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 30303-1299 http: // www.sbwc.georgia.gov
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 1.800.INGENIX (464.3649). OUR COMMITMENT TO ACCURACY Ingenix is committed to producing accurate and reliable materials. To report corrections, please visit www.shopingenix.com/accuracy or email accuracy@ingenix.com. You can also reach customer service by calling 1.800.INGENIX (464.3649), 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 30303-1299 404.656.3875 1.800.533.0682 Ingenix 1.800.INGENIX (464.3649)
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... 15 Section V: Evaluation and Management (E/M) Services... 17 Subsection A: Payment Ground Rules for E/M Category... 17 Subsection B: Payment Modifiers for E/M Category... 21 Section VI: Anesthesia Services... 27 Subsection A: Payment Ground Rules for Anesthesia Services... 27 Subsection B: Payment Modifiers for Anesthesia Services... 30 Section VII: Surgical Services... 41 Subsection A: Payment Ground Rules for Surgical Services... 41 Subsection B: Payment Modifiers for Surgical Services... 45 Section VIII: Diagnostic and Therapeutic Radiological Services... 171 Subsection A: Payment Ground Rules for Diagnostic and Therapeutic Radiological Services... 171 Subsection B: Payment Modifiers for Diagnostic and Therapeutic Radiological Services... 172 Section IX: Pathology and Laboratory Services... 219 Subsection A: Payment Ground Rules for Pathology and Laboratory Services...219 Subsection B: Payment Modifiers for Pathology and Laboratory Services...220 Section X: General Medicine Services... 253 Subsection A: Payment Ground Rules for General Medicine Services...253 Subsection B: Payment Modifiers for General Medicine Services...254 Section XI: Physical Medicine Services... 285 Subsection A: Payment Ground Rules for Physical Medicine Services...285 Subsection B: Payment Modifiers for Physical Medicine Services...287 Section XII: Home Health Services... 291 Section XIII: Transportation... 293 Subsection A: Non-Emergency Services...293 Subsection B: Ambulance and Air Services...295 Section XIV: Inpatient Hospital Payment Schedule... 297 Inpatient Reimbursement Methodology...297 Implants, Durable Medical Equipment (DME), and Supplies...297 Payment For Outliers...297 MS-DRG Exempt Hospitals...298 Disputed Medical Charges...298 Section XV: Outpatient Surgery Payment Schedule... 317 Surgical Services Provided by Outpatient Hospital and Ambulatory Surgery Centers...317 Implants, DME, and Supplies...318 Nonsurgical Radiology Services...318 Physical Therapy Services...318 Modifiers...318 Other Billing and Payment Requirements...318 Index... 329
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 2011. 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 http://www.sbwc.georgia.gov. 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
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.
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, 2011. 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
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 99201 99499 Anesthesia 00100 01999, 99100 99140 Surgery 10021 69990 Diagnostic & Therapeutic Radiology 70010 79999 Pathology & Laboratory 80047 89398 General Medicine 90281 96999, 97597 97606, 97802 97804, 98960 99091, 99143 99199, 99605 99607 Physical Medicine 97001 97546, 97750 97799, 97810 98943, FCE01 Home Health 99500 99602 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
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 2010. 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.
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. 34-9-205(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: http://www.sbwc.georgia.gov. CPT only 2010 American Medical Association. All Rights Reserved. 7
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.
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 2011. 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 99143 99150. 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 99143 99145) 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 99148 99150). 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) 99148 99150 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 99148 99150 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 http://www.cms.gov/nationalcorrectcodinited/ncciep/list.asp#topofpage. 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
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 99070. 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 99070 would not be reported. Custom-made orthotics/prosthetics and rental equipment are exempt from the supplies and equipment reimbursement formula; however, usual, customary, and reasonable charges will apply. Pharmaceuticals 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. 26-4-81, 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. 100-2, 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.
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. 100-4, chapter 12, section 20.4.3.) 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. 33-24-59.9, the RNFA shall not be on the staff of a hospital or the treating physician. Append the appropriate CPT procedure with 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 (97001 97004), 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 99354 99357 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 99441 99443 (physicians) and 98966 98968 (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 2011. 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 97010 97039). 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. 34-9-200.1(g). 2. CPT codes 97545 and 97546 report work hardening/work conditioning. CPT code 97545 reports the first two hours and CPT code 97546 reports each additional hour. The total dollar amount reimbursed for work hardening/work conditioning reported with these two CPT codes shall not exceed $327.26 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
Georgia Workers Compensation Medical Fee Schedule Section IV: General Reimbursement Requirements 4. CPT code 97750 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 99455 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 97760 Orthotic management and training (including assessment and fitting when not otherwise reported), for custom-made orthotics, CPT code 97761 Prosthetic training, and CPT code 97762 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 $250.00 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 $600.00 first hour or parts thereof $150.00 each additional 15 minutes For a no-show at an independent medical examination, reimbursement shall be at $150.00. 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 99455 must be used in billing an impairment rating, and no other evaluation and management CPT code can be used along with CPT code 99455 when billing for impairment ratings performed by the authorized treating physician. Work Hardening/Work Conditioning The CPT codes 97545 and 97546 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.
Section IV: General Reimbursement Requirements reimbursement is at 62.23 percent of charges. In compliance with O.C.G.A. 34-9-203(a), these usual, customary, and reasonable charges shall be limited to such charges as prevail in the State of Georgia for similar treatment. 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. 1926 Northlake Parkway, Suite 201 Tucker, GA 30084 (770) 723-1100; FAX (770) 723-1722 Mr. Clark Thomas, MPA, CAE, Executive Director Georgia Psychological Association 2200 Century Parkway, NE, Suite 660 Atlanta, GA 30345 (404) 634-6272; FAX (404) 634-8230 CPT only 2010 American Medical Association. All Rights Reserved. 13
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 30309 (404) 728-1974 4. If there is no appropriate peer review committee, the party requesting review may request a mediation conference by filing Form WC-14 with the Board. The charges submitted, which conform to the fee schedule adopted by the Board, shall be prima facie proof of the usual, customary, and reasonable charges for the medical services provided. 5. The employer/insurer shall, within 30 days from the date that a decision regarding the peer review of charges or treatment is issued by a peer review organization, make payment of disputed charges based upon the recommendations, or request a mediation conference. The peer review committee shall serve a copy of its decision upon the employee, if unrepresented, or the employee s attorney. A physician whose fee has been reduced by the peer review committee shall have 30 days from the date that the recommendation is mailed to request a hearing. In case of a mediation conference, the recommendations of the peer review committee shall be evidence of the usual, customary, and reasonable charges. 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. 34-9-203.) Appointed Physician (Refer to O.C.G.A. 34-9-205 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 99075 and paid within 30 days from receipt of billing. Payment for a deposition will be based on actual time spent reviewing medical records before giving medical testimony and actual time spent testifying. The following hourly rate will establish the maximum allowable reimbursement for this service: Time Rate $600.00 first hour or parts thereof $150.00 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 99080. Special reports meeting the above requirements will be reimbursed at a MAR of $60.00. 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.
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. 34-9-203 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
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.
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
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, 99366 99368, 99441 99444). 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 (97001 97004), 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 99354 99357 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 99441 99443 (physicians) and 98966 98968 (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 2011. 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 99354 99357 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 99358 and 99359 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 2011. 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. 34-9-200, 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.
Section V: Evaluation and Management (E/M) Services Evaluation and management consultation services will continue to be reported with CPT codes 99241 99245 for outpatient consultation services and codes 99251 99255 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
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 (99231 99233) or initial hospital consultation codes (99251 99255) 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 $150.00. 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.
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 99354 99357. 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 59. 32 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
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 200.1 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 99354 99357 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.
Section V: Evaluation and Management (E/M) Services Georgia Workers Compensation Medical Fee Schedule 99201 99499 EVALUATION AND MANAGEMENT Effective April 1, 2011 Medical Fee Schedule 99201 OFFICE OUTPT NEW 10 MIN 60.55 XXX 99202 OFFICE OUTPT NEW 20 MINUTES 104.58 XXX 99203 OFFICE OUTPT NEW 30 MIN 151.62 XXX 99204 OFFICE OUTPT NEW 45 MIN 233.19 XXX 99205 OFFICE OUTPT NEW 60 MIN 290.23 XXX 99211 OFFICE O/P EST 5 MIN 29.02 XXX 99212 OFFICE OUTPT EST 10 MIN 61.05 XXX 99213 OFFICE OUTPT EST15 MIN 101.58 XXX 99214 OFFICE OUTPT EST 25 MIN 150.62 XXX 99215 OFFICE OUTPT EST 40 MIN 202.66 XXX 99217 OBS CARE DSCHRG D MGMT 102.08 XXX 99218 1ST OBS CARE PR D LOW SEVERITY 94.58 XXX 99219 1ST OBS CARE PR D MODERATE SEVERITY 158.13 XXX 99220 1ST OBS CARE PR D HIGH SEVERITY 221.18 XXX 99221 1ST HOSP CARE PR D 30 MIN 143.11 XXX 99222 1ST HOSP CARE PR D 50 MIN 194.66 XXX 99223 1ST HOSP CARE PR D 70 MIN 285.73 XXX l # 99224 SBSQ OBS CARE PR D LOW SEVERITY 41.03 XXX l # 99225 SBSQ OBS CARE PR D MODERATE SEVERITY 72.56 XXX l # 99226 SBSQ OBS CARE PR D HIGH SEVERITY 108.59 XXX 99231 SBSQ HOSP CARE PR D 15 MIN 56.55 XXX 99232 SBSQ HOSP CARE PR D 25 MIN 102.08 XXX 99233 SBSQ HOSP CARE PR D 35 MIN 146.62 XXX 99234 OBS/I/P HOSP CARE LOW SEVERITY 193.65 XXX 99235 OBS/I/P HOSP CARE MODERATE SEVERITY 253.70 XXX 99236 OBS/I/P HOSP CARE HIGH SEVERITY 315.25 XXX 99238 HOSP DSCHRG D MGMT 30 MIN/< 101.58 XXX 99239 HOSP DSCHRG D MGMT > 30 MIN 149.12 XXX 99241 OFFICE CONSLTJ 15 MIN 68.55 XXX 99242 OFFICE CONSLTJ 30 MIN 129.10 XXX 99243 OFFICE CONSLTJ 40 MIN 176.14 XXX 99244 OFFICE CONSLTJ 60 MIN 260.21 XXX 99245 OFFICE CONSLTJ 80 MIN 318.25 XXX 99251 1ST INPT CONSLTJ 20 MIN 69.56 XXX 99252 1ST INPT CONSLTJ 40 MIN 107.09 XXX 99253 1ST INPT CONSLTJ 55 MIN 163.13 XXX 99254 1ST INPT CONSLTJ 80 MIN 235.19 XXX 99255 1ST INPT CONSLTJ 110 MIN 284.23 XXX 99281 EMER DEPT SELF LIMITED/MINOR 30.52 XXX 99282 EMER DEPT LOW TO MODERATE SEVERITY 59.55 XXX 99283 EMER DEPT MODERATE SEVERITY 90.07 XXX 99284 EMER DEPT HI SEVERITY&URGENT EVAL 170.14 XXX 99285 EMER DEPT HIGH SEVERITY&THREAT FUNCJ 249.20 XXX 99288 PHYS DIRION EMS ADVD LIFE SUPPORT BR XXX 99291 CC E/M CRITICALLY ILL/INJURED 1ST 30-74 MIN 389.31 XXX + 99292 CC E/M CRITICALLY ILL/INJURED EA 30 MIN 175.14 ZZZ Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 23
Georgia Workers Compensation Medical Fee Schedule Section V: Evaluation and Management (E/M) Services EVALUATION AND MANAGEMENT 99201 99499 Medical Fee Schedule Effective April 1, 2011 99304 1ST NF CARE PR D E/M LW SEVERITY 129.60 XXX 99305 1ST NF CARE PR D E/M MOD SEVERITY 182.15 XXX 99306 1ST NF CARE PR D E/M HI SEVERITY 231.69 XXX 99307 SBSQ NF CARE PR D E/M STABLE 62.05 XXX 99308 SBSQ NF CARE PR D E/M MINOR COMPLCTJ 95.58 XXX 99309 SBSQ NF CARE PR D E/M NEW PROBLEM 125.60 XXX 99310 SBSQ NF CARE PR D E/M UNSTABLE/NEW PROBLEM 186.15 XXX 99315 NF DSCHRG D MGMT 30 MIN/< 90.57 XXX 99316 NF DSCHRG D MGMT > 30 MIN 117.59 XXX 99318 E/M PT INVG ANNUAL NF ASSMT 132.61 XXX 99324 DOM/R-HOME LW SEVERITY 81.06 XXX 99325 DOM/R-HOME E/M NEW PT MOD SEVERITY 117.09 XXX 99326 DOM/R-HOME E/M NEW PT MOD HI SEVERITY 198.66 XXX 99327 DOM/R-HOME E/M NEW PT HI SEVERITY 261.21 XXX 99328 DOM/R-HOME E/M NEW PT SIGNIFICANT NEW PROBLEM 305.24 XXX 99334 DOM/R-HOME E/M EST PT SELF-LMTD/MINOR 86.07 XXX 99335 DOM/R-HOME E/M EST PT LW MOD SEVERITY 133.11 XXX 99336 DOM/R-HOME E/M EST PT MOD HI SEVERITY 187.65 XXX 99337 DOM/R-HOME E/M EST PT SIGNIFICANT NEW PROBLEM 270.22 XXX 99339 INDIV PHYS SUPVJ HOME/DOM/R-HOME MO 15-29 MIN 112.09 XXX 99340 INDIV PHYS SUPVJ HOME/DOM/R-HOME MO 30 MIN/> 157.13 XXX 99341 HOME VST NEW PT LOW SEVERITY 80.56 XXX 99342 HOME VST NEW PT MOD SEVERITY 117.09 XXX 99343 HOME VST NEW PT MOD TO HI SEVERITY 191.15 XXX 99344 HOME VST NEW PT HI SEVERITY 256.71 XXX 99345 HOME VST NEW PT UNSTABLE/SIGNIFICANT NEW PROBLEM 308.25 XXX 99347 HOME VST EST PT SELF LIMITED/MINOR 80.06 XXX 99348 HOME VST EST PT LOW TO MOD SEVERITY 121.10 XXX 99349 HOME VST EST PT MOD TO HI SEVERITY 179.14 XXX 99350 HOME VST EST PT UNSTABLE/SIGNIFICANT NEW PROBLEM 249.70 XXX + 99354 PROLNG PHYS SVC OFFICE O/P DIR CONTACT 1ST HR 140.61 ZZZ + 99355 PROLNG PHYS SVC OFFICE O/P DIR CONTACT EA 30 MIN 139.11 ZZZ + 99356 PROLONGED SERVICE I/P REQ UNIT/FLOOR TIME 1ST HR 128.60 ZZZ + 99357 PROLONGED SVC I/P REQ UNIT/FLOOR TIME EA 30 MIN 129.10 ZZZ 99358 PROLNG E/M SVC BEFORE&/AFTER DIR PT CARE 1ST HR 158.63 XXX + 99359 PROLNG E/M BEFORE&/AFTER DIR CARE EA 30 MIN 76.56 ZZZ 99360 PHYS STANDBY SVC PROLNG PHYS ATTN EA 30 MIN 89.57 XXX 99363 ANTICOAGULANT MGMT OUTPATIENT 1ST 90 DAYS 182.65 XXX 99364 ANTICOAGULANT MGMT OUTPATIENT EA SBSQ 90 DAYS 62.05 XXX 99366 TEAM CONFERENCE FACE-TO-FACE NONPHYSICIAN 62.05 XXX 99367 TEAM CONFERENCE NON-FACE-TO-FACE PHYSICIAN 82.07 XXX 99368 TEAM CONFERENCE NON-FACE-TO-FACE NONPHYSICIAN 53.04 XXX 99374 PHYS SUPVJ PT HOME HLTH AGENCY MO 15-29 MINUTES 101.08 XXX 99375 PHYS SUPVJ PT HOME HLTH AGENCY MO 30 MIN/> 156.12 XXX 99377 PHYS SUPVJ HOSPICE PT MO 15-29 MIN 101.08 XXX 99378 PHYS SUPVJ HOSPICE PT MO 30 MIN/> 159.13 XXX 24 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section V: Evaluation and Management (E/M) Services Georgia Workers Compensation Medical Fee Schedule 99201 99499 EVALUATION AND MANAGEMENT Effective April 1, 2011 Medical Fee Schedule 99379 PHYS SUPVJ NF PT MO 15-29 MIN 101.08 XXX 99380 PHYS SUPVJ NF PT MO 30 MIN/> 151.62 XXX 99381 1ST PREVENTIVE MEDICINE NEW PATIENT < 1YR 138.11 XXX 99382 1ST PREVENTIVE MEDICINE NEW PATIENT AGE 1-4 YRS 149.62 XXX 99383 1ST PREVENTIVE MEDICINE NEW PATIENT AGE 5-11 YRS 149.12 XXX 99384 1ST PREVENTIVE MEDICINE NEW PATIENT AGE 12-17 YR 162.13 XXX 99385 1ST PREVENTIVE MEDICINE NEW PATIENT AGE 18-39YRS 162.13 XXX 99386 1ST PREVENTIVE MEDICINE NEW PATIENT AGE 40-64YRS 188.65 XXX 99387 1ST PREVENTIVE MEDICINE NEW PATIENT AGE 65YRS&> 208.17 XXX 99391 PERIODIC PREVENTIVE MED ESTABLISHED PATIENT <1YR 116.59 XXX 99392 PERIODIC PREVENTIVE MED EST PATIENT AGE 1-4YRS 129.60 XXX 99393 PERIODIC PREVENTIVE MED EST PATIENT AGE 5-11YRS 129.10 XXX 99394 PERIODIC PREVENTIVE MED EST PATIENT AGE 12-17YRS 141.11 XXX 99395 PERIODIC PREVENTIVE MED EST PATIENT AGE 18-39YRS 141.61 XXX 99396 PERIODIC PREVENTIVE MED EST PATIENT AGE 40-64YRS 154.62 XXX 99397 PERIODIC PREVENTIVE MED EST PATIENT AGE 65YRS&> 174.14 XXX 99401 PREV MED CNSL INDIV SPX 15 MIN 53.04 XXX 99402 PREV MED CNSL INDIV SPX 30 MIN 91.57 XXX 99403 PREV MED CNSL INDIV SPX 45 MIN 127.60 XXX 99404 PREV MED CNSL INDIV SPX 60 MIN 164.13 XXX 99406 TOBACCO USE CESSATION INTERMEDIATE 3-10 MINUTES 20.02 XXX 99407 TOBACCO USE CESSATION INTENSIVE >10 MINUTES 39.03 XXX 99408 ALCOHOL/SUBSTANCE SCREEN & INTERVEN 15-30 MIN 51.04 XXX 99409 ALCOHOL/SUBSTANCE SCREEN & INTERVEN >30 MIN 99.08 XXX 99411 PREV MED CNSL GRP SPX 30 MIN 23.02 XXX 99412 PREV MED CNSL GRP SPX 60 MIN 30.02 XXX 99420 ADMN&INTERPJ HLTH RISK ASSMT INSTRUMENT 15.01 XXX 99429 UNLIS PREV MED SVC BR XXX 99441 PHYSICIAN TELEPHONE EVALUATION 5-10 MIN 20.52 XXX 99442 PHYSICIAN TELEPHONE EVALUATION 11-20 MIN 39.03 XXX 99443 PHYSICIAN TELEPHONE EVALUATION 21-30 MIN 57.55 XXX 99444 PHYSICIAN ONLINE EVALUATION & MANAGEMENT SERVICE 45.04 XXX 99450 BASIC LIFE AND/OR DISABILITY EXAMINATION BR XXX 99455 WORK RELATED/MED DBLT XM TREATING PHYS 202.66 XXX 99456 WORK RELATED/MED DBLT XM OTH/THN TREATING PHYS BR XXX 99460 1ST HOSP/BIRTHING CENTER CARE PER DAY NML NB 85.07 XXX 99461 1ST CARE PR DAY NML NB XCPT HOSP/BIRTHING CENTER 134.11 XXX 99462 SUBQ HOSPITAL CARE PER DAY E/M NORMAL NEWBORN 46.04 XXX 99463 1ST HOSP/BIRTHING CENTER NB ADMIT&DSCHG SM DATE 116.59 XXX 99464 ATTN AT DELIVERY& 1ST STABILIZATION OF NEWBORN 105.58 XXX 99465 DELIVERY/BIRTHING ROOM RESUSCITATION 204.16 XXX 99466 CRITICAL CARE INTERFACILITY TRANSPORT 30-74 MIN 389.81 XXX + 99467 CRITICAL CARE INTERFACILITY TRANSPORT EA 30 MIN 174.64 ZZZ 99468 1ST INPATIENT CRITICAL CARE PR DAY AGE 28 DAYS/< 1323.56 XXX 99469 SUBQ I/P CRITICAL CARE PR DAY AGE 28 DAYS/< 576.46 XXX 99471 INITIAL PED CRITICAL CARE 29 D THRU 24 MO 1140.41 XXX Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 25
Georgia Workers Compensation Medical Fee Schedule Section V: Evaluation and Management (E/M) Services EVALUATION AND MANAGEMENT 99201 99499 Medical Fee Schedule Effective April 1, 2011 99472 SUBSEQUENT PED CRITICAL CARE 29 D THRU 24 MO 573.96 XXX 99475 INITIAL PED CRITICAL CARE 2 THRU 5 YEARS 806.14 XXX 99476 SUBSEQUENT PED CRITICAL CARE 2 THRU 5 YEARS 488.39 XXX 99477 INITIAL HOSP NEONATE 28 D/< NOT CRITICALLY ILL 508.91 XXX 99478 SUBSEQUENT INTENSIVE CARE INFANT < 1500 GRAMS 202.16 XXX 99479 SUBSEQUENT INTENSIVE CARE INFANT 1500-2500 GRAMS 185.65 XXX 99480 SUBSEQUENT INTENSIVE CARE INFANT 2501-5000 GRAMS 173.14 XXX 99499 UNLIS E/M SVC BR XXX 26 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
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 99140 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 99140 Anesthesia complicated by emergency conditions, emergency is defined as existing when delay in treatment of the injured employee would lead to a significant increase in the threat to life or body part. 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
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 $36.56. 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 99100 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) 1 99116 Anesthesia complicated by utilization of total body hypothermia (List separately in addition to code for primary anesthesia procedure) 99135 Anesthesia complicated by utilization of controlled hypotension (List separately in addition to code for primary anesthesia procedure) 99140 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 $548.40. 01382 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) = $548.40 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 5 5 2 28 CPT only 2010 American Medical Association. All Rights Reserved.
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 $548.40. 01382-QY Anesthesiologist providing medical direction of one CRNA for arthroscopic procedure of knee joint 01382-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) = $548.40 Payment for anesthesiologist services 01382-QY @ 50%= $548.40 x 50% = $274.20 Payment for CRNA services 01382-QX @ 50% = $548.40 x 50% = $274.20 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
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 (00100 01999) 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 00100 01999. The operating surgeon should report the surgical procedure 10021 69990 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.
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 62310 62319 and 64400 64530. 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 62310 62319, 64400 64530). CPT only 2010 American Medical Association. All Rights Reserved. 31
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 92950. 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.
Section VI: Anesthesia Services Georgia Workers Compensation Medical Fee Schedule 00100 01999, 99100 99140 ANESTHESIA Effective April 1, 2011 Medical Fee Schedule CODE MOD DESCRIPTION BASE UNIT 00100 ANESTHESIA SALIVARY GLANDS WITH BIOPSY 5 00102 ANESTHESIA CLEFT LIP INVOLVING PLASTIC REPAIR 6 00103 ANESTHESIA EYELID RECONSTRUCTIVE PROCEDURE 5 00104 ANESTHESIA ELECTROCONVULSIVE THERAPY 4 00120 ANESTHESIA EXTERNAL MIDDLE & INNER EAR W/BIOPSY 5 00124 ANES EXTERNAL MIDDLE & INNER EAR W/BX OTOSCOPY 4 00126 ANES XTRNL MID & INNER EAR W/BX TYMPANOTOMY 4 00140 ANESTHESIA EYE NOT OTHERWISE SPECIFIED 5 00142 ANESTHESIA EYE LENS SURGERY 4 00144 ANESTHESIA EYE CORNEAL TRANSPLANT 6 00145 ANESTHESIA EYE VITREORETINAL SURGERY 6 00147 ANESTHESIA EYE IRIDECTOMY 4 00148 ANESTHESIA EYE OPHTHALMOSCOPY 4 00160 ANESTHESIA NOSE & ACCESSORY SINUSES 5 00162 ANES NOSE & ACCESSORY SINUSES RADICAL SURGERY 7 00164 ANES NOSE&ACCESSORY SINUSES BIOPSY SOFT TISSUE 4 00170 ANESTHESIA INTRAORAL WITH BIOPSY 5 00172 ANES INTRAORAL W/BIOPSY REPAIR CLEFT PALATE 6 00174 ANES INTRAORAL W/BX EXC RETROPHARYNGEAL TUMOR 6 00176 ANESTHESIA INTRAORAL W/BIOPSY RADICAL SURGERY 7 00190 ANESTHESIA FACIAL BONES OR SKULL 5 00192 ANES FACIAL BONES/SKULL RAD SURG W/PROGNATHISM 7 00210 ANESTHESIA INTRACRANIAL PROCEDURE NOS 11 00211 ANES INTRACRANIAL CRANIOTOMY/CRANIECTOMY HMTMA 10 00212 ANESTHESIA INTRACRANIAL PROCEDURE SUBDURAL TAPS 5 00214 ANES INTRACRANIAL BURR HOLES W/VENTRICULOGRAPHY 9 00215 ANES ICRA CRNOP/ELEVATION DEPRS SKULL FX XDRL 9 00216 ANESTHESIA INTRACRANIAL VASCULAR PROCEDURE 15 00218 ANES INTRACRANIAL PROCEDURE IN SITTING POSITION 13 00220 ANES INTRACRANIAL CEREBROSPINAL FLUID SHUNTING 10 00222 ANES INTRACRANIAL ELECTROCOAGULATION ICRA NERVE 6 00300 ANES INTEG MUSC&NRV HEAD NCK&POSTERIOR TRUNK 5 00320 ANES ESOPH THYR LARX TRACH&LYMPHTC NECK 1YR/> 6 00322 ANES ESOPH THYR LARX TRACH&LYMPHTC NCK BX THYR 3 00326 ANESTHESIA LARYNX & TRACHEA CHILDREN <1YEAR 7 00350 ANESTHESIA MAJOR VESSELS NECK 10 00352 ANESTHESIA MAJOR VESSELS NECK SIMPLE LIGATION 5 00400 ANES INTEG EXTREMITIES ANTERIOR TRUNK PERINEUM 3 00402 ANESTHESIA RECONSTRUCTIVE BREAST 5 00404 ANESTHESIA RADICAL/MODIFIED RADICAL BREAST 5 00406 ANES RADICAL/MODIFIED RADICAL BREAST W/NODE 13 00410 ANES INTEG SYS ELEC CONVERSION ARRHYTHMIAS 4 00450 ANESTHESIA CLAVICLE AND SCAPULA 5 00452 ANESTHESIA CLAVICLE & SCAPULA RADICAL SURGERY 6 00454 ANESTHESIA CLAVICLE & SCAPULA BIOPSY CLAVICLE 3 00470 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
Georgia Workers Compensation Medical Fee Schedule Section VI: Anesthesia Services ANESTHESIA 00100 01999, 99100 99140 Medical Fee Schedule Effective April 1, 2011 CODE MOD DESCRIPTION BASE UNIT 00472 ANESTHESIA PARTIAL RIB RESECTION THORACOPLASTY 10 00474 ANESTHESIA PARTIAL RIB RESECTION RADICAL 13 00500 ANESTHESIA ESOPHAGUS 15 00520 ANESTHESIA CLOSED CHEST W/BRONCHOSCOPY 6 00522 ANESTHESIA CLOSED CHEST NEEDLE BIOPSY PLEURA 4 00524 ANESTHESIA CLOSED CHEST PNEUMOCENTESIS 4 00528 ANES CLSD CHEST MEDIASTSC&THRSC W/O 1 LUNG VNTJ 8 00529 ANES CLOSED CHEST MEDIASTSC&THRSC W/1 LUNG VNTJ 11 00530 ANES PERMANENT TRANSVENOUS PACEMAKER INSERTION 4 00532 ANESTHESIA ACCESS CENTRAL VENOUS CIRCULATION 4 00534 ANES TRANSVENOUS INSJ/REPLACEMENT PACING CVDFB 7 00537 ANES CARDIAC ELECTROPHYSIOLOGIC W/RF ABLATION 7 00539 ANESTHESIA TRACHEOBRONCHIAL RECONSTRUCTION 18 00540 ANESTHESIA THRCM LUNG PLEURA DPHRM&MED THRSC 12 00541 ANES THRCM LUNG PLEURA DPHRM&MED THRSC 1 LUNG 15 00542 ANES THRCM LUNG PLEURA DPHRM&MED THRSC DCRTCTJ 15 00546 ANES THRCM LNG PLEUR DPHRM&MED THRSC PULM RESCJ 15 00548 ANES THRCM LNG PLEUR DPHRM&MED THRSC TRACH&BRNCH 17 00550 ANESTHESIA FOR STERNAL DEBRIDEMENT 10 00560 ANES HRT PRCRD SAC&GREAT VESSEL CH W/O PMP OXTJ 15 00561 ANES HRT PRCRD SAC&GREAT VSL CH W/PMP OXTJ <1YR 25 00562 ANES HRT PRCRD&GRT VSL CH W/PMP OXTJ PT AGE 1/> 20 00563 ANES HRT PRCRD&GREAT VSL CH W/PUMP OXTJ HYPTHRM 25 00566 ANES DIR CAB GRFG W/O PMP OXTJ 25 00567 ANES DIRECT CAB GRAFTING W/ PUMP OXYGENATOR 18 00580 ANES HEART TRANSPLANT/HEART/LUNG TRANSPLANT 20 00600 ANESTHESIA CERVICAL SPINE & CORD 10 00604 ANES CERVICAL SPINE&CORD W/PATIENT SITTING 13 00620 ANESTHESIA THORACIC SPINE & CORD 10 00622 ANES THORACIC SPINE&CORD THORACOLMBR SYMPTH 13 00625 ANES THRC SPINE & CORD ANT APPR W/O 1 LUNG VNTJ 13 00626 ANES THORACIC SPINE & C/D ANT APPR W/1 LNG VNTJ 15 00630 ANESTHESIA LUMBAR REGION 8 00632 ANESTHESIA LUMBAR REGION LUMBAR SYMPATHECTOMY 7 00634 ANESTHESIA LUMBAR CHEMONUCLEOLYSIS 10 00635 ANES DIAGNOSTIC/THERAPEUTIC LUMBAR PUNCTURE 4 00640 ANES MNPJ SPINE/CLSD CRV THORACIC/LUMBAR SPINE 3 00670 ANESTHESIA EXTENSIVE SPINE & SPINAL CORD 13 00700 ANESTHESIA UPPER ANTERIOR ABDOMINAL WALL 4 00702 ANES UPR ANT ABDL WALL PERCUTANEOUS LIVER BX 4 00730 ANESTHESIA UPPER POSTERIOR ABDOMINAL WALL 5 00740 ANES UPPER GI ENDOSCOPIC PROXIMAL TO DUODENUM 5 00750 ANESTHESIA HERNIA REPAIR UPPER ABDOMEN 4 00752 ANES HRNA RPR UPR ABD LMBR&VNT HRNAS&/WND DEHSN 6 00754 ANES HERNIA REPAIR UPPER ABDOMEN OMPHALOCELE 7 00756 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
Section VI: Anesthesia Services Georgia Workers Compensation Medical Fee Schedule 00100 01999, 99100 99140 ANESTHESIA Effective April 1, 2011 Medical Fee Schedule CODE MOD DESCRIPTION BASE UNIT 00770 ANESTHESIA MAJOR ABDOMINAL BLOOD VESSELS 15 00790 ANES INTRAPERITONEAL UPPER ABDOMEN W/LAPS 7 00792 ANES IPR UPR ABD LAPS PRTL HPTC/MGMT LVR HEMRRG 13 00794 ANES IPR UPPER ABD W/LAPS PNCRTECT PRTL/TOTAL 8 00796 ANES IPR UPPER ABD W/LAPS LIVER TRANSPLANT 30 00797 ANES IPR UPPER ABDOMEN LAPS GASTRIC RSTCV MO 11 00800 ANESTHESIA LOWER ANTERIOR ABDOMINAL WALL 4 00802 ANES LOWER ANT ABDOMINAL WALL PANNICULECTOMY 5 00810 ANES LOWER INTESTINAL NDSC DISTAL DUODENUM 5 00820 ANESTHESIA LOWER POSTERIOR ABDOMINAL WALL 5 00830 ANESTHESIA HERNIA REPAIR LOWER ABDOMEN 4 00832 ANES HRNA RPR LWR ABD VENTRAL&INCAL HRNAS 6 00834 ANES HERNIA REPAIR LOWER ABDOMEN NOS <1YR AGE 5 00836 ANES HRNA RPR LWR ABD NOS INFTS<37WK BRTH<50WK 6 00840 ANESTHESIA INTRAPERITONEAL LOWER ABD W/LAPS 6 00842 ANES IPR LOWER ABDOMEN W/LAPS AMNIOCENTESIS 4 00844 ANES IPR LOWER ABD W/LAPS ABDOMINOPRNL RESCJ 7 00846 ANES IPR LOWER ABD W/LAPS RAD HYSTERECTOMY 8 00848 ANES IPR PX LWR ABD W/LAPS PELVIC EXENTERATION 8 00851 ANES IPR PX LWR ABD W/LAPS TUBAL LIG/TRNSECTION 6 00860 ANES EXTRAPERITONEAL PX LWR ABD W/UR TRC NOS 6 00862 ANES XTRPRTL LOWER ABD UR TRACT RENAL DON NFRCT 7 00864 ANES XTRPRTL LOWER ABD W/URINARY TRACT TOT CSTC 8 00865 ANES XTRPRTL LWR ABD W/UR TRC RAD PRST8ECT 7 00866 ANES XTRPRTL LOWER ABD W/UR TRC ADRNLECTOMY 10 00868 ANES XTRPRTL LOWER ABD W/UR TRACT RENAL TRNSPL 10 00870 ANES XTRPRTL LOWER ABD W/UR TRACT CSTOLITHOTOMY 5 00872 ANES LITHOTRP XTRCORP SHOCK WAVE W/WATER BATH 7 00873 ANES LITHOTRP XTRCORP SHOCK WAVE W/O WATER BATH 5 00880 ANESTHESIA MAJOR LOWER ABDOMINAL VESSELS 15 00882 ANES MAJOR LOWER ABDOMINAL VESSELS IVC LIGATION 10 00902 ANESTHESIA ANORECTAL PROCEDURE 5 00904 ANESTHESIA RADICAL PERINEAL PROCEDURE 7 00906 ANESTHESIA VULVECTOMY 4 00908 ANESTHESIA PERINEAL PROSTATECTOMY 6 00910 ANESTHESIA TRANSURETHRAL W/URETHROCYSTOSCOPY 3 00912 ANES TRANSURETHRAL RESECTION OF BLADDER TUMOR 5 00914 ANESTHESIA TRANSURETHRAL RESECTION OF PROSTATE 5 00916 ANES TRURL POST-TRURL RESECTION BLEEDING 5 00918 ANES TRURL FRAGMNTJ MNPJ&/RMVL URTRL CALCULUS 5 00920 ANESTHESIA MALE GENITALIA INCL OPEN URETHRAL PX 3 00921 ANES VASECTOMY UNI/BI INCL OPEN URETHRAL PX 3 00922 ANES SEMINAL VESICLES INCL OPEN URETHRAL PX 6 00924 ANES UNDSCND TESTIS UNI/BI INCL OPEN URTL PX 4 00926 ANES RAD ORCHIECTOMY INGUN INCL OPEN URTL PX 4 00928 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
Georgia Workers Compensation Medical Fee Schedule Section VI: Anesthesia Services ANESTHESIA 00100 01999, 99100 99140 Medical Fee Schedule Effective April 1, 2011 CODE MOD DESCRIPTION BASE UNIT 00930 ANES ORCHIOPEXY UNI/BI INCL OPEN URETHRAL PX 4 00932 ANES COMPLETE AMPUTATION PENIS INCL OPEN URTL 4 00934 ANES RAD AMP PENIS W/BI INGUINAL NODE OPN URTL 6 00936 ANES RAD AMP PNS W/BI INGUN&ILIAC INCL OPN URTL 8 00938 ANES INSJ PENILE PROSTH PRNL INCL OPEN URTL 4 00940 ANESTHESIA VAGINAL PROCEDURE INCL BIOPSY 3 00942 ANES COLPTMY VAGNC COLPRPHY INCL BX W/OPN URTL 4 00944 ANESTHESIA VAGINAL HYSTERECTOMY INCL BIOPSY 6 00948 ANESTHESIA CERVICAL CERCLAGE INCLUDING BIOPSY 4 00950 ANESTHESIA CULDOSCOPY INCLUDING BIOPSY 5 00952 ANES HYSTEROSCOPY&/HYSTEROSALPINGOGRAPHY W/BX 4 01112 ANES BONE MARROW ASPIR&/BX ANT/PST ILIAC CREST 5 01120 ANESTHESIA ON BONY PELVIS 6 01130 ANESTHESIA BODY CAST APPLICATION OR REVISION 3 01140 ANESTHESIA INTERPELVIABDOMINAL AMPUTATION 15 01150 ANES RADICAL TUMOR PELVIS XCP HINDQUARTER AMP 10 01160 ANES CLOSED SYMPHYSIS PUBIS/SACROILIAC JOINT 4 01170 ANES OPEN SYMPHYSIS PUBIS/SACROILIAC JOINT 8 01173 ANES OPN RPR DISRPJ PELVIS/COLUMN FX ACETABULUM 12 01180 ANESTHESIA OBTURATOR NEURECTOMY EXTRAPELVIC 3 01190 ANESTHESIA OBTURATOR NEURECTOMY INTRAPELVIC 4 01200 ANESTHESIA HIP JOINT 4 01202 ANESTHESIA ARTHROSCOPY HIP JOINT 4 01210 ANESTHESIA OPEN PX HIP JOINT 6 01212 ANESTHESIA OPEN HIP JOINT DISARTICULATION 10 01214 ANESTHESIA OPEN TOTAL HIP ARTHROPLASTY 8 01215 ANESTHESIA OPEN REVISION TOTAL HIP ARTHROPLASTY 10 01220 ANESTHESIA UPPER 2/3 FEMUR CLOSED PROCEDURES 4 01230 ANESTHESIA UPPER 2/3 FEMUR OPEN PROCEDURES 6 01232 ANESTHESIA UPPER 2/3 FEMUR AMPUTATION 5 01234 ANES UPPER 2/3 FEMUR RADICAL RESCECTION 8 01250 ANES NERVE MUSC TENDON FASCIA&BURSAE UPPER LEG 4 01260 ANES VEINS OF UPPER LEG INCLUDING EXPLORATION 3 01270 ANESTHESIA ARTERIES UPPER LEG INCL BYPASS GRAFT 8 01272 ANES ART UPPER LEG W/BYPASS GRAFT FEM ART LIG 4 01274 ANES ARTERIES UPPER LEG W/BYP GRF FEM ART EMBLC 6 01320 ANES NERVE MUSC TENDON FSCA&BRS KNEE&/POP AREA 4 01340 ANESTHESIA LOWER 1/3 FEMUR CLOSED PROCEDURES 4 01360 ANESTHESIA LOWER 1/3 FEMUR OPEN PROCEDURES 5 01380 ANESTHESIA KNEE JOINT CLOSED PROCEDURES 3 01382 ANESTHESIA DIAGNOSTIC ARTHROSCOPIC KNEE JOINT 3 01390 ANES UPPER ENDS TIBIA FIBULA&/PATELLA CLOSED 3 01392 ANES UPPER ENDS TIBIA FIBULA&/PATELLA OPEN 4 01400 ANES OPEN/SURGICAL ARTHROSCOPIC KNEE JOINT 4 01402 ANESTHESIA ARTHROSCOPIC TOTAL KNEE ARTHROPLASTY 7 01404 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
Section VI: Anesthesia Services Georgia Workers Compensation Medical Fee Schedule 00100 01999, 99100 99140 ANESTHESIA Effective April 1, 2011 Medical Fee Schedule CODE MOD DESCRIPTION BASE UNIT 01420 ANES CAST APPLICATION REMOVAL/REPAIR KNEE JOINT 3 01430 ANESTHESIA VEINS KNEE & POPLITEAL AREA 3 01432 ANESTHESIA VEINS KNEE & POPLITEAL ARVEN FISTULA 6 01440 ANESTHESIA ARTERIES OF KNEE & POPLITEAL AREA 8 01442 ANES ART KNEE & POP/POP TEAEC +-PATCH GRAFT 8 01444 ANES ART KNE&POP/POP EXC&GRF/RPR OCCLS/ARYSM 8 01462 ANESTHESIA LOWER LEG ANKLE & FOOT CLOSED PX 3 01464 ANESTHESIA ANKLE &/FOOT ARTHROSCOPIC PX 3 01470 ANES NRV/MUS/TND/FASC LOWER LEG/ANKLE/FOOT 3 01472 ANES RPR RUPTURED ACHILLES TENDON +-PATCH GRAFT 5 01474 ANESTHESIA GASTROCNEMIUS RECESSION 5 01480 ANESTHESIA BONES LOWER LEG/ANKLE/FOOT OPEN PX 3 01482 ANES RADICAL RESECTION INCL BELOW KNEE AMP 4 01484 ANES OSTEOTOMY/OSTEOPLASTY TIBIA&/FIBULA OPEN 4 01486 ANESTHESIA TOTAL ANKLE REPLACEMENT OPEN 7 01490 ANES LOWER LEG CAST APPLICATION REMOVAL/REPAIR 3 01500 ANESTHESIA ARTERIES LOWER LEG W/BYPASS GRAFT 8 01502 ANES ART LOWER LEG W/BYP GRAFT EMBLC DIR/W/CATH 6 01520 ANESTHESIA VEINS OF LOWER LEG 3 01522 ANES VEINS LOWER LEG VENOUS THRMBC DIR/W/CATH 5 01610 ANES NERVE MUSCLE TENDON FSCA&BRS SHO&AXILLA 5 01620 ANES CLOSED HUMRL H/N STRNCLAV JOINT&SHO JOINT 4 01622 ANES SHOULDER JOINT DIAGNOSTIC ARTHROSCOPIC PX 4 01630 ANES ARTHRS HUMERAL H/N STRNCLAV&SHOULDER JOINT 5 01634 ANESTHESIA ARTHROSCOPIC SHOULDER DISARTICULATION 9 01636 ANES ARTHRS INTERTHORACOSCAPULAR AMPUTATION 15 01638 ANES ARTHROSCOPIC TOTAL SHOULDER REPLACEMENT 10 01650 ANESTHESIA ARTERIES SHOULDER & AXILLA 6 01652 ANESTHESIA AXILLARY-BRACHIAL ANEURYSM 10 01654 ANES ARTERIES SHOULDER & AXILLA BYPASS GRAFT 8 01656 ANESTHESIA AXILLARY-FEMORAL BYPASS GRAFT 10 01670 ANESTHESIA VEINS SHOULDER & AXILLA 4 01680 ANES SHOULDER CAST APPLICATION REMOVAL/REPAIR 3 01682 ANES SHOULDER SPICA APPLICATION REMOVAL/REPAIR 4 01710 ANES NRV MUSC TDN FSCA&BRS UPR ARM/ELBOW 3 01712 ANESTHESIA TENOTOMY ELBOW TO SHOULDER OPEN 5 01714 ANESTHESIA TENOPLASTY ELBOW TO SHOULDER 5 01716 ANESTHESIA BICEPS TENODESIS RUPTURE LONG TENDON 5 01730 ANESTHESIA HUMERUS & ELBOW CLOSED PX 3 01732 ANESTHESIA ELBOW JOINT DIAGNOSTIC ARTHROSCOPIC 3 01740 ANESTHESIA ELBOW OPEN/SURGICAL ARTHROSCOPIC 4 01742 ANESTHESIA HUMERUS ARTHROSCOPIC OSTEOTOMY 5 01744 ANES HUMERUS ARTHROSCOPIC REPAIR NON/MALUNION 5 01756 ANESTHESIA ELBOW ARTHROSCOPIC RADICAL PX 6 01758 ANES HUMERUS ARTHROSCOPIC EXCISION CYST/TUMOR 5 01760 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
Georgia Workers Compensation Medical Fee Schedule Section VI: Anesthesia Services ANESTHESIA 00100 01999, 99100 99140 Medical Fee Schedule Effective April 1, 2011 CODE MOD DESCRIPTION BASE UNIT 01770 ANESTHESIA ARTERIES UPPER ARM & ELBOW 6 01772 ANESTHESIA ARTERIES UPPER ARM&ELBOW EMBOLECTOMY 6 01780 ANESTHESIA VEINS UPPER ARM & ELBOW 3 01782 ANESTHESIA VEINS UPPER ARM&ELBOW PHLEBORRHAPHY 4 01810 ANES NERVE MUSCLE TDN FSCA&BRS F/ARM WRST&HAND 3 01820 ANES RADIUS ULNA WRIST/HAND BONES CLOSED PX 3 01829 ANESTHESIA WRIST DIAGNOSTIC ARTHROSCOPIC 3 01830 ANES ARTHRS/ENDOSCOPIC DSTL RADIUS DSTL U/W/H 3 01832 ANESTHESIA ARTHROSCOPIC TOTAL WRIST REPLACEMENT 6 01840 ANESTHESIA ARTERIES FOREARM WRIST & HAND 6 01842 ANES ARTERIES FOREARM WRIST&HAND EMBOLECTOMY 6 01844 ANESTHESIA VASCULAR SHUNT/SHUNT REVISION 6 01850 ANESTHESIA VEINS FOREARM WRIST & HAND 3 01852 ANES VEINS FOREARM WRIST&HAND PHLEBORRHAPHY 4 01860 ANES FOREARM WRIST/HAND CAST APPL RMVL/REPAIR 3 01916 ANESTHESIA DIAGNOSTIC ARTERIOGRAPHY/VENOGRAPH 5 01920 ANES C-CATHJ W/C ANGIOGRAPHY&VENTRICULOGRAPHY 7 01922 ANES NON-INVASIVE IMAGING/RADIATION THERAPY 7 01924 ANESTHESIA THER IVNTL RADIOLOGICAL ARTERIAL 5 01925 ANESTHESIA CAROTID/CORONARY THER IVNTL RAD 7 01926 ANES ICRA ICAR/AORTIC THER IVNTL RAD ARTL 8 01930 ANESTHESIA VENOUS/LYMPHATIC NOS THER IVNTL RAD 5 01931 ANESTHESIA INTRAHEPATIC/PORTAL THER IVNTL RAD 7 01932 ANESTHESIA INTRATHORACIC/JUGULAR THER IVNTL RAD 6 01933 ANES INTRACRANIAL THER IVNTL RAD VENS/LYMPHTC 7 01935 ANESTHESIA PERQ IMAGE GUIDED SPINE DIAGNOSTIC 5 01936 ANESTHESIA PERQ IMAGE GUIDED SPINE THERAPEUTIC 5 01951 ANES 2/3 DGR BRN EXC/DBRDMT +-GRF <4 % TBSA 3 01952 ANES 2/3 DGR BRN EXC/DBRDMT +-GRF 4-9 % TBSA 5 + 01953 ANES 2/3 DGR BRN EXC/DBRDMT +-GRF EA >9 % TBSA 1 01958 ANESTHESIA EXTERNAL CEPHALIC VERSION 5 01960 ANESTHESIA VAGINAL DELIVERY ONLY 5 01961 ANESTHESIA CESAREAN DELIVERY ONLY 7 01962 ANES URGENT HYSTERECTOMY FOLLOWING DELIVERY 8 01963 ANESTHESIA C HYST W/O ANY LABOR ANALG/ANES CARE 8 01965 ANESTHESIA INCOMPLETE/MISSED ABORTION 4 01966 ANESTHESIA INDUCED ABORTION 4 01967 NEURAXIAL LABOR ANALG/ANES PLND VAG DLVR 5 + 01968 ANES C DLVR FLWG NEURAXIAL LABOR ANALG/ANES 2 + 01969 ANES C HYST FLWG NEURAXIAL LABOR ANALG/ANES 5 01990 PHYSIOL SUPPORT HRVG ORGAN FROM BRN-DEAD PT 7 01991 ANES DX/THER NRV BLK/NJX OTH/THN PRONE POS 3 01992 ANES DX/THER NERVE BLOCK/INJECTION PRONE POS 5 01996 DAILY HOSP MGMT EDRL/SARACH CONT DRUG ADMN 3 01999 UNLISTED ANESTHESIA PROCEDURE BR + 99100 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
Section VI: Anesthesia Services Georgia Workers Compensation Medical Fee Schedule 00100 01999, 99100 99140 ANESTHESIA Effective April 1, 2011 Medical Fee Schedule CODE MOD DESCRIPTION BASE UNIT + 99116 ANES COMP UTILIZATION TOT BDY HYPOTHMIA See Page 28 + 99135 ANES COMP UTILIZATION CTRLLED HYPOTENSION See Page 28 + 99140 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
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. 33-24-59.9, the RNFA shall not be on the staff of a hospital or the treating physician. Should the services of a RNFA, NP, or PA be medically necessary, add 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
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 99241 through 99245. 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 99024. 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.
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
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, 20900 20938, 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 20999. 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.
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 69990 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 69990 in CPT 2011. Internal neurolysis requiring the use of an operating microscope is reported using CPT code 64727 and code 69990 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 69990 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
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 78. 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 25. 62 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.
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. 33-24-59.9, 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
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 10021 FINE NEEDLE ASPIRATION W/O IMAGING GUIDANCE 232.08 XXX 10022 FINE NEEDLE ASPIRATION WITH IMAGING GUIDANCE 222.67 XXX 10040 ACNE SURGERY 165.06 010 10060 INCISION & DRAINAGE ABSCESS SIMPLE/SINGLE 177.25 010 10061 INCISION&DRAINAGE ABSCESS COMPLICATED/MULTIPLE 295.78 010 10080 INCISION & DRAINAGE PILONIDAL CYST SIMPLE 271.41 010 10081 INCISION & DRAINAGE PILONIDAL CYST COMPLICATED 418.75 010 10120 INCISION&REMOVAL FOREIGN BODY SUBQ TISS SMPL 218.79 010 10121 INCISION&REMOVAL FOREIGN BODY SUBQ TISS COMP 424.84 010 10140 I&D HEMATOMA SEROMA/FLUID COLLECTION 250.92 010 10160 PUNCTURE ASPIRATION ABSCESS HEMATOMA BULLA/CYST 203.28 010 10180 INCISION&DRAINAGE COMPLEX PO WOUND INFECTION 381.64 010 11000 DBRDMT X10SV ECZMT/INFCT SKN UP 10% BDY SURF 84.75 000 + 11001 DBRDMT X10SV ECZMT/INFCT SKN EA 10% BDY SURF 34.34 ZZZ 11004 DBRDMT SKN SUBQ T/M/F NECRO INFCTJ GENT&PR 953.82 000 11005 DBRDMT SKN SUBQ T/M/F NECRO INFCTJ ABDL WALL 1278.40 000 11006 DBRDMT SKN SUBQ T/M/F NECRO INFCTJ GENT/ABDL 1163.74 000 + 11008 REMOVAL PROSTHETIC MATRL ABDL WALL FOR INFECTION 449.21 ZZZ s 11010 DBRDMT W/RMVL FM FX&/DISLC SKN&SUBQ TISS 767.71 010 s 11011 DBRDMT W/RMVL FM FX&/DISLC SKN SUBQ T/M/F MUSC 842.48 000 s 11012 DBRDMT FX&/DISLC SUBQ T/M/F BONE 1130.51 000 s 11042 DEBRIDEMENT SUBCUTANEOUS TISSUE 20 SQ CM/< 141.24 000 s 11043 DEBRIDEMENT MUSCLE & FASCIA 20 SQ CM/< 310.74 000 s 11044 DBRDMT BONE M&/F 20 SQ CM/< 474.14 000 l + # 11045 DBRDMT SUBCUTANEOUS TISSUE EA ADDL 20 SQ CM 50.40 ZZZ l + # 11046 DBRDMT M&/F EA ADDL 20 SQ CM 87.52 ZZZ l + # 11047 DEBRIDEMENT BONE EA ADDL 20 SQ CM/< 144.01 ZZZ 11055 PARING/CUTTING BENIGN HYPERKERATOTIC LESION 1 78.10 000 11056 PARING/CUTTING BENIGN HYPERKERATOTIC LESION 2-4< 93.61 000 11057 PARING/CUTTING BENIGN HYPERKERATOTIC LESION >4 110.78 000 11100 BX SKIN SUBCUTANEOUS&/MUCOUS MEMBRANE 1 LESION 166.72 000 + 11101 BIOPSY SKN SUBQ&/MUC MEMB EA SPX ADDL LESION 53.17 ZZZ 11200 REMOVAL SK TGS MLT FIBRQ TAGS ANY AREA UP&W/15< 136.26 010 + 11201 REMOVAL SK TGS MLT FIBRQ TAGS ANY AREA EA 10< 30.46 ZZZ 11300 SHAVING SKIN LES 1 TRUNK/ARM/LEG DIAM 0.5CM/< 110.23 000 11301 SHVG SKIN LES 1 TRUNK/ARM/LEG DIAM 0.6-1.0 CM 149.55 000 11302 SHVG SKN LESION 1 TRUNK/ARM/LEG DIAM 1.1-2.0 CM 178.91 000 11303 SHVG SKIN LESION 1 TRUNK/ARM/LEG DIAM >2.0 CM 211.04 000 11305 SHAVING SKIN LESION 1 S/N/H/F/G DIAM 0.5 CM/< 110.23 000 11306 SHAVING SKIN LESION 1 S/N/H/F/G DIAM 0.6-1.0 CM 152.88 000 11307 SHAVING SKIN LESION 1 S/N/H/F/G DIAM 1.1-2.0 CM 181.13 000 11308 SHAVING SKIN LESION 1 S/N/H/F/G DIAM >2.0 CM 200.51 000 11310 SHAVING SKIN LESION 1 F/E/E/N/L/M DIAM 0.5 CM/< 136.26 000 11311 SHVG SKIN LESION 1 F/E/E/N/L/M DIAM 0.6-1.0 CM 171.71 000 11312 SHVG SKIN LESION 1 F/E/E/N/L/M DIAM 1.1-2.0 CM 199.96 000 11313 SHAVING SKIN LESION 1 F/E/E/N/L/M DIAM >2.0 CM 248.15 000 48 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule 11400 EXC B9 LES MRGN XCP SK TG T/A/L 0.5 CM/< 190.54 010 11401 EXC B9 LES MRGN XCP SK TG T/A/L 0.6-1.0 CM 233.19 010 11402 EXC B9 LES MRGN XCP SK TG T/A/L 1.1-2.0 CM 259.78 010 11403 EXC B9 LES MRGN XCP SK TG T/A/L 2.1-3.0 CM 298.55 010 11404 EXC B9 LES MRGN XCP SK TG T/A/L 3.1-4.0 CM 339.54 010 11406 EXC B9 LES MRGN XCP SK TG T/A/L > 4.0 CM 484.11 010 11420 EXC B9 LES MRGN XCP SK TG S/N/H/F/G 0.5 CM/< 189.99 010 11421 EXC B9 LES MRGN XCP SK TG S/N/H/F/G 0.6-1.0CM 247.04 010 11422 EXC B9 LES MRGN XCP SK TG S/N/H/F/G 1.1-2.0CM 275.29 010 11423 EXC B9 LES MRGN XCP SK TG S/N/H/F/G 2.1-3.0CM 319.05 010 11424 EXC B9 LES MRGN XCP SK TG S/N/H/F/G 3.1-4.0CM 366.68 010 11426 EXC B9 LES MRGN XCP SK TG S/N/H/F/G > 4.0CM 524.54 010 11440 EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 0.5CM/< 209.93 010 11441 EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 0.6-1.0CM 264.21 010 11442 EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 1.1-2.0CM 298.00 010 11443 EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 2.1-3.0CM 355.05 010 11444 EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 3.1-4.0CM 446.44 010 11446 EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M > 4.0CM 614.83 010 11450 EXCISION HIDRADENITIS AXILLARY SMPL/INTRM RPR 581.60 090 11451 EXCISION HIDRADENITIS AXILLARY COMPLEX REPAIR 743.33 090 11462 EXCISION HIDRADENITIS INGUINAL SMPL/INTRM RPR 571.07 090 11463 EXCISION HIDRADENITIS INGUINAL COMPLEX REPAIR 758.84 090 11470 EXCISION H/P/P/U SIMPLE/INTERMEDIATE REPAIR 635.88 090 11471 EXCISION H/P/P/U COMPLEX REPAIR 786.54 090 11600 EXCISION MAL LESION TRUNK/ARM/LEG 0.5 CM/< 296.89 010 11601 EXCISION MAL LESION TRUNK/ARM/LEG 0.6-1.0 CM 361.14 010 11602 EXCISION MAL LESION TRUNK/ARM/LEG 1.1-2.0 CM 394.93 010 11603 EXCISION MAL LESION TRUNK/ARM/LEG 2.1-3.0 CM 448.66 010 11604 EXCISION MAL LESION TRUNK/ARM/LEG 3.1-4.0 CM 497.40 010 11606 EXCISION MALIGNANT LESION TRUNK/ARM/LEG >4.0 CM 704.56 010 11620 EXCISION MALIGNANT LESION S/N/H/F/G 0.5 CM/< 302.43 010 11621 EXCISION MALIGNANT LESION S/N/H/F/G 0.6-1.0 CM 363.91 010 11622 EXCISION MALIGNANT LESION S/N/H/F/G 1.1-2.0 CM 409.89 010 11623 EXCISION MALIGNANT LESION S/N/H/F/G 2.1-3.0 CM 479.12 010 11624 EXCISION MALIGNANT LESION S/N/H/F/G 3.1-4.0 CM 538.39 010 11626 EXCISION MALIGNANT LESION S/N/H/F/G > 4.0 CM 650.28 010 11640 EXCISION MALIGNANT LESION F/E/E/N/L/M 0.5 CM/< 314.06 010 11641 EXCISION MALIGNANT LES F/E/E/N/L/M 0.6-1.0 CM 379.98 010 11642 EXCISION MALIGNANT LES F/E/E/N/L/M 1.1-2.0 CM 435.37 010 11643 EXCISION MALIGNANT LES F/E/E/N/L/M 2.1-3.0 CM 512.91 010 11644 EXCISION MALIGNANT LES F/E/E/N/L/M 3.1-4.0 CM 632.00 010 11646 EXCISION MALIGNANT LESION F/E/E/N/L/M > 4.0 CM 827.53 010 11719 TRIMMING NONDYSTROPHIC NAILS ANY NUMBER 34.34 000 11720 DEBRIDEMENT NAIL ANY METHOD 1-5 49.85 000 11721 DEBRIDEMENT NAIL ANY METHOD 6/> 68.13 000 11730 AVULSION NAIL PLATE PARTIAL/COMPLETE SIMPLE 1 152.88 000 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 49
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 + 11732 AVULSION NAIL PLATE PARTIAL/COMPLETE SMPL EA 69.79 ZZZ 11740 EVACUATION SUBUNGUAL HEMATOMA 74.22 000 11750 EXCISION NAIL MATRIX PERMANENT REMOVAL 345.63 010 11752 EXC NAIL MATRIX PRM RMVL W/AMP TUFT DSTL PHALANX 498.51 010 11755 BIOPSY NAIL UNIT SPX 211.04 000 11760 REPAIR NAIL BED 342.86 010 11762 RECONSTRUCTION NAIL BED W/GRAFT 431.49 010 11765 WEDGE EXCISION SKIN NAIL FOLD 217.68 010 11770 EXCISION PILONIDAL CYST/SINUS SIMPLE 424.84 010 11771 EXCISION PILONIDAL CYST/SINUS EXTENSIVE 881.25 090 11772 EXCISION PILONIDAL CYST/SINUS COMPLICATED 1056.29 090 11900 INJECTION INTRALESIONAL UP TO & INCL 7 90.29 000 11901 INJECTION INTRALESIONAL >7 114.10 000 11920 TATTOOING INCL MICROPIGMENTATION 6.0 CM/< 283.60 000 11921 TATTOOING INCL MICROPIGMENTATION 6.1-20.0 CM 326.80 000 + 11922 TATTOOING INCL MICROPIGMENTATION EA 20.0 CM 98.04 ZZZ 11950 SUBCUTANEOUS INJECTION FILLING MATERIAL 1 CC/< 114.10 000 11951 SUBCUTANEOUS INJECTION FILLING MATRL 1.1-5.0 CC 162.29 000 11952 SUBCUTANEOUS INJECTION FILLING MATRL 5.1-10.0CC 208.82 000 11954 SUBCUTANEOUS INJECTION FILLING MATRL > 10.0 CC 259.78 000 11960 INSERTION TISSUE EXPANDER INCL SBSQ XPNSJ 1459.53 090 11970 REPLACEMENT TISS EXPANDER PERMANENT PROSTHESIS 991.48 090 11971 REMOVAL TISS EXPANDER W/O INSERTION PROSTHESIS 747.21 090 11975 INSERTION IMPLANTABLE CONTRACEPTIVE CAPSULES 204.39 XXX 11976 REMOVAL IMPLANTABLE CONTRACEPTIVE CAPSULES 234.85 000 11977 RMVL W/RINSJ IMPLANTABLE CONTRACEPTIVE CAPSULES 359.48 XXX 11980 SUBCUTANEOUS HORMONE PELLET IMPLANTATION 168.39 000 11981 INSJ NON-BIODEGRADABLE DRUG DELIVERY IMPLANT 217.68 XXX 11982 REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT 242.61 XXX 11983 RMVL W/RINSJ NON-BIODEGRADABLE DRUG DLVR IMPLT 360.59 XXX 12001 SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/< 155.65 000 12002 SMPL REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.6-7.5CM 182.79 000 12004 SIMPLE RPR SCALP/NECK/AX/GENIT/TRUNK 7.6-12.5CM 217.13 000 12005 SMPL RPR SCALP/NECK/AX/GENIT/TRUNK 12.6-20.0CM 279.72 000 12006 SMPL RPR SCALP/NECK/AX/GENIT/TRUNK 20.1-30.0CM 337.88 000 12007 SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK >30.0CM 393.82 000 12011 SIMPLE REPAIR F/E/E/N/L/M 2.5CM/< 186.66 000 12013 SIMPLE REPAIR F/E/E/N/L/M 2.6CM-5.0CM 200.51 000 12014 SIMPLE REPAIR F/E/E/N/L/M 5.1CM-7.5CM 237.62 000 12015 SIMPLE REPAIR F/E/E/N/L/M 7.6CM-12.5CM 291.35 000 12016 SIMPLE REPAIR F/E/E/N/L/M 12.6CM-20.0CM 364.47 000 12017 SIMPLE REPAIR F/E/E/N/L/M 20.1CM-30.0CM 281.38 000 12018 SIMPLE REPAIR F/E/E/N/L/M >30.0CM 333.45 000 12020 TX SUPERFICIAL WOUND DEHISCENCE SIMPLE CLOSURE 432.04 010 12021 TX SUPERFICIAL WOUND DEHISCENCE W/PACKING 257.01 010 12031 REPAIR INTERMEDIATE S/A/T/E 2.5 CM/< 391.05 010 50 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule 12032 REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM 492.42 010 12034 REPAIR INTERMEDIATE S/A/T/E 7.6-12.5 CM 491.31 010 12035 REPAIR INTERMEDIATE S/A/T/E 12.6-20.0CM 596.00 010 12036 REPAIR INTERMEDIATE S/A/T/E 20.1-30.0 CM 651.39 010 12037 REPAIR INTERMEDIATE S/A/T/E > 30.0 CM 730.04 010 12041 REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.5CM/< 408.22 010 12042 REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.6-7.5 CM 467.49 010 12044 REPAIR INTERMEDIATE N/H/F/XTRNL GENT 7.6-12.5CM 553.90 010 12045 REPAIR INTERMEDIATE N/H/F/XTRNL GENT 12.6-20 CM 593.78 010 12046 RPR INTERMEDIATE N/H/F/XTRNL GENT 20.1-30.0 CM 704.56 010 12047 REPAIR INTERMEDIATE N/H/F/XTRNL GENT >30.0 CM 764.94 010 12051 REPAIR INTERMEDIATE F/E/E/N/L/M&/MUC 2.5 CM/< 432.04 010 12052 REPAIR INTERMEDIATE F/E/E/N/L/M&/MUC 2.6-5.0 CM 492.97 010 12053 REPAIR INTERMEDIATE F/E/E/N/L/M&/MUC 5.1-7.5 CM 544.48 010 12054 REPAIR INTERMEDIATE F/E/E/N/L/M&/MUC 7.6-12.5 CM 577.72 010 12055 REPAIR INTERMEDIATE F/E/E/N/L/M&/MUC 12.6-20.0CM 693.48 010 12056 REPAIR INTERMEDIATE F/E/E/N/L/M&/MUC 20.1-30.0CM 827.53 010 12057 REPAIR INTERMEDIATE F/E/E/N/L/M&/MUC > 30.0 CM 943.85 010 13100 REPAIR COMPLEX TRUNK 1.1 CM-2.5 CM 504.60 010 13101 REPAIR COMPLEX TRUNK 2.6 CM-7.5 CM 641.42 010 + 13102 REPAIR COMPLEX TRUNK EA 5 CM/< 174.48 ZZZ 13120 REPAIR COMPLEX SCALP/ARM/LEG 1.1 CM-2.5 CM 525.10 010 13121 REPAIR COMPLEX SCALP/ARM/LEG 2.6 CM-7.5 CM 715.08 010 + 13122 REPAIR COMPLEX SCALP/ARM/LEG EA 5 CM/< 192.76 ZZZ 13131 REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 1.1 CM-2.5 CM 579.93 010 13132 REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6 CM-7.5 CM 939.41 010 + 13133 REPAIR COMPLEX F/C/C/M/N/AX/G/H/F EA 5 CM/< 272.52 ZZZ 13150 REPAIR COMPLEX EYELID/NOSE/EAR/LIP 1.0 CM/< 576.61 010 13151 REPAIR COMPLEX EYELID/NOSE/EAR/LIP 1.1-2.5 CM 656.93 010 13152 REPAIR COMPLEX EYELID/NOSE/EAR/LIP 2.6-7.5 CM 908.40 010 + 13153 REPAIR COMPLEX EYELID/NOSE/EAR/LIP EA 5 CM/< 299.11 ZZZ 13160 SEC CLSR SURG WOUND/DEHSN EXTENSIVE/COMPLICATED 1311.64 090 14000 ADJACENT TISSUE TRANSFER/REARGMT TRUNK 10 CM/< 1004.77 090 14001 ATT/REARRANGEMENT TRUNK 10.1-30.0CM 1297.79 090 14020 ATT/REARRANGEMENT SCALP/ARM/LEG 10 CM/< 1128.29 090 14021 ATT/REARRANGEMENT SCALP/ARM/LEG 10.1-30.0 CM 1417.98 090 14040 ATT/REARRANGEMENT F/C/C/M/N/AX/G/H/F 10 CM/< 1244.06 090 14041 ATT/REARGMT F/C/C/M/N/AX/G/H/F 10.1-30.0CM 1542.06 090 14060 ATT/REARGMT E/N/E/L DFCT 10 CM/< 1264.55 090 14061 ATT/REARGMT EYELID/NOSE/EAR/LIP 10.1-30.0 CM 1655.05 090 14301 ATT/R ANY AREA DEFECT 30.1-60SQCM 1786.88 090 + 14302 ATT/R ANY AREA DEFECT EA ADDL 30SQCM OR PART 382.19 ZZZ 14350 FILLETED FINGER/TOE FLAP W/PREPJ RECIPIENT SITE 1173.16 090 15002 PREP SITE TRUNK/ARM/LEG 1ST 100 SQ CM/1PCT 541.71 000 + 15003 PREP SITE T/A/L ADDL 100 SQ CM/1PCT 117.98 ZZZ 15004 PREP SITE F/S/N/H/F/G/M/D GT 1ST 100 SQ CM/1PCT 636.99 000 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 51
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 + 15005 PREP SITE F/S/N/H/F/G/M/D GT ADDL 100 SQ CM/1PCT 195.53 ZZZ 15040 HARVEST SKIN TISSUE CLTR SKIN AGRFT 100 CM/< 407.67 000 15050 PINCH GRAFT 1/MLT C> SM ULCER TIP/OTH AREA 2CM 899.53 090 15100 SPLIT AGRFT T/A/L 1ST 100 CM/</1% BDY INFT/CHLD 1389.74 090 + 15101 SPLIT AGRFT T/A/L EA 100 CM/EA 1% BDY INFT/CHLD 300.21 ZZZ 15110 EPIDRM AGRFT T/A/L 1ST 100 CM/</1% BDY INFT/CHLD 1370.90 090 + 15111 EPIDRM AGRFT T/A/L EA 100 CM/EA 1% BDY INFT/CHLD 191.65 ZZZ 15115 EPIDERMAL AGRFT F/S/N/H/F/G/M/D GT 1ST 100 CM 1392.50 090 + 15116 EPIDERMAL AGRFT F/S/N/H/F/G/M/D GT EA 100 CM/EA 275.29 ZZZ 15120 SPLIT AGRFT F/S/N/H/F/G/M/D GT 1ST 100 CM<1 % 1535.41 090 + 15121 SPLIT AGRFT F/S/N/H/F/G/M/D GT EA 100 CM/EA 1 % 429.27 ZZZ 15130 DERMAL AUTOGRAFT TRUNK/ARM/LEG 1ST 100 CM 1087.31 090 + 15131 DERMAL AUTOGRAFT TRUNK/ARM/LEG EA 100 CM/EA 164.51 ZZZ 15135 DERMAL AUTOGRAFT F/S/N/H/F/G/M/D GT 1ST 100 1402.47 090 + 15136 DERMAL AGRFT F/S/N/H/F/G/M/D GT EA 100 CM/EA 142.91 ZZZ 15150 CLTR EPIDERMAL AUTOGRAFT T/A/L 1ST 25 CM/< 1118.32 090 + 15151 CLTR EPIDERMAL AGRFT T/A/L ADDL 1 CM-75 CM 214.36 ZZZ + 15152 CLTR EPIDRM AGRFT T/A/L EA 100 CM/EA 1 % BDY 252.02 ZZZ 15155 CLTR EPIDRM AGRFT F/S/N/H/F/G/M/D GT 1ST 25CM/< 1041.33 090 + 15156 CLTR EPIDRM AGRFT F/S/N/H/F/G/M/D GT ADDL 1-75CM 274.73 ZZZ + 15157 CLTR EPIDRM AGRFT F/S/N/H/F/G/M/D GT EA 100 EA 266.98 ZZZ 15170 ACLR DRM RPLCMT T/A/L 1ST 100 CM/</1 % BDY 700.13 090 + 15171 ACLR DRM RPLCMT T/A/L EA 100 CM/EA 1 % BDY 152.88 ZZZ 15175 ACLR DRM RPLCMT F/S/N/H/F/G/M/D GT 1ST 100 CM 834.17 090 + 15176 ACLR DRM RPLCMT F/S/N/H/F/G/M/D GT EA 100 CM/EA 238.73 ZZZ 15200 FTH/GFT FREE W/DIRECT CLOSURE TRUNK 20 CM/< 1320.50 090 + 15201 FTH/GFT FR W/DIR CLSR TRNK EA 20 CM 239.28 ZZZ 15220 FTH/GFT FREE W/DIRECT CLOSURE S/A/L 20 CM/< 1242.95 090 + 15221 FTH/GFT FR W/DIR CLSR S/A/L EA 20 CM 221.56 ZZZ 15240 FTH/GFT FR W/DIR CLSR F/C/C/M/N/AX/G/H/F 20 CM/< 1502.73 090 + 15241 FTH/GFT FR W/DIR CLSR F/C/C/M/N/AX/G/H/F EA 20CM 298.55 ZZZ 15260 FTH/GFT FREE W/DIRECT CLOSURE N/E/E/L 20 CM/< 1629.57 090 + 15261 FTH/GFT FR W/DIR CLSR N/E/E/L EA 20 CM 348.40 ZZZ 15300 ALGRFT TEMPORARY CLOSURE T/A/L 1ST 100 CM/</1 561.10 090 + 15301 ALGRFT TEMPORARY CLOSURE T/A/L EA 100 CM/EA 101.92 ZZZ 15320 ALGRFT TEMP CLOSURE F/S/N/H/F/G/M/D 1ST 100CM 601.54 090 + 15321 ALGRFT TEMP CLOSURE F/S/N/H/F/G/M/D EA 100CM 152.88 ZZZ 15330 ACLR DERMAL ALLOGRAFT TRUNK/ARM/LEG 1ST 100 CM 521.77 090 + 15331 ACLR DERMAL ALLOGRAFT TRUNK/ARM/LEG EA 100CM/EA 103.58 ZZZ 15335 ACLR DRM ALLOGRAFT F/S/N/H/F/G/M/D GT 1ST 100CM 512.36 090 + 15336 ACLR DRM ALGRFT F/S/N/H/F/G/M/D GT EA 100 CM/EA 143.46 ZZZ 15340 TISSUE CULTURED ALLOGENEIC SKIN 1ST 25CM/< 503.50 010 + 15341 TISS CLTR ALGC SKN EA 25 CM 75.33 ZZZ 15360 TISSUE CLTR ALGC DRM TRUNK/ARM/LEG 1ST 100 CM 574.39 090 + 15361 TISSUE CLTR ALGC DERMAL T/A/L EA 100CM/EA 1 PCT 106.35 ZZZ 15365 TISS CLTR ALGC DRM F/S/N/H/F/G/M/D 1ST 100 CM 548.91 090 52 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule + 15366 TISS CLTR ALGC DRM F/S/N/H/F/G/M/D EA 100 CM 131.27 ZZZ 15400 XENOGRAFT TEMP CLOSURE TRUNK/ARM/LEG 1ST 100CM 650.83 090 + 15401 XENOGRAFT TEMP CLOSURE TRUNK/ARM/LEG EA 100CM 146.78 ZZZ 15420 XENOGRF TEMP CLOSURE F/S/N/H/F/G/M/D 1ST 100CM 706.78 090 + 15421 XENOGRAFT TEMP CLOSURE F/S/N/H/F/G/M/D EA 100CM 187.22 ZZZ 15430 ACELLULAR XENOGRAFT IMPLANT 1ST 100 CM/1 PCT 870.18 090 + 15431 ACELLULAR XENOGRAFT IMPLANT EA 100 CM/1 PCT 386.07 ZZZ 15570 FRMJ DIRECT/TUBED PEDICLE +-TRANSFER TRUNK 1440.14 090 15572 FRMJ DIRECT/TUBED PEDICLE +-TR SCALP ARMS/LEGS 1403.58 090 15574 FRMJ DIR/TUBED PEDCL +-TR FT/CH/CH/M/N/AX/G/H/F 1467.84 090 15576 FRMJ DIRECT/TUBED PEDICLE +-TR E/N/E/L/NTRORAL 1303.88 090 15600 DELAY FLAP/SECTIONING FLAP TRUNK 522.33 090 15610 DELAY FLAP/SECTIONING FLAP SCALP ARMS/LEGS 548.36 090 15620 DELAY FLAP/SECTIONING FLAP F/C/C/N/AX/G/H/F 705.11 090 15630 DELAY FLAP/SCTJ FLAP EYELIDS NOSE EARS/LIPS 745.55 090 15650 TRANSFER ANY PEDICLE FLAP ANY LOCATION 824.20 090 15731 FOREHEAD FLAP W/ PRESERVATION VASCULAR PEDICLE 1850.58 090 15732 MUSC MYOCUTANEOUS/FASCIOCUTANEOUS FLAP HEAD&NCK 2436.61 090 15734 MUSC MYOCUTANEOUS/FASCIOCUTANEOUS FLAP TRUNK 2476.49 090 15736 MUSC MYOCUTANEOUS/FASCIOCUTANEOUS FLAP UXTR 2179.04 090 15738 MUSC MYOCUTANEOUS/FASCIOCUTANEOUS FLAP LXTR 2319.73 090 15740 FLAP ISLAND PEDICLE 1660.59 090 15750 FLAP NEUROVASCULAR PEDICLE 1493.31 090 15756 FREE MUSCLE/MYOCUTANEOUS FLAP W/MVASC ANAST 3867.33 090 15757 FREE SKIN FLAP W/MICROVASCULAR ANASTOMOSIS 3828.56 090 15758 FREE FASCIAL FLAP W/MICROVASCULAR ANASTOMOSIS 3811.94 090 15760 GRAFT COMPOSITE W/PRIMARY CLOSURE DONOR AREA 1378.10 090 15770 GRAFT DERMA-FAT-FASCIA 1087.86 090 15775 PUNCH GRAFT HAIR TRANSPLANT 1-15 PUNCH GRAFTS 465.28 000 15776 PUNCH GRAFT HAIR TRANSPLANT >15 PUNCH GRAFTS 681.30 000 15780 DERMABRASION TOTAL FACE 1327.14 090 15781 DERMABRASION SEGMENTAL FACE 876.82 090 15782 DERMABRASION REGIONAL OTHER THAN FACE 892.33 090 15783 DERMABRASION SUPERFICIAL ANY SITE 785.98 090 15786 ABRASION 1 LESION 389.39 010 + 15787 ABRASION EACH ADDITIONAL 4 LESIONS OR LESS 76.99 ZZZ 15788 CHEMICAL PEEL FACIAL EPIDERMAL 721.18 090 15789 CHEMICAL PEEL FACIAL DERMAL 905.07 090 15792 CHEMICAL PEEL NONFACIAL EPIDERMAL 692.38 090 15793 CHEMICAL PEEL NONFACIAL DERMAL 783.21 090 15819 CERVICOPLASTY 1156.54 090 15820 BLEPHAROPLASTY LOWER EYELID 903.96 090 15821 BLEPHAROPLASTY LOWER EYELID HERNIATED FAT PAD 964.34 090 15822 BLEPHAROPLASTY UPPER EYELID 700.68 090 15823 BLEPHAROPLASTY UPPER EYELID W/EXCESSIVE SKIN 987.60 090 15824 RHYTIDECTOMY FOREHEAD 1786.88 000 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 53
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 15825 RHYTIDECTOMY NECK W/PLATYSMAL TIGHTENING 2009.55 000 15826 RHYTIDECTOMY GLABELLAR FROWN LINES 1451.77 000 15828 RHYTIDECTOMY CHEEK CHIN&NECK 3796.43 000 15829 RHYTIDECTOMY SMAS FLAP 4243.43 000 15830 EXCISION SKIN ABD INFRAUMBILICAL PANNICULECTOMY 1897.66 090 15832 EXCISION EXCESSIVE SKIN&SUBQ TISSUE THIGH 1502.18 090 15833 EXCISION EXCESSIVE SKIN&SUBQ TISSUE LEG 1410.78 090 15834 EXCISION EXCESSIVE SKIN&SUBQ TISSUE HIP 1420.20 090 15835 EXCISION EXCESSIVE SKIN&SUBQ TISSUE BUTTOCK 1502.73 090 15836 EXCISION EXCESSIVE SKIN&SUBQ TISSUE ARM 1173.16 090 15837 EXC EXCESSIVE SKIN&SUBQ TISSUE FOREARM/HAND 1338.78 090 15838 EXC EXCSV SKIN&SUBQ TISSUE SUBMENTAL FAT PAD 937.75 090 15839 EXCISION EXCESSIVE SKIN&SUBQ TISSUE OTHER AREA 1392.50 090 15840 GRAFT FACIAL NERVE PARALYSIS FREE FASCIAL GRAFT 1666.69 090 15841 GRAFT FACIAL NERVE PARALYSIS FREE MUSCLE GRAFT 2752.33 090 15842 GRF FACIAL NRV PALYSS FR MUSCLE FLAP MICROSURG 4129.32 090 15845 GRF FACIAL NERVE PARALYSIS REGIONAL MUSCLE TR 1591.91 090 + 15847 EXCISION EXCESSIVE SKIN & SUBQ TISSUE ABDOMEN 781.55 YYY 15850 REMOVAL SUTURES UNDER ANESTHESIA SAME SURGEON 139.03 XXX 15851 REMOVAL SUTURES UNDER ANESTHESIA OTHER SURGEON 152.32 000 15852 DRESSING CHANGE UNDER ANESTHESIA 76.44 000 15860 IV INJECTION TEST VASCULAR FLOW FLAP/GRAFT 178.36 000 15876 SUCTION ASSISTED LIPECTOMY HEAD&NECK BR 000 15877 SUCTION ASSISTED LIPECTOMY TRUNK BR 000 15878 SUCTION ASSISTED LIPECTOMY UPPER EXTREMITY BR 000 15879 SUCTION ASSISTED LIPECTOMY LOWER EXTREMITY BR 000 15920 EXC COCCYGEAL PR ULC W/COCCYGECTOMY W/PRIM SUTR 971.54 090 15922 EXC COCCYGEAL PR ULC W/COCCYGECTOMY W/FLAP CLSR 1251.26 090 15931 EXCISION SACRAL PRESSURE ULCER W/PRIMARY SUTURE 1087.31 090 15933 EXC SACRAL PRESSURE ULC W/PRIM SUTR W/OSTECTOMY 1347.08 090 15934 EXCISION SACRAL PRESSURE ULCER W/SKIN FLAP CLSR 1497.19 090 15935 EXC SACRAL PR ULCER W/SKN FLAP CLSR W/OSTECTOMY 1772.48 090 15936 EXC SAC PR ULC PREPJ MUSC/MYOQ FLAP/SKN GRF CLSR 1445.13 090 15937 EXC SAC PR ULC PREPJ MUSC/MYOQ FLAP/SKN GRF OSTC 1691.06 090 15940 EXC ISCHIAL PRESSURE ULCER W/PRIMARY SUTURE 1120.54 090 15941 EXC ISCHIAL PR ULC W/PRIM SUTR W/OSTC ISCHIECT 1452.88 090 15944 EXC ISCHIAL PRESSURE ULCER W/SKIN FLAP CLOSURE 1445.13 090 15945 EXC ISCHIAL PR ULC W/SKN FLAP CLSR W/OSTECTOMY 1604.09 090 15946 EXC ISCHIAL PR ULCER W/OSTC MUSC/MYOQ FLAP/SKIN 2667.03 090 15950 EXC TROCHANTERIC PRESSURE ULCER W/PRIMARY SUTR 921.14 090 15951 EXC TRCHNTRIC PR ULCER W/PRIM SUTR W/OSTECTOMY 1387.52 090 15952 EXC TROCHANTERIC PR ULCER W/SKIN FLAP CLOSURE 1355.95 090 15953 EXC TRCHNTRIC PR ULC W/SKN FLAP CLSR W/OSTECTOMY 1487.78 090 15956 EXC TROCHANTERIC PR ULCER MUSC/MYOQ FLAP/SKIN 1874.40 090 15958 EXC TRCHNTRIC PR ULC MUSC/MYOQ FLAP/SKIN W/OSTC 1912.62 090 15999 UNLISTED PROCEDURE EXCISION PRESSURE ULCER BR YYY 54 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule 16000 INITIAL TX 1ST DEGREE BURN LOCAL TX 109.67 000 16020 DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ SMALL 132.38 000 16025 DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ MEDIUM 237.62 000 16030 DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ LARGE 285.81 000 16035 ESCHAROTOMY FIRST INCISION 331.79 000 + 16036 ESCHAROTOMY EACH ADDITIONAL INCISION 134.04 ZZZ 17000 DESTRUCTION PREMALIGNANT LESION 1ST 129.61 010 + 17003 DESTRUCTION PREMALIGNANT LESION 2-14 EA 11.63 ZZZ * 17004 DESTRUCTION PREMALIGNANT LESION 15/> 280.27 010 17106 DESTRUCTION CUTANEOUS VASC PROLIFERATIVE <10CM 552.79 090 17107 DESTRUCTION CUTANEOUS VASCULAR PRLF 10.0-50.0CM 717.30 090 17108 DESTRUCTION CUTANEOUS VASCULAR PRLF >50.0CM 1024.72 090 17110 DESTRUCTION BENIGN LESIONS UP TO 14 176.69 010 17111 DESTRUCTION BENIGN LESIONS 15/> 210.48 010 17250 CHEMICAL CAUTERIZATION GRANULATION TISSUE 121.86 000 17260 DESTRUCTION MALIGNANT LESION T/A/L 0.5 CM/< 152.88 010 17261 DESTRUCTION MAL LESION TRUNK/ARM/LEG 0.6-1.0 CM 230.98 010 17262 DESTRUCTION MAL LESION TRUNK/ARM/LEG 1.1-2.0CM 280.27 010 17263 DESTRUCTION MAL LESION TRUNK/ARM/LEG 2.1-3.0CM 308.52 010 17264 DESTRUCTION MAL LESION TRUNK/ARM/LEG 3.1-4.0CM 330.68 010 17266 DESTRUCTION MAL LESION TRUNK/ARM/LEG > 4.0 CM 374.99 010 17270 DESTRUCTION MALIGNANT LESION S/N/H/F/G 0.5 CM/< 240.95 010 17271 DESTRUCTION MALIGNANT LESION S/N/H/F/G 0.6-1.0CM 264.76 010 17272 DESTRUCTION MALIGNANT LESION S/N/H/F/G 1.1-2.0CM 301.88 010 17273 DESTRUCTION MALIGNANT LESION S/N/H/F/G 2.1-3.0CM 336.22 010 17274 DESTRUCTION MALIGNANT LESION S/N/H/F/G 3.1-4.0CM 396.59 010 17276 DSTRJ MAL LES S/N/H/F/G LES DIAM > 4.0 CM 459.18 010 17280 DESTRUCTION MALIGNANT LESION F/E/E/N/L/M 0.5CM/< 225.99 010 17281 DESTRUCTION MAL LESION F/E/E/N/L/M 0.6-1.0CM 286.37 010 17282 DESTRUCTION MAL LESION F/E/E/N/L/M 1.1-2.0CM 331.79 010 17283 DESTRUCTION MAL LESION F/E/E/N/L/M 2.1-3.0CM 398.81 010 17284 DESTRUCTION MAL LESION F/E/E/N/L/M 3.1-4.0CM 462.51 010 17286 DESTRUCTION MAL LESION F/E/E/N/L/M > 4.0 CM 585.47 010 17311 MOHS MICROGRAPHIC H/N/H/F/G 1ST STAGE 5 BLOCKS 1088.97 000 + 17312 MOHS MICROGRAPHIC H/N/H/F/G EACH ADDL STAGE 649.72 ZZZ 17313 MOHS TRUNK/ARM/LEG 1ST STAGE 5 BLOCKS 993.14 000 + 17314 MOHS TRUNK/ARM/LEG EA STAGE AFTER 1ST STAGE 602.64 ZZZ + 17315 MOHS TRUNK/ARM/LEG EA ADDL BLOCK ANY STAGE 130.72 ZZZ 17340 CRYOTHERAPY CO2 SLUSH LIQ N2 ACNE 80.32 010 17360 CHEMICAL EXFOLIATION ACNE 213.81 010 17380 ELECTROLYSIS EPILATION EA 30 MINUTES 123.52 000 17999 UNLISTED PX SKIN MUC MEMBRANE &SUBQ TISSUE BR YYY 19000 PUNCTURE ASPIRATION CYST BREAST 177.25 000 + 19001 PUNCTURE ASPIRATION BREAST EA ADDL CYST 43.20 ZZZ 19020 MASTOTOMY W/EXPL/DRAINAGE ABSCESS DEEP 721.73 090 19030 INJECTION MAMMARY DUCTOGRAM/GALACTOGRAM 263.10 000 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 55
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 19100 BX BREAST NEEDLE CORE W/O IMAGING GUIDANCE SPX 231.53 000 19101 BIOPSY BREAST OPEN INCISIONAL 527.87 010 19102 BIOPSY BREAST NEEDLE CORE W/IMAGING GUIDANCE 346.74 000 19103 BREAST BIOPSY VACUUM ASSISTED/ROTATING DEVICE 891.23 000 19105 ABLTJ CRYOSURGICAL W/ US GID EA FIBROADENOMA 3317.86 000 19110 NIPPLE EXPLORATION 749.43 090 19112 EXCISION LACTIFEROUS DUCT FISTULA 703.45 090 19120 EXC CYST/ABERRANT BREAST TISSUE OPEN 1/> LES 763.83 090 19125 EXC BRST LES PREOP PLMT RAD MARKER OPN 1 LES 848.02 090 + 19126 EXC BRST LES PREOP PLMT RAD MARKER OPN EA ADDL 261.44 ZZZ 19260 EXCISION CHEST WALL TUMOR INCLUDING RIBS 1955.27 090 19271 EXC CHEST TUMOR W/RCNSTJ W/O MEDSTNL LMPHADEC 2652.07 090 19272 EXC CHEST TUMOR W/RCNSTJ W/MEDSTNL LMPHADEC 2936.78 090 19290 PREOP PLACEMENT LOCALIZATION WIRE BREAST 259.78 000 + 19291 PREOP PLMT LOCALIZATION WIRE BREAST EA LESION 110.23 ZZZ + 19295 IMG GID PLMT MTLC LOCLZJ CLIP PRQ BRST BX/ASPIR 147.34 ZZZ 19296 PLMT EXPANDABLE CATH BRST FOLLOWING PRTL MAST 6437.43 000 + 19297 PLMT EXPANDABLE CATH BRST CONCURRENT PRTL MAST 152.88 ZZZ K 19298 PLMT RADTHX BRACHYTX BRST FOLLOWING PRTL MAST 1975.21 000 19300 MASTECTOMY GYNECOMASTIA 810.36 090 19301 MASTECTOMY PARTIAL 1025.27 090 19302 MASTECTOMY PARTIAL W/AXILLARY LYMPHADENECTOMY 1414.11 090 19303 MASTECTOMY SIMPLE COMPLETE 1587.48 090 19304 MASTECTOMY SUBCUTANEOUS 902.86 090 19305 MAST RAD W/PECTORAL MUSCLES AXILLARY LYMPH NODES 1793.53 090 19306 MAST RAD W/PECTORAL MUSC AX INT MAM LYMPH NODES 1889.35 090 19307 MAST MODF RAD W/AX LYMPH NOD W/WO PECT/ALIS MIN 1889.91 090 19316 MASTOPEXY 1259.57 090 19318 REDUCTION MAMMAPLASTY 1828.42 090 19324 MAMMAPLASTY AUGMENTATION W/O PROSTHETIC IMPLANT 781.00 090 19325 MAMMAPLASTY AUGMENTATION W/PROSTHETIC IMPLANT 1054.63 090 19328 REMOVAL INTACT MAMMARY IMPLANT 804.26 090 19330 REMOVAL MAMMARY IMPLANT MATERIAL 1027.48 090 19340 IMMT INSJ BRST PROSTH FLWG MASTOPEXY MAST/RCNSTJ 1422.42 090 19342 DLYD INSJ BRST PROSTH FLWG MASTOPEXY MAST/RCNSTJ 1509.93 090 19350 NIPPLE/AREOLA RECONSTRUCTION 1353.73 090 19355 CORRECTION INVERTED NIPPLES 1132.17 090 19357 BRST RCNSTJ IMMT/DLYD W/TISS EXPANDER SBSQ XPNSJ 2413.90 090 19361 BRST RCNSTJ W/LATSMS D/SI FLAP WO PRSTHC IMPL 2762.85 090 19364 BREAST RECONSTRUCTION FREE FLAP 4563.58 090 19366 BREAST RECONSTRUCTION OTHER TECHNIQUE 2251.60 090 19367 BREAST RECONSTRUCTION TRAM FLAP 1 PEDICLE 2961.70 090 19368 BREAST RECONSTRUCTION TRAM 1 PEDCL MVASC ANAST 3661.28 090 19369 BREAST RECONSTRUCTION TRAM FLAP DOUBLE PEDICLE 3379.90 090 19370 OPEN PERIPROSTHETIC CAPSULOTOMY BREAST 1119.43 090 19371 PERIPROSTHETIC CAPSULECTOMY BREAST 1282.83 090 56 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule 19380 REVISION RECONSTRUCTED BREAST 1261.23 090 19396 PREPARATION MOULAGE CUSTOM BREAST IMPLANT 389.95 000 19499 UNLISTED PROCEDURE BREAST BR YYY s 20005 I&D SOFT TISSUE ABSCESS SUBFASC 481.89 010 20100 EXPLORATION PENETRATING WOUND SPX NECK 967.66 010 20101 EXPLORATION PENETRATING WOUND SPX CHEST 644.19 010 20102 EXPL PENETRATING WOUND SPX ABDOMEN/FLANK/BACK 759.95 010 20103 EXPLORATION PENETRATING WOUND SPX EXTREMITY 913.94 010 20150 EXCISION EPIPHYSEAL BAR 3088.86 090 20200 BIOPSY MUSCLE SUPERFICIAL 611.79 000 20205 BIOPSY MUSCLE DEEP 842.42 000 20206 BIOPSY MUSCLE PERCUTANEOUS NEEDLE 776.22 000 20220 BIOPSY BONE TROCAR/NEEDLE SUPERFICIAL 510.36 000 20225 BIOPSY BONE TROCAR/NEEDLE DEEP 1913.32 000 20240 BIOPSY BONE OPEN SUPERFICIAL 700.41 010 20245 BIOPSY BONE OPEN DEEP 1968.84 010 20250 BIOPSY VERTEBRAL BODY OPEN THORACIC 1184.08 010 20251 BIOPSY VERTEBRAL BODY OPEN LUMBAR/CERVICAL 1294.05 010 20500 INJECTION SINUS TRACT THERAPEUTIC SPX 176.69 010 20501 INJECTION SINUS TRACT DIAGNOSTIC 200.51 000 20520 REMOVAL FOREIGN BODY MUSCLE/TENDON SHEATH SIMPLE 311.85 010 20525 RMVL FOREIGN BODY MUSCLE/TENDON SHEATH DEEP/COMP 755.52 010 20526 INJECTION THERAPEUTIC CARPAL TUNNEL 120.20 000 20550 INJECTION 1 TENDON SHEATH/LIGAMENT APONEUROSIS 91.39 000 20551 INJECTION SINGLE TENDON ORIGIN/INSERTION 93.06 000 20552 INJECTION SINGLE/MLT TRIGGER POINT 1/2 MUSCLES 85.30 000 20553 INJECTION SINGLE/MLT TRIGGER POINT 3/> MUSCLES 96.38 000 20555 PLACEMENT NEEDLES MUSCLE SUBSEQUENT RADIOELEMENT 536.73 000 20600 ARTHROCENTESIS ASPIR&/INJECTION SMALL JT/BURSA 86.41 000 20605 ARTHROCENTESIS ASPIR&/INJECTION INTERM JT/BURSA 94.16 000 20610 ARTHROCENTESIS ASPIR&/INJECTION MAJOR JT/BURSA 125.18 000 20612 ASPIRATION&/INJECTION GANGLION CYST ANY LOCATION 93.61 000 20615 ASPIRATION&INJECTION TREATMENT BONE CYST 348.96 010 20650 INSERTION WIRE/PIN W/APPL SKELETAL TRACTION SPX 608.59 010 20660 APPLICATION CRANIAL TONG/STRTCTC FRAME W/REMOVAL 767.68 000 20661 APPLICATION HALO CRANIAL INCLUDING REMOVAL 1520.40 090 20662 APPLICATION HALO PELVIC INCLUDING REMOVAL 1343.17 090 20663 APPLICATION HALO FEMORAL INCLUDING REMOVAL 1421.11 090 s 20664 APPL HALO 6/> PINS THIN SKULL OSTEOLOGY 2540.06 090 20665 REMOVAL TONG/HALO APPLIED BY ANOTHER PHYSICIAN 341.66 010 20670 REMOVAL IMPLANT SUPERFICIAL SPX 1196.89 010 20680 REMOVAL IMPLANT DEEP 1884.49 090 20690 APPLICATION UNIPLANE EXTERNAL FIXATION SYSTEM 1792.67 090 20692 APPLICATION MULTIPLANE EXTERNAL FIXATION SYSTEM 3368.59 090 20693 ADJUSTMENT/REVJ XTRNL FIXATION SYSTEM REQ ANES 1417.91 090 20694 REMOVAL EXTERNAL FIXATION SYSTEM UNDER ANES 1310.07 090 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 57
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 20696 XTRNL FIXJ W/STEREOTACTIC ADJUSTMENT 1ST&SUBQ 3357.92 090 * 20697 XTRNL FIXJ W/STRTCTC ADJUSTMENT EXCHANGE STRUT 5261.63 000 20802 REPLANTATION ARM COMPLETE AMPUTATION 3750.46 090 20805 REPLANTATION FOREARM COMPLETE AMPUTATION 4640.02 090 20808 REPLANTATION HAND COMPLETE AMPUTATION 6788.04 090 20816 RPLJ DGT EXCEPT THMB MTCARPHLNGL JT COMPL AMP 3492.34 090 20822 RPLJ DGT EXCLUDING THMB SUBLIMIS TDN COMPL AMP 3086.88 090 20824 RPLJ THMB CARP/MTCRPL JT MP JT COMPL AMPUTATION 3531.67 090 20827 RPLJ THUMB DISTAL TIP MP JOINT COMPL AMPUTATION 3205.42 090 20838 REPLANTATION FOOT COMPLETE AMPUTATION 3850.16 090 20900 BONE GRAFT ANY DONOR AREA MINOR/SMALL 1283.38 000 20902 BONE GRAFT ANY DONOR AREA MAJOR/LARGE 1024.99 000 20910 CARTILAGE GRAFT COSTOCHONDRAL 1320.74 090 20912 CARTILAGE GRAFT NASAL SEPTUM 1528.95 090 20920 FASCIA LATA GRAFT BY STRIPPER 1257.75 090 20922 FASCIA LATA GRAFT INCISION & AREA EXPOSURE 1863.14 090 20924 TENDON GRAFT FROM A DISTANCE 1572.72 090 20926 TISSUE GRAFTS OTHER 1362.39 090 s + 20930 ALLOGRAFT FOR SPINE SURGERY ONLY MORSELIZED 381.17 XXX s + 20931 ALLOGRAFT FOR SPINE SURGERY ONLY STRUCTURAL 358.75 ZZZ + 20936 AUTOGRAFT SPINE SURGERY LOCAL FROM SAME INCISION 402.52 XXX + 20937 AUTOGRAFT SPINE SURGERY MORSELIZED SEP INCISION 537.05 ZZZ + 20938 AUTOGRAFT SPINE SURGERY BICORT/TRICORT SEP INC 589.37 ZZZ 20950 MNTR INTERSTITIAL FLUID PRESSURE CMPRT SYNDROME 762.34 000 20955 BONE GRAFT MICROVASCULAR ANASTOMOSIS FIBULA 8049.39 090 20956 BONE GRAFT MICROVASCULAR ANAST ILIAC CREST 8319.52 090 20957 BONE GRAFT MICROVASCULAR ANAST METATARSAL 8098.50 090 20962 B1 GRF W/MVASC ANAST OTH/THN ILIAC CREST/METAR 8247.98 090 20969 FREE OSTQ FLAP W/MVASC ANAST METAR/GREAT TOE 8876.86 090 20970 FREE OSTQ FLAP W/MVASC ANASTOMOSIS ILIAC CREST 8885.40 090 20972 FREE OSTQ FLAP W/MVASC ANASTOMOSIS METATARSAL 7216.58 090 20973 FR OSTQ FLAP W/MVASC ANAST GRT TOE W/WEB SPACE 8438.03 090 * 20974 ELECTRICAL STIMULATION BONE HEALING NONINVASIVE 215.68 000 * 20975 ELECTRICAL STIMULATION BONE HEALING INVASIVE 555.20 000 20979 LOW INTENSITY US STIMJ BONE HEALING NONINVASIVE 162.29 000 K 20982 ABLATION BONE TUMOR RF PERCUTANEOUS CT GUIDANCE 11229.00 000 + 20985 CPTR-ASST SURGICAL NAVIGATION IMAGE-LESS 467.65 ZZZ 20999 UNLISTED PROCEDURE MUSCSKELETAL SYSTEM GENERAL BR YYY 21010 ARTHROTOMY TEMPOROMANDIBULAR JOINT 1175.38 090 21011 EXCISION TUMOR SOFT TISS FACE/SCALP SUBQ < 2CM 535.62 090 21012 EXCISION TUMOR SOFT TISS FACE/SCALP SUBQ 2+CM 564.42 090 21013 EXC TUMOR SOFT TISS FACE&SCALP SUBFASCIAL < 2CM 827.53 090 21014 EXC TUMOR SOFT TISS FACE&SCALP SUBFASCIAL 2+CM 870.73 090 21015 RAD RESECTION TUMOR SOFT TISS FACE/SCALP < 2CM 1069.58 090 21016 RAD RESECTION TUMOR SOFT TISS FACE/SCALP 2+CM 1727.06 090 21025 EXCISION BONE MANDIBLE 1430.72 090 58 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule 21026 EXCISION FACIAL BONE 975.97 090 21029 REMOVAL CONTOURING BENIGN TUMOR FACIAL BONE 1244.61 090 21030 EXC BENIGN TUMOR/CYST MAXL/ZYGOMA ENCL & CURTG 818.11 090 21031 EXCISION TORUS MANDIBULARIS 615.94 090 21032 EXCISION MAXILLARY TORUS PALATINUS 626.46 090 21034 EXCISION MALIGNANT TUMOR MAXILLA/ZYGOMA 2162.43 090 21040 EXCISION BENIGN TUMOR/CYST MANDIBLE ENCL&/CURTG 824.20 090 21044 EXCISION MALIGNANT TUMOR MANDIBLE 1440.14 090 21045 EXCISION MALIGNANT TUMOR MANDIBLE RADICAL 2006.78 090 21046 EXC BENIGN TUMOR/CYST MNDBL INTRA-ORAL OSTEOT 1771.93 090 21047 EXC B9 TUM/CST MNDBL XTR-ORAL OSTEOT&PRTL MNDBLC 2118.67 090 21048 EXC BENIGN TUMOR/CYST MAXL INTRA-ORAL OSTEOT 1811.81 090 21049 EXC B9 TUM/CST MAXL XTR-ORAL OSTEOT&PRTL MAXLCT 2031.71 090 21050 CONDYLECTOMY TEMPOROMANDIBULAR JOINT SPX 1429.62 090 21060 MENISCECTOMY PRTL/COMPL TEMPOROMANDIBULAR JT SPX 1332.68 090 21070 CORONOIDECTOMY SPX 1015.85 090 21073 MANIPULATION TMJ THERAPEUTIC REQUIRE ANESTHESIA 623.14 090 21076 IMPRESSION&PREPARATION SURG OBTURATOR PROSTHESIS 1570.86 010 21077 IMPRESSION & PREPARATION ORBITAL PROSTHESIS 3914.41 090 21079 IMPRESSION&PREPARATION INTERIM OBTURATOR PROSTH 2658.17 090 21080 IMPRESSION&PREPJ DEFINITIVE OBTURATOR PROSTHESIS 3001.58 090 21081 IMPRESSION&PREPJ MANDIBULAR RESECTION PROSTHESIS 2754.54 090 21082 IMPRESSION&PREPJ PALATAL AUGMENTATION PROSTHESIS 2583.94 090 21083 IMPRESSION&PREPARATION PALATAL LIFT PROSTHESIS 2398.39 090 21084 IMPRESSION&PREPARATION SPEECH AID PROSTHESIS 2829.88 090 21085 IMPRESSION&PREPARATION ORAL SURGICAL SPLINT 1282.83 010 21086 IMPRESSION&PREPARATION AURICULAR PROSTHESIS 2874.74 090 21087 IMPRESSION&PREPARATION NASAL PROSTHESIS 2869.20 090 21088 IMPRESSION&PREPARATION FACIAL PROSTHESIS BR 090 21089 UNLISTED MAXILLOFACIAL PROSTHETIC PROCEDURE BR YYY 21100 APPL HALO APPLIANCE MAXILLOFACIAL FIXATION SPX 1052.41 090 21110 APPL INTERDENTAL FIXATION DEVICE NON-FX/DISLC 1245.17 090 21116 INJECTION TEMPOROMANDIBULAR JOINT ARTHROGRAPHY 236.52 000 21120 GENIOPLASTY AUGMENTATION 1032.47 090 21121 GENIOPLASTY SLIDING OSTEOTOMY SINGLE PIECE 1240.74 090 21122 GENIOPLASTY 2/> SLIDING OSTEOTOMIES 1132.17 090 21123 GENIOP SLIDING AGMNTJ W/INTERPOSAL BONE GRAFTS 1415.21 090 21125 AGMNTJ MNDBLR BODY/ANGLE PROSTHETIC MATERIAL 4921.96 090 21127 AGMNTJ MNDBLR BDY/ANGL W/B1 GRF ONLAY/INTERPOSAL 6010.92 090 21137 REDUCTION FOREHEAD CONTOURING ONLY 1169.28 090 21138 RDCTJ FHD CNTRG&PROSTHETIC MATRL/BONE GRAFT 1444.57 090 21139 RDCTJ FHD CNTRG&SETBACK ANT FRONTAL SINUS WALL 1603.54 090 21141 RCNSTJ MIDFACE LEFORT I 1 PIECE W/O BONE GRAFT 2239.42 090 21142 RCNSTJ MIDFACE LEFORT I 2 PIECES W/O BONE GRAFT 2257.70 090 21143 RCNSTJ MIDFACE LEFORT I 3/>PIECE W/O BONE GRAFT 2392.85 090 21145 RCNSTJ MIDFACE LEFORT I 1 PIECE W/BONE GRAFTS 2431.62 090 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 59
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 21146 RCNSTJ MIDFACE LEFORT I 2 PIECES W/BONE GRAFTS 2792.21 090 21147 RCNSTJ MIDFACE LEFORT I 3/>PIECE W/BONE GRAFTS 2665.37 090 21150 RCNSTJ MIDFACE LEFORT II ANTERIOR INTRUSION 2669.80 090 21151 RCNSTJ MIDFACE LEFORT II W/BONE GRAFTS 3197.11 090 21154 RCNSTJ MIDFACE LEFORT III W/O LEFORT I 3464.64 090 21155 RCNSTJ MIDFACE LEFORT III W/LEFORT I 3529.45 090 21159 RCNSTJ MIDFACE LEFORT III W/FHD W/O LEFORT I 4561.92 090 21160 RCNSTJ MIDFACE LEFORT III W/FHD W/LEFORT I 4376.92 090 21172 RCNSTJ SUPERIOR-LATERAL ORBITAL RIM&LOWER FHD 2911.85 090 21175 RCNSTJ BIFRONTAL SUPERIOR-LAT ORB RIMS&LWR FHD 3914.41 090 21179 RCNSTJ FOREHEAD&/SUPRAORB RIMS W/ALGRF/PROSTC 2489.78 090 21180 RCNSTJ FOREHEAD&/SUPRAORBITAL RIMS W/AUTOGRAFT 2710.23 090 21181 RCNSTJ CONTOURING BENIGN TUMOR CRNL BONES XTRC 1159.87 090 21182 RCNSTJ ORBIT/FHD/NASETHMD EXC B9 TUM GRF <40 CM 3240.32 090 21183 RCNSTJ ORBIT/FHD/NASETHMD EXC B9 GRF >40 <80 CM 3684.54 090 21184 RCNSTJ ORBIT/FHD/NASETHMD EXC B9 TUM GRF>80 CM 4056.76 090 21188 RCNSTJ MDFC OTH/THN LEFORT OSTEOT&BONE GRAFTS 2628.26 090 21193 RCNSTJ MNDBLR RAMI HRZNTL/VER/C/L OSTEOT W/O GRF 2140.27 090 21194 RCNSTJ MNDBLR RAMI HRZNTL/VER/C/L OSTEOT W/GRF 2278.19 090 21195 RCNSTJ MNDBLR RAMI&/BODY SGTL SPLT W/O INT RGD 2190.67 090 21196 RCNSTJ MNDBLR RAMI&/BDY SGTL SPLT W/INT RGD FIXJ 2397.28 090 21198 OSTEOTOMY MANDIBLE SEGMENTAL 1893.78 090 21199 OSTEOTOMY MANDIBLE SGMTL W/GENIOGLOSSUS ADVMNT 1668.90 090 21206 OSTEOTOMY MAXILLA SEGMENTAL 1982.96 090 21208 OSTEOPLASTY FACIAL BONES AUGMENTATION 2927.92 090 21209 OSTEOPLASTY FACIAL BONES REDUCTION 1355.39 090 21210 GRAFT BONE NASAL/MAXILLARY/MALAR AREAS 3501.76 090 21215 GRAFT BONE MANDIBLE 6107.86 090 21230 GRAFT RIB CRTLG AUTOGENOUS FACE/CHIN/NOSE/EAR 1268.43 090 21235 GRAFT EAR CRTLG AUTOGENOUS NOSE/EAR 1185.90 090 21240 ARTHRP TEMPOROMANDIBULAR JOINT +-AUTOGRAFT 1789.10 090 21242 ARTHROPLASTY TEMPOROMANDIBULAR JT W/ALLOGRAFT 1641.21 090 21243 ARTHRP TMPRMAND JOINT W/PROSTHETIC REPLACEMENT 2701.37 090 21244 RCNSTJ MNDBL XTRORAL W/TRANSOSTEAL BONE PLATE 1726.51 090 21245 RCNSTJ MNDBL/MAXL SUBPRIOSTEAL IMPLANT PARTIAL 1834.52 090 21246 RCNSTJ MNDBL/MAXL SUBPRIOSTEAL IMPLANT COMPLETE 1364.81 090 21247 RCNSTJ MNDBLR CONDYLE W/BONE CARTLG AUTOGRAFTS 2655.95 090 21248 RCNSTJ MANDIBLE/MAXL ENDOSTEAL IMPLANT PARTIAL 1746.45 090 21249 RCNSTJ MANDIBLE/MAXL ENDOSTEAL IMPLANT COMPLETE 2402.82 090 21255 RCNSTJ ZYGMTC ARCH/GLENOID FOSSA W/BONE CARTLG 2248.83 090 21256 RECONSTRUCTION ORBIT W/OSTEOTOMIES&BONE GRAFTS 1928.68 090 21260 PERIORBITAL OSTEOTOMIES BONE GRAFTS EXTRACRANIAL 2161.87 090 21261 PERIORBITAL OSTEOTOMIES W/BONE GRAFTS ICRA&XTRC 3600.35 090 21263 PERIORBITAL OSTEOTOMIES W/BONE GRAFTS W/FOREHEAD 3074.15 090 21267 ORBITAL REPOSITIONING W/BONE GRAFTS EXTRACRANIAL 2615.52 090 21268 ORBITAL REPOSITIONING W/BONE GRAFTS ICRA&XTRC 2993.83 090 60 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule 21270 MALAR AUGMENTATION PROSTHETIC MATERIAL 1538.18 090 21275 SECONDARY REVISION ORBITOCRANIOFACIAL RCNSTJ 1364.81 090 21280 MEDIAL CANTHOPEXY SPX 915.60 090 21282 LATERAL CANTHOPEXY 602.64 090 21295 REDUCTION MASSETER MUSCLE&BONE EXTRAORAL 286.92 090 21296 REDUCTION MASSETER MUSCLE&BONE INTRAORAL 651.39 090 21299 UNLISTED CRANIOFACIAL&MAXILLOFACIAL PROCEDURE BR YYY 21310 CLOSED TREATMENT NASAL FRACTURE W/O MANIPULATION 181.13 000 21315 CLOSED TX NASAL FRACTURE W/O STABILIZATION 437.03 010 21320 CLOSED TREATMENT NASAL FRACTURE W/STABILIZATION 412.10 010 21325 OPEN TREATMENT NASAL FRACTURE UNCOMPLICATED 768.26 090 21330 OPEN TX NASAL FX COMP W/INT&/XTRNL SKELETAL FIXJ 927.23 090 21335 OPEN TX NASAL FX W/CONCOMITANT OPTX FXD SEPTUM 1195.32 090 21336 OPEN TX NASAL SEPTAL FRACTURE +-STABILIZATION 1056.29 090 21337 CLOSED TX NASAL SEPTAL FRACTURE +-STABILIZATION 647.51 090 21338 OPEN TX NASOETHMOID FX W/O EXTERNAL FIXATION 1216.92 090 21339 OPEN TX NASOETHMOID FX W/EXTERNAL FIXATION 1311.08 090 21340 PERCUTANEOUS TX NASOETHMOID COMPLEX FRACTURE 1268.43 090 21343 OPEN TX DEPRESSED FRONTAL SINUS FRACTURE 1878.83 090 21344 OPEN TX COMPLICATED FRONTAL SINUS FRACTURE 2724.63 090 21345 CLOSED TX NASOMAXILLARY COMPLEX FRACTURE 1276.19 090 21346 OPTX NASOMAX CPLX FX LEFT II TYPE W/WIRG&FIXJ 1517.13 090 21347 OPTX NASOMAX CPLX FX LEFT II TYPE REQ MLT OPN 1797.41 090 21348 OPTX NASOMAX CPLX FX LEFT II TYPE W/B1 GRFG 1892.68 090 21355 PERCUTANEOUS TX MALAR AREA FRACTURE 721.18 010 21356 OPEN TX DEPRESSED ZYGOMATIC ARCH FRACTURE 801.49 010 21360 OPEN TX DEPRESSED MALAR FRACTURE 864.08 090 21365 OPEN TX COMP FX MALAR W/INTERNAL FX&MULT SURG 1822.88 090 21366 OPEN TX COMP FRACTURE MALAR AREA W/BONE GRAFT 2068.26 090 21385 OPEN TX ORBITAL FLOOR BLOWOUT FX TRANSANTRAL 1137.16 090 21386 OPEN TX ORBITAL FLOOR BLOWOUT FX PERIORBITAL 1086.20 090 21387 OPEN TX ORBITAL FLOOR BLOWOUT FX COMBINED APPR 1222.46 090 21390 OPTX ORB FLOOR BLWT FX PRI/BITAL APPR W/ALLPLSTC 1292.25 090 21395 OPTX ORB FLOOR BLWT FX PRI/BITAL APPR W/B1 GRF 1587.48 090 21400 CLSD TX FX ORBIT EXCEPT BLOWOUT W/O MANIPULATION 297.44 090 21401 CLOSED TX FX ORBIT EXCEPT BLOWOUT W/MANIPULATION 768.26 090 21406 OPEN TX FX ORBIT EXCEPT BLOWOUT W/O IMPLANT 895.10 090 21407 OPEN TX FX ORBIT EXCEPT BLOWOUT W/IMPLANT 1056.84 090 21408 OPEN TX FX ORBIT EXCEPT BLOWOUT W/BONE GRAFT 1473.37 090 21421 CLOSED TX PALATAL/MAXILLARY FX W/FIXATION/SPLINT 1210.83 090 21422 OPEN TREATMENT PALATAL/MAXILLARY FRACTURE 1079.55 090 21423 OPEN TX PALATAL/MAXILLARY FX COMP MULTIPLE APPR 1339.88 090 21431 CLOSED TX CRANIOFACIAL SEPARATION 1208.06 090 21432 OPEN TX CRANIOFACIAL SEP W/WIRING&/INT FIXJ 1143.80 090 21433 OPEN TX CRANIOFACIAL SEP COMPLICATED MLT APPR 2757.87 090 21435 OPEN TX CRANIOFACIAL SEP COMP W/INT&/XTRNL FIXJ 2126.42 090 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 61
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 21436 OPTX CRANFCL SEP LEFT III TYP COMP INT FIXJ W/B1 3350.54 090 21440 CLTX MANDIBULAR/MAXILLARY ALVEOLAR RIDGE FX SPX 894.55 090 21445 OPTX MANDIBULAR/MAXILLARY ALVEOLAR RIDGE FX SPX 1221.35 090 21450 CLOSED TX MANDIBULAR FRACTURE W/O MANIPULATION 937.75 090 21451 CLOSED TX MANDIBULAR FRACTURE W/MANIPULATION 1216.36 090 21452 PERCUTANEOUS TX MANDIBULAR FX W/EXTERNAL FIXJ 942.18 090 21453 CLOSED TX MANDIBULAR FX W/INTERDENTAL FIXATION 1420.75 090 21454 OPEN TX MANDIBULAR FX W/EXTERNAL FIXATION 903.96 090 21461 OPEN TX MANDIBULAR FX W/O INTERDENTAL FIXATION 3280.75 090 21462 OPEN TX MANDIBULAR FX W/INTERDENTAL FIXATION 3480.15 090 21465 OPEN TX MANDIBULAR CONDYLAR FX 1549.26 090 21470 OPTX COMP MANDIBULAR FX MLT APPR W/INT FIXATION 1968.01 090 21480 CLOSED TX TEMPOROMANDIBULAR DISLOCATION 1ST/SBSQ 148.45 000 21485 CLOSED TX TEMPOROMANDIBULAR DISLC COMP 1ST/SBSQ 1093.40 090 21490 OPEN TREATMENT TEMPOROMANDIBULAR DISLOCATION 1519.35 090 21495 OPEN TREATMENT HYOID FRACTURE 1142.70 090 21497 INTERDENTAL WIRING OTHER THAN FRACTURE 1096.17 090 21499 UNLISTED MUSCULOSKELETAL PROCEDURE HEAD BR YYY 21501 I&D DEEP ABSC/HMTMA SOFT TISSUE NECK/THORAX 720.62 090 21502 I&D DP ABSC/HMTMA SOFT TISS NCK/THORAX PRTL RIB 831.40 090 21510 INCISION DEEP OPENING BONE CORTEX THORAX 765.49 090 21550 BIOPSY SOFT TISSUE NECK/THORAX 415.43 010 # 21552 EXC TUMOR SOFT TISSUE NECK/ANT THORAX SUBQ 3+CM 741.12 090 # 21554 EXC TUMOR SOFT TISSUE NECK/THORAX SUBFASC 5+CM 1216.36 090 21555 EXC TUMOR SOFT TISSUE NECK/ANT THORAX SUBQ <3CM 662.46 090 21556 EXC TUMOR SOFT TISS NECK/THORAX SUBFASCIAL <5CM 837.50 090 21557 RAD RESECT TUMOR SOFT TISS NECK/ANT THORAX <5CM 1452.88 090 21558 RAD RESECT TUMOR SOFT TISS NECK/ANT THORAX 5+CM 2262.13 090 21600 EXCISION RIB PARTIAL 913.94 090 21610 COSTOTRANSVERSECTOMY SPX 1887.14 090 21615 EXCISION 1ST&/CERVICAL RIB 1082.87 090 21616 EXCISION 1ST&/CERVICAL RIB W/SYMPATHECTOMY 1323.27 090 21620 OSTECTOMY STERNUM PARTIAL 855.78 090 21627 STERNAL DEBRIDEMENT 896.76 090 21630 RADICAL RESECTION STERNUM 2074.36 090 21632 RADICAL RESECTION STERNUM W/MEDSTNL LMPHADEC 2064.39 090 21685 HYOID MYOTOMY & SUSPENSION 1642.31 090 21700 DIVISION SCALENUS ANTICUS W/O RESCJ CERVICAL RIB 701.79 090 21705 DIVISION SCALENUS ANTICUS RESECTION CERVICAL RIB 993.14 090 21720 DIVISION STERNOCLEIDOMASTOID OPEN W/O CAST 729.49 090 21725 DIVISION STERNOCLEIDOMASTOID OPEN CAST 864.08 090 21740 REPAIR PECTUS EXCAVATUM/CARINATUM OPEN 1706.01 090 21742 REPAIR PECTUS EXCAVATM/CARINATM MINLY W/O THRSC 1869.41 090 21743 REPAIR PECTUS EXCAVATM/CARINATM MINLY W/THRSC 2459.87 090 21750 CLOSURE MEDIAN STERNOTOMY SEP +-DEBRIDEMENT SPX 1159.87 090 21800 CLOSED TX RIB FRACTURE UNCOMPLICATED EACH 164.51 090 62 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule 21805 OPEN TX RIB FRACTURE W/O FIXATION EACH 425.95 090 21810 TX RIB FRACTURE EXTERNAL FIXATION FLAIL CHEST 846.36 090 21820 CLOSED TREATMENT STERNUM FRACTURE 218.24 090 21825 OPEN TX STERNUM FRACTURE +-SKELETAL FIXATION 922.24 090 21899 UNLISTED PROCEDURE NECK/THORAX BR YYY 21920 BIOPSY SOFT TISSUE BACK/FLANK SUPERFICIAL 415.98 010 21925 BIOPSY SOFT TISSUE BACK/FLANK DEEP 692.38 090 21930 EXCISION TUMOR SOFT TISSUE BACK/FLANK SUBQ <3CM 747.21 090 21931 EXCISION TUMOR SOFT TISSUE BACK/FLANK SUBQ 3+CM 774.35 090 21932 EXC TUMOR SOFT TISS BACK/FLANK SUBFASCIAL <5CM 1105.03 090 21933 EXC TUMOR SOFT TISS BACK/FLANK SUBFASCIAL 5+CM 1217.47 090 21935 RAD RESECTION TUMOR SOFT TISSUE BACK/FLANK <5CM 1677.76 090 21936 RAD RESECTION TUMOR SOFT TISSUE BACK/FLANK 5+CM 2358.51 090 22010 I&D DEEP ABSCESS PST SPINE CRV THRC/CERVICOTHRC 2920.16 090 22015 I&D DEEP ABSCESS PST SPINE LUMBAR SAC/LUMBOSAC 2874.25 090 22100 PRTL EXC PST VRT INTRNSC B1Y LES 1 VRT SGM CRV 2725.84 090 22101 PRTL EXC PST VRT INTRNSC B1Y LES 1 VRT SGM THRC 2668.18 090 22102 PRTL EXC PST VRT INTRNSC B1Y LES 1 VRT SGM LMBR 2563.55 090 + 22103 PRTL EXC PST VRT INTRNSC B1Y LES 1 VRT SGM EA 458.04 ZZZ 22110 PRTL EXC VRT BDY B1Y LES W/O SPI CORD 1 SGM CRV 3352.58 090 22112 PRTL EXC VRT BDY B1Y LES W/O SPI CORD 1 SGM THRC 3305.60 090 22114 PRTL EXC VRT BDY B1Y LES W/O SPI CORD 1 SGM LMBR 3092.06 090 + 22116 PRTL EXC VRT BDY B1Y LES W/O SPI CORD 1 SGM EA 447.37 ZZZ 22206 OSTEOTOMY SPINE POSTERIOR 3 COLUMN THORACIC 7377.81 090 22207 OSTEOTOMY SPINE POSTERIOR 3 COLUMN LUMBAR 7497.39 090 + 22208 OSTEOTOMY SPINE POSTERIOR 3 COLUMN EA ADDL SGM 1868.48 ZZZ 22210 OSTEOTOMY SPINE PST/PSTLAT APPR 1 VRT SGM CRV 5528.55 090 22212 OSTEOTOMY SPINE PST/PSTLAT APPR 1 VRT SGM THRC 4582.57 090 22214 OSTEOTOMY SPINE PST/PSTLAT APPR 1 VRT SGM LMBR 4612.46 090 + 22216 OSTEOT SPI PST/PSTLAT APPR 1 VRT SGM EA VRT SGM 1165.93 ZZZ 22220 OSTEOTOMY SPINE W/DSKC ANT APPR 1 VRT SGM CRV 5032.07 090 22222 OSTEOTOMY SPINE W/DSKC ANT APPR 1 VRT SGM THRC 4669.05 090 22224 OSTEOTOMY SPINE W/DSKC ANT APPR 1 VRT SGM LMBR 4930.64 090 + 22226 OSTEOT SPI W/DSKC ANT APPR 1 VRT SGM EA VRT SGM 1169.13 ZZZ 22305 CLOSED TX VERTEBRAL PROCESS FRACTURE 578.69 090 22310 CLTX VRT BDY FX W/O MNPJ REQ&W/CSTING/BRACING 926.76 090 s 22315 CLTX VRT FX&/DISLC CSTING/BRACING MNPJ/TRCJ 2714.09 090 22318 OPTX&/RDCTJ ODNTD FX&/DISLC ANT FIXJ W/O GRFG 5099.34 090 22319 OPTX&/RDCTJ ODNTD FX&/DISLC ANT W/INT FIXJ GRF 5680.16 090 22325 OPTX&/RDCTJ VRT FX&/DISLC PST 1 VRT SGM LMBR 4456.58 090 22326 OPTX&/RDCTJ VRT FX&/DISLC PST 1 VRT SGM CRV 4629.55 090 22327 OPTX&/RDCTJ VRT FX&/DISLC PST 1 VRT SGM THRC 4597.52 090 + 22328 OPTX&/RDCTJ VRT FX&/DISLC PST 1 VRT SGM EA SGM 904.34 ZZZ 22505 MANIPULATION SPINE REQUIRING ANESTHESIA 369.42 010 K 22520 PERCUTANEOUS VERTEBROPLASTY THORACIC 7006.25 010 K 22521 PERCUTANEOUS VERTEBROPLASTY LUMBAR 6873.85 010 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 63
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 + 22522 PERCUTANEOUS VERTEBROPLASTY EA ADDL THRC/LMBR 726.04 ZZZ 22523 PERCUTANEOUS VERTEBRAL AUGMENTATION THORACIC 1844.99 010 22524 PERCUTANEOUS VERTEBRAL AUGMENTATION LUMBAR 1773.45 010 + 22525 PERQ VERTEBRAL AUGMENTATION EA ADDL THRC/LMBR 828.54 ZZZ K 22526 PERQ INTRDSCL ELECTROTHRM ANNULOPLASTY 1 LVL 6568.49 010 + K 22527 PERQ INTRDSCL ELECTROTHRM ANNULOPLASTY ADDL LVL 5282.98 ZZZ 22532 ARTHRODESIS LATERAL EXTRACAVITARY THORACIC 5585.14 090 22533 ARTHRODESIS LATERAL EXTRACAVITARY LUMBAR 5261.63 090 + 22534 ARTHRODESIS LAT EXTRACAVITARY EA ADDL THRC/LMBR 1161.66 ZZZ 22548 ARTHRD ANT TRANSORAL/XTRORAL C1-C2 +-EXC ODNTD 6090.16 090 l 22551 ARTHRD ANT INTERBODY DECOMPRESS CERVICAL BELW C2 5460.22 090 l + 22552 ARTHRD ANT INTERDY CERVCL BELW C2 EA ADDL NTRSPC 1272.70 ZZZ 22554 ARTHRD ANT MIN DISCECT INTERBODY CERV BELW C2 3991.06 090 22556 ARTHRD ANT MIN DISCECTOMY INTERBODY THORACIC 5234.93 090 22558 ARTHRODESIS ANTERIOR INTERBODY LUMBAR 4837.75 090 + 22585 ARTHRODESIS ANTERIOR INTERBODY EA ADDL NTRSPC 1077.31 ZZZ 22590 ARTHRODESIS POSTERIOR CRANIOCERVICAL 4923.16 090 22595 ARTHRODESIS POSTERIOR ATLAS-AXIS C1-C2 4679.73 090 22600 ARTHRODESIS PST/PSTLAT CERVICAL BELW C2 SGM 3996.40 090 22610 ARTHRODESIS POSTERIOR/POSTEROLATERAL THORACIC 3915.26 090 22612 ARTHRODESIS POSTERIOR/POSTEROLATERAL LUMBAR 5008.58 090 + 22614 ARTHRODESIS POSTERIOR/POSTEROLATERAL EA ADDL 1255.62 ZZZ 22630 ARTHRODESIS POSTERIOR INTERBODY LUMBAR 4826.00 090 + 22632 ARTHRODESIS POSTERIOR INTERBODY EA ADDL 1023.92 ZZZ 22800 ARTHRODESIS POSTERIOR SPINAL DFRM UP 6 VRT SEG 4238.77 090 22802 ARTHRODESIS POSTERIOR SPINAL DFRM 7-12 VRT SEG 6637.89 090 22804 ARTHRODESIS POSTERIOR SPINAL DFRM 13/> VRT SEG 7651.14 090 22808 ARTHRODESIS ANTERIOR SPINAL DFRM 2-3 VRT SEG 5770.92 090 22810 ARTHRODESIS ANTERIOR SPINAL DFRM 4-7 VRT SEG 6419.01 090 22812 ARTHRODESIS POSTERIOR SPINAL DFRM 8/> VRT SEG 6938.98 090 22818 KYPHECTOMY SINGLE OR TWO SEGMENTS 6861.04 090 22819 KYPHECTOMY 3 OR MORE SEGMENTS 8573.63 090 22830 EXPLORATION SPINAL FUSION 2526.18 090 + 22840 POSTERIOR NON-SEGMENTAL INSTRUMENTATION 2446.10 ZZZ + 22841 INTERNAL SPINAL FIXATION WIRING SPINOUS PROCESS 1202.23 XXX + 22842 POSTERIOR SEGMENTAL INSTRUMENTATION 3-6 VRT SEG 2450.37 ZZZ + 22843 POSTERIOR SEGMENTAL INSTRUMENTATION 7-12 VRT SEG 2601.98 ZZZ + 22844 POSTERIOR SEGMENTAL INSTRUMENTATION 13/> VRT SEG 3141.17 ZZZ + 22845 ANTERIOR INSTRUMENTATION 2-3 VERTEBRAL SEGMENTS 2359.62 ZZZ + 22846 ANTERIOR INSTRUMENTATION 4-7 VERTEBRAL SEGMENTS 2448.24 ZZZ + 22847 ANTERIOR INSTRUMENTATION 8/> VERTEBRAL SEGMENTS 2798.44 ZZZ + 22848 PELVIC FIXATION OTHER THAN SACRUM 1150.98 ZZZ 22849 REINSERTION SPINAL FIXATION DEVICE 4089.29 090 22850 REMOVAL POSTERIOR NONSEGMENTAL INSTRUMENTATION 2243.24 090 s + 22851 APPLICATION INTERVERTEBRAL BIOMECHANICAL DEVICE 1309.00 ZZZ 22852 REMOVAL POSTERIOR SEGMENTAL INSTRUMENTATION 2143.94 090 64 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule 22855 REMOVAL ANTERIOR INSTRUMENTATION 3502.06 090 22856 TOT DISC ARTHRP ART DISC ANT APPRO 1 NTRSPC CRV 5202.90 090 22857 TOT DISC ARTHRP ART DISC ANT APPRO 1 NTRSPC LMBR 5272.30 090 22861 REVJ RPLCMT DISC ARTHROPLASTY ANT 1 NTRSPC CRV 6347.48 090 22862 REVJ RPLCMT DISC ARTHROPLASTY ANT 1 NTRSPC LMBR 6002.61 090 22864 RMVL DISC ARTHROPLASTY ANT 1 INTERSPACE CERVICAL 5958.83 090 22865 RMVL DISC ARTHROPLASTY ANT 1 INTERSPACE LUMBAR 6370.97 090 22899 UNLISTED PROCEDURE SPINE BR YYY 22900 EXC TUMOR SOFT TISSUE ABDL WALL SUBFASCIAL <5CM 857.99 090 22901 EXC TUMOR SOFT TISSUE ABDL WALL SUBFASCIAL 5+CM 1083.98 090 22902 EXC TUMOR SOFT TISSUE ABDOMINAL WALL SUBQ <3CM 711.76 090 22903 EXC TUMOR SOFT TISSUE ABDOMINAL WALL SUBQ 3+CM 727.82 090 22904 RAD RESECTION TUMOR SOFT TISSUE ABDL WALL <5CM 1694.93 090 22905 RAD RESECTION TUMOR SOFT TISSUE ABDL WALL 5+CM 2204.52 090 22999 UNLISTED PX ABDOMEN MUSCULOSKELETAL SYSTEM BR YYY 23000 REMOVAL SUBDELTOID CALCAREOUS DEPOSITS OPEN 1704.05 090 23020 CAPSULAR CONTRACTURE RELEASE 2134.33 090 23030 I&D SHOULDER DEEP ABSCESS/HEMATOMA 1326.08 010 23031 I&D SHOULDER INFECTED BURSA 1234.26 010 23035 INCISION BONE CORTEX SHOULDER AREA 2118.32 090 23040 ARTHROTOMY GLENOHUMERAL JT EXPL/DRG/RMVL FB 2232.56 090 23044 ARTHRT ACROMCLAV STRNCLAV JT EXPL/DRG/RMVL FB 1770.25 090 23065 BIOPSY SOFT TISSUE SHOULDER SUPERFICIAL 668.38 010 23066 BIOPSY SOFT TISSUE SHOULDER DEEP 1610.09 090 # 23071 EXCISION TUMOR SOFT TISSUE SHOULDER SUBQ 3+CM 1330.35 090 # 23073 EXC TUMOR SOFT TISSUE SHOULDER SUBFASCIAL 5+CM 2203.73 090 23075 EXCISION TUMOR SOFT TISSUE SHOULDER SUBQ <3CM 1236.40 090 23076 EXC TUMOR SOFT TISS SHOULDER SUBFASC <5CM 1680.56 090 23077 RAD RESECTION TUMOR SOFT TISSUE SHOULDER <5CM 3620.57 090 23078 RAD RESECTION TUMOR SOFT TISSUE SHOULDER 5+CM 4421.35 090 23100 ARTHROTOMY GLENOHUMERAL JOINT W/BIOPSY 1530.01 090 23101 ARTHRT ACROMCLAV/STRNCLAV JT W/BX&/EXC CRTLG 1390.15 090 23105 ARTHRT GLENOHUMRL JT W/SYNOVECTOMY +-BIOPSY 1974.18 090 23106 ARTHRT GLENOHUMRL JT STRNCLAV JT W/SYNVCT +-BX 1506.52 090 23107 ARTHRT GLENOHUMRL JT W/JT EXPL +-RMVL LOOSE/FB 2046.78 090 23120 CLAVICULECTOMY PARTIAL 1796.94 090 23125 CLAVICULECTOMY TOTAL 2189.85 090 23130 PARTIAL REPAIR OR REMOVAL OF SHOULDER BONE 1879.15 090 23140 EXC/CURTG BONE CYST/BENIGN TUMOR CLAV/SCAPULA 1611.16 090 23145 EXC/CURTG BONE CST/B9 TUM CLAV/SCAPULA W/AGRFT 2152.48 090 23146 EXC/CURTG BONE CST/B9 TUM CLAV/SCAPULA W/ALGRFT 1893.03 090 23150 EXC/CURTG BONE CYST/BENIGN TUMOR PROX HUMERUS 2037.17 090 23155 EXC/CURTG BONE CYST/BENIGN TUM PROX HUM W/AGRFT 2459.98 090 23156 EXC/CURTG BONE CYST/BENIGN TUM PROX HUM W/ALGRFT 2096.96 090 23170 SEQUESTRECTOMY CLAVICLE 1691.24 090 23172 SEQUESTRECTOMY SCAPULA 1729.67 090 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 65
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 23174 SEQUESTRECTOMY HUMERAL HEAD SURGERY NECK 2345.74 090 23180 PARTIAL EXCISION BONE CLAVICLE 2107.64 090 23182 PARTIAL EXCISION BONE SCAPULA 2059.59 090 23184 PARTIAL EXCISION BONE PROXIMAL HUMERUS 2294.49 090 23190 OSTECTOMY SCAPULA PARTIAL 1752.10 090 23195 RESECTION HUMERAL HEAD 2340.40 090 23200 RADICAL RESECTION TUMOR CLAVICLE 4418.14 090 23210 RADICAL RESECTION TUMOR SCAPULA 5169.80 090 23220 RADICAL RESECTION BONE TUMOR PROXIMAL HUMERUS 5707.92 090 23330 REMOVAL FOREIGN BODY SHOULDER SUBCUTANEOUS 705.75 010 23331 REMOVAL FOREIGN BODY SHOULDER DEEP 1826.83 090 23332 REMOVAL FOREIGN BODY SHOULDER COMPLICATED 2747.19 090 23350 INJECTION SHOULDER ARTHROGRAPHY/ CT/MRI ARTHG 465.52 000 23395 MUSCLE TRANSFER SHOULDER/UPPER ARM SINGLE 4011.35 090 23397 MUSCLE TRANSFER SHOULDER/UPPER ARM MULTIPLE 3575.73 090 23400 SCAPULOPEXY 3035.47 090 23405 TENOTOMY SHOULDER AREA 1 TENDON 1949.62 090 23406 TENOTOMY SHOULDER MULTIPLE THRU SAME INCISION 2429.02 090 23410 OPEN REPAIR OF ROTATOR CUFF ACUTE 2565.68 090 23412 OPEN REPAIR OF ROTATOR CUFF CHRONIC 2669.25 090 23415 CORACOACROMIAL LIGAMENT RELEASE +-ACROMIOPLASTY 2157.82 090 23420 RECONSTRUCTION ROTATOR CUFF AVULSION CHRONIC 3028.00 090 23430 TENODESIS LONG TENDON BICEPS 2307.30 090 23440 RESECTION/TRANSPLANTATION LONG TENDON BICEPS 2355.35 090 23450 CAPSULORRHAPHY ANTERIOR PUTTI-PLATT/MAGNUSON 2960.73 090 23455 CAPSULORRHAPHY ANTERIOR W/LABRAL REPAIR 3145.44 090 23460 CAPSULORRHAPHY ANTERIOR WITH BONE BLOCK 3416.64 090 23462 CAPSULORRHAPHY ANTERIOR W/CORACOID PROCESS TR 3357.92 090 23465 CAPSULORRHAPHY GLENOHUMERAL JT PST +-BONE BLK 3493.51 090 23466 CAPSULORRHAPHY GLENOHUMRL JT MULTI-DIRIONAL INS 3489.24 090 23470 ARTHROPLASTY GLENOHUMRL JT HEMIARTHROPLASTY 3792.47 090 23472 ARTHROPLASTY GLENOHUMERAL JOINT TOTAL SHOULDER 4698.95 090 23480 OSTEOTOMY CLAVICLE +-INTERNAL FIXATION 2555.01 090 23485 OSTEOTOMY CLAV +-INT FIXJ W/B1 GRF NON/MAL 3001.30 090 23490 PROPH TX +-METHYLMETHACRYLATE CLAVICLE 2721.57 090 23491 PROPH TX +-METHYLMETHACRYLATE PROXIMAL HUMERUS 3166.80 090 23500 CLSD TX CLAVICULAR FRACTURE W/O MANIPULATION 651.30 090 23505 CLSD TX CLAVICULAR FRACTURE W/MANIPULATION 1058.09 090 23515 OPEN TX CLAVICULAR FRACTURE INTERNAL FIXATION 2235.76 090 23520 CLSD TX STERNOCLAVICULAR DISLC W/O MANIPULATION 684.40 090 23525 CLOSED TX STERNOCLAVICULAR DISLC W/MANIPULATION 1121.09 090 23530 OPEN TX STERNOCLAVICULAR DISLC ACUTE/CHRONIC 1724.34 090 23532 OPTX STRNCLAV DISLC ACUTE/CHRONIC W/FASCIAL GRF 1928.27 090 23540 CLSD TX ACROMIOCLAVICULAR DISLC W/O MANIPULATION 664.11 090 23545 CLSD TX ACROMIOCLAVICULAR DISLC W/MANIPULATION 972.67 090 23550 OPEN TX ACROMIOCLAVICULAR DISLC ACUTE/CHRONIC 1770.25 090 66 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule 23552 OPTX ACROMCLAV DISLC ACUTE/CHRONIC W/FASCIAL GRF 2040.37 090 23570 CLOSED TX SCAPULAR FRACTURE W/O MANIPULATION 692.94 090 23575 CLTX SCAPULAR FX W/MANIPULATION +-SKEL TRACTION 1199.03 090 23585 OPEN TX SCAPULAR FX W/INTERNAL FIXATION IF PFRMD 3034.40 090 23600 CLTX PROXIMAL HUMERAL FRACTURE W/O MANIPULATION 972.67 090 23605 CLTX PROX HUMRL FX W/MANIPULATION +-SKEL TRACJ 1413.63 090 23615 OPEN TREATMENT PROXIMAL HUMERAL FRACTURE 2747.19 090 23616 OPEN PROX HUMERAL FRACTURE PROSTHETIC RPLCMT 3923.80 090 23620 CLTX GREATER HUMERAL TUBEROSITY FX W/O MNPJ 803.98 090 23625 CLTX GRTER HUMERAL TUBEROSITY FX W/MANIPULATION 1149.91 090 23630 OPEN TREATMENT GRTER HUMERAL TUBEROSITY FRACTURE 2400.19 090 23650 CLSD TX SHOULDER DISLC W/MANIPULATION W/O ANES 905.41 090 23655 CLSD TX SHOULDER DISLC W/MANIPULATION REQ ANES 1196.89 090 23660 OPEN TX ACUTE SHOULDER DISLOCATION 1802.28 090 23665 CLTX SHOULDER DISLC W/FX HUMERAL TUBRST W/MNPJ 1282.31 090 23670 OPEN TX SHOULDER DISLC W/HUMERAL TUBEROSITY FX 2691.67 090 23675 CLTX SHOULDER DISLC W/SURG/ANTMCL NCK FX W/MNPJ 1669.88 090 23680 OPEN TX SHOULDER DISLOCATION W/NECK FRACTURE 2872.11 090 23700 MNPJ W/ANES SHOULDER JOINT W/FIXATION APPARATUS 601.12 010 23800 ARTHRODESIS GLENOHUMERAL JOINT 3205.24 090 23802 ARTHRODESIS GLENOHUMERAL JT W/AUTOGENOUS GRAFT 3963.30 090 23900 INTERTHORACOSCAPULAR AMPUTATION 4247.31 090 23920 DISARTICULATION SHOULDER 3448.67 090 23921 DISRTCJ SHOULDER SECONDARY CLSR/SCAR REVISION 1367.72 090 23929 UNLISTED PROCEDURE SHOULDER BR YYY 23930 I&D UPPER ARM/ELBOW DEEP ABSCESS/HEMATOMA 1087.99 010 23931 INCISION&DRAINAGE UPPER ARM/ELBOW BURSA 860.57 010 23935 INC DEEP W/OPENING BONE CORTEX HUMERUS/ELBOW 1554.57 090 24000 ARTHRT ELBOW W/EXPLORATION DRAINAGE/REMOVAL FB 1470.22 090 24006 ARTHRT ELBOW CAPSULAR EXCISION CAPSULAR RLS SPX 2208.00 090 24065 BIOPSY SOFT TISSUE UPPER ARM/ELBOW SUPERFICIAL 787.96 010 24066 BIOPSY SOFT TISSUE UPPER ARM/ELBOW AREA DEEP 1846.05 090 # 24071 EXC TUMOR SOFT TISSUE UPPER ARM/ELBOW SUBQ 3+CM 1297.26 090 # 24073 EXC TUMOR SOFT TISS UPPER ARM/ELBW SUBFASC 5+CM 2211.21 090 24075 EXC TUMOR SOFT TISS UPPER ARM/ELBOW SUBQ <3CM 1499.05 090 24076 EXC TUMOR SOFT TISS UPR ARM/ELBOW SUBFASC <5CM 1639.99 090 24077 RAD RESECT TUMOR SOFT TISS UPPER ARM/ELBOW <5CM 3135.83 090 24079 RAD RESECT TUMOR SOFT TISS UPPER ARM/ELBOW 5+CM 4077.55 090 24100 ARTHROTOMY ELBOW W/SYNOVIAL BIOPSY ONLY 1269.50 090 24101 ARTHRT ELBOW W/JOINT EXPL +-BX +-RMVL LOOSE/FB 1542.83 090 24102 ARTHROTOMY ELBOW W/SYNOVECTOMY 1902.64 090 24105 EXCISION OLECRANON BURSA 1058.09 090 24110 EXCISION/CURTG BONE CYST/BENIGN TUMOR HUMERUS 1810.82 090 24115 EXC/CURTG BONE CYST/BENIGN TUMOR HUMERUS W/AGRFT 2279.54 090 24116 EXC/CURTG BONE CYST/BENIGN TUM HUMERUS W/ALGRFT 2685.27 090 24120 EXC/CURTG BONE CYST/BENIGN TUMOR H/N RDS/OLECRN 1623.97 090 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 67
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 24125 EXC/CURTG BONE CST/B9 TUM H/N RDS/OLECRN W/AGRFT 1903.71 090 24126 EXC/CURTG B1 CST/B9 TUM H/N RDS/OLECRN W/ALGRFT 2005.14 090 24130 EXCISION RADIAL HEAD 1563.11 090 24134 SEQUESTRECTOMY SHAFT/DISTAL HUMERUS 2329.72 090 24136 SEQUESTRECTOMY RADIAL HEAD OR NECK 1901.57 090 24138 SEQUESTRECTOMY OLECRANON PROCESS 2072.41 090 24140 PARTIAL EXCISION BONE HUMERUS 2204.80 090 24145 PARTIAL EXCISION BONE RADIAL HEAD/NECK 1854.59 090 24147 PARTIAL EXCISION BONE OLECRANON PROCESS 1938.94 090 24149 RAD RESCJ CAPSL TISS&HTRTPC BONE ELBW CONTRCT 3634.45 090 24150 RADICAL RESECTION TUMOR SHAFT/DISTAL HUMERUS 4597.52 090 24152 RADICAL RESECTION TUMOR RADIAL HEAD/NECK 3909.92 090 24155 RESECTION ELBOW JOINT ARTHRECTOMY 2651.10 090 24160 IMPLANT REMOVAL ELBOW JOINT 1875.95 090 24164 IMPLANT REMOVAL RADIAL HEAD 1538.56 090 24200 RMVL FOREIGN BODY UPPER ARM/ELBOW SUBCUTANEOUS 618.20 010 24201 REMOVAL FOREIGN BODY UPPER ARM/ELBOW DEEP 1700.85 090 24220 INJECTION ELBOW ARTHROGRAPHY 506.09 000 24300 MANIPULATION ELBOW UNDER ANESTHESIA 1238.53 090 24301 MUSCLE/TENDON TRANSFER UPPER ARM/ELBOW SINGLE 2336.13 090 24305 TENDON LENGTHENING UPPER ARM/ELBOW EA TENDON 1792.67 090 24310 TENOTOMY OPEN ELBOW TO SHOULDER EACH TENDON 1472.36 090 24320 TENOPLASTY ELBOW TO SHOULDER SINGLE 2420.48 090 24330 FLEXOR-PLASTY ELBOW 2227.22 090 24331 FLEXOR-PLASTY ELBOW W/EXTENSOR ADVANCEMENT 2502.69 090 24332 TENOLYSIS TRICEPS 1887.69 090 24340 TENODESIS BICEPS TENDON ELBOW SPX 1900.51 090 24341 REPAIR TENDON/MUSCLE UPPER ARM/ELBOW EA 2292.35 090 24342 RINSJ RPTD BICEPS/TRICEPS TDN DSTL +-TDN GRF 2424.75 090 24343 REPAIR LATERAL COLLATERAL LIGAMENT ELBOW 2179.18 090 24344 RCNSTJ LAT COLTRL LIGM ELBOW W/TENDON GRAFT 3411.30 090 24345 REPAIR MEDIAL COLLATERAL LIGAMENT ELBOW 2166.36 090 24346 RCNSTJ MEDIAL COLTRL LIGM ELBW W/TDN GRF 3416.64 090 24357 TENOTOMY ELBOW LATERAL/MEDIAL PERCUTANEOUS 1374.13 090 24358 TNOT ELBOW LATERAL/MEDIAL DEBRIDE OPEN 1617.57 090 24359 TNOT ELBOW LATERAL/MEDIAL DEBRIDE OPEN TDN RPR 2035.04 090 24360 ARTHROPLASTY ELBOW W/MEMBRANE 2803.78 090 24361 ARTHROPLASTY ELBOW W/DISTAL HUMRL PROSTC RPLCMT 3148.65 090 24362 ARTHRP ELBOW W/IMPLT&FSCA LATA LIGAMENT RCNSTJ 3314.14 090 24363 ARTHRP ELBOW W/DISTAL HUM&PROX UR PROSTC RPLCMT 4686.14 090 24365 ARTHROPLASTY RADIAL HEAD 1984.85 090 24366 ARTHROPLASTY RADIAL HEAD W/IMPLANT 2120.45 090 24400 OSTEOTOMY HUMERUS +-INTERNAL FIXATION 2550.74 090 24410 MLT OSTEOT W/RELIGNMT IMED ROD HUMERAL SHAFT 3279.97 090 24420 OSTEOPLASTY HUMERUS 3084.59 090 24430 REPAIR NON/MALUNION HUMERUS W/O GRAFT 3294.92 090 68 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule 24435 REPAIR NON/MALUNION HUMERUS W/ILIAC/OTH AGRFT 3351.51 090 24470 HEMIEPIPHYSEAL ARREST 2019.02 090 24495 DECOMPRESSION FASCT F/ARM W/BRACH ART EXPL 2044.65 090 24498 PROPHYLACTIC TX +-METHYLMETHACRYLATE HUMRL SHFT 2706.62 090 24500 CLSD TX HUMERAL SHAFT FRACTURE W/O MANIPULATION 1061.29 090 24505 CLTX HUMERAL SHFT FX W/MANIPULATION +-SKEL TRACJ 1517.20 090 24515 OPTX HUMERAL SHFT FX W/PLATE/SCREWS +-CERCLAGE 2725.84 090 24516 TX HUMERAL SHAFT FX W/INSJ IMED IMPLT +-CERCLAGE 2685.27 090 24530 CLTX SPRCNDYLR/TRANSCNDYLR HUMERAL FX+-MNPJ 1137.10 090 24535 CLTX SPRCNDYLR/TRANSCNDYLR HUMERAL FX W/MNPJ 1883.42 090 24538 PRQ SKEL FIXJ SPRCNDYLR/TRANSCNDYLR HUMERAL FX 2307.30 090 24545 OPEN TX HUMERAL SUPRACONDYLAR FRACTURE W/O XTN 2880.65 090 24546 OPEN TX HUMERAL SUPRACONDYLAR FRACTURE W/XTN 3259.69 090 24560 CLTX HUMERAL EPICONDYLAR FX MEDIAL/LAT W/O MNPJ 953.46 090 24565 CLTX HUMERAL EPICONDYLAR FX MEDIAL/LAT W/MNPJ 1591.94 090 24566 PRQ SKEL FIXJ HUMRL EPCNDYLR FX MEDIAL/LAT MNPJ 2206.94 090 24575 OPEN TX HUMERAL EPICONDYLAR FRACTURE 2273.13 090 24576 CLTX HUMERAL CONDYLAR FX MEDIAL/LAT W/O MNPJ 1011.11 090 24577 CLTX HUMERAL CONDYLAR FX MEDIAL/LATERAL W/MNPJ 1647.46 090 24579 OPEN TREATMENT HUMERAL CONDYLAR FRACTURE 2592.38 090 24582 PRQ SKEL FIXJ HUMRL CNDYLR FX MEDIAL/LAT W/MNPJ 2472.79 090 24586 OPTX PERIARTICULAR FRACTURE &/DISLOCATION ELBOW 3400.62 090 24587 OPTX PRIARTICULAR FX&/DISLC ELBW W/IMPLT ARTHRP 3394.22 090 24600 TREATMENT CLOSED ELBOW DISLOCATION W/O ANES 1090.12 090 24605 TREATMENT CLOSED ELBOW DISLOCATION REQ ANES 1426.45 090 24615 OPEN TX ACUTE/CHRONIC ELBOW DISLOCATION 2214.41 090 24620 CLOSED TX MONTEGGIA FX DISLOCATION ELBOW W/MNPJ 1705.12 090 24635 OPEN TX MONTEGGIA FRACTURE DISLOCATION ELBOW 2183.45 090 24640 CLTX RDL HEAD SUBLXTJ CHLD NURSEMAID ELBW W/MNPJ 385.44 010 24650 CLOSED TX RADIAL HEAD/NECK FX W/O MANIPULATION 775.15 090 24655 CLOSED TX RADIAL HEAD/NECK FX W/MANIPULATION 1314.34 090 24665 OPEN TX RADIAL HEAD/NECK FRACTURE 2012.61 090 24666 OPEN TX RADIAL HEAD/NECK FRACTURE PROSTHETIC 2272.07 090 24670 CLOSED TX ULNAR FRACTURE PROXIMAL END W/O MNPJ 866.97 090 24675 CLOSED TX ULNAR FRACTURE PROXIMAL END W MNPJ 1384.81 090 24685 OPEN TREATMENT ULNAR FRACTURE PROXIMAL END 2016.89 090 24800 ARTHRODESIS ELBOW JOINT LOCAL 2533.65 090 24802 ARTHRODESIS ELBOW JOINT W/AUTOGENOUS GRAFT 3120.89 090 24900 AMPUTATION ARM THRU HUMERUS W/PRIMARY CLOSURE 2259.25 090 24920 AMPUTATION ARM THRU HUMERUS OPEN CIRCULAR 2247.51 090 24925 AMP ARM THRU HUMERUS SECONDARY CLSR/SCAR REVJ 1741.42 090 24930 AMPUTATION ARM THRU HUMERUS RE-AMPUTATION 2382.04 090 24931 AMPUTATION ARM THRU HUMERUS W/IMPLANT 2405.53 090 24935 STUMP ELONGATION UPPER EXTREMITY 3013.05 090 24940 CINEPLASTY UPPER EXTREMITY COMPLETE PROCEDURE 3253.28 090 24999 UNLISTED PROCEDURE HUMERUS/ELBOW BR YYY Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 69
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 25000 INCISION EXTENSOR TENDON SHEATH WRIST 1059.16 090 25001 INCISION FLEXOR TENDON SHEATH WRIST 1043.14 090 25020 DCMPRN FASCT F/ARM&WRST FLXR/XTNSR W/O DBRDMT 1780.92 090 25023 DCMPRN FASCT F/ARM&/WRST FLXR/XTNSR W/DBRDMT 3428.38 090 25024 DCMPRN FASCT F/ARM&/WRST FLXR&XTNSR W/O DBRDMT 2416.21 090 25025 DCMPRN FASCT F/ARM&/WRST FLXR&XTNSR DBRDMT NV 3785.00 090 25028 I&D FOREARM&/WRIST DEEP ABSCESS/HEMATOMA 1597.28 090 25031 INCISION & DRAINAGE FOREARM&/WRIST BURSA 1121.09 090 25035 INCISION DEEP BONE CORTEX FOREARM&/WRIST 1910.12 090 25040 ARTHRT RDCRPL/MIDCARPL JT W/EXPL DRG/RMVL FB 1755.30 090 25065 BIOPSY SOFT TISSUE FOREARM&/WRIST SUPERFICIAL 784.76 010 25066 BIOPSY SOFT TISSUE FOREARM&/WRIST DEEP 1138.17 090 # 25071 EXC TUMOR SOFT TISS FOREARM AND/WRIST SUBQ 3+CM 1363.45 090 # 25073 EXC TUMOR SFT TISS FOREARM&//WRIST SUBFASC 3+CM 1704.05 090 25075 EXC TUMOR SOFT TISSUE FOREARM &/WRIST SUBQ <3CM 1481.97 090 25076 EXC TUMOR SOFT TISS FOREARM&/WRIST SUBFASC <3CM 1604.75 090 25077 RAD RESECT TUMOR SOFT TISS FOREARM&/WRIST <3CM 2748.26 090 25078 RAD RESCJ TUM SOFT TISSUE FOREARM&/WRIST 3+CM 3566.12 090 25085 CAPSULOTOMY WRIST 1418.97 090 25100 ARTHROTOMY WRIST JOINT WITH BIOPSY 1068.77 090 25101 ARTHRT WRST JT W/JT EXPL +-BX +-RMVL LOOSE/FB 1253.48 090 25105 ARTHROTOMY WRIST JOINT WITH SYNOVECTOMY 1509.73 090 25107 ARTHROTOMY DSTL RADIOULNAR JOINT RPR CARTILAGE 1914.39 090 25109 EXC TENDON FOREARM&/WRIST FLEXOR/EXTENSOR EA 1647.46 090 25110 EXCISION LESION TENDON SHEATH FOREARM&/WRIST 1083.72 090 25111 EXCISION GANGLION WRIST DORSAL/VOLAR PRIMARY 981.22 090 25112 EXCISION GANGLION WRIST DORSAL/VOLAR RECURRENT 1190.49 090 25115 RAD EXC BURSA SYNVA WRST/F/ARM TDN SHTHS FLXRS 2442.90 090 25116 RAD EXC BURSA SYNVA WRST/F/ARM TDN SHTHS XTNSRS 1947.48 090 25118 SYNOVECTOMY EXTENSOR TENDON SHTH WRIST 1 CMPRT 1184.08 090 25119 SYNVCT XTNSR TDN SHTH WRST 1 RESCJ DSTL ULNA 1558.84 090 25120 EXCISION/CURETTAGE CYST/TUMOR RADIUS/ULNA 1635.72 090 25125 EXC/CURTG CYST/TUMOR RADIUS/ULNA W/AUTOGRAFT 1931.47 090 25126 EXC/CURTG CYST/TUMOR RADIUS/ULNA W/ALLOGRAFT 1938.94 090 25130 EXCISION/CURETTAGE CYST/TUMOR CARPAL BONES 1394.42 090 25135 EXC/CURTG CYST/TUMOR CARPAL BONES W/AUTOGRAFT 1737.15 090 25136 EXC/CURTG CYST/TUMOR CARPAL BONES W/ALLOGRAFT 1530.01 090 25145 SEQUESTRECTOMY FOREARM &/WRIST 1689.10 090 25150 PARTIAL EXCISION BONE ULNA 1774.52 090 25151 PARTIAL EXCISION BONE RADIUS 1907.98 090 25170 RADICAL RESECTION TUMOR RADIUS OR ULNA 4421.35 090 25210 CARPECTOMY 1 BONE 1521.47 090 25215 CARPECTOMY ALL BONES PROXIMAL ROW 1937.88 090 25230 RADICAL STYLOIDECTOMY SPX 1341.03 090 25240 EXCISION DISTAL ULNA PARTIAL/COMPLETE 1344.23 090 25246 INJECTION WRIST ARTHROGRAPHY 514.63 000 70 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule 25248 EXPL W/REMOVAL DEEP FOREIGN BODY FOREARM/WRIST 1327.15 090 25250 REMOVAL WRIST PROSTHESIS SPX 1632.51 090 25251 REMOVAL WRIST PROSTH COMPLICATED W/TOTAL WRIST 2233.63 090 25259 MANIPULATION WRIST UNDER ANESTHESIA 1246.01 090 25260 RPR TDN/MUSC FLXR F/ARM&/WRST PRIM 1 EA TDN/MUSC 2042.51 090 25263 RPR TDN/MUSC FLXR F/ARM&/WRST SEC 1 EA TDN/MUSC 2035.04 090 25265 RPR TDN/MUSC FLXR F/ARM&/WRST SEC FR GRF EA 2419.41 090 25270 RPR TDN/MUSC XTNSR F/ARM&/WRST PRIM 1 EA TDN 1616.50 090 25272 RPR TDN/MUSC XTNSR F/ARM&/WRST SEC 1 EA TDN/MUSC 1815.09 090 25274 RPR TDN/MUSC XTNSR F/ARM&/WRST SEC FR GRF EA TDN 2173.84 090 25275 RPR TENDON SHEATH EXTENSOR F/ARM&/WRST W/GRAFT 2094.83 090 25280 LNGTH/SHRT FLXR/XTNSR TDN F/ARM&/WRST 1 EA TDN 1840.71 090 25290 TNOT FLXR/XTNSR TENDON FOREARM&/WRIST 1 EA 1500.12 090 25295 TNOLS FLXR/XTNSR TENDON FOREARM&/WRIST 1 EA 1713.66 090 25300 TENODESIS WRIST FLEXORS FINGERS 2132.20 090 25301 TENODESIS WRIST EXTENSORS FINGERS 2008.34 090 25310 TDN TRNSPLJ/TR FLXR/XTNSR F/ARM&/WRST 1 EA TDN 2006.21 090 25312 TDN TRNSPLJ/TR FLXR/XTNSR F/ARM&/WRST 1/TDN GRF 2329.72 090 25315 FLEXOR ORIGIN SLIDE FOREARM &/WRIST 2501.62 090 25316 FLEXOR ORIGIN SLIDE F/ARM&/WRST TENDON TRANSFER 2835.81 090 25320 CAPSL-RHPHY/RCNSTJ WRST OPN CARPL INS 3052.55 090 25332 ARTHRP WRST +-INTERPOS +-XTRNL/INT FIXJ 2628.68 090 25335 CENTRALIZATION WRST ULNA 2598.78 090 25337 RCNSTJ STABLJ DSTL U/DSTL JT 2 SOFT TISS STABLJ 2766.41 090 25350 OSTEOTOMY RADIUS DISTAL THIRD 2190.92 090 25355 OSTEOTOMY RADIUS MIDDLE/PROXIMAL THIRD 2483.47 090 25360 OSTEOTOMY ULNA 2131.13 090 25365 OSTEOTOMY RADIUS & ULNA 2940.45 090 25370 MLT OSTEOTOMIES W/RELIGNMT IMED ROD RADIUS/ULNA 3222.32 090 25375 MLT OSTEOTOMIES W/RELIGNMT IMED ROD RADIUS&ULNA 2893.47 090 25390 OSTEOPLASTY RADIUS/ULNA SHORTENING 2493.08 090 25391 OSTEOPLASTY RADIUS/ULNA LENGTHENING W/AUTOGRAFT 3207.37 090 25392 OSTEOPLASTY RADIUS & ULNA SHORTENING 3267.16 090 25393 OSTEOPLASTY RADIUS&ULNA LENGTHENING W/AUTOGRAFT 3718.80 090 25394 OSTEOPLASTY CARPAL BONE SHORTENING 2433.29 090 25400 RPIR NONUNION/MALUNION RADIUS/ULNA W/O AUTOGRAFT 2608.39 090 25405 RPR NONUNION/MALUNION RADIUS/ULNA W/AUTOGRAFT 3338.70 090 25415 RPR NONUNION/MALUNION RADIUS&ULNA W/O AUTOGRAFT 3164.66 090 25420 RPR NONUNION/MALUNION RADIUS&ULNA W/AUTOGRAFT 3764.71 090 25425 REPAIR DEFECT W/AUTOGRAFT RADIUS/ULNA 3183.88 090 25426 REPAIR DEFECT W/AUTOGRAFT RADIUS&ULNA 3504.19 090 25430 INSERTION VASCULAR PEDICLE CARPAL BONE 2175.97 090 25431 REPAIR NONUNION CARPAL BONE EACH BONE 2440.76 090 25440 RPR NONUNION SCAPHOID CARPAL BONE +-RDL STYLODC 2398.05 090 25441 ARTHROPLASTY W/PROSTHETIC RPLCMT DISTAL RADIUS 2885.99 090 25442 ARTHROPLASTY W/PROSTHETIC RPLCMT DISTAL ULNA 2452.51 090 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 71
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 25443 ARTHROPLASTY W/PROSTHETIC RPLCMT SCAPHOID CARPAL 2431.15 090 25444 ARTHROPLASTY W/PROSTHETIC REPLACEMENT LUNATE 2466.39 090 25445 ARTHROPLASTY W/PROSTHETIC REPLACEMENT TRAPEZIUM 2238.97 090 25446 ARTHRP W/PROSTC RPLCMT DSTL RDS&PRTL/CARPUS 3661.14 090 25447 ARTHRP INTERPOS INTERCARPAL/METACARPAL JOINTS 2555.01 090 25449 REVJ ARTHRP W/RMVL IMPLT WRST JT 3259.69 090 25450 EPIPHYSL ARRST EPIPHYSIOD/STAPLING DSTL RDS/U 1755.30 090 25455 EPIPHYSL ARRST EPIPHYSIOD/STAPLING DSTL RDS&U 1933.60 090 25490 PROPH TX N/P/PLTWR +-MMA RDS 2187.72 090 25491 PROPH TX N/P/PLTWR +-MMA U 2401.26 090 25492 PROPH TX N/P/PLTWR +-MMA RDS&U 2906.28 090 25500 CLOSED TX RADIAL SHAFT FRACTURE W/O MANIPULATION 798.64 090 25505 CLOSED TX RADIAL SHAFT FRACTURE W/MANIPULATION 1519.34 090 25515 OPEN TREATMENT RADIAL SHAFT FRACTURE 2066.00 090 25520 CLTX RDL SHFT FX&CLTX DISLC DSTL RAD/ULN JT 1702.98 090 25525 OPEN RDL SHAFT FX CLOSED RAD/ULN JT DISLOCATE 2452.51 090 25526 OPEN RDL SHAFT FX OPEN RAD/ULN JT DISLOCATE 3021.59 090 25530 CLOSED TX ULNAR SHAFT FRACTURE W/O MANIPULATION 774.08 090 25535 CLOSED TX ULNAR SHAFT FRACTURE W/MANIPULATION 1478.76 090 25545 OPEN TREATMENT OF ULNAR SHAFT FRACTURE 1926.13 090 25560 CLOSED TX RADIAL&ULNAR SHAFT FRACTURES W/O MNPJ 811.45 090 25565 CLOSED TX RADIAL&ULNAR SHAFT FRACTURES W/MNPJ 1586.60 090 25574 OPEN TX RADIAL & ULNAR SHAFT FX FIXJ RADIUS/ULNA 2071.34 090 25575 OPEN TX RDL& ULNAR SHAFT FX FIXJ RADIUS &ULNA 2786.70 090 25600 CLTX DSTL RADIAL FX/EPIPHYSL SEP W/O MNPJ 873.38 090 25605 CLTX DSTL RDL FX/EPIPHYSL SEP +-W/MNPJ 1894.10 090 25606 PERQ SKEL FIXJ DISTAL RADIAL FX/EPIPHYSL SEP 2057.46 090 25607 OPTX DSTL RADL X-ARTIC FX/EPIPHYSL SEP 2253.91 090 25608 OPTX DSTL RADL I-ARTIC FX/EPIPHYSL SEP 2 FRAG 2532.58 090 25609 OPTX DSTL RADL I-ARTIC FX/EPIPHYSL SEP 3 FRAG 3229.79 090 25622 CLOSED TX CARPAL SCAPHOID FRACTURE W/O MNPJ 903.27 090 25624 CLOSED TX CARPAL SCAPHOID FRACTURE W/MNPJ 1395.48 090 25628 OPEN TX CARPAL SCAPHOID NAVICULAR FRACTURE 2228.29 090 25630 CLTX CARPL B1 FX W/O MNPJ EA B1 915.02 090 25635 CLTX CARPL B1 FX W/MNPJ EA B1 1353.84 090 25645 OPEN TX CARPAL BONE FRACTURE OTH/THN SCAPHOID EA 1757.43 090 25650 CLOSED TREATMENT ULNAR STYLOID FRACTURE 959.86 090 25651 PRQ SKELETAL FIXATION ULNAR STYLOID FRACTURE 1483.04 090 25652 OPEN TREATMENT ULNAR STYLOID FRACTURE 1919.72 090 25660 CLTX RDCRPL/INTERCARPL DISLC 1+ B1S W/MNPJ 1233.19 090 25670 OPEN TX RADIOCARPAL/INTERCARPAL DISLC 1+ BONES 1874.88 090 25671 PRQ SKELETAL FIXJ DISTAL RADIOULNAR DISLOCATION 1627.17 090 25675 CLOSED TX DISTAL RADIOULNAR DISLOCATION W/MNPJ 1309.00 090 25676 OPEN TX DISTAL RADIOULNAR DISLC ACUTE/CHRONIC 1953.89 090 25680 CLTX TRANS-SCAPHOPRILUNAR TYP FX DISLC W/MNPJ 1416.84 090 25685 OPEN TX TRANS-SCAPHOPERILUNAR FRACTURE DISLC 2276.34 090 72 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule 25690 CLOSED TX LUNATE DISLOCATION W/MANIPULATION 1455.28 090 25695 OPEN TREATMENT LUNATE DISLOCATION 1962.43 090 25800 ARTHRD WRST COMPL W/O B1 GRF 2290.22 090 25805 ARTHRD WRST W/SLIDING GRF 2650.03 090 25810 ARTHRD WRST W/ILIAC/OTH AGRFT 2702.35 090 25820 ARTHRODESIS WRIST LIMITED W/O BONE GRAFT 1897.30 090 25825 ARTHRODESIS WRIST LIMITED W/AUTOGRAFT 2342.53 090 25830 ARTHRD DSTL RAD/ULN JT SGMTL RESCJ U +-B1 GRF 2950.06 090 25900 AMPUTATION FOREARM THROUGH RADIUS & ULNA 2279.54 090 25905 AMP FOREARM THRU RADIUS&ULNA OPEN CIRCULAR 2246.44 090 25907 AMP F/ARM THRU RADIUS&ULNA SEC CLOSURE/SCAR REVJ 1965.64 090 25909 AMP FOREARM THRU RADIUS&ULNA RE-AMPUTATION 2199.46 090 25915 KRUKENBERG PROCEDURE 3541.56 090 25920 DISARTICULATION THROUGH WRIST 2147.14 090 25922 DISARTICULATION THRU WRIST SEC CLOSURE/SCAR REVJ 1600.48 090 25924 DISARTICULATION THRU WRIST RE-AMPUTATION 1988.06 090 25927 TRANSMETACARPAL AMPUTATION 2470.66 090 25929 TRANSMETACARPAL AMPUTATION SEC CLOSURE/SCAR REVJ 1831.11 090 25931 TRANSMETACARPAL AMPUTATION RE-AMPUTATION 2153.55 090 25999 UNLISTED PROCEDURE FOREARM/WRIST BR YYY 26010 DRAINAGE FINGER ABSCESS SIMPLE 779.42 010 26011 DRAINAGE FINGER ABSCESS COMPLICATED 1180.88 010 26020 DRAINAGE TENDON SHEATH DIGIT&/PALM EACH 1329.29 090 26025 DRAINAGE OF PALMAR BURSA SINGLE BURSA 1289.78 090 26030 DRAINAGE OF PALMAR BURSA MULTIPLE BURSA 1519.34 090 26034 INCISION BONE CORTEX HAND/FINGER 1650.66 090 26035 DECOMPRESSION FINGERS&/HAND INJECTION INJURY 2618.00 090 26037 DECOMPRESSIVE FASCIOTOMY HAND 1768.11 090 26040 FASCIOTOMY PALMAR PERCUTANEOUS 948.12 090 26045 FASCIOTOMY PALMAR OPEN PARTIAL 1437.12 090 26055 TENDON SHEATH INCISION 1717.93 090 26060 TENOTOMY PERCUTANEOUS SINGLE EACH DIGIT 816.79 090 26070 ARTHRT EXPL DRG/RMVL LOOSE/FB CARP/MTCRPL JT 936.37 090 26075 ARTHRT EXPL DRG/RMVL LOOSE/FB MTCARPHLNGL JT EA 983.35 090 26080 ARTHRT EXPL DRG/RMVL LOOSE/FB IPHAL JT EA 1187.28 090 26100 ARTHROTOMY BIOPSY CARP/MTCRPL JOINT EACH 1008.98 090 26105 ARTHROTOMY BIOPSY MTCARPHLNGL JOINT EACH 1023.92 090 26110 ARTHROTOMY BIOPSY INTERPHALANGEAL JOINT EACH 980.15 090 # 26111 EX TUM/VASC MALF SFT TISS HAND/FNGR SUBQ 1.5+CM 1331.42 090 # 26113 EX TUM/VASC MAL SFT TIS HAND/FNGR SUBFSC 1.5+CM 1744.62 090 26115 EXC TUM/VASC MAL SFT TISS HAND/FNGR SUBQ <1.5CM 1713.66 090 26116 EXC TUM/VAS MAL SFT TIS HAND/FNGR SUBFASC<1.5CM 1622.90 090 26117 RAD RESECT TUMOR SOFT TISSUE HAND/FINGER <3CM 2266.73 090 26118 RAD RESCJ TUM SOFT TISSUE HAND/FINGER 3+CM 3413.44 090 26121 FASCT PALM +-Z-PLASTY TISS REARGMT/SKN GRF 1847.12 090 26123 FASCT PRTL PLMR 1 DGT PROX IPHAL JT +-TISS 2566.75 090 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 73
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 + 26125 FASCT PRTL PLMR 1 DGT PROX IPHAL JT +-Z-PLASTY 874.45 ZZZ 26130 SYNOVECTOMY CARPOMETACARPAL JOINT 1413.63 090 26135 SYNVCT MTCARPHLNGL JT W/INTRNSC RLS&XTNSR HOOD 1702.98 090 26140 SYNVCT PROX IPHAL JT W/XTNSR RCNSTJ EA IPHAL JT 1556.71 090 26145 SYNVCT TDN SHTH RAD FLXR TDN PALM&/FNGR EA TDN 1580.20 090 26160 EXC LES TDN SHTH/JT CAPSL HAND/FNGR 1742.49 090 26170 EXCISION TENDON PALM FLEXOR/EXTENSOR SINGLE EACH 1248.14 090 26180 EXCISION TENDON FINGER FLEXOR/EXTENSOR EACH 1354.91 090 26185 SESAMOIDECTOMY THUMB/FINGER SPX 1673.09 090 26200 EXCISION/CURETTAGE CYST/TUMOR METACARPAL 1389.08 090 26205 EXC/CURETTAGE CYST/TUMOR METACARPAL W/AUTOGRAFT 1866.34 090 26210 EXCISION/CURETTAGE CYST/TUMOR PHALANX FINGER 1358.11 090 26215 EXC/CURETTAGE CYST/TUMOR PHALANX FINGER W/AGRAFT 1732.88 090 26230 PARTIAL EXCISION BONE METACARPAL 1542.83 090 26235 PARTIAL EXCISION PROXIMAL/MIDDLE PHALANX FINGER 1525.74 090 26236 PARTIAL EXCISION DISTAL PHALANX FINGER 1358.11 090 26250 RADICAL RESECTION TUMOR METACARPAL 3079.25 090 26260 RAD RESECTION TUMOR PROX/MIDDLE PHALANX FINGER 2413.00 090 26262 RADICAL RESECTION TUMOR DISTAL PHALANX FINGER 1854.59 090 26320 REMOVAL IMPLANT FROM FINGER/HAND 1064.50 090 26340 MANIPULATION FINGER JOINT UNDER ANES EACH JOINT 1000.43 090 26350 RPR/ADVMNT FLXR TDN N/Z/2 1/2 W/O FR GRF EA TDN 2184.51 090 26352 RPR/ADVMNT FLXR TDN N/Z/2 2W/FR GRF EA TDN 2495.21 090 26356 RPR/ADVMNT FLXR TDN ZONE 2 1W/O FR GRF EA TDN 3333.36 090 26357 RPR/ADVMNT FLXR TDN ZONE 2 2W/O FR GRF EA TDN 2664.98 090 26358 RPR/ADVMNT FLXR TDN ZONE 2 2W/FR GRF EA TDN 2846.49 090 26370 RPR/ADVMNT TDN W/NTC SUPFCIS TDN PRIM EA TDN 2352.14 090 26372 RPR/ADVMNT TDN W/NTC SUPFCIS TDN 2 W/FR GRF EA 2725.84 090 26373 RPR/ADVMNT TDN W/NTC SUPFCIS TDN 2 W/O FR GRF EA 2604.12 090 26390 EXC FLXR TDN W/IMPLTJ SYNTH ROD DLYD TDN GRF H/F 2562.48 090 26392 RMVL SYNTH ROD&INSJ FLXR TDN GRF H/F EA ROD 2988.49 090 26410 REPAIR EXTENSOR TENDON HAND W/O GRAFT EACH 1733.94 090 26412 REPAIR EXTENSOR TENDON HAND W/GRAFT EACH 2102.30 090 26415 EXC XTNSR TDN W/IMPLTJ SYNTH ROD DLYD GRF H/F EA 2145.01 090 26416 RMVL SYNTH ROD&INSJ XTNSR TDN GRF H/F EA ROD 2576.36 090 26418 REPAIR EXTENSOR TENDON FINGER W/O GRAFT EACH 1759.57 090 26420 REPAIR EXTENSOR TENDON FINGER W/GRAFT EACH 2181.31 090 26426 RPR XTNSR TDN CTR SLIP 2 TISS W/LAT BAND EA FNGR 1663.48 090 26428 RPR XTNSR TDN CTR SLIP SEC W/FR GRF EA FNGR 2312.64 090 26432 CLTX DSTL XTNSR TDN INSJ +-PRQ PINNING 1521.47 090 26433 REPAIR EXTENSOR TENDON DISTAL INSERTION W/O GRF 1628.24 090 26434 REPAIR EXTENSOR TENDON DISTAL INSERTION W/GRAFT 1969.91 090 26437 REALIGNMENT EXTENSOR TENDON HAND EACH TENDON 1903.71 090 26440 TENOLYSIS FLEXOR TENDON PALM/FINGER EACH TENDON 1906.91 090 26442 TENOLYSIS FLEXOR TENDON PALM&FINGER EACH TENDON 2947.92 090 26445 TENOLYSIS EXTENSOR TENDON HAND/FINGER EACH 1773.45 090 74 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule 26449 TENOLYSIS CPLX XTNSR TENDON FINGER W/FOREARM EA 2268.86 090 26450 TENOTOMY FLEXOR PALM OPEN EACH TENDON 1235.33 090 26455 TENOTOMY FLEXOR FINGER OPEN EACH TENDON 1231.06 090 26460 TENOTOMY EXTENSOR HAND/FINGER OPEN EACH TENDON 1197.96 090 26471 TENODESIS PROXIMAL INTERPHALANGEAL JOINT EACH 1881.29 090 26474 TENODESIS DISTAL JOINT EACH 1835.38 090 26476 LENGTHENING TENDON EXTENSOR HAND/FINGER EACH 1796.94 090 26477 SHORTENING TENDON EXTENSOR HAND/FINGER EACH 1783.06 090 26478 LENGTHENING TENDON FLEXOR HAND/FINGER EACH 1913.32 090 26479 SHORTENING TENDON FLEXOR HAND/FINGER EACH 1907.98 090 26480 TR/TRNSPL TDN CARP/MTCRPL HAND W/O FR GRF EA TDN 2308.37 090 26483 TENDON TRANSFER TRANSPLANT CARP/MTCRPL GRAFT 2595.58 090 26485 TRANSFER/TRANSPLANT TENDON PALMAR W/O GRAFT EACH 2485.61 090 26489 TRANSFER/TRANSPLANT TENDON PALMAR W/GRAFT EACH 2790.97 090 26490 OPPONENSPLASTY SUPFCIS TDN TR TYP EA TDN 2439.69 090 26492 OPPONENSPLASTY TDN TR W/GRF EA TDN 2702.35 090 26494 OPPONENSPLASTY HYPOTHENAR MUSC TR 2448.24 090 26496 OPPONENSPLASTY OTH METHS 2631.88 090 26497 TR TDN RESTORE INTRNSC FUNCJ RING&SM FNGR 2656.44 090 26498 TR TDN RESTORE INTRNSC FUNCJ ALL 4 FNGRS 3529.82 090 26499 CORRECTION CLAW FINGER OTHER METHODS 2542.19 090 26500 RCNSTJ TENDON PULLEY EACH W/LOCAL TISSUES SPX 1924.00 090 26502 RCNSTJ TDN PULLEY EA TDN W/TDN/FSCAL GRF SPX 2191.99 090 26508 RELEASE THENAR MUSCLE 1932.54 090 26510 CROSS INTRINSIC TRANSFER EACH TENDON 1825.77 090 26516 CAPSULODESIS MTCARPHLNGL JOINT SINGLE DIGIT 2148.21 090 26517 CAPSULODESIS MTCARPHLNGL JOINT 2 DIGITS 2534.72 090 26518 CAPSULODESIS MTCARPHLNGL JOINT 3/4 DIGITS 2578.50 090 26520 CAPSULECTOMY/CAPSULOTOMY MTCARPHLNGL JOINT EACH 2001.94 090 26525 CAPSULECTOMY/CAPSULOTOMY IPHAL JOINT EACH 2003.01 090 26530 ARTHROPLASTY METACARPOPHALANGEAL JOINT EACH 1653.87 090 26531 ARTHRP MTCARPHLNGL JT W/PROSTC IMPLT EA JT 1925.06 090 26535 ARTHROPLASTY INTERPHALANGEAL JOINT EACH 1256.68 090 26536 ARTHROPLASTY INTERPHALANGEAL JT W/PROSTHETIC EA 2120.45 090 26540 RPR COLTRL LIGM MTCARPHLNGL/IPHAL JT 2021.16 090 26541 RCNSTJ COLTRL LIGM MTCARPHLNGL 1 W/TDN/FSCAL GRF 2453.57 090 26542 RCNSTJ COLTRL LIGM MTCARPHLNGL 1 W/LOCAL TISS 2091.62 090 26545 RCNSTJ COLTRL LIGM IPHAL JT 1 W/GRF EA JT 2136.47 090 26546 RPR NON-UNION MTCRPL/PHALANX 3025.86 090 26548 RPR&RCNSTJ FINGER VOLAR PLATE INTERPHALANGEAL JT 2347.87 090 26550 POLLICIZATION DIGIT 4867.64 090 26551 TR TOE-TO-HAND W/MVASC ANAST GRT TOE WRP/ARND 9479.04 090 26553 TR TOE-TO-HAND W/MVASC ANAST OTH/THN GRT TOE 1 9260.16 090 26554 TR TOE-TO-HAND W/MVASC ANAST OTH/THN GRT TOE 2 10158.10 090 26555 TR FNGR AXH POS W/O MVASC ANAST 4237.70 090 26556 TRANSFER FREE TOE JOINT W/MVASC ANASTOMOSIS 8869.38 090 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 75
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 26560 REPAIR SYNDACTYLY EACH SPACE W/SKIN FLAPS 1787.33 090 26561 REPAIR SYNDACTYLY EACH SPACE W/SKIN FLAPS&GRAFTS 2915.89 090 26562 REPAIR SYNDACTYLY EACH SPACE COMPLEX 3894.97 090 26565 OSTEOTOMY METACARPAL EACH 2084.15 090 26567 OSTEOTOMY PHALANX FINGER EACH 2086.29 090 26568 OSTEOPLASTY LENGTHENING METACARPAL/PHALANX 2754.67 090 26580 REPAIR CLEFT HAND 4213.14 090 26587 RCNSTJ POLYDACTYLOUS DGT SOFT TISS&B1 3210.57 090 26590 REPAIR MACRODACTYLIA EACH DIGIT 3919.53 090 26591 REPAIR INTRINSIC MUSCLES HAND EACH MUSCLE 1337.83 090 26593 RELEASE INTRINSIC MUSCLES HAND EACH MUSCLE 1830.04 090 26596 EXC CONSTRICTING RING FNGR W/MLT Z-PLASTIES 2300.89 090 26600 CLTX MTCRPL FX 1 W/O MNPJ EA B1 861.63 090 26605 CLTX MTCRPL FX 1 W/MNPJ EA B1 963.07 090 26607 CLTX MTCRPL FX W/MNPJ W/XTRNL FIXJ EA B1 1376.27 090 26608 PRQ SKEL FIXJ MTCRPL FX EA B1 1464.88 090 26615 OPEN TX METACARPAL FRACTURE SINGLE EA BONE 1746.76 090 26641 CLTX CARP/MTCRPL DISLC THMB W/MNPJ 1086.92 090 26645 CLTX CARP/MTCRPL FX DISLC THMB W/MNPJ 1273.77 090 26650 PRQ SKEL FIXATION CARP/MTCRPL FX DISLOCATE THUMB 1467.02 090 26665 OPEN TX CARPOMETACARPAL FRACTURE DISLOCATE THUMB 1919.72 090 26670 CLTX CARP/MTCRPL DISLC THMB MNPJ EA W/O ANES 992.96 090 26675 CLTX CARP/MTCRPL DISLC THMB MNPJ EA JT REQ ANES 1355.98 090 26676 PRQ SKEL FIXJ CARP/MTCRPL DISLC THMB MNPJ EA JT 1534.28 090 26685 OPEN TX CARPOMETACARPAL DISLOCATE NOT THUMB 1764.91 090 26686 OPTX CARP/MTCRPL DISLC THMB CPLX MLT/DLYD RDCTJ 1924.00 090 26700 CLTX MTCARPHLNGL DISLC 1 W/MNPJ W/O ANES 949.19 090 26705 CLTX MTCARPHLNGL DISLC 1 W/MNPJ REQ ANES 1249.21 090 26706 PRQ SKEL FIXJ MTCARPHLNGL DISLC 1 W/MNPJ 1343.17 090 26715 OPEN TREATMENT METACARPOPHALANGEAL DISLOCATION 1 1739.28 090 26720 CLTX PHLNGL FX PROX/MIDDLE PX/F/T W/O MNPJ EA 584.03 090 26725 CLTX PHLNGL FX PROX/MIDDLE PX/F/T W/MNPJ EA 1020.72 090 26727 PRQ SKEL FIXJ PHLNGL SHFT FX PROX/MIDDLE PX/F/T 1442.46 090 26735 OPEN TX PHALANGEAL SHAFT FRACTURE PROX/MIDDLE EA 1814.02 090 26740 CLTX ARTICULAR FX INVG MTCARPHLNGL/IPHAL JT W/O 679.06 090 26742 CLTX ARTICULAR FX INVG MTCARPHLNGL/IPHAL JT W/ 1110.41 090 26746 OPEN TX ARTICULAR FRACTURE MCP/IP JOINT EA 2251.78 090 26750 CLTX DSTL PHLNGL FX FNGR/THMB W/O MNPJ EA 543.46 090 26755 CLTX DSTL PHLNGL FX FNGR/THMB W/MNPJ EA 939.58 090 26756 PRQ SKEL FIXJ DSTL PHLNGL FX FNGR/THMB EA 1276.97 090 26765 OPEN TX DISTAL PHALANGEAL FRACTURE EACH 1506.52 090 26770 CLTX IPHAL JT DISLC 1 W/MNPJ W/O ANES 808.25 090 26775 CLTX IPHAL JT DISLC 1 W/MNPJ REQ ANES 1147.78 090 26776 PRQ SKEL FIXJ IPHAL JT DISLC 1 W/MNPJ 1354.91 090 26785 OPEN TX INTERPHALANGEAL JOINT DISLOCATION 1 1643.19 090 26820 FUSION OPPOSITION THUMB W/AUTOGENOUS GRAFT 2415.14 090 76 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule 26841 ARTHRD CARP/MTCRPL JT THMB +-INT FIXJ 2237.90 090 26842 ARTHRD CARP/MTCRPL JT THMB +-INT FIXJ W/AGRFT 2426.88 090 26843 ARTHRD CARP/MTCRPL JT DGT OTHER THAN THUMB EACH 2259.25 090 26844 ARTHRD CARP/MTCRPL JT DGT OTH/THN THMB W/AGRFT 2514.43 090 26850 ARTHRD MTCARPHLNGL JT +-INT FIXJ 2125.79 090 26852 ARTHRD MTCARPHLNGL JT +-INT FIXJ W/AGRFT 2439.69 090 26860 ARTHRD IPHAL JT +-INT FIXJ 1720.06 090 + 26861 ARTHRD IPHAL JT +-INT FIXJ EA IPHAL JT 328.85 ZZZ 26862 ARTHRD IPHAL JT +-INT FIXJ W/AGRFT 2224.02 090 + 26863 ARTHRD IPHAL JT +-INT FIXJ W/AGRFT EA JT 735.65 ZZZ 26910 AMP MTCRPL W/FNGR/THMB 1 +-INTEROSS TR 2200.53 090 26951 AMP F/TH 1/2 JT/PHALANX 1 W/NEURECT W/DIR CLSR 1963.50 090 26952 AMP F/TH 1/2 JT/PHALANX 1 W/NEURECT LOCAL FLAP 1989.13 090 26989 UNLIS PX HANDS/FNGRS BR YYY 26990 I&D PELVIS/HIP JT AREA DP ABSC/HMTMA 1924.00 090 26991 I&D PELVIS/HIP JT AREA INFCT BURSA 2163.16 090 26992 INCISION BONE CORTEX PELVIS&/HIP JOINT 2992.76 090 27000 TENOTOMY ADDUCTOR HIP PERCUTANEOUS SPX 1361.32 090 27001 TENOTOMY ADDUCTOR HIP OPEN 1673.09 090 27003 TX ADDUXOR SUBQ OPN W/OBTURATOR NEURECTOMY 1832.17 090 27005 TENOTOMY HIP FLEXOR OPEN SPX 2260.32 090 27006 TENOTOMY ABDUCTORS&/EXTENSOR HIP OPEN SPX 2290.22 090 27025 FASCIOTOMY HIP/THIGH ANY TYPE 2827.27 090 27027 DECOMPRESSION FASCIOTOMY PELVIC COMPARTMENT UNI 2594.51 090 27030 ARTHROTOMY HIP W/DRAINAGE 2926.57 090 27033 ARTHROTOMY HIP EXPLORATION/REMOVAL FOREIGN BODY 3046.15 090 27035 DNRVTJ HIP JT INTRAPEL/XTRPEL INTRA-ARTCLR BRNCH 3574.66 090 27036 CAPSLCTOMY/CAPSUL HIP W/RLS HIP FLXR MUSC 3137.97 090 27040 BIOPSY SOFT TISSUE PELVIS&HIP AREA SUPERFICIAL 1045.28 010 27041 BIOPSY SOFT TISSUE PELVIS&HIP DEEP/SUBFSCAL/IM 2110.84 090 # 27043 EXCISION TUMOR SOFT TISSUE PELVIS&HIP SUBQ 3+CM 1492.64 090 # 27045 EXC TUMOR SOFT TISSUE PELVIS & HIP SUBFASC 5+CM 2368.16 090 27047 EXC TUMOR SOFT TISSUE PELVIS & HIP SUBQ <3CM 1507.59 090 27048 EXC TUMOR SOFT TISSUE PELVIS & HIP SUBFASC <5CM 1849.26 090 27049 RAD RESECT TUMOR SOFT TISSUE PELVIS & HIP <5CM 4110.65 090 27050 ARTHROTOMY W/BIOPSY SACROILIAC JOINT 1168.06 090 27052 ARTHROTOMY W/BIOPSY HIP JOINT 1761.71 090 27054 ARTHROTOMY W/SYNOVECTOMY HIP JOINT 2120.45 090 27057 DCMPRN FASCIOTOMY PELVIC CMPRT DBRDMT MUSCLE UNI 2919.09 090 # 27059 RAD RESECTION TUMOR SOFT TISS PELVIS&HIP 5+CM 5797.61 090 27060 EXCISION ISCHIAL BURSA 1393.35 090 27062 EXCISION TROCHANTERIC BURSA/CALCIFICATION 1404.03 090 s 27065 EXCISION BONE CYST/B9 TUMOR SUPERFICIAL 1560.98 090 s 27066 EXCISION BONE CYST/B9 TUMOR DEEP 2521.91 090 s 27067 EXC B1 CST/B9 TUM W/AGRFT REQ SEP INC 3228.72 090 s 27070 PARTIAL EXCISION SUPERFICIAL PELVIS 2645.76 090 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 77
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 s 27071 PARTIAL EXCISION DEEP PELVIS 2833.68 090 27075 RAD RESCT TUMOR WING OF ILIUM 1 PUBIC/ISCHIAL 6583.44 090 27076 RAD RESCT TUMOR ILIUM ACETABULUM BOTH PUBIC 7535.83 090 27077 RADICAL RESCTION TUMOR INNOMINATE BONE TOTAL 8833.08 090 27078 RAD RESCT TUMOR ISCHIAL TUBEROSITY&GRT TRCHNTR 6018.62 090 27080 COCCYGECTOMY PRIMARY 1566.32 090 27086 RMVL FOREIGN BODY PELVIS/HIP SUBCUTANEOUS TISS 754.86 010 27087 REMOVAL FOREIGN BODY PELVIS/HIP DEEP 1957.09 090 27090 REMOVAL HIP PROSTHESIS SPX 2587.04 090 27091 RMVL HIP PROSTH COMP W/TOT HIP PROSTH MMA 5013.92 090 27093 INJECTION HIP ARTHROGRAPHY W/O ANESTHESIA 594.71 000 27095 INJECTION HIP ARTHROGRAPHY W/ANESTHESIA 728.17 000 27096 INJECTION SI JOINT ARTHROGRAPHY&/ANES/STEROID 579.76 000 27097 RELEASE/RECESSION HAMSTRING PROXIMAL 2092.69 090 27098 TRANSFER ADDUCTOR ISCHIUM 2068.13 090 27100 TR XTRNL OBLQ MUSC TRCHNTR W/FSCAL/TDN XTN GRF 2562.48 090 27105 TR PARASPI MUSC HIP FASC/TDN XTN GRF 2693.81 090 27110 TRANSFER ILIOPSOAS GREATER TROCHANTER FEMUR 3004.51 090 27111 TRANSFER ILIOPSOAS FEMORAL NECK 2733.31 090 27120 ACETABULOPLASTY 4052.99 090 27122 ACETABULOPLASTY RESECTION FEMORAL HEAD 3449.74 090 27125 HEMIARTHROPLASTY HIP PARTIAL 3540.49 090 27130 ARTHRP ACETBLR/PROX FEM PROSTC AGRFT/ALGRFT 4525.98 090 27132 CONV PREVIOUS HIP TOT HIP ARTHRP +-AGRFT/ALGRFT 5284.05 090 27134 REVJ TOT HIP ARTHRP BTH +-AGRFT/ALGRFT 6077.35 090 27137 REVJ TOT HIP ARTHRP ACTBLR ONLY +-AGRFT/ALGRFT 4651.97 090 27138 REVJ TOT HIP ARTHRP FEM ONLY +-ALGRFT 4840.95 090 27140 OSTEOTOMY&TRANSFER GREATER TROCHANTER SPX 2796.31 090 27146 OSTEOTOMY ILIAC ACETABULAR/INNOMINATE BONE 3996.40 090 27147 OSTEOTOMY ILIAC ACETABULAR/INNOMINATE HIP RDCTJ 4608.19 090 27151 OSTEOTOMY ILIAC ACETABULAR/INNOMINATE FEM OSTEOT 4891.13 090 27156 OSTEOT ILIAC ACTBLR/INNOMINATE B1 OSTEOT RDCTJ 5378.00 090 27158 OSTEOTOMY PELVIS BILATERAL 4364.76 090 27161 OSTEOTOMY FEMORAL NECK SPX 3808.49 090 27165 OSTEOT INTERTRCHNTRIC/SUBTRCHNTRIC W/INT/XTRNL 4299.63 090 27170 B1 GRF FEM H/N INTERTRCHNTRIC/SUBTRCHNTRIC AREA 3695.31 090 27175 TX SLP FEM EPIPHYSIS TRCJ W/O RDCTJ 2073.47 090 27176 TX SLP FEM EPIPHYSIS 1/MLT PINNING SITU 2853.96 090 27177 OPTX SLP FEM EPIPHYSIS 1/MLT PINNING/B1 GRF 3478.57 090 27178 OPTX SLP FEM EPIPHYSIS CLSD MNPJ 1/MLT PINNING 2844.35 090 27179 OPTX SLP FEM EPIPHYSIS OSTPL FEM NCK HEYMAN PX 3042.95 090 27181 OPTX SLP FEM EPIPHYSIS OSTEOT&INT FIXJ 3493.51 090 27185 EPIPHYSL ARRST EPIPHYSIOD/STAPLING TRCHNTR FEMUR 1871.68 090 27187 PROPH TX N/P/PLTWR +-MMA FEM NCK&PROX FEMUR 3100.60 090 27193 CLTX PEL RING FX DISLC DIAST/SUBLXTJ W/O MNPJ 1448.87 090 27194 CLTX PEL RING FX DISLC DIAST/SUBLXTJ W/MNPJ ANES 2156.75 090 78 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule 27200 CLOSED TREATMENT COCCYGEAL FRACTURE 538.12 090 27202 OPEN TREATMENT COCCYGEAL FRACTURE 1870.61 090 27215 OPTX ILIAC TUBRST AVLS/WING FX FIXJ IF PRFRMD 1980.58 090 27216 PERQ SKELETAL FIXATION PST PELVIC BONE FX&/DISLC 2927.63 090 27217 OPTX ANT PELVIC BONE FX&/DISLC INT FIXJ IF PFRMD 2763.21 090 27218 OPTX POST PEL BONE FX&/DISLC INT FIXJ IF PFRMD 3783.93 090 27220 CLTX ACETABULUM HIP/SOCKT FX W/O MNPJ 1630.38 090 27222 CLTX ACETABULUM HIP/SOCKT FX MNPJ +-SKEL TRACJ 3048.28 090 27226 OPTX PST/ANT ACTBLR WALL FX W/INT FIXJ 3281.04 090 27227 OPTX ACTBLR FX INVG ANT/PST 1 COLUMN/FX W/INT 5237.07 090 27228 OPTX ACTBLR FX INVG ANT&PST 2 COLUMNS FX W/INT 5979.12 090 27230 CLTX FEM FX PROX END NCK W/O MNPJ 1453.14 090 27232 CLTX FEM FX PROX END NCK W/MNPJ +-SKEL TRACJ 2394.85 090 27235 PRQ SKEL FIXJ FEM FX PROX END NCK 2844.35 090 27236 OPTX FEM FX PROX END NCK INT FIXJ/PROSTC RPLCMT 3740.15 090 27238 CLTX INTER/PERI/SUBTROCHANTERIC FEM FX W/O MNPJ 1407.23 090 27240 CLTX INTR/PERI/SBTRCHNTC FEM FX W/MNPJ 2979.95 090 27244 TX INTER/PR/SUBTRCHNTRIC FEM FX SCREW IMPLT 3847.99 090 27245 TX INTER/PR/SUBTRCHNTRIC FEM FX IMED IMPLTSCREW 3889.63 090 27246 CLTX GRTER TRCHNTRIC FX W/O MNPJ 1181.94 090 27248 OPEN TREATMENT GREATER TROCHANTERIC FRACTURE 2335.06 090 27250 CLTX HIP DISLC TRAUMTC W/O ANES 642.76 000 27252 CLTX HIP DISLC TRAUMTC REQ ANES 2354.28 090 27253 OPTX HIP DISLC TRAUMTC W/O INT FIXJ 2945.78 090 27254 OPTX HIP DISLC TRAUMTC W/ACTBLR WALL&FEM HEAD FX 3970.78 090 27256 TX SPON HIP DISLC ABDCT SPLNT/TRCJ W/O ANES 902.21 010 27257 TX SPON HIP DISLC ABDCT SPLNT/TRCJ W/MNPJ ANES 1041.01 010 27258 OPTX SPON HIP DISLC RPLCMT FEM HEAD ACTBLM 3468.96 090 27259 OPTX SPON HIP DISLC RPLCMT FEM HEAD ACTBLM SHRT 4864.44 090 27265 CLTX POST HIP ARTHRP DISLC W/O ANES 1207.57 090 27266 CLTX POST HIP ARTHRP DISLC REQ ANES 1800.14 090 27267 CLOSED TX FEMORAL FRACTURE PROX HEAD W/O MNPJ 1316.47 090 27268 CLOSED TX FEMORAL FRACTURE PROX HEAD W MNPJ 1630.38 090 27269 OPEN TX FEMORAL FRACTURE PROXIMAL END HEAD 3836.25 090 27275 MANIPULATION HIP JOINT GENERAL ANESTHESIA 549.87 010 27280 ARTHRODESIS SACROILIAC JOINT W/OBTAINING GRAFT 3213.78 090 27282 ARTHRODESIS SYMPHYSIS PUBIS W/OBTAINING GRAFT 2590.24 090 27284 ARTHRODESIS HIP JOINT W/OBTAINING GRAFT 4976.55 090 27286 ARTHRD HIP JT W/OBTG GRF W/SUBTRCHNTRIC OSTEOT 5208.24 090 27290 INTERPELVIABDOMINAL AMPUTATION 5025.66 090 27295 DISARTICULATION HIP 3983.59 090 27299 UNLISTED PROCEDURE PELVIS/HIP JOINT BR YYY 27301 I&D DP ABSC BURSA/HMTMA THI/KNE REGION 2047.85 090 27303 INC DP W/OPNG B1 CORTEX FEMUR/KNE 1982.72 090 27305 FASCIOTOMY ILIOTIBIAL OPEN 1465.95 090 27306 TENOTOMY PRQ ADDUCTOR/HAMSTRING 1 TENDON SPX 1160.59 090 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 79
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 27307 TENOTOMY PRQ ADDUCTOR/HAMSTRING MULTIPLE TENDON 1462.75 090 27310 ARTHRT KNE W/EXPL DRG/RMVL FB 2266.73 090 27323 BIOPSY SOFT TISSUE THIGH/KNEE AREA SUPERFICIAL 832.81 010 27324 BIOPSY SOFT TISSUE THIGH/KNEE AREA DEEP 1205.43 090 27325 NEURECTOMY HAMSTRING MUSCLE 1683.76 090 27326 NEURECTOMY POPLITEAL 1549.23 090 27327 EXCISION TUMOR SOFT TISSUE THIGH/KNEE SUBQ <3CM 1353.84 090 27328 EXC TUMOR SOFT TISSUE THIGH/KNEE SUBFASC <5CM 1830.04 090 # 27329 RAD RESECT TUMOR SOFT TISSUE THIGH/KNEE <5CM 3252.21 090 27330 ARTHROTOMY KNEE W/SYNOVIAL BIOPSY ONLY 1253.48 090 27331 ARTHRT KNE W/JT EXPL BX/RMVL LOOSE/FB 1465.95 090 27332 ARTHRT W/EXC SEMILUNAR CRTLG KNE MEDIAL/LAT 1982.72 090 27333 ARTHRT W/EXC SEMILUNAR CRTLG KNE MEDIAL&LAT 1806.55 090 27334 ARTHROTOMY W/SYNOVECTOMY KNEE ANTERIOR/POSTERIOR 2116.18 090 27335 ARTHRT W/SYNVCT KNE ANT&PST W/POP AREA 2375.63 090 # 27337 EXCISON TUMOR SOFT TISSUE THIGH/KNEE SUBQ 3+CM 1334.63 090 # 27339 EXC TUMOR SOFT TISSUE THIGH/KNEE SUBFASC 5+CM 2400.19 090 27340 EXCISION PREPATELLAR BURSA 1134.97 090 27345 EXCISION SYNOVIAL CYST POPLITEAL SPACE 1485.17 090 27347 EXCISION LESION MENISCUS/CAPSULE KNEE 1619.70 090 27350 PATELLECTOMY/HEMIPATELLECTOMY 2019.02 090 27355 EXCISION/CURETTAGE CYST/TUMOR FEMUR 1868.48 090 27356 EXCISION/CURETTAGE CYST/TUMOR FEMUR W/ALLOGRAFT 2287.01 090 27357 EXCISION/CURETTAGE CYST/TUMOR FEMUR W/AUTOGRAFT 2529.38 090 + 27358 EXCISION/CURETTAGE CYST/TUMOR FEMUR INT FIXATION 892.60 ZZZ 27360 PRTL EXC B1 FEMUR PROX TIBIA&/FIBULA 2643.63 090 27364 RAD RESECTION TUMOR SOFT TISSUE THIGH/KNEE 5+CM 4985.09 090 27365 RADICAL RESECTION TUMOR FEMUR OR KNEE 6116.85 090 27370 INJECTION KNEE ARTHROGRAPHY 525.31 000 27372 REMOVAL FOREIGN BODY DEEP THIGH/KNEE 1847.12 090 27380 SUTURE INFRAPATELLAR TENDON PRIMARY 1833.24 090 27381 SUTR INFRAPATELLAR TDN 2 RCNSTJ W/FSCAL/TDN GRF 2482.40 090 27385 SUTURE QUADRICEPS/HAMSTRING RUPTURE PRIMARY 1959.23 090 27386 SUTR QUADRICEPS/HAMSTRING MUSC RPT 2 RCNSTJ 2581.70 090 27390 TENOTOMY OPEN HAMSTRING KNEE HIP SINGLE TENDON 1373.06 090 27391 TENOTOMY OPN HAMSTRING KNEE HIP MULTIPLE 1 LEG 1778.79 090 27392 TENOTOMY OPEN HAMSTRING KNEE HIP MULTIPLE BI 2195.19 090 27393 LENGTHENING HAMSTRING TENDON SINGLE 1565.25 090 27394 LENGTHENING HAMSTRING TENDON MULTIPLE 1 LEG 2014.75 090 27395 LENGTHENING HAMSTRING TENDON MULTIPLE BILATERAL 2735.45 090 27396 TRANSPLANT/TRANSFER THIGH XTNSR TO FLXR 1 TENDON 1907.98 090 27397 TRANSPLANT/TRANSFER THIGH XTNSR TO FLXR MULT TDN 2839.01 090 27400 TRANSFER TENDON/MUSCLE HAMSTRINGS FEMUR 2148.21 090 27403 ARTHROTOMY W/MENISCUS REPAIR KNEE 1986.99 090 27405 RPR PRIMARY TORN LIGM&/CAPSULE KNEE COLLATERAL 2101.23 090 27407 REPAIR PRIMARY TORN LIGM&/CAPSULE KNEE CRUCIATE 2430.09 090 80 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule 27409 RPR 1 TORN LIGM&/CAPSL KNE COLTRL&CRUCIATE LIGMS 3009.85 090 27412 AUTOLOGOUS CHONDROCYTE IMPLANTATION KNEE 5169.80 090 27415 OSTEOCHONDRAL ALLOGRAFT KNEE OPEN 4283.61 090 27416 OSTEOCHONDRAL AUTOGRAFT KNEE OPEN MOSAICPLASTY 3037.61 090 27418 ANTERIOR TIBIAL TUBERCLEPLASTY 2591.31 090 27420 RCNSTJ DISLOCATING PATELLA 2320.11 090 27422 RCNSTJ DISLC PATELLA W/XTNSR RELIGNMT&/MUSC RLS 2310.50 090 27424 RCNSTJ DISLC PATELLA W/PATELLECTOMY 2313.71 090 27425 LATERAL RETINACULAR RELEASE OPEN 1374.13 090 27427 LIGAMENTOUS RECONSTRUCTION KNEE EXTRA-ARTICULAR 2229.36 090 27428 LIGAMENTOUS RECONSTRUCTION KNEE INTRA-ARTICULAR 3463.62 090 27429 LIGMOUS RCNSTJ AGMNTJ KNE INTRA-ARTICULAR XTR 3874.68 090 27430 QUADRICEPSPLASTY 2299.83 090 27435 CAPSULOTOMY POSTERIOR CAPSULAR RELEASE KNEE 2497.35 090 27437 ARTHROPLASTY PATELLA W/O PROSTHESIS 2052.12 090 27438 ARTHROPLASTY PATELLA W/PROSTHESIS 2618.00 090 27440 ARTHROPLASTY KNEE TIBIAL PLATEAU 2438.63 090 27441 ARTHRP KNEE TIBIAL PLATEAU DBRDMT&PRTL SYNVCT 2517.64 090 27442 ARTHROPLASTY FEM CONDYLES/TIBIAL PLATEAU KNEE 2707.69 090 27443 ARTHRP FEM CONDYLES/TIBL PLATU KNE DBRDMT&PRTL 2542.19 090 27445 ARTHROPLASTY KNEE HINGE PROSTHESIS 3934.47 090 27446 ARTHRP KNEE CONDYLE&PLATEAU MEDIAL/LAT CMPRT 3474.30 090 27447 ARTHRP KNE CONDYLE&PLATU MEDIAL&LAT CMPRTS 4837.75 090 27448 OSTEOTOMY FEMUR SHAFT/SUPRACONDYLAR W/O FIXATION 2552.87 090 27450 OSTEOTOMY FEMUR SHAFT/SUPRACONDYLAR W/FIXATION 3174.27 090 27454 OSTEOT MLT W/RELIGNMT IMED ROD FEM SHFT 4045.52 090 27455 OSTEOT PROX TIBIA FIB EXC/OSTEOT BEFORE EPIPHYSL 2939.38 090 27457 OSTEOT PROX TIBIA FIB EXC/OSTEOT AFTER EPIPHYSL 3017.32 090 27465 OSTEOPLASTY FEMUR SHORTENING EXCLUDING 64876 3894.97 090 27466 OSTEOPLASTY FEMUR LENGTHENING 3691.04 090 27468 OSTPL FEMUR CMBN LNGTH&SHRT W/FEM SGM TR 4194.99 090 27470 RPR NON/MAL FEMUR DSTL H/N W/O GRF 3692.11 090 27472 RPR NON/MAL FEMUR DSTL H/N W/ILIAC/AUTOG B1 GRF 3972.91 090 27475 ARREST EPIPHYSEAL DISTAL FEMUR 1909.05 090 27477 ARREST EPIPHYSEAL TIBIA&FIBULA PROXIMAL 2278.47 090 27479 ARRST EPIPHYSL CMBN DSTL FEMUR PROX TIBFIB 2699.15 090 27485 ARRST HEMIEPIPHYSL DSTL FEMUR/PROX TIBIA/FIBULA 2085.22 090 27486 REVJ TOT KNE ARTHRP +-ALGRFT 1 COMP 4423.48 090 27487 REVJ TOT KNE ARTHRP FEM&ENTIRE TIBL COMP 5553.11 090 27488 RMVL PROSTH TOT KNE PROSTH MMA +-INSJ SPACER 3761.51 090 27495 PROPH TX N/P/PLTWR +-MMA FEMUR 3537.29 090 27496 DCMPRN FASCT THI&/KNE 1 CMPRT 1626.11 090 27497 DCMPRN FASCT THI&/KNE 1 DBRDMT NV MUSC&/NRV 1753.16 090 27498 DCMPRN FASCT THI&/KNE MLT CMPRTS 1942.15 090 27499 DCMPRN FASCT THI&/KNE MLT DBRDMT NV MUSC&/NRV 2111.91 090 27500 CLOSED TX FEMORAL SHAFT FX W/O MANIPULATION 1585.53 090 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 81
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 27501 CLTX SPRCNDYLR/TRNSCNDYLR FEM FX W/O MNPJ 1554.57 090 27502 CLTX FEM SHFT FX W/MNPJ +-SKN/SKEL TRACJ 2436.49 090 27503 CLTX SPRCNDYLR/TRNSCNDYLR FEM FX W/MNPJ 2500.55 090 27506 OPTX FEM SHFT FX W/INSJ IMED IMPLT +-SCREW 4188.59 090 27507 OPTX FEM SHFT FX W/PLATE/SCREWS +-CERCLAGE 3062.16 090 27508 CLTX FEM FX DSTL END MEDIAL/LAT CONDYLE W/O MNPJ 1603.69 090 27509 PRQ SKEL FIXJ FEM FX DSTL END 1998.73 090 27510 CLTX FEM FX DSTL END MEDIAL/LAT CONDYLE W/MNPJ 2155.69 090 27511 OPEN TX FEMORAL SUPRACONDYLAR FRACTURE W/O XTN 3166.80 090 27513 OPEN TX FEMORAL SUPRACONDYLAR FRACTURE W XTN 3957.96 090 27514 OPEN TX FEMORAL FRACTURE DISTAL MED/LAT CONDYLE 3107.01 090 27516 CLTX DSTL FEM EPIPHYSL SEP W/O MNPJ 1533.22 090 27517 CLTX DSTL FEM EPIPHYSL SEP W/MNPJ +-SKN/SKEL 2121.52 090 27519 OPEN TX DISTAL FEMORAL EPIPHYSEAL SEPARATION 2843.29 090 27520 CLOSED TX PATELLAR FRACTURE W/O MANIPULATION 967.34 090 27524 OPTX PATLLR FX W/INT FIXJ/PATLLC&SOFT TISS RPR 2343.60 090 27530 CLTX TIBL FX PROX W/O MNPJ 1203.30 090 27532 CLTX TIBL FX PROX +-MNPJ W/SKEL TRACJ 1894.10 090 27535 OPEN TX TIBIAL FRACTURE PROXIMAL UNICONDYLAR 2841.15 090 27536 OPTX TIBL FX PROX BICONDYLAR +-INT FIXJ 3728.41 090 27538 CLTX INTERCONDYLAR SPI&/TUBRST FX KNE +-MNPJ 1434.99 090 27540 OPEN TX INTERCONDYLAR SPINE/TUBRST FRACTURE KNEE 2549.67 090 27550 CLOSED TX KNEE DISLOCATION W/O ANESTHESIA 1514.00 090 27552 CLOSED TX KNEE DISLOCATION W/ANESTHESIA 1934.67 090 27556 OPEN TX KNEE DISLOCATION W/O LIGAMENTOUS REPAIR 2796.31 090 27557 OPEN TX KNEE DISLOCATION W LIGAMENTOUS REPAIR 3347.24 090 27558 OPEN TX KNEE DISLOCATION W REPAIR/RECONSTRUCTION 3797.81 090 27560 CLOSED TX PATELLAR DISLOCATION W/O ANESTHESIA 1142.44 090 27562 CLOSED TX PATELLAR DISLOCATION W/ANESTHESIA 1461.68 090 27566 OPTX PATELLAR DISLC +-PRTL/TOT PATELLECTOMY 2782.43 090 27570 MANIPULATION KNEE JOINT UNDER GENERAL ANESTHESIA 460.18 010 27580 ARTHRODESIS KNEE ANY TECHNIQUE 4515.30 090 27590 AMPUTATION THIGH THROUGH FEMUR ANY LEVEL 2615.87 090 27591 AMP THI THRU FEMUR LVL IMMT FITG TQ W/1ST CST 2857.17 090 27592 AMPUTATION THIGH THRU FEMUR OPEN CIRCULAR 2220.82 090 27594 AMP THIGH THRU FEMUR SEC CLOSURE/SCAR REVISION 1609.02 090 27596 AMPUTATION THIGH THROUGH FEMUR RE-AMPUTATION 2320.11 090 27598 DISARTICULATION KNEE 2352.14 090 27599 UNLISTED PROCEDURE FEMUR/KNEE BR YYY 27600 DCMPRN FASCT LEG ANT&/LAT CMPRTS ONLY 1320.74 090 27601 DCMPRN FASCT LEG PST CMPRT ONLY 1396.55 090 27602 DCMPRN FASCT LEG ANT&/LAT&PST CMPRT 1621.84 090 27603 INCISION&DRAINAGE LEG/ANKLE ABSCESS/HEMATOMA 1645.33 090 27604 INCISION&DRAINAGE LEG/ANKLE INFECTED BURSA 1439.26 090 27605 TENOTOMY PRQ ACHILLES TENDON SPX LOCAL ANES 1071.97 010 27606 TENOTOMY PRQ ACHILLES TENDON SPX GENERAL ANES 905.41 010 82 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule 27607 INCISION LEG/ANKLE 1913.32 090 27610 ARTHROTOMY ANKLE W/EXPL DRAINAGE/REMOVAL FB 2037.17 090 27612 ARTHRT PST CAPSULAR RLS ANKLE +-ACHLL TDN LNGTH 1748.89 090 27613 BIOPSY SOFT TISSUE LEG/ANKLE AREA SUPERFICIAL 777.29 010 27614 BIOPSY SOFT TISSUE LEG/ANKLE AREA DEEP 1756.37 090 27615 RAD RESECTION TUMOR SOFT TISSUE LEG/ANKLE <5CM 3186.02 090 27616 RAD RESCJ TUM SOFT TISSUE LEG/ANKLE 5+CM 4072.21 090 27618 EXC TUMOR SOFT TISSUE LEG/ANKLE SUBQ <3CM 1359.18 090 27619 EXC TUMOR SOFT TISSUE LEG/ANKLE SUBFASCIAL <5CM 1560.98 090 27620 ARTHRT ANKLE W/JT EXPL +-BX +-RMVL LOOSE/FB 1428.58 090 27625 ARTHROTOMY W/SYNOVECTOMY ANKLE 1805.48 090 27626 ARTHROTOMY W/SYNOVECTOMY ANKLE TENOSYNOVECTOMY 1968.84 090 27630 EXCISION LESION TENDON SHEATH/CAPSULE LEG&/ANKLE 1682.70 090 # 27632 EXCISION TUMOR SOFT TISSUE LEG/ANKLE SUBQ 3+ CM 1320.74 090 # 27634 EXC TUMOR SOFT TISSUE LEG/ANKLE SUBFASC 5+CM 2141.81 090 27635 EXCISION/CURETTAGE BONE CYST/TUMOR TIBIA/FIBULA 1848.19 090 27637 EXC/CURETTAGE CYST/TUMOR TIBIA/FIBULA W/AGRAFT 2363.89 090 27638 EXC/CURETTAGE CYST/TUMOR TIBIA/FIBULA W/ALGRAFT 2424.75 090 27640 PARTIAL EXCISION BONE TIBIA 2660.71 090 27641 PARTIAL EXCISION BONE FIBULA 2119.38 090 27645 RADICAL RESECTION OF TUMOR TIBIA 5259.49 090 27646 RADICAL RESECTION TUMOR BONE FIBULA 4538.79 090 27647 RADICAL RESECTION OF TUMOR TALUS OR CALCANEUS 3393.15 090 27648 INJECTION ANKLE ARTHROGRAPHY 503.95 000 27650 REPAIR PRIMARY OPEN/PRQ RUPTURED ACHILLES TENDON 2084.15 090 27652 RPR PRIMARY OPEN/PRQ RUPTURED ACHILLES W/GRAFT 2219.75 090 27654 REPAIR SECONDARY ACHILLES TENDON +-GRAFT 2222.95 090 27656 REPAIR FASCIAL DEFECT LEG 1804.41 090 27658 REPAIR FLEXOR TENDON LEG PRIMARY W/O GRAFT EACH 1177.67 090 27659 RPR FLEXOR TENDON LEG SECONDARY W/O GRAFT EACH 1528.95 090 27664 RPR EXTENSOR TENDON LEG PRIMARY W/O GRAFT EACH 1134.97 090 27665 RPR EXTENSOR TENDON LEG SECONDARY +/-GRAFT EACH 1284.44 090 27675 RPR DISLOCATING PERONEAL TENDON W/O FIB OSTEOT 1542.83 090 27676 REPAIR DISLOCATING PERONEAL TENDON W/FIB OSTEOT 1946.42 090 27680 TENOLYSIS FLXR/XTNSR TENDON LEG&/ANKLE 1 EACH 1348.51 090 27681 TNOLS FLXR/XTNSR TDN LEG&/ANKLE MLT TDN 1660.27 090 27685 LNGTH/SHRT TDN LEG/ANKLE 1 TDN SPX 1986.99 090 27686 LNGTH/SHRT TDN LEG/ANKLE MLT TDN SAME INC EA 1737.15 090 27687 GASTROCNEMIUS RECESSION 1428.58 090 27690 TR/TRNSPL 1 TDN W/MUSC REDIRION/REROUTING SUPFC 1982.72 090 27691 TR/TRNSPL 1 TDN W/MUSC REDIRION/REROUTING DP 2345.74 090 + 27692 TR/TRNSPL 1 TDN W/MUSC REDIRION/REROUTING EA TDN 343.80 ZZZ 27695 RPR PRIMARY DISRUPTED LIGAMENT ANKLE COLLATERAL 1512.93 090 27696 RPR PRIM DISRUPTED LIGM ANKLE BTH COLTRL LIGMS 1774.52 090 27698 REPAIR SECONDARY DISRUPTED LIGAMENT ANKLE COLTRL 2023.29 090 27700 ARTHROPLASTY ANKLE 1871.68 090 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 83
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 27702 ARTHROPLASTY ANKLE W/IMPLANT 3079.25 090 27703 ARTHROPLASTY ANKLE REVISION TOTAL ANKLE 3567.19 090 27704 REMOVAL ANKLE IMPLANT 1785.19 090 27705 OSTEOTOMY TIBIA 2385.24 090 27707 OSTEOTOMY FIBULA 1247.07 090 27709 OSTEOTOMY TIBIA&FIBULA 3644.06 090 27712 OSTEOT MLT W/RELIGNMT IMED ROD 3449.74 090 27715 OSTEOPLASTY TIBIA&FIBULA LENGTHENING/SHORTENING 3322.68 090 27720 REPAIR NONUNION/MALUNION TIBIA W/O GRAFT 2740.79 090 27722 REPAIR NONUNION/MALUNION TIBIA W/SLIDING GRAFT 2760.00 090 27724 RPR NON/MAL TIBIA W/ILIAC/OTH AGRFT 4003.88 090 27725 RPR NON/MAL TIBIA SYNOSTOSIS W/FIBULA ANY METH 3797.81 090 27726 REPAIR FIBULA NONUNION/MALUNION W INT FIXATION 2989.56 090 27727 REPAIR CONGENITAL PSEUDARTHROSIS TIBIA 3143.31 090 27730 ARREST EPIPHYSEAL OPEN DISTAL TIBIA 1810.82 090 27732 ARREST EPIPHYSEAL OPEN DISTAL FIBULA 1322.88 090 27734 ARREST EPIPHYSEAL OPEN DISTAL TIBIA&FIBULA 1838.58 090 27740 ARRST EPIPHYSL ANY METH TIBFIB 1983.79 090 27742 ARRST EPIPHYSL ANY METH TIBFIB&DSTL FEMUR 2218.68 090 27745 PROPH TX N/P/PLTWR +-MMA TIBIA 2351.08 090 27750 CLTX TIBL SHFT FX W/O MNPJ 1038.87 090 27752 CLTX TIBL SHFT FX W/MNPJ +-SKEL TRACJ 1648.53 090 27756 PRQ SKEL FIXJ TIBL SHFT FX 1776.65 090 27758 OPTX TIBL SHFT FX W/PLATE/SCREWS +-CERCLAGE 2778.16 090 27759 TX TIBL SHFT FX IMED IMPLT +-SCREWS&/CERCLAGE 3130.50 090 27760 CLTX MEDIAL MALLS FX W/O MNPJ 1003.64 090 27762 CLTX MEDIAL MALLS FX W/MNPJ +-SKN/SKEL TRACJ 1471.29 090 27766 OPEN TREATMENT MEDIAL MALLEOLUS FRACTURE 1895.17 090 27767 CLOSED TREATMENT PST MALLEOLUS FRACTURE W/O MNPJ 831.74 090 27768 CLOSED TREATMENT PST MALLEOLUS FRACTURE W MNPJ 1309.00 090 27769 OPEN TREATMENT POSTERIOR MALLEOLUS FRACTURE 2234.70 090 27780 CLTX PROX FIBULA/SHFT FX W/O MNPJ 908.61 090 27781 CLTX PROX FIBULA/SHFT FX W/MNPJ 1288.71 090 27784 OPEN TREATMENT PROXIMAL FIBULA/SHAFT FRACTURE 2210.14 090 27786 CLTX DSTL FIBULAR FX LAT MALLS W/O MNPJ 949.19 090 27788 CLTX DSTL FIBULAR FX LAT MALLS W/MNPJ 1287.65 090 27792 OPEN TX DISTAL FIBULAR FRACTURE LAT MALLEOLUS 2211.21 090 27808 CLOSED TX BIMALLEOLAR ANKLE FRACTURE W/O MNPJ 999.37 090 27810 CLOSED TX BIMALLEOLAR ANKLE FRACTURE W MNPJ 1440.33 090 27814 OPEN TREATMENT BIMALLEOLAR ANKLE FRACTURE 2413.00 090 27816 CLTX TRIMAL ANKLE FX W/O MNPJ 949.19 090 27818 CLTX TRIMAL ANKLE FX W/MNPJ 1476.63 090 27822 OPEN TX TRIMALLEOLAR ANKLE FX W/O FIXJ PST LIP 2640.42 090 27823 OPEN TX TRIMALLEOLAR ANKLE FX W FIXJ PST LIP 3003.44 090 27824 CLTX FX W8 BRG ARTCLR PRTN DSTL TIBIA W/O MNPJ 944.91 090 27825 CLTX FX W8 BRG ARTCLR PRTN DSTL TIB W/SKEL TRACJ 1682.70 090 84 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule 27826 OPEN TREATMENT FRACTURE DISTAL TIBIA FIBULA 2596.65 090 27827 OPEN TREATMENT FRACTURE DISTAL TIBIA ONLY 3395.29 090 27828 OPEN TREATMENT FRACTURE DISTAL TIBIA & FIBULA 4065.80 090 27829 OPEN TX DISTAL TIBIOFIBULAR JOINT DISRUPTION 2106.57 090 27830 CLTX PROX TIBFIB JT DISLC W/O ANES 1126.42 090 27831 CLTX PROX TIBFIB JT DISLC REQ ANES 1202.23 090 27832 OPEN TX PROX TIBFIB JOINT DISLOCATE EXC PROX FIB 2298.76 090 27840 CLOSED TX ANKLE DISLOCATION W/O ANESTHESIA 1097.60 090 27842 CLTX ANKLE DISLC REQ ANES +-PRQ SKEL FIXJ 1521.47 090 27846 OPTX ANKLE DISLC W/O RPR/INT FIXJ 2294.49 090 27848 OPTX ANKLE DISLC W/RPR/INT/XTRNL FIXJ 2580.63 090 27860 MNPJ ANKLE UNDER GENERAL ANES 544.53 010 27870 ARTHRODESIS ANKLE OPEN 3268.23 090 27871 ARTHRODESIS TIBIOFIBULAR JOINT PROXIMAL/DISTAL 2163.16 090 27880 AMPUTATION LEG THROUGH TIBIA&FIBULA 2959.66 090 27881 AMP LEG THRU TIBFIB W/IMMT FITG TQ W/1ST CST 2801.64 090 27882 AMPUTATION LEG THRU TIBIA&FIBULA OPEN CIRCULAR 1982.72 090 27884 AMP LEG THRU TIBIA&FIBULA SEC CLOSURE/SCAR REVJ 1856.73 090 27886 AMP LEG THRU TIBIA&FIBULA RE-AMPUTATION 2116.18 090 27888 AMP ANKLE-MALLI TIBFIB W/PLSTC CLSR&RESCJ NRV 2179.18 090 27889 ANKLE DISARTICULATION 2166.36 090 27892 DCMPRN FASCT LEG ANT&/LAT W/DBRDMT MUSC&/NRV 1730.74 090 27893 DCMPRN FASCT LEG PST W/DBRDMT MUSC&/NRV 1831.11 090 27894 DCMPRN FASCT LEG ANT&/LAT&PST W/DBRDMT MUSC&/NRV 2702.35 090 27899 UNLISTED PROCEDURE LEG/ANKLE BR YYY 28001 INCISION&DRAINAGE BURSA FOOT 826.40 010 28002 I&D BELW FSCA FOOT 1 BURSAL SPACE 1564.18 010 28003 I&D BELW FSCA FOOT MLT AREAS 2083.08 090 28005 INCISION BONE CORTEX FOOT 1867.41 090 28008 FASCIOTOMY FOOT&/TOE 1306.86 090 28010 TENOTOMY PERCUTANEOUS TOE SINGLE TENDON 716.43 090 28011 TENOTOMY PERCUTANEOUS TOE MULTIPLE TENDON 1018.59 090 28020 ARTHRT W/EXPL DRG/RMVL LOOSE/FB NTRTRSL/TARS JT 1598.35 090 28022 ARTHRT W/EXPL DRG/RMVL LOOSE/FB MTTARPHLNGL JT 1446.73 090 28024 ARTHRT W/EXPL DRG/RMVL LOOSE/FB IPHAL JT 1366.66 090 28035 RELEASE TARSAL TUNNEL 1584.47 090 # 28039 EXCISION TUMOR SOFT TISSUE FOOT/TOE SUBQ 1.5+CM 1526.81 090 # 28041 EXC TUMOR SOFT TISSUE FOOT/TOE SUBFASC 1.5+CM 1401.89 090 28043 EXCISION TUMOR SOFT TISSUE FOOT/TOE SUBQ <1.5CM 1157.39 090 28045 EXC TUMOR SOFT TISSUE FOOT/TOE SUBFASC <1.5CM 1540.69 090 28046 RAD RESECTION TUMOR SOFT TISSUE FOOT/TOE <3CM 2343.60 090 28047 RAD RESECTION TUMOR SOFT TISSUE FOOT/TOE 3+CM 2914.82 090 28050 ARTHRT W/BX INTERTARSAL/TARS JT 1331.42 090 28052 ARTHRT W/BX METATARSOPHALANGEAL JT 1294.05 090 28054 ARTHRT W/BX IPHAL JT 1162.73 090 28055 NEURECTOMY INTRINSIC MUSCULATURE OF FOOT 1193.69 090 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 85
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 28060 FASCIECTOMY PLANTAR FASCIA PARTIAL SPX 1553.50 090 28062 FASCIOTOMY PLANTAR FASCIA RADICAL SPX 1790.53 090 28070 SYNVCT INTERTARSAL/TARSOMETATARSAL JT EA SPX 1579.13 090 28072 SYNOVECTOMY METATARSOPHALANGEAL JOINT EACH 1550.30 090 28080 EXCISION INTERDIGITAL MORTON NEUROMA SINGLE EACH 1544.96 090 28086 SYNOVECTOMY TENDON SHEATH FOOT FLEXOR 1645.33 090 28088 SYNOVECTOMY TENDON SHEATH FOOT EXTENSOR 1443.53 090 28090 EXC LESION TENDON SHEATH/CAPSULE W/SYNVCT FOOT 1409.36 090 28092 EXC LESION TENDON SHEATH/CAPSULE W/SYNVCT TOE EA 1281.24 090 28100 EXCISION/CURETTAGE CYST/TUMOR TALUS/CALCANEUS 1805.48 090 28102 EXC/CURTG CST/B9 TUM TALUS/CLCNS W/ILIAC/AGRFT 1741.42 090 28103 EXC/CURETTAGE CYST/TUMOR TALUS/CALCANEUS ALGRFT 1288.71 090 28104 EXC/CURTG CST/B9 TUM TARSAL/METAR 1543.89 090 28106 EXC/CURTG CST/B9 TUM TARSAL/METAR W/ILIAC/AGRFT 1383.74 090 28107 EXC/CURTG CST/B9 TUM TARSAL/METAR W/ALGRFT 1625.04 090 28108 EXC/CURTG CST/B9 TUM PHALANGES FOOT 1309.00 090 28110 OSTECTOMY PRTL 5TH METAR HEAD SPX 1381.60 090 28111 OSTECTOMY COMPLETE 1ST METATARSAL HEAD 1551.37 090 28112 OSTECTOMY COMPLETE OTHER METATARSAL HEAD 2/3/4 1486.24 090 28113 OSTECTOMY COMPLETE 5TH METATARSAL HEAD 1795.87 090 28114 OSTC COMPL ALL METAR HEADS W/PRTL PROX PHALANGC 3256.49 090 28116 OSTECTOMY TARSAL COALITION 2284.88 090 28118 OSTECTOMY CALCANEUS 1781.99 090 28119 OSTECTOMY CALCANEUS SPUR +-PLNTAR FSCAL RLS 1576.99 090 28120 PRTL EXC B1 TALUS/CALCANEUS 2156.75 090 28122 PRTL EXC B1 TARSAL/METAR B1 XCP TALUS/CALCANEUS 2001.94 090 28124 PRTL EXC B1 PHALANX TOE 1439.26 090 28126 RESECTION PARTIAL/COMPLETE PHALANGEAL BASE EACH 1181.94 090 28130 TALECTOMY ASTRAGALECTOMY 2164.23 090 28140 METATARSECTOMY 1879.15 090 28150 PHALANGECTOMY TOE EA TOE 1311.14 090 28153 RESECTION CONDYLE DISTAL END PHALANX EACH TOE 1237.46 090 28160 HEMIPHALANGC/IPHAL JT EXC TOE 1265.22 090 28171 RAD RESCJ TUMOR TARSAL EXCEPT TALUS/CALCANEUS 2638.29 090 28173 RADICAL RESECTION TUMOR METATARSAL 2389.51 090 28175 RADICAL RESECTION TUMOR PHALANX OR TOE 1504.39 090 28190 REMOVAL FOREIGN BODY FOOT SUBCUTANEOUS 761.27 010 28192 REMOVAL FOREIGN BODY FOOT DEEP 1429.65 090 28193 REMOVAL FOREIGN BODY FOOT COMPLICATED 1621.84 090 28200 RPR TDN FLXR FOOT 1/2 W/O FR GRF EA TDN 1433.92 090 28202 RPR TDN FLXR FOOT SEC W/FR GRF EA TDN 1820.43 090 28208 RPR TDN XTNSR FOOT 1/2 EA TDN 1400.82 090 28210 RPR TDN XTNSR FOOT SEC W/FR GRF EA TDN 1742.49 090 28220 TENOLYSIS FLEXOR FOOT SINGLE TENDON 1353.84 090 28222 TENOLYSIS FLEXOR FOOT MULTIPLE TENDONS 1550.30 090 28225 TENOLYSIS EXTENSOR FOOT SINGLE TENDON 1194.76 090 86 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule 28226 TENOLYSIS EXTENSOR FOOT MULTIPLE TENDON 1423.24 090 28230 TX OPN TDN FLXR FOOT 1/MLT TDN SPX 1301.53 090 28232 TX OPN TDN FLXR TOE 1 TDN SPX 1174.47 090 28234 TENOTOMY OPEN EXTENSOR FOOT/TOE EACH TENDON 1232.13 090 28238 RCNSTJ PST TIBL TDN W/EXC ACCESSORY TARSL NAVCLR 2056.39 090 28240 TENOTOMY LENGTHENING/RLS ABDUCTOR HALLUCIS MUSC 1334.63 090 28250 DIVISION PLANTAR FASCIA&MUSCLE SPX 1728.61 090 28260 CAPSULOTOMY MIDFOOT MEDIAL RELEASE ONLY SPX 2104.44 090 28261 CAPSULOTOMY MIDFOOT W/TENDON LENGTHENING 2947.92 090 28262 CAPSUL MIDFOOT W/PST TALOTIBL CAPSUL&TDN LNGTH 4253.72 090 28264 CAPSULOTOMY MIDTARSAL 2782.43 090 28270 CAPSUL MTTARPHLNGL JT +-TENORRHAPHY EA JT SPX 1475.56 090 28272 CAPSUL IPHAL JT EA JT SPX 1185.15 090 28280 SYNDACTYLIZATION TOES 1583.40 090 28285 CORRECTION HAMMERTOE 1418.97 090 28286 CORRECTION COCK-UP 5TH TOE W/PLASTIC CLOSURE 1374.13 090 28288 OSTC PRTL EXOSTC/CONDYLC METAR HEAD 1824.70 090 28289 HALLUX RGDUS CORRJ W/CHEILC 2240.03 090 28290 CORRJ HALLUX VALGUS +-SESMDC SMPL EXOSTECTOMY 1764.91 090 28292 KELLER/MCBRIDE/MAYO PROCEDURE 2392.72 090 28293 CORRJ HALLUX VALGUS +-SESMDC RESCJ JT W/IMPLT 3163.60 090 28294 CORRJ HALLUX VALGUS +-SESMDC W/TDN TRNSPLS 2229.36 090 28296 CORRJ HALLUX VALGUS +-SESMDC W/METAR OSTEOT 2186.65 090 28297 CORRJ HALLUX VALGUS +-SESMDC LAPIDUS-TYP PX 2509.10 090 28298 CORRJ HALLUX VALGUS +-SESMDC PHALANX OSTEOT 2181.31 090 28299 CORRJ HALLUX VALGUS +-SESMDC 2 OSTEOT 2743.99 090 28300 OSTEOTOMY CALCANEUS +-INTERNAL FIXATION 2077.74 090 28302 OSTEOTOMY TALUS 2171.70 090 28304 OSTEOTOMY TARSAL BONES OTH/THN CALCANEUS/TALUS 2440.76 090 28305 OSTEOT TARSAL OTH/THN CALCANEUS/TALUS W/AGRFT 2058.53 090 28306 OSTEOT +-LNGTH SHRT/CORRJ 1ST METAR 1859.93 090 28307 OSTEOT +-LNGTH SHRT/CORRJ 1ST METAR XCP 1ST TOE 2155.69 090 28308 OSTEOT +-LNGTH SHRT/CORRJ METAR XCP 1ST EA 1682.70 090 28309 OSTEOT +-LNGTH SHRT/ANGULAR CORRJ METAR MLT 2799.51 090 28310 OSTEOT SHRT CORRJ PROX PHALANX 1ST TOE 1630.38 090 28312 OSTEOT SHRT CORRJ OTH PHALANGES ANY TOE 1510.80 090 28313 RCNSTJ ANGULAR DFRM TOE SOFT TISS PX ONLY 1595.14 090 28315 SESAMOIDECTOMY FIRST TOE SPX 1436.06 090 28320 REPAIR NONUNION/MALUNION TARSAL BONES 1932.54 090 28322 RPR NON/MAL METAR +-B1 GRF 2386.31 090 28340 RCNSTJ TOE MACRODACTYLY SOFT TISSUE RESECTION 1800.14 090 28341 RCNSTJ TOE MACRODACTYLY REQUIRING BONE RESECTION 2078.81 090 28344 RECONSTRUCTION TOE POLYDACTYLY 1368.79 090 28345 RCNSTJ TOE SYNDACTYLY +-SKN GRF EA WEB 1647.46 090 28360 RECONSTRUCTION CLEFT FOOT 3268.23 090 28400 CLOSED TX CALCANEAL FRACTURE W/O MANIPULATION 749.53 090 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 87
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 28405 CLOSED TX CALCANEAL FRACTURE W/MANIPULATION 1196.89 090 28406 PRQ SKEL FIXJ CALCANEAL FX W/MNPJ 1630.38 090 28415 OPEN TREATMENT CALCANEAL FRACTURE 3523.41 090 28420 OPEN TREATMENT CALCANEAL FRACTURE W BONE GRAFT 3852.26 090 28430 CLOSED TX TALUS FRACTURE W/O MANIPULATION 705.75 090 28435 CLOSED TX TALUS FRACTURE W/ MANIPULATION 1043.14 090 28436 PRQ SKELETAL FIXATION TALUS FRACTURE W/MNPJ 1358.11 090 28445 OPEN TREATMENT TALUS FRACTURE 3326.95 090 28446 OPEN OSTEOCHONDRAL AUTOGRAFT TALUS 3787.13 090 28450 TX TARSAL B1 FX XCP TALUS&CALCN W/O MNPJ 649.16 090 28455 TX TARSAL B1 FX XCP TALUS&CALCN W/MNPJ 892.60 090 28456 PRQ SKEL FIXJ TARSL FX XCP TALUS&CALCNS W/MNPJ 933.17 090 28465 OPEN TX TARSAL FRACTURE XCP TALUS &CALCANEUS EA 1902.64 090 28470 CLOSED TX METATARSAL FRACTURE W/O MANIPULATION 641.69 090 28475 CLTX METAR FX W/MNPJ 787.96 090 28476 PRQ SKEL FIXJ METAR FX W/MNPJ 1060.23 090 28485 OPEN TREATMENT METATARSAL FRACTURE EACH 1651.73 090 28490 CLTX FX GRT TOE PHLX/PHLG W/O MNPJ 426.01 090 28495 CLTX FX GRT TOE PHLX/PHLG W/MNPJ 531.71 090 28496 PRQ SKEL FIXJ FX GRT TOE PHLX/PHLG W/MNPJ 1309.00 090 28505 OPEN TX FRACTURE GREAT TOE/PHALANX/PHALANGES 2041.44 090 28510 CLTX FX PHLX/PHLG OTH/THN GRT TOE W/O MNPJ 365.15 090 28515 CLTX FX PHLX/PHLG OTH/THN GRT TOE W/MNPJ 479.40 090 28525 OPEN TX FRACTURE PHALANX/PHALANGES NOT GREAT TOE 1731.81 090 28530 CLOSED TREATMENT SESAMOID FRACTURE 347.00 090 28531 OPEN TX SESAMOID FRACTURE +-INTERNAL FIXATION 1109.34 090 28540 CLTX TARSAL DISLC OTH/THN TALOTARSAL W/O ANES 612.86 090 28545 CLTX TARSAL DISLC OTH/THN TALOTARSAL W/ANES 832.81 090 28546 PRQ SKEL FIXJ TARSL DISLC XCP TALOTARSAL W/MNPJ 1602.62 090 28555 OPEN TREATMENT TARSAL BONE DISLOCATION 2679.93 090 28570 CLOSED TX TALOTARSAL JOINT DISLC W/O ANES 503.95 090 28575 CLOSED TX TALOTARSAL JOINT DISLOCATION W/ANES 1068.77 090 28576 PRQ SKEL FIXJ TALOTARSAL JT DISLC W/MNPJ 1167.00 090 28585 OPEN TREATMENT TALOTARSAL JOINT DISLOCATION 2823.00 090 28600 CLOSED TX TARSOMETATARSAL DISLOCATION W/O ANES 657.70 090 28605 CLOSED TX TARSOMETATARSAL DISLOCATION W/ANES 860.57 090 28606 PRQ SKEL FIXJ TARS JT DISLC W/MNPJ 1211.84 090 28615 OPEN TREATMENT TARSOMETATARSAL JOINT DISLOCATION 2452.51 090 28630 CLTX METATARSOPHLNGL JT DISLC W/O ANES 461.25 010 28635 CLTX METATARSOPHLNGL JT DISLC REQ ANES 541.32 010 28636 PRQ SKEL FIXJ METATARSOPHLNGL JT DISLC W/MNPJ 836.01 010 28645 OPEN TX METATARSOPHALANGEAL JOINT DISLOCATION 1943.21 090 28660 CLTX IPHAL JT DISLC W/O ANES 339.53 010 28665 CLTX IPHAL JT DISLC REQ ANES 475.13 010 28666 PRQ SKEL FIXJ IPHAL JT DISLC W/MNPJ 635.28 010 28675 OPEN TREATMENT INTERPHALANGEAL JOINT DISLOCATION 1770.25 090 88 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule 28705 ARTHRODESIS PANTALAR 4077.55 090 28715 ARTHRODESIS TRIPLE 3049.35 090 28725 ARTHRODESIS SUBTALAR 2484.54 090 28730 ARTHRD MIDTARSL/TARS MLT/TRANSVRS 2636.15 090 28735 ARTHRD MIDTARSL/TARS MLT/TRANSVRS W/OSTEOT 2489.88 090 28737 ARTHRD W/TDN LNGTH&ADVMNT TARSL NVCLR-CUNEIFORM 2140.74 090 28740 ARTHRODESIS MIDTARSOMETATARSAL SINGLE JOINT 2621.20 090 28750 ARTHRODESIS GREAT TOE METATARSOPHALANGEAL JOINT 2548.60 090 28755 ARTHRODESIS GREAT TOE INTERPHALANGEAL JOINT 1526.81 090 28760 ARTHRD W/XTNSR HALLUCIS LONGUS TR 1ST METAR NCK 2415.14 090 28800 AMPUTATION FOOT MIDTARSAL 1769.18 090 28805 AMPUTATION FOOT TRANSMETARSAL 2389.51 090 28810 AMPUTATION METATARSAL W/TOE SINGLE 1394.42 090 28820 AMPUTATION TOE METATARSOPHALANGEAL JOINT 1617.57 090 28825 AMPUTATION TOE INTERPHALANGEAL JOINT 1784.13 090 28890 ESWT HI NRG PFRMD PHYS W/US GDN INVG PLNTAR FSCA 1050.62 090 28899 UNLISTED PROCEDURE FOOT/TOES BR YYY 29000 APPLICATION HALO TYPE BODY CAST 893.66 000 29010 APPLICATION RISSER JACKET LOCALIZER BODY ONLY 863.77 000 29015 APPLICATION RISSER JACKET LOCALIZER BODY W/HEAD 727.10 000 29020 APPLICATION TURNBUCKLE JACKET BODY ONLY 651.30 000 29025 APPLICATION TURNBUCKLE JACKET BODY W/HEAD 766.61 000 29035 APPLICATION BODY CAST SHOULDER HIPS 754.86 000 29040 APPLICATION BODY CAST SHOULDER HIPS HEAD MINERVA 722.83 000 29044 APPLICATION BODY CAST SHOULDER HIPS W/ONE THIGH 832.81 000 29046 APPLICATION BODY CAST SHOULDER HIPS BOTH THIGHS 822.13 000 29049 APPLICATION CAST FIGURE-OF-8 282.94 000 29055 APPLICATION CAST SHOULDER SPICA 652.36 000 29058 APPLICATION CAST PLASTER VELPEAU 311.77 000 29065 APPLICATION CAST SHOULDER HAND LONG ARM 287.21 000 29075 APPLICATION CAST ELBOW FINGER SHORT ARM 267.99 000 29085 APPLICATION CAST HAND&LOWER FOREARM GAUNTLET 284.01 000 29086 APPLICATION CAST FINGER 225.28 000 29105 APPLICATION LONG ARM SPLINT SHOULDER HAND 260.52 000 29125 APPLICATION SHORT ARM SPLINT FOREARM-HAND STATIC 208.20 000 29126 APPLICATION SHORT ARM SPLINT DYNAMIC 237.03 000 29130 APPLICATION FINGER SPLINT STATIC 122.79 000 29131 APPLICATION FINGER SPLINT DYNAMIC 155.88 000 29200 STRAPPING THORAX 161.22 000 29240 STRAPPING SHOULDER 174.04 000 29260 STRAPPING ELBOW/WRIST 155.88 000 29280 STRAPPING HAND/FINGER 151.61 000 29305 APPLICATION HIP SPICA CAST 1 LEG 729.24 000 29325 APPL HIP SPICA CAST ONE&ONE-HALF SPICA/BOTH LEGS 810.38 000 29345 APPLICATION LONG LEG CAST THIGH-TOE 411.06 000 29355 APPLICATION LONG LEG CAST WALKER/AMBULATORY TYPE 427.08 000 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 89
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 29358 APPLICATION LONG LEG CAST BRACE 475.13 000 29365 APPLICATION CYLINDER CAST THIGH ANKLE 370.49 000 29405 APPLICATION SHORT LEG CAST BELOW KNEE-TOE 267.99 000 29425 APPLICATION SHORT LEG CAST WALKING/AMBULATORY 286.14 000 29435 APPLICATION PATELLAR TENDON BEARING CAST 359.81 000 29440 ADDING WALKER PREVIOUSLY APPLIED CAST 147.34 000 29445 APPLICATION RIGID TOTAL CONTACT LEG CAST 431.35 000 29450 APPL CLUBFOOT CAST MOLDING/MNPJ LONG/SHORT LEG 446.30 000 29505 APPLICATION LONG LEG SPLINT THIGH ANKLE/TOES 233.83 000 29515 APPLICATION SHORT LEG SPLINT CALF FOOT 217.81 000 29520 STRAPPING HIP 150.55 000 29530 STRAPPING KNEE 158.02 000 29540 STRAPPING ANKLE &/FOOT 103.57 000 29550 STRAPPING TOES 83.28 000 29580 STRAPPING UNNA BOOT 160.16 000 29581 APPL MLT-LAYER VENOUS WOUND COMPRESS BELOW KNEE 288.28 000 29590 DENIS-BROWNE SPLINT STRAPPING 162.29 000 29700 REMOVAL/BIVALVING GAUNTLET BOOT/BODY CAST 198.59 000 29705 REMOVAL/BIVALVING FULL ARM/FULL LEG CAST 202.86 000 29710 RMVL/BIVALV SHO/HIP SPICA MINERVA/RISSER JACKET 370.49 000 29715 REMOVAL/BIVALVING TURNBUCKLE JACKET 260.52 000 29720 REPAIR SPICA BODY CAST/JACKET 246.64 000 29730 WINDOWING CAST 196.46 000 29740 WEDGING CAST EXCEPT CLUBFOOT CASTS 276.53 000 29750 WEDGING CLUBFOOT CAST 311.77 000 29799 UNLISTED PROCEDURE CASTING/STRAPPING BR YYY 29800 ARTHRS TMPRMAND JT DX +-SYNVAL BX SPX 1629.31 090 29804 ARTHROSCOPY TEMPOROMANDIBULAR JOINT SURGICAL 2037.17 090 29805 ARTHROSCOPY SHOULDER DX +-SYNOVIAL BIOPSY SPX 1460.61 090 29806 ARTHROSCOPY SHOULDER SURGICAL CAPSULORRHAPHY 3318.41 090 29807 ARTHROSCOPY SHOULDER SURGICAL REPAIR SLAP LESION 3238.33 090 29819 ARTHROSCOPY SHOULDER SURGICAL REMOVAL LOOSE/FB 1824.70 090 29820 ARTHROSCOPY SHOULDER SURG SYNOVECTOMY PARTIAL 1679.49 090 29821 ARTHROSCOPY SHOULDER SURG SYNOVECTOMY COMPLETE 1838.58 090 29822 ARTHROSCOPY SHOULDER SURG DEBRIDEMENT LIMITED 1787.33 090 29823 ARTHROSCOPY SHOULDER SURG DEBRIDEMENT EXTENSIVE 1950.69 090 29824 ARTHROSCOPY SHOULDER DISTAL CLAVICULECTOMY 2098.03 090 29825 ARTHROSCOPY SHOULDER LYSIS&RESCJ ADHESION +-MNPJ 1820.43 090 29826 SHOULDER SCOPE BONE SHAVING 2079.88 090 29827 ARTHROSCOPY SHOULDER ROTATOR CUFF REPAIR 3379.27 090 29828 ARTHROSCOPY SHOULDER BICEPS TENODESIS 2865.71 090 29830 ARTHROSCOPY ELBOW DIAGNOSTIC +-SYNOVIAL BX SPX 1410.43 090 29834 ARTHROSCOPY ELBOW SURGICAL W/REMOVAL LOOSE/FB 1528.95 090 29835 ARTHROSCOPY ELBOW SURGICAL SYNOVECTOMY PARTIAL 1572.72 090 29836 ARTHROSCOPY ELBOW SURGICAL SYNOVECTOMY COMPLETE 1814.02 090 29837 ARTHROSCOPY ELBOW SURGICAL DEBRIDEMENT LIMITED 1645.33 090 90 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule 29838 ARTHROSCOPY ELBOW SURGICAL DEBRIDEMENT EXTENSIVE 1840.71 090 29840 ARTHROSCOPY WRIST DIAGNOSTIC +-SYNOVIAL BX SPX 1397.62 090 29843 ARTHROSCOPY WRIST INFECTION LAVAGE&DRAINAGE 1496.92 090 29844 ARTHROSCOPY WRIST SURGICAL SYNOVECTOMY PARTIAL 1543.89 090 29845 ARTHROSCOPY WRIST SURGICAL SYNOVECTOMY COMPLETE 1783.06 090 29846 ARTHRS WRST EXC&/RPR TRIANG FIBROCART&/JT DBRDMT 1619.70 090 29847 ARTHRS WRST SURG INT FIXJ F/FX/INS 1689.10 090 29848 NDSC WRST SURG W/RLS TRANSVRS CARPL LIGM 1571.65 090 29850 ARTHRS AID TX SPI&/FX KNE W/O FIXJ 1862.07 090 29851 ARTHRS AID TX SPI&/FX KNE W/FIXJ 2913.75 090 29855 ARTHRS AID TIBIAL FRACTURE PROXIMAL UNICONDYLAR 2451.44 090 29856 ARTHRS AID TIBIAL FX PROX UNICONDYLAR BICONDYLAR 3124.09 090 29860 ARTHROSCOPY HIP DIAGNOSTIC +-SYNOVIAL BIOPSY SPX 2057.46 090 29861 ARTHROSCOPY HIP SURGICAL W/REMOVAL LOOSE/FB 2264.59 090 29862 ARTHRS HIP DEBRIDEMENT/SHAVING ARTICULAR CRTLG 2541.13 090 29863 ARTHROSCOPY HIP SURGICAL W/SYNOVECTOMY 2533.65 090 29866 ARTHROSCOPY KNEE OSTEOCHONDRAL AGRFT MOSAICPLAST 3272.50 090 29867 ARTHROSCOPY KNEE OSTEOCHONDRAL ALLOGRAFT 3983.59 090 29868 ARTHROSCOPY KNEE MENISCAL TRNSPLJ MED/LAT 5249.88 090 29870 ARTHROSCOPY KNEE DIAGNOSTIC +-SYNOVIAL BX SPX 1815.09 090 29871 ARTHROSCOPY KNEE INFECTION LAVAGE & DRAINAGE 1593.01 090 29873 ARTHROSCOPY KNEE LATERAL RELEASE 1612.23 090 29874 ARTHROSCOPY KNEE REMOVAL LOOSE/FOREIGN BODY 1675.22 090 29875 ARTHROSCOPY KNEE SYNOVECTOMY LIMITED SPX 1539.62 090 29876 ARTHROSCOPY KNEE SYNOVECTOMY 2/>COMPARTMENTS 2040.37 090 29877 ARTHRS KNEE DEBRIDEMENT/SHAVING ARTCLR CRTLG 1932.54 090 29879 ARTHRS KNEE ABRASION ARTHRP/MLT DRLG/MICROFX 2062.80 090 29880 ARTHRS KNEE W/MENISCECTOMY MED&LAT W/SHAVING 2150.35 090 29881 ARTHRS KNE SURG W/MENISCECTOMY MED/LAT W/SHVG 2009.41 090 29882 ARTHROSCOPY KNEE W/MENISCUS RPR MEDIAL/LATERAL 2172.77 090 29883 ARTHROSCOPY KNEE W/MENISCUS RPR MEDIAL&LATERAL 2623.34 090 29884 ARTHROSCOPY KNEE W/LYSIS ADHESIONS+-MNPJ SPX 1927.20 090 29885 ARTHRS KNE DRLG OSTEO DISS GRFG 2335.06 090 29886 ARTHRS KNE DRLG OSTEO DISS LES 1970.97 090 29887 ARTHRS KNE DRLG OSTEO DISS LES INT FIXJ 2320.11 090 29888 ARTHRS AIDED ANT CRUCIATE LIGM RPR/AGMNTJ/RCNSTJ 3096.33 090 29889 ARTHRS AIDED PST CRUCIATE LIGM RPR/AGMNTJ/RCNSTJ 3810.62 090 29891 ARTHRS ANKLE EXC OSTCHNDRL DFCT W/DRLG DFCT 2156.75 090 29892 ARTHRS AID RPR LES/TALAR DOME FX/TIBL PLAFOND FX 2077.74 090 29893 ENDOSCOPIC PLANTAR FASCIOTOMY 1837.51 090 29894 ARTHROSCOPY ANKLE W/REMOVAL LOOSE/FOREIGN BODY 1609.02 090 29895 ARTHROSCOPY ANKLE SURGICAL SYNOVECTOMY PARTIAL 1538.56 090 29897 ARTHROSCOPY ANKLE SURGICAL DEBRIDEMENT LIMITED 1612.23 090 29898 ARTHROSCOPY ANKLE SURGICAL DEBRIDEMENT EXTENSIVE 1791.60 090 29899 ARTHROSCOPY ANKLE SURGICAL W/ANKLE ARTHRODESIS 3277.84 090 29900 ARTHROSCOPY METACARPOPHALANGEAL SYNOVIAL BIOPSY 1400.82 090 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 91
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 29901 ARTHRS METACARPOPHALANGEAL JOINT DEBRIDEMENT 1606.89 090 29902 ARTHRS MTCARPHLNGL JT W/RDCTJ UR COLTRL LIGM 1705.12 090 29904 ARTHRS SUBTALAR JOINT REMOVE LOOSE/FOREIGN BODY 1963.50 090 29905 ARTHROSCOPY SUBTALAR JOINT WITH SYNOVECTOMY 2122.59 090 29906 ARTHROSCOPY SUBTALAR JOINT WITH DEBRIDEMENT 2233.63 090 29907 ARTHROSCOPY SUBTALAR JOINT SUBTALAR ARTHRODESIS 2708.75 090 l # 29914 ARTHROSCOPY HIP W/FEMOROPLASTY 3237.27 090 l # 29915 ARTHROSCOPY HIP W/ACETABULOPLASTY 3298.13 090 l # 29916 ARTHROSCOPY HIP W/LABRAL REPAIR 3298.13 090 29999 UNLISTED PROCEDURE ARTHROSCOPY BR YYY 30000 DRAINAGE ABSCESS/HEMATOMA NASAL INT APPROACH 373.33 010 30020 DRAINAGE ABSCESS/HEMATOMA NASAL SEPTUM 369.45 010 30100 BIOPSY INTRANASAL 227.65 000 30110 EXCISION NASAL POLYP SIMPLE 369.45 010 30115 EXCISION NASAL POLYP EXTENSIVE 699.02 090 30117 EXCISION/DESTRUCTION INTRANASAL LESION INT APPR 1380.32 090 30118 EXCISION/DESTRUCTION INTRANASAL LESION XTRNL 1252.37 090 30120 EXCISION/SURGICAL PLANING SKIN NOSE RHINOPHYMA 841.93 090 30124 EXCISION DERMOID CYST NOSE SIMPLE SUBCUTANEOUS 444.23 090 30125 EXC DERMOID CYST NOSE COMPLEX UNDER BONE/CRTLG 995.91 090 30130 EXCISION INFERIOR TURBINATE PARTIAL/COMPLETE 613.72 090 30140 SUBMUCOUS RESCJ INFERIOR TURBINATE PRTL/COMPL 707.33 090 30150 RHINECTOMY PARTIAL 1271.20 090 30160 RHINECTOMY TOTAL 1275.08 090 30200 INJECTION TURBINATE THERAPEUTIC 182.79 000 30210 DISPLACEMENT THERAPY PROETZ TYPE 240.95 010 30220 INSERTION NASAL SEPTAL PROSTHESIS BUTTON 481.89 010 30300 REMOVAL FOREIGN BODY INTRANASAL OFFICE PROCEDURE 367.79 010 30310 REMOVAL FOREIGN BODY INTRANASAL GENERAL ANES 333.45 010 30320 RMVL FOREIGN BODY INTRANASAL LATERAL RHINOTOMY 735.03 090 30400 RHINP PRIM LAT&ALAR CRTLGS&/ELVTN NSL TIP 1666.69 090 30410 RHINP PRIM COMPLETE XTRNL PARTS 1960.25 090 30420 RHINOPLASTY PRIMARY W/MAJOR SEPTAL REPAIR 2243.30 090 30430 RHINOPLASTY SECONDARY MINOR REVISION 1477.25 090 30435 RHINOPLASTY SECONDARY INTERMEDIATE REVISION 1963.02 090 30450 RHINOPLASTY SECONDARY MAJOR REVISION 2502.52 090 30460 RHINP DFRM W/COLUM LNGTH TIP ONLY 1250.15 090 30462 RHINP DFRM COLUM LNGTH TIP SEPTUM OSTEOT 2550.16 090 30465 REPAIR NASAL VESTIBULAR STENOSIS 1602.43 090 30520 SEPTOP/SBMCSL RESCJ 1003.67 090 30540 REPAIR CHOANAL ATRESIA INTRANASAL 1107.25 090 30545 REPAIR CHOANAL ATRESIA TRANSPALATINE 1413.00 090 30560 LYSIS INTRANASAL SYNECHIA 436.47 010 30580 REPAIR FISTULA OROMAXILLARY 1021.39 090 30600 REPAIR FISTULA ORONASAL 932.21 090 30620 SEPTAL/OTHER INTRANASAL DERMATOPLASTY 1008.65 090 92 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule 30630 REPAIR NASAL SEPTAL PERFORATIONS 1018.62 090 30801 ABLTJ SOF TISS INF TURBS UNI/BI SUPFC 365.57 010 30802 ABLTJ SOF TISS INF TURBS UNI/BI SUPFC INTRAMURAL 469.15 010 30901 CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE 156.20 000 30903 CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX 319.60 000 30905 CTRL NSL HEMRRG PST PST NSL PACKS&/CAUT 1ST 396.59 000 30906 CTRL NSL HEMRRG PST PST NSL PACKS&/CAUT SBSQ 449.21 000 30915 LIGATION ARTERIES ETHMOIDAL 941.63 090 30920 LIGATION ARTERIES INT MAXILLARY TRANSANTRAL 1358.72 090 30930 FRACTURE NASAL INFERIOR TURBINATE THERAPEUTIC 199.96 010 30999 UNLISTED PROCEDURE NOSE BR YYY 31000 LAVAGE CANNULATION MAXILLARY SINUS 290.80 010 31002 LAVAGE CANNULATION SPHENOID SINUS 326.25 010 31020 SINUSOTOMY MAXILLARY ANTROTOMY INTRANASAL 778.78 090 31030 SINUSOTOMY MAXILLARY RAD W/O RMVL ANTROCH POLYPS 1116.11 090 31032 SINUSOT MAX ANTRT RAD W/RMVL ANTROCH POLYPS 928.34 090 31040 PTERYGOMAXILLARY FOSSA SURGERY ANY APPROACH 1220.24 090 31050 SINUSOTOMY SPHENOID +-BIOPSY 794.29 090 31051 SINUSOT SPHENOID W/MUCOSAL STRIPPING/RMVL POLYP 1047.98 090 31070 SINUSOTOMY FRONTAL EXTERNAL SIMPLE 711.76 090 31075 SINUSOTOMY FRONTAL TRANSORBITAL UNILATERAL 1276.19 090 31080 SINUSOTOMY FRNT OBLITERATIVE W/O FLAP BROW INC 1661.70 090 31081 SINUSOT FRNT OBLIT W/O OSTPL FLAP CORONAL INC 2247.73 090 31084 SINUSOT FRNT OBLIT W/OSTPL FLAP BROW INC 1904.31 090 31085 SINUSOT FRNT OBLIT W/OSTPL FLAP CORONAL INC 2180.15 090 31086 SINUSOT FRNT NONOBLIT W/OSTPL FLAP BROW INC 1827.87 090 31087 SINUSOT FRNT NONOBLIT W/OSTPL FLAP CORONAL INC 1777.47 090 31090 SINUSOT UNI 3/> PARANSL SINUSES 1652.84 090 31200 ETHMOIDECTOMY INTRANASAL ANTERIOR 887.35 090 31201 ETHMOIDECTOMY INTRANASAL TOTAL 1193.65 090 31205 ETHMOIDECTOMY EXTRANASAL TOTAL 1427.95 090 31225 MAXILLECTOMY W/O ORBITAL EXENTERATION 3035.37 090 31230 MAXILLECTOMY W/ORBITAL EXENTERATION 3387.10 090 31231 NASAL ENDOSCOPY DIAGNOSTIC UNI/BI SPX 309.63 000 31233 NSL/SINUS NDSC DX MAX SINUSC 432.60 000 31235 NSL/SINUS NDSC DX SPHENOID SINUSOSCOPY 490.20 000 31237 NSL/SINUS NDSC SURG W/BX POLYPC/DBRDMT SPX 530.64 000 31238 NSL/SINUS NDSC SURG W/CTRL NSL HEMRRG 546.15 000 31239 NSL/SINUS NDSC SURG W/DACRYOCSTORHINOSTOMY 1102.26 010 31240 NSL/SINUS NDSC SURG W/CONCHA BULLOSA RESCJ 267.53 000 31254 NASAL/SINUS ENDOSCOPY W/ETHMOIDECTOMY PARTIAL 455.86 000 31255 NASAL/SINUS ENDOSCOPY W/ETHMOIDECTOMY TOTAL 668.00 000 31256 NASAL/SINUS ENDOSCOPY W/MAXILLARY ANTROSTOMY 329.57 000 31267 NSL/SINUS NDSC MAX ANTROST W/RMVL TISS MAX SINUS 529.53 000 31276 NSL/SINUS NDSC W/FRNT SINUS EXPL 843.04 000 31287 NASAL/SINUS ENDOSCOPY W/SPHENOIDECTOMY 387.18 000 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 93
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 31288 NSL/SINUS NDSC SPHENDT RMVL TISS SPHENOID SINUS 449.77 000 31290 NSL/SINUS NDSC RPR CEREBSP FLU LEAK ETHMOID 1919.26 010 31291 NSL/SINUS NDSC RPR CEREBSP FLU LEAK SPHENOID 2035.03 010 31292 NSL/SINUS NDSC SURG W/MEDIAL/INF ORB WALL DCMPRN 1651.73 010 31293 NSL/SINUS NDSC MEDIAL ORB&INF ORB WALL DCMPRN 1799.62 010 31294 NSL/SINUS NDSC SURG W/OPTIC NRV DCMPRN 2062.17 010 l 31295 NSL/SINUS NDSC SURG W/DILAT MAXILLARY SINUS 3313.98 000 l 31296 NSL/SINUS NDSC SURG W/DILAT FRONTAL SINUS 6204.79 000 l 31297 NSL/SINUS NDSC SURG W/DILAT SPHENOID SINUS 6146.63 000 31299 UNLISTED PROCEDURE ACCESSORY SINUSES BR YYY 31300 LRYNGOT W/RMVL TUM/LARYNGOCELE CORDECTOMY 2066.05 090 31320 LARYNGOTOMY THYROTOMY LARYNGOFISSURE DX 1064.60 090 31360 LARGTOM TOT W/O RAD NCK DSJ 3364.39 090 31365 LARGTOM TOT W/RAD NCK DSJ 4177.51 090 31367 LARGTOM STOT SUPRAGLOTTIC W/O RAD NCK DSJ 3592.04 090 31368 LARGTOM STOT SUPRAGLOTTIC W/RAD NCK DSJ 3989.19 090 31370 PRTL LARGTOM HEMILARGTOM HRZNTL 3374.36 090 31375 PRTL LARGTOM HEMILARGTOM LATER> 3199.33 090 31380 PRTL LARGTOM HEMILARGTOM ANTER> 3151.14 090 31382 PRTL LARGTOM HEMILARGTOM ANTERO-LATERO-VER 3458.00 090 31390 PHARYNGOLARGTOM W/RAD NCK DSJ W/O RCNSTJ 4643.34 090 31395 PHARYNGOLARGTOM W/RAD NCK DSJ W/RCNSTJ 4902.02 090 31400 ARYTENOIDECTOMY/ARYTENOIDOPEXY XTRNL APPR 1637.88 090 31420 EPIGLOTTIDECTOMY 1370.35 090 * 31500 INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE 179.46 000 31502 TRACHEOTOMY TUBE CHANGE PRIOR TO FISTULA TRACT 57.61 000 31505 LARYNGOSCOPY INDIRECT DIAGNOSTIC SPX 135.15 000 31510 LARYNGOSCOPY INDIRECT W/BIOPSY 345.08 000 31511 LARYNGOSCOPY INDIRECT W/REMOVAL FOREIGN BODY 344.53 000 31512 LARYNGOSCOPY INDIRECT W/REMOVAL LESION 341.20 000 31513 LARYNGOSCOPY INDIRECT W/VOCAL CORD INJECTION 219.90 000 31515 LARYNGOSCOPY +-TRACHEOSCOPY ASPIRATION 340.09 000 31520 LARYNGOSCOPY +-TRACHEOSCOPY DIAGNOSTIC NEWBORN 259.23 000 31525 LARYNGOSCOPY +-TRACHEOSCOPY DX EXCEPT NEWBORN 410.44 000 31526 LARYNGOSCOPY +-TRACHEOSCOPY MICROSCOPE/TELESCOPE 263.66 000 31527 LARYNGOSCOPY +-TRACHEOSCOPY INSERTION OBTURATOR 324.59 000 31528 LARYNGOSCOPY +-TRACHEOSCOPY W/DILATION INITIAL 241.50 000 31529 LARYNGOSCOPY +-TRACHEOSCOPY DILATION SUBSEQUENT 270.30 000 31530 LARYNGOSCOPY W/FOREIGN BODY REMOVAL 330.68 000 31531 LARYNGOSCOPY F BODY RMVL MICROSCOPE/TELESCOPE 355.60 000 31535 LARYNGOSCOPY DIRECT OPERATIVE W/BIOPSY 317.38 000 31536 LARYNGOSCOPY W/BIOPSY MICROSCOPE/TELESCOPE 353.94 000 31540 LARGSC EXC TUM&/STRIPPING CORDS/EPIGL 406.56 000 31541 LARGSC EXC TUM&/STRPG CORDS/EPIGL MCRSCP/TLSCP 444.23 000 31545 LARGSC MCRSCP/TLSCP RMVL LES VOCAL C/D FLAP 607.63 000 31546 LARGSC MCRSCP/TLSCP RMVL LES VOCAL C/D GRF 920.58 000 94 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule 31560 LARYNGOSCOPY DIRECT OPERATIVE W/ARYTENOIDECTOMY 526.21 000 31561 LARGSC ARYTENOIDECTOMY MICROSCOPE/TELESCOPE 575.50 000 31570 LARYNGOSCOPE INJECTION VOCAL CORD THERAPEUTIC 563.32 000 31571 LARGSC W/NJX VOCAL CORD THER W/MCRSCP/TLSCP 418.75 000 31575 LARYNGOSCOPY FLEXIBLE FIBEROPTIC DIAGNOSTIC 187.77 000 31576 LARYNGOSCOPY FLEXIBLE FIBEROPTIC W/BIOPSY 367.79 000 31577 LARYNGOSCOPY FLX FIBEROPTIC RMVL FOREIGN BODY 397.15 000 31578 LARYNGOSCOPY FLEXIBLE FIBEROPTIC REMOVAL LESION 460.84 000 31579 LARYNGOSCOPY FLX/RGD FIBOPT W/STROBOSCOPY 352.83 XXX 31580 LARYNGOPLASTY LARYN WEB 2 STG W/KEEL INSJ&RMVL 1988.50 090 31582 LARYNGP LARYN STENOSIS GRF/CORE MOLD W/TRACHT 3120.12 090 31584 LARYNGOPLASTY W/OPN RDCTJ FX 2478.15 090 31587 LARYNGOPLASTY CRICOID SPLIT 1639.54 090 31588 LARYNGOPLASTY NOT OTHERWISE SPECIFIED 1871.07 090 31590 LARYNGEAL REINNERVATION NEUROMUSCULAR PEDICLE 1458.42 090 31595 SECTION RECURRENT LARYNGEAL NERVE THER UNI SPX 1253.48 090 31599 UNLISTED PROCEDURE LARYNX BR YYY 31600 TRACHEOSTOMY PLANNED SPX 657.48 000 31601 TRACHEOSTOMY PLANNED UNDER 2 YEARS SPX 433.15 000 31603 TRACHEOSTOMY EMERGENCY PROCEDURE TRANSTRACHEAL 370.56 000 31605 TRACHEOSTOMY EMERGENCY CRICOTHYROID MEMBRANE 302.43 000 31610 TRACHEOSTOMY FENESTRATION W/SKIN FLAPS 1165.41 090 31611 CONSTJ TRACHEOESOPHGL FSTL&INSJ SP PROSTH 879.59 090 31612 TRACHEAL PNXR PRQ W/TRANSTRACHEAL ASPIR&/NJX 132.38 000 31613 TRACHEOSTOMA REVJ SMPL W/O FLAP ROTATION 733.36 090 31614 TRACHEOSTOMA REVJ CPLX W/FLAP ROTATION 1224.67 090 K 31615 TRACHEOBRNCHSC THRU EST TRACHS INC 298.55 000 + K 31620 ENDOBRNCL US BRONCHOSCOPIC DX/THER IVNTJ 453.09 ZZZ K 31622 BRNCHSC INCL FLUOR GID DX W/CELL WASHG SPX 511.80 000 K 31623 BRNCHSC BRUSHING/PROTECTED BRUSHINGS 548.91 000 K 31624 BRNCHSC W/BRNCL ALVEOLAR LAVAGE 512.91 000 K 31625 BRNCHSC BRNCL/ENDOBRNCL BX 1+ SITS 551.13 000 K 31626 BRNCHSC W/PLMT FIDUCIAL MARKERS 1/MLT 721.73 000 + K 31627 BRNCHSC W/CPTR-ASST IMAGE-GUIDED NAVIGATION 2072.69 ZZZ K 31628 BRNCHSC W/TRANSBRNCL LUNG BX 1 LOBE 645.29 000 K 31629 BRNCHSC NDL BX TRACHEA MAIN STEM&/BRONCHUSI 1003.11 000 31630 BRNCHSC W/TRACHEAL/BRNCL DILAT/CLSD RDCTJ FX 335.11 000 31631 BRNCHSC W/PLACEMENT TRACHEAL STENT 382.19 000 + 31632 BRNCHSC W/TRANSBRNCL LUNG BX EA LOBE 116.32 ZZZ + 31633 BRNCHSC W/TRANSBRNCL NDL ASPIR BX EA LOBE 142.35 ZZZ l K 31634 BRONCHOSCOPY BALLOON OCCLUSION 2940.66 000 K 31635 BRNCHSC W/REMOVAL FOREIGN BODY 565.53 000 31636 BRNCHSC W/PLACEMENT BRNCL STENT 1ST BRONCHUS 370.01 000 + 31637 BRNCHSC EA MAJOR BRONCHUS STENTED 126.29 ZZZ 31638 BRNCHSC REVJ TRACHEAL/BRNCL STENT INS PREV SESS 423.18 000 31640 BRNCHSC W/EXCISION TUMOR 427.06 000 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 95
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 31641 BRNCHSC W/DSTRJ TUM RELIEF STENOSIS OTH/THN EXC 425.95 000 31643 BRNCHSC W/PLMT CATH INTRCV RADIOELMNT APPL 286.92 000 K 31645 BRNCHSC W/THER ASPIR TRACHEOBRNCL TREE 1ST 494.08 000 K 31646 BRNCHSC W/THER ASPIR TRACHEOBRNCL TREE SBSQ 450.32 000 K 31656 BRNCHSC W/NJX CONTRAST SGMTL BRONCHOG 500.73 000 31715 TRANSTRACHEAL INJECTION BRONCHOGRAPHY 87.52 000 31717 CATHETERIZATION W/BRONCHIAL BRUSH BIOPSY 465.28 000 31720 CATHETER ASPIRATION NASOTRACHEAL SPX 84.19 000 K 31725 CATH ASPIR TRACHEOBRNCL FIBERSCOPE BEDSIDE SPX 155.65 000 31730 TTRACH INTRO NDL WIRE DIL/STENT/TUBE O2 THER 1659.48 000 31750 TRACHEOPLASTY CERVICAL 2228.89 090 31755 TRACHEOPLASTY TRACHEOPHARYNGEAL FSTLJ EA STG 2816.58 090 31760 TRACHEOPLASTY INTRATHORACIC 2309.76 090 31766 CARINAL RECONSTRUCTION 2992.17 090 31770 BRONCHOPLASTY GRAFT REPAIR 2239.97 090 31775 BRONCHOPLASTY EXCISION STENOSIS & ANASTOMOSIS 2293.70 090 31780 EXCISION TRACHEAL STENOSIS&ANASTOMOSIS CERVICAL 1980.75 090 31781 EXC TRACHEAL STENOSIS&ANAST CERVICOTHORACIC 2369.58 090 31785 EXCISION TRACHEAL TUMOR/CARCINOMA CERVICAL 1788.54 090 31786 EXCISION TRACHEAL TUMOR/CARCINOMA THORACIC 2457.10 090 31800 SUTURE TRACHEAL WOUND/INJURY CERVICAL 1144.91 090 31805 SUTURE TRACHEAL WOUND/INJURY INTRATHORACIC 1369.79 090 31820 SURG CLSR TRACHS/FSTL W/O PLSTC RPR 708.99 090 31825 SURG CLSR TRACHS/FSTL W/PLSTC RPR 986.50 090 31830 REVISION TRACHEOSTOMY SCAR 716.19 090 31899 UNLISTED PROCEDURE TRACHEA BRONCHI BR YYY 32035 THORACOSTOMY W/RIB RESECTION EMPYEMA 1198.64 090 32036 THORACOSTOMY OPEN FLAP DRAINAGE EMPYEMA 1295.02 090 32095 THORACOTOMY LIMITED BIOPSY LUNG/PLEURA 1055.18 090 32100 THORACOTOMY WITH EXPLORATION 1606.86 090 32110 THORCOM MAJOR CTRL TRAUMTC HEMRRG&/RPR LNG TEAR 2441.04 090 32120 THORACOTOMY MAJOR POSTOPERATIVE COMPLICATIONS 1465.62 090 32124 THORACOTOMY MAJOR OPN INTRAPLEURAL PNEUMONOLYSIS 1555.91 090 32140 THORCOM W/ REMOVAL OF CYST 1658.38 090 32141 THORACOTOMY W/EXCISION BULLAE 2563.45 090 32150 THORCOM MAJOR W/RMVL INTRAPLEURAL FB/FIBRIN DEP 1676.10 090 32151 THORCOM MAJOR W/RMVL IPUL FB 1695.49 090 32160 THORACOTOMY MAJOR W/CARDIAC MASSAGE 1298.90 090 32200 PNEUMONOSTOMY W/OPEN DRAINAGE ABSCESS/CYST 1894.34 090 K 32201 PNEUMONOSTOMY PERCUTANEOUS DRAINAGE ABSCESS/CYST 1506.61 000 32215 PLEURAL SCARIFICATION REPEAT PNEUMOTHORAX 1341.55 090 32220 DECORTICATION PULMONARY TOTAL SPX 2674.78 090 32225 DECORTICATION PULMONARY PARTIAL SPX 1671.67 090 32310 PLEURECTOMY PARIETAL SPX 1538.18 090 32320 DECORTICATION & PARIETAL PLEURECTOMY 2684.75 090 32400 BIOPSY PLEURA PERCUTANEOUS NEEDLE 244.82 000 96 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule 32402 BIOPSY PLEURA OPEN 946.62 090 32405 BIOPSY LUNG/MEDIASTINUM PERCUTANEOUS NEEDLE 161.74 000 32420 PNEUMOCENTESIS PUNCTURE LUNG ASPIRATION 182.23 000 32421 THORACENTESIS PUNCTURE PLEURAL CAVITY ASPIRATION 253.13 000 32422 THORACENTESIS WITH INSERTION TUBE WATER SEAL 320.71 000 32440 REMOVAL OF LUNG 2650.41 090 32442 REMOVAL LUNG PNEUMONECTOMY EXTRAPLEURAL 4620.63 090 32445 REMOVAL LUNG TOTAL PNEUMONECTOMY EXTRAPLEURAL 5874.11 090 32480 RMVL LNG OTH/THN PNUMEC 1 LOBE LOBEC 2507.51 090 32482 RMVL LNG OTH/THN PNUMEC 2 LOBES BILOBEC 2680.32 090 32484 RMVL LNG OTH/THN PNUMEC 1 SGM SGMECTOMY 2430.51 090 32486 RMVL LNG XCP PNUMEC SLEEVE LOBECTOMY 3965.37 090 32488 RMVL LNG OTH/THN PNUMEC COMPLETION PNUMEC 4022.42 090 32491 RMVL LNG OTH/THN PNUMEC EXC-PLCTJ EMPHY LNG 2498.64 090 32500 RMVL LNG OTH/THN TOT PNUMEC WEDGE RESCJ 1/MLT 2431.07 090 + 32501 RESCJ&BRONCHOPLASTY PFRMD TM LOBEC/SGMECTOMY 417.09 ZZZ 32503 RESCJ APICAL LNG TUM W/O CH WALL RCNSTJ 3055.87 090 32504 RESCJ APICAL LNG TUM W/CH WALL RCNSTJ 3474.61 090 32540 EXTRAPLEURAL ENUCLEATION EMPYEMA EMPYEMECTOMY 2886.37 090 K 32550 INSERTION INDWELLING TUNNELED PLEURAL CATHETER 1298.34 000 K 32551 TUBE THORACOSTOMY INCLUDES WATER SEAL 285.26 000 32552 RMVL NDWELLG TUN PLEURAL CATH W/CUFF 307.41 010 K 32553 PLMT NTRSTL DEV RADJ THX GID PRQ INTRATHRC 1/MLT 1010.87 000 32560 INSTLJ VIA CHEST TUBE/CATH AGENT FOR PLEURODESIS 424.84 000 32561 INSTLJ VIA CH TUBE/CATH AGENT FBRNLYSIS 1ST DAY 157.31 000 32562 INSTLJ CH TUBE/CATH AGENT FBRNLYSIS SBSQ DAY 140.69 000 32601 THORSC DX LUNGS/PLEURAL SPACE/MED/PERICAR W/O BX 521.22 000 32602 THORACOSCOPY DX LUNGS&PLEURAL SPACE W/BX SPX 564.42 000 32603 THORACOSCOPY DX PERICARDIAL SAC W/O BIOPSY SPX 736.69 000 32604 THORACOSCOPY DX PERICARDIAL SAC W/BIOPSY SPX 817.56 000 32605 THORACOSCOPY DX MEDIASTINAL SPACE W/O BIOPSY SPX 649.72 000 32606 THORACOSCOPY DX MEDIASTINAL SPACE W/BIOPSY SPX 783.21 000 32650 THORACOSCOPY W/PLEURODESIS 1121.65 090 32651 THORACOSCOPY W/PARTIAL PULMONARY DECORTICATION 1824.55 090 32652 THRSC TOT PULM DCRTCTJ INTRAPLEURAL PNEUMONOLSS 2770.61 090 32653 THORACOSCOPY RMVL INTRAPLEURAL FB/FIBRIN DEPOSIT 1758.08 090 32654 THORACOSCOPY CONTROL TRAUMATIC HEMORRHAGE 1963.02 090 32655 THORACOSCOPY W/EXCISION BULLAE 1599.66 090 32656 THORACOSCOPY W/PARIETAL PLEURECTOMY 1342.65 090 32657 THRSC W/WEDGE RESCJ LNG 1/MLT 1324.93 090 32658 THRSC W/RMVL CLOT/FB FROM PRCRD SAC 1206.39 090 32659 THRSC CRTJ PRCRD WINDOW/PRTL RESCJ PRCRD SAC 1236.30 090 32660 THORACOSCOPY W/TOTAL PERICARDIECTOMY 1766.39 090 32661 THRSC W/EXC PRCRD CST TUM/MASS 1348.19 090 32662 THRSC W/EXC MEDSTNL CST TUM/MASS 1511.04 090 32663 THORACOSCOPY W/LOBECTOMY TOTAL/SGMTL 2360.72 090 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 97
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 32664 THORACOSCOPY W/THORACIC SYMPATHECTOMY 1426.85 090 32665 THORACOSCOPY W/ESOPHAGOMYOTOMY HELLER TYPE 2040.01 090 32800 REPAIR LUNG HERNIA THROUGH CHEST WALL 1573.63 090 32810 CLSR CH WALL FLWG OPN FLAP DRG EMPYEMA 1512.70 090 32815 OPEN CLOSURE MAJOR BRONCHIAL FISTULA 4667.72 090 32820 MAJOR RECONSTRUCTION CHEST WALL POSTTRAUMATIC 2252.16 090 32850 DONOR PNEUMONECTOMY FROM CADAVER DONOR BR XXX 32851 LUNG TRANSPLANT 1 W/O CARDIOPULMONARY BYPASS 4355.87 090 32852 LUNG TRANSPLANT 1 W/CARDIOPULMONARY BYPASS 4819.48 090 32853 LUNG TRANSPLANT 2 W/O CARDIOPULMONARY BYPASS 5180.63 090 32854 LUNG TRANSPLANT 2 W/CARDIOPULMONARY BYPASS 5667.50 090 32855 BKBENCH STANDARD PREPJ CDVR DON LNG ALGRFT UNI BR XXX 32856 BKBENCH STANDARD PREPJ CDVR DON LNG ALGRFT BI BR XXX 32900 RESECTION RIBS EXTRAPLEURAL ALL STAGES 2325.83 090 32905 THORACOPLASTY SCHEDE TYPE/EXTRAPLEURAL 2249.94 090 32906 THORACOP SCHEDE TYP/XTRPLEURAL CLSR BRNCPLR FSTL 2786.67 090 32940 PNEUMONOLSS XTRPRIOSTEAL W/FILLING/PACKING PX 2073.80 090 32960 PNEUMOTHORAX THER INTRAPLEURAL NJX AIR 230.98 000 32997 TOTAL LUNG LAVAGE UNILATERAL 585.47 000 32998 ABLATION PULMONARY TUMOR PERQ RF UNI 4707.60 000 32999 UNLISTED PROCEDURE LUNGS & PLEURA BR YYY K 33010 PERICARDIOCENTESIS INITIAL 206.05 000 K 33011 PERICARDIOCENTESIS SUBSEQUENT 206.05 000 33015 TUBE PERICARDIOSTOMY 875.72 090 33020 PERICARDIOTOMY REMOVAL CLOT/FOREIGN BODY PRIMARY 1478.91 090 33025 CRTJ PERICARDIAL WINDOW/PRTL RESECJ W/DRG/BX 1353.73 090 33030 PRICARDIECTOMY STOT/COMPL W/O CARD BYP 2180.70 090 33031 PRICARDIECTOMY STOT/COMPL W/CARD BYP 2428.30 090 33050 RESECJ PERICARDIAL CYST/TUMOR 1691.61 090 33120 EXC INTRACARDIAC TUMOR RESCJ CARDIOPULMONARY BYP 2639.33 090 33130 RESECTION EXTERNAL CARDIAC TUMOR 2350.20 090 33140 TRANSMYOCRD LASER REVSC THORCOM SPX 2703.59 090 + 33141 TRANSMYOCRD LASER REVSC PFRMD TM OTH OPN CAR PX 234.85 ZZZ 33202 INSERTION EPICARDIAL ELECTRODE OPEN 1316.07 090 33203 INSERTION EPICARDIAL ELECTRODE ENDOSCOPIC 1380.87 090 K 33206 INSJ/RPLCMT PRM PM W/TRANSVNS ELTRD ATR 787.09 090 K 33207 INSJ/RPLCMT PRM PM W/TRANSVNS ELTRD VENTR 838.60 090 K 33208 INSJ/RPLCMT PRM PM W/TRANSVNS ELTRD ATR&VENTR 905.63 090 K 33210 INSJ/RPLCMT TEMP TRANSVNS 1CHMBR ELTRD/PM CATH 310.74 000 K 33211 INSJ/RPLCMT TEMP TRANSVNS 2CHMBR PACG ELTRDS SPX 315.72 000 K 33212 INSJ/RPLCMT PM PLS GEN ONLY 1CHMBR ATR/VENTR 583.26 090 K 33213 INSJ/RPLCMT PM PLS GEN ONLY 2CHMBR 665.23 090 K 33214 UPG PM SYS CONV 1CHMBR SYS 2CHMBR SYS 830.30 090 33215 RPSG PREV IMPLTED PM/CVDFB R ATR/R VENTR ELTRD 526.76 090 K 33216 INSJ 1 TRANSVNS ELTRD PERM PACEMAKER OR CVDFB 650.28 090 K 33217 INSJ 2 TRANSVNS ELTRD PERM PACEMAKER OR CVDFB 646.40 090 98 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule K 33218 RPR 1 ELTRD 1CHMBR PRM PM/1CHMBR CVDFB 677.97 090 K 33220 RPR 2 ELTRDS 2 CHMBR PRM PM/2CHMBR CVDFB 683.51 090 K 33222 REVISION/RELOCATION SKIN POCKET PACEMAKER 596.55 090 K 33223 REVJ SKN POCKET FOR CARDIOVERTER-DEFIBRILLATOR 716.19 090 33224 INSJ ELTRD CAR VEN SYS ATTCH PM/CVDFB PLS GEN 877.38 000 + 33225 INSJ ELTRD CAR VEN SYS TM INSJ CVDFB/PM PLS GEN 790.97 ZZZ 33226 RPSG PREV IMPLTED CAR VEN SYS L VENTR ELTRD 844.70 000 K 33233 REMOVAL PERMANENT PACEMAKER PULSE GENERATOR 412.10 090 K 33234 RMVL TRANSVNS PM ELTRD 1 LEAD SYS ATR/VENTR 840.27 090 K 33235 RMVL TRANSVNS PM ELTRD DUAL LEAD SYS 1096.72 090 33236 RMVL PRM EPICAR PM&ELTRDS THORCOM 1 LEAD SYS 1332.68 090 33237 RMVL PRM EPICAR PM&ELTRDS THORCOM DUAL LEAD SYS 1427.40 090 33238 RMVL PRM TRANSVNS ELTRD THORCOM 1587.48 090 K 33240 INSJ 1/2CHMBR PACG CVDFB PLS GEN 800.39 090 K 33241 SUBQ RMVL 1/2CHMBR PACG CVDFB PLS GEN 388.28 090 33243 RMVL 1/2CHMBR PACG CVDFB ELTRD THORCOM 2334.69 090 K 33244 RMVL 1/2CHMBR PACG CVDFB ELTRD TRANSVNS XTRJ 1476.70 090 K 33249 INSJ/RPSG LEAD 1/2CHMBR CVDFB&INSJ PLS GEN 1569.20 090 33250 ABLTJ ARRHYTGNIC FOC/PTHWY TRC&/FOC 2507.51 090 33251 ABLTJ ARRHYTGNIC FOC/PTHWY TRC&/FOC CARD BYP 2780.58 090 33254 ABLATION & RCNSTJ ATRIA LMTD 2330.81 090 33255 ABLATION & RCNSTJ ATRIA X10SV W/O BYPASS 2828.21 090 33256 ABLATION & RCNSTJ ATRIA X10SV W/BYPASS 3361.62 090 + 33257 ATRIA ABLATE & RCNSTJ W OTHER PROCEDURE LIMITED 993.70 ZZZ + 33258 ATRIA ABLTJ &RCNSTJ W OTHER PX EXTENSIVE W/O BYP 1117.77 ZZZ + 33259 ATRIA ABLATE &RCNSTJ W OTHER PX EXTENSIVE W BYP 1443.46 ZZZ 33261 OPRATIVE ABLTJ VENTR ARRHYTGNIC FOC W/CARD BYP 2769.50 090 33265 NDSC ABLATION & RCNSTJ ATRIA LMTD W/O BYPASS 2303.12 090 33266 NDSC ABLATION & RCNSTJ ATRIA X10SV W/O BYPASS 3148.92 090 33282 IMPLANTATION PT-ACTIVATED CARDIAC EVENT RECORDER 558.89 090 33284 RMVL IMPLANTABLE PT-ACTIVATED CAR EVENT RECORDER 402.13 090 33300 REPAIR CARDIAC WOUND W/O BYPASS 4112.15 090 33305 REPAIR CARDIAC WOUND W/CARDIOPULMONARY BYPASS 6915.44 090 33310 CARDIOT EXPL W/RMVL FB ATR/VENTR THRMB W/O BYP 1969.67 090 33315 CARDIOT EXPL RMVL FB ATR/VENTR THRMB CARD BYP 2525.78 090 33320 SUTR RPR AORTA/GRT VSL W/O SHUNT/CARD BYP 1806.82 090 33321 SUTR RPR AORTA/GRT VSL W/SHUNT BYP 2019.52 090 33322 SUTR RPR AORTA/GRT VSL W/CARD BYP 2374.02 090 33330 INSJ GRF AORTA/GRT VSL W/O SHUNT/CARD BYP 2428.30 090 33332 INSJ GRF AORTA/GRT VSL W/SHUNT BYP 2382.32 090 33335 INSJ GRF AORTA/GRT VSL W/CARD BYP 3215.39 090 33400 VLVP AORTIC VALVE OPN W/CARD BYP 3905.55 090 33401 VLVP AORTIC VALVE OPN W/INFL OCCLUSION 2445.47 090 33403 VLVP AORTIC VALVE W/TRANSVENTR DILAT W/CARD BYP 2555.69 090 33404 CONSTRUCTION APICAL-AORTIC CONDUIT 3001.58 090 33405 RPLCMT A-VALVE PROSTC XCP HOMOGRF/STENT< VALVE 3926.60 090 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 99
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 33406 RPLCMT A-VALVE ALGRFT VALVE FRHAND 4919.19 090 33410 RPLCMT A-VALVE STENT< TISS VALVE 4353.65 090 s 33411 RPLCMT AORTIC VALVE ANNULUS ENLGMENT NONC SINUS 5731.20 090 33412 RPLCMT A-VALVE KONNO PROCEDURE 4221.83 090 33413 RPLCMT A-VALVE ROSS PX 5531.80 090 33414 RPR VENTR O/F TRC OBSTRCJ PATCH ENLGMENT O/F TRC 3711.68 090 33415 RESCJ/INC SUBVALVULAR TISSUE 3443.04 090 33416 VENTRICULOMYOTOMY-MYECTOMY 3465.75 090 33417 AORTOPLASTY SUPRAVALVULAR STENOSIS 2852.59 090 33420 VALVOTOMY MITRAL VALVE CLOSED HEART 2380.11 090 33422 VALVOTOMY MITRAL VALVE OPN HRT W/CARD BYP 2885.82 090 33425 VLVP MITRAL VALVE W/CARD BYP 4629.50 090 33426 VLVP MITRAL VALVE W/CARD BYP W/PROSTC RING 4092.77 090 33427 VLVP MITRAL VALVE W/CARD BYP RAD RCNSTJ +-RING 4213.52 090 33430 REPLACEMENT MITRAL VALVE W/CARDIOPULMONARY BYP 4792.90 090 33460 VALVECTOMY TRICUSPID VALVE W/CARDIOPULMONARY BYP 4121.57 090 33463 VALVULOPLASTY TRICUSPID VALVE W/O RING INSERTION 5243.22 090 33464 VALVULOPLASTY TRICUSPID VALVE W/RING INSERTION 4166.44 090 33465 REPLACEMENT TRICUSPID VALVE W/CARD BYPASS 4683.22 090 33468 TRICUSPID VALVE RPSG&PLCTJ EBSTEIN ANOMALY 3188.80 090 33470 VALVOTOMY PULMONARY VALVE CLSD HEART TRANSVENTR 2143.59 090 33471 VALVOTOMY PULM VALVE CLSD HRT VIA P-ART 2067.71 090 33472 VALVOTOMY PULM VALVE OPN HRT W/INFL OCCLUSION 2023.40 090 33474 VALVOTOMY PULM VALVE OPN HRT W/CARD BYP 3618.63 090 33475 REPLACEMENT PULMONARY VALVE 3994.73 090 33476 R VENTR RESCJ INFUND STEN +-COMMISSUROTOMY 2577.30 090 33478 O/F TRC AGMNTJ +-COMMISSUROTOMY/INFUND RESCJ 2683.65 090 33496 RPR NON-STRUCTURAL PROSTC VALVE DYSF CARD BYP 2849.26 090 33500 RPR C ARVEN/ARTERIOCAR CHAMBER FSTL W/CARD BYP 2694.72 090 33501 RPR C ARVEN/ARTERIOCAR CHAMBER FSTL W/O CARD BYP 1911.51 090 33502 RPR ANOM C ART FROM P-ART ORIGIN LIG 2170.73 090 33503 RPR ANOM C ART FROM P-ART ORIGIN GRF 2267.11 090 33504 RPR ANOM C ART FROM P-ART ORIGIN GRF W/CARD BYP 2487.56 090 33505 RPR ANOM C ART W/CONSTJ INTRAP-ART TUNNEL 3525.57 090 33506 RPR ANOM C ART FROM P-ART TO AORTA 3696.17 090 33507 RPR ANOM AORTIC ORIGIN C ART UNROOFING/TLCJ 2936.22 090 + 33508 NDSC SURG W/VID-ASSTD HARVEST VEIN CAB 27.70 ZZZ 33510 CORONARY ARTERY BYPASS 1 CORONARY VENOUS GRAFT 3343.34 090 33511 CORONARY ARTERY BYPASS 2 CORONARY VENOUS GRAFTS 3662.94 090 33512 CORONARY ARTERY BYPASS 3 CORONARY VENOUS GRAFTS 4154.80 090 33513 CORONARY ARTERY BYPASS 4 CORONARY VENOUS GRAFTS 4257.83 090 33514 CORONARY ARTERY BYPASS 5 CORONARY VENOUS GRAFTS 4507.08 090 33516 CORONARY ARTERY BYPASS 6/+ CORONARY VENOUS GRAFT 4697.63 090 + 33517 CORONARY ARTERY BYP W VEIN &ARTERY GRAFT 1 VEIN 321.26 ZZZ + 33518 CORONARY ARTERY BYP W VEIN &ARTERY GRAFT 2 VEIN 704.56 ZZZ + 33519 CORONARY ARTERY BYP W VEIN &ARTERY GRAFT 3 VEIN 933.88 ZZZ 100 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule + 33521 CORONARY ARTERY BYP W VEIN &ARTERY GRAFT 4 VEIN 1124.97 ZZZ + 33522 CORONARY ARTERY BYP W VEIN &ARTERY GRAFT 5 VEIN 1266.77 ZZZ + 33523 CORONARY ARTERY BYP W VEIN &ARTERY GRAFT 6 VEIN 1437.92 ZZZ + 33530 ROPRTJ CAB/VALVE PX > 1 MO AFTER ORIGINAL OPERJ 897.32 ZZZ 33533 CAB W/ARTL GRF 1 ARTL GRF 3234.78 090 33534 CAB W/ARTL GRF 2 C ARTL GRFS 3795.32 090 33535 CAB W/ARTL GRF 3 C ARTL GRFS 4227.36 090 33536 CAB W/ARTL GRF 4/> C ARTL GRFS 4546.97 090 33542 MYOCARDIAL RESECTION 4468.87 090 33545 RPR POSTINFRCJ VENTR SEPTAL DFCT 5252.08 090 33548 SURG VENTR RSTRJ PX W/PROSTC PATCH PFRMD 5096.43 090 + 33572 C ENDARTERCOMY OPN ANY METH 399.36 ZZZ 33600 CLSR ATRIOVENTRICULAR VALVE SUTURE/PATCH 2899.67 090 33602 CLSR SEMILUNAR VALVE AORTIC/PULM SUTR/PATCH 2763.96 090 33606 ANAST P-ART AORTA DAMUS-KAYE-STANSEL PX 3030.39 090 33608 RPR CAR ANOMAL XCP PULM ATRESIA VENTR SEPTL DFCT 3064.17 090 33610 RPR CAR ANOMAL SURG ENLGMENT VENTR SEPTL DFCT 3002.69 090 33611 RPR 2 OUTLET R VNTRC W/INTRAVENTR TUNNEL RPR 3351.65 090 33612 RPR 2 OUTLET R VNTRC RPR R VENTR O/F TRC OBSTRCJ 3363.83 090 33615 RPR CAR ANOMAL CLSR SEPTL DFCT SMPL FONTAN PX 3409.81 090 33617 RPR CPLX CAR ANOMAL MODF FONTAN PX 3654.63 090 33619 RPR 1 VNTRC W/O/F OBSTRCJ&AORTIC ARCH HYPOPLASIA 4642.24 090 l 33620 APPLICATION RIGHT & LEFT PULMONARY ARTERY BANDS 2819.35 090 l 33621 TTHRC CATHETER INSERT FOR STENT PLACEMENT 1513.81 090 l 33622 RECONSTRUCTION COMPLEX CARDIAC ANOMALY 5936.70 090 33641 RPR ATR SEPTAL DFCT SECUNDUM W/CARD BYP +-PATCH 2791.66 090 33645 DIR/PATCH CLSR SINUS VENOSUS +-ANOM PULM VEN DRG 2705.80 090 33647 RPR ATR&VENTR SEPTAL DFCT DIR/PATCH CLSR 2892.47 090 33660 RPR INCOMPL/PRTL AV CANAL +-AV VALVE RPR 3176.62 090 33665 RPR INTRM/TRANSJ AV CANAL +-AV VALVE RPR 3286.84 090 33670 RPR COMPL AV CANAL +-PROSTC VALVE 3392.64 090 33675 CLOSURE MULTIPLE VENTRICULAR SEPTAL DEFECTS 3374.91 090 33676 CLOSURE MULTIPLE VSD W/RESECTION 3196.00 090 33677 CLOSURE MULTIPLE VSD W/REMOVAL ARTERY BAND 3155.57 090 33681 CLSR 1 VENTR SEPTAL DFCT +- PATCH 3135.07 090 33684 CLSR V-SEPTL DFCT W/PULM VLVT/INFUND RESCJ 3242.53 090 33688 CLSR V-SEPTL DFCT W/RMVL P-ART BAND +-GUSSET 3213.17 090 33690 BANDING PULMONARY ARTERY 2072.14 090 33692 COMPL RPR TETRALOGY FALLOT W/O PULM ATRESIA 2751.22 090 33694 COMPL RPR T-FALLOT W/O PULM ATRESIA TANULR PATCH 3359.40 090 33697 COMPL RPR T-FALLOT W/PULM ATRESIA 3561.02 090 33702 RPR SINUS VALSALVA FISTULA 2634.90 090 33710 RPR SINUS VALSALVA FSTL W/RPR V-SEPTL DFCT 3022.08 090 33720 RPR SINUS VALSALVA ANEURYSM 2622.72 090 33722 CLOSURE AORTICO-LEFT VENTRICULAR TUNNEL 2826.55 090 33724 REPAIR ISOLATED PARTIAL PULM VENOUS RETURN 2634.90 090 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 101
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 33726 REPAIR PULMONARY VENOUS STENOSIS 3597.03 090 33730 COMPL RPR ANOM VEN RETURN 3385.44 090 33732 RPR C TRIATM/SUPVALVR RING RESCJ L ATR MEMB 2818.24 090 33735 ATR SEPTECT/SEPTOST CLSD HRT 2198.43 090 33736 ATR SEPTECT/SEPTOST OPN HRT W/CARD BYP 2395.62 090 33737 ATR SEPTECT/SEPTOST OPN HRT W/INFL OCCLUSION 2195.11 090 33750 SHUNT SUBCLA P-ART 2342.44 090 33755 SHUNT ASCENDING AORTA P-ART 2187.91 090 33762 SHUNT DESCENDING AORTA P-ART 2016.20 090 33764 SHUNT CTR W/PROSTC GRF 2202.86 090 33766 SHUNT SUPRIOR V/C P-ART FLO 1 LNG 2284.84 090 33767 SHUNT SUPRIOR V/C P-ART FLO BTH LNGS 2419.44 090 + 33768 ANAST CAVOPULM 2ND SUPRIOR V/C 662.46 ZZZ 33770 RPR TGA W/O SURG ENLGMNT V-SEPTL DFCT 3600.90 090 33771 RPR TGA ENLGMNT V-SEPTL DFCT 3430.86 090 33774 RPR TGA ATR BAFFLE W/CARD BYP 3076.91 090 33775 RPR TGA ATR BAFFLE W/RMVL PULM BAND 2922.93 090 33776 RPR TGA ATR BAFFLE W/CLSR V-SEPTL DFCT 3086.88 090 33777 RPR TGA ATR BAFFLE RPR SBPULMC OBSTRCJ 2846.49 090 33778 RPR TGA AORTIC P-ART RCNSTJ 3707.81 090 33779 RPR TGA AORTIC P-ART RCNSTJ W/RMVL PULM BAND 3677.90 090 33780 RPR TGA AORTIC P-ART RCNSTJ W/CLSR V-SEPTL DFCT 3772.06 090 33781 RPR TGA AORTIC P-ART RCNSTJ RPR SBPULMC OBSTRCJ 3645.77 090 33782 A-ROOT TLCJ VSD PULM STNS RPR W/O C OST RIMPLTJ 5438.19 090 33783 A-ROOT TLCJ VSD PULM STNS RPR W/ RIMPLTJ C OSTIA 5877.43 090 33786 TOTAL REPAIR TRUNCUS ARTERIOSUS 3496.22 090 33788 REIMPLANTATION ANOMALOUS PULMONARY ARTERY 2360.17 090 33800 AORTIC SSP TRACHEAL DCMPRN SPX 1671.67 090 33802 DIVISION ABERRANT VESSEL VASCULAR RING 1882.15 090 33803 DIVISION ABERRANT VESSEL W/REANASTOMOSIS 1948.07 090 33813 OBLTRJ AORTOPULM SEPTAL DFCT W/O CARD BYP 2181.81 090 33814 OBLTRJ AORTOPULM SEPTAL DFCT W/CARD BYP 2599.45 090 33820 REPAIR PATENT DUCTUS ARTERIOSUS LIGATION 1663.36 090 33822 RPR PATENT DUXUS ARTERIOSUS DIV UNDER 18 YR 1608.53 090 33824 RPR PATENT DUXUS ARTERIOSUS DIV 18 YR&OLDER 2023.40 090 33840 EXC COARCJ AORTA +-PDA W/DIR ANAST 2148.02 090 33845 EXC COARCTATION AORTA +-PDA W/GRF 2308.66 090 33851 EXC COARCJ AORTA W/L SUBCLA ART/PROSTC AS GUSSET 2357.95 090 33852 RPR HYPOPLSTC A-ARCH W/AGRFT/PROSTC 2377.34 090 33853 RPR HYPOPLSTC A-ARCH AGRFT/PROSTC CARD BYP 3177.17 090 s 33860 ASCENDING AORTA GRF W/CARD BYP & VALVE SSP 5470.87 090 s 33863 AS-AORT GRF W/CARD BYP & AORTIC ROOT RPLCMT 5394.43 090 s 33864 ASCENDING AORTA GRF VALVE SPARE ROOT REMODEL 5522.38 090 33870 TRANSVERSE ARCH GRAFT W/CARDIOPULMONARY BYPASS 4316.54 090 33875 DESCENDING THORACIC AORTA GRAFT +-BYPASS 3401.50 090 33877 RPR THORACOAAA W/GRF +-CARD BYP 6179.31 090 102 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule 33880 EVASC RPR DTA COVERAGE ART ORIGIN 1ST ENDOPROSTH 3136.18 090 33881 EVASC RPR DTA EXP COVERAGE W/O ART ORIGIN 2698.05 090 33883 PLMT PROX XTN PROSTH EVASC RPR DTA 1ST XTN 1955.82 090 + 33884 PLMT PROX XTN PROSTH EVASC RPR DTA EA PROX XTN 712.87 ZZZ 33886 PLMT DSTL XTN PROSTH DLYD AFTER EVASC RPR DTA 1697.70 090 33889 OPN SUBCLA CRTD ART TRPOS NCK INC ULAT 1395.27 000 33891 BYP GRF W/DTA RPR NCK INC 1723.18 000 33910 PULMONARY ARTERY EMBOLECTOMY W/CARD BYPASS 2864.77 090 33915 PULMONARY ARTERY EMBOLECTOMY W/O CARD BYPASS 2314.75 090 33916 PULM ENDARTERCOMY +-EMBOLECTOMY W/CARD BYP 2794.43 090 33917 RPR P-ART STENOSIS RCNSTJ W/PATCH/GRF 2510.27 090 33920 RPR PULM ATRESIA W/CONSTJ/RPLCMT CONDUIT 3105.72 090 33922 TRANSECTION PULMONARY ARTERY W/CARD BYPASS 2365.15 090 + 33924 LIG&TKDN SYSIC-TO-P-ART SHUNT W/CGEN HRT PX 485.22 ZZZ 33925 RPR P-ART ARBORIZJ ANOMAL UNIFCLIZJ W/O CARD BYP 2947.86 090 33926 RPR P-ART ARBORIZJ ANOMAL UNIFCLIZJ W/CARD BYP 4309.90 090 33930 DONOR CARDIECTOMY-PNEUMONECTOMY BR XXX 33933 BKBENCH PREPJ CDVR DON HRT/LNG ALGRFT BR XXX 33935 HRT-LNG TRNSPL W/RCP CARDIECTOMY-PNUMEC 5912.88 090 33940 DONOR CARDIECTOMY BR XXX 33944 BKBENCH STANDARD PREPJ CDVR DON HRT ALGRFT BR XXX 33945 HEART TRANSPLANT +-RECIPIENT CARDIECTOMY 8189.97 090 33960 PROLNG XTRCORP CRCJ 1ST 24 HR 1674.44 000 + 33961 PROLNG XTRCORP CRCJ EA 24 HR 925.01 ZZZ 33967 INSERTION INTRA-AORTIC BALLOON ASSIST DEV PRQ 457.52 000 33968 REMOVAL INTRA-AORTIC BALLOON ASSIST DEVICE PRQ 58.71 000 33970 INSJ I-AORT BALO ASSIST DEV THRU FEM ART OPN 617.60 000 33971 RMVL I-AORT BALO ASSIST DEV W/RPR FEM ART +-GRF 1218.03 090 33973 INSJ I-AORT BALO ASSIST DEV THRU AS-AORT 896.21 000 33974 RMVL I-AORT BALO DEV FROM AS-AORT RPR AS-AORT 1536.52 090 33975 INSJ VENTR ASSIST DEV XTRCORP 1 VNTRC 1880.49 XXX 33976 INSJ VENTR ASSIST DEV XTRCORP BIVENTR 2086.54 XXX 33977 REMOVAL VENTR ASSIST DEVICE XTRCORP 1 VENTRICLE 2051.09 090 33978 REMOVAL VENTR ASSIST DEVICE XTRCORP BIVENTR 2279.85 090 33979 INSJ VENTR ASSIST DEV IMPLTABLE ICORP 1 VNTRC 4112.15 XXX 33980 RMVL VENTR ASSIST DEV IMPLTABLE ICORP 1 VNTRC 6175.99 090 33981 RPLCMT XTRCORP VAD 1/BIVENTR PUMP 1/EA PUMP BR XXX 33982 RPLCMT VAD PMP IMPLTBL ICORP 1 VNTR W/O CARD BYP BR XXX 33983 RPLCMT VAD PMP IMPLTBL ICORP 1 VNTR W/CARD BYP BR XXX 33999 UNLISTED CARDIAC SURGERY BR YYY 34001 EMBLC/THRMBC CATH CRTD SUBCLA/INNOMINATE ART 1692.16 090 34051 EMBLC/THRMBC INNOMINATE SUBCLA ART 1683.86 090 34101 EMBLC/THRMBC AX BRACH INNOMINATE SUBCLA ART 1056.84 090 34111 EMBLC/THRMBC +-CATH RDL/UR ART ARM INC 1056.29 090 34151 EMBLC/THRMBC RNL CELIAC MESENTERY A-ILIAC ART 2441.04 090 34201 EMBLC/THRMBC FEMPOP A-ILIAC ART 1790.20 090 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 103
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 34203 EMBLC/THRMBC POP-TIBIO-PRONEAL ART LEG INC 1688.29 090 34401 THRMBC DIR/W/CATH V/C ILIAC VEIN ABDL INC 2552.37 090 34421 THRMBC DIR/W/CATH V/C ILIAC FEMPOP VEIN LEG INC 1285.05 090 34451 THRMBC DIR/W/CATH V/C ILIAC FEMPOP VEIN ABDL&LEG 2585.05 090 34471 THRMBC DIR/W/CATH SUBCLA VEIN NCK INC 1995.15 090 34490 THRMBC DIR/W/CATH AX&SUBCLA VEIN ARM INC 1067.92 090 34501 VALVULOPLASTY FEMORAL VEIN 1611.30 090 34502 RECONSTRUCTION VENA CAVA ANY METHOD 2626.04 090 34510 VENOUS VALVE TRANSPOSITION ANY VEIN DONOR 1925.36 090 34520 CROSS-OVER VEIN GRAFT VENOUS SYSTEM 1776.91 090 34530 SAPHENOPOPLITEAL VEIN ANASTOMOSIS 1664.47 090 34800 EVASC RPR AAA W/AORTO-AORTIC TUBE PROSTH 1973.55 090 34802 EVASC RPR AAA W/MDLR BFRC PROSTH 1 LIMB 2181.26 090 34803 EVASC RPR AAA W/MDLR BFRC PROSTH 2 LIMBS 2253.82 090 34804 EVASC RPR AAA W/UNIBDY BFRC PROSTH 2183.47 090 34805 EVASC RPR AAA AORTO-UNIILIAC/AORTO-UNIFEM PROSTH 2076.02 090 + 34806 TCAT PLACEMENT PHYSIOLOGIC SENSOR ANEURYSMAL SAC 180.02 ZZZ + 34808 EVASC PLMT ILIAC ART OCCLUSION DEV 357.82 ZZZ 34812 OPN FEM ART EXPOS DLVR EVASC PROSTH UNI 588.24 000 + 34813 PLMT FEM-FEM PROSTC GRF EVASC AORTIC ARYSM RPR 415.43 ZZZ 34820 ILIAC ART EXPOS PROSTH/ILIAC OCCLS EVASC UNI 848.02 000 34825 PLMT XTN PROSTH EVASC RPR ARYSM/DSJ 1ST VSL 1223.57 090 + 34826 PLMT XTN PROSTH EVASC RPR ARYSM/DSJ EA VSL 358.93 ZZZ 34830 OPN RPR ARYSM RPR ARTL TRAUMA TUBE PROSTH 3159.45 090 34831 OPN RPR ARYSM RPR ARTL TRMA AORTOBIILIAC PROSTH 3371.04 090 34832 OPN RPR ARYSM RPR ARTL TRMA AORTO-BIFEM PROSTH 3397.07 090 34833 ILIAC ART EXPOS W/CRTJ CONDUIT UNI 1066.26 000 34834 BRACH ART EXPOS DPLMNT AORTIC/ILIAC PROSTH UNI 481.89 000 s 34900 EVASC RPR ILIAC ART ILIO-ILIAC PROSTHESIS 1570.86 090 35001 DIR RPR ARYSM/&GRF INSJ CRTD SUBCLA ART 1973.55 090 35002 DIR RPR ARYSM&GRF INSJ RPTD ARYSM CRTD SUBCLA 2021.74 090 35005 DIR RPR ARYSM&GRF INSJ VRT ART 1917.05 090 35011 DIR RPR ARYSM&GRF INSJ AX-BRACH ART 1740.35 090 35013 DIR RPR ARYSM&GRF INSJ AX-BRACH ART 2177.93 090 35021 DIR RPR ARYSM&GRF INSJ INNOMINATE SUBCLA ART 2066.05 090 35022 DIR RPR ARYSM&GRF RPTD ARYSM INNOM SUBCLA ART 2421.10 090 35045 DIR RPR ARYSM&GRF INSJ RDL/UR ART 1706.57 090 35081 DIR RPR ARYSM&GRF INSJ ABDL AORTA 3070.82 090 35082 DIR RPR ARYSM&GRF INSJ RPTD ARYSM ABDL AORTA 3829.66 090 35091 DIR RPR ARYSM&GRF INSJ ABDL AORTA VISC VSL 3166.09 090 35092 DIR RPR ARYSM&GRF RPTD ARYSM ABDL AORTA VISC VSL 4563.03 090 35102 DIR RPR ARYSM&GRF INSJ ABDL AORTA ILIAC VSL 3316.75 090 35103 DIR RPR ARYSM&GRF RPTD ARYSM ABDL AORTA ILIAC 3928.81 090 35111 DIR RPR ARYSM&GRF INSJ SPLENIC ART 2487.01 090 35112 DIR RPR ARYSM&GRF INSJ RPTD ARYSM SPLENIC ART 3052.54 090 35121 DIR RPR ARYSM&GRF INSJ HEPATC CELIAC RNL/MSN ART 2887.48 090 104 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule 35122 DIR RPR ARYSM&GRF RPTD ARYSM HEPATC CEL RNL/MSN 3349.43 090 35131 DIR RPR ARYSM&GRF INSJ ILIAC ART 2444.36 090 35132 DIR RPR ARYSM&GRF INSJ RPTD ARYSM ILIAC ART 2912.41 090 35141 DIR RPR ARYSM&GRF INSJ COMMON FEM ART 1943.64 090 35142 DIR RPR ARYSM&GRF INSJ RPTD ARYSM COMMON FEM ART 2328.04 090 35151 DIR RPR ARYSM&GRF INSJ POP ART 2194.00 090 35152 DIR RPR ARYSM&GRF INSJ RPTD ARYSM POP ART 2513.04 090 35180 REPAIR CONGENITAL ARTERIOVENOUS FISTULA HEAD&NCK 1593.02 090 35182 RPR CONGENITAL ARTERIOVENOUS FISTULA THORAX&ABD 2959.49 090 35184 RPR CONGENITAL ARTERIOVENOUS FISTULA EXTREMITIES 1766.94 090 35188 RPR/TRAUMTC ARVEN FSTL HEAD&NCK 1423.52 090 35189 RPR/TRAUMTC ARVEN FSTL THORAX&ABD 2889.70 090 35190 RPR/TRAUMTC ARVEN FSTL XTR 1303.33 090 35201 REPAIR BLOOD VESSEL DIRECT NECK 1625.70 090 35206 REPAIR BLOOD VESSEL DIRECT UPPER EXTREMITY 1334.90 090 35207 REPAIR BLOOD VESSEL DIRECT HAND FINGER 1221.90 090 35211 RPR BLOOD VESSEL DIRECT INTRATHORACIC W/BYPASS 2367.92 090 35216 RPR BLOOD VESSEL DIRECT INTRATHORACIC W/O BYPASS 3443.60 090 35221 RPR BLOOD VESSEL DIRECT INTRA-ABDOMINAL 2446.58 090 35226 RPR BLOOD VESSEL DIRECT LOWER EXTREMITY 1461.19 090 35231 REPAIR BLOOD VESSEL W/VEIN GRAFT NECK 2020.07 090 35236 REPAIR BLOOD VESSEL W/VEIN GRAFT UPPER EXTREMITY 1696.60 090 35241 RPR BLOOD VESSEL VEIN GRAFT INTRATHORACIC W/BYP 2493.10 090 35246 RPR BLOOD VESSEL VEIN GRF INTRATHORACIC W/O BYP 2600.01 090 35251 REPAIR BLOOD VESSEL VEIN GRAFT INTRA-ABDOMINAL 2898.00 090 35256 REPAIR BLOOD VESSEL VEIN GRAFT LOWER EXTREMITY 1778.02 090 35261 REPAIR BLOOD VESSEL W/GRAFT OTHER/THAN VEIN NECK 1827.87 090 35266 RPR BLOOD VSL GRF OTH/THN VEIN UPPER EXTREMITY 1502.18 090 35271 RPR BLOOD VSL GRF OTH/THN VEIN INTRATHRC W/BYP 2379.55 090 35276 RPR BLOOD VSL GRF OTH/THN VEIN INTRATHRC W/O BYP 2471.50 090 35281 RPR BLVSL W/GRF OTH/THN VEIN INTRA-ABDL 2777.25 090 35286 RPR BLVSL W/GRF OTH/THN VEIN LXTR 1640.65 090 35301 TEAEC W/PATCH GRF CRTD VRT SUBCLA NCK INC 1840.06 090 35302 TEAEC W/GRAFT SUPERFICIAL FEMORAL ART 1962.47 090 35303 TEAEC W/GRAFT POPLITEAL ART 2164.64 090 35304 TEAEC W/GRAFT TIBIOPERONEAL TRUNK ART 2241.63 090 35305 TEAEC W/GRAFT TIBIAL/PERONEAL ART 1ST VESSEL 2159.66 090 + 35306 TEAEC W/GRAFT EA ADDL TIBIAL/PERONEAL ART 827.53 ZZZ 35311 TEAEC +-PATCH GRF SUBCLA INNOMINATE THRC INC 2644.87 090 35321 TEAEC +-PATCH GRF AX-BRACH 1562.00 090 35331 TEAEC +-PATCH GRF ABDL AORTA 2571.76 090 35341 TEAEC +-PATCH GRF MESENTERIC CELIAC/RNL 2404.48 090 35351 TEAEC +-PATCH GRF ILIAC 2254.93 090 35355 TEAEC +-PATCH GRF ILIOFEM 1828.98 090 35361 TEAEC +-PATCH GRF CMBN AORTOILIAC 2731.83 090 35363 TEAEC +-PATCH GRF CMBN AORTOILIOFEM 3018.20 090 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 105
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 35371 TEAEC +-PATCH GRF COMMON FEM 1444.02 090 35372 TEAEC +-PATCH GRF DP PROFUNDA FEM 1725.95 090 + 35390 ROPRTJ CRTD TEAEC > 1 MO AFTER ORIGINAL OPRATION 279.17 ZZZ + 35400 ANGIOSCOPY NON-C VSL/GRFS THER IVNTJ 261.99 ZZZ 35450 TRLUML BALO ANGIOP OPN RNL/OTH VISC ART 897.87 000 35452 TRLUML BALO ANGIOP OPN AORTIC 624.80 000 35458 TRLUML BALO ANGIOP OPN BRCH/CPHLC TRNK/BRNCH EA 853.01 000 35460 TRLUML BALO ANGIOP OPN VEN 543.93 000 s K 35471 TRLUML BALO ANGIOP PRQ RNL/VISC ART 4816.71 000 K 35472 TRLUML BALO ANGIOP PRQ AORTIC 3487.91 000 K 35475 TRLUML BALO ANGIOP PRQ BRCH/CPHLC TRNK/BRNCH EA 3785.35 000 K 35476 TRLUML BALO ANGIOP PRQ VEN 2860.34 000 + 35500 HARVEST UXTR VEIN 1 SGM LXTR/CAB PX 562.21 ZZZ 35501 BYP W/VEIN COMMON-IPSILATERAL CRTD 2751.78 090 35506 BYP W/VEIN CAROTID-SUBCLA/ SUBCLA CAROTID 2345.77 090 35508 BYP W/VEIN CRTD-VRT 2477.04 090 35509 BYP W/VEIN CAROTID-CONTRALATERAL CAROTID 2613.30 090 35510 BYP W/VEIN CRTD-BRACH 2215.05 090 35511 BYP W/VEIN SUBCLA-SUBCLA 2165.75 090 35512 BYP W/VEIN SUBCLA-BRACH 2165.75 090 35515 BYP W/VEIN SUBCLA-VRT 2349.09 090 35516 BYP W/VEIN SUBCLA-AX 2159.10 090 35518 BYP W/VEIN AX-AX 2067.15 090 35521 BYP W/VEIN AX-FEM 2326.93 090 35522 BYP W/VEIN AX-BRACH 2150.79 090 35523 BYPASS GRAFT WITH VEIN BRACHIAL-ULNAR/-RADIAL 2257.14 090 35525 BYP W/VEIN BRACH-BRACH 2004.56 090 s 35526 BYPASS W/VEIN AORTOSUBCLAV/CAROTID/INNOMINATE 2891.36 090 35531 BYP W/VEIN AORTOCELIAC/AORTOMESENTERIC 3549.95 090 35533 BYP W/VEIN AX-FEM-FEM 2859.23 090 35535 BYPASS GRAFT WITH VEIN HEPATORENAL 3089.65 090 35536 BYP W/VEIN SPLENORNL 3021.52 090 35537 BYP W/VEIN AORTOILIAC 3934.35 090 35538 BYP W/VEIN AORTOBI-ILIAC 4410.15 090 35539 BYP W/VEIN AORTOFEMORAL 3907.76 090 35540 BYP W/VEIN AORTOBIFEMORAL 4464.99 090 35548 BYP W/VEIN AORTOILIOFEM UNI 2079.34 090 35549 BYP W/VEIN AORTOILIOFEM BI 2404.48 090 35551 BYP W/VEIN AORTOFEMPOP 2653.73 090 35556 BYP W/VEIN FEMPOP 2456.55 090 35558 BYP W/VEIN FEM-FEM 2167.41 090 35560 BYP W/VEIN AORTORNL 3064.73 090 35563 BYP W/VEIN ILIOILIAC 2366.26 090 35565 BYP W/VEIN ILIOFEM 2322.50 090 35566 BYP FEM-ANT TIBL PST TIBL PRONEAL ART/OTH DSTL 2943.98 090 35570 BYP TIBL-TIBL/PRONEAL-TIBL/TIBL/PRONEAL TRK-TIBL 2396.73 090 106 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule 35571 BYP W/VEIN POP-TIBL-PRONEAL ART/OTH DSTL VSL 2351.86 090 + 35572 HARVEST FEMPOP VEIN 1 SGM VASC RCNSTJ PX 605.97 ZZZ 35583 IN-SITU VEIN BYP FEMPOP 2540.74 090 35585 IN-SITU FEM-ANT TIBL PST TIBL/PRONEAL ART 2954.50 090 35587 IN-SITU VEIN BYP POP-TIBL PRONEAL 2432.73 090 + 35600 HARVEST UPPER EXTREMITY ART 1 SEGMENT FOR CABG 446.44 ZZZ 35601 BYP OTH/THN VEIN COMMON-IPSILATERAL CRTD 2559.57 090 35606 BYP OTH/THN VEIN CRTD-SUBCLA 2072.14 090 35612 BYP OTH/THN VEIN SUBCLA-SUBCLA 1584.71 090 35616 BYP OTH/THN VEIN SUBCLA-AX 2057.18 090 35621 BYP OTH/THN VEIN AX-FEM 1940.31 090 35623 BYP OTH/THN VEIN AX-POP/-TIBL 2489.23 090 s 35626 BYPASS NOT VEIN AORTOSUBCLA/CAROTID/INNOMINATE 2731.83 090 35631 BYP OTH/THN VEIN AORTOCELIAC AORTOMSN AORTORNL 3253.61 090 35632 BYPASS GRAFT W/OTHER THAN VEIN ILIO-CELIAC 2934.01 090 35633 BYPASS GRAFT W/OTHER THAN VEIN ILIO-MESENTERIC 3205.97 090 35634 BYPASS GRAFT W/OTHER THAN VEIN ILIORENAL 2900.77 090 35636 BYP OTH/THN VEIN SPLENORNL 3019.31 090 35637 BYP OTH/THN VEIN AORTOILIAC 3014.88 090 35638 BYP OTH/THN VEIN AORTOBI-ILIAC 3081.90 090 35642 BYP OTH/THN VEIN CRTD-VRT 1900.43 090 35645 BYP OTH/THN VEIN SUBCLA-VRT 1812.36 090 35646 BYP OTH/THN VEIN AORTOBIFEM 3021.52 090 35647 BYP OTH/THN VEIN AORTOFEM 2744.02 090 35650 BYP OTH/THN VEIN AX-AX 1878.83 090 35651 BYP OTH/THN VEIN AORTOFEMPOP 2350.20 090 35654 BYP OTH/THN VEIN AX-FEM-FEM 2419.44 090 35656 BYP OTH/THN VEIN FEMPOP 1905.97 090 35661 BYP OTH/THN VEIN FEM-FEM 1914.28 090 35663 BYP OTH/THN VEIN ILIOILIAC 2206.74 090 35665 BYP OTH/THN VEIN ILIOFEM 2070.48 090 35666 BYP OTH/THN VEIN FEM-ANT TIBL PST TIBL/PRONEAL 2238.86 090 35671 BYP OTH/THN VEIN POP-TIBL/-PRONEAL ART 1972.44 090 + 35681 BYP COMPOSIT PROSTC&VEIN 140.14 ZZZ + 35682 BYP AUTOG COMPOSIT 2 SEG VEINS FROM 2 LOCATIONS 623.69 ZZZ + 35683 BYP AUTOG COMPOSIT 3/> SEG FROM 2/> LOCATIONS 730.59 ZZZ + 35685 PLMT VEIN PATCH/CUFF DSTL ANAST BYP CONDUIT 351.17 ZZZ + 35686 CRTJ DSTL ARVEN FSTL LXTR BYP SURG NON-HEMO 291.35 ZZZ 35691 TRPOS&/RIMPLTJ VRT CRTD ART 1701.58 090 35693 TRPOS&/RIMPLTJ VRT SUBCLA ART 1507.72 090 35694 TRPOS&/RIMPLTJ SUBCLA CRTD ART 1796.30 090 35695 TRPOS&/RIMPLTJ CRTD SUBCLA ART 1839.50 090 + 35697 RIMPLTJ VISC ART INFRARNL AORTIC PROSTH EA ART 261.44 ZZZ + 35700 ROPRTJ > 1 MO AFTER ORIGINAL OPRATION 269.20 ZZZ 35701 EXPL N/FLWD SURG RPR +-LSS ART CRTD ART 949.38 090 35721 EXPL N/FLWD SURG RPR +-LSS ART FEM ART 790.97 090 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 107
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 35741 EXPL N/FLWD SURG RPR +-LSS ART POP ART 876.82 090 35761 EXPL N/FLWD SURG RPR +-LSS ART OTH VSL 657.48 090 35800 EXPL PO HEMRRG THROMBOSIS/INFCTJ NCK 839.16 090 35820 EXPL PO HEMRRG THROMBOSIS/INFCTJ CH 3388.76 090 35840 EXPL PO HEMRRG THROMBOSIS/INFCTJ ABD 1095.06 090 35860 EXPL PO HEMRRG THROMBOSIS/INFCTJ XTR 707.88 090 35870 RPR GRF-ENTERIC FSTL 2357.95 090 35875 THRMBC ARTL/VEN GRF OTH/THN HEMO GRF/FSTL 1043.55 090 35876 THRMBC ARTL/VEN GRF XCP HEMO GRF/FSTL W/REVJ GRF 1661.15 090 35879 REVJ LXTR ARTL BYP OPN VEIN PATCH ANGIOP 1632.34 090 35881 REVJ LXTR ARTL BYP OPN W/SGMTL VEIN INTERPOS 1807.38 090 35883 REVISION FEMORAL ANAST OPEN NONAUTOG GRAFT 2115.90 090 35884 REVISION FEMORAL ANAST OPEN W/AUTOG GRAFT 2201.75 090 35901 EXC INFCT GRF NCK 880.15 090 35903 EXC INFCT GRF XTR 989.27 090 35905 EXC INFCT GRF THORAX 3013.77 090 35907 EXC INFCT GRF ABD 3374.91 090 36000 INTRO NDL/INTRACATH VEIN 40.99 XXX 36002 NJX PX PRQ TX XTR PSEUDOARYSM 274.73 000 36005 NJX PX XTR VNGRPH W/INTRO NDL/INTRACATH 569.41 000 36010 INTRO CATH SUPRIOR/IVC 925.57 XXX 36011 SLCTV CATH PLMT VEN SYS 1ST ORDER BRANCH 1517.69 XXX 36012 SLCTV CATH PLMT VEN SYS 2ND ORDER/> SLCTV BRANCH 1471.71 XXX 36013 INTRO CATH R HRT/MAIN P-ART 1339.88 XXX 36014 SLCTV CATH PLMT L/R P-ART 1404.69 XXX 36015 SLCTV CATH PLMT SGMTL/SUBSGMTL P-ART 1526.55 XXX 36100 INTRO NDL/INTRACATH CRTD/VRT ART 876.82 XXX 36120 INTRO NDL/INTRACATH RTRGR BRACH ART 744.44 XXX 36140 INTRO NDL/INTRACATH XTR ART 794.85 XXX K 36147 INTRO NDL/CATH AV SHUNT IST ACCESS W/ RAD EVAL 1347.64 XXX + K 36148 INTRO NDL/CATH AV SHUNT ADDL ACCESS THER IVNTJ 424.84 ZZZ 36160 INTRO NDL/INTRACATH AORTIC TRANSLMBR 860.76 XXX 36200 INTRO CATH AORTA 1075.67 XXX 36215 SLCTV CATHJ EA 1ST ORD THRC/BRCH/CPHLC BRNCH 1910.40 XXX 36216 SLCTV CATHJ 1ST 2ND ORD THRC/BRCH/CPHLC BRNCH 2102.05 XXX 36217 SLCTV CATHJ 3RD+ ORD SLCTV THRC/BRCH/CPHLC BRNCH 3432.52 XXX + 36218 SLCTV CATHJ EA 2ND+ ORD THRC/BRCH/CPHLC BRNCH 317.94 ZZZ 36245 SLCTV CATHJ EA 1ST ORD ABDL PEL/LXTR ART BRNCH 2015.64 XXX 36246 SLCTV CATHJ 2ND ORDER ABDL PEL/LXTR ART BRNCH 2036.14 XXX 36247 SLCTV CATHJ 3RD+ ORD SLCTV ABDL PEL/LXTR BRNCH 3200.99 XXX + 36248 SLCTV CATHJ EA 2ND+ ORD ABDL PEL/LXTR ART BRNCH 266.98 ZZZ 36260 INSJ IMPLTABLE IA NFS PMP 1027.48 090 36261 REVJ IMPLTED IA NFS PMP 639.75 090 36262 RMVL IMPLTED IA NFS PMP 482.45 090 36299 UNLIS PX VASC NJX BR YYY 36400 VNPNXR <3 YEARS PHYS SKILL FEM/JUG VEIN 47.64 XXX 108 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule 36405 VNPNXR <3 YEARS PHYS SKILL SCALP VEIN 39.33 XXX 36406 VNPNXR <3 YEARS PHYS SKILL OTHER VEIN 28.25 XXX 36410 VNPNXR 3 YEARS/> PHYS SKILL 29.91 XXX 36415 COLLJ VEN BLD VNPNXR 7.75 XXX 36416 COLLJ CAPILLARY BLD SPEC 7.75 XXX 36420 VNPNXR CUTDOWN UNDER AGE 1 YR 77.55 XXX 36425 VNPNXR CUTDOWN AGE 1/> 65.36 XXX 36430 TRANSFUSION BLD/BLD COMPONENTS 57.05 XXX 36440 PUSH TRANSFUSION BLD 2 YR/UNDER 93.61 XXX 36450 EXCHNG TRANSFUSION BLD NB 186.66 XXX 36455 EXCHNG TRANSFUSION BLD OTH/THN NB 197.19 XXX 36460 TRANSFUSION INTRAUTERINE FTL 592.12 XXX 36468 1/MLT NJXS SCLRSG SLNS SPIDER VEINS LIMB/TRNK BR 000 36469 1/MLT NJXS SCLRSG SLNS SPIDER VEINS FACE BR 000 36470 NJX SCLRSG SLN 1 VEIN 235.96 010 36471 NJX SCLRSG SLN MLT VEINS SM LEG 290.24 010 36475 ENDOVEN ABLTJ INCMPTNT VEIN XTR RF 1ST VEIN 3016.54 000 + 36476 ENDOVEN ABLTJ INCMPTNT VEIN XTR RF 2ND+ VEINS 659.14 ZZZ 36478 ENDOVEN ABLTJ INCMPTNT VEIN XTR LASER 1ST VEIN 2384.54 000 + 36479 ENDOVEN ABLTJ INCMPTNT VEIN XTR LASER 2ND+ VEINS 678.53 ZZZ K 36481 PRQ PORTAL VEIN CATHETERIZATION ANY METHOD 2068.26 000 36500 VEN CATHJ SLCTV ORGAN BLD SAMPLING 305.75 000 36510 CATHJ UMBILICAL VEIN DX/THER NB 173.92 000 36511 THER APHERESIS WHITE BLD CELLS 156.75 000 36512 THER APHERESIS RED BLD CELLS 151.77 000 36513 THER APHERESIS PLTLTS 165.62 000 36514 THER APHERESIS PLSM PHERESIS 849.68 000 36515 THER APHERESIS W/XTRCORP IMMUNODSPTJ&PLSM RENFS 3165.54 000 36516 THER APHRS XTRCORP SLCTV ADSRPJ/FILTRJ&RENFS 3498.99 000 36522 PHOTOPHERESIS XTRCORP 2226.12 000 K 36555 INSJ NON-TUN CTR CVC UNDER 5 YR 441.46 000 36556 INSJ NON-TUN CTR CVC AGE 5 YR/> 384.41 000 K 36557 INSJ TUN CTR CVC W/O SUBQ PORT/PMP UNDER 5 YR 1540.95 010 K 36558 INSJ TUN CTR CVC W/O SUBQ PORT/PMP AGE 5 YR/> 1326.59 010 K 36560 INSJ TUN CTR CTR VAD W/SUBQ PORT UNDER 5 YR 2076.02 010 K 36561 INSJ TUN CTR CTR VAD W/SUBQ PORT AGE 5 YR/> 1943.64 010 K 36563 INSJ TUN CTR CTR VAD W/SUBQ PMP 2066.60 010 K 36565 INSJ TUN VAD REQ 2 CATH 2 SITS W/O SUBQ PORT/PMP 1651.18 010 K 36566 INSJ TUN VAD REQ 2 CATH 2 SITS W/SUBQ PORT 7343.05 010 K 36568 INSJ PRPH CVC W/O SUBQ PORT/PMP UNDER 5 YR 489.09 000 36569 INSJ PRPH CVC W/O SUBQ PORT/PMP AGE 5 YR/> 423.73 000 K 36570 INSJ PRPH CTR VAD W/SUBQ PORT UNDER 5 YR 1850.58 010 K 36571 INSJ PRPH CTR VAD W/SUBQ PORT AGE 5 YR/> 2090.42 010 36575 RPR TUN/NON-TUN CTR VAD CATH W/O SUBQ PORT/PMP 266.43 000 K 36576 RPR CTR VAD W/SUBQ PORT/PMP CTR/PRPH INSJ SIT 615.94 010 K 36578 RPLCMT CATH CTR VAD SUBQ PORT/PMP 841.93 010 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 109
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 36580 RPLCMT COMPL NON-TUN CVC W/O SUBQ PORT/PMP 367.24 000 K 36581 RPLCMT COMPL TUN CVC W/O SUBQ PORT/PMP 1259.57 010 K 36582 RPLCMT COMPL TUN CTR VAD W/SUBQ PORT 1810.70 010 K 36583 RPLCMT COMPL TUN CTR VAD W/SUBQ PMP 2018.41 010 36584 RPLCMT COMPL PRPH CVC W/O SUBQ PORT/PMP 352.28 000 K 36585 RPLCMT COMPL PRPH CTR VAD W/SUBQ PORT 1819.56 010 36589 RMVL TUN CVC W/O SUBQ PORT/PMP 276.95 010 K 36590 RMVL TUN CTR VAD W/SUBQ PORT/PMP CTR/PRPH INSJ 470.82 010 36591 COLLECT BLOOD FROM IMPLANT VENOUS ACCESS DEVICE 37.67 XXX 36592 COLLECT BLOOD FROM CATHETER VENOUS NOS 42.10 XXX 36593 DECLOT BY THROMBOLYTIC AGENT IMPLANT DEVICE/CATH 47.08 XXX 36595 MCHNL RMVL PRICATH OBSTR CV DEV VIA VEN ACCESS 969.33 000 36596 MCHNL RMVL INTRAL OBSTR CV DEV THRU DEV LUMEN 223.22 000 36597 RPSG PREVIOUSLY PLACED CVC UNDER FLUOR GDN 206.60 000 36598 CNTRST NJX RAD EVAL CTR VAD FLUOR IMG&REPRT 186.11 000 36600 ARTL PNXR W/DRAWAL BLD DX 50.40 XXX * 36620 ARTL CATHJ/CANNULJ MNTR/TRANSFUSION SPX PRQ 83.09 000 36625 ARTL CATHJ/CANNULJ MNTR/TRANSFUSION SPX CUTDOWN 178.91 000 36640 ARTL CATHJ PROLNG NFS THER CHEMOTX CUTDOWN 211.04 000 36660 CATHETERIZATION UMBILICAL NEWBORN ART DX/THERAPY 125.74 000 36680 PLMT NDL INTRAOSS NFS 99.15 000 36800 INSJ CANNULA HEMO OTH PURPOSE SPX VEIN VEIN 268.64 000 36810 INSJ CANNULA HEMO OTH PURPOSE SPX ARVEN XTRNL 356.16 000 36815 INSJ CANNULA HEMO OTH SPX ARVEN XTRNL REVJ/CLSR 254.79 000 36818 ARVEN ANAST OPN UPR ARM CEPHALIC VEIN TRPOS 1152.11 090 36819 ARVEN ANAST OPN UPR ARM BASILIC VEIN TRPOS 1372.01 090 36820 ARVEN ANAST OPN F/ARM VEIN TRPOS 1381.98 090 36821 ARTERIOVENOUS ANASTOMOSIS OPEN DIRECT 1177.04 090 36822 INSJ CANNULA PROLNG XC-CIRCJ ECMO SPX 645.29 090 36823 INSJ CNULA ISLTD XC-CIRCJ REG CHEMOTX XTR RMVL 2210.06 090 36825 CRTJ ARVEN FSTL XCP DIR ARVEN ANAST AUTOG GRF 1396.94 090 36830 CRTJ ARVEN FSTL XCP DIR ARVEN ANAST NONAUTOG GRF 1131.06 090 36831 THRMBC OPN ARVEN FSTL W/O REVJ DIAL GRF 785.43 090 36832 REVJ OPN ARVEN FSTL W/O THRMBC DIAL GRF 998.13 090 36833 REVJ OPN ARVEN FSTL W/THRMBC DIAL GRF 1128.29 090 36835 INSJ THOMAS SHUNT SPX 819.77 090 36838 DSTL REVSC&INTERVAL LIG UXTR HEMO ACCESS 2002.35 090 36860 XTRNL CANNULA DECLTNG SPX W/O BALO CATH 331.23 000 36861 XTRNL CANNULA DECLTNG SPX W/BALO CATH 255.90 000 K 36870 THRMBC PRQ ARVEN FSTL AUTOG/NONAUTOG GRF 3081.90 090 37140 VEN ANAST OPN PORTOCAVAL 2408.91 090 37145 VEN ANAST OPN RENOPORTAL 2527.45 090 37160 VEN ANAST OPN CAVAL-MESENTERIC 2226.68 090 37180 VEN ANAST OPN SPLENORNL PROX 2488.12 090 37181 VEN ANAST OPN SPLENORNL DSTL 2685.86 090 37182 INSJ TRANSVNS INTRAHEPATC PORTOSYSIC SHUNT 1434.60 000 110 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule K 37183 REVJ TRANSVNS INTRAHEPATIC PORTOSYSTEMIC SHUNT 8880.12 000 K 37184 PRIM PRQ TRLUML MCHNL THRMBC 1ST VSL 3942.11 000 + K 37185 PRIM PRQ TRLUML MCHNL THRMBC SBSQ VSL 1301.67 ZZZ + K 37186 SEC PRQ TRLUML THRMBC 2565.11 ZZZ K 37187 PRQ TRLUML MCHNL THRMBC VEIN 3752.12 000 K 37188 PRQ TRLUML MCHNL THRMBC VEIN REPEAT TX 3164.43 000 37195 THROMBOLSS CERE IV NFS 1506.61 XXX 37200 TCAT BX 379.98 000 37201 TCAT THER NFS THROMBOLSS OTH/THN C 470.82 000 37202 TCAT THER NFS OTH/THN THROMBOLSS ANY TYP 572.73 000 K 37203 TCAT RETRIEVAL PRQ IV FB 2218.92 000 37204 TCAT OCCLS/EMBOLJ PRQ NON-CNS NON-HEAD/NCK 1531.53 000 s 37205 TCAT PLMT IV STENT PERCUTANEOUS 1ST VESSEL 7090.47 000 s + 37206 TCAT PLMT IV STENT PERCUTANEOUS EACH ADDL VESSEL 4263.92 ZZZ s 37207 TCAT PLMT IV STENT OPEN 1ST VESSEL 741.67 000 s + 37208 TCAT PLMT IV STENT OPEN EACH ADDL VESSEL 358.37 ZZZ 37209 EXCHNG PREV PLACED IV CATH THROMBOLYTIC THER 193.31 000 K 37210 UTERINE FIBROID EMBOLIZATION PERQ W/RAD GID 5896.27 000 K 37215 TCAT IV STENT CRV CRTD ART EMBOLIC PROTECJ 1902.09 090 K 37216 TCAT IV STENT CRV CRTD ART W/O EMBOLIC PROTECJ 1677.21 090 l K 37220 REVASCULARIZATION ILIAC ARTERY ANGIOP 1ST VSL 5170.66 000 l K 37221 REVSC OPN/PRQ ILIAC ART W/STNT PLMT & ANGIOP UNI 7639.94 000 l + K 37222 REVASCULARIZATION ILIAC ART ANGIOP EA IPSI VSL 1491.10 ZZZ l + K 37223 REVSC OPN/PRQ ILIAC ART W/STNT & ANGIOP IPSI VSL 4207.42 ZZZ l K 37224 REVSC OPN/PRG FEM/POP W/ANGIOPLASTY UNI 6211.99 000 l K 37225 REVSC OPN/PRQ FEM/POP W/ATHRC/ANGIOP SM VSL 17537.03 000 l K 37226 REVSC OPN/PRQ FEM/POP W/STNT/ANGIOP SM VSL 14678.90 000 l K 37227 REVSC OPN/PRQ FEM/POP W/STNT/ATHRC/ANGIOP SM VSL 23708.58 000 l K 37228 REVSC OPN/PRQ TIB/PERO W/ANGIOPLASTY UNI 8842.46 000 l K 37229 REVSC OPN/PRQ TIB/PERO W/ATHRC/ANGIOP SM VSL 17387.47 000 l K 37230 REVSC OPN/PRQ TIB/PERO W/STNT/ANGIOP SM VSL 13660.84 000 l K 37231 REVSC OPN/PRQ TIB/PERO W/STNT/ATHR/ANGIOP SM VSL 21918.93 000 l + K 37232 REVSC OPN/PRQ TIB/PERO W/ANGIOPLASTY UNI EA VSL 1986.29 ZZZ l + K 37233 REVSC OPN/PRQ TIB/PERO W/ATHRC/ANGIOP UNI EA VSL 2427.74 ZZZ l + K 37234 REVSC OPN/PRQ TIB/PERO W/STNT/ANGIOP UNI EA VSL 6323.88 ZZZ l + K 37235 REVSC OPN/PRQ TIB/PERO W/STNT/ATHR/ANGIOP EA VSL 6756.47 ZZZ + 37250 IV US NON-C VSL DX EVAL&/THER IVNTJ 1ST VSL 187.77 ZZZ + 37251 IV US NON-C VSL DX EVAL&/THER IVNTJ EA VSL 140.14 ZZZ 37500 VASC NDSC SEPS 1188.12 090 37501 UNLIS VASC NDSC PX BR YYY 37565 LIG INT JUG VEIN 1206.39 090 37600 LIG XTRNL CRTD ART 1210.27 090 37605 LIG INT/COMMON CRTD ART 1386.41 090 37606 LIG INT/COMMON CRTD ART W/GRADUAL OCCLS 861.31 090 37607 LIG/BANDING ANGIOACCESS ARVEN FSTL 644.19 090 37609 LIG/BX TEMPORAL ART 504.05 010 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 111
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 37615 LIG MAJOR ART NCK 859.10 090 37616 LIG MAJOR ART CH 1843.93 090 37617 LIG MAJOR ART ABD 2207.85 090 37618 LIG MAJOR ART XTR 650.28 090 37620 INTERRUPJ IVC SUTR LIG PLCTJ CLIP XTRVASC IV 1096.17 090 37650 LIG FEM VEIN 835.84 090 37660 LIG COMMON ILIAC VEIN 2112.02 090 37700 LIG&DIV LONG SAPH VEIN SAPHFEM JUNCT/INTERRUPJ 430.38 090 37718 LIG DIV&STRIPPING SHORT SAPHENOUS VEIN 743.89 090 37722 LIG DIV&STRIP LONG SAPH SAPHFEM JUNCT KNE/BELW 828.08 090 37735 LIG&DIV&COMPL STRIP LONG/SHORT SAPH RAD EXC 1075.67 090 37760 LIG PRFRATR VEIN SUBFSCAL RAD INCL SKN GRF 1 LEG 1095.61 090 37761 LIG PRFRATR VEIN SUBFSCAL OPEN INCL US GID 1 LEG 956.59 090 37765 STAB PHLEBT VARICOSE VEINS 1 XTR 10-20 STAB INCS 1103.37 090 37766 STAB PHLEBT VARICOSE VEINS 1 XTR > 20 INCS 1314.40 090 37780 LIG&DIV SHORT SAPH VEIN SAPHENOPOP JUNCT SPX 443.67 090 37785 LIG DIV&/EXC VARICOSE VEIN CLUSTER 1 LEG 598.21 090 37788 PEN REVSC ART +-VEIN GRF 2325.83 090 37790 PEN VEN OCCLUSIVE PX 803.71 090 37799 UNLIS PX VASC SURG BR YYY 38100 SPLENC TOT SPX 1842.27 090 38101 SPLENC PRTL SPX 1856.67 090 + 38102 SPLENC TOT EN BLOC X10SV DS CONJUNCT W/OTH PX 425.95 ZZZ 38115 RPR RPTD SPLEEN SPLENORRHAPHY +-PRTL SPLENC 2033.92 090 38120 LAPS SURG SPLENC 1687.18 090 38129 UNLIS LAPS PX SPLEEN BR YYY 38200 NJX PX SPLENOPORTOGRAPY 245.93 000 38204 MGMT RCP HEMATOP PROGENITOR CELL DON SEARCH&CELL 165.62 XXX 38205 BLD-DRV HEMATOP PROGEN CELL HRVG TRNSPLJ ALGNC 130.17 000 38206 BLD-DRV HEMATOP PROGEN CELL HRVG TRNSPLJ AUTOL 131.83 000 38207 TRNSPL PREPJ HEMATOP PROGEN CELLS CRYOPRSRV&STRG 77.55 XXX 38208 TRNSPL PREPJ HEMATOP PROGEN THAW PREV HRV 49.30 XXX 38209 TRNSPL PREPJ HEMATOP PROGEN THAW PREV HRV WASHG 21.05 XXX 38210 TRNSPL PREPJ HEMATOP PROGEN DEPLJ IN HRV T-CELL 137.92 XXX 38211 TRNSPL PREPJ HEMATOP PROGEN TUM CELL DEPLJ 125.18 XXX 38212 TRNSPL PREPJ HEMATOP PROGEN RED BLD CELL RMVL 81.98 XXX 38213 TRNSPL PREPJ HEMATOP PROGEN PLTLT DEPLJ 21.05 XXX 38214 TRNSPL PREPJ HEMATOP PROGEN PLSM VOL DEPLJ 70.90 XXX 38215 TRNSPL PREPJ HEMATOP PROGEN CONCENTRATION PLSM 81.98 XXX 38220 MARROW ASPIRATION ONLY 246.49 XXX 38221 MARROW BX NDL/TROCAR 266.43 XXX 38230 MARROW HRVG TRNSPLJ 559.44 010 38240 MARROW/BLD-DRV PRPH STEM CELL TRNSPLJ ALLOGENEIC 204.39 XXX 38241 MARROW/BLD-DRV PRPH STEM CELL TRNSPLJ AUTOL 203.84 XXX 38242 MARROW/BLD-DRV PRPH STEM CELL TRNSPLJ ALGC DON 155.65 000 38300 DRG LYMPH NODE ABSC/LYMPHADENITIS SMPL 443.67 010 112 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule 38305 DRG LYMPH NODE ABSC/LYMPHADENITIS X10SV 746.66 090 38308 LYMPHANGIOTOMY/OTH OPRATIONS LYMPHATIC CHANNELS 724.50 090 38380 SUTR&/LIG THRC DUX CRV APPR 931.66 090 38381 SUTR&/LIG THRC DUX THRC APPR 1345.42 090 38382 SUTR&/LIG THRC DUX ABDL APPR 1098.94 090 38500 BX/EXC LYMPH NODE OPN SUPFC 522.33 010 38505 BX/EXC LYMPH NODE NDL SUPFC 204.94 000 38510 BX/EXC LYMPH NODE OPN DP CRV NODE 836.94 010 38520 BX/EXC LYMPH NODE OPN DP CRV NODE W/EXC FAT PAD 753.86 090 38525 BX/EXC LYMPH NODE OPN DP AX NODE 691.27 090 38530 BX/EXC LYMPH NODE OPN INT MAM NODE 882.92 090 38542 DSJ DP JUG NODE 846.36 090 38550 EXC CSTIC HYGROMA AX/CRV W/O DP NEUROVASC DSJ 798.17 090 38555 EXC CSTIC HYGROMA AX/CRV W/DP NEUROVASC DSJ 1625.70 090 38562 LMTD LMPHADEC STAGING SPX PEL&PARA-AORTIC 1133.28 090 38564 LMTD LMPHADEC STAGING SPX RPR AORTIC&/SPLENIC 1138.26 090 38570 LAPS SURG RPR LYMPH NODE BX 1/MLT 878.49 010 38571 LAPS SURG BI TOT PEL LMPHADEC 1329.91 010 38572 LAPS BI TOT PEL LMPHADEC&PRI-AORTIC LYMPH BX 1/+ 1537.63 010 38589 UNLIS LAPS PX LYMPHATIC SYS BR YYY 38700 SUPRAHYOID LMPHADEC 1313.85 090 38720 CRV LMPHADEC COMPL 2194.55 090 38724 CRV LMPHADEC MODF RAD NCK DSJ 2375.12 090 38740 AX LMPHADEC SUPFC 1100.60 090 38745 AX LMPHADEC COMPL 1398.04 090 + 38746 THORCOM THRC W/MEDSTNL & REGIONAL LMPHADEC 436.47 ZZZ + 38747 ABDL LMPHADEC REG CELIAC GSTR PORTAL PRIPNCRTC 434.26 ZZZ 38760 INGUINOFEM LMPHADEC SUPFC W/CLOQUETS NODE SPX 1359.27 090 38765 INGUINOFEM LMPHADEC SUPFC W/PEL LMPHADEC 2089.86 090 38770 PEL LMPHADEC W/XTRNL ILIAC HYPOGSTR&OBTURATOR 1323.27 090 38780 RPR TABDL LMPHADEC X10SV W/PEL AORTIC&RNL 1693.27 090 38790 NJX PX LYMPHANGRPH 137.37 000 38792 INJECTION FOR IDENTIFICATION OF SENTINEL NODE 65.91 000 38794 CANNULATION THRC DUX 488.54 090 l + 38900 INTRAOP SENTINEL LYMPH ID W/DYE NJX 223.78 ZZZ 38999 UNLIS PX HEMIC/LYMPHATIC SYS BR YYY 39000 MEDIAST W/EXPL DRG RMVL FB/BX CRV APPR 825.86 090 39010 MEDIAST W/EXPL DRG RMVL FB/BX TTHRC APPR 1339.33 090 39200 RESECJ MEDIASTINAL CYST 1482.79 090 39220 RESECJ MEDIASTINAL TUMOR 1913.72 090 39400 MEDIASTINOSCOPY W/BX WHEN PERFORMED 848.57 010 39499 UNLIS PX MED BR YYY 39501 RPR LAC DPHRM ANY APPR 1380.87 090 39503 RPR NEONATAL DIPHRG HRNA +-CH TUBE INSJ 9856.65 090 39540 RPR DIPHRG HRNA OTH/THN NEONATAL TRAUMTC AQT 1415.77 090 39541 RPR DIPHRG HRNA OTH/THN NEONATAL TRAUMTC CHRNC 1534.30 090 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 113
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 39545 IMBRCJ OF DIAPHRAGM 1490.54 090 39560 RESCJ DPHRM SMPL RPR 1295.02 090 39561 RESCJ DPHRM CPLX RPR 2035.58 090 39599 UNLIS PX DPHRM BR YYY 40490 BX LIP 210.48 000 40500 VERMILIONECTOMY LIP SHV W/MUCOSAL ADVMNT 819.22 090 40510 EXC LIP TRANSVRS WEDGE EXC W/PRIM CLSR 783.77 090 40520 EXC LIP V-EXC W/PRIM DIR LINR CLSR 800.94 090 40525 EXC LIP FULL THKNS RCNSTJ W/LOCAL FLAP 913.38 090 40527 EXC LIP FULL THKNS RCNSTJ W/CROSS LIP FLAP 1045.21 090 40530 RESCJ LIP > ONE-4TH W/O RCNSTJ 884.02 090 40650 RPR LIP FULL THKNS VERMILION ONLY 675.20 090 40652 RPR LIP FULL THKNS UP HALF VER H8 787.09 090 40654 RPR LIP FULL THKNS > ONE-HALF VER H8/CPLX 926.67 090 40700 PLSTC RPR CL LIP/NSL DFRM PRIM PRTL/COMPL UNI 1578.62 090 40701 PLSTC RPR CL LIP/NSL DFRM PRIM BI 1 STG PX 1825.65 090 40702 PLSTC RPR CL LIP/NSL DFRM PRIM BI 1 2 STGS 1353.73 090 40720 PLSTC RPR CL LIP/NSL DFRM SEC RECRTJ DFCT&RECLSR 1616.28 090 40761 PLSTC RPR CL LIP/NSL DFRM W/CROSS LIP PEDCL FLAP 1796.85 090 40799 UNLIS PX LIPS BR YYY 40800 DRG ABSC CST HMTMA VESTIBULE MOUTH SMPL 332.34 010 40801 DRG ABSC CST HMTMA VESTIBULE MOUTH COMP 501.83 010 40804 RMVL EMBEDDED FB VESTIBULE MOUTH SMPL 340.65 010 40805 RMVL EMBEDDED FB VESTIBULE MOUTH COMP 520.67 010 40806 INC LABIAL FRENUM FREXOMY 170.60 000 40808 BX VESTIBULE MOUTH 297.44 010 40810 EXC LES MUCOSA&SBMCSL VESTIBULE MOUTH W/O RPR 330.12 010 40812 EXC LES MUCOSA&SBMCSL VESTIBULE SMPL RPR 458.63 010 40814 EXC LES MUCOSA&SBMCSL VESTIBULE CPLX RPR 617.60 090 40816 EXC LES MUCOSA&SBMCSL VESTIBULE CPLX EXC MUSC 649.72 090 40818 EXC MUCOSA VESTIBULE MOUTH AS DON GRF 570.52 090 40819 EXC FRENUM LABIAL/BUCCAL 491.31 090 40820 DSTRJ LES/SCAR VESTIBULE MOUTH PHYSICAL METHS 427.61 010 40830 CLSR LAC VESTIBULE MOUTH 2.5 CM/< 398.25 010 40831 CLSR LAC VESTIBULE MOUTH > 2.5 CM/CPLX 529.53 010 40840 VESTIBULOPLASTY ANT 1351.52 090 40842 VESTIBULOPLASTY PST UNI 1295.57 090 40843 VESTIBULOPLASTY PST BI 1730.94 090 40844 VESTIBULOPLASTY ENTIRE ARCH 2274.31 090 40845 VESTIBULOPLASTY CPLX W/RIDGE XTN MUSC RPSG 2389.52 090 40899 UNLIS PX VESTIBULE MOUTH BR YYY 41000 INTRAORAL I&D TONGUE/FLOOR LNGL 260.89 010 41005 INTRAORAL I&D TONGUE/FLOOR SUBLNGL SUPFC 360.59 010 41006 INTRAORAL I&D TONGUE/FLOOR SUBLNGL DP SPRMLHYD 581.60 090 41007 INTRAORAL I&D TONGUE/FLOOR SUBMENTAL SPACE 580.49 090 41008 INTRAORAL I&D TONGUE/FLOOR SUBMNDBLR SPACE 600.98 090 114 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule 41009 INTRAORAL I&D TONGUE/FLOOR MASTICATOR SPACE 639.75 090 41010 INC LNGL FRENUM FREXOMY 332.34 010 41015 XTRORAL I&D ABSC CST/HMTMA FLOOR MOUTH SUBLNGL 701.79 090 41016 XTRORAL I&D ABSC CST/HMTMA FLOOR MOUTH SUBMENTAL 701.79 090 41017 XTRORAL I&D ABSC CST/HMTMA FLOOR MOUTH SUBMNDBLR 707.88 090 41018 XTRORAL I&D FLOOR MASTICATOR SPACE 800.39 090 41019 PLACEMENT NEEDLE HEAD/NECK RADIOELEMENT APPLICAT 766.04 000 41100 BX TONGUE ANT 2-3RD 273.63 010 41105 BX TONGUE PST ONE-3RD 276.40 010 41108 BX FLOOR MOUTH 238.18 010 41110 EXC LES TONGUE W/O CLSR 343.97 010 41112 EXC LES TONGUE W/CLSR ANT 2-3RD 537.84 090 41113 EXC LES TONGUE W/CLSR PST ONE-3RD 586.58 090 41114 EXC LES TONGUE W/CLSR W/LOCAL TONGUE FLAP 1046.32 090 41115 EXC LNGL FRENUM FRENECTOMY 394.38 010 41116 EXC LES FLOOR MOUTH 531.74 090 41120 GLSSC < ONE-HALF TONGUE 1729.83 090 41130 GLSSC HEMIGLSSC 2140.27 090 41135 GLSSC PRTL W/UNI RAD NCK DSJ 3541.64 090 41140 GLSSC COMPL/TOT +-TRACHS W/O RAD NCK DSJ 3609.21 090 41145 GLSSC COMPL/TOT +-TRACHS W/UNI RAD NCK DSJ 4544.20 090 41150 GLSSC COMPOSIT W/RESCJ FLOOR&MNDBLR RESCJ 3597.58 090 41153 GLSSC COMPOSIT RESCJ FLOOR SUPRAHYOID NCK DSJ 3909.43 090 41155 GLSSC COMPOSIT RESCJ FLR MNDBLR RESCJ&RAD NCK 4885.95 090 41250 RPR LAC 2.5 CM/< FLOOR MOUTH&/ANT 2-3RD TONGUE 388.84 010 41251 RPR LAC 2.5 CM/< PST ONE-3RD TONGUE 407.12 010 41252 RPR LAC TONGUE FLOOR MOUTH > 2.6 CM/CPLX 505.16 010 41500 FIXJ TONGUE MCHNL OTH/THN SUTR 738.35 090 41510 SUTR TONGUE LIP MICROGNATHIA 623.14 090 41512 TONGUE BASE SUSPENSION PERMANENT SUTURE TQ 1018.62 090 41520 FRENOPLASTY SURG REVJ FRENUM EG W/Z-PLASTY 561.10 090 41530 SUBMUCOSAL ABLTJ TONGUE RF 1/> SITES PR SESSION 5253.74 010 41599 UNLIS PX TONGUE FLOOR MOUTH BR YYY 41800 DRG ABSC CST HMTMA FROM DENTOALVEOLAR STRUXS 396.04 010 41805 RMVL EMBEDDED FB FROM DENTALVLR STRUXS SOFT TISS 388.28 010 41806 RMVL EMBEDDED FB FROM DENTOALVEOLAR STRUXS B1 577.16 010 41820 GINGIVECTOMY EXC GINGIVA EA QUADRANT 407.12 000 41821 OPRCULECTOMY EXC PRICORONAL TISS 91.95 000 41822 EXC FIBROUS TUBEROSITIES DENTOALVEOLAR STRUXS 463.06 010 41823 EXC OSS TUBEROSITIES DENTOALVEOLAR STRUXS 687.39 090 41825 EXC LES/TUM XCP LISTED ABOVE DENTALVLR 336.77 010 41826 EXC LES/TUM XCP LISTED ABOVE DENTALVLR SMPL RPR 483.00 010 41827 EXC LES/TUM XCP LISTED ABOVE DENTALVLR CPLX RPR 699.02 090 41828 EXC HYPRPLSTC ALVEOLAR MUCOSA EA QUADRANT SPEC 487.43 010 41830 ALVEOLECTOMY W/CURTG OSTEITIS/SEQUESTRECTOMY 624.25 010 41850 DSTRJ LES XCP EXC DENTOALVEOLAR STRUXS 203.28 000 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 115
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 41870 PDONTAL MUCOSAL GRFG 508.48 000 41872 GINGIVOPLASTY EA QUADRANT SPEC 596.55 090 41874 ALVEOLOPLASTY EA QUADRANT SPEC 591.57 090 41899 UNLIS PX DENTOALVEOLAR STRUXS BR YYY 42000 DRG ABSC PALATE UVULA 254.24 010 42100 BX PALATE UVULA 243.16 010 42104 EXC LES PALATE UVULA W/O CLSR 345.08 010 42106 EXC LES PALATE UVULA W/SMPL PRIM CLSR 433.70 010 42107 EXC LES PALATE UVULA W/LOCAL FLAP CLSR 743.89 090 42120 RESCJ PALATE/X10SV RESCJ LES 1628.47 090 42140 UVULECTOMY EXC UVULA 413.21 090 42145 PALATOPHARYNGOPLASTY 1164.85 090 42160 DSTRJ LES PALATE/UVULA THERMAL CRYO/CHEM 384.41 010 42180 RPR LAC PALATE UP 2 CM 381.08 010 42182 RPR LAC PALATE > 2 CM/CPLX 530.08 010 42200 PALATOP CL PALATE SOFT&/HARD PALATE ONLY 1429.62 090 42205 PALATOP W/CLSR ALVEOLAR RIDGE SOFT TISS 1565.88 090 42210 PALATOP CLSR ALVEOLAR RIDGE GRF ALVEOLAR RIDGE 1732.60 090 42215 PALATOP CL PALATE MAJOR REVJ 1182.02 090 42220 PALATOP CL PALATE SEC LNGTH PX 863.53 090 42225 PALATOP CL PALATE ATTACHMENT PHARYNGEAL FLAP 1502.73 090 42226 LNGTH PALATE&PHARYNGEAL FLAP 1506.05 090 42227 LNGTH PALATE W/ISLAND FLAP 1438.48 090 42235 RPR ANT PALATE W/VOMER FLAP 1219.13 090 42260 RPR NASOLABIAL FSTL 1342.65 090 42280 MAX IMPRESJ PALATAL PROSTH 265.32 010 42281 INSJ PIN-RETAINED PALATAL PROSTH 334.00 010 42299 UNLIS PX PALATE UVULA BR YYY 42300 DRG ABSC PRTD SMPL 341.76 010 42305 DRG ABSC PRTD COMP 711.76 090 42310 DRG ABSC SUBMAX/SUBLNGL INTRAORAL 265.32 010 42320 DRG ABSC SUBMAX XTRNL 409.33 010 42330 SIALOT SUBMNDBLR SUBLNGL/PRTD UNCOMP INTRAORAL 379.98 010 42335 SIALOLITHOTOMY SUBMNDBLR SUBMAX COMP INTRAORAL 608.74 090 42340 SIALOLITHOTOMY PRTD XTRORAL/COMP INTRAORAL 758.29 090 42400 BX SALIVARY GLND NDL 175.59 000 42405 BX SALIVARY GLND INCAL 489.09 010 42408 EXC SUBLNGL SALIVARY CST RANULA 744.44 090 42409 MARSUPIALIZATION SUBLNGL SALIVARY CST RANULA 543.93 090 42410 EXC PRTD TUM/PRTD GLND LAT LOBE W/O NRV DSJ 1029.70 090 42415 EXC PRTD TUM/PRTD GLND LAT DSJ&PRSRV FACIAL NRV 1842.83 090 42420 EXC PRTD TUM/PRTD GLND TOT DSJ&PRSRV FACIAL NRV 2110.91 090 42425 EXC PRTD TUM/PRTD GLND TOT EN BLOC RMVL 1393.06 090 42426 EXC PRTD TUM/PRTD GLND TOT W/UNI RAD NCK DSJ 2252.71 090 42440 EXC SUBMNDBLR SUBMAX GLND 773.24 090 42450 EXC SUBLNGL GLND 741.67 090 116 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule 42500 PLSTC RPR SALIVARY DUX SIALODOCHOPLASTY PRIM 708.44 090 42505 PLSTC RPR SALIVARY DUX SIALODOCHOPLASTY SEC/COMP 910.61 090 42507 PRTD DUX DVRJ BI 851.90 090 42508 PRTD DUX DVRJ BI W/EXC 1 SUBMNDBLR GLND 1167.62 090 42509 PRTD DUX DVRJ BI W/EXC BTH SUBMNDBLR GLNDS 1357.06 090 42510 PAROTID DUCT DVRJ BILATERAL WITH LIG BOTH DUCTS 1044.66 090 42550 NJX SIALOGRAPY 227.10 000 42600 CLSR SALIVARY FSTL 792.08 090 42650 DILAT SALIVARY DUX 136.26 000 42660 DILAT&CATHJ SALIVARY DUX +-NJX 173.92 000 42665 LIG SALIVARY DUX INTRAORAL 511.80 090 42699 UNLIS PX SALIVARY GLNDS/DUXS BR YYY 42700 I&D ABSC PRITONSILLAR 309.63 010 42720 I&D ABSC RTRPHRNGL/PARAPHARYNGEAL INTRAORAL 749.98 010 42725 I&D ABSC RTRPHRNGL/PARAPHARYNGEAL XTRNL APPR 1343.21 090 42800 BX OROPHARYNX 260.33 010 42802 BX HYPOPHARYNX 388.84 010 42804 BX NASOPHARYNX VISIBLE LES SMPL 327.35 010 42806 BX NASOPHARYNX SURV UNKNOWN PRIM LES 367.79 010 42808 EXC/DSTRJ LES PHARYNX ANY METH 373.88 010 42809 RMVL FB FROM PHARYNX 279.17 010 42810 EXC BRANCHIAL CL CST CONFINED SKN&SUBQ TISS 636.43 090 42815 EXC BRANCHIAL CL CST EXTG BELW SUBQ TISS&/PHRNX 921.69 090 42820 TONSILLECTOMY&ADENOIDECTOMY UNDER AGE 12 482.45 090 42821 TONSILLECTOMY&ADENOIDECTOMY AGE 12/> 502.39 090 42825 TONSILLECTOMY 1/2 UNDER AGE 12 435.37 090 42826 TONSILLECTOMY 1/2 AGE 12/> 418.19 090 42830 ADENOIDECTOMY PRIM UNDER AGE 12 343.97 090 42831 ADENOIDECTOMY PRIM AGE 12/> 370.56 090 42835 ADENOIDECTOMY SEC UNDER AGE 12 295.78 090 42836 ADENOIDECTOMY SEC AGE 12/> 401.02 090 42842 RAD RESCJ TONSIL W/O CLSR 1631.79 090 42844 RAD RESCJ TONSIL CLSR W/LOCAL FLAP 2258.80 090 42845 RAD RESCJ TONSIL CLSR W/OTH FLAP 3671.25 090 42860 EXC TONSIL TAGS 312.40 090 42870 EXC/DSTRJ LNGL TONSIL ANY METH SPX 955.48 090 42890 LMTD PHARYNGECTOMY 2320.29 090 42892 RESCJ LAT PHRNGL WALL/PYRIFORM SINUS DIR CLSR 3061.96 090 42894 RESCJ PHRNGL WALL CLSR W/FLP OR FLP W/MVASC ANAS 3882.29 090 42900 SUTR PHARYNX WND/INJ 565.53 010 42950 PHARYNGOPLASTY PLSTC/RCNSTV OPRATION PHARYNX 1312.19 090 42953 PHARYNGOESOPHGL RPR 1594.68 090 42955 PHARYNGOSTOMY FSTLJ PHARYNX XTRNL FEEDING 1236.86 090 42960 CTRL OROPHARYNGEAL HEMRRG 1/2 SMPL 280.83 010 42961 CTRL OROPHARYNGEAL HEMRRG 1/2 COMP REQ HOSPITJ 697.91 090 42962 CTRL OROPHARYNGEAL HEMRRG 1/2 W/SEC SURG IVNTJ 860.76 090 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 117
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 42970 CTRL NASPHRYNGL HEMRRG 1/2 SMPL W/PST NSL PACKS 653.05 090 42971 CTRL NASPHRYNGL HEMRRG 1/2 COMP REQ HOSPIZATION 759.40 090 42972 CTRL NASPHRYNGL HEMRRG 1/2 W/SEC SURG IVNTJ 850.24 090 42999 UNLIS PX PHARYNX ADENOIDS/TONSILS BR YYY 43020 ESOPHAGOTOMY CRV APPR W/RMVL FB 880.15 090 43030 CRICOPHARYNGEAL MYOTOMY 864.08 090 43045 ESOPHAGOTOMY THRC APPR W/RMVL FB 2180.15 090 43100 EXC LES ESOPH W/PRIM RPR CRV APPR 1034.69 090 43101 EXC LES ESOPH W/PRIM RPR THRC/ABDL APPR 1686.07 090 43107 TOT ESPHG W/O THORCOM PHRNGSTRSTY/EGST 4217.39 090 43108 TOT ESPHG W/O THORCOM COLON NTRPSTJ/INT RCNSTJ 7498.70 090 43112 TOT ESPHG W/THORCOM W/PHRNGSTRSTY/EGST 4473.85 090 43113 TOT ESPHG W/THORCOM W/COLON NTRPSTJ/INT RCNSTJ 7399.55 090 43116 PRTL ESPHG CRV W/FR INTSTINAL GRF 8436.45 090 43117 PRTL ESPHG DSTL THORCOM ABDL INC EGST 4102.74 090 43118 PRTL ESPHG DSTL THORCOM ABDL INC NTRPSTJ/RCNSTJ 6125.58 090 43121 PRTL ESPHG DSTL THORCOM ONLY THRC EGST 4755.79 090 43122 PRTL ESPHG THORACOABDL/ABDL APPR EGST 4174.74 090 43123 PRTL ESPHG THORACOABDL/ABDL APPR NTRPSTJ/RCNSTJ 7565.72 090 43124 TOT/PRTL ESPHG W/O RCNSTJ W/CRV ESOPHAGOSTOMY 6504.45 090 43130 DIVERTICULECTOMY HYPOPHARYNX/ESOPH CRV APPR 1305.54 090 43135 DIVERTICULECTOMY HYPOPHARYNX/ESOPH THRC APPR 2479.81 090 K 43200 ESPHGSC RGD/FLX DX +-COLLJ SPEC BR/WA SPX 353.94 000 K 43201 ESPHGSC RGD/FLX DIRED SBMCSL NJX ANY SBST 483.55 000 K 43202 ESPHGSC RGD/FLX W/BX 1/MLT 463.06 000 K 43204 ESPHGSC RGD/FLX W/NJX SCLEROSIS ESOPHGL VARC 369.45 000 K 43205 ESPHGSC RGD/FLX W/BAND LIG ESOPHGL VARC 372.77 000 K 43215 ESPHGSC RGD/FLX W/RMVL FB 256.46 000 K 43216 ESPHGSC RGD/FLX RMVL TUM HOT BX FORCEPS/CAUT 339.54 000 K 43217 ESPHGSC RGD/FLX W/RMVL TUM SNARE TQ 619.81 000 K 43219 ESPHGSC RGD/FLX W/INSJ PLSTC TUBE/STENT 285.26 000 K 43220 ESPHGSC RGD/FLX W/BALO DILAT < 30 MM DIAM 211.04 000 K 43226 ESPHGSC RGD/FLX W/INSJ GD WIRE DILAT 235.41 000 K 43227 ESPHGSC RGD/FLX W/CTRL BLD 349.51 000 K 43228 ESPHGSC RGD/FLX ABLTJ TUM XCP HOT BX/CAUT/SNARE 371.11 000 K 43231 ESPHGSC RGD/FLX W/NDSC US XM 316.83 000 K 43232 ESPHGSC RGD/FLX W/TNDSC US-GID FINE NDL ASPIR/BX 436.47 000 K 43234 UPPER STOMACH-INTESTINE SCOPE SIMPLE 458.63 000 K 43235 UPPER STOMACH-INTESTINE SCOPE FOR DIAGNOSIS 485.77 000 K 43236 STOMACH-INTESTINE SCOPE INJECT INTESTINE WALL 602.09 000 K 43237 UPR GI NDSC NDSC US XM LMTD ESOPH 392.16 000 K 43238 UPR GI NDSC TNDSC US FINE NDL ASPIR/BX ESOPH 489.09 000 K 43239 UPPER STOMACH-INTESTINE SCOPE FOR BIOPSY 562.76 000 K 43240 UPR GI NDSC TRANSMURAL DRG PSEUDOCST 660.25 000 K 43241 UPR GI NDSC TNDSC INTRAL TUBE/CATH PLMT 258.67 000 K 43242 STOMACH-INTESTINE SCOPE ULTRASOUND GUIDED BIOPSY 705.11 000 118 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule K 43243 UPR GI NDSC NJX SCLEROSIS ESOPHGL&/GSTR VARC 445.34 000 K 43244 UPR GI NDSC BAND LIG ESOPHGL&/GSTR VARC 491.86 000 K 43245 UPR GI NDSC DILAT GSTR OUTLET FOR OBSTRCJ 312.95 000 K 43246 UPR GI NDSC DIRED PLMT PRQ GASTROSTOMY TUBE 418.75 000 K 43247 STOMACH-INTESTINE SCOPE FOR FOREIGN BODY REMOVAL 333.45 000 K 43248 UPR GI NDSC INSJ GD WIRE DILAT ESOPH > GD WIRE 313.51 000 K 43249 UPR GI NDSC BALO DILAT ESOPH < 30 MM DIAM 289.14 000 K 43250 UPR GI NDSC RMVL LES HOT BX/BIPOLAR CAUT 314.06 000 K 43251 UPR GI NDSC RMVL TUM POLYP/OTH LES SNARE TQ 362.80 000 K 43255 UPR GI NDSC CTRL BLD ANY METH 470.26 000 K 43256 UPR GI NDSC TNDSC STENT PLMT W/PREDILAT 424.29 000 K 43257 UPR GI NDSC DLVR THERMAL NRG SPHNCTR/CARDIA 529.53 000 K 43258 UPR GI NDSC ABLTJ LES X RMVL FORCEPS/CAUT/SNARE 444.23 000 K 43259 STOMACH-INTESTINE SCOPE WITH ULTRASOUND EXAM 505.71 000 K 43260 ERCP DX COLLJ SPEC BR/WA SPX 577.16 000 K 43261 ERCP W/BX 1/MLT 606.52 000 K 43262 ERCP W/SPHNCTROTOMY/PAPILLOTOMY 712.87 000 K 43263 ERCP W/PRESS MEAS SPHNCTR ODDI 702.90 000 K 43264 ERCP W/RMVL ST1/CALCULI BILIARY&/PNCRTC DUXS 855.78 000 K 43265 ERCP W/DSTRJ LITHOTRP ST1/CALCULI ANY METH 959.91 000 K 43267 ERCP W/INSJ NASOBILIARY/NASOPNCRTC DRG TUBE 710.10 000 K 43268 ERCP W/INSJ TUBE/STENT BILE/PNCRTC DUX 722.29 000 K 43269 ERCP W/RTRGR RMVL FB&/CHNG TUBE/STENT 789.86 000 K 43271 ERCP W/BALO DILAT AMPULLA BILIARY&/PNCRTC DUX 712.32 000 K 43272 ERCP W/ABLTJ LES X RMVL FORCEPS/CAUT/SNARE 712.87 000 + K 43273 ENDOSCOPIC PAPILLA CANNULATION BILE PANCREATIC 213.25 ZZZ 43279 LAPS ESOPHAGOMYOTOMY W/FUNDOPLASTY IF PERFORMED 2092.08 090 43280 LAPS SURG ESOPG/GSTR FUNDOPLASTY 1743.12 090 43281 LAPS RPR PARAESPHGL HRNA INCL FUNDPLSTY W/O MESH 2567.88 090 43282 LAPS RPR PARAESPHGL HRNA INCL FUNDPLSTY W/MESH 2885.27 090 l + 43283 LAPS ESOPHAGEAL LENGTHENING ADDL 267.53 ZZZ 43289 UNLIS LAPS PX ESOPH BR YYY 43300 ESPHGP CRV APPR W/O RPR TRACHEOESOPHGL FSTL 1018.07 090 43305 ESPHGP CRV APPR W/RPR TRACHEOESOPHGL FSTL 1818.45 090 43310 ESPHGP THRC APPR W/O RPR TRACHEOESOPHGL FSTL 2502.52 090 43312 ESPHGP THRC APPR W/RPR TRACHEOESOPHGL FSTL 2729.62 090 43313 ESPHGP CGEN DFCT THRC APPR W/O RPR FSTL 4618.42 090 43314 ESPHGP CGEN DFCT THRC APPR W/RPR FSTL 4712.58 090 43320 EGST+-VAGOTOMY&PYLOROPLASTY TABDL/TTHRC APPR 2260.47 090 43325 ESOPG/GSTR FUNDOPLASTY W/FUNDIC PATCH 2159.10 090 l 43327 ESOPG/GSTR FUNDOPLASTY W/LAPT 1346.53 090 l 43328 ESOPG/GSTR FUNDOPLASTY W/THORCOM 1977.98 090 43330 ESOPHAGOMYOTOMY HELLER TYP ABDL APPR 2126.98 090 43331 ESOPHAGOMYOTOMY HELLER TYP THRC APPR 2261.02 090 l 43332 RPR PARAESOPH HIATAL HERNIA W/LAPT W/O MESH 1928.68 090 l 43333 LAPT RPR PARAESOPH HIATAL HERNIA W/ MESH 2094.30 090 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 119
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 l 43334 RPR PARAESOPH HIATAL HERNIA W/THORCOM W/O MESH 2117.01 090 l 43335 RPR PARAESOPH HIATAL HERNIA W/THORCOM W/MESH 2280.96 090 l 43336 RPR PARAESOPH HIATAL HERNIA THORCOABDOM W/O MESH 2499.20 090 l 43337 RPR PARAESOPH HIATAL HERNIA THORCOABDOM W/MESH 2727.96 090 l + 43338 ESOPHAGUS LENGTHENING 222.11 ZZZ 43340 ESOPHAGOJEJUNOSTOMY W/O TOT GSTRCT ABDL APPR 2218.92 090 43341 ESOPHAGOJEJUNOSTOMY W/O TOT GSTRCT THRC APPR 2438.27 090 43350 ESOPHAGOSTOMY FSTLJ ESOPH XTRNL ABDL APPR 1995.15 090 43351 ESOPHAGOSTOMY FSTLJ ESOPH XTRNL THRC APPR 2181.81 090 43352 ESOPHAGOSTOMY FSTLJ ESOPH XTRNL CRV APPR 1785.77 090 43360 GI RCNSTJ PREV ESPHG/EXCLUSION W/STOMACH 3792.00 090 43361 GI RCNSTJ PREV ESPHG/EXCLUSION W/COLON SM INT 4223.49 090 43400 LIG DIR ESOPHGL VARC 2491.44 090 43401 TRNSXJ ESOPH W/RPR ESOPHGL VARC 2463.19 090 43405 LIG/STAPLING G-ESOP JUNCT PRE-ESOPHGL PRF8J 2466.52 090 43410 SUTR ESOPHGL WND/INJ CRV APPR 1709.34 090 43415 SUTR ESOPHGL WND/INJ TTHRC/TABDL APPR 2833.75 090 43420 CLSR ESOPHAGOSTOMY/FSTL CRV APPR 1668.90 090 43425 CLSR ESOPHAGOSTOMY/FSTL TTHRC/TABDL APPR 2480.92 090 43450 OPENING OF ESOPHAGUS 257.01 000 K 43453 DILAT ESOPH > GD WIRE 483.55 000 K 43456 DILAT ESOPH BALO/DILATOR RTRGR 978.74 000 K 43458 DILAT ESOPH BALO 30 MM DIAM/LGR ACHALASIA 634.22 000 43460 ESOPG/GSTR TAMPONADE W/BALO SENGSTAKEN TYP 367.79 000 43496 FR JEJUNUM TR W/MVASC ANAST BR 090 43499 UNLIS PX ESOPH BR YYY 43500 GSTRT W/EXPL/FB RMVL 1258.46 090 43501 GSTRT W/SUTR RPR BLD ULCER 2156.33 090 43502 GSTRT W/SUTR RPR PRE-ESOPG/GSTR LAC 2441.59 090 43510 GSTRT W/ESOPHGL DILAT&INSJ PRM INTRAL TUBE 1531.53 090 43520 PYLOROMYOTOMY CUTTING PYLORIC MUSC 1124.97 090 s 43605 BX STOMACH LAPT 1344.32 090 43610 EXC LOCAL ULCER/B9 TUM STOMACH 1572.52 090 43611 EXC LOCAL MAL TUM STOMACH 1958.04 090 43620 GSTRCT TOT W/ESOPHAGONTRSTM 3171.63 090 43621 GSTRCT TOT W/ROUX-EN-Y RCNSTJ 3643.00 090 43622 GSTRCT TOT W/FRMJ INTSTINAL POUCH ANY TYP 3694.51 090 43631 GSTRCT PRTL DSTL W/GASTRODUODENOSTOMY 2330.26 090 43632 GSTRCT PRTL DSTL W/GASTROJEJUNOSTOMY 3241.42 090 43633 GSTRCT PRTL DSTL W/ROUX-EN-Y RCNSTJ 3071.38 090 43634 GSTRCT PRTL DSTL W/FRMJ INTSTINAL POUCH 3397.62 090 + 43635 VAGOTOMY PFRMD W/PRTL DSTL GSTRCT 181.68 ZZZ 43640 VGTMY W/PYPS +-GASTROSTOMY TRUNCAL/SLCTV 1887.14 090 43641 VGTMY W/PYPS +-GASTROSTOMY PARIETAL CELL 1914.28 090 43644 LAPS GSTR RSTCV PX W/BYP ROUX-EN-Y <150 CM 2786.67 090 43645 LAPS GSTR RSTCV PX W/BYP&SM INT RCNSTJ 2978.87 090 120 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule 43647 LAPS IMPLTJ/RPLCMT GASTRIC NSTIM ELTRD ANTRUM BR YYY 43648 LAPS REVISION/RMVL GASTRIC NSTIM ELTRD ANTRUM BR YYY 43651 LAPS SURG TRNSXJ VAGUS NRV TRUNCAL 1042.44 090 43652 LAPS SURG TRNSXJ VAGUS NRV SLCTV/HILY SLCTV 1219.69 090 43653 LAPS SURG GASTROSTOMY W/O CONSTJ GSTR TUBE SPX 905.63 090 43659 UNLIS LAPS PX STOMACH BR YYY 43752 NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDN 67.58 000 l 43753 GASTRIC TUBE PLMT W/ASPIR & LAVAGE 33.79 000 l 43754 GASTRIC TUBE DX PLMT W/ASPIR 1 SPECIMEN 128.50 000 l 43755 GASTRIC TUBE DX PLMT W/ASPIR MULT SPECIMENS 196.08 000 l 43756 DUODENAL TUBE DX PLMT W/IMG GID 1 SPECIMEN 355.60 000 l 43757 DUODENAL TUBE DX PLMT W/IMG GID MULT SPECIMEN 457.52 000 43760 CHANGE GASTROSTOMY TUBE PERCUTANEOUS W/O GUIDE 658.59 000 43761 REPOS NASO/ORO GASTRIC FEEDING TUBE THRU DUO 196.63 000 43770 LAPS GASTRIC RESTRICTIVE PROCEDURE PLACE DEVICE 1789.10 090 43771 LAPS GASTRIC RESTRICTIVE PX REVISION DEVICE 2038.91 090 43772 LAPS GASTRIC RESTRICTIVE PX REMOVE DEVICE 1535.96 090 43773 LAPS GASTRIC RESTRICTIVE PX REMOVE&RPLCMT DEVICE 2038.91 090 43774 LAPS GASTRIC RESTRICTIVE PX REMOVE DEVICE &PORT 1540.40 090 43775 LAPS GSTRC RSTRICTIV PX LONGITUDINAL GASTRECTOMY 2118.11 XXX 43800 PYLOROPLASTY 1492.21 090 43810 GASTRODUODENOSTOMY 1624.03 090 43820 GASTROJEJUNOSTOMY W/O VAGOTOMY 2135.28 090 43825 GASTROJEJUNOSTOMY W/VAGOTOMY ANY TYP 2092.08 090 43830 GASTROSTOMY OPN W/O CONSTJ GSTR TUBE SPX 1114.45 090 43831 GASTROSTOMY OPN NEONATAL FEEDING 942.18 090 43832 GASTROSTOMY OPN W/CONSTJ GSTR TUBE 1692.16 090 43840 GASTRORRHAPHY SUTR PRF8 DUOL/GSTR ULCER WND/INJ 2164.09 090 43842 GSTR RSTCV W/O BYP VER-BANDED GSTP 1868.86 090 43843 GSTR RSTCV W/O BYP OTH/THN VER-BANDED GSTP 2042.23 090 43845 GSTR RSTCV W/PRTL GSTRCT 50-100 CM 3141.17 090 43846 GSTR RSTCV W/BYP W/SHORT LIMB 150 CM/< 2618.29 090 43847 GSTR RSTCV W/BYP W/SM INT RCNSTJ LIMIT ABSRPJ 2874.74 090 43848 REVISION OPEN GASTRIC RESTRICTIVE PX NOT DEVICE 3099.62 090 43850 REVJ GASTRODUOL ANAST W/RCNSTJ W/O VAGOTOMY 2603.33 090 43855 REVJ GASTRODUOL ANAST W/RCNSTJ W/VGTMY 2709.12 090 43860 REVJ GSTR/JJ ANAST W/RCNSTJ W/O VGTMY 2626.04 090 43865 REVJ GSTR/JJ ANAST W/RCNSTJ W/VGTMY 2739.59 090 43870 CLSR GASTROSTOMY SURG 1136.05 090 43880 CLSR GASTROCOLIC FSTL 2563.45 090 43881 IMPLTJ/RPLCMT GASTRIC NSTIM ELTRD ANTRUM OPEN BR YYY 43882 REVISION/RMVL GASTRIC NSTIM ELTRD ANTRUM OPEN BR YYY 43886 GSTR RSTCV PX OPN REVJ SUBQ PORT COMPONENT ONLY 567.19 090 43887 GSTR RSTCV PX OPN RMVL SUBQ PORT COMPONENT ONLY 514.57 090 43888 GSTR RSTCV OPN RMVL&RPLCMT SUBQ PORT 726.72 090 43999 UNLIS PX STOMACH BR YYY Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 121
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 44005 ENTEROLSS FRING INTSTINAL ADHESION SPX 1755.31 090 44010 DUODEXOMY EXPL BX/FB RMVL 1388.07 090 + 44015 TUBE/NDL CATH JEJUNOSTOMY ANY METH 233.19 ZZZ 44020 ENTEROTOMY SM INT OTH/THN DUO EXPL BX/FB RMVL 1558.67 090 44021 ENTEROTOMY SM INT OTH/THN DUO DCMPRN 1575.29 090 44025 COLOTOMY EXPL BX/FB RMVL 1583.60 090 44050 RDCTJ VOLVULUS INTUSSUSCEPTION INT HRNA LAPT 1497.19 090 44055 CORRJ MALROTATION BANDS&/RDCTJ VOLVULUS 2400.60 090 44100 BX INT CAPSL TUBE PRORAL 1+ SPECS 188.88 000 44110 EXC 1+ < SM/LG INT 1 ENTEROTOMY 1359.82 090 44111 EXC 1+ < SM/LG INT MLT ENTEROTOMIES 1579.72 090 44120 ENTRC RESCJ SM INT 1 RESCJ&ANAST 1960.81 090 + 44121 ENTRC RESCJ SM INT EA RESCJ&ANAST 392.72 ZZZ 44125 ENTRC RESCJ SM INT W/NTRSTM 1894.89 090 44126 ENTRC RESCJ ATRESIA RESCJ&ANAST W/O TAPRING 3945.98 090 44127 ENTRC RESCJ ATRESIA RESCJ&ANAST SGM W/TAPRING 4570.78 090 + 44128 ENTRC RESCJ ATRESIA EA RESCJ&ANAST 394.93 ZZZ 44130 ENTERONTRSTM ANAST INT +-CUTAN NTRSTM SPX 2090.97 090 44132 DON ENTRC OPN FROM CDVR DON BR XXX 44133 DON ENTRC OPN PRTL FROM LIV DON BR XXX 44135 INTSTINAL ALTRNSPLJ FROM CDVR DON BR XXX 44136 INTSTINAL ALTRNSPLJ FROM LIV DON BR XXX 44137 RMVL TRNSPLED INTSTINAL ALGRFT COMPL BR XXX + 44139 MOBLJ SPLENIC FLXR PFRMD CONJUNCT W/PRTL COLCT 196.63 ZZZ 44140 COLCT PRTL W/ANAST 2153.01 090 44141 COLCT PRTL W/SKN LVL CECOSTOMY/CLST 2907.98 090 44143 COLCT PRTL W/END CLST&CLSR DSTL SGM 2671.46 090 44144 COLCT PRTL W/RESCJ W/CLST/ILEOST&MUCOFSTL 2832.09 090 44145 COLCT PRTL W/COLOPXTSTMY LW PEL ANAST 2670.91 090 44146 COLCT PRTL W/COLOPXTSTMY LW PEL ANAST W/CLST 3385.99 090 44147 COLCT PRTL ABDL&TRANSANAL APPR 3097.41 090 44150 COLCT TOT ABDL W/O PRCTECT W/ILEOST/ILEOPXTS 2987.74 090 44151 COLCT TOT ABDL W/O PRCTECT W/CONTINENT ILEOST 3426.43 090 44155 COLCT TOT ABDL W/PRCTECT W/ILEOST 3323.95 090 44156 COLCT TOT ABDL W/PRCTECT W/CONTINENT ILEOST 3687.31 090 44157 COLCT TTL ABD W/PRCTECT ILEOANAL ANAST 3486.25 090 44158 COLCT TTL ABD W/PRCTECT ILEOANAL ANAST & RSVR 3568.78 090 44160 COLCT PRTL W/RMVL TERMINAL ILE W/ILEOCLST 1991.27 090 44180 LAPS ENTEROLSS FRING INTSTINAL ADHESION SPX 1478.36 090 44186 LAPS JEJUNOSTOMY 1048.53 090 44187 LAPS ILEOST/JEJUNOSTOMY NON-TUBE 1765.83 090 44188 LAPS CLST/SKN LVL CECOSTOMY 1959.14 090 44202 LAPS ENTRC RESCJ SM INT 1 RESCJ&ANAST 2228.34 090 + 44203 LAPS EA SM INT RESCJ&ANAST 393.27 ZZZ 44204 LAPS COLCT PRTL W/ANAST 2477.59 090 44205 LAPS COLCT PRTL W/RMVL TERMINAL ILE 2156.89 090 122 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule 44206 LAPS COLCT PRTL W/END CLST&CLSR DSTL SGM 2826.00 090 44207 LAPS COLCT PRTL W/COLOPXTSTMY LW ANAST 2945.64 090 44208 LAPS COLCT PRTL W/COLOPXTSTMY LW ANAST W/CLST 3200.43 090 44210 LAPS COLCT TOT W/O PRCTECT W/ILEOST/ILEOPXTS 2882.50 090 44211 LAPS COLCT TTL ABD W/PRCTECT ILEOANAL ANAST&RSVR 3595.92 090 44212 LAPS COLCT ABDL W/PRCTECT W/ILEOST 3305.12 090 + 44213 LAPS MOBLJ SPLENIC FLXR PFRMD W/PRTL COLCT 306.86 ZZZ 44227 LAPS CLSR NTRSTM LG/SM INT W/RESCJ&ANAST 2688.63 090 44238 UNLIS LAPS PX INT XCP RECTUM BR YYY 44300 PLACEMENT ENTEROSTOMY/CECOSTOMY TUBE OPEN 1351.52 090 44310 ILEOST/JEJUNOSTOMY NON-TUBE 1675.55 090 44312 REVJ ILEOST SMPL RLS SUPFC SCAR SPX 951.60 090 44314 REVJ ILEOST COMP RCNSTJ IN-DEPTH SPX 1620.16 090 44316 CONTINENT ILEOST KOCK PX SPX 2259.91 090 44320 CLST/SKN LVL CECOSTOMY 1925.36 090 44322 CLST/SKN LVL CECOSTOMY W/MLT BXS SPX 1572.52 090 44340 REVJ CLST SMPL RLS SUPFC SCAR SPX 987.05 090 44345 REVJ CLST COMP RCNSTJ IN-DEPTH SPX 1685.52 090 44346 REVJ CLST W/RPR PARACLST HRNA SPX 1893.23 090 K 44360 SCOPE OF UPPER SMALL INTESTINE 261.99 000 K 44361 SCOPE OF UPPER SMALL INTESTINE WITH BIOPSY 288.03 000 K 44363 ENTEROSCOPY > 2ND PRTN X ILE RMVL FB 343.42 000 K 44364 ENTEROSCOPY > 2ND PRTN X ILE RMVL LES SNARE 367.79 000 K 44365 ENTEROSCOPY > 2ND PRTN X ILE RMVL LES CAUT 328.46 000 K 44366 ENTEROSCOPY > 2ND PRTN X ILE CTRL BLD 432.60 000 K 44369 ENTEROSCOPY > 2ND PRTN X ILE ABLTJ LES 442.01 000 K 44370 ENTEROSCOPY > 2ND PRTN X ILE TNDSC STENT PLMT 477.46 000 K 44372 ENTEROSCOPY > 2ND PRTN X ILE W/PLMT PRQ TUBE 424.84 000 K 44373 ENTEROSCOPY > 2ND PRTN X ILE CONV GSTRST TUBE 341.76 000 K 44376 ENTEROSCOPY > 2ND PRTN W/ILE +-COLLJ SPEC SPX 505.71 000 K 44377 ENTEROSCOPY > 2ND PRTN W/ILE W/BX 1/MLT 535.07 000 K 44378 ENTEROSCOPY > 2ND PRTN ILE CTRL BLD 686.84 000 K 44379 ENTEROSCOPY > 2ND PRTN W/ILE W/STENT PLMT 727.82 000 K 44380 ILESC THRU STOMA DX +-COLLJ SPEC BR/WA SPX 113.00 000 K 44382 ILESC THRU STOMA W/BX 1/MLT 137.37 000 K 44383 ILESC THRU STOMA W/TNDSC STENT PLMT 279.72 000 K 44385 NDSC EVAL INTSTINAL POUCH DX +-COLLJ SPEC SPX 412.66 000 K 44386 NDSC EVAL INTSTINAL POUCH W/BX 1/MLT 568.30 000 K 44388 SCOPE OF COLON THRU OSTOMY FOR DIAGNOSIS 568.86 000 K 44389 SCOPE OF COLON WITH BIOPSY THRU OSTOMY 651.39 000 K 44390 COLSC THRU STOMA W/RMVL FB 757.18 000 K 44391 COLSC THRU STOMA CTRL BLD 829.74 000 K 44392 COLSC THRU STOMA RMVL LES CAUT 714.53 000 K 44393 COLSC THRU STOMA ABLTJ LES 827.53 000 K 44394 COLSC THRU STOMA W/RMVL TUM POLYP/OTH LES SNARE 824.20 000 K 44397 COLSC THRU STOMA W/TNDSC STENT PLMT 457.52 000 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 123
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 * K 44500 INTRO LONG GI TUBE SPX 40.43 000 44602 ENTERORRHAPHY 1 PRF8J 2252.71 090 44603 ENTERORRHAPHY MLT PRF8J 2584.50 090 44604 SUTR LG INT 1/MLT PRF8J W/O CLST 1698.81 090 44605 SUTR LG INT 1/MLT PRF8J W/CLST 2101.50 090 44615 INTSTINAL STRICTUROPLASTY+-DILAT OBSTRCJ 1730.38 090 44620 CLSR NTRSTM LG/SM INT 1388.07 090 44625 CLSR NTRSTM LG/SM RESCJ&ANAST OTH/THN CLRCT 1636.22 090 44626 CLSR NTRSTM LG/SM RESCJ&CLRCT ANAST 2586.16 090 44640 CLSR INTSTINAL CUTAN FSTL 2258.25 090 44650 CLSR ENTEROENTERIC/ENTEROCOLIC FSTL 2338.01 090 44660 CLSR ENTEROVES FSTL W/O INTSTINAL/BLDR RESCJ 2195.66 090 44661 CLSR ENTEROVES FSTL W/INT&/BLDR RESCJ 2516.92 090 44680 INTSTINAL PLCTJ SPX 1719.86 090 44700 EXCLUSION SM INT FROM PELVIS MESH/PROSTH/TISS 1632.90 090 + 44701 INTRAOP COLONIC LVG 271.41 ZZZ 44715 BKBENCH ALGRFT INT FASHIONING ART&VEIN BR XXX 44720 BKBENCH RCNSTJ INT ALGRFT VEN ANAST EA 413.76 XXX 44721 BKBENCH RCNSTJ INT ALGRFT ARTL ANAST EA 626.46 XXX 44799 UNLIS PX INT BR YYY 44800 EXC MECKEL'S DIVERTICULUM/OMPHALOMESENTERIC DUCT 1219.69 090 44820 EXC LES MESENTERY SPX 1346.53 090 44850 SUTR MESENTERY SPX 1196.42 090 44899 UNLISTED PX MECKEL'S DIVERTICULUM & MESENTERY BR YYY 44900 I&D APPENDICEAL ABSC OPN 1235.20 090 K 44901 I&D APPENDICEAL ABSC PRQ 1537.63 000 44950 APPENDEC 1029.70 090 + 44955 APPENDEC INDICATED PURPOSE OTH MAJOR PX X SPX 136.26 ZZZ 44960 APPENDEC RPTD APPENDIX ABSC/PRITONITIS 1399.15 090 44970 LAPS SURG APPENDEC 955.48 090 44979 UNLIS LAPS PX APPENDIX BR YYY 45000 TRANSRCT DRG PEL ABSC 670.77 090 45005 I&D SBMCSL ABSC RECTUM 413.21 010 45020 I&D DP SUPRALEVATOR PELVIRCT/RETRORCT ABSC 895.66 090 45100 BX ANRCT WALL ANAL APPR 469.15 090 45108 ANRCT MYOMECTOMY 578.27 090 45110 PRCTECT COMPL CMBN ABDOMINOPRNL W/CLST 2967.80 090 45111 PRCTECT PRTL RESCJ RECTUM TABDL APPR 1747.00 090 45112 PRCTECT CMBN ABDOMINOPRNL PULL-THRU PX 3035.37 090 45113 PRCTECT PRTL W/MUCOSEC ILEOANAL ANAST RSVR 3174.40 090 45114 PRCTECT PRTL W/ANAST ABDL&TRANSSAC APPR 2901.88 090 45116 PRCTECT PRTL W/ANAST TRANSSAC APPR ONLY 2514.71 090 45119 PRCTECT CMBN PULL-THRU W/RSVR W/NTRSTM 3126.77 090 45120 PRCTECT COMPL W/PULL-THRU PX&ANAST 2541.29 090 45121 PRCTECT COMPL W/STOT/TOT COLCT W/MLT BXS 2776.15 090 45123 PRCTECT PRTL W/O ANAST PRNL APPR 1780.79 090 124 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule 45126 PEL EXNTJ CLRCT MAL 4676.58 090 45130 EXC RCT PROCIDENTIA W/ANAST PRNL APPR 1738.69 090 45135 EXC RCT PROCIDENTIA W/ANAST ABDL&PRNL APPR 2183.47 090 45136 EXC ILEOANAL RSVR W/ILEOST 2898.56 090 45150 DIV STRIX RECTUM 631.45 090 45160 EXC RCT TUM PROCTOTOMY TRANSSAC/TRANSCOCCYGEAL 1613.51 090 45171 EXC RCT TUM NOT INCL MUSCULARIS PROPRIA 978.74 090 45172 EXC RCT TUM INCL MUSCULARIS PROPRIA 1336.01 090 45190 DSTRJ RCT TUM TRANSANAL APPR 1090.63 090 45300 PROCTOSGMDSC RGD DX +-COLLJ SPEC BR/WA SPX 185.00 000 K 45303 PROCTOSGMDSC RGD W/DILAT 1431.28 000 K 45305 PROCTOSGMDSC RGD W/BX 1/MLT 296.89 000 K 45307 PROCTOSGMDSC RGD W/RMVL FB 333.45 000 K 45308 PROCTOSGMDSC RGD RMVL 1 LES CAUT 313.51 000 K 45309 PROCTOSGMDSC RGD RMVL 1 LES SNARE TQ 334.00 000 K 45315 PROCTOSGMDSC RGD RMVL MLT TUM < CAUT/SNARE 370.01 000 K 45317 PROCTOSGMDSC RGD CTRL BLD 356.71 000 K 45320 PROCTOSGMDSC RGD ABLTJ LES 346.74 000 K 45321 PROCTOSGMDSC RGD DCMPRN VOLVULUS 174.48 000 K 45327 PROCTOSGMDSC RGD TNDSC STENT PLMT 206.60 000 45330 SCOPE OF SIGMOID COLON ONLY FOR DIAGNOSIS 224.33 000 45331 SCOPE OF SIGMOID COLON ONLY WITH BIOPSY 279.72 000 K 45332 SGMDSC FLX RMVL FB 466.94 000 K 45333 SGMDSC FLX RMVL LES CAUT 471.92 000 K 45334 SGMDSC FLX CTRL BLD 271.96 000 K 45335 SGMDSC FLX DIRED SBMCSL NJX ANY SBST 412.10 000 K 45337 SGMDSC FLX DCMPRN VOLVULUS ANY METH 235.41 000 K 45338 SGMDSC FLX RMVL TUM POLYP/OTH LES SNARE TQ 517.34 000 K 45339 SGMDSC FLX ABLTJ LES 545.59 000 K 45340 SGMDSC FLX DILAT BALO 1/MORE STRIXS 741.12 000 K 45341 SGMDSC FLX NDSC US XM 260.89 000 K 45342 SGMDSC FLX TNDSC US GID NDL ASPIR/BX 398.25 000 K 45345 SGMDSC FLX TNDSC STENT PLMT 289.69 000 K 45355 COLSC RGD/FLX TABDL VIA COLOTOMY 1/MLT 336.77 000 K 45378 SCOPE OF COLON FOR DIAGNOSIS 645.29 000 K 45379 COLSC FLX PROX SPLENIC FLXR RMVL FB 823.10 000 K 45380 SCOPE OF COLON WITH BIOPSY 771.03 000 K 45381 COLSC FLX PROX SPLENIC FLXR SBMCSL NJX 750.53 000 K 45382 COLSC FLX PROX SPLENIC FLXR CTRL BLD 1009.76 000 K 45383 COLSC FLX PROX SPLENIC FLXR ABLTJ LES 926.12 000 K 45384 COLSC FLX PROX SPLENIC FLXR RMVL LES CAUT 763.27 000 K 45385 COLSC FLX PROX SPLENIC FLXR RMVL LES SNARE TQ 869.07 000 K 45386 COLSC FLX PROX SPLENIC FLXR DILAT BALO 1+ STRIXS 1077.89 000 K 45387 COLSC FLX PROX SPLENIC FLXR TNDSC STENT PLMT 573.29 000 K 45391 COLSC FLX PROX SPLENIC FLXR NDSC US XM 491.86 000 K 45392 COLSC FLX PROX SPLENIC FLXR US GID NDL ASPIR/BX 632.00 000 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 125
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 45395 LAPS PRCTECT COMPL CMBN ABDOMINOPRNL W/CLST 3192.68 090 45397 LAPS PRCTECT CMBN PULL-THRU CRTJ RSVR 3443.60 090 45400 LAPS PROCTOPEXY FOR PROLAPSE 1848.36 090 45402 LAPS PROCTOPEXY FOR PROLAPSE SIGMOID RESCJ 2459.32 090 45499 UNLIS LAPS PX RECTUM BR YYY 45500 PROCTOPLASTY STENOSIS 823.10 090 45505 PROCTOPLASTY PROLAPSE MUC MEMB 922.24 090 45520 PRIRCT NJX SCLRSG SLN PROLAPSE 223.78 000 45540 PROCTOPEXY ABDL APPR 1693.27 090 45541 PROCTOPEXY PRNL APPR 1475.04 090 45550 PROCTOPEXY W/SIGMOID RESCJ ABDL APPR 2343.55 090 45560 RPR RECTOCELE SPX 1132.73 090 45562 EXPL RPR&PRESAC DRG RCT INJ 1785.22 090 45563 EXPL RPR&PRESAC DRG RCT INJ W/CLST 2617.18 090 45800 CLSR RECTOVESICAL FSTL 1949.17 090 45805 CLSR RECTOVESICAL FSTL W/CLST 2322.50 090 45820 CLSR RECTOURTL FSTL 1884.92 090 45825 CLSR RECTOURTL FSTL W/CLST 2328.04 090 45900 RDCTJ PROCIDENTIA SPX UNDER ANES 319.60 010 45905 DILAT ANAL SPHNCTR SPX UNDER ANES OTH/THN LOCAL 268.09 010 45910 DILAT RCT STRIX SPX UNDER ANES OTH/THN LOCAL 313.51 010 45915 RMVL FECAL IMPACTION/FB SPX UNDER ANES 506.26 010 45990 ANRCT XM SURG REQ ANES GENERAL SPI/EDRL DX 173.37 000 45999 UNLIS PX RECTUM BR YYY 46020 PLMT SETON 421.52 010 46030 RMVL ANAL SETON OTH MARKER 212.14 010 46040 I&D ISCHIORCT&/PRIRCT ABSC SPX 816.45 090 46045 I&D INTRAMURAL IM/ABSC TRANSANAL ANES 674.10 090 46050 I&D PRIANAL ABSC SUPFC 300.21 010 46060 I&D ISCHIORCT/INTRAMURAL ABSC +-SETON 738.35 090 46070 INC ANAL SEPTUM INFT 358.37 090 46080 SPHNCTROTOMY ANAL DIV SPHNCTR SPX 381.08 010 46083 INC THROMBOSED HEMORRHOID XTRNL 276.95 010 46200 FISSURECTOMY INCL SPHINCTEROTOMY WHEN PERFORMED 659.69 090 # 46220 EXCISION SINGLE EXTERNAL PAPILLA OR TAG ANUS 313.51 010 46221 HEMORRHOIDECTOMY INTERNAL RUBBER BAND LIGATIONS 408.22 010 46230 EXCISION MULTIPLE EXTERNAL PAPILLAE/TAGS ANUS 419.86 010 46250 HEMORRHOIDECTOMY XTRNL 2+ COLUMN/GROUP 705.67 090 46255 HEMORRHOIDECTOMY NTRNL & XTRNL 1 COLUMN/GROUP 776.57 090 46257 HRHC SMPL W/FISSURECTOMY 656.93 090 46258 HRHC 1 COL/GRP W/FSTULECTMY INCL FSSRECTOMY 731.70 090 46260 HEMORRHOIDECTOMY INT & XTRNL 2+ COLUMN/GROUP 741.67 090 46261 HRHC CPLX/X10SV W/FISSURECTOMY 829.19 090 46262 HRHC 2+ COL/GRP W/FSTULECTMY INCL FSSRECTMY 865.75 090 46270 SURG TX ANAL FSTL SUBQ 772.69 090 46275 SURG TX ANAL FISTULA INTERSPHINCTERIC 814.23 090 126 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule 46280 TX ANAL FSTL TRANS/SUPRA/XTRASPHNCTRC INCL SETON 727.82 090 46285 SURG TX ANAL FSTL 2ND STG 799.83 090 46288 CLSR ANAL FSTL W/RCT ADVMNT FLAP 854.11 090 # 46320 EXC THROMBOSED HEMORRHOID XTRNL 279.17 010 46500 NJX SCLRSG SLN HEMORRHOIDS 351.73 010 46505 CHEMODNRVTJ INT ANAL SPHNCTR 445.34 010 46600 ANOSC DX +-COLLJ SPEC BR/WA SPX 134.04 000 46604 ANOSC DILAT 890.12 000 46606 ANOSC BX 1/MLT 346.19 000 46608 ANOSC RMVL FB 357.27 000 46610 ANOSC RMVL 1 LES CAUT 351.17 000 46611 ANOSC RMVL 1 TUM POLYP/OTH LES SNARE TQ 274.18 000 46612 ANOSC RMVL MLT TUMS CAUT/SNARE 414.32 000 46614 ANOSC CTRL BLD 200.51 000 46615 ANOSC ABLTJ LES 229.87 000 46700 ANOPLASTY PLSTC OPRATION STRIX ADLT 1024.16 090 46705 ANOPLASTY PLSTC OPRATION STRIX INFT 772.14 090 46706 RPR ANAL FSTL W/FIBRIN GLUE 265.87 010 46707 REPAIR ANORECTAL FISTULA PLUG 763.83 090 46710 RPR ILEOANAL POUCH FSTL/POUCH ADVMNT TPRNL APPR 1749.22 090 46712 RPR ILEOANAL POUCH FSTL/POUCH ADVMNT CMBN APPR 3265.24 090 46715 RPR LW IMPRF8 ANUS W/ANOPRNL FSTL CUT-BK 774.91 090 46716 RPR LW IMPRF8 ANUS W/TRPOS FSTL 1840.61 090 46730 RPR HI IMPRF8 ANUS W/O FSTL PRNL/SACROPRNL APPR 2838.74 090 46735 RPR HI IMPRF8 ANUS W/O FSTL CMBN APPR 3291.27 090 46740 RPR HI IMPRF8 ANUS W/FSTL PRNL/SACROPRNL APPR 3397.07 090 46742 RPR HI IMPRF8 ANUS W/FSTL TABDL&SACROPRNL 3965.37 090 46744 RPR CLOACAL ANOMAL SACROPRNL 5418.25 090 46746 RPR CLOACAL ANOMAL CMBN ABDL&SACROPRNL 5739.51 090 46748 RPR CLOACAL ANOMAL CMBN ABDL&SACROPRNL W/GRF 6099.55 090 46750 SPHNCTROP ANAL INCONT/PROLAPSE ADLT 1216.36 090 46751 SPHNCTROP ANAL INCONT/PROLAPSE CHLD 983.73 090 46753 GRF THIERSCH RCT INCONT&/PROLAPSE 923.91 090 46754 RMVL THIERSCH WIRE/SUTR ANAL CANAL 459.18 010 46760 SPHNCTROP ANAL MUSC TRNSPL 1719.86 090 46761 SPHNCTROP ANAL LEVATOR MUSC IMBRCJ 1484.45 090 46762 SPHNCTROP ANAL IMPLTJ ARTIF SPHNCTR 1460.08 090 46900 DSTRJ LES ANUS SMPL CHEM 368.90 010 46910 DSTRJ LES ANUS SMPL ELTRDSICCATION 383.85 010 46916 DSTRJ LES ANUS SMPL CRYOSURG 370.56 010 46917 DSTRJ LES ANUS SMPL LASER SURG 724.50 010 46922 DSTRJ LES ANUS SMPL SURG EXC 405.45 010 46924 DSTRJ LES ANUS X10SV 827.53 010 46930 DESTRUCTION INTERNAL HEMORRHOID THERMAL ENERGY 331.79 090 46940 CURTG/CAUT ANAL FISSURE W/DILAT SPHNCTR SPX 1ST 348.40 010 46942 CURTG/CAUT ANAL FISSURE W/DILAT SPHNCTR SPX SBSQ 325.69 010 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 127
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 # 46945 HRHC NTRNL LIG OTH THAN RBBR BAND 1 COL/GRP 460.84 090 # 46946 HRHC NTRNL LIG OTH THAN RBBR BAND 2+ COL/GRP 480.23 090 # 46947 HEMORRHOIDOPEXY STAPLING 602.09 090 46999 UNLIS PX ANUS BR YYY 47000 BX LVR NDL PRQ 562.21 000 + 47001 BX LVR NDL DONE PURPOSE TM OTH MAJOR PX 167.83 ZZZ 47010 HEPATOTOMY OPN DRG ABSC/CST 1/2 STGS 1920.37 090 K 47011 HEPATOTOMY PRQ DRG ABSC/CST 1/2 STGS 309.08 000 47015 LAPT W/ASPIR&/NJX HEPATC PARASITIC CST/ABSCES 1848.36 090 47100 BX LVR WEDGE 1342.65 090 47120 HPTC RESCJ LVR PRTL LOBEC 3734.39 090 47122 HPTC RESCJ LVR TRISGMECTOMY 5520.17 090 47125 HPTC RESCJ LVR TOT L LOBEC 4942.45 090 47130 HPTC RESCJ LVR TOT R LOBEC 5305.81 090 47133 DON HPTC FROM CDVR DON BR XXX 47135 LVR ALTRNSPLJ ORTHOTOPIC PRTL/WHL DON ANY AGE 7863.72 090 47136 LVR ALTRNSPLJ HTRTPC PRTL/WHL DON ANY AGE 6677.26 090 47140 DON HPTC LIV DON L LAT SGM ONLY II&III 5708.49 090 47141 DON HPTC LIV DON TOT L LOBEC II III&IV 6208.67 090 47142 DON HPTC LIV DON TOT R LOBEC V VI VII&VIII 7536.92 090 47143 BKBENCH PREPJ CDVR WHL LVR GRF W/O TRISGM/LOBE BR XXX 47144 BKBENCH PREPJ CDVR WHL LVR GRF I&IV VIII BR 090 47145 BKBENCH PREPJ CDVR DON WHL LVR GRF I&V VIII BR XXX 47146 BKBENCH RCNSTJ LVR GRF VEN ANAST EA 534.51 XXX 47147 BKBENCH RCNSTJ LVR GRF ARTL ANAST EA 623.14 XXX 47300 MARSUPIALIZATION CST/ABSC LVR 1808.48 090 47350 MGMT LVR HEMRRG SMPL SUTR LVR WND/INJ 2195.66 090 47360 MGMT LVR HEMRRG CPLX SUTR WND/INJ 3002.69 090 47361 MGMT LVR HEMRRG EXPL WND DBRDMT COAGJ/SUTR 4853.27 090 47362 MGMT LVR HEMRRG RE-EXPL WND RMVL PACKING 2302.01 090 47370 LAPS SURG ABLTJ 1+ LVR TUM RF 1987.39 090 47371 LAPS SURG ABLTJ 1+ LVR TUM CRYOSURG 2026.72 090 47379 UNLIS LAPAROSCOPIC PX LVR BR YYY 47380 ABLTJ OPN 1+ LVR TUM RF 2315.86 090 47381 ABLTJ OPN 1+ LVR TUM CRYOSURG 2310.87 090 K 47382 ABLTJ 1+ LVR TUM PRQ RF 7550.21 010 47399 UNLIS PX LVR BR YYY 47400 HEPATCOTOMY/HEPATCOSTOMY W/EXPL DRG/RMVL ST1 3454.12 090 47420 CHOLEDOCHOT/OST W/O SPHNCTROTOMY/SPHNCTROP 2148.58 090 47425 CHOLEDOCHOT/OST W/SPHNCTROTOMY/SPHNCTROP 2180.70 090 47460 TRANSDUOL SPHNCTROTOMY/SPHNCTROP +-XTRJ ST1 SPX 2046.11 090 s 47480 CHOLECSTOT/CHOLECSTOST W/EXPL DRG/RMVL ST1 SPX 1384.20 090 s 47490 CHOLECSTOST PRQ W/IMG GID 595.44 010 47500 NJX PRQ TRANSHEPATC CHOLANGRPH 164.51 000 47505 NJX CHOLANGRPH THRU AN CATH 63.14 000 47510 INTRO PRQ TRANSHEPATC CATH BILIARY DRG 790.42 090 128 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule 47511 INTRO PRQ TRANSHEPATC STENT BILIARY DRG 977.63 090 K 47525 CHNG PRQ BILIARY DRG CATH 838.60 000 47530 REVJ&/RINSJ TRANSHEPATC TUBE 2360.72 090 + 47550 BILIARY NDSC INTRAOP 269.20 ZZZ 47552 BILIARY NDSC PRQ T-TUBE DX +-COLLJ SPEC SPX 530.64 000 47553 BILIARY NDSC PRQ T-TUBE W/BX 1/MLT 531.19 000 47554 BILIARY NDSC PRQ T-TUBE RMVL ST1 814.23 000 47555 BILIARY NDSC PRQ T-TUBE DILAT STRIX W/O STENT 630.89 000 47556 BILIARY NDSC PRQ T-TUBE DILAT STRIX W/STENT 715.08 000 47560 LAPS SURG W/GID TRANSHEPATC CHOLANGRPH W/O BX 436.47 000 47561 LAPS SURG W/GID TRANSHEPATC CHOLANGRPH W/BX 476.35 000 47562 LAPS SURG CHOLECSTC 1192.55 090 47563 LAPS SURG CHOLECSTC W/CHOLANGRPH 1208.61 090 47564 LAPS SURG CHOLECSTC W/EXPL COMMON DUX 1385.86 090 47570 LAPS SURG CHOLECSTONTRSTM 1239.63 090 47579 UNLIS LAPS PX BILIARY TRC BR YYY 47600 CHOLECSTC 1723.74 090 47605 CHOLECSTC CHOLANGRPH 1570.86 090 47610 CHOLECSTC EXPL DUX 2010.10 090 47612 CHOLECSTC EXPL DUX CHOLEDOCHONTRSTM 2031.71 090 47620 CHOLECSTC EXPL DUX SPHNCTROTOMY/SPHNCTROP 2207.85 090 47630 BILIARY DUX STONE XTRJ PRQ VIA BASKET/SNARE 916.70 090 47700 EXPL CGEN ATRESIA BILE DUXS 1679.42 090 47701 PORTONTRSTM 2823.78 090 47711 EXC BILE DUX TUM +-PRIM RPR XTRHEPATC 2498.09 090 47712 EXC BILE DUX TUM +-PRIM RPR INTRAHEPATC 3202.10 090 47715 EXC CHOLEDOCHAL CST 2118.11 090 47720 CHOLECSTONTRSTM DIR 1827.32 090 47721 CHOLECSTONTRSTM W/GASTRONTRSTM 2158.55 090 47740 CHOLECSTONTRSTM ROUX-EN-Y 2088.20 090 47741 CHOLECSTONTRSTM ROUX-EN-Y W/GASTRONTRSTM 2355.74 090 47760 ANAST XTRHEPATC BILIARY DUXS&GI 3593.70 090 47765 ANAST INTRAHEPATC DUXS&GI 4823.36 090 47780 ANAST ROUX-EN-Y XTRHEPATC BILIARY DUXS&GI 3939.89 090 47785 ANAST ROUX-EN-Y INTRAHEPATC BILIARY DUXS&GI 5166.23 090 47800 RCNSTJ PLSTC BILIARY DUXS W/END-TO-END ANAST 2530.77 090 47801 PLMT CHOLEDOCHAL STENT 1683.86 090 47802 U-TUBE HEPATCONTRSTM 2436.61 090 47900 SUTURE EXTRAHEPATIC BILE DUCT PRE-EXIST INJURY 2182.37 090 47999 UNLIS PX BILIARY TRC BR YYY 48000 PLACE DRAIN PERIPANCREATIC ACUTE PANCREATITIS 2977.21 090 48001 PLACE DRAIN PERIPANCREATIC W/CHOLECYSTOSTOMY 3709.47 090 48020 RMVL PNCRTC ST1 1881.04 090 48100 BX PNCRS OPN 1419.09 090 48102 BX PNCRS PRQ NDL 881.25 010 48105 RESECJ/DBRDMT PANCREAS NECROTIZING PANCREATITIS 4579.09 090 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 129
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 48120 EXC LES PNCRS 1773.03 090 48140 PNCRTECT DSTL STOT W/O PNCRTCOJEJUNOSTOMY 2505.29 090 48145 PNCRTECT DSTL STOT W/PNCRTCOJEJUNOSTOMY 2610.53 090 48146 PNCRTECT DSTL NR-TOT W/PRSRV DUO CHLD-TYP PX 2993.83 090 48148 EXC AMPULLA VATER 1989.05 090 48150 PNCRTECT PROX STOT W/PANCREATOJEJUNOSTOMY 4984.55 090 48152 PNCRTECT WHIPPLE W/O PANCREATOJEJUNOSTOMY 4628.39 090 48153 PNCRTECT W/PANCREATOJEJUNOSTOMY 4977.35 090 48154 PNCRTECT PROX STOT W/O PANCREATOJEJUNOSTOMY 4643.90 090 48155 PNCRTECT TOT 2899.11 090 48160 PNCRTECT TOT/STOT W/TRNSPLJ PNCRS/ISLET 5018.33 XXX + 48400 INJECTION INTRAOPERATIVE PANCREATOGRAPHY 171.71 ZZZ 48500 MARSUPIALIZATION PNCRTC CST 1828.42 090 48510 XTRNL DRG PSEUDOCST PNCRS OPN 1731.49 090 K 48511 XTRNL DRG PSEUDOCST PNCRS PRQ 1535.96 000 48520 INT ANAST PNCRTC CST GI TRC DIR 1751.43 090 48540 INT ANAST PNCRTC CST GI TRC ROUX-EN-Y 2078.23 090 48545 PANCREATORRHAPHY INJ 2143.04 090 48547 DUOL EXCLUSION W/GASTROJEJUNOSTOMY PNCRTC INJ 2866.43 090 48548 PANCREATICOJEJUNOSTOMY SIDE-TO-SIDE ANAST 2670.35 090 48550 DONOR PANCREATECTOMY DUODENAL SGM TRANSPLANT BR XXX 48551 BKBENCH PREPJ CDVR PNCRS ALGRFT BR XXX 48552 BKBENCH RCNSTJ CDVR PNCRS ALGRFT VEN ANAST EA 383.85 XXX 48554 TRNSPLJ PNCRTC ALGRFT 4056.21 090 48556 RMVL TRNSPLED PNCRTC ALGRFT 2016.75 090 48999 UNLIS PX PNCRS BR YYY 49000 EXPL LAPT EXPL CELIOTOMY +-BX SPX 1237.41 090 49002 REOPNG RECENT LAPT 1667.24 090 49010 EXPL RPR AREA +-BX SPX 1528.76 090 49020 DRG PRTL ABSC/LOCLZD PRITONITIS OPN 2552.93 090 K 49021 DRG PRTL ABSC/LOCLZD PRITONITIS PRQ 1461.74 000 49040 DRG SUBDIPHRG/SUBPHRENIC ABSC OPN 1605.76 090 K 49041 DRG SUBDIPHRG/SUBPHRENIC ABSC PRQ 1506.61 000 49060 DRG RPR ABSC OPN 1779.13 090 K 49061 DRG RPR ABSC PRQ 1474.48 000 49062 DRG XTRPRTL LYMPHOCELE PRTL CAVITY OPN 1203.62 090 49080 PRITONEOCNTS ABDL PCNTS/PRTL LVG 1ST 266.43 000 49081 PRITONEOCNTS ABDL PCNTS/PRTL LVG SBSQ 266.43 000 49180 BX ABDL/RPR MASS PRQ NDL 267.53 000 49203 EXCISION/DESTRUCTION OPEN ABDOMINAL TUMORS 5 CM 1925.36 090 49204 EXC/DESTRUCTION OPEN ABDMNL TUMORS 5.1-10.0 CM 2452.12 090 49205 EXC/DESTRUCTION OPEN ABDOMINAL TUMORS >10.0 CM 2814.37 090 49215 EXC PRESAC/SACROCOCCYGEAL TUM 3547.18 090 49220 STAGING LAPAROTOMY HODGKINS DISEASE/LYMPHOMA 1557.01 090 49250 UMBILECTOMY OMPHALECTOMY EXC UMBILICUS SPX 932.21 090 49255 OMNTC EPIPLOECTOMY RESCJ OMENTUM SPX 1264.00 090 130 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule 49320 LAPS ABD PRTM&OMENTUM DX +-SPEC BR/WA SPX 526.76 010 49321 LAPS SURG W/BX 1/MLT 557.78 010 49322 LAPS SURG W/ASPIR CAVITY/CST 1/MLT 599.32 010 49323 LAPS SURG W/DRG LYMPHOCELE PRTL CAVITY 1037.45 090 s 49324 LAPS INSERTION TUNNELED INTRAPERITONEAL CATHETER 634.77 010 49325 LAPS W/REVISION INTRAPERITONEAL CATHETER 679.64 010 + 49326 LAPS W/OMENTOPEXY 307.41 ZZZ l + 49327 LAPS W/INSERTION NTRSTL DEV W/IMG GID 1+ 215.47 ZZZ 49329 UNLIS LAPS PX ABD PRTM&OMENTUM BR YYY 49400 NJX AIR/CNTRST IN PRTL CAVITY SPX 257.01 000 49402 REMOVAL PERITONEAL FOREIGN BODY FROM CAVITY 1372.01 090 K 49411 INTERSTITIAL DEV PLMT RADIATION THERAPY 1/MLT 850.79 000 l + 49412 PLMT INTRSTL DEV OPN W/IMG GID 1+ 134.60 ZZZ l K 49418 INSJ INTRAPERITONEAL CATHETER W/IMG GID 2476.49 000 s 49419 INSERTION TUNNEL INTRAPERITONEAL CATH SUBQ PORT 713.98 090 s 49421 INSERTION TUNNEL INTRAPERITONEAL CATH DIAL OPEN 439.24 000 s 49422 REMOVAL TUNNELED INTRAPERITONEAL CATHETER 619.81 010 49423 EXCHNG ABSC/CST DRG CATH RAD GID SPX 930.00 000 49424 CNTRST NJX ASSMT ABSC/CST VIA DRG CATH/TUBE SPX 248.15 000 49425 INSJ PRTL-VEN SHUNT 1222.46 090 49426 REVJ PRTL-VEN SHUNT 1031.36 090 49427 INJECT EVALUATE PREVIOUS PERITONEAL-VENOUS SHUNT 75.88 000 49428 LIG PRTL-VEN SHUNT 702.35 010 49429 RMVL PRTL-VEN SHUNT 738.90 010 + 49435 INSJ SUBQ EXTENSION INTRAPERITONEAL CATHETER 194.42 ZZZ 49436 DELAYED CREATION EXIT SITE EMBEDDED CATHETER 299.11 010 K 49440 INSERT GASTROSTOMY TUBE PERCUTANEOUS 1776.91 010 K 49441 INSERT DUODENOSTOMY/JEJUNOSTOMY TUBE PERQ 1969.11 010 K 49442 INSERT CECOSTOMY/OTHER COLONIC TUBE PERCUTANEOUS 1652.28 010 K 49446 CONVERT GASTROSTOMY-GASTRO-JEJUNOSTOMY TUBE PERQ 1642.87 000 49450 REPLACE GASTROSTOMY/CECOSTOMY TUBE PERCUTANEOUS 1171.50 000 49451 REPLACE DUODENOSTOMY/JEJUNOSTOMY TUBE PERQ 1187.01 000 49452 REPLACEMENT GASTRO-JEJUNOSTOMY TUBE PERCUTANEOUS 1475.59 000 49460 OBSTRUCTIVE MATERIAL REMOVAL FROM GI TUBE 1292.80 000 49465 CONTRAST INJECTION PERQ RADIOLOGIC EVAL GI TUBE 281.94 000 49491 RPR 1ST INGUN HRNA PRETERM INFT RDC 1259.01 090 49492 RPR 1ST INGUN HRNA PRETERM INFT NCRC8 1525.44 090 49495 RPR 1ST INGUN HRNA FULL TERM INFT<6 MO RDC 644.19 090 49496 RPR 1ST INGUN HRNA FULL TERM INFT<6 MO NCRC8 983.73 090 49500 RPR 1ST INGUN HRNA AGE 6 MO-5 YRS RDC 613.17 090 49501 RPR 1ST INGUN HRNA AGE 6 MO-5 YRS NCRC8 960.46 090 49505 RPR 1ST INGUN HRNA AGE 5 YRS/> REDUCIBLE 826.97 090 49507 RPR 1ST INGUN HRNA AGE 5 YRS/> NCRC8 1016.96 090 49520 RPR RECRT INGUN HRNA ANY AGE RDC 1007.54 090 49521 RPR RECRT INGUN HRNA ANY AGE NCRC8 1223.57 090 49525 RPR INGUN HRNA SLIDING ANY AGE 912.27 090 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 131
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 49540 RPR LMBR HRNA 1079.55 090 49550 RPR 1ST FEM HRNA ANY AGE RDC 917.81 090 49553 RPR 1ST FEM HRNA ANY AGE NCRC8 1005.88 090 49555 RPR RECRT FEM HRNA RDC 953.26 090 49557 RPR RECRT FEM HRNA NCRC8 1156.54 090 49560 REPAIR FIRST ABDOMINAL WALL HERNIA 1178.70 090 49561 RPR 1ST INCAL/VNT HRNA NCRC8 1488.88 090 49565 RPR RECRT INCAL/VNT HRNA RDC 1227.44 090 49566 RPR RECRT INCAL/VNT HRNA NCRC8 1504.95 090 + 49568 IMPLANT MESH OPN HERNIA RPR/DEBRIDEMENT CLOSURE 434.26 ZZZ 49570 RPR EPIGSTR HRNA RDC SPX 658.03 090 49572 RPR EPIGSTR HRNA NCRC8 816.45 090 49580 RPR UMBILICAL HRNA < 5 YRS RDC 520.67 090 49582 RPR UMBILICAL HRNA <5 YRS NCRC8 762.17 090 49585 RPR UMBILICAL HRNA 5 YRS/> RDC 704.01 090 49587 RPR UMBILICAL HRNA AGE 5 YRS/> NCRC8 832.51 090 49590 RPR SPIGELIAN HRNA 911.17 090 49600 RPR SM OMPHALOCELE W/PRIM CLSR 1171.50 090 49605 RPR LG OMPHALOCELE/GASTROSCHISIS +-PROSTH 8014.38 090 49606 RPR LG OMPHALOCELE/GASTROSCHISIS RMVL PROSTH 1817.90 090 49610 RPR OMPHALOCELE GROSS TYP OPRATION 1ST STG 1100.05 090 49611 RPR OMPHALOCELE GROSS TYP OPRATION 2ND STG 892.33 090 49650 LAPS SURG RPR 1ST INGUN HRNA 678.53 090 49651 LAPS SURG RPR RECRT INGUN HRNA 883.47 090 49652 LAPS REPAIR HERNIA EXCEPT INCAL/INGUN REDUCIBLE 1172.61 090 49653 LAP RPR HRNA XCPT INCAL/INGUN NCRC8/STRANGULATED 1469.50 090 49654 LAPAROSCOPY REPAIR INCISIONAL HERNIA REDUCIBLE 1347.64 090 49655 LAPS RPR INCISIONAL HERNIA NCRC8/STRANGULATED 1621.82 090 49656 LAPS RPR RECURRENT INCISIONAL HERNIA REDUCIBLE 1352.62 090 49657 LAPS RPR RECURRENT INCAL HRNA NCRC8/STRANGULATED 1945.30 090 49659 UNLIS LAPS PX HRNAP HERNIORRHAPHY HERNIOTOMY BR YYY 49900 SEC ABDOMINAL WALL SUTURE EVISCERATION/DEHSN 1303.33 090 49904 OMENTAL FLAP XTR-ABDL 2375.12 090 + 49905 OMENTAL FLAP INTRA-ABDL 574.39 ZZZ 49906 FR OMENTAL FLAP W/MVASC ANAST BR 090 49999 UNLIS PX ABD PRTM&OMENTUM BR YYY 50010 RNL EXPL X NECESSITATING OTH SPEC PX 1218.03 090 50020 DRG PRIRNL/RNL ABSC OPN 1731.49 090 K 50021 DRG PRIRNL/RNL ABSC PRQ 1544.27 000 50040 NFROS NFROT W/DRG 1558.67 090 50045 NFROT W/EXPL 1563.11 090 50060 NEPHROLITHOTOMY RMVL ST1 1920.93 090 50065 NEPHROLITHOTOMY SECONDARY FOR CALCULUS 2023.95 090 50070 NEPHROLITHOTOMY COMP CGEN KDN ABNORMALITY 2003.46 090 50075 NEPHROLITHOTOMY RMVL LG STAGHORN ST1 2461.53 090 50080 PRQ NEPHROSTOLITHOTOMY/PYELOSTOLITHOTOMY UP 2 CM 1468.94 090 132 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule 50081 PRQ NEPHROSTOLITHOTOMY/PYELOSTOLITHOTOMY > 2 CM 2156.33 090 50100 TRNSXJ/RPSG ABERRANT RNL VSL SPX 1634.01 090 50120 PLOT W/EXPL 1593.57 090 50125 PLOT W/DRG PYELOSTOMY 1694.38 090 50130 PLOT W/RMVL ST1 1743.12 090 50135 PLOT COMP 1888.25 090 K 50200 RNL BX PRQ TROCAR/NDL 943.85 000 50205 RNL BX SURG EXPOS KDN 1212.49 090 50220 NFRCT W/PRTL URTREC ANY OPN RIB RESCJ 1749.22 090 50225 NFRCT W/PRTL URTREC ANY OPN RIB RESCJ COMP 2008.44 090 50230 NFRCT W/PRTL URTREC ANY OPN RIB RESCJ RAD 2159.66 090 50234 NFRCT W/TOT URTREC&BLDR CUFF THRU SM INC 2192.89 090 50236 NFRCT TOT URTREC&BLDR CUFF THRU SEP INC 2473.72 090 50240 NFRCT PRTL 2231.66 090 s 50250 OPEN ABLATION RENAL MASS CRYOSURG ULTRASOUND 2059.95 090 50280 EXC/UNROOFING CST KDN 1605.20 090 50290 EXC PRINEPHRIC CST 1527.10 090 50300 DON NFRCT FROM CDVR DON UNI/BI BR XXX 50320 DON NFRCT OPN FROM LIV DON 2306.44 090 50323 BKBENCH PREPJ CDVR RNL ALGRFT BR XXX 50325 BKBENCH PREPJ LIV RNL ALGRFT OPN/LAPS BR XXX 50327 BKBENCH RCNSTJ RNL ALGRFT VEN ANAST EA 353.39 XXX 50328 BKBENCH RCNSTJ RNL ALGRFT ARTL ANAST EA 309.08 XXX 50329 BKBENCH RCNSTJ ALGRFT URTRL ANAST EA 290.24 XXX 50340 RCP NFRCT SPX 1501.62 090 50360 RNL ALTRNSPLJ IMPLTJ GRF W/O RCP NFRCT 4099.97 090 50365 RNL ALTRNSPLJ IMPLTJ GRF W/RCP NFRCT 4618.42 090 50370 RMVL TRNSPLED RNL ALGRFT 1914.83 090 50380 RNL AUTOTRNSPLJ RIMPLTJ KDN 3237.55 090 K 50382 RMVL&RPLCMT INTLY DWELLING URTRL STENT 2088.76 000 K 50384 RMVL INTLY DWELLING URTRL STENT 1744.79 000 K 50385 REMOVE & REPLACE INT DWELL URETERAL STENT TRURL 2040.57 000 K 50386 REMOVE INT DWELL URETERAL STENT TRANSURETHRAL 1329.91 000 K 50387 RMVL&RPLCMT XTRNLLY ACCESSIBLE URTRL STENT 968.22 000 50389 RMVL NFROS TUBE REQ FLUOR GID 538.39 000 50390 ASPIR&/NJX RNL CST/PELVIS NDL PRQ 163.40 000 50391 INSTLJ AGT RNL PELVIS&/URTR THRU TUBE 211.04 000 50392 INTRO INTRACATH/CATH IN RNL PELVIS DRG&/NJX PRQ 301.32 000 50393 INTRO URTRL CATH/STENT THRU PELVIS DRG&/NJX PRQ 366.68 000 50394 NJX PX PLOG THRU TUBE/CATH 171.16 000 50395 INTRO GD PELVIS&/URTR W/DILAT NFROS TRC 304.65 000 50396 MANOMETRIC STDS THRU TUBE/NDWELLG URTRL CATH 196.08 000 50398 CHNG NFROS/PYELOSTOMY TUBE 876.27 000 50400 PLOP RNL PELVIS SMPL 1948.07 090 50405 PLOP RNL PELVIS COMP 2350.20 090 50500 NEPHRORRHAPHY SUTR KDN WND/INJ 2068.82 090 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 133
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 50520 CLSR NEPHROCUTAN/PYELOCUTAN FSTL 1738.14 090 50525 CLSR NEPHROVISC FSTL W/VISC RPR ABDL APPR 2407.80 090 50526 CLSR NEPHROVISC FSTL W/VISC RPR THRC APPR 2319.73 090 50540 SYMPHYSIOTOMY HORSESHOE KDN +-PLOP UNI/BI 1914.83 090 50541 LAPS ABLTJ RNL CSTS 1552.03 090 s 50542 LAPS ABLTJ RNL MASS LES W/INTRAOP US 1970.22 090 50543 LAPS PRTL NFRCT 2513.04 090 50544 LAPS PLOP 2107.04 090 50545 LAPS RADICAL NFRCT 2267.67 090 50546 LAPS NFRCT W/PRTL URTREC 2023.40 090 50547 LAPS DON NFRCT FROM LIV DON 2603.88 090 50548 LAPS NFRCT W/TOT URTREC 2278.19 090 50549 UNLIS LAPS PX RNL BR YYY 50551 RNL NDSC NFROS/PYELOSTOMY 612.06 000 50553 RNL NDSC NFROS/PYELOSTOMY URTRL CATHJ 650.28 000 50555 RNL NDSC NFROS/PYELOSTOMY BX 699.02 000 50557 RNL NDSC NFROS/PYELOSTOMY FULG&/INC +-BX 711.76 000 50561 RNL NDSC NFROS/PYELOSTOMY RMVL FB/ST1 808.69 000 50562 RNL NDSC NFROS/PYELOSTOMY RESCJ TUM 985.94 090 50570 RNL NDSC NFROT/PLOT 833.07 000 50572 RNL NDSC NFROT/PLOT W/URTRL CATHJ +-DILAT URTR 902.86 000 50574 RNL NDSC NFROT/PLOT BX 959.91 000 50575 RNL NDSC NFROT/PLOT W/ENDOPLOT 1211.93 000 50576 RNL NDSC NFROT FULGURATION&/INC +-BX 956.59 000 50580 RNL NDSC NFROT/PLOT W/RMVL FB/ST1 1028.04 000 50590 LITHOTRP XTRCORP SHOCK WAVE 1442.36 090 K 50592 ABLTJ 1+ RNL TUM PRQ UNI RF 5622.09 010 K 50593 ABLATION RENAL TUMOR UNILATERAL PERQ CRYOTHERAPY 7734.66 010 50600 URTROTOMY W/EXPL/DRG SPX 1576.95 090 50605 URETEROTOMY INSERTION INDWELLING STENT ALL TYPES 1601.88 090 50610 URTROLITHOTOMY UPPER ONE-THIRD URETER 1593.02 090 50620 URTROLITHOTOMY MIDDLE ONE-THIRD URETER 1523.78 090 50630 URTROLITHOTOMY LOWER ONE-THIRD URETER 1493.31 090 50650 URTREC W/BLDR CUFF SPX 1744.23 090 50660 URTREC TOT ECTOPIC URTR CMBN APPR 1922.03 090 50684 NJX URTRG/URTROPLOG THRU URTROST/URTRL CATH 245.93 000 50686 MANOMETRIC STDS THRU URTROST/NDWELLG URTRL CATH 240.95 000 50688 CHNG URTROST TUBE/XTRNLLY ACCESSIBLE STENT ILEAL 134.04 010 50690 NJX VISUALIZATION ILEAL CONDUIT&/URTROPLOG 163.95 000 50700 URTROPLASTY PLSTC OPRATION URTR 1554.80 090 50715 URTROLSS +-RPSG URTR RPR FIBROSIS 1934.22 090 50722 URETEROLYSIS FOR OVARIAN VEIN SYNDROME 1718.20 090 50725 URTROLSS RETROCAVAL URTR W/REANAST 1889.35 090 50727 REVJ UR-CUTAN ANAST 849.13 090 50728 REVJ UR-CUTAN ANAST RPR FSCAL DFCT&HRNA 1164.30 090 50740 URTROPYELOSTOMY ANAST URTR&RNL PELVIS 1970.22 090 134 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule 50750 URTROCALYCOSTOMY ANAST URTR RNL CALYX 1948.62 090 50760 URTROURTROST 1879.38 090 50770 TRANSURTROURTROST ANAST URTR CLAT URTR 1911.51 090 50780 URTRONEOCSTOST ANAST 1 URTR BLDR 1853.90 090 50782 URTRONEOCSTOST ANAST DUPLICATED URTR BLDR 1920.93 090 50783 URTRONEOCSTOST W/X10SV URTRL TAILORING 1918.16 090 50785 URTRONEOCSTOST W/VESICO-PSOAS HITCH/BLDR FLAP 2037.80 090 50800 URTRONTRSTM DIR ANAST URTR INT 1556.46 090 50810 URTROSIGMOIDOSTOMY CRTJ CLST INT ANAST 2189.57 090 50815 URTROCOLON CONDUIT INT ANAST 2056.63 090 50820 URTROILEAL CONDUIT W/INT ANAST 2210.06 090 50825 CONTINENT DVRJ W/INT ANAST W/ANY SGM SM&/LG INT 2789.44 090 50830 UR UNDVRJ 3017.65 090 50840 RPLCMT ALL/PART URTR INT SGM W/INT ANAST 2071.03 090 50845 CUTAN APPENDICO-VESICOSTOMY 2102.05 090 50860 URTROST TRNSPLJ URTR SKN 1587.48 090 50900 URTRORRHAPHY SUTR URTR SPX 1414.66 090 50920 CLSR URTROCUTAN FSTL 1483.90 090 50930 CLSR URTROVISC FSTL W/VISC RPR 1948.62 090 50940 DELIG URTR 1487.78 090 50945 LAPS URTROLITHOTOMY 1640.10 090 50947 LAPS URTRONEOCSTOST W/CSTSC&URTRL STENT PLMT 2323.06 090 50948 LAPS URTRONEOCSTOST W/O CSTSC&URTRL STENT PLMT 2155.78 090 50949 UNLIS LAPS PX URTR BR YYY 50951 NDSC THRU URTROST 639.75 000 50953 NDSC URTROST W/URTRL CATHJ 676.87 000 50955 NDSC THRU URTROST BX 736.69 000 50957 NDSC THRU URTROST FULG&/INC +-BX 727.82 000 50961 NDSC THRU URTROST RMVL FB/ST1 657.48 000 50970 NDSC THRU URTROTOMY 628.12 000 50972 NDSC THRU URTROTOMY URTRL CATHJ +-DILAT 606.52 000 50974 NDSC THRU URTROTOMY BX 802.05 000 50976 NDSC THRU URTROTOMY FULG&/INC +-BX 789.86 000 50980 NDSC THRU URTROTOMY RMVL FB/ST1 603.75 000 51020 CSTOTOMY/CSTOST FULG&/INSJ RADACT MATRL 789.31 090 51030 CSTOTOMY/CSTOST CRYOSURG DSTRJ INTRAVESICAL LES 782.11 090 51040 CSTOST CSTOTOMY W/DRG 489.09 090 51045 CSTOTOMY W/INSJ URTRL CATH/STENT SPX 815.34 090 51050 CSTOLITHOTOMY CSTOTOMY W/RMVL ST1 795.95 090 51060 TRANSVESICAL URTROLITHOTOMY 979.85 090 51065 CSTOTOMY W/ST1 BASKET XTRJ&/FRAGMENTATION 973.76 090 51080 DRG PRIVESICAL/PREVESICAL SPACE ABSC 685.17 090 51100 ASPIRATION BLADDER NEEDLE 104.13 000 51101 ASPIRATION BLADDER TROCAR/INTRACATHETER 212.70 000 51102 ASPIRATION BLADDER INSERT SUPRAPUBIC CATHETER 387.73 000 51500 EXC URACHAL CST/SINUS +-UMBILICAL HRNA RPR 1090.63 090 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 135
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 51520 CYSTOTOMY SIMPLE EXCISION VESICAL NECK 991.48 090 51525 CYSTOTOMY EXCISE BLADDER DIVERTICULUM 1/MULTIPLE 1449.00 090 51530 CYSTOTOMY EXCISION BLADDER TUMOR 1318.84 090 51535 CYSTOTOMY EXCISE/INCISE/REPAIR URETEROCELE 1301.67 090 51550 CSTC PRTL SMPL 1620.16 090 51555 CSTC PRTL COMP 2131.96 090 51565 CSTC PRTL W/RIMPLTJ URTR IN BLDR URTRONEOCSTOST 2172.40 090 51570 CSTC COMPL SPX 2484.80 090 51575 CSTC COMPL W/BI PEL LMPHADEC 3072.48 090 51580 CSTC COMPL W/TRNSPLJS 3200.43 090 51585 CSTC COMPL W/TRNSPLJS W/LMPHADEC 3563.79 090 51590 CSTC COMPL W/URTROILEAL CONDUIT/BLDR W/INT ANAST 3258.59 090 51595 CSTC COMPL W/CONDUIT/SIGMOID BLDR PEL LMPHADEC 3695.62 090 51596 CSTC COMPL W/CONTINENT DVRJ OPN NEOBLDR 3970.91 090 51597 PEL EXNTJ COMPL MAL 3860.68 090 51600 NJX CSTOGRAPY/VOIDING URETHROCSTOGRAPY 319.60 000 51605 NJX&PLMT CHAIN C+&/URETHROCSTOGRAPY 64.25 000 51610 NJX RTRGR URETHROCSTOGRAPY 183.34 000 51700 BLDR IRRIGATION SMPL LVG&/INSTLJ 142.91 000 51701 INSJ NON-NDWELLG BLDR CATH 97.49 000 51702 INSJ TEMP NDWELLG BLDR CATH SMPL 125.74 000 51703 INSJ TEMP NDWELLG BLDR CATH COMP 227.65 000 51705 CHNG CSTOST TUBE SMPL 185.00 010 51710 CHNG CSTOST TUBE COMP 257.56 010 51715 NDSC NJX IMPLT MATRL URT&/BLDR NCK 489.65 000 51720 BLDR INSTLJ ANTICARCINOGENIC AGT 188.33 000 51725 SMPL CSTOMETROGRAM 343.97 000 51725 26 SMPL CSTOMETROGRAM 126.84 000 51725 TC SMPL CSTOMETROGRAM 217.13 000 51726 BLADDER PRESSURE MEASUREMENT DURING FILLING 502.39 000 51726 26 BLADDER PRESSURE MEASUREMENT DURING FILLING 144.57 000 51726 TC BLADDER PRESSURE MEASUREMENT DURING FILLING 357.82 000 51727 COMPLEX CYSTOMETROGRAM URETHRAL PRESS PROFILE 499.62 000 51727 26 COMPLEX CYSTOMETROGRAM URETHRAL PRESS PROFILE 178.91 000 51727 TC COMPLEX CYSTOMETROGRAM URETHRAL PRESS PROFILE 320.71 000 51728 COMPLEX CYSTOMETROGRAM VOIDING PRESSURE STUDIES 494.63 000 51728 26 COMPLEX CYSTOMETROGRAM VOIDING PRESSURE STUDIES 175.03 000 51728 TC COMPLEX CYSTOMETROGRAM VOIDING PRESSURE STUDIES 319.60 000 51729 COMPLX CYSTOMETRO W/VOID PRESS&URETHRAL PROFILE 541.71 000 51729 26 COMPLX CYSTOMETRO W/VOID PRESS&URETHRAL PROFILE 211.04 000 51729 TC COMPLX CYSTOMETRO W/VOID PRESS&URETHRAL PROFILE 330.67 000 51736 SMPL UROFLOMETRY 57.61 XXX 51736 26 SMPL UROFLOMETRY 19.94 XXX 51736 TC SMPL UROFLOMETRY 37.67 XXX 51741 CPLX UROFLOMETRY 70.35 XXX 51741 26 CPLX UROFLOMETRY 27.14 XXX 136 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule 51741 TC CPLX UROFLOMETRY 43.21 XXX 51784 EMG STDS ANAL/URTL SPHNCTR OTH/THN NDL 335.66 000 51784 26 EMG STDS ANAL/URTL SPHNCTR OTH/THN NDL 128.50 000 51784 TC EMG STDS ANAL/URTL SPHNCTR OTH/THN NDL 207.16 000 51785 NDL EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ 368.90 000 51785 26 NDL EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ 129.06 000 51785 TC NDL EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ 239.84 000 51792 STIMULUS EVOKED RSPSE 379.98 000 51792 26 STIMULUS EVOKED RSPSE 93.61 000 51792 TC STIMULUS EVOKED RSPSE 286.37 000 + # 51797 VOID PRESSURE STUDIES INTRAABDOMINAL 220.45 ZZZ + # 51797 26 VOID PRESSURE STUDIES INTRAABDOMINAL 68.68 ZZZ + # 51797 TC VOID PRESSURE STUDIES INTRAABDOMINAL 151.77 ZZZ 51798 MEAS POST-VOIDING RESIDUAL URINE&/BLDR CAP 32.13 XXX 51800 CSTOPLASTY/CSTOURTP PLSTC ANY 1760.29 090 51820 CSTOURTP W/UNI/BI URTRONEOCSTOST 1792.97 090 51840 ANT VESICOURETHROPEXY/URETHROPEXY SMPL 1101.15 090 51841 ANT VESICOURETHROPEXY/URETHROPEXY COMP 1310.53 090 51845 ABDOMINO-VAG VESICAL NCK SSP +-NDSC CTRL 990.37 090 51860 CSTORR SUTR BLDR WND INJ/RPT SMPL 1240.18 090 51865 CSTORR SUTR BLDR WND INJ/RPT COMP 1501.07 090 51880 CLSR CSTOST SPX 786.54 090 51900 CLSR VESICOVAG FSTL ABDL APPR 1378.66 090 51920 CLSR VESICOUTERINE FSTL 1267.32 090 51925 CLSR VESICOUTERINE FSTL W/HYST 1761.40 090 51940 CLSR EXSTROPHY BLDR 2720.76 090 51960 ENTEROCSTOPLASTY W/INTSTINAL ANAST 2343.00 090 51980 CUTAN VESICOSTOMY 1197.53 090 51990 LAPAROSCOPY URETHRAL SUSPENSION STRESS INCONT 1261.23 090 51992 LAPAROSCOPY SLING OPERATION STRESS INCONT 1411.89 090 51999 UNLIS LAPS PX BLDR BR YYY 52000 CYSTOURETHROSCOPY 348.40 000 52001 CSTO W/IRRG&EVAC MLT OBSTRUCTING CLOTS 634.77 000 52005 SCOPE BLADDER INSERT TUBE FOR INJECTION 476.91 000 52007 CSTO W/URTRL CATHJ BRUSH BX URTR&/RNL PELVIS 855.78 000 52010 CSTO W/EJACULATORY DUX CATHJ 660.25 000 52204 CYSTOURETHROSCOPY WITH BIOPSY 691.82 000 52214 SCOPE BLADDER DESTRUCTION OF LESIONS 1033.02 000 52224 SCOPE BLADDER REMOVAL OF LESIONS SMALL 1234.64 000 52234 SCOPE BLADDER REMOVAL OF TUMORS SMALL 416.53 000 52235 SCOPE BLADDER REMOVAL OF TUMORS MEDIUM 488.54 000 52240 SCOPE BLADDER W/ REMOVAL OF TUMORS LARGE 853.56 000 52250 CSTO INSJ RADACT SBST +-BX/FULG 410.99 000 52260 SCOPE BLADDER OPENING OF BLADDER 355.05 000 52265 CYSTO BLADDER DILAT INTRSTL CYSTITIS LOCAL 675.20 000 52270 CSTO INT URETHROTOMY FEMALE 647.51 000 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 137
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 52275 CSTO INT URETHROTOMY MALE 880.70 000 52276 CSTO DIR VIS INT URETHROTOMY 449.77 000 52277 CSTO RESCJ XTRNL SPHNCTR 550.58 000 52281 CSTO CALIBRATION DILAT URTL STRIX/STENOSIS 478.57 000 52282 CYSTOURETHROSCOPY INSERTION PERM URETHRAL STENT 569.96 000 52283 CSTO STRD NJX IN STRIX 471.37 000 52285 SCOPE BLADDER OPEN NARROWED FEMALE URETHRA 475.25 000 52290 CSTO URTRL MEATOTOMY UNI/BI 413.76 000 52300 CSTO ORTHOTOPIC URTROCELE UNI/BI 479.68 000 52301 CSTO ECTOPIC URTROCELE UNI/BI 495.74 000 52305 CSTO INC/RESCJ ORIFICE BLDR DIVERTICULUM 1/MLT 471.92 000 52310 SCOPE BLADDER W/SIMPLE REMOVAL STONE & STENT 413.76 000 52315 SCOPE BLADDER W/COMPLEX REMOVAL STONE & STENT 724.50 000 52317 LITHOLAPAXY SMPL/SM < 2.5 CM 1499.96 000 52318 LITHOLAPAXY COMP/LG > 2.5 CM 802.05 000 52320 CSTO RMVL URTRL ST1 417.09 000 52325 CSTO FRAGMENTATION URTRL ST1 542.82 000 52327 CSTO W/SUBURTRIC NJX IMPLT MATRL 444.23 000 52330 CSTO MNPJ W/O RMVL URTRL ST1 1098.38 000 52332 SCOPE BLADDER & URETER INSERT STENT INTO URETER 817.00 000 52334 CSTO INSJ URTRL GD WIRE PRQ NFROS RTRGR 434.81 000 52341 CSTO W/TX URTRL STRIX 490.76 000 52342 CSTO W/TX URTROPEL JUNCT STRIX 533.41 000 52343 CSTO W/TX INTRA-RNL STRIX 593.78 000 52344 CSTO W/URTROSCOPY W/TX URTRL STRIX 644.19 000 52345 CSTO W/URTROSCOPY W/TX URTROPEL JUNCT STRIX 686.84 000 52346 CSTO W/URTROSCOPY W/TX INTRA-RNL STRIX 775.46 000 52351 CSTO W/URTROSCOPY&/PYELOSCOPY DX 531.19 000 52352 SCOPE BLADDER & URETER REMOVE OR MOVE STONES 624.25 000 52353 SCOPE BLADDER & URETER BREAK UP KIDNEY STONE 716.75 000 52354 CSTO/PYELOSCOPY BX&/FULG PEL LES 663.57 000 52355 CSTO/PYELOSCOPY RESCJ PEL TUM 790.42 000 52400 CSTO INC FULG/RESCJ URTL VALVES/FOLDS 810.91 090 52402 CSTO W/TRURL RESCJ/INC EJACULATORY DUXS 451.98 000 52450 TRURL INC PRST8 790.97 090 52500 SURGERY ON BLADDER NECK THROUGH URETHRA 822.54 090 52601 TRURL ELECTROSURG RESCJ PRST8 CTRL BLD COMPL 1409.12 090 52630 TRURL RESCJ RESIDUAL/REGROWTH OBSTR PRST8 TISSUE 747.77 090 52640 OPENING OF POSTOPERATIVE BLADDER NECK NARROWING 500.73 090 52647 LASER COAGULATION OF PROSTATE FOR URINE FLOW 3382.67 090 52648 LASER VAPORIZATION OF PROSTATE FOR URINE FLOW 3465.20 090 52649 LASER ENUCLEATION PROSTATE W MORCELLATION 1630.13 090 52700 TRURL DRG PROSTATIC ABSC 736.13 090 53000 URTT/URTS XTRNL SPX PENDULOUS URT 250.92 010 53010 URTT/URTS XTRNL SPX PRNL URT XTRNL 495.74 090 53020 MEATOTOMY CUTTING MEATUS SPX XCP INFT 163.95 000 138 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule 53025 MEATOTOMY CUTTING MEATUS SPX INFT 111.33 000 53040 DRG DP PRIURTL ABSC 660.25 090 53060 DRG OF SKENE'S GLAND ABSC OR CYST 307.97 010 53080 DRG PRNL UR XTRVASATION UNCOMP SPX 720.62 090 53085 DRG PRNL UR XTRVASATION COMP 1077.34 090 53200 BX URT 260.89 000 53210 URETHRECTOMY TOT W/CSTOST FEMALE 1300.00 090 53215 URETHRECTOMY TOT W/CSTOST MALE 1566.98 090 53220 EXC/FULGURATION CARC URT 762.72 090 53230 EXC URTL DIVERTICULUM SPX FEMALE 1023.61 090 53235 EXC URTL DIVERTICULUM SPX MALE 1070.13 090 53240 MARSUPIALIZATION URTL DIVERTICULUM MALE/FEMALE 718.41 090 53250 EXC OF BULBOURTL GLAND 724.50 090 53260 EXC/FULGURATION URTL POLYP DSTL URT 338.43 010 53265 EXC/FULGURATION URTL CARUNCLE 370.01 010 53270 EXC OR FULGURATION SKENE'S GLANDS 357.27 010 53275 EXC/FULGURATION URTL PROLAPSE 444.23 010 53400 URETHROPLASTY 1ST STG FISTULA/DIVERTICULUM/STRIX 1350.96 090 53405 URTP 2ND STG W/UR DVRJ 1476.14 090 53410 URTP ONE-STG RCNSTJ MALE ANT URT 1652.28 090 53415 URTP TRANSPUBIC/PRNL 1 STG RCNSTJ/RPR URT 1904.86 090 53420 URTP 2-STG RCNSTJ/RPR URT 1ST STG 1382.53 090 53425 URTP 2-STG RCNSTJ/RPR URT 2ND STG 1584.71 090 53430 URTP RCNSTJ FEMALE URT 1619.60 090 53431 URTP W/TUBULARIZATION POST URT&/LWR BLDR 1944.19 090 53440 SLING OPRATION CORRJ MALE UR INCONT 1486.67 090 53442 RMVL/REVJ SLING MALE UR INCONT 1313.30 090 53444 INSJ TANDEM CUFF 1339.33 090 53445 INSJ NFLTBL URTL/BLDR NCK SPHNCTR 1483.34 090 53446 RMVL NFLTBL URTL/BLDR NCK SPHNCTR 1086.20 090 53447 RMVL&RPLCMT NFLTBL NCK SPHNCTR SM SESS 1368.13 090 53448 RMVL&RPLCMT NFLTBL NCK SPHNCTR THRU INFCT FLD 2160.21 090 53449 RPR NFLTBL URTL/BLDR NCK SPHNCTR 1033.58 090 53450 URETHROMEATOPLASTY W/MUCOSAL ADVMNT 688.50 090 53460 URETHROMEATOPLASTY W/PRTL EXC DSTL URTL SGM 771.03 090 53500 URETHROLSS TRVG SEC OPN W/CSTO 1260.12 090 53502 URTORR SUTR URTL WND/INJ FEMALE 815.89 090 53505 URTORR SUTR URTL WND/INJ PEN 819.77 090 53510 URTORR SUTR URTL WND/INJ PRNL 1064.60 090 53515 URTORR SUTR URTL WND/INJ PROSTATOMEMBRANOUS 1338.22 090 53520 CLSR URETHROSTOMY/URETHROQ FSTL MALE SPX 937.20 090 53600 DILAT URTL STRIX DILATOR MALE 1ST 142.35 000 53601 DILAT URTL STRIX DILATOR MALE SBSQ 138.48 000 53605 DILAT URTL STRIX/VESICAL NCK DILATOR MALE ANES 108.56 000 53620 DILAT URTL STRIX FILIFORM&FOLLWR MALE 1ST 202.17 000 53621 DILAT URTL STRIX FILIFORM&FOLLWR MALE SBSQ 190.54 000 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 139
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 53660 DILAT FEMALE URT W/SUPPOSITORY&/INSTLJ 1ST 121.30 000 53661 DILAT FEMALE URT W/SUPPOSITORY&/INSTLJ SBSQ 120.20 000 53665 DILAT FEMALE URT GENERAL/CNDJ SPI ANES 64.81 000 53850 TRURL DSTRJ PRST8 TISS MICROWAVE THERMOTH 3831.88 090 53852 TRURL DSTRJ PRST8 TISS RF THERMOTH 3694.51 090 53855 INSERT TEMP PROSTATIC URETH STENT W/MEASUREMENT 1166.51 000 l 53860 TRURL RF FEMALE BLADDER NECK STRS URIN INCONT 2380.11 090 53899 UNLIS PX UR SYS BR YYY 54000 SLITTING PREPUCE DORSAL/LAT SPX NB 257.01 010 54001 SLITTING PREPUCE DORSAL/LAT SPX XCP NB 319.05 010 54015 I&D PNS DP 520.11 010 54050 DSTRJ LES PNS SMPL CHEM 214.36 010 54055 DSTRJ LES PNS SMPL ELTRDSICCATION 196.08 010 54056 DSTRJ LES PNS SMPL CRYOSURG 229.87 010 54057 DSTRJ LES PNS SMPL LASER SURG 230.42 010 54060 DSTRJ LES PNS SMPL SURG EXC 307.97 010 54065 DSTRJ LES PNS X10SV 360.59 010 54100 BX PNS SPX 327.35 000 54105 BX PNS DP STRUXS 456.41 010 54110 EXC PEN PLAQUE 1051.30 090 54111 EXC PEN PLAQUE GRF 5 CM LENGTH 1352.07 090 54112 EXC PEN PLAQUE GRF > 5 CM LENGTH 1584.71 090 54115 RMVL FB FROM DP PEN TISS 761.06 090 54120 AMP PNS PRTL 1065.70 090 54125 AMP PNS COMPL 1371.46 090 54130 AMP PNS RAD W/BI INGUINOFEM LMPHADEC 2014.53 090 54135 AMP PNS RAD BI PEL LMPHADEC 2555.14 090 54150 CIRCUMCISION W/CLAMP/OTH DEV W/BLOCK 274.73 000 54160 CIRCUMCISION NEONATE 381.64 010 54161 CIRCUMCISION >28 DAYS 332.34 010 54162 LSS/EXC PEN POST-CIRCUMCISION ADS 447.00 010 54163 RPR INCOMPL CIRCUMCISION 368.90 010 54164 FRENULOTOMY PNS 325.69 010 54200 NJX PEYRONIE 183.89 010 54205 NJX PEYRONIE EXPOS PLAQUE 901.75 090 54220 IRRIGATION CORPORA CAVERNOSA PRIAPISM 350.06 000 54230 INJECTION CORPORA CAVERNOSOGRAPY 162.85 000 54231 DYNAMIC CAVERNOSOMETRY NJX VASOACTIVE DRUGS 236.52 000 54235 NJX C/P/A CAVERNOSA W/PHARMACOLOGIC AGT 151.77 000 54240 PEN PLETHYSMOGRAPY 166.17 000 54240 26 PEN PLETHYSMOGRAPY 108.56 000 54240 TC PEN PLETHYSMOGRAPY 57.61 000 54250 NOCTURNAL PEN TUMESCENCE&/RGDITY TST 204.39 000 54250 26 NOCTURNAL PEN TUMESCENCE&/RGDITY TST 185.00 000 54250 TC NOCTURNAL PEN TUMESCENCE&/RGDITY TST 19.39 000 54300 PNS STRAIGHTENING CHORDEE 1088.97 090 140 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule 54304 PNS CORRJ CHORDEE 1ST STG HYPSPAD RPR 1272.86 090 54308 URTP 2ND STG HYPSPAD RPR < 3 CM 1234.64 090 54312 URTP 2ND STG HYPSPAD RPR > 3 CM 1414.11 090 54316 URTP 2ND STG HYPSPAD RPR SKN GRF 1722.08 090 54318 URTP 3RD STG HYPSPAD RPR RLS PNS 1207.50 090 54322 1 STG DSTL HYPSPAD RPR W/SMPL MEATAL ADVMNT 1325.48 090 54324 1 STG DSTL HYPSPAD RPR W/URTP SKN FLAPS 1645.08 090 54326 1 STG DSTL HYPSPAD RPR URTP SKN FLAPS&MOBLJ 1572.52 090 54328 1 STG DSTL HYPSPAD RPR W/X10SV DSJ 1583.05 090 54332 1 STG PROX PEN/PENOSCROTAL HYPSPAD RPR 1717.64 090 54336 1 STG PRNL HYPSPAD RPR REQ X10SV DSJ SKN GRF 1994.59 090 54340 RPR HYPSPAD COMPLCTJS CLSR INC/EXC SMPL 955.48 090 54344 RPR HYPSPAD COMPLCTJS MOBLJ FLAPS&URTP 1636.77 090 54348 RPR HYPSPAD COMPLCTJS X10SV DSJ&URTP FLAP/GRF 1896.00 090 54352 RPR HYPSPAD CRIPPLE REQ X10SV DSJ&EXC 2682.54 090 54360 PLSTC PNS CORRECT ANGULATION 1223.01 090 54380 PLSTC PNS EPSPAD DSTL SPHNCTR 1355.39 090 54385 PLSTC PNS EPSPAD DSTL SPHNCTR W/INCONT 1661.15 090 54390 PLSTC PNS EPSPAD DSTL SPHNCTR W/EXSTROPHY BLDR 2070.48 090 54400 INSJ PEN PROSTH NON-NFLTBL SEMI-RGD 895.66 090 54401 INSJ PEN PROSTH NFLTBL SELF-CONTAINED 1107.25 090 54405 INSJ MULTI-COMPONENT NFLTBL PEN PROSTH 1366.47 090 54406 RMVL NFLTBL PEN PROSTH W/O RPLCMT PROSTH 1232.43 090 54408 RPR COMPONENT MULTI-COMPONENT NFLTBL PEN PROSTH 1333.24 090 54410 RMVL&RPLCMT NFLTBL PEN PROSTH SM SESS 1453.43 090 54411 RMVL&RPLCMT NFLTBL PEN PROSTH THRU INFCT FLD 1729.83 090 54415 RMVL NON-NFLTBL/NFLTBL PEN PROSTH W/O RPLCMT 890.12 090 54416 RMVL&RPLCMT NON-NFLTBL/NFLTBL PROSTH SM SESS 1196.98 090 54417 RMVL&RPLCMT NON-NFLTBL/NFLTBL PEN INFCT SM SESS 1515.47 090 54420 C/P/A CAVERNOSA-SAPHENOUS VEIN SHUNT UNI/BI 1193.10 090 54430 C/P/A CAVERNOSA-CORPUS SPONGIOSUM SHUNT UNI/BI 1083.43 090 54435 CORPORA CAVERNOSA-GLANS PENIS FSTLJ PRIAPISM 704.01 090 54440 PLASTIC OPERATION PENIS INJURY 958.80 090 54450 FORESKN MNPJ W/LSS PREPUTIAL ADS&STRETCHING 120.20 000 54500 BX TSTIS NDL SPX 125.74 000 54505 BX TSTIS INCAL SPX 356.16 010 54512 EXC XTRPARENCHYMAL LES TSTIS 904.52 090 54520 ORCHIECTOMY SMPL SCROTAL/INGUN APPR 550.02 090 54522 ORCHIECTOMY PRTL 981.51 090 54530 ORCHIECTOMY RAD TUM INGUN APPR 853.56 090 54535 ORCHIECTOMY RAD TUM W/ABDL EXPL 1242.95 090 54550 EXPL UNDESCENDED TSTIS INGUN/SCROTAL AREA 825.86 090 54560 EXPL UNDESCENDED TSTIS W/ABDL EXPL 1134.94 090 54600 RDCTJ TORSION TSTIS +-FIXJ CLAT TSTIS 762.72 090 54620 FIXJ CLAT TSTIS SPX 507.37 010 54640 ORCHIOPEXY INGUN APPR +-HRNA RPR 800.94 090 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 141
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 54650 ORCHIOPEXY ABDL APPR INTRA-ABDL TSTIS 1191.44 090 54660 INSJ TSTICULAR PROSTH SPX 599.32 090 54670 SUTR/RPR TSTICULAR INJ 681.30 090 54680 TRNSPLJ TSTIS THI 1317.17 090 54690 LAPAROSCOPY SURGICAL ORCHIECTOMY 1152.67 090 54692 LAPAROSCOPY ORCHIOPEXY INTRA-ABDOMINAL TESTIS 1282.28 090 54699 UNLIS LAPS PX TSTIS BR YYY 54700 I&D EPIDIDYMIS TSTIS&/SCROTAL SPACE 358.37 010 54800 BX EPIDIDYMIS NDL 247.59 000 54830 EXC LOCAL LES EPIDIDYMIS 627.01 090 54840 EXC SPRMATOCELE +-EPIDIDYMECTOMY 542.82 090 54860 EPIDIDYMECTOMY UNI 705.67 090 54861 EPIDIDYMECTOMY BI 952.15 090 54865 EXPLORATION EPIDIDYMIS W/WO BIOPSY 602.64 090 54900 EPIDIDYMOVASOSTOMY ANAST EPIDIDYMIS UNI 1285.60 090 54901 EPIDIDYMOVASOSTOMY ANAST EPIDIDYMIS BI 1787.99 090 55000 PNXR ASPIR HYDROCELE TUNICA VAGIS +-NJX MED 201.07 000 55040 EXC HYDROCELE UNI 570.52 090 55041 EXC HYDROCELE BI 858.55 090 55060 RPR TUNICA VAGIS HYDROCELE BOTTLE TYP 640.31 090 55100 DRG SCROTAL WALL ABSC 366.13 010 55110 SCROTAL EXPL 653.05 090 55120 RMVL FB SCROTUM 599.32 090 55150 RESCJ SCROTUM 825.86 090 55175 SCROTOPLASTY SMPL 613.17 090 55180 SCROTOPLASTY COMP 1163.74 090 55200 VASOTOMY CANNULIZATION +-INC VAS UNI/BI SPX 784.88 090 55250 VASECT UNI/BI SPX W/PO SEMEN XM 700.13 090 55300 VASOTOMY VASOGRAMS UNI/BI 307.97 000 55400 VASOVASOSTOMY VASOVASORRHAPHY 843.59 090 55450 LIG PRQ VAS DEFERENS UNI/BI SPX 625.35 010 55500 EXC HYDROCELE SPRMATIC CORD UNI SPX 658.03 090 55520 EXC LES SPRMATIC CORD SPX 720.07 090 55530 EXC VARICOCELE/LIG SPRMATIC VEINS SPX 596.55 090 55535 EXC VARICOCELE/LIG SPRMATIC VEINS ABDL 721.18 090 55540 EXC VARICOCELE/LIG VEINS W/HRNA RPR 864.64 090 55550 LAPS LIG SPRMATIC VEINS VARICOCELE 713.42 090 55559 UNLIS LAPS SPRMATIC CORD BR YYY 55600 VESICULOTOMY 711.21 090 55605 VESICULOTOMY COMP 875.72 090 55650 VESICULECTOMY ANY APPR 1202.52 090 55680 EXC MULLERIAN DUX CST 573.84 090 55700 PROSTATE NEEDLE BIOPSY ANY APPROACH 380.53 000 55705 BX PRST8 INCAL ANY APPR 451.43 010 55706 BX PROSTATE STRTCTC SATURATION SAMPLING IMG GID 630.89 010 55720 PROSTATOTOMY XTRNL DRG ABSC SMPL 759.95 090 142 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule 55725 PROSTATOTOMY XTRNL DRG ABSC COMP 994.80 090 55801 PRST8ECT PRNL STOT 1836.18 090 55810 PRST8ECT PRNL RAD 2220.59 090 55812 PRST8ECT PRNL RAD LYMPH NODE BX 2714.11 090 55815 PRST8ECT PRNL RAD BI PEL LMPHADEC 2976.66 090 55821 PRST8ECT SUPRAPUBIC STOT 1/2 STGS 1475.59 090 55831 PRST8ECT RETROPUBIC STOT 1595.79 090 55840 PRST8ECT RETROPUBIC RAD +-NRV SPARING 2258.80 090 55842 PRST8ECT RETROPUBIC RAD LYMPH NODE BX 2418.33 090 55845 PRST8ECT RETROPUBIC RAD W/BI PEL LMPHADEC 2763.41 090 55860 EXPOS PRST8 ANY APPR INSJ RADACT SBST 1475.59 090 55862 EXPOS PRST8 INSJ RADACT NODE BX 1853.90 090 55865 EXPOS PRST8 INSJ RADACT BI PEL LMPHADEC 2254.93 090 s 55866 LAPS PRSTECT RETROPUBIC RAD W/NRV SPARING ROBOT 2925.15 090 55870 ELECTROEJACULATION 295.78 000 55873 CRYOSURG ABLATION PROSTATE US & MONITORING 10324.70 090 55875 TPRNL PLMT NDL/CATHS INTO PRST8 RADJ INSJ 1285.05 090 s 55876 PLACE INTERSTITIAL DEV RADIATION TX PROSTATE 1+ 229.87 000 55899 UNLIS MALE GEN SYS BR YYY 55920 PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL 732.26 000 55970 INTERSEX SURG MALE FEMALE BR XXX 55980 INTERSEX SURG FEMALE MALE BR XXX 56405 I&D VULVA/PRNL ABSC 179.46 010 56420 I&D OF BARTHOLIN'S GLAND ABSC 202.73 010 56440 MARSUPIALIZATION BARTHOLIN'S GLAND CYST 301.32 010 56441 LSS LABIAL ADS 240.39 010 56442 HYMENOTOMY SIMPLE INCISION 79.21 000 56501 DSTRJ LES VULVA SMPL 214.36 010 56515 DSTRJ LES VULVA X10SV 367.24 010 56605 BX VULVA/PR SPX 1 LES 135.71 000 + 56606 BX VULVA/PR SPX EA SEP ADDL LES 61.48 ZZZ 56620 VULVECTOMY SMPL PRTL 821.43 090 56625 VULVECTOMY SMPL COMPL 985.94 090 56630 VULVECTOMY RAD PRTL 1448.45 090 56631 VULVECTOMY RAD PRTL UNI INGUINOFEM LMPHADEC 1835.62 090 56632 VULVECTOMY RAD PRTL BI INGUINOFEM LMPHADEC 2133.07 090 56633 VULVECTOMY RAD COMPL 1882.71 090 56634 VULVECTOMY RAD COMPL UNI INGUINOFEM LMPHADEC 1990.16 090 56637 VULVECTOMY RAD COMPL BI INGUINOFEM LMPHADEC 2342.44 090 56640 VULVECTOMY RAD COMPL ILIAC&PEL LMPHADEC 2309.76 090 56700 PRTL HYMENECTOMY/REVJ HYMENAL RING 307.97 010 56740 EXC BARTHOLIN'S GLAND OR CYST 489.09 010 56800 PLSTC RPR INTROITUS 397.70 010 56805 CLITOROPLASTY INTERSEX STATE 1886.03 090 56810 PRINEOPLASTY RPR PR NONOBAL SPX 427.61 010 56820 COLPOSCOPY VULVA 181.13 000 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 143
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 56821 COLPOSCOPY VULVA W/BX 240.95 000 57000 COLPOTOMY W/EXPL 312.95 010 57010 COLPOTOMY W/DRG PEL ABSC 713.42 090 57020 COLPOCNTS SPX 154.54 000 57022 I&D VAG HMTMA OBAL/POSTPARTUM 275.84 010 57023 I&D VAG HMTMA NON-OBAL 512.36 010 57061 DSTRJ VAG LES SMPL 186.66 010 57065 DSTRJ VAG LES X10SV 314.06 010 57100 BX VAG MUCOSA SMPL SPX 144.01 000 57105 BX VAG MUCOSA X10SV REQ SUTR 221.56 010 57106 VAGNC PRTL RMVL VAG WALL 788.20 090 57107 VAGNC PRTL RMVL VAG WALL PARAVAG TISS 2306.99 090 57109 VAGNC PRTL RMVL VAG WALL W/BI TOT PEL LMPHADEC 2636.56 090 57110 VAGNC COMPL RMVL VAG WALL 1478.91 090 57111 VAGNC COMPL RMVL VAG WALL PARAVAG TISS 2652.63 090 57112 VAGNC COMPL RMVL VAG WALL TOT PEL LMPHADEC BX 2487.01 090 57120 COLPOCLEISIS LE FORT TYP 841.37 090 57130 EXC VAG SEPTUM 293.57 010 57135 EXC VAG CST/TUM 315.17 010 57150 IRRG VAG&/APPL MEDICAMENT DISEASE 78.10 000 s K 57155 INSJ UTERINE TANDEM&/VAG OVOIDS 535.07 000 l 57156 INSJ VAGINAL RADIATION DEVICE 244.27 000 57160 FITG&INSJ PESSARY/OTH INTRAVAG SUPPORT DEV 125.74 000 57170 DPHRM/CRV CAP FITG W/INSTRUCTIONS 106.35 000 57180 INTRO ANY HEMOSTATIC AGT/PACK VAG HEMRRG SPX 231.53 010 57200 COLPORRHAPHY SUTR INJ VAG 489.09 090 57210 COLPOPRINEORRHAPHY SUTR INJ VAG&/PR 601.54 090 57220 PLSTC URTL SPHNCTR VAG APPR 526.76 090 57230 PLSTC RPR URETHROCELE 658.59 090 57240 ANT COLPORRHAPHY RPR CSTOCELE +-RPR URETHROCELE 1096.17 090 57250 POST COLPORRHAPHY RPR RECTOCELE +-PRINEORRHAPHY 1100.05 090 57260 CMBN ANTEROPOST COLPORRHAPHY 1359.27 090 57265 CMBN ANTEROPOST COLPORRHAPHY W/NTRCL RPR 1497.75 090 + 57267 INSJ MESH/PROSTH PEL FLOOR DFCT EA SIT 428.16 ZZZ 57268 RPR NTRCL VAG APPR SPX 792.08 090 57270 RPR NTRCL ABDL APPR SPX 1313.30 090 57280 COLPOPEXY ABDL APPR 1576.95 090 57282 COLPOPEXY VAG XTR-PRTL APPR 826.97 090 57283 COLPOPEXY VAG INTRA-PRTL APPR 1138.26 090 57284 PARAVAGINAL DEFECT REPAIR OPEN ABDOMINAL APPR 1355.39 090 57285 PARAVAGINAL DEFECT REPAIR VAGINAL APPROACH 1116.11 090 57287 RMVL/REVJ SLING STRESS INCONTINENCE 1132.17 090 57288 SLING OPERATION STRESS INCONTINENCE 1174.82 090 57289 PREYRA PX W/ANT COLPORRHAPHY 1203.62 090 57291 CONSTJ ARTIF VAG W/O GRF 975.97 090 57292 CONSTJ ARTIF VAG W/GRF 1355.95 090 144 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule 57295 REVJ RMVL PROSTC VAG GRF VAG APPR 794.85 090 57296 REVJ W/RMVL PROSTHETIC VAG GRF ABD APPRO 1566.98 090 57300 CLSR RECTOVAG FSTL VAG/TRANSANAL APPR 899.53 090 57305 CLSR RECTOVAG FSTL ABDL APPR 1499.41 090 57307 CLSR RECTOVAG FSTL ABDL APPR W/CONCOMITANT CLST 1702.69 090 57308 CLSR RECTOVAG FSTL TPRNL PRNL BDY RCNSTJ 1063.49 090 57310 CLSR URETHROVAG FSTL 767.71 090 57311 CLSR URETHROVAG FSTL W/BULBOCAVERNOSUS TRNSPL 874.05 090 57320 CLSR VESICOVAG FSTL VAG APPR 887.90 090 57330 CLSR VESICOVAG FSTL TRANSVESICAL&VAG APPR 1230.21 090 57335 VAGINOPLASTY INTERSEX STATE 1920.93 090 57400 DILATION VAGINA W/ANESTHESIA OTHER THAN LOCAL 221.01 000 57410 PELVIC EXAMINATION W/ANESTHESIA OTHER THAN LOCAL 176.14 000 57415 REMOVAL IMPACTED VAG FB SPX W/ANES OTH/THN LOCAL 262.55 010 57420 COLPOSCOPY ENTIRE VAG W/CERVIX IF PRESENT 189.43 000 57421 COLPOSCOPY ENTIRE VAG W/CERVIX BX 255.35 000 57423 PARAVAGINAL DEFECT REPAIR LAPAROSCOPIC APPROACH 1519.35 090 57425 LAPS SURG COLPOPEXY SSP VAG APEX 1599.11 090 57426 REVISION PROSTHETIC VAGINAL GRAFT LAPAROSCOPIC 1386.41 090 57452 COLPOSCOPY CERVIX UPR/ADJ VAG 177.80 000 57454 COLPOSCOPY CERVIX BX CERVIX&ENDOCRV CURTG 252.02 000 57455 COLPOSCOPY CERVIX VAG BX CERVIX 234.30 000 57456 COLPOSCOPY CERVIX VAG ENDOCRV CURTG 221.56 000 57460 COLPOSCOPY CERVIX VAG LOOP ELTRD BX CERVIX 476.91 000 57461 COLPOSCOPY CERVIX VAG ELTRD CONIZATION CERVIX 536.73 000 57500 BIOPSY CERVIX 1/MLT OR EXCISION OF LESION 213.25 000 57505 ENDOCRV CURTG X DONE AS PART DILAT&CURTG 166.72 010 57510 CAUT CERVIX ELECTRO/THERMAL 216.02 010 57511 CAUT CERVIX CRYOCAUT 1ST/REPEAT 238.73 010 57513 CAUT CERVIX LASER ABLTJ 235.96 010 57520 CONIZATION CERVIX +-D&C RPR KNIFE/LASER 501.83 090 57522 CONIZATION CERVIX +-D&C RPR ELTRD EXC 433.15 090 57530 TRACHELECTOMY CERVICECTOMY AMP CERVIX SPX 565.53 090 57531 RAD TRACHELECTOMY W/BI PEL LMPHADEC 2815.47 090 57540 EXC CRV STUMP ABDL APPR 1281.72 090 57545 EXC CRV STUMP ABDL APPR W/PEL FLOOR RPR 1352.62 090 57550 EXC CRV STUMP VAG APPR 671.88 090 57555 EXC CRV STUMP VAG APPR W/ANT&/POST RPR 987.60 090 57556 EXC CRV STUMP VAG APPR W/RPR NTRCL 933.32 090 57558 DILATION & CURETTAGE CERVICAL STUMP 205.50 010 57700 CERCLAGE UTERINE CERVIX NONOBAL 510.70 090 57720 TRACHELORRHAPHY PLSTC RPR UTERINE CERVIX VAG 505.16 090 57800 DILAT CRV CANAL INSTRUMENTAL SPX 98.04 000 58100 ENDOMETRIAL BX +-ENDOCRV BX W/O DILAT SPX 180.02 000 + 58110 ENDOMETRIAL BX CONJUNCT W/COLPOSCOPY 79.21 ZZZ 58120 D&C DX&/THER 416.53 010 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 145
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 58140 MYOMECTOMY 1-4 250 GM ABDL 1509.38 090 58145 MYOMECTOMY 1-4 250 GM/< VAG 893.99 090 58146 MYOMECTOMY 5+ > 250 GM ABDL 1904.86 090 58150 TAH +-RMVL TUBE +-RMVL OVARY 1635.11 090 58152 TAH +-RMVL TUBE OVARY COLPO-URTCSTOPEXY 2052.75 090 58180 SUPRACRV ABDL HYST +-RMVL TUBE OVARY 1571.97 090 58200 TAH W/PRTL VAGNC PEL LYMPH NODE SAMPLING 2155.22 090 58210 RAD ABDL HYST W/BI PEL LMPHADEC 2880.28 090 58240 PEL EXNTJ GYNECOLOGIC MAL 4570.23 090 58260 VAG HYST 250 GM/< 1361.49 090 58262 VAG HYST 250 GM/< W/RMVL TUBE&/OVARY 1518.79 090 58263 VAG HYST 250 GM/< W/RMVL TUBE OVARY W/RPR NTRCL 1634.01 090 58267 VAG HYST 250 GM/< W/COLPO-URTCSTOPEXY 1738.14 090 58270 VAG HYST 250 GM/< W/RPR NTRCL 1452.33 090 58275 VAG HYST W/TOT/PRTL VAGNC 1620.16 090 58280 VAG HYST W/TOT/PRTL VAGNC W/RPR NTRCL 1732.60 090 58285 VAG HYST RAD SCHAUTA 2162.43 090 58290 VAGINAL HYSTERECTOMY UTERUS > 250 GM 1898.22 090 58291 VAG HYST > 250 GM RMVL TUBE&/OVARY 2058.85 090 58292 VAG HYST > 250 GM RMVL TUBE&/OVARY W/RPR NTRCL 2169.63 090 58293 VAG HYST > 250 GM COLPO-URTCSTOPEXY +-NDSC CTRL 2254.93 090 58294 VAG HYST > 250 GM RPR NTRCL 2009.00 090 58300 INSJ INTRAUTERINE DEV 117.43 XXX 58301 RMVL INTRAUTERINE DEV 157.31 000 58321 ARTIF INSEMINATION INTRA-CRV 121.86 000 58322 ARTIF INSEMINATION INTRA-UTERINE 141.80 000 58323 SPRM WASHG ARTIF INSEMINATION 28.80 000 58340 CATHJ&INTRO SALINE NFS SHG/HSG 200.51 000 58345 TRANSCRV INTRO FLP TUBE CATH +-HSG 460.84 010 58346 INSJ HEYMAN CAPSLS CLINICAL BRACHYTX 715.64 090 58350 CHROMOTUBATION OVIDUX MATRLS 158.97 010 58353 ENDOMETRIAL ABLTJ THERMAL W/O HYSTEROSCOPIC GID 1761.40 010 58356 ENDOMETRIAL CRYOABLTJ US CURTG 3263.58 010 58400 UTERINE SSP SPX 726.16 090 58410 UTERINE SSP PRESAC SYMPTH 1322.71 090 58520 HYSTERORRHAPHY RPR RPTD 1327.14 090 58540 HYSTEROPLASTY RPR UTERINE ANOMAL 1494.42 090 58541 LAPS SUPRACRV HYST 250 G/< 1415.21 090 58542 LAPS SUPRACRV HYST 250 G/< RMVL TUBE/OVARY 1580.83 090 58543 LAPS SUPRACRV HYST >250 G 1607.97 090 58544 LAPS SUPRACRV HYST >250 G RMVL TUBE/OVARY 1738.14 090 58545 LAPS MYOMECTOMY EXC 1-4 250 GM/< 1472.82 090 58546 LAPS MYOMECTOMY EXC 5+ > 250 GRAMS 1858.89 090 58548 LAPS W/RAD HYST W/BILAT LMPHADEC RMVL TUBE/OVARY 2937.89 090 58550 LAPS W/VAG HYST 250 GM/< 1453.43 090 58552 LAPS W/VAG HYST 250 GM/< RMVL TUBE&/OVARY 1612.40 090 146 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule 58553 LAPS W/VAG HYST > 250 GRAMS 1869.97 090 58554 LAPS VAG HYST > 250 GM RMVL TUBE&/OVARY 2162.98 090 58555 HYSTSC DX SPX 442.57 000 58558 HYSTSC BX ENDOMETRIUM&/POLYPC +-D&C 587.13 000 58559 HYSTSC LSS INTRAUTERINE ADS 566.64 000 58560 HYSTSC DIV/RESCJ INTRAUTERINE SEPTUM 639.75 000 58561 HYSTSC RMVL LEIOMYOMATA 904.52 000 58562 HYSTSC RMVL IMPACTED FB 613.72 000 58563 HYSTSC ENDOMETRIAL ABLTJ 2883.05 000 58565 HYSTSC OCCLUSION PLMT PRM 3138.40 090 58570 LAPAROSCOPY W TOTAL HYSTERECTOMY UTERUS 250 G/< 1521.56 090 58571 LAPS TOTAL HYSTERECTOMY 250 G/<W TUBE/OVARY 1685.52 090 58572 LAPAROSCOPY TOTAL HYSTERECTOMY UTERUS>250 G 1891.01 090 58573 LAPAROSCOPY TOT HYSTERECTOMY >250 G W TUBE/OVARY 2158.55 090 58578 UNLIS LAPS UTER BR YYY 58579 UNLIS HYSTSC UTER BR YYY 58600 LIG/TRNSXJ FLP TUBE ABDL/VAG APPR UNI/BI 599.32 090 58605 LIG/TRNSXJ FLP TUBE ABDL/VAG POSTPARTUM SPX 541.71 090 + 58611 LIG/TRNSXJ FLP TUBE DONE TM C DLVR/SURG 127.95 ZZZ 58615 OCCLUSION FLP TUBE DEV VAG/SUPRAPUBIC APPR 405.45 010 58660 LAPS LSS ADS SPX 1105.58 090 58661 LAPS RMVL ADNEXAL STRUXS 1058.50 010 58662 LAPS FULG/EXC OVARY VISCERA/PRTL SURF 1159.87 090 58670 LAPS FULG OVIDUXS 601.54 090 58671 LAPS OCCLUSION OVIDUXS DEV 600.98 090 58672 LAPS FIMBRIOPLASTY 1213.04 090 58673 LAPS SALPINGOSTOMY 1319.39 090 58679 UNLIS LAPS PX OVIDUX OVARY BR YYY 58700 SALPINGECTOMY COMPL/PRTL UNI/BI SPX 1270.65 090 58720 SALPINGO-OOPHORECTOMY COMPL/PRTL UNI/BI SPX 1184.79 090 58740 LSS ADS 1439.59 090 58750 TUBOTUBAL ANAST 1486.67 090 58752 TUBOUTERINE IMPLTJ 1401.92 090 58760 FIMBRIOPLASTY 1337.11 090 58770 SALPINGOSTOMY 1391.95 090 58800 DRG OVARIAN CST UNI/BI SPX VAG 526.21 090 58805 DRG OVARIAN CST UNI/BI SPX ABDL 663.02 090 58820 DRG OVARIAN ABSC VAG OPN 535.62 090 58822 DRG OVARIAN ABSC ABDL 1189.22 090 K 58823 DRG PEL ABSC TRVG/TRANSRCT PRQ 1488.33 000 58825 TRPOS OVARY 1152.11 090 58900 BX OVARY UNI/BI SPX 716.75 090 58920 WEDGE RESCJ/BISCTJ OVARY UNI/BI 1149.90 090 58925 OVARIAN CSTC UNI/BI 1213.59 090 58940 OOPHORECTOMY PRTL/TOT UNI/BI 843.59 090 58943 OOPHORECTOMY PRTL/TOT UNI/BI OVARIAN MAL 1851.69 090 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 147
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 58950 RESCJ PRIM PRTL MAL W/BSO&OMNTC 1769.16 090 58951 RESCJ PRIM PRTL MAL W/BSO&OMNTC TAH&LMPHADEC 2273.21 090 58952 RESCJ PRIM PRTL MAL W/BSO&OMNTC RAD DEBULKING 2565.66 090 58953 BSO W/OMNTC TAH&RAD DSJ DEBULKING 3174.40 090 58954 BSO W/OMNTC TAH DEBULKING W/LMPHADEC 3440.83 090 58956 BSO TOT OMNTC TAH MAL 2169.63 090 58957 RESECTION RECRT MAL W/OMENTECTOMY 2474.27 090 58958 RESECTION RECRT MAL W/OMENTECTOMY PEL LMPHADEC 2720.20 090 58960 LAPT STG/RESTG OVARIAN TUBAL/PRIM MAL 2ND LOOK 1521.56 090 58970 FOLLICLE PNXR OOCYTE RETRIEVAL ANY METH 348.40 000 58974 EMBRYO TR INTRAUTERINE 238.73 000 58976 GAMETE ZYGOTE/EMBRYO INTRAFLP TR ANY METH 394.38 000 58999 UNLIS PX FEMALE GEN SYS BR YYY 59000 AMNIOCNTS DX 209.93 000 59001 AMNIOCNTS THER AMNIOTIC FLU RDCTJ US GID 304.09 000 59012 CORDOCNTS INTRAUTERINE 338.99 000 59015 CHORNC VILLUS SAMPLING 258.12 000 59020 FTL CONTRCJ STRS TST 113.00 000 59020 26 FTL CONTRCJ STRS TST 60.93 000 59020 TC FTL CONTRCJ STRS TST 52.07 000 59025 FTL NON-STRS TST 76.99 000 59025 26 FTL NON-STRS TST 48.74 000 59025 TC FTL NON-STRS TST 28.25 000 59030 FTL SCALP BLD SAMPLING 162.29 000 59050 FTL MNTR LABOR PHYS WRTTN REPRT S&I 84.75 XXX 59051 FTL MNTR LABOR PHYS WRTTN REPRT INTERPJ ONLY 70.35 XXX 59070 TABDL AMNIONFS US GID 695.14 000 59072 FTL UMBILICAL CORD OCCLUSION W/US GID 874.05 000 59074 FTL FLU DRG US GID 681.85 000 59076 FTL SHUNT PLMT US GID 864.64 000 59100 HYSTOT ABDL 1379.76 090 59120 TX ECTOPIC PREGNANCY REQ SO 1318.84 090 59121 TX ECTOPIC PREGNANCY W/O SO 1320.50 090 59130 TX ECTOPIC PREGNANCY ABDL PREGNANCY 1358.72 090 59135 TX ECTOPIC PREGNANCY NTRSTL REQ TOT HYST 1358.16 090 59136 TX ECTOPIC PREGNANCY NTRSTL PRTL RESCJ UTER 1457.86 090 59140 TX ECTOPIC PREGNANCY CRV W/EVAC 587.69 090 59150 LAPS TX ECTOPIC PREGNANCY W/O SO 1275.63 090 59151 LAPS TX ECTOPIC PREGNANCY W/SO 1244.06 090 59160 CURTG POSTPARTUM 346.19 010 59200 INSJ CRV DILATOR SPX 120.75 000 59300 EPISIOTOMY/VAG RPR OTH/THN ATTENDING PHYS 317.38 000 59320 CERCLAGE CERVIX PREGNANCY VAG 253.13 000 59325 CERCLAGE CERVIX PREGNANCY ABDL 356.16 000 59350 HYSTERORRHAPHY RPTD UTER 465.83 000 59400 OB CARE ANTEPARTUM VAG DLVR&POSTPARTUM 3101.84 MMM 148 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule 59409 VAG DLVR ONLY 1218.58 MMM 59410 VAG DLVR ONLY POSTPARTUM CARE 1544.83 MMM 59412 XTRNL CEPHALIC VERSION +-TOCOLSS 157.31 MMM 59414 DLVR PLACENTA SPX 138.48 MMM 59425 ANTEPARTUM CARE ONLY 4-6 VSTS 690.16 MMM 59426 ANTEPARTUM CARE ONLY 7+ VSTS 1233.54 MMM 59430 POSTPARTUM CARE ONLY SPX 257.01 MMM 59510 OB ANTEPARTUM CARE C DLVR&POSTPARTUM 3454.12 MMM 59514 C DLVR ONLY 1383.09 MMM 59515 C DLVR ONLY W/POSTPARTUM CARE 1871.63 MMM + 59525 STOT/TOT HYST AFTER C DLVR 809.80 ZZZ 59610 OB ANTEPARTUM VAG DLVR&POSTPARTUM AFTER C DLVR 3268.56 MMM 59612 VAG DLVR AFTER C DLVR 1373.67 MMM 59614 VAG DLVR AFTER C DLVR POSTPARTUM CARE 1691.06 MMM 59618 ANTEPARTUM C DLVR&POSTPARTUM FA V AP C DLVER 3518.37 MMM 59620 C DLVR ONLY FA V AP C DLVER 1440.69 MMM 59622 C DLVR ONLY FA V AP C DLVER W/POSTPARTUM CARE 1939.76 MMM 59812 TX INCOMPL AB ANY TRI COMPLD SURGLY 523.44 090 59820 TX MISSED AB COMPLD SURGLY 1ST TRI 627.01 090 59821 TX MISSED AB COMPLD SURGLY 2ND TRI 633.11 090 59830 TX SEPTIC AB COMPLD SURGLY 723.95 090 59840 INDUCED AB DILAT&CURTG 355.05 010 59841 INDUCED AB DILAT&EVAC 631.45 010 59850 INDUCED AB 1+ IAM NJXS DLVR FETUS 567.19 090 59851 INDUCED AB 1+ IAM NJXS DLVR FETUS D&C&EVAC 660.80 090 59852 INDUCED AB 1+ IAM NJXS DLVR FETUS HYSTOT 821.43 090 59855 INDUCED AB 1+ VAG SUPP DLVR FETUS 689.05 090 59856 INDUCED AB 1+ VAG SUPP DLVR FETUS D&C&/EVAC 810.36 090 59857 INDUCED AB 1+ VAG SUPP DLVR FETUS HYSTOT 850.24 090 59866 MULTIFTL PREGNANCY RDCTJ 351.73 000 59870 UTERINE EVAC&CURTG HYDATIDIFORM MOLE 783.77 090 59871 RMVL CERCLAGE SUTR UNDER ANES 222.67 000 59897 UNLIS FTL INVASIVE W/US GID BR YYY 59898 UNLIS LAPS MATERNITY CARE&DLVR BR YYY 59899 UNLIS MATERNITY CARE&DLVR BR YYY 60000 I&D THYROGLOSSAL DUX CST INFCT 264.76 010 60100 BX THYR PRQ CORE NDL 182.79 000 60200 EXC CST/ADENOMA THYR/TRNSXJ ISTHMUS 1072.35 090 60210 PRTL THYR LOBEC UNI +-ISTHMUSECTOMY 1147.68 090 60212 PRTL THYR LOBEC UNI W/CLAT STOT LOBEC 1647.85 090 60220 TOT THYR LOBEC UNI +-ISTHMUSECTOMY 1252.92 090 60225 TOT THYR LOBEC UNI W/CLAT STOT LOBEC 1507.16 090 60240 TRDEC TOT/COMPL 1581.94 090 60252 THYROIDECTOMY TOTAL/SUBTOTAL LMTD NECK DISSECT 2146.36 090 60254 THYROIDECTOMY TOTAL/SUBTOTAL RAD NECK DISSECT 2753.44 090 60260 TRDEC RMVL REMAINING TISS FLWG RMVL PRTN 1785.77 090 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 149
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 60270 TRDEC W/SUBSTERNAL THYR STERNAL SPLT/TTHRC 2253.82 090 60271 TRDEC W/SUBSTERNAL THYR CRV APPR 1724.29 090 60280 EXC THYROGLOSSAL DUX CST/SINUS 723.95 090 60281 EXC THYROGLOSSAL DUX CST/SINUS RECRT 964.89 090 60300 ASPIRATION AND/OR INJECTION THYROID CYST 180.57 000 60500 PARATRDEC/EXPL PARATHYR 1653.39 090 60502 PARATRDEC/EXPL PARATHYR RE-EXPL 2077.13 090 60505 PARATRDEC/EXPL PARATHYR MEDSTNL STERNAL/TTHRC 2268.22 090 + 60512 PARATHYR AUTOTRNSPLJ 396.59 ZZZ 60520 THYMECTOMY PRTL/TOT TRANSCRV APPR SPX 1687.73 090 60521 THYMECTOMY PRTL/TOT W/O RAD MEDSTNL DSJ SPX 1901.54 090 60522 THYMECTOMY PRTL/TOT RAD MEDSTNL DSJ SPX 2303.12 090 60540 ADRNLECTOMY EXPL ADRNL TABDL LMBR/DORSAL SPX 1732.05 090 60545 ADRNLECTOMY EXPL ADRNL SPX EXC ADJ TUM 1989.61 090 60600 EXC CRTD BDY TUM W/O EXC CRTD ART 2372.91 090 60605 EXC CRTD BDY TUM W/EXC CRTD ART 2926.81 090 60650 LAPS ADRNLECTOMY PRTL/COMPL TABDL 1947.51 090 60659 UNLIS LAPS ENDOC SYS BR YYY 60699 UNLIS ENDOC SYS BR YYY 61000 SDRL TAP THRU FONTANELLE/SUTR INFT UNI/BI 1ST 176.14 000 61001 SDRL TAP THRU FONTANELLE/SUTR INFT UNI/BI SBSQ 187.22 000 61020 VENTR PNXR PREVIOUS BURR HOLE W/O NJX 221.01 000 61026 VENTR PNXR PREVIOUS BURR HOLE W/NJX 207.16 000 61050 CISTERNAL/LAT CRV C1-C2 PNXR W/O NJX SPX 168.94 000 61055 CISTERNAL/LAT CRV C1-C2 PNXR W/NJX 221.56 000 61070 PNXR SHUNT TUBING/RSVR ASPIR/NJX 135.71 000 61105 TDH SDRL/VENTR PNXR 733.92 090 * 61107 TDH SDRL/VENTR PNXR IMPLTING VENTR CATH/DEV 522.33 000 61108 TDH SDRL/VENTR PNXR EVAC&/DRG SDRL HMTMA 1456.20 090 61120 BURR HOLE VENTR PNXR 1199.75 090 61140 BURR HOLE/TREPHINE W/BX BRN/ICRA LES 2039.46 090 61150 BURR HOLE/TREPHINE W/DRG BRN ABSC/CST 2196.77 090 61151 BURR HOLE/TREPHINE W/SBSQ TAPPING ICRA ABSC/CST 1602.99 090 61154 BURR HOLE W/EVAC&/DRG HMTMA XDRL/SDRL 2047.77 090 61156 BURR HOLE W/ASPIR HMTMA/CST ICERE 2026.17 090 61210 BURR HOLE IMPLANT VENTRICULAR CATH/OTHER DEVICE 609.84 000 61215 INSJ SUBQ RSVR PMP/NFS SYS VENTR CATH 803.71 090 61250 BURR HOLE/TREPHINE STTL EXPL N/FLWD OTH SURG 1391.40 090 61253 BURR HOLE/TREPHINE ITTL UNI/BI 1371.46 090 61304 CRNEC/CRX EXPL STTL 2669.24 090 61305 CRNEC/CRX EXPL ITTL 3271.89 090 61312 CRANIECTOMY HMTMA SUPRATENTORIAL EXTRA/SUBDURAL 3387.10 090 61313 CRANIECTOMY HMTMA SUPRATENTORIAL INTRACEREBRAL 3222.04 090 61314 CRANIECTOMY HMTMA INFRATENTORIAL EXTRA/SUBDURAL 2968.90 090 61315 CRANIECTOMY HMTMA SUPRATENTORIAL INTRACEREBRAL 3371.59 090 + 61316 INC&SUBQ PLMT CRNL B1 GRF 144.57 ZZZ 150 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule 61320 CRNEC/CRX DRG ICRA ABSC STTL 3101.84 090 61321 CRNEC/CRX DRG ICRA ABSC ITTL 3452.46 090 61322 CRNEC/CRX DCMPRIVE W/O LOBEC 3846.28 090 61323 CRNEC/CRX DCMPRIVE W/LOBEC 3888.38 090 61330 DCMPRN ORBIT ONLY TRANSCRNL 2873.08 090 61332 EXPL ORBIT TRANSCRNL BX 3198.77 090 61333 EXPL ORBIT TRANSCRNL RMVL LES 3335.59 090 61334 EXPL ORBIT TRANSCRNL W/RMVL FB 2184.03 090 61340 STPL CRNL DCMPRN 2340.78 090 61343 CRNEC SOPL CRV LAM DCMPRN MEDULLA&SPI CORD 3582.63 090 61345 OTH CRNL DCMPRN POST FOSSA 3325.62 090 61440 CRX SCTJ TENTORIUM CEREBELLI SPX 3260.81 090 61450 CRNEC STPL SCTJ COMPRESSION/DCMPRN GANGLION 3128.43 090 61458 CRNEC SOPL EXPL/DCMPRN CRNL NRV 3273.55 090 61460 CRNEC SOPL SCTJ 1+ CRNL NRV 3409.25 090 61470 CRNEC SOPL MEDULLARY TRCOTOMY 3126.21 090 61480 CRNEC SOPL MESENCEPHAL TRCOTOMY/PEDUNCULOTOMY 2477.59 090 61490 CRX LOBOTOMY W/CINGULOTOMY 3091.32 090 61500 CRNEC EXC TUM/OTH B1 LES SKL 2177.38 090 61501 CRNEC OSTEOMYELITIS 1872.18 090 61510 CRNEC TREPH B1 FLAP CRX EXC TUM STTL 3550.50 090 61512 CRNEC TREPH B1 FLAP CRX EXC MENINGIOMA STTL 4164.22 090 61514 CRNEC TREPH B1 FLAP CRX EXC BRN ABSC STTL 3097.41 090 61516 CRNEC TREPH B1 FLAP CRX EXC CST STTL 3015.43 090 + 61517 IMPLTJ BRN INTRCV CHEMOTX AGT 144.01 ZZZ 61518 CRNEC EXC TUM ITTL/PFOS MENINGIOMA 4496.56 090 61519 CRNEC EXC TUM ITTL/PFOS MENINGIOMA 4821.15 090 61520 CRNEC EXC TUM ITTL/PFOS CRBLOPNT ANGL TUM 6149.95 090 61521 CRNEC EXC TUM ITTL/PFOS MIDLINE TUM BASE SKL 5201.12 090 61522 CRNEC ITTL/PFOS EXC ABSC 3569.89 090 61524 CRNEC ITTL/PFOS EXC/FENESTRATION CST 3386.54 090 61526 CRNEC EXC CRBLOPNT ANGL TUM 5926.18 090 61530 CRNEC EXC CRBLOPNT ANGL TUM MIDDLE/PFOS 5009.47 090 61531 SDRL IMPLTJ STRIP ELTRDS SEIZURE MNTR 1977.42 090 61533 CRX B1 FLAP IMPLTJ ELTRD RA SEIZURE MNTR 2477.04 090 61534 CRX B1 FLAP EXC EPILEPTOGENIC FOC W/O ECOG 2673.68 090 61535 CRX B1 FLAP RMVL ELTRD RA W/O EXC CERE TISS SPX 1612.96 090 61536 CRX B1 FLAP EXC CERE FOC W/ECOG 4221.27 090 61537 CRX B1 FLAP TEMPORAL LOBE W/O ECOG 4001.93 090 61538 CRX B1 FLAP LOBEC TEMPORAL LOBE W/ECOG 4329.28 090 61539 CRX B1 FLAP LOBEC OTH/THN TEMPORAL LOBE W/ECOG 3843.51 090 61540 CRX B1 FLAP LOBEC OTH/THN TEMPORAL LOBE W/O ECOG 3564.35 090 61541 CRX B1 FLAP TRNSXJ CORPUS CALLOSUM 3500.09 090 61542 CRX B1 FLAP TOT HEMISPHERCOMY 3652.42 090 61543 CRX B1 FLAP PRTL/STOT HEMISPHERCOMY 3522.80 090 61544 CRX B1 FLAP EXC/COAGJ CHOROID PLEXUS 3010.45 090 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 151
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 61545 CRX B1 FLAP EXC CRANIOPHARYNGIOMA 5191.70 090 61546 CRX HYPPHSEC/EXC PITUITARY TUM ICRA 3760.43 090 61548 HYPPHSEC/EXC PITUITARY TUM TRANSNSL/SEPTAL 2545.17 090 61550 CRNEC CRANIOSYNOSTOSIS 1 CRNL SUTR 1509.93 090 61552 CRNEC CRANIOSYNOSTOSIS MLT CRNL SUTRS 1917.60 090 61556 CRX CRANIOSYNOSTOSIS FRNT/PARIETAL B1 FLAP 2680.32 090 61557 CRX CRANIOSYNOSTOSIS BIFRNT B1 FLAP 2739.04 090 61558 X10SV CRNEC MLT SUTR CRANIOSYNOSTOSIS X W/B1 GRF 2890.25 090 61559 X10SV CRNEC MLT SUTR CRANIOSYNOSTOSIS B1 AGRFT 3364.94 090 61563 EXC B9 TUM CRNL B1 W/O OPTIC NRV DCMPRN 3230.34 090 61564 EXC B9 TUM CRNL B1 W/OPTIC NRV DCMPRN 3929.92 090 61566 CRX B1 FLAP SLCTV AMYGDALOHIPPOCAMPECTOMY 3677.34 090 61567 CRX B1 FLAP MLT SUBPIAL TRNSXJS W/ECOG 4197.45 090 61570 CRNEC/CRX EXC FB FROM BRN 3026.51 090 61571 CRNEC/CRX TX PENTRG WND BRN 3243.64 090 61575 TRANSORAL SB BX DCMPRN/EXC LES 4053.44 090 61576 TRANSORAL SB BX DCMPRN/EXC LES SPLTTING TONGUE 5788.26 090 61580 CRANFCL ACF XDRL W/O ORB EXNTJ 3999.71 090 61581 CRANFCL ACF XDRL ORB EXNTJ 4409.04 090 61582 CRANFCL ACF XDRL ELVTN LOBE 4838.87 090 61583 CRANFCL ACF IDRL ELVTN/RESCJ LOBE 4693.19 090 61584 OC ACF XDRL W/O ORB EXNTJ 4615.09 090 61585 OC ACF XDRL W/ORB EXNTJ 5145.18 090 61586 BICORONAL TRANSZYGMTC&/LEFT W/O B1 GRF 3794.77 090 61590 ITPRL PRE-AUR MCF&MSB 5041.04 090 61591 ITPRL POST-AUR MCF 5104.19 090 61592 OC ZYGMTC MCF 5143.52 090 61595 TRANSTEMPORAL PCF JUG FORAMEN/MSB 3861.79 090 61596 TRANSCOCHLEAR PCF JUG FORAMEN/MSB 4098.31 090 61597 TRANSCONDYLAR PCF JUG FORAMEN/MSB 4728.64 090 61598 TRANSPETROSAL PCF CLIVUS/FORAMEN MAGNUM 4456.68 090 61600 RESCJ/EXC LES BASE ACF XDRL 3485.69 090 61601 RESCJ/EXC LES BASE ACF IDRL W/RPR 3854.04 090 61605 RESCJ/EXC LES ITPRL FOSSA SPACE APEX XDRL 3599.80 090 61606 RESCJ/EXC LES ITPRL FOSSA SPACE APEX IDRL W/RPR 4887.06 090 61607 RESCJ/EXC LES PARASELLAR SINUS CLIVUS/MSB XDRL 4734.18 090 61608 RESCJ/EXC LES PARASELLAR SINUS CLIVUS/MSB IDRL 5273.13 090 + 61609 TRNSXJ/LIG CRTD ART SINUS W/O RPR 989.27 ZZZ + 61610 TRNSXJ/LIG CRTD ART SINUS W/RPR ANAST/GRF 3099.07 ZZZ + 61611 TRNSXJ/LIG CRTD ART PETROUS CANAL W/O RPR 635.88 ZZZ + 61612 TRNSXJ/LIG CRTD ART PETROUS CANAL RPR ANAST/GRF 2359.06 ZZZ 61613 OBLTRJ CRTD ARYSM ARVEN CRTD-FSTL DSJ 5309.69 090 61615 RESCJ/EXC LES BASE PCF VRT BODIES XDRL 3804.19 090 61616 RESCJ/EXC LES BASE PCF FORAMEN VRT BODIES IDRL 5391.66 090 61618 SEC RPR DURA CSF LEAK FR TISS GRF 2118.67 090 61619 SEC RPR DURA CSF LEAK LOCAL/REGIONALIZED FLAP 2433.84 090 152 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule 61623 EVASC TEMP BALO ARTL OCCLUSION 912.83 000 61624 TCAT PRM OCCLUSION/EMBOLIZATION PRQ CNS 1827.32 000 61626 TCAT PRM OCCLUSION/EMBOLIZATION PRQ NON-CNS 1429.62 000 61630 BALO ANGIOP ICRA PRQ 2095.96 XXX 61635 TCAT PLMT IV STENT ICRA W/BALO ANGIOP IF PFRMD 2264.90 XXX 61640 BALO DILAT ICRA PRQ 1ST VSL 1020.28 000 + 61641 BALO DILAT ICRA PRQ EA VSL SM VASC FAM 358.93 ZZZ + 61642 BALO DILAT ICRA PRQ EA VSL DIFF VASC FAM 716.75 ZZZ 61680 SURG ICRA ARVEN MALFRMJ STTL SMPL 3690.64 090 61682 SURG ICRA ARVEN MALFRMJ STTL CPLX 6877.22 090 61684 SURG ICRA ARVEN MALFRMJ ITTL SMPL 4630.05 090 61686 SURG ICRA ARVEN MALFRMJ ITTL CPLX 7389.58 090 61690 SURG ICRA ARVEN MALFRMJ DURAL SMPL 3558.81 090 61692 SURG ICRA ARVEN MALFRMJ DURAL CPLX 5990.98 090 61697 SURG CPLX ICRA ARYSM ICRA APPR CRTD CRCJ 6897.16 090 61698 CPLX ICRA ICRA VERTEBROBASILAR CRCJ 7541.35 090 61700 SMPL ICRA ICRA APPR CRTD CRCJ 5610.45 090 61702 SMPL ICRA ICRA VERTEBROBASILAR CRCJ 6555.96 090 61703 ICRA CRV APPL OCCLUDING CLAMP CRV CRTD ART 2208.95 090 61705 ARYSM VASC MALFRMJ/CRTD-OCCLUSION CRTD ART 4224.60 090 61708 ARYSM VASC MALFRMJ/ICRA ELECTROTHROMBOSIS 3371.59 090 61710 ARYSM VASC MALFRMJ IA EMBOLIZATION 3042.02 090 61711 ANAST ARTL XTRC-ICRA ARTS 4256.72 090 61720 CRTJ LES STRTCTC BURR GLOBUS PALLIDUS/THALAMUS 2020.63 090 61735 CRTJ LES STRTCTC BURR SUBCORTICAL STRUX OTH/THN 2463.19 090 61750 STRTCTC BX ASPIR/EXC BURR ICRA LES 2286.50 090 61751 STRTCTC BX ASPIR/EXC BURR ICRA LES W/CT&/MRG 2230.56 090 61760 STRTCTC IMPLTJ ELTRD CEREBRUM SEIZURE MNTR 2544.62 090 61770 STRTCTC LOCLZJ INSJ CATH/PRB PLMT RADJ SRC 2602.22 090 l + 61781 STRTCTC CPTR ASSTD PX IDRL CRNL 394.93 ZZZ l + 61782 STRTCTC CPTR ASSTD PX XDRL CRNL 324.03 ZZZ l + 61783 STRTCTC CPTR ASSTD PX SPINAL 394.93 ZZZ 61790 CRTJ LES STRTCTC PRQ NULYT GASSERIAN 1400.81 090 61791 CRTJ LES STRTCTC PRQ NULYT TRIGEMINAL TRC 1799.62 090 61796 STEREOTACTIC RADIOSURGERY 1 SIMPLE CRANIAL LES 1576.40 090 + 61797 STRTCTC RADIOSURGERY EA ADDL CRANIAL LES SIMPLE 356.16 ZZZ 61798 STEREOTACTIC RADIOSURGERY 1 COMPLEX CRANIAL LES 2105.37 090 + 61799 STRTCTC RADIOSURGERY EA ADDL CRANIAL LES COMPLEX 491.31 ZZZ + 61800 APPL STRTCTC HEADFRAME STEREOTACTIC RADIOSURGERY 246.49 ZZZ 61850 TDH/BURR IMPLTJ NSTIM ELTRD CORTICAL 1511.04 090 61860 CRNEC/CRX IMPLTJ NSTIM ELTRD CERE CORTICAL 2550.71 090 61863 STRTCTC IMPLTJ NSTIM ELTRD W/O MER 1ST RA 2438.82 090 + 61864 STRTCTC IMPLTJ NSTIM ELTRD W/O MER EA RA 471.37 ZZZ 61867 STRTCTC IMPLTJ NSTIM ELTRD W/MER 1ST RA 3728.30 090 + 61868 STRTCTC IMPLTJ NSTIM ELTRDW/MER EA RA 830.30 ZZZ 61870 CRNEC IMPLTJ NSTIM ELTRD CEREBELLAR CORTICAL 1928.13 090 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 153
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 61875 CRNEC IMPLTJ NSTIM ELTRD CEREBELLAR SUBCORTICAL 1668.35 090 61880 REVJ/RMVL ICRA NSTIM ELTRDS 904.52 090 61885 INSJ/RPLCMT CRNL NPGR 1 ELTRD RA 881.25 090 61886 INSJ/RPLCMT CRNL NPGR 2+ ELTRD RA 1344.87 090 61888 REVJ/RMVL CRNL NPGR 634.77 010 62000 ELVTN DEPRS SKL FX SMPL XDRL 1606.31 090 62005 ELVTN DEPRS SKL FX COMPOUND/COMMIND XDRL 2051.65 090 62010 ELVTN DEPRS SKL FX W/RPR DURA&/DBRDMT BRN 2479.81 090 62100 CRX RPR DURAL/CSF LEAK RHINORRHEA/OTORRHEA 2615.52 090 62115 RDCTJ CRANIOMEGALIC SKL X W/B1 GRFS/CRNOP 1999.58 090 62116 RDCTJ CRANIOMEGALIC SKL W/SMPL CRNOP 2886.93 090 62117 RDCTJ CRANIOMEGALIC REQ CRX&RCNSTJ +-B1 GRF 2848.71 090 62120 RPR ENCEPHALOCELE SKL VAULT W/CRNOP 2796.09 090 62121 CRANIOTOMY FOR ENCEPHALOCELE REPAIR SKULL BASE 2770.05 090 62140 CRANIOPLASTY SKULL DEFECT UP TO 5 CM DIAMETER 1691.06 090 62141 CRANIOPLASTY SKULL DEFECT LARGER THAN 5 CM DIAM 1857.78 090 62142 RMVL B1 FLAP/PROSTC PLATE SKL 1434.05 090 62143 RPLCMT B1 FLAP/PROSTC PLATE SKL 1679.98 090 62145 CRANIOPLASTY SKULL DEFECT REPARATIVE BRAIN SURG 2303.67 090 62146 CRNOP W/AGRFT UP 5 CM DIAM 2012.32 090 62147 CRNOP W/AGRFT > 5 CM DIAM 2373.46 090 + 62148 INCISE&RETRIEVAL SUBQ CRANIOPLASTY BONE GRAFT 208.27 ZZZ + 62160 NUNDSC ICRA PLMT/RPLCMT VENTR CATH SHUNT SYS 315.17 ZZZ 62161 NUNDSC ICRA DSJ ADS FENESTRATION SEPTUM CSTS 2465.96 090 62162 NUNDSC ICRA FENESTRATION/EXC CST PLMT CATH DRG 3084.12 090 62163 NUNDSC ICRA W/RETRIEVAL FB 1987.95 090 62164 NUNDSC ICRA EXC TUM PLMT CATH DRG 3374.91 090 62165 NUNDSC ICRA EXC PITUITARY TUM 2546.83 090 62180 VENTRICULOCISTERNOSTOMY 2606.10 090 62190 CRTJ SHUNT SARACH/SDRL-ATR-JUG-AUR 1489.44 090 62192 CRTJ SHUNT SARACH/SDRL-PRTL-PLEURAL OTH 1578.06 090 62194 RPLCMT/IRRG SARACH/SDRL CATH 636.43 010 62200 VENTRICULOCISTERNOSTOMY 3RD VNTRC 2237.76 090 62201 VENTRICULOCISTERNOSTOMY 3RD VNTRC NEURONDSC 1941.97 090 62220 CRTJ SHUNT VENTRICULO-ATR-JUG-AUR 1646.19 090 62223 CRTJ SHUNT VENTRICULO-PRTL-PLEURAL OTH 1702.69 090 62225 RPLCMT/IRRIGATION VENTR CATH 827.53 090 62230 RPLCMT/REVJ CSF SHUNT VALVE/CATH SHUNT SYS 1360.93 090 62252 REPRGRMG PRGRBL CEREBSP SHUNT 149.55 XXX 62252 26 REPRGRMG PRGRBL CEREBSP SHUNT 75.88 XXX 62252 TC REPRGRMG PRGRBL CEREBSP SHUNT 73.67 XXX 62256 RMVL COMPL CEREBSP FLU SHUNT SYS W/O RPLCMT 959.91 090 62258 RMVL COMPL CSF SHUNT SYS W/RPLCMT 1821.78 090 62263 PRQ LSS EDRL ADS SLN NJX/MCHNL LOCLZJ 2+ D 1155.44 010 62264 PRQ LSS EDRL ADS SLN NJX/MCHNL LOCLZJ 1 D 672.43 010 62267 PRQ ASPIR PULPOSUS/INTERVERTEBRAL DISC/PVRT TISS 402.13 000 154 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule 62268 PRQ ASPIR SPI CORD CST/SYRINX 574.39 000 62269 BX SPI CORD PRQ NDL 618.15 000 62270 SPI PNXR LMBR DX 253.13 000 62272 SPINAL PUNCTURE THER DRAIN CEREBROSPINAL FLUID 314.06 000 62273 NJX EDRL BLD/CLOT PATCH 273.07 000 62280 NJX/NFS NULYT SBST SBST SARACH 527.31 010 62281 NJX/NFS NULYT SBST EDRL CRV/THRC 422.63 010 62282 NJX/NFS NULYT SBST EDRL LMBR SAC 478.02 010 62284 INJECTION PROCEDURE MYELOGRAPHY/CT SPINAL 348.40 000 62287 DCMPRN PERQ NUCLEUS PULPOSUS 1/> LEVELS LUMBAR 895.66 090 62290 NJX DISKOGRAPY EA LVL LMBR 541.16 000 62291 NJX DISKOGRAPY EA LVL CRV/THRC 510.70 000 62292 NJX CHEMONUCLEOLSS DISKOGRAPY 1+ LMBR 887.35 090 62294 NJX ARTL OCCLUSION ARVEN MALFRMJ SPI 1118.88 090 62310 NJX C+-DX/THER SBST EDRL/SARACH CRV/THRC 375.54 000 62311 NJX C+-DX/THER SBST EDRL/SARACH LMBR SAC 322.37 000 62318 NJX NFS/BOLUS DX/SBST EDRL/SARACH CRV/THRC 386.07 000 62319 NJX NFS/BOLUS DX/SBST EDRL/SARACH LMBR SAC 307.97 000 62350 IMPLTJ REVJ/RPSG ITHCL/EDRL CATH PMP W/O LAM 635.32 010 62351 IMPLTJ REVJ/RPSG ITHCL/EDRL CATH W/LAM 1390.84 090 62355 RMVL PREVIOUSLY IMPLTED ITHCL/EDRL CATH 479.68 010 62360 IMPLTJ/RPLCMT ITHCL/EDRL DRUG NFS SUBQ RSVR 490.20 010 62361 IMPLTJ/RPLCMT ITHCL/EDRL NFS NON-PRGRBL PMP 632.55 010 62362 IMPLTJ/RPLCMT ITHCL/EDRL DRUG NFS PRGRBL PMP 663.02 010 62365 RMVL SUBQ RSVR/PMP 528.42 010 62367 ELEC ALYS PRGRBL PMP W/O REPRGRMG 65.36 XXX 62368 ELEC ALYS PRGRBL PMP REPRGRMG 94.16 XXX 63001 LAM W/O FACETEC FORAMOT/DSKC 1/2 VRT SEG CRV 3866.14 090 63003 LAM W/O FFD 1/2 VRT SEG THRC 3883.22 090 63005 LAM W/O FFD 1/2 VRT SEG LMBR 3686.77 090 63011 LAM W/O FFD 1/2 VRT SEG SAC 3395.29 090 63012 LAM W/RMVL ABNORMAL FACETS LMBR 3720.93 090 63015 LAM W/O FFD > 2 VRT SEG CRV 4642.36 090 63016 LAM W/O FFD > 2 VRT SEG THRC 4749.13 090 63017 LAM W/O FFD > 2 VRT SEG LMBR 3902.44 090 63020 LAMINOTOMY INCL OPN & NDSC 1 INTERSPACE CERVICAL 3649.40 090 63030 LAMINOTOMY INCL OPEN & NDSC 1 INTERSPACE LUMBAR 3021.59 090 + 63035 LAMOT INCL OPEN&NDSC EA ADDL INTERSPACE CRV/LMBR 615.00 ZZZ 63040 LAMOT PRTL FFD HRNA8 REEXPL 1 NTRSPC CRV 4404.26 090 63042 LAMOT PRTL FFD HRNA8 REEXPL 1 NTRSPC LMBR 4075.41 090 + 63043 LAMOT PRTL FFD HRNA8 REEXPL 1 NTRSPC EA CRV 1853.53 ZZZ + 63044 LAMOT W/PRTL FFD HRNA8 REEXPL 1 NTRSPC EA LMBR 1760.64 ZZZ 63045 LAM FACETEC&FORAMOT 1 SGM CRV 3980.39 090 63046 LAM FACETEC&FORAMOT 1 SGM THRC 3790.34 090 63047 LAM FACETEC&FORAMOT 1 SGM LMBR 3441.20 090 + 63048 LAM FACETEC&FORAMOT 1 SGM EA CRV THRC/LMBR 680.12 ZZZ Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 155
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 63050 LAMOP CRV W/DCMPRN SPI CORD 2/MORE VRT SEG 4924.23 090 63051 LAMOP CRV DCMPRN SPI CORD 2+ SEG RCNSTJ B1 5384.41 090 63055 TRANSPEDICULAR DCMPRN SPI CORD 1 SGM THRC 5112.15 090 63056 TRANSPEDICULAR DCMPRN SPI CORD 1 SGM LMBR 4645.56 090 + 63057 TRANSPEDICULAR DCMPRN 1 SGM EA THRC/LMBR 1028.20 ZZZ 63064 COSTOVRT DCMPRN THRC 1 SGM 5554.18 090 + 63066 COSTOVRT DCMPRN THRC EA SGM 661.97 ZZZ 63075 DSKC ANT DCMPRN CRV 1 NTRSPC 4316.71 090 + 63076 DSKC ANT DCMPRN CRV EA NTRSPC 799.71 ZZZ 63077 DSKC ANT DCMPRN THRC 1 NTRSPC 4717.10 090 + 63078 DSKC ANT DCMPRN THRC EA NTRSPC 620.33 ZZZ 63081 VCRPEC ANT DCMPRN CRV 1 SGM 5570.19 090 + 63082 VCRPEC ANT DCMPRN CRV EA SGM 859.50 ZZZ 63085 VCRPEC TTHRC DCMPRN THRC 1 SGM 5975.92 090 + 63086 VCRPEC TTHRC DCMPRN THRC EA SGM 611.79 ZZZ 63087 VCRPEC THORACOLMBR DCMPRN LWR THRC/LMBR 1 SGM 7537.96 090 + 63088 VCRPEC THORACOLMBR DCMPRN LWR THRC/LMBR EA SGM 827.47 ZZZ 63090 VCRPEC TRANSPRTL/RPR DCMPRN THRC LMBR/SAC 1 SGM 6193.73 090 + 63091 VCRPEC TRANSPRTL/RPR DCMPRN THRC LMBR/SAC EA SGM 569.08 ZZZ 63101 VCRPEC LAT XTRCAVITARY DCMPRN THRC 1 SGM 3786.46 090 63102 VCRPEC LAT XTRCAVITARY DCMPRN LMBR 1 SGM 3656.29 090 + 63103 VCRPEC LAT XTRCAVITARY DCMPRN THRC/LMBR EA SGM 485.77 ZZZ 63170 LAM W/MYELOTOMY CRV THRC/THORACOLMBR 4950.92 090 63172 LAM W/DRG IMED CST/SYRINX SARACH SPACE 4407.47 090 63173 LAM W/DRG IMED CST/SYRINX PRTL/PLEURAL SPACE 5415.37 090 63180 LAM&SCTJ DENTATE LIGMS CRV 1/2 SEG 4571.89 090 63182 LAM&SCTJ DENTATE LIGMS CRV > 2 SEG 4922.10 090 63185 LAM W/RHIZOTOMY 1/2 SEG 3717.73 090 63190 LAM W/RHIZOTOMY > 2 SEG 3976.11 090 63191 LAM W/SCTJ SPI ACCESSORY NRV 3719.87 090 63194 LAM CORDOTOMY SCTJ 1 TRC 1 STG CRV 4301.76 090 63195 LAM CORDOTOMY SCTJ 1 TRC 1 STG THRC 4791.84 090 63196 LAM CORDOTOMY SCTJ BTH TRCS 1 STG CRV 4516.37 090 63197 LAM CORDOTOMY SCTJ BTH TRCS 1 STG THRC 5359.85 090 63198 LAM CORDOTOMY SCTJ BTH TRCS 2 STGS CRV 4996.84 090 63199 LAM CORDOTOMY SCTJ BTH TRCS 2 STGS THRC 5507.20 090 63200 LAM RLS TETHERED SPI CORD LMBR 4767.28 090 63250 LAM EXC/OCCLUSION AVM SPI CORD CRV 9333.83 090 63251 LAM EXC/OCCLUSION AVM SPI CORD THRC 9560.19 090 63252 LAM EXC/OCCLUSION AVM SPI CORD THORACOLMBR 9552.71 090 63265 LAM EXC/EVAC ISPI LES OTH/THN NEO XDRL CRV 5232.80 090 63266 LAM EXC/EVAC ISPI LES OTH/THN NEO XDRL THRC 5390.82 090 63267 LAM EXC/EVAC ISPI LES OTH/THN NEO XDRL LMBR 4308.17 090 63268 LAM EXC/EVAC ISPI LES OTH/THN NEO XDRL SAC 4517.44 090 63270 LAM EXC ISPI LES OTH/THN NEO IDRL CRV 6510.83 090 63271 LAM EXC ISPI LES OTH/THN NEO IDRL THRC 6505.50 090 156 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule 63272 LAM EXC ISPI LES OTH/THN NEO IDRL LMBR 5978.05 090 63273 LAM EXC ISPI LES OTH/THN NEO IDRL SAC 5784.80 090 63275 LAM BX/EXC ISPI NEO XDRL CRV 5633.19 090 63276 LAM BX/EXC ISPI NEO XDRL THRC 5601.15 090 63277 LAM BX/EXC ISPI NEO XDRL LMBR 4865.51 090 63278 LAM BX/EXC ISPI NEO XDRL SAC 4944.52 090 63280 LAM BX/EXC ISPI NEO IDRL XMED CRV 6647.50 090 63281 LAM BX/EXC ISPI NEO IDRL XMED THRC 6582.37 090 63282 LAM BX/EXC ISPI NEO IDRL XMED LMBR 6200.13 090 63283 LAM BX/EXC ISPI NEO IDRL SAC 5939.62 090 63285 LAM BX/EXC ISPI NEO IDRL IMED CRV 8189.26 090 63286 LAM BX/EXC ISPI NEO IDRL IMED THRC 8089.96 090 63287 LAM BX/EXC ISPI NEO IDRL IMED THORACOLMBR 8630.22 090 63290 LAM BX/EXC ISPI NEO XDRL-IDRL LES ANY LVL 8756.21 090 + 63295 OSTPL RCNSTJ DORSAL SPI ELMNTS FLWG ISPI PX 1052.75 ZZZ 63300 VCRPEC LES 1 SGM XDRL CRV 5755.97 090 63301 VCRPEC LES 1 SGM XDRL THRC TTHRC 6821.54 090 63302 VCRPEC LES 1 SGM XDRL THRC THORACOLMBR 6747.86 090 63303 VCRPEC LES 1 SGM XDRL LMBR/SAC TRANSPRTL/RPR 7169.61 090 63304 VCRPEC LES 1 SGM IDRL CRV 7363.93 090 63305 VCRPEC LES 1 SGM IDRL THRC TTHRC 7726.94 090 63306 VCRPEC LES 1 SGM IDRL THRC THORACOLMBR 7211.25 090 63307 VCRPEC LES 1 SGM IDRL LMBR/SAC TRANSPRTL/RPR 7526.22 090 + 63308 VCRPEC LES 1 SGM EA SGM 1027.13 ZZZ 63600 CRTJ LES SPI CORD STRTCTC PRQ 2656.44 090 63610 STRTCTC STIMJ SPI CORD PRQ SPX N/FLWD OTH SURG 1400.26 000 63615 STRTCTC BX ASPIR/EXC LES SPI CORD 1979.08 090 63620 STEREOTACTIC RADIOSURGERY 1 SPINAL LESION 1721.52 090 + 63621 STEREOTACTIC RADIOSURGERY EA ADDL SPINAL LESION 408.78 ZZZ 63650 PRQ IMPLTJ NSTIM ELTRD RA EDRL 676.31 010 63655 LAM IMPLTJ NSTIM ELTRDS PLATE/PADDLE EDRL 1394.72 090 63661 RMVL SPINAL NSTIM ELTRD PRQ ARRAY INCL FLUOR 974.31 010 63662 RMVL SPINAL NSTIM ELTRD PLATE/PADDLE INCL FLUOR 1168.18 090 63663 REVJ INCL RPLCMT NSTIM ELTRD PRQ RA INCL FLUOR 1391.95 010 63664 REVJ INCL RPLCMT NSTIM ELTRD PLT/PDLE INCL FLUOR 1214.70 090 63685 INSJ/RPLCMT SPI NPGR DIR/INDUXIVE COUPLING 646.40 010 63688 REVJ/RMVL IMPLTED SPI NPGR 584.36 010 63700 RPR MENINGOCELE < 5 CM DIAM 2078.79 090 63702 RPR MENINGOCELE > 5 CM DIAM 2302.56 090 63704 RPR MYELOMENINGOCELE < 5 CM DIAM 2622.72 090 63706 RPR MYELOMENINGOCELE > 5 CM DIAM 2962.81 090 63707 RPR DURAL/CEREBSP FLU LEAK X REQ LAM 1469.50 090 63709 RPR DURAL/CSF LEAK/PSEUDOMENINGOCELE W/LAM 1783.56 090 63710 DURAL GRF SPI 1791.31 090 63740 CRTJ SHUNT LMBR SARACH-PRTL-PLEURAL/OTH W/LAM 1522.67 090 63741 CRTJ SHUNT LMBR SARACH-PRTL-PLEURAL PRQ X LAM 995.91 090 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 157
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 63744 RPLCMT IRRIGATION/REVJ LUMBOSARACH SHUNT 1072.35 090 63746 RMVL ENTIRE LUMBOSARACH SHUNT SYS W/O RPLCMT 948.83 090 64400 NJX ANES TRIGEMINAL NRV ANY DIV/BRANCH 183.89 000 64402 NJX ANES FACIAL NRV 183.34 000 64405 NJX ANES GRTER OCCIPITAL NRV 183.34 000 64408 NJX ANES VAGUS NRV 199.96 000 64410 NJX ANES PHRENIC NRV 241.50 000 64412 NJX ANES SPI ACCESSORY NRV 243.16 000 64413 NJX ANES CRV PLEXUS 193.31 000 64415 SINGLE NERVE BLOCK INJECTION ARM NERVE 199.40 000 64416 INJECTION ANES BRACHIAL PLEXUS CONT NFS CATH 132.38 000 64417 NJX ANES AX NRV 209.37 000 64418 NJX ANES SUPRASCAPULAR NRV 223.22 000 64420 NJX ANES INTERCOSTAL NRV 1 221.56 000 64421 MULTIPLE NERVE BLOCK INJECTIONS RIB NERVES 318.49 000 64425 NJX ANES ILIOINGUN ILIOHYPOGSTR NRV 212.70 000 64430 NJX ANES PUDENDAL NRV 232.64 000 64435 NJX ANES PARACRV NRV 229.87 000 64445 NJX ANES SCIATIC NRV 1 217.68 000 64446 INJECTION ANES SCIATIC NERVE CONT INFUSION CATH 134.60 000 64447 NJX ANES FEM NRV 1 193.87 000 64448 INJECTION ANES FEMORAL NERVE CONT INFUSION CATH 119.64 000 64449 INJECTION ANES LUMBAR PLEXUS POST CONT NFS CATH 136.81 000 64450 NJX ANES OTH PRPH NRV/BRANCH 166.72 000 64455 NJX ANES&/STEROID PLANTAR COMMON DIGITAL NERVE 79.76 000 s 64479 NJX ANES&/STRD W/IMG TFRML EDRL CRV/THRC 1 LVL 432.60 000 s + 64480 NJX ANES&/STRD W/IMG TFRML EDRL CRV/THRC EA LVL 206.05 ZZZ s 64483 NJX ANES&/STRD W/IMG TFRML EDRL LMBR/SAC 1 LVL 391.61 000 s + 64484 NJX ANES&/STRD W/IMG TFRML EDRL LMBR/SAC EA LVL 173.37 ZZZ 64490 NJX DX/THER AGT PVRT FACET JT CRV/THRC 1 LEVEL 320.15 000 + 64491 NJX DX/THER AGT PVRT FACET JT CRV/THRC 2ND LEVEL 158.42 ZZZ + 64492 NJX DX/THER AGT PVRT FACET JT CRV/THRC 3+ LEVEL 160.08 ZZZ 64493 NJX DX/THER AGT PVRT FACET JT LMBR/SAC 1 LEVEL 285.26 000 + 64494 NJX DX/THER AGT PVRT FACET JT LMBR/SAC 2ND LEVEL 142.91 ZZZ + 64495 NJX DX/THER AGT PVRT FACET JT LMBR/SAC 3+ LEVEL 145.12 ZZZ 64505 NJX ANES SPHENOPALATINE GANGLION 159.52 000 64508 NJX ANES CRTD SINUS SPX 170.05 000 64510 NJX ANES STELLATE GANGLION CRV SYMPATHETIC 219.90 000 64517 NJX ANES SUPRIOR HYPOGSTR PLEXUS 282.49 000 64520 NJX ANES LMBR/THRC PVRT SYMPATHETIC 311.29 000 64530 NJX ANES CELIAC PLEXUS +-RAD MNTR 315.17 000 64550 APPL SURF TC NSTIM 25.48 000 64553 PRQ IMPLTJ NSTIM ELTRDS CRNL NRV 335.66 010 64555 PRQ IMPLTJ NSTIM ELTRDS PRPH NRV 327.91 010 64560 PRQ IMPLTJ NSTIM ELTRDS AUTONOMIC NRV 373.33 010 64561 PRQ IMPLTJ NSTIM ELTRDS SAC NRV 1590.80 010 158 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule 64565 PRQ IMPLTJ NSTIM ELTRDS NEUROMUSCULAR 286.92 010 l 64566 POST TIB NEUROSTIMULATION PRQ NEEDLE ELECTRODE 210.48 000 l 64568 INC IMPLTJ CRNL NRV NSTIM ELTRDS & PULSE GENER 1046.32 090 l 64569 REVISION/REPLMT NSTIM CRNL ELTRDS 1033.02 090 l 64570 REMOVAL CRNL NRV NSTIM ELTRDS & PULSE GENERATOR 909.50 090 s 64575 INC IMPLTJ PERIPH NRV NSTIM ELTRDS 466.94 090 64577 INC IMPLTJ NSTIM ELTRDS AUTONOMIC NRV 547.25 090 64580 INC IMPLTJ NSTIM ELTRDS NEUROMUSCULAR 491.86 090 64581 INC IMPLTJ NSTIM ELTRDS SAC NRV 1152.11 090 64585 REVJ/RMVL PRPH NSTIM ELTRDS 475.25 010 64590 INSERTION/RPLCMT PERIPHERAL/GASTRIC NPGR 466.38 010 64595 REVISION/RMVL PERIPHERAL/GASTRIC NPGR 462.51 010 64600 DSTRJ TRIGEMINAL NRV SUPRAORB INFRAORB BRANCH 668.56 010 64605 DSTRJ NULYT TRIGEMINAL NRV 2/3 DIV 1054.63 010 64610 DSTRJ NULYT TRIGEMINAL NRV 2/3 DIV RAD MNTR 1186.45 010 l 64611 CHEMODENERV PAROTID&SUBMANDIBL SALIVARY GLNDS BI 163.40 010 64612 CHEMODNRVTJ MUSC MUSC INNERVATED FACIAL NRV 279.17 010 64613 CHEMODNRVTJ MUSC NCK MUSC 267.53 010 64614 CHEMODNRVTJ MUSC XTR&/TRNK MUSC 285.26 010 64620 DSTRJ NULYT INTERCOSTAL NRV 389.39 010 64622 DSTRJ NULYT PVRT FACET JT NRV LMBR/SAC 1 LVL 546.15 010 + 64623 DSTRJ NULYT PVRT FACET JT NRV LMBR/SAC EA LVL 203.84 ZZZ 64626 DSTRJ NULYT PVRT FACET JT NRV CRV/THRC 1 LVL 649.72 010 + 64627 DSTRJ NULYT PVRT FACET JT NRV CRV/THRC EA LVL 278.61 ZZZ 64630 DSTRJ NULYT PUDENDAL NRV 367.24 010 64632 DSTRJ NEUROLYTIC PLANTAR COMMON DIGITAL NERVE 138.48 010 64640 DSTRJ NULYT OTH PRPH NRV/BRANCH 355.05 010 64650 CHEMODNRVTJ ECCRINE GLNDS BTH AX 149.55 000 64653 CHEMODNRVTJ ECCRINE GLNDS OTH AREA PR D 178.91 000 64680 DSTRJ NULYT +-RAD MNTR CELIAC PLEXUS 511.25 010 64681 DSTRJ NULYT +-RAD MNTR SUPRIOR HYPOGSTR PLEXUS 608.74 010 64702 NEURP DGTAL 1/BTH SM DGT 1504.39 090 64704 NEURP NRV HAND/FOOT 1010.04 090 s 64708 NEURP MAJOR PRPH NRV ARM/LEG OPN OTH/THN SPEC 1507.59 090 s 64712 NEURP MAJOR PRPH NRV OPN ARM/LEG SCIATIC NRV 1717.93 090 s 64713 NEURP MAJOR PRPH NRV OPN ARM/LEG BRACH PLEXUS 2376.70 090 s 64714 NEURP MAJOR PRPH NRV OPN ARM/LEG LMBR PLEXUS 2101.23 090 64716 NEURP&/TRPOS CRNL NRV 1663.48 090 64718 NEURP&/TRPOS UR NRV ELBW 1815.09 090 64719 NEURP&/TRPOS UR NRV WRST 1229.99 090 64721 NEURP&/TRPOS MEDIAN NRV CARPL TUNNEL 1315.41 090 64722 DCMPRN UNSPECIFIED NRV 1073.04 090 64726 DCMPRN PLNTAR DGTAL NRV 865.90 090 + 64727 INT NEUROLSS REQ MCRSCP 584.03 ZZZ 64732 TRNSXJ/AVLSN SUPRAORB NRV 680.74 090 64734 TRNSXJ/AVLSN INFRAORB NRV 687.39 090 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 159
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 64736 TRNSXJ/AVLSN MENTAL NRV 701.79 090 64738 TRNSXJ/AVLSN INF ALVEOLAR NRV OSTEOM 839.71 090 64740 TRNSXJ/AVLSN LNGL NRV 746.66 090 64742 TRNSXJ/AVLSN FACIAL NRV DIFFIAL/COMPL 774.91 090 64744 TRNSXJ/AVLSN GRTER OCCIPITAL NRV 748.32 090 64746 TRNSXJ/AVLSN PHRENIC NRV 717.85 090 64752 TRNSXJ/AVLSN VAGUS NRV TTHRC 839.16 090 64755 TRNSXJ/AVLSN VAGUS NRV PROX STOMACH 1468.39 090 64760 TRNSXJ/AVLSN VAGUS NRV ABDL 804.26 090 64761 TRNSXJ/AVLSN PUDENDAL NRV 727.82 090 64763 TRNSXJ/AVLSN OBTURATOR NRV XTRPEL 855.78 090 64766 TRNSXJ/AVLSN OBTURATOR NRV INTRAPEL 958.80 090 64771 TRNSXJ/AVLSN OTH CRNL NRV XDRL 915.04 090 64772 TRNSXJ/AVLSN OTH SPI NRV XDRL 930.55 090 64774 EXC NEUROMA CUTAN NRV SURGLY IDENTIFIABLE 670.22 090 64776 EXC NEUROMA DGTAL NRV 1/BTH SM DGT 630.34 090 + 64778 EXC NEUROMA DGTAL NRV EA DGT 312.95 ZZZ 64782 EXC NEUROMA HAND/FOOT XCP DGTAL NRV 731.15 090 + 64783 EXC NEUROMA HAND/FOOT EA NRV XCP SM DGT 356.16 ZZZ 64784 EXC NEUROMA MAJOR PRPH NRV XCP SCIATIC 1182.02 090 64786 EXC NEUROMA SCIATIC NRV 1745.34 090 + 64787 IMPLTJ NRV END IN B1/MUSC 399.92 ZZZ 64788 EXC NEUROFIBROMA/NEUROLEMMOMA CUTAN NRV 640.31 090 64790 EXC NEUROFIBROMA/NEUROLEMMOMA MAJOR PRPH NRV 1349.30 090 64792 EXC NEUROFIBROMA/NEUROLEMMOMA X10SV 1843.38 090 64795 BX NRV 322.37 000 64802 SYMPTH CRV 999.79 090 64804 SYMPTH CERVICOTHRC 1328.25 090 64809 SYMPTH THORACOLMBR 1380.87 090 64818 SYMPTH LMBR 1086.20 090 64820 SYMPTH DGTAL ARTS EA DGT 1233.54 090 64821 SYMPTH RDL ART 1115.00 090 64822 SYMPTH UR ART 1106.69 090 64823 SYMPTH SUPFC PLMR ARCH 1255.69 090 64831 SUTR DGTAL NRV HAND/FOOT 1 NRV 1101.15 090 + 64832 SUTR DGTAL NRV HAND/FOOT EA DGTAL NRV 558.89 ZZZ 64834 SUTURE 1 NERVE HAND/FOOT COMMON SENSORY NERVE 1203.62 090 64835 SUTURE 1 NERVE MEDIAN MOTOR THENAR 1313.30 090 64836 SUTURE 1 NERVE ULNAR MOTOR 1314.40 090 + 64837 SUTR EA NRV HAND/FOOT 588.24 ZZZ 64840 SUTR POST TIBL NRV 1420.75 090 64856 SUTR PRPH NRV ARM/LEG XCP SCIATIC W/TRPOS 1648.96 090 64857 SUTR PRPH NRV ARM/LEG XCP SCIATIC W/O TRPOS 1716.54 090 64858 SUTR SCIATIC NRV 1981.30 090 + 64859 SUTR EA MAJOR PRPH NRV 431.49 ZZZ 64861 SUTR BRACH PLEXUS 2099.28 090 160 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule 64862 SUTR LMBR PLEXUS 2388.97 090 64864 SUTR FACIAL NRV XTRC 1408.01 090 64865 SUTR FACIAL NRV ITPRL +-GRFG 1858.33 090 64866 ANAST FACIAL-SPI ACCESSORY 1868.30 090 64868 ANAST FACIAL-HYPOGLOSSAL 1694.93 090 64870 ANAST FACIAL-PHRENIC 1773.59 090 + 64872 SUTR NRV REQ SEC/DLYD SUTR 188.88 ZZZ + 64874 SUTR NRV REQ X10SV MOBLJ/TRPOS NRV 286.92 ZZZ + 64876 SUTR NRV REQ SHRT B1 XTR 318.49 ZZZ 64885 NRV GRF HEAD/NCK <4 CM 1821.22 090 64886 NRV GRF HEAD/NCK >4 CM 2137.50 090 64890 NRV GRF 1 STRAND HAND/FOOT <4 CM 1763.62 090 64891 NRV GRF 1 STRAND HAND/FOOT >4 CM 1915.39 090 64892 NRV GRF 1 STRAND ARM/LEG <4 CM 1711.00 090 64893 NRV GRF 1 STRAND ARM/LEG >4 CM 1831.75 090 64895 NRV GRF MLT STRANDS HAND/FOOT <4 CM 2208.40 090 64896 NRV GRF MLT STRANDS HAND/FOOT > 4 CM 2506.95 090 64897 NRV GRF MLT STRANDS ARM/LEG <4 CM 2079.89 090 64898 NRV GRF MLT STRANDS ARM/LEG >4 CM 2245.51 090 + 64901 NRV GRF EA NRV 1 STRAND 1029.15 ZZZ + 64902 NRV GRF EA NRV MLT STRANDS 1187.56 ZZZ 64905 NRV PEDCL TR 1ST STG 1668.90 090 64907 NRV PEDCL TR 2ND STG 1873.84 090 64910 NERVE REPAIR W/CONDUIT EA NERVE 1330.47 090 64911 NERVE REPAIR W/AUTOGENOUS VEIN GRAFT EA NERVE 1660.04 090 64999 UNLIS PX NRVS SYS BR YYY 65091 EVSC OC CNTS W/O IMPLT 1016.41 090 65093 EVSC OC CNTS W/IMPLT 1006.99 090 65101 ENCL EYE W/O IMPLT 1177.04 090 65103 ENCL EYE IMPLT MUSC X ATTACHED IMPLT 1230.21 090 65105 ENCL EYE IMPLT MUSC ATTACHED IMPLT 1357.61 090 65110 EXNTJ ORBIT RMVL ORB CNTS ONLY 1905.42 090 65112 EXNTJ ORBIT RMVL ORB CNTS W/THER RMVL B1 2225.57 090 65114 EXNTJ ORBIT RMVL ORB CNTS W/MUSC/MYOQ FLAP 2332.47 090 65125 MODIFICAJ OC IMPLT W/PLMT/RPLCMT PEGS SPX 713.98 090 65130 INSJ OC IMPLT SEC AFTER EVSC SCLL SHELL 1167.07 090 65135 INSJ OC IMPLT AFTER ENCL MUSC X ATTACHED 1185.90 090 65140 INSJ OC IMPLT AFTER ENCL MUSC ATTACHED 1257.91 090 65150 RINSJ OC IMPLT +-CJNCL GRF 880.70 090 65155 RINSJ OC IMPLT RNFCMT&/ATTACHMENT MUSC 1357.61 090 65175 RMVL OC IMPLT 1021.95 090 65205 RMVL FB XTRNL EYE CJNCL SUPFC 87.52 000 65210 RMVL FB XTRNL EYE EMBEDDED SCJNCL/SCLL NONPRF8 108.56 000 65220 RMVL FB XTRNL EYE CRNL W/O SLIT LAMP 90.29 000 65222 RMVL FB XTRNL EYE CRNL W/SLIT LAMP 119.64 000 65235 RMVL FB IO FROM ANT CHAMBER EYE/LENS 1107.25 090 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 161
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 65260 RMVL FB IO FROM POST SGM MAG XTRJ ANT/POST ROUTE 1455.10 090 65265 RMVL FB IO FROM POST SGM NONMAG XTRJ 1753.09 090 65270 RPR LAC CJNC +-NONPRF8 LAC SCL DIR CLSR 411.55 010 65272 RPR LAC CJNC MOBLJ&REARGMT W/O HOSPIZATION 758.84 090 65273 RPR LAC CJNC MOBLJ&REARGMT W/HOSPIZATION 580.49 090 65275 RPR LAC CRN NONPRF8 +-RMVL FB 885.13 090 65280 RPR LAC CRN&/SCL PRF8 X INVG UVEAL TISS 1079.55 090 65285 RPR LAC CRN&/SCL PRF8 W/REPOS/RESCJ UVEAL TISS 1663.92 090 65286 RPR LAC APPL TISS GLUE WND CRN&/SCL 1092.29 090 65290 RPR WND EO MUSCLE TENDON&/TENON'S CAPSULE 792.08 090 65400 EXC LES CRN XCP PTERYGIUM 1054.07 090 65410 BX CRN 228.76 000 65420 EXC/TRPOS PTERYGIUM W/O GRF 796.51 090 65426 EXC/TRPOS PTERYGIUM W/GRF 1010.31 090 65430 CORNEA SCRAPING DIAGNOSTIC SMEAR &/CULTURE 181.13 000 65435 RMVL CRNL EPITHE +-CHEMOCAUT 126.84 000 65436 RMVL CRNL EPITHE W/APPL CHELATING AGT 614.83 090 65450 DSTRJ LES CRN CRTX PC/THERMOCAUT 503.50 090 65600 MLT PNXRS ANT CRN 612.06 090 65710 KERATOPLASTY ANTERIOR LAMELLAR 1735.92 090 65730 KERATOPLASTY PENTRG EXCEPT APHAKIA/PSEUDOPHAKIA 1927.02 090 65750 KERATOPLASTY PENTRG APHK 1935.88 090 65755 KERATOPLASTY PENTRG PSEUDOPHAKIA 1933.66 090 65756 KERATOPLASTY ENDOTHELIAL 1802.39 090 + 65757 BACKBENCH PREPJ CORNEAL ENDOTHELIAL ALLOGRAFT BR ZZZ 65760 KERATOMILEUSIS 1852.80 XXX 65765 KERATOPHAKIA 2686.42 XXX 65767 EPIKERATOPLASTY 2500.86 XXX 65770 KERATOPROSTH 2460.42 090 65771 RDL KERATOTOMY 1019.18 XXX 65772 CRNL RELAXING INC CORRJ INDUCED ASTIGMATISM 699.02 090 65775 CRNL WEDGE RESCJ CORRJ INDUCED ASTIGMATISM 838.05 090 l 65778 PLACE AMNIOTIC MEMB OCULAR SURFACE SELF RETAIN 2045.55 010 l 65779 PLACE AMNIOTIC MEMBRANE OCULAR SURFACE SUTURED 1850.58 010 s 65780 OCULAR SURFACE RECONSTRUCTION AMNIOTIC MEMBRANE 1385.30 090 65781 OCULAR SURFACE RECONSTRUCTION LIMBAL ALLOGRAFT 2038.91 090 65782 OCCULAR SURFACE RECONSTRUCTION LIMBAL AUTOGRAFT 1867.75 090 65800 PCNTS EYE SPX DX ASPIR AQUEOUS 234.85 000 65805 PCNTS EYE SPX THER RLS AQUEOUS 260.89 000 65810 PCNTS EYE SPX RMVL VTS&/DSCJ MEMB 738.35 090 65815 PCNTS EYE SPX RMVL BLD 1002.56 090 65820 GONIOTOMY 1137.16 090 65850 TRABECULOTOMY AB EXTERNO 1347.08 090 65855 TRABECULOPLASTY LASER SURG 1+ SESS 535.62 010 65860 SEVERING ADS ANT SGM LASER TQ SPX 531.19 090 65865 SEVERING ADS ANT SGM INCAL TQ SPX GONIOSYNECHIAE 718.96 090 162 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule 65870 SEVERING ADS ANT SGM INCAL SPX ANT SYNECHIAE 939.97 090 65875 SEVERING ADS ANT SGM INCAL SPX POST SYNECHIAE 984.83 090 65880 SEVERING ADS ANT SGM INCAL SPX CORNEOVITREAL 1005.88 090 65900 RMVL EPITHELIAL DOWNGROWTH ANT CHAMBER EYE 1466.73 090 65920 RMVL IMPLTED MATRL ANT SGM EYE 1227.44 090 65930 RMVL BLD CLOT ANT SGM EYE 1021.39 090 66020 NJX ANT CHAMBER EYE SPX AIR/LIQ 282.49 010 66030 NJX ANT CHAMBER EYE SPX MED 256.46 010 66130 EXC LES SCL 1123.86 090 66150 FSTLJ SCL GLC TREPH IRDEC 1323.27 090 66155 FSTLJ SCL GLC THERMOCAUT IRDEC 1322.16 090 66160 FSTLJ SCL GLC SCLERCOMY PUNCH/SCISSORS IRDEC 1496.08 090 66165 FSTLJ SCL GLC IRIDENCLEISIS/IRIDOTASIS 1296.68 090 66170 FSTLJ SCL GLC TRBEC AB EXTERNO 1863.87 090 66172 FSTLJ SCL GLC TRBEC AB EXTERNO SCARRING 2348.54 090 l 66174 TRLUML DILAT AQUEOUS CANAL W/O DEV/STNT 1601.32 090 l 66175 TRLUML DILAT AQUEOUS CANAL W/DEV/STNT 1815.68 090 66180 AQUEOUS SHUNT EO RSVR 1829.53 090 66185 REVJ AQUEOUS SHUNT EO RSVR 1190.33 090 66220 RPR SCLL STAPHYLOMA W/O GRF 1151.56 090 66225 RPR SCLL STAPHYLOMA W/GRF 1503.84 090 66250 REVJ/RPR OPRATIVE WND ANT SGM 1185.90 090 66500 IRIDOTOMY STAB INC SPX XCP TRANSFIXION 535.62 090 66505 IRIDOTOMY STAB INC SPX TRANSFIXION 587.13 090 66600 IRDEC CRNLSCLRL/CRNL SCTJ RMVL LES 1255.69 090 66605 IRDEC CRNLSCLRL/CRNL SCTJ CYCLECTOMY 1604.65 090 66625 IRDEC CRNLSCLRL/CRNL SCTJ PRPH GLC SPX 670.77 090 66630 IRDEC CRNLSCLRL/CRNL SCTJ SECTOR GLC SPX 901.75 090 66635 IRDEC CRNLSCLRL/CRNL SCTJ OPTICAL SPX 871.28 090 66680 RPR IRIS CILIARY BDY 831.40 090 66682 SUTR IRIS CILIARY BDY SPX RETRIEVAL SUTR 1008.65 090 66700 CILIARY BDY DSTRJ DTHRM 687.94 090 66710 CILIARY BDY DSTRJ CYCLOPC TRANSSCLL 704.56 090 66711 CILIARY BDY DSTRJ CYCLOPC NDSC 971.54 090 K 66720 CILIARY BDY DSTRJ CRTX 727.82 090 66740 CILIARY BDY DSTRJ CYCLODIAL 662.46 090 s 66761 IRIDOTOMY/IRDEC LASER SURG PER SESSION 513.47 010 66762 IRIDOPLASTY PC 1+ SESS 735.58 090 66770 DSTRJ CST/LES IRIS/CILIARY BDY 797.62 090 66820 DSCJ SEC MEMBRANOUS CTRC STAB INC 619.81 090 66821 POST-CATARACT LASER SURGERY 512.91 090 66825 RPSG IO LENS PROSTH REQ INC SPX 1183.13 090 66830 RMVL SEC MEMBRANOUS CTRC CORNEO-SCLL SCTJ 1083.43 090 66840 RMVL LENS MATRL ASPIR TQ 1+ STGS 1120.54 090 66850 RMVL LENS MATRL PHACOFRAGMENTATION ASPIR 1243.51 090 66852 RMVL LENS MATRL PARS PLNA APPR +-VTRC 1350.96 090 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 163
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 66920 RMVL LENS MATRL ICAPSL 1146.57 090 66930 REMOVAL LENS MATRL INTRACAPSULAR DISLOCATED LENS 1303.33 090 66940 RMVL LENS MATRL XCAPSL 1242.95 090 66982 XCAPSL CTRC RMVL INSJ LENS PROSTH 1 STG 1681.64 090 66983 ICAPSL CTRC XTRJ INSJ IO LENS PROSTH 1 STG 1136.05 090 66984 CATARACT REMOVAL INSERTION OF LENS 1210.27 090 66985 INSJ IO LENS PROSTH X W/CNCRNT RMVL 1199.19 090 66986 EXCHNG IO LENS 1427.40 090 + 66990 USE OPH ENDOSCOPE 139.58 ZZZ 66999 UNLIS ANT SGM EYE BR YYY 67005 RMVL VTS ANT APPR PRTL RMVL 761.06 090 67010 RMVL VTS ANT APPR STOT RMVL VTRC 849.68 090 67015 ASPIR/RLS FLU PARS PLNA 907.29 090 67025 NJX VTS SUB PARS PLNA/LIMBAL SPX 1148.23 090 67027 IMPLTJ INTRAVITREAL DRUG DLVR SYS RMVL VTS 1361.49 090 67028 INTRAVITREAL NJX PHARMACOLOGIC AGT SPX 209.37 000 67030 DSCJ VTS STRANDS PARS PLNA 800.39 090 67031 SEVERING VTS STRANDS LASER 1+ STGS 603.20 090 67036 VTRC MCHNL PARS PLNA 1511.59 090 67039 VTRC MCHNL PARS PLNA FOCAL ENDOLASER PC 1978.53 090 67040 VTRC MCHNL PARS PLNA ENDOLASER PANRTA PC 2237.20 090 67041 VITRECTOMY PARS PLANA REMOVE PRERETINAL MEMBRANE 2088.20 090 67042 VITRECTOMY PARS PLANA REMOVE INT MEMB RETINA 2388.97 090 67043 VITRECTOMY PARS PLANA REMOVE SUBRETINAL MEMBRANE 2559.57 090 67101 RPR RTA DTCHMNT 1+ SESS CRTX/DTHRM +-DRG 1235.20 090 67105 RPR RTA DTCHMNT 1+ SESS PC +-DRG SUBRTA 1123.31 090 67107 RPR RTA DTCHMNT SCLL BUCKLING +-IMPLT 1947.51 090 67108 RPR RTA DTCHMNT W/VTRC ANY METH 2532.43 090 67110 RPR RTA DTCHMNT NJX AIR/OTH GAS 1350.41 090 67112 RPR RTA DTCHMNT SCLL BUCKLING/VTRC PT 2089.31 090 67113 RPR COMPLEX RETINA DETACH VITRECTOMY & MEMB PEEL 2750.11 090 67115 RLS ENCIRCLING MATRL 773.24 090 67120 RMVL IMPLTED MATRL POST SGM EO 1045.76 090 67121 RMVL IMPLTED MATRL POST SGM IO 1451.77 090 67141 PROPH RTA DTCHMNT W/O DRG 1+ SESS CRTX DTHRM 828.08 090 67145 PROPH RTA DTCHMNT W/O DRG 1+ SESS 820.88 090 67208 DSTRJ LOCLZD LES RETINA 1+ SESS CRTX DTHRM 908.40 090 67210 DSTRJ LOCLZD LES RETINA 1+ SESS PC 1090.63 090 67218 DSTRJ LES RETINA 1+ SESS RADJ IMPLTJ 2117.56 090 67220 DSTRJ LES CHOROID PC 1+ SESS 1700.47 090 67221 DSTRJ LES CHOROID PDT 458.08 000 + 67225 DSTRJ LES CHOROID PDT 2ND EYE 1 SESS 45.97 ZZZ 67227 DESTRUCTION RETINOPATHY 1+ SESS DIATHERMY 925.57 090 67228 EXTENSIVE RETINOPATHY 1+ SESS PHOTOCOAGULATION 1846.70 090 67229 EXTENSIVE RETINOPATHY 1+ SESS PRETERM INFANT 1738.69 090 67250 SCLL RNFCMT SPX W/O GRF 1240.74 090 164 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule 67255 SCLL RNFCMT SPX W/GRF 1349.30 090 67299 UNLIS POST SGM BR YYY 67311 STRABISMUS RECESSION/RESCJ 1 HRZNTL MUSC 950.49 090 67312 STRABISMUS RECESSION/RESCJ 2 HRZNTL MUSC 1149.90 090 67314 STRABISMUS RECESSION/RESCJ 1 VER MUSC 1067.92 090 67316 STRABISMUS RECESSION/RESCJ 2/MORE VER MUSC 1292.25 090 67318 STRABISMUS ANY SUPRIOR OBLQ MUSC 1068.47 090 + 67320 TRPOS ANY EO MUSC 495.74 ZZZ + 67331 STRABISMUS PREVIOUS EYE X INVOLVE EO MUSC 496.85 ZZZ + 67332 STRABISMUS SCARRING EO MUSC/RSTCV MYOPATHY 540.05 ZZZ + 67334 STRABISMUS POST FIXJ SUTR TQ +-MUSC RECESSION 463.61 ZZZ + 67335 PLMT ADJUSTABLE SUTR STRABISMUS 243.16 ZZZ + 67340 STRABISMUS EXPL&/RPR DETACHED EO MUSC 551.68 ZZZ 67343 RLS X10SV SCAR TISS W/O DETACHING EO MUSC SPX 1049.64 090 67345 CHEMODNRVTJ EO MUSC 388.84 010 67346 BIOPSY EXTRAOCULAR MUSCLE 329.57 000 67399 UNLIS OC MUSC BR YYY 67400 ORBT W/O B1 FLAP EXPL +-BX 1487.78 090 67405 ORBT W/O B1 FLAP DRG ONLY 1236.86 090 67412 ORBT W/O B1 FLAP RMVL LES 1364.26 090 67413 ORBT W/O B1 FLAP RMVL FB 1375.89 090 67414 ORBT W/O B1 FLAP RMVL B1 DCMPRN 2068.82 090 67415 FINE NDL ASPIR ORB CNTS 168.39 000 67420 ORBT B1 FLAP/WINDOW LAT RMVL LES 2629.36 090 67430 ORBT B1 FLAP/WINDOW LAT RMVL FB 1899.32 090 67440 ORBT B1 FLAP/WINDOW LAT DRG 1883.81 090 67445 ORBT B1 FLAP/WINDOW LAT RMVL B1 DCMPRN 2272.65 090 67450 ORBT B1 FLAP/WINDOW LAT EXPL +-BX 1957.48 090 67500 RETROBULBAR NJX MED SPX 131.83 000 67505 RETROBULBAR NJX ALCOHOL 144.57 000 67515 NJX MED/OTHER SBST TENON'S CAPSULE 154.54 000 67550 ORB IMPLT INSJ 1552.03 090 67560 ORB IMPLT RMVL/REVJ 1545.38 090 67570 OPTIC NRV DCMPRN 1975.76 090 67599 UNLIS ORBIT BR YYY 67700 BLEPHAROTOMY DRG ABSC EYELID 412.66 010 67710 SEVERING TARSORRHAPHY 348.96 010 67715 CANTHOTOMY SPX 368.90 010 67800 EXC CHALAZION 1 200.51 010 67801 EXC CHALAZION MLT SM LID 259.23 010 67805 EXC CHALAZION MLT DIFF LIDS 321.82 010 67808 EXC CHALAZION ANES REQ HOSPIZATION 1/MLT 589.90 090 67810 BX EYELID 346.74 000 67820 CORRJ TRICHIASIS EPILATION FORCEPS ONLY 81.42 000 67825 CORRJ TRICHIASIS EPILATION OTH/THN FORCEPS 204.94 010 67830 CORRJ TRICHIASIS INC LID MRGN 417.09 010 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 165
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 67835 CORRJ TRICHIASIS INC LID MRGN W/FR MUC MEMB GRF 708.44 090 67840 EXC LES EYELID W/O CLSR/W/SMPL DIR CLSR 432.04 010 67850 DSTRJ LES LID MRGN <1 CM 343.42 010 67875 TEMP CLSR EYELIDS SUTR 269.75 000 67880 CONSTJ ADS MEDIAN TRPH/CTRPH 721.73 090 67882 CONSTJ ADS MEDIAN TRPH/CTRPH TRPOS PLATE 896.76 090 67900 RPR BROW PTOSIS 1017.51 090 67901 RPR BLPOS FRNTIS MUSC SUTR/OTH MATRL 1151.00 090 67902 RPR BLPOS FRNTIS MUSC AUTOL FSCAL SLING 1160.42 090 67903 RPR BLPOS LEVATOR RESCJ/ADVMNT INT 961.02 090 67904 RPR BLPOS LEVATOR RESCJ/ADVMNT XTRNL 1163.19 090 67906 RPR BLPOS SUPRIOR RECTUS FSCAL SLING 777.12 090 67908 RPR BLPOS CONJUNCTIVO-TARSO-MUSC-LEVATOR RESCJ 785.98 090 67909 RDCTJ >CORRJ PTOSIS 855.22 090 67911 CORRJ LID RETRCJ 897.87 090 67912 CORRJ LAGOPHTHALMOS IMPLTJ UPR EYELID LID LOAD 1396.38 090 67914 RPR ECTROPION SUTR 614.83 090 67915 RPR ECTROPION THERMOCAUT 541.16 090 67916 RPR ECTROPION EXC TARSAL WEDGE 851.34 090 67917 RPR ECTROPION X10SV 932.77 090 67921 RPR ENTROPION SUTR 588.80 090 67922 RPR ENTROPION THERMOCAUT 522.88 090 67923 RPR ENTROPION EXC TARSAL WEDGE 902.86 090 67924 RPR ENTROPION X10SV 931.66 090 67930 SUTR RECENT WND EYELID PRTL THKNS 582.15 010 67935 SUTR RECENT WND EYELID FULL THKNS 950.49 090 67938 RMVL EMBEDDED FB EYELID 376.65 010 67950 CANTHOPLASTY 912.83 090 67961 EXC&RPR EYELID < ONE-4TH LID MRGN 915.04 090 67966 EXC&RPR EYELID > ONE-4TH LID MRGN 1224.67 090 67971 RCNSTJ EYELID FULL THKNS < 2-3RD 1 STG 1177.59 090 67973 RCNSTJ EYELID FULL THKNS TOT LWR 1 STG 1521.56 090 67974 RCNSTJ EYELID FULL THKNS TOT UPR 1 STG 1517.13 090 67975 RCNSTJ EYELID FULL THKNS 2ND STG 1113.34 090 67999 UNLIS EYELIDS BR YYY 68020 INC CJNC DRG CST 187.22 010 68040 EXPRESSION CJNCL FOLLICLES 104.69 000 68100 BX CJNC 264.76 000 68110 EXC LES CJNC UP 1 CM 354.50 010 68115 EXC LES CJNC > 1 CM 481.34 010 68130 EXC LES CJNC W/ADJ SCL 819.22 090 68135 DSTRJ LES CJNC 244.82 010 68200 SCJNCL NJX 67.02 000 68320 CJP CJNCL GRF/X10SV REARGMT 1142.70 090 68325 CJP BUCCAL MUC MEMB GRF 1061.27 090 68326 CJP RCNSTJ CUL-DE-SAC CJNCL GRF/REARGMT 1039.12 090 166 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule 68328 CJP RCNSTJ CUL-DE-SAC BUCCAL MUC MEMB GRF 1149.34 090 68330 RPR SYMBLEPHARON CJP W/O GRF 957.14 090 68335 RPR SYMBLEPHARON FR GRF CJNC/BUCCAL MUC MEMB 1041.33 090 68340 RPR SYMBLEPHARON DIV 860.76 090 68360 CJNCL FLAP BRIDGE/PRTL SPX 840.27 090 68362 CJNCL FLAP TOT 1056.29 090 68371 HRVG CJNCL ALGRFT LIV DON 628.12 010 68399 UNLIS CJNC BR YYY 68400 INC DRG LACRIMAL GLND 440.35 010 68420 INC DRG LACRIMAL SAC 494.63 010 68440 SNIP INC LACRIMAL PUNCTUM 166.72 010 68500 EXC LACRIMAL GLND XCP TUM TOT 1596.89 090 68505 EXC LACRIMAL GLND XCP TUM PRTL 1570.31 090 68510 BX LACRIMAL GLND 716.19 000 68520 EXC LACRIMAL SAC 1074.57 090 68525 BX LACRIMAL SAC 439.24 000 68530 RMVL FB/DACRYOLITH LACRIMAL PSAGES 680.74 010 68540 EXC LACRIMAL GLND TUM FRNT APPR 1452.88 090 68550 EXC LACRIMAL GLND TUM INVG OSTEOM 1779.13 090 68700 PLSTC RPR CANALICULI 972.09 090 68705 CORRJ EVERTED PUNCTUM CAUT 374.99 010 68720 DACRYOCSTORHINOSTOMY 1206.39 090 68745 CONJUNCTIVORHINOSTOMY W/O TUBE 1226.33 090 68750 CONJUNCTIVORHINOSTOMY INSJ TUBE/STENT 1266.77 090 68760 CLSR LACRIMAL PUNCTUM THERMOCAUT LIG/LASER 317.94 010 68761 CLSR LACRIMAL PUNCTUM PLUG EA 230.98 010 68770 CLSR LACRIMAL FSTL SPX 987.60 090 68801 DILAT LACRIMAL PUNCTUM +-IRRG 193.87 010 68810 PROBE NASOLACRIMAL DUX +-IRRG 377.76 010 68811 PROBE NASOLACRIMAL DUX +-IRRG ANES 330.68 010 68815 PROBE NASOLACRIMAL DUX +-IRRG INSJ TUBE/STENT 698.47 010 68816 PROBE NASOLACRIMAL DUCT WITH CATHETER DILATION 1103.92 010 68840 PROBE LACRIMAL CANALICULI +-IRRG 200.51 010 68850 NJX CNTRST MEDIUM DACRYOCSTOGRAPY 97.49 000 68899 UNLIS LACRIMAL SYS BR YYY 69000 DRG XTRNL EAR ABSC/HMTMA SMPL 297.44 010 69005 DRG XTRNL EAR ABSC/HMTMA COMP 347.85 010 69020 DRG XTRNL AUD CANAL ABSC 378.31 010 69090 EAR PIERCING 50.96 XXX 69100 BX XTRNL EAR 167.83 000 69105 BX XTRNL AUD CANAL 228.76 000 69110 EXC XTRNL EAR PRTL SMPL RPR 746.10 090 69120 EXC XTRNL EAR COMPL AMP 659.69 090 69140 EXC EXOSTOSIS XTRNL AUD CANAL 1436.26 090 69145 EXC SOFT TISS LES XTRNL AUD CANAL 639.75 090 69150 RAD EXC XTRNL AUD CANAL LES W/O NCK DSJ 1721.52 090 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 167
Georgia Workers Compensation Medical Fee Schedule Section VII: Surgical Services SURGERY 10021 69990 Medical Fee Schedule Effective April 1, 2011 69155 RAD EXC XTRNL AUD CANAL LES NCK DSJ 2763.41 090 69200 RMVL FB XTRNL AUD CANAL W/O ANES 199.40 000 69205 RMVL FB XTRNL AUD CANAL ANES 166.72 010 69210 RMVL IMPACTED CERUMEN SPX 1/BTH EARS 81.42 000 69220 DBRDMT MSTDC CAVITY SMPL 224.33 000 69222 DBRDMT MSTDC CAVITY CPLX 360.04 010 K 69300 OTOPLASTY PROTRUDING EAR +-SIZE RDCTJ 1092.29 YYY 69310 RCNSTJ XTRNL AUD CANAL SPX 1785.77 090 69320 RCNSTJ XTRNL AUD CANAL CGEN ATRESIA 1 STG 2524.68 090 69399 UNLIS XTRNL EAR BR YYY 69400 EUSTACHIAN TUBE NFLTJ TRANSNSL CATHJ 236.52 000 69401 EUSTACHIAN TUBE NFLTJ TRANSNSL W/O CATHJ 137.92 000 69405 EUSTACHIAN TUBE CATHJ TRANSTYMPANIC 425.95 010 69420 MRGT ASPIR&/EUSTACHIAN TUBE NFLTJ 312.95 010 69421 MRGT ASPIR&/EUSTACHIAN TUBE NFLTJ ANES 247.59 010 69424 VENTILATING TUBE RMVL ANES 209.93 000 69433 TMPST LOCAL/TOPICAL ANES 326.25 010 69436 TMPST ANES 267.53 010 69440 MIDDLE EAR EXPL THRU POSTAUR/EAR CANAL INC 1129.96 090 69450 TYMPANOLSS TRANSCANAL 890.67 090 69501 TRANSMASTOID ANTRT 1204.18 090 69502 MSTDC COMPL 1601.32 090 69505 MSTDC MODF RAD 1981.85 090 69511 MSTDC RAD 2033.37 090 69530 PETROUS APICECTOMY RAD MSTDC 2728.51 090 69535 RESCJ TEMPORAL B1 XTRNL 4422.89 090 69540 EXC AURAL POLYP 341.76 010 69550 EXC AURAL GLOMUS TUM TRANSCANAL 1714.32 090 69552 EXC AURAL GLOMUS TUM TRANSMASTOID 2592.25 090 69554 EXC AURAL GLOMUS TUM EXTND 4132.09 090 69601 REVJ MSTDC RSLTG COMPL MSTDC 1724.29 090 69602 REVJ MSTDC RSLTG MODF RAD MSTDC 1794.08 090 69603 REVJ MSTDC RSLTG RAD MSTDC 2083.77 090 69604 REVJ MSTDC RSLTG TMPP 1841.72 090 69605 REVJ MSTDC W/APICECTOMY 2575.08 090 69610 TYMPANIC MEMB RPR +-SIT PREPJ PRF8J PATCH 638.09 010 69620 MYRINGOPLASTY 1136.05 090 69631 TMPP W/O MSTDC 1ST/REVJ W/O OCR 1451.77 090 69632 TMPP W/O MSTDC 1ST/REVJ OCR 1774.70 090 69633 TMPP W/O MSTDC 1ST/REVJ PROSTH TORP 1712.66 090 69635 TMPP ANTRT/MASTOIDOTOMY W/O OCR 2011.21 090 69636 TMPP ANTRT/MASTOIDOTOMY OCR 2273.21 090 69637 TMPP ANTRT/MASTOIDOTOMY PROSTH TORP 2266.56 090 69641 TMPP MSTDC W/O OCR 1714.32 090 69642 TMPP MSTDC OCR 2206.18 090 69643 TMPP MSTDC NTC/RCNSTED WALL W/O OCR 2016.20 090 168 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section VII: Surgical Services Georgia Workers Compensation Medical Fee Schedule 10021 69990 SURGERY Effective April 1, 2011 Medical Fee Schedule 69644 TMPP MSTDC NTC/RCNSTED CANAL WALL OCR 2439.38 090 69645 TMPP MSTDC RAD/COMPL W/O OCR 2394.51 090 69646 TMPP MSTDC RAD/COMPL OCR 2540.19 090 69650 STAPES MOBLJ 1314.96 090 69660 STAPEDECTOMY/STAPEDOTOMY 1529.87 090 69661 STAPEDECTOMY/STAPEDOTOMY W/FOOTPLATE DRILL OUT 1994.59 090 69662 REVJ STAPEDECTOMY/STAPEDOTOMY 1910.40 090 69666 RPR OVAL WINDOW FSTL 1329.36 090 69667 RPR ROUND WINDOW FSTL 1331.58 090 69670 MASTOID OBLTRJ SPX 1553.14 090 69676 TYMPANIC NEURECTOMY 1369.24 090 69700 CLSR POSTAUR FSTL MASTOID SPX 1135.50 090 69710 IMPLTJ/RPLCMT EMGNT B1 CNDJ DEV TEMPORAL B1 BR XXX 69711 RMVL/RPR EMGNT B1 CNDJ DEV TEMPORAL B1 1424.63 090 69714 IMPLTJ OI IMPLT B1 W/O MSTDC 1776.36 090 69715 IMPLTJ OI IMPLT B1 MSTDC 2200.64 090 69717 RPLCMT OI IMPLT B1 W/O MSTDC 1878.27 090 69718 RPLCMT OI IMPLT B1 MSTDC 2225.02 090 69720 DCMPRN NRV ITPRL LAT GENICULATE 1935.88 090 69725 DCMPRN NRV ITPRL MEDIAL GENICULATE 3113.47 090 69740 SUTR NRV ITPRL +-GRF/DCMPRN LAT GENICULATE 1932.00 090 69745 SUTR NRV ITPRL +-GRF/DCMPRN MEDIAL GENICULATE 2059.40 090 69799 UNLIS MIDDLE EAR BR YYY s 69801 LABYRINTHOTOMY TRANSCANAL 329.02 000 s 69802 LABYRINTHOTOMY MASTOIDECTOMY 1716.54 090 69805 ENDOLYMPHATIC SAC W/O SHUNT 1741.46 090 69806 ENDOLYMPHATIC SAC SHUNT 1560.89 090 69820 FENESTRATION SEMICIRCULAR CANAL 1417.43 090 69840 REVJ FENESTRATION OPRATION 1373.12 090 69905 LABYRINTHECTOMY TRANSCANAL 1515.47 090 69910 LABYRINTHECTOMY MSTDC 1684.96 090 69915 VSTBLR NRV SCTJ TRANSLABYRINTHINE APPR 2548.49 090 69930 COCHLEAR DEV IMPLTJ +-MSTDC 2034.47 090 69949 UNLIS INNER EAR BR YYY 69950 VSTBLR NRV SCTJ TRANSCRNL 3112.92 090 69955 TOT FACIAL NRV DCMPRN&/RPR 3281.30 090 69960 DCMPRN INT AUD CANAL 3191.57 090 69970 RMVL TUM TEMPORAL B1 3558.25 090 69979 UNLIS TEMPORAL B1 MIDDLE FOSSA BR YYY + 69990 MICROSURG TQS REQ USE OPRATING MCRSCP 358.93 ZZZ Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 169
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 96372 96374) 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
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 76140 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 61055 or 62284 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.
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 25. 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. 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
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.
Section VIII: Diagnostic and Therapeutic Radiological Services Georgia Workers Compensation Medical Fee Schedule 70010 79999 RADIOLOGY Effective April 1, 2011 Medical Fee Schedule 70010 MYELOGRAPY POST FOSSA RS&I 312.22 XXX 70010 26 MYELOGRAPY POST FOSSA RS&I 81.56 XXX 70010 TC MYELOGRAPY POST FOSSA RS&I 230.66 XXX 70015 CISTRNG POSITIVE CNTRST RS&I 359.18 XXX 70015 26 CISTRNG POSITIVE CNTRST RS&I 144.99 XXX 70015 TC CISTRNG POSITIVE CNTRST RS&I 214.19 XXX 70030 RADEX EYE DETCJ FB 70.02 XXX 70030 26 RADEX EYE DETCJ FB 20.60 XXX 70030 TC RADEX EYE DETCJ FB 49.42 XXX 70100 RADEX MNDBL PRTL < 4 VIEWS 80.73 XXX 70100 26 RADEX MNDBL PRTL < 4 VIEWS 22.24 XXX 70100 TC RADEX MNDBL PRTL < 4 VIEWS 58.49 XXX 70110 RADEX MNDBL COMPL MINIMUM 4 VIEWS 96.38 XXX 70110 26 RADEX MNDBL COMPL MINIMUM 4 VIEWS 29.66 XXX 70110 TC RADEX MNDBL COMPL MINIMUM 4 VIEWS 66.72 XXX 70120 RADEX MASTOIDS < 3 VIEWS PR SIDE 85.68 XXX 70120 26 RADEX MASTOIDS < 3 VIEWS PR SIDE 22.24 XXX 70120 TC RADEX MASTOIDS < 3 VIEWS PR SIDE 63.44 XXX 70130 RADEX MASTOIDS COMPL MINIMUM 3 VIEWS PR SIDE 136.75 XXX 70130 26 RADEX MASTOIDS COMPL MINIMUM 3 VIEWS PR SIDE 40.37 XXX 70130 TC RADEX MASTOIDS COMPL MINIMUM 3 VIEWS PR SIDE 96.38 XXX 70134 RADEX INT AUD MEATI COMPL 112.86 XXX 70134 26 RADEX INT AUD MEATI COMPL 40.37 XXX 70134 TC RADEX INT AUD MEATI COMPL 72.49 XXX 70140 RADEX FACIAL B1S < 3 VIEWS 74.14 XXX 70140 26 RADEX FACIAL B1S < 3 VIEWS 23.89 XXX 70140 TC RADEX FACIAL B1S < 3 VIEWS 50.25 XXX 70150 RADEX FACIAL B1S COMPL MINIMUM 3 VIEWS 104.62 XXX 70150 26 RADEX FACIAL B1S COMPL MINIMUM 3 VIEWS 31.30 XXX 70150 TC RADEX FACIAL B1S COMPL MINIMUM 3 VIEWS 73.32 XXX 70160 RADEX NSL B1S COMPL MINIMUM 3 VIEWS 80.73 XXX 70160 26 RADEX NSL B1S COMPL MINIMUM 3 VIEWS 20.60 XXX 70160 TC RADEX NSL B1S COMPL MINIMUM 3 VIEWS 60.13 XXX 70170 DACRYOCSTOGRAPY NASOLACRIMAL DUX RS&I 128.51 XXX 70170 26 DACRYOCSTOGRAPY NASOLACRIMAL DUX RS&I 37.07 XXX 70170 TC DACRYOCSTOGRAPY NASOLACRIMAL DUX RS&I 91.44 XXX 70190 RADEX OPTIC FORAMINA 87.32 XXX 70190 26 RADEX OPTIC FORAMINA 25.54 XXX 70190 TC RADEX OPTIC FORAMINA 61.78 XXX 70200 RADEX ORBITS COMPL MINIMUM 4 VIEWS 107.92 XXX 70200 26 RADEX ORBITS COMPL MINIMUM 4 VIEWS 33.78 XXX 70200 TC RADEX ORBITS COMPL MINIMUM 4 VIEWS 74.14 XXX 70210 RADEX SINUSES PARANSL < 3 VIEWS 75.79 XXX 70210 26 RADEX SINUSES PARANSL < 3 VIEWS 21.42 XXX 70210 TC RADEX SINUSES PARANSL < 3 VIEWS 54.37 XXX 70220 RADEX SINUSES PARANSL COMPL MINIMUM 3 VIEWS 94.74 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
Georgia Workers Compensation Medical Fee Schedule Section VIII: Diagnostic and Therapeutic Radiological Services RADIOLOGY 70010 79999 Medical Fee Schedule Effective April 1, 2011 70220 26 RADEX SINUSES PARANSL COMPL MINIMUM 3 VIEWS 29.66 XXX 70220 TC RADEX SINUSES PARANSL COMPL MINIMUM 3 VIEWS 65.08 XXX 70240 RADEX SELLA TURCICA 72.49 XXX 70240 26 RADEX SELLA TURCICA 23.07 XXX 70240 TC RADEX SELLA TURCICA 49.42 XXX 70250 RADEX SKL < 4 VIEWS 90.62 XXX 70250 26 RADEX SKL < 4 VIEWS 29.66 XXX 70250 TC RADEX SKL < 4 VIEWS 60.96 XXX 70260 RADEX SKL COMPL MINIMUM 4 VIEWS 115.33 XXX 70260 26 RADEX SKL COMPL MINIMUM 4 VIEWS 40.37 XXX 70260 TC RADEX SKL COMPL MINIMUM 4 VIEWS 74.96 XXX 70300 RADEX TEETH 1 VIEW 35.42 XXX 70300 26 RADEX TEETH 1 VIEW 14.00 XXX 70300 TC RADEX TEETH 1 VIEW 21.42 XXX 70310 RADEX TEETH PRTL XM < FULL MOUTH 91.44 XXX 70310 26 RADEX TEETH PRTL XM < FULL MOUTH 21.42 XXX 70310 TC RADEX TEETH PRTL XM < FULL MOUTH 70.02 XXX 70320 RADEX TEETH COMPL FULL MOUTH 122.75 XXX 70320 26 RADEX TEETH COMPL FULL MOUTH 28.01 XXX 70320 TC RADEX TEETH COMPL FULL MOUTH 94.74 XXX 70328 RADEX TMPRMAND JT OPN&CLSD MOUTH UNI 75.79 XXX 70328 26 RADEX TMPRMAND JT OPN&CLSD MOUTH UNI 22.24 XXX 70328 TC RADEX TMPRMAND JT OPN&CLSD MOUTH UNI 53.55 XXX 70330 RADEX TMPRMAND JT OPN&CLSD MOUTH BI 117.80 XXX 70330 26 RADEX TMPRMAND JT OPN&CLSD MOUTH BI 29.66 XXX 70330 TC RADEX TMPRMAND JT OPN&CLSD MOUTH BI 88.14 XXX 70332 TMPRMAND JT ARTHG RS&I 208.42 XXX 70332 26 TMPRMAND JT ARTHG RS&I 69.20 XXX 70332 TC TMPRMAND JT ARTHG RS&I 139.22 XXX 70336 MRI TMPRMAND JT 1097.30 XXX 70336 26 MRI TMPRMAND JT 177.94 XXX 70336 TC MRI TMPRMAND JT 919.36 XXX 70350 CEPHALOGRAM ORTHODONTIC 51.90 XXX 70350 26 CEPHALOGRAM ORTHODONTIC 23.07 XXX 70350 TC CEPHALOGRAM ORTHODONTIC 28.83 XXX 70355 ORTHOPANTOGRAM 52.72 XXX 70355 26 ORTHOPANTOGRAM 25.54 XXX 70355 TC ORTHOPANTOGRAM 27.18 XXX 70360 RADEX NCK SOFT TISS 67.55 XXX 70360 26 RADEX NCK SOFT TISS 20.60 XXX 70360 TC RADEX NCK SOFT TISS 46.95 XXX 70370 RADEX PHARYNX/LARX W/FLUOR&/MAGNIFICATION TQ 198.54 XXX 70370 26 RADEX PHARYNX/LARX W/FLUOR&/MAGNIFICATION TQ 38.72 XXX 70370 TC RADEX PHARYNX/LARX W/FLUOR&/MAGNIFICATION TQ 159.82 XXX 70371 CPLX DYNAMIC PHARYNGEAL&SP EVAL C/V REC 229.84 XXX 70371 26 CPLX DYNAMIC PHARYNGEAL&SP EVAL C/V REC 99.68 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
Section VIII: Diagnostic and Therapeutic Radiological Services Georgia Workers Compensation Medical Fee Schedule 70010 79999 RADIOLOGY Effective April 1, 2011 Medical Fee Schedule 70371 TC CPLX DYNAMIC PHARYNGEAL&SP EVAL C/V REC 130.16 XXX 70373 LARYNGOGRAPY CNTRST RS&I 200.18 XXX 70373 26 LARYNGOGRAPY CNTRST RS&I 51.08 XXX 70373 TC LARYNGOGRAPY CNTRST RS&I 149.10 XXX 70380 RADIOLOGIC EXAMINATION SALIVARY GLAND CALCULUS 96.38 XXX 70380 26 RADIOLOGIC EXAMINATION SALIVARY GLAND CALCULUS 22.24 XXX 70380 TC RADIOLOGIC EXAMINATION SALIVARY GLAND CALCULUS 74.14 XXX 70390 SIALOGRAPY RS&I 247.96 XXX 70390 26 SIALOGRAPY RS&I 46.96 XXX 70390 TC SIALOGRAPY RS&I 201.00 XXX 70450 CT HEAD/BRN C-MATRL 478.63 XXX 70450 26 CT HEAD/BRN C-MATRL 102.15 XXX 70450 TC CT HEAD/BRN C-MATRL 376.48 XXX 70460 CT HEAD/BRN C+ MATRL 623.62 XXX 70460 26 CT HEAD/BRN C+ MATRL 135.93 XXX 70460 TC CT HEAD/BRN C+ MATRL 487.69 XXX 70470 CT HEAD/BRN C-/C+ 754.60 XXX 70470 26 CT HEAD/BRN C-/C+ 154.05 XXX 70470 TC CT HEAD/BRN C-/C+ 600.55 XXX 70480 CT ORBIT SELLA/POST FOSSA/EAR C-MATRL 766.13 XXX 70480 26 CT ORBIT SELLA/POST FOSSA/EAR C-MATRL 154.87 XXX 70480 TC CT ORBIT SELLA/POST FOSSA/EAR C-MATRL 611.26 XXX 70481 CT ORBIT SELLA/POST FOSSA/EAR C+ MATRL 889.70 XXX 70481 26 CT ORBIT SELLA/POST FOSSA/EAR C+ MATRL 167.23 XXX 70481 TC CT ORBIT SELLA/POST FOSSA/EAR C+ MATRL 722.47 XXX 70482 CT ORBIT SELLA/POST FOSSA/EAR C-/C+ 1004.21 XXX 70482 26 CT ORBIT SELLA/POST FOSSA/EAR C-/C+ 174.65 XXX 70482 TC CT ORBIT SELLA/POST FOSSA/EAR C-/C+ 829.56 XXX 70486 CT MAXLFCL AREA C-MATRL 638.45 XXX 70486 26 CT MAXLFCL AREA C-MATRL 137.57 XXX 70486 TC CT MAXLFCL AREA C-MATRL 500.88 XXX 70487 CT MAXLFCL AREA C+ MATRL 769.43 XXX 70487 26 CT MAXLFCL AREA C+ MATRL 157.35 XXX 70487 TC CT MAXLFCL AREA C+ MATRL 612.08 XXX 70488 CT MAXLFCL AREA C-/C+ 935.01 XXX 70488 26 CT MAXLFCL AREA C-/C+ 171.35 XXX 70488 TC CT MAXLFCL AREA C-/C+ 763.66 XXX 70490 CT SOFT TISS NCK C-MATRL 626.09 XXX 70490 26 CT SOFT TISS NCK C-MATRL 154.87 XXX 70490 TC CT SOFT TISS NCK C-MATRL 471.22 XXX 70491 CT SOFT TISS NCK C+ MATRL 753.78 XXX 70491 26 CT SOFT TISS NCK C+ MATRL 166.41 XXX 70491 TC CT SOFT TISS NCK C+ MATRL 587.37 XXX 70492 CT SOFT TISS NCK C-/C+ 910.30 XXX 70492 26 CT SOFT TISS NCK C-/C+ 174.65 XXX 70492 TC CT SOFT TISS NCK C-/C+ 735.65 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
Georgia Workers Compensation Medical Fee Schedule Section VIII: Diagnostic and Therapeutic Radiological Services RADIOLOGY 70010 79999 Medical Fee Schedule Effective April 1, 2011 70496 CT ANGIOGRAPHY HEAD W/CONTRAST/NONCONTRAST 1445.77 XXX 70496 26 CT ANGIOGRAPHY HEAD W/CONTRAST/NONCONTRAST 212.54 XXX 70496 TC CT ANGIOGRAPHY HEAD W/CONTRAST/NONCONTRAST 1233.23 XXX 70498 CT ANGIOGRAPHY NECK W/CONTRAST/NONCONTRAST 1470.48 XXX 70498 26 CT ANGIOGRAPHY NECK W/CONTRAST/NONCONTRAST 212.54 XXX 70498 TC CT ANGIOGRAPHY NECK W/CONTRAST/NONCONTRAST 1257.94 XXX 70540 MRI ORBIT FACE &/NECK W/O CONTRAST 1216.75 XXX 70540 26 MRI ORBIT FACE &/NECK W/O CONTRAST 163.11 XXX 70540 TC MRI ORBIT FACE &/NECK W/O CONTRAST 1053.64 XXX 70542 MRI ORBIT FACE&NCK C+ MATRL 1360.09 XXX 70542 26 MRI ORBIT FACE&NCK C+ MATRL 196.06 XXX 70542 TC MRI ORBIT FACE&NCK C+ MATRL 1164.03 XXX 70543 MRI ORBIT FACE&NCK C-/C+ 1776.94 XXX 70543 26 MRI ORBIT FACE&NCK C-/C+ 258.67 XXX 70543 TC MRI ORBIT FACE&NCK C-/C+ 1518.27 XXX 70544 MRA HEAD C-MATRL 1330.44 XXX 70544 26 MRA HEAD C-MATRL 144.99 XXX 70544 TC MRA HEAD C-MATRL 1185.45 XXX 70545 MRA HEAD C+ MATRL 1322.20 XXX 70545 26 MRA HEAD C+ MATRL 144.99 XXX 70545 TC MRA HEAD C+ MATRL 1177.21 XXX 70546 MRA HEAD C-/C+ 2082.57 XXX 70546 26 MRA HEAD C-/C+ 218.31 XXX 70546 TC MRA HEAD C-/C+ 1864.26 XXX 70547 MRA NCK C-MATRL 1327.97 XXX 70547 26 MRA NCK C-MATRL 144.99 XXX 70547 TC MRA NCK C-MATRL 1182.98 XXX 70548 MRA NCK C+ MATRL 1393.87 XXX 70548 26 MRA NCK C+ MATRL 144.99 XXX 70548 TC MRA NCK C+ MATRL 1248.88 XXX 70549 MRA NCK C-/C+ 2083.39 XXX 70549 26 MRA NCK C-/C+ 217.48 XXX 70549 TC MRA NCK C-/C+ 1865.91 XXX 70551 MRI BRN BRN STEM C-MATRL 1258.77 XXX 70551 26 MRI BRN BRN STEM C-MATRL 178.76 XXX 70551 TC MRI BRN BRN STEM C-MATRL 1080.01 XXX 70552 MRI BRN BRN STEM C+ MATRL 1404.58 XXX 70552 26 MRI BRN BRN STEM C+ MATRL 216.66 XXX 70552 TC MRI BRN BRN STEM C+ MATRL 1187.92 XXX 70553 MRI BRN BRN STEM C-/C+ 1764.58 XXX 70553 26 MRI BRN BRN STEM C-/C+ 285.86 XXX 70553 TC MRI BRN BRN STEM C-/C+ 1478.72 XXX 70554 MRI BRAIN FUNCTIONAL W/O PHYSICIAN ADMNISTRATION 1388.10 XXX 70554 26 MRI BRAIN FUNCTIONAL W/O PHYSICIAN ADMNISTRATION 257.03 XXX 70554 TC MRI BRAIN FUNCTIONAL W/O PHYSICIAN ADMNISTRATION 1131.07 XXX 70555 MRI BRAIN FUNCTIONAL W/PHYSICIAN ADMNISTRATION 1860.96 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
Section VIII: Diagnostic and Therapeutic Radiological Services Georgia Workers Compensation Medical Fee Schedule 70010 79999 RADIOLOGY Effective April 1, 2011 Medical Fee Schedule 70555 26 MRI BRAIN FUNCTIONAL W/PHYSICIAN ADMNISTRATION 316.34 XXX 70555 TC MRI BRAIN FUNCTIONAL W/PHYSICIAN ADMNISTRATION 1544.62 XXX 70557 MRI BRN OPN ICRA PX C-MATRL 4082.75 XXX 70557 26 MRI BRN OPN ICRA PX C-MATRL 448.97 XXX 70557 TC MRI BRN OPN ICRA PX C-MATRL 3633.78 XXX 70558 MRI BRN OPN ICRA PX C+ MATRL 3617.31 XXX 70558 26 MRI BRN OPN ICRA PX C+ MATRL 397.90 XXX 70558 TC MRI BRN OPN ICRA PX C+ MATRL 3219.41 XXX 70559 MRI BRN OPN ICRA PX C-/C+ 3654.38 XXX 70559 26 MRI BRN OPN ICRA PX C-/C+ 402.01 XXX 70559 TC MRI BRN OPN ICRA PX C-/C+ 3252.37 XXX 71010 RADEX CH 1 VIEW FRNT 57.67 XXX 71010 26 RADEX CH 1 VIEW FRNT 21.42 XXX 71010 TC RADEX CH 1 VIEW FRNT 36.25 XXX 71015 RADEX CH STEREO FRNT 73.32 XXX 71015 26 RADEX CH STEREO FRNT 24.71 XXX 71015 TC RADEX CH STEREO FRNT 48.61 XXX 71020 RADEX CH 2 VIEWS FRNT&LAT 75.79 XXX 71020 26 RADEX CH 2 VIEWS FRNT&LAT 26.36 XXX 71020 TC RADEX CH 2 VIEWS FRNT&LAT 49.43 XXX 71021 RADEX CH 2 VIEWS FRNT&LAT APICAL LORDOTIC PX 93.09 XXX 71021 26 RADEX CH 2 VIEWS FRNT&LAT APICAL LORDOTIC PX 32.13 XXX 71021 TC RADEX CH 2 VIEWS FRNT&LAT APICAL LORDOTIC PX 60.96 XXX 71022 RADEX CH 2 VIEWS FRNT&LAT OBLQ PRJCJ 113.68 XXX 71022 26 RADEX CH 2 VIEWS FRNT&LAT OBLQ PRJCJ 37.07 XXX 71022 TC RADEX CH 2 VIEWS FRNT&LAT OBLQ PRJCJ 76.61 XXX 71023 RADEX CH 2 VIEWS FRNT&LAT FLUOR 168.88 XXX 71023 26 RADEX CH 2 VIEWS FRNT&LAT FLUOR 46.13 XXX 71023 TC RADEX CH 2 VIEWS FRNT&LAT FLUOR 122.75 XXX 71030 RADEX CH COMPL MINIMUM 4 VIEWS 112.86 XXX 71030 26 RADEX CH COMPL MINIMUM 4 VIEWS 37.07 XXX 71030 TC RADEX CH COMPL MINIMUM 4 VIEWS 75.79 XXX 71034 RADEX CH COMPL MINIMUM 4 VIEWS W/FLUOR 216.66 XXX 71034 26 RADEX CH COMPL MINIMUM 4 VIEWS W/FLUOR 56.84 XXX 71034 TC RADEX CH COMPL MINIMUM 4 VIEWS W/FLUOR 159.82 XXX 71035 RADEX CH SPEC VIEWS 86.50 XXX 71035 26 RADEX CH SPEC VIEWS 22.24 XXX 71035 TC RADEX CH SPEC VIEWS 64.26 XXX 71040 BRONCHOGRAPY UNI RS&I 235.61 XXX 71040 26 BRONCHOGRAPY UNI RS&I 67.55 XXX 71040 TC BRONCHOGRAPY UNI RS&I 168.06 XXX 71060 BRONCHOGRAPY BI RS&I 344.35 XXX 71060 26 BRONCHOGRAPY BI RS&I 88.97 XXX 71060 TC BRONCHOGRAPY BI RS&I 255.38 XXX 71090 INSJ PM FLUOR&RADIOGRAPY RS&I 230.66 XXX 71090 26 INSJ PM FLUOR&RADIOGRAPY RS&I 69.20 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
Georgia Workers Compensation Medical Fee Schedule Section VIII: Diagnostic and Therapeutic Radiological Services RADIOLOGY 70010 79999 Medical Fee Schedule Effective April 1, 2011 71090 TC INSJ PM FLUOR&RADIOGRAPY RS&I 161.46 XXX 71100 RADEX RIBS UNI 2 VIEWS 79.08 XXX 71100 26 RADEX RIBS UNI 2 VIEWS 26.36 XXX 71100 TC RADEX RIBS UNI 2 VIEWS 52.72 XXX 71101 RADEX RIBS UNI W/POSTEROANT CH MINIMUM 3 VIEWS 96.38 XXX 71101 26 RADEX RIBS UNI W/POSTEROANT CH MINIMUM 3 VIEWS 32.13 XXX 71101 TC RADEX RIBS UNI W/POSTEROANT CH MINIMUM 3 VIEWS 64.25 XXX 71110 RADEX RIBS BI 3 VIEWS 99.68 XXX 71110 26 RADEX RIBS BI 3 VIEWS 32.13 XXX 71110 TC RADEX RIBS BI 3 VIEWS 67.55 XXX 71111 RADEX RIBS BI W/POSTEROANT CH MINIMUM 4 VIEWS 128.51 XXX 71111 26 RADEX RIBS BI W/POSTEROANT CH MINIMUM 4 VIEWS 37.89 XXX 71111 TC RADEX RIBS BI W/POSTEROANT CH MINIMUM 4 VIEWS 90.62 XXX 71120 RADEX STERNUM MINIMUM 2 VIEWS 78.26 XXX 71120 26 RADEX STERNUM MINIMUM 2 VIEWS 23.89 XXX 71120 TC RADEX STERNUM MINIMUM 2 VIEWS 54.37 XXX 71130 RADEX STRNCLAV JT/JTS MINIMUM 3 VIEWS 91.44 XXX 71130 26 RADEX STRNCLAV JT/JTS MINIMUM 3 VIEWS 26.36 XXX 71130 TC RADEX STRNCLAV JT/JTS MINIMUM 3 VIEWS 65.08 XXX 71250 CT THORAX C-MATRL 610.44 XXX 71250 26 CT THORAX C-MATRL 123.57 XXX 71250 TC CT THORAX C-MATRL 486.87 XXX 71260 CT THORAX C+ MATRL 757.07 XXX 71260 26 CT THORAX C+ MATRL 150.76 XXX 71260 TC CT THORAX C+ MATRL 606.31 XXX 71270 CT THORAX C-/C+ 929.25 XXX 71270 26 CT THORAX C-/C+ 166.41 XXX 71270 TC CT THORAX C-/C+ 762.84 XXX 71275 CT ANGIOGRAPHY CHEST W/CONTRAST/NONCONTRAST 1156.62 XXX 71275 26 CT ANGIOGRAPHY CHEST W/CONTRAST/NONCONTRAST 233.14 XXX 71275 TC CT ANGIOGRAPHY CHEST W/CONTRAST/NONCONTRAST 923.48 XXX 71550 MRI CH C-MATRL 1374.92 XXX 71550 26 MRI CH C-MATRL 175.47 XXX 71550 TC MRI CH C-MATRL 1199.45 XXX 71551 MRI CH C+ MATRL 1549.57 XXX 71551 26 MRI CH C+ MATRL 208.42 XXX 71551 TC MRI CH C+ MATRL 1341.15 XXX 71552 MRI CH C-/C+ 2041.38 XXX 71552 26 MRI CH C-/C+ 273.50 XXX 71552 TC MRI CH C-/C+ 1767.88 XXX 71555 MRA CH C+-MATRL 1350.21 XXX 71555 26 MRA CH C+-MATRL 219.95 XXX 71555 TC MRA CH C+-MATRL 1130.26 XXX 72010 RADEX SPI ENTIRE SURV STD ANTEROPOST&LAT 181.24 XXX 72010 26 RADEX SPI ENTIRE SURV STD ANTEROPOST&LAT 55.19 XXX 72010 TC RADEX SPI ENTIRE SURV STD ANTEROPOST&LAT 126.05 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
Section VIII: Diagnostic and Therapeutic Radiological Services Georgia Workers Compensation Medical Fee Schedule 70010 79999 RADIOLOGY Effective April 1, 2011 Medical Fee Schedule 72020 RADEX SPI 1 VIEW SPEC LVL 58.49 XXX 72020 26 RADEX SPI 1 VIEW SPEC LVL 18.95 XXX 72020 TC RADEX SPI 1 VIEW SPEC LVL 39.54 XXX 72040 RADEX SPI CRV 2/3 VIEWS 95.56 XXX 72040 26 RADEX SPI CRV 2/3 VIEWS 28.83 XXX 72040 TC RADEX SPI CRV 2/3 VIEWS 66.73 XXX 72050 RADEX SPI CRV MINIMUM 4 VIEWS 129.34 XXX 72050 26 RADEX SPI CRV MINIMUM 4 VIEWS 38.72 XXX 72050 TC RADEX SPI CRV MINIMUM 4 VIEWS 90.62 XXX 72052 RADEX SPI CRV COMPL W/OBLQ&FLEXION&/XTN STDS 163.94 XXX 72052 26 RADEX SPI CRV COMPL W/OBLQ&FLEXION&/XTN STDS 44.49 XXX 72052 TC RADEX SPI CRV COMPL W/OBLQ&FLEXION&/XTN STDS 119.45 XXX 72069 RADEX SPI THORACOLMBR STANDING SCOLIOSIS 91.44 XXX 72069 26 RADEX SPI THORACOLMBR STANDING SCOLIOSIS 28.83 XXX 72069 TC RADEX SPI THORACOLMBR STANDING SCOLIOSIS 62.61 XXX 72070 RADEX SPI THRC 2 VIEWS 83.20 XXX 72070 26 RADEX SPI THRC 2 VIEWS 27.19 XXX 72070 TC RADEX SPI THRC 2 VIEWS 56.01 XXX 72072 RADEX SPI THRC 3 VIEWS 92.27 XXX 72072 26 RADEX SPI THRC 3 VIEWS 26.36 XXX 72072 TC RADEX SPI THRC 3 VIEWS 65.91 XXX 72074 RADEX SPI THRC MINIMUM 4 VIEWS 108.74 XXX 72074 26 RADEX SPI THRC MINIMUM 4 VIEWS 26.36 XXX 72074 TC RADEX SPI THRC MINIMUM 4 VIEWS 82.38 XXX 72080 RADEX SPI THORACOLMBR 2 VIEWS 89.79 XXX 72080 26 RADEX SPI THORACOLMBR 2 VIEWS 28.83 XXX 72080 TC RADEX SPI THORACOLMBR 2 VIEWS 60.96 XXX 72090 RADEX SPI SCOLIOSIS STD W/SUP&ERC STDS 121.10 XXX 72090 26 RADEX SPI SCOLIOSIS STD W/SUP&ERC STDS 37.07 XXX 72090 TC RADEX SPI SCOLIOSIS STD W/SUP&ERC STDS 84.03 XXX 72100 RADEX SPI LUMBOSAC 2/3 VIEWS 99.68 XXX 72100 26 RADEX SPI LUMBOSAC 2/3 VIEWS 28.83 XXX 72100 TC RADEX SPI LUMBOSAC 2/3 VIEWS 70.85 XXX 72110 RADEX SPI LUMBOSAC MINIMUM 4 VIEWS 135.93 XXX 72110 26 RADEX SPI LUMBOSAC MINIMUM 4 VIEWS 38.72 XXX 72110 TC RADEX SPI LUMBOSAC MINIMUM 4 VIEWS 97.21 XXX 72114 RADEX SPI LUMBOSAC COMPL W/BENDING VIEWS 182.06 XXX 72114 26 RADEX SPI LUMBOSAC COMPL W/BENDING VIEWS 46.13 XXX 72114 TC RADEX SPI LUMBOSAC COMPL W/BENDING VIEWS 135.93 XXX 72120 RADEX SPI LUMBOSAC BENDING MINIMUM 4 VIEWS 126.04 XXX 72120 26 RADEX SPI LUMBOSAC BENDING MINIMUM 4 VIEWS 28.83 XXX 72120 TC RADEX SPI LUMBOSAC BENDING MINIMUM 4 VIEWS 97.21 XXX 72125 CT CRV SPI C-MATRL 613.73 XXX 72125 26 CT CRV SPI C-MATRL 123.57 XXX 72125 TC CT CRV SPI C-MATRL 490.16 XXX 72126 CT CRV SPI C+ MATRL 755.42 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
Georgia Workers Compensation Medical Fee Schedule Section VIII: Diagnostic and Therapeutic Radiological Services RADIOLOGY 70010 79999 Medical Fee Schedule Effective April 1, 2011 72126 26 CT CRV SPI C+ MATRL 147.46 XXX 72126 TC CT CRV SPI C+ MATRL 607.96 XXX 72127 CT CRV SPI C-/C+ 915.24 XXX 72127 26 CT CRV SPI C-/C+ 153.23 XXX 72127 TC CT CRV SPI C-/C+ 762.01 XXX 72128 CT THRC SPI C-MATRL 612.91 XXX 72128 26 CT THRC SPI C-MATRL 123.57 XXX 72128 TC CT THRC SPI C-MATRL 489.34 XXX 72129 CT THRC SPI C+ MATRL 757.07 XXX 72129 26 CT THRC SPI C+ MATRL 148.28 XXX 72129 TC CT THRC SPI C+ MATRL 608.79 XXX 72130 CT THRC SPI C-/C+ 916.07 XXX 72130 26 CT THRC SPI C-/C+ 153.23 XXX 72130 TC CT THRC SPI C-/C+ 762.84 XXX 72131 CT LMBR SPI C-MATRL 611.26 XXX 72131 26 CT LMBR SPI C-MATRL 123.57 XXX 72131 TC CT LMBR SPI C-MATRL 487.69 XXX 72132 CT LMBR SPI C+ MATRL 755.42 XXX 72132 26 CT LMBR SPI C+ MATRL 148.28 XXX 72132 TC CT LMBR SPI C+ MATRL 607.14 XXX 72133 CT LMBR SPI C-/C+ 915.24 XXX 72133 26 CT LMBR SPI C-/C+ 153.23 XXX 72133 TC CT LMBR SPI C-/C+ 762.01 XXX 72141 MRI SPI CANAL&CNTS CRV C-MATRL 1136.02 XXX 72141 26 MRI SPI CANAL&CNTS CRV C-MATRL 194.42 XXX 72141 TC MRI SPI CANAL&CNTS CRV C-MATRL 941.60 XXX 72142 MRI SPI CANAL&CNTS CRV C+ MATRL 1421.06 XXX 72142 26 MRI SPI CANAL&CNTS CRV C+ MATRL 232.31 XXX 72142 TC MRI SPI CANAL&CNTS CRV C+ MATRL 1188.75 XXX 72146 MRI SPI CANAL&CNTS THRC C-MATRL 1152.50 XXX 72146 26 MRI SPI CANAL&CNTS THRC C-MATRL 194.42 XXX 72146 TC MRI SPI CANAL&CNTS THRC C-MATRL 958.08 XXX 72147 MRI SPI CANAL&CNTS THRC C+ MATRL 1281.83 XXX 72147 26 MRI SPI CANAL&CNTS THRC C+ MATRL 233.14 XXX 72147 TC MRI SPI CANAL&CNTS THRC C+ MATRL 1048.69 XXX 72148 MRI SPI CANAL&CNTS LMBR C-MATRL 1136.84 XXX 72148 26 MRI SPI CANAL&CNTS LMBR C-MATRL 180.41 XXX 72148 TC MRI SPI CANAL&CNTS LMBR C-MATRL 956.43 XXX 72149 MRI SPI CANAL&CNTS LMBR C+ MATRL 1397.99 XXX 72149 26 MRI SPI CANAL&CNTS LMBR C+ MATRL 216.66 XXX 72149 TC MRI SPI CANAL&CNTS LMBR C+ MATRL 1181.33 XXX 72156 MRI SPI CANAL&CNTS C-/C+ CRV 1765.40 XXX 72156 26 MRI SPI CANAL&CNTS C-/C+ CRV 312.22 XXX 72156 TC MRI SPI CANAL&CNTS C-/C+ CRV 1453.18 XXX 72157 MRI SPI CANAL&CNTS C-/C+ 1660.78 XXX 72157 26 MRI SPI CANAL&CNTS C-/C+ 312.22 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
Section VIII: Diagnostic and Therapeutic Radiological Services Georgia Workers Compensation Medical Fee Schedule 70010 79999 RADIOLOGY Effective April 1, 2011 Medical Fee Schedule 72157 TC MRI SPI CANAL&CNTS C-/C+ 1348.56 XXX 72158 MRI SPI CANAL&CNTS C-/C+ LMBR 1737.39 XXX 72158 26 MRI SPI CANAL&CNTS C-/C+ LMBR 287.51 XXX 72158 TC MRI SPI CANAL&CNTS C-/C+ LMBR 1449.88 XXX 72159 MRA SPI CANAL&CNTS C+-MATRL 1491.90 XXX 72159 26 MRA SPI CANAL&CNTS C+-MATRL 218.31 XXX 72159 TC MRA SPI CANAL&CNTS C+-MATRL 1273.59 XXX 72170 RADEX PELVIS 1/2 VIEWS 66.73 XXX 72170 26 RADEX PELVIS 1/2 VIEWS 23.07 XXX 72170 TC RADEX PELVIS 1/2 VIEWS 43.66 XXX 72190 RADEX PELVIS COMPL MINIMUM 3 VIEWS 102.98 XXX 72190 26 RADEX PELVIS COMPL MINIMUM 3 VIEWS 28.01 XXX 72190 TC RADEX PELVIS COMPL MINIMUM 3 VIEWS 74.97 XXX 72191 CT ANGIOGRAPHY PELVIS W/CONTRAST/NONCONTRAST 1108.83 XXX 72191 26 CT ANGIOGRAPHY PELVIS W/CONTRAST/NONCONTRAST 220.78 XXX 72191 TC CT ANGIOGRAPHY PELVIS W/CONTRAST/NONCONTRAST 888.05 XXX 72192 CT PELVIS C-MATRL 591.49 XXX 72192 26 CT PELVIS C-MATRL 130.98 XXX 72192 TC CT PELVIS C-MATRL 460.51 XXX 72193 CT PELVIS C+ MATRL 716.71 XXX 72193 26 CT PELVIS C+ MATRL 140.87 XXX 72193 TC CT PELVIS C+ MATRL 575.84 XXX 72194 CT PELVIS C-/C+ 917.71 XXX 72194 26 CT PELVIS C-/C+ 147.46 XXX 72194 TC CT PELVIS C-/C+ 770.25 XXX 72195 MRI PELVIS C-MATRL 1252.18 XXX 72195 26 MRI PELVIS C-MATRL 177.94 XXX 72195 TC MRI PELVIS C-MATRL 1074.24 XXX 72196 MRI PELVIS C+ MATRL 1386.46 XXX 72196 26 MRI PELVIS C+ MATRL 210.07 XXX 72196 TC MRI PELVIS C+ MATRL 1176.39 XXX 72197 MRI PELVIS C-/C+ 1806.59 XXX 72197 26 MRI PELVIS C-/C+ 272.68 XXX 72197 TC MRI PELVIS C-/C+ 1533.91 XXX 72198 MRA PELVIS C+-MATRL 1344.44 XXX 72198 26 MRA PELVIS C+-MATRL 217.48 XXX 72198 TC MRA PELVIS C+-MATRL 1126.96 XXX 72200 RADEX SI JTS < 3 VIEWS 72.49 XXX 72200 26 RADEX SI JTS < 3 VIEWS 20.60 XXX 72200 TC RADEX SI JTS < 3 VIEWS 51.89 XXX 72202 RADEX SI JTS 3/MORE VIEWS 84.85 XXX 72202 26 RADEX SI JTS 3/MORE VIEWS 23.07 XXX 72202 TC RADEX SI JTS 3/MORE VIEWS 61.78 XXX 72220 RADEX SACRUM&COCCYX MINIMUM 2 VIEWS 71.67 XXX 72220 26 RADEX SACRUM&COCCYX MINIMUM 2 VIEWS 20.60 XXX 72220 TC RADEX SACRUM&COCCYX MINIMUM 2 VIEWS 51.07 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
Georgia Workers Compensation Medical Fee Schedule Section VIII: Diagnostic and Therapeutic Radiological Services RADIOLOGY 70010 79999 Medical Fee Schedule Effective April 1, 2011 72240 MYELOGRAPY CRV RS&I 352.59 XXX 72240 26 MYELOGRAPY CRV RS&I 110.39 XXX 72240 TC MYELOGRAPY CRV RS&I 242.20 XXX 72255 MYELOGRAPY THRC RS&I 331.17 XXX 72255 26 MYELOGRAPY THRC RS&I 108.74 XXX 72255 TC MYELOGRAPY THRC RS&I 222.43 XXX 72265 MYELOGRAPY LUMBOSAC RS&I 336.11 XXX 72265 26 MYELOGRAPY LUMBOSAC RS&I 100.50 XXX 72265 TC MYELOGRAPY LUMBOSAC RS&I 235.61 XXX 72270 MYELOGRAPY 2/MORE REGIONS RS&I 523.11 XXX 72270 26 MYELOGRAPY 2/MORE REGIONS RS&I 160.64 XXX 72270 TC MYELOGRAPY 2/MORE REGIONS RS&I 362.47 XXX 72275 EPIDUROGRAPY RS&I 271.85 XXX 72275 26 EPIDUROGRAPY RS&I 92.27 XXX 72275 TC EPIDUROGRAPY RS&I 179.58 XXX 72285 DISKOGRAPY CRV/THRC RS&I 359.18 XXX 72285 26 DISKOGRAPY CRV/THRC RS&I 141.69 XXX 72285 TC DISKOGRAPY CRV/THRC RS&I 217.49 XXX 72291 RAD S&I PERQ VRTPLS/SACRPLSTY PR VRT BODY FLUOR 766.13 XXX 72291 26 RAD S&I PERQ VRTPLS/SACRPLSTY PR VRT BODY FLUOR 176.29 XXX 72291 TC RAD S&I PERQ VRTPLS/SACRPLSTY PR VRT BODY FLUOR 589.84 XXX 72292 RAD S&I PERQ VRTPLS/SACRPLSTY PER VRT BODY CT 788.38 XXX 72292 26 RAD S&I PERQ VRTPLS/SACRPLSTY PER VRT BODY CT 181.24 XXX 72292 TC RAD S&I PERQ VRTPLS/SACRPLSTY PER VRT BODY CT 607.14 XXX 72295 DISKOGRAPY LMBR RS&I 316.34 XXX 72295 26 DISKOGRAPY LMBR RS&I 102.15 XXX 72295 TC DISKOGRAPY LMBR RS&I 214.19 XXX 73000 RADEX CLAV COMPL 70.02 XXX 73000 26 RADEX CLAV COMPL 19.77 XXX 73000 TC RADEX CLAV COMPL 50.25 XXX 73010 RADEX SCAPULA COMPL 74.97 XXX 73010 26 RADEX SCAPULA COMPL 23.07 XXX 73010 TC RADEX SCAPULA COMPL 51.90 XXX 73020 RADEX SHO 1 VIEW 57.67 XXX 73020 26 RADEX SHO 1 VIEW 18.12 XXX 73020 TC RADEX SHO 1 VIEW 39.55 XXX 73030 RADEX SHO COMPL MINIMUM 2 VIEWS 75.79 XXX 73030 26 RADEX SHO COMPL MINIMUM 2 VIEWS 24.71 XXX 73030 TC RADEX SHO COMPL MINIMUM 2 VIEWS 51.08 XXX 73040 RADEX SHO ARTHG RS&I 262.79 XXX 73040 26 RADEX SHO ARTHG RS&I 66.73 XXX 73040 TC RADEX SHO ARTHG RS&I 196.06 XXX 73050 RADEX ACROMCLAV JTS BI +-W8ED DISTRCJ 93.91 XXX 73050 26 RADEX ACROMCLAV JTS BI +-W8ED DISTRCJ 27.19 XXX 73050 TC RADEX ACROMCLAV JTS BI +-W8ED DISTRCJ 66.72 XXX 73060 RADEX HUM MINIMUM 2 VIEWS 71.67 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
Section VIII: Diagnostic and Therapeutic Radiological Services Georgia Workers Compensation Medical Fee Schedule 70010 79999 RADIOLOGY Effective April 1, 2011 Medical Fee Schedule 73060 26 RADEX HUM MINIMUM 2 VIEWS 21.42 XXX 73060 TC RADEX HUM MINIMUM 2 VIEWS 50.25 XXX 73070 RADEX ELBW 2 VIEWS 69.20 XXX 73070 26 RADEX ELBW 2 VIEWS 18.95 XXX 73070 TC RADEX ELBW 2 VIEWS 50.25 XXX 73080 RADEX ELBW COMPL MINIMUM 3 VIEWS 83.20 XXX 73080 26 RADEX ELBW COMPL MINIMUM 3 VIEWS 20.60 XXX 73080 TC RADEX ELBW COMPL MINIMUM 3 VIEWS 62.60 XXX 73085 RADEX ELBW ARTHG RS&I 238.08 XXX 73085 26 RADEX ELBW ARTHG RS&I 66.73 XXX 73085 TC RADEX ELBW ARTHG RS&I 171.35 XXX 73090 RADEX F/ARM 2 VIEWS 68.38 XXX 73090 26 RADEX F/ARM 2 VIEWS 19.77 XXX 73090 TC RADEX F/ARM 2 VIEWS 48.61 XXX 73092 RADEX UXTR INFT MINIMUM 2 VIEWS 74.97 XXX 73092 26 RADEX UXTR INFT MINIMUM 2 VIEWS 19.77 XXX 73092 TC RADEX UXTR INFT MINIMUM 2 VIEWS 55.20 XXX 73100 RADEX WRST 2 VIEWS 75.79 XXX 73100 26 RADEX WRST 2 VIEWS 22.24 XXX 73100 TC RADEX WRST 2 VIEWS 53.55 XXX 73110 RADEX WRST COMPL MINIMUM 3 VIEWS 88.97 XXX 73110 26 RADEX WRST COMPL MINIMUM 3 VIEWS 21.42 XXX 73110 TC RADEX WRST COMPL MINIMUM 3 VIEWS 67.55 XXX 73115 RADEX WRST ARTHG RS&I 266.09 XXX 73115 26 RADEX WRST ARTHG RS&I 68.38 XXX 73115 TC RADEX WRST ARTHG RS&I 197.71 XXX 73120 RADEX HAND 2 VIEWS 67.55 XXX 73120 26 RADEX HAND 2 VIEWS 19.77 XXX 73120 TC RADEX HAND 2 VIEWS 47.78 XXX 73130 RADEX HAND MINIMUM 3 VIEWS 78.26 XXX 73130 26 RADEX HAND MINIMUM 3 VIEWS 20.60 XXX 73130 TC RADEX HAND MINIMUM 3 VIEWS 57.66 XXX 73140 RADEX FNGR MINIMUM 2 VIEWS 76.61 XXX 73140 26 RADEX FNGR MINIMUM 2 VIEWS 16.48 XXX 73140 TC RADEX FNGR MINIMUM 2 VIEWS 60.13 XXX 73200 CT UXTR C-MATRL 597.26 XXX 73200 26 CT UXTR C-MATRL 123.57 XXX 73200 TC CT UXTR C-MATRL 473.69 XXX 73201 CT UXTR C+ MATRL 729.06 XXX 73201 26 CT UXTR C+ MATRL 140.87 XXX 73201 TC CT UXTR C+ MATRL 588.19 XXX 73202 CT UXTR C-/C+ 932.54 XXX 73202 26 CT UXTR C-/C+ 147.46 XXX 73202 TC CT UXTR C-/C+ 785.08 XXX 73206 CT ANGIOGRAPHY UPPER EXTREMITY 1056.94 XXX 73206 26 CT ANGIOGRAPHY UPPER EXTREMITY 218.31 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
Georgia Workers Compensation Medical Fee Schedule Section VIII: Diagnostic and Therapeutic Radiological Services RADIOLOGY 70010 79999 Medical Fee Schedule Effective April 1, 2011 73206 TC CT ANGIOGRAPHY UPPER EXTREMITY 838.63 XXX 73218 MRI UXTR OTH/THN JT C-MATRL 1259.59 XXX 73218 26 MRI UXTR OTH/THN JT C-MATRL 163.11 XXX 73218 TC MRI UXTR OTH/THN JT C-MATRL 1096.48 XXX 73219 MRI UXTR OTH/THN JT C+ MATRL 1363.39 XXX 73219 26 MRI UXTR OTH/THN JT C+ MATRL 196.89 XXX 73219 TC MRI UXTR OTH/THN JT C+ MATRL 1166.50 XXX 73220 MRI UXTR OTH/THN JT C-/C+ 1800.83 XXX 73220 26 MRI UXTR OTH/THN JT C-/C+ 260.32 XXX 73220 TC MRI UXTR OTH/THN JT C-/C+ 1540.51 XXX 73221 MRI ANY JT UXTR C-MATRL 1187.10 XXX 73221 26 MRI ANY JT UXTR C-MATRL 166.41 XXX 73221 TC MRI ANY JT UXTR C-MATRL 1020.69 XXX 73222 MRI ANY JT UXTR C+ MATRL 1293.37 XXX 73222 26 MRI ANY JT UXTR C+ MATRL 196.89 XXX 73222 TC MRI ANY JT UXTR C+ MATRL 1096.48 XXX 73223 MRI ANY JT UXTR C-/C+ 1709.39 XXX 73223 26 MRI ANY JT UXTR C-/C+ 259.50 XXX 73223 TC MRI ANY JT UXTR C-/C+ 1449.89 XXX 73225 MRA UXTR C+-MATRL 1468.01 XXX 73225 26 MRA UXTR C+-MATRL 210.07 XXX 73225 TC MRA UXTR C+-MATRL 1257.94 XXX 73500 RADEX HIP UNI 1 VIEW 65.90 XXX 73500 26 RADEX HIP UNI 1 VIEW 23.07 XXX 73500 TC RADEX HIP UNI 1 VIEW 42.83 XXX 73510 RADEX HIP UNI COMPL MINIMUM 2 VIEWS 94.74 XXX 73510 26 RADEX HIP UNI COMPL MINIMUM 2 VIEWS 28.01 XXX 73510 TC RADEX HIP UNI COMPL MINIMUM 2 VIEWS 66.73 XXX 73520 RADEX HIPS BI 2 VIEWS ANTEROPOST PELVIS 99.68 XXX 73520 26 RADEX HIPS BI 2 VIEWS ANTEROPOST PELVIS 32.95 XXX 73520 TC RADEX HIPS BI 2 VIEWS ANTEROPOST PELVIS 66.73 XXX 73525 RADEX HIP ARTHG RS&I 244.67 XXX 73525 26 RADEX HIP ARTHG RS&I 68.38 XXX 73525 TC RADEX HIP ARTHG RS&I 176.29 XXX 73530 RADEX HIP OPRATIVE PX 84.03 XXX 73530 26 RADEX HIP OPRATIVE PX 36.25 XXX 73530 TC RADEX HIP OPRATIVE PX 47.78 XXX 73540 RADEX PELVIS&HIPS INFT/CHLD MINIMUM 2 VIEWS 99.68 XXX 73540 26 RADEX PELVIS&HIPS INFT/CHLD MINIMUM 2 VIEWS 26.36 XXX 73540 TC RADEX PELVIS&HIPS INFT/CHLD MINIMUM 2 VIEWS 73.32 XXX 73542 RAD XM SI JT ARTHG RS&I 201.01 XXX 73542 26 RAD XM SI JT ARTHG RS&I 71.67 XXX 73542 TC RAD XM SI JT ARTHG RS&I 129.34 XXX 73550 RADEX FEMUR 2 VIEWS 70.02 XXX 73550 26 RADEX FEMUR 2 VIEWS 22.24 XXX 73550 TC RADEX FEMUR 2 VIEWS 47.78 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
Section VIII: Diagnostic and Therapeutic Radiological Services Georgia Workers Compensation Medical Fee Schedule 70010 79999 RADIOLOGY Effective April 1, 2011 Medical Fee Schedule 73560 RADEX KNE 1/2 VIEWS 74.97 XXX 73560 26 RADEX KNE 1/2 VIEWS 23.07 XXX 73560 TC RADEX KNE 1/2 VIEWS 51.90 XXX 73562 RADEX KNE 3 VIEWS 89.79 XXX 73562 26 RADEX KNE 3 VIEWS 24.71 XXX 73562 TC RADEX KNE 3 VIEWS 65.08 XXX 73564 RADEX KNE COMPL 4/MORE VIEWS 102.98 XXX 73564 26 RADEX KNE COMPL 4/MORE VIEWS 28.83 XXX 73564 TC RADEX KNE COMPL 4/MORE VIEWS 74.15 XXX 73565 RADEX KNE BTH KNES STANDING ANTEROPOST 83.20 XXX 73565 26 RADEX KNE BTH KNES STANDING ANTEROPOST 23.89 XXX 73565 TC RADEX KNE BTH KNES STANDING ANTEROPOST 59.31 XXX 73580 RADEX KNE ARTHG RS&I 321.28 XXX 73580 26 RADEX KNE ARTHG RS&I 70.85 XXX 73580 TC RADEX KNE ARTHG RS&I 250.43 XXX 73590 RADEX TIBFIB 2 VIEWS 67.55 XXX 73590 26 RADEX TIBFIB 2 VIEWS 20.60 XXX 73590 TC RADEX TIBFIB 2 VIEWS 46.95 XXX 73592 RADEX LXTR INFT MINIMUM 2 VIEWS 75.79 XXX 73592 26 RADEX LXTR INFT MINIMUM 2 VIEWS 19.77 XXX 73592 TC RADEX LXTR INFT MINIMUM 2 VIEWS 56.02 XXX 73600 RADEX ANKLE 2 VIEWS 69.20 XXX 73600 26 RADEX ANKLE 2 VIEWS 19.77 XXX 73600 TC RADEX ANKLE 2 VIEWS 49.43 XXX 73610 RADEX ANKLE COMPL MINIMUM 3 VIEWS 79.08 XXX 73610 26 RADEX ANKLE COMPL MINIMUM 3 VIEWS 20.60 XXX 73610 TC RADEX ANKLE COMPL MINIMUM 3 VIEWS 58.48 XXX 73615 RADEX ANKLE ARTHG RS&I 253.73 XXX 73615 26 RADEX ANKLE ARTHG RS&I 68.38 XXX 73615 TC RADEX ANKLE ARTHG RS&I 185.35 XXX 73620 RADEX FOOT 2 VIEWS 66.73 XXX 73620 26 RADEX FOOT 2 VIEWS 18.95 XXX 73620 TC RADEX FOOT 2 VIEWS 47.78 XXX 73630 RADEX FOOT COMPL MINIMUM 3 VIEWS 77.44 XXX 73630 26 RADEX FOOT COMPL MINIMUM 3 VIEWS 20.60 XXX 73630 TC RADEX FOOT COMPL MINIMUM 3 VIEWS 56.84 XXX 73650 RADEX CALCANEUS MINIMUM 2 VIEWS 68.38 XXX 73650 26 RADEX CALCANEUS MINIMUM 2 VIEWS 19.77 XXX 73650 TC RADEX CALCANEUS MINIMUM 2 VIEWS 48.61 XXX 73660 RADEX TOE MINIMUM 2 VIEWS 71.67 XXX 73660 26 RADEX TOE MINIMUM 2 VIEWS 15.65 XXX 73660 TC RADEX TOE MINIMUM 2 VIEWS 56.02 XXX 73700 CT LXTR C-MATRL 598.08 XXX 73700 26 CT LXTR C-MATRL 123.57 XXX 73700 TC CT LXTR C-MATRL 474.51 XXX 73701 CT LXTR C+ MATRL 735.65 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
Georgia Workers Compensation Medical Fee Schedule Section VIII: Diagnostic and Therapeutic Radiological Services RADIOLOGY 70010 79999 Medical Fee Schedule Effective April 1, 2011 73701 26 CT LXTR C+ MATRL 140.87 XXX 73701 TC CT LXTR C+ MATRL 594.78 XXX 73702 CT LXTR C-/C+ 937.48 XXX 73702 26 CT LXTR C-/C+ 148.28 XXX 73702 TC CT LXTR C-/C+ 789.20 XXX 73706 CT ANGIOGRAPHY LOWER EXTREMITY 1163.21 XXX 73706 26 CT ANGIOGRAPHY LOWER EXTREMITY 231.49 XXX 73706 TC CT ANGIOGRAPHY LOWER EXTREMITY 931.72 XXX 73718 MRI LXTR OTH/THN JT C-MATRL 1234.05 XXX 73718 26 MRI LXTR OTH/THN JT C-MATRL 163.11 XXX 73718 TC MRI LXTR OTH/THN JT C-MATRL 1070.94 XXX 73719 MRI IMG LXTR OTH/THN JT C+ MATRL 1359.27 XXX 73719 26 MRI IMG LXTR OTH/THN JT C+ MATRL 196.06 XXX 73719 TC MRI IMG LXTR OTH/THN JT C+ MATRL 1163.21 XXX 73720 MRI LXTR OTH/THN JT C-/C+ 1802.47 XXX 73720 26 MRI LXTR OTH/THN JT C-/C+ 259.50 XXX 73720 TC MRI LXTR OTH/THN JT C-/C+ 1542.97 XXX 73721 MRI ANY JT LXTR C-MATRL 1209.34 XXX 73721 26 MRI ANY JT LXTR C-MATRL 165.58 XXX 73721 TC MRI ANY JT LXTR C-MATRL 1043.76 XXX 73722 MRI ANY JT LXTR C+ MATRL 1314.78 XXX 73722 26 MRI ANY JT LXTR C+ MATRL 198.54 XXX 73722 TC MRI ANY JT LXTR C+ MATRL 1116.24 XXX 73723 MRI ANY JT LXTR C-/C+ 1706.09 XXX 73723 26 MRI ANY JT LXTR C-/C+ 259.50 XXX 73723 TC MRI ANY JT LXTR C-/C+ 1446.59 XXX 73725 MRA LXTR C+-MATRL 1347.74 XXX 73725 26 MRA LXTR C+-MATRL 219.95 XXX 73725 TC MRA LXTR C+-MATRL 1127.79 XXX 74000 RADEX ABD 1 ANTEROPOST VIEW 60.96 XXX 74000 26 RADEX ABD 1 ANTEROPOST VIEW 21.42 XXX 74000 TC RADEX ABD 1 ANTEROPOST VIEW 39.54 XXX 74010 RADEX ABD ANTEROPOST&ADDL OBLQ&CONE VIEWS 93.09 XXX 74010 26 RADEX ABD ANTEROPOST&ADDL OBLQ&CONE VIEWS 27.19 XXX 74010 TC RADEX ABD ANTEROPOST&ADDL OBLQ&CONE VIEWS 65.90 XXX 74020 RADEX ABD COMPL W/DCBTS&/ERC VIEWS 98.03 XXX 74020 26 RADEX ABD COMPL W/DCBTS&/ERC VIEWS 32.13 XXX 74020 TC RADEX ABD COMPL W/DCBTS&/ERC VIEWS 65.90 XXX 74022 RADEX ABD COMPL AQT ABD W/S/E/D VIEWS 1 VIEW CH 117.80 XXX 74022 26 RADEX ABD COMPL AQT ABD W/S/E/D VIEWS 1 VIEW CH 37.89 XXX 74022 TC RADEX ABD COMPL AQT ABD W/S/E/D VIEWS 1 VIEW CH 79.91 XXX 74150 CT ABD C-MATRL 601.37 XXX 74150 26 CT ABD C-MATRL 144.17 XXX 74150 TC CT ABD C-MATRL 457.20 XXX 74160 CT ABD C+ MATRL 813.09 XXX 74160 26 CT ABD C+ MATRL 154.05 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
Section VIII: Diagnostic and Therapeutic Radiological Services Georgia Workers Compensation Medical Fee Schedule 70010 79999 RADIOLOGY Effective April 1, 2011 Medical Fee Schedule 74160 TC CT ABD C+ MATRL 659.04 XXX 74170 CT ABD C-/C+ 1074.24 XXX 74170 26 CT ABD C-/C+ 169.70 XXX 74170 TC CT ABD C-/C+ 904.54 XXX 74175 CT ANGIOGRAPHY ABDOMEN W/CONTRAST/NONCONTRAST 1177.21 XXX 74175 26 CT ANGIOGRAPHY ABDOMEN W/CONTRAST/NONCONTRAST 231.49 XXX 74175 TC CT ANGIOGRAPHY ABDOMEN W/CONTRAST/NONCONTRAST 945.72 XXX l 74176 CT ABD & PELVIS W/O CONTRAST 524.76 XXX l 74176 26 CT ABD & PELVIS W/O CONTRAST 205.13 XXX l 74176 TC CT ABD & PELVIS W/O CONTRAST 319.63 XXX l 74177 CT ABD & PELVIS W/CONTRAST 824.62 XXX l 74177 26 CT ABD & PELVIS W/CONTRAST 215.01 XXX l 74177 TC CT ABD & PELVIS W/CONTRAST 609.61 XXX l 74178 CT ABD & PELVIS W/O CONTRST 1+ BODY REGNS 1043.75 XXX l 74178 26 CT ABD & PELVIS W/O CONTRST 1+ BODY REGNS 238.08 XXX l 74178 TC CT ABD & PELVIS W/O CONTRST 1+ BODY REGNS 805.67 XXX 74181 MRI ABD C-MATRL 1120.37 XXX 74181 26 MRI ABD C-MATRL 176.29 XXX 74181 TC MRI ABD C-MATRL 944.08 XXX 74182 MRI ABD C+ MATRL 1515.79 XXX 74182 26 MRI ABD C+ MATRL 209.25 XXX 74182 TC MRI ABD C+ MATRL 1306.54 XXX 74183 MRI ABD C-/C+ 1809.06 XXX 74183 26 MRI ABD C-/C+ 271.85 XXX 74183 TC MRI ABD C-/C+ 1537.21 XXX 74185 MRA ABD C+-MATRL 1341.97 XXX 74185 26 MRA ABD C+-MATRL 217.48 XXX 74185 TC MRA ABD C+-MATRL 1124.49 XXX 74190 PRITONEOGRAM RS&I 148.28 XXX 74190 26 PRITONEOGRAM RS&I 59.31 XXX 74190 TC PRITONEOGRAM RS&I 88.97 XXX 74210 RADEX PHARYNX&/CRV ESOPH 191.12 XXX 74210 26 RADEX PHARYNX&/CRV ESOPH 42.84 XXX 74210 TC RADEX PHARYNX&/CRV ESOPH 148.28 XXX 74220 RADEX ESOPH 219.95 XXX 74220 26 RADEX ESOPH 56.02 XXX 74220 TC RADEX ESOPH 163.93 XXX 74230 SWLNG FUNCJ W/CINERADIOGRAPY/VIDRADIOGRAPY 223.25 XXX 74230 26 SWLNG FUNCJ W/CINERADIOGRAPY/VIDRADIOGRAPY 64.26 XXX 74230 TC SWLNG FUNCJ W/CINERADIOGRAPY/VIDRADIOGRAPY 158.99 XXX 74235 RMVL FB ESOPHGL W/USE BALO CATH RS&I 452.27 XXX 74235 26 RMVL FB ESOPHGL W/USE BALO CATH RS&I 158.17 XXX 74235 TC RMVL FB ESOPHGL W/USE BALO CATH RS&I 294.10 XXX 74240 RADEX GI TRC UPR +-DLYD FLMS W/O KUB 272.68 XXX 74240 26 RADEX GI TRC UPR +-DLYD FLMS W/O KUB 84.03 XXX 74240 TC RADEX GI TRC UPR +-DLYD FLMS W/O KUB 188.65 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
Georgia Workers Compensation Medical Fee Schedule Section VIII: Diagnostic and Therapeutic Radiological Services RADIOLOGY 70010 79999 Medical Fee Schedule Effective April 1, 2011 74241 RADEX GI TRC UPR +-DLYD FLMS W/KUB 289.15 XXX 74241 26 RADEX GI TRC UPR +-DLYD FLMS W/KUB 82.38 XXX 74241 TC RADEX GI TRC UPR +-DLYD FLMS W/KUB 206.77 XXX 74245 RADEX GI TRC UPR W/SM INT W/MLT SRL FLMS 431.67 XXX 74245 26 RADEX GI TRC UPR W/SM INT W/MLT SRL FLMS 110.39 XXX 74245 TC RADEX GI TRC UPR W/SM INT W/MLT SRL FLMS 321.28 XXX 74246 RADEX GI UPR C+ +-GLUC/DLYD FLMS W/O KUB 309.75 XXX 74246 26 RADEX GI UPR C+ +-GLUC/DLYD FLMS W/O KUB 84.03 XXX 74246 TC RADEX GI UPR C+ +-GLUC/DLYD FLMS W/O KUB 225.72 XXX 74247 RADEX GI UPR C+ +-GLUC +-DLYD FLMS W/KUB 344.35 XXX 74247 26 RADEX GI UPR C+ +-GLUC +-DLYD FLMS W/KUB 84.03 XXX 74247 TC RADEX GI UPR C+ +-GLUC +-DLYD FLMS W/KUB 260.32 XXX 74249 RADEX GI UPR C+ +-GLUC W/SM INT FOLLW-THRU 465.45 XXX 74249 26 RADEX GI UPR C+ +-GLUC W/SM INT FOLLW-THRU 110.39 XXX 74249 TC RADEX GI UPR C+ +-GLUC W/SM INT FOLLW-THRU 355.06 XXX 74250 RADEX SM INT W/MLT SRL FLMS 259.50 XXX 74250 26 RADEX SM INT W/MLT SRL FLMS 56.84 XXX 74250 TC RADEX SM INT W/MLT SRL FLMS 202.66 XXX 74251 RADEX SM INT W/MLT SRL FLMS VIA ENTEROCLSS TUBE 891.35 XXX 74251 26 RADEX SM INT W/MLT SRL FLMS VIA ENTEROCLSS TUBE 84.03 XXX 74251 TC RADEX SM INT W/MLT SRL FLMS VIA ENTEROCLSS TUBE 807.32 XXX 74260 DUODENOGRAPY HYPOTONIC 735.65 XXX 74260 26 DUODENOGRAPY HYPOTONIC 60.14 XXX 74260 TC DUODENOGRAPY HYPOTONIC 675.51 XXX 74261 CT COLONOGRPHY DX IMAGE POSTPROCESS NO CONTRAST 1254.65 XXX 74261 26 CT COLONOGRPHY DX IMAGE POSTPROCESS NO CONTRAST 281.74 XXX 74261 TC CT COLONOGRPHY DX IMAGE POSTPROCESS NO CONTRAST 972.91 XXX 74262 CT COLONOGRPHY DX IMAGE POSTPROCESS W/CONTRAST 1393.87 XXX 74262 26 CT COLONOGRPHY DX IMAGE POSTPROCESS W/CONTRAST 294.92 XXX 74262 TC CT COLONOGRPHY DX IMAGE POSTPROCESS W/CONTRAST 1098.95 XXX 74263 CT COLONOGRAPHY SCREENING IMAGE POSTPROCESSING 1853.55 XXX 74263 26 CT COLONOGRAPHY SCREENING IMAGE POSTPROCESSING 280.09 XXX 74263 TC CT COLONOGRAPHY SCREENING IMAGE POSTPROCESSING 1573.46 XXX 74270 RADEX COLON BARIUM ENEMA +-KUB 373.18 XXX 74270 26 RADEX COLON BARIUM ENEMA +-KUB 84.03 XXX 74270 TC RADEX COLON BARIUM ENEMA +-KUB 289.15 XXX 74280 RADEX COLON C+ W/SPEC HI DNS BARIUM +-GLUC 517.35 XXX 74280 26 RADEX COLON C+ W/SPEC HI DNS BARIUM +-GLUC 119.45 XXX 74280 TC RADEX COLON C+ W/SPEC HI DNS BARIUM +-GLUC 397.90 XXX 74283 THER ENEMA C+ RDCTJ INTUSSUSCEPTION/OBSTRCJ 499.22 XXX 74283 26 THER ENEMA C+ RDCTJ INTUSSUSCEPTION/OBSTRCJ 239.73 XXX 74283 TC THER ENEMA C+ RDCTJ INTUSSUSCEPTION/OBSTRCJ 259.49 XXX 74290 CCG ORAL CNTRST 166.41 XXX 74290 26 CCG ORAL CNTRST 37.89 XXX 74290 TC CCG ORAL CNTRST 128.52 XXX 74291 CCG ORAL CNTRST ADDL/REPEAT XM/MLT D XM 155.70 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
Section VIII: Diagnostic and Therapeutic Radiological Services Georgia Workers Compensation Medical Fee Schedule 70010 79999 RADIOLOGY Effective April 1, 2011 Medical Fee Schedule 74291 26 CCG ORAL CNTRST ADDL/REPEAT XM/MLT D XM 23.89 XXX 74291 TC CCG ORAL CNTRST ADDL/REPEAT XM/MLT D XM 131.81 XXX 74300 CHOLANGRPH&/PCG INTRAOP RS&I 126.87 XXX 74300 26 CHOLANGRPH&/PCG INTRAOP RS&I 44.49 XXX 74300 TC CHOLANGRPH&/PCG INTRAOP RS&I 82.38 XXX + 74301 CHOLANGRPH&/PCG ADDL SET INTRAOP RS&I 77.44 ZZZ + 74301 26 CHOLANGRPH&/PCG ADDL SET INTRAOP RS&I 27.19 ZZZ + 74301 TC CHOLANGRPH&/PCG ADDL SET INTRAOP RS&I 50.25 ZZZ 74305 CHOLANGRPH&/PCG THRU CATH RS&I 148.28 XXX 74305 26 CHOLANGRPH&/PCG THRU CATH RS&I 51.90 XXX 74305 TC CHOLANGRPH&/PCG THRU CATH RS&I 96.38 XXX 74320 CHOLANGRPH PRQ TRANSHEPATC RS&I 263.62 XXX 74320 26 CHOLANGRPH PRQ TRANSHEPATC RS&I 65.90 XXX 74320 TC CHOLANGRPH PRQ TRANSHEPATC RS&I 197.72 XXX 74327 PO BILIARY ST1 RMVL PRQ RS&I 336.11 XXX 74327 26 PO BILIARY ST1 RMVL PRQ RS&I 91.44 XXX 74327 TC PO BILIARY ST1 RMVL PRQ RS&I 244.67 XXX 74328 NDSC CATHJ BILIARY DUX SYS RS&I 290.80 XXX 74328 26 NDSC CATHJ BILIARY DUX SYS RS&I 87.32 XXX 74328 TC NDSC CATHJ BILIARY DUX SYS RS&I 203.48 XXX 74329 NDSC CATHJ PNCRTC DUX SYS RS&I 249.61 XXX 74329 26 NDSC CATHJ PNCRTC DUX SYS RS&I 87.32 XXX 74329 TC NDSC CATHJ PNCRTC DUX SYS RS&I 162.29 XXX 74330 CMBN NDSC CATHJ BILIARY&PNCRTC DUX SYSS RS&I 415.20 XXX 74330 26 CMBN NDSC CATHJ BILIARY&PNCRTC DUX SYSS RS&I 112.04 XXX 74330 TC CMBN NDSC CATHJ BILIARY&PNCRTC DUX SYSS RS&I 303.16 XXX 74340 INTRO LONG GI TUBE W/MLT FLUOR&FLMS RS&I 266.91 XXX 74340 26 INTRO LONG GI TUBE W/MLT FLUOR&FLMS RS&I 66.73 XXX 74340 TC INTRO LONG GI TUBE W/MLT FLUOR&FLMS RS&I 200.18 XXX 74355 PRQ PLMT ENTEROCLSS TUBE RS&I 354.23 XXX 74355 26 PRQ PLMT ENTEROCLSS TUBE RS&I 95.56 XXX 74355 TC PRQ PLMT ENTEROCLSS TUBE RS&I 258.67 XXX 74360 INTRAL DILAT STRIXS&/OBSTRCJS RS&I 294.92 XXX 74360 26 INTRAL DILAT STRIXS&/OBSTRCJS RS&I 70.85 XXX 74360 TC INTRAL DILAT STRIXS&/OBSTRCJS RS&I 224.07 XXX 74363 PRQ TRANSHEPATC DILAT BILIARY DUX STRIX RS&I 313.04 XXX 74363 26 PRQ TRANSHEPATC DILAT BILIARY DUX STRIX RS&I 109.57 XXX 74363 TC PRQ TRANSHEPATC DILAT BILIARY DUX STRIX RS&I 203.47 XXX 74400 UROGRAPY PLOG IV +-KUB +-TOMOG 272.68 XXX 74400 26 UROGRAPY PLOG IV +-KUB +-TOMOG 59.31 XXX 74400 TC UROGRAPY PLOG IV +-KUB +-TOMOG 213.37 XXX 74410 UROGRAPY NFS DRIP TQ&/BOLUS TQ 280.92 XXX 74410 26 UROGRAPY NFS DRIP TQ&/BOLUS TQ 60.14 XXX 74410 TC UROGRAPY NFS DRIP TQ&/BOLUS TQ 220.78 XXX 74415 UROGRAPY NFS DRIP TQ&/BOLUS TQ W/NEPHROTOMOG 331.99 XXX 74415 26 UROGRAPY NFS DRIP TQ&/BOLUS TQ W/NEPHROTOMOG 59.31 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
Georgia Workers Compensation Medical Fee Schedule Section VIII: Diagnostic and Therapeutic Radiological Services RADIOLOGY 70010 79999 Medical Fee Schedule Effective April 1, 2011 74415 TC UROGRAPY NFS DRIP TQ&/BOLUS TQ W/NEPHROTOMOG 272.68 XXX 74420 X-RAY URINARY TRACT EXAM WITH CONTRAST MATERIAL 296.57 XXX 74420 26 X-RAY URINARY TRACT EXAM WITH CONTRAST MATERIAL 44.49 XXX 74420 TC X-RAY URINARY TRACT EXAM WITH CONTRAST MATERIAL 252.08 XXX 74425 UROGRAPY ANTEGRADE RS&I 164.76 XXX 74425 26 UROGRAPY ANTEGRADE RS&I 44.49 XXX 74425 TC UROGRAPY ANTEGRADE RS&I 120.27 XXX 74430 CSTOGRAPY MINIMUM 3 VIEWS RS&I 148.28 XXX 74430 26 CSTOGRAPY MINIMUM 3 VIEWS RS&I 37.89 XXX 74430 TC CSTOGRAPY MINIMUM 3 VIEWS RS&I 110.39 XXX 74440 VASOGRAPY VESICULOGRAPY/EPIDIDYMOGRAPY RS&I 210.89 XXX 74440 26 VASOGRAPY VESICULOGRAPY/EPIDIDYMOGRAPY RS&I 46.96 XXX 74440 TC VASOGRAPY VESICULOGRAPY/EPIDIDYMOGRAPY RS&I 163.93 XXX 74445 C/P/A CAVERNOSOGRAPY RS&I 251.26 XXX 74445 26 C/P/A CAVERNOSOGRAPY RS&I 143.34 XXX 74445 TC C/P/A CAVERNOSOGRAPY RS&I 107.92 XXX 74450 URETHROCSTOGRAPY RTRGR RS&I 178.76 XXX 74450 26 URETHROCSTOGRAPY RTRGR RS&I 41.19 XXX 74450 TC URETHROCSTOGRAPY RTRGR RS&I 137.57 XXX 74455 URETHROCSTOGRAPY VOIDING RS&I 218.31 XXX 74455 26 URETHROCSTOGRAPY VOIDING RS&I 39.54 XXX 74455 TC URETHROCSTOGRAPY VOIDING RS&I 178.77 XXX 74470 RADEX RNL CST STD TRANSLMBR C+ RS&I 185.36 XXX 74470 26 RADEX RNL CST STD TRANSLMBR C+ RS&I 66.73 XXX 74470 TC RADEX RNL CST STD TRANSLMBR C+ RS&I 118.63 XXX 74475 INTRO CATH IN RNL PELVIS DRG&/NJX PRQ RS&I 272.68 XXX 74475 26 INTRO CATH IN RNL PELVIS DRG&/NJX PRQ RS&I 65.90 XXX 74475 TC INTRO CATH IN RNL PELVIS DRG&/NJX PRQ RS&I 206.78 XXX 74480 INTRO URTRL CATH/STENT PRQ RS&I 273.50 XXX 74480 26 INTRO URTRL CATH/STENT PRQ RS&I 65.90 XXX 74480 TC INTRO URTRL CATH/STENT PRQ RS&I 207.60 XXX 74485 DILAT NFROS URTRS/URT RS&I 269.38 XXX 74485 26 DILAT NFROS URTRS/URT RS&I 65.90 XXX 74485 TC DILAT NFROS URTRS/URT RS&I 203.48 XXX 74710 PELVIMETRY +-PLACENTAL LOCLZJ 96.38 XXX 74710 26 PELVIMETRY +-PLACENTAL LOCLZJ 40.37 XXX 74710 TC PELVIMETRY +-PLACENTAL LOCLZJ 56.01 XXX 74740 HSG RS&I 192.77 XXX 74740 26 HSG RS&I 45.31 XXX 74740 TC HSG RS&I 147.46 XXX 74742 TRANSCRV CATHJ FLP TUBE RS&I 214.19 XXX 74742 26 TRANSCRV CATHJ FLP TUBE RS&I 74.97 XXX 74742 TC TRANSCRV CATHJ FLP TUBE RS&I 139.22 XXX 74775 PRINEOGRAM 212.54 XXX 74775 26 PRINEOGRAM 76.61 XXX 74775 TC PRINEOGRAM 135.93 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
Section VIII: Diagnostic and Therapeutic Radiological Services Georgia Workers Compensation Medical Fee Schedule 70010 79999 RADIOLOGY Effective April 1, 2011 Medical Fee Schedule 75557 CARDIAC MRI MORPHOLOGY & FUNCTION W/O CONTRAST 1089.06 XXX 75557 26 CARDIAC MRI MORPHOLOGY & FUNCTION W/O CONTRAST 288.33 XXX 75557 TC CARDIAC MRI MORPHOLOGY & FUNCTION W/O CONTRAST 800.73 XXX 75559 CARDIAC MRI W/O CONTRAST W STRESS IMAGING 1575.11 XXX 75559 26 CARDIAC MRI W/O CONTRAST W STRESS IMAGING 366.59 XXX 75559 TC CARDIAC MRI W/O CONTRAST W STRESS IMAGING 1208.52 XXX 75561 CARDIAC MRI W/W/O CONTRAST & FURTHER SEQ 1474.60 XXX 75561 26 CARDIAC MRI W/W/O CONTRAST & FURTHER SEQ 319.63 XXX 75561 TC CARDIAC MRI W/W/O CONTRAST & FURTHER SEQ 1154.97 XXX 75563 CARDIAC MRI W/W/O CONTRAST W STRESS 1795.06 XXX 75563 26 CARDIAC MRI W/W/O CONTRAST W STRESS 376.48 XXX 75563 TC CARDIAC MRI W/W/O CONTRAST W STRESS 1418.58 XXX + 75565 CARDIAC MRI FOR VELOCITY FLOW MAPPING 180.41 ZZZ + 75565 26 CARDIAC MRI FOR VELOCITY FLOW MAPPING 30.48 ZZZ + 75565 TC CARDIAC MRI FOR VELOCITY FLOW MAPPING 149.93 ZZZ 75571 CT HEART NO CONTRAST QUANT EVAL CORONRY CALCIUM 259.50 XXX 75571 26 CT HEART NO CONTRAST QUANT EVAL CORONRY CALCIUM 66.73 XXX 75571 TC CT HEART NO CONTRAST QUANT EVAL CORONRY CALCIUM 192.77 XXX 75572 CT HEART CONTRAST EVAL CARDIAC STRUCTURE&MORPH 710.94 XXX 75572 26 CT HEART CONTRAST EVAL CARDIAC STRUCTURE&MORPH 203.48 XXX 75572 TC CT HEART CONTRAST EVAL CARDIAC STRUCTURE&MORPH 507.46 XXX 75573 CT HRT CONTRST CARDIAC STRUCT&MORPH CONG HRT DX 967.14 XXX 75573 26 CT HRT CONTRST CARDIAC STRUCT&MORPH CONG HRT DX 298.22 XXX 75573 TC CT HRT CONTRST CARDIAC STRUCT&MORPH CONG HRT DX 668.92 XXX 75574 CTA HRT CORNRY ART/BYPASS GRFTS CONTRST 3D POST 1080.83 XXX 75574 26 CTA HRT CORNRY ART/BYPASS GRFTS CONTRST 3D POST 280.09 XXX 75574 TC CTA HRT CORNRY ART/BYPASS GRFTS CONTRST 3D POST 800.74 XXX 75600 AORTOGRAPY THRC W/O SRLOGRAPY RS&I 657.39 XXX 75600 26 AORTOGRAPY THRC W/O SRLOGRAPY RS&I 61.79 XXX 75600 TC AORTOGRAPY THRC W/O SRLOGRAPY RS&I 595.60 XXX 75605 AORTOGRAPY THRC SRLOGRAPY RS&I 523.11 XXX 75605 26 AORTOGRAPY THRC SRLOGRAPY RS&I 140.87 XXX 75605 TC AORTOGRAPY THRC SRLOGRAPY RS&I 382.24 XXX 75625 AORTOGRAPY ABDL SRLOGRAPY RS&I 523.94 XXX 75625 26 AORTOGRAPY ABDL SRLOGRAPY RS&I 140.87 XXX 75625 TC AORTOGRAPY ABDL SRLOGRAPY RS&I 383.07 XXX 75630 AORTOGRAPY ABDL BI ILIOFEM LXTR CATH RS&I 610.44 XXX 75630 26 AORTOGRAPY ABDL BI ILIOFEM LXTR CATH RS&I 218.31 XXX 75630 TC AORTOGRAPY ABDL BI ILIOFEM LXTR CATH RS&I 392.13 XXX 75635 CTA AA&BI ILIOFEM LXTR RS&I C-/C+ POST-PXESSING 1318.90 XXX 75635 26 CTA AA&BI ILIOFEM LXTR RS&I C-/C+ POST-PXESSING 292.45 XXX 75635 TC CTA AA&BI ILIOFEM LXTR RS&I C-/C+ POST-PXESSING 1026.45 XXX 75650 ANGRPH CERVICOCERE CATH W/VSL ORIGIN RS&I 568.42 XXX 75650 26 ANGRPH CERVICOCERE CATH W/VSL ORIGIN RS&I 182.88 XXX 75650 TC ANGRPH CERVICOCERE CATH W/VSL ORIGIN RS&I 385.54 XXX 75658 ANGRPH BRACH RTRGR RS&I 582.43 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
Georgia Workers Compensation Medical Fee Schedule Section VIII: Diagnostic and Therapeutic Radiological Services RADIOLOGY 70010 79999 Medical Fee Schedule Effective April 1, 2011 75658 26 ANGRPH BRACH RTRGR RS&I 156.52 XXX 75658 TC ANGRPH BRACH RTRGR RS&I 425.91 XXX 75660 ANGRPH XTRNL CRTD UNI SLCTV RS&I 590.66 XXX 75660 26 ANGRPH XTRNL CRTD UNI SLCTV RS&I 158.17 XXX 75660 TC ANGRPH XTRNL CRTD UNI SLCTV RS&I 432.49 XXX 75662 ANGRPH XTRNL CRTD BI SLCTV RS&I 702.70 XXX 75662 26 ANGRPH XTRNL CRTD BI SLCTV RS&I 205.13 XXX 75662 TC ANGRPH XTRNL CRTD BI SLCTV RS&I 497.57 XXX 75665 ANGRPH CRTD CERE UNI RS&I 616.20 XXX 75665 26 ANGRPH CRTD CERE UNI RS&I 163.94 XXX 75665 TC ANGRPH CRTD CERE UNI RS&I 452.26 XXX 75671 ANGRPH CRTD CERE BI RS&I 718.35 XXX 75671 26 ANGRPH CRTD CERE BI RS&I 204.30 XXX 75671 TC ANGRPH CRTD CERE BI RS&I 514.05 XXX 75676 ANGRPH CRTD CRV UNI RS&I 591.49 XXX 75676 26 ANGRPH CRTD CRV UNI RS&I 163.11 XXX 75676 TC ANGRPH CRTD CRV UNI RS&I 428.38 XXX 75680 ANGRPH CRTD CRV BI RS&I 669.75 XXX 75680 26 ANGRPH CRTD CRV BI RS&I 204.30 XXX 75680 TC ANGRPH CRTD CRV BI RS&I 465.45 XXX 75685 ANGRPH VRT CRV&/ICRA RS&I 593.96 XXX 75685 26 ANGRPH VRT CRV&/ICRA RS&I 161.46 XXX 75685 TC ANGRPH VRT CRV&/ICRA RS&I 432.50 XXX 75705 ANGRPH SPI SLCTV RS&I 691.99 XXX 75705 26 ANGRPH SPI SLCTV RS&I 262.79 XXX 75705 TC ANGRPH SPI SLCTV RS&I 429.20 XXX 75710 ANGRPH XTR UNI RS&I 567.60 XXX 75710 26 ANGRPH XTR UNI RS&I 136.75 XXX 75710 TC ANGRPH XTR UNI RS&I 430.85 XXX 75716 ANGRPH XTR BI RS&I 656.57 XXX 75716 26 ANGRPH XTR BI RS&I 160.64 XXX 75716 TC ANGRPH XTR BI RS&I 495.93 XXX 75722 ANGRPH RNL UNI SLCTV W/FLUSH AORTOGRAM RS&I 550.30 XXX 75722 26 ANGRPH RNL UNI SLCTV W/FLUSH AORTOGRAM RS&I 140.87 XXX 75722 TC ANGRPH RNL UNI SLCTV W/FLUSH AORTOGRAM RS&I 409.43 XXX 75724 ANGRPH RNL BI SLCTV W/FLUSH AORTOGRAM RS&I 652.45 XXX 75724 26 ANGRPH RNL BI SLCTV W/FLUSH AORTOGRAM RS&I 186.18 XXX 75724 TC ANGRPH RNL BI SLCTV W/FLUSH AORTOGRAM RS&I 466.27 XXX 75726 ANGRPH VISC SLCTV/SUPRASLCTV RS&I 563.48 XXX 75726 26 ANGRPH VISC SLCTV/SUPRASLCTV RS&I 139.22 XXX 75726 TC ANGRPH VISC SLCTV/SUPRASLCTV RS&I 424.26 XXX 75731 ANGRPH ADRNL UNI SLCTV RS&I 571.72 XXX 75731 26 ANGRPH ADRNL UNI SLCTV RS&I 140.87 XXX 75731 TC ANGRPH ADRNL UNI SLCTV RS&I 430.85 XXX 75733 ANGRPH ADRNL BI SLCTV RS&I 658.22 XXX 75733 26 ANGRPH ADRNL BI SLCTV RS&I 163.94 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
Section VIII: Diagnostic and Therapeutic Radiological Services Georgia Workers Compensation Medical Fee Schedule 70010 79999 RADIOLOGY Effective April 1, 2011 Medical Fee Schedule 75733 TC ANGRPH ADRNL BI SLCTV RS&I 494.28 XXX 75736 ANGRPH PEL SLCTV/SUPRASLCTV RS&I 561.01 XXX 75736 26 ANGRPH PEL SLCTV/SUPRASLCTV RS&I 137.57 XXX 75736 TC ANGRPH PEL SLCTV/SUPRASLCTV RS&I 423.44 XXX 75741 ANGRPH PULM UNI SLCTV RS&I 533.00 XXX 75741 26 ANGRPH PULM UNI SLCTV RS&I 159.82 XXX 75741 TC ANGRPH PULM UNI SLCTV RS&I 373.18 XXX 75743 ANGRPH PULM BI SLCTV RS&I 596.43 XXX 75743 26 ANGRPH PULM BI SLCTV RS&I 202.65 XXX 75743 TC ANGRPH PULM BI SLCTV RS&I 393.78 XXX 75746 ANGRPH PULM NONSLCTV CATH/VEN NJX RS&I 545.36 XXX 75746 26 ANGRPH PULM NONSLCTV CATH/VEN NJX RS&I 139.22 XXX 75746 TC ANGRPH PULM NONSLCTV CATH/VEN NJX RS&I 406.14 XXX 75756 ANGRPH INT MAM RS&I 588.19 XXX 75756 26 ANGRPH INT MAM RS&I 156.52 XXX 75756 TC ANGRPH INT MAM RS&I 431.67 XXX + 75774 ANGRPH SLCTV EA VSL STUDIED AFTER BASIC XM RS&I 387.19 ZZZ + 75774 26 ANGRPH SLCTV EA VSL STUDIED AFTER BASIC XM RS&I 44.49 ZZZ + 75774 TC ANGRPH SLCTV EA VSL STUDIED AFTER BASIC XM RS&I 342.70 ZZZ 75791 ANGIOGRPHY AV SHUNT COMPLETE EVAL FLUOR S&I 795.79 XXX 75791 26 ANGIOGRPHY AV SHUNT COMPLETE EVAL FLUOR S&I 200.18 XXX 75791 TC ANGIOGRPHY AV SHUNT COMPLETE EVAL FLUOR S&I 595.61 XXX 75801 LYMPHANGRPH XTR ONLY UNI RS&I 639.27 XXX 75801 26 LYMPHANGRPH XTR ONLY UNI RS&I 108.74 XXX 75801 TC LYMPHANGRPH XTR ONLY UNI RS&I 530.53 XXX 75803 LYMPHANGRPH XTR ONLY BI RS&I 659.04 XXX 75803 26 LYMPHANGRPH XTR ONLY BI RS&I 144.99 XXX 75803 TC LYMPHANGRPH XTR ONLY BI RS&I 514.05 XXX 75805 LYMPHANGRPH PEL/ABDL UNI RS&I 669.75 XXX 75805 26 LYMPHANGRPH PEL/ABDL UNI RS&I 100.50 XXX 75805 TC LYMPHANGRPH PEL/ABDL UNI RS&I 569.25 XXX 75807 LYMPHANGRPH PEL/ABDL BI RS&I 729.06 XXX 75807 26 LYMPHANGRPH PEL/ABDL BI RS&I 145.81 XXX 75807 TC LYMPHANGRPH PEL/ABDL BI RS&I 583.25 XXX 75809 SHUNTOGRAM NDWELLG NONVASC SHUNT RS&I 238.08 XXX 75809 26 SHUNTOGRAM NDWELLG NONVASC SHUNT RS&I 57.67 XXX 75809 TC SHUNTOGRAM NDWELLG NONVASC SHUNT RS&I 180.41 XXX 75810 SPLENOPORTOGRAPY RS&I 1295.84 XXX 75810 26 SPLENOPORTOGRAPY RS&I 142.52 XXX 75810 TC SPLENOPORTOGRAPY RS&I 1153.32 XXX 75820 VNGRPH XTR UNI RS&I 305.63 XXX 75820 26 VNGRPH XTR UNI RS&I 85.68 XXX 75820 TC VNGRPH XTR UNI RS&I 219.95 XXX 75822 VNGRPH XTR BI RS&I 374.83 XXX 75822 26 VNGRPH XTR BI RS&I 128.51 XXX 75822 TC VNGRPH XTR BI RS&I 246.32 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
Georgia Workers Compensation Medical Fee Schedule Section VIII: Diagnostic and Therapeutic Radiological Services RADIOLOGY 70010 79999 Medical Fee Schedule Effective April 1, 2011 75825 VNGRPH CAVAL INF SRLOGRAPY RS&I 501.69 XXX 75825 26 VNGRPH CAVAL INF SRLOGRAPY RS&I 137.57 XXX 75825 TC VNGRPH CAVAL INF SRLOGRAPY RS&I 364.12 XXX 75827 VNGRPH CAVAL SUPRIOR SRLOGRAPY RS&I 507.46 XXX 75827 26 VNGRPH CAVAL SUPRIOR SRLOGRAPY RS&I 135.93 XXX 75827 TC VNGRPH CAVAL SUPRIOR SRLOGRAPY RS&I 371.53 XXX 75831 VNGRPH RNL UNI SLCTV RS&I 523.94 XXX 75831 26 VNGRPH RNL UNI SLCTV RS&I 151.58 XXX 75831 TC VNGRPH RNL UNI SLCTV RS&I 372.36 XXX 75833 VNGRPH RNL BI SLCTV RS&I 588.19 XXX 75833 26 VNGRPH RNL BI SLCTV RS&I 176.29 XXX 75833 TC VNGRPH RNL BI SLCTV RS&I 411.90 XXX 75840 VNGRPH ADRNL UNI SLCTV RS&I 514.05 XXX 75840 26 VNGRPH ADRNL UNI SLCTV RS&I 149.11 XXX 75840 TC VNGRPH ADRNL UNI SLCTV RS&I 364.94 XXX 75842 VNGRPH ADRNL BI SLCTV RS&I 589.84 XXX 75842 26 VNGRPH ADRNL BI SLCTV RS&I 180.41 XXX 75842 TC VNGRPH ADRNL BI SLCTV RS&I 409.43 XXX 75860 VNGRPH VEN SINUS/JUG CATH RS&I 518.17 XXX 75860 26 VNGRPH VEN SINUS/JUG CATH RS&I 141.69 XXX 75860 TC VNGRPH VEN SINUS/JUG CATH RS&I 376.48 XXX 75870 VNGRPH SUPRIOR SGTL SINUS RS&I 511.58 XXX 75870 26 VNGRPH SUPRIOR SGTL SINUS RS&I 138.40 XXX 75870 TC VNGRPH SUPRIOR SGTL SINUS RS&I 373.18 XXX 75872 VNGRPH EDRL RS&I 690.34 XXX 75872 26 VNGRPH EDRL RS&I 148.28 XXX 75872 TC VNGRPH EDRL RS&I 542.06 XXX 75880 VNGRPH ORB RS&I 417.67 XXX 75880 26 VNGRPH ORB RS&I 87.32 XXX 75880 TC VNGRPH ORB RS&I 330.35 XXX 75885 PRQ TRANSHEPATC PORTOGRAPY HEMODYN EVAL RS&I 547.00 XXX 75885 26 PRQ TRANSHEPATC PORTOGRAPY HEMODYN EVAL RS&I 174.65 XXX 75885 TC PRQ TRANSHEPATC PORTOGRAPY HEMODYN EVAL RS&I 372.35 XXX 75887 PRQ TRANSHEPATC PORTOGRAPY W/O HEMODYN EVAL RS&I 551.12 XXX 75887 26 PRQ TRANSHEPATC PORTOGRAPY W/O HEMODYN EVAL RS&I 173.00 XXX 75887 TC PRQ TRANSHEPATC PORTOGRAPY W/O HEMODYN EVAL RS&I 378.12 XXX 75889 HEPATC VNGRPH WDG/FR HEMODYN EVAL RS&I 510.76 XXX 75889 26 HEPATC VNGRPH WDG/FR HEMODYN EVAL RS&I 138.40 XXX 75889 TC HEPATC VNGRPH WDG/FR HEMODYN EVAL RS&I 372.36 XXX 75891 HEPATC VNGRPH WDG/FR W/O HEMODYN EVAL RS&I 511.58 XXX 75891 26 HEPATC VNGRPH WDG/FR W/O HEMODYN EVAL RS&I 138.40 XXX 75891 TC HEPATC VNGRPH WDG/FR W/O HEMODYN EVAL RS&I 373.18 XXX 75893 VEN SAMPLING THRU CATH +-ANGRPH RS&I 433.32 XXX 75893 26 VEN SAMPLING THRU CATH +-ANGRPH RS&I 63.43 XXX 75893 TC VEN SAMPLING THRU CATH +-ANGRPH RS&I 369.89 XXX 75894 TCAT THER EMBOLIZATION ANY METH RS&I 2365.95 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
Section VIII: Diagnostic and Therapeutic Radiological Services Georgia Workers Compensation Medical Fee Schedule 70010 79999 RADIOLOGY Effective April 1, 2011 Medical Fee Schedule 75894 26 TCAT THER EMBOLIZATION ANY METH RS&I 165.58 XXX 75894 TC TCAT THER EMBOLIZATION ANY METH RS&I 2200.37 XXX 75896 TCAT THER NFS ANY METH RS&I 2090.80 XXX 75896 26 TCAT THER NFS ANY METH RS&I 167.23 XXX 75896 TC TCAT THER NFS ANY METH RS&I 1923.57 XXX 75898 ANGRPH CATH F-UP STD TCAT THER EMBOLIZATION/NFS 314.69 XXX 75898 26 ANGRPH CATH F-UP STD TCAT THER EMBOLIZATION/NFS 210.89 XXX 75898 TC ANGRPH CATH F-UP STD TCAT THER EMBOLIZATION/NFS 103.80 XXX 75900 EXCHNG CATH THROMBOLYTIC THER C+ MNTR RS&I 406.13 XXX 75900 26 EXCHNG CATH THROMBOLYTIC THER C+ MNTR RS&I 60.96 XXX 75900 TC EXCHNG CATH THROMBOLYTIC THER C+ MNTR RS&I 345.17 XXX 75901 MCHNL RMVL PRICATH OBSTR MATRL RS&I 406.96 XXX 75901 26 MCHNL RMVL PRICATH OBSTR MATRL RS&I 59.31 XXX 75901 TC MCHNL RMVL PRICATH OBSTR MATRL RS&I 347.65 XXX 75902 MCHNL RMVL INTRAL OBSTR MATRL RS&I 187.83 XXX 75902 26 MCHNL RMVL INTRAL OBSTR MATRL RS&I 47.78 XXX 75902 TC MCHNL RMVL INTRAL OBSTR MATRL RS&I 140.05 XXX 75940 PRQ PLMT IVC FILTER RS&I 1351.03 XXX 75940 26 PRQ PLMT IVC FILTER RS&I 67.55 XXX 75940 TC PRQ PLMT IVC FILTER RS&I 1283.48 XXX 75945 IV US RS&I 1ST VSL 457.21 XXX 75945 26 IV US RS&I 1ST VSL 50.25 XXX 75945 TC IV US RS&I 1ST VSL 406.96 XXX + 75946 IV US RS&I EA NON-C VSL 464.62 ZZZ + 75946 26 IV US RS&I EA NON-C VSL 51.08 ZZZ + 75946 TC IV US RS&I EA NON-C VSL 413.54 ZZZ 75952 EVASC RPR INFRARNL AAA/DSJ RS&I 575.84 XXX 75952 26 EVASC RPR INFRARNL AAA/DSJ RS&I 575.84 XXX 75952 TC EVASC RPR INFRARNL AAA/DSJ RS&I 0.00 XXX 75953 PLMT XTN PROSTH EVASC RPR INFRARNL RS&I 175.47 XXX 75953 26 PLMT XTN PROSTH EVASC RPR INFRARNL RS&I 175.47 XXX 75953 TC PLMT XTN PROSTH EVASC RPR INFRARNL RS&I 0.00 XXX s 75954 EVASC RPR ILIAC ART W/ILIO-ILIAC PROSTH RS&I 287.51 XXX s 75954 26 EVASC RPR ILIAC ART W/ILIO-ILIAC PROSTH RS&I 287.51 XXX s 75954 TC EVASC RPR ILIAC ART W/ILIO-ILIAC PROSTH RS&I 0.00 XXX 75956 EVASC RPR DTA COVERAGE L SUBCLA ORIGIN RS&I 904.53 XXX 75956 26 EVASC RPR DTA COVERAGE L SUBCLA ORIGIN RS&I 904.53 XXX 75956 TC EVASC RPR DTA COVERAGE L SUBCLA ORIGIN RS&I 0.00 XXX 75957 EVASC RPR DTA X COVERAGE L SUBCLA ORIGIN RS&I 773.55 XXX 75957 26 EVASC RPR DTA X COVERAGE L SUBCLA ORIGIN RS&I 773.55 XXX 75957 TC EVASC RPR DTA X COVERAGE L SUBCLA ORIGIN RS&I 0.00 XXX 75958 PLMT PROX XTN PROSTH EVASC RPR DTA RS&I 514.05 XXX 75958 26 PLMT PROX XTN PROSTH EVASC RPR DTA RS&I 514.05 XXX 75958 TC PLMT PROX XTN PROSTH EVASC RPR DTA RS&I 0.00 XXX 75959 PLMT DSTL XTN PROSTH AFTER EVASC RPR DTA RS&I 454.74 XXX 75959 26 PLMT DSTL XTN PROSTH AFTER EVASC RPR DTA RS&I 454.74 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
Georgia Workers Compensation Medical Fee Schedule Section VIII: Diagnostic and Therapeutic Radiological Services RADIOLOGY 70010 79999 Medical Fee Schedule Effective April 1, 2011 75959 TC PLMT DSTL XTN PROSTH AFTER EVASC RPR DTA RS&I 0.00 XXX s 75960 TCAT IV STNT ILIA/LOW EXT ART PRQ/OPN RSI EA VSL 471.21 XXX s 75960 26 TCAT IV STNT ILIA/LOW EXT ART PRQ/OPN RSI EA VSL 99.68 XXX s 75960 TC TCAT IV STNT ILIA/LOW EXT ART PRQ/OPN RSI EA VSL 371.53 XXX 75961 TCAT RETRIEVAL PRQ IV FB RS&I 897.94 XXX 75961 26 TCAT RETRIEVAL PRQ IV FB RS&I 514.05 XXX 75961 TC TCAT RETRIEVAL PRQ IV FB RS&I 383.89 XXX s 75962 TRANSLUMINAL BALLOON ANGIOP PERIPHERAL ART RSI 516.52 XXX s 75962 26 TRANSLUMINAL BALLOON ANGIOP PERIPHERAL ART RSI 65.08 XXX s 75962 TC TRANSLUMINAL BALLOON ANGIOP PERIPHERAL ART RSI 451.44 XXX s + 75964 TRLUML BALOON ANGIOP PERIPHER EA ADDL ARTERY RSI 322.11 ZZZ s + 75964 26 TRLUML BALOON ANGIOP PERIPHER EA ADDL ARTERY RSI 44.49 ZZZ s + 75964 TC TRLUML BALOON ANGIOP PERIPHER EA ADDL ARTERY RSI 277.62 ZZZ 75966 TRLUML BALO ANGIOP RNL/OTH VISC ART RS&I 621.15 XXX 75966 26 TRLUML BALO ANGIOP RNL/OTH VISC ART RS&I 161.46 XXX 75966 TC TRLUML BALO ANGIOP RNL/OTH VISC ART RS&I 459.69 XXX + 75968 TRLUML BALO ANGIOP EA VISC ART RS&I 315.52 ZZZ + 75968 26 TRLUML BALO ANGIOP EA VISC ART RS&I 43.66 ZZZ + 75968 TC TRLUML BALO ANGIOP EA VISC ART RS&I 271.86 ZZZ 75970 TCAT BX RS&I 1144.26 XXX 75970 26 TCAT BX RS&I 102.98 XXX 75970 TC TCAT BX RS&I 1041.28 XXX 75978 TRLUML BALO ANGIOP VEN RS&I 517.35 XXX 75978 26 TRLUML BALO ANGIOP VEN RS&I 64.26 XXX 75978 TC TRLUML BALO ANGIOP VEN RS&I 453.09 XXX 75980 PRQ TRANSHEPATC BILIARY DRG C+ MNTR RS&I 684.58 XXX 75980 26 PRQ TRANSHEPATC BILIARY DRG C+ MNTR RS&I 177.94 XXX 75980 TC PRQ TRANSHEPATC BILIARY DRG C+ MNTR RS&I 506.64 XXX 75982 PRQ BILIARY DRG/DRG STENT RS&I 773.55 XXX 75982 26 PRQ BILIARY DRG/DRG STENT RS&I 177.94 XXX 75982 TC PRQ BILIARY DRG/DRG STENT RS&I 595.61 XXX 75984 CHNG PRQ TUBE/DRAINAGE CATH W CONTRAST RS&I 280.09 XXX 75984 26 CHNG PRQ TUBE/DRAINAGE CATH W CONTRAST RS&I 87.32 XXX 75984 TC CHNG PRQ TUBE/DRAINAGE CATH W CONTRAST RS&I 192.77 XXX 75989 RAD GID PRQ DRG W/PLMT CATH RS&I 330.34 XXX 75989 26 RAD GID PRQ DRG W/PLMT CATH RS&I 142.52 XXX 75989 TC RAD GID PRQ DRG W/PLMT CATH RS&I 187.82 XXX 76000 FLUOR SPX <1 HR PHYS TM OTH/THN 71023/71034 188.65 XXX 76000 26 FLUOR SPX <1 HR PHYS TM OTH/THN 71023/71034 20.60 XXX 76000 TC FLUOR SPX <1 HR PHYS TM OTH/THN 71023/71034 168.05 XXX 76001 FLUOR PHYS TM > 1 HR ASSISTING NON-RAD PHYS 346.00 XXX 76001 26 FLUOR PHYS TM > 1 HR ASSISTING NON-RAD PHYS 86.50 XXX 76001 TC FLUOR PHYS TM > 1 HR ASSISTING NON-RAD PHYS 259.50 XXX 76010 RADEX FROM NOSE RECTUM FB 1 VIEW CHLD 67.55 XXX 76010 26 RADEX FROM NOSE RECTUM FB 1 VIEW CHLD 22.24 XXX 76010 TC RADEX FROM NOSE RECTUM FB 1 VIEW CHLD 45.31 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
Section VIII: Diagnostic and Therapeutic Radiological Services Georgia Workers Compensation Medical Fee Schedule 70010 79999 RADIOLOGY Effective April 1, 2011 Medical Fee Schedule 76080 RAD XM ABSC/FSTL/SINUS TRC RAD S&I 152.40 XXX 76080 26 RAD XM ABSC/FSTL/SINUS TRC RAD S&I 65.90 XXX 76080 TC RAD XM ABSC/FSTL/SINUS TRC RAD S&I 86.50 XXX 76098 RAD XM SURG SPEC 46.96 XXX 76098 26 RAD XM SURG SPEC 19.77 XXX 76098 TC RAD XM SURG SPEC 27.19 XXX 76100 RADEX 1 PLNE BDY SCTJ OTH/THN UROGRAPY 299.04 XXX 76100 26 RADEX 1 PLNE BDY SCTJ OTH/THN UROGRAPY 74.97 XXX 76100 TC RADEX 1 PLNE BDY SCTJ OTH/THN UROGRAPY 224.07 XXX 76101 RADEX CPLX MOTION BDY SCTJ OTH/THN UROGRAPY UNI 430.02 XXX 76101 26 RADEX CPLX MOTION BDY SCTJ OTH/THN UROGRAPY UNI 81.56 XXX 76101 TC RADEX CPLX MOTION BDY SCTJ OTH/THN UROGRAPY UNI 348.46 XXX 76102 RADEX CPLX MOTION BDY SCTJ OTH/THN UROGRAPY BI 577.48 XXX 76102 26 RADEX CPLX MOTION BDY SCTJ OTH/THN UROGRAPY BI 83.20 XXX 76102 TC RADEX CPLX MOTION BDY SCTJ OTH/THN UROGRAPY BI 494.28 XXX 76120 CINERADIOGRAPY/VIDRADIOGRAPY XCPT WHERE SPEC 187.00 XXX 76120 26 CINERADIOGRAPY/VIDRADIOGRAPY XCPT WHERE SPEC 46.13 XXX 76120 TC CINERADIOGRAPY/VIDRADIOGRAPY XCPT WHERE SPEC 140.87 XXX + 76125 CINERADIOGRAPY/VIDRADIOGRAPY ROUTINE XM 114.51 ZZZ + 76125 26 CINERADIOGRAPY/VIDRADIOGRAPY ROUTINE XM 35.42 ZZZ + 76125 TC CINERADIOGRAPY/VIDRADIOGRAPY ROUTINE XM 79.09 ZZZ 76140 CONSLTJ X-RAY XM MADE ELSEWHERE WRTTN REPRT BR XXX 76376 3D RNDR I&R CT MRI US/OTH X REQ POSTPCX 174.65 XXX 76376 26 3D RNDR I&R CT MRI US/OTH X REQ POSTPCX 24.71 XXX 76376 TC 3D RNDR I&R CT MRI US/OTH X REQ POSTPCX 149.94 XXX 76377 3D RNDR I&R CT MRI US/OTH REQ POSTPCX 227.37 XXX 76377 26 3D RNDR I&R CT MRI US/OTH REQ POSTPCX 95.56 XXX 76377 TC 3D RNDR I&R CT MRI US/OTH REQ POSTPCX 131.81 XXX 76380 CT LMTD/LOCLZD F-UP STD 461.33 XXX 76380 26 CT LMTD/LOCLZD F-UP STD 117.80 XXX 76380 TC CT LMTD/LOCLZD F-UP STD 343.53 XXX 76390 MRI SPECTROSCOPY 1150.02 XXX 76390 26 MRI SPECTROSCOPY 168.06 XXX 76390 TC MRI SPECTROSCOPY 981.96 XXX 76496 UNLIS FLUOR PX BR XXX 76497 UNLIS CT PX BR XXX 76498 UNLIS MRI PX BR XXX 76499 UNLIS DX RADIOGRAPIC PX BR XXX 76506 ECHOENCEPHALOGRAPY REAL TIME IMAGING 294.10 XXX 76506 26 ECHOENCEPHALOGRAPY REAL TIME IMAGING 76.61 XXX 76506 TC ECHOENCEPHALOGRAPY REAL TIME IMAGING 217.49 XXX 76510 OPH US DX B-SCAN&QUAN A-SCAN SM PT ENCTR 406.13 XXX 76510 26 OPH US DX B-SCAN&QUAN A-SCAN SM PT ENCTR 225.72 XXX 76510 TC OPH US DX B-SCAN&QUAN A-SCAN SM PT ENCTR 180.41 XXX 76511 OPH US DX QUAN A-SCAN ONLY 241.37 XXX 76511 26 OPH US DX QUAN A-SCAN ONLY 123.57 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
Georgia Workers Compensation Medical Fee Schedule Section VIII: Diagnostic and Therapeutic Radiological Services RADIOLOGY 70010 79999 Medical Fee Schedule Effective April 1, 2011 76511 TC OPH US DX QUAN A-SCAN ONLY 117.80 XXX 76512 OPH US DX B-SCAN +-A-SCAN 224.07 XXX 76512 26 OPH US DX B-SCAN +-A-SCAN 126.04 XXX 76512 TC OPH US DX B-SCAN +-A-SCAN 98.03 XXX 76513 OPH US DX ANT SGM US IMMERSION B-SCAN/HR BIOM 213.36 XXX 76513 26 OPH US DX ANT SGM US IMMERSION B-SCAN/HR BIOM 82.38 XXX 76513 TC OPH US DX ANT SGM US IMMERSION B-SCAN/HR BIOM 130.98 XXX 76514 OPH US DX CRNL PACHYMETRY UNI/BI 33.78 XXX 76514 26 OPH US DX CRNL PACHYMETRY UNI/BI 23.07 XXX 76514 TC OPH US DX CRNL PACHYMETRY UNI/BI 10.71 XXX 76516 OPH BMTRY US ECHOGRAPY A-SCAN 174.65 XXX 76516 26 OPH BMTRY US ECHOGRAPY A-SCAN 70.85 XXX 76516 TC OPH BMTRY US ECHOGRAPY A-SCAN 103.80 XXX 76519 OPH BMTRY US ECHOGRAPY A-SCAN IO LENS PWR CAL 189.47 XXX 76519 26 OPH BMTRY US ECHOGRAPY A-SCAN IO LENS PWR CAL 73.32 XXX 76519 TC OPH BMTRY US ECHOGRAPY A-SCAN IO LENS PWR CAL 116.15 XXX 76529 OPH ULTRASONIC FB LOCLZJ 178.76 XXX 76529 26 OPH ULTRASONIC FB LOCLZJ 77.44 XXX 76529 TC OPH ULTRASONIC FB LOCLZJ 101.32 XXX 76536 US SOFT TISS HEAD&NCK R-T IMG 288.33 XXX 76536 26 US SOFT TISS HEAD&NCK R-T IMG 67.55 XXX 76536 TC US SOFT TISS HEAD&NCK R-T IMG 220.78 XXX 76604 US CHEST R-T W/IMAGE DOCUMENTATION 214.19 XXX 76604 26 US CHEST R-T W/IMAGE DOCUMENTATION 65.90 XXX 76604 TC US CHEST R-T W/IMAGE DOCUMENTATION 148.29 XXX 76645 US BREAST R-T W/IMAGE DOCUMENTATION 233.96 XXX 76645 26 US BREAST R-T W/IMAGE DOCUMENTATION 65.90 XXX 76645 TC US BREAST R-T W/IMAGE DOCUMENTATION 168.06 XXX 76700 US ABDOMINAL R-T W/IMAGE DOCUMENTATION 342.70 XXX 76700 26 US ABDOMINAL R-T W/IMAGE DOCUMENTATION 97.21 XXX 76700 TC US ABDOMINAL R-T W/IMAGE DOCUMENTATION 245.49 XXX 76705 ULTRASOUND ABDOMINAL R-T W/IMAGE LIMITED 260.32 XXX 76705 26 ULTRASOUND ABDOMINAL R-T W/IMAGE LIMITED 70.85 XXX 76705 TC ULTRASOUND ABDOMINAL R-T W/IMAGE LIMITED 189.47 XXX 76770 US RETROPERITONEAL R-T W/IMAGE COMPL 325.40 XXX 76770 26 US RETROPERITONEAL R-T W/IMAGE COMPL 88.97 XXX 76770 TC US RETROPERITONEAL R-T W/IMAGE COMPL 236.43 XXX 76775 US RPR B-SCAN&/R-T IMG LMTD 271.85 XXX 76775 26 US RPR B-SCAN&/R-T IMG LMTD 70.85 XXX 76775 TC US RPR B-SCAN&/R-T IMG LMTD 201.00 XXX 76776 US TRNSPL KDN R-T IMG +- DUPLEX DOP STD 369.06 XXX 76776 26 US TRNSPL KDN R-T IMG +- DUPLEX DOP STD 91.44 XXX 76776 TC US TRNSPL KDN R-T IMG +- DUPLEX DOP STD 277.62 XXX 76800 US SPI CANAL&CNTS 324.58 XXX 76800 26 US SPI CANAL&CNTS 133.46 XXX 76800 TC US SPI CANAL&CNTS 191.12 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
Section VIII: Diagnostic and Therapeutic Radiological Services Georgia Workers Compensation Medical Fee Schedule 70010 79999 RADIOLOGY Effective April 1, 2011 Medical Fee Schedule 76801 US PG UTER IMG F&MAT 14 WK TABDL 1/1ST GESTATION 317.16 XXX 76801 26 US PG UTER IMG F&MAT 14 WK TABDL 1/1ST GESTATION 118.63 XXX 76801 TC US PG UTER IMG F&MAT 14 WK TABDL 1/1ST GESTATION 198.53 XXX + 76802 US PG UTER F&MAT 14 WK TABDL EA GESTATION 170.53 ZZZ + 76802 26 US PG UTER F&MAT 14 WK TABDL EA GESTATION 99.68 ZZZ + 76802 TC US PG UTER F&MAT 14 WK TABDL EA GESTATION 70.85 ZZZ 76805 US PG UTER F&MAT AFTER 1ST TRI 1/1ST GESTATION 363.30 XXX 76805 26 US PG UTER F&MAT AFTER 1ST TRI 1/1ST GESTATION 118.63 XXX 76805 TC US PG UTER F&MAT AFTER 1ST TRI 1/1ST GESTATION 244.67 XXX + 76810 US PG UTER F&MAT AFTER 1ST TRI ABDL EA GESTATION 238.08 ZZZ + 76810 26 US PG UTER F&MAT AFTER 1ST TRI ABDL EA GESTATION 116.98 ZZZ + 76810 TC US PG UTER F&MAT AFTER 1ST TRI ABDL EA GESTATION 121.10 ZZZ 76811 US PG UTER F&MAT DETAILED FTL XM 1ST GESTATION 470.39 XXX 76811 26 US PG UTER F&MAT DETAILED FTL XM 1ST GESTATION 227.37 XXX 76811 TC US PG UTER F&MAT DETAILED FTL XM 1ST GESTATION 243.02 XXX + 76812 US PG UTER F&MAT DETAILED FTL ANTMC XM EA 498.40 ZZZ + 76812 26 US PG UTER F&MAT DETAILED FTL ANTMC XM EA 212.54 ZZZ + 76812 TC US PG UTER F&MAT DETAILED FTL ANTMC XM EA 285.86 ZZZ 76813 US FETAL NUCHAL TRANSLUCENCY 1ST GESTATION 308.93 XXX 76813 26 US FETAL NUCHAL TRANSLUCENCY 1ST GESTATION 140.87 XXX 76813 TC US FETAL NUCHAL TRANSLUCENCY 1ST GESTATION 168.06 XXX + 76814 US FETAL NUCHAL TRANSLUCENCY EA ADDL GESTATION 196.89 XXX + 76814 26 US FETAL NUCHAL TRANSLUCENCY EA ADDL GESTATION 117.80 XXX + 76814 TC US FETAL NUCHAL TRANSLUCENCY EA ADDL GESTATION 79.09 XXX 76815 US PG UTER R-T IMG LMTD 1+ FETUSES 222.43 XXX 76815 26 US PG UTER R-T IMG LMTD 1+ FETUSES 76.61 XXX 76815 TC US PG UTER R-T IMG LMTD 1+ FETUSES 145.82 XXX 76816 US PG UTER R-T IMG F-UP TABDL APPR PR FETUS 285.03 XXX 76816 26 US PG UTER R-T IMG F-UP TABDL APPR PR FETUS 102.15 XXX 76816 TC US PG UTER R-T IMG F-UP TABDL APPR PR FETUS 182.88 XXX 76817 US PG UTER R-T IMG TRVG 252.08 XXX 76817 26 US PG UTER R-T IMG TRVG 89.79 XXX 76817 TC US PG UTER R-T IMG TRVG 162.29 XXX 76818 FTL BIOPHYSICAL PROFILE NON-STRS TSTG 298.22 XXX 76818 26 FTL BIOPHYSICAL PROFILE NON-STRS TSTG 126.04 XXX 76818 TC FTL BIOPHYSICAL PROFILE NON-STRS TSTG 172.18 XXX 76819 FTL BIOPHYSICAL PROFILE W/O NON-STRS TSTG 224.07 XXX 76819 26 FTL BIOPHYSICAL PROFILE W/O NON-STRS TSTG 93.09 XXX 76819 TC FTL BIOPHYSICAL PROFILE W/O NON-STRS TSTG 130.98 XXX 76820 DOP VELOCIMETRY FTL UMBILICAL ART 113.68 XXX 76820 26 DOP VELOCIMETRY FTL UMBILICAL ART 59.31 XXX 76820 TC DOP VELOCIMETRY FTL UMBILICAL ART 54.37 XXX 76821 DOP VELOCIMETRY FTL MIDDLE CERE ART 237.25 XXX 76821 26 DOP VELOCIMETRY FTL MIDDLE CERE ART 84.85 XXX 76821 TC DOP VELOCIMETRY FTL MIDDLE CERE ART 152.40 XXX 76825 ECHO FTL CV SYS R-T REC 528.88 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
Georgia Workers Compensation Medical Fee Schedule Section VIII: Diagnostic and Therapeutic Radiological Services RADIOLOGY 70010 79999 Medical Fee Schedule Effective April 1, 2011 76825 26 ECHO FTL CV SYS R-T REC 198.54 XXX 76825 TC ECHO FTL CV SYS R-T REC 330.34 XXX 76826 ECHO FTL CV SYS R-T REC REPEAT STD 304.81 XXX 76826 26 ECHO FTL CV SYS R-T REC REPEAT STD 98.86 XXX 76826 TC ECHO FTL CV SYS R-T REC REPEAT STD 205.95 XXX 76827 DOP ECHO FTL SPECTRAL DISPLAY COMPL 161.46 XXX 76827 26 DOP ECHO FTL SPECTRAL DISPLAY COMPL 68.38 XXX 76827 TC DOP ECHO FTL SPECTRAL DISPLAY COMPL 93.08 XXX 76828 DOP ECHO FTL PLSD SPECTRAL DISPLAY REPEAT STD 118.63 XXX 76828 26 DOP ECHO FTL PLSD SPECTRAL DISPLAY REPEAT STD 66.73 XXX 76828 TC DOP ECHO FTL PLSD SPECTRAL DISPLAY REPEAT STD 51.90 XXX 76830 US TRVG 304.81 XXX 76830 26 US TRVG 83.20 XXX 76830 TC US TRVG 221.61 XXX 76831 SALINE NFS SHG SIS COL FLO DOP PFRMD 305.63 XXX 76831 26 SALINE NFS SHG SIS COL FLO DOP PFRMD 86.50 XXX 76831 TC SALINE NFS SHG SIS COL FLO DOP PFRMD 219.13 XXX 76856 US PELVIC NONOB REAL-TIME IMG COMPLETE 303.98 XXX 76856 26 US PELVIC NONOB REAL-TIME IMG COMPLETE 83.20 XXX 76856 TC US PELVIC NONOB REAL-TIME IMG COMPLETE 220.78 XXX 76857 US PEL NONOB B-SCAN&/R-T IMG LMTD/F-UP+C97 247.14 XXX 76857 26 US PEL NONOB B-SCAN&/R-T IMG LMTD/F-UP+C97 47.78 XXX 76857 TC US PEL NONOB B-SCAN&/R-T IMG LMTD/F-UP+C97 199.36 XXX 76870 US SCROTUM&CNTS 302.33 XXX 76870 26 US SCROTUM&CNTS 78.26 XXX 76870 TC US SCROTUM&CNTS 224.07 XXX 76872 US TRANSRCT 342.70 XXX 76872 26 US TRANSRCT 85.68 XXX 76872 TC US TRANSRCT 257.02 XXX 76873 US TRANSRCT PRST8 VOL STD BRACHYTX PLNNING SPX 434.14 XXX 76873 26 US TRANSRCT PRST8 VOL STD BRACHYTX PLNNING SPX 189.47 XXX 76873 TC US TRANSRCT PRST8 VOL STD BRACHYTX PLNNING SPX 244.67 XXX l 76881 US EXTREMITY NON-VASC REAL-TIME IMG COMPL 279.27 XXX l 76881 26 US EXTREMITY NON-VASC REAL-TIME IMG COMPL 70.02 XXX l 76881 TC US EXTREMITY NON-VASC REAL-TIME IMG COMPL 209.25 XXX l 76882 US EXTREMITY NON-VASC REAL-TIME IMG LMTD 73.32 XXX l 76882 26 US EXTREMITY NON-VASC REAL-TIME IMG LMTD 48.60 XXX l 76882 TC US EXTREMITY NON-VASC REAL-TIME IMG LMTD 24.72 XXX 76885 US INFT HIPS R-T IMG DYNAMIC REQ PHYS MNPJ 354.23 XXX 76885 26 US INFT HIPS R-T IMG DYNAMIC REQ PHYS MNPJ 89.79 XXX 76885 TC US INFT HIPS R-T IMG DYNAMIC REQ PHYS MNPJ 264.44 XXX 76886 US INFT HIPS R-T IMG LMTD STATIC X PHYS MNPJ 280.92 XXX 76886 26 US INFT HIPS R-T IMG LMTD STATIC X PHYS MNPJ 74.97 XXX 76886 TC US INFT HIPS R-T IMG LMTD STATIC X PHYS MNPJ 205.95 XXX 76930 US PRICARDIOCNTS IMG S&I 220.78 XXX 76930 26 US PRICARDIOCNTS IMG S&I 82.38 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
Section VIII: Diagnostic and Therapeutic Radiological Services Georgia Workers Compensation Medical Fee Schedule 70010 79999 RADIOLOGY Effective April 1, 2011 Medical Fee Schedule 76930 TC US PRICARDIOCNTS IMG S&I 138.40 XXX 76932 US ENDOMYOCRD BX IMG S&I 231.49 XXX 76932 26 US ENDOMYOCRD BX IMG S&I 85.68 XXX 76932 TC US ENDOMYOCRD BX IMG S&I 145.81 XXX 76936 US CMPRN RPR ARTL PSEUDOARYSM/ARVEN FSTL 756.25 XXX 76936 26 US CMPRN RPR ARTL PSEUDOARYSM/ARVEN FSTL 248.79 XXX 76936 TC US CMPRN RPR ARTL PSEUDOARYSM/ARVEN FSTL 507.46 XXX + 76937 US VASC ACCESS SITS VSL PATENCY NDL ENTRY 84.85 ZZZ + 76937 26 US VASC ACCESS SITS VSL PATENCY NDL ENTRY 37.07 ZZZ + 76937 TC US VASC ACCESS SITS VSL PATENCY NDL ENTRY 47.78 ZZZ 76940 US &MNTR PARENCHYMAL TISSUE ABLATION 413.55 XXX 76940 26 US &MNTR PARENCHYMAL TISSUE ABLATION 256.20 XXX 76940 TC US &MNTR PARENCHYMAL TISSUE ABLATION 157.35 XXX 76941 US INTRAUTERINE FTL TFUJ/CORDOCNTS IMG S&I 309.75 XXX 76941 26 US INTRAUTERINE FTL TFUJ/CORDOCNTS IMG S&I 167.23 XXX 76941 TC US INTRAUTERINE FTL TFUJ/CORDOCNTS IMG S&I 142.52 XXX 76942 US NDL PLMT IMG S&I 480.28 XXX 76942 26 US NDL PLMT IMG S&I 81.56 XXX 76942 TC US NDL PLMT IMG S&I 398.72 XXX 76945 US CHORNC VILLUS SAMPLING IMG S&I 229.02 XXX 76945 26 US CHORNC VILLUS SAMPLING IMG S&I 82.38 XXX 76945 TC US CHORNC VILLUS SAMPLING IMG S&I 146.64 XXX 76946 US AMNIOCNTS IMG S&I 92.27 XXX 76946 26 US AMNIOCNTS IMG S&I 45.31 XXX 76946 TC US AMNIOCNTS IMG S&I 46.96 XXX 76948 US ASPIR OVA IMG S&I 93.91 XXX 76948 26 US ASPIR OVA IMG S&I 46.96 XXX 76948 TC US ASPIR OVA IMG S&I 46.95 XXX 76950 US PLMT RADJ THER FLDS 168.06 XXX 76950 26 US PLMT RADJ THER FLDS 70.85 XXX 76950 TC US PLMT RADJ THER FLDS 97.21 XXX 76965 US NTRSTL RADIOELMNT APPL 287.51 XXX 76965 26 US NTRSTL RADIOELMNT APPL 165.58 XXX 76965 TC US NTRSTL RADIOELMNT APPL 121.93 XXX 76970 US STD F-UP SPEC 233.96 XXX 76970 26 US STD F-UP SPEC 49.43 XXX 76970 TC US STD F-UP SPEC 184.53 XXX 76975 GI NDSC US S&I 257.03 XXX 76975 26 GI NDSC US S&I 105.45 XXX 76975 TC GI NDSC US S&I 151.58 XXX 76977 US B1 DNS MEAS&INTERPJ PRPH SIT ANY METH 25.54 XXX 76977 26 US B1 DNS MEAS&INTERPJ PRPH SIT ANY METH 6.59 XXX 76977 TC US B1 DNS MEAS&INTERPJ PRPH SIT ANY METH 18.95 XXX 76998 ULTRASONIC GUIDANCE INTRAOPERATIVE 158.99 XXX 76998 26 ULTRASONIC GUIDANCE INTRAOPERATIVE 158.99 XXX 76998 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
Georgia Workers Compensation Medical Fee Schedule Section VIII: Diagnostic and Therapeutic Radiological Services RADIOLOGY 70010 79999 Medical Fee Schedule Effective April 1, 2011 76999 UNLIS US PX BR XXX + 77001 FLUOR GID CTR VAD PLMT RPLCMT/RMVL 278.44 ZZZ + 77001 26 FLUOR GID CTR VAD PLMT RPLCMT/RMVL 46.96 ZZZ + 77001 TC FLUOR GID CTR VAD PLMT RPLCMT/RMVL 231.48 ZZZ 77002 FLUOROSCOPIC GUIDANCE NEEDLE PLACEMENT 183.71 XXX 77002 26 FLUOROSCOPIC GUIDANCE NEEDLE PLACEMENT 66.73 XXX 77002 TC FLUOROSCOPIC GUIDANCE NEEDLE PLACEMENT 116.98 XXX s 77003 FLUOR GID & LOCLZJ NDL/CATH SPI DX/THER NJX 151.58 XXX s 77003 26 FLUOR GID & LOCLZJ NDL/CATH SPI DX/THER NJX 71.67 XXX s 77003 TC FLUOR GID & LOCLZJ NDL/CATH SPI DX/THER NJX 79.91 XXX 77011 CT GUIDANCE STEREOTACTIC LOCALIZATION 1173.09 XXX 77011 26 CT GUIDANCE STEREOTACTIC LOCALIZATION 147.46 XXX 77011 TC CT GUIDANCE STEREOTACTIC LOCALIZATION 1025.63 XXX 77012 CT GUIDANCE NEEDLE PLACEMENT 397.07 XXX 77012 26 CT GUIDANCE NEEDLE PLACEMENT 138.40 XXX 77012 TC CT GUIDANCE NEEDLE PLACEMENT 258.67 XXX 77013 CT GUIDANCE &MONITORING VISC TISS ABLATION 1374.92 XXX 77013 26 CT GUIDANCE &MONITORING VISC TISS ABLATION 495.10 XXX 77013 TC CT GUIDANCE &MONITORING VISC TISS ABLATION 879.82 XXX 77014 CT GUIDANCE RADIATION THERAPY FLDS PLACEMENT 465.45 XXX 77014 26 CT GUIDANCE RADIATION THERAPY FLDS PLACEMENT 102.98 XXX 77014 TC CT GUIDANCE RADIATION THERAPY FLDS PLACEMENT 362.47 XXX 77021 MR GUIDANCE NEEDLE PLACEMENT 1053.64 XXX 77021 26 MR GUIDANCE NEEDLE PLACEMENT 184.53 XXX 77021 TC MR GUIDANCE NEEDLE PLACEMENT 869.11 XXX 77022 MR GUIDANCE &MONITORING TISSUE ABLATION 1687.14 XXX 77022 26 MR GUIDANCE &MONITORING TISSUE ABLATION 523.11 XXX 77022 TC MR GUIDANCE &MONITORING TISSUE ABLATION 1164.03 XXX 77031 STRTCTC LOCLZJ GID BREAST BX/NEEDLE PLACEMENT 392.13 XXX 77031 26 STRTCTC LOCLZJ GID BREAST BX/NEEDLE PLACEMENT 194.42 XXX 77031 TC STRTCTC LOCLZJ GID BREAST BX/NEEDLE PLACEMENT 197.71 XXX 77032 MAMMOGRAPHIC GID NEEDLE PLACEMENTT BREAST 135.93 XXX 77032 26 MAMMOGRAPHIC GID NEEDLE PLACEMENTT BREAST 67.55 XXX 77032 TC MAMMOGRAPHIC GID NEEDLE PLACEMENTT BREAST 68.38 XXX + 77051 COMPUTER-AIDED DETECTION DX MAMMOGRAPHY 28.01 ZZZ + 77051 26 COMPUTER-AIDED DETECTION DX MAMMOGRAPHY 7.41 ZZZ + 77051 TC COMPUTER-AIDED DETECTION DX MAMMOGRAPHY 20.60 ZZZ + 77052 COMPUTER-AIDED DETECTION SCREENING MAMMOGRAPHY 28.01 ZZZ + 77052 26 COMPUTER-AIDED DETECTION SCREENING MAMMOGRAPHY 7.41 ZZZ + 77052 TC COMPUTER-AIDED DETECTION SCREENING MAMMOGRAPHY 20.60 ZZZ 77053 MAMMARY DUCTOGRAM OR GALACTOGRAM SINGLE 164.76 XXX 77053 26 MAMMARY DUCTOGRAM OR GALACTOGRAM SINGLE 42.84 XXX 77053 TC MAMMARY DUCTOGRAM OR GALACTOGRAM SINGLE 121.92 XXX 77054 MAMMARY DUCTOGRAM OR GALACTOGRAM MULTIPLE 223.25 XXX 77054 26 MAMMARY DUCTOGRAM OR GALACTOGRAM MULTIPLE 55.19 XXX 77054 TC MAMMARY DUCTOGRAM OR GALACTOGRAM MULTIPLE 168.06 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
Section VIII: Diagnostic and Therapeutic Radiological Services Georgia Workers Compensation Medical Fee Schedule 70010 79999 RADIOLOGY Effective April 1, 2011 Medical Fee Schedule 77055 MAMMOGRAPHY UNILATERAL 210.07 XXX 77055 26 MAMMOGRAPHY UNILATERAL 84.85 XXX 77055 TC MAMMOGRAPHY UNILATERAL 125.22 XXX 77056 MAMMOGRAPHY BILATERAL 268.56 XXX 77056 26 MAMMOGRAPHY BILATERAL 105.45 XXX 77056 TC MAMMOGRAPHY BILATERAL 163.11 XXX 77057 SCREENING MAMMOGRAPHY BILATERAL 196.89 XXX 77057 26 SCREENING MAMMOGRAPHY BILATERAL 84.85 XXX 77057 TC SCREENING MAMMOGRAPHY BILATERAL 112.04 XXX 77058 MRI BREAST UNILATERAL 1839.55 XXX 77058 26 MRI BREAST UNILATERAL 197.71 XXX 77058 TC MRI BREAST UNILATERAL 1641.84 XXX 77059 MRI BREAST BILATERAL 1908.74 XXX 77059 26 MRI BREAST BILATERAL 197.71 XXX 77059 TC MRI BREAST BILATERAL 1711.03 XXX 77071 MANUAL APPL STRESS PFRMD PHYS JOINT RADIOGRAPHY 113.68 XXX 77072 BONE AGE STUDIES 57.67 XXX 77072 26 BONE AGE STUDIES 23.07 XXX 77072 TC BONE AGE STUDIES 34.60 XXX 77073 BONE LENGTH STUDIES 95.56 XXX 77073 26 BONE LENGTH STUDIES 36.25 XXX 77073 TC BONE LENGTH STUDIES 59.31 XXX 77074 RADIOLOGIC EXAMINATION OSSEOUS SURVEY LIMITED 170.53 XXX 77074 26 RADIOLOGIC EXAMINATION OSSEOUS SURVEY LIMITED 55.19 XXX 77074 TC RADIOLOGIC EXAMINATION OSSEOUS SURVEY LIMITED 115.34 XXX 77075 RADIOLOGIC EXAMINATION OSSEOUS SURVEY COMPL 250.44 XXX 77075 26 RADIOLOGIC EXAMINATION OSSEOUS SURVEY COMPL 65.08 XXX 77075 TC RADIOLOGIC EXAMINATION OSSEOUS SURVEY COMPL 185.36 XXX 77076 RADIOLOGIC EXAMINATION OSSEOUS SURVEY INFANT 244.67 XXX 77076 26 RADIOLOGIC EXAMINATION OSSEOUS SURVEY INFANT 83.20 XXX 77076 TC RADIOLOGIC EXAMINATION OSSEOUS SURVEY INFANT 161.47 XXX 77077 JOINT SURVEY SINGLE VIEW 2 OR MORE JOINTS 102.98 XXX 77077 26 JOINT SURVEY SINGLE VIEW 2 OR MORE JOINTS 40.37 XXX 77077 TC JOINT SURVEY SINGLE VIEW 2 OR MORE JOINTS 62.61 XXX 77078 CT BONE MINERAL DENSITY STUDY 1+ SITS AXIAL SKEL 383.07 XXX 77078 26 CT BONE MINERAL DENSITY STUDY 1+ SITS AXIAL SKEL 29.66 XXX 77078 TC CT BONE MINERAL DENSITY STUDY 1+ SITS AXIAL SKEL 353.41 XXX 77079 CT BONE MINERAL DENSITY STUDY 1+ SITS APPND 123.57 XXX 77079 26 CT BONE MINERAL DENSITY STUDY 1+ SITS APPND 26.36 XXX 77079 TC CT BONE MINERAL DENSITY STUDY 1+ SITS APPND 97.21 XXX 77080 DXA BONE DENSITY STUDY 1+ SITS AXIAL SKEL 236.43 XXX 77080 26 DXA BONE DENSITY STUDY 1+ SITS AXIAL SKEL 26.36 XXX 77080 TC DXA BONE DENSITY STUDY 1+ SITS AXIAL SKEL 210.07 XXX 77081 DXA BONE DENSITY STUDY 1+ SITS APPENDICULAR SKEL 70.02 XXX 77081 26 DXA BONE DENSITY STUDY 1+ SITS APPENDICULAR SKEL 23.89 XXX 77081 TC DXA BONE DENSITY STUDY 1+ SITS APPENDICULAR SKEL 46.13 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
Georgia Workers Compensation Medical Fee Schedule Section VIII: Diagnostic and Therapeutic Radiological Services RADIOLOGY 70010 79999 Medical Fee Schedule Effective April 1, 2011 77082 DXA BONE DENSITY STUDY VERTEBRAL FRACTURE 67.55 XXX 77082 26 DXA BONE DENSITY STUDY VERTEBRAL FRACTURE 15.65 XXX 77082 TC DXA BONE DENSITY STUDY VERTEBRAL FRACTURE 51.90 XXX 77083 RADIOGRAPHIC ABSORPTIOMETRY 1+ SITS 60.96 XXX 77083 26 RADIOGRAPHIC ABSORPTIOMETRY 1+ SITS 23.89 XXX 77083 TC RADIOGRAPHIC ABSORPTIOMETRY 1+ SITS 37.07 XXX 77084 BONE MARROW BLOOD SUPPLY 1284.30 XXX 77084 26 BONE MARROW BLOOD SUPPLY 195.24 XXX 77084 TC BONE MARROW BLOOD SUPPLY 1089.06 XXX 77261 THER RAD TX PLNNING SMPL 175.47 XXX 77262 THER RAD TX PLNNING INTRM 264.44 XXX 77263 THER RAD TX PLNNING CPLX 392.13 XXX 77280 THER RAD SIMULAJ-AIDED FLD SETTING SMPL 458.03 XXX 77280 26 THER RAD SIMULAJ-AIDED FLD SETTING SMPL 84.85 XXX 77280 TC THER RAD SIMULAJ-AIDED FLD SETTING SMPL 373.18 XXX 77285 THER RAD SIMULAJ-AIDED FLD SETTING INTRM 803.21 XXX 77285 26 THER RAD SIMULAJ-AIDED FLD SETTING INTRM 127.69 XXX 77285 TC THER RAD SIMULAJ-AIDED FLD SETTING INTRM 675.52 XXX 77290 THER RAD SIMULAJ-AIDED FLD SETTING CPLX 1285.13 XXX 77290 26 THER RAD SIMULAJ-AIDED FLD SETTING CPLX 189.47 XXX 77290 TC THER RAD SIMULAJ-AIDED FLD SETTING CPLX 1095.66 XXX 77295 THER RAD SIMULAJ-AIDED FLD SETTING 3-DIMENSIONAL 1369.16 XXX 77295 26 THER RAD SIMULAJ-AIDED FLD SETTING 3-DIMENSIONAL 556.07 XXX 77295 TC THER RAD SIMULAJ-AIDED FLD SETTING 3-DIMENSIONAL 813.09 XXX 77299 UNLIS PX THER RAD CLINICAL TX PLNNING BR XXX 77300 BASIC RADJ DOSIM CAL 169.70 XXX 77300 26 BASIC RADJ DOSIM CAL 75.79 XXX 77300 TC BASIC RADJ DOSIM CAL 93.91 XXX 77301 NTSTY MODUL RADTHX PLN DOSE-VOL HISTOS 5063.07 XXX 77301 26 NTSTY MODUL RADTHX PLN DOSE-VOL HISTOS 973.73 XXX 77301 TC NTSTY MODUL RADTHX PLN DOSE-VOL HISTOS 4089.34 XXX 77305 TELETHX ISODOSE PLN SMPL 161.46 XXX 77305 26 TELETHX ISODOSE PLN SMPL 84.85 XXX 77305 TC TELETHX ISODOSE PLN SMPL 76.61 XXX 77310 TELETHX ISODOSE PLN INTRM 228.19 XXX 77310 26 TELETHX ISODOSE PLN INTRM 127.69 XXX 77310 TC TELETHX ISODOSE PLN INTRM 100.50 XXX 77315 TELETHX ISODOSE PLN CPLX 346.00 XXX 77315 26 TELETHX ISODOSE PLN CPLX 189.47 XXX 77315 TC TELETHX ISODOSE PLN CPLX 156.53 XXX 77321 SPEC TELETHX PORT PLN PARTS HEMIBDY TOT BDY 259.50 XXX 77321 26 SPEC TELETHX PORT PLN PARTS HEMIBDY TOT BDY 114.51 XXX 77321 TC SPEC TELETHX PORT PLN PARTS HEMIBDY TOT BDY 144.99 XXX 77326 BRACHYTX ISODOSE PLN SMPL 351.76 XXX 77326 26 BRACHYTX ISODOSE PLN SMPL 112.04 XXX 77326 TC BRACHYTX ISODOSE PLN SMPL 239.72 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
Section VIII: Diagnostic and Therapeutic Radiological Services Georgia Workers Compensation Medical Fee Schedule 70010 79999 RADIOLOGY Effective April 1, 2011 Medical Fee Schedule 77327 BRACHYTX ISODOSE PLN INTRM 498.40 XXX 77327 26 BRACHYTX ISODOSE PLN INTRM 168.88 XXX 77327 TC BRACHYTX ISODOSE PLN INTRM 329.52 XXX 77328 BRACHYTX ISODOSE PLN CPLX 673.04 XXX 77328 26 BRACHYTX ISODOSE PLN CPLX 253.73 XXX 77328 TC BRACHYTX ISODOSE PLN CPLX 419.31 XXX 77331 SPEC DOSIM ONLY PRESCRIBED TREATING PHYS 153.23 XXX 77331 26 SPEC DOSIM ONLY PRESCRIBED TREATING PHYS 106.27 XXX 77331 TC SPEC DOSIM ONLY PRESCRIBED TREATING PHYS 46.96 XXX 77332 TX DEV DESIGN&CONSTJ SMPL SMPL BLK SMPL BOLUS 191.12 XXX 77332 26 TX DEV DESIGN&CONSTJ SMPL SMPL BLK SMPL BOLUS 65.90 XXX 77332 TC TX DEV DESIGN&CONSTJ SMPL SMPL BLK SMPL BOLUS 125.22 XXX 77333 TX DEV DESIGN&CONSTJ INTRM 144.99 XXX 77333 26 TX DEV DESIGN&CONSTJ INTRM 102.15 XXX 77333 TC TX DEV DESIGN&CONSTJ INTRM 42.84 XXX 77334 TX DEV DESIGN&CONSTJ CPLX 372.36 XXX 77334 26 TX DEV DESIGN&CONSTJ CPLX 149.93 XXX 77334 TC TX DEV DESIGN&CONSTJ CPLX 222.43 XXX 77336 CONTINUING MEDICAL PHYSICS CONSLTJ PR WK 126.87 XXX 77338 MLC IMRT DESIGN & CONSTRUCTION PER IMRT PLAN 1162.38 XXX 77338 26 MLC IMRT DESIGN & CONSTRUCTION PER IMRT PLAN 528.06 XXX 77338 TC MLC IMRT DESIGN & CONSTRUCTION PER IMRT PLAN 634.32 XXX 77370 SPEC MEDICAL RADJ PHYSICS CONSLTJ 282.56 XXX K 77371 RADIATION DELIVERY STEREOTACTIC CRANIAL COBALT 3413.83 XXX 77372 RADIATION DELIVERY STEREOTACTIC CRANIAL LINEAR 2065.27 XXX 77373 STEREOTACTIC BODY RADIATION DELIVERY 3856.21 XXX 77399 UNLIS MEDICAL RADJ DOSIM TX DEV SPEC SVCS BR XXX 77401 RADJ DLVR SUPFC&/ORTHO VOLTAGE 61.79 XXX 77402 RADJ DLVR 1 AREA 1/PRLL OPSD PORTS SMPL <5MEV 427.55 XXX 77403 RADJ DLVR 1 AREA 1/PRLL OPSD PORTS SMPL 6-10MEV 317.99 XXX 77404 RADJ DLVR 1 AREA 1/PRLL OPSD PORTS SMPL 11-19MEV 353.41 XXX 77406 RADJ DLVR 1 AREA 1/PRLL OPSD PORTS SMPL 20MEV/< 356.71 XXX 77407 RADJ DLVR 2 AREAS 3/>PORTS 1 MLT BLKS <5MEV 619.50 XXX 77408 RADJ DLVR 2 AREAS 3/>PORTS 1 MLT BLKS 6-1MEV 432.50 XXX 77409 RADJ DLVR 2 AREAS 3/>PORTS 1 MLT BLKS 11-19MEV 481.10 XXX 77411 RADJ DLVR 2 AREAS 3/> PORTS 1 TX AREA 20 MEV/< 478.63 XXX 77412 RADJ DLVR 3/> AREAS CUSTOM BLKING <5MEV 564.30 XXX 77413 RADJ DLVR 3/> AREAS CUSTOM BLKING 6-10MEV 568.42 XXX 77414 RADJ DLVR 3/> AREAS CUSTOM BLKING 11-19MEV 635.97 XXX 77416 RADJ DLVR 3/> AREAS CUSTOM BLKING 20MEV/< 639.27 XXX 77417 THER RAD PORT FLM 36.25 XXX 77418 NTSTY MODUL DLVR 1/MLT FLDS/ARCS PR TX SESSION 1260.41 XXX 77421 STRSC X-RAY GDN LOCLZJ TARGET VOL DLVR RADJ THER 266.91 XXX 77421 26 STRSC X-RAY GDN LOCLZJ TARGET VOL DLVR RADJ THER 46.96 XXX 77421 TC STRSC X-RAY GDN LOCLZJ TARGET VOL DLVR RADJ THER 219.95 XXX 77422 HI NRG NEUTRON RADJ TX DLVR 1 TX AREA 482.75 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
Georgia Workers Compensation Medical Fee Schedule Section VIII: Diagnostic and Therapeutic Radiological Services RADIOLOGY 70010 79999 Medical Fee Schedule Effective April 1, 2011 77423 HI NRG NEUTRON RADJ TX DLVR 1/> ISOCENTER 613.73 XXX 77427 RADJ TX MGMT 5 TXS 437.44 XXX 77431 RADJ THER MGMT COMPL 1/2 FXJS ONLY 239.73 XXX 77432 STERETCTC RADIATION TX MANAGEMENT CRANIAL LESION 991.03 XXX 77435 STEREOTACTIC BODY RADIATION MANAGEMENT 1641.83 XXX 77470 SPEC TX PX 490.16 XXX 77470 26 SPEC TX PX 254.55 XXX 77470 TC SPEC TX PX 235.61 XXX 77499 UNLIS THER RAD TX MGMT BR XXX 77520 PROTON TX DLVR SMPL W/O COMPENSATION BR XXX 77522 PROTON TX DLVR SMPL COMPENSATION BR XXX 77523 PROTON TX DLVR INTRM BR XXX 77525 PROTON TX DLVR CPLX BR XXX K 77600 HYPRTHM XTRNLLY GEN SUPFC 988.56 XXX K 77600 26 HYPRTHM XTRNLLY GEN SUPFC 189.47 XXX K 77600 TC HYPRTHM XTRNLLY GEN SUPFC 799.09 XXX K 77605 HYPRTHM XTRNLLY GEN DP 2258.86 XXX K 77605 26 HYPRTHM XTRNLLY GEN DP 271.03 XXX K 77605 TC HYPRTHM XTRNLLY GEN DP 1987.83 XXX K 77610 HYPRTHM GEN NTRSTL PRB 5/FEWER 2057.03 XXX K 77610 26 HYPRTHM GEN NTRSTL PRB 5/FEWER 186.18 XXX K 77610 TC HYPRTHM GEN NTRSTL PRB 5/FEWER 1870.85 XXX K 77615 HYPRTHM GEN NTRSTL PRB > 5 2358.54 XXX K 77615 26 HYPRTHM GEN NTRSTL PRB > 5 253.73 XXX K 77615 TC HYPRTHM GEN NTRSTL PRB > 5 2104.81 XXX 77620 HYPRTHM GEN INTRCV PRB 1166.50 XXX 77620 26 HYPRTHM GEN INTRCV PRB 182.88 XXX 77620 TC HYPRTHM GEN INTRCV PRB 983.62 XXX 77750 NFS/INSTLJ RADIOELMNT SLN 3 MO F-UP CARE 855.10 090 77750 26 NFS/INSTLJ RADIOELMNT SLN 3 MO F-UP CARE 608.79 090 77750 TC NFS/INSTLJ RADIOELMNT SLN 3 MO F-UP CARE 246.31 090 77761 INTRCV RADJ SRC APPL SMPL 893.00 090 77761 26 INTRCV RADJ SRC APPL SMPL 466.27 090 77761 TC INTRCV RADJ SRC APPL SMPL 426.73 090 77762 INTRCV RADJ SRC APPL INTRM 1200.28 090 77762 26 INTRCV RADJ SRC APPL INTRM 701.05 090 77762 TC INTRCV RADJ SRC APPL INTRM 499.23 090 77763 INTRCV RADJ SRC APPL CPLX 1698.68 090 77763 26 INTRCV RADJ SRC APPL CPLX 1052.82 090 77763 TC INTRCV RADJ SRC APPL CPLX 645.86 090 77776 NTRSTL RADJ SRC APPL SMPL 1023.16 090 77776 26 NTRSTL RADJ SRC APPL SMPL 577.48 090 77776 TC NTRSTL RADJ SRC APPL SMPL 445.68 090 77777 NTRSTL RADJ SRC APPL INTRM 1417.76 090 77777 26 NTRSTL RADJ SRC APPL INTRM 930.89 090 77777 TC NTRSTL RADJ SRC APPL INTRM 486.87 090 + 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
Section VIII: Diagnostic and Therapeutic Radiological Services Georgia Workers Compensation Medical Fee Schedule 70010 79999 RADIOLOGY Effective April 1, 2011 Medical Fee Schedule 77778 NTRSTL RADJ SRC APPL CPLX 2041.38 090 77778 26 NTRSTL RADJ SRC APPL CPLX 1378.22 090 77778 TC NTRSTL RADJ SRC APPL CPLX 663.16 090 77785 REMOTE AFTLD RADIONUCLIDE BRACHYTX 1 CHANNEL 533.00 XXX 77785 26 REMOTE AFTLD RADIONUCLIDE BRACHYTX 1 CHANNEL 173.00 XXX 77785 TC REMOTE AFTLD RADIONUCLIDE BRACHYTX 1 CHANNEL 360.00 XXX 77786 REMOTE AFTLD RADIONUCLIDE BRACHYTX 2-12 CHANNEL 1384.81 XXX 77786 26 REMOTE AFTLD RADIONUCLIDE BRACHYTX 2-12 CHANNEL 392.13 XXX 77786 TC REMOTE AFTLD RADIONUCLIDE BRACHYTX 2-12 CHANNEL 992.68 XXX 77787 REMOTE AFTLD RADIONUCLIDE BRACHYTX > 12 CHANNEL 2208.61 XXX 77787 26 REMOTE AFTLD RADIONUCLIDE BRACHYTX > 12 CHANNEL 599.73 XXX 77787 TC REMOTE AFTLD RADIONUCLIDE BRACHYTX > 12 CHANNEL 1608.88 XXX 77789 SURF APPL RADJ SRC 269.38 000 77789 26 SURF APPL RADJ SRC 139.22 000 77789 TC SURF APPL RADJ SRC 130.16 000 77790 SUPVJ HANDLING LOADING RADJ SRC 220.78 XXX 77790 26 SUPVJ HANDLING LOADING RADJ SRC 126.87 XXX 77790 TC SUPVJ HANDLING LOADING RADJ SRC 93.91 XXX 77799 UNLIS CLINICAL BRACHYTX BR XXX 78000 THYR UPTK 1 DETER 174.65 XXX 78000 26 THYR UPTK 1 DETER 23.07 XXX 78000 TC THYR UPTK 1 DETER 151.58 XXX 78001 THYR UPTK MLT DETERS 224.07 XXX 78001 26 THYR UPTK MLT DETERS 31.30 XXX 78001 TC THYR UPTK MLT DETERS 192.77 XXX 78003 THYR UPTK STIMJ SUPRJ/DSCHRG X 1ST UPTK STD 194.42 XXX 78003 26 THYR UPTK STIMJ SUPRJ/DSCHRG X 1ST UPTK STD 39.54 XXX 78003 TC THYR UPTK STIMJ SUPRJ/DSCHRG X 1ST UPTK STD 154.88 XXX 78006 THYR IMG UPTK 1 DETER 571.72 XXX 78006 26 THYR IMG UPTK 1 DETER 59.31 XXX 78006 TC THYR IMG UPTK 1 DETER 512.41 XXX 78007 THYR IMG UPTK MLT DETERS 473.69 XXX 78007 26 THYR IMG UPTK MLT DETERS 60.14 XXX 78007 TC THYR IMG UPTK MLT DETERS 413.55 XXX 78010 THYR IMG ONLY 394.60 XXX 78010 26 THYR IMG ONLY 45.31 XXX 78010 TC THYR IMG ONLY 349.29 XXX 78011 THYR IMG VASC FLO 435.79 XXX 78011 26 THYR IMG VASC FLO 55.19 XXX 78011 TC THYR IMG VASC FLO 380.60 XXX 78015 THYR CARC METASTASES IMG LMTD AREA 522.29 XXX 78015 26 THYR CARC METASTASES IMG LMTD AREA 79.91 XXX 78015 TC THYR CARC METASTASES IMG LMTD AREA 442.38 XXX 78016 THYR CARC METASTASES IMG ADDL STD 738.95 XXX 78016 26 THYR CARC METASTASES IMG ADDL STD 91.44 XXX 78016 TC THYR CARC METASTASES IMG ADDL STD 647.51 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
Georgia Workers Compensation Medical Fee Schedule Section VIII: Diagnostic and Therapeutic Radiological Services RADIOLOGY 70010 79999 Medical Fee Schedule Effective April 1, 2011 78018 THYR CARC METASTASES IMG WHBDY 772.72 XXX 78018 26 THYR CARC METASTASES IMG WHBDY 101.33 XXX 78018 TC THYR CARC METASTASES IMG WHBDY 671.39 XXX + 78020 THYR CARC METASTASES UPTK 209.25 ZZZ + 78020 26 THYR CARC METASTASES UPTK 70.02 ZZZ + 78020 TC THYR CARC METASTASES UPTK 139.23 ZZZ 78070 PARATHYR IMG 402.01 XXX 78070 26 PARATHYR IMG 98.03 XXX 78070 TC PARATHYR IMG 303.98 XXX 78075 ADRNL IMG CORTEX&/MEDULLA 1033.05 XXX 78075 26 ADRNL IMG CORTEX&/MEDULLA 87.32 XXX 78075 TC ADRNL IMG CORTEX&/MEDULLA 945.73 XXX 78099 UNLIS ENDOC PX DX NUC MED BR XXX 78102 B1 MARROW IMG LMTD AREA 403.66 XXX 78102 26 B1 MARROW IMG LMTD AREA 65.08 XXX 78102 TC B1 MARROW IMG LMTD AREA 338.58 XXX 78103 B1 MARROW IMG MLT AREAS 532.17 XXX 78103 26 B1 MARROW IMG MLT AREAS 88.15 XXX 78103 TC B1 MARROW IMG MLT AREAS 444.02 XXX 78104 B1 MARROW IMG WHBDY 604.67 XXX 78104 26 B1 MARROW IMG WHBDY 94.74 XXX 78104 TC B1 MARROW IMG WHBDY 509.93 XXX 78110 PLSM VOL RP VOL-DIL TQ SPX 1 SAMPLING 201.01 XXX 78110 26 PLSM VOL RP VOL-DIL TQ SPX 1 SAMPLING 23.07 XXX 78110 TC PLSM VOL RP VOL-DIL TQ SPX 1 SAMPLING 177.94 XXX 78111 PLSM VOL RP VOL-DIL TQ SPX MLT SAMPLINGS 212.54 XXX 78111 26 PLSM VOL RP VOL-DIL TQ SPX MLT SAMPLINGS 25.54 XXX 78111 TC PLSM VOL RP VOL-DIL TQ SPX MLT SAMPLINGS 187.00 XXX 78120 RBC VOL DETER SPX 1 SAMPLING 213.36 XXX 78120 26 RBC VOL DETER SPX 1 SAMPLING 28.01 XXX 78120 TC RBC VOL DETER SPX 1 SAMPLING 185.35 XXX 78121 RBC VOL DETER SPX MLT SAMPLINGS 244.67 XXX 78121 26 RBC VOL DETER SPX MLT SAMPLINGS 37.89 XXX 78121 TC RBC VOL DETER SPX MLT SAMPLINGS 206.78 XXX 78122 WHL BLD VOL DETER RP VOL-DIL TQ 272.68 XXX 78122 26 WHL BLD VOL DETER RP VOL-DIL TQ 51.90 XXX 78122 TC WHL BLD VOL DETER RP VOL-DIL TQ 220.78 XXX 78130 RBC SURV STD 376.48 XXX 78130 26 RBC SURV STD 74.97 XXX 78130 TC RBC SURV STD 301.51 XXX 78135 RBC SURV STD DIFFIAL ORGAN/TISS KIN 832.86 XXX 78135 26 RBC SURV STD DIFFIAL ORGAN/TISS KIN 78.26 XXX 78135 TC RBC SURV STD DIFFIAL ORGAN/TISS KIN 754.60 XXX 78140 LBLD RBC SQSJ DIFFIAL ORGAN/TISS 337.76 XXX 78140 26 LBLD RBC SQSJ DIFFIAL ORGAN/TISS 74.14 XXX 78140 TC LBLD RBC SQSJ DIFFIAL ORGAN/TISS 263.62 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
Section VIII: Diagnostic and Therapeutic Radiological Services Georgia Workers Compensation Medical Fee Schedule 70010 79999 RADIOLOGY Effective April 1, 2011 Medical Fee Schedule 78185 SPLEEN IMG ONLY +-VASC FLO 487.69 XXX 78185 26 SPLEEN IMG ONLY +-VASC FLO 47.78 XXX 78185 TC SPLEEN IMG ONLY +-VASC FLO 439.91 XXX 78190 KIN STD PLTLT SURV +-DIFFIAL ORGAN/TISS LOCLZJ 917.71 XXX 78190 26 KIN STD PLTLT SURV +-DIFFIAL ORGAN/TISS LOCLZJ 129.34 XXX 78190 TC KIN STD PLTLT SURV +-DIFFIAL ORGAN/TISS LOCLZJ 788.37 XXX 78191 PLTLT SURV STD 430.02 XXX 78191 26 PLTLT SURV STD 74.14 XXX 78191 TC PLTLT SURV STD 355.88 XXX 78195 LYMPHATICS&LYMPH NOD IMG 855.10 XXX 78195 26 LYMPHATICS&LYMPH NOD IMG 144.17 XXX 78195 TC LYMPHATICS&LYMPH NOD IMG 710.93 XXX 78199 UNLIS HEMATOP RET/ENDO&LYMPHATIC DX NUC MED BR XXX 78201 LVR IMG STATIC ONLY 450.62 XXX 78201 26 LVR IMG STATIC ONLY 52.72 XXX 78201 TC LVR IMG STATIC ONLY 397.90 XXX 78202 LVR IMG VASC FLO 490.98 XXX 78202 26 LVR IMG VASC FLO 57.67 XXX 78202 TC LVR IMG VASC FLO 433.31 XXX 78205 LVR IMG SPECT 551.95 XXX 78205 26 LVR IMG SPECT 84.85 XXX 78205 TC LVR IMG SPECT 467.10 XXX 78206 LVR IMG SPECT VASC FLO 843.57 XXX 78206 26 LVR IMG SPECT VASC FLO 113.68 XXX 78206 TC LVR IMG SPECT VASC FLO 729.89 XXX 78215 LVR&SPLEEN IMG STATIC ONLY 466.27 XXX 78215 26 LVR&SPLEEN IMG STATIC ONLY 59.31 XXX 78215 TC LVR&SPLEEN IMG STATIC ONLY 406.96 XXX 78216 LVR&SPLEEN IMG VASC FLO 317.16 XXX 78216 26 LVR&SPLEEN IMG VASC FLO 67.55 XXX 78216 TC LVR&SPLEEN IMG VASC FLO 249.61 XXX 78220 LVR FUNCJ STD HEPATBL AGT SRL IMAGES 331.17 XXX 78220 26 LVR FUNCJ STD HEPATBL AGT SRL IMAGES 56.84 XXX 78220 TC LVR FUNCJ STD HEPATBL AGT SRL IMAGES 274.33 XXX 78223 HEPATBL DUX SYS IMG GLBLDR 802.38 XXX 78223 26 HEPATBL DUX SYS IMG GLBLDR 100.50 XXX 78223 TC HEPATBL DUX SYS IMG GLBLDR 701.88 XXX 78230 SALIVARY GLND IMG 402.84 XXX 78230 26 SALIVARY GLND IMG 54.37 XXX 78230 TC SALIVARY GLND IMG 348.47 XXX 78231 SALIVARY GLND IMG SRL IMAGES 312.22 XXX 78231 26 SALIVARY GLND IMG SRL IMAGES 60.96 XXX 78231 TC SALIVARY GLND IMG SRL IMAGES 251.26 XXX 78232 SALIVARY GLND FUNCJ STD 285.03 XXX 78232 26 SALIVARY GLND FUNCJ STD 53.55 XXX 78232 TC SALIVARY GLND FUNCJ STD 231.48 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
Georgia Workers Compensation Medical Fee Schedule Section VIII: Diagnostic and Therapeutic Radiological Services RADIOLOGY 70010 79999 Medical Fee Schedule Effective April 1, 2011 78258 ESOPHGL MOTILITY 553.59 XXX 78258 26 ESOPHGL MOTILITY 88.97 XXX 78258 TC ESOPHGL MOTILITY 464.62 XXX 78261 GSTR MUCOSA IMG 606.32 XXX 78261 26 GSTR MUCOSA IMG 84.03 XXX 78261 TC GSTR MUCOSA IMG 522.29 XXX 78262 G-ESOP RFLX STD 593.96 XXX 78262 26 G-ESOP RFLX STD 79.08 XXX 78262 TC G-ESOP RFLX STD 514.88 XXX 78264 GSTR EMPTYING STD 692.82 XXX 78264 26 GSTR EMPTYING STD 93.09 XXX 78264 TC GSTR EMPTYING STD 599.73 XXX 78267 UREA BRTH TST C-14 ISOTOPIC ACQUISJ ALYS 27.19 XXX 78268 UREA BRTH TST C-14 ISOTOPIC ALYS 229.84 XXX 78270 VIT B-12 ABSRPJ STD W/O INTRNSC FACTOR 196.89 XXX 78270 26 VIT B-12 ABSRPJ STD W/O INTRNSC FACTOR 23.89 XXX 78270 TC VIT B-12 ABSRPJ STD W/O INTRNSC FACTOR 173.00 XXX 78271 VIT B-12 ABSRPJ STD INTRNSC FACTOR 207.60 XXX 78271 26 VIT B-12 ABSRPJ STD INTRNSC FACTOR 23.89 XXX 78271 TC VIT B-12 ABSRPJ STD INTRNSC FACTOR 183.71 XXX 78272 VIT B-12 ABSRPJ STD CMBN W/&W/O INTRNSC FACTOR 220.78 XXX 78272 26 VIT B-12 ABSRPJ STD CMBN W/&W/O INTRNSC FACTOR 31.30 XXX 78272 TC VIT B-12 ABSRPJ STD CMBN W/&W/O INTRNSC FACTOR 189.48 XXX 78278 AQT GI BLD LOSS IMG 837.80 XXX 78278 26 AQT GI BLD LOSS IMG 118.63 XXX 78278 TC AQT GI BLD LOSS IMG 719.17 XXX 78282 GI PROTEIN LOSS 187.83 XXX 78282 26 GI PROTEIN LOSS 46.96 XXX 78282 TC GI PROTEIN LOSS 140.87 XXX 78290 INT IMG 779.31 XXX 78290 26 INT IMG 82.38 XXX 78290 TC INT IMG 696.93 XXX 78291 PRTL-VEN SHUNT PATENCY TST 612.91 XXX 78291 26 PRTL-VEN SHUNT PATENCY TST 105.45 XXX 78291 TC PRTL-VEN SHUNT PATENCY TST 507.46 XXX 78299 UNLIS GI PX DX NUC MED BR XXX 78300 B1&/JT IMG LMTD AREA 427.55 XXX 78300 26 B1&/JT IMG LMTD AREA 74.97 XXX 78300 TC B1&/JT IMG LMTD AREA 352.58 XXX 78305 B1&/JT IMG MLT AREAS 564.30 XXX 78305 26 B1&/JT IMG MLT AREAS 98.86 XXX 78305 TC B1&/JT IMG MLT AREAS 465.44 XXX 78306 B1&/JT IMG WHBDY 614.55 XXX 78306 26 B1&/JT IMG WHBDY 102.98 XXX 78306 TC B1&/JT IMG WHBDY 511.57 XXX 78315 B1&/JT IMG 3 PHASE STD 836.98 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
Section VIII: Diagnostic and Therapeutic Radiological Services Georgia Workers Compensation Medical Fee Schedule 70010 79999 RADIOLOGY Effective April 1, 2011 Medical Fee Schedule 78315 26 B1&/JT IMG 3 PHASE STD 121.92 XXX 78315 TC B1&/JT IMG 3 PHASE STD 715.06 XXX 78320 B1&/JT IMG TOMOG SPECT 592.31 XXX 78320 26 B1&/JT IMG TOMOG SPECT 123.57 XXX 78320 TC B1&/JT IMG TOMOG SPECT 468.74 XXX 78350 B1 DNS STD 1+ SITS 1 PHTN ABSRPTM 79.91 XXX 78350 26 B1 DNS STD 1+ SITS 1 PHTN ABSRPTM 26.36 XXX 78350 TC B1 DNS STD 1+ SITS 1 PHTN ABSRPTM 53.55 XXX 78351 B1 DNS STD 1+ SITS DUAL PHTN ABSRPTM 1+ SITS 36.25 XXX 78351 26 B1 DNS STD 1+ SITS DUAL PHTN ABSRPTM 1+ SITS 10.71 XXX 78351 TC B1 DNS STD 1+ SITS DUAL PHTN ABSRPTM 1+ SITS 25.54 XXX 78399 UNLIS MUSCSKEL PX DX NUC MED BR XXX 78414 DETER CTR C-V HEMODYN NON-IMG +-RX 1/MLT 181.24 XXX 78414 26 DETER CTR C-V HEMODYN NON-IMG +-RX 1/MLT 54.37 XXX 78414 TC DETER CTR C-V HEMODYN NON-IMG +-RX 1/MLT 126.87 XXX 78428 CAR SHUNT DETCJ 470.39 XXX 78428 26 CAR SHUNT DETCJ 95.56 XXX 78428 TC CAR SHUNT DETCJ 374.83 XXX 78445 NON-CAR VASC FLO IMG 415.20 XXX 78445 26 NON-CAR VASC FLO IMG 56.84 XXX 78445 TC NON-CAR VASC FLO IMG 358.36 XXX 78451 MYOCARDIAL SPECT SINGLE STUDY AT REST OR STRESS 827.10 XXX 78451 26 MYOCARDIAL SPECT SINGLE STUDY AT REST OR STRESS 159.82 XXX 78451 TC MYOCARDIAL SPECT SINGLE STUDY AT REST OR STRESS 667.28 XXX 78452 MYOCARDIAL SPECT MULTIPLE STUDIES 1158.26 XXX 78452 26 MYOCARDIAL SPECT MULTIPLE STUDIES 188.65 XXX 78452 TC MYOCARDIAL SPECT MULTIPLE STUDIES 969.61 XXX 78453 MYOCARDIAL PERFUSION PLANAR 1 STUDY REST/STRESS 710.94 XXX 78453 26 MYOCARDIAL PERFUSION PLANAR 1 STUDY REST/STRESS 116.98 XXX 78453 TC MYOCARDIAL PERFUSION PLANAR 1 STUDY REST/STRESS 593.96 XXX 78454 MYOCARDIAL PERFUSION PLANAR MULTIPLE STUDIES 1026.45 XXX 78454 26 MYOCARDIAL PERFUSION PLANAR MULTIPLE STUDIES 155.70 XXX 78454 TC MYOCARDIAL PERFUSION PLANAR MULTIPLE STUDIES 870.75 XXX 78456 AQT VEN THROMBOSIS IMG PEPTIDE 858.40 XXX 78456 26 AQT VEN THROMBOSIS IMG PEPTIDE 123.57 XXX 78456 TC AQT VEN THROMBOSIS IMG PEPTIDE 734.83 XXX 78457 VEN THROMBOSIS IMG VENOGRAM UNI 473.69 XXX 78457 26 VEN THROMBOSIS IMG VENOGRAM UNI 92.27 XXX 78457 TC VEN THROMBOSIS IMG VENOGRAM UNI 381.42 XXX 78458 VEN THROMBOSIS IMG VENOGRAM BI 476.16 XXX 78458 26 VEN THROMBOSIS IMG VENOGRAM BI 103.80 XXX 78458 TC VEN THROMBOSIS IMG VENOGRAM BI 372.36 XXX 78459 MYOCRD IMG P+ EMIJ TOMOG METAB EVAL 1075.88 XXX 78459 26 MYOCRD IMG P+ EMIJ TOMOG METAB EVAL 182.88 XXX 78459 TC MYOCRD IMG P+ EMIJ TOMOG METAB EVAL 893.00 XXX 78466 MYOCRD IMG INFARCT AVID PLNR QUAL/QUAN 438.26 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
Georgia Workers Compensation Medical Fee Schedule Section VIII: Diagnostic and Therapeutic Radiological Services RADIOLOGY 70010 79999 Medical Fee Schedule Effective April 1, 2011 78466 26 MYOCRD IMG INFARCT AVID PLNR QUAL/QUAN 84.85 XXX 78466 TC MYOCRD IMG INFARCT AVID PLNR QUAL/QUAN 353.41 XXX 78468 MYOCRD IMG INFARCT AVID PLNR EJEC FXJ 1ST PS TQ 531.35 XXX 78468 26 MYOCRD IMG INFARCT AVID PLNR EJEC FXJ 1ST PS TQ 99.68 XXX 78468 TC MYOCRD IMG INFARCT AVID PLNR EJEC FXJ 1ST PS TQ 431.67 XXX 78469 MYOCRD IMG INFARCT AVID PLNR TOMOG SPECT +-QUAN 625.26 XXX 78469 26 MYOCRD IMG INFARCT AVID PLNR TOMOG SPECT +-QUAN 115.33 XXX 78469 TC MYOCRD IMG INFARCT AVID PLNR TOMOG SPECT +-QUAN 509.93 XXX 78472 CARD BPI GTD =BRM PLNR 1 STD REST/STRS 611.26 XXX 78472 26 CARD BPI GTD =BRM PLNR 1 STD REST/STRS 119.45 XXX 78472 TC CARD BPI GTD =BRM PLNR 1 STD REST/STRS 491.81 XXX 78473 CARD BPI GTD =BRM MLT STD WALL MOTION STD 807.32 XXX 78473 26 CARD BPI GTD =BRM MLT STD WALL MOTION STD 180.41 XXX 78473 TC CARD BPI GTD =BRM MLT STD WALL MOTION STD 626.91 XXX 78481 CARD BPI PLNR 1ST PS 1 STD PLUS EJEC FXJ 509.93 XXX 78481 26 CARD BPI PLNR 1ST PS 1 STD PLUS EJEC FXJ 122.75 XXX 78481 TC CARD BPI PLNR 1ST PS 1 STD PLUS EJEC FXJ 387.18 XXX 78483 CARD BPI PLNR 1ST PS MLT STD PLUS EJEC FXJ 707.64 XXX 78483 26 CARD BPI PLNR 1ST PS MLT STD PLUS EJEC FXJ 185.36 XXX 78483 TC CARD BPI PLNR 1ST PS MLT STD PLUS EJEC FXJ 522.28 XXX 78491 MYOCRD IMG P+ EMIJ TOMOG PRFUJ 1 STD 1158.26 XXX 78491 26 MYOCRD IMG P+ EMIJ TOMOG PRFUJ 1 STD 185.36 XXX 78491 TC MYOCRD IMG P+ EMIJ TOMOG PRFUJ 1 STD 972.90 XXX 78492 MYOCRD IMG P+ EMIJ TOMOG PRFUJ MLT STD 1467.19 XXX 78492 26 MYOCRD IMG P+ EMIJ TOMOG PRFUJ MLT STD 234.78 XXX 78492 TC MYOCRD IMG P+ EMIJ TOMOG PRFUJ MLT STD 1232.41 XXX 78494 CARD BPI GTD =BRM SPECT REST WALL MOTION 650.80 XXX 78494 26 CARD BPI GTD =BRM SPECT REST WALL MOTION 146.64 XXX 78494 TC CARD BPI GTD =BRM SPECT REST WALL MOTION 504.16 XXX + 78496 CARD BPI GTD =BRM 1 STD REST R VENTR EJEC FXJ 196.06 ZZZ + 78496 26 CARD BPI GTD =BRM 1 STD REST R VENTR EJEC FXJ 60.96 ZZZ + 78496 TC CARD BPI GTD =BRM 1 STD REST R VENTR EJEC FXJ 135.10 ZZZ 78499 UNLIS CV DX NUC MED BR XXX 78580 PULM PI PART 515.70 XXX 78580 26 PULM PI PART 88.15 XXX 78580 TC PULM PI PART 427.55 XXX 78584 PULM PI PART VNTJ 1 BRTH 370.71 XXX 78584 26 PULM PI PART VNTJ 1 BRTH 119.45 XXX 78584 TC PULM PI PART VNTJ 1 BRTH 251.26 XXX 78585 PULM PI PART VNTJ RBRTHING&WSHOT +-1 BRTH 856.75 XXX 78585 26 PULM PI PART VNTJ RBRTHING&WSHOT +-1 BRTH 130.16 XXX 78585 TC PULM PI PART VNTJ RBRTHING&WSHOT +-1 BRTH 726.59 XXX 78586 PULM VI AERSL 1 PROJECTION 403.66 XXX 78586 26 PULM VI AERSL 1 PROJECTION 46.96 XXX 78586 TC PULM VI AERSL 1 PROJECTION 356.70 XXX 78587 PULM VI AERSL MLT PRJCJ 505.81 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
Section VIII: Diagnostic and Therapeutic Radiological Services Georgia Workers Compensation Medical Fee Schedule 70010 79999 RADIOLOGY Effective April 1, 2011 Medical Fee Schedule 78587 26 PULM VI AERSL MLT PRJCJ 58.49 XXX 78587 TC PULM VI AERSL MLT PRJCJ 447.32 XXX 78588 PULM PI PART VNTJ IMG AERSL 1/MLT PRJCJ 830.39 XXX 78588 26 PULM PI PART VNTJ IMG AERSL 1/MLT PRJCJ 130.16 XXX 78588 TC PULM PI PART VNTJ IMG AERSL 1/MLT PRJCJ 700.23 XXX 78591 PULM VI GASEOUS 1 PRJCJ 408.60 XXX 78591 26 PULM VI GASEOUS 1 PRJCJ 47.78 XXX 78591 TC PULM VI GASEOUS 1 PRJCJ 360.82 XXX 78593 PULM VI GASEOUS RBRTHING&WSHOT 1 PRJCJ 475.33 XXX 78593 26 PULM VI GASEOUS RBRTHING&WSHOT 1 PRJCJ 59.31 XXX 78593 TC PULM VI GASEOUS RBRTHING&WSHOT 1 PRJCJ 416.02 XXX 78594 PULM VI GASEOUS RBRTHING&WSHOT MLT PRJCJ 525.58 XXX 78594 26 PULM VI GASEOUS RBRTHING&WSHOT MLT PRJCJ 62.61 XXX 78594 TC PULM VI GASEOUS RBRTHING&WSHOT MLT PRJCJ 462.97 XXX 78596 PULM QUAN DIFFIAL FUNCJ VNTJ/PRFUJ STD 903.71 XXX 78596 26 PULM QUAN DIFFIAL FUNCJ VNTJ/PRFUJ STD 147.46 XXX 78596 TC PULM QUAN DIFFIAL FUNCJ VNTJ/PRFUJ STD 756.25 XXX 78599 UNLIS RESPIR PX DX NUC MED BR XXX 78600 BRAIN IMAGING <4 STATIC VIEWS 435.79 XXX 78600 26 BRAIN IMAGING <4 STATIC VIEWS 52.72 XXX 78600 TC BRAIN IMAGING <4 STATIC VIEWS 383.07 XXX 78601 BRAIN IMAGING <4 STATIC VIEWS W/VASCULAR FLOW 517.35 XXX 78601 26 BRAIN IMAGING <4 STATIC VIEWS W/VASCULAR FLOW 60.96 XXX 78601 TC BRAIN IMAGING <4 STATIC VIEWS W/VASCULAR FLOW 456.39 XXX 78605 BRAIN IMAGING MIN 4 STATIC VIEWS 478.63 XXX 78605 26 BRAIN IMAGING MIN 4 STATIC VIEWS 65.08 XXX 78605 TC BRAIN IMAGING MIN 4 STATIC VIEWS 413.55 XXX 78606 BRAIN IMAGING MIN 4 STATIC VIEWS W VASCULAR FLOW 785.08 XXX 78606 26 BRAIN IMAGING MIN 4 STATIC VIEWS W VASCULAR FLOW 74.97 XXX 78606 TC BRAIN IMAGING MIN 4 STATIC VIEWS W VASCULAR FLOW 710.11 XXX 78607 BRAIN IMAGING TOMOGRAPHIC SPECT 879.82 XXX 78607 26 BRAIN IMAGING TOMOGRAPHIC SPECT 144.17 XXX 78607 TC BRAIN IMAGING TOMOGRAPHIC SPECT 735.65 XXX 78608 BRN IMG P+ EMIJ TOMOG METAB EVAL 1503.44 XXX 78608 26 BRN IMG P+ EMIJ TOMOG METAB EVAL 180.41 XXX 78608 TC BRN IMG P+ EMIJ TOMOG METAB EVAL 1323.03 XXX 78609 BRN IMG P+ EMIJ TOMOG PRFUJ EVAL 183.71 XXX 78609 26 BRN IMG P+ EMIJ TOMOG PRFUJ EVAL 183.71 XXX 78609 TC BRN IMG P+ EMIJ TOMOG PRFUJ EVAL 0.00 XXX 78610 BRN IMG VASC FLO ONLY 430.02 XXX 78610 26 BRN IMG VASC FLO ONLY 36.25 XXX 78610 TC BRN IMG VASC FLO ONLY 393.77 XXX 78630 CEREBSP FLU FLO IMG X INTRO MATRL CISTRNG 815.56 XXX 78630 26 CEREBSP FLU FLO IMG X INTRO MATRL CISTRNG 81.56 XXX 78630 TC CEREBSP FLU FLO IMG X INTRO MATRL CISTRNG 734.00 XXX 78635 CEREBSP FLU FLO IMG X INTRO MATRL VENTRG 777.67 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
Georgia Workers Compensation Medical Fee Schedule Section VIII: Diagnostic and Therapeutic Radiological Services RADIOLOGY 70010 79999 Medical Fee Schedule Effective April 1, 2011 78635 26 CEREBSP FLU FLO IMG X INTRO MATRL VENTRG 72.49 XXX 78635 TC CEREBSP FLU FLO IMG X INTRO MATRL VENTRG 705.18 XXX 78645 CEREBSP FLU FLO IMG X INTRO MATRL SHUNT EVAL 766.96 XXX 78645 26 CEREBSP FLU FLO IMG X INTRO MATRL SHUNT EVAL 68.38 XXX 78645 TC CEREBSP FLU FLO IMG X INTRO MATRL SHUNT EVAL 698.58 XXX 78647 CEREBSP FLU FLO IMG X INTRO MATRL TOMOG SPECT 842.75 XXX 78647 26 CEREBSP FLU FLO IMG X INTRO MATRL TOMOG SPECT 106.27 XXX 78647 TC CEREBSP FLU FLO IMG X INTRO MATRL TOMOG SPECT 736.48 XXX 78650 CEREBSP FLU LEAKAGE DETCJ&LOCLZJ 799.09 XXX 78650 26 CEREBSP FLU LEAKAGE DETCJ&LOCLZJ 73.32 XXX 78650 TC CEREBSP FLU LEAKAGE DETCJ&LOCLZJ 725.77 XXX 78660 RP DACRYOCSTOGRAPY 429.20 XXX 78660 26 RP DACRYOCSTOGRAPY 65.08 XXX 78660 TC RP DACRYOCSTOGRAPY 364.12 XXX 78699 UNLIS NRVS SYS PX DX NUC MED BR XXX 78700 KIDNEY IMAGING MORPHOLOGY 427.55 XXX 78700 26 KIDNEY IMAGING MORPHOLOGY 55.19 XXX 78700 TC KIDNEY IMAGING MORPHOLOGY 372.36 XXX 78701 KDN IMG VASC FLO 516.52 XXX 78701 26 KDN IMG VASC FLO 59.31 XXX 78701 TC KDN IMG VASC FLO 457.21 XXX 78707 KIDNEY IMG MORPHOLOGY VASCULAR FLOW 1 W/O RX 576.66 XXX 78707 26 KIDNEY IMG MORPHOLOGY VASCULAR FLOW 1 W/O RX 113.68 XXX 78707 TC KIDNEY IMG MORPHOLOGY VASCULAR FLOW 1 W/O RX 462.98 XXX 78708 KIDNEY IMG MORPHOLOGY VASCULAR FLOW 1 W RX 438.26 XXX 78708 26 KIDNEY IMG MORPHOLOGY VASCULAR FLOW 1 W RX 144.17 XXX 78708 TC KIDNEY IMG MORPHOLOGY VASCULAR FLOW 1 W RX 294.09 XXX 78709 KIDNEY IMG MORPHOLOGY VASCULAR FLOW MULTIPLE 888.88 XXX 78709 26 KIDNEY IMG MORPHOLOGY VASCULAR FLOW MULTIPLE 168.06 XXX 78709 TC KIDNEY IMG MORPHOLOGY VASCULAR FLOW MULTIPLE 720.82 XXX 78710 KIDNEY IMAGING MORPHOLOGY TOMOGRAPHIC 539.59 XXX 78710 26 KIDNEY IMAGING MORPHOLOGY TOMOGRAPHIC 75.79 XXX 78710 TC KIDNEY IMAGING MORPHOLOGY TOMOGRAPHIC 463.80 XXX 78725 KDN FUNCJ STD NON-IMG RADIOISOTOPIC STD 248.79 XXX 78725 26 KDN FUNCJ STD NON-IMG RADIOISOTOPIC STD 44.49 XXX 78725 TC KDN FUNCJ STD NON-IMG RADIOISOTOPIC STD 204.30 XXX + 78730 URINARY BLADDER RESIDUAL STUDY 181.24 ZZZ + 78730 26 URINARY BLADDER RESIDUAL STUDY 19.77 ZZZ + 78730 TC URINARY BLADDER RESIDUAL STUDY 161.47 ZZZ 78740 URTRL RFLX STD RP VOIDING CSTOGRAM 537.12 XXX 78740 26 URTRL RFLX STD RP VOIDING CSTOGRAM 70.02 XXX 78740 TC URTRL RFLX STD RP VOIDING CSTOGRAM 467.10 XXX 78761 TESTICULAR IMAGING WITH VASCULAR FLOW 515.70 XXX 78761 26 TESTICULAR IMAGING WITH VASCULAR FLOW 86.50 XXX 78761 TC TESTICULAR IMAGING WITH VASCULAR FLOW 429.20 XXX 78799 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
Section VIII: Diagnostic and Therapeutic Radiological Services Georgia Workers Compensation Medical Fee Schedule 70010 79999 RADIOLOGY Effective April 1, 2011 Medical Fee Schedule 78800 RP LOCLZJ TUM/DSTRBJ AGT LMTD AREA 453.91 XXX 78800 26 RP LOCLZJ TUM/DSTRBJ AGT LMTD AREA 79.08 XXX 78800 TC RP LOCLZJ TUM/DSTRBJ AGT LMTD AREA 374.83 XXX 78801 RP LOCLZJ TUM/DSTRBJ AGT MLT AREAS 612.91 XXX 78801 26 RP LOCLZJ TUM/DSTRBJ AGT MLT AREAS 94.74 XXX 78801 TC RP LOCLZJ TUM/DSTRBJ AGT MLT AREAS 518.17 XXX 78802 RP LOCLZJ TUM/DSTRBJ AGT WHBDY 1 D IMG 792.50 XXX 78802 26 RP LOCLZJ TUM/DSTRBJ AGT WHBDY 1 D IMG 102.15 XXX 78802 TC RP LOCLZJ TUM/DSTRBJ AGT WHBDY 1 D IMG 690.35 XXX 78803 RP LOCLZJ TUM/DSTRBJ AGT TOMOG SPECT 851.81 XXX 78803 26 RP LOCLZJ TUM/DSTRBJ AGT TOMOG SPECT 128.51 XXX 78803 TC RP LOCLZJ TUM/DSTRBJ AGT TOMOG SPECT 723.30 XXX 78804 RP LOCLZJ TUM/DSTRBJ AGT WHBDY REQ 2/> D IMG 1407.87 XXX 78804 26 RP LOCLZJ TUM/DSTRBJ AGT WHBDY REQ 2/> D IMG 126.87 XXX 78804 TC RP LOCLZJ TUM/DSTRBJ AGT WHBDY REQ 2/> D IMG 1281.00 XXX 78805 RP LOCLZJ INFLAMMATORY PROCESS LMTD AREA 447.32 XXX 78805 26 RP LOCLZJ INFLAMMATORY PROCESS LMTD AREA 87.32 XXX 78805 TC RP LOCLZJ INFLAMMATORY PROCESS LMTD AREA 360.00 XXX 78806 RP LOCLZJ INFLAMMATORY PROCESS WHBDY 820.50 XXX 78806 26 RP LOCLZJ INFLAMMATORY PROCESS WHBDY 102.15 XXX 78806 TC RP LOCLZJ INFLAMMATORY PROCESS WHBDY 718.35 XXX 78807 RP LOCLZJ INFLAMMATORY PROCESS TOMOG SPECT 850.16 XXX 78807 26 RP LOCLZJ INFLAMMATORY PROCESS TOMOG SPECT 126.87 XXX 78807 TC RP LOCLZJ INFLAMMATORY PROCESS TOMOG SPECT 723.29 XXX 78808 NJX RP LOCLZJ NON-IMG PROBE STUDY INTRAVENOUS 104.62 XXX 78811 PET IMAGING LIMITED AREA CHEST HEAD/NECK 1613.00 XXX 78811 26 PET IMAGING LIMITED AREA CHEST HEAD/NECK 193.59 XXX 78811 TC PET IMAGING LIMITED AREA CHEST HEAD/NECK 1419.41 XXX 78812 PET IMAGING SKULL BASE TO MID-THIGH 1970.53 XXX 78812 26 PET IMAGING SKULL BASE TO MID-THIGH 236.43 XXX 78812 TC PET IMAGING SKULL BASE TO MID-THIGH 1734.10 XXX 78813 PET IMAGING WHOLE BODY 2059.50 XXX 78813 26 PET IMAGING WHOLE BODY 247.14 XXX 78813 TC PET IMAGING WHOLE BODY 1812.36 XXX 78814 PET IMAGING CT FOR ATTENUATION LIMITED AREA 2244.86 XXX 78814 26 PET IMAGING CT FOR ATTENUATION LIMITED AREA 269.38 XXX 78814 TC PET IMAGING CT FOR ATTENUATION LIMITED AREA 1975.48 XXX 78815 PET IMAGING CT ATTENUATION SKULL BASE MID-THIGH 2498.59 XXX 78815 26 PET IMAGING CT ATTENUATION SKULL BASE MID-THIGH 299.86 XXX 78815 TC PET IMAGING CT ATTENUATION SKULL BASE MID-THIGH 2198.73 XXX 78816 PET IMAGING FOR CT ATTENUATION WHOLE BODY 2539.78 XXX 78816 26 PET IMAGING FOR CT ATTENUATION WHOLE BODY 304.81 XXX 78816 TC PET IMAGING FOR CT ATTENUATION WHOLE BODY 2234.97 XXX 78999 UNLIS MISC DX NUC MED BR XXX 79005 RP THER ORAL ADMN 346.00 XXX 79005 26 RP THER ORAL ADMN 213.36 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
Georgia Workers Compensation Medical Fee Schedule Section VIII: Diagnostic and Therapeutic Radiological Services RADIOLOGY 70010 79999 Medical Fee Schedule Effective April 1, 2011 79005 TC RP THER ORAL ADMN 132.64 XXX 79101 RP THER IV ADMN 391.31 XXX 79101 26 RP THER IV ADMN 247.14 XXX 79101 TC RP THER IV ADMN 144.17 XXX 79200 RP THER INTRCV ADMN 406.13 XXX 79200 26 RP THER INTRCV ADMN 242.20 XXX 79200 TC RP THER INTRCV ADMN 163.93 XXX 79300 RP THER NTRSTL RADACT COL ADMN 329.52 XXX 79300 26 RP THER NTRSTL RADACT COL ADMN 197.71 XXX 79300 TC RP THER NTRSTL RADACT COL ADMN 131.81 XXX 79403 RP THER RADIOLBLD MONOCLONAL ANTB IV NFS 494.28 XXX 79403 26 RP THER RADIOLBLD MONOCLONAL ANTB IV NFS 271.03 XXX 79403 TC RP THER RADIOLBLD MONOCLONAL ANTB IV NFS 223.25 XXX 79440 RP THER INTRA-ARTICULAR ADMN 381.42 XXX 79440 26 RP THER INTRA-ARTICULAR ADMN 243.84 XXX 79440 TC RP THER INTRA-ARTICULAR ADMN 137.58 XXX 79445 RP THER IA PART ADMN 531.35 XXX 79445 26 RP THER IA PART ADMN 291.63 XXX 79445 TC RP THER IA PART ADMN 239.72 XXX 79999 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
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 80500 and 80502 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 36415. For collection of capillary blood specimen, see CPT code 36416. For collection of blood specimen from a completely implantable venous access device, see CPT code 36591. For handling, see CPT codes 99000 and 99001. B. Only the physician or laboratory drawing the blood or obtaining the specimen is entitled to a collection and handling fee. C. Relative value units for specimen collection, handling, and patient administrative service are assigned in relation to the complexity of the process. D. Although there is no billing for the test itself, the physician or laboratory performing the service can report a collection and handling charge. The test ordered and the name of the testing facility should be indicated. E. When collection and handling are performed at the testing facility (laboratory), the laboratory may include separate charges for these services. Professional Component The maximum allowable reimbursement (MAR) includes the professional component (PC) plus the technical component (TC). 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
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 80047 80076) 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.
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 25. 90 Reference (Outside) Laboratory: When laboratory procedures are performed by a party other than the treating or reporting physician, the procedure may be identified by adding 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 86701 86703). 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
Georgia Workers Compensation Medical Fee Schedule Section IX: Pathology and Laboratory Services PATHOLOGY AND LABORATORY 80047 89398 Medical Fee Schedule Effective April 1, 2011 80047 BASIC METABOLIC PANEL CALCIUM IONIZED 15.99 XXX 80048 BASIC METABOLIC PANEL CALCIUM TOTAL 15.99 XXX 80050 GENERAL HLTH PANEL 54.36 XXX 80051 ELECTROLYTE PANEL 13.25 XXX 80053 COMPRE METAB PANEL 20.10 XXX 80055 OB PANEL 79.48 XXX 80061 LIPID PANEL 31.52 XXX 80069 RNL FUNCJ PANEL 16.44 XXX 80074 AQT HEP PANEL 89.08 XXX 80076 HEPATC FUNCJ PANEL 15.53 XXX 80100 DRUG SCR QUAL MLT DRUG CLASSES CHROM EA PX 27.41 XXX 80101 DRUG SCR QUAL 1 DRUG CLASS METH EA DRUG CLASS 37.46 XXX 80102 DRUG CONFIRMATION EA PX 25.12 XXX 80103 TISS PREPJ DRUG ALYS 32.89 XXX l # 80104 DRUG SCRN QUAL 1+ CLASS NONCHROMOTOGRAPHIC EA 47.51 XXX 80150 AMIKACIN 28.32 XXX 80152 AMITRIPTYLINE 33.80 XXX 80154 BENZODIAZEPINES 35.17 XXX 80156 CARBAMAZEPINE TOT 27.41 XXX 80157 CARBAMAZEPINE FR 25.12 XXX 80158 CYCLOSPORINE 34.26 XXX 80160 DESIPRAMINE 32.43 XXX 80162 DIGOXIN 25.12 XXX 80164 DIPROPYLACETIC ACID 25.58 XXX 80166 DOXEPIN 29.24 XXX 80168 ETHOSUXIMIDE 31.06 XXX 80170 GENTAMICIN 31.06 XXX 80172 GOLD 30.61 XXX 80173 HALOPRIDOL 27.41 XXX 80174 IMIPRAMINE 32.43 XXX 80176 LIDOCAINE 27.86 XXX 80178 LITHIUM 12.33 XXX 80182 NORTRIPTYLINE 25.58 XXX 80184 PHENOBARBITAL 21.47 XXX 80185 PHENYTOIN TOT 25.12 XXX 80186 PHENYTOIN FR 26.04 XXX 80188 PRIMIDONE 31.52 XXX 80190 PROCAINAMIDE 31.52 XXX 80192 PROCAINAMIDE METABOLITES 31.52 XXX 80194 QUINIDINE 27.41 XXX 80195 SIROLIMUS 26.04 XXX 80196 SALICYLATE 13.25 XXX 80197 TACROLIMUS 26.04 XXX 80198 THEOPHYLLINE 26.95 XXX 80200 TOBRAMYCIN 30.61 XXX 80201 TOPIRAMATE 22.38 XXX 222 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section IX: Pathology and Laboratory Services Georgia Workers Compensation Medical Fee Schedule 80047 89398 PATHOLOGY AND LABORATORY Effective April 1, 2011 Medical Fee Schedule 80202 VANCOMYCIN 25.58 XXX 80299 QUAN DRUG NES 26.04 XXX 80400 ACTH STIMJ PANEL ADRNL INSUFFICIENCY 93.19 XXX 80402 ACTH STIMJ PANEL 21 HYDROXYLASE DEFNCY 151.66 XXX 80406 ACTH STIMJ PANEL 3 BETA-HYDROXYDEHYD DEFNCY 159.42 XXX 80408 ALDOSTERONE SUPRJ EVAL PANEL 173.58 XXX 80410 CALCITONIN STIMJ PANEL 143.89 XXX 80412 CORTICOTROPIC RELEASING HORM STIMJ PANEL 446.29 XXX 80414 CHORNC GONAD STIMJ PANEL TSTOSTERONE RSPSE 74.46 XXX 80415 CHORNC GONAD STIMJ PANEL ESTRADIOL RSPSE 74.46 XXX 80416 RNL VEIN RENIN STIMJ PANEL 222.00 XXX 80417 PRPH VEIN RENIN STIMJ PANEL 95.01 XXX 80418 CMBN RAPID ANT PITUITARY EVAL PANEL 991.26 XXX 80420 DXMETHASONE SUPRJ PANEL 48 HR 123.79 XXX 80422 GLUC TOLERANCE PANEL INSULINOMA 84.05 XXX 80424 GLUC TOLERANCE PANEL PHEOCHROMOCYTOMA 84.05 XXX 80426 GONAD RELEASING HORM STIMJ PANEL 232.97 XXX 80428 GROWTH HORM STIMJ PANEL 128.82 XXX 80430 GROWTH HORM SUPRJ PANEL GLUC ADMN 128.82 XXX 80432 INSULIN-INDUCED C-PEPTIDE SUPRJ PANEL 252.61 XXX 80434 INSULIN TOLERANCE PANEL ACTH INSUFFICIENCY 158.51 XXX 80435 INSULIN TOLERANCE PANEL GROWTH HORM DEFNCY 168.56 XXX 80436 METYRAPONE PANEL 163.53 XXX 80438 TRH STIMJ PANEL 1 HR 94.10 XXX 80439 TRH STIMJ PANEL 2 HR 99.13 XXX 80440 TRH STIMJ PANEL HYPRPROLACTINEMIA 99.13 XXX 80500 CLIN PATH CONSLTJ LIMITED 27.86 XXX 80502 CLIN PATH CONSLTJ COMPRE 85.88 XXX 81000 URNLS DIP STICK/TABLET RGNT NON-AUTO MIC 5.94 XXX 81001 URNLS DIP STICK/TABLET RGNT AUTO MIC 5.94 XXX 81002 URNLS DIP STICK/TABLET RGNT NON-AUTO W/O MIC 5.02 XXX 81003 URNLS DIP STICK/TABLET RGNT AUTO W/O MIC 4.11 XXX 81005 URNLS QUAL/SEMIQUAN XCPT IAS 4.11 XXX 81007 URNLS BACTERIURIA SCR XCPT CULTURE/DIPSTICK 5.02 XXX 81015 URNLS MCRSCP ONLY 5.94 XXX 81020 URNLS 2/3 GLASS TST 6.85 XXX 81025 URINE PREGNANCY TST VIS COLOR CMPRSN METHS 11.88 XXX 81050 VOL MEAS TMD COLLJ EA 5.48 XXX 81099 UNLIS URNLS BR XXX 82000 ACETALDEHYDE BLD 23.30 XXX 82003 ACETAMINOPHEN 38.37 XXX 82009 ACETONE/OTH KETONE BODIES SERUM QUAL 8.68 XXX 82010 ACETONE/OTH KETONE BODIES SERUM QUAN 15.53 XXX 82013 ACETYLCHOLINESTERASE 21.01 XXX 82016 ACYLCARNITINES QUAL EA SPEC 26.04 XXX 82017 ACYLCARNITINES QUAN EA SPEC 31.98 XXX Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 223
Georgia Workers Compensation Medical Fee Schedule Section IX: Pathology and Laboratory Services PATHOLOGY AND LABORATORY 80047 89398 Medical Fee Schedule Effective April 1, 2011 82024 ADRENOCORTICOTROPIC HORM 73.09 XXX 82030 ADENOSINE 5-MONOPHOSPHATE CYCLIC 48.88 XXX 82040 ALBUMIN SERUM PLASMA/WHOLE BLOOD 9.14 XXX 82042 ALBUMIN URINE/OTH SRC QUAN EA SPEC 9.59 XXX 82043 ALBUMIN URINE MICROALBUMIN QUAN 10.96 XXX 82044 ALBUMIN URINE MICROALBUMIN SEMIQUAN 8.68 XXX 82045 ALBUMIN ISCHEMIA MODF 64.41 XXX 82055 ALCOHOL ANY SPEC XCPT BRTH 20.56 XXX 82075 ALCOHOL BRTH 22.84 XXX 82085 ALDOLASE 18.27 XXX 82088 ALDOSTERONE 77.20 XXX 82101 ALKALOIDS URINE QUAN 56.64 XXX 82103 ALPHA-1-ANTITRYPSIN TOT 25.58 XXX 82104 ALPHA-1-ANTITRYPSIN PHEXYP 27.41 XXX 82105 ALPHA-FETOPROTEIN SERUM 31.52 XXX 82106 ALPHA-FETOPROTEIN AMNIOTIC FLU 31.52 XXX 82107 AFP-L3 FRACTION ISOFORM & TOTAL AFP W/RATIO 121.97 XXX 82108 ALUMINUM 48.42 XXX 82120 AMINES VAG FLU QUAL 7.31 XXX 82127 AMINO ACIDS 1 QUAL EA SPEC 26.04 XXX 82128 AMINO ACIDS MLT QUAL EA SPEC 26.04 XXX 82131 AMINO ACIDS 1 QUAN EA SPEC 31.98 XXX 82135 AMINOLEVULINIC ACID DELTA 31.06 XXX 82136 AMINO ACIDS 2-5 AMINO ACIDS QUAN EA SPEC 31.98 XXX 82139 AMINO ACIDS 6/> AMINO ACIDS QUAN EA SPEC 31.98 XXX 82140 AMMONIA 27.41 XXX 82143 AMNIOTIC FLU SCAN 12.79 XXX 82145 AMPHETAMINE/METHAMPHETAMINE 29.24 XXX 82150 AMYLASE 12.33 XXX 82154 ANDROSTANEDIOL GLUCURONIDE 54.36 XXX 82157 ANDROSTENEDIONE 55.27 XXX 82160 ANDROSTERONE 47.51 XXX 82163 ANGIOTENSIN II 38.83 XXX 82164 ANGIOTENSIN I-CONVERTING ENZYME 27.41 XXX 82172 APOLIPOPROTEIN EA 29.24 XXX 82175 ARSENIC 36.09 XXX 82180 ASCORBIC ACID BLD 18.73 XXX 82190 ATOMIC ABSRPJ SPECTROSCOPY EA ANAL 28.32 XXX 82205 BARBITURATES NES 21.47 XXX 82232 BETA-2 MICROGLOBULIN 30.61 XXX 82239 BILE ACIDS TOT 32.43 XXX 82240 BILE ACIDS CHOLYLGLYCINE 50.25 XXX 82247 BILIRUBIN TOT 9.59 XXX 82248 BILIRUBIN DIR 9.59 XXX 82252 BILIRUBIN FECES QUAL 8.68 XXX 82261 BIOTINIDASE EA SPEC 31.98 XXX 224 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section IX: Pathology and Laboratory Services Georgia Workers Compensation Medical Fee Schedule 80047 89398 PATHOLOGY AND LABORATORY Effective April 1, 2011 Medical Fee Schedule 82270 BLD OCLT PROXIDASE ACTV QUAL FECES 1 DETER 5.94 XXX 82271 BLD OCLT PROXIDASE ACTV QUAL OTH SRCS 5.94 XXX 82272 BLOOD OCCULT PEROXIDASE ACTV QUAL FECES 1-3 SPEC 5.94 XXX 82274 BLD OCLT FECAL HGB DETER IA QUAL FECES 1-3 30.15 XXX 82286 BRADYKININ 13.25 XXX 82300 CADMIUM 43.85 XXX 82306 25 HYDROXY INCLUDES FRACTIONS IF PERFORMED 56.19 XXX 82308 CALCITONIN 50.70 XXX 82310 CALCIUM TOT 9.59 XXX 82330 CALCIUM IONIZED 26.04 XXX 82331 CALCIUM AFTER CALCIUM NFS TST 9.59 XXX 82340 CALCIUM URINE QUAN TMD SPEC 11.42 XXX 82355 ST1 QUAL ALYS 21.93 XXX 82360 ST1 QUAN ALYS CHEM 24.21 XXX 82365 ST1 INFRARED SPECTROSCOPY 24.21 XXX 82370 ST1 X-RAY DIFFXJ 23.75 XXX 82373 CARBOHYDRATE DEFICIENT TRRIN 34.26 XXX 82374 CARBON DIOXIDE 9.14 XXX 82375 CARBOXYHEMOGLOBIN QUANTITATIVE 23.30 XXX 82376 CARBOXYHEMOGLOBIN QUALITATIVE 11.42 XXX 82378 CARCINOEMBRYONIC AG 36.09 XXX 82379 CARNITINE QUAN EA SPEC 31.98 XXX 82380 CAROTENE 17.36 XXX 82382 CATECHOLAMINES TOT URINE 32.43 XXX 82383 CATECHOLAMINES BLD 47.51 XXX 82384 CATECHOLAMINES FXJATED 47.96 XXX 82387 CATHEPSIN-D 39.28 XXX 82390 CERULOPLASMIN 20.56 XXX 82397 CHEMILUMINESCENT ASSAY 26.95 XXX 82415 CHLORAMPHENICOL 23.75 XXX 82435 CHLORIDE BLD 8.68 XXX 82436 CHLORIDE URINE 9.59 XXX 82438 CHLORIDE OTH SRC 9.14 XXX 82441 CHLORINATED HYDROCARBONS SCR 11.42 XXX 82465 CHOLESTEROL SERUM/WHL BLD TOT 8.22 XXX 82480 CHOLINESTERASE SERUM 15.07 XXX 82482 CHOLINESTERASE RBC 14.62 XXX 82485 CHONDROITIN B SULFATE QUAN 39.28 XXX 82486 CHROM QUAL COLUMN ANAL NES 34.26 XXX 82487 CHROM QUAL PAPR 1-DIMENSIONAL ANAL NES 30.15 XXX 82488 CHROM QUAL PAPR 2-DIMENSIONAL ANAL NES 40.66 XXX 82489 CHROM QUAL THIN LYR ANAL NES 35.17 XXX 82491 CHROM QUAN COLUMN 1 ANAL NES 34.26 XXX 82492 CHROM QUAN COLUMN MLT ANALS 34.26 XXX 82495 CHROMIUM 38.37 XXX 82507 CITRATE 52.53 XXX Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 225
Georgia Workers Compensation Medical Fee Schedule Section IX: Pathology and Laboratory Services PATHOLOGY AND LABORATORY 80047 89398 Medical Fee Schedule Effective April 1, 2011 82520 COCAINE/METABOLITE 28.78 XXX 82523 COLLAGEN CROSS LINKS ANY METH 35.17 XXX 82525 COPPR 23.30 XXX 82528 CORTICOSTERONE 42.48 XXX 82530 CORTISOL FR 31.52 XXX 82533 CORTISOL TOT 31.06 XXX 82540 CREATINE 8.68 XXX 82541 COL-CHR/MS QUAL 1 STATIONARY&MOBILE PHASE 34.26 XXX 82542 COL-CHR/MS QUAN 1 STATIONARY&MOBILE PHASE 34.26 XXX 82543 COL-CHR/MS STABLE ISOTOPE DIL 1 ANAL 34.26 XXX 82544 COL-CHR/MS STABLE ISOTOPE DIL MLT ANALS 34.26 XXX 82550 CREATINE KINASE TOT 12.33 XXX 82552 CREATINE KINASE ISOENZYMES 25.58 XXX 82553 CREATINE KINASE MB FXJ ONLY 21.93 XXX 82554 CREATINE KINASE ISOFORMS 22.38 XXX 82565 CREATININE BLD 9.59 XXX 82570 CREATININE OTH SRC 9.59 XXX 82575 CREATININE CLEARANCE 17.82 XXX 82585 CRYOFIBRN 16.44 XXX 82595 CRYOGLOBULIN QUAL/SEMI-QUAN 12.33 XXX 82600 CYANIDE 36.54 XXX 82607 CYANOCOBALAMIN 28.32 XXX 82608 CYANOCOBALAMIN UNSAT BNDNG CAP 26.95 XXX 82610 CYSTATIN C 25.58 XXX 82615 CSTINE&HOMOCSTINE URINE QUAL 15.53 XXX 82626 DEHYDROEPIANDROSTERONE 47.96 XXX 82627 DEHYDROEPIANDROSTERONE-SULFATE 42.03 XXX 82633 DESOXYCORTICOSTERONE 11-58.47 XXX 82634 DEOXYCORTISOL 11-55.27 XXX 82638 DIBUCAINE NUMBER 23.30 XXX 82646 DIHYDROCODEINONE 39.28 XXX 82649 DIHYDROMORPHINONE 48.42 XXX 82651 DIHYDROTSTOSTERONE 48.88 XXX # 82652 1 25 DIHYDROXY INCLUDES FRACTIONS IF PERFORMED 72.63 XXX 82654 DIMETHADIONE 26.04 XXX 82656 ELASTASE PNCRTC FECAL QUAL/SEMI-QUAN 21.93 XXX 82657 NZM ACTV CELLS/TISS NONRADACT SUBSTRATE EA 34.26 XXX 82658 NZM ACTV CELLS/TISS RADACT SUBSTRATE EA 34.26 XXX 82664 ELECTROP TQ NES 64.87 XXX 82666 EPIANDROSTERONE 40.66 XXX 82668 ERYTHROPOIETIN 35.63 XXX 82670 ESTRADIOL 52.99 XXX 82671 STRGNS FXJATED 61.21 XXX 82672 STRGNS TOT 41.11 XXX 82677 ESTRIOL 45.68 XXX 82679 ESTRONE 47.05 XXX 226 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section IX: Pathology and Laboratory Services Georgia Workers Compensation Medical Fee Schedule 80047 89398 PATHOLOGY AND LABORATORY Effective April 1, 2011 Medical Fee Schedule 82690 ETHCHLORVYNOL 32.89 XXX 82693 ETHYLENE GLYCOL 28.32 XXX 82696 ETIOCHOLANOLONE 44.77 XXX 82705 FAT/LIPIDS FECES QUAL 9.59 XXX 82710 FAT/LIPIDS FECES QUAN 31.98 XXX 82715 FAT DIFFIAL FECES QUAN 32.43 XXX 82725 FATTY ACIDS NONESTERIFIED 25.12 XXX 82726 VERY LONG CHAIN FATTY ACIDS 34.26 XXX 82728 FERRITIN 25.58 XXX 82731 FTL FIBRONECTIN CERVICOVAG SECRETIONS SEMI-QUAN 121.97 XXX 82735 FLUORIDE 35.17 XXX 82742 FLURAZEPAM 37.46 XXX 82746 FOLIC ACID SERUM 27.86 XXX 82747 FOLIC ACID RBC 32.89 XXX 82757 FRUCTOSE SEMEN 32.89 XXX 82759 GALACTOKINASE RBC 40.66 XXX 82760 GALACTOSE 21.01 XXX 82775 GALACTOSE-1-PHOSPHATE URIDYL TRASE QUAN 39.74 XXX 82776 GALACTOSE-1-PHOSPHATE URIDYL TRASE SCR 15.99 XXX 82784 GAMMAGLOBULIN IGA IGD IGG IGM EACH 17.82 XXX 82785 GAMMAGLOBULIN IGE 31.06 XXX 82787 GAMMAGLOBULIN IMMUNOGLOBULIN SUBCLASSES 15.07 XXX 82800 GASES BLD PH ONLY 15.99 XXX 82803 BLOOD GASES ANY COMBINATION PH PCO2 PO2 CO2 HCO3 36.54 XXX 82805 GASES BLD PH DIR MEAS XCPT PLS OXIMTRY 53.90 XXX 82810 GASES BLD O2 SATURATION ONLY DIR MEAS 16.44 XXX 82820 HGB-O2 AFFINITY PO2 50% SATURATION OXYGEN 18.73 XXX l 82930 GASTRIC ACID ANALYIS W/PH EA SPECIMEN 10.51 XXX 82938 GASTRIN AFTER SECRETIN STIMJ 33.35 XXX 82941 GASTRIN 33.35 XXX 82943 GLUC 26.95 XXX 82945 GLUC BDY FLU OTH/THN BLD 7.31 XXX 82946 GLUC TOLERANCE TST 28.32 XXX 82947 GLUC QUAN BLD 7.31 XXX 82948 GLUC BLD RGNT STRIP 5.94 XXX 82950 GLUC POST GLUC DOSE GLUC 9.14 XXX 82951 GLUC TOLERANCE TST GTT 3 SPEC GLUC 24.21 XXX s + 82952 GLUCOSE TOLERANCE EA ADDL BEYOND 3 SPECIMENS 7.31 XXX 82953 GLUC TOLBUTAMIDE TOLERANCE TST 28.78 XXX 82955 GLUC-6-PHOSPHATE DEHYD QUAN 18.27 XXX 82960 GLUC-6-PHOSPHATE DEHYD SCR 11.42 XXX 82962 GLUC BLD GLUC MNTR DEV CLEARED FDA SPEC HOME USE 4.57 XXX 82963 GLUCOSIDASE BETA 40.66 XXX 82965 GLUTAMATE DEHYD 14.62 XXX 82975 GLUTAMINE 30.15 XXX 82977 GLUTAMYLTRASE GAMMA 13.70 XXX Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 227
Georgia Workers Compensation Medical Fee Schedule Section IX: Pathology and Laboratory Services PATHOLOGY AND LABORATORY 80047 89398 Medical Fee Schedule Effective April 1, 2011 82978 GLUTATHIONE 26.95 XXX 82979 GLUTATHIONE REDUXASE RBC 13.25 XXX 82980 GLUTETHIMIDE 34.72 XXX 82985 GLYCATED PROTEIN 28.32 XXX 83001 GONAD FOLLICLE STIMULATING HORM 35.17 XXX 83002 GONAD LTNZNG HORM 35.17 XXX 83003 GROWTH HORM HUMAN 31.52 XXX 83008 GUANOSINE MONOPHOSPHATE CYCLIC 31.98 XXX 83009 HPYLORI BLD NON-RADACT ISOTOPE 127.45 XXX 83010 HAPTOGLOBIN QUAN 23.75 XXX 83012 HAPTOGLOBIN PHEXYP 32.43 XXX 83013 HPYLORI BRTH NON-RADACT ISOTOPE 127.45 XXX 83014 HPYLORI DRUG ADMN 15.07 XXX 83015 HEAVY METAL SCR 35.63 XXX 83018 HEAVY METAL QUAN EA 41.57 XXX 83020 HGB FXJ&QUAN ELECTROPHORESIS 50.25 XXX 83020 26 HGB FXJ&QUAN ELECTROPHORESIS 26.04 XXX 83020 TC HGB FXJ&QUAN ELECTROPHORESIS 24.21 XXX 83021 HGB FXJ&QUAN CHROM 34.26 XXX 83026 HGB COPPR SULFATE METH NON-AUTO 4.57 XXX 83030 HGB F CHEM 15.53 XXX 83033 HGB F QUAL 11.42 XXX 83036 HGB GLYCOSYLATED 18.27 XXX 83037 HGB GLYCOSYLATED DEV CLEARED FDA HOME USE 18.27 XXX 83045 HGB METHGB QUAL 9.59 XXX 83050 HGB METHGB QUAN 13.70 XXX 83051 HGB PLSM 13.70 XXX 83055 HGB SULFHGB QUAL 9.14 XXX 83060 HGB SULFHGB QUAN 15.53 XXX 83065 HGB THERMOLABILE 13.25 XXX 83068 HGB UNSTABLE SCR 15.99 XXX 83069 HGB URINE 7.31 XXX 83070 HEMOSIDERIN QUAL 9.14 XXX 83071 HEMOSIDERIN QUAN 12.79 XXX 83080 B-HEXOSAMINIDASE EA ASSAY 31.98 XXX 83088 HISTAM 55.73 XXX 83090 HOMOCSTEINE 31.98 XXX 83150 HOMOVANILLIC ACID 36.54 XXX 83491 HYDROXYCORTICOSTRDS 17 33.35 XXX 83497 HYDROXYINDOLACETIC ACID 5 24.21 XXX 83498 HYDROXYPROGST 17-D 51.62 XXX 83499 HYDROXYPROGST 20-47.51 XXX 83500 HYDROXYPROLINE FR 42.94 XXX 83505 HYDROXYPROLINE TOT 46.14 XXX 83516 IMMUNOASSAY ANALYTE QUAL/SEMIQUAL MULTIPLE STEP 21.93 XXX 83518 IMMUNOASSAY ANALYTE QUAL/SEMIQUAL SINGLE STEP 15.99 XXX 228 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section IX: Pathology and Laboratory Services Georgia Workers Compensation Medical Fee Schedule 80047 89398 PATHOLOGY AND LABORATORY Effective April 1, 2011 Medical Fee Schedule 83519 IMMUNOASSAY ANALYTE QUANT RADIOIMMUNOASSAY 25.58 XXX 83520 IMMUNOASSAY ANALYTE QUANTITATIVE NOS 24.67 XXX 83525 INSULIN TOT 21.47 XXX 83527 INSULIN FR 24.67 XXX 83528 INTRNSC FACTOR 30.15 XXX 83540 IRON 12.33 XXX 83550 IRON BNDNG CAP 16.44 XXX 83570 ISOCITRIC DEHYD 16.90 XXX 83582 KETOGENIC STRDS FXJ 26.95 XXX 83586 KETOSTRDS 17 TOT 24.21 XXX 83593 KETOSTRDS 17-FXJ 49.79 XXX 83605 LACTATE 20.10 XXX 83615 LACTATE DEHYD 11.42 XXX 83625 LACTATE DEHYD ISOENZYMES SEP&QUAN 24.21 XXX 83630 LACTOFERRIN FECAL QUAL 37.00 XXX 83631 LACTOFERRIN FECAL QUAN 37.00 XXX 83632 LACTOGEN HPL HUMAN CHORNC SOMAT 38.37 XXX 83633 LACTOSE URINE QUAL 10.51 XXX 83634 LACTOSE URINE QUAN 21.93 XXX 83655 LEAD 22.84 XXX 83661 FTL LNG MATRT ASSMT L/S RATIO 41.57 XXX 83662 FTL LNG MATRT ASSMT FOAM STABILITY TST 35.63 XXX 83663 FTL LNG MATRT ASSMT FLUORESCENCE POLARIZATION 35.63 XXX 83664 FTL LNG MATRT ASSMT LAMELLAR BDY DNS 35.63 XXX 83670 LEUCINE AMINOPEPTIDASE LAP 17.36 XXX 83690 LIPASE 13.25 XXX 83695 LIPOPROTEIN A 24.67 XXX 83698 LIPOPROTEIN-ASSOCIATED PHOSPHOLIPASE A2 64.41 XXX 83700 LIPOPROTEIN BLD ELECTROP SEP&QUAN 21.47 XXX 83701 LIPOPROTEIN BLD HR SUBCLASSES 47.05 XXX 83704 LIPOPROTEIN BLD QUAN NUMBERS&SUBCLASSES 59.84 XXX 83718 LIPOPROTEIN DIR MEAS HI DNS CHOLESTEROL 15.53 XXX 83719 LIPOPROTEIN DIR MEAS VLDL CHOLESTEROL 21.93 XXX 83721 LIPOPROTEIN DIR MEAS LDL CHOLESTEROL 17.82 XXX 83727 LTNZNG RELEASING FACTOR 32.43 XXX 83735 MAGNESIUM 12.79 XXX 83775 MALATE DEHYD 14.16 XXX 83785 MANGANESE 46.59 XXX 83788 MASS SPECT&TANDEM MASS SPECT ANAL QUAL EA SPEC 34.26 XXX 83789 MASS SPECT&TANDEM MASS SPECT ANAL QUAN EA SPEC 34.26 XXX 83805 MEPROBAMATE 33.35 XXX 83825 MERCURY QUAN 30.61 XXX 83835 METANEPHRINES 31.98 XXX 83840 METHADONE 31.06 XXX 83857 METHEMALBUMIN 20.56 XXX 83858 METHSUXIMIDE 27.86 XXX Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 229
Georgia Workers Compensation Medical Fee Schedule Section IX: Pathology and Laboratory Services PATHOLOGY AND LABORATORY 80047 89398 Medical Fee Schedule Effective April 1, 2011 l 83861 MICROFLUID ANALYSIS TEAR OSMOLARITY 31.52 XXX 83864 MUCOPOLYSACS ACID QUAN 37.46 XXX 83866 MUCOPOLYSACS ACID SCR 18.73 XXX 83872 MUCIN SYNVAL FLU ROPES TST 10.96 XXX 83873 MYELIN BASIC PROTEIN CEREBSP FLU 32.43 XXX 83874 MYOGLOBIN 24.21 XXX 83876 MYELOPEROXIDASE MPO 64.41 XXX 83880 NATRIURETIC PEPTIDE 64.41 XXX 83883 NEPHELOMETRY EA ANAL NES 25.58 XXX 83885 NICKEL 46.14 XXX 83887 NICOTINE 44.77 XXX 83890 MOLEC DIAG ISOL/XTRJ EA NUCLEIC ACID TYPE 7.77 XXX 83891 MOLEC ISOL/XTRJ HP NUCLEIC ACID EA TYPE 7.77 XXX 83892 MOLEC ENZYMATIC DIGESTION EA ENZYME TX 7.77 XXX 83893 MOLEC DOT/SLOT BLOT EA NUCLEIC ACID PREPJ 7.77 XXX 83894 MOLEC SEP GEL ELECTROPHORESIS EACH PREPJ 7.77 XXX 83896 MOLEC NUCLEIC ACID PRB EA 7.77 XXX 83897 MOLEC NUCLEIC ACID TR EA NUCLEIC ACID PREPJ 7.77 XXX 83898 MOLECULAR DX AMPLIFICATION TARGET EA SEQUENCE 31.52 XXX 83900 MOLECULAR DX AMP TARGET MULTIPLEX 1ST 2 SEQ 63.50 XXX + 83901 MOLECULAR DX AMP TARGET MULTIPLEX EA ADDL SEQ 31.52 XXX 83902 MOLEC REVERSE TRANSCRIPTION 26.95 XXX 83903 MOLEC MUTATION SCANNING PROPERTIES 1 SGM EACH 31.52 XXX 83904 MOLEC MUTATION ID SEQUENCING 1 SGM EA SGM 31.52 XXX 83905 MOLEC MUTATION ALLELE TRANSCRIPTION 1 SGM EA 31.52 XXX 83906 MOLEC MUTATION ALLELE SPEC TRANSLATION 1 SGM EA 31.52 XXX 83907 MOLEC LSS CELLS PRIOR NUCLEIC ACID XTRJ 25.12 XXX 83908 MOLECULAR DX AMPLIFICATION SIGNAL EA SEQUENCE 31.52 XXX 83909 MOLEC SEP&ID HR TQ 31.52 XXX 83912 MOLEC DX I&R 32.43 XXX 83912 26 MOLEC DX I&R 24.67 XXX 83912 TC MOLEC DX I&R 7.76 XXX 83913 MOLECULAR DIAGNOSTICS RNA STABILIZATION 25.12 XXX 83914 MUTATION ID ENZYMATIC LIG/PRIMER XTN 1 SGM EA 31.52 XXX 83915 NUCLEOTIDASE 5'- 21.01 XXX 83916 OLIGOCLONAL IMMUNE 37.91 XXX 83918 ORGANIC ACIDS TOT QUAN EA SPEC 31.06 XXX 83919 ORGANIC ACIDS QUAL EA SPEC 31.06 XXX 83921 ORGANIC ACID 1 QUAN 31.06 XXX 83925 OPIATE(S) DRUG AND METABOLITES EACH PROCEDURE 37.00 XXX 83930 OSMOLALITY BLD 12.33 XXX 83935 OSMOLALITY URINE 12.79 XXX 83937 OSTEOCALCIN 56.64 XXX 83945 OXALATE 24.21 XXX 83950 ONCOPROTEIN HER-2/NEU 121.97 XXX 83951 ONCOPROTEIN DES-GAMMA-CARBOXY-PROTHROMBIN DCP 121.97 XXX 230 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section IX: Pathology and Laboratory Services Georgia Workers Compensation Medical Fee Schedule 80047 89398 PATHOLOGY AND LABORATORY Effective April 1, 2011 Medical Fee Schedule 83970 PARATHORM 78.11 XXX 83986 PH BODY FLUID NOS 6.85 XXX 83987 PH EXHALED BREATH CONDENSATE 30.15 XXX 83992 PHENCYCLIDINE 27.86 XXX 83993 CALPROTECTIN FECAL 37.00 XXX 84022 PHEXHIAZINE 29.69 XXX 84030 PHENYLALA9 BLD 10.51 XXX 84035 PHENYLKETONES QUAL 6.85 XXX 84060 PHOSPHATASE ACID TOT 14.16 XXX 84061 PHOSPHATASE ACID FORENSIC XM 15.07 XXX 84066 PHOSPHATASE ACID PROSTATIC 18.27 XXX 84075 PHOSPHATASE ALKALINE 9.59 XXX 84078 PHOSPHATASE ALKALINE HEAT STABLE TOT X W/ 13.70 XXX 84080 PHOSPHATASE ALKALINE ISOENZYMES 27.86 XXX 84081 PHOSPHATIDYLGLYCEROL 31.06 XXX 84085 PHOSPHOGLUCONATE 6-DEHYD RBC 12.79 XXX 84087 PHOSPHOHEXOSE ISOMERASE 19.64 XXX 84100 PHOSPHORUS INORGANIC 9.14 XXX 84105 PHOSPHORUS INORGANIC URINE 9.59 XXX 84106 PORPHOBILINOGEN URINE QUAL 8.22 XXX 84110 PORPHOBILINOGEN URINE QUAN 15.99 XXX l 84112 PLACENTAL ALPHA MICROGLOBULIN C/V QUAL 121.97 XXX 84119 PORPHYRINS URINE QUAL 16.44 XXX 84120 PORPHYRINS URINE QUAN&FXJ 27.86 XXX 84126 PORPHYRINS FECES QUAN 48.42 XXX 84127 PORPHYRINS FECES QUAL 21.93 XXX 84132 POTASSIUM SERUM PLASMA/WHOLE BLOOD 8.68 XXX 84133 POTASSIUM URINE 8.22 XXX 84134 PREALBUMIN 27.41 XXX 84135 PREGNANEDIOL 36.09 XXX 84138 PREGNANETRIOL 35.63 XXX 84140 PREGNENOLONE 39.28 XXX 84143 17-HYDROXYPREGNENOLONE 43.40 XXX 84144 PROGST 39.28 XXX 84145 PROCALCITONIN (PCT) 50.70 XXX 84146 PROLACTIN 36.54 XXX 84150 PROSTAGLNDIN EA 47.05 XXX 84152 PRST8 SPEC AG CPLXED DIR MEAS 34.72 XXX 84153 PRST8 SPEC AG TOT 34.72 XXX 84154 PRST8 SPEC AG FR 34.72 XXX 84155 PROTEIN XCPT REFRACTOMETRY SERUM PLASMA/WHL BLD 6.85 XXX 84156 PROTEIN TOT XCPT REFRACTOMETRY URINE 6.85 XXX 84157 PROTEIN TOT XCPT REFRACTOMETRY OTH SRC 6.85 XXX 84160 PROTEIN TOT REFRACTOMETRY ANY SRC 9.59 XXX 84163 PREGNANCY-ASSOCIATED PLSM PROTEIN-A 28.32 XXX 84165 PROTEIN ELECTROP FXJ&QUAN SERUM 46.14 XXX Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 231
Georgia Workers Compensation Medical Fee Schedule Section IX: Pathology and Laboratory Services PATHOLOGY AND LABORATORY 80047 89398 Medical Fee Schedule Effective April 1, 2011 84165 26 PROTEIN ELECTROP FXJ&QUAN SERUM 25.58 XXX 84165 TC PROTEIN ELECTROP FXJ&QUAN SERUM 20.56 XXX 84166 PROTEIN ELECTROP FXJ&QUAN OTH FLUS CONCENTRATION 59.38 XXX 84166 26 PROTEIN ELECTROP FXJ&QUAN OTH FLUS CONCENTRATION 25.58 XXX 84166 TC PROTEIN ELECTROP FXJ&QUAN OTH FLUS CONCENTRATION 33.80 XXX 84181 PROTEIN WSTRN BLOT I&R BLD/OTH FLU 58.47 XXX 84181 26 PROTEIN WSTRN BLOT I&R BLD/OTH FLU 26.04 XXX 84181 TC PROTEIN WSTRN BLOT I&R BLD/OTH FLU 32.43 XXX 84182 PROTEIN WSTRN BLOT BLD/OTH FLU IMMUNOLOGICAL 59.84 XXX 84182 26 PROTEIN WSTRN BLOT BLD/OTH FLU IMMUNOLOGICAL 25.58 XXX 84182 TC PROTEIN WSTRN BLOT BLD/OTH FLU IMMUNOLOGICAL 34.26 XXX 84202 PROTOPORPHYRIN RBC QUAN 26.95 XXX 84203 PROTOPORPHYRIN RBC SCR 16.44 XXX 84206 PROINSULIN 33.80 XXX 84207 PYRIDOXAL PHOSPHATE 52.99 XXX 84210 PYRUVATE 20.56 XXX 84220 PYRUVATE KINASE 17.82 XXX 84228 QUININE 21.93 XXX 84233 RCPTR ASSAY STRGN 121.97 XXX 84234 RCPTR ASSAY PROGST 122.88 XXX 84235 RCPTR ASSAY ENDOC OTH/THN STRGN/PROGST 99.13 XXX 84238 RCPTR ASSAY NON-ENDOC SPEC RCPTR 68.98 XXX 84244 RENIN 41.57 XXX 84252 RIBOFLAVIN 38.37 XXX 84255 SELENIUM 48.42 XXX 84260 SEROTONIN 58.47 XXX 84270 SEX HORM BNDNG GLOBULIN 41.11 XXX 84275 SIALIC ACID 25.58 XXX 84285 SILICA 44.77 XXX 84295 SODIUM SERUM PLASMA OR WHOLE BLOOD 9.14 XXX 84300 SODIUM URINE 9.14 XXX 84302 SODIUM OTH SRC 9.14 XXX 84305 SOMATOMEDIN 40.20 XXX 84307 SOMATOSTATIN 34.72 XXX 84311 SPECTROPHOTOMETRY ANAL NES 13.25 XXX 84315 SPEC GRAVITY XCPT URINE 4.57 XXX 84375 SUGARS CHROMATOGRAPIC TLC/PAPR CHROM 37.00 XXX 84376 SUGARS MONO DI&OLIGOS 1 QUAL EA SPEC 10.51 XXX 84377 SUGARS MONO DI&OLIGOS MLT QUAL EA SPEC 10.51 XXX 84378 SUGARS MONO DI&OLIGOS 1 QUAN EA SPEC 21.93 XXX 84379 SUGARS MONO DI&OLIGOS MLT QUAN EA SPEC 21.93 XXX 84392 SULFATE URINE 9.14 XXX 84402 TSTOSTERONE FR 47.96 XXX 84403 TSTOSTERONE TOT 48.88 XXX 84425 THIAMINE 40.20 XXX 84430 THIOCYANATE 21.93 XXX 232 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section IX: Pathology and Laboratory Services Georgia Workers Compensation Medical Fee Schedule 80047 89398 PATHOLOGY AND LABORATORY Effective April 1, 2011 Medical Fee Schedule 84431 THROMBOXANE METABOLITE W/WO THROMBOXANE URINE 31.98 XXX 84432 THYROGLOBULIN 30.61 XXX 84436 THYROXINE TOT 12.79 XXX 84437 THYROXINE REQ ELUTION 12.33 XXX 84439 THYROXINE FR 16.90 XXX 84442 THYROXINE BNDNG GLOBULIN 27.86 XXX 84443 THYR STIMULATING HORM 31.98 XXX 84445 THYR STIMULATING IGS 96.38 XXX 84446 TOCOPHEROL ALPHA 26.95 XXX 84449 TRANSCORTIN 34.26 XXX 84450 TRANSFERASE ASPARTATE AMINO 9.59 XXX 84460 TRANSFERASE ALANINE AMINO 10.05 XXX 84466 TRANSFERRIN 24.21 XXX 84478 TRIGLYCERIDES 10.96 XXX 84479 THYR HORM UPTK/THYR HORM BNDNG RATIO 12.33 XXX 84480 TRIIODOTHYRO9 T3 TOT 26.95 XXX 84481 TRIIODOTHYRO9 T3 FR 31.98 XXX 84482 TRIIODOTHYRO9 T3 REVERSE 29.69 XXX 84484 TROPONIN QUAN 18.73 XXX 84485 TRYPSIN DUOL FLU 14.16 XXX 84488 TRYPSIN FECES QUAL 13.70 XXX 84490 TRYPSIN FECES QUAN 24-HR COLLJ 14.62 XXX 84510 TYROSINE 19.64 XXX 84512 TROPONIN QUAL 14.62 XXX 84520 UREA N QUAN 7.31 XXX 84525 UREA N SEMIQUAN 7.31 XXX 84540 UREA N URINE 9.14 XXX 84545 UREA N CLEARANCE 12.33 XXX 84550 URIC ACID BLD 8.68 XXX 84560 URIC ACID OTH SRC 9.14 XXX 84577 UROBILINOGEN FECES QUAN 23.75 XXX 84578 UROBILINOGEN URINE QUAL 5.94 XXX 84580 UROBILINOGEN URINE QUAN TMD SPEC 13.25 XXX 84583 UROBILINOGEN URINE SEMIQUAN 9.59 XXX 84585 VANILLYLMANDELIC ACID URINE 29.24 XXX 84586 VASOACTIVE INTSTINAL PEPTIDE 66.69 XXX 84588 VASOPRESSIN 64.41 XXX 84590 VIT 21.93 XXX 84591 VIT NOS 21.93 XXX 84597 VIT K 26.04 XXX 84600 VOLATILES 30.61 XXX 84620 XYLOSE ABSRPJ TST BLD&/URINE 22.38 XXX 84630 ZINC 21.47 XXX 84681 C-PEPTIDE 39.28 XXX 84702 GONAD CHORNC QUAN 28.32 XXX 84703 GONAD CHORNC QUAL 14.16 XXX Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 233
Georgia Workers Compensation Medical Fee Schedule Section IX: Pathology and Laboratory Services PATHOLOGY AND LABORATORY 80047 89398 Medical Fee Schedule Effective April 1, 2011 84704 GONADOTROPIN CHORIONIC HCG FREE BETA CHAIN 28.32 XXX 84830 OVUL TSTS VIS COLOR CMPRSN METHS 19.19 XXX 84999 UNLIS CHEMISTRY BR XXX 85002 BLEEDING TM 8.68 XXX 85004 BLD# AUTO DIFFIAL WBC CNT 12.33 XXX 85007 BLD# BLD SMR MCRSCP XM MNL DIFFIAL WBC CNT 6.40 XXX 85008 BLD# BLD SMR MCRSCP XM W/O MNL DIFFIAL WBC CNT 6.40 XXX 85009 BLD# MNL DIFFIAL WBC CNT BUFFY COAT 6.85 XXX 85013 BLD# SPUN MICROHEMATOCRIT 4.57 XXX 85014 BLD# HEMATOCRIT 4.57 XXX 85018 BLD# HGB 4.57 XXX 85025 BLD# COMPL AUTO HHRWP&AUTO DIFFIAL 14.62 XXX 85027 BLD# COMPL AUTO HHRWP 12.33 XXX 85032 BLD# MNL C-CNT RBC WBC/PLTLT EA 8.22 XXX 85041 BLD# RED BLD CELL AUTO 5.48 XXX 85044 BLD# RETICULOCYTE MNL 8.22 XXX 85045 BLD# RETICULOCYTE AUTO 7.77 XXX 85046 BLD# RETICULOCYTES AUTO 1+ CELL MEAS 10.51 XXX 85048 BLD# WBC AUTO 5.02 XXX 85049 BLD# PLTLT AUTO 8.68 XXX 85055 RETICULATED PLTLT ASSAY 50.70 XXX 85060 BLD SMR PRPH INTERPJ PHYS WRTTN REPRT 31.06 XXX 85097 B1 MARROW SMR INTERPJ 115.11 XXX 85130 CHROMOGENIC SUBSTRATE ASSAY 22.38 XXX 85170 CLOT RETRCJ 6.85 XXX 85175 CLOT LSS TM WHL BLD DIL 8.68 XXX 85210 CLTNG FACTOR II PROTHROMBIN SPEC 24.67 XXX 85220 CLTNG FACTOR V ACG/PROACCELERIN LABILE FACTOR 33.35 XXX 85230 CLTNG FACTOR VII PROCONVERTIN STABLE FACTOR 33.80 XXX 85240 CLTNG FACTOR VIII AHG 1 STG 33.80 XXX 85244 CLTNG FACTOR VIII RELATED AG 38.83 XXX 85245 CLTNG FACTOR VIII VW FACTOR RISTOCETIN COFACTOR 43.40 XXX 85246 CLTNG FACTOR VIII VW FACTOR AG 43.40 XXX 85247 CLTNG FACTOR VIII MULTMTRIC ALYS 43.40 XXX 85250 CLTNG FACTOR IX PTC/CHRISTMAS 36.09 XXX 85260 CLTNG FACTOR X STUART-PROWER 33.80 XXX 85270 CLTNG FACTOR XI PTA 33.80 XXX 85280 CLTNG FACTOR XII HAGEMAN 36.54 XXX 85290 CLTNG FACTOR XIII FIBRIN STABILIZING 31.06 XXX 85291 CLTNG FACTOR XIII FIBRIN STABILIZING SCR SOLUB 16.90 XXX 85292 CLTNG PREKALLIKREIN ASSAY FLETCHER FACTOR ASSAY 35.63 XXX 85293 CLTNG HI MOLEC WEIGHT KININOGEN ASSAY 35.63 XXX 85300 CLTNG NHBTORS ANTITHROMBIN III ACTV 22.38 XXX 85301 CLTNG NHBTORS ANTITHROMBIN III AG ASSAY 20.56 XXX 85302 CLTNG NHBTORS PROTEIN C AG 22.84 XXX 85303 CLTNG NHBTORS PROTEIN C ACTV 26.04 XXX 234 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section IX: Pathology and Laboratory Services Georgia Workers Compensation Medical Fee Schedule 80047 89398 PATHOLOGY AND LABORATORY Effective April 1, 2011 Medical Fee Schedule 85305 CLTNG NHBTORS PROTEIN S TOT 21.93 XXX 85306 CLTNG NHBTORS PROTEIN S FR 28.78 XXX 85307 ACTIVATED PROTEIN C APC RESISTANCE ASSAY 28.78 XXX 85335 FACTOR NHBTOR TST 24.21 XXX 85337 THROMBOMODULIN 19.64 XXX 85345 COAGJ TM LEE&WHITE 8.22 XXX 85347 COAGJ TM ACTIVATED 8.22 XXX 85348 COAGJ TM OTH METHS 6.85 XXX 85360 EUGLOBULIN LSS 15.99 XXX 85362 FIBRIN DGRADJ SPLT PRODUXS AGGLUJ SLIDE SEMIQUAN 13.25 XXX 85366 FIBRIN DGRADJ SPLT PRODUXS PARACOAGJ 16.44 XXX 85370 FIBRIN DGRADJ SPLT PRODUXS QUAN 21.47 XXX 85378 FIBRIN DGRADJ PRODUXS D-DIMER QUAL/SEMIQUAN 13.70 XXX 85379 FIBRIN DGRADJ PRODUXS D-DIMER QUAN 19.19 XXX 85380 FIBRIN DGRADJ PRODUXS D-DIMER ULTRSENS 19.19 XXX 85384 FIBRN ACTV 15.99 XXX 85385 FIBRN AG 15.99 XXX 85390 FIBRINOLYSINS/COAGULOPATHY SCR I&R 36.09 XXX 85390 26 FIBRINOLYSINS/COAGULOPATHY SCR I&R 26.49 XXX 85390 TC FIBRINOLYSINS/COAGULOPATHY SCR I&R 9.60 XXX 85396 COAGJ/FBRNLYS ASSAY WHL BLD USE ADDITIVE PR D 25.58 XXX 85397 COAGJ&FIBRINOLYSIS FUNCTIONAL ACTV NOS EA ANAL 43.40 XXX 85400 FBRNLYC FACTORS&NHBTORS PLASMIN 16.90 XXX 85410 FBRNLYC FACTORS&NHBTORS ALPHA-2 ANTIPLASMIN 14.62 XXX 85415 FBRNLYC FACTORS&NHBTORS PLSMNG ACTIVATOR 32.43 XXX 85420 FBRNLYC FACTORS&NHBTORS PLSMNG XCPT AGIC ASSAY 12.33 XXX 85421 FBRNLYC FACTORS&NHBTORS PLSMNG AGIC ASSAY 19.19 XXX 85441 HEINZ BODIES DIR 7.77 XXX 85445 HEINZ BODIES INDUCED ACETYL PHENYLHYDRAZINE 12.79 XXX 85460 HGB/RBCS FTL F&MAT HEMRRG DIFFIAL LSS 14.62 XXX 85461 HGB/RBCS FTL F&MAT HEMRRG ROSETTE 12.33 XXX 85475 HEMOLYSIN ACID 16.90 XXX 85520 HEPARIN ASSAY 24.67 XXX 85525 HEPARIN NEUTRALIZATION 22.38 XXX 85530 HEPARIN-PROTAMINE TOLERANCE TST 26.95 XXX 85536 IRON STAIN PRPH BLD 12.33 XXX 85540 WBC ALKALINE PHOSPHATASE CNT 16.44 XXX 85547 MCHNL FRAGILITY RBC 16.44 XXX 85549 MURAMIDASE 35.63 XXX 85555 OSMOTIC FRAGILITY RBC UNINCUBATED 12.79 XXX 85557 OSMOTIC FRAGILITY RBC INCUBATED 25.12 XXX 85576 PLTLT AGGREGATION EA AGT 66.69 XXX 85576 26 PLTLT AGGREGATION EA AGT 26.04 XXX 85576 TC PLTLT AGGREGATION EA AGT 40.65 XXX s 85597 PHOSPHOLIPID NEUTRALIZATION PLATELET 33.80 XXX l 85598 PHOSPHOLIPID NEUTRALIZATION HEXAGONAL 33.80 XXX Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 235
Georgia Workers Compensation Medical Fee Schedule Section IX: Pathology and Laboratory Services PATHOLOGY AND LABORATORY 80047 89398 Medical Fee Schedule Effective April 1, 2011 85610 PROTHROMBIN TM 7.31 XXX 85611 PROTHROMBIN TM SUBJ PLSM FXJS EA 7.31 XXX 85612 RUSSELL VIPR VENOM TM UNDILD 18.27 XXX 85613 RUSSELL VIPR VENOM TM DILD 18.27 XXX 85635 REPTILASE TST 18.73 XXX 85651 SEDIMENTATION RATE RBC NON-AUTO 6.85 XXX 85652 SEDIMENTATION RATE RBC AUTO 5.02 XXX 85660 SICKLING RBC RDCTJ 10.51 XXX 85670 THROMBIN TM PLSM 10.96 XXX 85675 THROMBIN TM TITER 12.79 XXX 85705 THROMBOPLASTIN NHBTION TISS 18.27 XXX 85730 THROMBOPLASTIN TM PRTL PLSM/WHL BLD 11.42 XXX 85732 THROMBOPLASTIN TM PRTL SUBJ PLSM FXJS EA 12.33 XXX 85810 VISCOSITY 21.93 XXX 85999 UNLIS HEMATOLOGY&COAGJ BR XXX 86000 AGGLUTININS FEBRILE EA AG 13.25 XXX 86001 ALLG SPEC IGG QUAN/SEMIQUAN EA ALLG 10.05 XXX 86003 ALLG SPEC IGE QUAN/SEMIQUAN EA ALLG 10.05 XXX 86005 ALLG SPEC IGE QUAL MULTIALLG SCR 15.07 XXX 86021 ANTB ID WBC ANTIBODIES 28.32 XXX 86022 ANTB ID PLTLT ANTIBODIES 34.72 XXX 86023 ANTB ID PLTLT ASSOCIATED IG ASSAY 23.75 XXX 86038 ANA 22.84 XXX 86039 ANA TITER 21.01 XXX 86060 ANTISTREPTOLYSIN 0 TITER 13.70 XXX 86063 ANTISTREPTOLYSIN 0 SCR 10.96 XXX 86077 BLD BANK PHYS SVCS DIFFC CROSS MATCH&/EVAL REPRT 68.52 XXX 86078 BLD BANK PHYS SVCS INVSTGJ TFUJ RXN REPRT 68.98 XXX 86079 BLD BANK PHYS SVCS AUTHJ DEVIJ STANDARD REPRT 68.98 XXX 86140 C-REACTIVE PROTEIN 9.59 XXX 86141 C-REACTIVE PROTEIN HI SENSITIVITY 24.67 XXX 86146 BETA 2 GLYCOPROTEIN I ANTB EA 47.96 XXX 86147 CARDIOLIPIN ANTB EA IG CLASS 47.96 XXX 86148 ANTI-PHOSPHATIDYLSERINE ANTB 30.61 XXX 86155 CHEMOTAXIS ASSAY SPEC METH 30.15 XXX 86156 COLD AGGLUTININ SCR 12.79 XXX 86157 COLD AGGLUTININ TITER 15.07 XXX 86160 COMPLEMENT AG EA COMPONENT 22.84 XXX 86161 COMPLEMENT FUNCJAL ACTV EA COMPONENT 22.84 XXX 86162 COMPLEMENT TOT HEMOLYTIC 38.37 XXX 86171 COMPLEMENT FIXJ TSTS EA AG 18.73 XXX 86185 CNTERIMMUNOELECTROPHORESIS EA AG 16.90 XXX 86200 CYCLIC CITRULLINATED PEPTIDE ANTB 24.67 XXX 86215 DEOXYRIBONUCLEASE ANTB 25.12 XXX 86225 DNA ANTB NATIVE/2 STRANDED 26.04 XXX 86226 DNA ANTB 1 STRANDED 22.84 XXX 236 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section IX: Pathology and Laboratory Services Georgia Workers Compensation Medical Fee Schedule 80047 89398 PATHOLOGY AND LABORATORY Effective April 1, 2011 Medical Fee Schedule 86235 XTRCABLE NUC AG ANTB ANY METH EA ANTB 33.80 XXX 86243 FC RCPTR 38.83 XXX 86255 FLUORESCENT NONNFCT AGT ANTB SCR EA ANTB 48.88 XXX 86255 26 FLUORESCENT NONNFCT AGT ANTB SCR EA ANTB 26.04 XXX 86255 TC FLUORESCENT NONNFCT AGT ANTB SCR EA ANTB 22.84 XXX 86256 FLUORESCENT NONNFCT AGT ANTB TITER EA ANTB 47.96 XXX 86256 26 FLUORESCENT NONNFCT AGT ANTB TITER EA ANTB 25.12 XXX 86256 TC FLUORESCENT NONNFCT AGT ANTB TITER EA ANTB 22.84 XXX 86277 GROWTH HORM HUMAN ANTB 29.69 XXX 86280 HEMAGGLUJ NHBTION TST 15.53 XXX 86294 IA TUMOR ANTIGEN QUAL/SEMIQUANTITATIVE 37.00 XXX 86300 IA TUM AG QUAN CA 15-3 39.28 XXX 86301 IA TUM AG QUAN CA 19-9 39.28 XXX 86304 IA TUM AG QUAN CA 125 39.28 XXX 86305 HUMAN EPIDIDYMIS PROTEIN 4 (HE4) 39.28 XXX 86308 HTROPHL ANTIBODIES SCR 9.59 XXX 86309 HTROPHL ANTIBODIES TITER 12.33 XXX 86310 HTROPHL ANTIBODIES TIT AFTER ABSRPJ 14.16 XXX 86316 IA TUM AG OTH AG QUAN EA 39.28 XXX 86317 IA NFCT AGT ANTB QUAN NOS 28.32 XXX 86318 IA NFCT AGT ANTB QUAL/SEMIQUAN 1 STEP METH 24.67 XXX 86320 IMMUNOELECTROPHORESIS SERUM 67.61 XXX 86320 26 IMMUNOELECTROPHORESIS SERUM 25.12 XXX 86320 TC IMMUNOELECTROPHORESIS SERUM 42.49 XXX 86325 IMMUNOELECTROPHORESIS OTH FLUS CONCENTRATION 67.15 XXX 86325 26 IMMUNOELECTROPHORESIS OTH FLUS CONCENTRATION 24.67 XXX 86325 TC IMMUNOELECTROPHORESIS OTH FLUS CONCENTRATION 42.48 XXX 86327 IMMUNOELECTROPHORESIS CROSSED 72.63 XXX 86327 26 IMMUNOELECTROPHORESIS CROSSED 29.69 XXX 86327 TC IMMUNOELECTROPHORESIS CROSSED 42.94 XXX 86329 IMMUNODIFFUSION NES 26.49 XXX 86331 IMMUNODIFFUSION GEL DIFFUSION QUAL EA AG/ANTB 22.84 XXX 86332 IMMUNE CPLX ASSAY 46.14 XXX 86334 IMMUNOFIXJ ELECTROPHORESIS SERUM 68.52 XXX 86334 26 IMMUNOFIXJ ELECTROPHORESIS SERUM 26.04 XXX 86334 TC IMMUNOFIXJ ELECTROPHORESIS SERUM 42.48 XXX 86335 IMMUNOFIXJ ELECTROPHORESIS OTH FLU 81.31 XXX 86335 26 IMMUNOFIXJ ELECTROPHORESIS OTH FLU 25.58 XXX 86335 TC IMMUNOFIXJ ELECTROPHORESIS OTH FLU 55.73 XXX 86336 INHIBIN 29.69 XXX 86337 INSULIN ANTIBODIES 40.66 XXX 86340 INTRNSC FACTOR ANTIBODIES 28.32 XXX 86341 ISLET CELL ANTB 37.46 XXX 86343 WBC HISTAM RLS TST 23.75 XXX 86344 WBC PHAGOCYTOSIS 15.07 XXX 86352 CELLULAR FUNCTION ASSAY STIMUL&DETECT BIOMARKER 257.18 XXX Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 237
Georgia Workers Compensation Medical Fee Schedule Section IX: Pathology and Laboratory Services PATHOLOGY AND LABORATORY 80047 89398 Medical Fee Schedule Effective April 1, 2011 86353 LYMPHOCYTE TR MITOGEN/AG INDUCED BLASTOGENESIS 92.73 XXX 86355 B CELLS TOT CNT 71.26 XXX 86356 MONONUCLEAR CELL ANTIGEN QUANTITATIVE NOS EA 50.70 XXX 86357 NATURAL KILLER CELLS TOT CNT 71.26 XXX 86359 T CELLS TOT CNT 71.26 XXX 86360 T CELLS ABSOLUTE CD4&CD8 CNT RATIO 89.08 XXX 86361 T CELLS ABSOLUTE CD4 CNT 50.70 XXX 86367 STEM CELLS TOT CNT 71.26 XXX 86376 MICROSOMAL ANTIBODIES EA 27.41 XXX 86378 MIGRATION NHBTORY FACTOR TST MIF 37.46 XXX 86382 NEUTRALIZATION TST VIRAL 31.98 XXX 86384 NITROBLUE TETRAZOLIUM DYE TST NTD 21.47 XXX 86403 PART AGGLUJ SCR EA ANTB 19.19 XXX 86406 PART AGGLUJ TITER EA ANTB 20.10 XXX 86430 RHEUMATOID FACTOR QUAL 10.51 XXX 86431 RHEUMATOID FACTOR QUAN 10.51 XXX s 86480 TB CELL MEDIATED ANTIGN RESPNSE GAMMA INTERFER 117.40 XXX l 86481 TB ANTIGEN RESPONSE GAMMA INTERFERON T-CELL SUSP 117.40 XXX 86485 SKN TST CANDIDA 17.82 XXX 86486 SKIN TEST UNLISTED ANTIGEN EACH 6.85 XXX 86490 SKN TST COCCIDIOIDOMYCOSIS 9.14 XXX 86510 SKN TST HISTOPLASMOSIS 8.68 XXX 86580 SKN TST TUBERCULOSIS ID 10.05 XXX 86590 STREPTOKINASE ANTB 21.01 XXX 86592 SYPHILIS TEST NON TREPONEMAL ANTIBODY QUAL 8.22 XXX 86593 SYPHILIS TST QUAN 8.22 XXX 86602 ANTB ACTINOMYCES 19.19 XXX 86603 ANTB ADENOVIRUS 24.21 XXX 86606 ANTB ASPRGILLUS 28.32 XXX 86609 ANTB BACTERIUM NES 24.21 XXX 86611 ANTB BARTONELLA 19.19 XXX 86612 ANTB BLASTOMYCES 24.21 XXX 86615 ANTB BORDETELLA 25.12 XXX 86617 ANTB BORRELIA BURGDORFERI CONFIRMATORY TST 29.24 XXX 86618 ANTB BORRELIA BURGDORFERI LYME DISEASE 32.43 XXX 86619 ANTB BORRELIA RELAPSING FEVER 25.12 XXX 86622 ANTB BRUCELLA 16.90 XXX 86625 ANTB CAMPYLOBACTER 24.67 XXX 86628 ANTB CANDIDA 22.84 XXX 86631 ANTB CHLAMYDIA 22.38 XXX 86632 ANTB CHLAMYDIA IGM 24.21 XXX 86635 ANTB COCCIDIOIDES 21.93 XXX 86638 ANTB COXIELLA BRNETII Q FEVER 22.84 XXX 86641 ANTB CRYPTOCOCCUS 27.41 XXX 86644 ANTB CMV CMV 27.41 XXX 86645 ANTB CMV CMV IGM 31.98 XXX 238 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section IX: Pathology and Laboratory Services Georgia Workers Compensation Medical Fee Schedule 80047 89398 PATHOLOGY AND LABORATORY Effective April 1, 2011 Medical Fee Schedule 86648 ANTB DIPHTHERIA 28.78 XXX 86651 ANTB ENCEPHALITIS CALIFORNIA LA CROSSE 25.12 XXX 86652 ANTB ENCEPHALITIS EASTERN EQUINE 25.12 XXX 86653 ANTB ENCEPHALITIS ST. LOUIS 25.12 XXX 86654 ANTB ENCEPHALITIS WSTRN EQUINE 25.12 XXX 86658 ANTB ENTEROVIRUS 24.67 XXX 86663 ANTB EPSTEIN-BARR EB VIRUS EARLY AG EA 24.67 XXX 86664 ANTB EPSTEIN-BARR EB VIRUS NUC AG EBNA 28.78 XXX 86665 ANTB EPSTEIN-BARR EB VIRUS VIRAL CAPSID VCA 34.26 XXX 86666 ANTB EHRLICHIA 19.19 XXX 86668 ANTB FRANCISELLA TULARENSIS 19.64 XXX 86671 ANTB FUNGUS NES 23.30 XXX 86674 ANTB GIARDIA LAMBLIA 27.86 XXX 86677 ANTB HELICOBACTER PYLORI 27.41 XXX 86682 ANTB HELMINTH NES 24.67 XXX 86684 ANTB HAEMOPHILUS INF 30.15 XXX 86687 ANTB HTLV-I 15.99 XXX 86688 ANTB HTLV-II 26.49 XXX 86689 ANTB HTLV/HIV ANTB CONFIRMATORY TST 36.54 XXX 86692 ANTB HEP DELTA AGT 32.43 XXX 86694 ANTB HERPES SMPLX NON-SPEC TYP TST 27.41 XXX 86695 ANTB HERPES SMPLX TYP 1 25.12 XXX 86696 ANTB HERPES SMPLX TYP 2 36.54 XXX 86698 ANTB HISTOPLSM 23.75 XXX 86701 ANTB HIV-1 16.90 XXX 86702 ANTB HIV-2 25.58 XXX 86703 ANTB HIV-1&HIV-2 1 ASSAY 26.04 XXX 86704 HEP B CORE ANTB HBCAB TOT 22.84 XXX 86705 HEP B CORE ANTB HBCAB IGM ANTB 22.38 XXX 86706 HEP B SURF ANTB HBSAB 20.56 XXX 86707 HEP BE ANTB HBEAB 21.93 XXX 86708 HEP ANTB HAAB TOT 23.30 XXX 86709 HEP ANTB HAAB IGM ANTB 21.47 XXX 86710 ANTB INF VIRUS 25.58 XXX 86713 ANTB LEGIONELLA 28.78 XXX 86717 ANTB LEISHMANIA 23.30 XXX 86720 ANTB LEPTOSPIRA 25.12 XXX 86723 ANTB LISTERIA MONOCYTOGENES 25.12 XXX 86727 ANTB LYMPHOCYTIC CHORIOMENINGITIS 24.21 XXX 86729 ANTB LYMPHOGRANULOMA VENEREUM 22.38 XXX 86732 ANTB MUCORMYCOSIS 25.12 XXX 86735 ANTB MUMPS 24.67 XXX 86738 ANTB MYCOPLSM 25.12 XXX 86741 ANTB NEISSERIA MENINGITIDIS 25.12 XXX 86744 ANTB NOCARDIA 25.12 XXX 86747 ANTB PARVOVIRUS 28.32 XXX Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 239
Georgia Workers Compensation Medical Fee Schedule Section IX: Pathology and Laboratory Services PATHOLOGY AND LABORATORY 80047 89398 Medical Fee Schedule Effective April 1, 2011 86750 ANTB PLASMODIUM MALARIA 25.12 XXX 86753 ANTB PROTOZOA NES 23.30 XXX 86756 ANTB RSV 24.21 XXX 86757 ANTB RICKETTSIA 36.54 XXX 86759 ANTB ROTAVIRUS 25.12 XXX 86762 ANTB RUBELLA 27.41 XXX 86765 ANTB RUBEOLA 24.21 XXX 86768 ANTB SALMONELLA 25.12 XXX 86771 ANTB SHIGELLA 25.12 XXX 86774 ANTB TETANUS 27.86 XXX 86777 ANTB TOXOPLSM 27.41 XXX 86778 ANTB TOXOPLSM IGM 27.41 XXX 86780 ANTIBODY TREPONEMA PALLIDUM 25.12 XXX 86784 ANTB TRICHINELLA 23.75 XXX 86787 ANTB VARICELLA-ZOSTER 24.21 XXX 86788 ANTIBODY WEST NILE VIRUS IGM 31.98 XXX 86789 ANTIBODY WEST NILE VIRUS 27.41 XXX 86790 ANTB VIRUS NES 24.21 XXX 86793 ANTB YERSINIA 25.12 XXX 86800 THYROGLOBULIN ANTB 30.15 XXX 86803 HEP C ANTB 26.95 XXX 86804 HEP C ANTB CONFIRMATORY TST 29.24 XXX 86805 LPHOCYTOTOXICITY ASSAY VIS CROSSMATCH TITRJ 99.13 XXX 86806 LPHOCYTOTOXICITY ASSAY VIS CROSSMATCH W/O TITRJ 89.99 XXX 86807 SERUM SCR % REACTIVE ANTB STANDARD METH 74.92 XXX 86808 SERUM SCR % REACTIVE ANTB PRA QUICK METH 56.19 XXX 86812 HLA TYPING B/C 1 AG 48.88 XXX 86813 HLA TYPING B/C MLT AGS 109.63 XXX 86816 HLA TYPING DR/DQ 1 AG 52.53 XXX 86817 HLA TYPING DR/DQ MLT AGS 121.97 XXX 86821 HLA TYPING LYMPHOCYTE CULTURE MIXED 106.89 XXX 86822 HLA TYPING LYMPHOCYTE CULTURE PRIMED 68.98 XXX 86825 HLA CROSSMATCH NONCYTOTOXIC 1ST SERUM/DILUTION 152.11 XXX + 86826 HLA CROSSMATCH NONCYTOTOXIC EA+ SERUM/DILUTION 50.70 XXX 86849 UNLIS IMMUNOLOGY BR XXX 86850 ANTB SCR RBC EA SERUM TQ 21.93 XXX 86860 ANTB ELUTION EA ELUTION 28.32 XXX 86870 ANTB ID RBC ANTIBODIES EA PANEL EA SERUM TQ 38.83 XXX 86880 ANTIHUMAN GLOBULIN DIR EA ANTISERUM 10.05 XXX 86885 ANTIHUMAN GLOBULIN INDIR QUAL EA REAGENT CELL 10.96 XXX 86886 ANTIHUMAN GLOBULIN INDIRECT EA ANTIBODY TITER 9.59 XXX 86890 AUTOL BLD/COMPONENT COLLJ STORAGE PREDEPOSITED 89.53 XXX 86891 AUTOL BLD/COMPONENT COLLJ STORAGE SALVAGE 126.08 XXX 86900 BLD TYPING ABO 5.48 XXX 86901 BLD TYPING RH D 5.48 XXX l 86902 BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA 7.31 XXX 240 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section IX: Pathology and Laboratory Services Georgia Workers Compensation Medical Fee Schedule 80047 89398 PATHOLOGY AND LABORATORY Effective April 1, 2011 Medical Fee Schedule 86904 BLD TYPING AG SCR UNIT PT SERUM SCR 17.82 XXX 86905 BLD TYPING RBC AGS OTH/THN ABO/RH D EA 7.31 XXX 86906 BLD TYPING RH PHEXYPING COMPL 14.62 XXX 86910 BLD TYPING PATERNITY PR INDIV ABO RH&MN 23.30 XXX 86911 BLD TYPING PATERNITY PR INDIV EA AG SYS 20.10 XXX 86920 COMPATIBILITY EA UNIT IMMT SPIN 31.52 XXX 86921 COMPATIBILITY EA UNIT INCUBATION 28.32 XXX 86922 COMPATIBILITY EA UNIT ANTIGLOBULIN 33.80 XXX 86923 COMPATIBILITY EA UNIT ELEC 25.12 XXX 86927 FRSH FROZEN PLSM THAWING EA UNIT 17.82 XXX 86930 FROZEN BLD EA UNIT FRZING PREPJ 105.06 XXX 86931 FROZEN BLD EA UNIT THAWING 79.03 XXX 86932 FROZEN BLD EA UNIT FRZING PREPJ&THAWING 89.53 XXX 86940 HEMOLYSINS&AGGLUTININS AUTO SCR EA 15.53 XXX 86941 HEMOLYSINS&AGGLUTININS INCUBATED 22.84 XXX 86945 IRRADJ BLD PRODUX EA UNIT 26.49 XXX 86950 WBC TRANSFUSION 68.52 XXX 86960 VOL RDCTJ BLD/BLD PRODUX EA UNIT 29.24 XXX 86965 PLING PLTLTS/OTH BLD PRODUXS 29.24 XXX 86970 PRTX RBC ANTB CHEM AGT/DRUGS 26.49 XXX 86971 PRTX RBC ANTB INCUBATION NZM EA 21.01 XXX 86972 PRTX RBC ANTB DNS GRADIENT SEP 37.00 XXX 86975 PRTX SRM INCUBATION DRUGS EA 28.32 XXX 86976 PRTX SRM ANTB ID DIL 31.52 XXX 86977 PRTX SRM ANTB ID INCUBATION NHBTORS EA 31.52 XXX 86978 PRTX SRM ANTB ID DIFFIAL RBC ABSRPJ 31.52 XXX 86985 SPLTTING BLD/BLD PRODUXS EA UNIT 23.30 XXX 86999 UNLIS TRANSFUSION MED BR XXX 87001 ANIMAL INOCULATION SM ANIMAL OBS 25.12 XXX 87003 ANIMAL INOCULATION SM ANIMAL OBS&DSJ 31.98 XXX 87015 CONCENTRATION NFCT AGT 12.79 XXX 87040 CUL BACT BLD AERC ISOL 19.64 XXX 87045 CUL BACT STL AERC ISOL SALMONELLA&SHIGELLA 17.82 XXX 87046 CUL BACT STL AERC ADDL PATHOGENS&ID EA 17.82 XXX 87070 CUL BACT XCPT URINE BLD/STL AERC ISOL 16.44 XXX 87071 CUL BACT QUAN AERC ISOL XCPT UR BLD/STOOL 17.82 XXX 87073 CUL BACT QUAN ANAERC ISOL XCPT UR BLD/STOOL 17.82 XXX 87075 CUL BACT BLD ANAERC ISOL 17.82 XXX 87076 CUL BACT ANAERC ADDL METHS DEFINITIVE EA ISOL 15.07 XXX 87077 CUL BACT AERC ADDL METHS DEFINITIVE EA ISOL 15.07 XXX 87081 CUL PRSMPTV PTHGNC ORGANISMS SCR 12.33 XXX 87084 CUL PRSMPTV PTHGNC ORGANISMS SCR DNS CHART 16.44 XXX 87086 CUL BACT QUAN COLONY CNT URINE 15.07 XXX 87088 CULTURE BCT ISOL&PRSMPTV ID ISOLATE EA URINE 15.53 XXX 87101 CUL FNGI MOLD/YEAST PRSMPTV ID SKN HAIR/NAIL 14.62 XXX 87102 CUL FNGI MOLD/YEAST PRSMPTV ID OTH XCPT BLD 15.99 XXX Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 241
Georgia Workers Compensation Medical Fee Schedule Section IX: Pathology and Laboratory Services PATHOLOGY AND LABORATORY 80047 89398 Medical Fee Schedule Effective April 1, 2011 87103 CUL FNGI MOLD/YEAST ISOL PRSMPTV ID ISOL BLD 16.90 XXX 87106 CUL FNGI DEFINITIVE ID EA ORGANISM YEAST 19.64 XXX 87107 CUL FNGI DEFINITIVE ID EA ORGANISM MOLD 19.64 XXX 87109 CUL MYCOPLSM ANY SRC 29.24 XXX 87110 CUL CHLAMYDIA ANY SRC 37.00 XXX 87116 CUL TUBERCLE/OTH ACID-FAST BACILLI ANY ISOL 20.56 XXX 87118 CUL MYCOBACTERIAL DEFINITIVE ID EA ISOL 20.56 XXX 87140 CULTYP IMFLUOR METH EA ANTISERUM 10.51 XXX 87143 CULTYP GAS LIQ CHROM/HI PRESS LIQ CHROM 23.75 XXX 87147 CULTYP IMMUNOLOGIC OTH/THN IMFLUOR PR ANTISERUM 9.59 XXX 87149 CULTYP NUC ACID DIR PRB CULT/ISOLATE EA ORGNISM 37.91 XXX 87150 CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM 66.24 XXX 87152 CULTYP ID PLS FLD GEL TYP 10.05 XXX 87153 CULTYP NUCLEIC ACID SEQUENCING METH EA ISOLATE 218.35 XXX 87158 CULTYP OTH METHS 10.05 XXX 87164 DARK FLD XM ANY SRC SPEC COLLJ 46.59 XXX 87164 26 DARK FLD XM ANY SRC SPEC COLLJ 26.04 XXX 87164 TC DARK FLD XM ANY SRC SPEC COLLJ 20.55 XXX 87166 DARK FLD XM ANY SRC W/O COLLJ 21.47 XXX 87168 MACROSCOPIC XM ARTHROPOD 8.22 XXX 87169 MACROSCOPIC XM PARASIT 8.22 XXX 87172 PINWORM XM 8.22 XXX 87176 HOMOGENIZATION TISS CUL 10.96 XXX 87177 OVA&PARASITS DIR SMRS CONCENTRATION&ID 16.90 XXX 87181 SC STD ANTMCRB AGT AGAR DIL METH PR AGT 9.14 XXX 87184 SC STD ANTMCRB AGT DISK METH PR PLATE 13.25 XXX 87185 SC STD ANTMCRB AGT ENZYME DETCJ PR NZM 9.14 XXX 87186 SC ANTMCRB MICRODIL/AGAR EA MULTI-ANTMCRB PLATE 16.44 XXX + 87187 SC ANTMCRB MICRODIL/AGAR DIL MLC EA PLATE 19.64 XXX 87188 SC STD ANTMCRB AGT MACROBROTH DIL METH EA AGT 12.33 XXX 87190 SC ANTMCRB MYCOBACTERIA PROPRTN EA AGT 10.51 XXX 87197 SERUM BACTERICIDAL TITER 28.32 XXX 87205 SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL 8.22 XXX 87206 SMR PRIM SRC FLUORESCENT&/AFS BCT FNGI PARASITS 10.05 XXX 87207 SMR PRIM SRC SPEC STAIN BODIES/PARASITS 37.46 XXX 87207 26 SMR PRIM SRC SPEC STAIN BODIES/PARASITS 26.04 XXX 87207 TC SMR PRIM SRC SPEC STAIN BODIES/PARASITS 11.42 XXX 87209 SMR PRIM SRC CPLX SPEC STAIN OVA&PARASITS 33.80 XXX 87210 SMR PRIM SRC WET MOUNT NFCT AGT 8.22 XXX 87220 TISS KOH SLIDE SAMPS SKN/HR/NLS FNGI/ECTOPARASIT 8.22 XXX 87230 TOXIN/ANTITOXIN ASSAY TISS CUL 37.46 XXX 87250 VIRUS INOCULATION EGGS/SM ANIMAL OBS&DSJ 37.00 XXX 87252 VIRUS TISS CUL INOCULATION CYTOPATHIC EFFECT 49.33 XXX 87253 VIRUS TISS CUL ADDL STD/ID EA ISOLATE 38.37 XXX 87254 VIRUS CENTRIFUGE ENHNCD ID IMFLUOR STAIN EA 37.00 XXX 87255 VIRUS ID NON-IMMUNOLOGIC OTH/THN CYTOPATHIC 63.95 XXX 242 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section IX: Pathology and Laboratory Services Georgia Workers Compensation Medical Fee Schedule 80047 89398 PATHOLOGY AND LABORATORY Effective April 1, 2011 Medical Fee Schedule 87260 IAADI ADENOVIRUS 22.84 XXX 87265 IAADI BORDETELLA PRTUSSIS/PARAPRTUSSIS 22.84 XXX 87267 IAADI ENTEROVIRUS DIR FLUORESCENT ANTB 22.84 XXX 87269 IAADI GIARDIA 22.84 XXX 87270 IAADI CHLAMYDIA TRACHOMATIS 22.84 XXX 87271 IAADICMV DIR FLUORESCENT ANTB 22.84 XXX 87272 IAADI CRYPTOSPORIDIUM 22.84 XXX 87273 IAADI HERPES SMPLX VIRUS TYP 2 22.84 XXX 87274 IAADI HERPES SMPLX VIRUS TYP 1 22.84 XXX 87275 IAADI INF B VIRUS 22.84 XXX 87276 IAADI INF VIRUS 22.84 XXX 87277 IAADI LEGIONELLA MICDADEI 22.84 XXX 87278 IAADI LEGIONELLA PNEUMOPHILA 22.84 XXX 87279 IAADI PARAINF VIRUS EA TYP 22.84 XXX 87280 IAADI RSV 22.84 XXX 87281 IAADI PNEUMOCSTIS CARINII 22.84 XXX 87283 IAADI RUBEOLA 22.84 XXX 87285 IAADI TREPONEMA PALLIDUM 22.84 XXX 87290 IAADI VARICELLA ZOSTER VIRUS 22.84 XXX 87299 IAADI NOS EA ORGANISM 22.84 XXX 87300 IAADI POLYV MLT ORGANISMS EA POLYV ANTISERUM 22.84 XXX 87301 IAAD EIA ADENOVIRUS ENTERIC TYP 40/41 22.84 XXX 87305 IAAD EIA QUAL/SEMIQUAN MULTIPLE STEP ASPERGILLUS 22.84 XXX 87320 IAAD EIA CHLAMYDIA TRACHOMATIS 22.84 XXX 87324 IAAD EIA CLOSTRIDIUM DIFFICILE TOXIN 22.84 XXX 87327 IAAD EIA CRYPTOCOCCUS NEOFORMANS 22.84 XXX 87328 IAAD EIA CRYPTOSPORIDIUM 22.84 XXX 87329 IAAD EIA GIARDIA 22.84 XXX 87332 IAAD EIA CMV 22.84 XXX 87335 IAAD EIA ESCHERICHIA COLI 0157 22.84 XXX 87336 IAAD EIA ENTAMOEBA HISTOLYTICA DISPAR GRP 22.84 XXX 87337 IAAD EIA ENTAMOEBA HISTOLYTICA GRP 22.84 XXX 87338 IAAD EIA HPYLORI STOOL 27.41 XXX 87339 IAAD EIA HPYLORI 22.84 XXX 87340 IAAD EIA HEP B SURF AG 19.64 XXX 87341 IAAD EIA HEP B SURF AG NEUTRALIZATION 19.64 XXX 87350 IAAD EIA HEP BE AG 21.93 XXX 87380 IAAD EIA HEP DELTA AGT 31.06 XXX 87385 IAAD EIA HISTOPLSM CAPSULATUM 22.84 XXX 87390 IAAD EIA HIV-1 33.35 XXX 87391 IAAD EIA HIV-2 33.35 XXX 87400 IAAD EIA INF/B EA 22.84 XXX 87420 IAAD EIA RSV 22.84 XXX 87425 IAAD EIA ROTAVIRUS 22.84 XXX 87427 IAAD EIA SHIGA-LIKE TOXIN 22.84 XXX 87430 IAAD EIA STREPTOCOCCUS GRP 22.84 XXX Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 243
Georgia Workers Compensation Medical Fee Schedule Section IX: Pathology and Laboratory Services PATHOLOGY AND LABORATORY 80047 89398 Medical Fee Schedule Effective April 1, 2011 87449 IAAD EIA NOS EA ORGANISM 22.84 XXX 87450 IAAD EIA NOS EA ORGANISM 18.27 XXX 87451 IAAD EIA POLYV MLT ORGANISMS EA POLYV ANTISERUM 18.27 XXX 87470 IADNA BARTONELLA DIR PRB 37.91 XXX 87471 IADNA BARTONELLA AMP PRB 66.24 XXX 87472 IADNA BARTONELLA QUAN 80.85 XXX 87475 IADNA BORRELIA BURGDORFERI DIR PRB 37.91 XXX 87476 IADNA BORRELIA BURGDORFERI AMP PRB 66.24 XXX 87477 IADNA BORRELIA BURGDORFERI QUAN 80.85 XXX 87480 IADNA CANDIDA SPECIES DIR PRB 37.91 XXX 87481 IADNA CANDIDA SPECIES AMP PRB 66.24 XXX 87482 IADNA CANDIDA SPECIES QUAN 79.03 XXX 87485 IADNA CHLAMYDIA PNEUMONIAE DIR PRB 37.91 XXX 87486 IADNA CHLAMYDIA PNEUMONIAE AMP PRB 66.24 XXX 87487 IADNA CHLAMYDIA PNEUMONIAE QUAN 80.85 XXX 87490 IADNA CHLAMYDIA TRACHOMATIS DIR PRB 37.91 XXX 87491 IADNA CHLAMYDIA TRACHOMATIS AMP PRB 66.24 XXX 87492 IADNA CHLAMYDIA TRACHOMATIS QUAN 66.24 XXX 87493 INF AGENT DET NUC ACID CLOSTRIDIUM AMP PROBE 66.24 XXX 87495 IADNA CMV DIR PRB 37.91 XXX 87496 IADNA CMV AMP PRB 66.24 XXX 87497 IADNA CMV QUAN 80.85 XXX 87498 IADNA ENTEROVIRUS AMPLIFIED PROBE TECHNIQUE 66.24 XXX 87500 INFECTIOUS AGENT DNA/RNA VANCOMYCIN RESISTANCE 66.24 XXX l 87501 INFECTIOUS AGENT DNA/RNA INFLUENZA EA TYPE 97.30 XXX l 87502 INFECTIOUS AGENT DNA/RNA INFLUENZA 1ST 2 TYPES 160.79 XXX l + 87503 NFCT AGENT DNA/RNA INFLUENZA 1+ TYPES EA ADDL 39.28 XXX 87510 IADNA GARDNERELLA VAGIS DIR PRB 37.91 XXX 87511 IADNA GARDNERELLA VAGIS AMP PRB 66.24 XXX 87512 IADNA GARDNERELLA VAGIS QUAN 79.03 XXX 87515 IADNA HEP B VIRUS DIR PRB 37.91 XXX 87516 IADNA HEP B VIRUS AMP PRB 66.24 XXX 87517 IADNA HEP B VIRUS QUAN 80.85 XXX 87520 IADNA HEP C DIR PRB 37.91 XXX 87521 IADNA HEP C AMP PRB 66.24 XXX 87522 IADNA HEP C QUAN 80.85 XXX 87525 IADNA HEP G DIR PRB 37.91 XXX 87526 IADNA HEP G AMP PRB 66.24 XXX 87527 IADNA HEP G QUAN 79.03 XXX 87528 IADNA HERPES SMPLX VIRUS DIR PRB 37.91 XXX 87529 IADNA HERPES SMPLX VIRUS AMP PRB 66.24 XXX 87530 IADNA HERPES SMPLX VIRUS QUAN 80.85 XXX 87531 IADNA HERPES VIRUS-6 DIR PRB 37.91 XXX 87532 IADNA HERPES VIRUS-6 AMP PRB 66.24 XXX 87533 IADNA HERPES VIRUS-6 QUAN 79.03 XXX 87534 IADNA HIV-1 DIR PRB 37.91 XXX 244 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section IX: Pathology and Laboratory Services Georgia Workers Compensation Medical Fee Schedule 80047 89398 PATHOLOGY AND LABORATORY Effective April 1, 2011 Medical Fee Schedule 87535 IADNA HIV-1 AMP PRB 66.24 XXX 87536 IADNA HIV-1 QUAN 160.79 XXX 87537 IADNA HIV-2 DIR PRB 37.91 XXX 87538 IADNA HIV-2 AMP PRB 66.24 XXX 87539 IADNA HIV-2 QUAN 80.85 XXX 87540 IADNA LEGIONELLA PNEUMOPHILA DIR PRB 37.91 XXX 87541 IADNA LEGIONELLA PNEUMOPHILA AMP PRB 66.24 XXX 87542 IADNA LEGIONELLA PNEUMOPHILA QUAN 79.03 XXX 87550 IADNA MYCOBACTERIA SPECIES DIR PRB 37.91 XXX 87551 IADNA MYCOBACTERIA SPECIES AMP PRB 66.24 XXX 87552 IADNA MYCOBACTERIA SPECIES QUAN 80.85 XXX 87555 IADNA MYCOBACTERIA TUBERCULOSIS DIR PRB 37.91 XXX 87556 IADNA MYCOBACTERIA TUBERCULOSIS AMP PRB 66.24 XXX 87557 IADNA MYCOBACTERIA TUBERCULOSIS QUAN 80.85 XXX 87560 IADNA MYCOBACTERIA AVIUM-INTRACLRE DIR PRB 37.91 XXX 87561 IADNA MYCOBACTERIA AVIUM-INTRACLRE AMP PRB 66.24 XXX 87562 IADNA MYCOBACTERIA AVIUM-INTRACLRE QUAN 80.85 XXX 87580 IADNA MYCOPLSM PNEUMONIAE DIR PRB 37.91 XXX 87581 IADNA MYCOPLSM PNEUMONIAE AMP PRB 66.24 XXX 87582 IADNA MYCOPLSM PNEUMONIAE QUAN 79.03 XXX 87590 IADNA NEISSERIA GONORRHOEAE DIR PRB 37.91 XXX 87591 IADNA NEISSERIA GONORRHOEAE AMP PRB 66.24 XXX 87592 IADNA NEISSERIA GONORRHOEAE QUAN 80.85 XXX 87620 IADNA PAPLMVIRUS HUMAN DIR PRB 37.91 XXX 87621 IADNA PAPLMVIRUS HUMAN AMP PRB 66.24 XXX 87622 IADNA PAPLMVIRUS HUMAN QUAN 79.03 XXX 87640 IADNA S. AUREUS AMP PRB TQ 66.24 XXX 87641 IADNA S. AUREUS METHICILLIN RESISTANT AMP PRB TQ 66.24 XXX 87650 IADNA STREPTOCOCCUS GRP DIR PRB 37.91 XXX 87651 IADNA STREPTOCOCCUS GRP AMP PRB 66.24 XXX 87652 IADNA STREPTOCOCCUS GRP QUAN 79.03 XXX 87653 IADNA STREPTOCOCCUS GROUP B AMPLIFIED PROBE TQ 66.24 XXX 87660 IADNA TRICHOMONAS VAGIS DIR PRB 37.91 XXX 87797 IADNA NOS DIR PRB EA ORGANISM 37.91 XXX 87798 IADNA NOS AMP PRB EA ORGANISM 66.24 XXX 87799 IADNA NOS QUAN EA ORGANISM 80.85 XXX 87800 IADNA MLT ORGANISMS DIR PRB 75.83 XXX 87801 IADNA MLT ORGANISMS AMP PRB 132.93 XXX 87802 IAADIADOO STREPTOCOCCUS GRP B 22.84 XXX 87803 IAADIADOO CLOSTRIDIUM DIFFICILE TOXIN 22.84 XXX 87804 IAADIADOO INF 22.84 XXX 87807 IAADIADOO RSV 22.84 XXX 87808 IAADIADOO TRICHOMONAS VAGINALIS 22.84 XXX 87809 INFECTIOUS AGENT IMMUNOASSAY OPTICAL ADENOVIRUS 22.84 XXX 87810 CHLAMYDIA TRACHOMATIS 22.84 XXX 87850 IAADIADOO NEISSERIA GONORRHOEAE 22.84 XXX Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 245
Georgia Workers Compensation Medical Fee Schedule Section IX: Pathology and Laboratory Services PATHOLOGY AND LABORATORY 80047 89398 Medical Fee Schedule Effective April 1, 2011 87880 IAADIADOO STREPTOCOCCUS GRP 22.84 XXX 87899 IAADIADOO NOS 22.84 XXX 87900 NFCT AGT DRUG SC PHEXYP PREDICT 246.67 XXX s 87901 NFCT AGT GEXYP HIV 1 REV TRANSCRIP&PROTEAS REGNS 486.95 XXX 87902 NFCT AGT GEXYP HEP C VIRUS 486.95 XXX 87903 NFCT AGT PHEXYP RESISTANCE TISS CUL HIV 1 1-10 924.56 XXX + 87904 NFCT AGT PHEXYP RESISTANCE TISS CUL HIV 1 EA 1-5 49.33 XXX 87905 INFECTIOUS AGENT ENZYMATIC ACTV OTH/THN VIRUS 23.30 XXX l # 87906 NFCT GEXYP DNA/RNA HIV 1 OTHER REGION 243.47 XXX 87999 UNLIS MICROBIOLOGY BR XXX 88000 NECROPSY GROSS XM W/O CNS 261.29 XXX 88005 NECROPSY GROSS XM BRN 305.14 XXX 88007 NECROPSY GROSS XM BRN&SPI CORD 319.76 XXX 88012 NECROPSY GROSS XM INFT BRN 261.29 XXX 88014 NECROPSY GROSS XM STILLBORN/NB BRN 239.82 XXX 88016 NECROPSY GROSS XM MACERATED STILLBORN 333.92 XXX 88020 NECROPSY GROSS&MCRSCP W/O CNS 450.40 XXX 88025 NECROPSY GROSS&MCRSCP BRN 435.79 XXX 88027 NECROPSY GROSS&MCRSCP BRN&SPI CORD 465.02 XXX 88028 NECROPSY GROSS&MCRSCP INFT BRN 261.29 XXX 88029 NECROPSY GROSS&MCRSCP STILLBORN/NB BRN 261.29 XXX 88036 NECROPSY LMTD GROSS&/MCRSCP REGIONAL 130.64 XXX 88037 NECROPSY LMTD GROSS&/MCRSCP 1 ORGAN 116.03 XXX 88040 NECROPSY FORENSIC XM 726.31 XXX 88045 NECROPSY CORONER'S CALL 72.63 XXX 88099 UNLIS NECROPSY BR XXX 88104 CYTP FLU WASHGS/BRUSHINGS XCPT C/V SMRS INTERPJ 87.71 XXX 88104 26 CYTP FLU WASHGS/BRUSHINGS XCPT C/V SMRS INTERPJ 37.00 XXX 88104 TC CYTP FLU WASHGS/BRUSHINGS XCPT C/V SMRS INTERPJ 50.71 XXX 88106 CYTP FLU BR/WA XCPT C/V FILTER METH ONLY INTERPJ 107.35 XXX 88106 26 CYTP FLU BR/WA XCPT C/V FILTER METH ONLY INTERPJ 36.54 XXX 88106 TC CYTP FLU BR/WA XCPT C/V FILTER METH ONLY INTERPJ 70.81 XXX 88107 CYTP FLU BR/WA XCPT C/V SMRS&FILTER INTERPJ 134.76 XXX 88107 26 CYTP FLU BR/WA XCPT C/V SMRS&FILTER INTERPJ 51.16 XXX 88107 TC CYTP FLU BR/WA XCPT C/V SMRS&FILTER INTERPJ 83.60 XXX 88108 CYTP CONCENTRATION SMRS&INTERPJ 101.41 XXX 88108 26 CYTP CONCENTRATION SMRS&INTERPJ 36.54 XXX 88108 TC CYTP CONCENTRATION SMRS&INTERPJ 64.87 XXX 88112 CYTP SLCTV CELL ENHANCEMENT INTERPJ XCPT C/V 137.95 XXX 88112 26 CYTP SLCTV CELL ENHANCEMENT INTERPJ XCPT C/V 75.83 XXX 88112 TC CYTP SLCTV CELL ENHANCEMENT INTERPJ XCPT C/V 62.12 XXX l 88120 CYTP INSITU HYBRID URINE SPEC 3-5 PROBES EA MNL 613.48 XXX l 88120 26 CYTP INSITU HYBRID URINE SPEC 3-5 PROBES EA MNL 70.35 XXX l 88120 TC CYTP INSITU HYBRID URINE SPEC 3-5 PROBES EA MNL 543.13 XXX l 88121 CYTP INSITU HYBRID URNE SPEC 3-5 PROBES CPTR EA 518.01 XXX l 88121 26 CYTP INSITU HYBRID URNE SPEC 3-5 PROBES CPTR EA 62.58 XXX 246 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section IX: Pathology and Laboratory Services Georgia Workers Compensation Medical Fee Schedule 80047 89398 PATHOLOGY AND LABORATORY Effective April 1, 2011 Medical Fee Schedule l 88121 TC CYTP INSITU HYBRID URNE SPEC 3-5 PROBES CPTR EA 455.43 XXX 88125 CYTP FORENSIC 29.69 XXX 88125 26 CYTP FORENSIC 17.82 XXX 88125 TC CYTP FORENSIC 11.87 XXX 88130 SEX CHROMATIN ID BARR BODIES 28.32 XXX 88140 SEX CHROMATIN ID PRPH BLD SMR 15.07 XXX 88141 CYTP C/V REQ INTERPJ PHYS 38.83 XXX 88142 CYTP C/V FLU AUTO THIN MNL PHYS 38.37 XXX 88143 CYTP C/V FLU AUTO THIN MNL SCR&RESCR PHYS 38.37 XXX 88147 CYTP SMRS C/V SCR AUTO SYS PHYS 21.47 XXX 88148 CYTP SMRS C/V SCR AUTO SYS MNL RESCR PHYS 28.78 XXX 88150 CYTP SLIDES C/V MNL SCR UNDER PHYS 20.10 XXX 88152 CYTP SLIDES C/V MNL SCR&CPTR RESCR PHYS 20.10 XXX 88153 CYTP SLIDES C/V MNL SCR&RESCR PHYS 20.10 XXX 88154 CYTP SLIDES C/V MNL SCR&CPTR-RESCR CELL S&R PHYS 20.10 XXX + 88155 CYTP SLIDES C/V DEFINITIVE HORMONAL EVAL 11.42 XXX 88160 CYTP SMRS ANY OTH SRC SCR&INTERPJ 73.09 XXX 88160 26 CYTP SMRS ANY OTH SRC SCR&INTERPJ 32.89 XXX 88160 TC CYTP SMRS ANY OTH SRC SCR&INTERPJ 40.20 XXX 88161 CYTP SMRS ANY OTH SRC PREPJ SCR&INTERPJ 73.09 XXX 88161 26 CYTP SMRS ANY OTH SRC PREPJ SCR&INTERPJ 31.98 XXX 88161 TC CYTP SMRS ANY OTH SRC PREPJ SCR&INTERPJ 41.11 XXX 88162 CYTP SMRS ANY OTH SRC EXTND STD > 5 SLIDES 105.06 XXX 88162 26 CYTP SMRS ANY OTH SRC EXTND STD > 5 SLIDES 49.79 XXX 88162 TC CYTP SMRS ANY OTH SRC EXTND STD > 5 SLIDES 55.27 XXX 88164 CYTP SLIDES C/V MNL SCR PHYS 20.10 XXX 88165 CYTP SLIDES C/V MNL SCR&RESCR PHYS 20.10 XXX 88166 CYTP SLIDES C/V MNL SCR&CPTR RESCR PHYS 20.10 XXX 88167 CYTP SLIDES C/V MNL SCR&CPTR RESCR CELL S&R PHYS 20.10 XXX s 88172 CYTP FINE NDL ASPIRATE IMMT CYTOHIST STD DX 1ST 68.06 XXX s 88172 26 CYTP FINE NDL ASPIRATE IMMT CYTOHIST STD DX 1ST 40.20 XXX s 88172 TC CYTP FINE NDL ASPIRATE IMMT CYTOHIST STD DX 1ST 27.86 XXX 88173 CYTP FINE NDL ASPIRATE I&R 185.00 XXX 88173 26 CYTP FINE NDL ASPIRATE I&R 91.82 XXX 88173 TC CYTP FINE NDL ASPIRATE I&R 93.18 XXX 88174 CYTP C/V AUTO THIN LYR PREPJ SCR SYS PHYS 40.20 XXX 88175 CYTP C/V AUTO THIN LYR PREPJ SCR MNL RESCR PHYS 50.25 XXX l + # 88177 CYTP C/V AUTO THIN LYR PREPJ ADEQUACY EA EVAL 37.46 ZZZ l + # 88177 26 CYTP C/V AUTO THIN LYR PREPJ ADEQUACY EA EVAL 28.78 ZZZ l + # 88177 TC CYTP C/V AUTO THIN LYR PREPJ ADEQUACY EA EVAL 8.68 ZZZ 88182 FLO CYTOMETRY CELL CYCLE/DNA ALYS 139.78 XXX 88182 26 FLO CYTOMETRY CELL CYCLE/DNA ALYS 46.59 XXX 88182 TC FLO CYTOMETRY CELL CYCLE/DNA ALYS 93.19 XXX 88184 FLO CYTOMETRY CELL SURF MARKER TECHL ONLY 1ST 112.83 XXX + 88185 FLO CYTOMETRY CELL SURF MARKER TECHL ONLY EA 67.61 ZZZ 88187 FLO CYTOMETRY INTERPJ 2-8 MARKERS 90.90 XXX Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 247
Georgia Workers Compensation Medical Fee Schedule Section IX: Pathology and Laboratory Services PATHOLOGY AND LABORATORY 80047 89398 Medical Fee Schedule Effective April 1, 2011 88188 FLO CYTOMETRY INTERPJ 9-15 MARKERS 112.83 XXX 88189 FLO CYTOMETRY INTERPJ 16/> MARKERS 138.87 XXX 88199 UNLIS CYTP BR XXX 88230 TISS CUL NON-NEO DISORDERS LYMPHOCYTE 220.63 XXX 88233 TISS CUL NON-NEO DISORDERS SKN/OTH SOLID TISS BX 266.31 XXX 88235 TISS CUL NON-NEO DISORDERS AMNIOTIC/CHORNC CELLS 278.65 XXX 88237 TISS CUL NEO DISORDERS B1 MARROW BLD CELLS 238.91 XXX 88239 TISS CUL NEO DISORDERS SOLID TUM 279.10 XXX 88240 CRYOPRSRV FRZING&STORAGE CELLS EA CELL LINE 19.19 XXX 88241 THAWING&XPNSJ FROZEN CELLS EA ALIQUOT 19.19 XXX 88245 CHRMSM BRKG BASELINE SISTER 20-25 CLL 281.85 XXX 88248 CHRMSM BRKG BASELINE BRKG 50-100 CLL 327.53 XXX 88249 CHRMSM BRKG SYNDS SCORE 100 CLL 327.53 XXX 88261 CHRMSM CNT 5 CLL 1KARYOTYP BANDING 334.38 XXX 88262 CHRMSM CNT 15-20 CLL 2KARYOTYP BANDING 235.71 XXX 88263 CHRMSM CNT 45 CLL MOSAICISM 2KARYOTYP 284.13 XXX 88264 CHRMSM ANALYZE 20-25 CELLS 235.71 XXX 88267 CHRMSM ALYS AMNIOTIC/VILLUS 15 CLL 1KARYOTYP 340.32 XXX 88269 CHRMSM SITU AMNIOTIC CLL 6-12 COLONIES 1KARYOTYP 314.74 XXX 88271 MOLEC CYTOGENETICS DNA PRB EA 40.66 XXX 88272 MOLEC CYTG CHRMOML ISH 3-5 CLL 50.70 XXX 88273 MOLEC CYTG CHRMOML ISH 10-30 CLL 60.75 XXX 88274 MOLEC CYTG INTERPHASE ISH 25-99 CLL 65.78 XXX 88275 MOLEC CYTG INTERPHASE ISH ANALYZE 100-300 CLL 75.83 XXX 88280 CHRMSM ALYS ADDL KARYOTYP EA STD 47.51 XXX 88283 CHRMSM ALYS ADDL SPECIZED BANDING 129.73 XXX 88285 CHRMSM ALYS ADDL CELLS CNTED EA STD 36.09 XXX 88289 CHRMSM ALYS ADDL HR STD 65.32 XXX 88291 CYTOGENETICS&MOLEC CYTOGENETICS I&R 39.28 XXX 88299 UNLIS CYTOGENETIC STD BR XXX 88300 LVL I-SURG PATH GROSS XM ONLY 36.09 XXX 88300 26 LVL I-SURG PATH GROSS XM ONLY 5.94 XXX 88300 TC LVL I-SURG PATH GROSS XM ONLY 30.15 XXX 88302 LVL II-SURG PATH GROSS&MCRSCP XM 71.72 XXX 88302 26 LVL II-SURG PATH GROSS&MCRSCP XM 8.68 XXX 88302 TC LVL II-SURG PATH GROSS&MCRSCP XM 63.04 XXX 88304 LEVEL III-SURG PATH GROSS&MICROSCOPIC XM 84.05 XXX 88304 26 LEVEL III-SURG PATH GROSS&MICROSCOPIC XM 14.62 XXX 88304 TC LEVEL III-SURG PATH GROSS&MICROSCOPIC XM 69.43 XXX 88305 LVL IV-SURG PATH GROSS&MCRSCP XM 142.52 XXX 88305 26 LVL IV-SURG PATH GROSS&MCRSCP XM 48.88 XXX 88305 TC LVL IV-SURG PATH GROSS&MCRSCP XM 93.64 XXX 88307 LVL V-SURG PATH GROSS&MCRSCP XM 304.23 XXX 88307 26 LVL V-SURG PATH GROSS&MCRSCP XM 106.89 XXX 88307 TC LVL V-SURG PATH GROSS&MCRSCP XM 197.34 XXX 88309 LVL VI-SURG PATH GROSS&MCRSCP XM 460.91 XXX 248 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section IX: Pathology and Laboratory Services Georgia Workers Compensation Medical Fee Schedule 80047 89398 PATHOLOGY AND LABORATORY Effective April 1, 2011 Medical Fee Schedule 88309 26 LVL VI-SURG PATH GROSS&MCRSCP XM 186.83 XXX 88309 TC LVL VI-SURG PATH GROSS&MCRSCP XM 274.08 XXX + 88311 DECALCIFICATION PX 25.12 XXX + 88311 26 DECALCIFICATION PX 15.99 XXX + 88311 TC DECALCIFICATION PX 9.13 XXX 88312 SPECIAL STAINS GROUP 1 MICROORGANISMS I&R EACH 143.44 XXX 88312 26 SPECIAL STAINS GROUP 1 MICROORGANISMS I&R EACH 35.17 XXX 88312 TC SPECIAL STAINS GROUP 1 MICROORGANISMS I&R EACH 108.27 XXX 88313 SPECIAL STAINS GROUP II ALL OTHER I&R EACH 104.61 XXX 88313 26 SPECIAL STAINS GROUP II ALL OTHER I&R EACH 15.53 XXX 88313 TC SPECIAL STAINS GROUP II ALL OTHER I&R EACH 89.08 XXX + 88314 SPECIAL STAINS HISTOCHEMICAL W/FROZEN SECTION 121.05 XXX + 88314 26 SPECIAL STAINS HISTOCHEMICAL W/FROZEN SECTION 30.15 XXX + 88314 TC SPECIAL STAINS HISTOCHEMICAL W/FROZEN SECTION 90.90 XXX 88318 DETERMINATIVE HISTOCHEMISTRY ID CHEM COMPONENTS 156.68 XXX 88318 26 DETERMINATIVE HISTOCHEMISTRY ID CHEM COMPONENTS 27.86 XXX 88318 TC DETERMINATIVE HISTOCHEMISTRY ID CHEM COMPONENTS 128.82 XXX 88319 DETERMINATIVE HCHEM/CCHEM ID NZM EA 196.88 XXX 88319 26 DETERMINATIVE HCHEM/CCHEM ID NZM EA 35.63 XXX 88319 TC DETERMINATIVE HCHEM/CCHEM ID NZM EA 161.25 XXX 88321 CONSLTJ&REPRT SLIDES PREPARED ELSEWHERE 121.97 XXX 88323 CONSLTJ&REPRT MATRL REQ PREPJ SLIDES 191.86 XXX 88323 26 CONSLTJ&REPRT MATRL REQ PREPJ SLIDES 112.83 XXX 88323 TC CONSLTJ&REPRT MATRL REQ PREPJ SLIDES 79.03 XXX 88325 CONSLTJ COMPRE REVIEW REPRT REFERRED MATRL 268.14 XXX 88329 PATH CONSLTJ SURG 69.89 XXX 88331 PATH CONSLTJ SURG 1ST BLK FROZEN SCTJ 1 SPEC 122.88 XXX 88331 26 PATH CONSLTJ SURG 1ST BLK FROZEN SCTJ 1 SPEC 79.94 XXX 88331 TC PATH CONSLTJ SURG 1ST BLK FROZEN SCTJ 1 SPEC 42.94 XXX s + 88332 PATH CONSLTJ SURG EA BLK FROZEN SCTJ 54.36 XXX s + 88332 26 PATH CONSLTJ SURG EA BLK FROZEN SCTJ 39.28 XXX s + 88332 TC PATH CONSLTJ SURG EA BLK FROZEN SCTJ 15.08 XXX 88333 PATH CONSLTJ SURG CYTOLOGIC XM 1ST SIT 127.90 XXX 88333 26 PATH CONSLTJ SURG CYTOLOGIC XM 1ST SIT 80.85 XXX 88333 TC PATH CONSLTJ SURG CYTOLOGIC XM 1ST SIT 47.05 XXX s + 88334 PATH CONSLTJ SURG CYTOL XM EA ADDL 79.03 XXX s + 88334 26 PATH CONSLTJ SURG CYTOL XM EA ADDL 49.33 XXX s + 88334 TC PATH CONSLTJ SURG CYTOL XM EA ADDL 29.70 XXX 88342 IMCYTCHM TISS IMMUNOPROXIDASE EA ANTB 139.78 XXX 88342 26 IMCYTCHM TISS IMMUNOPROXIDASE EA ANTB 55.27 XXX 88342 TC IMCYTCHM TISS IMMUNOPROXIDASE EA ANTB 84.51 XXX 88346 IMFLUOR STD EA ANTB DIR METH 137.04 XXX 88346 26 IMFLUOR STD EA ANTB DIR METH 55.27 XXX 88346 TC IMFLUOR STD EA ANTB DIR METH 81.77 XXX 88347 IMFLUOR STD EA ANTB INDIR METH 103.69 XXX 88347 26 IMFLUOR STD EA ANTB INDIR METH 51.16 XXX Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 249
Georgia Workers Compensation Medical Fee Schedule Section IX: Pathology and Laboratory Services PATHOLOGY AND LABORATORY 80047 89398 Medical Fee Schedule Effective April 1, 2011 88347 TC IMFLUOR STD EA ANTB INDIR METH 52.53 XXX 88348 ELECTRON MIC DX 915.43 XXX 88348 26 ELECTRON MIC DX 98.21 XXX 88348 TC ELECTRON MIC DX 817.22 XXX 88349 ELECTRON MIC SCANNING 482.84 XXX 88349 26 ELECTRON MIC SCANNING 52.08 XXX 88349 TC ELECTRON MIC SCANNING 430.76 XXX 88355 M/PHMTRC ALYS SKEL MUSC 287.33 XXX 88355 26 M/PHMTRC ALYS SKEL MUSC 112.37 XXX 88355 TC M/PHMTRC ALYS SKEL MUSC 174.96 XXX 88356 M/PHMTRC ALYS NRV 380.51 XXX 88356 26 M/PHMTRC ALYS NRV 176.32 XXX 88356 TC M/PHMTRC ALYS NRV 204.19 XXX 88358 M/PHMTRC ALYS TUM 100.50 XXX 88358 26 M/PHMTRC ALYS TUM 56.64 XXX 88358 TC M/PHMTRC ALYS TUM 43.86 XXX 88360 M/PHMTRC ALYS TUM IMHCHEM EA ANTB MNL 165.82 XXX 88360 26 M/PHMTRC ALYS TUM IMHCHEM EA ANTB MNL 70.35 XXX 88360 TC M/PHMTRC ALYS TUM IMHCHEM EA ANTB MNL 95.47 XXX 88361 M/PHMTRC ALYS TUM IMHCHEM EA ANTB CPTR 203.73 XXX 88361 26 M/PHMTRC ALYS TUM IMHCHEM EA ANTB CPTR 74.92 XXX 88361 TC M/PHMTRC ALYS TUM IMHCHEM EA ANTB CPTR 128.81 XXX 88362 NRV TEASING PREPJS 379.60 XXX 88362 26 NRV TEASING PREPJS 143.89 XXX 88362 TC NRV TEASING PREPJS 235.71 XXX l 88363 EXAM & SELECT ARCHIVE TISSUE MOLECULAR ANALYSIS 51.16 XXX 88365 SITU HYBRIDIZATION EA PRB 222.46 XXX 88365 26 SITU HYBRIDIZATION EA PRB 76.74 XXX 88365 TC SITU HYBRIDIZATION EA PRB 145.72 XXX 88367 M/PHMTRC ALYS ISH EA PRB CPTR-ASST TECHNOLOGY 344.43 XXX 88367 26 M/PHMTRC ALYS ISH EA PRB CPTR-ASST TECHNOLOGY 81.77 XXX 88367 TC M/PHMTRC ALYS ISH EA PRB CPTR-ASST TECHNOLOGY 262.66 XXX 88368 M/PHMTRC ALYS ISH EA PRB MNL 295.55 XXX 88368 26 M/PHMTRC ALYS ISH EA PRB MNL 83.59 XXX 88368 TC M/PHMTRC ALYS ISH EA PRB MNL 211.96 XXX 88371 PROTEIN ALYS WSTRN BLOT I&R 67.61 XXX 88371 26 PROTEIN ALYS WSTRN BLOT I&R 25.58 XXX 88371 TC PROTEIN ALYS WSTRN BLOT I&R 42.03 XXX 88372 PROTEIN ALYS WSTRN BLOT I&R IMMUNOLOGICAL EA 68.98 XXX 88372 26 PROTEIN ALYS WSTRN BLOT I&R IMMUNOLOGICAL EA 26.04 XXX 88372 TC PROTEIN ALYS WSTRN BLOT I&R IMMUNOLOGICAL EA 42.94 XXX 88380 MICRODISSECTION PREP IDENTIFIED TARGET LASER 235.25 XXX 88380 26 MICRODISSECTION PREP IDENTIFIED TARGET LASER 97.30 XXX 88380 TC MICRODISSECTION PREP IDENTIFIED TARGET LASER 137.95 XXX 88381 MICRODISSECTION PREP IDENTIFIED TARGET MANUAL 247.59 XXX 88381 26 MICRODISSECTION PREP IDENTIFIED TARGET MANUAL 71.72 XXX 250 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section IX: Pathology and Laboratory Services Georgia Workers Compensation Medical Fee Schedule 80047 89398 PATHOLOGY AND LABORATORY Effective April 1, 2011 Medical Fee Schedule 88381 TC MICRODISSECTION PREP IDENTIFIED TARGET MANUAL 175.87 XXX 88384 RA-BASED EVAL MLT MOLEC PRBS 11 THRU 50 PRBS 469.13 XXX 88384 26 RA-BASED EVAL MLT MOLEC PRBS 11 THRU 50 PRBS 51.62 XXX 88384 TC RA-BASED EVAL MLT MOLEC PRBS 11 THRU 50 PRBS 417.51 XXX 88385 RA-BASED EVAL MLT MOLEC PRBS 51 THRU 250 PRBS 771.99 XXX 88385 26 RA-BASED EVAL MLT MOLEC PRBS 51 THRU 250 PRBS 88.16 XXX 88385 TC RA-BASED EVAL MLT MOLEC PRBS 51 THRU 250 PRBS 683.83 XXX 88386 RA-BASED EVAL MLT MOLEC PRBS 251 THRU 500 PRBS 861.07 XXX 88386 26 RA-BASED EVAL MLT MOLEC PRBS 251 THRU 500 PRBS 116.03 XXX 88386 TC RA-BASED EVAL MLT MOLEC PRBS 251 THRU 500 PRBS 745.04 XXX 88387 MACRO EXAM DISSECT&PREP TISS NONMICRO STD EA 54.36 XXX 88387 26 MACRO EXAM DISSECT&PREP TISS NONMICRO STD EA 42.48 XXX 88387 TC MACRO EXAM DISSECT&PREP TISS NONMICRO STD EA 11.88 XXX + 88388 MACR EXM DISS&PRP NONMICR IMPRNT/CONSLT/FRZ SEC 31.52 XXX + 88388 26 MACR EXM DISS&PRP NONMICR IMPRNT/CONSLT/FRZ SEC 25.58 XXX + 88388 TC MACR EXM DISS&PRP NONMICR IMPRNT/CONSLT/FRZ SEC 5.94 XXX 88399 UNLIS SURG PATH PX BR XXX 88720 BILIRUBIN TOTAL TRANSCUTANEOUS 9.59 XXX 88738 HGB QUANTITATIVE TRANSCUTANEOUS 9.59 XXX 88740 HEMOGLOBIN QUAN TC PER DAY CARBOXYHEMOGLOBIN 9.59 XXX 88741 HEMOGLOBIN QUANTITATIVE TC PER DAY METHEMOGLOBIN 9.59 XXX l 88749 UNLISTED IN VIVO LAB SERVICE BR XXX 89049 CAFFEINE HALOTHANE CONTRCURE 342.60 XXX 89050 C-CNT MISC BDY FLUS XCPT BLD 9.14 XXX 89051 C-CNT MISC BDY FLUS XCPT BLD DIFFIAL CNT 10.51 XXX 89055 WBC ASSMT FECAL QUAL/SEMIQUAN 8.22 XXX 89060 CRYSTAL ID LIGHT MIC ALYS TISSUE/ANY FLU 39.74 XXX 89060 26 CRYSTAL ID LIGHT MIC ALYS TISSUE/ANY FLU 26.04 XXX 89060 TC CRYSTAL ID LIGHT MIC ALYS TISSUE/ANY FLU 13.70 XXX 89125 FAT STAIN FECES URINE/RESPIR SECRETIONS 8.22 XXX 89160 MEAT FIBERS FECES 6.85 XXX 89190 NSL SMR EOSINOPHILS 9.14 XXX 89220 SPTM OBTG SPEC AERSL INDUCED SPX 21.47 XXX 89230 SWEAT COLLJ IONTOPHORESIS 4.11 XXX 89240 UNLIS MISC PATH BR XXX 89250 CUL OOCYTE/EMBRYO < 4 D 1318.78 XXX 89251 CUL OOCYTE/EMBRYO < 4 D CO-CULT OCYTE/EMBRY 1371.77 XXX 89253 ASSTD EMBRYO HATCHING MICROTQS ANY METH BR XXX 89254 OOCYTE ID FROM FOLLICULAR FLU BR XXX 89255 PREPJ EMBRYO TR BR XXX 89257 SPRM ID FROM ASPIR OTH/THN SEMINAL BR XXX 89258 CRYOPRESERVATION EMBRYO(S) BR XXX 89259 CRYOPRESERVATION SPERM BR XXX 89260 SPRM ISOL SMPL PREP INSEMINATION/DX SEMEN ALYS BR XXX 89261 SPRM ISOL CPLX PREP INSEMINATION/DX SEMEN ALYS BR XXX 89264 SPRM ID FROM TSTIS TISS FRSH/CRYOPRSRVD BR XXX Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 251
Georgia Workers Compensation Medical Fee Schedule Section IX: Pathology and Laboratory Services PATHOLOGY AND LABORATORY 80047 89398 Medical Fee Schedule Effective April 1, 2011 89268 INSEMINATION OOCYTES BR XXX 89272 EXTND CUL OOCYTE/EMBRYO 4-7 D BR XXX 89280 ASSTD FERTILIZATION MICROTQ </EQUAL 10 OOCYTES BR XXX 89281 ASSTD FERTILIZATION MICROTQ > 10 OOCYTES BR XXX 89290 BX OOCYTE MICROTQ </EQUAL 5 EMBRY BR XXX 89291 BX OOCYTE MICROTQ > 5 EMBRY BR XXX 89300 SEMEN ALYS PRESENCE&/MOTILITY SPRM HUHNER 16.90 XXX 89310 SEMEN ALYS MOTILITY&CNT X W/HUHNER TST 16.44 XXX 89320 SEMEN ANALYSIS VOLUME COUNT MOTILITY DIFFERENT 22.84 XXX 89321 SEMEN ANALYSIS SPERM PRESENCE&/MOTILITY SPRM 22.84 XXX 89322 SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA 29.24 XXX 89325 SPRM ANTIBODIES 20.10 XXX 89329 SPRM EVAL HAMSTER PENETRATION TST 39.74 XXX 89330 SPRM EVAL CRV MUCUS PENETRATION 18.73 XXX 89331 SPERM EVALUATION RETROGRADE EJACULATION URINE 37.00 XXX 89335 CRYOPRSRV REPRDTVE TISS TSTICULAR BR XXX 89342 STORAGE PR YR EMBRYO BR XXX 89343 STORAGE PR YR SPRM/SEMEN BR XXX 89344 STORAGE PR YR REPRDTVE TISS TSTICULAR/OVARIAN BR XXX 89346 STORAGE PR YR OOCYTE BR XXX 89352 THAWING CRYOPRSRVD EMBRYO BR XXX 89353 THAWING CRYOPRSRVD SPRM/SEMEN EA ALIQUOT BR XXX 89354 THAWING CRYOPRSRVD TSTICULAR/OVARIAN BR XXX 89356 THAWING CRYOPRSRVD OOCYTES EA ALIQUOT BR XXX 89398 UNLISTED REPRODUCTIVE MEDICINE LAB PROCEDURE BR XXX 252 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
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 99070 (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 90476 90749 are reported in addition to an immunization administration CPT code(s) 90460 90474. Hydration services shall use CPT code(s) 96360, 96361 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) 96365 96379 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
Georgia Workers Compensation Medical Fee Schedule medicine evaluations (97001 97004), 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 99354 99357 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 99441 99443 (physicians) and 98966 98968 (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 2011. 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.
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 25. 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. 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 99353 99357 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
Georgia Workers Compensation Medical Fee Schedule Section X: General Medicine Services MEDICINE 90281 96999, 97597 97606, 97802 97804, 98960 99091, 99143 99199, 99605 99607 Medical Fee Schedule Effective April 1, 2011 90281 IMMUNE GLOBULIN IG HUMAN IM USE BR XXX 90283 IMMUNE GLOBULIN IGIV HUMAN IV USE BR XXX 90284 IMMUNE GLOBULIN HUMAN SUBQ INFUSION 100 MG EA BR XXX 90287 BOTULINUM ANTITOXIN EQUINE ANY ROUTE BR XXX 90288 BOTULISM IMMUNE GLOBULIN HUMAN INTRAVENOUS USE BR XXX 90291 CYTOMEGALOVIRUS IMMUNE GLOBULIN HUMAN IV BR XXX 90296 DIPHTHERIA ANTITOXIN EQUINE ANY ROUTE BR XXX 90371 HEPATITIS B IMMUNE GLOBULIN HBIG HUMAN IM 189.43 XXX 90375 RABIES IMMUNE GLOBULIN RIG HUMAN IM/SUBQ 261.99 XXX 90376 RABIES IG HEAT-TREATED HUMAN IM/SUBQ 257.01 XXX 90378 RESPIRATORY SYNCYTIAL VIRUS IG IM 50 MG E BR XXX 90384 RHO(D) IMMUNE GLOBULIN HUMAN FULL-DOSE IM 135.15 XXX 90385 RHO(D) IMMUNE GLOBULIN HUMAN MINI-DOSE IM 39.88 XXX 90386 RHO(D) IMMUNE GLOBULIN HUMAN IV 144.57 XXX 90389 TETANUS IMMUNE GLOBULIN TIG HUMAN IM 125.18 XXX 90393 VACCINIA IMMUNE GLOBULIN HUMAN IM BR XXX 90396 VARICELLA-ZOSTER IMMUNE GLOBULIN HUMAN IM 139.03 XXX 90399 UNLISTED IMMUNE GLOBULIN BR XXX l 90460 IMADM THROUGH 18YR ANY ROUTE 1ST VAC/TOXOID 37.67 XXX l + 90461 IMADM THROUGH 18YR ANY ROUTE EA ADDL VAC/TOXOID 18.83 ZZZ l 90470 IMMUNE ADMIN H1N1 IM/NASAL INCL CNSL 33.23 XXX 90471 IMADM PRQ ID SUBQ/IM NJXS 1 VACC 37.67 XXX + 90472 IMADM PRQ ID SUBQ/IM NJXS EA VACC 18.83 ZZZ 90473 IMADM INTRANSL/ORAL 1 VACC 37.67 XXX + 90474 IMADM INTRANSL/ORAL EA VACC 18.83 ZZZ 90476 ADENOVIRUS VACCINE TYPE 4 LIVE ORAL BR XXX 90477 ADENOVIRUS VACCINE TYPE 7 LIVE FOR ORAL BR XXX 90581 ANTHRAX VACCINE SUBCUTANEOUS USE 160.63 XXX 90585 BACILLUS CALMETTE-GUERIN VACC FOR TB LIVE PERQ 186.66 XXX 90586 BCG BLDR CANCER LIVE INTRAVESICAL 185.00 XXX 90632 HEPATITIS A VACCINE ADULT FOR INTRAMUSCULAR USE 83.09 XXX 90633 HEPATITIS A VACCINE PEDIATRIC 2 DOSE SCHEDULE IM 38.77 XXX 90634 HEPATITIS A VACCINE PEDIATRIC 3 DOSE SCHEDULE IM 40.43 XXX 90636 HEPATITIS A & B VACCINE HEPA-HEPB ADULT IM 105.79 XXX l 90644 MENINGOCOCCAL & HIB CONJ VACCINE 4 DOSE IM 31.02 XXX 90645 HEMOPHILUS INFLUENZA B VACC HBOC CONJ 4 DOSE IM 31.02 XXX 90646 HEMOPHILUS INFLUENZA B VACCINE PRP-D BOOSTER IM 31.02 XXX 90647 HEMOPHILUS INFLUENZA B VACCINE PRP-OMP 3 DOSE IM 32.68 XXX 90648 HEMOPHILUS INFLUENZA B VACCINE PRP-T 4 DOSE IM 31.02 XXX 90649 HUMAN PAPILLOMA VIRUS VACCINE QUADRIV 3 DOSE IM 146.23 XXX s 90650 HUMAN PAPILLOMA VIRUS BIVALENT VACCINE 3 DOSE IM BR XXX 90654 INFLUENZA VACCINE PRSV FREE ID USE BR XXX 90655 INFLUENZA VIRUS VACC SPLIT PRSRV FREE 6-35 MO IM 24.37 XXX 90656 INFLUENZA VIRUS VACC SPLIT PRSRV FR 3 YEARS + IM 22.71 XXX 90657 INFLUENZA VIRUS VACCINE SPLIT VIRUS 6-35 MO IM 10.52 XXX 90658 INFLUENZA VIRUS VACCINE SPLIT VIRUS 3 YEARS + IM 17.72 XXX 256 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section X: General Medicine Services Georgia Workers Compensation Medical Fee Schedule 90281 96999, 97597 97606, 97802 97804, 98960 99091, 99143 99199, 99605 99607 MEDICINE Effective April 1, 2011 Medical Fee Schedule 90660 INFLUENZA VIRUS VACCINE LIVE INTRANASAL 36.56 XXX 90661 INFLUENZA VACCINE CELL CULT PRSRV FREE IM BR XXX s 90662 INFLUENZA VACCINE SPLT PRSRV FREE INC ANTIGEN IM 47.64 XXX s 90663 INFLUENZA VACCINE PANDEMIC FORMULATION H1N1 BR XXX l 90664 INFLUENZA VACCINE PANDEMIC LIVE INTRANASAL USE BR XXX # 90665 LYME DISEASE VACCINE ADULT IM BR XXX l 90666 INFLUENZA VACCINE PANDEMIC PRSV FREE IM USE BR XXX l 90667 INFLUENZA VACCINE PANDEMIC ADJUVANT IM USE BR XXX l 90668 INFLUENZA VACCINE PANDEMIC IM USE BR XXX 90669 PNEUMOCOCCAL CONJ VACCINE 7 VALENT IM 155.65 XXX s 90670 PNEUMOCOCCAL CONJ VACCINE 13 VALENT IM 201.62 XXX 90675 RABIES VACCINE INTRAMUSCULAR 316.83 XXX 90676 RABIES VACCINE INTRADERMAL BR XXX 90680 ROTAVIRUS VACCINE PENTAVALENT 3 DOSE LIVE ORAL 86.96 XXX 90681 ROTAVIRUS VACC HUMAN ATTENUATED 2 DOSE LIVE ORAL 86.96 XXX 90690 TYPHOID VACCINE LIVE ORAL 44.31 XXX 90691 TYPHOID VACCINE VI CAPSULAR POLYSACCHARIDE IM 97.49 XXX 90692 TYPHOID VACC H-P INACTIVATED SUBQ/INTRADERMAL BR XXX 90693 TYPHOID VACCINE AKD SUBQ U.S. MILITARY BR XXX 90696 DTAP-IPV INACTIVATED IF ADMIN PTS AGE 4-6 YRS IM BR XXX 90698 DTAP-HIB-IPV VACCINE IM 86.96 XXX 90700 DTAP VACCINE < 7 YR IM 28.80 XXX 90701 DIPHTHERIA TETANUS TOXOID PERTUSSIS VACCINE IM 31.57 XXX 90702 DIPHTHERIA TETANUS TOXOID ADSORBED < 7 YR IM 23.82 XXX 90703 TETANUS TOXOID ADSORBED INTRAMUSCULAR 44.87 XXX 90704 MUMPS VIRUS VACCINE LIVE SUBCUTANEOUS 29.91 XXX 90705 MEASLES VIRUS VACCINE LIVE SUBCUTANEOUS 31.02 XXX 90706 RUBELLA VIRUS VACCINE LIVE SUBCUTANEOUS 31.02 XXX 90707 MEASLES MUMPS RUBELLA VIRUS VACCINE LIVE SUBQ 57.61 XXX 90708 MEASLES & RUBELLA VIRUS VACCINE LIVE SUBQ BR XXX 90710 MEASLES MUMPS RUBELLA VARICELLA VACC LIVE SUBQ 153.98 XXX 90712 POLIOVIRUS VACCINE ANY LIVE ORAL BR XXX 90713 POLIOVIRUS VACCINE INACTIVATED SUBQ/IM 32.68 XXX 90714 TD TOXOIDS ADSORBED PRSRV FR 7 YR + IM 30.46 XXX 90715 TDAP VACCINE 7 YR + IM 65.91 XXX 90716 VARICELLA VIRUS VACCINE LIVE SUBQ 84.75 XXX 90717 YELLOW FEVER VACCINE LIVE SUBQ 105.79 XXX 90718 TETANUS & DIPHTHERIA TOXOIDS ADSORBED 7 YR + IM 38.77 XXX 90719 DIPHTHERIA TOXOID INTRAMUSCULAR BR XXX 90720 DTP-HIB VACCINE INTRAMUSCULAR BR XXX 90721 DTAP-HIB VACCINE INTRAMUSCULAR BR XXX 90723 DTAP-HEPB-IPV VACCINE INTRAMUSCULAR 84.75 XXX 90725 CHOLERA VACCINE INJECTABLE BR XXX 90727 PLAGUE VACCINE INTRAMUSCULAR BR XXX 90732 PNEUMOCOCCAL POLYSAC VACCINE 23-V 2 YR + SUBQ/IM 80.87 XXX 90733 MENINGOCOCCAL POLYSAC VACCINE SUBCUTANEOUS 168.39 XXX Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 257
Georgia Workers Compensation Medical Fee Schedule Section X: General Medicine Services MEDICINE 90281 96999, 97597 97606, 97802 97804, 98960 99091, 99143 99199, 99605 99607 Medical Fee Schedule Effective April 1, 2011 90734 MENINGOCOCCAL CONJ VACCINE TETRAVALENT IM 109.67 XXX 90735 JAPANESE ENCEPHALITIS VIRUS VACCINE SUBCUTANEOUS 166.17 XXX 90736 ZOSTER SHINGLES VACCINE LIVE SUBCUTANEOUS 185.00 XXX 90738 JAPANESE ENCEPHALITIS VACCINE INACTIVATED IM 76.44 XXX 90740 HEPATITIS B VACCINE DIALYSIS DOSAGE 3 DOSE IM 194.42 XXX 90743 HEPATITIS B VACCINE ADOLESCENT 2 DOSE IM 39.33 XXX 90744 HEPATITIS B VACCINE PEDIATRIC3 DOSE IM 39.33 XXX 90746 HEPATITIS B VACCINE ADULT DOSAGE INTRAMUSCULAR 97.49 XXX 90747 HEPATITIS B VACCINE DIALYSIS DOSAGE 4 DOSE IM 194.42 XXX 90748 HEPB-HIB VACCINE INTRAMUSCULAR 64.81 XXX 90749 UNLISTED VACCINE/TOXOID BR XXX 90801 PSYC DX INTERVIEW XM 250.92 XXX 90802 IA PSYC DX INTERVIEW XM W/PLAY 272.52 XXX 90804 IPI-OB-M/S OFFICE 20-30 MIN 103.03 XXX 90805 IPI-OB-M/S OFFICE 20-30 MIN MEDICAL E/M 117.43 XXX 90806 IPI-OB-M/S OFFICE 45-50 MIN 138.48 XXX 90807 IPI-OB-M/S OFFICE 45-50 MIN MEDICAL E/M 162.85 XXX 90808 IPI-OB-M/S OFFICE 75-80 MIN 203.84 XXX 90809 IPI-OB-M/S OFFICE 75-80 MIN MEDICAL E/M 228.76 XXX 90810 INDIV PSYCTX IA 20-30 MIN 106.35 XXX 90811 INDIV PSYCTX IA 20-30 MIN MEDICAL E/M 132.38 XXX 90812 INDIV PSYCTX IA 45-50 MIN 151.77 XXX 90813 INDIV PSYCTX IA 45-50 MIN MEDICAL E/M 176.69 XXX 90814 INDIV PSYCTX IA 75-80 MIN 218.79 XXX 90815 INDIV PSYCTX IA 75-80 MIN MEDICAL E/M 248.70 XXX 90816 IPI-OB-M/S I/P 20-30 MIN 85.85 XXX 90817 IPI-OB-M/S I/P 20-30 MIN MEDICAL E/M 103.58 XXX 90818 IPI-OB-M/S I/P 45-50 MIN 127.40 XXX 90819 IPI-OB-M/S I/P 45-50 MIN MEDICAL E/M 148.45 XXX 90821 IPI-OB-M/S I/P 75-80 MIN 188.88 XXX 90822 IPI-OB-M/S I/P 75-80 MIN MEDICAL E/M 213.25 XXX 90823 INDIV PSYCTX IA I/P 20-30 MIN 93.61 XXX 90824 INDIV PSYCTX IA I/P 20-30 MIN MEDICAL E/M 111.89 XXX 90826 INDIV PSYCTX IA I/P 45-50 MIN 136.26 XXX 90827 INDIV PSYCTX IA I/P 45-50 MIN MEDICAL E/M 155.09 XXX 90828 INDIV PSYCTX IA I/P 75-80 MIN 196.63 XXX 90829 INDIV PSYCTX IA I/P 75-80 MIN MEDICAL E/M 219.90 XXX 90845 PSYCHOALYS 129.61 XXX 90846 FAM PSYCTX W/O PT PRESENT 137.37 XXX 90847 FAM PSYCTX W/PT PRESENT 171.16 XXX 90849 MLT-FAM GRP PSYCTX 55.39 XXX 90853 GRP PSYCTX 52.07 XXX 90857 IA GRP PSYCTX 59.82 XXX 90862 PHARMACOLOGIC MGMT MIN MEDICAL PSYCTX 94.16 XXX 90865 NARCOSYNTHESIS PSYC DX&THER PURPOSES 257.01 XXX l 90867 TRANSCRANIAL MAG STIMJ TX PLANNING BR YYY 258 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section X: General Medicine Services Georgia Workers Compensation Medical Fee Schedule 90281 96999, 97597 97606, 97802 97804, 98960 99091, 99143 99199, 99605 99607 MEDICINE Effective April 1, 2011 Medical Fee Schedule l 90868 TRANSCRANIAL MAG STIMJ TX DLVR & MGMT BR YYY 90870 ELECTROCONVULSIVE THER 271.96 000 90875 INDIV PSYCPHYSTX BFB TRAINJ 20-30 MIN 118.53 XXX 90876 INDIV PSYCPHYSTX BFB TRAINJ 45-50 MIN 175.59 XXX 90880 HYPXH 163.95 XXX 90882 ENVIRONMENTAL IVNTJ MGMT PURPOSES PSYC PT 129.61 XXX 90885 PSYC EVAL HOSP RECORDS DX PURPOSES 80.87 XXX 90887 INTERPJ/EXPLNAJ RESULTS PSYC XMS FAM 141.80 XXX 90889 PREPJ REPORT PSYC STATUS 109.12 XXX 90899 UNLIS PSYC SVC/PX BR XXX 90901 BFB TRAINJ ANY MODALITY 59.82 000 90911 BFB TRAINJ PRNL MUSC 142.35 000 90935 HEMO PX W/1 PHYS EVAL 121.86 000 90937 HEMO REPEATED EVAL +-REVJ DIAL RX 173.92 000 90940 HEMO ACCESS FLO STD 94.72 XXX 90940 26 HEMO ACCESS FLO STD 37.67 XXX 90940 TC HEMO ACCESS FLO STD 57.05 XXX 90945 DIAL OTH/THN HEMO 1 PHYS EVAL 134.60 000 90947 DIAL OTH/THN HEMO REPEATED PHYS EVALS 203.84 000 90951 ESRD RELATED SVC MONTHLY <2 YR OLD 4/>VISITS 1557.57 XXX 90952 ESRD RELATED SVC MONTHLY <2 YR OLD 2/3 VISITS 1183.13 XXX 90953 ESRD RELATED SVC MONTHLY <2 YR OLD 1 VISIT 788.75 XXX 90954 ESRD RELATED SVC MONTHLY 2-11 YR OLD 4/>VISITS 1306.65 XXX 90955 ESRD RELATED SVC MONTHLY 2-11 YR OLD 2/3 VISITS 738.35 XXX 90956 ESRD RELATED SVC MONTHLY 2-11 YR OLD 1 VISIT 506.82 XXX 90957 ESRD RELATED SVC MONTHLY 12-19 YR OLD 4/>VISITS 1045.21 XXX 90958 ESRD RELATED SVC MONTHLY 12-19 YR OLD 2/3 VISITS 707.88 XXX 90959 ESRD RELATED SVC MONTHLY 12-19 YR OLD 1 VISIT 471.37 XXX 90960 ESRD RELATED SVC MONTHLY 20&> YR OLD 4/> VISITS 464.72 XXX 90961 ESRD RELATED SVC MONTHLY 20&> YR OLD 2/3 VISITS 382.19 XXX 90962 ESRD RELATED SVC MONTHLY 20&> YR OLD 1 VISIT 285.81 XXX 90963 ESRD SVC HOME DIALYSIS FULL MONTH <2YR OLD 890.12 XXX 90964 ESRD SVC HOME DIALYSIS FULL MONTH 2-11 YR OLD 756.07 XXX 90965 ESRD SVC HOME DIALYSIS FULL MONTH 12-19 YR OLD 720.62 XXX 90966 ESRD SVC HOME DIALYSIS FULL MONTH 20 YR OLD 379.98 XXX 90967 ESRD RELATED SVC <FULL MONTH < 2 YR OLD 30.46 XXX 90968 ESRD RELATED SVC <FULL MONTH 2-11 YR OLD 24.93 XXX 90969 ESRD RELATED SVC <FULL MONTH 12-19 YR OLD 24.37 XXX 90970 ESRD RELATED SVC <FULL MONTH 20&> YR OLD 12.74 XXX 90989 DIAL TRAINJ COMPLD COURSE 591.57 XXX 90993 DIAL TRAINJ COURSE X COMPLD PR SESS 127.40 XXX 90997 HEMOPRFJ 145.12 000 90999 UNLIS DIAL I/P/O/P BR XXX s 91010 ESOPHGL MOTILITY STD W/I&R 2D 305.75 000 s 91010 26 ESOPHGL MOTILITY STD W/I&R 2D 112.44 000 s 91010 TC ESOPHGL MOTILITY STD W/I&R 2D 193.31 000 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 259
Georgia Workers Compensation Medical Fee Schedule Section X: General Medicine Services MEDICINE 90281 96999, 97597 97606, 97802 97804, 98960 99091, 99143 99199, 99605 99607 Medical Fee Schedule Effective April 1, 2011 l + 91013 ESOPHGL MOTILITY STD W/I&R STIM/PERFUSION 37.67 ZZZ l + 91013 26 ESOPHGL MOTILITY STD W/I&R STIM/PERFUSION 16.06 ZZZ l + 91013 TC ESOPHGL MOTILITY STD W/I&R STIM/PERFUSION 21.61 ZZZ 91020 GSTR MOTILITY STD 386.62 000 91020 26 GSTR MOTILITY STD 125.74 000 91020 TC GSTR MOTILITY STD 260.88 000 91022 DUOL MOTILITY STD 298.55 000 91022 26 DUOL MOTILITY STD 127.40 000 91022 TC DUOL MOTILITY STD 171.15 000 91030 ESOPH ACID PRFJ TST ESOPHAGITIS 229.87 000 91030 26 ESOPH ACID PRFJ TST ESOPHAGITIS 80.87 000 91030 TC ESOPH ACID PRFJ TST ESOPHAGITIS 149.00 000 91034 ESOPH G-ESOP RFLX NCATH ELTRD PLMT 322.37 000 91034 26 ESOPH G-ESOP RFLX NCATH ELTRD PLMT 84.19 000 91034 TC ESOPH G-ESOP RFLX NCATH ELTRD PLMT 238.18 000 91035 ESOPH G-ESOP RFLX TLMTR ELTRD PLMT 793.18 000 91035 26 ESOPH G-ESOP RFLX TLMTR ELTRD PLMT 139.03 000 91035 TC ESOPH G-ESOP RFLX TLMTR ELTRD PLMT 654.15 000 91037 ESOPHGL FUNCJ G-ESOP RFLX IMPD ELTRD PLMT 266.98 000 91037 26 ESOPHGL FUNCJ G-ESOP RFLX IMPD ELTRD PLMT 86.96 000 91037 TC ESOPHGL FUNCJ G-ESOP RFLX IMPD ELTRD PLMT 180.02 000 91038 ESOPHGL FUNCJ G-ESOP RFLX IMPD ELTRD PROLNG 487.43 000 91038 26 ESOPHGL FUNCJ G-ESOP RFLX IMPD ELTRD PROLNG 96.93 000 91038 TC ESOPHGL FUNCJ G-ESOP RFLX IMPD ELTRD PROLNG 390.50 000 91040 ESOPHGL BALO DISTENSION PROVOCATION STD 558.89 000 91040 26 ESOPHGL BALO DISTENSION PROVOCATION STD 81.42 000 91040 TC ESOPHGL BALO DISTENSION PROVOCATION STD 477.47 000 91065 BRTH HYDROGEN TST 129.61 000 91065 26 BRTH HYDROGEN TST 17.17 000 91065 TC BRTH HYDROGEN TST 112.44 000 91110 GI TRC IMG INTRAL ESOPH THRU ILE PHYS I&R 1499.96 XXX 91110 26 GI TRC IMG INTRAL ESOPH THRU ILE PHYS I&R 321.26 XXX 91110 TC GI TRC IMG INTRAL ESOPH THRU ILE PHYS I&R 1178.70 XXX 91111 GASTROINTESTINAL TRACT IMAGING ESOPHAGUS 1200.86 XXX 91111 26 GASTROINTESTINAL TRACT IMAGING ESOPHAGUS 88.62 XXX 91111 TC GASTROINTESTINAL TRACT IMAGING ESOPHAGUS 1112.24 XXX l 91117 COLON MOTILITY STDY MIN 6 HR CONT RECORD W/I&R 232.08 000 91120 RCT SENSATION TONE&COMPLIANCE 627.57 XXX 91120 26 RCT SENSATION TONE&COMPLIANCE 81.42 XXX 91120 TC RCT SENSATION TONE&COMPLIANCE 546.15 XXX 91122 ANRCT MANO 372.77 000 91122 26 ANRCT MANO 146.23 000 91122 TC ANRCT MANO 226.54 000 91132 EGG DX TC 230.42 XXX 91132 26 EGG DX TC 45.97 XXX 91132 TC EGG DX TC 184.45 XXX 260 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section X: General Medicine Services Georgia Workers Compensation Medical Fee Schedule 90281 96999, 97597 97606, 97802 97804, 98960 99091, 99143 99199, 99605 99607 MEDICINE Effective April 1, 2011 Medical Fee Schedule 91133 EGG DX TC PROVOCATIVE TSTG 281.38 XXX 91133 26 EGG DX TC PROVOCATIVE TSTG 59.27 XXX 91133 TC EGG DX TC PROVOCATIVE TSTG 222.11 XXX 91299 UNLIS DX GASTROENTEROLOGY BR XXX 92002 OPH MEDICAL XM&EVAL INTRM NEW PT 122.97 XXX 92004 OPH MEDICAL XM&EVAL COMPRE NEW PT 1+ VST 228.21 XXX 92012 OPH MEDICAL XM&EVAL INTRM EST PT 130.17 XXX 92014 OPH MEDICAL XM&EVAL COMPRE EST PT 1+ VST 188.88 XXX 92015 DETER REFRACTIVE STATE 43.76 XXX 92018 OPH XM&EVAL ANES +-MNPJ GLOBE COMPL 225.99 XXX 92019 OPH XM&EVAL ANES +-MNPJ GLOBE LMTD 109.12 XXX 92020 GONIOSCOPY SPX 42.65 XXX 92025 COMPUTERIZED CORNEAL TOPOGRAPHY UNI/BI 57.05 XXX 92025 26 COMPUTERIZED CORNEAL TOPOGRAPHY UNI/BI 31.02 XXX 92025 TC COMPUTERIZED CORNEAL TOPOGRAPHY UNI/BI 26.03 XXX 92060 SENSIMOTR XM W/MLT MEAS OC DEVIJ W/I&R SPX 98.59 XXX 92060 26 SENSIMOTR XM W/MLT MEAS OC DEVIJ W/I&R SPX 60.93 XXX 92060 TC SENSIMOTR XM W/MLT MEAS OC DEVIJ W/I&R SPX 37.66 XXX 92065 ORTHOPTIC&/PLEOPTIC TRAINJ 79.21 XXX 92065 26 ORTHOPTIC&/PLEOPTIC TRAINJ 28.80 XXX 92065 TC ORTHOPTIC&/PLEOPTIC TRAINJ 50.41 XXX 92070 FITG C-LENS TX DISEASE SUPPLY LENS 109.12 XXX 92081 VIS FLD XM UNI/BI I&R LMTD XM 79.21 XXX 92081 26 VIS FLD XM UNI/BI I&R LMTD XM 27.14 XXX 92081 TC VIS FLD XM UNI/BI I&R LMTD XM 52.07 XXX 92082 VIS FLD XM UNI/BI I&R INTRM XM 110.23 XXX 92082 26 VIS FLD XM UNI/BI I&R INTRM XM 36.00 XXX 92082 TC VIS FLD XM UNI/BI I&R INTRM XM 74.23 XXX 92083 VIS FLD XM UNI/BI I&R EXTND XM 137.37 XXX 92083 26 VIS FLD XM UNI/BI I&R EXTND XM 44.87 XXX 92083 TC VIS FLD XM UNI/BI I&R EXTND XM 92.50 XXX 92100 SRL TNMTRY SPX MLT MEAS IO PRESS 147.89 XXX 92120 TNGRPHY I&R REC INDENTAJ TNMTR SUCJ 120.75 XXX 92130 TNGRPHY WATER PROVOCATION 134.04 XXX l 92132 CMPTR OPHTHALMIC DX IMG ANT SEGMT W/I&R UNI/BI 59.27 XXX l 92132 26 CMPTR OPHTHALMIC DX IMG ANT SEGMT W/I&R UNI/BI 34.34 XXX l 92132 TC CMPTR OPHTHALMIC DX IMG ANT SEGMT W/I&R UNI/BI 24.93 XXX l 92133 COMPUTERIZED OPHTHALMIC IMAGING OPTIC NERVE 72.56 XXX l 92133 26 COMPUTERIZED OPHTHALMIC IMAGING OPTIC NERVE 47.64 XXX l 92133 TC COMPUTERIZED OPHTHALMIC IMAGING OPTIC NERVE 24.92 XXX l 92134 COMPUTERIZED OPHTHALMIC IMAGING RETINA 72.56 XXX l 92134 26 COMPUTERIZED OPHTHALMIC IMAGING RETINA 47.64 XXX l 92134 TC COMPUTERIZED OPHTHALMIC IMAGING RETINA 24.92 XXX 92136 OPH BMTRY PRTL COHER INTRFRMTRY IO LENS PWR CAL 135.15 XXX 92136 26 OPH BMTRY PRTL COHER INTRFRMTRY IO LENS PWR CAL 48.19 XXX 92136 TC OPH BMTRY PRTL COHER INTRFRMTRY IO LENS PWR CAL 86.96 XXX Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 261
Georgia Workers Compensation Medical Fee Schedule Section X: General Medicine Services MEDICINE 90281 96999, 97597 97606, 97802 97804, 98960 99091, 99143 99199, 99605 99607 Medical Fee Schedule Effective April 1, 2011 92140 PROVOCATIVE TSTS GLC I&R W/O TNGRPHY 95.82 XXX 92225 OPSCPY EXTND RTA DRAWING I&R 1ST 41.54 XXX 92226 OPSCPY EXTND RTA DRAWING I&R SBSQ 37.11 XXX l 92227 REMOTE IMG DX RETINL DIS W/ALYS & REPORT UNI/BI 18.83 XXX l 92228 REMOTE IMG MGT RETINL DIS W/I&R UNI/BI 48.74 XXX l 92228 26 REMOTE IMG MGT RETINL DIS W/I&R UNI/BI 28.25 XXX l 92228 TC REMOTE IMG MGT RETINL DIS W/I&R UNI/BI 20.49 XXX 92230 FLUORESCEIN ANGIOSCOPY I&R 93.61 XXX 92235 FLUORESCEIN ANGRPH I&R 212.70 XXX 92235 26 FLUORESCEIN ANGRPH I&R 73.67 XXX 92235 TC FLUORESCEIN ANGRPH I&R 139.03 XXX 92240 INDOCYA9-GREEN ANGRPH I&R 388.28 XXX 92240 26 INDOCYA9-GREEN ANGRPH I&R 99.15 XXX 92240 TC INDOCYA9-GREEN ANGRPH I&R 289.13 XXX 92250 FUNDUS PHTGRPHY I&R 119.64 XXX 92250 26 FUNDUS PHTGRPHY I&R 37.67 XXX 92250 TC FUNDUS PHTGRPHY I&R 81.97 XXX 92260 OPHTHALMODYNAMOMETRY 28.80 XXX 92265 NDL OCULOEMG 1+ EO MUSC 1/OU I&R 127.40 XXX 92265 26 NDL OCULOEMG 1+ EO MUSC 1/OU I&R 69.79 XXX 92265 TC NDL OCULOEMG 1+ EO MUSC 1/OU I&R 57.61 XXX 92270 ELECTRO-OCULOGRAPY I&R 142.35 XXX 92270 26 ELECTRO-OCULOGRAPY I&R 66.47 XXX 92270 TC ELECTRO-OCULOGRAPY I&R 75.88 XXX 92275 ELECTRORETINOGRAPY I&R 230.98 XXX 92275 26 ELECTRORETINOGRAPY I&R 90.84 XXX 92275 TC ELECTRORETINOGRAPY I&R 140.14 XXX 92283 COLOR VIS XM EXTND ANOMALOSCOPE/EQUIV 79.21 XXX 92283 26 COLOR VIS XM EXTND ANOMALOSCOPE/EQUIV 14.40 XXX 92283 TC COLOR VIS XM EXTND ANOMALOSCOPE/EQUIV 64.81 XXX 92284 DARK ADAPTATION XM I&R 96.38 XXX 92284 26 DARK ADAPTATION XM I&R 19.39 XXX 92284 TC DARK ADAPTATION XM I&R 76.99 XXX 92285 XTRNL OC PHTGRPHY I&R PROGRESS 45.42 XXX 92285 26 XTRNL OC PHTGRPHY I&R PROGRESS 6.65 XXX 92285 TC XTRNL OC PHTGRPHY I&R PROGRESS 38.77 XXX 92286 SPEC ANT SGM PHTGRPHY I&R SPECLR ENDOTHELIAL 193.31 XXX 92286 26 SPEC ANT SGM PHTGRPHY I&R SPECLR ENDOTHELIAL 57.05 XXX 92286 TC SPEC ANT SGM PHTGRPHY I&R SPECLR ENDOTHELIAL 136.26 XXX 92287 SPEC ANT SGM PHTGRPHY I&R FLUORESCEIN ANGRPH 189.43 XXX 92287 26 SPEC ANT SGM PHTGRPHY I&R FLUORESCEIN ANGRPH 49.30 XXX 92287 TC SPEC ANT SGM PHTGRPHY I&R FLUORESCEIN ANGRPH 140.13 XXX 92310 RX&FITG C-LENS SUPVJ CRNL LENS OU XCPT APHK 152.32 XXX 92311 RX&FITG C-LENS SUPVJ CRNL LENS APHK 1O 156.75 XXX 92312 RX&FITG C-LENS SUPVJ CRNL LENS APHK OU 177.80 XXX 92313 RX&FITG C-LENS SUPVJ CRNLSCLRL LENS 153.98 XXX 262 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section X: General Medicine Services Georgia Workers Compensation Medical Fee Schedule 90281 96999, 97597 97606, 97802 97804, 98960 99091, 99143 99199, 99605 99607 MEDICINE Effective April 1, 2011 Medical Fee Schedule 92314 RX C-LENS SUPVJ&DIRION FITG TECH OU XCPT APHK 123.52 XXX 92315 RX C-LENS SUPVJ FITG TECH CRNL APHK 1O 114.10 XXX 92316 RX C-LENS SUPVJ FITG TECH CRNL APHK OU 152.88 XXX 92317 RX C-LENS SUPVJ FITG TECH CRNLSCLRL 113.55 XXX 92325 MODIFICAJ C-LENS SPX SUPVJ ADAPTATION 54.84 XXX 92326 RPLCMT C-LENS 58.16 XXX 92340 FITG SPECTLS XCPT APHK MONOFOCAL 57.61 XXX 92341 FITG SPECTLS XCPT APHK BIFOCAL 65.91 XXX 92342 FITG SPECTLS XCPT APHK MLTFCL 71.45 XXX 92352 FITG SPECTL PROSTH APHK MONOFOCAL 65.36 XXX 92353 FITG SPECTL PROSTH APHK MLTFCL 75.33 XXX 92354 FITG SPECTL MOUNTED LW VIS AID 1 ELMNT 92.50 XXX 92355 FITG SPECTL MOUNTED LW VIS AID TLSCP 64.81 XXX 92358 PROSTH APHK TEMP DISPOSABLE/LOAN MATRLS 23.26 XXX 92370 RPR&REFITG SPECTLS XCPT APHK 50.40 XXX 92371 RPR&REFITG SPECTLS SPECTL PROSTH APHK 21.05 XXX 92499 UNLIS OPH SVC BR XXX 92502 OTOLARYNGOLOGIC XM ANES 157.86 000 92504 BINOC MIC 49.30 XXX 92506 EVAL SP LANG VOICE COMUNICAJ&/AUD 272.52 XXX 92507 TX SP LANG COMUNICAJ PCX DISORDER INDIV 134.04 XXX 92508 TX SP LANG COMUNICAJ PCX DISORDER 2/> 43.76 XXX 92511 NASOPHARYNGOSCOPY W/ENDOSCOPE SPX 260.89 XXX 92512 NSL FUNCJ STD 100.26 XXX 92516 FACIAL NRV FUNCJ STD 110.78 XXX 92520 LARYN FUNCJ STD 110.23 XXX 92526 TX SWLNG DYSF&/ORAL FUNCJ FEEDING 153.43 XXX 92531 SPON NYSTAGMUS GAZE 29.36 XXX 92532 POSAL NYSTAGMUS TST 33.79 XXX 92533 CALORIC VSTBLR TST EA IRRIGATION 48.74 XXX 92534 OKN TST 36.56 XXX 92540 VSTBLR FUNCJ NYSTAG FOVL&PERPH STIMJ OSCIL TRKG 158.42 XXX 92540 26 VSTBLR FUNCJ NYSTAG FOVL&PERPH STIMJ OSCIL TRKG 127.95 XXX 92540 TC VSTBLR FUNCJ NYSTAG FOVL&PERPH STIMJ OSCIL TRKG 30.47 XXX 92541 SPON NYSTAGMUS TST 74.22 XXX 92541 26 SPON NYSTAGMUS TST 33.23 XXX 92541 TC SPON NYSTAGMUS TST 40.99 XXX 92542 POSAL NYSTAGMUS TST 73.67 XXX 92542 26 POSAL NYSTAGMUS TST 27.70 XXX 92542 TC POSAL NYSTAGMUS TST 45.97 XXX 92543 CALORIC VSTBLR TST EA IRRIGATION REC 36.56 XXX 92543 26 CALORIC VSTBLR TST EA IRRIGATION REC 8.86 XXX 92543 TC CALORIC VSTBLR TST EA IRRIGATION REC 27.70 XXX 92544 OKN TST BIDIREC FOVEAL/PRPH STIMJ REC 60.38 XXX 92544 26 OKN TST BIDIREC FOVEAL/PRPH STIMJ REC 21.60 XXX 92544 TC OKN TST BIDIREC FOVEAL/PRPH STIMJ REC 38.78 XXX Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 263
Georgia Workers Compensation Medical Fee Schedule Section X: General Medicine Services MEDICINE 90281 96999, 97597 97606, 97802 97804, 98960 99091, 99143 99199, 99605 99607 Medical Fee Schedule Effective April 1, 2011 92545 OSCILLATING TRACKING TST W/REC 56.50 XXX 92545 26 OSCILLATING TRACKING TST W/REC 19.39 XXX 92545 TC OSCILLATING TRACKING TST W/REC 37.11 XXX 92546 SINUSOIDAL VER AXIS ROTATIONAL TSTG 153.43 XXX 92546 26 SINUSOIDAL VER AXIS ROTATIONAL TSTG 23.82 XXX 92546 TC SINUSOIDAL VER AXIS ROTATIONAL TSTG 129.61 XXX + 92547 USE VER ELTRDS 8.31 ZZZ + 92547 26 USE VER ELTRDS 1.66 ZZZ + 92547 TC USE VER ELTRDS 6.65 ZZZ 92548 CPTRIZED DYNAMIC POSTUROGRAPY 166.72 XXX 92548 26 CPTRIZED DYNAMIC POSTUROGRAPY 41.54 XXX 92548 TC CPTRIZED DYNAMIC POSTUROGRAPY 125.18 XXX 92550 TYMPANOMETRY AND REFLEX THRESHOLD MEASUREMENTS 33.79 XXX 92551 SCR TST PURE TONE AIR ONLY 18.83 XXX 92552 PURE TONE AUDIOMTRY AIR ONLY 41.54 XXX 92553 PURE TONE AUDIOMTRY AIR&B1 52.62 XXX 92555 SP AUDIOMTRY THRESHOLD 30.46 XXX 92556 SP AUDIOMTRY THRESHOLD SP RECOGNIJ 47.08 XXX 92557 COMPRE AUDIOMTRY THRESHOLD EVAL SP RECOGNIJ 65.91 XXX 92559 AUDIOMETRIC TSTG GRPS 46.53 XXX 92560 BEKESY AUDIOMTRY SCR 32.68 XXX 92561 BEKESY AUDIOMTRY DX 53.17 XXX 92562 LOUDNESS BALANCE BINAURAL/MONAURAL 51.51 XXX 92563 TONE DECAY 40.43 XXX 92564 SHORT INCREMENT SENSITIVITY INDEX 36.56 XXX 92565 STENGER TST PURE TONE 21.05 XXX 92567 TYMPANOMETRY 24.93 XXX 92568 ACOUS RFLX THRESHOLD 27.14 XXX 92570 ACOUSTIC IMMIT TEST TYMPANOM/ACOUST REFLX/DECAY 52.07 XXX 92571 FILTERED SP 32.68 XXX 92572 STAGGERED SPONDAIC WORD 51.51 XXX 92575 SENSORINEURAL ACUITY LVL 80.32 XXX 92576 SYNTH SENTENCE ID 43.20 XXX 92577 STENGER SP 26.59 XXX 92579 VIS RNFCMT AUDIOMTRY 70.90 XXX 92582 CONDITIONING PLAY AUDIOMTRY 83.64 XXX 92583 SELECT PICTURE AUDIOMTRY 58.16 XXX 92584 ELECTROCOCHLEOGRAPY 108.56 XXX 92585 AEP ERA&/TSTG CNS COMPRE 184.45 XXX 92585 26 AEP ERA&/TSTG CNS COMPRE 41.54 XXX 92585 TC AEP ERA&/TSTG CNS COMPRE 142.91 XXX 92586 AEP ERA&/TSTG CNS LMTD 114.66 XXX 92587 EVOKED OTOACOUS EMIJS LMTD 60.38 XXX 92587 26 EVOKED OTOACOUS EMIJS LMTD 11.63 XXX 92587 TC EVOKED OTOACOUS EMIJS LMTD 48.75 XXX 92588 EVOKED OTOACOUS EMIJS COMPRE/DX EVAL 108.01 XXX 264 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section X: General Medicine Services Georgia Workers Compensation Medical Fee Schedule 90281 96999, 97597 97606, 97802 97804, 98960 99091, 99143 99199, 99605 99607 MEDICINE Effective April 1, 2011 Medical Fee Schedule 92588 26 EVOKED OTOACOUS EMIJS COMPRE/DX EVAL 30.46 XXX 92588 TC EVOKED OTOACOUS EMIJS COMPRE/DX EVAL 77.55 XXX 92590 HEARING AID XM&SELECTION MONAURAL 85.85 XXX 92591 HEARING AID XM&SELECTION BINAURAL 108.56 XXX 92592 HEARING AID CHECK MONAURAL 34.34 XXX 92593 HEARING AID CHECK BINAURAL 56.50 XXX 92594 ELECTROACOUS EVAL HEARING AID MONAURAL 32.68 XXX 92595 ELECTROACOUS EVAL HEARING AID BINAURAL 69.79 XXX 92596 EAR PROTECTOR ATTENUATION MEAS 64.81 XXX 92597 EVAL&/FITG VOICE PROSTC DEV SUPPLEMENT O-SP 159.52 XXX 92601 ALYS COCHLEAR IMPLT PT <7 YR PRGRMG 237.62 XXX 92602 ALYS COCHLEAR IMPLT PT <7 YR SBSQ REPRGRMG 146.78 XXX 92603 ALYS COCHLEAR IMPLT 7 YR/> PRGRMG 232.08 XXX 92604 ALYS COCHLEAR IMPLT 7 YR/> SBSQ REPRGRMG 137.37 XXX 92605 EVAL RX N-SP-GENRATJ AUGMNT COMUNICAJ DEV BR XXX 92606 THER SVC N-SP-GENRATJ DEV PRGRMG&MODIFICAJ 132.94 XXX 92607 RX SP-GENRATJ AUGMNT&COMUNICAJ DEV 1ST HR 287.47 XXX + 92608 RX SP-GENRATJ AUGMNT&COMUNICAJ DEV EA 30 MIN 85.30 ZZZ 92609 THER SP-GENRATJ DEV PRGRMG&MODIFICAJ 188.88 XXX 92610 EVAL ORAL&PHARYNGEAL SWLNG FUNCJ 171.16 XXX 92611 MOTION FLUOR EVAL SWLNG FUNCJ C/V REC 185.00 XXX 92612 FLX FIBOPT NDSC EVAL SWLNG C/V REC 271.96 XXX 92613 FLX FIBOPT NDSC EVAL SWLNG C/V REC PHYS I&R 62.59 XXX 92614 FLX FIBOPT NDSC EVAL LARYN SENS C/V REC 242.05 XXX 92615 FLX FIBOPT NDSC EVAL LARYN SENS PHYS I&R 55.39 XXX 92616 FLX FIBOPT NDSC EVAL SWLNG&LARYN SENS C/V REC 327.91 XXX 92617 FLX FIBOPT NDSC EVAL SWLNG&LARYN SENS PHYS I&R 68.68 XXX 92620 EVAL CTR AUD FUNCJ W/REPRT 1ST 60 MIN 134.60 XXX 92621 EVAL CTR AUD FUNCJ W/REPRT EA 15 MIN 31.02 ZZZ 92625 ASSMT TINNITUS 103.03 XXX 92626 EVAL AUD RHAB STATUS 1ST HR 136.81 XXX + 92627 EVAL AUD RHAB STATUS EA 15 MIN 33.23 ZZZ 92630 AUD RHAB PRELNG HEARING LOSS BR XXX 92633 AUD RHAB POST-LNGL HEARING LOSS BR XXX 92640 ANALYSIS W/PRGRMG AUD BRAINSTEM IMPLANT PR HR 161.18 XXX 92700 UNLIS OTORHINOLARYNGOLOGICAL SVC BR XXX 92950 CARDIOPULM RESUSCITATION 458.08 000 K 92953 TEMP TC PACG 18.28 000 K 92960 CARDIOVERSION ELECTIVE ARRHYT XTRNL 392.72 000 K 92961 CARDIOVERSION ELECTIVE ARRHYT INT SPX 415.43 000 92970 CARDIOASSIST-METH CRC ASSIST INT 291.91 000 92971 CARDIOASSIST-METH CRC ASSIST XTRNL 161.74 000 + K 92973 PRQ TRLUML C THRMBC 311.85 ZZZ + K 92974 TCAT PLMT RADJ DLVR DEV SBSQ C IV BRACHYTX 285.81 ZZZ K 92975 THROMBOLSS C INTRAC NFS SLCTV C ANGRPH 689.05 000 92977 THROMBOLSS C IV NFS 150.66 XXX Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 265
Georgia Workers Compensation Medical Fee Schedule Section X: General Medicine Services MEDICINE 90281 96999, 97597 97606, 97802 97804, 98960 99091, 99143 99199, 99605 99607 Medical Fee Schedule Effective April 1, 2011 + K 92978 IV US C VSL DX&/THER 1ST VSL 446.44 ZZZ + K 92978 26 IV US C VSL DX&/THER 1ST VSL 156.20 ZZZ + K 92978 TC IV US C VSL DX&/THER 1ST VSL 290.24 ZZZ + K 92979 IV US C VSL DX&/THER EA VSL 271.96 ZZZ + K 92979 26 IV US C VSL DX&/THER EA VSL 125.18 ZZZ + K 92979 TC IV US C VSL DX&/THER EA VSL 146.78 ZZZ K 92980 TCAT PLMT AN INTRAC STENT PRQ 1 VSL 1423.52 000 + K 92981 TCAT PLMT INTRAC STENT PRQ EA VSL 395.48 ZZZ K 92982 PRQ TRLUML C BALO ANGIOP 1 VSL 1054.63 000 + K 92984 PRQ TRLUML C BALO ANGIOP EA VSL 281.94 ZZZ K 92986 PRQ BALO VLVP AORTIC VALVE 2349.09 090 K 92987 PRQ BALO VLVP MITRAL VALVE 2424.42 090 92990 PRQ BALO VLVP PULM VALVE 1886.58 090 92992 ATR SEPTECT/SEPTOST TRANSVNS BALO 1702.69 090 92993 ATR SEPTECT/SEPTOST BLADE METH 1346.53 090 K 92995 PRQ TRLUML C ATHRC 1 VSL 1161.53 000 + K 92996 PRQ TRLUML C ATHRC EA VSL 310.74 ZZZ 92997 PRQ TRLUML P-ART BALO ANGIOP 1 VSL 1118.88 000 + 92998 PRQ TRLUML P-ART BALO ANGIOP EA VSL 562.76 ZZZ 93000 ECG ROUTINE ECG W/LEAST 12 LDS W/I&R 32.13 XXX 93005 ECG ROUTINE ECG W/LEAST 12 LDS TRCG ONLY W/O I&R 17.72 XXX 93010 ECG ROUTINE ECG W/LEAST 12 LDS I&R ONLY 14.40 XXX 93015 CV STRS TST XERS&/OR RX CONT ECG PHYS SI&R 150.66 XXX 93016 CV STRS TST XERS&/OR RX CONT ECG PHYS SUPVJ 37.67 XXX 93017 CV STRS TST XERS&/OR RX CONT ECG TRCG ONLY 88.07 XXX 93018 CV STRS TST XERS&/OR RX CONT ECG I&R ONLY 24.93 XXX 93024 ERGONOVINE PROVOCATION TST 190.54 XXX 93024 26 ERGONOVINE PROVOCATION TST 98.04 XXX 93024 TC ERGONOVINE PROVOCATION TST 92.50 XXX 93025 MICROVOLT T-WAVE ASSESS VENTRICULAR ARRHYTHMIAS 314.62 XXX 93025 26 MICROVOLT T-WAVE ASSESS VENTRICULAR ARRHYTHMIAS 63.70 XXX 93025 TC MICROVOLT T-WAVE ASSESS VENTRICULAR ARRHYTHMIAS 250.92 XXX 93040 RHYTHM ECG 1-3 LDS W/I&R 21.60 XXX 93041 RHYTHM ECG 1-3 LDS TRCG ONLY W/O I&R 9.42 XXX 93042 RHYTHM ECG 1-3 LDS I&R ONLY 12.19 XXX s 93224 XTRNL ECG UP TO 48 HR RECORD SCAN STOR W/PHY R&I 157.86 XXX s 93225 XTRNL ECG UP TO 48 HR RECORDING 45.97 XXX s 93226 EXTERNAL ECG SCANNING ANALYSIS REPORT 67.58 XXX s 93227 XTRNL ECG CONTINUOUS RHYTHM PHYS REVIEW&INTERPJ 44.31 XXX s 93228 XTRNL MOBILE CV TELEMETRY W/PHYS R&I W/REPORT 42.10 XXX s 93229 XTRNL MOBILE CV TELEMETRY W/TECHNICAL SUPPORT 1110.57 XXX s 93268 XTRNL PT ACTIV ECG TRANSMIS PHYS R&I 30 DAYS 408.78 XXX s 93270 XTRNL PT ACTIVATED ECG RECORD MONITOR 30 DAYS 24.93 XXX s 93271 XTRNL PT ACTIVATED ECG REC DWNLD 30 DAYS 341.76 XXX s 93272 XTRNL PT ACTIVTD ECG DWNLD 30 DAYS PHYS R&I 42.10 XXX 93278 SAECG +-ECG 57.05 XXX 266 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section X: General Medicine Services Georgia Workers Compensation Medical Fee Schedule 90281 96999, 97597 97606, 97802 97804, 98960 99091, 99143 99199, 99605 99607 MEDICINE Effective April 1, 2011 Medical Fee Schedule 93278 26 SAECG +-ECG 20.49 XXX 93278 TC SAECG +-ECG 36.56 XXX 93279 PROGRAM EVAL IMPLANTABLE IN PRSN 1 LD PACEMAKER 85.85 XXX 93279 26 PROGRAM EVAL IMPLANTABLE IN PRSN 1 LD PACEMAKER 55.94 XXX 93279 TC PROGRAM EVAL IMPLANTABLE IN PRSN 1 LD PACEMAKER 29.91 XXX 93280 PROGRAM EVAL IMPLANTABLE IN PERSN DUAL LD PACER 101.36 XXX 93280 26 PROGRAM EVAL IMPLANTABLE IN PERSN DUAL LD PACER 66.47 XXX 93280 TC PROGRAM EVAL IMPLANTABLE IN PERSN DUAL LD PACER 34.89 XXX 93281 PROGRAM EVAL IMPLANTABLE IN PRSN MULTI LD PACER 117.98 XXX 93281 26 PROGRAM EVAL IMPLANTABLE IN PRSN MULTI LD PACER 77.55 XXX 93281 TC PROGRAM EVAL IMPLANTABLE IN PRSN MULTI LD PACER 40.43 XXX 93282 PROGRAM EVAL IMPLANTABLE IN PERSN 1 LD CARD/DFB 108.56 XXX 93282 26 PROGRAM EVAL IMPLANTABLE IN PERSN 1 LD CARD/DFB 72.56 XXX 93282 TC PROGRAM EVAL IMPLANTABLE IN PERSN 1 LD CARD/DFB 36.00 XXX 93283 PROGRM EVAL IMPLANTABLE IN PRSN DUAL L CARD/DFB 139.03 XXX 93283 26 PROGRM EVAL IMPLANTABLE IN PRSN DUAL L CARD/DFB 97.49 XXX 93283 TC PROGRM EVAL IMPLANTABLE IN PRSN DUAL L CARD/DFB 41.54 XXX 93284 PROGRM EVAL IMPLANTABLE IN PRSN MLT LD CARD/DFB 154.54 XXX 93284 26 PROGRM EVAL IMPLANTABLE IN PRSN MLT LD CARD/DFB 107.46 XXX 93284 TC PROGRM EVAL IMPLANTABLE IN PRSN MLT LD CARD/DFB 47.08 XXX 93285 PROGRAM EVAL IMPLANTABLE DEV IN PRSN ILR SYSTEM 72.01 XXX 93285 26 PROGRAM EVAL IMPLANTABLE DEV IN PRSN ILR SYSTEM 44.31 XXX 93285 TC PROGRAM EVAL IMPLANTABLE DEV IN PRSN ILR SYSTEM 27.70 XXX 93286 PERI-PX EVAL&PROGRAM IN PRSN PACEMAKER SYSTEM 43.20 XXX 93286 26 PERI-PX EVAL&PROGRAM IN PRSN PACEMAKER SYSTEM 23.82 XXX 93286 TC PERI-PX EVAL&PROGRAM IN PRSN PACEMAKER SYSTEM 19.38 XXX 93287 PERI-PX EVAL&PROGRAM CARDIOVERTER/DEFIBRILLATOR 56.50 XXX 93287 26 PERI-PX EVAL&PROGRAM CARDIOVERTER/DEFIBRILLATOR 35.45 XXX 93287 TC PERI-PX EVAL&PROGRAM CARDIOVERTER/DEFIBRILLATOR 21.05 XXX 93288 INTERROGATION EVAL IN PERSON 1/DUAL/MLT LEAD PM 64.81 XXX 93288 26 INTERROGATION EVAL IN PERSON 1/DUAL/MLT LEAD PM 36.56 XXX 93288 TC INTERROGATION EVAL IN PERSON 1/DUAL/MLT LEAD PM 28.25 XXX 93289 INTERROGATION EVAL F2F 1/DUAL/MLT LEADS CVDFB 111.33 XXX 93289 26 INTERROGATION EVAL F2F 1/DUAL/MLT LEADS CVDFB 76.44 XXX 93289 TC INTERROGATION EVAL F2F 1/DUAL/MLT LEADS CVDFB 34.89 XXX 93290 INTERROGATION EVAL F2F IMPLANTABLE CV MNTR SYS 49.85 XXX 93290 26 INTERROGATION EVAL F2F IMPLANTABLE CV MNTR SYS 33.79 XXX 93290 TC INTERROGATION EVAL F2F IMPLANTABLE CV MNTR SYS 16.06 XXX 93291 INTERROGATION EVALUATION IN PERSON ILR SYSTEM 62.04 XXX 93291 26 INTERROGATION EVALUATION IN PERSON ILR SYSTEM 36.56 XXX 93291 TC INTERROGATION EVALUATION IN PERSON ILR SYSTEM 25.48 XXX 93292 INTERROGATION EVAL IN PERSON WR DEFIBRILLATOR 55.94 XXX 93292 26 INTERROGATION EVAL IN PERSON WR DEFIBRILLATOR 36.56 XXX 93292 TC INTERROGATION EVAL IN PERSON WR DEFIBRILLATOR 19.38 XXX 93293 TRANSTELEPHONIC RHYTHM STRIP PACEMAKER EVAL 91.39 XXX 93293 26 TRANSTELEPHONIC RHYTHM STRIP PACEMAKER EVAL 26.03 XXX Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 267
Georgia Workers Compensation Medical Fee Schedule Section X: General Medicine Services MEDICINE 90281 96999, 97597 97606, 97802 97804, 98960 99091, 99143 99199, 99605 99607 Medical Fee Schedule Effective April 1, 2011 93293 TC TRANSTELEPHONIC RHYTHM STRIP PACEMAKER EVAL 65.36 XXX 93294 INTERROGATION EVAL REMOTE </90 D 1/2/MLT LEAD PM 56.50 XXX 93295 INTERROGATION EVAL REMOTE </90 D 1/2/> LD CVDFB 111.33 XXX 93296 INTERROGATION REMOTE </90 D TECHNICIAN REVIEW 53.17 XXX 93297 INTERROGATION EVAL REMOTE </30 D CV MNTR SYS 42.10 XXX 93298 INTERROGATION EVALUATION REMOTE </30 D ILR SYS 45.42 XXX 93299 INTERROGATION EVAL REMOTE </30 D TECH REVIEW BR XXX 93303 COMPLETE TTHRC ECHO CONGENITAL CARDIAC ANOMALY 342.86 XXX 93303 26 COMPLETE TTHRC ECHO CONGENITAL CARDIAC ANOMALY 108.01 XXX 93303 TC COMPLETE TTHRC ECHO CONGENITAL CARDIAC ANOMALY 234.85 XXX 93304 F-UP/LIMITED TTHRC ECHO CONGENITAL CAR ANOMALY 218.79 XXX 93304 26 F-UP/LIMITED TTHRC ECHO CONGENITAL CAR ANOMALY 62.04 XXX 93304 TC F-UP/LIMITED TTHRC ECHO CONGENITAL CAR ANOMALY 156.75 XXX 93306 ECHO TTHRC R-T 2D -+M-MODE COMPL SPEC&COLOR DOP 379.42 XXX 93306 26 ECHO TTHRC R-T 2D -+M-MODE COMPL SPEC&COLOR DOP 110.23 XXX 93306 TC ECHO TTHRC R-T 2D -+M-MODE COMPL SPEC&COLOR DOP 269.19 XXX 93307 TTHRC R-T IMG 2D +-M-MODE REC COMPL 241.50 XXX 93307 26 TTHRC R-T IMG 2D +-M-MODE REC COMPL 77.55 XXX 93307 TC TTHRC R-T IMG 2D +-M-MODE REC COMPL 163.95 XXX 93308 TTHRC R-T IMG 2D +-M-MODE REC F-UP/LMTD 171.71 XXX 93308 26 TTHRC R-T IMG 2D +-M-MODE REC F-UP/LMTD 44.31 XXX 93308 TC TTHRC R-T IMG 2D +-M-MODE REC F-UP/LMTD 127.40 XXX K 93312 TEE R-T IMG 2D W/PRB IMG ACQUISJ I&R 527.87 XXX K 93312 26 TEE R-T IMG 2D W/PRB IMG ACQUISJ I&R 179.46 XXX K 93312 TC TEE R-T IMG 2D W/PRB IMG ACQUISJ I&R 348.41 XXX K 93313 TEE R-T IMG 2D W/PROBE PLMT ONLY 67.58 XXX K 93314 TEE R-T IMG 2D IMG ACQUISJ I&R ONLY 465.28 XXX K 93314 26 TEE R-T IMG 2D IMG ACQUISJ I&R ONLY 102.47 XXX K 93314 TC TEE R-T IMG 2D IMG ACQUISJ I&R ONLY 362.81 XXX K 93315 TEE CGEN CAR ANOML PRB ACQUISJ I&R 475.25 XXX K 93315 26 TEE CGEN CAR ANOML PRB ACQUISJ I&R 237.62 XXX K 93315 TC TEE CGEN CAR ANOML PRB ACQUISJ I&R 237.63 XXX K 93316 TEE CGEN CAR ANOML PLMT PRB ONLY 73.11 XXX K 93317 TEE CGEN CAR ANOML IMG ACQUISJ I&R 309.08 XXX K 93317 26 TEE CGEN CAR ANOML IMG ACQUISJ I&R 154.54 XXX K 93317 TC TEE CGEN CAR ANOML IMG ACQUISJ I&R 154.54 XXX K 93318 TEE PROBE MONITORING ASSMT CAR PUMP FUNCTION 374.44 XXX K 93318 26 TEE PROBE MONITORING ASSMT CAR PUMP FUNCTION 187.22 XXX K 93318 TC TEE PROBE MONITORING ASSMT CAR PUMP FUNCTION 187.22 XXX + 93320 DOP ECHO COMPL 101.92 ZZZ + 93320 26 DOP ECHO COMPL 31.57 ZZZ + 93320 TC DOP ECHO COMPL 70.35 ZZZ + 93321 DOP ECHO P-W&/OR CONT W/SPECTRAL F-UP/LMTD STD 47.64 ZZZ + 93321 26 DOP ECHO P-W&/OR CONT W/SPECTRAL F-UP/LMTD STD 12.74 ZZZ + 93321 TC DOP ECHO P-W&/OR CONT W/SPECTRAL F-UP/LMTD STD 34.90 ZZZ + 93325 DOP ECHO COLOR FLO VEL MAPG 58.16 ZZZ 268 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section X: General Medicine Services Georgia Workers Compensation Medical Fee Schedule 90281 96999, 97597 97606, 97802 97804, 98960 99091, 99143 99199, 99605 99607 MEDICINE Effective April 1, 2011 Medical Fee Schedule + 93325 26 DOP ECHO COLOR FLO VEL MAPG 6.09 ZZZ + 93325 TC DOP ECHO COLOR FLO VEL MAPG 52.07 ZZZ 93350 ECHO TTHRC R-T 2D -+M-MODE COMPLETE REST&STRS 342.86 XXX 93350 26 ECHO TTHRC R-T 2D -+M-MODE COMPLETE REST&STRS 124.07 XXX 93350 TC ECHO TTHRC R-T 2D -+M-MODE COMPLETE REST&STRS 218.79 XXX 93351 ECHO TTHRC R-T 2D -+M-MODE REST&STRS CONT ECG 403.79 XXX 93351 26 ECHO TTHRC R-T 2D -+M-MODE REST&STRS CONT ECG 149.55 XXX 93351 TC ECHO TTHRC R-T 2D -+M-MODE REST&STRS CONT ECG 254.24 XXX + 93352 USE OF ECHO CONTRAST AGENT DURING STRESS ECHO 59.27 ZZZ l K 93451 RIGHT HEART CATH O2 SATURATION & CARDIAC OUTPUT 1244.61 000 l K 93451 26 RIGHT HEART CATH O2 SATURATION & CARDIAC OUTPUT 242.05 000 l K 93451 TC RIGHT HEART CATH O2 SATURATION & CARDIAC OUTPUT 1002.56 000 l K 93452 L HRT CATH W/NJX L VENTRICULOGRAPHY IMG S&I 1381.98 000 l K 93452 26 L HRT CATH W/NJX L VENTRICULOGRAPHY IMG S&I 424.29 000 l K 93452 TC L HRT CATH W/NJX L VENTRICULOGRAPHY IMG S&I 957.69 000 l K 93453 R & L HRT CATH W/NJX L VENTRICULOG IMG S&I 1808.48 000 l K 93453 26 R & L HRT CATH W/NJX L VENTRICULOG IMG S&I 556.12 000 l K 93453 TC R & L HRT CATH W/NJX L VENTRICULOG IMG S&I 1252.36 000 l K 93454 CATH PLMT & NJX CORONARY ART ANGIO IMG S&I 1425.18 000 l K 93454 26 CATH PLMT & NJX CORONARY ART ANGIO IMG S&I 427.61 000 l K 93454 TC CATH PLMT & NJX CORONARY ART ANGIO IMG S&I 997.57 000 l K 93455 CATH PLMT & NJX CORONARY ART/GRFT ANGIO IMG S&I 1662.81 000 l K 93455 26 CATH PLMT & NJX CORONARY ART/GRFT ANGIO IMG S&I 493.52 000 l K 93455 TC CATH PLMT & NJX CORONARY ART/GRFT ANGIO IMG S&I 1169.29 000 l K 93456 CATH PLMT R HRT & ARTS W/NJX & ANGIO IMG S&I 1783.56 000 l K 93456 26 CATH PLMT R HRT & ARTS W/NJX & ANGIO IMG S&I 547.25 000 l K 93456 TC CATH PLMT R HRT & ARTS W/NJX & ANGIO IMG S&I 1236.31 000 l K 93457 CATH PLMT R HRT/ARTS/GRFTS W/NJX&ANGIO IMG S&I 2021.18 000 l K 93457 26 CATH PLMT R HRT/ARTS/GRFTS W/NJX&ANGIO IMG S&I 613.72 000 l K 93457 TC CATH PLMT R HRT/ARTS/GRFTS W/NJX&ANGIO IMG S&I 1407.46 000 l K 93458 CATH PLMT L HRT & ARTS W/NJX & ANGIO IMG S&I 1719.86 000 l K 93458 26 CATH PLMT L HRT & ARTS W/NJX & ANGIO IMG S&I 521.77 000 l K 93458 TC CATH PLMT L HRT & ARTS W/NJX & ANGIO IMG S&I 1198.09 000 l K 93459 CATH PLMT L HRT/ARTS/GRFTS WNJX & ANGIO IMG S&I 1899.32 000 l K 93459 26 CATH PLMT L HRT/ARTS/GRFTS WNJX & ANGIO IMG S&I 587.13 000 l K 93459 TC CATH PLMT L HRT/ARTS/GRFTS WNJX & ANGIO IMG S&I 1312.19 000 l K 93460 R & L HRT CATH WINJX HRT ART& L VENTR IMG S&I 2032.81 000 l K 93460 26 R & L HRT CATH WINJX HRT ART& L VENTR IMG S&I 654.16 000 l K 93460 TC R & L HRT CATH WINJX HRT ART& L VENTR IMG S&I 1378.65 000 l K 93461 R&L HRT CATH W/INJEC HRT ART/GRFT&L VENT IMG S&I 2329.15 000 l K 93461 26 R&L HRT CATH W/INJEC HRT ART/GRFT&L VENT IMG S&I 721.73 000 l K 93461 TC R&L HRT CATH W/INJEC HRT ART/GRFT&L VENT IMG S&I 1607.42 000 l + K 93462 LEFT HEART CATH BY TRANSEPTAL PUNCTURE 332.34 ZZZ l + K 93463 MEDICATION ADMIN & HEMODYNAMIC MEASURMENT 176.14 ZZZ l + K 93464 PHYSIOLOGIC EXERCISE STUDY & HEMODYNAMIC MEASURE 410.99 ZZZ l + K 93464 26 PHYSIOLOGIC EXERCISE STUDY & HEMODYNAMIC MEASURE 155.09 ZZZ Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 269
Georgia Workers Compensation Medical Fee Schedule Section X: General Medicine Services MEDICINE 90281 96999, 97597 97606, 97802 97804, 98960 99091, 99143 99199, 99605 99607 Medical Fee Schedule Effective April 1, 2011 l + K 93464 TC PHYSIOLOGIC EXERCISE STUDY & HEMODYNAMIC MEASURE 255.90 ZZZ * 93503 INSERTION FLOW DIRECTED CATHETER FOR MONITORING 218.79 000 K 93505 ENDOMYOCARDIAL BIOPSY 1307.76 000 K 93505 26 ENDOMYOCARDIAL BIOPSY 407.67 000 K 93505 TC ENDOMYOCARDIAL BIOPSY 900.09 000 K 93530 R HRT CATHETERIZATION CONGENITAL CARDIAC ANOMALY 1529.87 000 K 93530 26 R HRT CATHETERIZATION CONGENITAL CARDIAC ANOMALY 397.70 000 K 93530 TC R HRT CATHETERIZATION CONGENITAL CARDIAC ANOMALY 1132.17 000 93531 CMBN R HRT & RETROGRADE L HRT CATHJ CGEN ANOMALY 3128.43 000 93531 26 CMBN R HRT & RETROGRADE L HRT CATHJ CGEN ANOMALY 782.11 000 93531 TC CMBN R HRT & RETROGRADE L HRT CATHJ CGEN ANOMALY 2346.32 000 93532 CMBN R HRT T-SEPTAL L HRT CATHJ NTC SEPTUM CGEN 3719.99 000 93532 26 CMBN R HRT T-SEPTAL L HRT CATHJ NTC SEPTUM CGEN 930.00 000 93532 TC CMBN R HRT T-SEPTAL L HRT CATHJ NTC SEPTUM CGEN 2789.99 000 93533 CMBN R HRT T-SEPTAL L HRT CATHJ SEPTAL OPNG CGEN 3124.00 000 93533 26 CMBN R HRT T-SEPTAL L HRT CATHJ SEPTAL OPNG CGEN 624.80 000 93533 TC CMBN R HRT T-SEPTAL L HRT CATHJ SEPTAL OPNG CGEN 2499.20 000 K 93561 INDIC DIL STD ARTL&/OR VEN CATHJ W/OUTP MEAS 74.78 000 K 93561 26 INDIC DIL STD ARTL&/OR VEN CATHJ W/OUTP MEAS 40.43 000 K 93561 TC INDIC DIL STD ARTL&/OR VEN CATHJ W/OUTP MEAS 34.35 000 K 93562 INDIC DIL STD ARTL&/OR VEN CATHJ SBSQ OUTP MEAS 32.13 000 K 93562 26 INDIC DIL STD ARTL&/OR VEN CATHJ SBSQ OUTP MEAS 12.19 000 K 93562 TC INDIC DIL STD ARTL&/OR VEN CATHJ SBSQ OUTP MEAS 19.94 000 l + K 93563 NJX SEL HRT ART CONGENITAL HRT CATH W/S&I 91.39 ZZZ l + K 93564 NJX SEL HRT ART/GRFT CONGENITAL HRT CATH W/S&I 93.06 ZZZ l + K 93565 NJX SEL L VENT/ATRIAL ANGIO HRT CATH W/S&I 70.35 ZZZ l + K 93566 NJX SEL R VENT/ATRIAL ANGIO HRT CATH W/S&I 275.84 ZZZ l + K 93567 NJX SUPRAVALV AORTOG HRT CATH W/S&I 227.65 ZZZ l + K 93568 NJX PULMONARY ANGIO HRT CATH W/S&I 249.26 ZZZ + K 93571 IV DOP VEL&/OR PRESS C/FLO RSRV MEAS 1ST VSL 443.12 ZZZ + K 93571 26 IV DOP VEL&/OR PRESS C/FLO RSRV MEAS 1ST VSL 155.09 ZZZ + K 93571 TC IV DOP VEL&/OR PRESS C/FLO RSRV MEAS 1ST VSL 288.03 ZZZ + K 93572 IV DOP VEL&/OR PRESS C/FLO RSRV MEAS ADDL VSL 264.21 ZZZ + K 93572 26 IV DOP VEL&/OR PRESS C/FLO RSRV MEAS ADDL VSL 124.07 ZZZ + K 93572 TC IV DOP VEL&/OR PRESS C/FLO RSRV MEAS ADDL VSL 140.14 ZZZ 93580 PRQ TCAT CLSR CGEN INTRATRL COMUNICAJ W/IMPLT 1721.52 000 93581 PRQ TCAT CLSR CGEN VENTR SEPTAL DFCT W/IMPLT 2284.28 000 * 93600 BUNDLE OF HIS RECORDING 333.45 000 * 93600 26 BUNDLE OF HIS RECORDING 199.96 000 * 93600 TC BUNDLE OF HIS RECORDING 133.49 000 * 93602 INTRA-ATRIAL RECORDING 276.95 000 * 93602 26 INTRA-ATRIAL RECORDING 199.40 000 * 93602 TC INTRA-ATRIAL RECORDING 77.55 000 * 93603 R VENTRICULAR REC 316.28 000 * 93603 26 R VENTRICULAR REC 199.40 000 * 93603 TC R VENTRICULAR REC 116.88 000 270 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section X: General Medicine Services Georgia Workers Compensation Medical Fee Schedule 90281 96999, 97597 97606, 97802 97804, 98960 99091, 99143 99199, 99605 99607 MEDICINE Effective April 1, 2011 Medical Fee Schedule + K 93609 INTRA-VNTR MAPG TCHYCAR SIT W/CATH MNPJ 658.03 ZZZ + K 93609 26 INTRA-VNTR MAPG TCHYCAR SIT W/CATH MNPJ 473.58 ZZZ + K 93609 TC INTRA-VNTR MAPG TCHYCAR SIT W/CATH MNPJ 184.45 ZZZ * 93610 INTRA-ATRIAL PACING 378.31 000 * 93610 26 INTRA-ATRIAL PACING 283.60 000 * 93610 TC INTRA-ATRIAL PACING 94.71 000 * 93612 INTRAVENTRICAL PACING 392.16 000 * 93612 26 INTRAVENTRICAL PACING 282.49 000 * 93612 TC INTRAVENTRICAL PACING 109.67 000 + K 93613 ICAR EPHYS 3-DIMENSIONAL MAPG 664.13 ZZZ + K 93613 26 ICAR EPHYS 3-DIMENSIONAL MAPG 477.46 ZZZ + K 93613 TC ICAR EPHYS 3-DIMENSIONAL MAPG 186.67 ZZZ * K 93615 ESOPHGL REC ATR EGRM +-VENTR EGRM 106.35 000 * K 93615 26 ESOPHGL REC ATR EGRM +-VENTR EGRM 84.19 000 * K 93615 TC ESOPHGL REC ATR EGRM +-VENTR EGRM 22.16 000 * K 93616 ESOPHGL REC ATR EGRM +-VENTR EGRM W/PACG 146.78 000 * K 93616 26 ESOPHGL REC ATR EGRM +-VENTR EGRM W/PACG 110.23 000 * K 93616 TC ESOPHGL REC ATR EGRM +-VENTR EGRM W/PACG 36.55 000 * K 93618 INDCTJ ARRHYT ELEC PACG 672.99 000 * K 93618 26 INDCTJ ARRHYT ELEC PACG 403.79 000 * K 93618 TC INDCTJ ARRHYT ELEC PACG 269.20 000 K 93619 COMPRE ELECTROPHYSIOLOGIC W/O ARRHYT INDUCTION 1224.67 000 K 93619 26 COMPRE ELECTROPHYSIOLOGIC W/O ARRHYT INDUCTION 697.91 000 K 93619 TC COMPRE ELECTROPHYSIOLOGIC W/O ARRHYT INDUCTION 526.76 000 K 93620 COMPRE ELECTROPHYSIOLOGIC ARRHYTHMIA INDUCTION 1468.39 000 K 93620 26 COMPRE ELECTROPHYSIOLOGIC ARRHYTHMIA INDUCTION 1101.15 000 K 93620 TC COMPRE ELECTROPHYSIOLOGIC ARRHYTHMIA INDUCTION 367.24 000 + K 93621 COMPRE ELECTROPHYSIOLOGIC W/L ATR PAC/REC 265.32 ZZZ + K 93621 26 COMPRE ELECTROPHYSIOLOGIC W/L ATR PAC/REC 198.85 ZZZ + K 93621 TC COMPRE ELECTROPHYSIOLOGIC W/L ATR PAC/REC 66.47 ZZZ + K 93622 COMPRE ELECTROPHYSIOLOGIC W/L VENTR PAC/REC 389.95 ZZZ + K 93622 26 COMPRE ELECTROPHYSIOLOGIC W/L VENTR PAC/REC 292.46 ZZZ + K 93622 TC COMPRE ELECTROPHYSIOLOGIC W/L VENTR PAC/REC 97.49 ZZZ + 93623 PROGRAMMED STIMJ&PACG AFTER IV DRUG NFS 361.14 ZZZ + 93623 26 PROGRAMMED STIMJ&PACG AFTER IV DRUG NFS 270.86 ZZZ + 93623 TC PROGRAMMED STIMJ&PACG AFTER IV DRUG NFS 90.28 ZZZ K 93624 ELECTROPHYSIOLOGIC FOLLOW-UP W/PAC/REC W/ARRHYT 588.24 000 K 93624 26 ELECTROPHYSIOLOGIC FOLLOW-UP W/PAC/REC W/ARRHYT 458.63 000 K 93624 TC ELECTROPHYSIOLOGIC FOLLOW-UP W/PAC/REC W/ARRHYT 129.61 000 * 93631 INTRAOP EPICAR&ENDOCAR PACG&MAPG 921.14 000 * 93631 26 INTRAOP EPICAR&ENDOCAR PACG&MAPG 690.71 000 * 93631 TC INTRAOP EPICAR&ENDOCAR PACG&MAPG 230.43 000 K 93640 EPHYS EVAL PACG CVDFB LDS INITIAL IMPLAN/REPLACE 832.51 000 K 93640 26 EPHYS EVAL PACG CVDFB LDS INITIAL IMPLAN/REPLACE 332.89 000 K 93640 TC EPHYS EVAL PACG CVDFB LDS INITIAL IMPLAN/REPLACE 499.62 000 K 93641 EPHYS EVAL PACG CVDFB LDS W/TSTG OF PULSE GEN 1060.72 000 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 271
Georgia Workers Compensation Medical Fee Schedule Section X: General Medicine Services MEDICINE 90281 96999, 97597 97606, 97802 97804, 98960 99091, 99143 99199, 99605 99607 Medical Fee Schedule Effective April 1, 2011 K 93641 26 EPHYS EVAL PACG CVDFB LDS W/TSTG OF PULSE GEN 562.21 000 K 93641 TC EPHYS EVAL PACG CVDFB LDS W/TSTG OF PULSE GEN 498.51 000 K 93642 EPHYS EVAL PACG CVDFB PRGRMG/REPRGRMG PARAMETERS 697.36 000 K 93642 26 EPHYS EVAL PACG CVDFB PRGRMG/REPRGRMG PARAMETERS 417.64 000 K 93642 TC EPHYS EVAL PACG CVDFB PRGRMG/REPRGRMG PARAMETERS 279.72 000 K 93650 ICAR CATHETER ABLATION ATRIOVENTR NODE FUNCTION 1011.98 000 K 93651 ICAR CATH ABLTJ ARRHYTGNIC FOC SUPVENTR TCHYCAR 1540.95 000 K 93652 ICAR CATH ABLATION ARRHYTGNIC FOC VENTR TCHYCAR 1677.21 000 93660 CARDIOVASCULAR FUNCTION EVAL W/TILT TABLE W/MNTR 268.09 000 93660 26 CARDIOVASCULAR FUNCTION EVAL W/TILT TABLE W/MNTR 160.63 000 93660 TC CARDIOVASCULAR FUNCTION EVAL W/TILT TABLE W/MNTR 107.46 000 + 93662 ICE DURING THER/DX IVNTJ INCL IMG S&I 323.48 ZZZ + 93662 26 ICE DURING THER/DX IVNTJ INCL IMG S&I 242.61 ZZZ + 93662 TC ICE DURING THER/DX IVNTJ INCL IMG S&I 80.87 ZZZ 93668 PRPH ARTL DISEASE RHAB PR SESS 30.46 XXX 93701 BIOMPEDANCE-DERIVED PHYSIOLOGIC CV ANALYSIS 43.76 XXX 93701 26 BIOMPEDANCE-DERIVED PHYSIOLOGIC CV ANALYSIS 11.63 XXX 93701 TC BIOMPEDANCE-DERIVED PHYSIOLOGIC CV ANALYSIS 32.13 XXX 93720 PLETHYSMOGRAPY TOT BDY W/I&R 79.76 XXX 93720 26 PLETHYSMOGRAPY TOT BDY W/I&R 32.13 XXX 93720 TC PLETHYSMOGRAPY TOT BDY W/I&R 47.63 XXX 93721 PLETHYSMOGRAPY TOT BDY TRCG ONLY W/O I&R 66.47 XXX 93722 PLETHYSMOGRAPY TOT BDY I&R ONLY 13.29 XXX 93724 ELEC ALYS ANTITACHYCARDIA PM SYSTEM 489.65 000 93724 26 ELEC ALYS ANTITACHYCARDIA PM SYSTEM 414.32 000 93724 TC ELEC ALYS ANTITACHYCARDIA PM SYSTEM 75.33 000 93740 TEMPRATURE GRADIENT STD 14.40 XXX 93740 26 TEMPRATURE GRADIENT STD 11.63 XXX 93740 TC TEMPRATURE GRADIENT STD 2.77 XXX 93745 1ST SET-UP&PRGRMG BY PHYS OF WEARABLE CVDFB BR XXX 93750 INTERROGATION VAD IN PRSON W/PHYSICIAN ANALYSIS 83.64 XXX 93770 DETER VEN PRESS 14.40 XXX 93770 26 DETER VEN PRESS 13.29 XXX 93770 TC DETER VEN PRESS 1.11 XXX 93784 AMBL BLD PRESS W/TAPE&/DISK 24+ HR ALYS I&R 101.36 XXX 93786 AMBL BLD PRESS W/TAPE&/DISK 24+ HR + REC ONLY 50.96 XXX 93788 AMBL BLD PRESS W/TAPE/DISK 24+ HR ALYS W/REPRT 19.39 XXX 93790 AMBL BLD PRESS TAPE&/DISK 24+ HR PHYS REV W/I&R 31.02 XXX 93797 OUTPATIENT CARDIAC REHAB W/O CONT ECG MONITOR 29.36 000 93798 OUTPATIENT CARDIAC REHAB W/CONT ECG MONITORING 41.54 000 93799 UNLIS CV SVC/PX BR XXX 93875 N-INVAS PHYSIOLOGIC STD XTRC ART COMPL BI STD 172.26 XXX 93875 26 N-INVAS PHYSIOLOGIC STD XTRC ART COMPL BI STD 17.72 XXX 93875 TC N-INVAS PHYSIOLOGIC STD XTRC ART COMPL BI STD 154.54 XXX 93880 DUP-SCAN XTRC ART COMPL BI STD 408.22 XXX 93880 26 DUP-SCAN XTRC ART COMPL BI STD 49.30 XXX 272 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section X: General Medicine Services Georgia Workers Compensation Medical Fee Schedule 90281 96999, 97597 97606, 97802 97804, 98960 99091, 99143 99199, 99605 99607 MEDICINE Effective April 1, 2011 Medical Fee Schedule 93880 TC DUP-SCAN XTRC ART COMPL BI STD 358.92 XXX 93882 DUP-SCAN XTRC ART UNI/LMTD STD 283.04 XXX 93882 26 DUP-SCAN XTRC ART UNI/LMTD STD 33.23 XXX 93882 TC DUP-SCAN XTRC ART UNI/LMTD STD 249.81 XXX 93886 TCD STD ICRA ART COMPL STD 540.05 XXX 93886 26 TCD STD ICRA ART COMPL STD 76.44 XXX 93886 TC TCD STD ICRA ART COMPL STD 463.61 XXX 93888 TCD STD ICRA ART LMTD STD 343.97 XXX 93888 26 TCD STD ICRA ART LMTD STD 50.96 XXX 93888 TC TCD STD ICRA ART LMTD STD 293.01 XXX 93890 TCD STD ICRA ART VASOREACTV STD 441.46 XXX 93890 26 TCD STD ICRA ART VASOREACTV STD 80.32 XXX 93890 TC TCD STD ICRA ART VASOREACTV STD 361.14 XXX 93892 TCD STD ICRA ART EMBOLI DETCJ W/O IV MBUBB NJX 520.67 XXX 93892 26 TCD STD ICRA ART EMBOLI DETCJ W/O IV MBUBB NJX 93.06 XXX 93892 TC TCD STD ICRA ART EMBOLI DETCJ W/O IV MBUBB NJX 427.61 XXX 93893 TCD STD ICRA ART EMBOLI DETCJ W/IV MBUBB NJX 543.93 XXX 93893 26 TCD STD ICRA ART EMBOLI DETCJ W/IV MBUBB NJX 93.61 XXX 93893 TC TCD STD ICRA ART EMBOLI DETCJ W/IV MBUBB NJX 450.32 XXX s 93922 NON-INVAS PHYSIOLOGIC STD EXTREMITY ART 2 LEVEL 180.02 XXX s 93922 26 NON-INVAS PHYSIOLOGIC STD EXTREMITY ART 2 LEVEL 19.94 XXX s 93922 TC NON-INVAS PHYSIOLOGIC STD EXTREMITY ART 2 LEVEL 160.08 XXX s 93923 NON-INVASIVE PHYSIOLOGIC STUDY EXTREMITY 3 LEVLS 278.61 XXX s 93923 26 NON-INVASIVE PHYSIOLOGIC STUDY EXTREMITY 3 LEVLS 37.11 XXX s 93923 TC NON-INVASIVE PHYSIOLOGIC STUDY EXTREMITY 3 LEVLS 241.50 XXX s 93924 N-INVAS PHYSIOLOGIC STD LXTR ART COMPL BI 347.85 XXX s 93924 26 N-INVAS PHYSIOLOGIC STD LXTR ART COMPL BI 40.99 XXX s 93924 TC N-INVAS PHYSIOLOGIC STD LXTR ART COMPL BI 306.86 XXX 93925 DUP-SCAN LXTR ART/ARTL BPGS COMPL BI STD 516.23 XXX 93925 26 DUP-SCAN LXTR ART/ARTL BPGS COMPL BI STD 47.08 XXX 93925 TC DUP-SCAN LXTR ART/ARTL BPGS COMPL BI STD 469.15 XXX 93926 DUP-SCAN LXTR ART/ARTL BPGS UNI/LMTD STD 335.66 XXX 93926 26 DUP-SCAN LXTR ART/ARTL BPGS UNI/LMTD STD 32.68 XXX 93926 TC DUP-SCAN LXTR ART/ARTL BPGS UNI/LMTD STD 302.98 XXX 93930 DUP-SCAN UXTR ART/ARTL BPGS COMPL BI STD 406.56 XXX 93930 26 DUP-SCAN UXTR ART/ARTL BPGS COMPL BI STD 37.67 XXX 93930 TC DUP-SCAN UXTR ART/ARTL BPGS COMPL BI STD 368.89 XXX 93931 DUP-SCAN UXTR ART/ARTL BPGS UNI/LMTD STD 271.96 XXX 93931 26 DUP-SCAN UXTR ART/ARTL BPGS UNI/LMTD STD 25.48 XXX 93931 TC DUP-SCAN UXTR ART/ARTL BPGS UNI/LMTD STD 246.48 XXX 93965 N-INVAS PHYSIOLOGIC STD XTR VEINS COMPL BI STD 206.60 XXX 93965 26 N-INVAS PHYSIOLOGIC STD XTR VEINS COMPL BI STD 28.80 XXX 93965 TC N-INVAS PHYSIOLOGIC STD XTR VEINS COMPL BI STD 177.80 XXX 93970 DUP-SCAN XTR VEINS COMPL BI STD 420.96 XXX 93970 26 DUP-SCAN XTR VEINS COMPL BI STD 56.50 XXX 93970 TC DUP-SCAN XTR VEINS COMPL BI STD 364.46 XXX Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 273
Georgia Workers Compensation Medical Fee Schedule Section X: General Medicine Services MEDICINE 90281 96999, 97597 97606, 97802 97804, 98960 99091, 99143 99199, 99605 99607 Medical Fee Schedule Effective April 1, 2011 93971 DUP-SCAN XTR VEINS UNI/LMTD STD 276.40 XXX 93971 26 DUP-SCAN XTR VEINS UNI/LMTD STD 37.11 XXX 93971 TC DUP-SCAN XTR VEINS UNI/LMTD STD 239.29 XXX 93975 DUP-SCAN ARTL FLO ABDL/PEL/SCROT&/RPR ORGN COMPL 619.81 XXX 93975 26 DUP-SCAN ARTL FLO ABDL/PEL/SCROT&/RPR ORGN COMPL 147.89 XXX 93975 TC DUP-SCAN ARTL FLO ABDL/PEL/SCROT&/RPR ORGN COMPL 471.92 XXX 93976 DUP-SCAN ARTL FLO ABDL/PEL/SCROT&/RPR ORGN LMTD 355.05 XXX 93976 26 DUP-SCAN ARTL FLO ABDL/PEL/SCROT&/RPR ORGN LMTD 99.15 XXX 93976 TC DUP-SCAN ARTL FLO ABDL/PEL/SCROT&/RPR ORGN LMTD 255.90 XXX 93978 DUP-SCAN AORTA IVC ILIAC VASCL/BPGS COMPL 396.04 XXX 93978 26 DUP-SCAN AORTA IVC ILIAC VASCL/BPGS COMPL 54.28 XXX 93978 TC DUP-SCAN AORTA IVC ILIAC VASCL/BPGS COMPL 341.76 XXX 93979 DUP-SCAN AORTA IVC ILIAC VASCL/BPGS UNI/LMTD 274.18 XXX 93979 26 DUP-SCAN AORTA IVC ILIAC VASCL/BPGS UNI/LMTD 36.00 XXX 93979 TC DUP-SCAN AORTA IVC ILIAC VASCL/BPGS UNI/LMTD 238.18 XXX 93980 DUP-SCAN ARTL INFL&VEN O/F PEN VSL COMPL 287.47 XXX 93980 26 DUP-SCAN ARTL INFL&VEN O/F PEN VSL COMPL 103.03 XXX 93980 TC DUP-SCAN ARTL INFL&VEN O/F PEN VSL COMPL 184.44 XXX 93981 DUP-SCAN ARTL INFL&VEN O/F PEN VSL F-UP/LMTD STD 196.63 XXX 93981 26 DUP-SCAN ARTL INFL&VEN O/F PEN VSL F-UP/LMTD STD 36.00 XXX 93981 TC DUP-SCAN ARTL INFL&VEN O/F PEN VSL F-UP/LMTD STD 160.63 XXX 93982 IMPLANT WIRELESS PRESS SENSOR STUDY ANEURYSM SAC 70.35 XXX 93990 DUP-SCAN OF HEMODIALYSIS ACCESS 343.42 XXX 93990 26 DUP-SCAN OF HEMODIALYSIS ACCESS 21.05 XXX 93990 TC DUP-SCAN OF HEMODIALYSIS ACCESS 322.37 XXX 94002 VENTILATION ASSIST & MGMT INPATIENT 1ST DAY 147.89 XXX 94003 VENTILATION ASSIST & MGMT INPATIENT EA SBSQ DAY 106.35 XXX 94004 VENTILATION ASSIST & MGMT NURSING FAC PR DAY 77.55 XXX 94005 HOME VENTILATOR MGMT CARE OVERSIGHT 30 MIN/> 149.00 XXX 94010 SPMTRY W/VC EXPIRATORY FLO +-MXML VOL VNTJ 57.61 XXX 94010 26 SPMTRY W/VC EXPIRATORY FLO +-MXML VOL VNTJ 13.85 XXX 94010 TC SPMTRY W/VC EXPIRATORY FLO +-MXML VOL VNTJ 43.76 XXX K 94011 MEAS SPIROMTRC FORCD EXPIRATORY FLO INFANT-2 YR 161.18 XXX K 94012 MEAS SPIRO FORCD EXP FLO PRE&POST BRONCH INF-2Y 248.70 XXX K 94013 MEAS LUNG VOLUMES INFANT OR CHILD THRU 2 YRS 50.96 XXX 94014 PT-INITIATE SPIROMETRIC RECORDING&PHYS R&I 79.76 XXX 94014 26 PT-INITIATE SPIROMETRIC RECORDING&PHYS R&I 32.13 XXX 94014 TC PT-INITIATE SPIROMETRIC RECORDING&PHYS R&I 47.63 XXX 94015 PATIENT-INITIATED SPIROMETRIC RECORDING 39.88 XXX 94016 PATIENT-INITIATED SPIROMETRIC PHYS R&I ONLY 39.88 XXX 94060 BRNCDILAT RSPSE SPMTRY PRE&POST-BRNCDILAT ADMN 99.15 XXX 94060 26 BRNCDILAT RSPSE SPMTRY PRE&POST-BRNCDILAT ADMN 23.82 XXX 94060 TC BRNCDILAT RSPSE SPMTRY PRE&POST-BRNCDILAT ADMN 75.33 XXX 94070 BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT 97.49 XXX 94070 26 BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT 46.53 XXX 94070 TC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT 50.96 XXX 274 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section X: General Medicine Services Georgia Workers Compensation Medical Fee Schedule 90281 96999, 97597 97606, 97802 97804, 98960 99091, 99143 99199, 99605 99607 MEDICINE Effective April 1, 2011 Medical Fee Schedule 94150 VC TOT SPX 39.33 XXX 94150 26 VC TOT SPX 6.09 XXX 94150 TC VC TOT SPX 33.24 XXX 94200 MAX BRTHING CAP MXML VOL VNTJ 39.33 XXX 94200 26 MAX BRTHING CAP MXML VOL VNTJ 8.86 XXX 94200 TC MAX BRTHING CAP MXML VOL VNTJ 30.47 XXX 94240 FUNCTIONAL RESIDUAL CAPACITY OR RESIDUAL VOLUME 65.36 XXX 94240 26 FUNCTIONAL RESIDUAL CAPACITY OR RESIDUAL VOLUME 19.94 XXX 94240 TC FUNCTIONAL RESIDUAL CAPACITY OR RESIDUAL VOLUME 45.42 XXX 94250 EXP GAS COLLJ QUAN 1 PX SPX 41.54 XXX 94250 26 EXP GAS COLLJ QUAN 1 PX SPX 8.86 XXX 94250 TC EXP GAS COLLJ QUAN 1 PX SPX 32.68 XXX 94260 THRC GAS VOL 53.17 XXX 94260 26 THRC GAS VOL 9.97 XXX 94260 TC THRC GAS VOL 43.20 XXX 94350 DETER MALDISTRIBJ OF INSPIRED GAS N WSHOT CURVE 56.50 XXX 94350 26 DETER MALDISTRIBJ OF INSPIRED GAS N WSHOT CURVE 19.94 XXX 94350 TC DETER MALDISTRIBJ OF INSPIRED GAS N WSHOT CURVE 36.56 XXX 94360 DETER RESIST TO AIRFLO OSCILLATORY/PLETHYSMOGRAP 72.56 XXX 94360 26 DETER RESIST TO AIRFLO OSCILLATORY/PLETHYSMOGRAP 19.94 XXX 94360 TC DETER RESIST TO AIRFLO OSCILLATORY/PLETHYSMOGRAP 52.62 XXX 94370 DETER AIRWY CLOSING VOL 1 BRTH TSTS 55.94 XXX 94370 26 DETER AIRWY CLOSING VOL 1 BRTH TSTS 19.94 XXX 94370 TC DETER AIRWY CLOSING VOL 1 BRTH TSTS 36.00 XXX 94375 RESPIR FLO VOL LOOP 62.59 XXX 94375 26 RESPIR FLO VOL LOOP 23.82 XXX 94375 TC RESPIR FLO VOL LOOP 38.77 XXX 94400 BRTHING RSPSE CO2 CO2 RSPSE CURVE 87.52 XXX 94400 26 BRTHING RSPSE CO2 CO2 RSPSE CURVE 30.46 XXX 94400 TC BRTHING RSPSE CO2 CO2 RSPSE CURVE 57.06 XXX 94450 BRTHING RSPSE HYPOXIA HYPOXIA RSPSE CURVE 96.38 XXX 94450 26 BRTHING RSPSE HYPOXIA HYPOXIA RSPSE CURVE 31.02 XXX 94450 TC BRTHING RSPSE HYPOXIA HYPOXIA RSPSE CURVE 65.36 XXX 94452 HAST W/PHYS I&R 93.61 XXX 94452 26 HAST W/PHYS I&R 23.26 XXX 94452 TC HAST W/PHYS I&R 70.35 XXX 94453 HAST W/PHYS I&R W/SUPPL O2 TITRJ 126.84 XXX 94453 26 HAST W/PHYS I&R W/SUPPL O2 TITRJ 30.46 XXX 94453 TC HAST W/PHYS I&R W/SUPPL O2 TITRJ 96.38 XXX * 94610 INTRAPULMONARY SURFACTANT ADMINISTRATION 96.38 XXX 94620 PULM STRS TSTG SMPL 103.58 XXX 94620 26 PULM STRS TSTG SMPL 49.85 XXX 94620 TC PULM STRS TSTG SMPL 53.73 XXX 94621 PULM STRS TSTG CPLX 265.32 XXX 94621 26 PULM STRS TSTG CPLX 111.89 XXX 94621 TC PULM STRS TSTG CPLX 153.43 XXX Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 275
Georgia Workers Compensation Medical Fee Schedule Section X: General Medicine Services MEDICINE 90281 96999, 97597 97606, 97802 97804, 98960 99091, 99143 99199, 99605 99607 Medical Fee Schedule Effective April 1, 2011 94640 PRESSURIZED/NONPRESSURIZED INHALATION TREATMENT 26.03 XXX 94642 PENTAMIDINE AERSL INHALATION PNEUMOCYSTIS/PROPH 69.24 XXX 94644 CONTINUOUS INHALATION TREATMENT 1ST HR 65.36 XXX + 94645 CONTINUOUS INHALATION TREATMENT EA ADDL HR 23.82 XXX 94660 CPAP VNTJ CPAP INITIATION&MGMT 96.93 XXX 94662 CNP VNTJ CNP INITIATION&MGMT 58.71 XXX 94664 DEMO&/EVAL OF PT UTILIZ AERSL GEN/NEB/INHLR/IPPB 26.03 XXX 94667 MNPJ CH WALL FACILITATE LNG FUNCJ 1 DEMO&/EVAL 36.56 XXX 94668 MNPJ CH FACILITATE LNG FUNCJ SBSQ 35.45 XXX 94680 O2 UPTK EXP GAS ALYS REST&XERS DIR SMPL 95.82 XXX 94680 26 O2 UPTK EXP GAS ALYS REST&XERS DIR SMPL 20.49 XXX 94680 TC O2 UPTK EXP GAS ALYS REST&XERS DIR SMPL 75.33 XXX 94681 O2 UPTK EXP GAS ALYS W/CO2 OUTPUT % O2 XTRC 93.06 XXX 94681 26 O2 UPTK EXP GAS ALYS W/CO2 OUTPUT % O2 XTRC 15.51 XXX 94681 TC O2 UPTK EXP GAS ALYS W/CO2 OUTPUT % O2 XTRC 77.55 XXX 94690 O2 UPTK EXP GAS ALYS REST INDIR SPX 84.19 XXX 94690 26 O2 UPTK EXP GAS ALYS REST INDIR SPX 6.09 XXX 94690 TC O2 UPTK EXP GAS ALYS REST INDIR SPX 78.10 XXX 94720 CARBON MONOXIDE DIFFW/CAP 85.30 XXX 94720 26 CARBON MONOXIDE DIFFW/CAP 19.94 XXX 94720 TC CARBON MONOXIDE DIFFW/CAP 65.36 XXX 94725 MEMB DIFFUSION CAP 97.49 XXX 94725 26 MEMB DIFFUSION CAP 20.49 XXX 94725 TC MEMB DIFFUSION CAP 77.00 XXX 94750 PULM COMPLIANCE STD 126.84 XXX 94750 26 PULM COMPLIANCE STD 17.72 XXX 94750 TC PULM COMPLIANCE STD 109.12 XXX 94760 NONINVASIVE EAR/PULSE OXIMETRY SINGLE DETER 4.43 XXX 94761 NONINVASIVE EAR/PULSE OXIMETRY MULTIPLE DETER 7.20 XXX 94762 NONINVASIVE EAR/PULSE OXIMETRY OVERNIGHT MONITOR 32.68 XXX 94770 CARBON DIOXIDE EXP GAS DETER INFRARED ANALYZER 37.67 XXX 94770 26 CARBON DIOXIDE EXP GAS DETER INFRARED ANALYZER 7.75 XXX 94770 TC CARBON DIOXIDE EXP GAS DETER INFRARED ANALYZER 29.92 XXX 94772 CIRCADIAN RESPIR PATTERN REC 12-24 HR INFT BR XXX 94774 PED APNEA MONITOR ATTACHMENT PHYS I&R BR YYY 94775 PED APNEA MONITOR ATTACHMENT BR YYY 94776 PED APNEA MONITOR ANALYSES COMPUTER BR YYY 94777 PED APNEA MONITOR PHYSICIAN REVIEW BR YYY 94799 UNLIS PULM SVC/PX BR XXX 95004 PERCUTANEOUS TESTS W/ALLERGENIC EXTRACTS 10.52 XXX 95010 PERQ TSTS SEQL&INCRL RX/BIOLOGIC/VNM IMMT RXN 29.91 XXX 95012 NITRIC OXIDE EXPIRED GAS DETERMINATION 33.79 XXX 95015 IQ TSTS SEQL&INCRL RX/BIOLOGIC/VNM IMMT RXN 23.26 XXX 95024 INTRACUTANEOUS TESTS W/ALLERGENIC EXTRACTS 12.19 XXX 95027 INTRACUTANEOUS TESTS W/ALLERGENIC XTRCS AIRBORNE 7.75 XXX 95028 IQ TSTS W/ALLGIC XTRCS DLYD TYP RXN W/READING 20.49 XXX 276 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section X: General Medicine Services Georgia Workers Compensation Medical Fee Schedule 90281 96999, 97597 97606, 97802 97804, 98960 99091, 99143 99199, 99605 99607 MEDICINE Effective April 1, 2011 Medical Fee Schedule 95044 PATCH/APPL TST SPEC NUMBER TSTS 9.97 XXX 95052 PHOTO PATCH TST SPEC NUMBER TSTS 11.63 XXX 95056 PHOTO TSTS 66.47 XXX 95060 OPH MUC MEMB TSTS 46.53 XXX 95065 DIR NSL MUC MEMB TST 39.88 XXX 95070 INHLJ BRNCL CHALLENGE TSTG W/HISTAM/METHACHOL 62.04 XXX 95071 INHLJ BRNCL CHALLENGE TSTG W/AGS/GASES 83.09 XXX 95075 INGESTION CHALLENGE TEST 104.69 XXX 95115 PROF SVCS ALLG IMMNTX X W/PRV ALLGIC XTRCS 1 NJX 16.62 XXX 95117 PROF SVCS ALLG IMMNTX X W/PRV ALLGIC XTRCS NJXS 20.49 XXX 95120 PROF SVCS ALLG IMMNTX W/PRV ALLGIC XTRC 1 NJX 19.94 XXX 95125 PROF SVCS ALLG IMMNTX W/PRV ALLGIC XTRC 2/> NJXS 25.48 XXX 95130 PROF SVCS ALLG IMMNTX W/PRV XTRC 1 STING INSECT 34.90 XXX 95131 PROF SVCS ALLG IMMNTX W/PRV XTRC 2 STING INSECT 44.31 XXX 95132 PROF SVCS ALLG IMMNTX W/PRV ALLGIC XTRC 3 INSECT 54.28 XXX 95133 PROF SVCS ALLG IMMNTX W/PRV ALLGIC XTRC 4 INSECT 64.81 XXX 95134 PROF SVCS ALLG IMMNTX W/PRV ALLGIC XTRC 5 INSECT 78.10 XXX 95144 PREPJ& ANTIGEN PRV ALLERGEN IMMUNOTHERAPY 1 DOSE 20.49 XXX 95145 PREPJ& ANTIGEN ALLERGEN IMMUNOTHERAPY 1 INSECT 31.02 XXX 95146 PREPJ& ANTIGEN ALLERGEN IMMUNOTHERAPY 2 INSECTS 54.28 XXX 95147 PREPJ& ANTIGEN ALLERGEN IMMUNOTHERAPY 3 INSECTS 50.96 XXX 95148 PREPJ& ANTIGEN ALLERGEN IMMUNOTHERAPY 4 INSECTS 73.67 XXX 95149 PREPJ& ANTIGEN ALLERGEN IMMUNOTHERAPY 5 INSECTS 98.04 XXX 95165 PREPJ& ALLERGEN IMMUNOTHERAPY 1/MLT ANTIGEN 20.49 XXX 95170 PREPJ& ANTIGEN ALLERGEN IMMUNOTHERAPY WHL INSECT 16.06 XXX 95180 RAPID DESENSITIZATION PX EA HR 229.87 XXX 95199 UNLIS ALL/CLINICAL IMMUNOLOGIC SVC/PX BR XXX 95250 GLUC MNTR CONT REC FROM INTERSTITIAL TISS FLUID 241.50 XXX 95251 GLUC MNTR CONT REC FROM NTRSTL TISS FLU I&R 68.13 XXX l # 95800 SLP STDY UNATND W/HRT RATE/O2 SAT/RESP/SLP TIME 335.11 XXX l # 95800 26 SLP STDY UNATND W/HRT RATE/O2 SAT/RESP/SLP TIME 94.72 XXX l # 95800 TC SLP STDY UNATND W/HRT RATE/O2 SAT/RESP/SLP TIME 240.39 XXX l # 95801 SLP STDY UNATND W/MIN HRT RATE/O2 SAT/RESP ANAL 157.86 XXX l # 95801 26 SLP STDY UNATND W/MIN HRT RATE/O2 SAT/RESP ANAL 83.64 XXX l # 95801 TC SLP STDY UNATND W/MIN HRT RATE/O2 SAT/RESP ANAL 74.22 XXX 95803 ACTIGRAPHY TESTING RECORDING ANALYSIS I&R 264.76 XXX 95803 26 ACTIGRAPHY TESTING RECORDING ANALYSIS I&R 76.44 XXX 95803 TC ACTIGRAPHY TESTING RECORDING ANALYSIS I&R 188.32 XXX 95805 MLT SLEEP LATENCY/MAINT OF WAKEFULNESS TSTG 669.11 XXX 95805 26 MLT SLEEP LATENCY/MAINT OF WAKEFULNESS TSTG 100.81 XXX 95805 TC MLT SLEEP LATENCY/MAINT OF WAKEFULNESS TSTG 568.30 XXX 95806 SLEEP STD AIRFLOW HRT RATE&O2 SAT EFFORT UNATTN 296.89 XXX 95806 26 SLEEP STD AIRFLOW HRT RATE&O2 SAT EFFORT UNATTN 102.47 XXX 95806 TC SLEEP STD AIRFLOW HRT RATE&O2 SAT EFFORT UNATTN 194.42 XXX 95807 SLEEP STD REC VNTJ RESPIR ECG/HRT RATE&O2 ATTN 766.04 XXX 95807 26 SLEEP STD REC VNTJ RESPIR ECG/HRT RATE&O2 ATTN 103.03 XXX Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 277
Georgia Workers Compensation Medical Fee Schedule Section X: General Medicine Services MEDICINE 90281 96999, 97597 97606, 97802 97804, 98960 99091, 99143 99199, 99605 99607 Medical Fee Schedule Effective April 1, 2011 95807 TC SLEEP STD REC VNTJ RESPIR ECG/HRT RATE&O2 ATTN 663.01 XXX 95808 POLYSM SLEEP STAGING 1-3 ADDL PARAM 1059.06 XXX 95808 26 POLYSM SLEEP STAGING 1-3 ADDL PARAM 146.78 XXX 95808 TC POLYSM SLEEP STAGING 1-3 ADDL PARAM 912.28 XXX 95810 POLYSM SLEEP STAGING 4/> ADDL PARAM 1131.62 XXX 95810 26 POLYSM SLEEP STAGING 4/> ADDL PARAM 204.39 XXX 95810 TC POLYSM SLEEP STAGING 4/> ADDL PARAM 927.23 XXX 95811 POLYSM SLEEP STAGING 4/> ADDL PARAM W/CPAP TX 1221.35 XXX 95811 26 POLYSM SLEEP STAGING 4/> ADDL PARAM W/CPAP TX 213.81 XXX 95811 TC POLYSM SLEEP STAGING 4/> ADDL PARAM W/CPAP TX 1007.54 XXX 95812 EEG EXTND MNTR 41-60 MIN 513.47 XXX 95812 26 EEG EXTND MNTR 41-60 MIN 88.07 XXX 95812 TC EEG EXTND MNTR 41-60 MIN 425.40 XXX 95813 EEG EXTND MNTR > 1 HR 578.83 XXX 95813 26 EEG EXTND MNTR > 1 HR 140.69 XXX 95813 TC EEG EXTND MNTR > 1 HR 438.14 XXX 95816 EEG W/REC AWAKE&DROWSY 475.80 XXX 95816 26 EEG W/REC AWAKE&DROWSY 89.18 XXX 95816 TC EEG W/REC AWAKE&DROWSY 386.62 XXX 95819 EEG W/REC AWAKE&ASLEEP 530.64 XXX 95819 26 EEG W/REC AWAKE&ASLEEP 88.62 XXX 95819 TC EEG W/REC AWAKE&ASLEEP 442.02 XXX 95822 EEG REC COMA/SLEEP ONLY 496.29 XXX 95822 26 EEG REC COMA/SLEEP ONLY 88.62 XXX 95822 TC EEG REC COMA/SLEEP ONLY 407.67 XXX 95824 EEG CERE DEATH EVAL ONLY 157.86 XXX 95824 26 EEG CERE DEATH EVAL ONLY 61.48 XXX 95824 TC EEG CERE DEATH EVAL ONLY 96.38 XXX 95827 EEG ALL NIGHT REC 911.72 XXX 95827 26 EEG ALL NIGHT REC 88.62 XXX 95827 TC EEG ALL NIGHT REC 823.10 XXX 95829 ELECTROCORTICOGRAM SURG SPX 2434.94 XXX 95829 26 ELECTROCORTICOGRAM SURG SPX 504.05 XXX 95829 TC ELECTROCORTICOGRAM SURG SPX 1930.89 XXX 95830 INSERTION SPHENOIDAL ELECTRODES EEG RECORDING 310.74 XXX 95831 MUSC TSTG MNL W/REPRT XTR EX HAND/TRNK 47.08 XXX 95832 MUSC TSTG MNL W/REPRT HAND +-CMPRSN NML SIDE 45.42 XXX 95833 MUSC TSTG MNL W/REPRT TOT EVAL BDY EX HANDS 59.82 XXX 95834 MUSC TSTG MNL W/REPRT TOT EVAL BDY W/HANDS 75.33 XXX 95851 ROM MEAS&REPRT EA XTR EX HAND/EA TRNK SCTJ SPINE 28.25 XXX 95852 ROM MEAS&REPRT HAND +-CMPRSN NML SIDE 23.82 XXX s 95857 CHOLINESTERASE INHIBITOR CHALLENGE TEST 76.44 XXX 95860 NDL EMG 1 XTR +-RELATED PARASPI AREAS 147.34 XXX 95860 26 NDL EMG 1 XTR +-RELATED PARASPI AREAS 80.87 XXX 95860 TC NDL EMG 1 XTR +-RELATED PARASPI AREAS 66.47 XXX 95861 NDL EMG 2 XTR +-RELATED PARASPI AREAS 213.81 XXX 278 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section X: General Medicine Services Georgia Workers Compensation Medical Fee Schedule 90281 96999, 97597 97606, 97802 97804, 98960 99091, 99143 99199, 99605 99607 MEDICINE Effective April 1, 2011 Medical Fee Schedule 95861 26 NDL EMG 2 XTR +-RELATED PARASPI AREAS 129.06 XXX 95861 TC NDL EMG 2 XTR +-RELATED PARASPI AREAS 84.75 XXX 95863 NDL EMG 3 XTR +-RELATED PARASPI AREAS 258.12 XXX 95863 26 NDL EMG 3 XTR +-RELATED PARASPI AREAS 155.09 XXX 95863 TC NDL EMG 3 XTR +-RELATED PARASPI AREAS 103.03 XXX 95864 NDL EMG 4 XTR +-RELATED PARASPI AREAS 283.60 XXX 95864 26 NDL EMG 4 XTR +-RELATED PARASPI AREAS 165.62 XXX 95864 TC NDL EMG 4 XTR +-RELATED PARASPI AREAS 117.98 XXX 95865 NDL EMG LARX 194.97 XXX 95865 26 NDL EMG LARX 132.38 XXX 95865 TC NDL EMG LARX 62.59 XXX 95866 NDL EMG HEMIDPHRM 168.94 XXX 95866 26 NDL EMG HEMIDPHRM 104.13 XXX 95866 TC NDL EMG HEMIDPHRM 64.81 XXX 95867 NDL EMG CRNL NRV SUPPLIED MUSC UNI 130.72 XXX 95867 26 NDL EMG CRNL NRV SUPPLIED MUSC UNI 66.47 XXX 95867 TC NDL EMG CRNL NRV SUPPLIED MUSC UNI 64.25 XXX 95868 NDL EMG CRNL NRV SUPPLIED MUSC BI 177.25 XXX 95868 26 NDL EMG CRNL NRV SUPPLIED MUSC BI 98.04 XXX 95868 TC NDL EMG CRNL NRV SUPPLIED MUSC BI 79.21 XXX 95869 NDL EMG THRC PARASPI MUSC EXCLUDING T1/T12 95.27 XXX 95869 26 NDL EMG THRC PARASPI MUSC EXCLUDING T1/T12 31.02 XXX 95869 TC NDL EMG THRC PARASPI MUSC EXCLUDING T1/T12 64.25 XXX 95870 NDL EMG LMTD STD MUSC 1 XTR/NON-LIMB UNI/BI 93.06 XXX 95870 26 NDL EMG LMTD STD MUSC 1 XTR/NON-LIMB UNI/BI 30.46 XXX 95870 TC NDL EMG LMTD STD MUSC 1 XTR/NON-LIMB UNI/BI 62.60 XXX 95872 NDL EMG W/1 FIBER ELTRD QUAN MEAS JITTER 289.69 XXX 95872 26 NDL EMG W/1 FIBER ELTRD QUAN MEAS JITTER 232.64 XXX 95872 TC NDL EMG W/1 FIBER ELTRD QUAN MEAS JITTER 57.05 XXX + 95873 ESTIM GDN CONJUNCT CHEMODNRVTJ 94.72 ZZZ + 95873 26 ESTIM GDN CONJUNCT CHEMODNRVTJ 32.13 ZZZ + 95873 TC ESTIM GDN CONJUNCT CHEMODNRVTJ 62.59 ZZZ + 95874 NDL EMG GDN CONJUNCT CHEMODNRVTJ 90.29 ZZZ + 95874 26 NDL EMG GDN CONJUNCT CHEMODNRVTJ 31.02 ZZZ + 95874 TC NDL EMG GDN CONJUNCT CHEMODNRVTJ 59.27 ZZZ 95875 ISCHEMIC LIMB XERS TST SPEC ACQUISJ METAB 171.16 XXX 95875 26 ISCHEMIC LIMB XERS TST SPEC ACQUISJ METAB 90.84 XXX 95875 TC ISCHEMIC LIMB XERS TST SPEC ACQUISJ METAB 80.32 XXX * 95900 NRV CNDJ AMPLT&STD EA NRV MOTOR W/O F-WAVE STD 98.04 XXX * 95900 26 NRV CNDJ AMPLT&STD EA NRV MOTOR W/O F-WAVE STD 34.90 XXX * 95900 TC NRV CNDJ AMPLT&STD EA NRV MOTOR W/O F-WAVE STD 63.14 XXX * 95903 NRV CNDJ AMPLT&STD EA NRV MOTOR W/F-WAVE STD 113.55 XXX * 95903 26 NRV CNDJ AMPLT&STD EA NRV MOTOR W/F-WAVE STD 49.85 XXX * 95903 TC NRV CNDJ AMPLT&STD EA NRV MOTOR W/F-WAVE STD 63.70 XXX * 95904 NRV CNDJ AMPLT&STD EA NRV SENS 86.41 XXX * 95904 26 NRV CNDJ AMPLT&STD EA NRV SENS 28.25 XXX Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 279
Georgia Workers Compensation Medical Fee Schedule Section X: General Medicine Services MEDICINE 90281 96999, 97597 97606, 97802 97804, 98960 99091, 99143 99199, 99605 99607 Medical Fee Schedule Effective April 1, 2011 * 95904 TC NRV CNDJ AMPLT&STD EA NRV SENS 58.16 XXX * 95905 MOTOR &/SENS NRV CNDJ PRECONF ELTRD ARRAY LIMB 137.37 XXX * 95905 26 MOTOR &/SENS NRV CNDJ PRECONF ELTRD ARRAY LIMB 4.99 XXX * 95905 TC MOTOR &/SENS NRV CNDJ PRECONF ELTRD ARRAY LIMB 132.38 XXX + 95920 INTRAOP NEUROPHYSIOLOGY TSTG PR HR 258.12 ZZZ + 95920 26 INTRAOP NEUROPHYSIOLOGY TSTG PR HR 173.92 ZZZ + 95920 TC INTRAOP NEUROPHYSIOLOGY TSTG PR HR 84.20 ZZZ 95921 TSTG ANS FUNCJ CARDIOVAGAL INNERVAJ PARASYMP 130.17 XXX 95921 26 TSTG ANS FUNCJ CARDIOVAGAL INNERVAJ PARASYMP 72.56 XXX 95921 TC TSTG ANS FUNCJ CARDIOVAGAL INNERVAJ PARASYMP 57.61 XXX 95922 TSTG ANS FUNCJ VASOMOTOR ADRENERGIC INNERVAJ 160.63 XXX 95922 26 TSTG ANS FUNCJ VASOMOTOR ADRENERGIC INNERVAJ 77.55 XXX 95922 TC TSTG ANS FUNCJ VASOMOTOR ADRENERGIC INNERVAJ 83.08 XXX 95923 TSTG ANS FUNCJ SUDOMOTOR 235.96 XXX 95923 26 TSTG ANS FUNCJ SUDOMOTOR 74.22 XXX 95923 TC TSTG ANS FUNCJ SUDOMOTOR 161.74 XXX 95925 SHORT-LATENCY SOMATOSENS EP STD UPR LIMBS 255.35 XXX 95925 26 SHORT-LATENCY SOMATOSENS EP STD UPR LIMBS 43.76 XXX 95925 TC SHORT-LATENCY SOMATOSENS EP STD UPR LIMBS 211.59 XXX 95926 SHORT-LATENCY SOMATOSENS EP STD LWR LIMBS 247.59 XXX 95926 26 SHORT-LATENCY SOMATOSENS EP STD LWR LIMBS 44.87 XXX 95926 TC SHORT-LATENCY SOMATOSENS EP STD LWR LIMBS 202.72 XXX 95927 SHORT-LATENCY SOMATOSENS EP STD TRNK/HEAD 232.08 XXX 95927 26 SHORT-LATENCY SOMATOSENS EP STD TRNK/HEAD 44.31 XXX 95927 TC SHORT-LATENCY SOMATOSENS EP STD TRNK/HEAD 187.77 XXX 95928 CTR MOTOR EP STD TRANSCRNL MOTOR STIMJ UPR LIMBS 381.08 XXX 95928 26 CTR MOTOR EP STD TRANSCRNL MOTOR STIMJ UPR LIMBS 123.52 XXX 95928 TC CTR MOTOR EP STD TRANSCRNL MOTOR STIMJ UPR LIMBS 257.56 XXX 95929 CTR MOTOR EP STD TRANSCRNL MOTOR STIMJ LWR LIMBS 403.79 XXX 95929 26 CTR MOTOR EP STD TRANSCRNL MOTOR STIMJ LWR LIMBS 124.07 XXX 95929 TC CTR MOTOR EP STD TRANSCRNL MOTOR STIMJ LWR LIMBS 279.72 XXX 95930 VISUAL EP TSTG CNS CHECKERBOARD/FLASH 217.13 XXX 95930 26 VISUAL EP TSTG CNS CHECKERBOARD/FLASH 28.80 XXX 95930 TC VISUAL EP TSTG CNS CHECKERBOARD/FLASH 188.33 XXX 95933 MNTR SEIZURE CMPTR 16>CHAN EEG UNATND EA 24 HR 120.75 XXX 95933 26 MNTR SEIZURE CMPTR 16>CHAN EEG UNATND EA 24 HR 49.30 XXX 95933 TC MNTR SEIZURE CMPTR 16>CHAN EEG UNATND EA 24 HR 71.45 XXX 95934 H-REFLEX AMPLT&LATENCY GASTRCN/SOLEUS MUSC 91.39 XXX 95934 26 H-REFLEX AMPLT&LATENCY GASTRCN/SOLEUS MUSC 42.10 XXX 95934 TC H-REFLEX AMPLT&LATENCY GASTRCN/SOLEUS MUSC 49.29 XXX 95936 H-REFLEX AMPLT&LATENCY OTH/THN GASTRCN/SOLEUS 75.33 XXX 95936 26 H-REFLEX AMPLT&LATENCY OTH/THN GASTRCN/SOLEUS 44.87 XXX 95936 TC H-REFLEX AMPLT&LATENCY OTH/THN GASTRCN/SOLEUS 30.46 XXX 95937 NEUROMUSCULAR JUNCT TSTG EA NRV ANY 1 METH 105.24 XXX 95937 26 NEUROMUSCULAR JUNCT TSTG EA NRV ANY 1 METH 54.28 XXX 95937 TC NEUROMUSCULAR JUNCT TSTG EA NRV ANY 1 METH 50.96 XXX 280 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section X: General Medicine Services Georgia Workers Compensation Medical Fee Schedule 90281 96999, 97597 97606, 97802 97804, 98960 99091, 99143 99199, 99605 99607 MEDICINE Effective April 1, 2011 Medical Fee Schedule 95950 MONITOR ID& LATERALIZATION SEIZURE FOCUS EEG 440.90 XXX 95950 26 MONITOR ID& LATERALIZATION SEIZURE FOCUS EEG 124.07 XXX 95950 TC MONITOR ID& LATERALIZATION SEIZURE FOCUS EEG 316.83 XXX 95951 LOCALIZE CEREBRAL SEIZURE CABLE/RADIO EEG/VIDEO 1262.89 XXX 95951 26 LOCALIZE CEREBRAL SEIZURE CABLE/RADIO EEG/VIDEO 505.16 XXX 95951 TC LOCALIZE CEREBRAL SEIZURE CABLE/RADIO EEG/VIDEO 757.73 XXX s 95953 LOCALIZE CEREBRAL SEIZURE CPTR PORTABLE EEG 672.99 XXX s 95953 26 LOCALIZE CEREBRAL SEIZURE CPTR PORTABLE EEG 255.90 XXX s 95953 TC LOCALIZE CEREBRAL SEIZURE CPTR PORTABLE EEG 417.09 XXX 95954 RX/PHYSICAL ACTIVAJ PHYS ATTN DURING EEG ACTIVAJ 505.71 XXX 95954 26 RX/PHYSICAL ACTIVAJ PHYS ATTN DURING EEG ACTIVAJ 185.56 XXX 95954 TC RX/PHYSICAL ACTIVAJ PHYS ATTN DURING EEG ACTIVAJ 320.15 XXX 95955 EEG NONICRA SURG 273.63 XXX 95955 26 EEG NONICRA SURG 81.98 XXX 95955 TC EEG NONICRA SURG 191.65 XXX s 95956 MNTR SEIZURE CMPTR 16>CHAN EEG ATND EA 24 HR 1645.64 XXX s 95956 26 MNTR SEIZURE CMPTR 16>CHAN EEG ATND EA 24 HR 289.14 XXX s 95956 TC MNTR SEIZURE CMPTR 16>CHAN EEG ATND EA 24 HR 1356.50 XXX 95957 DGTAL ALYS EEG 552.24 XXX 95957 26 DGTAL ALYS EEG 163.40 XXX 95957 TC DGTAL ALYS EEG 388.84 XXX 95958 WADA ACTIVATION TEST HEMISPHERIC FUNCTION W/EEG 739.46 XXX 95958 26 WADA ACTIVATION TEST HEMISPHERIC FUNCTION W/EEG 348.96 XXX 95958 TC WADA ACTIVATION TEST HEMISPHERIC FUNCTION W/EEG 390.50 XXX 95961 FUNCJAL CORT&SUBCORT MAPG ELTRDS 1 HR PHYS ATTN 409.33 XXX 95961 26 FUNCJAL CORT&SUBCORT MAPG ELTRDS 1 HR PHYS ATTN 247.59 XXX 95961 TC FUNCJAL CORT&SUBCORT MAPG ELTRDS 1 HR PHYS ATTN 161.74 XXX + 95962 FUNCJAL CORT&SUBCORT MAPG ELTRDS EA HR PHYS ATTN 368.34 ZZZ + 95962 26 FUNCJAL CORT&SUBCORT MAPG ELTRDS EA HR PHYS ATTN 264.76 ZZZ + 95962 TC FUNCJAL CORT&SUBCORT MAPG ELTRDS EA HR PHYS ATTN 103.58 ZZZ 95965 MAGNETOENCEPHALOGRAPHY SPON BRAIN ACTIVITY 3412.02 XXX 95965 26 MAGNETOENCEPHALOGRAPHY SPON BRAIN ACTIVITY 682.40 XXX 95965 TC MAGNETOENCEPHALOGRAPHY SPON BRAIN ACTIVITY 2729.62 XXX 95966 MAGNETOENCEPHALOGRAPY EVOKED FIELDS 1 MODALITY 1703.24 XXX 95966 26 MAGNETOENCEPHALOGRAPY EVOKED FIELDS 1 MODALITY 340.65 XXX 95966 TC MAGNETOENCEPHALOGRAPY EVOKED FIELDS 1 MODALITY 1362.59 XXX + 95967 MAGNETOENCEPHALOGRAPY EVOKED FIELDS EACH ADDL 1478.91 ZZZ + 95967 26 MAGNETOENCEPHALOGRAPY EVOKED FIELDS EACH ADDL 295.78 ZZZ + 95967 TC MAGNETOENCEPHALOGRAPY EVOKED FIELDS EACH ADDL 1183.13 ZZZ 95970 ELEC ALYS NSTIM PLS GEN BRN/SC/PERPH W/O REPRGRM 95.82 XXX 95971 ELEC ALYS NSTIM PLS GEN SMPL SC/PERPH W/PRGRMG 94.16 XXX 95972 ELEC ALYS NSTIM PLS GEN CPLX SC/PERPH 1ST HR 173.37 XXX + 95973 ELEC ALYS NSTIM PLS GEN CPLX SC/PERPH EA 30 MIN 97.49 ZZZ 95974 ELEC ALYS NSTIM PLS GEN CPLX CRNL NRV 1ST HR 301.32 XXX + 95975 ELEC ALYS NSTIM PLS GEN CPLX CRNL NRV EA 30 MIN 162.85 ZZZ 95978 ELEC ALYS NSTIM PLS GEN CPLX DP BRN 1ST HR 365.02 XXX Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 281
Georgia Workers Compensation Medical Fee Schedule Section X: General Medicine Services MEDICINE 90281 96999, 97597 97606, 97802 97804, 98960 99091, 99143 99199, 99605 99607 Medical Fee Schedule Effective April 1, 2011 + 95979 ELEC ALYS NSTIM PLS GEN CPLX DP BRN EA 30 MIN 159.52 ZZZ 95980 ELEC ALYS NSTIM PLS GEN GASTRIC INTRAOP W/PRGRMG 73.67 XXX 95981 ELEC ALYS NSTIM GEN GASTRIC SBSQ W/O REPRGRMG 49.85 XXX 95982 ELEC ALYS NSTIM PLS GEN GASTRIC SBSQ W/REPRGRMG 77.55 XXX 95990 REFILL&MAINTENANCE PUMP DRUG DLVR SPINAL/BRAIN 122.97 XXX 95991 RFL&MAIN IMPLT PMP/RSVR RX DLVR SPI/BRN BY PHYS 171.71 XXX * 95992 CANALITH REPOSITIONING PROCEDURE 69.24 XXX 95999 UNLIS NEUROLOGICAL/NEUROMUSCULAR DX PX BR XXX 96000 COMPRE CPTR MTN ALYS VIDEO TAPING 3-D KINEMATICS 148.45 XXX 96001 COMPRE CPTR MTN ALYS W/DYN PLNTR PRES MEAS WALKG 163.40 XXX 96002 DYN SURF EMG WALKG/FUNCJAL ACTV 1-12 MUSC 34.34 XXX 96003 DYN FINE WIRE EMG WALKG/FUNCJAL ACTV 1 MUSC 30.46 XXX 96004 PHYS R&I CPTR MTN ALYS WALKG/FUNCJAL ACTV REPRT 181.68 XXX 96020 TEST SELECTION & ADMN FUNCTIONAL BRAIN MAPPING BR XXX 96040 MEDICAL GENETICS COUNSELING EA 30 MIN 73.11 XXX 96101 PSYCHOLOGICAL TESTING PR HR F2F TIME W/PT 135.15 XXX 96102 PSYCL TSTG PR HR ADMN BY TECH PR HR 108.56 XXX 96103 PSYCL TSTG PR HR ADMN BY CPTR W/PROF I&R 91.39 XXX 96105 ASSMT APHASIA W/I&R PR HR 173.92 XXX 96110 DEVELOPMENTAL TSTG LMTD W/I&R 13.29 XXX 96111 DEVELOPMENTAL TSTG EXTND W/I&R 204.39 XXX 96116 NUBHVL STATUS XM PR HR F2F W/PT INTERPJ&PREPJ 148.45 XXX 96118 NUROPSYC TESTING PR HR F2F W/PT + INTERPJ TIME 158.42 XXX 96119 NUROPSYC TSTG WPROF I&R ADMN BY TECH PR HR 114.66 XXX 96120 NUROPSYC TSTG ADMN BY CPTR W/PROF I&R 134.04 XXX 96125 STANDARDIZED COGNITIVE PERFORMANCE TESTING 152.88 XXX 96150 HLTH&BEHAVIOR ASSMT EA 15 MIN F2F W/PT 1ST ASSMT 34.34 XXX 96151 HLTH&BEHAVIOR ASSMT EA 15 MIN F2F W/PT RE-ASSMT 33.23 XXX 96152 HLTH&BEHAVIOR IVNTJ EA 15 MIN F2F INDIV 31.57 XXX 96153 HLTH&BEHAVIOR IVNTJ EA 15 MIN F2F GRP 2/> PTS 7.75 XXX 96154 HLTH&BEHAVIOR IVNTJ EA 15 MIN F2F FAM W/PT 31.02 XXX 96155 HLTH&BEHAVIOR IVNTJ EA 15 MIN F2F FAM W/O PT 37.11 XXX 96360 IV INFUSION HYDRATION INITIAL 31 MIN-1 HOUR 93.06 XXX + 96361 IV INFUSION HYDRATION EACH ADDITIONAL HOUR 24.93 ZZZ 96365 IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR 115.77 XXX + 96366 IV INFUSION THERAPY PROPHYLAXIS/DX EA HOUR 35.45 ZZZ + 96367 IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR 53.73 ZZZ + 96368 IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS 31.57 ZZZ 96369 SUBCUTANEOUS INFUSION INITIAL 1 HR W/PUMP SET-UP 278.61 XXX + 96370 SUBCUTANEOUS INFUSION EACH ADDITIONAL HOUR 24.93 ZZZ + 96371 SUBQ INFUSION ADDITIONAL PUMP INFUSION SITE 130.72 ZZZ 96372 THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM 37.67 XXX 96373 THERAPEUTIC PROPHYLACTIC/DX NJX INTRA-ARTERIAL 31.02 XXX 96374 THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG 90.84 XXX + 96375 THERAPEUTIC INJECTION IV PUSH EACH NEW DRUG 37.11 ZZZ + 96376 THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC 22.71 ZZZ 282 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
Section X: General Medicine Services Georgia Workers Compensation Medical Fee Schedule 90281 96999, 97597 97606, 97802 97804, 98960 99091, 99143 99199, 99605 99607 MEDICINE Effective April 1, 2011 Medical Fee Schedule 96379 UNLISTED THERAPEUTIC PROPH/DX IV/IA NJX/NFS BR XXX 96401 CHEMOTX ADMN SUBQ/IM NON-HORMONAL ANTI-NEO 118.53 XXX 96402 CHEMOTX ADMN SUBQ/IM HORMONAL ANTI-NEO 57.05 XXX 96405 CHEMOTX ADMN ILESN UP&W/7 < 140.14 000 96406 CHEMOTX ADMN ILESN > 7 192.76 000 96409 CHEMOTX ADMN IV PUSH TQ 1/1ST SBST/DRUG 183.89 XXX + 96411 CHEMOTX ADMN IV PUSH TQ EA SBST/DRUG 103.03 ZZZ 96413 CHEMOTX ADMN IV NFS TQ UP 1 HR 1/1ST SBST/DRUG 238.73 XXX + 96415 CHEMOTHERAPY ADMN IV INFUSION TQ EA HR 50.96 ZZZ 96416 CHEMOTX ADMN TQ INIT PROLNG CHEMOTX NFUS PMP 263.10 XXX + 96417 CHEMOTX ADMN IV NFS TQ EA SEQL NFS TO 1 HR 117.98 ZZZ 96420 CHEMOTX ADMN IA PUSH TQ 177.80 XXX 96422 CHEMOTX ADMN IA NFS TQ UP 1 HR 285.81 XXX + 96423 CHEMOTHERAPY ADMN INTRAARTERIAL INFUSION EA HR 130.17 ZZZ 96425 CHEMOTX ADMN IA NFS > 8 HR PRTBLE IMPLTBL PMP 293.01 XXX 96440 CHEMOTX ADMN PLEURAL CAVITY REQ&W/THORACNTS 1188.12 000 l 96446 CHEMOTX ADMN PRTL CAVITY PORT/CATH 288.58 XXX 96450 CHEMOTX ADMN CNS REQ&W/SPI PNXR 324.03 000 96521 RFL/MAIN PORTABLE PMP 217.13 XXX 96522 REFILL&MAINTENANCE PUMP DRUG DLVR SYSTEMIC 181.13 XXX 96523 IRRIGATION IMPLANTED VAD FOR DRUG DLVR 41.54 XXX 96542 CHEMOTX NJX SUBARACHND/INTRAVENTR RSVR 1+ AGENTS 207.16 XXX 96549 UNLIS CHEMOTX PX BR XXX 96567 PDT XTRNL APPL LIGHT DSTR LES SKN BY ACTIVJ RX 213.25 XXX + 96570 PDT NDSC ABL ABNOR TISS VIA ACTIVJ RX 30 MIN 96.93 ZZZ + 96571 PDT NDSC ABL ABNOR TISS VIA ACTIVJ RX A 15 MIN 44.31 ZZZ 96900 ACTIXH ULTRAVIOLET LIGHT 33.79 XXX 96902 MCRSCP XM HAIR PLUCK/CLIP FOR CNTS/STRUCT ABNORM 35.45 XXX 96904 WHOLE BODY INTEGUMENTARY PHOTOGRAPHY 110.78 XXX 96910 PHOTOCHEMOTX TAR&UVB/PETROLATUM/UVB 113.00 XXX 96912 PHOTOCHEMOTX PSORALENS&ULTRAVIOLET PUVA 145.12 XXX 96913 PHOTOCHEMOTHERAPY DERMATOSES 4-8 HRS SUPERVISION 201.62 XXX 96920 LASER SKIN DISEASE PSORIASIS TOT AREA <250 SQ CM 282.49 000 96921 LASER SKIN DISEASE PSORIASIS 250-500 SQ CM 283.04 000 96922 LASER SKIN DISEASE PSORIASIS >500 SQ CM 407.12 000 96999 UNLIS SPEC DERMATOLOGICAL SVC/PX BR XXX s 97597 DEBRIDEMENT OPEN WOUND 20 SQ CM< 104.64 000 s + 97598 DEBRIDEMENT OPEN WOUND ADDL 20 SQ CM 35.05 ZZZ 97602 RMVL DEVITAL TISS N-SLCTV DBRDMT W/O ANES 1 SESS 50.35 XXX 97605 NEG PRESS WND THER </EQUAL 50 SQ CM 57.26 XXX 97606 NEG PRESS WND THER > 50 SQ CM 61.21 XXX 97802 MED NUTR THER 1ST ASSMT&IVNTJ INDIV EA 15 MIN 46.40 XXX 97803 MED NUTR THER RE-ASSMT&IVNTJ INDIV EA 15 MIN 40.48 XXX 97804 MED NUTR THER GRP2/> INDIV EA 30 MIN 20.24 XXX 98960 EDUCATION&TRAINING SELF-MGMT NONPHYS 1 PT 42.65 XXX 98961 EDUCATION&TRAINING SELF-MGMT NONPHYS 2-4 PTS 20.49 XXX Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 283
Georgia Workers Compensation Medical Fee Schedule Section X: General Medicine Services MEDICINE 90281 96999, 97597 97606, 97802 97804, 98960 99091, 99143 99199, 99605 99607 Medical Fee Schedule Effective April 1, 2011 98962 EDUCATION&TRAINING SELF-MGMT NONPHYS 5-8 PTS 15.51 XXX 98966 NONPHYSICIAN TELEPHONE ASSESSMENT 5-10 MIN 22.71 XXX 98967 NONPHYSICIAN TELEPHONE ASSESSMENT 11-20 MIN 43.20 XXX 98968 NONPHYSICIAN TELEPHONE ASSESSMENT 21-30 MIN 63.70 XXX 98969 NONPHYSICIAN ONLINE ASSESSMENT AND MANAGEMENT 34.90 XXX 99000 HANDLG&/OR CONVEY OF SPEC FOR TR OFFICE TO LAB 11.08 XXX 99001 HANDLG&/OR CONVEY OF SPEC FOR TR FROM PT TO LAB 12.74 XXX 99002 HANDLING CONVEY/ANY OTH SVC INVG DEV FIT BY PHYS 13.85 XXX 99024 PO F-UP VST RELATED TO ORIGINAL PX BR XXX 99026 HOSP MANDATED CALL SVC IN-HOSP EA HR BR XXX 99027 HOSP MANDATED CALL SVC OUT-OF-HOSP EA HR BR XXX 99050 SVCS PRV OFFICE OTH/THN REG SCHEDD HRS 36.00 XXX 99051 SVC PRV OFFICE REG SCHEDD EVN WKEND/HOLIDAY HRS BR XXX 99053 SVC PRV BTW 10 PM&8 AM AT 24-HR FAC BR XXX 99056 SVC TYPICAL PRV OFFICE PRV OUT OFFICE REQUEST PT 34.34 XXX 99058 SVC PRV EMER BASIS OFFICE DISRUPTS OFFICE SVCS 43.20 XXX 99060 SVC PRV EMER OUT OFFICE DISRUPTS OFFICE SVC 47.64 XXX 99070 SUPPLIES&MATERIALS PRV BY PHYS >&ABOVE BR XXX 99071 EDUCATIONAL SUPPLIES PRV BY THE PHYS AT COST BR XXX 99075 MEDICAL TSTIMONY See Page 14 XXX 99078 PHYS EDUCATIONAL SVCS RENDERED PTS GRP SETTING BR XXX 99080 SPEC REPORTS > USUAL MED COMUNICAJ/STAND RPRTG See Page 14 XXX 99082 UNUSUAL TRAVEL BR XXX 99090 ALYS CLINICAL DATA STORED CPTRS BR XXX 99091 COLLJ&INTERPJ PHYSIO DATA DIG STRD/TRANS 30 MIN 90.84 XXX * 99143 M-SEDATJ BY SM PHYS PERFRMG SVC < 5 YR 103.58 XXX * 99144 M-SEDAJ BY SM PHYS PERFRMG SVC 5+ YR 85.85 XXX + 99145 M-SEDAJ BY SM PHYS PERFRMG SVC EA 15 MIN 34.34 ZZZ 99148 M-SEDATION BY PHYS OTH/THN HC PROF PERFRMG < 5 94.72 XXX 99149 M-SEDATION BY PHYS OTH/THN HC PROF PERFRMG 5+ 77.55 XXX + 99150 M-SEDAJ PHYS OTH/THN HC PROF PERFRMG EA 15 MIN 34.34 ZZZ 99170 COLLJ/INT PHYSIO DATA DIG STRD/TRANS MINIM 30MIN 235.41 000 99172 VSL FUNC SCRNG AUTO SEMI-AUTO BI QUAN DETERM 34.34 XXX 99172 26 VSL FUNC SCRNG AUTO SEMI-AUTO BI QUAN DETERM 6.65 XXX 99172 TC VSL FUNC SCRNG AUTO SEMI-AUTO BI QUAN DETERM 27.69 XXX 99173 SCREENING 4.43 XXX 99174 OCULAR PHOTOSCREENING INTERPRETATION BILATERAL 45.42 XXX 99175 IPECAC/SIMILAR ADMN EMESIS&OBS STOMACH EMPTIED 39.88 XXX 99183 PHYS ATTN&SUPVJ HYPRBARIC OXYGEN THER PR SESS 338.99 XXX 99190 ASSEM/OPRATN PMP OXTJ/HEAT EXCHNGR EA HR 859.10 XXX 99191 ASSEM/OPRATN PMP OXTJ/HEAT EXCHNGR 3/4 HR 600.98 XXX 99192 ASSEM/OPRATN PMP OXTJ/HEAT EXCHNGR 1/2 HR 429.27 XXX 99195 PHLEBOTOMY THER SPX 140.69 XXX 99199 UNLIS SPEC SVC PX/REPRT BR XXX 99605 MEDICATION THERAPY 1ST 15 MIN NEW PATIENT BR XXX 99606 MEDICATION THERAPY F2F 1ST 15 MIN ESTABLISHED PT BR XXX + 99607 MEDICATION THERAPY F2F EA ADDITIONAL 15 MIN BR XXX 284 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
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 (97001 97004), 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 99354 99357 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 99441 99443 (physicians) and 98966 98968 (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 2011. 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 97001 Physical therapy evaluation, is a one-time-only charge. If the patient changes treatment facilities, another one-time-only evaluation may be charged. CPT code 97002 Physical therapy re-evaluation, may be charged if the existing patient suffers a reoccurrence of the same medical condition at least one month after the date of the last visit for therapy or the existing patient sustains an additional injury and requires additional physical therapy. CPT code 97003 Occupational therapy evaluation, is a one-time-only charge. If the patient changes treatment facilities, a one-time-only evaluation may be charged. CPT code 97004 Occupational therapy re-evaluation, may be CPT only 2010 American Medical Association. All Rights Reserved. 285
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 97010 97039). The only exceptions to this are: 1. If injured employee is diagnosed as catastrophic. 2. CPT codes 97545 and 97546 (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 $600.00 per FCE). 4. CPT code 97750 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 99455 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 97762 is used to checkout the orthotic/prosthetic for any medically necessary adjustments. 6. By mutual agreement of all parties. CPT code 97010 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 98940 98943. Licensed osteopaths may bill using CPT codes 98925 98929. 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 97750 97755). Fabrication of Orthotics Orthotics must be billed separately for professional fitting and supplies. CPT code 97760 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 99070. (See Materials Supplied by the Health Care Provider in section IV.) 286 CPT only 2010 American Medical Association. All Rights Reserved.
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 99070. (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 99354 99357. 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
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 25. 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. 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 99353 99357 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.
Section XI: Physical Medicine Services Georgia Workers Compensation Medical Fee Schedule 97001 97546, 97750 97799, 97810 98943, FCE01 PHYSICAL MEDICINE Effective April 1, 2011 Medical Fee Schedule 97001 PHYSICAL THER EVAL 105.14 XXX 97002 PHYSICAL THER RE-EVAL 58.24 XXX 97003 OCCUPATIONAL THER EVAL 116.00 XXX 97004 OCCUPATIONAL THER RE-EVAL 70.58 XXX 97005 ATHLETIC TRAINJ EVAL 0.00 XXX 97006 ATHLETIC TRAINJ RE-EVAL 0.00 XXX 97010 APPL MODALITY 1+ AREAS HOT/COLD PACKS 7.90 XXX 97012 APPL MODALITY 1+ AREAS TRCJ MCHNL 22.21 XXX 97014 APPL MODALITY 1+ AREAS ELEC STIMJ UNATTN 21.22 XXX 97016 APPL MODALITY 1+ AREAS VASOPNEUMATIC DEV 25.17 XXX 97018 APPL MODALITY 1+ AREAS PARAFFIN BATH 13.82 XXX 97022 APPL MODALITY 1+ AREAS WP 29.62 XXX 97024 APPL MODALITY 1+ AREAS DTHRM 8.88 XXX 97026 APPL MODALITY 1+ AREAS INFRARED 7.90 XXX 97028 APPL MODALITY 1+ AREAS ULTRAVIOLET 9.87 XXX 97032 APPL MODALITY 1+ AREAS ELEC STIMJ EA 15 MIN 25.67 XXX 97033 APPL MODALITY 1+ AREAS IONTOPHORESIS EA 15 MIN 40.97 XXX 97034 APPL MODALITY 1+ AREAS CNTRST BATHS EA 15 MIN 23.69 XXX 97035 APPL MODALITY 1+ AREAS US EA 15 MIN 17.28 XXX 97036 APPL MODALITY 1+ AREAS HUBBARD TANK EA 15 MIN 42.45 XXX 97039 UNLIS MODALITY SPEC TYP&TM IF CONSTANT ATTN BR XXX 97110 THER PX 1+ AREAS EA 15 MIN THER XERSS 42.94 XXX 97112 THER PX 1+ AREAS EA 15 MIN NEUROMUSC REEDUCAJ 44.92 XXX 97113 THER PX 1+ AREAS EA 15 MIN AQUATIC THER W/XERSS 56.27 XXX 97116 THER PX 1+ AREAS EA 15 MIN GAIT TRAINJ W/STAIR 38.01 XXX 97124 THER PX 1+ AREAS EA 15 MIN MASSAGE 35.05 XXX 97139 UNLIS THER PX SPEC BR XXX 97140 MNL THER TQS 1+ REGIONS EA 15 MIN 40.48 XXX 97150 THER PX GRP 2/> INDIVS 27.64 XXX 97530 THER ACTV DIR PT CONTACT BY PROVIDER EA 15 MIN 46.89 XXX 97532 DEVELOPMENT OF COGNITIVE SKILLS EA 15 MIN 36.53 XXX 97533 SENSORY INTEGRATIVE TQS EA 15 MIN 39.98 XXX 97535 SELF-CARE/HOME MGMT TRAINING EA 15 MIN 46.89 XXX 97537 COMMUNITY/WORK REINTEGRATION TRAINJ EA 15 MIN 40.97 XXX 97542 WHEELCHAIR MGMT EA 15 MIN 41.46 XXX 97545 WORK HARDENING/CONDITIONING 1ST 2 HR 182.14 XXX + 97546 WORK HARDENING/CONDITIONING EA HR 72.56 ZZZ 97750 PHYSICAL PERFORMANCE TST/MEAS W/RPRT 15 MIN 45.41 XXX 97755 ASSTV TECHN ASSMT DIR CNTCT W/REPRT 15 MIN 49.85 XXX 97760 ORTHOTIC MGMT&TRAINJ UXTR LXTR&/TRNK EA 15 MIN 50.84 XXX 97761 PROSTC TRAINJ UPR&/LXTR EA 15 MIN 44.92 XXX 97762 CHECKOUT ORTHOTIC/PROSTHETIC USE 58.74 XXX 97799 UNLIS PHYSICAL MED/RHAB SVC/PX BR XXX 97810 ACUP 1/> NDLS W/O ELEC STIMJ 1ST 15 MIN 51.83 XXX + 97811 ACUP 1/> NDLS W/O ELEC STIMJ EA 15 MIN 39.49 ZZZ 97813 ACUP 1/> NDLS W/ELEC STIMJ 1ST 15 MIN 55.78 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
Georgia Workers Compensation Medical Fee Schedule Section XI: Physical Medicine Services PHYSICAL MEDICINE 97001 97546, 97750 97799, 97810 98943, FCE01 Medical Fee Schedule Effective April 1, 2011 + 97814 ACUP 1/> NDLS W/ELEC STIMJ EA 15 MIN W/RE-INSJ 44.92 ZZZ 98925 OSTEOPATHIC MANIPULATIVE TX 1-2 BDY REGIONS 43.93 000 98926 OSTEOPATHIC MANIPULATIVE TX 3-4 BDY REGIONS 58.74 000 98927 OSTEOPATHIC MANIPULATIVE TX 5-6 BDY REGIONS 76.51 000 98928 OSTEOPATHIC MANIPULATIVE TX 7-8 BDY REGIONS 89.34 000 98929 OSTEOPATHIC MANIPULATIVE TX 9-10 BDY REGIONS 103.16 000 98940 CMT SPI 1-2 REGIONS 37.02 000 98941 CMT SPI 3-4 REGIONS 51.33 000 98942 CMT SPI 5 REGIONS 66.14 000 98943 CMT XTRSPI 1+ REGIONS 35.05 XXX FCE01 FUNCTIONAL CAPACITY EVALUATION (GEORGIA SPECIFIC) See Page 286 + 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
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: $126.28 per visit Registered Nurse $103.32 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
Georgia Workers Compensation Medical Fee Schedule Section XII: Home Health Services HOME HEALTH SERVICES 99500 99602 Medical Fee Schedule Effective April 1, 2011 99500 HOME VST PRENATAL MNTR&ASSMT BR XXX 99501 HOME VST POSTNATAL ASSMT&F-UP CARE BR XXX 99502 HOME VST NB CARE&ASSMT BR XXX 99503 HOME VST RESPIR THER CARE BR XXX 99504 HOME VST MCHNL VNTJ CARE BR XXX 99505 HOME VST STOMA CARE&MAINT CLST&CSTOST BR XXX 99506 HOME VST IM NJXS BR XXX 99507 HOME VST CARE&MAINT CATH BR XXX 99509 HOME VST ASSISTANCE DAILY LIV&PRSONAL CARE BR XXX 99510 HOME VST INDIV FAM/MARRIAGE CNSL BR XXX 99511 HOME VST FECAL IMPACTION MGMT&ENEMA ADMN BR XXX 99512 HOME VST HEMO BR XXX 99600 UNLIS HOME VST SVC/PX BR XXX 99601 HOME NFS/SPECTY DRUG ADMN PR VST <2 HR BR XXX + 99602 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
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 $78.28. CPT only 2010 American Medical Association. All Rights Reserved. 293
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; $104.36 charge for very remote (50 miles or more) areas. 294 CPT only 2010 American Medical Association. All Rights Reserved.
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. 34-9-203(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) ($501.60 + $11.40) for a total of $513.00. If this service also required ambulance service, basic life support, emergency transport (BLS emergency) (A0429), add $546.82 to the earlier calculation of $513.00, giving a new total of $1059.82 ($546.82 + $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 $406.15 $410.12 transport, level 1 (ALS 1) A0427 Ambulance service, advanced life support, emergency $643.05 $649.36 transport, level 1 (ALS 1 emergency) A0428 Ambulance service, basic life support, non-emergency $338.45 $341.76 transport (BLS) A0429 Ambulance service, basic life support, emergency transport $541.52 $546.82 (BLS emergency) A0430 Ambulance service, conventional air services, transport, one $3,982.18 $5,973.27 way (fixed wing) A0431 Ambulance service, conventional air services, transport, one $4,629.87 $6,944.80 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 $592.28 $598.08 A0433 Advanced life support, level 2 (ALS2) $930.74 $939.84 A0434 Specialty care transport (SCT) $1,152.26 $1,163.56 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
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 $8,201.53. Any MS-DRGs outside of this schedule will be reimbursed at 62.23 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 40,000.00 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
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 $100,000.00 $31,751.00 $28,249.00 $12,712.00 $44,463.00 Example B $18,000.00 $31,751.00 0.00 0.00 $31,751.00 Example C $45,000.00 $31,751.00 <0 or 0 0.00 $31,751.00 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 40,000.00 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.
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 216061.93 002 Heart Transplant or Implant of Heart Assist System without MCC 111644.97 003 ECMO or Tracheostomy with Mechanical Ventilation 96+ Hours or Principal Diagnosis Except Face, Mouth 148643.71 and Neck with Major O.R. 004 Tracheostomy with Mechanical Ventilation 96+ Hours or Principal Diagnosis Except Face, Mouth and Neck 92187.66 without Major O.R. 005 Liver Transplant with MCC or Intestinal Transplant 83467.79 006 Liver Transplant without MCC 39656.86 007 Lung Transplant 76561.28 008 Simultaneous Pancreas/Kidney Transplant 40705.83 010 Pancreas Transplant 31027.21 011 Tracheostomy for Face, Mouth, and Neck Diagnoses with MCC 39093.41 012 Tracheostomy for Face, Mouth, and Neck Diagnoses with CC 25679.81 013 Tracheostomy for Face, Mouth, and Neck Diagnoses without CC/MCC 15997.08 014 Allogeneic Bone Marrow Transplant 95094.28 015 Autologous Bone Marrow Transplant 48802.38 020 Intracranial Vascular Procedures with Principal Diagnosis of Hemorrhage with MCC 67645.40 021 Intracranial Vascular Procedures with Principal Diagnosis of Hemorrhage with CC 51576.14 022 Intracranial Vascular Procedures with Principal Diagnosis of Hemorrhage without CC/MCC 34102.78 023 Craniotomy with Major Device Implant/Acute Complex Central Nervous System Principal Diagnosis with 41731.85 MCC or Chemo Implant 024 Craniotomy with Major Device Implant/Acute Complex Central Nervous System Principal Diagnosis without 28665.99 MCC 025 Craniotomy and Endovascular Intracranial Procedures with MCC 39018.78 026 Craniotomy and Endovascular Intracranial Procedures with CC 24461.06 027 Craniotomy and Endovascular Intracranial Procedures without CC/MCC 17475.00 028 Spinal Procedures with MCC 43918.37 029 Spinal Procedures with CC or Spinal Neurostimulator 23572.02 030 Spinal Procedures without CC/MCC 13477.57 031 Ventricular Shunt Procedures with MCC 33840.33 032 Ventricular Shunt Procedures with CC 15763.34 033 Ventricular Shunt Procedures without CC/MCC 11175.40 034 Carotid Artery Stent Procedure with MCC 28903.83 035 Carotid Artery Stent Procedure with CC 17581.62 036 Carotid Artery Stent Procedure without CC/MCC 13442.31 037 Extracranial Procedures with MCC 25870.09 038 Extracranial Procedures with CC 12681.21 039 Extracranial Procedures without CC/MCC 8353.26 040 Peripheral/Cranial Nerve and Other Nervous System Procedures with MCC 32275.48 041 Peripheral/Cranial Nerve and Other Nervous System Procedures with CC or Peripheral Neurostimulator 17575.88 042 Peripheral/Cranial Nerve and Other Nervous System Procedures without CC/MCC 13864.69 052 Spinal Disorders and Injuries with CC/MCC 13211.84 053 Spinal Disorders and Injuries without CC/MCC 6922.91 054 Nervous System Neoplasms with MCC 12189.93 055 Nervous System Neoplasms without MCC 8733.81 056 Degenerative Nervous System Disorders with MCC 13735.92 057 Degenerative Nervous System Disorders without MCC 7668.43 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 299
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 13004.35 059 Multiple Sclerosis and Cerebellar Ataxia with CC 8046.52 060 Multiple Sclerosis and Cerebellar Ataxia without CC/MCC 6215.12 061 Acute Ischemic Stroke with Use of Thrombolytic Agent with MCC 24250.28 062 Acute Ischemic Stroke with Use of Thrombolytic Agent with CC 15975.76 063 Acute Ischemic Stroke with Use of Thrombolytic Agent without CC/MCC 12508.15 064 Intracranial Hemorrhage or Cerebral Infarction with MCC 15315.54 065 Intracranial Hemorrhage or Cerebral Infarction with CC 9568.73 066 Intracranial Hemorrhage or Cerebral Infarction without CC/MCC 6723.61 067 Nonspecific Cerebrovascular Accident and Precerebral Occlusion without Infarction with MCC 11671.60 068 Nonspecific Cerebrovascular Accident and Precerebral Occlusion without Infarction without MCC 7177.16 069 Transient Ischemia 5996.14 070 Nonspecific Cerebrovascular Disorders with MCC 15104.76 071 Nonspecific Cerebrovascular Disorders with CC 9065.97 072 Nonspecific Cerebrovascular Disorders without CC/MCC 6150.33 073 Cranial and Peripheral Nerve Disorders with MCC 10585.71 074 Cranial and Peripheral Nerve Disorders without MCC 7058.24 075 Viral Meningitis with CC/MCC 13587.47 076 Viral Meningitis without CC/MCC 7422.38 077 Hypertensive Encephalopathy with MCC 14250.98 078 Hypertensive Encephalopathy with CC 8327.83 079 Hypertensive Encephalopathy without CC/MCC 6178.21 080 Nontraumatic Stupor and Coma with MCC 9767.20 081 Nontraumatic Stupor and Coma without MCC 6062.57 082 Traumatic Stupor and Coma, Coma Greater Than One Hour with MCC 16509.68 083 Traumatic Stupor and Coma, Coma Greater Than One Hour with CC 10878.51 084 Traumatic Stupor and Coma, Coma Greater Than One Hour without CC/MCC 7347.75 085 Traumatic Stupor and Coma, Coma Less Than One Hour with MCC 17570.14 086 Traumatic Stupor and Coma, Coma Less Than One Hour with CC 9883.66 087 Traumatic Stupor and Coma, Coma Less Than One Hour without CC/MCC 6502.99 088 Concussion with MCC 12197.32 089 Concussion with CC 7928.42 090 Concussion without CC/MCC 5681.20 091 Other Disorders of Nervous System with MCC 13383.26 092 Other Disorders of Nervous System with CC 7712.72 093 Other Disorders of Nervous System without CC/MCC 5599.18 094 Bacterial and Tuberculous Infections of Nervous System with MCC 30156.21 095 Bacterial and Tuberculous Infections of Nervous System with CC 19664.81 096 Bacterial and Tuberculous Infections of Nervous System without CC/MCC 15785.48 097 Nonbacterial Infections of Nervous System Except Viral Meningitis with MCC 26401.55 098 Nonbacterial Infections of Nervous System Except Viral Meningitis with CC 15669.84 099 Nonbacterial Infections of Nervous System Except Viral Meningitis without CC/MCC 9910.73 100 Seizures with MCC 12390.05 101 Seizures without MCC 6248.75 102 Headaches with MCC 8437.73 103 Headaches without MCC 5495.85 300 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
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 15017.82 114 Orbital Procedures without CC/MCC 7372.36 115 Extraocular Procedures Except Orbit 9910.73 116 Intraocular Procedures with CC/MCC 10395.44 117 Intraocular Procedures without CC/MCC 5991.22 121 Acute Major Eye Infections with CC/MCC 7466.67 122 Acute Major Eye Infections without CC/MCC 5349.04 123 Neurological Eye Disorders 5859.17 124 Other Disorders of the Eye with MCC 9762.28 125 Other Disorders of the Eye without MCC 5625.43 129 Major Head and Neck Procedures with CC/MCC or Major Device 18329.60 130 Major Head and Neck Procedures without CC/MCC 10087.06 131 Cranial/Facial Procedures with CC/MCC 17153.50 132 Cranial/Facial Procedures without CC/MCC 10208.44 133 Other Ear, Nose, Mouth and Throat O.R. Procedures with CC/MCC 13942.60 134 Other Ear, Nose, Mouth and Throat O.R. Procedures without CC/MCC 6982.78 135 Sinus and Mastoid Procedures with CC/MCC 15650.16 136 Sinus and Mastoid Procedures without CC/MCC 7997.31 137 Mouth Procedures with CC/MCC 10667.73 138 Mouth Procedures without CC/MCC 6430.82 139 Salivary Gland Procedures 7181.26 146 Ear, Nose, Mouth and Throat Malignancy with MCC 17949.87 147 Ear, Nose, Mouth and Throat Malignancy with CC 10180.56 148 Ear, Nose, Mouth and Throat Malignancy without CC/MCC 6615.35 149 Dysequilibrium 5239.96 150 Epistaxis with MCC 10504.52 151 Epistaxis without MCC 5243.24 152 Otitis Media and Upper Respiratory Infection with MCC 7860.35 153 Otitis Media and Upper Respiratory Infection without MCC 5158.76 154 Other Ear, Nose, Mouth and Throat Diagnoses with MCC 11453.44 155 Other Ear, Nose, Mouth and Throat Diagnoses with CC 7395.32 156 Other Ear, Nose, Mouth and Throat Diagnoses without CC/MCC 5106.27 157 Dental and Oral Diseases with MCC 12953.50 158 Dental and Oral Diseases with CC 7403.52 159 Dental and Oral Diseases without CC/MCC 4836.44 163 Major Chest Procedures with MCC 41686.74 164 Major Chest Procedures with CC 21517.53 165 Major Chest Procedures without CC/MCC 14564.28 166 Other Respiratory System O.R. Procedures with MCC 30659.78 167 Other Respiratory System O.R. Procedures with CC 16868.09 168 Other Respiratory System O.R. Procedures without CC/MCC 10668.55 175 Pulmonary Embolism with MCC 13201.18 176 Pulmonary Embolism without MCC 8780.56 177 Respiratory Infections and Inflammations with MCC 16950.10 178 Respiratory Infections and Inflammations with CC 12209.62 179 Respiratory Infections and Inflammations without CC/MCC 8087.53 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 301
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 14238.68 181 Respiratory Neoplasms with CC 9991.10 182 Respiratory Neoplasms without CC/MCC 6639.96 183 Major Chest Trauma with MCC 12254.73 184 Major Chest Trauma with CC 8000.59 185 Major Chest Trauma without CC/MCC 5579.50 186 Pleural Effusion with MCC 12824.73 187 Pleural Effusion with CC 9043.83 188 Pleural Effusion without CC/MCC 6297.13 189 Pulmonary Edema and Respiratory Failure 10505.34 190 Chronic Obstructive Pulmonary Disease with MCC 9779.50 191 Chronic Obstructive Pulmonary Disease with CC 7984.19 192 Chronic Obstructive Pulmonary Disease without CC/MCC 5921.50 193 Simple Pneumonia and Pleurisy with MCC 12134.98 194 Simple Pneumonia and Pleurisy with CC 8326.19 195 Simple Pneumonia and Pleurisy without CC/MCC 5819.81 196 Interstitial Lung Disease with MCC 13173.30 197 Interstitial Lung Disease with CC 9166.03 198 Interstitial Lung Disease without CC/MCC 6727.72 199 Pneumothorax with MCC 14676.64 200 Pneumothorax with CC 8408.21 201 Pneumothorax without CC/MCC 5913.30 202 Bronchitis and Asthma with CC/MCC 6908.97 203 Bronchitis and Asthma without CC/MCC 4987.35 204 Respiratory Signs and Symptoms 5506.51 205 Other Respiratory System Diagnoses with MCC 10639.02 206 Other Respiratory System Diagnoses without MCC 6212.66 207 Respiratory System Diagnosis with Ventilator Support 96+ Hours 42703.73 208 Respiratory System Diagnosis with Ventilator Support <96 Hours 18560.06 215 Other Heart Assist System Implant 103409.81 216 Cardiac Valve and Other Major Cardiothoracic Procedures with Cardiac Catheterization with MCC 82210.50 217 Cardiac Valve and Other Major Cardiothoracic Procedures with Cardiac Catheterization with CC 55801.57 218 Cardiac Valve and Other Major Cardiothoracic Procedures with Cardiac Catheterization without CC/MCC 43708.41 219 Cardiac Valve and Other Major Cardiothoracic Procedures without Cardiac Catheterization with MCC 66293.79 220 Cardiac Valve and Other Major Cardiothoracic Procedures without Cardiac Catheterization with CC 44113.57 221 Cardiac Valve and Other Major Cardiothoracic Procedures without Cardiac Catheterization without CC/MCC 36743.67 222 Cardiac Defibrillator Implant with Cardiac Catheterization with Acute Myocardial Infarction/Heart Failure/Shock 69901.64 with MCC 223 Cardiac Defibrillator Implant with Cardiac Catheterization with Acute Myocardial Infarction/Heart Failure/Shock 52694.83 without MCC 224 Cardiac Defibrillator Implant with Cardiac Catheterization without Acute Myocardial Infarction/Heart Failure/Shock 62183.18 with MCC 225 Cardiac Defibrillator Implant with Cardiac Catheterization without Acute Myocardial Infarction/Heart Failure/Shock 49374.85 without MCC 226 Cardiac Defibrillator Implant without Cardiac Catheterization with MCC 52908.07 227 Cardiac Defibrillator Implant without Cardiac Catheterization without MCC 42595.47 228 Other Cardiothoracic Procedures with MCC 62234.03 229 Other Cardiothoracic Procedures with CC 39158.20 302 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
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 29075.24 231 Coronary Bypass with PTCA with MCC 64449.26 232 Coronary Bypass with PTCA without MCC 47718.96 233 Coronary Bypass with Cardiac Catheterization with MCC 59117.45 234 Coronary Bypass with Cardiac Catheterization without MCC 39597.81 235 Coronary Bypass without Cardiac Catheterization with MCC 48003.56 236 Coronary Bypass without Cardiac Catheterization without MCC 30925.51 237 Major Cardiovascular Procedures with MCC or Thoracic Aortic Aneurysm Repair 42568.40 238 Major Cardiovascular Procedures without MCC 25285.32 239 Amputation for Circulatory System Disorders Except Upper Limb and Toe with MCC 37353.05 240 Amputation for Circulatory System Disorders Except Upper Limb and Toe with CC 21807.05 241 Amputation for Circulatory System Disorders Except Upper Limb and Toe without CC/MCC 11999.66 242 Permanent Cardiac Pacemaker Implant with MCC 30572.84 243 Permanent Cardiac Pacemaker Implant with CC 21740.62 244 Permanent Cardiac Pacemaker Implant without CC/MCC 16729.48 245 AICD Generator Procedures 34845.02 246 Percutaneous Cardiovascular Procedure with Drug-Eluting Stent with MCC or 4+ Vessels/Stents 26082.51 247 Percutaneous Cardiovascular Procedure with Drug-Eluting Stent without MCC 16149.63 248 Percutaneous Cardiovascular Procedure with Non Drug-Eluting Stent with MCC or 4+ Vessels/Stents 23987.83 249 Percutaneous Cardiovascular Procedure with Non Drug-Eluting Stent without MCC 14542.95 250 Percutaneous Cardiovascular Procedure without Coronary Artery Stent with MCC 23649.93 251 Percutaneous Cardiovascular Procedure without Coronary Artery Stent without MCC 14756.19 252 Other Vascular Procedures with MCC 24402.83 253 Other Vascular Procedures with CC 19695.15 254 Other Vascular Procedures without CC/MCC 13247.11 255 Upper Limb and Toe Amputation for Circulatory System Disorders with MCC 20539.09 256 Upper Limb and Toe Amputation for Circulatory System Disorders with CC 13097.02 257 Upper Limb and Toe Amputation for Circulatory System Disorders without CC/MCC 7996.49 258 Cardiac Pacemaker Device Replacement with MCC 23686.02 259 Cardiac Pacemaker Device Replacement without MCC 15036.69 260 Cardiac Pacemaker Revision Except Device Replacement with MCC 29115.43 261 Cardiac Pacemaker Revision Except Device Replacement with CC 13507.10 262 Cardiac Pacemaker Revision Except Device Replacement without CC/MCC 9223.44 263 Vein Ligation and Stripping 14405.99 264 Other Circulatory System O.R. Procedures 20753.97 265 AICD Lead Procedures 18992.28 280 Acute Myocardial Infarction, Discharged Alive with MCC 15175.29 281 Acute Myocardial Infarction, Discharged Alive with CC 9769.66 282 Acute Myocardial Infarction, Discharged Alive without CC/MCC 6613.71 283 Acute Myocardial Infarction, Expired with MCC 14066.44 284 Acute Myocardial Infarction, Expired with CC 7289.52 285 Acute Myocardial Infarction, Expired without CC/MCC 4684.71 286 Circulatory Disorders Except Acute Myocardial Infarction, with Cardiac Catheterization with MCC 16414.54 287 Circulatory Disorders Except Acute Myocardial Infarction, with Cardiac Catheterization without MCC 8922.44 288 Acute and Subacute Endocarditis with MCC 24110.04 289 Acute and Subacute Endocarditis with CC 15166.27 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 303
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 10628.36 291 Heart Failure and Shock with MCC 12255.55 292 Heart Failure and Shock with CC 8449.22 293 Heart Failure and Shock without CC/MCC 5620.51 294 Deep Vein Thrombophlebitis with CC/MCC 8507.45 295 Deep Vein Thrombophlebitis without CC/MCC 5251.44 296 Cardiac Arrest, Unexplained with MCC 9589.23 297 Cardiac Arrest, Unexplained with CC 5570.48 298 Cardiac Arrest, Unexplained without CC/MCC 3688.23 299 Peripheral Vascular Disorders with MCC 11541.19 300 Peripheral Vascular Disorders with CC 8017.82 301 Peripheral Vascular Disorders without CC/MCC 5425.31 302 Atherosclerosis with MCC 8000.59 303 Atherosclerosis without MCC 4781.49 304 Hypertension with MCC 8417.23 305 Hypertension without MCC 5034.10 306 Cardiac Congenital and Valvular Disorders with MCC 12029.18 307 Cardiac Congenital and Valvular Disorders without MCC 6539.90 308 Cardiac Arrhythmia and Conduction Disorders with MCC 10119.87 309 Cardiac Arrhythmia and Conduction Disorders with CC 6878.62 310 Cardiac Arrhythmia and Conduction Disorders without CC/MCC 4682.25 311 Angina Pectoris 4158.18 312 Syncope and Collapse 5882.14 313 Chest Pain 4510.02 314 Other Circulatory System Diagnoses with MCC 14881.68 315 Other Circulatory System Diagnoses with CC 7939.90 316 Other Circulatory System Diagnoses without CC/MCC 5041.48 326 Stomach, Esophageal and Duodenal Procedures with MCC 47685.34 327 Stomach, Esophageal and Duodenal Procedures with CC 22333.59 328 Stomach, Esophageal and Duodenal Procedures without CC/MCC 11726.55 329 Major Small and Large Bowel Procedures with MCC 43309.82 330 Major Small and Large Bowel Procedures with CC 21184.55 331 Major Small and Large Bowel Procedures without CC/MCC 13341.43 332 Rectal Resection with MCC 39888.14 333 Rectal Resection with CC 20471.02 334 Rectal Resection without CC/MCC 13105.22 335 Peritoneal Adhesiolysis with MCC 35083.68 336 Peritoneal Adhesiolysis with CC 19237.51 337 Peritoneal Adhesiolysis without CC/MCC 12129.24 338 Appendectomy with Complicated Principal Diagnosis with MCC 26339.21 339 Appendectomy with Complicated Principal Diagnosis with CC 15303.23 340 Appendectomy with Complicated Principal Diagnosis without CC/MCC 10164.16 341 Appendectomy without Complicated Principal Diagnosis with MCC 18570.72 342 Appendectomy without Complicated Principal Diagnosis with CC 10863.75 343 Appendectomy without Complicated Principal Diagnosis without CC/MCC 7847.22 344 Minor Small and Large Bowel Procedures with MCC 25905.35 304 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
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 13971.31 346 Minor Small and Large Bowel Procedures without CC/MCC 9745.88 347 Anal and Stomal Procedures with MCC 19833.76 348 Anal and Stomal Procedures with CC 11240.20 349 Anal and Stomal Procedures without CC/MCC 6545.64 350 Inguinal and Femoral Hernia Procedures with MCC 20402.95 351 Inguinal and Femoral Hernia Procedures with CC 11104.05 352 Inguinal and Femoral Hernia Procedures without CC/MCC 7076.28 353 Hernia Procedures Except Inguinal and Femoral with MCC 22562.41 354 Hernia Procedures Except Inguinal and Femoral with CC 12731.24 355 Hernia Procedures Except Inguinal and Femoral without CC/MCC 8471.36 356 Other Digestive System O.R. Procedures with MCC 33046.42 357 Other Digestive System O.R. Procedures with CC 17605.40 358 Other Digestive System O.R. Procedures without CC/MCC 10670.19 368 Major Esophageal Disorders with MCC 14416.65 369 Major Esophageal Disorders with CC 8834.69 370 Major Esophageal Disorders without CC/MCC 6188.87 371 Major Gastrointestinal Disorders and Peritoneal Infections with MCC 17211.73 372 Major Gastrointestinal Disorders and Peritoneal Infections with CC 10608.68 373 Major Gastrointestinal Disorders and Peritoneal Infections without CC/MCC 7052.50 374 Digestive Malignancy with MCC 16955.84 375 Digestive Malignancy with CC 10498.78 376 Digestive Malignancy without CC/MCC 6953.26 377 GI Hemorrhage with MCC 14386.30 378 GI Hemorrhage with CC 8426.25 379 GI Hemorrhage without CC/MCC 5860.81 380 Complicated Peptic Ulcer with MCC 16120.93 381 Complicated Peptic Ulcer with CC 9191.45 382 Complicated Peptic Ulcer without CC/MCC 6667.84 383 Uncomplicated Peptic Ulcer with MCC 9827.07 384 Uncomplicated Peptic Ulcer without MCC 6828.59 385 Inflammatory Bowel Disease with MCC 15666.56 386 Inflammatory Bowel Disease with CC 8558.30 387 Inflammatory Bowel Disease without CC/MCC 6407.86 388 GI Obstruction with MCC 13497.26 389 GI Obstruction with CC 7663.51 390 GI Obstruction without CC/MCC 5223.55 391 Esophagitis, Gastroenteritis and Miscellaneous Digestive Disorders with MCC 9472.77 392 Esophagitis, Gastroenteritis and Miscellaneous Digestive Disorders without MCC 5882.96 393 Other Digestive System Diagnoses with MCC 13608.80 394 Other Digestive System Diagnoses with CC 8151.50 395 Other Digestive System Diagnoses without CC/MCC 5535.21 405 Pancreas, Liver and Shunt Procedures with MCC 45717.79 406 Pancreas, Liver and Shunt Procedures with CC 22792.87 407 Pancreas, Liver and Shunt Procedures without CC/MCC 15308.16 408 Biliary Tract Procedures Except Only Cholecystectomy with or without C.D.E. with MCC 32287.78 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 305
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 20401.31 410 Biliary Tract Procedures Except Only Cholecystectomy with or without C.D.E. without CC/MCC 13215.95 411 Cholecystectomy with C.D.E. with MCC 30196.39 412 Cholecystectomy with C.D.E. with CC 20431.65 413 Cholecystectomy with C.D.E. without CC/MCC 14090.23 414 Cholecystectomy Except by Laparoscope without C.D.E. with MCC 30079.11 415 Cholecystectomy Except by Laparoscope without C.D.E. with CC 17138.74 416 Cholecystectomy Except by Laparoscope without C.D.E. without CC/MCC 10727.60 417 Laparoscopic Cholecystectomy without C.D.E. with MCC 20527.61 418 Laparoscopic Cholecystectomy without C.D.E. with CC 13939.32 419 Laparoscopic Cholecystectomy without C.D.E. without CC/MCC 9594.15 420 Hepatobiliary Diagnostic Procedures with MCC 29888.84 421 Hepatobiliary Diagnostic Procedures with CC 15509.09 422 Hepatobiliary Diagnostic Procedures without CC/MCC 10450.39 423 Other Hepatobiliary or Pancreas O.R. Procedures with MCC 36559.96 424 Other Hepatobiliary or Pancreas O.R. Procedures with CC 19958.42 425 Other Hepatobiliary or Pancreas O.R. Procedures without CC/MCC 13346.35 432 Cirrhosis and Alcoholic Hepatitis with MCC 13943.42 433 Cirrhosis and Alcoholic Hepatitis with CC 7830.82 434 Cirrhosis and Alcoholic Hepatitis without CC/MCC 5045.58 435 Malignancy of Hepatobiliary System or Pancreas with MCC 14777.52 436 Malignancy of Hepatobiliary System or Pancreas with CC 10018.17 437 Malignancy of Hepatobiliary System or Pancreas without CC/MCC 7384.66 438 Disorders of Pancreas Except Malignancy with MCC 15043.25 439 Disorders of Pancreas Except Malignancy with CC 8274.52 440 Disorders of Pancreas Except Malignancy without CC/MCC 5650.85 441 Disorders of Liver Except Malignancy, Cirrhosis, Alcoholic Hepatitis with MCC 14961.23 442 Disorders of Liver Except Malignancy, Cirrhosis, Alcoholic Hepatitis with CC 8084.25 443 Disorders of Liver Except Malignancy, Cirrhosis, Alcoholic Hepatitis without CC/MCC 5425.31 444 Disorders of the Biliary Tract with MCC 12782.90 445 Disorders of the Biliary Tract with CC 8765.80 446 Disorders of the Biliary Tract without CC/MCC 6078.15 453 Combined Anterior/Posterior Spinal Fusion with MCC 84191.17 454 Combined Anterior/Posterior Spinal Fusion with CC 59509.48 455 Combined Anterior/Posterior Spinal Fusion without CC/MCC 44540.87 456 Spinal Fusion Except Cervical with Spinal Curvature/Malignancy/Infection or 9+ Fusions with MCC 76179.91 457 Spinal Fusion Except Cervical with Spinal Curvature/Malignancy/Infection or 9+ Fusions with CC 50869.17 458 Spinal Fusion Except Cervical with Spinal Curvature/Malignancy/Infection or 9+ Fusions without CC/MCC 40498.33 459 Spinal Fusion Except Cervical with MCC 53363.25 460 Spinal Fusion Except Cervical without MCC 31750.58 461 Bilateral or Multiple Major Joint Procedures of Lower Extremity with MCC 40503.26 462 Bilateral or Multiple Major Joint Procedures of Lower Extremity without MCC 27413.61 463 Wound Debridement and Skin Graft Except Hand, for Musculo-Connective Tissue Disorders with MCC 40993.71 464 Wound Debridement and Skin Graft Except Hand, for Musculo-Connective Tissue Disorders with CC 23397.32 465 Wound Debridement and Skin Graft Except Hand, for Musculo-Connective Tissue Disorders without 14684.84 CC/MCC 466 Revision of Hip or Knee Replacement with MCC 40305.60 306 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
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 26508.17 468 Revision of Hip or Knee Replacement without CC/MCC 21100.90 469 Major Joint Replacement or Reattachment of Lower Extremity with MCC 28478.99 470 Major Joint Replacement or Reattachment of Lower Extremity without MCC 17255.20 471 Cervical Spinal Fusion with MCC 38794.06 472 Cervical Spinal Fusion with CC 22736.28 473 Cervical Spinal Fusion without CC/MCC 17032.94 474 Amputation for Musculoskeletal System and Connective Tissue Disorders with MCC 28627.44 475 Amputation for Musculoskeletal System and Connective Tissue Disorders with CC 16070.08 476 Amputation for Musculoskeletal System and Connective Tissue Disorders without CC/MCC 8135.92 477 Biopsies of Musculoskeletal System and Connective Tissue with MCC 27299.61 478 Biopsies of Musculoskeletal System and Connective Tissue with CC 18491.17 479 Biopsies of Musculoskeletal System and Connective Tissue without CC/MCC 13423.44 480 Hip and Femur Procedures Except Major Joint with MCC 25374.71 481 Hip and Femur Procedures Except Major Joint with CC 15489.41 482 Hip and Femur Procedures Except Major Joint without CC/MCC 12607.39 483 Major Joint and Limb Reattachment Procedures of Upper Extremity with CC/MCC 19699.25 484 Major Joint and Limb Reattachment Procedures of Upper Extremity without CC/MCC 16037.27 485 Knee Procedures with Principal Diagnosis of Infection with MCC 26352.34 486 Knee Procedures with Principal Diagnosis of Infection with CC 16681.09 487 Knee Procedures with Principal Diagnosis of Infection without CC/MCC 12075.93 488 Knee Procedures without Principal Diagnosis of Infection with CC/MCC 14120.57 489 Knee Procedures without Principal Diagnosis of Infection without CC/MCC 9957.48 490 Back and Neck Procedures Except Spinal Fusion with CC/MCC or Disc Device/Neurostimulator 14693.86 491 Back and Neck Procedures Except Spinal Fusion without CC/MCC 8131.00 492 Lower Extremity and Humerus Procedures Except Hip, Foot, Femur with MCC 25154.09 493 Lower Extremity and Humerus Procedures Except Hip, Foot, Femur with CC 15188.41 494 Lower Extremity and Humerus Procedures Except Hip, Foot, Femur without CC/MCC 10776.81 495 Local Excision and Removal Internal Fixation Devices Except Hip and Femur with MCC 23524.45 496 Local Excision and Removal Internal Fixation Devices Except Hip and Femur with CC 13292.22 497 Local Excision and Removal Internal Fixation Devices Except Hip and Femur without CC/MCC 8833.05 498 Local Excision and Removal Internal Fixation Devices of Hip and Femur with CC/MCC 16330.89 499 Local Excision and Removal Internal Fixation Devices of Hip and Femur without CC/MCC 8133.46 500 Soft Tissue Procedures with MCC 24840.79 501 Soft Tissue Procedures with CC 12996.14 502 Soft Tissue Procedures without CC/MCC 8451.68 503 Foot Procedures with MCC 18706.87 504 Foot Procedures with CC 12864.10 505 Foot Procedures without CC/MCC 8833.05 506 Major Thumb or Joint Procedures 9690.11 507 Major Shoulder or Elbow Joint Procedures with CC/MCC 15345.88 508 Major Shoulder or Elbow Joint Procedures without CC/MCC 11446.06 509 Arthroscopy 10783.37 510 Shoulder, Elbow or Forearm Procedure, Except Major Joint Procedure with MCC 17800.60 511 Shoulder, Elbow or Forearm Procedure, Except Major Joint Procedure with CC 12048.05 512 Shoulder, Elbow or Forearm Procedure, Except Major Joint Procedure without CC/MCC 8579.62 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 307
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 10667.73 514 Hand or Wrist Procedures, Except Major Thumb or Joint Procedures without CC/MCC 6732.64 515 Other Musculoskeletal System and Connective Tissue O.R. Procedure with MCC 26157.96 516 Other Musculoskeletal System and Connective Tissue O.R. Procedure with CC 15783.02 517 Other Musculoskeletal System and Connective Tissue O.R. Procedure without CC/MCC 12135.80 533 Fractures of Femur with MCC 12841.14 534 Fractures of Femur without MCC 6233.98 535 Fractures of Hip and Pelvis with MCC 11094.21 536 Fractures of Hip and Pelvis without MCC 5897.72 537 Sprains, Strains, and Dislocations of Hip, Pelvis and Thigh with CC/MCC 6786.77 538 Sprains, Strains, and Dislocations of Hip, Pelvis and Thigh without CC/MCC 5009.49 539 Osteomyelitis with MCC 16786.07 540 Osteomyelitis with CC 10765.33 541 Osteomyelitis without CC/MCC 7145.99 542 Pathological Fractures and Musculoskeletal and Connective Tissue Malignancy with MCC 16010.21 543 Pathological Fractures and Musculoskeletal and Connective Tissue Malignancy with CC 9511.31 544 Pathological Fractures and Musculoskeletal and Connective Tissue Malignancy without CC/MCC 6376.69 545 Connective Tissue Disorders with MCC 20886.84 546 Connective Tissue Disorders with CC 9605.63 547 Connective Tissue Disorders without CC/MCC 6026.48 548 Septic Arthritis with MCC 16114.37 549 Septic Arthritis with CC 9870.54 550 Septic Arthritis without CC/MCC 6787.59 551 Medical Back Problems with MCC 13448.87 552 Medical Back Problems without MCC 6728.54 553 Bone Diseases and Arthropathies with MCC 9312.84 554 Bone Diseases and Arthropathies without MCC 5586.88 555 Signs and Symptoms of Musculoskeletal System and Connective Tissue with MCC 8983.96 556 Signs and Symptoms of Musculoskeletal System and Connective Tissue without MCC 5386.76 557 Tendonitis, Myositis and Bursitis with MCC 13139.67 558 Tendonitis, Myositis and Bursitis without MCC 7236.21 559 Aftercare, Musculoskeletal System and Connective Tissue with MCC 14530.65 560 Aftercare, Musculoskeletal System and Connective Tissue with CC 8219.57 561 Aftercare, Musculoskeletal System and Connective Tissue without CC/MCC 5093.97 562 Fractures, Sprains, Strains and Dislocations Except Femur, Hip, Pelvis and Thigh with MCC 11436.21 563 Fractures, Sprains, Strains and Dislocations Except Femur, Hip, Pelvis and Thigh without MCC 5866.55 564 Other Musculoskeletal System and Connective Tissue Diagnoses with MCC 12057.89 565 Other Musculoskeletal System and Connective Tissue Diagnoses with CC 7459.29 566 Other Musculoskeletal System and Connective Tissue Diagnoses without CC/MCC 5433.51 573 Skin Graft and/or Debridement for Skin Ulcer or Cellulitis with MCC 26622.99 574 Skin Graft and/or Debridement for Skin Ulcer or Cellulitis with CC 15316.36 575 Skin Graft and/or Debridement for Skin Ulcer or Cellulitis without CC/MCC 8938.85 576 Skin Graft and/or Debridement Except for Skin Ulcer or Cellulitis with MCC 32189.36 577 Skin Graft and/or Debridement Except for Skin Ulcer or Cellulitis with CC 13971.31 578 Skin Graft and/or Debridement Except for Skin Ulcer or Cellulitis without CC/MCC 8542.71 579 Other Skin, Subcutaneous Tissue and Breast Procedures with MCC 24256.85 308 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
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 12268.67 581 Other Skin, Subcutaneous Tissue and Breast Procedures without CC/MCC 7564.27 582 Mastectomy for Malignancy with CC/MCC 8666.56 583 Mastectomy for Malignancy without CC/MCC 6933.57 584 Breast Biopsy, Local Excision and Other Breast Procedures with CC/MCC 12427.78 585 Breast Biopsy, Local Excision and Other Breast Procedures without CC/MCC 8538.61 592 Skin Ulcers with MCC 14491.28 593 Skin Ulcers with CC 8783.02 594 Skin Ulcers without CC/MCC 6225.78 595 Major Skin Disorders with MCC 15328.66 596 Major Skin Disorders without MCC 7200.12 597 Malignant Breast Disorders with MCC 12791.11 598 Malignant Breast Disorders with CC 8702.64 599 Malignant Breast Disorders without CC/MCC 5138.26 600 Nonmalignant Breast Disorders with CC/MCC 7875.11 601 Nonmalignant Breast Disorders without CC/MCC 5517.99 602 Cellulitis with MCC 12095.62 603 Cellulitis without MCC 6870.42 604 Trauma to the Skin, Subcutaneous Tissue and Breast with MCC 10137.91 605 Trauma to the Skin, Subcutaneous Tissue & Breast without MCC 5890.34 606 Minor Skin Disorders with MCC 10729.24 607 Minor Skin Disorders without MCC 5623.79 614 Adrenal and Pituitary Procedures with CC/MCC 20138.04 615 Adrenal and Pituitary Procedures without CC/MCC 11457.54 616 Amputation of Lower Limb for Endocrine, Nutritional, and Metabolic Disorders with MCC 36852.75 617 Amputation of Lower Limb for Endocrine, Nutritional, and Metabolic Disorders with CC 16407.98 618 Amputation of Lower Limb for Endocrine, Nutritional, and Metabolic Disorders without CC/MCC 9846.76 619 O.R. Procedures for Obesity with MCC 28880.87 620 O.R. Procedures for Obesity with CC 15276.99 621 O.R. Procedures for Obesity without CC/MCC 12094.80 622 Skin Grafts and Wound Debridement for Endocrine, Nutritional and Metabolic Disorders with MCC 28021.35 623 Skin Grafts and Wound Debridement for Endocrine, Nutritional and Metabolic Disorders with CC 15220.40 624 Skin Grafts and Wound Debridement for Endocrine, Nutritional and Metabolic Disorders without CC/MCC 8301.59 625 Thyroid, Parathyroid and Thyroglossal Procedures with MCC 18390.29 626 Thyroid, Parathyroid and Thyroglossal Procedures with CC 9596.61 627 Thyroid, Parathyroid and Thyroglossal Procedures without CC/MCC 6414.42 628 Other Endocrine, Nutritional and Metabolic O.R. Procedures with MCC 27736.75 629 Other Endocrine, Nutritional and Metabolic O.R. Procedures with CC 18576.47 630 Other Endocrine, Nutritional and Metabolic O.R. Procedures without CC/MCC 11616.65 637 Diabetes with MCC 11861.05 638 Diabetes with CC 6812.19 639 Diabetes without CC/MCC 4546.93 640 Nutritional and Miscellaneous Metabolic Disorders with MCC 9349.74 641 Nutritional and Miscellaneous Metabolic Disorders without MCC 5672.18 642 Inborn Errors of Metabolism 8439.37 643 Endocrine Disorders with MCC 14893.16 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 309
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 8738.73 645 Endocrine Disorders without CC/MCC 5903.46 652 Kidney Transplant 24967.10 653 Major Bladder Procedures with MCC 49971.10 654 Major Bladder Procedures with CC 24648.88 655 Major Bladder Procedures without CC/MCC 16047.93 656 Kidney and Ureter Procedures for Neoplasm with MCC 29290.12 657 Kidney and Ureter Procedures for Neoplasm with CC 16406.34 658 Kidney and Ureter Procedures for Neoplasm without CC/MCC 11665.86 659 Kidney and Ureter Procedures for Non-neoplasm with MCC 28695.51 660 Kidney and Ureter Procedures for Non-neoplasm with CC 15607.51 661 Kidney and Ureter Procedures for Non-neoplasm without CC/MCC 10367.55 662 Minor Bladder Procedures with MCC 24734.17 663 Minor Bladder Procedures with CC 12071.01 664 Minor Bladder Procedures without CC/MCC 9082.37 665 Prostatectomy with MCC 23499.84 666 Prostatectomy with CC 13483.32 667 Prostatectomy without CC/MCC 6494.79 668 Transurethral Procedures with MCC 20647.35 669 Transurethral Procedures with CC 10331.47 670 Transurethral Procedures without CC/MCC 6372.59 671 Urethral Procedures with CC/MCC 11810.20 672 Urethral Procedures without CC/MCC 6466.91 673 Other Kidney and Urinary Tract Procedures with MCC 23997.68 674 Other Kidney and Urinary Tract Procedures with CC 17169.08 675 Other Kidney and Urinary Tract Procedures without CC/MCC 10972.83 682 Renal Failure with MCC 13456.25 683 Renal Failure with CC 8400.83 684 Renal Failure without CC/MCC 5402.35 685 Admit for Renal Dialysis 7335.45 686 Kidney and Urinary Tract Neoplasms with MCC 14957.95 687 Kidney and Urinary Tract Neoplasms with CC 8888.82 688 Kidney and Urinary Tract Neoplasms without CC/MCC 5313.77 689 Kidney and Urinary Tract Infections with MCC 9993.56 690 Kidney and Urinary Tract Infections without MCC 6449.68 691 Urinary Stones with ESW Lithotripsy with CC/MCC 13250.39 692 Urinary Stones with ESW Lithotripsy without CC/MCC 9174.23 693 Urinary Stones without ESW Lithotripsy with MCC 11076.17 694 Urinary Stones without ESW Lithotripsy without MCC 5819.81 695 Kidney and Urinary Tract Signs and Symptoms with MCC 9909.09 696 Kidney and Urinary Tract Signs and Symptoms without MCC 5404.81 697 Urethral Stricture 6373.41 698 Other Kidney and Urinary Tract Diagnoses with MCC 13202.82 699 Other Kidney and Urinary Tract Diagnoses with CC 8200.71 700 Other Kidney and Urinary Tract Diagnoses without CC/MCC 5541.77 707 Major Male Pelvic Procedures with CC/MCC 14555.26 310 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
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 10318.34 709 Penis Procedures with CC/MCC 15279.45 710 Penis Procedures without CC/MCC 10425.78 711 Testes Procedures with CC/MCC 14466.68 712 Testes Procedures without CC/MCC 6630.12 713 Transurethral Prostatectomy with CC/MCC 9679.45 714 Transurethral Prostatectomy without CC/MCC 5367.08 715 Other Male Reproductive System O.R. Procedures for Malignancy with CC/MCC 14297.73 716 Other Male Reproductive System O.R. Procedures for Malignancy without CC/MCC 8180.21 717 Other Male Reproductive System O.R. Procedures Except Malignancy with CC/MCC 13235.63 718 Other Male Reproductive System O.R. Procedures Except Malignancy without CC/MCC 6597.31 722 Malignancy, Male Reproductive System with MCC 13853.20 723 Malignancy, Male Reproductive System with CC 8357.36 724 Malignancy, Male Reproductive System without CC/MCC 5093.97 725 Benign Prostatic Hypertrophy with MCC 10450.39 726 Benign Prostatic Hypertrophy without MCC 5751.73 727 Inflammation of the Male Reproductive System with MCC 11200.83 728 Inflammation of the Male Reproductive System without MCC 6243.00 729 Other Male Reproductive System Diagnoses with CC/MCC 8112.95 730 Other Male Reproductive System Diagnoses without CC/MCC 5260.46 734 Pelvic Evisceration, Radical Hysterectomy and Radical Vulvectomy with CC/MCC 19982.21 735 Pelvic Evisceration, Radical Hysterectomy and Radical Vulvectomy without CC/MCC 9582.67 736 Uterine and Adnexa Procedures for Ovarian or Adnexal Malignancy with MCC 36039.98 737 Uterine and Adnexa Procedures for Ovarian or Adnexal Malignancy with CC 16710.62 738 Uterine and Adnexa Procedures for Ovarian or Adnexal Malignancy without CC/MCC 10107.57 739 Uterine, Adnexa Procedures for Nonovarian/Adnexal Malignancy with MCC 28131.25 740 Uterine, Adnexa Procedures for Nonovarian/Adnexal Malignancy with CC 12531.94 741 Uterine, Adnexa Procedures for Nonovarian/Adnexal Malignancy without CC/MCC 9004.46 742 Uterine and Adnexa Procedures for Nonmalignancy with CC/MCC 11386.18 743 Uterine and Adnexa Procedures for Nonmalignancy without CC/MCC 7446.17 744 D&C, Conization, Laparoscopy and Tubal Interruption with CC/MCC 12426.14 745 D&C, Conization, Laparoscopy and Tubal Interruption without CC/MCC 6598.13 746 Vagina, Cervix and Vulva Procedures with CC/MCC 10967.91 747 Vagina, Cervix and Vulva Procedures without CC/MCC 7259.99 748 Female Reproductive System Reconstructive Procedures 7519.98 749 Other Female Reproductive System O.R. Procedures with CC/MCC 20729.37 750 Other Female Reproductive System O.R. Procedures without CC/MCC 7683.19 754 Malignancy, Female Reproductive System with MCC 16645.01 755 Malignancy, Female Reproductive System with CC 9385.83 756 Malignancy, Female Reproductive System without CC/MCC 5216.99 757 Infections, Female Reproductive System with MCC 13585.83 758 Infections, Female Reproductive System with CC 8991.34 759 Infections, Female Reproductive System without CC/MCC 6042.89 760 Menstrual and Other Female Reproductive System Disorders with CC/MCC 6879.44 761 Menstrual and Other Female Reproductive System Disorders without CC/MCC 4280.38 765 Cesarean Section with CC/MCC 9242.30 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 311
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 6557.12 767 Vaginal Delivery with Sterilization and/or D&C 7472.41 768 Vaginal Delivery with O.R. Procedure Except Sterilization and/or D&C 14854.61 769 Postpartum and Postabortion Diagnoses with O.R. Procedure 16920.58 770 Abortion with D&C, Aspiration Curettage or Hysterotomy 5755.01 774 Vaginal Delivery with Complicating Diagnoses 5616.41 775 Vaginal Delivery without Complicating Diagnoses 4310.72 776 Postpartum and Postabortion Diagnoses without O.R. Procedure 5341.66 777 Ectopic Pregnancy 6074.05 778 Threatened Abortion 4053.20 779 Abortion without D&C 4355.83 780 False Labor 1873.23 781 Other Antepartum Diagnoses with Medical Complications 5584.42 782 Other Antepartum Diagnoses without Medical Complications 3890.81 789 Neonates, Died or Transferred to Another Acute Care Facility 12201.42 790 Extreme Immaturity or Respiratory Distress Syndrome, Neonate 40235.07 791 Prematurity with Major Problems 27479.23 792 Prematurity without Major Problems 16580.21 793 Full Term Neonate with Major Problems 28227.21 794 Neonate with Other Significant Problems 9990.28 795 Normal Newborn 1352.43 799 Splenectomy with MCC 40543.44 800 Splenectomy with CC 21220.64 801 Splenectomy without CC/MCC 12782.90 802 Other O.R. Procedures of the Blood and Blood-Forming Organs with MCC 29665.75 803 Other O.R. Procedures of the Blood and Blood-Forming Organs with CC 15504.99 804 Other O.R. Procedures of the Blood and Blood-Forming Organs without CC/MCC 8567.32 808 Major Hematologic/Immunologic Diagnoses Except Sickle Cell Crisis and Coagulation with MCC 17616.07 809 Major Hematologic/Immunologic Diagnoses Except Sickle Cell Crisis and Coagulation with CC 9801.65 810 Major Hematologic/Immunologic Diagnoses Except Sickle Cell Crisis and Coagulation without CC/MCC 7570.01 811 Red Blood Cell Disorders with MCC 10288.00 812 Red Blood Cell Disorders without MCC 6525.96 813 Coagulation Disorders 11787.24 814 Reticuloendothelial and Immunity Disorders with MCC 13475.93 815 Reticuloendothelial and Immunity Disorders with CC 8221.21 816 Reticuloendothelial and Immunity Disorders without CC/MCC 5591.80 820 Lymphoma and Leukemia with Major O.R. Procedure with MCC 46840.58 821 Lymphoma and Leukemia with Major O.R. Procedure with CC 19682.03 822 Lymphoma and Leukemia with Major O.R. Procedure without CC/MCC 10049.33 823 Lymphoma and Nonacute Leukemia with Other O.R. Procedure with MCC 37431.78 824 Lymphoma and Nonacute Leukemia with Other O.R. Procedure with CC 18908.63 825 Lymphoma and Nonacute Leukemia with Other O.R. Procedure without CC/MCC 10184.66 826 Myeloproliferative Disorders or Poorly Differentiated Neoplasms with Major O.R. Procedure with MCC 39913.57 827 Myeloproliferative Disorders or Poorly Differentiated Neoplasms with Major O.R. Procedure with CC 17599.66 828 Myeloproliferative Disorders or Poorly Differentiated Neoplasms with Major O.R. Procedure without 11368.14 CC/MCC 829 Myeloproliferative Disorders or Poorly Differentiated Neoplasms with Other O.R. Procedure with CC/MCC 22220.41 312 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
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 9002.00 834 Acute Leukemia without Major O.R. Procedure with MCC 40414.68 835 Acute Leukemia without Major O.R. Procedure with CC 19916.60 836 Acute Leukemia without Major O.R. Procedure without CC/MCC 9338.26 837 Chemotherapy with Acute Leukemia as Secondary Diagnosis or with High Dose Chemotherapy Agent with 54621.37 MCC 838 Chemotherapy with Acute Leukemia as Secondary Diagnosis with CC or High Dose Chemotherapy Agent 25775.77 839 Chemotherapy with Acute Leukemia as Secondary Diagnosis without CC/MCC 10516.82 840 Lymphoma and Nonacute Leukemia with MCC 24044.43 841 Lymphoma and Nonacute Leukemia with CC 13430.83 842 Lymphoma and Nonacute Leukemia without CC/MCC 8520.57 843 Other Myeloproliferative Disorders or Poorly Differentiated Neoplasm Diagnoses with MCC 15060.47 844 Other Myeloproliferative Disorders or Poorly Differentiated Neoplasm Diagnoses with CC 9792.63 845 Other Myeloproliferative Disorders or Poorly Differentiated Neoplasm Diagnoses without CC/MCC 6585.01 846 Chemotherapy without Acute Leukemia as Secondary Diagnosis with MCC 18011.38 847 Chemotherapy without Acute Leukemia as Secondary Diagnosis with CC 8086.71 848 Chemotherapy without Acute Leukemia as Secondary Diagnosis without CC/MCC 6625.20 849 Radiotherapy 10356.07 853 Infectious and Parasitic Diseases with O.R. Procedure with MCC 45302.79 854 Infectious and Parasitic Diseases with O.R. Procedure with CC 22868.33 855 Infectious and Parasitic Diseases with O.R. Procedure without CC/MCC 11315.65 856 Postoperative or Posttraumatic Infections with O.R. Procedure with MCC 42070.57 857 Postoperative or Posttraumatic Infections with O.R. Procedure with CC 17202.71 858 Postoperative or Posttraumatic Infections with O.R. Procedure without CC/MCC 10703.00 862 Postoperative and Posttraumatic Infections with MCC 16002.01 863 Postoperative and Posttraumatic Infections without MCC 8029.30 864 Fever 6787.59 865 Viral Illness with MCC 12836.21 866 Viral Illness without MCC 6119.98 867 Other Infectious and Parasitic Diseases Diagnoses with MCC 20264.34 868 Other Infectious and Parasitic Diseases Diagnoses with CC 9525.26 869 Other Infectious and Parasitic Diseases Diagnoses without CC/MCC 5910.84 870 Septicemia or Severe Sepsis with Mechanical Ventilation 96+ Hours 47819.02 871 Septicemia or Severe Sepsis without Mechanical Ventilation 96+ Hours with MCC 15643.60 872 Septicemia or Severe Sepsis without Mechanical Ventilation 96+ Hours without MCC 9468.67 876 O.R. Procedure with Principal Diagnoses of Mental Illness 23081.57 880 Acute Adjustment Reaction and Psychosocial Dysfunction 5052.96 881 Depressive Neuroses 5066.91 882 Neuroses Except Depressive 5147.28 883 Disorders of Personality and Impulse Control 8770.72 884 Organic Disturbances and Mental Retardation 7633.98 885 Psychoses 7415.00 886 Behavioral and Developmental Disorders 6481.67 887 Other Mental Disorder Diagnoses 6469.37 894 Alcohol/Drug Abuse or Dependence, Left Against Medical Advice 3341.30 895 Alcohol/Drug Abuse or Dependence with Rehabilitation Therapy 8427.07 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 313
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 11945.53 897 Alcohol/Drug Abuse or Dependence without Rehabilitation Therapy without MCC 5341.66 901 Wound Debridements for Injuries with MCC 32020.41 902 Wound Debridements for Injuries with CC 14698.78 903 Wound Debridements for Injuries without CC/MCC 8713.31 904 Skin Grafts for Injuries with CC/MCC 24059.19 905 Skin Grafts for Injuries without CC/MCC 9607.27 906 Hand Procedures for Injuries 8493.50 907 Other O.R. Procedures for Injuries with MCC 31385.62 908 Other O.R. Procedures for Injuries with CC 15788.77 909 Other O.R. Procedures for Injuries without CC/MCC 9476.05 913 Traumatic Injury with MCC 11026.14 914 Traumatic Injury without MCC 5736.15 915 Allergic Reactions with MCC 11688.82 916 Allergic Reactions without MCC 3991.68 917 Poisoning and Toxic Effects of Drugs with MCC 12194.03 918 Poisoning and Toxic Effects of Drugs without MCC 5141.54 919 Complications of Treatment with MCC 13042.89 920 Complications of Treatment with CC 8025.20 921 Complications of Treatment without CC/MCC 5098.07 922 Other Injury, Poisoning and Toxic Effect Diagnoses with MCC 11054.02 923 Other Injury, Poisoning and Toxic Effect Diagnoses without MCC 5583.60 927 Extensive Burns or Full Thickness Burns with Mechanical Ventilation 96+ Hours with Skin Graft 103873.20 928 Full Thickness Burn with Skin Graft or Inhalation Injury with CC/MCC 39140.98 929 Full Thickness Burn with Skin Graft or Inhalation Injury without CC/MCC 16859.89 933 Extensive Burns or Full Thickness Burns with Mechanical Ventilation 96+ Hours without Skin Graft 18026.14 934 Full Thickness Burn without Skin Graft or Inhalation Injury 11117.99 935 Nonextensive Burns 20873.25 939 O.R. Procedure with Diagnoses of Other Contact with Health Services with MCC 23540.03 940 O.R. Procedure with Diagnoses of Other Contact with Health Services with CC 13776.11 941 O.R. Procedure with Diagnoses of Other Contact with Health Services without CC/MCC 9396.49 945 Rehabilitation with CC/MCC 10493.86 946 Rehabilitation without CC/MCC 9245.58 947 Signs and Symptoms with MCC 8982.32 948 Signs and Symptoms without MCC 5630.35 949 Aftercare with CC/MCC 8206.45 950 Aftercare without CC/MCC 4133.57 951 Other Factors Influencing Health Status 5407.27 955 Craniotomy for Multiple Significant Trauma 45383.99 956 Limb Reattachment, Hip and Femur Procedures for Multiple Significant Trauma 27642.44 957 Other O.R. Procedures for Multiple Significant Trauma with MCC 51275.15 958 Other O.R. Procedures for Multiple Significant Trauma with CC 30913.21 959 Other O.R. Procedures for Multiple Significant Trauma without CC/MCC 19034.11 963 Other Multiple Significant Trauma with MCC 23065.16 964 Other Multiple Significant Trauma with CC 12221.10 965 Other Multiple Significant Trauma without CC/MCC 7697.96 314 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
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 45168.29 970 HIV with Extensive O.R. Procedure without MCC 21943.19 974 HIV with Major Related Condition with MCC 21200.13 975 HIV with Major Related Condition with CC 11186.89 976 HIV with Major Related Condition without CC/MCC 7360.87 977 HIV with or without Other Related Condition 8600.12 981 Extensive O.R. Procedure Unrelated to Principal Diagnosis with MCC 41527.63 982 Extensive O.R. Procedure Unrelated to Principal Diagnosis with CC 24114.14 983 Extensive O.R. Procedure Unrelated to Principal Diagnosis without CC/MCC 14571.66 984 Prostatic O.R. Procedure Unrelated to Principal Diagnosis with MCC 27263.53 985 Prostatic O.R. Procedure Unrelated to Principal Diagnosis with CC 17639.85 986 Prostatic O.R. Procedure Unrelated to Principal Diagnosis without CC/MCC 9136.50 987 Nonextensive O.R. Procedure Unrelated to Principal Diagnosis with MCC 28291.18 988 Nonextensive O.R. Procedure Unrelated to Principal Diagnosis with CC 15368.85 989 Nonextensive O.R. Procedure Unrelated to Principal Diagnosis without CC/MCC 8684.60 998 Principal Diagnosis Invalid as Discharge Diagnosis NA 999 Ungroupable NA Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 315
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 62.23 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: 62.23 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 62.23 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 62.23 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
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 70010-TC for technical component is $230.66 Maximum allowed rate = $230.66 + 10 percent ($23.07) = $253.73 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 44. 318 CPT only 2010 American Medical Association. All Rights Reserved.
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 03.01 REMOVAL OF FOREIGN BODY FROM SPINAL CANAL 9596.91 03.09 OTHER EXPLORATION&DECOMPRESSION OF SPINAL CANAL 9885.70 03.21 PERCUTANEOUS CHORDOTOMY 3153.37 03.31 SPINAL TAP 961.09 03.53 REPAIR OF VERTEBRAL FRACTURE 9331.50 03.6 LYSIS OF ADHESIONS OF SPINAL CORD&NERVE ROOTS 3030.61 03.8 INJECTION OF DESTRUCTIVE AGENT INTO SPINAL CANAL 2721.93 03.90 INSRT SPINAL CANAL CATH-INFUS THERAP/PALLIATIVE 7996.25 03.91 INJECTION ANESTHETIC INTO SPINAL CANAL ANALGESIA 1316.53 03.92 INJECTION OF OTHER AGENT INTO SPINAL CANAL 989.16 03.93 IMPL/REPLACEMENT SPINAL NEUROSTIMULATOR LEAD(S) 14885.26 03.94 REMOVAL OF SPINAL NEUROSTIMULATOR LEAD(S) 2972.14 03.95 SPINAL BLOOD PATCH 838.33 03.96 PERCUTANEOUS DENERVATION OF FACET 2007.54 03.97 REVISION OF SPINAL THECAL SHUNT 5761.89 03.99 OTH OP SPINAL CORD&SPINAL CANAL STRUCTURES 4230.22 04.02 DIVISION OF TRIGEMINAL NERVE 2064.83 04.07 OTH EXCISION/AVULSION CRANIAL&PERIPHERAL NERVES 4075.88 04.2 DESTRUCTION OF CRANIAL AND PERIPHERAL NERVES 2633.07 04.3 SUTURE OF CRANIAL AND PERIPHERAL NERVES 6215.54 04.43 RELEASE OF CARPAL TUNNEL 2997.87 04.44 RELEASE OF TARSAL TUNNEL 3752.01 04.49 OTH PERIPHERAL NERVE/GANG DECOMPRS/LYSIS ADHES 4862.76 04.5 CRANIAL OR PERIPHERAL NERVE GRAFT 10604.77 04.6 TRANSPOSITION OF CRANIAL AND PERIPHERAL NERVES 5381.90 04.75 REV PREVIOUS REPAIR CRANIAL&PERIPHERAL NERVES 4916.54 04.76 REPAIR OLD TRAUMATIC INJURY CRANIAL&PERIPH NERV 4372.87 04.79 OTHER NEUROPLASTY 2464.70 04.81 INJECTION ANESTHETIC INTO PERIPHERAL NERVE ANALG 1371.48 04.92 IMPL/REPL PERIPHERAL NEUROSTIMULATOR LEAD(S) 17746.33 05.29 OTHER SYMPATHECTOMY AND GANGLIONECTOMY 3407.09 05.31 INJECTION ANESTHETIC IN SYMPATHETIC NERVE ANALG 1162.20 05.39 OTHER INJECTION INTO SYMPATHETIC NERVE/GANGLION 3464.38 06.11 CLOSED BIOPSY OF THYROID GLAND 726.08 08.33 REPR BLEPHAROPTOSIS-RESECT/ADVANCE LEVATOR 5540.90 08.43 REPAIR ENTROPION OR ECTROPION W/WEDGE RESECTION 6167.60 08.44 REPAIR ENTROPION/ECTROPION W/LID RECONSTRUCTION 4130.83 08.59 OTHER ADJUSTMENT OF LID POSITION 8550.46 08.86 LOWER EYELID RHYTIDECTOMY 6186.31 08.89 OTHER EYELID REPAIR 4858.08 08.92 CRYOSURGICAL EPILATION OF EYELID 2898.48 09.83 CONJUNCTIVORHINOSTOMY W/INSERTION TUBE OR STENT 3357.98 11.51 SUTURE OF CORNEAL LACERATION 2738.29 11.64 OTHER PENETRATING KERATOPLASTY 8626.46 12.39 OTHER IRIDOPLASTY 16381.86 12.81 SUTURE OF LACERATION OF SCLERA 11533.13 MAR Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 319
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 12.84 EXCISION OR DESTRUCTION OF LESION OF SCLERA 1904.65 13.19 OTHER INTRACAPSULAR EXTRACTION OF LENS 3942.59 13.41 PHACOEMULSIFICATION AND ASPIRATION OF CATARACT 4267.63 13.42 MECH PHACOFRAGATION&ASPIR CATARACT POST ROUTE 4212.68 13.64 DISCISSION OF SECONDARY MEMBRANE 475.87 13.70 INSERTION OF PSEUDOPHAKOS NOS 4120.31 13.72 SEC INSERTION OF INTRAOCULAR LENS PROSTHESIS 2613.19 13.8 REMOVAL OF IMPLANTED LENS 5019.43 14.01 REMOVAL FB FROM POST SEGMENT EYE W/USE MAGNET 6168.78 14.24 DESTRUC CHORIORETINAL LESION LASER PHOTOCOAGULAT 10603.61 14.32 REPAIR OF RETINAL TEAR BY CRYOTHERAPY 4737.66 14.39 OTHER REPAIR OF RETINAL TEAR 14657.27 14.41 SCLERAL BUCKLING WITH IMPLANT 5357.34 14.49 OTHER SCLERAL BUCKLING 8276.87 14.74 OTHER MECHANICAL VITRECTOMY 6420.15 15.13 RESECTION OF ONE EXTRAOCULAR MUSCLE 3858.40 15.3 OP>=2 EXTRAOCCULAR MUSC W/TEMP DETACH-1/BOTH 3395.40 15.7 REPAIR OF INJURY OF EXTRAOCULAR MUSCLE 6936.95 16.72 REMOVAL OF ORBITAL IMPLANT 8825.23 16.82 REPAIR OF RUPTURE OF EYEBALL 4839.38 18.29 EXCISION/DESTRUCTION OTHER LESION EXTERNAL EAR 5187.80 19.11 STAPEDECTOMY WITH INCUS REPLACEMENT 10912.27 19.4 MYRINGOPLASTY 2360.64 19.52 TYPE II TYMPANOPLASTY 2229.69 19.53 TYPE III TYMPANOPLASTY 2468.22 19.9 OTHER REPAIR OF MIDDLE EAR 6650.49 20.1 REMOVAL OF TYMPANOSTOMY TUBE 1199.61 20.49 OTHER MASTOIDECTOMY 2588.64 21.32 LOCAL EXCISION OR DESTRUCTION OTHER LESION NOSE 7634.96 21.5 SUBMUCOUS RESECTION OF NASAL SEPTUM 3657.30 21.69 OTHER TURBINECTOMY 1792.40 21.71 CLOSED REDUCTION OF NASAL FRACTURE 3156.88 21.72 OPEN REDUCTION OF NASAL FRACTURE 4291.02 21.84 REVISION RHINOPLASTY 5322.26 21.86 LIMITED RHINOPLASTY 4190.46 21.87 OTHER RHINOPLASTY 6081.08 21.88 OTHER SEPTOPLASTY 4609.04 21.89 OTHER REPAIR AND PLASTIC OPERATIONS ON NOSE 10373.27 22.2 INTRANASAL ANTROTOMY 1705.89 22.52 SPHENOIDOTOMY 8204.38 22.63 ETHMOIDECTOMY 6657.51 27.43 OTHER EXCISION OF LESION OR TISSUE OF LIP 2096.40 30.09 OTHER EXCISION/DESTRUCTION LESION/TISSUE LARYNX 3322.91 33.27 CLOSED ENDOSCOPIC BIOPSY OF LUNG 2140.83 34.91 THORACENTESIS 496.92 37.89 REVISION OR REMOVAL OF PACEMAKER DEVICE 5159.75 320 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
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 38.03 INCISION OF UPPER LIMB VESSELS 5021.77 38.59 LIGATION&STRIPPING OF LOWER LIMB VARICOSE VEINS 4872.12 38.63 OTHER EXCISION OF UPPER LIMB VESSELS 2732.45 38.7 INTERRUPTION OF THE VENA CAVA 6829.38 38.83 OTHER SURGICAL OCCLUSION OF UPPER LIMB VESSELS 3499.46 38.89 OTHER SURGICAL OCCLUSION OF LOWER LIMB VEINS 7069.07 38.91 ARTERIAL CATHETERIZATION 3539.21 38.93 VENOUS CATHETERIZATION NOT ELSEWHERE CLASSIFIED 1638.07 39.49 OTHER REVISION OF VASCULAR PROCEDURE 7611.59 39.50 ANGIOPLASTY/ATHERECT OTH NON-CORONARY VESSEL(S) 12038.23 40.19 OTHER DIAGNOSTIC PROCEDURES LYMPHATIC STRUCTURES 1519.97 40.24 EXCISION OF INGUINAL LYMPH NODE 4305.04 42.92 DILATION OF ESOPHAGUS 1601.82 45.16 ESOPHAGOGASTRODUODENOSCOPY WITH CLOSED BIOPSY 1262.75 45.25 CLOSED [ENDOSCOPIC] BIOPSY OF LARGE INTESTINE 1205.46 46.85 DILATION OF INTESTINE 1308.35 49.12 ANAL FISTULECTOMY 1877.76 49.46 EXCISION OF HEMORRHOIDS 3188.45 50.0 HEPATOTOMY 3685.36 51.23 LAPAROSCOPIC CHOLECYSTECTOMY 5903.36 53.00 UNILATERAL REPAIR OF INGUINAL HERNIA NOS 4710.77 53.01 OTH & OPEN REPAIR OF DIRECT INGUINAL HERNIA 4641.78 53.02 OTHER & OPEN REPAIR OF INDIRECT INGUINAL HERNIA 4764.54 53.03 OTH & OPEN REP DIRECT ING HERNIA W/GRAFT/PROSTH 5090.76 53.04 OTH & OPN REP INDIRECT ING HERNIA W/GRAFT/PROSTH 5492.96 53.05 UNILAT REPAIR ING HERNIA W/GRAFT/PROSTHESIS NOS 5170.26 53.11 OTH & OPEN BILATERAL REP DIRECT INGUINAL HERNIA 5167.92 53.14 OTH & OPEN BILAT REP DIR ING HERNIA W/GRAFT/PROS 7233.92 53.15 OTH & OPEN BILAT REP INDIR ING HERNIA W/GFT/PROS 6855.10 53.16 OTH&OPEN BIL REP ING HERN 1 DIR&1 INDIR GFT/PROS 10870.18 53.17 BILAT ING HERNIA REPAIR W/GRAFT/PROSTHESIS NOS 7045.68 53.21 UNILAT REPAIR FEMORAL HERNIA W/GRAFT/PROSTHESIS 3691.21 53.29 OTHER UNILATERAL FEMORAL HERNIORRHAPHY 2369.99 53.41 OTH & OPEN REP UMBILICAL HERNIA W/GRAFT/PROSTH 6685.57 53.49 OTHER OPEN UMBILICAL HERNIORRHAPHY 4057.18 53.51 INCISIONAL HERNIA REPAIR 3024.76 53.59 REPAIR OTHER HERNIA ANTERIOR ABDOMINAL WALL 3624.56 53.61 OTH & OPEN INCISIONAL HERNIA REP W/GRAFT/PROSTH 5668.35 53.69 OTH & OPEN REP OTH HERN ANT ABD WALL W/GFT/PROS 8518.89 54.0 INCISION OF ABDOMINAL WALL 6124.34 54.59 OTHER LYSIS OF PERITONEAL ADHESIONS 7104.15 54.91 PERCUTANEOUS ABDOMINAL DRAINAGE 5039.31 57.0 TRANSURETHRAL CLEARANCE OF BLADDER 6006.25 58.1 URETHRAL MEATOTOMY 2537.19 58.5 RELEASE OF URETHRAL STRICTURE 3715.76 59.79 OTHER REPAIR OF URINARY STRESS INCONTINENCE 3363.83 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 321
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 3547.40 62.5 ORCHIOPEXY 2944.08 63.3 EXC OTH LESION/TISSUE SPERMATIC CORD&EPIDIDYMIS 3806.96 64.0 CIRCUMCISION 2240.21 64.96 REMOVAL OF INTERNAL PROSTHESIS OF PENIS 3660.81 64.97 INSERTION/REPLCMT INFLATABLE PENILE PROSTHESIS 23058.06 64.98 OTHER OPERATIONS ON PENIS 6789.62 68.23 ENDOMETRIAL ABLATION 4875.62 69.09 OTHER DILATION AND CURETTAGE OF UTERUS 4167.08 69.52 ASPIRATION CURETTAGE FOLLOWING DELIVERY/ABORTION 4681.53 76.5 TEMPOROMANDIBULAR ARTHROPLASTY 6129.02 76.64 OTHER ORTHOGNATHIC SURGERY ON MANDIBLE 8148.25 76.65 SEGMENTAL OSTEOPLASTY OF MAXILLA 3829.18 76.66 TOTAL OSTEOPLASTY OF MAXILLA 9911.43 76.72 OPEN REDUCTION OF MALAR AND ZYGOMATIC FRACTURE 5497.65 76.73 CLOSED REDUCTION OF MAXILLARY FRACTURE 7658.35 76.74 OPEN REDUCTION OF MAXILLARY FRACTURE 5302.38 76.76 OPEN REDUCTION OF MANDIBULAR FRACTURE 9600.41 76.79 OTHER OPEN REDUCTION OF FACIAL FRACTURE 7551.95 76.91 BONE GRAFT TO FACIAL BONE 6662.18 76.97 REMOVAL INTERNAL FIXATION DEVICE FROM FCE BONE 4876.79 76.99 OTHER OPERATIONS ON FACIAL BONES AND JOINTS 9525.59 77.07 SEQUESTRECTOMY OF TIBIA AND FIBULA 4939.93 77.13 OTHER INCISION OF RADIUS&ULNA WITHOUT DIVISION 4514.33 77.15 OTHER INCISION OF FEMUR WITHOUT DIVISION 5697.58 77.28 WEDGE OSTEOTOMY OF TARSALS AND METATARSALS 2926.54 77.33 OTHER DIVISION OF RADIUS AND ULNA 7862.96 77.34 OTHER DIVISION OF CARPALS AND METACARPALS 4963.31 77.37 OTHER DIVISION OF TIBIA AND FIBULA 7658.35 77.38 OTHER DIVISION OF TARSALS AND METATARSALS 19601.87 77.49 BIOPSY OF OTHER BONE EXCEPT FACIAL BONES 30025.41 77.53 OTHER BUNIONECTOMY WITH SOFT TISSUE CORRECTION 6321.94 77.58 OTHER EXCISION FUSION AND REPAIR OF TOES 8268.68 77.61 LOCAL EXCISION LESION/TISSUE SCAPULA CLAV&THORAX 3380.20 77.63 LOCAL EXCISION LESION OR TISSUE RADIUS&ULNA 2890.29 77.64 LOCAL EXCISION LESION/TISSUE CARPALS&METACARPALS 2156.03 77.65 LOCAL EXCISION OF LESION OR TISSUE OF FEMUR 5865.95 77.66 LOCAL EXCISION OF LESION OR TISSUE OF PATELLA 15580.94 77.67 LOCAL EXCISION LESION OR TISSUE TIBIA&FIBULA 6456.40 77.68 LOCAL EXCISION LESION/TISSUE TARSALS&METATARSALS 4426.64 77.69 LOCAL EXCISION LESION/TISSUE OTH BONE NO FCE BNS 4103.94 77.79 EXCISION OF OTHER BONE GRAFT EXCEPT FACIAL BONES 9713.83 77.81 OTHER PARTIAL OSTECTOMY SCAPULA CLAVICLE&THORAX 6728.83 77.82 OTHER PARTIAL OSTECTOMY OF HUMERUS 3669.00 77.83 OTHER PARTIAL OSTECTOMY OF RADIUS AND ULNA 5436.85 77.84 OTHER PARTIAL OSTECTOMY OF CARPALS&METACARPALS 8585.54 322 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
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 77.86 OTHER PARTIAL OSTECTOMY OF PATELLA 4276.99 77.88 OTHER PARTIAL OSTECTOMY OF TARSALS&METATARSALS 3173.25 77.89 OTH PARTIAL OSTECTOMY OTH BONE EXCEPT FACIAL BNS 2651.78 77.94 TOTAL OSTECTOMY OF CARPALS AND METACARPALS 4709.59 77.98 TOTAL OSTECTOMY OF TARSALS AND METATARSALS 3353.31 77.99 TOTAL OSTECTOMY OTHER BONE EXCEPT FACIAL BONES 3976.50 78.03 BONE GRAFT OF RADIUS AND ULNA 12086.17 78.04 BONE GRAFT OF CARPALS AND METACARPALS 3656.14 78.07 BONE GRAFT OF TIBIA AND FIBULA 10114.87 78.09 BONE GRAFT OF OTHER BONE EXCEPT FACIAL BONES 7665.36 78.13 APPLICATION OF EXTERNAL FIXATOR DEVC RADIUS&ULNA 3633.91 78.17 APPLICATION EXTERNAL FIXATOR DEVC TIBIA&FIBULA 2196.95 78.19 APPLICATION OF EXTERNAL FIXATOR DEVICE OTHER 4088.74 78.23 LIMB SHORTENING PROCEDURES RADIUS AND ULNA 11434.91 78.33 LIMB LENGTHENING PROCEDURES RADIUS AND ULNA 6272.83 78.43 OTHER REPAIR OR PLASTIC OPERATIONS RADIUS&ULNA 5257.96 78.47 OTHER REPAIR OR PLASTIC OPERATIONS TIBIA&FIBULA 12594.77 78.49 OTH REPAIR/PLASTIC OP OTH BONE NO FCE BNS 2810.79 78.51 INTRL FIX SCAPULA CLAV&THOR W/O FRACTURE RDUC 10034.19 78.52 INTERNAL FIX HUMERUS WITHOUT FRACTURE REDUCTION 11325.01 78.54 INTRL FIX CARPALS&MCS WITHOUT FRACTURE REDUCTION 5137.52 78.55 INTERNAL FIXATION FEM WITHOUT FRACTURE REDUCTION 6084.59 78.57 INTRL FIX TIBIA&FIB WITHOUT FRACTURE REDUCTION 7739.03 78.58 INTRL FIX TARSALS&MTS WITHOUT FRACTURE REDUCTION 5557.27 78.59 INTRL FIX OTH BONE NO FCE BNS W/O FRACTURE RDUC 10374.43 78.61 REMOVAL IMPL DEVICE FROM SCAPULA CLAV&THORAX 5779.43 78.62 REMOVAL OF IMPLANTED DEVICE FROM HUMERUS 5632.10 78.63 REMOVAL OF IMPLANTED DEVICE FROM RADIUS AND ULNA 3476.07 78.64 REMOVAL IMPL DEVICE FROM CARPALS&METACARPALS 3614.04 78.65 REMOVAL OF IMPLANTED DEVICE FROM FEMUR 4648.79 78.66 REMOVAL OF IMPLANTED DEVICE FROM PATELLA 3818.65 78.67 REMOVAL OF IMPLANTED DEVICE FROM TIBIA&FIBULA 4383.38 78.68 REMOVAL IMPLANTED DEVICE FROM TARSAL&METATARSALS 4009.24 78.69 REMOVAL OF IMPLANTED DEVICE FROM OTHER BONE 4179.94 78.75 OSTEOCLASIS OF FEMUR 5760.71 78.77 OSTEOCLASIS OF TIBIA AND FIBULA 4351.82 79.02 CLOS RDUC FRACTURE RADIUS&ULNA WITHOUT INTRL FIX 5302.38 79.04 CLOS RDUC FRACTURE PHALANG HAND W/O INTRL FIX 3499.46 79.06 CLOS RDUC FRACTURE TIBIA&FIB WITHOUT INTRL FIX 2428.45 79.11 CLOS REDUCTION FRACTURE HUMERUS W/INTERNAL FIX 6596.71 79.12 CLOS REDUCTION FRACTURE RADIUS&ULNA W/INTRL FIX 3965.98 79.13 CLOS REDUCTION FRACTURE CARPALS&MCS W/INTRL FIX 2828.33 79.14 CLOS REDUCTION FRACTURE PHALANG HAND W/INTRL FIX 2948.76 79.16 CLOS REDUCTION FRACTURE TIBIA&FIB W/INTERNAL FIX 7687.58 79.17 CLOS REDUCTION FRACTURE TARSALS&MTS W/INTRL FIX 5062.70 79.21 OPEN REDUCTION FRACTURE HUM WITHOUT INTERNAL FIX 7802.16 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 323
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 79.22 OPEN RDUC FRACTURE RADIUS&ULNA WITHOUT INTRL FIX 9738.39 79.24 OPEN RDUC FRACTURE PHALANG HAND W/O INTRL FIX 1991.17 79.27 OPEN RDUC FRACTURE TARSALS&MTS WITHOUT INTRL FIX 3715.76 79.29 OPN RED FX OTH SPEC BONE EXP FCE BNS W/O INT FIX 3810.46 79.31 OPEN REDUCTION FRACTURE HUMERUS W/INTERNAL FIX 11017.50 79.32 OPEN REDUCTION FRACTURE RADIUS&ULNA W/INTRL FIX 7175.47 79.33 OPEN REDUCTION FRACTURE CARPALS&MCS W/INTRL FIX 4851.07 79.34 OPEN REDUCTION FRACTURE PHALANG HAND W/INTRL FIX 4246.59 79.35 OPEN REDUCTION FRACTURE FEM W/INTERNAL FIXATION 10776.65 79.36 OPEN REDUCTION FRACTURE TIBIA&FIB W/INTERNAL FIX 6138.38 79.37 OPEN REDUCTION FRACTURE TARSALS&MTS W/INTRL FIX 6779.11 79.38 OPEN REDUCTION FRACTURE PHALANGES FT W/INTRL FIX 3968.31 79.39 OPN RED FX OTH SPEC BONE EXP FACE BNS W/INT FIX 6438.87 79.63 DEBRIDEMENT OPEN FRACTURE CARPALS&METACARPALS 2748.82 79.64 DEBRIDEMENT OPEN FRACTURE PHALANGES HAND 3919.20 79.66 DEBRIDEMENT OF OPEN FRACTURE OF TIBIA AND FIBULA 4948.11 79.71 CLOSED REDUCTION OF DISLOCATION OF SHOULDER 3956.62 79.72 CLOSED REDUCTION OF DISLOCATION OF ELBOW 1458.01 79.74 CLOSED REDUCTION OF DISLOCATION OF HAND&FINGER 1883.60 79.81 OPEN REDUCTION OF DISLOCATION OF SHOULDER 7043.35 79.84 OPEN REDUCTION OF DISLOCATION OF HAND AND FINGER 5019.43 79.87 OPEN REDUCTION OF DISLOCATION OF ANKLE 3038.78 79.88 OPEN REDUCTION OF DISLOCATION OF FOOT AND TOE 12226.47 80.04 ARTHRTMY REMVAL OF PROSTH W/O RPLCE HAND&FINGER 5367.86 80.11 OTHER ARTHROTOMY OF SHOULDER 7352.02 80.12 OTHER ARTHROTOMY OF ELBOW 5828.53 80.13 OTHER ARTHROTOMY OF WRIST 1979.48 80.14 OTHER ARTHROTOMY OF HAND AND FINGER 2029.75 80.16 OTHER ARTHROTOMY OF KNEE 4787.93 80.17 OTHER ARTHROTOMY OF ANKLE 6658.67 80.21 ARTHROSCOPY OF SHOULDER 7117.01 80.22 ARTHROSCOPY OF ELBOW 8490.83 80.23 ARTHROSCOPY OF WRIST 4761.04 80.26 ARTHROSCOPY OF KNEE 5211.18 80.27 ARTHROSCOPY OF ANKLE 4073.54 80.35 BIOPSY OF JOINT STRUCTURE OF HIP 558.88 80.36 BIOPSY OF JOINT STRUCTURE OF KNEE 2977.98 80.41 DIVISION JOINT CAPSULE LIGAMENT/CART SHOULDER 5899.85 80.42 DIVISION JOINT CAPSULE LIGAMENT/CARTILAGE ELBOW 5384.23 80.44 DIVISION JOINT CAPSULE LIGAMENT/CART HAND&FINGER 4928.23 80.46 DIVISION JOINT CAPSULE LIGAMENT/CARTILAGE KNEE 4832.36 80.47 DIVISION JOINT CAPSULE LIGAMENT/CARTILAGE ANKLE 5760.71 80.48 DIVISION JOINT CAPSULE LIGAMENT/CART FOOT&TOE 3911.02 80.51 EXCISION OF INTERVERTEBRAL DISC 8737.53 80.59 OTHER DESTRUCTION OF INTERVERTEBRAL DISC 5372.54 80.6 EXCISION OF SEMILUNAR CARTILAGE OF KNEE 4743.51 324 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
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 80.72 SYNOVECTOMY OF ELBOW 3921.54 80.73 SYNOVECTOMY OF WRIST 5153.90 80.74 SYNOVECTOMY OF HAND AND FINGER 3753.17 80.76 SYNOVECTOMY OF KNEE 4745.84 80.77 SYNOVECTOMY OF ANKLE 5153.90 80.81 OTH LOCAL EXCISION/DESTRUC LESION SHOULDER JOINT 6872.64 80.82 OTH LOCAL EXCISION/DESTRUC LESION ELBOW JOINT 5407.61 80.83 OTH LOCAL EXCISION/DESTRUC LESION WRIST JOINT 5373.71 80.84 OTH LOCAL EXC/DESTRUC LESION JOINT HAND&FINGER 3264.45 80.85 OTH LOCAL EXCISION/DESTRUCTION LESION HIP JOINT 9830.75 80.86 OTH LOCAL EXCISION/DESTRUCTION LESION KNEE JOINT 5436.85 80.87 OTH LOCAL EXCISION/DESTRUCTION LESION ANK JOINT 4983.19 80.88 OTH LOCAL EXCISION/DESTRUC LESION JOINT FOOT&TOE 8729.36 80.91 OTHER EXCISION OF SHOULDER JOINT 5786.44 80.92 OTHER EXCISION OF ELBOW JOINT 4424.30 80.94 OTHER EXCISION OF JOINT OF HAND AND FINGER 4680.37 81.02 OTH CERVICAL FUSION ANT COLUMN ANT TECHNIQUE 15644.08 81.03 OTH CERVICAL FUSION POST COLUMN POST TECHNIQUE 13168.86 81.06 LUMBAR LUMBOSACRAL FUSION ANT COLUMN ANT TECH 58194.12 81.08 LUMBAR LUMBOSACRAL FUSION ANT COLUMN POST TECH 31472.90 81.11 ANKLE FUSION 19826.35 81.13 SUBTALAR FUSION 13027.38 81.14 MIDTARSAL FUSION 11733.06 81.16 METATARSOPHALANGEAL FUSION 8161.12 81.25 CARPORADIAL FUSION 6678.54 81.26 METACARPOCARPAL FUSION 7558.96 81.27 METACARPOPHALANGEAL FUSION 2851.72 81.28 INTERPHALANGEAL FUSION 5930.25 81.29 ARTHRODESIS OF OTHER SPECIFIED JOINT 7401.12 81.32 REFUSION OTH C-SPINE ANTERIOR COLUMN ANT TECH 18139.18 81.33 REFUSION OTH C-SPINE POSTERIOR COLUMN POST TECH 10667.91 81.40 REPAIR OF HIP NOT ELSEWHERE CLASSIFIED 11956.38 81.43 TRIAD KNEE REPAIR 5732.65 81.44 PATELLAR STABILIZATION 6969.68 81.45 OTHER REPAIR OF THE CRUCIATE LIGAMENTS 10002.63 81.46 OTHER REPAIR OF THE COLLATERAL LIGAMENTS 6610.73 81.47 OTHER REPAIR OF KNEE 5909.20 81.49 OTHER REPAIR OF ANKLE 6959.16 81.71 ARTHPLSTY METACARPOPHALANGEAL&IP JOINT W/IMPLANT 11403.34 81.72 ARTHPLSTY MCP&IP JOINT WITHOUT IMPLANT 3633.91 81.74 ARTHRPLSTY CARPOCARPAL/CMC JOINT WITH IMPLANT 4883.81 81.75 ARTHRPLSTY CARPOCARPAL/CMC JOINT WITHOUT IMPLANT 5180.78 81.79 OTHER REPAIR OF HAND FINGERS AND WRIST 5758.38 81.81 PARTIAL SHOULDER REPLACEMENT 13477.53 81.82 REPAIR OF RECURRENT DISLOCATION OF SHOULDER 7681.74 81.83 OTHER REPAIR OF SHOULDER 7571.82 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 325
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 81.84 TOTAL ELBOW REPLACEMENT 10311.29 81.85 OTHER REPAIR OF ELBOW 8154.10 81.91 ARTHROCENTESIS 1311.86 81.92 INJ THERAPEUTIC SUBSTANCE IN JOINT/LIGAMENT 1058.14 81.93 SUTURE OF CAPSULE OR LIGAMENT OF UPPER EXTREMITY 7443.21 81.94 SUTURE OF CAPSULE OR LIGAMENT OF ANKLE AND FOOT 3285.50 81.95 SUTURE CAPSULE OR LIGAMENT OTHER LOWER EXTREMITY 8245.29 81.96 OTHER REPAIR OF JOINT 5764.22 81.97 REVISION OF JOINT REPLACEMENT OF UPPER EXTREMITY 4613.72 82.01 EXPLORATION OF TENDON SHEATH OF HAND 2628.39 82.02 MYOTOMY OF HAND 3902.84 82.09 OTHER INCISION OF SOFT TISSUE OF HAND 3118.30 82.11 TENOTOMY OF HAND 3933.24 82.19 OTHER DIVISION OF SOFT TISSUE OF HAND 8013.79 82.21 EXCISION OF LESION OF TENDON SHEATH OF HAND 3020.08 82.29 EXCISION OF OTHER LESION OF SOFT TISSUE OF HAND 1407.73 82.33 OTHER TENONECTOMY OF HAND 2854.06 82.35 OTHER FASCIECTOMY OF HAND 3356.81 82.36 OTHER MYECTOMY OF HAND 6067.05 82.42 DELAYED SUTURE OF FLEXOR TENDON OF HAND 5683.55 82.43 DELAYED SUTURE OF OTHER TENDON OF HAND 2392.22 82.44 OTHER SUTURE OF FLEXOR TENDON OF HAND 4971.50 82.45 OTHER SUTURE OF OTHER TENDON OF HAND 3231.71 82.56 OTHER HAND TENDON TRANSFER OR TRANSPLANTATION 3425.80 82.57 OTHER HAND TENDON TRANSPOSITION 4134.34 82.71 TENDON PULLEY RECONSTRUCTION ON HAND 6426.00 82.79 PLASTIC OPERATION HAND W/OTHER GRAFT OR IMPLANT 7085.43 82.84 REPAIR OF MALLET FINGER 2360.64 82.85 OTHER TENODESIS OF HAND 5157.41 82.86 OTHER TENOPLASTY OF HAND 3173.25 82.91 LYSIS OF ADHESIONS OF HAND 4462.89 83.01 EXPLORATION OF TENDON SHEATH 3960.13 83.02 MYOTOMY 3898.16 83.03 BURSOTOMY 4091.08 83.09 OTHER INCISION OF SOFT TISSUE 3431.65 83.13 OTHER TENOTOMY 5017.10 83.14 FASCIOTOMY 3858.40 83.19 OTHER DIVISION OF SOFT TISSUE 8625.29 83.21 OPEN BIOPSY OF SOFT TISSUE 3499.46 83.31 EXCISION OF LESION OF TENDON SHEATH 3939.08 83.39 EXCISION OF LESION OF OTHER SOFT TISSUE 4676.86 83.42 OTHER TENONECTOMY 4050.15 83.44 OTHER FASCIECTOMY 2858.73 83.45 OTHER MYECTOMY 1410.07 83.5 BURSECTOMY 4558.77 83.61 SUTURE OF TENDON SHEATH 5271.98 326 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
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 83.62 DELAYED SUTURE OF TENDON 4068.86 83.63 ROTATOR CUFF REPAIR 7431.52 83.64 OTHER SUTURE OF TENDON 5069.71 83.65 OTHER SUTURE OF MUSCLE OR FASCIA 4488.62 83.71 ADVANCEMENT OF TENDON 3948.44 83.73 REATTACHMENT OF TENDON 4825.34 83.75 TENDON TRANSFER OR TRANSPLANTATION 5570.14 83.81 TENDON GRAFT 9536.11 83.83 TENDON PULLEY RECONSTRUCT MUSCLE TENDON&FASCIA 4547.07 83.85 OTHER CHANGE IN MUSCLE OR TENDON LENGTH 5240.42 83.86 QUADRICEPSPLASTY 5557.27 83.87 OTHER PLASTIC OPERATIONS ON MUSCLE 5422.81 83.88 OTHER PLASTIC OPERATIONS ON TENDON 6297.39 83.91 LYSIS OF ADHESIONS OF MUSCLE TENDON FASCIA&BURSA 5043.98 83.98 INJ LOCLY ACTING TX SBSTNC IN OTH SFT TISSUE 354.28 84.01 AMPUTATION AND DISARTICULATION OF FINGER 3705.24 84.02 AMPUTATION AND DISARTICULATION OF THUMB 4312.06 84.11 AMPUTATION OF TOE 3350.97 84.22 FINGER REATTACHMENT 4372.87 84.3 REVISION OF AMPUTATION STUMP 2973.31 85.11 CLOSED BIOPSY OF BREAST 2140.83 85.12 OPEN BIOPSY OF BREAST 2629.57 85.21 LOCAL EXCISION OF LESION OF BREAST 2952.27 86.01 ASPIRATION OF SKIN AND SUBCUTANEOUS TISSUE 3893.49 86.02 INJECTION OR TATTOOING OF SKIN LESION OR DEFECT 4317.90 86.04 OTH INCISION W/DRAINAGE SKIN&SUBCUTANEOUS TISSUE 2820.14 86.05 INCI W/REMOVAL FB/DEVICE FROM SKIN & SUBQ TISSUE 2666.98 86.06 INSERTION OF TOTALLY IMPLANTABLE INFUSION PUMP 19183.29 86.11 CLOSED BIOPSY OF SKIN AND SUBCUTANEOUS TISSUE 285.29 86.22 EXCISIONAL DEBRIDEMENT WOUND INFECTION OR BURN 1410.07 86.23 REMOVAL OF NAIL NAILBED OR NAIL FOLD 2876.27 86.24 CHEMOSURGERY OF SKIN 1419.42 86.25 DERMABRASION 11282.91 86.28 NONEXCISIONAL DEBRIDEMENT WOUND INFECTION/BURN 1211.31 86.4 RADICAL EXCISION OF SKIN LESION 5330.45 86.59 CLOSURE SKIN&SUBCUTANEOUS TISSUE OTHER SITES 2657.62 86.61 FULL-THICKNESS SKIN GRAFT TO HAND 4810.14 86.62 OTHER SKIN GRAFT TO HAND 4178.77 86.63 FULL-THICKNESS SKIN GRAFT TO OTHER SITES 4446.52 86.65 HETEROGRAFT TO SKIN 790.39 86.66 HOMOGRAFT TO SKIN 3522.84 86.67 DERMAL REGENERATIVE GRAFT 7689.92 86.69 OTHER SKIN GRAFT TO OTHER SITES 4286.34 86.71 CUTTING&PREPARATION OF PEDICLE GRAFTS OR FLAPS 3632.75 86.72 ADVANCEMENT OF PEDICLE GRAFT 2414.43 86.73 ATTACHMENT OF PEDICLE OR FLAP GRAFT TO HAND 4068.86 Fee data 2011 Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 327
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 86.74 ATTACHMENT PEDICLE OR FLAP GRAFT TO OTHER SITES 5648.47 86.75 REVISION OF PEDICLE OR FLAP GRAFT 2218.00 86.84 RELAXATION OF SCAR OR WEB CONTRACTURE OF SKIN 4841.72 86.86 ONYCHOPLASTY 3576.62 86.89 OTH REPAIR&RECONSTRUCT SKIN&SUBCUTANEOUS TISSUE 4136.68 86.93 INSERTION OF TISSUE EXPANDER 7727.34 328 CPT only 2010 American Medical Association. All Rights Reserved. Fee data 2011 Ingenix
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
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 44 330 CPT only 2010 American Medical Association. All Rights Reserved.