GEORGIA. The MEDICAL FEE SCHEDULE WORKERS' COMPENSATION. Effective 04/01/2011 FOR SERVICES PROVIDED UNDER THE GEORGIA WORKERS' COMPENSATION LAW

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1 The GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE Effective 04/01/2011 FOR SERVICES PROVIDED UNDER THE GEORGIA WORKERS' COMPENSATION LAW Adopted by: State Board of Workers' Compensation 270 Peachtree Street, NW Atlanta, Georgia http: //

2 COPYRIGHT All fee schedule amounts are copyright 2011 State of Georgia. The Current Procedural Terminology (CPT) five-digit numeric codes, descriptions, and two-digit numeric modifiers representing physician, anesthesiology, and other medical services are the 2011 edition as produced or copyright 2010 by the American Medical Association. AMERICAN MEDICAL ASSOCIATION NOTICE CPT codes, descriptions and other material only copyright 2010 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. AMA does not directly or indirectly practice medicine or dispense medical services. AMA assumes no liability for data contained or not contained herein. 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 CPT 2011 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. PUBLISHER S NOTICE The Georgia Workers Compensation Medical 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, however, cannot be guaranteed. Ingenix worked closely with the Georgia State Board of Workers Compensation in the development, formatting, and production of this fee schedule. However, all decisions resulting in the final content of this schedule were made solely by the Georgia State Board of Workers Compensation. This publication is made available with the understanding that the publisher is not engaged in rendering legal and other services that require a professional license. For additional copies of this publication or other fee schedules, please call INGENIX ( ). OUR COMMITMENT TO ACCURACY Ingenix is committed to producing accurate and reliable materials. To report corrections, please visit or [email protected]. You can also reach customer service by calling INGENIX ( ), option 1. Questions concerning the application of the schedules of medical and hospital fees should be addressed to: Georgia State Board of Workers Compensation 270 Peachtree Street, NW Atlanta, GA Ingenix INGENIX ( )

3 Contents Section I: Background... 1 Format of the Fee Schedule... 1 Section II: Effective Date... 3 Section III: Introduction to the Fee Schedules... 5 Subsection A: Introduction to the Physician Portion of the Fee Schedule... 5 Subsection B: Introduction to the Transportation Portion of the Fee Schedule... 6 Subsection C: Introduction to the Inpatient Hospital Portion of the Fee Schedule... 6 Subsection D: Introduction to the Outpatient Surgery/ASC Portion of the Fee Schedule... 6 Section IV: General Reimbursement Requirements... 7 Considerations for Reimbursement... 7 Special Rules and Limitations... 9 Overview Section V: Evaluation and Management (E/M) Services Subsection A: Payment Ground Rules for E/M Category Subsection B: Payment Modifiers for E/M Category Section VI: Anesthesia Services Subsection A: Payment Ground Rules for Anesthesia Services Subsection B: Payment Modifiers for Anesthesia Services Section VII: Surgical Services Subsection A: Payment Ground Rules for Surgical Services Subsection B: Payment Modifiers for Surgical Services Section VIII: Diagnostic and Therapeutic Radiological Services Subsection A: Payment Ground Rules for Diagnostic and Therapeutic Radiological Services Subsection B: Payment Modifiers for Diagnostic and Therapeutic Radiological Services Section IX: Pathology and Laboratory Services Subsection A: Payment Ground Rules for Pathology and Laboratory Services Subsection B: Payment Modifiers for Pathology and Laboratory Services Section X: General Medicine Services Subsection A: Payment Ground Rules for General Medicine Services Subsection B: Payment Modifiers for General Medicine Services Section XI: Physical Medicine Services Subsection A: Payment Ground Rules for Physical Medicine Services Subsection B: Payment Modifiers for Physical Medicine Services Section XII: Home Health Services Section XIII: Transportation Subsection A: Non-Emergency Services Subsection B: Ambulance and Air Services Section XIV: Inpatient Hospital Payment Schedule Inpatient Reimbursement Methodology Implants, Durable Medical Equipment (DME), and Supplies Payment For Outliers MS-DRG Exempt Hospitals Disputed Medical Charges Section XV: Outpatient Surgery Payment Schedule Surgical Services Provided by Outpatient Hospital and Ambulatory Surgery Centers Implants, DME, and Supplies Nonsurgical Radiology Services Physical Therapy Services Modifiers Other Billing and Payment Requirements Index

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5 Section I: Background The Georgia 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 providers services in the 2010 version of The 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. 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. Employers, insurance carriers, self-insurers, or other payors shall use these rules for the purpose of approving and reimbursing medical charges submitted by physicians, hospitals, ambulatory surgical centers, or other medical providers for services performed in the treatment of work-related injuries or illnesses. The physician portion of 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 2011 Current Procedural Terminology (CPT), copyrighted by the American Medical Association (AMA). Any use or interpretation of CPT service descriptions not specifically described herein shall be based on CPT The transportation portion of the fee schedule includes maximum allowable rates for non-emergency transportation services. Non-emergency services are based on state-specific codes used only for workers' compensation billing purposes. Reimbursement for ambulance and air transportation is determined using the appropriate calculations for urban and rural base rate and mileage found in the Ambulance and Air Services subsection of the Transportation chapter. Ambulance and air transportation services are reported with HCPCS codes. The hospital inpatient/outpatient surgery portion of the fee schedule includes fee amounts for specific medical services and procedures as identified using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), volume 3, and Medicare severity diagnosis-related group (MS-DRG) numeric identifying codes. ICD-9-CM, volume 3, used for reporting the facility component of medical services and procedures, is maintained and updated by four cooperating parties: the American Hospital Association (AHA), the Centers for Medicare and Medicaid Services (CMS), the National Center for Health Statistics (NCHS), and the American Health Information Management Association (AHIMA). MS-DRGs used for reimbursement of inpatient hospital services are developed and updated annually by CMS. 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, MS-DRG descriptive terms and numeric identifying codes for reporting inpatient medical services and procedures, and selected ICD-9-CM, volume 3, descriptive terms and numeric identifying codes for reporting the facility component of 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 instructed otherwise in this document. Current Board forms are available on the Board s website FORMAT OF THE FEE SCHEDULE This fee schedule represents the maximum amount of reimbursement providers may receive for medical or surgical services for the treatment of work-related injuries and illnesses covered under the workers compensation laws of the State of Georgia. The fee schedule document is divided into 15 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 CPT only 2010 American Medical Association. All Rights Reserved. 1

6 Georgia Workers Compensation Medical Fee Schedule 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. Background II. Effective Date III. Introduction to the Fee Schedule IV. General Reimbursement Requirements V. Evaluation and Management Services VI. Anesthesia Services VII. Surgical Services VIII. Diagnostic and Therapeutic Radiological Services IX. Pathology and Laboratory Services X. General Medicine Services XI. Physical Medicine Services XII. Home Health Services XIII. Transportation XIV. Inpatient Hospital Payment Schedule XV. Outpatient Surgery Payment Schedule Section I: Background 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. 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. 2 CPT only 2010 American Medical Association. All Rights Reserved.

7 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 April 1, Any treatment or service rendered on or after the effective date is subject to the payment methodologies and fee reimbursements described herein. CPT only 2010 American Medical Association. All Rights Reserved. 3

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9 Section III: Introduction to the Fee Schedules SUBSECTION A: INTRODUCTION TO THE Physician PORTION OF THE FEE SCHEDULE The Georgia Workers Compensation Medical Fee Schedule is based upon the Resource Based Relative Value Scale (RBRVS). The reimbursable amount for each CPT numeric identifying procedure is derived from the total relative value and a conversion factor statistically determined from actual charge data in the State of Georgia. To determine the maximum allowable reimbursement (MAR) for each procedure, the unit value was multiplied by the applicable dollar conversion factor in effect on the date of payment. Providers are reimbursed the lesser of billed charges or the fee schedule amount. How to Use This Fee Schedule The maximum allowable reimbursement (MAR) for CPT codes is generally separable into eight distinct sections based on the category or type of service rendered plus a transportation fee schedule, which applies Georgia state-specific codes with MAR. Each category of service has separate instructions for the application of ground rules and modifier adjustments. The categories of service subject to this fee schedule are: General Medical Services CPT Codes Categories Evaluation & Management Anesthesia , Surgery Diagnostic & Therapeutic Radiology Pathology & Laboratory General Medicine , , , , , Physical Medicine , , , FCE01 Home Health The ground rules, modifier rules, and fee schedule reimbursement for primary or global services are included in sections V through XII of this fee schedule. As indicated, the MAR is subject to modification based on the included specific rules. See the Contents for referencing the specific subsections and page numbers. For each procedure, the fee schedule table includes the following details (if applicable): New (l), changed descriptor (s), add-on (+), modifier 51 exempt (*), moderate (conscious) sedation (K), or resequenced code (#) icons Five-digit CPT code number CPT description MAR (Maximum allowable reimbursement) Maximum reimbursement for professional component modifier 26 Maximum reimbursement for technical component modifier TC FUD (Follow-up day limits) The total 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, physical status modifiers, qualifying circumstances, and a dollar conversion CPT only 2010 American Medical Association. All Rights Reserved. 5

10 Georgia Workers Compensation Medical Fee Schedule factor. See the Anesthesia section for an explanation of how anesthesia fee amounts are to be determined. The American Medical Association (AMA) introduced a new numbering methodology of resequencing in CPT According to the AMA, there are instances where a new code is needed within an existing grouping of codes and an unused code number is not available. In the instance where the existing codes will not be changed or have minimal changes, the AMA will assign a code that is not in numeric sequence with the related codes. The resequenced codes and descriptions are placed with their related codes out of numeric sequence in the CPT book. Resequenced CPT codes within The Georgia Workers' Compensation Medical Fee Schedule display in their numeric order and are identified with the # icon. Category II and Category III CPT codes are not recognized for The Georgia Workers Compensation Medical Fee Schedule and will not be reimbursed. SUBSECTION B: INTRODUCTION TO THE Transportation PORTION OF THE FEE SCHEDULE The Georgia Workers Compensation Medical Fee Schedule includes maximum allowable rates for non-emergency transportation services. Non-emergency services are based on state-specific codes used only for workers compensation billing purposes. Reimbursement for ambulance and air transportation is determined using the appropriate calculations for urban and rural base rate and mileage found in the Ambulance and Air Services subsection of the Transportation chapter. Ambulance and air transportation services are reported with HCPCS codes. Providers are Section III: Introduction to the Fee Schedules reimbursed the lesser of billed charges or the fee schedule amount. SUBSECTION C: INTRODUCTION TO THE Inpatient Hospital PORTION OF THE FEE SCHEDULE For inpatient hospital services, The Georgia Workers Compensation Medical Fee Schedule is based upon the CMS 2011 Medicare severity diagnosis-related group (MS-DRG) relative weights. The reimbursable amount of each MS-DRG is derived from the total relative weights and a base rate (conversion factor) statistically determined from actual charge data in the State of Georgia. To determine the MAR for each MS-DRG, the unit weight is multiplied by the applicable dollar base rate in effect on the date payment is made. The ground rules for inpatient hospital fee schedule reimbursement are included in section XIV of this fee schedule. As indicated, the MAR is subject to modification based on the included specific rules. See the Contents for referencing the specific subsections and page numbers. SUBSECTION D: INTRODUCTION TO THE Outpatient Surgery/ASC PORTION OF THE FEE SCHEDULE To determine the MAR for outpatient surgery facility services, the 2011 ICD-9-CM, volume 3, procedure codes are used in conjunction with Georgia Hospital Association information. The ground rules for outpatient surgery facility fee schedule reimbursement are included in section XV of this fee schedule. As indicated, the MAR is subject to modification based on the included specific rules. See the Contents for referencing the specific subsections and page numbers. 6 CPT only 2010 American Medical Association. All Rights Reserved.

11 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, Medicare severity diagnosis-related groups (MS-DRG) developed by CMS, and International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), volume 3, codes updated by four cooperating parties: the American Hospital Association (AHA), the Centers for Medicare and Medicaid Services (CMS), the National Center for Health Statistics (NCHS), and the American Health Information Management Association (AHIMA). Modifiers that might affect reimbursement for specific services are also located in each section. 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. The Georgia Workers Compensation Medical Fee Schedule is the reimbursement guideline for Georgia facilities and providers. (Refer to O.C.G.A (b)) Occasionally, an individual who is injured in another state will seek treatment from a medical provider in Georgia. In such a case, the injury may not be under the jurisdiction of the Georgia Act. If the injury is under the jurisdiction of another state s workers compensation act, the policy and procedures listed in this manual would not apply. 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 Employee s Waiver of Confidentiality Authorization to Treat All-Inclusive Fees CPT Codes, Guidelines, and Icons National Correct Coding Initiative (CCI) Edits The following describes, in general, the principles and requirements that must be met for establishing applicability of this fee schedule. 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. For a copy of Rule 205, see the Board s website: CPT only 2010 American Medical Association. All Rights Reserved. 7

12 Georgia Workers Compensation Medical Fee Schedule 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. 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 principal 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 hospital and outpatient surgery facilities, all-inclusive services combines certain facility services and procedures, including all necessary durable medical equipment (DME) and supplies for reimbursement, into a single MS-DRG for inpatient services or a single ICD-9-CM, volume 3, procedure code that reflects the overall level of services, procedures, and supplies needed for the inpatient hospital or outpatient surgery facility service. The particular services/procedures/supplies will be reimbursed using the single MS-DRG amount for inpatient services and the single ICD-9-CM amount for outpatient surgery facility services established by the fee schedule. For medical professionals billing CPT codes for surgical procedures, all-inclusive services also include all preoperative and postoperative visits listed in the 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 would normally be allowed. There are certain exceptions to the all-inclusive services and fees provision as indicated by the explanation of separate procedures 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. Section IV: General Reimbursement Requirements CPT Codes, Guidelines, and Icons New and Revised CPT Codes New and revised codes are identified using the same symbols found in the CPT book. CPT codes that are new for 2011 are identified with the l symbol. CPT codes with substantially changed descriptors for 2011 are identified with the s symbol. Separate Procedures Certain procedures are an inherent portion of a procedure or 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 and is performed alone for a specific purpose, it may be considered a separate procedure. Add-On Procedures The CPT book identifies procedures that are always performed in addition to the primary procedure and designates them with a + symbol. Add-on codes are never reported for stand-alone services but are reported secondarily in addition to the primary procedure. Specific language is used to identify add-on procedures such as each additional or (List separately in addition to primary procedure). The same physician that performed the primary service/procedure must perform the add-on service/procedure. Add-on codes describe additional intra-service work associated with the primary service/procedure (e.g., additional digit(s), lesions(s), neurorrhaphy(s), vertebral segment(s), tendon(s), joint(s)). Fee schedule amounts for add-on codes are not subject to reduction and should be reimbursed at the lesser of 100 percent of the listed value or the billed amount. Do not append modifier 51 to a code identified as an add-on procedure. Designated add-on codes are identified in Appendix D of the CPT book. Please reference CPT 2011 for the most current list of add-on codes. Exempt From Modifier 51 Procedures The * symbol is used to identify CPT codes that are exempt from the use of modifier 51, but have NOT been designated as CPT add-on procedures/services. As the description implies, modifier 51 exempt procedures are not subject to multiple procedure rules and as such modifier 51 does not apply. Fee schedule amounts for modifier 51 exempt codes are not subject to reduction and 8 CPT only 2010 American Medical Association. All Rights Reserved.

13 Section IV: General Reimbursement Requirements should be reimbursed at the lesser of 100 percent of the listed value or the billed amount. Modifier 51 exempt services and procedures can be found in Appendix E of CPT CPT Codes that Include Moderate (Conscious) Sedation Some CPT codes include moderate (conscious) sedation as an inherent component of the procedure. These are identified in the CPT book with a K symbol. Because these services include moderate (conscious) sedation, special rules apply when reporting the moderate (conscious) sedation CPT codes Moderate (conscious) sedation services provided by the same physician performing the diagnostic or therapeutic service that the sedation supports and requiring the presence of a second independent trained observer for monitoring purposes (CPT codes ) may not be reported in conjunction with CPT codes identified with a K symbol and listed in Appendix G of the CPT book. In rare instances, a second physician other than the physician performing the diagnostic or therapeutic service may be required to provide the moderate (conscious) sedation service (CPT codes ). When these sedation services are performed in a facility setting (e.g., hospital, outpatient hospital/ambulatory surgery center, skilled nursing facility), the second physician may report the moderate (conscious) sedation service with CPT code(s) in conjunction with CPT codes identified with a K symbol and listed in Appendix G. However, when the second physician performs the moderate (conscious) sedation services in a nonfacility setting (e.g., physician office, freestanding imaging center) CPT codes should not be reported separately and are not reimbursable when performed in conjunction with CPT codes identified with a K symbol and listed in Appendix G. See Appendix G in CPT 2011 for a list of CPT codes that includes moderate (conscious) sedation. Modifier Services A modifier is the method used by the reporting physician to indicate or flag a service or procedure code regarding special circumstances affecting that service. The service or procedure description is not affected. When applicable, the modifying circumstance should be identified by the addition of the appropriate two-digit modifier code. The two-digit modifier should be placed after the usual procedure number. 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 modifiers will follow. Only certain modifiers in each of the categories (Evaluation and Management, Anesthesia, Surgery, Pathology/Laboratory, Radiology, General Medicine, and Georgia Workers Compensation Medical Fee Schedule Physical Medicine) will be recognized for reimbursement purposes. The acceptable modifiers for each category will be discussed in that section of the fee schedule. National Correct Coding Initiative (CCI) Edits The CPT book provides descriptive terms and identifying codes for reporting medical services and procedures performed by physicians. A multitude of codes is necessary because of the wide spectrum of services provided by various medical providers. Because many medical services can be rendered by different methods as well as combinations of various procedures, multiple codes describing similar services are frequently necessary to accurately reflect the service provided. While often only one procedure is performed at a patient encounter, it is also possible that multiple procedures be performed at the same encounter. In the latter case, a comprehensive code describing multiple services commonly performed together may be defined by a single CPT code. While the CPT coding system is used by providers to communicate payable services, payors must also be able to identify comprehensive codes that describe multiple procedures performed together. To accomplish this, CMS developed an edit system known as the National Correct Coding Initiative (CCI). This edit system identifies three types of services that should not be reported together. These include: Services that are a component of a more comprehensive service Services that are mutually exclusive Services that should not be reported together for other reasons The State of Georgia uses National CCI edits to identify services that are commonly performed together and that should not be billed separately when the services are provided at the same encounter. The complete list of CCI edits is too extensive to duplicate here; however, the information is available on the CMS website at SPECIAL RULES AND LIMITATIONS Specific circumstances might affect eligibility for reimbursement or the amount of reimbursement for specific services. The following listed circumstances could have an effect on eligibility or reimbursement for services. Urgent Care Facility Services performed in an urgent care facility shall be billed utilizing the most current and applicable CPT numeric CPT only 2010 American Medical Association. All Rights Reserved. 9

14 Georgia Workers Compensation Medical Fee Schedule identifying codes and modifiers. All rules and guidelines shall apply as outlined in the April 1, 2011 Georgia Workers Compensation Medical Fee Schedule. Reimbursement shall be at the rate established in the Georgia Physician Schedule. Materials Supplied by the Health Care Provider Supplies, DME, Orthotics, Prosthetics Medical supplies provided by the physician or other medical provider (e.g., sterile trays) over and above those usually included with the office visit (e.g., Band-Aids and cotton swabs) or other services rendered may be listed separately using CPT code Medical supplies and durable medical equipment are reimbursed at cost times 1.5 plus $4.00 for handling charges. Charges greater than $50.00 must be accompanied by a copy of the wholesale vendor invoice(s) showing the actual cost of the item. Certain procedures include supplies; therefore, CPT code 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 All prescription drugs must be dispensed using an Orange Book therapeutic equivalent drug(s) (GENERIC) when available unless designated in the doctor s own handwriting on the face of the prescription, in accordance with O.C.G.A , that Brand Medically Necessary or Brand Necessary is required. Prescription drugs will be reimbursed at the current average wholesale price (AWP) as published by Medispan, plus a dispensing fee of $6.15 for generic medications and $4.11 for brand name medications. All bills submitted for reimbursement must include the National Drug Code (NDC) of the product provided unless the product provided is a repackaged unit-of-use product. All pharmaceutical bills submitted for repackaged products must include the NDC of the original manufacturer or distributor s stock package used in the repackaging process. The reimbursement allowed shall be based on the current published manufacturer s AWP price of the product as of the date of dispensing. When the authorized treating physician prescribes pharmaceuticals, the prescription will indicate by stamp or other means that it is for a workers compensation claim. 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 MS-DRG or ICD-9-CM level if the wholesale vendor invoice for this item is included with the facility bill. This additional charge above the MAR, taking into account Section IV: General Reimbursement Requirements 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 wholesale vendor invoice is included in the facility bill. Physician Extenders (PE) Clinical Nurse Specialist (CNS), Nurse Practitioner (NP), or Physician Assistant (PA) 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. For scheduled visits, the Board requires a physician to provide evaluation and treatment in the course of the first visit. In situations of major/minor emergency, urgent care injuries, or other medical conditions requiring immediate attention, and where that care is provided in a medical facility staffed by physician extenders (PE) under the direction and supervision of a physician, services by the physician extender are covered for the initial treatment and visit. If follow-up treatment is necessary, the patient must then be referred to a physician for follow-up visit, treatment, and/or evaluation. Medical facilities covered include occupational medical centers, hospital emergency rooms, hospital-based clinics, rural health clinics, or federally qualified health centers. The federal tax ID number for the supervising physician is to be used on claims for services rendered by a PE. Subsequent visits to a PE who is under the general supervision of the physician shall be paid in accordance with the Board fee schedule. When professional services are directly performed by a CNS, NP, or PA, the reimbursement shall be at 85 percent 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 and incident to rules apply as specified in the Medicare Benefit Policy Manual, Pub , chapter 15, secs. 60.1, 60.2, 60.3, the applicable reimbursement shall be at 100 percent of the fee schedule or the provider s charge, whichever is less. While the supervising physician is responsible for the overall direction and management of the professional activities of the CNS, NP, 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. See the Medicare Benefit Policy Manual, Pub. 10 CPT only 2010 American Medical Association. All Rights Reserved.

15 Section IV: General Reimbursement Requirements 100-2, chapter 15, section 190(C) for Medicare requirements for PA supervision, section 200(D) for NP collaboration/supervision, and section 210(D) for CNS collaboration/supervision. 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 percent 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 records indicate that a first assistant is used less than 5 percent of the time nationwide for a particular surgical procedure, then the procedure is added to the restricted 5 percent list. (See the Medicare Claims Processing Manual, Pub , chapter 12, section ) CPT codes that have assistant at surgery restrictions are updated each year and can be found in the current Medicare National Physician Fee Schedule Relative Value File. The column Surg Asst in the above referenced file provides a numeric code (0, 1, 2, or 9) that identifies any restrictions related to assistant at surgery services. The restrictions related to these numeric codes are as follows: Surgical Assistant Ind Payment Restriction 0 Payment restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to establish medical necessity. 1 Statutory payment restriction for assistants at surgery applies to this procedure. Assistant at surgery may not be paid. 2 Payment restriction for assistants at surgery does not apply to this procedure. Assistant at surgery may be paid. 9 Concept does not apply. 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 , the RNFA shall not be on the staff of a hospital or the treating physician. Append the appropriate CPT procedure with modifier AS. When an office is billing for both the primary surgeon and the surgical assistant, two lines are used on the CMS-1500 or a Uniform Billing 04 (UB-04). Georgia Workers Compensation Medical Fee Schedule Interpretation In circumstances where an interpreter is required during face-to-face evaluation and management services, or physical medicine evaluations ( ), provided to the injured worker by a physician or PE, whether interpretation is provided live, via telephone or video, add state-specific modifier TR to the E/M code. Reimbursement will be an additional 25 percent of the lesser of billed charges or maximum allowable rate of that code only. Prolonged service codes may not be used in combination with this modifier. Additional reimbursement as outlined above does not apply to independent medical evaluations (IME). In circumstances where an interpreter is required for an injured worker, and the service is provided by telephone with a physician or qualified non-physician health care provider, use the appropriate CPT codes (physicians) and (qualified non-physician health care providers), and append state-specific modifier TR. These codes should be used in accordance with the guidelines and descriptions found in CPT Reimbursement will be an additional 25 percent of the lesser of billed charges or maximum allowable rate of that code only. 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 and/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 codes ). Each unit (15-minutes) reported counts as one charge. Exemptions to this rule are as follows: 1. An injured worker has been diagnosed with a catastrophic injury O.C.G.A (g). 2. CPT codes and report work hardening/work conditioning. CPT code reports the first two hours and CPT code reports each additional hour. The total dollar amount reimbursed for work hardening/work conditioning reported with these two CPT codes shall not exceed $ per visit/day. 3. State-specific code FCE01 must be used for billing functional capacity evaluation. The maximum allowable rate of reimbursement is $45.41 per 15 minutes (not to exceed $600.00). CPT only 2010 American Medical Association. All Rights Reserved. 11

16 Georgia Workers Compensation Medical Fee Schedule Section IV: General Reimbursement Requirements 4. CPT code must be used by physical/occupational therapists when billing for Physical Performance Test/Measurements that are required by the treating physician in preparing an impairment rating. No more than 4 time units per visit per day can be billed. An additional physical medicine treatment can be conducted on the same day, with reimbursement in accordance with Section XI Physical Medicine Services. Modifier 59 may be used when multiple procedures are performed on the same day. 5. CPT code should be used by the treating physician when performing an impairment rating. 6. Under the guidelines above, Physical Performance Test/Measurement testing and functional capacity evaluation can be performed on the same day by physical/occupational therapists. Modifier 59 may be used when multiple procedures are performed on the same day. 7. Reporting CPT code Orthotic management and training (including assessment and fitting when not otherwise reported), for custom-made orthotics, CPT code Prosthetic training, and CPT code Checkout for orthotic/prosthetic use, established patient. 8. By mutual agreement of all parties. Independent Medical Exam (IME) Employers/insurers have the right to request that the injured employee 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 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 $30.00 per day) and lodging. When travel is by private vehicle, the rate of mileage shall be according to Board Rule 203(e). 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 costs of such diagnostic procedures in excess of $ 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 the reimbursement amount for an IME. The provider shall complete Board Form WC-20 (a) Medical Report or the CMS-1500 form. Use state-specific code IME01 when reporting an independent medical exam (IME). The following hourly rate will establish the maximum allowable reimbursement for this service. Time Rate $ first hour or parts thereof $ each additional 15 minutes For a no-show at an independent medical examination, reimbursement shall be at $ Impairment Evaluation The basis to determine 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 CMS-1500 form and submit the form to the employer/insurer when a permanent partial disability rating is determined. If a physical examination is necessary, evaluation and management CPT code must be used in billing an impairment rating, and no other evaluation and management CPT code can be used along with CPT code when billing for impairment ratings performed by the authorized treating physician. Work Hardening/Work Conditioning The CPT codes and 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 Service or Procedure and New CPT Codes 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 medical professional services or procedures, payors should apply usual, customary, and reasonable charges. When reporting unlisted procedure MS-DRG or ICD-9-CM procedure codes, 12 CPT only 2010 American Medical Association. All Rights Reserved.

17 Section IV: General Reimbursement Requirements reimbursement is at percent of charges. In compliance with O.C.G.A (a), these usual, customary, and reasonable charges shall be limited to such charges as prevail in the State of Georgia for similar treatment. Annually on January 1 of each calendar year, the American Medical Association (AMA) releases updates to CPT codes, with new CPT codes added, CPT codes deleted, and CPT codes revised. The Georgia Workers Compensation Medical Fee Schedule may not have the AMA s most current updated information until after January 1. In this case, a maximum allowable reimbursement rate will not be assigned. New codes without an assigned fee should be considered to fall under the BR or by report maximum allowable reimbursement until the next fee schedule update. 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 infrequently provided, unusual, varies from other described procedures, or a new technique, methodology, or code 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 as performed is required Nature, extent, and need (diagnosis and rationale) for the service or procedure Time and effort required to perform the service or procedure Skill level necessary for performance of service or procedure Equipment use (if applicable) 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 (including major and supplementary surgical procedures if appropriate) Concurrent problems Follow-up care Payment will be determined based upon usual, customary, and reasonable charges. Georgia Workers Compensation Medical Fee Schedule Medical Expense Disputes Employers/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. Employers/insurers shall not unilaterally change any CPT, MS-DRG, or ICD-9-CM code of the provider. All automatically conformed charges according to the fee schedule shall be for the CPT 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 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: Mr. Michael Walsh, CAE, Executive Director Georgia Chiropractic Association, Inc Northlake Parkway, Suite 201 Tucker, GA (770) ; FAX (770) Mr. Clark Thomas, MPA, CAE, Executive Director Georgia Psychological Association 2200 Century Parkway, NE, Suite 660 Atlanta, GA (404) ; FAX (404) CPT only 2010 American Medical Association. All Rights Reserved. 13

18 Georgia Workers Compensation Medical Fee Schedule Section IV: General Reimbursement Requirements Mr. Stuart Platt, M.S.P.T., P.T., Principal Appropriate Utilization Group, LLC 881 Piedmont Avenue Atlanta, GA (404) 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. 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. (Refer to O.C.G.A ) Appointed Physician (Refer to O.C.G.A and Board Rule 205.) 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 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: Time Rate $ first hour or parts thereof $ each additional 15 minutes Special Reports Special reports such as insurance forms that convey more than the information conveyed in usual medical communication or standard reporting forms should be reported with CPT code Special reports meeting the above requirements will be reimbursed at a MAR of $ 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 14 CPT only 2010 American Medical Association. All Rights Reserved.

19 Section IV: General Reimbursement Requirements the services rendered. All bills must be submitted using CPT, ICD-9-CM, or MS-DRG codes either on Board Form WC-20(a), CMS-1500, or a Uniform Billing 04 (UB-04). 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 medical 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 that, by law, is responsible for payment of medical services. Generally, costs for these copies will be charged against the party responsible for payment of medical expenses. (Refer to Board Rule 200(f)(1)(2)(3)) Medical records copy charges under a workers compensation claim shall be billed at thirty dollars ($30), sales tax (if applicable), and actual cost for postage to mail the documents per request. This fee shall cover any request of up to 150 copied pages, and includes any costs associated with research, retrieval, and certification of the records or information requests. Any request that is for more than 150 copied pages shall be billed at twenty cents ($0.20) per page, or image if on CD or other electronic storage device that allows electronic retrieval, or copies made from microfilm, and shall include any costs associated with research, retrieval, and certification of the records or information requested. No additional fee beyond the twenty-cent ($0.20) per-page charge shall be billed for requests over 150 pages other than actual cost for postage to mail the documents per request and sales tax (if applicable). Example 1: 50-page document $0.20 x 50 pages = $10.00 Total Charges: $30.00 plus actual cost for postage and sales tax, if applicable Example 2: 175-page document $0.20 x 175 pages = $35.00 Total Charges: $35.00 plus actual cost for postage and sales tax, if applicable Georgia Workers Compensation Medical Fee Schedule Providers who use a medical records company to make and provide copies of medical records must ensure that reimbursement requirements are followed in accordance to the above fee schedule guidelines. X-ray copy charges will be billed at $9.50 per copy. Late Payment All reasonable medical, surgical, hospital, pharmacy goods and services shall be payable by the employer or its workers compensation insurer within 30 days of receipt of such charges and reports required by the Board. In the event that any documents or other information needed to process the claim or any portion thereof have not been provided to the employer or insurer, an explanation of benefits with payment information indicating why the charge has been reduced or disallowed shall be provided by the employer/insurer within 30 days of receipt of such charges. If any charges for health care goods or services, for which all Board-required information is provided, are not paid within the 30-day period, penalties shall be added to such charges and paid at the same time as and in addition to the charges claimed for such services. Refer to O.C.G.A and Board Rule 203 for complete rules and regulations. Broken or Missed Appointments No fees shall be allowed for broken or missed office visits, with the exception of independent medical examination (see IME this section). Notify the employer/insurer if the injured employee is not following the prescribed course of treatment. OVERVIEW The preceding guidelines outline reimbursement in general. Specific rules regarding reimbursement for services rendered by specific category should supplement the general guidelines (i.e., Evaluation and Management, Anesthesia, Surgery, Radiology, Pathology and Laboratory, General Medicine, and Physical Medicine). These specific guidelines are in addition to rules established for the usage of CPT codes by the American Medical Association (AMA), Medicare severity diagnosis-related groups (MS-DRG) developed by CMS, and International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), volume 3, codes updated by four cooperating parties: the American Hospital Association (AHA), the Centers for Medicare and Medicaid Services (CMS), the National Center for Health Statistics (NCHS), and the American Health Information Management Association (AHIMA). The following sections will describe payment in general terms by the category of service provided. CPT only 2010 American Medical Association. All Rights Reserved. 15

20 Georgia Workers Compensation Medical Fee Schedule Sections V through XII of the fee schedule provide specific payment ground rules separately for each of the eight medical professional service categories, section XIII provides specific ground rules for transportation, and sections XIV through XV provide specific payment ground rules for hospital inpatient/outpatient surgery services. Explanation of the modifiers and the maximum allowable reimbursement is included in each of these sections of the fee schedule. Section IV: General Reimbursement Requirements The payment ground rules are provided in 11 separate fee subsections. The ground rules encompass the 10 distinct medical and hospital inpatient/outpatient surgery service categories and transportation. 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. 16 CPT only 2010 American Medical Association. All Rights Reserved.

21 Section V: Evaluation and Management (E/M) Services SUBSECTION A: 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 of 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. Definitions 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 Except as provided herein, 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. Each time an injured worker has a new compensable workers compensation injury, the initial evaluation shall be coded as a new patient. 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 Services No distinction is made between new and established patients in the emergency department. Emergency department services should be reported for any patient (new or established) who presents for treatment in the emergency department. CPT only 2010 American Medical Association. All Rights Reserved. 17

22 Georgia Workers Compensation Medical Fee Schedule 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 injury/illness which is not a second opinion) will not be reimbursed. The authorized treating physician should coordinate care by all specialists. 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 (99363, , ). When a patient encounter occurs, any counseling and/or coordination of care with other health care providers as part of or as a result of the encounter are considered part of the E/M code for that session, and no additional reimbursement is warranted except when the patient encounter includes a board-certified rehabilitation supplier or case manager for the specific purpose of discussing the progress of the patient s treatment plan or an independent living plan related to the workers compensation injury. Under these conditions, add modifier RS to the appropriate E/M code, and reimbursement shall be at an additional 50 percent of the fee schedule MAR. Interpretation In circumstances where an interpreter is required during face-to-face evaluation and management services, or physical medicine evaluations ( ), provided to the injured worker by a physician or PE, whether interpretation is provided live, via telephone or video, add state-specific modifier TR to the E/M code. Reimbursement will be an additional 25 percent of the lesser of billed charges or maximum allowable rate of that code only. Prolonged service codes may not be used in combination with this modifier. Additional reimbursement as outlined above does not apply to independent medical evaluations (IME). In circumstances where an interpreter is required for an injured worker, and the service is provided by telephone with a physician or qualified non-physician health care provider, use the appropriate CPT codes (physicians) and (qualified non-physician health care providers), and append state-specific modifier TR. These codes should be used in accordance with the guidelines and descriptions found in CPT Reimbursement will be an additional 25 percent of the lesser of billed charges or maximum allowable rate of that code only. Section V: Evaluation and Management (E/M) Services Prolonged Services Codes are used when a physician provides prolonged services involving direct face-to-face patient contact that is beyond the usual service (see section IV for additional rules). Codes and are used when a physician provides prolonged services not involving direct face-to-face patient contact that is beyond the usual non-face-to-face component of physician service time. These codes should be used in accordance with the guidelines and descriptions found in CPT 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 Injured employee and family education Consultations As defined in the CPT book, consultation is a 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 , the injured employee becomes an established patient 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, follow CPT guidelines for reporting the consultation service. When a second opinion is requested by the employer/insurer, append modifier 32 to identify the service as a mandated consultation. 18 CPT only 2010 American Medical Association. All Rights Reserved.

23 Section V: Evaluation and Management (E/M) Services Evaluation and management consultation services will continue to be reported with CPT codes for outpatient consultation services and codes for inpatient consultation services. The rules and guidelines regarding the definition, documentation, and reporting of consultation services as contained in the CPT book will apply unless superseded by these guidelines. Consultation services will be reimbursed at the lesser of the MAR or billed amount. Referral 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 Georgia Workers Compensation Medical Fee Schedule 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. 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 postencounter time is CPT only 2010 American Medical Association. All Rights Reserved. 19

24 Georgia Workers Compensation Medical Fee Schedule 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. 2. Unit/floor time (hospital observation services, inpatient hospital care, 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. Nonfloor 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 Department Services An emergency department (ED) 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 ED physician, who is responsible for the care of the injured employee in the ED, reports an appropriate level ED evaluation and 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 modifier 25 appended to the E/M code. Section V: Evaluation and Management (E/M) Services 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, only the initial inpatient hospital care code would be submitted for reimbursement. Critical Care 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 ( ) or initial hospital consultation codes ( ) as appropriate. The critical care codes are used to report the total time the physician spends providing constant attention to a critically ill or 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 $ Unusual Service or Procedure Services that may necessitate skills and time of the physician over and above that usually required should be substantiated by report (see section IV). Unlisted Services An E/M service may be provided that is not listed in this section of the CPT codes. These services should be reported using an unlisted code and substantiated using a report. For these procedures a BR (by report) designation has been used in the fee schedule. Reimbursement for such procedures must be justified by report (see section IV). Physician Extenders (PE) Clinical Nurse Specialist (CNS), Nurse Practitioner (NP), or Physician Assistant (PA) Refer to General Reimbursement Requirements for a complete discussion of billing procedures for physician extenders (see section IV). 20 CPT only 2010 American Medical Association. All Rights Reserved.

25 Section V: Evaluation and 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 the appropriate modifier following the procedure code. The two-digit modifier should be placed after the usual procedure number. 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 (Evaluation and Management, Anesthesia, Surgery, Pathology and 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 this fee schedule. Note: Modifier 21 has been deleted. To report prolonged physician services, see Modifier 22 changed in CPT 2008 and is not to be appended to an E/M service. The following modifiers will be recognized for reimbursement by the fee schedule for evaluation and management (E/M) codes: 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 modifier 24 to the appropriate level of E/M service. 25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of a Procedure or Other Service: It may be necessary 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. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting the E/M Georgia Workers Compensation Medical Fee Schedule services on the same date. This circumstance may be reported by adding 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 the decision to perform surgery. See modifier 57. For significant, separately identifiable non-e/m services, see modifier Mandated Services: Services related to mandated consultation and/or related services (e.g., third-party payor, governmental, legislative or regulatory requirement) may be identified by adding 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 modifier 52, signifying that the service is reduced. This provides a means of reporting reduced services without disturbing the identification of the basic service. Note: For hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or canceled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for ASC hospital outpatient use). When reporting a reduced service, it is expected that the billed amount will be reduced by the provider. The amount of the reduction is at the discretion of the provider, but should reflect a level of reimbursement commensurate with the actual work done. 53 Discontinued Procedure: Under certain circumstances, the physician may elect to terminate 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 modifier 53 to the code reported by the physician for the discontinued procedure. 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. For outpatient hospital/ambulatory surgery center (ASC) reporting of a previously scheduled procedure/service that is partially reduced or canceled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for ASC hospital outpatient use). 57 Decision for Surgery: An evaluation and management service that resulted in the initial decision to perform CPT only 2010 American Medical Association. All Rights Reserved. 21

26 Georgia Workers Compensation Medical Fee Schedule the surgery may be identified by adding modifier 57 to the appropriate level of E/M service. 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. PE Physician Assistant, Clinical Nurse Specialist, or Nurse Practitioner (State-Specific Modifier): Evaluation and management services performed by a physician assistant, clinical nurse specialist, or nurse practitioner are identified by adding modifier PE to the usual evaluation and management CPT code unless incident to rules apply. No modifier is appended when incident to rules apply. 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. Modifier PE will be reimbursed at 85 percent of the MAR. Section V: Evaluation and Management (E/M) Services RS Rehabilitation Supplier (State-Specific Modifier): The rehabilitation supplier or case manager must be Board registered. In conformity with Board Rules or 208, the purpose of the scheduled office visit must be to discuss the progress of the patient s treatment plan or an independent living plan on a workers compensation injury. Modifier RS will be reimbursed at an additional 50 percent of the fee schedule MAR. TR Interpretation (State-Specific Modifier): In circumstances where an interpreter is required during face-to-face evaluation and management services provided to the injured worker by a physician or PE, add state-specific modifier TR to the E/M code. Reimbursement will be an additional 25 percent of the lesser of billed charges or MAR of that code only. Prolonged service codes may not be used in combination with the TR modifier unless it is documented that the reason for the code is additional time required as a result of factors beyond the need for an interpreter. Additional reimbursement as outlined above does not apply to independent medical evaluations (IME). 22 CPT only 2010 American Medical Association. All Rights Reserved.

27 Section V: Evaluation and Management (E/M) Services Georgia Workers Compensation Medical Fee Schedule EVALUATION AND MANAGEMENT Effective April 1, 2011 Medical Fee Schedule OFFICE OUTPT NEW 10 MIN XXX OFFICE OUTPT NEW 20 MINUTES XXX OFFICE OUTPT NEW 30 MIN XXX OFFICE OUTPT NEW 45 MIN XXX OFFICE OUTPT NEW 60 MIN XXX OFFICE O/P EST 5 MIN XXX OFFICE OUTPT EST 10 MIN XXX OFFICE OUTPT EST15 MIN XXX OFFICE OUTPT EST 25 MIN XXX OFFICE OUTPT EST 40 MIN XXX OBS CARE DSCHRG D MGMT XXX ST OBS CARE PR D LOW SEVERITY XXX ST OBS CARE PR D MODERATE SEVERITY XXX ST OBS CARE PR D HIGH SEVERITY XXX ST HOSP CARE PR D 30 MIN XXX ST HOSP CARE PR D 50 MIN XXX ST HOSP CARE PR D 70 MIN XXX l # SBSQ OBS CARE PR D LOW SEVERITY XXX l # SBSQ OBS CARE PR D MODERATE SEVERITY XXX l # SBSQ OBS CARE PR D HIGH SEVERITY XXX SBSQ HOSP CARE PR D 15 MIN XXX SBSQ HOSP CARE PR D 25 MIN XXX SBSQ HOSP CARE PR D 35 MIN XXX OBS/I/P HOSP CARE LOW SEVERITY XXX OBS/I/P HOSP CARE MODERATE SEVERITY XXX OBS/I/P HOSP CARE HIGH SEVERITY XXX HOSP DSCHRG D MGMT 30 MIN/< XXX HOSP DSCHRG D MGMT > 30 MIN XXX OFFICE CONSLTJ 15 MIN XXX OFFICE CONSLTJ 30 MIN XXX OFFICE CONSLTJ 40 MIN XXX OFFICE CONSLTJ 60 MIN XXX OFFICE CONSLTJ 80 MIN XXX ST INPT CONSLTJ 20 MIN XXX ST INPT CONSLTJ 40 MIN XXX ST INPT CONSLTJ 55 MIN XXX ST INPT CONSLTJ 80 MIN XXX ST INPT CONSLTJ 110 MIN XXX EMER DEPT SELF LIMITED/MINOR XXX EMER DEPT LOW TO MODERATE SEVERITY XXX EMER DEPT MODERATE SEVERITY XXX EMER DEPT HI SEVERITY&URGENT EVAL XXX EMER DEPT HIGH SEVERITY&THREAT FUNCJ XXX PHYS DIRION EMS ADVD LIFE SUPPORT BR XXX CC E/M CRITICALLY ILL/INJURED 1ST MIN XXX CC E/M CRITICALLY ILL/INJURED EA 30 MIN ZZZ Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 23

28 Georgia Workers Compensation Medical Fee Schedule Section V: Evaluation and Management (E/M) Services EVALUATION AND MANAGEMENT Medical Fee Schedule Effective April 1, ST NF CARE PR D E/M LW SEVERITY XXX ST NF CARE PR D E/M MOD SEVERITY XXX ST NF CARE PR D E/M HI SEVERITY XXX SBSQ NF CARE PR D E/M STABLE XXX SBSQ NF CARE PR D E/M MINOR COMPLCTJ XXX SBSQ NF CARE PR D E/M NEW PROBLEM XXX SBSQ NF CARE PR D E/M UNSTABLE/NEW PROBLEM XXX NF DSCHRG D MGMT 30 MIN/< XXX NF DSCHRG D MGMT > 30 MIN XXX E/M PT INVG ANNUAL NF ASSMT XXX DOM/R-HOME LW SEVERITY XXX DOM/R-HOME E/M NEW PT MOD SEVERITY XXX DOM/R-HOME E/M NEW PT MOD HI SEVERITY XXX DOM/R-HOME E/M NEW PT HI SEVERITY XXX DOM/R-HOME E/M NEW PT SIGNIFICANT NEW PROBLEM XXX DOM/R-HOME E/M EST PT SELF-LMTD/MINOR XXX DOM/R-HOME E/M EST PT LW MOD SEVERITY XXX DOM/R-HOME E/M EST PT MOD HI SEVERITY XXX DOM/R-HOME E/M EST PT SIGNIFICANT NEW PROBLEM XXX INDIV PHYS SUPVJ HOME/DOM/R-HOME MO MIN XXX INDIV PHYS SUPVJ HOME/DOM/R-HOME MO 30 MIN/> XXX HOME VST NEW PT LOW SEVERITY XXX HOME VST NEW PT MOD SEVERITY XXX HOME VST NEW PT MOD TO HI SEVERITY XXX HOME VST NEW PT HI SEVERITY XXX HOME VST NEW PT UNSTABLE/SIGNIFICANT NEW PROBLEM XXX HOME VST EST PT SELF LIMITED/MINOR XXX HOME VST EST PT LOW TO MOD SEVERITY XXX HOME VST EST PT MOD TO HI SEVERITY XXX HOME VST EST PT UNSTABLE/SIGNIFICANT NEW PROBLEM XXX PROLNG PHYS SVC OFFICE O/P DIR CONTACT 1ST HR ZZZ PROLNG PHYS SVC OFFICE O/P DIR CONTACT EA 30 MIN ZZZ PROLONGED SERVICE I/P REQ UNIT/FLOOR TIME 1ST HR ZZZ PROLONGED SVC I/P REQ UNIT/FLOOR TIME EA 30 MIN ZZZ PROLNG E/M SVC BEFORE&/AFTER DIR PT CARE 1ST HR XXX PROLNG E/M BEFORE&/AFTER DIR CARE EA 30 MIN ZZZ PHYS STANDBY SVC PROLNG PHYS ATTN EA 30 MIN XXX ANTICOAGULANT MGMT OUTPATIENT 1ST 90 DAYS XXX ANTICOAGULANT MGMT OUTPATIENT EA SBSQ 90 DAYS XXX TEAM CONFERENCE FACE-TO-FACE NONPHYSICIAN XXX TEAM CONFERENCE NON-FACE-TO-FACE PHYSICIAN XXX TEAM CONFERENCE NON-FACE-TO-FACE NONPHYSICIAN XXX PHYS SUPVJ PT HOME HLTH AGENCY MO MINUTES XXX PHYS SUPVJ PT HOME HLTH AGENCY MO 30 MIN/> XXX PHYS SUPVJ HOSPICE PT MO MIN XXX PHYS SUPVJ HOSPICE PT MO 30 MIN/> XXX 24 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

29 Section V: Evaluation and Management (E/M) Services Georgia Workers Compensation Medical Fee Schedule EVALUATION AND MANAGEMENT Effective April 1, 2011 Medical Fee Schedule PHYS SUPVJ NF PT MO MIN XXX PHYS SUPVJ NF PT MO 30 MIN/> XXX ST PREVENTIVE MEDICINE NEW PATIENT < 1YR XXX ST PREVENTIVE MEDICINE NEW PATIENT AGE 1-4 YRS XXX ST PREVENTIVE MEDICINE NEW PATIENT AGE 5-11 YRS XXX ST PREVENTIVE MEDICINE NEW PATIENT AGE YR XXX ST PREVENTIVE MEDICINE NEW PATIENT AGE 18-39YRS XXX ST PREVENTIVE MEDICINE NEW PATIENT AGE 40-64YRS XXX ST PREVENTIVE MEDICINE NEW PATIENT AGE 65YRS&> XXX PERIODIC PREVENTIVE MED ESTABLISHED PATIENT <1YR XXX PERIODIC PREVENTIVE MED EST PATIENT AGE 1-4YRS XXX PERIODIC PREVENTIVE MED EST PATIENT AGE 5-11YRS XXX PERIODIC PREVENTIVE MED EST PATIENT AGE 12-17YRS XXX PERIODIC PREVENTIVE MED EST PATIENT AGE 18-39YRS XXX PERIODIC PREVENTIVE MED EST PATIENT AGE 40-64YRS XXX PERIODIC PREVENTIVE MED EST PATIENT AGE 65YRS&> XXX PREV MED CNSL INDIV SPX 15 MIN XXX PREV MED CNSL INDIV SPX 30 MIN XXX PREV MED CNSL INDIV SPX 45 MIN XXX PREV MED CNSL INDIV SPX 60 MIN XXX TOBACCO USE CESSATION INTERMEDIATE 3-10 MINUTES XXX TOBACCO USE CESSATION INTENSIVE >10 MINUTES XXX ALCOHOL/SUBSTANCE SCREEN & INTERVEN MIN XXX ALCOHOL/SUBSTANCE SCREEN & INTERVEN >30 MIN XXX PREV MED CNSL GRP SPX 30 MIN XXX PREV MED CNSL GRP SPX 60 MIN XXX ADMN&INTERPJ HLTH RISK ASSMT INSTRUMENT XXX UNLIS PREV MED SVC BR XXX PHYSICIAN TELEPHONE EVALUATION 5-10 MIN XXX PHYSICIAN TELEPHONE EVALUATION MIN XXX PHYSICIAN TELEPHONE EVALUATION MIN XXX PHYSICIAN ONLINE EVALUATION & MANAGEMENT SERVICE XXX BASIC LIFE AND/OR DISABILITY EXAMINATION BR XXX WORK RELATED/MED DBLT XM TREATING PHYS XXX WORK RELATED/MED DBLT XM OTH/THN TREATING PHYS BR XXX ST HOSP/BIRTHING CENTER CARE PER DAY NML NB XXX ST CARE PR DAY NML NB XCPT HOSP/BIRTHING CENTER XXX SUBQ HOSPITAL CARE PER DAY E/M NORMAL NEWBORN XXX ST HOSP/BIRTHING CENTER NB ADMIT&DSCHG SM DATE XXX ATTN AT DELIVERY& 1ST STABILIZATION OF NEWBORN XXX DELIVERY/BIRTHING ROOM RESUSCITATION XXX CRITICAL CARE INTERFACILITY TRANSPORT MIN XXX CRITICAL CARE INTERFACILITY TRANSPORT EA 30 MIN ZZZ ST INPATIENT CRITICAL CARE PR DAY AGE 28 DAYS/< XXX SUBQ I/P CRITICAL CARE PR DAY AGE 28 DAYS/< XXX INITIAL PED CRITICAL CARE 29 D THRU 24 MO XXX Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 25

30 Georgia Workers Compensation Medical Fee Schedule Section V: Evaluation and Management (E/M) Services EVALUATION AND MANAGEMENT Medical Fee Schedule Effective April 1, SUBSEQUENT PED CRITICAL CARE 29 D THRU 24 MO XXX INITIAL PED CRITICAL CARE 2 THRU 5 YEARS XXX SUBSEQUENT PED CRITICAL CARE 2 THRU 5 YEARS XXX INITIAL HOSP NEONATE 28 D/< NOT CRITICALLY ILL XXX SUBSEQUENT INTENSIVE CARE INFANT < 1500 GRAMS XXX SUBSEQUENT INTENSIVE CARE INFANT GRAMS XXX SUBSEQUENT INTENSIVE CARE INFANT GRAMS XXX UNLIS E/M SVC BR XXX 26 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

31 Section VI: Anesthesia Services SUBSECTION A: PAYMENT GROUND RULES FOR ANESTHESIA SERVICES General Guidelines Anesthesia services reported must be those performed by or under the medical direction and supervision of an anesthesiologist, certified registered nurse anesthetist (CRNA), or anesthesiology assistant (AA) during the provision of any procedure by another provider. Modifier QX or QZ should be listed when the procedure is provided by the CRNA or AA. Anesthesia services include, but are not limited to, general or regional supplementation of local anesthesia as well as other supportive services considered necessary by the anesthesiologist. Fee schedule amounts for anesthesia services are determined on a different basis than fee determinations for other physician services. A relative unit value and dollar conversion factor basis is used. The listed relative values for anesthesia services are based on CMS anesthesia base values. 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. Services involving administration of anesthesia are reported by the use of the anesthesia five-digit procedure codes 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. 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 should be used to define these procedures. These procedures shall not be reported alone, but would be reported as additional procedure codes qualifying an anesthesia procedure or service. In procedure code 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. Unusual Service or Procedure Services that may necessitate skills and time of the physician over and above that usually required should be substantiated by report (see section IV). Unlisted Services An Anesthesia service may be provided that is not listed in this section of the CPT codes. These services should be reported using an unlisted code and substantiated using a report. For these procedures a BR (by report) designation has been used in the fee schedule. Reimbursement for such procedures must be justified by report (see section IV). 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 physical status modifiers, qualifying circumstances, plus time units. Anesthesia Values All anesthesia values are determined based on basic unit values for each anesthesia procedure code, the total time of services provided, physical status modifiers, qualifying circumstances, 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 base value includes the usual pre- and postoperative visits, intubation, care by the anesthesiologist during the procedure, the administration of fluids and blood, the usual monitoring services and extubation. Usual forms of monitoring included in the anesthesia service are electrocardiogram (ECG), temperature, blood pressure, oximetry, capnography, and mass spectrometry. Central venous, intra-arterial, and Swan-Ganz monitoring are considered unusual and are not included and may be coded CPT only 2010 American Medical Association. All Rights Reserved. 27

32 Georgia Workers Compensation Medical Fee Schedule Section VI: Anesthesia Services and billed separately. Documentation of the medical necessity for these types of unusual monitoring is required. 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 $ This amount will be applied to the anesthesia values as described in the fee schedule. Physical Status Modifiers To report all anesthesia services use both the five-digit anesthesia code and a physical status modifier. These modifying units may be added to the basic unit values. The initial letter P followed by a single digit as defined below represents physical status modifiers: Physical Status Modifiers Unit Value P1 A normal, healthy patient 0 P2 A patient with mild systemic disease 0 P3 A patient with severe systemic disease 1 P4 A patient w/severe systemic disease 2 that is a constant threat to life P5 A moribund patient who is not 3 expected to survive without the operation P6 A declared brain-dead patient whose organs are being removed for donor purposes 0 Qualifying Circumstances Often anesthesia services are provided during times when other circumstances that affect the anesthesia service provided are present. These special circumstances include emergently required procedures, management of body temperature or blood flow, and patient age. These codes are not reported alone, but are used as an additional description of circumstances that affect the anesthesia service provided. When appropriate, more than one qualifying circumstance code may be reported. The following units may be added to the basic unit values for qualifying circumstances: Qualifying Circumstances Unit Value Anesthesia for a patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure) Anesthesia complicated by utilization of total body hypothermia (List separately in addition to code for primary anesthesia procedure) Anesthesia complicated by utilization of controlled hypotension (List separately in addition to code for primary anesthesia procedure) Anesthesia complicated by emergency conditions (specify) (List separately in addition to code for primary anesthesia procedure) Time Reporting Anesthesia time is continuous from the start of anesthesia, when the anesthesiologist, CRNA, or AA begins the preparation of the injured employee for anesthesia in the operating room or an equivalent area, and ends when the injured employee is placed under postoperative care, such as transfer to the recovery room. The time value is computed by allowing one unit for each ten (10) minutes of anesthesia time during the duration of the service or significant portion thereof with a significant portion being defined as five (5) minutes or more. In instances where total time units are less than ten (10) minutes, but five (5) minutes or more for the entire procedure, then one (1) time unit would be paid. For anesthesia lasting a total of 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 two (2) hours for services provided using anesthesia with a basic unit of three, no physical status modifiers, and no qualifying circumstances, the anesthesia fee would be $ Anesthesia for arthroscopic procedure of knee joint Dollar Conversion Unit = $36.56 Basic Value = 3 Time Unit Value = 12 (6 units per hour x 2 hrs) Modifier Value = 0 Anesthesia Fee = ($36.56 x 3 Basic Value) + ($36.56 x 12 Time Unit Value) + ($36.56 x 0 Modifier Value) = $ Required Modifiers Modifiers are required when reporting anesthesia services. When two modifiers identifying the provider or level of supervision (e.g., AD, QK, QX, QY) are applicable to a single code, indicate each modifier on the same bill on separate lines. Services reported without the required modifiers will be paid at the lowest allowed percentage (50%). See the CPT only 2010 American Medical Association. All Rights Reserved.

33 Section VI: Anesthesia Services Georgia Workers Compensation Medical Fee Schedule Modifier subsection for a description of the required modifiers. Listed below are reimbursement guidelines for anesthesia services performed by anesthesiologists, CRNAs, and AAs. Reimbursement for Anesthesia Administered by an Anesthesiologist Anesthesiologist services billed with modifier AA, reporting anesthesia services performed personally by the anesthesiologist, are reimbursed at 100 percent. Reimbursement for Medical Direction of CRNA or AA Services by an Anesthesiologist Anesthesiologist services billed with modifier QK, reporting the supervision of two, three, or four CRNAs and/or AAs, are reimbursed at 50 percent. Anesthesiologist services billed with modifier AD, reporting the supervision of more than four CRNAs and/or AAs, where the anesthesiologist is not present at the time of induction, are paid as follows: (3 base units + time units) x 50 percent. When the anesthesiologist is present for induction, an additional time unit is paid when supporting documentation is submitted. Reimbursement is as follows: (3 base units + time units + 1 time unit for induction) x 50 percent. Anesthesiologist services billed with modifier QY reporting the supervision of one CRNA or AA are reimbursed at 50 percent. Note: When an anesthesiologist, employing a CRNA and/or AA, bills for anesthesia services, the anesthesiologist and CRNA or AA are both reimbursed at 50 percent. Reimbursement for Anesthesia Administered by a CRNA or AA CRNA or AA services billed with modifier QX, reporting medically directed services, are reimbursed at 50 percent. CRNA or AA services billed with modifier QZ, reporting services without medical direction, are reimbursed at 100 percent. Example of anesthesia fee calculation when an anesthesiologist provides medical direction of one CRNA: Given a total time of two (2) hours for services provided using anesthesia with a basic unit of three, no physical status modifiers, and no qualifying circumstances, the total anesthesia fee would be $ QY Anesthesiologist providing medical direction of one CRNA for arthroscopic procedure of knee joint QX CRNA providing anesthesia for arthroscopic procedure of knee joint under the direction of an anesthesiologist Dollar Conversion Unit = $36.56 Basic Value = 3 Time Unit Value = 12 (6 units per hour x 2 hrs) Modifier Value = 0 Total Anesthesia Fee = ($36.56 x 3 Basic Value) + ($36.56 x 12 Time Unit Value) + ($36.56 x 0 Modifier Value) = $ Payment for anesthesiologist services 50%= $ x 50% = $ Payment for CRNA services 50% = $ x 50% = $ Second Attending Anesthesiologist, CRNA, or AA When it is necessary to have a second attending anesthesiologist, CRNA, or AA assist with the preparation and conduction of anesthesia, these circumstances should be substantiated by special report. Reimbursement is as follows: In the case where an anesthesiologist assumes the role of second anesthesiologist, both anesthesiologists should report their services with modifier AA. The first anesthesiologist will be reimbursed for the full basic value plus time and modifying units at 100 percent. The second anesthesiologist will be reimbursed for a basic value of five units plus time and modifying units at 100 percent. When the basic value assigned to the procedure is less than five, both the first anesthesiologist and the second anesthesiologist will be reimbursed at 100 percent of the actual unit value of the procedure being performed. When a CRNA or AA assumes the role of second anesthesiologist, a medical direction situation does not exist and the anesthesiologist should bill with modifier AA, then the CRNA or AA should bill with modifier QZ. The first anesthesiologist will be reimbursed for the full basic value plus time and modifying units at 100 percent. The CRNA or AA will be reimbursed for a basic value of five units plus time and modifying units at 100 percent. When the basic value assigned to the procedure is less than five, both the first anesthesiologist and the CRNA/AA assuming the role of second anesthesiologist will be reimbursed at 100 percent of the actual unit value of the procedure being performed. CPT only 2010 American Medical Association. All Rights Reserved. 29

34 Georgia Workers Compensation Medical Fee Schedule Reporting Multiple Anesthesia Providers and Modifiers When the services of more than one anesthesia provider are reported on the same billing the following steps should be followed: 1. The services of each provider should be reported on separate lines 2. The appropriate modifier for each provider should be reported with the anesthesia code for the service 3. The rendering provider s ID number should be reported 4. The modifiers identifying the provider type of service (AA, AD, QK, QX, QY, QZ) should be reported first, followed by other HCPCS or CPT modifiers SUBSECTION B: PAYMENT MODIFIERS FOR ANESTHESIA SERVICES All anesthesia services are reported by use of the anesthesia five-digit procedure code ( ) plus the addition of a physical status modifier as outlined above. The added units for each physical status modifier are listed in the table in the physical status modifier paragraph above. It may be necessary to further modify listed services using CPT or HCPCS Level II modifiers. These modifiers indicate 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 the appropriate modifier following the procedure code. When two modifiers identifying the provider or level of supervision (e.g., AD, QK, QX, QY) are applicable to a single code, indicate each modifier on the same bill on separate lines. 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. Anesthesia Modifiers Under certain circumstances, medical services and procedures may need to be further modified. Modifiers commonly used in anesthesia are: 22 Increased Procedural Services: When the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. Documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). Note: This modifier should not be appended to an E/M service. Section VI: Anesthesia Services 23 Unusual Anesthesia: Occasionally, a procedure, which 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 modifier 23 to the procedure code of the basic service. 47 Anesthesia by Surgeon: Regional or general anesthesia provided by the surgeon may be reported by adding modifier 47 to the basic service. (This does not include local anesthesia.) Note: Modifier 47 would not be used as a modifier for the anesthesia procedures The operating surgeon should report the surgical procedure with modifier 47 appended when billing for anesthesia services. 53 Discontinued Procedure: Under certain circumstances, the physician may elect to terminate 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 modifier 53 to the code reported by the physician for the discontinued procedure. 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. For outpatient hospital/ambulatory surgery center (ASC) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for ASC hospital outpatient use). 59 Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision or 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 individual. 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. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M 30 CPT only 2010 American Medical Association. All Rights Reserved.

35 Section VI: Anesthesia Services service with a non-e/m service performed on the same date, see modifier 25. AA Anesthesia Services Performed Personally by Anesthesiologist: Report modifier AA when the anesthesia services are personally performed by an anesthesiologist. Claims submitted with modifier AA are reimbursed at 100 percent. AD Medical Supervision by a Physician; More Than Four Concurrent Anesthesia Procedures: Report modifier AD when the anesthesiologist supervises more than four concurrent anesthesia procedures. Claims submitted with modifier AD are reimbursed as described in the preceding section. G8 Monitored Anesthesia Care (MAC) for Deep, Complex, Complicated or Markedly Invasive Surgical Procedures: Report modifier G8 when monitored anesthesia care is required for deep, complex, complicated, or markedly invasive surgical procedures. G9 Monitored Anesthesia Care for Patient Who Has a History of Severe Cardiopulmonary Condition: Report modifier G9 when monitored anesthesia care is required for a patient who has a history of severe cardiopulmonary condition. NT No Time (State Specific Modifier): If the surgeon or attending physician administers a local or regional block for anesthesia during a procedure, the bill should so indicate with the use of modifier NT for no time. QK Medical Direction of Two, Three, or Four Concurrent Anesthesia Procedures Involving Qualified Individuals: Report modifier QK when the anesthesiologist supervises two, three, or four concurrent anesthesia procedures. Claims submitted with modifier QK are reimbursed at 50 percent. QS Monitored Anesthesia Care Service: The QS modifier is for informational purposes. QX CRNA or AA Service with Medical Direction by a Physician (Modified by State): Regional or general anesthesia provided by the CRNA or AA with medical direction by a physician may be reported by adding modifier QX. Claims submitted with modifier QX are reimbursed at 50 percent. QY Medical Supervision of One CRNA or AA by an Anesthesiologist (Modified by State): Report modifier QY when the anesthesiologist supervises one CRNA or AA. Claims submitted with modifier QY are reimbursed at 50 percent. QZ CRNA or AA Service without Medical Direction by a Physician (Modified by State): Regional or general Georgia Workers Compensation Medical Fee Schedule anesthesia provided by the CRNA or AA without medical direction by a physician may be reported by adding modifier QZ. Claims submitted with modifier QZ are reimbursed at 100 percent. Physical Status Modifiers Physical status modifiers reflect the patient s state of health. Individuals undergoing surgery may be healthy or may have varying degrees of system disease. A patient s health status affects the work related to providing the anesthesia service. A listing of physical status modifiers and the modifying units associated with each is provided in Subsection A: Payment Ground Rules for Anesthesia Services. Qualifying Circumstances Qualifying circumstances that significantly impact the character of the anesthesia service provided and associated relative values are listed in Subsection A: Payment Ground Rules for Anesthesia Services. Miscellaneous Anesthesia Services Provided by the Operating Surgeon 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 anesthesia, the value shall be the lesser of the basic unit value without benefit for time or 25 percent of the total dollar value of the surgery. (See modifier 47 for guidelines on reporting administration of anesthesia by the attending surgeon.) 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. (See modifier 47 for guidelines on reporting administration of anesthesia by the attending surgeon.) If the surgeon or attending physician administers a local or regional block for anesthesia during a procedure, the bill should so indicate with the use of a modifier NT for no time. Nerve Block For diagnostic or therapeutic nerve block, see and For diagnostic or therapeutic nerve blocks performed by the surgeon, anesthesiologist, CRNA, or AA, only one reimbursement per procedure shall be allowed, regardless of the time required (e.g., see codes , ). CPT only 2010 American Medical Association. All Rights Reserved. 31

36 Georgia Workers Compensation Medical Fee Schedule Moderate (Conscious) Sedation For reporting requirements and reimbursement guidelines related to moderate (conscious) sedation services, see Section IV: General Reimbursement Requirements, CPT Codes That Include Moderate (Conscious) Sedation. Field Avoidance 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. Multiple Procedures 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. 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. Section VI: Anesthesia Services Adjunctive Services Adjunctive services provided during anesthesia and certain other circumstances may warrant an additional charge. Identify by using the appropriate unit value modifier. Cardiopulmonary Resuscitation For cardiopulmonary resuscitation (independent procedure), see Time Units The time value is computed by allowing one unit for each ten (10) minutes of anesthesia time during the duration of the service or significant portion thereof with a significant portion being defined as five (5) minutes or more. In instances where total time units are less than ten (10) minutes, but five (5) minutes or more for the entire procedure, then one (1) time unit would be paid. For anesthesia lasting a total of less than five minutes, only base units without time units will be used to calculate reimbursement by the fee schedule. (See Subsection A: Payment Ground Rules for Anesthesia Services, for additional information on reporting of time units.) 32 CPT only 2010 American Medical Association. All Rights Reserved.

37 Section VI: Anesthesia Services Georgia Workers Compensation Medical Fee Schedule , ANESTHESIA Effective April 1, 2011 Medical Fee Schedule CODE MOD DESCRIPTION BASE UNIT ANESTHESIA SALIVARY GLANDS WITH BIOPSY ANESTHESIA CLEFT LIP INVOLVING PLASTIC REPAIR ANESTHESIA EYELID RECONSTRUCTIVE PROCEDURE ANESTHESIA ELECTROCONVULSIVE THERAPY ANESTHESIA EXTERNAL MIDDLE & INNER EAR W/BIOPSY ANES EXTERNAL MIDDLE & INNER EAR W/BX OTOSCOPY ANES XTRNL MID & INNER EAR W/BX TYMPANOTOMY ANESTHESIA EYE NOT OTHERWISE SPECIFIED ANESTHESIA EYE LENS SURGERY ANESTHESIA EYE CORNEAL TRANSPLANT ANESTHESIA EYE VITREORETINAL SURGERY ANESTHESIA EYE IRIDECTOMY ANESTHESIA EYE OPHTHALMOSCOPY ANESTHESIA NOSE & ACCESSORY SINUSES ANES NOSE & ACCESSORY SINUSES RADICAL SURGERY ANES NOSE&ACCESSORY SINUSES BIOPSY SOFT TISSUE ANESTHESIA INTRAORAL WITH BIOPSY ANES INTRAORAL W/BIOPSY REPAIR CLEFT PALATE ANES INTRAORAL W/BX EXC RETROPHARYNGEAL TUMOR ANESTHESIA INTRAORAL W/BIOPSY RADICAL SURGERY ANESTHESIA FACIAL BONES OR SKULL ANES FACIAL BONES/SKULL RAD SURG W/PROGNATHISM ANESTHESIA INTRACRANIAL PROCEDURE NOS ANES INTRACRANIAL CRANIOTOMY/CRANIECTOMY HMTMA ANESTHESIA INTRACRANIAL PROCEDURE SUBDURAL TAPS ANES INTRACRANIAL BURR HOLES W/VENTRICULOGRAPHY ANES ICRA CRNOP/ELEVATION DEPRS SKULL FX XDRL ANESTHESIA INTRACRANIAL VASCULAR PROCEDURE ANES INTRACRANIAL PROCEDURE IN SITTING POSITION ANES INTRACRANIAL CEREBROSPINAL FLUID SHUNTING ANES INTRACRANIAL ELECTROCOAGULATION ICRA NERVE ANES INTEG MUSC&NRV HEAD NCK&POSTERIOR TRUNK ANES ESOPH THYR LARX TRACH&LYMPHTC NECK 1YR/> ANES ESOPH THYR LARX TRACH&LYMPHTC NCK BX THYR ANESTHESIA LARYNX & TRACHEA CHILDREN <1YEAR ANESTHESIA MAJOR VESSELS NECK ANESTHESIA MAJOR VESSELS NECK SIMPLE LIGATION ANES INTEG EXTREMITIES ANTERIOR TRUNK PERINEUM ANESTHESIA RECONSTRUCTIVE BREAST ANESTHESIA RADICAL/MODIFIED RADICAL BREAST ANES RADICAL/MODIFIED RADICAL BREAST W/NODE ANES INTEG SYS ELEC CONVERSION ARRHYTHMIAS ANESTHESIA CLAVICLE AND SCAPULA ANESTHESIA CLAVICLE & SCAPULA RADICAL SURGERY ANESTHESIA CLAVICLE & SCAPULA BIOPSY CLAVICLE ANESTHESIA PARTIAL RIB RESECTION 6 + Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 33

38 Georgia Workers Compensation Medical Fee Schedule Section VI: Anesthesia Services ANESTHESIA , Medical Fee Schedule Effective April 1, 2011 CODE MOD DESCRIPTION BASE UNIT ANESTHESIA PARTIAL RIB RESECTION THORACOPLASTY ANESTHESIA PARTIAL RIB RESECTION RADICAL ANESTHESIA ESOPHAGUS ANESTHESIA CLOSED CHEST W/BRONCHOSCOPY ANESTHESIA CLOSED CHEST NEEDLE BIOPSY PLEURA ANESTHESIA CLOSED CHEST PNEUMOCENTESIS ANES CLSD CHEST MEDIASTSC&THRSC W/O 1 LUNG VNTJ ANES CLOSED CHEST MEDIASTSC&THRSC W/1 LUNG VNTJ ANES PERMANENT TRANSVENOUS PACEMAKER INSERTION ANESTHESIA ACCESS CENTRAL VENOUS CIRCULATION ANES TRANSVENOUS INSJ/REPLACEMENT PACING CVDFB ANES CARDIAC ELECTROPHYSIOLOGIC W/RF ABLATION ANESTHESIA TRACHEOBRONCHIAL RECONSTRUCTION ANESTHESIA THRCM LUNG PLEURA DPHRM&MED THRSC ANES THRCM LUNG PLEURA DPHRM&MED THRSC 1 LUNG ANES THRCM LUNG PLEURA DPHRM&MED THRSC DCRTCTJ ANES THRCM LNG PLEUR DPHRM&MED THRSC PULM RESCJ ANES THRCM LNG PLEUR DPHRM&MED THRSC TRACH&BRNCH ANESTHESIA FOR STERNAL DEBRIDEMENT ANES HRT PRCRD SAC&GREAT VESSEL CH W/O PMP OXTJ ANES HRT PRCRD SAC&GREAT VSL CH W/PMP OXTJ <1YR ANES HRT PRCRD&GRT VSL CH W/PMP OXTJ PT AGE 1/> ANES HRT PRCRD&GREAT VSL CH W/PUMP OXTJ HYPTHRM ANES DIR CAB GRFG W/O PMP OXTJ ANES DIRECT CAB GRAFTING W/ PUMP OXYGENATOR ANES HEART TRANSPLANT/HEART/LUNG TRANSPLANT ANESTHESIA CERVICAL SPINE & CORD ANES CERVICAL SPINE&CORD W/PATIENT SITTING ANESTHESIA THORACIC SPINE & CORD ANES THORACIC SPINE&CORD THORACOLMBR SYMPTH ANES THRC SPINE & CORD ANT APPR W/O 1 LUNG VNTJ ANES THORACIC SPINE & C/D ANT APPR W/1 LNG VNTJ ANESTHESIA LUMBAR REGION ANESTHESIA LUMBAR REGION LUMBAR SYMPATHECTOMY ANESTHESIA LUMBAR CHEMONUCLEOLYSIS ANES DIAGNOSTIC/THERAPEUTIC LUMBAR PUNCTURE ANES MNPJ SPINE/CLSD CRV THORACIC/LUMBAR SPINE ANESTHESIA EXTENSIVE SPINE & SPINAL CORD ANESTHESIA UPPER ANTERIOR ABDOMINAL WALL ANES UPR ANT ABDL WALL PERCUTANEOUS LIVER BX ANESTHESIA UPPER POSTERIOR ABDOMINAL WALL ANES UPPER GI ENDOSCOPIC PROXIMAL TO DUODENUM ANESTHESIA HERNIA REPAIR UPPER ABDOMEN ANES HRNA RPR UPR ABD LMBR&VNT HRNAS&/WND DEHSN ANES HERNIA REPAIR UPPER ABDOMEN OMPHALOCELE ANES HRNA REPAIR UPR ABD TABDL RPR DIPHRG HRNA 7 + Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure 34 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

39 Section VI: Anesthesia Services Georgia Workers Compensation Medical Fee Schedule , ANESTHESIA Effective April 1, 2011 Medical Fee Schedule CODE MOD DESCRIPTION BASE UNIT ANESTHESIA MAJOR ABDOMINAL BLOOD VESSELS ANES INTRAPERITONEAL UPPER ABDOMEN W/LAPS ANES IPR UPR ABD LAPS PRTL HPTC/MGMT LVR HEMRRG ANES IPR UPPER ABD W/LAPS PNCRTECT PRTL/TOTAL ANES IPR UPPER ABD W/LAPS LIVER TRANSPLANT ANES IPR UPPER ABDOMEN LAPS GASTRIC RSTCV MO ANESTHESIA LOWER ANTERIOR ABDOMINAL WALL ANES LOWER ANT ABDOMINAL WALL PANNICULECTOMY ANES LOWER INTESTINAL NDSC DISTAL DUODENUM ANESTHESIA LOWER POSTERIOR ABDOMINAL WALL ANESTHESIA HERNIA REPAIR LOWER ABDOMEN ANES HRNA RPR LWR ABD VENTRAL&INCAL HRNAS ANES HERNIA REPAIR LOWER ABDOMEN NOS <1YR AGE ANES HRNA RPR LWR ABD NOS INFTS<37WK BRTH<50WK ANESTHESIA INTRAPERITONEAL LOWER ABD W/LAPS ANES IPR LOWER ABDOMEN W/LAPS AMNIOCENTESIS ANES IPR LOWER ABD W/LAPS ABDOMINOPRNL RESCJ ANES IPR LOWER ABD W/LAPS RAD HYSTERECTOMY ANES IPR PX LWR ABD W/LAPS PELVIC EXENTERATION ANES IPR PX LWR ABD W/LAPS TUBAL LIG/TRNSECTION ANES EXTRAPERITONEAL PX LWR ABD W/UR TRC NOS ANES XTRPRTL LOWER ABD UR TRACT RENAL DON NFRCT ANES XTRPRTL LOWER ABD W/URINARY TRACT TOT CSTC ANES XTRPRTL LWR ABD W/UR TRC RAD PRST8ECT ANES XTRPRTL LOWER ABD W/UR TRC ADRNLECTOMY ANES XTRPRTL LOWER ABD W/UR TRACT RENAL TRNSPL ANES XTRPRTL LOWER ABD W/UR TRACT CSTOLITHOTOMY ANES LITHOTRP XTRCORP SHOCK WAVE W/WATER BATH ANES LITHOTRP XTRCORP SHOCK WAVE W/O WATER BATH ANESTHESIA MAJOR LOWER ABDOMINAL VESSELS ANES MAJOR LOWER ABDOMINAL VESSELS IVC LIGATION ANESTHESIA ANORECTAL PROCEDURE ANESTHESIA RADICAL PERINEAL PROCEDURE ANESTHESIA VULVECTOMY ANESTHESIA PERINEAL PROSTATECTOMY ANESTHESIA TRANSURETHRAL W/URETHROCYSTOSCOPY ANES TRANSURETHRAL RESECTION OF BLADDER TUMOR ANESTHESIA TRANSURETHRAL RESECTION OF PROSTATE ANES TRURL POST-TRURL RESECTION BLEEDING ANES TRURL FRAGMNTJ MNPJ&/RMVL URTRL CALCULUS ANESTHESIA MALE GENITALIA INCL OPEN URETHRAL PX ANES VASECTOMY UNI/BI INCL OPEN URETHRAL PX ANES SEMINAL VESICLES INCL OPEN URETHRAL PX ANES UNDSCND TESTIS UNI/BI INCL OPEN URTL PX ANES RAD ORCHIECTOMY INGUN INCL OPEN URTL PX ANES RAD ORCHIECTOMY ABDOMINAL INCL OPN URTL 6 + Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 35

40 Georgia Workers Compensation Medical Fee Schedule Section VI: Anesthesia Services ANESTHESIA , Medical Fee Schedule Effective April 1, 2011 CODE MOD DESCRIPTION BASE UNIT ANES ORCHIOPEXY UNI/BI INCL OPEN URETHRAL PX ANES COMPLETE AMPUTATION PENIS INCL OPEN URTL ANES RAD AMP PENIS W/BI INGUINAL NODE OPN URTL ANES RAD AMP PNS W/BI INGUN&ILIAC INCL OPN URTL ANES INSJ PENILE PROSTH PRNL INCL OPEN URTL ANESTHESIA VAGINAL PROCEDURE INCL BIOPSY ANES COLPTMY VAGNC COLPRPHY INCL BX W/OPN URTL ANESTHESIA VAGINAL HYSTERECTOMY INCL BIOPSY ANESTHESIA CERVICAL CERCLAGE INCLUDING BIOPSY ANESTHESIA CULDOSCOPY INCLUDING BIOPSY ANES HYSTEROSCOPY&/HYSTEROSALPINGOGRAPHY W/BX ANES BONE MARROW ASPIR&/BX ANT/PST ILIAC CREST ANESTHESIA ON BONY PELVIS ANESTHESIA BODY CAST APPLICATION OR REVISION ANESTHESIA INTERPELVIABDOMINAL AMPUTATION ANES RADICAL TUMOR PELVIS XCP HINDQUARTER AMP ANES CLOSED SYMPHYSIS PUBIS/SACROILIAC JOINT ANES OPEN SYMPHYSIS PUBIS/SACROILIAC JOINT ANES OPN RPR DISRPJ PELVIS/COLUMN FX ACETABULUM ANESTHESIA OBTURATOR NEURECTOMY EXTRAPELVIC ANESTHESIA OBTURATOR NEURECTOMY INTRAPELVIC ANESTHESIA HIP JOINT ANESTHESIA ARTHROSCOPY HIP JOINT ANESTHESIA OPEN PX HIP JOINT ANESTHESIA OPEN HIP JOINT DISARTICULATION ANESTHESIA OPEN TOTAL HIP ARTHROPLASTY ANESTHESIA OPEN REVISION TOTAL HIP ARTHROPLASTY ANESTHESIA UPPER 2/3 FEMUR CLOSED PROCEDURES ANESTHESIA UPPER 2/3 FEMUR OPEN PROCEDURES ANESTHESIA UPPER 2/3 FEMUR AMPUTATION ANES UPPER 2/3 FEMUR RADICAL RESCECTION ANES NERVE MUSC TENDON FASCIA&BURSAE UPPER LEG ANES VEINS OF UPPER LEG INCLUDING EXPLORATION ANESTHESIA ARTERIES UPPER LEG INCL BYPASS GRAFT ANES ART UPPER LEG W/BYPASS GRAFT FEM ART LIG ANES ARTERIES UPPER LEG W/BYP GRF FEM ART EMBLC ANES NERVE MUSC TENDON FSCA&BRS KNEE&/POP AREA ANESTHESIA LOWER 1/3 FEMUR CLOSED PROCEDURES ANESTHESIA LOWER 1/3 FEMUR OPEN PROCEDURES ANESTHESIA KNEE JOINT CLOSED PROCEDURES ANESTHESIA DIAGNOSTIC ARTHROSCOPIC KNEE JOINT ANES UPPER ENDS TIBIA FIBULA&/PATELLA CLOSED ANES UPPER ENDS TIBIA FIBULA&/PATELLA OPEN ANES OPEN/SURGICAL ARTHROSCOPIC KNEE JOINT ANESTHESIA ARTHROSCOPIC TOTAL KNEE ARTHROPLASTY ANESTHESIA ARTHROSCOPIC KNEE DISARTICULATION 5 + Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure 36 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

41 Section VI: Anesthesia Services Georgia Workers Compensation Medical Fee Schedule , ANESTHESIA Effective April 1, 2011 Medical Fee Schedule CODE MOD DESCRIPTION BASE UNIT ANES CAST APPLICATION REMOVAL/REPAIR KNEE JOINT ANESTHESIA VEINS KNEE & POPLITEAL AREA ANESTHESIA VEINS KNEE & POPLITEAL ARVEN FISTULA ANESTHESIA ARTERIES OF KNEE & POPLITEAL AREA ANES ART KNEE & POP/POP TEAEC +-PATCH GRAFT ANES ART KNE&POP/POP EXC&GRF/RPR OCCLS/ARYSM ANESTHESIA LOWER LEG ANKLE & FOOT CLOSED PX ANESTHESIA ANKLE &/FOOT ARTHROSCOPIC PX ANES NRV/MUS/TND/FASC LOWER LEG/ANKLE/FOOT ANES RPR RUPTURED ACHILLES TENDON +-PATCH GRAFT ANESTHESIA GASTROCNEMIUS RECESSION ANESTHESIA BONES LOWER LEG/ANKLE/FOOT OPEN PX ANES RADICAL RESECTION INCL BELOW KNEE AMP ANES OSTEOTOMY/OSTEOPLASTY TIBIA&/FIBULA OPEN ANESTHESIA TOTAL ANKLE REPLACEMENT OPEN ANES LOWER LEG CAST APPLICATION REMOVAL/REPAIR ANESTHESIA ARTERIES LOWER LEG W/BYPASS GRAFT ANES ART LOWER LEG W/BYP GRAFT EMBLC DIR/W/CATH ANESTHESIA VEINS OF LOWER LEG ANES VEINS LOWER LEG VENOUS THRMBC DIR/W/CATH ANES NERVE MUSCLE TENDON FSCA&BRS SHO&AXILLA ANES CLOSED HUMRL H/N STRNCLAV JOINT&SHO JOINT ANES SHOULDER JOINT DIAGNOSTIC ARTHROSCOPIC PX ANES ARTHRS HUMERAL H/N STRNCLAV&SHOULDER JOINT ANESTHESIA ARTHROSCOPIC SHOULDER DISARTICULATION ANES ARTHRS INTERTHORACOSCAPULAR AMPUTATION ANES ARTHROSCOPIC TOTAL SHOULDER REPLACEMENT ANESTHESIA ARTERIES SHOULDER & AXILLA ANESTHESIA AXILLARY-BRACHIAL ANEURYSM ANES ARTERIES SHOULDER & AXILLA BYPASS GRAFT ANESTHESIA AXILLARY-FEMORAL BYPASS GRAFT ANESTHESIA VEINS SHOULDER & AXILLA ANES SHOULDER CAST APPLICATION REMOVAL/REPAIR ANES SHOULDER SPICA APPLICATION REMOVAL/REPAIR ANES NRV MUSC TDN FSCA&BRS UPR ARM/ELBOW ANESTHESIA TENOTOMY ELBOW TO SHOULDER OPEN ANESTHESIA TENOPLASTY ELBOW TO SHOULDER ANESTHESIA BICEPS TENODESIS RUPTURE LONG TENDON ANESTHESIA HUMERUS & ELBOW CLOSED PX ANESTHESIA ELBOW JOINT DIAGNOSTIC ARTHROSCOPIC ANESTHESIA ELBOW OPEN/SURGICAL ARTHROSCOPIC ANESTHESIA HUMERUS ARTHROSCOPIC OSTEOTOMY ANES HUMERUS ARTHROSCOPIC REPAIR NON/MALUNION ANESTHESIA ELBOW ARTHROSCOPIC RADICAL PX ANES HUMERUS ARTHROSCOPIC EXCISION CYST/TUMOR ANES ARTHROSCOPIC TOTAL ELBOW REPLACEMENT 7 + Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 37

42 Georgia Workers Compensation Medical Fee Schedule Section VI: Anesthesia Services ANESTHESIA , Medical Fee Schedule Effective April 1, 2011 CODE MOD DESCRIPTION BASE UNIT ANESTHESIA ARTERIES UPPER ARM & ELBOW ANESTHESIA ARTERIES UPPER ARM&ELBOW EMBOLECTOMY ANESTHESIA VEINS UPPER ARM & ELBOW ANESTHESIA VEINS UPPER ARM&ELBOW PHLEBORRHAPHY ANES NERVE MUSCLE TDN FSCA&BRS F/ARM WRST&HAND ANES RADIUS ULNA WRIST/HAND BONES CLOSED PX ANESTHESIA WRIST DIAGNOSTIC ARTHROSCOPIC ANES ARTHRS/ENDOSCOPIC DSTL RADIUS DSTL U/W/H ANESTHESIA ARTHROSCOPIC TOTAL WRIST REPLACEMENT ANESTHESIA ARTERIES FOREARM WRIST & HAND ANES ARTERIES FOREARM WRIST&HAND EMBOLECTOMY ANESTHESIA VASCULAR SHUNT/SHUNT REVISION ANESTHESIA VEINS FOREARM WRIST & HAND ANES VEINS FOREARM WRIST&HAND PHLEBORRHAPHY ANES FOREARM WRIST/HAND CAST APPL RMVL/REPAIR ANESTHESIA DIAGNOSTIC ARTERIOGRAPHY/VENOGRAPH ANES C-CATHJ W/C ANGIOGRAPHY&VENTRICULOGRAPHY ANES NON-INVASIVE IMAGING/RADIATION THERAPY ANESTHESIA THER IVNTL RADIOLOGICAL ARTERIAL ANESTHESIA CAROTID/CORONARY THER IVNTL RAD ANES ICRA ICAR/AORTIC THER IVNTL RAD ARTL ANESTHESIA VENOUS/LYMPHATIC NOS THER IVNTL RAD ANESTHESIA INTRAHEPATIC/PORTAL THER IVNTL RAD ANESTHESIA INTRATHORACIC/JUGULAR THER IVNTL RAD ANES INTRACRANIAL THER IVNTL RAD VENS/LYMPHTC ANESTHESIA PERQ IMAGE GUIDED SPINE DIAGNOSTIC ANESTHESIA PERQ IMAGE GUIDED SPINE THERAPEUTIC ANES 2/3 DGR BRN EXC/DBRDMT +-GRF <4 % TBSA ANES 2/3 DGR BRN EXC/DBRDMT +-GRF 4-9 % TBSA ANES 2/3 DGR BRN EXC/DBRDMT +-GRF EA >9 % TBSA ANESTHESIA EXTERNAL CEPHALIC VERSION ANESTHESIA VAGINAL DELIVERY ONLY ANESTHESIA CESAREAN DELIVERY ONLY ANES URGENT HYSTERECTOMY FOLLOWING DELIVERY ANESTHESIA C HYST W/O ANY LABOR ANALG/ANES CARE ANESTHESIA INCOMPLETE/MISSED ABORTION ANESTHESIA INDUCED ABORTION NEURAXIAL LABOR ANALG/ANES PLND VAG DLVR ANES C DLVR FLWG NEURAXIAL LABOR ANALG/ANES ANES C HYST FLWG NEURAXIAL LABOR ANALG/ANES PHYSIOL SUPPORT HRVG ORGAN FROM BRN-DEAD PT ANES DX/THER NRV BLK/NJX OTH/THN PRONE POS ANES DX/THER NERVE BLOCK/INJECTION PRONE POS DAILY HOSP MGMT EDRL/SARACH CONT DRUG ADMN UNLISTED ANESTHESIA PROCEDURE BR ANESTHESIA EXTREME AGE PATIENT UNDER 1 YR&> 70 See Page 28 + Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure 38 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

43 Section VI: Anesthesia Services Georgia Workers Compensation Medical Fee Schedule , ANESTHESIA Effective April 1, 2011 Medical Fee Schedule CODE MOD DESCRIPTION BASE UNIT ANES COMP UTILIZATION TOT BDY HYPOTHMIA See Page ANES COMP UTILIZATION CTRLLED HYPOTENSION See Page ANES COMP EMER CONDITIONS SPEC See Page 28 + Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 39

44

45 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). CPT Surgical Package Definition Inherent in the provision of any surgical procedure are certain components that may not be specifically identified in the code description, but are nonetheless included. These services may include the following components: Local anesthesia including topical, infiltration, metacarpal/metatarsal/digital block One E/M service, other than the decision for surgery, on the date prior to, or date of the procedure and includes related history and physical Postoperative services immediately following the procedure including discussion with the family and other physicians, dictation of operative report, writing operative summary and orders in the patient chart Evaluation of the patient after transfer from the post anesthesia recovery area Postoperative follow-up care associated with the procedure Unusual Service or Procedure Services that may necessitate skills and time of the physician over and above that usually required should be substantiated by report (see section IV). Unlisted Service or Procedure Some services performed are not described by any CPT code. These services should be reported using an unlisted code and substantiated using a report. The unlisted services and accompanying codes are listed at the end of each Surgery subsection. Unlisted service or procedure codes must be selected from the appropriate subsection of the Surgery chapter. For these procedures a BR (by report) designation has been used in the fee schedule. Reimbursement for such procedures must be justified by report (see section IV). 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 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 percent 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 assistant (PA) if utilized in the place of an assistant surgeon during surgical procedures are to be reimbursed at 10 percent of the primary surgeon s fee. In accordance with O.C.G.A , 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 modifier AS to the usual procedure number to identify the services and list on a separate line from surgeon s fee on the CMS-1500 or a Uniform Billing 04 (UB-04) or electronic form. Separate Procedure Performed by Assistants Certain procedures are an inherent portion of a procedure or 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. Co-Surgeons When medically indicated during surgery, and when two different specialists are performing separate procedures for treatment of a common problem, each physician shall reduce CPT only 2010 American Medical Association. All Rights Reserved. 41

46 Georgia Workers Compensation Medical Fee Schedule the fee of their particular procedure by 25 percent 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. Immediate Preoperative Visits and Other Services by the Surgeon Under most circumstances, including ordinary referrals, the immediate preoperative 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. If a health care provider other than the physician performing the surgery performs the preoperative history and physical, then it shall be billed using modifier 56. Total reimbursement for preoperative and postoperative components should not exceed that defined by the listed value except under the following circumstances: A. When the preoperative 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. 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 preoperative visit is a consultation as defined in this schedule, use CPT codes through C. When procedures not usually part of the basic surgical procedure (e.g., bronchoscopy before chest surgery) are provided during the immediate preoperative 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 22. E. Suture removal by the same physician or an associate will be included in the charge for the original procedure. Follow-Up Days The number of consecutive postoperative follow-up days allowed is listed in the column titled FUD adjacent to the MAR column for the specific surgical CPT code. The number of follow-up days allowed is the FUD for the primary procedure. For procedures in the fee schedule designating Section VII: Surgical Services 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 for subsequent encounters. When 000 is listed in the FUD column, services provided the day of the procedure are included in the fee schedule amount. When 010 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 090 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. When MMM appears in the FUD column, the code represents a maternity service and the normal follow-up concept does not apply. When XXX appears in the FUD column, the global surgery concept does not apply. When YYY appears in the FUD column, the service is too variable to assign a follow-up period and the follow-up days are to be determined by report. When ZZZ appears in the FUD column, the code is an add-on service and, therefore, is treated in the global period of the other procedure billed. To report a postoperative follow-up visit for documentation purposes only, use CPT code 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. Follow-Up Care For Diagnostic Procedures A diagnostic procedure is one in which the patient is still being diagnosed with consideration for possible treatment. Care related to recover from diagnostic procedures is included in the appropriate diagnostic procedure code. Ongoing care for the condition or symptoms that prompted the diagnostic procedure or other conditions is not included and may be listed separately. Follow-Up Care For Therapeutic Surgical Procedures A therapeutic procedure is one that provides a therapy or treatment for the patient s condition. Such therapy may be surgical. If complications, exacerbations or the recurrence or presence of other conditions or injuries require additional services during the postoperative period of the original therapeutic surgical service, those services may be reported separately. 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 42 CPT only 2010 American Medical Association. All Rights Reserved.

47 Section VII: Surgical Services and in accordance with medical ethics. (See modifier 54 or 55.) 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 (e.g., presurgical assessment). 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). Failed Endoscopic Service When an endoscopic service is attempted and fails and another surgical service is necessary, only the successful service may be reported. For example, if a laparoscopic cholecystectomy is attempted and fails and an open cholecystectomy is performed, only the open cholecystectomy can be reported. Sequential Procedures An initial approach to a procedure may be followed at the same encounter by a second, usually more invasive approach. There may be separate CPT codes describing each service. The second procedure is usually performed because the initial approach was unsuccessful in accomplishing the medically necessary service; these procedures are considered sequential procedures. Only the CPT code for one of the services, generally the more invasive service, should be reported. An example of this situation is a failed laparoscopic cholecystectomy, followed by an open cholecystectomy at the same session. Only the code for the successful procedure, in this case the open cholecystectomy, may be reported. This rule does not apply to planned multiple surgical procedures but they are subject to the modifier 51 rule for multiple procedures. Incidental Procedures Incidental procedures, which are not customary, will not be reimbursed (e.g., an appendectomy during a cholecystectomy). Separate Procedure Certain procedures are an inherent portion of a procedure or service identified by the inclusion of the term separate procedure. When a procedure that is ordinarily a component of a larger procedure is performed at the same session, it should not be reported in addition to the code for Georgia Workers Compensation Medical Fee Schedule the total procedure or service of which it is considered an integral component. When a separate procedure is carried out as a separate entity not immediately related to other services, the indicated value for a separate procedure is applicable. Therefore, 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. (See modifier 59.) Surgical Destruction Destruction or ablation of tissue is considered an inherent portion of surgical procedures, and may be by any of the following methods used alone or in combination: electrosurgery, cryosurgery, laser, and chemical treatment. Unless specified by the CPT code description, destruction by any method does not change the selection of code to report the surgical service. Bilateral and Multiple Surgical Procedures Bilateral procedures require that modifier 50 be listed beside the surgery CPT code, thereby providing for supplemental reimbursement. Where multiple procedures are performed at the same operative site, the primary procedure is billed at 100 percent, and all other procedures are billed at 50 percent of the listed fee. Bilateral and secondary surgical procedures performed in separate areas will be billed at 100 percent of the listed fee. Where bilateral surgical procedures are performed through a common incision, the primary procedure will be billed at 100 percent, and the second procedure on the opposite side will be billed at 50 percent 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 percent 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. Subsection Information In the CPT book, several of the surgery subsections have definitions, guidelines, and instructions for reporting services contained in the subsection. This information generally follows the subsection heading. Adhere to the CPT only 2010 American Medical Association. All Rights Reserved. 43

48 Georgia Workers Compensation Medical Fee Schedule coding definitions, guidelines, and instructions contained in the CPT book unless otherwise instructed here. Wound Repair (Closure) Wound repair (closure) procedures may be accomplished by one or more of the following techniques: sutures, staples, or tissue adhesives. Wound closure or dressing may also include adhesive strips. When adhesive strips are the only method of closure, the service is reported using the appropriate E/M code. The repair of wounds may be classified as simple, intermediate, or complex: Simple Repair: Surgical closure of a superficial wound, requiring single layer closure of the skin (epidermis, dermis, or subcutaneous tissue). Local anesthesia is included. Simple repair includes chemical or electrocauterization. Intermediate Repair: Surgical closure of a wound requiring closure of one or more of the deeper subcutaneous tissue and non-muscle fascia layers in addition to suturing the skin. Simple wounds with heavy contamination that require extensive debridement may also be considered to require intermediate repair. Complex Repair: Surgical closure of a wound requiring more than layered closure of the deeper subcutaneous tissue and fascia (i.e., debridement, scar excision, placement of stents or retention sutures, and sometimes site preparation or undermining that creates the defect requiring complex closure). Excision of benign or malignant lesions is not inherent in complex repairs. Surgical Injections Surgical injections delineated as per injection by CPT descriptor and nomenclature warrant additional reimbursement per injection and are subject to the multiple procedure rules within the same body area. Bone and Other Tissue Grafts When a separate incision is used to obtain grafts, they may be reported separately. If the code description includes obtaining the graft, a separate code may not be reported. Grafts include autogenous bone, cartilage, tendon, fascia lata grafts or other tissues. Grafting codes, , do not usually require co-surgeons and should not be reported with modifier 62. Plastic and metallic implant or nonautogenous graft materials supplied by the physician are to be valued at the cost to the facility. A wholesale vendor invoice must be included with the bill sent to the payor. Notice to the payor Section VII: Surgical Services shall be given in advance of this added charge for the graft, except in emergency/urgent care procedures. Carticel The carticel (cartilage growth process) may be billed by using CPT code A special report describing the physician s use of carticel must accompany the billing of this code. 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 Application of Casts Casting and strapping codes are used to report replacement procedures during or after the period of follow-up care. These codes can also be used when the cast application or strapping is an initial service performed to stabilize or protect a fracture, injury, or dislocation without a restorative treatment or procedure. A restorative treatment or procedure rendered by another physician following the application of the initial cast, splint, or strap may be reported with a treatment of fracture and/or dislocation code. A physician who applies the initial cast, strap, or splint and also assumes all the subsequent fracture, dislocation, or injury care cannot use the application of casts and strapping codes as an initial service. The first cast, splint, or strap application is included as part of the service of the treatment of the fracture and dislocation codes. Initial stabilization using a temporary cast, splint, or strap is inherent in the definitive treatment of the fracture or dislocation and not separately reported. Only when a significant or separate service is provided may an E/M code be reported with the application of a cast, splint, or strap. When an initial service consists of cast application or strapping in addition to evaluation and management, and definitive treatment will not be provided, the cast, splint, or strapping may be reported in addition to the appropriate E/M code. Vertebral Arthrodesis All arthrodesis procedures include vertebral graft preparations, such as discectomy necessary to accomplish the arthrodesis. Arthroscopic Surgery Arthroscopic surgery procedures include diagnostic exams, simple debridement or removal of foreign bodies in the global fees; therefore, only one fee will be allowed unless special circumstances warrant otherwise. Special circumstances may include multiple procedures involving different compartments or approaches for the same joint, 44 CPT only 2010 American Medical Association. All Rights Reserved.

49 Section VII: Surgical Services arthroscopically assisted open procedures, and reconstruction of multiple structures. In such cases multiple procedures may be reimbursed in accordance with CCI edits, however, operative notes must be sent for review. Microsurgery Code is used to report the use of a surgical microscope for microsurgery techniques. This code is an add-on code and should not be reported with modifier 51. Do not report the use of magnifying loupes or corrected vision separately. The descriptions of some codes specify the use of microsurgery. A list of these codes can be found with code in CPT Internal neurolysis requiring the use of an operating microscope is reported using CPT code and code is not reported at the same surgical session. Microsurgery is allowed only in the case of surgery on nerves or blood vessels not explicitly excluded in CPT guidelines. For those operative surgical procedures requiring the use of the operative microscope, CPT code shall be used, and an additional fee of 25 percent of the billed procedure (not to exceed $358.93) will be allowed. 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 the appropriate two-digit modifier following the procedure code. When two modifiers are applicable to a single code, indicate each modifier on the bill. 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 (Evaluation and Management, 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 Increased Procedural Services: When the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. Georgia Workers Compensation Medical Fee Schedule Documentation must support the substantial additional work and the reason for the additional work (i.e., increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). Note: This modifier should not be appended to an E/M service. 25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service: Refer to E/M section. 26 Professional Component: 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 modifier 26 to the usual procedure number. 47 Anesthesia by Surgeon: Refer to Anesthesia section. 50 Bilateral Procedure: Unless otherwise identified in the listings, bilateral procedures that are performed at the same session should be identified by adding modifier 50 to the appropriate five-digit code. Unless otherwise indicated, the total reimbursed for the bilateral procedure is 150 percent of the fee schedule for unilateral surgery. 51 Multiple Procedures: When multiple procedures, other than evaluation and management services, physical medicine and rehabilitation services, or provision of supplies (e.g., vaccines) are performed at the same session by the same provider, the primary procedure or service may be reported as listed. The additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). Note: This modifier should not be appended to designated add-on codes (see Appendix D of the CPT book). When each procedure is clearly defined, the following values shall prevail: 100 percent of the first or major procedure 50 percent of all additional procedures 52 Reduced Services: Under certain circumstances, a service or procedure is partially reduced or eliminated at the physician s discretion. Under these circumstances, the service provided can be identified by its usual procedure number and the addition of modifier 52 signifying that the service is reduced. This provides a means of reporting reduced services without disturbing the identification of the basic service. Note: For hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 CPT only 2010 American Medical Association. All Rights Reserved. 45

50 Georgia Workers Compensation Medical Fee Schedule (see modifiers approved for ASC hospital outpatient use). 53 Discontinued Procedure: Under certain circumstances, the physician may elect to terminate 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 modifier 53 to the code reported by the physician for the discontinued procedure. 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. For outpatient hospital/ambulatory surgery center (ASC) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for ASC hospital outpatient use). 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 modifier 54 to the usual procedure number. See Section VII: 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 physician performed the postoperative management and another physician performed the surgical procedure, the postoperative component may be identified by adding modifier 55 to the usual procedure number. The maximum reimbursement for this modifier is 20 percent of the total value of the surgery. 56 Preoperative Management Only: When one physician performed the preoperative care and evaluation and another physician performed the surgical procedure, the preoperative component may be identified by adding modifier 56 to the usual procedure number. The maximum reimbursement for this modifier is 10 percent of the total value of the surgery. 57 Decision for Surgery: An evaluation and management service that resulted in the initial decision to perform the surgery may be identified by adding modifier 57 to the appropriate level of E/M service. 58 Staged or Related Procedure or Service by the Same Physician During the Postoperative Period: It may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more Section VII: Surgical Services extensive than the original procedure; or (c) for therapy following a surgical procedure. This circumstance may be reported by adding modifier 58 to the staged or related procedure. Note: For treatment of a problem that requires a return to the operating or procedure room (e.g., unanticipated clinical condition), see modifier Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision or 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 individual. 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. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-e/m service performed on the same date, see modifier Two Surgeons: When two surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. Each surgeon should report the co-surgery once using the same procedure code. If additional procedure(s) (including add-on procedure(s) are performed during the same surgical session, separate code(s) may also be reported with modifier 62 added. Note: If a co-surgeon acts as an assistant in the performance of additional procedure(s) during the same surgical session, those services may be reported using separate procedure code(s) with modifier 80 or modifier 82 added, as appropriate. The reimbursement amount applicable for each co-surgeon is 75 percent of the surgical CPT code listed in the fee schedule. 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 46 CPT only 2010 American Medical Association. All Rights Reserved.

51 Section VII: Surgical Services with the addition of modifier 66 to the basic procedure number used for reporting services. 76 Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional: It may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. This circumstance may be reported by adding modifier 76 to the repeated procedure or service. Note: This modifier should not be appended to an E/M service. 77 Repeat Procedure or Service by Another Physician or Other Qualified Health Care Professional: It may be necessary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service. This circumstance may be reported by adding modifier 77 to the repeated procedure or service. Note: This modifier should not be appended to an E/M service. 78 Unplanned Return to the Operating Room/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period: It may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). When this procedure is related to the first and requires the use of the operating or procedure room, it may be reported by adding modifier 78 to the related procedure. (For repeat procedures, see modifier 76.) 79 Unrelated Procedure or Service by the Same Physician during the Postoperative Period: The physician 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 modifier 79. (For repeat procedures on the same day, see modifier 76.) 80 Assistant Surgeon: Surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). 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. These services are valued at 20 percent of the listed value. 81 Minimum Assistant Surgeon: Minimum surgical assistant services are identified by adding modifier 81 to Georgia Workers Compensation Medical Fee Schedule the usual procedure number. These services are valued at 20 percent of the listed value. 82 Assistant Surgeon (when qualified resident surgeon not available): The unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). 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. AS Physician Assistant, Nurse Practitioner, Clinical Nurse Specialist Services, or Registered Nurse First Assistant (RNFA) for Assistant at Surgery: Report modifier AS when a physician assistant, nurse practitioner, clinical nurse specialist, or registered nurse first assistant, provides assistant at surgery services. Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery are reimbursed at 10 percent of the listed value. LT Left Side: Used to identify procedures performed on the left side of the body. PE Physician Assistant or Nurse Practitioner (State Specific Modifier): Physician assistant, registered nurse first assistant, or nurse practitioner services are identified by adding 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 Nursing and/or licensed or certified in the state where services are provided. In accordance with O.C.G.A , the RNFA shall not be on the staff of a hospital or the treating physician. Modifier PE will be at 85 percent of the MAR. RT Right Side: Used to identify procedures performed on the right side of the body. TC 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 modifier TC to the usual procedure number. CPT only 2010 American Medical Association. All Rights Reserved. 47

52 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, FINE NEEDLE ASPIRATION W/O IMAGING GUIDANCE XXX FINE NEEDLE ASPIRATION WITH IMAGING GUIDANCE XXX ACNE SURGERY INCISION & DRAINAGE ABSCESS SIMPLE/SINGLE INCISION&DRAINAGE ABSCESS COMPLICATED/MULTIPLE INCISION & DRAINAGE PILONIDAL CYST SIMPLE INCISION & DRAINAGE PILONIDAL CYST COMPLICATED INCISION&REMOVAL FOREIGN BODY SUBQ TISS SMPL INCISION&REMOVAL FOREIGN BODY SUBQ TISS COMP I&D HEMATOMA SEROMA/FLUID COLLECTION PUNCTURE ASPIRATION ABSCESS HEMATOMA BULLA/CYST INCISION&DRAINAGE COMPLEX PO WOUND INFECTION DBRDMT X10SV ECZMT/INFCT SKN UP 10% BDY SURF DBRDMT X10SV ECZMT/INFCT SKN EA 10% BDY SURF ZZZ DBRDMT SKN SUBQ T/M/F NECRO INFCTJ GENT&PR DBRDMT SKN SUBQ T/M/F NECRO INFCTJ ABDL WALL DBRDMT SKN SUBQ T/M/F NECRO INFCTJ GENT/ABDL REMOVAL PROSTHETIC MATRL ABDL WALL FOR INFECTION ZZZ s DBRDMT W/RMVL FM FX&/DISLC SKN&SUBQ TISS s DBRDMT W/RMVL FM FX&/DISLC SKN SUBQ T/M/F MUSC s DBRDMT FX&/DISLC SUBQ T/M/F BONE s DEBRIDEMENT SUBCUTANEOUS TISSUE 20 SQ CM/< s DEBRIDEMENT MUSCLE & FASCIA 20 SQ CM/< s DBRDMT BONE M&/F 20 SQ CM/< l + # DBRDMT SUBCUTANEOUS TISSUE EA ADDL 20 SQ CM ZZZ l + # DBRDMT M&/F EA ADDL 20 SQ CM ZZZ l + # DEBRIDEMENT BONE EA ADDL 20 SQ CM/< ZZZ PARING/CUTTING BENIGN HYPERKERATOTIC LESION PARING/CUTTING BENIGN HYPERKERATOTIC LESION 2-4< PARING/CUTTING BENIGN HYPERKERATOTIC LESION > BX SKIN SUBCUTANEOUS&/MUCOUS MEMBRANE 1 LESION BIOPSY SKN SUBQ&/MUC MEMB EA SPX ADDL LESION ZZZ REMOVAL SK TGS MLT FIBRQ TAGS ANY AREA UP&W/15< REMOVAL SK TGS MLT FIBRQ TAGS ANY AREA EA 10< ZZZ SHAVING SKIN LES 1 TRUNK/ARM/LEG DIAM 0.5CM/< SHVG SKIN LES 1 TRUNK/ARM/LEG DIAM CM SHVG SKN LESION 1 TRUNK/ARM/LEG DIAM CM SHVG SKIN LESION 1 TRUNK/ARM/LEG DIAM >2.0 CM SHAVING SKIN LESION 1 S/N/H/F/G DIAM 0.5 CM/< SHAVING SKIN LESION 1 S/N/H/F/G DIAM CM SHAVING SKIN LESION 1 S/N/H/F/G DIAM CM SHAVING SKIN LESION 1 S/N/H/F/G DIAM >2.0 CM SHAVING SKIN LESION 1 F/E/E/N/L/M DIAM 0.5 CM/< SHVG SKIN LESION 1 F/E/E/N/L/M DIAM CM SHVG SKIN LESION 1 F/E/E/N/L/M DIAM CM SHAVING SKIN LESION 1 F/E/E/N/L/M DIAM >2.0 CM CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

53 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule EXC B9 LES MRGN XCP SK TG T/A/L 0.5 CM/< EXC B9 LES MRGN XCP SK TG T/A/L CM EXC B9 LES MRGN XCP SK TG T/A/L CM EXC B9 LES MRGN XCP SK TG T/A/L CM EXC B9 LES MRGN XCP SK TG T/A/L CM EXC B9 LES MRGN XCP SK TG T/A/L > 4.0 CM EXC B9 LES MRGN XCP SK TG S/N/H/F/G 0.5 CM/< EXC B9 LES MRGN XCP SK TG S/N/H/F/G CM EXC B9 LES MRGN XCP SK TG S/N/H/F/G CM EXC B9 LES MRGN XCP SK TG S/N/H/F/G CM EXC B9 LES MRGN XCP SK TG S/N/H/F/G CM EXC B9 LES MRGN XCP SK TG S/N/H/F/G > 4.0CM EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 0.5CM/< EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M CM EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M CM EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M CM EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M CM EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M > 4.0CM EXCISION HIDRADENITIS AXILLARY SMPL/INTRM RPR EXCISION HIDRADENITIS AXILLARY COMPLEX REPAIR EXCISION HIDRADENITIS INGUINAL SMPL/INTRM RPR EXCISION HIDRADENITIS INGUINAL COMPLEX REPAIR EXCISION H/P/P/U SIMPLE/INTERMEDIATE REPAIR EXCISION H/P/P/U COMPLEX REPAIR EXCISION MAL LESION TRUNK/ARM/LEG 0.5 CM/< EXCISION MAL LESION TRUNK/ARM/LEG CM EXCISION MAL LESION TRUNK/ARM/LEG CM EXCISION MAL LESION TRUNK/ARM/LEG CM EXCISION MAL LESION TRUNK/ARM/LEG CM EXCISION MALIGNANT LESION TRUNK/ARM/LEG >4.0 CM EXCISION MALIGNANT LESION S/N/H/F/G 0.5 CM/< EXCISION MALIGNANT LESION S/N/H/F/G CM EXCISION MALIGNANT LESION S/N/H/F/G CM EXCISION MALIGNANT LESION S/N/H/F/G CM EXCISION MALIGNANT LESION S/N/H/F/G CM EXCISION MALIGNANT LESION S/N/H/F/G > 4.0 CM EXCISION MALIGNANT LESION F/E/E/N/L/M 0.5 CM/< EXCISION MALIGNANT LES F/E/E/N/L/M CM EXCISION MALIGNANT LES F/E/E/N/L/M CM EXCISION MALIGNANT LES F/E/E/N/L/M CM EXCISION MALIGNANT LES F/E/E/N/L/M CM EXCISION MALIGNANT LESION F/E/E/N/L/M > 4.0 CM TRIMMING NONDYSTROPHIC NAILS ANY NUMBER DEBRIDEMENT NAIL ANY METHOD DEBRIDEMENT NAIL ANY METHOD 6/> AVULSION NAIL PLATE PARTIAL/COMPLETE SIMPLE Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 49

54 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, AVULSION NAIL PLATE PARTIAL/COMPLETE SMPL EA ZZZ EVACUATION SUBUNGUAL HEMATOMA EXCISION NAIL MATRIX PERMANENT REMOVAL EXC NAIL MATRIX PRM RMVL W/AMP TUFT DSTL PHALANX BIOPSY NAIL UNIT SPX REPAIR NAIL BED RECONSTRUCTION NAIL BED W/GRAFT WEDGE EXCISION SKIN NAIL FOLD EXCISION PILONIDAL CYST/SINUS SIMPLE EXCISION PILONIDAL CYST/SINUS EXTENSIVE EXCISION PILONIDAL CYST/SINUS COMPLICATED INJECTION INTRALESIONAL UP TO & INCL INJECTION INTRALESIONAL > TATTOOING INCL MICROPIGMENTATION 6.0 CM/< TATTOOING INCL MICROPIGMENTATION CM TATTOOING INCL MICROPIGMENTATION EA 20.0 CM ZZZ SUBCUTANEOUS INJECTION FILLING MATERIAL 1 CC/< SUBCUTANEOUS INJECTION FILLING MATRL CC SUBCUTANEOUS INJECTION FILLING MATRL CC SUBCUTANEOUS INJECTION FILLING MATRL > 10.0 CC INSERTION TISSUE EXPANDER INCL SBSQ XPNSJ REPLACEMENT TISS EXPANDER PERMANENT PROSTHESIS REMOVAL TISS EXPANDER W/O INSERTION PROSTHESIS INSERTION IMPLANTABLE CONTRACEPTIVE CAPSULES XXX REMOVAL IMPLANTABLE CONTRACEPTIVE CAPSULES RMVL W/RINSJ IMPLANTABLE CONTRACEPTIVE CAPSULES XXX SUBCUTANEOUS HORMONE PELLET IMPLANTATION INSJ NON-BIODEGRADABLE DRUG DELIVERY IMPLANT XXX REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT XXX RMVL W/RINSJ NON-BIODEGRADABLE DRUG DLVR IMPLT XXX SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/< SMPL REPAIR SCALP/NECK/AX/GENIT/TRUNK CM SIMPLE RPR SCALP/NECK/AX/GENIT/TRUNK CM SMPL RPR SCALP/NECK/AX/GENIT/TRUNK CM SMPL RPR SCALP/NECK/AX/GENIT/TRUNK CM SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK >30.0CM SIMPLE REPAIR F/E/E/N/L/M 2.5CM/< SIMPLE REPAIR F/E/E/N/L/M 2.6CM-5.0CM SIMPLE REPAIR F/E/E/N/L/M 5.1CM-7.5CM SIMPLE REPAIR F/E/E/N/L/M 7.6CM-12.5CM SIMPLE REPAIR F/E/E/N/L/M 12.6CM-20.0CM SIMPLE REPAIR F/E/E/N/L/M 20.1CM-30.0CM SIMPLE REPAIR F/E/E/N/L/M >30.0CM TX SUPERFICIAL WOUND DEHISCENCE SIMPLE CLOSURE TX SUPERFICIAL WOUND DEHISCENCE W/PACKING REPAIR INTERMEDIATE S/A/T/E 2.5 CM/< CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

55 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule REPAIR INTERMEDIATE S/A/T/E CM REPAIR INTERMEDIATE S/A/T/E CM REPAIR INTERMEDIATE S/A/T/E CM REPAIR INTERMEDIATE S/A/T/E CM REPAIR INTERMEDIATE S/A/T/E > 30.0 CM REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.5CM/< REPAIR INTERMEDIATE N/H/F/XTRNL GENT CM REPAIR INTERMEDIATE N/H/F/XTRNL GENT CM REPAIR INTERMEDIATE N/H/F/XTRNL GENT CM RPR INTERMEDIATE N/H/F/XTRNL GENT CM REPAIR INTERMEDIATE N/H/F/XTRNL GENT >30.0 CM REPAIR INTERMEDIATE F/E/E/N/L/M&/MUC 2.5 CM/< REPAIR INTERMEDIATE F/E/E/N/L/M&/MUC CM REPAIR INTERMEDIATE F/E/E/N/L/M&/MUC CM REPAIR INTERMEDIATE F/E/E/N/L/M&/MUC CM REPAIR INTERMEDIATE F/E/E/N/L/M&/MUC CM REPAIR INTERMEDIATE F/E/E/N/L/M&/MUC CM REPAIR INTERMEDIATE F/E/E/N/L/M&/MUC > 30.0 CM REPAIR COMPLEX TRUNK 1.1 CM-2.5 CM REPAIR COMPLEX TRUNK 2.6 CM-7.5 CM REPAIR COMPLEX TRUNK EA 5 CM/< ZZZ REPAIR COMPLEX SCALP/ARM/LEG 1.1 CM-2.5 CM REPAIR COMPLEX SCALP/ARM/LEG 2.6 CM-7.5 CM REPAIR COMPLEX SCALP/ARM/LEG EA 5 CM/< ZZZ REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 1.1 CM-2.5 CM REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6 CM-7.5 CM REPAIR COMPLEX F/C/C/M/N/AX/G/H/F EA 5 CM/< ZZZ REPAIR COMPLEX EYELID/NOSE/EAR/LIP 1.0 CM/< REPAIR COMPLEX EYELID/NOSE/EAR/LIP CM REPAIR COMPLEX EYELID/NOSE/EAR/LIP CM REPAIR COMPLEX EYELID/NOSE/EAR/LIP EA 5 CM/< ZZZ SEC CLSR SURG WOUND/DEHSN EXTENSIVE/COMPLICATED ADJACENT TISSUE TRANSFER/REARGMT TRUNK 10 CM/< ATT/REARRANGEMENT TRUNK CM ATT/REARRANGEMENT SCALP/ARM/LEG 10 CM/< ATT/REARRANGEMENT SCALP/ARM/LEG CM ATT/REARRANGEMENT F/C/C/M/N/AX/G/H/F 10 CM/< ATT/REARGMT F/C/C/M/N/AX/G/H/F CM ATT/REARGMT E/N/E/L DFCT 10 CM/< ATT/REARGMT EYELID/NOSE/EAR/LIP CM ATT/R ANY AREA DEFECT SQCM ATT/R ANY AREA DEFECT EA ADDL 30SQCM OR PART ZZZ FILLETED FINGER/TOE FLAP W/PREPJ RECIPIENT SITE PREP SITE TRUNK/ARM/LEG 1ST 100 SQ CM/1PCT PREP SITE T/A/L ADDL 100 SQ CM/1PCT ZZZ PREP SITE F/S/N/H/F/G/M/D GT 1ST 100 SQ CM/1PCT Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 51

56 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, PREP SITE F/S/N/H/F/G/M/D GT ADDL 100 SQ CM/1PCT ZZZ HARVEST SKIN TISSUE CLTR SKIN AGRFT 100 CM/< PINCH GRAFT 1/MLT C> SM ULCER TIP/OTH AREA 2CM SPLIT AGRFT T/A/L 1ST 100 CM/</1% BDY INFT/CHLD SPLIT AGRFT T/A/L EA 100 CM/EA 1% BDY INFT/CHLD ZZZ EPIDRM AGRFT T/A/L 1ST 100 CM/</1% BDY INFT/CHLD EPIDRM AGRFT T/A/L EA 100 CM/EA 1% BDY INFT/CHLD ZZZ EPIDERMAL AGRFT F/S/N/H/F/G/M/D GT 1ST 100 CM EPIDERMAL AGRFT F/S/N/H/F/G/M/D GT EA 100 CM/EA ZZZ SPLIT AGRFT F/S/N/H/F/G/M/D GT 1ST 100 CM<1 % SPLIT AGRFT F/S/N/H/F/G/M/D GT EA 100 CM/EA 1 % ZZZ DERMAL AUTOGRAFT TRUNK/ARM/LEG 1ST 100 CM DERMAL AUTOGRAFT TRUNK/ARM/LEG EA 100 CM/EA ZZZ DERMAL AUTOGRAFT F/S/N/H/F/G/M/D GT 1ST DERMAL AGRFT F/S/N/H/F/G/M/D GT EA 100 CM/EA ZZZ CLTR EPIDERMAL AUTOGRAFT T/A/L 1ST 25 CM/< CLTR EPIDERMAL AGRFT T/A/L ADDL 1 CM-75 CM ZZZ CLTR EPIDRM AGRFT T/A/L EA 100 CM/EA 1 % BDY ZZZ CLTR EPIDRM AGRFT F/S/N/H/F/G/M/D GT 1ST 25CM/< CLTR EPIDRM AGRFT F/S/N/H/F/G/M/D GT ADDL 1-75CM ZZZ CLTR EPIDRM AGRFT F/S/N/H/F/G/M/D GT EA 100 EA ZZZ ACLR DRM RPLCMT T/A/L 1ST 100 CM/</1 % BDY ACLR DRM RPLCMT T/A/L EA 100 CM/EA 1 % BDY ZZZ ACLR DRM RPLCMT F/S/N/H/F/G/M/D GT 1ST 100 CM ACLR DRM RPLCMT F/S/N/H/F/G/M/D GT EA 100 CM/EA ZZZ FTH/GFT FREE W/DIRECT CLOSURE TRUNK 20 CM/< FTH/GFT FR W/DIR CLSR TRNK EA 20 CM ZZZ FTH/GFT FREE W/DIRECT CLOSURE S/A/L 20 CM/< FTH/GFT FR W/DIR CLSR S/A/L EA 20 CM ZZZ FTH/GFT FR W/DIR CLSR F/C/C/M/N/AX/G/H/F 20 CM/< FTH/GFT FR W/DIR CLSR F/C/C/M/N/AX/G/H/F EA 20CM ZZZ FTH/GFT FREE W/DIRECT CLOSURE N/E/E/L 20 CM/< FTH/GFT FR W/DIR CLSR N/E/E/L EA 20 CM ZZZ ALGRFT TEMPORARY CLOSURE T/A/L 1ST 100 CM/</ ALGRFT TEMPORARY CLOSURE T/A/L EA 100 CM/EA ZZZ ALGRFT TEMP CLOSURE F/S/N/H/F/G/M/D 1ST 100CM ALGRFT TEMP CLOSURE F/S/N/H/F/G/M/D EA 100CM ZZZ ACLR DERMAL ALLOGRAFT TRUNK/ARM/LEG 1ST 100 CM ACLR DERMAL ALLOGRAFT TRUNK/ARM/LEG EA 100CM/EA ZZZ ACLR DRM ALLOGRAFT F/S/N/H/F/G/M/D GT 1ST 100CM ACLR DRM ALGRFT F/S/N/H/F/G/M/D GT EA 100 CM/EA ZZZ TISSUE CULTURED ALLOGENEIC SKIN 1ST 25CM/< TISS CLTR ALGC SKN EA 25 CM ZZZ TISSUE CLTR ALGC DRM TRUNK/ARM/LEG 1ST 100 CM TISSUE CLTR ALGC DERMAL T/A/L EA 100CM/EA 1 PCT ZZZ TISS CLTR ALGC DRM F/S/N/H/F/G/M/D 1ST 100 CM CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

57 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule TISS CLTR ALGC DRM F/S/N/H/F/G/M/D EA 100 CM ZZZ XENOGRAFT TEMP CLOSURE TRUNK/ARM/LEG 1ST 100CM XENOGRAFT TEMP CLOSURE TRUNK/ARM/LEG EA 100CM ZZZ XENOGRF TEMP CLOSURE F/S/N/H/F/G/M/D 1ST 100CM XENOGRAFT TEMP CLOSURE F/S/N/H/F/G/M/D EA 100CM ZZZ ACELLULAR XENOGRAFT IMPLANT 1ST 100 CM/1 PCT ACELLULAR XENOGRAFT IMPLANT EA 100 CM/1 PCT ZZZ FRMJ DIRECT/TUBED PEDICLE +-TRANSFER TRUNK FRMJ DIRECT/TUBED PEDICLE +-TR SCALP ARMS/LEGS FRMJ DIR/TUBED PEDCL +-TR FT/CH/CH/M/N/AX/G/H/F FRMJ DIRECT/TUBED PEDICLE +-TR E/N/E/L/NTRORAL DELAY FLAP/SECTIONING FLAP TRUNK DELAY FLAP/SECTIONING FLAP SCALP ARMS/LEGS DELAY FLAP/SECTIONING FLAP F/C/C/N/AX/G/H/F DELAY FLAP/SCTJ FLAP EYELIDS NOSE EARS/LIPS TRANSFER ANY PEDICLE FLAP ANY LOCATION FOREHEAD FLAP W/ PRESERVATION VASCULAR PEDICLE MUSC MYOCUTANEOUS/FASCIOCUTANEOUS FLAP HEAD&NCK MUSC MYOCUTANEOUS/FASCIOCUTANEOUS FLAP TRUNK MUSC MYOCUTANEOUS/FASCIOCUTANEOUS FLAP UXTR MUSC MYOCUTANEOUS/FASCIOCUTANEOUS FLAP LXTR FLAP ISLAND PEDICLE FLAP NEUROVASCULAR PEDICLE FREE MUSCLE/MYOCUTANEOUS FLAP W/MVASC ANAST FREE SKIN FLAP W/MICROVASCULAR ANASTOMOSIS FREE FASCIAL FLAP W/MICROVASCULAR ANASTOMOSIS GRAFT COMPOSITE W/PRIMARY CLOSURE DONOR AREA GRAFT DERMA-FAT-FASCIA PUNCH GRAFT HAIR TRANSPLANT 1-15 PUNCH GRAFTS PUNCH GRAFT HAIR TRANSPLANT >15 PUNCH GRAFTS DERMABRASION TOTAL FACE DERMABRASION SEGMENTAL FACE DERMABRASION REGIONAL OTHER THAN FACE DERMABRASION SUPERFICIAL ANY SITE ABRASION 1 LESION ABRASION EACH ADDITIONAL 4 LESIONS OR LESS ZZZ CHEMICAL PEEL FACIAL EPIDERMAL CHEMICAL PEEL FACIAL DERMAL CHEMICAL PEEL NONFACIAL EPIDERMAL CHEMICAL PEEL NONFACIAL DERMAL CERVICOPLASTY BLEPHAROPLASTY LOWER EYELID BLEPHAROPLASTY LOWER EYELID HERNIATED FAT PAD BLEPHAROPLASTY UPPER EYELID BLEPHAROPLASTY UPPER EYELID W/EXCESSIVE SKIN RHYTIDECTOMY FOREHEAD Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 53

58 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, RHYTIDECTOMY NECK W/PLATYSMAL TIGHTENING RHYTIDECTOMY GLABELLAR FROWN LINES RHYTIDECTOMY CHEEK CHIN&NECK RHYTIDECTOMY SMAS FLAP EXCISION SKIN ABD INFRAUMBILICAL PANNICULECTOMY EXCISION EXCESSIVE SKIN&SUBQ TISSUE THIGH EXCISION EXCESSIVE SKIN&SUBQ TISSUE LEG EXCISION EXCESSIVE SKIN&SUBQ TISSUE HIP EXCISION EXCESSIVE SKIN&SUBQ TISSUE BUTTOCK EXCISION EXCESSIVE SKIN&SUBQ TISSUE ARM EXC EXCESSIVE SKIN&SUBQ TISSUE FOREARM/HAND EXC EXCSV SKIN&SUBQ TISSUE SUBMENTAL FAT PAD EXCISION EXCESSIVE SKIN&SUBQ TISSUE OTHER AREA GRAFT FACIAL NERVE PARALYSIS FREE FASCIAL GRAFT GRAFT FACIAL NERVE PARALYSIS FREE MUSCLE GRAFT GRF FACIAL NRV PALYSS FR MUSCLE FLAP MICROSURG GRF FACIAL NERVE PARALYSIS REGIONAL MUSCLE TR EXCISION EXCESSIVE SKIN & SUBQ TISSUE ABDOMEN YYY REMOVAL SUTURES UNDER ANESTHESIA SAME SURGEON XXX REMOVAL SUTURES UNDER ANESTHESIA OTHER SURGEON DRESSING CHANGE UNDER ANESTHESIA IV INJECTION TEST VASCULAR FLOW FLAP/GRAFT SUCTION ASSISTED LIPECTOMY HEAD&NECK BR SUCTION ASSISTED LIPECTOMY TRUNK BR SUCTION ASSISTED LIPECTOMY UPPER EXTREMITY BR SUCTION ASSISTED LIPECTOMY LOWER EXTREMITY BR EXC COCCYGEAL PR ULC W/COCCYGECTOMY W/PRIM SUTR EXC COCCYGEAL PR ULC W/COCCYGECTOMY W/FLAP CLSR EXCISION SACRAL PRESSURE ULCER W/PRIMARY SUTURE EXC SACRAL PRESSURE ULC W/PRIM SUTR W/OSTECTOMY EXCISION SACRAL PRESSURE ULCER W/SKIN FLAP CLSR EXC SACRAL PR ULCER W/SKN FLAP CLSR W/OSTECTOMY EXC SAC PR ULC PREPJ MUSC/MYOQ FLAP/SKN GRF CLSR EXC SAC PR ULC PREPJ MUSC/MYOQ FLAP/SKN GRF OSTC EXC ISCHIAL PRESSURE ULCER W/PRIMARY SUTURE EXC ISCHIAL PR ULC W/PRIM SUTR W/OSTC ISCHIECT EXC ISCHIAL PRESSURE ULCER W/SKIN FLAP CLOSURE EXC ISCHIAL PR ULC W/SKN FLAP CLSR W/OSTECTOMY EXC ISCHIAL PR ULCER W/OSTC MUSC/MYOQ FLAP/SKIN EXC TROCHANTERIC PRESSURE ULCER W/PRIMARY SUTR EXC TRCHNTRIC PR ULCER W/PRIM SUTR W/OSTECTOMY EXC TROCHANTERIC PR ULCER W/SKIN FLAP CLOSURE EXC TRCHNTRIC PR ULC W/SKN FLAP CLSR W/OSTECTOMY EXC TROCHANTERIC PR ULCER MUSC/MYOQ FLAP/SKIN EXC TRCHNTRIC PR ULC MUSC/MYOQ FLAP/SKIN W/OSTC UNLISTED PROCEDURE EXCISION PRESSURE ULCER BR YYY 54 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

59 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule INITIAL TX 1ST DEGREE BURN LOCAL TX DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ SMALL DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ MEDIUM DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ LARGE ESCHAROTOMY FIRST INCISION ESCHAROTOMY EACH ADDITIONAL INCISION ZZZ DESTRUCTION PREMALIGNANT LESION 1ST DESTRUCTION PREMALIGNANT LESION 2-14 EA ZZZ * DESTRUCTION PREMALIGNANT LESION 15/> DESTRUCTION CUTANEOUS VASC PROLIFERATIVE <10CM DESTRUCTION CUTANEOUS VASCULAR PRLF CM DESTRUCTION CUTANEOUS VASCULAR PRLF >50.0CM DESTRUCTION BENIGN LESIONS UP TO DESTRUCTION BENIGN LESIONS 15/> CHEMICAL CAUTERIZATION GRANULATION TISSUE DESTRUCTION MALIGNANT LESION T/A/L 0.5 CM/< DESTRUCTION MAL LESION TRUNK/ARM/LEG CM DESTRUCTION MAL LESION TRUNK/ARM/LEG CM DESTRUCTION MAL LESION TRUNK/ARM/LEG CM DESTRUCTION MAL LESION TRUNK/ARM/LEG CM DESTRUCTION MAL LESION TRUNK/ARM/LEG > 4.0 CM DESTRUCTION MALIGNANT LESION S/N/H/F/G 0.5 CM/< DESTRUCTION MALIGNANT LESION S/N/H/F/G CM DESTRUCTION MALIGNANT LESION S/N/H/F/G CM DESTRUCTION MALIGNANT LESION S/N/H/F/G CM DESTRUCTION MALIGNANT LESION S/N/H/F/G CM DSTRJ MAL LES S/N/H/F/G LES DIAM > 4.0 CM DESTRUCTION MALIGNANT LESION F/E/E/N/L/M 0.5CM/< DESTRUCTION MAL LESION F/E/E/N/L/M CM DESTRUCTION MAL LESION F/E/E/N/L/M CM DESTRUCTION MAL LESION F/E/E/N/L/M CM DESTRUCTION MAL LESION F/E/E/N/L/M CM DESTRUCTION MAL LESION F/E/E/N/L/M > 4.0 CM MOHS MICROGRAPHIC H/N/H/F/G 1ST STAGE 5 BLOCKS MOHS MICROGRAPHIC H/N/H/F/G EACH ADDL STAGE ZZZ MOHS TRUNK/ARM/LEG 1ST STAGE 5 BLOCKS MOHS TRUNK/ARM/LEG EA STAGE AFTER 1ST STAGE ZZZ MOHS TRUNK/ARM/LEG EA ADDL BLOCK ANY STAGE ZZZ CRYOTHERAPY CO2 SLUSH LIQ N2 ACNE CHEMICAL EXFOLIATION ACNE ELECTROLYSIS EPILATION EA 30 MINUTES UNLISTED PX SKIN MUC MEMBRANE &SUBQ TISSUE BR YYY PUNCTURE ASPIRATION CYST BREAST PUNCTURE ASPIRATION BREAST EA ADDL CYST ZZZ MASTOTOMY W/EXPL/DRAINAGE ABSCESS DEEP INJECTION MAMMARY DUCTOGRAM/GALACTOGRAM Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 55

60 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, BX BREAST NEEDLE CORE W/O IMAGING GUIDANCE SPX BIOPSY BREAST OPEN INCISIONAL BIOPSY BREAST NEEDLE CORE W/IMAGING GUIDANCE BREAST BIOPSY VACUUM ASSISTED/ROTATING DEVICE ABLTJ CRYOSURGICAL W/ US GID EA FIBROADENOMA NIPPLE EXPLORATION EXCISION LACTIFEROUS DUCT FISTULA EXC CYST/ABERRANT BREAST TISSUE OPEN 1/> LES EXC BRST LES PREOP PLMT RAD MARKER OPN 1 LES EXC BRST LES PREOP PLMT RAD MARKER OPN EA ADDL ZZZ EXCISION CHEST WALL TUMOR INCLUDING RIBS EXC CHEST TUMOR W/RCNSTJ W/O MEDSTNL LMPHADEC EXC CHEST TUMOR W/RCNSTJ W/MEDSTNL LMPHADEC PREOP PLACEMENT LOCALIZATION WIRE BREAST PREOP PLMT LOCALIZATION WIRE BREAST EA LESION ZZZ IMG GID PLMT MTLC LOCLZJ CLIP PRQ BRST BX/ASPIR ZZZ PLMT EXPANDABLE CATH BRST FOLLOWING PRTL MAST PLMT EXPANDABLE CATH BRST CONCURRENT PRTL MAST ZZZ K PLMT RADTHX BRACHYTX BRST FOLLOWING PRTL MAST MASTECTOMY GYNECOMASTIA MASTECTOMY PARTIAL MASTECTOMY PARTIAL W/AXILLARY LYMPHADENECTOMY MASTECTOMY SIMPLE COMPLETE MASTECTOMY SUBCUTANEOUS MAST RAD W/PECTORAL MUSCLES AXILLARY LYMPH NODES MAST RAD W/PECTORAL MUSC AX INT MAM LYMPH NODES MAST MODF RAD W/AX LYMPH NOD W/WO PECT/ALIS MIN MASTOPEXY REDUCTION MAMMAPLASTY MAMMAPLASTY AUGMENTATION W/O PROSTHETIC IMPLANT MAMMAPLASTY AUGMENTATION W/PROSTHETIC IMPLANT REMOVAL INTACT MAMMARY IMPLANT REMOVAL MAMMARY IMPLANT MATERIAL IMMT INSJ BRST PROSTH FLWG MASTOPEXY MAST/RCNSTJ DLYD INSJ BRST PROSTH FLWG MASTOPEXY MAST/RCNSTJ NIPPLE/AREOLA RECONSTRUCTION CORRECTION INVERTED NIPPLES BRST RCNSTJ IMMT/DLYD W/TISS EXPANDER SBSQ XPNSJ BRST RCNSTJ W/LATSMS D/SI FLAP WO PRSTHC IMPL BREAST RECONSTRUCTION FREE FLAP BREAST RECONSTRUCTION OTHER TECHNIQUE BREAST RECONSTRUCTION TRAM FLAP 1 PEDICLE BREAST RECONSTRUCTION TRAM 1 PEDCL MVASC ANAST BREAST RECONSTRUCTION TRAM FLAP DOUBLE PEDICLE OPEN PERIPROSTHETIC CAPSULOTOMY BREAST PERIPROSTHETIC CAPSULECTOMY BREAST CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

61 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule REVISION RECONSTRUCTED BREAST PREPARATION MOULAGE CUSTOM BREAST IMPLANT UNLISTED PROCEDURE BREAST BR YYY s I&D SOFT TISSUE ABSCESS SUBFASC EXPLORATION PENETRATING WOUND SPX NECK EXPLORATION PENETRATING WOUND SPX CHEST EXPL PENETRATING WOUND SPX ABDOMEN/FLANK/BACK EXPLORATION PENETRATING WOUND SPX EXTREMITY EXCISION EPIPHYSEAL BAR BIOPSY MUSCLE SUPERFICIAL BIOPSY MUSCLE DEEP BIOPSY MUSCLE PERCUTANEOUS NEEDLE BIOPSY BONE TROCAR/NEEDLE SUPERFICIAL BIOPSY BONE TROCAR/NEEDLE DEEP BIOPSY BONE OPEN SUPERFICIAL BIOPSY BONE OPEN DEEP BIOPSY VERTEBRAL BODY OPEN THORACIC BIOPSY VERTEBRAL BODY OPEN LUMBAR/CERVICAL INJECTION SINUS TRACT THERAPEUTIC SPX INJECTION SINUS TRACT DIAGNOSTIC REMOVAL FOREIGN BODY MUSCLE/TENDON SHEATH SIMPLE RMVL FOREIGN BODY MUSCLE/TENDON SHEATH DEEP/COMP INJECTION THERAPEUTIC CARPAL TUNNEL INJECTION 1 TENDON SHEATH/LIGAMENT APONEUROSIS INJECTION SINGLE TENDON ORIGIN/INSERTION INJECTION SINGLE/MLT TRIGGER POINT 1/2 MUSCLES INJECTION SINGLE/MLT TRIGGER POINT 3/> MUSCLES PLACEMENT NEEDLES MUSCLE SUBSEQUENT RADIOELEMENT ARTHROCENTESIS ASPIR&/INJECTION SMALL JT/BURSA ARTHROCENTESIS ASPIR&/INJECTION INTERM JT/BURSA ARTHROCENTESIS ASPIR&/INJECTION MAJOR JT/BURSA ASPIRATION&/INJECTION GANGLION CYST ANY LOCATION ASPIRATION&INJECTION TREATMENT BONE CYST INSERTION WIRE/PIN W/APPL SKELETAL TRACTION SPX APPLICATION CRANIAL TONG/STRTCTC FRAME W/REMOVAL APPLICATION HALO CRANIAL INCLUDING REMOVAL APPLICATION HALO PELVIC INCLUDING REMOVAL APPLICATION HALO FEMORAL INCLUDING REMOVAL s APPL HALO 6/> PINS THIN SKULL OSTEOLOGY REMOVAL TONG/HALO APPLIED BY ANOTHER PHYSICIAN REMOVAL IMPLANT SUPERFICIAL SPX REMOVAL IMPLANT DEEP APPLICATION UNIPLANE EXTERNAL FIXATION SYSTEM APPLICATION MULTIPLANE EXTERNAL FIXATION SYSTEM ADJUSTMENT/REVJ XTRNL FIXATION SYSTEM REQ ANES REMOVAL EXTERNAL FIXATION SYSTEM UNDER ANES Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 57

62 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, XTRNL FIXJ W/STEREOTACTIC ADJUSTMENT 1ST&SUBQ * XTRNL FIXJ W/STRTCTC ADJUSTMENT EXCHANGE STRUT REPLANTATION ARM COMPLETE AMPUTATION REPLANTATION FOREARM COMPLETE AMPUTATION REPLANTATION HAND COMPLETE AMPUTATION RPLJ DGT EXCEPT THMB MTCARPHLNGL JT COMPL AMP RPLJ DGT EXCLUDING THMB SUBLIMIS TDN COMPL AMP RPLJ THMB CARP/MTCRPL JT MP JT COMPL AMPUTATION RPLJ THUMB DISTAL TIP MP JOINT COMPL AMPUTATION REPLANTATION FOOT COMPLETE AMPUTATION BONE GRAFT ANY DONOR AREA MINOR/SMALL BONE GRAFT ANY DONOR AREA MAJOR/LARGE CARTILAGE GRAFT COSTOCHONDRAL CARTILAGE GRAFT NASAL SEPTUM FASCIA LATA GRAFT BY STRIPPER FASCIA LATA GRAFT INCISION & AREA EXPOSURE TENDON GRAFT FROM A DISTANCE TISSUE GRAFTS OTHER s ALLOGRAFT FOR SPINE SURGERY ONLY MORSELIZED XXX s ALLOGRAFT FOR SPINE SURGERY ONLY STRUCTURAL ZZZ AUTOGRAFT SPINE SURGERY LOCAL FROM SAME INCISION XXX AUTOGRAFT SPINE SURGERY MORSELIZED SEP INCISION ZZZ AUTOGRAFT SPINE SURGERY BICORT/TRICORT SEP INC ZZZ MNTR INTERSTITIAL FLUID PRESSURE CMPRT SYNDROME BONE GRAFT MICROVASCULAR ANASTOMOSIS FIBULA BONE GRAFT MICROVASCULAR ANAST ILIAC CREST BONE GRAFT MICROVASCULAR ANAST METATARSAL B1 GRF W/MVASC ANAST OTH/THN ILIAC CREST/METAR FREE OSTQ FLAP W/MVASC ANAST METAR/GREAT TOE FREE OSTQ FLAP W/MVASC ANASTOMOSIS ILIAC CREST FREE OSTQ FLAP W/MVASC ANASTOMOSIS METATARSAL FR OSTQ FLAP W/MVASC ANAST GRT TOE W/WEB SPACE * ELECTRICAL STIMULATION BONE HEALING NONINVASIVE * ELECTRICAL STIMULATION BONE HEALING INVASIVE LOW INTENSITY US STIMJ BONE HEALING NONINVASIVE K ABLATION BONE TUMOR RF PERCUTANEOUS CT GUIDANCE CPTR-ASST SURGICAL NAVIGATION IMAGE-LESS ZZZ UNLISTED PROCEDURE MUSCSKELETAL SYSTEM GENERAL BR YYY ARTHROTOMY TEMPOROMANDIBULAR JOINT EXCISION TUMOR SOFT TISS FACE/SCALP SUBQ < 2CM EXCISION TUMOR SOFT TISS FACE/SCALP SUBQ 2+CM EXC TUMOR SOFT TISS FACE&SCALP SUBFASCIAL < 2CM EXC TUMOR SOFT TISS FACE&SCALP SUBFASCIAL 2+CM RAD RESECTION TUMOR SOFT TISS FACE/SCALP < 2CM RAD RESECTION TUMOR SOFT TISS FACE/SCALP 2+CM EXCISION BONE MANDIBLE CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

63 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule EXCISION FACIAL BONE REMOVAL CONTOURING BENIGN TUMOR FACIAL BONE EXC BENIGN TUMOR/CYST MAXL/ZYGOMA ENCL & CURTG EXCISION TORUS MANDIBULARIS EXCISION MAXILLARY TORUS PALATINUS EXCISION MALIGNANT TUMOR MAXILLA/ZYGOMA EXCISION BENIGN TUMOR/CYST MANDIBLE ENCL&/CURTG EXCISION MALIGNANT TUMOR MANDIBLE EXCISION MALIGNANT TUMOR MANDIBLE RADICAL EXC BENIGN TUMOR/CYST MNDBL INTRA-ORAL OSTEOT EXC B9 TUM/CST MNDBL XTR-ORAL OSTEOT&PRTL MNDBLC EXC BENIGN TUMOR/CYST MAXL INTRA-ORAL OSTEOT EXC B9 TUM/CST MAXL XTR-ORAL OSTEOT&PRTL MAXLCT CONDYLECTOMY TEMPOROMANDIBULAR JOINT SPX MENISCECTOMY PRTL/COMPL TEMPOROMANDIBULAR JT SPX CORONOIDECTOMY SPX MANIPULATION TMJ THERAPEUTIC REQUIRE ANESTHESIA IMPRESSION&PREPARATION SURG OBTURATOR PROSTHESIS IMPRESSION & PREPARATION ORBITAL PROSTHESIS IMPRESSION&PREPARATION INTERIM OBTURATOR PROSTH IMPRESSION&PREPJ DEFINITIVE OBTURATOR PROSTHESIS IMPRESSION&PREPJ MANDIBULAR RESECTION PROSTHESIS IMPRESSION&PREPJ PALATAL AUGMENTATION PROSTHESIS IMPRESSION&PREPARATION PALATAL LIFT PROSTHESIS IMPRESSION&PREPARATION SPEECH AID PROSTHESIS IMPRESSION&PREPARATION ORAL SURGICAL SPLINT IMPRESSION&PREPARATION AURICULAR PROSTHESIS IMPRESSION&PREPARATION NASAL PROSTHESIS IMPRESSION&PREPARATION FACIAL PROSTHESIS BR UNLISTED MAXILLOFACIAL PROSTHETIC PROCEDURE BR YYY APPL HALO APPLIANCE MAXILLOFACIAL FIXATION SPX APPL INTERDENTAL FIXATION DEVICE NON-FX/DISLC INJECTION TEMPOROMANDIBULAR JOINT ARTHROGRAPHY GENIOPLASTY AUGMENTATION GENIOPLASTY SLIDING OSTEOTOMY SINGLE PIECE GENIOPLASTY 2/> SLIDING OSTEOTOMIES GENIOP SLIDING AGMNTJ W/INTERPOSAL BONE GRAFTS AGMNTJ MNDBLR BODY/ANGLE PROSTHETIC MATERIAL AGMNTJ MNDBLR BDY/ANGL W/B1 GRF ONLAY/INTERPOSAL REDUCTION FOREHEAD CONTOURING ONLY RDCTJ FHD CNTRG&PROSTHETIC MATRL/BONE GRAFT RDCTJ FHD CNTRG&SETBACK ANT FRONTAL SINUS WALL RCNSTJ MIDFACE LEFORT I 1 PIECE W/O BONE GRAFT RCNSTJ MIDFACE LEFORT I 2 PIECES W/O BONE GRAFT RCNSTJ MIDFACE LEFORT I 3/>PIECE W/O BONE GRAFT RCNSTJ MIDFACE LEFORT I 1 PIECE W/BONE GRAFTS Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 59

64 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, RCNSTJ MIDFACE LEFORT I 2 PIECES W/BONE GRAFTS RCNSTJ MIDFACE LEFORT I 3/>PIECE W/BONE GRAFTS RCNSTJ MIDFACE LEFORT II ANTERIOR INTRUSION RCNSTJ MIDFACE LEFORT II W/BONE GRAFTS RCNSTJ MIDFACE LEFORT III W/O LEFORT I RCNSTJ MIDFACE LEFORT III W/LEFORT I RCNSTJ MIDFACE LEFORT III W/FHD W/O LEFORT I RCNSTJ MIDFACE LEFORT III W/FHD W/LEFORT I RCNSTJ SUPERIOR-LATERAL ORBITAL RIM&LOWER FHD RCNSTJ BIFRONTAL SUPERIOR-LAT ORB RIMS&LWR FHD RCNSTJ FOREHEAD&/SUPRAORB RIMS W/ALGRF/PROSTC RCNSTJ FOREHEAD&/SUPRAORBITAL RIMS W/AUTOGRAFT RCNSTJ CONTOURING BENIGN TUMOR CRNL BONES XTRC RCNSTJ ORBIT/FHD/NASETHMD EXC B9 TUM GRF <40 CM RCNSTJ ORBIT/FHD/NASETHMD EXC B9 GRF >40 <80 CM RCNSTJ ORBIT/FHD/NASETHMD EXC B9 TUM GRF>80 CM RCNSTJ MDFC OTH/THN LEFORT OSTEOT&BONE GRAFTS RCNSTJ MNDBLR RAMI HRZNTL/VER/C/L OSTEOT W/O GRF RCNSTJ MNDBLR RAMI HRZNTL/VER/C/L OSTEOT W/GRF RCNSTJ MNDBLR RAMI&/BODY SGTL SPLT W/O INT RGD RCNSTJ MNDBLR RAMI&/BDY SGTL SPLT W/INT RGD FIXJ OSTEOTOMY MANDIBLE SEGMENTAL OSTEOTOMY MANDIBLE SGMTL W/GENIOGLOSSUS ADVMNT OSTEOTOMY MAXILLA SEGMENTAL OSTEOPLASTY FACIAL BONES AUGMENTATION OSTEOPLASTY FACIAL BONES REDUCTION GRAFT BONE NASAL/MAXILLARY/MALAR AREAS GRAFT BONE MANDIBLE GRAFT RIB CRTLG AUTOGENOUS FACE/CHIN/NOSE/EAR GRAFT EAR CRTLG AUTOGENOUS NOSE/EAR ARTHRP TEMPOROMANDIBULAR JOINT +-AUTOGRAFT ARTHROPLASTY TEMPOROMANDIBULAR JT W/ALLOGRAFT ARTHRP TMPRMAND JOINT W/PROSTHETIC REPLACEMENT RCNSTJ MNDBL XTRORAL W/TRANSOSTEAL BONE PLATE RCNSTJ MNDBL/MAXL SUBPRIOSTEAL IMPLANT PARTIAL RCNSTJ MNDBL/MAXL SUBPRIOSTEAL IMPLANT COMPLETE RCNSTJ MNDBLR CONDYLE W/BONE CARTLG AUTOGRAFTS RCNSTJ MANDIBLE/MAXL ENDOSTEAL IMPLANT PARTIAL RCNSTJ MANDIBLE/MAXL ENDOSTEAL IMPLANT COMPLETE RCNSTJ ZYGMTC ARCH/GLENOID FOSSA W/BONE CARTLG RECONSTRUCTION ORBIT W/OSTEOTOMIES&BONE GRAFTS PERIORBITAL OSTEOTOMIES BONE GRAFTS EXTRACRANIAL PERIORBITAL OSTEOTOMIES W/BONE GRAFTS ICRA&XTRC PERIORBITAL OSTEOTOMIES W/BONE GRAFTS W/FOREHEAD ORBITAL REPOSITIONING W/BONE GRAFTS EXTRACRANIAL ORBITAL REPOSITIONING W/BONE GRAFTS ICRA&XTRC CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

65 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule MALAR AUGMENTATION PROSTHETIC MATERIAL SECONDARY REVISION ORBITOCRANIOFACIAL RCNSTJ MEDIAL CANTHOPEXY SPX LATERAL CANTHOPEXY REDUCTION MASSETER MUSCLE&BONE EXTRAORAL REDUCTION MASSETER MUSCLE&BONE INTRAORAL UNLISTED CRANIOFACIAL&MAXILLOFACIAL PROCEDURE BR YYY CLOSED TREATMENT NASAL FRACTURE W/O MANIPULATION CLOSED TX NASAL FRACTURE W/O STABILIZATION CLOSED TREATMENT NASAL FRACTURE W/STABILIZATION OPEN TREATMENT NASAL FRACTURE UNCOMPLICATED OPEN TX NASAL FX COMP W/INT&/XTRNL SKELETAL FIXJ OPEN TX NASAL FX W/CONCOMITANT OPTX FXD SEPTUM OPEN TX NASAL SEPTAL FRACTURE +-STABILIZATION CLOSED TX NASAL SEPTAL FRACTURE +-STABILIZATION OPEN TX NASOETHMOID FX W/O EXTERNAL FIXATION OPEN TX NASOETHMOID FX W/EXTERNAL FIXATION PERCUTANEOUS TX NASOETHMOID COMPLEX FRACTURE OPEN TX DEPRESSED FRONTAL SINUS FRACTURE OPEN TX COMPLICATED FRONTAL SINUS FRACTURE CLOSED TX NASOMAXILLARY COMPLEX FRACTURE OPTX NASOMAX CPLX FX LEFT II TYPE W/WIRG&FIXJ OPTX NASOMAX CPLX FX LEFT II TYPE REQ MLT OPN OPTX NASOMAX CPLX FX LEFT II TYPE W/B1 GRFG PERCUTANEOUS TX MALAR AREA FRACTURE OPEN TX DEPRESSED ZYGOMATIC ARCH FRACTURE OPEN TX DEPRESSED MALAR FRACTURE OPEN TX COMP FX MALAR W/INTERNAL FX&MULT SURG OPEN TX COMP FRACTURE MALAR AREA W/BONE GRAFT OPEN TX ORBITAL FLOOR BLOWOUT FX TRANSANTRAL OPEN TX ORBITAL FLOOR BLOWOUT FX PERIORBITAL OPEN TX ORBITAL FLOOR BLOWOUT FX COMBINED APPR OPTX ORB FLOOR BLWT FX PRI/BITAL APPR W/ALLPLSTC OPTX ORB FLOOR BLWT FX PRI/BITAL APPR W/B1 GRF CLSD TX FX ORBIT EXCEPT BLOWOUT W/O MANIPULATION CLOSED TX FX ORBIT EXCEPT BLOWOUT W/MANIPULATION OPEN TX FX ORBIT EXCEPT BLOWOUT W/O IMPLANT OPEN TX FX ORBIT EXCEPT BLOWOUT W/IMPLANT OPEN TX FX ORBIT EXCEPT BLOWOUT W/BONE GRAFT CLOSED TX PALATAL/MAXILLARY FX W/FIXATION/SPLINT OPEN TREATMENT PALATAL/MAXILLARY FRACTURE OPEN TX PALATAL/MAXILLARY FX COMP MULTIPLE APPR CLOSED TX CRANIOFACIAL SEPARATION OPEN TX CRANIOFACIAL SEP W/WIRING&/INT FIXJ OPEN TX CRANIOFACIAL SEP COMPLICATED MLT APPR OPEN TX CRANIOFACIAL SEP COMP W/INT&/XTRNL FIXJ Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 61

66 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, OPTX CRANFCL SEP LEFT III TYP COMP INT FIXJ W/B CLTX MANDIBULAR/MAXILLARY ALVEOLAR RIDGE FX SPX OPTX MANDIBULAR/MAXILLARY ALVEOLAR RIDGE FX SPX CLOSED TX MANDIBULAR FRACTURE W/O MANIPULATION CLOSED TX MANDIBULAR FRACTURE W/MANIPULATION PERCUTANEOUS TX MANDIBULAR FX W/EXTERNAL FIXJ CLOSED TX MANDIBULAR FX W/INTERDENTAL FIXATION OPEN TX MANDIBULAR FX W/EXTERNAL FIXATION OPEN TX MANDIBULAR FX W/O INTERDENTAL FIXATION OPEN TX MANDIBULAR FX W/INTERDENTAL FIXATION OPEN TX MANDIBULAR CONDYLAR FX OPTX COMP MANDIBULAR FX MLT APPR W/INT FIXATION CLOSED TX TEMPOROMANDIBULAR DISLOCATION 1ST/SBSQ CLOSED TX TEMPOROMANDIBULAR DISLC COMP 1ST/SBSQ OPEN TREATMENT TEMPOROMANDIBULAR DISLOCATION OPEN TREATMENT HYOID FRACTURE INTERDENTAL WIRING OTHER THAN FRACTURE UNLISTED MUSCULOSKELETAL PROCEDURE HEAD BR YYY I&D DEEP ABSC/HMTMA SOFT TISSUE NECK/THORAX I&D DP ABSC/HMTMA SOFT TISS NCK/THORAX PRTL RIB INCISION DEEP OPENING BONE CORTEX THORAX BIOPSY SOFT TISSUE NECK/THORAX # EXC TUMOR SOFT TISSUE NECK/ANT THORAX SUBQ 3+CM # EXC TUMOR SOFT TISSUE NECK/THORAX SUBFASC 5+CM EXC TUMOR SOFT TISSUE NECK/ANT THORAX SUBQ <3CM EXC TUMOR SOFT TISS NECK/THORAX SUBFASCIAL <5CM RAD RESECT TUMOR SOFT TISS NECK/ANT THORAX <5CM RAD RESECT TUMOR SOFT TISS NECK/ANT THORAX 5+CM EXCISION RIB PARTIAL COSTOTRANSVERSECTOMY SPX EXCISION 1ST&/CERVICAL RIB EXCISION 1ST&/CERVICAL RIB W/SYMPATHECTOMY OSTECTOMY STERNUM PARTIAL STERNAL DEBRIDEMENT RADICAL RESECTION STERNUM RADICAL RESECTION STERNUM W/MEDSTNL LMPHADEC HYOID MYOTOMY & SUSPENSION DIVISION SCALENUS ANTICUS W/O RESCJ CERVICAL RIB DIVISION SCALENUS ANTICUS RESECTION CERVICAL RIB DIVISION STERNOCLEIDOMASTOID OPEN W/O CAST DIVISION STERNOCLEIDOMASTOID OPEN CAST REPAIR PECTUS EXCAVATUM/CARINATUM OPEN REPAIR PECTUS EXCAVATM/CARINATM MINLY W/O THRSC REPAIR PECTUS EXCAVATM/CARINATM MINLY W/THRSC CLOSURE MEDIAN STERNOTOMY SEP +-DEBRIDEMENT SPX CLOSED TX RIB FRACTURE UNCOMPLICATED EACH CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

67 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule OPEN TX RIB FRACTURE W/O FIXATION EACH TX RIB FRACTURE EXTERNAL FIXATION FLAIL CHEST CLOSED TREATMENT STERNUM FRACTURE OPEN TX STERNUM FRACTURE +-SKELETAL FIXATION UNLISTED PROCEDURE NECK/THORAX BR YYY BIOPSY SOFT TISSUE BACK/FLANK SUPERFICIAL BIOPSY SOFT TISSUE BACK/FLANK DEEP EXCISION TUMOR SOFT TISSUE BACK/FLANK SUBQ <3CM EXCISION TUMOR SOFT TISSUE BACK/FLANK SUBQ 3+CM EXC TUMOR SOFT TISS BACK/FLANK SUBFASCIAL <5CM EXC TUMOR SOFT TISS BACK/FLANK SUBFASCIAL 5+CM RAD RESECTION TUMOR SOFT TISSUE BACK/FLANK <5CM RAD RESECTION TUMOR SOFT TISSUE BACK/FLANK 5+CM I&D DEEP ABSCESS PST SPINE CRV THRC/CERVICOTHRC I&D DEEP ABSCESS PST SPINE LUMBAR SAC/LUMBOSAC PRTL EXC PST VRT INTRNSC B1Y LES 1 VRT SGM CRV PRTL EXC PST VRT INTRNSC B1Y LES 1 VRT SGM THRC PRTL EXC PST VRT INTRNSC B1Y LES 1 VRT SGM LMBR PRTL EXC PST VRT INTRNSC B1Y LES 1 VRT SGM EA ZZZ PRTL EXC VRT BDY B1Y LES W/O SPI CORD 1 SGM CRV PRTL EXC VRT BDY B1Y LES W/O SPI CORD 1 SGM THRC PRTL EXC VRT BDY B1Y LES W/O SPI CORD 1 SGM LMBR PRTL EXC VRT BDY B1Y LES W/O SPI CORD 1 SGM EA ZZZ OSTEOTOMY SPINE POSTERIOR 3 COLUMN THORACIC OSTEOTOMY SPINE POSTERIOR 3 COLUMN LUMBAR OSTEOTOMY SPINE POSTERIOR 3 COLUMN EA ADDL SGM ZZZ OSTEOTOMY SPINE PST/PSTLAT APPR 1 VRT SGM CRV OSTEOTOMY SPINE PST/PSTLAT APPR 1 VRT SGM THRC OSTEOTOMY SPINE PST/PSTLAT APPR 1 VRT SGM LMBR OSTEOT SPI PST/PSTLAT APPR 1 VRT SGM EA VRT SGM ZZZ OSTEOTOMY SPINE W/DSKC ANT APPR 1 VRT SGM CRV OSTEOTOMY SPINE W/DSKC ANT APPR 1 VRT SGM THRC OSTEOTOMY SPINE W/DSKC ANT APPR 1 VRT SGM LMBR OSTEOT SPI W/DSKC ANT APPR 1 VRT SGM EA VRT SGM ZZZ CLOSED TX VERTEBRAL PROCESS FRACTURE CLTX VRT BDY FX W/O MNPJ REQ&W/CSTING/BRACING s CLTX VRT FX&/DISLC CSTING/BRACING MNPJ/TRCJ OPTX&/RDCTJ ODNTD FX&/DISLC ANT FIXJ W/O GRFG OPTX&/RDCTJ ODNTD FX&/DISLC ANT W/INT FIXJ GRF OPTX&/RDCTJ VRT FX&/DISLC PST 1 VRT SGM LMBR OPTX&/RDCTJ VRT FX&/DISLC PST 1 VRT SGM CRV OPTX&/RDCTJ VRT FX&/DISLC PST 1 VRT SGM THRC OPTX&/RDCTJ VRT FX&/DISLC PST 1 VRT SGM EA SGM ZZZ MANIPULATION SPINE REQUIRING ANESTHESIA K PERCUTANEOUS VERTEBROPLASTY THORACIC K PERCUTANEOUS VERTEBROPLASTY LUMBAR Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 63

68 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, PERCUTANEOUS VERTEBROPLASTY EA ADDL THRC/LMBR ZZZ PERCUTANEOUS VERTEBRAL AUGMENTATION THORACIC PERCUTANEOUS VERTEBRAL AUGMENTATION LUMBAR PERQ VERTEBRAL AUGMENTATION EA ADDL THRC/LMBR ZZZ K PERQ INTRDSCL ELECTROTHRM ANNULOPLASTY 1 LVL K PERQ INTRDSCL ELECTROTHRM ANNULOPLASTY ADDL LVL ZZZ ARTHRODESIS LATERAL EXTRACAVITARY THORACIC ARTHRODESIS LATERAL EXTRACAVITARY LUMBAR ARTHRODESIS LAT EXTRACAVITARY EA ADDL THRC/LMBR ZZZ ARTHRD ANT TRANSORAL/XTRORAL C1-C2 +-EXC ODNTD l ARTHRD ANT INTERBODY DECOMPRESS CERVICAL BELW C l ARTHRD ANT INTERDY CERVCL BELW C2 EA ADDL NTRSPC ZZZ ARTHRD ANT MIN DISCECT INTERBODY CERV BELW C ARTHRD ANT MIN DISCECTOMY INTERBODY THORACIC ARTHRODESIS ANTERIOR INTERBODY LUMBAR ARTHRODESIS ANTERIOR INTERBODY EA ADDL NTRSPC ZZZ ARTHRODESIS POSTERIOR CRANIOCERVICAL ARTHRODESIS POSTERIOR ATLAS-AXIS C1-C ARTHRODESIS PST/PSTLAT CERVICAL BELW C2 SGM ARTHRODESIS POSTERIOR/POSTEROLATERAL THORACIC ARTHRODESIS POSTERIOR/POSTEROLATERAL LUMBAR ARTHRODESIS POSTERIOR/POSTEROLATERAL EA ADDL ZZZ ARTHRODESIS POSTERIOR INTERBODY LUMBAR ARTHRODESIS POSTERIOR INTERBODY EA ADDL ZZZ ARTHRODESIS POSTERIOR SPINAL DFRM UP 6 VRT SEG ARTHRODESIS POSTERIOR SPINAL DFRM 7-12 VRT SEG ARTHRODESIS POSTERIOR SPINAL DFRM 13/> VRT SEG ARTHRODESIS ANTERIOR SPINAL DFRM 2-3 VRT SEG ARTHRODESIS ANTERIOR SPINAL DFRM 4-7 VRT SEG ARTHRODESIS POSTERIOR SPINAL DFRM 8/> VRT SEG KYPHECTOMY SINGLE OR TWO SEGMENTS KYPHECTOMY 3 OR MORE SEGMENTS EXPLORATION SPINAL FUSION POSTERIOR NON-SEGMENTAL INSTRUMENTATION ZZZ INTERNAL SPINAL FIXATION WIRING SPINOUS PROCESS XXX POSTERIOR SEGMENTAL INSTRUMENTATION 3-6 VRT SEG ZZZ POSTERIOR SEGMENTAL INSTRUMENTATION 7-12 VRT SEG ZZZ POSTERIOR SEGMENTAL INSTRUMENTATION 13/> VRT SEG ZZZ ANTERIOR INSTRUMENTATION 2-3 VERTEBRAL SEGMENTS ZZZ ANTERIOR INSTRUMENTATION 4-7 VERTEBRAL SEGMENTS ZZZ ANTERIOR INSTRUMENTATION 8/> VERTEBRAL SEGMENTS ZZZ PELVIC FIXATION OTHER THAN SACRUM ZZZ REINSERTION SPINAL FIXATION DEVICE REMOVAL POSTERIOR NONSEGMENTAL INSTRUMENTATION s APPLICATION INTERVERTEBRAL BIOMECHANICAL DEVICE ZZZ REMOVAL POSTERIOR SEGMENTAL INSTRUMENTATION CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

69 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule REMOVAL ANTERIOR INSTRUMENTATION TOT DISC ARTHRP ART DISC ANT APPRO 1 NTRSPC CRV TOT DISC ARTHRP ART DISC ANT APPRO 1 NTRSPC LMBR REVJ RPLCMT DISC ARTHROPLASTY ANT 1 NTRSPC CRV REVJ RPLCMT DISC ARTHROPLASTY ANT 1 NTRSPC LMBR RMVL DISC ARTHROPLASTY ANT 1 INTERSPACE CERVICAL RMVL DISC ARTHROPLASTY ANT 1 INTERSPACE LUMBAR UNLISTED PROCEDURE SPINE BR YYY EXC TUMOR SOFT TISSUE ABDL WALL SUBFASCIAL <5CM EXC TUMOR SOFT TISSUE ABDL WALL SUBFASCIAL 5+CM EXC TUMOR SOFT TISSUE ABDOMINAL WALL SUBQ <3CM EXC TUMOR SOFT TISSUE ABDOMINAL WALL SUBQ 3+CM RAD RESECTION TUMOR SOFT TISSUE ABDL WALL <5CM RAD RESECTION TUMOR SOFT TISSUE ABDL WALL 5+CM UNLISTED PX ABDOMEN MUSCULOSKELETAL SYSTEM BR YYY REMOVAL SUBDELTOID CALCAREOUS DEPOSITS OPEN CAPSULAR CONTRACTURE RELEASE I&D SHOULDER DEEP ABSCESS/HEMATOMA I&D SHOULDER INFECTED BURSA INCISION BONE CORTEX SHOULDER AREA ARTHROTOMY GLENOHUMERAL JT EXPL/DRG/RMVL FB ARTHRT ACROMCLAV STRNCLAV JT EXPL/DRG/RMVL FB BIOPSY SOFT TISSUE SHOULDER SUPERFICIAL BIOPSY SOFT TISSUE SHOULDER DEEP # EXCISION TUMOR SOFT TISSUE SHOULDER SUBQ 3+CM # EXC TUMOR SOFT TISSUE SHOULDER SUBFASCIAL 5+CM EXCISION TUMOR SOFT TISSUE SHOULDER SUBQ <3CM EXC TUMOR SOFT TISS SHOULDER SUBFASC <5CM RAD RESECTION TUMOR SOFT TISSUE SHOULDER <5CM RAD RESECTION TUMOR SOFT TISSUE SHOULDER 5+CM ARTHROTOMY GLENOHUMERAL JOINT W/BIOPSY ARTHRT ACROMCLAV/STRNCLAV JT W/BX&/EXC CRTLG ARTHRT GLENOHUMRL JT W/SYNOVECTOMY +-BIOPSY ARTHRT GLENOHUMRL JT STRNCLAV JT W/SYNVCT +-BX ARTHRT GLENOHUMRL JT W/JT EXPL +-RMVL LOOSE/FB CLAVICULECTOMY PARTIAL CLAVICULECTOMY TOTAL PARTIAL REPAIR OR REMOVAL OF SHOULDER BONE EXC/CURTG BONE CYST/BENIGN TUMOR CLAV/SCAPULA EXC/CURTG BONE CST/B9 TUM CLAV/SCAPULA W/AGRFT EXC/CURTG BONE CST/B9 TUM CLAV/SCAPULA W/ALGRFT EXC/CURTG BONE CYST/BENIGN TUMOR PROX HUMERUS EXC/CURTG BONE CYST/BENIGN TUM PROX HUM W/AGRFT EXC/CURTG BONE CYST/BENIGN TUM PROX HUM W/ALGRFT SEQUESTRECTOMY CLAVICLE SEQUESTRECTOMY SCAPULA Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 65

70 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, SEQUESTRECTOMY HUMERAL HEAD SURGERY NECK PARTIAL EXCISION BONE CLAVICLE PARTIAL EXCISION BONE SCAPULA PARTIAL EXCISION BONE PROXIMAL HUMERUS OSTECTOMY SCAPULA PARTIAL RESECTION HUMERAL HEAD RADICAL RESECTION TUMOR CLAVICLE RADICAL RESECTION TUMOR SCAPULA RADICAL RESECTION BONE TUMOR PROXIMAL HUMERUS REMOVAL FOREIGN BODY SHOULDER SUBCUTANEOUS REMOVAL FOREIGN BODY SHOULDER DEEP REMOVAL FOREIGN BODY SHOULDER COMPLICATED INJECTION SHOULDER ARTHROGRAPHY/ CT/MRI ARTHG MUSCLE TRANSFER SHOULDER/UPPER ARM SINGLE MUSCLE TRANSFER SHOULDER/UPPER ARM MULTIPLE SCAPULOPEXY TENOTOMY SHOULDER AREA 1 TENDON TENOTOMY SHOULDER MULTIPLE THRU SAME INCISION OPEN REPAIR OF ROTATOR CUFF ACUTE OPEN REPAIR OF ROTATOR CUFF CHRONIC CORACOACROMIAL LIGAMENT RELEASE +-ACROMIOPLASTY RECONSTRUCTION ROTATOR CUFF AVULSION CHRONIC TENODESIS LONG TENDON BICEPS RESECTION/TRANSPLANTATION LONG TENDON BICEPS CAPSULORRHAPHY ANTERIOR PUTTI-PLATT/MAGNUSON CAPSULORRHAPHY ANTERIOR W/LABRAL REPAIR CAPSULORRHAPHY ANTERIOR WITH BONE BLOCK CAPSULORRHAPHY ANTERIOR W/CORACOID PROCESS TR CAPSULORRHAPHY GLENOHUMERAL JT PST +-BONE BLK CAPSULORRHAPHY GLENOHUMRL JT MULTI-DIRIONAL INS ARTHROPLASTY GLENOHUMRL JT HEMIARTHROPLASTY ARTHROPLASTY GLENOHUMERAL JOINT TOTAL SHOULDER OSTEOTOMY CLAVICLE +-INTERNAL FIXATION OSTEOTOMY CLAV +-INT FIXJ W/B1 GRF NON/MAL PROPH TX +-METHYLMETHACRYLATE CLAVICLE PROPH TX +-METHYLMETHACRYLATE PROXIMAL HUMERUS CLSD TX CLAVICULAR FRACTURE W/O MANIPULATION CLSD TX CLAVICULAR FRACTURE W/MANIPULATION OPEN TX CLAVICULAR FRACTURE INTERNAL FIXATION CLSD TX STERNOCLAVICULAR DISLC W/O MANIPULATION CLOSED TX STERNOCLAVICULAR DISLC W/MANIPULATION OPEN TX STERNOCLAVICULAR DISLC ACUTE/CHRONIC OPTX STRNCLAV DISLC ACUTE/CHRONIC W/FASCIAL GRF CLSD TX ACROMIOCLAVICULAR DISLC W/O MANIPULATION CLSD TX ACROMIOCLAVICULAR DISLC W/MANIPULATION OPEN TX ACROMIOCLAVICULAR DISLC ACUTE/CHRONIC CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

71 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule OPTX ACROMCLAV DISLC ACUTE/CHRONIC W/FASCIAL GRF CLOSED TX SCAPULAR FRACTURE W/O MANIPULATION CLTX SCAPULAR FX W/MANIPULATION +-SKEL TRACTION OPEN TX SCAPULAR FX W/INTERNAL FIXATION IF PFRMD CLTX PROXIMAL HUMERAL FRACTURE W/O MANIPULATION CLTX PROX HUMRL FX W/MANIPULATION +-SKEL TRACJ OPEN TREATMENT PROXIMAL HUMERAL FRACTURE OPEN PROX HUMERAL FRACTURE PROSTHETIC RPLCMT CLTX GREATER HUMERAL TUBEROSITY FX W/O MNPJ CLTX GRTER HUMERAL TUBEROSITY FX W/MANIPULATION OPEN TREATMENT GRTER HUMERAL TUBEROSITY FRACTURE CLSD TX SHOULDER DISLC W/MANIPULATION W/O ANES CLSD TX SHOULDER DISLC W/MANIPULATION REQ ANES OPEN TX ACUTE SHOULDER DISLOCATION CLTX SHOULDER DISLC W/FX HUMERAL TUBRST W/MNPJ OPEN TX SHOULDER DISLC W/HUMERAL TUBEROSITY FX CLTX SHOULDER DISLC W/SURG/ANTMCL NCK FX W/MNPJ OPEN TX SHOULDER DISLOCATION W/NECK FRACTURE MNPJ W/ANES SHOULDER JOINT W/FIXATION APPARATUS ARTHRODESIS GLENOHUMERAL JOINT ARTHRODESIS GLENOHUMERAL JT W/AUTOGENOUS GRAFT INTERTHORACOSCAPULAR AMPUTATION DISARTICULATION SHOULDER DISRTCJ SHOULDER SECONDARY CLSR/SCAR REVISION UNLISTED PROCEDURE SHOULDER BR YYY I&D UPPER ARM/ELBOW DEEP ABSCESS/HEMATOMA INCISION&DRAINAGE UPPER ARM/ELBOW BURSA INC DEEP W/OPENING BONE CORTEX HUMERUS/ELBOW ARTHRT ELBOW W/EXPLORATION DRAINAGE/REMOVAL FB ARTHRT ELBOW CAPSULAR EXCISION CAPSULAR RLS SPX BIOPSY SOFT TISSUE UPPER ARM/ELBOW SUPERFICIAL BIOPSY SOFT TISSUE UPPER ARM/ELBOW AREA DEEP # EXC TUMOR SOFT TISSUE UPPER ARM/ELBOW SUBQ 3+CM # EXC TUMOR SOFT TISS UPPER ARM/ELBW SUBFASC 5+CM EXC TUMOR SOFT TISS UPPER ARM/ELBOW SUBQ <3CM EXC TUMOR SOFT TISS UPR ARM/ELBOW SUBFASC <5CM RAD RESECT TUMOR SOFT TISS UPPER ARM/ELBOW <5CM RAD RESECT TUMOR SOFT TISS UPPER ARM/ELBOW 5+CM ARTHROTOMY ELBOW W/SYNOVIAL BIOPSY ONLY ARTHRT ELBOW W/JOINT EXPL +-BX +-RMVL LOOSE/FB ARTHROTOMY ELBOW W/SYNOVECTOMY EXCISION OLECRANON BURSA EXCISION/CURTG BONE CYST/BENIGN TUMOR HUMERUS EXC/CURTG BONE CYST/BENIGN TUMOR HUMERUS W/AGRFT EXC/CURTG BONE CYST/BENIGN TUM HUMERUS W/ALGRFT EXC/CURTG BONE CYST/BENIGN TUMOR H/N RDS/OLECRN Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 67

72 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, EXC/CURTG BONE CST/B9 TUM H/N RDS/OLECRN W/AGRFT EXC/CURTG B1 CST/B9 TUM H/N RDS/OLECRN W/ALGRFT EXCISION RADIAL HEAD SEQUESTRECTOMY SHAFT/DISTAL HUMERUS SEQUESTRECTOMY RADIAL HEAD OR NECK SEQUESTRECTOMY OLECRANON PROCESS PARTIAL EXCISION BONE HUMERUS PARTIAL EXCISION BONE RADIAL HEAD/NECK PARTIAL EXCISION BONE OLECRANON PROCESS RAD RESCJ CAPSL TISS&HTRTPC BONE ELBW CONTRCT RADICAL RESECTION TUMOR SHAFT/DISTAL HUMERUS RADICAL RESECTION TUMOR RADIAL HEAD/NECK RESECTION ELBOW JOINT ARTHRECTOMY IMPLANT REMOVAL ELBOW JOINT IMPLANT REMOVAL RADIAL HEAD RMVL FOREIGN BODY UPPER ARM/ELBOW SUBCUTANEOUS REMOVAL FOREIGN BODY UPPER ARM/ELBOW DEEP INJECTION ELBOW ARTHROGRAPHY MANIPULATION ELBOW UNDER ANESTHESIA MUSCLE/TENDON TRANSFER UPPER ARM/ELBOW SINGLE TENDON LENGTHENING UPPER ARM/ELBOW EA TENDON TENOTOMY OPEN ELBOW TO SHOULDER EACH TENDON TENOPLASTY ELBOW TO SHOULDER SINGLE FLEXOR-PLASTY ELBOW FLEXOR-PLASTY ELBOW W/EXTENSOR ADVANCEMENT TENOLYSIS TRICEPS TENODESIS BICEPS TENDON ELBOW SPX REPAIR TENDON/MUSCLE UPPER ARM/ELBOW EA RINSJ RPTD BICEPS/TRICEPS TDN DSTL +-TDN GRF REPAIR LATERAL COLLATERAL LIGAMENT ELBOW RCNSTJ LAT COLTRL LIGM ELBOW W/TENDON GRAFT REPAIR MEDIAL COLLATERAL LIGAMENT ELBOW RCNSTJ MEDIAL COLTRL LIGM ELBW W/TDN GRF TENOTOMY ELBOW LATERAL/MEDIAL PERCUTANEOUS TNOT ELBOW LATERAL/MEDIAL DEBRIDE OPEN TNOT ELBOW LATERAL/MEDIAL DEBRIDE OPEN TDN RPR ARTHROPLASTY ELBOW W/MEMBRANE ARTHROPLASTY ELBOW W/DISTAL HUMRL PROSTC RPLCMT ARTHRP ELBOW W/IMPLT&FSCA LATA LIGAMENT RCNSTJ ARTHRP ELBOW W/DISTAL HUM&PROX UR PROSTC RPLCMT ARTHROPLASTY RADIAL HEAD ARTHROPLASTY RADIAL HEAD W/IMPLANT OSTEOTOMY HUMERUS +-INTERNAL FIXATION MLT OSTEOT W/RELIGNMT IMED ROD HUMERAL SHAFT OSTEOPLASTY HUMERUS REPAIR NON/MALUNION HUMERUS W/O GRAFT CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

73 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule REPAIR NON/MALUNION HUMERUS W/ILIAC/OTH AGRFT HEMIEPIPHYSEAL ARREST DECOMPRESSION FASCT F/ARM W/BRACH ART EXPL PROPHYLACTIC TX +-METHYLMETHACRYLATE HUMRL SHFT CLSD TX HUMERAL SHAFT FRACTURE W/O MANIPULATION CLTX HUMERAL SHFT FX W/MANIPULATION +-SKEL TRACJ OPTX HUMERAL SHFT FX W/PLATE/SCREWS +-CERCLAGE TX HUMERAL SHAFT FX W/INSJ IMED IMPLT +-CERCLAGE CLTX SPRCNDYLR/TRANSCNDYLR HUMERAL FX+-MNPJ CLTX SPRCNDYLR/TRANSCNDYLR HUMERAL FX W/MNPJ PRQ SKEL FIXJ SPRCNDYLR/TRANSCNDYLR HUMERAL FX OPEN TX HUMERAL SUPRACONDYLAR FRACTURE W/O XTN OPEN TX HUMERAL SUPRACONDYLAR FRACTURE W/XTN CLTX HUMERAL EPICONDYLAR FX MEDIAL/LAT W/O MNPJ CLTX HUMERAL EPICONDYLAR FX MEDIAL/LAT W/MNPJ PRQ SKEL FIXJ HUMRL EPCNDYLR FX MEDIAL/LAT MNPJ OPEN TX HUMERAL EPICONDYLAR FRACTURE CLTX HUMERAL CONDYLAR FX MEDIAL/LAT W/O MNPJ CLTX HUMERAL CONDYLAR FX MEDIAL/LATERAL W/MNPJ OPEN TREATMENT HUMERAL CONDYLAR FRACTURE PRQ SKEL FIXJ HUMRL CNDYLR FX MEDIAL/LAT W/MNPJ OPTX PERIARTICULAR FRACTURE &/DISLOCATION ELBOW OPTX PRIARTICULAR FX&/DISLC ELBW W/IMPLT ARTHRP TREATMENT CLOSED ELBOW DISLOCATION W/O ANES TREATMENT CLOSED ELBOW DISLOCATION REQ ANES OPEN TX ACUTE/CHRONIC ELBOW DISLOCATION CLOSED TX MONTEGGIA FX DISLOCATION ELBOW W/MNPJ OPEN TX MONTEGGIA FRACTURE DISLOCATION ELBOW CLTX RDL HEAD SUBLXTJ CHLD NURSEMAID ELBW W/MNPJ CLOSED TX RADIAL HEAD/NECK FX W/O MANIPULATION CLOSED TX RADIAL HEAD/NECK FX W/MANIPULATION OPEN TX RADIAL HEAD/NECK FRACTURE OPEN TX RADIAL HEAD/NECK FRACTURE PROSTHETIC CLOSED TX ULNAR FRACTURE PROXIMAL END W/O MNPJ CLOSED TX ULNAR FRACTURE PROXIMAL END W MNPJ OPEN TREATMENT ULNAR FRACTURE PROXIMAL END ARTHRODESIS ELBOW JOINT LOCAL ARTHRODESIS ELBOW JOINT W/AUTOGENOUS GRAFT AMPUTATION ARM THRU HUMERUS W/PRIMARY CLOSURE AMPUTATION ARM THRU HUMERUS OPEN CIRCULAR AMP ARM THRU HUMERUS SECONDARY CLSR/SCAR REVJ AMPUTATION ARM THRU HUMERUS RE-AMPUTATION AMPUTATION ARM THRU HUMERUS W/IMPLANT STUMP ELONGATION UPPER EXTREMITY CINEPLASTY UPPER EXTREMITY COMPLETE PROCEDURE UNLISTED PROCEDURE HUMERUS/ELBOW BR YYY Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 69

74 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, INCISION EXTENSOR TENDON SHEATH WRIST INCISION FLEXOR TENDON SHEATH WRIST DCMPRN FASCT F/ARM&WRST FLXR/XTNSR W/O DBRDMT DCMPRN FASCT F/ARM&/WRST FLXR/XTNSR W/DBRDMT DCMPRN FASCT F/ARM&/WRST FLXR&XTNSR W/O DBRDMT DCMPRN FASCT F/ARM&/WRST FLXR&XTNSR DBRDMT NV I&D FOREARM&/WRIST DEEP ABSCESS/HEMATOMA INCISION & DRAINAGE FOREARM&/WRIST BURSA INCISION DEEP BONE CORTEX FOREARM&/WRIST ARTHRT RDCRPL/MIDCARPL JT W/EXPL DRG/RMVL FB BIOPSY SOFT TISSUE FOREARM&/WRIST SUPERFICIAL BIOPSY SOFT TISSUE FOREARM&/WRIST DEEP # EXC TUMOR SOFT TISS FOREARM AND/WRIST SUBQ 3+CM # EXC TUMOR SFT TISS FOREARM&//WRIST SUBFASC 3+CM EXC TUMOR SOFT TISSUE FOREARM &/WRIST SUBQ <3CM EXC TUMOR SOFT TISS FOREARM&/WRIST SUBFASC <3CM RAD RESECT TUMOR SOFT TISS FOREARM&/WRIST <3CM RAD RESCJ TUM SOFT TISSUE FOREARM&/WRIST 3+CM CAPSULOTOMY WRIST ARTHROTOMY WRIST JOINT WITH BIOPSY ARTHRT WRST JT W/JT EXPL +-BX +-RMVL LOOSE/FB ARTHROTOMY WRIST JOINT WITH SYNOVECTOMY ARTHROTOMY DSTL RADIOULNAR JOINT RPR CARTILAGE EXC TENDON FOREARM&/WRIST FLEXOR/EXTENSOR EA EXCISION LESION TENDON SHEATH FOREARM&/WRIST EXCISION GANGLION WRIST DORSAL/VOLAR PRIMARY EXCISION GANGLION WRIST DORSAL/VOLAR RECURRENT RAD EXC BURSA SYNVA WRST/F/ARM TDN SHTHS FLXRS RAD EXC BURSA SYNVA WRST/F/ARM TDN SHTHS XTNSRS SYNOVECTOMY EXTENSOR TENDON SHTH WRIST 1 CMPRT SYNVCT XTNSR TDN SHTH WRST 1 RESCJ DSTL ULNA EXCISION/CURETTAGE CYST/TUMOR RADIUS/ULNA EXC/CURTG CYST/TUMOR RADIUS/ULNA W/AUTOGRAFT EXC/CURTG CYST/TUMOR RADIUS/ULNA W/ALLOGRAFT EXCISION/CURETTAGE CYST/TUMOR CARPAL BONES EXC/CURTG CYST/TUMOR CARPAL BONES W/AUTOGRAFT EXC/CURTG CYST/TUMOR CARPAL BONES W/ALLOGRAFT SEQUESTRECTOMY FOREARM &/WRIST PARTIAL EXCISION BONE ULNA PARTIAL EXCISION BONE RADIUS RADICAL RESECTION TUMOR RADIUS OR ULNA CARPECTOMY 1 BONE CARPECTOMY ALL BONES PROXIMAL ROW RADICAL STYLOIDECTOMY SPX EXCISION DISTAL ULNA PARTIAL/COMPLETE INJECTION WRIST ARTHROGRAPHY CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

75 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule EXPL W/REMOVAL DEEP FOREIGN BODY FOREARM/WRIST REMOVAL WRIST PROSTHESIS SPX REMOVAL WRIST PROSTH COMPLICATED W/TOTAL WRIST MANIPULATION WRIST UNDER ANESTHESIA RPR TDN/MUSC FLXR F/ARM&/WRST PRIM 1 EA TDN/MUSC RPR TDN/MUSC FLXR F/ARM&/WRST SEC 1 EA TDN/MUSC RPR TDN/MUSC FLXR F/ARM&/WRST SEC FR GRF EA RPR TDN/MUSC XTNSR F/ARM&/WRST PRIM 1 EA TDN RPR TDN/MUSC XTNSR F/ARM&/WRST SEC 1 EA TDN/MUSC RPR TDN/MUSC XTNSR F/ARM&/WRST SEC FR GRF EA TDN RPR TENDON SHEATH EXTENSOR F/ARM&/WRST W/GRAFT LNGTH/SHRT FLXR/XTNSR TDN F/ARM&/WRST 1 EA TDN TNOT FLXR/XTNSR TENDON FOREARM&/WRIST 1 EA TNOLS FLXR/XTNSR TENDON FOREARM&/WRIST 1 EA TENODESIS WRIST FLEXORS FINGERS TENODESIS WRIST EXTENSORS FINGERS TDN TRNSPLJ/TR FLXR/XTNSR F/ARM&/WRST 1 EA TDN TDN TRNSPLJ/TR FLXR/XTNSR F/ARM&/WRST 1/TDN GRF FLEXOR ORIGIN SLIDE FOREARM &/WRIST FLEXOR ORIGIN SLIDE F/ARM&/WRST TENDON TRANSFER CAPSL-RHPHY/RCNSTJ WRST OPN CARPL INS ARTHRP WRST +-INTERPOS +-XTRNL/INT FIXJ CENTRALIZATION WRST ULNA RCNSTJ STABLJ DSTL U/DSTL JT 2 SOFT TISS STABLJ OSTEOTOMY RADIUS DISTAL THIRD OSTEOTOMY RADIUS MIDDLE/PROXIMAL THIRD OSTEOTOMY ULNA OSTEOTOMY RADIUS & ULNA MLT OSTEOTOMIES W/RELIGNMT IMED ROD RADIUS/ULNA MLT OSTEOTOMIES W/RELIGNMT IMED ROD RADIUS&ULNA OSTEOPLASTY RADIUS/ULNA SHORTENING OSTEOPLASTY RADIUS/ULNA LENGTHENING W/AUTOGRAFT OSTEOPLASTY RADIUS & ULNA SHORTENING OSTEOPLASTY RADIUS&ULNA LENGTHENING W/AUTOGRAFT OSTEOPLASTY CARPAL BONE SHORTENING RPIR NONUNION/MALUNION RADIUS/ULNA W/O AUTOGRAFT RPR NONUNION/MALUNION RADIUS/ULNA W/AUTOGRAFT RPR NONUNION/MALUNION RADIUS&ULNA W/O AUTOGRAFT RPR NONUNION/MALUNION RADIUS&ULNA W/AUTOGRAFT REPAIR DEFECT W/AUTOGRAFT RADIUS/ULNA REPAIR DEFECT W/AUTOGRAFT RADIUS&ULNA INSERTION VASCULAR PEDICLE CARPAL BONE REPAIR NONUNION CARPAL BONE EACH BONE RPR NONUNION SCAPHOID CARPAL BONE +-RDL STYLODC ARTHROPLASTY W/PROSTHETIC RPLCMT DISTAL RADIUS ARTHROPLASTY W/PROSTHETIC RPLCMT DISTAL ULNA Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 71

76 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, ARTHROPLASTY W/PROSTHETIC RPLCMT SCAPHOID CARPAL ARTHROPLASTY W/PROSTHETIC REPLACEMENT LUNATE ARTHROPLASTY W/PROSTHETIC REPLACEMENT TRAPEZIUM ARTHRP W/PROSTC RPLCMT DSTL RDS&PRTL/CARPUS ARTHRP INTERPOS INTERCARPAL/METACARPAL JOINTS REVJ ARTHRP W/RMVL IMPLT WRST JT EPIPHYSL ARRST EPIPHYSIOD/STAPLING DSTL RDS/U EPIPHYSL ARRST EPIPHYSIOD/STAPLING DSTL RDS&U PROPH TX N/P/PLTWR +-MMA RDS PROPH TX N/P/PLTWR +-MMA U PROPH TX N/P/PLTWR +-MMA RDS&U CLOSED TX RADIAL SHAFT FRACTURE W/O MANIPULATION CLOSED TX RADIAL SHAFT FRACTURE W/MANIPULATION OPEN TREATMENT RADIAL SHAFT FRACTURE CLTX RDL SHFT FX&CLTX DISLC DSTL RAD/ULN JT OPEN RDL SHAFT FX CLOSED RAD/ULN JT DISLOCATE OPEN RDL SHAFT FX OPEN RAD/ULN JT DISLOCATE CLOSED TX ULNAR SHAFT FRACTURE W/O MANIPULATION CLOSED TX ULNAR SHAFT FRACTURE W/MANIPULATION OPEN TREATMENT OF ULNAR SHAFT FRACTURE CLOSED TX RADIAL&ULNAR SHAFT FRACTURES W/O MNPJ CLOSED TX RADIAL&ULNAR SHAFT FRACTURES W/MNPJ OPEN TX RADIAL & ULNAR SHAFT FX FIXJ RADIUS/ULNA OPEN TX RDL& ULNAR SHAFT FX FIXJ RADIUS &ULNA CLTX DSTL RADIAL FX/EPIPHYSL SEP W/O MNPJ CLTX DSTL RDL FX/EPIPHYSL SEP +-W/MNPJ PERQ SKEL FIXJ DISTAL RADIAL FX/EPIPHYSL SEP OPTX DSTL RADL X-ARTIC FX/EPIPHYSL SEP OPTX DSTL RADL I-ARTIC FX/EPIPHYSL SEP 2 FRAG OPTX DSTL RADL I-ARTIC FX/EPIPHYSL SEP 3 FRAG CLOSED TX CARPAL SCAPHOID FRACTURE W/O MNPJ CLOSED TX CARPAL SCAPHOID FRACTURE W/MNPJ OPEN TX CARPAL SCAPHOID NAVICULAR FRACTURE CLTX CARPL B1 FX W/O MNPJ EA B CLTX CARPL B1 FX W/MNPJ EA B OPEN TX CARPAL BONE FRACTURE OTH/THN SCAPHOID EA CLOSED TREATMENT ULNAR STYLOID FRACTURE PRQ SKELETAL FIXATION ULNAR STYLOID FRACTURE OPEN TREATMENT ULNAR STYLOID FRACTURE CLTX RDCRPL/INTERCARPL DISLC 1+ B1S W/MNPJ OPEN TX RADIOCARPAL/INTERCARPAL DISLC 1+ BONES PRQ SKELETAL FIXJ DISTAL RADIOULNAR DISLOCATION CLOSED TX DISTAL RADIOULNAR DISLOCATION W/MNPJ OPEN TX DISTAL RADIOULNAR DISLC ACUTE/CHRONIC CLTX TRANS-SCAPHOPRILUNAR TYP FX DISLC W/MNPJ OPEN TX TRANS-SCAPHOPERILUNAR FRACTURE DISLC CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

77 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule CLOSED TX LUNATE DISLOCATION W/MANIPULATION OPEN TREATMENT LUNATE DISLOCATION ARTHRD WRST COMPL W/O B1 GRF ARTHRD WRST W/SLIDING GRF ARTHRD WRST W/ILIAC/OTH AGRFT ARTHRODESIS WRIST LIMITED W/O BONE GRAFT ARTHRODESIS WRIST LIMITED W/AUTOGRAFT ARTHRD DSTL RAD/ULN JT SGMTL RESCJ U +-B1 GRF AMPUTATION FOREARM THROUGH RADIUS & ULNA AMP FOREARM THRU RADIUS&ULNA OPEN CIRCULAR AMP F/ARM THRU RADIUS&ULNA SEC CLOSURE/SCAR REVJ AMP FOREARM THRU RADIUS&ULNA RE-AMPUTATION KRUKENBERG PROCEDURE DISARTICULATION THROUGH WRIST DISARTICULATION THRU WRIST SEC CLOSURE/SCAR REVJ DISARTICULATION THRU WRIST RE-AMPUTATION TRANSMETACARPAL AMPUTATION TRANSMETACARPAL AMPUTATION SEC CLOSURE/SCAR REVJ TRANSMETACARPAL AMPUTATION RE-AMPUTATION UNLISTED PROCEDURE FOREARM/WRIST BR YYY DRAINAGE FINGER ABSCESS SIMPLE DRAINAGE FINGER ABSCESS COMPLICATED DRAINAGE TENDON SHEATH DIGIT&/PALM EACH DRAINAGE OF PALMAR BURSA SINGLE BURSA DRAINAGE OF PALMAR BURSA MULTIPLE BURSA INCISION BONE CORTEX HAND/FINGER DECOMPRESSION FINGERS&/HAND INJECTION INJURY DECOMPRESSIVE FASCIOTOMY HAND FASCIOTOMY PALMAR PERCUTANEOUS FASCIOTOMY PALMAR OPEN PARTIAL TENDON SHEATH INCISION TENOTOMY PERCUTANEOUS SINGLE EACH DIGIT ARTHRT EXPL DRG/RMVL LOOSE/FB CARP/MTCRPL JT ARTHRT EXPL DRG/RMVL LOOSE/FB MTCARPHLNGL JT EA ARTHRT EXPL DRG/RMVL LOOSE/FB IPHAL JT EA ARTHROTOMY BIOPSY CARP/MTCRPL JOINT EACH ARTHROTOMY BIOPSY MTCARPHLNGL JOINT EACH ARTHROTOMY BIOPSY INTERPHALANGEAL JOINT EACH # EX TUM/VASC MALF SFT TISS HAND/FNGR SUBQ 1.5+CM # EX TUM/VASC MAL SFT TIS HAND/FNGR SUBFSC 1.5+CM EXC TUM/VASC MAL SFT TISS HAND/FNGR SUBQ <1.5CM EXC TUM/VAS MAL SFT TIS HAND/FNGR SUBFASC<1.5CM RAD RESECT TUMOR SOFT TISSUE HAND/FINGER <3CM RAD RESCJ TUM SOFT TISSUE HAND/FINGER 3+CM FASCT PALM +-Z-PLASTY TISS REARGMT/SKN GRF FASCT PRTL PLMR 1 DGT PROX IPHAL JT +-TISS Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 73

78 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, FASCT PRTL PLMR 1 DGT PROX IPHAL JT +-Z-PLASTY ZZZ SYNOVECTOMY CARPOMETACARPAL JOINT SYNVCT MTCARPHLNGL JT W/INTRNSC RLS&XTNSR HOOD SYNVCT PROX IPHAL JT W/XTNSR RCNSTJ EA IPHAL JT SYNVCT TDN SHTH RAD FLXR TDN PALM&/FNGR EA TDN EXC LES TDN SHTH/JT CAPSL HAND/FNGR EXCISION TENDON PALM FLEXOR/EXTENSOR SINGLE EACH EXCISION TENDON FINGER FLEXOR/EXTENSOR EACH SESAMOIDECTOMY THUMB/FINGER SPX EXCISION/CURETTAGE CYST/TUMOR METACARPAL EXC/CURETTAGE CYST/TUMOR METACARPAL W/AUTOGRAFT EXCISION/CURETTAGE CYST/TUMOR PHALANX FINGER EXC/CURETTAGE CYST/TUMOR PHALANX FINGER W/AGRAFT PARTIAL EXCISION BONE METACARPAL PARTIAL EXCISION PROXIMAL/MIDDLE PHALANX FINGER PARTIAL EXCISION DISTAL PHALANX FINGER RADICAL RESECTION TUMOR METACARPAL RAD RESECTION TUMOR PROX/MIDDLE PHALANX FINGER RADICAL RESECTION TUMOR DISTAL PHALANX FINGER REMOVAL IMPLANT FROM FINGER/HAND MANIPULATION FINGER JOINT UNDER ANES EACH JOINT RPR/ADVMNT FLXR TDN N/Z/2 1/2 W/O FR GRF EA TDN RPR/ADVMNT FLXR TDN N/Z/2 2W/FR GRF EA TDN RPR/ADVMNT FLXR TDN ZONE 2 1W/O FR GRF EA TDN RPR/ADVMNT FLXR TDN ZONE 2 2W/O FR GRF EA TDN RPR/ADVMNT FLXR TDN ZONE 2 2W/FR GRF EA TDN RPR/ADVMNT TDN W/NTC SUPFCIS TDN PRIM EA TDN RPR/ADVMNT TDN W/NTC SUPFCIS TDN 2 W/FR GRF EA RPR/ADVMNT TDN W/NTC SUPFCIS TDN 2 W/O FR GRF EA EXC FLXR TDN W/IMPLTJ SYNTH ROD DLYD TDN GRF H/F RMVL SYNTH ROD&INSJ FLXR TDN GRF H/F EA ROD REPAIR EXTENSOR TENDON HAND W/O GRAFT EACH REPAIR EXTENSOR TENDON HAND W/GRAFT EACH EXC XTNSR TDN W/IMPLTJ SYNTH ROD DLYD GRF H/F EA RMVL SYNTH ROD&INSJ XTNSR TDN GRF H/F EA ROD REPAIR EXTENSOR TENDON FINGER W/O GRAFT EACH REPAIR EXTENSOR TENDON FINGER W/GRAFT EACH RPR XTNSR TDN CTR SLIP 2 TISS W/LAT BAND EA FNGR RPR XTNSR TDN CTR SLIP SEC W/FR GRF EA FNGR CLTX DSTL XTNSR TDN INSJ +-PRQ PINNING REPAIR EXTENSOR TENDON DISTAL INSERTION W/O GRF REPAIR EXTENSOR TENDON DISTAL INSERTION W/GRAFT REALIGNMENT EXTENSOR TENDON HAND EACH TENDON TENOLYSIS FLEXOR TENDON PALM/FINGER EACH TENDON TENOLYSIS FLEXOR TENDON PALM&FINGER EACH TENDON TENOLYSIS EXTENSOR TENDON HAND/FINGER EACH CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

79 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule TENOLYSIS CPLX XTNSR TENDON FINGER W/FOREARM EA TENOTOMY FLEXOR PALM OPEN EACH TENDON TENOTOMY FLEXOR FINGER OPEN EACH TENDON TENOTOMY EXTENSOR HAND/FINGER OPEN EACH TENDON TENODESIS PROXIMAL INTERPHALANGEAL JOINT EACH TENODESIS DISTAL JOINT EACH LENGTHENING TENDON EXTENSOR HAND/FINGER EACH SHORTENING TENDON EXTENSOR HAND/FINGER EACH LENGTHENING TENDON FLEXOR HAND/FINGER EACH SHORTENING TENDON FLEXOR HAND/FINGER EACH TR/TRNSPL TDN CARP/MTCRPL HAND W/O FR GRF EA TDN TENDON TRANSFER TRANSPLANT CARP/MTCRPL GRAFT TRANSFER/TRANSPLANT TENDON PALMAR W/O GRAFT EACH TRANSFER/TRANSPLANT TENDON PALMAR W/GRAFT EACH OPPONENSPLASTY SUPFCIS TDN TR TYP EA TDN OPPONENSPLASTY TDN TR W/GRF EA TDN OPPONENSPLASTY HYPOTHENAR MUSC TR OPPONENSPLASTY OTH METHS TR TDN RESTORE INTRNSC FUNCJ RING&SM FNGR TR TDN RESTORE INTRNSC FUNCJ ALL 4 FNGRS CORRECTION CLAW FINGER OTHER METHODS RCNSTJ TENDON PULLEY EACH W/LOCAL TISSUES SPX RCNSTJ TDN PULLEY EA TDN W/TDN/FSCAL GRF SPX RELEASE THENAR MUSCLE CROSS INTRINSIC TRANSFER EACH TENDON CAPSULODESIS MTCARPHLNGL JOINT SINGLE DIGIT CAPSULODESIS MTCARPHLNGL JOINT 2 DIGITS CAPSULODESIS MTCARPHLNGL JOINT 3/4 DIGITS CAPSULECTOMY/CAPSULOTOMY MTCARPHLNGL JOINT EACH CAPSULECTOMY/CAPSULOTOMY IPHAL JOINT EACH ARTHROPLASTY METACARPOPHALANGEAL JOINT EACH ARTHRP MTCARPHLNGL JT W/PROSTC IMPLT EA JT ARTHROPLASTY INTERPHALANGEAL JOINT EACH ARTHROPLASTY INTERPHALANGEAL JT W/PROSTHETIC EA RPR COLTRL LIGM MTCARPHLNGL/IPHAL JT RCNSTJ COLTRL LIGM MTCARPHLNGL 1 W/TDN/FSCAL GRF RCNSTJ COLTRL LIGM MTCARPHLNGL 1 W/LOCAL TISS RCNSTJ COLTRL LIGM IPHAL JT 1 W/GRF EA JT RPR NON-UNION MTCRPL/PHALANX RPR&RCNSTJ FINGER VOLAR PLATE INTERPHALANGEAL JT POLLICIZATION DIGIT TR TOE-TO-HAND W/MVASC ANAST GRT TOE WRP/ARND TR TOE-TO-HAND W/MVASC ANAST OTH/THN GRT TOE TR TOE-TO-HAND W/MVASC ANAST OTH/THN GRT TOE TR FNGR AXH POS W/O MVASC ANAST TRANSFER FREE TOE JOINT W/MVASC ANASTOMOSIS Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 75

80 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, REPAIR SYNDACTYLY EACH SPACE W/SKIN FLAPS REPAIR SYNDACTYLY EACH SPACE W/SKIN FLAPS&GRAFTS REPAIR SYNDACTYLY EACH SPACE COMPLEX OSTEOTOMY METACARPAL EACH OSTEOTOMY PHALANX FINGER EACH OSTEOPLASTY LENGTHENING METACARPAL/PHALANX REPAIR CLEFT HAND RCNSTJ POLYDACTYLOUS DGT SOFT TISS&B REPAIR MACRODACTYLIA EACH DIGIT REPAIR INTRINSIC MUSCLES HAND EACH MUSCLE RELEASE INTRINSIC MUSCLES HAND EACH MUSCLE EXC CONSTRICTING RING FNGR W/MLT Z-PLASTIES CLTX MTCRPL FX 1 W/O MNPJ EA B CLTX MTCRPL FX 1 W/MNPJ EA B CLTX MTCRPL FX W/MNPJ W/XTRNL FIXJ EA B PRQ SKEL FIXJ MTCRPL FX EA B OPEN TX METACARPAL FRACTURE SINGLE EA BONE CLTX CARP/MTCRPL DISLC THMB W/MNPJ CLTX CARP/MTCRPL FX DISLC THMB W/MNPJ PRQ SKEL FIXATION CARP/MTCRPL FX DISLOCATE THUMB OPEN TX CARPOMETACARPAL FRACTURE DISLOCATE THUMB CLTX CARP/MTCRPL DISLC THMB MNPJ EA W/O ANES CLTX CARP/MTCRPL DISLC THMB MNPJ EA JT REQ ANES PRQ SKEL FIXJ CARP/MTCRPL DISLC THMB MNPJ EA JT OPEN TX CARPOMETACARPAL DISLOCATE NOT THUMB OPTX CARP/MTCRPL DISLC THMB CPLX MLT/DLYD RDCTJ CLTX MTCARPHLNGL DISLC 1 W/MNPJ W/O ANES CLTX MTCARPHLNGL DISLC 1 W/MNPJ REQ ANES PRQ SKEL FIXJ MTCARPHLNGL DISLC 1 W/MNPJ OPEN TREATMENT METACARPOPHALANGEAL DISLOCATION CLTX PHLNGL FX PROX/MIDDLE PX/F/T W/O MNPJ EA CLTX PHLNGL FX PROX/MIDDLE PX/F/T W/MNPJ EA PRQ SKEL FIXJ PHLNGL SHFT FX PROX/MIDDLE PX/F/T OPEN TX PHALANGEAL SHAFT FRACTURE PROX/MIDDLE EA CLTX ARTICULAR FX INVG MTCARPHLNGL/IPHAL JT W/O CLTX ARTICULAR FX INVG MTCARPHLNGL/IPHAL JT W/ OPEN TX ARTICULAR FRACTURE MCP/IP JOINT EA CLTX DSTL PHLNGL FX FNGR/THMB W/O MNPJ EA CLTX DSTL PHLNGL FX FNGR/THMB W/MNPJ EA PRQ SKEL FIXJ DSTL PHLNGL FX FNGR/THMB EA OPEN TX DISTAL PHALANGEAL FRACTURE EACH CLTX IPHAL JT DISLC 1 W/MNPJ W/O ANES CLTX IPHAL JT DISLC 1 W/MNPJ REQ ANES PRQ SKEL FIXJ IPHAL JT DISLC 1 W/MNPJ OPEN TX INTERPHALANGEAL JOINT DISLOCATION FUSION OPPOSITION THUMB W/AUTOGENOUS GRAFT CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

81 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule ARTHRD CARP/MTCRPL JT THMB +-INT FIXJ ARTHRD CARP/MTCRPL JT THMB +-INT FIXJ W/AGRFT ARTHRD CARP/MTCRPL JT DGT OTHER THAN THUMB EACH ARTHRD CARP/MTCRPL JT DGT OTH/THN THMB W/AGRFT ARTHRD MTCARPHLNGL JT +-INT FIXJ ARTHRD MTCARPHLNGL JT +-INT FIXJ W/AGRFT ARTHRD IPHAL JT +-INT FIXJ ARTHRD IPHAL JT +-INT FIXJ EA IPHAL JT ZZZ ARTHRD IPHAL JT +-INT FIXJ W/AGRFT ARTHRD IPHAL JT +-INT FIXJ W/AGRFT EA JT ZZZ AMP MTCRPL W/FNGR/THMB 1 +-INTEROSS TR AMP F/TH 1/2 JT/PHALANX 1 W/NEURECT W/DIR CLSR AMP F/TH 1/2 JT/PHALANX 1 W/NEURECT LOCAL FLAP UNLIS PX HANDS/FNGRS BR YYY I&D PELVIS/HIP JT AREA DP ABSC/HMTMA I&D PELVIS/HIP JT AREA INFCT BURSA INCISION BONE CORTEX PELVIS&/HIP JOINT TENOTOMY ADDUCTOR HIP PERCUTANEOUS SPX TENOTOMY ADDUCTOR HIP OPEN TX ADDUXOR SUBQ OPN W/OBTURATOR NEURECTOMY TENOTOMY HIP FLEXOR OPEN SPX TENOTOMY ABDUCTORS&/EXTENSOR HIP OPEN SPX FASCIOTOMY HIP/THIGH ANY TYPE DECOMPRESSION FASCIOTOMY PELVIC COMPARTMENT UNI ARTHROTOMY HIP W/DRAINAGE ARTHROTOMY HIP EXPLORATION/REMOVAL FOREIGN BODY DNRVTJ HIP JT INTRAPEL/XTRPEL INTRA-ARTCLR BRNCH CAPSLCTOMY/CAPSUL HIP W/RLS HIP FLXR MUSC BIOPSY SOFT TISSUE PELVIS&HIP AREA SUPERFICIAL BIOPSY SOFT TISSUE PELVIS&HIP DEEP/SUBFSCAL/IM # EXCISION TUMOR SOFT TISSUE PELVIS&HIP SUBQ 3+CM # EXC TUMOR SOFT TISSUE PELVIS & HIP SUBFASC 5+CM EXC TUMOR SOFT TISSUE PELVIS & HIP SUBQ <3CM EXC TUMOR SOFT TISSUE PELVIS & HIP SUBFASC <5CM RAD RESECT TUMOR SOFT TISSUE PELVIS & HIP <5CM ARTHROTOMY W/BIOPSY SACROILIAC JOINT ARTHROTOMY W/BIOPSY HIP JOINT ARTHROTOMY W/SYNOVECTOMY HIP JOINT DCMPRN FASCIOTOMY PELVIC CMPRT DBRDMT MUSCLE UNI # RAD RESECTION TUMOR SOFT TISS PELVIS&HIP 5+CM EXCISION ISCHIAL BURSA EXCISION TROCHANTERIC BURSA/CALCIFICATION s EXCISION BONE CYST/B9 TUMOR SUPERFICIAL s EXCISION BONE CYST/B9 TUMOR DEEP s EXC B1 CST/B9 TUM W/AGRFT REQ SEP INC s PARTIAL EXCISION SUPERFICIAL PELVIS Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 77

82 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, 2011 s PARTIAL EXCISION DEEP PELVIS RAD RESCT TUMOR WING OF ILIUM 1 PUBIC/ISCHIAL RAD RESCT TUMOR ILIUM ACETABULUM BOTH PUBIC RADICAL RESCTION TUMOR INNOMINATE BONE TOTAL RAD RESCT TUMOR ISCHIAL TUBEROSITY&GRT TRCHNTR COCCYGECTOMY PRIMARY RMVL FOREIGN BODY PELVIS/HIP SUBCUTANEOUS TISS REMOVAL FOREIGN BODY PELVIS/HIP DEEP REMOVAL HIP PROSTHESIS SPX RMVL HIP PROSTH COMP W/TOT HIP PROSTH MMA INJECTION HIP ARTHROGRAPHY W/O ANESTHESIA INJECTION HIP ARTHROGRAPHY W/ANESTHESIA INJECTION SI JOINT ARTHROGRAPHY&/ANES/STEROID RELEASE/RECESSION HAMSTRING PROXIMAL TRANSFER ADDUCTOR ISCHIUM TR XTRNL OBLQ MUSC TRCHNTR W/FSCAL/TDN XTN GRF TR PARASPI MUSC HIP FASC/TDN XTN GRF TRANSFER ILIOPSOAS GREATER TROCHANTER FEMUR TRANSFER ILIOPSOAS FEMORAL NECK ACETABULOPLASTY ACETABULOPLASTY RESECTION FEMORAL HEAD HEMIARTHROPLASTY HIP PARTIAL ARTHRP ACETBLR/PROX FEM PROSTC AGRFT/ALGRFT CONV PREVIOUS HIP TOT HIP ARTHRP +-AGRFT/ALGRFT REVJ TOT HIP ARTHRP BTH +-AGRFT/ALGRFT REVJ TOT HIP ARTHRP ACTBLR ONLY +-AGRFT/ALGRFT REVJ TOT HIP ARTHRP FEM ONLY +-ALGRFT OSTEOTOMY&TRANSFER GREATER TROCHANTER SPX OSTEOTOMY ILIAC ACETABULAR/INNOMINATE BONE OSTEOTOMY ILIAC ACETABULAR/INNOMINATE HIP RDCTJ OSTEOTOMY ILIAC ACETABULAR/INNOMINATE FEM OSTEOT OSTEOT ILIAC ACTBLR/INNOMINATE B1 OSTEOT RDCTJ OSTEOTOMY PELVIS BILATERAL OSTEOTOMY FEMORAL NECK SPX OSTEOT INTERTRCHNTRIC/SUBTRCHNTRIC W/INT/XTRNL B1 GRF FEM H/N INTERTRCHNTRIC/SUBTRCHNTRIC AREA TX SLP FEM EPIPHYSIS TRCJ W/O RDCTJ TX SLP FEM EPIPHYSIS 1/MLT PINNING SITU OPTX SLP FEM EPIPHYSIS 1/MLT PINNING/B1 GRF OPTX SLP FEM EPIPHYSIS CLSD MNPJ 1/MLT PINNING OPTX SLP FEM EPIPHYSIS OSTPL FEM NCK HEYMAN PX OPTX SLP FEM EPIPHYSIS OSTEOT&INT FIXJ EPIPHYSL ARRST EPIPHYSIOD/STAPLING TRCHNTR FEMUR PROPH TX N/P/PLTWR +-MMA FEM NCK&PROX FEMUR CLTX PEL RING FX DISLC DIAST/SUBLXTJ W/O MNPJ CLTX PEL RING FX DISLC DIAST/SUBLXTJ W/MNPJ ANES CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

83 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule CLOSED TREATMENT COCCYGEAL FRACTURE OPEN TREATMENT COCCYGEAL FRACTURE OPTX ILIAC TUBRST AVLS/WING FX FIXJ IF PRFRMD PERQ SKELETAL FIXATION PST PELVIC BONE FX&/DISLC OPTX ANT PELVIC BONE FX&/DISLC INT FIXJ IF PFRMD OPTX POST PEL BONE FX&/DISLC INT FIXJ IF PFRMD CLTX ACETABULUM HIP/SOCKT FX W/O MNPJ CLTX ACETABULUM HIP/SOCKT FX MNPJ +-SKEL TRACJ OPTX PST/ANT ACTBLR WALL FX W/INT FIXJ OPTX ACTBLR FX INVG ANT/PST 1 COLUMN/FX W/INT OPTX ACTBLR FX INVG ANT&PST 2 COLUMNS FX W/INT CLTX FEM FX PROX END NCK W/O MNPJ CLTX FEM FX PROX END NCK W/MNPJ +-SKEL TRACJ PRQ SKEL FIXJ FEM FX PROX END NCK OPTX FEM FX PROX END NCK INT FIXJ/PROSTC RPLCMT CLTX INTER/PERI/SUBTROCHANTERIC FEM FX W/O MNPJ CLTX INTR/PERI/SBTRCHNTC FEM FX W/MNPJ TX INTER/PR/SUBTRCHNTRIC FEM FX SCREW IMPLT TX INTER/PR/SUBTRCHNTRIC FEM FX IMED IMPLTSCREW CLTX GRTER TRCHNTRIC FX W/O MNPJ OPEN TREATMENT GREATER TROCHANTERIC FRACTURE CLTX HIP DISLC TRAUMTC W/O ANES CLTX HIP DISLC TRAUMTC REQ ANES OPTX HIP DISLC TRAUMTC W/O INT FIXJ OPTX HIP DISLC TRAUMTC W/ACTBLR WALL&FEM HEAD FX TX SPON HIP DISLC ABDCT SPLNT/TRCJ W/O ANES TX SPON HIP DISLC ABDCT SPLNT/TRCJ W/MNPJ ANES OPTX SPON HIP DISLC RPLCMT FEM HEAD ACTBLM OPTX SPON HIP DISLC RPLCMT FEM HEAD ACTBLM SHRT CLTX POST HIP ARTHRP DISLC W/O ANES CLTX POST HIP ARTHRP DISLC REQ ANES CLOSED TX FEMORAL FRACTURE PROX HEAD W/O MNPJ CLOSED TX FEMORAL FRACTURE PROX HEAD W MNPJ OPEN TX FEMORAL FRACTURE PROXIMAL END HEAD MANIPULATION HIP JOINT GENERAL ANESTHESIA ARTHRODESIS SACROILIAC JOINT W/OBTAINING GRAFT ARTHRODESIS SYMPHYSIS PUBIS W/OBTAINING GRAFT ARTHRODESIS HIP JOINT W/OBTAINING GRAFT ARTHRD HIP JT W/OBTG GRF W/SUBTRCHNTRIC OSTEOT INTERPELVIABDOMINAL AMPUTATION DISARTICULATION HIP UNLISTED PROCEDURE PELVIS/HIP JOINT BR YYY I&D DP ABSC BURSA/HMTMA THI/KNE REGION INC DP W/OPNG B1 CORTEX FEMUR/KNE FASCIOTOMY ILIOTIBIAL OPEN TENOTOMY PRQ ADDUCTOR/HAMSTRING 1 TENDON SPX Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 79

84 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, TENOTOMY PRQ ADDUCTOR/HAMSTRING MULTIPLE TENDON ARTHRT KNE W/EXPL DRG/RMVL FB BIOPSY SOFT TISSUE THIGH/KNEE AREA SUPERFICIAL BIOPSY SOFT TISSUE THIGH/KNEE AREA DEEP NEURECTOMY HAMSTRING MUSCLE NEURECTOMY POPLITEAL EXCISION TUMOR SOFT TISSUE THIGH/KNEE SUBQ <3CM EXC TUMOR SOFT TISSUE THIGH/KNEE SUBFASC <5CM # RAD RESECT TUMOR SOFT TISSUE THIGH/KNEE <5CM ARTHROTOMY KNEE W/SYNOVIAL BIOPSY ONLY ARTHRT KNE W/JT EXPL BX/RMVL LOOSE/FB ARTHRT W/EXC SEMILUNAR CRTLG KNE MEDIAL/LAT ARTHRT W/EXC SEMILUNAR CRTLG KNE MEDIAL&LAT ARTHROTOMY W/SYNOVECTOMY KNEE ANTERIOR/POSTERIOR ARTHRT W/SYNVCT KNE ANT&PST W/POP AREA # EXCISON TUMOR SOFT TISSUE THIGH/KNEE SUBQ 3+CM # EXC TUMOR SOFT TISSUE THIGH/KNEE SUBFASC 5+CM EXCISION PREPATELLAR BURSA EXCISION SYNOVIAL CYST POPLITEAL SPACE EXCISION LESION MENISCUS/CAPSULE KNEE PATELLECTOMY/HEMIPATELLECTOMY EXCISION/CURETTAGE CYST/TUMOR FEMUR EXCISION/CURETTAGE CYST/TUMOR FEMUR W/ALLOGRAFT EXCISION/CURETTAGE CYST/TUMOR FEMUR W/AUTOGRAFT EXCISION/CURETTAGE CYST/TUMOR FEMUR INT FIXATION ZZZ PRTL EXC B1 FEMUR PROX TIBIA&/FIBULA RAD RESECTION TUMOR SOFT TISSUE THIGH/KNEE 5+CM RADICAL RESECTION TUMOR FEMUR OR KNEE INJECTION KNEE ARTHROGRAPHY REMOVAL FOREIGN BODY DEEP THIGH/KNEE SUTURE INFRAPATELLAR TENDON PRIMARY SUTR INFRAPATELLAR TDN 2 RCNSTJ W/FSCAL/TDN GRF SUTURE QUADRICEPS/HAMSTRING RUPTURE PRIMARY SUTR QUADRICEPS/HAMSTRING MUSC RPT 2 RCNSTJ TENOTOMY OPEN HAMSTRING KNEE HIP SINGLE TENDON TENOTOMY OPN HAMSTRING KNEE HIP MULTIPLE 1 LEG TENOTOMY OPEN HAMSTRING KNEE HIP MULTIPLE BI LENGTHENING HAMSTRING TENDON SINGLE LENGTHENING HAMSTRING TENDON MULTIPLE 1 LEG LENGTHENING HAMSTRING TENDON MULTIPLE BILATERAL TRANSPLANT/TRANSFER THIGH XTNSR TO FLXR 1 TENDON TRANSPLANT/TRANSFER THIGH XTNSR TO FLXR MULT TDN TRANSFER TENDON/MUSCLE HAMSTRINGS FEMUR ARTHROTOMY W/MENISCUS REPAIR KNEE RPR PRIMARY TORN LIGM&/CAPSULE KNEE COLLATERAL REPAIR PRIMARY TORN LIGM&/CAPSULE KNEE CRUCIATE CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

85 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule RPR 1 TORN LIGM&/CAPSL KNE COLTRL&CRUCIATE LIGMS AUTOLOGOUS CHONDROCYTE IMPLANTATION KNEE OSTEOCHONDRAL ALLOGRAFT KNEE OPEN OSTEOCHONDRAL AUTOGRAFT KNEE OPEN MOSAICPLASTY ANTERIOR TIBIAL TUBERCLEPLASTY RCNSTJ DISLOCATING PATELLA RCNSTJ DISLC PATELLA W/XTNSR RELIGNMT&/MUSC RLS RCNSTJ DISLC PATELLA W/PATELLECTOMY LATERAL RETINACULAR RELEASE OPEN LIGAMENTOUS RECONSTRUCTION KNEE EXTRA-ARTICULAR LIGAMENTOUS RECONSTRUCTION KNEE INTRA-ARTICULAR LIGMOUS RCNSTJ AGMNTJ KNE INTRA-ARTICULAR XTR QUADRICEPSPLASTY CAPSULOTOMY POSTERIOR CAPSULAR RELEASE KNEE ARTHROPLASTY PATELLA W/O PROSTHESIS ARTHROPLASTY PATELLA W/PROSTHESIS ARTHROPLASTY KNEE TIBIAL PLATEAU ARTHRP KNEE TIBIAL PLATEAU DBRDMT&PRTL SYNVCT ARTHROPLASTY FEM CONDYLES/TIBIAL PLATEAU KNEE ARTHRP FEM CONDYLES/TIBL PLATU KNE DBRDMT&PRTL ARTHROPLASTY KNEE HINGE PROSTHESIS ARTHRP KNEE CONDYLE&PLATEAU MEDIAL/LAT CMPRT ARTHRP KNE CONDYLE&PLATU MEDIAL&LAT CMPRTS OSTEOTOMY FEMUR SHAFT/SUPRACONDYLAR W/O FIXATION OSTEOTOMY FEMUR SHAFT/SUPRACONDYLAR W/FIXATION OSTEOT MLT W/RELIGNMT IMED ROD FEM SHFT OSTEOT PROX TIBIA FIB EXC/OSTEOT BEFORE EPIPHYSL OSTEOT PROX TIBIA FIB EXC/OSTEOT AFTER EPIPHYSL OSTEOPLASTY FEMUR SHORTENING EXCLUDING OSTEOPLASTY FEMUR LENGTHENING OSTPL FEMUR CMBN LNGTH&SHRT W/FEM SGM TR RPR NON/MAL FEMUR DSTL H/N W/O GRF RPR NON/MAL FEMUR DSTL H/N W/ILIAC/AUTOG B1 GRF ARREST EPIPHYSEAL DISTAL FEMUR ARREST EPIPHYSEAL TIBIA&FIBULA PROXIMAL ARRST EPIPHYSL CMBN DSTL FEMUR PROX TIBFIB ARRST HEMIEPIPHYSL DSTL FEMUR/PROX TIBIA/FIBULA REVJ TOT KNE ARTHRP +-ALGRFT 1 COMP REVJ TOT KNE ARTHRP FEM&ENTIRE TIBL COMP RMVL PROSTH TOT KNE PROSTH MMA +-INSJ SPACER PROPH TX N/P/PLTWR +-MMA FEMUR DCMPRN FASCT THI&/KNE 1 CMPRT DCMPRN FASCT THI&/KNE 1 DBRDMT NV MUSC&/NRV DCMPRN FASCT THI&/KNE MLT CMPRTS DCMPRN FASCT THI&/KNE MLT DBRDMT NV MUSC&/NRV CLOSED TX FEMORAL SHAFT FX W/O MANIPULATION Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 81

86 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, CLTX SPRCNDYLR/TRNSCNDYLR FEM FX W/O MNPJ CLTX FEM SHFT FX W/MNPJ +-SKN/SKEL TRACJ CLTX SPRCNDYLR/TRNSCNDYLR FEM FX W/MNPJ OPTX FEM SHFT FX W/INSJ IMED IMPLT +-SCREW OPTX FEM SHFT FX W/PLATE/SCREWS +-CERCLAGE CLTX FEM FX DSTL END MEDIAL/LAT CONDYLE W/O MNPJ PRQ SKEL FIXJ FEM FX DSTL END CLTX FEM FX DSTL END MEDIAL/LAT CONDYLE W/MNPJ OPEN TX FEMORAL SUPRACONDYLAR FRACTURE W/O XTN OPEN TX FEMORAL SUPRACONDYLAR FRACTURE W XTN OPEN TX FEMORAL FRACTURE DISTAL MED/LAT CONDYLE CLTX DSTL FEM EPIPHYSL SEP W/O MNPJ CLTX DSTL FEM EPIPHYSL SEP W/MNPJ +-SKN/SKEL OPEN TX DISTAL FEMORAL EPIPHYSEAL SEPARATION CLOSED TX PATELLAR FRACTURE W/O MANIPULATION OPTX PATLLR FX W/INT FIXJ/PATLLC&SOFT TISS RPR CLTX TIBL FX PROX W/O MNPJ CLTX TIBL FX PROX +-MNPJ W/SKEL TRACJ OPEN TX TIBIAL FRACTURE PROXIMAL UNICONDYLAR OPTX TIBL FX PROX BICONDYLAR +-INT FIXJ CLTX INTERCONDYLAR SPI&/TUBRST FX KNE +-MNPJ OPEN TX INTERCONDYLAR SPINE/TUBRST FRACTURE KNEE CLOSED TX KNEE DISLOCATION W/O ANESTHESIA CLOSED TX KNEE DISLOCATION W/ANESTHESIA OPEN TX KNEE DISLOCATION W/O LIGAMENTOUS REPAIR OPEN TX KNEE DISLOCATION W LIGAMENTOUS REPAIR OPEN TX KNEE DISLOCATION W REPAIR/RECONSTRUCTION CLOSED TX PATELLAR DISLOCATION W/O ANESTHESIA CLOSED TX PATELLAR DISLOCATION W/ANESTHESIA OPTX PATELLAR DISLC +-PRTL/TOT PATELLECTOMY MANIPULATION KNEE JOINT UNDER GENERAL ANESTHESIA ARTHRODESIS KNEE ANY TECHNIQUE AMPUTATION THIGH THROUGH FEMUR ANY LEVEL AMP THI THRU FEMUR LVL IMMT FITG TQ W/1ST CST AMPUTATION THIGH THRU FEMUR OPEN CIRCULAR AMP THIGH THRU FEMUR SEC CLOSURE/SCAR REVISION AMPUTATION THIGH THROUGH FEMUR RE-AMPUTATION DISARTICULATION KNEE UNLISTED PROCEDURE FEMUR/KNEE BR YYY DCMPRN FASCT LEG ANT&/LAT CMPRTS ONLY DCMPRN FASCT LEG PST CMPRT ONLY DCMPRN FASCT LEG ANT&/LAT&PST CMPRT INCISION&DRAINAGE LEG/ANKLE ABSCESS/HEMATOMA INCISION&DRAINAGE LEG/ANKLE INFECTED BURSA TENOTOMY PRQ ACHILLES TENDON SPX LOCAL ANES TENOTOMY PRQ ACHILLES TENDON SPX GENERAL ANES CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

87 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule INCISION LEG/ANKLE ARTHROTOMY ANKLE W/EXPL DRAINAGE/REMOVAL FB ARTHRT PST CAPSULAR RLS ANKLE +-ACHLL TDN LNGTH BIOPSY SOFT TISSUE LEG/ANKLE AREA SUPERFICIAL BIOPSY SOFT TISSUE LEG/ANKLE AREA DEEP RAD RESECTION TUMOR SOFT TISSUE LEG/ANKLE <5CM RAD RESCJ TUM SOFT TISSUE LEG/ANKLE 5+CM EXC TUMOR SOFT TISSUE LEG/ANKLE SUBQ <3CM EXC TUMOR SOFT TISSUE LEG/ANKLE SUBFASCIAL <5CM ARTHRT ANKLE W/JT EXPL +-BX +-RMVL LOOSE/FB ARTHROTOMY W/SYNOVECTOMY ANKLE ARTHROTOMY W/SYNOVECTOMY ANKLE TENOSYNOVECTOMY EXCISION LESION TENDON SHEATH/CAPSULE LEG&/ANKLE # EXCISION TUMOR SOFT TISSUE LEG/ANKLE SUBQ 3+ CM # EXC TUMOR SOFT TISSUE LEG/ANKLE SUBFASC 5+CM EXCISION/CURETTAGE BONE CYST/TUMOR TIBIA/FIBULA EXC/CURETTAGE CYST/TUMOR TIBIA/FIBULA W/AGRAFT EXC/CURETTAGE CYST/TUMOR TIBIA/FIBULA W/ALGRAFT PARTIAL EXCISION BONE TIBIA PARTIAL EXCISION BONE FIBULA RADICAL RESECTION OF TUMOR TIBIA RADICAL RESECTION TUMOR BONE FIBULA RADICAL RESECTION OF TUMOR TALUS OR CALCANEUS INJECTION ANKLE ARTHROGRAPHY REPAIR PRIMARY OPEN/PRQ RUPTURED ACHILLES TENDON RPR PRIMARY OPEN/PRQ RUPTURED ACHILLES W/GRAFT REPAIR SECONDARY ACHILLES TENDON +-GRAFT REPAIR FASCIAL DEFECT LEG REPAIR FLEXOR TENDON LEG PRIMARY W/O GRAFT EACH RPR FLEXOR TENDON LEG SECONDARY W/O GRAFT EACH RPR EXTENSOR TENDON LEG PRIMARY W/O GRAFT EACH RPR EXTENSOR TENDON LEG SECONDARY +/-GRAFT EACH RPR DISLOCATING PERONEAL TENDON W/O FIB OSTEOT REPAIR DISLOCATING PERONEAL TENDON W/FIB OSTEOT TENOLYSIS FLXR/XTNSR TENDON LEG&/ANKLE 1 EACH TNOLS FLXR/XTNSR TDN LEG&/ANKLE MLT TDN LNGTH/SHRT TDN LEG/ANKLE 1 TDN SPX LNGTH/SHRT TDN LEG/ANKLE MLT TDN SAME INC EA GASTROCNEMIUS RECESSION TR/TRNSPL 1 TDN W/MUSC REDIRION/REROUTING SUPFC TR/TRNSPL 1 TDN W/MUSC REDIRION/REROUTING DP TR/TRNSPL 1 TDN W/MUSC REDIRION/REROUTING EA TDN ZZZ RPR PRIMARY DISRUPTED LIGAMENT ANKLE COLLATERAL RPR PRIM DISRUPTED LIGM ANKLE BTH COLTRL LIGMS REPAIR SECONDARY DISRUPTED LIGAMENT ANKLE COLTRL ARTHROPLASTY ANKLE Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 83

88 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, ARTHROPLASTY ANKLE W/IMPLANT ARTHROPLASTY ANKLE REVISION TOTAL ANKLE REMOVAL ANKLE IMPLANT OSTEOTOMY TIBIA OSTEOTOMY FIBULA OSTEOTOMY TIBIA&FIBULA OSTEOT MLT W/RELIGNMT IMED ROD OSTEOPLASTY TIBIA&FIBULA LENGTHENING/SHORTENING REPAIR NONUNION/MALUNION TIBIA W/O GRAFT REPAIR NONUNION/MALUNION TIBIA W/SLIDING GRAFT RPR NON/MAL TIBIA W/ILIAC/OTH AGRFT RPR NON/MAL TIBIA SYNOSTOSIS W/FIBULA ANY METH REPAIR FIBULA NONUNION/MALUNION W INT FIXATION REPAIR CONGENITAL PSEUDARTHROSIS TIBIA ARREST EPIPHYSEAL OPEN DISTAL TIBIA ARREST EPIPHYSEAL OPEN DISTAL FIBULA ARREST EPIPHYSEAL OPEN DISTAL TIBIA&FIBULA ARRST EPIPHYSL ANY METH TIBFIB ARRST EPIPHYSL ANY METH TIBFIB&DSTL FEMUR PROPH TX N/P/PLTWR +-MMA TIBIA CLTX TIBL SHFT FX W/O MNPJ CLTX TIBL SHFT FX W/MNPJ +-SKEL TRACJ PRQ SKEL FIXJ TIBL SHFT FX OPTX TIBL SHFT FX W/PLATE/SCREWS +-CERCLAGE TX TIBL SHFT FX IMED IMPLT +-SCREWS&/CERCLAGE CLTX MEDIAL MALLS FX W/O MNPJ CLTX MEDIAL MALLS FX W/MNPJ +-SKN/SKEL TRACJ OPEN TREATMENT MEDIAL MALLEOLUS FRACTURE CLOSED TREATMENT PST MALLEOLUS FRACTURE W/O MNPJ CLOSED TREATMENT PST MALLEOLUS FRACTURE W MNPJ OPEN TREATMENT POSTERIOR MALLEOLUS FRACTURE CLTX PROX FIBULA/SHFT FX W/O MNPJ CLTX PROX FIBULA/SHFT FX W/MNPJ OPEN TREATMENT PROXIMAL FIBULA/SHAFT FRACTURE CLTX DSTL FIBULAR FX LAT MALLS W/O MNPJ CLTX DSTL FIBULAR FX LAT MALLS W/MNPJ OPEN TX DISTAL FIBULAR FRACTURE LAT MALLEOLUS CLOSED TX BIMALLEOLAR ANKLE FRACTURE W/O MNPJ CLOSED TX BIMALLEOLAR ANKLE FRACTURE W MNPJ OPEN TREATMENT BIMALLEOLAR ANKLE FRACTURE CLTX TRIMAL ANKLE FX W/O MNPJ CLTX TRIMAL ANKLE FX W/MNPJ OPEN TX TRIMALLEOLAR ANKLE FX W/O FIXJ PST LIP OPEN TX TRIMALLEOLAR ANKLE FX W FIXJ PST LIP CLTX FX W8 BRG ARTCLR PRTN DSTL TIBIA W/O MNPJ CLTX FX W8 BRG ARTCLR PRTN DSTL TIB W/SKEL TRACJ CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

89 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule OPEN TREATMENT FRACTURE DISTAL TIBIA FIBULA OPEN TREATMENT FRACTURE DISTAL TIBIA ONLY OPEN TREATMENT FRACTURE DISTAL TIBIA & FIBULA OPEN TX DISTAL TIBIOFIBULAR JOINT DISRUPTION CLTX PROX TIBFIB JT DISLC W/O ANES CLTX PROX TIBFIB JT DISLC REQ ANES OPEN TX PROX TIBFIB JOINT DISLOCATE EXC PROX FIB CLOSED TX ANKLE DISLOCATION W/O ANESTHESIA CLTX ANKLE DISLC REQ ANES +-PRQ SKEL FIXJ OPTX ANKLE DISLC W/O RPR/INT FIXJ OPTX ANKLE DISLC W/RPR/INT/XTRNL FIXJ MNPJ ANKLE UNDER GENERAL ANES ARTHRODESIS ANKLE OPEN ARTHRODESIS TIBIOFIBULAR JOINT PROXIMAL/DISTAL AMPUTATION LEG THROUGH TIBIA&FIBULA AMP LEG THRU TIBFIB W/IMMT FITG TQ W/1ST CST AMPUTATION LEG THRU TIBIA&FIBULA OPEN CIRCULAR AMP LEG THRU TIBIA&FIBULA SEC CLOSURE/SCAR REVJ AMP LEG THRU TIBIA&FIBULA RE-AMPUTATION AMP ANKLE-MALLI TIBFIB W/PLSTC CLSR&RESCJ NRV ANKLE DISARTICULATION DCMPRN FASCT LEG ANT&/LAT W/DBRDMT MUSC&/NRV DCMPRN FASCT LEG PST W/DBRDMT MUSC&/NRV DCMPRN FASCT LEG ANT&/LAT&PST W/DBRDMT MUSC&/NRV UNLISTED PROCEDURE LEG/ANKLE BR YYY INCISION&DRAINAGE BURSA FOOT I&D BELW FSCA FOOT 1 BURSAL SPACE I&D BELW FSCA FOOT MLT AREAS INCISION BONE CORTEX FOOT FASCIOTOMY FOOT&/TOE TENOTOMY PERCUTANEOUS TOE SINGLE TENDON TENOTOMY PERCUTANEOUS TOE MULTIPLE TENDON ARTHRT W/EXPL DRG/RMVL LOOSE/FB NTRTRSL/TARS JT ARTHRT W/EXPL DRG/RMVL LOOSE/FB MTTARPHLNGL JT ARTHRT W/EXPL DRG/RMVL LOOSE/FB IPHAL JT RELEASE TARSAL TUNNEL # EXCISION TUMOR SOFT TISSUE FOOT/TOE SUBQ 1.5+CM # EXC TUMOR SOFT TISSUE FOOT/TOE SUBFASC 1.5+CM EXCISION TUMOR SOFT TISSUE FOOT/TOE SUBQ <1.5CM EXC TUMOR SOFT TISSUE FOOT/TOE SUBFASC <1.5CM RAD RESECTION TUMOR SOFT TISSUE FOOT/TOE <3CM RAD RESECTION TUMOR SOFT TISSUE FOOT/TOE 3+CM ARTHRT W/BX INTERTARSAL/TARS JT ARTHRT W/BX METATARSOPHALANGEAL JT ARTHRT W/BX IPHAL JT NEURECTOMY INTRINSIC MUSCULATURE OF FOOT Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 85

90 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, FASCIECTOMY PLANTAR FASCIA PARTIAL SPX FASCIOTOMY PLANTAR FASCIA RADICAL SPX SYNVCT INTERTARSAL/TARSOMETATARSAL JT EA SPX SYNOVECTOMY METATARSOPHALANGEAL JOINT EACH EXCISION INTERDIGITAL MORTON NEUROMA SINGLE EACH SYNOVECTOMY TENDON SHEATH FOOT FLEXOR SYNOVECTOMY TENDON SHEATH FOOT EXTENSOR EXC LESION TENDON SHEATH/CAPSULE W/SYNVCT FOOT EXC LESION TENDON SHEATH/CAPSULE W/SYNVCT TOE EA EXCISION/CURETTAGE CYST/TUMOR TALUS/CALCANEUS EXC/CURTG CST/B9 TUM TALUS/CLCNS W/ILIAC/AGRFT EXC/CURETTAGE CYST/TUMOR TALUS/CALCANEUS ALGRFT EXC/CURTG CST/B9 TUM TARSAL/METAR EXC/CURTG CST/B9 TUM TARSAL/METAR W/ILIAC/AGRFT EXC/CURTG CST/B9 TUM TARSAL/METAR W/ALGRFT EXC/CURTG CST/B9 TUM PHALANGES FOOT OSTECTOMY PRTL 5TH METAR HEAD SPX OSTECTOMY COMPLETE 1ST METATARSAL HEAD OSTECTOMY COMPLETE OTHER METATARSAL HEAD 2/3/ OSTECTOMY COMPLETE 5TH METATARSAL HEAD OSTC COMPL ALL METAR HEADS W/PRTL PROX PHALANGC OSTECTOMY TARSAL COALITION OSTECTOMY CALCANEUS OSTECTOMY CALCANEUS SPUR +-PLNTAR FSCAL RLS PRTL EXC B1 TALUS/CALCANEUS PRTL EXC B1 TARSAL/METAR B1 XCP TALUS/CALCANEUS PRTL EXC B1 PHALANX TOE RESECTION PARTIAL/COMPLETE PHALANGEAL BASE EACH TALECTOMY ASTRAGALECTOMY METATARSECTOMY PHALANGECTOMY TOE EA TOE RESECTION CONDYLE DISTAL END PHALANX EACH TOE HEMIPHALANGC/IPHAL JT EXC TOE RAD RESCJ TUMOR TARSAL EXCEPT TALUS/CALCANEUS RADICAL RESECTION TUMOR METATARSAL RADICAL RESECTION TUMOR PHALANX OR TOE REMOVAL FOREIGN BODY FOOT SUBCUTANEOUS REMOVAL FOREIGN BODY FOOT DEEP REMOVAL FOREIGN BODY FOOT COMPLICATED RPR TDN FLXR FOOT 1/2 W/O FR GRF EA TDN RPR TDN FLXR FOOT SEC W/FR GRF EA TDN RPR TDN XTNSR FOOT 1/2 EA TDN RPR TDN XTNSR FOOT SEC W/FR GRF EA TDN TENOLYSIS FLEXOR FOOT SINGLE TENDON TENOLYSIS FLEXOR FOOT MULTIPLE TENDONS TENOLYSIS EXTENSOR FOOT SINGLE TENDON CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

91 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule TENOLYSIS EXTENSOR FOOT MULTIPLE TENDON TX OPN TDN FLXR FOOT 1/MLT TDN SPX TX OPN TDN FLXR TOE 1 TDN SPX TENOTOMY OPEN EXTENSOR FOOT/TOE EACH TENDON RCNSTJ PST TIBL TDN W/EXC ACCESSORY TARSL NAVCLR TENOTOMY LENGTHENING/RLS ABDUCTOR HALLUCIS MUSC DIVISION PLANTAR FASCIA&MUSCLE SPX CAPSULOTOMY MIDFOOT MEDIAL RELEASE ONLY SPX CAPSULOTOMY MIDFOOT W/TENDON LENGTHENING CAPSUL MIDFOOT W/PST TALOTIBL CAPSUL&TDN LNGTH CAPSULOTOMY MIDTARSAL CAPSUL MTTARPHLNGL JT +-TENORRHAPHY EA JT SPX CAPSUL IPHAL JT EA JT SPX SYNDACTYLIZATION TOES CORRECTION HAMMERTOE CORRECTION COCK-UP 5TH TOE W/PLASTIC CLOSURE OSTC PRTL EXOSTC/CONDYLC METAR HEAD HALLUX RGDUS CORRJ W/CHEILC CORRJ HALLUX VALGUS +-SESMDC SMPL EXOSTECTOMY KELLER/MCBRIDE/MAYO PROCEDURE CORRJ HALLUX VALGUS +-SESMDC RESCJ JT W/IMPLT CORRJ HALLUX VALGUS +-SESMDC W/TDN TRNSPLS CORRJ HALLUX VALGUS +-SESMDC W/METAR OSTEOT CORRJ HALLUX VALGUS +-SESMDC LAPIDUS-TYP PX CORRJ HALLUX VALGUS +-SESMDC PHALANX OSTEOT CORRJ HALLUX VALGUS +-SESMDC 2 OSTEOT OSTEOTOMY CALCANEUS +-INTERNAL FIXATION OSTEOTOMY TALUS OSTEOTOMY TARSAL BONES OTH/THN CALCANEUS/TALUS OSTEOT TARSAL OTH/THN CALCANEUS/TALUS W/AGRFT OSTEOT +-LNGTH SHRT/CORRJ 1ST METAR OSTEOT +-LNGTH SHRT/CORRJ 1ST METAR XCP 1ST TOE OSTEOT +-LNGTH SHRT/CORRJ METAR XCP 1ST EA OSTEOT +-LNGTH SHRT/ANGULAR CORRJ METAR MLT OSTEOT SHRT CORRJ PROX PHALANX 1ST TOE OSTEOT SHRT CORRJ OTH PHALANGES ANY TOE RCNSTJ ANGULAR DFRM TOE SOFT TISS PX ONLY SESAMOIDECTOMY FIRST TOE SPX REPAIR NONUNION/MALUNION TARSAL BONES RPR NON/MAL METAR +-B1 GRF RCNSTJ TOE MACRODACTYLY SOFT TISSUE RESECTION RCNSTJ TOE MACRODACTYLY REQUIRING BONE RESECTION RECONSTRUCTION TOE POLYDACTYLY RCNSTJ TOE SYNDACTYLY +-SKN GRF EA WEB RECONSTRUCTION CLEFT FOOT CLOSED TX CALCANEAL FRACTURE W/O MANIPULATION Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 87

92 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, CLOSED TX CALCANEAL FRACTURE W/MANIPULATION PRQ SKEL FIXJ CALCANEAL FX W/MNPJ OPEN TREATMENT CALCANEAL FRACTURE OPEN TREATMENT CALCANEAL FRACTURE W BONE GRAFT CLOSED TX TALUS FRACTURE W/O MANIPULATION CLOSED TX TALUS FRACTURE W/ MANIPULATION PRQ SKELETAL FIXATION TALUS FRACTURE W/MNPJ OPEN TREATMENT TALUS FRACTURE OPEN OSTEOCHONDRAL AUTOGRAFT TALUS TX TARSAL B1 FX XCP TALUS&CALCN W/O MNPJ TX TARSAL B1 FX XCP TALUS&CALCN W/MNPJ PRQ SKEL FIXJ TARSL FX XCP TALUS&CALCNS W/MNPJ OPEN TX TARSAL FRACTURE XCP TALUS &CALCANEUS EA CLOSED TX METATARSAL FRACTURE W/O MANIPULATION CLTX METAR FX W/MNPJ PRQ SKEL FIXJ METAR FX W/MNPJ OPEN TREATMENT METATARSAL FRACTURE EACH CLTX FX GRT TOE PHLX/PHLG W/O MNPJ CLTX FX GRT TOE PHLX/PHLG W/MNPJ PRQ SKEL FIXJ FX GRT TOE PHLX/PHLG W/MNPJ OPEN TX FRACTURE GREAT TOE/PHALANX/PHALANGES CLTX FX PHLX/PHLG OTH/THN GRT TOE W/O MNPJ CLTX FX PHLX/PHLG OTH/THN GRT TOE W/MNPJ OPEN TX FRACTURE PHALANX/PHALANGES NOT GREAT TOE CLOSED TREATMENT SESAMOID FRACTURE OPEN TX SESAMOID FRACTURE +-INTERNAL FIXATION CLTX TARSAL DISLC OTH/THN TALOTARSAL W/O ANES CLTX TARSAL DISLC OTH/THN TALOTARSAL W/ANES PRQ SKEL FIXJ TARSL DISLC XCP TALOTARSAL W/MNPJ OPEN TREATMENT TARSAL BONE DISLOCATION CLOSED TX TALOTARSAL JOINT DISLC W/O ANES CLOSED TX TALOTARSAL JOINT DISLOCATION W/ANES PRQ SKEL FIXJ TALOTARSAL JT DISLC W/MNPJ OPEN TREATMENT TALOTARSAL JOINT DISLOCATION CLOSED TX TARSOMETATARSAL DISLOCATION W/O ANES CLOSED TX TARSOMETATARSAL DISLOCATION W/ANES PRQ SKEL FIXJ TARS JT DISLC W/MNPJ OPEN TREATMENT TARSOMETATARSAL JOINT DISLOCATION CLTX METATARSOPHLNGL JT DISLC W/O ANES CLTX METATARSOPHLNGL JT DISLC REQ ANES PRQ SKEL FIXJ METATARSOPHLNGL JT DISLC W/MNPJ OPEN TX METATARSOPHALANGEAL JOINT DISLOCATION CLTX IPHAL JT DISLC W/O ANES CLTX IPHAL JT DISLC REQ ANES PRQ SKEL FIXJ IPHAL JT DISLC W/MNPJ OPEN TREATMENT INTERPHALANGEAL JOINT DISLOCATION CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

93 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule ARTHRODESIS PANTALAR ARTHRODESIS TRIPLE ARTHRODESIS SUBTALAR ARTHRD MIDTARSL/TARS MLT/TRANSVRS ARTHRD MIDTARSL/TARS MLT/TRANSVRS W/OSTEOT ARTHRD W/TDN LNGTH&ADVMNT TARSL NVCLR-CUNEIFORM ARTHRODESIS MIDTARSOMETATARSAL SINGLE JOINT ARTHRODESIS GREAT TOE METATARSOPHALANGEAL JOINT ARTHRODESIS GREAT TOE INTERPHALANGEAL JOINT ARTHRD W/XTNSR HALLUCIS LONGUS TR 1ST METAR NCK AMPUTATION FOOT MIDTARSAL AMPUTATION FOOT TRANSMETARSAL AMPUTATION METATARSAL W/TOE SINGLE AMPUTATION TOE METATARSOPHALANGEAL JOINT AMPUTATION TOE INTERPHALANGEAL JOINT ESWT HI NRG PFRMD PHYS W/US GDN INVG PLNTAR FSCA UNLISTED PROCEDURE FOOT/TOES BR YYY APPLICATION HALO TYPE BODY CAST APPLICATION RISSER JACKET LOCALIZER BODY ONLY APPLICATION RISSER JACKET LOCALIZER BODY W/HEAD APPLICATION TURNBUCKLE JACKET BODY ONLY APPLICATION TURNBUCKLE JACKET BODY W/HEAD APPLICATION BODY CAST SHOULDER HIPS APPLICATION BODY CAST SHOULDER HIPS HEAD MINERVA APPLICATION BODY CAST SHOULDER HIPS W/ONE THIGH APPLICATION BODY CAST SHOULDER HIPS BOTH THIGHS APPLICATION CAST FIGURE-OF APPLICATION CAST SHOULDER SPICA APPLICATION CAST PLASTER VELPEAU APPLICATION CAST SHOULDER HAND LONG ARM APPLICATION CAST ELBOW FINGER SHORT ARM APPLICATION CAST HAND&LOWER FOREARM GAUNTLET APPLICATION CAST FINGER APPLICATION LONG ARM SPLINT SHOULDER HAND APPLICATION SHORT ARM SPLINT FOREARM-HAND STATIC APPLICATION SHORT ARM SPLINT DYNAMIC APPLICATION FINGER SPLINT STATIC APPLICATION FINGER SPLINT DYNAMIC STRAPPING THORAX STRAPPING SHOULDER STRAPPING ELBOW/WRIST STRAPPING HAND/FINGER APPLICATION HIP SPICA CAST 1 LEG APPL HIP SPICA CAST ONE&ONE-HALF SPICA/BOTH LEGS APPLICATION LONG LEG CAST THIGH-TOE APPLICATION LONG LEG CAST WALKER/AMBULATORY TYPE Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 89

94 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, APPLICATION LONG LEG CAST BRACE APPLICATION CYLINDER CAST THIGH ANKLE APPLICATION SHORT LEG CAST BELOW KNEE-TOE APPLICATION SHORT LEG CAST WALKING/AMBULATORY APPLICATION PATELLAR TENDON BEARING CAST ADDING WALKER PREVIOUSLY APPLIED CAST APPLICATION RIGID TOTAL CONTACT LEG CAST APPL CLUBFOOT CAST MOLDING/MNPJ LONG/SHORT LEG APPLICATION LONG LEG SPLINT THIGH ANKLE/TOES APPLICATION SHORT LEG SPLINT CALF FOOT STRAPPING HIP STRAPPING KNEE STRAPPING ANKLE &/FOOT STRAPPING TOES STRAPPING UNNA BOOT APPL MLT-LAYER VENOUS WOUND COMPRESS BELOW KNEE DENIS-BROWNE SPLINT STRAPPING REMOVAL/BIVALVING GAUNTLET BOOT/BODY CAST REMOVAL/BIVALVING FULL ARM/FULL LEG CAST RMVL/BIVALV SHO/HIP SPICA MINERVA/RISSER JACKET REMOVAL/BIVALVING TURNBUCKLE JACKET REPAIR SPICA BODY CAST/JACKET WINDOWING CAST WEDGING CAST EXCEPT CLUBFOOT CASTS WEDGING CLUBFOOT CAST UNLISTED PROCEDURE CASTING/STRAPPING BR YYY ARTHRS TMPRMAND JT DX +-SYNVAL BX SPX ARTHROSCOPY TEMPOROMANDIBULAR JOINT SURGICAL ARTHROSCOPY SHOULDER DX +-SYNOVIAL BIOPSY SPX ARTHROSCOPY SHOULDER SURGICAL CAPSULORRHAPHY ARTHROSCOPY SHOULDER SURGICAL REPAIR SLAP LESION ARTHROSCOPY SHOULDER SURGICAL REMOVAL LOOSE/FB ARTHROSCOPY SHOULDER SURG SYNOVECTOMY PARTIAL ARTHROSCOPY SHOULDER SURG SYNOVECTOMY COMPLETE ARTHROSCOPY SHOULDER SURG DEBRIDEMENT LIMITED ARTHROSCOPY SHOULDER SURG DEBRIDEMENT EXTENSIVE ARTHROSCOPY SHOULDER DISTAL CLAVICULECTOMY ARTHROSCOPY SHOULDER LYSIS&RESCJ ADHESION +-MNPJ SHOULDER SCOPE BONE SHAVING ARTHROSCOPY SHOULDER ROTATOR CUFF REPAIR ARTHROSCOPY SHOULDER BICEPS TENODESIS ARTHROSCOPY ELBOW DIAGNOSTIC +-SYNOVIAL BX SPX ARTHROSCOPY ELBOW SURGICAL W/REMOVAL LOOSE/FB ARTHROSCOPY ELBOW SURGICAL SYNOVECTOMY PARTIAL ARTHROSCOPY ELBOW SURGICAL SYNOVECTOMY COMPLETE ARTHROSCOPY ELBOW SURGICAL DEBRIDEMENT LIMITED CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

95 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule ARTHROSCOPY ELBOW SURGICAL DEBRIDEMENT EXTENSIVE ARTHROSCOPY WRIST DIAGNOSTIC +-SYNOVIAL BX SPX ARTHROSCOPY WRIST INFECTION LAVAGE&DRAINAGE ARTHROSCOPY WRIST SURGICAL SYNOVECTOMY PARTIAL ARTHROSCOPY WRIST SURGICAL SYNOVECTOMY COMPLETE ARTHRS WRST EXC&/RPR TRIANG FIBROCART&/JT DBRDMT ARTHRS WRST SURG INT FIXJ F/FX/INS NDSC WRST SURG W/RLS TRANSVRS CARPL LIGM ARTHRS AID TX SPI&/FX KNE W/O FIXJ ARTHRS AID TX SPI&/FX KNE W/FIXJ ARTHRS AID TIBIAL FRACTURE PROXIMAL UNICONDYLAR ARTHRS AID TIBIAL FX PROX UNICONDYLAR BICONDYLAR ARTHROSCOPY HIP DIAGNOSTIC +-SYNOVIAL BIOPSY SPX ARTHROSCOPY HIP SURGICAL W/REMOVAL LOOSE/FB ARTHRS HIP DEBRIDEMENT/SHAVING ARTICULAR CRTLG ARTHROSCOPY HIP SURGICAL W/SYNOVECTOMY ARTHROSCOPY KNEE OSTEOCHONDRAL AGRFT MOSAICPLAST ARTHROSCOPY KNEE OSTEOCHONDRAL ALLOGRAFT ARTHROSCOPY KNEE MENISCAL TRNSPLJ MED/LAT ARTHROSCOPY KNEE DIAGNOSTIC +-SYNOVIAL BX SPX ARTHROSCOPY KNEE INFECTION LAVAGE & DRAINAGE ARTHROSCOPY KNEE LATERAL RELEASE ARTHROSCOPY KNEE REMOVAL LOOSE/FOREIGN BODY ARTHROSCOPY KNEE SYNOVECTOMY LIMITED SPX ARTHROSCOPY KNEE SYNOVECTOMY 2/>COMPARTMENTS ARTHRS KNEE DEBRIDEMENT/SHAVING ARTCLR CRTLG ARTHRS KNEE ABRASION ARTHRP/MLT DRLG/MICROFX ARTHRS KNEE W/MENISCECTOMY MED&LAT W/SHAVING ARTHRS KNE SURG W/MENISCECTOMY MED/LAT W/SHVG ARTHROSCOPY KNEE W/MENISCUS RPR MEDIAL/LATERAL ARTHROSCOPY KNEE W/MENISCUS RPR MEDIAL&LATERAL ARTHROSCOPY KNEE W/LYSIS ADHESIONS+-MNPJ SPX ARTHRS KNE DRLG OSTEO DISS GRFG ARTHRS KNE DRLG OSTEO DISS LES ARTHRS KNE DRLG OSTEO DISS LES INT FIXJ ARTHRS AIDED ANT CRUCIATE LIGM RPR/AGMNTJ/RCNSTJ ARTHRS AIDED PST CRUCIATE LIGM RPR/AGMNTJ/RCNSTJ ARTHRS ANKLE EXC OSTCHNDRL DFCT W/DRLG DFCT ARTHRS AID RPR LES/TALAR DOME FX/TIBL PLAFOND FX ENDOSCOPIC PLANTAR FASCIOTOMY ARTHROSCOPY ANKLE W/REMOVAL LOOSE/FOREIGN BODY ARTHROSCOPY ANKLE SURGICAL SYNOVECTOMY PARTIAL ARTHROSCOPY ANKLE SURGICAL DEBRIDEMENT LIMITED ARTHROSCOPY ANKLE SURGICAL DEBRIDEMENT EXTENSIVE ARTHROSCOPY ANKLE SURGICAL W/ANKLE ARTHRODESIS ARTHROSCOPY METACARPOPHALANGEAL SYNOVIAL BIOPSY Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 91

96 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, ARTHRS METACARPOPHALANGEAL JOINT DEBRIDEMENT ARTHRS MTCARPHLNGL JT W/RDCTJ UR COLTRL LIGM ARTHRS SUBTALAR JOINT REMOVE LOOSE/FOREIGN BODY ARTHROSCOPY SUBTALAR JOINT WITH SYNOVECTOMY ARTHROSCOPY SUBTALAR JOINT WITH DEBRIDEMENT ARTHROSCOPY SUBTALAR JOINT SUBTALAR ARTHRODESIS l # ARTHROSCOPY HIP W/FEMOROPLASTY l # ARTHROSCOPY HIP W/ACETABULOPLASTY l # ARTHROSCOPY HIP W/LABRAL REPAIR UNLISTED PROCEDURE ARTHROSCOPY BR YYY DRAINAGE ABSCESS/HEMATOMA NASAL INT APPROACH DRAINAGE ABSCESS/HEMATOMA NASAL SEPTUM BIOPSY INTRANASAL EXCISION NASAL POLYP SIMPLE EXCISION NASAL POLYP EXTENSIVE EXCISION/DESTRUCTION INTRANASAL LESION INT APPR EXCISION/DESTRUCTION INTRANASAL LESION XTRNL EXCISION/SURGICAL PLANING SKIN NOSE RHINOPHYMA EXCISION DERMOID CYST NOSE SIMPLE SUBCUTANEOUS EXC DERMOID CYST NOSE COMPLEX UNDER BONE/CRTLG EXCISION INFERIOR TURBINATE PARTIAL/COMPLETE SUBMUCOUS RESCJ INFERIOR TURBINATE PRTL/COMPL RHINECTOMY PARTIAL RHINECTOMY TOTAL INJECTION TURBINATE THERAPEUTIC DISPLACEMENT THERAPY PROETZ TYPE INSERTION NASAL SEPTAL PROSTHESIS BUTTON REMOVAL FOREIGN BODY INTRANASAL OFFICE PROCEDURE REMOVAL FOREIGN BODY INTRANASAL GENERAL ANES RMVL FOREIGN BODY INTRANASAL LATERAL RHINOTOMY RHINP PRIM LAT&ALAR CRTLGS&/ELVTN NSL TIP RHINP PRIM COMPLETE XTRNL PARTS RHINOPLASTY PRIMARY W/MAJOR SEPTAL REPAIR RHINOPLASTY SECONDARY MINOR REVISION RHINOPLASTY SECONDARY INTERMEDIATE REVISION RHINOPLASTY SECONDARY MAJOR REVISION RHINP DFRM W/COLUM LNGTH TIP ONLY RHINP DFRM COLUM LNGTH TIP SEPTUM OSTEOT REPAIR NASAL VESTIBULAR STENOSIS SEPTOP/SBMCSL RESCJ REPAIR CHOANAL ATRESIA INTRANASAL REPAIR CHOANAL ATRESIA TRANSPALATINE LYSIS INTRANASAL SYNECHIA REPAIR FISTULA OROMAXILLARY REPAIR FISTULA ORONASAL SEPTAL/OTHER INTRANASAL DERMATOPLASTY CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

97 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule REPAIR NASAL SEPTAL PERFORATIONS ABLTJ SOF TISS INF TURBS UNI/BI SUPFC ABLTJ SOF TISS INF TURBS UNI/BI SUPFC INTRAMURAL CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX CTRL NSL HEMRRG PST PST NSL PACKS&/CAUT 1ST CTRL NSL HEMRRG PST PST NSL PACKS&/CAUT SBSQ LIGATION ARTERIES ETHMOIDAL LIGATION ARTERIES INT MAXILLARY TRANSANTRAL FRACTURE NASAL INFERIOR TURBINATE THERAPEUTIC UNLISTED PROCEDURE NOSE BR YYY LAVAGE CANNULATION MAXILLARY SINUS LAVAGE CANNULATION SPHENOID SINUS SINUSOTOMY MAXILLARY ANTROTOMY INTRANASAL SINUSOTOMY MAXILLARY RAD W/O RMVL ANTROCH POLYPS SINUSOT MAX ANTRT RAD W/RMVL ANTROCH POLYPS PTERYGOMAXILLARY FOSSA SURGERY ANY APPROACH SINUSOTOMY SPHENOID +-BIOPSY SINUSOT SPHENOID W/MUCOSAL STRIPPING/RMVL POLYP SINUSOTOMY FRONTAL EXTERNAL SIMPLE SINUSOTOMY FRONTAL TRANSORBITAL UNILATERAL SINUSOTOMY FRNT OBLITERATIVE W/O FLAP BROW INC SINUSOT FRNT OBLIT W/O OSTPL FLAP CORONAL INC SINUSOT FRNT OBLIT W/OSTPL FLAP BROW INC SINUSOT FRNT OBLIT W/OSTPL FLAP CORONAL INC SINUSOT FRNT NONOBLIT W/OSTPL FLAP BROW INC SINUSOT FRNT NONOBLIT W/OSTPL FLAP CORONAL INC SINUSOT UNI 3/> PARANSL SINUSES ETHMOIDECTOMY INTRANASAL ANTERIOR ETHMOIDECTOMY INTRANASAL TOTAL ETHMOIDECTOMY EXTRANASAL TOTAL MAXILLECTOMY W/O ORBITAL EXENTERATION MAXILLECTOMY W/ORBITAL EXENTERATION NASAL ENDOSCOPY DIAGNOSTIC UNI/BI SPX NSL/SINUS NDSC DX MAX SINUSC NSL/SINUS NDSC DX SPHENOID SINUSOSCOPY NSL/SINUS NDSC SURG W/BX POLYPC/DBRDMT SPX NSL/SINUS NDSC SURG W/CTRL NSL HEMRRG NSL/SINUS NDSC SURG W/DACRYOCSTORHINOSTOMY NSL/SINUS NDSC SURG W/CONCHA BULLOSA RESCJ NASAL/SINUS ENDOSCOPY W/ETHMOIDECTOMY PARTIAL NASAL/SINUS ENDOSCOPY W/ETHMOIDECTOMY TOTAL NASAL/SINUS ENDOSCOPY W/MAXILLARY ANTROSTOMY NSL/SINUS NDSC MAX ANTROST W/RMVL TISS MAX SINUS NSL/SINUS NDSC W/FRNT SINUS EXPL NASAL/SINUS ENDOSCOPY W/SPHENOIDECTOMY Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 93

98 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, NSL/SINUS NDSC SPHENDT RMVL TISS SPHENOID SINUS NSL/SINUS NDSC RPR CEREBSP FLU LEAK ETHMOID NSL/SINUS NDSC RPR CEREBSP FLU LEAK SPHENOID NSL/SINUS NDSC SURG W/MEDIAL/INF ORB WALL DCMPRN NSL/SINUS NDSC MEDIAL ORB&INF ORB WALL DCMPRN NSL/SINUS NDSC SURG W/OPTIC NRV DCMPRN l NSL/SINUS NDSC SURG W/DILAT MAXILLARY SINUS l NSL/SINUS NDSC SURG W/DILAT FRONTAL SINUS l NSL/SINUS NDSC SURG W/DILAT SPHENOID SINUS UNLISTED PROCEDURE ACCESSORY SINUSES BR YYY LRYNGOT W/RMVL TUM/LARYNGOCELE CORDECTOMY LARYNGOTOMY THYROTOMY LARYNGOFISSURE DX LARGTOM TOT W/O RAD NCK DSJ LARGTOM TOT W/RAD NCK DSJ LARGTOM STOT SUPRAGLOTTIC W/O RAD NCK DSJ LARGTOM STOT SUPRAGLOTTIC W/RAD NCK DSJ PRTL LARGTOM HEMILARGTOM HRZNTL PRTL LARGTOM HEMILARGTOM LATER> PRTL LARGTOM HEMILARGTOM ANTER> PRTL LARGTOM HEMILARGTOM ANTERO-LATERO-VER PHARYNGOLARGTOM W/RAD NCK DSJ W/O RCNSTJ PHARYNGOLARGTOM W/RAD NCK DSJ W/RCNSTJ ARYTENOIDECTOMY/ARYTENOIDOPEXY XTRNL APPR EPIGLOTTIDECTOMY * INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE TRACHEOTOMY TUBE CHANGE PRIOR TO FISTULA TRACT LARYNGOSCOPY INDIRECT DIAGNOSTIC SPX LARYNGOSCOPY INDIRECT W/BIOPSY LARYNGOSCOPY INDIRECT W/REMOVAL FOREIGN BODY LARYNGOSCOPY INDIRECT W/REMOVAL LESION LARYNGOSCOPY INDIRECT W/VOCAL CORD INJECTION LARYNGOSCOPY +-TRACHEOSCOPY ASPIRATION LARYNGOSCOPY +-TRACHEOSCOPY DIAGNOSTIC NEWBORN LARYNGOSCOPY +-TRACHEOSCOPY DX EXCEPT NEWBORN LARYNGOSCOPY +-TRACHEOSCOPY MICROSCOPE/TELESCOPE LARYNGOSCOPY +-TRACHEOSCOPY INSERTION OBTURATOR LARYNGOSCOPY +-TRACHEOSCOPY W/DILATION INITIAL LARYNGOSCOPY +-TRACHEOSCOPY DILATION SUBSEQUENT LARYNGOSCOPY W/FOREIGN BODY REMOVAL LARYNGOSCOPY F BODY RMVL MICROSCOPE/TELESCOPE LARYNGOSCOPY DIRECT OPERATIVE W/BIOPSY LARYNGOSCOPY W/BIOPSY MICROSCOPE/TELESCOPE LARGSC EXC TUM&/STRIPPING CORDS/EPIGL LARGSC EXC TUM&/STRPG CORDS/EPIGL MCRSCP/TLSCP LARGSC MCRSCP/TLSCP RMVL LES VOCAL C/D FLAP LARGSC MCRSCP/TLSCP RMVL LES VOCAL C/D GRF CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

99 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule LARYNGOSCOPY DIRECT OPERATIVE W/ARYTENOIDECTOMY LARGSC ARYTENOIDECTOMY MICROSCOPE/TELESCOPE LARYNGOSCOPE INJECTION VOCAL CORD THERAPEUTIC LARGSC W/NJX VOCAL CORD THER W/MCRSCP/TLSCP LARYNGOSCOPY FLEXIBLE FIBEROPTIC DIAGNOSTIC LARYNGOSCOPY FLEXIBLE FIBEROPTIC W/BIOPSY LARYNGOSCOPY FLX FIBEROPTIC RMVL FOREIGN BODY LARYNGOSCOPY FLEXIBLE FIBEROPTIC REMOVAL LESION LARYNGOSCOPY FLX/RGD FIBOPT W/STROBOSCOPY XXX LARYNGOPLASTY LARYN WEB 2 STG W/KEEL INSJ&RMVL LARYNGP LARYN STENOSIS GRF/CORE MOLD W/TRACHT LARYNGOPLASTY W/OPN RDCTJ FX LARYNGOPLASTY CRICOID SPLIT LARYNGOPLASTY NOT OTHERWISE SPECIFIED LARYNGEAL REINNERVATION NEUROMUSCULAR PEDICLE SECTION RECURRENT LARYNGEAL NERVE THER UNI SPX UNLISTED PROCEDURE LARYNX BR YYY TRACHEOSTOMY PLANNED SPX TRACHEOSTOMY PLANNED UNDER 2 YEARS SPX TRACHEOSTOMY EMERGENCY PROCEDURE TRANSTRACHEAL TRACHEOSTOMY EMERGENCY CRICOTHYROID MEMBRANE TRACHEOSTOMY FENESTRATION W/SKIN FLAPS CONSTJ TRACHEOESOPHGL FSTL&INSJ SP PROSTH TRACHEAL PNXR PRQ W/TRANSTRACHEAL ASPIR&/NJX TRACHEOSTOMA REVJ SMPL W/O FLAP ROTATION TRACHEOSTOMA REVJ CPLX W/FLAP ROTATION K TRACHEOBRNCHSC THRU EST TRACHS INC K ENDOBRNCL US BRONCHOSCOPIC DX/THER IVNTJ ZZZ K BRNCHSC INCL FLUOR GID DX W/CELL WASHG SPX K BRNCHSC BRUSHING/PROTECTED BRUSHINGS K BRNCHSC W/BRNCL ALVEOLAR LAVAGE K BRNCHSC BRNCL/ENDOBRNCL BX 1+ SITS K BRNCHSC W/PLMT FIDUCIAL MARKERS 1/MLT K BRNCHSC W/CPTR-ASST IMAGE-GUIDED NAVIGATION ZZZ K BRNCHSC W/TRANSBRNCL LUNG BX 1 LOBE K BRNCHSC NDL BX TRACHEA MAIN STEM&/BRONCHUSI BRNCHSC W/TRACHEAL/BRNCL DILAT/CLSD RDCTJ FX BRNCHSC W/PLACEMENT TRACHEAL STENT BRNCHSC W/TRANSBRNCL LUNG BX EA LOBE ZZZ BRNCHSC W/TRANSBRNCL NDL ASPIR BX EA LOBE ZZZ l K BRONCHOSCOPY BALLOON OCCLUSION K BRNCHSC W/REMOVAL FOREIGN BODY BRNCHSC W/PLACEMENT BRNCL STENT 1ST BRONCHUS BRNCHSC EA MAJOR BRONCHUS STENTED ZZZ BRNCHSC REVJ TRACHEAL/BRNCL STENT INS PREV SESS BRNCHSC W/EXCISION TUMOR Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 95

100 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, BRNCHSC W/DSTRJ TUM RELIEF STENOSIS OTH/THN EXC BRNCHSC W/PLMT CATH INTRCV RADIOELMNT APPL K BRNCHSC W/THER ASPIR TRACHEOBRNCL TREE 1ST K BRNCHSC W/THER ASPIR TRACHEOBRNCL TREE SBSQ K BRNCHSC W/NJX CONTRAST SGMTL BRONCHOG TRANSTRACHEAL INJECTION BRONCHOGRAPHY CATHETERIZATION W/BRONCHIAL BRUSH BIOPSY CATHETER ASPIRATION NASOTRACHEAL SPX K CATH ASPIR TRACHEOBRNCL FIBERSCOPE BEDSIDE SPX TTRACH INTRO NDL WIRE DIL/STENT/TUBE O2 THER TRACHEOPLASTY CERVICAL TRACHEOPLASTY TRACHEOPHARYNGEAL FSTLJ EA STG TRACHEOPLASTY INTRATHORACIC CARINAL RECONSTRUCTION BRONCHOPLASTY GRAFT REPAIR BRONCHOPLASTY EXCISION STENOSIS & ANASTOMOSIS EXCISION TRACHEAL STENOSIS&ANASTOMOSIS CERVICAL EXC TRACHEAL STENOSIS&ANAST CERVICOTHORACIC EXCISION TRACHEAL TUMOR/CARCINOMA CERVICAL EXCISION TRACHEAL TUMOR/CARCINOMA THORACIC SUTURE TRACHEAL WOUND/INJURY CERVICAL SUTURE TRACHEAL WOUND/INJURY INTRATHORACIC SURG CLSR TRACHS/FSTL W/O PLSTC RPR SURG CLSR TRACHS/FSTL W/PLSTC RPR REVISION TRACHEOSTOMY SCAR UNLISTED PROCEDURE TRACHEA BRONCHI BR YYY THORACOSTOMY W/RIB RESECTION EMPYEMA THORACOSTOMY OPEN FLAP DRAINAGE EMPYEMA THORACOTOMY LIMITED BIOPSY LUNG/PLEURA THORACOTOMY WITH EXPLORATION THORCOM MAJOR CTRL TRAUMTC HEMRRG&/RPR LNG TEAR THORACOTOMY MAJOR POSTOPERATIVE COMPLICATIONS THORACOTOMY MAJOR OPN INTRAPLEURAL PNEUMONOLYSIS THORCOM W/ REMOVAL OF CYST THORACOTOMY W/EXCISION BULLAE THORCOM MAJOR W/RMVL INTRAPLEURAL FB/FIBRIN DEP THORCOM MAJOR W/RMVL IPUL FB THORACOTOMY MAJOR W/CARDIAC MASSAGE PNEUMONOSTOMY W/OPEN DRAINAGE ABSCESS/CYST K PNEUMONOSTOMY PERCUTANEOUS DRAINAGE ABSCESS/CYST PLEURAL SCARIFICATION REPEAT PNEUMOTHORAX DECORTICATION PULMONARY TOTAL SPX DECORTICATION PULMONARY PARTIAL SPX PLEURECTOMY PARIETAL SPX DECORTICATION & PARIETAL PLEURECTOMY BIOPSY PLEURA PERCUTANEOUS NEEDLE CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

101 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule BIOPSY PLEURA OPEN BIOPSY LUNG/MEDIASTINUM PERCUTANEOUS NEEDLE PNEUMOCENTESIS PUNCTURE LUNG ASPIRATION THORACENTESIS PUNCTURE PLEURAL CAVITY ASPIRATION THORACENTESIS WITH INSERTION TUBE WATER SEAL REMOVAL OF LUNG REMOVAL LUNG PNEUMONECTOMY EXTRAPLEURAL REMOVAL LUNG TOTAL PNEUMONECTOMY EXTRAPLEURAL RMVL LNG OTH/THN PNUMEC 1 LOBE LOBEC RMVL LNG OTH/THN PNUMEC 2 LOBES BILOBEC RMVL LNG OTH/THN PNUMEC 1 SGM SGMECTOMY RMVL LNG XCP PNUMEC SLEEVE LOBECTOMY RMVL LNG OTH/THN PNUMEC COMPLETION PNUMEC RMVL LNG OTH/THN PNUMEC EXC-PLCTJ EMPHY LNG RMVL LNG OTH/THN TOT PNUMEC WEDGE RESCJ 1/MLT RESCJ&BRONCHOPLASTY PFRMD TM LOBEC/SGMECTOMY ZZZ RESCJ APICAL LNG TUM W/O CH WALL RCNSTJ RESCJ APICAL LNG TUM W/CH WALL RCNSTJ EXTRAPLEURAL ENUCLEATION EMPYEMA EMPYEMECTOMY K INSERTION INDWELLING TUNNELED PLEURAL CATHETER K TUBE THORACOSTOMY INCLUDES WATER SEAL RMVL NDWELLG TUN PLEURAL CATH W/CUFF K PLMT NTRSTL DEV RADJ THX GID PRQ INTRATHRC 1/MLT INSTLJ VIA CHEST TUBE/CATH AGENT FOR PLEURODESIS INSTLJ VIA CH TUBE/CATH AGENT FBRNLYSIS 1ST DAY INSTLJ CH TUBE/CATH AGENT FBRNLYSIS SBSQ DAY THORSC DX LUNGS/PLEURAL SPACE/MED/PERICAR W/O BX THORACOSCOPY DX LUNGS&PLEURAL SPACE W/BX SPX THORACOSCOPY DX PERICARDIAL SAC W/O BIOPSY SPX THORACOSCOPY DX PERICARDIAL SAC W/BIOPSY SPX THORACOSCOPY DX MEDIASTINAL SPACE W/O BIOPSY SPX THORACOSCOPY DX MEDIASTINAL SPACE W/BIOPSY SPX THORACOSCOPY W/PLEURODESIS THORACOSCOPY W/PARTIAL PULMONARY DECORTICATION THRSC TOT PULM DCRTCTJ INTRAPLEURAL PNEUMONOLSS THORACOSCOPY RMVL INTRAPLEURAL FB/FIBRIN DEPOSIT THORACOSCOPY CONTROL TRAUMATIC HEMORRHAGE THORACOSCOPY W/EXCISION BULLAE THORACOSCOPY W/PARIETAL PLEURECTOMY THRSC W/WEDGE RESCJ LNG 1/MLT THRSC W/RMVL CLOT/FB FROM PRCRD SAC THRSC CRTJ PRCRD WINDOW/PRTL RESCJ PRCRD SAC THORACOSCOPY W/TOTAL PERICARDIECTOMY THRSC W/EXC PRCRD CST TUM/MASS THRSC W/EXC MEDSTNL CST TUM/MASS THORACOSCOPY W/LOBECTOMY TOTAL/SGMTL Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 97

102 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, THORACOSCOPY W/THORACIC SYMPATHECTOMY THORACOSCOPY W/ESOPHAGOMYOTOMY HELLER TYPE REPAIR LUNG HERNIA THROUGH CHEST WALL CLSR CH WALL FLWG OPN FLAP DRG EMPYEMA OPEN CLOSURE MAJOR BRONCHIAL FISTULA MAJOR RECONSTRUCTION CHEST WALL POSTTRAUMATIC DONOR PNEUMONECTOMY FROM CADAVER DONOR BR XXX LUNG TRANSPLANT 1 W/O CARDIOPULMONARY BYPASS LUNG TRANSPLANT 1 W/CARDIOPULMONARY BYPASS LUNG TRANSPLANT 2 W/O CARDIOPULMONARY BYPASS LUNG TRANSPLANT 2 W/CARDIOPULMONARY BYPASS BKBENCH STANDARD PREPJ CDVR DON LNG ALGRFT UNI BR XXX BKBENCH STANDARD PREPJ CDVR DON LNG ALGRFT BI BR XXX RESECTION RIBS EXTRAPLEURAL ALL STAGES THORACOPLASTY SCHEDE TYPE/EXTRAPLEURAL THORACOP SCHEDE TYP/XTRPLEURAL CLSR BRNCPLR FSTL PNEUMONOLSS XTRPRIOSTEAL W/FILLING/PACKING PX PNEUMOTHORAX THER INTRAPLEURAL NJX AIR TOTAL LUNG LAVAGE UNILATERAL ABLATION PULMONARY TUMOR PERQ RF UNI UNLISTED PROCEDURE LUNGS & PLEURA BR YYY K PERICARDIOCENTESIS INITIAL K PERICARDIOCENTESIS SUBSEQUENT TUBE PERICARDIOSTOMY PERICARDIOTOMY REMOVAL CLOT/FOREIGN BODY PRIMARY CRTJ PERICARDIAL WINDOW/PRTL RESECJ W/DRG/BX PRICARDIECTOMY STOT/COMPL W/O CARD BYP PRICARDIECTOMY STOT/COMPL W/CARD BYP RESECJ PERICARDIAL CYST/TUMOR EXC INTRACARDIAC TUMOR RESCJ CARDIOPULMONARY BYP RESECTION EXTERNAL CARDIAC TUMOR TRANSMYOCRD LASER REVSC THORCOM SPX TRANSMYOCRD LASER REVSC PFRMD TM OTH OPN CAR PX ZZZ INSERTION EPICARDIAL ELECTRODE OPEN INSERTION EPICARDIAL ELECTRODE ENDOSCOPIC K INSJ/RPLCMT PRM PM W/TRANSVNS ELTRD ATR K INSJ/RPLCMT PRM PM W/TRANSVNS ELTRD VENTR K INSJ/RPLCMT PRM PM W/TRANSVNS ELTRD ATR&VENTR K INSJ/RPLCMT TEMP TRANSVNS 1CHMBR ELTRD/PM CATH K INSJ/RPLCMT TEMP TRANSVNS 2CHMBR PACG ELTRDS SPX K INSJ/RPLCMT PM PLS GEN ONLY 1CHMBR ATR/VENTR K INSJ/RPLCMT PM PLS GEN ONLY 2CHMBR K UPG PM SYS CONV 1CHMBR SYS 2CHMBR SYS RPSG PREV IMPLTED PM/CVDFB R ATR/R VENTR ELTRD K INSJ 1 TRANSVNS ELTRD PERM PACEMAKER OR CVDFB K INSJ 2 TRANSVNS ELTRD PERM PACEMAKER OR CVDFB CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

103 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule K RPR 1 ELTRD 1CHMBR PRM PM/1CHMBR CVDFB K RPR 2 ELTRDS 2 CHMBR PRM PM/2CHMBR CVDFB K REVISION/RELOCATION SKIN POCKET PACEMAKER K REVJ SKN POCKET FOR CARDIOVERTER-DEFIBRILLATOR INSJ ELTRD CAR VEN SYS ATTCH PM/CVDFB PLS GEN INSJ ELTRD CAR VEN SYS TM INSJ CVDFB/PM PLS GEN ZZZ RPSG PREV IMPLTED CAR VEN SYS L VENTR ELTRD K REMOVAL PERMANENT PACEMAKER PULSE GENERATOR K RMVL TRANSVNS PM ELTRD 1 LEAD SYS ATR/VENTR K RMVL TRANSVNS PM ELTRD DUAL LEAD SYS RMVL PRM EPICAR PM&ELTRDS THORCOM 1 LEAD SYS RMVL PRM EPICAR PM&ELTRDS THORCOM DUAL LEAD SYS RMVL PRM TRANSVNS ELTRD THORCOM K INSJ 1/2CHMBR PACG CVDFB PLS GEN K SUBQ RMVL 1/2CHMBR PACG CVDFB PLS GEN RMVL 1/2CHMBR PACG CVDFB ELTRD THORCOM K RMVL 1/2CHMBR PACG CVDFB ELTRD TRANSVNS XTRJ K INSJ/RPSG LEAD 1/2CHMBR CVDFB&INSJ PLS GEN ABLTJ ARRHYTGNIC FOC/PTHWY TRC&/FOC ABLTJ ARRHYTGNIC FOC/PTHWY TRC&/FOC CARD BYP ABLATION & RCNSTJ ATRIA LMTD ABLATION & RCNSTJ ATRIA X10SV W/O BYPASS ABLATION & RCNSTJ ATRIA X10SV W/BYPASS ATRIA ABLATE & RCNSTJ W OTHER PROCEDURE LIMITED ZZZ ATRIA ABLTJ &RCNSTJ W OTHER PX EXTENSIVE W/O BYP ZZZ ATRIA ABLATE &RCNSTJ W OTHER PX EXTENSIVE W BYP ZZZ OPRATIVE ABLTJ VENTR ARRHYTGNIC FOC W/CARD BYP NDSC ABLATION & RCNSTJ ATRIA LMTD W/O BYPASS NDSC ABLATION & RCNSTJ ATRIA X10SV W/O BYPASS IMPLANTATION PT-ACTIVATED CARDIAC EVENT RECORDER RMVL IMPLANTABLE PT-ACTIVATED CAR EVENT RECORDER REPAIR CARDIAC WOUND W/O BYPASS REPAIR CARDIAC WOUND W/CARDIOPULMONARY BYPASS CARDIOT EXPL W/RMVL FB ATR/VENTR THRMB W/O BYP CARDIOT EXPL RMVL FB ATR/VENTR THRMB CARD BYP SUTR RPR AORTA/GRT VSL W/O SHUNT/CARD BYP SUTR RPR AORTA/GRT VSL W/SHUNT BYP SUTR RPR AORTA/GRT VSL W/CARD BYP INSJ GRF AORTA/GRT VSL W/O SHUNT/CARD BYP INSJ GRF AORTA/GRT VSL W/SHUNT BYP INSJ GRF AORTA/GRT VSL W/CARD BYP VLVP AORTIC VALVE OPN W/CARD BYP VLVP AORTIC VALVE OPN W/INFL OCCLUSION VLVP AORTIC VALVE W/TRANSVENTR DILAT W/CARD BYP CONSTRUCTION APICAL-AORTIC CONDUIT RPLCMT A-VALVE PROSTC XCP HOMOGRF/STENT< VALVE Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 99

104 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, RPLCMT A-VALVE ALGRFT VALVE FRHAND RPLCMT A-VALVE STENT< TISS VALVE s RPLCMT AORTIC VALVE ANNULUS ENLGMENT NONC SINUS RPLCMT A-VALVE KONNO PROCEDURE RPLCMT A-VALVE ROSS PX RPR VENTR O/F TRC OBSTRCJ PATCH ENLGMENT O/F TRC RESCJ/INC SUBVALVULAR TISSUE VENTRICULOMYOTOMY-MYECTOMY AORTOPLASTY SUPRAVALVULAR STENOSIS VALVOTOMY MITRAL VALVE CLOSED HEART VALVOTOMY MITRAL VALVE OPN HRT W/CARD BYP VLVP MITRAL VALVE W/CARD BYP VLVP MITRAL VALVE W/CARD BYP W/PROSTC RING VLVP MITRAL VALVE W/CARD BYP RAD RCNSTJ +-RING REPLACEMENT MITRAL VALVE W/CARDIOPULMONARY BYP VALVECTOMY TRICUSPID VALVE W/CARDIOPULMONARY BYP VALVULOPLASTY TRICUSPID VALVE W/O RING INSERTION VALVULOPLASTY TRICUSPID VALVE W/RING INSERTION REPLACEMENT TRICUSPID VALVE W/CARD BYPASS TRICUSPID VALVE RPSG&PLCTJ EBSTEIN ANOMALY VALVOTOMY PULMONARY VALVE CLSD HEART TRANSVENTR VALVOTOMY PULM VALVE CLSD HRT VIA P-ART VALVOTOMY PULM VALVE OPN HRT W/INFL OCCLUSION VALVOTOMY PULM VALVE OPN HRT W/CARD BYP REPLACEMENT PULMONARY VALVE R VENTR RESCJ INFUND STEN +-COMMISSUROTOMY O/F TRC AGMNTJ +-COMMISSUROTOMY/INFUND RESCJ RPR NON-STRUCTURAL PROSTC VALVE DYSF CARD BYP RPR C ARVEN/ARTERIOCAR CHAMBER FSTL W/CARD BYP RPR C ARVEN/ARTERIOCAR CHAMBER FSTL W/O CARD BYP RPR ANOM C ART FROM P-ART ORIGIN LIG RPR ANOM C ART FROM P-ART ORIGIN GRF RPR ANOM C ART FROM P-ART ORIGIN GRF W/CARD BYP RPR ANOM C ART W/CONSTJ INTRAP-ART TUNNEL RPR ANOM C ART FROM P-ART TO AORTA RPR ANOM AORTIC ORIGIN C ART UNROOFING/TLCJ NDSC SURG W/VID-ASSTD HARVEST VEIN CAB ZZZ CORONARY ARTERY BYPASS 1 CORONARY VENOUS GRAFT CORONARY ARTERY BYPASS 2 CORONARY VENOUS GRAFTS CORONARY ARTERY BYPASS 3 CORONARY VENOUS GRAFTS CORONARY ARTERY BYPASS 4 CORONARY VENOUS GRAFTS CORONARY ARTERY BYPASS 5 CORONARY VENOUS GRAFTS CORONARY ARTERY BYPASS 6/+ CORONARY VENOUS GRAFT CORONARY ARTERY BYP W VEIN &ARTERY GRAFT 1 VEIN ZZZ CORONARY ARTERY BYP W VEIN &ARTERY GRAFT 2 VEIN ZZZ CORONARY ARTERY BYP W VEIN &ARTERY GRAFT 3 VEIN ZZZ 100 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

105 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule CORONARY ARTERY BYP W VEIN &ARTERY GRAFT 4 VEIN ZZZ CORONARY ARTERY BYP W VEIN &ARTERY GRAFT 5 VEIN ZZZ CORONARY ARTERY BYP W VEIN &ARTERY GRAFT 6 VEIN ZZZ ROPRTJ CAB/VALVE PX > 1 MO AFTER ORIGINAL OPERJ ZZZ CAB W/ARTL GRF 1 ARTL GRF CAB W/ARTL GRF 2 C ARTL GRFS CAB W/ARTL GRF 3 C ARTL GRFS CAB W/ARTL GRF 4/> C ARTL GRFS MYOCARDIAL RESECTION RPR POSTINFRCJ VENTR SEPTAL DFCT SURG VENTR RSTRJ PX W/PROSTC PATCH PFRMD C ENDARTERCOMY OPN ANY METH ZZZ CLSR ATRIOVENTRICULAR VALVE SUTURE/PATCH CLSR SEMILUNAR VALVE AORTIC/PULM SUTR/PATCH ANAST P-ART AORTA DAMUS-KAYE-STANSEL PX RPR CAR ANOMAL XCP PULM ATRESIA VENTR SEPTL DFCT RPR CAR ANOMAL SURG ENLGMENT VENTR SEPTL DFCT RPR 2 OUTLET R VNTRC W/INTRAVENTR TUNNEL RPR RPR 2 OUTLET R VNTRC RPR R VENTR O/F TRC OBSTRCJ RPR CAR ANOMAL CLSR SEPTL DFCT SMPL FONTAN PX RPR CPLX CAR ANOMAL MODF FONTAN PX RPR 1 VNTRC W/O/F OBSTRCJ&AORTIC ARCH HYPOPLASIA l APPLICATION RIGHT & LEFT PULMONARY ARTERY BANDS l TTHRC CATHETER INSERT FOR STENT PLACEMENT l RECONSTRUCTION COMPLEX CARDIAC ANOMALY RPR ATR SEPTAL DFCT SECUNDUM W/CARD BYP +-PATCH DIR/PATCH CLSR SINUS VENOSUS +-ANOM PULM VEN DRG RPR ATR&VENTR SEPTAL DFCT DIR/PATCH CLSR RPR INCOMPL/PRTL AV CANAL +-AV VALVE RPR RPR INTRM/TRANSJ AV CANAL +-AV VALVE RPR RPR COMPL AV CANAL +-PROSTC VALVE CLOSURE MULTIPLE VENTRICULAR SEPTAL DEFECTS CLOSURE MULTIPLE VSD W/RESECTION CLOSURE MULTIPLE VSD W/REMOVAL ARTERY BAND CLSR 1 VENTR SEPTAL DFCT +- PATCH CLSR V-SEPTL DFCT W/PULM VLVT/INFUND RESCJ CLSR V-SEPTL DFCT W/RMVL P-ART BAND +-GUSSET BANDING PULMONARY ARTERY COMPL RPR TETRALOGY FALLOT W/O PULM ATRESIA COMPL RPR T-FALLOT W/O PULM ATRESIA TANULR PATCH COMPL RPR T-FALLOT W/PULM ATRESIA RPR SINUS VALSALVA FISTULA RPR SINUS VALSALVA FSTL W/RPR V-SEPTL DFCT RPR SINUS VALSALVA ANEURYSM CLOSURE AORTICO-LEFT VENTRICULAR TUNNEL REPAIR ISOLATED PARTIAL PULM VENOUS RETURN Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 101

106 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, REPAIR PULMONARY VENOUS STENOSIS COMPL RPR ANOM VEN RETURN RPR C TRIATM/SUPVALVR RING RESCJ L ATR MEMB ATR SEPTECT/SEPTOST CLSD HRT ATR SEPTECT/SEPTOST OPN HRT W/CARD BYP ATR SEPTECT/SEPTOST OPN HRT W/INFL OCCLUSION SHUNT SUBCLA P-ART SHUNT ASCENDING AORTA P-ART SHUNT DESCENDING AORTA P-ART SHUNT CTR W/PROSTC GRF SHUNT SUPRIOR V/C P-ART FLO 1 LNG SHUNT SUPRIOR V/C P-ART FLO BTH LNGS ANAST CAVOPULM 2ND SUPRIOR V/C ZZZ RPR TGA W/O SURG ENLGMNT V-SEPTL DFCT RPR TGA ENLGMNT V-SEPTL DFCT RPR TGA ATR BAFFLE W/CARD BYP RPR TGA ATR BAFFLE W/RMVL PULM BAND RPR TGA ATR BAFFLE W/CLSR V-SEPTL DFCT RPR TGA ATR BAFFLE RPR SBPULMC OBSTRCJ RPR TGA AORTIC P-ART RCNSTJ RPR TGA AORTIC P-ART RCNSTJ W/RMVL PULM BAND RPR TGA AORTIC P-ART RCNSTJ W/CLSR V-SEPTL DFCT RPR TGA AORTIC P-ART RCNSTJ RPR SBPULMC OBSTRCJ A-ROOT TLCJ VSD PULM STNS RPR W/O C OST RIMPLTJ A-ROOT TLCJ VSD PULM STNS RPR W/ RIMPLTJ C OSTIA TOTAL REPAIR TRUNCUS ARTERIOSUS REIMPLANTATION ANOMALOUS PULMONARY ARTERY AORTIC SSP TRACHEAL DCMPRN SPX DIVISION ABERRANT VESSEL VASCULAR RING DIVISION ABERRANT VESSEL W/REANASTOMOSIS OBLTRJ AORTOPULM SEPTAL DFCT W/O CARD BYP OBLTRJ AORTOPULM SEPTAL DFCT W/CARD BYP REPAIR PATENT DUCTUS ARTERIOSUS LIGATION RPR PATENT DUXUS ARTERIOSUS DIV UNDER 18 YR RPR PATENT DUXUS ARTERIOSUS DIV 18 YR&OLDER EXC COARCJ AORTA +-PDA W/DIR ANAST EXC COARCTATION AORTA +-PDA W/GRF EXC COARCJ AORTA W/L SUBCLA ART/PROSTC AS GUSSET RPR HYPOPLSTC A-ARCH W/AGRFT/PROSTC RPR HYPOPLSTC A-ARCH AGRFT/PROSTC CARD BYP s ASCENDING AORTA GRF W/CARD BYP & VALVE SSP s AS-AORT GRF W/CARD BYP & AORTIC ROOT RPLCMT s ASCENDING AORTA GRF VALVE SPARE ROOT REMODEL TRANSVERSE ARCH GRAFT W/CARDIOPULMONARY BYPASS DESCENDING THORACIC AORTA GRAFT +-BYPASS RPR THORACOAAA W/GRF +-CARD BYP CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

107 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule EVASC RPR DTA COVERAGE ART ORIGIN 1ST ENDOPROSTH EVASC RPR DTA EXP COVERAGE W/O ART ORIGIN PLMT PROX XTN PROSTH EVASC RPR DTA 1ST XTN PLMT PROX XTN PROSTH EVASC RPR DTA EA PROX XTN ZZZ PLMT DSTL XTN PROSTH DLYD AFTER EVASC RPR DTA OPN SUBCLA CRTD ART TRPOS NCK INC ULAT BYP GRF W/DTA RPR NCK INC PULMONARY ARTERY EMBOLECTOMY W/CARD BYPASS PULMONARY ARTERY EMBOLECTOMY W/O CARD BYPASS PULM ENDARTERCOMY +-EMBOLECTOMY W/CARD BYP RPR P-ART STENOSIS RCNSTJ W/PATCH/GRF RPR PULM ATRESIA W/CONSTJ/RPLCMT CONDUIT TRANSECTION PULMONARY ARTERY W/CARD BYPASS LIG&TKDN SYSIC-TO-P-ART SHUNT W/CGEN HRT PX ZZZ RPR P-ART ARBORIZJ ANOMAL UNIFCLIZJ W/O CARD BYP RPR P-ART ARBORIZJ ANOMAL UNIFCLIZJ W/CARD BYP DONOR CARDIECTOMY-PNEUMONECTOMY BR XXX BKBENCH PREPJ CDVR DON HRT/LNG ALGRFT BR XXX HRT-LNG TRNSPL W/RCP CARDIECTOMY-PNUMEC DONOR CARDIECTOMY BR XXX BKBENCH STANDARD PREPJ CDVR DON HRT ALGRFT BR XXX HEART TRANSPLANT +-RECIPIENT CARDIECTOMY PROLNG XTRCORP CRCJ 1ST 24 HR PROLNG XTRCORP CRCJ EA 24 HR ZZZ INSERTION INTRA-AORTIC BALLOON ASSIST DEV PRQ REMOVAL INTRA-AORTIC BALLOON ASSIST DEVICE PRQ INSJ I-AORT BALO ASSIST DEV THRU FEM ART OPN RMVL I-AORT BALO ASSIST DEV W/RPR FEM ART +-GRF INSJ I-AORT BALO ASSIST DEV THRU AS-AORT RMVL I-AORT BALO DEV FROM AS-AORT RPR AS-AORT INSJ VENTR ASSIST DEV XTRCORP 1 VNTRC XXX INSJ VENTR ASSIST DEV XTRCORP BIVENTR XXX REMOVAL VENTR ASSIST DEVICE XTRCORP 1 VENTRICLE REMOVAL VENTR ASSIST DEVICE XTRCORP BIVENTR INSJ VENTR ASSIST DEV IMPLTABLE ICORP 1 VNTRC XXX RMVL VENTR ASSIST DEV IMPLTABLE ICORP 1 VNTRC RPLCMT XTRCORP VAD 1/BIVENTR PUMP 1/EA PUMP BR XXX RPLCMT VAD PMP IMPLTBL ICORP 1 VNTR W/O CARD BYP BR XXX RPLCMT VAD PMP IMPLTBL ICORP 1 VNTR W/CARD BYP BR XXX UNLISTED CARDIAC SURGERY BR YYY EMBLC/THRMBC CATH CRTD SUBCLA/INNOMINATE ART EMBLC/THRMBC INNOMINATE SUBCLA ART EMBLC/THRMBC AX BRACH INNOMINATE SUBCLA ART EMBLC/THRMBC +-CATH RDL/UR ART ARM INC EMBLC/THRMBC RNL CELIAC MESENTERY A-ILIAC ART EMBLC/THRMBC FEMPOP A-ILIAC ART Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 103

108 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, EMBLC/THRMBC POP-TIBIO-PRONEAL ART LEG INC THRMBC DIR/W/CATH V/C ILIAC VEIN ABDL INC THRMBC DIR/W/CATH V/C ILIAC FEMPOP VEIN LEG INC THRMBC DIR/W/CATH V/C ILIAC FEMPOP VEIN ABDL&LEG THRMBC DIR/W/CATH SUBCLA VEIN NCK INC THRMBC DIR/W/CATH AX&SUBCLA VEIN ARM INC VALVULOPLASTY FEMORAL VEIN RECONSTRUCTION VENA CAVA ANY METHOD VENOUS VALVE TRANSPOSITION ANY VEIN DONOR CROSS-OVER VEIN GRAFT VENOUS SYSTEM SAPHENOPOPLITEAL VEIN ANASTOMOSIS EVASC RPR AAA W/AORTO-AORTIC TUBE PROSTH EVASC RPR AAA W/MDLR BFRC PROSTH 1 LIMB EVASC RPR AAA W/MDLR BFRC PROSTH 2 LIMBS EVASC RPR AAA W/UNIBDY BFRC PROSTH EVASC RPR AAA AORTO-UNIILIAC/AORTO-UNIFEM PROSTH TCAT PLACEMENT PHYSIOLOGIC SENSOR ANEURYSMAL SAC ZZZ EVASC PLMT ILIAC ART OCCLUSION DEV ZZZ OPN FEM ART EXPOS DLVR EVASC PROSTH UNI PLMT FEM-FEM PROSTC GRF EVASC AORTIC ARYSM RPR ZZZ ILIAC ART EXPOS PROSTH/ILIAC OCCLS EVASC UNI PLMT XTN PROSTH EVASC RPR ARYSM/DSJ 1ST VSL PLMT XTN PROSTH EVASC RPR ARYSM/DSJ EA VSL ZZZ OPN RPR ARYSM RPR ARTL TRAUMA TUBE PROSTH OPN RPR ARYSM RPR ARTL TRMA AORTOBIILIAC PROSTH OPN RPR ARYSM RPR ARTL TRMA AORTO-BIFEM PROSTH ILIAC ART EXPOS W/CRTJ CONDUIT UNI BRACH ART EXPOS DPLMNT AORTIC/ILIAC PROSTH UNI s EVASC RPR ILIAC ART ILIO-ILIAC PROSTHESIS DIR RPR ARYSM/&GRF INSJ CRTD SUBCLA ART DIR RPR ARYSM&GRF INSJ RPTD ARYSM CRTD SUBCLA DIR RPR ARYSM&GRF INSJ VRT ART DIR RPR ARYSM&GRF INSJ AX-BRACH ART DIR RPR ARYSM&GRF INSJ AX-BRACH ART DIR RPR ARYSM&GRF INSJ INNOMINATE SUBCLA ART DIR RPR ARYSM&GRF RPTD ARYSM INNOM SUBCLA ART DIR RPR ARYSM&GRF INSJ RDL/UR ART DIR RPR ARYSM&GRF INSJ ABDL AORTA DIR RPR ARYSM&GRF INSJ RPTD ARYSM ABDL AORTA DIR RPR ARYSM&GRF INSJ ABDL AORTA VISC VSL DIR RPR ARYSM&GRF RPTD ARYSM ABDL AORTA VISC VSL DIR RPR ARYSM&GRF INSJ ABDL AORTA ILIAC VSL DIR RPR ARYSM&GRF RPTD ARYSM ABDL AORTA ILIAC DIR RPR ARYSM&GRF INSJ SPLENIC ART DIR RPR ARYSM&GRF INSJ RPTD ARYSM SPLENIC ART DIR RPR ARYSM&GRF INSJ HEPATC CELIAC RNL/MSN ART CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

109 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule DIR RPR ARYSM&GRF RPTD ARYSM HEPATC CEL RNL/MSN DIR RPR ARYSM&GRF INSJ ILIAC ART DIR RPR ARYSM&GRF INSJ RPTD ARYSM ILIAC ART DIR RPR ARYSM&GRF INSJ COMMON FEM ART DIR RPR ARYSM&GRF INSJ RPTD ARYSM COMMON FEM ART DIR RPR ARYSM&GRF INSJ POP ART DIR RPR ARYSM&GRF INSJ RPTD ARYSM POP ART REPAIR CONGENITAL ARTERIOVENOUS FISTULA HEAD&NCK RPR CONGENITAL ARTERIOVENOUS FISTULA THORAX&ABD RPR CONGENITAL ARTERIOVENOUS FISTULA EXTREMITIES RPR/TRAUMTC ARVEN FSTL HEAD&NCK RPR/TRAUMTC ARVEN FSTL THORAX&ABD RPR/TRAUMTC ARVEN FSTL XTR REPAIR BLOOD VESSEL DIRECT NECK REPAIR BLOOD VESSEL DIRECT UPPER EXTREMITY REPAIR BLOOD VESSEL DIRECT HAND FINGER RPR BLOOD VESSEL DIRECT INTRATHORACIC W/BYPASS RPR BLOOD VESSEL DIRECT INTRATHORACIC W/O BYPASS RPR BLOOD VESSEL DIRECT INTRA-ABDOMINAL RPR BLOOD VESSEL DIRECT LOWER EXTREMITY REPAIR BLOOD VESSEL W/VEIN GRAFT NECK REPAIR BLOOD VESSEL W/VEIN GRAFT UPPER EXTREMITY RPR BLOOD VESSEL VEIN GRAFT INTRATHORACIC W/BYP RPR BLOOD VESSEL VEIN GRF INTRATHORACIC W/O BYP REPAIR BLOOD VESSEL VEIN GRAFT INTRA-ABDOMINAL REPAIR BLOOD VESSEL VEIN GRAFT LOWER EXTREMITY REPAIR BLOOD VESSEL W/GRAFT OTHER/THAN VEIN NECK RPR BLOOD VSL GRF OTH/THN VEIN UPPER EXTREMITY RPR BLOOD VSL GRF OTH/THN VEIN INTRATHRC W/BYP RPR BLOOD VSL GRF OTH/THN VEIN INTRATHRC W/O BYP RPR BLVSL W/GRF OTH/THN VEIN INTRA-ABDL RPR BLVSL W/GRF OTH/THN VEIN LXTR TEAEC W/PATCH GRF CRTD VRT SUBCLA NCK INC TEAEC W/GRAFT SUPERFICIAL FEMORAL ART TEAEC W/GRAFT POPLITEAL ART TEAEC W/GRAFT TIBIOPERONEAL TRUNK ART TEAEC W/GRAFT TIBIAL/PERONEAL ART 1ST VESSEL TEAEC W/GRAFT EA ADDL TIBIAL/PERONEAL ART ZZZ TEAEC +-PATCH GRF SUBCLA INNOMINATE THRC INC TEAEC +-PATCH GRF AX-BRACH TEAEC +-PATCH GRF ABDL AORTA TEAEC +-PATCH GRF MESENTERIC CELIAC/RNL TEAEC +-PATCH GRF ILIAC TEAEC +-PATCH GRF ILIOFEM TEAEC +-PATCH GRF CMBN AORTOILIAC TEAEC +-PATCH GRF CMBN AORTOILIOFEM Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 105

110 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, TEAEC +-PATCH GRF COMMON FEM TEAEC +-PATCH GRF DP PROFUNDA FEM ROPRTJ CRTD TEAEC > 1 MO AFTER ORIGINAL OPRATION ZZZ ANGIOSCOPY NON-C VSL/GRFS THER IVNTJ ZZZ TRLUML BALO ANGIOP OPN RNL/OTH VISC ART TRLUML BALO ANGIOP OPN AORTIC TRLUML BALO ANGIOP OPN BRCH/CPHLC TRNK/BRNCH EA TRLUML BALO ANGIOP OPN VEN s K TRLUML BALO ANGIOP PRQ RNL/VISC ART K TRLUML BALO ANGIOP PRQ AORTIC K TRLUML BALO ANGIOP PRQ BRCH/CPHLC TRNK/BRNCH EA K TRLUML BALO ANGIOP PRQ VEN HARVEST UXTR VEIN 1 SGM LXTR/CAB PX ZZZ BYP W/VEIN COMMON-IPSILATERAL CRTD BYP W/VEIN CAROTID-SUBCLA/ SUBCLA CAROTID BYP W/VEIN CRTD-VRT BYP W/VEIN CAROTID-CONTRALATERAL CAROTID BYP W/VEIN CRTD-BRACH BYP W/VEIN SUBCLA-SUBCLA BYP W/VEIN SUBCLA-BRACH BYP W/VEIN SUBCLA-VRT BYP W/VEIN SUBCLA-AX BYP W/VEIN AX-AX BYP W/VEIN AX-FEM BYP W/VEIN AX-BRACH BYPASS GRAFT WITH VEIN BRACHIAL-ULNAR/-RADIAL BYP W/VEIN BRACH-BRACH s BYPASS W/VEIN AORTOSUBCLAV/CAROTID/INNOMINATE BYP W/VEIN AORTOCELIAC/AORTOMESENTERIC BYP W/VEIN AX-FEM-FEM BYPASS GRAFT WITH VEIN HEPATORENAL BYP W/VEIN SPLENORNL BYP W/VEIN AORTOILIAC BYP W/VEIN AORTOBI-ILIAC BYP W/VEIN AORTOFEMORAL BYP W/VEIN AORTOBIFEMORAL BYP W/VEIN AORTOILIOFEM UNI BYP W/VEIN AORTOILIOFEM BI BYP W/VEIN AORTOFEMPOP BYP W/VEIN FEMPOP BYP W/VEIN FEM-FEM BYP W/VEIN AORTORNL BYP W/VEIN ILIOILIAC BYP W/VEIN ILIOFEM BYP FEM-ANT TIBL PST TIBL PRONEAL ART/OTH DSTL BYP TIBL-TIBL/PRONEAL-TIBL/TIBL/PRONEAL TRK-TIBL CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

111 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule BYP W/VEIN POP-TIBL-PRONEAL ART/OTH DSTL VSL HARVEST FEMPOP VEIN 1 SGM VASC RCNSTJ PX ZZZ IN-SITU VEIN BYP FEMPOP IN-SITU FEM-ANT TIBL PST TIBL/PRONEAL ART IN-SITU VEIN BYP POP-TIBL PRONEAL HARVEST UPPER EXTREMITY ART 1 SEGMENT FOR CABG ZZZ BYP OTH/THN VEIN COMMON-IPSILATERAL CRTD BYP OTH/THN VEIN CRTD-SUBCLA BYP OTH/THN VEIN SUBCLA-SUBCLA BYP OTH/THN VEIN SUBCLA-AX BYP OTH/THN VEIN AX-FEM BYP OTH/THN VEIN AX-POP/-TIBL s BYPASS NOT VEIN AORTOSUBCLA/CAROTID/INNOMINATE BYP OTH/THN VEIN AORTOCELIAC AORTOMSN AORTORNL BYPASS GRAFT W/OTHER THAN VEIN ILIO-CELIAC BYPASS GRAFT W/OTHER THAN VEIN ILIO-MESENTERIC BYPASS GRAFT W/OTHER THAN VEIN ILIORENAL BYP OTH/THN VEIN SPLENORNL BYP OTH/THN VEIN AORTOILIAC BYP OTH/THN VEIN AORTOBI-ILIAC BYP OTH/THN VEIN CRTD-VRT BYP OTH/THN VEIN SUBCLA-VRT BYP OTH/THN VEIN AORTOBIFEM BYP OTH/THN VEIN AORTOFEM BYP OTH/THN VEIN AX-AX BYP OTH/THN VEIN AORTOFEMPOP BYP OTH/THN VEIN AX-FEM-FEM BYP OTH/THN VEIN FEMPOP BYP OTH/THN VEIN FEM-FEM BYP OTH/THN VEIN ILIOILIAC BYP OTH/THN VEIN ILIOFEM BYP OTH/THN VEIN FEM-ANT TIBL PST TIBL/PRONEAL BYP OTH/THN VEIN POP-TIBL/-PRONEAL ART BYP COMPOSIT PROSTC&VEIN ZZZ BYP AUTOG COMPOSIT 2 SEG VEINS FROM 2 LOCATIONS ZZZ BYP AUTOG COMPOSIT 3/> SEG FROM 2/> LOCATIONS ZZZ PLMT VEIN PATCH/CUFF DSTL ANAST BYP CONDUIT ZZZ CRTJ DSTL ARVEN FSTL LXTR BYP SURG NON-HEMO ZZZ TRPOS&/RIMPLTJ VRT CRTD ART TRPOS&/RIMPLTJ VRT SUBCLA ART TRPOS&/RIMPLTJ SUBCLA CRTD ART TRPOS&/RIMPLTJ CRTD SUBCLA ART RIMPLTJ VISC ART INFRARNL AORTIC PROSTH EA ART ZZZ ROPRTJ > 1 MO AFTER ORIGINAL OPRATION ZZZ EXPL N/FLWD SURG RPR +-LSS ART CRTD ART EXPL N/FLWD SURG RPR +-LSS ART FEM ART Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 107

112 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, EXPL N/FLWD SURG RPR +-LSS ART POP ART EXPL N/FLWD SURG RPR +-LSS ART OTH VSL EXPL PO HEMRRG THROMBOSIS/INFCTJ NCK EXPL PO HEMRRG THROMBOSIS/INFCTJ CH EXPL PO HEMRRG THROMBOSIS/INFCTJ ABD EXPL PO HEMRRG THROMBOSIS/INFCTJ XTR RPR GRF-ENTERIC FSTL THRMBC ARTL/VEN GRF OTH/THN HEMO GRF/FSTL THRMBC ARTL/VEN GRF XCP HEMO GRF/FSTL W/REVJ GRF REVJ LXTR ARTL BYP OPN VEIN PATCH ANGIOP REVJ LXTR ARTL BYP OPN W/SGMTL VEIN INTERPOS REVISION FEMORAL ANAST OPEN NONAUTOG GRAFT REVISION FEMORAL ANAST OPEN W/AUTOG GRAFT EXC INFCT GRF NCK EXC INFCT GRF XTR EXC INFCT GRF THORAX EXC INFCT GRF ABD INTRO NDL/INTRACATH VEIN XXX NJX PX PRQ TX XTR PSEUDOARYSM NJX PX XTR VNGRPH W/INTRO NDL/INTRACATH INTRO CATH SUPRIOR/IVC XXX SLCTV CATH PLMT VEN SYS 1ST ORDER BRANCH XXX SLCTV CATH PLMT VEN SYS 2ND ORDER/> SLCTV BRANCH XXX INTRO CATH R HRT/MAIN P-ART XXX SLCTV CATH PLMT L/R P-ART XXX SLCTV CATH PLMT SGMTL/SUBSGMTL P-ART XXX INTRO NDL/INTRACATH CRTD/VRT ART XXX INTRO NDL/INTRACATH RTRGR BRACH ART XXX INTRO NDL/INTRACATH XTR ART XXX K INTRO NDL/CATH AV SHUNT IST ACCESS W/ RAD EVAL XXX + K INTRO NDL/CATH AV SHUNT ADDL ACCESS THER IVNTJ ZZZ INTRO NDL/INTRACATH AORTIC TRANSLMBR XXX INTRO CATH AORTA XXX SLCTV CATHJ EA 1ST ORD THRC/BRCH/CPHLC BRNCH XXX SLCTV CATHJ 1ST 2ND ORD THRC/BRCH/CPHLC BRNCH XXX SLCTV CATHJ 3RD+ ORD SLCTV THRC/BRCH/CPHLC BRNCH XXX SLCTV CATHJ EA 2ND+ ORD THRC/BRCH/CPHLC BRNCH ZZZ SLCTV CATHJ EA 1ST ORD ABDL PEL/LXTR ART BRNCH XXX SLCTV CATHJ 2ND ORDER ABDL PEL/LXTR ART BRNCH XXX SLCTV CATHJ 3RD+ ORD SLCTV ABDL PEL/LXTR BRNCH XXX SLCTV CATHJ EA 2ND+ ORD ABDL PEL/LXTR ART BRNCH ZZZ INSJ IMPLTABLE IA NFS PMP REVJ IMPLTED IA NFS PMP RMVL IMPLTED IA NFS PMP UNLIS PX VASC NJX BR YYY VNPNXR <3 YEARS PHYS SKILL FEM/JUG VEIN XXX 108 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

113 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule VNPNXR <3 YEARS PHYS SKILL SCALP VEIN XXX VNPNXR <3 YEARS PHYS SKILL OTHER VEIN XXX VNPNXR 3 YEARS/> PHYS SKILL XXX COLLJ VEN BLD VNPNXR 7.75 XXX COLLJ CAPILLARY BLD SPEC 7.75 XXX VNPNXR CUTDOWN UNDER AGE 1 YR XXX VNPNXR CUTDOWN AGE 1/> XXX TRANSFUSION BLD/BLD COMPONENTS XXX PUSH TRANSFUSION BLD 2 YR/UNDER XXX EXCHNG TRANSFUSION BLD NB XXX EXCHNG TRANSFUSION BLD OTH/THN NB XXX TRANSFUSION INTRAUTERINE FTL XXX /MLT NJXS SCLRSG SLNS SPIDER VEINS LIMB/TRNK BR /MLT NJXS SCLRSG SLNS SPIDER VEINS FACE BR NJX SCLRSG SLN 1 VEIN NJX SCLRSG SLN MLT VEINS SM LEG ENDOVEN ABLTJ INCMPTNT VEIN XTR RF 1ST VEIN ENDOVEN ABLTJ INCMPTNT VEIN XTR RF 2ND+ VEINS ZZZ ENDOVEN ABLTJ INCMPTNT VEIN XTR LASER 1ST VEIN ENDOVEN ABLTJ INCMPTNT VEIN XTR LASER 2ND+ VEINS ZZZ K PRQ PORTAL VEIN CATHETERIZATION ANY METHOD VEN CATHJ SLCTV ORGAN BLD SAMPLING CATHJ UMBILICAL VEIN DX/THER NB THER APHERESIS WHITE BLD CELLS THER APHERESIS RED BLD CELLS THER APHERESIS PLTLTS THER APHERESIS PLSM PHERESIS THER APHERESIS W/XTRCORP IMMUNODSPTJ&PLSM RENFS THER APHRS XTRCORP SLCTV ADSRPJ/FILTRJ&RENFS PHOTOPHERESIS XTRCORP K INSJ NON-TUN CTR CVC UNDER 5 YR INSJ NON-TUN CTR CVC AGE 5 YR/> K INSJ TUN CTR CVC W/O SUBQ PORT/PMP UNDER 5 YR K INSJ TUN CTR CVC W/O SUBQ PORT/PMP AGE 5 YR/> K INSJ TUN CTR CTR VAD W/SUBQ PORT UNDER 5 YR K INSJ TUN CTR CTR VAD W/SUBQ PORT AGE 5 YR/> K INSJ TUN CTR CTR VAD W/SUBQ PMP K INSJ TUN VAD REQ 2 CATH 2 SITS W/O SUBQ PORT/PMP K INSJ TUN VAD REQ 2 CATH 2 SITS W/SUBQ PORT K INSJ PRPH CVC W/O SUBQ PORT/PMP UNDER 5 YR INSJ PRPH CVC W/O SUBQ PORT/PMP AGE 5 YR/> K INSJ PRPH CTR VAD W/SUBQ PORT UNDER 5 YR K INSJ PRPH CTR VAD W/SUBQ PORT AGE 5 YR/> RPR TUN/NON-TUN CTR VAD CATH W/O SUBQ PORT/PMP K RPR CTR VAD W/SUBQ PORT/PMP CTR/PRPH INSJ SIT K RPLCMT CATH CTR VAD SUBQ PORT/PMP Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 109

114 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, RPLCMT COMPL NON-TUN CVC W/O SUBQ PORT/PMP K RPLCMT COMPL TUN CVC W/O SUBQ PORT/PMP K RPLCMT COMPL TUN CTR VAD W/SUBQ PORT K RPLCMT COMPL TUN CTR VAD W/SUBQ PMP RPLCMT COMPL PRPH CVC W/O SUBQ PORT/PMP K RPLCMT COMPL PRPH CTR VAD W/SUBQ PORT RMVL TUN CVC W/O SUBQ PORT/PMP K RMVL TUN CTR VAD W/SUBQ PORT/PMP CTR/PRPH INSJ COLLECT BLOOD FROM IMPLANT VENOUS ACCESS DEVICE XXX COLLECT BLOOD FROM CATHETER VENOUS NOS XXX DECLOT BY THROMBOLYTIC AGENT IMPLANT DEVICE/CATH XXX MCHNL RMVL PRICATH OBSTR CV DEV VIA VEN ACCESS MCHNL RMVL INTRAL OBSTR CV DEV THRU DEV LUMEN RPSG PREVIOUSLY PLACED CVC UNDER FLUOR GDN CNTRST NJX RAD EVAL CTR VAD FLUOR IMG&REPRT ARTL PNXR W/DRAWAL BLD DX XXX * ARTL CATHJ/CANNULJ MNTR/TRANSFUSION SPX PRQ ARTL CATHJ/CANNULJ MNTR/TRANSFUSION SPX CUTDOWN ARTL CATHJ PROLNG NFS THER CHEMOTX CUTDOWN CATHETERIZATION UMBILICAL NEWBORN ART DX/THERAPY PLMT NDL INTRAOSS NFS INSJ CANNULA HEMO OTH PURPOSE SPX VEIN VEIN INSJ CANNULA HEMO OTH PURPOSE SPX ARVEN XTRNL INSJ CANNULA HEMO OTH SPX ARVEN XTRNL REVJ/CLSR ARVEN ANAST OPN UPR ARM CEPHALIC VEIN TRPOS ARVEN ANAST OPN UPR ARM BASILIC VEIN TRPOS ARVEN ANAST OPN F/ARM VEIN TRPOS ARTERIOVENOUS ANASTOMOSIS OPEN DIRECT INSJ CANNULA PROLNG XC-CIRCJ ECMO SPX INSJ CNULA ISLTD XC-CIRCJ REG CHEMOTX XTR RMVL CRTJ ARVEN FSTL XCP DIR ARVEN ANAST AUTOG GRF CRTJ ARVEN FSTL XCP DIR ARVEN ANAST NONAUTOG GRF THRMBC OPN ARVEN FSTL W/O REVJ DIAL GRF REVJ OPN ARVEN FSTL W/O THRMBC DIAL GRF REVJ OPN ARVEN FSTL W/THRMBC DIAL GRF INSJ THOMAS SHUNT SPX DSTL REVSC&INTERVAL LIG UXTR HEMO ACCESS XTRNL CANNULA DECLTNG SPX W/O BALO CATH XTRNL CANNULA DECLTNG SPX W/BALO CATH K THRMBC PRQ ARVEN FSTL AUTOG/NONAUTOG GRF VEN ANAST OPN PORTOCAVAL VEN ANAST OPN RENOPORTAL VEN ANAST OPN CAVAL-MESENTERIC VEN ANAST OPN SPLENORNL PROX VEN ANAST OPN SPLENORNL DSTL INSJ TRANSVNS INTRAHEPATC PORTOSYSIC SHUNT CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

115 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule K REVJ TRANSVNS INTRAHEPATIC PORTOSYSTEMIC SHUNT K PRIM PRQ TRLUML MCHNL THRMBC 1ST VSL K PRIM PRQ TRLUML MCHNL THRMBC SBSQ VSL ZZZ + K SEC PRQ TRLUML THRMBC ZZZ K PRQ TRLUML MCHNL THRMBC VEIN K PRQ TRLUML MCHNL THRMBC VEIN REPEAT TX THROMBOLSS CERE IV NFS XXX TCAT BX TCAT THER NFS THROMBOLSS OTH/THN C TCAT THER NFS OTH/THN THROMBOLSS ANY TYP K TCAT RETRIEVAL PRQ IV FB TCAT OCCLS/EMBOLJ PRQ NON-CNS NON-HEAD/NCK s TCAT PLMT IV STENT PERCUTANEOUS 1ST VESSEL s TCAT PLMT IV STENT PERCUTANEOUS EACH ADDL VESSEL ZZZ s TCAT PLMT IV STENT OPEN 1ST VESSEL s TCAT PLMT IV STENT OPEN EACH ADDL VESSEL ZZZ EXCHNG PREV PLACED IV CATH THROMBOLYTIC THER K UTERINE FIBROID EMBOLIZATION PERQ W/RAD GID K TCAT IV STENT CRV CRTD ART EMBOLIC PROTECJ K TCAT IV STENT CRV CRTD ART W/O EMBOLIC PROTECJ l K REVASCULARIZATION ILIAC ARTERY ANGIOP 1ST VSL l K REVSC OPN/PRQ ILIAC ART W/STNT PLMT & ANGIOP UNI l + K REVASCULARIZATION ILIAC ART ANGIOP EA IPSI VSL ZZZ l + K REVSC OPN/PRQ ILIAC ART W/STNT & ANGIOP IPSI VSL ZZZ l K REVSC OPN/PRG FEM/POP W/ANGIOPLASTY UNI l K REVSC OPN/PRQ FEM/POP W/ATHRC/ANGIOP SM VSL l K REVSC OPN/PRQ FEM/POP W/STNT/ANGIOP SM VSL l K REVSC OPN/PRQ FEM/POP W/STNT/ATHRC/ANGIOP SM VSL l K REVSC OPN/PRQ TIB/PERO W/ANGIOPLASTY UNI l K REVSC OPN/PRQ TIB/PERO W/ATHRC/ANGIOP SM VSL l K REVSC OPN/PRQ TIB/PERO W/STNT/ANGIOP SM VSL l K REVSC OPN/PRQ TIB/PERO W/STNT/ATHR/ANGIOP SM VSL l + K REVSC OPN/PRQ TIB/PERO W/ANGIOPLASTY UNI EA VSL ZZZ l + K REVSC OPN/PRQ TIB/PERO W/ATHRC/ANGIOP UNI EA VSL ZZZ l + K REVSC OPN/PRQ TIB/PERO W/STNT/ANGIOP UNI EA VSL ZZZ l + K REVSC OPN/PRQ TIB/PERO W/STNT/ATHR/ANGIOP EA VSL ZZZ IV US NON-C VSL DX EVAL&/THER IVNTJ 1ST VSL ZZZ IV US NON-C VSL DX EVAL&/THER IVNTJ EA VSL ZZZ VASC NDSC SEPS UNLIS VASC NDSC PX BR YYY LIG INT JUG VEIN LIG XTRNL CRTD ART LIG INT/COMMON CRTD ART LIG INT/COMMON CRTD ART W/GRADUAL OCCLS LIG/BANDING ANGIOACCESS ARVEN FSTL LIG/BX TEMPORAL ART Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 111

116 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, LIG MAJOR ART NCK LIG MAJOR ART CH LIG MAJOR ART ABD LIG MAJOR ART XTR INTERRUPJ IVC SUTR LIG PLCTJ CLIP XTRVASC IV LIG FEM VEIN LIG COMMON ILIAC VEIN LIG&DIV LONG SAPH VEIN SAPHFEM JUNCT/INTERRUPJ LIG DIV&STRIPPING SHORT SAPHENOUS VEIN LIG DIV&STRIP LONG SAPH SAPHFEM JUNCT KNE/BELW LIG&DIV&COMPL STRIP LONG/SHORT SAPH RAD EXC LIG PRFRATR VEIN SUBFSCAL RAD INCL SKN GRF 1 LEG LIG PRFRATR VEIN SUBFSCAL OPEN INCL US GID 1 LEG STAB PHLEBT VARICOSE VEINS 1 XTR STAB INCS STAB PHLEBT VARICOSE VEINS 1 XTR > 20 INCS LIG&DIV SHORT SAPH VEIN SAPHENOPOP JUNCT SPX LIG DIV&/EXC VARICOSE VEIN CLUSTER 1 LEG PEN REVSC ART +-VEIN GRF PEN VEN OCCLUSIVE PX UNLIS PX VASC SURG BR YYY SPLENC TOT SPX SPLENC PRTL SPX SPLENC TOT EN BLOC X10SV DS CONJUNCT W/OTH PX ZZZ RPR RPTD SPLEEN SPLENORRHAPHY +-PRTL SPLENC LAPS SURG SPLENC UNLIS LAPS PX SPLEEN BR YYY NJX PX SPLENOPORTOGRAPY MGMT RCP HEMATOP PROGENITOR CELL DON SEARCH&CELL XXX BLD-DRV HEMATOP PROGEN CELL HRVG TRNSPLJ ALGNC BLD-DRV HEMATOP PROGEN CELL HRVG TRNSPLJ AUTOL TRNSPL PREPJ HEMATOP PROGEN CELLS CRYOPRSRV&STRG XXX TRNSPL PREPJ HEMATOP PROGEN THAW PREV HRV XXX TRNSPL PREPJ HEMATOP PROGEN THAW PREV HRV WASHG XXX TRNSPL PREPJ HEMATOP PROGEN DEPLJ IN HRV T-CELL XXX TRNSPL PREPJ HEMATOP PROGEN TUM CELL DEPLJ XXX TRNSPL PREPJ HEMATOP PROGEN RED BLD CELL RMVL XXX TRNSPL PREPJ HEMATOP PROGEN PLTLT DEPLJ XXX TRNSPL PREPJ HEMATOP PROGEN PLSM VOL DEPLJ XXX TRNSPL PREPJ HEMATOP PROGEN CONCENTRATION PLSM XXX MARROW ASPIRATION ONLY XXX MARROW BX NDL/TROCAR XXX MARROW HRVG TRNSPLJ MARROW/BLD-DRV PRPH STEM CELL TRNSPLJ ALLOGENEIC XXX MARROW/BLD-DRV PRPH STEM CELL TRNSPLJ AUTOL XXX MARROW/BLD-DRV PRPH STEM CELL TRNSPLJ ALGC DON DRG LYMPH NODE ABSC/LYMPHADENITIS SMPL CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

117 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule DRG LYMPH NODE ABSC/LYMPHADENITIS X10SV LYMPHANGIOTOMY/OTH OPRATIONS LYMPHATIC CHANNELS SUTR&/LIG THRC DUX CRV APPR SUTR&/LIG THRC DUX THRC APPR SUTR&/LIG THRC DUX ABDL APPR BX/EXC LYMPH NODE OPN SUPFC BX/EXC LYMPH NODE NDL SUPFC BX/EXC LYMPH NODE OPN DP CRV NODE BX/EXC LYMPH NODE OPN DP CRV NODE W/EXC FAT PAD BX/EXC LYMPH NODE OPN DP AX NODE BX/EXC LYMPH NODE OPN INT MAM NODE DSJ DP JUG NODE EXC CSTIC HYGROMA AX/CRV W/O DP NEUROVASC DSJ EXC CSTIC HYGROMA AX/CRV W/DP NEUROVASC DSJ LMTD LMPHADEC STAGING SPX PEL&PARA-AORTIC LMTD LMPHADEC STAGING SPX RPR AORTIC&/SPLENIC LAPS SURG RPR LYMPH NODE BX 1/MLT LAPS SURG BI TOT PEL LMPHADEC LAPS BI TOT PEL LMPHADEC&PRI-AORTIC LYMPH BX 1/ UNLIS LAPS PX LYMPHATIC SYS BR YYY SUPRAHYOID LMPHADEC CRV LMPHADEC COMPL CRV LMPHADEC MODF RAD NCK DSJ AX LMPHADEC SUPFC AX LMPHADEC COMPL THORCOM THRC W/MEDSTNL & REGIONAL LMPHADEC ZZZ ABDL LMPHADEC REG CELIAC GSTR PORTAL PRIPNCRTC ZZZ INGUINOFEM LMPHADEC SUPFC W/CLOQUETS NODE SPX INGUINOFEM LMPHADEC SUPFC W/PEL LMPHADEC PEL LMPHADEC W/XTRNL ILIAC HYPOGSTR&OBTURATOR RPR TABDL LMPHADEC X10SV W/PEL AORTIC&RNL NJX PX LYMPHANGRPH INJECTION FOR IDENTIFICATION OF SENTINEL NODE CANNULATION THRC DUX l INTRAOP SENTINEL LYMPH ID W/DYE NJX ZZZ UNLIS PX HEMIC/LYMPHATIC SYS BR YYY MEDIAST W/EXPL DRG RMVL FB/BX CRV APPR MEDIAST W/EXPL DRG RMVL FB/BX TTHRC APPR RESECJ MEDIASTINAL CYST RESECJ MEDIASTINAL TUMOR MEDIASTINOSCOPY W/BX WHEN PERFORMED UNLIS PX MED BR YYY RPR LAC DPHRM ANY APPR RPR NEONATAL DIPHRG HRNA +-CH TUBE INSJ RPR DIPHRG HRNA OTH/THN NEONATAL TRAUMTC AQT RPR DIPHRG HRNA OTH/THN NEONATAL TRAUMTC CHRNC Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 113

118 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, IMBRCJ OF DIAPHRAGM RESCJ DPHRM SMPL RPR RESCJ DPHRM CPLX RPR UNLIS PX DPHRM BR YYY BX LIP VERMILIONECTOMY LIP SHV W/MUCOSAL ADVMNT EXC LIP TRANSVRS WEDGE EXC W/PRIM CLSR EXC LIP V-EXC W/PRIM DIR LINR CLSR EXC LIP FULL THKNS RCNSTJ W/LOCAL FLAP EXC LIP FULL THKNS RCNSTJ W/CROSS LIP FLAP RESCJ LIP > ONE-4TH W/O RCNSTJ RPR LIP FULL THKNS VERMILION ONLY RPR LIP FULL THKNS UP HALF VER H RPR LIP FULL THKNS > ONE-HALF VER H8/CPLX PLSTC RPR CL LIP/NSL DFRM PRIM PRTL/COMPL UNI PLSTC RPR CL LIP/NSL DFRM PRIM BI 1 STG PX PLSTC RPR CL LIP/NSL DFRM PRIM BI 1 2 STGS PLSTC RPR CL LIP/NSL DFRM SEC RECRTJ DFCT&RECLSR PLSTC RPR CL LIP/NSL DFRM W/CROSS LIP PEDCL FLAP UNLIS PX LIPS BR YYY DRG ABSC CST HMTMA VESTIBULE MOUTH SMPL DRG ABSC CST HMTMA VESTIBULE MOUTH COMP RMVL EMBEDDED FB VESTIBULE MOUTH SMPL RMVL EMBEDDED FB VESTIBULE MOUTH COMP INC LABIAL FRENUM FREXOMY BX VESTIBULE MOUTH EXC LES MUCOSA&SBMCSL VESTIBULE MOUTH W/O RPR EXC LES MUCOSA&SBMCSL VESTIBULE SMPL RPR EXC LES MUCOSA&SBMCSL VESTIBULE CPLX RPR EXC LES MUCOSA&SBMCSL VESTIBULE CPLX EXC MUSC EXC MUCOSA VESTIBULE MOUTH AS DON GRF EXC FRENUM LABIAL/BUCCAL DSTRJ LES/SCAR VESTIBULE MOUTH PHYSICAL METHS CLSR LAC VESTIBULE MOUTH 2.5 CM/< CLSR LAC VESTIBULE MOUTH > 2.5 CM/CPLX VESTIBULOPLASTY ANT VESTIBULOPLASTY PST UNI VESTIBULOPLASTY PST BI VESTIBULOPLASTY ENTIRE ARCH VESTIBULOPLASTY CPLX W/RIDGE XTN MUSC RPSG UNLIS PX VESTIBULE MOUTH BR YYY INTRAORAL I&D TONGUE/FLOOR LNGL INTRAORAL I&D TONGUE/FLOOR SUBLNGL SUPFC INTRAORAL I&D TONGUE/FLOOR SUBLNGL DP SPRMLHYD INTRAORAL I&D TONGUE/FLOOR SUBMENTAL SPACE INTRAORAL I&D TONGUE/FLOOR SUBMNDBLR SPACE CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

119 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule INTRAORAL I&D TONGUE/FLOOR MASTICATOR SPACE INC LNGL FRENUM FREXOMY XTRORAL I&D ABSC CST/HMTMA FLOOR MOUTH SUBLNGL XTRORAL I&D ABSC CST/HMTMA FLOOR MOUTH SUBMENTAL XTRORAL I&D ABSC CST/HMTMA FLOOR MOUTH SUBMNDBLR XTRORAL I&D FLOOR MASTICATOR SPACE PLACEMENT NEEDLE HEAD/NECK RADIOELEMENT APPLICAT BX TONGUE ANT 2-3RD BX TONGUE PST ONE-3RD BX FLOOR MOUTH EXC LES TONGUE W/O CLSR EXC LES TONGUE W/CLSR ANT 2-3RD EXC LES TONGUE W/CLSR PST ONE-3RD EXC LES TONGUE W/CLSR W/LOCAL TONGUE FLAP EXC LNGL FRENUM FRENECTOMY EXC LES FLOOR MOUTH GLSSC < ONE-HALF TONGUE GLSSC HEMIGLSSC GLSSC PRTL W/UNI RAD NCK DSJ GLSSC COMPL/TOT +-TRACHS W/O RAD NCK DSJ GLSSC COMPL/TOT +-TRACHS W/UNI RAD NCK DSJ GLSSC COMPOSIT W/RESCJ FLOOR&MNDBLR RESCJ GLSSC COMPOSIT RESCJ FLOOR SUPRAHYOID NCK DSJ GLSSC COMPOSIT RESCJ FLR MNDBLR RESCJ&RAD NCK RPR LAC 2.5 CM/< FLOOR MOUTH&/ANT 2-3RD TONGUE RPR LAC 2.5 CM/< PST ONE-3RD TONGUE RPR LAC TONGUE FLOOR MOUTH > 2.6 CM/CPLX FIXJ TONGUE MCHNL OTH/THN SUTR SUTR TONGUE LIP MICROGNATHIA TONGUE BASE SUSPENSION PERMANENT SUTURE TQ FRENOPLASTY SURG REVJ FRENUM EG W/Z-PLASTY SUBMUCOSAL ABLTJ TONGUE RF 1/> SITES PR SESSION UNLIS PX TONGUE FLOOR MOUTH BR YYY DRG ABSC CST HMTMA FROM DENTOALVEOLAR STRUXS RMVL EMBEDDED FB FROM DENTALVLR STRUXS SOFT TISS RMVL EMBEDDED FB FROM DENTOALVEOLAR STRUXS B GINGIVECTOMY EXC GINGIVA EA QUADRANT OPRCULECTOMY EXC PRICORONAL TISS EXC FIBROUS TUBEROSITIES DENTOALVEOLAR STRUXS EXC OSS TUBEROSITIES DENTOALVEOLAR STRUXS EXC LES/TUM XCP LISTED ABOVE DENTALVLR EXC LES/TUM XCP LISTED ABOVE DENTALVLR SMPL RPR EXC LES/TUM XCP LISTED ABOVE DENTALVLR CPLX RPR EXC HYPRPLSTC ALVEOLAR MUCOSA EA QUADRANT SPEC ALVEOLECTOMY W/CURTG OSTEITIS/SEQUESTRECTOMY DSTRJ LES XCP EXC DENTOALVEOLAR STRUXS Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 115

120 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, PDONTAL MUCOSAL GRFG GINGIVOPLASTY EA QUADRANT SPEC ALVEOLOPLASTY EA QUADRANT SPEC UNLIS PX DENTOALVEOLAR STRUXS BR YYY DRG ABSC PALATE UVULA BX PALATE UVULA EXC LES PALATE UVULA W/O CLSR EXC LES PALATE UVULA W/SMPL PRIM CLSR EXC LES PALATE UVULA W/LOCAL FLAP CLSR RESCJ PALATE/X10SV RESCJ LES UVULECTOMY EXC UVULA PALATOPHARYNGOPLASTY DSTRJ LES PALATE/UVULA THERMAL CRYO/CHEM RPR LAC PALATE UP 2 CM RPR LAC PALATE > 2 CM/CPLX PALATOP CL PALATE SOFT&/HARD PALATE ONLY PALATOP W/CLSR ALVEOLAR RIDGE SOFT TISS PALATOP CLSR ALVEOLAR RIDGE GRF ALVEOLAR RIDGE PALATOP CL PALATE MAJOR REVJ PALATOP CL PALATE SEC LNGTH PX PALATOP CL PALATE ATTACHMENT PHARYNGEAL FLAP LNGTH PALATE&PHARYNGEAL FLAP LNGTH PALATE W/ISLAND FLAP RPR ANT PALATE W/VOMER FLAP RPR NASOLABIAL FSTL MAX IMPRESJ PALATAL PROSTH INSJ PIN-RETAINED PALATAL PROSTH UNLIS PX PALATE UVULA BR YYY DRG ABSC PRTD SMPL DRG ABSC PRTD COMP DRG ABSC SUBMAX/SUBLNGL INTRAORAL DRG ABSC SUBMAX XTRNL SIALOT SUBMNDBLR SUBLNGL/PRTD UNCOMP INTRAORAL SIALOLITHOTOMY SUBMNDBLR SUBMAX COMP INTRAORAL SIALOLITHOTOMY PRTD XTRORAL/COMP INTRAORAL BX SALIVARY GLND NDL BX SALIVARY GLND INCAL EXC SUBLNGL SALIVARY CST RANULA MARSUPIALIZATION SUBLNGL SALIVARY CST RANULA EXC PRTD TUM/PRTD GLND LAT LOBE W/O NRV DSJ EXC PRTD TUM/PRTD GLND LAT DSJ&PRSRV FACIAL NRV EXC PRTD TUM/PRTD GLND TOT DSJ&PRSRV FACIAL NRV EXC PRTD TUM/PRTD GLND TOT EN BLOC RMVL EXC PRTD TUM/PRTD GLND TOT W/UNI RAD NCK DSJ EXC SUBMNDBLR SUBMAX GLND EXC SUBLNGL GLND CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

121 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule PLSTC RPR SALIVARY DUX SIALODOCHOPLASTY PRIM PLSTC RPR SALIVARY DUX SIALODOCHOPLASTY SEC/COMP PRTD DUX DVRJ BI PRTD DUX DVRJ BI W/EXC 1 SUBMNDBLR GLND PRTD DUX DVRJ BI W/EXC BTH SUBMNDBLR GLNDS PAROTID DUCT DVRJ BILATERAL WITH LIG BOTH DUCTS NJX SIALOGRAPY CLSR SALIVARY FSTL DILAT SALIVARY DUX DILAT&CATHJ SALIVARY DUX +-NJX LIG SALIVARY DUX INTRAORAL UNLIS PX SALIVARY GLNDS/DUXS BR YYY I&D ABSC PRITONSILLAR I&D ABSC RTRPHRNGL/PARAPHARYNGEAL INTRAORAL I&D ABSC RTRPHRNGL/PARAPHARYNGEAL XTRNL APPR BX OROPHARYNX BX HYPOPHARYNX BX NASOPHARYNX VISIBLE LES SMPL BX NASOPHARYNX SURV UNKNOWN PRIM LES EXC/DSTRJ LES PHARYNX ANY METH RMVL FB FROM PHARYNX EXC BRANCHIAL CL CST CONFINED SKN&SUBQ TISS EXC BRANCHIAL CL CST EXTG BELW SUBQ TISS&/PHRNX TONSILLECTOMY&ADENOIDECTOMY UNDER AGE TONSILLECTOMY&ADENOIDECTOMY AGE 12/> TONSILLECTOMY 1/2 UNDER AGE TONSILLECTOMY 1/2 AGE 12/> ADENOIDECTOMY PRIM UNDER AGE ADENOIDECTOMY PRIM AGE 12/> ADENOIDECTOMY SEC UNDER AGE ADENOIDECTOMY SEC AGE 12/> RAD RESCJ TONSIL W/O CLSR RAD RESCJ TONSIL CLSR W/LOCAL FLAP RAD RESCJ TONSIL CLSR W/OTH FLAP EXC TONSIL TAGS EXC/DSTRJ LNGL TONSIL ANY METH SPX LMTD PHARYNGECTOMY RESCJ LAT PHRNGL WALL/PYRIFORM SINUS DIR CLSR RESCJ PHRNGL WALL CLSR W/FLP OR FLP W/MVASC ANAS SUTR PHARYNX WND/INJ PHARYNGOPLASTY PLSTC/RCNSTV OPRATION PHARYNX PHARYNGOESOPHGL RPR PHARYNGOSTOMY FSTLJ PHARYNX XTRNL FEEDING CTRL OROPHARYNGEAL HEMRRG 1/2 SMPL CTRL OROPHARYNGEAL HEMRRG 1/2 COMP REQ HOSPITJ CTRL OROPHARYNGEAL HEMRRG 1/2 W/SEC SURG IVNTJ Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 117

122 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, CTRL NASPHRYNGL HEMRRG 1/2 SMPL W/PST NSL PACKS CTRL NASPHRYNGL HEMRRG 1/2 COMP REQ HOSPIZATION CTRL NASPHRYNGL HEMRRG 1/2 W/SEC SURG IVNTJ UNLIS PX PHARYNX ADENOIDS/TONSILS BR YYY ESOPHAGOTOMY CRV APPR W/RMVL FB CRICOPHARYNGEAL MYOTOMY ESOPHAGOTOMY THRC APPR W/RMVL FB EXC LES ESOPH W/PRIM RPR CRV APPR EXC LES ESOPH W/PRIM RPR THRC/ABDL APPR TOT ESPHG W/O THORCOM PHRNGSTRSTY/EGST TOT ESPHG W/O THORCOM COLON NTRPSTJ/INT RCNSTJ TOT ESPHG W/THORCOM W/PHRNGSTRSTY/EGST TOT ESPHG W/THORCOM W/COLON NTRPSTJ/INT RCNSTJ PRTL ESPHG CRV W/FR INTSTINAL GRF PRTL ESPHG DSTL THORCOM ABDL INC EGST PRTL ESPHG DSTL THORCOM ABDL INC NTRPSTJ/RCNSTJ PRTL ESPHG DSTL THORCOM ONLY THRC EGST PRTL ESPHG THORACOABDL/ABDL APPR EGST PRTL ESPHG THORACOABDL/ABDL APPR NTRPSTJ/RCNSTJ TOT/PRTL ESPHG W/O RCNSTJ W/CRV ESOPHAGOSTOMY DIVERTICULECTOMY HYPOPHARYNX/ESOPH CRV APPR DIVERTICULECTOMY HYPOPHARYNX/ESOPH THRC APPR K ESPHGSC RGD/FLX DX +-COLLJ SPEC BR/WA SPX K ESPHGSC RGD/FLX DIRED SBMCSL NJX ANY SBST K ESPHGSC RGD/FLX W/BX 1/MLT K ESPHGSC RGD/FLX W/NJX SCLEROSIS ESOPHGL VARC K ESPHGSC RGD/FLX W/BAND LIG ESOPHGL VARC K ESPHGSC RGD/FLX W/RMVL FB K ESPHGSC RGD/FLX RMVL TUM HOT BX FORCEPS/CAUT K ESPHGSC RGD/FLX W/RMVL TUM SNARE TQ K ESPHGSC RGD/FLX W/INSJ PLSTC TUBE/STENT K ESPHGSC RGD/FLX W/BALO DILAT < 30 MM DIAM K ESPHGSC RGD/FLX W/INSJ GD WIRE DILAT K ESPHGSC RGD/FLX W/CTRL BLD K ESPHGSC RGD/FLX ABLTJ TUM XCP HOT BX/CAUT/SNARE K ESPHGSC RGD/FLX W/NDSC US XM K ESPHGSC RGD/FLX W/TNDSC US-GID FINE NDL ASPIR/BX K UPPER STOMACH-INTESTINE SCOPE SIMPLE K UPPER STOMACH-INTESTINE SCOPE FOR DIAGNOSIS K STOMACH-INTESTINE SCOPE INJECT INTESTINE WALL K UPR GI NDSC NDSC US XM LMTD ESOPH K UPR GI NDSC TNDSC US FINE NDL ASPIR/BX ESOPH K UPPER STOMACH-INTESTINE SCOPE FOR BIOPSY K UPR GI NDSC TRANSMURAL DRG PSEUDOCST K UPR GI NDSC TNDSC INTRAL TUBE/CATH PLMT K STOMACH-INTESTINE SCOPE ULTRASOUND GUIDED BIOPSY CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

123 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule K UPR GI NDSC NJX SCLEROSIS ESOPHGL&/GSTR VARC K UPR GI NDSC BAND LIG ESOPHGL&/GSTR VARC K UPR GI NDSC DILAT GSTR OUTLET FOR OBSTRCJ K UPR GI NDSC DIRED PLMT PRQ GASTROSTOMY TUBE K STOMACH-INTESTINE SCOPE FOR FOREIGN BODY REMOVAL K UPR GI NDSC INSJ GD WIRE DILAT ESOPH > GD WIRE K UPR GI NDSC BALO DILAT ESOPH < 30 MM DIAM K UPR GI NDSC RMVL LES HOT BX/BIPOLAR CAUT K UPR GI NDSC RMVL TUM POLYP/OTH LES SNARE TQ K UPR GI NDSC CTRL BLD ANY METH K UPR GI NDSC TNDSC STENT PLMT W/PREDILAT K UPR GI NDSC DLVR THERMAL NRG SPHNCTR/CARDIA K UPR GI NDSC ABLTJ LES X RMVL FORCEPS/CAUT/SNARE K STOMACH-INTESTINE SCOPE WITH ULTRASOUND EXAM K ERCP DX COLLJ SPEC BR/WA SPX K ERCP W/BX 1/MLT K ERCP W/SPHNCTROTOMY/PAPILLOTOMY K ERCP W/PRESS MEAS SPHNCTR ODDI K ERCP W/RMVL ST1/CALCULI BILIARY&/PNCRTC DUXS K ERCP W/DSTRJ LITHOTRP ST1/CALCULI ANY METH K ERCP W/INSJ NASOBILIARY/NASOPNCRTC DRG TUBE K ERCP W/INSJ TUBE/STENT BILE/PNCRTC DUX K ERCP W/RTRGR RMVL FB&/CHNG TUBE/STENT K ERCP W/BALO DILAT AMPULLA BILIARY&/PNCRTC DUX K ERCP W/ABLTJ LES X RMVL FORCEPS/CAUT/SNARE K ENDOSCOPIC PAPILLA CANNULATION BILE PANCREATIC ZZZ LAPS ESOPHAGOMYOTOMY W/FUNDOPLASTY IF PERFORMED LAPS SURG ESOPG/GSTR FUNDOPLASTY LAPS RPR PARAESPHGL HRNA INCL FUNDPLSTY W/O MESH LAPS RPR PARAESPHGL HRNA INCL FUNDPLSTY W/MESH l LAPS ESOPHAGEAL LENGTHENING ADDL ZZZ UNLIS LAPS PX ESOPH BR YYY ESPHGP CRV APPR W/O RPR TRACHEOESOPHGL FSTL ESPHGP CRV APPR W/RPR TRACHEOESOPHGL FSTL ESPHGP THRC APPR W/O RPR TRACHEOESOPHGL FSTL ESPHGP THRC APPR W/RPR TRACHEOESOPHGL FSTL ESPHGP CGEN DFCT THRC APPR W/O RPR FSTL ESPHGP CGEN DFCT THRC APPR W/RPR FSTL EGST+-VAGOTOMY&PYLOROPLASTY TABDL/TTHRC APPR ESOPG/GSTR FUNDOPLASTY W/FUNDIC PATCH l ESOPG/GSTR FUNDOPLASTY W/LAPT l ESOPG/GSTR FUNDOPLASTY W/THORCOM ESOPHAGOMYOTOMY HELLER TYP ABDL APPR ESOPHAGOMYOTOMY HELLER TYP THRC APPR l RPR PARAESOPH HIATAL HERNIA W/LAPT W/O MESH l LAPT RPR PARAESOPH HIATAL HERNIA W/ MESH Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 119

124 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, 2011 l RPR PARAESOPH HIATAL HERNIA W/THORCOM W/O MESH l RPR PARAESOPH HIATAL HERNIA W/THORCOM W/MESH l RPR PARAESOPH HIATAL HERNIA THORCOABDOM W/O MESH l RPR PARAESOPH HIATAL HERNIA THORCOABDOM W/MESH l ESOPHAGUS LENGTHENING ZZZ ESOPHAGOJEJUNOSTOMY W/O TOT GSTRCT ABDL APPR ESOPHAGOJEJUNOSTOMY W/O TOT GSTRCT THRC APPR ESOPHAGOSTOMY FSTLJ ESOPH XTRNL ABDL APPR ESOPHAGOSTOMY FSTLJ ESOPH XTRNL THRC APPR ESOPHAGOSTOMY FSTLJ ESOPH XTRNL CRV APPR GI RCNSTJ PREV ESPHG/EXCLUSION W/STOMACH GI RCNSTJ PREV ESPHG/EXCLUSION W/COLON SM INT LIG DIR ESOPHGL VARC TRNSXJ ESOPH W/RPR ESOPHGL VARC LIG/STAPLING G-ESOP JUNCT PRE-ESOPHGL PRF8J SUTR ESOPHGL WND/INJ CRV APPR SUTR ESOPHGL WND/INJ TTHRC/TABDL APPR CLSR ESOPHAGOSTOMY/FSTL CRV APPR CLSR ESOPHAGOSTOMY/FSTL TTHRC/TABDL APPR OPENING OF ESOPHAGUS K DILAT ESOPH > GD WIRE K DILAT ESOPH BALO/DILATOR RTRGR K DILAT ESOPH BALO 30 MM DIAM/LGR ACHALASIA ESOPG/GSTR TAMPONADE W/BALO SENGSTAKEN TYP FR JEJUNUM TR W/MVASC ANAST BR UNLIS PX ESOPH BR YYY GSTRT W/EXPL/FB RMVL GSTRT W/SUTR RPR BLD ULCER GSTRT W/SUTR RPR PRE-ESOPG/GSTR LAC GSTRT W/ESOPHGL DILAT&INSJ PRM INTRAL TUBE PYLOROMYOTOMY CUTTING PYLORIC MUSC s BX STOMACH LAPT EXC LOCAL ULCER/B9 TUM STOMACH EXC LOCAL MAL TUM STOMACH GSTRCT TOT W/ESOPHAGONTRSTM GSTRCT TOT W/ROUX-EN-Y RCNSTJ GSTRCT TOT W/FRMJ INTSTINAL POUCH ANY TYP GSTRCT PRTL DSTL W/GASTRODUODENOSTOMY GSTRCT PRTL DSTL W/GASTROJEJUNOSTOMY GSTRCT PRTL DSTL W/ROUX-EN-Y RCNSTJ GSTRCT PRTL DSTL W/FRMJ INTSTINAL POUCH VAGOTOMY PFRMD W/PRTL DSTL GSTRCT ZZZ VGTMY W/PYPS +-GASTROSTOMY TRUNCAL/SLCTV VGTMY W/PYPS +-GASTROSTOMY PARIETAL CELL LAPS GSTR RSTCV PX W/BYP ROUX-EN-Y <150 CM LAPS GSTR RSTCV PX W/BYP&SM INT RCNSTJ CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

125 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule LAPS IMPLTJ/RPLCMT GASTRIC NSTIM ELTRD ANTRUM BR YYY LAPS REVISION/RMVL GASTRIC NSTIM ELTRD ANTRUM BR YYY LAPS SURG TRNSXJ VAGUS NRV TRUNCAL LAPS SURG TRNSXJ VAGUS NRV SLCTV/HILY SLCTV LAPS SURG GASTROSTOMY W/O CONSTJ GSTR TUBE SPX UNLIS LAPS PX STOMACH BR YYY NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDN l GASTRIC TUBE PLMT W/ASPIR & LAVAGE l GASTRIC TUBE DX PLMT W/ASPIR 1 SPECIMEN l GASTRIC TUBE DX PLMT W/ASPIR MULT SPECIMENS l DUODENAL TUBE DX PLMT W/IMG GID 1 SPECIMEN l DUODENAL TUBE DX PLMT W/IMG GID MULT SPECIMEN CHANGE GASTROSTOMY TUBE PERCUTANEOUS W/O GUIDE REPOS NASO/ORO GASTRIC FEEDING TUBE THRU DUO LAPS GASTRIC RESTRICTIVE PROCEDURE PLACE DEVICE LAPS GASTRIC RESTRICTIVE PX REVISION DEVICE LAPS GASTRIC RESTRICTIVE PX REMOVE DEVICE LAPS GASTRIC RESTRICTIVE PX REMOVE&RPLCMT DEVICE LAPS GASTRIC RESTRICTIVE PX REMOVE DEVICE &PORT LAPS GSTRC RSTRICTIV PX LONGITUDINAL GASTRECTOMY XXX PYLOROPLASTY GASTRODUODENOSTOMY GASTROJEJUNOSTOMY W/O VAGOTOMY GASTROJEJUNOSTOMY W/VAGOTOMY ANY TYP GASTROSTOMY OPN W/O CONSTJ GSTR TUBE SPX GASTROSTOMY OPN NEONATAL FEEDING GASTROSTOMY OPN W/CONSTJ GSTR TUBE GASTRORRHAPHY SUTR PRF8 DUOL/GSTR ULCER WND/INJ GSTR RSTCV W/O BYP VER-BANDED GSTP GSTR RSTCV W/O BYP OTH/THN VER-BANDED GSTP GSTR RSTCV W/PRTL GSTRCT CM GSTR RSTCV W/BYP W/SHORT LIMB 150 CM/< GSTR RSTCV W/BYP W/SM INT RCNSTJ LIMIT ABSRPJ REVISION OPEN GASTRIC RESTRICTIVE PX NOT DEVICE REVJ GASTRODUOL ANAST W/RCNSTJ W/O VAGOTOMY REVJ GASTRODUOL ANAST W/RCNSTJ W/VGTMY REVJ GSTR/JJ ANAST W/RCNSTJ W/O VGTMY REVJ GSTR/JJ ANAST W/RCNSTJ W/VGTMY CLSR GASTROSTOMY SURG CLSR GASTROCOLIC FSTL IMPLTJ/RPLCMT GASTRIC NSTIM ELTRD ANTRUM OPEN BR YYY REVISION/RMVL GASTRIC NSTIM ELTRD ANTRUM OPEN BR YYY GSTR RSTCV PX OPN REVJ SUBQ PORT COMPONENT ONLY GSTR RSTCV PX OPN RMVL SUBQ PORT COMPONENT ONLY GSTR RSTCV OPN RMVL&RPLCMT SUBQ PORT UNLIS PX STOMACH BR YYY Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 121

126 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, ENTEROLSS FRING INTSTINAL ADHESION SPX DUODEXOMY EXPL BX/FB RMVL TUBE/NDL CATH JEJUNOSTOMY ANY METH ZZZ ENTEROTOMY SM INT OTH/THN DUO EXPL BX/FB RMVL ENTEROTOMY SM INT OTH/THN DUO DCMPRN COLOTOMY EXPL BX/FB RMVL RDCTJ VOLVULUS INTUSSUSCEPTION INT HRNA LAPT CORRJ MALROTATION BANDS&/RDCTJ VOLVULUS BX INT CAPSL TUBE PRORAL 1+ SPECS EXC 1+ < SM/LG INT 1 ENTEROTOMY EXC 1+ < SM/LG INT MLT ENTEROTOMIES ENTRC RESCJ SM INT 1 RESCJ&ANAST ENTRC RESCJ SM INT EA RESCJ&ANAST ZZZ ENTRC RESCJ SM INT W/NTRSTM ENTRC RESCJ ATRESIA RESCJ&ANAST W/O TAPRING ENTRC RESCJ ATRESIA RESCJ&ANAST SGM W/TAPRING ENTRC RESCJ ATRESIA EA RESCJ&ANAST ZZZ ENTERONTRSTM ANAST INT +-CUTAN NTRSTM SPX DON ENTRC OPN FROM CDVR DON BR XXX DON ENTRC OPN PRTL FROM LIV DON BR XXX INTSTINAL ALTRNSPLJ FROM CDVR DON BR XXX INTSTINAL ALTRNSPLJ FROM LIV DON BR XXX RMVL TRNSPLED INTSTINAL ALGRFT COMPL BR XXX MOBLJ SPLENIC FLXR PFRMD CONJUNCT W/PRTL COLCT ZZZ COLCT PRTL W/ANAST COLCT PRTL W/SKN LVL CECOSTOMY/CLST COLCT PRTL W/END CLST&CLSR DSTL SGM COLCT PRTL W/RESCJ W/CLST/ILEOST&MUCOFSTL COLCT PRTL W/COLOPXTSTMY LW PEL ANAST COLCT PRTL W/COLOPXTSTMY LW PEL ANAST W/CLST COLCT PRTL ABDL&TRANSANAL APPR COLCT TOT ABDL W/O PRCTECT W/ILEOST/ILEOPXTS COLCT TOT ABDL W/O PRCTECT W/CONTINENT ILEOST COLCT TOT ABDL W/PRCTECT W/ILEOST COLCT TOT ABDL W/PRCTECT W/CONTINENT ILEOST COLCT TTL ABD W/PRCTECT ILEOANAL ANAST COLCT TTL ABD W/PRCTECT ILEOANAL ANAST & RSVR COLCT PRTL W/RMVL TERMINAL ILE W/ILEOCLST LAPS ENTEROLSS FRING INTSTINAL ADHESION SPX LAPS JEJUNOSTOMY LAPS ILEOST/JEJUNOSTOMY NON-TUBE LAPS CLST/SKN LVL CECOSTOMY LAPS ENTRC RESCJ SM INT 1 RESCJ&ANAST LAPS EA SM INT RESCJ&ANAST ZZZ LAPS COLCT PRTL W/ANAST LAPS COLCT PRTL W/RMVL TERMINAL ILE CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

127 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule LAPS COLCT PRTL W/END CLST&CLSR DSTL SGM LAPS COLCT PRTL W/COLOPXTSTMY LW ANAST LAPS COLCT PRTL W/COLOPXTSTMY LW ANAST W/CLST LAPS COLCT TOT W/O PRCTECT W/ILEOST/ILEOPXTS LAPS COLCT TTL ABD W/PRCTECT ILEOANAL ANAST&RSVR LAPS COLCT ABDL W/PRCTECT W/ILEOST LAPS MOBLJ SPLENIC FLXR PFRMD W/PRTL COLCT ZZZ LAPS CLSR NTRSTM LG/SM INT W/RESCJ&ANAST UNLIS LAPS PX INT XCP RECTUM BR YYY PLACEMENT ENTEROSTOMY/CECOSTOMY TUBE OPEN ILEOST/JEJUNOSTOMY NON-TUBE REVJ ILEOST SMPL RLS SUPFC SCAR SPX REVJ ILEOST COMP RCNSTJ IN-DEPTH SPX CONTINENT ILEOST KOCK PX SPX CLST/SKN LVL CECOSTOMY CLST/SKN LVL CECOSTOMY W/MLT BXS SPX REVJ CLST SMPL RLS SUPFC SCAR SPX REVJ CLST COMP RCNSTJ IN-DEPTH SPX REVJ CLST W/RPR PARACLST HRNA SPX K SCOPE OF UPPER SMALL INTESTINE K SCOPE OF UPPER SMALL INTESTINE WITH BIOPSY K ENTEROSCOPY > 2ND PRTN X ILE RMVL FB K ENTEROSCOPY > 2ND PRTN X ILE RMVL LES SNARE K ENTEROSCOPY > 2ND PRTN X ILE RMVL LES CAUT K ENTEROSCOPY > 2ND PRTN X ILE CTRL BLD K ENTEROSCOPY > 2ND PRTN X ILE ABLTJ LES K ENTEROSCOPY > 2ND PRTN X ILE TNDSC STENT PLMT K ENTEROSCOPY > 2ND PRTN X ILE W/PLMT PRQ TUBE K ENTEROSCOPY > 2ND PRTN X ILE CONV GSTRST TUBE K ENTEROSCOPY > 2ND PRTN W/ILE +-COLLJ SPEC SPX K ENTEROSCOPY > 2ND PRTN W/ILE W/BX 1/MLT K ENTEROSCOPY > 2ND PRTN ILE CTRL BLD K ENTEROSCOPY > 2ND PRTN W/ILE W/STENT PLMT K ILESC THRU STOMA DX +-COLLJ SPEC BR/WA SPX K ILESC THRU STOMA W/BX 1/MLT K ILESC THRU STOMA W/TNDSC STENT PLMT K NDSC EVAL INTSTINAL POUCH DX +-COLLJ SPEC SPX K NDSC EVAL INTSTINAL POUCH W/BX 1/MLT K SCOPE OF COLON THRU OSTOMY FOR DIAGNOSIS K SCOPE OF COLON WITH BIOPSY THRU OSTOMY K COLSC THRU STOMA W/RMVL FB K COLSC THRU STOMA CTRL BLD K COLSC THRU STOMA RMVL LES CAUT K COLSC THRU STOMA ABLTJ LES K COLSC THRU STOMA W/RMVL TUM POLYP/OTH LES SNARE K COLSC THRU STOMA W/TNDSC STENT PLMT Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 123

128 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, 2011 * K INTRO LONG GI TUBE SPX ENTERORRHAPHY 1 PRF8J ENTERORRHAPHY MLT PRF8J SUTR LG INT 1/MLT PRF8J W/O CLST SUTR LG INT 1/MLT PRF8J W/CLST INTSTINAL STRICTUROPLASTY+-DILAT OBSTRCJ CLSR NTRSTM LG/SM INT CLSR NTRSTM LG/SM RESCJ&ANAST OTH/THN CLRCT CLSR NTRSTM LG/SM RESCJ&CLRCT ANAST CLSR INTSTINAL CUTAN FSTL CLSR ENTEROENTERIC/ENTEROCOLIC FSTL CLSR ENTEROVES FSTL W/O INTSTINAL/BLDR RESCJ CLSR ENTEROVES FSTL W/INT&/BLDR RESCJ INTSTINAL PLCTJ SPX EXCLUSION SM INT FROM PELVIS MESH/PROSTH/TISS INTRAOP COLONIC LVG ZZZ BKBENCH ALGRFT INT FASHIONING ART&VEIN BR XXX BKBENCH RCNSTJ INT ALGRFT VEN ANAST EA XXX BKBENCH RCNSTJ INT ALGRFT ARTL ANAST EA XXX UNLIS PX INT BR YYY EXC MECKEL'S DIVERTICULUM/OMPHALOMESENTERIC DUCT EXC LES MESENTERY SPX SUTR MESENTERY SPX UNLISTED PX MECKEL'S DIVERTICULUM & MESENTERY BR YYY I&D APPENDICEAL ABSC OPN K I&D APPENDICEAL ABSC PRQ APPENDEC APPENDEC INDICATED PURPOSE OTH MAJOR PX X SPX ZZZ APPENDEC RPTD APPENDIX ABSC/PRITONITIS LAPS SURG APPENDEC UNLIS LAPS PX APPENDIX BR YYY TRANSRCT DRG PEL ABSC I&D SBMCSL ABSC RECTUM I&D DP SUPRALEVATOR PELVIRCT/RETRORCT ABSC BX ANRCT WALL ANAL APPR ANRCT MYOMECTOMY PRCTECT COMPL CMBN ABDOMINOPRNL W/CLST PRCTECT PRTL RESCJ RECTUM TABDL APPR PRCTECT CMBN ABDOMINOPRNL PULL-THRU PX PRCTECT PRTL W/MUCOSEC ILEOANAL ANAST RSVR PRCTECT PRTL W/ANAST ABDL&TRANSSAC APPR PRCTECT PRTL W/ANAST TRANSSAC APPR ONLY PRCTECT CMBN PULL-THRU W/RSVR W/NTRSTM PRCTECT COMPL W/PULL-THRU PX&ANAST PRCTECT COMPL W/STOT/TOT COLCT W/MLT BXS PRCTECT PRTL W/O ANAST PRNL APPR CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

129 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule PEL EXNTJ CLRCT MAL EXC RCT PROCIDENTIA W/ANAST PRNL APPR EXC RCT PROCIDENTIA W/ANAST ABDL&PRNL APPR EXC ILEOANAL RSVR W/ILEOST DIV STRIX RECTUM EXC RCT TUM PROCTOTOMY TRANSSAC/TRANSCOCCYGEAL EXC RCT TUM NOT INCL MUSCULARIS PROPRIA EXC RCT TUM INCL MUSCULARIS PROPRIA DSTRJ RCT TUM TRANSANAL APPR PROCTOSGMDSC RGD DX +-COLLJ SPEC BR/WA SPX K PROCTOSGMDSC RGD W/DILAT K PROCTOSGMDSC RGD W/BX 1/MLT K PROCTOSGMDSC RGD W/RMVL FB K PROCTOSGMDSC RGD RMVL 1 LES CAUT K PROCTOSGMDSC RGD RMVL 1 LES SNARE TQ K PROCTOSGMDSC RGD RMVL MLT TUM < CAUT/SNARE K PROCTOSGMDSC RGD CTRL BLD K PROCTOSGMDSC RGD ABLTJ LES K PROCTOSGMDSC RGD DCMPRN VOLVULUS K PROCTOSGMDSC RGD TNDSC STENT PLMT SCOPE OF SIGMOID COLON ONLY FOR DIAGNOSIS SCOPE OF SIGMOID COLON ONLY WITH BIOPSY K SGMDSC FLX RMVL FB K SGMDSC FLX RMVL LES CAUT K SGMDSC FLX CTRL BLD K SGMDSC FLX DIRED SBMCSL NJX ANY SBST K SGMDSC FLX DCMPRN VOLVULUS ANY METH K SGMDSC FLX RMVL TUM POLYP/OTH LES SNARE TQ K SGMDSC FLX ABLTJ LES K SGMDSC FLX DILAT BALO 1/MORE STRIXS K SGMDSC FLX NDSC US XM K SGMDSC FLX TNDSC US GID NDL ASPIR/BX K SGMDSC FLX TNDSC STENT PLMT K COLSC RGD/FLX TABDL VIA COLOTOMY 1/MLT K SCOPE OF COLON FOR DIAGNOSIS K COLSC FLX PROX SPLENIC FLXR RMVL FB K SCOPE OF COLON WITH BIOPSY K COLSC FLX PROX SPLENIC FLXR SBMCSL NJX K COLSC FLX PROX SPLENIC FLXR CTRL BLD K COLSC FLX PROX SPLENIC FLXR ABLTJ LES K COLSC FLX PROX SPLENIC FLXR RMVL LES CAUT K COLSC FLX PROX SPLENIC FLXR RMVL LES SNARE TQ K COLSC FLX PROX SPLENIC FLXR DILAT BALO 1+ STRIXS K COLSC FLX PROX SPLENIC FLXR TNDSC STENT PLMT K COLSC FLX PROX SPLENIC FLXR NDSC US XM K COLSC FLX PROX SPLENIC FLXR US GID NDL ASPIR/BX Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 125

130 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, LAPS PRCTECT COMPL CMBN ABDOMINOPRNL W/CLST LAPS PRCTECT CMBN PULL-THRU CRTJ RSVR LAPS PROCTOPEXY FOR PROLAPSE LAPS PROCTOPEXY FOR PROLAPSE SIGMOID RESCJ UNLIS LAPS PX RECTUM BR YYY PROCTOPLASTY STENOSIS PROCTOPLASTY PROLAPSE MUC MEMB PRIRCT NJX SCLRSG SLN PROLAPSE PROCTOPEXY ABDL APPR PROCTOPEXY PRNL APPR PROCTOPEXY W/SIGMOID RESCJ ABDL APPR RPR RECTOCELE SPX EXPL RPR&PRESAC DRG RCT INJ EXPL RPR&PRESAC DRG RCT INJ W/CLST CLSR RECTOVESICAL FSTL CLSR RECTOVESICAL FSTL W/CLST CLSR RECTOURTL FSTL CLSR RECTOURTL FSTL W/CLST RDCTJ PROCIDENTIA SPX UNDER ANES DILAT ANAL SPHNCTR SPX UNDER ANES OTH/THN LOCAL DILAT RCT STRIX SPX UNDER ANES OTH/THN LOCAL RMVL FECAL IMPACTION/FB SPX UNDER ANES ANRCT XM SURG REQ ANES GENERAL SPI/EDRL DX UNLIS PX RECTUM BR YYY PLMT SETON RMVL ANAL SETON OTH MARKER I&D ISCHIORCT&/PRIRCT ABSC SPX I&D INTRAMURAL IM/ABSC TRANSANAL ANES I&D PRIANAL ABSC SUPFC I&D ISCHIORCT/INTRAMURAL ABSC +-SETON INC ANAL SEPTUM INFT SPHNCTROTOMY ANAL DIV SPHNCTR SPX INC THROMBOSED HEMORRHOID XTRNL FISSURECTOMY INCL SPHINCTEROTOMY WHEN PERFORMED # EXCISION SINGLE EXTERNAL PAPILLA OR TAG ANUS HEMORRHOIDECTOMY INTERNAL RUBBER BAND LIGATIONS EXCISION MULTIPLE EXTERNAL PAPILLAE/TAGS ANUS HEMORRHOIDECTOMY XTRNL 2+ COLUMN/GROUP HEMORRHOIDECTOMY NTRNL & XTRNL 1 COLUMN/GROUP HRHC SMPL W/FISSURECTOMY HRHC 1 COL/GRP W/FSTULECTMY INCL FSSRECTOMY HEMORRHOIDECTOMY INT & XTRNL 2+ COLUMN/GROUP HRHC CPLX/X10SV W/FISSURECTOMY HRHC 2+ COL/GRP W/FSTULECTMY INCL FSSRECTMY SURG TX ANAL FSTL SUBQ SURG TX ANAL FISTULA INTERSPHINCTERIC CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

131 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule TX ANAL FSTL TRANS/SUPRA/XTRASPHNCTRC INCL SETON SURG TX ANAL FSTL 2ND STG CLSR ANAL FSTL W/RCT ADVMNT FLAP # EXC THROMBOSED HEMORRHOID XTRNL NJX SCLRSG SLN HEMORRHOIDS CHEMODNRVTJ INT ANAL SPHNCTR ANOSC DX +-COLLJ SPEC BR/WA SPX ANOSC DILAT ANOSC BX 1/MLT ANOSC RMVL FB ANOSC RMVL 1 LES CAUT ANOSC RMVL 1 TUM POLYP/OTH LES SNARE TQ ANOSC RMVL MLT TUMS CAUT/SNARE ANOSC CTRL BLD ANOSC ABLTJ LES ANOPLASTY PLSTC OPRATION STRIX ADLT ANOPLASTY PLSTC OPRATION STRIX INFT RPR ANAL FSTL W/FIBRIN GLUE REPAIR ANORECTAL FISTULA PLUG RPR ILEOANAL POUCH FSTL/POUCH ADVMNT TPRNL APPR RPR ILEOANAL POUCH FSTL/POUCH ADVMNT CMBN APPR RPR LW IMPRF8 ANUS W/ANOPRNL FSTL CUT-BK RPR LW IMPRF8 ANUS W/TRPOS FSTL RPR HI IMPRF8 ANUS W/O FSTL PRNL/SACROPRNL APPR RPR HI IMPRF8 ANUS W/O FSTL CMBN APPR RPR HI IMPRF8 ANUS W/FSTL PRNL/SACROPRNL APPR RPR HI IMPRF8 ANUS W/FSTL TABDL&SACROPRNL RPR CLOACAL ANOMAL SACROPRNL RPR CLOACAL ANOMAL CMBN ABDL&SACROPRNL RPR CLOACAL ANOMAL CMBN ABDL&SACROPRNL W/GRF SPHNCTROP ANAL INCONT/PROLAPSE ADLT SPHNCTROP ANAL INCONT/PROLAPSE CHLD GRF THIERSCH RCT INCONT&/PROLAPSE RMVL THIERSCH WIRE/SUTR ANAL CANAL SPHNCTROP ANAL MUSC TRNSPL SPHNCTROP ANAL LEVATOR MUSC IMBRCJ SPHNCTROP ANAL IMPLTJ ARTIF SPHNCTR DSTRJ LES ANUS SMPL CHEM DSTRJ LES ANUS SMPL ELTRDSICCATION DSTRJ LES ANUS SMPL CRYOSURG DSTRJ LES ANUS SMPL LASER SURG DSTRJ LES ANUS SMPL SURG EXC DSTRJ LES ANUS X10SV DESTRUCTION INTERNAL HEMORRHOID THERMAL ENERGY CURTG/CAUT ANAL FISSURE W/DILAT SPHNCTR SPX 1ST CURTG/CAUT ANAL FISSURE W/DILAT SPHNCTR SPX SBSQ Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 127

132 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, 2011 # HRHC NTRNL LIG OTH THAN RBBR BAND 1 COL/GRP # HRHC NTRNL LIG OTH THAN RBBR BAND 2+ COL/GRP # HEMORRHOIDOPEXY STAPLING UNLIS PX ANUS BR YYY BX LVR NDL PRQ BX LVR NDL DONE PURPOSE TM OTH MAJOR PX ZZZ HEPATOTOMY OPN DRG ABSC/CST 1/2 STGS K HEPATOTOMY PRQ DRG ABSC/CST 1/2 STGS LAPT W/ASPIR&/NJX HEPATC PARASITIC CST/ABSCES BX LVR WEDGE HPTC RESCJ LVR PRTL LOBEC HPTC RESCJ LVR TRISGMECTOMY HPTC RESCJ LVR TOT L LOBEC HPTC RESCJ LVR TOT R LOBEC DON HPTC FROM CDVR DON BR XXX LVR ALTRNSPLJ ORTHOTOPIC PRTL/WHL DON ANY AGE LVR ALTRNSPLJ HTRTPC PRTL/WHL DON ANY AGE DON HPTC LIV DON L LAT SGM ONLY II&III DON HPTC LIV DON TOT L LOBEC II III&IV DON HPTC LIV DON TOT R LOBEC V VI VII&VIII BKBENCH PREPJ CDVR WHL LVR GRF W/O TRISGM/LOBE BR XXX BKBENCH PREPJ CDVR WHL LVR GRF I&IV VIII BR BKBENCH PREPJ CDVR DON WHL LVR GRF I&V VIII BR XXX BKBENCH RCNSTJ LVR GRF VEN ANAST EA XXX BKBENCH RCNSTJ LVR GRF ARTL ANAST EA XXX MARSUPIALIZATION CST/ABSC LVR MGMT LVR HEMRRG SMPL SUTR LVR WND/INJ MGMT LVR HEMRRG CPLX SUTR WND/INJ MGMT LVR HEMRRG EXPL WND DBRDMT COAGJ/SUTR MGMT LVR HEMRRG RE-EXPL WND RMVL PACKING LAPS SURG ABLTJ 1+ LVR TUM RF LAPS SURG ABLTJ 1+ LVR TUM CRYOSURG UNLIS LAPAROSCOPIC PX LVR BR YYY ABLTJ OPN 1+ LVR TUM RF ABLTJ OPN 1+ LVR TUM CRYOSURG K ABLTJ 1+ LVR TUM PRQ RF UNLIS PX LVR BR YYY HEPATCOTOMY/HEPATCOSTOMY W/EXPL DRG/RMVL ST CHOLEDOCHOT/OST W/O SPHNCTROTOMY/SPHNCTROP CHOLEDOCHOT/OST W/SPHNCTROTOMY/SPHNCTROP TRANSDUOL SPHNCTROTOMY/SPHNCTROP +-XTRJ ST1 SPX s CHOLECSTOT/CHOLECSTOST W/EXPL DRG/RMVL ST1 SPX s CHOLECSTOST PRQ W/IMG GID NJX PRQ TRANSHEPATC CHOLANGRPH NJX CHOLANGRPH THRU AN CATH INTRO PRQ TRANSHEPATC CATH BILIARY DRG CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

133 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule INTRO PRQ TRANSHEPATC STENT BILIARY DRG K CHNG PRQ BILIARY DRG CATH REVJ&/RINSJ TRANSHEPATC TUBE BILIARY NDSC INTRAOP ZZZ BILIARY NDSC PRQ T-TUBE DX +-COLLJ SPEC SPX BILIARY NDSC PRQ T-TUBE W/BX 1/MLT BILIARY NDSC PRQ T-TUBE RMVL ST BILIARY NDSC PRQ T-TUBE DILAT STRIX W/O STENT BILIARY NDSC PRQ T-TUBE DILAT STRIX W/STENT LAPS SURG W/GID TRANSHEPATC CHOLANGRPH W/O BX LAPS SURG W/GID TRANSHEPATC CHOLANGRPH W/BX LAPS SURG CHOLECSTC LAPS SURG CHOLECSTC W/CHOLANGRPH LAPS SURG CHOLECSTC W/EXPL COMMON DUX LAPS SURG CHOLECSTONTRSTM UNLIS LAPS PX BILIARY TRC BR YYY CHOLECSTC CHOLECSTC CHOLANGRPH CHOLECSTC EXPL DUX CHOLECSTC EXPL DUX CHOLEDOCHONTRSTM CHOLECSTC EXPL DUX SPHNCTROTOMY/SPHNCTROP BILIARY DUX STONE XTRJ PRQ VIA BASKET/SNARE EXPL CGEN ATRESIA BILE DUXS PORTONTRSTM EXC BILE DUX TUM +-PRIM RPR XTRHEPATC EXC BILE DUX TUM +-PRIM RPR INTRAHEPATC EXC CHOLEDOCHAL CST CHOLECSTONTRSTM DIR CHOLECSTONTRSTM W/GASTRONTRSTM CHOLECSTONTRSTM ROUX-EN-Y CHOLECSTONTRSTM ROUX-EN-Y W/GASTRONTRSTM ANAST XTRHEPATC BILIARY DUXS&GI ANAST INTRAHEPATC DUXS&GI ANAST ROUX-EN-Y XTRHEPATC BILIARY DUXS&GI ANAST ROUX-EN-Y INTRAHEPATC BILIARY DUXS&GI RCNSTJ PLSTC BILIARY DUXS W/END-TO-END ANAST PLMT CHOLEDOCHAL STENT U-TUBE HEPATCONTRSTM SUTURE EXTRAHEPATIC BILE DUCT PRE-EXIST INJURY UNLIS PX BILIARY TRC BR YYY PLACE DRAIN PERIPANCREATIC ACUTE PANCREATITIS PLACE DRAIN PERIPANCREATIC W/CHOLECYSTOSTOMY RMVL PNCRTC ST BX PNCRS OPN BX PNCRS PRQ NDL RESECJ/DBRDMT PANCREAS NECROTIZING PANCREATITIS Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 129

134 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, EXC LES PNCRS PNCRTECT DSTL STOT W/O PNCRTCOJEJUNOSTOMY PNCRTECT DSTL STOT W/PNCRTCOJEJUNOSTOMY PNCRTECT DSTL NR-TOT W/PRSRV DUO CHLD-TYP PX EXC AMPULLA VATER PNCRTECT PROX STOT W/PANCREATOJEJUNOSTOMY PNCRTECT WHIPPLE W/O PANCREATOJEJUNOSTOMY PNCRTECT W/PANCREATOJEJUNOSTOMY PNCRTECT PROX STOT W/O PANCREATOJEJUNOSTOMY PNCRTECT TOT PNCRTECT TOT/STOT W/TRNSPLJ PNCRS/ISLET XXX INJECTION INTRAOPERATIVE PANCREATOGRAPHY ZZZ MARSUPIALIZATION PNCRTC CST XTRNL DRG PSEUDOCST PNCRS OPN K XTRNL DRG PSEUDOCST PNCRS PRQ INT ANAST PNCRTC CST GI TRC DIR INT ANAST PNCRTC CST GI TRC ROUX-EN-Y PANCREATORRHAPHY INJ DUOL EXCLUSION W/GASTROJEJUNOSTOMY PNCRTC INJ PANCREATICOJEJUNOSTOMY SIDE-TO-SIDE ANAST DONOR PANCREATECTOMY DUODENAL SGM TRANSPLANT BR XXX BKBENCH PREPJ CDVR PNCRS ALGRFT BR XXX BKBENCH RCNSTJ CDVR PNCRS ALGRFT VEN ANAST EA XXX TRNSPLJ PNCRTC ALGRFT RMVL TRNSPLED PNCRTC ALGRFT UNLIS PX PNCRS BR YYY EXPL LAPT EXPL CELIOTOMY +-BX SPX REOPNG RECENT LAPT EXPL RPR AREA +-BX SPX DRG PRTL ABSC/LOCLZD PRITONITIS OPN K DRG PRTL ABSC/LOCLZD PRITONITIS PRQ DRG SUBDIPHRG/SUBPHRENIC ABSC OPN K DRG SUBDIPHRG/SUBPHRENIC ABSC PRQ DRG RPR ABSC OPN K DRG RPR ABSC PRQ DRG XTRPRTL LYMPHOCELE PRTL CAVITY OPN PRITONEOCNTS ABDL PCNTS/PRTL LVG 1ST PRITONEOCNTS ABDL PCNTS/PRTL LVG SBSQ BX ABDL/RPR MASS PRQ NDL EXCISION/DESTRUCTION OPEN ABDOMINAL TUMORS 5 CM EXC/DESTRUCTION OPEN ABDMNL TUMORS CM EXC/DESTRUCTION OPEN ABDOMINAL TUMORS >10.0 CM EXC PRESAC/SACROCOCCYGEAL TUM STAGING LAPAROTOMY HODGKINS DISEASE/LYMPHOMA UMBILECTOMY OMPHALECTOMY EXC UMBILICUS SPX OMNTC EPIPLOECTOMY RESCJ OMENTUM SPX CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

135 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule LAPS ABD PRTM&OMENTUM DX +-SPEC BR/WA SPX LAPS SURG W/BX 1/MLT LAPS SURG W/ASPIR CAVITY/CST 1/MLT LAPS SURG W/DRG LYMPHOCELE PRTL CAVITY s LAPS INSERTION TUNNELED INTRAPERITONEAL CATHETER LAPS W/REVISION INTRAPERITONEAL CATHETER LAPS W/OMENTOPEXY ZZZ l LAPS W/INSERTION NTRSTL DEV W/IMG GID ZZZ UNLIS LAPS PX ABD PRTM&OMENTUM BR YYY NJX AIR/CNTRST IN PRTL CAVITY SPX REMOVAL PERITONEAL FOREIGN BODY FROM CAVITY K INTERSTITIAL DEV PLMT RADIATION THERAPY 1/MLT l PLMT INTRSTL DEV OPN W/IMG GID ZZZ l K INSJ INTRAPERITONEAL CATHETER W/IMG GID s INSERTION TUNNEL INTRAPERITONEAL CATH SUBQ PORT s INSERTION TUNNEL INTRAPERITONEAL CATH DIAL OPEN s REMOVAL TUNNELED INTRAPERITONEAL CATHETER EXCHNG ABSC/CST DRG CATH RAD GID SPX CNTRST NJX ASSMT ABSC/CST VIA DRG CATH/TUBE SPX INSJ PRTL-VEN SHUNT REVJ PRTL-VEN SHUNT INJECT EVALUATE PREVIOUS PERITONEAL-VENOUS SHUNT LIG PRTL-VEN SHUNT RMVL PRTL-VEN SHUNT INSJ SUBQ EXTENSION INTRAPERITONEAL CATHETER ZZZ DELAYED CREATION EXIT SITE EMBEDDED CATHETER K INSERT GASTROSTOMY TUBE PERCUTANEOUS K INSERT DUODENOSTOMY/JEJUNOSTOMY TUBE PERQ K INSERT CECOSTOMY/OTHER COLONIC TUBE PERCUTANEOUS K CONVERT GASTROSTOMY-GASTRO-JEJUNOSTOMY TUBE PERQ REPLACE GASTROSTOMY/CECOSTOMY TUBE PERCUTANEOUS REPLACE DUODENOSTOMY/JEJUNOSTOMY TUBE PERQ REPLACEMENT GASTRO-JEJUNOSTOMY TUBE PERCUTANEOUS OBSTRUCTIVE MATERIAL REMOVAL FROM GI TUBE CONTRAST INJECTION PERQ RADIOLOGIC EVAL GI TUBE RPR 1ST INGUN HRNA PRETERM INFT RDC RPR 1ST INGUN HRNA PRETERM INFT NCRC RPR 1ST INGUN HRNA FULL TERM INFT<6 MO RDC RPR 1ST INGUN HRNA FULL TERM INFT<6 MO NCRC RPR 1ST INGUN HRNA AGE 6 MO-5 YRS RDC RPR 1ST INGUN HRNA AGE 6 MO-5 YRS NCRC RPR 1ST INGUN HRNA AGE 5 YRS/> REDUCIBLE RPR 1ST INGUN HRNA AGE 5 YRS/> NCRC RPR RECRT INGUN HRNA ANY AGE RDC RPR RECRT INGUN HRNA ANY AGE NCRC RPR INGUN HRNA SLIDING ANY AGE Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 131

136 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, RPR LMBR HRNA RPR 1ST FEM HRNA ANY AGE RDC RPR 1ST FEM HRNA ANY AGE NCRC RPR RECRT FEM HRNA RDC RPR RECRT FEM HRNA NCRC REPAIR FIRST ABDOMINAL WALL HERNIA RPR 1ST INCAL/VNT HRNA NCRC RPR RECRT INCAL/VNT HRNA RDC RPR RECRT INCAL/VNT HRNA NCRC IMPLANT MESH OPN HERNIA RPR/DEBRIDEMENT CLOSURE ZZZ RPR EPIGSTR HRNA RDC SPX RPR EPIGSTR HRNA NCRC RPR UMBILICAL HRNA < 5 YRS RDC RPR UMBILICAL HRNA <5 YRS NCRC RPR UMBILICAL HRNA 5 YRS/> RDC RPR UMBILICAL HRNA AGE 5 YRS/> NCRC RPR SPIGELIAN HRNA RPR SM OMPHALOCELE W/PRIM CLSR RPR LG OMPHALOCELE/GASTROSCHISIS +-PROSTH RPR LG OMPHALOCELE/GASTROSCHISIS RMVL PROSTH RPR OMPHALOCELE GROSS TYP OPRATION 1ST STG RPR OMPHALOCELE GROSS TYP OPRATION 2ND STG LAPS SURG RPR 1ST INGUN HRNA LAPS SURG RPR RECRT INGUN HRNA LAPS REPAIR HERNIA EXCEPT INCAL/INGUN REDUCIBLE LAP RPR HRNA XCPT INCAL/INGUN NCRC8/STRANGULATED LAPAROSCOPY REPAIR INCISIONAL HERNIA REDUCIBLE LAPS RPR INCISIONAL HERNIA NCRC8/STRANGULATED LAPS RPR RECURRENT INCISIONAL HERNIA REDUCIBLE LAPS RPR RECURRENT INCAL HRNA NCRC8/STRANGULATED UNLIS LAPS PX HRNAP HERNIORRHAPHY HERNIOTOMY BR YYY SEC ABDOMINAL WALL SUTURE EVISCERATION/DEHSN OMENTAL FLAP XTR-ABDL OMENTAL FLAP INTRA-ABDL ZZZ FR OMENTAL FLAP W/MVASC ANAST BR UNLIS PX ABD PRTM&OMENTUM BR YYY RNL EXPL X NECESSITATING OTH SPEC PX DRG PRIRNL/RNL ABSC OPN K DRG PRIRNL/RNL ABSC PRQ NFROS NFROT W/DRG NFROT W/EXPL NEPHROLITHOTOMY RMVL ST NEPHROLITHOTOMY SECONDARY FOR CALCULUS NEPHROLITHOTOMY COMP CGEN KDN ABNORMALITY NEPHROLITHOTOMY RMVL LG STAGHORN ST PRQ NEPHROSTOLITHOTOMY/PYELOSTOLITHOTOMY UP 2 CM CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

137 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule PRQ NEPHROSTOLITHOTOMY/PYELOSTOLITHOTOMY > 2 CM TRNSXJ/RPSG ABERRANT RNL VSL SPX PLOT W/EXPL PLOT W/DRG PYELOSTOMY PLOT W/RMVL ST PLOT COMP K RNL BX PRQ TROCAR/NDL RNL BX SURG EXPOS KDN NFRCT W/PRTL URTREC ANY OPN RIB RESCJ NFRCT W/PRTL URTREC ANY OPN RIB RESCJ COMP NFRCT W/PRTL URTREC ANY OPN RIB RESCJ RAD NFRCT W/TOT URTREC&BLDR CUFF THRU SM INC NFRCT TOT URTREC&BLDR CUFF THRU SEP INC NFRCT PRTL s OPEN ABLATION RENAL MASS CRYOSURG ULTRASOUND EXC/UNROOFING CST KDN EXC PRINEPHRIC CST DON NFRCT FROM CDVR DON UNI/BI BR XXX DON NFRCT OPN FROM LIV DON BKBENCH PREPJ CDVR RNL ALGRFT BR XXX BKBENCH PREPJ LIV RNL ALGRFT OPN/LAPS BR XXX BKBENCH RCNSTJ RNL ALGRFT VEN ANAST EA XXX BKBENCH RCNSTJ RNL ALGRFT ARTL ANAST EA XXX BKBENCH RCNSTJ ALGRFT URTRL ANAST EA XXX RCP NFRCT SPX RNL ALTRNSPLJ IMPLTJ GRF W/O RCP NFRCT RNL ALTRNSPLJ IMPLTJ GRF W/RCP NFRCT RMVL TRNSPLED RNL ALGRFT RNL AUTOTRNSPLJ RIMPLTJ KDN K RMVL&RPLCMT INTLY DWELLING URTRL STENT K RMVL INTLY DWELLING URTRL STENT K REMOVE & REPLACE INT DWELL URETERAL STENT TRURL K REMOVE INT DWELL URETERAL STENT TRANSURETHRAL K RMVL&RPLCMT XTRNLLY ACCESSIBLE URTRL STENT RMVL NFROS TUBE REQ FLUOR GID ASPIR&/NJX RNL CST/PELVIS NDL PRQ INSTLJ AGT RNL PELVIS&/URTR THRU TUBE INTRO INTRACATH/CATH IN RNL PELVIS DRG&/NJX PRQ INTRO URTRL CATH/STENT THRU PELVIS DRG&/NJX PRQ NJX PX PLOG THRU TUBE/CATH INTRO GD PELVIS&/URTR W/DILAT NFROS TRC MANOMETRIC STDS THRU TUBE/NDWELLG URTRL CATH CHNG NFROS/PYELOSTOMY TUBE PLOP RNL PELVIS SMPL PLOP RNL PELVIS COMP NEPHRORRHAPHY SUTR KDN WND/INJ Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 133

138 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, CLSR NEPHROCUTAN/PYELOCUTAN FSTL CLSR NEPHROVISC FSTL W/VISC RPR ABDL APPR CLSR NEPHROVISC FSTL W/VISC RPR THRC APPR SYMPHYSIOTOMY HORSESHOE KDN +-PLOP UNI/BI LAPS ABLTJ RNL CSTS s LAPS ABLTJ RNL MASS LES W/INTRAOP US LAPS PRTL NFRCT LAPS PLOP LAPS RADICAL NFRCT LAPS NFRCT W/PRTL URTREC LAPS DON NFRCT FROM LIV DON LAPS NFRCT W/TOT URTREC UNLIS LAPS PX RNL BR YYY RNL NDSC NFROS/PYELOSTOMY RNL NDSC NFROS/PYELOSTOMY URTRL CATHJ RNL NDSC NFROS/PYELOSTOMY BX RNL NDSC NFROS/PYELOSTOMY FULG&/INC +-BX RNL NDSC NFROS/PYELOSTOMY RMVL FB/ST RNL NDSC NFROS/PYELOSTOMY RESCJ TUM RNL NDSC NFROT/PLOT RNL NDSC NFROT/PLOT W/URTRL CATHJ +-DILAT URTR RNL NDSC NFROT/PLOT BX RNL NDSC NFROT/PLOT W/ENDOPLOT RNL NDSC NFROT FULGURATION&/INC +-BX RNL NDSC NFROT/PLOT W/RMVL FB/ST LITHOTRP XTRCORP SHOCK WAVE K ABLTJ 1+ RNL TUM PRQ UNI RF K ABLATION RENAL TUMOR UNILATERAL PERQ CRYOTHERAPY URTROTOMY W/EXPL/DRG SPX URETEROTOMY INSERTION INDWELLING STENT ALL TYPES URTROLITHOTOMY UPPER ONE-THIRD URETER URTROLITHOTOMY MIDDLE ONE-THIRD URETER URTROLITHOTOMY LOWER ONE-THIRD URETER URTREC W/BLDR CUFF SPX URTREC TOT ECTOPIC URTR CMBN APPR NJX URTRG/URTROPLOG THRU URTROST/URTRL CATH MANOMETRIC STDS THRU URTROST/NDWELLG URTRL CATH CHNG URTROST TUBE/XTRNLLY ACCESSIBLE STENT ILEAL NJX VISUALIZATION ILEAL CONDUIT&/URTROPLOG URTROPLASTY PLSTC OPRATION URTR URTROLSS +-RPSG URTR RPR FIBROSIS URETEROLYSIS FOR OVARIAN VEIN SYNDROME URTROLSS RETROCAVAL URTR W/REANAST REVJ UR-CUTAN ANAST REVJ UR-CUTAN ANAST RPR FSCAL DFCT&HRNA URTROPYELOSTOMY ANAST URTR&RNL PELVIS CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

139 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule URTROCALYCOSTOMY ANAST URTR RNL CALYX URTROURTROST TRANSURTROURTROST ANAST URTR CLAT URTR URTRONEOCSTOST ANAST 1 URTR BLDR URTRONEOCSTOST ANAST DUPLICATED URTR BLDR URTRONEOCSTOST W/X10SV URTRL TAILORING URTRONEOCSTOST W/VESICO-PSOAS HITCH/BLDR FLAP URTRONTRSTM DIR ANAST URTR INT URTROSIGMOIDOSTOMY CRTJ CLST INT ANAST URTROCOLON CONDUIT INT ANAST URTROILEAL CONDUIT W/INT ANAST CONTINENT DVRJ W/INT ANAST W/ANY SGM SM&/LG INT UR UNDVRJ RPLCMT ALL/PART URTR INT SGM W/INT ANAST CUTAN APPENDICO-VESICOSTOMY URTROST TRNSPLJ URTR SKN URTRORRHAPHY SUTR URTR SPX CLSR URTROCUTAN FSTL CLSR URTROVISC FSTL W/VISC RPR DELIG URTR LAPS URTROLITHOTOMY LAPS URTRONEOCSTOST W/CSTSC&URTRL STENT PLMT LAPS URTRONEOCSTOST W/O CSTSC&URTRL STENT PLMT UNLIS LAPS PX URTR BR YYY NDSC THRU URTROST NDSC URTROST W/URTRL CATHJ NDSC THRU URTROST BX NDSC THRU URTROST FULG&/INC +-BX NDSC THRU URTROST RMVL FB/ST NDSC THRU URTROTOMY NDSC THRU URTROTOMY URTRL CATHJ +-DILAT NDSC THRU URTROTOMY BX NDSC THRU URTROTOMY FULG&/INC +-BX NDSC THRU URTROTOMY RMVL FB/ST CSTOTOMY/CSTOST FULG&/INSJ RADACT MATRL CSTOTOMY/CSTOST CRYOSURG DSTRJ INTRAVESICAL LES CSTOST CSTOTOMY W/DRG CSTOTOMY W/INSJ URTRL CATH/STENT SPX CSTOLITHOTOMY CSTOTOMY W/RMVL ST TRANSVESICAL URTROLITHOTOMY CSTOTOMY W/ST1 BASKET XTRJ&/FRAGMENTATION DRG PRIVESICAL/PREVESICAL SPACE ABSC ASPIRATION BLADDER NEEDLE ASPIRATION BLADDER TROCAR/INTRACATHETER ASPIRATION BLADDER INSERT SUPRAPUBIC CATHETER EXC URACHAL CST/SINUS +-UMBILICAL HRNA RPR Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 135

140 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, CYSTOTOMY SIMPLE EXCISION VESICAL NECK CYSTOTOMY EXCISE BLADDER DIVERTICULUM 1/MULTIPLE CYSTOTOMY EXCISION BLADDER TUMOR CYSTOTOMY EXCISE/INCISE/REPAIR URETEROCELE CSTC PRTL SMPL CSTC PRTL COMP CSTC PRTL W/RIMPLTJ URTR IN BLDR URTRONEOCSTOST CSTC COMPL SPX CSTC COMPL W/BI PEL LMPHADEC CSTC COMPL W/TRNSPLJS CSTC COMPL W/TRNSPLJS W/LMPHADEC CSTC COMPL W/URTROILEAL CONDUIT/BLDR W/INT ANAST CSTC COMPL W/CONDUIT/SIGMOID BLDR PEL LMPHADEC CSTC COMPL W/CONTINENT DVRJ OPN NEOBLDR PEL EXNTJ COMPL MAL NJX CSTOGRAPY/VOIDING URETHROCSTOGRAPY NJX&PLMT CHAIN C+&/URETHROCSTOGRAPY NJX RTRGR URETHROCSTOGRAPY BLDR IRRIGATION SMPL LVG&/INSTLJ INSJ NON-NDWELLG BLDR CATH INSJ TEMP NDWELLG BLDR CATH SMPL INSJ TEMP NDWELLG BLDR CATH COMP CHNG CSTOST TUBE SMPL CHNG CSTOST TUBE COMP NDSC NJX IMPLT MATRL URT&/BLDR NCK BLDR INSTLJ ANTICARCINOGENIC AGT SMPL CSTOMETROGRAM SMPL CSTOMETROGRAM TC SMPL CSTOMETROGRAM BLADDER PRESSURE MEASUREMENT DURING FILLING BLADDER PRESSURE MEASUREMENT DURING FILLING TC BLADDER PRESSURE MEASUREMENT DURING FILLING COMPLEX CYSTOMETROGRAM URETHRAL PRESS PROFILE COMPLEX CYSTOMETROGRAM URETHRAL PRESS PROFILE TC COMPLEX CYSTOMETROGRAM URETHRAL PRESS PROFILE COMPLEX CYSTOMETROGRAM VOIDING PRESSURE STUDIES COMPLEX CYSTOMETROGRAM VOIDING PRESSURE STUDIES TC COMPLEX CYSTOMETROGRAM VOIDING PRESSURE STUDIES COMPLX CYSTOMETRO W/VOID PRESS&URETHRAL PROFILE COMPLX CYSTOMETRO W/VOID PRESS&URETHRAL PROFILE TC COMPLX CYSTOMETRO W/VOID PRESS&URETHRAL PROFILE SMPL UROFLOMETRY XXX SMPL UROFLOMETRY XXX TC SMPL UROFLOMETRY XXX CPLX UROFLOMETRY XXX CPLX UROFLOMETRY XXX 136 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

141 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule TC CPLX UROFLOMETRY XXX EMG STDS ANAL/URTL SPHNCTR OTH/THN NDL EMG STDS ANAL/URTL SPHNCTR OTH/THN NDL TC EMG STDS ANAL/URTL SPHNCTR OTH/THN NDL NDL EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ NDL EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ TC NDL EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ STIMULUS EVOKED RSPSE STIMULUS EVOKED RSPSE TC STIMULUS EVOKED RSPSE # VOID PRESSURE STUDIES INTRAABDOMINAL ZZZ + # VOID PRESSURE STUDIES INTRAABDOMINAL ZZZ + # TC VOID PRESSURE STUDIES INTRAABDOMINAL ZZZ MEAS POST-VOIDING RESIDUAL URINE&/BLDR CAP XXX CSTOPLASTY/CSTOURTP PLSTC ANY CSTOURTP W/UNI/BI URTRONEOCSTOST ANT VESICOURETHROPEXY/URETHROPEXY SMPL ANT VESICOURETHROPEXY/URETHROPEXY COMP ABDOMINO-VAG VESICAL NCK SSP +-NDSC CTRL CSTORR SUTR BLDR WND INJ/RPT SMPL CSTORR SUTR BLDR WND INJ/RPT COMP CLSR CSTOST SPX CLSR VESICOVAG FSTL ABDL APPR CLSR VESICOUTERINE FSTL CLSR VESICOUTERINE FSTL W/HYST CLSR EXSTROPHY BLDR ENTEROCSTOPLASTY W/INTSTINAL ANAST CUTAN VESICOSTOMY LAPAROSCOPY URETHRAL SUSPENSION STRESS INCONT LAPAROSCOPY SLING OPERATION STRESS INCONT UNLIS LAPS PX BLDR BR YYY CYSTOURETHROSCOPY CSTO W/IRRG&EVAC MLT OBSTRUCTING CLOTS SCOPE BLADDER INSERT TUBE FOR INJECTION CSTO W/URTRL CATHJ BRUSH BX URTR&/RNL PELVIS CSTO W/EJACULATORY DUX CATHJ CYSTOURETHROSCOPY WITH BIOPSY SCOPE BLADDER DESTRUCTION OF LESIONS SCOPE BLADDER REMOVAL OF LESIONS SMALL SCOPE BLADDER REMOVAL OF TUMORS SMALL SCOPE BLADDER REMOVAL OF TUMORS MEDIUM SCOPE BLADDER W/ REMOVAL OF TUMORS LARGE CSTO INSJ RADACT SBST +-BX/FULG SCOPE BLADDER OPENING OF BLADDER CYSTO BLADDER DILAT INTRSTL CYSTITIS LOCAL CSTO INT URETHROTOMY FEMALE Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 137

142 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, CSTO INT URETHROTOMY MALE CSTO DIR VIS INT URETHROTOMY CSTO RESCJ XTRNL SPHNCTR CSTO CALIBRATION DILAT URTL STRIX/STENOSIS CYSTOURETHROSCOPY INSERTION PERM URETHRAL STENT CSTO STRD NJX IN STRIX SCOPE BLADDER OPEN NARROWED FEMALE URETHRA CSTO URTRL MEATOTOMY UNI/BI CSTO ORTHOTOPIC URTROCELE UNI/BI CSTO ECTOPIC URTROCELE UNI/BI CSTO INC/RESCJ ORIFICE BLDR DIVERTICULUM 1/MLT SCOPE BLADDER W/SIMPLE REMOVAL STONE & STENT SCOPE BLADDER W/COMPLEX REMOVAL STONE & STENT LITHOLAPAXY SMPL/SM < 2.5 CM LITHOLAPAXY COMP/LG > 2.5 CM CSTO RMVL URTRL ST CSTO FRAGMENTATION URTRL ST CSTO W/SUBURTRIC NJX IMPLT MATRL CSTO MNPJ W/O RMVL URTRL ST SCOPE BLADDER & URETER INSERT STENT INTO URETER CSTO INSJ URTRL GD WIRE PRQ NFROS RTRGR CSTO W/TX URTRL STRIX CSTO W/TX URTROPEL JUNCT STRIX CSTO W/TX INTRA-RNL STRIX CSTO W/URTROSCOPY W/TX URTRL STRIX CSTO W/URTROSCOPY W/TX URTROPEL JUNCT STRIX CSTO W/URTROSCOPY W/TX INTRA-RNL STRIX CSTO W/URTROSCOPY&/PYELOSCOPY DX SCOPE BLADDER & URETER REMOVE OR MOVE STONES SCOPE BLADDER & URETER BREAK UP KIDNEY STONE CSTO/PYELOSCOPY BX&/FULG PEL LES CSTO/PYELOSCOPY RESCJ PEL TUM CSTO INC FULG/RESCJ URTL VALVES/FOLDS CSTO W/TRURL RESCJ/INC EJACULATORY DUXS TRURL INC PRST SURGERY ON BLADDER NECK THROUGH URETHRA TRURL ELECTROSURG RESCJ PRST8 CTRL BLD COMPL TRURL RESCJ RESIDUAL/REGROWTH OBSTR PRST8 TISSUE OPENING OF POSTOPERATIVE BLADDER NECK NARROWING LASER COAGULATION OF PROSTATE FOR URINE FLOW LASER VAPORIZATION OF PROSTATE FOR URINE FLOW LASER ENUCLEATION PROSTATE W MORCELLATION TRURL DRG PROSTATIC ABSC URTT/URTS XTRNL SPX PENDULOUS URT URTT/URTS XTRNL SPX PRNL URT XTRNL MEATOTOMY CUTTING MEATUS SPX XCP INFT CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

143 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule MEATOTOMY CUTTING MEATUS SPX INFT DRG DP PRIURTL ABSC DRG OF SKENE'S GLAND ABSC OR CYST DRG PRNL UR XTRVASATION UNCOMP SPX DRG PRNL UR XTRVASATION COMP BX URT URETHRECTOMY TOT W/CSTOST FEMALE URETHRECTOMY TOT W/CSTOST MALE EXC/FULGURATION CARC URT EXC URTL DIVERTICULUM SPX FEMALE EXC URTL DIVERTICULUM SPX MALE MARSUPIALIZATION URTL DIVERTICULUM MALE/FEMALE EXC OF BULBOURTL GLAND EXC/FULGURATION URTL POLYP DSTL URT EXC/FULGURATION URTL CARUNCLE EXC OR FULGURATION SKENE'S GLANDS EXC/FULGURATION URTL PROLAPSE URETHROPLASTY 1ST STG FISTULA/DIVERTICULUM/STRIX URTP 2ND STG W/UR DVRJ URTP ONE-STG RCNSTJ MALE ANT URT URTP TRANSPUBIC/PRNL 1 STG RCNSTJ/RPR URT URTP 2-STG RCNSTJ/RPR URT 1ST STG URTP 2-STG RCNSTJ/RPR URT 2ND STG URTP RCNSTJ FEMALE URT URTP W/TUBULARIZATION POST URT&/LWR BLDR SLING OPRATION CORRJ MALE UR INCONT RMVL/REVJ SLING MALE UR INCONT INSJ TANDEM CUFF INSJ NFLTBL URTL/BLDR NCK SPHNCTR RMVL NFLTBL URTL/BLDR NCK SPHNCTR RMVL&RPLCMT NFLTBL NCK SPHNCTR SM SESS RMVL&RPLCMT NFLTBL NCK SPHNCTR THRU INFCT FLD RPR NFLTBL URTL/BLDR NCK SPHNCTR URETHROMEATOPLASTY W/MUCOSAL ADVMNT URETHROMEATOPLASTY W/PRTL EXC DSTL URTL SGM URETHROLSS TRVG SEC OPN W/CSTO URTORR SUTR URTL WND/INJ FEMALE URTORR SUTR URTL WND/INJ PEN URTORR SUTR URTL WND/INJ PRNL URTORR SUTR URTL WND/INJ PROSTATOMEMBRANOUS CLSR URETHROSTOMY/URETHROQ FSTL MALE SPX DILAT URTL STRIX DILATOR MALE 1ST DILAT URTL STRIX DILATOR MALE SBSQ DILAT URTL STRIX/VESICAL NCK DILATOR MALE ANES DILAT URTL STRIX FILIFORM&FOLLWR MALE 1ST DILAT URTL STRIX FILIFORM&FOLLWR MALE SBSQ Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 139

144 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, DILAT FEMALE URT W/SUPPOSITORY&/INSTLJ 1ST DILAT FEMALE URT W/SUPPOSITORY&/INSTLJ SBSQ DILAT FEMALE URT GENERAL/CNDJ SPI ANES TRURL DSTRJ PRST8 TISS MICROWAVE THERMOTH TRURL DSTRJ PRST8 TISS RF THERMOTH INSERT TEMP PROSTATIC URETH STENT W/MEASUREMENT l TRURL RF FEMALE BLADDER NECK STRS URIN INCONT UNLIS PX UR SYS BR YYY SLITTING PREPUCE DORSAL/LAT SPX NB SLITTING PREPUCE DORSAL/LAT SPX XCP NB I&D PNS DP DSTRJ LES PNS SMPL CHEM DSTRJ LES PNS SMPL ELTRDSICCATION DSTRJ LES PNS SMPL CRYOSURG DSTRJ LES PNS SMPL LASER SURG DSTRJ LES PNS SMPL SURG EXC DSTRJ LES PNS X10SV BX PNS SPX BX PNS DP STRUXS EXC PEN PLAQUE EXC PEN PLAQUE GRF 5 CM LENGTH EXC PEN PLAQUE GRF > 5 CM LENGTH RMVL FB FROM DP PEN TISS AMP PNS PRTL AMP PNS COMPL AMP PNS RAD W/BI INGUINOFEM LMPHADEC AMP PNS RAD BI PEL LMPHADEC CIRCUMCISION W/CLAMP/OTH DEV W/BLOCK CIRCUMCISION NEONATE CIRCUMCISION >28 DAYS LSS/EXC PEN POST-CIRCUMCISION ADS RPR INCOMPL CIRCUMCISION FRENULOTOMY PNS NJX PEYRONIE NJX PEYRONIE EXPOS PLAQUE IRRIGATION CORPORA CAVERNOSA PRIAPISM INJECTION CORPORA CAVERNOSOGRAPY DYNAMIC CAVERNOSOMETRY NJX VASOACTIVE DRUGS NJX C/P/A CAVERNOSA W/PHARMACOLOGIC AGT PEN PLETHYSMOGRAPY PEN PLETHYSMOGRAPY TC PEN PLETHYSMOGRAPY NOCTURNAL PEN TUMESCENCE&/RGDITY TST NOCTURNAL PEN TUMESCENCE&/RGDITY TST TC NOCTURNAL PEN TUMESCENCE&/RGDITY TST PNS STRAIGHTENING CHORDEE CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

145 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule PNS CORRJ CHORDEE 1ST STG HYPSPAD RPR URTP 2ND STG HYPSPAD RPR < 3 CM URTP 2ND STG HYPSPAD RPR > 3 CM URTP 2ND STG HYPSPAD RPR SKN GRF URTP 3RD STG HYPSPAD RPR RLS PNS STG DSTL HYPSPAD RPR W/SMPL MEATAL ADVMNT STG DSTL HYPSPAD RPR W/URTP SKN FLAPS STG DSTL HYPSPAD RPR URTP SKN FLAPS&MOBLJ STG DSTL HYPSPAD RPR W/X10SV DSJ STG PROX PEN/PENOSCROTAL HYPSPAD RPR STG PRNL HYPSPAD RPR REQ X10SV DSJ SKN GRF RPR HYPSPAD COMPLCTJS CLSR INC/EXC SMPL RPR HYPSPAD COMPLCTJS MOBLJ FLAPS&URTP RPR HYPSPAD COMPLCTJS X10SV DSJ&URTP FLAP/GRF RPR HYPSPAD CRIPPLE REQ X10SV DSJ&EXC PLSTC PNS CORRECT ANGULATION PLSTC PNS EPSPAD DSTL SPHNCTR PLSTC PNS EPSPAD DSTL SPHNCTR W/INCONT PLSTC PNS EPSPAD DSTL SPHNCTR W/EXSTROPHY BLDR INSJ PEN PROSTH NON-NFLTBL SEMI-RGD INSJ PEN PROSTH NFLTBL SELF-CONTAINED INSJ MULTI-COMPONENT NFLTBL PEN PROSTH RMVL NFLTBL PEN PROSTH W/O RPLCMT PROSTH RPR COMPONENT MULTI-COMPONENT NFLTBL PEN PROSTH RMVL&RPLCMT NFLTBL PEN PROSTH SM SESS RMVL&RPLCMT NFLTBL PEN PROSTH THRU INFCT FLD RMVL NON-NFLTBL/NFLTBL PEN PROSTH W/O RPLCMT RMVL&RPLCMT NON-NFLTBL/NFLTBL PROSTH SM SESS RMVL&RPLCMT NON-NFLTBL/NFLTBL PEN INFCT SM SESS C/P/A CAVERNOSA-SAPHENOUS VEIN SHUNT UNI/BI C/P/A CAVERNOSA-CORPUS SPONGIOSUM SHUNT UNI/BI CORPORA CAVERNOSA-GLANS PENIS FSTLJ PRIAPISM PLASTIC OPERATION PENIS INJURY FORESKN MNPJ W/LSS PREPUTIAL ADS&STRETCHING BX TSTIS NDL SPX BX TSTIS INCAL SPX EXC XTRPARENCHYMAL LES TSTIS ORCHIECTOMY SMPL SCROTAL/INGUN APPR ORCHIECTOMY PRTL ORCHIECTOMY RAD TUM INGUN APPR ORCHIECTOMY RAD TUM W/ABDL EXPL EXPL UNDESCENDED TSTIS INGUN/SCROTAL AREA EXPL UNDESCENDED TSTIS W/ABDL EXPL RDCTJ TORSION TSTIS +-FIXJ CLAT TSTIS FIXJ CLAT TSTIS SPX ORCHIOPEXY INGUN APPR +-HRNA RPR Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 141

146 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, ORCHIOPEXY ABDL APPR INTRA-ABDL TSTIS INSJ TSTICULAR PROSTH SPX SUTR/RPR TSTICULAR INJ TRNSPLJ TSTIS THI LAPAROSCOPY SURGICAL ORCHIECTOMY LAPAROSCOPY ORCHIOPEXY INTRA-ABDOMINAL TESTIS UNLIS LAPS PX TSTIS BR YYY I&D EPIDIDYMIS TSTIS&/SCROTAL SPACE BX EPIDIDYMIS NDL EXC LOCAL LES EPIDIDYMIS EXC SPRMATOCELE +-EPIDIDYMECTOMY EPIDIDYMECTOMY UNI EPIDIDYMECTOMY BI EXPLORATION EPIDIDYMIS W/WO BIOPSY EPIDIDYMOVASOSTOMY ANAST EPIDIDYMIS UNI EPIDIDYMOVASOSTOMY ANAST EPIDIDYMIS BI PNXR ASPIR HYDROCELE TUNICA VAGIS +-NJX MED EXC HYDROCELE UNI EXC HYDROCELE BI RPR TUNICA VAGIS HYDROCELE BOTTLE TYP DRG SCROTAL WALL ABSC SCROTAL EXPL RMVL FB SCROTUM RESCJ SCROTUM SCROTOPLASTY SMPL SCROTOPLASTY COMP VASOTOMY CANNULIZATION +-INC VAS UNI/BI SPX VASECT UNI/BI SPX W/PO SEMEN XM VASOTOMY VASOGRAMS UNI/BI VASOVASOSTOMY VASOVASORRHAPHY LIG PRQ VAS DEFERENS UNI/BI SPX EXC HYDROCELE SPRMATIC CORD UNI SPX EXC LES SPRMATIC CORD SPX EXC VARICOCELE/LIG SPRMATIC VEINS SPX EXC VARICOCELE/LIG SPRMATIC VEINS ABDL EXC VARICOCELE/LIG VEINS W/HRNA RPR LAPS LIG SPRMATIC VEINS VARICOCELE UNLIS LAPS SPRMATIC CORD BR YYY VESICULOTOMY VESICULOTOMY COMP VESICULECTOMY ANY APPR EXC MULLERIAN DUX CST PROSTATE NEEDLE BIOPSY ANY APPROACH BX PRST8 INCAL ANY APPR BX PROSTATE STRTCTC SATURATION SAMPLING IMG GID PROSTATOTOMY XTRNL DRG ABSC SMPL CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

147 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule PROSTATOTOMY XTRNL DRG ABSC COMP PRST8ECT PRNL STOT PRST8ECT PRNL RAD PRST8ECT PRNL RAD LYMPH NODE BX PRST8ECT PRNL RAD BI PEL LMPHADEC PRST8ECT SUPRAPUBIC STOT 1/2 STGS PRST8ECT RETROPUBIC STOT PRST8ECT RETROPUBIC RAD +-NRV SPARING PRST8ECT RETROPUBIC RAD LYMPH NODE BX PRST8ECT RETROPUBIC RAD W/BI PEL LMPHADEC EXPOS PRST8 ANY APPR INSJ RADACT SBST EXPOS PRST8 INSJ RADACT NODE BX EXPOS PRST8 INSJ RADACT BI PEL LMPHADEC s LAPS PRSTECT RETROPUBIC RAD W/NRV SPARING ROBOT ELECTROEJACULATION CRYOSURG ABLATION PROSTATE US & MONITORING TPRNL PLMT NDL/CATHS INTO PRST8 RADJ INSJ s PLACE INTERSTITIAL DEV RADIATION TX PROSTATE UNLIS MALE GEN SYS BR YYY PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL INTERSEX SURG MALE FEMALE BR XXX INTERSEX SURG FEMALE MALE BR XXX I&D VULVA/PRNL ABSC I&D OF BARTHOLIN'S GLAND ABSC MARSUPIALIZATION BARTHOLIN'S GLAND CYST LSS LABIAL ADS HYMENOTOMY SIMPLE INCISION DSTRJ LES VULVA SMPL DSTRJ LES VULVA X10SV BX VULVA/PR SPX 1 LES BX VULVA/PR SPX EA SEP ADDL LES ZZZ VULVECTOMY SMPL PRTL VULVECTOMY SMPL COMPL VULVECTOMY RAD PRTL VULVECTOMY RAD PRTL UNI INGUINOFEM LMPHADEC VULVECTOMY RAD PRTL BI INGUINOFEM LMPHADEC VULVECTOMY RAD COMPL VULVECTOMY RAD COMPL UNI INGUINOFEM LMPHADEC VULVECTOMY RAD COMPL BI INGUINOFEM LMPHADEC VULVECTOMY RAD COMPL ILIAC&PEL LMPHADEC PRTL HYMENECTOMY/REVJ HYMENAL RING EXC BARTHOLIN'S GLAND OR CYST PLSTC RPR INTROITUS CLITOROPLASTY INTERSEX STATE PRINEOPLASTY RPR PR NONOBAL SPX COLPOSCOPY VULVA Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 143

148 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, COLPOSCOPY VULVA W/BX COLPOTOMY W/EXPL COLPOTOMY W/DRG PEL ABSC COLPOCNTS SPX I&D VAG HMTMA OBAL/POSTPARTUM I&D VAG HMTMA NON-OBAL DSTRJ VAG LES SMPL DSTRJ VAG LES X10SV BX VAG MUCOSA SMPL SPX BX VAG MUCOSA X10SV REQ SUTR VAGNC PRTL RMVL VAG WALL VAGNC PRTL RMVL VAG WALL PARAVAG TISS VAGNC PRTL RMVL VAG WALL W/BI TOT PEL LMPHADEC VAGNC COMPL RMVL VAG WALL VAGNC COMPL RMVL VAG WALL PARAVAG TISS VAGNC COMPL RMVL VAG WALL TOT PEL LMPHADEC BX COLPOCLEISIS LE FORT TYP EXC VAG SEPTUM EXC VAG CST/TUM IRRG VAG&/APPL MEDICAMENT DISEASE s K INSJ UTERINE TANDEM&/VAG OVOIDS l INSJ VAGINAL RADIATION DEVICE FITG&INSJ PESSARY/OTH INTRAVAG SUPPORT DEV DPHRM/CRV CAP FITG W/INSTRUCTIONS INTRO ANY HEMOSTATIC AGT/PACK VAG HEMRRG SPX COLPORRHAPHY SUTR INJ VAG COLPOPRINEORRHAPHY SUTR INJ VAG&/PR PLSTC URTL SPHNCTR VAG APPR PLSTC RPR URETHROCELE ANT COLPORRHAPHY RPR CSTOCELE +-RPR URETHROCELE POST COLPORRHAPHY RPR RECTOCELE +-PRINEORRHAPHY CMBN ANTEROPOST COLPORRHAPHY CMBN ANTEROPOST COLPORRHAPHY W/NTRCL RPR INSJ MESH/PROSTH PEL FLOOR DFCT EA SIT ZZZ RPR NTRCL VAG APPR SPX RPR NTRCL ABDL APPR SPX COLPOPEXY ABDL APPR COLPOPEXY VAG XTR-PRTL APPR COLPOPEXY VAG INTRA-PRTL APPR PARAVAGINAL DEFECT REPAIR OPEN ABDOMINAL APPR PARAVAGINAL DEFECT REPAIR VAGINAL APPROACH RMVL/REVJ SLING STRESS INCONTINENCE SLING OPERATION STRESS INCONTINENCE PREYRA PX W/ANT COLPORRHAPHY CONSTJ ARTIF VAG W/O GRF CONSTJ ARTIF VAG W/GRF CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

149 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule REVJ RMVL PROSTC VAG GRF VAG APPR REVJ W/RMVL PROSTHETIC VAG GRF ABD APPRO CLSR RECTOVAG FSTL VAG/TRANSANAL APPR CLSR RECTOVAG FSTL ABDL APPR CLSR RECTOVAG FSTL ABDL APPR W/CONCOMITANT CLST CLSR RECTOVAG FSTL TPRNL PRNL BDY RCNSTJ CLSR URETHROVAG FSTL CLSR URETHROVAG FSTL W/BULBOCAVERNOSUS TRNSPL CLSR VESICOVAG FSTL VAG APPR CLSR VESICOVAG FSTL TRANSVESICAL&VAG APPR VAGINOPLASTY INTERSEX STATE DILATION VAGINA W/ANESTHESIA OTHER THAN LOCAL PELVIC EXAMINATION W/ANESTHESIA OTHER THAN LOCAL REMOVAL IMPACTED VAG FB SPX W/ANES OTH/THN LOCAL COLPOSCOPY ENTIRE VAG W/CERVIX IF PRESENT COLPOSCOPY ENTIRE VAG W/CERVIX BX PARAVAGINAL DEFECT REPAIR LAPAROSCOPIC APPROACH LAPS SURG COLPOPEXY SSP VAG APEX REVISION PROSTHETIC VAGINAL GRAFT LAPAROSCOPIC COLPOSCOPY CERVIX UPR/ADJ VAG COLPOSCOPY CERVIX BX CERVIX&ENDOCRV CURTG COLPOSCOPY CERVIX VAG BX CERVIX COLPOSCOPY CERVIX VAG ENDOCRV CURTG COLPOSCOPY CERVIX VAG LOOP ELTRD BX CERVIX COLPOSCOPY CERVIX VAG ELTRD CONIZATION CERVIX BIOPSY CERVIX 1/MLT OR EXCISION OF LESION ENDOCRV CURTG X DONE AS PART DILAT&CURTG CAUT CERVIX ELECTRO/THERMAL CAUT CERVIX CRYOCAUT 1ST/REPEAT CAUT CERVIX LASER ABLTJ CONIZATION CERVIX +-D&C RPR KNIFE/LASER CONIZATION CERVIX +-D&C RPR ELTRD EXC TRACHELECTOMY CERVICECTOMY AMP CERVIX SPX RAD TRACHELECTOMY W/BI PEL LMPHADEC EXC CRV STUMP ABDL APPR EXC CRV STUMP ABDL APPR W/PEL FLOOR RPR EXC CRV STUMP VAG APPR EXC CRV STUMP VAG APPR W/ANT&/POST RPR EXC CRV STUMP VAG APPR W/RPR NTRCL DILATION & CURETTAGE CERVICAL STUMP CERCLAGE UTERINE CERVIX NONOBAL TRACHELORRHAPHY PLSTC RPR UTERINE CERVIX VAG DILAT CRV CANAL INSTRUMENTAL SPX ENDOMETRIAL BX +-ENDOCRV BX W/O DILAT SPX ENDOMETRIAL BX CONJUNCT W/COLPOSCOPY ZZZ D&C DX&/THER Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 145

150 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, MYOMECTOMY GM ABDL MYOMECTOMY GM/< VAG MYOMECTOMY 5+ > 250 GM ABDL TAH +-RMVL TUBE +-RMVL OVARY TAH +-RMVL TUBE OVARY COLPO-URTCSTOPEXY SUPRACRV ABDL HYST +-RMVL TUBE OVARY TAH W/PRTL VAGNC PEL LYMPH NODE SAMPLING RAD ABDL HYST W/BI PEL LMPHADEC PEL EXNTJ GYNECOLOGIC MAL VAG HYST 250 GM/< VAG HYST 250 GM/< W/RMVL TUBE&/OVARY VAG HYST 250 GM/< W/RMVL TUBE OVARY W/RPR NTRCL VAG HYST 250 GM/< W/COLPO-URTCSTOPEXY VAG HYST 250 GM/< W/RPR NTRCL VAG HYST W/TOT/PRTL VAGNC VAG HYST W/TOT/PRTL VAGNC W/RPR NTRCL VAG HYST RAD SCHAUTA VAGINAL HYSTERECTOMY UTERUS > 250 GM VAG HYST > 250 GM RMVL TUBE&/OVARY VAG HYST > 250 GM RMVL TUBE&/OVARY W/RPR NTRCL VAG HYST > 250 GM COLPO-URTCSTOPEXY +-NDSC CTRL VAG HYST > 250 GM RPR NTRCL INSJ INTRAUTERINE DEV XXX RMVL INTRAUTERINE DEV ARTIF INSEMINATION INTRA-CRV ARTIF INSEMINATION INTRA-UTERINE SPRM WASHG ARTIF INSEMINATION CATHJ&INTRO SALINE NFS SHG/HSG TRANSCRV INTRO FLP TUBE CATH +-HSG INSJ HEYMAN CAPSLS CLINICAL BRACHYTX CHROMOTUBATION OVIDUX MATRLS ENDOMETRIAL ABLTJ THERMAL W/O HYSTEROSCOPIC GID ENDOMETRIAL CRYOABLTJ US CURTG UTERINE SSP SPX UTERINE SSP PRESAC SYMPTH HYSTERORRHAPHY RPR RPTD HYSTEROPLASTY RPR UTERINE ANOMAL LAPS SUPRACRV HYST 250 G/< LAPS SUPRACRV HYST 250 G/< RMVL TUBE/OVARY LAPS SUPRACRV HYST >250 G LAPS SUPRACRV HYST >250 G RMVL TUBE/OVARY LAPS MYOMECTOMY EXC GM/< LAPS MYOMECTOMY EXC 5+ > 250 GRAMS LAPS W/RAD HYST W/BILAT LMPHADEC RMVL TUBE/OVARY LAPS W/VAG HYST 250 GM/< LAPS W/VAG HYST 250 GM/< RMVL TUBE&/OVARY CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

151 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule LAPS W/VAG HYST > 250 GRAMS LAPS VAG HYST > 250 GM RMVL TUBE&/OVARY HYSTSC DX SPX HYSTSC BX ENDOMETRIUM&/POLYPC +-D&C HYSTSC LSS INTRAUTERINE ADS HYSTSC DIV/RESCJ INTRAUTERINE SEPTUM HYSTSC RMVL LEIOMYOMATA HYSTSC RMVL IMPACTED FB HYSTSC ENDOMETRIAL ABLTJ HYSTSC OCCLUSION PLMT PRM LAPAROSCOPY W TOTAL HYSTERECTOMY UTERUS 250 G/< LAPS TOTAL HYSTERECTOMY 250 G/<W TUBE/OVARY LAPAROSCOPY TOTAL HYSTERECTOMY UTERUS>250 G LAPAROSCOPY TOT HYSTERECTOMY >250 G W TUBE/OVARY UNLIS LAPS UTER BR YYY UNLIS HYSTSC UTER BR YYY LIG/TRNSXJ FLP TUBE ABDL/VAG APPR UNI/BI LIG/TRNSXJ FLP TUBE ABDL/VAG POSTPARTUM SPX LIG/TRNSXJ FLP TUBE DONE TM C DLVR/SURG ZZZ OCCLUSION FLP TUBE DEV VAG/SUPRAPUBIC APPR LAPS LSS ADS SPX LAPS RMVL ADNEXAL STRUXS LAPS FULG/EXC OVARY VISCERA/PRTL SURF LAPS FULG OVIDUXS LAPS OCCLUSION OVIDUXS DEV LAPS FIMBRIOPLASTY LAPS SALPINGOSTOMY UNLIS LAPS PX OVIDUX OVARY BR YYY SALPINGECTOMY COMPL/PRTL UNI/BI SPX SALPINGO-OOPHORECTOMY COMPL/PRTL UNI/BI SPX LSS ADS TUBOTUBAL ANAST TUBOUTERINE IMPLTJ FIMBRIOPLASTY SALPINGOSTOMY DRG OVARIAN CST UNI/BI SPX VAG DRG OVARIAN CST UNI/BI SPX ABDL DRG OVARIAN ABSC VAG OPN DRG OVARIAN ABSC ABDL K DRG PEL ABSC TRVG/TRANSRCT PRQ TRPOS OVARY BX OVARY UNI/BI SPX WEDGE RESCJ/BISCTJ OVARY UNI/BI OVARIAN CSTC UNI/BI OOPHORECTOMY PRTL/TOT UNI/BI OOPHORECTOMY PRTL/TOT UNI/BI OVARIAN MAL Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 147

152 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, RESCJ PRIM PRTL MAL W/BSO&OMNTC RESCJ PRIM PRTL MAL W/BSO&OMNTC TAH&LMPHADEC RESCJ PRIM PRTL MAL W/BSO&OMNTC RAD DEBULKING BSO W/OMNTC TAH&RAD DSJ DEBULKING BSO W/OMNTC TAH DEBULKING W/LMPHADEC BSO TOT OMNTC TAH MAL RESECTION RECRT MAL W/OMENTECTOMY RESECTION RECRT MAL W/OMENTECTOMY PEL LMPHADEC LAPT STG/RESTG OVARIAN TUBAL/PRIM MAL 2ND LOOK FOLLICLE PNXR OOCYTE RETRIEVAL ANY METH EMBRYO TR INTRAUTERINE GAMETE ZYGOTE/EMBRYO INTRAFLP TR ANY METH UNLIS PX FEMALE GEN SYS BR YYY AMNIOCNTS DX AMNIOCNTS THER AMNIOTIC FLU RDCTJ US GID CORDOCNTS INTRAUTERINE CHORNC VILLUS SAMPLING FTL CONTRCJ STRS TST FTL CONTRCJ STRS TST TC FTL CONTRCJ STRS TST FTL NON-STRS TST FTL NON-STRS TST TC FTL NON-STRS TST FTL SCALP BLD SAMPLING FTL MNTR LABOR PHYS WRTTN REPRT S&I XXX FTL MNTR LABOR PHYS WRTTN REPRT INTERPJ ONLY XXX TABDL AMNIONFS US GID FTL UMBILICAL CORD OCCLUSION W/US GID FTL FLU DRG US GID FTL SHUNT PLMT US GID HYSTOT ABDL TX ECTOPIC PREGNANCY REQ SO TX ECTOPIC PREGNANCY W/O SO TX ECTOPIC PREGNANCY ABDL PREGNANCY TX ECTOPIC PREGNANCY NTRSTL REQ TOT HYST TX ECTOPIC PREGNANCY NTRSTL PRTL RESCJ UTER TX ECTOPIC PREGNANCY CRV W/EVAC LAPS TX ECTOPIC PREGNANCY W/O SO LAPS TX ECTOPIC PREGNANCY W/SO CURTG POSTPARTUM INSJ CRV DILATOR SPX EPISIOTOMY/VAG RPR OTH/THN ATTENDING PHYS CERCLAGE CERVIX PREGNANCY VAG CERCLAGE CERVIX PREGNANCY ABDL HYSTERORRHAPHY RPTD UTER OB CARE ANTEPARTUM VAG DLVR&POSTPARTUM MMM 148 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

153 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule VAG DLVR ONLY MMM VAG DLVR ONLY POSTPARTUM CARE MMM XTRNL CEPHALIC VERSION +-TOCOLSS MMM DLVR PLACENTA SPX MMM ANTEPARTUM CARE ONLY 4-6 VSTS MMM ANTEPARTUM CARE ONLY 7+ VSTS MMM POSTPARTUM CARE ONLY SPX MMM OB ANTEPARTUM CARE C DLVR&POSTPARTUM MMM C DLVR ONLY MMM C DLVR ONLY W/POSTPARTUM CARE MMM STOT/TOT HYST AFTER C DLVR ZZZ OB ANTEPARTUM VAG DLVR&POSTPARTUM AFTER C DLVR MMM VAG DLVR AFTER C DLVR MMM VAG DLVR AFTER C DLVR POSTPARTUM CARE MMM ANTEPARTUM C DLVR&POSTPARTUM FA V AP C DLVER MMM C DLVR ONLY FA V AP C DLVER MMM C DLVR ONLY FA V AP C DLVER W/POSTPARTUM CARE MMM TX INCOMPL AB ANY TRI COMPLD SURGLY TX MISSED AB COMPLD SURGLY 1ST TRI TX MISSED AB COMPLD SURGLY 2ND TRI TX SEPTIC AB COMPLD SURGLY INDUCED AB DILAT&CURTG INDUCED AB DILAT&EVAC INDUCED AB 1+ IAM NJXS DLVR FETUS INDUCED AB 1+ IAM NJXS DLVR FETUS D&C&EVAC INDUCED AB 1+ IAM NJXS DLVR FETUS HYSTOT INDUCED AB 1+ VAG SUPP DLVR FETUS INDUCED AB 1+ VAG SUPP DLVR FETUS D&C&/EVAC INDUCED AB 1+ VAG SUPP DLVR FETUS HYSTOT MULTIFTL PREGNANCY RDCTJ UTERINE EVAC&CURTG HYDATIDIFORM MOLE RMVL CERCLAGE SUTR UNDER ANES UNLIS FTL INVASIVE W/US GID BR YYY UNLIS LAPS MATERNITY CARE&DLVR BR YYY UNLIS MATERNITY CARE&DLVR BR YYY I&D THYROGLOSSAL DUX CST INFCT BX THYR PRQ CORE NDL EXC CST/ADENOMA THYR/TRNSXJ ISTHMUS PRTL THYR LOBEC UNI +-ISTHMUSECTOMY PRTL THYR LOBEC UNI W/CLAT STOT LOBEC TOT THYR LOBEC UNI +-ISTHMUSECTOMY TOT THYR LOBEC UNI W/CLAT STOT LOBEC TRDEC TOT/COMPL THYROIDECTOMY TOTAL/SUBTOTAL LMTD NECK DISSECT THYROIDECTOMY TOTAL/SUBTOTAL RAD NECK DISSECT TRDEC RMVL REMAINING TISS FLWG RMVL PRTN Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 149

154 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, TRDEC W/SUBSTERNAL THYR STERNAL SPLT/TTHRC TRDEC W/SUBSTERNAL THYR CRV APPR EXC THYROGLOSSAL DUX CST/SINUS EXC THYROGLOSSAL DUX CST/SINUS RECRT ASPIRATION AND/OR INJECTION THYROID CYST PARATRDEC/EXPL PARATHYR PARATRDEC/EXPL PARATHYR RE-EXPL PARATRDEC/EXPL PARATHYR MEDSTNL STERNAL/TTHRC PARATHYR AUTOTRNSPLJ ZZZ THYMECTOMY PRTL/TOT TRANSCRV APPR SPX THYMECTOMY PRTL/TOT W/O RAD MEDSTNL DSJ SPX THYMECTOMY PRTL/TOT RAD MEDSTNL DSJ SPX ADRNLECTOMY EXPL ADRNL TABDL LMBR/DORSAL SPX ADRNLECTOMY EXPL ADRNL SPX EXC ADJ TUM EXC CRTD BDY TUM W/O EXC CRTD ART EXC CRTD BDY TUM W/EXC CRTD ART LAPS ADRNLECTOMY PRTL/COMPL TABDL UNLIS LAPS ENDOC SYS BR YYY UNLIS ENDOC SYS BR YYY SDRL TAP THRU FONTANELLE/SUTR INFT UNI/BI 1ST SDRL TAP THRU FONTANELLE/SUTR INFT UNI/BI SBSQ VENTR PNXR PREVIOUS BURR HOLE W/O NJX VENTR PNXR PREVIOUS BURR HOLE W/NJX CISTERNAL/LAT CRV C1-C2 PNXR W/O NJX SPX CISTERNAL/LAT CRV C1-C2 PNXR W/NJX PNXR SHUNT TUBING/RSVR ASPIR/NJX TDH SDRL/VENTR PNXR * TDH SDRL/VENTR PNXR IMPLTING VENTR CATH/DEV TDH SDRL/VENTR PNXR EVAC&/DRG SDRL HMTMA BURR HOLE VENTR PNXR BURR HOLE/TREPHINE W/BX BRN/ICRA LES BURR HOLE/TREPHINE W/DRG BRN ABSC/CST BURR HOLE/TREPHINE W/SBSQ TAPPING ICRA ABSC/CST BURR HOLE W/EVAC&/DRG HMTMA XDRL/SDRL BURR HOLE W/ASPIR HMTMA/CST ICERE BURR HOLE IMPLANT VENTRICULAR CATH/OTHER DEVICE INSJ SUBQ RSVR PMP/NFS SYS VENTR CATH BURR HOLE/TREPHINE STTL EXPL N/FLWD OTH SURG BURR HOLE/TREPHINE ITTL UNI/BI CRNEC/CRX EXPL STTL CRNEC/CRX EXPL ITTL CRANIECTOMY HMTMA SUPRATENTORIAL EXTRA/SUBDURAL CRANIECTOMY HMTMA SUPRATENTORIAL INTRACEREBRAL CRANIECTOMY HMTMA INFRATENTORIAL EXTRA/SUBDURAL CRANIECTOMY HMTMA SUPRATENTORIAL INTRACEREBRAL INC&SUBQ PLMT CRNL B1 GRF ZZZ 150 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

155 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule CRNEC/CRX DRG ICRA ABSC STTL CRNEC/CRX DRG ICRA ABSC ITTL CRNEC/CRX DCMPRIVE W/O LOBEC CRNEC/CRX DCMPRIVE W/LOBEC DCMPRN ORBIT ONLY TRANSCRNL EXPL ORBIT TRANSCRNL BX EXPL ORBIT TRANSCRNL RMVL LES EXPL ORBIT TRANSCRNL W/RMVL FB STPL CRNL DCMPRN CRNEC SOPL CRV LAM DCMPRN MEDULLA&SPI CORD OTH CRNL DCMPRN POST FOSSA CRX SCTJ TENTORIUM CEREBELLI SPX CRNEC STPL SCTJ COMPRESSION/DCMPRN GANGLION CRNEC SOPL EXPL/DCMPRN CRNL NRV CRNEC SOPL SCTJ 1+ CRNL NRV CRNEC SOPL MEDULLARY TRCOTOMY CRNEC SOPL MESENCEPHAL TRCOTOMY/PEDUNCULOTOMY CRX LOBOTOMY W/CINGULOTOMY CRNEC EXC TUM/OTH B1 LES SKL CRNEC OSTEOMYELITIS CRNEC TREPH B1 FLAP CRX EXC TUM STTL CRNEC TREPH B1 FLAP CRX EXC MENINGIOMA STTL CRNEC TREPH B1 FLAP CRX EXC BRN ABSC STTL CRNEC TREPH B1 FLAP CRX EXC CST STTL IMPLTJ BRN INTRCV CHEMOTX AGT ZZZ CRNEC EXC TUM ITTL/PFOS MENINGIOMA CRNEC EXC TUM ITTL/PFOS MENINGIOMA CRNEC EXC TUM ITTL/PFOS CRBLOPNT ANGL TUM CRNEC EXC TUM ITTL/PFOS MIDLINE TUM BASE SKL CRNEC ITTL/PFOS EXC ABSC CRNEC ITTL/PFOS EXC/FENESTRATION CST CRNEC EXC CRBLOPNT ANGL TUM CRNEC EXC CRBLOPNT ANGL TUM MIDDLE/PFOS SDRL IMPLTJ STRIP ELTRDS SEIZURE MNTR CRX B1 FLAP IMPLTJ ELTRD RA SEIZURE MNTR CRX B1 FLAP EXC EPILEPTOGENIC FOC W/O ECOG CRX B1 FLAP RMVL ELTRD RA W/O EXC CERE TISS SPX CRX B1 FLAP EXC CERE FOC W/ECOG CRX B1 FLAP TEMPORAL LOBE W/O ECOG CRX B1 FLAP LOBEC TEMPORAL LOBE W/ECOG CRX B1 FLAP LOBEC OTH/THN TEMPORAL LOBE W/ECOG CRX B1 FLAP LOBEC OTH/THN TEMPORAL LOBE W/O ECOG CRX B1 FLAP TRNSXJ CORPUS CALLOSUM CRX B1 FLAP TOT HEMISPHERCOMY CRX B1 FLAP PRTL/STOT HEMISPHERCOMY CRX B1 FLAP EXC/COAGJ CHOROID PLEXUS Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 151

156 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, CRX B1 FLAP EXC CRANIOPHARYNGIOMA CRX HYPPHSEC/EXC PITUITARY TUM ICRA HYPPHSEC/EXC PITUITARY TUM TRANSNSL/SEPTAL CRNEC CRANIOSYNOSTOSIS 1 CRNL SUTR CRNEC CRANIOSYNOSTOSIS MLT CRNL SUTRS CRX CRANIOSYNOSTOSIS FRNT/PARIETAL B1 FLAP CRX CRANIOSYNOSTOSIS BIFRNT B1 FLAP X10SV CRNEC MLT SUTR CRANIOSYNOSTOSIS X W/B1 GRF X10SV CRNEC MLT SUTR CRANIOSYNOSTOSIS B1 AGRFT EXC B9 TUM CRNL B1 W/O OPTIC NRV DCMPRN EXC B9 TUM CRNL B1 W/OPTIC NRV DCMPRN CRX B1 FLAP SLCTV AMYGDALOHIPPOCAMPECTOMY CRX B1 FLAP MLT SUBPIAL TRNSXJS W/ECOG CRNEC/CRX EXC FB FROM BRN CRNEC/CRX TX PENTRG WND BRN TRANSORAL SB BX DCMPRN/EXC LES TRANSORAL SB BX DCMPRN/EXC LES SPLTTING TONGUE CRANFCL ACF XDRL W/O ORB EXNTJ CRANFCL ACF XDRL ORB EXNTJ CRANFCL ACF XDRL ELVTN LOBE CRANFCL ACF IDRL ELVTN/RESCJ LOBE OC ACF XDRL W/O ORB EXNTJ OC ACF XDRL W/ORB EXNTJ BICORONAL TRANSZYGMTC&/LEFT W/O B1 GRF ITPRL PRE-AUR MCF&MSB ITPRL POST-AUR MCF OC ZYGMTC MCF TRANSTEMPORAL PCF JUG FORAMEN/MSB TRANSCOCHLEAR PCF JUG FORAMEN/MSB TRANSCONDYLAR PCF JUG FORAMEN/MSB TRANSPETROSAL PCF CLIVUS/FORAMEN MAGNUM RESCJ/EXC LES BASE ACF XDRL RESCJ/EXC LES BASE ACF IDRL W/RPR RESCJ/EXC LES ITPRL FOSSA SPACE APEX XDRL RESCJ/EXC LES ITPRL FOSSA SPACE APEX IDRL W/RPR RESCJ/EXC LES PARASELLAR SINUS CLIVUS/MSB XDRL RESCJ/EXC LES PARASELLAR SINUS CLIVUS/MSB IDRL TRNSXJ/LIG CRTD ART SINUS W/O RPR ZZZ TRNSXJ/LIG CRTD ART SINUS W/RPR ANAST/GRF ZZZ TRNSXJ/LIG CRTD ART PETROUS CANAL W/O RPR ZZZ TRNSXJ/LIG CRTD ART PETROUS CANAL RPR ANAST/GRF ZZZ OBLTRJ CRTD ARYSM ARVEN CRTD-FSTL DSJ RESCJ/EXC LES BASE PCF VRT BODIES XDRL RESCJ/EXC LES BASE PCF FORAMEN VRT BODIES IDRL SEC RPR DURA CSF LEAK FR TISS GRF SEC RPR DURA CSF LEAK LOCAL/REGIONALIZED FLAP CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

157 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule EVASC TEMP BALO ARTL OCCLUSION TCAT PRM OCCLUSION/EMBOLIZATION PRQ CNS TCAT PRM OCCLUSION/EMBOLIZATION PRQ NON-CNS BALO ANGIOP ICRA PRQ XXX TCAT PLMT IV STENT ICRA W/BALO ANGIOP IF PFRMD XXX BALO DILAT ICRA PRQ 1ST VSL BALO DILAT ICRA PRQ EA VSL SM VASC FAM ZZZ BALO DILAT ICRA PRQ EA VSL DIFF VASC FAM ZZZ SURG ICRA ARVEN MALFRMJ STTL SMPL SURG ICRA ARVEN MALFRMJ STTL CPLX SURG ICRA ARVEN MALFRMJ ITTL SMPL SURG ICRA ARVEN MALFRMJ ITTL CPLX SURG ICRA ARVEN MALFRMJ DURAL SMPL SURG ICRA ARVEN MALFRMJ DURAL CPLX SURG CPLX ICRA ARYSM ICRA APPR CRTD CRCJ CPLX ICRA ICRA VERTEBROBASILAR CRCJ SMPL ICRA ICRA APPR CRTD CRCJ SMPL ICRA ICRA VERTEBROBASILAR CRCJ ICRA CRV APPL OCCLUDING CLAMP CRV CRTD ART ARYSM VASC MALFRMJ/CRTD-OCCLUSION CRTD ART ARYSM VASC MALFRMJ/ICRA ELECTROTHROMBOSIS ARYSM VASC MALFRMJ IA EMBOLIZATION ANAST ARTL XTRC-ICRA ARTS CRTJ LES STRTCTC BURR GLOBUS PALLIDUS/THALAMUS CRTJ LES STRTCTC BURR SUBCORTICAL STRUX OTH/THN STRTCTC BX ASPIR/EXC BURR ICRA LES STRTCTC BX ASPIR/EXC BURR ICRA LES W/CT&/MRG STRTCTC IMPLTJ ELTRD CEREBRUM SEIZURE MNTR STRTCTC LOCLZJ INSJ CATH/PRB PLMT RADJ SRC l STRTCTC CPTR ASSTD PX IDRL CRNL ZZZ l STRTCTC CPTR ASSTD PX XDRL CRNL ZZZ l STRTCTC CPTR ASSTD PX SPINAL ZZZ CRTJ LES STRTCTC PRQ NULYT GASSERIAN CRTJ LES STRTCTC PRQ NULYT TRIGEMINAL TRC STEREOTACTIC RADIOSURGERY 1 SIMPLE CRANIAL LES STRTCTC RADIOSURGERY EA ADDL CRANIAL LES SIMPLE ZZZ STEREOTACTIC RADIOSURGERY 1 COMPLEX CRANIAL LES STRTCTC RADIOSURGERY EA ADDL CRANIAL LES COMPLEX ZZZ APPL STRTCTC HEADFRAME STEREOTACTIC RADIOSURGERY ZZZ TDH/BURR IMPLTJ NSTIM ELTRD CORTICAL CRNEC/CRX IMPLTJ NSTIM ELTRD CERE CORTICAL STRTCTC IMPLTJ NSTIM ELTRD W/O MER 1ST RA STRTCTC IMPLTJ NSTIM ELTRD W/O MER EA RA ZZZ STRTCTC IMPLTJ NSTIM ELTRD W/MER 1ST RA STRTCTC IMPLTJ NSTIM ELTRDW/MER EA RA ZZZ CRNEC IMPLTJ NSTIM ELTRD CEREBELLAR CORTICAL Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 153

158 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, CRNEC IMPLTJ NSTIM ELTRD CEREBELLAR SUBCORTICAL REVJ/RMVL ICRA NSTIM ELTRDS INSJ/RPLCMT CRNL NPGR 1 ELTRD RA INSJ/RPLCMT CRNL NPGR 2+ ELTRD RA REVJ/RMVL CRNL NPGR ELVTN DEPRS SKL FX SMPL XDRL ELVTN DEPRS SKL FX COMPOUND/COMMIND XDRL ELVTN DEPRS SKL FX W/RPR DURA&/DBRDMT BRN CRX RPR DURAL/CSF LEAK RHINORRHEA/OTORRHEA RDCTJ CRANIOMEGALIC SKL X W/B1 GRFS/CRNOP RDCTJ CRANIOMEGALIC SKL W/SMPL CRNOP RDCTJ CRANIOMEGALIC REQ CRX&RCNSTJ +-B1 GRF RPR ENCEPHALOCELE SKL VAULT W/CRNOP CRANIOTOMY FOR ENCEPHALOCELE REPAIR SKULL BASE CRANIOPLASTY SKULL DEFECT UP TO 5 CM DIAMETER CRANIOPLASTY SKULL DEFECT LARGER THAN 5 CM DIAM RMVL B1 FLAP/PROSTC PLATE SKL RPLCMT B1 FLAP/PROSTC PLATE SKL CRANIOPLASTY SKULL DEFECT REPARATIVE BRAIN SURG CRNOP W/AGRFT UP 5 CM DIAM CRNOP W/AGRFT > 5 CM DIAM INCISE&RETRIEVAL SUBQ CRANIOPLASTY BONE GRAFT ZZZ NUNDSC ICRA PLMT/RPLCMT VENTR CATH SHUNT SYS ZZZ NUNDSC ICRA DSJ ADS FENESTRATION SEPTUM CSTS NUNDSC ICRA FENESTRATION/EXC CST PLMT CATH DRG NUNDSC ICRA W/RETRIEVAL FB NUNDSC ICRA EXC TUM PLMT CATH DRG NUNDSC ICRA EXC PITUITARY TUM VENTRICULOCISTERNOSTOMY CRTJ SHUNT SARACH/SDRL-ATR-JUG-AUR CRTJ SHUNT SARACH/SDRL-PRTL-PLEURAL OTH RPLCMT/IRRG SARACH/SDRL CATH VENTRICULOCISTERNOSTOMY 3RD VNTRC VENTRICULOCISTERNOSTOMY 3RD VNTRC NEURONDSC CRTJ SHUNT VENTRICULO-ATR-JUG-AUR CRTJ SHUNT VENTRICULO-PRTL-PLEURAL OTH RPLCMT/IRRIGATION VENTR CATH RPLCMT/REVJ CSF SHUNT VALVE/CATH SHUNT SYS REPRGRMG PRGRBL CEREBSP SHUNT XXX REPRGRMG PRGRBL CEREBSP SHUNT XXX TC REPRGRMG PRGRBL CEREBSP SHUNT XXX RMVL COMPL CEREBSP FLU SHUNT SYS W/O RPLCMT RMVL COMPL CSF SHUNT SYS W/RPLCMT PRQ LSS EDRL ADS SLN NJX/MCHNL LOCLZJ 2+ D PRQ LSS EDRL ADS SLN NJX/MCHNL LOCLZJ 1 D PRQ ASPIR PULPOSUS/INTERVERTEBRAL DISC/PVRT TISS CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

159 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule PRQ ASPIR SPI CORD CST/SYRINX BX SPI CORD PRQ NDL SPI PNXR LMBR DX SPINAL PUNCTURE THER DRAIN CEREBROSPINAL FLUID NJX EDRL BLD/CLOT PATCH NJX/NFS NULYT SBST SBST SARACH NJX/NFS NULYT SBST EDRL CRV/THRC NJX/NFS NULYT SBST EDRL LMBR SAC INJECTION PROCEDURE MYELOGRAPHY/CT SPINAL DCMPRN PERQ NUCLEUS PULPOSUS 1/> LEVELS LUMBAR NJX DISKOGRAPY EA LVL LMBR NJX DISKOGRAPY EA LVL CRV/THRC NJX CHEMONUCLEOLSS DISKOGRAPY 1+ LMBR NJX ARTL OCCLUSION ARVEN MALFRMJ SPI NJX C+-DX/THER SBST EDRL/SARACH CRV/THRC NJX C+-DX/THER SBST EDRL/SARACH LMBR SAC NJX NFS/BOLUS DX/SBST EDRL/SARACH CRV/THRC NJX NFS/BOLUS DX/SBST EDRL/SARACH LMBR SAC IMPLTJ REVJ/RPSG ITHCL/EDRL CATH PMP W/O LAM IMPLTJ REVJ/RPSG ITHCL/EDRL CATH W/LAM RMVL PREVIOUSLY IMPLTED ITHCL/EDRL CATH IMPLTJ/RPLCMT ITHCL/EDRL DRUG NFS SUBQ RSVR IMPLTJ/RPLCMT ITHCL/EDRL NFS NON-PRGRBL PMP IMPLTJ/RPLCMT ITHCL/EDRL DRUG NFS PRGRBL PMP RMVL SUBQ RSVR/PMP ELEC ALYS PRGRBL PMP W/O REPRGRMG XXX ELEC ALYS PRGRBL PMP REPRGRMG XXX LAM W/O FACETEC FORAMOT/DSKC 1/2 VRT SEG CRV LAM W/O FFD 1/2 VRT SEG THRC LAM W/O FFD 1/2 VRT SEG LMBR LAM W/O FFD 1/2 VRT SEG SAC LAM W/RMVL ABNORMAL FACETS LMBR LAM W/O FFD > 2 VRT SEG CRV LAM W/O FFD > 2 VRT SEG THRC LAM W/O FFD > 2 VRT SEG LMBR LAMINOTOMY INCL OPN & NDSC 1 INTERSPACE CERVICAL LAMINOTOMY INCL OPEN & NDSC 1 INTERSPACE LUMBAR LAMOT INCL OPEN&NDSC EA ADDL INTERSPACE CRV/LMBR ZZZ LAMOT PRTL FFD HRNA8 REEXPL 1 NTRSPC CRV LAMOT PRTL FFD HRNA8 REEXPL 1 NTRSPC LMBR LAMOT PRTL FFD HRNA8 REEXPL 1 NTRSPC EA CRV ZZZ LAMOT W/PRTL FFD HRNA8 REEXPL 1 NTRSPC EA LMBR ZZZ LAM FACETEC&FORAMOT 1 SGM CRV LAM FACETEC&FORAMOT 1 SGM THRC LAM FACETEC&FORAMOT 1 SGM LMBR LAM FACETEC&FORAMOT 1 SGM EA CRV THRC/LMBR ZZZ Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 155

160 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, LAMOP CRV W/DCMPRN SPI CORD 2/MORE VRT SEG LAMOP CRV DCMPRN SPI CORD 2+ SEG RCNSTJ B TRANSPEDICULAR DCMPRN SPI CORD 1 SGM THRC TRANSPEDICULAR DCMPRN SPI CORD 1 SGM LMBR TRANSPEDICULAR DCMPRN 1 SGM EA THRC/LMBR ZZZ COSTOVRT DCMPRN THRC 1 SGM COSTOVRT DCMPRN THRC EA SGM ZZZ DSKC ANT DCMPRN CRV 1 NTRSPC DSKC ANT DCMPRN CRV EA NTRSPC ZZZ DSKC ANT DCMPRN THRC 1 NTRSPC DSKC ANT DCMPRN THRC EA NTRSPC ZZZ VCRPEC ANT DCMPRN CRV 1 SGM VCRPEC ANT DCMPRN CRV EA SGM ZZZ VCRPEC TTHRC DCMPRN THRC 1 SGM VCRPEC TTHRC DCMPRN THRC EA SGM ZZZ VCRPEC THORACOLMBR DCMPRN LWR THRC/LMBR 1 SGM VCRPEC THORACOLMBR DCMPRN LWR THRC/LMBR EA SGM ZZZ VCRPEC TRANSPRTL/RPR DCMPRN THRC LMBR/SAC 1 SGM VCRPEC TRANSPRTL/RPR DCMPRN THRC LMBR/SAC EA SGM ZZZ VCRPEC LAT XTRCAVITARY DCMPRN THRC 1 SGM VCRPEC LAT XTRCAVITARY DCMPRN LMBR 1 SGM VCRPEC LAT XTRCAVITARY DCMPRN THRC/LMBR EA SGM ZZZ LAM W/MYELOTOMY CRV THRC/THORACOLMBR LAM W/DRG IMED CST/SYRINX SARACH SPACE LAM W/DRG IMED CST/SYRINX PRTL/PLEURAL SPACE LAM&SCTJ DENTATE LIGMS CRV 1/2 SEG LAM&SCTJ DENTATE LIGMS CRV > 2 SEG LAM W/RHIZOTOMY 1/2 SEG LAM W/RHIZOTOMY > 2 SEG LAM W/SCTJ SPI ACCESSORY NRV LAM CORDOTOMY SCTJ 1 TRC 1 STG CRV LAM CORDOTOMY SCTJ 1 TRC 1 STG THRC LAM CORDOTOMY SCTJ BTH TRCS 1 STG CRV LAM CORDOTOMY SCTJ BTH TRCS 1 STG THRC LAM CORDOTOMY SCTJ BTH TRCS 2 STGS CRV LAM CORDOTOMY SCTJ BTH TRCS 2 STGS THRC LAM RLS TETHERED SPI CORD LMBR LAM EXC/OCCLUSION AVM SPI CORD CRV LAM EXC/OCCLUSION AVM SPI CORD THRC LAM EXC/OCCLUSION AVM SPI CORD THORACOLMBR LAM EXC/EVAC ISPI LES OTH/THN NEO XDRL CRV LAM EXC/EVAC ISPI LES OTH/THN NEO XDRL THRC LAM EXC/EVAC ISPI LES OTH/THN NEO XDRL LMBR LAM EXC/EVAC ISPI LES OTH/THN NEO XDRL SAC LAM EXC ISPI LES OTH/THN NEO IDRL CRV LAM EXC ISPI LES OTH/THN NEO IDRL THRC CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

161 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule LAM EXC ISPI LES OTH/THN NEO IDRL LMBR LAM EXC ISPI LES OTH/THN NEO IDRL SAC LAM BX/EXC ISPI NEO XDRL CRV LAM BX/EXC ISPI NEO XDRL THRC LAM BX/EXC ISPI NEO XDRL LMBR LAM BX/EXC ISPI NEO XDRL SAC LAM BX/EXC ISPI NEO IDRL XMED CRV LAM BX/EXC ISPI NEO IDRL XMED THRC LAM BX/EXC ISPI NEO IDRL XMED LMBR LAM BX/EXC ISPI NEO IDRL SAC LAM BX/EXC ISPI NEO IDRL IMED CRV LAM BX/EXC ISPI NEO IDRL IMED THRC LAM BX/EXC ISPI NEO IDRL IMED THORACOLMBR LAM BX/EXC ISPI NEO XDRL-IDRL LES ANY LVL OSTPL RCNSTJ DORSAL SPI ELMNTS FLWG ISPI PX ZZZ VCRPEC LES 1 SGM XDRL CRV VCRPEC LES 1 SGM XDRL THRC TTHRC VCRPEC LES 1 SGM XDRL THRC THORACOLMBR VCRPEC LES 1 SGM XDRL LMBR/SAC TRANSPRTL/RPR VCRPEC LES 1 SGM IDRL CRV VCRPEC LES 1 SGM IDRL THRC TTHRC VCRPEC LES 1 SGM IDRL THRC THORACOLMBR VCRPEC LES 1 SGM IDRL LMBR/SAC TRANSPRTL/RPR VCRPEC LES 1 SGM EA SGM ZZZ CRTJ LES SPI CORD STRTCTC PRQ STRTCTC STIMJ SPI CORD PRQ SPX N/FLWD OTH SURG STRTCTC BX ASPIR/EXC LES SPI CORD STEREOTACTIC RADIOSURGERY 1 SPINAL LESION STEREOTACTIC RADIOSURGERY EA ADDL SPINAL LESION ZZZ PRQ IMPLTJ NSTIM ELTRD RA EDRL LAM IMPLTJ NSTIM ELTRDS PLATE/PADDLE EDRL RMVL SPINAL NSTIM ELTRD PRQ ARRAY INCL FLUOR RMVL SPINAL NSTIM ELTRD PLATE/PADDLE INCL FLUOR REVJ INCL RPLCMT NSTIM ELTRD PRQ RA INCL FLUOR REVJ INCL RPLCMT NSTIM ELTRD PLT/PDLE INCL FLUOR INSJ/RPLCMT SPI NPGR DIR/INDUXIVE COUPLING REVJ/RMVL IMPLTED SPI NPGR RPR MENINGOCELE < 5 CM DIAM RPR MENINGOCELE > 5 CM DIAM RPR MYELOMENINGOCELE < 5 CM DIAM RPR MYELOMENINGOCELE > 5 CM DIAM RPR DURAL/CEREBSP FLU LEAK X REQ LAM RPR DURAL/CSF LEAK/PSEUDOMENINGOCELE W/LAM DURAL GRF SPI CRTJ SHUNT LMBR SARACH-PRTL-PLEURAL/OTH W/LAM CRTJ SHUNT LMBR SARACH-PRTL-PLEURAL PRQ X LAM Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 157

162 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, RPLCMT IRRIGATION/REVJ LUMBOSARACH SHUNT RMVL ENTIRE LUMBOSARACH SHUNT SYS W/O RPLCMT NJX ANES TRIGEMINAL NRV ANY DIV/BRANCH NJX ANES FACIAL NRV NJX ANES GRTER OCCIPITAL NRV NJX ANES VAGUS NRV NJX ANES PHRENIC NRV NJX ANES SPI ACCESSORY NRV NJX ANES CRV PLEXUS SINGLE NERVE BLOCK INJECTION ARM NERVE INJECTION ANES BRACHIAL PLEXUS CONT NFS CATH NJX ANES AX NRV NJX ANES SUPRASCAPULAR NRV NJX ANES INTERCOSTAL NRV MULTIPLE NERVE BLOCK INJECTIONS RIB NERVES NJX ANES ILIOINGUN ILIOHYPOGSTR NRV NJX ANES PUDENDAL NRV NJX ANES PARACRV NRV NJX ANES SCIATIC NRV INJECTION ANES SCIATIC NERVE CONT INFUSION CATH NJX ANES FEM NRV INJECTION ANES FEMORAL NERVE CONT INFUSION CATH INJECTION ANES LUMBAR PLEXUS POST CONT NFS CATH NJX ANES OTH PRPH NRV/BRANCH NJX ANES&/STEROID PLANTAR COMMON DIGITAL NERVE s NJX ANES&/STRD W/IMG TFRML EDRL CRV/THRC 1 LVL s NJX ANES&/STRD W/IMG TFRML EDRL CRV/THRC EA LVL ZZZ s NJX ANES&/STRD W/IMG TFRML EDRL LMBR/SAC 1 LVL s NJX ANES&/STRD W/IMG TFRML EDRL LMBR/SAC EA LVL ZZZ NJX DX/THER AGT PVRT FACET JT CRV/THRC 1 LEVEL NJX DX/THER AGT PVRT FACET JT CRV/THRC 2ND LEVEL ZZZ NJX DX/THER AGT PVRT FACET JT CRV/THRC 3+ LEVEL ZZZ NJX DX/THER AGT PVRT FACET JT LMBR/SAC 1 LEVEL NJX DX/THER AGT PVRT FACET JT LMBR/SAC 2ND LEVEL ZZZ NJX DX/THER AGT PVRT FACET JT LMBR/SAC 3+ LEVEL ZZZ NJX ANES SPHENOPALATINE GANGLION NJX ANES CRTD SINUS SPX NJX ANES STELLATE GANGLION CRV SYMPATHETIC NJX ANES SUPRIOR HYPOGSTR PLEXUS NJX ANES LMBR/THRC PVRT SYMPATHETIC NJX ANES CELIAC PLEXUS +-RAD MNTR APPL SURF TC NSTIM PRQ IMPLTJ NSTIM ELTRDS CRNL NRV PRQ IMPLTJ NSTIM ELTRDS PRPH NRV PRQ IMPLTJ NSTIM ELTRDS AUTONOMIC NRV PRQ IMPLTJ NSTIM ELTRDS SAC NRV CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

163 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule PRQ IMPLTJ NSTIM ELTRDS NEUROMUSCULAR l POST TIB NEUROSTIMULATION PRQ NEEDLE ELECTRODE l INC IMPLTJ CRNL NRV NSTIM ELTRDS & PULSE GENER l REVISION/REPLMT NSTIM CRNL ELTRDS l REMOVAL CRNL NRV NSTIM ELTRDS & PULSE GENERATOR s INC IMPLTJ PERIPH NRV NSTIM ELTRDS INC IMPLTJ NSTIM ELTRDS AUTONOMIC NRV INC IMPLTJ NSTIM ELTRDS NEUROMUSCULAR INC IMPLTJ NSTIM ELTRDS SAC NRV REVJ/RMVL PRPH NSTIM ELTRDS INSERTION/RPLCMT PERIPHERAL/GASTRIC NPGR REVISION/RMVL PERIPHERAL/GASTRIC NPGR DSTRJ TRIGEMINAL NRV SUPRAORB INFRAORB BRANCH DSTRJ NULYT TRIGEMINAL NRV 2/3 DIV DSTRJ NULYT TRIGEMINAL NRV 2/3 DIV RAD MNTR l CHEMODENERV PAROTID&SUBMANDIBL SALIVARY GLNDS BI CHEMODNRVTJ MUSC MUSC INNERVATED FACIAL NRV CHEMODNRVTJ MUSC NCK MUSC CHEMODNRVTJ MUSC XTR&/TRNK MUSC DSTRJ NULYT INTERCOSTAL NRV DSTRJ NULYT PVRT FACET JT NRV LMBR/SAC 1 LVL DSTRJ NULYT PVRT FACET JT NRV LMBR/SAC EA LVL ZZZ DSTRJ NULYT PVRT FACET JT NRV CRV/THRC 1 LVL DSTRJ NULYT PVRT FACET JT NRV CRV/THRC EA LVL ZZZ DSTRJ NULYT PUDENDAL NRV DSTRJ NEUROLYTIC PLANTAR COMMON DIGITAL NERVE DSTRJ NULYT OTH PRPH NRV/BRANCH CHEMODNRVTJ ECCRINE GLNDS BTH AX CHEMODNRVTJ ECCRINE GLNDS OTH AREA PR D DSTRJ NULYT +-RAD MNTR CELIAC PLEXUS DSTRJ NULYT +-RAD MNTR SUPRIOR HYPOGSTR PLEXUS NEURP DGTAL 1/BTH SM DGT NEURP NRV HAND/FOOT s NEURP MAJOR PRPH NRV ARM/LEG OPN OTH/THN SPEC s NEURP MAJOR PRPH NRV OPN ARM/LEG SCIATIC NRV s NEURP MAJOR PRPH NRV OPN ARM/LEG BRACH PLEXUS s NEURP MAJOR PRPH NRV OPN ARM/LEG LMBR PLEXUS NEURP&/TRPOS CRNL NRV NEURP&/TRPOS UR NRV ELBW NEURP&/TRPOS UR NRV WRST NEURP&/TRPOS MEDIAN NRV CARPL TUNNEL DCMPRN UNSPECIFIED NRV DCMPRN PLNTAR DGTAL NRV INT NEUROLSS REQ MCRSCP ZZZ TRNSXJ/AVLSN SUPRAORB NRV TRNSXJ/AVLSN INFRAORB NRV Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 159

164 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, TRNSXJ/AVLSN MENTAL NRV TRNSXJ/AVLSN INF ALVEOLAR NRV OSTEOM TRNSXJ/AVLSN LNGL NRV TRNSXJ/AVLSN FACIAL NRV DIFFIAL/COMPL TRNSXJ/AVLSN GRTER OCCIPITAL NRV TRNSXJ/AVLSN PHRENIC NRV TRNSXJ/AVLSN VAGUS NRV TTHRC TRNSXJ/AVLSN VAGUS NRV PROX STOMACH TRNSXJ/AVLSN VAGUS NRV ABDL TRNSXJ/AVLSN PUDENDAL NRV TRNSXJ/AVLSN OBTURATOR NRV XTRPEL TRNSXJ/AVLSN OBTURATOR NRV INTRAPEL TRNSXJ/AVLSN OTH CRNL NRV XDRL TRNSXJ/AVLSN OTH SPI NRV XDRL EXC NEUROMA CUTAN NRV SURGLY IDENTIFIABLE EXC NEUROMA DGTAL NRV 1/BTH SM DGT EXC NEUROMA DGTAL NRV EA DGT ZZZ EXC NEUROMA HAND/FOOT XCP DGTAL NRV EXC NEUROMA HAND/FOOT EA NRV XCP SM DGT ZZZ EXC NEUROMA MAJOR PRPH NRV XCP SCIATIC EXC NEUROMA SCIATIC NRV IMPLTJ NRV END IN B1/MUSC ZZZ EXC NEUROFIBROMA/NEUROLEMMOMA CUTAN NRV EXC NEUROFIBROMA/NEUROLEMMOMA MAJOR PRPH NRV EXC NEUROFIBROMA/NEUROLEMMOMA X10SV BX NRV SYMPTH CRV SYMPTH CERVICOTHRC SYMPTH THORACOLMBR SYMPTH LMBR SYMPTH DGTAL ARTS EA DGT SYMPTH RDL ART SYMPTH UR ART SYMPTH SUPFC PLMR ARCH SUTR DGTAL NRV HAND/FOOT 1 NRV SUTR DGTAL NRV HAND/FOOT EA DGTAL NRV ZZZ SUTURE 1 NERVE HAND/FOOT COMMON SENSORY NERVE SUTURE 1 NERVE MEDIAN MOTOR THENAR SUTURE 1 NERVE ULNAR MOTOR SUTR EA NRV HAND/FOOT ZZZ SUTR POST TIBL NRV SUTR PRPH NRV ARM/LEG XCP SCIATIC W/TRPOS SUTR PRPH NRV ARM/LEG XCP SCIATIC W/O TRPOS SUTR SCIATIC NRV SUTR EA MAJOR PRPH NRV ZZZ SUTR BRACH PLEXUS CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

165 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule SUTR LMBR PLEXUS SUTR FACIAL NRV XTRC SUTR FACIAL NRV ITPRL +-GRFG ANAST FACIAL-SPI ACCESSORY ANAST FACIAL-HYPOGLOSSAL ANAST FACIAL-PHRENIC SUTR NRV REQ SEC/DLYD SUTR ZZZ SUTR NRV REQ X10SV MOBLJ/TRPOS NRV ZZZ SUTR NRV REQ SHRT B1 XTR ZZZ NRV GRF HEAD/NCK <4 CM NRV GRF HEAD/NCK >4 CM NRV GRF 1 STRAND HAND/FOOT <4 CM NRV GRF 1 STRAND HAND/FOOT >4 CM NRV GRF 1 STRAND ARM/LEG <4 CM NRV GRF 1 STRAND ARM/LEG >4 CM NRV GRF MLT STRANDS HAND/FOOT <4 CM NRV GRF MLT STRANDS HAND/FOOT > 4 CM NRV GRF MLT STRANDS ARM/LEG <4 CM NRV GRF MLT STRANDS ARM/LEG >4 CM NRV GRF EA NRV 1 STRAND ZZZ NRV GRF EA NRV MLT STRANDS ZZZ NRV PEDCL TR 1ST STG NRV PEDCL TR 2ND STG NERVE REPAIR W/CONDUIT EA NERVE NERVE REPAIR W/AUTOGENOUS VEIN GRAFT EA NERVE UNLIS PX NRVS SYS BR YYY EVSC OC CNTS W/O IMPLT EVSC OC CNTS W/IMPLT ENCL EYE W/O IMPLT ENCL EYE IMPLT MUSC X ATTACHED IMPLT ENCL EYE IMPLT MUSC ATTACHED IMPLT EXNTJ ORBIT RMVL ORB CNTS ONLY EXNTJ ORBIT RMVL ORB CNTS W/THER RMVL B EXNTJ ORBIT RMVL ORB CNTS W/MUSC/MYOQ FLAP MODIFICAJ OC IMPLT W/PLMT/RPLCMT PEGS SPX INSJ OC IMPLT SEC AFTER EVSC SCLL SHELL INSJ OC IMPLT AFTER ENCL MUSC X ATTACHED INSJ OC IMPLT AFTER ENCL MUSC ATTACHED RINSJ OC IMPLT +-CJNCL GRF RINSJ OC IMPLT RNFCMT&/ATTACHMENT MUSC RMVL OC IMPLT RMVL FB XTRNL EYE CJNCL SUPFC RMVL FB XTRNL EYE EMBEDDED SCJNCL/SCLL NONPRF RMVL FB XTRNL EYE CRNL W/O SLIT LAMP RMVL FB XTRNL EYE CRNL W/SLIT LAMP RMVL FB IO FROM ANT CHAMBER EYE/LENS Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 161

166 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, RMVL FB IO FROM POST SGM MAG XTRJ ANT/POST ROUTE RMVL FB IO FROM POST SGM NONMAG XTRJ RPR LAC CJNC +-NONPRF8 LAC SCL DIR CLSR RPR LAC CJNC MOBLJ&REARGMT W/O HOSPIZATION RPR LAC CJNC MOBLJ&REARGMT W/HOSPIZATION RPR LAC CRN NONPRF8 +-RMVL FB RPR LAC CRN&/SCL PRF8 X INVG UVEAL TISS RPR LAC CRN&/SCL PRF8 W/REPOS/RESCJ UVEAL TISS RPR LAC APPL TISS GLUE WND CRN&/SCL RPR WND EO MUSCLE TENDON&/TENON'S CAPSULE EXC LES CRN XCP PTERYGIUM BX CRN EXC/TRPOS PTERYGIUM W/O GRF EXC/TRPOS PTERYGIUM W/GRF CORNEA SCRAPING DIAGNOSTIC SMEAR &/CULTURE RMVL CRNL EPITHE +-CHEMOCAUT RMVL CRNL EPITHE W/APPL CHELATING AGT DSTRJ LES CRN CRTX PC/THERMOCAUT MLT PNXRS ANT CRN KERATOPLASTY ANTERIOR LAMELLAR KERATOPLASTY PENTRG EXCEPT APHAKIA/PSEUDOPHAKIA KERATOPLASTY PENTRG APHK KERATOPLASTY PENTRG PSEUDOPHAKIA KERATOPLASTY ENDOTHELIAL BACKBENCH PREPJ CORNEAL ENDOTHELIAL ALLOGRAFT BR ZZZ KERATOMILEUSIS XXX KERATOPHAKIA XXX EPIKERATOPLASTY XXX KERATOPROSTH RDL KERATOTOMY XXX CRNL RELAXING INC CORRJ INDUCED ASTIGMATISM CRNL WEDGE RESCJ CORRJ INDUCED ASTIGMATISM l PLACE AMNIOTIC MEMB OCULAR SURFACE SELF RETAIN l PLACE AMNIOTIC MEMBRANE OCULAR SURFACE SUTURED s OCULAR SURFACE RECONSTRUCTION AMNIOTIC MEMBRANE OCULAR SURFACE RECONSTRUCTION LIMBAL ALLOGRAFT OCCULAR SURFACE RECONSTRUCTION LIMBAL AUTOGRAFT PCNTS EYE SPX DX ASPIR AQUEOUS PCNTS EYE SPX THER RLS AQUEOUS PCNTS EYE SPX RMVL VTS&/DSCJ MEMB PCNTS EYE SPX RMVL BLD GONIOTOMY TRABECULOTOMY AB EXTERNO TRABECULOPLASTY LASER SURG 1+ SESS SEVERING ADS ANT SGM LASER TQ SPX SEVERING ADS ANT SGM INCAL TQ SPX GONIOSYNECHIAE CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

167 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule SEVERING ADS ANT SGM INCAL SPX ANT SYNECHIAE SEVERING ADS ANT SGM INCAL SPX POST SYNECHIAE SEVERING ADS ANT SGM INCAL SPX CORNEOVITREAL RMVL EPITHELIAL DOWNGROWTH ANT CHAMBER EYE RMVL IMPLTED MATRL ANT SGM EYE RMVL BLD CLOT ANT SGM EYE NJX ANT CHAMBER EYE SPX AIR/LIQ NJX ANT CHAMBER EYE SPX MED EXC LES SCL FSTLJ SCL GLC TREPH IRDEC FSTLJ SCL GLC THERMOCAUT IRDEC FSTLJ SCL GLC SCLERCOMY PUNCH/SCISSORS IRDEC FSTLJ SCL GLC IRIDENCLEISIS/IRIDOTASIS FSTLJ SCL GLC TRBEC AB EXTERNO FSTLJ SCL GLC TRBEC AB EXTERNO SCARRING l TRLUML DILAT AQUEOUS CANAL W/O DEV/STNT l TRLUML DILAT AQUEOUS CANAL W/DEV/STNT AQUEOUS SHUNT EO RSVR REVJ AQUEOUS SHUNT EO RSVR RPR SCLL STAPHYLOMA W/O GRF RPR SCLL STAPHYLOMA W/GRF REVJ/RPR OPRATIVE WND ANT SGM IRIDOTOMY STAB INC SPX XCP TRANSFIXION IRIDOTOMY STAB INC SPX TRANSFIXION IRDEC CRNLSCLRL/CRNL SCTJ RMVL LES IRDEC CRNLSCLRL/CRNL SCTJ CYCLECTOMY IRDEC CRNLSCLRL/CRNL SCTJ PRPH GLC SPX IRDEC CRNLSCLRL/CRNL SCTJ SECTOR GLC SPX IRDEC CRNLSCLRL/CRNL SCTJ OPTICAL SPX RPR IRIS CILIARY BDY SUTR IRIS CILIARY BDY SPX RETRIEVAL SUTR CILIARY BDY DSTRJ DTHRM CILIARY BDY DSTRJ CYCLOPC TRANSSCLL CILIARY BDY DSTRJ CYCLOPC NDSC K CILIARY BDY DSTRJ CRTX CILIARY BDY DSTRJ CYCLODIAL s IRIDOTOMY/IRDEC LASER SURG PER SESSION IRIDOPLASTY PC 1+ SESS DSTRJ CST/LES IRIS/CILIARY BDY DSCJ SEC MEMBRANOUS CTRC STAB INC POST-CATARACT LASER SURGERY RPSG IO LENS PROSTH REQ INC SPX RMVL SEC MEMBRANOUS CTRC CORNEO-SCLL SCTJ RMVL LENS MATRL ASPIR TQ 1+ STGS RMVL LENS MATRL PHACOFRAGMENTATION ASPIR RMVL LENS MATRL PARS PLNA APPR +-VTRC Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 163

168 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, RMVL LENS MATRL ICAPSL REMOVAL LENS MATRL INTRACAPSULAR DISLOCATED LENS RMVL LENS MATRL XCAPSL XCAPSL CTRC RMVL INSJ LENS PROSTH 1 STG ICAPSL CTRC XTRJ INSJ IO LENS PROSTH 1 STG CATARACT REMOVAL INSERTION OF LENS INSJ IO LENS PROSTH X W/CNCRNT RMVL EXCHNG IO LENS USE OPH ENDOSCOPE ZZZ UNLIS ANT SGM EYE BR YYY RMVL VTS ANT APPR PRTL RMVL RMVL VTS ANT APPR STOT RMVL VTRC ASPIR/RLS FLU PARS PLNA NJX VTS SUB PARS PLNA/LIMBAL SPX IMPLTJ INTRAVITREAL DRUG DLVR SYS RMVL VTS INTRAVITREAL NJX PHARMACOLOGIC AGT SPX DSCJ VTS STRANDS PARS PLNA SEVERING VTS STRANDS LASER 1+ STGS VTRC MCHNL PARS PLNA VTRC MCHNL PARS PLNA FOCAL ENDOLASER PC VTRC MCHNL PARS PLNA ENDOLASER PANRTA PC VITRECTOMY PARS PLANA REMOVE PRERETINAL MEMBRANE VITRECTOMY PARS PLANA REMOVE INT MEMB RETINA VITRECTOMY PARS PLANA REMOVE SUBRETINAL MEMBRANE RPR RTA DTCHMNT 1+ SESS CRTX/DTHRM +-DRG RPR RTA DTCHMNT 1+ SESS PC +-DRG SUBRTA RPR RTA DTCHMNT SCLL BUCKLING +-IMPLT RPR RTA DTCHMNT W/VTRC ANY METH RPR RTA DTCHMNT NJX AIR/OTH GAS RPR RTA DTCHMNT SCLL BUCKLING/VTRC PT RPR COMPLEX RETINA DETACH VITRECTOMY & MEMB PEEL RLS ENCIRCLING MATRL RMVL IMPLTED MATRL POST SGM EO RMVL IMPLTED MATRL POST SGM IO PROPH RTA DTCHMNT W/O DRG 1+ SESS CRTX DTHRM PROPH RTA DTCHMNT W/O DRG 1+ SESS DSTRJ LOCLZD LES RETINA 1+ SESS CRTX DTHRM DSTRJ LOCLZD LES RETINA 1+ SESS PC DSTRJ LES RETINA 1+ SESS RADJ IMPLTJ DSTRJ LES CHOROID PC 1+ SESS DSTRJ LES CHOROID PDT DSTRJ LES CHOROID PDT 2ND EYE 1 SESS ZZZ DESTRUCTION RETINOPATHY 1+ SESS DIATHERMY EXTENSIVE RETINOPATHY 1+ SESS PHOTOCOAGULATION EXTENSIVE RETINOPATHY 1+ SESS PRETERM INFANT SCLL RNFCMT SPX W/O GRF CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

169 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule SCLL RNFCMT SPX W/GRF UNLIS POST SGM BR YYY STRABISMUS RECESSION/RESCJ 1 HRZNTL MUSC STRABISMUS RECESSION/RESCJ 2 HRZNTL MUSC STRABISMUS RECESSION/RESCJ 1 VER MUSC STRABISMUS RECESSION/RESCJ 2/MORE VER MUSC STRABISMUS ANY SUPRIOR OBLQ MUSC TRPOS ANY EO MUSC ZZZ STRABISMUS PREVIOUS EYE X INVOLVE EO MUSC ZZZ STRABISMUS SCARRING EO MUSC/RSTCV MYOPATHY ZZZ STRABISMUS POST FIXJ SUTR TQ +-MUSC RECESSION ZZZ PLMT ADJUSTABLE SUTR STRABISMUS ZZZ STRABISMUS EXPL&/RPR DETACHED EO MUSC ZZZ RLS X10SV SCAR TISS W/O DETACHING EO MUSC SPX CHEMODNRVTJ EO MUSC BIOPSY EXTRAOCULAR MUSCLE UNLIS OC MUSC BR YYY ORBT W/O B1 FLAP EXPL +-BX ORBT W/O B1 FLAP DRG ONLY ORBT W/O B1 FLAP RMVL LES ORBT W/O B1 FLAP RMVL FB ORBT W/O B1 FLAP RMVL B1 DCMPRN FINE NDL ASPIR ORB CNTS ORBT B1 FLAP/WINDOW LAT RMVL LES ORBT B1 FLAP/WINDOW LAT RMVL FB ORBT B1 FLAP/WINDOW LAT DRG ORBT B1 FLAP/WINDOW LAT RMVL B1 DCMPRN ORBT B1 FLAP/WINDOW LAT EXPL +-BX RETROBULBAR NJX MED SPX RETROBULBAR NJX ALCOHOL NJX MED/OTHER SBST TENON'S CAPSULE ORB IMPLT INSJ ORB IMPLT RMVL/REVJ OPTIC NRV DCMPRN UNLIS ORBIT BR YYY BLEPHAROTOMY DRG ABSC EYELID SEVERING TARSORRHAPHY CANTHOTOMY SPX EXC CHALAZION EXC CHALAZION MLT SM LID EXC CHALAZION MLT DIFF LIDS EXC CHALAZION ANES REQ HOSPIZATION 1/MLT BX EYELID CORRJ TRICHIASIS EPILATION FORCEPS ONLY CORRJ TRICHIASIS EPILATION OTH/THN FORCEPS CORRJ TRICHIASIS INC LID MRGN Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 165

170 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, CORRJ TRICHIASIS INC LID MRGN W/FR MUC MEMB GRF EXC LES EYELID W/O CLSR/W/SMPL DIR CLSR DSTRJ LES LID MRGN <1 CM TEMP CLSR EYELIDS SUTR CONSTJ ADS MEDIAN TRPH/CTRPH CONSTJ ADS MEDIAN TRPH/CTRPH TRPOS PLATE RPR BROW PTOSIS RPR BLPOS FRNTIS MUSC SUTR/OTH MATRL RPR BLPOS FRNTIS MUSC AUTOL FSCAL SLING RPR BLPOS LEVATOR RESCJ/ADVMNT INT RPR BLPOS LEVATOR RESCJ/ADVMNT XTRNL RPR BLPOS SUPRIOR RECTUS FSCAL SLING RPR BLPOS CONJUNCTIVO-TARSO-MUSC-LEVATOR RESCJ RDCTJ >CORRJ PTOSIS CORRJ LID RETRCJ CORRJ LAGOPHTHALMOS IMPLTJ UPR EYELID LID LOAD RPR ECTROPION SUTR RPR ECTROPION THERMOCAUT RPR ECTROPION EXC TARSAL WEDGE RPR ECTROPION X10SV RPR ENTROPION SUTR RPR ENTROPION THERMOCAUT RPR ENTROPION EXC TARSAL WEDGE RPR ENTROPION X10SV SUTR RECENT WND EYELID PRTL THKNS SUTR RECENT WND EYELID FULL THKNS RMVL EMBEDDED FB EYELID CANTHOPLASTY EXC&RPR EYELID < ONE-4TH LID MRGN EXC&RPR EYELID > ONE-4TH LID MRGN RCNSTJ EYELID FULL THKNS < 2-3RD 1 STG RCNSTJ EYELID FULL THKNS TOT LWR 1 STG RCNSTJ EYELID FULL THKNS TOT UPR 1 STG RCNSTJ EYELID FULL THKNS 2ND STG UNLIS EYELIDS BR YYY INC CJNC DRG CST EXPRESSION CJNCL FOLLICLES BX CJNC EXC LES CJNC UP 1 CM EXC LES CJNC > 1 CM EXC LES CJNC W/ADJ SCL DSTRJ LES CJNC SCJNCL NJX CJP CJNCL GRF/X10SV REARGMT CJP BUCCAL MUC MEMB GRF CJP RCNSTJ CUL-DE-SAC CJNCL GRF/REARGMT CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

171 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule CJP RCNSTJ CUL-DE-SAC BUCCAL MUC MEMB GRF RPR SYMBLEPHARON CJP W/O GRF RPR SYMBLEPHARON FR GRF CJNC/BUCCAL MUC MEMB RPR SYMBLEPHARON DIV CJNCL FLAP BRIDGE/PRTL SPX CJNCL FLAP TOT HRVG CJNCL ALGRFT LIV DON UNLIS CJNC BR YYY INC DRG LACRIMAL GLND INC DRG LACRIMAL SAC SNIP INC LACRIMAL PUNCTUM EXC LACRIMAL GLND XCP TUM TOT EXC LACRIMAL GLND XCP TUM PRTL BX LACRIMAL GLND EXC LACRIMAL SAC BX LACRIMAL SAC RMVL FB/DACRYOLITH LACRIMAL PSAGES EXC LACRIMAL GLND TUM FRNT APPR EXC LACRIMAL GLND TUM INVG OSTEOM PLSTC RPR CANALICULI CORRJ EVERTED PUNCTUM CAUT DACRYOCSTORHINOSTOMY CONJUNCTIVORHINOSTOMY W/O TUBE CONJUNCTIVORHINOSTOMY INSJ TUBE/STENT CLSR LACRIMAL PUNCTUM THERMOCAUT LIG/LASER CLSR LACRIMAL PUNCTUM PLUG EA CLSR LACRIMAL FSTL SPX DILAT LACRIMAL PUNCTUM +-IRRG PROBE NASOLACRIMAL DUX +-IRRG PROBE NASOLACRIMAL DUX +-IRRG ANES PROBE NASOLACRIMAL DUX +-IRRG INSJ TUBE/STENT PROBE NASOLACRIMAL DUCT WITH CATHETER DILATION PROBE LACRIMAL CANALICULI +-IRRG NJX CNTRST MEDIUM DACRYOCSTOGRAPY UNLIS LACRIMAL SYS BR YYY DRG XTRNL EAR ABSC/HMTMA SMPL DRG XTRNL EAR ABSC/HMTMA COMP DRG XTRNL AUD CANAL ABSC EAR PIERCING XXX BX XTRNL EAR BX XTRNL AUD CANAL EXC XTRNL EAR PRTL SMPL RPR EXC XTRNL EAR COMPL AMP EXC EXOSTOSIS XTRNL AUD CANAL EXC SOFT TISS LES XTRNL AUD CANAL RAD EXC XTRNL AUD CANAL LES W/O NCK DSJ Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 167

172 Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY Medical Fee Schedule Effective April 1, RAD EXC XTRNL AUD CANAL LES NCK DSJ RMVL FB XTRNL AUD CANAL W/O ANES RMVL FB XTRNL AUD CANAL ANES RMVL IMPACTED CERUMEN SPX 1/BTH EARS DBRDMT MSTDC CAVITY SMPL DBRDMT MSTDC CAVITY CPLX K OTOPLASTY PROTRUDING EAR +-SIZE RDCTJ YYY RCNSTJ XTRNL AUD CANAL SPX RCNSTJ XTRNL AUD CANAL CGEN ATRESIA 1 STG UNLIS XTRNL EAR BR YYY EUSTACHIAN TUBE NFLTJ TRANSNSL CATHJ EUSTACHIAN TUBE NFLTJ TRANSNSL W/O CATHJ EUSTACHIAN TUBE CATHJ TRANSTYMPANIC MRGT ASPIR&/EUSTACHIAN TUBE NFLTJ MRGT ASPIR&/EUSTACHIAN TUBE NFLTJ ANES VENTILATING TUBE RMVL ANES TMPST LOCAL/TOPICAL ANES TMPST ANES MIDDLE EAR EXPL THRU POSTAUR/EAR CANAL INC TYMPANOLSS TRANSCANAL TRANSMASTOID ANTRT MSTDC COMPL MSTDC MODF RAD MSTDC RAD PETROUS APICECTOMY RAD MSTDC RESCJ TEMPORAL B1 XTRNL EXC AURAL POLYP EXC AURAL GLOMUS TUM TRANSCANAL EXC AURAL GLOMUS TUM TRANSMASTOID EXC AURAL GLOMUS TUM EXTND REVJ MSTDC RSLTG COMPL MSTDC REVJ MSTDC RSLTG MODF RAD MSTDC REVJ MSTDC RSLTG RAD MSTDC REVJ MSTDC RSLTG TMPP REVJ MSTDC W/APICECTOMY TYMPANIC MEMB RPR +-SIT PREPJ PRF8J PATCH MYRINGOPLASTY TMPP W/O MSTDC 1ST/REVJ W/O OCR TMPP W/O MSTDC 1ST/REVJ OCR TMPP W/O MSTDC 1ST/REVJ PROSTH TORP TMPP ANTRT/MASTOIDOTOMY W/O OCR TMPP ANTRT/MASTOIDOTOMY OCR TMPP ANTRT/MASTOIDOTOMY PROSTH TORP TMPP MSTDC W/O OCR TMPP MSTDC OCR TMPP MSTDC NTC/RCNSTED WALL W/O OCR CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

173 Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule SURGERY Effective April 1, 2011 Medical Fee Schedule TMPP MSTDC NTC/RCNSTED CANAL WALL OCR TMPP MSTDC RAD/COMPL W/O OCR TMPP MSTDC RAD/COMPL OCR STAPES MOBLJ STAPEDECTOMY/STAPEDOTOMY STAPEDECTOMY/STAPEDOTOMY W/FOOTPLATE DRILL OUT REVJ STAPEDECTOMY/STAPEDOTOMY RPR OVAL WINDOW FSTL RPR ROUND WINDOW FSTL MASTOID OBLTRJ SPX TYMPANIC NEURECTOMY CLSR POSTAUR FSTL MASTOID SPX IMPLTJ/RPLCMT EMGNT B1 CNDJ DEV TEMPORAL B1 BR XXX RMVL/RPR EMGNT B1 CNDJ DEV TEMPORAL B IMPLTJ OI IMPLT B1 W/O MSTDC IMPLTJ OI IMPLT B1 MSTDC RPLCMT OI IMPLT B1 W/O MSTDC RPLCMT OI IMPLT B1 MSTDC DCMPRN NRV ITPRL LAT GENICULATE DCMPRN NRV ITPRL MEDIAL GENICULATE SUTR NRV ITPRL +-GRF/DCMPRN LAT GENICULATE SUTR NRV ITPRL +-GRF/DCMPRN MEDIAL GENICULATE UNLIS MIDDLE EAR BR YYY s LABYRINTHOTOMY TRANSCANAL s LABYRINTHOTOMY MASTOIDECTOMY ENDOLYMPHATIC SAC W/O SHUNT ENDOLYMPHATIC SAC SHUNT FENESTRATION SEMICIRCULAR CANAL REVJ FENESTRATION OPRATION LABYRINTHECTOMY TRANSCANAL LABYRINTHECTOMY MSTDC VSTBLR NRV SCTJ TRANSLABYRINTHINE APPR COCHLEAR DEV IMPLTJ +-MSTDC UNLIS INNER EAR BR YYY VSTBLR NRV SCTJ TRANSCRNL TOT FACIAL NRV DCMPRN&/RPR DCMPRN INT AUD CANAL RMVL TUM TEMPORAL B UNLIS TEMPORAL B1 MIDDLE FOSSA BR YYY MICROSURG TQS REQ USE OPRATING MCRSCP ZZZ Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 169

174

175 Section VIII: Diagnostic and Therapeutic Radiological Services SUBSECTION A: PAYMENT GROUND RULES FOR DIAGNOSTIC AND 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 combined 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 Consultation with the authorized treating physician A written report, signed by the 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 five-digit CPT 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 will be allowed. The TC includes the charges for personnel, materials (including ionic contrast media and drugs), film or xerography or digital images, 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 modifier TC. 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. 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 ) are included in the contrast studies. Subject Listings Subject listings apply when radiological services are performed by or under the responsible supervision of a physician. CPT only 2010 American Medical Association. All Rights Reserved. 171

176 Georgia Workers Compensation Medical Fee Schedule Supervision and Interpretation Radiology services containing an invasive component are reported by the radiologist for supervision of the procedure and the personnel involved with performing the examination, reading the film, and preparing the written report. The injection is administered and coded with the appropriate code outside the Radiology (70000 series) section and a code for the radiological portion of the procedure is designated as the supervision and interpretation portion. These services may be performed by a single physician who reports both services or may be split between a radiologist and another physician. Radiation oncology services are not considered to be part of the supervision and interpretation procedures. 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 CPT code is reimbursable. The review of diagnostic tests is included in the evaluation and 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. Injection Procedure Fees include all usual pre- and postinjection 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. Procedures that include with contrast are considered to be those intravascular, intra-articular, or intrathecal injections of contrast for imaging services. Contrasted studies include computed tomography (CT), computed tomographic angiography (CTA), magnetic resonance imaging (MRI), and magnetic resonance angiography (MRA). Administration of oral or rectal contrast media does not necessarily meet the guidelines of a contrasted study. Intra-articular joint injections are reported with the codes that identify the specific joint. Arthrography, when performed, is reported using the supervision and interpretation code for the specific joint. Specific imaging Section VIII: Diagnostic and Therapeutic Radiological Services modalities of CT or MRI should also be reported when performed whether the sole procedure or in combination with an arthrography. The appropriate code identifying multiple images should be used when non-contrasted and contrasted studies are performed at the same session. Intravascular or intrathecal injections are included in spinal CT, MRI, or MRA contrasted studies. Codes or may also be used to report intrathecal injections. No separate reimbursement is made for intravascular (IV) injections. 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. Unusual Service or Procedure Services that may necessitate skills and time of the physician over and above that usually required should be substantiated by report (see section IV). Unlisted Service or Procedure Some services performed are not described by any CPT code. Unlisted services should be reported using an unlisted code and substantiated by report. The unlisted services and accompanying codes are listed at the end of each Radiology subsection. Unlisted service or procedure codes must be selected from the appropriate subsection of the Radiology chapter. For these procedures a BR (by report) designation has been used in the fee schedule. Reimbursement for such procedures must be justified by report (see section IV). SUBSECTION B: PAYMENT MODIFIERS FOR DIAGNOSTIC AND 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 the appropriate modifier following the procedure code. When two modifiers are applicable to a single code, indicate each modifier on the bill. 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 (Evaluation and Management Services, 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. 172 CPT only 2010 American Medical Association. All Rights Reserved.

177 Section VIII: Diagnostic and Therapeutic Radiological Services The following modifiers will be recognized for reimbursement by the fee schedule for diagnostic and therapeutic radiology services codes: 22 Increased Procedural Services: When the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. Documentation must support the substantial additional work and the reason for the additional work (i.e., increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). Note: This modifier should not be appended to an E/M service. 26 Professional Component: 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 modifier 26 to the usual procedure number. 50 Bilateral Procedure: Unless otherwise identified in the listings, bilateral procedures that are performed at the same session should be identified by adding modifier 50 to the appropriate five-digit code. Unless otherwise indicated, the total reimbursed for the bilateral procedure is 150 percent of the fee schedule for unilateral surgery. 52 Reduced Services: Under certain circumstances, a service or procedure is partially reduced or eliminated at the physician s discretion. Under these circumstances, the service provided can be identified by its usual procedure number and the addition of modifier 52 signifying that the service is reduced. This provides a means of reporting reduced services without disturbing the identification of the basic service. Note: For hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for ASC hospital outpatient use). 53 Discontinued Procedure: Under certain circumstances, the physician may elect to terminate 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 modifier 53 to the code reported by the physician for the discontinued procedure. 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. For outpatient hospital/ambulatory Georgia Workers Compensation Medical Fee Schedule surgery center (ASC) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for ASC hospital outpatient use). 59 Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision or 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 individual. 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. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-e/m service performed on the same date, see modifier Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional: It may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. This circumstance may be reported by adding modifier 76 to the repeated procedure or service. Note: This modifier should not be appended to an E/M service. 77 Repeat Procedure or Service by Another Physician or Other Qualified Health Care Professional: It may be necessary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service. This circumstance may be reported by adding modifier 77 to the repeated procedure or service. Note: This modifier should not be appended to an E/M service. 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. CPT only 2010 American Medical Association. All Rights Reserved. 173

178 Georgia Workers Compensation Medical Fee Schedule LT Left Side: Used to identify procedures performed on the left side of the body. RT Right Side: Used to identify procedures performed on the right side of the body. TC Technical Component Only: Certain procedures are a combination of a physician component and a technical Section VIII: Diagnostic and Therapeutic Radiological Services component. When the technical component is reported separately, the service may be identified by adding modifier TC to the usual procedure number. 174 CPT only 2010 American Medical Association. All Rights Reserved.

179 Section VIII: Diagnostic and Therapeutic Radiological Services Georgia Workers Compensation Medical Fee Schedule RADIOLOGY Effective April 1, 2011 Medical Fee Schedule MYELOGRAPY POST FOSSA RS&I XXX MYELOGRAPY POST FOSSA RS&I XXX TC MYELOGRAPY POST FOSSA RS&I XXX CISTRNG POSITIVE CNTRST RS&I XXX CISTRNG POSITIVE CNTRST RS&I XXX TC CISTRNG POSITIVE CNTRST RS&I XXX RADEX EYE DETCJ FB XXX RADEX EYE DETCJ FB XXX TC RADEX EYE DETCJ FB XXX RADEX MNDBL PRTL < 4 VIEWS XXX RADEX MNDBL PRTL < 4 VIEWS XXX TC RADEX MNDBL PRTL < 4 VIEWS XXX RADEX MNDBL COMPL MINIMUM 4 VIEWS XXX RADEX MNDBL COMPL MINIMUM 4 VIEWS XXX TC RADEX MNDBL COMPL MINIMUM 4 VIEWS XXX RADEX MASTOIDS < 3 VIEWS PR SIDE XXX RADEX MASTOIDS < 3 VIEWS PR SIDE XXX TC RADEX MASTOIDS < 3 VIEWS PR SIDE XXX RADEX MASTOIDS COMPL MINIMUM 3 VIEWS PR SIDE XXX RADEX MASTOIDS COMPL MINIMUM 3 VIEWS PR SIDE XXX TC RADEX MASTOIDS COMPL MINIMUM 3 VIEWS PR SIDE XXX RADEX INT AUD MEATI COMPL XXX RADEX INT AUD MEATI COMPL XXX TC RADEX INT AUD MEATI COMPL XXX RADEX FACIAL B1S < 3 VIEWS XXX RADEX FACIAL B1S < 3 VIEWS XXX TC RADEX FACIAL B1S < 3 VIEWS XXX RADEX FACIAL B1S COMPL MINIMUM 3 VIEWS XXX RADEX FACIAL B1S COMPL MINIMUM 3 VIEWS XXX TC RADEX FACIAL B1S COMPL MINIMUM 3 VIEWS XXX RADEX NSL B1S COMPL MINIMUM 3 VIEWS XXX RADEX NSL B1S COMPL MINIMUM 3 VIEWS XXX TC RADEX NSL B1S COMPL MINIMUM 3 VIEWS XXX DACRYOCSTOGRAPY NASOLACRIMAL DUX RS&I XXX DACRYOCSTOGRAPY NASOLACRIMAL DUX RS&I XXX TC DACRYOCSTOGRAPY NASOLACRIMAL DUX RS&I XXX RADEX OPTIC FORAMINA XXX RADEX OPTIC FORAMINA XXX TC RADEX OPTIC FORAMINA XXX RADEX ORBITS COMPL MINIMUM 4 VIEWS XXX RADEX ORBITS COMPL MINIMUM 4 VIEWS XXX TC RADEX ORBITS COMPL MINIMUM 4 VIEWS XXX RADEX SINUSES PARANSL < 3 VIEWS XXX RADEX SINUSES PARANSL < 3 VIEWS XXX TC RADEX SINUSES PARANSL < 3 VIEWS XXX RADEX SINUSES PARANSL COMPL MINIMUM 3 VIEWS XXX + Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 175

180 Georgia Workers Compensation Medical Fee Schedule Section VIII: Diagnostic and Therapeutic Radiological Services RADIOLOGY Medical Fee Schedule Effective April 1, RADEX SINUSES PARANSL COMPL MINIMUM 3 VIEWS XXX TC RADEX SINUSES PARANSL COMPL MINIMUM 3 VIEWS XXX RADEX SELLA TURCICA XXX RADEX SELLA TURCICA XXX TC RADEX SELLA TURCICA XXX RADEX SKL < 4 VIEWS XXX RADEX SKL < 4 VIEWS XXX TC RADEX SKL < 4 VIEWS XXX RADEX SKL COMPL MINIMUM 4 VIEWS XXX RADEX SKL COMPL MINIMUM 4 VIEWS XXX TC RADEX SKL COMPL MINIMUM 4 VIEWS XXX RADEX TEETH 1 VIEW XXX RADEX TEETH 1 VIEW XXX TC RADEX TEETH 1 VIEW XXX RADEX TEETH PRTL XM < FULL MOUTH XXX RADEX TEETH PRTL XM < FULL MOUTH XXX TC RADEX TEETH PRTL XM < FULL MOUTH XXX RADEX TEETH COMPL FULL MOUTH XXX RADEX TEETH COMPL FULL MOUTH XXX TC RADEX TEETH COMPL FULL MOUTH XXX RADEX TMPRMAND JT OPN&CLSD MOUTH UNI XXX RADEX TMPRMAND JT OPN&CLSD MOUTH UNI XXX TC RADEX TMPRMAND JT OPN&CLSD MOUTH UNI XXX RADEX TMPRMAND JT OPN&CLSD MOUTH BI XXX RADEX TMPRMAND JT OPN&CLSD MOUTH BI XXX TC RADEX TMPRMAND JT OPN&CLSD MOUTH BI XXX TMPRMAND JT ARTHG RS&I XXX TMPRMAND JT ARTHG RS&I XXX TC TMPRMAND JT ARTHG RS&I XXX MRI TMPRMAND JT XXX MRI TMPRMAND JT XXX TC MRI TMPRMAND JT XXX CEPHALOGRAM ORTHODONTIC XXX CEPHALOGRAM ORTHODONTIC XXX TC CEPHALOGRAM ORTHODONTIC XXX ORTHOPANTOGRAM XXX ORTHOPANTOGRAM XXX TC ORTHOPANTOGRAM XXX RADEX NCK SOFT TISS XXX RADEX NCK SOFT TISS XXX TC RADEX NCK SOFT TISS XXX RADEX PHARYNX/LARX W/FLUOR&/MAGNIFICATION TQ XXX RADEX PHARYNX/LARX W/FLUOR&/MAGNIFICATION TQ XXX TC RADEX PHARYNX/LARX W/FLUOR&/MAGNIFICATION TQ XXX CPLX DYNAMIC PHARYNGEAL&SP EVAL C/V REC XXX CPLX DYNAMIC PHARYNGEAL&SP EVAL C/V REC XXX + Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure 176 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

181 Section VIII: Diagnostic and Therapeutic Radiological Services Georgia Workers Compensation Medical Fee Schedule RADIOLOGY Effective April 1, 2011 Medical Fee Schedule TC CPLX DYNAMIC PHARYNGEAL&SP EVAL C/V REC XXX LARYNGOGRAPY CNTRST RS&I XXX LARYNGOGRAPY CNTRST RS&I XXX TC LARYNGOGRAPY CNTRST RS&I XXX RADIOLOGIC EXAMINATION SALIVARY GLAND CALCULUS XXX RADIOLOGIC EXAMINATION SALIVARY GLAND CALCULUS XXX TC RADIOLOGIC EXAMINATION SALIVARY GLAND CALCULUS XXX SIALOGRAPY RS&I XXX SIALOGRAPY RS&I XXX TC SIALOGRAPY RS&I XXX CT HEAD/BRN C-MATRL XXX CT HEAD/BRN C-MATRL XXX TC CT HEAD/BRN C-MATRL XXX CT HEAD/BRN C+ MATRL XXX CT HEAD/BRN C+ MATRL XXX TC CT HEAD/BRN C+ MATRL XXX CT HEAD/BRN C-/C XXX CT HEAD/BRN C-/C XXX TC CT HEAD/BRN C-/C XXX CT ORBIT SELLA/POST FOSSA/EAR C-MATRL XXX CT ORBIT SELLA/POST FOSSA/EAR C-MATRL XXX TC CT ORBIT SELLA/POST FOSSA/EAR C-MATRL XXX CT ORBIT SELLA/POST FOSSA/EAR C+ MATRL XXX CT ORBIT SELLA/POST FOSSA/EAR C+ MATRL XXX TC CT ORBIT SELLA/POST FOSSA/EAR C+ MATRL XXX CT ORBIT SELLA/POST FOSSA/EAR C-/C XXX CT ORBIT SELLA/POST FOSSA/EAR C-/C XXX TC CT ORBIT SELLA/POST FOSSA/EAR C-/C XXX CT MAXLFCL AREA C-MATRL XXX CT MAXLFCL AREA C-MATRL XXX TC CT MAXLFCL AREA C-MATRL XXX CT MAXLFCL AREA C+ MATRL XXX CT MAXLFCL AREA C+ MATRL XXX TC CT MAXLFCL AREA C+ MATRL XXX CT MAXLFCL AREA C-/C XXX CT MAXLFCL AREA C-/C XXX TC CT MAXLFCL AREA C-/C XXX CT SOFT TISS NCK C-MATRL XXX CT SOFT TISS NCK C-MATRL XXX TC CT SOFT TISS NCK C-MATRL XXX CT SOFT TISS NCK C+ MATRL XXX CT SOFT TISS NCK C+ MATRL XXX TC CT SOFT TISS NCK C+ MATRL XXX CT SOFT TISS NCK C-/C XXX CT SOFT TISS NCK C-/C XXX TC CT SOFT TISS NCK C-/C XXX + Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 177

182 Georgia Workers Compensation Medical Fee Schedule Section VIII: Diagnostic and Therapeutic Radiological Services RADIOLOGY Medical Fee Schedule Effective April 1, CT ANGIOGRAPHY HEAD W/CONTRAST/NONCONTRAST XXX CT ANGIOGRAPHY HEAD W/CONTRAST/NONCONTRAST XXX TC CT ANGIOGRAPHY HEAD W/CONTRAST/NONCONTRAST XXX CT ANGIOGRAPHY NECK W/CONTRAST/NONCONTRAST XXX CT ANGIOGRAPHY NECK W/CONTRAST/NONCONTRAST XXX TC CT ANGIOGRAPHY NECK W/CONTRAST/NONCONTRAST XXX MRI ORBIT FACE &/NECK W/O CONTRAST XXX MRI ORBIT FACE &/NECK W/O CONTRAST XXX TC MRI ORBIT FACE &/NECK W/O CONTRAST XXX MRI ORBIT FACE&NCK C+ MATRL XXX MRI ORBIT FACE&NCK C+ MATRL XXX TC MRI ORBIT FACE&NCK C+ MATRL XXX MRI ORBIT FACE&NCK C-/C XXX MRI ORBIT FACE&NCK C-/C XXX TC MRI ORBIT FACE&NCK C-/C XXX MRA HEAD C-MATRL XXX MRA HEAD C-MATRL XXX TC MRA HEAD C-MATRL XXX MRA HEAD C+ MATRL XXX MRA HEAD C+ MATRL XXX TC MRA HEAD C+ MATRL XXX MRA HEAD C-/C XXX MRA HEAD C-/C XXX TC MRA HEAD C-/C XXX MRA NCK C-MATRL XXX MRA NCK C-MATRL XXX TC MRA NCK C-MATRL XXX MRA NCK C+ MATRL XXX MRA NCK C+ MATRL XXX TC MRA NCK C+ MATRL XXX MRA NCK C-/C XXX MRA NCK C-/C XXX TC MRA NCK C-/C XXX MRI BRN BRN STEM C-MATRL XXX MRI BRN BRN STEM C-MATRL XXX TC MRI BRN BRN STEM C-MATRL XXX MRI BRN BRN STEM C+ MATRL XXX MRI BRN BRN STEM C+ MATRL XXX TC MRI BRN BRN STEM C+ MATRL XXX MRI BRN BRN STEM C-/C XXX MRI BRN BRN STEM C-/C XXX TC MRI BRN BRN STEM C-/C XXX MRI BRAIN FUNCTIONAL W/O PHYSICIAN ADMNISTRATION XXX MRI BRAIN FUNCTIONAL W/O PHYSICIAN ADMNISTRATION XXX TC MRI BRAIN FUNCTIONAL W/O PHYSICIAN ADMNISTRATION XXX MRI BRAIN FUNCTIONAL W/PHYSICIAN ADMNISTRATION XXX + Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure 178 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

183 Section VIII: Diagnostic and Therapeutic Radiological Services Georgia Workers Compensation Medical Fee Schedule RADIOLOGY Effective April 1, 2011 Medical Fee Schedule MRI BRAIN FUNCTIONAL W/PHYSICIAN ADMNISTRATION XXX TC MRI BRAIN FUNCTIONAL W/PHYSICIAN ADMNISTRATION XXX MRI BRN OPN ICRA PX C-MATRL XXX MRI BRN OPN ICRA PX C-MATRL XXX TC MRI BRN OPN ICRA PX C-MATRL XXX MRI BRN OPN ICRA PX C+ MATRL XXX MRI BRN OPN ICRA PX C+ MATRL XXX TC MRI BRN OPN ICRA PX C+ MATRL XXX MRI BRN OPN ICRA PX C-/C XXX MRI BRN OPN ICRA PX C-/C XXX TC MRI BRN OPN ICRA PX C-/C XXX RADEX CH 1 VIEW FRNT XXX RADEX CH 1 VIEW FRNT XXX TC RADEX CH 1 VIEW FRNT XXX RADEX CH STEREO FRNT XXX RADEX CH STEREO FRNT XXX TC RADEX CH STEREO FRNT XXX RADEX CH 2 VIEWS FRNT&LAT XXX RADEX CH 2 VIEWS FRNT&LAT XXX TC RADEX CH 2 VIEWS FRNT&LAT XXX RADEX CH 2 VIEWS FRNT&LAT APICAL LORDOTIC PX XXX RADEX CH 2 VIEWS FRNT&LAT APICAL LORDOTIC PX XXX TC RADEX CH 2 VIEWS FRNT&LAT APICAL LORDOTIC PX XXX RADEX CH 2 VIEWS FRNT&LAT OBLQ PRJCJ XXX RADEX CH 2 VIEWS FRNT&LAT OBLQ PRJCJ XXX TC RADEX CH 2 VIEWS FRNT&LAT OBLQ PRJCJ XXX RADEX CH 2 VIEWS FRNT&LAT FLUOR XXX RADEX CH 2 VIEWS FRNT&LAT FLUOR XXX TC RADEX CH 2 VIEWS FRNT&LAT FLUOR XXX RADEX CH COMPL MINIMUM 4 VIEWS XXX RADEX CH COMPL MINIMUM 4 VIEWS XXX TC RADEX CH COMPL MINIMUM 4 VIEWS XXX RADEX CH COMPL MINIMUM 4 VIEWS W/FLUOR XXX RADEX CH COMPL MINIMUM 4 VIEWS W/FLUOR XXX TC RADEX CH COMPL MINIMUM 4 VIEWS W/FLUOR XXX RADEX CH SPEC VIEWS XXX RADEX CH SPEC VIEWS XXX TC RADEX CH SPEC VIEWS XXX BRONCHOGRAPY UNI RS&I XXX BRONCHOGRAPY UNI RS&I XXX TC BRONCHOGRAPY UNI RS&I XXX BRONCHOGRAPY BI RS&I XXX BRONCHOGRAPY BI RS&I XXX TC BRONCHOGRAPY BI RS&I XXX INSJ PM FLUOR&RADIOGRAPY RS&I XXX INSJ PM FLUOR&RADIOGRAPY RS&I XXX + Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 179

184 Georgia Workers Compensation Medical Fee Schedule Section VIII: Diagnostic and Therapeutic Radiological Services RADIOLOGY Medical Fee Schedule Effective April 1, TC INSJ PM FLUOR&RADIOGRAPY RS&I XXX RADEX RIBS UNI 2 VIEWS XXX RADEX RIBS UNI 2 VIEWS XXX TC RADEX RIBS UNI 2 VIEWS XXX RADEX RIBS UNI W/POSTEROANT CH MINIMUM 3 VIEWS XXX RADEX RIBS UNI W/POSTEROANT CH MINIMUM 3 VIEWS XXX TC RADEX RIBS UNI W/POSTEROANT CH MINIMUM 3 VIEWS XXX RADEX RIBS BI 3 VIEWS XXX RADEX RIBS BI 3 VIEWS XXX TC RADEX RIBS BI 3 VIEWS XXX RADEX RIBS BI W/POSTEROANT CH MINIMUM 4 VIEWS XXX RADEX RIBS BI W/POSTEROANT CH MINIMUM 4 VIEWS XXX TC RADEX RIBS BI W/POSTEROANT CH MINIMUM 4 VIEWS XXX RADEX STERNUM MINIMUM 2 VIEWS XXX RADEX STERNUM MINIMUM 2 VIEWS XXX TC RADEX STERNUM MINIMUM 2 VIEWS XXX RADEX STRNCLAV JT/JTS MINIMUM 3 VIEWS XXX RADEX STRNCLAV JT/JTS MINIMUM 3 VIEWS XXX TC RADEX STRNCLAV JT/JTS MINIMUM 3 VIEWS XXX CT THORAX C-MATRL XXX CT THORAX C-MATRL XXX TC CT THORAX C-MATRL XXX CT THORAX C+ MATRL XXX CT THORAX C+ MATRL XXX TC CT THORAX C+ MATRL XXX CT THORAX C-/C XXX CT THORAX C-/C XXX TC CT THORAX C-/C XXX CT ANGIOGRAPHY CHEST W/CONTRAST/NONCONTRAST XXX CT ANGIOGRAPHY CHEST W/CONTRAST/NONCONTRAST XXX TC CT ANGIOGRAPHY CHEST W/CONTRAST/NONCONTRAST XXX MRI CH C-MATRL XXX MRI CH C-MATRL XXX TC MRI CH C-MATRL XXX MRI CH C+ MATRL XXX MRI CH C+ MATRL XXX TC MRI CH C+ MATRL XXX MRI CH C-/C XXX MRI CH C-/C XXX TC MRI CH C-/C XXX MRA CH C+-MATRL XXX MRA CH C+-MATRL XXX TC MRA CH C+-MATRL XXX RADEX SPI ENTIRE SURV STD ANTEROPOST&LAT XXX RADEX SPI ENTIRE SURV STD ANTEROPOST&LAT XXX TC RADEX SPI ENTIRE SURV STD ANTEROPOST&LAT XXX + Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure 180 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

185 Section VIII: Diagnostic and Therapeutic Radiological Services Georgia Workers Compensation Medical Fee Schedule RADIOLOGY Effective April 1, 2011 Medical Fee Schedule RADEX SPI 1 VIEW SPEC LVL XXX RADEX SPI 1 VIEW SPEC LVL XXX TC RADEX SPI 1 VIEW SPEC LVL XXX RADEX SPI CRV 2/3 VIEWS XXX RADEX SPI CRV 2/3 VIEWS XXX TC RADEX SPI CRV 2/3 VIEWS XXX RADEX SPI CRV MINIMUM 4 VIEWS XXX RADEX SPI CRV MINIMUM 4 VIEWS XXX TC RADEX SPI CRV MINIMUM 4 VIEWS XXX RADEX SPI CRV COMPL W/OBLQ&FLEXION&/XTN STDS XXX RADEX SPI CRV COMPL W/OBLQ&FLEXION&/XTN STDS XXX TC RADEX SPI CRV COMPL W/OBLQ&FLEXION&/XTN STDS XXX RADEX SPI THORACOLMBR STANDING SCOLIOSIS XXX RADEX SPI THORACOLMBR STANDING SCOLIOSIS XXX TC RADEX SPI THORACOLMBR STANDING SCOLIOSIS XXX RADEX SPI THRC 2 VIEWS XXX RADEX SPI THRC 2 VIEWS XXX TC RADEX SPI THRC 2 VIEWS XXX RADEX SPI THRC 3 VIEWS XXX RADEX SPI THRC 3 VIEWS XXX TC RADEX SPI THRC 3 VIEWS XXX RADEX SPI THRC MINIMUM 4 VIEWS XXX RADEX SPI THRC MINIMUM 4 VIEWS XXX TC RADEX SPI THRC MINIMUM 4 VIEWS XXX RADEX SPI THORACOLMBR 2 VIEWS XXX RADEX SPI THORACOLMBR 2 VIEWS XXX TC RADEX SPI THORACOLMBR 2 VIEWS XXX RADEX SPI SCOLIOSIS STD W/SUP&ERC STDS XXX RADEX SPI SCOLIOSIS STD W/SUP&ERC STDS XXX TC RADEX SPI SCOLIOSIS STD W/SUP&ERC STDS XXX RADEX SPI LUMBOSAC 2/3 VIEWS XXX RADEX SPI LUMBOSAC 2/3 VIEWS XXX TC RADEX SPI LUMBOSAC 2/3 VIEWS XXX RADEX SPI LUMBOSAC MINIMUM 4 VIEWS XXX RADEX SPI LUMBOSAC MINIMUM 4 VIEWS XXX TC RADEX SPI LUMBOSAC MINIMUM 4 VIEWS XXX RADEX SPI LUMBOSAC COMPL W/BENDING VIEWS XXX RADEX SPI LUMBOSAC COMPL W/BENDING VIEWS XXX TC RADEX SPI LUMBOSAC COMPL W/BENDING VIEWS XXX RADEX SPI LUMBOSAC BENDING MINIMUM 4 VIEWS XXX RADEX SPI LUMBOSAC BENDING MINIMUM 4 VIEWS XXX TC RADEX SPI LUMBOSAC BENDING MINIMUM 4 VIEWS XXX CT CRV SPI C-MATRL XXX CT CRV SPI C-MATRL XXX TC CT CRV SPI C-MATRL XXX CT CRV SPI C+ MATRL XXX + Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 181

186 Georgia Workers Compensation Medical Fee Schedule Section VIII: Diagnostic and Therapeutic Radiological Services RADIOLOGY Medical Fee Schedule Effective April 1, CT CRV SPI C+ MATRL XXX TC CT CRV SPI C+ MATRL XXX CT CRV SPI C-/C XXX CT CRV SPI C-/C XXX TC CT CRV SPI C-/C XXX CT THRC SPI C-MATRL XXX CT THRC SPI C-MATRL XXX TC CT THRC SPI C-MATRL XXX CT THRC SPI C+ MATRL XXX CT THRC SPI C+ MATRL XXX TC CT THRC SPI C+ MATRL XXX CT THRC SPI C-/C XXX CT THRC SPI C-/C XXX TC CT THRC SPI C-/C XXX CT LMBR SPI C-MATRL XXX CT LMBR SPI C-MATRL XXX TC CT LMBR SPI C-MATRL XXX CT LMBR SPI C+ MATRL XXX CT LMBR SPI C+ MATRL XXX TC CT LMBR SPI C+ MATRL XXX CT LMBR SPI C-/C XXX CT LMBR SPI C-/C XXX TC CT LMBR SPI C-/C XXX MRI SPI CANAL&CNTS CRV C-MATRL XXX MRI SPI CANAL&CNTS CRV C-MATRL XXX TC MRI SPI CANAL&CNTS CRV C-MATRL XXX MRI SPI CANAL&CNTS CRV C+ MATRL XXX MRI SPI CANAL&CNTS CRV C+ MATRL XXX TC MRI SPI CANAL&CNTS CRV C+ MATRL XXX MRI SPI CANAL&CNTS THRC C-MATRL XXX MRI SPI CANAL&CNTS THRC C-MATRL XXX TC MRI SPI CANAL&CNTS THRC C-MATRL XXX MRI SPI CANAL&CNTS THRC C+ MATRL XXX MRI SPI CANAL&CNTS THRC C+ MATRL XXX TC MRI SPI CANAL&CNTS THRC C+ MATRL XXX MRI SPI CANAL&CNTS LMBR C-MATRL XXX MRI SPI CANAL&CNTS LMBR C-MATRL XXX TC MRI SPI CANAL&CNTS LMBR C-MATRL XXX MRI SPI CANAL&CNTS LMBR C+ MATRL XXX MRI SPI CANAL&CNTS LMBR C+ MATRL XXX TC MRI SPI CANAL&CNTS LMBR C+ MATRL XXX MRI SPI CANAL&CNTS C-/C+ CRV XXX MRI SPI CANAL&CNTS C-/C+ CRV XXX TC MRI SPI CANAL&CNTS C-/C+ CRV XXX MRI SPI CANAL&CNTS C-/C XXX MRI SPI CANAL&CNTS C-/C XXX + Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure 182 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

187 Section VIII: Diagnostic and Therapeutic Radiological Services Georgia Workers Compensation Medical Fee Schedule RADIOLOGY Effective April 1, 2011 Medical Fee Schedule TC MRI SPI CANAL&CNTS C-/C XXX MRI SPI CANAL&CNTS C-/C+ LMBR XXX MRI SPI CANAL&CNTS C-/C+ LMBR XXX TC MRI SPI CANAL&CNTS C-/C+ LMBR XXX MRA SPI CANAL&CNTS C+-MATRL XXX MRA SPI CANAL&CNTS C+-MATRL XXX TC MRA SPI CANAL&CNTS C+-MATRL XXX RADEX PELVIS 1/2 VIEWS XXX RADEX PELVIS 1/2 VIEWS XXX TC RADEX PELVIS 1/2 VIEWS XXX RADEX PELVIS COMPL MINIMUM 3 VIEWS XXX RADEX PELVIS COMPL MINIMUM 3 VIEWS XXX TC RADEX PELVIS COMPL MINIMUM 3 VIEWS XXX CT ANGIOGRAPHY PELVIS W/CONTRAST/NONCONTRAST XXX CT ANGIOGRAPHY PELVIS W/CONTRAST/NONCONTRAST XXX TC CT ANGIOGRAPHY PELVIS W/CONTRAST/NONCONTRAST XXX CT PELVIS C-MATRL XXX CT PELVIS C-MATRL XXX TC CT PELVIS C-MATRL XXX CT PELVIS C+ MATRL XXX CT PELVIS C+ MATRL XXX TC CT PELVIS C+ MATRL XXX CT PELVIS C-/C XXX CT PELVIS C-/C XXX TC CT PELVIS C-/C XXX MRI PELVIS C-MATRL XXX MRI PELVIS C-MATRL XXX TC MRI PELVIS C-MATRL XXX MRI PELVIS C+ MATRL XXX MRI PELVIS C+ MATRL XXX TC MRI PELVIS C+ MATRL XXX MRI PELVIS C-/C XXX MRI PELVIS C-/C XXX TC MRI PELVIS C-/C XXX MRA PELVIS C+-MATRL XXX MRA PELVIS C+-MATRL XXX TC MRA PELVIS C+-MATRL XXX RADEX SI JTS < 3 VIEWS XXX RADEX SI JTS < 3 VIEWS XXX TC RADEX SI JTS < 3 VIEWS XXX RADEX SI JTS 3/MORE VIEWS XXX RADEX SI JTS 3/MORE VIEWS XXX TC RADEX SI JTS 3/MORE VIEWS XXX RADEX SACRUM&COCCYX MINIMUM 2 VIEWS XXX RADEX SACRUM&COCCYX MINIMUM 2 VIEWS XXX TC RADEX SACRUM&COCCYX MINIMUM 2 VIEWS XXX + Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 183

188 Georgia Workers Compensation Medical Fee Schedule Section VIII: Diagnostic and Therapeutic Radiological Services RADIOLOGY Medical Fee Schedule Effective April 1, MYELOGRAPY CRV RS&I XXX MYELOGRAPY CRV RS&I XXX TC MYELOGRAPY CRV RS&I XXX MYELOGRAPY THRC RS&I XXX MYELOGRAPY THRC RS&I XXX TC MYELOGRAPY THRC RS&I XXX MYELOGRAPY LUMBOSAC RS&I XXX MYELOGRAPY LUMBOSAC RS&I XXX TC MYELOGRAPY LUMBOSAC RS&I XXX MYELOGRAPY 2/MORE REGIONS RS&I XXX MYELOGRAPY 2/MORE REGIONS RS&I XXX TC MYELOGRAPY 2/MORE REGIONS RS&I XXX EPIDUROGRAPY RS&I XXX EPIDUROGRAPY RS&I XXX TC EPIDUROGRAPY RS&I XXX DISKOGRAPY CRV/THRC RS&I XXX DISKOGRAPY CRV/THRC RS&I XXX TC DISKOGRAPY CRV/THRC RS&I XXX RAD S&I PERQ VRTPLS/SACRPLSTY PR VRT BODY FLUOR XXX RAD S&I PERQ VRTPLS/SACRPLSTY PR VRT BODY FLUOR XXX TC RAD S&I PERQ VRTPLS/SACRPLSTY PR VRT BODY FLUOR XXX RAD S&I PERQ VRTPLS/SACRPLSTY PER VRT BODY CT XXX RAD S&I PERQ VRTPLS/SACRPLSTY PER VRT BODY CT XXX TC RAD S&I PERQ VRTPLS/SACRPLSTY PER VRT BODY CT XXX DISKOGRAPY LMBR RS&I XXX DISKOGRAPY LMBR RS&I XXX TC DISKOGRAPY LMBR RS&I XXX RADEX CLAV COMPL XXX RADEX CLAV COMPL XXX TC RADEX CLAV COMPL XXX RADEX SCAPULA COMPL XXX RADEX SCAPULA COMPL XXX TC RADEX SCAPULA COMPL XXX RADEX SHO 1 VIEW XXX RADEX SHO 1 VIEW XXX TC RADEX SHO 1 VIEW XXX RADEX SHO COMPL MINIMUM 2 VIEWS XXX RADEX SHO COMPL MINIMUM 2 VIEWS XXX TC RADEX SHO COMPL MINIMUM 2 VIEWS XXX RADEX SHO ARTHG RS&I XXX RADEX SHO ARTHG RS&I XXX TC RADEX SHO ARTHG RS&I XXX RADEX ACROMCLAV JTS BI +-W8ED DISTRCJ XXX RADEX ACROMCLAV JTS BI +-W8ED DISTRCJ XXX TC RADEX ACROMCLAV JTS BI +-W8ED DISTRCJ XXX RADEX HUM MINIMUM 2 VIEWS XXX + Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure 184 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

189 Section VIII: Diagnostic and Therapeutic Radiological Services Georgia Workers Compensation Medical Fee Schedule RADIOLOGY Effective April 1, 2011 Medical Fee Schedule RADEX HUM MINIMUM 2 VIEWS XXX TC RADEX HUM MINIMUM 2 VIEWS XXX RADEX ELBW 2 VIEWS XXX RADEX ELBW 2 VIEWS XXX TC RADEX ELBW 2 VIEWS XXX RADEX ELBW COMPL MINIMUM 3 VIEWS XXX RADEX ELBW COMPL MINIMUM 3 VIEWS XXX TC RADEX ELBW COMPL MINIMUM 3 VIEWS XXX RADEX ELBW ARTHG RS&I XXX RADEX ELBW ARTHG RS&I XXX TC RADEX ELBW ARTHG RS&I XXX RADEX F/ARM 2 VIEWS XXX RADEX F/ARM 2 VIEWS XXX TC RADEX F/ARM 2 VIEWS XXX RADEX UXTR INFT MINIMUM 2 VIEWS XXX RADEX UXTR INFT MINIMUM 2 VIEWS XXX TC RADEX UXTR INFT MINIMUM 2 VIEWS XXX RADEX WRST 2 VIEWS XXX RADEX WRST 2 VIEWS XXX TC RADEX WRST 2 VIEWS XXX RADEX WRST COMPL MINIMUM 3 VIEWS XXX RADEX WRST COMPL MINIMUM 3 VIEWS XXX TC RADEX WRST COMPL MINIMUM 3 VIEWS XXX RADEX WRST ARTHG RS&I XXX RADEX WRST ARTHG RS&I XXX TC RADEX WRST ARTHG RS&I XXX RADEX HAND 2 VIEWS XXX RADEX HAND 2 VIEWS XXX TC RADEX HAND 2 VIEWS XXX RADEX HAND MINIMUM 3 VIEWS XXX RADEX HAND MINIMUM 3 VIEWS XXX TC RADEX HAND MINIMUM 3 VIEWS XXX RADEX FNGR MINIMUM 2 VIEWS XXX RADEX FNGR MINIMUM 2 VIEWS XXX TC RADEX FNGR MINIMUM 2 VIEWS XXX CT UXTR C-MATRL XXX CT UXTR C-MATRL XXX TC CT UXTR C-MATRL XXX CT UXTR C+ MATRL XXX CT UXTR C+ MATRL XXX TC CT UXTR C+ MATRL XXX CT UXTR C-/C XXX CT UXTR C-/C XXX TC CT UXTR C-/C XXX CT ANGIOGRAPHY UPPER EXTREMITY XXX CT ANGIOGRAPHY UPPER EXTREMITY XXX + Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 185

190 Georgia Workers Compensation Medical Fee Schedule Section VIII: Diagnostic and Therapeutic Radiological Services RADIOLOGY Medical Fee Schedule Effective April 1, TC CT ANGIOGRAPHY UPPER EXTREMITY XXX MRI UXTR OTH/THN JT C-MATRL XXX MRI UXTR OTH/THN JT C-MATRL XXX TC MRI UXTR OTH/THN JT C-MATRL XXX MRI UXTR OTH/THN JT C+ MATRL XXX MRI UXTR OTH/THN JT C+ MATRL XXX TC MRI UXTR OTH/THN JT C+ MATRL XXX MRI UXTR OTH/THN JT C-/C XXX MRI UXTR OTH/THN JT C-/C XXX TC MRI UXTR OTH/THN JT C-/C XXX MRI ANY JT UXTR C-MATRL XXX MRI ANY JT UXTR C-MATRL XXX TC MRI ANY JT UXTR C-MATRL XXX MRI ANY JT UXTR C+ MATRL XXX MRI ANY JT UXTR C+ MATRL XXX TC MRI ANY JT UXTR C+ MATRL XXX MRI ANY JT UXTR C-/C XXX MRI ANY JT UXTR C-/C XXX TC MRI ANY JT UXTR C-/C XXX MRA UXTR C+-MATRL XXX MRA UXTR C+-MATRL XXX TC MRA UXTR C+-MATRL XXX RADEX HIP UNI 1 VIEW XXX RADEX HIP UNI 1 VIEW XXX TC RADEX HIP UNI 1 VIEW XXX RADEX HIP UNI COMPL MINIMUM 2 VIEWS XXX RADEX HIP UNI COMPL MINIMUM 2 VIEWS XXX TC RADEX HIP UNI COMPL MINIMUM 2 VIEWS XXX RADEX HIPS BI 2 VIEWS ANTEROPOST PELVIS XXX RADEX HIPS BI 2 VIEWS ANTEROPOST PELVIS XXX TC RADEX HIPS BI 2 VIEWS ANTEROPOST PELVIS XXX RADEX HIP ARTHG RS&I XXX RADEX HIP ARTHG RS&I XXX TC RADEX HIP ARTHG RS&I XXX RADEX HIP OPRATIVE PX XXX RADEX HIP OPRATIVE PX XXX TC RADEX HIP OPRATIVE PX XXX RADEX PELVIS&HIPS INFT/CHLD MINIMUM 2 VIEWS XXX RADEX PELVIS&HIPS INFT/CHLD MINIMUM 2 VIEWS XXX TC RADEX PELVIS&HIPS INFT/CHLD MINIMUM 2 VIEWS XXX RAD XM SI JT ARTHG RS&I XXX RAD XM SI JT ARTHG RS&I XXX TC RAD XM SI JT ARTHG RS&I XXX RADEX FEMUR 2 VIEWS XXX RADEX FEMUR 2 VIEWS XXX TC RADEX FEMUR 2 VIEWS XXX + Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure 186 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

191 Section VIII: Diagnostic and Therapeutic Radiological Services Georgia Workers Compensation Medical Fee Schedule RADIOLOGY Effective April 1, 2011 Medical Fee Schedule RADEX KNE 1/2 VIEWS XXX RADEX KNE 1/2 VIEWS XXX TC RADEX KNE 1/2 VIEWS XXX RADEX KNE 3 VIEWS XXX RADEX KNE 3 VIEWS XXX TC RADEX KNE 3 VIEWS XXX RADEX KNE COMPL 4/MORE VIEWS XXX RADEX KNE COMPL 4/MORE VIEWS XXX TC RADEX KNE COMPL 4/MORE VIEWS XXX RADEX KNE BTH KNES STANDING ANTEROPOST XXX RADEX KNE BTH KNES STANDING ANTEROPOST XXX TC RADEX KNE BTH KNES STANDING ANTEROPOST XXX RADEX KNE ARTHG RS&I XXX RADEX KNE ARTHG RS&I XXX TC RADEX KNE ARTHG RS&I XXX RADEX TIBFIB 2 VIEWS XXX RADEX TIBFIB 2 VIEWS XXX TC RADEX TIBFIB 2 VIEWS XXX RADEX LXTR INFT MINIMUM 2 VIEWS XXX RADEX LXTR INFT MINIMUM 2 VIEWS XXX TC RADEX LXTR INFT MINIMUM 2 VIEWS XXX RADEX ANKLE 2 VIEWS XXX RADEX ANKLE 2 VIEWS XXX TC RADEX ANKLE 2 VIEWS XXX RADEX ANKLE COMPL MINIMUM 3 VIEWS XXX RADEX ANKLE COMPL MINIMUM 3 VIEWS XXX TC RADEX ANKLE COMPL MINIMUM 3 VIEWS XXX RADEX ANKLE ARTHG RS&I XXX RADEX ANKLE ARTHG RS&I XXX TC RADEX ANKLE ARTHG RS&I XXX RADEX FOOT 2 VIEWS XXX RADEX FOOT 2 VIEWS XXX TC RADEX FOOT 2 VIEWS XXX RADEX FOOT COMPL MINIMUM 3 VIEWS XXX RADEX FOOT COMPL MINIMUM 3 VIEWS XXX TC RADEX FOOT COMPL MINIMUM 3 VIEWS XXX RADEX CALCANEUS MINIMUM 2 VIEWS XXX RADEX CALCANEUS MINIMUM 2 VIEWS XXX TC RADEX CALCANEUS MINIMUM 2 VIEWS XXX RADEX TOE MINIMUM 2 VIEWS XXX RADEX TOE MINIMUM 2 VIEWS XXX TC RADEX TOE MINIMUM 2 VIEWS XXX CT LXTR C-MATRL XXX CT LXTR C-MATRL XXX TC CT LXTR C-MATRL XXX CT LXTR C+ MATRL XXX + Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 187

192 Georgia Workers Compensation Medical Fee Schedule Section VIII: Diagnostic and Therapeutic Radiological Services RADIOLOGY Medical Fee Schedule Effective April 1, CT LXTR C+ MATRL XXX TC CT LXTR C+ MATRL XXX CT LXTR C-/C XXX CT LXTR C-/C XXX TC CT LXTR C-/C XXX CT ANGIOGRAPHY LOWER EXTREMITY XXX CT ANGIOGRAPHY LOWER EXTREMITY XXX TC CT ANGIOGRAPHY LOWER EXTREMITY XXX MRI LXTR OTH/THN JT C-MATRL XXX MRI LXTR OTH/THN JT C-MATRL XXX TC MRI LXTR OTH/THN JT C-MATRL XXX MRI IMG LXTR OTH/THN JT C+ MATRL XXX MRI IMG LXTR OTH/THN JT C+ MATRL XXX TC MRI IMG LXTR OTH/THN JT C+ MATRL XXX MRI LXTR OTH/THN JT C-/C XXX MRI LXTR OTH/THN JT C-/C XXX TC MRI LXTR OTH/THN JT C-/C XXX MRI ANY JT LXTR C-MATRL XXX MRI ANY JT LXTR C-MATRL XXX TC MRI ANY JT LXTR C-MATRL XXX MRI ANY JT LXTR C+ MATRL XXX MRI ANY JT LXTR C+ MATRL XXX TC MRI ANY JT LXTR C+ MATRL XXX MRI ANY JT LXTR C-/C XXX MRI ANY JT LXTR C-/C XXX TC MRI ANY JT LXTR C-/C XXX MRA LXTR C+-MATRL XXX MRA LXTR C+-MATRL XXX TC MRA LXTR C+-MATRL XXX RADEX ABD 1 ANTEROPOST VIEW XXX RADEX ABD 1 ANTEROPOST VIEW XXX TC RADEX ABD 1 ANTEROPOST VIEW XXX RADEX ABD ANTEROPOST&ADDL OBLQ&CONE VIEWS XXX RADEX ABD ANTEROPOST&ADDL OBLQ&CONE VIEWS XXX TC RADEX ABD ANTEROPOST&ADDL OBLQ&CONE VIEWS XXX RADEX ABD COMPL W/DCBTS&/ERC VIEWS XXX RADEX ABD COMPL W/DCBTS&/ERC VIEWS XXX TC RADEX ABD COMPL W/DCBTS&/ERC VIEWS XXX RADEX ABD COMPL AQT ABD W/S/E/D VIEWS 1 VIEW CH XXX RADEX ABD COMPL AQT ABD W/S/E/D VIEWS 1 VIEW CH XXX TC RADEX ABD COMPL AQT ABD W/S/E/D VIEWS 1 VIEW CH XXX CT ABD C-MATRL XXX CT ABD C-MATRL XXX TC CT ABD C-MATRL XXX CT ABD C+ MATRL XXX CT ABD C+ MATRL XXX + Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure 188 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

193 Section VIII: Diagnostic and Therapeutic Radiological Services Georgia Workers Compensation Medical Fee Schedule RADIOLOGY Effective April 1, 2011 Medical Fee Schedule TC CT ABD C+ MATRL XXX CT ABD C-/C XXX CT ABD C-/C XXX TC CT ABD C-/C XXX CT ANGIOGRAPHY ABDOMEN W/CONTRAST/NONCONTRAST XXX CT ANGIOGRAPHY ABDOMEN W/CONTRAST/NONCONTRAST XXX TC CT ANGIOGRAPHY ABDOMEN W/CONTRAST/NONCONTRAST XXX l CT ABD & PELVIS W/O CONTRAST XXX l CT ABD & PELVIS W/O CONTRAST XXX l TC CT ABD & PELVIS W/O CONTRAST XXX l CT ABD & PELVIS W/CONTRAST XXX l CT ABD & PELVIS W/CONTRAST XXX l TC CT ABD & PELVIS W/CONTRAST XXX l CT ABD & PELVIS W/O CONTRST 1+ BODY REGNS XXX l CT ABD & PELVIS W/O CONTRST 1+ BODY REGNS XXX l TC CT ABD & PELVIS W/O CONTRST 1+ BODY REGNS XXX MRI ABD C-MATRL XXX MRI ABD C-MATRL XXX TC MRI ABD C-MATRL XXX MRI ABD C+ MATRL XXX MRI ABD C+ MATRL XXX TC MRI ABD C+ MATRL XXX MRI ABD C-/C XXX MRI ABD C-/C XXX TC MRI ABD C-/C XXX MRA ABD C+-MATRL XXX MRA ABD C+-MATRL XXX TC MRA ABD C+-MATRL XXX PRITONEOGRAM RS&I XXX PRITONEOGRAM RS&I XXX TC PRITONEOGRAM RS&I XXX RADEX PHARYNX&/CRV ESOPH XXX RADEX PHARYNX&/CRV ESOPH XXX TC RADEX PHARYNX&/CRV ESOPH XXX RADEX ESOPH XXX RADEX ESOPH XXX TC RADEX ESOPH XXX SWLNG FUNCJ W/CINERADIOGRAPY/VIDRADIOGRAPY XXX SWLNG FUNCJ W/CINERADIOGRAPY/VIDRADIOGRAPY XXX TC SWLNG FUNCJ W/CINERADIOGRAPY/VIDRADIOGRAPY XXX RMVL FB ESOPHGL W/USE BALO CATH RS&I XXX RMVL FB ESOPHGL W/USE BALO CATH RS&I XXX TC RMVL FB ESOPHGL W/USE BALO CATH RS&I XXX RADEX GI TRC UPR +-DLYD FLMS W/O KUB XXX RADEX GI TRC UPR +-DLYD FLMS W/O KUB XXX TC RADEX GI TRC UPR +-DLYD FLMS W/O KUB XXX + Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 189

194 Georgia Workers Compensation Medical Fee Schedule Section VIII: Diagnostic and Therapeutic Radiological Services RADIOLOGY Medical Fee Schedule Effective April 1, RADEX GI TRC UPR +-DLYD FLMS W/KUB XXX RADEX GI TRC UPR +-DLYD FLMS W/KUB XXX TC RADEX GI TRC UPR +-DLYD FLMS W/KUB XXX RADEX GI TRC UPR W/SM INT W/MLT SRL FLMS XXX RADEX GI TRC UPR W/SM INT W/MLT SRL FLMS XXX TC RADEX GI TRC UPR W/SM INT W/MLT SRL FLMS XXX RADEX GI UPR C+ +-GLUC/DLYD FLMS W/O KUB XXX RADEX GI UPR C+ +-GLUC/DLYD FLMS W/O KUB XXX TC RADEX GI UPR C+ +-GLUC/DLYD FLMS W/O KUB XXX RADEX GI UPR C+ +-GLUC +-DLYD FLMS W/KUB XXX RADEX GI UPR C+ +-GLUC +-DLYD FLMS W/KUB XXX TC RADEX GI UPR C+ +-GLUC +-DLYD FLMS W/KUB XXX RADEX GI UPR C+ +-GLUC W/SM INT FOLLW-THRU XXX RADEX GI UPR C+ +-GLUC W/SM INT FOLLW-THRU XXX TC RADEX GI UPR C+ +-GLUC W/SM INT FOLLW-THRU XXX RADEX SM INT W/MLT SRL FLMS XXX RADEX SM INT W/MLT SRL FLMS XXX TC RADEX SM INT W/MLT SRL FLMS XXX RADEX SM INT W/MLT SRL FLMS VIA ENTEROCLSS TUBE XXX RADEX SM INT W/MLT SRL FLMS VIA ENTEROCLSS TUBE XXX TC RADEX SM INT W/MLT SRL FLMS VIA ENTEROCLSS TUBE XXX DUODENOGRAPY HYPOTONIC XXX DUODENOGRAPY HYPOTONIC XXX TC DUODENOGRAPY HYPOTONIC XXX CT COLONOGRPHY DX IMAGE POSTPROCESS NO CONTRAST XXX CT COLONOGRPHY DX IMAGE POSTPROCESS NO CONTRAST XXX TC CT COLONOGRPHY DX IMAGE POSTPROCESS NO CONTRAST XXX CT COLONOGRPHY DX IMAGE POSTPROCESS W/CONTRAST XXX CT COLONOGRPHY DX IMAGE POSTPROCESS W/CONTRAST XXX TC CT COLONOGRPHY DX IMAGE POSTPROCESS W/CONTRAST XXX CT COLONOGRAPHY SCREENING IMAGE POSTPROCESSING XXX CT COLONOGRAPHY SCREENING IMAGE POSTPROCESSING XXX TC CT COLONOGRAPHY SCREENING IMAGE POSTPROCESSING XXX RADEX COLON BARIUM ENEMA +-KUB XXX RADEX COLON BARIUM ENEMA +-KUB XXX TC RADEX COLON BARIUM ENEMA +-KUB XXX RADEX COLON C+ W/SPEC HI DNS BARIUM +-GLUC XXX RADEX COLON C+ W/SPEC HI DNS BARIUM +-GLUC XXX TC RADEX COLON C+ W/SPEC HI DNS BARIUM +-GLUC XXX THER ENEMA C+ RDCTJ INTUSSUSCEPTION/OBSTRCJ XXX THER ENEMA C+ RDCTJ INTUSSUSCEPTION/OBSTRCJ XXX TC THER ENEMA C+ RDCTJ INTUSSUSCEPTION/OBSTRCJ XXX CCG ORAL CNTRST XXX CCG ORAL CNTRST XXX TC CCG ORAL CNTRST XXX CCG ORAL CNTRST ADDL/REPEAT XM/MLT D XM XXX + Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure 190 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

195 Section VIII: Diagnostic and Therapeutic Radiological Services Georgia Workers Compensation Medical Fee Schedule RADIOLOGY Effective April 1, 2011 Medical Fee Schedule CCG ORAL CNTRST ADDL/REPEAT XM/MLT D XM XXX TC CCG ORAL CNTRST ADDL/REPEAT XM/MLT D XM XXX CHOLANGRPH&/PCG INTRAOP RS&I XXX CHOLANGRPH&/PCG INTRAOP RS&I XXX TC CHOLANGRPH&/PCG INTRAOP RS&I XXX CHOLANGRPH&/PCG ADDL SET INTRAOP RS&I ZZZ CHOLANGRPH&/PCG ADDL SET INTRAOP RS&I ZZZ TC CHOLANGRPH&/PCG ADDL SET INTRAOP RS&I ZZZ CHOLANGRPH&/PCG THRU CATH RS&I XXX CHOLANGRPH&/PCG THRU CATH RS&I XXX TC CHOLANGRPH&/PCG THRU CATH RS&I XXX CHOLANGRPH PRQ TRANSHEPATC RS&I XXX CHOLANGRPH PRQ TRANSHEPATC RS&I XXX TC CHOLANGRPH PRQ TRANSHEPATC RS&I XXX PO BILIARY ST1 RMVL PRQ RS&I XXX PO BILIARY ST1 RMVL PRQ RS&I XXX TC PO BILIARY ST1 RMVL PRQ RS&I XXX NDSC CATHJ BILIARY DUX SYS RS&I XXX NDSC CATHJ BILIARY DUX SYS RS&I XXX TC NDSC CATHJ BILIARY DUX SYS RS&I XXX NDSC CATHJ PNCRTC DUX SYS RS&I XXX NDSC CATHJ PNCRTC DUX SYS RS&I XXX TC NDSC CATHJ PNCRTC DUX SYS RS&I XXX CMBN NDSC CATHJ BILIARY&PNCRTC DUX SYSS RS&I XXX CMBN NDSC CATHJ BILIARY&PNCRTC DUX SYSS RS&I XXX TC CMBN NDSC CATHJ BILIARY&PNCRTC DUX SYSS RS&I XXX INTRO LONG GI TUBE W/MLT FLUOR&FLMS RS&I XXX INTRO LONG GI TUBE W/MLT FLUOR&FLMS RS&I XXX TC INTRO LONG GI TUBE W/MLT FLUOR&FLMS RS&I XXX PRQ PLMT ENTEROCLSS TUBE RS&I XXX PRQ PLMT ENTEROCLSS TUBE RS&I XXX TC PRQ PLMT ENTEROCLSS TUBE RS&I XXX INTRAL DILAT STRIXS&/OBSTRCJS RS&I XXX INTRAL DILAT STRIXS&/OBSTRCJS RS&I XXX TC INTRAL DILAT STRIXS&/OBSTRCJS RS&I XXX PRQ TRANSHEPATC DILAT BILIARY DUX STRIX RS&I XXX PRQ TRANSHEPATC DILAT BILIARY DUX STRIX RS&I XXX TC PRQ TRANSHEPATC DILAT BILIARY DUX STRIX RS&I XXX UROGRAPY PLOG IV +-KUB +-TOMOG XXX UROGRAPY PLOG IV +-KUB +-TOMOG XXX TC UROGRAPY PLOG IV +-KUB +-TOMOG XXX UROGRAPY NFS DRIP TQ&/BOLUS TQ XXX UROGRAPY NFS DRIP TQ&/BOLUS TQ XXX TC UROGRAPY NFS DRIP TQ&/BOLUS TQ XXX UROGRAPY NFS DRIP TQ&/BOLUS TQ W/NEPHROTOMOG XXX UROGRAPY NFS DRIP TQ&/BOLUS TQ W/NEPHROTOMOG XXX + Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 191

196 Georgia Workers Compensation Medical Fee Schedule Section VIII: Diagnostic and Therapeutic Radiological Services RADIOLOGY Medical Fee Schedule Effective April 1, TC UROGRAPY NFS DRIP TQ&/BOLUS TQ W/NEPHROTOMOG XXX X-RAY URINARY TRACT EXAM WITH CONTRAST MATERIAL XXX X-RAY URINARY TRACT EXAM WITH CONTRAST MATERIAL XXX TC X-RAY URINARY TRACT EXAM WITH CONTRAST MATERIAL XXX UROGRAPY ANTEGRADE RS&I XXX UROGRAPY ANTEGRADE RS&I XXX TC UROGRAPY ANTEGRADE RS&I XXX CSTOGRAPY MINIMUM 3 VIEWS RS&I XXX CSTOGRAPY MINIMUM 3 VIEWS RS&I XXX TC CSTOGRAPY MINIMUM 3 VIEWS RS&I XXX VASOGRAPY VESICULOGRAPY/EPIDIDYMOGRAPY RS&I XXX VASOGRAPY VESICULOGRAPY/EPIDIDYMOGRAPY RS&I XXX TC VASOGRAPY VESICULOGRAPY/EPIDIDYMOGRAPY RS&I XXX C/P/A CAVERNOSOGRAPY RS&I XXX C/P/A CAVERNOSOGRAPY RS&I XXX TC C/P/A CAVERNOSOGRAPY RS&I XXX URETHROCSTOGRAPY RTRGR RS&I XXX URETHROCSTOGRAPY RTRGR RS&I XXX TC URETHROCSTOGRAPY RTRGR RS&I XXX URETHROCSTOGRAPY VOIDING RS&I XXX URETHROCSTOGRAPY VOIDING RS&I XXX TC URETHROCSTOGRAPY VOIDING RS&I XXX RADEX RNL CST STD TRANSLMBR C+ RS&I XXX RADEX RNL CST STD TRANSLMBR C+ RS&I XXX TC RADEX RNL CST STD TRANSLMBR C+ RS&I XXX INTRO CATH IN RNL PELVIS DRG&/NJX PRQ RS&I XXX INTRO CATH IN RNL PELVIS DRG&/NJX PRQ RS&I XXX TC INTRO CATH IN RNL PELVIS DRG&/NJX PRQ RS&I XXX INTRO URTRL CATH/STENT PRQ RS&I XXX INTRO URTRL CATH/STENT PRQ RS&I XXX TC INTRO URTRL CATH/STENT PRQ RS&I XXX DILAT NFROS URTRS/URT RS&I XXX DILAT NFROS URTRS/URT RS&I XXX TC DILAT NFROS URTRS/URT RS&I XXX PELVIMETRY +-PLACENTAL LOCLZJ XXX PELVIMETRY +-PLACENTAL LOCLZJ XXX TC PELVIMETRY +-PLACENTAL LOCLZJ XXX HSG RS&I XXX HSG RS&I XXX TC HSG RS&I XXX TRANSCRV CATHJ FLP TUBE RS&I XXX TRANSCRV CATHJ FLP TUBE RS&I XXX TC TRANSCRV CATHJ FLP TUBE RS&I XXX PRINEOGRAM XXX PRINEOGRAM XXX TC PRINEOGRAM XXX + Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure 192 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

197 Section VIII: Diagnostic and Therapeutic Radiological Services Georgia Workers Compensation Medical Fee Schedule RADIOLOGY Effective April 1, 2011 Medical Fee Schedule CARDIAC MRI MORPHOLOGY & FUNCTION W/O CONTRAST XXX CARDIAC MRI MORPHOLOGY & FUNCTION W/O CONTRAST XXX TC CARDIAC MRI MORPHOLOGY & FUNCTION W/O CONTRAST XXX CARDIAC MRI W/O CONTRAST W STRESS IMAGING XXX CARDIAC MRI W/O CONTRAST W STRESS IMAGING XXX TC CARDIAC MRI W/O CONTRAST W STRESS IMAGING XXX CARDIAC MRI W/W/O CONTRAST & FURTHER SEQ XXX CARDIAC MRI W/W/O CONTRAST & FURTHER SEQ XXX TC CARDIAC MRI W/W/O CONTRAST & FURTHER SEQ XXX CARDIAC MRI W/W/O CONTRAST W STRESS XXX CARDIAC MRI W/W/O CONTRAST W STRESS XXX TC CARDIAC MRI W/W/O CONTRAST W STRESS XXX CARDIAC MRI FOR VELOCITY FLOW MAPPING ZZZ CARDIAC MRI FOR VELOCITY FLOW MAPPING ZZZ TC CARDIAC MRI FOR VELOCITY FLOW MAPPING ZZZ CT HEART NO CONTRAST QUANT EVAL CORONRY CALCIUM XXX CT HEART NO CONTRAST QUANT EVAL CORONRY CALCIUM XXX TC CT HEART NO CONTRAST QUANT EVAL CORONRY CALCIUM XXX CT HEART CONTRAST EVAL CARDIAC STRUCTURE&MORPH XXX CT HEART CONTRAST EVAL CARDIAC STRUCTURE&MORPH XXX TC CT HEART CONTRAST EVAL CARDIAC STRUCTURE&MORPH XXX CT HRT CONTRST CARDIAC STRUCT&MORPH CONG HRT DX XXX CT HRT CONTRST CARDIAC STRUCT&MORPH CONG HRT DX XXX TC CT HRT CONTRST CARDIAC STRUCT&MORPH CONG HRT DX XXX CTA HRT CORNRY ART/BYPASS GRFTS CONTRST 3D POST XXX CTA HRT CORNRY ART/BYPASS GRFTS CONTRST 3D POST XXX TC CTA HRT CORNRY ART/BYPASS GRFTS CONTRST 3D POST XXX AORTOGRAPY THRC W/O SRLOGRAPY RS&I XXX AORTOGRAPY THRC W/O SRLOGRAPY RS&I XXX TC AORTOGRAPY THRC W/O SRLOGRAPY RS&I XXX AORTOGRAPY THRC SRLOGRAPY RS&I XXX AORTOGRAPY THRC SRLOGRAPY RS&I XXX TC AORTOGRAPY THRC SRLOGRAPY RS&I XXX AORTOGRAPY ABDL SRLOGRAPY RS&I XXX AORTOGRAPY ABDL SRLOGRAPY RS&I XXX TC AORTOGRAPY ABDL SRLOGRAPY RS&I XXX AORTOGRAPY ABDL BI ILIOFEM LXTR CATH RS&I XXX AORTOGRAPY ABDL BI ILIOFEM LXTR CATH RS&I XXX TC AORTOGRAPY ABDL BI ILIOFEM LXTR CATH RS&I XXX CTA AA&BI ILIOFEM LXTR RS&I C-/C+ POST-PXESSING XXX CTA AA&BI ILIOFEM LXTR RS&I C-/C+ POST-PXESSING XXX TC CTA AA&BI ILIOFEM LXTR RS&I C-/C+ POST-PXESSING XXX ANGRPH CERVICOCERE CATH W/VSL ORIGIN RS&I XXX ANGRPH CERVICOCERE CATH W/VSL ORIGIN RS&I XXX TC ANGRPH CERVICOCERE CATH W/VSL ORIGIN RS&I XXX ANGRPH BRACH RTRGR RS&I XXX + Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 193

198 Georgia Workers Compensation Medical Fee Schedule Section VIII: Diagnostic and Therapeutic Radiological Services RADIOLOGY Medical Fee Schedule Effective April 1, ANGRPH BRACH RTRGR RS&I XXX TC ANGRPH BRACH RTRGR RS&I XXX ANGRPH XTRNL CRTD UNI SLCTV RS&I XXX ANGRPH XTRNL CRTD UNI SLCTV RS&I XXX TC ANGRPH XTRNL CRTD UNI SLCTV RS&I XXX ANGRPH XTRNL CRTD BI SLCTV RS&I XXX ANGRPH XTRNL CRTD BI SLCTV RS&I XXX TC ANGRPH XTRNL CRTD BI SLCTV RS&I XXX ANGRPH CRTD CERE UNI RS&I XXX ANGRPH CRTD CERE UNI RS&I XXX TC ANGRPH CRTD CERE UNI RS&I XXX ANGRPH CRTD CERE BI RS&I XXX ANGRPH CRTD CERE BI RS&I XXX TC ANGRPH CRTD CERE BI RS&I XXX ANGRPH CRTD CRV UNI RS&I XXX ANGRPH CRTD CRV UNI RS&I XXX TC ANGRPH CRTD CRV UNI RS&I XXX ANGRPH CRTD CRV BI RS&I XXX ANGRPH CRTD CRV BI RS&I XXX TC ANGRPH CRTD CRV BI RS&I XXX ANGRPH VRT CRV&/ICRA RS&I XXX ANGRPH VRT CRV&/ICRA RS&I XXX TC ANGRPH VRT CRV&/ICRA RS&I XXX ANGRPH SPI SLCTV RS&I XXX ANGRPH SPI SLCTV RS&I XXX TC ANGRPH SPI SLCTV RS&I XXX ANGRPH XTR UNI RS&I XXX ANGRPH XTR UNI RS&I XXX TC ANGRPH XTR UNI RS&I XXX ANGRPH XTR BI RS&I XXX ANGRPH XTR BI RS&I XXX TC ANGRPH XTR BI RS&I XXX ANGRPH RNL UNI SLCTV W/FLUSH AORTOGRAM RS&I XXX ANGRPH RNL UNI SLCTV W/FLUSH AORTOGRAM RS&I XXX TC ANGRPH RNL UNI SLCTV W/FLUSH AORTOGRAM RS&I XXX ANGRPH RNL BI SLCTV W/FLUSH AORTOGRAM RS&I XXX ANGRPH RNL BI SLCTV W/FLUSH AORTOGRAM RS&I XXX TC ANGRPH RNL BI SLCTV W/FLUSH AORTOGRAM RS&I XXX ANGRPH VISC SLCTV/SUPRASLCTV RS&I XXX ANGRPH VISC SLCTV/SUPRASLCTV RS&I XXX TC ANGRPH VISC SLCTV/SUPRASLCTV RS&I XXX ANGRPH ADRNL UNI SLCTV RS&I XXX ANGRPH ADRNL UNI SLCTV RS&I XXX TC ANGRPH ADRNL UNI SLCTV RS&I XXX ANGRPH ADRNL BI SLCTV RS&I XXX ANGRPH ADRNL BI SLCTV RS&I XXX + Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure 194 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

199 Section VIII: Diagnostic and Therapeutic Radiological Services Georgia Workers Compensation Medical Fee Schedule RADIOLOGY Effective April 1, 2011 Medical Fee Schedule TC ANGRPH ADRNL BI SLCTV RS&I XXX ANGRPH PEL SLCTV/SUPRASLCTV RS&I XXX ANGRPH PEL SLCTV/SUPRASLCTV RS&I XXX TC ANGRPH PEL SLCTV/SUPRASLCTV RS&I XXX ANGRPH PULM UNI SLCTV RS&I XXX ANGRPH PULM UNI SLCTV RS&I XXX TC ANGRPH PULM UNI SLCTV RS&I XXX ANGRPH PULM BI SLCTV RS&I XXX ANGRPH PULM BI SLCTV RS&I XXX TC ANGRPH PULM BI SLCTV RS&I XXX ANGRPH PULM NONSLCTV CATH/VEN NJX RS&I XXX ANGRPH PULM NONSLCTV CATH/VEN NJX RS&I XXX TC ANGRPH PULM NONSLCTV CATH/VEN NJX RS&I XXX ANGRPH INT MAM RS&I XXX ANGRPH INT MAM RS&I XXX TC ANGRPH INT MAM RS&I XXX ANGRPH SLCTV EA VSL STUDIED AFTER BASIC XM RS&I ZZZ ANGRPH SLCTV EA VSL STUDIED AFTER BASIC XM RS&I ZZZ TC ANGRPH SLCTV EA VSL STUDIED AFTER BASIC XM RS&I ZZZ ANGIOGRPHY AV SHUNT COMPLETE EVAL FLUOR S&I XXX ANGIOGRPHY AV SHUNT COMPLETE EVAL FLUOR S&I XXX TC ANGIOGRPHY AV SHUNT COMPLETE EVAL FLUOR S&I XXX LYMPHANGRPH XTR ONLY UNI RS&I XXX LYMPHANGRPH XTR ONLY UNI RS&I XXX TC LYMPHANGRPH XTR ONLY UNI RS&I XXX LYMPHANGRPH XTR ONLY BI RS&I XXX LYMPHANGRPH XTR ONLY BI RS&I XXX TC LYMPHANGRPH XTR ONLY BI RS&I XXX LYMPHANGRPH PEL/ABDL UNI RS&I XXX LYMPHANGRPH PEL/ABDL UNI RS&I XXX TC LYMPHANGRPH PEL/ABDL UNI RS&I XXX LYMPHANGRPH PEL/ABDL BI RS&I XXX LYMPHANGRPH PEL/ABDL BI RS&I XXX TC LYMPHANGRPH PEL/ABDL BI RS&I XXX SHUNTOGRAM NDWELLG NONVASC SHUNT RS&I XXX SHUNTOGRAM NDWELLG NONVASC SHUNT RS&I XXX TC SHUNTOGRAM NDWELLG NONVASC SHUNT RS&I XXX SPLENOPORTOGRAPY RS&I XXX SPLENOPORTOGRAPY RS&I XXX TC SPLENOPORTOGRAPY RS&I XXX VNGRPH XTR UNI RS&I XXX VNGRPH XTR UNI RS&I XXX TC VNGRPH XTR UNI RS&I XXX VNGRPH XTR BI RS&I XXX VNGRPH XTR BI RS&I XXX TC VNGRPH XTR BI RS&I XXX + Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 195

200 Georgia Workers Compensation Medical Fee Schedule Section VIII: Diagnostic and Therapeutic Radiological Services RADIOLOGY Medical Fee Schedule Effective April 1, VNGRPH CAVAL INF SRLOGRAPY RS&I XXX VNGRPH CAVAL INF SRLOGRAPY RS&I XXX TC VNGRPH CAVAL INF SRLOGRAPY RS&I XXX VNGRPH CAVAL SUPRIOR SRLOGRAPY RS&I XXX VNGRPH CAVAL SUPRIOR SRLOGRAPY RS&I XXX TC VNGRPH CAVAL SUPRIOR SRLOGRAPY RS&I XXX VNGRPH RNL UNI SLCTV RS&I XXX VNGRPH RNL UNI SLCTV RS&I XXX TC VNGRPH RNL UNI SLCTV RS&I XXX VNGRPH RNL BI SLCTV RS&I XXX VNGRPH RNL BI SLCTV RS&I XXX TC VNGRPH RNL BI SLCTV RS&I XXX VNGRPH ADRNL UNI SLCTV RS&I XXX VNGRPH ADRNL UNI SLCTV RS&I XXX TC VNGRPH ADRNL UNI SLCTV RS&I XXX VNGRPH ADRNL BI SLCTV RS&I XXX VNGRPH ADRNL BI SLCTV RS&I XXX TC VNGRPH ADRNL BI SLCTV RS&I XXX VNGRPH VEN SINUS/JUG CATH RS&I XXX VNGRPH VEN SINUS/JUG CATH RS&I XXX TC VNGRPH VEN SINUS/JUG CATH RS&I XXX VNGRPH SUPRIOR SGTL SINUS RS&I XXX VNGRPH SUPRIOR SGTL SINUS RS&I XXX TC VNGRPH SUPRIOR SGTL SINUS RS&I XXX VNGRPH EDRL RS&I XXX VNGRPH EDRL RS&I XXX TC VNGRPH EDRL RS&I XXX VNGRPH ORB RS&I XXX VNGRPH ORB RS&I XXX TC VNGRPH ORB RS&I XXX PRQ TRANSHEPATC PORTOGRAPY HEMODYN EVAL RS&I XXX PRQ TRANSHEPATC PORTOGRAPY HEMODYN EVAL RS&I XXX TC PRQ TRANSHEPATC PORTOGRAPY HEMODYN EVAL RS&I XXX PRQ TRANSHEPATC PORTOGRAPY W/O HEMODYN EVAL RS&I XXX PRQ TRANSHEPATC PORTOGRAPY W/O HEMODYN EVAL RS&I XXX TC PRQ TRANSHEPATC PORTOGRAPY W/O HEMODYN EVAL RS&I XXX HEPATC VNGRPH WDG/FR HEMODYN EVAL RS&I XXX HEPATC VNGRPH WDG/FR HEMODYN EVAL RS&I XXX TC HEPATC VNGRPH WDG/FR HEMODYN EVAL RS&I XXX HEPATC VNGRPH WDG/FR W/O HEMODYN EVAL RS&I XXX HEPATC VNGRPH WDG/FR W/O HEMODYN EVAL RS&I XXX TC HEPATC VNGRPH WDG/FR W/O HEMODYN EVAL RS&I XXX VEN SAMPLING THRU CATH +-ANGRPH RS&I XXX VEN SAMPLING THRU CATH +-ANGRPH RS&I XXX TC VEN SAMPLING THRU CATH +-ANGRPH RS&I XXX TCAT THER EMBOLIZATION ANY METH RS&I XXX + Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure 196 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

201 Section VIII: Diagnostic and Therapeutic Radiological Services Georgia Workers Compensation Medical Fee Schedule RADIOLOGY Effective April 1, 2011 Medical Fee Schedule TCAT THER EMBOLIZATION ANY METH RS&I XXX TC TCAT THER EMBOLIZATION ANY METH RS&I XXX TCAT THER NFS ANY METH RS&I XXX TCAT THER NFS ANY METH RS&I XXX TC TCAT THER NFS ANY METH RS&I XXX ANGRPH CATH F-UP STD TCAT THER EMBOLIZATION/NFS XXX ANGRPH CATH F-UP STD TCAT THER EMBOLIZATION/NFS XXX TC ANGRPH CATH F-UP STD TCAT THER EMBOLIZATION/NFS XXX EXCHNG CATH THROMBOLYTIC THER C+ MNTR RS&I XXX EXCHNG CATH THROMBOLYTIC THER C+ MNTR RS&I XXX TC EXCHNG CATH THROMBOLYTIC THER C+ MNTR RS&I XXX MCHNL RMVL PRICATH OBSTR MATRL RS&I XXX MCHNL RMVL PRICATH OBSTR MATRL RS&I XXX TC MCHNL RMVL PRICATH OBSTR MATRL RS&I XXX MCHNL RMVL INTRAL OBSTR MATRL RS&I XXX MCHNL RMVL INTRAL OBSTR MATRL RS&I XXX TC MCHNL RMVL INTRAL OBSTR MATRL RS&I XXX PRQ PLMT IVC FILTER RS&I XXX PRQ PLMT IVC FILTER RS&I XXX TC PRQ PLMT IVC FILTER RS&I XXX IV US RS&I 1ST VSL XXX IV US RS&I 1ST VSL XXX TC IV US RS&I 1ST VSL XXX IV US RS&I EA NON-C VSL ZZZ IV US RS&I EA NON-C VSL ZZZ TC IV US RS&I EA NON-C VSL ZZZ EVASC RPR INFRARNL AAA/DSJ RS&I XXX EVASC RPR INFRARNL AAA/DSJ RS&I XXX TC EVASC RPR INFRARNL AAA/DSJ RS&I 0.00 XXX PLMT XTN PROSTH EVASC RPR INFRARNL RS&I XXX PLMT XTN PROSTH EVASC RPR INFRARNL RS&I XXX TC PLMT XTN PROSTH EVASC RPR INFRARNL RS&I 0.00 XXX s EVASC RPR ILIAC ART W/ILIO-ILIAC PROSTH RS&I XXX s EVASC RPR ILIAC ART W/ILIO-ILIAC PROSTH RS&I XXX s TC EVASC RPR ILIAC ART W/ILIO-ILIAC PROSTH RS&I 0.00 XXX EVASC RPR DTA COVERAGE L SUBCLA ORIGIN RS&I XXX EVASC RPR DTA COVERAGE L SUBCLA ORIGIN RS&I XXX TC EVASC RPR DTA COVERAGE L SUBCLA ORIGIN RS&I 0.00 XXX EVASC RPR DTA X COVERAGE L SUBCLA ORIGIN RS&I XXX EVASC RPR DTA X COVERAGE L SUBCLA ORIGIN RS&I XXX TC EVASC RPR DTA X COVERAGE L SUBCLA ORIGIN RS&I 0.00 XXX PLMT PROX XTN PROSTH EVASC RPR DTA RS&I XXX PLMT PROX XTN PROSTH EVASC RPR DTA RS&I XXX TC PLMT PROX XTN PROSTH EVASC RPR DTA RS&I 0.00 XXX PLMT DSTL XTN PROSTH AFTER EVASC RPR DTA RS&I XXX PLMT DSTL XTN PROSTH AFTER EVASC RPR DTA RS&I XXX + Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 197

202 Georgia Workers Compensation Medical Fee Schedule Section VIII: Diagnostic and Therapeutic Radiological Services RADIOLOGY Medical Fee Schedule Effective April 1, TC PLMT DSTL XTN PROSTH AFTER EVASC RPR DTA RS&I 0.00 XXX s TCAT IV STNT ILIA/LOW EXT ART PRQ/OPN RSI EA VSL XXX s TCAT IV STNT ILIA/LOW EXT ART PRQ/OPN RSI EA VSL XXX s TC TCAT IV STNT ILIA/LOW EXT ART PRQ/OPN RSI EA VSL XXX TCAT RETRIEVAL PRQ IV FB RS&I XXX TCAT RETRIEVAL PRQ IV FB RS&I XXX TC TCAT RETRIEVAL PRQ IV FB RS&I XXX s TRANSLUMINAL BALLOON ANGIOP PERIPHERAL ART RSI XXX s TRANSLUMINAL BALLOON ANGIOP PERIPHERAL ART RSI XXX s TC TRANSLUMINAL BALLOON ANGIOP PERIPHERAL ART RSI XXX s TRLUML BALOON ANGIOP PERIPHER EA ADDL ARTERY RSI ZZZ s TRLUML BALOON ANGIOP PERIPHER EA ADDL ARTERY RSI ZZZ s TC TRLUML BALOON ANGIOP PERIPHER EA ADDL ARTERY RSI ZZZ TRLUML BALO ANGIOP RNL/OTH VISC ART RS&I XXX TRLUML BALO ANGIOP RNL/OTH VISC ART RS&I XXX TC TRLUML BALO ANGIOP RNL/OTH VISC ART RS&I XXX TRLUML BALO ANGIOP EA VISC ART RS&I ZZZ TRLUML BALO ANGIOP EA VISC ART RS&I ZZZ TC TRLUML BALO ANGIOP EA VISC ART RS&I ZZZ TCAT BX RS&I XXX TCAT BX RS&I XXX TC TCAT BX RS&I XXX TRLUML BALO ANGIOP VEN RS&I XXX TRLUML BALO ANGIOP VEN RS&I XXX TC TRLUML BALO ANGIOP VEN RS&I XXX PRQ TRANSHEPATC BILIARY DRG C+ MNTR RS&I XXX PRQ TRANSHEPATC BILIARY DRG C+ MNTR RS&I XXX TC PRQ TRANSHEPATC BILIARY DRG C+ MNTR RS&I XXX PRQ BILIARY DRG/DRG STENT RS&I XXX PRQ BILIARY DRG/DRG STENT RS&I XXX TC PRQ BILIARY DRG/DRG STENT RS&I XXX CHNG PRQ TUBE/DRAINAGE CATH W CONTRAST RS&I XXX CHNG PRQ TUBE/DRAINAGE CATH W CONTRAST RS&I XXX TC CHNG PRQ TUBE/DRAINAGE CATH W CONTRAST RS&I XXX RAD GID PRQ DRG W/PLMT CATH RS&I XXX RAD GID PRQ DRG W/PLMT CATH RS&I XXX TC RAD GID PRQ DRG W/PLMT CATH RS&I XXX FLUOR SPX <1 HR PHYS TM OTH/THN 71023/ XXX FLUOR SPX <1 HR PHYS TM OTH/THN 71023/ XXX TC FLUOR SPX <1 HR PHYS TM OTH/THN 71023/ XXX FLUOR PHYS TM > 1 HR ASSISTING NON-RAD PHYS XXX FLUOR PHYS TM > 1 HR ASSISTING NON-RAD PHYS XXX TC FLUOR PHYS TM > 1 HR ASSISTING NON-RAD PHYS XXX RADEX FROM NOSE RECTUM FB 1 VIEW CHLD XXX RADEX FROM NOSE RECTUM FB 1 VIEW CHLD XXX TC RADEX FROM NOSE RECTUM FB 1 VIEW CHLD XXX + Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure 198 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

203 Section VIII: Diagnostic and Therapeutic Radiological Services Georgia Workers Compensation Medical Fee Schedule RADIOLOGY Effective April 1, 2011 Medical Fee Schedule RAD XM ABSC/FSTL/SINUS TRC RAD S&I XXX RAD XM ABSC/FSTL/SINUS TRC RAD S&I XXX TC RAD XM ABSC/FSTL/SINUS TRC RAD S&I XXX RAD XM SURG SPEC XXX RAD XM SURG SPEC XXX TC RAD XM SURG SPEC XXX RADEX 1 PLNE BDY SCTJ OTH/THN UROGRAPY XXX RADEX 1 PLNE BDY SCTJ OTH/THN UROGRAPY XXX TC RADEX 1 PLNE BDY SCTJ OTH/THN UROGRAPY XXX RADEX CPLX MOTION BDY SCTJ OTH/THN UROGRAPY UNI XXX RADEX CPLX MOTION BDY SCTJ OTH/THN UROGRAPY UNI XXX TC RADEX CPLX MOTION BDY SCTJ OTH/THN UROGRAPY UNI XXX RADEX CPLX MOTION BDY SCTJ OTH/THN UROGRAPY BI XXX RADEX CPLX MOTION BDY SCTJ OTH/THN UROGRAPY BI XXX TC RADEX CPLX MOTION BDY SCTJ OTH/THN UROGRAPY BI XXX CINERADIOGRAPY/VIDRADIOGRAPY XCPT WHERE SPEC XXX CINERADIOGRAPY/VIDRADIOGRAPY XCPT WHERE SPEC XXX TC CINERADIOGRAPY/VIDRADIOGRAPY XCPT WHERE SPEC XXX CINERADIOGRAPY/VIDRADIOGRAPY ROUTINE XM ZZZ CINERADIOGRAPY/VIDRADIOGRAPY ROUTINE XM ZZZ TC CINERADIOGRAPY/VIDRADIOGRAPY ROUTINE XM ZZZ CONSLTJ X-RAY XM MADE ELSEWHERE WRTTN REPRT BR XXX D RNDR I&R CT MRI US/OTH X REQ POSTPCX XXX D RNDR I&R CT MRI US/OTH X REQ POSTPCX XXX TC 3D RNDR I&R CT MRI US/OTH X REQ POSTPCX XXX D RNDR I&R CT MRI US/OTH REQ POSTPCX XXX D RNDR I&R CT MRI US/OTH REQ POSTPCX XXX TC 3D RNDR I&R CT MRI US/OTH REQ POSTPCX XXX CT LMTD/LOCLZD F-UP STD XXX CT LMTD/LOCLZD F-UP STD XXX TC CT LMTD/LOCLZD F-UP STD XXX MRI SPECTROSCOPY XXX MRI SPECTROSCOPY XXX TC MRI SPECTROSCOPY XXX UNLIS FLUOR PX BR XXX UNLIS CT PX BR XXX UNLIS MRI PX BR XXX UNLIS DX RADIOGRAPIC PX BR XXX ECHOENCEPHALOGRAPY REAL TIME IMAGING XXX ECHOENCEPHALOGRAPY REAL TIME IMAGING XXX TC ECHOENCEPHALOGRAPY REAL TIME IMAGING XXX OPH US DX B-SCAN&QUAN A-SCAN SM PT ENCTR XXX OPH US DX B-SCAN&QUAN A-SCAN SM PT ENCTR XXX TC OPH US DX B-SCAN&QUAN A-SCAN SM PT ENCTR XXX OPH US DX QUAN A-SCAN ONLY XXX OPH US DX QUAN A-SCAN ONLY XXX + Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 199

204 Georgia Workers Compensation Medical Fee Schedule Section VIII: Diagnostic and Therapeutic Radiological Services RADIOLOGY Medical Fee Schedule Effective April 1, TC OPH US DX QUAN A-SCAN ONLY XXX OPH US DX B-SCAN +-A-SCAN XXX OPH US DX B-SCAN +-A-SCAN XXX TC OPH US DX B-SCAN +-A-SCAN XXX OPH US DX ANT SGM US IMMERSION B-SCAN/HR BIOM XXX OPH US DX ANT SGM US IMMERSION B-SCAN/HR BIOM XXX TC OPH US DX ANT SGM US IMMERSION B-SCAN/HR BIOM XXX OPH US DX CRNL PACHYMETRY UNI/BI XXX OPH US DX CRNL PACHYMETRY UNI/BI XXX TC OPH US DX CRNL PACHYMETRY UNI/BI XXX OPH BMTRY US ECHOGRAPY A-SCAN XXX OPH BMTRY US ECHOGRAPY A-SCAN XXX TC OPH BMTRY US ECHOGRAPY A-SCAN XXX OPH BMTRY US ECHOGRAPY A-SCAN IO LENS PWR CAL XXX OPH BMTRY US ECHOGRAPY A-SCAN IO LENS PWR CAL XXX TC OPH BMTRY US ECHOGRAPY A-SCAN IO LENS PWR CAL XXX OPH ULTRASONIC FB LOCLZJ XXX OPH ULTRASONIC FB LOCLZJ XXX TC OPH ULTRASONIC FB LOCLZJ XXX US SOFT TISS HEAD&NCK R-T IMG XXX US SOFT TISS HEAD&NCK R-T IMG XXX TC US SOFT TISS HEAD&NCK R-T IMG XXX US CHEST R-T W/IMAGE DOCUMENTATION XXX US CHEST R-T W/IMAGE DOCUMENTATION XXX TC US CHEST R-T W/IMAGE DOCUMENTATION XXX US BREAST R-T W/IMAGE DOCUMENTATION XXX US BREAST R-T W/IMAGE DOCUMENTATION XXX TC US BREAST R-T W/IMAGE DOCUMENTATION XXX US ABDOMINAL R-T W/IMAGE DOCUMENTATION XXX US ABDOMINAL R-T W/IMAGE DOCUMENTATION XXX TC US ABDOMINAL R-T W/IMAGE DOCUMENTATION XXX ULTRASOUND ABDOMINAL R-T W/IMAGE LIMITED XXX ULTRASOUND ABDOMINAL R-T W/IMAGE LIMITED XXX TC ULTRASOUND ABDOMINAL R-T W/IMAGE LIMITED XXX US RETROPERITONEAL R-T W/IMAGE COMPL XXX US RETROPERITONEAL R-T W/IMAGE COMPL XXX TC US RETROPERITONEAL R-T W/IMAGE COMPL XXX US RPR B-SCAN&/R-T IMG LMTD XXX US RPR B-SCAN&/R-T IMG LMTD XXX TC US RPR B-SCAN&/R-T IMG LMTD XXX US TRNSPL KDN R-T IMG +- DUPLEX DOP STD XXX US TRNSPL KDN R-T IMG +- DUPLEX DOP STD XXX TC US TRNSPL KDN R-T IMG +- DUPLEX DOP STD XXX US SPI CANAL&CNTS XXX US SPI CANAL&CNTS XXX TC US SPI CANAL&CNTS XXX + Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure 200 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

205 Section VIII: Diagnostic and Therapeutic Radiological Services Georgia Workers Compensation Medical Fee Schedule RADIOLOGY Effective April 1, 2011 Medical Fee Schedule US PG UTER IMG F&MAT 14 WK TABDL 1/1ST GESTATION XXX US PG UTER IMG F&MAT 14 WK TABDL 1/1ST GESTATION XXX TC US PG UTER IMG F&MAT 14 WK TABDL 1/1ST GESTATION XXX US PG UTER F&MAT 14 WK TABDL EA GESTATION ZZZ US PG UTER F&MAT 14 WK TABDL EA GESTATION ZZZ TC US PG UTER F&MAT 14 WK TABDL EA GESTATION ZZZ US PG UTER F&MAT AFTER 1ST TRI 1/1ST GESTATION XXX US PG UTER F&MAT AFTER 1ST TRI 1/1ST GESTATION XXX TC US PG UTER F&MAT AFTER 1ST TRI 1/1ST GESTATION XXX US PG UTER F&MAT AFTER 1ST TRI ABDL EA GESTATION ZZZ US PG UTER F&MAT AFTER 1ST TRI ABDL EA GESTATION ZZZ TC US PG UTER F&MAT AFTER 1ST TRI ABDL EA GESTATION ZZZ US PG UTER F&MAT DETAILED FTL XM 1ST GESTATION XXX US PG UTER F&MAT DETAILED FTL XM 1ST GESTATION XXX TC US PG UTER F&MAT DETAILED FTL XM 1ST GESTATION XXX US PG UTER F&MAT DETAILED FTL ANTMC XM EA ZZZ US PG UTER F&MAT DETAILED FTL ANTMC XM EA ZZZ TC US PG UTER F&MAT DETAILED FTL ANTMC XM EA ZZZ US FETAL NUCHAL TRANSLUCENCY 1ST GESTATION XXX US FETAL NUCHAL TRANSLUCENCY 1ST GESTATION XXX TC US FETAL NUCHAL TRANSLUCENCY 1ST GESTATION XXX US FETAL NUCHAL TRANSLUCENCY EA ADDL GESTATION XXX US FETAL NUCHAL TRANSLUCENCY EA ADDL GESTATION XXX TC US FETAL NUCHAL TRANSLUCENCY EA ADDL GESTATION XXX US PG UTER R-T IMG LMTD 1+ FETUSES XXX US PG UTER R-T IMG LMTD 1+ FETUSES XXX TC US PG UTER R-T IMG LMTD 1+ FETUSES XXX US PG UTER R-T IMG F-UP TABDL APPR PR FETUS XXX US PG UTER R-T IMG F-UP TABDL APPR PR FETUS XXX TC US PG UTER R-T IMG F-UP TABDL APPR PR FETUS XXX US PG UTER R-T IMG TRVG XXX US PG UTER R-T IMG TRVG XXX TC US PG UTER R-T IMG TRVG XXX FTL BIOPHYSICAL PROFILE NON-STRS TSTG XXX FTL BIOPHYSICAL PROFILE NON-STRS TSTG XXX TC FTL BIOPHYSICAL PROFILE NON-STRS TSTG XXX FTL BIOPHYSICAL PROFILE W/O NON-STRS TSTG XXX FTL BIOPHYSICAL PROFILE W/O NON-STRS TSTG XXX TC FTL BIOPHYSICAL PROFILE W/O NON-STRS TSTG XXX DOP VELOCIMETRY FTL UMBILICAL ART XXX DOP VELOCIMETRY FTL UMBILICAL ART XXX TC DOP VELOCIMETRY FTL UMBILICAL ART XXX DOP VELOCIMETRY FTL MIDDLE CERE ART XXX DOP VELOCIMETRY FTL MIDDLE CERE ART XXX TC DOP VELOCIMETRY FTL MIDDLE CERE ART XXX ECHO FTL CV SYS R-T REC XXX + Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 201

206 Georgia Workers Compensation Medical Fee Schedule Section VIII: Diagnostic and Therapeutic Radiological Services RADIOLOGY Medical Fee Schedule Effective April 1, ECHO FTL CV SYS R-T REC XXX TC ECHO FTL CV SYS R-T REC XXX ECHO FTL CV SYS R-T REC REPEAT STD XXX ECHO FTL CV SYS R-T REC REPEAT STD XXX TC ECHO FTL CV SYS R-T REC REPEAT STD XXX DOP ECHO FTL SPECTRAL DISPLAY COMPL XXX DOP ECHO FTL SPECTRAL DISPLAY COMPL XXX TC DOP ECHO FTL SPECTRAL DISPLAY COMPL XXX DOP ECHO FTL PLSD SPECTRAL DISPLAY REPEAT STD XXX DOP ECHO FTL PLSD SPECTRAL DISPLAY REPEAT STD XXX TC DOP ECHO FTL PLSD SPECTRAL DISPLAY REPEAT STD XXX US TRVG XXX US TRVG XXX TC US TRVG XXX SALINE NFS SHG SIS COL FLO DOP PFRMD XXX SALINE NFS SHG SIS COL FLO DOP PFRMD XXX TC SALINE NFS SHG SIS COL FLO DOP PFRMD XXX US PELVIC NONOB REAL-TIME IMG COMPLETE XXX US PELVIC NONOB REAL-TIME IMG COMPLETE XXX TC US PELVIC NONOB REAL-TIME IMG COMPLETE XXX US PEL NONOB B-SCAN&/R-T IMG LMTD/F-UP+C XXX US PEL NONOB B-SCAN&/R-T IMG LMTD/F-UP+C XXX TC US PEL NONOB B-SCAN&/R-T IMG LMTD/F-UP+C XXX US SCROTUM&CNTS XXX US SCROTUM&CNTS XXX TC US SCROTUM&CNTS XXX US TRANSRCT XXX US TRANSRCT XXX TC US TRANSRCT XXX US TRANSRCT PRST8 VOL STD BRACHYTX PLNNING SPX XXX US TRANSRCT PRST8 VOL STD BRACHYTX PLNNING SPX XXX TC US TRANSRCT PRST8 VOL STD BRACHYTX PLNNING SPX XXX l US EXTREMITY NON-VASC REAL-TIME IMG COMPL XXX l US EXTREMITY NON-VASC REAL-TIME IMG COMPL XXX l TC US EXTREMITY NON-VASC REAL-TIME IMG COMPL XXX l US EXTREMITY NON-VASC REAL-TIME IMG LMTD XXX l US EXTREMITY NON-VASC REAL-TIME IMG LMTD XXX l TC US EXTREMITY NON-VASC REAL-TIME IMG LMTD XXX US INFT HIPS R-T IMG DYNAMIC REQ PHYS MNPJ XXX US INFT HIPS R-T IMG DYNAMIC REQ PHYS MNPJ XXX TC US INFT HIPS R-T IMG DYNAMIC REQ PHYS MNPJ XXX US INFT HIPS R-T IMG LMTD STATIC X PHYS MNPJ XXX US INFT HIPS R-T IMG LMTD STATIC X PHYS MNPJ XXX TC US INFT HIPS R-T IMG LMTD STATIC X PHYS MNPJ XXX US PRICARDIOCNTS IMG S&I XXX US PRICARDIOCNTS IMG S&I XXX + Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure 202 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

207 Section VIII: Diagnostic and Therapeutic Radiological Services Georgia Workers Compensation Medical Fee Schedule RADIOLOGY Effective April 1, 2011 Medical Fee Schedule TC US PRICARDIOCNTS IMG S&I XXX US ENDOMYOCRD BX IMG S&I XXX US ENDOMYOCRD BX IMG S&I XXX TC US ENDOMYOCRD BX IMG S&I XXX US CMPRN RPR ARTL PSEUDOARYSM/ARVEN FSTL XXX US CMPRN RPR ARTL PSEUDOARYSM/ARVEN FSTL XXX TC US CMPRN RPR ARTL PSEUDOARYSM/ARVEN FSTL XXX US VASC ACCESS SITS VSL PATENCY NDL ENTRY ZZZ US VASC ACCESS SITS VSL PATENCY NDL ENTRY ZZZ TC US VASC ACCESS SITS VSL PATENCY NDL ENTRY ZZZ US &MNTR PARENCHYMAL TISSUE ABLATION XXX US &MNTR PARENCHYMAL TISSUE ABLATION XXX TC US &MNTR PARENCHYMAL TISSUE ABLATION XXX US INTRAUTERINE FTL TFUJ/CORDOCNTS IMG S&I XXX US INTRAUTERINE FTL TFUJ/CORDOCNTS IMG S&I XXX TC US INTRAUTERINE FTL TFUJ/CORDOCNTS IMG S&I XXX US NDL PLMT IMG S&I XXX US NDL PLMT IMG S&I XXX TC US NDL PLMT IMG S&I XXX US CHORNC VILLUS SAMPLING IMG S&I XXX US CHORNC VILLUS SAMPLING IMG S&I XXX TC US CHORNC VILLUS SAMPLING IMG S&I XXX US AMNIOCNTS IMG S&I XXX US AMNIOCNTS IMG S&I XXX TC US AMNIOCNTS IMG S&I XXX US ASPIR OVA IMG S&I XXX US ASPIR OVA IMG S&I XXX TC US ASPIR OVA IMG S&I XXX US PLMT RADJ THER FLDS XXX US PLMT RADJ THER FLDS XXX TC US PLMT RADJ THER FLDS XXX US NTRSTL RADIOELMNT APPL XXX US NTRSTL RADIOELMNT APPL XXX TC US NTRSTL RADIOELMNT APPL XXX US STD F-UP SPEC XXX US STD F-UP SPEC XXX TC US STD F-UP SPEC XXX GI NDSC US S&I XXX GI NDSC US S&I XXX TC GI NDSC US S&I XXX US B1 DNS MEAS&INTERPJ PRPH SIT ANY METH XXX US B1 DNS MEAS&INTERPJ PRPH SIT ANY METH 6.59 XXX TC US B1 DNS MEAS&INTERPJ PRPH SIT ANY METH XXX ULTRASONIC GUIDANCE INTRAOPERATIVE XXX ULTRASONIC GUIDANCE INTRAOPERATIVE XXX TC ULTRASONIC GUIDANCE INTRAOPERATIVE 0.00 XXX + Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 203

208 Georgia Workers Compensation Medical Fee Schedule Section VIII: Diagnostic and Therapeutic Radiological Services RADIOLOGY Medical Fee Schedule Effective April 1, UNLIS US PX BR XXX FLUOR GID CTR VAD PLMT RPLCMT/RMVL ZZZ FLUOR GID CTR VAD PLMT RPLCMT/RMVL ZZZ TC FLUOR GID CTR VAD PLMT RPLCMT/RMVL ZZZ FLUOROSCOPIC GUIDANCE NEEDLE PLACEMENT XXX FLUOROSCOPIC GUIDANCE NEEDLE PLACEMENT XXX TC FLUOROSCOPIC GUIDANCE NEEDLE PLACEMENT XXX s FLUOR GID & LOCLZJ NDL/CATH SPI DX/THER NJX XXX s FLUOR GID & LOCLZJ NDL/CATH SPI DX/THER NJX XXX s TC FLUOR GID & LOCLZJ NDL/CATH SPI DX/THER NJX XXX CT GUIDANCE STEREOTACTIC LOCALIZATION XXX CT GUIDANCE STEREOTACTIC LOCALIZATION XXX TC CT GUIDANCE STEREOTACTIC LOCALIZATION XXX CT GUIDANCE NEEDLE PLACEMENT XXX CT GUIDANCE NEEDLE PLACEMENT XXX TC CT GUIDANCE NEEDLE PLACEMENT XXX CT GUIDANCE &MONITORING VISC TISS ABLATION XXX CT GUIDANCE &MONITORING VISC TISS ABLATION XXX TC CT GUIDANCE &MONITORING VISC TISS ABLATION XXX CT GUIDANCE RADIATION THERAPY FLDS PLACEMENT XXX CT GUIDANCE RADIATION THERAPY FLDS PLACEMENT XXX TC CT GUIDANCE RADIATION THERAPY FLDS PLACEMENT XXX MR GUIDANCE NEEDLE PLACEMENT XXX MR GUIDANCE NEEDLE PLACEMENT XXX TC MR GUIDANCE NEEDLE PLACEMENT XXX MR GUIDANCE &MONITORING TISSUE ABLATION XXX MR GUIDANCE &MONITORING TISSUE ABLATION XXX TC MR GUIDANCE &MONITORING TISSUE ABLATION XXX STRTCTC LOCLZJ GID BREAST BX/NEEDLE PLACEMENT XXX STRTCTC LOCLZJ GID BREAST BX/NEEDLE PLACEMENT XXX TC STRTCTC LOCLZJ GID BREAST BX/NEEDLE PLACEMENT XXX MAMMOGRAPHIC GID NEEDLE PLACEMENTT BREAST XXX MAMMOGRAPHIC GID NEEDLE PLACEMENTT BREAST XXX TC MAMMOGRAPHIC GID NEEDLE PLACEMENTT BREAST XXX COMPUTER-AIDED DETECTION DX MAMMOGRAPHY ZZZ COMPUTER-AIDED DETECTION DX MAMMOGRAPHY 7.41 ZZZ TC COMPUTER-AIDED DETECTION DX MAMMOGRAPHY ZZZ COMPUTER-AIDED DETECTION SCREENING MAMMOGRAPHY ZZZ COMPUTER-AIDED DETECTION SCREENING MAMMOGRAPHY 7.41 ZZZ TC COMPUTER-AIDED DETECTION SCREENING MAMMOGRAPHY ZZZ MAMMARY DUCTOGRAM OR GALACTOGRAM SINGLE XXX MAMMARY DUCTOGRAM OR GALACTOGRAM SINGLE XXX TC MAMMARY DUCTOGRAM OR GALACTOGRAM SINGLE XXX MAMMARY DUCTOGRAM OR GALACTOGRAM MULTIPLE XXX MAMMARY DUCTOGRAM OR GALACTOGRAM MULTIPLE XXX TC MAMMARY DUCTOGRAM OR GALACTOGRAM MULTIPLE XXX + Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure 204 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

209 Section VIII: Diagnostic and Therapeutic Radiological Services Georgia Workers Compensation Medical Fee Schedule RADIOLOGY Effective April 1, 2011 Medical Fee Schedule MAMMOGRAPHY UNILATERAL XXX MAMMOGRAPHY UNILATERAL XXX TC MAMMOGRAPHY UNILATERAL XXX MAMMOGRAPHY BILATERAL XXX MAMMOGRAPHY BILATERAL XXX TC MAMMOGRAPHY BILATERAL XXX SCREENING MAMMOGRAPHY BILATERAL XXX SCREENING MAMMOGRAPHY BILATERAL XXX TC SCREENING MAMMOGRAPHY BILATERAL XXX MRI BREAST UNILATERAL XXX MRI BREAST UNILATERAL XXX TC MRI BREAST UNILATERAL XXX MRI BREAST BILATERAL XXX MRI BREAST BILATERAL XXX TC MRI BREAST BILATERAL XXX MANUAL APPL STRESS PFRMD PHYS JOINT RADIOGRAPHY XXX BONE AGE STUDIES XXX BONE AGE STUDIES XXX TC BONE AGE STUDIES XXX BONE LENGTH STUDIES XXX BONE LENGTH STUDIES XXX TC BONE LENGTH STUDIES XXX RADIOLOGIC EXAMINATION OSSEOUS SURVEY LIMITED XXX RADIOLOGIC EXAMINATION OSSEOUS SURVEY LIMITED XXX TC RADIOLOGIC EXAMINATION OSSEOUS SURVEY LIMITED XXX RADIOLOGIC EXAMINATION OSSEOUS SURVEY COMPL XXX RADIOLOGIC EXAMINATION OSSEOUS SURVEY COMPL XXX TC RADIOLOGIC EXAMINATION OSSEOUS SURVEY COMPL XXX RADIOLOGIC EXAMINATION OSSEOUS SURVEY INFANT XXX RADIOLOGIC EXAMINATION OSSEOUS SURVEY INFANT XXX TC RADIOLOGIC EXAMINATION OSSEOUS SURVEY INFANT XXX JOINT SURVEY SINGLE VIEW 2 OR MORE JOINTS XXX JOINT SURVEY SINGLE VIEW 2 OR MORE JOINTS XXX TC JOINT SURVEY SINGLE VIEW 2 OR MORE JOINTS XXX CT BONE MINERAL DENSITY STUDY 1+ SITS AXIAL SKEL XXX CT BONE MINERAL DENSITY STUDY 1+ SITS AXIAL SKEL XXX TC CT BONE MINERAL DENSITY STUDY 1+ SITS AXIAL SKEL XXX CT BONE MINERAL DENSITY STUDY 1+ SITS APPND XXX CT BONE MINERAL DENSITY STUDY 1+ SITS APPND XXX TC CT BONE MINERAL DENSITY STUDY 1+ SITS APPND XXX DXA BONE DENSITY STUDY 1+ SITS AXIAL SKEL XXX DXA BONE DENSITY STUDY 1+ SITS AXIAL SKEL XXX TC DXA BONE DENSITY STUDY 1+ SITS AXIAL SKEL XXX DXA BONE DENSITY STUDY 1+ SITS APPENDICULAR SKEL XXX DXA BONE DENSITY STUDY 1+ SITS APPENDICULAR SKEL XXX TC DXA BONE DENSITY STUDY 1+ SITS APPENDICULAR SKEL XXX + Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 205

210 Georgia Workers Compensation Medical Fee Schedule Section VIII: Diagnostic and Therapeutic Radiological Services RADIOLOGY Medical Fee Schedule Effective April 1, DXA BONE DENSITY STUDY VERTEBRAL FRACTURE XXX DXA BONE DENSITY STUDY VERTEBRAL FRACTURE XXX TC DXA BONE DENSITY STUDY VERTEBRAL FRACTURE XXX RADIOGRAPHIC ABSORPTIOMETRY 1+ SITS XXX RADIOGRAPHIC ABSORPTIOMETRY 1+ SITS XXX TC RADIOGRAPHIC ABSORPTIOMETRY 1+ SITS XXX BONE MARROW BLOOD SUPPLY XXX BONE MARROW BLOOD SUPPLY XXX TC BONE MARROW BLOOD SUPPLY XXX THER RAD TX PLNNING SMPL XXX THER RAD TX PLNNING INTRM XXX THER RAD TX PLNNING CPLX XXX THER RAD SIMULAJ-AIDED FLD SETTING SMPL XXX THER RAD SIMULAJ-AIDED FLD SETTING SMPL XXX TC THER RAD SIMULAJ-AIDED FLD SETTING SMPL XXX THER RAD SIMULAJ-AIDED FLD SETTING INTRM XXX THER RAD SIMULAJ-AIDED FLD SETTING INTRM XXX TC THER RAD SIMULAJ-AIDED FLD SETTING INTRM XXX THER RAD SIMULAJ-AIDED FLD SETTING CPLX XXX THER RAD SIMULAJ-AIDED FLD SETTING CPLX XXX TC THER RAD SIMULAJ-AIDED FLD SETTING CPLX XXX THER RAD SIMULAJ-AIDED FLD SETTING 3-DIMENSIONAL XXX THER RAD SIMULAJ-AIDED FLD SETTING 3-DIMENSIONAL XXX TC THER RAD SIMULAJ-AIDED FLD SETTING 3-DIMENSIONAL XXX UNLIS PX THER RAD CLINICAL TX PLNNING BR XXX BASIC RADJ DOSIM CAL XXX BASIC RADJ DOSIM CAL XXX TC BASIC RADJ DOSIM CAL XXX NTSTY MODUL RADTHX PLN DOSE-VOL HISTOS XXX NTSTY MODUL RADTHX PLN DOSE-VOL HISTOS XXX TC NTSTY MODUL RADTHX PLN DOSE-VOL HISTOS XXX TELETHX ISODOSE PLN SMPL XXX TELETHX ISODOSE PLN SMPL XXX TC TELETHX ISODOSE PLN SMPL XXX TELETHX ISODOSE PLN INTRM XXX TELETHX ISODOSE PLN INTRM XXX TC TELETHX ISODOSE PLN INTRM XXX TELETHX ISODOSE PLN CPLX XXX TELETHX ISODOSE PLN CPLX XXX TC TELETHX ISODOSE PLN CPLX XXX SPEC TELETHX PORT PLN PARTS HEMIBDY TOT BDY XXX SPEC TELETHX PORT PLN PARTS HEMIBDY TOT BDY XXX TC SPEC TELETHX PORT PLN PARTS HEMIBDY TOT BDY XXX BRACHYTX ISODOSE PLN SMPL XXX BRACHYTX ISODOSE PLN SMPL XXX TC BRACHYTX ISODOSE PLN SMPL XXX + Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure 206 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

211 Section VIII: Diagnostic and Therapeutic Radiological Services Georgia Workers Compensation Medical Fee Schedule RADIOLOGY Effective April 1, 2011 Medical Fee Schedule BRACHYTX ISODOSE PLN INTRM XXX BRACHYTX ISODOSE PLN INTRM XXX TC BRACHYTX ISODOSE PLN INTRM XXX BRACHYTX ISODOSE PLN CPLX XXX BRACHYTX ISODOSE PLN CPLX XXX TC BRACHYTX ISODOSE PLN CPLX XXX SPEC DOSIM ONLY PRESCRIBED TREATING PHYS XXX SPEC DOSIM ONLY PRESCRIBED TREATING PHYS XXX TC SPEC DOSIM ONLY PRESCRIBED TREATING PHYS XXX TX DEV DESIGN&CONSTJ SMPL SMPL BLK SMPL BOLUS XXX TX DEV DESIGN&CONSTJ SMPL SMPL BLK SMPL BOLUS XXX TC TX DEV DESIGN&CONSTJ SMPL SMPL BLK SMPL BOLUS XXX TX DEV DESIGN&CONSTJ INTRM XXX TX DEV DESIGN&CONSTJ INTRM XXX TC TX DEV DESIGN&CONSTJ INTRM XXX TX DEV DESIGN&CONSTJ CPLX XXX TX DEV DESIGN&CONSTJ CPLX XXX TC TX DEV DESIGN&CONSTJ CPLX XXX CONTINUING MEDICAL PHYSICS CONSLTJ PR WK XXX MLC IMRT DESIGN & CONSTRUCTION PER IMRT PLAN XXX MLC IMRT DESIGN & CONSTRUCTION PER IMRT PLAN XXX TC MLC IMRT DESIGN & CONSTRUCTION PER IMRT PLAN XXX SPEC MEDICAL RADJ PHYSICS CONSLTJ XXX K RADIATION DELIVERY STEREOTACTIC CRANIAL COBALT XXX RADIATION DELIVERY STEREOTACTIC CRANIAL LINEAR XXX STEREOTACTIC BODY RADIATION DELIVERY XXX UNLIS MEDICAL RADJ DOSIM TX DEV SPEC SVCS BR XXX RADJ DLVR SUPFC&/ORTHO VOLTAGE XXX RADJ DLVR 1 AREA 1/PRLL OPSD PORTS SMPL <5MEV XXX RADJ DLVR 1 AREA 1/PRLL OPSD PORTS SMPL 6-10MEV XXX RADJ DLVR 1 AREA 1/PRLL OPSD PORTS SMPL 11-19MEV XXX RADJ DLVR 1 AREA 1/PRLL OPSD PORTS SMPL 20MEV/< XXX RADJ DLVR 2 AREAS 3/>PORTS 1 MLT BLKS <5MEV XXX RADJ DLVR 2 AREAS 3/>PORTS 1 MLT BLKS 6-1MEV XXX RADJ DLVR 2 AREAS 3/>PORTS 1 MLT BLKS 11-19MEV XXX RADJ DLVR 2 AREAS 3/> PORTS 1 TX AREA 20 MEV/< XXX RADJ DLVR 3/> AREAS CUSTOM BLKING <5MEV XXX RADJ DLVR 3/> AREAS CUSTOM BLKING 6-10MEV XXX RADJ DLVR 3/> AREAS CUSTOM BLKING 11-19MEV XXX RADJ DLVR 3/> AREAS CUSTOM BLKING 20MEV/< XXX THER RAD PORT FLM XXX NTSTY MODUL DLVR 1/MLT FLDS/ARCS PR TX SESSION XXX STRSC X-RAY GDN LOCLZJ TARGET VOL DLVR RADJ THER XXX STRSC X-RAY GDN LOCLZJ TARGET VOL DLVR RADJ THER XXX TC STRSC X-RAY GDN LOCLZJ TARGET VOL DLVR RADJ THER XXX HI NRG NEUTRON RADJ TX DLVR 1 TX AREA XXX + Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 207

212 Georgia Workers Compensation Medical Fee Schedule Section VIII: Diagnostic and Therapeutic Radiological Services RADIOLOGY Medical Fee Schedule Effective April 1, HI NRG NEUTRON RADJ TX DLVR 1/> ISOCENTER XXX RADJ TX MGMT 5 TXS XXX RADJ THER MGMT COMPL 1/2 FXJS ONLY XXX STERETCTC RADIATION TX MANAGEMENT CRANIAL LESION XXX STEREOTACTIC BODY RADIATION MANAGEMENT XXX SPEC TX PX XXX SPEC TX PX XXX TC SPEC TX PX XXX UNLIS THER RAD TX MGMT BR XXX PROTON TX DLVR SMPL W/O COMPENSATION BR XXX PROTON TX DLVR SMPL COMPENSATION BR XXX PROTON TX DLVR INTRM BR XXX PROTON TX DLVR CPLX BR XXX K HYPRTHM XTRNLLY GEN SUPFC XXX K HYPRTHM XTRNLLY GEN SUPFC XXX K TC HYPRTHM XTRNLLY GEN SUPFC XXX K HYPRTHM XTRNLLY GEN DP XXX K HYPRTHM XTRNLLY GEN DP XXX K TC HYPRTHM XTRNLLY GEN DP XXX K HYPRTHM GEN NTRSTL PRB 5/FEWER XXX K HYPRTHM GEN NTRSTL PRB 5/FEWER XXX K TC HYPRTHM GEN NTRSTL PRB 5/FEWER XXX K HYPRTHM GEN NTRSTL PRB > XXX K HYPRTHM GEN NTRSTL PRB > XXX K TC HYPRTHM GEN NTRSTL PRB > XXX HYPRTHM GEN INTRCV PRB XXX HYPRTHM GEN INTRCV PRB XXX TC HYPRTHM GEN INTRCV PRB XXX NFS/INSTLJ RADIOELMNT SLN 3 MO F-UP CARE NFS/INSTLJ RADIOELMNT SLN 3 MO F-UP CARE TC NFS/INSTLJ RADIOELMNT SLN 3 MO F-UP CARE INTRCV RADJ SRC APPL SMPL INTRCV RADJ SRC APPL SMPL TC INTRCV RADJ SRC APPL SMPL INTRCV RADJ SRC APPL INTRM INTRCV RADJ SRC APPL INTRM TC INTRCV RADJ SRC APPL INTRM INTRCV RADJ SRC APPL CPLX INTRCV RADJ SRC APPL CPLX TC INTRCV RADJ SRC APPL CPLX NTRSTL RADJ SRC APPL SMPL NTRSTL RADJ SRC APPL SMPL TC NTRSTL RADJ SRC APPL SMPL NTRSTL RADJ SRC APPL INTRM NTRSTL RADJ SRC APPL INTRM TC NTRSTL RADJ SRC APPL INTRM Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure 208 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

213 Section VIII: Diagnostic and Therapeutic Radiological Services Georgia Workers Compensation Medical Fee Schedule RADIOLOGY Effective April 1, 2011 Medical Fee Schedule NTRSTL RADJ SRC APPL CPLX NTRSTL RADJ SRC APPL CPLX TC NTRSTL RADJ SRC APPL CPLX REMOTE AFTLD RADIONUCLIDE BRACHYTX 1 CHANNEL XXX REMOTE AFTLD RADIONUCLIDE BRACHYTX 1 CHANNEL XXX TC REMOTE AFTLD RADIONUCLIDE BRACHYTX 1 CHANNEL XXX REMOTE AFTLD RADIONUCLIDE BRACHYTX 2-12 CHANNEL XXX REMOTE AFTLD RADIONUCLIDE BRACHYTX 2-12 CHANNEL XXX TC REMOTE AFTLD RADIONUCLIDE BRACHYTX 2-12 CHANNEL XXX REMOTE AFTLD RADIONUCLIDE BRACHYTX > 12 CHANNEL XXX REMOTE AFTLD RADIONUCLIDE BRACHYTX > 12 CHANNEL XXX TC REMOTE AFTLD RADIONUCLIDE BRACHYTX > 12 CHANNEL XXX SURF APPL RADJ SRC SURF APPL RADJ SRC TC SURF APPL RADJ SRC SUPVJ HANDLING LOADING RADJ SRC XXX SUPVJ HANDLING LOADING RADJ SRC XXX TC SUPVJ HANDLING LOADING RADJ SRC XXX UNLIS CLINICAL BRACHYTX BR XXX THYR UPTK 1 DETER XXX THYR UPTK 1 DETER XXX TC THYR UPTK 1 DETER XXX THYR UPTK MLT DETERS XXX THYR UPTK MLT DETERS XXX TC THYR UPTK MLT DETERS XXX THYR UPTK STIMJ SUPRJ/DSCHRG X 1ST UPTK STD XXX THYR UPTK STIMJ SUPRJ/DSCHRG X 1ST UPTK STD XXX TC THYR UPTK STIMJ SUPRJ/DSCHRG X 1ST UPTK STD XXX THYR IMG UPTK 1 DETER XXX THYR IMG UPTK 1 DETER XXX TC THYR IMG UPTK 1 DETER XXX THYR IMG UPTK MLT DETERS XXX THYR IMG UPTK MLT DETERS XXX TC THYR IMG UPTK MLT DETERS XXX THYR IMG ONLY XXX THYR IMG ONLY XXX TC THYR IMG ONLY XXX THYR IMG VASC FLO XXX THYR IMG VASC FLO XXX TC THYR IMG VASC FLO XXX THYR CARC METASTASES IMG LMTD AREA XXX THYR CARC METASTASES IMG LMTD AREA XXX TC THYR CARC METASTASES IMG LMTD AREA XXX THYR CARC METASTASES IMG ADDL STD XXX THYR CARC METASTASES IMG ADDL STD XXX TC THYR CARC METASTASES IMG ADDL STD XXX + Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 209

214 Georgia Workers Compensation Medical Fee Schedule Section VIII: Diagnostic and Therapeutic Radiological Services RADIOLOGY Medical Fee Schedule Effective April 1, THYR CARC METASTASES IMG WHBDY XXX THYR CARC METASTASES IMG WHBDY XXX TC THYR CARC METASTASES IMG WHBDY XXX THYR CARC METASTASES UPTK ZZZ THYR CARC METASTASES UPTK ZZZ TC THYR CARC METASTASES UPTK ZZZ PARATHYR IMG XXX PARATHYR IMG XXX TC PARATHYR IMG XXX ADRNL IMG CORTEX&/MEDULLA XXX ADRNL IMG CORTEX&/MEDULLA XXX TC ADRNL IMG CORTEX&/MEDULLA XXX UNLIS ENDOC PX DX NUC MED BR XXX B1 MARROW IMG LMTD AREA XXX B1 MARROW IMG LMTD AREA XXX TC B1 MARROW IMG LMTD AREA XXX B1 MARROW IMG MLT AREAS XXX B1 MARROW IMG MLT AREAS XXX TC B1 MARROW IMG MLT AREAS XXX B1 MARROW IMG WHBDY XXX B1 MARROW IMG WHBDY XXX TC B1 MARROW IMG WHBDY XXX PLSM VOL RP VOL-DIL TQ SPX 1 SAMPLING XXX PLSM VOL RP VOL-DIL TQ SPX 1 SAMPLING XXX TC PLSM VOL RP VOL-DIL TQ SPX 1 SAMPLING XXX PLSM VOL RP VOL-DIL TQ SPX MLT SAMPLINGS XXX PLSM VOL RP VOL-DIL TQ SPX MLT SAMPLINGS XXX TC PLSM VOL RP VOL-DIL TQ SPX MLT SAMPLINGS XXX RBC VOL DETER SPX 1 SAMPLING XXX RBC VOL DETER SPX 1 SAMPLING XXX TC RBC VOL DETER SPX 1 SAMPLING XXX RBC VOL DETER SPX MLT SAMPLINGS XXX RBC VOL DETER SPX MLT SAMPLINGS XXX TC RBC VOL DETER SPX MLT SAMPLINGS XXX WHL BLD VOL DETER RP VOL-DIL TQ XXX WHL BLD VOL DETER RP VOL-DIL TQ XXX TC WHL BLD VOL DETER RP VOL-DIL TQ XXX RBC SURV STD XXX RBC SURV STD XXX TC RBC SURV STD XXX RBC SURV STD DIFFIAL ORGAN/TISS KIN XXX RBC SURV STD DIFFIAL ORGAN/TISS KIN XXX TC RBC SURV STD DIFFIAL ORGAN/TISS KIN XXX LBLD RBC SQSJ DIFFIAL ORGAN/TISS XXX LBLD RBC SQSJ DIFFIAL ORGAN/TISS XXX TC LBLD RBC SQSJ DIFFIAL ORGAN/TISS XXX + Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure 210 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

215 Section VIII: Diagnostic and Therapeutic Radiological Services Georgia Workers Compensation Medical Fee Schedule RADIOLOGY Effective April 1, 2011 Medical Fee Schedule SPLEEN IMG ONLY +-VASC FLO XXX SPLEEN IMG ONLY +-VASC FLO XXX TC SPLEEN IMG ONLY +-VASC FLO XXX KIN STD PLTLT SURV +-DIFFIAL ORGAN/TISS LOCLZJ XXX KIN STD PLTLT SURV +-DIFFIAL ORGAN/TISS LOCLZJ XXX TC KIN STD PLTLT SURV +-DIFFIAL ORGAN/TISS LOCLZJ XXX PLTLT SURV STD XXX PLTLT SURV STD XXX TC PLTLT SURV STD XXX LYMPHATICS&LYMPH NOD IMG XXX LYMPHATICS&LYMPH NOD IMG XXX TC LYMPHATICS&LYMPH NOD IMG XXX UNLIS HEMATOP RET/ENDO&LYMPHATIC DX NUC MED BR XXX LVR IMG STATIC ONLY XXX LVR IMG STATIC ONLY XXX TC LVR IMG STATIC ONLY XXX LVR IMG VASC FLO XXX LVR IMG VASC FLO XXX TC LVR IMG VASC FLO XXX LVR IMG SPECT XXX LVR IMG SPECT XXX TC LVR IMG SPECT XXX LVR IMG SPECT VASC FLO XXX LVR IMG SPECT VASC FLO XXX TC LVR IMG SPECT VASC FLO XXX LVR&SPLEEN IMG STATIC ONLY XXX LVR&SPLEEN IMG STATIC ONLY XXX TC LVR&SPLEEN IMG STATIC ONLY XXX LVR&SPLEEN IMG VASC FLO XXX LVR&SPLEEN IMG VASC FLO XXX TC LVR&SPLEEN IMG VASC FLO XXX LVR FUNCJ STD HEPATBL AGT SRL IMAGES XXX LVR FUNCJ STD HEPATBL AGT SRL IMAGES XXX TC LVR FUNCJ STD HEPATBL AGT SRL IMAGES XXX HEPATBL DUX SYS IMG GLBLDR XXX HEPATBL DUX SYS IMG GLBLDR XXX TC HEPATBL DUX SYS IMG GLBLDR XXX SALIVARY GLND IMG XXX SALIVARY GLND IMG XXX TC SALIVARY GLND IMG XXX SALIVARY GLND IMG SRL IMAGES XXX SALIVARY GLND IMG SRL IMAGES XXX TC SALIVARY GLND IMG SRL IMAGES XXX SALIVARY GLND FUNCJ STD XXX SALIVARY GLND FUNCJ STD XXX TC SALIVARY GLND FUNCJ STD XXX + Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 211

216 Georgia Workers Compensation Medical Fee Schedule Section VIII: Diagnostic and Therapeutic Radiological Services RADIOLOGY Medical Fee Schedule Effective April 1, ESOPHGL MOTILITY XXX ESOPHGL MOTILITY XXX TC ESOPHGL MOTILITY XXX GSTR MUCOSA IMG XXX GSTR MUCOSA IMG XXX TC GSTR MUCOSA IMG XXX G-ESOP RFLX STD XXX G-ESOP RFLX STD XXX TC G-ESOP RFLX STD XXX GSTR EMPTYING STD XXX GSTR EMPTYING STD XXX TC GSTR EMPTYING STD XXX UREA BRTH TST C-14 ISOTOPIC ACQUISJ ALYS XXX UREA BRTH TST C-14 ISOTOPIC ALYS XXX VIT B-12 ABSRPJ STD W/O INTRNSC FACTOR XXX VIT B-12 ABSRPJ STD W/O INTRNSC FACTOR XXX TC VIT B-12 ABSRPJ STD W/O INTRNSC FACTOR XXX VIT B-12 ABSRPJ STD INTRNSC FACTOR XXX VIT B-12 ABSRPJ STD INTRNSC FACTOR XXX TC VIT B-12 ABSRPJ STD INTRNSC FACTOR XXX VIT B-12 ABSRPJ STD CMBN W/&W/O INTRNSC FACTOR XXX VIT B-12 ABSRPJ STD CMBN W/&W/O INTRNSC FACTOR XXX TC VIT B-12 ABSRPJ STD CMBN W/&W/O INTRNSC FACTOR XXX AQT GI BLD LOSS IMG XXX AQT GI BLD LOSS IMG XXX TC AQT GI BLD LOSS IMG XXX GI PROTEIN LOSS XXX GI PROTEIN LOSS XXX TC GI PROTEIN LOSS XXX INT IMG XXX INT IMG XXX TC INT IMG XXX PRTL-VEN SHUNT PATENCY TST XXX PRTL-VEN SHUNT PATENCY TST XXX TC PRTL-VEN SHUNT PATENCY TST XXX UNLIS GI PX DX NUC MED BR XXX B1&/JT IMG LMTD AREA XXX B1&/JT IMG LMTD AREA XXX TC B1&/JT IMG LMTD AREA XXX B1&/JT IMG MLT AREAS XXX B1&/JT IMG MLT AREAS XXX TC B1&/JT IMG MLT AREAS XXX B1&/JT IMG WHBDY XXX B1&/JT IMG WHBDY XXX TC B1&/JT IMG WHBDY XXX B1&/JT IMG 3 PHASE STD XXX + Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure 212 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

217 Section VIII: Diagnostic and Therapeutic Radiological Services Georgia Workers Compensation Medical Fee Schedule RADIOLOGY Effective April 1, 2011 Medical Fee Schedule B1&/JT IMG 3 PHASE STD XXX TC B1&/JT IMG 3 PHASE STD XXX B1&/JT IMG TOMOG SPECT XXX B1&/JT IMG TOMOG SPECT XXX TC B1&/JT IMG TOMOG SPECT XXX B1 DNS STD 1+ SITS 1 PHTN ABSRPTM XXX B1 DNS STD 1+ SITS 1 PHTN ABSRPTM XXX TC B1 DNS STD 1+ SITS 1 PHTN ABSRPTM XXX B1 DNS STD 1+ SITS DUAL PHTN ABSRPTM 1+ SITS XXX B1 DNS STD 1+ SITS DUAL PHTN ABSRPTM 1+ SITS XXX TC B1 DNS STD 1+ SITS DUAL PHTN ABSRPTM 1+ SITS XXX UNLIS MUSCSKEL PX DX NUC MED BR XXX DETER CTR C-V HEMODYN NON-IMG +-RX 1/MLT XXX DETER CTR C-V HEMODYN NON-IMG +-RX 1/MLT XXX TC DETER CTR C-V HEMODYN NON-IMG +-RX 1/MLT XXX CAR SHUNT DETCJ XXX CAR SHUNT DETCJ XXX TC CAR SHUNT DETCJ XXX NON-CAR VASC FLO IMG XXX NON-CAR VASC FLO IMG XXX TC NON-CAR VASC FLO IMG XXX MYOCARDIAL SPECT SINGLE STUDY AT REST OR STRESS XXX MYOCARDIAL SPECT SINGLE STUDY AT REST OR STRESS XXX TC MYOCARDIAL SPECT SINGLE STUDY AT REST OR STRESS XXX MYOCARDIAL SPECT MULTIPLE STUDIES XXX MYOCARDIAL SPECT MULTIPLE STUDIES XXX TC MYOCARDIAL SPECT MULTIPLE STUDIES XXX MYOCARDIAL PERFUSION PLANAR 1 STUDY REST/STRESS XXX MYOCARDIAL PERFUSION PLANAR 1 STUDY REST/STRESS XXX TC MYOCARDIAL PERFUSION PLANAR 1 STUDY REST/STRESS XXX MYOCARDIAL PERFUSION PLANAR MULTIPLE STUDIES XXX MYOCARDIAL PERFUSION PLANAR MULTIPLE STUDIES XXX TC MYOCARDIAL PERFUSION PLANAR MULTIPLE STUDIES XXX AQT VEN THROMBOSIS IMG PEPTIDE XXX AQT VEN THROMBOSIS IMG PEPTIDE XXX TC AQT VEN THROMBOSIS IMG PEPTIDE XXX VEN THROMBOSIS IMG VENOGRAM UNI XXX VEN THROMBOSIS IMG VENOGRAM UNI XXX TC VEN THROMBOSIS IMG VENOGRAM UNI XXX VEN THROMBOSIS IMG VENOGRAM BI XXX VEN THROMBOSIS IMG VENOGRAM BI XXX TC VEN THROMBOSIS IMG VENOGRAM BI XXX MYOCRD IMG P+ EMIJ TOMOG METAB EVAL XXX MYOCRD IMG P+ EMIJ TOMOG METAB EVAL XXX TC MYOCRD IMG P+ EMIJ TOMOG METAB EVAL XXX MYOCRD IMG INFARCT AVID PLNR QUAL/QUAN XXX + Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 213

218 Georgia Workers Compensation Medical Fee Schedule Section VIII: Diagnostic and Therapeutic Radiological Services RADIOLOGY Medical Fee Schedule Effective April 1, MYOCRD IMG INFARCT AVID PLNR QUAL/QUAN XXX TC MYOCRD IMG INFARCT AVID PLNR QUAL/QUAN XXX MYOCRD IMG INFARCT AVID PLNR EJEC FXJ 1ST PS TQ XXX MYOCRD IMG INFARCT AVID PLNR EJEC FXJ 1ST PS TQ XXX TC MYOCRD IMG INFARCT AVID PLNR EJEC FXJ 1ST PS TQ XXX MYOCRD IMG INFARCT AVID PLNR TOMOG SPECT +-QUAN XXX MYOCRD IMG INFARCT AVID PLNR TOMOG SPECT +-QUAN XXX TC MYOCRD IMG INFARCT AVID PLNR TOMOG SPECT +-QUAN XXX CARD BPI GTD =BRM PLNR 1 STD REST/STRS XXX CARD BPI GTD =BRM PLNR 1 STD REST/STRS XXX TC CARD BPI GTD =BRM PLNR 1 STD REST/STRS XXX CARD BPI GTD =BRM MLT STD WALL MOTION STD XXX CARD BPI GTD =BRM MLT STD WALL MOTION STD XXX TC CARD BPI GTD =BRM MLT STD WALL MOTION STD XXX CARD BPI PLNR 1ST PS 1 STD PLUS EJEC FXJ XXX CARD BPI PLNR 1ST PS 1 STD PLUS EJEC FXJ XXX TC CARD BPI PLNR 1ST PS 1 STD PLUS EJEC FXJ XXX CARD BPI PLNR 1ST PS MLT STD PLUS EJEC FXJ XXX CARD BPI PLNR 1ST PS MLT STD PLUS EJEC FXJ XXX TC CARD BPI PLNR 1ST PS MLT STD PLUS EJEC FXJ XXX MYOCRD IMG P+ EMIJ TOMOG PRFUJ 1 STD XXX MYOCRD IMG P+ EMIJ TOMOG PRFUJ 1 STD XXX TC MYOCRD IMG P+ EMIJ TOMOG PRFUJ 1 STD XXX MYOCRD IMG P+ EMIJ TOMOG PRFUJ MLT STD XXX MYOCRD IMG P+ EMIJ TOMOG PRFUJ MLT STD XXX TC MYOCRD IMG P+ EMIJ TOMOG PRFUJ MLT STD XXX CARD BPI GTD =BRM SPECT REST WALL MOTION XXX CARD BPI GTD =BRM SPECT REST WALL MOTION XXX TC CARD BPI GTD =BRM SPECT REST WALL MOTION XXX CARD BPI GTD =BRM 1 STD REST R VENTR EJEC FXJ ZZZ CARD BPI GTD =BRM 1 STD REST R VENTR EJEC FXJ ZZZ TC CARD BPI GTD =BRM 1 STD REST R VENTR EJEC FXJ ZZZ UNLIS CV DX NUC MED BR XXX PULM PI PART XXX PULM PI PART XXX TC PULM PI PART XXX PULM PI PART VNTJ 1 BRTH XXX PULM PI PART VNTJ 1 BRTH XXX TC PULM PI PART VNTJ 1 BRTH XXX PULM PI PART VNTJ RBRTHING&WSHOT +-1 BRTH XXX PULM PI PART VNTJ RBRTHING&WSHOT +-1 BRTH XXX TC PULM PI PART VNTJ RBRTHING&WSHOT +-1 BRTH XXX PULM VI AERSL 1 PROJECTION XXX PULM VI AERSL 1 PROJECTION XXX TC PULM VI AERSL 1 PROJECTION XXX PULM VI AERSL MLT PRJCJ XXX + Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure 214 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

219 Section VIII: Diagnostic and Therapeutic Radiological Services Georgia Workers Compensation Medical Fee Schedule RADIOLOGY Effective April 1, 2011 Medical Fee Schedule PULM VI AERSL MLT PRJCJ XXX TC PULM VI AERSL MLT PRJCJ XXX PULM PI PART VNTJ IMG AERSL 1/MLT PRJCJ XXX PULM PI PART VNTJ IMG AERSL 1/MLT PRJCJ XXX TC PULM PI PART VNTJ IMG AERSL 1/MLT PRJCJ XXX PULM VI GASEOUS 1 PRJCJ XXX PULM VI GASEOUS 1 PRJCJ XXX TC PULM VI GASEOUS 1 PRJCJ XXX PULM VI GASEOUS RBRTHING&WSHOT 1 PRJCJ XXX PULM VI GASEOUS RBRTHING&WSHOT 1 PRJCJ XXX TC PULM VI GASEOUS RBRTHING&WSHOT 1 PRJCJ XXX PULM VI GASEOUS RBRTHING&WSHOT MLT PRJCJ XXX PULM VI GASEOUS RBRTHING&WSHOT MLT PRJCJ XXX TC PULM VI GASEOUS RBRTHING&WSHOT MLT PRJCJ XXX PULM QUAN DIFFIAL FUNCJ VNTJ/PRFUJ STD XXX PULM QUAN DIFFIAL FUNCJ VNTJ/PRFUJ STD XXX TC PULM QUAN DIFFIAL FUNCJ VNTJ/PRFUJ STD XXX UNLIS RESPIR PX DX NUC MED BR XXX BRAIN IMAGING <4 STATIC VIEWS XXX BRAIN IMAGING <4 STATIC VIEWS XXX TC BRAIN IMAGING <4 STATIC VIEWS XXX BRAIN IMAGING <4 STATIC VIEWS W/VASCULAR FLOW XXX BRAIN IMAGING <4 STATIC VIEWS W/VASCULAR FLOW XXX TC BRAIN IMAGING <4 STATIC VIEWS W/VASCULAR FLOW XXX BRAIN IMAGING MIN 4 STATIC VIEWS XXX BRAIN IMAGING MIN 4 STATIC VIEWS XXX TC BRAIN IMAGING MIN 4 STATIC VIEWS XXX BRAIN IMAGING MIN 4 STATIC VIEWS W VASCULAR FLOW XXX BRAIN IMAGING MIN 4 STATIC VIEWS W VASCULAR FLOW XXX TC BRAIN IMAGING MIN 4 STATIC VIEWS W VASCULAR FLOW XXX BRAIN IMAGING TOMOGRAPHIC SPECT XXX BRAIN IMAGING TOMOGRAPHIC SPECT XXX TC BRAIN IMAGING TOMOGRAPHIC SPECT XXX BRN IMG P+ EMIJ TOMOG METAB EVAL XXX BRN IMG P+ EMIJ TOMOG METAB EVAL XXX TC BRN IMG P+ EMIJ TOMOG METAB EVAL XXX BRN IMG P+ EMIJ TOMOG PRFUJ EVAL XXX BRN IMG P+ EMIJ TOMOG PRFUJ EVAL XXX TC BRN IMG P+ EMIJ TOMOG PRFUJ EVAL 0.00 XXX BRN IMG VASC FLO ONLY XXX BRN IMG VASC FLO ONLY XXX TC BRN IMG VASC FLO ONLY XXX CEREBSP FLU FLO IMG X INTRO MATRL CISTRNG XXX CEREBSP FLU FLO IMG X INTRO MATRL CISTRNG XXX TC CEREBSP FLU FLO IMG X INTRO MATRL CISTRNG XXX CEREBSP FLU FLO IMG X INTRO MATRL VENTRG XXX + Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 215

220 Georgia Workers Compensation Medical Fee Schedule Section VIII: Diagnostic and Therapeutic Radiological Services RADIOLOGY Medical Fee Schedule Effective April 1, CEREBSP FLU FLO IMG X INTRO MATRL VENTRG XXX TC CEREBSP FLU FLO IMG X INTRO MATRL VENTRG XXX CEREBSP FLU FLO IMG X INTRO MATRL SHUNT EVAL XXX CEREBSP FLU FLO IMG X INTRO MATRL SHUNT EVAL XXX TC CEREBSP FLU FLO IMG X INTRO MATRL SHUNT EVAL XXX CEREBSP FLU FLO IMG X INTRO MATRL TOMOG SPECT XXX CEREBSP FLU FLO IMG X INTRO MATRL TOMOG SPECT XXX TC CEREBSP FLU FLO IMG X INTRO MATRL TOMOG SPECT XXX CEREBSP FLU LEAKAGE DETCJ&LOCLZJ XXX CEREBSP FLU LEAKAGE DETCJ&LOCLZJ XXX TC CEREBSP FLU LEAKAGE DETCJ&LOCLZJ XXX RP DACRYOCSTOGRAPY XXX RP DACRYOCSTOGRAPY XXX TC RP DACRYOCSTOGRAPY XXX UNLIS NRVS SYS PX DX NUC MED BR XXX KIDNEY IMAGING MORPHOLOGY XXX KIDNEY IMAGING MORPHOLOGY XXX TC KIDNEY IMAGING MORPHOLOGY XXX KDN IMG VASC FLO XXX KDN IMG VASC FLO XXX TC KDN IMG VASC FLO XXX KIDNEY IMG MORPHOLOGY VASCULAR FLOW 1 W/O RX XXX KIDNEY IMG MORPHOLOGY VASCULAR FLOW 1 W/O RX XXX TC KIDNEY IMG MORPHOLOGY VASCULAR FLOW 1 W/O RX XXX KIDNEY IMG MORPHOLOGY VASCULAR FLOW 1 W RX XXX KIDNEY IMG MORPHOLOGY VASCULAR FLOW 1 W RX XXX TC KIDNEY IMG MORPHOLOGY VASCULAR FLOW 1 W RX XXX KIDNEY IMG MORPHOLOGY VASCULAR FLOW MULTIPLE XXX KIDNEY IMG MORPHOLOGY VASCULAR FLOW MULTIPLE XXX TC KIDNEY IMG MORPHOLOGY VASCULAR FLOW MULTIPLE XXX KIDNEY IMAGING MORPHOLOGY TOMOGRAPHIC XXX KIDNEY IMAGING MORPHOLOGY TOMOGRAPHIC XXX TC KIDNEY IMAGING MORPHOLOGY TOMOGRAPHIC XXX KDN FUNCJ STD NON-IMG RADIOISOTOPIC STD XXX KDN FUNCJ STD NON-IMG RADIOISOTOPIC STD XXX TC KDN FUNCJ STD NON-IMG RADIOISOTOPIC STD XXX URINARY BLADDER RESIDUAL STUDY ZZZ URINARY BLADDER RESIDUAL STUDY ZZZ TC URINARY BLADDER RESIDUAL STUDY ZZZ URTRL RFLX STD RP VOIDING CSTOGRAM XXX URTRL RFLX STD RP VOIDING CSTOGRAM XXX TC URTRL RFLX STD RP VOIDING CSTOGRAM XXX TESTICULAR IMAGING WITH VASCULAR FLOW XXX TESTICULAR IMAGING WITH VASCULAR FLOW XXX TC TESTICULAR IMAGING WITH VASCULAR FLOW XXX UNLIS GENITOUR DX NUC MED BR XXX + Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure 216 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

221 Section VIII: Diagnostic and Therapeutic Radiological Services Georgia Workers Compensation Medical Fee Schedule RADIOLOGY Effective April 1, 2011 Medical Fee Schedule RP LOCLZJ TUM/DSTRBJ AGT LMTD AREA XXX RP LOCLZJ TUM/DSTRBJ AGT LMTD AREA XXX TC RP LOCLZJ TUM/DSTRBJ AGT LMTD AREA XXX RP LOCLZJ TUM/DSTRBJ AGT MLT AREAS XXX RP LOCLZJ TUM/DSTRBJ AGT MLT AREAS XXX TC RP LOCLZJ TUM/DSTRBJ AGT MLT AREAS XXX RP LOCLZJ TUM/DSTRBJ AGT WHBDY 1 D IMG XXX RP LOCLZJ TUM/DSTRBJ AGT WHBDY 1 D IMG XXX TC RP LOCLZJ TUM/DSTRBJ AGT WHBDY 1 D IMG XXX RP LOCLZJ TUM/DSTRBJ AGT TOMOG SPECT XXX RP LOCLZJ TUM/DSTRBJ AGT TOMOG SPECT XXX TC RP LOCLZJ TUM/DSTRBJ AGT TOMOG SPECT XXX RP LOCLZJ TUM/DSTRBJ AGT WHBDY REQ 2/> D IMG XXX RP LOCLZJ TUM/DSTRBJ AGT WHBDY REQ 2/> D IMG XXX TC RP LOCLZJ TUM/DSTRBJ AGT WHBDY REQ 2/> D IMG XXX RP LOCLZJ INFLAMMATORY PROCESS LMTD AREA XXX RP LOCLZJ INFLAMMATORY PROCESS LMTD AREA XXX TC RP LOCLZJ INFLAMMATORY PROCESS LMTD AREA XXX RP LOCLZJ INFLAMMATORY PROCESS WHBDY XXX RP LOCLZJ INFLAMMATORY PROCESS WHBDY XXX TC RP LOCLZJ INFLAMMATORY PROCESS WHBDY XXX RP LOCLZJ INFLAMMATORY PROCESS TOMOG SPECT XXX RP LOCLZJ INFLAMMATORY PROCESS TOMOG SPECT XXX TC RP LOCLZJ INFLAMMATORY PROCESS TOMOG SPECT XXX NJX RP LOCLZJ NON-IMG PROBE STUDY INTRAVENOUS XXX PET IMAGING LIMITED AREA CHEST HEAD/NECK XXX PET IMAGING LIMITED AREA CHEST HEAD/NECK XXX TC PET IMAGING LIMITED AREA CHEST HEAD/NECK XXX PET IMAGING SKULL BASE TO MID-THIGH XXX PET IMAGING SKULL BASE TO MID-THIGH XXX TC PET IMAGING SKULL BASE TO MID-THIGH XXX PET IMAGING WHOLE BODY XXX PET IMAGING WHOLE BODY XXX TC PET IMAGING WHOLE BODY XXX PET IMAGING CT FOR ATTENUATION LIMITED AREA XXX PET IMAGING CT FOR ATTENUATION LIMITED AREA XXX TC PET IMAGING CT FOR ATTENUATION LIMITED AREA XXX PET IMAGING CT ATTENUATION SKULL BASE MID-THIGH XXX PET IMAGING CT ATTENUATION SKULL BASE MID-THIGH XXX TC PET IMAGING CT ATTENUATION SKULL BASE MID-THIGH XXX PET IMAGING FOR CT ATTENUATION WHOLE BODY XXX PET IMAGING FOR CT ATTENUATION WHOLE BODY XXX TC PET IMAGING FOR CT ATTENUATION WHOLE BODY XXX UNLIS MISC DX NUC MED BR XXX RP THER ORAL ADMN XXX RP THER ORAL ADMN XXX + Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 217

222 Georgia Workers Compensation Medical Fee Schedule Section VIII: Diagnostic and Therapeutic Radiological Services RADIOLOGY Medical Fee Schedule Effective April 1, TC RP THER ORAL ADMN XXX RP THER IV ADMN XXX RP THER IV ADMN XXX TC RP THER IV ADMN XXX RP THER INTRCV ADMN XXX RP THER INTRCV ADMN XXX TC RP THER INTRCV ADMN XXX RP THER NTRSTL RADACT COL ADMN XXX RP THER NTRSTL RADACT COL ADMN XXX TC RP THER NTRSTL RADACT COL ADMN XXX RP THER RADIOLBLD MONOCLONAL ANTB IV NFS XXX RP THER RADIOLBLD MONOCLONAL ANTB IV NFS XXX TC RP THER RADIOLBLD MONOCLONAL ANTB IV NFS XXX RP THER INTRA-ARTICULAR ADMN XXX RP THER INTRA-ARTICULAR ADMN XXX TC RP THER INTRA-ARTICULAR ADMN XXX RP THER IA PART ADMN XXX RP THER IA PART ADMN XXX TC RP THER IA PART ADMN XXX RP THER UNLIS PX BR XXX + Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure 218 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

223 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 and 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 nor the pathology consultation CPT codes and are reimbursable under this circumstance. The review of diagnostic tests is included in the evaluation and management (E/M) codes. 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 CPT code For collection of capillary blood specimen, see CPT code For collection of blood specimen from a completely implantable venous access device, see CPT code For handling, see CPT codes and 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). 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 five-digit CPT code without modifier 26 indicates that the charge includes both the professional and technical components. CPT only 2010 American Medical Association. All Rights Reserved. 219

224 Georgia Workers Compensation Medical Fee Schedule 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 five-digit CPT 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 TC. 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 services 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 report (see section IV). Procedures Listed without Specified Unit Values Fees are not shown for some procedures listed in the schedule that are rarely provided, unusual, variable, new, or unlisted services. The unlisted services and accompanying codes are listed at the end of each Pathology/Laboratory subsection. Unlisted service or procedure codes must be selected from the appropriate subsection of the Pathology/Laboratory chapter. For these procedures a BR (by report) designation has been used in the fee schedule. Reimbursement for such procedures must be justified by report (see section IV). 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). Panel Tests When billing for panel tests (CPT codes ) 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. Section IX: Pathology and Laboratory Services 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. 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 the appropriate two-digit modifier following the procedure code. When two modifiers are applicable to a single code, indicate each modifier on the bill. 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 (Evaluation and Management, 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 Increased Procedural Services: When the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. Documentation must support the substantial additional work and the reason for the additional work (i.e., increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). Note: This modifier should not be appended to an E/M service. 26 Professional Component: 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 modifier 26 to the usual procedure number. 53 Discontinued Procedure: Under certain circumstances, the physician may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the well-being of the patient, it 220 CPT only 2010 American Medical Association. All Rights Reserved.

225 Section IX: Pathology and Laboratory Services may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. This circumstance may be reported by adding modifier 53 to the code reported by the physician for the discontinued procedure. 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. For outpatient hospital/ambulatory surgery center (ASC) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for ASC hospital outpatient use). 59 Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision or 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 individual. 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. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-e/m service performed on the same date, see modifier 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 modifier 90 to the usual procedure number. Georgia Workers Compensation Medical Fee Schedule 91 Repeat Clinical Diagnostic Laboratory Test: In the course of treatment of the patient, it may be necessary to repeat the same laboratory test on the same day to obtain subsequent (multiple) test results. Under these circumstances, the laboratory test performed can be identified by its usual procedure number and the addition of modifier 91. Note: This modifier may not be used when tests are rerun to confirm initial results; due to testing problems with specimens or equipment; or for any other reason when a normal, one-time, reportable result is all that is required. This modifier may not be used when other code(s) describe a series of test results (e.g., glucose tolerance tests, evocative/suppression testing). This modifier may only be used for laboratory test(s) performed more than once on the same day on the same patient. 92 Alternative Laboratory Platform Testing: When laboratory testing is being performed using a kit or transportable instrument that wholly or in part consists of a single use, disposable analytical chamber, the service may be identified by adding modifier 92 to the usual laboratory procedure code (HIV testing ). The test does not require permanent dedicated space; hence by its design it may be hand carried or transported to the vicinity of the patient for immediate testing at that site, although location of the testing is not in itself determinative of the use of this modifier. 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. TC 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 modifier TC to the usual procedure number. CPT only 2010 American Medical Association. All Rights Reserved. 221

226 Georgia Workers Compensation Medical Fee Schedule Section IX: Pathology and Laboratory Services PATHOLOGY AND LABORATORY Medical Fee Schedule Effective April 1, BASIC METABOLIC PANEL CALCIUM IONIZED XXX BASIC METABOLIC PANEL CALCIUM TOTAL XXX GENERAL HLTH PANEL XXX ELECTROLYTE PANEL XXX COMPRE METAB PANEL XXX OB PANEL XXX LIPID PANEL XXX RNL FUNCJ PANEL XXX AQT HEP PANEL XXX HEPATC FUNCJ PANEL XXX DRUG SCR QUAL MLT DRUG CLASSES CHROM EA PX XXX DRUG SCR QUAL 1 DRUG CLASS METH EA DRUG CLASS XXX DRUG CONFIRMATION EA PX XXX TISS PREPJ DRUG ALYS XXX l # DRUG SCRN QUAL 1+ CLASS NONCHROMOTOGRAPHIC EA XXX AMIKACIN XXX AMITRIPTYLINE XXX BENZODIAZEPINES XXX CARBAMAZEPINE TOT XXX CARBAMAZEPINE FR XXX CYCLOSPORINE XXX DESIPRAMINE XXX DIGOXIN XXX DIPROPYLACETIC ACID XXX DOXEPIN XXX ETHOSUXIMIDE XXX GENTAMICIN XXX GOLD XXX HALOPRIDOL XXX IMIPRAMINE XXX LIDOCAINE XXX LITHIUM XXX NORTRIPTYLINE XXX PHENOBARBITAL XXX PHENYTOIN TOT XXX PHENYTOIN FR XXX PRIMIDONE XXX PROCAINAMIDE XXX PROCAINAMIDE METABOLITES XXX QUINIDINE XXX SIROLIMUS XXX SALICYLATE XXX TACROLIMUS XXX THEOPHYLLINE XXX TOBRAMYCIN XXX TOPIRAMATE XXX 222 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

227 Section IX: Pathology and Laboratory Services Georgia Workers Compensation Medical Fee Schedule PATHOLOGY AND LABORATORY Effective April 1, 2011 Medical Fee Schedule VANCOMYCIN XXX QUAN DRUG NES XXX ACTH STIMJ PANEL ADRNL INSUFFICIENCY XXX ACTH STIMJ PANEL 21 HYDROXYLASE DEFNCY XXX ACTH STIMJ PANEL 3 BETA-HYDROXYDEHYD DEFNCY XXX ALDOSTERONE SUPRJ EVAL PANEL XXX CALCITONIN STIMJ PANEL XXX CORTICOTROPIC RELEASING HORM STIMJ PANEL XXX CHORNC GONAD STIMJ PANEL TSTOSTERONE RSPSE XXX CHORNC GONAD STIMJ PANEL ESTRADIOL RSPSE XXX RNL VEIN RENIN STIMJ PANEL XXX PRPH VEIN RENIN STIMJ PANEL XXX CMBN RAPID ANT PITUITARY EVAL PANEL XXX DXMETHASONE SUPRJ PANEL 48 HR XXX GLUC TOLERANCE PANEL INSULINOMA XXX GLUC TOLERANCE PANEL PHEOCHROMOCYTOMA XXX GONAD RELEASING HORM STIMJ PANEL XXX GROWTH HORM STIMJ PANEL XXX GROWTH HORM SUPRJ PANEL GLUC ADMN XXX INSULIN-INDUCED C-PEPTIDE SUPRJ PANEL XXX INSULIN TOLERANCE PANEL ACTH INSUFFICIENCY XXX INSULIN TOLERANCE PANEL GROWTH HORM DEFNCY XXX METYRAPONE PANEL XXX TRH STIMJ PANEL 1 HR XXX TRH STIMJ PANEL 2 HR XXX TRH STIMJ PANEL HYPRPROLACTINEMIA XXX CLIN PATH CONSLTJ LIMITED XXX CLIN PATH CONSLTJ COMPRE XXX URNLS DIP STICK/TABLET RGNT NON-AUTO MIC 5.94 XXX URNLS DIP STICK/TABLET RGNT AUTO MIC 5.94 XXX URNLS DIP STICK/TABLET RGNT NON-AUTO W/O MIC 5.02 XXX URNLS DIP STICK/TABLET RGNT AUTO W/O MIC 4.11 XXX URNLS QUAL/SEMIQUAN XCPT IAS 4.11 XXX URNLS BACTERIURIA SCR XCPT CULTURE/DIPSTICK 5.02 XXX URNLS MCRSCP ONLY 5.94 XXX URNLS 2/3 GLASS TST 6.85 XXX URINE PREGNANCY TST VIS COLOR CMPRSN METHS XXX VOL MEAS TMD COLLJ EA 5.48 XXX UNLIS URNLS BR XXX ACETALDEHYDE BLD XXX ACETAMINOPHEN XXX ACETONE/OTH KETONE BODIES SERUM QUAL 8.68 XXX ACETONE/OTH KETONE BODIES SERUM QUAN XXX ACETYLCHOLINESTERASE XXX ACYLCARNITINES QUAL EA SPEC XXX ACYLCARNITINES QUAN EA SPEC XXX Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 223

228 Georgia Workers Compensation Medical Fee Schedule Section IX: Pathology and Laboratory Services PATHOLOGY AND LABORATORY Medical Fee Schedule Effective April 1, ADRENOCORTICOTROPIC HORM XXX ADENOSINE 5-MONOPHOSPHATE CYCLIC XXX ALBUMIN SERUM PLASMA/WHOLE BLOOD 9.14 XXX ALBUMIN URINE/OTH SRC QUAN EA SPEC 9.59 XXX ALBUMIN URINE MICROALBUMIN QUAN XXX ALBUMIN URINE MICROALBUMIN SEMIQUAN 8.68 XXX ALBUMIN ISCHEMIA MODF XXX ALCOHOL ANY SPEC XCPT BRTH XXX ALCOHOL BRTH XXX ALDOLASE XXX ALDOSTERONE XXX ALKALOIDS URINE QUAN XXX ALPHA-1-ANTITRYPSIN TOT XXX ALPHA-1-ANTITRYPSIN PHEXYP XXX ALPHA-FETOPROTEIN SERUM XXX ALPHA-FETOPROTEIN AMNIOTIC FLU XXX AFP-L3 FRACTION ISOFORM & TOTAL AFP W/RATIO XXX ALUMINUM XXX AMINES VAG FLU QUAL 7.31 XXX AMINO ACIDS 1 QUAL EA SPEC XXX AMINO ACIDS MLT QUAL EA SPEC XXX AMINO ACIDS 1 QUAN EA SPEC XXX AMINOLEVULINIC ACID DELTA XXX AMINO ACIDS 2-5 AMINO ACIDS QUAN EA SPEC XXX AMINO ACIDS 6/> AMINO ACIDS QUAN EA SPEC XXX AMMONIA XXX AMNIOTIC FLU SCAN XXX AMPHETAMINE/METHAMPHETAMINE XXX AMYLASE XXX ANDROSTANEDIOL GLUCURONIDE XXX ANDROSTENEDIONE XXX ANDROSTERONE XXX ANGIOTENSIN II XXX ANGIOTENSIN I-CONVERTING ENZYME XXX APOLIPOPROTEIN EA XXX ARSENIC XXX ASCORBIC ACID BLD XXX ATOMIC ABSRPJ SPECTROSCOPY EA ANAL XXX BARBITURATES NES XXX BETA-2 MICROGLOBULIN XXX BILE ACIDS TOT XXX BILE ACIDS CHOLYLGLYCINE XXX BILIRUBIN TOT 9.59 XXX BILIRUBIN DIR 9.59 XXX BILIRUBIN FECES QUAL 8.68 XXX BIOTINIDASE EA SPEC XXX 224 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

229 Section IX: Pathology and Laboratory Services Georgia Workers Compensation Medical Fee Schedule PATHOLOGY AND LABORATORY Effective April 1, 2011 Medical Fee Schedule BLD OCLT PROXIDASE ACTV QUAL FECES 1 DETER 5.94 XXX BLD OCLT PROXIDASE ACTV QUAL OTH SRCS 5.94 XXX BLOOD OCCULT PEROXIDASE ACTV QUAL FECES 1-3 SPEC 5.94 XXX BLD OCLT FECAL HGB DETER IA QUAL FECES XXX BRADYKININ XXX CADMIUM XXX HYDROXY INCLUDES FRACTIONS IF PERFORMED XXX CALCITONIN XXX CALCIUM TOT 9.59 XXX CALCIUM IONIZED XXX CALCIUM AFTER CALCIUM NFS TST 9.59 XXX CALCIUM URINE QUAN TMD SPEC XXX ST1 QUAL ALYS XXX ST1 QUAN ALYS CHEM XXX ST1 INFRARED SPECTROSCOPY XXX ST1 X-RAY DIFFXJ XXX CARBOHYDRATE DEFICIENT TRRIN XXX CARBON DIOXIDE 9.14 XXX CARBOXYHEMOGLOBIN QUANTITATIVE XXX CARBOXYHEMOGLOBIN QUALITATIVE XXX CARCINOEMBRYONIC AG XXX CARNITINE QUAN EA SPEC XXX CAROTENE XXX CATECHOLAMINES TOT URINE XXX CATECHOLAMINES BLD XXX CATECHOLAMINES FXJATED XXX CATHEPSIN-D XXX CERULOPLASMIN XXX CHEMILUMINESCENT ASSAY XXX CHLORAMPHENICOL XXX CHLORIDE BLD 8.68 XXX CHLORIDE URINE 9.59 XXX CHLORIDE OTH SRC 9.14 XXX CHLORINATED HYDROCARBONS SCR XXX CHOLESTEROL SERUM/WHL BLD TOT 8.22 XXX CHOLINESTERASE SERUM XXX CHOLINESTERASE RBC XXX CHONDROITIN B SULFATE QUAN XXX CHROM QUAL COLUMN ANAL NES XXX CHROM QUAL PAPR 1-DIMENSIONAL ANAL NES XXX CHROM QUAL PAPR 2-DIMENSIONAL ANAL NES XXX CHROM QUAL THIN LYR ANAL NES XXX CHROM QUAN COLUMN 1 ANAL NES XXX CHROM QUAN COLUMN MLT ANALS XXX CHROMIUM XXX CITRATE XXX Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 225

230 Georgia Workers Compensation Medical Fee Schedule Section IX: Pathology and Laboratory Services PATHOLOGY AND LABORATORY Medical Fee Schedule Effective April 1, COCAINE/METABOLITE XXX COLLAGEN CROSS LINKS ANY METH XXX COPPR XXX CORTICOSTERONE XXX CORTISOL FR XXX CORTISOL TOT XXX CREATINE 8.68 XXX COL-CHR/MS QUAL 1 STATIONARY&MOBILE PHASE XXX COL-CHR/MS QUAN 1 STATIONARY&MOBILE PHASE XXX COL-CHR/MS STABLE ISOTOPE DIL 1 ANAL XXX COL-CHR/MS STABLE ISOTOPE DIL MLT ANALS XXX CREATINE KINASE TOT XXX CREATINE KINASE ISOENZYMES XXX CREATINE KINASE MB FXJ ONLY XXX CREATINE KINASE ISOFORMS XXX CREATININE BLD 9.59 XXX CREATININE OTH SRC 9.59 XXX CREATININE CLEARANCE XXX CRYOFIBRN XXX CRYOGLOBULIN QUAL/SEMI-QUAN XXX CYANIDE XXX CYANOCOBALAMIN XXX CYANOCOBALAMIN UNSAT BNDNG CAP XXX CYSTATIN C XXX CSTINE&HOMOCSTINE URINE QUAL XXX DEHYDROEPIANDROSTERONE XXX DEHYDROEPIANDROSTERONE-SULFATE XXX DESOXYCORTICOSTERONE XXX DEOXYCORTISOL XXX DIBUCAINE NUMBER XXX DIHYDROCODEINONE XXX DIHYDROMORPHINONE XXX DIHYDROTSTOSTERONE XXX # DIHYDROXY INCLUDES FRACTIONS IF PERFORMED XXX DIMETHADIONE XXX ELASTASE PNCRTC FECAL QUAL/SEMI-QUAN XXX NZM ACTV CELLS/TISS NONRADACT SUBSTRATE EA XXX NZM ACTV CELLS/TISS RADACT SUBSTRATE EA XXX ELECTROP TQ NES XXX EPIANDROSTERONE XXX ERYTHROPOIETIN XXX ESTRADIOL XXX STRGNS FXJATED XXX STRGNS TOT XXX ESTRIOL XXX ESTRONE XXX 226 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

231 Section IX: Pathology and Laboratory Services Georgia Workers Compensation Medical Fee Schedule PATHOLOGY AND LABORATORY Effective April 1, 2011 Medical Fee Schedule ETHCHLORVYNOL XXX ETHYLENE GLYCOL XXX ETIOCHOLANOLONE XXX FAT/LIPIDS FECES QUAL 9.59 XXX FAT/LIPIDS FECES QUAN XXX FAT DIFFIAL FECES QUAN XXX FATTY ACIDS NONESTERIFIED XXX VERY LONG CHAIN FATTY ACIDS XXX FERRITIN XXX FTL FIBRONECTIN CERVICOVAG SECRETIONS SEMI-QUAN XXX FLUORIDE XXX FLURAZEPAM XXX FOLIC ACID SERUM XXX FOLIC ACID RBC XXX FRUCTOSE SEMEN XXX GALACTOKINASE RBC XXX GALACTOSE XXX GALACTOSE-1-PHOSPHATE URIDYL TRASE QUAN XXX GALACTOSE-1-PHOSPHATE URIDYL TRASE SCR XXX GAMMAGLOBULIN IGA IGD IGG IGM EACH XXX GAMMAGLOBULIN IGE XXX GAMMAGLOBULIN IMMUNOGLOBULIN SUBCLASSES XXX GASES BLD PH ONLY XXX BLOOD GASES ANY COMBINATION PH PCO2 PO2 CO2 HCO XXX GASES BLD PH DIR MEAS XCPT PLS OXIMTRY XXX GASES BLD O2 SATURATION ONLY DIR MEAS XXX HGB-O2 AFFINITY PO2 50% SATURATION OXYGEN XXX l GASTRIC ACID ANALYIS W/PH EA SPECIMEN XXX GASTRIN AFTER SECRETIN STIMJ XXX GASTRIN XXX GLUC XXX GLUC BDY FLU OTH/THN BLD 7.31 XXX GLUC TOLERANCE TST XXX GLUC QUAN BLD 7.31 XXX GLUC BLD RGNT STRIP 5.94 XXX GLUC POST GLUC DOSE GLUC 9.14 XXX GLUC TOLERANCE TST GTT 3 SPEC GLUC XXX s GLUCOSE TOLERANCE EA ADDL BEYOND 3 SPECIMENS 7.31 XXX GLUC TOLBUTAMIDE TOLERANCE TST XXX GLUC-6-PHOSPHATE DEHYD QUAN XXX GLUC-6-PHOSPHATE DEHYD SCR XXX GLUC BLD GLUC MNTR DEV CLEARED FDA SPEC HOME USE 4.57 XXX GLUCOSIDASE BETA XXX GLUTAMATE DEHYD XXX GLUTAMINE XXX GLUTAMYLTRASE GAMMA XXX Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 227

232 Georgia Workers Compensation Medical Fee Schedule Section IX: Pathology and Laboratory Services PATHOLOGY AND LABORATORY Medical Fee Schedule Effective April 1, GLUTATHIONE XXX GLUTATHIONE REDUXASE RBC XXX GLUTETHIMIDE XXX GLYCATED PROTEIN XXX GONAD FOLLICLE STIMULATING HORM XXX GONAD LTNZNG HORM XXX GROWTH HORM HUMAN XXX GUANOSINE MONOPHOSPHATE CYCLIC XXX HPYLORI BLD NON-RADACT ISOTOPE XXX HAPTOGLOBIN QUAN XXX HAPTOGLOBIN PHEXYP XXX HPYLORI BRTH NON-RADACT ISOTOPE XXX HPYLORI DRUG ADMN XXX HEAVY METAL SCR XXX HEAVY METAL QUAN EA XXX HGB FXJ&QUAN ELECTROPHORESIS XXX HGB FXJ&QUAN ELECTROPHORESIS XXX TC HGB FXJ&QUAN ELECTROPHORESIS XXX HGB FXJ&QUAN CHROM XXX HGB COPPR SULFATE METH NON-AUTO 4.57 XXX HGB F CHEM XXX HGB F QUAL XXX HGB GLYCOSYLATED XXX HGB GLYCOSYLATED DEV CLEARED FDA HOME USE XXX HGB METHGB QUAL 9.59 XXX HGB METHGB QUAN XXX HGB PLSM XXX HGB SULFHGB QUAL 9.14 XXX HGB SULFHGB QUAN XXX HGB THERMOLABILE XXX HGB UNSTABLE SCR XXX HGB URINE 7.31 XXX HEMOSIDERIN QUAL 9.14 XXX HEMOSIDERIN QUAN XXX B-HEXOSAMINIDASE EA ASSAY XXX HISTAM XXX HOMOCSTEINE XXX HOMOVANILLIC ACID XXX HYDROXYCORTICOSTRDS XXX HYDROXYINDOLACETIC ACID XXX HYDROXYPROGST 17-D XXX HYDROXYPROGST XXX HYDROXYPROLINE FR XXX HYDROXYPROLINE TOT XXX IMMUNOASSAY ANALYTE QUAL/SEMIQUAL MULTIPLE STEP XXX IMMUNOASSAY ANALYTE QUAL/SEMIQUAL SINGLE STEP XXX 228 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

233 Section IX: Pathology and Laboratory Services Georgia Workers Compensation Medical Fee Schedule PATHOLOGY AND LABORATORY Effective April 1, 2011 Medical Fee Schedule IMMUNOASSAY ANALYTE QUANT RADIOIMMUNOASSAY XXX IMMUNOASSAY ANALYTE QUANTITATIVE NOS XXX INSULIN TOT XXX INSULIN FR XXX INTRNSC FACTOR XXX IRON XXX IRON BNDNG CAP XXX ISOCITRIC DEHYD XXX KETOGENIC STRDS FXJ XXX KETOSTRDS 17 TOT XXX KETOSTRDS 17-FXJ XXX LACTATE XXX LACTATE DEHYD XXX LACTATE DEHYD ISOENZYMES SEP&QUAN XXX LACTOFERRIN FECAL QUAL XXX LACTOFERRIN FECAL QUAN XXX LACTOGEN HPL HUMAN CHORNC SOMAT XXX LACTOSE URINE QUAL XXX LACTOSE URINE QUAN XXX LEAD XXX FTL LNG MATRT ASSMT L/S RATIO XXX FTL LNG MATRT ASSMT FOAM STABILITY TST XXX FTL LNG MATRT ASSMT FLUORESCENCE POLARIZATION XXX FTL LNG MATRT ASSMT LAMELLAR BDY DNS XXX LEUCINE AMINOPEPTIDASE LAP XXX LIPASE XXX LIPOPROTEIN A XXX LIPOPROTEIN-ASSOCIATED PHOSPHOLIPASE A XXX LIPOPROTEIN BLD ELECTROP SEP&QUAN XXX LIPOPROTEIN BLD HR SUBCLASSES XXX LIPOPROTEIN BLD QUAN NUMBERS&SUBCLASSES XXX LIPOPROTEIN DIR MEAS HI DNS CHOLESTEROL XXX LIPOPROTEIN DIR MEAS VLDL CHOLESTEROL XXX LIPOPROTEIN DIR MEAS LDL CHOLESTEROL XXX LTNZNG RELEASING FACTOR XXX MAGNESIUM XXX MALATE DEHYD XXX MANGANESE XXX MASS SPECT&TANDEM MASS SPECT ANAL QUAL EA SPEC XXX MASS SPECT&TANDEM MASS SPECT ANAL QUAN EA SPEC XXX MEPROBAMATE XXX MERCURY QUAN XXX METANEPHRINES XXX METHADONE XXX METHEMALBUMIN XXX METHSUXIMIDE XXX Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 229

234 Georgia Workers Compensation Medical Fee Schedule Section IX: Pathology and Laboratory Services PATHOLOGY AND LABORATORY Medical Fee Schedule Effective April 1, 2011 l MICROFLUID ANALYSIS TEAR OSMOLARITY XXX MUCOPOLYSACS ACID QUAN XXX MUCOPOLYSACS ACID SCR XXX MUCIN SYNVAL FLU ROPES TST XXX MYELIN BASIC PROTEIN CEREBSP FLU XXX MYOGLOBIN XXX MYELOPEROXIDASE MPO XXX NATRIURETIC PEPTIDE XXX NEPHELOMETRY EA ANAL NES XXX NICKEL XXX NICOTINE XXX MOLEC DIAG ISOL/XTRJ EA NUCLEIC ACID TYPE 7.77 XXX MOLEC ISOL/XTRJ HP NUCLEIC ACID EA TYPE 7.77 XXX MOLEC ENZYMATIC DIGESTION EA ENZYME TX 7.77 XXX MOLEC DOT/SLOT BLOT EA NUCLEIC ACID PREPJ 7.77 XXX MOLEC SEP GEL ELECTROPHORESIS EACH PREPJ 7.77 XXX MOLEC NUCLEIC ACID PRB EA 7.77 XXX MOLEC NUCLEIC ACID TR EA NUCLEIC ACID PREPJ 7.77 XXX MOLECULAR DX AMPLIFICATION TARGET EA SEQUENCE XXX MOLECULAR DX AMP TARGET MULTIPLEX 1ST 2 SEQ XXX MOLECULAR DX AMP TARGET MULTIPLEX EA ADDL SEQ XXX MOLEC REVERSE TRANSCRIPTION XXX MOLEC MUTATION SCANNING PROPERTIES 1 SGM EACH XXX MOLEC MUTATION ID SEQUENCING 1 SGM EA SGM XXX MOLEC MUTATION ALLELE TRANSCRIPTION 1 SGM EA XXX MOLEC MUTATION ALLELE SPEC TRANSLATION 1 SGM EA XXX MOLEC LSS CELLS PRIOR NUCLEIC ACID XTRJ XXX MOLECULAR DX AMPLIFICATION SIGNAL EA SEQUENCE XXX MOLEC SEP&ID HR TQ XXX MOLEC DX I&R XXX MOLEC DX I&R XXX TC MOLEC DX I&R 7.76 XXX MOLECULAR DIAGNOSTICS RNA STABILIZATION XXX MUTATION ID ENZYMATIC LIG/PRIMER XTN 1 SGM EA XXX NUCLEOTIDASE 5' XXX OLIGOCLONAL IMMUNE XXX ORGANIC ACIDS TOT QUAN EA SPEC XXX ORGANIC ACIDS QUAL EA SPEC XXX ORGANIC ACID 1 QUAN XXX OPIATE(S) DRUG AND METABOLITES EACH PROCEDURE XXX OSMOLALITY BLD XXX OSMOLALITY URINE XXX OSTEOCALCIN XXX OXALATE XXX ONCOPROTEIN HER-2/NEU XXX ONCOPROTEIN DES-GAMMA-CARBOXY-PROTHROMBIN DCP XXX 230 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

235 Section IX: Pathology and Laboratory Services Georgia Workers Compensation Medical Fee Schedule PATHOLOGY AND LABORATORY Effective April 1, 2011 Medical Fee Schedule PARATHORM XXX PH BODY FLUID NOS 6.85 XXX PH EXHALED BREATH CONDENSATE XXX PHENCYCLIDINE XXX CALPROTECTIN FECAL XXX PHEXHIAZINE XXX PHENYLALA9 BLD XXX PHENYLKETONES QUAL 6.85 XXX PHOSPHATASE ACID TOT XXX PHOSPHATASE ACID FORENSIC XM XXX PHOSPHATASE ACID PROSTATIC XXX PHOSPHATASE ALKALINE 9.59 XXX PHOSPHATASE ALKALINE HEAT STABLE TOT X W/ XXX PHOSPHATASE ALKALINE ISOENZYMES XXX PHOSPHATIDYLGLYCEROL XXX PHOSPHOGLUCONATE 6-DEHYD RBC XXX PHOSPHOHEXOSE ISOMERASE XXX PHOSPHORUS INORGANIC 9.14 XXX PHOSPHORUS INORGANIC URINE 9.59 XXX PORPHOBILINOGEN URINE QUAL 8.22 XXX PORPHOBILINOGEN URINE QUAN XXX l PLACENTAL ALPHA MICROGLOBULIN C/V QUAL XXX PORPHYRINS URINE QUAL XXX PORPHYRINS URINE QUAN&FXJ XXX PORPHYRINS FECES QUAN XXX PORPHYRINS FECES QUAL XXX POTASSIUM SERUM PLASMA/WHOLE BLOOD 8.68 XXX POTASSIUM URINE 8.22 XXX PREALBUMIN XXX PREGNANEDIOL XXX PREGNANETRIOL XXX PREGNENOLONE XXX HYDROXYPREGNENOLONE XXX PROGST XXX PROCALCITONIN (PCT) XXX PROLACTIN XXX PROSTAGLNDIN EA XXX PRST8 SPEC AG CPLXED DIR MEAS XXX PRST8 SPEC AG TOT XXX PRST8 SPEC AG FR XXX PROTEIN XCPT REFRACTOMETRY SERUM PLASMA/WHL BLD 6.85 XXX PROTEIN TOT XCPT REFRACTOMETRY URINE 6.85 XXX PROTEIN TOT XCPT REFRACTOMETRY OTH SRC 6.85 XXX PROTEIN TOT REFRACTOMETRY ANY SRC 9.59 XXX PREGNANCY-ASSOCIATED PLSM PROTEIN-A XXX PROTEIN ELECTROP FXJ&QUAN SERUM XXX Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 231

236 Georgia Workers Compensation Medical Fee Schedule Section IX: Pathology and Laboratory Services PATHOLOGY AND LABORATORY Medical Fee Schedule Effective April 1, PROTEIN ELECTROP FXJ&QUAN SERUM XXX TC PROTEIN ELECTROP FXJ&QUAN SERUM XXX PROTEIN ELECTROP FXJ&QUAN OTH FLUS CONCENTRATION XXX PROTEIN ELECTROP FXJ&QUAN OTH FLUS CONCENTRATION XXX TC PROTEIN ELECTROP FXJ&QUAN OTH FLUS CONCENTRATION XXX PROTEIN WSTRN BLOT I&R BLD/OTH FLU XXX PROTEIN WSTRN BLOT I&R BLD/OTH FLU XXX TC PROTEIN WSTRN BLOT I&R BLD/OTH FLU XXX PROTEIN WSTRN BLOT BLD/OTH FLU IMMUNOLOGICAL XXX PROTEIN WSTRN BLOT BLD/OTH FLU IMMUNOLOGICAL XXX TC PROTEIN WSTRN BLOT BLD/OTH FLU IMMUNOLOGICAL XXX PROTOPORPHYRIN RBC QUAN XXX PROTOPORPHYRIN RBC SCR XXX PROINSULIN XXX PYRIDOXAL PHOSPHATE XXX PYRUVATE XXX PYRUVATE KINASE XXX QUININE XXX RCPTR ASSAY STRGN XXX RCPTR ASSAY PROGST XXX RCPTR ASSAY ENDOC OTH/THN STRGN/PROGST XXX RCPTR ASSAY NON-ENDOC SPEC RCPTR XXX RENIN XXX RIBOFLAVIN XXX SELENIUM XXX SEROTONIN XXX SEX HORM BNDNG GLOBULIN XXX SIALIC ACID XXX SILICA XXX SODIUM SERUM PLASMA OR WHOLE BLOOD 9.14 XXX SODIUM URINE 9.14 XXX SODIUM OTH SRC 9.14 XXX SOMATOMEDIN XXX SOMATOSTATIN XXX SPECTROPHOTOMETRY ANAL NES XXX SPEC GRAVITY XCPT URINE 4.57 XXX SUGARS CHROMATOGRAPIC TLC/PAPR CHROM XXX SUGARS MONO DI&OLIGOS 1 QUAL EA SPEC XXX SUGARS MONO DI&OLIGOS MLT QUAL EA SPEC XXX SUGARS MONO DI&OLIGOS 1 QUAN EA SPEC XXX SUGARS MONO DI&OLIGOS MLT QUAN EA SPEC XXX SULFATE URINE 9.14 XXX TSTOSTERONE FR XXX TSTOSTERONE TOT XXX THIAMINE XXX THIOCYANATE XXX 232 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

237 Section IX: Pathology and Laboratory Services Georgia Workers Compensation Medical Fee Schedule PATHOLOGY AND LABORATORY Effective April 1, 2011 Medical Fee Schedule THROMBOXANE METABOLITE W/WO THROMBOXANE URINE XXX THYROGLOBULIN XXX THYROXINE TOT XXX THYROXINE REQ ELUTION XXX THYROXINE FR XXX THYROXINE BNDNG GLOBULIN XXX THYR STIMULATING HORM XXX THYR STIMULATING IGS XXX TOCOPHEROL ALPHA XXX TRANSCORTIN XXX TRANSFERASE ASPARTATE AMINO 9.59 XXX TRANSFERASE ALANINE AMINO XXX TRANSFERRIN XXX TRIGLYCERIDES XXX THYR HORM UPTK/THYR HORM BNDNG RATIO XXX TRIIODOTHYRO9 T3 TOT XXX TRIIODOTHYRO9 T3 FR XXX TRIIODOTHYRO9 T3 REVERSE XXX TROPONIN QUAN XXX TRYPSIN DUOL FLU XXX TRYPSIN FECES QUAL XXX TRYPSIN FECES QUAN 24-HR COLLJ XXX TYROSINE XXX TROPONIN QUAL XXX UREA N QUAN 7.31 XXX UREA N SEMIQUAN 7.31 XXX UREA N URINE 9.14 XXX UREA N CLEARANCE XXX URIC ACID BLD 8.68 XXX URIC ACID OTH SRC 9.14 XXX UROBILINOGEN FECES QUAN XXX UROBILINOGEN URINE QUAL 5.94 XXX UROBILINOGEN URINE QUAN TMD SPEC XXX UROBILINOGEN URINE SEMIQUAN 9.59 XXX VANILLYLMANDELIC ACID URINE XXX VASOACTIVE INTSTINAL PEPTIDE XXX VASOPRESSIN XXX VIT XXX VIT NOS XXX VIT K XXX VOLATILES XXX XYLOSE ABSRPJ TST BLD&/URINE XXX ZINC XXX C-PEPTIDE XXX GONAD CHORNC QUAN XXX GONAD CHORNC QUAL XXX Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 233

238 Georgia Workers Compensation Medical Fee Schedule Section IX: Pathology and Laboratory Services PATHOLOGY AND LABORATORY Medical Fee Schedule Effective April 1, GONADOTROPIN CHORIONIC HCG FREE BETA CHAIN XXX OVUL TSTS VIS COLOR CMPRSN METHS XXX UNLIS CHEMISTRY BR XXX BLEEDING TM 8.68 XXX BLD# AUTO DIFFIAL WBC CNT XXX BLD# BLD SMR MCRSCP XM MNL DIFFIAL WBC CNT 6.40 XXX BLD# BLD SMR MCRSCP XM W/O MNL DIFFIAL WBC CNT 6.40 XXX BLD# MNL DIFFIAL WBC CNT BUFFY COAT 6.85 XXX BLD# SPUN MICROHEMATOCRIT 4.57 XXX BLD# HEMATOCRIT 4.57 XXX BLD# HGB 4.57 XXX BLD# COMPL AUTO HHRWP&AUTO DIFFIAL XXX BLD# COMPL AUTO HHRWP XXX BLD# MNL C-CNT RBC WBC/PLTLT EA 8.22 XXX BLD# RED BLD CELL AUTO 5.48 XXX BLD# RETICULOCYTE MNL 8.22 XXX BLD# RETICULOCYTE AUTO 7.77 XXX BLD# RETICULOCYTES AUTO 1+ CELL MEAS XXX BLD# WBC AUTO 5.02 XXX BLD# PLTLT AUTO 8.68 XXX RETICULATED PLTLT ASSAY XXX BLD SMR PRPH INTERPJ PHYS WRTTN REPRT XXX B1 MARROW SMR INTERPJ XXX CHROMOGENIC SUBSTRATE ASSAY XXX CLOT RETRCJ 6.85 XXX CLOT LSS TM WHL BLD DIL 8.68 XXX CLTNG FACTOR II PROTHROMBIN SPEC XXX CLTNG FACTOR V ACG/PROACCELERIN LABILE FACTOR XXX CLTNG FACTOR VII PROCONVERTIN STABLE FACTOR XXX CLTNG FACTOR VIII AHG 1 STG XXX CLTNG FACTOR VIII RELATED AG XXX CLTNG FACTOR VIII VW FACTOR RISTOCETIN COFACTOR XXX CLTNG FACTOR VIII VW FACTOR AG XXX CLTNG FACTOR VIII MULTMTRIC ALYS XXX CLTNG FACTOR IX PTC/CHRISTMAS XXX CLTNG FACTOR X STUART-PROWER XXX CLTNG FACTOR XI PTA XXX CLTNG FACTOR XII HAGEMAN XXX CLTNG FACTOR XIII FIBRIN STABILIZING XXX CLTNG FACTOR XIII FIBRIN STABILIZING SCR SOLUB XXX CLTNG PREKALLIKREIN ASSAY FLETCHER FACTOR ASSAY XXX CLTNG HI MOLEC WEIGHT KININOGEN ASSAY XXX CLTNG NHBTORS ANTITHROMBIN III ACTV XXX CLTNG NHBTORS ANTITHROMBIN III AG ASSAY XXX CLTNG NHBTORS PROTEIN C AG XXX CLTNG NHBTORS PROTEIN C ACTV XXX 234 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

239 Section IX: Pathology and Laboratory Services Georgia Workers Compensation Medical Fee Schedule PATHOLOGY AND LABORATORY Effective April 1, 2011 Medical Fee Schedule CLTNG NHBTORS PROTEIN S TOT XXX CLTNG NHBTORS PROTEIN S FR XXX ACTIVATED PROTEIN C APC RESISTANCE ASSAY XXX FACTOR NHBTOR TST XXX THROMBOMODULIN XXX COAGJ TM LEE&WHITE 8.22 XXX COAGJ TM ACTIVATED 8.22 XXX COAGJ TM OTH METHS 6.85 XXX EUGLOBULIN LSS XXX FIBRIN DGRADJ SPLT PRODUXS AGGLUJ SLIDE SEMIQUAN XXX FIBRIN DGRADJ SPLT PRODUXS PARACOAGJ XXX FIBRIN DGRADJ SPLT PRODUXS QUAN XXX FIBRIN DGRADJ PRODUXS D-DIMER QUAL/SEMIQUAN XXX FIBRIN DGRADJ PRODUXS D-DIMER QUAN XXX FIBRIN DGRADJ PRODUXS D-DIMER ULTRSENS XXX FIBRN ACTV XXX FIBRN AG XXX FIBRINOLYSINS/COAGULOPATHY SCR I&R XXX FIBRINOLYSINS/COAGULOPATHY SCR I&R XXX TC FIBRINOLYSINS/COAGULOPATHY SCR I&R 9.60 XXX COAGJ/FBRNLYS ASSAY WHL BLD USE ADDITIVE PR D XXX COAGJ&FIBRINOLYSIS FUNCTIONAL ACTV NOS EA ANAL XXX FBRNLYC FACTORS&NHBTORS PLASMIN XXX FBRNLYC FACTORS&NHBTORS ALPHA-2 ANTIPLASMIN XXX FBRNLYC FACTORS&NHBTORS PLSMNG ACTIVATOR XXX FBRNLYC FACTORS&NHBTORS PLSMNG XCPT AGIC ASSAY XXX FBRNLYC FACTORS&NHBTORS PLSMNG AGIC ASSAY XXX HEINZ BODIES DIR 7.77 XXX HEINZ BODIES INDUCED ACETYL PHENYLHYDRAZINE XXX HGB/RBCS FTL F&MAT HEMRRG DIFFIAL LSS XXX HGB/RBCS FTL F&MAT HEMRRG ROSETTE XXX HEMOLYSIN ACID XXX HEPARIN ASSAY XXX HEPARIN NEUTRALIZATION XXX HEPARIN-PROTAMINE TOLERANCE TST XXX IRON STAIN PRPH BLD XXX WBC ALKALINE PHOSPHATASE CNT XXX MCHNL FRAGILITY RBC XXX MURAMIDASE XXX OSMOTIC FRAGILITY RBC UNINCUBATED XXX OSMOTIC FRAGILITY RBC INCUBATED XXX PLTLT AGGREGATION EA AGT XXX PLTLT AGGREGATION EA AGT XXX TC PLTLT AGGREGATION EA AGT XXX s PHOSPHOLIPID NEUTRALIZATION PLATELET XXX l PHOSPHOLIPID NEUTRALIZATION HEXAGONAL XXX Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 235

240 Georgia Workers Compensation Medical Fee Schedule Section IX: Pathology and Laboratory Services PATHOLOGY AND LABORATORY Medical Fee Schedule Effective April 1, PROTHROMBIN TM 7.31 XXX PROTHROMBIN TM SUBJ PLSM FXJS EA 7.31 XXX RUSSELL VIPR VENOM TM UNDILD XXX RUSSELL VIPR VENOM TM DILD XXX REPTILASE TST XXX SEDIMENTATION RATE RBC NON-AUTO 6.85 XXX SEDIMENTATION RATE RBC AUTO 5.02 XXX SICKLING RBC RDCTJ XXX THROMBIN TM PLSM XXX THROMBIN TM TITER XXX THROMBOPLASTIN NHBTION TISS XXX THROMBOPLASTIN TM PRTL PLSM/WHL BLD XXX THROMBOPLASTIN TM PRTL SUBJ PLSM FXJS EA XXX VISCOSITY XXX UNLIS HEMATOLOGY&COAGJ BR XXX AGGLUTININS FEBRILE EA AG XXX ALLG SPEC IGG QUAN/SEMIQUAN EA ALLG XXX ALLG SPEC IGE QUAN/SEMIQUAN EA ALLG XXX ALLG SPEC IGE QUAL MULTIALLG SCR XXX ANTB ID WBC ANTIBODIES XXX ANTB ID PLTLT ANTIBODIES XXX ANTB ID PLTLT ASSOCIATED IG ASSAY XXX ANA XXX ANA TITER XXX ANTISTREPTOLYSIN 0 TITER XXX ANTISTREPTOLYSIN 0 SCR XXX BLD BANK PHYS SVCS DIFFC CROSS MATCH&/EVAL REPRT XXX BLD BANK PHYS SVCS INVSTGJ TFUJ RXN REPRT XXX BLD BANK PHYS SVCS AUTHJ DEVIJ STANDARD REPRT XXX C-REACTIVE PROTEIN 9.59 XXX C-REACTIVE PROTEIN HI SENSITIVITY XXX BETA 2 GLYCOPROTEIN I ANTB EA XXX CARDIOLIPIN ANTB EA IG CLASS XXX ANTI-PHOSPHATIDYLSERINE ANTB XXX CHEMOTAXIS ASSAY SPEC METH XXX COLD AGGLUTININ SCR XXX COLD AGGLUTININ TITER XXX COMPLEMENT AG EA COMPONENT XXX COMPLEMENT FUNCJAL ACTV EA COMPONENT XXX COMPLEMENT TOT HEMOLYTIC XXX COMPLEMENT FIXJ TSTS EA AG XXX CNTERIMMUNOELECTROPHORESIS EA AG XXX CYCLIC CITRULLINATED PEPTIDE ANTB XXX DEOXYRIBONUCLEASE ANTB XXX DNA ANTB NATIVE/2 STRANDED XXX DNA ANTB 1 STRANDED XXX 236 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

241 Section IX: Pathology and Laboratory Services Georgia Workers Compensation Medical Fee Schedule PATHOLOGY AND LABORATORY Effective April 1, 2011 Medical Fee Schedule XTRCABLE NUC AG ANTB ANY METH EA ANTB XXX FC RCPTR XXX FLUORESCENT NONNFCT AGT ANTB SCR EA ANTB XXX FLUORESCENT NONNFCT AGT ANTB SCR EA ANTB XXX TC FLUORESCENT NONNFCT AGT ANTB SCR EA ANTB XXX FLUORESCENT NONNFCT AGT ANTB TITER EA ANTB XXX FLUORESCENT NONNFCT AGT ANTB TITER EA ANTB XXX TC FLUORESCENT NONNFCT AGT ANTB TITER EA ANTB XXX GROWTH HORM HUMAN ANTB XXX HEMAGGLUJ NHBTION TST XXX IA TUMOR ANTIGEN QUAL/SEMIQUANTITATIVE XXX IA TUM AG QUAN CA XXX IA TUM AG QUAN CA XXX IA TUM AG QUAN CA XXX HUMAN EPIDIDYMIS PROTEIN 4 (HE4) XXX HTROPHL ANTIBODIES SCR 9.59 XXX HTROPHL ANTIBODIES TITER XXX HTROPHL ANTIBODIES TIT AFTER ABSRPJ XXX IA TUM AG OTH AG QUAN EA XXX IA NFCT AGT ANTB QUAN NOS XXX IA NFCT AGT ANTB QUAL/SEMIQUAN 1 STEP METH XXX IMMUNOELECTROPHORESIS SERUM XXX IMMUNOELECTROPHORESIS SERUM XXX TC IMMUNOELECTROPHORESIS SERUM XXX IMMUNOELECTROPHORESIS OTH FLUS CONCENTRATION XXX IMMUNOELECTROPHORESIS OTH FLUS CONCENTRATION XXX TC IMMUNOELECTROPHORESIS OTH FLUS CONCENTRATION XXX IMMUNOELECTROPHORESIS CROSSED XXX IMMUNOELECTROPHORESIS CROSSED XXX TC IMMUNOELECTROPHORESIS CROSSED XXX IMMUNODIFFUSION NES XXX IMMUNODIFFUSION GEL DIFFUSION QUAL EA AG/ANTB XXX IMMUNE CPLX ASSAY XXX IMMUNOFIXJ ELECTROPHORESIS SERUM XXX IMMUNOFIXJ ELECTROPHORESIS SERUM XXX TC IMMUNOFIXJ ELECTROPHORESIS SERUM XXX IMMUNOFIXJ ELECTROPHORESIS OTH FLU XXX IMMUNOFIXJ ELECTROPHORESIS OTH FLU XXX TC IMMUNOFIXJ ELECTROPHORESIS OTH FLU XXX INHIBIN XXX INSULIN ANTIBODIES XXX INTRNSC FACTOR ANTIBODIES XXX ISLET CELL ANTB XXX WBC HISTAM RLS TST XXX WBC PHAGOCYTOSIS XXX CELLULAR FUNCTION ASSAY STIMUL&DETECT BIOMARKER XXX Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 237

242 Georgia Workers Compensation Medical Fee Schedule Section IX: Pathology and Laboratory Services PATHOLOGY AND LABORATORY Medical Fee Schedule Effective April 1, LYMPHOCYTE TR MITOGEN/AG INDUCED BLASTOGENESIS XXX B CELLS TOT CNT XXX MONONUCLEAR CELL ANTIGEN QUANTITATIVE NOS EA XXX NATURAL KILLER CELLS TOT CNT XXX T CELLS TOT CNT XXX T CELLS ABSOLUTE CD4&CD8 CNT RATIO XXX T CELLS ABSOLUTE CD4 CNT XXX STEM CELLS TOT CNT XXX MICROSOMAL ANTIBODIES EA XXX MIGRATION NHBTORY FACTOR TST MIF XXX NEUTRALIZATION TST VIRAL XXX NITROBLUE TETRAZOLIUM DYE TST NTD XXX PART AGGLUJ SCR EA ANTB XXX PART AGGLUJ TITER EA ANTB XXX RHEUMATOID FACTOR QUAL XXX RHEUMATOID FACTOR QUAN XXX s TB CELL MEDIATED ANTIGN RESPNSE GAMMA INTERFER XXX l TB ANTIGEN RESPONSE GAMMA INTERFERON T-CELL SUSP XXX SKN TST CANDIDA XXX SKIN TEST UNLISTED ANTIGEN EACH 6.85 XXX SKN TST COCCIDIOIDOMYCOSIS 9.14 XXX SKN TST HISTOPLASMOSIS 8.68 XXX SKN TST TUBERCULOSIS ID XXX STREPTOKINASE ANTB XXX SYPHILIS TEST NON TREPONEMAL ANTIBODY QUAL 8.22 XXX SYPHILIS TST QUAN 8.22 XXX ANTB ACTINOMYCES XXX ANTB ADENOVIRUS XXX ANTB ASPRGILLUS XXX ANTB BACTERIUM NES XXX ANTB BARTONELLA XXX ANTB BLASTOMYCES XXX ANTB BORDETELLA XXX ANTB BORRELIA BURGDORFERI CONFIRMATORY TST XXX ANTB BORRELIA BURGDORFERI LYME DISEASE XXX ANTB BORRELIA RELAPSING FEVER XXX ANTB BRUCELLA XXX ANTB CAMPYLOBACTER XXX ANTB CANDIDA XXX ANTB CHLAMYDIA XXX ANTB CHLAMYDIA IGM XXX ANTB COCCIDIOIDES XXX ANTB COXIELLA BRNETII Q FEVER XXX ANTB CRYPTOCOCCUS XXX ANTB CMV CMV XXX ANTB CMV CMV IGM XXX 238 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

243 Section IX: Pathology and Laboratory Services Georgia Workers Compensation Medical Fee Schedule PATHOLOGY AND LABORATORY Effective April 1, 2011 Medical Fee Schedule ANTB DIPHTHERIA XXX ANTB ENCEPHALITIS CALIFORNIA LA CROSSE XXX ANTB ENCEPHALITIS EASTERN EQUINE XXX ANTB ENCEPHALITIS ST. LOUIS XXX ANTB ENCEPHALITIS WSTRN EQUINE XXX ANTB ENTEROVIRUS XXX ANTB EPSTEIN-BARR EB VIRUS EARLY AG EA XXX ANTB EPSTEIN-BARR EB VIRUS NUC AG EBNA XXX ANTB EPSTEIN-BARR EB VIRUS VIRAL CAPSID VCA XXX ANTB EHRLICHIA XXX ANTB FRANCISELLA TULARENSIS XXX ANTB FUNGUS NES XXX ANTB GIARDIA LAMBLIA XXX ANTB HELICOBACTER PYLORI XXX ANTB HELMINTH NES XXX ANTB HAEMOPHILUS INF XXX ANTB HTLV-I XXX ANTB HTLV-II XXX ANTB HTLV/HIV ANTB CONFIRMATORY TST XXX ANTB HEP DELTA AGT XXX ANTB HERPES SMPLX NON-SPEC TYP TST XXX ANTB HERPES SMPLX TYP XXX ANTB HERPES SMPLX TYP XXX ANTB HISTOPLSM XXX ANTB HIV XXX ANTB HIV XXX ANTB HIV-1&HIV-2 1 ASSAY XXX HEP B CORE ANTB HBCAB TOT XXX HEP B CORE ANTB HBCAB IGM ANTB XXX HEP B SURF ANTB HBSAB XXX HEP BE ANTB HBEAB XXX HEP ANTB HAAB TOT XXX HEP ANTB HAAB IGM ANTB XXX ANTB INF VIRUS XXX ANTB LEGIONELLA XXX ANTB LEISHMANIA XXX ANTB LEPTOSPIRA XXX ANTB LISTERIA MONOCYTOGENES XXX ANTB LYMPHOCYTIC CHORIOMENINGITIS XXX ANTB LYMPHOGRANULOMA VENEREUM XXX ANTB MUCORMYCOSIS XXX ANTB MUMPS XXX ANTB MYCOPLSM XXX ANTB NEISSERIA MENINGITIDIS XXX ANTB NOCARDIA XXX ANTB PARVOVIRUS XXX Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 239

244 Georgia Workers Compensation Medical Fee Schedule Section IX: Pathology and Laboratory Services PATHOLOGY AND LABORATORY Medical Fee Schedule Effective April 1, ANTB PLASMODIUM MALARIA XXX ANTB PROTOZOA NES XXX ANTB RSV XXX ANTB RICKETTSIA XXX ANTB ROTAVIRUS XXX ANTB RUBELLA XXX ANTB RUBEOLA XXX ANTB SALMONELLA XXX ANTB SHIGELLA XXX ANTB TETANUS XXX ANTB TOXOPLSM XXX ANTB TOXOPLSM IGM XXX ANTIBODY TREPONEMA PALLIDUM XXX ANTB TRICHINELLA XXX ANTB VARICELLA-ZOSTER XXX ANTIBODY WEST NILE VIRUS IGM XXX ANTIBODY WEST NILE VIRUS XXX ANTB VIRUS NES XXX ANTB YERSINIA XXX THYROGLOBULIN ANTB XXX HEP C ANTB XXX HEP C ANTB CONFIRMATORY TST XXX LPHOCYTOTOXICITY ASSAY VIS CROSSMATCH TITRJ XXX LPHOCYTOTOXICITY ASSAY VIS CROSSMATCH W/O TITRJ XXX SERUM SCR % REACTIVE ANTB STANDARD METH XXX SERUM SCR % REACTIVE ANTB PRA QUICK METH XXX HLA TYPING B/C 1 AG XXX HLA TYPING B/C MLT AGS XXX HLA TYPING DR/DQ 1 AG XXX HLA TYPING DR/DQ MLT AGS XXX HLA TYPING LYMPHOCYTE CULTURE MIXED XXX HLA TYPING LYMPHOCYTE CULTURE PRIMED XXX HLA CROSSMATCH NONCYTOTOXIC 1ST SERUM/DILUTION XXX HLA CROSSMATCH NONCYTOTOXIC EA+ SERUM/DILUTION XXX UNLIS IMMUNOLOGY BR XXX ANTB SCR RBC EA SERUM TQ XXX ANTB ELUTION EA ELUTION XXX ANTB ID RBC ANTIBODIES EA PANEL EA SERUM TQ XXX ANTIHUMAN GLOBULIN DIR EA ANTISERUM XXX ANTIHUMAN GLOBULIN INDIR QUAL EA REAGENT CELL XXX ANTIHUMAN GLOBULIN INDIRECT EA ANTIBODY TITER 9.59 XXX AUTOL BLD/COMPONENT COLLJ STORAGE PREDEPOSITED XXX AUTOL BLD/COMPONENT COLLJ STORAGE SALVAGE XXX BLD TYPING ABO 5.48 XXX BLD TYPING RH D 5.48 XXX l BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA 7.31 XXX 240 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

245 Section IX: Pathology and Laboratory Services Georgia Workers Compensation Medical Fee Schedule PATHOLOGY AND LABORATORY Effective April 1, 2011 Medical Fee Schedule BLD TYPING AG SCR UNIT PT SERUM SCR XXX BLD TYPING RBC AGS OTH/THN ABO/RH D EA 7.31 XXX BLD TYPING RH PHEXYPING COMPL XXX BLD TYPING PATERNITY PR INDIV ABO RH&MN XXX BLD TYPING PATERNITY PR INDIV EA AG SYS XXX COMPATIBILITY EA UNIT IMMT SPIN XXX COMPATIBILITY EA UNIT INCUBATION XXX COMPATIBILITY EA UNIT ANTIGLOBULIN XXX COMPATIBILITY EA UNIT ELEC XXX FRSH FROZEN PLSM THAWING EA UNIT XXX FROZEN BLD EA UNIT FRZING PREPJ XXX FROZEN BLD EA UNIT THAWING XXX FROZEN BLD EA UNIT FRZING PREPJ&THAWING XXX HEMOLYSINS&AGGLUTININS AUTO SCR EA XXX HEMOLYSINS&AGGLUTININS INCUBATED XXX IRRADJ BLD PRODUX EA UNIT XXX WBC TRANSFUSION XXX VOL RDCTJ BLD/BLD PRODUX EA UNIT XXX PLING PLTLTS/OTH BLD PRODUXS XXX PRTX RBC ANTB CHEM AGT/DRUGS XXX PRTX RBC ANTB INCUBATION NZM EA XXX PRTX RBC ANTB DNS GRADIENT SEP XXX PRTX SRM INCUBATION DRUGS EA XXX PRTX SRM ANTB ID DIL XXX PRTX SRM ANTB ID INCUBATION NHBTORS EA XXX PRTX SRM ANTB ID DIFFIAL RBC ABSRPJ XXX SPLTTING BLD/BLD PRODUXS EA UNIT XXX UNLIS TRANSFUSION MED BR XXX ANIMAL INOCULATION SM ANIMAL OBS XXX ANIMAL INOCULATION SM ANIMAL OBS&DSJ XXX CONCENTRATION NFCT AGT XXX CUL BACT BLD AERC ISOL XXX CUL BACT STL AERC ISOL SALMONELLA&SHIGELLA XXX CUL BACT STL AERC ADDL PATHOGENS&ID EA XXX CUL BACT XCPT URINE BLD/STL AERC ISOL XXX CUL BACT QUAN AERC ISOL XCPT UR BLD/STOOL XXX CUL BACT QUAN ANAERC ISOL XCPT UR BLD/STOOL XXX CUL BACT BLD ANAERC ISOL XXX CUL BACT ANAERC ADDL METHS DEFINITIVE EA ISOL XXX CUL BACT AERC ADDL METHS DEFINITIVE EA ISOL XXX CUL PRSMPTV PTHGNC ORGANISMS SCR XXX CUL PRSMPTV PTHGNC ORGANISMS SCR DNS CHART XXX CUL BACT QUAN COLONY CNT URINE XXX CULTURE BCT ISOL&PRSMPTV ID ISOLATE EA URINE XXX CUL FNGI MOLD/YEAST PRSMPTV ID SKN HAIR/NAIL XXX CUL FNGI MOLD/YEAST PRSMPTV ID OTH XCPT BLD XXX Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 241

246 Georgia Workers Compensation Medical Fee Schedule Section IX: Pathology and Laboratory Services PATHOLOGY AND LABORATORY Medical Fee Schedule Effective April 1, CUL FNGI MOLD/YEAST ISOL PRSMPTV ID ISOL BLD XXX CUL FNGI DEFINITIVE ID EA ORGANISM YEAST XXX CUL FNGI DEFINITIVE ID EA ORGANISM MOLD XXX CUL MYCOPLSM ANY SRC XXX CUL CHLAMYDIA ANY SRC XXX CUL TUBERCLE/OTH ACID-FAST BACILLI ANY ISOL XXX CUL MYCOBACTERIAL DEFINITIVE ID EA ISOL XXX CULTYP IMFLUOR METH EA ANTISERUM XXX CULTYP GAS LIQ CHROM/HI PRESS LIQ CHROM XXX CULTYP IMMUNOLOGIC OTH/THN IMFLUOR PR ANTISERUM 9.59 XXX CULTYP NUC ACID DIR PRB CULT/ISOLATE EA ORGNISM XXX CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM XXX CULTYP ID PLS FLD GEL TYP XXX CULTYP NUCLEIC ACID SEQUENCING METH EA ISOLATE XXX CULTYP OTH METHS XXX DARK FLD XM ANY SRC SPEC COLLJ XXX DARK FLD XM ANY SRC SPEC COLLJ XXX TC DARK FLD XM ANY SRC SPEC COLLJ XXX DARK FLD XM ANY SRC W/O COLLJ XXX MACROSCOPIC XM ARTHROPOD 8.22 XXX MACROSCOPIC XM PARASIT 8.22 XXX PINWORM XM 8.22 XXX HOMOGENIZATION TISS CUL XXX OVA&PARASITS DIR SMRS CONCENTRATION&ID XXX SC STD ANTMCRB AGT AGAR DIL METH PR AGT 9.14 XXX SC STD ANTMCRB AGT DISK METH PR PLATE XXX SC STD ANTMCRB AGT ENZYME DETCJ PR NZM 9.14 XXX SC ANTMCRB MICRODIL/AGAR EA MULTI-ANTMCRB PLATE XXX SC ANTMCRB MICRODIL/AGAR DIL MLC EA PLATE XXX SC STD ANTMCRB AGT MACROBROTH DIL METH EA AGT XXX SC ANTMCRB MYCOBACTERIA PROPRTN EA AGT XXX SERUM BACTERICIDAL TITER XXX SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL 8.22 XXX SMR PRIM SRC FLUORESCENT&/AFS BCT FNGI PARASITS XXX SMR PRIM SRC SPEC STAIN BODIES/PARASITS XXX SMR PRIM SRC SPEC STAIN BODIES/PARASITS XXX TC SMR PRIM SRC SPEC STAIN BODIES/PARASITS XXX SMR PRIM SRC CPLX SPEC STAIN OVA&PARASITS XXX SMR PRIM SRC WET MOUNT NFCT AGT 8.22 XXX TISS KOH SLIDE SAMPS SKN/HR/NLS FNGI/ECTOPARASIT 8.22 XXX TOXIN/ANTITOXIN ASSAY TISS CUL XXX VIRUS INOCULATION EGGS/SM ANIMAL OBS&DSJ XXX VIRUS TISS CUL INOCULATION CYTOPATHIC EFFECT XXX VIRUS TISS CUL ADDL STD/ID EA ISOLATE XXX VIRUS CENTRIFUGE ENHNCD ID IMFLUOR STAIN EA XXX VIRUS ID NON-IMMUNOLOGIC OTH/THN CYTOPATHIC XXX 242 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

247 Section IX: Pathology and Laboratory Services Georgia Workers Compensation Medical Fee Schedule PATHOLOGY AND LABORATORY Effective April 1, 2011 Medical Fee Schedule IAADI ADENOVIRUS XXX IAADI BORDETELLA PRTUSSIS/PARAPRTUSSIS XXX IAADI ENTEROVIRUS DIR FLUORESCENT ANTB XXX IAADI GIARDIA XXX IAADI CHLAMYDIA TRACHOMATIS XXX IAADICMV DIR FLUORESCENT ANTB XXX IAADI CRYPTOSPORIDIUM XXX IAADI HERPES SMPLX VIRUS TYP XXX IAADI HERPES SMPLX VIRUS TYP XXX IAADI INF B VIRUS XXX IAADI INF VIRUS XXX IAADI LEGIONELLA MICDADEI XXX IAADI LEGIONELLA PNEUMOPHILA XXX IAADI PARAINF VIRUS EA TYP XXX IAADI RSV XXX IAADI PNEUMOCSTIS CARINII XXX IAADI RUBEOLA XXX IAADI TREPONEMA PALLIDUM XXX IAADI VARICELLA ZOSTER VIRUS XXX IAADI NOS EA ORGANISM XXX IAADI POLYV MLT ORGANISMS EA POLYV ANTISERUM XXX IAAD EIA ADENOVIRUS ENTERIC TYP 40/ XXX IAAD EIA QUAL/SEMIQUAN MULTIPLE STEP ASPERGILLUS XXX IAAD EIA CHLAMYDIA TRACHOMATIS XXX IAAD EIA CLOSTRIDIUM DIFFICILE TOXIN XXX IAAD EIA CRYPTOCOCCUS NEOFORMANS XXX IAAD EIA CRYPTOSPORIDIUM XXX IAAD EIA GIARDIA XXX IAAD EIA CMV XXX IAAD EIA ESCHERICHIA COLI XXX IAAD EIA ENTAMOEBA HISTOLYTICA DISPAR GRP XXX IAAD EIA ENTAMOEBA HISTOLYTICA GRP XXX IAAD EIA HPYLORI STOOL XXX IAAD EIA HPYLORI XXX IAAD EIA HEP B SURF AG XXX IAAD EIA HEP B SURF AG NEUTRALIZATION XXX IAAD EIA HEP BE AG XXX IAAD EIA HEP DELTA AGT XXX IAAD EIA HISTOPLSM CAPSULATUM XXX IAAD EIA HIV XXX IAAD EIA HIV XXX IAAD EIA INF/B EA XXX IAAD EIA RSV XXX IAAD EIA ROTAVIRUS XXX IAAD EIA SHIGA-LIKE TOXIN XXX IAAD EIA STREPTOCOCCUS GRP XXX Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 243

248 Georgia Workers Compensation Medical Fee Schedule Section IX: Pathology and Laboratory Services PATHOLOGY AND LABORATORY Medical Fee Schedule Effective April 1, IAAD EIA NOS EA ORGANISM XXX IAAD EIA NOS EA ORGANISM XXX IAAD EIA POLYV MLT ORGANISMS EA POLYV ANTISERUM XXX IADNA BARTONELLA DIR PRB XXX IADNA BARTONELLA AMP PRB XXX IADNA BARTONELLA QUAN XXX IADNA BORRELIA BURGDORFERI DIR PRB XXX IADNA BORRELIA BURGDORFERI AMP PRB XXX IADNA BORRELIA BURGDORFERI QUAN XXX IADNA CANDIDA SPECIES DIR PRB XXX IADNA CANDIDA SPECIES AMP PRB XXX IADNA CANDIDA SPECIES QUAN XXX IADNA CHLAMYDIA PNEUMONIAE DIR PRB XXX IADNA CHLAMYDIA PNEUMONIAE AMP PRB XXX IADNA CHLAMYDIA PNEUMONIAE QUAN XXX IADNA CHLAMYDIA TRACHOMATIS DIR PRB XXX IADNA CHLAMYDIA TRACHOMATIS AMP PRB XXX IADNA CHLAMYDIA TRACHOMATIS QUAN XXX INF AGENT DET NUC ACID CLOSTRIDIUM AMP PROBE XXX IADNA CMV DIR PRB XXX IADNA CMV AMP PRB XXX IADNA CMV QUAN XXX IADNA ENTEROVIRUS AMPLIFIED PROBE TECHNIQUE XXX INFECTIOUS AGENT DNA/RNA VANCOMYCIN RESISTANCE XXX l INFECTIOUS AGENT DNA/RNA INFLUENZA EA TYPE XXX l INFECTIOUS AGENT DNA/RNA INFLUENZA 1ST 2 TYPES XXX l NFCT AGENT DNA/RNA INFLUENZA 1+ TYPES EA ADDL XXX IADNA GARDNERELLA VAGIS DIR PRB XXX IADNA GARDNERELLA VAGIS AMP PRB XXX IADNA GARDNERELLA VAGIS QUAN XXX IADNA HEP B VIRUS DIR PRB XXX IADNA HEP B VIRUS AMP PRB XXX IADNA HEP B VIRUS QUAN XXX IADNA HEP C DIR PRB XXX IADNA HEP C AMP PRB XXX IADNA HEP C QUAN XXX IADNA HEP G DIR PRB XXX IADNA HEP G AMP PRB XXX IADNA HEP G QUAN XXX IADNA HERPES SMPLX VIRUS DIR PRB XXX IADNA HERPES SMPLX VIRUS AMP PRB XXX IADNA HERPES SMPLX VIRUS QUAN XXX IADNA HERPES VIRUS-6 DIR PRB XXX IADNA HERPES VIRUS-6 AMP PRB XXX IADNA HERPES VIRUS-6 QUAN XXX IADNA HIV-1 DIR PRB XXX 244 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

249 Section IX: Pathology and Laboratory Services Georgia Workers Compensation Medical Fee Schedule PATHOLOGY AND LABORATORY Effective April 1, 2011 Medical Fee Schedule IADNA HIV-1 AMP PRB XXX IADNA HIV-1 QUAN XXX IADNA HIV-2 DIR PRB XXX IADNA HIV-2 AMP PRB XXX IADNA HIV-2 QUAN XXX IADNA LEGIONELLA PNEUMOPHILA DIR PRB XXX IADNA LEGIONELLA PNEUMOPHILA AMP PRB XXX IADNA LEGIONELLA PNEUMOPHILA QUAN XXX IADNA MYCOBACTERIA SPECIES DIR PRB XXX IADNA MYCOBACTERIA SPECIES AMP PRB XXX IADNA MYCOBACTERIA SPECIES QUAN XXX IADNA MYCOBACTERIA TUBERCULOSIS DIR PRB XXX IADNA MYCOBACTERIA TUBERCULOSIS AMP PRB XXX IADNA MYCOBACTERIA TUBERCULOSIS QUAN XXX IADNA MYCOBACTERIA AVIUM-INTRACLRE DIR PRB XXX IADNA MYCOBACTERIA AVIUM-INTRACLRE AMP PRB XXX IADNA MYCOBACTERIA AVIUM-INTRACLRE QUAN XXX IADNA MYCOPLSM PNEUMONIAE DIR PRB XXX IADNA MYCOPLSM PNEUMONIAE AMP PRB XXX IADNA MYCOPLSM PNEUMONIAE QUAN XXX IADNA NEISSERIA GONORRHOEAE DIR PRB XXX IADNA NEISSERIA GONORRHOEAE AMP PRB XXX IADNA NEISSERIA GONORRHOEAE QUAN XXX IADNA PAPLMVIRUS HUMAN DIR PRB XXX IADNA PAPLMVIRUS HUMAN AMP PRB XXX IADNA PAPLMVIRUS HUMAN QUAN XXX IADNA S. AUREUS AMP PRB TQ XXX IADNA S. AUREUS METHICILLIN RESISTANT AMP PRB TQ XXX IADNA STREPTOCOCCUS GRP DIR PRB XXX IADNA STREPTOCOCCUS GRP AMP PRB XXX IADNA STREPTOCOCCUS GRP QUAN XXX IADNA STREPTOCOCCUS GROUP B AMPLIFIED PROBE TQ XXX IADNA TRICHOMONAS VAGIS DIR PRB XXX IADNA NOS DIR PRB EA ORGANISM XXX IADNA NOS AMP PRB EA ORGANISM XXX IADNA NOS QUAN EA ORGANISM XXX IADNA MLT ORGANISMS DIR PRB XXX IADNA MLT ORGANISMS AMP PRB XXX IAADIADOO STREPTOCOCCUS GRP B XXX IAADIADOO CLOSTRIDIUM DIFFICILE TOXIN XXX IAADIADOO INF XXX IAADIADOO RSV XXX IAADIADOO TRICHOMONAS VAGINALIS XXX INFECTIOUS AGENT IMMUNOASSAY OPTICAL ADENOVIRUS XXX CHLAMYDIA TRACHOMATIS XXX IAADIADOO NEISSERIA GONORRHOEAE XXX Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 245

250 Georgia Workers Compensation Medical Fee Schedule Section IX: Pathology and Laboratory Services PATHOLOGY AND LABORATORY Medical Fee Schedule Effective April 1, IAADIADOO STREPTOCOCCUS GRP XXX IAADIADOO NOS XXX NFCT AGT DRUG SC PHEXYP PREDICT XXX s NFCT AGT GEXYP HIV 1 REV TRANSCRIP&PROTEAS REGNS XXX NFCT AGT GEXYP HEP C VIRUS XXX NFCT AGT PHEXYP RESISTANCE TISS CUL HIV XXX NFCT AGT PHEXYP RESISTANCE TISS CUL HIV 1 EA XXX INFECTIOUS AGENT ENZYMATIC ACTV OTH/THN VIRUS XXX l # NFCT GEXYP DNA/RNA HIV 1 OTHER REGION XXX UNLIS MICROBIOLOGY BR XXX NECROPSY GROSS XM W/O CNS XXX NECROPSY GROSS XM BRN XXX NECROPSY GROSS XM BRN&SPI CORD XXX NECROPSY GROSS XM INFT BRN XXX NECROPSY GROSS XM STILLBORN/NB BRN XXX NECROPSY GROSS XM MACERATED STILLBORN XXX NECROPSY GROSS&MCRSCP W/O CNS XXX NECROPSY GROSS&MCRSCP BRN XXX NECROPSY GROSS&MCRSCP BRN&SPI CORD XXX NECROPSY GROSS&MCRSCP INFT BRN XXX NECROPSY GROSS&MCRSCP STILLBORN/NB BRN XXX NECROPSY LMTD GROSS&/MCRSCP REGIONAL XXX NECROPSY LMTD GROSS&/MCRSCP 1 ORGAN XXX NECROPSY FORENSIC XM XXX NECROPSY CORONER'S CALL XXX UNLIS NECROPSY BR XXX CYTP FLU WASHGS/BRUSHINGS XCPT C/V SMRS INTERPJ XXX CYTP FLU WASHGS/BRUSHINGS XCPT C/V SMRS INTERPJ XXX TC CYTP FLU WASHGS/BRUSHINGS XCPT C/V SMRS INTERPJ XXX CYTP FLU BR/WA XCPT C/V FILTER METH ONLY INTERPJ XXX CYTP FLU BR/WA XCPT C/V FILTER METH ONLY INTERPJ XXX TC CYTP FLU BR/WA XCPT C/V FILTER METH ONLY INTERPJ XXX CYTP FLU BR/WA XCPT C/V SMRS&FILTER INTERPJ XXX CYTP FLU BR/WA XCPT C/V SMRS&FILTER INTERPJ XXX TC CYTP FLU BR/WA XCPT C/V SMRS&FILTER INTERPJ XXX CYTP CONCENTRATION SMRS&INTERPJ XXX CYTP CONCENTRATION SMRS&INTERPJ XXX TC CYTP CONCENTRATION SMRS&INTERPJ XXX CYTP SLCTV CELL ENHANCEMENT INTERPJ XCPT C/V XXX CYTP SLCTV CELL ENHANCEMENT INTERPJ XCPT C/V XXX TC CYTP SLCTV CELL ENHANCEMENT INTERPJ XCPT C/V XXX l CYTP INSITU HYBRID URINE SPEC 3-5 PROBES EA MNL XXX l CYTP INSITU HYBRID URINE SPEC 3-5 PROBES EA MNL XXX l TC CYTP INSITU HYBRID URINE SPEC 3-5 PROBES EA MNL XXX l CYTP INSITU HYBRID URNE SPEC 3-5 PROBES CPTR EA XXX l CYTP INSITU HYBRID URNE SPEC 3-5 PROBES CPTR EA XXX 246 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

251 Section IX: Pathology and Laboratory Services Georgia Workers Compensation Medical Fee Schedule PATHOLOGY AND LABORATORY Effective April 1, 2011 Medical Fee Schedule l TC CYTP INSITU HYBRID URNE SPEC 3-5 PROBES CPTR EA XXX CYTP FORENSIC XXX CYTP FORENSIC XXX TC CYTP FORENSIC XXX SEX CHROMATIN ID BARR BODIES XXX SEX CHROMATIN ID PRPH BLD SMR XXX CYTP C/V REQ INTERPJ PHYS XXX CYTP C/V FLU AUTO THIN MNL PHYS XXX CYTP C/V FLU AUTO THIN MNL SCR&RESCR PHYS XXX CYTP SMRS C/V SCR AUTO SYS PHYS XXX CYTP SMRS C/V SCR AUTO SYS MNL RESCR PHYS XXX CYTP SLIDES C/V MNL SCR UNDER PHYS XXX CYTP SLIDES C/V MNL SCR&CPTR RESCR PHYS XXX CYTP SLIDES C/V MNL SCR&RESCR PHYS XXX CYTP SLIDES C/V MNL SCR&CPTR-RESCR CELL S&R PHYS XXX CYTP SLIDES C/V DEFINITIVE HORMONAL EVAL XXX CYTP SMRS ANY OTH SRC SCR&INTERPJ XXX CYTP SMRS ANY OTH SRC SCR&INTERPJ XXX TC CYTP SMRS ANY OTH SRC SCR&INTERPJ XXX CYTP SMRS ANY OTH SRC PREPJ SCR&INTERPJ XXX CYTP SMRS ANY OTH SRC PREPJ SCR&INTERPJ XXX TC CYTP SMRS ANY OTH SRC PREPJ SCR&INTERPJ XXX CYTP SMRS ANY OTH SRC EXTND STD > 5 SLIDES XXX CYTP SMRS ANY OTH SRC EXTND STD > 5 SLIDES XXX TC CYTP SMRS ANY OTH SRC EXTND STD > 5 SLIDES XXX CYTP SLIDES C/V MNL SCR PHYS XXX CYTP SLIDES C/V MNL SCR&RESCR PHYS XXX CYTP SLIDES C/V MNL SCR&CPTR RESCR PHYS XXX CYTP SLIDES C/V MNL SCR&CPTR RESCR CELL S&R PHYS XXX s CYTP FINE NDL ASPIRATE IMMT CYTOHIST STD DX 1ST XXX s CYTP FINE NDL ASPIRATE IMMT CYTOHIST STD DX 1ST XXX s TC CYTP FINE NDL ASPIRATE IMMT CYTOHIST STD DX 1ST XXX CYTP FINE NDL ASPIRATE I&R XXX CYTP FINE NDL ASPIRATE I&R XXX TC CYTP FINE NDL ASPIRATE I&R XXX CYTP C/V AUTO THIN LYR PREPJ SCR SYS PHYS XXX CYTP C/V AUTO THIN LYR PREPJ SCR MNL RESCR PHYS XXX l + # CYTP C/V AUTO THIN LYR PREPJ ADEQUACY EA EVAL ZZZ l + # CYTP C/V AUTO THIN LYR PREPJ ADEQUACY EA EVAL ZZZ l + # TC CYTP C/V AUTO THIN LYR PREPJ ADEQUACY EA EVAL 8.68 ZZZ FLO CYTOMETRY CELL CYCLE/DNA ALYS XXX FLO CYTOMETRY CELL CYCLE/DNA ALYS XXX TC FLO CYTOMETRY CELL CYCLE/DNA ALYS XXX FLO CYTOMETRY CELL SURF MARKER TECHL ONLY 1ST XXX FLO CYTOMETRY CELL SURF MARKER TECHL ONLY EA ZZZ FLO CYTOMETRY INTERPJ 2-8 MARKERS XXX Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 247

252 Georgia Workers Compensation Medical Fee Schedule Section IX: Pathology and Laboratory Services PATHOLOGY AND LABORATORY Medical Fee Schedule Effective April 1, FLO CYTOMETRY INTERPJ 9-15 MARKERS XXX FLO CYTOMETRY INTERPJ 16/> MARKERS XXX UNLIS CYTP BR XXX TISS CUL NON-NEO DISORDERS LYMPHOCYTE XXX TISS CUL NON-NEO DISORDERS SKN/OTH SOLID TISS BX XXX TISS CUL NON-NEO DISORDERS AMNIOTIC/CHORNC CELLS XXX TISS CUL NEO DISORDERS B1 MARROW BLD CELLS XXX TISS CUL NEO DISORDERS SOLID TUM XXX CRYOPRSRV FRZING&STORAGE CELLS EA CELL LINE XXX THAWING&XPNSJ FROZEN CELLS EA ALIQUOT XXX CHRMSM BRKG BASELINE SISTER CLL XXX CHRMSM BRKG BASELINE BRKG CLL XXX CHRMSM BRKG SYNDS SCORE 100 CLL XXX CHRMSM CNT 5 CLL 1KARYOTYP BANDING XXX CHRMSM CNT CLL 2KARYOTYP BANDING XXX CHRMSM CNT 45 CLL MOSAICISM 2KARYOTYP XXX CHRMSM ANALYZE CELLS XXX CHRMSM ALYS AMNIOTIC/VILLUS 15 CLL 1KARYOTYP XXX CHRMSM SITU AMNIOTIC CLL 6-12 COLONIES 1KARYOTYP XXX MOLEC CYTOGENETICS DNA PRB EA XXX MOLEC CYTG CHRMOML ISH 3-5 CLL XXX MOLEC CYTG CHRMOML ISH CLL XXX MOLEC CYTG INTERPHASE ISH CLL XXX MOLEC CYTG INTERPHASE ISH ANALYZE CLL XXX CHRMSM ALYS ADDL KARYOTYP EA STD XXX CHRMSM ALYS ADDL SPECIZED BANDING XXX CHRMSM ALYS ADDL CELLS CNTED EA STD XXX CHRMSM ALYS ADDL HR STD XXX CYTOGENETICS&MOLEC CYTOGENETICS I&R XXX UNLIS CYTOGENETIC STD BR XXX LVL I-SURG PATH GROSS XM ONLY XXX LVL I-SURG PATH GROSS XM ONLY 5.94 XXX TC LVL I-SURG PATH GROSS XM ONLY XXX LVL II-SURG PATH GROSS&MCRSCP XM XXX LVL II-SURG PATH GROSS&MCRSCP XM 8.68 XXX TC LVL II-SURG PATH GROSS&MCRSCP XM XXX LEVEL III-SURG PATH GROSS&MICROSCOPIC XM XXX LEVEL III-SURG PATH GROSS&MICROSCOPIC XM XXX TC LEVEL III-SURG PATH GROSS&MICROSCOPIC XM XXX LVL IV-SURG PATH GROSS&MCRSCP XM XXX LVL IV-SURG PATH GROSS&MCRSCP XM XXX TC LVL IV-SURG PATH GROSS&MCRSCP XM XXX LVL V-SURG PATH GROSS&MCRSCP XM XXX LVL V-SURG PATH GROSS&MCRSCP XM XXX TC LVL V-SURG PATH GROSS&MCRSCP XM XXX LVL VI-SURG PATH GROSS&MCRSCP XM XXX 248 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

253 Section IX: Pathology and Laboratory Services Georgia Workers Compensation Medical Fee Schedule PATHOLOGY AND LABORATORY Effective April 1, 2011 Medical Fee Schedule LVL VI-SURG PATH GROSS&MCRSCP XM XXX TC LVL VI-SURG PATH GROSS&MCRSCP XM XXX DECALCIFICATION PX XXX DECALCIFICATION PX XXX TC DECALCIFICATION PX 9.13 XXX SPECIAL STAINS GROUP 1 MICROORGANISMS I&R EACH XXX SPECIAL STAINS GROUP 1 MICROORGANISMS I&R EACH XXX TC SPECIAL STAINS GROUP 1 MICROORGANISMS I&R EACH XXX SPECIAL STAINS GROUP II ALL OTHER I&R EACH XXX SPECIAL STAINS GROUP II ALL OTHER I&R EACH XXX TC SPECIAL STAINS GROUP II ALL OTHER I&R EACH XXX SPECIAL STAINS HISTOCHEMICAL W/FROZEN SECTION XXX SPECIAL STAINS HISTOCHEMICAL W/FROZEN SECTION XXX TC SPECIAL STAINS HISTOCHEMICAL W/FROZEN SECTION XXX DETERMINATIVE HISTOCHEMISTRY ID CHEM COMPONENTS XXX DETERMINATIVE HISTOCHEMISTRY ID CHEM COMPONENTS XXX TC DETERMINATIVE HISTOCHEMISTRY ID CHEM COMPONENTS XXX DETERMINATIVE HCHEM/CCHEM ID NZM EA XXX DETERMINATIVE HCHEM/CCHEM ID NZM EA XXX TC DETERMINATIVE HCHEM/CCHEM ID NZM EA XXX CONSLTJ&REPRT SLIDES PREPARED ELSEWHERE XXX CONSLTJ&REPRT MATRL REQ PREPJ SLIDES XXX CONSLTJ&REPRT MATRL REQ PREPJ SLIDES XXX TC CONSLTJ&REPRT MATRL REQ PREPJ SLIDES XXX CONSLTJ COMPRE REVIEW REPRT REFERRED MATRL XXX PATH CONSLTJ SURG XXX PATH CONSLTJ SURG 1ST BLK FROZEN SCTJ 1 SPEC XXX PATH CONSLTJ SURG 1ST BLK FROZEN SCTJ 1 SPEC XXX TC PATH CONSLTJ SURG 1ST BLK FROZEN SCTJ 1 SPEC XXX s PATH CONSLTJ SURG EA BLK FROZEN SCTJ XXX s PATH CONSLTJ SURG EA BLK FROZEN SCTJ XXX s TC PATH CONSLTJ SURG EA BLK FROZEN SCTJ XXX PATH CONSLTJ SURG CYTOLOGIC XM 1ST SIT XXX PATH CONSLTJ SURG CYTOLOGIC XM 1ST SIT XXX TC PATH CONSLTJ SURG CYTOLOGIC XM 1ST SIT XXX s PATH CONSLTJ SURG CYTOL XM EA ADDL XXX s PATH CONSLTJ SURG CYTOL XM EA ADDL XXX s TC PATH CONSLTJ SURG CYTOL XM EA ADDL XXX IMCYTCHM TISS IMMUNOPROXIDASE EA ANTB XXX IMCYTCHM TISS IMMUNOPROXIDASE EA ANTB XXX TC IMCYTCHM TISS IMMUNOPROXIDASE EA ANTB XXX IMFLUOR STD EA ANTB DIR METH XXX IMFLUOR STD EA ANTB DIR METH XXX TC IMFLUOR STD EA ANTB DIR METH XXX IMFLUOR STD EA ANTB INDIR METH XXX IMFLUOR STD EA ANTB INDIR METH XXX Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 249

254 Georgia Workers Compensation Medical Fee Schedule Section IX: Pathology and Laboratory Services PATHOLOGY AND LABORATORY Medical Fee Schedule Effective April 1, TC IMFLUOR STD EA ANTB INDIR METH XXX ELECTRON MIC DX XXX ELECTRON MIC DX XXX TC ELECTRON MIC DX XXX ELECTRON MIC SCANNING XXX ELECTRON MIC SCANNING XXX TC ELECTRON MIC SCANNING XXX M/PHMTRC ALYS SKEL MUSC XXX M/PHMTRC ALYS SKEL MUSC XXX TC M/PHMTRC ALYS SKEL MUSC XXX M/PHMTRC ALYS NRV XXX M/PHMTRC ALYS NRV XXX TC M/PHMTRC ALYS NRV XXX M/PHMTRC ALYS TUM XXX M/PHMTRC ALYS TUM XXX TC M/PHMTRC ALYS TUM XXX M/PHMTRC ALYS TUM IMHCHEM EA ANTB MNL XXX M/PHMTRC ALYS TUM IMHCHEM EA ANTB MNL XXX TC M/PHMTRC ALYS TUM IMHCHEM EA ANTB MNL XXX M/PHMTRC ALYS TUM IMHCHEM EA ANTB CPTR XXX M/PHMTRC ALYS TUM IMHCHEM EA ANTB CPTR XXX TC M/PHMTRC ALYS TUM IMHCHEM EA ANTB CPTR XXX NRV TEASING PREPJS XXX NRV TEASING PREPJS XXX TC NRV TEASING PREPJS XXX l EXAM & SELECT ARCHIVE TISSUE MOLECULAR ANALYSIS XXX SITU HYBRIDIZATION EA PRB XXX SITU HYBRIDIZATION EA PRB XXX TC SITU HYBRIDIZATION EA PRB XXX M/PHMTRC ALYS ISH EA PRB CPTR-ASST TECHNOLOGY XXX M/PHMTRC ALYS ISH EA PRB CPTR-ASST TECHNOLOGY XXX TC M/PHMTRC ALYS ISH EA PRB CPTR-ASST TECHNOLOGY XXX M/PHMTRC ALYS ISH EA PRB MNL XXX M/PHMTRC ALYS ISH EA PRB MNL XXX TC M/PHMTRC ALYS ISH EA PRB MNL XXX PROTEIN ALYS WSTRN BLOT I&R XXX PROTEIN ALYS WSTRN BLOT I&R XXX TC PROTEIN ALYS WSTRN BLOT I&R XXX PROTEIN ALYS WSTRN BLOT I&R IMMUNOLOGICAL EA XXX PROTEIN ALYS WSTRN BLOT I&R IMMUNOLOGICAL EA XXX TC PROTEIN ALYS WSTRN BLOT I&R IMMUNOLOGICAL EA XXX MICRODISSECTION PREP IDENTIFIED TARGET LASER XXX MICRODISSECTION PREP IDENTIFIED TARGET LASER XXX TC MICRODISSECTION PREP IDENTIFIED TARGET LASER XXX MICRODISSECTION PREP IDENTIFIED TARGET MANUAL XXX MICRODISSECTION PREP IDENTIFIED TARGET MANUAL XXX 250 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

255 Section IX: Pathology and Laboratory Services Georgia Workers Compensation Medical Fee Schedule PATHOLOGY AND LABORATORY Effective April 1, 2011 Medical Fee Schedule TC MICRODISSECTION PREP IDENTIFIED TARGET MANUAL XXX RA-BASED EVAL MLT MOLEC PRBS 11 THRU 50 PRBS XXX RA-BASED EVAL MLT MOLEC PRBS 11 THRU 50 PRBS XXX TC RA-BASED EVAL MLT MOLEC PRBS 11 THRU 50 PRBS XXX RA-BASED EVAL MLT MOLEC PRBS 51 THRU 250 PRBS XXX RA-BASED EVAL MLT MOLEC PRBS 51 THRU 250 PRBS XXX TC RA-BASED EVAL MLT MOLEC PRBS 51 THRU 250 PRBS XXX RA-BASED EVAL MLT MOLEC PRBS 251 THRU 500 PRBS XXX RA-BASED EVAL MLT MOLEC PRBS 251 THRU 500 PRBS XXX TC RA-BASED EVAL MLT MOLEC PRBS 251 THRU 500 PRBS XXX MACRO EXAM DISSECT&PREP TISS NONMICRO STD EA XXX MACRO EXAM DISSECT&PREP TISS NONMICRO STD EA XXX TC MACRO EXAM DISSECT&PREP TISS NONMICRO STD EA XXX MACR EXM DISS&PRP NONMICR IMPRNT/CONSLT/FRZ SEC XXX MACR EXM DISS&PRP NONMICR IMPRNT/CONSLT/FRZ SEC XXX TC MACR EXM DISS&PRP NONMICR IMPRNT/CONSLT/FRZ SEC 5.94 XXX UNLIS SURG PATH PX BR XXX BILIRUBIN TOTAL TRANSCUTANEOUS 9.59 XXX HGB QUANTITATIVE TRANSCUTANEOUS 9.59 XXX HEMOGLOBIN QUAN TC PER DAY CARBOXYHEMOGLOBIN 9.59 XXX HEMOGLOBIN QUANTITATIVE TC PER DAY METHEMOGLOBIN 9.59 XXX l UNLISTED IN VIVO LAB SERVICE BR XXX CAFFEINE HALOTHANE CONTRCURE XXX C-CNT MISC BDY FLUS XCPT BLD 9.14 XXX C-CNT MISC BDY FLUS XCPT BLD DIFFIAL CNT XXX WBC ASSMT FECAL QUAL/SEMIQUAN 8.22 XXX CRYSTAL ID LIGHT MIC ALYS TISSUE/ANY FLU XXX CRYSTAL ID LIGHT MIC ALYS TISSUE/ANY FLU XXX TC CRYSTAL ID LIGHT MIC ALYS TISSUE/ANY FLU XXX FAT STAIN FECES URINE/RESPIR SECRETIONS 8.22 XXX MEAT FIBERS FECES 6.85 XXX NSL SMR EOSINOPHILS 9.14 XXX SPTM OBTG SPEC AERSL INDUCED SPX XXX SWEAT COLLJ IONTOPHORESIS 4.11 XXX UNLIS MISC PATH BR XXX CUL OOCYTE/EMBRYO < 4 D XXX CUL OOCYTE/EMBRYO < 4 D CO-CULT OCYTE/EMBRY XXX ASSTD EMBRYO HATCHING MICROTQS ANY METH BR XXX OOCYTE ID FROM FOLLICULAR FLU BR XXX PREPJ EMBRYO TR BR XXX SPRM ID FROM ASPIR OTH/THN SEMINAL BR XXX CRYOPRESERVATION EMBRYO(S) BR XXX CRYOPRESERVATION SPERM BR XXX SPRM ISOL SMPL PREP INSEMINATION/DX SEMEN ALYS BR XXX SPRM ISOL CPLX PREP INSEMINATION/DX SEMEN ALYS BR XXX SPRM ID FROM TSTIS TISS FRSH/CRYOPRSRVD BR XXX Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 251

256 Georgia Workers Compensation Medical Fee Schedule Section IX: Pathology and Laboratory Services PATHOLOGY AND LABORATORY Medical Fee Schedule Effective April 1, INSEMINATION OOCYTES BR XXX EXTND CUL OOCYTE/EMBRYO 4-7 D BR XXX ASSTD FERTILIZATION MICROTQ </EQUAL 10 OOCYTES BR XXX ASSTD FERTILIZATION MICROTQ > 10 OOCYTES BR XXX BX OOCYTE MICROTQ </EQUAL 5 EMBRY BR XXX BX OOCYTE MICROTQ > 5 EMBRY BR XXX SEMEN ALYS PRESENCE&/MOTILITY SPRM HUHNER XXX SEMEN ALYS MOTILITY&CNT X W/HUHNER TST XXX SEMEN ANALYSIS VOLUME COUNT MOTILITY DIFFERENT XXX SEMEN ANALYSIS SPERM PRESENCE&/MOTILITY SPRM XXX SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA XXX SPRM ANTIBODIES XXX SPRM EVAL HAMSTER PENETRATION TST XXX SPRM EVAL CRV MUCUS PENETRATION XXX SPERM EVALUATION RETROGRADE EJACULATION URINE XXX CRYOPRSRV REPRDTVE TISS TSTICULAR BR XXX STORAGE PR YR EMBRYO BR XXX STORAGE PR YR SPRM/SEMEN BR XXX STORAGE PR YR REPRDTVE TISS TSTICULAR/OVARIAN BR XXX STORAGE PR YR OOCYTE BR XXX THAWING CRYOPRSRVD EMBRYO BR XXX THAWING CRYOPRSRVD SPRM/SEMEN EA ALIQUOT BR XXX THAWING CRYOPRSRVD TSTICULAR/OVARIAN BR XXX THAWING CRYOPRSRVD OOCYTES EA ALIQUOT BR XXX UNLISTED REPRODUCTIVE MEDICINE LAB PROCEDURE BR XXX 252 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

257 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., CPT code 99199), and adequately describe the service provided. Materials and supplies not usually considered part of the procedure may be separately reported with CPT code (see Materials Supplied by the Health Care Provider in section IV). 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 CPT codes are reported in addition to an immunization administration CPT code(s) Hydration services shall use CPT code(s) 96360, and will not include the cost of the prepackaged fluid and electrolytes, which will be billed and paid separately. A therapeutic, prophylactic or diagnostic injection shall use CPT code(s) 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. Osteopathic, 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) section. 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 predetermined 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. Multiple Procedures It is appropriate to designate multiple procedures that are rendered on the same date by separate entries. Add-on Codes Some of the listed procedures are commonly carried out in addition to the primary procedure performed. Add-on procedures are not reported as stand-alone codes. All add-on codes are exempt from the multiple procedure concept, and as such, modifier 51 does not apply. These additional or supplemental procedures, designated as add-on codes, can be readily identified by specific nomenclature in the CPT description which includes phrases such as each additional or (List separately in addition to primary procedure). Separate Procedure Certain procedures are an inherent portion of a procedure or service, and do not warrant a separate charge. When such a procedure is carried out as a separate entity not immediately related to other services, the indicated value for a separate procedure is applicable. Therefore, 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. It may be necessary to report a separate procedure with modifier 59 if it is a different session, encounter, procedure, surgery, site, separate incision, lesion, or separate injury. Interpretation In circumstances where an interpreter is required during face-to-face evaluation and management services, or physical CPT only 2010 American Medical Association. All Rights Reserved. 253

258 Georgia Workers Compensation Medical Fee Schedule medicine evaluations ( ), provided to the injured worker by a physician or PE, whether interpretation is provided live, via telephone or video, add state-specific modifier TR to the E/M code. Reimbursement will be an additional 25 percent of the lesser of billed charges or maximum allowable rate of that code only. Prolonged service codes may not be used in combination with this modifier. Additional reimbursement as outlined above does not apply to independent medical evaluations (IME). In circumstances where an interpreter is required for an injured worker, and the service is provided by telephone with a physician or qualified non-physician health care provider, use the appropriate CPT codes (physicians) and (qualified non-physician health care providers), and append state-specific modifier TR. These codes should be used in accordance with the guidelines and descriptions found in CPT Reimbursement will be an additional 25 percent of the lesser of billed charges or maximum allowable rate of that code only. Unusual Service or Procedure Services that may necessitate skills and time of the physician over and above that usually required should be substantiated by report (see section IV). Unlisted Service or Procedure Some services performed are not described by any CPT code. These services should be reported using an unlisted code, substantiating it by report. The unlisted services and accompanying codes are listed at the end of each Medicine subsection. Unlisted service or procedure codes must be selected from the appropriate subsection of the Medicine chapter. For these procedures a BR (by report) designation has been used in the fee schedule. Reimbursement for such procedures must be justified by report (see section IV). 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 the appropriate modifier following the procedure code. When two modifiers are applicable to a single code, indicate each modifier on the bill. 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 (Evaluation and Management, Anesthesia, Surgery, Pathology/Laboratory, Radiology, General Medicine, and Section X: General Medicine Services 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 Increased Procedural Services: When the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. Documentation must support the substantial additional work and the reason for the additional work (i.e., increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). Note: This modifier should not be appended to an E/M service. 26 Professional Component: 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 modifier 26 to the usual procedure number. 50 Bilateral Procedure: Unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate five-digit code. 52 Reduced Services: Under certain circumstances, a service or procedure is partially reduced or eliminated at the physician s discretion. Under these circumstances, the service provided can be identified by its usual procedure number and the addition of modifier 52 signifying that the service is reduced. This provides a means of reporting reduced services without disturbing the identification of the basic service. Note: For hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for ASC hospital outpatient use). 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 modifier 53 to the code for the discontinued procedure. Note: This modifier is not used to report the 254 CPT only 2010 American Medical Association. All Rights Reserved.

259 Section X: General Medicine Services elective cancellation of a procedure before the patient s anesthesia induction and/or surgical preparation in the operating suite. For outpatient hospital/ambulatory surgery center (ASC) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifier 73 and 74 (see modifiers approved for ASC hospital outpatient use). 59 Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision or 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 individual. 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. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-e/m service performed on the same date, see modifier Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional: It may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. This circumstance may be reported by adding modifier 76 to the repeated procedure or service. Note: This modifier should not be appended to an E/M service. Georgia Workers Compensation Medical Fee Schedule 77 Repeat Procedure or Service by Another Physician or Other Qualified Health Care Professional: It may be necessary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service. This circumstance may be reported by adding modifier 77 to the repeated procedure/service. Note: This modifier should not be appended to an E/M service. 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. LT Left Side: Used to identify procedures performed on the left side of the body. RT Right Side: Used to identify procedures performed on the right side of the body. TC 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 modifier TC to the usual procedure number. TR Interpretation: In circumstances where an interpreter is required during face-to-face evaluation and management services provided to the injured worker by a physician or PE, add state-specific modifier TR to the E/M code. Reimbursement will be an additional 25 percent of the lesser of billed charges or maximum allowable rate of that code only. Prolonged service codes may not be used in combination with the TR modifier unless it is documented that the reason for the code is additional time required as a result of factors beyond the need for an interpreter. Additional reimbursement as outlined above does not apply to independent medical evaluations (IME). CPT only 2010 American Medical Association. All Rights Reserved. 255

260 Georgia Workers Compensation Medical Fee Schedule Section X: General Medicine Services MEDICINE , , , , , Medical Fee Schedule Effective April 1, IMMUNE GLOBULIN IG HUMAN IM USE BR XXX IMMUNE GLOBULIN IGIV HUMAN IV USE BR XXX IMMUNE GLOBULIN HUMAN SUBQ INFUSION 100 MG EA BR XXX BOTULINUM ANTITOXIN EQUINE ANY ROUTE BR XXX BOTULISM IMMUNE GLOBULIN HUMAN INTRAVENOUS USE BR XXX CYTOMEGALOVIRUS IMMUNE GLOBULIN HUMAN IV BR XXX DIPHTHERIA ANTITOXIN EQUINE ANY ROUTE BR XXX HEPATITIS B IMMUNE GLOBULIN HBIG HUMAN IM XXX RABIES IMMUNE GLOBULIN RIG HUMAN IM/SUBQ XXX RABIES IG HEAT-TREATED HUMAN IM/SUBQ XXX RESPIRATORY SYNCYTIAL VIRUS IG IM 50 MG E BR XXX RHO(D) IMMUNE GLOBULIN HUMAN FULL-DOSE IM XXX RHO(D) IMMUNE GLOBULIN HUMAN MINI-DOSE IM XXX RHO(D) IMMUNE GLOBULIN HUMAN IV XXX TETANUS IMMUNE GLOBULIN TIG HUMAN IM XXX VACCINIA IMMUNE GLOBULIN HUMAN IM BR XXX VARICELLA-ZOSTER IMMUNE GLOBULIN HUMAN IM XXX UNLISTED IMMUNE GLOBULIN BR XXX l IMADM THROUGH 18YR ANY ROUTE 1ST VAC/TOXOID XXX l IMADM THROUGH 18YR ANY ROUTE EA ADDL VAC/TOXOID ZZZ l IMMUNE ADMIN H1N1 IM/NASAL INCL CNSL XXX IMADM PRQ ID SUBQ/IM NJXS 1 VACC XXX IMADM PRQ ID SUBQ/IM NJXS EA VACC ZZZ IMADM INTRANSL/ORAL 1 VACC XXX IMADM INTRANSL/ORAL EA VACC ZZZ ADENOVIRUS VACCINE TYPE 4 LIVE ORAL BR XXX ADENOVIRUS VACCINE TYPE 7 LIVE FOR ORAL BR XXX ANTHRAX VACCINE SUBCUTANEOUS USE XXX BACILLUS CALMETTE-GUERIN VACC FOR TB LIVE PERQ XXX BCG BLDR CANCER LIVE INTRAVESICAL XXX HEPATITIS A VACCINE ADULT FOR INTRAMUSCULAR USE XXX HEPATITIS A VACCINE PEDIATRIC 2 DOSE SCHEDULE IM XXX HEPATITIS A VACCINE PEDIATRIC 3 DOSE SCHEDULE IM XXX HEPATITIS A & B VACCINE HEPA-HEPB ADULT IM XXX l MENINGOCOCCAL & HIB CONJ VACCINE 4 DOSE IM XXX HEMOPHILUS INFLUENZA B VACC HBOC CONJ 4 DOSE IM XXX HEMOPHILUS INFLUENZA B VACCINE PRP-D BOOSTER IM XXX HEMOPHILUS INFLUENZA B VACCINE PRP-OMP 3 DOSE IM XXX HEMOPHILUS INFLUENZA B VACCINE PRP-T 4 DOSE IM XXX HUMAN PAPILLOMA VIRUS VACCINE QUADRIV 3 DOSE IM XXX s HUMAN PAPILLOMA VIRUS BIVALENT VACCINE 3 DOSE IM BR XXX INFLUENZA VACCINE PRSV FREE ID USE BR XXX INFLUENZA VIRUS VACC SPLIT PRSRV FREE 6-35 MO IM XXX INFLUENZA VIRUS VACC SPLIT PRSRV FR 3 YEARS + IM XXX INFLUENZA VIRUS VACCINE SPLIT VIRUS 6-35 MO IM XXX INFLUENZA VIRUS VACCINE SPLIT VIRUS 3 YEARS + IM XXX 256 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

261 Section X: General Medicine Services Georgia Workers Compensation Medical Fee Schedule , , , , , MEDICINE Effective April 1, 2011 Medical Fee Schedule INFLUENZA VIRUS VACCINE LIVE INTRANASAL XXX INFLUENZA VACCINE CELL CULT PRSRV FREE IM BR XXX s INFLUENZA VACCINE SPLT PRSRV FREE INC ANTIGEN IM XXX s INFLUENZA VACCINE PANDEMIC FORMULATION H1N1 BR XXX l INFLUENZA VACCINE PANDEMIC LIVE INTRANASAL USE BR XXX # LYME DISEASE VACCINE ADULT IM BR XXX l INFLUENZA VACCINE PANDEMIC PRSV FREE IM USE BR XXX l INFLUENZA VACCINE PANDEMIC ADJUVANT IM USE BR XXX l INFLUENZA VACCINE PANDEMIC IM USE BR XXX PNEUMOCOCCAL CONJ VACCINE 7 VALENT IM XXX s PNEUMOCOCCAL CONJ VACCINE 13 VALENT IM XXX RABIES VACCINE INTRAMUSCULAR XXX RABIES VACCINE INTRADERMAL BR XXX ROTAVIRUS VACCINE PENTAVALENT 3 DOSE LIVE ORAL XXX ROTAVIRUS VACC HUMAN ATTENUATED 2 DOSE LIVE ORAL XXX TYPHOID VACCINE LIVE ORAL XXX TYPHOID VACCINE VI CAPSULAR POLYSACCHARIDE IM XXX TYPHOID VACC H-P INACTIVATED SUBQ/INTRADERMAL BR XXX TYPHOID VACCINE AKD SUBQ U.S. MILITARY BR XXX DTAP-IPV INACTIVATED IF ADMIN PTS AGE 4-6 YRS IM BR XXX DTAP-HIB-IPV VACCINE IM XXX DTAP VACCINE < 7 YR IM XXX DIPHTHERIA TETANUS TOXOID PERTUSSIS VACCINE IM XXX DIPHTHERIA TETANUS TOXOID ADSORBED < 7 YR IM XXX TETANUS TOXOID ADSORBED INTRAMUSCULAR XXX MUMPS VIRUS VACCINE LIVE SUBCUTANEOUS XXX MEASLES VIRUS VACCINE LIVE SUBCUTANEOUS XXX RUBELLA VIRUS VACCINE LIVE SUBCUTANEOUS XXX MEASLES MUMPS RUBELLA VIRUS VACCINE LIVE SUBQ XXX MEASLES & RUBELLA VIRUS VACCINE LIVE SUBQ BR XXX MEASLES MUMPS RUBELLA VARICELLA VACC LIVE SUBQ XXX POLIOVIRUS VACCINE ANY LIVE ORAL BR XXX POLIOVIRUS VACCINE INACTIVATED SUBQ/IM XXX TD TOXOIDS ADSORBED PRSRV FR 7 YR + IM XXX TDAP VACCINE 7 YR + IM XXX VARICELLA VIRUS VACCINE LIVE SUBQ XXX YELLOW FEVER VACCINE LIVE SUBQ XXX TETANUS & DIPHTHERIA TOXOIDS ADSORBED 7 YR + IM XXX DIPHTHERIA TOXOID INTRAMUSCULAR BR XXX DTP-HIB VACCINE INTRAMUSCULAR BR XXX DTAP-HIB VACCINE INTRAMUSCULAR BR XXX DTAP-HEPB-IPV VACCINE INTRAMUSCULAR XXX CHOLERA VACCINE INJECTABLE BR XXX PLAGUE VACCINE INTRAMUSCULAR BR XXX PNEUMOCOCCAL POLYSAC VACCINE 23-V 2 YR + SUBQ/IM XXX MENINGOCOCCAL POLYSAC VACCINE SUBCUTANEOUS XXX Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 257

262 Georgia Workers Compensation Medical Fee Schedule Section X: General Medicine Services MEDICINE , , , , , Medical Fee Schedule Effective April 1, MENINGOCOCCAL CONJ VACCINE TETRAVALENT IM XXX JAPANESE ENCEPHALITIS VIRUS VACCINE SUBCUTANEOUS XXX ZOSTER SHINGLES VACCINE LIVE SUBCUTANEOUS XXX JAPANESE ENCEPHALITIS VACCINE INACTIVATED IM XXX HEPATITIS B VACCINE DIALYSIS DOSAGE 3 DOSE IM XXX HEPATITIS B VACCINE ADOLESCENT 2 DOSE IM XXX HEPATITIS B VACCINE PEDIATRIC3 DOSE IM XXX HEPATITIS B VACCINE ADULT DOSAGE INTRAMUSCULAR XXX HEPATITIS B VACCINE DIALYSIS DOSAGE 4 DOSE IM XXX HEPB-HIB VACCINE INTRAMUSCULAR XXX UNLISTED VACCINE/TOXOID BR XXX PSYC DX INTERVIEW XM XXX IA PSYC DX INTERVIEW XM W/PLAY XXX IPI-OB-M/S OFFICE MIN XXX IPI-OB-M/S OFFICE MIN MEDICAL E/M XXX IPI-OB-M/S OFFICE MIN XXX IPI-OB-M/S OFFICE MIN MEDICAL E/M XXX IPI-OB-M/S OFFICE MIN XXX IPI-OB-M/S OFFICE MIN MEDICAL E/M XXX INDIV PSYCTX IA MIN XXX INDIV PSYCTX IA MIN MEDICAL E/M XXX INDIV PSYCTX IA MIN XXX INDIV PSYCTX IA MIN MEDICAL E/M XXX INDIV PSYCTX IA MIN XXX INDIV PSYCTX IA MIN MEDICAL E/M XXX IPI-OB-M/S I/P MIN XXX IPI-OB-M/S I/P MIN MEDICAL E/M XXX IPI-OB-M/S I/P MIN XXX IPI-OB-M/S I/P MIN MEDICAL E/M XXX IPI-OB-M/S I/P MIN XXX IPI-OB-M/S I/P MIN MEDICAL E/M XXX INDIV PSYCTX IA I/P MIN XXX INDIV PSYCTX IA I/P MIN MEDICAL E/M XXX INDIV PSYCTX IA I/P MIN XXX INDIV PSYCTX IA I/P MIN MEDICAL E/M XXX INDIV PSYCTX IA I/P MIN XXX INDIV PSYCTX IA I/P MIN MEDICAL E/M XXX PSYCHOALYS XXX FAM PSYCTX W/O PT PRESENT XXX FAM PSYCTX W/PT PRESENT XXX MLT-FAM GRP PSYCTX XXX GRP PSYCTX XXX IA GRP PSYCTX XXX PHARMACOLOGIC MGMT MIN MEDICAL PSYCTX XXX NARCOSYNTHESIS PSYC DX&THER PURPOSES XXX l TRANSCRANIAL MAG STIMJ TX PLANNING BR YYY 258 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

263 Section X: General Medicine Services Georgia Workers Compensation Medical Fee Schedule , , , , , MEDICINE Effective April 1, 2011 Medical Fee Schedule l TRANSCRANIAL MAG STIMJ TX DLVR & MGMT BR YYY ELECTROCONVULSIVE THER INDIV PSYCPHYSTX BFB TRAINJ MIN XXX INDIV PSYCPHYSTX BFB TRAINJ MIN XXX HYPXH XXX ENVIRONMENTAL IVNTJ MGMT PURPOSES PSYC PT XXX PSYC EVAL HOSP RECORDS DX PURPOSES XXX INTERPJ/EXPLNAJ RESULTS PSYC XMS FAM XXX PREPJ REPORT PSYC STATUS XXX UNLIS PSYC SVC/PX BR XXX BFB TRAINJ ANY MODALITY BFB TRAINJ PRNL MUSC HEMO PX W/1 PHYS EVAL HEMO REPEATED EVAL +-REVJ DIAL RX HEMO ACCESS FLO STD XXX HEMO ACCESS FLO STD XXX TC HEMO ACCESS FLO STD XXX DIAL OTH/THN HEMO 1 PHYS EVAL DIAL OTH/THN HEMO REPEATED PHYS EVALS ESRD RELATED SVC MONTHLY <2 YR OLD 4/>VISITS XXX ESRD RELATED SVC MONTHLY <2 YR OLD 2/3 VISITS XXX ESRD RELATED SVC MONTHLY <2 YR OLD 1 VISIT XXX ESRD RELATED SVC MONTHLY 2-11 YR OLD 4/>VISITS XXX ESRD RELATED SVC MONTHLY 2-11 YR OLD 2/3 VISITS XXX ESRD RELATED SVC MONTHLY 2-11 YR OLD 1 VISIT XXX ESRD RELATED SVC MONTHLY YR OLD 4/>VISITS XXX ESRD RELATED SVC MONTHLY YR OLD 2/3 VISITS XXX ESRD RELATED SVC MONTHLY YR OLD 1 VISIT XXX ESRD RELATED SVC MONTHLY 20&> YR OLD 4/> VISITS XXX ESRD RELATED SVC MONTHLY 20&> YR OLD 2/3 VISITS XXX ESRD RELATED SVC MONTHLY 20&> YR OLD 1 VISIT XXX ESRD SVC HOME DIALYSIS FULL MONTH <2YR OLD XXX ESRD SVC HOME DIALYSIS FULL MONTH 2-11 YR OLD XXX ESRD SVC HOME DIALYSIS FULL MONTH YR OLD XXX ESRD SVC HOME DIALYSIS FULL MONTH 20 YR OLD XXX ESRD RELATED SVC <FULL MONTH < 2 YR OLD XXX ESRD RELATED SVC <FULL MONTH 2-11 YR OLD XXX ESRD RELATED SVC <FULL MONTH YR OLD XXX ESRD RELATED SVC <FULL MONTH 20&> YR OLD XXX DIAL TRAINJ COMPLD COURSE XXX DIAL TRAINJ COURSE X COMPLD PR SESS XXX HEMOPRFJ UNLIS DIAL I/P/O/P BR XXX s ESOPHGL MOTILITY STD W/I&R 2D s ESOPHGL MOTILITY STD W/I&R 2D s TC ESOPHGL MOTILITY STD W/I&R 2D Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 259

264 Georgia Workers Compensation Medical Fee Schedule Section X: General Medicine Services MEDICINE , , , , , Medical Fee Schedule Effective April 1, 2011 l ESOPHGL MOTILITY STD W/I&R STIM/PERFUSION ZZZ l ESOPHGL MOTILITY STD W/I&R STIM/PERFUSION ZZZ l TC ESOPHGL MOTILITY STD W/I&R STIM/PERFUSION ZZZ GSTR MOTILITY STD GSTR MOTILITY STD TC GSTR MOTILITY STD DUOL MOTILITY STD DUOL MOTILITY STD TC DUOL MOTILITY STD ESOPH ACID PRFJ TST ESOPHAGITIS ESOPH ACID PRFJ TST ESOPHAGITIS TC ESOPH ACID PRFJ TST ESOPHAGITIS ESOPH G-ESOP RFLX NCATH ELTRD PLMT ESOPH G-ESOP RFLX NCATH ELTRD PLMT TC ESOPH G-ESOP RFLX NCATH ELTRD PLMT ESOPH G-ESOP RFLX TLMTR ELTRD PLMT ESOPH G-ESOP RFLX TLMTR ELTRD PLMT TC ESOPH G-ESOP RFLX TLMTR ELTRD PLMT ESOPHGL FUNCJ G-ESOP RFLX IMPD ELTRD PLMT ESOPHGL FUNCJ G-ESOP RFLX IMPD ELTRD PLMT TC ESOPHGL FUNCJ G-ESOP RFLX IMPD ELTRD PLMT ESOPHGL FUNCJ G-ESOP RFLX IMPD ELTRD PROLNG ESOPHGL FUNCJ G-ESOP RFLX IMPD ELTRD PROLNG TC ESOPHGL FUNCJ G-ESOP RFLX IMPD ELTRD PROLNG ESOPHGL BALO DISTENSION PROVOCATION STD ESOPHGL BALO DISTENSION PROVOCATION STD TC ESOPHGL BALO DISTENSION PROVOCATION STD BRTH HYDROGEN TST BRTH HYDROGEN TST TC BRTH HYDROGEN TST GI TRC IMG INTRAL ESOPH THRU ILE PHYS I&R XXX GI TRC IMG INTRAL ESOPH THRU ILE PHYS I&R XXX TC GI TRC IMG INTRAL ESOPH THRU ILE PHYS I&R XXX GASTROINTESTINAL TRACT IMAGING ESOPHAGUS XXX GASTROINTESTINAL TRACT IMAGING ESOPHAGUS XXX TC GASTROINTESTINAL TRACT IMAGING ESOPHAGUS XXX l COLON MOTILITY STDY MIN 6 HR CONT RECORD W/I&R RCT SENSATION TONE&COMPLIANCE XXX RCT SENSATION TONE&COMPLIANCE XXX TC RCT SENSATION TONE&COMPLIANCE XXX ANRCT MANO ANRCT MANO TC ANRCT MANO EGG DX TC XXX EGG DX TC XXX TC EGG DX TC XXX 260 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

265 Section X: General Medicine Services Georgia Workers Compensation Medical Fee Schedule , , , , , MEDICINE Effective April 1, 2011 Medical Fee Schedule EGG DX TC PROVOCATIVE TSTG XXX EGG DX TC PROVOCATIVE TSTG XXX TC EGG DX TC PROVOCATIVE TSTG XXX UNLIS DX GASTROENTEROLOGY BR XXX OPH MEDICAL XM&EVAL INTRM NEW PT XXX OPH MEDICAL XM&EVAL COMPRE NEW PT 1+ VST XXX OPH MEDICAL XM&EVAL INTRM EST PT XXX OPH MEDICAL XM&EVAL COMPRE EST PT 1+ VST XXX DETER REFRACTIVE STATE XXX OPH XM&EVAL ANES +-MNPJ GLOBE COMPL XXX OPH XM&EVAL ANES +-MNPJ GLOBE LMTD XXX GONIOSCOPY SPX XXX COMPUTERIZED CORNEAL TOPOGRAPHY UNI/BI XXX COMPUTERIZED CORNEAL TOPOGRAPHY UNI/BI XXX TC COMPUTERIZED CORNEAL TOPOGRAPHY UNI/BI XXX SENSIMOTR XM W/MLT MEAS OC DEVIJ W/I&R SPX XXX SENSIMOTR XM W/MLT MEAS OC DEVIJ W/I&R SPX XXX TC SENSIMOTR XM W/MLT MEAS OC DEVIJ W/I&R SPX XXX ORTHOPTIC&/PLEOPTIC TRAINJ XXX ORTHOPTIC&/PLEOPTIC TRAINJ XXX TC ORTHOPTIC&/PLEOPTIC TRAINJ XXX FITG C-LENS TX DISEASE SUPPLY LENS XXX VIS FLD XM UNI/BI I&R LMTD XM XXX VIS FLD XM UNI/BI I&R LMTD XM XXX TC VIS FLD XM UNI/BI I&R LMTD XM XXX VIS FLD XM UNI/BI I&R INTRM XM XXX VIS FLD XM UNI/BI I&R INTRM XM XXX TC VIS FLD XM UNI/BI I&R INTRM XM XXX VIS FLD XM UNI/BI I&R EXTND XM XXX VIS FLD XM UNI/BI I&R EXTND XM XXX TC VIS FLD XM UNI/BI I&R EXTND XM XXX SRL TNMTRY SPX MLT MEAS IO PRESS XXX TNGRPHY I&R REC INDENTAJ TNMTR SUCJ XXX TNGRPHY WATER PROVOCATION XXX l CMPTR OPHTHALMIC DX IMG ANT SEGMT W/I&R UNI/BI XXX l CMPTR OPHTHALMIC DX IMG ANT SEGMT W/I&R UNI/BI XXX l TC CMPTR OPHTHALMIC DX IMG ANT SEGMT W/I&R UNI/BI XXX l COMPUTERIZED OPHTHALMIC IMAGING OPTIC NERVE XXX l COMPUTERIZED OPHTHALMIC IMAGING OPTIC NERVE XXX l TC COMPUTERIZED OPHTHALMIC IMAGING OPTIC NERVE XXX l COMPUTERIZED OPHTHALMIC IMAGING RETINA XXX l COMPUTERIZED OPHTHALMIC IMAGING RETINA XXX l TC COMPUTERIZED OPHTHALMIC IMAGING RETINA XXX OPH BMTRY PRTL COHER INTRFRMTRY IO LENS PWR CAL XXX OPH BMTRY PRTL COHER INTRFRMTRY IO LENS PWR CAL XXX TC OPH BMTRY PRTL COHER INTRFRMTRY IO LENS PWR CAL XXX Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 261

266 Georgia Workers Compensation Medical Fee Schedule Section X: General Medicine Services MEDICINE , , , , , Medical Fee Schedule Effective April 1, PROVOCATIVE TSTS GLC I&R W/O TNGRPHY XXX OPSCPY EXTND RTA DRAWING I&R 1ST XXX OPSCPY EXTND RTA DRAWING I&R SBSQ XXX l REMOTE IMG DX RETINL DIS W/ALYS & REPORT UNI/BI XXX l REMOTE IMG MGT RETINL DIS W/I&R UNI/BI XXX l REMOTE IMG MGT RETINL DIS W/I&R UNI/BI XXX l TC REMOTE IMG MGT RETINL DIS W/I&R UNI/BI XXX FLUORESCEIN ANGIOSCOPY I&R XXX FLUORESCEIN ANGRPH I&R XXX FLUORESCEIN ANGRPH I&R XXX TC FLUORESCEIN ANGRPH I&R XXX INDOCYA9-GREEN ANGRPH I&R XXX INDOCYA9-GREEN ANGRPH I&R XXX TC INDOCYA9-GREEN ANGRPH I&R XXX FUNDUS PHTGRPHY I&R XXX FUNDUS PHTGRPHY I&R XXX TC FUNDUS PHTGRPHY I&R XXX OPHTHALMODYNAMOMETRY XXX NDL OCULOEMG 1+ EO MUSC 1/OU I&R XXX NDL OCULOEMG 1+ EO MUSC 1/OU I&R XXX TC NDL OCULOEMG 1+ EO MUSC 1/OU I&R XXX ELECTRO-OCULOGRAPY I&R XXX ELECTRO-OCULOGRAPY I&R XXX TC ELECTRO-OCULOGRAPY I&R XXX ELECTRORETINOGRAPY I&R XXX ELECTRORETINOGRAPY I&R XXX TC ELECTRORETINOGRAPY I&R XXX COLOR VIS XM EXTND ANOMALOSCOPE/EQUIV XXX COLOR VIS XM EXTND ANOMALOSCOPE/EQUIV XXX TC COLOR VIS XM EXTND ANOMALOSCOPE/EQUIV XXX DARK ADAPTATION XM I&R XXX DARK ADAPTATION XM I&R XXX TC DARK ADAPTATION XM I&R XXX XTRNL OC PHTGRPHY I&R PROGRESS XXX XTRNL OC PHTGRPHY I&R PROGRESS 6.65 XXX TC XTRNL OC PHTGRPHY I&R PROGRESS XXX SPEC ANT SGM PHTGRPHY I&R SPECLR ENDOTHELIAL XXX SPEC ANT SGM PHTGRPHY I&R SPECLR ENDOTHELIAL XXX TC SPEC ANT SGM PHTGRPHY I&R SPECLR ENDOTHELIAL XXX SPEC ANT SGM PHTGRPHY I&R FLUORESCEIN ANGRPH XXX SPEC ANT SGM PHTGRPHY I&R FLUORESCEIN ANGRPH XXX TC SPEC ANT SGM PHTGRPHY I&R FLUORESCEIN ANGRPH XXX RX&FITG C-LENS SUPVJ CRNL LENS OU XCPT APHK XXX RX&FITG C-LENS SUPVJ CRNL LENS APHK 1O XXX RX&FITG C-LENS SUPVJ CRNL LENS APHK OU XXX RX&FITG C-LENS SUPVJ CRNLSCLRL LENS XXX 262 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

267 Section X: General Medicine Services Georgia Workers Compensation Medical Fee Schedule , , , , , MEDICINE Effective April 1, 2011 Medical Fee Schedule RX C-LENS SUPVJ&DIRION FITG TECH OU XCPT APHK XXX RX C-LENS SUPVJ FITG TECH CRNL APHK 1O XXX RX C-LENS SUPVJ FITG TECH CRNL APHK OU XXX RX C-LENS SUPVJ FITG TECH CRNLSCLRL XXX MODIFICAJ C-LENS SPX SUPVJ ADAPTATION XXX RPLCMT C-LENS XXX FITG SPECTLS XCPT APHK MONOFOCAL XXX FITG SPECTLS XCPT APHK BIFOCAL XXX FITG SPECTLS XCPT APHK MLTFCL XXX FITG SPECTL PROSTH APHK MONOFOCAL XXX FITG SPECTL PROSTH APHK MLTFCL XXX FITG SPECTL MOUNTED LW VIS AID 1 ELMNT XXX FITG SPECTL MOUNTED LW VIS AID TLSCP XXX PROSTH APHK TEMP DISPOSABLE/LOAN MATRLS XXX RPR&REFITG SPECTLS XCPT APHK XXX RPR&REFITG SPECTLS SPECTL PROSTH APHK XXX UNLIS OPH SVC BR XXX OTOLARYNGOLOGIC XM ANES BINOC MIC XXX EVAL SP LANG VOICE COMUNICAJ&/AUD XXX TX SP LANG COMUNICAJ PCX DISORDER INDIV XXX TX SP LANG COMUNICAJ PCX DISORDER 2/> XXX NASOPHARYNGOSCOPY W/ENDOSCOPE SPX XXX NSL FUNCJ STD XXX FACIAL NRV FUNCJ STD XXX LARYN FUNCJ STD XXX TX SWLNG DYSF&/ORAL FUNCJ FEEDING XXX SPON NYSTAGMUS GAZE XXX POSAL NYSTAGMUS TST XXX CALORIC VSTBLR TST EA IRRIGATION XXX OKN TST XXX VSTBLR FUNCJ NYSTAG FOVL&PERPH STIMJ OSCIL TRKG XXX VSTBLR FUNCJ NYSTAG FOVL&PERPH STIMJ OSCIL TRKG XXX TC VSTBLR FUNCJ NYSTAG FOVL&PERPH STIMJ OSCIL TRKG XXX SPON NYSTAGMUS TST XXX SPON NYSTAGMUS TST XXX TC SPON NYSTAGMUS TST XXX POSAL NYSTAGMUS TST XXX POSAL NYSTAGMUS TST XXX TC POSAL NYSTAGMUS TST XXX CALORIC VSTBLR TST EA IRRIGATION REC XXX CALORIC VSTBLR TST EA IRRIGATION REC 8.86 XXX TC CALORIC VSTBLR TST EA IRRIGATION REC XXX OKN TST BIDIREC FOVEAL/PRPH STIMJ REC XXX OKN TST BIDIREC FOVEAL/PRPH STIMJ REC XXX TC OKN TST BIDIREC FOVEAL/PRPH STIMJ REC XXX Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 263

268 Georgia Workers Compensation Medical Fee Schedule Section X: General Medicine Services MEDICINE , , , , , Medical Fee Schedule Effective April 1, OSCILLATING TRACKING TST W/REC XXX OSCILLATING TRACKING TST W/REC XXX TC OSCILLATING TRACKING TST W/REC XXX SINUSOIDAL VER AXIS ROTATIONAL TSTG XXX SINUSOIDAL VER AXIS ROTATIONAL TSTG XXX TC SINUSOIDAL VER AXIS ROTATIONAL TSTG XXX USE VER ELTRDS 8.31 ZZZ USE VER ELTRDS 1.66 ZZZ TC USE VER ELTRDS 6.65 ZZZ CPTRIZED DYNAMIC POSTUROGRAPY XXX CPTRIZED DYNAMIC POSTUROGRAPY XXX TC CPTRIZED DYNAMIC POSTUROGRAPY XXX TYMPANOMETRY AND REFLEX THRESHOLD MEASUREMENTS XXX SCR TST PURE TONE AIR ONLY XXX PURE TONE AUDIOMTRY AIR ONLY XXX PURE TONE AUDIOMTRY AIR&B XXX SP AUDIOMTRY THRESHOLD XXX SP AUDIOMTRY THRESHOLD SP RECOGNIJ XXX COMPRE AUDIOMTRY THRESHOLD EVAL SP RECOGNIJ XXX AUDIOMETRIC TSTG GRPS XXX BEKESY AUDIOMTRY SCR XXX BEKESY AUDIOMTRY DX XXX LOUDNESS BALANCE BINAURAL/MONAURAL XXX TONE DECAY XXX SHORT INCREMENT SENSITIVITY INDEX XXX STENGER TST PURE TONE XXX TYMPANOMETRY XXX ACOUS RFLX THRESHOLD XXX ACOUSTIC IMMIT TEST TYMPANOM/ACOUST REFLX/DECAY XXX FILTERED SP XXX STAGGERED SPONDAIC WORD XXX SENSORINEURAL ACUITY LVL XXX SYNTH SENTENCE ID XXX STENGER SP XXX VIS RNFCMT AUDIOMTRY XXX CONDITIONING PLAY AUDIOMTRY XXX SELECT PICTURE AUDIOMTRY XXX ELECTROCOCHLEOGRAPY XXX AEP ERA&/TSTG CNS COMPRE XXX AEP ERA&/TSTG CNS COMPRE XXX TC AEP ERA&/TSTG CNS COMPRE XXX AEP ERA&/TSTG CNS LMTD XXX EVOKED OTOACOUS EMIJS LMTD XXX EVOKED OTOACOUS EMIJS LMTD XXX TC EVOKED OTOACOUS EMIJS LMTD XXX EVOKED OTOACOUS EMIJS COMPRE/DX EVAL XXX 264 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

269 Section X: General Medicine Services Georgia Workers Compensation Medical Fee Schedule , , , , , MEDICINE Effective April 1, 2011 Medical Fee Schedule EVOKED OTOACOUS EMIJS COMPRE/DX EVAL XXX TC EVOKED OTOACOUS EMIJS COMPRE/DX EVAL XXX HEARING AID XM&SELECTION MONAURAL XXX HEARING AID XM&SELECTION BINAURAL XXX HEARING AID CHECK MONAURAL XXX HEARING AID CHECK BINAURAL XXX ELECTROACOUS EVAL HEARING AID MONAURAL XXX ELECTROACOUS EVAL HEARING AID BINAURAL XXX EAR PROTECTOR ATTENUATION MEAS XXX EVAL&/FITG VOICE PROSTC DEV SUPPLEMENT O-SP XXX ALYS COCHLEAR IMPLT PT <7 YR PRGRMG XXX ALYS COCHLEAR IMPLT PT <7 YR SBSQ REPRGRMG XXX ALYS COCHLEAR IMPLT 7 YR/> PRGRMG XXX ALYS COCHLEAR IMPLT 7 YR/> SBSQ REPRGRMG XXX EVAL RX N-SP-GENRATJ AUGMNT COMUNICAJ DEV BR XXX THER SVC N-SP-GENRATJ DEV PRGRMG&MODIFICAJ XXX RX SP-GENRATJ AUGMNT&COMUNICAJ DEV 1ST HR XXX RX SP-GENRATJ AUGMNT&COMUNICAJ DEV EA 30 MIN ZZZ THER SP-GENRATJ DEV PRGRMG&MODIFICAJ XXX EVAL ORAL&PHARYNGEAL SWLNG FUNCJ XXX MOTION FLUOR EVAL SWLNG FUNCJ C/V REC XXX FLX FIBOPT NDSC EVAL SWLNG C/V REC XXX FLX FIBOPT NDSC EVAL SWLNG C/V REC PHYS I&R XXX FLX FIBOPT NDSC EVAL LARYN SENS C/V REC XXX FLX FIBOPT NDSC EVAL LARYN SENS PHYS I&R XXX FLX FIBOPT NDSC EVAL SWLNG&LARYN SENS C/V REC XXX FLX FIBOPT NDSC EVAL SWLNG&LARYN SENS PHYS I&R XXX EVAL CTR AUD FUNCJ W/REPRT 1ST 60 MIN XXX EVAL CTR AUD FUNCJ W/REPRT EA 15 MIN ZZZ ASSMT TINNITUS XXX EVAL AUD RHAB STATUS 1ST HR XXX EVAL AUD RHAB STATUS EA 15 MIN ZZZ AUD RHAB PRELNG HEARING LOSS BR XXX AUD RHAB POST-LNGL HEARING LOSS BR XXX ANALYSIS W/PRGRMG AUD BRAINSTEM IMPLANT PR HR XXX UNLIS OTORHINOLARYNGOLOGICAL SVC BR XXX CARDIOPULM RESUSCITATION K TEMP TC PACG K CARDIOVERSION ELECTIVE ARRHYT XTRNL K CARDIOVERSION ELECTIVE ARRHYT INT SPX CARDIOASSIST-METH CRC ASSIST INT CARDIOASSIST-METH CRC ASSIST XTRNL K PRQ TRLUML C THRMBC ZZZ + K TCAT PLMT RADJ DLVR DEV SBSQ C IV BRACHYTX ZZZ K THROMBOLSS C INTRAC NFS SLCTV C ANGRPH THROMBOLSS C IV NFS XXX Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 265

270 Georgia Workers Compensation Medical Fee Schedule Section X: General Medicine Services MEDICINE , , , , , Medical Fee Schedule Effective April 1, K IV US C VSL DX&/THER 1ST VSL ZZZ + K IV US C VSL DX&/THER 1ST VSL ZZZ + K TC IV US C VSL DX&/THER 1ST VSL ZZZ + K IV US C VSL DX&/THER EA VSL ZZZ + K IV US C VSL DX&/THER EA VSL ZZZ + K TC IV US C VSL DX&/THER EA VSL ZZZ K TCAT PLMT AN INTRAC STENT PRQ 1 VSL K TCAT PLMT INTRAC STENT PRQ EA VSL ZZZ K PRQ TRLUML C BALO ANGIOP 1 VSL K PRQ TRLUML C BALO ANGIOP EA VSL ZZZ K PRQ BALO VLVP AORTIC VALVE K PRQ BALO VLVP MITRAL VALVE PRQ BALO VLVP PULM VALVE ATR SEPTECT/SEPTOST TRANSVNS BALO ATR SEPTECT/SEPTOST BLADE METH K PRQ TRLUML C ATHRC 1 VSL K PRQ TRLUML C ATHRC EA VSL ZZZ PRQ TRLUML P-ART BALO ANGIOP 1 VSL PRQ TRLUML P-ART BALO ANGIOP EA VSL ZZZ ECG ROUTINE ECG W/LEAST 12 LDS W/I&R XXX ECG ROUTINE ECG W/LEAST 12 LDS TRCG ONLY W/O I&R XXX ECG ROUTINE ECG W/LEAST 12 LDS I&R ONLY XXX CV STRS TST XERS&/OR RX CONT ECG PHYS SI&R XXX CV STRS TST XERS&/OR RX CONT ECG PHYS SUPVJ XXX CV STRS TST XERS&/OR RX CONT ECG TRCG ONLY XXX CV STRS TST XERS&/OR RX CONT ECG I&R ONLY XXX ERGONOVINE PROVOCATION TST XXX ERGONOVINE PROVOCATION TST XXX TC ERGONOVINE PROVOCATION TST XXX MICROVOLT T-WAVE ASSESS VENTRICULAR ARRHYTHMIAS XXX MICROVOLT T-WAVE ASSESS VENTRICULAR ARRHYTHMIAS XXX TC MICROVOLT T-WAVE ASSESS VENTRICULAR ARRHYTHMIAS XXX RHYTHM ECG 1-3 LDS W/I&R XXX RHYTHM ECG 1-3 LDS TRCG ONLY W/O I&R 9.42 XXX RHYTHM ECG 1-3 LDS I&R ONLY XXX s XTRNL ECG UP TO 48 HR RECORD SCAN STOR W/PHY R&I XXX s XTRNL ECG UP TO 48 HR RECORDING XXX s EXTERNAL ECG SCANNING ANALYSIS REPORT XXX s XTRNL ECG CONTINUOUS RHYTHM PHYS REVIEW&INTERPJ XXX s XTRNL MOBILE CV TELEMETRY W/PHYS R&I W/REPORT XXX s XTRNL MOBILE CV TELEMETRY W/TECHNICAL SUPPORT XXX s XTRNL PT ACTIV ECG TRANSMIS PHYS R&I 30 DAYS XXX s XTRNL PT ACTIVATED ECG RECORD MONITOR 30 DAYS XXX s XTRNL PT ACTIVATED ECG REC DWNLD 30 DAYS XXX s XTRNL PT ACTIVTD ECG DWNLD 30 DAYS PHYS R&I XXX SAECG +-ECG XXX 266 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

271 Section X: General Medicine Services Georgia Workers Compensation Medical Fee Schedule , , , , , MEDICINE Effective April 1, 2011 Medical Fee Schedule SAECG +-ECG XXX TC SAECG +-ECG XXX PROGRAM EVAL IMPLANTABLE IN PRSN 1 LD PACEMAKER XXX PROGRAM EVAL IMPLANTABLE IN PRSN 1 LD PACEMAKER XXX TC PROGRAM EVAL IMPLANTABLE IN PRSN 1 LD PACEMAKER XXX PROGRAM EVAL IMPLANTABLE IN PERSN DUAL LD PACER XXX PROGRAM EVAL IMPLANTABLE IN PERSN DUAL LD PACER XXX TC PROGRAM EVAL IMPLANTABLE IN PERSN DUAL LD PACER XXX PROGRAM EVAL IMPLANTABLE IN PRSN MULTI LD PACER XXX PROGRAM EVAL IMPLANTABLE IN PRSN MULTI LD PACER XXX TC PROGRAM EVAL IMPLANTABLE IN PRSN MULTI LD PACER XXX PROGRAM EVAL IMPLANTABLE IN PERSN 1 LD CARD/DFB XXX PROGRAM EVAL IMPLANTABLE IN PERSN 1 LD CARD/DFB XXX TC PROGRAM EVAL IMPLANTABLE IN PERSN 1 LD CARD/DFB XXX PROGRM EVAL IMPLANTABLE IN PRSN DUAL L CARD/DFB XXX PROGRM EVAL IMPLANTABLE IN PRSN DUAL L CARD/DFB XXX TC PROGRM EVAL IMPLANTABLE IN PRSN DUAL L CARD/DFB XXX PROGRM EVAL IMPLANTABLE IN PRSN MLT LD CARD/DFB XXX PROGRM EVAL IMPLANTABLE IN PRSN MLT LD CARD/DFB XXX TC PROGRM EVAL IMPLANTABLE IN PRSN MLT LD CARD/DFB XXX PROGRAM EVAL IMPLANTABLE DEV IN PRSN ILR SYSTEM XXX PROGRAM EVAL IMPLANTABLE DEV IN PRSN ILR SYSTEM XXX TC PROGRAM EVAL IMPLANTABLE DEV IN PRSN ILR SYSTEM XXX PERI-PX EVAL&PROGRAM IN PRSN PACEMAKER SYSTEM XXX PERI-PX EVAL&PROGRAM IN PRSN PACEMAKER SYSTEM XXX TC PERI-PX EVAL&PROGRAM IN PRSN PACEMAKER SYSTEM XXX PERI-PX EVAL&PROGRAM CARDIOVERTER/DEFIBRILLATOR XXX PERI-PX EVAL&PROGRAM CARDIOVERTER/DEFIBRILLATOR XXX TC PERI-PX EVAL&PROGRAM CARDIOVERTER/DEFIBRILLATOR XXX INTERROGATION EVAL IN PERSON 1/DUAL/MLT LEAD PM XXX INTERROGATION EVAL IN PERSON 1/DUAL/MLT LEAD PM XXX TC INTERROGATION EVAL IN PERSON 1/DUAL/MLT LEAD PM XXX INTERROGATION EVAL F2F 1/DUAL/MLT LEADS CVDFB XXX INTERROGATION EVAL F2F 1/DUAL/MLT LEADS CVDFB XXX TC INTERROGATION EVAL F2F 1/DUAL/MLT LEADS CVDFB XXX INTERROGATION EVAL F2F IMPLANTABLE CV MNTR SYS XXX INTERROGATION EVAL F2F IMPLANTABLE CV MNTR SYS XXX TC INTERROGATION EVAL F2F IMPLANTABLE CV MNTR SYS XXX INTERROGATION EVALUATION IN PERSON ILR SYSTEM XXX INTERROGATION EVALUATION IN PERSON ILR SYSTEM XXX TC INTERROGATION EVALUATION IN PERSON ILR SYSTEM XXX INTERROGATION EVAL IN PERSON WR DEFIBRILLATOR XXX INTERROGATION EVAL IN PERSON WR DEFIBRILLATOR XXX TC INTERROGATION EVAL IN PERSON WR DEFIBRILLATOR XXX TRANSTELEPHONIC RHYTHM STRIP PACEMAKER EVAL XXX TRANSTELEPHONIC RHYTHM STRIP PACEMAKER EVAL XXX Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 267

272 Georgia Workers Compensation Medical Fee Schedule Section X: General Medicine Services MEDICINE , , , , , Medical Fee Schedule Effective April 1, TC TRANSTELEPHONIC RHYTHM STRIP PACEMAKER EVAL XXX INTERROGATION EVAL REMOTE </90 D 1/2/MLT LEAD PM XXX INTERROGATION EVAL REMOTE </90 D 1/2/> LD CVDFB XXX INTERROGATION REMOTE </90 D TECHNICIAN REVIEW XXX INTERROGATION EVAL REMOTE </30 D CV MNTR SYS XXX INTERROGATION EVALUATION REMOTE </30 D ILR SYS XXX INTERROGATION EVAL REMOTE </30 D TECH REVIEW BR XXX COMPLETE TTHRC ECHO CONGENITAL CARDIAC ANOMALY XXX COMPLETE TTHRC ECHO CONGENITAL CARDIAC ANOMALY XXX TC COMPLETE TTHRC ECHO CONGENITAL CARDIAC ANOMALY XXX F-UP/LIMITED TTHRC ECHO CONGENITAL CAR ANOMALY XXX F-UP/LIMITED TTHRC ECHO CONGENITAL CAR ANOMALY XXX TC F-UP/LIMITED TTHRC ECHO CONGENITAL CAR ANOMALY XXX ECHO TTHRC R-T 2D -+M-MODE COMPL SPEC&COLOR DOP XXX ECHO TTHRC R-T 2D -+M-MODE COMPL SPEC&COLOR DOP XXX TC ECHO TTHRC R-T 2D -+M-MODE COMPL SPEC&COLOR DOP XXX TTHRC R-T IMG 2D +-M-MODE REC COMPL XXX TTHRC R-T IMG 2D +-M-MODE REC COMPL XXX TC TTHRC R-T IMG 2D +-M-MODE REC COMPL XXX TTHRC R-T IMG 2D +-M-MODE REC F-UP/LMTD XXX TTHRC R-T IMG 2D +-M-MODE REC F-UP/LMTD XXX TC TTHRC R-T IMG 2D +-M-MODE REC F-UP/LMTD XXX K TEE R-T IMG 2D W/PRB IMG ACQUISJ I&R XXX K TEE R-T IMG 2D W/PRB IMG ACQUISJ I&R XXX K TC TEE R-T IMG 2D W/PRB IMG ACQUISJ I&R XXX K TEE R-T IMG 2D W/PROBE PLMT ONLY XXX K TEE R-T IMG 2D IMG ACQUISJ I&R ONLY XXX K TEE R-T IMG 2D IMG ACQUISJ I&R ONLY XXX K TC TEE R-T IMG 2D IMG ACQUISJ I&R ONLY XXX K TEE CGEN CAR ANOML PRB ACQUISJ I&R XXX K TEE CGEN CAR ANOML PRB ACQUISJ I&R XXX K TC TEE CGEN CAR ANOML PRB ACQUISJ I&R XXX K TEE CGEN CAR ANOML PLMT PRB ONLY XXX K TEE CGEN CAR ANOML IMG ACQUISJ I&R XXX K TEE CGEN CAR ANOML IMG ACQUISJ I&R XXX K TC TEE CGEN CAR ANOML IMG ACQUISJ I&R XXX K TEE PROBE MONITORING ASSMT CAR PUMP FUNCTION XXX K TEE PROBE MONITORING ASSMT CAR PUMP FUNCTION XXX K TC TEE PROBE MONITORING ASSMT CAR PUMP FUNCTION XXX DOP ECHO COMPL ZZZ DOP ECHO COMPL ZZZ TC DOP ECHO COMPL ZZZ DOP ECHO P-W&/OR CONT W/SPECTRAL F-UP/LMTD STD ZZZ DOP ECHO P-W&/OR CONT W/SPECTRAL F-UP/LMTD STD ZZZ TC DOP ECHO P-W&/OR CONT W/SPECTRAL F-UP/LMTD STD ZZZ DOP ECHO COLOR FLO VEL MAPG ZZZ 268 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

273 Section X: General Medicine Services Georgia Workers Compensation Medical Fee Schedule , , , , , MEDICINE Effective April 1, 2011 Medical Fee Schedule DOP ECHO COLOR FLO VEL MAPG 6.09 ZZZ TC DOP ECHO COLOR FLO VEL MAPG ZZZ ECHO TTHRC R-T 2D -+M-MODE COMPLETE REST&STRS XXX ECHO TTHRC R-T 2D -+M-MODE COMPLETE REST&STRS XXX TC ECHO TTHRC R-T 2D -+M-MODE COMPLETE REST&STRS XXX ECHO TTHRC R-T 2D -+M-MODE REST&STRS CONT ECG XXX ECHO TTHRC R-T 2D -+M-MODE REST&STRS CONT ECG XXX TC ECHO TTHRC R-T 2D -+M-MODE REST&STRS CONT ECG XXX USE OF ECHO CONTRAST AGENT DURING STRESS ECHO ZZZ l K RIGHT HEART CATH O2 SATURATION & CARDIAC OUTPUT l K RIGHT HEART CATH O2 SATURATION & CARDIAC OUTPUT l K TC RIGHT HEART CATH O2 SATURATION & CARDIAC OUTPUT l K L HRT CATH W/NJX L VENTRICULOGRAPHY IMG S&I l K L HRT CATH W/NJX L VENTRICULOGRAPHY IMG S&I l K TC L HRT CATH W/NJX L VENTRICULOGRAPHY IMG S&I l K R & L HRT CATH W/NJX L VENTRICULOG IMG S&I l K R & L HRT CATH W/NJX L VENTRICULOG IMG S&I l K TC R & L HRT CATH W/NJX L VENTRICULOG IMG S&I l K CATH PLMT & NJX CORONARY ART ANGIO IMG S&I l K CATH PLMT & NJX CORONARY ART ANGIO IMG S&I l K TC CATH PLMT & NJX CORONARY ART ANGIO IMG S&I l K CATH PLMT & NJX CORONARY ART/GRFT ANGIO IMG S&I l K CATH PLMT & NJX CORONARY ART/GRFT ANGIO IMG S&I l K TC CATH PLMT & NJX CORONARY ART/GRFT ANGIO IMG S&I l K CATH PLMT R HRT & ARTS W/NJX & ANGIO IMG S&I l K CATH PLMT R HRT & ARTS W/NJX & ANGIO IMG S&I l K TC CATH PLMT R HRT & ARTS W/NJX & ANGIO IMG S&I l K CATH PLMT R HRT/ARTS/GRFTS W/NJX&ANGIO IMG S&I l K CATH PLMT R HRT/ARTS/GRFTS W/NJX&ANGIO IMG S&I l K TC CATH PLMT R HRT/ARTS/GRFTS W/NJX&ANGIO IMG S&I l K CATH PLMT L HRT & ARTS W/NJX & ANGIO IMG S&I l K CATH PLMT L HRT & ARTS W/NJX & ANGIO IMG S&I l K TC CATH PLMT L HRT & ARTS W/NJX & ANGIO IMG S&I l K CATH PLMT L HRT/ARTS/GRFTS WNJX & ANGIO IMG S&I l K CATH PLMT L HRT/ARTS/GRFTS WNJX & ANGIO IMG S&I l K TC CATH PLMT L HRT/ARTS/GRFTS WNJX & ANGIO IMG S&I l K R & L HRT CATH WINJX HRT ART& L VENTR IMG S&I l K R & L HRT CATH WINJX HRT ART& L VENTR IMG S&I l K TC R & L HRT CATH WINJX HRT ART& L VENTR IMG S&I l K R&L HRT CATH W/INJEC HRT ART/GRFT&L VENT IMG S&I l K R&L HRT CATH W/INJEC HRT ART/GRFT&L VENT IMG S&I l K TC R&L HRT CATH W/INJEC HRT ART/GRFT&L VENT IMG S&I l + K LEFT HEART CATH BY TRANSEPTAL PUNCTURE ZZZ l + K MEDICATION ADMIN & HEMODYNAMIC MEASURMENT ZZZ l + K PHYSIOLOGIC EXERCISE STUDY & HEMODYNAMIC MEASURE ZZZ l + K PHYSIOLOGIC EXERCISE STUDY & HEMODYNAMIC MEASURE ZZZ Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 269

274 Georgia Workers Compensation Medical Fee Schedule Section X: General Medicine Services MEDICINE , , , , , Medical Fee Schedule Effective April 1, 2011 l + K TC PHYSIOLOGIC EXERCISE STUDY & HEMODYNAMIC MEASURE ZZZ * INSERTION FLOW DIRECTED CATHETER FOR MONITORING K ENDOMYOCARDIAL BIOPSY K ENDOMYOCARDIAL BIOPSY K TC ENDOMYOCARDIAL BIOPSY K R HRT CATHETERIZATION CONGENITAL CARDIAC ANOMALY K R HRT CATHETERIZATION CONGENITAL CARDIAC ANOMALY K TC R HRT CATHETERIZATION CONGENITAL CARDIAC ANOMALY CMBN R HRT & RETROGRADE L HRT CATHJ CGEN ANOMALY CMBN R HRT & RETROGRADE L HRT CATHJ CGEN ANOMALY TC CMBN R HRT & RETROGRADE L HRT CATHJ CGEN ANOMALY CMBN R HRT T-SEPTAL L HRT CATHJ NTC SEPTUM CGEN CMBN R HRT T-SEPTAL L HRT CATHJ NTC SEPTUM CGEN TC CMBN R HRT T-SEPTAL L HRT CATHJ NTC SEPTUM CGEN CMBN R HRT T-SEPTAL L HRT CATHJ SEPTAL OPNG CGEN CMBN R HRT T-SEPTAL L HRT CATHJ SEPTAL OPNG CGEN TC CMBN R HRT T-SEPTAL L HRT CATHJ SEPTAL OPNG CGEN K INDIC DIL STD ARTL&/OR VEN CATHJ W/OUTP MEAS K INDIC DIL STD ARTL&/OR VEN CATHJ W/OUTP MEAS K TC INDIC DIL STD ARTL&/OR VEN CATHJ W/OUTP MEAS K INDIC DIL STD ARTL&/OR VEN CATHJ SBSQ OUTP MEAS K INDIC DIL STD ARTL&/OR VEN CATHJ SBSQ OUTP MEAS K TC INDIC DIL STD ARTL&/OR VEN CATHJ SBSQ OUTP MEAS l + K NJX SEL HRT ART CONGENITAL HRT CATH W/S&I ZZZ l + K NJX SEL HRT ART/GRFT CONGENITAL HRT CATH W/S&I ZZZ l + K NJX SEL L VENT/ATRIAL ANGIO HRT CATH W/S&I ZZZ l + K NJX SEL R VENT/ATRIAL ANGIO HRT CATH W/S&I ZZZ l + K NJX SUPRAVALV AORTOG HRT CATH W/S&I ZZZ l + K NJX PULMONARY ANGIO HRT CATH W/S&I ZZZ + K IV DOP VEL&/OR PRESS C/FLO RSRV MEAS 1ST VSL ZZZ + K IV DOP VEL&/OR PRESS C/FLO RSRV MEAS 1ST VSL ZZZ + K TC IV DOP VEL&/OR PRESS C/FLO RSRV MEAS 1ST VSL ZZZ + K IV DOP VEL&/OR PRESS C/FLO RSRV MEAS ADDL VSL ZZZ + K IV DOP VEL&/OR PRESS C/FLO RSRV MEAS ADDL VSL ZZZ + K TC IV DOP VEL&/OR PRESS C/FLO RSRV MEAS ADDL VSL ZZZ PRQ TCAT CLSR CGEN INTRATRL COMUNICAJ W/IMPLT PRQ TCAT CLSR CGEN VENTR SEPTAL DFCT W/IMPLT * BUNDLE OF HIS RECORDING * BUNDLE OF HIS RECORDING * TC BUNDLE OF HIS RECORDING * INTRA-ATRIAL RECORDING * INTRA-ATRIAL RECORDING * TC INTRA-ATRIAL RECORDING * R VENTRICULAR REC * R VENTRICULAR REC * TC R VENTRICULAR REC CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

275 Section X: General Medicine Services Georgia Workers Compensation Medical Fee Schedule , , , , , MEDICINE Effective April 1, 2011 Medical Fee Schedule + K INTRA-VNTR MAPG TCHYCAR SIT W/CATH MNPJ ZZZ + K INTRA-VNTR MAPG TCHYCAR SIT W/CATH MNPJ ZZZ + K TC INTRA-VNTR MAPG TCHYCAR SIT W/CATH MNPJ ZZZ * INTRA-ATRIAL PACING * INTRA-ATRIAL PACING * TC INTRA-ATRIAL PACING * INTRAVENTRICAL PACING * INTRAVENTRICAL PACING * TC INTRAVENTRICAL PACING K ICAR EPHYS 3-DIMENSIONAL MAPG ZZZ + K ICAR EPHYS 3-DIMENSIONAL MAPG ZZZ + K TC ICAR EPHYS 3-DIMENSIONAL MAPG ZZZ * K ESOPHGL REC ATR EGRM +-VENTR EGRM * K ESOPHGL REC ATR EGRM +-VENTR EGRM * K TC ESOPHGL REC ATR EGRM +-VENTR EGRM * K ESOPHGL REC ATR EGRM +-VENTR EGRM W/PACG * K ESOPHGL REC ATR EGRM +-VENTR EGRM W/PACG * K TC ESOPHGL REC ATR EGRM +-VENTR EGRM W/PACG * K INDCTJ ARRHYT ELEC PACG * K INDCTJ ARRHYT ELEC PACG * K TC INDCTJ ARRHYT ELEC PACG K COMPRE ELECTROPHYSIOLOGIC W/O ARRHYT INDUCTION K COMPRE ELECTROPHYSIOLOGIC W/O ARRHYT INDUCTION K TC COMPRE ELECTROPHYSIOLOGIC W/O ARRHYT INDUCTION K COMPRE ELECTROPHYSIOLOGIC ARRHYTHMIA INDUCTION K COMPRE ELECTROPHYSIOLOGIC ARRHYTHMIA INDUCTION K TC COMPRE ELECTROPHYSIOLOGIC ARRHYTHMIA INDUCTION K COMPRE ELECTROPHYSIOLOGIC W/L ATR PAC/REC ZZZ + K COMPRE ELECTROPHYSIOLOGIC W/L ATR PAC/REC ZZZ + K TC COMPRE ELECTROPHYSIOLOGIC W/L ATR PAC/REC ZZZ + K COMPRE ELECTROPHYSIOLOGIC W/L VENTR PAC/REC ZZZ + K COMPRE ELECTROPHYSIOLOGIC W/L VENTR PAC/REC ZZZ + K TC COMPRE ELECTROPHYSIOLOGIC W/L VENTR PAC/REC ZZZ PROGRAMMED STIMJ&PACG AFTER IV DRUG NFS ZZZ PROGRAMMED STIMJ&PACG AFTER IV DRUG NFS ZZZ TC PROGRAMMED STIMJ&PACG AFTER IV DRUG NFS ZZZ K ELECTROPHYSIOLOGIC FOLLOW-UP W/PAC/REC W/ARRHYT K ELECTROPHYSIOLOGIC FOLLOW-UP W/PAC/REC W/ARRHYT K TC ELECTROPHYSIOLOGIC FOLLOW-UP W/PAC/REC W/ARRHYT * INTRAOP EPICAR&ENDOCAR PACG&MAPG * INTRAOP EPICAR&ENDOCAR PACG&MAPG * TC INTRAOP EPICAR&ENDOCAR PACG&MAPG K EPHYS EVAL PACG CVDFB LDS INITIAL IMPLAN/REPLACE K EPHYS EVAL PACG CVDFB LDS INITIAL IMPLAN/REPLACE K TC EPHYS EVAL PACG CVDFB LDS INITIAL IMPLAN/REPLACE K EPHYS EVAL PACG CVDFB LDS W/TSTG OF PULSE GEN Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 271

276 Georgia Workers Compensation Medical Fee Schedule Section X: General Medicine Services MEDICINE , , , , , Medical Fee Schedule Effective April 1, 2011 K EPHYS EVAL PACG CVDFB LDS W/TSTG OF PULSE GEN K TC EPHYS EVAL PACG CVDFB LDS W/TSTG OF PULSE GEN K EPHYS EVAL PACG CVDFB PRGRMG/REPRGRMG PARAMETERS K EPHYS EVAL PACG CVDFB PRGRMG/REPRGRMG PARAMETERS K TC EPHYS EVAL PACG CVDFB PRGRMG/REPRGRMG PARAMETERS K ICAR CATHETER ABLATION ATRIOVENTR NODE FUNCTION K ICAR CATH ABLTJ ARRHYTGNIC FOC SUPVENTR TCHYCAR K ICAR CATH ABLATION ARRHYTGNIC FOC VENTR TCHYCAR CARDIOVASCULAR FUNCTION EVAL W/TILT TABLE W/MNTR CARDIOVASCULAR FUNCTION EVAL W/TILT TABLE W/MNTR TC CARDIOVASCULAR FUNCTION EVAL W/TILT TABLE W/MNTR ICE DURING THER/DX IVNTJ INCL IMG S&I ZZZ ICE DURING THER/DX IVNTJ INCL IMG S&I ZZZ TC ICE DURING THER/DX IVNTJ INCL IMG S&I ZZZ PRPH ARTL DISEASE RHAB PR SESS XXX BIOMPEDANCE-DERIVED PHYSIOLOGIC CV ANALYSIS XXX BIOMPEDANCE-DERIVED PHYSIOLOGIC CV ANALYSIS XXX TC BIOMPEDANCE-DERIVED PHYSIOLOGIC CV ANALYSIS XXX PLETHYSMOGRAPY TOT BDY W/I&R XXX PLETHYSMOGRAPY TOT BDY W/I&R XXX TC PLETHYSMOGRAPY TOT BDY W/I&R XXX PLETHYSMOGRAPY TOT BDY TRCG ONLY W/O I&R XXX PLETHYSMOGRAPY TOT BDY I&R ONLY XXX ELEC ALYS ANTITACHYCARDIA PM SYSTEM ELEC ALYS ANTITACHYCARDIA PM SYSTEM TC ELEC ALYS ANTITACHYCARDIA PM SYSTEM TEMPRATURE GRADIENT STD XXX TEMPRATURE GRADIENT STD XXX TC TEMPRATURE GRADIENT STD 2.77 XXX ST SET-UP&PRGRMG BY PHYS OF WEARABLE CVDFB BR XXX INTERROGATION VAD IN PRSON W/PHYSICIAN ANALYSIS XXX DETER VEN PRESS XXX DETER VEN PRESS XXX TC DETER VEN PRESS 1.11 XXX AMBL BLD PRESS W/TAPE&/DISK 24+ HR ALYS I&R XXX AMBL BLD PRESS W/TAPE&/DISK 24+ HR + REC ONLY XXX AMBL BLD PRESS W/TAPE/DISK 24+ HR ALYS W/REPRT XXX AMBL BLD PRESS TAPE&/DISK 24+ HR PHYS REV W/I&R XXX OUTPATIENT CARDIAC REHAB W/O CONT ECG MONITOR OUTPATIENT CARDIAC REHAB W/CONT ECG MONITORING UNLIS CV SVC/PX BR XXX N-INVAS PHYSIOLOGIC STD XTRC ART COMPL BI STD XXX N-INVAS PHYSIOLOGIC STD XTRC ART COMPL BI STD XXX TC N-INVAS PHYSIOLOGIC STD XTRC ART COMPL BI STD XXX DUP-SCAN XTRC ART COMPL BI STD XXX DUP-SCAN XTRC ART COMPL BI STD XXX 272 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

277 Section X: General Medicine Services Georgia Workers Compensation Medical Fee Schedule , , , , , MEDICINE Effective April 1, 2011 Medical Fee Schedule TC DUP-SCAN XTRC ART COMPL BI STD XXX DUP-SCAN XTRC ART UNI/LMTD STD XXX DUP-SCAN XTRC ART UNI/LMTD STD XXX TC DUP-SCAN XTRC ART UNI/LMTD STD XXX TCD STD ICRA ART COMPL STD XXX TCD STD ICRA ART COMPL STD XXX TC TCD STD ICRA ART COMPL STD XXX TCD STD ICRA ART LMTD STD XXX TCD STD ICRA ART LMTD STD XXX TC TCD STD ICRA ART LMTD STD XXX TCD STD ICRA ART VASOREACTV STD XXX TCD STD ICRA ART VASOREACTV STD XXX TC TCD STD ICRA ART VASOREACTV STD XXX TCD STD ICRA ART EMBOLI DETCJ W/O IV MBUBB NJX XXX TCD STD ICRA ART EMBOLI DETCJ W/O IV MBUBB NJX XXX TC TCD STD ICRA ART EMBOLI DETCJ W/O IV MBUBB NJX XXX TCD STD ICRA ART EMBOLI DETCJ W/IV MBUBB NJX XXX TCD STD ICRA ART EMBOLI DETCJ W/IV MBUBB NJX XXX TC TCD STD ICRA ART EMBOLI DETCJ W/IV MBUBB NJX XXX s NON-INVAS PHYSIOLOGIC STD EXTREMITY ART 2 LEVEL XXX s NON-INVAS PHYSIOLOGIC STD EXTREMITY ART 2 LEVEL XXX s TC NON-INVAS PHYSIOLOGIC STD EXTREMITY ART 2 LEVEL XXX s NON-INVASIVE PHYSIOLOGIC STUDY EXTREMITY 3 LEVLS XXX s NON-INVASIVE PHYSIOLOGIC STUDY EXTREMITY 3 LEVLS XXX s TC NON-INVASIVE PHYSIOLOGIC STUDY EXTREMITY 3 LEVLS XXX s N-INVAS PHYSIOLOGIC STD LXTR ART COMPL BI XXX s N-INVAS PHYSIOLOGIC STD LXTR ART COMPL BI XXX s TC N-INVAS PHYSIOLOGIC STD LXTR ART COMPL BI XXX DUP-SCAN LXTR ART/ARTL BPGS COMPL BI STD XXX DUP-SCAN LXTR ART/ARTL BPGS COMPL BI STD XXX TC DUP-SCAN LXTR ART/ARTL BPGS COMPL BI STD XXX DUP-SCAN LXTR ART/ARTL BPGS UNI/LMTD STD XXX DUP-SCAN LXTR ART/ARTL BPGS UNI/LMTD STD XXX TC DUP-SCAN LXTR ART/ARTL BPGS UNI/LMTD STD XXX DUP-SCAN UXTR ART/ARTL BPGS COMPL BI STD XXX DUP-SCAN UXTR ART/ARTL BPGS COMPL BI STD XXX TC DUP-SCAN UXTR ART/ARTL BPGS COMPL BI STD XXX DUP-SCAN UXTR ART/ARTL BPGS UNI/LMTD STD XXX DUP-SCAN UXTR ART/ARTL BPGS UNI/LMTD STD XXX TC DUP-SCAN UXTR ART/ARTL BPGS UNI/LMTD STD XXX N-INVAS PHYSIOLOGIC STD XTR VEINS COMPL BI STD XXX N-INVAS PHYSIOLOGIC STD XTR VEINS COMPL BI STD XXX TC N-INVAS PHYSIOLOGIC STD XTR VEINS COMPL BI STD XXX DUP-SCAN XTR VEINS COMPL BI STD XXX DUP-SCAN XTR VEINS COMPL BI STD XXX TC DUP-SCAN XTR VEINS COMPL BI STD XXX Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 273

278 Georgia Workers Compensation Medical Fee Schedule Section X: General Medicine Services MEDICINE , , , , , Medical Fee Schedule Effective April 1, DUP-SCAN XTR VEINS UNI/LMTD STD XXX DUP-SCAN XTR VEINS UNI/LMTD STD XXX TC DUP-SCAN XTR VEINS UNI/LMTD STD XXX DUP-SCAN ARTL FLO ABDL/PEL/SCROT&/RPR ORGN COMPL XXX DUP-SCAN ARTL FLO ABDL/PEL/SCROT&/RPR ORGN COMPL XXX TC DUP-SCAN ARTL FLO ABDL/PEL/SCROT&/RPR ORGN COMPL XXX DUP-SCAN ARTL FLO ABDL/PEL/SCROT&/RPR ORGN LMTD XXX DUP-SCAN ARTL FLO ABDL/PEL/SCROT&/RPR ORGN LMTD XXX TC DUP-SCAN ARTL FLO ABDL/PEL/SCROT&/RPR ORGN LMTD XXX DUP-SCAN AORTA IVC ILIAC VASCL/BPGS COMPL XXX DUP-SCAN AORTA IVC ILIAC VASCL/BPGS COMPL XXX TC DUP-SCAN AORTA IVC ILIAC VASCL/BPGS COMPL XXX DUP-SCAN AORTA IVC ILIAC VASCL/BPGS UNI/LMTD XXX DUP-SCAN AORTA IVC ILIAC VASCL/BPGS UNI/LMTD XXX TC DUP-SCAN AORTA IVC ILIAC VASCL/BPGS UNI/LMTD XXX DUP-SCAN ARTL INFL&VEN O/F PEN VSL COMPL XXX DUP-SCAN ARTL INFL&VEN O/F PEN VSL COMPL XXX TC DUP-SCAN ARTL INFL&VEN O/F PEN VSL COMPL XXX DUP-SCAN ARTL INFL&VEN O/F PEN VSL F-UP/LMTD STD XXX DUP-SCAN ARTL INFL&VEN O/F PEN VSL F-UP/LMTD STD XXX TC DUP-SCAN ARTL INFL&VEN O/F PEN VSL F-UP/LMTD STD XXX IMPLANT WIRELESS PRESS SENSOR STUDY ANEURYSM SAC XXX DUP-SCAN OF HEMODIALYSIS ACCESS XXX DUP-SCAN OF HEMODIALYSIS ACCESS XXX TC DUP-SCAN OF HEMODIALYSIS ACCESS XXX VENTILATION ASSIST & MGMT INPATIENT 1ST DAY XXX VENTILATION ASSIST & MGMT INPATIENT EA SBSQ DAY XXX VENTILATION ASSIST & MGMT NURSING FAC PR DAY XXX HOME VENTILATOR MGMT CARE OVERSIGHT 30 MIN/> XXX SPMTRY W/VC EXPIRATORY FLO +-MXML VOL VNTJ XXX SPMTRY W/VC EXPIRATORY FLO +-MXML VOL VNTJ XXX TC SPMTRY W/VC EXPIRATORY FLO +-MXML VOL VNTJ XXX K MEAS SPIROMTRC FORCD EXPIRATORY FLO INFANT-2 YR XXX K MEAS SPIRO FORCD EXP FLO PRE&POST BRONCH INF-2Y XXX K MEAS LUNG VOLUMES INFANT OR CHILD THRU 2 YRS XXX PT-INITIATE SPIROMETRIC RECORDING&PHYS R&I XXX PT-INITIATE SPIROMETRIC RECORDING&PHYS R&I XXX TC PT-INITIATE SPIROMETRIC RECORDING&PHYS R&I XXX PATIENT-INITIATED SPIROMETRIC RECORDING XXX PATIENT-INITIATED SPIROMETRIC PHYS R&I ONLY XXX BRNCDILAT RSPSE SPMTRY PRE&POST-BRNCDILAT ADMN XXX BRNCDILAT RSPSE SPMTRY PRE&POST-BRNCDILAT ADMN XXX TC BRNCDILAT RSPSE SPMTRY PRE&POST-BRNCDILAT ADMN XXX BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT XXX BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT XXX TC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT XXX 274 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

279 Section X: General Medicine Services Georgia Workers Compensation Medical Fee Schedule , , , , , MEDICINE Effective April 1, 2011 Medical Fee Schedule VC TOT SPX XXX VC TOT SPX 6.09 XXX TC VC TOT SPX XXX MAX BRTHING CAP MXML VOL VNTJ XXX MAX BRTHING CAP MXML VOL VNTJ 8.86 XXX TC MAX BRTHING CAP MXML VOL VNTJ XXX FUNCTIONAL RESIDUAL CAPACITY OR RESIDUAL VOLUME XXX FUNCTIONAL RESIDUAL CAPACITY OR RESIDUAL VOLUME XXX TC FUNCTIONAL RESIDUAL CAPACITY OR RESIDUAL VOLUME XXX EXP GAS COLLJ QUAN 1 PX SPX XXX EXP GAS COLLJ QUAN 1 PX SPX 8.86 XXX TC EXP GAS COLLJ QUAN 1 PX SPX XXX THRC GAS VOL XXX THRC GAS VOL 9.97 XXX TC THRC GAS VOL XXX DETER MALDISTRIBJ OF INSPIRED GAS N WSHOT CURVE XXX DETER MALDISTRIBJ OF INSPIRED GAS N WSHOT CURVE XXX TC DETER MALDISTRIBJ OF INSPIRED GAS N WSHOT CURVE XXX DETER RESIST TO AIRFLO OSCILLATORY/PLETHYSMOGRAP XXX DETER RESIST TO AIRFLO OSCILLATORY/PLETHYSMOGRAP XXX TC DETER RESIST TO AIRFLO OSCILLATORY/PLETHYSMOGRAP XXX DETER AIRWY CLOSING VOL 1 BRTH TSTS XXX DETER AIRWY CLOSING VOL 1 BRTH TSTS XXX TC DETER AIRWY CLOSING VOL 1 BRTH TSTS XXX RESPIR FLO VOL LOOP XXX RESPIR FLO VOL LOOP XXX TC RESPIR FLO VOL LOOP XXX BRTHING RSPSE CO2 CO2 RSPSE CURVE XXX BRTHING RSPSE CO2 CO2 RSPSE CURVE XXX TC BRTHING RSPSE CO2 CO2 RSPSE CURVE XXX BRTHING RSPSE HYPOXIA HYPOXIA RSPSE CURVE XXX BRTHING RSPSE HYPOXIA HYPOXIA RSPSE CURVE XXX TC BRTHING RSPSE HYPOXIA HYPOXIA RSPSE CURVE XXX HAST W/PHYS I&R XXX HAST W/PHYS I&R XXX TC HAST W/PHYS I&R XXX HAST W/PHYS I&R W/SUPPL O2 TITRJ XXX HAST W/PHYS I&R W/SUPPL O2 TITRJ XXX TC HAST W/PHYS I&R W/SUPPL O2 TITRJ XXX * INTRAPULMONARY SURFACTANT ADMINISTRATION XXX PULM STRS TSTG SMPL XXX PULM STRS TSTG SMPL XXX TC PULM STRS TSTG SMPL XXX PULM STRS TSTG CPLX XXX PULM STRS TSTG CPLX XXX TC PULM STRS TSTG CPLX XXX Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 275

280 Georgia Workers Compensation Medical Fee Schedule Section X: General Medicine Services MEDICINE , , , , , Medical Fee Schedule Effective April 1, PRESSURIZED/NONPRESSURIZED INHALATION TREATMENT XXX PENTAMIDINE AERSL INHALATION PNEUMOCYSTIS/PROPH XXX CONTINUOUS INHALATION TREATMENT 1ST HR XXX CONTINUOUS INHALATION TREATMENT EA ADDL HR XXX CPAP VNTJ CPAP INITIATION&MGMT XXX CNP VNTJ CNP INITIATION&MGMT XXX DEMO&/EVAL OF PT UTILIZ AERSL GEN/NEB/INHLR/IPPB XXX MNPJ CH WALL FACILITATE LNG FUNCJ 1 DEMO&/EVAL XXX MNPJ CH FACILITATE LNG FUNCJ SBSQ XXX O2 UPTK EXP GAS ALYS REST&XERS DIR SMPL XXX O2 UPTK EXP GAS ALYS REST&XERS DIR SMPL XXX TC O2 UPTK EXP GAS ALYS REST&XERS DIR SMPL XXX O2 UPTK EXP GAS ALYS W/CO2 OUTPUT % O2 XTRC XXX O2 UPTK EXP GAS ALYS W/CO2 OUTPUT % O2 XTRC XXX TC O2 UPTK EXP GAS ALYS W/CO2 OUTPUT % O2 XTRC XXX O2 UPTK EXP GAS ALYS REST INDIR SPX XXX O2 UPTK EXP GAS ALYS REST INDIR SPX 6.09 XXX TC O2 UPTK EXP GAS ALYS REST INDIR SPX XXX CARBON MONOXIDE DIFFW/CAP XXX CARBON MONOXIDE DIFFW/CAP XXX TC CARBON MONOXIDE DIFFW/CAP XXX MEMB DIFFUSION CAP XXX MEMB DIFFUSION CAP XXX TC MEMB DIFFUSION CAP XXX PULM COMPLIANCE STD XXX PULM COMPLIANCE STD XXX TC PULM COMPLIANCE STD XXX NONINVASIVE EAR/PULSE OXIMETRY SINGLE DETER 4.43 XXX NONINVASIVE EAR/PULSE OXIMETRY MULTIPLE DETER 7.20 XXX NONINVASIVE EAR/PULSE OXIMETRY OVERNIGHT MONITOR XXX CARBON DIOXIDE EXP GAS DETER INFRARED ANALYZER XXX CARBON DIOXIDE EXP GAS DETER INFRARED ANALYZER 7.75 XXX TC CARBON DIOXIDE EXP GAS DETER INFRARED ANALYZER XXX CIRCADIAN RESPIR PATTERN REC HR INFT BR XXX PED APNEA MONITOR ATTACHMENT PHYS I&R BR YYY PED APNEA MONITOR ATTACHMENT BR YYY PED APNEA MONITOR ANALYSES COMPUTER BR YYY PED APNEA MONITOR PHYSICIAN REVIEW BR YYY UNLIS PULM SVC/PX BR XXX PERCUTANEOUS TESTS W/ALLERGENIC EXTRACTS XXX PERQ TSTS SEQL&INCRL RX/BIOLOGIC/VNM IMMT RXN XXX NITRIC OXIDE EXPIRED GAS DETERMINATION XXX IQ TSTS SEQL&INCRL RX/BIOLOGIC/VNM IMMT RXN XXX INTRACUTANEOUS TESTS W/ALLERGENIC EXTRACTS XXX INTRACUTANEOUS TESTS W/ALLERGENIC XTRCS AIRBORNE 7.75 XXX IQ TSTS W/ALLGIC XTRCS DLYD TYP RXN W/READING XXX 276 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

281 Section X: General Medicine Services Georgia Workers Compensation Medical Fee Schedule , , , , , MEDICINE Effective April 1, 2011 Medical Fee Schedule PATCH/APPL TST SPEC NUMBER TSTS 9.97 XXX PHOTO PATCH TST SPEC NUMBER TSTS XXX PHOTO TSTS XXX OPH MUC MEMB TSTS XXX DIR NSL MUC MEMB TST XXX INHLJ BRNCL CHALLENGE TSTG W/HISTAM/METHACHOL XXX INHLJ BRNCL CHALLENGE TSTG W/AGS/GASES XXX INGESTION CHALLENGE TEST XXX PROF SVCS ALLG IMMNTX X W/PRV ALLGIC XTRCS 1 NJX XXX PROF SVCS ALLG IMMNTX X W/PRV ALLGIC XTRCS NJXS XXX PROF SVCS ALLG IMMNTX W/PRV ALLGIC XTRC 1 NJX XXX PROF SVCS ALLG IMMNTX W/PRV ALLGIC XTRC 2/> NJXS XXX PROF SVCS ALLG IMMNTX W/PRV XTRC 1 STING INSECT XXX PROF SVCS ALLG IMMNTX W/PRV XTRC 2 STING INSECT XXX PROF SVCS ALLG IMMNTX W/PRV ALLGIC XTRC 3 INSECT XXX PROF SVCS ALLG IMMNTX W/PRV ALLGIC XTRC 4 INSECT XXX PROF SVCS ALLG IMMNTX W/PRV ALLGIC XTRC 5 INSECT XXX PREPJ& ANTIGEN PRV ALLERGEN IMMUNOTHERAPY 1 DOSE XXX PREPJ& ANTIGEN ALLERGEN IMMUNOTHERAPY 1 INSECT XXX PREPJ& ANTIGEN ALLERGEN IMMUNOTHERAPY 2 INSECTS XXX PREPJ& ANTIGEN ALLERGEN IMMUNOTHERAPY 3 INSECTS XXX PREPJ& ANTIGEN ALLERGEN IMMUNOTHERAPY 4 INSECTS XXX PREPJ& ANTIGEN ALLERGEN IMMUNOTHERAPY 5 INSECTS XXX PREPJ& ALLERGEN IMMUNOTHERAPY 1/MLT ANTIGEN XXX PREPJ& ANTIGEN ALLERGEN IMMUNOTHERAPY WHL INSECT XXX RAPID DESENSITIZATION PX EA HR XXX UNLIS ALL/CLINICAL IMMUNOLOGIC SVC/PX BR XXX GLUC MNTR CONT REC FROM INTERSTITIAL TISS FLUID XXX GLUC MNTR CONT REC FROM NTRSTL TISS FLU I&R XXX l # SLP STDY UNATND W/HRT RATE/O2 SAT/RESP/SLP TIME XXX l # SLP STDY UNATND W/HRT RATE/O2 SAT/RESP/SLP TIME XXX l # TC SLP STDY UNATND W/HRT RATE/O2 SAT/RESP/SLP TIME XXX l # SLP STDY UNATND W/MIN HRT RATE/O2 SAT/RESP ANAL XXX l # SLP STDY UNATND W/MIN HRT RATE/O2 SAT/RESP ANAL XXX l # TC SLP STDY UNATND W/MIN HRT RATE/O2 SAT/RESP ANAL XXX ACTIGRAPHY TESTING RECORDING ANALYSIS I&R XXX ACTIGRAPHY TESTING RECORDING ANALYSIS I&R XXX TC ACTIGRAPHY TESTING RECORDING ANALYSIS I&R XXX MLT SLEEP LATENCY/MAINT OF WAKEFULNESS TSTG XXX MLT SLEEP LATENCY/MAINT OF WAKEFULNESS TSTG XXX TC MLT SLEEP LATENCY/MAINT OF WAKEFULNESS TSTG XXX SLEEP STD AIRFLOW HRT RATE&O2 SAT EFFORT UNATTN XXX SLEEP STD AIRFLOW HRT RATE&O2 SAT EFFORT UNATTN XXX TC SLEEP STD AIRFLOW HRT RATE&O2 SAT EFFORT UNATTN XXX SLEEP STD REC VNTJ RESPIR ECG/HRT RATE&O2 ATTN XXX SLEEP STD REC VNTJ RESPIR ECG/HRT RATE&O2 ATTN XXX Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 277

282 Georgia Workers Compensation Medical Fee Schedule Section X: General Medicine Services MEDICINE , , , , , Medical Fee Schedule Effective April 1, TC SLEEP STD REC VNTJ RESPIR ECG/HRT RATE&O2 ATTN XXX POLYSM SLEEP STAGING 1-3 ADDL PARAM XXX POLYSM SLEEP STAGING 1-3 ADDL PARAM XXX TC POLYSM SLEEP STAGING 1-3 ADDL PARAM XXX POLYSM SLEEP STAGING 4/> ADDL PARAM XXX POLYSM SLEEP STAGING 4/> ADDL PARAM XXX TC POLYSM SLEEP STAGING 4/> ADDL PARAM XXX POLYSM SLEEP STAGING 4/> ADDL PARAM W/CPAP TX XXX POLYSM SLEEP STAGING 4/> ADDL PARAM W/CPAP TX XXX TC POLYSM SLEEP STAGING 4/> ADDL PARAM W/CPAP TX XXX EEG EXTND MNTR MIN XXX EEG EXTND MNTR MIN XXX TC EEG EXTND MNTR MIN XXX EEG EXTND MNTR > 1 HR XXX EEG EXTND MNTR > 1 HR XXX TC EEG EXTND MNTR > 1 HR XXX EEG W/REC AWAKE&DROWSY XXX EEG W/REC AWAKE&DROWSY XXX TC EEG W/REC AWAKE&DROWSY XXX EEG W/REC AWAKE&ASLEEP XXX EEG W/REC AWAKE&ASLEEP XXX TC EEG W/REC AWAKE&ASLEEP XXX EEG REC COMA/SLEEP ONLY XXX EEG REC COMA/SLEEP ONLY XXX TC EEG REC COMA/SLEEP ONLY XXX EEG CERE DEATH EVAL ONLY XXX EEG CERE DEATH EVAL ONLY XXX TC EEG CERE DEATH EVAL ONLY XXX EEG ALL NIGHT REC XXX EEG ALL NIGHT REC XXX TC EEG ALL NIGHT REC XXX ELECTROCORTICOGRAM SURG SPX XXX ELECTROCORTICOGRAM SURG SPX XXX TC ELECTROCORTICOGRAM SURG SPX XXX INSERTION SPHENOIDAL ELECTRODES EEG RECORDING XXX MUSC TSTG MNL W/REPRT XTR EX HAND/TRNK XXX MUSC TSTG MNL W/REPRT HAND +-CMPRSN NML SIDE XXX MUSC TSTG MNL W/REPRT TOT EVAL BDY EX HANDS XXX MUSC TSTG MNL W/REPRT TOT EVAL BDY W/HANDS XXX ROM MEAS&REPRT EA XTR EX HAND/EA TRNK SCTJ SPINE XXX ROM MEAS&REPRT HAND +-CMPRSN NML SIDE XXX s CHOLINESTERASE INHIBITOR CHALLENGE TEST XXX NDL EMG 1 XTR +-RELATED PARASPI AREAS XXX NDL EMG 1 XTR +-RELATED PARASPI AREAS XXX TC NDL EMG 1 XTR +-RELATED PARASPI AREAS XXX NDL EMG 2 XTR +-RELATED PARASPI AREAS XXX 278 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

283 Section X: General Medicine Services Georgia Workers Compensation Medical Fee Schedule , , , , , MEDICINE Effective April 1, 2011 Medical Fee Schedule NDL EMG 2 XTR +-RELATED PARASPI AREAS XXX TC NDL EMG 2 XTR +-RELATED PARASPI AREAS XXX NDL EMG 3 XTR +-RELATED PARASPI AREAS XXX NDL EMG 3 XTR +-RELATED PARASPI AREAS XXX TC NDL EMG 3 XTR +-RELATED PARASPI AREAS XXX NDL EMG 4 XTR +-RELATED PARASPI AREAS XXX NDL EMG 4 XTR +-RELATED PARASPI AREAS XXX TC NDL EMG 4 XTR +-RELATED PARASPI AREAS XXX NDL EMG LARX XXX NDL EMG LARX XXX TC NDL EMG LARX XXX NDL EMG HEMIDPHRM XXX NDL EMG HEMIDPHRM XXX TC NDL EMG HEMIDPHRM XXX NDL EMG CRNL NRV SUPPLIED MUSC UNI XXX NDL EMG CRNL NRV SUPPLIED MUSC UNI XXX TC NDL EMG CRNL NRV SUPPLIED MUSC UNI XXX NDL EMG CRNL NRV SUPPLIED MUSC BI XXX NDL EMG CRNL NRV SUPPLIED MUSC BI XXX TC NDL EMG CRNL NRV SUPPLIED MUSC BI XXX NDL EMG THRC PARASPI MUSC EXCLUDING T1/T XXX NDL EMG THRC PARASPI MUSC EXCLUDING T1/T XXX TC NDL EMG THRC PARASPI MUSC EXCLUDING T1/T XXX NDL EMG LMTD STD MUSC 1 XTR/NON-LIMB UNI/BI XXX NDL EMG LMTD STD MUSC 1 XTR/NON-LIMB UNI/BI XXX TC NDL EMG LMTD STD MUSC 1 XTR/NON-LIMB UNI/BI XXX NDL EMG W/1 FIBER ELTRD QUAN MEAS JITTER XXX NDL EMG W/1 FIBER ELTRD QUAN MEAS JITTER XXX TC NDL EMG W/1 FIBER ELTRD QUAN MEAS JITTER XXX ESTIM GDN CONJUNCT CHEMODNRVTJ ZZZ ESTIM GDN CONJUNCT CHEMODNRVTJ ZZZ TC ESTIM GDN CONJUNCT CHEMODNRVTJ ZZZ NDL EMG GDN CONJUNCT CHEMODNRVTJ ZZZ NDL EMG GDN CONJUNCT CHEMODNRVTJ ZZZ TC NDL EMG GDN CONJUNCT CHEMODNRVTJ ZZZ ISCHEMIC LIMB XERS TST SPEC ACQUISJ METAB XXX ISCHEMIC LIMB XERS TST SPEC ACQUISJ METAB XXX TC ISCHEMIC LIMB XERS TST SPEC ACQUISJ METAB XXX * NRV CNDJ AMPLT&STD EA NRV MOTOR W/O F-WAVE STD XXX * NRV CNDJ AMPLT&STD EA NRV MOTOR W/O F-WAVE STD XXX * TC NRV CNDJ AMPLT&STD EA NRV MOTOR W/O F-WAVE STD XXX * NRV CNDJ AMPLT&STD EA NRV MOTOR W/F-WAVE STD XXX * NRV CNDJ AMPLT&STD EA NRV MOTOR W/F-WAVE STD XXX * TC NRV CNDJ AMPLT&STD EA NRV MOTOR W/F-WAVE STD XXX * NRV CNDJ AMPLT&STD EA NRV SENS XXX * NRV CNDJ AMPLT&STD EA NRV SENS XXX Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 279

284 Georgia Workers Compensation Medical Fee Schedule Section X: General Medicine Services MEDICINE , , , , , Medical Fee Schedule Effective April 1, 2011 * TC NRV CNDJ AMPLT&STD EA NRV SENS XXX * MOTOR &/SENS NRV CNDJ PRECONF ELTRD ARRAY LIMB XXX * MOTOR &/SENS NRV CNDJ PRECONF ELTRD ARRAY LIMB 4.99 XXX * TC MOTOR &/SENS NRV CNDJ PRECONF ELTRD ARRAY LIMB XXX INTRAOP NEUROPHYSIOLOGY TSTG PR HR ZZZ INTRAOP NEUROPHYSIOLOGY TSTG PR HR ZZZ TC INTRAOP NEUROPHYSIOLOGY TSTG PR HR ZZZ TSTG ANS FUNCJ CARDIOVAGAL INNERVAJ PARASYMP XXX TSTG ANS FUNCJ CARDIOVAGAL INNERVAJ PARASYMP XXX TC TSTG ANS FUNCJ CARDIOVAGAL INNERVAJ PARASYMP XXX TSTG ANS FUNCJ VASOMOTOR ADRENERGIC INNERVAJ XXX TSTG ANS FUNCJ VASOMOTOR ADRENERGIC INNERVAJ XXX TC TSTG ANS FUNCJ VASOMOTOR ADRENERGIC INNERVAJ XXX TSTG ANS FUNCJ SUDOMOTOR XXX TSTG ANS FUNCJ SUDOMOTOR XXX TC TSTG ANS FUNCJ SUDOMOTOR XXX SHORT-LATENCY SOMATOSENS EP STD UPR LIMBS XXX SHORT-LATENCY SOMATOSENS EP STD UPR LIMBS XXX TC SHORT-LATENCY SOMATOSENS EP STD UPR LIMBS XXX SHORT-LATENCY SOMATOSENS EP STD LWR LIMBS XXX SHORT-LATENCY SOMATOSENS EP STD LWR LIMBS XXX TC SHORT-LATENCY SOMATOSENS EP STD LWR LIMBS XXX SHORT-LATENCY SOMATOSENS EP STD TRNK/HEAD XXX SHORT-LATENCY SOMATOSENS EP STD TRNK/HEAD XXX TC SHORT-LATENCY SOMATOSENS EP STD TRNK/HEAD XXX CTR MOTOR EP STD TRANSCRNL MOTOR STIMJ UPR LIMBS XXX CTR MOTOR EP STD TRANSCRNL MOTOR STIMJ UPR LIMBS XXX TC CTR MOTOR EP STD TRANSCRNL MOTOR STIMJ UPR LIMBS XXX CTR MOTOR EP STD TRANSCRNL MOTOR STIMJ LWR LIMBS XXX CTR MOTOR EP STD TRANSCRNL MOTOR STIMJ LWR LIMBS XXX TC CTR MOTOR EP STD TRANSCRNL MOTOR STIMJ LWR LIMBS XXX VISUAL EP TSTG CNS CHECKERBOARD/FLASH XXX VISUAL EP TSTG CNS CHECKERBOARD/FLASH XXX TC VISUAL EP TSTG CNS CHECKERBOARD/FLASH XXX MNTR SEIZURE CMPTR 16>CHAN EEG UNATND EA 24 HR XXX MNTR SEIZURE CMPTR 16>CHAN EEG UNATND EA 24 HR XXX TC MNTR SEIZURE CMPTR 16>CHAN EEG UNATND EA 24 HR XXX H-REFLEX AMPLT&LATENCY GASTRCN/SOLEUS MUSC XXX H-REFLEX AMPLT&LATENCY GASTRCN/SOLEUS MUSC XXX TC H-REFLEX AMPLT&LATENCY GASTRCN/SOLEUS MUSC XXX H-REFLEX AMPLT&LATENCY OTH/THN GASTRCN/SOLEUS XXX H-REFLEX AMPLT&LATENCY OTH/THN GASTRCN/SOLEUS XXX TC H-REFLEX AMPLT&LATENCY OTH/THN GASTRCN/SOLEUS XXX NEUROMUSCULAR JUNCT TSTG EA NRV ANY 1 METH XXX NEUROMUSCULAR JUNCT TSTG EA NRV ANY 1 METH XXX TC NEUROMUSCULAR JUNCT TSTG EA NRV ANY 1 METH XXX 280 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

285 Section X: General Medicine Services Georgia Workers Compensation Medical Fee Schedule , , , , , MEDICINE Effective April 1, 2011 Medical Fee Schedule MONITOR ID& LATERALIZATION SEIZURE FOCUS EEG XXX MONITOR ID& LATERALIZATION SEIZURE FOCUS EEG XXX TC MONITOR ID& LATERALIZATION SEIZURE FOCUS EEG XXX LOCALIZE CEREBRAL SEIZURE CABLE/RADIO EEG/VIDEO XXX LOCALIZE CEREBRAL SEIZURE CABLE/RADIO EEG/VIDEO XXX TC LOCALIZE CEREBRAL SEIZURE CABLE/RADIO EEG/VIDEO XXX s LOCALIZE CEREBRAL SEIZURE CPTR PORTABLE EEG XXX s LOCALIZE CEREBRAL SEIZURE CPTR PORTABLE EEG XXX s TC LOCALIZE CEREBRAL SEIZURE CPTR PORTABLE EEG XXX RX/PHYSICAL ACTIVAJ PHYS ATTN DURING EEG ACTIVAJ XXX RX/PHYSICAL ACTIVAJ PHYS ATTN DURING EEG ACTIVAJ XXX TC RX/PHYSICAL ACTIVAJ PHYS ATTN DURING EEG ACTIVAJ XXX EEG NONICRA SURG XXX EEG NONICRA SURG XXX TC EEG NONICRA SURG XXX s MNTR SEIZURE CMPTR 16>CHAN EEG ATND EA 24 HR XXX s MNTR SEIZURE CMPTR 16>CHAN EEG ATND EA 24 HR XXX s TC MNTR SEIZURE CMPTR 16>CHAN EEG ATND EA 24 HR XXX DGTAL ALYS EEG XXX DGTAL ALYS EEG XXX TC DGTAL ALYS EEG XXX WADA ACTIVATION TEST HEMISPHERIC FUNCTION W/EEG XXX WADA ACTIVATION TEST HEMISPHERIC FUNCTION W/EEG XXX TC WADA ACTIVATION TEST HEMISPHERIC FUNCTION W/EEG XXX FUNCJAL CORT&SUBCORT MAPG ELTRDS 1 HR PHYS ATTN XXX FUNCJAL CORT&SUBCORT MAPG ELTRDS 1 HR PHYS ATTN XXX TC FUNCJAL CORT&SUBCORT MAPG ELTRDS 1 HR PHYS ATTN XXX FUNCJAL CORT&SUBCORT MAPG ELTRDS EA HR PHYS ATTN ZZZ FUNCJAL CORT&SUBCORT MAPG ELTRDS EA HR PHYS ATTN ZZZ TC FUNCJAL CORT&SUBCORT MAPG ELTRDS EA HR PHYS ATTN ZZZ MAGNETOENCEPHALOGRAPHY SPON BRAIN ACTIVITY XXX MAGNETOENCEPHALOGRAPHY SPON BRAIN ACTIVITY XXX TC MAGNETOENCEPHALOGRAPHY SPON BRAIN ACTIVITY XXX MAGNETOENCEPHALOGRAPY EVOKED FIELDS 1 MODALITY XXX MAGNETOENCEPHALOGRAPY EVOKED FIELDS 1 MODALITY XXX TC MAGNETOENCEPHALOGRAPY EVOKED FIELDS 1 MODALITY XXX MAGNETOENCEPHALOGRAPY EVOKED FIELDS EACH ADDL ZZZ MAGNETOENCEPHALOGRAPY EVOKED FIELDS EACH ADDL ZZZ TC MAGNETOENCEPHALOGRAPY EVOKED FIELDS EACH ADDL ZZZ ELEC ALYS NSTIM PLS GEN BRN/SC/PERPH W/O REPRGRM XXX ELEC ALYS NSTIM PLS GEN SMPL SC/PERPH W/PRGRMG XXX ELEC ALYS NSTIM PLS GEN CPLX SC/PERPH 1ST HR XXX ELEC ALYS NSTIM PLS GEN CPLX SC/PERPH EA 30 MIN ZZZ ELEC ALYS NSTIM PLS GEN CPLX CRNL NRV 1ST HR XXX ELEC ALYS NSTIM PLS GEN CPLX CRNL NRV EA 30 MIN ZZZ ELEC ALYS NSTIM PLS GEN CPLX DP BRN 1ST HR XXX Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 281

286 Georgia Workers Compensation Medical Fee Schedule Section X: General Medicine Services MEDICINE , , , , , Medical Fee Schedule Effective April 1, ELEC ALYS NSTIM PLS GEN CPLX DP BRN EA 30 MIN ZZZ ELEC ALYS NSTIM PLS GEN GASTRIC INTRAOP W/PRGRMG XXX ELEC ALYS NSTIM GEN GASTRIC SBSQ W/O REPRGRMG XXX ELEC ALYS NSTIM PLS GEN GASTRIC SBSQ W/REPRGRMG XXX REFILL&MAINTENANCE PUMP DRUG DLVR SPINAL/BRAIN XXX RFL&MAIN IMPLT PMP/RSVR RX DLVR SPI/BRN BY PHYS XXX * CANALITH REPOSITIONING PROCEDURE XXX UNLIS NEUROLOGICAL/NEUROMUSCULAR DX PX BR XXX COMPRE CPTR MTN ALYS VIDEO TAPING 3-D KINEMATICS XXX COMPRE CPTR MTN ALYS W/DYN PLNTR PRES MEAS WALKG XXX DYN SURF EMG WALKG/FUNCJAL ACTV 1-12 MUSC XXX DYN FINE WIRE EMG WALKG/FUNCJAL ACTV 1 MUSC XXX PHYS R&I CPTR MTN ALYS WALKG/FUNCJAL ACTV REPRT XXX TEST SELECTION & ADMN FUNCTIONAL BRAIN MAPPING BR XXX MEDICAL GENETICS COUNSELING EA 30 MIN XXX PSYCHOLOGICAL TESTING PR HR F2F TIME W/PT XXX PSYCL TSTG PR HR ADMN BY TECH PR HR XXX PSYCL TSTG PR HR ADMN BY CPTR W/PROF I&R XXX ASSMT APHASIA W/I&R PR HR XXX DEVELOPMENTAL TSTG LMTD W/I&R XXX DEVELOPMENTAL TSTG EXTND W/I&R XXX NUBHVL STATUS XM PR HR F2F W/PT INTERPJ&PREPJ XXX NUROPSYC TESTING PR HR F2F W/PT + INTERPJ TIME XXX NUROPSYC TSTG WPROF I&R ADMN BY TECH PR HR XXX NUROPSYC TSTG ADMN BY CPTR W/PROF I&R XXX STANDARDIZED COGNITIVE PERFORMANCE TESTING XXX HLTH&BEHAVIOR ASSMT EA 15 MIN F2F W/PT 1ST ASSMT XXX HLTH&BEHAVIOR ASSMT EA 15 MIN F2F W/PT RE-ASSMT XXX HLTH&BEHAVIOR IVNTJ EA 15 MIN F2F INDIV XXX HLTH&BEHAVIOR IVNTJ EA 15 MIN F2F GRP 2/> PTS 7.75 XXX HLTH&BEHAVIOR IVNTJ EA 15 MIN F2F FAM W/PT XXX HLTH&BEHAVIOR IVNTJ EA 15 MIN F2F FAM W/O PT XXX IV INFUSION HYDRATION INITIAL 31 MIN-1 HOUR XXX IV INFUSION HYDRATION EACH ADDITIONAL HOUR ZZZ IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR XXX IV INFUSION THERAPY PROPHYLAXIS/DX EA HOUR ZZZ IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR ZZZ IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS ZZZ SUBCUTANEOUS INFUSION INITIAL 1 HR W/PUMP SET-UP XXX SUBCUTANEOUS INFUSION EACH ADDITIONAL HOUR ZZZ SUBQ INFUSION ADDITIONAL PUMP INFUSION SITE ZZZ THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM XXX THERAPEUTIC PROPHYLACTIC/DX NJX INTRA-ARTERIAL XXX THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG XXX THERAPEUTIC INJECTION IV PUSH EACH NEW DRUG ZZZ THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC ZZZ 282 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

287 Section X: General Medicine Services Georgia Workers Compensation Medical Fee Schedule , , , , , MEDICINE Effective April 1, 2011 Medical Fee Schedule UNLISTED THERAPEUTIC PROPH/DX IV/IA NJX/NFS BR XXX CHEMOTX ADMN SUBQ/IM NON-HORMONAL ANTI-NEO XXX CHEMOTX ADMN SUBQ/IM HORMONAL ANTI-NEO XXX CHEMOTX ADMN ILESN UP&W/7 < CHEMOTX ADMN ILESN > CHEMOTX ADMN IV PUSH TQ 1/1ST SBST/DRUG XXX CHEMOTX ADMN IV PUSH TQ EA SBST/DRUG ZZZ CHEMOTX ADMN IV NFS TQ UP 1 HR 1/1ST SBST/DRUG XXX CHEMOTHERAPY ADMN IV INFUSION TQ EA HR ZZZ CHEMOTX ADMN TQ INIT PROLNG CHEMOTX NFUS PMP XXX CHEMOTX ADMN IV NFS TQ EA SEQL NFS TO 1 HR ZZZ CHEMOTX ADMN IA PUSH TQ XXX CHEMOTX ADMN IA NFS TQ UP 1 HR XXX CHEMOTHERAPY ADMN INTRAARTERIAL INFUSION EA HR ZZZ CHEMOTX ADMN IA NFS > 8 HR PRTBLE IMPLTBL PMP XXX CHEMOTX ADMN PLEURAL CAVITY REQ&W/THORACNTS l CHEMOTX ADMN PRTL CAVITY PORT/CATH XXX CHEMOTX ADMN CNS REQ&W/SPI PNXR RFL/MAIN PORTABLE PMP XXX REFILL&MAINTENANCE PUMP DRUG DLVR SYSTEMIC XXX IRRIGATION IMPLANTED VAD FOR DRUG DLVR XXX CHEMOTX NJX SUBARACHND/INTRAVENTR RSVR 1+ AGENTS XXX UNLIS CHEMOTX PX BR XXX PDT XTRNL APPL LIGHT DSTR LES SKN BY ACTIVJ RX XXX PDT NDSC ABL ABNOR TISS VIA ACTIVJ RX 30 MIN ZZZ PDT NDSC ABL ABNOR TISS VIA ACTIVJ RX A 15 MIN ZZZ ACTIXH ULTRAVIOLET LIGHT XXX MCRSCP XM HAIR PLUCK/CLIP FOR CNTS/STRUCT ABNORM XXX WHOLE BODY INTEGUMENTARY PHOTOGRAPHY XXX PHOTOCHEMOTX TAR&UVB/PETROLATUM/UVB XXX PHOTOCHEMOTX PSORALENS&ULTRAVIOLET PUVA XXX PHOTOCHEMOTHERAPY DERMATOSES 4-8 HRS SUPERVISION XXX LASER SKIN DISEASE PSORIASIS TOT AREA <250 SQ CM LASER SKIN DISEASE PSORIASIS SQ CM LASER SKIN DISEASE PSORIASIS >500 SQ CM UNLIS SPEC DERMATOLOGICAL SVC/PX BR XXX s DEBRIDEMENT OPEN WOUND 20 SQ CM< s DEBRIDEMENT OPEN WOUND ADDL 20 SQ CM ZZZ RMVL DEVITAL TISS N-SLCTV DBRDMT W/O ANES 1 SESS XXX NEG PRESS WND THER </EQUAL 50 SQ CM XXX NEG PRESS WND THER > 50 SQ CM XXX MED NUTR THER 1ST ASSMT&IVNTJ INDIV EA 15 MIN XXX MED NUTR THER RE-ASSMT&IVNTJ INDIV EA 15 MIN XXX MED NUTR THER GRP2/> INDIV EA 30 MIN XXX EDUCATION&TRAINING SELF-MGMT NONPHYS 1 PT XXX EDUCATION&TRAINING SELF-MGMT NONPHYS 2-4 PTS XXX Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 283

288 Georgia Workers Compensation Medical Fee Schedule Section X: General Medicine Services MEDICINE , , , , , Medical Fee Schedule Effective April 1, EDUCATION&TRAINING SELF-MGMT NONPHYS 5-8 PTS XXX NONPHYSICIAN TELEPHONE ASSESSMENT 5-10 MIN XXX NONPHYSICIAN TELEPHONE ASSESSMENT MIN XXX NONPHYSICIAN TELEPHONE ASSESSMENT MIN XXX NONPHYSICIAN ONLINE ASSESSMENT AND MANAGEMENT XXX HANDLG&/OR CONVEY OF SPEC FOR TR OFFICE TO LAB XXX HANDLG&/OR CONVEY OF SPEC FOR TR FROM PT TO LAB XXX HANDLING CONVEY/ANY OTH SVC INVG DEV FIT BY PHYS XXX PO F-UP VST RELATED TO ORIGINAL PX BR XXX HOSP MANDATED CALL SVC IN-HOSP EA HR BR XXX HOSP MANDATED CALL SVC OUT-OF-HOSP EA HR BR XXX SVCS PRV OFFICE OTH/THN REG SCHEDD HRS XXX SVC PRV OFFICE REG SCHEDD EVN WKEND/HOLIDAY HRS BR XXX SVC PRV BTW 10 PM&8 AM AT 24-HR FAC BR XXX SVC TYPICAL PRV OFFICE PRV OUT OFFICE REQUEST PT XXX SVC PRV EMER BASIS OFFICE DISRUPTS OFFICE SVCS XXX SVC PRV EMER OUT OFFICE DISRUPTS OFFICE SVC XXX SUPPLIES&MATERIALS PRV BY PHYS >&ABOVE BR XXX EDUCATIONAL SUPPLIES PRV BY THE PHYS AT COST BR XXX MEDICAL TSTIMONY See Page 14 XXX PHYS EDUCATIONAL SVCS RENDERED PTS GRP SETTING BR XXX SPEC REPORTS > USUAL MED COMUNICAJ/STAND RPRTG See Page 14 XXX UNUSUAL TRAVEL BR XXX ALYS CLINICAL DATA STORED CPTRS BR XXX COLLJ&INTERPJ PHYSIO DATA DIG STRD/TRANS 30 MIN XXX * M-SEDATJ BY SM PHYS PERFRMG SVC < 5 YR XXX * M-SEDAJ BY SM PHYS PERFRMG SVC 5+ YR XXX M-SEDAJ BY SM PHYS PERFRMG SVC EA 15 MIN ZZZ M-SEDATION BY PHYS OTH/THN HC PROF PERFRMG < XXX M-SEDATION BY PHYS OTH/THN HC PROF PERFRMG XXX M-SEDAJ PHYS OTH/THN HC PROF PERFRMG EA 15 MIN ZZZ COLLJ/INT PHYSIO DATA DIG STRD/TRANS MINIM 30MIN VSL FUNC SCRNG AUTO SEMI-AUTO BI QUAN DETERM XXX VSL FUNC SCRNG AUTO SEMI-AUTO BI QUAN DETERM 6.65 XXX TC VSL FUNC SCRNG AUTO SEMI-AUTO BI QUAN DETERM XXX SCREENING 4.43 XXX OCULAR PHOTOSCREENING INTERPRETATION BILATERAL XXX IPECAC/SIMILAR ADMN EMESIS&OBS STOMACH EMPTIED XXX PHYS ATTN&SUPVJ HYPRBARIC OXYGEN THER PR SESS XXX ASSEM/OPRATN PMP OXTJ/HEAT EXCHNGR EA HR XXX ASSEM/OPRATN PMP OXTJ/HEAT EXCHNGR 3/4 HR XXX ASSEM/OPRATN PMP OXTJ/HEAT EXCHNGR 1/2 HR XXX PHLEBOTOMY THER SPX XXX UNLIS SPEC SVC PX/REPRT BR XXX MEDICATION THERAPY 1ST 15 MIN NEW PATIENT BR XXX MEDICATION THERAPY F2F 1ST 15 MIN ESTABLISHED PT BR XXX MEDICATION THERAPY F2F EA ADDITIONAL 15 MIN BR XXX 284 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

289 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., CPT code 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), 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. Interpretation In circumstances where an interpreter is required during face-to-face evaluation and management services, or physical medicine evaluations ( ), provided to the injured worker by a physician or PE, whether interpretation is provided live, via telephone or video, add state-specific modifier TR to the E/M code. Reimbursement will be an additional 25 percent of the lesser of billed charges or maximum allowable rate of that code only. Prolonged service codes may not be used in combination with this modifier. Additional reimbursement as outlined above does not apply to independent medical evaluations (IME). In circumstances where an interpreter is required for an injured worker, and the service is provided by telephone with a physician or qualified non-physician health care provider, use the appropriate CPT codes (physicians) and (qualified non-physician health care providers), and append state-specific modifier TR. These codes should be used in accordance with the guidelines and descriptions found in CPT Reimbursement will be an additional 25 percent of the lesser of billed charges or maximum allowable rate of that code only. Unusual Service or Procedure Services that may necessitate skills and time of the physician over and above that usually required should be substantiated by report (see section IV). Unlisted Service or Procedure Some services performed are not described by any CPT code. Unlisted services should be reported using an unlisted code and substantiated by report. The unlisted services and accompanying codes are listed at the end of each Physical Medicine subsection. Unlisted service or procedure codes must be selected from the appropriate subsection of the Physical Medicine chapter. For these procedures a BR (by report) designation has been used in the fee schedule. Reimbursement for such procedures must be justified by report (see section IV). Initial Evaluation and Re-evaluation by Physical Therapists or Occupational Therapists CPT code 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 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 the existing patient sustains an additional injury and requires additional physical therapy. CPT code 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 Occupational therapy re-evaluation, may be CPT only 2010 American Medical Association. All Rights Reserved. 285

290 Georgia Workers Compensation Medical Fee Schedule 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 the 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 physical medicine procedures are subject to the following rules and limitations. No more than four physical medicine procedures, modalities or time units will be reimbursed in one visit by each type of medical provider. No more than two of the four CPT code charges can be modality codes (CPT codes ). The only exceptions to this are: 1. If injured employee is diagnosed as catastrophic. 2. CPT codes and (see Section IV: General Reimbursment Requirements, Physical Medicine Maximum Per Visit and/or Day for more details). 3. State-specific code FCE01 must be used for billing functional capacity evaluation. The maximum allowable rate of reimbursement is $45.41 per each 15 minutes (not to exceed $ per FCE). 4. CPT code must be used by physical/ occupational therapists when billing for Physical Performance Test/Measurements that are required by the treating physician in preparing an impairment rating. No more than 4 time units per visit per day can be billed. Additional physical medicine treatment can be conducted on the same day, with reimbursement in accordance with Section XI: Physical Medicine Services. Modifier 59 may be used when multiple procedures are performed on the same day. CPT code shall be used by the treating physician when performing an impairment rating. Under the guidelines above, Physical Performance Test/Measurement testing and FCE can be performed on the same day by Section XI: Physical Medicine Services physical/occupational therapists. Modifier 59 may be used when multiple procedures are performed on the same day. 5. CPT code 97760, Management and training (including assessment and fitting when not otherwise reported) for orthotics, CPT code 97761, Prosthetic training, and CPT code 97762, Checkout for orthotic/prosthetic use, established patient. CPT code is used to checkout the orthotic/prosthetic for any medically necessary adjustments. 6. By mutual agreement of all parties. CPT code covers the application of one or more hot or cold packs and should be billed only once per treatment session. This code should not be used to bill the application of each individual pack. For additional information on reimbursement related to these exceptions, see Section IV: General Reimbursement Requirements. Manipulation Codes Special codes are designated for use by chiropractors and osteopaths to bill for manipulation services. When billing for manipulation services, licensed chiropractors may bill using CPT codes Licensed osteopaths may bill using CPT codes The chiropractic manipulative treatment codes include a premanipulation patient assessment. Additional evaluation and management (E/M) services may be reported separately using modifier 25, if the injured employee s condition requires a significant, separately identifiable E/M service, which is above and beyond the usual preservice and postservice work associated with the procedure. 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 (CPT codes ). Fabrication of Orthotics Orthotics must be billed separately for professional fitting and supplies. CPT code 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 or by agreement of the parties. Additional medical supplies may not exceed medical supplies reimbursement formula. Medical supplies shall be reported using CPT code (See Materials Supplied by the Health Care Provider in section IV.) 286 CPT only 2010 American Medical Association. All Rights Reserved.

291 Section XI: 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 (See Materials Supplied by the Health Care Provider in section IV.) 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 the appropriate modifier following the procedure code. When two modifiers are applicable to a single code, indicate each modifier on the bill. 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 (Evaluation and Management, 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. Note: Modifier 21 has been deleted. To report prolonged physician services, see The following modifiers will be recognized for reimbursement by the fee schedule for physical medicine services codes: 22 Increased Procedural Services: When the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. Documentation must support the substantial additional work and the reason for the additional work (i.e., increased intensity, time, technical difficulty of procedure, severity of patient s condition, physical and mental effort required). Note: This modifier should not be appended to an E/M service. 24 Unrelated Evaluation and Management Service by the Same Physician during a Postoperative Period: The physician may need to indicate that an evaluation and management service was performed during a Georgia Workers Compensation Medical Fee Schedule postoperative period for a reason(s) unrelated to the original procedure. This circumstance may be reported by adding modifier 24 to the appropriate level of E/M service. 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 modifier 26 to the usual procedure number. 52 Reduced Services: Under certain circumstances, a service or procedure is partially reduced or eliminated at the physician s discretion. Under these circumstances, the service provided can be identified by its usual procedure number and the addition of modifier 52 signifying that the service is reduced. This provides a means of reporting reduced services without disturbing the identification of the basic service. Note: For hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for ASC hospital outpatient use). 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 modifier 53 to the code for the discontinued procedure. 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. For outpatient hospital/ambulatory surgery center (ASC) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for ASC hospital outpatient use). 59 Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision or excision, separate lesion, or separate injury (or area of injury in extensive injuries) CPT only 2010 American Medical Association. All Rights Reserved. 287

292 Georgia Workers Compensation Medical Fee Schedule not ordinarily encountered or performed on the same day by the same individual. 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. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-e/m service performed on the same date, see modifier 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. Section XI: Physical Medicine Services TC 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 modifier TC to the usual procedure number. TR Interpretation: In circumstances where an interpreter is required during face-to-face evaluation and management services provided to the injured worker by a physician or PE, add state-specific modifier TR to the E/M code. Reimbursement will be an additional 25 percent of the lesser of billed charges or maximum allowable rate of that code only. Prolonged service codes may not be used in combination with the TR modifier unless it is documented that the reason for the code is additional time required as a result of factors beyond the need for an interpreter. Additional reimbursement as outlined above does not apply to independent medical evaluations (IME). 288 CPT only 2010 American Medical Association. All Rights Reserved.

293 Section XI: Physical Medicine Services Georgia Workers Compensation Medical Fee Schedule , , , FCE01 PHYSICAL MEDICINE Effective April 1, 2011 Medical Fee Schedule PHYSICAL THER EVAL XXX PHYSICAL THER RE-EVAL XXX OCCUPATIONAL THER EVAL XXX OCCUPATIONAL THER RE-EVAL XXX ATHLETIC TRAINJ EVAL 0.00 XXX ATHLETIC TRAINJ RE-EVAL 0.00 XXX APPL MODALITY 1+ AREAS HOT/COLD PACKS 7.90 XXX APPL MODALITY 1+ AREAS TRCJ MCHNL XXX APPL MODALITY 1+ AREAS ELEC STIMJ UNATTN XXX APPL MODALITY 1+ AREAS VASOPNEUMATIC DEV XXX APPL MODALITY 1+ AREAS PARAFFIN BATH XXX APPL MODALITY 1+ AREAS WP XXX APPL MODALITY 1+ AREAS DTHRM 8.88 XXX APPL MODALITY 1+ AREAS INFRARED 7.90 XXX APPL MODALITY 1+ AREAS ULTRAVIOLET 9.87 XXX APPL MODALITY 1+ AREAS ELEC STIMJ EA 15 MIN XXX APPL MODALITY 1+ AREAS IONTOPHORESIS EA 15 MIN XXX APPL MODALITY 1+ AREAS CNTRST BATHS EA 15 MIN XXX APPL MODALITY 1+ AREAS US EA 15 MIN XXX APPL MODALITY 1+ AREAS HUBBARD TANK EA 15 MIN XXX UNLIS MODALITY SPEC TYP&TM IF CONSTANT ATTN BR XXX THER PX 1+ AREAS EA 15 MIN THER XERSS XXX THER PX 1+ AREAS EA 15 MIN NEUROMUSC REEDUCAJ XXX THER PX 1+ AREAS EA 15 MIN AQUATIC THER W/XERSS XXX THER PX 1+ AREAS EA 15 MIN GAIT TRAINJ W/STAIR XXX THER PX 1+ AREAS EA 15 MIN MASSAGE XXX UNLIS THER PX SPEC BR XXX MNL THER TQS 1+ REGIONS EA 15 MIN XXX THER PX GRP 2/> INDIVS XXX THER ACTV DIR PT CONTACT BY PROVIDER EA 15 MIN XXX DEVELOPMENT OF COGNITIVE SKILLS EA 15 MIN XXX SENSORY INTEGRATIVE TQS EA 15 MIN XXX SELF-CARE/HOME MGMT TRAINING EA 15 MIN XXX COMMUNITY/WORK REINTEGRATION TRAINJ EA 15 MIN XXX WHEELCHAIR MGMT EA 15 MIN XXX WORK HARDENING/CONDITIONING 1ST 2 HR XXX WORK HARDENING/CONDITIONING EA HR ZZZ PHYSICAL PERFORMANCE TST/MEAS W/RPRT 15 MIN XXX ASSTV TECHN ASSMT DIR CNTCT W/REPRT 15 MIN XXX ORTHOTIC MGMT&TRAINJ UXTR LXTR&/TRNK EA 15 MIN XXX PROSTC TRAINJ UPR&/LXTR EA 15 MIN XXX CHECKOUT ORTHOTIC/PROSTHETIC USE XXX UNLIS PHYSICAL MED/RHAB SVC/PX BR XXX ACUP 1/> NDLS W/O ELEC STIMJ 1ST 15 MIN XXX ACUP 1/> NDLS W/O ELEC STIMJ EA 15 MIN ZZZ ACUP 1/> NDLS W/ELEC STIMJ 1ST 15 MIN XXX + Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 289

294 Georgia Workers Compensation Medical Fee Schedule Section XI: Physical Medicine Services PHYSICAL MEDICINE , , , FCE01 Medical Fee Schedule Effective April 1, ACUP 1/> NDLS W/ELEC STIMJ EA 15 MIN W/RE-INSJ ZZZ OSTEOPATHIC MANIPULATIVE TX 1-2 BDY REGIONS OSTEOPATHIC MANIPULATIVE TX 3-4 BDY REGIONS OSTEOPATHIC MANIPULATIVE TX 5-6 BDY REGIONS OSTEOPATHIC MANIPULATIVE TX 7-8 BDY REGIONS OSTEOPATHIC MANIPULATIVE TX 9-10 BDY REGIONS CMT SPI 1-2 REGIONS CMT SPI 3-4 REGIONS CMT SPI 5 REGIONS CMT XTRSPI 1+ REGIONS XXX FCE01 FUNCTIONAL CAPACITY EVALUATION (GEORGIA SPECIFIC) See Page Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure 290 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

295 Section XII: Home Health 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. When four hours or more of care are provided, hourly rates, based upon the licensure below, will apply. The maximum allowable hourly rate for specific providers is as follows: Registered Nurse (RN) $49.02 per hour weekday $57.42 per hour weekend and holiday day Licensed Practical Nurse (LPN) $36.41 per hour weekday $42.01 per hour weekend and holiday day Certified Nurse Assistant/Personal Care Attendant (CNA/PCA) Non-credentialed Care, Including Family Members $10.13 per hour with a maximum of 12 hours per day When care is provided for less than four hours, the allowed rate will be per visit as indicated below: $ per visit Registered Nurse $ per visit Licensed Practical Nurse $64.29 per visit Certified Nurse Assistant or Personal Care Attendant Physical Therapist, Occupational Therapist and Speech-Language Therapist are reimbursed according to the fee schedule for CPT codes provided plus $34.44 per visit. Note: Domestic services (e.g., lawn mowing services, home cleaning) are not included in this payment system. $24.11 per hour weekday $27.56 per hour weekend and holiday day CPT only 2010 American Medical Association. All Rights Reserved. 291

296 Georgia Workers Compensation Medical Fee Schedule Section XII: Home Health Services HOME HEALTH SERVICES Medical Fee Schedule Effective April 1, HOME VST PRENATAL MNTR&ASSMT BR XXX HOME VST POSTNATAL ASSMT&F-UP CARE BR XXX HOME VST NB CARE&ASSMT BR XXX HOME VST RESPIR THER CARE BR XXX HOME VST MCHNL VNTJ CARE BR XXX HOME VST STOMA CARE&MAINT CLST&CSTOST BR XXX HOME VST IM NJXS BR XXX HOME VST CARE&MAINT CATH BR XXX HOME VST ASSISTANCE DAILY LIV&PRSONAL CARE BR XXX HOME VST INDIV FAM/MARRIAGE CNSL BR XXX HOME VST FECAL IMPACTION MGMT&ENEMA ADMN BR XXX HOME VST HEMO BR XXX UNLIS HOME VST SVC/PX BR XXX HOME NFS/SPECTY DRUG ADMN PR VST <2 HR BR XXX HOME NFS/SPECTY DRUG ADMN PR VST <2 HR EA HR BR XXX + Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure 292 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

297 Section XIII: Transportation SUBSECTION A: NON-EMERGENCY SERVICES The following are guidelines for reimbursement of non-emergency transportation. These codes are Georgia state-specific and should be used for workers compensation billing purposes. General Guidelines Codes and fees specify ambulatory and lift van reimbursements separately. Flat-rate, pick-up fees are not applicable. Additional gasoline surcharge fees are not reimbursable as they are included in fee schedule reimbursement. Very remote areas are considered 50 miles or more. Wait-time fees are reimbursed at the fee rates listed below. A cumulative total-day wait time of one hour or more can be charged. There is no wait-time reimbursement for anything less than one hour for an entire day. Any transportation fees outside of this schedule should be negotiated between the payor and provider before services are rendered. Ambulatory: Code Description Maximum Allowable Rate TP010 Per-mile charge $2.15 per mile TP015 Wait-time charge first hour $26.10 first 60 minutes TP016 Wait-time charge additional time $6.53 each additional 15 minutes TP020 Minimum charge Only one minimum fee of $31.31 allowable for entire day. If mileage exceeds $31.31, use per-mile rate (TP010) TP025 After hours, weekends, and holidays Regular working hours are considered to be Monday through Friday, 6:00 a.m. to 6:00 p.m. Saturday and Sunday are considered to be weekend days. An additional charge not to exceed $26.10 per day may be billed if pick-up time is earlier than 6:00 a.m. or later than 6:00 p.m. weekdays. An additional charge not to exceed $26.10 per day may be billed for pickup on weekend days and holidays. TP030 Wheelchair handling A $10.43 charge for each time a wheelchair is folded and loaded into a trunk or backseat, with a maximum daily charge of $41.75 may be billed. TP035 Hands-on passenger assistance If hands-on assistance is needed to move a patient in and out of the vehicle, a fee according to the degree of assistance that is required should be negotiated with the payor prior to travel. TP040 Additional fees rural areas Negotiate fee prior. TP045 Passenger pick-up fees when driver is leaving from and returning home No additional reimbursement unless it is a very remote area, and then reimbursement must be negotiated prior. TP046 Rush less than 24 business hours $26.10 TP047 Late cancellation two business $31.31 hours or less TP050 No-call/no-show charges A $52.18 charge may be billed; very remote areas (50 miles or more) may charge $ CPT only 2010 American Medical Association. All Rights Reserved. 293

298 Georgia Workers Compensation Medical Fee Schedule Section XIII: Transportation Lift Vans: Code Description Maximum Allowable Rate TP100 Per-mile charge $3.08 per mile TP105 Wait-time charge first hour $41.75 first 60 minutes TP106 Wait-time charge additional time $10.70 each additional 15 minutes TP110 Loading and unloading of patient $41.75 per trip, not to exceed $83.50 per day TP115 After hours, weekends, and holidays Regular working hours are considered to be Monday through Friday, 6:00 a.m. to 6:00 p.m. Saturday and Sunday are considered to be weekend days. An additional charge not to exceed $26.10 per day may be billed if pick-up time is earlier than 6:00 a.m. or later than 6:00 p.m. weekdays. An additional charge not to exceed $26.10 per day may be billed for pick-up on weekend days and holidays. TP120 Additional handling fees If stretcher transportation or other unusual handling is required, this should be identified and negotiated prior. Otherwise charges are included in loading fees. TP125 Additional fees rural areas Negotiate fee prior. TP130 Passenger pick-up when driver is leaving from and returning home No additional reimbursement unless it is a very remote area, and then reimbursement must be negotiated prior. TP131 Rush less than 24 business hours $26.10 TP132 Late cancellation two business $41.75 hours or less TP135 No-call/no-show charges A $78.28 charge may be billed; $ charge for very remote (50 miles or more) areas. 294 CPT only 2010 American Medical Association. All Rights Reserved.

299 Section XIII: Transportation SUBSECTION B: AMBULANCE AND AIR SERVICES The following guidelines are for reimbursement of ambulance and air transportation. These services are reported with HCPCS ambulance and air transportation codes. The table below indicates the HCPCS codes and their reimbursement for transportation services using the appropriate calculations for urban and rural base rate and mileage. For the purpose of determining the definition of rural mileage versus urban mileage, any county outside of the eight (8) counties listed below would be considered rural: Cherokee County Clayton County Cobb County Dekalb County Douglas County Fulton County Gwinnett County Paulding County Georgia Workers Compensation Medical Fee Schedule Charges for services and mileage must be based on loaded mileage only, e.g., from the pickup of a patient to his/her arrival at the destination. Unloaded trips and mileage are not reimbursable. Any ambulance and air transportation fees outside of this schedule should be paid at usual, customary, and reasonable charges in compliance with O.C.G.A (a), and reasonable charges shall be limited to such charges as prevail in the state of Georgia for similar treatment or services. Example fee calculation: Given a total mileage of 44 miles under A0425 for ground ambulance service in a rural area, multiply the rural mileage times total miles ($11.40 x 44 = $501.60) and add the value of rural base rate ($11.40) ($ $11.40) for a total of $ If this service also required ambulance service, basic life support, emergency transport (BLS emergency) (A0429), add $ to the earlier calculation of $513.00, giving a new total of $ ($ $513.00). HCPCS CODE DESCRIPTION BASE RATE & URBAN MILEAGE RURAL BASE RATE & RURAL MILEAGE A0425 Ground mileage, per statute mile, and base rate $11.28 $11.40 A0426 Ambulance service, advanced life support, non-emergency $ $ transport, level 1 (ALS 1) A0427 Ambulance service, advanced life support, emergency $ $ transport, level 1 (ALS 1 emergency) A0428 Ambulance service, basic life support, non-emergency $ $ transport (BLS) A0429 Ambulance service, basic life support, emergency transport $ $ (BLS emergency) A0430 Ambulance service, conventional air services, transport, one $3, $5, way (fixed wing) A0431 Ambulance service, conventional air services, transport, one $4, $6, way (rotary wing) A0432 Paramedic intercept (PI), rural area, transport furnished by a volunteer ambulance company which is prohibited by state law from billing third-party payers $ $ A0433 Advanced life support, level 2 (ALS2) $ $ A0434 Specialty care transport (SCT) $1, $1, A0435 Fixed wing air mileage, per statute mile $11.60 $17.40 A0436 Rotary wing air mileage, per statute mile $30.93 $46.40 CPT only 2010 American Medical Association. All Rights Reserved. 295

300

301 Section XIV: Inpatient Hospital Payment Schedule INPATIENT REIMBURSEMENT METHODOLOGY Inpatient hospital maximum allowable reimbursement (MAR) totals are provided by MS-DRG in this schedule. As of the date of publication, the MS-DRG maximum allowable reimbursement is based upon the 2011 CMS relative weights multiplied by a base rate of $8, Any MS-DRGs outside of this schedule will be reimbursed at percent of charge. Reimbursement will be effective for the date of discharge. MS-DRG MARs represent payment in full, unless the outlier payment is applicable or a contract between a payor/provider is negotiated. MS-DRGs 945 and 946 (Rehabilitation) are exempt from the Hospital Payment Fee Schedule. Reimbursements for inpatient rehabilitation should be negotiated by the facility and the payor, on a case-by-case basis, prior to services being rendered. If a payment rate has not been negotiated prior to services being rendered, the hospital will be reimbursed based on the MS-DRG payment schedule, which is calculated by multiplying the current relative weight of MS-DRG 945 or 946 and the current year s Georgia Workers Compensation base rate of $8,201.53, plus any applicable reimbursable outlier costs. IMPLANTS, DURABLE MEDICAL EQUIPMENT (DME), AND SUPPLIES Generally, durable medical equipment and supplies provided or administered in a hospital setting are not separately reimbursed since they are included in the payment reimbursement. However, surgical implantables are exempted from this rule. A provider shall submit a hard copy of the wholesale vendor invoice for the implantable(s) at the cost to the hospital, ambulatory surgery center, or other provider. In some cases, vendor invoices list multiple items; therefore, a copy of a multiple-item vendor invoice shall be acceptable. In this case, the payor shall calculate reimbursement for items used per procedure. Clarification of which implant is used for each procedure billed will facilitate reimbursement. Only the actual invoiced cost of the item(s) will be reimbursed. Tax, handling, and freight charges are included in the hospital s invoiced cost and shall not be reimbursed. Implantable(s) are not subject to outlier reimbursement. PAYMENT FOR OUTLIERS Most MS-DRG payments will be at the base rate times the MS-DRG weight. However, to provide additional reimbursement where the Georgia Workers Compensation Board deems the MS-DRG payment inadequate to cover the costs incurred by the facility, the Board has established an outlier payment for high-cost cases. Implantables are not subject to outlier reimbursement. The outlier payment will be made according to the following formula: Outlier Charge = Total Billed Charges MS-DRG Payment implants if applicable 40, If Outlier Charge > 0, then Outlier Payment = 0.45 x Outlier Charge If Outlier Charge is 0, then Outlier Payment = 0 CPT only 2010 American Medical Association. All Rights Reserved. 297

302 Georgia Workers Compensation Medical Fee Schedule Section XIV: Inpatient Hospital Payment Schedule Example for MS-DRG 460: Total Billed Charges MS-DRG Payment Outlier Charge Outlier Payment Total Payment Example A $100, $31, $28, $12, $44, Example B $18, $31, $31, Example C $45, $31, <0 or $31, Note: Amounts in the above example are rounded to the nearest dollar amount. For MS-DRGs 927, 928, 929, 933, 934, 935, 003 and 004, the outlier payment will be made according to the following formula: Outlier Charge = Total Billed Charges MS-DRG Payment implants if applicable 40, If Outlier Charge > 0, then Outlier Payment = 0.65 x Outlier Charge. If Outlier Charge is 0, then Outlier Payment = 0 MS-DRG EXEMPT HOSPITALS The following freestanding rehabilitation or freestanding long-term acute care hospitals are exempt from the Inpatient Hospital Payment Schedule: Shepherd Center Roosevelt Warm Springs Institute Walton Rehabilitation Hospital Central Georgia Rehabilitation Hospital, LLC (formerly HealthSouth Central Georgia Rehabilitation Hospital) Kindred Hospital Atlanta Windy Hill Hospital 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(c)(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. 298 CPT only 2010 American Medical Association. All Rights Reserved.

303 Section XIV: Inpatient Hospital Payment Schedule Effective April 1, 2011 Georgia Workers Compensation Medical Fee Schedule MS-DRG Inpatient Hospital Fee Schedule MS-DRG DESCRIPTION FEE 001 Heart Transplant or Implant of Heart Assist System with MCC Heart Transplant or Implant of Heart Assist System without MCC ECMO or Tracheostomy with Mechanical Ventilation 96+ Hours or Principal Diagnosis Except Face, Mouth and Neck with Major O.R. 004 Tracheostomy with Mechanical Ventilation 96+ Hours or Principal Diagnosis Except Face, Mouth and Neck without Major O.R. 005 Liver Transplant with MCC or Intestinal Transplant Liver Transplant without MCC Lung Transplant Simultaneous Pancreas/Kidney Transplant Pancreas Transplant Tracheostomy for Face, Mouth, and Neck Diagnoses with MCC Tracheostomy for Face, Mouth, and Neck Diagnoses with CC Tracheostomy for Face, Mouth, and Neck Diagnoses without CC/MCC Allogeneic Bone Marrow Transplant Autologous Bone Marrow Transplant Intracranial Vascular Procedures with Principal Diagnosis of Hemorrhage with MCC Intracranial Vascular Procedures with Principal Diagnosis of Hemorrhage with CC Intracranial Vascular Procedures with Principal Diagnosis of Hemorrhage without CC/MCC Craniotomy with Major Device Implant/Acute Complex Central Nervous System Principal Diagnosis with MCC or Chemo Implant 024 Craniotomy with Major Device Implant/Acute Complex Central Nervous System Principal Diagnosis without MCC 025 Craniotomy and Endovascular Intracranial Procedures with MCC Craniotomy and Endovascular Intracranial Procedures with CC Craniotomy and Endovascular Intracranial Procedures without CC/MCC Spinal Procedures with MCC Spinal Procedures with CC or Spinal Neurostimulator Spinal Procedures without CC/MCC Ventricular Shunt Procedures with MCC Ventricular Shunt Procedures with CC Ventricular Shunt Procedures without CC/MCC Carotid Artery Stent Procedure with MCC Carotid Artery Stent Procedure with CC Carotid Artery Stent Procedure without CC/MCC Extracranial Procedures with MCC Extracranial Procedures with CC Extracranial Procedures without CC/MCC Peripheral/Cranial Nerve and Other Nervous System Procedures with MCC Peripheral/Cranial Nerve and Other Nervous System Procedures with CC or Peripheral Neurostimulator Peripheral/Cranial Nerve and Other Nervous System Procedures without CC/MCC Spinal Disorders and Injuries with CC/MCC Spinal Disorders and Injuries without CC/MCC Nervous System Neoplasms with MCC Nervous System Neoplasms without MCC Degenerative Nervous System Disorders with MCC Degenerative Nervous System Disorders without MCC Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 299

304 Georgia Workers Compensation Medical Fee Schedule MS-DRG Section XIV: Inpatient Hospital Payment Schedule Inpatient Hospital Fee Schedule Effective April 1, 2011 MS-DRG DESCRIPTION FEE 058 Multiple Sclerosis and Cerebellar Ataxia with MCC Multiple Sclerosis and Cerebellar Ataxia with CC Multiple Sclerosis and Cerebellar Ataxia without CC/MCC Acute Ischemic Stroke with Use of Thrombolytic Agent with MCC Acute Ischemic Stroke with Use of Thrombolytic Agent with CC Acute Ischemic Stroke with Use of Thrombolytic Agent without CC/MCC Intracranial Hemorrhage or Cerebral Infarction with MCC Intracranial Hemorrhage or Cerebral Infarction with CC Intracranial Hemorrhage or Cerebral Infarction without CC/MCC Nonspecific Cerebrovascular Accident and Precerebral Occlusion without Infarction with MCC Nonspecific Cerebrovascular Accident and Precerebral Occlusion without Infarction without MCC Transient Ischemia Nonspecific Cerebrovascular Disorders with MCC Nonspecific Cerebrovascular Disorders with CC Nonspecific Cerebrovascular Disorders without CC/MCC Cranial and Peripheral Nerve Disorders with MCC Cranial and Peripheral Nerve Disorders without MCC Viral Meningitis with CC/MCC Viral Meningitis without CC/MCC Hypertensive Encephalopathy with MCC Hypertensive Encephalopathy with CC Hypertensive Encephalopathy without CC/MCC Nontraumatic Stupor and Coma with MCC Nontraumatic Stupor and Coma without MCC Traumatic Stupor and Coma, Coma Greater Than One Hour with MCC Traumatic Stupor and Coma, Coma Greater Than One Hour with CC Traumatic Stupor and Coma, Coma Greater Than One Hour without CC/MCC Traumatic Stupor and Coma, Coma Less Than One Hour with MCC Traumatic Stupor and Coma, Coma Less Than One Hour with CC Traumatic Stupor and Coma, Coma Less Than One Hour without CC/MCC Concussion with MCC Concussion with CC Concussion without CC/MCC Other Disorders of Nervous System with MCC Other Disorders of Nervous System with CC Other Disorders of Nervous System without CC/MCC Bacterial and Tuberculous Infections of Nervous System with MCC Bacterial and Tuberculous Infections of Nervous System with CC Bacterial and Tuberculous Infections of Nervous System without CC/MCC Nonbacterial Infections of Nervous System Except Viral Meningitis with MCC Nonbacterial Infections of Nervous System Except Viral Meningitis with CC Nonbacterial Infections of Nervous System Except Viral Meningitis without CC/MCC Seizures with MCC Seizures without MCC Headaches with MCC Headaches without MCC CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

305 Section XIV: Inpatient Hospital Payment Schedule Effective April 1, 2011 Georgia Workers Compensation Medical Fee Schedule MS-DRG Inpatient Hospital Fee Schedule MS-DRG DESCRIPTION FEE 113 Orbital Procedures with CC/MCC Orbital Procedures without CC/MCC Extraocular Procedures Except Orbit Intraocular Procedures with CC/MCC Intraocular Procedures without CC/MCC Acute Major Eye Infections with CC/MCC Acute Major Eye Infections without CC/MCC Neurological Eye Disorders Other Disorders of the Eye with MCC Other Disorders of the Eye without MCC Major Head and Neck Procedures with CC/MCC or Major Device Major Head and Neck Procedures without CC/MCC Cranial/Facial Procedures with CC/MCC Cranial/Facial Procedures without CC/MCC Other Ear, Nose, Mouth and Throat O.R. Procedures with CC/MCC Other Ear, Nose, Mouth and Throat O.R. Procedures without CC/MCC Sinus and Mastoid Procedures with CC/MCC Sinus and Mastoid Procedures without CC/MCC Mouth Procedures with CC/MCC Mouth Procedures without CC/MCC Salivary Gland Procedures Ear, Nose, Mouth and Throat Malignancy with MCC Ear, Nose, Mouth and Throat Malignancy with CC Ear, Nose, Mouth and Throat Malignancy without CC/MCC Dysequilibrium Epistaxis with MCC Epistaxis without MCC Otitis Media and Upper Respiratory Infection with MCC Otitis Media and Upper Respiratory Infection without MCC Other Ear, Nose, Mouth and Throat Diagnoses with MCC Other Ear, Nose, Mouth and Throat Diagnoses with CC Other Ear, Nose, Mouth and Throat Diagnoses without CC/MCC Dental and Oral Diseases with MCC Dental and Oral Diseases with CC Dental and Oral Diseases without CC/MCC Major Chest Procedures with MCC Major Chest Procedures with CC Major Chest Procedures without CC/MCC Other Respiratory System O.R. Procedures with MCC Other Respiratory System O.R. Procedures with CC Other Respiratory System O.R. Procedures without CC/MCC Pulmonary Embolism with MCC Pulmonary Embolism without MCC Respiratory Infections and Inflammations with MCC Respiratory Infections and Inflammations with CC Respiratory Infections and Inflammations without CC/MCC Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 301

306 Georgia Workers Compensation Medical Fee Schedule MS-DRG Section XIV: Inpatient Hospital Payment Schedule Inpatient Hospital Fee Schedule Effective April 1, 2011 MS-DRG DESCRIPTION FEE 180 Respiratory Neoplasms with MCC Respiratory Neoplasms with CC Respiratory Neoplasms without CC/MCC Major Chest Trauma with MCC Major Chest Trauma with CC Major Chest Trauma without CC/MCC Pleural Effusion with MCC Pleural Effusion with CC Pleural Effusion without CC/MCC Pulmonary Edema and Respiratory Failure Chronic Obstructive Pulmonary Disease with MCC Chronic Obstructive Pulmonary Disease with CC Chronic Obstructive Pulmonary Disease without CC/MCC Simple Pneumonia and Pleurisy with MCC Simple Pneumonia and Pleurisy with CC Simple Pneumonia and Pleurisy without CC/MCC Interstitial Lung Disease with MCC Interstitial Lung Disease with CC Interstitial Lung Disease without CC/MCC Pneumothorax with MCC Pneumothorax with CC Pneumothorax without CC/MCC Bronchitis and Asthma with CC/MCC Bronchitis and Asthma without CC/MCC Respiratory Signs and Symptoms Other Respiratory System Diagnoses with MCC Other Respiratory System Diagnoses without MCC Respiratory System Diagnosis with Ventilator Support 96+ Hours Respiratory System Diagnosis with Ventilator Support <96 Hours Other Heart Assist System Implant Cardiac Valve and Other Major Cardiothoracic Procedures with Cardiac Catheterization with MCC Cardiac Valve and Other Major Cardiothoracic Procedures with Cardiac Catheterization with CC Cardiac Valve and Other Major Cardiothoracic Procedures with Cardiac Catheterization without CC/MCC Cardiac Valve and Other Major Cardiothoracic Procedures without Cardiac Catheterization with MCC Cardiac Valve and Other Major Cardiothoracic Procedures without Cardiac Catheterization with CC Cardiac Valve and Other Major Cardiothoracic Procedures without Cardiac Catheterization without CC/MCC Cardiac Defibrillator Implant with Cardiac Catheterization with Acute Myocardial Infarction/Heart Failure/Shock with MCC 223 Cardiac Defibrillator Implant with Cardiac Catheterization with Acute Myocardial Infarction/Heart Failure/Shock without MCC 224 Cardiac Defibrillator Implant with Cardiac Catheterization without Acute Myocardial Infarction/Heart Failure/Shock with MCC 225 Cardiac Defibrillator Implant with Cardiac Catheterization without Acute Myocardial Infarction/Heart Failure/Shock without MCC 226 Cardiac Defibrillator Implant without Cardiac Catheterization with MCC Cardiac Defibrillator Implant without Cardiac Catheterization without MCC Other Cardiothoracic Procedures with MCC Other Cardiothoracic Procedures with CC CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

307 Section XIV: Inpatient Hospital Payment Schedule Effective April 1, 2011 Georgia Workers Compensation Medical Fee Schedule MS-DRG Inpatient Hospital Fee Schedule MS-DRG DESCRIPTION FEE 230 Other Cardiothoracic Procedures without CC/MCC Coronary Bypass with PTCA with MCC Coronary Bypass with PTCA without MCC Coronary Bypass with Cardiac Catheterization with MCC Coronary Bypass with Cardiac Catheterization without MCC Coronary Bypass without Cardiac Catheterization with MCC Coronary Bypass without Cardiac Catheterization without MCC Major Cardiovascular Procedures with MCC or Thoracic Aortic Aneurysm Repair Major Cardiovascular Procedures without MCC Amputation for Circulatory System Disorders Except Upper Limb and Toe with MCC Amputation for Circulatory System Disorders Except Upper Limb and Toe with CC Amputation for Circulatory System Disorders Except Upper Limb and Toe without CC/MCC Permanent Cardiac Pacemaker Implant with MCC Permanent Cardiac Pacemaker Implant with CC Permanent Cardiac Pacemaker Implant without CC/MCC AICD Generator Procedures Percutaneous Cardiovascular Procedure with Drug-Eluting Stent with MCC or 4+ Vessels/Stents Percutaneous Cardiovascular Procedure with Drug-Eluting Stent without MCC Percutaneous Cardiovascular Procedure with Non Drug-Eluting Stent with MCC or 4+ Vessels/Stents Percutaneous Cardiovascular Procedure with Non Drug-Eluting Stent without MCC Percutaneous Cardiovascular Procedure without Coronary Artery Stent with MCC Percutaneous Cardiovascular Procedure without Coronary Artery Stent without MCC Other Vascular Procedures with MCC Other Vascular Procedures with CC Other Vascular Procedures without CC/MCC Upper Limb and Toe Amputation for Circulatory System Disorders with MCC Upper Limb and Toe Amputation for Circulatory System Disorders with CC Upper Limb and Toe Amputation for Circulatory System Disorders without CC/MCC Cardiac Pacemaker Device Replacement with MCC Cardiac Pacemaker Device Replacement without MCC Cardiac Pacemaker Revision Except Device Replacement with MCC Cardiac Pacemaker Revision Except Device Replacement with CC Cardiac Pacemaker Revision Except Device Replacement without CC/MCC Vein Ligation and Stripping Other Circulatory System O.R. Procedures AICD Lead Procedures Acute Myocardial Infarction, Discharged Alive with MCC Acute Myocardial Infarction, Discharged Alive with CC Acute Myocardial Infarction, Discharged Alive without CC/MCC Acute Myocardial Infarction, Expired with MCC Acute Myocardial Infarction, Expired with CC Acute Myocardial Infarction, Expired without CC/MCC Circulatory Disorders Except Acute Myocardial Infarction, with Cardiac Catheterization with MCC Circulatory Disorders Except Acute Myocardial Infarction, with Cardiac Catheterization without MCC Acute and Subacute Endocarditis with MCC Acute and Subacute Endocarditis with CC Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 303

308 Georgia Workers Compensation Medical Fee Schedule MS-DRG Section XIV: Inpatient Hospital Payment Schedule Inpatient Hospital Fee Schedule Effective April 1, 2011 MS-DRG DESCRIPTION FEE 290 Acute and Subacute Endocarditis without CC/MCC Heart Failure and Shock with MCC Heart Failure and Shock with CC Heart Failure and Shock without CC/MCC Deep Vein Thrombophlebitis with CC/MCC Deep Vein Thrombophlebitis without CC/MCC Cardiac Arrest, Unexplained with MCC Cardiac Arrest, Unexplained with CC Cardiac Arrest, Unexplained without CC/MCC Peripheral Vascular Disorders with MCC Peripheral Vascular Disorders with CC Peripheral Vascular Disorders without CC/MCC Atherosclerosis with MCC Atherosclerosis without MCC Hypertension with MCC Hypertension without MCC Cardiac Congenital and Valvular Disorders with MCC Cardiac Congenital and Valvular Disorders without MCC Cardiac Arrhythmia and Conduction Disorders with MCC Cardiac Arrhythmia and Conduction Disorders with CC Cardiac Arrhythmia and Conduction Disorders without CC/MCC Angina Pectoris Syncope and Collapse Chest Pain Other Circulatory System Diagnoses with MCC Other Circulatory System Diagnoses with CC Other Circulatory System Diagnoses without CC/MCC Stomach, Esophageal and Duodenal Procedures with MCC Stomach, Esophageal and Duodenal Procedures with CC Stomach, Esophageal and Duodenal Procedures without CC/MCC Major Small and Large Bowel Procedures with MCC Major Small and Large Bowel Procedures with CC Major Small and Large Bowel Procedures without CC/MCC Rectal Resection with MCC Rectal Resection with CC Rectal Resection without CC/MCC Peritoneal Adhesiolysis with MCC Peritoneal Adhesiolysis with CC Peritoneal Adhesiolysis without CC/MCC Appendectomy with Complicated Principal Diagnosis with MCC Appendectomy with Complicated Principal Diagnosis with CC Appendectomy with Complicated Principal Diagnosis without CC/MCC Appendectomy without Complicated Principal Diagnosis with MCC Appendectomy without Complicated Principal Diagnosis with CC Appendectomy without Complicated Principal Diagnosis without CC/MCC Minor Small and Large Bowel Procedures with MCC CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

309 Section XIV: Inpatient Hospital Payment Schedule Effective April 1, 2011 Georgia Workers Compensation Medical Fee Schedule MS-DRG Inpatient Hospital Fee Schedule MS-DRG DESCRIPTION FEE 345 Minor Small and Large Bowel Procedures with CC Minor Small and Large Bowel Procedures without CC/MCC Anal and Stomal Procedures with MCC Anal and Stomal Procedures with CC Anal and Stomal Procedures without CC/MCC Inguinal and Femoral Hernia Procedures with MCC Inguinal and Femoral Hernia Procedures with CC Inguinal and Femoral Hernia Procedures without CC/MCC Hernia Procedures Except Inguinal and Femoral with MCC Hernia Procedures Except Inguinal and Femoral with CC Hernia Procedures Except Inguinal and Femoral without CC/MCC Other Digestive System O.R. Procedures with MCC Other Digestive System O.R. Procedures with CC Other Digestive System O.R. Procedures without CC/MCC Major Esophageal Disorders with MCC Major Esophageal Disorders with CC Major Esophageal Disorders without CC/MCC Major Gastrointestinal Disorders and Peritoneal Infections with MCC Major Gastrointestinal Disorders and Peritoneal Infections with CC Major Gastrointestinal Disorders and Peritoneal Infections without CC/MCC Digestive Malignancy with MCC Digestive Malignancy with CC Digestive Malignancy without CC/MCC GI Hemorrhage with MCC GI Hemorrhage with CC GI Hemorrhage without CC/MCC Complicated Peptic Ulcer with MCC Complicated Peptic Ulcer with CC Complicated Peptic Ulcer without CC/MCC Uncomplicated Peptic Ulcer with MCC Uncomplicated Peptic Ulcer without MCC Inflammatory Bowel Disease with MCC Inflammatory Bowel Disease with CC Inflammatory Bowel Disease without CC/MCC GI Obstruction with MCC GI Obstruction with CC GI Obstruction without CC/MCC Esophagitis, Gastroenteritis and Miscellaneous Digestive Disorders with MCC Esophagitis, Gastroenteritis and Miscellaneous Digestive Disorders without MCC Other Digestive System Diagnoses with MCC Other Digestive System Diagnoses with CC Other Digestive System Diagnoses without CC/MCC Pancreas, Liver and Shunt Procedures with MCC Pancreas, Liver and Shunt Procedures with CC Pancreas, Liver and Shunt Procedures without CC/MCC Biliary Tract Procedures Except Only Cholecystectomy with or without C.D.E. with MCC Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 305

310 Georgia Workers Compensation Medical Fee Schedule MS-DRG Section XIV: Inpatient Hospital Payment Schedule Inpatient Hospital Fee Schedule Effective April 1, 2011 MS-DRG DESCRIPTION FEE 409 Biliary Tract Procedures Except Only Cholecystectomy with or without C.D.E. with CC Biliary Tract Procedures Except Only Cholecystectomy with or without C.D.E. without CC/MCC Cholecystectomy with C.D.E. with MCC Cholecystectomy with C.D.E. with CC Cholecystectomy with C.D.E. without CC/MCC Cholecystectomy Except by Laparoscope without C.D.E. with MCC Cholecystectomy Except by Laparoscope without C.D.E. with CC Cholecystectomy Except by Laparoscope without C.D.E. without CC/MCC Laparoscopic Cholecystectomy without C.D.E. with MCC Laparoscopic Cholecystectomy without C.D.E. with CC Laparoscopic Cholecystectomy without C.D.E. without CC/MCC Hepatobiliary Diagnostic Procedures with MCC Hepatobiliary Diagnostic Procedures with CC Hepatobiliary Diagnostic Procedures without CC/MCC Other Hepatobiliary or Pancreas O.R. Procedures with MCC Other Hepatobiliary or Pancreas O.R. Procedures with CC Other Hepatobiliary or Pancreas O.R. Procedures without CC/MCC Cirrhosis and Alcoholic Hepatitis with MCC Cirrhosis and Alcoholic Hepatitis with CC Cirrhosis and Alcoholic Hepatitis without CC/MCC Malignancy of Hepatobiliary System or Pancreas with MCC Malignancy of Hepatobiliary System or Pancreas with CC Malignancy of Hepatobiliary System or Pancreas without CC/MCC Disorders of Pancreas Except Malignancy with MCC Disorders of Pancreas Except Malignancy with CC Disorders of Pancreas Except Malignancy without CC/MCC Disorders of Liver Except Malignancy, Cirrhosis, Alcoholic Hepatitis with MCC Disorders of Liver Except Malignancy, Cirrhosis, Alcoholic Hepatitis with CC Disorders of Liver Except Malignancy, Cirrhosis, Alcoholic Hepatitis without CC/MCC Disorders of the Biliary Tract with MCC Disorders of the Biliary Tract with CC Disorders of the Biliary Tract without CC/MCC Combined Anterior/Posterior Spinal Fusion with MCC Combined Anterior/Posterior Spinal Fusion with CC Combined Anterior/Posterior Spinal Fusion without CC/MCC Spinal Fusion Except Cervical with Spinal Curvature/Malignancy/Infection or 9+ Fusions with MCC Spinal Fusion Except Cervical with Spinal Curvature/Malignancy/Infection or 9+ Fusions with CC Spinal Fusion Except Cervical with Spinal Curvature/Malignancy/Infection or 9+ Fusions without CC/MCC Spinal Fusion Except Cervical with MCC Spinal Fusion Except Cervical without MCC Bilateral or Multiple Major Joint Procedures of Lower Extremity with MCC Bilateral or Multiple Major Joint Procedures of Lower Extremity without MCC Wound Debridement and Skin Graft Except Hand, for Musculo-Connective Tissue Disorders with MCC Wound Debridement and Skin Graft Except Hand, for Musculo-Connective Tissue Disorders with CC Wound Debridement and Skin Graft Except Hand, for Musculo-Connective Tissue Disorders without CC/MCC 466 Revision of Hip or Knee Replacement with MCC CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

311 Section XIV: Inpatient Hospital Payment Schedule Effective April 1, 2011 Georgia Workers Compensation Medical Fee Schedule MS-DRG Inpatient Hospital Fee Schedule MS-DRG DESCRIPTION FEE 467 Revision of Hip or Knee Replacement with CC Revision of Hip or Knee Replacement without CC/MCC Major Joint Replacement or Reattachment of Lower Extremity with MCC Major Joint Replacement or Reattachment of Lower Extremity without MCC Cervical Spinal Fusion with MCC Cervical Spinal Fusion with CC Cervical Spinal Fusion without CC/MCC Amputation for Musculoskeletal System and Connective Tissue Disorders with MCC Amputation for Musculoskeletal System and Connective Tissue Disorders with CC Amputation for Musculoskeletal System and Connective Tissue Disorders without CC/MCC Biopsies of Musculoskeletal System and Connective Tissue with MCC Biopsies of Musculoskeletal System and Connective Tissue with CC Biopsies of Musculoskeletal System and Connective Tissue without CC/MCC Hip and Femur Procedures Except Major Joint with MCC Hip and Femur Procedures Except Major Joint with CC Hip and Femur Procedures Except Major Joint without CC/MCC Major Joint and Limb Reattachment Procedures of Upper Extremity with CC/MCC Major Joint and Limb Reattachment Procedures of Upper Extremity without CC/MCC Knee Procedures with Principal Diagnosis of Infection with MCC Knee Procedures with Principal Diagnosis of Infection with CC Knee Procedures with Principal Diagnosis of Infection without CC/MCC Knee Procedures without Principal Diagnosis of Infection with CC/MCC Knee Procedures without Principal Diagnosis of Infection without CC/MCC Back and Neck Procedures Except Spinal Fusion with CC/MCC or Disc Device/Neurostimulator Back and Neck Procedures Except Spinal Fusion without CC/MCC Lower Extremity and Humerus Procedures Except Hip, Foot, Femur with MCC Lower Extremity and Humerus Procedures Except Hip, Foot, Femur with CC Lower Extremity and Humerus Procedures Except Hip, Foot, Femur without CC/MCC Local Excision and Removal Internal Fixation Devices Except Hip and Femur with MCC Local Excision and Removal Internal Fixation Devices Except Hip and Femur with CC Local Excision and Removal Internal Fixation Devices Except Hip and Femur without CC/MCC Local Excision and Removal Internal Fixation Devices of Hip and Femur with CC/MCC Local Excision and Removal Internal Fixation Devices of Hip and Femur without CC/MCC Soft Tissue Procedures with MCC Soft Tissue Procedures with CC Soft Tissue Procedures without CC/MCC Foot Procedures with MCC Foot Procedures with CC Foot Procedures without CC/MCC Major Thumb or Joint Procedures Major Shoulder or Elbow Joint Procedures with CC/MCC Major Shoulder or Elbow Joint Procedures without CC/MCC Arthroscopy Shoulder, Elbow or Forearm Procedure, Except Major Joint Procedure with MCC Shoulder, Elbow or Forearm Procedure, Except Major Joint Procedure with CC Shoulder, Elbow or Forearm Procedure, Except Major Joint Procedure without CC/MCC Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 307

312 Georgia Workers Compensation Medical Fee Schedule MS-DRG Section XIV: Inpatient Hospital Payment Schedule Inpatient Hospital Fee Schedule Effective April 1, 2011 MS-DRG DESCRIPTION FEE 513 Hand or Wrist Procedures, Except Major Thumb or Joint Procedures with CC/MCC Hand or Wrist Procedures, Except Major Thumb or Joint Procedures without CC/MCC Other Musculoskeletal System and Connective Tissue O.R. Procedure with MCC Other Musculoskeletal System and Connective Tissue O.R. Procedure with CC Other Musculoskeletal System and Connective Tissue O.R. Procedure without CC/MCC Fractures of Femur with MCC Fractures of Femur without MCC Fractures of Hip and Pelvis with MCC Fractures of Hip and Pelvis without MCC Sprains, Strains, and Dislocations of Hip, Pelvis and Thigh with CC/MCC Sprains, Strains, and Dislocations of Hip, Pelvis and Thigh without CC/MCC Osteomyelitis with MCC Osteomyelitis with CC Osteomyelitis without CC/MCC Pathological Fractures and Musculoskeletal and Connective Tissue Malignancy with MCC Pathological Fractures and Musculoskeletal and Connective Tissue Malignancy with CC Pathological Fractures and Musculoskeletal and Connective Tissue Malignancy without CC/MCC Connective Tissue Disorders with MCC Connective Tissue Disorders with CC Connective Tissue Disorders without CC/MCC Septic Arthritis with MCC Septic Arthritis with CC Septic Arthritis without CC/MCC Medical Back Problems with MCC Medical Back Problems without MCC Bone Diseases and Arthropathies with MCC Bone Diseases and Arthropathies without MCC Signs and Symptoms of Musculoskeletal System and Connective Tissue with MCC Signs and Symptoms of Musculoskeletal System and Connective Tissue without MCC Tendonitis, Myositis and Bursitis with MCC Tendonitis, Myositis and Bursitis without MCC Aftercare, Musculoskeletal System and Connective Tissue with MCC Aftercare, Musculoskeletal System and Connective Tissue with CC Aftercare, Musculoskeletal System and Connective Tissue without CC/MCC Fractures, Sprains, Strains and Dislocations Except Femur, Hip, Pelvis and Thigh with MCC Fractures, Sprains, Strains and Dislocations Except Femur, Hip, Pelvis and Thigh without MCC Other Musculoskeletal System and Connective Tissue Diagnoses with MCC Other Musculoskeletal System and Connective Tissue Diagnoses with CC Other Musculoskeletal System and Connective Tissue Diagnoses without CC/MCC Skin Graft and/or Debridement for Skin Ulcer or Cellulitis with MCC Skin Graft and/or Debridement for Skin Ulcer or Cellulitis with CC Skin Graft and/or Debridement for Skin Ulcer or Cellulitis without CC/MCC Skin Graft and/or Debridement Except for Skin Ulcer or Cellulitis with MCC Skin Graft and/or Debridement Except for Skin Ulcer or Cellulitis with CC Skin Graft and/or Debridement Except for Skin Ulcer or Cellulitis without CC/MCC Other Skin, Subcutaneous Tissue and Breast Procedures with MCC CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

313 Section XIV: Inpatient Hospital Payment Schedule Effective April 1, 2011 Georgia Workers Compensation Medical Fee Schedule MS-DRG Inpatient Hospital Fee Schedule MS-DRG DESCRIPTION FEE 580 Other Skin, Subcutaneous Tissue and Breast Procedures with CC Other Skin, Subcutaneous Tissue and Breast Procedures without CC/MCC Mastectomy for Malignancy with CC/MCC Mastectomy for Malignancy without CC/MCC Breast Biopsy, Local Excision and Other Breast Procedures with CC/MCC Breast Biopsy, Local Excision and Other Breast Procedures without CC/MCC Skin Ulcers with MCC Skin Ulcers with CC Skin Ulcers without CC/MCC Major Skin Disorders with MCC Major Skin Disorders without MCC Malignant Breast Disorders with MCC Malignant Breast Disorders with CC Malignant Breast Disorders without CC/MCC Nonmalignant Breast Disorders with CC/MCC Nonmalignant Breast Disorders without CC/MCC Cellulitis with MCC Cellulitis without MCC Trauma to the Skin, Subcutaneous Tissue and Breast with MCC Trauma to the Skin, Subcutaneous Tissue & Breast without MCC Minor Skin Disorders with MCC Minor Skin Disorders without MCC Adrenal and Pituitary Procedures with CC/MCC Adrenal and Pituitary Procedures without CC/MCC Amputation of Lower Limb for Endocrine, Nutritional, and Metabolic Disorders with MCC Amputation of Lower Limb for Endocrine, Nutritional, and Metabolic Disorders with CC Amputation of Lower Limb for Endocrine, Nutritional, and Metabolic Disorders without CC/MCC O.R. Procedures for Obesity with MCC O.R. Procedures for Obesity with CC O.R. Procedures for Obesity without CC/MCC Skin Grafts and Wound Debridement for Endocrine, Nutritional and Metabolic Disorders with MCC Skin Grafts and Wound Debridement for Endocrine, Nutritional and Metabolic Disorders with CC Skin Grafts and Wound Debridement for Endocrine, Nutritional and Metabolic Disorders without CC/MCC Thyroid, Parathyroid and Thyroglossal Procedures with MCC Thyroid, Parathyroid and Thyroglossal Procedures with CC Thyroid, Parathyroid and Thyroglossal Procedures without CC/MCC Other Endocrine, Nutritional and Metabolic O.R. Procedures with MCC Other Endocrine, Nutritional and Metabolic O.R. Procedures with CC Other Endocrine, Nutritional and Metabolic O.R. Procedures without CC/MCC Diabetes with MCC Diabetes with CC Diabetes without CC/MCC Nutritional and Miscellaneous Metabolic Disorders with MCC Nutritional and Miscellaneous Metabolic Disorders without MCC Inborn Errors of Metabolism Endocrine Disorders with MCC Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 309

314 Georgia Workers Compensation Medical Fee Schedule MS-DRG Section XIV: Inpatient Hospital Payment Schedule Inpatient Hospital Fee Schedule Effective April 1, 2011 MS-DRG DESCRIPTION FEE 644 Endocrine Disorders with CC Endocrine Disorders without CC/MCC Kidney Transplant Major Bladder Procedures with MCC Major Bladder Procedures with CC Major Bladder Procedures without CC/MCC Kidney and Ureter Procedures for Neoplasm with MCC Kidney and Ureter Procedures for Neoplasm with CC Kidney and Ureter Procedures for Neoplasm without CC/MCC Kidney and Ureter Procedures for Non-neoplasm with MCC Kidney and Ureter Procedures for Non-neoplasm with CC Kidney and Ureter Procedures for Non-neoplasm without CC/MCC Minor Bladder Procedures with MCC Minor Bladder Procedures with CC Minor Bladder Procedures without CC/MCC Prostatectomy with MCC Prostatectomy with CC Prostatectomy without CC/MCC Transurethral Procedures with MCC Transurethral Procedures with CC Transurethral Procedures without CC/MCC Urethral Procedures with CC/MCC Urethral Procedures without CC/MCC Other Kidney and Urinary Tract Procedures with MCC Other Kidney and Urinary Tract Procedures with CC Other Kidney and Urinary Tract Procedures without CC/MCC Renal Failure with MCC Renal Failure with CC Renal Failure without CC/MCC Admit for Renal Dialysis Kidney and Urinary Tract Neoplasms with MCC Kidney and Urinary Tract Neoplasms with CC Kidney and Urinary Tract Neoplasms without CC/MCC Kidney and Urinary Tract Infections with MCC Kidney and Urinary Tract Infections without MCC Urinary Stones with ESW Lithotripsy with CC/MCC Urinary Stones with ESW Lithotripsy without CC/MCC Urinary Stones without ESW Lithotripsy with MCC Urinary Stones without ESW Lithotripsy without MCC Kidney and Urinary Tract Signs and Symptoms with MCC Kidney and Urinary Tract Signs and Symptoms without MCC Urethral Stricture Other Kidney and Urinary Tract Diagnoses with MCC Other Kidney and Urinary Tract Diagnoses with CC Other Kidney and Urinary Tract Diagnoses without CC/MCC Major Male Pelvic Procedures with CC/MCC CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

315 Section XIV: Inpatient Hospital Payment Schedule Effective April 1, 2011 Georgia Workers Compensation Medical Fee Schedule MS-DRG Inpatient Hospital Fee Schedule MS-DRG DESCRIPTION FEE 708 Major Male Pelvic Procedures without CC/MCC Penis Procedures with CC/MCC Penis Procedures without CC/MCC Testes Procedures with CC/MCC Testes Procedures without CC/MCC Transurethral Prostatectomy with CC/MCC Transurethral Prostatectomy without CC/MCC Other Male Reproductive System O.R. Procedures for Malignancy with CC/MCC Other Male Reproductive System O.R. Procedures for Malignancy without CC/MCC Other Male Reproductive System O.R. Procedures Except Malignancy with CC/MCC Other Male Reproductive System O.R. Procedures Except Malignancy without CC/MCC Malignancy, Male Reproductive System with MCC Malignancy, Male Reproductive System with CC Malignancy, Male Reproductive System without CC/MCC Benign Prostatic Hypertrophy with MCC Benign Prostatic Hypertrophy without MCC Inflammation of the Male Reproductive System with MCC Inflammation of the Male Reproductive System without MCC Other Male Reproductive System Diagnoses with CC/MCC Other Male Reproductive System Diagnoses without CC/MCC Pelvic Evisceration, Radical Hysterectomy and Radical Vulvectomy with CC/MCC Pelvic Evisceration, Radical Hysterectomy and Radical Vulvectomy without CC/MCC Uterine and Adnexa Procedures for Ovarian or Adnexal Malignancy with MCC Uterine and Adnexa Procedures for Ovarian or Adnexal Malignancy with CC Uterine and Adnexa Procedures for Ovarian or Adnexal Malignancy without CC/MCC Uterine, Adnexa Procedures for Nonovarian/Adnexal Malignancy with MCC Uterine, Adnexa Procedures for Nonovarian/Adnexal Malignancy with CC Uterine, Adnexa Procedures for Nonovarian/Adnexal Malignancy without CC/MCC Uterine and Adnexa Procedures for Nonmalignancy with CC/MCC Uterine and Adnexa Procedures for Nonmalignancy without CC/MCC D&C, Conization, Laparoscopy and Tubal Interruption with CC/MCC D&C, Conization, Laparoscopy and Tubal Interruption without CC/MCC Vagina, Cervix and Vulva Procedures with CC/MCC Vagina, Cervix and Vulva Procedures without CC/MCC Female Reproductive System Reconstructive Procedures Other Female Reproductive System O.R. Procedures with CC/MCC Other Female Reproductive System O.R. Procedures without CC/MCC Malignancy, Female Reproductive System with MCC Malignancy, Female Reproductive System with CC Malignancy, Female Reproductive System without CC/MCC Infections, Female Reproductive System with MCC Infections, Female Reproductive System with CC Infections, Female Reproductive System without CC/MCC Menstrual and Other Female Reproductive System Disorders with CC/MCC Menstrual and Other Female Reproductive System Disorders without CC/MCC Cesarean Section with CC/MCC Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 311

316 Georgia Workers Compensation Medical Fee Schedule MS-DRG Section XIV: Inpatient Hospital Payment Schedule Inpatient Hospital Fee Schedule Effective April 1, 2011 MS-DRG DESCRIPTION FEE 766 Cesarean Section without CC/MCC Vaginal Delivery with Sterilization and/or D&C Vaginal Delivery with O.R. Procedure Except Sterilization and/or D&C Postpartum and Postabortion Diagnoses with O.R. Procedure Abortion with D&C, Aspiration Curettage or Hysterotomy Vaginal Delivery with Complicating Diagnoses Vaginal Delivery without Complicating Diagnoses Postpartum and Postabortion Diagnoses without O.R. Procedure Ectopic Pregnancy Threatened Abortion Abortion without D&C False Labor Other Antepartum Diagnoses with Medical Complications Other Antepartum Diagnoses without Medical Complications Neonates, Died or Transferred to Another Acute Care Facility Extreme Immaturity or Respiratory Distress Syndrome, Neonate Prematurity with Major Problems Prematurity without Major Problems Full Term Neonate with Major Problems Neonate with Other Significant Problems Normal Newborn Splenectomy with MCC Splenectomy with CC Splenectomy without CC/MCC Other O.R. Procedures of the Blood and Blood-Forming Organs with MCC Other O.R. Procedures of the Blood and Blood-Forming Organs with CC Other O.R. Procedures of the Blood and Blood-Forming Organs without CC/MCC Major Hematologic/Immunologic Diagnoses Except Sickle Cell Crisis and Coagulation with MCC Major Hematologic/Immunologic Diagnoses Except Sickle Cell Crisis and Coagulation with CC Major Hematologic/Immunologic Diagnoses Except Sickle Cell Crisis and Coagulation without CC/MCC Red Blood Cell Disorders with MCC Red Blood Cell Disorders without MCC Coagulation Disorders Reticuloendothelial and Immunity Disorders with MCC Reticuloendothelial and Immunity Disorders with CC Reticuloendothelial and Immunity Disorders without CC/MCC Lymphoma and Leukemia with Major O.R. Procedure with MCC Lymphoma and Leukemia with Major O.R. Procedure with CC Lymphoma and Leukemia with Major O.R. Procedure without CC/MCC Lymphoma and Nonacute Leukemia with Other O.R. Procedure with MCC Lymphoma and Nonacute Leukemia with Other O.R. Procedure with CC Lymphoma and Nonacute Leukemia with Other O.R. Procedure without CC/MCC Myeloproliferative Disorders or Poorly Differentiated Neoplasms with Major O.R. Procedure with MCC Myeloproliferative Disorders or Poorly Differentiated Neoplasms with Major O.R. Procedure with CC Myeloproliferative Disorders or Poorly Differentiated Neoplasms with Major O.R. Procedure without CC/MCC 829 Myeloproliferative Disorders or Poorly Differentiated Neoplasms with Other O.R. Procedure with CC/MCC CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

317 Section XIV: Inpatient Hospital Payment Schedule Effective April 1, 2011 Georgia Workers Compensation Medical Fee Schedule MS-DRG Inpatient Hospital Fee Schedule MS-DRG DESCRIPTION FEE 830 Myeloproliferative Disorders or Poorly Differentiated Neoplasms with Other O.R. Procedure without CC/MCC Acute Leukemia without Major O.R. Procedure with MCC Acute Leukemia without Major O.R. Procedure with CC Acute Leukemia without Major O.R. Procedure without CC/MCC Chemotherapy with Acute Leukemia as Secondary Diagnosis or with High Dose Chemotherapy Agent with MCC 838 Chemotherapy with Acute Leukemia as Secondary Diagnosis with CC or High Dose Chemotherapy Agent Chemotherapy with Acute Leukemia as Secondary Diagnosis without CC/MCC Lymphoma and Nonacute Leukemia with MCC Lymphoma and Nonacute Leukemia with CC Lymphoma and Nonacute Leukemia without CC/MCC Other Myeloproliferative Disorders or Poorly Differentiated Neoplasm Diagnoses with MCC Other Myeloproliferative Disorders or Poorly Differentiated Neoplasm Diagnoses with CC Other Myeloproliferative Disorders or Poorly Differentiated Neoplasm Diagnoses without CC/MCC Chemotherapy without Acute Leukemia as Secondary Diagnosis with MCC Chemotherapy without Acute Leukemia as Secondary Diagnosis with CC Chemotherapy without Acute Leukemia as Secondary Diagnosis without CC/MCC Radiotherapy Infectious and Parasitic Diseases with O.R. Procedure with MCC Infectious and Parasitic Diseases with O.R. Procedure with CC Infectious and Parasitic Diseases with O.R. Procedure without CC/MCC Postoperative or Posttraumatic Infections with O.R. Procedure with MCC Postoperative or Posttraumatic Infections with O.R. Procedure with CC Postoperative or Posttraumatic Infections with O.R. Procedure without CC/MCC Postoperative and Posttraumatic Infections with MCC Postoperative and Posttraumatic Infections without MCC Fever Viral Illness with MCC Viral Illness without MCC Other Infectious and Parasitic Diseases Diagnoses with MCC Other Infectious and Parasitic Diseases Diagnoses with CC Other Infectious and Parasitic Diseases Diagnoses without CC/MCC Septicemia or Severe Sepsis with Mechanical Ventilation 96+ Hours Septicemia or Severe Sepsis without Mechanical Ventilation 96+ Hours with MCC Septicemia or Severe Sepsis without Mechanical Ventilation 96+ Hours without MCC O.R. Procedure with Principal Diagnoses of Mental Illness Acute Adjustment Reaction and Psychosocial Dysfunction Depressive Neuroses Neuroses Except Depressive Disorders of Personality and Impulse Control Organic Disturbances and Mental Retardation Psychoses Behavioral and Developmental Disorders Other Mental Disorder Diagnoses Alcohol/Drug Abuse or Dependence, Left Against Medical Advice Alcohol/Drug Abuse or Dependence with Rehabilitation Therapy Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 313

318 Georgia Workers Compensation Medical Fee Schedule MS-DRG Section XIV: Inpatient Hospital Payment Schedule Inpatient Hospital Fee Schedule Effective April 1, 2011 MS-DRG DESCRIPTION FEE 896 Alcohol/Drug Abuse or Dependence without Rehabilitation Therapy with MCC Alcohol/Drug Abuse or Dependence without Rehabilitation Therapy without MCC Wound Debridements for Injuries with MCC Wound Debridements for Injuries with CC Wound Debridements for Injuries without CC/MCC Skin Grafts for Injuries with CC/MCC Skin Grafts for Injuries without CC/MCC Hand Procedures for Injuries Other O.R. Procedures for Injuries with MCC Other O.R. Procedures for Injuries with CC Other O.R. Procedures for Injuries without CC/MCC Traumatic Injury with MCC Traumatic Injury without MCC Allergic Reactions with MCC Allergic Reactions without MCC Poisoning and Toxic Effects of Drugs with MCC Poisoning and Toxic Effects of Drugs without MCC Complications of Treatment with MCC Complications of Treatment with CC Complications of Treatment without CC/MCC Other Injury, Poisoning and Toxic Effect Diagnoses with MCC Other Injury, Poisoning and Toxic Effect Diagnoses without MCC Extensive Burns or Full Thickness Burns with Mechanical Ventilation 96+ Hours with Skin Graft Full Thickness Burn with Skin Graft or Inhalation Injury with CC/MCC Full Thickness Burn with Skin Graft or Inhalation Injury without CC/MCC Extensive Burns or Full Thickness Burns with Mechanical Ventilation 96+ Hours without Skin Graft Full Thickness Burn without Skin Graft or Inhalation Injury Nonextensive Burns O.R. Procedure with Diagnoses of Other Contact with Health Services with MCC O.R. Procedure with Diagnoses of Other Contact with Health Services with CC O.R. Procedure with Diagnoses of Other Contact with Health Services without CC/MCC Rehabilitation with CC/MCC Rehabilitation without CC/MCC Signs and Symptoms with MCC Signs and Symptoms without MCC Aftercare with CC/MCC Aftercare without CC/MCC Other Factors Influencing Health Status Craniotomy for Multiple Significant Trauma Limb Reattachment, Hip and Femur Procedures for Multiple Significant Trauma Other O.R. Procedures for Multiple Significant Trauma with MCC Other O.R. Procedures for Multiple Significant Trauma with CC Other O.R. Procedures for Multiple Significant Trauma without CC/MCC Other Multiple Significant Trauma with MCC Other Multiple Significant Trauma with CC Other Multiple Significant Trauma without CC/MCC CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

319 Section XIV: Inpatient Hospital Payment Schedule Effective April 1, 2011 Georgia Workers Compensation Medical Fee Schedule MS-DRG Inpatient Hospital Fee Schedule MS-DRG DESCRIPTION FEE 969 HIV with Extensive O.R. Procedure with MCC HIV with Extensive O.R. Procedure without MCC HIV with Major Related Condition with MCC HIV with Major Related Condition with CC HIV with Major Related Condition without CC/MCC HIV with or without Other Related Condition Extensive O.R. Procedure Unrelated to Principal Diagnosis with MCC Extensive O.R. Procedure Unrelated to Principal Diagnosis with CC Extensive O.R. Procedure Unrelated to Principal Diagnosis without CC/MCC Prostatic O.R. Procedure Unrelated to Principal Diagnosis with MCC Prostatic O.R. Procedure Unrelated to Principal Diagnosis with CC Prostatic O.R. Procedure Unrelated to Principal Diagnosis without CC/MCC Nonextensive O.R. Procedure Unrelated to Principal Diagnosis with MCC Nonextensive O.R. Procedure Unrelated to Principal Diagnosis with CC Nonextensive O.R. Procedure Unrelated to Principal Diagnosis without CC/MCC Principal Diagnosis Invalid as Discharge Diagnosis NA 999 Ungroupable NA Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 315

320

321 Section XV: Outpatient Surgery Payment Schedule SURGICAL SERVICES PROVIDED BY OUTPATIENT HOSPITAL AND AMBULATORY SURGERY CENTERS Payment for outpatient surgical services and associated goods rendered by a hospital or an ambulatory surgery center must be submitted on form Uniform Billing 04 (UB-04). 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 Fee Schedule for the procedure listed in locator Field 74 of UB-04 on the facility s bill. This payment schedule is not all-inclusive. For any UB-04 for which a corresponding ICD-9-CM, volume 3 code listed in Field 74 of Form UB-04 does not exist in the above-referenced listing and schedule, payment shall be made at percent of charges (excluding implants, which are reimbursed as discussed below). No additional payment shall be required even if other procedures are listed in Fields 74A-E (UB-04), except as follows: Facilities may receive additional payment in excess of the fee for the primary procedure listed in fields above if (1) the additional procedures are performed on a separate and distinct body part or system, and (2) the additional procedures would not normally be considered an integral part of a larger procedure or incidental to another procedure performed during the same session. In order to receive the additional payment, facilities must code the additional procedures in Field 74A-E (UB-04) of the bill, include a concise medical justification for the additional procedures in the Remarks section of the UB-04 (Field 80), and provide an itemized bill and a copy of the operating room notes reflecting that the additional procedures meet the criteria listed above. When multiple procedures are performed that meet the above requirements and the procedures are included in the ICD-9-CM, volume 3 listing, payment shall be at the lower of: 1. Billed charges, or 2. Primary procedure: 100 percent of the amount specified in the ICD-9-CM, volume 3 listing Each additional procedure: 75 percent of the amount specified in the ICD-9-CM, volume 3 listing When multiple procedures are performed that meet the above requirements and the additional procedures are not included in the ICD-9-CM, volume 3 listing, payment shall be at the lower of: 1. Billed charges, or 2. Primary procedure: 100 percent of the amount specified in the ICD-9-CM, volume 3 listing Each additional procedure: percent of the difference between the total charges and the listed amount for the primary procedure, calculated as follows: (Total charges Primary procedure listed amount) x percent When multiple procedures are performed that meet the above requirements and neither the primary nor the additional procedures are included in the ICD-9-CM, volume 3 listing, payment shall be percent of billed charges (excluding implants, which are reimbursed as discussed below). Multiple procedures, consisting of an endoscopic or arthroscopic procedure followed by an open procedure on the same body part or system, do not warrant separate reimbursement. The higher valued procedure, usually the open procedure, should be listed in Field 74 (UB-04) and will be reimbursed as the primary procedure. The endoscopic or arthroscopic procedure is considered to be part of the larger procedure and will not be reimbursed separately. CPT only 2010 American Medical Association. All Rights Reserved. 317

322 Georgia Workers Compensation Medical Fee Schedule IMPLANTS, DME, AND SUPPLIES See Inpatient Hospital Payment Schedule for rules related to implants, DME, and supplies. NONSURGICAL RADIOLOGY SERVICES Radiology services, including discography, myelography, arthrography, and epidurography, not performed incident to surgical sessions shall be reimbursed at 10 percent above the technical component set forth in the fee schedule. The reimbursement is based upon the CPT codes, as well as pharmaceuticals and supplies as appropriate, which are reported in Field 44 of Form UB-04 on the facility s bill. Note that ICD-9-CM, volume 3 procedure codes are not valid to report these services. 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 TC calculation: MAR for CPT code TC for technical component is $ Maximum allowed rate = $ percent ($23.07) = $ PHYSICAL THERAPY SERVICES Physical therapy services shall be reimbursed at the maximum allowable rate (MAR) set forth in the provider fee schedule. The reimbursement is based upon the CPT codes which are reported in Field 44 of Form UB-04 on the facility s bill. Note that ICD-9-CM, volume 3 procedure codes are not valid to report these services. (See Section XI: Physical Medicine Services for guidelines.) MODIFIERS A modifier is the methodology used by the reporting physician to indicate or flag a service or procedure code regarding special circumstances affecting that service. The service or procedure description is not affected. 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. All facilities that bill for Section XV: Outpatient Surgery Payment Schedule services on the UB-04 forms are required to include all appropriate CPT and HCPCS codes and applicable modifiers in Field 44. The following modifiers will be recognized for reimbursement by the fee schedule for outpatient surgery services reported on hospital outpatient facility and ambulatory surgery center claims: 73 Discontinued Out-Patient Hospital/Ambulatory Surgery Center (ASC) Procedure Prior to the Administration of Anesthesia: Due to extenuating circumstances or those that threaten the well-being of the patient, the physician may cancel a surgical or diagnostic procedure subsequent to the patient s surgical preparation (including sedation when provided, and being taken to the room where the procedure is to be performed), but prior to the administration of anesthesia (local, regional block(s), or general). Under these circumstances, the intended service that is prepared for but cancelled can be reported by its usual procedure number and the addition of modifier 73. Note: The elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. For physician reporting of a discontinued procedure, see modifier 53. Reimbursement By Report. 74 Discontinued Out-Patient Hospital/Ambulatory Surgery Center (ASC) Procedure After Administration of Anesthesia: Due to extenuating circumstances or those that threaten the well-being of the patient, the physician may terminate a surgical or diagnostic procedure after the administration of anesthesia (local, regional block(s), general) or after the procedure was started (incision made, intubation started, scope inserted, etc.). Under these circumstances, the procedure started but terminated can be reported by its usual procedure number and the addition of modifier 74. Note: The elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. For physician reporting of a discontinued procedure, see modifier 53. Reimbursement By Report. OTHER BILLING AND PAYMENT REQUIREMENTS All facilities that bill for services on UB-04 forms are required to include all appropriate CPT and HCPCS codes in Field CPT only 2010 American Medical Association. All Rights Reserved.

323 Section XV: Outpatient Surgery Payment Schedule Effective April 1, 2011 Georgia Workers Compensation Medical Fee Schedule ICD-9-CM Outpatient Surgery Fee Schedule ICD-9-CM DESCRIPTION REMOVAL OF FOREIGN BODY FROM SPINAL CANAL OTHER EXPLORATION&DECOMPRESSION OF SPINAL CANAL PERCUTANEOUS CHORDOTOMY SPINAL TAP REPAIR OF VERTEBRAL FRACTURE LYSIS OF ADHESIONS OF SPINAL CORD&NERVE ROOTS INJECTION OF DESTRUCTIVE AGENT INTO SPINAL CANAL INSRT SPINAL CANAL CATH-INFUS THERAP/PALLIATIVE INJECTION ANESTHETIC INTO SPINAL CANAL ANALGESIA INJECTION OF OTHER AGENT INTO SPINAL CANAL IMPL/REPLACEMENT SPINAL NEUROSTIMULATOR LEAD(S) REMOVAL OF SPINAL NEUROSTIMULATOR LEAD(S) SPINAL BLOOD PATCH PERCUTANEOUS DENERVATION OF FACET REVISION OF SPINAL THECAL SHUNT OTH OP SPINAL CORD&SPINAL CANAL STRUCTURES DIVISION OF TRIGEMINAL NERVE OTH EXCISION/AVULSION CRANIAL&PERIPHERAL NERVES DESTRUCTION OF CRANIAL AND PERIPHERAL NERVES SUTURE OF CRANIAL AND PERIPHERAL NERVES RELEASE OF CARPAL TUNNEL RELEASE OF TARSAL TUNNEL OTH PERIPHERAL NERVE/GANG DECOMPRS/LYSIS ADHES CRANIAL OR PERIPHERAL NERVE GRAFT TRANSPOSITION OF CRANIAL AND PERIPHERAL NERVES REV PREVIOUS REPAIR CRANIAL&PERIPHERAL NERVES REPAIR OLD TRAUMATIC INJURY CRANIAL&PERIPH NERV OTHER NEUROPLASTY INJECTION ANESTHETIC INTO PERIPHERAL NERVE ANALG IMPL/REPL PERIPHERAL NEUROSTIMULATOR LEAD(S) OTHER SYMPATHECTOMY AND GANGLIONECTOMY INJECTION ANESTHETIC IN SYMPATHETIC NERVE ANALG OTHER INJECTION INTO SYMPATHETIC NERVE/GANGLION CLOSED BIOPSY OF THYROID GLAND REPR BLEPHAROPTOSIS-RESECT/ADVANCE LEVATOR REPAIR ENTROPION OR ECTROPION W/WEDGE RESECTION REPAIR ENTROPION/ECTROPION W/LID RECONSTRUCTION OTHER ADJUSTMENT OF LID POSITION LOWER EYELID RHYTIDECTOMY OTHER EYELID REPAIR CRYOSURGICAL EPILATION OF EYELID CONJUNCTIVORHINOSTOMY W/INSERTION TUBE OR STENT SUTURE OF CORNEAL LACERATION OTHER PENETRATING KERATOPLASTY OTHER IRIDOPLASTY SUTURE OF LACERATION OF SCLERA MAR Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 319

324 Georgia Workers Compensation Medical Fee Schedule ICD-9-CM Section XV: Outpatient Surgery Payment Schedule Outpatient Surgery Fee Schedule Effective April 1, 2011 ICD-9-CM DESCRIPTION MAR EXCISION OR DESTRUCTION OF LESION OF SCLERA OTHER INTRACAPSULAR EXTRACTION OF LENS PHACOEMULSIFICATION AND ASPIRATION OF CATARACT MECH PHACOFRAGATION&ASPIR CATARACT POST ROUTE DISCISSION OF SECONDARY MEMBRANE INSERTION OF PSEUDOPHAKOS NOS SEC INSERTION OF INTRAOCULAR LENS PROSTHESIS REMOVAL OF IMPLANTED LENS REMOVAL FB FROM POST SEGMENT EYE W/USE MAGNET DESTRUC CHORIORETINAL LESION LASER PHOTOCOAGULAT REPAIR OF RETINAL TEAR BY CRYOTHERAPY OTHER REPAIR OF RETINAL TEAR SCLERAL BUCKLING WITH IMPLANT OTHER SCLERAL BUCKLING OTHER MECHANICAL VITRECTOMY RESECTION OF ONE EXTRAOCULAR MUSCLE OP>=2 EXTRAOCCULAR MUSC W/TEMP DETACH-1/BOTH REPAIR OF INJURY OF EXTRAOCULAR MUSCLE REMOVAL OF ORBITAL IMPLANT REPAIR OF RUPTURE OF EYEBALL EXCISION/DESTRUCTION OTHER LESION EXTERNAL EAR STAPEDECTOMY WITH INCUS REPLACEMENT MYRINGOPLASTY TYPE II TYMPANOPLASTY TYPE III TYMPANOPLASTY OTHER REPAIR OF MIDDLE EAR REMOVAL OF TYMPANOSTOMY TUBE OTHER MASTOIDECTOMY LOCAL EXCISION OR DESTRUCTION OTHER LESION NOSE SUBMUCOUS RESECTION OF NASAL SEPTUM OTHER TURBINECTOMY CLOSED REDUCTION OF NASAL FRACTURE OPEN REDUCTION OF NASAL FRACTURE REVISION RHINOPLASTY LIMITED RHINOPLASTY OTHER RHINOPLASTY OTHER SEPTOPLASTY OTHER REPAIR AND PLASTIC OPERATIONS ON NOSE INTRANASAL ANTROTOMY SPHENOIDOTOMY ETHMOIDECTOMY OTHER EXCISION OF LESION OR TISSUE OF LIP OTHER EXCISION/DESTRUCTION LESION/TISSUE LARYNX CLOSED ENDOSCOPIC BIOPSY OF LUNG THORACENTESIS REVISION OR REMOVAL OF PACEMAKER DEVICE CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

325 Section XV: Outpatient Surgery Payment Schedule Effective April 1, 2011 Georgia Workers Compensation Medical Fee Schedule ICD-9-CM Outpatient Surgery Fee Schedule ICD-9-CM DESCRIPTION MAR INCISION OF UPPER LIMB VESSELS LIGATION&STRIPPING OF LOWER LIMB VARICOSE VEINS OTHER EXCISION OF UPPER LIMB VESSELS INTERRUPTION OF THE VENA CAVA OTHER SURGICAL OCCLUSION OF UPPER LIMB VESSELS OTHER SURGICAL OCCLUSION OF LOWER LIMB VEINS ARTERIAL CATHETERIZATION VENOUS CATHETERIZATION NOT ELSEWHERE CLASSIFIED OTHER REVISION OF VASCULAR PROCEDURE ANGIOPLASTY/ATHERECT OTH NON-CORONARY VESSEL(S) OTHER DIAGNOSTIC PROCEDURES LYMPHATIC STRUCTURES EXCISION OF INGUINAL LYMPH NODE DILATION OF ESOPHAGUS ESOPHAGOGASTRODUODENOSCOPY WITH CLOSED BIOPSY CLOSED [ENDOSCOPIC] BIOPSY OF LARGE INTESTINE DILATION OF INTESTINE ANAL FISTULECTOMY EXCISION OF HEMORRHOIDS HEPATOTOMY LAPAROSCOPIC CHOLECYSTECTOMY UNILATERAL REPAIR OF INGUINAL HERNIA NOS OTH & OPEN REPAIR OF DIRECT INGUINAL HERNIA OTHER & OPEN REPAIR OF INDIRECT INGUINAL HERNIA OTH & OPEN REP DIRECT ING HERNIA W/GRAFT/PROSTH OTH & OPN REP INDIRECT ING HERNIA W/GRAFT/PROSTH UNILAT REPAIR ING HERNIA W/GRAFT/PROSTHESIS NOS OTH & OPEN BILATERAL REP DIRECT INGUINAL HERNIA OTH & OPEN BILAT REP DIR ING HERNIA W/GRAFT/PROS OTH & OPEN BILAT REP INDIR ING HERNIA W/GFT/PROS OTH&OPEN BIL REP ING HERN 1 DIR&1 INDIR GFT/PROS BILAT ING HERNIA REPAIR W/GRAFT/PROSTHESIS NOS UNILAT REPAIR FEMORAL HERNIA W/GRAFT/PROSTHESIS OTHER UNILATERAL FEMORAL HERNIORRHAPHY OTH & OPEN REP UMBILICAL HERNIA W/GRAFT/PROSTH OTHER OPEN UMBILICAL HERNIORRHAPHY INCISIONAL HERNIA REPAIR REPAIR OTHER HERNIA ANTERIOR ABDOMINAL WALL OTH & OPEN INCISIONAL HERNIA REP W/GRAFT/PROSTH OTH & OPEN REP OTH HERN ANT ABD WALL W/GFT/PROS INCISION OF ABDOMINAL WALL OTHER LYSIS OF PERITONEAL ADHESIONS PERCUTANEOUS ABDOMINAL DRAINAGE TRANSURETHRAL CLEARANCE OF BLADDER URETHRAL MEATOTOMY RELEASE OF URETHRAL STRICTURE OTHER REPAIR OF URINARY STRESS INCONTINENCE Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 321

326 Georgia Workers Compensation Medical Fee Schedule ICD-9-CM Section XV: Outpatient Surgery Payment Schedule Outpatient Surgery Fee Schedule Effective April 1, 2011 ICD-9-CM DESCRIPTION MAR 61.2 EXCISION OF HYDROCELE ORCHIOPEXY EXC OTH LESION/TISSUE SPERMATIC CORD&EPIDIDYMIS CIRCUMCISION REMOVAL OF INTERNAL PROSTHESIS OF PENIS INSERTION/REPLCMT INFLATABLE PENILE PROSTHESIS OTHER OPERATIONS ON PENIS ENDOMETRIAL ABLATION OTHER DILATION AND CURETTAGE OF UTERUS ASPIRATION CURETTAGE FOLLOWING DELIVERY/ABORTION TEMPOROMANDIBULAR ARTHROPLASTY OTHER ORTHOGNATHIC SURGERY ON MANDIBLE SEGMENTAL OSTEOPLASTY OF MAXILLA TOTAL OSTEOPLASTY OF MAXILLA OPEN REDUCTION OF MALAR AND ZYGOMATIC FRACTURE CLOSED REDUCTION OF MAXILLARY FRACTURE OPEN REDUCTION OF MAXILLARY FRACTURE OPEN REDUCTION OF MANDIBULAR FRACTURE OTHER OPEN REDUCTION OF FACIAL FRACTURE BONE GRAFT TO FACIAL BONE REMOVAL INTERNAL FIXATION DEVICE FROM FCE BONE OTHER OPERATIONS ON FACIAL BONES AND JOINTS SEQUESTRECTOMY OF TIBIA AND FIBULA OTHER INCISION OF RADIUS&ULNA WITHOUT DIVISION OTHER INCISION OF FEMUR WITHOUT DIVISION WEDGE OSTEOTOMY OF TARSALS AND METATARSALS OTHER DIVISION OF RADIUS AND ULNA OTHER DIVISION OF CARPALS AND METACARPALS OTHER DIVISION OF TIBIA AND FIBULA OTHER DIVISION OF TARSALS AND METATARSALS BIOPSY OF OTHER BONE EXCEPT FACIAL BONES OTHER BUNIONECTOMY WITH SOFT TISSUE CORRECTION OTHER EXCISION FUSION AND REPAIR OF TOES LOCAL EXCISION LESION/TISSUE SCAPULA CLAV&THORAX LOCAL EXCISION LESION OR TISSUE RADIUS&ULNA LOCAL EXCISION LESION/TISSUE CARPALS&METACARPALS LOCAL EXCISION OF LESION OR TISSUE OF FEMUR LOCAL EXCISION OF LESION OR TISSUE OF PATELLA LOCAL EXCISION LESION OR TISSUE TIBIA&FIBULA LOCAL EXCISION LESION/TISSUE TARSALS&METATARSALS LOCAL EXCISION LESION/TISSUE OTH BONE NO FCE BNS EXCISION OF OTHER BONE GRAFT EXCEPT FACIAL BONES OTHER PARTIAL OSTECTOMY SCAPULA CLAVICLE&THORAX OTHER PARTIAL OSTECTOMY OF HUMERUS OTHER PARTIAL OSTECTOMY OF RADIUS AND ULNA OTHER PARTIAL OSTECTOMY OF CARPALS&METACARPALS CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

327 Section XV: Outpatient Surgery Payment Schedule Effective April 1, 2011 Georgia Workers Compensation Medical Fee Schedule ICD-9-CM Outpatient Surgery Fee Schedule ICD-9-CM DESCRIPTION MAR OTHER PARTIAL OSTECTOMY OF PATELLA OTHER PARTIAL OSTECTOMY OF TARSALS&METATARSALS OTH PARTIAL OSTECTOMY OTH BONE EXCEPT FACIAL BNS TOTAL OSTECTOMY OF CARPALS AND METACARPALS TOTAL OSTECTOMY OF TARSALS AND METATARSALS TOTAL OSTECTOMY OTHER BONE EXCEPT FACIAL BONES BONE GRAFT OF RADIUS AND ULNA BONE GRAFT OF CARPALS AND METACARPALS BONE GRAFT OF TIBIA AND FIBULA BONE GRAFT OF OTHER BONE EXCEPT FACIAL BONES APPLICATION OF EXTERNAL FIXATOR DEVC RADIUS&ULNA APPLICATION EXTERNAL FIXATOR DEVC TIBIA&FIBULA APPLICATION OF EXTERNAL FIXATOR DEVICE OTHER LIMB SHORTENING PROCEDURES RADIUS AND ULNA LIMB LENGTHENING PROCEDURES RADIUS AND ULNA OTHER REPAIR OR PLASTIC OPERATIONS RADIUS&ULNA OTHER REPAIR OR PLASTIC OPERATIONS TIBIA&FIBULA OTH REPAIR/PLASTIC OP OTH BONE NO FCE BNS INTRL FIX SCAPULA CLAV&THOR W/O FRACTURE RDUC INTERNAL FIX HUMERUS WITHOUT FRACTURE REDUCTION INTRL FIX CARPALS&MCS WITHOUT FRACTURE REDUCTION INTERNAL FIXATION FEM WITHOUT FRACTURE REDUCTION INTRL FIX TIBIA&FIB WITHOUT FRACTURE REDUCTION INTRL FIX TARSALS&MTS WITHOUT FRACTURE REDUCTION INTRL FIX OTH BONE NO FCE BNS W/O FRACTURE RDUC REMOVAL IMPL DEVICE FROM SCAPULA CLAV&THORAX REMOVAL OF IMPLANTED DEVICE FROM HUMERUS REMOVAL OF IMPLANTED DEVICE FROM RADIUS AND ULNA REMOVAL IMPL DEVICE FROM CARPALS&METACARPALS REMOVAL OF IMPLANTED DEVICE FROM FEMUR REMOVAL OF IMPLANTED DEVICE FROM PATELLA REMOVAL OF IMPLANTED DEVICE FROM TIBIA&FIBULA REMOVAL IMPLANTED DEVICE FROM TARSAL&METATARSALS REMOVAL OF IMPLANTED DEVICE FROM OTHER BONE OSTEOCLASIS OF FEMUR OSTEOCLASIS OF TIBIA AND FIBULA CLOS RDUC FRACTURE RADIUS&ULNA WITHOUT INTRL FIX CLOS RDUC FRACTURE PHALANG HAND W/O INTRL FIX CLOS RDUC FRACTURE TIBIA&FIB WITHOUT INTRL FIX CLOS REDUCTION FRACTURE HUMERUS W/INTERNAL FIX CLOS REDUCTION FRACTURE RADIUS&ULNA W/INTRL FIX CLOS REDUCTION FRACTURE CARPALS&MCS W/INTRL FIX CLOS REDUCTION FRACTURE PHALANG HAND W/INTRL FIX CLOS REDUCTION FRACTURE TIBIA&FIB W/INTERNAL FIX CLOS REDUCTION FRACTURE TARSALS&MTS W/INTRL FIX OPEN REDUCTION FRACTURE HUM WITHOUT INTERNAL FIX Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 323

328 Georgia Workers Compensation Medical Fee Schedule ICD-9-CM Section XV: Outpatient Surgery Payment Schedule Outpatient Surgery Fee Schedule Effective April 1, 2011 ICD-9-CM DESCRIPTION MAR OPEN RDUC FRACTURE RADIUS&ULNA WITHOUT INTRL FIX OPEN RDUC FRACTURE PHALANG HAND W/O INTRL FIX OPEN RDUC FRACTURE TARSALS&MTS WITHOUT INTRL FIX OPN RED FX OTH SPEC BONE EXP FCE BNS W/O INT FIX OPEN REDUCTION FRACTURE HUMERUS W/INTERNAL FIX OPEN REDUCTION FRACTURE RADIUS&ULNA W/INTRL FIX OPEN REDUCTION FRACTURE CARPALS&MCS W/INTRL FIX OPEN REDUCTION FRACTURE PHALANG HAND W/INTRL FIX OPEN REDUCTION FRACTURE FEM W/INTERNAL FIXATION OPEN REDUCTION FRACTURE TIBIA&FIB W/INTERNAL FIX OPEN REDUCTION FRACTURE TARSALS&MTS W/INTRL FIX OPEN REDUCTION FRACTURE PHALANGES FT W/INTRL FIX OPN RED FX OTH SPEC BONE EXP FACE BNS W/INT FIX DEBRIDEMENT OPEN FRACTURE CARPALS&METACARPALS DEBRIDEMENT OPEN FRACTURE PHALANGES HAND DEBRIDEMENT OF OPEN FRACTURE OF TIBIA AND FIBULA CLOSED REDUCTION OF DISLOCATION OF SHOULDER CLOSED REDUCTION OF DISLOCATION OF ELBOW CLOSED REDUCTION OF DISLOCATION OF HAND&FINGER OPEN REDUCTION OF DISLOCATION OF SHOULDER OPEN REDUCTION OF DISLOCATION OF HAND AND FINGER OPEN REDUCTION OF DISLOCATION OF ANKLE OPEN REDUCTION OF DISLOCATION OF FOOT AND TOE ARTHRTMY REMVAL OF PROSTH W/O RPLCE HAND&FINGER OTHER ARTHROTOMY OF SHOULDER OTHER ARTHROTOMY OF ELBOW OTHER ARTHROTOMY OF WRIST OTHER ARTHROTOMY OF HAND AND FINGER OTHER ARTHROTOMY OF KNEE OTHER ARTHROTOMY OF ANKLE ARTHROSCOPY OF SHOULDER ARTHROSCOPY OF ELBOW ARTHROSCOPY OF WRIST ARTHROSCOPY OF KNEE ARTHROSCOPY OF ANKLE BIOPSY OF JOINT STRUCTURE OF HIP BIOPSY OF JOINT STRUCTURE OF KNEE DIVISION JOINT CAPSULE LIGAMENT/CART SHOULDER DIVISION JOINT CAPSULE LIGAMENT/CARTILAGE ELBOW DIVISION JOINT CAPSULE LIGAMENT/CART HAND&FINGER DIVISION JOINT CAPSULE LIGAMENT/CARTILAGE KNEE DIVISION JOINT CAPSULE LIGAMENT/CARTILAGE ANKLE DIVISION JOINT CAPSULE LIGAMENT/CART FOOT&TOE EXCISION OF INTERVERTEBRAL DISC OTHER DESTRUCTION OF INTERVERTEBRAL DISC EXCISION OF SEMILUNAR CARTILAGE OF KNEE CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

329 Section XV: Outpatient Surgery Payment Schedule Effective April 1, 2011 Georgia Workers Compensation Medical Fee Schedule ICD-9-CM Outpatient Surgery Fee Schedule ICD-9-CM DESCRIPTION MAR SYNOVECTOMY OF ELBOW SYNOVECTOMY OF WRIST SYNOVECTOMY OF HAND AND FINGER SYNOVECTOMY OF KNEE SYNOVECTOMY OF ANKLE OTH LOCAL EXCISION/DESTRUC LESION SHOULDER JOINT OTH LOCAL EXCISION/DESTRUC LESION ELBOW JOINT OTH LOCAL EXCISION/DESTRUC LESION WRIST JOINT OTH LOCAL EXC/DESTRUC LESION JOINT HAND&FINGER OTH LOCAL EXCISION/DESTRUCTION LESION HIP JOINT OTH LOCAL EXCISION/DESTRUCTION LESION KNEE JOINT OTH LOCAL EXCISION/DESTRUCTION LESION ANK JOINT OTH LOCAL EXCISION/DESTRUC LESION JOINT FOOT&TOE OTHER EXCISION OF SHOULDER JOINT OTHER EXCISION OF ELBOW JOINT OTHER EXCISION OF JOINT OF HAND AND FINGER OTH CERVICAL FUSION ANT COLUMN ANT TECHNIQUE OTH CERVICAL FUSION POST COLUMN POST TECHNIQUE LUMBAR LUMBOSACRAL FUSION ANT COLUMN ANT TECH LUMBAR LUMBOSACRAL FUSION ANT COLUMN POST TECH ANKLE FUSION SUBTALAR FUSION MIDTARSAL FUSION METATARSOPHALANGEAL FUSION CARPORADIAL FUSION METACARPOCARPAL FUSION METACARPOPHALANGEAL FUSION INTERPHALANGEAL FUSION ARTHRODESIS OF OTHER SPECIFIED JOINT REFUSION OTH C-SPINE ANTERIOR COLUMN ANT TECH REFUSION OTH C-SPINE POSTERIOR COLUMN POST TECH REPAIR OF HIP NOT ELSEWHERE CLASSIFIED TRIAD KNEE REPAIR PATELLAR STABILIZATION OTHER REPAIR OF THE CRUCIATE LIGAMENTS OTHER REPAIR OF THE COLLATERAL LIGAMENTS OTHER REPAIR OF KNEE OTHER REPAIR OF ANKLE ARTHPLSTY METACARPOPHALANGEAL&IP JOINT W/IMPLANT ARTHPLSTY MCP&IP JOINT WITHOUT IMPLANT ARTHRPLSTY CARPOCARPAL/CMC JOINT WITH IMPLANT ARTHRPLSTY CARPOCARPAL/CMC JOINT WITHOUT IMPLANT OTHER REPAIR OF HAND FINGERS AND WRIST PARTIAL SHOULDER REPLACEMENT REPAIR OF RECURRENT DISLOCATION OF SHOULDER OTHER REPAIR OF SHOULDER Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 325

330 Georgia Workers Compensation Medical Fee Schedule ICD-9-CM Section XV: Outpatient Surgery Payment Schedule Outpatient Surgery Fee Schedule Effective April 1, 2011 ICD-9-CM DESCRIPTION MAR TOTAL ELBOW REPLACEMENT OTHER REPAIR OF ELBOW ARTHROCENTESIS INJ THERAPEUTIC SUBSTANCE IN JOINT/LIGAMENT SUTURE OF CAPSULE OR LIGAMENT OF UPPER EXTREMITY SUTURE OF CAPSULE OR LIGAMENT OF ANKLE AND FOOT SUTURE CAPSULE OR LIGAMENT OTHER LOWER EXTREMITY OTHER REPAIR OF JOINT REVISION OF JOINT REPLACEMENT OF UPPER EXTREMITY EXPLORATION OF TENDON SHEATH OF HAND MYOTOMY OF HAND OTHER INCISION OF SOFT TISSUE OF HAND TENOTOMY OF HAND OTHER DIVISION OF SOFT TISSUE OF HAND EXCISION OF LESION OF TENDON SHEATH OF HAND EXCISION OF OTHER LESION OF SOFT TISSUE OF HAND OTHER TENONECTOMY OF HAND OTHER FASCIECTOMY OF HAND OTHER MYECTOMY OF HAND DELAYED SUTURE OF FLEXOR TENDON OF HAND DELAYED SUTURE OF OTHER TENDON OF HAND OTHER SUTURE OF FLEXOR TENDON OF HAND OTHER SUTURE OF OTHER TENDON OF HAND OTHER HAND TENDON TRANSFER OR TRANSPLANTATION OTHER HAND TENDON TRANSPOSITION TENDON PULLEY RECONSTRUCTION ON HAND PLASTIC OPERATION HAND W/OTHER GRAFT OR IMPLANT REPAIR OF MALLET FINGER OTHER TENODESIS OF HAND OTHER TENOPLASTY OF HAND LYSIS OF ADHESIONS OF HAND EXPLORATION OF TENDON SHEATH MYOTOMY BURSOTOMY OTHER INCISION OF SOFT TISSUE OTHER TENOTOMY FASCIOTOMY OTHER DIVISION OF SOFT TISSUE OPEN BIOPSY OF SOFT TISSUE EXCISION OF LESION OF TENDON SHEATH EXCISION OF LESION OF OTHER SOFT TISSUE OTHER TENONECTOMY OTHER FASCIECTOMY OTHER MYECTOMY BURSECTOMY SUTURE OF TENDON SHEATH CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

331 Section XV: Outpatient Surgery Payment Schedule Effective April 1, 2011 Georgia Workers Compensation Medical Fee Schedule ICD-9-CM Outpatient Surgery Fee Schedule ICD-9-CM DESCRIPTION MAR DELAYED SUTURE OF TENDON ROTATOR CUFF REPAIR OTHER SUTURE OF TENDON OTHER SUTURE OF MUSCLE OR FASCIA ADVANCEMENT OF TENDON REATTACHMENT OF TENDON TENDON TRANSFER OR TRANSPLANTATION TENDON GRAFT TENDON PULLEY RECONSTRUCT MUSCLE TENDON&FASCIA OTHER CHANGE IN MUSCLE OR TENDON LENGTH QUADRICEPSPLASTY OTHER PLASTIC OPERATIONS ON MUSCLE OTHER PLASTIC OPERATIONS ON TENDON LYSIS OF ADHESIONS OF MUSCLE TENDON FASCIA&BURSA INJ LOCLY ACTING TX SBSTNC IN OTH SFT TISSUE AMPUTATION AND DISARTICULATION OF FINGER AMPUTATION AND DISARTICULATION OF THUMB AMPUTATION OF TOE FINGER REATTACHMENT REVISION OF AMPUTATION STUMP CLOSED BIOPSY OF BREAST OPEN BIOPSY OF BREAST LOCAL EXCISION OF LESION OF BREAST ASPIRATION OF SKIN AND SUBCUTANEOUS TISSUE INJECTION OR TATTOOING OF SKIN LESION OR DEFECT OTH INCISION W/DRAINAGE SKIN&SUBCUTANEOUS TISSUE INCI W/REMOVAL FB/DEVICE FROM SKIN & SUBQ TISSUE INSERTION OF TOTALLY IMPLANTABLE INFUSION PUMP CLOSED BIOPSY OF SKIN AND SUBCUTANEOUS TISSUE EXCISIONAL DEBRIDEMENT WOUND INFECTION OR BURN REMOVAL OF NAIL NAILBED OR NAIL FOLD CHEMOSURGERY OF SKIN DERMABRASION NONEXCISIONAL DEBRIDEMENT WOUND INFECTION/BURN RADICAL EXCISION OF SKIN LESION CLOSURE SKIN&SUBCUTANEOUS TISSUE OTHER SITES FULL-THICKNESS SKIN GRAFT TO HAND OTHER SKIN GRAFT TO HAND FULL-THICKNESS SKIN GRAFT TO OTHER SITES HETEROGRAFT TO SKIN HOMOGRAFT TO SKIN DERMAL REGENERATIVE GRAFT OTHER SKIN GRAFT TO OTHER SITES CUTTING&PREPARATION OF PEDICLE GRAFTS OR FLAPS ADVANCEMENT OF PEDICLE GRAFT ATTACHMENT OF PEDICLE OR FLAP GRAFT TO HAND Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 327

332 Georgia Workers Compensation Medical Fee Schedule ICD-9-CM Section XV: Outpatient Surgery Payment Schedule Outpatient Surgery Fee Schedule Effective April 1, 2011 ICD-9-CM DESCRIPTION MAR ATTACHMENT PEDICLE OR FLAP GRAFT TO OTHER SITES REVISION OF PEDICLE OR FLAP GRAFT RELAXATION OF SCAR OR WEB CONTRACTURE OF SKIN ONYCHOPLASTY OTH REPAIR&RECONSTRUCT SKIN&SUBCUTANEOUS TISSUE INSERTION OF TISSUE EXPANDER CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix

333 Index A add-on 46 procedures 8 air transportation 295 allografts 10 ambulance transportation 295 ambulatory surgery 317 ambulatory surgery center 9, 21, 30, 46, 173, 221, 318 anesthesia 27, 31, 318 services 27, 28, 32 values 27, 28 appointed physician 14 arthroscopic surgery 44 ASC 46, 173 ASC hospital 21, 30, 46, 173, 221, 254, 255, 287 authorization to treat 7 B base unit values 27 bilateral procedures 45, 173 bone and other tissue grafts 44 broken or missed appointments 15 by report 13, 42, 220, 318 C carticel 44 casting 44 catastrophic injury 11 CCI (see National Correct Coding Initiative) 7 chiropractors 286 clinical nurse specialist 10, 20, 22 collection and handling procedures 219 concurrent care 18 services by more than one physician 43 concurrent care 18 confidentiality 7 considerations for reimbursement 7 consultations 17, 18, 20, 220 conversion factor 5, 6, 27 coordination of care 18 co-surgeons 41 counseling 18, 19, 43 CPT 5, 7, 8, 9, 10, 11, 12, 14, 15, 17, 18, 20, 22, 30, 32, 41, 42, 43, 44, 45, 171, 172, 219, 220, 285, 286, 291, 318 critical care 20 D deposition/testimony, physician 14 drugs 10, 171 durable medical equipment 8, 10 E emergency room 17 emergency room services 20 exempt from modifier 51 codes 8 F follow-up days 8, 41, 42 fractures 44 functional capacity 11, 12, 286 H home care 291 I impairment 12, 19, 286 implants 10, 318 independent medical exam 12 inpatient hospital 6, 8, 20, 318 instrumentation 10 CPT only 2010 American Medical Association. All Rights Reserved. 329

334 Georgia Workers Compensation Medical Fee Schedule interpreter 11, 18, 22, 253, 254, 255, 285, 288 L late payment 15 M manipulation codes 286 medical records 14 microsurgery 45 missed appointments 15, 20 moderate conscious sedation 5 modifiers for anesthesia 30 diagnostic and therapeutic radiological services 172 pathology and laboratory services 220 physical medicine services 287 surgical services 45 MS-DRG 8, 10, 13, 15 multiple concurrent physical medicine procedures and modalities 286 procedures 9, 32, 43, 45, 220, 317 surgeons 43 N National Correct Coding Initiative (CCI) 7, 9, 45 nature of presenting problem 19 new & established patient 17 new CPT codes 12 no show/missed appointments 20 nurse practitioner 10, 20, 22, 41, 47 nursing facility services 20 O occupational therapists 11, 285, 286 on-call or substitute physician 17 one-time-only 285 orthotic 286 orthotics 12, 286 osteopaths 286 outpatient hospital 9, 21, 30, 46, 173, 221, 317 P panel tests 220 peer review 13, 14 physical therapy 285, 318 physician extenders 10, 20 testimony 14 preauthorization 7 professional component 5, 45, 171, 172, 173, 219, 220 Q qualifying circumstances 5, 27, 28, 31 R referral 219 rental equipment 10 S separate procedure 8, 41, 43 separate procedure code(s) 46 special report 13, 29, 44 surgical assistants 41 destruction 43 package 41 T Index technical component 5, 45, 47, 171, 173, 174, 219, 220, 221 TENS units 287 time 8, 10, 12, 13, 14, 15, 17, 19, 27, 29, 31, 32, 220, 286 time reporting 28 transportation 16, 293 air 295 ambulance 295 non-emergency 5, 293 U unlisted service or procedure 12, 20, 41, 254 urgent care facility 9 W work hardening 11, 12 wound repair CPT only 2010 American Medical Association. All Rights Reserved.