N/A

$2,910

N/A

$2,513

N/A

Section VII: Surgical Services

Page 74

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

22846 ANT INSTRUM; 4 TO 7 VERTEB SEGMT 22847 ANT INSTRUM; 8/MORE VERTEB SEGMT 22848 PELV FIX OTH THAN SACRUM 22849 REINSERTION SPINAL FIXA DEVICE 22850 REMOV POST NONSEGMENTAL INSTRUM 22851 APPLIC PROSTH DEVICE TO VERTEB DEFEC/INTERSPACE 22852 REMOV POST SEGMT INSTRUM 22855 REMOV ANT INSTRUM 22899 UNLISTED PROC SPINE 22900 EXC ABD WALL TUMOR SUBFASCIAL 22999 UNLISTED PROC ABD MS SYST 23000 REMOV SUBDELTOID CALCAREOUS DEPOSITS OPEN METHD 23020 CAPSULAR CONTRACTURE RELEASE (SEVER TYPE PROC) 23030 I&D SHOULDER AREA; DEEP ABSCESS/HEMATOMA 23031 I&D SHOULDER AREA; INFEC BURSA 23035 INCS DEEP W/OPEN CORTEX SHOULDER AREA 23040 ARTHROTOMY GLENOHUMERAL JT W/EXPLOR-REMOV FB 23044 ARTHROTOMY AC/STERNOCLAV JT W/EXPLOR-REMOV FB 23065 BX SOFT TISS SHOULDER AREA; SUPERF 23066 BX SOFT TISS SHOULDER AREA; DEEP 23075 EXC TUMOR SHOULDER AREA; SUBQ 23076 EXC TUMOR SHOULDER AREA; DEEP SUBFASCIAL/IM 23077 RADICAL RESECT TUMOR SOFT TISS SHOULDER AREA 23100 ARTHROTOMY W/BX GLENOHUMERAL JT 23101 ARTHROTOMY W/BX/EXC TORN CARTILAGE-AC/SC JT 23105 ARTHROTOMY W/SYNOVECTOMY; GLENOHUMERAL JT 23106 ARTHROTOMY W/SYNOVECTOMY; STERNOCLAVICULAR JT 23107 ARTHROTOMY-GLENOHUMERAL JT W/EXPLOR W/WO REMOV 23120 CLAVICULECTOMY; PART 23125 CLAVICULECTOMY; TOT 23130 ACROMIOPLASTY/ACROMIONECTOMY PART 23140 EXC/CURET BONE CYST/BEN TUMOR CLAV/SCAPULA 23145 EXC/CURET BONE CYST/TUMOR CLAV/SCAP; W/AUTOGFT 23146 EXC/CURET BONE CYST/TUMOR CLAV/SCAP; W/ALLOGFT 23150 EXC/CURET BONE CYST/BEN TUMOR PROX HUMERUS 23155 EXC/CURET BONE CYST/TUMOR PROX HUMERUS; W/AUTOGF 23156 EXC/CURET BONE CYST/TUMOR PROX HUMERUS; W/ALLOGF 23170 SEQUESTRECTOMY CLAV 23172 SEQUESTRECTOMY SCAPULA 23174 SEQUESTRECTOMY HUMERAL HEAD TO SURG NECK 23180 PART EXC BONE CLAV 23182 PART EXC BONE SCAPULA 23184 PART EXC BONE PROX HUMERUS 23190 OSTECTOMY SCAPULA PART 23195 RESECT HUMERAL HEAD 23200 RADICAL RESECT TUMOR; CLAV

$2,764

N/A

$3,036

N/A

$1,119

N/A

$1,989

90

$1,361

90

$1,186

N/A

$1,570

90

$2,617

90

BR

N/A

$586

90

BR

N/A

$648

90

$1,296

90

$432

10

$432

10

$864

90

$1,231

90

$756

90

$151

10

$453

90

$367

10

$734

90

$3,347

90

$1,080

90

$1,145

90

$1,944

90

$1,296

90

$1,425

90

$1,080

90

$1,728

90

$1,080

90

$669

90

$1,004

90

$864

90

$1,296

90

$1,620

90

$1,404

90

$972

90

$1,296

90

$2,160

90

$885

90

$864

90

$1,296

90

$702

90

$1,728

90

$1,296

90

Section VII: Surgical Services

Page 75

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

23210 RADICAL RESECT TUMOR; SCAPULA 23220 RADICAL RESECT TUMOR PROX HUMERUS 23221 RADICAL RESECT TUMOR PROX HUMERUS; W/AUTOGFT 23222 RAD RESECT TUMOR PROX HUMERUS; W/PROSTH REPLAC 23330 REMOV FB SHOULDER; SUBQ 23331 REMOV FB SHOULDER; DEEP 23332 REMOV FB SHOULDER; COMPLIC INCL'TOT SHOULDER' 23350 INJ PROC SHOULDER ARTHROGRAPHY 23395 MUSCL TRANSF ANY TYPE-SHOULDER/UPPER ARM; SNGL 23397 MUSCL TRANSF ANY TYPE-SHOULDER/UPPER ARM; MX 23400 SCAPULOPEXY 23405 TENOMYOTOMY SHOULDER AREA; SNGL 23406 TENOMYOTOMY SHOULDER AREA; MX THRU SAME INCS 23410 REPR RUPT MUSCULOTENDINOUS CUFF; ACUTE 23412 REPR RUPT MUSCULOTENDINOUS CUFF; CHRONIC 23415 CORACOACROMIAL LIG RELEASE W/WO ACROMIOPLASTY 23420 REPR COMPLT SHOULDER CUFF AVULSION CHRONIC 23430 TENODESIS LONG TENDON BICEPS 23440 RESECT/TRANSPL LONG TENDON BICEPS 23450 CAPSULORRHAPHY ANT; PUTTI-PLATT/MAGNUSON TYPE 23455 CAPSULORRHAPHY ANT; BANKART TYPE W/WO STAPLING 23460 CAPSULORRHAPHY ANT ANY TYPE; W/BONE BLOCK 23462 CAPSULORRHAPHY ANT ANY TYPE; W/CORACOID TRANSF 23465 CAPSULORRHAPHY RECUR DISLOC POST; W/WO BONE BLOC 23466 CAPSULORRHAPHY W/ANY TYPE MULTI-DIREC INSTABILTY 23470 ARTHROPLASTY W/PROX HUMERAL IMPLNT 23472 ARTHROPLASTY W/GLENOID & PROX HUMERAL REPLAC 23480 OSTEOTOMY CLAV W/WO INT FIXA 23485 OSTEOTOMY CLAV W/WO INT FIXA; W/GFT-NON/MALUNION 23490 PROPHYLACTIC TX W/WO METHYLMETHACRYLATE; CLAV 23491 PROPHYLACTIC TX; PROX HUMERUS & HUMERAL HEAD 23500 CLO TX CLAV FX; WO MANIP 23505 CLO TX CLAV FX; W/MANIP 23515 OPEN TX CLAV FX W/WO INT/EXT FIXA 23520 CLO TX STERNOCLAVICULAR DISLOC; W/O MANIP 23525 CLO TX STERNOCLAVICULAR DISLOC; W/MANIP 23530 OPEN TX STERNOCLAVICULAR DISLOC ACUTE/CHRONIC 23532 OPEN TX STERNCLAV DISLOC ACUTE/CHRON; W/FASC GFT 23540 CLO TX ACROMIOCLAVICULAR DISLOC; WO MANIP 23545 CLO TX ACROMIOCLAVICULAR DISLOC; W/MANIP 23550 OPEN TX ACROMIOCLAV DISLOC ACUTE/CHRONIC 23552 OPEN TX AC DISLOC ACUTE/CHRONIC; W/FASCIAL GFT 23570 CLO TX SCAPULAR FX; WO MANIP 23575 CLO TX SCAPULAR FX; W/MANIP W/WO SKELET TRACTION 23585 OPEN TX SCAPULAR FX W/WO INT FIXA 23600 CLO TX PROX HUMERAL FX; WO MANIP

$2,160

90

$2,160

90

$2,591

90

$2,591

90

$130

10

$648

90

$2,375

90

$108

0

$2,160

90

$1,911

90

$2,160

90

$1,080

90

$1,404

90

$1,630

90

$1,944

90

$1,123

90

$2,483

90

$1,468

90

$1,296

90

$2,030

90

$2,267

90

$2,160

90

$2,160

90

$2,160

90

$2,635

90

$2,160

90

$3,887

90

$1,080

90

$1,512

90

$1,296

90

$1,620

90

$212

90

$334

90

$1,011

90

$263

90

$344

90

$1,011

90

$1,213

90

$202

90

$303

90

$1,334

90

$1,738

90

$253

90

$354

90

$1,415

90

$323

90

Section VII: Surgical Services

Page 76

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

23605 CLO TX PROX HUMERAL FX; W/MANIP W/WO SKELE TRACT 23615 OPEN TX PROX HUMER FX W/WO INT/EXT FIXA REPR 23616 OPEN TX PROX HUMER FX; W/PROX HUMER PROSTH REPLA 23620 CLO TX GREATER TUBEROSITY FX; WO MANIP 23625 CLO TX GREATER TUBEROSITY FX; W/MANIP 23630 OPEN TX GREATER TUBEROSITY FX W/WO INT/EXT FIXA 23650 CLO TX SHOULDER DISLOC W/MANIP; WO ANES 23655 CLO TX SHOULDER DISLOC W/MANIP; REQUIRING ANES 23660 OPEN TX ACUTE SHOULDER DISLOC 23665 CLO TX SHOULDR DISLOC W/FX GR TUBEROSITY W/MANIP 23670 OPEN TX SHLDR DISLOC W/FX TUBER W/WO INT/EXT FIX 23675 CLO TX SHOULDER DISLOC W/SURG NECK FX W/MANIP 23680 OPEN TX SHOULDER DISLOC W/SURG NECK FX W/WO FIXA 23700 MANIP W/ANES SHLDR JT INCL APPLIC FIXA APPARATUS 23800 ARTHRODESIS SHOULDER JT; W/WO LOCAL BONE GFT 23802 ARTHRODESIS SHOULDER JT; W/PRIM AUTOGEN GFT 23900 INTERTHORACOSCAPULAR AMPUTA 23920 DISART SHOULDER 23921 DISART SHOULDER; SECNDRY CLO/SCAR REVIS 23929 UNLISTED PROC SHOULDER 23930 I&D UPPER ARM/ELBOW AREA; DEEP ABSCESS/HEMATOMA 23931 I&D UPPER ARM/ELBOW AREA; INFEC BURSA 23935 INCS DEEP W/OPEN BONE CORTEX HUMERUS/ELBOW 24000 ARTHROTOMY ELBOW-INFEC W/EXPLOR/DRAIN/REMOV FB 24006 ARTHROTOMY ELBOW W/CAPSULAR EXC (SEPART PROC) 24065 BX SOFT TISS UPPER ARM/ELBOW AREA; SUPERF 24066 BX SOFT TISS UPPER ARM/ELBOW AREA; DEEP 24075 EXC TUMOR UPPER ARM/ELBOW AREA; SUBQ 24076 EXC TUMOR UPPER ARM/ELBOW; DEEP/SUBFACIAL/IM 24077 RAD RESECT TUMOR SOFT TISS UP ARM/ELBOW AREA 24100 ARTHROTOMY ELBOW; W/SYNOVIAL BX ONLY 24101 ARTHROTOMY ELBOW; W/JT EXPLOR W/WO BX-REMOV FB 24102 ARTHROTOMY ELBOW; W/SYNOVECTOMY 24105 EXC OLECRANON BURSA 24110 EXC/CURET BONE CYST/BEN TUMOR HUMERUS 24115 EXC/CURET BONE CYST/BEN TUMOR HUMERUS; W/AUTOGFT 24116 EXC/CURET BONE CYST/BEN TUMOR HUMERUS; W/ALLOGFT 24120 EXC/CURET BONE CYST/BEN TUMOR-HEAD/NECK RADIUS 24125 EXC/CURET BONE CYST-HEAD/NECK RADIUS; W/AUTOGFT 24126 EXC/CURET BONE CYST-HEAD/NECK RADIUS; W/ALLOGFT 24130 EXC RADIAL HEAD 24134 SEQUESTRECTOMY SHAFT/DISTAL HUMERUS 24136 SEQUESTRECTOMY RADIAL HEAD/NECK 24138 SEQUESTRECTOMY OLECRANON PROCESS 24140 PART EXC BONE HUMERUS 24145 PART EXC BONE RADIAL HEAD/NECK

$526

90

$1,415

90

$2,426

90

$303

90

$425

90

$1,071

90

$283

90

$425

90

$1,213

90

$404

90

$1,617

90

$606

90

$1,880

90

$354

10

$1,880

90

$2,325

90

$2,567

90

$1,920

90

$606

90

BR

N/A

$389

10

$389

10

$777

90

$1,068

90

$1,068

90

$117

10

$389

90

$340

90

$622

90

$1,943

90

$874

90

$1,068

90

$1,399

90

$525

90

$1,166

90

$1,457

90

$1,263

90

$991

90

$1,321

90

$1,321

90

$835

90

$1,166

90

$1,166

90

$1,166

90

$1,166

90

$874

90

Section VII: Surgical Services

Page 77

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

24147 PART EXC BONE OLECRANON PROCESS 24149 RAD RESECT CAPSULE-SOFT TISS-BONE ELB (SEP PROC) 24150 RADICAL RESECT TUMOR SHAFT/DISTAL HUMERUS 24151 RAD RESECT TUMOR SHAFT/DISTAL HUMERUS; W/AUTOGFT 24152 RADICAL RESECT TUMOR RADIAL HEAD/NECK 24153 RAD RESECT TUMOR RADIAL HEAD/NECK; W/AUTOGFT 24155 RESECT ELBOW JT 24160 IMPLNT REMOV; ELBOW JT 24164 IMPLNT REMOV; RADIAL HEAD 24200 REMOV FB UPPER ARM/ELBOW AREA; SUBQ 24201 REMOV FB UPPER ARM/ELBOW AREA; DEEP 24220 INJ PROC ELBOW ARTHROGRAPHY 24301 MUSCL/TENDON TRANSF UPPER ARM/ELBOW SNGL 24305 TENDON LENGTHENING UPPER ARM/ELBOW SNGL EA 24310 TENOTOMY OPEN ELBOW TO SHOULDER SNGL EA 24320 TENOPLASTY W/MUSCL TRANSF W/WO GFT ELBO-SHLDR 1 24330 FLEXOR-PLASTY ELBOW 24331 FLEXOR-PLASTY ELBOW; W/EXTENSOR ADVANCEMENT 24340 TENODESIS BICEPS TENDON @ ELBOW (SEPART PROC) 24341 REPR TENDON/MUSC-UP ARM/ELB-EA-PRI/SECNDRY 24342 REINSRT RUPT BICEPS/TRICEPS DISTAL-W/WO TEND GFT 24350 FASCIOTOMY LAT/MEDIAL 24351 FASCIOTOMY LAT/MED; W/EXTENSOR ORIGIN DETACHMNT 24352 FASCIOTOMY LAT/MED; W/ANNULAR LIGAMNT RESECT 24354 FASCIOTOMY LAT/MEDIAL; W/STRIPPING 24356 FASCIOTOMY LAT/MEDIAL; W/PART OSTECTOMY 24360 ARTHROPLASTY ELBOW; W/MEMBRN 24361 ARTHROPLASTY ELBOW; W/DISTAL HUMERAL PROSTH REPL 24362 ARTHROPLASTY ELBOW; W/IMPLNT & LIGMNT RECON 24363 ARTHROPLASTY ELBOW; W/'TOTAL ELBOW' REPLAC 24365 ARTHROPLASTY RADIAL HEAD 24366 ARTHROPLASTY RADIAL HEAD; W/IMPLNT 24400 OSTEOTOMY HUMERUS W/WO INT FIXA 24410 MX OSTEOTOMIES W/REALIGN INTRAMEDUL ROD HUMERAL 24420 OSTEOPLASTY HUMERUS 24430 REPR NONUNION/MALUNION HUMERUS; WO GFT 24435 REPR NON-MALUNION HUMERUS; W/ILIAC/OTHER AUTOGFT 24470 HEMIEPIPHYSEAL ARREST 24495 DECOMPRESS FASCIOTOMY FOREARM W/BRACH ART EXPLOR 24498 PROPHYLACTIC TX W/WO METHYLMETHACRYLATE HUMERUS 24500 CLO TX HUMERAL SHAFT FX; WO MANIP 24505 CLO TX HUMERAL SHAFT FX; W/MANIP W/WO TRACTION 24515 OPEN TX HUMERAL FX W/PLATE/SCREWS W/WO CERCLAGE 24516 OPEN TX HUMERAL FX W/INSRT IMPLNT W/WO CERCLAGE 24530 CLO TX SUPRA TRANSCONDYLAR HUMERAL FX; WO MANIP 24535 CLO TX SUPRACONDYL HUMERAL FX; W/MANIP W/WO TRAC

$777

90

$1,496

90

$1,651

90

$2,428

90

$2,137

90

$2,428

90

$1,496

90

$1,068

90

$971

90

$117

10

$389

90

$102

0

$1,360

90

$583

90

$486

90

$1,554

90

$1,166

90

$1,554

90

$1,049

90

$1,321

90

$1,379

90

$583

90

$680

90

$777

90

$777

90

$971

90

$2,137

90

$2,137

90

$2,137

90

$3,205

90

$874

90

$1,068

90

$1,321

90

$1,554

90

$1,554

90

$1,651

90

$1,943

90

$1,515

90

$1,166

90

$1,554

90

$338

90

$581

90

$1,395

90

$1,690

90

$380

90

$676

90

Section VII: Surgical Services

Page 78

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

24538 PERCUT FIXA SUPRACONDYL HUMER FX W/WO INTERCONDY 24545 OPEN TX HUMER SUPRACONDYL FX; WO INTERCOND EXTEN 24546 OPEN TX HUMER SUPRACONDYL FX; W/INTERCOND EXTEN 24560 CLO TX HUMERAL EPICONDYLAR FX MED/LAT; WO MANIP 24565 CLO TX HUMERAL EPICONDYLAR FX MED/LAT; W/MANIP 24566 PERQ SKELET FIX HUMRL EPICONDYL FX MED/LAT W/MAN 24575 OPEN TX HUMERAL EPICONDYL FX MED/LAT W/WO FIXA 24576 CLO TX HUMERAL CONDYL FX MED/LAT; WO MANIP 24577 CLO TX HUMERAL CONDYL FX MED/LAT; W/MANIP 24579 OPEN TX HUMER CONDYL FX MED/LAT W/WO INT/EXT FIX 24582 PERQ SKELET FIX HUMRL CONDYL FX MED/LAT W/MANIP 24586 OPEN TX PERIARTICULAR FX &/OR DISLOC ELBOW 24587 OPEN TX PERIARTIC FX/DISLOC ELB; W/IMPLNT ARTHRO 24600 TX CLO ELBOW DISLOC; WO ANES 24605 TX CLO ELBOW DISLOC; REQUIRING ANES 24615 OPEN TX ACUTE/CHRONIC ELBOW DISLOC 24620 CLO TX MONTEGGIA TYPE FX DISLOC-ELBOW W/MANIP 24635 OPEN TX MONTEGGIA TYPE FX DISLOC-ELBOW W/WO FIXA * 24640 CLO TX RADIAL HEAD SUBLUXATION CHILD W/MANIP 24650 CLO TX RADIAL HEAD/NECK FX; WO MANIP 24655 CLO TX RADIAL HEAD/NECK FX; W/MANIP 24665 OPEN TX RADIAL HEAD/NECK FX W/WO INT FIXA 24666 OPEN TX RADIAL HEAD FX; RAD HEAD PROSTH REPLAC 24670 CLO TX ULNAR FX PROX END; WO MANIP 24675 CLO TX ULNAR FX PROX END; W/MANIP 24685 OPEN TX ULNAR FX PROX END W/WO INT/EXT FIXA 24800 ARTHRODESIS ELBOW JT; W/WO AUTOGFT/ALLOGFT 24802 ARTHRODESIS ELBOW JT; W/AUTOGFT 24900 AMPUTA ARM THRU HUMERUS; W/PRIMARY CLO 24920 AMPUTA ARM THRU HUMERUS; OPEN CIRCULAR 24925 AMPUTA ARM THRU HUMERUS; SECNDRY CLO/SCAR REVIS 24930 AMPUTA ARM THRU HUMERUS; RE-AMPUTA 24931 AMPUTA ARM THRU HUMERUS; W/IMPLNT 24935 STUMP ELONGATION UPPER EXTREM 24940 CINEPLASTY UPPER EXTREM COMPLT PROC 24999 UNLISTED PROC HUMERUS/ELBOW 25000 TENDON SHEATH INCS; RADIAL STYLOID (DEQUERVAIN) 25020 DECOMP FASCIOT FOREARM/WRIST; FLEXOR/EXTENSOR 25023 DECOMP FASCIOT FOREARM; W/DEBRID NONVIABLE MUSCL 25028 I&D FOREARM/WRIST; DEEP ABSCESS/HEMATOMA 25031 I&D FOREARM &/OR WRIST; INFEC BURSA 25035 INCS DEEP W/OPEN BONE CORTEX FOREARM/WRIST 25040 ARTHROTOMY RADIO/MIDCARPAL W/EXPLOR/DRAIN/FB REM 25065 BX SOFT TISS FOREARM &/OR WRIST; SUPERF 25066 BX SOFT TISS FOREARM &/OR WRIST; DEEP 25075 EXC TUMOR FOREARM &/OR WRIST AREA; SUBQ

$1,162

90

$1,479

90

$1,796

90

$370

90

$539

90

$909

90

$1,099

90

$306

90

$507

90

$1,289

90

$866

90

$1,690

90

$2,324

90

$296

90

$444

90

$1,204

90

$634

90

$1,553

90

$114

10

$291

90

$433

90

$1,067

90

$1,363

90

$275

90

$486

90

$1,141

90

$1,690

90

$2,113

90

$1,057

90

$845

90

$423

90

$1,057

90

$1,204

90

$1,585

90

$1,585

90

BR

N/A

$540

90

$652

90

$838

90

$428

90

$372

90

$745

90

$857

90

$149

10

$372

90

$335

90

Section VII: Surgical Services

Page 79

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

25076 EXC TUMOR FOREARM/WRIST AREA; DEEP/SUBFASCIAL/IM 25077 RAD RESECT TUMOR SOFT TISS FOREARM/WRIST AREA 25085 CAPSULOTOMY WRIST 25100 ARTHROTOMY WRIST JT; W/BX 25101 ARTHROTOMY WRIST JT; W/EXPLOR W/WO BX/REMOV FB 25105 ARTHROTOMY WRIST JT; W/SYNOVECTOMY 25107 ARTHROTOMY DISTAL RADIOULNAR JT 25110 EXC LES TENDON SHEATH FOREARM/WRIST 25111 EXC GANGLION WRIST; PRIM 25112 EXC GANGLION WRIST; RECURRENT 25115 RAD EXC BURSA WRIST TENDON SHEATHS; FLEXORS 25116 RAD EXC BURSA WRIST; EXTENSORS W/WO TRANSPOSIT 25118 SYNOVECTOMY EXTENSOR TENDON SHEATH WRIST SNGL 25119 SYNOVECTOMY EXTENSOR WRIST SNGL; RESECT ULNA 25120 EXC/CURET BONE CYST/BEN TUMOR RADIUS/ULNA 25125 EXC/CURET BONE CYST/TUMOR RADIUS/ULNA; W/AUTOGFT 25126 EXC/CURET BONE CYST/TUMOR RADIUS/ULNA; W/ALLOGFT 25130 EXC/CURET BONE CYST/BEN TUMOR CARPAL BONES 25135 EXC/CURET BONE CYST/TUMOR CARPAL BONES; W/AUTOGF 25136 EXC/CURET BONE CYST/TUMOR CARPAL BONES; W/ALLOGF 25145 SEQUESTRECTOMY FOREARM &/OR WRIST 25150 PART EXC BONE; ULNA 25151 PART EXC BONE; RADIUS 25170 RADICAL RESECT TUMOR RADIUS/ULNA 25210 CARPECTOMY; 1 BONE 25215 CARPECTOMY; ALL BONES PROX ROW 25230 RADIAL STYLOIDECTOMY (SEPART PROC) 25240 EXC DISTAL ULNA PART/COMPLT 25246 INJ PROC WRIST ARTHROGRAPHY 25248 EXPLOR W/REMOV DEEP FB FOREARM/WRIST 25250 REMOV WRIST PROSTH; (SEPART PROC) 25251 REMOV WRIST PROSTH; COMPLIC INCL'TOT WRIST' 25260 REPR TENDON/MUSCL-FLEXOR-WRIST; PRIM SNGL EA 25263 REPR TENDON/MUSCL-FLEXOR-WRIST; SECNDRY SNGL EA 25265 REPR TENDON/MUSCL-FLEXOR-WRIST; 2ND W/FREE GFT 25270 REPR TENDON/MUSCL-EXTENSOR-WRIST; PRIM SNGL EA 25272 REPR TENDON/MUSCL-EXTENSOR-WRIST; SECNDRY SNGL 25274 REPR TENDON/MUSCL EXTENSOR SECNDRY W/GFT WRIST 25280 LENGTHEN/SHORTEN FLEX/EXTEN WRIST SNGL EA TENDON 25290 TENOTOMY OPEN FLEX/EXTEN TENDON WRIST SNGL EA 25295 TENOLYSIS FLEX/EXTEN-FOREARM/WRIST SNGL EA TENDN 25300 TENODESIS @ WRIST; FLEXORS FINGERS 25301 TENODESIS @ WRIST; EXTENSORS FINGERS 25310 TENDON TRANSPL/TRANSF FLEX/EXTEN WRIST SNGL; EA 25312 TENDON TRANSPL/TRANSF WRIST SNGL; W/TENDON GFT 25315 FLEXOR ORIGIN SLIDE FOREARM &/OR WRIST;

$559

90

$1,862

90

$1,117

90

$745

90

$968

90

$1,024

90

$1,061

90

$428

90

$559

90

$596

90

$1,080

90

$1,080

90

$838

90

$931

90

$931

90

$1,117

90

$1,117

90

$931

90

$1,117

90

$1,117

90

$1,117

90

$931

90

$931

90

$1,490

90

$745

90

$1,303

90

$708

90

$745

90

$116

0

$466

90

$466

90

$614

90

$782

90

$931

90

$1,024

90

$652

90

$745

90

$931

90

$745

90

$466

90

$670

90

$1,303

90

$1,117

90

$1,210

90

$1,303

90

$1,490

90

Section VII: Surgical Services

Page 80

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

25316 FLEXOR ORIGIN SLIDE WRIST; W/TENDON(S) TRANSF 25320 CAPSULOR/RECON WRIST ANY METHOD-CARP INSTABIL 25332 ARTHROPLASTY WRIST; W/WO INTERPOSITION-W/WO FIXA 25335 CENTRALIZATION WRIST ULNA 25337 RECON WRIST-SECNDRY-W/WO OPEN REDUC RADULNAR JT 25350 OSTEOTOMY RADIUS; DISTAL THIRD 25355 OSTEOTOMY RADIUS; MID/PROX THIRD 25360 OSTEOTOMY; ULNA 25365 OSTEOTOMY; RADIUS & ULNA 25370 MX OSTEOTOMIES W/REALIGN ON ROD; RADIUS/ULNA 25375 MX OSTEOTOMIES W/REALIGN ON ROD; RADIUS & ULNA 25390 OSTEOPLASTY RADIUS/ULNA; SHORTENING 25391 OSTEOPLASTY RADIUS/ULNA; LENGTHENING W/AUTOGFT 25392 OSTEOPLASTY RADIUS & ULNA; SHORTENING 25393 OSTEOPLASTY RADIUS & ULNA; LENGTHENING W/AUTOGFT 25400 REPR NON/MALUNION RADIUS/ULNA; WO GFT 25405 REPR NON/MALUNION RAD/ULNA; W/ILIAC/OTHER AUTOGF 25415 REPR NONUNION/MALUNION RADIUS & ULNA; WO GFT 25420 REPR NON/MALUNION RADIUS & ULNA; W/ILIAC/AUTOGFT 25425 REPR DEFECT W/AUTOGFT; RADIUS/ULNA 25426 REPR DEFECT W/AUTOGFT; RADIUS & ULNA 25440 REPR NONUNION SCAPHOID W/WO RADIAL STYLOIDECTOMY 25441 ARTHROPLASTY W/PROSTH REPLAC; DISTAL RADIUS 25442 ARTHROPLASTY W/PROSTH REPLAC; DISTAL ULNA 25443 ARTHROPLASTY W/PROSTH REPLAC; SCAPHOID 25444 ARTHROPLASTY W/PROSTH REPLAC; LUNATE 25445 ARTHROPLASTY W/PROSTH REPLAC; TRAPEZIUM 25446 ARTHROPLASTY W/PROS REPLAC; DIST RAD/PART CARPUS 25447 INTERPOSIT ARTHROPLASTY-INTERCARPAL/CARPOMETACAR 25449 REVIS ARTHROPLASTY INCL REMOV IMPLNT WRIST JT 25450 EPIPHYSEAL ARREST-STAPLING; DISTAL RADIUS/UNLA 25455 EPIPHYSEAL ARREST-STAPLING; DIST RADIUS & ULNA 25490 PROPHYLACTIC TX W/WO METHYLMETHACRYLATE; RADIUS 25491 PROPHYLACTIC TX W/WO METHYLMETHACRYLATE; ULNA 25492 PROPHYLACTIC TX W/WO METHYLMETHA; RADIUS & ULNA 25500 CLO TX RADIAL SHAFT FX; WO MANIP 25505 CLO TX RADIAL SHAFT FX; W/MANIP 25515 OPEN TX RADIAL SHAFT FX W/WO INT/EXT FIXA 25520 CLO TX RADIAL SHAFT FX W/DISLOC DIST RAD-ULNA JT 25525 OPEN TX RAD SHAFT FX W/FIXA & CLO TX RADULNAR JT 25526 OPEN TX RAD SHAFT FX W/FIX & OPEN TX RADULNAR JT 25530 CLO TX ULNAR SHAFT FX; WO MANIP 25535 CLO TX ULNAR SHAFT FX; W/MANIP 25545 OPEN TX ULNAR SHAFT FX W/WO INT/EXT FIXA 25560 CLO TX RADIAL & ULNAR SHAFT FX; WO MANIP 25565 CLO TX RADIAL & ULNAR SHAFT FX; W/MANIP

$1,862

90

$1,583

90

$1,676

90

$2,328

90

$1,583

90

$1,024

90

$1,303

90

$1,024

90

$1,490

90

$1,303

90

$1,862

90

$1,303

90

$1,490

90

$1,583

90

$1,676

90

$1,210

90

$1,490

90

$1,490

90

$1,769

90

$1,397

90

$1,583

90

$1,397

90

$1,583

90

$1,583

90

$1,583

90

$1,769

90

$1,769

90

$2,421

90

$1,397

90

$1,117

90

$559

90

$931

90

$1,024

90

$1,024

90

$1,210

90

$281

90

$478

90

$1,040

90

$478

90

$1,218

90

$1,405

90

$300

90

$450

90

$1,040

90

$375

90

$712

90

Section VII: Surgical Services

Page 81

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

25574 OPEN TX RADIAL & ULNAR SHAFT FX W/FIX; RAD/ULNA 25575 OPEN TX RAD & ULNA SHAFT FX W/FIX; RADIUS & ULNA 25600 CLO TX DIST RAD FX W/WO FX ULNA STYLOID; WO MANI 25605 CLO TX DIST RAD FX W/WO FX ULNA STYLOID; W/MANIP 25611 PERCUT FIX DISTAL RAD FX W/WO FX ULNA W/MANIP 25620 OPEN TX DISTAL RAD FX W/WO FX ULNA W/WO FIXA 25622 CLO TX CARPAL SCAPHOID FX; WO MANIP 25624 CLO TX CARPAL SCAPHOID FX; W/MANIP 25628 OPEN TX CARPAL SCAPHOID FX W/WO INT/EXT FIXA 25630 CLO TX CARPAL BONE FX; WO MANIP EA BONE 25635 CLO TX CARPAL BONE FX; W/MANIP EA BONE 25645 OPEN TX CARPAL BONE FX EA BONE 25650 CLO TX ULNAR STYLOID FX 25660 CLO TX RADIO-/INTERCARPAL DISLOC 1/MORE W/MANIP 25670 OPEN TX RADIOCARPAL/INTERCARP DISLOC 1/MORE BONE 25675 CLO TX DISTAL RADIOULNAR DISLOC W/MANIP 25676 OPEN TX DISTAL RADIOULNAR DISLOC ACUTE/CHRONIC 25680 CLO TX TRANS-SCAPHOPERILUNAR FX DISLOC W/MANIP 25685 OPEN TX TRANS-SCAPHOPERILUNAR TYPE FX DISLOC 25690 CLO TX LUNATE DISLOC W/MANIP 25695 OPEN TX LUNATE DISLOC 25800 ARTHRODESIS WRIST JT; WO BONE GFT 25805 ARTHRODESIS WRIST JT; W/SLIDING GFT 25810 ARTHRODESIS WRIST JT; W/ILIAC/OTHER AUTOGFT 25820 INTERCARPAL FUSION; WO BONE GFT 25825 INTERCARPAL FUSION; W/AUTOGFT 25830 ARTHRODESIS RADIOULN JT-RESECT ULNA-W/WO BON GFT 25900 AMPUTA FOREARM THRU RADIUS & ULNA 25905 AMPUTA FOREARM THRU RADIUS & ULNA; OPEN CIRCULAR 25907 AMPUTA FOREARM; SECNDRY CLO/SCAR REVIS 25909 AMPUTA FOREARM THRU RADIUS & ULNA; RE-AMPUTA 25915 KRUKENBERG PROC 25920 DISART THRU WRIST 25922 DISART THRU WRIST; SECNDRY CLO/SCAR REVIS 25924 DISART THRU WRIST; RE-AMPUTA 25927 TRANSMETACARPAL AMPUTA 25929 TRANSMETACARPAL AMPUTA; SECNDRY CLO/SCAR REVIS 25931 TRANSMETACARPAL AMPUTA; RE-AMPUTA 25999 UNLISTED PROC FOREARM/WRIST * 26010 DRAINAGE FINGER ABSCESS; SIMPL * 26011 DRAINAGE FINGER ABSCESS; COMPLIC 26020 DRAINAGE TENDON SHEATH 1 DIGIT &/OR PALM 26025 DRAINAGE PALMAR BURSA; SNGL ULNAR/RADIAL 26030 DRAINAGE PALMAR BURSA; MX/COMPLIC 26034 INCS DEEP W/OPEN BONE CORTEX HAND/FINGER 26035 DECOMP FINGERS &/OR HAND INJ INJURY

$1,387

90

$1,518

90

$323

90

$497

90

$843

90

$1,012

90

$347

90

$450

90

$974

90

$286

90

$468

90

$703

90

$412

90

$468

90

$937

90

$375

90

$750

90

$665

90

$1,274

90

$562

90

$1,143

90

$1,162

90

$1,405

90

$1,611

90

$1,349

90

$1,836

90

$1,499

90

$1,124

90

$974

90

$431

90

$1,124

90

$1,255

90

$1,124

90

$375

90

$1,124

90

$1,124

90

$375

90

$1,124

90

BR

N/A

$80

10

$301

10

$603

90

$603

90

$1,406

90

$643

90

$1,406

90

Section VII: Surgical Services

Page 82

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

26037 DECOMP FASCIOTOMY HAND 26040 FASCIOTOMY PALMAR DUPUYTREN'S CONTRACT; PERCUT 26045 FASCIOTOMY PALMAR DUPUYTREN'S CONTRCT; OPEN PART 26055 TENDON SHEATH INCS 26060 TENOTOMY PERCUT SNGL EA DIGIT 26070 ARTHROT W/EXPLOR/DRAIN/REMOV FB; CARPOMETACRP JT 26075 ARTHROT W/EXPLOR/DRAIN/REMOV FB; MCP JT 26080 ARTHROT W/EXPLOR/DRAIN/REMOV FB;IP JT EA 26100 ARTHROTOMY W/SYNOVIAL BX; CARPOMETACARPAL JT 26105 ARTHROTOMY W/SYNOVIAL BX; MCP JT 26110 ARTHROTOMY W/SYNOVIAL BX; IP JT EA 26115 EXC TUMOR/VASCUL MALFORM HAND/FINGER; SUBQ 26116 EXC TUMOR/VASCULAR MALFORM HAND/FINGER; DEEP/IM 26117 RADICAL RESECT TUMOR SOFT TISS HAND/FINGER 26121 FASCIECT PALM ONLY W/WO Z-PLASTY/SKIN GFT (INCL) 26123 FASCIECT PART PALMAR W/REL 1 DIGT W/WO Z-PLASTY; 26125 FASCIECT PART PALM W/REL 1 DIGIT; EA ADD DIGIT 26130 SYNOVECTOMY CARPOMETACARPAL JT 26135 SYNOVECTOMY MCP JT INCL RELEAS & RECON EA DIGIT 26140 SYNOVECTOMY PROX IP JT INCL RECON EA IP JT 26145 SYNOVECTOMY RADICAL FLEXOR PALM/FINGER SNGL EA 26160 EXC LES TENDON SHEATH/CAPSULE HAND/FINGER 26170 EXC TENDON PALM FLEXOR SNGL (SEPART PROC) EA 26180 EXC TENDON FINGER FLEXOR (SEPART PROC) 26185 SESAMOIDECTOMY THUMB/FINGER (SEPART PROC) 26200 EXC/CURET BONE CYST/BEN TUMOR METACARPAL 26205 EXC/CURET BONE CYST/TUMOR METACARPAL; W/AUTOGFT 26210 EXC/CURET BONE/TUMOR PROX/MID/DIST PHALANX FINGR 26215 EXC BONE CYST PROX/MID/DIST PHALANX; W/AUTOGFT 26230 PART EXC BONE; METACARPAL 26235 PART EXC BONE; PROX/MID PHALANX FINGER 26236 PART EXC BONE; DISTAL PHALANX FINGER 26250 RADICAL RESECT TUMOR METACARPAL 26255 RADICAL RESECT TUMOR METACARPAL; W/AUTOGFT 26260 RADICAL RESECT TUMOR PROX/MID PHALANX FINGER 26261 RADICAL RESECT TUMOR PROX/MID FINGER; W/AUTOGFT 26262 RADICAL RESECT TUMOR DISTAL PHALANX FINGER 26320 REMOV IMPLNT FROM FINGER/HAND 26350 FLEXOR TENDON REPR 1; PRIM/SECNDRY WO GFT-EA 26352 FLEX TENDON REPR NOT 'NO MAN'S LAND'; 2ND W/GFT 26356 FLEXOR TENDON REPR SNGL; PRIM EA TENDON 26357 FLEXOR TENDON REPR SNGL; SECNDRY EA TENDON 26358 FLEX TENDON REPR IN NO MAN'S LAND"; 2ND W/GFT" 26370 PROFUNDUS TENDON REPR W/INTACT SUBLIMIS; PRIM 26372 PROFUNDUS TENDON REPR; SECNDRY W/FREE GFT 26373 PROFUNDUS TENDON REPR; SECNDRY WO FREE GFT

$603

90

$422

90

$603

90

$522

90

$261

90

$603

90

$603

90

$482

90

$603

90

$502

90

$422

90

$402

90

$643

90

$2,110

90

$1,306

90

$1,507

90

$502

N/A

$904

90

$804

90

$703

90

$804

90

$462

90

$502

90

$502

90

$542

90

$603

90

$804

90

$553

90

$804

90

$643

90

$603

90

$563

90

$1,005

90

$1,406

90

$1,005

90

$1,205

90

$1,005

90

$448

90

$993

90

$1,362

90

$1,362

90

$1,654

90

$1,849

90

$1,168

90

$1,362

90

$1,168

90

Section VII: Surgical Services

Page 83

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

26390 FLEXOR TENDON EXC-IMPLNT TUBE/ROD-HAND/FINGER 26392 REMOV TUBE/ROD & INSRT FLEX TENDON GFT HAND/FING 26410 EXTENSOR TENDON REPR-DORSUM HAND; WO GFT EA TEND 26412 EXTENSOR TENDON REPR-DORSUM HAND; W/GFT EA TEND 26415 EXTENSOR TENDON EXC-IMPLNT ROD-DELAYED GFT HAND 26416 REMOV ROD-INSRT EXTEN TENDON GFT HAND/FINGER 26418 EXTENSOR TENDON REPR DORSUM FINGER; WO GFT EA 26420 EXTENSOR TENDON REPR DORSUM FINGR; W/GFT EA TEND 26426 EXTENSOR TENDON REPR-CENTRAL SLIP; W/LOCAL TISS 26428 EXTENSOR TENDON REPR-CENTRAL SLIP; W/FREE GFT 26432 EXTENSOR TENDON REPR-DIST INSRT-CLO W/WO PINNING 26433 EXTENSOR TENDON REPR-DIST INSRT-OPEN; WO GFT 26434 EXTENSOR TENDON REPR-DIST INSRT-OPEN; W/FREE GFT 26437 EXTENSOR TENDON REALIGNMENT HAND 26440 TENOLYSIS FLEXOR; PALM/FINGER SNGL EA TENDON 26442 TENOLYSIS FLEXOR; PALM & FINGER SINGL EA TENDON 26445 TENOLYSIS EXTENSOR DORSUM HAND/FINGER; EA TENDON 26449 TENOLYSIS COMPLX-EXTENSOR-FINGR INCL HAND/FORARM 26450 TENOTOMY FLEXOR SNGL PALM OPEN EA 26455 TENOTOMY FLEXOR SNGL FINGER OPEN EA 26460 TENOTOMY EXTENSOR HAND/FINGER SNGL OPEN EA 26471 TENODESIS; PROX IP JT STABILIZATION 26474 TENODESIS; DISTAL JT STABILIZATION 26476 TENDON LENGTHENING EXTENSOR HAND/FINGER SNGL EA 26477 TENDON SHORTENING EXTENSOR HAND/FINGER SNGL EA 26478 TENDON LENGTHENING FLEXOR HAND/FINGER SNGL EA 26479 TENDON SHORTENING FLEXOR HAND/FINGER SNGL EA 26480 TENDON TRANSF/TRANSPL DORSUM HAND SNGL; WO GFT 26483 TENDON TRANSF/TRANSPL DORSUM HAND SNGL; W/GFT EA 26485 TENDON TRANSF/TRANSPL PALMAR SNGL EA; WO GFT 26489 TENDON TRANSF/TRANSPL PALMAR SNGL EA; W/GFT EA 26490 OPPONENSPLASTY; SUBLIMIS TENDON TRANSF TYPE 26492 OPPONENSPLASTY; TENDON TRANSF W/GFT 26494 OPPONENSPLASTY; HYPOTHENAR MUSCL TRANSF 26496 OPPONENSPLASTY; OTHER METHD 26497 TENDON TRANSF-RESTORE FUNCT; RING & SM FINGER 26498 TENDON TRANSF-RESTORE FUNCT; ALL 4 FINGERS 26499 CORRECT CLAW FINGER OTHER METHD 26500 TENDON PULLEY RECON; W/LOCAL TISS (SEPART PROC) 26502 TENDON PULLEY RECON; W/TENDON/FASC GFT (SEP PRO) 26504 TENDON PULLEY RECON; W/TENDON PROSTH (SEP PRO) 26508 THENAR MUSCL RELEASE THUMB CONTRACTURE 26510 CROSS INTRINSIC TRANSF 26516 CAPSULODESIS M-P JT STABILIZATION; SNGL DIGIT 26517 CAPSULODESIS M-P JT STABILIZATION; 2 DIGITS 26518 CAPSULODESIS M-P JT STABILIZATION; 3-4 DIGITS

$1,168

90

$1,362

90

$584

90

$817

90

$856

90

$1,202

90

$642

90

$876

90

$973

90

$1,362

90

$467

90

$681

90

$876

90

$778

90

$584

90

$876

90

$603

90

$905

90

$487

90

$487

90

$487

90

$973

90

$584

90

$584

90

$584

90

$778

90

$778

90

$1,012

90

$1,246

90

$1,304

90

$1,537

90

$1,168

90

$1,460

90

$1,557

90

$1,557

90

$1,362

90

$1,654

90

$1,897

90

$681

90

$915

90

$1,109

90

$778

90

$1,654

90

$973

90

$1,168

90

$1,557

90

Section VII: Surgical Services

Page 84

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

26520 CAPSULECTOMY/CAPSULOTOMY CONTRACT; MCP JT 1 EA 26525 CAPSULECTOMY/CAPSULOTOMY CONTRACT; IP JT SNGL EA 26530 ARTHROPLASTY MCP JT; SNGL EA 26531 ARTHROPLASTY MCP JT; W/PROSTH IMPLNT SNGL EA 26535 ARTHROPLASTY IP JT; SNGL EA 26536 ARTHROPLASTY IP JT; W/PROSTH IMPLNT SNGL EA 26540 REPR COLLATERAL LIGAMNT MCP/INTERPHALAN JT 26541 RECON COLLATERAL LIGAMNT MCP JT-SING; W/TEND GFT 26542 RECON COLLATERAL LIGAMNT MCP JT-SING; W/LOC TISS 26545 RECON COLLATERAL LIG IP JT SNGL INCL GFT EA JT 26546 REPR NON-UNION METACARP/PHALYNX (INCL BONE GFT) 26548 REPR & RECON FINGER VOLAR PLATE IP JT 26550 POLLICIZATION A DIGIT 26551 TOE-TO-HAND TRANS W/MICROVASC ANASTOM; GRT TOE 26553 TOE-TO-HAND TRANS W/MICROVAS ANAST; NOT GR TOE-1 26554 TOE-TO-HAND TRANS W/MICROVAS ANAST; NOT GR TOE-2 26555 POSIT CHANGE OTHER FINGER 26556 FREE TOE JT TRANS W/MICROVASC ANASTOM 26560 REPR SYNDACTYLY EA WEB SPACE; W/SKIN FLAPS 26561 REPR SYNDACTYLY EA WEB SPACE; W/SKIN FLAPS & GFT 26562 REPR SYNDACTYLY EA WEB SPACE; COMPLX 26565 OSTEOTOMY CORRECT DEFORM; METACARPAL 26567 OSTEOTOMY CORRECT DEFORM; PHALANX FINGER 26568 OSTEOPLASTY LENGTHENING METACARPAL/PHALANX 26580 REPR CLEFT HAND 26585 REPR BIFID DIGIT 26587 RECON SUPERNUMERARY DIGIT SOFT TISS & BONE 26590 REPR MACRODACTYLIA 26591 REPR INTRINSIC MUSCL HAND 26593 RELEASE INTRINSIC MUSCL HAND 26596 EXC CONSTRICTING RING OF FINGER W/MX Z-PLASTIES 26597 RELEASE CONTRACT W/GFT/Z-PLASTIES HAND/FINGER 26600 CLO TX METACARPAL FX SNGL; WO MANIP EA BONE 26605 CLO TX METACARPAL FX SNGL; W/MANIP EA BONE 26607 CLO TX METACARPAL FX W/MANIP W/FIXA EA BONE 26608 PERCUT SKELETAL FIXA METACARPAL FX EA BONE 26615 OPEN TX METACARPAL FX SNGL W/WO FIXA EA BONE 26641 CLO TX CARPOMETACARPAL DISLOC THUMB W/MANIP 26645 CLO TX CARPOMETACARPAL FX DISLOC THUMB W/MANIP 26650 PERCUT SKELETAL FIX FX DISLOC THUMB W/WO EXT FIX 26665 OPEN TX FX DISLOC THUMB W/WO INT/EXT FIXA 26670 CLO TX DISLOC-NOT THUMB-SNGL W/MANIP; WO ANES 26675 CLO TX DISLOC-NOT THUMB-SNGL W/MANIP; REQ ANES 26676 PERCUT SKELET FIX DISLOC-NOT THUMB-SNGL; W/MANIP 26685 OPEN TX DISLOC-NOT THUMB; SNGL W/WO INT/EXT FIXA 26686 OPEN TX DISLOC-NOT THUMB; COMPLX/MX/DELAY REDUCT

$778

90

$778

90

$973

90

$1,070

90

$817

90

$1,070

90

$973

90

$1,168

90

$1,362

90

$973

90

$1,031

90

$1,070

90

$2,335

90

$4,145

90

$3,600

90

$6,454

90

$1,557

90

$5,694

90

$973

90

$1,168

90

$2,919

90

$876

90

$778

90

$1,265

90

$2,478

90

$1,858

90

$805

90

$991

90

$867

90

$743

90

$1,487

90

$1,611

90

$216

90

$324

90

$589

90

$688

90

$756

90

$265

90

$363

90

$697

90

$1,031

90

$216

90

$324

90

$511

90

$805

90

$1,120

90

Section VII: Surgical Services

Page 85

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

26700 CLO TX MCP DISLOC SNGL W/MANIP; WO ANES 26705 CLO TX MCP DISLOC SNGL W/MANIP; REQ ANES 26706 PERCUT SKELETAL FIXA MCP DISLOC SNGL W/MANIP 26715 OPEN TX MCP DISLOC SNGL W/WO INT/EXT FIXA 26720 CLO TX PHALANGEAL SHAFT FX PROX/MID; WO MANIP EA 26725 CLO TX PHALANGEALFX PROX/MID; W/MANIP W/WO TRACT 26727 PERCUT FIXA UNSTABLE FX PROX/MID W/MANIP EA 26735 OPEN TX PHALANG FX PROX/MID W/WO INT/EXT FIX EA 26740 CLO TX ARTICULR FX INVOLV MCP/IP JT; WO MANIP EA 26742 CLO TX ARTICULAR FX INVOLV MCP/IP JT; W/MANIP EA 26746 OPEN TX ARTICULR FX INVOLV MCP/IP JT W/WO FIX EA 26750 CLO TX DIST PHALANGEAL FX FINGER/THUMB; WO MANIP 26755 CLO TX DIST PHALANGEAL FX FINGER/THUMB; W/MANIP 26756 PERCUT SKELETAL FIXA DISTAL PHALANGEAL FX EA 26765 OPEN TX DIST PHALANGEAL FX W/WO INT/EXT FIXA EA 26770 CLO TX IP JT DISLOC SNGL W/MANIP; WO ANES 26775 CLO TX IP JT DISLOC SNGL W/MANIP; REQ ANES 26776 PERCUT SKELETAL FIXA IP JT DISLOC SNGL W/MANIP 26785 OPEN TX IP JT DISLOC W/WO INT/EXT FIXA SNGL 26820 FUSION IN OPPOSITION THUMB W/AUTOG GFT 26841 ARTHRODESIS CARPOMETACARPAL JT THUMB W/WO FIXA 26842 ARTHRODESIS JT THUMB W/WO INT FIXA; W/AUTOGFT 26843 ARTHRODESIS CARPOMETACARPAL JT DIGITS NOT THUMB 26844 ARTHRODESIS JT DIGITS NOT THUMB; W/AUTOGFT 26850 ARTHRODESIS MCP JT W/WO INT FIXA 26852 ARTHRODESIS MCP JT W/WO INT FIXA; W/AUTOGFT 26860 ARTHRODESIS IP JT W/WO INT FIXA 26861 ARTHRODESIS IP JT W/WO INT FIXA; EA ADD IP JT 26862 ARTHRODESIS IP JT W/WO INT FIXA; W/AUTOGFT 26863 ARTHRODESIS IP JT W/WO FIX; W/AUTOGFT EA ADD JT 26910 AMPUTA METACARPAL W/FINGER/THUMB 1 W/WO TRANSF 26951 AMPUTA FINGER ANY JT INCL NEURECT; W/DIRECT CLO 26952 AMPUTA FINGER ANY JT; W/LOCAL ADVANCEMENT FLAPS 26989 UNLISTED PROC HANDS/FINGERS 26990 I&D PELVIS/HIP JT AREA; DEEP ABSCESS/HEMATOMA 26991 I&D PELVIS/HIP JT AREA; INFEC BURSA 26992 INCS DEEP W/OPEN BONE CORTEX PELVIS &/OR HIP 27000 TENOTOMY ADDUCTOR HIP SUBQ CLO (SEPART PROC) 27001 TENOTOMY ADDUCTOR HIP SUBQ OPEN 27003 TENOTOMY ADDUCT SUBQ OPEN W/OBTURATOR NEURECTOMY 27005 TENOTOMY ILIOPSOAS OPEN (SEPART PROC) 27006 TENOTOMY ABDUCTORS HIP OPEN (SEPART PROC) 27025 FASCIOTOMY HIP/THIGH ANY TYPE 27030 ARTHROTOMY HIP INFEC W/DRAINAGE 27033 ARTHROTOMY HIP W/EXPLOR/REMOV LOOSE BODY/FB 27035 HIP JT DENERVATION FEMORAL/OBTURATOR NERVES

$196

90

$295

90

$432

90

$737

90

$147

90

$255

90

$471

90

$688

90

$226

90

$334

90

$904

90

$128

90

$196

90

$393

90

$550

90

$138

90

$206

90

$334

90

$550

90

$1,179

90

$982

90

$1,179

90

$982

90

$1,179

90

$825

90

$1,022

90

$737

90

$368

N/A

$933

90

$452

N/A

$884

90

$589

90

$786

90

BR

N/A

$524

90

$655

90

$764

90

$328

90

$655

90

$764

90

$873

90

$873

90

$1,310

90

$1,528

90

$1,528

90

$1,878

90

Section VII: Surgical Services

Page 86

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

27036 CAPSULEC/CAPSULOT HIP W/WO EXC BON W/MUSC RELEAS 27040 BX SOFT TISS PELVIS & HIP AREA; SUPERF 27041 BX SOFT TISS PELVIS & HIP AREA; DEEP 27047 EXC TUMOR PELVIS & HIP AREA; SUBQ 27048 EXC TUMOR PELVIS & HIP AREA; DEEP/SUBFASCIAL/IM 27049 RADICAL RESECT TUMOR SOFT TISS PELVIS & HIP AREA 27050 ARTHROTOMY W/BX; SACROILIAC JT 27052 ARTHROTOMY W/BX; HIP JT 27054 ARTHROTOMY W/SYNOVECTOMY HIP JT 27060 EXC; ISCHIAL BURSA 27062 EXC; TROCH BURSA/CALCIFICATION 27065 EXC BONE CYST/BEN TUMOR; SUPERF W/WO AUTOGFT 27066 EXC BONE CYST/BEN TUMOR; DEEP W/WO AUTOGFT 27067 EXC BONE CYST/TUMOR; W/AUTOGFT REQ SEPART INCS 27070 PART EXC; SUPERF-ILIUM/PUBIS/GRT TROCH FEMUR 27071 PART EXC; DEEP-ILIUM/PUBIS/GRT TROCH FEMUR 27075 RAD RESECT TUMOR/INFEC; WING ILIUM 1 RAMUS/PUBIS 27076 RAD RESECT TUMOR; ILIUM W/ACETABULUM BOTH RAMI 27077 RADICAL RESECT TUMOR/INFEC; INNOMINATE BONE TOT 27078 RAD RESECT TUMOR; ISCHIAL TUBER GRTR TROCHANTER 27079 RAD RESECT TUMR; ISCH TUB GRTR TROCH W/SKIN FLAP 27080 COCCYGECTOMY PRIM * 27086 REMOV FB PELVIS/HIP; SUBQ TISS 27087 REMOV FB PELVIS/HIP; DEEP 27090 REMOV HIP PROSTH; (SEPART PROC) 27091 REMOV HIP PROSTH; COMPLIC INCL 'TOT HIP' 27093 INJ PROC HIP ARTHROGRAPHY; WO ANES 27095 INJ PROC HIP ARTHROGRAPHY; W/ANES 27096 INJECTION PROC FOR SACROILIAC JOINT 27097 HAMSTRING RECESSION PROX 27098 ADDUCTOR TRANSF TO ISCHIUM 27100 TRANSF EXT OBLIQ MUSCL-GR TROCH INCL TENDN EXTEN 27105 TRANSF PARASPINAL MUSCL TO HIP 27110 TRANSF ILIOPSOAS; TO GREATER TROCH 27111 TRANSF ILIOPSOAS; TO FEMORAL NECK 27120 ACETABULOPLASTY 27122 ACETABULOPLASTY; RESECT FEMORAL HEAD 27125 PART HIP REPLAC PROSTH 27130 ARTHROPLASTY ACETABULAR & PROX FEM PROSTH REPLAC 27132 CONVERSION PREV HIP TO TOTAL HIP REPLAC W/WO GFT 27134 REVIS TOT HIP ARTHROPLASTY; BOTH COMPON W/WO GFT 27137 REVIS TOT HIP ARTHROPLASTY; ACETABULAR ONLY 27138 REVIS TOT HIP ARTHROPLASTY; FEMORAL ONLY W/WO GF 27140 OSTEOTOMY & TRANSF GREATER TROCH (SEPART PROC) 27146 OSTEOTOMY ILIAC/ACETABULAR/INNOMINATE BONE 27147 OSTEOTOMY ILIAC/ACETAB/INNOMIN; W/OPEN REDUC HIP

$1,798

90

$131

10

$437

90

$426

90

$1,201

90

$3,384

90

$655

90

$1,528

90

$2,402

90

$655

90

$677

90

$873

90

$1,463

90

$1,725

90

$764

90

$1,419

90

$2,620

90

$3,275

90

$4,367

90

$1,310

90

$1,965

90

$873

90

$131

10

$655

90

$1,288

90

$3,384

90

$175

0

$262

0

$659

0

$1,528

90

$1,747

90

$2,184

90

$2,184

90

$2,729

90

$1,747

90

$2,620

90

$2,184

90

$2,948

90

$4,149

90

$4,913

90

$5,350

90

$4,258

90

$4,258

90

$1,092

90

$2,184

90

$2,839

90

Section VII: Surgical Services

Page 87

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

27151 OSTEOTOMY ILIAC/ACETAB/INNOMIN; W/FEM OSTEOTOMY 27156 OSTEOTOMY ILIAC; W/FEM OSTEOT & W/OPEN REDUC HIP 27158 OSTEOTOMY PELVIS BILAT 27161 OSTEOTOMY FEMORAL NECK (SEPART PROC) 27165 OSTEOTOMY INTER-/SUBTROCH INCL INT/EXT FIX/CAST 27170 BONE GFT FEM HEAD/NECK/INTER-SUBTROCH AREA 27175 TX SLIPPED FEMORAL EPIPHYSIS; BY TRACT WO REDUCT 27176 TX SLIPPED FEMORAL EPIPHYSIS; BY SNGL/MX PINNING 27177 OPEN TX SLIP'D FEM EPIPHYS; SNGL/MX PIN/BONE GFT 27178 OPEN TX SLIP'D FEM EPIPHYS; CLO MANIP W/PINNING 27179 OPEN TX SLIP'D FEM EPIPHYS; OSTEOPLASTY FEM NECK 27181 OPEN TX SLIP'D FEM EPIPHYS; OSTEOTOMY & INT FIXA 27185 EPIPHYSEAL ARREST-EPIPHYSIODESIS/STAPL GRT TROCH 27187 PROPHYLACTIC TX FEMORAL NECK & PROX FEMUR 27193 CLO TX PELVIC RING FX/DISLOC/DIASTASIS; WO MANIP 27194 CLO TX PELVIC RING FX/DISLOC; W/MANIP W/ANES 27200 CLO TX COCCYGEAL FX 27202 OPEN TX COCCYGEAL FX 27215 OPEN TX ILIAC SPINE/WING FX W/INT FIXA 27216 PERCUT SKELETAL FIX POST PELVIC RING FX/DISLOC 27217 OPEN TX ANT RING FX &/OR DISLOC W/INT FIXA 27218 OPEN TX POST RING FX &/OR DISLOC W/INT FIXA 27220 CLO TX ACETABULUM FX; WO MANIP 27222 CLO TX ACETAB FX; W/MANIP W/WO SKELETAL TRACT 27226 OPEN TX POST/ANT ACETABULAR WALL FX W/INT FIXA 27227 OPEN TX ACETAB FX INVOL ANT/POST COLUM W/INT FIX 27228 OPEN TX ACETAB FX W/T-FX W/INT FIXA 27230 CLO TX FEMORAL FX PROX END NECK; WO MANIP 27232 CLO TX FEM FX PROX END NECK; W/MANIP W/WO TRACT 27235 PERCUT SKELET FIX FEM FX PROX END NECK-DISPLACED 27236 OPEN TX FEM FX PROX END NECK INT FIX/PROS REPLAC 27238 CLO TX INTER-/PER-/SUBTROCH FEM FX; WO MANIP 27240 CLO TX INTER/PER/SUB-TROCHANTER FEM FX; W/MANIP 27244 OPEN TX INTERTROCH FEM FX; W/IMPLNT W/WO CERCLAG 27245 OPEN TX INTERTROCH FEM FX; W/IMPLNT W/WO SCREWS 27246 CLO TX GREATER TROCH FX WO MANIP 27248 OPEN TX GREATER TROCH FX W/WO INT/EXT FIXA 27250 CLO TX HIP DISLOC TRAUMATIC; WO ANES 27252 CLO TX HIP DISLOC TRAUMATIC; REQUIRING ANES 27253 OPEN TX HIP DISLOC TRAUMATIC WO INT FIXA 27254 OPEN TX HIP DISLOC TRAUMA W/ACETAB & FEM HEAD FX * 27256 TX SPONTAN HIP DISLOC-ABDUCTION; WO ANES/MANIP * 27257 TX SPONTAN HIP DISLOC-ABDUCT; W/MANIP REQ ANES 27258 OPEN TX SPONTAN HIP DISLOC REPLA FEM HEAD ACETAB 27259 OPEN TX SPONTAN HIP DISLOC; W/FEM SHAFT SHORTEN 27265 CLO TX POST HIP ARTHROPLASTY DISLOC; WO ANES

$2,839

90

$3,166

90

$3,275

90

$2,074

90

$2,686

90

$2,620

90

$1,528

90

$2,184

90

$2,511

90

$2,620

90

$1,856

90

$2,620

90

$1,201

90

$2,402

90

$499

90

$834

90

$225

90

$345

90

$1,755

90

$805

90

$1,841

90

$2,023

90

$479

90

$1,055

90

$1,592

90

$2,071

90

$3,643

90

$513

90

$1,055

90

$2,057

90

$2,129

90

$537

90

$767

90

$1,985

90

$2,176

90

$345

90

$671

90

$479

90

$719

90

$1,438

90

$1,918

90

$786

10

$959

10

$1,803

90

$2,109

90

$479

90

Section VII: Surgical Services

Page 88

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

27266 CLO TX HIP ARTHROPLSTY DISLOC; W/REGION/GEN ANES * 27275 MANIP HIP JT REQUIRING GEN ANES
27280 ARTHRODESIS SACROILIAC JT 27282 ARTHRODESIS SYMPHYSIS PUBIS 27284 ARTHRODESIS HIP JT 27286 ARTHRODESIS HIP JT; W/SUBTROCH OSTEOTOMY 27290 INTERPELVIABDOMINAL AMPUTA 27295 DIASART HIP 27299 UNLISTED PROC PELVIS/HIP JT 27301 I&D DEEP ABSCESS INFEC BURSA/HEMATOMA THIGH/KNEE 27303 INCS DEEP W/OPEN BONE CORTEX/FEMUR/KNEE 27305 FASCIOTOMY ILIOTIBIAL OPEN 27306 TENOTOMY SUBQ CLO ADDUCTOR (SEPART PROC); SNGL 27307 TENOTOMY SUBQ CLO ADDUCTOR (SEPART PROC); MX 27310 ARTHROTOMY KNEE-INFEC W/EXPLOR/DRAIN/REMOV FB 27315 NEURECTOMY HAMSTRING MUSCL 27320 NEURECTOMY POP 27323 BX SOFT TISS THIGH/KNEE AREA; SUPERF 27324 BX SOFT TISS THIGH/KNEE AREA; DEEP 27327 EXC TUMOR THIGH/KNEE AREA; SUBQ 27328 EXC TUMOR THIGH/KNEE; DEEP/SUBFASCIAL/IM 27329 RADICAL RESECT TUMOR SOFT TISS THIGH/KNEE AREA 27330 ARTHROTOMY KNEE; W/SYNOVIAL BX ONLY 27331 ARTHROTOMY KNEE; W/JT EXPLOR W/WO BX/REMOV FB 27332 ARTHROTOMY KNEE W/MENISECTOMY; MEDIAL/LAT 27333 ARTHROTOMY KNEE W/MENISECTOMY; MEDIAL & LAT 27334 ARTHROTOMY KNEE W/SYNOVECTOMY; ANT/POST 27335 ARTHROTOMY KNEE W/SYNOVEC; ANT & POST INCL POP 27340 EXC PREPATELLAR BURSA 27345 EXC SYNOVIAL CYST POP SPACE 27347 REMOVE KNEE CYST 27350 PATELLECTOMY/HEMIPATELLECTOMY 27355 EXC/CURET BONE CYST/BEN TUMOR FEMUR 27356 EXC/CURET BONE CYST/BEN TUMOR FEMUR; W/ALLOGFT 27357 EXC/CURET BONE CYST/BEN TUMOR FEMUR; W/AUTOGFT 27358 EXC/CURET BONE CYST/BEN TUMOR W/INT FIXA 27360 PART EXC BONE FEMUR PROX TIBIA &/OR FIBULA 27365 RADICAL RESECT TUMOR BONE FEMUR/KNEE 27370 INJ PROC KNEE ARTHROGRAPHY 27372 REMOV FB DEEP THIGH REGION/KNEE AREA 27380 SUTURE INFRAPATELLAR TENDON; PRIM 27381 SUTURE INFRAPATELLAR TENDON; 2ND RECON INCL GFT 27385 SUTURE QUADRICEPS/HAMSTRING MUSCL RUPT; PRIM 27386 SUTURE QUADRICEPS MUSCL RUPT; 2ND RECON INCL GFT 27390 TENOTOMY OPEN HAMSTRING KNEE TO HIP; SNGL 27391 TENOTOMY OPEN HAMSTRING KNEE TO HIP; MX 1 LEG

$719

90

$403

10

$1,779

90

$1,726

90

$2,397

90

$2,493

90

$3,452

90

$2,876

90

BR

N/A

$446

90

$743

90

$637

90

$424

90

$637

90

$1,273

90

$1,061

90

$1,061

90

$127

10

$530

90

$361

90

$721

90

$3,077

90

$1,167

90

$1,337

90

$1,591

90

$2,334

90

$1,697

90

$1,952

90

$658

90

$955

90

$768

90

$1,422

90

$1,167

90

$1,379

90

$1,591

90

$796

N/A

$1,167

90

$3,077

90

$117

0

$530

90

$1,109

90

$1,465

90

$1,360

90

$1,674

90

$523

90

$837

90

Section VII: Surgical Services

Page 89

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

27392 TENOTOMY OPEN HAMSTRING KNEE TO HIP; MX BILAT 27393 LENGTHENING HAMSTRING TENDON; SNGL 27394 LENGTHENING HAMSTRING TENDON; MX 1 LEG 27395 LENGTHENING HAMSTRING TENDON; MX BILAT 27396 TRANSPL HAMSTRING TENDON TO PATELLA; SNGL 27397 TRANSPL HAMSTRING TENDON TO PATELLA; MX 27400 TENDON/MUSCL TRANSF HAMSTRINGS TO FEMUR 27403 ARTHROTOMY W/OPEN MENISCUS REPR 27405 REPR PRIM TORN LIGAMNT/CAPSULE KNEE; COLLATERAL 27407 REPR PRIM TORN LIGAMNT/CAPSULE KNEE; CRUCIATE 27409 REPR PRIM TORN LIGAM KNEE; COLLATERAL & CRUCIATE 27418 ANT TIBIAL TUBERCLEPLASTY 27420 RECON RECURRENT DISLOC PATELLA 27422 RECON RECURRENT DISLOC PATELLA; W/EXTENS REALIGN 27424 RECON RECURRENT DISLOC PATELLA; W/PATELLECTOMY 27425 LAT RETINACULAR RELEASE 27427 LIGAMNT RECON KNEE; EXTRA-ARTICULAR 27428 LIGAMNT RECON KNEE; INTRA-ARTICULAR 27429 LIGAMNT RECON KNEE; INTRA & EXTRA-ARTICULAR 27430 QUADRICEPSPLASTY 27435 CAPSULOTOMY KNEE POST CAPSULAR RELEASE 27437 ARTHROPLASTY PATELLA; WO PROSTH 27438 ARTHROPLASTY PATELLA; W/PROSTH 27440 ARTHROPLASTY KNEE TIBIAL PLATEAU 27441 ARTHROPLASTY KNEE TIB PLATEAU; W/DEBRID/SYNOVECT 27442 ARTHROPLASTY KNEE FEMORAL CONDYLES/TIB PLATEAUS 27443 ARTHROPLASTY KNEE FEM CONDYLES; W/DEBRID/SYNOVEC 27445 ARTHROPLASTY KNEE CONSTRAINED PROSTH 27446 ARTHROPLASTY KNEE CONDYLE & PLATEAU; MEDIAL/LAT 27447 ARTHROPLASTY KNEE CONDYLE & PLATEAU; MED & LAT 27448 OSTEOTOMY FEMUR SHAFT/SUPRACONDYLAR; WO FIXA 27450 OSTEOTOMY FEMUR SHAFT/SUPRACONDYLAR; W/FIXA 27454 OSTEOTOMY MX FEM SHAFT W/REALIGN INTRAMEDUL ROD 27455 OSTEOTOMY PROX TIBIA; BEFORE EPIPHYSEAL CLO 27457 OSTEOTOMY PROX TIBIA; AFTER EPIPHYSEAL CLO 27465 OSTEOPLASTY FEMUR; SHORTENING 27466 OSTEOPLASTY FEMUR; LENGTHENING 27468 OSTEOPLASTY FEMUR; COMBO LENGTHEN & SHORTEN 27470 REPR NON-MALUNION FEMUR DISTAL; WO GFT 27472 REPR NON-/MALUNION FEMUR; W/ILIAC/AUTOGEN GFT 27475 EPIPHYSEAL ARREST BY STAPLING; DISTAL FEMUR 27477 EPIPHYSEAL ARREST BY STAPLING; TIBIA & FIBULA 27479 EPIPHYSEAL ARREST; COMBO DIST FEMUR PROX TIB/FIB 27485 ARREST HEMIEPIPHYSEAL DISTAL FEMUR/PROX LEG 27486 REVIS TOT KNEE ARTHROPL W/WO ALLOGFT; 1 COMPON 27487 REVIS TOT KNEE ARTHROPL W/WO ALLOGFT; ALL COMPON

$1,256

90

$628

90

$1,046

90

$1,465

90

$1,256

90

$1,465

90

$1,256

90

$1,674

90

$1,643

90

$1,883

90

$2,197

90

$2,197

90

$1,737

90

$1,800

90

$1,883

90

$1,570

90

$2,511

90

$2,972

90

$2,930

90

$1,465

90

$1,256

90

$1,465

90

$1,674

90

$1,779

90

$2,093

90

$1,883

90

$2,302

90

$3,139

90

$3,055

90

$3,934

90

$1,674

90

$1,883

90

$2,093

90

$1,674

90

$1,946

90

$2,093

90

$2,930

90

$3,767

90

$2,093

90

$2,407

90

$1,988

90

$2,197

90

$2,511

90

$1,570

90

$3,139

90

$4,604

90

Section VII: Surgical Services

Page 90

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

27488 REMOV KNEE PROSTH INCL 'TOT KNEE' 27495 PROPHYLACTIC TX W/WO METHYLMETHACRYLATE FEMUR 27496 DECOMP FASCIOTOMY THIGH &/OR KNEE 1 COMPART 27497 DECOMP FASCIOT THIGH/KNEE 1 COMPART; W/DEBRID 27498 DECOMP FASCIOTOMY THIGH &/OR KNEE MX COMPART 27499 DECOMP FASCIOT THIGH/KNEE MX COMPART; W/DEBRID 27500 CLO TX FEMORAL SHAFT FX WO MANIP 27501 CLO TX SUPRA-/TRANSCONDYLAR FEMORAL FX WO MANIP 27502 CLO TX FEMORAL SHAFT FX W/MANIP W/WO TRACTION 27503 CLO TX SUPRA/TRANSCONDYLAR FEM FX W/MANIP 27506 OPEN TX FEM SHFT FX W/WO FIX W/IMPLNT W/WO SCREW 27507 OPEN TX FEM SHAFT FX W/PLATE/SCREWS W/WO CERCLAG 27508 CLO TX FEM FX DIST END MED/LAT CONYLE WO MANIP 27509 PERCUT SKELET FIX FEM FX DISTAL/FEM EPIPHYSL SEP 27510 CLO TX FEM FX DIST END MED/LAT CONDYLE W/MANIP 27511 OPEN TX FEM SUPRACONDYL FX WO INTERCONDYL EXTEN 27513 OPEN TX FEM SUPRACONDYL FX W/INTERCONDYLAR EXTEN 27514 OPEN TX FEM FX DIST END MED/LAT CONDYLE W/WO FIX 27516 CLO TX DIST FEMORAL EPIPHYSEAL SEPART; WO MANIP 27517 CLO TX FEM EPIPHYSEAL SEPART; W/MANIP W/WO TRACT 27519 OPEN TX DIST FEMORAL EPIPHYSEAL SEPART W/WO FIXA 27520 CLO TX PATELLAR FX WO MANIP 27524 OPEN TX PATELLA FX W/FIX PART/COMPLT PATELLECTMY 27530 CLO TX TIBIAL FX PROX; WO MANIP 27532 CLO TX TIB FX PROX; W/WO MANIP W/SKELETAL TRACT 27535 OPEN TX TIB FX PROX; UNICONDYL W/WO INT/EXT FIXA 27536 OPEN TX TIBIAL FX PROX; BICONDYLAR W/WO INT FIXA 27538 CLO TX INTERCOND SPINE/TUBEROS FX KNEE W/WO MANI 27540 OPEN TX INTERCOND SPINE/TUBEROS FX KNEE W/WO FIX 27550 CLO TX KNEE DISLOC; WO ANES 27552 CLO TX KNEE DISLOC; REQUIRING ANES 27556 OPEN TX KNEE DISLO W/WO FIX; WO PRI LIGAMNT REPR 27557 OPEN TX KNEE DISLO W/WO FIX; W/PRIM LIGAMNT REPR 27558 OPEN TX KNEE DISLO; W/PRIM LIGAMNT REPR W/AUGMEN 27560 CLO TX PATELLAR DISLOC; WO ANES 27562 CLO TX PATELLAR DISLOC; REQUIRING ANES 27566 OPEN TX PATELLA DISLOC W/WO PART/TOT PATELLECTMY * 27570 MANIP KNEE JT UNDER GEN ANES 27580 FUSION KNEE ANY TECH 27590 AMPUTA THIGH THRU FEMUR ANY LEVEL 27591 AMPUTA THIGH THRU FEMUR; IMMED FIT INCL 1ST CAST 27592 AMPUTA THIGH THRU FEMUR ANY LEVEL; OPEN CIRCULAR 27594 AMPUTA THIGH FEMUR; SECNDRY CLO/SCAR REVIS 27596 AMPUTA THIGH THRU FEMUR ANY LEVEL; RE-AMPUTA 27598 DIASART AT KNEE 27599 UNLISTED PROC FEMUR/KNEE

$2,511

90

$1,779

90

$670

90

$900

90

$942

90

$1,172

90

$666

90

$818

90

$951

90

$1,142

90

$2,188

90

$1,998

90

$571

90

$1,161

90

$818

90

$1,998

90

$2,283

90

$2,036

90

$628

90

$799

90

$1,712

90

$338

90

$1,303

90

$438

90

$590

90

$1,446

90

$1,608

90

$495

90

$1,427

90

$304

90

$457

90

$1,598

90

$2,340

90

$2,740

90

$238

90

$357

90

$1,142

90

$323

10

$1,903

90

$1,389

90

$1,427

90

$1,712

90

$571

90

$1,332

90

$1,522

90

BR

N/A

Section VII: Surgical Services

Page 91

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

27600 DECOMP FASCIOTOMY LEG; ANT &/OR LAT COMPART ONLY 27601 DECOMP FASCIOTOMY LEG; POST COMPART ONLY 27602 DECOMP FASCIOT LEG; ANT &/ LAT & POST COMPART 27603 I&D LEG/ANK; DEEP ABSCESS/HEMATOMA 27604 I&D LEG/ANK; INFEC BURSA * 27605 TENOTOMY ACHILLES SUBQ (SEPART PROC); LOCAL ANES 27606 TENOTOMY ACHILLES SUBQ (SEPART PROC); GEN ANES 27607 INCS DEEP W/OPEN BONE CORTEX LEG/ANK 27610 ARTHROTOMY ANK-INFEC-W/EXPLOR/DRAIN/REMOV FB 27612 ARTHROTOMY ANK W/WO ACHILLES TENDON LENGTHENING 27613 BX SOFT TISS LEG/ANK AREA; SUPERF 27614 BX SOFT TISS LEG/ANK AREA; DEEP 27615 RADICAL RESECT TUMOR SOFT TISS LEG/ANK AREA 27618 EXC TUMOR LEG/ANK AREA; SUBQ 27619 EXC TUMOR LEG/ANK AREA; DEEP/SUBFASCIAL/IM 27620 ARTHROTOMY ANK W/JT EXPLOR W/WO BX-REMOV FB 27625 ARTHROTOMY ANK W/SYNOVECTOMY; 27626 ARTHROTOMY ANK W/SYNOVECTOMY; INCL TENOSYNOVECT 27630 EXC LES TENDON SHEATH/CAPSULE LEG &/OR ANK 27635 EXC/CURET BONE CYST/BEN TUMOR TIBIA/FIBULA 27637 EXC/CURET BONE CYST/BEN TUMOR TIB/FIB; W/AUTOGFT 27638 EXC/CURET BONE CYST/BEN TUMOR TIB/FIB; W/ALLOGFT 27640 PART EXC BONE; TIBIA 27641 PART EXC BONE; FIBULA 27645 RADICAL RESECT BONE TUMOR; TIBIA 27646 RADICAL RESECT BONE TUMOR; FIBULA 27647 RADICAL RESECT BONE TUMOR; TALUS/CALCAN 27648 INJ PROC ANK ARTHROGRAPHY 27650 REPR PRIM OP/PERCUT RUPT ACHILLES TENDON 27652 REPR PRIM OP/PERCUT RUPT ACHILLES TENDON; W/GFT 27654 REPR SECNDRY RUPT ACHILLES TENDON W/WO GFT 27656 REPR FASCIAL DEFECT LEG 27658 REPR/SUTURE FLEXOR TENDON LEG; PRIM WO GFT 1 EA 27659 REPR/SUTURE FLEXOR TENDON LEG; 2ND W/WO GFT 1 EA 27664 REPR/SUTURE EXTENSOR TENDON LEG; PRIM WO GFT 1 27665 REPR/SUTURE EXTENSOR TENDON LEG; 2ND W/WO GFT 1 27675 REPR DISLOC PERONEAL TENDONS; WO FIB OSTEOTOMY 27676 REPR DISLOC PERONEAL TENDONS; W/FIB OSTEOTOMY 27680 TENOLYSIS INCL TIBIA FIBULA & ANK FLEXOR; SNGL 27681 TENOLYSIS INCL TIB/FIB & ANK FLEXOR; MX EA 27685 LENGTHEN/SHORTEN TENDON LEG/ANK; 1 (SEPART PROC) 27686 LENGTHEN/SHORTEN TENDON LEG/ANK; MX EA 27687 GASTROCNEMIUS RECESSION 27690 TRANSF/TRANSPL SNGL TENDON; SUPERF 27691 TRANSF/TRANSPL SNGL TENDON; DEEP 27692 TRANSF/TRANSPL SNGL TENDON; EA ADD TENDON

$673

90

$718

90

$987

90

$538

90

$202

90

$292

10

$449

10

$897

90

$1,144

90

$1,122

90

$269

10

$494

90

$2,513

90

$381

90

$763

90

$1,211

90

$1,570

90

$1,570

90

$572

90

$1,256

90

$1,683

90

$1,570

90

$1,503

90

$1,346

90

$1,795

90

$1,570

90

$1,683

90

$135

0

$1,391

90

$1,660

90

$1,570

90

$673

90

$785

90

$1,010

90

$561

90

$785

90

$673

90

$785

90

$673

90

$897

90

$808

90

$897

90

$785

90

$1,122

90

$1,458

90

$224

N/A

Section VII: Surgical Services

Page 92

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

27695 SUTURE PRIM TORN/RUPT/SEVERD LIG ANK; COLLATERAL 27696 SUTURE PRIM TORN/RUPT LIG ANK; BOTH COLLATERAL 27698 SUTURE SECNDRY REPR TORN/RUPT LIG ANK COLLATERAL 27700 ARTHROPLASTY ANK 27702 ARTHROPLASTY ANK; W/IMPLNT 27703 ARTHROPLASTY ANK; SECNDRY RECON TOT ANK 27704 REMOV ANK IMPLNT 27705 OSTEOTOMY; TIBIA 27707 OSTEOTOMY; FIBULA 27709 OSTEOTOMY; TIBIA & FIBULA 27712 OSTEOTOMY; MX W/REALIGNMENT INTRAMEDULLARY ROD 27715 OSTEOPLASTY TIBIA & FIBULA LENGTHENING 27720 REPR NONUNION/MALUNION TIBIA; WO GFT 27722 REPR NONUNION/MALUNION TIBIA; W/SLIDING GFT 27724 REPR NON/MALUNION TIBIA; W/ILIAC-OTHER AUTOGFT 27725 REPR NON/MALUNION TIBIA; BY SYNOSTOSIS W/FIBULA 27727 REPR CONGEN PSEUDARTHROSIS TIBIA 27730 EPIPHYSEAL ARREST-EPIPHYSIODESIS/STAPL; DIST TIB 27732 EPIPHYSEAL ARREST-EPIPHYSIODESIS/STAPLL DIST FIB 27734 EPIPHYSEAL ARREST-EPIPHYSIODESIS; DIST TIB & FIB 27740 EPIPHYSEAL ARREST COMBO PROX & DIST TIB & FIB 27742 EPIPHYSEAL ARREST PROX-DIST TIB-FIB; & DIST FEMR 27745 PROPHYLACTIC TX W/WO METHYLMETHACRYLATE TIBIA 27750 CLO TX TIBIAL SHAFT FX; WO MANIP 27752 CLO TX TIB SHAFT FX; W/MANIP W/WO SKELETAL TRACT 27756 PERCUT SKELETAL FIXA TIBIAL SHAFT FX 27758 OPEN TX TIB SHAFT FX W/PLATE/SCREWS W/WO CERCLAG 27759 OPEN TX TIB SHAFT FX-IMPLNT-W/WO SCREWS/CERCLAGE 27760 CLO TX MEDIAL MALLEOLUS FX; WO MANIP 27762 CLO TX MED MALLEOLUS FX; W/MANIP W/WO TRACTION 27766 OPEN TX MEDIAL MALLEOLUS FX W/WO INT/EXT FIXA 27780 CLO TX PROX FIBULA/SHAFT FX; WO MANIP 27781 CLO TX PROX FIBULA/SHAFT FX; W/MANIP 27784 OPEN TX PROX FIBULA/SHAFT FX W/WO INT/EXT FIXA 27786 CLO TX DISTAL FIBULAR FX; WO MANIP 27788 CLO TX DISTAL FIBULAR FX; W/MANIP 27792 OPEN TX DISTAL FIBULAR FX W/WO INT/EXT FIXA 27808 CLO TX BIMALLEOLAR ANK FX; WO MANIP 27810 CLO TX BIMALLEOLAR ANK FX; W/MANIP 27814 OPEN TX BIMALLEOLAR ANK FX W/WO INT/EXT FIXA 27816 CLO TX TRIMALLEOLAR ANK FX; WO MANIP 27818 CLO TX TRIMALLEOLAR ANK FX; W/MANIP 27822 OPEN TX TRIMALLEOLR FX MED/LAT; WO FIXA POST LIP 27823 OPEN TX TRIMALLEOLAR FX MED/LAT; W/FIXA POST LIP 27824 CLO TX FX WT BEARING ARTICUL-DIST TIB; WO MANIP 27825 CLO TX FX ARTICUL-DIST TIB; W/TRACT/REQ MANIP

$1,279

90

$1,840

90

$1,683

90

$2,243

90

$3,814

90

$3,253

90

$1,234

90

$1,570

90

$785

90

$1,795

90

$2,019

90

$2,692

90

$2,019

90

$2,131

90

$2,356

90

$3,141

90

$2,468

90

$1,122

90

$897

90

$1,570

90

$2,019

90

$2,356

90

$1,907

90

$469

90

$772

90

$1,252

90

$1,773

90

$1,898

90

$349

90

$521

90

$1,001

90

$287

90

$375

90

$980

90

$334

90

$459

90

$1,064

90

$386

90

$730

90

$1,377

90

$428

90

$834

90

$1,606

90

$1,898

90

$428

90

$834

90

Section VII: Surgical Services

Page 93

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

27826 OPEN TX FX WT BEARING DIST TIB W/FIXA; FIB ONLY 27827 OPEN TX FX WT BEARING DIST TIB W/FIX; TIBIA ONLY 27828 OPEN TX FX WT BEARING DIST TIB W/FIX; TIB & FIB 27829 OPEN TX DIST TIBIOFIBULAR JT DISRUPT W/WO FIXA 27830 CLO TX PROX TIBIOFIBULAR JT DISLOC; WO ANES 27831 CLO TX PROX TIBIOFIBULAR JT DISLOC; REQ ANES 27832 OPEN TX PROX TIB-FIB JT DISLOC W/EXC PROX FIBULA 27840 CLO TX ANK DISLOC; WO ANES 27842 CLO TX ANK DISLOC; REQ ANES W/WO PERCUT SKEL FIX 27846 OPEN TX ANK DISLOC W/WO PERCUT SKEL FIX; WO REPR 27848 OPEN TX ANK DISLOC W/WO FIX; W/REPR/INT/EXT FIX * 27860 MANIP ANK UNDER GEN ANES 27870 ARTHRODESIS ANK ANY METHD 27871 ARTHRODESIS TIBIOFIBULAR JT PROX/DISTAL 27880 AMPUTA LEG THRU TIBIA & FIBULA 27881 AMPUTA LEG THRU TIB & FIB; W/IMMED FIT INCL CAST 27882 AMPUTA LEG THRU TIBIA & FIBULA; OPEN CIRCULAR 27884 AMPUTA LEG-TIB & FIB; SECNDRY CLO/SCAR REVIS 27886 AMPUTA LEG THRU TIBIA & FIBULA; RE-AMPUTA 27888 AMPUTA ANK-MALLEOLI W/PLASTIC CLO & RESECT NERV 27889 ANK DIASART 27892 DECOMP FASCIOT LEG; ANT/LAT COMPRT-ONLY W/DEBRID 27893 DECOMP FASCIOT LEG; POST COMPRT ONLY W/DEBRID 27894 DECOMP FASCIOT LEG; ANT/LAT/POST COMPRT W/DEBRID 27899 UNLISTED PROC LEG/ANK * 28001 I&D INFEC BURSA FT * 28002 DEEP DISSECTION BELOW FASCIA; 1 BURSA SPACE-SPEC 28003 DEEP DISSECTION BELOW FASCIA; MX AREAS 28005 INCS DEEP W/OPEN BONE CORTEX FT 28008 FASCIOTOMY FT &/OR TOE 28010 TENOTOMY SUBQ TOE; SNGL 28011 TENOTOMY SUBQ TOE; MX 28020 ARTHROTOMY W/EXPLOR; INTERTARS/TARSOMETATARS JT 28022 ARTHROTOMY W/EXPLOR; METATARSOPHALANGEAL JT 28024 ARTHROTOMY W/EXPLOR; IP JT 28030 NEURECTOMY INTRINSIC MUSCL FT 28035 TARSAL TUNNEL RELEASE 28043 EXC TUMOR FT; SUBQ 28045 EXC TUMOR FT; DEEP/SUBFASCIAL/IM 28046 RADICAL RESECT TUMOR SOFT TISS FT 28050 ARTHROTOMY SYNOVIAL BX; INTERTARSAL/TARSOMETA JT 28052 ARTHROTOMY SYNOVIAL BX; METATARSOPHALANGEAL JT 28054 ARTHROTOMY SYNOVIAL BX; IP JT 28060 FASCIECTOMY EXC PLANTAR FASCIA; PART (SEP PRO) 28062 FASCIECTOMY PLANTAR; RADICAL (SEPART PROC) 28070 SYNOVECTOMY; INTERTARSAL/TARSOMETATARSAL JT EA

$1,669

90

$1,731

90

$1,982

90

$991

90

$271

90

$407

90

$834

90

$282

90

$475

90

$1,252

90

$1,460

90

$282

10

$1,982

90

$1,460

90

$1,408

90

$1,669

90

$1,147

90

$626

90

$1,398

90

$1,460

90

$1,460

90

$897

90

$897

90

$1,168

90

BR

N/A

$141

10

$403

10

$604

90

$644

90

$503

90

$222

90

$302

90

$665

90

$564

90

$463

90

$705

90

$1,007

90

$362

90

$564

90

$2,819

90

$604

90

$503

90

$403

90

$695

90

$1,218

90

$503

90

Section VII: Surgical Services

Page 94

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

28072 SYNOVECTOMY; METATARSOPHALANGEAL JT EA 28080 EXC INTERDIGITAL NEUROMA SNGL EA 28086 SYNOVECTOMY TENDON SHEATH FT; FLEXOR 28088 SYNOVECTOMY TENDON SHEATH FT; EXTENSOR 28090 EXC LES TENDON/FIBROUS SHEATH/CAPSULE; FT 28092 EXC LES TENDON/FIBROUS SHEATH/CAPSULE; TOES 28100 EXC/CURET BONE CYST/BEN TUMOR TALUS/CALCAN 28102 EXC/CURET BONE CYST TALUS/CALCAC; W/ILIAC/AUTOGF 28103 EXC/CURET BONE CYST TALUS/CALCAN; W/ALLOGFT 28104 EXC/CURET BONE CYST TARSAL/METATARS EX TALUS 28106 EXC/CURET BONE CYST TARSAL EX TALUS; W/AUTOGFT 28107 EXC/CURET BONE CYST TARSAL EX TALUS; W/ALLOGFT 28108 EXC/CURET BONE CYST/BEN TUMOR PHALANGES FT 28110 OSTEOTOMY PART EXC 5TH METATARSAL HEAD (SEP PRO) 28111 OSTECTOMY COMPLT EXC; FIRST METATARSAL HEAD 28112 OSTECTOMY COMPLT EXC; OTHER METATARSAL HEAD 28113 OSTECTOMY COMPLT EXC; FIFTH METATARSAL HEAD 28114 OSTECTOMY-COMPLT; ALL METATARS HEADS EXCLD 1ST 28116 OSTECTOMY EXC TARSAL COALITION 28118 OSTECTOMY CALCAN 28119 OSTECTOMY CALCAN; SPUR W/WO PLANTAR FASC RELEASE 28120 PART EXC BONE TALUS/CALCAN 28122 PART EXC BONE TARSAL/METATARS EX TALUS/CALCAN 28124 PART EXC BONE PHALANX TOE 28126 RESECT PART/COMPLT PHALAN BASE-1 TOE EA 28130 TALECTOMY 28140 METATARSECTOMY 28150 PHALANGECTOMY TOE SNGL EA 28153 RESECT HEAD PHALANX TOE 28160 HEMIPHALANGECTOMY/IP JT EXC TOE SNGL EA 28171 RADICAL RESECT BONE TUMOR; TARSAL NOT TALUS/CALC 28173 RADICAL RESECT BONE TUMOR; METATARSAL 28175 RADICAL RESECT BONE TUMOR; PHALANX TOE * 28190 REMOV FB FT; SUBQ 28192 REMOV FB FT; DEEP 28193 REMOV FB FT; COMPLIC 28200 REPR/SUTURE TENDON FT FLEXOR 1; PRIM/2ND EA TEND 28202 REPR/SUTURE TENDON FT FLEXOR 1; 2ND W/GFT EA 28208 REPR/SUTURE TENDON FT EXTENSOR 1; PRIM/2ND EA 28210 REPR/SUTURE TENDON FT EXTENSOR 1; 2ND W/GFT EA 28220 TENOLYSIS FLEXOR FT; SNGL 28222 TENOLYSIS FLEXOR FT; MX 28225 TENOLYSIS EXTENSOR FT; SNGL 28226 TENOLYSIS EXTENSOR FT; MX 28230 TENOTOMY OPEN FLEXOR; FT SNGL/MX (SEPART PROC) 28232 TENOTOMY OPEN FLEXOR; TOE SNGL (SEPART PROC)

$403

90

$544

90

$705

90

$705

90

$493

90

$342

90

$906

90

$1,309

90

$1,007

90

$705

90

$1,007

90

$1,007

90

$503

90

$604

90

$806

90

$604

90

$604

90

$1,309

90

$1,007

90

$846

90

$806

90

$785

90

$685

90

$503

90

$463

90

$1,208

90

$806

90

$564

90

$503

90

$503

90

$1,007

90

$806

90

$564

90

$272

10

$463

90

$665

90

$801

90

$1,012

90

$411

90

$559

90

$632

90

$780

90

$369

90

$485

90

$379

90

$200

90

Section VII: Surgical Services

Page 95

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

28234 TENOTOMY OPEN EXTENSOR FT/TOE 28238 ADVANC POST TIB TENDON W/EXC ACCES NAVICULAR 28240 TENOTOMY LENGTHEN/RELEASE ABDUCTOR HALLUCIS MUSL 28250 DIVISION PLANTAR FASCIA & MUSCL (SEPART PROC) 28260 CAPSULOTOMY MIDFOOT; MEDIAL RELEASE (SEPART PRO) 28261 CAPSULOTOMY MIDFOOT; W/TENDON LENGTHENING 28262 CAPSULOTOMY MIDFT; EXTEN W/POST TALOTIB CAPSULOT 28264 CAPSULOTOMY MIDTARSAL 28270 CAPSULOTOMY; MTP JT-SNGL-EA JT (SEPART PROC) 28272 CAPSULOTOMY; IP JT-SNGL-EA JT (SEPART PROC) 28280 WEBBING OR (CREATE SYNDACTYLISM TOES) 28285 HAMMERTOE OR; 1 TOE 28286 COCK-UP 5TH TOE OR W/PLASTIC SKIN CLO 28288 OSTECTOMY PART SNGL 1ST-5TH EA METATARSAL HEAD 28289 REPAIR HALLUX RIGIDUS 28290 HALLUX VALGUS-W/WO SESAMOIDECT; SIMPL EXOSTECTMY 28292 HALLUX VALGUS; KELLER/MCBRIDE/MAYO TYPE PROC 28293 HALLUX VALGUS-W/WO SESAMOIDEC; RESEC JT W/IMPLNT 28294 HALLUX VALGUS CORRECT; W/TENDON TRANSPL 28296 HALLUX VALGUS CORRECT; W/METATARSAL OSTEOTOMY 28297 HALLUX VALGUS-W/WO SESAMOIDECT; LAPIDUS TYPE PRO 28298 HALLUX VALGUS W/WO SESAMOIDECT; BY PHALANX OSTEC 28299 HALLUX VALGUS-W/WO SESAMOIDECT; BY OTHER METHD 28300 OSTEOTOMY; CALCAN W/WO INT FIXA 28302 OSTEOTOMY; TALUS 28304 OSTEOTOMY MIDTARSAL BONES NOT CALCAN/TALUS 28305 OSTEOT MIDTARSAL NOT CALCAN/TALUS; W/AUTOGFT 28306 OSTEOT METATARSAL BASE/SHAFT SNGL; 1ST METATARS 28307 OSTEOT BASE/SHAFT SNGL; 1ST METATARSAL W/AUTOGFT 28308 OSTEOT BASE/SHAFT SNGL; NOT 1ST METATARSAL 28309 OSTEOTOMY METATARSALS MX CAVUS FT 28310 OSTEOTOMY; PROX PHALANX 1ST TOE (SEPART PROC) 28312 OSTEOTOMY; OTHER PHALANGES ANY TOE 28313 RECON ANGULAR DEFORM TOE SOFT TISS PROC ONLY 28315 SESAMOIDECTOMY FIRST TOE (SEPART PROC) 28320 REPR NONUNION/MALUNION; TARSAL BONES 28322 REPR NON/MALUNION; METATARSAL W/WO BONE GFT 28340 RECON TOE MACRODACTYLY; SOFT TISS RESECT 28341 RECON TOE MACRODACTYLY; REQUIRING BONE RESECT 28344 RECON TOE; POLYDACTYLY 28345 RECON TOE; SYNDACTYLY W/WO SKIN GFT EA WEB 28360 RECON CLEFT FT 28400 CLO TX CALCAN FX; WO MANIP 28405 CLO TX CALCAN FX; W/MANIP 28406 PERCUT SKELETAL FIXA CALCAN FX W/MANIP 28415 OPEN TX CALCAN FX W/WO INT/EXT FIXA

$242

90

$949

90

$464

90

$801

90

$1,054

90

$1,265

90

$1,886

90

$1,370

90

$422

90

$316

90

$527

90

$611

90

$632

90

$632

90

$759

90

$885

90

$1,138

90

$1,286

90

$1,159

90

$1,433

90

$1,265

90

$1,075

90

$1,579

90

$1,117

90

$1,086

90

$970

90

$1,054

90

$906

90

$1,022

90

$696

90

$864

90

$611

90

$506

90

$422

90

$569

90

$843

90

$759

90

$1,294

90

$1,553

90

$776

90

$1,035

90

BR

90

$309

90

$502

90

$676

90

$1,236

90

Section VII: Surgical Services

Page 96

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

28420 OPEN TX CALCAN FX W/WO FIX; W/PRI ILIA/AUTOG GFT 28430 CLO TX TALUS FX; WO MANIP 28435 CLO TX TALUS FX; W/MANIP 28436 PERCUT SKELETAL FIXA TALUS FX W/MANIP 28445 OPEN TX TALUS FX W/WO INT/EXT FIXA 28450 TX TARSAL BONE FX; WO MANIP EA 28455 TX TARSAL BONE FX; W/MANIP EA 28456 PERCUT SKELETAL FIX TARSAL BONE FX W/MANIP EA 28465 OPEN TX TARSAL BONE FX W/WO INT/EXT FIXA EA 28470 CLO TX METATARSAL FX; WO MANIP EA 28475 CLO TX METATARSAL FX; W/MANIP EA 28476 PERCUT SKELETAL FIXA METATARSAL FX W/MANIP EA 28485 OPEN TX METATARSAL FX W/WO INT/EXT FIXA EA 28490 CLO TX FX GREAT TOE PHALANX/PHALANGES; WO MANIP 28495 CLO TX FX GRT TOE PHALANX/PHALANGES; W/MANIP 28496 PERCUT SKELETAL FIX FX GREAT TOE-PHALANX-W/MANIP 28505 OPEN TX FX GREAT TOE-PHALANX/PHALANGES-W/WO FIXA 28510 CLO TX FX PHALANX OTHER THAN GREAT TOE; WO MANIP 28515 CLO TX FX PHALANX NOT GREAT TOE; W/MANIP EA 28525 OPEN TX FX PHALNX NOT GR TOE W/WO INT/EXT FIX EA 28530 CLO TX SESAMOID FX 28531 OPEN TX SESAMOID FX W/WO INT FIXA 28540 CLO TX TARSAL BONE DISLOC-NOT TALOTARS; WO ANES 28545 CLO TX TARSAL BONE DISLOC NOT TALOTARS; W/ANES 28546 PERCUT FIX TARSAL DISLOC-NOT TALOTARS W/MANIP 28555 OPEN TX TARSAL BONE DISLOC W/WO INT/EXT FIXA 28570 CLO TX TALOTARSAL JT DISLOC; WO ANES 28575 CLO TX TALOTARSAL JT DISLOC; REQUIRING ANES 28576 PERCUT SKELETAL FIX TALOTARSAL JT DISLOC W/MANIP 28585 OPEN TX TALOTARSAL JT DISLOC W/WO INT/EXT FIXA 28600 CLO TX TARSOMETATARSAL JT DISLOC; WO ANES 28605 CLO TX TARSOMETATARSAL JT DISLOC; REQUIRING ANES 28606 PERCUT SKELETAL FIX TARSOMETAT JT DISLOC W/MANIP 28615 OPEN TX TARSOMETAT JT DISLOC W/WO INT/EXT FIXA * 28630 CLO TX METATARSOPHALANGEAL JT DISLOC; WO ANES * 28635 CLO TX METATARSOPHALANGEAL JT DISLOC; REQ ANES 28636 PERCUT SKELET FIX METATARSOPHAL JT DISL W/MANIP 28645 OPEN TX METATARSPHAL JT DISLOC W/WO INT/EXT FIXA * 28660 CLO TX IP JT DISLOC; WO ANES * 28665 CLO TX IP JT DISLOC; REQUIRING ANES 28666 PERCUT SKELETAL FIXA IP JT DISLOC W/MANIP 28675 OPEN TX IP JT DISLOC W/WO INT/EXT FIXA 28705 PANTALAR ARTHRODESIS 28715 TRIPLE ARTHRODESIS 28725 SUBTALAR ARTHRODESIS 28730 ARTHRODESIS MIDTARS/TARSOMETAT MX/TRANSVERSE

$1,506

90

$314

90

$425

90

$618

90

$1,236

90

$285

90

$386

90

$579

90

$840

90

$232

90

$319

90

$579

90

$753

90

$130

90

$212

90

$309

90

$497

90

$106

90

$159

90

$406

90

$193

90

$386

90

$193

90

$290

90

$348

90

$744

90

$232

90

$348

90

$464

90

$966

90

$193

90

$290

90

$512

90

$908

90

$155

10

$232

10

$309

10

$483

90

$97

10

$145

10

$174

10

$367

90

$1,931

90

$1,758

90

$1,410

90

$1,197

90

Section VII: Surgical Services

Page 97

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

28735 ARTHRODESIS MIDTARS/TARSOMETAT MX; W/OSTEOTOMY 28737 ARTHRODESIS MIDTARSAL W/TENDON LENGTHEN/ADVANCE 28740 ARTHRODESIS MIDTARSAL/TARSOMETATARSAL SNGL 28750 ARTHRODESIS GREAT TOE; METATARSOPHALANGEAL JT 28755 ARTHRODESIS GREAT TOE; IP JT 28760 ARTHRODESIS GREAT TOE IP JT W/EXTENSOR TRANSF 28800 AMPUTA FT; MIDTARSAL 28805 AMPUTA FT; TRANSMETATARSAL 28810 AMPUTA METATARSAL W/TOE SNGL 28820 AMPUTA TOE; METATARSOPHALANGEAL JT 28825 AMPUTA TOE; IP JT 28899 UNLISTED PROC FT/TOES 29000 APPLIC HALO TYPE BODY CAST 29010 APPLIC RISSER JACKET LOCALIZ BODY; ONLY 29015 APPLIC RISSER JACKET LOCALIZ BODY; INCL HEAD 29020 APPLIC TURNBUCKLE JACKET BODY; ONLY 29025 APPLIC TURNBUCKLE JACKET BODY; INCL HEAD 29035 APPLIC BODY CAST SHOULDER TO HIPS 29040 APPLIC BODY CAST SHOULDR-HIPS; INCL HEAD-MINERVA 29044 APPLIC BODY CAST SHOULDER TO HIPS; INCL 1 THIGH 29046 APPLIC BODY CAST SHOULDER-HIPS; INCL BOTH THIGHS 29049 APPLIC; PLASTER FIGURE-8 29055 APPLIC; SHOULDER SPICA 29058 APPLIC; PLASTER VELPEAU 29065 APPLIC; SHOULDER TO HAND 29075 APPLIC; ELBOW TO FINGER 29085 APPLIC; HAND & LOWER FOREARM 29105 APPLIC LONG ARM SPLINT 29125 APPLIC SHORT ARM SPLINT; STATIC 29126 APPLIC SHORT ARM SPLINT; DYNAMIC 29130 APPLIC FINGER SPLINT; STATIC 29131 APPLIC FINGER SPLINT; DYNAMIC 29200 STRAPPING; THORAX 29220 STRAPPING; LOW BACK 29240 STRAPPING; SHOULDER 29260 STRAPPING; ELBOW/WRIST 29280 STRAPPING; HAND/FINGER 29305 APPLIC HIP SPICA CAST; 1 LEG 29325 APPLIC HIP SPICA CAST; 1-1/2 SPICA/BOTH LEGS 29345 APPLIC LONG LEG CAST 29355 APPLIC LONG LEG CAST; WALKER/AMBULATORY TYPE 29358 APPLIC LONG LEG CAST BRACE 29365 APPLIC CYLINDER CAST 29405 APPLIC SHORT LEG CAST 29425 APPLIC SHORT LEG CAST; WALKING/AMB TYPE 29435 APPLIC PATELLAR TENDON BEARING CAST

$1,352

90

$1,159

90

$927

90

$850

90

$599

90

$763

90

$966

90

$966

90

$676

90

$502

90

$444

90

BR

N/A

$450

0

$360

0

$450

0

$360

0

$450

0

$180

0

$270

0

$216

0

$252

0

$90

0

$180

0

$108

0

$99

0

$76

0

$72

0

$63

0

$54

0

$72

0

$36

0

$63

0

$36

0

$54

0

$36

0

$31

0

$27

0

$252

0

$306

0

$130

0

$144

0

$252

0

$117

0

$108

0

$126

0

$162

0

Section VII: Surgical Services

Page 98

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

29440 ADD WALKER TO PREV APPLIC CAST 29445 APPLIC RIGID TOT CONTACT LEG CAST 29450 APPLIC CLUBFT CAST W/MOLDING/MANIP LONG/SHORT 29505 APPLIC LONG LEG SPLINT 29515 APPLIC SHORT LEG SPLINT 29520 STRAPPING; HIP 29530 STRAPPING; KNEE 29540 STRAPPING; ANK 29550 STRAPPING; TOES 29580 STRAPPING; UNNA BOOT 29590 DENIS-BROWNE SPLINT STRAPPING 29700 REMOV/BIVALVING; GAUNTLET BOOT BODY CAST 29705 REMOV/BIVALVING; FULL ARM FULL LEG CAST 29710 REMOV/BIVALV; SHOULDR/HIP SPICA MINERVA/RISSER 29715 REMOV/BIVALVING; TURNBUCKLE JACKET 29720 REPR SPICA BODY CAST/JACKET 29730 WINDOWING CAST 29740 WEDGING CAST 29750 WEDGING CLUBFT CAST 29799 UNLISTED PROC CASTING/STRAPPING 29800 ARTHROSCOPY-TMJ-DX W/WO SYNOVIAL BX (SEP PRO) 29804 ARTHROSCOPY TEMPOROMANDIBULAR JT SURG 29815 ARTHROSCOPY SHOULDER DX W/WO BX (SEPART PROC) 29819 ARTHROSCOPY SHOULDER SURG; W/REMOV LOOSE/FB 29820 ARTHROSCOPY SHOULDER SURG; SYNOVECTOMY PART 29821 ARTHROSCOPY SHOULDER SURG; SYNOVECTOMY COMPLT 29822 ARTHROSCOPY SHOULDER SURG; DEBRID LTD 29823 ARTHROSCOPY SHOULDER SURG; DEBRID EXTEN 29825 ARTHROSCOPY SHOULDER SURG; W/LYSIS ADHESIONS 29826 ARTHROSCOPY SHOULDER SURG; DECOMP SUBACROM SPACE 29830 ARTHROSCOPY ELBOW DX W/WO SYNOVIAL BX (SEP PRO) 29834 ARTHROSCOPY ELBOW SURG; W/REMOV LOOSE/FB 29835 ARTHROSCOPY ELBOW SURG; SYNOVECTOMY PART 29836 ARTHROSCOPY ELBOW SURG; SYNOVECTOMY COMPLT 29837 ARTHROSCOPY ELBOW SURG; DEBRID LTD 29838 ARTHROSCOPY ELBOW SURG; DEBRID EXTEN 29840 ARTHROSCOPY WRIST DX W/WO SYNOVIAL BX (SEP PRO) 29843 ARTHROSCOPY WRIST SURG; INFEC/LAVAGE & DRAINAGE 29844 ARTHROSCOPY WRIST SURG; SYNOVECTOMY PART 29845 ARTHROSCOPY WRIST SURG; SYNOVECTOMY COMPLT 29846 ARTHROSCOPY WRIST SURG; EXC/REPR TRIANG FIBROCAR 29847 ARTHROSCOPY WRIST SURG; INT FIX-FX/INSTABILITY 29848 ARTHROSCOPY WRIST SURG; W/RELEAS TRANSVER LIGAMT 29850 ARTHROSCOPICALLY AIDED TX FX KNEE; WO FIX 29851 ARTHROSCOPICALLY AIDED TX FX KNEE; W/FIX 29855 ARTHROSCOPICALLY AIDED TX TIB FX; UNICONDYL

$36

0

$234

0

$76

0

$90

0

$58

0

$54

0

$41

0

$36

0

$22

0

$50

0

$54

0

$36

0

$41

0

$72

0

$90

0

$27

0

$32

0

$49

0

$41

0

BR

N/A

$1,119

90

$1,913

90

$814

90

$1,343

90

$1,424

90

$1,729

90

$1,546

90

$2,126

90

$1,628

90

$2,126

90

$814

90

$1,485

90

$1,628

90

$1,933

90

$1,485

90

$1,892

90

$895

90

$1,017

90

$1,424

90

$1,628

90

$1,526

90

$1,831

90

$1,139

90

$1,445

90

$1,587

90

$1,546

90

Section VII: Surgical Services

Page 99

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

29856 ARTHROSCOPICALLY AIDED TX TIB FX; BICONDYLAR 29860 HIP ARTHROSCOPY, DX 29861 HIP ARTHROSCOPY/SURGERY 29862 HIP ARTHROSCOPY/SURGERY 29863 HIP ARTHROSCOPY/SURGERY 29870 ARTHROSCOPY KNEE DX W/WO SYNOVIAL BX (SEP PRO) 29871 ARTHROSCOPY KNEE SURG; INFEC/LAVAGE & DRAINAGE 29874 ARTHROSCOPY KNEE SURG; REMOV LOOSE/FB 29875 ARTHROSCOPY KNEE SURG; SYNOVECTOMY LTD (SEP PRO) 29876 ARTHROSCOPY KNEE SURG; SYNOVECTOMY MAJOR 29877 ARTHROSCOPY KNEE SURG; DEBRID/SHAV ARTIC CARTIL 29879 ARTHROSCOPY KNEE SURG; ABRASION ARTHROPLASTY 29880 ARTHROSCOPY KNEE SURG; W/MENISECTMY (MED & LAT) 29881 ARTHROSCOPY KNEE SURG; W/MENISECTMY (MEDIAL/LAT) 29882 ARTHROSCOPY KNEE SURG; W/MENISCUS REPR (MED/LAT) 29883 ARTHROSCPY KNEE SURG; W/MENISCUS REPR (MED & LAT 29884 ARTHROSCOPY KNEE SURG; W/LYSIS ADHES (SEP PRO) 29885 ARTHROSCOPY KNEE SURG; DRILLING W/GFT W/WO FIX 29886 ARTHROSCOPY KNEE SURG; DRILL-OSTEOCHOND LES 29887 ARTHROSCOPY KNEE; DRILL-OSTEOCHOND LES W/FIXA 29888 ARTHROSCOPICALLY AIDED ACL REPAIR/AUGMENT/RECON 29889 ARTHROSCOPICALLY AIDED PCL REPAIR/AUGMENT/RECON 29891 ANKLE ARTHROSCOPY/SURGERY 29892 ANKLE ARTHROSCOPY/SURGERY 29893 SCOPE, PLANTAR FASCIOTOMY 29894 ARTHROSCOPY ANK SURG; W/REMOV LOOSE/FB 29895 ARTHROSCOPY ANK SURG; SYNOVECTOMY PART 29897 ARTHROSCOPY ANK SURG; DEBRID LTD 29898 ARTHROSCOPY ANK SURG; DEBRID EXTEN 29909 UNLISTED PROC ARTHROSCOPY * 30000 DRAINAGE ABSCESS/HEMATOMA-NASAL-INT APPROACH * 30020 DRAINAGE ABSCESS/HEMATOMA NASAL SEPTUM 30100 BX INTRANASAL 30110 EXC NASAL POLYP SIMPL 30115 EXC NASAL POLYP EXTEN 30117 EXC/DESTRCT INTRANASAL LES; INT APPROACH 30118 EXC/DESTRCT INTRANASAL LES; EXT APPROACH 30120 EXC/SURG PLANING SKIN NOSE RHINOPHYMA 30124 EXC DERMOID CYST NOSE; SIMPL SKIN SUBQ 30125 EXC DERMOID CYST NOSE; COMPLX UNDER BONE/CARTIL 30130 EXC TURBINATE PART/COMPLT 30140 SUBMUCOUS RESECT TURBINATE PART/COMPLT 30150 RHINECTOMY; PART 30160 RHINECTOMY; TOT * 30200 INJ INTO TURBINATE THERAP * 30210 DISPLACEMENT THERAP

$1,719

90

$1,327

90

$1,735

90

$2,245

90

$2,245

90

$763

90

$1,221

90

$1,546

90

$1,526

90

$1,821

90

$1,628

90

$1,835

90

$2,238

90

$1,851

90

$2,004

90

$2,604

90

$1,526

90

$2,238

90

$1,790

90

$2,136

90

$3,276

90

$3,276

90

$1,608

90

$1,539

90

$839

90

$1,567

90

$1,567

90

$1,465

90

$2,055

90

BR

N/A

$96

10

$135

10

$116

0

$212

10

$501

90

$385

90

$963

90

$1,155

90

$385

90

$1,444

90

$501

90

$712

90

$578

90

$963

90

$53

0

$29

10

Section VII: Surgical Services

Page 100

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

30220 INSRT NASAL SEPTAL PROSTH * 30300 REMOV FB INTRANASAL; OFFIC TYPE PROC
30310 REMOV FB INTRANASAL; REQUIRING GEN ANES 30320 REMOV FB INTRANASAL; BY LAT RHINOTOMY 30400 RHINOPLASTY PRIM; LAT & ALAR CARTIL/ELEVAT TIP 30410 RHINOPLASTY PRIM; COMPLT-EXT PARTS-ELEVAT TIP 30420 RHINOPLASTY PRIMARY; INCL MAJOR SEPTAL REPR 30430 RHINOPLASTY SECNDRY; MINOR REVIS 30435 RHINOPLASTY SECNDRY; INTERMED REVIS 30450 RHINOPLASTY SECNDRY; MAJOR REVIS 30460 RHINOPLASTY-DEFORM CLEFT LIP; TIP ONLY 30462 RHINOPLASTY-DEFORM CLEFT LIP; TIP/SEPTUM/OSTEOT 30520 SEPTOPLASTY/SMR W/WO CARTIL SCORING/REPLAC W/GFT 30540 REPR CHOANAL ATRESIA; INTRANASAL 30545 REPR CHOANAL ATRESIA; TRANSPALATINE * 30560 LYSIS INTRANASAL SYNECHIA 30580 REPR FISTULA; OROMAXILLARY 30600 REPR FISTULA; ORONASAL 30620 SEPTAL/OTHER INTRANASAL DERMATOPLASTY 30630 REPR NASAL SEPTAL PERFORATIONS * 30801 CAUT MUCOSA TURBIN UNI-/BILAT (SEP PRO); SUPERF 30802 CAUT MUCOS TURBIN UNI-/BILAT (SEP PRO); INTRAMUR * 30901 CONTRL NASAL HEMORR-ANT-SIMPL ANY METHD * 30903 CONTRL NASAL HEMORR-ANT-COMPLX ANY METHD * 30905 CONTRL NASAL HEMORR-POST-W/PACKS-CAUT; INIT * 30906 CONTRL NASAL HEMORR-POST-W/PACKS-CAUT; SUBSQT 30915 LIG ART; ETHMO 30920 LIG ART; INT MAXIL ART TRANSANTRAL 30930 FX NASAL TURBINATE THERAP 30999 UNLISTED PROC NOSE * 31000 LAVAGE BY CANNULATION; MAXIL SINUS * 31002 LAVAGE BY CANNULATION; SPHENOID SINUS 31020 SINUSOTOMY MAXIL; INTRANASAL 31030 SINUSOTMY MAXIL; RAD WO REMOV ANTROCHOANAL POLYP 31032 SINUSOTMY MAXIL; RAD W/REMOV ANTROCHOANAL POLYPS 31040 PTERYGOMAXILLARY FOSSA SURG ANY APPROACH 31050 SINUSOTOMY SPHENOID W/WO BX 31051 SINUSOTOMY SPHENOID W/WO BX; W/MUCOS STRIPPING 31070 SINUSOTOMY FRONTAL; EXT SIMPL 31075 SINUSOTOMY FRONTAL; TRANSORBITAL UNILAT 31080 SINUSOTOMY FRONTAL; OBLIT-W/O FLAP-BROW INCS 31081 SINUSOTOMY FRONTAL; OBLIT WO FLAP CORONAL INCS 31084 SINUSOTOMY FRONTAL; OBLIT-W/FLAP-BROW INCS 31085 SINUSOTOMY FRONTAL; OBLIT-W/FLAP-CORONAL INCS 31086 SINUSOTOMY FRONT; NONOBLIT W/FLAP-BROW INCS 31087 SINUSOTOMY FRONT; NONOBLIT W/FLAP-CORONAL INCS

$298

10

$77

10

$356

10

$770

90

$1,795

90

$2,334

90

$3,097

90

$898

90

$1,459

90

$2,334

90

$1,234

90

$3,288

90

$1,683

90

$1,347

90

$2,020

90

$180

10

$1,122

90

$1,122

90

$1,908

90

$1,380

90

$202

10

$382

10

$112

0

$180

0

$348

0

$325

0

$1,234

90

$1,908

90

$224

10

BR

N/A

$95

10

$189

10

$548

90

$1,228

90

$1,417

90

$2,646

90

$1,890

90

$1,984

90

$945

90

$1,606

90

$1,890

90

$1,890

90

$2,268

90

$2,268

90

$2,268

90

$2,268

90

Section VII: Surgical Services

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SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

31090 SINUSOTOMY COMBO 3/MORE SINUSES 31200 ETHMO; INTRANASAL ANT 31201 ETHMO; INTRANASAL TOT 31205 ETHMO; EXTRANASAL TOT 31225 MAXILLECTOMY; WO ORBITAL EXENTERATION 31230 MAXILLECTOMY; W/ORBITAL EXENTERATION 31231 NASAL ENDO DX UNILAT/BILAT (SEPART PROC) 31233 NASAL/SINUS ENDO DX W/MAXIL SINUSOSCOPY 31235 NASAL/SINUS ENDO DX W/SPHENOID SINUSOSCOPY 31237 NASAL/SINUS ENDO SURG; W/BX/POLYPECTOMY/DEBRID 31238 NASAL/SINUS ENDO SURG; W/CONTRL EPISTAXIS 31239 NASAL/SINUS ENDO SURG; W/DACRYOCYSTORHINOSTOMY 31240 NASAL/SINUS ENDO SURG; W/CONCHA BULLOSA RESECT 31254 NASAL/SINUS ENDO-OR; W/PART ETHMO 31255 NASAL/SINUS ENDO-OR; W/TOT ETHMO 31256 NASAL/SINUS ENDO-OR-W/MAXIL ANTROSTOMY; 31267 NASAL/SINUS ENDO-OR-W/MAXIL ANTROS; W/TISS REMOV 31276 NASAL/SINUS ENDO-OR-W/FRONT EXPLOR W/WO TISS REM 31287 NASAL/SINUS ENDO SURG W/SPHENOIDOTOMY 31288 NASAL/SINUS ENDO W/SPHENOIDOT; REMOV TISS-SINUS 31290 NASAL ENDO SURG REPR CSF LEAK; ETHMOID REGION 31291 NASAL ENDO SURG REPR CSF LEAK; SPHENOID REGION 31292 NASAL ENDO SURG; MED/INFERIOR ORBIT WALL DECOMP 31293 NASAL ENDO SURG; MED & INFERIOR ORBIT WALL DECOM 31294 NASAL SINUS ENDO SURG; W/OPTIC NERV DECOMP 31299 UNLISTED PROC ACCES SINUSES 31300 LARYNGOTOMY; W/REMOV TUMOR/LARYNGOCELE/CORDECTMY 31320 LARYNGOTOMY; DX 31360 LARYNGECTOMY; TOT WO RADICAL NECK DISSECTION 31365 LARYNGECTOMY; TOT W/RADICAL NECK DISSECTION 31367 LARYNGECTOMY; SUBTL SUPRAGLOTTIC WO RAD NECK 31368 LARYNGECTOMY; SUBTL SUPRAGLOTTIC W/RAD NECK 31370 PART LARYNGECTOMY; HORIZONTAL 31375 PART LARYNGECTOMY; LATEROVERTICAL 31380 PART LARYNGECTOMY; ANTEROVERTICAL 31382 PART LARYNGECTOMY; ANTERO-LATERO-VERTICAL 31390 PHARYNGOLARYNGECTOMY W/RAD NECK WO RECON 31395 PHARYNGOLARYNGECTOMY W/RAD NECK; W/RECON 31400 ARYTENOIDECTOMY/ARYTENOIDOPEXY EXT APPROACH 31420 EPIGLOTTIDECTOMY 31500 INTUBATION ENDOTRACHEAL EMER PROC 31502 TRACHEOTOMY TUBE CHANGE BEFOR ESTAB FISTULA TRAC 31505 LARYNGOSCOPY INDIRECT (SEPART PROC); DX 31510 LARYNGOSCOPY INDIRECT (SEPART PROC); W/BX 31511 LARYNGOSCOPY INDIRECT (SEPART PROC); W/REMOV FB 31512 LARYNGOSCOPY INDIRECT (SEPART PROC); W/REMOV LES

$2,835

90

$992

90

$1,323

90

$1,474

90

$2,929

90

$3,440

90

$354

0

$453

0

$921

0

$765

0

$496

0

$1,133

10

$567

0

$1,006

0

$1,374

0

$793

0

$1,190

0

$1,190

0

$992

0

$1,091

0

$1,275

10

$1,275

10

$1,133

10

$1,275

10

$1,357

10

BR

N/A

$1,902

90

$856

90

$2,567

90

$3,804

90

$2,567

90

$3,804

90

$2,567

90

$2,092

90

$2,092

90

$2,092

90

$3,328

90

$4,374

90

$1,712

90

$1,426

90

$190

0

$162

0

$164

0

$450

0

$511

0

$613

0

Section VII: Surgical Services

Page 102

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

31513 LARYNGOSCOPY INDIREC (SEP PRO); W/VOCAL CORD INJ 31515 LARYNGOSCOPY DIRECT W/WO TRACHEOSCOPY; ASPIRAT 31520 LARYNGOSCOPY DIRECT W/WO TRACHEOSCOPY; DX NB 31525 LARYNGOSCOPY DIRECT W/WO TRACHEOSCOPY; DX EX NB 31526 LARYNGOSCOPY DIR W/WO TRACHEOSCPY; DX W/OR MICRO 31527 LARYNGOSCOPY DIRECT; W/INSRT OBTURATOR 31528 LARYNGOSCOPY DIR W/WO TRACHEOSCOPY; W/DILAT INIT 31529 LARYNGOSCOPY DIR W/WO TRACHEOSCP; W/DILAT SUBSQT 31530 LARYNGOSCOPY DIRECT OR W/FB REMOV 31531 LARYNGOSCOPY DIRECT OR W/FB REMOV; W/OR MICRO 31535 LARYNGOSCOPY DIRECT OR W/BX 31536 LARYNGOSCOPY DIRECT OR W/BX; W/OPERATING MICRO 31540 LARYNGOSCOPY DIR OR W/EXC TUMOR/STRIP VOCAL CORD 31541 LARYNGOSCOPY DIR OR W/EXC TUMOR; W/OR MICRO 31560 LARYNGOSCOPY DIRECT OR W/ARYTENOIDECTOMY 31561 LARYNGOSCOPY DIR OR W/ARYTENOIDECT; W/OR MICRO 31570 LARYNGOSCOPY DIR W/INJ INTO VOCAL CORDS; THERAP 31571 LARYNGOSCP DIR W/INJ VOCAL CORDS THERAP; W/MICRO 31575 LARYNGOSCOPY FLEXIBLE FIBEROPTIC; DX 31576 LARYNGOSCOPY FLEXIBLE FIBEROPTIC; W/BX 31577 LARYNGOSCOPY FLEXIBLE FIBEROPTIC; W/REMOV FB 31578 LARYNGOSCOPY FLEXIBLE FIBEROPTIC; W/REMOV LES 31579 LARYNGOSCOPY-FLEX/RIGID FIBEROPTIC W/STROBOSCOPY 31580 LARYNGOPLASTY; LARYNGEL WEB W/KEEL INSRT & REMOV 31582 LARYNGOPLASTY; STENOSIS W/GFT INCL TRACHEOTOMY 31584 LARYNGOPLASTY; W/OPEN REDUCTION FX 31585 TX CLO LARYNGEAL FX; WO MANIP 31586 TX CLO LARYNGEAL FX; W/CLO MANIP REDUCTION 31587 LARYNGOPLASTY CRICOID SPLIT 31588 LARYNGOPLASTY NOS 31590 LARYNGEAL REINNERVATION BY NEUROMUSCULAR PEDICLE 31595 SECT RECUR LARYNGEAL NERV THERAP (SEP PRO) UNILA 31599 UNLISTED PROC LARYNX 31600 TRACHEOSTOMY PLANNED (SEPART PROC) 31601 TRACHEOSTOMY PLANNED (SEPART PROC); UNDER 2 YR 31603 TRACHEOSTOMY EMER PROC; TRANSTRACHEAL 31605 TRACHEOSTOMY EMER PROC; CRICOTHYROID MEMBRN 31610 TRACHEOSTOMY FENESTRATION PROC W/SKIN FLAPS 31611 CONSTRUCT TRACHEOESOPHAG FISTULA & INSRT PROSTH 31612 TRACHEAL PUNCT-PERCUT-W/TRANSTRACH ASPIRAT/INJ 31613 TRACHEOSTOMA REVIS; SIMPL WO FLAP ROTATION 31614 TRACHEOSTOMA REVIS; COMPLX W/FLAP ROTATION 31615 TRACHEOBRONCHOSCOPY THRU ESTAB TRACHEOSTOMY INCS 31622 BRONCHOSCOPY; DX W/WO CELL WASHING/BRUSHING 31623 DX BRONCHOSCOPE/BRUSH 31624 DX BRONCHOSCOPE/LAVAGE

$818

0

$307

0

$266

0

$450

0

$542

0

$1,022

0

$613

0

$511

0

$654

0

$787

0

$654

0

$787

0

$787

0

$940

0

$869

0

$1,042

0

$715

0

$859

0

$215

0

$470

0

$715

0

$818

0

$552

0

$2,044

90

$1,840

90

$1,942

90

$307

90

$511

90

$1,840

90

BR

90

$2,248

90

$1,022

90

BR

N/A

$658

0

$751

0

$751

0

$658

0

$1,127

90

$1,221

90

$150

0

$564

90

$1,127

90

$376

0

$498

0

$505

0

$505

0

Section VII: Surgical Services

Page 103

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

31625 BRONCHOSCOPY; W/BX 31628 BRONCHOSCOPY; W/TRANSBRONCH LUNG BX W/WO FLUORO 31629 BRONCHOSCOPY; W/TRANSBRONCHIAL NEEDLE ASPIRAT BX 31630 BRONCHOSCP; W/TRACH/BRONCH DILAT/CLO REDUCT FX 31631 BRONCHOSCOPY; W/TRACH DILAT PLCMT TRACHEAL STENT 31635 BRONCHOSCOPY; W/REMOV FB 31640 BRONCHOSCOPY; W/EXC TUMOR 31641 BRONCHOSCOPY; W/DESTRCT TUMOR/RELIEF STENOSIS 31643 DX BRONCHOSCOPE/CATHETER 31645 BRONCHOSCPY; W/THERAP ASPIRAT TRACHEOBRONCH INIT 31646 BRONCHOSCP; W/THERAP ASPIRAT TRACHEOBRONC SUBSQT 31656 BRONCHOSCP; W/INJ CONTRAST MAT-SEGMT BRONCHOGRAP 31700 CATH TRANSGLOTTIC (SEPART PROC) 31708 INSTILL CONTRAST-LARYNGOGRAPHY/BRONCHOGRAPHY 31710 CATH BRONCHOGRAPHY W/WO INSTLL CONTRAST MAT 31715 TRANSTRACHEAL INJ BRONCHOGRAPHY 31717 CATH W/BRONCHIAL BRUSH BX 31720 CATH ASPIRAT (SEPART PROC); NASOTRACHEAL 31725 CATH ASPIRAT (SEP PRO); TRACHEOBRONCH W/FIBERSCP 31730 TRANSTRACH INTRO INDWELLING TUBE-O2 THERAP 31750 TRACHEOPLASTY; CERV 31755 TRACHEOPLASTY; TRACHEOPHARYNG FISTULIZATION 31760 TRACHEOPLASTY; INTRATHORACIC 31766 CARINAL RECON 31770 BRONCHOPLASTY; GFT REPR 31775 BRONCHOPLASTY; EXC STENOSIS & ANASTOM 31780 EXC TRACHEAL STENOSIS & ANASTOM; CERV 31781 EXC TRACHEAL STENOSIS & ANASTOM; CERVICOTHORACIC 31785 EXC TRACHEAL TUMOR/CARCINOMA; CERV 31786 EXC TRACHEAL TUMOR/CARCINOMA; THORACIC 31800 SUTURE TRACHEAL WOUND/INJURY; CERV 31805 SUTURE TRACHEAL WOUND/INJURY; INTRATHORACIC 31820 SURG CLO TRACHEOSTOMY/FISTULA; WO PLASTIC REPR 31825 SURG CLO TRACHEOSTOMY/FISTULA; W/PLASTIC REPR 31830 REVIS TRACHEOSTOMY SCAR 31899 UNLISTED PROC TRACHEA BRONCHI * 32000 THORACENTESIS-ASPIRAT-INIT/SUBSQT 32002 THORACENTESIS W/INSRT TUBE (SEPART PROC) 32005 CHEM PLEURODESIS 32020 TUBE THORACOSTOMY W/WO WATER SEAL (SEPART PROC) 32035 THORACOSTOMY; W/RIB RESECT EMPYEMA 32036 THORACOSTOMY; W/OPEN FLAP-DRAINAGE EMPYEMA 32095 THORACOTOMY LTD BX LUNG/PLEURA 32100 THORACOTOMY MAJOR; W/EXPLOR & BX 32110 THORACOTOMY MAJOR; W/CONTRL TRAUMATIC HEMORR 32120 THORACOTOMY MAJOR; POSTOP COMPLIC

$507

0

$564

0

$658

0

$601

0

$751

0

$939

0

$939

0

$1,221

0

$586

0

$507

0

$507

0

$432

0

$282

0

$94

0

$132

0

$122

0

$94

0

$94

0

$188

0

$188

0

$1,879

90

$2,254

90

$2,254

90

$2,499

90

$2,499

90

$2,499

90

$2,348

90

$2,630

90

$2,160

90

$2,536

90

$1,221

90

$1,691

90

$564

90

$751

90

$564

90

BR

N/A

$156

0

$293

0

$195

0

$488

0

$1,269

90

$1,464

90

$1,464

90

$1,562

90

$1,796

90

$1,952

90

Section VII: Surgical Services

Page 104

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

32124 THORACOTOMY MAJ; W/OPEN INTRAPLEURAL PNEUMONOLYS 32140 THORACOTOMY MAJ; W/CYST REMOV W/WO PLEURAL PROC 32141 THORACOTOMY MAJOR; W/EXC-PLICATION BULLAE 32150 THORACOTOMY MAJOR; W/REMOV INTRAPLEURAL FB 32151 THORACOTOMY MAJOR; W/REMOV INTRAPULMONARY FB 32160 THORACOTOMY MAJOR; W/CARDIAC MASSAGE 32200 PNEUMONOSTOMY W/OPEN DRAINAGE ABSCESS/CYST 32201 PERCUT DRAINAGE, LUNG LESION 32215 PLEURAL SCARIFICATION REPEAT PNEUMOTHORAX 32220 DECORTIC PULM (SEPART PROC); TOT 32225 DECORTIC PULM (SEPART PROC); PART 32310 PLEURECTOMY, PARIETAL (SEPART PROC) 32320 DECORTIC & PARIETAL PLEURECTOMY * 32400 BX PLEURA; PERCUT NEEDLE 32402 BX PLEURA; OPEN 32405 BX LUNG/MEDIASTINUM PERCUT NEEDLE * 32420 PNEUMONOCENTESIS-PUNCT LUNG ASPIRAT 32440 REMOV LUNG TOT PNEUMONECTOMY 32442 REMOV LUNG; W/RESECT SEGMT TRACHEA W/ANASTOM 32445 REMOV LUNG TOT PNEUMONECTOMY; EX TRAPLEURAL 32480 REMOV LUNG OTHER THAN TOT PNEUMONECTOMY; 1 LOBE 32482 REMOV LUNG OTHER THAN TOT PNEUMONECTOMY; 2 LOBES 32484 REMOV LUNG OTHER THAN TOT PNEUMONECTOMY; 1 SEGMT 32486 REMOV LUNG NOT TOT; W/CIRCUM RESECT SEGMT BRONCH 32488 REMOV LUNG; REMAIN LUNG AFTER PREV REMOV-PORTION 32491 REMOV LUNG NOT TOT; EXC-PLICATN, LUNG VOL REDUC 32500 REMOV LUNG NOT TOT PNEUMONECT; WEDGE RESECT 1/MX 32501 RESECT & REPR BRONCH @ TIME LOBEC/SEGMENTECTOMY 32520 RESECT LUNG; W/RESECT CHEST WALL 32522 RESECT LUNG; W/RECON CHEST WALL WO PROSTH 32525 RESECT LUNG; W/MAJOR RECON CHEST WALL W/PROSTH 32540 EXTRAPLEURAL ENUCLEATION EMPYEMA 32601 THORACOSCOPY DX (SEP PRO); LUNGS & PLEURAL WO BX 32602 THORACOSCOPY DX (SEP PRO); LUNGS & PLEURAL W/BX 32603 THORACOSCOPY DX (SEP PRO); PERICARDIAL SAC WO BX 32604 THORACOSCOPY DX (SEP PRO); PERICARDIAL SAC W/BX 32605 THORACOSCOPY DX (SEP PRO); MEDIASTIN SPACE WO BX 32606 THORACOSCOPY DX (SEP PRO); MEDIASTIN SPACE W/BX 32650 THORACOSCOPY SURG; W/PLEURODESIS ANY METHD 32651 THORACOSCOPY SURG; W/PART PULM DECORTIC 32652 THORACOSCOPY SURG; W/TOT PULM DECORTIC/PNEUMOLYS 32653 THORACOSCOPY SURG; W/REMOV INTRAPLEURAL FB 32654 THORACOSCOPY SURG; W/CONTRL TRAUMATIC HEMORR 32655 THORACOSCOPY SURG; W/EXC-PLICAT BULLAE 32656 THORACOSCOPY SURG; W/PARIETAL PLEURECTOMY 32657 THORACOSCOPY SURG; W/WEDGE RESECT LUNG 1/MX

$1,562

90

$1,952

90

$1,952

90

$1,855

90

$1,855

90

$1,952

90

$1,269

90

$565

0

$1,718

90

$1,952

90

$1,464

90

$1,855

90

$2,343

90

$215

0

$976

90

$332

0

$195

0

$2,538

90

$3,260

90

$2,928

90

$2,343

90

$2,440

90

$2,343

90

$3,026

90

$3,163

90

$2,915

90

$1,952

90

$586

N/A

$2,928

90

$3,319

90

$3,514

90

$1,952

90

$586

0

$683

0

$781

0

$879

0

$683

0

$781

0

$1,601

90

$1,659

90

$1,718

90

$1,659

90

$1,757

90

$1,855

90

$1,757

90

$1,952

90

Section VII: Surgical Services

Page 105

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

32658 THORACOSCOPY SURG; W/REMOV CLOT/FB-PERICARD SAC 32659 THORACOSCOPY SURG; W/CREAT PERICARD WINDOW 32660 THORACOSCOPY SURG; W/TOT PERICARDECTOMY 32661 THORACOSCOPY SURG; W/EXC PERICARD CYST/TUMOR/MAS 32662 THORACOSCOPY SURG; W/EXC MEDIASTIN CYST/TUMOR 32663 THORACOSCOPY SURG; W/LOBEC TOT/SEGMT 32664 THORACOSCOPY SURG; W/THORACIC SYMPATHECTOMY 32665 THORACOSCOPY SURG; W/ESOPHAGOMYOTOMY 32800 REPR LUNG HERNIA THRU CHEST WALL 32810 CLO CHEST WALL FOLLOWING OPEN FLAP DRAIN EMPYEMA 32815 OPEN CLO MAJOR BRONCHIAL FISTULA 32820 MAJOR RECON CHEST WALL 32850 DONOR PNEUMONECTOMY W/PREP & MAINTENANCE ALLOGFT 32851 LUNG TRANSPL SNGL; WO CARDIOPULM BYPASS 32852 LUNG TRANSPL SNGL; W/CARDIOPULM BYPASS 32853 LUNG TRANSPL DBL; WO CARDIOPULM BYPASS 32854 LUNG TRANSPL DBL; W/CARDIOPULM BYPASS 32900 RESECT RIBS EXTRAPLEURAL ALL STAGES 32905 THORACOPLASTY SCHEDE TYPE/EXTRAPLEURAL 32906 THORACOPLASTY; W/CLO BRONCHOPLEURAL FISTULA 32940 PNEUMOLYSIS EXTRAPERIOSTEAL INCL FILL/PACK PROC * 32960 PNEUMOTHORAX THERAP-INTRAPLEURAL INJ AIR 32997 TOTAL LUNG LAVAGE (UNILAT) 32999 UNLISTED PROC LUNGS & PLEURA * 33010 PERICARDIOCENTESIS; INIT * 33011 PERICARDIOCENTESIS; SUBSQT 33015 TUBE PERICARDIOSTOMY 33020 PERICARDIOTOMY REMOV CLOT/FB 33025 CREATION PERICARDIAL WINDOW/PART RESECT DRAIN 33030 PERICARDIECTOMY SUBTL/COMPLT; WO CP BYPASS 33031 PERICARDIECTOMY SUBTL/COMPLT; W/CP BYPASS 33050 EXC PERICARDIAL CYST/TUMOR 33140 TRANSMYOCARDIAL LASER REVAS. BY THORACOTOMY 33250 OR ABLAT SUPRAVENT ARRHYTH FOCUS; WO CP BYPASS 33251 OR ABLATION SUPRAVENT ARRHYTH FOCUS; W/CP BYPASS 33253 OPER INCIS & RECON ATRIA-TX ATRIAL FIB/FLUTTER 33261 OPER ABLATION VENT ARRHYTH FOCUS W/CP BYPASS 33282 IMPLANTATION OF CARDIAC EVENT RECORDER 33284 REMOVAL OF AN IMPLANTABLE CARDIAC EVENT RECORDER 33300 REPR CARDIAC WOUND; WO BYPASS 33305 REPR CARDIAC WOUND; W/CARDIOPULMONARY BYPASS 33310 CARDIOTOMY EXPLOR; WO BYPASS 33315 CARDIOTOMY EXPLOR; W/CARDIOPULMONARY BYPASS 33320 SUTURE REPR AORTA/GRT VESSELS; WO SHUNT/BYPASS 33321 SUTURE REPR AORTA/GRT VESSELS; W/SHUNT BYPASS 33322 SUTURE REPR AORTA/GRT VESSELS; W/CP BYPASS

$2,089

90

$2,050

90

$2,597

90

$2,343

90

$2,245

90

$2,538

90

$2,187

90

$2,147

90

$1,562

90

$781

90

$2,733

90

$2,440

90

$1,725

N/A

$5,074

90

$5,683

90

$6,089

90

$6,597

90

$1,367

90

$1,757

90

$2,733

90

$1,171

90

$146

0

$512

0

BR

N/A

$286

0

$175

0

$382

90

$1,910

90

$1,952

90

$2,228

90

$4,032

90

$2,122

90

$2,912

90

$2,462

90

$3,247

90

$4,385

90

$3,034

90

$1,017

90

$791

90

$2,334

90

$3,501

90

$2,546

90

$4,244

90

$2,398

90

$2,928

90

$3,268

90

Section VII: Surgical Services

Page 106

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

33330 INSRT GFT AORTA/GRT VESSELS; WO SHUNT/BYPASS 33332 INSRT GFT AORTA/GRT VESSELS; W/SHUNT BYPASS 33335 INSRT GFT AORTA/GRT VESSELS; W/CP BYPASS 33500 REPR CORONARY AV CHAMBER FISTULA; W/CP BYPASS 33501 REPR CORONARY AV CHAMBER FISTULA; WO CP BYPASS 33502 REPR ANOMALOUS CORONARY ART; LIG 33503 ANOMALOUS CORONARY ART; GFT WO CP BYPASS 33504 ANOMALOUS CORONARY ART; GFT W/CP BYPASS 33505 REPR ANOMALOUS CORON ART; CONSTRUC INTRAPULM ART 33506 REPR ANOMALOUS CORON ART; TRNSLOC PULM ART-AORTA 35180 REPR CONGEN AV FISTULA; HEAD & NECK 35182 REPR CONGEN AV FISTULA; THORAX & ABD 35184 REPR CONGEN AV FISTULA; EXTREM 35188 REPR ACQUIRED/TRAUMATIC AV FISTULA; HEAD & NECK 35189 REPR ACQUIRED/TRAUMATIC AV FISTULA; THORAX & ABD 35190 REPR ACQUIRED/TRAUMATIC AV FISTULA; EXTREM 35201 REPR BLD VESSEL DIRECT; NECK 35206 REPR BLD VESSEL DIRECT; UPPER EXTREM 35207 REPR BLD VESSEL DIRECT; HAND-FINGER 35211 REPR BLD VESSEL DIRECT; INTRATHORACIC W/BYPASS 35216 REPR BLD VESSEL DIRECT; INTRATHORACIC WO BYPASS 35221 REPR BLD VESSEL DIRECT; INTRA-ABD 35226 REPR BLD VESSEL DIRECT; LOWER EXTREM 35231 REPR BLD VESSEL W/VEIN GFT; NECK 35236 REPR BLD VESSEL W/VEIN GFT; UPPER EXTREM 35241 REPR BLD VESS W/VEIN GFT; INTRATHORACIC W/BYPASS 35246 REPR BLD VESS W/VEIN GFT; INTRATHORAC WO BYPASS 35251 REPR BLD VESSEL W/VEIN GFT; INTRA-ABD 35256 REPR BLD VESSEL W/VEIN GFT; LOWER EXTREM 35261 REPR BLD VESSEL W/GFT OTHER THAN VEIN; NECK 35266 REPR BLD VESS W/GFT OTHER THAN VEIN; UPPR EXTREM 35271 REPR BLD VESS W/GFT NOT VEIN; INTRATHORAC W/BYPS 35276 REPR BLD VESS W/GFT NOT VEIN; INTRATHOR WO BYPAS 35281 REPR BLD VESSEL W/GFT OTHER THAN VEIN; INTRA-ABD 35286 REPR BLD VESS W/GFT OTHER THAN VEIN; LOWR EXTREM 35301 THROMBOENDARTERECT; CAROTID/SUBCLAV BY NECK INCS 35311 THROMBOENDARTERECT; SUBCLAV/INNOMIN-THORAC INCS 35321 THROMBOENDARTERECT W/WO GFT; AXILRY-BRACHIAL 35331 THROMBOENDARTERECTOMY W/WO PATCH GFT; ABD AORTA 35341 THROMBOENDARTERECT; MESENTERIC/CELIAC/RENAL 35351 THROMBOENDARTERECTOMY W/WO PATCH GFT; ILIAC 35355 THROMBOENDARTERECT W/WO PATCH GFT; ILIOFEMORAL 35361 THROMBOENDARTERECT W/WO GFT; COMBO AORTOILIAC 35363 THROMBOENDARTERECTOMY; COMBO AORTOILIOFEMORAL 35371 THROMBOENDARTERECT W/WO GFT; COMMON FEMORAL 35372 THROMBOENDARTERECT W/WO PATCH GFT; DEEP FEMORAL

$3,501

90

$3,904

90

$4,329

90

$4,221

90

$2,814

90

$2,180

90

$2,972

90

$4,360

90

$4,736

90

$4,736

90

$2,160

90

$1,980

90

$2,160

90

$2,160

90

$1,980

90

$2,160

90

$2,160

90

$1,746

90

$1,854

90

$2,969

90

$2,519

90

$2,519

90

$1,656

90

$2,339

90

$2,339

90

$3,329

90

$2,429

90

$2,429

90

$2,339

90

$2,339

90

$2,339

90

$3,329

90

$2,429

90

$2,429

90

$2,339

90

$2,339

90

$2,339

90

$2,339

90

$2,609

90

$2,160

90

$2,160

90

$2,339

90

$2,609

90

$2,879

90

$1,800

90

$1,800

90

Section VII: Surgical Services

Page 107

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

35381 THROMBOENDARTERECT; FEM &/OR POP &/OR TIBIOPERON 35390 REOPERAT CAROTID THROMBOENDARTERECT > 1 MO-ORIG 35400 ANGIOSCOPY 35450 TRANSLUMNL BALLOON ANGIOPL OPEN; RENAL/VISC ART 35452 TRANSLUMINAL BALLOON ANGIOPLASTY OPEN; AORTIC 35454 TRANSLUMINAL BALLOON ANGIOPLASTY OPEN; ILIAC 35456 TRANSLUMINAL BALLOON ANGIOPLASTY OPEN; FEMOR-POP 35458 TRNSLM BALLOON ANGPLST-OPEN; BRACHCEPH/BRNCH-EA 35459 TRANSLUMINAL BALLOON ANGIOPL OPEN; TIBIOPERONAL 35460 TRANSLUMINAL BALLOON ANGIOPLASTY OPEN; VENOUS 35470 TRNSLM BALLOON ANGPLST-PERC; TIBIOPERON BRNCH-EA 35471 TRANSLUMINAL BALLOON ANGIOPL PERCUT; RENAL ART 35472 TRANSLUMINAL BALLOON ANGIOPLASTY PERCUT; AORTIC 35473 TRANSLUMINAL BALLOON ANGIOPLASTY PERCUT; ILIAC 35474 TRANSLUMINAL BALLOON ANGIOPLSTY PERCUT; FEM-POP 35475 TRNSLM BLOON ANGPLST-PERC; BRACHCEPHAL/BRNCH-EA 35476 TRANSLUMINAL BALLOON ANGIOPLASTY PERCUT; VENOUS 35480 TRANSLUMINL PERIPHERAL ATHERECT OPEN; RENAL ART 35481 TRANSLUMINAL PERIPHERAL ATHERECTOMY OPEN; AORTIC 35482 TRANSLUMINAL PERIPHERAL ATHERECTOMY OPEN; ILIAC 35483 TRANSLUM PERIPHERAL ATHERECTOMY OPEN; FEMOR-POP 35484 TRNSLM ATHERECTOMY-OPEN; BRACHIOCEPHAL/BRNCHS-EA 35485 TRANSLUM PERIPHERAL ATHERECT OPEN; TIBIOPERONEL 35490 TRANSLUM PERIPH ATHERECT PERCUT; RENAL/VISCERAL 35491 TRANSLUMINAL PERIPH ATHERECTOMY PERCUT; AORTIC 35492 TRANSLUMINL PERIPHERAL ATHERECTOMY PERCUT; ILIAC 35493 TRANSLUM PERIPHERAL ATHERECT PERCUT; FEMORAL-POP 35494 TRNSLM ATHERECTOMY-PERC; BRACHIOCEPHAL/BRNCHS-EA 35495 TRANSLUM PERIPH ATHERECT PERCUT; TIBIOPERONEAL 35500 HARVEST VEIN FOR BYPASS 35501 BYPASS GFT W/VEIN; CAROTID 35506 BYPASS GFT W/VEIN; CAROTID-SUBCLAVIAN 35507 BYPASS GFT W/VEIN; SUBCLAVIAN-CAROTID 35508 BYPASS GFT W/VEIN; CAROTID-VERTEBRAL 35509 BYPASS GFT W/VEIN; CAROTID-CAROTID 35511 BYPASS GFT W/VEIN; SUBCLAVIAN-SUBCLAVIAN 35515 BYPASS GFT W/VEIN; SUBCLAVIAN-VERTEBRAL 35516 BYPASS GFT W/VEIN; SUBCLAVIAN-AXILRY 35518 BYPASS GFT W/VEIN; AXILRY-AXILRY 35521 BYPASS GFT W/VEIN; AXILRY-FEMORAL 35526 BYPASS GFT W/VEIN; AORTOSUBCLAVIAN/CAROTID 35531 BYPASS GFT W/VEIN; AORTOCELIAC/AORTOMESENTERIC 35533 BYPASS GFT W/VEIN; AXILRY-FEMORAL-FEMORAL 35536 BYPASS GFT W/VEIN; SPLENORENAL 35541 BYPASS GFT W/VEIN; AORTOILIAC/BI-ILIAC 35546 BYPASS GFT W/VEIN; AORTOFEMORAL/BIFEMORAL

$1,800

90

$569

N/A

$883

N/A

$1,602

0

$1,800

0

$1,440

0

$1,476

0

$1,440

0

$1,350

0

$1,444

0

$1,224

0

$1,440

0

$1,620

0

$1,296

0

$1,332

0

$1,296

0

$1,143

0

$1,764

0

$1,980

0

$1,584

0

$1,620

0

$1,584

0

$1,494

0

$1,584

0

$1,782

0

$1,422

0

$1,458

0

$1,422

0

$1,350

0

$355

N/A

$2,353

90

$2,353

90

$2,353

90

$2,647

90

$2,353

90

$2,353

90

$2,647

90

$2,353

90

$2,745

90

$2,353

90

$2,607

90

$2,705

90

$3,431

90

$2,607

90

$2,607

90

$2,941

90

Section VII: Surgical Services

Page 108

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

35548 BYPASS GFT W/VEIN; AORTOILIOFEMORAL UNILAT 35549 BYPASS GFT W/VEIN; AORTOILIOFEMORAL BILAT 35551 BYPASS GFT W/VEIN; AORTOFEMORAL-POP 35556 BYPASS GFT W/VEIN; FEMORAL-POP 35558 BYPASS GFT W/VEIN; FEMORAL-FEMORAL 35560 BYPASS GFT W/VEIN; AORTORENAL 35563 BYPASS GFT W/VEIN; ILIOILIAC 35565 BYPASS GFT W/VEIN; ILIOFEMORAL 35566 BYPASS GFT W/VEIN; FEM-ANT TIB/POST TIB/DISTAL 35571 BYPASS GFT W/VEIN; POP-TIB/-PERONEAL ART/DISTAL 35582 IN-SITU VEIN BYPASS; AORTOFEMORAL-POP 35583 IN-SITU VEIN BYPASS; FEMORAL-POP 35585 IN-SITU VEIN BYPASS; FEM-ANT TIB/POST TIB/PERONL 35587 IN-SITU VEIN BYPASS; POP-TIBIAL/PERONEAL 35601 BYPASS GFT W/OTHER THAN VEIN; CAROTID 35606 BYPASS GFT W/OTHER THAN VEIN; CAROTID-SUBCLAVIAN 35612 BYPASS GFT W/OTHER THAN VEIN; SUBCLAVIAN-SUBCLAV 35616 BYPASS GFT W/OTHER THAN VEIN; SUBCLAVIAN-AXILRY 35621 BYPASS GFT W/OTHER THAN VEIN; AXILRY-FEMORAL 35623 BYPASS GFT W/OTHER THAN VEIN; AX-POP/-TIBIAL 35626 BYPASS GFT W/OTHER THAN VEIN; AORTOSUBCLAV/CAROT 35631 BYPASS GFT NOT VEIN; AORTOCELIAC/AORTOMESENTERIC 35636 BYPASS GFT W/OTHER THAN VEIN; SPLENORENAL 35641 BYPASS GFT W/OTHER THAN VEIN; AORTILIAC/BI-ILIAC 35642 BYPASS GFT W/OTHER THAN VEIN; CAROTID-VERTEBRAL 35645 BYPASS GFT W/OTHER THAN VEIN; SUBCLAV-VERTEBRAL 35646 BYPASS GFT W/OTHER THAN VEIN; AORTOFEM/BIFEM 35650 BYPASS GFT W/OTHER THAN VEIN; AXILRY-AXILRY 35651 BYPASS GFT W/OTHER THAN VEIN; AORTOFEMORAL-POP 35654 BYPASS GFT W/OTHER THAN VEIN; AXILRY-FEM-FEM 35656 BYPASS GFT W/OTHER THAN VEIN; FEMORAL-POP 35661 BYPASS GFT W/OTHER THAN VEIN; FEMORAL-FEMORAL 35663 BYPASS GFT W/OTHER THAN VEIN; ILIOILIAC 35665 BYPASS GFT W/OTHER THAN VEIN; ILIOFEMORAL 35666 BYPASS GFT NOT VEIN; FEM-ANT TIB/POST TIB/PERONL 35671 BYPASS GFT W/OTHER THAN VEIN; POP-TIB/-PERONEAL 35681 BYPASS GFT COMPOSITE 35682 COMPOSITE BYPASS GRAFT 35683 COMPOSITE BYPASS GRAFT 35691 TRANSPOSIT &/OR REIMPLNT; VERTEB TO CAROTID ART 35693 TRANSPOSIT &/OR REIMPLNT; VERTEB TO SUBCLAV ART 35694 TRANSPOSIT &/OR REIMPLNT; SUBCLAV TO CAROTID ART 35695 TRANSPOSIT &/OR REIMPLNT; CAROTID TO SUBCLAV ART 35700 REOPERAT FEM-POP/FEM-ANT TIB > 1 MO AFTR ORIG OR 35701 EXPLOR W/WO LYSIS ART; CAROTID ART 35721 EXPLOR W/WO LYSIS ART; FEMORAL ART

$2,647

90

$3,529

90

$3,019

90

$2,549

90

$2,353

90

$2,941

90

$2,451

90

$2,451

90

$2,941

90

$2,941

90

$2,490

90

$2,686

90

$3,078

90

$2,451

90

$2,254

90

$2,254

90

$2,254

90

$2,254

90

$2,353

90

$3,058

90

$2,411

90

$2,509

90

$2,411

90

$2,960

90

$2,451

90

$2,451

90

$3,235

90

$2,451

90

$2,823

90

$3,431

90

$2,451

90

$2,353

90

$2,490

90

$2,451

90

$2,451

90

$2,941

90

$640

N/A

$702

N/A

$803

N/A

$2,353

90

$2,353

90

$2,353

90

$2,353

90

$690

N/A

$1,117

90

$882

90

Section VII: Surgical Services

Page 109

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

35741 EXPLOR W/WO LYSIS ART; POP ART 35761 EXPLOR W/WO LYSIS ART; OTHER VESSELS 35800 EXPLOR POSTOP HEMORR THROMBOSIS/INFEC; NECK 35820 EXPLOR POSTOP HEMORR THROMBOSIS/INFEC; CHEST 35840 EXPLOR POSTOP HEMORR THROMBOSIS/INFEC; ABD 35860 EXPLOR POSTOP HEMORR/THROMBOSIS/INFEC; EXTREM 35870 REPR GFT-ENTERIC FISTULA 35875 THROMBECTOMY ART/VENOUS GFT 35876 THROMBECTOMY ART/VENOUS GFT; W/REVIS GFT 35879 REVISION, LOWER EXTREMITY ARTERY BYPASS 35881 REVISION, LOWER EXTREMITY ARTERY BYPASS 35901 EXC INFEC GFT; NECK 35903 EXC INFEC GFT; EXTREM 35905 EXC INFEC GFT; THORAX 35907 EXC INFEC GFT; ABD * 36000 INTRO NEEDLE/INTRACATHETER VEIN 36005 INJ PROC CONTRAST VENOGRAPHY 36010 INTRO CATH SUPER/INFERIOR VENA CAVA 36011 SELECT CATH PLCMT VENOUS SYST; 1ST ORDER BRANCH 36012 SELECT CATH PLCMT VENOUS; 2ND ORDER/MORE SELECT 36013 INTRO CATH RT HEART/MAIN PULM ART 36014 SELECT CATH PLCMT LT/RT PULM ART 36015 SELECT CATH PLCMT SEGMT/SUBSEGMENTAL PULM ART 36100 INTRO NEEDLE/INTRACATH CAROTID/VERTEB ART 36120 INTRO NEEDLE/INTRACATH; RETROGRADE BRACHIAL ART 36140 INTRO NEEDLE/INTRACATHETER; EXTREM ART 36145 INTRO NEEDLE/INTRACATH; AV SHUNT CREATED DIALYS 36160 INTRO NEEDLE/INTRACATHETER AORTIC TRANSLUMBAR 36200 INTRO CATH AORTA 36215 SELECT CATH PLCMT ART SYST; EA 1ST ORDER THORAC 36216 SELECT CATH PLCMT ART SYST; INIT 2ND ORDER THORA 36217 SELECT CATH PLCMT ART SYST; INIT 3RD ORDER THORA 36218 SELECT CATH PLCMT ART; ADD 2ND & 3RD & BEYOND 36245 SELECT CATH PLCMT ART SYST; EA 1ST ORDER ABD 36246 SELECT CATH PLCMT ART SYST; INIT 2ND ORDER ABD 36247 SELECT CATH PLCMT ART SYST; INIT 3RD ORDER ABD 36248 SELECT CATH PLCMT ART; ADD 2ND & 3RD & BEYND ABD 36260 INSRT IMPLNT INTRA-ART INFUSION PUMP 36261 REVIS IMPLNT INTRA-ART INFUSION PUMP 36262 REMOV IMPLNT INTRA-ART INFUSION PUMP 36299 UNLISTED PROC VASCULAR INJ * 36410 VENIPUNCT >3 YR W/MD SKILL (SEP PRO) NOT ROUTINE * 36415 ROUTINE VENIPUNCT/FINGER/HEEL STICK-COLLEC SPECM * 36489 PLCMT CENTRAL VENOUS CATH; PERCUT OVER AGE 2 36520 THERAP APHERESIS 36521 THERAPEUTIC APHERESIS

$882

90

$980

90

$1,078

90

$1,470

90

$1,274

90

$1,039

90

$3,529

90

$1,245

90

$1,470

90

$1,908

90

$2,090

90

$1,176

90

$1,176

90

$1,470

90

$1,412

90

$65

N/A

$128

0

$330

N/A

$367

N/A

$441

N/A

$367

N/A

$441

N/A

$514

N/A

$404

N/A

$367

N/A

$275

N/A

$321

N/A

$459

N/A

$413

N/A

$441

N/A

$569

N/A

$667

N/A

$147

N/A

$459

N/A

$514

N/A

$642

N/A

$119

N/A

$1,101

90

$551

90

$459

90

BR

N/A

$38

N/A

$8

N/A

$231

0

$320

0

$240

0

Section VII: Surgical Services

Page 110

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

36522 PHOTOPHERESIS EXTRACORPOREAL 36530 INSRT IMPLNT IV INFUSION PUMP 36531 REVIS IMPLNT IV INFUSION PUMP 36532 REMOV IMPLNT IV INFUSION PUMP 36533 INSRT IMPLNT VENOUS ACCES PORT W/WO RESERVOIR 36534 REVIS IMPLNT VENOUS ACCES PORT &/OR RESERVOIR 36535 REMOV IMPLNT VENOUS ACCES PORT &/OR RESERVOIR 36550 DECLOTTING BY THROMBOLYTIC AGENT 36600 ART PUNCT WITHDRAWAL BLD DX 36620 ART CATH/CANNULAT-SAMPL MONITOR (SEP PRO); PERQ 36625 ART CATH/CANNULAT-SAMPL/MONITOR (SEP PRO); CUTDN 36640 ART CATH PROLONGED INFUSION THERAP CUTDOWN * 36660 CATH UMBILICAL-ART-NB-DX/THERAP 36680 PLCMT NEEDLE INTRAOSSEOUS INFUSION 36800 INSRT CANNULA (SEPART PROC); VEIN-VEIN 36810 INSRT CANNULA (SEPART PROC); AV-EXT 36815 INSRT CANNULA (SEPART PROC); AV-EXT REVIS/CLO 36819 ARTERIOVENOUS ANASTOMOSIS 36821 AV ANASTOM DIRECT ANY SITE (SEPART PROC) 36822 INSRT CANNULA PROLONG EXTRACORP CIRC (SEP PROC) 36823 INSERTION CANNULA(S) 36825 CREATE AV FISTULA (SEPART PROC); AUTOG GFT 36830 CREATE AV FISTULA (SEPART PROC); NONAUTOG GFT 36831 AV FISTULA EXCISION 36832 REVIS-AV FIST W/WO THROMBEC AUTOG/NONAUTOG (SP) 36833 AV FISTULA REVISION 36834 PLASTIC REPR AV ANEURY (SEPART PROC) 36835 INSRT THOMAS SHUNT (SEPART PROC) 36860 CANNULA DECLOT (SEPART PROC); WO BALLOON CATH 36861 CANNULA DECLOTTING (SEPART PROC); W/BALLOON CATH 37140 VENOUS ANASTOM; PORTOCAVAL 37145 VENOUS ANASTOM; RENOPORTAL 37160 VENOUS ANASTOM; CAVAL-MESENTERIC 37180 VENOUS ANASTOM; SPLENORENAL PROX 37181 VENOUS ANASTOM; SPLENORENAL DISTAL 37195 THROMBOLYTIC THERAPY, STROKE 37200 TRANSCATH BX 37201 TRANSCATH THERAP INFUSION-THROMBOLYSIS NOT CORON 37202 TRANSCATH THERAP INFUSION NOT THROMBOLYSIS 37203 TRANSCATH RETRIEVAL PERCUT-IV FB 37204 TRANSCATH OCCLUD/EMBOLIZAT-PERCUT-NON CNS/HEAD 37205 TRANSCATH PLCMT IV STENT PERCUT; INIT VESSEL 37206 TRANSCATH PLCMT IV STENT PERCUT; EA ADD VESSEL 37207 TRANSCATH PLCMT IV STENT OPEN; INIT VESSEL 37208 TRANSCATH PLCMT IV STENT OPEN; EA ADD VESSEL 37209 EXCHG PREV PLCD ART CATH DURING THROMBOLYT THERA

$382

0

$825

10

$704

10

$463

10

$863

10

$639

10

$517

10

$74

N/A

$41

N/A

$139

0

$139

0

$245

0

$163

0

$151

0

$310

0

$730

0

$511

0

$1,790

90

$1,138

90

$822

90

$1,014

N/A

$1,461

90

$1,470

90

$686

90

$1,287

90

$1,989

90

$1,461

90

$1,826

90

$274

0

$420

0

$2,830

90

$2,830

90

$2,830

90

$2,830

90

$2,830

90

$489

N/A

$657

0

$712

0

$584

0

$529

0

$1,735

0

$1,169

0

$584

N/A

$1,169

0

$584

N/A

$256

0

Section VII: Surgical Services

Page 111

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

37250 INTRAVASC US (NOT CORN) DURING THERAP; INITIAL 37251 INTRAVASC US (NOT CORN) DURING THERAP; EA ADD 37565 LIG INT JUGULAR VEIN 37600 LIG; EXT CAROTID ART 37605 LIG; INT/COMMON CAROTID ART 37606 LIG; INT/COMMON CAROTID ART W/GRADUAL OCCLUD 37607 LIG/BANDING ANGIO ACCESS AV FISTULA 37609 LIG/BX TEMPORAL ART 37615 LIG MAJOR ART; NECK 37616 LIG MAJOR ART; CHEST 37617 LIG MAJOR ART; ABD 37618 LIG MAJOR ART; EXTREM 37620 INTERRUPTION PART/COMPLT-INFERIOR VENA CAVA 37650 LIG FEMORAL VEIN 37660 LIG COMMON ILIAC VEIN 37700 LIG & DIVIS LONG SAPHENOUS VEIN @ SAPHENOFEMORAL 37720 LIG & DIVIS & COMPLT STRIP LONG/SHORT SAPHENOUS 37730 LIG & DIVIS & COMPLT STRIP LONG & SHORT SAPHENOU 37735 LIG & STRIP LONG/SHORT SAPHENOUS W/RAD EXC ULCER 37760 LIG PERFORATORS-SUBFASCIAL RADICAL W/WO SKIN GFT 37780 LIG SHORT SAPHENOUS VEIN @ SAPHENOPOP (SEP PRO) 37785 LIG DIVIS &/OR EXC RECURRENT/SECNDRY VARICOSE 37788 PENILE REVASCULARIZATION ART W/WO VEIN GFT 37790 PENILE VENOUS OCCLUD PROC 37799 UNLISTED PROC VASCULAR SURG 38100 SPLENECTOMY; TOT (SEPART PROC) 38101 SPLENECTOMY; PART (SEPART PROC) 38102 SPLENECTOMY; TOT W/OTHER PROC (REPORT IN ADD) 38115 REPR RUPT SPLEEN W/WO PART SPLENECTOMY 38120 LAPAROSCOPY, SURGICAL, SPLENECTOMY 38129 UNLISTED LAPAROSCOPY PROC, SPLEEN 38200 INJ PROC SPLENOPORTOGRAPHY 38230 BONE MARROW HARVESTING TRANSPL 38231 BLD-DERIVED STEM CELL HARVEST-TRANSPL PER COLLEC 38240 BONE MARROW/STEM CELL TRANSPL; ALLOGENIC 38241 BONE MARROW/STEM CELL TRANSPL; AUTOLOGOUS * 38300 DRAINAGE LYMPH NODE ABSCESS/LYMPHADENITIS; SIMPL 38305 DRAINAGE LYMPH NODE ABSCESS/LYMPHADENITIS; EXTEN 38308 LYMPHANGIOTOMY/OTHER OR ON LYMPHATIC CHANNELS 38380 SUTURE &/OR LIG THORACIC DUCT; CERV APPROACH 38381 SUTURE &/OR LIG THORACIC DUCT; THORACIC APPROACH 38382 SUTURE &/OR LIG THORACIC DUCT; ABD APPROACH 38500 BX/EXC LYMPH NODE; SUPERF (SEPART PROC) 38505 BX/EXC LYMPH NODE; BY NEEDLE SUPERF 38510 BX/EXC LYMPH NODE; DEEP CERV NODE 38520 BX/EXC LYMPH NODE; DEEP CERV NODE W/EXC FAT PAD

$182

N/A

$119

N/A

$913

90

$822

90

$822

90

$913

90

$365

90

$365

10

$730

90

$1,369

90

$1,095

90

$913

90

$1,369

90

$548

90

$548

90

$712

90

$840

90

$1,041

90

$1,598

90

$1,114

90

$183

90

$493

90

$2,520

90

$949

90

BR

N/A

$1,851

90

$1,851

90

$926

N/A

$1,748

90

BR

N/A

BR

N/A

$350

0

$730

10

$350

0

$530

N/A

$478

N/A

$103

10

$206

90

$411

90

$1,028

90

$2,057

90

$1,748

90

$370

10

$206

0

$617

90

$514

90

Section VII: Surgical Services

Page 112

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

38525 BX/EXC LYMPH NODE; DEEP AXILRY NODE 38530 BX/EXC LYMPH NODE; INT MAMMARY NODE (SEP PRO) 38542 DISSECTION DEEP JUGULAR NODE 38550 EXC CYSTIC HYGROMA AXIL/CERV; WO NEUROVAS DISSEC 38555 EXC CYSTIC HYGROMA AXIL/CERV; W/NEUROVASC DISSEC 38562 LTD LYMPHADENECTOMY (SEPART PROC); PELVIC 38564 LTD LYMPHADENECT (SEPART PROC); RETROPERITONEAL 38570 LAPAROSCOPY, SURG; 38571 LAPAROSCOPY, SURG; 38572 LAPAROSCOPY, SURG; 38589 LAPAROSCOPY, SURG, UNLISTED PROC 38700 SUPRAHYOID LYMPHADENECTOMY 38720 CERV LYMPHADENECTOMY (COMPLETE) 38724 CERV LYMPHADENECTOMY (MODIFIED RAD NECK DISECT) 38740 AXILRY LYMPHADENECTOMY; SUPERF 38745 AXILRY LYMPHADENECTOMY; COMPLT 38746 THORACIC LYMPHADENECTOMY REGIONAL INCL NODES 38747 ABD LYMPHADENECTOMY REGIONAL INCL NODES 38760 INGUINOFEM LYMPHADENECT SUPERF (SEPART PROC) 38765 INGUINOFEM LYMPHADENECTOMY SUPERF W/PELVIC LYMPH 38770 PELVIC LYMPHADENECTOMY W/EXT ILIAC (SEPART PROC) 38780 RETROPERITONEAL TRANSABD LYMPHADNECT (SEP PRO) 38790 INJ PROC LYMPHANGIOGRAPHY 38792 IDENTIFY SENTINEL NODE 38794 CANNULATION THORACIC DUCT 38999 UNLISTED PROC HEMIC/LYMPHATIC SYST 39000 MEDIASTINOTOMY W/EXPLOR/DRAIN/REMOV FB/BX; CERV 39010 MEDIASTINOTOMY W/EXPLOR/DRAIN/BX; TRANSTHORACIC 39200 EXC MEDIASTINAL CYST 39220 EXC MEDIASTINAL TUMOR 39400 MEDIASTINOSCOPY W/WO BX 39499 UNLISTED PROC MEDIASTINUM 39501 REPR LACERATION DIAPHRAGM ANY APPROACH 39502 REPR PARAESOPHAGEAL HIATUS HERNIA EXC NEONAT 39503 REPR NEONAT DIAPHRAGMATIC HERNIA W/WO CHEST TUBE 39520 REPR DIAPHRAGMATIC HERNIA; TRANSTHORACIC 39530 REPR DIAPHRAGM HERNIA; COMBO THORACOABD 39531 REPR DIAPHRAGM HERNIA; THORACOABD W/DILAT STRICT 39540 REPR DIAPHRAGMATIC HERNIA-TRAUMATIC; ACUTE 39541 REPR DIAPHRAGMATIC HERNIA-TRAUMATIC; CHRONIC 39545 IMBRICATION DIAPHRAGM-EVENTRATION; PARALYTIC/NON 39560 RESECTION, DIAPHRAGM; W/ SIMPLE REPAIR 39561 RESECTION, DIAPHRAGM; W/ COMPLEX REPAIR 39599 UNLISTED PROC DIAPHRAGM 40490 BX LIP 40500 VERMILIONECTOMY W/MUCOS ADVANCEMENT

$617

90

$720

90

$782

90

$617

90

$1,645

90

$1,543

90

$1,748

90

$1,143

10

$1,483

10

$1,726

10

BR

N/A

$1,234

90

$2,365

90

$2,468

90

$823

90

$1,748

90

$524

N/A

$586

N/A

$1,028

90

$2,160

90

$1,872

90

$3,085

90

$350

0

$224

0

$309

90

BR

N/A

$884

90

$1,831

90

$2,057

90

$2,262

90

$823

10

BR

N/A

$1,851

90

$1,851

90

$2,262

90

$1,769

90

$1,954

90

$2,262

90

$2,345

90

$1,769

90

$2,262

90

$1,594

90

$2,182

90

BR

N/A

$95

0

$834

90

Section VII: Surgical Services

Page 113

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

40510 EXC LIP; TRANSVERSE WEDGE EXC W/PRIM CLO 40520 EXC LIP; V-EXC W/PRIM DIRECT LINEAR CLO 40525 EXC LIP; FULL THICK RECON W/LOCAL FLAP 40527 EXC LIP; FULL THICK RECON W/CROSS LIP FLAP 40530 RESECT LIP MORE THAN 1-FOURTH WO RECON 40650 REPR LIP FULL THICK; VERMILION ONLY 40652 REPR LIP FULL THICK; UP TO HALF VERTICAL HEIGHT 40654 REPR LIP FULL THICK; > 1/2 VERTICAL HT/COMPLX 40700 PLASTIC REPR CLEFT LIP/NASAL DEFORM; PRIM UNILAT 40701 PLASTIC REPR CLEFT LIP; PRIM BILAT-1 STAGE PROC 40702 PLASTIC REPR CLEFT LIP; PRIM BILAT-1 OF 2 STAGES 40720 PLASTIC REPR CLEFT LIP; SECNDRY-RECREAT & RECLO 40761 PLASTIC REPR CLEFT LIP; W/CROSS LIP PEDICLE FLAP 40799 UNLISTED PROC LIPS 40800 DRAIN ABSCESS/CYST VESTIBULE MOUTH; SIMPL 40801 DRAIN ABSCESS/CYST VESTIBULE MOUTH; COMPLIC * 40804 REMOV EMBEDDED FB VESTIBULE MOUTH; SIMPL 40805 REMOV EMBEDDED FB VESTIBULE MOUTH; COMPLIC 40806 INCS LABIAL FRENUM 40808 BX VESTIBULE MOUTH 40810 EXC LES-MUCOS/SUBMUCOSA-VESTIBULE MOUTH; WO REPR 40812 EXC LES-MUCOS/SUBMUCOSA-MOUTH; W/SIMPL REPR 40814 EXC LES-MUCOS/SUBMUCOSA-MOUTH; W/COMPLX REPR 40816 EXC LES-VESTIBULE-MOUTH; COMPLX W/EXC MUSCL 40818 EXC MUCOS VESTIBULE MOUTH AS DONOR GFT 40819 EXC FRENUM LABIAL/BUCCAL 40820 DESTRCT LES/SCAR VESTIBULE MOUTH-PHYSICAL METHD 40830 CLO LACERATION VESTIBULE MOUTH; 2.5 CM/LESS 40831 CLO LACERATION VESTIBULE MOUTH; > 2.5 CM/COMPLX 40840 VESTIBULOPLASTY; ANT 40842 VESTIBULOPLASTY; POST UNILAT 40843 VESTIBULOPLASTY; POST BILAT 40844 VESTIBULOPLASTY; ENTIRE ARCH 40845 VESTIBULOPLASTY; COMPLX 40899 UNLISTED PROC VESTIBULE MOUTH * 41000 INTRAORAL I&D ABSCESS/CYST TONGUE/MOUTH; LINGUAL * 41005 INTRAORAL I&D ABSCESS TONGUE/MOUTH; SUBLINGUAL 41006 INTRAORAL I&D ABSCESS; SUBLINGUAL SUPRAMYLOHYOID 41007 INTRAORAL I&D ABSCESS/CYST; SUBMENTAL SPACE 41008 INTRAORAL I&D ABSCESS/CYST; SUBMANDIBULAR SPACE 41009 INTRAORAL I&D ABSCESS/CYST; MASTICATOR SPACE 41010 INCS LINGUAL FRENUM 41015 EXTRAORAL I&D ABSCESS FLOOR MOUTH; SUBLINGUAL 41016 EXTRAORAL I&D ABSCESS FLOOR MOUTH; SUBMENTAL 41017 EXTRAORAL I&D ABSCESS FLOOR MOUTH; SUBMANDIBULAR 41018 EXTRAORAL I&D ABSCESS MOUTH; MASTICATOR SPACE

$860

90

$688

90

$1,376

90

$1,617

90

$688

90

$430

90

$568

90

$808

90

$1,892

90

$2,176

90

$1,892

90

$1,608

90

$2,270

90

BR

N/A

$90

10

$464

10

$138

10

$413

10

$206

0

$138

10

$172

10

$215

10

$516

90

$671

90

$284

90

$241

90

$206

10

$138

10

$344

10

$688

90

$533

90

$757

90

$1,204

90

$1,462

90

BR

N/A

$152

10

$172

10

$476

90

$476

90

$476

90

$476

90

$229

10

$495

90

$381

90

$495

90

$495

90

Section VII: Surgical Services

Page 114

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

41100 BX TONGUE; ANT TWO-THIRDS 41105 BX TONGUE; POST ONE-THIRD 41108 BX FLOOR MOUTH 41110 EXC LES TONGUE WO CLO 41112 EXC LES TONGUE W/CLO; ANT TWO-THIRDS 41113 EXC LES TONGUE W/CLO; POST ONE-THIRD 41114 EXC LES TONGUE W/CLO; W/LOCAL TONGUE FLAP 41115 EXC LINGUAL FRENUM 41116 EXC LES FLOOR MOUTH 41120 GLOSSECTOMY; < ONE-HALF TONGUE 41130 GLOSSECTOMY; HEMIGLOSSECTOMY 41135 GLOSSECTOMY; PART W/UNILAT RADICAL NECK DISSECT 41140 GLOSSECTOMY; COMPLT/TOT W/WO TRACH WO RAD NCEK 41145 GLOSSECTOMY; COMPLT/TOT W/UNILAT RADICAL NECK 41150 GLOSSECTOMY; COMPOSITE WO RADICAL NECK DISSECT 41153 GLOSSECTOMY; COMPOSITE W/SUPRAHYOID NECK DISSECT 41155 GLOSSECTOMY; COMPOSITE & RADICAL NECK DISSECTION * 41250 REPR LACERATION 2.5 CM/LESS; ANT 2/3 TONGUE * 41251 REPR LACERATION 2.5 CM/LESS; POST 1/3 TONGUE * 41252 REPR LACERAT TONGUE/FLOOR MOUTH > 2.6 CM/COMPLX 41500 FIXA TONGUE MECH OTHER THAN SUTURE 41510 SUTURE TONGUE TO LIP MICROGNATHIA 41520 FRENOPLASTY 41599 UNLISTED PROC TONGUE FLOOR MOUTH * 41800 DRAINAGE ABSCESS/CYST FROM DENTOALVEOLAR STRUCT 41805 REMOV EMBED FB-DENTOALVEOLAR STRUCT; SOFT TISS 41806 REMOV EMBEDDED FB-DENTOALVEOLAR STRUCT; BONE 41820 GINGIVECTOMY EXC GINGIVA EA QUADRANT 41821 OPERCULECTOMY EXC PERICORONAL TISS 41822 EXC FIBROUS TUBEROSITIES DENTOALVEOLAR STRUCT 41823 EXC OSSEOUS TUBEROSITIES DENTOALVEOLAR STRUCT 41825 EXC LES/TUMOR DENTOALVEOLAR STRUCT; WO REPR 41826 EXC LES/TUMOR DENTOALVEOLAR STRUCT; W/SIMPL REPR 41827 EXC LES DENTOALVEOLAR STRUCT; W/COMPLX REPR 41828 EXC HYPERPLASTIC ALVEOLAR MUCOS EA QUADRANT 41830 ALVEOLECTOMY INCL CURET OSTEITIS/SEQUESTRECTOMY 41850 DESTRCT LES DENTOALVEOLAR STRUCT 41870 PERIODONTAL MUCOS GFT 41872 GINGIVOPLASTY EA QUADRANT 41874 ALVEOLOPLASTY EA QUADRANT 41899 UNLISTED PROC DENTOALVEOLAR STRUCT * 42000 DRAINAGE ABSCESS PALATE UVULA 42100 BX PALATE UVULA 42104 EXC LES PALATE UVULA; WO CLO 42106 EXC LES PALATE UVULA; W/SIMPL PRIM CLO 42107 EXC LES PALATE UVULA; W/LOCAL FLAP CLO

$152

10

$191

10

$133

10

$172

10

$419

90

$495

90

$457

90

$305

10

$572

90

$1,029

90

$1,601

90

$2,858

90

$1,867

90

$3,239

90

$2,954

90

$3,239

90

$3,906

90

$172

10

$152

10

$686

10

$381

90

$686

90

$457

90

BR

N/A

$152

10

$172

10

$191

10

$381

N/A

$86

N/A

$191

10

$438

90

$191

10

$333

10

$524

90

$553

10

$457

10

$191

N/A

$476

N/A

$572

90

$400

90

BR

N/A

$172

10

$191

10

$276

10

$353

10

$629

90

Section VII: Surgical Services

Page 115

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

42120 RESECT PALATE/EXTEN RESECT LES 42140 UVULECTOMY EXC UVULA 42145 PALATOPHARYNGOPLASTY 42160 DESTRCT LES PALATE/UVULA 42180 REPR LACERATION PALATE; UP TO 2 CM 42182 REPR LACERATION PALATE; OVER 2 CM/COMPLX 42200 PALATOPLASTY-CLEFT PALATE SOFT &/OR HARD PALATE 42205 PALATOPLASTY-CLEFT PALATE; SOFT TISS ONLY 42210 PALATOPLASTY CLEFT PALATE; W/BONE GFT-ALVEOLAR 42215 PALATOPLASTY CLEFT PALATE; MAJOR REVIS 42220 PALATOPLASTY CLEFT PALATE; SECNDRY LENGTHENING 42225 PALATOPLASTY CLEFT PALATE; ATTACH PHARYNGEAL FLP 42226 LENGTHENING PALATE & PHARYNGEAL FLAP 42227 LENGTHENING PALATE W/ISLAND FLAP 42235 REPR ANT PALATE INCL VOMER FLAP 42260 REPR NASOLABIAL FISTULA 42280 MAXIL IMPRESSION PALATAL PROSTH 42281 INSRT PIN-RETAINED PALATAL PROSTH 42299 UNLISTED PROC PALATE UVULA * 42300 DRAINAGE ABSCESS; PAROTID SIMPL 42305 DRAINAGE ABSCESS; PAROTID COMPLIC * 42310 DRAINAGE ABSCESS; SUBMAXIL/SUBLINGUAL INTRAORAL * 42320 DRAINAGE ABSCESS; SUBMAXILLARY EXT 42325 FISTULIZATION SUBLINGUAL SALIVARY CYST 42326 FISTULIZATION SUBLINGUAL SALIVARY CYST; W/PROSTH 42330 SIALOLITHOTOMY; SUBMANDIBULAR UNCOMP INTRAORAL 42335 SIALOLITHOTOMY; SUBMANDIBULAR COMPLIC INTRAORAL 42340 SIALOLITHOTOMY; PAROTID/COMPLIC INTRAORAL * 42400 BX SALIVARY GLAND; NEEDLE 42405 BX SALIVARY GLAND; INCS 42408 EXC SUBLINGUAL SALIVARY CYST 42409 MARSUPIALIZATION SUBLINGUAL SALIVARY CYST 42410 EXC PAROTID TUMOR; LAT LOBE WO NERVE DISSECTION 42415 EXC PAROTID TUMOR; LAT LOBE W/DISSECTION NERVE 42420 EXC PAROTID TUMOR; TOT W/DISSECT & PRESERV NERVE 42425 EXC PAROTID TUMOR; TOT W/SACRIFICE FACIAL NERVE 42426 EXC PAROTID TUMOR; TOT W/UNILAT RAD NECK DISSECT 42440 EXC SUBMANDIBULAR GLAND 42450 EXC SUBLINGUAL GLAND 42500 PLASTIC REPR SALIVARY DUCT; PRIM/SIMPL 42505 PLASTIC REPR SALIVARY DUCT; SECNDRY/COMPLIC 42507 PAROTID DUCT DIVERSION BILAT 42508 PAROTID DIVERSION BILAT; W/EXC 1 SUBMANDIB GLAND 42509 PAROTID DIVERSION BILAT; W/EXC BOTH GLANDS 42510 PAROTID DIVERSION BILAT; W/LIG SUBMANDIB DUCTS 42550 INJ PROC SIALOGRAPHY

$1,010

90

$400

90

$1,725

90

$114

10

$210

10

$515

10

$2,230

90

$2,344

90

$2,954

90

$2,858

90

$2,191

90

$1,906

90

$2,382

90

$2,382

90

$1,734

90

$953

90

$172

10

$343

10

BR

N/A

$133

10

$286

90

$172

10

$191

10

$248

90

$400

90

$286

10

$629

90

$953

90

$114

0

$238

10

$476

90

$476

90

$781

90

$1,810

90

$2,001

90

$1,334

90

$2,954

90

$1,458

90

$667

90

$762

90

$1,143

90

$1,239

90

$1,610

90

$1,810

90

$1,524

90

$81

0

Section VII: Surgical Services

Page 116

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

42600 CLO SALIVARY FISTULA * 42650 DILAT SALIVARY DUCT * 42660 DILAT & CATH SALIVARY DUCT W/WO INJ
42665 LIG SALIVARY DUCT INTRAORAL 42699 UNLISTED PROC SALIVARY GLANDS/DUCTS * 42700 I&D ABSCESS; PERITONSILLAR 42720 I&D ABSCESS; RETROPHARYNGEAL INTRAORAL APPROACH 42725 I&D ABSCESS; RETROPHARYNGEAL EXT APPROACH 42800 BX; OROPHARYNX 42802 BX; HYPOPHARYNX 42804 BX; NASOPHARYNX VISIBLE LES SIMPL 42806 BX; NASOPHARYNX SURVEY-UNKNOWN PRIM LES 42808 EXC/DESTRCT LES PHARYNX ANY METHD 42809 REMOV FB FROM PHARYNX 42810 EXC BRANCHIAL CLEFT CYST-CONFINED TO SKIN/SUBQ 42815 EXC BRANCHIAL CLEFT CYST-BENEATH SUBQ INTO PHARY 42900 SUTURE PHARYNX WOUND/INJURY 42950 PHARYNGOPLASTY 42953 PHARYNGOESOPHAGEAL REPR 42955 PHARYNGOSTOMY 42960 CONTRL OROPHARYNG HEMORR PRIM/SECNDRY; SIMPL 42961 CONTRL OROPHARYNG HEMORR; COMPLIC W/HOSPITALIZAT 42962 CONTRL OROPHARYNG HEMORR; W/SECNDRY SURG INTERV 42970 CONTRL NASOPHARYNG HEMORR; SIMPL W/PACKS/CAUTERY 42971 CONTRL NASOPHARYNG HEMORR; COMPLIC W/HOSPITALIZ 42972 CONTRL NASOPHARYNG HEMORR; W/SECNDRY SURG INTERV 42999 UNLISTED PROC PHARYNX/ADENOIDS/TONSILS 43020 ESOPHAGOTOMY CERV APPROACH; W/REMOV FB 43030 CRICOPHARYNGEAL MYOTOMY 43045 ESOPHAGOTOMY THORACIC APPROACH, W/REMOV FB 43100 EXC LES ESOPHAGUS W/PRIMARY REPR; CERV 43101 EXC LES ESOPHAGUS W/PRIMARY REPR; THORACIC/ABD 43107 TOT ESOPHAGECT WO THORCTMY; W/PHARYNGOGASTROST 43108 TOT ESOPHAGECT WO THORCTMY; W/INTRPOS/SB RECON 43112 TOT ESOPHAGECT W/THORCTMY; W/PHARYNGOGASTROST 43113 TOT ESOPHAGECT W/THORCTMY; W/INTRPOS/SB RECON 43116 PART ESOPHAGECT-CERV-W/GFT/MICROVAS ANAS/RECON 43117 PART ESOPHAGECT W/THOR, ABD INCS; W/ESOPHGASTRST 43118 PART ESOPHAGECT W/THOR, ABD INCS; W/SB RECON 43121 PART ESOPHAGECT W/THORCTMY, W/ESOPHGASTROST 43122 PART ESOPHAGECT THORABD APPRO; W/ESOPHGASTROST 43123 PART ESOPHAGECT THORABD APPRO; W/INTRPOS/SB RECN 43124 TOT/PART ESOPHAGECT WO RECON W/CERV ESOPHAGOSTMY 43130 DIVERTICULECTOMY HYPOPHARYNX/ESOPHAGUS; CERV 43135 DIVERTICULECTOMY HYPOPHARYNX/ESOPHAGUS; THORACIC 43200 ESOPHAGOSCOPY RIGID/FLEX; DX W/WO COLLEC SPECMN

$953

90

$57

0

$86

0

$114

90

BR

N/A

$234

10

$379

10

$668

90

$156

10

$178

10

$156

10

$312

10

$401

10

$223

10

$512

90

$1,270

90

$624

10

$1,560

90

$1,961

90

$512

90

$245

10

$390

90

$468

90

$334

90

$434

90

$490

90

BR

N/A

$1,254

90

$1,254

90

$1,755

90

$1,343

90

$1,746

90

$3,170

90

$3,672

90

$3,260

90

$3,761

90

$4,299

90

$3,493

90

$4,012

90

$3,313

90

$3,403

90

$3,913

90

$3,027

90

$1,343

90

$1,746

90

$394

0

Section VII: Surgical Services

Page 117

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

43202 ESOPHAGOSCOPY RIGID/FLEX; W/BX 1/MX 43204 ESOPHAGOSCOPY RIGID/FLEX; W/INJ-SCLEROSIS VARICE 43205 ESOPHAGOSCOPY RIGID/FLEX; W/BAND LIG VARICES 43215 ESOPHAGOSCOPY RIGID/FLEX; W/REMOV FB 43216 ESOPHAGOSCOPY RIGID/FLEX; REMOV TUMOR/POLYP/LES 43217 ESOPHAGOSCOPY RIGID/FLEX; W/REMOV LES-SNARE TECH 43219 ESOPHAGOSCOPY RIGID/FLEX; W/INSRT TUBE/STENT 43220 ESOPHAGOSCOPY RIGID/FLEX; W/BALLOON DILAT 43226 ESOPHAGOSCOPY RIGID/FLEX; W/INSRT GUIDE WIRE 43227 ESOPHAGOSCOPY RIGID/FLEX; W/CONTRL BLEEDING 43228 ESOPHAGOSCOPY RIGID/FLEX; W/ABLAT TUMR-NOT AMENA 43234 UGI ENDO SIMPL PRIM EXAM (SEPART PROC) 43235 UGI ENDO; DX W/WO COLLEC SPECMN-BRUSH/WASH (SEP) 43239 UGI ENDO; W/BX 1/MX 43241 UGI ENDO; W/TRANSENDOSCOPIC TUBE/CATH PLCMT 43243 UGI ENDO; W/INJ SCLEROSIS-ESOPH/GASTRIC VARICES 43244 UGI ENDO; W/BAND LIG ESOPH &/OR GASTRIC VARICES 43245 UGI ENDO; W/DILAT OUTLET-OBSTRUC ANY METHD 43246 UGI ENDO; W/DIRECTED PLCMT PERQ GASTROSTOMY TUBE 43247 UGI ENDO; W/REMOV FB 43248 UGI ENDO; W/INSRT GUIDE WIRE-DILAT ESOPHAGUS 43249 UGI ENDO; W/BALLOON DILAT ESOPHAGUS (<30MM DIAM) 43250 UGI ENDO; W/REMOV TUMOR/POLYP/LES-HOT BX FORCEPS 43251 UGI ENDO; W/REMOV TUMOR/POLYP/OTHER LES-SNARE 43255 UGI ENDO; W/CONTRL BLEEDING ANY METHD 43258 UGI ENDO; W/ABLAT LES NOT AMENABLE TO CAUT/SNARE 43259 UGI ENDO; W/ENDO ULTRASOUND EXAM 43260 ERCP; DX W/WO COLLEC SPECMN-BRUSH/WASH (SEP PRO) 43261 ENDO RETROGRAD CHOLANGIOPANCREATOG; W/BX 1/MX 43262 ERCP; W/SPHINCTEROTOMY/PAPILLOTOMY 43263 ERCP; W/PRESS MEASUR-SPHINCTER ODDI 43264 ERCP; W/ENDO RETRO REMOV STONE-BILI/PANCREAT DUC 43265 ERCP; W/ENDO RETRO DESTRCT-LITH STONE-ANY METHD 43267 ERCP; W/ENDO RETRO INSRT NASOBILI DRAINAGE TUBE 43268 ERCP; W/ENDO RETRO INSRT TUBE/STENT-BILE DUCT 43269 ERCP; W/ENDO RETRO REMOV FB &/OR CHANGE TUBE 43271 ERCP; W/ENDO RETRO BALOON DILAT-AMPULLA/BILI DUC 43272 ERCP; W/ABLAT TUMOR/LES NOT AMENABLE TO SNARE 43280 LAPAROSCOPY, ESOPHAGOGASTRIC FUNDOPLASTY 43289 UNLISTED PROC, LAPAROSCOPY, ESOPHAGUS 43300 ESOPHAGOPLASTY CERV; WO REPR TRACHEOESOPHAG FIST 43305 ESOPHAGOPLASTY CERV; W/REPR TRACHEOESOPHAG FIST 43310 ESOPHAGOPLASTY THORACIC; WO REPR FISTULA 43312 ESOPHAGOPLASTY THORACIC; W/REPR FISTULA 43320 ESOPHAGOGASTROST W/WO VAGOTOMY THOR/ABD APPROACH 43324 ESOPHAGOGASTRIC FUNDOPLASTY

$430

0

$591

0

$591

0

$573

0

$627

0

$627

0

$537

0

$484

0

$430

0

$591

0

$537

0

$358

0

$394

0

$457

0

$501

0

$645

0

$609

0

$537

0

$788

0

$537

0

$475

0

$519

0

$591

0

$591

0

$627

0

$654

0

$475

0

$663

0

$743

0

$1,039

0

$896

0

$1,128

0

$1,057

0

$985

0

$1,003

0

$878

0

$967

0

$752

0

$2,232

90

BR

N/A

$1,651

90

$2,422

90

$2,752

90

$3,126

90

$2,202

90

$2,180

90

Section VII: Surgical Services

Page 118

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

43325 ESOPHAGOGASTRIC FUNDOPLASTY; W/FUNDIC PATCH 43326 ESOPHAGOGASTRIC FUNDOPLASTY; W/GASTROPLASTY 43330 ESOPHAGOMYOTOMY; ABD APPROACH 43331 ESOPHAGOMYOTOMY; THORACIC APPROACH 43340 ESOPHAGOJEJUNOSTOMY; ABD APPROACH 43341 ESOPHAGOJEJUNOSTOMY; THORACIC APPROACH 43350 ESOPHAGOSTOMY FISTULIZATION-EXT; ABD APPROACH 43351 ESOPHAGOSTOMY FISTULIZATION-EXT; THORACIC 43352 ESOPHAGOSTOMY FISTULIZATION-EXT; CERV APPROACH 43360 GI RECON-PREV ESOPHAGECTOMY; W/STOMACH 43361 GI RECON-PREV ESOPHAGECTOMY; W/BOWEL RECON 43400 LIG DIRECT ESOPH VARICES 43401 TRANSECTION ESOPHAGUS W/REPR ESOPH VARICES 43405 LIG/STAPLE GASTESOPH JNCTN-EXIST ESOPH PERFORATN 43410 SUTURE ESOPH WOUND/INJURY; CERV APPROACH 43415 SUTURE ESOPH WOUND/INJURY; THORAC/ABD APPROACH 43420 CLO ESOPHAGOSTOMY/FISTULA; CERV APPROACH 43425 CLO ESOPHAGOSTOMY/FISTULA; THORACIC/ABD APPROACH * 43450 DILAT ESOPH-UNGUIDED SOUND/BOUGIE-1/MX PASSES 43453 DILAT ESOPH OVER GUIDE WIRE 43456 DILAT ESOPH BALLOON/DILAT RETRO 43458 DILAT ESOPHAGUS W/BALLOON-ACHALASIA 43460 ESOPHAGOGASTRIC TAMPONADE W/BALLOON 43496 FREE JEJUNUM TRANS W/MICROVASC ANASTOM 43499 UNLISTED PROC ESOPHAGUS 43500 GASTROTOMY; W/EXPLOR/FB REMOV 43501 GASTROTOMY; W/SUTURE REPR BLEEDING ULCER 43502 GASTROTOMY; W/SUTURE REPR EXIST ESOGAST LACERATN 43510 GASTROTOMY; W/ESOPH DILAT & INSRT PERM TUBE 43520 PYLOROMYOTOMY CUTTING PYLORIC MUSCL 43600 BX STOMACH; BY CAPSULE/TUBE/PERORAL 43605 BX STOMACH; BY LAPAROTOMY 43610 EXC LOCAL; ULCER/BEN TUMOR-STOMACH 43611 EXC LOCAL; MALIG TUMOR STOMACH 43620 GASTRECTOMY TOT; W/ESOPHAGOENTEROSTOMY 43621 GASTRECTOMY TOT; W/ROUX-EN-Y RECON 43622 GASTRECTOMY TOT; W/FORMAT INTEST POUCH ANY TYPE 43631 GASTRECTOMY PART DISTAL; W/GASTRODUODENOSTOMY 43632 GASTRECTOMY PART DISTAL; W/GASTROJEJUNOSTOMY 43633 GASTRECTOMY PART DISTAL; W/ROUX-EN-Y RECON 43634 GASTRECTOMY PART DISTAL; W/FORM INTESTINAL POUCH 43635 VAGOTOMY W/PART DIST GASTRECTOMY 43638 GASTRECTOMY PART INCL ESOPHAGOGASTROST W/VAGOTMY 43639 GASTRECTOMY PART W/VAGOTOMY; W/PYLORO-PLSTY/TOMY 43640 VAGOTOMY INCL PYLOROPLASTY; TRUNCAL/SELECT 43641 VAGOTOMY INCL PYLOROPLASTY; PARIETAL CELL

$2,532

90

$2,862

90

$1,926

90

$2,092

90

$2,532

90

$2,862

90

$1,541

90

$1,761

90

$1,321

90

$3,589

90

$4,469

90

$2,202

90

$1,211

90

$1,211

90

$1,277

90

$2,114

90

$1,321

90

$1,783

90

$154

0

$286

0

$440

0

$638

0

$462

0

$5,959

90

BR

N/A

$1,164

90

$1,610

90

$1,610

90

$1,028

90

$1,164

90

$194

0

$1,358

90

$1,494

90

$1,717

90

$2,715

90

$3,588

90

$3,928

90

$1,940

90

$1,940

90

$2,560

90

$3,152

90

$727

N/A

$2,425

90

$3,103

90

$1,872

90

$2,231

90

Section VII: Surgical Services

Page 119

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

43651 LAPAROSCOPY, TRANSECTION, VAGUS NERVES, TRUNCAL 43652 LAPAROSCOPY, TRANSECTION, VAGUS NERVES 43653 LAPAROSCOPY, GASTROSTOMY 43659 UNLISTED PROC, LAPAROSCOPY, STOMACH 43750 PERCUT PLCMT GASTROSTOMY TUBE * 43760 CHANGE GASTROSTOMY TUBE 43761 REPOSIT GASTRIC FEEDING TUBE THRU DUODENUM 43800 PYLOROPLASTY 43810 GASTRODUODENOSTOMY 43820 GASTROJEJUNOSTOMY; WO VAGOTOMY 43825 GASTROJEJUNOSTOMY; W/VAGOTOMY ANY TYPE 43830 GASTROSTOMY TEMPORARY (SEPART PROC) 43831 GASTROSTOMY TEMP (SEPART PROC); NEONAT FEEDING 43832 GASTROSTOMY PERM W/CONSTRUCTION GASTRIC TUBE 43840 GASTRORRHAPHY SUTURE-PERFORATED ULCER/WOUND 43842 GASTRIC RESTRICT WO BYP-MORBID OBES; VERTCL BAND 43843 GAST RESTRICT WO BYP-MORBID OBES; NOT VERT BAND 43846 GAST RESTRICT W/BYP-MORBID OBES; SHORT ROUX-EN-Y 43847 GAST RESTRIC W/BYP-MORBID OBES; W/SM BOWEL RECON 43848 REVIS GASTRIC RESTRICT PROC (SEPART PROC) 43850 REVIS GASTRODUODENAL ANASTOM W/RECON; WO VAGOTMY 43855 REVIS GASTRODUODENAL ANASTOM W/RECON; W/VAGOTOMY 43860 REVIS GASTROJEJUNAL ANASTOM; WO VAGOTOMY 43865 REVIS GASTROJEJUNAL ANASTOM; W/VAGOTOMY 43870 CLO GASTROSTOMY SURG 43880 CLO GASTROCOLIC FISTULA 43999 UNLISTED PROC STOMACH 44005 ENTEROLYSIS (SEPART PROC) 44010 DUODENOTOMY-EXPLOR/BX/FB REMOV 44015 TUBE/NEEDLE CATH JEJUNOST-ENTERAL ALIMEN-INTRAOP 44020 ENTEROTOMY-SM BOWEL; EXPLOR/BX/FB REMOV 44021 ENTEROTOMY-SM BOWEL-NOT DUODENUM; DECOMP 44025 COLOTOMY EXPLOR BX/FB REMOV 44050 REDUCT VOLVULUS/INTUSSUSCEPTION BY LAPAROTOMY 44055 CORRECT MALROTATION BY LYSIS DUODENAL BANDS 44100 BX INTESTINE BY CAPSULE/TUBE/PERORAL 44110 EXC 1/MORE LES-BOWEL WO ANASTOM; 1 ENTEROTOMY 44111 EXC 1/MORE LES-BOWEL WO ANASTOM; MX ENTEROTOMIES 44120 ENTERECTOMY SM INTES; SNGL RESECT & ANASTOM 44121 ENTERECTOMY SM INTES; EA ADD RESECT & ANASTOM 44125 ENTERECTOMY SM INTES; W/ENTEROSTOMY 44130 ENTEROENTEROSTOMY W/WO CUTAN ENTEROST (SEP PROC) 44139 MOBILIZA SPLENIC FLEXURE PERFMD W/PART COLECTOMY 44140 COLECTOMY PART; W/ANASTOM 44141 COLECTOMY PART; W/SKIN LEVEL CECOSTOMY/COLOSTOMY 44143 COLECTOMY PART; W/END COLOSTOMY & CLO DIST SEGMT

$1,416

90

$1,695

90

$1,225

90

BR

N/A

$795

10

$116

0

$189

0

$1,358

90

$1,455

90

$1,464

90

$1,746

90

$1,171

90

$1,183

90

$1,393

90

$1,455

90

$2,677

90

$3,006

90

$3,375

90

$3,375

90

$3,274

90

$1,940

90

$2,231

90

$1,940

90

$2,231

90

$970

90

$1,455

90

BR

N/A

$1,511

90

$1,511

90

$695

N/A

$1,511

90

$1,309

90

$1,511

90

$1,309

90

$1,773

90

$222

0

$1,329

90

$2,014

90

$1,853

90

$927

N/A

$1,954

90

$1,773

90

$131

N/A

$2,014

90

$2,115

90

$2,115

90

Section VII: Surgical Services

Page 120

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

44144 COLECTOMY PART; W/RESECT & CREATION MUCOFISTULA 44145 COLECTOMY PART; W/COLOPROCTOSTOMY 44146 COLECTOMY PART; W/COLOPROCTOSTOMY W/COLOSTOMY 44147 COLECTOMY PART; ABD & TRANSANAL APPROACH 44150 COLECTOMY-TOT ABD-WO PROCTECTOMY; W/ILEOSTOMY 44151 COLECTOMY WO PROCTECTOMY; W/CONTINENT ILEOSTOMY 44152 COLECTOMY WO PROCTECTOMY; W/RECTAL MUCOSECTOMY 44153 COLECTOMY WO PROCTECT; W/CREAT ILEAL RESERVOIR 44155 COLECTOMY-TOT ABD-W/PROCTECTOMY; W/ILEOSTOMY 44156 COLECTOMY-TOT ABD-W/PROCTECT; W/CONTINENT ILEOST 44160 COLECTOMY W/REMOV TERM ILEUM & ILEOCOLOSTOMY 44200 LAPAROSCOPY, ENTEROLYSIS (SEP PROC) 44201 LAPAROSCOPY, JEJUNOSTOMY 44202 LAPAROSCOPY, INTESTINAL RESECTION 44209 UNLISTED PROC, LAPAROSCOPY, INTESTINE 44300 ENTEROSTOMY/CECOSTOMY TUBE (SEPART PROC) 44310 ILEOSTOMY/JEJUNOSTOMY NON-TUBE (SEPART PROC) 44312 REVIS ILEOSTOMY; SIMPL (SEPART PROC) 44314 REVIS ILEOSTOMY; COMPLIC (SEPART PROC) 44316 CONTINENT ILEOSTOMY (SEPART PROC) 44320 COLOSTOMY/SKIN LEVEL CECOSTOMY; (SEPART PROC) 44322 COLOSTOMY/CECOSTOMY; W/MX BX (SEPART PROC) 44340 REVIS COLOSTOMY; SIMPL (SEPART PROC) 44345 REVIS COLOSTOMY; COMPLIC (SEPART PROC) 44346 REVIS COLOSTOMY; W/REPR HERNIA (SEPART PROC) 44360 SM INTEST ENDO ENTEROSC NOT ILEUM; DX W/WO SPECM 44361 SM INTESTINAL ENDO NOT ILEUM; W/BX 1/MX 44363 SM INTESTINAL ENDO NOT ILEUM; W/REMOV FB 44364 SM INTESTINAL ENDO NOT ILEUM; W/REMOV LES-SNARE 44365 SM INTEST ENDO WO ILEUM; W/REMOV TUMOR/POLYP/LES 44366 SM INTESTINAL ENDO NOT ILEUM; W/CONTRL BLEEDING 44369 SM INTEST ENDO NOT ILEUM; W/ABLAT TUMOR NOT SNAR 44372 SM INTEST ENDO NOT ILEUM; W/PLCMT JEJUNOST TUBE 44373 SM INTESTINAL ENDO; W/GASTRO TUBE TO JEJUNO TUBE 44376 SM INTESTINL ENDO W/ILEUM; DX W/WO COLLEC SPECMN 44377 SM INTESTINAL W/ILEUM; W/BX 1/MX 44378 SM INTEST ENDO W/ILEUM; W/CONTRL BLEED ANY METHD 44380 ILEOSCOPY-STOMA; DX W/WO COLLEC SPECMN (SEP PRO) 44382 ILEOSCOPY-STOMA; W/BX 1/MX 44385 ENDO EVAL SM INTEST POUCH; DX W/WO COLLEC SPECMN 44386 ENDO EVAL SM INTESTINAL POUCH; W/BX 1/MX 44388 COLONOSCOPY-STOMA; DX W/WO COLLEC SPECMN 44389 COLONOSCOPY-STOMA; W/BX 1/MX 44390 COLONOSCOPY-STOMA; W/REMOV FB 44391 COLONOSCOPY-STOMA; W/CONTRL BLEEDING ANY METHD 44392 COLONOSCOPY-STOMA; W/REMOV TUMOR/LES-FORCEP/CAUT

$2,216

90

$2,216

90

$2,518

90

$2,921

90

$2,518

90

$3,525

90

$3,525

90

$3,928

90

$3,223

90

$4,431

90

$2,216

90

$1,760

90

BR

N/A

$2,676

90

BR

N/A

$969

90

$1,253

90

$434

90

$1,336

90

$2,088

90

$969

90

$1,136

90

$426

90

$969

90

$1,136

90

$468

0

$501

0

$501

0

$568

0

$568

0

$668

0

$568

0

$468

0

$468

0

$518

0

$568

0

$785

0

$367

0

$484

0

$443

0

$518

0

$501

0

$585

0

$585

0

$802

0

$685

0

Section VII: Surgical Services

Page 121

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

44393 COLONOSCOPY-STOMA; W/ABLAT TUMOR NOT AMENAB-SNAR 44394 COLONSCOPY-STOMA; W/REMOV TUMOR/POLYP/LES 44500 INTRO LONG GI TUBE (SEPART PROC) 44602 SUTURE SM INTESTINE; SNGL PERFORATION 44603 SUTURE SM INTESTINE; MX PERFORATIONS 44604 SUTURE LG INTESTINE; WO COLOSTOMY 44605 SUTURE LG INTESTINE; W/COLOSTOMY 44615 INTEST STRICTUROPLASTY W/WO DILAT-INTEST OBSTRUC 44620 CLO ENTEROSTOMY LG/SM INTEST 44625 CLO ENTEROSTOMY LG/SM INTEST; W/RESECT & ANASTOM 44626 REPAIR BOWEL OPENING 44640 CLO INTESTINAL CUT FISTULA 44650 CLO ENTEROENTERIC/ENTEROCOLIC FISTULA 44660 CLO ENTEROVESICAL FISTULA; WO INTESTINAL RESECT 44661 CLO ENTEROVESICAL FISTULA; W/BOWEL RESECT 44680 INTESTINAL PLICATION (SEPART PROC) 44700 SUSPEND BOWEL W/PROSTHESIS 44799 UNLISTED PROC INTESTINE 44800 EXC MECKEL'S DIVERTIC/OMPHALOMESENTERIC DUCT 44820 EXC LES MESENTERY (SEPART PROC) 44850 SUTURE MESENTERY (SEPART PROC) 44899 UNLISTED PROC MECKEL'S DIVERTIC & MESENTERY 44900 I&D APPENDICEAL ABSCESS TRANSABDOMINAL 44901 DRAIN, APP ABSCESS, PERC 44950 APPENDECTOMY 44955 APPY; WHEN DONE PURPOSE @ TIME OF OTHER PROC 44960 APPY; RUPT APPY W/ABSCESS/GEN PERITONITIS 44970 LAPAROSCOPY, APPENDECTOMY 44979 UNLISTED PROC, LAPAROSCOPY, APPENDIX 45000 TRANSRECTAL DRAINAGE PELVIC ABSCESS 45005 I&D SUBMUCOSAL ABSCESS RECTUM 45020 I&D DEEP SUPRALEVATOR/PELVIRECTAL ABSCESS 45100 BX ANORECTAL WALL ANAL APPROACH 45108 ANORECTAL MYOMECTOMY 45110 PROCTECTOMY; COMPLT-ABDOMINOPERINEAL W/COLOSTOMY 45111 PROCTECTOMY; PART RESECT RECTUM TRNSABD APPROACH 45112 PROCTECTOMY COMB ABDOMINOPERINEAL PULL-THRU PROC 45113 PROCTECTOMY PART W/RECTAL MUCOSECT-ILEOANAL ANAS 45114 PROCTECTOMY PART W/ANASTOM; ABD & TRANSSACRAL 45116 PROCTECTOMY PART W/ANASTOM; TRANSACRAL ONLY 45119 REMOVE, RECTUM W/RESERVOIR 45120 PROCTECTOMY COMPLT; W/PULL-THRU & ANASTOM 45121 PROCTECTOMY COMPLT; W/SUBTL/TOT COLECTMY & MX BX 45123 PROCTECTOMY PART WO ANASTOM-PERINEAL APPROACH 45126 PELVIC EXENTERATION 45130 EXC RECTAL PROCIDENTIA W/ANASTOM; PERINEAL

$685

0

$685

0

$70

0

$1,253

90

$1,461

90

$1,253

90

$1,420

90

$1,503

90

$919

90

$1,369

90

$2,222

90

$969

90

$1,169

90

$1,169

90

$1,837

90

$1,503

90

$1,754

90

BR

N/A

$1,002

90

$835

90

$1,002

90

BR

N/A

$854

90

$427

0

$976

90

$528

N/A

$1,219

90

$1,037

90

BR

N/A

$332

90

$266

10

$428

90

$380

90

$950

90

$2,470

90

$1,995

90

$2,470

90

$3,040

90

$2,850

90

$1,995

90

$3,284

90

$2,850

90

$2,470

90

$1,615

90

$3,243

90

$1,577

90

Section VII: Surgical Services

Page 122

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

45135 EXC RECTAL PROCIDENTIA W/ANASTOM; ABD & PERINEAL 45150 DIVISION STRICT RECTUM 45160 EXC RECTAL TUMOR-PROCTOTOMY/TRANSACRAL APPROACH 45170 EXC RECTAL TUMOR TRANSANAL APPROACH 45190 DESTRCT RECTAL TUMOR ANY METHD TRANSANAL APPRO 45300 PROCTOSIGMOIDOSCOPY RIGID; DX W/WO COLLEC SPECMN 45303 PROCTOSIGMOIDOSCOPY RIGID; W/DILAT ANY METHD 45305 PROCTOSIGMOIDOSCOPY RIGID; W/BX 1/MX 45307 PROCTOSIGMOIDOSCOPY RIGID; W/REMOV FB 45308 PROCTOSIGMOIDOSCOPY RIGID; REMOV LES-HOT FORCEPS 45309 PROCTOSIGMOIDOSCOPY RIGID; REMOV LES-SNARE 45315 PROCTOSIGMOIDOS RIGID; W/REMOV LES-FORCEPS/SNARE 45317 PROCTOSIGMOIDOSCOPY RIGID; W/CONTRL BLEEDING 45320 PROCTOSIGMOIDOSCOPY RIGID; W/ABLAT LES-NOT SNARE 45321 PROCTOSIGMOIDOSCOPY RIGID W/DECOMP VOLVULUS 45330 SIGMOIDOSCOPY FLEX; DX W/WO COLLEC SPECMN 45331 SIGMOIDOSCOPY FLEX; W/BX 1/MX 45332 SIGMOIDOSCOPY FLEX; W/REMOV FB 45333 SIGMOIDOSCOPY FLEX; W/REMOV LES-FORCEPS/CAUT 45334 SIGMOIDOSCOPY FLEX; W/CONTRL BLEEDING ANY METHD 45337 SIGMOIDOSCOPY FLEX; W/DECOMP VOLVULUS ANY METHD 45338 SIGMOIDOSCOPY FLEX; REMOV LES-SNARE 45339 SIGMOIDOSCOPY FLEX; ABLAT TUMOR/LES-NOT AMENABLE 45355 COLONOSCOPY RIGID/FLEX TRNSABD VIA COLOTOMY 1/MX 45378 COLONOSCOPY FLEX-PROX SPLEN FLEX; DX (SEP PRO) 45379 COLONOSCOPY FLEX-PROX SPLEN FLEX; W/REMOV FB 45380 COLONOSCOPY FLEX-PROX SPLEN FLEX; W/BX 1/MX 45382 COLONOSCOPY FLEX-PROX SPLEN FLEX; W/CONTRL BLEED 45383 COLONOSCOPY FLEX; W/ABLAT LES NOT AMENABLE-SNARE 45384 COLONOSCOPY FLEX; REMOV TUMOR/LES HOT BX FORCEPS 45385 COLONOSCOPY FLEX; W/REMOV TUMOR/LES BY SNARE 45500 PROCTOPLASTY; STENOSIS 45505 PROCTOPLASTY; PROLAPSE MUCOS MEMBRN 45520 PERIRECTAL INJ SCLEROSING SOLUTION PROLAPSE 45540 PROCTOPEXY PROLAPSE; ABD APPROACH 45541 PROCTOPEXY PROLAPSE; PERINEAL APPROACH 45550 PROCTOPEXY COMBO W/SIGMOID RESECT-ABD APPROACH 45560 REPR RECTOCELE (SEPART PROC) 45562 EXPLOR, REPR & DRAIN PRESACRUM-RECTAL INJURY; 45563 EXPLOR, REPR & DRAIN-RECTAL INJURY; W/COLOSTOMY 45800 CLO RECTOVESICAL FISTULA 45805 CLO RECTOVESICAL FISTULA; W/COLOSTOMY 45820 CLO RECTOURETHRAL FISTULA 45825 CLO RECTOURETHRAL FISTULA; W/COLOSTOMY * 45900 REDUCTION PROCIDENTIA (SEPART PROC) UNDER ANES * 45905 DILAT ANAL SPHINCTER (SEP PRO) W/ANES-NOT LOCAL

$2,660

90

$665

90

$1,710

90

$760

90

$380

90

$81

0

$105

0

$133

0

$190

0

$190

0

$190

0

$304

0

$285

0

$304

0

$247

0

$134

0

$195

0

$243

0

$422

0

$365

0

$341

0

$422

0

$422

0

$260

0

$509

0

$594

0

$560

0

$679

0

$722

0

$722

0

$722

0

$1,022

90

$1,022

90

$74

0

$1,673

90

$1,673

90

$1,952

90

$632

90

$1,766

90

$1,952

90

$1,766

90

$1,952

90

$1,766

90

$1,952

90

$112

10

$167

10

Section VII: Surgical Services

Page 123

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

45910 DILAT RECTAL STRICT (SEP PRO) W/ANES-NOT LOCAL * 45915 REMOV FECAL IMPACTION/FB (SEP PRO) W/GEN ANES
45999 UNLISTED PROC RECTUM * 46030 REMOV ANAL SETON OTHER MARKER
46040 I&D ISCHIORECTAL &/OR PERIRECT ABSCESS (SEP PRO) 46045 I&D INTRAMURAL/IM ABSCESS TRANSANAL UNDER ANES * 46050 I&D PERIANAL ABSCESS SUPERF 46060 I&D ISCHIORECTAL/INTRAMURAL ABSCESS W/FISTULECT 46070 INCS ANAL SEPTUM (INFANT) * 46080 SPHINCTEROTOMY ANAL DIVIS SPHINCTER (SEP PRO) 46083 INCS THROMBOSED HEMORRHOID EXT 46200 FISSURECTOMY W/WO SPHINCTEROTOMY 46210 CRYPTECTOMY; SNGL 46211 CRYPTECTOMY; MX (SEPART PROC) 46220 PAPILLECTOMY/EXC SNGL TAG ANUS (SEPART PROC) 46221 HEMORRHOIDECTOMY BY SIMPL LIG 46230 EXC EXT HEMORRHOID TAGS &/OR MX PAPILLAE 46250 HEMORRHOIDECTOMY EXT COMPLT 46255 HEMORRHOIDECTOMY INT & EXT SIMPL 46257 HEMORRHOIDECTOMY INT & EXT SIMPL; W/FISSURECTOMY 46258 HEMORRHOIDECTOMY INT & EXT SIMPL; W/FISTULECTOMY 46260 HEMORRHOIDECTOMY INT & EXT COMPLX/EXTEN 46261 HEMORRHOIDECTOMY COMPLX/EXTEN; W/FISSURECTOMY 46262 HEMORRHOIDECTOMY COMPLX/EXTEN; W/FISTULECTOMY 46270 SURG TX ANAL FISTULA; SUBQ 46275 SURG TX ANAL FISTULA; SUBMUSCULAR 46280 SURG TX ANAL FISTULA; COMPLX/MX W/WO PLCMT SETON 46285 SURG TX ANAL FISTULA; 2ND STAGE 46288 CLO ANAL FISTULA W/RECTAL ADVANCEMENT FLAP * 46320 ENUCLEATION/EXC EXT THROMBOTIC HEMORRHOID * 46500 INJ SCLEROSING SOLUTION HEMORRHOIDS 46600 ANOSCOPY; DX W/WO COLLEC SPECMN (SEPART PROC) 46604 ANOSCOPY; DILAT ANY METHD 46606 ANOSCOPY; W/BX 1/MX 46608 ANOSCOPY; W/REMOV FB 46610 ANOSCOPY; W/REMOV 1 TUMOR/POLYP/LES-FORCEPS/CAUT 46611 ANOSCOPY; W/REMOV 1 TUMOR/POLYP/LES-SNARE TECH 46612 ANOSCOPY; W/REMOV MX TUMOR/LES-FORCEP/CAUT/SNARE 46614 ANOSCOPY; W/CONTRL BLEEDING ANY METHD 46615 ANOSCOPY; W/ABLAT TUMOR/LES NOT AMENABLE-FORCEPS 46700 ANOPLASTY PLASTIC OR STRICT; ADULT 46705 ANOPLASTY PLASTIC OR STRICT; INFANT 46715 REPR LOW IMPERFORATE ANUS; W/ANOPERINEAL FISTULA 46716 REPR LOW IMPERFORATE ANUS; W/TRANSPOSIT FISTULA 46730 REPR HIGH IMPERFORATE ANUS; PERINEAL/SACROPERINL 46735 REPR HIGH IMPERFORATE ANUS; COMBO APPROACHES

$316

10

$316

10

BR

N/A

$91

10

$347

90

$388

90

$146

10

$876

90

$146

90

$383

10

$105

10

$599

90

$193

90

$696

90

$116

10

$174

10

$145

10

$580

90

$773

90

$821

90

$870

90

$966

90

$1,015

90

$1,063

90

$580

90

$850

90

$986

90

$309

90

$966

90

$145

10

$53

10

$39

0

$77

0

$77

0

$77

0

$154

0

$154

0

$179

0

$171

0

$179

0

$707

90

$794

90

$690

90

$863

90

$1,725

90

$1,898

90

Section VII: Surgical Services

Page 124

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

46740 REPR HI IMPERFORATE ANUS W/FIST; PERINEL/SACROPR 46742 REPR HI IMPERFORAT ANUS W/FIST; COMBO APPROACHES 46744 REPR CLOACAL ANOMALY-SACROPERINEAL APPROACH 46746 REPR CLOACAL ANOMALY-COMBO ABD-SACROPER APPROACH 46748 REPR CLOACAL ANOMALY; W/VAG LENGTH-GFT/FLAP 46750 SPHINCTEROPLASTY-ANAL-INCONT/PROLAPSE; ADULT 46751 SPHINCTEROPLASTY-ANAL-INCONT/PROLAPSE; CHILD 46753 GFT RECTAL INCONT &/OR PROLAPSE 46754 REMOV THIERSCH WIRE/SUTURE ANAL CANAL 46760 SPHINCTEROPLASTY ANAL-ADULT; MUSCL TRANSPL 46761 SPHINCTEROPLASTY-ANAL; LEVATOR MUSCL IMBRICATION 46762 SPHINCTEROPLASTY-ANAL; IMPLNT ARTIFICIAL SPHINCT * 46900 DESTRCT LES ANUS SIMPL; CHEM * 46910 DESTRCT LES ANUS SIMPL; ELECTRODESICCATION 46916 DESTRCT LES ANUS SIMPL; CRYOSURGERY 46917 DESTRCT LES ANUS SIMPL; LASER SURG 46922 DESTRCT LES ANUS SIMPL; SURG EXC 46924 DESTRCT LES ANUS EXTEN ANY METHD 46934 DESTRCT HEMORRHOIDS ANY METHD; INT 46935 DESTRCT HEMORRHOIDS ANY METHD; EXT 46936 DESTRCT HEMORRHOIDS ANY METHD; INT & EXT 46937 CRYOSURGERY RECTAL TUMOR; BEN 46938 CRYOSURGERY RECTAL TUMOR; MALIG 46940 CURET/CAUT ANAL FISSURE (SEPART PROC); INIT 46942 CURET/CAUT ANAL FISSURE (SEPART PROC); SUBSQT 46945 LIG INT HEMORRHOIDS; SNGL PROC 46946 LIG INT HEMORRHOIDS; MX PROC 46999 UNLISTED PROC ANUS 47300 MARSUPIALIZATION CYST/ABSCESS LIVER 47350 MGMT LIVER HEMORR; SIMPL SUT LIVER WOUND/INJURY 47360 MGMT LIVER HEMORR; COMPLX SUT W/WO HEPAT ART LIG 47361 MGMT LIVER HEMORR; EXPLOR/EXTEN DEBRID/COAG/SUT 47362 MGMT LIVER HEMORR; RE-EXPLOR WOUND-REMOV PACKING 47399 UNLISTED PROC LIVER 49000 EXPLOR LAPAROTOMY-CELIOTOMY W/WO BX (SEP PRO) 49002 REOPENING RECENT LAPAROTOMY 49010 EXPLOR RETROPERITONEAL AREA W/WO BX (SEP PRO) 49020 DRAIN PERITONEAL ABSC-NOT APPENDICEAL; OPEN 49021 DRAIN PERITONEAL ABSC/LOCAL PERITONITIS; PERCUT 49040 DRAINAGE SUBDIAPHRAGMATIC/SUBPHRENIC ABSCESS 49041 PERCUT DRAIN ABDOM ABSCESS 49060 DRAINAGE RETROPERITONEAL ABSCESS 49061 PERCUTDRAIN RETROPER ABSCESS 49062 DRAIN TO PERITONEAL CAVITY * 49080 PERITONEOCENTESIS-ABD PARACENTESIS; INIT * 49081 PERITONEOCENTESIS-ABD PARACENTESIS; SUBSQT

$2,070

90

$2,277

90

$2,812

90

$3,097

90

$3,424

90

$949

90

$863

90

$604

90

$138

10

$1,208

90

$1,725

90

$2,156

90

$69

10

$129

10

$155

10

$345

10

$233

10

$518

10

$233

90

$229

10

$483

90

$259

10

$431

90

$86

10

$86

10

$138

90

$207

90

BR

N/A

$1,601

90

$1,601

90

$2,193

90

$2,632

90

$1,316

90

BR

N/A

$1,279

90

$1,279

90

$1,279

90

$1,173

90

$256

0

$1,450

90

$665

0

$1,386

90

$610

0

$1,386

90

$171

0

$128

0

Section VII: Surgical Services

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SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

49085 REMOV PERITONEAL FB FROM PERITONEAL CAVITY * 49180 BX ABD/RETROPERITONEAL MASS PERCUT NEEDLE
49200 EXC/DESTRCT INTRA-ABD/RETROPERITONEAL TUMORS 49201 EXC/DESTRCT INTRA-ABD TUMORS/CYSTS; EXTEN 49215 EXC PRESACRAL/SACROCOCCYGEAL TUMOR 49220 STAGING CELIOTOMY-HODGKIN'S DISEASE/LYMPHOMA 49250 UMBILECTOMY/OMPHALECTOMY-EXC UMBILICUS (SEP PRO) 49255 OMENTECTOMY/EPIPLOECTOMY-RESEC OMENTUM (SEP PRO) 49320 LAPAROSCOPY, DX W/ OR W/O SPECIMEN(S) 49321 LAPAROSCOPY, W/ BX (SINGLE/MULTIPLE) 49322 LAPAROSCOPY, W/ CAVITY/CYST ASPIRATION 49323 LAPAROSCOPY, W/ LYMPHOCELE DRAINAGE 49329 UNLISTED PROC, LAPAROSCOPY, * 49400 INJ AIR/CONTRAST-PERITONEAL CAVITY (SEP PRO) * 49420 INSRT INTRAPERITONEAL CANNULA-DRAIN; TEMPORARY 49421 INSRT INTRAPERITONEAL CANNULA-DRAIN; PERM 49422 REMOV PERM INTRAPERITONEAL CANNULA/CATH 49423 EXCHANGE DRAINAGE CATH 49424 ASSESS CYST, CONTRAST INJ 49425 INSRT PERITONEAL-VENOUS SHUNT 49426 REVIS PERITONEAL-VENOUS SHUNT 49427 INJ PROC-EVAL PREV PLACED PERITON-VENOUS SHUNT 49428 LIG PERITONEAL-VENOUS SHUNT 49429 REMOV PERITONEAL-VENOUS SHUNT 49495 REPR INIT ING HERNIA < 6 MO; REDUCIBLE 49496 REPR INIT ING HERNIA < 6 MO; INCARCERAT/STRANGUL 49500 REPR INIT ING HERNIA 6 MO-< 5 YR; REDUCIBLE 49501 REPR INIT ING HERNIA 6MO-<5YR; INCARCERAT/STRANG 49505 REPR INIT ING HERNIA 5 YR/MORE; REDUCIBLE 49507 REPR INIT ING HERNIA 5 YR/MORE; INCARC/STRANGUL 49520 REPR RECURRENT ING HERNIA ANY AGE; REDUCIBLE 49521 REPR RECUR ING HERNIA; INCARCERAT/STRANGULATED 49525 REPR ING HERNIA SLIDING ANY AGE 49540 REPR LUMBAR HERNIA 49550 REPR INIT FEM HERNIA ANY AGE; REDUCIBLE 49553 REPR INIT FEM HERNIA REDUCIBLE; INCARCER/STRANG 49555 REPR RECUR FEM HERNIA; REDUCIBLE 49557 REPR RECUR FEM HERNIA; INCARCERAT/STRANGULATED 49560 REPR INIT INCS HERNIA; REDUCIBLE 49561 REPR INIT INCS HERNIA; INCARCERAT/STRANGULATED 49565 REPR RECUR INCS HERNIA; REDUCIBLE 49566 REPR RECUR INCS HERNIA; INCARCERAT/STRANGULATED 49568 IMPLNT MESH/OTHER PROSTH-INCS HERNIA REPR 49570 REPR EPIGASTRIC HERNIA; REDUCIBLE (SEPART PROC) 49572 REPR EPIGASTRIC HERNIA; INCARCERATED/STRANGULATD 49580 REPR UMBILICAL HERNIA < 5 YR; REDUCIBLE

$1,002

90

$320

0

$1,706

90

$2,132

90

$2,409

90

$2,132

90

$746

90

$1,066

90

$596

10

$636

10

$660

10

$1,020

90

BR

N/A

$126

0

$342

0

$719

90

$539

10

$457

0

$261

0

$1,132

90

$1,132

90

$117

0

$360

10

$917

10

$937

90

$1,069

90

$844

90

$975

90

$900

90

$1,031

90

$1,109

90

$1,270

90

$1,048

90

$1,048

90

$907

90

$1,048

90

$988

90

$1,129

90

$1,210

90

$1,391

90

$1,391

90

$1,593

90

$323

N/A

$706

90

$882

90

$786

90

Section VII: Surgical Services

Page 126

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

49582 REPR UMBILIC HERNIA <5 YR; INCARCERAT/STRANGULAT 49585 REPR UMBILICAL HERNIA 5 YR/OVER; REDUCIBLE 49587 REPR UMBILIC HERNIA 5 YR/OVER; INCARCER/STRANGUL 49590 REPR SPIGELIAN HERNIA 49600 REPR SM OMPHALOCELE W/PRIM CLO 49605 REPR LG OMPHALOCELE/GASTROSCHISIS; W/WO PROSTH 49606 REPR LG OMPHALOCELE; W/REMOV PROSTH REDUC & CLO 49610 REPR OMPHALOCELE; FIRST STAGE 49611 REPR OMPHALOCELE; SECOND STAGE 49650 LAPAROSCOPY, REPAIR, INGUINAL HERNIA, INITIAL 49651 LAPAROSCOPY, REPAIR, INGUINAL HERNIA, RECURRENT 49659 UNLISTED PROC, LAPAROSCOPY, HERNIA. 49900 SUTURE SECNDRY ABD WALL EVISCERATION/DEHISCENCE 49905 OMENTAL FLAP 49906 FREE OMENTAL FLAP W/MICROVASC ANASTOM 49999 UNLISTED PROC ABD PERITONEUM & OMENTUM 50010 RENAL EXPLOR WO NECES OTHER SPECIFIC PROC * 50020 DRAINAGE PERIRENAL/RENAL ABSCESS (SEPART PROC) 50021 PERCUT DRAIN RENAL ABSCESS 50040 NEPHROSTOMY NEPHROTOMY W/DRAINAGE 50045 NEPHROTOMY W/EXPLOR 50060 NEPHROLITHOTOMY; REMOV CALCU 50065 NEPHROLITHOTOMY; SECNDRY SURG FOR CALCU 50070 NEPHROLITHOTOMY; COMPLIC BY CONGEN KIDNEY ABN 50075 NEPHROLITHOTOMY; REMOV LG STAGHORN CALCU 50080 PERCUT NEPHROSTOLITHOTOMY W/WO DILAT; UP TO 2 CM 50081 PERCUT NEPHROSTOLITHOTOMY W/WO DILAT; OVER 2 CM 50100 TRANSECT/REPOSIT ABERRANT RENAL VESS (SEP PRO) 50120 PYELOTOMY; W/EXPLOR 50125 PYELOTOMY; W/DRAINAGE PYELOSTOMY 50130 PYELOTOMY; W/REMOV CALCU 50135 PYELOTOMY; COMPLIC 50200 RENAL BX; PERCUT BY TROCAR/NEEDLE 50205 RENAL BX; BY SURG EXPOSURE KIDNEY 50220 NEPHRECTOMY INCL PART URETERECTOMY W/RIB RESECT 50225 NEPHRECT W/PART URETERECT; PREV SURG SAME KIDNEY 50230 NEPHRECTOMY; RADICAL W/REGIONAL LYMPHADENECTOMY 50234 NEPHRECTOMY W/TOT URETERECTOMY; THRU SAME INCS 50236 NEPHRECTOMY W/TOT URETERECTOMY; THRU SEPART INCS 50240 NEPHRECTOMY PART 50280 EXC/UNROOFING CYST KIDNEY 50290 EXC PERINEPHRIC CYST 50300 DONOR NEPHRECTOMY W/PREP/MAINT ALLOGFT; CADAVER 50320 DONOR NEPHRECTOMY W/PREP/MAINT; LIVE DONOR 50340 RECIPIENT NEPHRECTOMY (SEPART PROC) 50360 RENAL ALLOTRANSPL; EXCLD DONOR & RECIP NEPHRECT

$907

90

$907

90

$1,048

90

$1,008

90

$1,109

90

$1,814

90

$1,361

90

$1,109

90

$1,109

90

$802

90

$1,029

90

BR

N/A

$1,008

90

$806

N/A

$3,167

90

BR

N/A

$1,275

90

$1,139

90

$424

0

$1,530

90

$1,530

90

$1,615

90

$2,040

90

$1,972

90

$2,091

90

$1,649

90

$1,895

90

$1,020

90

$1,530

90

$1,530

90

$1,530

90

$1,870

90

$306

0

$765

90

$1,530

90

$1,870

90

$2,430

90

$1,870

90

$1,955

90

$1,870

90

$1,360

90

$1,360

90

$1,530

N/A

$2,742

90

$1,530

90

$3,280

90

Section VII: Surgical Services

Page 127

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

50365 RENAL ALLOTRANSPL; W/RECIPIENT NEPHRECTOMY 50370 REMOV TRANSPL RENAL ALLOGFT 50380 RENAL AUTOTRANSPLANTATION REIMPLANTATION KIDNEY * 50390 ASPIRAT &/OR INJ RENAL CYST/PELVIS-NEEDLE PERCUT 50392 INTRO INTRACATH/CATH-RENAL PELVIS-DRAIN PERCUT 50393 INTRO URETERAL CATH THRU RENAL PELVIS PERCUT 50394 INJ PROC PYELOGRAPHY THRU NEPHROSTOMY TUBE 50395 INTRO-GUIDE-RENAL PELVIS W/DILAT ESTAB NEPHROST 50396 MANOMETRIC STUDIES THRU NEPHROSTOMY TUBE * 50398 CHANGE NEPHROSTOMY/PYELOSTOMY TUBE 50400 PYELOPLASTY W/WO PLASTIC ON URETER; SIMPL 50405 PYELOPLASTY W/WO PLASTIC ON URETER; COMPLIC 50500 NEPHRORRHAPHY SUTURE KIDNEY WOUND/INJURY 50520 CLO NEPHROCUTANEOUS/PYELOCUTANEOUS FISTULA 50525 CLO NEPHROVISCERAL FISTULA W/VISCERAL REPR; ABD 50526 CLO NEPHROVISCERAL FISTULA; THORACIC 50540 SYMPHYSIOTOMY W/WO PYELOPLASTY UNILAT/BILAT 50541 LAPAROSCOPY, ABLATION OF RENAL CYSTS 50544 LAPAROSCOPY, PYELOPLASTY 50546 LAPAROSCOPY, NEPHRECTOMY 50547 LAPAROSCOPY, NEPHRECTOMY, LIVING DONOR 50548 LAPAROSCOPICALLY ASSISTED NEPHROURETERECTOMY 50549 UNLISTED PROC, LAPAROSCOPY, RENAL 50551 RENAL ENDO-ESTAB NEPHROSTOMY EXCLUS OF RAD 50553 RENAL ENDO-ESTAB NEPHROSTOMY; W/URETHERAL CATH 50555 RENAL ENDO-ESTAB NEPHROSTOMY; W/BX 50557 RENAL ENDO-ESTAB NEPHROSTOMY; W/FULG &/OR INCS 50559 RENAL ENDO-ESTAB NEPHROST; INSRT RADIOACT SUBSTA 50561 RENAL ENDO-ESTAB NEPHROSTOMY; W/REMOV FB/CALCU 50570 RENAL ENDO-NEPHROTOMY; W/WO IRRIGA EXCLUS OF RAD 50572 RENAL ENDO-NEPHROTOMY; W/URETERAL CATH 50574 RENAL ENDO-NEPHROTOMY EXCLUS OF RAD; W/BX 50575 RENAL ENDO-NEPHROTOMY; W/ENDOPYELOTOMY 50576 RENAL ENDO-NEPHROTOMY; W/FULG &/OR INCS W/WO BX 50578 RENAL ENDO-NEPHROTOMY; W/INSRT RADIOACT SUBSTANC 50580 RENAL ENDO-NEPHROTOMY EXCLUS OF RAD; REMOV FB 50590 LITH EXTRACORPOREAL SHOCK WAVE 50600 URETEROTOMY W/EXPLOR OR DRAINAGE (SEPART PROC) 50605 URETEROTOMY INSRT INDWELLING STENT ALL TYPES 50610 URETEROLITHOTOMY; UPPER 1/3 URETER 50620 URETEROLITHOTOMY; MID 1/3 URETER 50630 URETEROLITHOTOMY; LOWER 1/3 URETER 50650 URETERECTOMY W/BLADDER CUFF (SEPART PROC) 50660 URETERECTOMY TOT-COMBO ABD/VAG &/OR PERINEAL 50684 INJ PROC-URETEROGRAPHY THRU URETEROSTOMY/CATH 50686 MANOMETRIC STUDIES THRU URETEROSTOMY/CATH

$4,130

90

$1,360

90

$2,719

90

$238

0

$357

0

$374

0

$85

0

$510

0

$85

0

$76

0

$1,700

90

$2,040

90

$1,530

90

$1,530

90

$1,870

90

$1,870

90

$2,379

90

$1,273

90

$1,754

90

$1,627

90

$2,090

90

$1,909

90

BR

N/A

$170

0

$357

0

$391

0

$459

0

$510

0

$544

0

$204

0

$391

0

$408

0

$680

0

$493

0

$544

0

$578

0

$1,810

90

$1,369

90

$856

90

$1,455

90

$1,369

90

$1,455

90

$1,540

90

$1,797

90

$56

0

$68

0

Section VII: Surgical Services

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SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

* 50688 CHANGE URETEROSTOMY TUBE 50690 INJ PROC-VISUALIZ ILEAL CONDUIT OF RAD 50700 URETEROPLASTY PLASTIC OR URETER 50715 URETEROLYSIS W/WO REPOSIT URETER 50722 URETEROLYSIS OVARIAN VEIN SYNDROME 50725 URETEROLYSIS W/REANASTOM UPPER URIN TRACT 50727 REVIS URIN-CUT ANASTOM 50728 REVIS URIN-CUT ANASTOM; W/REPR FASCIAL DEFECT 50740 URETEROPYELOSTOMY ANASTOM URETER & RENAL PELVIS 50750 URETEROCALYCOSTOMY ANASTOM URETER TO RENAL CALYX 50760 URETEROURETEROSTOMY 50770 TRANSURETEROURETEROSTOMY ANASTOM URETER-CONTRALA 50780 URETERONEOCYSTOSTOMY; ANASTOM SNGL URETER 50782 URETERONEOCYSTOSTOMY; ANASTOM DUPLIC URETER 50783 URETERONEOCYSTOSTOMY; W/EXTEN URETERAL TAILORING 50785 URETERONEOCYSTOSTOMY; W/VESICO-PSOAS HITCH 50800 URETEROENTEROSTOMY DIREC ANASTOM URETER-INTESTIN 50810 URETEROSIGMOIDOSTOMY W/CREAT SIGMOID BLADDER 50815 URETEROCOLON CONDUIT INCL BOWEL ANASTOM 50820 URETEROILEAL CONDUIT INCL BOWEL ANASTOM 50825 CONTINENT DIVERSION INCL BOWEL ANASTOM 50830 URIN UNDIVERSION 50840 REPL ALL/PART URETER BY BOWEL SEGMT W/ANASTOM 50845 CUT APPENDICO-VESICOSTOMY 50860 URETEROSTOMY TRANSPL URETER TO SKIN 50900 URETERORRHAPHY SUTURE URETER (SEPART PROC) 50920 CLO URETEROCUTANEOUS FISTULA 50930 CLO URETEROVISCERAL FISTULA 50940 DELIGATION URETER 50945 LAPAROSCOPY, URETEROLITHOTOMY 50951 URETERAL ENDO-URETEROSTOMY EXCLUS OF RAD SERV 50953 URETERAL ENDO-URETEROSTOMY; W/URETERAL CATH 50955 URETERAL ENDO-URETEROSTOMY W/WO IRRIGA; W/BX 50957 URETERAL ENDO-URETEROSTOMY; W/FULG &/OR INCS 50959 URETERAL ENDO-URETEROSTOMY; W/INSRT RADIOACTIVE 50961 URETERAL ENDO-URETEROSTOMY; W/REMOV FB/CALCU 50970 URETERAL ENDO-URETEROTOMY EXCLUS OF RAD SERV 50972 URETERAL ENDO-URETEROTOMY; W/URETERAL CATH 50974 URETERAL ENDO-URETEROTOMY W/WO IRRIGA; W/BX 50976 URETERAL ENDO-URETEROTOMY; W/FULG &/OR INCS 50978 URETERAL ENDO-URETEROTOMY; W/INSRT RADIOACTIVE 50980 URETERAL ENDO-URETEROTOMY; W/REMOV FB/CALCU
* 51000 ASPIRAT BLADDER BY NEEDLE * 51005 ASPIRAT BLADDER; BY TROCAR/INTRACATHETER
51010 ASPIRAT BLADDER; W/INSRT SUPRAPUBIC CATH 51020 CYSTOTOMY/CYSTOSTOMY; W/FULG &/OR INSRT RADIOACT

$51

10

$68

0

$1,540

90

$1,540

90

$1,198

90

$2,054

90

$1,027

90

$1,369

90

$1,797

90

$1,883

90

$1,797

90

$1,883

90

$1,797

90

$1,968

90

$2,054

90

$2,139

90

$1,797

90

$2,738

90

$2,738

90

$2,738

90

$2,995

90

$1,711

90

$2,738

90

$1,951

90

$1,369

90

$1,540

90

$1,540

90

$1,883

90

$1,540

90

$1,541

90

$154

0

$342

0

$377

0

$445

0

$496

0

$531

0

$188

0

$377

0

$411

0

$479

0

$531

0

$565

0

$69

0

$80

0

$228

10

$1,371

90

Section VII: Surgical Services

Page 129

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

51030 CYSTOTOMY/CYSTOSTOMY; W/CRYOSURG DESTRCT LES 51040 CYSTOSTOMY CYSTOTOMY W/DRAINAGE 51045 CYSTOTOMY W/INSRT URETERAL CATH/STENT (SEP PRO) 51050 CYSTOLITHOTOMY WO VESICAL NECK RESECT 51060 TRANSVESICAL URETEROLITHOTOMY 51065 CYSTOTOMY W/STONE BASKET EXTRACT URETERAL CALCU 51080 DRAINAGE PERIVESICAL/PREVESICAL SPACE ABSCESS 51500 EXC URACHAL CYST W/WO UMBILICAL HERNIA REPR 51520 CYSTOTOMY; SIMPL EXC VESICAL NECK (SEPART PROC) 51525 CYSTOTOMY; EXC BLADDER DIVERTIC 1/MX (SEP PRO) 51530 CYSTOTOMY; EXC BLADDER TUMOR 51535 CYSTOTOMY EXC INCS/REPR URETEROCELE 51550 CYSTECTOMY PART; SIMPL 51555 CYSTECTOMY PART; COMPLIC 51565 CYSTECTOMY PART W/REIMPLNT URETER INTO BLADDER 51570 CYSTECTOMY COMPLT; (SEPART PROC) 51575 CYSTECTOMY COMPLT; W/BILAT PELVIC LYMPHADENECTMY 51580 CYSTECTOMY COMPLT W/URETEROSIGMOIDOSTOMY 51585 CYSTECTOMY W/URETERSIGMOIDOSTOMY; W/LYMPHADENECT 51590 CYSTECTOMY COMPLT W/URETEROILEAL CONDUIT 51595 CYSTECTOMY COMPLT W/SIDMOID BLADDER; W/LYMPHADEN 51596 CYSTECTOMY COMPLT W/CONTINENT DIVERSION 51597 PELVIC EXENTERATION FOR PROSTATIC/URETHRAL MALIG * 51600 INJ PROC-CYSTOGRAPHY/VOIDING URETHROCYSTOGRAPHY 51605 INJ PROC/PLCMT CHAIN-CONTRAST URETHROCYSTOGRAPHY 51610 INJ PROC RETROGRADE URETHROCYSTOGRAPHY * 51700 BLADDER IRRIGA SIMPL LAVAGE &/OR INSTILL * 51705 CHANGE CYSTOSTOMY TUBE; SIMPL * 51710 CHANGE CYSTOSTOMY TUBE; COMPLIC 51715 ENDO INJ IMPLNT MAT-URETHRE &/OR BLADDER NECK 51720 BLADDER INSTILL ANTICARCINOGENIC AGENT 51725 SIMPL CYSTOMETROGRAM 51726 COMPLX CYSTOMETROGRAM 51736 SIMPL UROFLOWMETRY 51741 COMPLX UROFLOWMETRY 51772 URETHRAL PRESS PROFILE STUDIES ANY TECH 51784 EMG ANAL/URETHRAL SPHINCTER-NOT NEEDLE-ANY TECH 51785 NEEDLE EMG STDY ANAL/URETHRAL SPHINCTER ANY TECH 51792 STIMULUS EVOKED RESPONSE 51795 VOIDING PRESS STUDIES; BLADDER VOIDING PRESS 51797 VOIDING PRESS STUDIES; INTRA-ABD VOIDING PRESS 51800 CYSTOPLASTY/CYSTOURETHROPLASTY WO RESECT VESICAL 51820 CYSTOURETHROPLASTY W/UNILAT/BILAT URETERONEOCYST 51840 ANT VESICOURETHROPEXY/URETHROPEXY; SIMPL 51841 ANT VESICOURETHROPEXY/URETHROPEXY; COMPLIC 51845 ABD-VAG VESICAL NECK SUSPEN W/WO ENDO CONTRL

$1,371

90

$1,142

90

$1,257

90

$1,371

90

$1,828

90

$1,599

90

$1,028

90

$1,485

90

$1,599

90

$2,056

90

$1,599

90

$1,599

90

$1,599

90

$2,056

90

$2,513

90

$2,742

90

$4,113

90

$4,044

90

$5,027

90

$5,209

90

$5,986

90

$5,712

90

$6,512

90

$69

0

$91

0

$103

0

$46

0

$69

10

$274

10

$548

0

$91

0

$107 $91 0

$123 $105 0

$53 $45 0

$66 $56 0

$115 $98 0

$115 $98 0

$115 $98 0

$115 $98 0

$107 $91 0

$123 $105 0

$2,129

90

$3,086

90

$1,660

90

$1,873

90

$1,596

90

Section VII: Surgical Services

Page 130

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

51860 CYSTORRHAPHY WOUND/INJURY/RUPT; SIMPL 51865 CYSTORRHAPHY WOUND/INJURY/RUPT; COMPLIC 51880 CLO CYSTOSTOMY (SEPART PROC) 51900 CLO VESICOVAGINAL FISTULA ABD APPROACH 51920 CLO VESICOUTERINE FISTULA 51925 CLO VESICOUTERINE FISTULA; W/HYST 51940 CLO BLADDER EXSTROPHY 51960 ENTEROCYSTOPLASTY INCL BOWEL ANASTOM 51980 CUT VESICOSTOMY 51990 LAPAROSCOPY, URETHRAL SUSPENSION 51992 LAPAROSCOPY, SLING OPERATION 52000 CYSTOURETHROSCOPY (SEPART PROC) 52005 CYSTOURETHROSCOPY W/URETERAL CATH EXCLUS-RAD 52007 CYSTOURETHROSCOPY EXCLUS-RAD SERV; W/BRUSH BX 52010 CYSTOURETHROSCOPY W/EJACULATORY DUCT CATH 52204 CYSTOURETHROSCOPY W/BX 52214 CYSTOURETHROSCOPY W/FULG TRIGONE/BLADDER NECK 52224 CYSTOURETHROSCOPY W/FULG/TX MINOR (< 0.5CM) LES 52234 CYSTOURETHROSCOPY W/FULG &/OR RESECT; SM TUMOR 52235 CYSTOURETHROSCOPY W/FULG &/OR RESECT; MED TUMOR 52240 CYSTOURETHROSCOPY W/FULG &/OR RESECT; LG TUMOR 52250 CYSTOURETHROSCOPY W/INSRT RADIOACT SUBSTANCE 52260 CYSTOURETHROSCOPY W/DILAT BLADDER; GEN ANES 52265 CYSTOURETHROSCOPY W/DILAT BLADDER; LOCAL ANES 52270 CYSTOURETHROSCOPY W/INT URETHROTOMY; FE 52275 CYSTOURETHROSCOPY W/INT URETHROTOMY; MALE 52276 CYSTOURETHROSCOPY W/DIREC VISION INT URETHROTOMY 52277 CYSTOURETHROSCOPY W/RESECT EXT SPHINCTER 52281 CYSTOURETHROSCOPY W/CALIBRAT &/OR DILAT URETHRAL 52282 CYSTOSCOPY, IMPLANT STENT 52283 CYSTOURETHROSCOPY W/STEROID INJ INTO STRICT 52285 CYSTOURETHROSCOPY TX FE URETHRAL SYNDROME 52290 CYSTOURETHROSCOPY; W/URETERAL MEATOTOMY 52300 CYSTOURETHROSCPY; W/RESECT ORTHOTOP URETEROCELE 52301 CYSTOURETHROSCOPY; W/RESECT ECTOPIC URETEROCELE 52305 CYSTOURETHROSCOPY; W/INCS BLADDER DIVERTIC 52310 CYSTOURETHROSCOPY W/REMOV FB (SEP PRO); SIMPL 52315 CYSTOURETHROSCOPY W/REMOV FB (SEP PRO); COMPLIC 52317 LITH: CRUSH CALCU-BLADDER; SIMPL/SM (< 2.5 CM) 52318 LITH: CRUSH CALCU-BLADDER; COMPLIC/LG (>2.5 CM) 52700 TRANSURETHRAL DRAINAGE PROSTATIC ABSCESS 53000 URETHROTOMY EXT (SEPART PROC); PENDULOUS URETHRA 53010 URETHROTOMY EXT (SEPART PROC); PERINEAL URETHRA 53020 MEATOTOMY CUT MEATUS (SEPART PROC); EX INFANT 53040 DRAINAGE DEEP PERIURETHRAL ABSCESS 53060 DRAINAGE SKENE'S GLAND ABSCESS/CYST

$1,490

90

$1,916

90

$958

90

$2,235

90

$1,916

90

$2,235

90

$1,277

90

$3,406

90

$1,916

90

$1,395

90

$1,519

90

$235

0

$385

0

$428

0

$406

0

$403

0

$403

0

$424

0

$636

0

$1,060

0

$1,484

0

$488

0

$382

0

$403

0

$466

0

$572

0

$784

0

$594

0

$382

0

$981

0

$371

0

$477

0

$424

0

$572

0

$572

0

$572

0

$424

0

$700

0

$869

0

$1,166

0

$757

90

$214

10

$446

90

$178

0

$268

90

$107

10

Section VII: Surgical Services

Page 131

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

53080 DRAIN PERINEAL URIN EXTRAVASAT; UNCOMP (SEP PRO) 53085 DRAINAGE PERINEAL URIN EXTRAVASATION; COMPLIC 53200 BX URETHRA 53210 URETHRECTOMY TOT INCL CYSTOSTOMY; FE 53215 URETHRECTOMY TOT INCL CYSTOSTOMY; MALE 53220 EXC/FULG CARCINOMA URETHRA 53230 EXC URETHRAL DIVERTIC (SEPART PROC); FE 53235 EXC URETHRAL DIVERTIC (SEPART PROC); MALE 53240 MARSUPIALIZATION URETHRAL DIVERTIC MALE/FE 53250 EXC BULBOURETHRAL GLAND 53260 EXC/FULG; URETHRAL POLYP DISTAL URETHRA 53265 EXC/FULG; URETHRAL CARUNCLE 53270 EXC/FULG; SKENE'S GLANDS 53275 EXC/FULG; URETHRAL PROLAPSE 53400 URETHROPLASTY; 1ST STAGE-FISTULA/DIVERTIC/STRICT 53405 URETHROPLASTY; 2ND STAGE INCL URIN DIVERSION 53410 URETHROPLASTY 1-STAGE RECON MALE ANT URETHRA 53415 URETHROPLASTY 1 STAGE RECON PROSTATIC URETHRA 53420 URETHROPLASTY 2-STAGE RECON URETHRA; 1ST STAGE 53425 URETHROPLASTY, 2-STAGE RECON URETHRA; 2ND STAGE 53430 URETHROPLASTY RECON FE URETHRA 53440 OR CORRECT MALE URIN INCONT W/WO INTRO PROSTH 53442 REMOV PERINEAL PROSTH FOR CONTINENCE 53443 URETHROPLASTY W/TUBULARIZ POST URETHRA-INCONTIN 53445 OR-CORRECT URIN INCONT W/PLCMT SPHINCTER 53447 REMOV/REPR/REPLAC INFLATABLE SPHINCTER 53449 SURG CORRECT HYDRAULIC ABNL INFLATABLE SPHINCTER 53450 URETHROMEATOPLASTY W/MUCOS ADVANCEMENT 53460 URETHROMEATOPLASTY W/PART EXC DISTAL URETHRL SEG 53502 URETHRORRHAPHY SUTURE URETHRAL WOUND/INJURY; FE 53505 URETHRORRHAPHY SUTURE URETHRAL WOUND; PENILE 53510 URETHRORRHAPHY SUTURE URETHRAL WOUND PERINEAL 53515 URETHRORRHAPHY SUTURE WOUND; PROSTATOMEMBRANOUS 53520 CLO URETHROSTOMY FISTULA MALE (SEPART PROC) * 53600 DILAT URETHRAL STRICT-SOUND DILAT-MALE; INIT * 53601 DILAT URETHRAL STRICT-SOUND/DILAT-MALE; SUBSQT 53605 DILAT URETHRAL STRICT-MALE-GEN/CONDUCTION ANES * 53620 DILAT URETHRAL STRICT-FILLIFORM-MALE; INIT * 53621 DILAT URETHRAL STRICT-FILLIFORM-MALE; SUBSQT * 53660 DILAT FE URETHRA INCL SUPPOSITORY; INIT * 53661 DILAT FE URETHRA INCL SUPPOSITORY; SUBSQT 53665 DILAT FE URETHRA GEN/CONDUCTION ANES * 53670 CATH URETHRA; SIMPL * 53675 CATH URETHRA; COMPLIC 53850 PROSTATIC MICROWAVE THERMOTX 53852 PROSTATIC RF THERMOTX

$268

90

$446

90

$178

0

$1,159

90

$1,427

90

$892

90

$1,070

90

$1,070

90

$446

90

$981

90

$125

10

$268

10

$268

10

$357

10

$892

90

$1,249

90

$1,427

90

$1,605

90

$1,605

90

$1,605

90

$1,249

90

$1,605

90

$535

90

$1,605

90

$3,835

90

$535

90

$892

90

$357

90

$392

90

$892

90

$892

90

$1,159

90

$1,784

90

$624

90

$54

0

$40

0

$125

0

$76

0

$61

0

$45

0

$36

0

$103

0

$34

0

$62

0

$1,208

90

$1,263

90

Section VII: Surgical Services

Page 132

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

53899 UNLISTED PROC URIN SYST * 60000 I&D THYROGLOSSAL CYST INFEC
60001 ASPIRAT &/OR INJ THYROID CYST * 60100 BX THYROID PERCUT CORE NEEDLE
60200 EXC CYST/ADENOMA THYROID/TRANSECTION ISTHMUS 60210 PART THYROID LOBEC UNILAT; W/WO ISTHMUSECTOMY 60212 PART THYROID LOBEC UNILAT; W/CONTRALAT SUBTL LOB 60220 TOT THYROID LOBEC UNILAT; W/WO ISTHMUSECTOMY 60225 TOT THYROID LOBEC UNILAT; W/CONTRALAT SUBTL LOBE 60240 THYROIDECTOMY TOT/COMPLT 60252 THYROIDECTOMY TOT/SUBTL-MALIG; W/LTD NECK DISSEC 60254 THYROIDECTOMY TOT/SUBTL-MALIG; W/RAD NECK DISSEC 60260 THYROIDECTOMY-REMOV REMAIN TISS-PREV REMOV PORTN 60270 THYROIDECTOMY INCL SUBSTERNL GLAND; STERNL SPLIT 60271 THYROIDECTOMY INCL SUBSTERNL GLAND; CERV APPROA 60280 EXC THYROGLOSSAL DUCT CYST/SINUS 60281 EXC THYROGLOSSAL DUCT CYST/SINUS; RECURRENT 60500 PARATHYROIDECTOMY/EXPLOR PARATHYROID 60502 PARATHYROIDECTOMY/EXPLOR PARATHYROID; RE-EXPLOR 60505 PARATHYROIDECTOMY; W/MEDIASTINAL EXPLOR 60512 PARATHYROID AUTOTRANSPL 60520 THYMECTOMY PART/TOT; TRANSCERV (SEPART PROC) 60521 THYMECTOMY PART/TOT; STERN SPLIT (SEPART PROC) 60522 THYMECTOMY; W/RADICAL MEDIASTIN DISSEC (SEP PRO) 60540 ADRENALECTOMY/EXPLOR ADRENAL GLAND (SEPART PROC) 60545 ADRENALECTOMY (SEP PRO); W/EXC RETROPERIT TUMOR 60600 EXC CAROTID BODY TUMOR; WO EXC CAROTID ART 60605 EXC CAROTID BODY TUMOR; W/EXC CAROTID ART 60650 LAPAROSCOPY, W/ TRANSABD PARTL/COMPLETE ADRENAL. 60659 UNLISTED PROC, LAPAROSCOPY, ENDOCRINE SYSTEM 60699 UNLISTED PROC ENDOCRINE SYST * 61000 SUBDURAL TAP-FONTANELLE INFANT UNI/BILAT; INIT * 61001 SUBDURAL TAP-FONTANELLE INFANT; SUBSQT TAPS * 61020 VENTRICULAR PUNCT-PREV BURR HOLE/SUTURE; WO INJ * 61026 VENTRICULAR PUNCT-THRU SUTURE; W/INJ DRUG-DX/TX 61050 CISTERNAL/LAT CERV PUNCT; WO INJ (SEPART PROC) * 61055 CISTERNAL PUNCT; W/INJ DRUG/OTHER-DX/TX * 61070 PUNCT SHUNT TUBING/RESERVOIR-ASPIRAT/INJ PROC * 61105 TWIST DRILL HOLE; NOT FOLLOWED BY OTHER SURG * 61107 TWIST DRILL HOLE; INPLNT VENT CATH/RECORD DEVICE 61108 TWIST DRILL HOLE; EVACUAT &/OR DRAIN HEMATOMA 61120 BURR HOLE-VENT PUNCT; NOT FOLLOWED BY OTHER SURG 61140 BURR HOLE/TREPHINE; W/BX-BRAIN/INTRACRAN LES 61150 BURR HOLE/TREPHINE; W/DRAIN BRAIN ABSCESS/CYST 61151 BURR HOLE; W/SUBSQT TAPPING INTRACRAN ABSCESS 61154 BURR HOLE W/EVACUATION &/OR DRAIN HEMATOMA

BR

N/A

$123

10

$76

0

$164

0

$1,124

90

$1,533

90

$1,737

90

$1,492

90

$1,860

90

$1,839

90

$2,657

90

$3,270

90

$1,696

90

$2,146

90

$1,839

90

$1,226

90

$1,288

90

$1,880

90

$2,064

90

$2,453

90

$376

N/A

$2,105

90

$2,146

90

$2,667

90

$1,993

90

$2,555

90

$2,044

90

$2,350

90

BR

N/A

BR

N/A

BR

N/A

$237

0

$166

0

$261

0

$261

0

$237

0

$379

0

$213

0

$1,185

90

$1,540

0

$2,370

90

$1,185

90

$2,607

90

$2,607

90

$355

90

$2,962

90

Section VII: Surgical Services

Page 133

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

61156 BURR HOLE; W/ASPIRAT HEMATOMA/CYST INTRACEREBRAL 61210 BURR HOLE; IMPLNT VENTRICULAR CATH (SEPART PROC) 61215 INSRT SUBQ RESERVOIR/PUMP-CONNECT TO VENT CATH 61250 BURR HOLE/TREPHINE-SUPRATENTOR-NO OTHER SURG 61253 BURR HOLE/TREPHINE-INFRATENTORIAL-UNILAT/BILAT 61304 CRANIECTOMY/CRANIOTOMY EXPLOR; SUPRATENTORIAL 61305 CRANIECTOMY/CRANIOTOMY EXPLOR; INFRATENTORIAL 61312 CRANIECTOMY-HEMATOMA-SUPRATENT; EXTRA/SUBDURAL 61313 CRANIECTOMY-HEMATOMA-SUPRATENT; INTRACEREBRAL 61314 CRANIECTOMY-HEMATOMA-INFRATENT; EXTRA/SUBDURAL 61315 CRANIECTOMY-HEMATOMA-INFRATENT; INTRACEREBELLAR 61320 CRANIECTOMY DRAIN INTRACRAN ABSCESS; SUPRATENT 61321 CRANIECTOMY DRAIN INTRACRAN ABSCESS; INFRATENT 61330 DECOMP ORBIT ONLY TRANSCRANIAL APPROACH 61332 EXPLOR ORBIT; W/BX 61333 EXPLOR ORBIT; W/REMOV LES 61334 EXPLOR ORBIT; W/REMOV FB 61340 OTHER CRANIAL DECOMP SUPRATENTORIAL 61343 CRANIECTOMY-SUBOCCIPIT W/LAMINEC W/WO DURAL GFT 61345 OTHER CRANIAL DECOMP POST FOSSA 61440 CRANIOTOMY-SECT TENTORIUM CEREBELLI (SEP PRO) 61450 CRANIECTOMY-SUBTEMPORAL-SECT GASSERIAN GANGLION 61458 CRANIECTOMY SUBOCCIPITAL; EXPLOR CRANIAL NERV 61460 CRANIECTOMY SUBOCCIPIT; SECT-1/MORE CRANIAL NERV 61470 CRANIECTOMY SUBOCCIPITAL; MEDULLARY TRACTOTOMY 61480 CRANIECTOMY SUBOCCIPITAL; PEDUNCULOTOMY 61490 CRANIOTOMY LOBOTOMY INCL CINGULOTOMY 61500 CRANIECTOMY; W/EXC TUMOR/OTHER BONE LES-SKULL 61501 CRANIECTOMY; OSTEOMYELITIS 61510 CRANIECTOMY; EXC BRAIN TUMOR-SUPRATENTORIAL 61512 CRANIECTOMY; EXC MENINGOMA-SUPRATENTORIAL 61514 CRANIECTOMY; EXC BRAIN ABSCESS-SUPRATENTORIAL 61516 CRANIECTOMY; EXC/FENESTRATION CYST-SUPRATENT 61518 CRANIECTOMY-EXC TUMOR-POST FOSSA; EX MENINGIOMA 61519 CRANIECTOMY-EXC TUMOR-POST FOSSA; MENINGIOMA 61520 CRANIECTOMY-POST FOSSA; CEREBELLOPONTINE ANGLE 61521 CRANIECTOMY-EXC TUMOR; MIDLINE TUMOR @ BASE SKUL 61522 CRANIECTOMY INFRATENTORIAL; EXC BRAIN ABSCESS 61524 CRANIECTOMY INFRATENTORIAL; EXC/FENESTRAT CYST 61526 CRANIECTOMY-TRANSTEMPORAL-EXC CEREBELLOPONTINE 61530 CRANIECTOMY; COMBO W/POST FOSSA CRANIOTOMY 61531 SUBDURAL IMPLNT STRIP ELECTRODES THRU BURR HOLE 61533 CRANIOTOMY W/ELEVAT FLAP; IMPLNT ELECTRODE ARRAY 61534 CRANIOTOMY W/ELEV FLAP; EXC EPILEPTOGENIC FOCUS 61535 CRANIOTOMY W/FLAP; REMOV ELECT ARRAY (SEP PRO) 61536 CRANIOTOMY W/FLAP; EXC CEREBRAL EPILEPTOGENIC

$2,607

90

$1,588

0

$1,540

90

$1,540

90

$2,370

90

$3,460

90

$3,792

90

$4,029

90

$4,266

90

$3,555

90

$4,029

90

$4,147

90

$3,792

90

$3,247

90

$3,365

90

$3,602

90

$3,081

90

$2,393

90

$6,019

90

$2,251

90

$2,820

90

$3,792

90

$4,763

90

$4,574

90

$3,057

90

$2,749

90

$2,702

90

$3,910

90

$3,081

90

$5,332

90

$5,332

90

$4,503

90

$4,503

90

$5,332

90

$5,522

90

$5,522

90

$5,972

90

$4,503

90

$4,503

90

$4,740

90

$4,977

90

$2,891

90

$4,621

90

$4,811

90

$3,081

90

$4,740

90

Section VII: Surgical Services

Page 134

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

61538 CRANIOTOMY W/FLAP; LOBECTOMY TEMPORAL LOBE 61539 CRANIOTOMY W/FLAP; LOBECTOMY-NOT TEMPORAL LOBE 61541 CRANIOTOMY W/FLAP; TRANSECTION CORPUS CALLOSUM 61542 CRANIOTOMY W/FLAP; TOT HEMISPHERECTOMY 61543 CRANIOTOMY W/FLAP; PART/SUBTL HEMISPHERECTOMY 61544 CRANIOTOMY W/FLAP; COAGULATION CHOROID PLEXUS 61545 CRANIOTOMY W/FLAP; EXC CRANIOPHARYNGIOMA 61546 CRANIOTOMY-HYPOPHYSECTOMY-INTRACRAN APPROACH 61548 HYPOPHYSECTOMY-TRANSNASAL NONSTEREOTACTIC 61550 CRANIECTOMY-CRANIOSYNOSTOSIS; 1 CRANIAL SUTURE 61552 CRANIECTOMY-CRANIOSYNOSTOSIS; MX CRANIAL SUTURES 61556 CRANIOTOMY-CRANIOSYNOSTOSIS; FRONTAL BONE FLAP 61557 CRANIOTOMY CRANIOSYNOSTOSIS; BIFRONTAL BONE FLAP 61558 EXTEN CRANIECTOMY-CRANIOSYNOSTOSIS; NOT REQ GFT 61559 EXTEN CRANIECTOMY; RECONTOUR W/OSTEOTOM/AUTOGFT 61563 EXC INTRA & EXTRACRAN BEN TUMOR; WO OPTIC NERV 61564 EXC INTRA & EXTRACRAN BEN TUMOR; W/OPTIC NERV 61570 CRANIECTOMY/CRANIOTOMY; W/EXC FB FROM BRAIN 61571 CRANIECT/CRANIOT; W/TX PENETRATING WOUND BRAIN 61575 TRANSORAL APPROACH SKULL BASE-BX/DECOMP/EXC LES 61576 TRANSORAL APPROACH SKULL BASE; W/SPLIT TONGUE 61580 CRANIOFAC-ANT CRAN FOSSA; XTRDURL WO MAXILLECTMY 61581 CRANIOFAC-ANT CRAN FOSSA; XTRDURL INCL MAXILLECT 61582 CRANIOFAC APPROACH; EXTRDURL ELEVAT FRONTAL LOBE 61583 CRANIOFAC APPROACH; EXTRDURL RESECT FRONTAL LOBE 61584 ORBITOCRANIAL APPROACH; WO ORBITAL EXENTERATION 61585 ORBITOCRANIAL APPROACH; W/ORBITAL EXENTERATION 61586 BICORONAL/TRANSZYGO/LEFORT APPRCH-ANT CRAN FOSSA 61590 INFRATEMP APPROACH-MID FOSSA INCL PAROTIDECTOMY 61591 INFRATEMP APPROACH-MID FOSSA INCL MASTOIDECTOMY 61592 ORBITOCRAN ZYGOMATIC APPROACH INCL OSTEOTOMY ZYG 61595 TRANSTEMP APPROACH-POST FOSSA INCL MASTOIDECT 61596 TRANSCOCHLEAR APPROACH INCL LABYRINTHECTOMY 61597 TRANSCONDYL APPROACH INCL RESECT C1-C3 BODY(S) 61598 TRANSPETROSAL APPROACH INCL LIG SUPERIOR SINUS 61600 RESECT/EXC LES BASE ANT CRAN FOSSA; EXTRADURAL 61601 RESECT/EXC LES BASE ANT CRAN FOSSA; INTRADURAL 61605 RESECT/EXC LES INFRATEMPORAL FOSSA; EXTRADURAL 61606 RESECT/EXC LES INFRATEMPORAL FOSSA; INTRADURAL 61607 RESECT/EXC LES PARASELLAR AREA; EXTRADURAL 61608 RESECT/EXC LES PARASELLAR; INTRADURAL INCL REPR 61609 TRANSECT/LIG CAROTID ART-CAVERNUS SINUS; WO REPR 61610 TRANSECT/LIG CAROTID ART; W/REPR-ANASTOM/GFT 61611 TRANSECT/LIG CAROTID ART-PETROUS CANAL; WO REPR 61612 TRANSECT CAROTID ART-PETROUS CANAL; W/REPR-GFT 61613 OBLIT CAROTID ANEURY/AV MALFORM/FIST-DISSECTION

$4,977

90

$4,977

90

$5,924

90

$5,924

90

$5,924

90

$4,147

90

$5,924

90

$5,095

90

$4,858

90

$2,962

90

$3,555

90

$3,460

90

$4,147

90

$4,266

90

$5,095

90

$4,668

90

$5,616

90

$5,308

90

$5,308

90

$3,673

90

$3,910

90

$2,962

90

$4,147

90

$4,266

90

$4,503

90

$2,962

90

$4,147

90

$2,962

90

$4,720

90

$4,930

90

$4,455

90

$3,958

90

$4,266

90

$5,498

90

$3,555

90

$3,934

90

$4,218

90

$4,455

90

$5,948

90

$5,569

90

$6,469

90

$1,588

N/A

$4,787

N/A

$1,185

N/A

$4,479

N/A

$6,351

90

Section VII: Surgical Services

Page 135

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

61615 RESECT/EXC LES POST CRAN FOSSA; EXTRADURAL 61616 RESECT/EXC LES POST CRAN FOSSA; INTRADURAL W/REP 61618 SECNDRY REPR DURA FOLLOWING SURG; FREE TISS GFT 61619 SECNDRY REPR DURA; LOCAL/REGION PEDICL/MYOQ FLAP 61624 TRANSCATH OCCLUD PERCUT; CENTRAL NERVOUS SYST 61626 TRANSCATH OCCLUD PERCUT; NON-CNS/HEAD/NECK 61680 SURG INTRACRAN AV MALFORM; SUPRATENTORIAL SIMPL 61682 SURG INTRACRAN AV MALFORM; SUPRATENTORIAL COMPLX 61684 SURG INTRACRAN AV MALFORM; INFRATENTORIAL SIMPL 61686 SURG INTRACRAN AV MALFORM; INFRATENTORIAL COMPLX 61690 SURG INTRACRAN AV MALFORM; DURAL SIMPL 61692 SURG INTRACRAN AV MALFORM; DURAL COMPLX 61700 SURG ANEURY INTRACRAN APPROACH; CAROTID CIRCULAT 61702 SURG ANEURY INTRACRAN; VERTEBRAL-BASILAR CIRCULA 61703 SURG INTRACRAN ANEURY-CERV-APPLIC CLAMP-CAROTID 61705 SURG ANEURY; INTRACRAN & CERV OCCLUD CAROTID ART 61708 SURG ANEURY; INTRACRAN ELECTROTHROMBOSIS 61710 SURG ANEURY; INTRA-ART EMBOLIZATION/BALLOON CATH 61711 ANASTOM ART EXTRACRANIAL-INTRACRAN ART 61720 CREAT LES-STEREOTACTIC METHD; GLOBUS PALLIDUS 61735 CREAT LES-STEREOTACTIC; SUBCORTICAL STRUCT 61750 STEREOTACTIC BX/ASPIRAT/EXC INTRACRAN LES 61751 STEREOTACTIC BX/ASPIRAT/EXC INTRACRAN LES; W/CAT 61760 STEREOTACTIC IMPLNT DEPTH ELECTRODES-CEREBRUM 61770 STEREOTACTIC LOCALIZ W/INSRT CATH BRACHYTHERAPY 61790 CREAT LES-STEREOTAC PERCUT; GASSERIAN GANGLION 61791 CREAT LES-STEREOTAC; TRIGEMINAL MEDULLARY TRACT 61793 STEREOTACTIC RADIOSURG (PART BEAM/GAMMA/ACCEL) 61795 STEREOTACTIC COMPUTER ASSIST VOLUM INTRACRAN 61850 TWIST DRILL-IMPLNT NEUROSTIM ELECTRODE; CORTICAL 61860 CRANIECTOMY IMPLNT ELECTROD CEREBRAL; CORTICAL 61862 STEREOTACTIC IMPLANT NEUROSTIMULATOR ARRAY 61870 CRANIECTOMY IMPLNT ELECTROD CEREBELLAR; CORTICAL 61875 CRANIECTOMY IMPLNT ELECTROD CEREBELLAR; SUBCORTI 61880 REVIS/REMOV INTRACRAN NEUROSTIMULATOR ELECTRODES 61885 INCS & SUBQ PLCMT CRANIAL NEUROSTIM GEN/RECEIVER 61886 SUBQ PLACEMENT CRANIAL NEUROSTIMULATOR PULSE GEN. 61888 REVIS/REMOV CRANIAL NEUROSTIM PULSE GEN/RECEIVER 62000 ELEVATION DEPRESSED SKULL FX; SIMPL EXTRADURAL 62005 ELEVAT SKULL FX; COMPOUND/COMMINUTED EXTRADURAL 62010 ELEVAT SKULL FX; W/REPR DURA &/OR DEBRID BRAIN 62100 CRANIOT-REPR DURAL/CSF LEAK INCL SURG-OTORRHEA 62115 REDUCT CRANIOMEGALIC SKULL; NOT REQ BONE GFT 62116 REDUCT CRANIOMEGALIC SKULL; W/SIMPL CRANIOPLASTY 62117 REDUCT CRANIOMEGALIC SKULL; W/CRANIOT & RECON 62120 REPR ENCEPHALOCELE SKULL VAULT INCL CRANIOPLASTY

$4,882

90

$6,659

90

$3,555

90

$5,687

90

$4,029

0

$2,773

0

$5,332

90

$6,398

90

$6,398

90

$7,678

90

$4,621

90

$5,545

90

$6,161

90

$6,754

90

$3,199

90

$5,332

90

$4,740

90

$1,896

90

$4,977

90

$4,455

90

$4,455

90

$4,266

90

$4,380

90

$4,266

90

$4,266

90

$2,915

90

$2,915

90

$5,261

90

$1,047

N/A

$2,536

90

$3,555

90

$3,757

90

$3,910

90

$3,910

90

$3,981

90

$963

90

$1,570

90

$664

10

$2,512

90

$3,318

90

$3,886

90

$4,147

90

$4,168

90

$4,421

90

$5,052

90

$3,555

90

Section VII: Surgical Services

Page 136

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

62121 CRANIOTOMY REPR ENCEPHALOCELE SKULL BASE 62140 CRANIOPLASTY SKULL DEFECT; UP TO 5 CM DIAMETER 62141 CRANIOPLASTY SKULL DEFECT; > 5 CM DIAMETER 62142 REMOV BONE FLAP/PROSTH PLATE-SKULL 62143 REPLAC BONE FLAP/PROSTH PLATE-SKULL 62145 CRANIOPLSTY-SKULL DEFECT W/REPARATIVE BRAIN SURG 62146 CRANIOPLASTY W/AUTOGFT; UP TO 5 CM DIAMETER 62147 CRANIOPLASTY W/AUTOGFT; > 5 CM DIAMETER 62180 VENTRICULOCISTERNOSTOMY 62190 CREAT SHUNT; SUBARACHNOID/SUBDURAL-ATRIAL 62192 CREAT SHUNT; SUBARACHNOID/SUBDURAL-PERITONEAL 62194 REPLAC/IRRIGA SUBARACHNOID/SUBDURAL CATH 62200 VENTRICULOCISTERNOSTOMY THIRD VENTRICLE 62201 VENTRICULOCISTERNOST-3RD VENT; STEREOTACTIC METH 62220 CREAT SHUNT; VENTRICULO-ATRIAL/JUGULAR/-AURICUL 62223 CREAT SHUNT; VENTRICULO-PERITONEAL/-PLEURAL 62225 REPLAC/IRRIGA VENTRICULAR CATH 62230 REPLAC/REVIS CSF SHUNT/OBSTRUC VALV/DISTAL CATH 62256 REMOV COMPLT CSF SHUNT SYST; WO REPLAC 62258 REMOV COMPLT CSF SHUNT; W/REPLAC-SIMILAR SHUNT 62263 LYSIS, PERCUTANEOUS, EPIDURAL ADHESIONS * 62268 PERCUT ASPIRAT SPINAL CORD CYST/SYRINX * 62269 BX SPINAL CORD PERCUT NEEDLE * 62270 SPINAL PUNCT LUMBAR DX * 62272 SPINAL PUNCT THERAP DRAINAGE SPINAL FLUID * 62273 INJ LUMBAR EPIDURAL BLD/CLOT PATCH * 62280 INJ NEUROLYTIC SUBSTANCE; SUBARACHNOID * 62281 INJ NEUROLYTIC SUBSTANCE; EPIDURAL/CERV/THORACIC * 62282 INJ NEUROLYTIC SUBSTANCE; EPIDURAL/LUMBAR/CAUDAL * 62284 INJ PROC-MYELOGRAPHY &/OR CAT-SPINAL 62287 ASPIRAT PROC-PERCUT-NUCLEUS PULPOSUS-1/MX-LUMBAR * 62290 INJ PROC DISKOGRAPHY EA LEVEL; LUMBAR * 62291 INJ PROC DISKOGRAPHY EA LEVEL; CERV 62292 INJ PROC-CHEMONUCLEOLYSIS-DISK; 1/MX LUMBAR 62294 INJ PROC ART-OCCLUD AV MALFORM SPINAL 62310 INJECTION, DX/THERAPEUTIC; CERVICAL/THORACIC 62311 INJECTION, DX/THERAPEUTIC; LUMBAR/SACRAL 62318 INJECTION/INFUSION/BOLUS; CERVICAL/THORACIC 62319 INJECTION/INFUSION/BOLUS; LUMBAR/SACRAL 62350 IMPLNT/REVIS THECAL/EPIDUR CATH; WO LAMINECT 62351 IMPLNT/REVIS INTHECAL/EPIDUR CATH; W/LAMINECT 62355 REMOV PREV IMPLNT INTRATHECAL/EPIDURAL CATH 62360 IMPLNT/REPLAC DEVIC-EPIDUR DRUG INFUS; SUBQ RESV 62361 IMPLNT/REPLAC DEVIC-EPIDUR INFUS; NONPROGRM PUMP 62362 IMPLNT/REPLAC DEVIC-EPIDUR INFUS; PROGRMBLE PUMP 62365 REMOV PREV IMPLNT SUBQ RESERVOIR/PUMP

$3,555

90

$3,057

90

$3,721

90

$2,133

90

$2,844

90

$3,792

90

$3,768

90

$4,621

90

$2,891

90

$2,725

90

$2,725

90

$1,185

10

$4,147

90

$3,768

90

$2,962

90

$3,199

90

$1,540

90

$2,251

90

$1,398

90

$3,247

90

$1,174

0

$1,201

0

$1,017

0

$123

0

$166

0

$306

0

$375

10

$351

10

$470

10

$351

0

$2,143

90

$314

0

$393

0

$1,848

90

$351

90

$434

0

$439

0

$453

0

$442

0

$2,086

90

$2,403

90

$924

90

$961

90

$961

90

$1,017

90

$610

90

Section VII: Surgical Services

Page 137

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

62367 ELEC ANALYS PROGRAMBLE IMPLNT PUMP; WO REPROGRAM 62368 ELEC ANALYS PROGRAMBLE IMPLNT PUMP; W/REPROGRAM 63001 LAMINECT W/EXPLOR WO FACETECT 1-2 VERTEB; CERV 63003 LAMINECT W/EXPLOR WO FACETECT 1-2 VERTEB; THORAC 63005 LAMINECT W/EXPLOR 1-2 VERTEB; LUMBAR EX SPONDYLO 63011 LAMINECTOMY W/EXPLOR 1-2 VERTEB SEGMT; SACRAL 63012 LAMINECT W/REMOV ABNL FACETS-SPONDYLOLIST LUMBAR 63015 LAMINECTOMY W/EXPLOR > 2 VERTEBRAL SEGMT; CERV 63016 LAMINECT W/EXPLOR > 2 VERTEBRAL SEGMT; THORACIC 63017 LAMINECTOMY W/EXPLOR > 2 VERTEBRAL SEGMT; LUMBAR 63020 LAMINOTOMY W/DECOMP NERV ROOT; 1 INTERSPACE CERV 63030 LAMINOT W/DECOMP NERV ROOT; 1 INTERSPACE LUMBAR 63035 LAMINOT W/DECOMP; EA ADD INTERSPACE CERV/LUMBAR 63040 LAMINOTOMY W/DECOMP NERV ROOT RE-EXPLOR; CERV 63042 LAMINOTOMY W/DECOMP NERV ROOT RE-EXPLOR; LUMBAR 63045 LAMINECTOMY SNGL VERTEBRAL SEGMT-UNI/BIL; CERV 63046 LAMINECTOMY SNGL VERTEBRAL SEGMT-UNI/BIL; THORAC 63047 LAMINECTOMY SNGL VERTEBRAL SEGMT-UNI/BIL; LUMBAR 63048 LAMINECTMY 1 SEGMT-UNI/BIL; EA ADD CERV/THOR/LUM 63055 TRANSPEDICULAR APPROACH SNGL SEGMT; THORACIC 63056 TRANSPEDICULAR APPROACH SNGL SEGMT; LUMBAR 63057 TRANSPEDICULAR APPROACH SNGL SEGMT; EA ADD SEGMT 63064 COSTOVERTEBRAL W/DECOMP THORACIC; SNGL SEGMT 63066 COSTOVERTEBRAL W/DECOMP THORACIC; EA ADD SEGMT 63075 DISKECTOMY ANT W/DECOMP; CERV SNGL INTERSPACE 63076 DISKECTOMY ANT W/DECOMP; CERV EA ADD INTERSPACE 63077 DISKECTOMY ANT W/DECOMP; THORACIC 1 INTERSPACE 63078 DISKECTOMY ANT; THORACIC EA ADD INTERSPACE 63081 VERTEBRAL CORPECTOMY-ANT W/DECOMP; CERV 1 SEGMT 63082 VERTEBRAL CORPECTOMY-ANT; CERV EA ADD SEGMT 63085 VERTEBRAL CORPECT TRANSTHORACIC; THORACIC 1 SEGM 63086 VERTEBRAL CORPECT TRANSTHOR; THORACIC EA AD SEGM 63087 VERTEBRAL CORPECTOMY LOW THORACIC/LUMBAR; 1 SEGM 63088 VERTEBRAL CORPECTOMY LOW THORACIC/LUMBAR; EA ADD 63090 VERTEBRAL CORPECTOMY TRANSPERITON LUMB/SACRAL; 1 63091 VERTEBRAL CORPECTOMY LUMBAR/SACRAL; EA ADD SEGMT 63170 LAMINECTOMY W/MYELOTOMY CERV/THORACIC/THORACOLUM 63172 LAMINECTOMY W/DRAIN CYST; TO SUBARACHNOID SPACE 63173 LAMINECTOMY W/DRAIN CYST; TO PERITONEAL SPACE 63180 LAMINECTOMY & SECT DENTATE LIGAMNT CERV; 1-2 SEG 63182 LAMINECTOMY & SECT DENTATE LIGAMNT CERV; >2 SEGM 63185 LAMINECTOMY W/RHIZOTOMY; 1 OR 2 SEGMT 63190 LAMINECTOMY W/RHIZOTOMY; MORE THAN 2 SEGMT 63191 LAMINECTOMY W/SECT SPINAL ACCES NERV 63194 LAMINECTOMY W/SECT 1 SPINOTHALAMIC TRACT; CERV 63195 LAMINECTOMY W/SECT 1 SPINOTHALAM TRACT; THORACIC

$73 $110 $2,696 $3,081 $2,599 $2,927 $3,081 $3,312 $3,466 $3,312 $3,042 $2,957 $963 $3,312 $3,447 $3,658 $3,562 $3,562 $1,155 $3,947 $3,593 $1,309 $3,312 $1,098 $3,042 $1,020 $2,888 $963 $3,658 $1,213 $3,658 $1,213 $3,504 $1,175 $3,466 $1,155 $2,927 $3,235 $3,562 $2,927 $3,504 $2,927 $3,504 $2,619 $2,455 $2,455

$63 N/A $96 N/A
90 90 90 90 90 90 90 90 90 90 N/A 90 90 90 90 90 N/A 90 90 N/A 90 N/A 90 N/A 90 N/A 90 N/A 90 N/A 90 N/A 90 N/A 90 90 90 90 90 90 90 90 90 90

Section VII: Surgical Services

Page 138

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

63196 LAMINECTOMY W/SECT BOTH SPINOTHALAMIC; CERV 63197 LAMINECTOMY W/SECT BOTH SPINOTHALAMIC; THORACIC 63198 LAMINECTOMY-2 STAGES WITHIN 14 DA; CERV 63199 LAMINECTOMY-2 STAGES WITHIN 14 DA; THORACIC 63200 LAMINECTOMY W/RELEASE TETHERED CORD LUMBAR 63250 LAMINECTOMY-EXC/OCCLUD AV MALFORM CORD; CERV 63251 LAMINECTOMY-EXC/OCCLUD AV MALFORM CORD; THORACIC 63252 LAMINECTOMY-EXC AV MALFORM CORD; THORACOLUMBAR 63265 LAMINECTOMY-EXC INTRASPINAL LES-EXTRADURAL; CERV 63266 LAMINECTOMY-EXC LES-EXTRADURAL; THORACIC 63267 LAMINECTOMY-EXC LES-EXTRADURAL; LUMBAR 63268 LAMINECTOMY-EXC LES-EXTRADURAL; SACRAL 63270 LAMINECTOMY-EXC INTRASPINAL LES-INTRADURAL; CERV 63271 LAMINECTOMY-EXC LES-INTRADURAL; THORACIC 63272 LAMINECTOMY-EXC LES INTRADURAL; LUMBAR 63273 LAMINECTOMY-EXC LES-INTRADURAL; SACRAL 63275 LAMINECTOMY BX/EXC NEOPLSM; EXTRADURAL-CERV 63276 LAMINECTOMY BX/EXC NEOPLSM; EXTRADURAL-THORACIC 63277 LAMINECTOMY BX/EXC NEOPLSM; EXTRADURAL-LUMBAR 63278 LAMINECTOMY BX/EXC NEOPLSM; EXTRADURAL-SACRAL 63280 LAMINECTOMY-NEOPLSM; INTRADURAL EXTRAMEDUL CERV 63281 LAMINECTOMY-NEOPLSM; INTRADUR EXTRAMEDUL THORAC 63282 LAMINECTOMY-NEOPLSM; INTRADUR EXTRAMEDUL LUMBAR 63283 LAMINECTOMY-BX/EXC NEOPLSM; INTRADURAL SACRAL 63285 LAMINECTOMY; INTRADURAL INTRAMEDULLARY CERV 63286 LAMINECTOMY; INTRADURAL INTRAMEDULLARY THORACIC 63287 LAMINECT; INTRADURAL INTRAMEDULLARY THORACOLUMB 63290 LAMINECTOMY; COMBO EXTRA-INTRADURL LES ANY LEVEL 63300 VERTEBRAL CORPECTOMY 1 SEGMT; EXTRADURAL CERV 63301 VERTEB CORPECT; EXTRADURAL THORAC-TRANSTHORACIC 63302 VERTEB CORPECT; EXTRADURAL THORAC-THORACOLUMBAR 63303 VERTEB CORPECT; LUMBAR/SACRAL TRANSPERITONEAL 63304 VERTEBRAL CORPECTOMY 1 SEGMT; INTRADURAL CERV 63305 VERTEB CORPECT; INTRADURAL THORAC-TRANSTHORACIC 63306 VERTEB CORPECT; INTRADURAL THORAC-THORACOLUMBAR 63307 VERTEB CORPECT; INTRADUR LUMB/SACRAL-TRANSPERITO 63308 VERTEBRAL CORPECTOMY 1 SEGMT; EA ADD SEGMT 63600 CREAT LES-SPINAL CORD-STEREOTACTIC METHD PERCUT 63610 STEREOTACTIC STIM-CORD-PERCUT SEP PRO WO SURG 63615 STEREOTACTIC BX/ASPIRAT/EXC LES SPINAL CORD 63650 PERCUT IMPLNT NEUROSTIM ELECTRODES; EPIDURAL 63655 LAMINECTOMY IMPLNT NEUROSTIM ELECTRODE; EPIDURAL 63660 REVIS/REMOV SPINAL NEUROSTIMULATOR ELECTRODES 63685 INCS & SUBQ PLCMT SPINAL NEUROSTIM PULSE GEN 63688 REVIS/REMOV IMPLNT SPINAL NEUROSTIM PULSE GEN 63700 REPR MENINGOCELE; LESS THAN 5 CM DIAMETER

$2,830

90

$2,715

90

$3,081

90

$3,081

90

$3,081

90

$3,158

90

$2,927

90

$3,697

90

$3,081

90

$3,081

90

$2,773

90

$2,349

90

$3,235

90

$3,235

90

$3,466

90

$2,927

90

$3,543

90

$3,543

90

$3,235

90

$2,734

90

$3,851

90

$3,851

90

$4,236

90

$3,273

90

$4,236

90

$4,236

90

$4,621

90

$4,539

90

$2,388

90

$2,465

90

$2,465

90

$2,465

90

$2,388

90

$2,465

90

$2,465

90

$2,465

90

$828

N/A

$1,925

90

$1,540

0

$2,503

90

$2,830

90

$3,235

90

$1,444

90

$1,165

90

$963

90

$2,311

90

Section VII: Surgical Services

Page 139

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

63702 REPR MENINGOCELE; LARGER THAN 5 CM DIAMETER 63704 REPR MYELOMENINGOCELE; LESS THAN 5 CM DIAMETER 63706 REPR MYELOMENINGOCELE; LARGER THAN 5 CM DIAMETER 63707 REPR DURAL/CSF LEAK NOT REQUIRING LAMINECTOMY 63709 REPR DURAL/CSF LEAK/PSEUDOMENINGOCELE W/LAMINECT 63710 DURAL GFT SPINAL 63740 CREAT SHUNT LUMBAR SUBARACH-PERITON; W/LAMINECT 63741 CREAT SHUNT LUMBAR; PERCUT WO LAMINECTOMY 63744 REPLAC IRRIGA/REVIS LUMBOSUBARACHNOID SHUNT 63746 REMOV LUMBOSUBARACHNOID SHUNT SYST WO REPLAC * 64400 INJ ANES AGENT; TRIGEMINAL NERV ANY DIVISION * 64402 INJ ANES AGENT; FACIAL NERV * 64405 INJ ANES AGENT; GREATER OCCIPT NERV * 64408 INJ ANES AGENT; VAGUS NERV * 64410 INJ ANES AGENT; PHRENIC NERV * 64412 INJ ANES AGENT; SPINAL ACCES NERV * 64413 INJ ANES AGENT; CERV PLEXUS * 64415 INJ ANES AGENT; BRACHIAL PLEXUS * 64417 INJ ANES AGENT; AXILRY NERV * 64418 INJ ANES AGENT; SUPRASCAPULAR NERV * 64420 INJ ANES AGENT; INTERCOSTAL NERV SNGL * 64421 INJ ANES AGENT; INTERCOSTAL NERV-MX-REGION BLOCK * 64425 INJ ANES AGENT; ILIOINGUINAL ILIOHYPOGASTRC NERV * 64430 INJ ANES AGENT; PUDENDAL NERV * 64435 INJ ANES AGENT; PARACERVICAL NERV * 64445 INJ ANES AGENT; SCIATIC NERV * 64450 INJ ANES AGENT; OTHER PERIPHERAL NERV/BRANCH 64470 INJECTION, ANESTH./STEROID; CERVICAL/THORACIC, SINGLE 64472 INJECTION, ANESTH./STEROID; CERVICAL/THORACIC, ADD'L 64475 INJECTION, ANESTH./STEROID; LUMBAR/SACRAL, SINGLE 64476 INJECTION, ANESTH./STEROID; LUMBAR/SACRAL, ADD'L 64479 INJECTION, ANESTH./STEROID; CERVICAL/THORACIC, SINGLE 64480 INJECTION, ANESTH./STEROID; CERVICAL/THORACIC, ADD'L 64483 INJECTION, ANESTH./STEROID; LUMBAR/SACRAL, SINGLE 64484 INJECTION, ANESTH./STEROID; LUMBAR/SACRAL, ADD'L * 64505 INJ ANES AGENT; SPHENOPALATINE GANGLION * 64508 INJ ANES AGENT; CAROTID SINUS (SEPART PROC) * 64510 INJ ANES AGENT; STELLATE GANGLION * 64520 INJ ANES AGENT; LUMBAR/THORACIC * 64530 INJ ANES AGENT; CELIAC PLEXUS W/WO RAD MONITOR 64550 APPLIC SURFACE NEUROSTIMULATOR 64553 PERCUT IMPLNT NEUROSTIM ELECTRODES; CRANIAL NERV 64555 PERCUT IMPLNT NEUROSTIM ELECTRODES; PERIPHERAL 64560 PERCUT IMPLNT NEUROSTIM ELECTRODES; AUTONOMIC 64565 PERCUT IMPLNT NEUROSTIM ELECTRODES; NEUROMUSCUL 64573 INCS IMPLNT NEUROSTIM ELECTRODES; CRANIAL NERV

$2,503

90

$2,696

90

$2,792

90

$2,888

90

$3,081

90

$2,696

90

$2,311

90

$1,252

90

$1,155

90

$866

90

$85

0

$113

0

$132

0

$113

0

$113

0

$160

0

$151

0

$142

0

$142

0

$132

0

$151

0

$236

0

$160

0

$123

0

$113

0

$123

0

$74

0

$271

0

$228

N/A

$241

0

$229

N/A

$294

0

$266

N/A

$272

0

$251

N/A

$94

0

$94

0

$264

0

$245

0

$311

0

$66

0

$151

10

$151

10

$151

10

$151

10

$189

90

Section VII: Surgical Services

Page 140

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

64575 INCS IMPLNT NEUROSTIM ELECTRODES; PERIPHERAL 64577 INCS IMPLNT NEUROSTIM ELECTRODES; AUTONOMIC 64580 INCS IMPLNT NEUROSTIM ELECTRODES; NEUROMUSCULAR 64585 REVIS/REMOV PERIPHERAL NEUROSTIMULATOR ELECTRODE 64590 INCS & SUBQ PLCMT PERIPHERAL NEUROSTIM PULSE GEN 64595 REVIS/REMOV PERIPHERAL NEUROSTIM PULSE GEN 64600 DESTRCT TRIGEMINAL; SUPRAORBITAL/INFRAORBITAL 64605 DESTRCT TRIGEMINAL; 2ND & 3RD DIV @ FORAMEN OVAL 64610 DESTRCT TRIGEMINAL; 2ND & 3RD DIV W/RADIOLOGIC 64612 DESTRCT; MUSCL ENERVATED BY FACIAL NERV 64613 DESTRCT BY NEUROLYTIC AGENT; CERV SPINAL MUSCL 64620 DESTRCT BY NEUROLYTIC AGENT; INTERCOSTAL NERV 64622 DESTRCT; PARAVERTEB FACET JT NERV LUMBAR-1 LEVEL 64623 DESTRCT; FACET JT NERV LUMBAR EA ADD LEVEL 64626 DESTRUCTION, NEUROLYTIC; CERVICAL/THORACIC, SINGLE LEVEL 64627 DESTRUCTION, NEUROLYTIC; CERVICAL/THORACIC, ADD'L LEVEL 64630 DESTRCT BY NEUROLYTIC AGENT; PUDENDAL NERV 64640 DESTRCT; OTHER PERIPHERAL NERV/BRANCH 64680 DESTRCT CELIAC PLEXUS W/WO RAD MONITOR 64702 NEUROPLASTY; DIGITAL 1/BOTH SAME DIGIT 64704 NEUROPLASTY; NERV HAND/FT 64708 NEUROPLSTY MAJ PERIPHRL NERV ARM/LEG; NOT SPECIF 64712 NEUROPLASTY MAJ PERIPHERAL NERV ARM/LEG; SCIATIC 64713 NEUROPLASTY MAJ PERIPHERAL NERV; BRACHIAL PLEXUS 64714 NEUROPLASTY MAJ PERIPHERAL NERV; LUMBAR PLEXUS 64716 NEUROPLASTY &/OR TRANSPOSITION; CRANIAL NERV 64718 NEUROPLASTY &/OR TRANSPOSIT; ULNAR NERV @ ELBOW 64719 NEUROPLASTY &/OR TRANSPOSIT; ULNAR NERV @ WRIST 64721 NEUROPLASTY &/OR TRANSPO; MEDIAN @ CARPAL TUNNEL 64722 DECOMP; UNSPECIFIED NERV (SPECIFY) 64726 DECOMP; PLANTAR DIGITAL NERV 64727 INT NEUROLYSIS REQUIRING USE OR MICRO 64732 TRANSECTION/AVULSION SUPRAORBITAL NERV 64734 TRANSECTION/AVULSION INFRAORBITAL NERV 64736 TRANSECTION/AVULSION MENTAL NERV 64738 TRANSECT/AVULSION INFERIOR ALVEOLAR NERV-OSTEOT 64740 TRANSECTION/AVULSION LINGUAL NERV 64742 TRANSECT/AVULSION FACIAL NERV DIFF/COMPLT 64744 TRANSECTION/AVULSION GREATER OCCIPT NERV 64746 TRANSECTION/AVULSION PHRENIC NERV 64752 TRANSECTION/AVULSION VAGUS NERV TRANSTHORACIC 64755 TRANSECTION/AVULSION VAGI LTD TO PROX STOMACH 64760 TRANSECTION/AVULSION VAGUS NERV ABD 64761 TRANSECTION/AVULSION PUDENDAL NERV 64763 TRANSECT/AVULSION OBTURATOR NERV EXTRAPELVIC 64766 TRANSECT/AVULSION OBTURATOR NERV INTRAPELVIC

$226

90

$226

90

$226

90

$226

10

$226

10

$189

10

$205

10

$293

10

$332

10

$332

10

$332

10

$161

10

$317

10

$204

N/A

$568

10

$341

N/A

$264

10

$176

10

$235

10

$587

90

$704

90

$1,173

90

$1,369

90

$1,447

90

$1,076

90

$1,271

90

$1,271

90

$851

90

$900

90

$900

90

$391

90

BR

N/A

$587

90

$587

90

$704

90

$860

90

$1,076

90

$1,076

90

$684

90

$489

90

$1,467

90

$2,151

90

$1,369

90

$489

90

$587

90

$880

90

Section VII: Surgical Services

Page 141

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

64771 TRANSECT/AVULSION OTHER CRANIAL NERV EXTRADURAL 64772 TRANSECT/AVULSION OTHER SPINAL NERV EXTRADURAL 64774 EXC NEUROMA; CUT NERV SURGICALLY IDENT 64776 EXC NEUROMA; DIGITAL NERV 1/BOTH SAME DIGIT 64778 EXC NEUROMA; DIGITAL NERV EA ADD DIGIT 64782 EXC NEUROMA; HAND/FT EX DIGITAL NERV 64783 EXC NEUROMA; HAND/FT EA ADD NERV EX SAME DIGIT 64784 EXC NEUROMA; MAJOR PERIPHERAL NERV EX SCIATIC 64786 EXC NEUROMA; SCIATIC NERV 64787 IMPLNT NERV END INTO BONE/MUSCL 64788 EXC NEUROFIBROMA/NEUROLEMMOMA; CUT NERV 64790 EXC NEUROFIBROMA/NEUROLEMMOMA; MAJ PERIPHERAL 64792 EXC NEUROFIBROMA/NEUROLEMMOMA; EXTEN 64795 BX NERV 64802 SYMPATHECTOMY CERV 64804 SYMPATHECTOMY CERVICOTHORACIC 64809 SYMPATHECTOMY THORACOLUMBAR 64818 SYMPATHECTOMY LUMBAR 64820 SYMPATHECTOMY DIG ARTS W/MAGNIFICA-EA DIGIT 64831 SUTURE DIGITAL NERV HAND/FT; 1 NERV 64832 SUTURE DIGITAL NERV HAND/FT; EA ADD DIGITAL NERV 64834 SUTURE 1 NERV HAND/FT; COMMON SENSORY NERV 64835 SUTURE 1 NERV HAND/FT; MEDIAN MOTOR THENAR 64836 SUTURE 1 NERV HAND/FT; ULNAR MOTOR 64837 SUTURE EA ADD NERV HAND/FT 64840 SUTURE POST TIBIAL NERV 64856 SUTURE MAJ NERV ARM/LEG EX-SCIATIC; W/TRANSPOSIT 64857 SUTURE MAJ NERV ARM/LEG; WO TRANSPOSIT 64858 SUTURE SCIATIC NERV 64859 SUTURE EA ADD MAJOR PERIPHERAL NERV 64861 SUTURE BRACHIAL PLEXUS 64862 SUTURE LUMBAR PLEXUS 64864 SUTURE FACIAL NERV; EXTRACRANIAL 64865 SUTURE FACIAL NERV; INFRATEMPORAL W/WO GFT 64866 ANASTOM; FACIAL-SPINAL ACCES 64868 ANASTOM; FACIAL-HYPOGLOSSAL 64870 ANASTOM; FACIAL-PHRENIC 64872 SUTURE NERV; REQUIRING SECNDRY/DELAYED SUTURE 64874 SUTURE NERV; REQ EXTEN MOBILIZAT/TRANSPOSIT NERV 64876 SUTURE NERV; REQUIRING SHORTENING BONE EXTREM 64885 NERV GFT HEAD/NECK; UP TO 4 CM LENGTH 64886 NERV GFT HEAD/NECK; MORE THAN 4 CM LENGTH 64890 NERV GFT 1 STRAND HAND/FT; UP TO 4 CM LENGTH 64891 NERV GFT 1 STRAND HAND/FT; > 4 CM LENGTH 64892 NERV GFT 1 STRAND ARM/LEG; UP TO 4 CM LENGTH 64893 NERV GFT 1 STRAND ARM/LEG; > 4 CM LENGTH

$978

90

$587

90

$450

90

$469

90

$191

N/A

$626

90

$313

N/A

$919

90

$1,310

90

$684

N/A

$704

90

$1,076

90

$1,271

90

$391

0

$1,418

90

$2,073

90

$2,014

90

$1,467

90

$724

90

$733

90

$489

N/A

$802

90

$841

90

$978

90

$489

N/A

$1,173

90

$1,467

90

$1,173

90

$1,369

90

$606

N/A

$1,369

90

$1,721

90

$1,330

90

$1,662

90

$2,347

90

$2,347

90

$2,347

90

$404

N/A

$253

N/A

$253

N/A

$1,589

90

$1,956

90

$1,271

90

$1,565

90

$1,271

90

$1,565

90

Section VII: Surgical Services

Page 142

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

64895 NERV GFT MX STRAND HAND/FT; UP TO 4 CM LENGTH 64896 NERV GFT MX STRAND HAND/FT; > 4 CM LENGTH 64897 NERV GFT MX STRAND ARM/LEG; UP TO 4 CM LENGTH 64898 NERV GFT MX STRAND ARM/LEG; > 4 CM LENGTH 64901 NERV GFT EA ADD NERV; SNGL STRAND 64902 NERV GFT EA ADD NERV; MX STRANDS 64905 NERV PEDICLE TRANSF; FIRST STAGE 64907 NERV PEDICLE TRANSF; SECOND STAGE 64999 UNLISTED PROC NERV SYST 65091 EVISCERATION OCULAR CONTENTS; WO IMPLNT 65093 EVISCERATION OCULAR CONTENTS; W/IMPLNT 65101 ENUCLEATION EYE; WO IMPLNT 65103 ENUCLEAT EYE; W/IMPLNT MUSCL NOT ATTACHED-IMPLNT 65105 ENUCLEATION EYE; W/IMPLNT MUSCL ATTACHED-IMPLNT 65110 EXENTERATION ORBIT REMOV ORBITAL CONTENTS; ONLY 65112 EXENTERATION ORBITAL CONTENTS; W/REMOV BONE 65114 EXENTERAT ORBITAL CONTENTS; W/MUSCL/MYOCUT FLAP 65125 MODIF OCULAR IMPLNT W/PLC/REPLC PEGS (SEP PROC) 65130 INSRT OCULAR IMPLNT SECNDRY; AFTER EVISCERATION 65135 INSRT OCULAR IMPLNT SECNDRY; AFTER ENUCLEATION 65140 INSRT OCULAR IMPLNT; ENUCLEAT-MUSCL ATTACH-IMPLT 65150 REINSRT OCULAR IMPLNT; W/WO CONJUNC GFT 65155 REINSRT OCULAR IMPLNT; W/FOREIGN MAT REINFORCE 65175 REMOV OCULAR IMPLNT * 65205 REMOV FB EXT EYE; CONJUNC SUPERF * 65210 REMOV FB EXT EYE; CONJUNC EMBEDDED/SUBCONJUNC * 65220 REMOV FB EXT EYE; CORNEAL WO SLIT LAMP * 65222 REMOV FB EXT EYE; CORNEAL W/SLIT LAMP 65235 REMOV FB IO; FROM ANT CHAMBER/LENS 65260 REMOV FB IO; POST SEGMT-MAGNETIC EXTRACTION 65265 REMOV FB IO; POST SEGMT NONMAGNETIC EXTRACTION * 65270 REPR LACERAT; CONJUNC W/WO LACERAT SCLERA 65272 REPR LACERAT; CONJUNC BY MOBILIZA WO HOSP 65273 REPR LACERAT; CONJUNC BY MOBILIZA W/HOSP 65275 REPR LACERAT; CORNEA NONPERFORAT W/WO REMOV FB 65280 REPR LACERAT; CORNEA PERFORATING WO UVEAL TISS 65285 REPR LACERAT; CORNEA W/REPOSIT/RESECT UVEAL TISS 65286 REPR LACERAT; APPLIC TISS GLUE WOUNDS CORNEA 65290 REPR WOUND EXTRAOCULAR MUSCL/TENDON &/OR TENON'S 65400 EXC LES CORNEA EX PTERYGIUM * 65410 BX CORNEA 65420 EXC/TRANSPOSITION PTERYGIUM; WO GFT 65426 EXC/TRANSPOSITION PTERYGIUM; W/GFT * 65430 SCRAPING CORNEA DX SMEAR &/OR CULTURE * 65435 REMOV CORNEAL EPITHELIUM; W/WO CHEMOCAUTERIZAT 65436 REMOV CORNEAL EPITHELIUM; W/APPLIC CHELAT AGENT

$1,917

90

$2,347

90

$1,917

90

$2,347

90

$636

N/A

$958

N/A

$782

90

$1,115

90

BR

N/A

$1,123

90

$1,226

90

$1,123

90

$1,226

90

$1,532

90

$2,043

90

$2,298

90

$2,451

90

$600

90

$1,123

90

$1,277

90

$1,532

90

$1,123

90

$1,532

90

$817

90

$59

0

$66

0

$74

0

$84

0

$1,328

90

$1,328

90

$1,532

90

$123

10

$184

90

$306

90

$266

90

$1,226

90

$1,634

90

$613

90

$817

90

$799

90

$143

0

$628

90

$856

90

$67

0

$95

0

$190

90

Section VII: Surgical Services

Page 143

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

65450 DESTRCT LES CORNEA-CRYOTHERAPY/PHOTOCOAGULATION 65600 MX PUNCTURES ANT CORNEA 65710 KERATOPLASTY; LAMELLAR 65730 KERATOPLASTY; PENETRATING (EX APHAKIA) 65750 KERATOPLASTY; PENETRATING (APHAKIA) 65755 KERATOPLASTY; PENETRATING (PSEUDOAPHAKIA) 65760 KERATOMILEUSIS 65765 KERATOPHAKIA 65767 EPIKERATOPLASTY 65770 KERATOPROSTHESIS 65771 RADIAL KERATOTOMY 65772 CORNEAL RELAXING INCS CORRECT INDUCE ASTIGMATISM 65775 CORNEAL WEDGE RESECT CORRECT INDUCED ASTIGMATISM 65800 PARACENTESIS ANT CHAMBER (SEP PRO); W/DX ASPIRAT * 65805 PARACENTESIS ANT CHAMB (SEP PRO); RELEAS AQUEOUS 65810 PARACENTESIS (SEPART PROC); W/REMOV VITREOUS 65815 PARACENTESIS (SEPART PROC); W/REMOV BLD 65820 GONIOTOMY 65850 TRABECULOTOMY AB EXT 65855 TRABECULOPLASTY-LASER SURG 1/MORE SESSIONS 65860 SEVERING ADHESIONS ANT SEGMT LASER (SEPART PROC) 65865 SEVERING ADHESIONS (SEP PRO); GONIOSYNECHIAE 65870 SEVERING ADHESIONS (SEPART PROC); ANT SYNECHIAE 65875 SEVERING ADHESIONS (SEPART PROC); POST SYNECHIAE 65880 SEVERING ADHESIONS (SEPART PROC); CORNEOVITREAL 65900 REMOV EPITHELIAL DOWNGROWTH ANT CHAMBER EYE 65920 REMOV IMPLNT MAT ANT SEGMT EYE 65930 REMOV BLD CLOT ANT SEGMT EYE 66020 INJ ANT CHAMBER (SEPART PROC); AIR/LIQUID 66030 INJ ANT CHAMBER (SEPART PROC); MEDS 66130 EXC LES SCLERA 66150 FISTULIZAT SCLERA-GLAU; TREPHINAT W/IRIDECTOMY 66155 FISTULIZAT SCLERA; THERMOCAUTERIZATION W/IRIDECT 66160 FISTULIZAT SCLERA; SCLERECTOMY W/PUNCH W/IRIDECT 66165 FISTULIZAT SCLERA; IRIDENCLEISIS/IRIDOTASIS 66170 FISTULIZAT SCLER;TRABECULECT AB EXT-NO OTHR SURG 66172 FISTULIZAT SCLERA; TRABECULECT AB EXT W/SCARRING 66180 AQUEOUS SHUNT-EXTRAOCULAR RESERVOIR 66185 REVIS AQUEOUS SHUNT-EXTRAOCULAR RESERVOIR 66220 REPR SCLERAL STAPHYLOMA; WO GFT 66225 REPR SCLERAL STAPHYLOMA; W/GFT 66250 REVIS/REPR OPERATIVE WOUND ANT SEGMT 66500 IRIDOTOMY-STAB INCS (SEP PRO); EX TRANSFIXION 66505 IRIDOTOMY-STAB INCS (SEP PRO); W/TRANSFIXION 66600 IRIDECTOMY W/CORNEOSCLERAL SECT; REMOV LES 66605 IRIDECTOMY W/CORNEOSCLERAL SECT; W/CYCLECTOMY

$152

90

$513

90

$2,092

90

$2,567

90

$2,662

90

$2,757

90

$2,377

N/A

$2,757

N/A

$2,567

N/A

$2,567

90

$1,398

N/A

$685

90

$856

90

$140

0

$140

0

$702

90

$790

90

$1,141

90

$1,053

90

$948

90

$702

90

$1,053

90

$755

90

$755

90

$755

90

$1,088

90

$1,404

90

$895

90

$175

10

$123

10

$847

90

$1,355

90

$1,271

90

$1,271

90

$1,271

90

$1,440

90

$1,728

90

$1,610

90

$966

90

$1,864

90

$2,203

90

$932

90

$424

90

$339

90

$1,271

90

$1,728

90

Section VII: Surgical Services

Page 144

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

66625 IRIDECTOMY; PERIPHERAL GLAU (SEPART PROC) 66630 IRIDECTOMY; SECTOR GLAU (SEPART PROC) 66635 IRIDECTOMY; 'OPTICAL' (SEPART PROC) 66680 REPR IRIS CILIARY BODY 66682 SUTURE IRIS CILIARY BODY (SEPART PROC) 66700 CILIARY BODY DESTRCT; DIATHERMY 66710 CILIARY BODY DESTRCT; CYCLOPHOTOCOAGULATION 66720 CILIARY BODY DESTRCT; CRYOTHERAPY 66740 CILIARY BODY DESTRCT; CYCLODIALYSIS 66761 IRIDOTOMY/IRIDECTOMY BY LASER SURG 66762 IRIDOPLASTY BY PHOTOCOAGULATION 66770 DESTRCT CYST/LES IRIS/CILIARY BODY 66820 DISCISSION SECNDRY MEMBRN CATARACT; STAB INCS 66821 DISCISSION SECNDRY MEMBRN CATARACT; LASER SURG 66825 REPOSIT IO LENS PROSTH REQ INCS (SEPART PROC) 66830 REMOV 2ND MEMBRN CATARACT W/CORNEO-SCLERAL SECT 66840 REMOV LENS MAT; ASPIRAT TECH 1/MORE STAGES 66850 REMOV LENS MAT; PHACOFRAGMENTAT TECH W/ASPIRAT 66852 REMOV LENS MAT; PARS PLANA APPROACH W/WO VITRECT 66920 REMOV LENS MAT; INTRACAPSULAR 66930 REMOV LENS MAT; INTRACAPSULAR DISLOC LENS 66940 REMOV LENS MAT; EXTRACAPSULAR 66983 INTRACAPSULAR CATARACT EXTRAC W/INSRT IOL PROSTH 66984 EXTRACAPSULAR CATARACT REMOV W/INSRT IOL PROSTH 66985 INSRT IOL PROSTH (SECNDRY IMPLNT) 66986 EXCHG IO LENS 66999 UNLISTED PROC ANT SEGMT EYE 67005 REMOV VITREOUS ANT APPROACH; PART REMOV 67010 REMOV VITREOUS ANT; SUBTL REMOV W/MECH VITRECT 67015 ASPIRAT/RELEASE VITREOUS/SUBRETINAL FLUID 67025 INJ VITREOUS SUBSTITUTE-W/WO ASPIRAT (SEP PRO) 67027 IMPLANT EYE DRUG SYSTEM 67028 INTRAVITREAL INJ-PHARMACOLOGIC AGENT (SEP PRO) 67030 DISCISSION VITREOUS STRANDS PARS PLANA APPROACH 67031 SEVERING VITREOUS STRANDS/MEMBRN-LASER SURG 67036 VITRECTOMY MECH PARS PLANA APPROACH 67038 VITRECTOMY MECH; W/EPIRETINAL MEMBRN STRIPPING 67039 VITRECTOMY MECH; W/FOCAL ENDOLASER PHOTOCOAGULAT 67040 VITRECTOMY MECH; W/ENDOLASER PANRETINAL PHOTOCOA 67101 REPR RETINAL DETACHMENT; CRYOTHERAPY/DIATHERMY 67105 REPR RETINAL DETACHMENT; PHOTOCOAGULATION 67107 REPR RETINAL DETACHMENT; SCLERAL BUCKLING 67108 REPR RETINAL DETACHMENT; W/VITRECTOMY ANY METHD 67110 REPR RETINAL DETACHMENT; INJ AIR/OTHER GAS 67112 REPR RETINAL DETACHMENT; PREV OPERATED UPON 67115 RELEASE ENCIRCLING MAT

$949

90

$949

90

$949

90

$779

90

$932

90

$813

90

$847

90

$813

90

$1,101

90

$847

90

$864

90

$847

90

$684

90

$765

90

$1,332

90

$832

90

$1,518

90

$1,632

90

$1,959

90

$1,436

90

$1,632

90

$1,551

90

$1,616

90

$1,698

90

$1,371

90

$1,528

90

BR

N/A

$1,569

90

$1,830

90

$732

90

$871

90

$332

90

$340

0

$1,046

90

$871

90

$2,527

90

$3,224

90

$2,789

90

$2,963

90

$1,482

90

$1,482

90

$2,231

90

$3,486

90

$1,743

90

$1,970

90

$662

90

Section VII: Surgical Services

Page 145

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

67120 REMOV IMPLNT MAT POST SEGMT; EXTRAOCULAR 67121 REMOV IMPLNT MAT POST SEGMT; IO 67141 PROPHYLAXIS RETINAL DETACH WO DRAIN; CRYOTHERAPY 67145 PROPHYLAXIS RETINAL DETACH; PHOTOCOAGULATION 67208 DESTRCT LOCALIZ LES RETINA; CRYOTHERAPY/DIATHERM 67210 DESTRCT LOCALIZ LES RETINA; PHOTOCOAGULATION 67218 DESTRCT LOCALIZ LES RETINA; RADIATION-IMPLNT 67220 TREAT CHOROID LESION 67227 DESTRCT PROGRESSIVE RETINOPATHY; CRYOTHERAPY 67228 DESTRCT PROGRESSIVE RETINOPATHY; PHOTOCOAGULAT 67250 SCLERAL REINFORCEMENT (SEPART PROC); WO GFT 67255 SCLERAL REINFORCEMENT (SEPART PROC); W/GFT 67299 UNLISTED PROC POST SEGMT 67311 STRABISMUS SURG; 1 HORIZONTAL MUSCL 67312 STRABISMUS SURG; 2 HORIZONTAL MUSCL 67314 STRABISMUS SURG; 1 VERTICAL MUSCL 67316 STRABISMUS SURG; 2/MORE VERTICAL MUSCL 67318 STRABISMUS SURG ANY PROC SUPER OBLIQ MUSCL 67320 TRANSPOSITION PROC-ANY EXTRAOCULAR MUSCL 67331 STRABISMUS SURG-PT W/PREV EYE SURG 67332 STRABISMUS SURG-PT W/SCARRING EXTRAOCULAR MUSCL 67334 STRABISMUS SURG-POST FIXA SUTURE TECH W/WO MUSCL 67335 PLCMT ADJUSTABLE SUTURE-DURING STRABISMUS SURG 67340 STRABISMUS SURG EXPLOR &/OR REPR DETACHED MUSCL 67343 RELEASE EXTEN SCAR TISS WO DETACHING (SEP PRO) 67345 CHEMODENERVATION EXTRAOCULAR MUSCL 67350 BX EXTRAOCULAR MUSCL 67399 UNLISTED PROC OCULAR MUSCL 67400 ORBITOTOMY WO BONE FLAP; EXPLOR W/WO BX 67405 ORBITOTOMY WO BONE FLAP; W/DRAINAGE ONLY 67412 ORBITOTOMY WO BONE FLAP; W/REMOV LES 67413 ORBITOTOMY WO BONE FLAP; W/REMOV FB 67414 ORBITOTOMY WO BONE FLAP; W/REMOV BONE DECOMP 67415 FINE NEEDLE ASPIRAT ORBITAL CONTENTS 67420 ORBITOTOMY W/BONE FLAP/WINDOW; W/REMOV LES 67430 ORBITOTOMY W/BONE FLAP/WINDOW; W/REMOV FB 67440 ORBITOTOMY W/BONE FLAP/WINDOW; W/DRAIN 67445 ORBITOTOMY W/BONE FLAP/WINDOW; W/REMOV BONE 67450 ORBITOTOMY W/BONE FLAP/WINDOW; EXPLOR W/WO BX * 67500 RETROBULBAR INJ; MEDS 67505 RETROBULBAR INJ; ALCOHOL * 67515 INJ THERAP AGENT INTO TENON'S CAPSULE 67550 ORBITAL IMPLNT; INSRT 67560 ORBITAL IMPLNT; REMOV/REVIS 67570 OPTIC NERV DECOMP 67599 UNLISTED PROC ORBIT

$837

90

$959

90

$924

90

$959

90

$944

90

$978

90

$1,888

90

$1,214

90

$1,012

90

$1,047

90

$1,373

90

$1,716

90

BR

N/A

$1,205

90

$1,507

90

$1,326

90

$1,658

90

$1,507

90

$804

N/A

$402

N/A

$854

N/A

$1,326

N/A

$402

N/A

$753

N/A

$603

90

$382

10

$362

0

BR

N/A

$1,708

90

$1,406

90

$1,607

90

$1,607

90

$1,607

90

$241

0

$2,813

90

$2,652

90

$2,511

90

$2,569

90

$1,969

90

$92

0

$201

0

$90

0

$1,205

90

$1,205

90

$2,009

90

BR

N/A

Section VII: Surgical Services

Page 146

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

* 67700 BLEPHAROTOMY DRAINAGE ABSCESS EYELID * 67710 SEVERING TARSORRHAPHY * 67715 CANTHOTOMY (SEPART PROC)
67800 EXC CHALAZION; SNGL 67801 EXC CHALAZION; MX SAME LID 67805 EXC CHALAZION; MX DIFF LIDS 67808 EXC CHALAZION; GEN ANES &/OR REQ HOSP-1/MX * 67810 BX EYELID * 67820 CORRECT TRICHIASIS; EPILATION BY FORCEPS ONLY * 67825 CORRECT TRICHIASIS; EPILATION-OTH THAN FORCEPS 67830 CORRECT TRICHIASIS; INCS LID MARGIN 67835 CORRECT TRICHIASIS; INCS LID MARGIN W/MEMBRN GFT * 67840 EXC LES EYELID WO CLO OR W/SIMPL DIRECT CLO * 67850 DESTRCT LES LID MARGIN 67875 TEMPORARY CLO EYELIDS BY SUTURE 67880 CONSTRUCT INTERMARGINAL ADHESIONS 67882 CONSTRCT INTERMARG ADHESIONS; W/TRANSPOSIT TARSL 67900 REPR BROW PTOSIS 67901 REPR BLEPHAROPTOSIS; W/SUTUE/OTHER MAT 67902 REPR BLEPHAROPTOSIS; W/FASCIAL SLING 67903 REPR BLEPHAROPTOSIS; LEVATOR RESECT-INT APPROACH 67904 REPR BLEPHAROPTOSIS; LEVATOR RESECT-EXT APPROACH 67906 REPR BLEPHAROPTOSIS; SUPER RECTUS TECH-FASCIAL 67908 REPR BLEPHAROPTOSIS; CONJUNC-TARSO-MULLER'S 67909 REDUCTION OVERCORRECTION PTOSIS 67911 CORRECT LID RETRACTION 67914 REPR ECTROPION; SUTURE 67915 REPR ECTROPION; THERMOCAUTERIZATION 67916 REPR ECTROPION; BLEPHAROPLASTY EXC TARSAL WEDGE 67917 REPR ECTROPION; BLEPHAROPLASTY EXTEN 67921 REPR ENTROPION; SUTURE 67922 REPR ENTROPION; THERMOCAUTERIZATION 67923 REPR ENTROPION; BLEPHAROPLASTY EXC TARSAL WEDGE 67924 REPR ENTROPION; BLEPHAROPLASTY EXTEN 67930 SUTURE RECENT WOUND EYELID DIR CLO; PART THICK 67935 SUTURE RECENT WOUND EYELID DIR CLO; FULL THICK 67938 REMOV EMBEDDED FB EYELID 67950 CANTHOPLASTY 67961 EXC & REPR EYELID; UP TO 1/4 LID MARGIN 67966 EXC & REPR EYELID > 1/4 LID MARGIN 67971 RECON EYELID FULL THICK; UP TO 2/3 LID 1 STAGE 67973 RECON EYELID; TOT LID LOWER 1 STAGE/1ST STAGE 67974 RECON EYELID; TOT LID UPPER 1 STAGE/1ST STAGE 67975 RECON EYELID FULL THICK-TRANSF FLAP; 2ND STAGE 67999 UNLISTED PROC EYELIDS 68020 INCS CONJUNC DRAINAGE CYST

$79

10

$99

10

$119

10

$119

10

$159

10

$179

10

$308

90

$119

0

$50

0

$119

10

$139

10

$993

90

$169

10

$149

10

$199

0

$487

90

$695

90

$618

90

$1,291

90

$1,291

90

$1,877

90

$1,787

90

$1,698

90

$1,390

90

$1,192

90

$1,589

90

$556

90

$169

90

$814

90

$993

90

$427

90

$169

90

$814

90

$1,033

90

$367

10

$496

90

$99

10

$1,192

90

$1,092

90

$1,390

90

$1,390

90

$1,589

90

$1,787

90

$496

90

BR

N/A

$89

10

Section VII: Surgical Services

Page 147

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

68040 EXPRESSION CONJUNC FOLLICLES EG TRACHOMA 68100 BX CONJUNC 68110 EXC LES CONJUNC; UP TO 1 CM 68115 EXC LES CONJUNC; OVER 1 CM 68130 EXC LES CONJUNC; W/ADJACENT SCLERA * 68135 DESTRCT LES CONJUNC * 68200 SUBCONJUNCTIVAL INJ 68320 CONJUNCTIVOPLASTY; W/CONJUNC GFT/EXTEN REARRANG 68325 CONJUNCTIVOPLASTY; W/BUCCAL MUCOS MEMBRN GFT 68326 CONJUNCTIVOPLASTY RECON CUL-DE-SAC; W/GFT 68328 CONJUNCTIVOPLASTY RECON CUL-DE-SAC; W/BUCCAL GFT 68330 REPR SYMBLEPHARON; CONJUNCTIVOPLASTY WO GFT 68335 REPR SYMBLEPHARON; W/FREE GFT CONJUNC/BUCCAL 68340 REPR SYMBLEPHARON; DIVIS SYMBLEPHARON W/WO INSRT 68360 CONJUNC FLAP; BRIDGE/PART (SEPART PROC) 68362 CONJUNC FLAP; TOT 68399 UNLISTED PROC CONJUNC 68400 INCS DRAINAGE LACRIMAL GLAND 68420 INCS DRAINAGE LACRIMAL SAC * 68440 SNIP INCS LACRIMAL PUNCTUM 68500 EXC LACRIMAL GLAND EX TUMOR; TOT 68505 EXC LACRIMAL GLAND EX TUMOR; PART 68510 BX LACRIMAL GLAND 68520 EXC LACRIMAL SAC 68525 BX LACRIMAL SAC 68530 REMOV FB/DACRYOLITH LACRIMAL PASSAGES 68540 EXC LACRIMAL GLAND TUMOR; FRONTAL APPROACH 68550 EXC LACRIMAL GLAND TUMOR; INVOLV OSTEOTOMY 68700 PLASTIC REPR CANALICULI 68705 CORRECT EVERTED PUNCTUM CAUT 68720 DACRYOCYSTORHINOSTOMY 68745 CONJUNCTIVORHINOSTOMY; WO TUBE 68750 CONJUNCTIVORHINOSTOMY; W/INSRT TUBE/STENT 68760 CLO LACRIMAL PUNCTUM; THERMOCAUT/LIG/LASER SURG 68761 CLO LACRIMAL PUNCTUM; BY PLUG EA 68770 CLO LACRIMAL FISTULA (SEPART PROC) 68801 DILAT LACRIMAL PUNCTUM W/WO IRRIGA 68810 PROBING NASOLACRIMAL DUCT W/WO IRRIGA; 68811 PROBE NASOLACRIMAL DUCT W/WO IRRIG; REQ GEN ANES 68815 PROBE NASOLACRIM DUCT W/WO IRRIG; W/INSERT TUBE * 68840 PROBING LACRIMAL CANALICULI W/WO IRRIGA * 68850 INJ CONTRAST MEDIUM DACRYOCYSTOGRAPHY 68899 UNLISTED PROC LACRIMAL SYST * 69000 DRAINAGE EXT EAR ABSCESS/HEMATOMA; SIMPL 69005 DRAINAGE EXT EAR ABSCESS/HEMATOMA; COMPLIC * 69020 DRAINAGE EXT AUDITORY CANAL ABSCESS

$89

0

$139

0

$189

10

$298

10

$596

90

$159

10

$79

0

$1,192

90

$1,390

90

$1,291

90

$1,489

90

$596

90

$894

90

$894

90

$695

90

$993

90

BR

N/A

$251

10

$206

10

$114

10

$1,371

90

$1,143

90

$229

0

$1,029

90

$229

0

$800

10

$1,714

90

$1,714

90

$1,257

90

$183

10

$1,943

90

$1,829

90

$2,057

90

$183

10

$137

10

$571

90

$69

10

$171

10

$251

10

$343

10

$91

10

$114

0

BR

N/A

$109

10

$358

10

$119

10

Section VII: Surgical Services

Page 148

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

69090 EAR PIERCING 69100 BX EXT EAR 69105 BX EXT AUDITORY CANAL 69110 EXC EXT EAR; PART SIMPL REPR 69120 EXC EXT EAR; COMPLT AMPUTA 69140 EXC EXOSTOSIS EXT AUDITORY CANAL 69145 EXC SOFT TISS LES EXT AUDITORY CANAL 69150 RAD EXC EXT AUDITORY CANAL LES; WO NECK DISSECT 69155 RAD EXC EXT AUDITORY CANAL LES; W/NECK DISSECT 69200 REMOV FB-EXT AUDITORY CANAL; WO GEN ANES 69205 REMOV FB-EXT AUDITORY CANAL; W/GEN ANES 69210 REMOV IMPACTED CERUMEN (SEP PRO) 1/BOTH EARS 69220 DEBRID MASTOIDEC CAVITY SIMPL 69222 DEBRID MASTOIDEC CAVITY COMPLX 69300 OTOPLASTY PROTRUDING EAR W/WO SIZE REDUCTION 69310 RECON EXT AUDITORY CANAL (SEPART PROC) 69320 RECON EXT AUDITORY CANAL CONGEN ATRESIA; 1 STAGE 69399 UNLISTED PROC EXT EAR 69400 EUSTACHIAN TUBE INFLATION TRANSNASAL; W/CATH 69401 EUSTACHIAN TUBE INFLATION TRANSNASAL; WO CATH 69405 EUSTACHIAN TUBE CATH TRANSTYMPANIC 69410 FOCAL APPLIC PHASE CONTRL SUBSTANCE MID EAR * 69420 MYRINGOTOMY INCL ASPIRAT &/OR EUSTACHIAN INFLAT * 69421 MYRINGOTOMY INCL ASPIRAT REQ GEN ANES 69424 VENTILATING TUBE REMOV-INSRT BY ANOTHER PHYS * 69433 TYMPANOSTOMY LOCAL/TOPICAL ANES 69436 TYMPANOSTOMY GEN ANES 69440 MID EAR EXPLOR-POSTAURICULAR/EAR CANAL INCS 69450 TYMPANOLYSIS TRANSCANAL 69501 TRANSMASTOID ANTROTOMY 69502 MASTOIDEC; COMPLT 69505 MASTOIDEC; MODIF RADICAL 69511 MASTOIDEC; RADICAL 69530 PETROUS APICECTOMY INCL RADICAL MASTOIDEC 69535 RESECT TEMPORAL BONE EXT APPROACH 69540 EXC AURAL POLYP 69550 EXC AURAL GLOMUS TUMOR; TRANSCANAL 69552 EXC AURAL GLOMUS TUMOR; TRANSMASTOID 69554 EXC AURAL GLOMUS TUMOR; EXTEN 69601 REVIS MASTOIDEC; RESULTING-COMPLT MASTOIDEC 69602 REVIS MASTOIDEC; RESULT-MODIF RAD MASTOIDEC 69603 REVIS MASTOIDEC; RESULTING-RADICAL MASTOIDEC 69604 REVIS MASTOIDEC; RESULTING-TYMPANOPLASTY 69605 REVIS MASTOIDEC; W/APICECTOMY 69610 TYMPANIC MEMBRN REPR W/WO SITE PREP W/WO PATCH 69620 MYRINGOPLASTY

$50

N/A

$149

0

$149

0

$597

90

$1,393

90

$2,387

90

$398

90

$1,492

90

$2,189

90

$109

0

$438

10

$44

0

$60

0

$269

10

$1,293

N/A

$1,890

90

$1,890

90

BR

N/A

$90

0

$45

0

$90

10

$90

0

$247

10

$337

10

$225

0

$337

10

$450

10

$1,462

90

$1,462

90

$1,574

90

$2,091

90

$2,361

90

$2,699

90

$3,373

90

$3,373

90

$270

10

$2,249

90

$2,699

90

$3,373

90

$1,687

90

$2,699

90

$2,699

90

$2,699

90

$2,924

90

$202

10

$1,799

90

Section VII: Surgical Services

Page 149

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MARPC/-26 FUD

69631 TYMPANOPLASTY WO MASTOIDEC; WO OSSICULAR CHAIN 69632 TYMPANOPLASTY WO MASTOIDEC; W/OSSICULAR CHAIN 69633 TYMPANOPLASTY WO MASTOIDEC; W/CHAIN & PROSTH 69635 TYMPANOPLASTY W/ANTROTOMY; WO OSSICULAR CHAIN 69636 TYMPANOPLASTY W/ANTROTOMY; W/OSSICULAR CHAIN 69637 TYMPANOPLASTY W/ANTROTOMY; W/CHAIN & PROSTH 69641 TYMPANOPLASTY W/MASTOIDEC; WO OSSICULAR CHAIN 69642 TYMPANOPLASTY W/MASTOIDEC; W/OSSICULAR CHAIN 69643 TYMPANOPLASTY W/MASTOIDEC; W/INTACT/RECON WALL 69644 TYMPANOPLASTY W/MASTOIDEC; W/RECON CANAL WALL 69645 TYMPANOPLASTY W/MASTOIDEC; RADICAL/COMPLT 69646 TYMPANOPLASTY W/MASTOIDEC; RAD W/CHAIN RECON 69650 STAPES MOBILIZATION 69660 STAPEDECTOMY/STAPEDOTOMY W/REESTABLISHMENT 69661 STAPEDECTOMY/STAPEDOTOMY; W/FOOTPLATE DRILL OUT 69662 REVIS STAPEDECTOMY/STAPEDOTOMY 69666 REPR OVAL WINDOW FISTULA 69667 REPR ROUND WINDOW FISTULA 69670 MASTOID OBLIT (SEPART PROC) 69676 TYMPANIC NEURECTOMY 69700 CLO POSTAURICULAR FISTULA MASTOID (SEPART PROC) 69710 IMPLNT/REPLAC ELECTROMAGNETIC BONE HEARING DEVIC 69711 REMOV/REPR ELECTROMAGNETIC BONE HEARING DEVICE 69720 DECOMP FACIAL NERV INTRATEMPORAL; LAT-GENICULATE 69725 DECOMP FACIAL NERV; INCL MEDIAL-GENICULATE GANGL 69740 SUTURE FACIAL NERV W/WO GFT; LAT-GENICULATE 69745 SUTURE FACIAL NERV; INCL MEDIAL-GENICULATE GANGL 69799 UNLISTED PROC MID EAR 69801 LABYRINTHOT W/OTH NONEXC DESTRUC PROC; TRNSCANAL 69802 LABYRINTHOT W/NONEXC DESTRUCT PROC; W/MASTOIDEC 69805 ENDOLYMPHATIC SAC OR; WO SHUNT 69806 ENDOLYMPHATIC SAC OR; W/SHUNT 69820 FENESTRATION SEMICIRCULAR CANAL 69840 REVIS FENESTRATION OR 69905 LABYRINTHECTOMY; TRANSCANAL 69910 LABYRINTHECTOMY; W/MASTOIDEC 69915 VESTIBULAR NERV SECT TRANSLABYRINTHINE APPROACH 69930 COCHLEAR DEVICE IMPLNT W/WO MASTOIDEC 69949 UNLISTED PROC INNER EAR 69950 VESTIBULAR NERV SECT-TRANSCRANIAL APPROACH 69955 TOT FACIAL NERV DECOMP &/OR REPR 69960 DECOMP INT AUDITORY CANAL 69970 REMOV TUMOR TEMPORAL BONE 69979 UNLISTED PROC TEMPORAL BONE-MID FOSSA APPROACH 69990 MICROSURGERY ADD-ON

$2,429

90

$2,744

90

$2,924

90

$2,811

90

$2,991

90

$3,148

90

$3,036

90

$3,193

90

$3,148

90

$3,328

90

$3,036

90

$3,261

90

$1,574

90

$2,519

90

$2,519

90

$3,014

90

$2,249

90

$2,249

90

$2,699

90

$1,574

90

$675

90

$1,067

N/A

$800

90

$2,699

90

$4,498

90

$3,148

90

$4,498

90

BR

N/A

$2,024

90

$2,699

90

$2,699

90

$3,238

90

$2,699

90

$1,462

90

$2,249

90

$2,699

90

$4,048

90

$3,148

90

BR

N/A

$4,498

90

$4,498

90

$4,498

90

$5,622

90

BR

N/A

BR

N/A

Section VII: Surgical Services

Page 150

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VIII:

DIAGNOSTIC & THERAPEUTIC RADIOLOGICAL SERVICES

SUBSECTION A:

PAYMENT GROUND RULES FOR DIAGNOSTIC &

THERAPEUTIC RADIOLOGICAL SERVICES

General Guidelines

The Maximum Allowed Rate (MAR) column for a radiological procedure includes the professional component (PC) and the technical component (TC). Under no circumstances shall the MAR for a procedure be more than the value of the TC and the PC. This value is applicable in any situation in which a single charge is made to include both professional services and the technical cost of providing that service. Identification of a procedure without modifier 26 indicates that the charge includes both the "professional" and the "technical" components.

The PC fee amount represents the value of the professional radiological services of the physician. This component is applicable in any situation in which the physician submits a bill for these professional services only. It does not include the cost of personnel, materials, space, equipment or other facilities. The PC fee amount includes: examination of the injured employee; when indicated, performance and/or supervision of the procedure; interpretation and written report of the examination; and consultation with the authorized treating physician. A written report, signed by interpreting physician, is considered an integral part of a radiological procedure or interpretation and shall not be reimbursed separately.

To identify a charge for the PC, use the 5-digit procedure code followed by modifier 26. If a "0" fee amount appears in the PC column, the procedure is assumed to be purely technical in nature and no PC charge should be submitted.

The TC includes the charges for personnel, materials, including ionic contrast media and drugs, film or xerography, space, equipment and other facility resources. The technical component maximum allowable reimbursement excludes radioisotope cost. To identify a charge for the TC only, use the procedure code followed by the modifier 27.

A complete examination includes all of the necessary views for optimal examination of the body part for the suspected condition. If the reimbursement of multiple single views exceeds the cost of a complete examination, reimbursement shall be based on the complete examination value. Definitions and items unique to radiology are listed below:

Noninvasive/interventional diagnostic imaging includes standard radiographs, single or multiple views, contrast studies, computerized tomography and magnetic resonance imaging. In the event that radiographs have to be repeated in the course of a radiographic encounter due to substandard quality, only one unit of service for the code can be billed.

Section VIII: Diagnostic & Therapeutic Radiological Services

Page 151

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VIII:

DIAGNOSTIC & THERAPEUTIC RADIOLOGICAL SERVICES

SUBSECTION A:

PAYMENT GROUND RULES FOR DIAGNOSTIC &

THERAPEUTIC RADIOLOGICAL SERVICES

Interventional/invasive diagnostic imaging When a contrast can be administered orally (upper

GI) or rectally (barium enema), the administration is included as part of the procedure and no

administration service is billed. When contrast material is parenterally administered, whether the

timing of the injection has to correlate with the procedure or not (e.g. IVP, Ct scans, gadolinium),

the administration and the injection (e.g. CPT codes 36000, 36406, 36410, and 90782-90784) are

included in the contrast studies.

Subject Listings

Apply when radiological services are performed by or under the responsible supervision of a physician.

Supervision and Interpretation

When two physicians perform a procedure, the radiological portion of the procedure is designated as "radiological supervision and interpretation". When a physician performs both the procedure and provides imaging supervision and interpretation, a combination of procedure codes outside the 70000 series and imaging supervision and interpretation codes are to be used.

Review of Diagnostic Studies

No separate charge is warranted for prior studies reviewed in conjunction with a visit, consultation, record review, or other evaluation by the medical practitioner or other medical personnel; neither the professional component value modifier 26 nor the radiological consultation code 76140 is reimbursable. The review of diagnostic tests is included in the Evaluation & Management codes.

Written Report(s)

A written report, signed by the interpreting physician, should be considered an integral part of a radiological procedure or interpretation.

Unbundling of "Entrance" Fees

Unbundling of fees to free standing diagnostic radiology centers will not be allowed. Any entrance fees billed in addition to the global or testing procedure code will not be reimbursed.

Section VIII: Diagnostic & Therapeutic Radiological Services

Page 152

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VIII:

DIAGNOSTIC & THERAPEUTIC RADIOLOGICAL SERVICES

SUBSECTION A: Injection Procedure

PAYMENT GROUND RULES FOR DIAGNOSTIC & THERAPEUTIC RADIOLOGICAL SERVICES

Fees include all usual pre- and post-injection care specifically related to the injection procedure, necessary local anesthesia, placement of needle or catheter, and injection of contrast media with or without auto power injection, or contrast material in computerized axial tomogram (CAT) of spine either by intrathecal or intravenous injection. For intrathecal injection, include the code 61055 or 62284. IV injection of contrast material is included in the CAT procedure and shall not be reimbursed separately.

When introducing additional materials through the same puncture site, reimbursement shall be allowed for the materials only. Usual, customary and reasonable charges will apply to such charges.

Section VIII: Diagnostic & Therapeutic Radiological Services

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STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VIII:

DIAGNOSTIC & THERAPEUTIC RADIOLOGICAL SERVICES

SUBSECTION B:

PAYMENT MODIFIERS FOR DIAGNOSTIC &

THERAPEUTIC RADIOLOGICAL SERVICES

A modifier indicates a service or procedure performed has been altered by some specific

circumstance but has not changed its definition or code. The modifying circumstance shall be

identified by use of a hyphen and the appropriate modifier following the procedure code. When

two modifiers are applicable to a single code, indicate each modifier, preceded by a hyphen, on

the bill. The modifier may also be reported by using a separate five-digit code in addition to the

procedure code. If more than one modifier is used, place the "Multiple Modifiers" code `99'

immediately after the procedure code. This indicates that one or more additional modifier codes

will follow. Only certain modifiers in each of the categories (anesthesia, surgery,

pathology/laboratory, radiology, general medicine, and physical medicine) will be recognized for

reimbursement purposes.

The modifiers listed below may differ from those published by the American Medical Association. Medical providers submitting workers' compensation billing shall use only the modifiers set out in the fee schedule..

The following modifiers will be recognized for reimbursement by the fee schedule for diagnostic and therapeutic radiology services codes:

-22 Unusual Procedure Services: When the service(s) provided is greater than that usually required for the listed procedure, it may be identified by adding modifier (-22) to the usual procedure number or by use of the separate five digit modifier code 09922. A report may also be appropriate.

-26 Professional Component Only: Certain procedures are a combination of a professional component and a technical component. When the professional component is reported separately, the service may be identified by adding the modifier (-26) to the usual procedure number or the service may be reported by use of the five-digit modifier code 09926.

-27 Technical Component Only: Certain procedures are a combination of a professional component and a technical component. When the technical component is reported separately, the service may be identified by adding the modifier (-27) to the usual procedure number or the service may be reported by use of the five-digit modifier code 09927.

Section VIII: Diagnostic & Therapeutic Radiological Services

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STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VIII:

DIAGNOSTIC & THERAPEUTIC RADIOLOGICAL SERVICES

SUBSECTION B:

PAYMENT MODIFIERS FOR DIAGNOSTIC &

THERAPEUTIC RADIOLOGICAL SERVICES

-53 Discontinued Procedure: Under certain circumstances, the physician may elect to end a

surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten

the well being of the patient, it may be necessary to indicate that a surgical or diagnostic

procedure was started but discontinued. This circumstance may be reported by adding the

modifier (-53) to the code for the discontinued procedure or by using the separate five-

digit modifier 09953. Note: This modifier is not used to report the elective cancellation

of a procedure before the patient's anesthesia induction and/or surgical preparation in the

operating suite.

-59 Distinct Procedural Service: Under certain circumstances, the medical provider may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier (-59) is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician. However, when another already established modifier is appropriate it should be used rather than modifier (-59). Only if no more descriptive modifier is available, and the use of modifier (-59) best explains the circumstances, should modifier (-59) be used. Modifier code 09959 may be used as an alternative to modifier (-59).

Multiple Modifiers: Under certain circumstances, two or more modifiers may be necessary to completely delineate a service. In such situations, modifier (-99) should be added to the basic procedure and other applicable modifiers may be listed as part of the description of the service. Modifier code 09999 may be used as an alternative to modifier (-99).

Section VIII: Diagnostic & Therapeutic Radiological Services

Page 155

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION VIII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MAR PC/-26 FUD

70010 70015 70030 70100 70110 70120 70130 70134 70140 70150 70160 70170 70190 70200 70210 70220 70240 70250 70260 70300 70310 70320 70328 70330 70332 70336 70350 70355 70360 70370 70371 70373 70380 70390 70450 70460 70470 70480 70481 70482 70486 70487 70488 70490 70491 70492

MYELOGRAPHY POST FOSSA-RAD S & I CISTERNOGRAPHY POS CONTRAST-RAD S & I RAD EXAM EYE DETECTION FB RAD EXAM MANDIB; PART LESS THAN 4 VIEWS RAD EXAM MANDIB; COMPLT MINI 4 VIEWS RAD EXAM MASTOIDS; LESS THAN 3 VIEWS PER SIDE RAD EXAM MASTOIDS; COMPLT MINI 3 VIEWS-SIDE RAD EXAM INT AUDITORY MEATI COMPLT RAD EXAM FACIAL BONES; LESS THAN 3 VIEWS RAD EXAM FACIAL BONES; COMPLT MINI 3 VIEWS RAD EXAM NASAL BONES COMPLT MINI 3 VIEWS DACRYOCYSTOGRAPHY NASOLACRIMAL DUCT-RAD S & I RAD EXAM; OPTIC FORAMINA RAD EXAM; ORBITS COMPLT MINI 4 VIEWS RAD EXAM SINUSES PARANASAL LESS THAN 3 VIEWS RAD EXAM SINUSES PARANASAL COMPLT MINI 3 VIEWS RAD EXAM SELLA TURCICA RAD EXAM SKULL; LESS THAN 4 VIEWS W/WO STEREO RAD EXAM SKULL; COMPLT MINI 4 VIEWS W/WO STEREO RAD EXAM TEETH; SNGL VIEW RAD EXAM TEETH; PART EXAM LESS THAN FULL MOUTH RAD EXAM TEETH; COMPLT FULL MOUTH RAD EXAM TMJ OPEN & CLO MOUTH; UNILAT RAD EXAM TMJ OPEN & CLO MOUTH; BILAT TMJ ARTHROGRAPHY-RAD S & I MRI TEMPOROMANDIBULAR JT CEPHALOGRAM ORTHODONTIC ORTHOPANTOGRAM RAD EXAM; NECK SOFT TISS RAD EXAM; PHARYNX/LARYNX INCL FLUORO &/OR MAGNIF COMPLX DYNAMIC PHARYNGEAL & SPEECH EVAL LARYNGOGRAPHY CONTRAST-RAD S & I RAD EXAM SALIVARY GLAND CALCU SIALOGRAPHY-RAD S & I CAT HEAD/BRAIN; WO CONTRAST MAT CAT HEAD/BRAIN; W/CONTRAST MAT CAT HEAD/BRAIN; WO CONTRAST FOLLOWED BY CONTRAST CAT ORBIT/SELLA/OUTER-MID-INNER EAR; WO CONTRAST CAT ORBIT/SELLA/OUTER-MID-INNER EAR; W/CONTRAST CAT ORBIT/SELLA/EAR; WO CONTRAST THEN CONTRAST CAT MAXILLOFACIAL AREA; WO CONTRAST CAT MAXILLOFACIAL AREA; W/CONTRAST CAT MAXILLOFACIAL; WO CONTRAST THEN CONTRAST CAT SOFT TISS NECK; WO CONTRAST CAT SOFT TISS NECK; W/CONTRAST CAT SOFT TISS NECK; WO CONTRAST THEN CONTRAST

$369 $302 $117
$75 $127
$75 $143 $164 $109 $134
$84 $131 $107 $136
$92 $151
$92 $109 $151
$32 $60 $114 $138 $201 $314 $1,367 $101 $99 $104 $230 $399 $252 $126 $255 $445 $537 $653 $484 $564 $673 $500 $576 $684 $540 $604 $752

$129 N/A $106 N/A
$47 N/A $30 N/A $51 N/A $30 N/A $57 N/A $66 N/A $44 N/A $54 N/A $34 N/A $46 N/A $43 N/A $54 N/A $37 N/A $60 N/A $37 N/A $44 N/A $60 N/A $13 N/A $24 N/A $46 N/A $55 N/A $81 N/A $110 N/A $274 N/A $40 N/A $40 N/A $42 N/A $92 N/A $160 N/A $88 N/A $50 N/A $89 N/A $111 N/A $134 N/A $163 N/A $121 N/A $141 N/A $168 N/A $125 N/A $144 N/A $171 N/A $135 N/A $151 N/A $188 N/A

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SECTION VIII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MAR PC/-26 FUD

70540 70544 70545 70546 70547 70548 70549 70551 70552 70553 71010 71015 71020 71021 71022 71023 71030 71034 71035 71040 71060 71090 71100 71101 71110 71111 71120 71130 71250 71260 71270 71550 71555 72010 72020 72040 72050 72052 72069 72070 72072 72074 72080 72090 72100 72110

MRI ORBIT FACE & NECK MRI ANGIO HEAD WO CONTRAST MAT MRI ANGIO HEAD W/ CONTRAST MAT MRI ANGIO HEAD W/WO CONTRAST MAT MRI ANGIO NECK WO CONTRAST MAT MRI ANGIO NECK W/ CONTRAST MAT MRI ANGIO NECK W/WO CONTRAST MAT MRI BRAIN; WO CONTRAST MRI BRAIN; W/CONTRAST MRI BRAIN; WO CONTRAST FOLLOWED BY CONTRAST RAD EXAM CHEST; SNGL VIEW FRONTAL RAD EXAM CHEST; STEREO FRONTAL RAD EXAM CHEST 2 VIEWS FRONTAL & LAT RAD EXAM CHEST-FRONT & LAT; W/APICAL LORDOTIC RAD EXAM CHEST-FRONT & LAT; W/OBLIQ PROJ RAD EXAM CHEST, FRONT & LAT; W/FLUOROSCOPY RAD EXAM CHEST COMPLT MINI 4 VIEWS RAD EXAM CHEST COMPLT MINI 4 VIEWS; W/FLUOROSCPY RAD EXAM CHEST SPECIAL VIEWS BRONCHOGRAPHY UNILAT-RAD S & I BRONCHOGRAPHY BILAT-RAD S & I INSRT PACEMAKER FLUORO & RADIOGRAPHY-RAD S & I RAD EXAM RIBS UNILAT; 2 VIEWS RAD EXAM RIBS UNILAT; W/PA CHEST MINI 3 VIEWS RAD EXAM RIBS BILAT; 3 VIEWS RAD EXAM RIBS BILAT; W/PA CHEST MINI 4 VIEWS RAD EXAM; STERNUM MINI 2 VIEWS RAD EXAM; STERNOCLAVICULAR JT/JTS MINI 3 VIEWS CAT THORAX; WO CONTRAST MAT CAT THORAX; W/CONTRAST MAT CAT THORAX; WO CONTRAST THEN W/CONTRAST MRI CHEST MRI ANGIO CHEST W/WO CONTRAST MAT RAD EXAM SPINE-ENTIRE-SURVEY STUDY AP & LAT RAD EXAM SPINE SNGL VIEW SPEC LEVEL RAD EXAM SPINE CERV; ANTEROPOSTERIOR & LAT RAD EXAM SPINE CERV; MINI 4 VIEWS RAD EXAM SPINE CERV; COMPLT INCL OBLIQ & FLEX RAD EXAM SPINE THORACOLUMBAR STANDING RAD EXAM SPINE; THORACIC ANTEROPOSTERIOR & LAT RAD EXAM SPINE; THORACIC AP & LAT W/SWIM VIEW RAD EXAM SPINE; THORACIC COMPLT W/OBLIQ MINI 4 RAD EXAM SPINE; THORACOLUMBAR AP & LAT RAD EXAM SPINE; SCOLIOSIS STUDY W/SUPINE & ERECT RAD EXAM SPINE LUMBOSACRAL; AP & LAT RAD EXAM SPINE LUMBOSACRAL; COMPLT W/OBLIQ VIEWS

$1,034 $1,177 $1,177 $1,177 $1,177 $1,177 $1,177
$965 $1,177 $1,333
$60 $69 $69 $102 $104 $119 $114 $179 $75 $143 $194 $186 $79 $91 $96 $114 $69 $84 $513 $597 $716 $1,244 $1,265 $193 $71 $101 $129 $153 $99 $97 $105 $120 $102 $120 $92 $134

$207 N/A $236 N/A $236 N/A $236 N/A $236 N/A $236 N/A $236 N/A $193 N/A $236 N/A $267 N/A
$24 N/A $28 N/A $28 N/A $41 N/A $42 N/A $48 N/A $45 N/A $72 N/A $30 N/A $50 N/A $68 N/A $65 N/A $32 N/A $36 N/A $38 N/A $45 N/A $28 N/A $33 N/A $128 N/A $149 N/A $179 N/A $249 N/A $253 N/A $77 N/A $28 N/A $40 N/A $51 N/A $61 N/A $40 N/A $39 N/A $42 N/A $48 N/A $41 N/A $48 N/A $37 N/A $54 N/A

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SECTION VIII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MAR PC/-26 FUD

72114 72120 72125 72126 72127 72128 72129 72130 72131 72132 72133 72141 72142 72146 72147 72148 72149 72156 72157 72158 72159 72170 72190 72192 72193 72194 72196 72198 72200 72202 72220 72240 72255 72265 72270 72275 72285 72295 73000 73010 73020 73030 73040 73050 73060 73070

RAD EXAM SPINE LUMBOSACRAL; COMPLT INCL BENDING RAD EXAM SPINE LUMBOSACRAL BENDING ONLY MINI 4 CAT CERV SPINE; WO CONTRAST CAT CERV SPINE; W/CONTRAST CAT CERV SPINE; WO CONTRAST THEN W/CONTRAST CAT THORACIC SPINE; WO CONTRAST CAT THORACIC SPINE; W/CONTRAST CAT THORACIC SPINE; WO CONTRAST THEN W/CONTRAST CAT LUMBAR SPINE; WO CONTRAST CAT LUMBAR SPINE; W/CONTRAST CAT LUMBAR SPINE; WO CONTRAST THEN W/CONTRAST MRI SPINAL CANAL & CONTENTS CERV; WO CONTRAST MRI SPINAL CANAL & CONTENTS CERV; W/CONTRAST MRI SPINAL CANAL & CONTENTS THORACIC; WO CONTRST MRI SPINAL CANAL & CONTENTS THORACIC; W/CONTRAST MRI SPINAL CANAL & CONTENTS LUMBAR; WO CONTRAST MRI SPINAL CANAL & CONTENTS LUMBAR; W/CONTRAST MRI SPINAL CANAL WO THEN W/CONTRAST CERV MRI SPINAL CANAL WO THEN W/CONTRAST; THORACIC MRI SPINAL CANAL WO THEN W/CONTRAST; LUMBAR MRI ANGIO SPINAL CANAL & CONTENTS W/WO CONTRAST RAD EXAM PELVIS; ANTEROPOSTERIOR ONLY RAD EXAM PELVIS; COMPLT MINI 3 VIEWS CAT PELVIS; WO CONTRAST CAT PELVIS; W/CONTRAST CAT PELVIS; WO CONTRAST THEN W/CONTRAST MRI PELVIS MRI ANGIO PELVIS W/WO CONTRAST MAT RAD EXAM SACROILIAC JT; LESS THAN 3 VIEWS RAD EXAM SACROILIAC JT; 3/MORE VIEWS RAD EXAM SACRUM & COCCYX MINI 2 VIEWS MYELOGRAPHY CERV-RAD S & I MYELOGRAPHY THORACIC-RAD S & I MYELOGRAPHY LUMBOSACRAL-RAD S & I MYELOGRAPHY ENTIRE SPINAL CANAL-RAD S & I EPIDUROGRAPHY, RADIOLOGICAL S & I DISKOGRAPHY CERV-RAD S & I DISKOGRAPHY LUMBAR-RAD S & I RAD EXAM; CLAV COMPLT RAD EXAM; SCAPULA COMPLT RAD EXAM SHOULDER; 1 VIEW RAD EXAM SHOULDER; COMPLT MINI 2 VIEWS RAD EXAM SHOULDER ARTHROGRAPHY-RAD S & I RAD EXAM; ACROMIOCLAV JT BILAT W/WO WT DISTRACT RAD EXAM; HUMERUS MINI 2 VIEWS RAD EXAM ELBOW; ANTEROPOSTERIOR & LAT VIEWS

$169 $131 $537 $612 $735 $537 $612 $735 $537 $612 $735 $917 $1,135 $1,001 $1,101 $951 $1,086 $1,323 $1,362 $1,291 $1,183
$63 $80 $449 $511 $618 $938 $1,151 $67 $79 $68 $356 $331 $349 $469 $257 $600 $528 $83 $87 $74 $94 $250 $83 $78 $70

$68 N/A $53 N/A $134 N/A $153 N/A $184 N/A $134 N/A $153 N/A $184 N/A $134 N/A $153 N/A $184 N/A $184 N/A $227 N/A $200 N/A $220 N/A $190 N/A $217 N/A $265 N/A $273 N/A $258 N/A $237 N/A $25 N/A $32 N/A $112 N/A $128 N/A $155 N/A $188 N/A $230 N/A $27 N/A $32 N/A $27 N/A $125 N/A $116 N/A $122 N/A $164 N/A $61 N/A $263 N/A $185 N/A $33 N/A $35 N/A $29 N/A $37 N/A $88 N/A $33 N/A $31 N/A $28 N/A

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SECTION VIII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MAR PC/-26 FUD

73080 73085 73090 73092 73100 73110 73115 73120 73130 73140 73200 73201 73202 73220 73221 73225 73500 73510 73520 73525 73530 73540 73542 73550 73560 73562 73564 73565 73580 73590 73592 73600 73610 73615 73620 73630 73650 73660 73700 73701 73702 73720 73721 73725 74000 74010

RAD EXAM ELBOW; COMPLT MINI 3 VIEWS RAD EXAM ELBOW ARTHROGRAPHY-RAD S & I RAD EXAM; FOREARM ANTEROPOSTERIOR & LAT VIEWS RAD EXAM; UPPER EXTREM INFANT MINI 2 VIEWS RAD EXAM WRIST; ANTEROPOSTERIOR & LAT VIEWS RAD EXAM WRIST; COMPLT MINI 3 VIEWS RAD EXAM WRIST ARTHROGRAPHY-RAD S & I RAD EXAM HAND; 2 VIEWS RAD EXAM HAND; MINI 3 VIEWS RAD EXAM FINGER(S) MINI 2 VIEWS CAT UPPER EXTREM; WO CONTRAST CAT UPPER EXTREM; W/CONTRAST CAT UPPER EXTREM; WO CONTRAST THEN W/CONTRAST MRI UPPER EXTREM OTHER THAN JT MRI ANY JT UPPER EXTREM MRI ANGIO UPPER EXTREM W/WO CONTRAST MAT RAD EXAM HIP; UNILAT 1 VIEW RAD EXAM HIP; COMPLT MINI 2 VIEWS RAD EXAM HIPS BILAT MIN 2 VIEWS W/AP VIEW PELVIS RAD EXAM HIP ARTHROGRAPHY-RAD S & I RAD EXAM HIP DURING OR PROC RAD EXAM PELVIS & HIPS INFANT/CHILD MINI 2 VIEWS RADIOLOGIC EXAM, SACROILIAC JOINT, ARTH. RAD EXAM FEMUR ANTEROPOSTERIOR & LAT VIEWS RAD EXAM KNEE; ANTEROPOSTERIOR & LAT VIEWS RAD EXAM KNEE; AP & LAT W/OBLIQ MINI 3 VIEWS RAD EXAM KNEE; INCL OBLIQ & TUNNEL &/OR PATELLAR RAD EXAM KNEE; BOTH KNEES STANDING AP RAD EXAM KNEE ARTHROGRAPHY-RAD S & I RAD EXAM; TIB & FIB AP & LAT VIEWS RAD EXAM; LOWER EXTREM INFANT MINI 2 VIEWS RAD EXAM ANK; ANTEROPOSTERIOR & LAT VIEWS RAD EXAM ANK; COMPLT MINI 3 VIEWS RAD EXAM ANK ARTHROGRAPHY-RAD S & I RAD EXAM FT; ANTEROPOSTERIOR & LAT VIEWS RAD EXAM FT; COMPLT MINI 3 VIEWS RAD EXAM; CALCAN MINI 2 VIEWS RAD EXAM; TOE(S) MINI 2 VIEWS CAT LOWER EXTREM; WO CONTRAST CAT LOWER EXTREM; W/CONTRAST CAT LOWER EXTREM; WO CONTRAST THEN W/CONTRAST MRI LOWER EXTREM OTHER THAN JT MRI ANY JT LOWER EXTREM MRI ANGIO LOWER EXTREM W/WO CONTRAST MAT RAD EXAM ABD; SNGL ANTEROPOSTERIOR VIEW RAD EXAM ABD; AP & ADD OBLIQ & CONE VIEWS

$78 $246
$67 $71 $62 $70 $177 $63 $70 $53 $541 $616 $744 $1,131 $1,103 $1,193 $76 $94 $121 $283 $126 $103 $330 $91 $83 $98 $111 $83 $336 $91 $91 $82 $88 $279 $85 $88 $76 $67 $431 $491 $594 $902 $880 $977 $59 $73

$31 N/A $86 N/A $27 N/A $28 N/A $25 N/A $28 N/A $62 N/A $25 N/A $28 N/A $21 N/A $135 N/A $154 N/A $186 N/A $227 N/A $221 N/A $239 N/A $30 N/A $38 N/A $48 N/A $99 N/A $50 N/A $41 N/A $82 N/A $36 N/A $33 N/A $39 N/A $44 N/A $33 N/A $118 N/A $36 N/A $36 N/A $33 N/A $35 N/A $98 N/A $34 N/A $35 N/A $30 N/A $27 N/A $108 N/A $123 N/A $149 N/A $181 N/A $176 N/A $196 N/A $23 N/A $29 N/A

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SECTION VIII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MAR PC/-26 FUD

74020 74022 74150 74160 74170 74181 74185 74190 74210 74220 74230 74235 74240 74241 74245 74246 74247 74249 74250 74251 74260 74270 74280 74283 74290 74291 74300 74301 74305 74320 74327 74328 74329 74330 74340 74350 74355 74360 74363 74400 74410 74415 74420 74425 74430 74440

RAD EXAM ABD; COMPLT INCL DECUBITUS &/OR ERECT RAD EXAM ABD; COMPLT ACUTE ABD SERIES-PA CHEST CAT ABD; WO CONTRAST CAT ABD; W/CONTRAST CAT ABD; WO CONTRAST THEN W/CONTRAST MRI ABD MRI ANGIO ABD W/WO CONTRAST MAT PERITONEOGRAM-RAD S & I RAD EXAM; PHARYNX &/OR CERV ESOPH RAD EXAM; ESOPH SWALLOWING FUNCT PHARYNX &/OR ESOPH W/CINERAD REMOV FB ESOPH W/USE BALLOON CATH-RAD S & I RAD EXAM GI TRACT UPPER; W/WO DELAY FILM WO KUB RAD EXAM GI TRACT UPPER; W/WO DELAY FILM W/KUB RAD EXAM GI TRACT UPPER; W/SM BOWEL W/MX SERIAL RAD EXAM GI TRACT UPPER-AIR CONTRAST; WO KUB RAD EXAM GI TRACT UPPER-AIR CONTRAST; W/KUB RAD EXAM GI TRACT UPPER-AIR CONTRAST; W/SM BOWEL RAD EXAM SM BOWEL INCL MX SERIAL FILMS RAD EXAM SM BOWEL W/MX SERIAL; VIA ENTEROCLYSIS DUODENOGRAPHY HYPOTONIC RAD EXAM COLON; BARIUM ENEMA W/WO KUB RAD EXAM COLON; AIR CONTRAST W/HI DENSITY BARIUM BARIUM ENEMA THERAP REDUCTION INTUSSUSCEPTION CHOLECYSTOGRAPHY ORAL CONTRAST CHOLECYSTOGRAPHY ORAL CONTRAST; ADD/REPEAT EXAM CHOLANGIOGRAPHY; INTRAOP-RAD S & I CHOLANGIOGRAPHY; ADD SET INTRAOP-RAD S & I CHOLANGIOGRAPHY; POSTOP-RAD S & I CHOLANGIOGRAPHY PERCUT TRANSHEPATIC-RAD S & I POSTOP BILI DUCT STONE REMOV-RAD S & I ENDO CATH-BILI DUCTAL SYST-RAD S & I ENDO CATH-PANCREATIC DUCTAL SYST-RAD S & I COMBO ENDO CATH-BILI & PANCREAT DUCTAL-RAD S & I INTRO LONG GI TUBE INCL MX FLUORO/FILMS-RAD S&I PERCUT PLCMT GASTROSTOMY TUBE-RAD S & I PERCUT PLCMT ENTEROCLYSIS TUBE-RAD S & I INTRALUMINAL DILAT STRICT &/OR OBSTRUC-RAD S & I PERCUT TRANSHEPATIC DILAT BILI STRICT-RAD S & I UROGRAPHY IV W/WO KUB W/WO TOMOGRAPHY UROGRAPHY INFUSION DRIP TECH &/OR BOLUS TECH UROGRAPHY INFUSION DRIP &/OR BOLUS; W/NEPHROTOM UROGRAPHY RETROGRADE W/WO KUB UROGRAPHY ANTEGRADE-RAD S & I CYSTOGRAPHY MINI 3 VIEWS-RAD S & I VASOGRPHY/VESICULOGRPHY/EPIDIDYMOGRPHY-RAD S & I

$81 $113 $594 $689 $831 $1,113 $1,339 $106 $122 $127 $154 $308 $170 $171 $277 $182 $191 $283 $142 $164 $165 $199 $261 $300 $102
$64 $123
$70 $127 $313 $400 $341 $340 $361 $185 $268 $270 $356 $256 $166 $177 $199 $110 $127 $104 $116

$32 N/A $45 N/A $148 N/A $172 N/A $208 N/A $223 N/A $268 N/A $37 N/A $49 N/A $51 N/A $62 N/A $108 N/A $68 N/A $68 N/A $111 N/A $73 N/A $76 N/A $113 N/A $57 N/A $65 N/A $66 N/A $80 N/A $104 N/A $120 N/A $41 N/A $26 N/A $43 N/A $25 N/A $44 N/A $110 N/A $140 N/A $119 N/A $119 N/A $126 N/A $65 N/A $94 N/A $94 N/A $125 N/A $90 N/A $66 N/A $71 N/A $79 N/A $44 N/A $44 N/A $36 N/A $41 N/A

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SECTION VIII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MAR PC/-26 FUD

74445 74450 74455 74470 74475 74480 74485 74710 74740 74742 74775 75552 75553 75554 75555 75556 75600 75605 75625 75630 75650 75658 75660 75662 75665 75671 75676 75680 75685 75705 75710 75716 75722 75724 75726 75731 75733 75736 75741 75743 75746 75756 75774 75790 75801 75803

CORPORA CAVERNOSOGRAPHY-RAD S & I URETHROCYSTOGRAPHY RETROGRADE-RAD S & I URETHROCYSTOGRAPHY VOIDING-RAD S & I RAD EXAM-RENAL CYST STUDY-TRANSLUMBAR-RAD S & I INTRO INTRACATH-RENAL PELVIS-PERCUT-RAD S & I INTRO URETERAL CATH THRU RENAL PELVIS-RAD S & I DILAT NEPHROSTOMY/URETERS/URETHRA-RAD S & I PELVIMETRY W/WO PLACENTAL LOCALIZ HYSTEROSALPINGOGRAPHY-RAD S & I TRANSCERV CATH FALLOPIAN TUBE-RAD S & I PERINEOGRAM CARDIAC MRI-MORPHOLOGY; WO CONTRAST MAT CARDIAC MRI-MORPHOLOGY; W/CONTRAST MAT CARDIAC MRI-FUNCT W/WO MORPHOLOGY; COMPLT STUDY CARDIAC MRI-FUNCT W/WO MORPHOLOGY; LTD STUDY CARDIAC MRI VELOCITY-FLOW MAPPING AORTOGRAPHY THORACIC WO SERIALOGRAPHY-RAD S & I AORTOGRAPHY THORACIC-SERIALOGRAPHY-RAD S & I AORTOGRAPHY ABD-SERIALOGRAPHY-RAD S & I AORTOGRAPHY ABD+BILAT ILIOFEM LOWER EXTREM-S & I ANGIO CERVICOCEREBRAL CATH INCL VESSEL ORIG-S&I ANGIO BRACHIAL RETROGRADE-RAD S & I ANGIO EXT CAROTID UNILAT SELECT-RAD S & I ANGIO EXT CAROTID BILAT SELECT-RAD S & I ANGIO CAROTID CEREBRAL UNILAT-RAD S & I ANGIO CAROTID CEREBRAL BILAT-RAD S & I ANGIO CAROTID CERV UNILAT-RAD S & I ANGIO CAROTID CERV BILAT-RAD S & I ANGIO VERTEBRAL CERV &/OR INTRACRAN-RAD S & I ANGIO SPINAL SELECT-RAD S & I ANGIO EXTREM UNILAT-RAD S & I ANGIO EXTREM BILAT-RAD S & I ANGIO RENAL UNILAT SELECT-RAD S & I ANGIO RENAL BILAT SELECT-RAD S & I ANGIO VISCERAL SELECT/SUPRASELECT-RAD S & I ANGIO ADRENAL UNILAT SELECT-RAD S & I ANGIO ADRENAL BILAT SELECT-RAD S & I ANGIO PELVIC SELECT/SUPRASELECT-RAD S & I ANGIO PULM UNILAT SELECT-RAD S & I ANGIO PULM BILAT SELECT-RAD S & I ANGIO PULM-NONSELECT CATH/VENOUS INJ-RAD S & I ANGIO INT MAMMARY-RAD S & I ANGIO SELECT EA ADD VESSEL-AFTER BASIC EXAM-S&I ANGIO AV SHUNT-RAD S & I LYMPHANGIOGRAPHY EXTREM ONLY UNILAT-RAD S & I LYMPHANGIOGRAPHY EXTREM ONLY BILAT-RAD S & I

$153 $138 $151 $144 $402 $488 $268 $106 $132 $149 $171 $1,015 $1,044 $1,032 $1,025 $1,665 $493 $986 $986 $1,104 $1,104 $1,104 $1,104 $1,324 $1,104 $1,324 $1,104 $1,324 $1,104 $986 $986 $1,104 $986 $1,183 $986 $986 $1,104 $986 $1,104 $1,324 $986 $986 $789 $493 $501 $603

$54 N/A $48 N/A $53 N/A $50 N/A $141 N/A $171 N/A $94 N/A $42 N/A $46 N/A $52 N/A $68 N/A $203 N/A $209 N/A $207 N/A $205 N/A $303 N/A $49 N/A $148 N/A $148 N/A $166 N/A $166 N/A $166 N/A $166 N/A $199 N/A $166 N/A $199 N/A $166 N/A $199 N/A $166 N/A $197 N/A $148 N/A $166 N/A $148 N/A $178 N/A $148 N/A $148 N/A $166 N/A $148 N/A $166 N/A $199 N/A $148 N/A $148 N/A $79 N/A $173 N/A $100 N/A $121 N/A

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SECTION VIII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MAR PC/-26 FUD

75805 75807 75809 75810 75820 75822 75825 75827 75831 75833 75840 75842 75860 75870 75872 75880 75885 75887 75889 75891 75893 75894 75896 75898 75900 75940 75945 75946 75960 75961 75962 75964 75966 75968 75970 75978 75980 75982 75984 75989 75992 75993 75994 75995 75996 76000

LYMPHANGIOGRAPHY PELVIC/ABD UNILAT-RAD S & I LYMPHANGIOGRAPHY PELVIC/ABD BILAT-RAD S & I SHUNTOGM INVESTIGAT PREV PLACED SHUNT-RAD S & I SPLENOPORTOGRAPHY-RAD S & I VENOGRAPHY EXTREM UNILAT-RAD S & I VENOGRAPHY EXTREM BILAT-RAD S & I VENOGRAPHY CAVAL INFERIOR W/SERIALOG-RAD S & I VENOGRAPHY CAVAL SUPER W/SERIALOGRAPHY-RAD S & I VENOGRAPHY RENAL UNILAT SELECT-RAD S & I VENOGRAPHY RENAL BILAT SELECT-RAD S & I VENOGRAPHY ADRENAL UNILAT SELECT-RAD S & I VENOGRAPHY ADRENAL BILAT SELECT-RAD S & I VENOGRAPHY SINUS/JUGULAR CATH-RAD S & I VENOGRAPHY SUPER SAGITTAL SINUS-RAD S & I VENOGRAPHY EPIDURAL-RAD S & I VENOGRAPHY ORBITAL-RAD S & I PERCUT TRANSHEPATIC PORTOGRAPHY W/EVAL-RAD S & I PERCUT TRANSHEPATIC PORTOGRPHY WO EVAL-RAD S & I HEPATIC VENOGRAPHY WEDGED/FREE W/EVAL-RAD S & I HEPATIC VENOGRAPHY WEDGED/FREE WO EVAL-RAD S & I VENOUS SAMPL THRU CATH W/WO ANGIO-RAD S & I TRANSCATH THERAP EMBOLIZATION-RAD S & I TRANSCATH THERAP INFUSION-ANY METHD-RAD S & I ANGIO THRU EXIST CATH F/U STUDY-THERAP EMBOLIZAT EXCHG PREV PLCD ART CATH DUR THERAP-RAD S & I PERCUT PLCMT IVC FILTER-RAD S & I INTRAVASC US (NON-CORN) RAD S/I; INITIAL VESSEL INTRAVASC US (NON-CORN) RAD S/I; EA ADD VESSEL TRANSCATH INTRO IV STENT PERCUT/OP-RAD S & I-EA TRANSCATH RETRIEVAL PERCUT IV FB-RAD S & I TRANSLUMINAL BALLOON ANGIOPLSTY PERIPH ART-S & I TRANSLUM BALLOON ANGIOPL EA ADD PERIPH ART-S & I TRANSLUM BALOON ANGIOPL RENAL/VISCERAL ART-S & I TRANSLUM BALLOON ANGIOPL EA ADD VISCERAL ART-S&I TRANSCATH BX-RAD S & I TRANSLUMINAL BALLOON ANGIOPL VENOUS-RAD S & I PERCUT TRANSHEPATIC BILI DRAIN W/CONTRST-RAD S&I PERCUT PLCMT DRAIN CATH-INOPER OBSTRCT-RAD S & I CHANGE PERCUT DRAIN CATH W/CONTRST MONITOR-S & I RAD GUIDANC PERQ DRAIN ABSCESS/SPECMN COLLEC-S&I TRANSLUMINAL ATHERECTOMY PERIPHERAL ART-RAD S&I TRANSLUM ATHERECTOMY EA ADD PERIPHER ART-RAD S&I TRANSLUMINAL ATHERECTOMY RENAL-RAD S & I TRANSLUMINAL ATHERECTOMY VISCERAL-RAD S & I TRANSLUM ATHERECT EA ADD VISCERAL ART-RAD S & I FLUORO (SEP PRO) TO 1 HR TIME-NOT 71023/71034

$650 $697 $215 $967 $228 $344 $967 $967 $942 $1,126 $605 $993 $884 $791 $1,010 $290 $1,173 $577 $1,038 $1,005 $415 $2,432 $2,138 $629 $508 $1,124 $643 $375 $1,498 $2,561 $1,544 $833 $1,650 $848 $974 $1,781 $583 $627 $218 $440 $2,033 $672 $1,268 $2,126 $1,173 $136

$130 N/A $139 N/A
$75 N/A $145 N/A
$80 N/A $120 N/A $145 N/A $145 N/A $141 N/A $169 N/A
$91 N/A $149 N/A $133 N/A $119 N/A $152 N/A
$44 N/A $176 N/A
$87 N/A $156 N/A $151 N/A
$42 N/A $244 N/A $214 N/A $472 N/A
$51 N/A $113 N/A $107 N/A $107 N/A $150 N/A $257 N/A $155 N/A
$83 N/A $165 N/A
$85 N/A $98 N/A $179 N/A $175 N/A $188 N/A $76 N/A $154 N/A $204 N/A $67 N/A $127 N/A $213 N/A $118 N/A $47 N/A

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CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MAR PC/-26 FUD

76001 76003 76005 76006 76010 76020 76040 76061 76062 76065 76066 76070 76075 76076 76078 76080 76086 76088 76090 76091 76092 76093 76094 76095 76096 76098 76100 76101 76102 76120 76125 76140 76150 76350 76355 76360 76370 76375 76380 76390 76400 76499 76506 76511 76512 76513

FLUORO PHYS TIME > 1 HR-ASSIST NON-RAD PHYS FLUORO LOCALIZ NEEDLE BX/FINE NEEDLE ASPIRAT FLUOROSCOPIC GUIDE & LOCALIZATION X-RAY STRESS VIEW RAD EXAM NOSE TO RECTUM FOR FB SNGL FILM-CHILD BONE AGE STUDIES BONE LENGTH STUDIES RAD EXAM OSSEOUS SURVEY; LTD RAD EXAM OSSEOUS SURVEY; COMPLT RAD EXAM OSSEOUS SURVEY INFANT JT SURVEY SNGL VIEW 1/MORE JT CT BONE DENSITY STUDY DUAL ENERGY X-RAY ABSORPTIOMETRY BONE DENSITY DUAL ENERGY X-RAY STUDY PHOTODENSITOMETRY RAD EXAM FISTULA/SINUS TRACT STUDY-RAD S & I MAMMARY DUCTOGM/GALACTOGM-SNGL DUCT-RAD S & I MAMMARY DUCTOGRAM/GALACTOGRAM-MX DUCTS-RAD S & I MAMMO; UNILAT MAMMO; BILAT SCREENING MAMMO BILAT MRI BREAST WO &/OR W/CONTRAST; UNILAT MRI BREAST WO &/OR W/CONTRAST; BILAT STEREOTACTIC LOCALIZ BREAST BX-EA LES-RAD S & I PREOP PLCMT NEEDLE LOCALIZ WIRE BREAST-RAD S & I RAD EXAM SURG SPECMN RAD EXAM 1 PLANE BODY SECT OTHER THAN W/UROGRPHY RAD EXAM COMPLX MOTION BODY SECT-NOT UROG; UNILA RAD EXAM COMPLX MOTION BODY SECT-NOT UROG; BILAT CINERADIOGRAPHY EX WHERE SPEC INCL CINERADIOGRAPHY-COMPLEMENT ROUTINE EXAM CONS X-RAY EXAM MADE ELSEWHERE WRITTEN REPORT XERORADIOGRAPHY SUBTRACTION CONJUNCTION W/CONTRAST STUDIES CT GUIDANCE STEREOTACTIC LOCALIZ CT GUIDANCE NEEDLE BX-RAD S & I CT GUIDANCE PLCMT RADIATION THERAP FIELDS CT CORONAL SAGITTAL MULTIPLANAR/OBLIQ/3-D RECON CT LTD/LOCALIZ F/U STUDY MR SPECTROSCOPY MRI BONE MARROW BLD SUPPLY UNLISTED DX RAD PROC ECHO B-SCAN &/OR REAL TIME W/A-MODE WHERE INDICA OPHTH ULTRASOUND ECHO DX; A-SCAN ONLY OPHTH ULTRASOUND ECHO DX; CONTACT B-SCAN OPHTH ULTRASOUND ECHO DX; IMMERSION B-SCAN

$581 $184 $203
$51 $70 $89 $105 $148 $197 $92 $91 $559 $202 $161 $80 $113 $206 $243 $108 $136 $92 $1,564 $2,054 $333 $154 $55 $160 $197 $259 $136 $111 $70 $62 $71 $525 $720 $462 $376 $436 $1,337 $1,078 BR $207 $226 $250 $258

$194 N/A $64 N/A $74 N/A N/A $25 N/A $31 N/A $37 N/A $59 N/A $79 N/A $37 N/A $36 N/A
$140 N/A $81 N/A $27 N/A $27 N/A $40 N/A $41 N/A $49 N/A $43 N/A $54 N/A $37 N/A
$313 N/A $411 N/A $133 N/A
$62 N/A $22 N/A $64 N/A $79 N/A $103 N/A $54 N/A $44 N/A $70 N/A
N/A $14 N/A $131 N/A $144 N/A $116 N/A $38 N/A $128 N/A $214 N/A $216 N/A
N/A $93 N/A $102 N/A $112 N/A $115 N/A

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CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MAR PC/-26 FUD

76516 76519 76529 76536 76604 76645 76700 76705 76770 76775 76778 76800 76805 76810 76815 76816 76818 76825 76826 76827 76828 76830 76831 76856 76857 76870 76872 76873 76880 76885 76886 76930 76932 76936 76941 76942 76945 76946 76948 76950 76965 76970 76975 76977 76986 76999

OPHTH BIOMETRY BY ULTRASOUND ECHO A-SCAN OPHTH BIOMETRY A-SCAN; W/IO LENS POWER CALCULAT OPHTH ULTRASONIC FB LOCALIZ ECHO-SOFT TISS HEAD & NECK B-SCAN W/IMAGE DOCUMN ECHO CHEST B-SCAN &/OR REAL TIME W/IMAGE DOCUMEN ECHO BREAST(S) B-SCAN &/OR REAL TIME W/IMAGE DOC ECHO ABD B-SCAN W/IMAGE DOCUMEN; COMPLT ECHO ABD B-SCAN &/OR REAL TIME W/IMAGE DOC; LTD ECHO RETROPERITON B-SCAN W/IMAGE DOCUMEN; COMPLT ECHO RETROPERITON B-SCAN W/IMAGE DOCUMEN; LTD ECHO TRANSPL KIDNEY B-SCAN W/IMAGE DOCUMEN ECHO SPINAL CANAL & CONTENTS ECHO PG UTERUS B-SCAN W/IMAGE DOCUMEN; COMPLT ECHO PG UTERUS B-SCAN; COMPLT MX GEST > 1ST TRIM ECHO PG UTERUS B-SCAN W/IMAGE DOCUMEN; LTD ECHO PG UTERUS B-SCAN W/IMAGE DOCUMEN; REPEAT FETAL BIOPHYSICAL PROFILE ECHO FETAL-CV SYST-REAL TIME W/IMAGE DOCUMEN ECHO FETAL-CV SYST-REAL TIME W/DOCUMEN; REPEAT DOPPLER ECHO FETAL-CV SYST-PULSED WAVE; COMPLT DOPPLER ECHO FETAL-CV SYST-PULSED WAVE; REPEAT ECHO TRANSVAGINAL ECHO EXAM, UTERUS ECHO PELVIC B-SCAN W/IMAGE DOCUMEN; COMPLT ECHO PELVIC B-SCAN W/IMAGE DOCUMEN; LTD/F U ECHO SCROTUM & CONTENTS ECHO TRANSRECTAL ECHOGRAPHY, TRANSRECTAL; PROSTATE VOLUME STUDY ECHO EXTREM NON-VASCULAR B-SCAN W/IMAGE DOCUMEN ECHO EXAM, INFANT HIPS ECHO EXAM, INFANT HIPS ULTRASONIC GUIDANCE PERICARDIOCENTESIS-RAD S & I ULTRASONIC GUIDANCE ENDOMYOCARDIAL BX-RAD S & I US GUID COMPRESS REPR ART PSEUDO-ANEUR/AV FISTUL US GUID IN UTERO FETAL TRNSFUS/CORDCENTESIS-S&I ULTRASONIC GUIDANCE NEEDLE BX-RAD S & I US GUID CHORIONIC VILLUS SAMPL-RAD S & I ULTRASONIC GUIDANCE AMNIOCENTESIS-RAD S & I ULTRASONIC GUIDANCE ASPIRAT OVA-RAD S & I ECHO PLCMT RADIATION THERAP FIELDS B-SCAN US GUID INTERST RADIOELEMENT APPLIC ULTRASOUND STUDY F/U GI ENDO ULTRASND-RAD S & I US BONE DENSITY MEASURE ECHO INTRAOPERATIVE UNLISTED ULTRASOUND PROC

$238 $238 $214 $189 $246 $183 $228 $171 $218 $140 $237 $249 $246 $359 $181 $159 $257 $327 $196 $209 $125 $278 $278 $243 $223 $209 $298 $437 $209 $258 $225 $209 $241 $739 $202 $271 $202 $225 $257 $250 $501 $162 $364 $122 $491
BR

$107 N/A $107 N/A
$96 N/A $85 N/A $110 N/A $82 N/A $103 N/A $77 N/A $98 N/A $63 N/A $107 N/A $112 N/A $111 N/A $161 N/A $81 N/A $71 N/A $116 N/A $147 N/A $88 N/A $94 N/A $56 N/A $125 N/A $120 N/A $110 N/A $100 N/A $94 N/A $134 N/A $201 N/A $94 N/A $113 N/A $100 N/A $94 N/A $108 N/A $332 N/A $91 N/A $122 N/A $91 N/A $101 N/A $116 N/A $113 N/A $225 N/A $70 N/A $164 N/A $122 N/A $221 N/A
N/A

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SECTION VIII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MAR PC/-26 FUD

77300 77305 77310 77315 77321 77326 77327 77328 77331 77332 77333 77334 77336 77370 77399 77401 77402 77403 77404 77406 77407 77408 77409 77411 77412 77413 77414 77416 77417 77427 77431 77432 77470 77499 77520 77523 77600 77605 77610 77615 77620 77750 77761 77762 77763 77776

BASIC RAD DOSIMETRY CALCULAT-WHEN PRESCRIB BY MD TELETHERAPY ISODOSE PLAN; SIMPL TELETHERAPY ISODOSE PLAN; INTERMED TELETHERAPY ISODOSE PLAN; COMPLX SPEC TELETHERAP PORT PLAN PARTICLES HEMI-TOT BOD BRACHYTHERAP ISODOSE CALCULATION; SIMPL BRACHYTHERAP ISODOSE CALCULATION; INTERMED BRACHYTHERAP ISODOSE CALCULATION; COMPLX SPECIAL DOSIMETRY-WHEN PRESCRIB BY TX PHYS TX DEVICES DESIGN & CONSTRUCTION; SIMPL TX DEVICES DESIGN & CONSTRUCTION; INTERMED TX DEVICES DESIGN & CONSTRUCTION; COMPLX CONT MED RADIAT PHYSICS CONS W/QA REPORT WK-THER SPECIAL MED RADIATION PHYSICS CONS UNLIST PROC MED RAD PHYSICS/DOSIMETRY & TX DIVIC RADIATION TX DELIV SUPERF &/OR ORTHO VOLTAGE RAD TX DELIV-1 TX AREA-1 PORT-SMPL BLOC; TO 5MEV RAD TX DELIV-1 TX AREA-1 PORT-SMPL BLOC; 6-10MEV RADIATION TX DELIV-1 TX AREA-1 PORT; 11-19 MEV RADIAT TX DELIV-1 TX AREA-1 PORT; 20 MEV/GREATER RAD TX DELIV-2 TX AREAS-3/MORE PORTS; TO 5 MEV RAD TX DELIV-2 TX AREAS-3/MORE PORTS; 6-10 MEV RAD TX DELIV-2 TX AREAS-3/MORE PORTS; 11-19 MEV RAD TX DELIV-2 TX AREAS-3/MORE PORTS; 20 MEV/GRT RADIATION TX DELIV-3/MORE TX AREAS; UP TO 5 MEV RADIATION TX DELIV-3/MORE TX AREAS; 6-10 MEV RADIATION TX DELIV-3/MORE TX AREAS; 11-19 MEV RADIAT TX DELIV-3/MORE TX AREAS; 20 MEV/GREATER THERAP RAD PORT FILM RADIATION TREATMENT MANAGEMENT, 5 TREATMENTS RADIATION THERAP MGMT W/COMPLT COURSE THERAP STEREOTACTIC RADIATION TX MGMT CEREBRAL LES SPECIAL TX PROC UNLISTED PROC THERAP RAD CLINICAL TX MGMT PROTON BEAM DELIVERY, SINGLE AREA PROTON BEAM DELIVERY, 1-2 AREAS, 2+ PORTS HYPERTHERMIA EXT GEN; SUPERF HYPERTHERMIA EXT GEN; DEEP HYPERTHERMIA GEN-INTERSTITIAL PROBE; 5/LESS APPL HYPERTHERMIA GEN-INTERSTITIAL PROBE; > 5 APPLIC HYPERTHERMIA GEN BY INTRACAVITARY PROBE INFUSION/INSTLL RADIOELEMENT SOLUTION INTRACAVITARY RADIOELEMENT APPLIC; SIMPL INTRACAVITARY RADIOELEMENT APPLIC; INTERMED INTRACAVITARY RADIOELEMENT APPLIC; COMPLX INTERSTITIAL RADIOELEMENT APPLIC; SIMPL

$214 $269 $291 $335 $399 $239 $359 $508 $142 $191 $234 $452 $158 $246
BR $103 $105 $121 $135 $145 $135 $135 $135 $135 $149 $164 $167 $175 $104 $325 $139 $1,211 $737
BR BR BR $497 $670 $378 $550 $323 $598 $500 $739 $1,016 $658

$107 N/A $121 N/A $145 N/A $184 N/A $140 N/A $108 N/A $162 N/A $254 N/A $114 N/A
$96 N/A $117 N/A $203 N/A
N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $139 N/A $1,211 N/A $106 N/A N/A N/A N/A $249 N/A $335 N/A $189 N/A $275 N/A $161 N/A $508 90 $375 90 $554 90 $812 90 $526 N/A

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SECTION VIII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MAR PC/-26 FUD

77777 77778 77781 77782 77783 77784 77789 77790 77799 78000 78001 78003 78006 78007 78010 78011 78015 78016 78018 78020 78070 78075 78099 78102 78103 78104 78110 78111 78120 78121 78122 78130 78135 78140 78160 78162 78170 78172 78185 78190 78191 78195 78199 78201 78202 78205

INTERSTITIAL RADIOELEMENT APPLIC; INTERMED INTERSTITIAL RADIOELEMENT APPLIC; COMPLX REMOTE AFTERLOAD BRACHYTHERAP; 1-4 SOURCE POSIT REMOTE AFTERLOAD BRACHYTHERAP 5-8 SOURCE POSIT REMOTE AFTERLOAD BRACHYTHERAP; 9-12 SOURCE POSIT REMOTE AFTERLOAD BRACHYTHERAP; > 12 SOURCE POSIT SURFACE APPLIC RADIOELEMENT SUPERVS HANDLING LOADING-RADIOELEMENT UNLISTED PROC CLINICAL BRACHYTHERAP THYROID UPTAKE; SNGL DETERM THYROID UPTAKE; MX DETERM THYROID UPTAKE; STIM SUPPRESSION/DISCHG THYROID IMAGING W/UPTAKE; SNGL DETERM THYROID IMAGING W/UPTAKE; MX DETERM THYROID IMAGING; ONLY THYROID IMAGING; W/VASCULAR FLOW THYROID CARCINOMA METASTASES IMAGING; LTD AREA THYROID CA METASTASES IMAG; W/ADD STUDIES THYROID CARCINOMA METASTASES IMAGING; WHOLE BODY THYROID MET UPTAKE PARATHYROID IMAGING ADRENAL IMAGING CORTEX &/OR MEDULLA UNLISTED ENDOCRINE PROC DX NUCLEAR MEDS BONE MARROW IMAGING; LTD AREA BONE MARROW IMAGING; MX AREAS BONE MARROW IMAGING; WHOLE BODY PLASMA VOLUM RADIOPHARM (SEPART PROC); 1 SAMPL PLASMA VOLUM RADIOPHARM (SEPART PROC); MX SAMPL RED CELL VOLUM DETERM (SEPART PROC); SNGL SAMPL RED CELL VOLUM DETERM (SEPART PROC); MX SAMPL WHOLE BLD VOLUM DETERM W/SEPART PLASMA/RBC VOLUM RED CELL SURVIVAL STUDY RED CELL SURVIVAL STUDY; DIFF ORGAN/TISS KINETIC LABELED RED CELL SEQUESTRATION DIFF ORGAN/TISS PLASMA RADIOIRON DISAP RATE RADIOIRON ORAL ABSORPTION RADIOIRON RED CELL UTILIZ CHELATABLE IRON ESTIMATION TOT BODY IRON SPLEEN IMAGING ONLY W/WO VASCULAR FLOW KINETICS STUDY PLATELET SURVIVAL W/WO DIFF ORGAN PLATELET SURVIVAL STUDY LYMPHATICS & LYMPH GLANDS IMAGING UNLIST HEMATOPOIETIC & LYMPHATIC PROC-DX NUCLEAR LIVER IMAGING; STATIC ONLY LIVER IMAGING; W/VASCULAR FLOW LIVER IMAGING (SPECT)

$1,076 $1,495 $1,200 $1,263 $1,353 $1,493
$123 $155
BR $92 $123 $110 $204 $231 $139 $221 $276 $293 $460 $59 $123 $184 BR $215 $337 $368 $123 $184 $135 $227 $344 $276 $299 $271 $184 $288 $279 $101 $209 $350 $394 $340 BR $275 $302 $563

$807 90 $1,195 90
$180 90 $253 90 $338 90 $448 90
$98 90 $124 N/A
N/A $28 N/A $37 N/A $33 N/A $61 N/A $69 N/A $42 N/A $66 N/A $83 N/A $88 N/A $138 N/A $52 N/A $37 N/A $55 N/A
N/A $54 N/A $84 N/A $92 N/A $31 N/A $46 N/A $34 N/A $57 N/A $86 N/A $69 N/A $75 N/A $68 N/A $46 N/A $72 N/A $70 N/A $25 N/A $52 N/A $87 N/A $99 N/A $85 N/A
N/A $69 N/A $76 N/A $141 N/A

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SECTION VIII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MAR PC/-26 FUD

78206 78215 78216 78220 78223 78230 78231 78232 78258 78261 78262 78264 78267 78268 78270 78271 78272 78278 78282 78290 78291 78299 78300 78305 78306 78315 78320 78350 78351 78399 78414 78428 78445 78455 78456 78457 78458 78459 78460 78461 78464 78465 78466 78468 78469 78472

LIVER IMAGE (3-D) W/FLOW LIVER & SPLEEN IMAGING; STATIC ONLY LIVER & SPLEEN IMAGING; W/VASCULAR FLOW LIVER FUNCT STUDY W/HEPATOBILI AGENTS W/IMAGES HEPATOBILI DUCT SYST IMAGING INCL GB W/WO FUNCT SALIVARY GLAND IMAGING SALIVARY GLAND IMAGING; W/SERIAL IMAGES SALIVARY GLAND FUNCT STUDY ESOPH MOTILITY GASTRIC MUCOS IMAGING GASTROESOPHAGEAL REFLUX STUDY GASTRIC EMPTYING STUDY BREATH TEST, C-14 UREA; ACQUISITION & ANALYSIS BREATH TEST, C-14 UREA; ANALYSIS VIT B-12 ABSORPTION STUDY; WO INTRINSIC FACTOR VIT B-12 ABSORPTION STUDY; W/INTRINSIC FACTOR VIT B-12 ABSORPTION STUDIES COMBO W/WO INTRINSIC ACUTE GI BLD LOSS IMAGING GI PROT LOSS BOWEL IMAGING PERITONEAL-VENOUS SHUNT PATENCY TEST UNLISTED GI PROC DX NUCLEAR MEDS BONE &/OR JT IMAGING; LTD AREA BONE &/OR JT IMAGING; MX AREAS BONE &/OR JT IMAGING; WHOLE BODY BONE &/OR JT IMAGING; 3 PHASE STUDY BONE &/OR JT IMAGING; TOMOGRAPHIC (SPECT) BONE DENSITY STUDY; SNGL PHOTON ABSORPTIOMETRY BONE DENSITY STUDY; DUAL PHOTON ABSORPTIOMETRY UNLISTED MS PROC DX NUCLEAR MEDS DETERM CENTRAL C-V HEMODYNAMICS SNGL/MX DETERM CARDIAC SHUNT DETECTION NON-CARDIAC VASCULAR FLOW IMAGING VENOUS THROMBOSIS STUDY IMAGING, PEPTIDE, ACUTE VENOUS THROMBOSIS VENOUS THROMBOSIS IMAGING; UNILAT VENOUS THROMBOSIS IMAGING; BILAT MYOCARDIAL IMAG-PET-METABOLIC EVAL MYOCARDIAL PERFUS IMAG; SNGL STUDY REST/STRESS MYOCARDIAL PERFUS IMAG; MX STUDIES REST/STRESS MYOCARDIAL PERFUS IMAG; TOMO (SPECT) SNGL STUDY MYOCARDIAL PERFUS IMAG; TOMO (SPECT) MX STUDIES MYOCARDIAL IMAG INFARCT AVID PLANAR; QUAL/QUAN MYOCARDIAL IMAG PLANAR; W/EJECT FRACT-1ST PASS MYOCARDIAL IMAG PLANAR; TOMOGRPH SPECT W/WO QUAN CARDIAC BLD POOL IMAG GATED EQUILIB; SNGL STUDY

$683 $378 $441 $360 $354 $232 $242 $247 $346 $327 $357 $367
$22 $38 $147 $155 $181 $416 $231 $316 $275 BR $252 $312 $334 $356 $440 $117 $161 BR $318 $251 $302 $318 $549 $259 $392 $2,543 $397 $624 $550 $843 $380 $348 $407 $398

$683 N/A $95 N/A
$110 N/A $90 N/A $89 N/A $58 N/A $60 N/A $62 N/A $87 N/A $82 N/A $89 N/A $92 N/A N/A N/A $37 N/A $39 N/A $45 N/A
$104 N/A $58 N/A $79 N/A $69 N/A N/A $76 N/A $94 N/A
$100 N/A $107 N/A $132 N/A
$35 N/A $48 N/A
N/A $95 N/A $75 N/A $91 N/A $95 N/A $135 N/A $76 N/A $118 N/A $432 N/A $119 N/A $187 N/A $165 N/A $253 N/A $114 N/A $104 N/A $122 N/A $119 N/A

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SECTION VIII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MAR PC/-26 FUD

78473 78478 78480 78481 78483 78491 78492 78494 78496 78499 78580 78584 78585 78586 78587 78588 78591 78593 78594 78596 78599 78600 78601 78605 78606 78607 78608 78609 78610 78615 78630 78635 78645 78647 78650 78660 78699 78700 78701 78704 78707 78708 78709 78710 78715 78725

CARDIAC BLD POOL IMAG GATED EQUILIB; MX STUDIES MYOCARDIAL PERFUS STUDY W/WALL MOTION QUAL/QUAN MYOCARDIAL PERFUSION STUDY W/EJECT FRACTION CARDIAC BLD POOL IMAG 1ST PASS; SNGL STUDY CARDIAC BLD POOL IMAG 1ST PASS; MX STUDIES HEART IMAGE (PET) SINGLE HEART IMAGE (PET) MULTIPLE HEART IMAGE, SPECT HEART FIRST PASS ADD-ON UNLISTED CARDIOVASCULAR PROC DX NUCLEAR MEDS PULM PERFUSION IMAGING PARTICULATE PULM PERFUS IMAG PARTICULATE W/VENT; SNGL BREATH PULM PERFUS PARTICULATE W/VENT; REBREATH & WASH PULM VENTILATION IMAGING AEROSOL; SNGL PROJ PULM VENTILATION IMAGING AEROSOL; MX PROJ PERFUSION LUNG IMAGE PULM VENTILAT IMAG GASEOUS SNGL BREATH SNGL PROJ PULM VENTILAT IMAG GASEOUS W/REBREATH; SNGL PROJ PULM VENTILAT IMAG GASEOUS W/REBREATH; MX PROJ PULM QUAN DIFF FUNCT STUDY UNLISTED RESPIRATORY PROC DX NUCLEAR MEDS BRAIN IMAGING LTD PROC; STATIC BRAIN IMAGING LTD PROC; W/VASCULAR FLOW BRAIN IMAGING COMPLT STUDY; STATIC BRAIN IMAGING COMPLT STUDY; W/VASCULAR FLOW BRAIN IMAGING COMPLT STUDY; TOMOGRAPHIC (SPECT) BRAIN IMAG POSITRON EMISSION TOMOGRPY; METABOLIC BRAIN IMAG POSITRON EMISSION TOMOGRPY; PERFUSION BRAIN IMAGING VASCULAR FLOW ONLY CEREBRAL BLD FLOW CEREBROSPINAL FLUID FLOW IMAGING; CISTERNOGRAPHY CEREBROSPINAL FLUID FLOW IMAG; VENTRICULOGRAPHY CEREBROSPINAL FLUID FLOW IMAGING; SHUNT EVAL CEREBROSPINAL FLUID FLOW IMAG; TOMO (SPECT) CSF LEAKAGE DETECTION & LOCALIZ RADIOPHARM DACRYOCYSTOGRAPHY UNLISTED NERV SYST PROC DX NUCLEAR MEDS KIDNEY IMAGING; STATIC ONLY KIDNEY IMAGING; W/VASCULAR FLOW KIDNEY IMAGING; W/FUNCT STUDY KIDNEY IMAGING; W/VASCULAR FLOW & FUNCT STUDY KIDNEY FLOW & FUNCTION IMAGE KIDNEY FLOW & FUNCTION IMAGE KIDNEY IMAGING; TOMOGRAPHIC (SPECT) KIDNEY VASCULAR FLOW ONLY KIDNEY FUNCT STUDY WO PHARMACOLOGIC INTERVENTION

$717 $139 $133 $422 $868 $3,035 $3,657 $584 $220
BR $351 $364 $542 $231 $295 $448 $278 $324 $389 $220
BR $275 $348 $341 $391 $597 $2,446 $2,862 $159 $356 $442 $348 $348 $512 $487 $232
BR $291 $342 $391 $390 $478 $573 $536 $164 $308

$215 N/A $42 N/A $40 N/A
$126 N/A $260 N/A $519 N/A $623 N/A $584 N/A $220 N/A
N/A $88 N/A $91 N/A $136 N/A $58 N/A $74 N/A $112 N/A $70 N/A $81 N/A $97 N/A $55 N/A
N/A $69 N/A $87 N/A $85 N/A $98 N/A $149 N/A $416 N/A $489 N/A $40 N/A $89 N/A $111 N/A $87 N/A $87 N/A $128 N/A $122 N/A $58 N/A
N/A $87 N/A $102 N/A $117 N/A $117 N/A $166 N/A $199 N/A $161 N/A $49 N/A $92 N/A

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SECTION VIII:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MAR PC/-26 FUD

78730 78740 78760 78761 78799 78800 78801 78802 78803 78805 78806 78807 78810 78890 78891 78990 78999 79000 79001 79020 79030 79035 79100 79200 79300 79400 79420 79440 79900 79999

URIN BLADDER RESIDUAL STUDY URETERAL REFLUX STUDY TESTICULAR IMAGING TESTICULAR IMAGING; W/VASCULAR FLOW UNLISTED GENITOURINARY PROC DX NUCLEAR MEDS RADIOPHARM LOCALIZ TUMOR; LTD AREA RADIOPHARM LOCALIZ TUMOR; MX AREAS RADIOPHARM LOCALIZ TUMOR; WHOLE BODY RADIOPHARM LOCALIZ TUMOR; TOMOGRAPHIC (SPECT) RADIOPHARM LOCALIZ ABSCESS; LTD AREA RADIOPHARM LOCALIZ ABSCESS; WHOLE BODY RADIOPHARM LOCALIZ ABSCESS; TOMOGRAPHIC (SPECT) TUMOR IMAGING-PET-METABOLIC EVAL GEN AUTO DATA: INTERACT PROCESS; SIMPL TO 30 MIN GEN AUTO DATA: INTERACT PROCESS; COMPLX > 30 MIN PROVISION DX RADIOPHARM UNLISTED MISC PROC DX NUCLEAR MEDS RADIOPHARM THERAP HYPERTHYROID; INIT W/EVAL PT RADIOPHARM THERAP HYPERTHYROID; SUBSQT EA THER RADIOPHARM THERAP THYROID SUPPRESS INCL PT EVAL RADIOPHARM ABLATION GLAND-THYROID CARCINOMA RADIOPHARM THERAP METASTASES THYROID CARCINOMA RADIOPHARM THERAP CHRONIC LEUKEMIA EA-TX INTRACAVITARY RADIOACTIVE COLLOID THERAP INTERSTITIAL RADIOACTIVE COLLOID THERAP RADIOPHARM THERAP NONTHYROID NONHEMATOLOGIC IV RADIOPHARM THERAP PARTICULATE INTRA-ARTICULAR RADIOPHARM THERAP PROVISION THERAP RADIOPHARM UNLISTED RADIOPHARM THERAP PROC

$137 $245 $280 $327
BR $249 $315 $397 $423 $222 $380 $423 $2,442 $113 $170
$85 BR $397 $226 $390 $394 $499 $295 $368 $233 $337 $397 $448 BR BR

$41 N/A $73 N/A $84 N/A $98 N/A
N/A $62 N/A $79 N/A $99 N/A $106 N/A $55 N/A $95 N/A $106 N/A $415 N/A $11 N/A $17 N/A
N/A N/A $238 N/A $136 N/A $234 N/A $236 N/A $300 N/A $177 N/A $221 N/A $140 N/A $202 N/A $240 N/A $269 N/A N/A N/A

Section VIII: Diagnostic & Therapeutic Radiological Services

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SECTION IX:

PATHOLOGY AND LABORATORY SERVICES

SUBSECTION A:

PAYMENT GROUND RULES FOR PATHOLOGY AND

LABORATORY SERVICES

General Guidelines

Physicians should include CPT codes for specific performance of diagnostic tests/studies for which specific CPT codes are available. Items used by all physicians in reporting their services are presented in the introduction. Definitions and explanations unique to pathology and laboratory are included below.

Services in Pathology & Laboratory

Services are those provided by the pathologist or by the technologists under responsible supervision of a physician. The fees listed in this section include recording of the specimen, performance of the test, and reporting of the result. The fees do not include specimen collection, specimen transfer, or individual patient administrative services.

Review of Diagnostic Studies

The medical practitioner or other medical personnel warrant no separate charge for the review of prior studies in conjunction with a visit, consultation, record review, or other evaluation. Neither the professional component modifier 26 or the pathology consultation codes 80500 and 80502 are reimbursable under this circumstance. The review of diagnostic tests is included in the Evaluation & Management (E/M) Codes.

Laboratory Visits Only

A "visit for laboratory tests only" (99007) may be billed when an injured employee is seen by a physician or laboratory solely for the performance of laboratory tests and complete administrative processing of the injured employee for registration and individual direct or third party insurance billing is required. This includes all routine handling and routine specimen collection, except collection of blood or special urine specimens and/or other specimens requiring extensive special preparation. In such cases, bill the special procedures required (99008-99014). The laboratory visit also applies if a specimen is brought to the laboratory, provided complete administrative processing described above is provided.

Section IX Pathology & Laboratory Services

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SECTION IX:

PATHOLOGY AND LABORATORY SERVICES

SUBSECTION A:

PAYMENT GROUND RULES FOR PATHOLOGY AND

LABORATORY SERVICES

Referral Laboratory Tests

The laboratory tests and services listed in this section when performed by other than the billing physician shall be billed at the value charged by the referral (outside) laboratory under the applicable procedure number with the appropriate modifier 90; the name of the referral laboratory and the charge made by that laboratory should also be identified.

Collection and Handling Procedures

Fees assigned to each test represent only the cost of performing the individual test, whether it is manual or automated (mechanized). The collection, handling and patient administrative services have been assigned separate fees and separate code numbers.

A. Report a collection, handling and patient administrative service separately, where applicable. For venipuncture see procedure 36415. For handling, see procedures 99000 and 99001.

B. Only the physician or laboratory drawing the blood or obtaining the specimen is entitled to a collection and handling fee.

C. Relative value units for specimen collection, handling, and patient administrative service are assigned in relation to the complexity of the process.

D. Although there is no billing for the test itself, the physician or laboratory performing the service can report a collection and handling charge. The test ordered and the name of the testing facility should be indicated.

E. When collection and handling are performed at the testing facility (laboratory), the laboratory may include separate charges for these services.

Professional Component
The maximum allowable reimbursement (MAR) includes the professional component (PC) plus the technical component (TC). The value for injection procedure is not included except when procedure is starred. This value is applicable in any situation in which a single charge is made to include both professional services and the technical cost of providing that service. Identification of a procedure by the 5-digit code without modifier 26 indicates that the charge includes both the "professional" and "technical" components.

Section IX Pathology & Laboratory Services

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SECTION IX:

PATHOLOGY AND LABORATORY SERVICES

SUBSECTION A:

PAYMENT GROUND RULES FOR PATHOLOGY AND

LABORATORY SERVICES

The professional component percentage represents the value of the professional pathology

services of the physician. This includes: examination of the injured employee; when indicated

performance and/or supervision of the procedure; interpretation and written report of the

laboratory procedure; and consultation with the authorized treating physician. This component is

applicable in any situation in which the physician submits a bill for these professional services

only. It does not include the cost of personnel, materials, space, equipment or other facilities. To

identify the charge for the professional component, use the 5-digit procedure code followed by

modifier 26.

The technical component includes the charges for personnel, materials, space, equipment and other facilities, and should be reported using modifier 27. In no instance will the sum of the charges for the professional and technical components of a service be greater than the value of the total service listed.

Separate or Multiple Procedures

It is appropriate to designate multiple procedures that are rendered at the same session by separate entries.

Unusual Service or Procedure

Services that may necessitate skills and time of the physician over and above that usually required should be substantiated by Special Report (detailed below).

Unlisted Service Or Procedure

When an unlisted service or procedure is provided, the values used should be substantiated by Special Report (detailed below). Identify by name or description.

Procedures Listed without Specified Unit Values

Fees are not shown for some procedures listed in the schedule that are rarely provided, unusual, variable, or new. For these procedures a "BR", designation has been used in the fee schedule. Reimbursement for such procedures must be justified by Special Report (detailed below).

Section IX Pathology & Laboratory Services

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SECTION IX:

PATHOLOGY AND LABORATORY SERVICES

SUBSECTION A: Special Report

PAYMENT GROUND RULES FOR PATHOLOGY AND LABORATORY SERVICES

A service that is rarely provided, unusual, variable, or new, may require a special report in determining medical appropriateness of the service. Pertinent information should include an adequate definition or description of the nature, extent, and need for the procedure; and the time, effort and equipment necessary to provide the service. Additional items that may be included are complexity of symptoms, final diagnosis, pertinent physical findings, diagnostic and therapeutic procedures, concurrent problems, and follow-up care.

Indices or Ratios

Tests that produce an index or ratio based on mathematical calculations from two or more other results may not be billed as a separate independent test (e.g., A/G ratio, free thyroxin index).

Automated Multichannel Tests

These tests, frequently ordered in groups and done on equipment that performs multiple tests simultaneously, are listed by the number of tests performed. When billing for these test groups, use the code number corresponding to the number of tests in the group. These tests shall not be reimbursed individually.

Panel Tests

When billing for panel tests (80050-80092) use the code number corresponding to the appropriate panel test. These tests shall not be reimbursed separately. Any tests in addition to a particular panel or a second panel of tests shall be billed separately.

Consultations
A clinical pathology study is a service that includes a written report rendered by the pathologist in response to a request from an authorized treating physician in relation to a test result(s) requiring additional medical interpretive judgment. Reporting on a test result(s) without medical interpretation is not considered a clinical pathology consultation and shall not be reimbursed as such.

Section IX Pathology & Laboratory Services

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SECTION IX:

PATHOLOGY AND LABORATORY SERVICES

SUBSECTION B:

PAYMENT MODIFIERS FOR PATHOLOGY AND

LABORATORY SERVICES

A modifier indicates a service or procedure performed has been altered by some specific

circumstance but has not changed its definition or code. The modifying circumstance shall be

identified by use of a hyphen and the appropriate modifier following the procedure code. When

two modifiers are applicable to a single code, indicate each modifier, preceded by a hyphen, on

the bill. The modifier may also be reported by using a separate five-digit code in addition to the

procedure code. If more than one modifier is used, place the "Multiple Modifiers" code -99

immediately after the procedure code. This indicates that one or more additional modifier codes

will follow. Only certain modifiers in each of the categories (anesthesia, surgery,

pathology/laboratory, radiology, general medicine, and physical medicine) will be recognized for

reimbursement purposes.

The modifiers listed below may differ from those published by the American Medical Association. Providers submitting workers' compensation billing shall use only the modifiers set out in the fee schedule.

The following modifiers will be recognized for reimbursement by the fee schedule for Pathology and Laboratory codes:

-22 Unusual Procedure Services: When the service(s) provided is greater than that usually required for the listed procedure, it may be identified by adding modifier (-22) to the usual procedure number or by use of the separate five digit modifier code 09922. A report may also be appropriate.

-26 Professional Component Only: Certain procedures are a combination of a physician component and a technical component. When the physician component is reported separately, the service may be identified by adding the modifier (-26) to the usual procedure number or the service may be reported by use of the five-digit modifier code 09926.

-27 Technical Component Only: Certain procedures are a combination of a physician component and a technical component. When the technical component is reported separately, the service may be identified by adding the modifier (-27) to the usual procedure number or the service may be reported by use of the five-digit modifier code 09927.

Section IX Pathology & Laboratory Services

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SECTION IX:

PATHOLOGY AND LABORATORY SERVICES

SUBSECTION B:

PAYMENT MODIFIERS FOR PATHOLOGY AND

LABORATORY SERVICES

-53 Discontinued Procedure: Under certain circumstances, the physician may elect to end a

surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten

the well being of the patient, it may be necessary to indicate that a surgical or diagnostic

procedure was started but discontinued. This circumstance may be reported by adding the

modifier (-53) to the code for the discontinued procedure or by using the separate five-

digit modifier 09953. Note: This modifier is not used to report the elective cancellation

of a procedure before the patient's anesthesia induction and/or surgical preparation in the

operating suite.

-59 Distinct Procedural Service: Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier (-59) is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician. However, when another already established modifier is appropriate it should be used rather than modifier (-59). Only if no more descriptive modifier is available, and the use of modifier (-59) best explains the circumstances, should modifier (59) be used. Modifier code 09959 may be used as an alternative to modifier (-59).

-90 Reference (Outside) Laboratory: When laboratory procedures are performed by a party other than the treating or reporting physician, the procedure may be identified by adding the modifier (-90) to the usual procedure number or by using the separate five-digit modifier code 09990.

-99 Multiple Modifiers: Under certain circumstances, two or more modifiers may be necessary to completely delineate a service. In such situations modifier (-99) should be added to the basic procedure, and other applicable modifiers may be listed as part of the description of the service. Modifier code 09999 may be used as an alternative to modifier (-99).

Section IX Pathology & Laboratory Services

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SECTION IX:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MAR PC/-26 FUD

80048 80050 80051 80053 80055 80061 80069 80072 80074 80076 80090 80100 80101 80102 80103 80150 80152 80154 80156 80158 80160 80162 80164 80166 80168 80170 80172 80174 80176 80178 80182 80184 80185 80186 80188 80190 80192 80194 80196 80197 80198 80200 80201 80202 80299 80400

BASIC METABOLIC PANEL (DO NOT USE W/ 80053) GENERAL HEALTH PANEL ELECTROLYTE PANEL COMPREHENSIVE METABOLIC PANEL (DO NOT USE W/ 80048, 80076) OB PANEL LIPID PANEL RENAL FUNCTION PANEL ARTHRITIS PANEL ACUTE HEPATITIS PANEL HEPATITIS FUNCTION PANEL (DO NOT USE W/ 80053) TORCH ANTIB PANEL DRUG SCREEN; MX DRUG CLASSES EA PROC DRUG SCREEN; SNGL DRUG CLASS EA DRUG CLASS DRUG CONFIRM EA PROC TISS PREP DRUG ANALY AMIKACIN AMITRIPTYLINE BENZODIAZEPINES CARBAMAZEPINE CYCLOSPORINE DESIPRAMINE DIGOXIN DIPROPYLACETIC ACID DOXEPIN ETHOSUXIMIDE GENTAMICIN GOLD IMIPRAMINE LIDOCAINE LITHIUM NORTRIPTYLINE PHENOBARBITAL PHENYTOIN; TOT PHENYTOIN; FREE PRIMIDONE PROCAINAMIDE PROCAINAMIDE; W/METABOLITES QUINIDINE SALICYLATE TACROLIMUS THEOPHYLLINE TOBRAMYCIN ASSAY FOR TOPIRAMATE VANCOMYCIN QUAN DRUG NES ACTH STIM PANEL; ADRENAL INSUFF

$22 $49 $33 $28 $56 $34 $23 $48 $125 $21 $66 $39 $31 $44 $22 $40 $44 $44 $35 $53 $44 $34 $35 $44 $40 $35 $35 $44 $35 $20 $44 $35 $34 $35 $35 $35 $49 $35 $21 $53 $34 $40 $38 $35 $44 $83

N/A $48 N/A $13 N/A
N/A $19 N/A $12 N/A
N/A $17 N/A
N/A N/A $28 N/A $11 N/A $9 N/A $13 N/A $8 N/A $13 N/A $14 N/A $14 N/A $11 N/A $18 N/A $15 N/A $10 N/A $11 N/A $12 N/A $16 N/A $12 N/A $10 N/A $13 N/A $11 N/A $8 N/A $14 N/A $10 N/A $9 N/A $10 N/A $11 N/A $11 N/A $19 N/A $11 N/A $6 N/A $12 N/A $8 N/A $13 N/A $13 N/A $12 N/A N/A $28 N/A

Section IX Pathology & Laboratory Services

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STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION IX:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MAR PC/-26 FUD

80402 80406 80408 80410 80412 80414 80415 80416 80417 80418 80420 80422 80424 80426 80428 80430 80432 80434 80435 80436 80438 80439 80440 80500 80502 81000 81001 81002 81003 81005 81007 81015 81020 81025 81050 81099 82000 82003 82009 82010 82013 82016 82017 82024 82030 82040

ACTH STIM PANEL; 21 HYDROXYLASE DEFICIENCY ACTH STIM PANEL; 3 BETA-HYDROXYDEHYDROGENASE DEF ALDOSTERONE SUPPRESSION EVAL PANEL CALCITONIN STIM PANEL CORTICOTROPIC RELEASING HORMONE STIM PANEL CHORIONIC GONADOTROPHIN STIM PANEL; TESTOSTERONE CHORIONIC GONADOTROP STIM PANEL; ESTRADIOL RESPO RENAL VEIN RENIN STIM PANEL PERIPHERAL VEIN RENIN STIM PANEL COMBO RAPID PITUITARY EVAL PANEL DEXAMETHASONE SUPPRESSION PANEL 48 HR GLUCAGON TOLERANCE PANEL; INSULINOMA GLUCAGON TOLERANCE PANEL; PHEOCHROMOCYTOMA GONADOTROPIN RELEASING HORMONE STIM PANEL GROWTH HORMONE STIM PANEL GROWTH HORMONE SUPPRESSION PANEL INSULIN-INDUCED C-PEPTIDE SUPPRRESSION PANEL INSULIN TOLERANCE PANEL; ACTH INSUFF INSULIN TOLERANCE PANEL; GROWTH HORMONE DEFICIEN METYRAPONE PANEL THYROTROPIN RELEASE HORMONE STIM PANEL; 1 HR THYROTROPIN RELEASE HORMONE STIM PANEL; 2 HR THYROTROP RELEASE HORMONE STIM; HYPERPROLACTINEM CLINIC PATH CONS; LTD WO REVIEW HX & MED RECORDS CLINIC PATH CONS; COMP COMPLX DX W/REVIEW UA DIP STICK/TABLET REAGENT; NON-AUTO W/MICRO UA DIP STICK/TABLET REAGENT; AUTO W/MICRO UA DIP STICK/TABLET REAGENT; WO MICRO NON-AUTO UA DIP STICK/TABLET REAGENT; WO MICRO AUTO UA; QUAL/SEMIQUAN EX IMMUNOASSAYS UA; BACTERURIA SCRN NON-CULT TECH COMMERCIAL KIT UA; MICRO ONLY UA; 2 OR 3 GLASS TEST URIN PG TEST BY VISUAL COLOR COMPAR METHD VOLUM MEASUR TIMED COLLEC EA UNLISTED UA PROC ACETALDEHYDE BLD ACETAMINOPHEN ACETONE/OTHER KETONE BODIES SERUM; QUAL ACETONE/OTHER KETONE BODIES SERUM; QUAN ACETYLCHOLINESTERASE ACYLCARNITINES, QUAL ACYLCARNITINES, QUANT ADRENOCORTICOTROPIC HORMONE ADENOSINE 5'-MONOPHOSPHATE CYCLIC ALBUMIN; SERUM

$153 $142 $191 $170 $424
$63 $63 $198 $85 $1,180 $150 $94 $91 $221 $110 $134 $239 $159 $169 $155 $74 $93 $88 $40 $79 $11 $11
$9 $9 $8 $12 $9 $11 $17 $8 BR $43 $42 $9 $18 $37 $38 $46 $83 $65 $12

$48 N/A $44 N/A $69 N/A $57 N/A $141 N/A $20 N/A $19 N/A $69 N/A $29 N/A $337 N/A $46 N/A $28 N/A $27 N/A $53 N/A $24 N/A $34 N/A $57 N/A $49 N/A $51 N/A $46 N/A $23 N/A $17 N/A $17 N/A $40 N/A $79 N/A
$5 N/A $5 N/A $4 N/A $3 N/A $3 N/A $4 N/A $4 N/A $4 N/A $8 N/A $3 N/A
N/A $13 N/A $11 N/A
$3 N/A $6 N/A $11 N/A
N/A N/A $25 N/A $26 N/A $4 N/A

Section IX Pathology & Laboratory Services

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SECTION IX:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MAR PC/-26 FUD

82042 82043 82044 82055 82075 82085 82088 82101 82103 82104 82105 82106 82108 82120 82127 82128 82131 82135 82136 82139 82140 82143 82145 82150 82154 82157 82160 82163 82164 82172 82175 82180 82190 82205 82232 82239 82240 82247 82248 82251 82252 82261 82270 82273 82286 82300

ALBUMIN; URIN QUAN ALBUMIN; URIN MICROALBUMIN QUAN ALBUMIN; URIN MICROALBUMIN SEMIQUAN ALCOHOL; ANY SPECMN EX BREATH ALCOHOL; BREATH ALDOLASE ALDOSTERONE ALKALOIDS URIN QUAN ALPHA-1-ANTITRYPSIN; TOT ALPHA-1-ANTITRYPSIN; PHENOTYPE ALPHA-FETOPROTEIN; SERUM ALPHA-FETOPROTEIN; AMNIOTIC FLUID ALUMINUM AMINES, VAGINAL FLUID, QUALITATIVE AMINO ACID, SINGLE QUAL AMINO ACIDS QUAL AMINO ACIDS QUAN EA AMINOLEVULINIC ACID DELTA AMINO ACIDS, 2-5 QUANT AMINO ACIDS, 6+ QUANT AMMONIA AMNIOTIC FLUID SCAN AMPHETAMINE/METHAMPHETAMINE AMYLASE ANDROSTANEDIOL GLUCURONIDE ANDROSTENEDIONE ANDROSTERONE ANGIOTENSIN II ANGIOTENSIN I- CONVERTING ENZYME APOLIPOPROTEIN EA ARSENIC ASCORBIC ACID BLD ATOMIC ABSORPTION SPECTROSCOPY EA ANALYTE BARBITURATES NES BETA-2 MICROGLOBULIN BILE ACIDS; TOT BILE ACIDS; CHOLYLGLYCINE BILIRUBIN TOTAL BILIRUBIN DIRECT BILI; TOT & DIRECT BILI; FECES QUAL ASSAY BIOTINIDASE BLD OCCULT; FECES SCREEN 1-3 SIMULTANEOUS DETERM BLD OCCULT; OTHER SOURCES QUAL BRADYKININ CADMIUM

$15 $32 $17 $28 $17 $28 $74 $46 $37 $51 $43 $43 $55
$6 $42 $27 $125 $41 $34 $34 $32 $34 $46 $15 $60 $55 $60 $55 $46 $30 $51 $27 $55 $37 $51 $30 $66 $12 $12 $14
$8 $47
$9 $9 $74 $52

$4 N/A $10 N/A
$5 N/A $8 N/A $5 N/A $8 N/A $23 N/A $14 N/A $13 N/A $17 N/A $14 N/A $14 N/A $17 N/A
N/A N/A $7 N/A $28 N/A $13 N/A N/A N/A $10 N/A $11 N/A $13 N/A $5 N/A $24 N/A $17 N/A $20 N/A $16 N/A $14 N/A $10 N/A $16 N/A $9 N/A $19 N/A $11 N/A $17 N/A $11 N/A $20 N/A N/A N/A $4 N/A $2 N/A N/A $4 N/A $2 N/A $20 N/A $16 N/A

Section IX Pathology & Laboratory Services

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STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION IX:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MAR PC/-26 FUD

82306 82307 82308 82310 82330 82331 82340 82355 82360 82365 82370 82374 82375 82376 82378 82379 82380 82382 82383 82384 82387 82390 82397 82415 82435 82436 82438 82441 82465 82480 82482 82485 82486 82487 82488 82489 82491 82492 82495 82507 82520 82523 82525 82528 82530 82533

CALCIFEDIOL CALCIFEROL CALCITONIN CALCIUM; TOT CALCIUM; IONIZED CALCIUM; AFTER CALCIUM INFUSION TEST CALCIUM; URIN QUAN TIMED SPECMN CALCU; QUAL ANALY CALCU; QUAN ANALY CHEM CALCU; INFRARED SPECTROSCOPY CALCU; X-RAY DIFFRACTION CARBON DIOXIDE CARBON MONOXIDE; QUAN CARBON MONOXIDE; QUAL CARCINOEMBRYONIC ANTIG ASSAY CARNITINE CAROTENE CATECHOLAMINES; TOT URIN CATECHOLAMINES; BLD CATECHOLAMINES; FRACTIONATED CATHEPSIN-D CERULOPLASMIN CHEMILUMINESCENT ASSAY CHLORAMPHENICOL CHLORIDE; BLD CHLORIDE; URIN CHLORIDE; OTHER SOURCE CHLORINATED HYDROCARBONS SCREEN CHOL SERUM TOT CHOLINESTERASE; SERUM CHOLINESTERASE; RBC CHONDROITIN B SULFATE QUAN CHROMATOGRAPHY QUAL; COLUMN ANALYTE NES CHROMATOGRAPHY QUAL; PAPER 1-DIMEN ANALYTE NES CHROMATOGRAPHY QUAL; PAPER 2-DIMEN ANALYTE NES CHROMATOGRAPHY QUAL; THIN LAYER ANALYTE NES CHROMATOGRAPHY QUAN COLUMN ANALYTE NES CHROMOTOGRAPHY, QUANT, MULT CHROMIUM CITRATE COCAINE/METABOLITE COLLAGEN CROSS LINKS-ANY METHD COPPER CORTICOSTERONE CORTISOL; FREE CORTISOL; TOT

$71

$24 N/A

$71

$24 N/A

$72

$22 N/A

$12

$4 N/A

$35

$10 N/A

$15

$5 N/A

$15

$5 N/A

$33

$11 N/A

$36

$12 N/A

$36

$10 N/A

$33

$11 N/A

$12

$4 N/A

$32

$9 N/A

$11

$3 N/A

$49

$14 N/A

$55

N/A

$28

$8 N/A

$49

$15 N/A

$71

$21 N/A

$71

$21 N/A

$66

$19 N/A

$30

$9 N/A

$35

$12 N/A

$47

$14 N/A

$12

$3 N/A

$13

$4 N/A

$13

$4 N/A

$34

$11 N/A

$12

$3 N/A

$23

$6 N/A

$34

$10 N/A

$56

$13 N/A

$53

$18 N/A

$41

$13 N/A

$56

$19 N/A

$41

$13 N/A

$47

$14 N/A

$41

N/A

$56

$19 N/A

$71

$21 N/A

$47

$15 N/A

$52

$21 N/A

$38

$11 N/A

$56

$18 N/A

$52

$16 N/A

$44

$12 N/A

Section IX Pathology & Laboratory Services

Page 179

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION IX:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MAR PC/-26 FUD

82540 82541 82542 82543 82544 82550 82552 82553 82554 82565 82570 82575 82585 82595 82600 82607 82608 82615 82626 82627 82633 82634 82638 82646 82649 82651 82652 82654 82657 82658 82664 82666 82668 82670 82671 82672 82677 82679 82690 82693 82696 82705 82710 82715 82725 82726

CREATINE COLUMN CHROMOTOGRAPHY QUAL COLUMN CHROMOTOGRAPHY QUANT COLUMN CHROMOTOGRAPH/ISOTOPE COLUMN CHROMOTOGRAPHY QUANT CREATINE KINASE; TOT CREATINE KINASE; ISOENZYMES CREATINE KINASE; MB FRACTION ONLY CREATINE KINASE; ISOFORMS CREATININE; BLD CREATININE; OTHER SOURCE CREATININE; CLEARANCE CRYOFIBRINOGEN CRYOGLOBULIN CYANIDE CYANOCOBALAMIN CYANOCOBALAMIN; UNSATURATED BINDING CAPACITY CYSTINE & HOMOCYSTINE URIN QUAL DEHYDROEPIANDROSTERONE DEHYDROEPIANDROSTERONE-SULFATE DESOXYCORTICOSTERONE 11DEOXYCORTISOL 11DIBUCAINE NUMBER DIHYDROCODEINONE DIHYDROMORPHINONE DIHYDROTESTOSTERONE DIHYDROXYVITAMIN D 1 25DIMETHADIONE ENZYME CELL ACTIVITY ENZYME CELL ACTIVITY RA ELEC-PHORE TECH NES EPIANDROSTERONE ERYTHROPOIETIN ESTRADIOL ESTROGENS; FRACTIONATED ESTROGENS; TOT ESTRIOL ESTRONE ETHCHLORVYNOL ETHYLENE GLYCOL ETIOCHOLANOLONE FAT/LIPIDS FECES; QUAL FAT/LIPIDS FECES; QUAN FAT DIFF FECES QUAN FATTY ACIDS NONESTERIFIED LONG CHAIN FATTY ACIDS

$14

$5 N/A

$44

N/A

$44

N/A

$44

N/A

$44

N/A

$12

$3 N/A

$38

$11 N/A

$17

$6 N/A

$33

$11 N/A

$12

$2 N/A

$15

$4 N/A

$27

$9 N/A

$19

$4 N/A

$19

$6 N/A

$38

$11 N/A

$38

$11 N/A

$43

$14 N/A

$28

$9 N/A

$71

$23 N/A

$61

$20 N/A

$81

$24 N/A

$71

$21 N/A

$29

$9 N/A

$51

$15 N/A

$51

$20 N/A

$61

$24 N/A

$81

$24 N/A

$51

$15 N/A

$52

N/A

$52

N/A

$47

$15 N/A

$61

$18 N/A

$66

$20 N/A

$48

$15 N/A

$86

$24 N/A

$61

$17 N/A

$44

$15 N/A

$66

$20 N/A

$34

$14 N/A

$51

$16 N/A

$71

$24 N/A

$15

$6 N/A

$57

$18 N/A

$24

$8 N/A

$24

$8 N/A

$49

N/A

Section IX Pathology & Laboratory Services

Page 180

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION IX:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MAR PC/-26 FUD

82728 82731 82735 82742 82746 82747 82757 82759 82760 82775 82776 82784 82785 82787 82800 82803 82805 82810 82820 82926 82928 82938 82941 82943 82946 82947 82948 82950 82951 82952 82953 82955 82960 82962 82963 82965 82975 82977 82978 82979 82980 82985 83001 83002 83003 83008

FERRITIN FETAL FIBRONECTIN FLUORIDE FLURAZEPAM FOLIC ACID; SERUM FOLIC ACID; RBC FRUCTOSE SEMEN GALACTOKINASE RBC GALACTOSE GALACTOSE-1-PHOSPHATE URIDYL TRANSFERASE; QUAN GALACTOSE-1-PHOSPHATE URIDYL TRANSFERASE; SCREEN GG; IGA, IGD, IGG, IGM, EA GG; IGE GG; IMMUNOGLOBULIN SUBCLASSES GASES BLD PH ONLY GASES BLD ANY COMBO-PH/PCO2/PO2/CO2/HCO3 GASES BLD ANY COMBO; W/O2 SAT EX OXIMETRY GASES BLD O2 SAT ONLY DIREC MEASUR EX OXIMETRY HGB-O2 AFFINITY GASTRIC ACID FREE & TOT EA SPECMN GASTRIC ACID FREE/TOT; EA SPECMN GASTRIN AFTER SECRETIN STIM GASTRIN GLUCAGON GLUCAGON TOLERANCE TEST GLU; QUAN GLU; BLD REAGENT STRIP GLU; POST GLU DOSE GLU; TOLERANCE TEST 3 SPECMN GLU; TOLERANCE TEST EA ADD BEYOND 3 SPECMN GLU; TOLBUTAMIDE TOLERANCE TEST GLU-6-PHOSPHATE DEHYDROGENASE; QUAN GLU-6-PHOSPHATE DEHYDROGENASE; SCREEN GLU BLD MONITOR CLEARED-FDA-HOME USE GLUCOSIDASE BETA GLUTAMATE DEHYDROGENASE GLUTAMINE GLUTAMYLTRANSFERASE GAMMA GLUTATHIONE GLUTATHIONE REDUCTASE RBC GLUTETHIMIDE GLYCATED PROT GONADOTROPIN; FOLLICLE STIM HORMONE GONADOTROPIN; LUTEINIZING HORMONE GROWTH HORMONE HUMAN GUANOSINE MONOPHOSPHATE CYCLIC

$38 $44 $44 $51 $42 $50 $26 $33 $34 $43 $14 $35 $44 $109 $26 $52 $56 $29 $36 $16 $15 $50 $50 $60 $34 $13 $10 $17 $38 $10 $44 $39 $20 $10 $51 $14 $35 $13 $36 $25 $51 $21 $51 $51 $51 $61

$11 N/A N/A
$15 N/A $16 N/A $14 N/A $17 N/A
$8 N/A $10 N/A $11 N/A $13 N/A
$3 N/A $10 N/A $15 N/A $35 N/A
$8 N/A $16 N/A $17 N/A
$9 N/A $12 N/A
$4 N/A $6 N/A $17 N/A $16 N/A $19 N/A $9 N/A $4 N/A $4 N/A $6 N/A $13 N/A $3 N/A $15 N/A $11 N/A $6 N/A $2 N/A $16 N/A $5 N/A $11 N/A $4 N/A $10 N/A $7 N/A $12 N/A $6 N/A $15 N/A $16 N/A $14 N/A $18 N/A

Section IX Pathology & Laboratory Services

Page 181

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION IX:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MAR PC/-26 FUD

83010 83012 83013 83014 83015 83018 83020 83021 83026 83030 83033 83036 83045 83050 83051 83055 83060 83065 83068 83069 83070 83071 83080 83088 83150 83491 83497 83498 83499 83500 83505 83516 83518 83519 83520 83525 83527 83528 83540 83550 83570 83582 83586 83593 83605 83615

HAPTOGLOBIN; QUAN HAPTOGLOBIN; PHENOTYPES H PYLORI BREATH TEST ANAL H PYLORI DRUG ADMIN/COLLECT HEAVY METAL; SCREEN HEAVY METAL; QUAN EA HGB ELEC-PHORE HEMOGLOBIN CHROMOTOGRAPHY HGB; BY COPPER SULFATE METHD NON-AUTOMATED HGB; F CHEM HGB; F QUAL TEST FECAL HGB; GLYCATED HGB; METHEMOGLOBIN QUAL HGB; METHEMOGLOBIN QUAN HGB; PLASMA HGB; SULFHEMOGLOBIN QUAL HGB; SULFHEMOGLOBIN QUAN HGB; THERMOLABILE HGB; UNSTABLE SCREEN HGB; URIN HEMOSIDERIN; QUAL HEMOSIDERIN; QUAN B HEXOSAMINIDASE ASSAY HISTAMINE HOMOVANILLIC ACID HYDROXYCORTICOSTEROIDS 17HYDROXYINDOLACETIC ACID 5HYDROXYPROGESTERONE 17-D HYDROXYPROGESTERONE 20HYDROXYPROLINE; FREE HYDROXYPROLINE; TOT IMMUNOASSAY ANALYTE NOT AB/INFECT AG; MX STEP IMMUNOASSAY ANALYTE NOT AB/INFECT AG; SNGL STEP IMMUNOASSAY ANALYTE QUAN; BY RADIOPHARM TECH IMMUNOASSAY ANALYTE QUAN; NOS INSULIN; TOT INSULIN; FREE INTRINSIC FACTOR IRON IRON BINDING CAPACITY ISOCITRIC DEHYDROGENASE KETOGENIC STEROIDS FRACTIONATION KETOSTEROIDS 17-; TOT KETOSTEROIDS 17-; FRACTIONATION LACTATE LACTATE DEHYDROGENASE

$35 $38 $148 $22 $62 $66 $35 $52
$9 $25 $14 $27
$9 $11 $12 $16 $22
$8 $10
$8 $11 $11 $35 $73 $47 $56 $44 $64 $51 $47 $61 $30 $19 $40 $34 $37 $42 $49 $12 $17 $23 $39 $38 $83 $30 $12

$11 N/A $15 N/A
N/A N/A $19 N/A $19 N/A $11 N/A N/A $5 N/A $9 N/A $4 N/A $10 N/A $3 N/A $4 N/A $4 N/A $5 N/A $6 N/A $3 N/A $3 N/A $2 N/A $4 N/A $3 N/A N/A $22 N/A $16 N/A $16 N/A $14 N/A $21 N/A $15 N/A $15 N/A $18 N/A $10 N/A $7 N/A $14 N/A $11 N/A $11 N/A $13 N/A $16 N/A $3 N/A $4 N/A $7 N/A $10 N/A $13 N/A $26 N/A $10 N/A $4 N/A

Section IX Pathology & Laboratory Services

Page 182

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION IX:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MAR PC/-26 FUD

83625 83632 83633 83634 83655 83661 83662 83670 83690 83715 83716 83718 83719 83721 83727 83735 83775 83785 83788 83789 83805 83825 83835 83840 83857 83858 83864 83866 83872 83873 83874 83883 83885 83887 83890 83891 83892 83893 83894 83896 83897 83898 83901 83902 83903 83904

LACTATE DEHYDROGENASE; ISOENZYMES SEPART & QUAN LACTOGEN HUMN PLACENT HUMN CHORIONIC SOMATOMAMMO LACTOSE URIN; QUAL LACTOSE URIN; QUAN LEAD LECITHIN-SPHINGOMYELIN RATIO; QUAN LECITHIN-SPHINGOMYELIN RATIO;FOAM STABILITY TEST LEUCINE AMINOPEPTIDASE LIPASE LIPOPROTEIN BLD; ELEC-PHORE SEPART & QUAN ASSAY BLOOD LIPOPROTEINS LIPOPROTEIN DIRECT MEASUR; HIGH DENSITY CHOL LIPOPROTEIN DIRECT MEASUR; VLDL CHOL LIPOPROTEIN DIRECT MEASUR; LDL CHOL LUTEINIZING RELEASING FACTOR MAGNESIUM MALATE DEHYDROGENASE MANGANESE MASS SPECTROMETRY QUAL MASS SPECTROMETRY QUANT MEPROBAMATE MERCURY QUAN METANEPHRINES METHADONE METHEMALBUMIN METHSUXIMIDE MUCOPOLYSACCHARIDES ACID; QUAN MUCOPOLYSACCHARIDES ACID; SCREEN MUCIN SYNOVIAL FLUID MYELIN BASIC PROT CSF MYOGLOBIN NEPHELOMETRY EA ANALYTE NES NICKEL NICOTINE MOLECULAR DX; MOLEC ISOLATION/EXTRACTION MOLECULE ISOLATE NUCLEIC MOLECULAR DX; ENZYMATIC DIGESTION MOLECULE DOT/SLOT/BLOT MOLECULAR DX; SEPARATION MOLECULAR DX; NUCLEIC ACID PROBE EA MOLECULE NUCLEIC TRANSFER MOLECULAR DX; AMPLIFICATION (PCR) EA MOLECULE NUCLEIC AMP MOLECULAR DX; REVERSE TRANSCRIPTION MOLECULE MUTATION SCAN MOLECULE MUTATION IDENTIFY

$38

$10 N/A

$60

$20 N/A

$11

$3 N/A

$21

$6 N/A

$24

$7 N/A

$81

$25 N/A

$24

$8 N/A

$34

$10 N/A

$22

$8 N/A

$29

$7 N/A

$56

N/A

$18

$5 N/A

$20

$7 N/A

$19

$6 N/A

$52

$17 N/A

$14

$5 N/A

$23

$7 N/A

$61

$18 N/A

$42

N/A

$42

N/A

$51

$17 N/A

$53

$17 N/A

$53

$15 N/A

$51

$17 N/A

$30

$10 N/A

$51

$16 N/A

$30

$8 N/A

$19

$5 N/A

$13

$4 N/A

$56

$19 N/A

$46

$15 N/A

$37

$11 N/A

$54

$17 N/A

$51

$15 N/A

$25

$7 N/A

$23

N/A

$20

$6 N/A

$28

N/A

$35

$10 N/A

$35

$10 N/A

$22

N/A

$75

$24 N/A

$75

N/A

$36

$12 N/A

$37

N/A

$37

N/A

Section IX Pathology & Laboratory Services

Page 183

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION IX:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MAR PC/-26 FUD

83905 83906 83912 83915 83916 83918 83919 83925 83930 83935 83937 83945 83970 83986 83992 84022 84030 84035 84060 84061 84066 84075 84078 84080 84081 84085 84087 84100 84105 84106 84110 84119 84120 84126 84127 84132 84133 84134 84135 84138 84140 84143 84144 84146 84150 84153

MOLECULE MUTATION IDENTIFY MOLECULE MUTATION IDENTIFY MOLECULAR DX; INTERPT & REPORT NUCLEOTIDASE 5'OLIGOCLONAL IMMUNOGLOBULIN ORGANIC ACIDS QUAN ASSAY ORGANIC ACIDS QUAL OPIATES OSMOLALITY; BLD OSMOLALITY; URIN OSTEOCALCIN OXALATE PARATHORMONE PH BODY FLUID EX BLD PHENCYCLIDINE PHENOTHIAZINE PHENYLALANINE BLD PHENYLKETONES QUAL PHOSPHATASE ACID; TOT PHOSPHATASE ACID; FORENSIC EXAM PHOSPHATASE ACID; PROSTATIC PHOSPHATASE ALKALINE PHOSPHATASE ALKALINE; HEAT STABLE PHOSPHATASE ALKALINE; ISOENZYMES PHOSPHATIDYLGLYCEROL PHOSPHOGLUCONATE 6- DEHYDROGENASE RBC PHOSPHOHEXOSE ISOMERASE PHOSPHORUS INORGANIC PHOSPHORUS INORGANIC; URIN PORPHOBILINOGEN URIN; QUAL PORPHOBILINOGEN URIN; QUAN PORPHYRINS URIN; QUAL PORPHYRINS URIN; QUAN & FRACTIONATION PORPHYRINS FECES; QUAN PORPHYRINS FECES; QUAL POTASSIUM; SERUM POTASSIUM; URIN PREALBUMIN PREGNANEDIOL PREGNANETRIOL PREGNENOLONE 17-HYDROXYPREGNENOLONE PROGESTERONE PROLACTIN PROSTAGLANDIN EA PROSTATE SPEC ANTIG

$37

N/A

$37

N/A

$33

$17 N/A

$28

$9 N/A

$49

$17 N/A

$76

$22 N/A

$76

N/A

$51

$15 N/A

$15

$5 N/A

$22

$7 N/A

$73

$26 N/A

$36

$13 N/A

$81

$27 N/A

$11

$4 N/A

$51

$15 N/A

$41

$13 N/A

$14

$4 N/A

$10

$3 N/A

$25

$8 N/A

$28

$9 N/A

$33

$12 N/A

$13

$4 N/A

$25

$7 N/A

$43

$13 N/A

$61

$20 N/A

$26

$9 N/A

$28

$8 N/A

$13

$4 N/A

$16

$5 N/A

$19

$4 N/A

$25

$8 N/A

$26

$8 N/A

$48

$14 N/A

$46

$14 N/A

$13

$5 N/A

$13

$4 N/A

$14

$4 N/A

$30

$9 N/A

$51

$17 N/A

$51

$17 N/A

$61

$13 N/A

$61

$20 N/A

$51

$10 N/A

$51

$17 N/A

$56

$17 N/A

$51

$17 N/A

Section IX Pathology & Laboratory Services

Page 184

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION IX:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MAR PC/-26 FUD

84154 84155 84160 84165 84181 84182 84202 84203 84206 84207 84210 84220 84228 84233 84234 84235 84238 84244 84252 84255 84260 84270 84275 84285 84295 84300 84305 84307 84311 84315 84375 84376 84377 84378 84379 84392 84402 84403 84425 84430 84432 84436 84437 84439 84442 84443

PSA FREE PROT; TOT EX REFRACTOMETRY PROT; REFRACTOMETRIC PROT; ELEC-PHORE FRACTIONATION & QUAN PROT; WESTERN BLOT BLD/OTHER FLUID PROT; WESTERN BLOT IMMUNOL PROBE-BAND ID EA PROTOPORPHYRIN RBC; QUAN PROTOPORPHYRIN RBC; SCREEN PROINSULIN PYRIDOXAL PHOSPHATE PYRUVATE PYRUVATE KINASE QUININE RECEPTOR ASSAY; ESTROGEN RECEPTOR ASSAY; PROGESTERONE RECEPTR ASSAY; ENDOCRINE NOT ESTROGN/PROGESTERON RECEPTOR ASSAY; NON-ENDOCRINE RENIN RIBOFLAVIN SELENIUM SEROTONIN SEX HORMONE BINDING GLOB SIALIC ACID SILICA SODIUM; SERUM SODIUM; URIN SOMATOMEDIN SOMATOSTATIN SPECTROPHOTOMETRY ANALYTE NES SPEC GRAVITY SUGARS CHROMATOGRAPHIC TLC/PAPER CHROMATOGRAPHY SUGARS SINGLE QUAL SUGARS MULTIPLE QUAL SUGARS SINGLE QUANT SUGARS MULTIPLE QUANT SULFATE URIN TESTOSTERONE; FREE TESTOSTERONE; TOT THIAMINE THIOCYANATE THYROGLOBULIN THYROXINE; TOT THYROXINE; REQUIRING ELUTION THYROXINE; FREE THYROXINE BINDING GLOB THYROID STIM HORMONE

$51 $13 $10 $36 $56 $81 $32 $18 $76 $76 $36 $30 $40 $72 $72 $72 $101 $65 $42 $51 $93 $54 $32 $69 $13 $14 $76 $56 $22
$7 $40 $12 $12 $29 $29 $10 $62 $51 $60 $38 $55 $20 $22 $33 $38 $46

N/A $5 N/A $4 N/A $7 N/A $17 N/A $24 N/A $11 N/A $6 N/A $24 N/A $23 N/A $14 N/A $10 N/A $13 N/A $22 N/A $22 N/A $21 N/A $33 N/A $22 N/A $13 N/A $15 N/A $28 N/A $16 N/A $10 N/A $20 N/A $4 N/A $5 N/A $24 N/A $18 N/A $7 N/A $3 N/A $12 N/A
N/A N/A N/A N/A $2 N/A $19 N/A $15 N/A $19 N/A $12 N/A $17 N/A $5 N/A $7 N/A $9 N/A $10 N/A $11 N/A

Section IX Pathology & Laboratory Services

Page 185

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION IX:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MAR PC/-26 FUD

84445 84446 84449 84450 84460 84466 84478 84479 84480 84481 84482 84484 84485 84488 84490 84510 84512 84520 84525 84540 84545 84550 84560 84577 84578 84580 84583 84585 84586 84588 84590 84597 84600 84620 84630 84681 84702 84703 84830 84999 85002 85007 85008 85009 85013 85014

THYROID STIM IMMUNOGLOBULINS TOCOPHEROL ALPHA TRANSCORTIN TRANSFERASE; ASPARTATE AMINO TRANSFERASE; ALANINE AMINO TRANSFERRIN TRIGLYCERIDES THYROID HORMONE UPTAKE/HORMONE BINDING RATIO TRIIODOTHYRONINE T3; TOT (TT3) TRIIODOTHYRONINE; FREE TRIIODOTHYRONINE; REVERSE TROPONIN TRYPSIN; DUODENAL FLUID TRYPSIN; FECES QUAL TRYPSIN; FECES QUAN 24-HR COLLEC TYROSINE TROPONIN, QUAL UREA NITRO; QUAN UREA NITRO; SEMIQUANTITATIVE UREA NITRO URIN UREA NITRO CLEARANCE URIC ACID; BLD URIC ACID; OTHER SOURCE UROBILINOGEN FECES QUAN UROBILINOGEN URIN; QUAL UROBILINOGEN URIN; QUAN TIMED SPECMN UROBILINOGEN URIN; SEMIQUAN VANILLYLMANDELIC ACID URIN VASOACTIVE INTESTINAL PEPTIDE VASOPRESSIN VITAMIN A VITAMIN K VOLATILES XYLOSE ABSORPTION TEST BLD &/OR URIN ZINC C-PEPTIDE GONADOTROPIN CHORIONIC; QUAN GONADOTROPIN CHORIONIC; QUAL OVULATION TESTS VISUAL COLOR COMPAR METHD UNLISTED CHEM PROC BLEEDING TIME BLD CT; MANUAL DIFF WBC CT BLD CT; MANUAL BLD SMEAR EXAM WO DIFF PARAMETERS BLD CT; DIFF WBC CT BUFFY COAT BLD CT; SPUN MICROHEMATOCRIT BLD CT; OTHER THAN SPUN HEMATOCRIT

$142 $44 $52 $14 $14 $38 $14 $20 $44 $58 $49 $28 $22 $14 $16 $28 $20 $14 $11 $17 $22 $14 $17 $22 $10 $21 $10 $55 $84 $90 $51 $50 $38 $48 $44 $66 $44 $25 $27 BR $20 $12 $8 $12 $9 $9

$43 N/A $14 N/A $18 N/A
$4 N/A $5 N/A $13 N/A $4 N/A $7 N/A $15 N/A $19 N/A $16 N/A $9 N/A $6 N/A $4 N/A $5 N/A $9 N/A $6 N/A $4 N/A $3 N/A $6 N/A $6 N/A $5 N/A $5 N/A $7 N/A $3 N/A $6 N/A $3 N/A $17 N/A $27 N/A $30 N/A $17 N/A $15 N/A $11 N/A $14 N/A $14 N/A $22 N/A $14 N/A $8 N/A $9 N/A
N/A $7 N/A $4 N/A $3 N/A $4 N/A $2 N/A $2 N/A

Section IX Pathology & Laboratory Services

Page 186

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION IX:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MAR PC/-26 FUD

85018 85021 85022 85023 85024 85025 85027 85031 85041 85044 85045 85046 85048 85060 85095 85097 85102 85130 85170 85175 85210 85220 85230 85240 85244 85245 85246 85247 85250 85260 85270 85280 85290 85291 85292 85293 85300 85301 85302 85303 85305 85306 85335 85337 85345 85347

BLD CT; HGB BLD CT; HG AUTOMATED BLD CT; HG AUTOMATED & MANUAL DIFF WBC CT BLD CT; HG/PLATELET CT AUTO & MANUAL WBC BLD CT; HG/PLATELET CT AUTO & AUTO PART WBC BLD CT; HG/PLATELET CT AUTO & AUTO COMPLT WBC BLD CT; HG & PLATELET CT AUTOMATED BLD CT; HG MANUAL COMPLT CBC BLD CT; RED BLD CELL ONLY BLD CT; RETICULOCYTE CT MANUAL BLD CT; RETICULOCYTE CT FLOW CYTOMETRY RETICYTE, HGB CONCENTRATE BLD CT; WHITE BLD CELL BLD SMEAR PERIPHERAL INTERPT-PHYS W/WRIT REPORT BONE MARROW; ASPIRAT ONLY BONE MARROW; SMEAR INTERPT ONLY W/WO DIF CELL CT BONE MARROW BX NEEDLE/TROCAR CHROMOGENIC SUBSTRATE ASSAY CLOT RETRACTION CLOT LYSIS TIME WHOLE BLD DILUT CLOTTING; FACTOR II PROTHROMBIN SPEC CLOTTING; FACTOR V LABILE FACTOR CLOTTING; FACTOR VII CLOTTING; FACTOR VIII 1 STAGE CLOTTING; FACTOR VIII RELATED ANTIG CLOT; FACTOR VIII VW FACTOR RISTOCETIN COFACTOR CLOTTING; FACTOR VIII VW FACTOR ANTIG CLOT; VIII VON WILLEBRAND FACT MX-METRIC ANALY CLOTTING; FACTOR IX CLOTTING; FACTOR X CLOTTING; FACTOR XI CLOTTING; FACTOR XII CLOTTING; FACTOR XIII CLOTTING; FACTOR XIII SCREEN SOLUBILITY CLOTTING; PREKALLIKREIN ASSAY CLOTTING; HIGH MOLECULAR WT KININOGEN ASSAY CLOT INHIBIT/ANTICOAG; ANTITHROMBIN III ACTIVITY CLOT INHIB/ANTICOAG;ANTITHROMBIN III ANTIG ASSAY CLOT INHIBIT/ANTICOAGULANTS; PROT C ANTIG CLOT INHIBIT/ANTICOAGULANTS; PROT C ACTIVITY CLOTTING INHIBIT OR ANTICOAGULANTS; PROT S TOT CLOTTING INHIBIT/ANTICOAGULANTS; PROT S FREE FACTOR INHIBIT TEST THROMBOMODULIN COAGULATION TIME; LEE & WHITE COAGULATION TIME; ACTIVATED

$9 $15 $17 $21 $18 $18 $17 $18
$8 $15 $14 $16 $10 $34 $114 $96 $139 $32 $11 $21 $32 $64 $64 $70 $86 $54 $86 $86 $70 $64 $70 $70 $64 $31 $64 $64 $57 $54 $59 $64 $70 $70 $29 $54 $11 $11

$4 N/A $4 N/A $5 N/A $7 N/A $5 N/A $5 N/A $6 N/A $5 N/A $4 N/A $5 N/A $5 N/A
N/A $4 N/A $34 N/A $114 N/A $96 N/A $125 N/A $11 N/A $4 N/A $7 N/A $9 N/A $21 N/A $19 N/A $22 N/A $27 N/A $18 N/A $29 N/A $29 N/A $20 N/A $19 N/A $20 N/A $20 N/A $19 N/A $10 N/A $22 N/A $22 N/A $19 N/A $18 N/A $20 N/A $21 N/A $24 N/A $23 N/A $10 N/A $18 N/A $3 N/A $3 N/A

Section IX Pathology & Laboratory Services

Page 187

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION IX:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MAR PC/-26 FUD

85348 85360 85362 85366 85370 85378 85379 85384 85385 85390 85400 85410 85415 85420 85421 85441 85445 85460 85461 85475 85520 85525 85530 85535 85540 85547 85549 85555 85557 85576 85585 85590 85595 85597 85610 85611 85612 85613 85635 85651 85652 85660 85670 85675 85705 85730

COAGULATION TIME; OTHER METHD EUGLOBULIN LYSIS FIBRIN DEGRAD PROD; AGGLUTINATION SLIDE-SEMIQUAN FIBRIN DEGRADATION PRODUCTS; PARACOAGULATION FIBRIN DEGRADATION PRODUCTS; QUAN FIBRIN DEGRADATION PROD D-DIMER; SEMIQUAN FIBRIN DEGRADATION PRODUCTS D-DIMER; QUAN FIBRINOGEN; ACTIVITY FIBRINOGEN; ANTIG FIBRINOLYSINS/COAGULOPATHY SCREEN INTERPT/REPORT FIBRINOLYTIC FACTORS & INHIBIT; PLASMIN FIBRINOLYTIC FACT & INHIBIT; ALPHA-2 ANTIPLASMIN FIBRINOLYTIC FACT & INHIBIT; PLASMINOGEN ACTIVAT FIBRNOLYTC FACT/INHIB; PLASMINOGEN NOT ANTIGENIC FIBRINOLYTIC FACT/INHIB; PLASMINOGEN ANTIG ASSAY HEINZ BODIES; DIRECT HEINZ BODIES; INDUCED ACETYL PHENYLHYDRAZINE HGB/RBC FETAL-FETOMATERNAL HEMORR; DIFF LYSIS HGB/RBC FETAL-FETOMATERNAL HEMORR; ROSETTE HEMOLYSIN; ACID HEPARIN ASSAY HEPARIN NEUTRALIZATION HEPARIN-PROTAMINE TOLERANCE TEST IRON STAIN LEUKOCYTE ALKALINE PHOSPHATASE W/CT MECH FRAGILITY RBC MURAMIDASE OSMOTIC FRAGILITY RBC; UNINCUBATED OSMOTIC FRAGILITY RBC; INCUBATED PLATELET; AGGREGATION EA AGENT PLATELET; ESTIMATION SMEAR ONLY PLATELET; MANUAL CT PLATELET; AUTOMATED CT PLATELET NEUTRALIZATION PROTHROMBIN TIME PROTHROMBIN TIME; SUBSTITUT PLASMA FRACTIONS EA RUSSELL VIPER VENOM TIME; UNDILUTED RUSSELL VIPER VENOM TIME; DILUTED REPTILASE TEST SED RATE ERYTHROCYTE NON-AUTOMATED SED RATE, ERYTHROCYTE; AUTO SICKLING RBC REDUCTION THROMBIN TIME; PLASMA THROMBIN TIME; TITER THROMBOPLASTIN INHIBIT; TISS THROMBOPLASTIN TIME PART; PLASMA/WHOLE BLD

$17

$6 N/A

$34

$9 N/A

$24

$10 N/A

$34

$9 N/A

$34

$9 N/A

$28

$9 N/A

$32

$11 N/A

$21

$7 N/A

$27

$9 N/A

$27

$27 N/A

$51

$14 N/A

$51

$14 N/A

$40

$14 N/A

$51

$13 N/A

$64

$20 N/A

$10

$3 N/A

$15

$5 N/A

$29

$8 N/A

$29

$8 N/A

$36

$10 N/A

$43

$12 N/A

$43

$14 N/A

$43

$13 N/A

$18

$7 N/A

$27

$8 N/A

$25

$7 N/A

$55

$18 N/A

$27

$8 N/A

$54

$16 N/A

$54

$11 N/A

$9

$2 N/A

$13

$4 N/A

$13

$5 N/A

$38

$12 N/A

$15

$5 N/A

$16

$5 N/A

$30

$9 N/A

$35

$10 N/A

$21

$7 N/A

$13

$3 N/A

$13

$3 N/A

$15

$5 N/A

$20

$5 N/A

$23

$8 N/A

$41

$14 N/A

$18

$5 N/A

Section IX Pathology & Laboratory Services

Page 188

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION IX:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MAR PC/-26 FUD

85732 85810 85999 86000 86003 86005 86021 86022 86023 86038 86039 86060 86063 86077 86078 86079 86140 86147 86148 86155 86156 86157 86160 86161 86162 86171 86185 86215 86225 86226 86235 86243 86255 86256 86277 86280 86308 86309 86310 86316 86317 86318 86320 86325 86327 86329

THROMBOPLASTN TIME PART; SUBSTIT PLASMA FRACT EA VISCOSITY UNLISTED HEMATOLOGY & COAGULATION PROC AGGLUTININS FEBRILE EA ANTIG ALLERG SPEC IGE; QUAN/SEMI-QUAN, EA ALLERG ALLERG SPEC IGE; QUAL MULTIALLERG SCREEN ANTIB IDENT; LEUKOCYTE ANTIB ANTIB IDENT; PLATELET ANTIB ANTIB IDENT; PLATELET ASSOC IMMUNOGLOBULIN ASSAY ANTINUCLEAR ANTIB ANTINUCLEAR ANTIB; TITER ANTISTREPTOLYSIN 0; TITER ANTISTREPTOLYSIN 0; SCREEN BLD BNK PHYS SERV; DIFF X-MATCH/EVAL IRREG ANTIB BLD BNK PHYS SERV; INVESTIGAT TRANSFUSION REACT BLD BNK PHYS SERV; AUTHORIZAT DEVIAT STAND PROC C-REACTIVE PROT CARDIOLIPIN ANTIB PHOSPHOLIPID ANTIBODY CHEMOTAXIS ASSAY SPEC METHD COLD AGGLUTININ; SCREEN COLD AGGLUTININ; TITER COMPLEMENT; ANTIG EA COMPONENT COMPLEMENT; FUNCT ACTIVITY EA COMPONENT COMPLEMENT; TOT HEMOLYTIC COMPLEMENT FIXA TESTS EA ANTIG COUNTERIMMUNOELECTROPHORESIS EA ANTIG DEOXYRIBONUCLEASE ANTIB DNA ANTIB; NATIVE/DOUBLE STRANDED DNA ANTIB; SNGL STRANDED EXTRACTABLE NUCLEAR ANTIG ANTIB ANY METHD FC RECEPTOR FLUORESCENT ANTIB; SCREEN EA ANTIB FLUORESCENT ANTIB; TITER EA ANTIB GROWTH HORMONE HUMAN ANTIB HEMAGGLUTINATION INHIBIT TEST HETEROPHILE ANTIB; SCREENING HETEROPHILE ANTIB; TITER HETEROPHILE ANTIB; TITER AFTER ABSORPT IMMUNOASSAY TUMOR ANTIG EA IMMUNOASSAY INFEC AGENT ANTIB QUAN NES IMMUNOASSAY INFEC AGENT ANTIB SNGL STEP IMMUNOELECTROPHORESIS; SERUM IMMUNOELECTROPHORESIS; OTHER FLUIDS W/CONCNTRAT IMMUNOELECTROPHORESIS; CROSSED IMMUNODIFFUSION; NES

$21

$7 N/A

$25

$5 N/A

BR

N/A

$22

$8 N/A

$10

$3 N/A

$47

$19 N/A

$57

$16 N/A

$86

$28 N/A

$47

$16 N/A

$33

$11 N/A

$33

$11 N/A

$23

$6 N/A

$17

$5 N/A

$60

$60 N/A

$69

$69 N/A

$43

$43 N/A

$18

$6 N/A

$66

$22 N/A

$77

$29 N/A

$26

$8 N/A

$17

$5 N/A

$22

$7 N/A

$42

$10 N/A

$42

$10 N/A

$59

$20 N/A

$27

$8 N/A

$26

$9 N/A

$37

$12 N/A

$41

$12 N/A

$41

$14 N/A

$36

$11 N/A

$44

$14 N/A

$33

$11 N/A

$41

$14 N/A

$33

$11 N/A

$27

$6 N/A

$12

$5 N/A

$16

$4 N/A

$18

$6 N/A

$37

$11 N/A

$17

$5 N/A

$17

$7 N/A

$44

$9 N/A

$46

$9 N/A

$35

$7 N/A

$34

$11 N/A

Section IX Pathology & Laboratory Services

Page 189

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION IX:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MAR PC/-26 FUD

86331 86332 86334 86337 86340 86341 86343 86344 86353 86359 86360 86361 86376 86378 86382 86384 86403 86406 86430 86431 86485 86490 86510 86580 86585 86586 86590 86592 86593 86602 86603 86606 86609 86612 86615 86617 86618 86619 86622 86625 86628 86631 86632 86635 86638 86641

IMMUNODIFFUSION; GEL DIFFUS QUAL EA ANTIG/ANTIB IMMUNE COMPLX ASSAY IMMUNOFIXATION ELEC-PHORE INSULIN ANTIB INTRINSIC FACTOR ANTIB ISLET CELL ANTIBODY LEUKOCYTE HISTAMINE RELEASE TEST LEUKOCYTE PHAGOCYTOSIS LYMPHOCYTE TRANSFORM MITOGEN/ANTIG INDUCED BLAST T CELLS; TOT CT T CELLS; T4 & T8 INCL RATIO T CELL ABSOLUTE COUNT MICROSOMAL ANTIB EA MIGRATION INHIBIT FACTOR TEST NEUTRALIZATION TEST VIRAL NITROBLUE TETRAZOLIUM DYE TEST PARTICLE AGGLUTINATION; SCREEN-EA ANTIB PARTICLE AGGLUTINATION; TITER EA ANTIB RHEUMATOID FACTOR; QUAL RHEUMATOID FACTOR; QUAN SKIN TEST; CANDIDA SKIN TEST; COCCIDIOIDOMYCOSIS SKIN TEST; HISTOPLASMOSIS SKIN TEST; TUBERCULOSIS INTRADERMAL SKIN TEST; TUBERCULOSIS TINE TEST SKIN TEST; UNLISTED ANTIG EA STREPTOKINASE ANTIB SYPHILIS TEST; QUAL SYPHILIS TEST; QUAN ANTIB; ACTINOMYCES ANTIB; ADENOVIRUS ANTIB; ASPERGILLUS ANTIB; BACTERIUM NES ANTIB; BLASTOMYCES ANTIB; BORDETELLA BORRELIA BURGDORFERI CONFIRM TEST ANTIB; BORRELIA BURGDORFERI ANTIB; BORRELIA ANTIB; BRUCELLA ANTIB; CAMPYLOBACTER ANTIB; CANDIDA ANTIB; CHLAMYDIA ANTIB; CHLAMYDIA IGM ANTIB; COCCIDIOIDES ANTIB; COXIELLA BRUNETII ANTIB; CRYPTOCOCCUS

$32 $40 $38 $44 $31 $25 $43 $25 $139 $66 $99 $74 $42 $45 $46 $35 $16 $18 $19 $22 $15 $14 $15 $13 $10 $15 $18 $13 $14 $40 $40 $44 $55 $44 $50 $53 $50 $40 $30 $50 $48 $35 $39 $48 $40 $30

$10 N/A $14 N/A
$8 N/A $15 N/A $10 N/A
$8 N/A $14 N/A
$9 N/A $42 N/A $22 N/A $33 N/A $24 N/A $13 N/A $15 N/A $14 N/A $12 N/A
$3 N/A $5 N/A $6 N/A $8 N/A $5 N/A $4 N/A $5 N/A $4 N/A $3 N/A
N/A $6 N/A $3 N/A $4 N/A $12 N/A $13 N/A $15 N/A $17 N/A $13 N/A $15 N/A $18 N/A $16 N/A $12 N/A $10 N/A $15 N/A $15 N/A $11 N/A $12 N/A $14 N/A $13 N/A $10 N/A

Section IX Pathology & Laboratory Services

Page 190

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION IX:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MAR PC/-26 FUD

86644 86645 86648 86651 86652 86653 86654 86658 86663 86664 86665 86668 86671 86674 86677 86682 86684 86687 86688 86689 86692 86694 86695 86698 86701 86702 86703 86704 86705 86706 86707 86708 86709 86710 86713 86717 86720 86723 86727 86729 86732 86735 86738 86741 86744 86747

ANTIB; CYTOMEGALOVIRUS ANTIB; CYTOMEGALOVIRUS IGM ANTIB; DIPHTHERIA ANTIB; ENCEPHALITIS CALIFORNIA ANTIB; ENCEPHALITIS EASTERN EQUINE ANTIB; ENCEPHALITIS ST. LOUIS ANTIB; ENCEPHALITIS WESTERN EQUINE ANTIB; ENTEROVIRUS ANTIB; EPSTEIN-BARR VIRUS EARLY ANTIG ANTIB; EPSTEIN-BARR VIRUS NUCLEAR ANTIG ANTIB; EPSTEIN-BARR VIRUS VIRAL CAPSID ANTIB; FRANCISELLA TULARENSIS ANTIB; FUNGUS NES ANTIB; GIARDIA LAMBLIA ANTIB; HELICOBACTER PYLORI ANTIB; HELMINTH NES ANTIB; HEMOPHILUS INFLUENZA ANTIB; HTLV I ANTIB; HTLV-II ANTIB; HTLV/HIV ANTIB CONFIRM TEST ANTIB; HEPATITIS DELTA AGENT ANTIB; HERPES SIMPLEX NON-SPEC TYPE TEST ANTIB; HERPES SIMPLEX TYPE I ANTIB; HISTOPLASMA ANTIB; HIV-1 ANTIB; HIV-2 ANTIB; HIV-1 & HIV-2 SNGL ASSAY HEP B CORE AB TEST, IGG & M HEP B CORE AB TEST, IGM HEPATITIS B SURFACE AB TEST HEPATITIS BE AB TEST HEP A AB TEST, IGG & M HEP A AB TEST, IGM ANTIB; INFLUENZA VIRUS ANTIB; LEGIONELLA ANTIB; LEISHMANIA ANTIB; LEPTOSPIRA ANTIB; LISTERIA MONOCYTOGENES ANTIB; LYMPHOCYTIC CHORIOMENINGITIS ANTIB; LYMPHOGRANULOMA VENEREUM ANTIB; MUCORMYCOSIS ANTIB; MUMPS ANTIB; MYCOPLASMA ANTIB; NEISSERIA MENINGITIDIS ANTIB; NOCARDIA ANTIB; PARVOVIRUS

$46

$15 N/A

$51

$18 N/A

$44

$15 N/A

$40

$14 N/A

$40

$14 N/A

$40

$14 N/A

$40

$14 N/A

$40

$14 N/A

$48

$17 N/A

$48

$16 N/A

$52

$17 N/A

$30

$9 N/A

$55

$17 N/A

$40

$13 N/A

$54

$19 N/A

$55

$19 N/A

$50

$17 N/A

$40

$12 N/A

$38

$12 N/A

$53

$18 N/A

$50

$17 N/A

$44

$15 N/A

$44

$15 N/A

$40

$13 N/A

$34

$10 N/A

$50

$17 N/A

$34

$11 N/A

$48

$16 N/A

$51

$16 N/A

$37

$13 N/A

$40

$13 N/A

$47

$14 N/A

$43

$14 N/A

$33

$11 N/A

$48

$15 N/A

$40

$13 N/A

$40

$14 N/A

$40

$14 N/A

$40

$13 N/A

$40

$13 N/A

$40

$14 N/A

$40

$14 N/A

$40

$14 N/A

$40

$14 N/A

$40

$14 N/A

$50

$16 N/A

Section IX Pathology & Laboratory Services

Page 191

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION IX:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MAR PC/-26 FUD

86750 86753 86756 86759 86762 86765 86768 86771 86774 86777 86778 86781 86784 86787 86790 86793 86800 86803 86804 86805 86806 86807 86808 86812 86813 86816 86817 86821 86822 86849 86850 86860 86870 86880 86885 86886 86890 86891 86900 86901 86903 86904 86905 86906 86910 86911

ANTIB; PLASMODIUM ANTIB; PROTOZOA NES ANTIB; RESPIRATORY SYNCYTIAL VIRUS ANTIB; ROTAVIRUS ANTIB; RUBELLA ANTIB; RUBEOLA ANTIB; SALMONELLA ANTIB; SHIGELLA ANTIB; TETANUS ANTIB; TOXOPLASMA ANTIB; TOXOPLASMA IGM ANTIB; TREPONEMA PALLIDUM CONFIRM TEST ANTIB; TRICHINELLA ANTIB; VARICELLA-ZOSTER ANTIB; VIRUS NES ANTIB; YERSINIA THYROGLOBULIN ANTIB HEPATITIS C AB TEST HEP C AB TEST, CONFIRM LYMPHOCYTOTOXICITY ASSAY VISUAL X-MATCH W/TITRAT LYMPHOCYTOTOXICITY ASSY VISUAL X-MATCH;WO TITRAT SERUM SCREEN CYTOTOXIC % REACTIVE ANTIB; STANDRD SERUM SCREEN CYTOTOXIC % REACTIVE ANTIB; QUICK HLA TYPING; A B/C SNGL ANTIG HLA TYPING; A B/C MX ANTIG HLA TYPING; DR/DQ SNGL ANTIG HLA TYPING; DR/DQ MX ANTIG HLA TYPING; LYMPHOCYTE CULTURE MIX HLA TYPING; LYMPHOCYTE CULTURE PRIMED UNLISTED IMMUNOLOGY PROC ANTIB SCREEN RBC EA SERUM TECH ANTIB ELUTION EA ELUTION ANTIB IDENT RBC ANTIB EA PANEL EA SERUM TECH ANTIHUMAN GLOB TEST; DIRECT EA ANTISERUM ANTIHUMAN GLOB TEST; INDIRECT QUAL EA ANTISERUM ANTIHUMAN GLOB TEST; INDIRECT TITER EA ANTISERUM AUTOLGUS BLD/COMP COLLEC PROCES/STOR; PREDEPOSIT AUTOLOGOUS BLD/COMP; INTRA/POSTOP SALVAGE BLD TYPING; ABO BLD TYPING; RH BLD TYP; ANTIG SCREN COMPAT UNIT REAGENT EA UNIT BLD TYP; ANTIG SCRN COMPAT UNIT PT SERUM EA UNIT BLD TYPING; RBC ANTIG OTHER THAN ABO/RH EA BLD TYPING; RH PHENOTYPING COMPLT BLD TYP PATERNITY TEST/INDIVIDI;ABO-RH & MN BLD TYPING PATERNTY TST/INDIVI; EA ADD ANTIG SYS

$40 $55 $40 $40 $23 $50 $40 $40 $50 $38 $47 $34 $40 $44 $55 $40 $43 $39 $43 $147 $49 $49 $55 $70 $99 $94 $271 $211 $70 BR $20 $20 $35 $11 $14 $18 $79 $124 $11 $10 $16 $15 $12 $17 $22 $17

$14 N/A $17 N/A $13 N/A $14 N/A
$8 N/A $16 N/A $14 N/A $14 N/A $16 N/A $13 N/A $15 N/A $11 N/A $14 N/A $14 N/A $19 N/A $14 N/A $14 N/A $14 N/A $14 N/A $50 N/A $16 N/A $15 N/A $16 N/A $21 N/A $30 N/A $28 N/A $81 N/A $63 N/A $23 N/A
N/A $7 N/A $7 N/A $8 N/A $4 N/A $4 N/A $6 N/A $12 N/A $37 N/A $3 N/A $4 N/A $6 N/A $5 N/A $3 N/A $5 N/A $7 N/A $6 N/A

Section IX Pathology & Laboratory Services

Page 192

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION IX:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MAR PC/-26 FUD

86915 86920 86921 86922 86927 86930 86931 86932 86940 86941 86945 86950 86965 86970 86971 86972 86975 86976 86977 86978 86985 86999 87001 87003 87015 87040 87045 87070 87075 87076 87081 87084 87086 87088 87101 87102 87103 87106 87109 87110 87116 87118 87140 87143 87147 87158

BONE MARROW MODIFICATION/TX ELIMINATE CELL COMPAT TEST EA UNIT; IMMED SPIN TECH COMPAT TEST EA UNIT; INCUBATION TECH COMPAT TEST EA UNIT; ANTIGLOBULIN TECH FRESH FROZEN PLASMA THAWING EA UNIT FROZEN BLD PREP FREEZING EA UNIT FROZEN BLD PREP FREEZING EA UNIT; W/THAWING FROZEN BLD PREP FREEZ EA; W/FREEZING & THAWING HEMOLYSINS & AGGLUTININS; AUTO SCREEN EA HEMOLYSINS & AGGLUTINS; INCUBATED IRRADIATION BLD PRODUCT EA UNIT LEUKOCYTE TRANSFUSION POOLING PLATELETS/OTHER BLD PRODUCTS PRETX RBC'S; INCUBATION W/CHEM AGENTS/DRUGS EA PRETX RBC'S; INCUBATION W/ENZYMES EA PRETX RBC'S; DENSITY GRADIENT SEPARATION PRETX SERUM-RBC ANTIB ID; INCUBATION W/DRUGS EA PRETX SERUM-RBC ANTIB ID; BY DILUTION PRETX SERUM-RBC ANTIB ID; INCUB W/INHIBITORS EA PRETX SERUM-ANTIB ID; DIFF RED CELL ABSORPT EA SPLITTING BLD/BLD PRODUCTS EA UNIT UNLISTED TRANSFUSION MEDS PROC ANIMAL INOCULATION SMALL ANIMAL; W/OBSRV ANIMAL INOCUL SM ANIMAL; W/OBSRV & DISSECTION CONCNTRAT PARASITES OVA/TUBERCLE BACILLUS CULTURE BACTERIAL DEFINITIVE; BLD CULTURE BACTERIAL DEFINITIVE; STOOL CULTURE BACTERIAL DEFINITIVE; ANY OTHER SOURCE CULTURE BACTERIAL ANY SOURCE; ANAEROBIC CULT BACT ANY SOURCE; DEFIN ID EA ANAEROBIC CULTURE BACTERIAL SCREENING ONLY SNGL ORGANISMS CULT PRESUMPT SCRN ONLY KIT; W/COLONY ESTIMATES CULTURE BACTERIAL URIN; QUAN COLONY CT CULTURE BACTERIAL URIN; IDENT ADD QUAN/KIT CULTURE FUNGI ISOLATION; SKIN CULTURE FUNGI ISOLATION; OTHER SOURCE CULTURE FUNGI ISOLATION; BLD CULTURE FUNGI DEFINITIVE IDENT EA FUNGUS CULTURE MYCOPLASMA ANY SOURCE CULTURE CHLAMYDIA CULT TB/AFB/MYCOBACTERIA; ANY SOURCE ISOLAT ONLY CULT MYCOBACTERIA DEFINITIVE IDENT EA ORGANISM CULTURE TYPING; FLUORESCENT METHD EA ANTISERUM CULTURE TYPING; GAS LIQUID CHROMATOGRAPHY METHD CULT TYP; SEROLOGIC AGGLUT GROUPING/ANTISERUM CULTURE TYPING; OTHER METHD

$104 $22 $20 $12 $11 $99
$109 $119
$21 $22 $30 $55 $14 $16 $16 $15 $10
$8 $10 $22 $21 BR $25 $36 $19 $25 $30 $25 $25 $28 $15 $18 $23 $22 $19 $24 $27 $25 $52 $36 $29 $24 $15 $35 $13 $12

N/A $5 N/A $6 N/A $4 N/A $3 N/A $30 N/A $33 N/A $36 N/A $6 N/A $6 N/A $9 N/A $16 N/A $4 N/A $5 N/A $4 N/A $5 N/A $3 N/A $2 N/A $3 N/A $7 N/A $7 N/A
N/A $8 N/A $12 N/A $6 N/A $9 N/A $10 N/A $8 N/A $9 N/A $10 N/A $4 N/A $6 N/A $5 N/A $8 N/A $6 N/A $7 N/A $9 N/A $7 N/A $17 N/A $11 N/A $8 N/A $7 N/A $4 N/A $11 N/A $4 N/A $3 N/A

Section IX Pathology & Laboratory Services

Page 193

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION IX:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MAR PC/-26 FUD

87164 87166 87176 87177 87181 87184 87186 87187 87188 87190 87197 87205 87206 87207 87210 87220 87230 87250 87252 87253 87260 87265 87270 87272 87274 87276 87278 87280 87285 87290 87299 87301 87320 87324 87328 87332 87335 87338 87340 87350 87380 87385 87390 87391 87420 87425

DARK FIELD EXAM ANY SOURCE; INCL SPECMN COLLEC DARK FIELD EXAM ANY SOURCE; WO COLLEC ENDOTOXIN BACTERIAL; HOMOGENIZATION TISS CULT OVA & PARASITES DIRECT SMEARS CONCNTRAT & IDENT SENSITIV ANTIBIOT; AGAR DIFF METHD PER ANTIBIOT SENSITIVITY ANTIBIOTIC; DISK METHOD/PLATE SENSITIV ANTIBIOTIC; MICROTITR MIC ANY # ANTIBIO SENSITIV ANTIBIOTIC; MINI BACTERICIDAL CONCNTRAT SENSITIV ANTIBIOTIC; MACROTUBE DILUT EA ANTIBIOT SENSITIV ANTIBIOTIC; TUBERCLE BACILLUS EA DRUG SERUM BACTERICIDAL TITER SMEAR PRIM SOURCE W/INTERPT; ROUTINE STAIN SMEAR PRIM SOURCE W/INTERPT; FLUORSC & ACID FAST SMEAR PRIM SOURCE W/INTERPT; SPECIAL STAIN SMEAR PRIM W/INTERPT; WET MOUNT W/SMIPL STAIN TISS EXAM FUNGI TOXIN/ANTITOXIN ASSAY TISS CULTURE VIRUS ID; INOC EGGS/SM ANIMAL W/OBSRV & DISSECT VIRUS IDENT; TISS CULTURE INOCULATION & OBSRV VIRUS IDENT; TISS CULTURE ADD STUDIES EA ISOLATE ADENOVIRUS AG, DFA PERTUSSIS AG, DFA CHYLMD TRACH AG, DFA CRYPTOSPORIDUM AG, DFA HERPES SIMPLEX AG, DFA INFLUENZA AG, DFA LEGION PNEUMO AG, DFA RESP SYNCYTIAL AG, DFA TREPON PALLIDUM AG, DFA VARICELLA AG, DFA AG DETECTION NOS, DFA ADENOVIRUS AG, EIA CHYLMD TRACH AG, EIA CLOSTRIDIUM AG, EIA CRYPTOSPOR AG, EIA CYTOMEGALOVIRUS AG, EIA E COLI 0157 AG, EIA ENZYME IMMUNOASSAY (EIA) QUALITATIVE/SEMIQUANTITATIVE HEPATITIS B SURFACE AG, EIA HEPATITIS B AG, EIA HEPATITIS DELTA AG, EIA HISTOPLASMA CAPSUL AG, EIA HIV-1 AG, EIA HIV-2 AG, EIA RESP SYNCYTIAL AG, EIA ROTAVIRUS AG, EIA

$28

$23 N/A

$24

$7 N/A

$17

$6 N/A

$28

$10 N/A

$16

$5 N/A

$19

$5 N/A

$22

$6 N/A

$22

$3 N/A

$22

$6 N/A

$14

$4 N/A

$30

$10 N/A

$12

$4 N/A

$22

$5 N/A

$20

$7 N/A

$11

$3 N/A

$14

$5 N/A

$42

$13 N/A

$51

$20 N/A

$47

$15 N/A

$47

$14 N/A

$36

$12 N/A

$36

$12 N/A

$36

$12 N/A

$36

$12 N/A

$36

$12 N/A

$36

$12 N/A

$36

$12 N/A

$36

$12 N/A

$36

$12 N/A

$36

$12 N/A

$36

$12 N/A

$36

$12 N/A

$36

$12 N/A

$36

$12 N/A

$36

$12 N/A

$36

$12 N/A

$36

$12 N/A

BR

N/A

$28

$9 N/A

$28

$9 N/A

$46

$15 N/A

$36

$12 N/A

$51

$17 N/A

$51

$17 N/A

$36

$12 N/A

$36

$12 N/A

Section IX Pathology & Laboratory Services

Page 194

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION IX:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MAR PC/-26 FUD

87430 87449 87450 87470 87471 87472 87475 87476 87477 87480 87481 87482 87485 87486 87487 87490 87491 87492 87495 87496 87497 87510 87511 87512 87515 87516 87517 87520 87521 87522 87525 87526 87527 87528 87529 87530 87531 87532 87533 87534 87535 87536 87537 87538 87539 87540

STREP A AG, EIA AG DETECT NOS, EIA, MULT AG DETECT NOS, EIA, SINGLE BARTONELLA, DNA, DIR PROBE BARTONELLA, DNA, AMP PROBE BARTONELLA, DNA, QUANT LYME DIS, DNA, DIR PROBE LYME DIS, DNA, AMP PROBE LYME DIS, DNA, QUANT CANDIDA, DNA, DIR PROBE CANDIDA, DNA, AMP PROBE CANDIDA, DNA, QUANT CHYLMD PNEUM, DNA, DIR PROBE CHYLMD PNEUM, DNA, AMP PROBE CHYLMD PNEUM, DNA, QUANT CHYLMD TRACH, DNA, DIR PROBE CHYLMD TRACH, DNA, AMP PROBE CHYLMD TRACH, DNA, QUANT CYTOMEG, DNA, DIR PROBE CYTOMEG, DNA, AMP PROBE CYTOMEG, DNA, QUANT GARDNER VAG, DNA, DIR PROBE GARDNER VAG, DNA, AMP PROBE GARDNER VAG, DNA, QUANT HEPATITIS B, DNA, DIR PROBE HEPATITIS B , DNA, AMP PROBE HEPATITIS B , DNA, QUANT HEPATITIS C , RNA, DIR PROBE HEPATITIS C , RNA, AMP PROBE HEPATITIS C, RNA, QUANT HEPATITIS G , DNA, DIR PROBE HEPATITIS G, DNA, AMP PROBE HEPATITIS G, DNA, QUANT HSV, DNA, DIR PROBE HSV, DNA, AMP PROBE HSV, DNA, QUANT HHV-6, DNA, DIR PROBE HHV-6, DNA, AMP PROBE HHV-6, DNA, QUANT HIV-1, DNA, DIR PROBE HIV-1, DNA, AMP PROBE HIV-1, DNA, QUANT HIV-2, DNA, DIR PROBE HIV-2, DNA, AMP PROBE HIV-2, DNA, QUANT LEGION PNEUMO, DNA, DIR PROB

$36 $36 $29 $55 $96 $116 $54 $96 $116 $55 $96 $113 $55 $96 $116 $55 $96 $96 $55 $96 $116 $55 $96 $113 $55 $96 $126 $55 $96 $116 $55 $96 $113 $55 $96 $116 $55 $96 $113 $55 $96 $113 $55 $96 $116 $55

$12 N/A $12 N/A
$9 N/A $17 N/A $32 N/A $38 N/A $17 N/A $32 N/A $38 N/A $17 N/A $32 N/A $38 N/A $17 N/A $32 N/A $38 N/A $17 N/A $32 N/A $32 N/A $17 N/A $32 N/A $38 N/A $17 N/A $32 N/A $38 N/A $17 N/A $32 N/A $38 N/A $17 N/A $32 N/A $38 N/A $17 N/A $32 N/A $38 N/A $17 N/A $32 N/A $38 N/A $17 N/A $32 N/A $38 N/A $17 N/A $32 N/A $38 N/A $17 N/A $32 N/A $38 N/A $17 N/A

Section IX Pathology & Laboratory Services

Page 195

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION IX:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MAR PC/-26 FUD

87541 87542 87550 87551 87552 87555 87556 87557 87560 87561 87562 87580 87581 87582 87590 87591 87592 87620 87621 87622 87650 87651 87652 87797 87798 87799 87810 87850 87880 87899 87999 88000 88005 88007 88012 88014 88016 88020 88025 88027 88028 88029 88036 88037 88040 88045

LEGION PNEUMO, DNA, AMP PROB LEGION PNEUMO, DNA, QUANT MYCOBACTERIA, DNA, DIR PROBE MYCOBACTERIA, DNA, AMP PROBE MYCOBACTERIA, DNA, QUANT M.TUBERCULO, DNA, DIR PROBE M.TUBERCULO, DNA, AMP PROBE M.TUBERCULO, DNA, QUANT M.AVIUM-INTRA, DNA, DIR PROB M.AVIUM-INTRA, DNA, AMP PROB M.AVIUM-INTRA, DNA, QUANT M.PNEUMON, DNA, DIR PROBE M.PNEUMON, DNA, AMP PROBE M.PNEUMON, DNA, QUANT N.GONORRHOEAE, DNA, DIR PROB N.GONORRHOEAE, DNA, AMP PROB N.GONORRHOEAE, DNA, QUANT HPV, DNA, DIR PROBE HPV, DNA, AMP PROBE HPV, DNA, QUANT STREP A, DNA, DIR PROBE STREP A, DNA, AMP PROBE STREP A, DNA, QUANT DETECT AGENT NOS, DNA, DIR DETECT AGENT NOS, DNA, AMP DETECT AGENT NOS, DNA, QUANT CHYLMD TRACH ASSAY W/OPTIC N. GONORRHOEAE ASSAY W/OPTIC STREP A ASSAY W/OPTIC AGENT NOS ASSAY W/OPTIC UNLISTED MICROBIOLOGY PROC NECROPSY GROSS EXAM ONLY; WO CNS NECROPSY GROSS EXAM ONLY; W/BRAIN NECROPSY GROSS EXAM ONLY; W/BRAIN & SPINAL CORD NECROPSY GROSS EXAM ONLY; INFANT W/BRAIN NECROPSY GROSS EXAM ONLY; STILLBORN/NB W/BRAIN NECROPSY GROSS EXAM ONLY; MACERATED STILLBORN NECROPSY GROSS & MICRO; WO CNS NECROPSY GROSS & MICRO; W/BRAIN NECROPSY GROSS & MICRO; W/BRAIN & SPINAL CORD NECROPSY GROSS & MICRO; INFANT W/BRAIN NECROPSY GROSS & MICRO; STILLBORN/NB W/BRAIN NECROPSY LTD GROSS &/OR MICRO; REGIONAL NECROPSY LTD GROSS &/OR MICRO; SNGL ORGAN NECROPSY; FORENSIC EXAM NECROPSY; CORONER'S CALL

$96 $113
$55 $96 $116 $55 $96 $116 $55 $96 $116 $55 $96 $113 $55 $96 $116 $55 $96 $113 $55 $96 $113 $55 $96 $116 $36 $36 $36 $36 BR $307 $341 $375 $282 $282 $343 $441 $475 $509 $282 $282 $183 $134 $730 $61

$32 N/A $38 N/A $17 N/A $32 N/A $38 N/A $17 N/A $32 N/A $38 N/A $17 N/A $32 N/A $38 N/A $17 N/A $32 N/A $38 N/A $17 N/A $32 N/A $38 N/A $17 N/A $32 N/A $38 N/A $17 N/A $32 N/A $38 N/A $17 N/A $32 N/A $38 N/A $12 N/A $12 N/A $12 N/A $12 N/A
N/A $307 N/A $341 N/A $375 N/A $282 N/A $282 N/A $343 N/A $441 N/A $475 N/A $509 N/A $282 N/A $282 N/A $183 N/A $134 N/A $730 N/A
$61 N/A

Section IX Pathology & Laboratory Services

Page 196

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION IX:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MAR PC/-26 FUD

88099 88104 88106 88107 88108 88125 88130 88140 88141 88142 88143 88144 88145 88147 88148 88150 88152 88153 88154 88155 88160 88161 88162 88164 88165 88166 88167 88170 88171 88172 88173 88180 88182 88199 88230 88233 88235 88237 88239 88240 88241 88245 88248 88249 88261 88262

UNLISTED NECROPSY PROC CYTOPATH NOT CERV/VAG; SMEARS W/INTERPT CYTOPATHOLOGY NO CERV/VAG; FILTER ONLY W/INTERPT CYTOPATH NO CERV/VAG;SMEAR/FILTER PREP W/INTERPT CYTOPATH NO CERV/VAG; CONCNTRAT TECH SMEAR/INTER CYTOPATHOLOGY FORENSIC SEX CHROMATIN IDENT; BARR BODIES SEX CHROMATIN ID; PERIPHERL BLD SMEAR POLYMORPHN CYTPATH C/VAG INTERPRET CYTPATH C/VAG T/LAYER CYTPATH C/VAG T/LAYER REDO CYTPATHC/VAGT/LAYERAUTO REDO CYTPATH C/VAG T/LAYER SELECT CYTPATH C/VAG AUTOMATED CYTPATH C/VAG AUTO RESCREEN CYTPTH SMEARS CERV/VAG 1-3; SCRN TECH PHYS SUPER CYTPATH C/VAG AUTO REDO CYTPATH C/VAG REDO CYTPATH C/VAG SELECT CYTOPATH SMEARS CERV/VAG 1-3; W/DEF HORMONL EVAL CYTOPATH SMEARS ANY OTHR SOURCE; SCREEN & INTRPT CYTOPATH SMEARS OTHR SOURCE; PREP/SCREEN/INTERPT CYTOPATH SMEARS OTHR SOURCE; EXTEND STDY >5 SLDS CYTPATH TBS C/VAG MANUAL CYTPATH TBS C/VAG REDO CYTPATH TBS C/VAG AUTO REDO CYTPATH TBS C/VAG SELECT FINE NEEDL ASPIRAT W/WO PREP SMEARS; SUPERF TISS FINE NEEDL ASPIRAT; DEEP TISS W/RAD GUIDE EVAL FINE NEEDL ASPIRAT; IMMED CYTOHISTOLIC STDY EVAL FINE NEEDL ASPIRAT; INTERPT & REPORT FLOW CYTOMETRY; EA CELL SURFACE MARKER FLOW CYTOMETRY; CELL CYCLE/DNA ANALY UNLISTED CYTOPATHOLOGY PROC TISS CULTURE CHROMOSOME ANALY; LYMPHOCYTE TISS CULT CHROMOS ANALY; SKIN/OTHR SOLID TISS BX TISS CULT CHRMSM ANALY; AMNIOT FLD/CHORION VILLS TISS CULTURE CHROMOSOME ANALY; BONE MARROW CELLS TISS CULTURE CHROMOSOME ANALY; OTHER TISS CELL CRYOPRESERVE/STORAGE FROZEN CELL PREPARATION CHROMOSOME ANALY; SCORE 25 CELLS CT 5 CELLS CHROMOSOME ANALY; SCORE 100 CELLS CT 20 CELLS CHROMOSOME ANALYSIS, 100 CHROMO ANALY; CT 5 CELLS 1 KARYOTYPE W/BANDING CHROMO ANALY; CT 15-20 CELLS 2 KARYOTYPES W/BAND

BR $45 $40 $57 $52 $36 $23 $18 $27 $16 $91 $101 $107 $80 $101 $15 $104 $278 $352 $17 $32 $36 $61 $68 $81 $93 $100 $83 $113 $65 $85 $82 $230 BR $141 $53 $299 $230 $91 $12
$7 $195 $391 $375 $378 $456

N/A $36 N/A $32 N/A $46 N/A $41 N/A $33 N/A
$2 N/A $5 N/A $27 N/A $3 N/A
N/A N/A N/A N/A N/A $5 N/A $11 N/A N/A N/A $3 N/A $22 N/A $22 N/A $36 N/A N/A N/A N/A N/A $67 N/A $96 N/A $65 N/A $72 N/A $17 N/A $46 N/A N/A $42 N/A $16 N/A $90 N/A $69 N/A $27 N/A N/A N/A $20 N/A $39 N/A N/A $38 N/A $46 N/A

Section IX Pathology & Laboratory Services

Page 197

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION IX:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MAR PC/-26 FUD

88263 88264 88267 88269 88271 88272 88273 88274 88275 88280 88283 88285 88289 88291 88299 88300 88302 88304 88305 88307 88309 88311 88312 88313 88314 88318 88319 88321 88323 88325 88329 88331 88332 88342 88346 88347 88348 88349 88355 88356 88358 88362 88365 88371 88372 88399

CHROMO ANALY; CT 45 CEL MOSAICISM 2 KARYO W/BAND CHROMOSOME ANALYSIS, 20-25 CHROMO ANALY AMNIO FLUID CT 15 CELLS 1 KARYOTYPE CHROMO ANALY AMNIO FLUID CELLS CT 6-12 COLONIES CYTOGENETICS, DNA PROBE CYTOGENETICS, 3-5 CYTOGENETICS, 10-30 CYTOGENETICS, 25-99 CYTOGENETICS, 100-300 CHROMOSOME ANALY; ADD KARYOTYPES EA STUDY CHROMOSOME ANALY; ADD SPECIALIZED BANDING TECH CHROMOSOME ANALY; ADD CELLS COUNTED EA STUDY CHROMOSOME ANALY; ADD HIGH RESOLUTION STUDY CYTO/MOLECULAR REPORT UNLISTED CYTOGENETIC STUDY LEVEL I- SURG PATH GROSS EXAM ONLY LEVEL II-SURG PATH GROSS/MICRO EXAM LEVEL III-SURG PATH GROSS/MICRO EXAM LEVEL IV-SURG PATH GROSS/MICRO EXAM LEVEL V-SURG PATH GROSS/MICRO EXAM LEVEL VI-SURG PATH GROSS/MICRO EXAM DECALCIFICATION PROC SPECIAL STAINS; GRP I MICROORGANISMS EA SPEC STAINS; GRP II ALL BUT ICYTOCHEM/IPEROX EA SPECIAL STAINS; HISTOCHEM STAINING W/FROZEN SECT DETERM HISTOCHEMISTRY TO IDENT CHEM COMPONENTS DETERM HISTOCHEM/CYTOCHEM TO ID ENZYM CONSTIT EA CONS & REPORT REF SLIDES PREP ELSEWHERE CONS & REPORT REF MAT REQUIRING PREP SLIDES CONS COMP W/REVIEW RECORD/SPECMN W/REPRT REF MAT PATH CONS DURING SURG PATH CONS DURING SURG; W/FROZEN SECT SNGL SPECMN PATH CONS DURING SURG; EA ADD BLOCK W/FROZN SECT IMMUNOCYTOCHEMISTRY EA ANTIB IMMUNOFLUORESCENT STUDY EA ANTIB; DIRECT METHD IMMUNOFLUOR STUDY EA ANTIB; INDIRECT METHD ELECTRON MICRO; DX ELECTRON MICRO; SCANNING MORPHOMETRIC ANALY; SKELETAL MUSCL MORPHOMETRIC ANALY; NERV MORPHOMETRIC ANALY; TUMOR NERV TEASING PREP TISS IN SITU HYBRIDIZATION INTERPT & REPORT PROT ANALY TISS WESTERN BLOT W/INTERPT & REPORT PROT ANALY W BLOT W/INTRPT/REPRT; IMMUN PROBE EA UNLISTED SURG PATH PROC

$469 $193 $514 $452
$58 $72 $87 $94 $108 $148 $117 $137 $98
$8 BR $20 $38 $50 $73 $117 $162 $19 $28 $21 $38 $31 $47 $63 $73 $98 $46 $89 $53 $70 $51 $54 $209 $142 $167 $153 $138 $94 $49 $42 $59 BR

$47 N/A N/A
$51 N/A $45 N/A
N/A N/A N/A N/A N/A $15 N/A $12 N/A $14 N/A $10 N/A N/A N/A $14 N/A $23 N/A $30 N/A $51 N/A $87 N/A $121 N/A $15 N/A $22 N/A $17 N/A $27 N/A $25 N/A $38 N/A $63 N/A $59 N/A $98 N/A $46 N/A $67 N/A $40 N/A $56 N/A $41 N/A $44 N/A $147 N/A $99 N/A $125 N/A $115 N/A $104 N/A $71 N/A $39 N/A $8 N/A $12 N/A N/A

Section IX Pathology & Laboratory Services

Page 198

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION IX:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MAR PC/-26 FUD

89050 89051 89060 89100 89105 89125 89130 89132 89135 89136 89140 89141 89160 89190 89250 89251 89252 89253 89254 89255 89256 89257 89258 89259 89260 89261 89264 89300 89310 89320 89325 89329 89330 89350 89355 89360 89365 89399

CELL CT MISC BODY FLUIDS EX BLD CELL CT MISC BODY FLUIDS EX BLD; W/DIFF CT CRYSTAL ID LITE MICRO W/WO LENS ANALY ANY FLUID DUODENAL INTUB/ASPIRAT; 1 SPECMN + APPRO TEST DUODENL INTUB/ASPIR; COLLEC MX FRACT SPECMN 1/2 FAT STAIN FECES URIN/SPUTUM GASTRIC INTUBAT & ASPIR DX EA SPECMN CHEM ANALY GASTRIC INTUBAT & ASPIR DX EA SPECMN; AFTR STIM GASTRIC INTUB/ASPIRAT/FRACTIONAL COLLEC; 1 HR GASTRIC INTUB/ASPIRAT/FRACTIONAL COLLEC; 2 HRS GASTRC INTUB/ASPIR/FRCT COLLC; 2HR + GASTRC STIM GASTRC INTUB/ASPIR/FRCT COLLC; 3HR + GASTRC STIM MEAT FIBERS FECES NASAL SMEAR EOSINOPHILS CULTURE & FERTILIZATION OOCYTE(S) CULTURE OOCYTE W/EMBRYOS ASSIST OOCYTE FERTILIZATION EMBRYO HATCHING OOCYTE IDENTIFICATION PREPARE EMBRYO FOR TRANSFER PREPARE CRYOPRESERVED EMBRYO SPERM IDENTIFICATION CRYOPRESERVATION, EMBRYO CRYOPRESERVATION, SPERM SPERM ISOLATION, SIMPLE SPERM ISOLATION, COMPLEX SPERM TISSUE IDENTIFY SEMEN ANALY; PRESENCE/MOTILITY INCL HUHNER TEST SEMEN ANALY; MOTILITY & CT SEMEN ANALY; COMPLT SPERM ANTIB SPERM EVAL; HAMSTER PENETRATION TEST SPERM; CERV MUCOS PENETRAT W/WO SPINNBARKEIT SPUTUM AEROSOL INDUCED TECH (SEPART PROC) STARCH GRANULES FECES SWEAT COLLEC BY IONTOPHORESIS WATER LOAD TEST UNLISTED MISC PATH TEST

$16 $19 $19 $69 $89 $15 $30 $30 $48 $48 $69 $69
$9 $14 $666 BR BR BR BR BR BR BR BR BR BR BR BR $35 $33 $50 $84 $223 $56 $21 $10 $40 $24 BR

$5 N/A $6 N/A $6 N/A $69 N/A $89 N/A $5 N/A $30 N/A $30 N/A $48 N/A $48 N/A $69 N/A $69 N/A $3 N/A $5 N/A $577 N/A
N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12 N/A $9 N/A $14 N/A $23 N/A $81 N/A $16 N/A $7 N/A $3 N/A $11 N/A $7 N/A N/A

Section IX Pathology & Laboratory Services

Page 199

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION X:

GENERAL MEDICINE SERVICES

SUBSECTION A: PAYMENT GROUND RULES FOR GENERAL MEDICINE SERVICES
General Guidelines

Some of the commonalties are repeated here for the convenience of those medical providers referring to this section on General Medicine. If no appropriate code is found for medical services performed by a provider, use the appropriate unlisted code (e.g., 99199), and adequately describe the service provided.

Supplies and materials provided by the physician (e.g., sterile trays, etc.), over and above that usually provided during an office visit or other services rendered may be charged for separately and coded separately (e.g., code 99070). A physician office visit code may be charged in addition to the code for modalities/procedures only if the accompanying documentation clearly indicates that the physician actually examined the worker during the office visit.

To report the administration of a vaccine/toxoid, the vaccine/toxoid product codes 90700-90749 must be used in addition to an immunization administration code(s) 90471 or 90472. A therapeutic injection shall use CPT code 90782 and will not include the cost of the drug, which will be billed and paid separately.

Definitions

The following services represent definitions and special billing considerations for general medicine services. Chiropractic and physical therapist service reimbursements are explained in the Physical Medicine Section. Evaluation and management (E/M) services are thoroughly explained in Evaluation and Management (E/M) services.

Office Visits

An evaluation and management code may be reported separately only if the injured employee requires a separate evaluation for treatment determination. (See Evaluation and Management Section for further details on appropriate codes). If the injured employee has a pre-determined medical treatment plan by the authorized treating physician or referring physician, a separate E/M code for an office visit should not be charged and will not be reimbursed.

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SECTION X:

GENERAL MEDICINE SERVICES

SUBSECTION B: PAYMENT MODIFIERS FOR GENERAL MEDICINE SERVICES A modifier indicates a service or procedure performed has been altered by some specific circumstance but has not changed its definition or code. The modifying circumstance shall be identified by use of a hyphen and the appropriate modifier following the procedure code. When two modifiers are applicable to a single code, indicate each modifier, preceded by a hyphen, on the bill. The modifier may also be reported by using a separate five-digit code in addition to the procedure code. If more than one modifier is used, place the "multiple modifiers" code -99 immediately after the procedure code. This indicates that one or more additional modifier codes will follow. Only certain modifiers in each of the categories (anesthesia, surgery, pathology/laboratory, radiology, general medicine, and physical medicine) will be recognized for reimbursement purposes.

The modifiers listed below may differ from those published by the American Medical Association. Providers submitting workers' compensation billing shall use only the modifiers set out in the fee schedule.

The following modifiers will be recognized for reimbursement by the fee schedule for general medicine codes:

-22 Unusual Procedure Services: When the service(s) provided is greater than that usually required for the listed procedure, it may be identified by adding modifier (-22) to the usual procedure number or by use of the separate five digit modifier code 09922. A report may also be appropriate.

-26 Professional Component Only: Certain procedures are a combination of a physician component and a technical component. When the medical provider component is reported separately, the service may be identified by adding the modifier (-26) to the usual procedure number or the service may be reported by use of the five-digit modifier code 09926.

-27 Technical Component Only: Certain procedures are a combination of a medical provider component and a technical component. When the technical component is reported separately, the service may be identified by adding the modifier (-27) to the usual procedure number or the service may be reported by use of the five-digit modifier code 09927.

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SECTION X:

GENERAL MEDICINE SERVICES

SUBSECTION B: PAYMENT MODIFIERS FOR GENERAL MEDICINE SERVICES -53 Discontinued Procedure. Due to extenuating circumstances or those that threaten the
well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. This circumstance may be reported by adding the modifier (-53) to the code for the discontinued procedure or by using the separate fivedigit modifier 09953. Note: This modifier is not used to report the elective cancellation of a procedure before the patient's anesthesia induction and/or surgical preparation in the operating suite.

-59 Distinct Procedural Service: Under certain circumstances, the medical provider may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier (-59) is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician. However, when another already established modifier is appropriate it should be used rather than modifier (-59). Only if no more descriptive modifier is available, and the use of modifier (-59) best explains the circumstances, should modifier (-59) be used. Modifier code 09959 may be used as an alternative to modifier (-59).

-99 Multiple Modifiers: Under certain circumstances, two or more modifiers may be necessary to completely delineate a service. In such situations modifier (-99) should be added to the basic procedure, and other applicable modifiers may be listed as part of the description of the service. Modifier code 09999 may be used as an alternative to modifier (-99).

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SECTION X:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MAR PC/-26 FUD

90281 90283 90287 90288 90291 90296 90371 90375 90376 90378 90379 90384 90385 90386 90389 90393 90396 90399 90471 90472 90476 90477 90581 90585 90586 90632 90633 90634 90636 90645 90646 90647 90648 90657 90658 90659 90660 90665 90669 90675 90676 90680 90690 90691 90692 90693

HUMAN IG, IM HUMAN IG, IV BOTULINUM ANTITOXIN BOTULISM IG, IV CMV IG, IV DIPHTHERIA ANTITOXIN HEPB IG, IM RABIES IG, IM/SC RABIES IG, HEAT TREATED RESPIRATORY SYNCYTIAL VIRUS IMMUNE GLOBULIN RSV IG, IV RH IG, FULL-DOSE, IM RH IG, MINIDOSE, IM RH IG, IV TETANUS IG, IM VACCINA IG, IM VARICELLA-ZOSTER IG, IM IMMUNE GLOBULIN IMMUNIZATION ADMIN, SINGLE IMMUNIZATION ADMIN, 2+ ADENOVIRUS VACCINE, TYPE 4 ADENOVIRUS VACCINE, TYPE 7 ANTHRAX VACCINE, SC BCG VACCINE, PERCUT BCG VACCINE, INTRAVESICAL HEPA VACCINE ADULT IM HEPA VACCINE PED/ADOL-2 DOSE HEPA VACCINE PED/ADOL-3 DOSE HEPA/HEPB VACCINE ADULT IM HIB VACCINE, HBOC, IM HIB VACCINE, PRP-D, IM HIB VACCINE, PRP-OMP, IM HIB VACCINE, PRP-T, IM FLU VACCINE, 6-35 MO, IM FLU VACCINE, 3 YRS, IM FLU VACCINE, WHOLE, IM FLU VACCINE, NASAL LYME DISEASE VACCINE, IM PNEUMOCOCCAL VACCINE, PED RABIES VACCINE, IM RABIES VACCINE, ID ROTOVIRUS VACCINE, ORAL TYPHOID VACCINE, ORAL TYPHOID VACCINE, IM TYPHOID VACCINE, H-P, SC/ID TYPHOID VACCINE, AKD, SC

BR

N/A

BR

N/A

BR

N/A

BR

N/A

BR

N/A

BR

N/A

BR

N/A

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N/A

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N/A

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N/A

BR

N/A

BR

N/A

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N/A

$7

N/A

$11

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N/A

Section X: General Medicine Services

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SECTION X:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MAR PC/-26 FUD

90700 90701 90702 90703 90704 90705 90706 90707 90708 90709 90710 90712 90713 90716 90717 90718 90719 90720 90721 90725 90727 90732 90733 90735 90744 90746 90747 90748 90749 90780 90781 90782 90783 90784 90788 90799 90801 90802 90804 90805 90806 90807 90808 90809 90810 90811

IMMUNIZ ACTIVE; DIPHTH/TET TOX/ACELLULAR PERTUSS IMMUNIZ ACTIVE; DIPHTHERIA/TETANUS/PERTUSSIS IMMUNIZ ACTIVE; DIPHTHERIA & TETANUS TOXOIDS IMMUNIZ ACTIVE; TETANUS TOXOID IMMUNIZ ACTIVE; MUMPS VIRUS VACCINE LIVE IMMUNIZ ACTIVE; MEASLES VIRUS LIVE ATTENUATED IMMUNIZ ACTIVE; RUBELLA VIRUS VACCINE LIVE IMMUNIZ ACTIVE; MEASLES/MUMPS/RUBELLA VIRUS LIVE IMMUNIZ ACTIVE; MEASLES & RUBELLA VIRUS LIVE IMMUNIZ ACTIVE; RUBELLA & MUMPS VIRUS LIVE IMMUNIZ ACTIVE; MEASLES/MUMPS/RUBELA & VARICELLA IMMUNIZ ACTIVE; POLIOVIRUS VACCINE LIVE ORAL IMMUNIZ ACTIVE; POLIOMYELITIS VACCINE IMMUNIZ ACTIVE; VARICELLA VACCINE IMMUNIZ ACTIVE; YELLOW FEVER VACCINE IMMUNIZ ACTIVE; TET & DIPHTH TOX ABSORBED ADULT IMMUNIZ ACTIVE; DIPHTHERIA TOXOID IMMUNIZ ACTIVE; DIP/TET/PERTUSS & H INFLUENZA B IMMUNIZ ACTIVE; DIP/TET/ACELL PERTUS & H FLU B IMMUNIZ ACTIVE; CHOLERA VACCINE IMMUNIZ ACTIVE; PLAGUE VACCINE IMMUNIZ ACTIVE; PNEUMOCOCCAL VACCINE POLYVALENT IMMUNIZ ACTIVE; MENINGOCOCCAL POLYSACCHARIDE IMMUNIZ ACTIVE; ENCEPHALITIS VIRUS VACCINE IMMUNIZ ACTIVE HEPATITIS B VACCINE; NB TO 11 YR IMMUNIZ ACTIVE HEPATITIS B VACCINE; 20 YR & OVER IMMUNIZ ACTIVE HEP B VACC; DIAL/IMMUNOSUPP PT HEPB/HIB VACCINE, IM UNLIST IMMUZ PROC IV INFUS THERAP/DX-BY PHYS/SUPERVS; TO 1 HR IV INFUS THERAP/DX-BY PHYS/SUPERVS; EA HR TO 8HR THERAPY/DX INJ;SUBQ/IM PLUS CHARGE FOR MEDICATION THERAP/DX INJ; INTRA-ART THERAP/DX INJ; IV IM INJ ANTIBIOTIC UNLISTED THERAP/DX INJ PSYCH DX INTERVIEW W/HX-MENTAL-STATUS-DISPOSIT INTAC PSY DX INTERVIEW PSYTX, OFFICE (20-30) PSYTX, OFFICE (20-30) W/E&M PSYTX, OFFICE (45-50) PSYTX, OFFICE (45-50) W/E&M PSYTX, OFFICE (75-80) PSYTX, OFFICE (75-80) W/E&M INTAC PSYTX, OFFICE (20-30) INTAC PSYTX, OFF 20-30 W/E&M

$24

N/A

$20

N/A

$13

N/A

$13

N/A

$19

N/A

$23

N/A

$18

N/A

$22

N/A

$20

N/A

$20

N/A

$29

N/A

$21

N/A

$24

N/A

$43

N/A

$41

N/A

$14

N/A

$20

N/A

$34

N/A

$38

N/A

$14

N/A

$17

N/A

$15

N/A

$47

N/A

$18

N/A

$19

N/A

$49

N/A

$114

N/A

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N/A

BR

N/A

$72

N/A

$72

N/A

$15

N/A

$31

N/A

$29

N/A

$15

N/A

BR

N/A

$163

N/A

$172

N/A

$81

N/A

$91

N/A

$110

N/A

$123

N/A

$163

N/A

$180

N/A

$91

N/A

$102

N/A

Section X: General Medicine Services

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STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION X:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MAR PC/-26 FUD

90812 90813 90814 90815 90816 90817 90818 90819 90821 90822 90823 90824 90826 90827 90828 90829 90845 90846 90847 90849 90853 90857 90862 90865 90870 90871 90880 90882 90885 90887 90889 90899 90901 90911 90918 90919 90920 90921 90922 90923 90924 90925 90935 90937 90945 90947

INTAC PSYTX, OFFICE (45-50) INTAC PSYTX, OFF 45-50 W/E&M INTAC PSYTX, OFFICE (75-80) INTAC PSYTX, OFF 75-80 W/E&M PSYTX, HOSP (20-30) PSYTX, HOSP (20-30) W/E&M PSYTX, HOSP (45-50) PSYTX, HOSP (45-50) W/E&M PSYTX, HOSP (75-80) PSYTX, HOSP (75-80) W/E&M INTAC PSYTX, HOSP (20-30) INTAC PSYTX, HSP 20-30 W/E&M INTAC PSYTX, HOSP (45-50) INTAC PSYTX, HSP 45-50 W/E&M INTAC PSYTX, HOSP (75-80) INTAC PSYTX, HSP 75-80 W/E&M MED PSYCHOANALYSIS FAMILY MED PSYCHOTHERAP (WO PT PRESENT) FAMILY MED PSYCHOTHERAP & DRUG MGMT WHEN INDICAT MX-FAMILY GRP MED PSYCHOTHERAP & DRUG MGMT GRP MED PSYCHOTHERAP & DRUG MGMT WHEN INDICATED INTERACTIVE GRP MED PSYCHOTHERAP PHARM MGMT W/SCRIPT USE & REVIEW-MIN PSYCHOTH NARCOSYNTHESIS ELEC-CONVULS THERAP; SNGL SEIZURE ELEC-CONVULS THERAP; MX SEIZURES PER DA MED HYPNOTHERAP ENVIRONM INTERVEN-MED MGMT PURP-W/AGENCIES/INSTI PSY EVALUATION OF RECORDS INTERPT/EXPLAN RESULTS EXAM/PROC/DATA TO FAMILY PREP REPORT PT'S STATUS/HX/TX/PROGRESS FOR OTHER UNLISTED PSYCH SERV/PROC BIOFEEDBACK TRAINING-ANY MODALITY BIOFEEDBACK TRAIN-ANORECTAL INCL EMG &/MANOMETRY ESRD RELATED SERV-FULL MO; PTS < 2 YR AGE ESRD RELATED SERV-FULL MO; 2 - 12 BIRTHDAYS ESRD RELATED SERV-FULL MO; 12 - 19 YR ESRD RELATED SERV-FULL MO; PTS AGE 20 & OVER ESRD RELATED SERV PER DA; PT < 2 YR ESRD RELAT SERV PER DA; PT 2 TO 11 YR ESRD RELAT SERV PER DA; PT 12 TO 19 YR ESRD RELAT SERV PER DA; PT 20 YR & OVER HEMODIALYSIS PROC W/SNGL PHYS EVAL HEMODIALYSIS PROC W/REPEAT EVAL W/WO REVIS DIALY DIALYSIS PROC OTHER THAN HEMODIALYSIS W/1 EVAL DIALYSIS OTHER THAN HEMODIALYSIS W/REPEAT EVAL

$118

N/A

$132

N/A

$165

N/A

$182

N/A

$88

N/A

$99

N/A

$119

N/A

$133

N/A

$176

N/A

$194

N/A

$99

N/A

$111

N/A

$130

N/A

$143

N/A

$178

N/A

$197

N/A

$123

N/A

$112

N/A

$123

N/A

$85

N/A

$60

N/A

$77

N/A

$68

N/A

$178

N/A

$193

0

$259

0

$121

N/A

$99

N/A

$189

N/A

$125

N/A

$125

N/A

BR

N/A

$88

0

$130

0

$370

N/A

$330

N/A

$295

N/A

$242

N/A

$22

N/A

$21

N/A

$20

N/A

$19

N/A

$166

0

$263

0

$156

0

$243

0

Section X: General Medicine Services

Page 205

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION X:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MAR PC/-26 FUD

90989 90993 90997 90999 91000 91010 91011 91012 91020 91030 91032 91033 91052 91055 91060 91065 91100 91105 91122 91299 92002 92004 92012 92014 92015 92018 92019 92020 92060 92065 92070 92081 92082 92083 92100 92120 92130 92135 92140 92225 92226 92230 92235 92240 92250 92260

DIALYSIS TRAIN-PT-INCL HELPR WHERE APPLIC-COMPLT DIALYSIS TRAIN-PT-COURSE NOT COMPLT-PER SESSION HEMOPERFUSION UNLISTED DIALYSIS PROC INPT/OUTPT ESOPH INTUBATION & COLLECT-CYTOLOGY W/PREP (SEP) ESOPH MOTILITY STUDY ESOPH MOTILITY STUDY; W/MECHOLYL/SIMILAR STIM ESOPH MOTILITY STUDY; W/ACID PERFUSION STUDIES ESOPHAGOGASTRIC MANOMETRIC STUDIES ESOPHAGUS ACID PERFUSION TEST ESOPHAGITIS ESOPH ACID REFLUX TEST W/INTRALUMNL PH ELECTRODE ESOPH ACID REFLUX TEST; PROLONGED RECORDING GASTRIC ANALY TEST W/INJ STIM GASTRIC SECRETION GASTRIC INTUBAT WASH & PREP SLIDES (SEPART PROC) GASTRIC SALINE LOAD TEST BREATH HYDROGEN TEST INTESTINAL BLEED TUBE-PASSAGE POSIT & MONITOR GASTRIC INTUBATION & ASPIRAT/LAVAGE TX ANORECTAL MANOMETRY UNLISTED DX GASTROENTEROLOGY PROC OPHTH SERV: MED EXAM & EVAL; INTERMED NEW PT OPHTH SERV: MED EXAM; COMP NEW PT 1/MORE VISITS OPHTH SERV: MED EXAM & EVAL; INITERMED ESTAB PT OPHTH SERV: MED EXAM & EVAL; COMP ESTAB PT DETERM REFRACTIVE STATE OPHTH EXAM & EVAL-GEN ANES; COMPLT OPHTH EXAM & EVAL-GEN ANES; LTD GONIOSCOPY (SEPART PROC) SENSORIMOTOR EXAM W/MX MEASUR OCULAR DEVIA (SEP) ORTHOPTIC &/OR PLEOPTIC TRAIN W/MED DIRECT FITTING CONTACT LENS-TX DISEASE INCL SUPPLY LENS VISUAL FIELD EXAM UNILAT/BILAT W/I&R; LTD VISUAL FIELD EXAM UNI/BIL W/I&R; INTERMED VISUAL FIELD EXAM UNILAT/BILAT W/I&R; EXTEN SERIAL TONOMETRY (SEPART PROC) W/I&R SAME DA TONOGRAPHY W/I&R-RECORD INDENTAT TONOMETER TONOGRAPHY W/WATER PROVOCATION OPTHALMIC DX IMAGING PROVOCATIVE TESTS-GLAU W/I&R WO TONOGRAPY OPHTH EXTEN W/RETINAL DRAW W/I&R; INIT OPHTH EXTEN W/RETINAL DRAW W/I&R; SUBSQT FLUORESCEIN ANGIOSCOPY W/I&R FLUORESCEIN ANGIOGRAPHY W/I&R INDOCYANINE-GREEN ANGIO W/INTERP & REPORT FUNDUS PHOTOGRAPHY W/I&R OPHTHALMODYNAMOMETRY

$445 $75
$185 BR $55
$203 $234 $243 $170
$93 $161 $239 $107
$68 $63 $123 $66 $65 $176 BR $47 $62 $44 $54 $19 $194 $90 $38 $56 $30 $139 $38 $64 $97 $35 $42 $42 $38 $41 $44 $38 $54 $141 $141 $44 $52

N/A N/A
0 N/A $44 0 $162 0 $187 0 $195 0 $136 0 $83 0 $129 0 $191 0 $96 0 $55 0 $51 0 $98 0
0 0 $141 0 N/A N/A N/A N/A N/A N/A N/A N/A N/A $30 N/A $20 N/A N/A $8 N/A $13 N/A $19 N/A N/A N/A N/A $18 N/A N/A N/A N/A N/A $42 N/A $42 N/A $13 N/A N/A

Section X: General Medicine Services

Page 206

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION X:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MAR PC/-26 FUD

92265 92270 92275 92283 92284 92285 92286 92287 92310 92311 92312 92313 92314 92315 92316 92317 92325 92326 92330 92335 92340 92341 92342 92352 92353 92354 92355 92358 92370 92371 92390 92391 92392 92393 92395 92396 92499 92502 92504 92506 92507 92508 92510 92511 92512 92516

NEEDLE OCULOELECTROMYOGRAPHY 1/MORE MUSCL W/I&R ELEC-OCULOGRAPHY W/I&R ELECTRORETINOGRAPHY W/I&R COLOR VISION EXAM EXTEN EG. ANOMALOSCOPE/EQUIVAL DARK ADAPTATION EXAM W/I&R EXT OCULAR PHOTOG W/I&R-DOCUMENT MED PROGRESS SPEC ANT SEGMT PHOTO W/I&R; W/MICRO/CELL CNT SPECIAL ANT SEGMT PHOTO; W/FLUOROESCEIN ANGIOGR SCRIPT & FIT CONTACT LENS; CORNEAL EX APHAKIA SCRIPT & FIT CONTACT LENS; CORNEAL-APHAKIA-1EYE SCRIPT CONTACT LENS; CORNEAL-APHAKIA-BOTH EYES SCRIPT & FIT CONTACT LENS; CORNEOSCLERAL LENS SCRIPT W/FIT BY TECH; LENS BOTH EYES EX APHAKIA SCRIPT W/FIT BY TECH; LENS-APHAKIA-1 EYE SCRIPT W/FIT BY TECH; LENS-APHAKIA-BOTH EYES SCRIPT W/FIT BY TECH; CORNEOSCLERAL LENS MODIFICAT LENS (SEP PRO) W/MED SUPERVS ADAPTAT REPLAC CONTACT LENS SCRIPT FIT & SUPPLY OCULAR PROSTH W/SUPERVS ADAP SCRIPT OCULAR PROSTH & DIRECT FIT & SUPPLY-TECH FIT SPECTACLES EX APHAKIA; MONOFOCAL FITTING SPECTACLES EX APHAKIA; BIFOCAL FIT SPECTACLES EX APHAKIA; MULTIFOCAL NOT BIFOCL FITTING SPECTACLE PROSTH APHAKIA; MONOFOCAL FITTING SPECTACLE PROSTH APHAKIA; MULTIFOCAL FIT SPECTACL MOUNTED LO VISION AID; 1 ELEMNT SYS FIT SPECTACL MOUNT LO VISION AID; TELESCOP/OTHER PROSTH SERV APHAKIA TEMPORARY REPR & REFITTING SPECTACLES; EX APHAKIA REPR & REFIT SPECTACLE; SPECTACLE PROSTH APHAKIA SUPPLY SPECTACLE EX PROSTH-APHAK & LO VISION AID SUPPLY CONTACT LENSES EX PROSTH APHAKIA SUPPLY LOW VISION AIDS SUPPLY OCULAR PROSTH SUPPLY PERM PROSTH-APHAKIA; SPECTACLES SUPPLY PERM PROSTH APHAKIA; CONTACT LENSES UNLISTED OPHTH SERV/PROC OTOLARYNGOLOGIC EXAM UNDER GEN ANES BINOCULAR MICRO (SEPART DX PROC) EVAL SPEECH/LANG/VOICE/COMMUN/AUDITORY PROCESS TX SPEECH/LANG/VOICE/COMMUN/AUD DISORDER; INDIV TX SPEECH/LANG/VOICE/COMMUN/AUD DISORDER; 2/MORE AURAL REHAB FOLLOW COCHLEAR IMPLNT W/WO SPCH PRO NASOPHARYNGOSCOPY W/ENDO (SEPART PROC) NASAL FUNCT STUDIES FACIAL NERV FUNCT STUDIES

$103 $103 $103
$38 $55 $30 $145 $181 $91 $79 $103 $130 $93 $87 $144 $93 $49 $54 $238 $178 $53 $58 $80 $24 $26 $25 $27 $58 $78 $128 BR BR BR BR BR BR BR $154 $23 $86 $65 $55 $175 $89 $64 $71

$41 N/A $41 N/A $41 N/A $27 N/A $39 N/A $21 N/A $29 N/A $54 N/A
N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A
0 N/A N/A N/A N/A N/A
0 N/A N/A

Section X: General Medicine Services

Page 207

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION X:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MAR PC/-26 FUD

92520 92525 92526 92531 92532 92533 92534 92541 92542 92543 92544 92545 92546 92547 92548 92551 92552 92553 92555 92556 92557 92559 92560 92561 92562 92563 92564 92565 92567 92568 92569 92571 92572 92573 92575 92576 92577 92579 92582 92583 92584 92585 92587 92588 92589 92590

LARYNGEAL FUNCT STUDIES EVAL SWALLOWING & ORAL FUNCT-FEEDING TX SWALLOWING DYSFUNCT &/OR ORAL FUNCT-FEEDING SPONTANEOUS NYSTAGMUS INCL GAZE POSIT NYSTAGMUS CALORIC VESTIBULAR TEST EA IRRIGA OPTOKINETIC NYSTAGMUS SPONTANEOUS NYSTAGMUS TEST W/GATE & FIX W/RECORD POSIT NYSTAGMUS TEST MINI 4 POSIT W RECORDING CALORIC VESTIBULAR TEST EA IRRIGA W/RECORDING OPTOKINETIC NYSTAGMS BIDIRECT/FOVEAL/PERIPH STIM OSCILLATING TRACKING TEST W/RECORDING SINUSOIDAL VERTICAL AXIS ROTATIONAL TESTING USE-VERTICAL ELECT IN ABOVE TESTS = 1 ADD TEST COMPUTERIZED DYNAMIC POSTUROGRAPHY SCREENING TEST PURE TONE AIR ONLY PURE TONE AUDIOMETRY; AIR ONLY PURE TONE AUDIOMETRY; AIR & BONE SPEECH AUDIOMETRY THRESHOLD; SPEECH AUDIOMETRY THRESHOLD; W/SPEECH RECOGNITN COMP AUDIOMETRY THRESHOLD EVAL & SPEECH RECOGNI AUDIOMETRIC TESTING GRP BEKESY AUDIOMETRY; SCREENING BEKESY AUDIOMETRY; DX LOUDNESS BALANCE TEST ALTERN BINAURAL/MONAURAL TONE DECAY TEST SHORT INCREMENT SENSITIVITY INDX STENGER TEST PURE TONE TYMPANOMETRY ACOUSTIC REFLEX TESTING ACOUSTIC REFLEX DECAY TEST FILTERED SPEECH TEST STAGGERED SPONDAIC WORD TEST LOMBARD TEST SENSORINEURAL ACUITY LEVEL TEST SYNTHETIC SENTENCE IDENT TEST STENGER TEST SPEECH VISUAL REINFORCEMENT AUDIOMETRY CONDITIONING PLAY AUDIOMETRY SELECT PICTURE AUDIOMETRY ELECTROCOCHLEOGRAPHY AUDITORY EVOKED POTENTIALS &/OR TEST-CNS EVOKED OTOACOUSTIC EMISSIONS; LTD EVOKED OTOACOUSTIC EMISSIONS; COMP/DX EVAL CENTRAL AUDITORY FUNCT TEST HEARING AID EXAM & SELECT; MONAURAL

$139 $132
$67 $21 $24 $38 $17 $51 $46 $59 $28 $28 $44 $27 $157 $14 $21 $32 $17 $28 $57 $47 $28 $55 $14 $24 $24 $20 $22 $19 $20 $30 $24 $16 $24 $22 $20 $39 $42 $28 $163 $191 $40 $57 $34 $55

N/A N/A N/A N/A N/A N/A N/A $41 N/A $36 N/A $47 N/A $22 N/A $22 N/A $35 N/A $21 N/A $64 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $95 N/A $10 N/A $16 N/A N/A N/A

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CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MAR PC/-26 FUD

92591 92592 92593 92594 92595 92596 92597 92598 92599 92950 92953 92960 92961 92970 92971 92975 92977 92978 92979 92980 92981 92982 92984 92986 92987 92990 92992 92993 92995 92996 92997 92998 93000 93005 93010 93012 93014 93015 93016 93017 93018 93024 93040 93041 93042 93224

HEARING AID EXAM & SELECT; BINAURAL HEARING AID CHECK; MONAURAL HEARING AID CHECK; BINAURAL ELECTROACOUSTIC EVAL HEARING AID; MONAURAL ELECTROACOUSTIC EVAL HEARING AID; BINAURAL EAR PROTECTOR ATTENUATION MEASUR EVAL VOICE PROSTH/ALTERNATE COMMUN DEVICE MOD VOICE PROSTH/ALTERNATE COMMUN DEVICE UNLISTED OTORHINOLARYNGOLOGICAL SERV OR PROC CARDIOPULMONARY RESUSCITATION TEMPORARY TRANSCUTANEOUS PACING CARDIOVERSION ELECT ELEC CONVERSION ARRHY EXT CARDIOVERSION, ELECTIVE; INTERNAL (SEP PROC) CARDIOASSIST-METHD CIRCULATORY ASSIST; INT CARDIOASSIST-METHD CIRCULATORY ASSIST; EXT THROMBOLYSIS CORON; INTRACORON INFUS INCL ANGIO THROMBOLYSIS CORONARY; IV INFUSION INTRAVASC US (CORN/GFT) DUR THERAP-S/I&R-INITIAL INTRAVASC US (CORN/GFT) DUR THERAP-S/I&R-EA ADD TRNSCATH PLCMT INTRACORONRY STENT-PERC; SNGL VSL TRNSCATH PLCMT INCORONARY STENT-PERC; EA ADD VSL PERQ TRNSLUMNL CORON BALOON ANGIOPLSTY; 1 VESSEL PERQ TRNSLUMNL CORON BALOON ANGIOPLSTY; EA ADD PERCUT BALLOON VALVULOPLASTY; AORTIC VALVE PERCUT BALLOON VALVULOPLASTY; MITRAL VALV PERCUT BALLOON VALVULOPLASTY; PULM VALVE ATRIAL SEPTECT/SEPTOST; TRANSVEN METHD BALLOON ATRIAL SEPTECT/SEPTOST; BLADE METHD PERQ TRNSLUM CORON ATHEREC W/WO ANGIOPL; 1 VESSL PERQ TRNSLUM CORON ATHEREC W/WO ANGIOPL; EA ADD PUL ART BALLOON REPAIR, PERC PUL ART BALLOON REPAIR, PERC ECG-ROUTINE W/12 LEADS; W/INTERPT & REPORT ECG-ROUTINE ECG W/12 LEADS; TRACING ONLY ECG-ROUTINE W/12 LEADS; INTERPT & REPORT ONLY TELEPHONIC POST-SX ECG/30 DA; TRACING ONLY TELEPHONIC POST-SX ECG/30 DA; INTERPT & REPORT CV STRESS TEST W/TREADMILL-PHARM; INTRPT & REPRT CV STRESS TEST W/TREADMILL; PHY SUPERVS ONLY CV STRESS TEST W/TREADMILL; TRACING ONLY CV STRESS TEST W/TREADMILL; INTERPT & REPRT ONLY ERGONOVINE PROVOCATION TEST RHYTHM ECG 1-3 LEADS; W/INTERPT & REPORT RHYTHM ECG 1-3 LEADS; TRACING ONLY RHYTHM ECG 1-3 LEADS; INTERPT & REPORT ONLY ECG-24 HR W/SUPERIMPOSIT SCAN; REPRT-REVW-INTRPT

$83 $24 $37 $27 $40 $20 $114 $68 BR $329 $91 $274 $397 $304 $91 $1,000 $507 $719 $369 $2,428 $1,214 $2,160 $1,080 $2,069 $2,276 $1,704 $3,199 $2,242 $2,312 $1,156 $2,112 $809 $42 $25 $17 $73 $49 $244 $61 $122 $61 $227 $26
$9 $17 $270

N/A N/A N/A N/A N/A N/A N/A N/A N/A
0 0 0 0 0 0 0 N/A $502 N/A $246 N/A $2,428 0 $1,214 N/A $2,160 0 $1,080 N/A $2,069 90 $2,276 90 $1,704 90 90 90 $2,312 0 $1,156 N/A 0 N/A $17 N/A N/A $17 N/A N/A $49 N/A $122 N/A $61 N/A N/A $61 N/A $136 N/A $17 N/A N/A $17 N/A $108 N/A

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CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MAR PC/-26 FUD

93225 93226 93227 93230 93231 93232 93233 93235 93236 93237 93268 93270 93271 93272 93278 93303 93304 93307 93308 93312 93313 93314 93315 93316 93317 93320 93321 93325 93350 93501 93503 93505 93508 93510 93511 93514 93524 93526 93527 93528 93529 93530 93531 93532 93533 93536

ECG-24 HR W/SUPERIMPOSIT SCAN; RECORDING ECG-24 HR W/SUPERIMPOSIT SCAN; ANALY W/REPORT ECG-24 HR W/SUPERIMPOSIT SCAN; MD REVIEW & REPRT ECG-24 HR W/MINI PRINTOUT; REPORT-REVIEW-INTERPT ECG-24 HR W/MINI PRINTOUT; RECORDING ECG-24 HR W/PRINTOUT; MICROPROCESS ANALY W/REPRT ECG-24 HR W/PRINTOUT; PHYS REVIEW & INTERPT ECG-24HR COMPUTR MONITOR; W/ANALY-REPRT-REVW-INT ECG-24 HR COMPUTR; MONITOR & DATA ANALY W/REPORT ECG-24 HR COMPUTR MONITOR; PHYS REVIEW & INTERPT PT DEMAND RECORD/30 DA; W/TRNSMIS/MD REVW/INTERP PT DEMAND RECORD/30 DA; HOOK-UP/RECORD/DISCONNCT PT DEMAND RECORD/30 DA; MONIT/RECV TRNSMIS/ANALY PT DEMAND RECORD/30 DA; MD REVIEW & INTERP ONLY SIGNAL-AVERAGED ELECTROCARDIOGRAPHY W/WO ECG TRANSTHORACIC ECHO-CONGEN CARDIAC ANOM; COMPLT TRANSTHORACIC ECHO-CONGEN CARDIAC ANOM; F/U, LTD ECHO TRNSTHORAC REAL-TIME W/WO M-MODE; COMPLT ECHO TRNSTHORAC REAL-TIME W/WO M-MODE; F/U-LTD ECHO TRANSESOPH REAL-TIME; W/PROBE PLCMT & REPRT ECHO REAL-TIME TRANSESOPH; PLCMT PROBE ONLY ECHO TRANSESOPH; IMAGE ACQUISIT INTERPT & REPORT TRANSESOPH ECHO-CONGEN CARDIAC ANOM; TOTAL SERV TRANSESOPH ECHO-CONG CARD ANOM; PLCMT PROBE ONLY TRANSESOPH ECHO-CONG CARD ANOM; IMAGE ACQUIS-I&R DOPPLER ECHO CONT WAVE W/SPECTRAL DISPLY; COMPLT DOPPLER ECHO CONT WAVE W/SPECTRAL DISPLY; F/U DOPPLER COLOR FLOW VELOCITY MAPPING ECHO TRNSTHORAC DUR REST & STRESS W/INTERP & REP RT HEART CATH INSRT & PLCMT FLO DIREC CATH-MONITOR PURPOSES ENDOMYOCARDIAL BX CATH PLACEMENT, ANGIOGRAPHY LT HEART CATH RETROGRAD-BRACH/AX/FEM ART; PERCUT LT HRT CATH RETROGRAD-BRACH/AX/FEM ART; CUTDOWN LT HEART CATH BY LT VENTRICULAR PUNCT COMBO TRANSSEPTAL & RETROGRADE LT HEART CATH COMBO RT HEART CATH & RETROGRADE LT HEART CATH COMBO RT HRT & TRNSSEPTL LT HRT CATH THRU SEPTUM COMBO RT HEART CATH W/LT VENTRICULAR PUNCT COMBO RT HRT & LT HRT CATH THRU EXIST SEPTL OPEN RT HEART CATH, CONGENITAL R & L HEART CATH, CONGENITAL R & L HEART CATH, CONGENITAL R & L HEART CATH, CONGENITAL PERCUT INSRT INTRA-AORTIC BALLOON CATH

$65 $97 $108 $264 $63 $95 $106 $244 $147 $98 $236 $47 $95 $95 $138 $299 $167 $272 $152 $390 $97 $292 $429 $107 $321 $166 $100 $118 $484 $900 $195 $415 $629 $1,661 $1,661 $1,784 $2,035 $2,077 $2,136 $2,097 $1,901 $1,214 $3,035 $3,157 $2,762 $443

N/A N/A $108 N/A $106 N/A N/A N/A $106 N/A $98 N/A N/A $98 N/A $94 N/A N/A N/A $95 N/A $55 N/A $120 N/A $67 N/A $109 N/A $61 N/A $175 N/A $97 N/A $117 N/A $193 N/A $107 N/A $129 N/A $67 N/A $40 N/A $47 N/A $194 N/A $405 0
0 $228 0 $223 0 $747 0 $747 0 $803 0 $915 0 $934 0 $961 0 $944 0 $855 0 $389 0 $680 0 $850 0 $473 0
0

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SECTION X:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MAR PC/-26 FUD

93539 93540 93541 93542 93543 93544 93545 93555 93556 93561 93562 93571 93572 93600 93602 93603 93607 93609 93610 93612 93615 93616 93618 93619 93620 93621 93622 93623 93624 93631 93640 93641 93642 93650 93651 93652 93660 93720 93721 93722 93724 93727 93731 93732 93733 93734

INJ PROC DURING CARDIAC CATH; ART CONDUITS INJ PROC DURING CARDIAC CATH; AORTOCORON VEN GFT INJ PROC DURING CARDIAC CATH; PULM ANGIO INJ PROC-CARDIAC CATH; RT VENT/RT ARTIAL ANGIO INJ PROC-CARDIAC CATH; LT VENT/LT ATRIAL ANGIO INJ PROC DURING CARDIAC CATH; AORTOGRAPHY INJ PROC-CARDIAC CATH; SELECT CORONARY ANGIO IMAG SUPERVS I & R-CARD CATH; VENT/ATRIAL ANGIO IMAG SUPERVS I & R-CARD CATH; PULM ANGIOGRAPHY INDICATOR DILUT STUDIES; W/CARDIAC OUTPUT MEASUR INDICAT DILUT STUDY; SUBSQT MEASUR CARD OUTPUT HEART FLOW RESERVE MEASURE HEART FLOW RESERVE MEASURE BUNDLE HIS RECORDING INTRA-ATRIAL RECORDING RT VENTRICULAR RECORDING LT VENTRICULAR RECORDING INTRAVENT/-ATRIAL MAP TACHY SITE W/CATH MANIP INTRA-ATRIAL PACING INTRAVENTRICULAR PACING ESOPH RECORD ATRIAL ELECTROGM W/WO VENT ELECTROG ESOPH RECORD ATRIAL ELECTROGM; W/PACING INDUCTION ARRHY BY ELEC PACING COMP ELECTROPHYSIOLOGIC EVAL; WO INDUCTION ARRHY COMP ELECTROPHYSIOLOGIC EVAL; W/INDUCT ARRHY COMP ELECTROPHYSIOLOGIC EVAL; W/LT ATRIAL RECORD COMP ELECTROPHYSIOLOGIC EVAL; W/LT VENT RECORD PROGRAM STIM & PACING AFTER IV DRUG INFUSION ELECTROPHYSIOLOGIC F/U INCL INDUCT/ATTEMPT ARRHY INTRA-OP PACING & MAPPING-LOCALIZ SITE OF TACHY ELECTROPHYS EVAL LEADS @ TIME OF IMPLNT/REPLAC ELECTROPHYS EVAL LEADS @ IMPLNT; W/TEST GEN ELECTROPHYSIOLOGIC EVAL CARDIOVERTER-DEFIB INTRACARD CATH ABLAT-AV NODE FUNCT W/WO TEMP PAC INTRACARD CATH ABLAT ARRHY FOCUS; TX TACHYCARDIA INTRACARD CATH ABLAT ARRHY; TX VENT TACHY CARDIA EVAL CARDVASC FUNCT W/TILT TABLE W/ECG/BP MONITR PLETHYSMOGRAPHY TOT BODY; W/INTERPT & REPORT PLETHYSMOGRAPHY TOT BODY; TRACING ONLY PLETHYSMOGRAPHY TOT BODY; INTERPT & REPORT ONLY ELECT ANALY ANTITACHY PACEMAKER SYST ELECTRONIC ANALYSIS, IMPLANTABLE LOOP RECORDER (ILR) ELECT ANALY DUAL-CHAMBER INT PACMKR; W/PROGRAM ELECT ANALY DUAL-CHAMBER INT PACMKR; W/REPROGRAM ELECT ANALY DUAL-CHAMBER INT PACMKR; TELEPHONIC ELECT ANALY 1-CHMBR PACMKR SYST; WO REPROGRAM

$51 $57 $44 $44 $37 $37 $59 $282 $429 $97 $47 $339 $314 $395 $225 $255 $255 $887 $284 $333 $37 $163 $945 $1,540 $1,962 $2,232 $2,232 $506 $1,236 $1,375 $1,016 $1,252 $1,505 $2,421 $2,468 $2,468 $460 $111 $67 $45 $664 $49 $82 $87 $55 $70

$51 0 $57 0 $44 0 $44 0 $37 0 $37 0 $59 0 $42 N/A $64 N/A $39 0 $19 0 $125 N/A $101 N/A $217 0 $124 0 $140 0 $140 0 $488 0 $156 0 $183 0 $20 0 $90 0 $520 0 $847 0 $1,080 0 $1,228 0 $1,228 0 $279 N/A $680 0 $889 0 $521 0 $660 0 $785 0 $1,332 0 $1,358 0 $1,358 0 $212 0 $45 N/A
N/A $45 N/A $398 0
N/A $49 N/A $61 N/A $19 N/A $42 N/A

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CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MAR PC/-26 FUD

93735 93736 93737 93738 93740 93741 93742 93743 93744 93760 93762 93770 93784 93786 93788 93790 93797 93798 93799 93875 93880 93882 93886 93888 93922 93923 93924 93925 93926 93930 93931 93965 93970 93971 93975 93976 93978 93979 93980 93981 93990 94010 94014 94015 94016 94060

ELECT ANALY 1-CHMBR PACMKR SYST; W/REPROGRAM ELECT ANALY 1-CHMBR PACMKR SYST; TELEPHONIC ANAL ELECT ANALY CARDIOVERTER/DEFIB; WO REPROGRAM ELECT ANALY CARDIOVERTER/DEFIB; W/REPROGRAM TEMP GRADIENT STUDIES ELECTRONIC ANALYSIS, PACING CARDIO/DEFIB; ELECTRONIC ANALYSIS, PACING CARDIO/DEFIB; ELECTRONIC ANALYSIS, PACING CARDIO/DEFIB; ELECTRONIC ANALYSIS, PACING CARDIO/DEFIB; THERMOGRAM; CEPHALIC THERMOGRAM; PERIPHERAL DETERM VENOUS PRESS AMB BP MONITOR MIN 24 HR; RECORD-INTERPT-REPORT AMB BP MONITOR MIN 24 HR; RECORDING ONLY AMB BP MONITOR MIN 24 HR; SCANNING ANALY W/REPRT AMB BP MONITOR MIN 24 HR; REVW W/INTERPT & REPRT PHYS SERV-OUTPT CARDIAC REHAB; WO CONT ECG MONIT PHYS SERV-OUTPT CARDIAC REHAB; W/CONT ECG MONIT UNLISTED CARDIOVASCULAR SERV/PROC NONINVASIV PHYSIOLOG STDIES EXTRACRAN ART BILAT DUPLEX SCAN EXTRACRANIAL ART; COMPLT BILAT STUDY DUPLEX SCAN EXTRACRAN ART; UNILAT/LTD STUDY TRANSCRAN DOPPLER STDY INTRACRAN ART; COMPLT TRANSCRAN DOPPLER STDY INTRACRAN ART; LTD NONINVASIV PHYSIOLOG STDY-UP/LO EXTREM ART 1 LEV NONINVASIV PHYSIOL STDY-UP/LO EXTM ART MX LEVELS NONINVASIV PHYSIOL STDY-LO EXTM ART COMPLT BILAT DUPLEX SCAN LOWR EXTREM ART/BYPASS; COMPLT BILAT DUPLEX SCAN LOWR EXTREM ART/BYPASS; UNI/LTD STDY DUPLEX SCAN UPPR EXTREM ART/BYPASS; COMPLT BILAT DUPLEX SCAN UPPR EXTREM ART/BYPASS; UNI/LTD STDY NON-INVASIV PHYSIOLOG STDIES EXTREM VEINS BILAT DUPLEX SCAN-EXTREM VEINS; COMPLT BILAT STUDY DUPLEX SCAN-EXTREM VEINS; UNILAT/LTD STUDY DUPLEX SCAN IN-OUTFLO ABD/PELVIC ORGANS; COMPLT DUPLEX SCAN IN/OUT-FLOW ABD/PELVIC ORGANS; LTD DUPLEX SCAN AORTA/INFER VENA CAVA/GFTS; COMPLT DUPLEX SCAN AORTA/IVC/ILIAC/BYPASS GFTS; UNI/LTD DUPLEX SCAN IN-OUT FLO PENILE VESSELS; COMPLT DUPLEX SCAN IN-OUT FLO PENILE VESSELS; F/U-LTD DUPLEX SCAN HEMODIALYSIS ACCESS SPIROMETRY W/RECRD-TOT & TIMED VC-EXPIR FLO RATE PATIENT RECORDED SPIROMETRY PATIENT RECORDED SPIROMETRY REVIEW PATIENT SPIROMETRY BRONCHOSPSM EVAL: SPIROM PRE & POST BRONCHODILAT

$74 $46 $59 $74 $105 $136 $171 $155 $193 $141 $207 $16 $257 $39 $116 $103 $42 $54 BR $151 $287 $206 $317 $190 $182 $211 $199 $271 $162 $266 $138 $170 $260 $162 $231 $149 $246 $148 $220 $145 $135 $53 $39 $45 $24 $82

$51 N/A $18 N/A $35 N/A $51 N/A $79 N/A $66 N/A $74 N/A $85 N/A $97 N/A $28 N/A $41 N/A $14 N/A $103 N/A
N/A N/A $103 N/A $42 0 $54 0 N/A $60 N/A $115 N/A $82 N/A $127 N/A $76 N/A $73 N/A $84 N/A $80 N/A $108 N/A $65 N/A $106 N/A $55 N/A $68 N/A $104 N/A $65 N/A $92 N/A $60 N/A $98 N/A $59 N/A $88 N/A $58 N/A $54 N/A $21 N/A N/A N/A N/A $33 N/A

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CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MAR PC/-26 FUD

94070 94150 94200 94240 94250 94260 94350 94360 94370 94375 94400 94450 94620 94621 94640 94642 94650 94651 94652 94656 94657 94660 94662 94664 94665 94667 94668 94680 94681 94690 94720 94725 94750 94760 94761 94762 94770 94772 94799 95004 95010 95015 95024 95027 95028 95044

PROLONGED EVAL-BRONCHOSPASM W/MX SPIRO DETERM VITAL CAPACITY TOT (SEPART PROC) MAX BREATHING CAPACITY MAX VOLUNTARY VENTILATION FUNCT RESIDUAL CAPACITY/RESIDUAL VOLUM: MX METHD EXPIRED GAS COLLEC QUAN SNGL PROC (SEPART PROC) THORACIC GAS VOLUM DETERM MALDISTRIBUTION INSPIRED GAS: MX BREATH DETERM RESIST AIRFLO-OSCILLATORY/PLETHYSMOGRAPHY DETERM AIRWAY CLO VOLUM SNGL BREATH TESTS RESPIRATORY FLOW VOLUM LOOP BREATHING RESPONSE TO CO2 BREATHING RESPONSE TO HYPOXIA PULM STRESS TESTING SIMPL/COMPLX PULM STRESS TEST/COMPLEX NONPRESSURIZED INHALA TX ACUTE AIRWAY OBSTUC AEROSOL INHALA PENTAMIDINE PC PNEUMON TX/PROPHYL IPPB TX AIR/O2 W/WO NEBULIZ MED; INIT DEMO/EVAL IPPB TX AIR/O2 W/WO NEBULIZ MED; SUBSQT IPPB TX AIR/O2 W/WO NEBULIZ MED; NB INFANT VENTILATION ASSIST & MGMT; 1 ST DA VENTILATION ASSIST & MGMT; SUBSQT DA CONT POS AIRWAY PRESS VENTILATION INIT & MGMT CONT NEG PRESS VENTILATION INIT & MGMT AEROSOL/VAPOR INHALA; INIT DEMO &/ EVAL AEROSOL/VAPOR INHALA; SUBSQT MANIP CHEST WALL-FACIL LUNG FUNCT; 1ST DEMO/EVAL MANIP CHEST WALL-FACILIT LUNG FUNCT; SUBSQT O2 UPTAKE EXPIRED GAS; REST/EXERCISE DIREC SIMPL O2 UPTAKE EXPIRED GAS; W/CO2 OUTPUT % O2 EXTRACT O2 UPTAKE EXPIRED GAS; REST INDIREC (SEP PRO ) CARBON MONOXIDE DIFFUS CAPACITY ANY METHD MEMBRN DIFFUS CAPACITY PULM COMPLIANCE STUDY ANY METHD NONINVASIVE EAR/PULSE OXIMETRY-O2 SAT; 1 DETERM NONINVASIVE EAR/PULSE OXIMETRY O2 SAT; MX DETERM NONINVAS OXIMETRY-O2 SAT; OVERNITE (SEPART PROC) CO2 EXPIRED GAS DETERM-INFRARED ANALY CIRCADIAN RESP PATTRN RECRD 12-24 HR CONT-INFANT UNLISTED PULM SERV/PROC PERQ W/ALLERG EXTRACT-IMMED REACT-SPEC # TEST PERQ SEQUENT & INCREMEN-IMMED REACT-SPEC # TESTS INTRACUT SEQUENT/INCREM-IMMED REACT-SPEC # TESTS INTRACUT W/ALLERG EXTRCT-IMMED REACT-SPEC # TEST SKIN END POINT TITRATION INTRACUT W/ALLERG EXTRACT-DELAYED REACT-# TESTS PATCH/APPLIC TEST(S)

$168 $17 $41 $64 $16 $59 $60 $61 $57 $63
$126 $101 $226 $107
$22 $98 $23 $19 $35 $160 $85 $121 $79 $26 $21 $32 $25 $84 $158 $32 $68 $121 $97 $22 $37 $46 $63 BR BR
$4 $6 $10 $6 $57 $11 $14

$67 N/A $7 N/A $8 N/A
$13 N/A $3 N/A
$12 N/A $12 N/A $12 N/A $11 N/A $13 N/A $25 N/A $20 N/A $45 N/A $98 N/A
$7 N/A N/A
$8 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A
$34 N/A $63 N/A $13 N/A $27 N/A $48 N/A $39 N/A
N/A N/A N/A $25 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A

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SECTION X:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MAR PC/-26 FUD

95052 95056 95060 95065 95070 95071 95075 95078 95115 95117 95120 95125 95130 95131 95132 95133 95134 95144 95145 95146 95147 95148 95149 95165 95170 95180 95199 95805 95806 95807 95808 95810 95811 95812 95813 95816 95819 95822 95824 95827 95829 95830 95831 95832 95833 95834

PHOTO PATCH TEST(S) PHOTO TESTS OPHTH MUCOS MEMBRN TESTS DIRECT NASAL MUCOS MEMBRN TEST INHALA BRONCHIAL CHALLENGE; W/HISTAMINE-COMPOUND INHALA BRONCHIAL CHALLENGE; W/ANTIG-GASES SPEC INGESTION CHALLENGE TEST PROVOCATIVE TESTING PROF SERV ALLERG IMMUNOTX NOT INCL EXTRCT; 1 INJ PROF SERV ALLERG IMMUNOTX WO EXTRACT; 2/MORE INJ PROF SERV ALLERG IMMUNOTX INCL EXTRACT; 1 INJ PROF SERV ALLERG IMMUNOTX INCL EXTRACT; 2/> INJ PROF ALLERG IMMUNOTX INCL EXTRACT; 1 INSECT VENM PROF ALLERG IMMUNOTX INCL EXTRACT; 2 INSECT VENM PROF ALLERG IMMUNOTX INCL EXTRACT; 3 INSECT VENM PROF ALLERG IMMUNOTX INCL EXTRACT; 4 INSECT VENM PROF ALLERG IMMUNOTX INCL EXTRACT; 5 INSECT VENM PRO SERV SUPERVS/PROVS-IMMUNOTX; 1/MX ANTIG-1 VL PRO SERV SUPERVS/PROVIS-IMMUNOTX; 1 VENOM PRO SERV-SUPERVS/PROVIS-IMMUNOTX; 2 VENOMS PRO SERV-SUPERVS/PROVIS-IMMUNOTX; 3 VENOMS PRO SERV-SUPERVS/PROVIS-IMMUNOTX; 4 VENOMS PRO SERV-SUPERVS/PROVIS-IMMUNOTX; 5 VENOMS PRO SERV-SUPERVS/PROVIS-IMMUNOTX; 1/MX ANTIG PRO-IMMUNOTX; WHOLE BODY EXTRACT BITING INSECT RAPID DESENZT PROC EA HR UNLISTED ALLERG/CLINICAL IMMUNOLOGIC SERV/PROC MX SLEEP LATENCY TEST DURING MX NAP OPPORTUNITY SLEEP STUDY, UNATTENDED SLEEP STDY 3/MORE PARAMETERS-SLEEP ATTEND TECHNO POLYSOMNOGRAPHY; SLEEP STAGING W/1-3 ADD PARAMET POLYSOMNOGRAPHY; W/4-MORE ADD PARAMETERS POLYSOMNOGRAPHY W/CPAP EEG EXTEND MONITOR; UP TO 1 HR EEG EXTEND MONITOR; >1 HR EEG INCL AWAKE & DROWSY W/HYPERVENT/PHOTIC STIMU EEG INCL AWAKE & ASLEEP W/HYPERVENT/PHOTIC STIMU EEG; SLEEP ONLY EEG; CEREBRAL DEATH EVAL ONLY EEG; ALL NIGHT SLEEP ONLY ELECTROCORTICOGRAM AT SURG (SEPART PROC) INSRT-PHYS SPHENOIDAL ELECTRODES-EEG MUSCL TEST MANUAL (SEPART PROC); EXTREM/TRUNK MUSCL TEST MANUAL (SEPART PROC); HAND MUSCL TEST MANUAL (SEPART); TOT BODY-EXCL HANDS MUSCL TEST MANUAL (SEPART); TOT BODY-INCL HANDS

$19 $5
$22 $18 $146 $146 $115 $58
$7 $10
$9 $11 $16 $20 $24 $29 $35 $26 $20 $24 $29 $34 $40
$9 BR $96 BR $365 $1,171 $516 $561 $602 $1,048 $35 $415 $213 $180 $164 $139 $205 $334 $119 $34 $35 $82 $90

N/A N/A N/A N/A N/A N/A N/A N/A
0 0 N/A N/A N/A N/A N/A N/A N/A 0 0 0 0 0 0 0 0 0 0 $146 N/A $502 N/A $206 N/A $225 N/A $241 N/A $524 N/A $14 N/A $197 N/A $70 N/A $71 N/A $66 N/A $56 N/A $82 N/A $334 N/A $119 N/A N/A N/A N/A N/A

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SECTION X:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MAR PC/-26 FUD

95851 95852 95857 95858 95860 95861 95863 95864 95867 95868 95869 95870 95872 95875 95900 95903 95904 95920 95921 95922 95923 95925 95926 95927 95930 95933 95934 95936 95937 95950 95951 95953 95954 95955 95956 95957 95958 95961 95962 95970 95971 95972 95973 95974 95975 95999

ROM MEASUR-REPORT (SEPART); EA EXTREM/TRUNK SECT ROM MEASUR-REPORT (SEP); HAND W/WO COMPAR W/NORM TENSILON TEST MYASTHENIA GRAVIS TENSILON TEST-MYASTHENIA GRAVIS; W/EMG NEEDLE EMG; 1 EXTREM & RELATED PARASPINAL AREAS NEEDLE EMG; 2 EXTREM & RELATED PARASPINAL AREAS NEEDLE EMG; 3 EXTREM & RELATED PARASPINAL AREAS NEEDLE EMG; 4 EXTREM & RELATED PARASPINAL AREAS NEEDLE EMG CRANIAL NERV SUPPLIED MUSCL; UNILAT NEEDLE EMG CRANIAL NERV SUPPLIED MUSCL; BILAT NEEDLE EMG LTD STUDY SPEC MUSCL MUSCLE TEST, NON-PARASPINAL NEEDLE EMG W/QUAN MEAS-ANY/ALL SITES EA MUS STDY ISCHEMIC LIMB EXER W/NEEDLE EMG W/LACTIC ACID NERV CONDUC STUDY EA NERV; MOTOR WO F-WAVE STUDY NERV CONDUC STUDY EA NERV; MOTOR W/F-WAVE STUDY NERV CONDUC STUDY EA NERV-ANY/ALL SITES; SENSORY INTRAOPERATIVE NEUROPHYSIOLOGY TESTING PER HOUR AUTONOM NERV SYST FUNCT TEST; CARDIOVAGAL INNERV AUTONOM NERV SYST FUNCT TEST; VASOMOTOR INNERVAT AUTONOM NERV SYST FUNCT TEST; SUDOMOTOR SOMATOSENSORY TESTING 1/MORE NERV; UPPER LIMBS SOMATOSENSORY TESTING 1/MORE NERV; LOWER LIMBS SOMATOSENSORY TESTING 1/MORE NERV; TRUNK/HEAD VEP TESTING CNS-CHECKERBOARD/FLASH ORBICULARIS OCULI REFLEX BY ELEC-DX TESTING H-REFLEX AMP & LATENCY STUDY; GASTROCNEM/SOLEUS H-REFLEX & LATENCY STUDY; NOT GASTROCNEM/SOLEUS NEUROMUSCULAR JUNCTION TEST EA NERV ANY 1 METHD MONITOR-ID/LATERALIZA-CEREBRAL SEIZ-EEG EA 24 HR MONITOR CEREBRAL SEIZ-CABLE/RADIO-EEG-EA 24 HR MONITOR CEREBRAL SEIZ FOCUS-PORT EEG; EA 24 HR PHARM/PHYS ACTIVAT-MD ATTEND-EEG RECRD ACTIV PHS EEG DURING NONINTRACRANIAL SURG MONIT CEREB SEIZ FOCUS-TELEMETRY EEG EA 24 HR DIGITAL ANALY EEG WADA ACTIVAT TEST HEMISPHERIC FUNCT INCL EEG FUNCT CORTICAL MAPPING; INIT HR-MD ATTENDANCE FUNCT CORTICAL MAPPING; EA ADD HR-MD ATTENDANCE NEUROSTIM ANALYZE,NO PROGRAM SIMPLE NEUROSTIM ANALYZE COMPLEX NEUROSTIM ANALYZE COMPLEX NEUROSTIM ANALYZE COMPLEX CRANIAL NEUROSTIM COMPLEX CRANIAL NEUROSTIM UNLISTED NEUROLOGICAL/NEUROMUSCULAR DX PROC

$33 $33 $67 $193 $134 $174 $226 $294 $139 $242 $103 $69 $237 $47 $77 $120 $75 $250 $104 $113 $104 $217 $217 $217 $103 $87 $86 $86 $81 $411 $528 $475 $103 $185 $475 $232 $293 $322 $205 $28 $45 $88 $55 $154 $92 BR

N/A N/A N/A $154 N/A $107 N/A $139 N/A $181 N/A $235 N/A $111 N/A $194 N/A $82 N/A $49 N/A $190 N/A $33 N/A $60 N/A $96 N/A $59 N/A $250 N/A $71 N/A $76 N/A $71 N/A $174 N/A $174 N/A $174 N/A $51 N/A $70 N/A $69 N/A $69 N/A $65 N/A $165 N/A $211 N/A $190 N/A $103 N/A $185 N/A $190 N/A $102 N/A $234 N/A $322 N/A $205 N/A N/A N/A N/A N/A N/A N/A N/A

Section X: General Medicine Services

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STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION X:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MAR PC/-26 FUD

96100 96105 96110 96111 96115 96117 96400 96405 96406 96408 96410 96412 96414 96420 96422 96423 96425 96440 96445 96450 96520 96530 96542 96545 96549 96570 96571 96900 96902 96910 96912 96913 96999 97532 97533 99000 99001 99002 99024 99025 99050 99052 99054 99056 99058 99070

PSYCH TESTING W/I&R PER HR ASSESS APHASIA W/I&R PER HR DEVELOPMENTAL TESTING; LTD W/I&R DEVELOPMENTAL TESTING; EXTEN W/I&R NEUROBEHAVIORAL STATUS EXAM W/I&R PER HR NEUROPSYCH TESTING BATTERY W/I&R PER HR CHEMOTX ADMIN SUBCUT/IM W/WO LOCAL ANES CHEMOTX ADMIN INTRALES; TO & INCL 7 LES CHEMOTX ADMIN INTRALES; > 7 LES CHEMOTX ADMIN IV; PUSH TECH CHEMOTX ADMIN IV; INFUSION TECH UP-1 HR CHEMOTX ADMIN IV; INFUSION TECH 1-8 HR EA ADD HR CHEMOTX ADMIN IV; INFUSION TECH-PROLONGED W/PUMP CHEMOTX ADMIN INTRA-ART; PUSH TECH CHEMOTX ADMIN INTRA-ART; INFUSION TECH TO 1 HR CHEMOTX INTRA-ART; INFUS TECH 1-8 HR EA ADD HR CHEMOTX INTRA-ART; INFUSION-INIT PROLONG W/PUMP CHEMOTX-PLEURAL CAVITY-REQ & INCL THORACENTESIS CHEMOTX-PERITONEAL CAVIT-REQ & W/PERITONEOCENTES CHEMOTX-CNS-REQ & INCL LUMBAR PUNCT REFILLING & MAINTENANCE PORTABLE PUMP REFILLING & MAINTENANCE IMPLNT PUMP/RESERVOIR CHEMOTX INJ SUBARACH/INTRAVENTRIC-1/MX AGENTS PROVISION CHEMOTX AGENT UNLISTED CHEMOTX PROC ENDOSCOPIC PHOTODYNAMIC THERAPY; 1ST 30 MIN ENDOSCOPIC PHOTODYNAMIC THERAPY; EACH ADD'L 15 MIN ACTINOTHERAPY TRICHOGRAM PHOTOCHEMOTX; TAR & UV B/PETROLATUM & UV B PHOTOCHEMOTHERAPY; PSORALENS & ULTRAVIOLET A PHOTOCHEMOTX REQ 4-8 HRS CARE W/SUPERVS BY PHYS UNLISTED SPECIAL DERM SERV/PROC DEVELOPMT COGNITIVE SKILLS 1-ON-1 EA 15 MIN SENSORY INTEGRAT TECHNIQUE 1-ON-1 EA 15 MIN HANDL &/OR CONVEY SPECMN-TRANSF OFFIC TO LAB HANDL &/OR CONVEY SPECMN-TRANSF FROM PT TO LAB HANDL/CONVEY/OTHER SERV INVOLV DEVICES POSTOP F/U VISIT INCLD GLOBAL SERV INIT VISIT WHEN (*) SURG PROC = MAJ SERV @ VISIT SERV REQUEST AFTR OFFIC HRS ADD TO BASIC SERV SERV REQUEST BETWEEN 10 PM & 8 AM ADD TO BASIC SERV REQUESTED SUN & HOLIDAYS ADD BASIC SERV SERV PROVID @ REQ OF PT @ LOCATION NOT IN OFFIC OFFIC SERV PROVID-EMER BASIS SUPPL/MAT PROVID-PHYS NOT INCL W/VISIT/OTHR SERV

$130

N/A

$167

N/A

$93

N/A

$142

N/A

$134

N/A

$128

N/A

$30

N/A

$48

0

$72

0

$53

N/A

$80

N/A

$67

N/A

$93

N/A

$67

N/A

$98

N/A

$77

N/A

$118

N/A

$174

0

$174

0

$154

0

$45

N/A

$45

N/A

$109

N/A

$39

N/A

BR

N/A

$112

0

$61

0

$22

N/A

$28

N/A

$25

N/A

$29

N/A

BR

N/A

BR

N/A

$30

N/A

$30

N/A

$8

N/A

$9

N/A

$13

N/A

BR

N/A

$35

N/A

$23

N/A

$23

N/A

$23

N/A

$31

N/A

$32

N/A

BR

N/A

Section X: General Medicine Services

Page 216

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION X:
CPT DESCRIPTION

MAXIMUM ALLOWABLE REIMBURSEMENT
MAR PC/-26 FUD

99071 99075 99080 99082 99090 99116 99135 99140 99141 99142 99173 99175 99183 99185 99186 99190 99191 99192 99195 99199

EDUCAT SUPPL PROVID-PHYS @ COST TO PHYS MEDICAL TESTIMONY 1ST HR./ EACH ADD./PARTS THEROF $100 SPEC REPORTS > INFO IN USUAL MED COMMUNICAT/FORM UNUSUAL TRAVEL ANALYS INFORM DATA STORED-COMPUTERS ANES COMPLIC BY UTILIZ TOT BODY HYPOTHERMIA ANES COMPLIC BY UTILIZ CONTRL HYPOTENSION ANES COMPLIC BY EMER CONDITIONS SEDATION, IV/IM OR INHALANT SEDATION, ORAL/RECTAL/NASAL SCREENING, VISUAL ACUITY, QUANTITATIVE, BILAT IPECAC/SIMILR ADMIN FOR EMESIS & CONT OBSRV PHYS ATTEND & SUPERVS HYPERBARIC O2 THERAP/SESSN HYPOTHERMIA; REGIONAL HYPOTHERMIA; TOT BODY ASSEMBLY & OPERAT-PUMP W/OXYGENATR/EXCHGR; EA HR ASSEMBLY & OPERAT-PUMP W/OXYGENATR/EXCHGR; 3/4HR ASSEMBLY &/OR PUMP W/OXYGENATOR/HEAT EXCHG PHLEBOTOMY THERAP (SEPART PROC) UNLISTED SPECIAL SERV/REPORT

BR $300
$60 BR $142 $32 X 5 $32 X 5 $32 X 2 $84 $65 BR $45 $262 $31 $149 $727 $545 $364 $48 BR

N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $262 N/A $12 N/A $59 N/A N/A N/A N/A N/A N/A

Section X: General Medicine Services

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STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE
SECTION XI: PHYSICAL MEDICINE SERVICES

SUBSECTION A: PAYMENT GROUND RULES FOR PHYSICAL MEDICINE SERVICES
General Guidelines
Protocols used by physicians in reporting their services are generally described below. Some of the commonalties with other subsections may be repeated here. If no appropriate code is found for medical services performed by a medical provider, use the appropriate unlisted code (e.g., 99199), and adequately describe the service provided. Chiropractic and physical therapy service reimbursements are explained in this section.
Supplies and materials provided by the medical provider (e.g., sterile trays, etc.), over and above that usually provided during an office visit, or other services rendered, may be charged for separately and coded separately. A physician office visit code may be charged in addition to the code for modalities/procedures only if the accompanying documentation clearly indicates that the physician or medical provider actually examined the worker during the office visit.
Initial Evaluation and Re-evaluation by Physical Therapists or Occupational Therapists
CPT code 97001 physical therapy evaluation is a one time only charge. If the patient changes treatment facilities, another one time only evaluation may be charged. CPT code 97002 physical therapy re-evaluation may be charged if the existing patient suffers a reoccurrence of the same medical condition at least one month after the date of the last visit for therapy or existing patient sustains an additional injury and requires additional physical therapy.
CPT code 97003 occupational therapy evaluation is a one time only charge. If the patient changes treatment facilities, a one time only evaluation may be charged. CPT code 97004 occupational therapy re-evaluation may be charged if the existing patient suffers a reoccurrence of the same medical condition at least one month after the date of the last visit for therapy or existing patient sustains an additional injury and requires additional occupational therapy.
Exam Visits to Occupational Therapists or Physical Therapists
Services performed by a physical therapist and/or occupational therapist shall be under the prescription of the authorized treating physician detailing the type, frequency, and duration of therapy to be provided. Only physical therapists and/or occupational therapists procedures and services are billable and there will be no reimbursement for office visits.
Multiple Concurrent Physical Medicine Procedures and Modalities
Multiple concurrent physician medicine procedures are subject to the following rules and limitations.

Section XI: Physical Medicine Services

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STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE
SECTION XI: PHYSICAL MEDICINE SERVICES
SUBSECTION A: PAYMENT GROUND RULES FOR PHYSICAL MEDICINE SERVICES
No more than four physical medicine procedures, modalities or times units will be reimbursed in one visit. No more than two of the four CPT code charges can be modality codes (CPT codes 97010-97039). The only exceptions to this are: 1) if injured employee is diagnosed as "catastrophic"; 2) CPT codes 97545 and 97750; 3) fitting and training for custom-made orthotics/prosthetics; and 4) by mutual agreement of all parties.
Code 97010 covers the application of one or more hot or cold packs. This code should not be used to bill the application of each individual pack.
Manipulation Codes
Special codes are designated for use by chiropractors and osteopaths to bill for manipulation services. The chiropractic manipulative treatment codes include a pre-manipulation patient assessment. Additional evaluation and management (E/M) services may be reported separately using the modifier 25, if the injured employee's condition requires a significant, separately identifiable E/M service, which is above and beyond the usual pre-service and post-service work association with the procedure.
Licensed osteopaths may bill utilizing CPT codes 98925-98929. Licensed chiropractors may bill utilizing CPT codes 98940-98943.
Tests and Measurements
Test and measurement codes are included in the value of an evaluation and management service when performed on the same day as test and measurement services (97703-97750). Osteopaths should not bill range of motion or muscle strength testing under the 95800 series codes.
Fabrication of Orthotics
Orthotics must be billed for professional fitting and supplies separately. Procedure code 97504 must be used for a medical provider or therapist to fabricate orthotics. Custom-made orthotics and prosthetics are exempt from the medical supplies reimbursement formula; however, usual, customary and reasonable charges will apply and/or by agreement of the parties. Additional medical supplies may not exceed medical supplies reimbursement formula. Medical supplies shall be reported using CPT code 99070.

Section XI: Physical Medicine Services

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STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE
SECTION XI: PHYSICAL MEDICINE SERVICES
SUBSECTION A: PAYMENT GROUND RULES FOR PHYSICAL MEDICINE SERVICES
Tens Units
Tens units (transcutaneous electrical nerve stimulation) must be prescribed by the authorized treating physician. Rental equipment is subject to usual, customary and reasonable charges or by agreement. Rental equipment is exempt from the reimbursement formula. The purchase of such units will be subject to durable/medical supplies reimbursement formula utilizing CPT code 99070.

Section XI: Physical Medicine Services

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STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE
SECTION XI: PHYSICAL MEDICINE SERVICES
SUBSECTION B: PAYMENT MODIFIERS FOR PHYSICAL MEDICINE SERVICES A modifier indicates a service or procedure performed has been altered by some specific circumstance but has not changed its definition or code. The modifying circumstance shall be identified by use of a hyphen and the appropriate modifier following the procedure code. When two modifiers are applicable to a single code, indicate each modifier, preceded by a hyphen, on the bill. The modifier may also be reported by using a separate five-digit code in addition to the procedure code. If more than one modifier is used, place the "multiple modifiers" code -99 immediately after the procedure code. This indicates that one or more additional modifier codes will follow. Only certain modifiers in each of the categories (anesthesia, surgery, pathology/laboratory, radiology, general medicine, and physical medicine) will be recognized for reimbursement purposes.
The modifiers listed below may differ from those published by the American Medical Association. Medical providers submitting workers' compensation billing shall use only the modifiers set out in the fee schedule.
The following modifiers will be recognized for reimbursement by the fee schedule for physical medicine services codes:
-21 Prolonged Evaluation and Management Services: When the face-to-face or floor/unit service(s) provided is prolonged or otherwise greater than that usually required for the highest level of E/M service within a given category, it may be identified by adding modifier (-21) to the E/M code number or using the separate five digit modifier code 09921. A report may also be appropriate.
-22 Unusual Procedural Services: When the service(s) provided is greater than that usually required for the listed procedure, it may be identified by adding modifier (-22) to the usual procedure number or using the separate five digit modifier code 09922. A report may also be appropriate.
-24 Unrelated Evaluation and Management Service by the Same Physician during a Postoperative Period: The medical provider may need to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure. This circumstance may be reported by adding the modifier (-24) to the appropriate level of E/M service or using the separate five-digit modifier 09924.
-25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of a Procedure or Other Service: The physician may need to indicate that on the day a procedure or service identified by a CPT code was performed, the patient's condition required a significant, separately identifiable
-26

Section XI: Physical Medicine Services

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STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE
SECTION XI: PHYSICAL MEDICINE SERVICES
SUBSECTION B: PAYMENT MODIFIERS FOR PHYSICAL MEDICINE SERVICES E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. This circumstance may be reported by adding the modifier (-25) to the appropriate level of E/M service or the separate five-digit modifier 09925.
-26 Professional Component Only: Certain procedures are a combination of a physician component and a technical component. When the physician component is reported separately, the service may be identified by adding the modifier (-26) to the usual procedure number or the service may be reported by use of the five-digit modifier code 09926.
-27 Technical Component Only: Certain procedures are a combination of a physician component and a technical component. When the technical component is reported separately, the service may be identified by adding the modifier (-27) to the usual procedure number or the service may be reported by use of the five-digit modifier code 09927.
-52 Reduced Services: Under certain circumstances, a service or procedure is partially reduced or eliminated at the physician's election. Under these circumstances, the service provided can be identified by its usual procedure number and the addition of the modifier (-52) signifying that the service is reduced. This provides a means of reporting reduced services without disturbing the identification of the basic service. Modifier code 09952 may be used as an alternative to modifier (-52).
-53 Discontinued Procedure: Under certain circumstances, the physician may elect to end a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. This circumstance may be reported by adding the modifier (-53) to the code for the discontinued procedure or by using the separate five-digit modifier 09953. Note: This modifier is not used to report the elective cancellation of a procedure before the patient's anesthesia induction and/or surgical preparation in the operating suite.
-59 Distinct Procedural Service: Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier (-59) is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician. However, when another already established modifier is appropriate it should be used rather than modifier (-59). Only if no more descriptive modifier is available, and the use of modifier (-59) best explains the circumstances, should modifier (-59) be used. Modifier code 09959 may be used as an alternative to modifier (-59).

Section XI: Physical Medicine Services

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STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE
SECTION XI: PHYSICAL MEDICINE SERVICES
SUBSECTION B: PAYMENT MODIFIERS FOR PHYSICAL MEDICINE SERVICES
-99 Multiple Modifiers: Under certain circumstances, two or more modifiers may be necessary to completely delineate a service. In such situations modifier (-99) should be added to the basic procedure, and other applicable modifiers may be listed as part of the description of the service. Modifier code 09999 may be used as an alternative to modifier (-99).

Section XI: Physical Medicine Services

Page 223

STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION XI: MAXIMUM ALLOWABLE REIMBURSEMENT

CPT DESCRIPTION

MAR PC/-26 FUD

97001 97002 97003 97004 97010 97012 97014 97016 97018 97020 97022 97024 97026 97028 97032 97033 97034 97035 97036 97039 97110 97112 97113 97116 97124 97139 97140 97150 97504 97520 97530 97532 97533 97535 97537 97542 97545 97546 97703 97750 97780 97781 97799 98925 98926

PT EVALUATION PT RE-EVALUATION OT EVALUATION OT RE-EVALUATION APPLIC MODAL 1/> AREAS; HOT/COLD PACKS APPLIC MODAL 1/> AREAS; TRACTION-MECH APPLIC MODAL 1/> AREAS; ELEC STIM APPLIC MODAL 1/> AREAS; VASOPNEUMATIC DEVICES APPLIC MODAL 1/> AREAS; PARAFFIN BATH APPLIC MODAL 1/> AREAS; MICROWAVE APPLIC MODAL 1/> AREAS; WHIRLPOOL APPLIC MODAL 1/> AREAS; DIATHERMY APPLIC MODAL 1/> AREAS; INFRARED APPLIC MODAL 1/> AREAS; ULTRAVIOLET APPLIC MODAL 1/> AREAS; ELEC STIM EA 15 MIN APPLIC MODAL 1/> AREAS; IONTOPHORESIS EA 15 MIN APPLIC MODAL 1/> AREAS; CONTRAST BATHS EA 15 MIN APPLIC MODAL 1/> AREAS; ULTRASOUND EA 15 MIN APPLIC MODAL 1/> AREAS; HUBBARD TANK EA 15 MIN UNLIST MODAL (SPECIFY TYPE/TIME-CONSTANT ATTEND) THERAP PROC 1/> AREAS EA 15 MIN; EXERCISES THERAP PROC 1/> AREAS EA 15 MIN; BALANCE/COORDIN THERAP PROC 1/> AREAS EA 15 MIN; AQUATIC THERAP THERAP PROC 1/> AREAS EA 15 MIN; GAIT TRAINING THERAP PROC 1/> AREAS EA 15 MIN; MASSAGE THERAP PROC 1/> AREAS EA 15 MIN; UNLISTED MANUAL THERAPY THERAP PROC(S)-GROUP ORTHOTICS FIT & TRAIN-UP &/LOW EXTREMS-EA 15 MIN PROSTH TRAIN-UP &/LOW EXTREM EA 15 MIN THERAP ACTIVITIES DIRECT PT CONTACT EA 15 MIN DEVELOPMT COGNITIVE SKILLS 1-ON-1 EA 15 MIN SENSORY INTEGRATION TECHNIQUES 1-ON-1 EA 15 MIN SELF CARE/HOME MGMT TRAIN-1 ON 1-EA 15 MIN COMMUNITY/WORK REINTEGRAT TRAIN-1 ON 1-EA 15 MIN WHEELCHAIR MGMT/PROPULSION TRAIN-EA 15 MIN WORK HARDENING/CONDITIONING; INIT 2 HR WORK HARDENING/CONDITIONING; EA ADD HR CHECKOUT ORTHO/PROSTH USE-ESTAB PT-EA 15 MIN PHYS PERFORMANCETEST/MEASUR W/REPT EA 15 MIN (MAX600) ACUPUNCTURE W/O STIM ACUPUNCTURE W/STIM UNLISTED PHYS MEDS/REHAB SERV/PROC OSTEOPATHIC MANIP TX; 1-2 BODY REGIONS INVOLVED OSTEOPATHIC MANIP TX; 3-4 BODY REGIONS INVOLVED

$80

N/A

$54

N/A

$80

N/A

$54

N/A

$7

N/A

$16

N/A

$12

N/A

$20

N/A

$16

N/A

$16

N/A

$25

N/A

$16

N/A

$5

N/A

$5

N/A

$20

N/A

$30

N/A

$14

N/A

$15

N/A

$40

N/A

BR

N/A

$30

N/A

$26

N/A

$40

N/A

$24

N/A

$18

N/A

BR

N/A

$24

N/A

$18

N/A

$30

N/A

$30

N/A

$35

N/A

$30

N/A

$30

N/A

$22

N/A

$22

N/A

$15

N/A

$100

N/A

$37

N/A

$22

N/A

$37

N/A

$6

N/A

$11

N/A

BR

N/A

$32

0

$42

0

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SECTION XI: MAXIMUM ALLOWABLE REIMBURSEMENT

CPT DESCRIPTION

MAR PC/-26 FUD

98927 98928 98929 98940 98941 98942 98943

OSTEOPATHIC MANIP TX; 5-6 BODY REGIONS INVOLVED OSTEOPATHIC MANIP TX; 7-8 BODY REGIONS INVOLVED OSTEOPATHIC MANIP TX; 9-10 BODY REGIONS INVOLVED CHIROPRACTIC MANIP TX; SPINAL 1-2 REGIONS CHIROPRACTIC MANIP TX; SPINAL 3-4 REGIONS CHIROPRACTIC MANIP TX; SPINAL 5 REGIONS CHIROPRACTIC MANIP TX; EXTRASPINAL 1/> REGIONS

$49

0

$54

0

$56

0

$32

0

$42

0

$49

0

$30

N/A

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SECTION XII: HOME CARE SERVICES
When home care is medically necessary for employees injured on the job, the authorized treating physician will set requirements for the level of care to be utilized. The maximum allowable rate for specific providers is as follows:
Registered Nurse (RN) $42.70 per hour weekday $50.02 per hour weekend day
Licensed Practical Nurse (LPN) $31.72 per hour weekday $36.60 per hour weekend day
Certified Nurse Assistant/Personal Care Attendant (CAN/PCA) $21.00 per hour weekday $24.00 per hour weekend day
Family Members $8.50 per hour with a maximum of 12 hours per day.
When care is provided for less than four hours, allowed rate will be $110.00 per visit Registered Nurse; $90.00 per visit Licensed Practical Nurse and $56.00 per visit Certified Nurse Assistant or Personal Care Attendant. If more than four hours of care is provided, hourly rates, based upon the above licensure, will apply. Domestic services (i.e. lawn mowing services, home cleaning, etc.) are not included in this payment system.
Physical Therapist, Occupational Therapist and Speech Therapist are reimbursed according to the fee schedule for CPT codes provided plus $30.00 per visit.

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SECTION XIII: INPATIENT HOSPITAL PAYMENT SCHEDULE
BASE PAYMENT
All inpatient hospital charges for payment under the Workers' Compensation Hospital Payment Schedule, excluding payments for Outlier Diagnostic Related Groups, shall not exceed the lower of:
(a) provider billed charges; or (b) the average per case amount calculated for each DRG.
IMPLANTABLES
Generally, durable medical equipment and supplies provided or administered in a hospital setting are not separately reimbursed since they are included in the payment rate. However, surgical implantables (e.g. rods, pins, screws, plates, and comparable items) that are medically necessary are excepted from this rule. Accordingly, additional reimbursement is allowed for medically necessary implantables. Reimbursement for the implantables shall be at cost to the hospital or ambulatory surgery center if the vendor invoice is provided to payor. Tax, handling, and charges for freight are included in the hospital's cost and shall not be reimbursed separately.
PAYMENT FOR OUTLIER DRGS
Definition of Outlier: A case falling outside the number of days allowed for stay in the hospital for a given DRG.
A bill listing a DRG with an additional outlier payment shall be calculated according to the following formula:
1. Per diem Divide the total amount of billed charges by the number of days covered by the bill.
2. Outlier Days Subtract the outlier length of stay threshold for that DRG from the actual length of stay (in days) covered by the bill.
3. Outlier Charges Multiply the number of outlier days from step 2 times the per diem for the bill from step 1.
4. Outlier Payment Multiply the outlier charges from step 3 by 40%. Add the 40% to the DRG average. Pay that amount.
Catastrophic burns that are defined in OCGA 34-9-200.1(4) as "second or third degree burns over 25 percent of the body as a whole or third degree burns to 5 percent or more of the face or hands" will be exempt from the DRG Hospital Payment schedule; however, usual, customary, and reasonable charges apply.

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SECTION XIII: INPATIENT HOSPITAL PAYMENT SCHEDULE
DRG burn codes 506 through 511 are suspended effective May 30th, 2001. Rates of reimbursement shall be negotiated with the payor in advance unless hospitalization is urgent care or emergency and, in that event, concurrent authorization shall be negotiated. When hospital charges for these codes are disputed as not being usual, customary, and reasonable, prior to an audit of the charges and within 30 days of receipt of all necessary documentation, the charges will be paid at 76.6% of the hospital charges, unless a lesser amount can be documented. Any health care provider whose fee is reduced and disputes that fee, or any employer/insurer who has made payment but disputes the charges may request a mediation conference at the Board.
The following freestanding rehabilitation and long-term acute care hospitals are exempt from the DRG Hospital Payment Schedule; however, usual, customary, and reasonable charges will apply to these facilities:
Shepherd Spinal Center Roosevelt Warm Springs Institute Walton Rehabilitation Hospital Central Georgia Rehabilitation Hospital Vencor Hospital Decatur Hospital Windy Hill Hospital Select Specialty Hospital (Atlanta and Augusta)
DISPUTED MEDICAL CHARGES
Any hospital whose charges are disputed and any party disputing such charges must comply with the requirements of the law, Board Rules, and, if applicable, rules of the appropriate peer review committee before the Board will issue an order regarding payment of any disputed charges. Pursuant to Board Rule 203(b)(5), if there is no appropriate peer review committee for hospital charges, the party requesting review may request a mediation conference by filing Form WC-14 with the Board. If the dispute is not resolved through mediation, a hearing may be requested.

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SECTION XIII: INPATIENT HOSPITAL PAYMENT SCHEDULE

DRG DESCRIPTION

MAR

001 craniotomy except for trauma age 002 craniotomy for trauma age> 17 004 spinal procedure 005 extracranial vascular procedures 006 carpal tunnel 007 periph/cranial nerv/other proc WCC 008 peripheral/cranial nerve/other proc WOCC 018 cranial and peripheral nerve WCC 019 cranial/peripheral nerve disorders WOCC 024 seizure/headache WCC 025 seizure/headache WOCC 027 traumatic stupor/coma, coma>1 hr 028 traumatic stupor/coma, coma<1 hr WCC 029 trauma/stupor/coma <1 hour WOCC 031 concussion WCC 032 concussion WOCC 034 other disorders of nervous system WCC 035 other disorder nervous system WOCC 036 retinal procedures 039 lens procedures with or without vitrectomy 040 extraocular proc ex orbit age> 17 042 extraocular proc. ex retina/iris 063 ear/nose/mouth/throat o.r. proc. 077 other resp system O.R. procedure WOCC 078 pulmonary embolism 079 resp infect/inflam age> 17 WCC 083 major chest trauma WCC 084 major chest trauma WOCC 088 chronic obstructive pulmonary disease 089 simple pneumonia/pleurisy age> 17 WCC 094 pneumothorax WCC 095 pneumothorax WOCC 101 other respiratory system WCC 112 percutaneous cardiovascular procedures
Section XIII: Inpatient Hospital Payment Schedule

$19,217 $22,270 $12,871 $10,801 $3,838 $15,196 $7,796 $7,814 $3,712 $4,983 $3,452 $9,325 $5,665 $4,247 $2,815 $3,232 $9,206 $3,490 $5,713 $5,146 $4,609 $5,231 $8,741 $6,304 $11,399 $10,520 $5,898 $3,237 $6,470 $7,404 $6,979 $2,216 $7,060 $14,851

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SECTION XIII: INPATIENT HOSPITAL PAYMENT SCHEDULE

DRG DESCRIPTION

MAR

113 amp cir sys disor ex upper limb/toe 125 circ dis ex AMI w/cath wo complx dx 128 deep vein thrombophlebitis 130 peripheral vascular disorders WCC 131 peripheral vascular disorders WOCC 132 atherosclerosis WCC 141 syncope & collapse WCC 143 chest pain 148 major small/large bowel procedures WCC 150 peritoneal adhesiolysis WCC 159 hernia proc. ex ingnl/fmrl age> 17 WCC 160 hernia procedure WOCC 161 ingnl/fmrl hernia proc age > 17 WCC 162 ingnl/fmrl hernia proc WOCC 174 GI hemorrhage WCC 182 esophagitis, gastro/misc. digest disor WCC 183 esophgts/gstrnt/misc diges > 17 WOCC 207 disorder biliary tract WCC 209 major joint & limb reattachment procedures 210 hip/femur proc ex maj joint WCC 211 hip/femur proc ex maj joint WOCC 213 amp muscskel syst/connec tiss disor 216 biopsies muscskel syst/connec tissue 218 lower extr/humr hip WCC 219 lower extr/humr procedures except hip WOCC 223 major shoulder/elbow procedure WCC 224 shoulder/elbow/upper ext WCC 225 foot procedures 226 soft tissue procedure WCC 227 soft tissue procedure WOCC 228 major thumb/joint proc./hand/wrist WOCC 229 hand/wrist procedure WOCC 231 local excis/rmvl int fix ex hip 232 arthroscopy 233 other muskelet sys/conn tis O.R. WCC

$17,365 $5,732 $4,615 $6,213 $4,734 $7,951 $4,274 $3,675 $24,633 $22,162 $7,929 $4,511 $6,492 $4,120 $6,343 $5,142 $3,246 $7,154 $17,569 $14,594 $9,957 $11,274 $11,868 $9,245 $7,601 $6,496 $6,035 $7,593 $8,692 $5,863 $7,531 $4,616 $8,069 $6,302 $15,532

Section XIII: Inpatient Hospital Payment Schedule

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SECTION XIII: INPATIENT HOSPITAL PAYMENT SCHEDULE

DRG DESCRIPTION

MAR

234 other muskelet sys o.r. procedure 237 sprns/strns dislo hip/pelvis/thigh 239 path fract/muskelet conn tiss malig 243 medical back problems 247 symp muscskeleton sytm/conn tissue 248 tendonitis, myositis and bursitis 250 fx/sp/st/disl forearm/hnd/foot age > 17 WCC 251 dislocated arm/hand/foot WOCC 253 fx/sp/st/dis uparm.lleg ex ft >17 WCC 254 upper arm/leg/foot 256 other muscskelet sys/conn tissue dx 263 skin graft/debrid skn ulcer/cel WCC 264 skin graft/debrid skn ulcer/cel WOCC 265 skin graft/debrid ex skn ulc/cel WCC 266 skin graft/debrid ex skn WOCC 270 other skin, sub tissue/breast proc. WOCC 277 cellulitis WCC 278 cellulitis WOCC 280 trauma/skin subcut tissue WCC 281 trauma/skin subcut tissue WOCC 418 postop & post-traumatic infections 430 psychoses 439 skin grafts for injuries 440 wound debridement for injuries 441 hand procedures for injuries 443 other o.r. proc for injuries 442 other OR procedure for injuries WCC 445 traumatic injury WOCC 447 allergic reactions age > 17 449 poisoning/toxi effect drugs age > 17 WCC 450 poisoning/toxic effect drugs age > 17 WOCC 453 complications of treatment WOCC 454 other injury/poison/tox effect WCC 455 other injury/poison/tox effect WOCC 461 OR procedure with diagno other con healserv

$9,741 $3,418 $8,717 $4,346 $4,470 $4,237 $3,209 $2,340 $6,339 $3,204 $5,320 $16,313 $7,007 $17,958 $8,274 $5,155 $5,273 $3,169 $3,788 $2,661 $6,379 $8,305 $13,662 $8,726 $6,673 $6,709 $13,826 $3,764 $2,546 $4,867 $3,035 $3,016 $4,852 $1,519 $21,231

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SECTION XIII: INPATIENT HOSPITAL PAYMENT SCHEDULE

DRG DESCRIPTION

MAR

477 non-exten O.R. proc unrelated to prin dx 479 other vascular procedures WOCC 483 tracheostomy excep face, mouth neck 485 limb reattach hip/femur proc MST 491 major joint and limb reattach/upper extrem 496 combined anterior/posterior fusion 497 spinal fusion WCC 498 spinal fusion WOCC 499 back\neck procedure excep fusion WCC 500 back\neck procedure excep fusion WOCC 501 knee procedure\infection WCC 502 knee procedure\infection WOCC 503 knee procedure without infection

$9,373 $9,403 $118,408 $30,013 $10,932 $17,551 $17,551 $7,951 $12,451 $6,796 $12,390 $8,254 $8,254

OUTLIER DIAGNOSTIC RELATED GROUPS DRG DESCRIPTION
009 spinal disorders/injuries 217 debrid/graft ex had mskelt. conn. tissue 236 fractures of hip/pelvis 249 aftercare muscskelt syst/conn tissue 415 o.r. proc infectious/parasitic dis 462 rehabilitation 468 extensive o.r. proc unrelated prin. 486 other o.r. proc. for multiple sig. trauma 487 other multiple significant traums

MAR Days
$7,972 27 $14,213 14 $7,146 21 $6,445 11 $18,414 23 $15,176 55 $16,248 20 $39,754 67 $15,392 52

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SECTION XIV: OUTPATIENT SURGERY PAYMENT SCHEDULE
SURGICAL SERVICES PROVIDED BY OUTPATIENT HOSPTIAL AND AMBULATORY SURGERY CENTERS
Payment for outpatient surgical services and associated goods rendered by a hospital or ambulatory surgical center must be submitted on HCFA-Uniform Billing (UB-92). Claims not containing the required information, which is outlined below, may cause delay in payment. Payment shall be the lower of :
1. Billed charges, or 2. the fee set forth in the Outpatient Surgery Payment Schedule listed in locator field 80 of
Form UB-92 on the facility's bill. This payment schedule is not all-inclusive. For any UB-92 for which a corresponding ICD-9 does not exist in the above-referenced listing and schedule, payment shall be made according to the usual, customary, and reasonable charges prevailing in the State of Georgia (O.C.G.A. 34-9-203, O.C.G.A. 34-9-205, and Board Rule 203).
No additional payment shall be required even if other procedures are listed in Field 81 of Form UB92, except as follows: Facilities may receive additional payment in excess of the fees listed in the ICD-9 Listing if (1) more than one principal procedure is performed during the same operative session, (2) each additional principal procedure is performed on a separate and distinct body part or system, and (3) the additional principal procedures would not normally be considered an integral part of a larger procedure or incidental to another procedure performed during the same session. Additional principal procedures meeting these criteria shall be paid at 75% of the difference between the amount specified in the ICD-9 Listing for the principal procedure in Field 80 and the total amount of the bill. In order to receive the additional payment, facilities must code the additional principal procedures in Field 81 of the bill, include a concise medical justification for the additional principal procedures in the "Remarks" section of the UB-92 (Field 84), and provide an itemized bill and a copy of the Operating Room notes reflecting that the additional principal procedures meet the criteria listed above.
IMPLANTABLES
Generally, durable medical equipment and supplies provided or administered in a hospital setting are not separately reimbursed since they are included in the payment rate. However, surgical implantables (e.g. rods, pins, screws, plates, and comparable items) that are medically necessary are excepted from this rule. Accordingly, additional reimbursement is allowed for medically necessary implantables. Reimbursement for the implantables shall be at cost to the hospital or ambulatory surgery center if the vendor invoice is provided to payor. Tax, handling, and charges for freight are included in the hospital's cost and shall not be reimbursed separately.

NON-SURGICAL RADIOLOGY SERVICES
Section XIV: Outpatient Surgery Payment Schedule

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STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE
SECTION XIV: OUTPATIENT SURGERY PAYMENT SCHEDULE
Radiology services not performed incident to surgical sessions shall be reimbursed at 10% above the technical component set forth in the fee schedule for those procedures for which CPT codes appear in Field 44 of Form UB-92 on the facility's bill. The technical component reimbursement for a procedure is the value of the total maximum allowable rate (MAR) column minus the professional column.
Example For Technical Component only Modifier 27 Calculation
Given CPT code 70010-27 for technical component plus 10% would be $264.00
Maximum Allowed Rate $369.00Professional $129.00= Technical Component $240.00 Plus (+) Ten Percent (10%) $24.00=$264.00.
PHYSICAL THERAPY SERVICES
Physical therapy services shall be reimbursed a the maximum allowable rate (MAR) set forth in the fee schedule for those procedures when the CPT codes appear in Field 44 of Form UB-92 on the facility's bill.
OTHER BILLING AND PAYMENT REQUIREMENTS
All those facilities that bill for services on UB-92 forms are required to include all appropriate CPT and HCPCS codes in Field 44. For any UB-92 for when an ICD-9 principal procedure code is not listed in the fee schedule in field 80, payment shall be made according to the usual, customary, and reasonable charges prevailing in the State of Georgia (O.C.G.A. 34-9-203, 34-9-205, 5 and Rule 203).

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SECTION XIV: OUTPATIENT SURGERY PAYMENT SCHEDULE

ICD-9 DESCRIPTION

MAR

03.39 Other Diag Proce Spinal Cord/Canal Structures 04.04 Other Inci Cranial/Peripheral Nerves 04.07 Periph Nerve Excision Nerves 04.30 Suture Cranial Peripheral Nerves 04.43 Carpal Tunnel Release 04.44 Release of Tarsal Tunnel 04.49 Other Peripher Nerve/Ganglion Decomp Lysis Adhes 04.50 Cranial-Peripheral Nerve Graft 04.60 Trans Cranial/Peripheral Nerves 04.79 Other Neuroplasty 08.83 Other Rep Lacer Eyelid, Part Thickness 11.51 Suture of Corneal Laceration 11.59 Other Repair of Cornea 11.64 Other Penetrating Keratoplasty 11.73 Keratoprosthesis 12.00 Removal Intraocular FB Ante Seg of Eye Nos 13.41 Cataract Phacoemuls/Aspiration 14.60 Remove Surgically Implanted Material Pos Seg Eye 14.74 Other Mechanical Vitrectomy 16.64 Other Revision of Enucleation Socket 18.09 Other Incision of External Ear 18.79 Other Plastic Repair of External Ear 19.40 Myringoplasty 19.52 Type 11 Tympanoplasty 19.60 Revision of Tympanoplasty 20.99 Other Opera Middle/Inner Ear 21.10 Incision of Nose 21.50 Submucous Resec of Nasal Septum 21.71 Close Reduction Nasal FX 21.72 Open Reduction of Nasal FX 21.82 Closure of Nasal Fistula 21.84 Revision Rhinoplasty 21.87 other Rhinoplasty 21.88 Other Septoplasty 25.10 Excision or Destruction of Lesion / Tissue of Tongue 25.59 Other Rep/Plastic Oper on Tongue 26.21 Marsupialization Salivary Gland Cyst 27.00 Drainage of Face/Floor of Mouth 33.24 CL Endoscopic Biopsy of Bronchus 34.71 Suture of Laceration of Chest Wall 37.22 Left Heart Cardiac Catheterization 40.11 Lymphatic Structure Biopsy

$1,280 $3,190 $2,721 $2,438 $2,200 $3,281 $3,185 $3,958 $3,200 $2,413 $1,113 $3,920 $3,012 $4,474 $3,179 $3,501 $4,099 $3,935 $6,635 $3,122 $2,951 $2,923 $3,034 $4,436 $4,439 $2,654 $2,420 $3,507 $1,634 $3,026 $1,867 $3,591 $3,566 $2,808 $2,149 $1,837 $3,055 $2,733 $1,336 $2,086 $3,751 $3,114

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SECTION XIV: OUTPATIENT SURGERY PAYMENT SCHEDULE

ICD-9 DESCRIPTION

MAR

53.00 Unilateral of Inguinal Hernia 53.01 Repair of Direct Inguinal Hernia 53.02 Repair Indir Ing Hernia 53.03 Dir Ing Hernia Rep w/ Graft 53.04 Repair Indir Ingu Hern w/Graft/Prosthesis 53.05 Repair Ing Hernia w./Graft/Pros NOS 53.10 Bila Rep of Inq, Hernia NOS 53.11 Bilat Rep Dir Ing Hern 53.12 Bilateral Rep of Ind Ingu Hernia 53.13 Bila Rep Ing/Hern/, One Dir/One Indir 53.14 Bila Rep Dir Ingu/Hern w/Graft-Pros 53.16 BI Rep Ing Her I D/L Ind w/Graft-Pros 53.17 Bilat Ingu Hern Rep w/Graft or Pros NOS 53.49 Other Umbilical Herniorrhaphy 53.51 Incision Hernia Repair 53.59 Repair Other Hern Ant Abdom Wall 53.61 Inc Hernia Repair w/Prosthesis 53.69 Rep Oth Hern Anter Abdom Wall W/Prosthesis 54.24 Cl (Perci)(Needle)Biopsy Intra Abd Mass 57.32 Other Cystocopy 57.49 Oth Transureth Exc/Destr Bladd Les/Tis 58.00 Urethrotomy 61.00 Inc-Drain Scrotum/Tunica Vaginalis 61.20 Exc of Hydrocele (of Tunica Vaginalis) 63.10 Exc-Varicocele/Hydrocele Sperm Cord 63.30 Exc Oth Les Tis Sperm Cord/Epididymis 76.50 Temporoinandibular Arthroplasty 76.72 Op Red Malar/Zygomatic Fracture 76.99 Other operations on facial bones/joints 77.12 Other Incision Bone w/o Division-Humerus 77.15 Other Incision Bone w/o Division-Fernur 77.17 Other Incision Bone w/o Division-Tib & Fib 77.18 Other Incision Bone w/o Division-Tars & Meta 77.19 Other Incision Bone w/o Division-Other 77.33 Oth Div Bone-Radius & Ulna 77.37 Oth Div Bone-Tibia & Fibula 77.57 Repair of Claw Toe 77.58 Other Exc Fusion/Rep of Toes 77.64 Local Exc Les Carpal & Metacarpals 77.65 Local Exc Bone Les Femur 77.66 Local Exc Les Patella 77.67 Local Exc Les Tibia/Fibula 77.68 Local Exc Les Tarsal & Metatarsals

$3,360 $4,045 $3,227 $4,071 $3,996 $4,806 $2,947 $3,897 $3,307 $3,815 $6,124 $3,021 $5,019 $2,246 $2,906 $2,619 $3,607 $3,620 $2,424 $2,268 $2,524 $2,245 $2,417 $3,202 $2,670 $1,957 $3,068 $2,993 $4,814 $2,328 $4,387 $3,733 $3,326 $3,428 $4,715 $7,024 $3,585 $2,627 $2,387 $3,364 $3,405 $3,162 $3,371

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SECTION XIV: OUTPATIENT SURGERY PAYMENT SCHEDULE

ICD-9 DESCRIPTION

MAR

77.79 Excision of Bone for Graft-Tarsal & Metatarsals 77.81 Other Partial Cstec-Scap/Clav/Thorax 77.82 Other Partial Ostec-Humerus 77.83 Other Partial Ostec Radius & Ulna 77.84 Oth Partial Ostec-Carpals & Metacarpals 77.86 Other Partial Ostec-Patella 77.88 Other Partial Ostec-Tarsals & Metatarsals 77.89 Other Partial Ostectomy 77.96 Total Ostectomy-Patella 77.99 Total Ostectomy-Other 78.08 Bone Graft-Tarsal & Metatarsals 78.09 Bone Graft-Other 78.17 App Ext Fix Device-Tibia & Fib 78.19 App Ext Fix Device-Other 78.23 Limb Shortening-Radius 78.47 Other Rep/ PI Oper-Tib & Fib 78.57 Int Fix w/o Frac Red-Tibia/Fib 78.59 Int Fix - Bone w/o Frac Reduc 78.61 Remov of Impl Dev-Scap/Clav/Thorax 78.62 Remove Int Fix-Humerus 78.63 Remove Int Fix-Radius/U 78.64 Remove Int Fix-Metac/Ca 78.65 Remove Int Fix Dev-Fem 78.66 Remove Int Fix-Patella 78.67 Remove Int Fix-Tib/Fibu 78.68 Remov Int Fix-Metat/Tarsal 78.69 Remove Implanted Device 79.03 Cl Fx Reduc-Carpal & Metacarpals 79.12 Cl Red-Int Fix Rad/Ulna 79.13 Cl Red-Int Fix Metac/C 79.14 Cl Red-Int Fix Finger 79.15 Cl Red- Int Fix/Femur 79.16 Cl Red-Int Fix Tib/Fib 79.18 Cl Red-Int Fix-Toe 79.19 Cl Red-Int Fix-Other 79.22 Open Reduc w/o Int Fix-Radius/Ulna 79.24 Open Reduc w/o Int Fix-Finger 79.26 Open Reduc w/o Int Fix-Tib & Fib 79.31 Open Red-Int Fix Humer 79.32 OP Red-Int Fix Rad/Uln 79.33 OP Red-Int Fix Metac/Carpal 79.34 Open Red-Int Fix Finger 79.36 Op Red-Int Fix-Tib & Fib (ORIF)

$2,785 $2,747 $2,628 $2,958 $1,957 $3,425 $2,713 $2,504 $3,324 $2,891 $3,544 $6,414 $7,006 $6,315 $4,731 $3,275 $4,076 $1,071 $2,533 $2,184 $2,287 $1,862 $2,865 $2,080 $2,387 $1,983 $1,987 $2,013 $2,979 $2,233 $2,234 $3,721 $4,415 $1,674 $2,414 $2,592 $2,518 $3,537 $4,014 $4,180 $3,604 $2,897 $3,307

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SECTION XIV: OUTPATIENT SURGERY PAYMENT SCHEDULE

ICD-9 DESCRIPTION

MAR

79.37 Op Red-Irit Fix Metat/Tarsal (ORIF)

$3,449

79.39 Open Red-Frac w/Int Fix (ORIF FX Other )

$3,893

79.64 Debride Op FX Finger

$1,239

79.73 Closed Reduc Disloc-Wrist

$2,378

79.84 Open Reduc of Disloc of Hand/Finger

$2,393

80.03 Arthrotomy Removal of Pros/Wrist

$2,242

80.12 Other Arthrotomy-Elbow

$3,153

80.14 Other Arthrotomy-Hand

$3,135

80.16 Other Arthrotomy-Knee

$2,497

80.17 Other Arthrotomy-Ankle

$2,845

80.21 Arthroscopy-Shoulder

$3,186

80.23 Arthroscopy-Wrist

$3,899

80.26 Arthroscopy-Knee

$3,140

80.27 Arthroscopy-Ankle

$2,193

80.36 Knee Joint Biopsy

$2,773

80.41 Division Joint Capsule/Ligament/Cartilage-Shoulder $4,423

80.42 Division Joint Capsule/Ligament/Cartilage- Elbow $3,033

80.44 Division Joint Capsule/Ligament/Cartilage-Hand $4,539

80.46 Division Joint Capsule/Ligament/Cartilage-Knee

$3,228

80.48 Division Joint Capsule/Ligament/Cartilage- Foot

$3,963

80.51 Excis of intervert disc (surgical)

$6,796

80.59 Other Destruction Intervertebral Disc

$4,213

80.60 Excision of Semilunar Cartilage of Knee

$3,013

80.72 Synovectomy, Elbow

$3,027

80.76 Synovectomy, Knee

$3,217

80.77 Synovectomy, Ankle

$3,138

80.81 Other Local Excis/Destruct-Lesion of Joint-Shoulder $3,623

80.82 Other Local Excis/Destruct-Lesion of Joint-Elbow $2,315

80.83 Other Local Excis/Destruct-Lesion of Joint-Wrist

$2,422

80.84 Other Local Excis/Destruct-Lesion of Joint-Hand

$2,234

80.85 Other Local Excis/Destruct-Lesion of Joint--Hip

$3,511

80.86 Other Local Excis/Destruct-Lesion of Joint-Knee

$3,025

80.87 Other Local Excis/Destruct-Lesion of Joint-Ankle $3,346

80.88 Other Local Excis/Destruct-Lesion of Joint-Foot

$2,754

80.89 Other Local Excis/Destruct-Lesion of Joint-Other Site $5,894

80.92 Other Excision of Joints- Elbow

$2,055

80.94 Other Excision of Joints-Hand/Finger

$3,522

81.13 Subtalar Fusion

$5,157

81.26 Metacarpocarpal Fusion

$4,127

81.28 Interphalangeal Fusion

$2,402

81.45 Other Repair of the Cruciate Lig

$6,247

81.47 Other Repair of Knee

$3,934

81.49 Other Repair of Ankle

$4,623

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SECTION XIV: OUTPATIENT SURGERY PAYMENT SCHEDULE

ICD-9 DESCRIPTION

MAR

81.71 Arthroplasty/Repair-Meta/Interphala Joint w/Implant 81.75 Arthroplasty Carpo/Carpometacarpal Joint W/O Imp 81.79 Other Repairs-Hand, Fingers, or Wrist 81.82 Repair of Recurrent Dislocation of Shoulder 81.83 Other Repair-Shoulder 81.84 Total Elbow Replacement 81.85 Other Repair of Elbow 81.93 Suture Capsular/Ligaments of Upper Extremity 81.96 Other Repair of Joint 82.01 Exploration Tendon Sheath of Hand 82.09 Other Incision of Soft Tissue of Hand 82.11 Tenotomy of Hand 82.21 Exc Les Tend Sheath Hand 82.22 Excision of Lesion of Muscle Hand 82.29 Excision Other Lesion Soft Tissue-Hand 82.33 Other Tenonectoray of Hand 82.41 Suture of Tendon Sheath-Hand 82.42 Delayed Suture of Flexor Tendon Hand 82.43 Delay Suture Other Hand Tendon 82.44 Other Suture Flexor Tendon of Hand 82.45 Other Suture Other Hand Tendon 82.56 Other Hand Muscle Transplantation 82.71 Tendon Pulley Reconstruction 82.79 Plastic Operation Hand w/Other Graft or Implant 82.84 Repair of Mallet Finger 82.85 Other Tenodesis of Hand 82.86 Other Tenoplasty Hand 82.91 Lysis of Adhesion of Hand 83.01 Tendon Sheath Exploration 83.02 Myotomy 83.09 Other Incision of Soft Tissue 83.13 Other Tenotomy 83.14 Fasciotomy 83.19 Other Div of Soft Tissue 83.21 Biopsy Of Soft Tissue 83.31 Excision of Lesion of Tendon Sheath 83.39 Excision of Lesion Other Soft Tissue 83.42 Other Tenonectomy 83.44 Other Fasciectomy 83.50 Bursectomy 83.61 Suture of Tendon Sheath 83.63 Rotator Cuff Repair 83.64 Other Suture of Tendon

$3,891 $3,678 $2,462 $4,954 $4,036 $3,719 $3,166 $4,440 $3,571 $2,267 $1,405 $2,040 $2,332 $1,553 $1,423 $1,480 $3,161 $3,240 $1,861 $2,257 $2,445 $4,493 $3,703 $4,116 $2,439 $3,311 $2,948 $2,881 $2,062 $3,199 $1,384 $2,997 $2,596 $3,057 $5,426 $2,644 $2,355 $1,960 $2,793 $2,663 $3,613 $4,568 $3,745

Section XIV: Outpatient Surgery Payment Schedule

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STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

SECTION XIV: OUTPATIENT SURGERY PAYMENT SCHEDULE

ICD-9 DESCRIPTION

MAR

83.65 Other Suture of Muscle/Fascia 83.75 Tendon Transfer Transplantation 83.86 Quadriceplasty 83.88 Other Plastic OPs Tend 83.91 Lysis Adhes-Mus/Ten/Pas/Burs 84.01 Amputa/Disarticula-Finger 84.11 Toe Amputation 84.30 Revision of Amputation Stump 85.21 Local Excis-Lesion of Breast 86.30 Other Loc Exc-Destruc Les Skin/Subcu Tissue 86.61 Full Thickness Skin Graft Hand 86.62 Other Skin Graft to Hand 86.63 Full Thick Skin Graft-Other Sites 86.69 Other Skin Graft-Other Sites 86.71 Cutting/Prep of Pedicle Grafts-Flaps 86.73 Attach of Pedicle-Flap Graft to Hand 86.84 Relax Scar-Web Contracture of Skin 86.89 Other Rep-Recon Skin/Subcu Tissue 97.88 Removal Ext immobilize Device

$2,674 $4,161 $6,056 $2,655 $2,173 $2,343 $2,786 $2,634 $3,042 $2,346 $1,799 $3,249 $2,293 $1,851 $2,473 $1,479 $3,396 $3,427 $2,087

Section XIV: Outpatient Surgery Payment Schedule

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STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE

INDEX

Add on codes 58

Allografts 11

Anesthesia services 35

Arthroscopic surgery 56

Assistant surgeon 51, 55

Authorization to treat 8, 17

Bilateral surgical procedures 55, 56, 57

Bone grafts

11, 53

By report procedures 14, 28, 50

Broken appointments 28

Carticel 51

Casting 53

Catastrophic injury 12

Clinical nurse specialist (CNS) 11, 31

Concurrent services by more than one physician 53

Confidentiality 8

Consultations 24, 26, 27

Coordination of care with other health care providers 24

Critical care 28

Custom made orthotics/prosthetics 10

Definitions

Established patient 22, 23, 54

New patient 22, 23, 54

MAR (maximum allowable reimbursement)

5, 171

FUD (follow-up days) 49, 52, 53

CPT (current procedural terminology) ii, 1

Depositions by physician 18

Downcoding 15

Drugs

10

Durable medical equipment 10

Emergency room services 23, 27, 52

Endoscopic service 49

Fractures 53

Impairment evaluation 14

Independent medical exam 13, 14

Implants 11

Implantables 11, 227, 234

Injection procedures 50, 56, 153, 171

Instrumentation

11

Interpreter 12

Late payment 20

Manipulation codes 219

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STATE OF GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE
Medical expense disputes 15 Medical records 19 Medical treatment disputes 17 Medical supplies 10 Microsurgery 56 Missed appointments 28 Multiple procedures 42, 55, 58,172 Multiple concurrent physical medicine procedures and modalities 218, 219 Multiple surgeons 55 No shows for appointments 56 Nurse practitioner (NP) 11, 31, 51, 56, 61 Nursing facility services 28 Orthotics 10, 219 Peer review 15, 16, 17 Physician assistants (PA) 11, 31, 51, 56, 61 Pharmaceuticals 10 Physical medicine maximum per visit/day 12, 219 Physician extenders (PE) 11, 31, 51, 56, 61 Physician testimony 18 Preauthorization 8, 17 Professional component 5, 151, 152, 154, 171, 172, 174, 201, 222 Referral 25 Rehabilitation nurse first assistant (RNFA) 11, 51, 56, 61 Rental equipment 10 Sequential procedures 49 Spinal instrumentation 11 Starred procedures 6, 9, 54 Surgical assistants 51 Surgical destruction 54 Technical component 5, 151, 154, 172, 174, 201, 222 Tens units 220 Tests and measurements 219 Time 26 Translator 12 Travel 13 Unlisted services 14, 28, 50 Work hardening 14
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