Exhibit 4 Effective January 1, Outpatient Surgery Facility Groupers and Fees 1/1/09 Group Description 1/1/09 1/1/09 Dollar Value

Transcription

1 Exhibit 4 Effective January 1, 2009 Outpatient Surgery Facility s and Fees 1 Level I Photochemotherapy 2 Level I Fine Needle Biopsy/Aspiration 3 Bone Marrow Biopsy/Aspiration $ Level I Needle Biopsy/ Aspiration Except Bone Marrow $ Level II Needle Biopsy/Aspiration Except Bone Marrow $ Level I Incision & Drainage 7 Level II Incision & Drainage $1, Level III Incision and Drainage $1, Level I Debridement & Destruction 13 Level II Debridement & Destruction 15 Level III Debridement & Destruction $ Level IV Debridement & Destruction $ Level VI Debridement & Destruction $2, Level I Excision/ Biopsy $ Level II Excision/ Biopsy $ Level III Excision/ Biopsy $1, Level IV Excision/ Biopsy $2, Exploration Penetrating Wound $1, Level I Breast Surgery $2, Level II Breast Surgery $3, Level III Breast Surgery $4, Smoking Cessation Services 33 Partial Hospitalization 34 Mental Health Services Composite 35 Arterial/Venous Puncture 37 Level IV Needle Biopsy/Aspiration Except Bone Marrow $1, Level I Implantation of Neurostimulator $3, Percutaneous Implantation of Neurostimulator Electrodes, $3, Excluding Cranial Nerve 41 Level I Arthroscopy $3, Level II Arthroscopy $4, Closed Treatment Fracture Finger/Toe/Trunk $ Bone/Joint Manipulation Under Anesthesia $1, Arthroplasty without Prosthesis $3, Level I Arthroplasty with Prosthesis $5, Level I Musculoskeletal Procedures Except Hand and Foot $2, Level II Musculoskeletal Procedures Except Hand and Foot $3, Level III Musculoskeletal Procedures Except Hand and Foot $4, Level IV Musculoskeletal Procedures Except Hand and Foot $8,600.06

2 53 Level I Hand Musculoskeletal Procedures $1, Level II Hand Musculoskeletal Procedures $2, Level I Foot Musculoskeletal Procedures $2, Level II Foot Musculoskeletal Procedures $4, Bunion Procedures $3, Level I Strapping and Cast Application 60 Manipulation Therapy 61 Laminectomy, Laparoscopy, or Incision for Implantation of $3, Neurostimulator Electrodes, Excluding Cranial Nerve 62 Level I Treatment Fracture/Dislocation $2, Level II Treatment Fracture/Dislocation $4, Level III Treatment Fracture/Dislocation $6, Level I Stereotactic Radiosurgery, MRgFUS, and MEG $1, Level II Stereotactic Radiosurgery, MRgFUS, and MEG 67 Level III Stereotactic Radiosurgery, MRgFUS, and MEG $6, Thoracoscopy $3, Thoracentesis/Lavage Procedures $ Level I Endoscopy Upper Airway 72 Level II Endoscopy Upper Airway 73 Level III Endoscopy Upper Airway $ Level IV Endoscopy Upper Airway $1, Level V Endoscopy Upper Airway $2, Level I Endoscopy Lower Airway $1, Level I Pulmonary Treatment 78 Level II Pulmonary Treatment 79 Ventilation Initiation and Management 80 Diagnostic Cardiac Catheterization $4, Coronary or Non-Coronary Atherectomy $9, Coronary or Non-Coronary Angioplasty and Percutaneous $4, Valvuloplasty 84 Level I Electrophysiologic Procedures $1, Level II Electrophysiologic Procedures $5, Level III Electrophysiologic Procedures $10, Thrombectomy $4, Insertion/Replacement of Permanent Pacemaker and Electrodes $3, Insertion/Replacement of Pacemaker Pulse Generator $2, Level II Vascular Ligation $4, Level I Vascular Ligation $2, Vascular Reconstruction/Fistula Repair without Device $3, Level I Resuscitation and Cardioversion $ Cardiac Rehabilitation 96 Non-Invasive Vascular Studies 97 Cardiac and Ambulatory Blood Pressure Monitoring 99 Electrocardiograms 100 Cardiac Stress Tests

3 101 Tilt Table Evaluation 103 Miscellaneous Vascular Procedures $1, Transcatheter Placement of Intracoronary Stents $9, Repair/Revision/Removal of Pacemakers, AICDs, or Vascular $2, Devices 106 Insertion/Replacement of Pacemaker Leads and/or Electrodes $3, Insertion of Cardioverter-Defibrillator $3, Insertion/Replacement/Repair of Cardioverter-Defibrillator Leads $4, Removal/Repair of Implanted Devices $ Transfusion $ Blood Product Exchange $1, Apheresis and Stem Cell Procedures $3, Excision Lymphatic System $2, Thyroid/Lymphadenectomy Procedures $4, Cannula/Access Device Procedures $3, Level I Tube changes and Repositioning $ Refilling of Infusion Pump 126 Level I Urinary and Anal Procedures 127 Level IV Stereotactic Radiosurgery, MRgFUS, and MEG $13, Echocardiogram with Contrast 130 Level I Laparoscopy $3, Level II Laparoscopy $4, Level III Laparoscopy $7, Level I Skin Repair 134 Level II Skin Repair 135 Level III Skin Repair $ Level IV Skin Repair $1, Level V Skin Repair $2, Esophageal Dilation without Endoscopy $ Level I Upper GI Procedures $ Small Intestine Endoscopy $1, Lower GI Endoscopy $ Level I Sigmoidoscopy and Anoscopy $ Level II Sigmoidoscopy and Anoscopy $ Level I Anal/Rectal Procedures $ Level III Anal/Rectal Procedures $2, Level IV Anal/Rectal Procedures $3, Endoscopic Retrograde Cholangio-Pancreatography (ERCP) $2, Level I Percutaneous Abdominal and Biliary Procedures $3, Peritoneal and Abdominal Procedures $2, Hernia/Hydrocele Procedures $3, Level II Anal/Rectal Procedures $1, Level III Urinary and Anal Procedures $ Colorectal Cancer Screening: Barium Enema

4 158 Colorectal Cancer Screening: Colonoscopy 159 Colorectal Cancer Screening: Flexible Sigmoidoscopy 160 Level I Cystourethroscopy and other Genitourinary Procedures $ Level II Cystourethroscopy and other Genitourinary Procedures $1, Level III Cystourethroscopy and other Genitourinary Procedures $2, Level IV Cystourethroscopy and other Genitourinary Procedures $3, Level II Urinary and Anal Procedures 165 Level IV Urinary and Anal Procedures $2, Level I Urethral Procedures $2, Level II Urethral Procedures $3, Lithotripsy $4, Dialysis $ Level II Male Genital Procedures $3, Level I Male Genital Procedures $2, Prostate Biopsy $1, Level II Female Reproductive Proc 189 Level III Female Reproductive Proc 190 Level I Hysteroscopy $2, Level I Female Reproductive Proc 192 Level IV Female Reproductive Proc $ Level V Female Reproductive Proc $2, Level VI Female Reproductive Procedures $3, Level VII Female Reproductive Procedures $4, Level IV Nerve Injections $1, Level I Nerve Injections $ Level II Nerve Injections $ Level III Nerve Injections $ Laminotomies and Laminectomies $5, Level II Extended EEG and Sleep Studies $1, Spine Fusions $5, Nervous System Injections $ Level I Extended EEG and Sleep Studies 215 Level I Nerve and Muscle Tests 216 Level III Nerve and Muscle Tests 218 Level II Nerve and Muscle Tests 220 Level I Nerve Procedures $1, Level II Nerve Procedures $3, Level II Implantation of Neurostimulator $3, Implantation of Catheter/Reservoir/Shunt $3, Implantation of Neurostimulator Electrodes, Cranial Nerve $4, Implantation of Drug Infusion Device $3, Transcatherter Placement of Intravascular Shunts $9, Level I Eye Tests & Treatments 231 Level III Eye Tests & Treatments $235.94

5 232 Level I Anterior Segment Eye Procedures $ Level II Anterior Segment Eye Procedures $1, Level III Anterior Segment Eye Procedures $2, Level I Posterior Segment Eye Procedures $ Level II Posterior Segment Eye Procedures $1, Level III Posterior Segment Eye Procedures $3, Level I Repair and Plastic Eye Procedures $ Level II Repair and Plastic Eye Procedures $ Level III Repair and Plastic Eye Procedures $2, Level IV Repair and Plastic Eye Procedures $2, Level V Repair and Plastic Eye Procedures $4, Strabismus/Muscle Procedures $2, Corneal and Amniotic Membrane Transplant $4, Level I Cataract Procedures without IOL Insert $1, Cataract Procedures with IOL Insert $2, Laser Eye Procedures $ Level II Cataract Procedures without IOL Insert $3, Nasal Cauterization/Packing 251 Level I ENT Procedures $ Level II ENT Procedures $ Level III ENT Procedures $1, Level IV ENT Procedures $2, Level V ENT Procedures $4, Tonsil and Adenoid Procedures $2, Level VI ENT Procedures $7, Level I Plain Film Except Teeth 261 Level II Plain Film Except Teeth Including Bone Density Measurement 262 Plain Film of Teeth 263 Level I Miscellaneous Radiology Procedures 265 Level I Diagnostic and Screening Ultrasound 266 Level II Diagnostic and Screening Ultrasound 267 Level III Diagnostic and Screening Ultrasound 269 Level II Echocardiogram Without Contrast Except Transesophageal 270 Transesophageal Echocardiogram Without Contrast 272 Fluoroscopy 274 Myelography 275 Arthrography 276 Level I Digestive Radiology 277 Level II Digestive Radiology 278 Diagnostic Urography 279 Level II Angiography and Venography 280 Level III Angiography and Venography 282 Miscellaneous Computed Axial Tomography

6 283 Computed Tomography with Contrast 284 Magnetic Resonance Imaging and Magnetic Resonance Angiography with Contrast 288 Bone Density:Axial Skeleton 293 Level V Anterior Segment Eye Procedures $9, Hyperthermia and Radiation Treatment Procedures 300 Level I Radiation Therapy 301 Level II Radiation Therapy 303 Treatment Device Construction 304 Level I Therapeutic Radiation Treatment Preparation 305 Level II Therapeutic Radiation Treatment Preparation 307 Myocardial Positron Emission Tomography (PET) imaging 308 Non-Myocardial Positron Emission Tomography (PET) imaging 310 Level III Therapeutic Radiation Treatment Preparation 312 Radioelement Applications 313 Brachytherapy 315 Level III Implantation of Neurostimulator $4, Electroconvulsive Therapy 322 Brief Individual Psychotherapy 323 Extended Individual Psychotherapy 324 Family Psychotherapy 325 Group Psychotherapy 330 Dental Procedures 332 Computed Tomography without Contrast 333 Computed Tomography without Contrast followed by Contrast) 335 Magnetic Resonance Imaging, Miscellaneous 336 Magnetic Resonance Imaging and Magnetic Resonance Angiography without Contrast 337 Magnetic Resonance Imaging and Magnetic Resonance Angiography without Contrast followed by Contrast 340 Minor Ancillary Procedures 341 Skin Tests 342 Level I Pathology 343 Level III Pathology 344 Level IV Pathology 345 Level I Transfusion Laboratory Procedures 346 Level II Transfusion Laboratory Procedures 347 Level III Transfusion Laboratory Procedures 350 Administration of flu and PPV vaccine 360 Level I Alimentary Tests 361 Level II Alimentary Tests 363 Level I Otorhinolaryngologic Function Tests 364 Level I Audiometry 365 Level II Audiometry

7 366 Level III Audiometry 367 Level I Pulmonary Test 368 Level II Pulmonary Tests 369 Level III Pulmonary Tests 370 Allergy Tests 373 Level I Neuropsychological Testing 377 Level II Cardiac Imaging 378 Level II Pulmonary Imaging 379 Injection adenosine 6 MG 381 Single Allergy Tests 382 Level II Neuropsychological Testing 384 GI Procedures with Stents $2, Level I Prosthetic Urological Procedures $3, Level II Prosthetic Urological Procedures $5, Level II Hysteroscopy $3, Discography $2, Level I Non-imaging Nuclear Medicine 390 Level I Endocrine Imaging 391 Level II Endocrine Imaging 392 Level II Non-imaging Nuclear Medicine 393 Hematologic Processing & Studies 394 Hepatobiliary Imaging 395 GI Tract Imaging 396 Bone Imaging 397 Vascular Imaging 398 Level I Cardiac Imaging 400 Hematopoietic Imaging 401 Level I Pulmonary Imaging 402 Level II Nervous System Imaging 403 Level I Nervous System Imaging 404 Renal and Genitourinary Studies 406 Level I Tumor/Infection Imaging 407 Level I Radionuclide Therapy 408 Level III Tumor/Infection Imaging 409 Red Blood Cell Tests 412 IMRT Treatment Delivery 413 Level II Radionuclide Therapy 415 Level II Endoscopy Lower Airway $2, Insertion of Left Ventricular Pacing Elect. $4, Level II Upper GI Procedures $2, Level II Percutaneous Abdominal and Biliary Procedures $4, Level II Arthroplasty with Prosthesis $13, Level II Strapping and Cast Application 427 Level II Tube Changes and Repositioning $1,662.58

8 428 Level III Sigmoidoscopy and Anoscopy $2, Level V Cystourethroscopy and other Genitourinary Procedures $4, Health and Behavior Services 433 Level II Pathology 434 Cardiac Defect Repair $14, Level I Drug Administration 437 Level II Drug Administration 438 Level III Drug Administration 439 Level IV Drug Administration 440 Level V Drug Administration 441 Level VI Drug Administration 442 Dosimetric Drug Administration 604 Level 1 Hospital Clinic Visits 605 Level 2 Hospital Clinic Visits 606 Level 3 Hospital Clinic Visits 607 Level 4 Hospital Clinic Visits 608 Level 5 Hospital Clinic Visits 609 Level 1 Emergency Visits 613 Level 2 Emergency Visits 614 Level 3 Emergency Visits 615 Level 4 Emergency Visits 616 Level 5 Emergency Visits 617 Critical Care 618 Trauma Response with Critical Care 621 Level I Vascular Access Procedures $1, Level II Vascular Access Procedures $2, Level III Vascular Access Procedures $3, Phlebotomy and Minor Vascular Access Device Procedures 625 Level IV Vascular Access Procedures $3, Level IV Breast Surgery $6, Complex Interstitial Radiation Source Application 652 Insertion of Intraperitoneal and Pleural Catheters $3, Vascular Reconstruction/Fistula Repair with Device $4, Insertion/Replacement of a permanent dual chamber pacemaker $2, Insertion/Replacement/Conversion of a permanent dual chamber $3, pacemaker 656 Transcatheter Placement of Intracoronary Drug-Eluting Stents 659 Hyperbaric Oxygen 660 Level II Otorhinolaryngologic Function Tests 661 Level V Pathology 662 CT Angiography 663 Level I Electronic Analysis of Devices 664 Level I Proton Beam Radiation Therapy

9 665 Bone Density:AppendicularSkeleton 667 Level II Proton Beam Radiation Therapy 668 Level I Angiography and Venography 672 Level IV Posterior Segment Eye Procedures $4, Level IV Anterior Segment Eye Procedures $4, Prostate Cryoablation $13, Thrombolysis and Thrombectomy 678 External Counterpulsation 679 Level II Resuscitation and Cardioversion 680 Insertion of Patient Activated Event Recorders $2, Knee Arthroplasty $5, Level V Debridement & Destruction $ Level II Photochemotherapy 685 Level III Needle Biopsy/Aspiration Except Bone Marrow $1, Revision/Removal of Neurostimulator Electrodes $2, Revision/Removal of Neurostimulator Pulse Generator Receiver $3, Electronic Analysis of Cardioverter-defibrillators 690 Electronic Analysis of Pacemakers and other Cardiac Devices 691 Level III Electronic Analysis of Devices 692 Level II Electronic Analysis of Devices 694 Mohs Surgery 697 Level I Echocardiogram Without Contrast Except Transesophageal 698 Level II Eye Tests & Treatments 699 Level IV Eye Tests & Treatments $1,488.33