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<strong>The</strong><br />
GEORGIA<br />
WORKERS' COMPENSATION<br />
<strong>MEDICAL</strong> <strong>FEE</strong> <strong>SCHEDULE</strong><br />
Effective 04/01/2011<br />
FOR SERVICES PROVIDED UNDER THE GEORGIA WORKERS' COMPENSATION LAW<br />
Adopted by:<br />
State Board of Workers' Compensation<br />
270 Peachtree Street, NW<br />
Atlanta, <strong>Georgia</strong> 30303-1299<br />
http: // www.sbwc.georgia.gov
COPYRIGHT<br />
All fee schedule amounts are copyright 2011 State of <strong>Georgia</strong>.<br />
<strong>The</strong> Current Procedural Terminology (CPT) five-digit numeric codes, descriptions, and two-digit numeric modifiers<br />
representing physician, anesthesiology, and other medical services are the 2011 edition as produced or copyright<br />
2010 by the American Medical Association.<br />
AMERICAN <strong>MEDICAL</strong> ASSOCIATION NOTICE<br />
CPT codes, descriptions and other material only copyright 2010 American Medical Association. All Rights Reserved.<br />
No fee schedules, basic units, relative values or related listings are included in CPT. AMA does not directly or<br />
indirectly practice medicine or dispense medical services. AMA assumes no liability for data contained or not<br />
contained herein.<br />
STATE OF GEORGIA DISCLAIMER<br />
This document establishes professional medical fee reimbursement amounts for covered services rendered to injured<br />
employees in the state of <strong>Georgia</strong> and provides general guidelines for the appropriate coding and administration of<br />
workers’ medical claims. Generally, the reimbursement guidelines are in accordance with, and recommended<br />
adherence to, the commercial guidelines established by the AMA according to CPT 2011 codes. However, certain<br />
exceptions to these general rules are proscribed in this document. Providers and payors are instructed to adhere to<br />
any and all special rules that follow.<br />
PUBLISHER’S NOTICE<br />
<strong>The</strong> <strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule is designed to be an accurate and authoritative source of<br />
information about medical coding and reimbursement. Every reasonable effort has been made to verify its accuracy,<br />
and all information is believed reliable at the time of publication. Absolute accuracy, however, cannot be guaranteed.<br />
Ingenix worked closely with the <strong>Georgia</strong> State Board of Workers’ Compensation in the development, formatting, and<br />
production of this fee schedule. However, all decisions resulting in the final content of this schedule were made solely<br />
by the <strong>Georgia</strong> State Board of Workers’ Compensation.<br />
This publication is made available with the understanding that the publisher is not engaged in rendering legal and<br />
other services that require a professional license. For additional copies of this publication or other fee schedules,<br />
please call 1.800.INGENIX (464.3649).<br />
OUR COMMITMENT TO ACCURACY<br />
Ingenix is committed to producing accurate and reliable materials.<br />
To report corrections, please visit www.shopingenix.com/accuracy or email accuracy@ingenix.com. You can also<br />
reach customer service by calling 1.800.INGENIX (464.3649), option 1.<br />
Questions concerning the application of the schedules of medical and hospital fees should be addressed to:<br />
<strong>Georgia</strong> State Board of Workers’ Compensation • 270 Peachtree Street, NW • Atlanta, GA 30303-1299<br />
404.656.3875 • 1.800.533.0682<br />
Ingenix<br />
1.800.INGENIX (464.3649)
Contents<br />
Section I: Background................................................................ 1<br />
Format of the Fee Schedule ............................................ 1<br />
Section II: Effective Date ........................................................... 3<br />
Section III: Introduction to the Fee Schedules...................... 5<br />
Subsection A: Introduction to the Physician Portion<br />
of the Fee Schedule...................................................... 5<br />
Subsection B: Introduction to the Transportation<br />
Portion of the Fee Schedule ......................................... 6<br />
Subsection C: Introduction to the Inpatient <strong>Hospital</strong><br />
Portion of the Fee Schedule ......................................... 6<br />
Subsection D: Introduction to the Outpatient<br />
Surgery/ASC Portion of the Fee Schedule..................... 6<br />
Section IV: General Reimbursement Requirements ............. 7<br />
Considerations for Reimbursement................................. 7<br />
Special Rules and Limitations ......................................... 9<br />
Overview ...................................................................... 15<br />
Section V: Evaluation and Management (E/M) Services... 17<br />
Subsection A: Payment Ground Rules for E/M<br />
Category ................................................................... 17<br />
Subsection B: Payment Modifiers for E/M Category ...... 21<br />
Section VI: Anesthesia Services ........................................... 27<br />
Subsection A: Payment Ground Rules for Anesthesia<br />
Services...................................................................... 27<br />
Subsection B: Payment Modifiers for<br />
Anesthesia Services .................................................... 30<br />
Section VII: Surgical Services .............................................. 41<br />
Subsection A: Payment Ground Rules for Surgical<br />
Services...................................................................... 41<br />
Subsection B: Payment Modifiers for Surgical<br />
Services...................................................................... 45<br />
Section VIII: Diagnostic and <strong>The</strong>rapeutic Radiological<br />
Services............................................................................ 171<br />
Subsection A: Payment Ground Rules for Diagnostic<br />
and <strong>The</strong>rapeutic Radiological Services ..................... 171<br />
Subsection B: Payment Modifiers for Diagnostic and<br />
<strong>The</strong>rapeutic Radiological Services ............................ 172<br />
Section IX: Pathology and Laboratory Services ............... 219<br />
Subsection A: Payment Ground Rules for Pathology<br />
and Laboratory Services............................................219<br />
Subsection B: Payment Modifiers for Pathology and<br />
Laboratory Services...................................................220<br />
Section X: General Medicine Services............................... 253<br />
Subsection A: Payment Ground Rules for General<br />
Medicine Services .....................................................253<br />
Subsection B: Payment Modifiers for General Medicine<br />
Services ....................................................................254<br />
Section XI: Physical Medicine Services ............................ 285<br />
Subsection A: Payment Ground Rules for Physical<br />
Medicine Services .....................................................285<br />
Subsection B: Payment Modifiers for Physical<br />
Medicine Services .....................................................287<br />
Section XII: Home Health Services...................................... 291<br />
Section XIII: Transportation .................................................. 293<br />
Subsection A: Non-Emergency Services.......................293<br />
Subsection B: Ambulance and Air Services .................295<br />
Section XIV: Inpatient <strong>Hospital</strong> Payment Schedule.......... 297<br />
Inpatient Reimbursement Methodology.......................297<br />
Implants, Durable Medical Equipment (DME),<br />
and Supplies.............................................................297<br />
Payment For Outliers ..................................................297<br />
MS-DRG Exempt <strong>Hospital</strong>s..........................................298<br />
Disputed Medical Charges ...........................................298<br />
Section XV: Outpatient Surgery Payment Schedule ......... 317<br />
Surgical Services Provided by Outpatient <strong>Hospital</strong><br />
and Ambulatory Surgery Centers..............................317<br />
Implants, DME, and Supplies ......................................318<br />
Nonsurgical Radiology Services ...................................318<br />
Physical <strong>The</strong>rapy Services............................................318<br />
Modifiers .....................................................................318<br />
Other Billing and Payment Requirements ....................318<br />
Index .......................................................................................... 329
Section I: Background<br />
<strong>The</strong> <strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule has<br />
been prepared to establish maximum fee amounts and<br />
uniform payment guidelines for reimbursing medical<br />
providers for the treatment of injured employees subject to<br />
the authority of the <strong>Georgia</strong> State Board of Workers’<br />
Compensation. This fee schedule completely replaces the<br />
previous fee schedule for medical providers’ services in the<br />
2010 version of <strong>The</strong> <strong>Georgia</strong> Workers’ Compensation Medical<br />
Fee Schedule. All rules stated herein are pursuant to Official<br />
Code of <strong>Georgia</strong> Annotated (O.C.G.A.) §34-9 et seq.<br />
<strong>The</strong> fee schedule has been prepared in accordance with the<br />
statutes and regulations established by the State of <strong>Georgia</strong>.<br />
In accordance with such statutes and regulations, the fee amounts<br />
included herein are deemed to represent usual, customary, and<br />
reasonable reimbursement amounts for the specific services<br />
rendered.<br />
Employers, insurance carriers, self-insurers, or other payors<br />
shall use these rules for the purpose of approving and<br />
reimbursing medical charges submitted by physicians,<br />
hospitals, ambulatory surgical centers, or other medical<br />
providers for services performed in the treatment of<br />
work-related injuries or illnesses.<br />
<strong>The</strong> physician portion of the fee schedule includes fee<br />
amounts for specific medical services and procedures as<br />
identified using CPT numeric identifying codes and<br />
modifiers for reporting medical services and procedures as<br />
established by the 2011 Current Procedural Terminology<br />
(CPT), copyrighted by the American Medical Association<br />
(AMA). Any use or interpretation of CPT service descriptions<br />
not specifically described herein shall be based on CPT 2011.<br />
<strong>The</strong> transportation portion of the fee schedule includes<br />
maximum allowable rates for non-emergency transportation<br />
services. Non-emergency services are based on state-specific<br />
codes used only for workers' compensation billing purposes.<br />
Reimbursement for ambulance and air transportation is<br />
determined using the appropriate calculations for urban and<br />
rural base rate and mileage found in the Ambulance and Air<br />
Services subsection of the Transportation chapter.<br />
Ambulance and air transportation services are reported with<br />
HCPCS codes.<br />
<strong>The</strong> hospital inpatient/outpatient surgery portion of the fee<br />
schedule includes fee amounts for specific medical services<br />
and procedures as identified using International<br />
Classification of Diseases, Ninth Revision, Clinical<br />
Modification (ICD-9-CM), volume 3, and Medicare severity<br />
diagnosis-related group (MS-DRG) numeric identifying<br />
codes. ICD-9-CM, volume 3, used for reporting the facility<br />
component of medical services and procedures, is<br />
maintained and updated by four cooperating parties: the<br />
American <strong>Hospital</strong> Association (AHA), the Centers for<br />
Medicare and Medicaid Services (CMS), the National Center<br />
for Health Statistics (NCHS), and the American Health<br />
Information Management Association (AHIMA). MS-DRGs<br />
used for reimbursement of inpatient hospital services are<br />
developed and updated annually by CMS.<br />
This fee schedule has been updated to contain the complete<br />
and most current listing of CPT descriptive terms and<br />
numeric identifying codes and modifiers for reporting<br />
medical services and procedures, MS-DRG descriptive terms<br />
and numeric identifying codes for reporting inpatient<br />
medical services and procedures, and selected ICD-9-CM,<br />
volume 3, descriptive terms and numeric identifying codes<br />
for reporting the facility component of medical services and<br />
procedures. All payors and medical providers are required to<br />
follow the general rules and requirements for reimbursement<br />
established by the AMA unless specifically instructed<br />
otherwise in this document.<br />
Current Board forms are available on the Board’s website<br />
http://www.sbwc.georgia.gov.<br />
FORMAT OF THE <strong>FEE</strong> <strong>SCHEDULE</strong><br />
This fee schedule represents the maximum amount of<br />
reimbursement providers may receive for medical or surgical<br />
services for the treatment of work-related injuries and<br />
illnesses covered under the workers’ compensation laws of<br />
the State of <strong>Georgia</strong>.<br />
<strong>The</strong> fee schedule document is divided into 15 sections in<br />
order to provide specific details regarding the different types<br />
of rules that determine the amount of reimbursement<br />
payable for a specific service and circumstance. Payors<br />
should note that the requirements specified in the fee<br />
CPT only © 2010 American Medical Association. All Rights Reserved. 1
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
schedule are intended to provide uniform payment policies<br />
and procedures in applying usual, customary, and reasonable<br />
payment. <strong>The</strong> following sections are included in this fee<br />
schedule:<br />
I. Background<br />
II. Effective Date<br />
III. Introduction to the Fee Schedule<br />
IV. General Reimbursement Requirements<br />
V. Evaluation and Management Services<br />
VI. Anesthesia Services<br />
VII. Surgical Services<br />
VIII. Diagnostic and <strong>The</strong>rapeutic Radiological Services<br />
IX. Pathology and Laboratory Services<br />
X. General Medicine Services<br />
XI. Physical Medicine Services<br />
XII. Home Health Services<br />
XIII. Transportation<br />
XIV. Inpatient <strong>Hospital</strong> Payment Schedule<br />
XV. Outpatient Surgery Payment Schedule<br />
Section I: Background<br />
Within each section, you will find definitions and medical<br />
terms that explain services provided. Also, in certain sections<br />
there is an index of procedures by CPT code identifiers. Use<br />
each specific section in addition to general ground rules for<br />
clarification of terms and services.<br />
<strong>The</strong> fee schedule is designed to be an accurate and<br />
authoritative source of information about medical coding<br />
and reimbursement. Every reasonable effort has been made<br />
to verify its accuracy and all information is believed reliable<br />
at the time of publication. Absolute accuracy and<br />
completeness, however, is neither intended nor guaranteed.<br />
<strong>The</strong> rules and guidelines described herein cannot specifically<br />
refer to every payment contingency; the usual, customary,<br />
and reasonable fee will govern treatment provided under<br />
unusual circumstances.<br />
<strong>The</strong> <strong>Georgia</strong> State Board of Workers’ Compensation reserves<br />
the authority to determine applicability of all rules of the fee<br />
schedule. Any physician, other medical professional, or<br />
other entity having questions regarding applicability to their<br />
individual reimbursement as it applies to the fee schedule,<br />
should direct any such question to the Board or to such<br />
other authority as directed by the Board.<br />
2 CPT only © 2010 American Medical Association. All Rights Reserved.
Section II: Effective Date<br />
<strong>The</strong>se rules shall be applicable to all medical services<br />
rendered on or after the effective date of this fee schedule,<br />
which shall be April 1, 2011. Any treatment or service<br />
rendered on or after the effective date is subject to the<br />
payment methodologies and fee reimbursements described<br />
herein.<br />
CPT only © 2010 American Medical Association. All Rights Reserved. 3
Section III: Introduction to the<br />
Fee Schedules<br />
SUBSECTION A: INTRODUCTION TO THE Physician<br />
PORTION OF THE <strong>FEE</strong> <strong>SCHEDULE</strong><br />
<strong>The</strong> <strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule is<br />
based upon the Resource Based Relative Value Scale<br />
(RBRVS). <strong>The</strong> reimbursable amount for each CPT numeric<br />
identifying procedure is derived from the total relative value<br />
and a conversion factor statistically determined from actual<br />
charge data in the State of <strong>Georgia</strong>. To determine the<br />
maximum allowable reimbursement (MAR) for each<br />
procedure, the unit value was multiplied by the applicable<br />
dollar conversion factor in effect on the date of payment.<br />
Providers are reimbursed the lesser of billed charges or the<br />
fee schedule amount.<br />
How to Use This Fee Schedule<br />
<strong>The</strong> maximum allowable reimbursement (MAR) for CPT<br />
codes is generally separable into eight distinct sections based<br />
on the category or type of service rendered plus a<br />
transportation fee schedule, which applies <strong>Georgia</strong><br />
state-specific codes with MAR. Each category of service has<br />
separate instructions for the application of ground rules and<br />
modifier adjustments. <strong>The</strong> categories of service subject to<br />
this fee schedule are:<br />
General Medical Services CPT Codes<br />
Categories<br />
Evaluation & Management 99201–99499<br />
Anesthesia 00100–01999,<br />
99100–99140<br />
Surgery 10021–69990<br />
Diagnostic & <strong>The</strong>rapeutic Radiology 70010–79999<br />
Pathology & Laboratory 80047–89398<br />
General Medicine 90281–96999,<br />
97597–97606,<br />
97802–97804,<br />
98960–99091,<br />
99143–99199,<br />
99605–99607<br />
Physical Medicine 97001–97546,<br />
97750–97799,<br />
97810–98943,<br />
FCE01<br />
Home Health 99500–99602<br />
<strong>The</strong> ground rules, modifier rules, and fee schedule<br />
reimbursement for primary or global services are included in<br />
sections V through XII of this fee schedule. As indicated, the<br />
MAR is subject to modification based on the included<br />
specific rules. See the Contents for referencing the specific<br />
subsections and page numbers.<br />
For each procedure, the fee schedule table includes the<br />
following details (if applicable):<br />
• New (l), changed descriptor (s), add-on (+), modifier<br />
51 exempt (*), moderate (conscious) sedation (K), or<br />
resequenced code (#) icons<br />
• Five-digit CPT code number<br />
• CPT description<br />
• MAR (Maximum allowable reimbursement)<br />
– Maximum reimbursement for professional<br />
component modifier 26<br />
– Maximum reimbursement for technical component<br />
modifier TC<br />
• FUD (Follow-up day limits)<br />
<strong>The</strong> total MAR includes the professional component for a<br />
procedure and the technical component. Under no<br />
circumstances shall the MAR be more than the value of the<br />
technical component and the professional component<br />
combined for a procedure.<br />
For anesthesia fee amounts, the table includes basic relative<br />
values. Anesthesia fees are determined somewhat differently<br />
than other services using a relative value, physical status<br />
modifiers, qualifying circumstances, and a dollar conversion<br />
CPT only © 2010 American Medical Association. All Rights Reserved. 5
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
factor. See the Anesthesia section for an explanation of how<br />
anesthesia fee amounts are to be determined.<br />
<strong>The</strong> American Medical Association (AMA) introduced a new<br />
numbering methodology of resequencing in CPT 2010.<br />
According to the AMA, there are instances where a new code<br />
is needed within an existing grouping of codes and an<br />
unused code number is not available. In the instance where<br />
the existing codes will not be changed or have minimal<br />
changes, the AMA will assign a code that is not in numeric<br />
sequence with the related codes. <strong>The</strong> resequenced codes and<br />
descriptions are placed with their related codes out of<br />
numeric sequence in the CPT book.<br />
Resequenced CPT codes within <strong>The</strong> <strong>Georgia</strong> Workers'<br />
Compensation Medical Fee Schedule display in their numeric<br />
order and are identified with the # icon.<br />
Category II and Category III CPT codes are not recognized<br />
for <strong>The</strong> <strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
and will not be reimbursed.<br />
SUBSECTION B: INTRODUCTION TO THE<br />
Transportation PORTION OF THE <strong>FEE</strong> <strong>SCHEDULE</strong><br />
<strong>The</strong> <strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
includes maximum allowable rates for non-emergency<br />
transportation services. Non-emergency services are based<br />
on state-specific codes used only for workers’ compensation<br />
billing purposes. Reimbursement for ambulance and air<br />
transportation is determined using the appropriate<br />
calculations for urban and rural base rate and mileage found<br />
in the Ambulance and Air Services subsection of the<br />
Transportation chapter. Ambulance and air transportation<br />
services are reported with HCPCS codes. Providers are<br />
Section III: Introduction to the Fee Schedules<br />
reimbursed the lesser of billed charges or the fee schedule<br />
amount.<br />
SUBSECTION C: INTRODUCTION TO THE Inpatient<br />
<strong>Hospital</strong> PORTION OF THE <strong>FEE</strong> <strong>SCHEDULE</strong><br />
For inpatient hospital services, <strong>The</strong> <strong>Georgia</strong> Workers’<br />
Compensation Medical Fee Schedule is based upon the CMS<br />
2011 Medicare severity diagnosis-related group (MS-DRG)<br />
relative weights. <strong>The</strong> reimbursable amount of each MS-DRG<br />
is derived from the total relative weights and a base rate<br />
(conversion factor) statistically determined from actual<br />
charge data in the State of <strong>Georgia</strong>. To determine the MAR<br />
for each MS-DRG, the unit weight is multiplied by the<br />
applicable dollar base rate in effect on the date payment is<br />
made.<br />
<strong>The</strong> ground rules for inpatient hospital fee schedule<br />
reimbursement are included in section XIV of this fee<br />
schedule. As indicated, the MAR is subject to modification<br />
based on the included specific rules. See the Contents for<br />
referencing the specific subsections and page numbers.<br />
SUBSECTION D: INTRODUCTION TO THE Outpatient<br />
Surgery/ASC PORTION OF THE <strong>FEE</strong> <strong>SCHEDULE</strong><br />
To determine the MAR for outpatient surgery facility<br />
services, the 2011 ICD-9-CM, volume 3, procedure codes<br />
are used in conjunction with <strong>Georgia</strong> <strong>Hospital</strong> Association<br />
information.<br />
<strong>The</strong> ground rules for outpatient surgery facility fee schedule<br />
reimbursement are included in section XV of this fee<br />
schedule. As indicated, the MAR is subject to modification<br />
based on the included specific rules. See the Contents for<br />
referencing the specific subsections and page numbers.<br />
6 CPT only © 2010 American Medical Association. All Rights Reserved.
Section IV: General<br />
Reimbursement Requirements<br />
This section outlines reimbursement in general. Specific<br />
guidelines by service category follow these general<br />
guidelines. <strong>The</strong> following guidelines are intended to provide<br />
rules for reimbursement of services provided in the State of<br />
<strong>Georgia</strong> under the workers’ compensation law for CPT codes<br />
developed by the American Medical Association (AMA)<br />
according to AMA guidelines, Medicare severity<br />
diagnosis-related groups (MS-DRG) developed by CMS, and<br />
International Classification of Diseases, Ninth Revision,<br />
Clinical Modification (ICD-9-CM), volume 3, codes updated<br />
by four cooperating parties: the American <strong>Hospital</strong><br />
Association (AHA), the Centers for Medicare and Medicaid<br />
Services (CMS), the National Center for Health Statistics<br />
(NCHS), and the American Health Information Management<br />
Association (AHIMA). Modifiers that might affect<br />
reimbursement for specific services are also located in each<br />
section.<br />
No physician, hospital, or medical provider shall bill the<br />
employee for authorized medical treatment. If an employee<br />
fails to notify a physician, hospital, or medical supplier that<br />
he/she is being treated for an injury covered by workers’<br />
compensation insurance, such provider of medical services<br />
shall not be civilly liable to any person for erroneous billing<br />
for such covered treatment if the billing error is corrected by<br />
the medical provider upon notice of the same. If a provider’s<br />
charge is greater than the maximum allowable rate (MAR),<br />
the provider must not bill the employee or the<br />
employer/insurer for the difference. <strong>The</strong> fees listed in the fee<br />
schedule represent all-inclusive and global fee amounts.<br />
It is important to recognize that the listing of a code number,<br />
the service or procedure, and the approved fee are not<br />
restricted to a specific specialty group. Any procedure or<br />
service and fee listed in this book may be used to designate<br />
the services rendered by any qualified physician. Such<br />
services, however, must be performed within the scope of<br />
his/her licensed practice as defined by <strong>Georgia</strong> law. <strong>The</strong><br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule is the<br />
reimbursement guideline for <strong>Georgia</strong> facilities and providers.<br />
(Refer to O.C.G.A. § 34-9-205(b))<br />
Occasionally, an individual who is injured in another state<br />
will seek treatment from a medical provider in <strong>Georgia</strong>. In<br />
such a case, the injury may not be under the jurisdiction of<br />
the <strong>Georgia</strong> Act. If the injury is under the jurisdiction of<br />
another state’s workers’ compensation act, the policy and<br />
procedures listed in this manual would not apply.<br />
CONSIDERATIONS FOR REIMBURSEMENT<br />
<strong>The</strong>re are certain key principles and requirements as<br />
described in this section that may apply for determining the<br />
appropriate fee reimbursement amount under this fee<br />
schedule. <strong>The</strong>se essential principles include:<br />
• Medical Service<br />
• Employee’s Waiver of Confidentiality<br />
• Authorization to Treat<br />
• All-Inclusive Fees<br />
• CPT Codes, Guidelines, and Icons<br />
• National Correct Coding Initiative (CCI) Edits<br />
<strong>The</strong> following describes, in general, the principles and<br />
requirements that must be met for establishing applicability<br />
of this fee schedule.<br />
Authorization to Treat<br />
Preauthorization or precertification for the medical<br />
treatment or testing of an injured employee, other than as<br />
required by a certified managed care organization, is not<br />
required by Chapter 9 of Title 34 of the Official Code of<br />
<strong>Georgia</strong> Annotated (O.C.G.A.), referred to as the Workers’<br />
Compensation Act, as a condition for payment of services<br />
rendered. In the event that an authorized treating physician<br />
requests preauthorization or precertification for medical<br />
treatment or testing of an employee, the procedures<br />
provided in Board Rule 205 shall be followed. For a copy of<br />
Rule 205, see the Board’s website:<br />
http://www.sbwc.georgia.gov.<br />
CPT only © 2010 American Medical Association. All Rights Reserved. 7
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
<strong>The</strong> Board may require recommendations from a panel of<br />
appropriate peers of the physician, hospital, or other medical<br />
supplier in determining whether fees submitted and<br />
necessity of services rendered are reasonable. <strong>The</strong><br />
recommendations of the panel of appropriate peers shall be<br />
evidence of the reasonableness of fees and necessity of<br />
services that the Board shall consider in its determination of<br />
appropriateness.<br />
All-Inclusive Fees<br />
<strong>The</strong> fee amounts listed in the fee schedule were determined<br />
under the principle of “all-inclusive services.” “All-inclusive<br />
services” combines certain physician services and<br />
procedures, including all necessary care, treatment, and<br />
routine supplies and services for reimbursement, into a<br />
single principal or global procedure, which reflects the<br />
overall level of services or procedures needed for the<br />
encounter. <strong>The</strong> particular services/procedures will be<br />
reimbursed using the single global fee amount established by<br />
the fee schedule.<br />
For hospital and outpatient surgery facilities, “all-inclusive<br />
services” combines certain facility services and procedures,<br />
including all necessary durable medical equipment (DME)<br />
and supplies for reimbursement, into a single MS-DRG for<br />
inpatient services or a single ICD-9-CM, volume 3,<br />
procedure code that reflects the overall level of services,<br />
procedures, and supplies needed for the inpatient hospital or<br />
outpatient surgery facility service. <strong>The</strong> particular<br />
services/procedures/supplies will be reimbursed using the<br />
single MS-DRG amount for inpatient services and the single<br />
ICD-9-CM amount for outpatient surgery facility services<br />
established by the fee schedule.<br />
For medical professionals billing CPT codes for surgical<br />
procedures, “all-inclusive services” also include all<br />
preoperative and postoperative visits listed in the follow-up<br />
days (FUD) column, plus examinations necessary for<br />
preparing the injured employee for surgery. <strong>The</strong> follow-up<br />
days refers to the time frame during which all services<br />
integral to the surgical procedure are covered by a single<br />
payment. For diagnostic laboratory testing, the primary or<br />
global fee includes both the performance of the test and the<br />
interpretation of results provided to the injured employee.<br />
No reimbursement for a separate visit would normally be<br />
allowed.<br />
<strong>The</strong>re are certain exceptions to the “all-inclusive services and<br />
fees” provision as indicated by the explanation of “separate<br />
procedures” mentioned below. To the extent that other rules<br />
or guidance provided along with this fee schedule do not<br />
address every exception to this “all-inclusive services and<br />
fees” principle, insurers and other payors should be guided<br />
by industry standard practices regarding usual, reasonable,<br />
and customary fees.<br />
Section IV: General Reimbursement Requirements<br />
CPT Codes, Guidelines, and Icons<br />
New and Revised CPT Codes<br />
New and revised codes are identified using the same symbols<br />
found in the CPT book. CPT codes that are new for 2011 are<br />
identified with the l symbol. CPT codes with substantially<br />
changed descriptors for 2011 are identified with the s<br />
symbol.<br />
Separate Procedures<br />
Certain procedures are an inherent portion of a procedure or<br />
service and do not warrant a separate identification. If,<br />
however, such a procedure is performed independently of,<br />
and is not immediately related to, other services, it may be<br />
listed as a “separate procedure.” Thus, when a procedure<br />
that is ordinarily a component of a larger procedure and is<br />
performed alone for a specific purpose, it may be considered<br />
a separate procedure.<br />
Add-On Procedures<br />
<strong>The</strong> CPT book identifies procedures that are always<br />
performed in addition to the primary procedure and<br />
designates them with a + symbol. Add-on codes are never<br />
reported for stand-alone services but are reported<br />
secondarily in addition to the primary procedure. Specific<br />
language is used to identify add-on procedures such as “each<br />
additional” or “(List separately in addition to primary<br />
procedure).”<br />
<strong>The</strong> same physician that performed the primary<br />
service/procedure must perform the add-on<br />
service/procedure. Add-on codes describe additional<br />
intra-service work associated with the primary<br />
service/procedure (e.g., additional digit(s), lesions(s),<br />
neurorrhaphy(s), vertebral segment(s), tendon(s), joint(s)).<br />
Fee schedule amounts for add-on codes are not subject to<br />
reduction and should be reimbursed at the lesser of 100<br />
percent of the listed value or the billed amount. Do not<br />
append modifier 51 to a code identified as an add-on<br />
procedure.<br />
Designated add-on codes are identified in Appendix D of the<br />
CPT book. Please reference CPT 2011 for the most current<br />
list of add-on codes.<br />
Exempt From Modifier 51 Procedures<br />
<strong>The</strong> * symbol is used to identify CPT codes that are exempt<br />
from the use of modifier 51, but have NOT been designated<br />
as CPT add-on procedures/services.<br />
As the description implies, modifier 51 exempt procedures<br />
are not subject to multiple procedure rules and as such<br />
modifier 51 does not apply. Fee schedule amounts for<br />
modifier 51 exempt codes are not subject to reduction and<br />
8 CPT only © 2010 American Medical Association. All Rights Reserved.
Section IV: General Reimbursement Requirements<br />
should be reimbursed at the lesser of 100 percent of the<br />
listed value or the billed amount.<br />
Modifier 51 exempt services and procedures can be found in<br />
Appendix E of CPT 2011.<br />
CPT Codes that Include Moderate (Conscious) Sedation<br />
Some CPT codes include moderate (conscious) sedation as<br />
an inherent component of the procedure. <strong>The</strong>se are<br />
identified in the CPT book with a K symbol. Because these<br />
services include moderate (conscious) sedation, special rules<br />
apply when reporting the moderate (conscious) sedation<br />
CPT codes 99143–99150. Moderate (conscious) sedation<br />
services provided by the same physician performing the<br />
diagnostic or therapeutic service that the sedation supports<br />
and requiring the presence of a second independent trained<br />
observer for monitoring purposes (CPT codes<br />
99143–99145) may not be reported in conjunction with<br />
CPT codes identified with a K symbol and listed in<br />
Appendix G of the CPT book. In rare instances, a second<br />
physician other than the physician performing the diagnostic<br />
or therapeutic service may be required to provide the<br />
moderate (conscious) sedation service (CPT codes<br />
99148–99150). When these sedation services are performed<br />
in a facility setting (e.g., hospital, outpatient<br />
hospital/ambulatory surgery center, skilled nursing facility),<br />
the second physician may report the moderate (conscious)<br />
sedation service with CPT code(s) 99148–99150 in<br />
conjunction with CPT codes identified with a K symbol and<br />
listed in Appendix G. However, when the second physician<br />
performs the moderate (conscious) sedation services in a<br />
nonfacility setting (e.g., physician office, freestanding<br />
imaging center) CPT codes 99148–99150 should not be<br />
reported separately and are not reimbursable when<br />
performed in conjunction with CPT codes identified with a<br />
K symbol and listed in Appendix G. See Appendix G in CPT<br />
2011 for a list of CPT codes that includes moderate<br />
(conscious) sedation.<br />
Modifier Services<br />
A modifier is the method used by the reporting physician to<br />
indicate or flag a service or procedure code regarding special<br />
circumstances affecting that service. <strong>The</strong> service or<br />
procedure description is not affected. When applicable, the<br />
modifying circumstance should be identified by the addition<br />
of the appropriate two-digit modifier code. <strong>The</strong> two-digit<br />
modifier should be placed after the usual procedure number.<br />
If more than one modifier is used, place the “Multiple<br />
Modifiers” code 99 immediately after the procedure code.<br />
This indicates that one or more additional modifiers will<br />
follow.<br />
Only certain modifiers in each of the categories (Evaluation<br />
and Management, Anesthesia, Surgery,<br />
Pathology/Laboratory, Radiology, General Medicine, and<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Physical Medicine) will be recognized for reimbursement<br />
purposes. <strong>The</strong> acceptable modifiers for each category will be<br />
discussed in that section of the fee schedule.<br />
National Correct Coding Initiative (CCI) Edits<br />
<strong>The</strong> CPT book provides descriptive terms and identifying<br />
codes for reporting medical services and procedures<br />
performed by physicians. A multitude of codes is necessary<br />
because of the wide spectrum of services provided by various<br />
medical providers. Because many medical services can be<br />
rendered by different methods as well as combinations of<br />
various procedures, multiple codes describing similar<br />
services are frequently necessary to accurately reflect the<br />
service provided. While often only one procedure is<br />
performed at a patient encounter, it is also possible that<br />
multiple procedures be performed at the same encounter. In<br />
the latter case, a comprehensive code describing multiple<br />
services commonly performed together may be defined by a<br />
single CPT code.<br />
While the CPT coding system is used by providers to<br />
communicate payable services, payors must also be able to<br />
identify comprehensive codes that describe multiple<br />
procedures performed together. To accomplish this, CMS<br />
developed an edit system known as the National Correct<br />
Coding Initiative (CCI). This edit system identifies three<br />
types of services that should not be reported together. <strong>The</strong>se<br />
include:<br />
• Services that are a component of a more comprehensive<br />
service<br />
• Services that are mutually exclusive<br />
• Services that should not be reported together for other<br />
reasons<br />
<strong>The</strong> State of <strong>Georgia</strong> uses National CCI edits to identify<br />
services that are commonly performed together and that<br />
should not be billed separately when the services are<br />
provided at the same encounter. <strong>The</strong> complete list of CCI<br />
edits is too extensive to duplicate here; however, the<br />
information is available on the CMS website at<br />
http://www.cms.gov/NationalCorrectCodInitEd/NCCIEP/list<br />
.asp#TopOfPage.<br />
SPECIAL RULES AND LIMITATIONS<br />
Specific circumstances might affect eligibility for<br />
reimbursement or the amount of reimbursement for specific<br />
services. <strong>The</strong> following listed circumstances could have an<br />
effect on eligibility or reimbursement for services.<br />
Urgent Care Facility<br />
Services performed in an urgent care facility shall be billed<br />
utilizing the most current and applicable CPT numeric<br />
CPT only © 2010 American Medical Association. All Rights Reserved. 9
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
identifying codes and modifiers. All rules and guidelines<br />
shall apply as outlined in the April 1, 2011 <strong>Georgia</strong> Workers’<br />
Compensation Medical Fee Schedule. Reimbursement shall be<br />
at the rate established in the <strong>Georgia</strong> Physician Schedule.<br />
Materials Supplied by the Health Care Provider —<br />
Supplies, DME, Orthotics, Prosthetics<br />
Medical supplies provided by the physician or other medical<br />
provider (e.g., sterile trays) over and above those usually<br />
included with the office visit (e.g., Band-Aids and cotton<br />
swabs) or other services rendered may be listed separately<br />
using CPT code 99070. Medical supplies and durable<br />
medical equipment are reimbursed at cost times 1.5 plus<br />
$4.00 for handling charges. Charges greater than $50.00<br />
must be accompanied by a copy of the wholesale vendor<br />
invoice(s) showing the actual cost of the item. Certain<br />
procedures include supplies; therefore, CPT code 99070<br />
would not be reported. Custom-made orthotics/prosthetics<br />
and rental equipment are exempt from the supplies and<br />
equipment reimbursement formula; however, usual,<br />
customary, and reasonable charges will apply.<br />
Pharmaceuticals<br />
All prescription drugs must be dispensed using an Orange<br />
Book therapeutic equivalent drug(s) (GENERIC) when<br />
available unless designated in the doctor’s own handwriting<br />
on the face of the prescription, in accordance with O.C.G.A.<br />
§ 26-4-81, that “Brand Medically Necessary” or “Brand<br />
Necessary” is required.<br />
Prescription drugs will be reimbursed at the current average<br />
wholesale price (AWP) as published by Medispan, plus a<br />
dispensing fee of $6.15 for generic medications and $4.11<br />
for brand name medications. All bills submitted for<br />
reimbursement must include the National Drug Code (NDC)<br />
of the product provided unless the product provided is a<br />
repackaged unit-of-use product. All pharmaceutical bills<br />
submitted for repackaged products must include the NDC of<br />
the original manufacturer or distributor’s stock package used<br />
in the repackaging process. <strong>The</strong> reimbursement allowed<br />
shall be based on the current published manufacturer’s AWP<br />
price of the product as of the date of dispensing.<br />
When the authorized treating physician prescribes<br />
pharmaceuticals, the prescription will indicate by stamp or<br />
other means that it is for a workers’ compensation claim.<br />
Implants/Allografts/Instrumentation<br />
Certain high cost implants such as, but not limited to, bone<br />
grafts and cartilage supplied by vendor companies shall be<br />
reimbursed at cost in addition to the reimbursement at the<br />
appropriate MS-DRG or ICD-9-CM level if the wholesale<br />
vendor invoice for this item is included with the facility bill.<br />
This additional charge above the MAR, taking into account<br />
Section IV: General Reimbursement Requirements<br />
reasonable cost, medical necessity, and appropriateness,<br />
shall be negotiated in advance with the payor.<br />
Instrumentation inserted in surgical procedures is to be<br />
reimbursed to the provider at cost when the wholesale<br />
vendor invoice is included in the facility bill.<br />
Physician Extenders (PE)—Clinical Nurse Specialist<br />
(CNS), Nurse Practitioner (NP), or Physician<br />
Assistant (PA)<br />
<strong>The</strong> clinical nurse specialist (CNS), nurse practitioner (NP),<br />
or physician assistant (PA), if qualified by training and<br />
experience as determined by the supervising physician, may<br />
perform medical treatments, diagnostic procedures, or other<br />
delegated duties and tasks which are allowable by law,<br />
approved by the state licensing board, and which fall within<br />
the normal scope of practice of the supervising physician.<br />
For scheduled visits, the Board requires a physician to<br />
provide evaluation and treatment in the course of the first<br />
visit. In situations of major/minor emergency, urgent care<br />
injuries, or other medical conditions requiring immediate<br />
attention, and where that care is provided in a medical<br />
facility staffed by physician extenders (PE) under the<br />
direction and supervision of a physician, services by the<br />
physician extender are covered for the initial treatment and<br />
visit. If follow-up treatment is necessary, the patient must<br />
then be referred to a physician for follow-up visit, treatment,<br />
and/or evaluation.<br />
Medical facilities covered include occupational medical<br />
centers, hospital emergency rooms, hospital-based clinics,<br />
rural health clinics, or federally qualified health centers.<br />
<strong>The</strong> federal tax ID number for the supervising physician is to<br />
be used on claims for services rendered by a PE. Subsequent<br />
visits to a PE who is under the general supervision of the<br />
physician shall be paid in accordance with the Board fee<br />
schedule. When professional services are directly performed<br />
by a CNS, NP, or PA, the reimbursement shall be at 85<br />
percent of the fee schedule MAR or the provider’s charge,<br />
whichever is less. If the CNS, NP, or PA renders the service<br />
under the general supervision of a physician and “incident<br />
to” rules apply as specified in the Medicare Benefit Policy<br />
Manual, Pub. 100-2, chapter 15, secs. 60.1, 60.2, 60.3, the<br />
applicable reimbursement shall be at 100 percent of the fee<br />
schedule or the provider’s charge, whichever is less. While<br />
the supervising physician is responsible for the overall<br />
direction and management of the professional activities of<br />
the CNS, NP, or PA, the supervising physician is not<br />
required to physically be on site at the time of service.<br />
However, if the supervising physician is not physically<br />
present with the CNS, NP, or PA, he or she must be<br />
immediately available to the CNS, NP, or PA for consultation<br />
purposes by telephone or other effective, reliable means of<br />
communication. See the Medicare Benefit Policy Manual, Pub.<br />
10 CPT only © 2010 American Medical Association. All Rights Reserved.
Section IV: General Reimbursement Requirements<br />
100-2, chapter 15, section 190(C) for Medicare<br />
requirements for PA supervision, section 200(D) for NP<br />
collaboration/supervision, and section 210(D) for CNS<br />
collaboration/supervision.<br />
It is the responsibility of the supervising physician to ensure<br />
compliance with all ethical and licensing standards and to<br />
co-sign all medical notes. Append the appropriate CPT<br />
procedure with modifier PE. Physicians may not bill for<br />
oversight of these services in addition to an office visit.<br />
Reimbursement of PA, NP, or registered nurse first assistant<br />
(RNFA) as a surgical assistant shall be at 10 percent of the<br />
MAR for the CPT code or the practitioner’s usual and<br />
customary charge, whichever is less, for those procedures<br />
that are exempt from the Medicare “5 percent rule.” If<br />
Medicare records indicate that a first assistant is used less<br />
than 5 percent of the time nationwide for a particular<br />
surgical procedure, then the procedure is added to the<br />
restricted 5 percent list. (See the Medicare Claims Processing<br />
Manual, Pub. 100-4, chapter 12, section 20.4.3.) CPT codes<br />
that have assistant at surgery restrictions are updated each<br />
year and can be found in the current Medicare National<br />
Physician Fee Schedule Relative Value File. <strong>The</strong> column “Surg<br />
Asst” in the above referenced file provides a numeric code<br />
(0, 1, 2, or 9) that identifies any restrictions related to<br />
assistant at surgery services. <strong>The</strong> restrictions related to these<br />
numeric codes are as follows:<br />
Surgical<br />
Assistant Ind Payment Restriction<br />
0 Payment restriction for assistants at surgery<br />
applies to this procedure unless supporting<br />
documentation is submitted to establish<br />
medical necessity.<br />
1 Statutory payment restriction for assistants at<br />
surgery applies to this procedure. Assistant at<br />
surgery may not be paid.<br />
2 Payment restriction for assistants at surgery<br />
does not apply to this procedure. Assistant at<br />
surgery may be paid.<br />
9 Concept does not apply.<br />
If circumstances warrant the concurrent services of a<br />
surgeon and one of the types of assistants as listed herein<br />
and it is medically necessary, those services may be<br />
performed by a physician extender (PE) in the place of an<br />
assistant surgeon when medically appropriate. In accord<br />
with O.C.G.A. §33-24-59.9, the RNFA shall not be on the<br />
staff of a hospital or the treating physician. Append the<br />
appropriate CPT procedure with modifier AS. When an<br />
office is billing for both the primary surgeon and the surgical<br />
assistant, two lines are used on the CMS-1500 or a Uniform<br />
Billing 04 (UB-04).<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Interpretation<br />
In circumstances where an interpreter is required during<br />
face-to-face evaluation and management services, or physical<br />
medicine evaluations (97001–97004), provided to the<br />
injured worker by a physician or PE, whether interpretation<br />
is provided live, via telephone or video, add state-specific<br />
modifier TR to the E/M code. Reimbursement will be an<br />
additional 25 percent of the lesser of billed charges or<br />
maximum allowable rate of that code only. Prolonged service<br />
codes 99354–99357 may not be used in combination with<br />
this modifier. Additional reimbursement as outlined above<br />
does not apply to independent medical evaluations (IME).<br />
In circumstances where an interpreter is required for an<br />
injured worker, and the service is provided by telephone<br />
with a physician or qualified non-physician health care<br />
provider, use the appropriate CPT codes 99441–99443<br />
(physicians) and 98966–98968 (qualified non-physician<br />
health care providers), and append state-specific modifier<br />
TR. <strong>The</strong>se codes should be used in accordance with the<br />
guidelines and descriptions found in CPT 2011.<br />
Reimbursement will be an additional 25 percent of the lesser<br />
of billed charges or maximum allowable rate of that code<br />
only.<br />
Physical <strong>The</strong>rapists/Occupational <strong>The</strong>rapists<br />
Services performed by a physical therapist and/or<br />
occupational therapist shall be under the direction of the<br />
authorized treating physician detailing the type, frequency,<br />
and duration of therapy to be provided. Physical therapists<br />
and/or occupational therapists cannot be reimbursed for<br />
office visits. See Physical Medicine for a full discussion of<br />
these services.<br />
Physical Medicine Maximum Per Visit and/or Day<br />
No more than four charges will be reimbursed per visit/day<br />
regardless of medical necessity. No more than two of the<br />
charges can be modality codes (CPT codes 97010–97039).<br />
Each unit (15-minutes) reported counts as one charge.<br />
Exemptions to this rule are as follows:<br />
1. An injured worker has been diagnosed with a catastrophic<br />
injury O.C.G.A. §34-9-200.1(g).<br />
2. CPT codes 97545 and 97546 report work hardening/work<br />
conditioning. CPT code 97545 reports the first<br />
two hours and CPT code 97546 reports each additional<br />
hour. <strong>The</strong> total dollar amount reimbursed for work<br />
hardening/work conditioning reported with these two<br />
CPT codes shall not exceed $327.26 per visit/day.<br />
3. State-specific code FCE01 must be used for billing functional<br />
capacity evaluation. <strong>The</strong> maximum allowable rate<br />
of reimbursement is $45.41 per 15 minutes (not to<br />
exceed $600.00).<br />
CPT only © 2010 American Medical Association. All Rights Reserved. 11
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section IV: General Reimbursement Requirements<br />
4. CPT code 97750 must be used by physical/occupational<br />
therapists when billing for Physical Performance<br />
Test/Measurements that are required by the treating<br />
physician in preparing an impairment rating. No more<br />
than 4 time units per visit per day can be billed. An<br />
additional physical medicine treatment can be conducted<br />
on the same day, with reimbursement in accordance<br />
with Section XI – Physical Medicine Services.<br />
Modifier 59 may be used when multiple procedures are<br />
performed on the same day.<br />
5. CPT code 99455 should be used by the treating physician<br />
when performing an impairment rating.<br />
6. Under the guidelines above, Physical Performance<br />
Test/Measurement testing and functional capacity evaluation<br />
can be performed on the same day by physical/occupational<br />
therapists. Modifier 59 may be used<br />
when multiple procedures are performed on the same<br />
day.<br />
7. Reporting CPT code 97760 Orthotic management and<br />
training (including assessment and fitting when not otherwise<br />
reported), for custom-made orthotics, CPT code<br />
97761 Prosthetic training, and CPT code 97762 Checkout<br />
for orthotic/prosthetic use, established patient.<br />
8. By mutual agreement of all parties.<br />
Independent Medical Exam (IME)<br />
Employers/insurers have the right to request that the injured<br />
employee submit to an independent medical examination<br />
(IME), performed by a duly qualified physician or surgeon<br />
designated and paid by the employer/insurer. <strong>The</strong><br />
employer/insurer must notify the employee in writing at<br />
least 10 days in advance of the time and place of the<br />
examination. Advance payment of travel expenses must<br />
accompany the notice. Travel beyond the employee’s home<br />
city shall include the actual cost of meals (up to $30.00 per<br />
day) and lodging. When travel is by private vehicle, the rate<br />
of mileage shall be according to Board Rule 203(e). <strong>The</strong><br />
employee shall have the right to have present at such<br />
examination any duly qualified physician or surgeon,<br />
provided and paid for by the employee.<br />
<strong>The</strong> employee, after an accepted compensable injury and<br />
within 120 days of receipt of any income benefits, shall have<br />
the right to one IME performed at a reasonable time and<br />
place, within this state or within 50 miles of the employee’s<br />
residence, by a duly qualified physician or surgeon<br />
designated by the employee and paid for by the<br />
employer/insurer. <strong>The</strong> employer or insurer shall be notified<br />
in writing in advance. Such examination shall not repeat any<br />
diagnostic procedures which have been performed since the<br />
date of the employee’s injury unless the costs of such<br />
diagnostic procedures in excess of $250.00 are paid for by a<br />
party other than the employer or insurer.<br />
Payment for independent medical examinations will be<br />
based on time spent in the review of medical records, test<br />
reports, a physical examination, and a written report<br />
regarding the medical condition of the injured employee.<br />
Time will be the essential factor in determining the<br />
reimbursement amount for an IME. <strong>The</strong> provider shall<br />
complete Board Form WC-20 (a) Medical Report or the<br />
CMS-1500 form. Use state-specific code IME01 when<br />
reporting an independent medical exam (IME).<br />
<strong>The</strong> following hourly rate will establish the maximum<br />
allowable reimbursement for this service.<br />
Time Rate<br />
$600.00—first hour or parts thereof<br />
$150.00—each additional 15 minutes<br />
For a no-show at an independent medical examination,<br />
reimbursement shall be at $150.00.<br />
Impairment Evaluation<br />
<strong>The</strong> basis to determine permanent impairment should be the<br />
Guide to the Evaluation of Permanent Impairment, Fifth<br />
Edition, published by the American Medical Association.<br />
Permanent partial impairment (PPI) applies to any<br />
measurable, objective loss of function of some part of the<br />
body after the stage of maximum medical improvement<br />
(MMI) has been reached and the condition is stationary. <strong>The</strong><br />
authorized treating physician shall complete Board Form<br />
WC-20 (a) Medical Report or the CMS-1500 form and<br />
submit the form to the employer/insurer when a permanent<br />
partial disability rating is determined. If a physical<br />
examination is necessary, evaluation and management CPT<br />
code 99455 must be used in billing an impairment rating,<br />
and no other evaluation and management CPT code can be<br />
used along with CPT code 99455 when billing for<br />
impairment ratings performed by the authorized treating<br />
physician.<br />
Work Hardening/Work Conditioning<br />
<strong>The</strong> CPT codes 97545 and 97546 can only be used by<br />
physician referral and when treatment is initiated and<br />
directly supervised by the physician, chiropractor, licensed<br />
physical therapist, or licensed occupational therapist.<br />
Unlisted Service or Procedure and New CPT Codes<br />
A service or procedure may be provided that is not listed in<br />
this schedule. When reporting such a service, the<br />
appropriate unlisted procedure code may be used to indicate<br />
the service. When reviewing charges for unlisted medical<br />
professional services or procedures, payors should apply<br />
usual, customary, and reasonable charges. When reporting<br />
unlisted procedure MS-DRG or ICD-9-CM procedure codes,<br />
12 CPT only © 2010 American Medical Association. All Rights Reserved.
Section IV: General Reimbursement Requirements<br />
reimbursement is at 62.23 percent of charges. In compliance<br />
with O.C.G.A. §34-9-203(a), these usual, customary, and<br />
reasonable charges shall be limited to such charges as prevail<br />
in the State of <strong>Georgia</strong> for similar treatment.<br />
Annually on January 1 of each calendar year, the American<br />
Medical Association (AMA) releases updates to CPT codes,<br />
with new CPT codes added, CPT codes deleted, and CPT<br />
codes revised. <strong>The</strong> <strong>Georgia</strong> Workers’ Compensation Medical Fee<br />
Schedule may not have the AMA’s most current updated<br />
information until after January 1. In this case, a maximum<br />
allowable reimbursement rate will not be assigned. New<br />
codes without an assigned fee should be considered to fall<br />
under the “BR” or “by report” maximum allowable<br />
reimbursement until the next fee schedule update.<br />
By Report<br />
If a procedure is not among those listed in the fee schedule, a<br />
reasonable fee must be charged, and may require a special<br />
report. A service that is infrequently provided, unusual,<br />
varies from other described procedures, or a new technique,<br />
methodology, or code may require a special report in<br />
determining the medical appropriateness of the service.<br />
Pertinent information should include:<br />
• Adequate definition and description of procedure or<br />
service as performed is required<br />
• Nature, extent, and need (diagnosis and rationale) for<br />
the service or procedure<br />
• Time and effort required to perform the service or<br />
procedure<br />
• Skill level necessary for performance of service or<br />
procedure<br />
• Equipment use (if applicable)<br />
• Other information as needed<br />
Additional items that may be included are:<br />
• Complexity of symptoms<br />
• Final diagnosis<br />
• Pertinent physical findings (such as size, location(s),<br />
and number of lesion(s), if appropriate)<br />
• Diagnostic and therapeutic procedures (including major<br />
and supplementary surgical procedures if appropriate)<br />
• Concurrent problems<br />
• Follow-up care<br />
Payment will be determined based upon usual, customary,<br />
and reasonable charges.<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Medical Expense Disputes<br />
Employers/insurers may conform charges according to the<br />
fee schedule adopted by the Board, and the charges listed in<br />
the fee schedule shall be presumed usual, customary, and<br />
reasonable and shall be paid within 30 days from the date of<br />
receipt of charges. Employers/insurers shall not unilaterally<br />
change any CPT, MS-DRG, or ICD-9-CM code of the<br />
provider. All automatically conformed charges according to<br />
the fee schedule shall be for the CPT code listed by the<br />
provider. In situations where charges have been reduced or<br />
payment of a bill denied, the carrier, self-insured employer,<br />
or third-party administrator shall provide an explanation of<br />
benefits (EOB) with payment information explaining why<br />
the charge has been reduced or disallowed, along with a<br />
narrative explanation of each EOB code used. In all claims,<br />
any health service provider whose fee is reduced to conform<br />
to the fee schedule and who disputes that fee, or any<br />
employer/insurer who disputes the CPT code used by the<br />
provider for services rendered shall, in the first instance,<br />
request peer review of the charges, and may thereafter<br />
request a mediation conference by filing Form WC-14 with<br />
the Board. For charges not contained in the fee schedule and<br />
which are disputed within 30 days as not being usual,<br />
customary, and reasonable, the aggrieved party shall follow<br />
these procedures:<br />
1. An employer or insurer shall pay when due all charges<br />
deemed reasonable, and follow the procedures set forth<br />
in subsection (2) for review of only those specified<br />
charges that are disputed.<br />
2. For charges not contained in the fee schedule and which<br />
are disputed as not being the usual, customary, and reasonable<br />
charges prevailing in the State of <strong>Georgia</strong>, the<br />
employer, insurer, or physician shall file a request for<br />
peer review with a peer review organization authorized<br />
by the Board within 30 days of the receipt of charges by<br />
the employer/insurer, and shall serve a copy of the<br />
request and supporting documentation upon all parties<br />
and counsel.<br />
3. <strong>The</strong> peer review committees approved by the Board are<br />
listed below. <strong>The</strong>se committees may be contacted at the<br />
following addresses and telephone numbers:<br />
Mr. Michael Walsh, CAE, Executive Director<br />
<strong>Georgia</strong> Chiropractic Association, Inc.<br />
1926 Northlake Parkway, Suite 201<br />
Tucker, GA 30084<br />
(770) 723-1100; FAX (770) 723-1722<br />
Mr. Clark Thomas, MPA, CAE, Executive Director<br />
<strong>Georgia</strong> Psychological Association<br />
2200 Century Parkway, NE, Suite 660<br />
Atlanta, GA 30345<br />
(404) 634-6272; FAX (404) 634-8230<br />
CPT only © 2010 American Medical Association. All Rights Reserved. 13
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section IV: General Reimbursement Requirements<br />
Mr. Stuart Platt, M.S.P.T., P.T., Principal<br />
Appropriate Utilization Group, LLC<br />
881 Piedmont Avenue<br />
Atlanta, GA 30309<br />
(404) 728-1974<br />
4. If there is no appropriate peer review committee, the<br />
party requesting review may request a mediation conference<br />
by filing Form WC-14 with the Board. <strong>The</strong> charges<br />
submitted, which conform to the fee schedule adopted<br />
by the Board, shall be prima facie proof of the usual,<br />
customary, and reasonable charges for the medical services<br />
provided.<br />
5. <strong>The</strong> employer/insurer shall, within 30 days from the<br />
date that a decision regarding the peer review of charges<br />
or treatment is issued by a peer review organization,<br />
make payment of disputed charges based upon the recommendations,<br />
or request a mediation conference. <strong>The</strong><br />
peer review committee shall serve a copy of its decision<br />
upon the employee, if unrepresented, or the employee’s<br />
attorney. A physician whose fee has been reduced by the<br />
peer review committee shall have 30 days from the date<br />
that the recommendation is mailed to request a hearing.<br />
In case of a mediation conference, the recommendations<br />
of the peer review committee shall be evidence of the<br />
usual, customary, and reasonable charges.<br />
6. In cases where the peer review committee recommends<br />
that the fee be reduced, the employer/insurer shall pay<br />
the physician the fee amount recommended by the peer<br />
review committee less the filing costs initially paid by<br />
the employer/insurer. In the event the peer review committee<br />
recommends the entire fee be disallowed, the<br />
employer/insurer may automatically deduct the filing<br />
costs for the peer review from future allowable expenses<br />
submitted by the physician for treatment or services<br />
rendered to the employee arising out of the same injury.<br />
(Refer to O.C.G.A. §34-9-203.)<br />
Appointed Physician<br />
(Refer to O.C.G.A. § 34-9-205 and Board Rule 205.)<br />
<strong>The</strong> Board or an Administrative Law Judge may, upon<br />
application of either party or upon their own motion,<br />
appoint one or more disinterested and duly qualified<br />
physicians or surgeons to perform any necessary medical<br />
examination of an employee, and to report or testify with<br />
respect thereto. <strong>The</strong> physician or surgeon shall be allowed<br />
travel expenses and a reasonable fee, to be paid by either or<br />
both parties, as directed by the Board, any Board member, or<br />
an Administrative Law Judge.<br />
Physician Testimony/Deposition<br />
Physicians and surgeons may be called upon or may be<br />
issued a subpoena, which is a legal instrument of the court<br />
requiring any citizen to appear in court as a witness at a<br />
specified time, to testify as an expert witness before the<br />
Workers’ Compensation Board. <strong>The</strong> expert witness is legally<br />
bound to declare his/her knowledge of the case and express<br />
medical opinions according to the rules of the court.<br />
Hearings are conducted in an informal manner. Witnesses<br />
are sworn and their testimony is recorded. Generally, the<br />
parties to the claim offer medical testimony related to the<br />
extent of the injury and whether the injured employee is<br />
physically able to return to his/her former job duties or is<br />
able to accept other more limited employment.<br />
In most instances, testimony of physicians is obtained<br />
through deposition. <strong>The</strong> deposition generally serves to<br />
relieve the physician of the necessity of going to court.<br />
Physicians and surgeons shall be given two weeks prior<br />
notice to giving medical testimony and such testimony shall<br />
be scheduled at a mutually agreeable time and place.<br />
Charges for medical testimony should be reported using CPT<br />
code 99075 and paid within 30 days from receipt of billing.<br />
Payment for a deposition will be based on actual time spent<br />
reviewing medical records before giving medical testimony<br />
and actual time spent testifying. <strong>The</strong> following hourly rate<br />
will establish the maximum allowable reimbursement for<br />
this service:<br />
Time Rate<br />
$600.00—first hour or parts thereof<br />
$150.00—each additional 15 minutes<br />
Special Reports<br />
Special reports such as insurance forms that convey more<br />
than the information conveyed in usual medical<br />
communication or standard reporting forms should be<br />
reported with CPT code 99080. Special reports meeting the<br />
above requirements will be reimbursed at a MAR of $60.00.<br />
Malpractice Liability<br />
<strong>The</strong> employer/insurer shall not be liable in damages for<br />
malpractice by a physician or surgeon furnished pursuant to<br />
the workers’ compensation law, but the consequences of any<br />
malpractice shall be deemed part of the injury resulting from<br />
the accident and the employee shall be compensated for<br />
such injury.<br />
Medical Records<br />
<strong>The</strong> medical provider’s medical record is the basis for<br />
determining medical necessity and for substantiating the<br />
service(s) rendered; therefore, the medical record must be<br />
legible and should include the following: office notes and/or<br />
surgical notes, progress notes, operative notes, diagnostic<br />
test results, and any other information necessary to support<br />
14 CPT only © 2010 American Medical Association. All Rights Reserved.
Section IV: General Reimbursement Requirements<br />
the services rendered. All bills must be submitted using CPT,<br />
ICD-9-CM, or MS-DRG codes either on Board Form<br />
WC-20(a), CMS-1500, or a Uniform Billing 04 (UB-04).<br />
<strong>The</strong>se forms must be properly filled out, with attached<br />
documentation, at no charge to the party responsible for<br />
payment.<br />
Failure to submit supporting documentation and forms<br />
required by the Board might jeopardize or delay payment.<br />
Medical providers are only required to submit the complete<br />
set of documentation once. If documentation is incomplete,<br />
the medical provider is required to submit the missing<br />
information. After the complete documentation has been<br />
submitted to the payor once, the medical provider can<br />
charge for additional copies in accordance with costs defined<br />
below.<br />
Services provided pursuant to the Workers’ Compensation<br />
Act are not confidential from the employer/insurer that, by<br />
law, is responsible for payment of medical services.<br />
Generally, costs for these copies will be charged against the<br />
party responsible for payment of medical expenses. (Refer to<br />
Board Rule 200(f)(1)(2)(3))<br />
Medical records copy charges under a workers’<br />
compensation claim shall be billed at thirty dollars ($30),<br />
sales tax (if applicable), and actual cost for postage to mail<br />
the documents per request. This fee shall cover any request<br />
of up to 150 copied pages, and includes any costs associated<br />
with research, retrieval, and certification of the records or<br />
information requests.<br />
Any request that is for more than 150 copied pages shall be<br />
billed at twenty cents ($0.20) per page, or image if on CD or<br />
other electronic storage device that allows electronic<br />
retrieval, or copies made from microfilm, and shall include<br />
any costs associated with research, retrieval, and certification<br />
of the records or information requested. No additional fee<br />
beyond the twenty-cent ($0.20) per-page charge shall be<br />
billed for requests over 150 pages other than actual cost for<br />
postage to mail the documents per request and sales tax (if<br />
applicable).<br />
Example 1:<br />
50-page document<br />
$0.20 x 50 pages = $10.00<br />
Total Charges: $30.00 plus actual cost for postage and<br />
sales tax, if applicable<br />
Example 2:<br />
175-page document<br />
$0.20 x 175 pages = $35.00<br />
Total Charges: $35.00 plus actual cost for postage and<br />
sales tax, if applicable<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Providers who use a medical records company to make and<br />
provide copies of medical records must ensure that<br />
reimbursement requirements are followed in accordance to<br />
the above fee schedule guidelines. X-ray copy charges will be<br />
billed at $9.50 per copy.<br />
Late Payment<br />
All reasonable medical, surgical, hospital, pharmacy goods<br />
and services shall be payable by the employer or its workers’<br />
compensation insurer within 30 days of receipt of such<br />
charges and reports required by the Board. In the event that<br />
any documents or other information needed to process the<br />
claim or any portion thereof have not been provided to the<br />
employer or insurer, an explanation of benefits with<br />
payment information indicating why the charge has been<br />
reduced or disallowed shall be provided by the<br />
employer/insurer within 30 days of receipt of such charges.<br />
If any charges for health care goods or services, for which all<br />
Board-required information is provided, are not paid within<br />
the 30-day period, penalties shall be added to such charges<br />
and paid at the same time as and in addition to the charges<br />
claimed for such services. Refer to O.C.G.A.<br />
§ 34-9-203 and Board Rule 203 for complete rules and<br />
regulations.<br />
Broken or Missed Appointments<br />
No fees shall be allowed for broken or missed office visits,<br />
with the exception of independent medical examination (see<br />
IME this section). Notify the employer/insurer if the injured<br />
employee is not following the prescribed course of<br />
treatment.<br />
OVERVIEW<br />
<strong>The</strong> preceding guidelines outline reimbursement in general.<br />
Specific rules regarding reimbursement for services rendered<br />
by specific category should supplement the general<br />
guidelines (i.e., Evaluation and Management, Anesthesia,<br />
Surgery, Radiology, Pathology and Laboratory, General<br />
Medicine, and Physical Medicine). <strong>The</strong>se specific guidelines<br />
are in addition to rules established for the usage of CPT<br />
codes by the American Medical Association (AMA), Medicare<br />
severity diagnosis-related groups (MS-DRG) developed by<br />
CMS, and International Classification of Diseases, Ninth<br />
Revision, Clinical Modification (ICD-9-CM), volume 3,<br />
codes updated by four cooperating parties: the American<br />
<strong>Hospital</strong> Association (AHA), the Centers for Medicare and<br />
Medicaid Services (CMS), the National Center for Health<br />
Statistics (NCHS), and the American Health Information<br />
Management Association (AHIMA). <strong>The</strong> following sections<br />
will describe payment in general terms by the category of<br />
service provided.<br />
CPT only © 2010 American Medical Association. All Rights Reserved. 15
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Sections V through XII of the fee schedule provide specific<br />
payment ground rules separately for each of the eight<br />
medical professional service categories, section XIII provides<br />
specific ground rules for transportation, and sections XIV<br />
through XV provide specific payment ground rules for<br />
hospital inpatient/outpatient surgery services. Explanation of<br />
the modifiers and the maximum allowable reimbursement is<br />
included in each of these sections of the fee schedule.<br />
Section IV: General Reimbursement Requirements<br />
<strong>The</strong> payment ground rules are provided in 11 separate fee<br />
subsections. <strong>The</strong> ground rules encompass the 10 distinct<br />
medical and hospital inpatient/outpatient surgery service<br />
categories and transportation. <strong>The</strong> rules for one service<br />
category may include certain principles that apply equally to<br />
another service category. Similarly, the ground rules<br />
applicable to one category of service apply equally to all<br />
professional providers regardless of provider specialty.<br />
16 CPT only © 2010 American Medical Association. All Rights Reserved.
Section V: Evaluation and<br />
Management (E/M) Services<br />
SUBSECTION A: PAYMENT GROUND RULES FOR E/M<br />
CATEGORY<br />
General Guidelines<br />
<strong>The</strong> E/M section is divided into broad categories such as<br />
office visits, hospital visits, and consultations. Most of the<br />
categories are further divided into two or more subcategories<br />
of E/M services. For example, there are two subcategories of<br />
office visits (new patient and established patient) and there<br />
are two subcategories of hospital visits (initial and<br />
subsequent). <strong>The</strong> subcategories of E/M services are further<br />
classified into levels of E/M services that are identified by<br />
specific codes. This classification is important because the<br />
nature of a physician’s work varies by type of service, place<br />
of service, and the injured employee’s status.<br />
Physicians should include CPT codes for specific<br />
performance of diagnostic tests/studies for which specific<br />
CPT codes are available. <strong>The</strong>se CPT codes should be<br />
reported separately, in addition to the appropriate E/M code.<br />
<strong>The</strong> basic format of the levels of E/M service is the same for<br />
most categories:<br />
• First, a unique code number is listed.<br />
• Second, the place and/or type of service is specified,<br />
e.g., office consultation.<br />
• Third, the content of the service is defined, e.g.,<br />
comprehensive history and comprehensive<br />
examination.<br />
• Fourth, the nature of the presenting problem(s) usually<br />
associated with a given level is described.<br />
• Fifth, the time typically required to provide the service<br />
is specified. (A detailed discussion of time is provided<br />
on subsequent pages.)<br />
<strong>The</strong> fee amounts listed in the fee schedule were determined<br />
under the principle of “all-inclusive services.” <strong>The</strong> principle<br />
of “all-inclusive services” combines certain physician services<br />
and procedures, including all necessary care, treatment, and<br />
routine supplies and services for reimbursement, into a<br />
single principle or global procedure, which reflects the<br />
overall level of services or procedures needed for the<br />
encounter. <strong>The</strong> particular services/procedures will be<br />
reimbursed using the single global fee amount established by<br />
the fee schedule.<br />
Definitions<br />
Certain key words and phrases are used throughout the E/M<br />
section. <strong>The</strong> following definitions are intended to reduce the<br />
potential for differing interpretations and to increase the<br />
consistency of reporting by physicians in differing<br />
specialties.<br />
New & Established Patient<br />
Except as provided herein, a new patient is one who has not<br />
received any professional services from a physician or<br />
another physician of the same specialty who belongs to the<br />
same group practice, within the past three years. Each time<br />
an injured worker has a new compensable workers’<br />
compensation injury, the initial evaluation shall be coded as<br />
a new patient.<br />
An established patient is one who has received professional<br />
services from a physician or another physician of the same<br />
specialty who belongs to the same group practice, within the<br />
past three years.<br />
On-Call or Substitute Physician<br />
In the instance where a physician is on call for or is covering<br />
for the authorized treating physician, the injured employee’s<br />
encounter will be classified as it would have been by the<br />
physician who is not available.<br />
Emergency Services<br />
No distinction is made between new and established patients<br />
in the emergency department. Emergency department<br />
services should be reported for any patient (new or<br />
established) who presents for treatment in the emergency<br />
department.<br />
CPT only © 2010 American Medical Association. All Rights Reserved. 17
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Concurrent Care<br />
Providing similar service (e.g., hospital visits by more than<br />
one physician) to the same injured employee on the same<br />
day for treatment of the same illness is concurrent care.<br />
When concurrent care is provided, no special reporting is<br />
required. Duplicate services, however, (e.g., visit by a<br />
physician of the same subspecialty for the same injury/illness<br />
which is not a second opinion) will not be reimbursed. <strong>The</strong><br />
authorized treating physician should coordinate care by all<br />
specialists.<br />
Coordination of Care<br />
When no patient encounter occurs, coordination of care by<br />
the authorized treating physician with other health care<br />
providers outside normal practice is reported and billed<br />
using case management codes (99363, 99366–99368,<br />
99441–99444). When a patient encounter occurs, any<br />
counseling and/or coordination of care with other health<br />
care providers as part of or as a result of the encounter are<br />
considered part of the E/M code for that session, and no<br />
additional reimbursement is warranted except when the<br />
patient encounter includes a board-certified rehabilitation<br />
supplier or case manager for the specific purpose of<br />
discussing the progress of the patient’s treatment plan or an<br />
independent living plan related to the workers’<br />
compensation injury. Under these conditions, add modifier<br />
RS to the appropriate E/M code, and reimbursement shall be<br />
at an additional 50 percent of the fee schedule MAR.<br />
Interpretation<br />
In circumstances where an interpreter is required during<br />
face-to-face evaluation and management services, or physical<br />
medicine evaluations (97001–97004), provided to the<br />
injured worker by a physician or PE, whether interpretation<br />
is provided live, via telephone or video, add state-specific<br />
modifier TR to the E/M code. Reimbursement will be an<br />
additional 25 percent of the lesser of billed charges or<br />
maximum allowable rate of that code only. Prolonged service<br />
codes 99354–99357 may not be used in combination with<br />
this modifier. Additional reimbursement as outlined above<br />
does not apply to independent medical evaluations (IME).<br />
In circumstances where an interpreter is required for an<br />
injured worker, and the service is provided by telephone<br />
with a physician or qualified non-physician health care<br />
provider, use the appropriate CPT codes 99441–99443<br />
(physicians) and 98966–98968 (qualified non-physician<br />
health care providers), and append state-specific modifier<br />
TR. <strong>The</strong>se codes should be used in accordance with the<br />
guidelines and descriptions found in CPT 2011.<br />
Reimbursement will be an additional 25 percent of the lesser<br />
of billed charges or maximum allowable rate of that code<br />
only.<br />
Section V: Evaluation and Management (E/M) Services<br />
Prolonged Services<br />
Codes 99354–99357 are used when a physician provides<br />
prolonged services involving direct face-to-face patient<br />
contact that is beyond the usual service (see section IV for<br />
additional rules).<br />
Codes 99358 and 99359 are used when a physician provides<br />
prolonged services not involving direct face-to-face patient<br />
contact that is beyond the usual non-face-to-face component<br />
of physician service time. <strong>The</strong>se codes should be used in<br />
accordance with the guidelines and descriptions found in<br />
CPT 2011.<br />
Counseling<br />
Counseling is defined as a discussion with an injured<br />
employee and/or family concerning one or more of the<br />
following areas:<br />
• Diagnostic results, impressions, and/or recommended<br />
diagnostic studies<br />
• Prognosis<br />
• Risks and benefits of management (treatment) options<br />
• Instructions for management (treatment) and/or<br />
follow-up<br />
• Importance of compliance with chosen management<br />
(treatment) options<br />
• Risk factor reduction<br />
• Injured employee and family education<br />
Consultations<br />
As defined in the CPT book, consultation is a type of service<br />
provided by a physician whose opinion or advice regarding<br />
evaluation and/or management of a specific problem is<br />
requested by another physician or appropriate source.<br />
Consultations are reimbursable only to physicians with the<br />
appropriate specialty for the services provided. A consulting<br />
physician shall only initiate diagnostic and/or therapeutic<br />
services with approval from the authorized treating<br />
physician. Following a consultation, if the consulting<br />
physician assumes responsibility for management of all or<br />
any part of the injured employee’s condition(s) in accordance<br />
with O.C.G.A. §34-9-200, the injured employee becomes an<br />
“established patient” under the care of the consulting<br />
physician.<br />
When a second opinion is requested or required regarding<br />
the necessity or appropriateness of a recommended medical<br />
treatment or surgical procedure by the injured employee or<br />
employer/insurer, follow CPT guidelines for reporting the<br />
consultation service. When a second opinion is requested by<br />
the employer/insurer, append modifier 32 to identify the<br />
service as a mandated consultation.<br />
18 CPT only © 2010 American Medical Association. All Rights Reserved.
Section V: Evaluation and Management (E/M) Services<br />
Evaluation and management consultation services will<br />
continue to be reported with CPT codes 99241–99245 for<br />
outpatient consultation services and codes 99251–99255 for<br />
inpatient consultation services. <strong>The</strong> rules and guidelines<br />
regarding the definition, documentation, and reporting of<br />
consultation services as contained in the CPT book will<br />
apply unless superseded by these guidelines. Consultation<br />
services will be reimbursed at the lesser of the MAR or billed<br />
amount.<br />
Referral<br />
Transfer of total or specific care of an injured employee from<br />
one physician to another physician who is not providing a<br />
consultation but rather full care and treatment of an injured<br />
employee constitutes a referral. Only the authorized treating<br />
physician is authorized to make a referral.<br />
After a referral is made and a consulting physician initiates<br />
health care treatments at the request of the authorized<br />
treating physician, the consulting physician then becomes a<br />
referral physician. <strong>The</strong> referral physician shall only initiate<br />
treatment if approved or recommended by the authorized<br />
treating physician. Once a referral physician initiates<br />
treatment, communications shall continue between the<br />
authorized treating physician and the referral physician.<br />
A referral physician shall not make subsequent referrals to<br />
additional physicians. <strong>The</strong> authorized treating physician is<br />
the only physician authorized to coordinate care and<br />
referrals of any and all treatments from referral physicians.<br />
Employees may make one change from the authorized<br />
treating physician to another physician of his/her choice on<br />
the panel without authorization or referral. This constitutes a<br />
change of authorized treating physician.<br />
Nature of Presenting Problem<br />
A presenting problem is a disease, condition, illness, injury,<br />
symptom, sign, finding, complaint, or other reason for<br />
encounter, with or without a diagnosis being established at<br />
the time of the encounter. <strong>The</strong> E/M codes recognize five<br />
types of presenting problems that are defined below. <strong>The</strong><br />
information, however, merely contributes to code selection.<br />
• Minimal—A problem that may not require the presence<br />
of a physician, but service is provided under the<br />
physician’s supervision.<br />
• Self-limited or minor—A problem that either runs a<br />
definite and prescribed course, is transient in nature and<br />
is not likely to permanently alter health status or has a<br />
good prognosis with management/compliance.<br />
• Low severity—A problem for which the risk of<br />
morbidity without treatment is low, there is little to no<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
risk of mortality without treatment, and full recovery<br />
without functional impairment is expected.<br />
• Moderate severity—A problem for which the risk of<br />
morbidity without treatment is moderate, there is<br />
moderate risk of mortality without treatment, and the<br />
prognosis is uncertain OR there is an increased<br />
probability of prolonged functional impairment.<br />
• High severity—A problem for which the risk of<br />
morbidity without treatment is high to extreme, there is<br />
a moderate to high risk of mortality without treatment<br />
OR high probability of severe, prolonged functional<br />
impairment.<br />
Time<br />
<strong>The</strong> inclusion of time in the definitions of levels of E/M<br />
services is to assist physicians in selecting the most<br />
appropriate level of E/M service. It should be recognized that<br />
the specific time expressed in the visit code descriptions is<br />
an average; therefore, it represents a range of times, which<br />
may be higher or lower depending on actual clinical<br />
circumstances.<br />
Time is not a descriptive component for the emergency<br />
department levels of E/M services because emergency<br />
department services are typically provided on a variable<br />
intensity basis, often involving multiple encounters with<br />
several patients over an extended period. <strong>The</strong>refore, it is<br />
often difficult for physicians to provide accurate estimates of<br />
the time spent face-to-face with the injured employee.<br />
Intra-service time is defined as face-to-face time during office<br />
and other outpatient visits and as unit/floor time for hospital<br />
and inpatient visits. This distinction is necessary because<br />
most of the work of typical office visits takes place during<br />
the face-to-face time with the injured employee, while most<br />
of the work of typical hospital visits takes place during the<br />
time spent on the injured employee’s floor or unit.<br />
1. Face-to-face time (office and other outpatient visits and<br />
office consultations)—For coding purposes, face-to-face<br />
time for these services is defined as only that time that<br />
the physician spends face-to-face with the injured<br />
employee and/or family. This includes the time in which<br />
the physician performs such tasks as obtaining a history,<br />
performing a physical examination, and counseling the<br />
injured employee.<br />
Physicians also spend time doing work before or after<br />
the face-to-face time with the injured employee,<br />
performing such tasks as reviewing records and tests,<br />
arranging for further services, and communicating<br />
further with other professionals and the injured<br />
employee through written reports and telephone<br />
contact. This non-face-to-face time for office<br />
services—also called pre- and postencounter time—is<br />
CPT only © 2010 American Medical Association. All Rights Reserved. 19
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
not included in the time component described in the<br />
E/M codes; however, it was included in calculating the<br />
total work of typical services in physician surveys.<br />
Thus, the face-to-face time associated with the services<br />
described by any E/M code is a valid proxy for the total<br />
work done before, during, and after the visit.<br />
2. Unit/floor time (hospital observation services, inpatient<br />
hospital care, hospital consultations, nursing facility)—For<br />
reporting purposes, intra-service time for<br />
these services is defined as unit/floor time, which<br />
includes the time that the physician is present on the<br />
injured employee’s hospital unit and at the bedside rendering<br />
services for that injured employee. This includes<br />
the time in which the physician establishes and/or<br />
reviews the injured employee’s chart, examines the<br />
injured employee, writes notes and communicates with<br />
other professionals and the injured employee’s family.<br />
Nonfloor time—In the hospital, pre- and post-time<br />
includes time spent off the injured employee’s floor<br />
performing such tasks as reviewing pathology and<br />
radiology findings in another part of the hospital. This<br />
pre- and post-time is not included in the time<br />
component described in these codes; however, it was<br />
included in calculating the total work of typical services<br />
in physician surveys.<br />
Thus, the unit/floor time associated with the services<br />
described by any code is a valid proxy for the total work<br />
done before, during, and after the visit.<br />
Emergency Department Services<br />
An emergency department (ED) is defined as an organized<br />
hospital-based facility for the provision of unscheduled<br />
episodic services to patients who require immediate medical<br />
attention. <strong>The</strong> facility must be available 24 hours a day.<br />
Only the ED physician, who is responsible for the care of the<br />
injured employee in the ED, reports an appropriate level ED<br />
evaluation and management service code. If the care of the<br />
injured employee is then directly transferred to another<br />
physician or if the non-ED physician is the only physician to<br />
see the injured employee in the emergency room and that<br />
physician elects to evaluate the injured employee while<br />
he/she is still in the emergency department, the physician<br />
would report that E/M service with the appropriate office or<br />
other outpatient service code. If, however, that physician<br />
elects to admit the injured employee based on the evaluation<br />
performed, only the initial inpatient hospital care code<br />
should be reported. Of course, any other procedures<br />
performed should be reported in addition, with modifier 25<br />
appended to the E/M code.<br />
Section V: Evaluation and Management (E/M) Services<br />
If another physician performs a consultation on a patient,<br />
then that physician would submit reimbursement requests<br />
using an appropriate office or other outpatient consultation<br />
code. Again, if this consultation results in a hospital<br />
admission, only the initial inpatient hospital care code would<br />
be submitted for reimbursement.<br />
Critical Care<br />
Critical care includes the care of critically ill patients in a<br />
variety of medical emergencies that require the constant<br />
attendance of the physician. Critical care is usually, but not<br />
always, given in a critical care area, such as the coronary care<br />
unit, intensive care unit, respiratory care unit, or the<br />
emergency care facility. Services for an injured employee<br />
who is not critically ill but happens to be in a critical care<br />
unit are reported using subsequent hospital care codes<br />
(99231–99233) or initial hospital consultation codes<br />
(99251–99255) as appropriate. <strong>The</strong> critical care codes are<br />
used to report the total time the physician spends providing<br />
constant attention to a critically ill or injured employee.<br />
Nursing Facility Services, Domiciliary, Rest Home or Boarding<br />
Home, Custodial Care, Home Services, Newborn Services<br />
<strong>The</strong>se services will be reimbursed only if the documented<br />
condition is directly related to or is the consequence of the<br />
compensable injury.<br />
Broken or Missed Appointments<br />
No fees shall be allowed for broken or missed office visits.<br />
Notify the employer/insurer if the injured employee is not<br />
following the prescribed course of treatment. <strong>The</strong> only<br />
exception will be for a no-show independent medical<br />
examination (IME) with a maximum charge of $150.00.<br />
Unusual Service or Procedure<br />
Services that may necessitate skills and time of the physician<br />
over and above that usually required should be substantiated<br />
by report (see section IV).<br />
Unlisted Services<br />
An E/M service may be provided that is not listed in this<br />
section of the CPT codes. <strong>The</strong>se services should be reported<br />
using an unlisted code and substantiated using a report. For<br />
these procedures a “BR” (by report) designation has been<br />
used in the fee schedule. Reimbursement for such<br />
procedures must be justified by report (see section IV).<br />
Physician Extenders (PE) — Clinical Nurse Specialist (CNS),<br />
Nurse Practitioner (NP), or Physician Assistant (PA)<br />
Refer to “General Reimbursement Requirements” for a<br />
complete discussion of billing procedures for physician<br />
extenders (see section IV).<br />
20 CPT only © 2010 American Medical Association. All Rights Reserved.
Section V: Evaluation and Management (E/M) Services<br />
SUBSECTION B: PAYMENT MODIFIERS FOR E/M<br />
CATEGORY<br />
A modifier indicates that a service or procedure performed<br />
has been altered by some specific circumstance but has not<br />
changed its definition or code. <strong>The</strong> modifying circumstance<br />
shall be identified by the appropriate modifier following the<br />
procedure code. <strong>The</strong> two-digit modifier should be placed<br />
after the usual procedure number. If more than one modifier<br />
is used, place the “Multiple Modifiers” code 99 immediately<br />
after the procedure code. This indicates that one or more<br />
additional modifier codes will follow. Only certain modifiers<br />
in each of the categories (Evaluation and Management,<br />
Anesthesia, Surgery, Pathology and Laboratory, Radiology,<br />
General Medicine, and Physical Medicine) will be recognized<br />
for reimbursement purposes.<br />
<strong>The</strong> modifiers listed below may differ from those published<br />
by the American Medical Association. Medical providers<br />
submitting workers’ compensation billing shall use only the<br />
modifiers set out in this fee schedule.<br />
Note: Modifier 21 has been deleted. To report prolonged<br />
physician services, see 99354–99357. Modifier 22 changed in<br />
CPT 2008 and is not to be appended to an E/M service.<br />
<strong>The</strong> following modifiers will be recognized for<br />
reimbursement by the fee schedule for evaluation and<br />
management (E/M) codes:<br />
24 Unrelated Evaluation and Management Service by<br />
the Same Physician during a Postoperative Period:<br />
<strong>The</strong> physician may need to indicate that an E/M service<br />
was performed during a postoperative period for a<br />
reason(s) unrelated to the original procedure. This<br />
circumstance may be reported by adding modifier 24 to<br />
the appropriate level of E/M service.<br />
25 Significant, Separately Identifiable Evaluation and<br />
Management Service by the Same Physician on the<br />
Same Day of a Procedure or Other Service: It may be<br />
necessary to indicate that on the day a procedure or<br />
service identified by a CPT code was performed, the<br />
patient’s condition required a significant, separately<br />
identifiable E/M service above and beyond the other<br />
service provided or beyond the usual preoperative and<br />
postoperative care associated with the procedure that<br />
was performed. A significant, separately identifiable E/M<br />
service is defined or substantiated by documentation<br />
that satisfies the relevant criteria for the respective E/M<br />
service to be reported (see Evaluation and Management<br />
Services Guidelines for instructions on determining<br />
level of E/M service). <strong>The</strong> E/M service may be prompted<br />
by the symptom or condition for which the procedure<br />
and/or service was provided. As such, different<br />
diagnoses are not required for reporting the E/M<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
services on the same date. This circumstance may be<br />
reported by adding modifier 25 to the appropriate level<br />
of E/M service. Note: This modifier is not used to report<br />
an E/M service that resulted in the decision to perform<br />
surgery. See modifier 57. For significant, separately<br />
identifiable non-E/M services, see modifier 59.<br />
32 Mandated Services: Services related to mandated<br />
consultation and/or related services (e.g., third-party<br />
payor, governmental, legislative or regulatory<br />
requirement) may be identified by adding modifier 32<br />
to the basic procedure.<br />
52 Reduced Services: Under certain circumstances, a<br />
service or procedure is partially reduced or eliminated at<br />
the physician’s election. Under these circumstances, the<br />
service provided can be identified by its usual procedure<br />
number and the addition of modifier 52, signifying that<br />
the service is reduced. This provides a means of<br />
reporting reduced services without disturbing the<br />
identification of the basic service. Note: For hospital<br />
outpatient reporting of a previously scheduled<br />
procedure/service that is partially reduced or canceled<br />
as a result of extenuating circumstances or those that<br />
threaten the well-being of the patient prior to or after<br />
administration of anesthesia, see modifiers 73 and 74<br />
(see modifiers approved for ASC hospital outpatient<br />
use).<br />
When reporting a reduced service, it is expected that the<br />
billed amount will be reduced by the provider. <strong>The</strong><br />
amount of the reduction is at the discretion of the<br />
provider, but should reflect a level of reimbursement<br />
commensurate with the actual work done.<br />
53 Discontinued Procedure: Under certain circumstances,<br />
the physician may elect to terminate a surgical or<br />
diagnostic procedure. Due to extenuating circumstances<br />
or those that threaten the well-being of the patient, it<br />
may be necessary to indicate that a surgical or diagnostic<br />
procedure was started but discontinued. This<br />
circumstance may be reported by adding modifier 53 to<br />
the code reported by the physician for the discontinued<br />
procedure. Note: This modifier is not used to report the<br />
elective cancellation of a procedure prior to the patient’s<br />
anesthesia induction and/or surgical preparation in the<br />
operating suite. For outpatient hospital/ambulatory<br />
surgery center (ASC) reporting of a previously<br />
scheduled procedure/service that is partially reduced or<br />
canceled as a result of extenuating circumstances or<br />
those that threaten the well-being of the patient prior to<br />
or after administration of anesthesia, see modifiers 73<br />
and 74 (see modifiers approved for ASC hospital<br />
outpatient use).<br />
57 Decision for Surgery: An evaluation and management<br />
service that resulted in the initial decision to perform<br />
CPT only © 2010 American Medical Association. All Rights Reserved. 21
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
the surgery may be identified by adding modifier 57 to<br />
the appropriate level of E/M service.<br />
99 Multiple Modifiers: Under certain circumstances, two<br />
or more modifiers may be necessary to completely<br />
delineate a service. In such situations, modifier 99<br />
should be added to the basic procedure, and other<br />
applicable modifiers may be listed as part of the<br />
description of the service.<br />
PE Physician Assistant, Clinical Nurse Specialist, or<br />
Nurse Practitioner (State-Specific Modifier):<br />
Evaluation and management services performed by a<br />
physician assistant, clinical nurse specialist, or nurse<br />
practitioner are identified by adding modifier PE to the<br />
usual evaluation and management CPT code unless<br />
“incident to” rules apply. No modifier is appended when<br />
“incident to” rules apply. A physician assistant must be<br />
properly licensed by the Composite Board of Medical<br />
Examiners in <strong>Georgia</strong> and/or licensed or certified in the<br />
state where services are provided. A clinical nurse<br />
specialist (CNS) or nurse practitioner (NP) must be<br />
properly licensed by the <strong>Georgia</strong> Board of Nursing<br />
and/or licensed or certified in the state where services<br />
are provided. Modifier PE will be reimbursed at 85<br />
percent of the MAR.<br />
Section V: Evaluation and Management (E/M) Services<br />
RS Rehabilitation Supplier (State-Specific Modifier):<br />
<strong>The</strong> rehabilitation supplier or case manager must be<br />
Board registered. In conformity with Board Rules 200.1<br />
or 208, the purpose of the scheduled office visit must be<br />
to discuss the progress of the patient’s treatment plan or<br />
an independent living plan on a workers’ compensation<br />
injury. Modifier RS will be reimbursed at an additional<br />
50 percent of the fee schedule MAR.<br />
TR Interpretation (State-Specific Modifier): In<br />
circumstances where an interpreter is required during<br />
face-to-face evaluation and management services<br />
provided to the injured worker by a physician or PE,<br />
add state-specific modifier TR to the E/M code.<br />
Reimbursement will be an additional 25 percent of the<br />
lesser of billed charges or MAR of that code only.<br />
Prolonged service codes 99354–99357 may not be used<br />
in combination with the TR modifier unless it is<br />
documented that the reason for the code is additional<br />
time required as a result of factors beyond the need for<br />
an interpreter. Additional reimbursement as outlined<br />
above does not apply to independent medical<br />
evaluations (IME).<br />
22 CPT only © 2010 American Medical Association. All Rights Reserved.
Section V: Evaluation and Management (E/M) Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
99201–99499 EVALUATION AND MANAGEMENT<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
99201 OFFICE OUTPT NEW 10 MIN 60.55 XXX<br />
99202 OFFICE OUTPT NEW 20 MINUTES 104.58 XXX<br />
99203 OFFICE OUTPT NEW 30 MIN 151.62 XXX<br />
99204 OFFICE OUTPT NEW 45 MIN 233.19 XXX<br />
99205 OFFICE OUTPT NEW 60 MIN 290.23 XXX<br />
99211 OFFICE O/P EST 5 MIN 29.02 XXX<br />
99212 OFFICE OUTPT EST 10 MIN 61.05 XXX<br />
99213 OFFICE OUTPT EST15 MIN 101.58 XXX<br />
99214 OFFICE OUTPT EST 25 MIN 150.62 XXX<br />
99215 OFFICE OUTPT EST 40 MIN 202.66 XXX<br />
99217 OBS CARE DSCHRG D MGMT 102.08 XXX<br />
99218 1ST OBS CARE PR D LOW SEVERITY 94.58 XXX<br />
99219 1ST OBS CARE PR D MODERATE SEVERITY 158.13 XXX<br />
99220 1ST OBS CARE PR D HIGH SEVERITY 221.18 XXX<br />
99221 1ST HOSP CARE PR D 30 MIN 143.11 XXX<br />
99222 1ST HOSP CARE PR D 50 MIN 194.66 XXX<br />
99223 1ST HOSP CARE PR D 70 MIN 285.73 XXX<br />
l # 99224 SBSQ OBS CARE PR D LOW SEVERITY 41.03 XXX<br />
l # 99225 SBSQ OBS CARE PR D MODERATE SEVERITY 72.56 XXX<br />
l # 99226 SBSQ OBS CARE PR D HIGH SEVERITY 108.59 XXX<br />
99231 SBSQ HOSP CARE PR D 15 MIN 56.55 XXX<br />
99232 SBSQ HOSP CARE PR D 25 MIN 102.08 XXX<br />
99233 SBSQ HOSP CARE PR D 35 MIN 146.62 XXX<br />
99234 OBS/I/P HOSP CARE LOW SEVERITY 193.65 XXX<br />
99235 OBS/I/P HOSP CARE MODERATE SEVERITY 253.70 XXX<br />
99236 OBS/I/P HOSP CARE HIGH SEVERITY 315.25 XXX<br />
99238 HOSP DSCHRG D MGMT 30 MIN/< 101.58 XXX<br />
99239 HOSP DSCHRG D MGMT > 30 MIN 149.12 XXX<br />
99241 OFFICE CONSLTJ 15 MIN 68.55 XXX<br />
99242 OFFICE CONSLTJ 30 MIN 129.10 XXX<br />
99243 OFFICE CONSLTJ 40 MIN 176.14 XXX<br />
99244 OFFICE CONSLTJ 60 MIN 260.21 XXX<br />
99245 OFFICE CONSLTJ 80 MIN 318.25 XXX<br />
99251 1ST INPT CONSLTJ 20 MIN 69.56 XXX<br />
99252 1ST INPT CONSLTJ 40 MIN 107.09 XXX<br />
99253 1ST INPT CONSLTJ 55 MIN 163.13 XXX<br />
99254 1ST INPT CONSLTJ 80 MIN 235.19 XXX<br />
99255 1ST INPT CONSLTJ 110 MIN 284.23 XXX<br />
99281 EMER DEPT SELF LIMITED/MINOR 30.52 XXX<br />
99282 EMER DEPT LOW TO MODERATE SEVERITY 59.55 XXX<br />
99283 EMER DEPT MODERATE SEVERITY 90.07 XXX<br />
99284 EMER DEPT HI SEVERITY&URGENT EVAL 170.14 XXX<br />
99285 EMER DEPT HIGH SEVERITY&THREAT FUNCJ 249.20 XXX<br />
99288 PHYS DIRION EMS ADVD LIFE SUPPORT BR XXX<br />
99291 CC E/M CRITICALLY ILL/INJURED 1ST 30-74 MIN 389.31 XXX<br />
+ 99292 CC E/M CRITICALLY ILL/INJURED EA 30 MIN 175.14 ZZZ<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 23
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section V: Evaluation and Management (E/M) Services<br />
EVALUATION AND MANAGEMENT 99201–99499<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
99304 1ST NF CARE PR D E/M LW SEVERITY 129.60 XXX<br />
99305 1ST NF CARE PR D E/M MOD SEVERITY 182.15 XXX<br />
99306 1ST NF CARE PR D E/M HI SEVERITY 231.69 XXX<br />
99307 SBSQ NF CARE PR D E/M STABLE 62.05 XXX<br />
99308 SBSQ NF CARE PR D E/M MINOR COMPLCTJ 95.58 XXX<br />
99309 SBSQ NF CARE PR D E/M NEW PROBLEM 125.60 XXX<br />
99310 SBSQ NF CARE PR D E/M UNSTABLE/NEW PROBLEM 186.15 XXX<br />
99315 NF DSCHRG D MGMT 30 MIN/< 90.57 XXX<br />
99316 NF DSCHRG D MGMT > 30 MIN 117.59 XXX<br />
99318 E/M PT INVG ANNUAL NF ASSMT 132.61 XXX<br />
99324 DOM/R-HOME LW SEVERITY 81.06 XXX<br />
99325 DOM/R-HOME E/M NEW PT MOD SEVERITY 117.09 XXX<br />
99326 DOM/R-HOME E/M NEW PT MOD HI SEVERITY 198.66 XXX<br />
99327 DOM/R-HOME E/M NEW PT HI SEVERITY 261.21 XXX<br />
99328 DOM/R-HOME E/M NEW PT SIGNIFICANT NEW PROBLEM 305.24 XXX<br />
99334 DOM/R-HOME E/M EST PT SELF-LMTD/MINOR 86.07 XXX<br />
99335 DOM/R-HOME E/M EST PT LW MOD SEVERITY 133.11 XXX<br />
99336 DOM/R-HOME E/M EST PT MOD HI SEVERITY 187.65 XXX<br />
99337 DOM/R-HOME E/M EST PT SIGNIFICANT NEW PROBLEM 270.22 XXX<br />
99339 INDIV PHYS SUPVJ HOME/DOM/R-HOME MO 15-29 MIN 112.09 XXX<br />
99340 INDIV PHYS SUPVJ HOME/DOM/R-HOME MO 30 MIN/> 157.13 XXX<br />
99341 HOME VST NEW PT LOW SEVERITY 80.56 XXX<br />
99342 HOME VST NEW PT MOD SEVERITY 117.09 XXX<br />
99343 HOME VST NEW PT MOD TO HI SEVERITY 191.15 XXX<br />
99344 HOME VST NEW PT HI SEVERITY 256.71 XXX<br />
99345 HOME VST NEW PT UNSTABLE/SIGNIFICANT NEW PROBLEM 308.25 XXX<br />
99347 HOME VST EST PT SELF LIMITED/MINOR 80.06 XXX<br />
99348 HOME VST EST PT LOW TO MOD SEVERITY 121.10 XXX<br />
99349 HOME VST EST PT MOD TO HI SEVERITY 179.14 XXX<br />
99350 HOME VST EST PT UNSTABLE/SIGNIFICANT NEW PROBLEM 249.70 XXX<br />
+ 99354 PROLNG PHYS SVC OFFICE O/P DIR CONTACT 1ST HR 140.61 ZZZ<br />
+ 99355 PROLNG PHYS SVC OFFICE O/P DIR CONTACT EA 30 MIN 139.11 ZZZ<br />
+ 99356 PROLONGED SERVICE I/P REQ UNIT/FLOOR TIME 1ST HR 128.60 ZZZ<br />
+ 99357 PROLONGED SVC I/P REQ UNIT/FLOOR TIME EA 30 MIN 129.10 ZZZ<br />
99358 PROLNG E/M SVC BEFORE&/AFTER DIR PT CARE 1ST HR 158.63 XXX<br />
+ 99359 PROLNG E/M BEFORE&/AFTER DIR CARE EA 30 MIN 76.56 ZZZ<br />
99360 PHYS STANDBY SVC PROLNG PHYS ATTN EA 30 MIN 89.57 XXX<br />
99363 ANTICOAGULANT MGMT OUTPATIENT 1ST 90 DAYS 182.65 XXX<br />
99364 ANTICOAGULANT MGMT OUTPATIENT EA SBSQ 90 DAYS 62.05 XXX<br />
99366 TEAM CONFERENCE FACE-TO-FACE NONPHYSICIAN 62.05 XXX<br />
99367 TEAM CONFERENCE NON-FACE-TO-FACE PHYSICIAN 82.07 XXX<br />
99368 TEAM CONFERENCE NON-FACE-TO-FACE NONPHYSICIAN 53.04 XXX<br />
99374 PHYS SUPVJ PT HOME HLTH AGENCY MO 15-29 MINUTES 101.08 XXX<br />
99375 PHYS SUPVJ PT HOME HLTH AGENCY MO 30 MIN/> 156.12 XXX<br />
99377 PHYS SUPVJ HOSPICE PT MO 15-29 MIN 101.08 XXX<br />
99378 PHYS SUPVJ HOSPICE PT MO 30 MIN/> 159.13 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
24 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section V: Evaluation and Management (E/M) Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
99201–99499 EVALUATION AND MANAGEMENT<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
99379 PHYS SUPVJ NF PT MO 15-29 MIN 101.08 XXX<br />
99380 PHYS SUPVJ NF PT MO 30 MIN/> 151.62 XXX<br />
99381 1ST PREVENTIVE MEDICINE NEW PATIENT < 1YR 138.11 XXX<br />
99382 1ST PREVENTIVE MEDICINE NEW PATIENT AGE 1-4 YRS 149.62 XXX<br />
99383 1ST PREVENTIVE MEDICINE NEW PATIENT AGE 5-11 YRS 149.12 XXX<br />
99384 1ST PREVENTIVE MEDICINE NEW PATIENT AGE 12-17 YR 162.13 XXX<br />
99385 1ST PREVENTIVE MEDICINE NEW PATIENT AGE 18-39YRS 162.13 XXX<br />
99386 1ST PREVENTIVE MEDICINE NEW PATIENT AGE 40-64YRS 188.65 XXX<br />
99387 1ST PREVENTIVE MEDICINE NEW PATIENT AGE 65YRS&> 208.17 XXX<br />
99391 PERIODIC PREVENTIVE MED ESTABLISHED PATIENT 174.14 XXX<br />
99401 PREV MED CNSL INDIV SPX 15 MIN 53.04 XXX<br />
99402 PREV MED CNSL INDIV SPX 30 MIN 91.57 XXX<br />
99403 PREV MED CNSL INDIV SPX 45 MIN 127.60 XXX<br />
99404 PREV MED CNSL INDIV SPX 60 MIN 164.13 XXX<br />
99406 TOBACCO USE CESSATION INTERMEDIATE 3-10 MINUTES 20.02 XXX<br />
99407 TOBACCO USE CESSATION INTENSIVE >10 MINUTES 39.03 XXX<br />
99408 ALCOHOL/SUBSTANCE SCREEN & INTERVEN 15-30 MIN 51.04 XXX<br />
99409 ALCOHOL/SUBSTANCE SCREEN & INTERVEN >30 MIN 99.08 XXX<br />
99411 PREV MED CNSL GRP SPX 30 MIN 23.02 XXX<br />
99412 PREV MED CNSL GRP SPX 60 MIN 30.02 XXX<br />
99420 ADMN&INTERPJ HLTH RISK ASSMT INSTRUMENT 15.01 XXX<br />
99429 UNLIS PREV MED SVC BR XXX<br />
99441 PHYSICIAN TELEPHONE EVALUATION 5-10 MIN 20.52 XXX<br />
99442 PHYSICIAN TELEPHONE EVALUATION 11-20 MIN 39.03 XXX<br />
99443 PHYSICIAN TELEPHONE EVALUATION 21-30 MIN 57.55 XXX<br />
99444 PHYSICIAN ONLINE EVALUATION & MANAGEMENT SERVICE 45.04 XXX<br />
99450 BASIC LIFE AND/OR DISABILITY EXAMINATION BR XXX<br />
99455 WORK RELATED/MED DBLT XM TREATING PHYS 202.66 XXX<br />
99456 WORK RELATED/MED DBLT XM OTH/THN TREATING PHYS BR XXX<br />
99460 1ST HOSP/BIRTHING CENTER CARE PER DAY NML NB 85.07 XXX<br />
99461 1ST CARE PR DAY NML NB XCPT HOSP/BIRTHING CENTER 134.11 XXX<br />
99462 SUBQ HOSPITAL CARE PER DAY E/M NORMAL NEWBORN 46.04 XXX<br />
99463 1ST HOSP/BIRTHING CENTER NB ADMIT&DSCHG SM DATE 116.59 XXX<br />
99464 ATTN AT DELIVERY& 1ST STABILIZATION OF NEWBORN 105.58 XXX<br />
99465 DELIVERY/BIRTHING ROOM RESUSCITATION 204.16 XXX<br />
99466 CRITICAL CARE INTERFACILITY TRANSPORT 30-74 MIN 389.81 XXX<br />
+ 99467 CRITICAL CARE INTERFACILITY TRANSPORT EA 30 MIN 174.64 ZZZ<br />
99468 1ST INPATIENT CRITICAL CARE PR DAY AGE 28 DAYS/< 1323.56 XXX<br />
99469 SUBQ I/P CRITICAL CARE PR DAY AGE 28 DAYS/< 576.46 XXX<br />
99471 INITIAL PED CRITICAL CARE 29 D THRU 24 MO 1140.41 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 25
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section V: Evaluation and Management (E/M) Services<br />
EVALUATION AND MANAGEMENT 99201–99499<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
99472 SUBSEQUENT PED CRITICAL CARE 29 D THRU 24 MO 573.96 XXX<br />
99475 INITIAL PED CRITICAL CARE 2 THRU 5 YEARS 806.14 XXX<br />
99476 SUBSEQUENT PED CRITICAL CARE 2 THRU 5 YEARS 488.39 XXX<br />
99477 INITIAL HOSP NEONATE 28 D/< NOT CRITICALLY ILL 508.91 XXX<br />
99478 SUBSEQUENT INTENSIVE CARE INFANT < 1500 GRAMS 202.16 XXX<br />
99479 SUBSEQUENT INTENSIVE CARE INFANT 1500-2500 GRAMS 185.65 XXX<br />
99480 SUBSEQUENT INTENSIVE CARE INFANT 2501-5000 GRAMS 173.14 XXX<br />
99499 UNLIS E/M SVC BR XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
26 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VI: Anesthesia Services<br />
SUBSECTION A: PAYMENT GROUND RULES FOR<br />
ANESTHESIA SERVICES<br />
General Guidelines<br />
Anesthesia services reported must be those performed by or<br />
under the medical direction and supervision of an<br />
anesthesiologist, certified registered nurse anesthetist<br />
(CRNA), or anesthesiology assistant (AA) during the<br />
provision of any procedure by another provider. Modifier<br />
QX or QZ should be listed when the procedure is provided<br />
by the CRNA or AA. Anesthesia services include, but are not<br />
limited to, general or regional supplementation of local<br />
anesthesia as well as other supportive services considered<br />
necessary by the anesthesiologist.<br />
Fee schedule amounts for anesthesia services are determined<br />
on a different basis than fee determinations for other<br />
physician services. A relative unit value and dollar<br />
conversion factor basis is used. <strong>The</strong> listed relative values for<br />
anesthesia services are based on CMS anesthesia base values.<br />
A dollar conversion factor has been established for<br />
anesthesia services to be multiplied by the total number of<br />
units applicable for a particular service. <strong>The</strong> unit values<br />
described in this section reflect the relativity of charges for<br />
procedures within this section only.<br />
Services involving administration of anesthesia are reported<br />
by the use of the anesthesia five-digit procedure codes and<br />
modifier codes.<br />
Anesthesia service reimbursement is determined using<br />
relative base unit values for each procedure code, the total<br />
time of services provided, physical status modifiers (if any),<br />
and a conversion factor.<br />
Many anesthesia services are provided under particularly<br />
difficult circumstances, depending on factors such as<br />
extraordinary condition of injured employee, notable<br />
operative conditions, or unusual risk factors. Procedure<br />
codes 99100, 99116, 99135, and 99140 should be used to<br />
define these procedures. <strong>The</strong>se procedures shall not be<br />
reported alone, but would be reported as additional<br />
procedure codes qualifying an anesthesia procedure or<br />
service. In procedure code 99140 Anesthesia complicated by<br />
emergency conditions, emergency is defined as existing<br />
when delay in treatment of the injured employee would lead<br />
to a significant increase in the threat to life or body part.<br />
Unusual Service or Procedure<br />
Services that may necessitate skills and time of the physician<br />
over and above that usually required should be substantiated<br />
by report (see section IV).<br />
Unlisted Services<br />
An Anesthesia service may be provided that is not listed in<br />
this section of the CPT codes. <strong>The</strong>se services should be<br />
reported using an unlisted code and substantiated using a<br />
report. For these procedures a “BR” (by report) designation<br />
has been used in the fee schedule. Reimbursement for such<br />
procedures must be justified by report (see section IV).<br />
Anesthesia Billing Procedures<br />
<strong>The</strong> total anesthesia value (TAV) for each procedure is<br />
defined by adding a basic value, which is related to the<br />
complexity of the service, and physical status modifiers,<br />
qualifying circumstances, plus time units.<br />
Anesthesia Values<br />
All anesthesia values are determined based on basic unit<br />
values for each anesthesia procedure code, the total time of<br />
services provided, physical status modifiers, qualifying<br />
circumstances, and the conversion factor as shown below.<br />
Conversion Factor x TAV = ANESTHESIA <strong>FEE</strong>, or<br />
Conversion Factor x (Basic value + time unit value +<br />
modifier value) = ANESTHESIA <strong>FEE</strong><br />
Base Unit Values<br />
<strong>The</strong> base value includes the usual pre- and postoperative<br />
visits, intubation, care by the anesthesiologist during the<br />
procedure, the administration of fluids and blood, the usual<br />
monitoring services and extubation. Usual forms of<br />
monitoring included in the anesthesia service are<br />
electrocardiogram (ECG), temperature, blood pressure,<br />
oximetry, capnography, and mass spectrometry. Central<br />
venous, intra-arterial, and Swan-Ganz monitoring are<br />
considered unusual and are not included and may be coded<br />
CPT only © 2010 American Medical Association. All Rights Reserved. 27
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VI: Anesthesia Services<br />
and billed separately. Documentation of the medical<br />
necessity for these types of unusual monitoring is required.<br />
Dollar Conversion Factor<br />
Reimbursement for anesthesia services is based on a dollar<br />
conversion unit multiplied by the total anesthesia value<br />
(TAV) determined for each service rendered. <strong>The</strong> conversion<br />
factor for anesthesia is $36.56. This amount will be applied<br />
to the anesthesia values as described in the fee schedule.<br />
Physical Status Modifiers<br />
To report all anesthesia services use both the five-digit<br />
anesthesia code and a physical status modifier. <strong>The</strong>se<br />
modifying units may be added to the basic unit values. <strong>The</strong><br />
initial letter “P” followed by a single digit as defined below<br />
represents physical status modifiers:<br />
Physical Status Modifiers<br />
Unit Value<br />
P1 A normal, healthy patient 0<br />
P2 A patient with mild systemic disease 0<br />
P3 A patient with severe systemic disease 1<br />
P4 A patient w/severe systemic disease 2<br />
that is a constant threat to life<br />
P5 A moribund patient who is not<br />
3<br />
expected to survive without the<br />
operation<br />
P6 A declared brain-dead patient whose<br />
organs are being removed for donor<br />
purposes<br />
0<br />
Qualifying Circumstances<br />
Often anesthesia services are provided during times when<br />
other circumstances that affect the anesthesia service<br />
provided are present. <strong>The</strong>se special circumstances include<br />
emergently required procedures, management of body<br />
temperature or blood flow, and patient age. <strong>The</strong>se codes are<br />
not reported alone, but are used as an additional description<br />
of circumstances that affect the anesthesia service provided.<br />
When appropriate, more than one qualifying circumstance<br />
code may be reported.<br />
<strong>The</strong> following units may be added to the basic unit values for<br />
qualifying circumstances:<br />
Qualifying Circumstances<br />
Unit Value<br />
99100 Anesthesia for a patient of extreme age,<br />
younger than 1 year and older than 70<br />
(List separately in addition to code for<br />
primary anesthesia procedure)<br />
1<br />
99116 Anesthesia complicated by utilization<br />
of total body hypothermia (List<br />
separately in addition to code for<br />
primary anesthesia procedure)<br />
99135 Anesthesia complicated by utilization<br />
of controlled hypotension (List<br />
separately in addition to code for<br />
primary anesthesia procedure)<br />
99140 Anesthesia complicated by emergency<br />
conditions (specify) (List separately in<br />
addition to code for primary anesthesia<br />
procedure)<br />
Time Reporting<br />
Anesthesia time is continuous from the start of anesthesia,<br />
when the anesthesiologist, CRNA, or AA begins the<br />
preparation of the injured employee for anesthesia in the<br />
operating room or an equivalent area, and ends when the<br />
injured employee is placed under postoperative care, such as<br />
transfer to the recovery room. <strong>The</strong> time value is computed by<br />
allowing one unit for each ten (10) minutes of anesthesia<br />
time during the duration of the service or significant portion<br />
thereof with a significant portion being defined as five (5)<br />
minutes or more. In instances where total time units are less<br />
than ten (10) minutes, but five (5) minutes or more for the<br />
entire procedure, then one (1) time unit would be paid. For<br />
anesthesia lasting a total of less than five minutes, only base<br />
units without time units will be used to calculate<br />
reimbursement by the fee schedule. Acceptable time<br />
reporting requires that the hours and minutes of anesthesia<br />
be submitted.<br />
Example Anesthesia Fee Calculation<br />
Given a total time of two (2) hours for services provided<br />
using anesthesia with a basic unit of three, no physical status<br />
modifiers, and no qualifying circumstances, the anesthesia<br />
fee would be $548.40.<br />
01382 — Anesthesia for arthroscopic procedure of knee joint<br />
Dollar Conversion Unit = $36.56<br />
Basic Value = 3<br />
Time Unit Value = 12 (6 units per hour x 2 hrs)<br />
Modifier Value = 0<br />
Anesthesia Fee = ($36.56 x 3 Basic Value) + ($36.56 x 12<br />
Time Unit Value) + ($36.56 x 0 Modifier Value) = $548.40<br />
Required Modifiers<br />
Modifiers are required when reporting anesthesia services.<br />
When two modifiers identifying the provider or level of<br />
supervision (e.g., AD, QK, QX, QY) are applicable to a single<br />
code, indicate each modifier on the same bill on separate<br />
lines. Services reported without the required modifiers will<br />
be paid at the lowest allowed percentage (50%). See the<br />
5<br />
5<br />
2<br />
28 CPT only © 2010 American Medical Association. All Rights Reserved.
Section VI: Anesthesia Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Modifier subsection for a description of the required<br />
modifiers. Listed below are reimbursement guidelines for<br />
anesthesia services performed by anesthesiologists, CRNAs,<br />
and AAs.<br />
Reimbursement for Anesthesia Administered by an Anesthesiologist<br />
• Anesthesiologist services billed with modifier AA,<br />
reporting anesthesia services performed personally by<br />
the anesthesiologist, are reimbursed at 100 percent.<br />
Reimbursement for Medical Direction of CRNA or AA Services by an<br />
Anesthesiologist<br />
• Anesthesiologist services billed with modifier QK,<br />
reporting the supervision of two, three, or four CRNAs<br />
and/or AAs, are reimbursed at 50 percent.<br />
• Anesthesiologist services billed with modifier AD,<br />
reporting the supervision of more than four CRNAs<br />
and/or AAs, where the anesthesiologist is not present at<br />
the time of induction, are paid as follows: (3 base units<br />
+ time units) x 50 percent. When the anesthesiologist is<br />
present for induction, an additional time unit is paid<br />
when supporting documentation is submitted.<br />
Reimbursement is as follows: (3 base units + time units<br />
+ 1 time unit for induction) x 50 percent.<br />
• Anesthesiologist services billed with modifier QY<br />
reporting the supervision of one CRNA or AA are<br />
reimbursed at 50 percent.<br />
Note: When an anesthesiologist, employing a CRNA and/or<br />
AA, bills for anesthesia services, the anesthesiologist and<br />
CRNA or AA are both reimbursed at 50 percent.<br />
Reimbursement for Anesthesia Administered by a CRNA or AA<br />
• CRNA or AA services billed with modifier QX, reporting<br />
medically directed services, are reimbursed at 50<br />
percent.<br />
• CRNA or AA services billed with modifier QZ, reporting<br />
services without medical direction, are reimbursed at<br />
100 percent.<br />
Example of anesthesia fee calculation when an<br />
anesthesiologist provides medical direction of one CRNA:<br />
Given a total time of two (2) hours for services provided<br />
using anesthesia with a basic unit of three, no physical status<br />
modifiers, and no qualifying circumstances, the total<br />
anesthesia fee would be $548.40.<br />
01382-QY — Anesthesiologist providing medical direction<br />
of one CRNA for arthroscopic procedure of knee joint<br />
01382-QX — CRNA providing anesthesia for arthroscopic<br />
procedure of knee joint under the direction of an<br />
anesthesiologist<br />
Dollar Conversion Unit = $36.56<br />
Basic Value = 3<br />
Time Unit Value = 12 (6 units per hour x 2 hrs)<br />
Modifier Value = 0<br />
Total Anesthesia Fee = ($36.56 x 3 Basic Value) + ($36.56 x<br />
12 Time Unit Value) + ($36.56 x 0 Modifier Value) =<br />
$548.40<br />
Payment for anesthesiologist services 01382-QY @ 50%=<br />
$548.40 x 50% = $274.20<br />
Payment for CRNA services 01382-QX @ 50% = $548.40 x<br />
50% = $274.20<br />
Second Attending Anesthesiologist, CRNA, or AA<br />
When it is necessary to have a second attending<br />
anesthesiologist, CRNA, or AA assist with the preparation<br />
and conduction of anesthesia, these circumstances should be<br />
substantiated by special report. Reimbursement is as follows:<br />
• In the case where an anesthesiologist assumes the role of<br />
second anesthesiologist, both anesthesiologists should<br />
report their services with modifier AA. <strong>The</strong> first<br />
anesthesiologist will be reimbursed for the full basic<br />
value plus time and modifying units at 100 percent. <strong>The</strong><br />
second anesthesiologist will be reimbursed for a basic<br />
value of five units plus time and modifying units at 100<br />
percent. When the basic value assigned to the procedure<br />
is less than five, both the first anesthesiologist and the<br />
second anesthesiologist will be reimbursed at 100<br />
percent of the actual unit value of the procedure being<br />
performed.<br />
• When a CRNA or AA assumes the role of second<br />
anesthesiologist, a medical direction situation does not<br />
exist and the anesthesiologist should bill with modifier<br />
AA, then the CRNA or AA should bill with modifier QZ.<br />
<strong>The</strong> first anesthesiologist will be reimbursed for the full<br />
basic value plus time and modifying units at 100<br />
percent. <strong>The</strong> CRNA or AA will be reimbursed for a basic<br />
value of five units plus time and modifying units at 100<br />
percent. When the basic value assigned to the procedure<br />
is less than five, both the first anesthesiologist and the<br />
CRNA/AA assuming the role of second anesthesiologist<br />
will be reimbursed at 100 percent of the actual unit<br />
value of the procedure being performed.<br />
CPT only © 2010 American Medical Association. All Rights Reserved. 29
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Reporting Multiple Anesthesia Providers and Modifiers<br />
When the services of more than one anesthesia provider are<br />
reported on the same billing the following steps should be<br />
followed:<br />
1. <strong>The</strong> services of each provider should be reported on<br />
separate lines<br />
2. <strong>The</strong> appropriate modifier for each provider should be<br />
reported with the anesthesia code for the service<br />
3. <strong>The</strong> rendering provider’s ID number should be reported<br />
4. <strong>The</strong> modifiers identifying the provider type of service<br />
(AA, AD, QK, QX, QY, QZ) should be reported first, followed<br />
by other HCPCS or CPT modifiers<br />
SUBSECTION B: PAYMENT MODIFIERS FOR<br />
ANESTHESIA SERVICES<br />
All anesthesia services are reported by use of the anesthesia<br />
five-digit procedure code (00100–01999) plus the addition<br />
of a physical status modifier as outlined above. <strong>The</strong> added<br />
units for each physical status modifier are listed in the table<br />
in the physical status modifier paragraph above.<br />
It may be necessary to further modify listed services using<br />
CPT or HCPCS Level II modifiers. <strong>The</strong>se modifiers indicate a<br />
service or procedure performed has been altered by some<br />
specific circumstance but has not changed its definition or<br />
code. <strong>The</strong> modifying circumstance shall be identified by the<br />
appropriate modifier following the procedure code. When<br />
two modifiers identifying the provider or level of supervision<br />
(e.g., AD, QK, QX, QY) are applicable to a single code,<br />
indicate each modifier on the same bill on separate lines.<br />
<strong>The</strong> modifiers listed below may differ from those published<br />
by the American Medical Association. Medical providers<br />
submitting workers’ compensation billing shall use only the<br />
modifiers set out in the Medical Fee Guideline.<br />
Anesthesia Modifiers<br />
Under certain circumstances, medical services and<br />
procedures may need to be further modified. Modifiers<br />
commonly used in anesthesia are:<br />
22 Increased Procedural Services: When the work<br />
required to provide a service is substantially greater than<br />
typically required, it may be identified by adding<br />
modifier 22 to the usual procedure code.<br />
Documentation must support the substantial additional<br />
work and the reason for the additional work (ie,<br />
increased intensity, time, technical difficulty of<br />
procedure, severity of patient's condition, physical and<br />
mental effort required). Note: This modifier should not<br />
be appended to an E/M service.<br />
Section VI: Anesthesia Services<br />
23 Unusual Anesthesia: Occasionally, a procedure, which<br />
usually requires either no anesthesia or local anesthesia,<br />
because of unusual circumstances must be done under<br />
general anesthesia. This circumstance may be reported<br />
by adding modifier 23 to the procedure code of the<br />
basic service.<br />
47 Anesthesia by Surgeon: Regional or general anesthesia<br />
provided by the surgeon may be reported by adding<br />
modifier 47 to the basic service. (This does not include<br />
local anesthesia.) Note: Modifier 47 would not be used<br />
as a modifier for the anesthesia procedures<br />
00100–01999. <strong>The</strong> operating surgeon should report the<br />
surgical procedure 10021–69990 with modifier 47<br />
appended when billing for anesthesia services.<br />
53 Discontinued Procedure: Under certain circumstances,<br />
the physician may elect to terminate a surgical or<br />
diagnostic procedure. Due to extenuating circumstances<br />
or those that threaten the well-being of the patient, it<br />
may be necessary to indicate that a surgical or diagnostic<br />
procedure was started but discontinued. This<br />
circumstance may be reported by adding modifier 53 to<br />
the code reported by the physician for the discontinued<br />
procedure. Note: This modifier is not used to report the<br />
elective cancellation of a procedure prior to the patient’s<br />
anesthesia induction and/or surgical preparation in the<br />
operating suite. For outpatient hospital/ambulatory<br />
surgery center (ASC) reporting of a previously<br />
scheduled procedure/service that is partially reduced or<br />
cancelled as a result of extenuating circumstances or<br />
those that threaten the well-being of the patient prior to<br />
or after administration of anesthesia, see modifiers 73<br />
and 74 (see modifiers approved for ASC hospital<br />
outpatient use).<br />
59 Distinct Procedural Service: Under certain<br />
circumstances, it may be necessary to indicate that a<br />
procedure or service was distinct or independent from<br />
other non-E/M services performed on the same day.<br />
Modifier 59 is used to identify procedures/services,<br />
other than E/M services, that are not normally reported<br />
together but are appropriate under the circumstances.<br />
Documentation must support a different session,<br />
different procedure or surgery, different site or organ<br />
system, separate incision or excision, separate lesion, or<br />
separate injury (or area of injury in extensive injuries)<br />
not ordinarily encountered or performed on the same<br />
day by the same individual. However, when another<br />
already established modifier is appropriate, it should be<br />
used rather than modifier 59. Only if no more<br />
descriptive modifier is available, and the use of modifier<br />
59 best explains the circumstances, should modifier 59<br />
be used. Note: Modifier 59 should not be appended to<br />
an E/M service. To report a separate and distinct E/M<br />
30 CPT only © 2010 American Medical Association. All Rights Reserved.
Section VI: Anesthesia Services<br />
service with a non-E/M service performed on the same<br />
date, see modifier 25.<br />
AA Anesthesia Services Performed Personally by<br />
Anesthesiologist: Report modifier AA when the<br />
anesthesia services are personally performed by an<br />
anesthesiologist. Claims submitted with modifier AA are<br />
reimbursed at 100 percent.<br />
AD Medical Supervision by a Physician; More Than Four<br />
Concurrent Anesthesia Procedures: Report modifier<br />
AD when the anesthesiologist supervises more than four<br />
concurrent anesthesia procedures. Claims submitted<br />
with modifier AD are reimbursed as described in the<br />
preceding section.<br />
G8 Monitored Anesthesia Care (MAC) for Deep,<br />
Complex, Complicated or Markedly Invasive<br />
Surgical Procedures: Report modifier G8 when<br />
monitored anesthesia care is required for deep,<br />
complex, complicated, or markedly invasive surgical<br />
procedures.<br />
G9 Monitored Anesthesia Care for Patient Who Has a<br />
History of Severe Cardiopulmonary Condition:<br />
Report modifier G9 when monitored anesthesia care is<br />
required for a patient who has a history of severe<br />
cardiopulmonary condition.<br />
NT No Time (State Specific Modifier): If the surgeon or<br />
attending physician administers a local or regional block<br />
for anesthesia during a procedure, the bill should so<br />
indicate with the use of modifier NT for “no time.”<br />
QK Medical Direction of Two, Three, or Four<br />
Concurrent Anesthesia Procedures Involving<br />
Qualified Individuals: Report modifier QK when the<br />
anesthesiologist supervises two, three, or four<br />
concurrent anesthesia procedures. Claims submitted<br />
with modifier QK are reimbursed at 50 percent.<br />
QS Monitored Anesthesia Care Service: <strong>The</strong> QS modifier<br />
is for informational purposes.<br />
QX CRNA or AA Service with Medical Direction by a<br />
Physician (Modified by State): Regional or general<br />
anesthesia provided by the CRNA or AA with medical<br />
direction by a physician may be reported by adding<br />
modifier QX. Claims submitted with modifier QX are<br />
reimbursed at 50 percent.<br />
QY Medical Supervision of One CRNA or AA by an<br />
Anesthesiologist (Modified by State): Report modifier<br />
QY when the anesthesiologist supervises one CRNA or<br />
AA. Claims submitted with modifier QY are reimbursed<br />
at 50 percent.<br />
QZ CRNA or AA Service without Medical Direction by a<br />
Physician (Modified by State): Regional or general<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
anesthesia provided by the CRNA or AA without<br />
medical direction by a physician may be reported by<br />
adding modifier QZ. Claims submitted with modifier<br />
QZ are reimbursed at 100 percent.<br />
Physical Status Modifiers<br />
Physical status modifiers reflect the patient’s state of health.<br />
Individuals undergoing surgery may be healthy or may have<br />
varying degrees of system disease. A patient’s health status<br />
affects the work related to providing the anesthesia service. A<br />
listing of physical status modifiers and the modifying units<br />
associated with each is provided in Subsection A: Payment<br />
Ground Rules for Anesthesia Services.<br />
Qualifying Circumstances<br />
Qualifying circumstances that significantly impact the<br />
character of the anesthesia service provided and associated<br />
relative values are listed in Subsection A: Payment Ground<br />
Rules for Anesthesia Services.<br />
Miscellaneous<br />
Anesthesia Services Provided by the Operating Surgeon<br />
Local infiltration, digital block, or topical anesthesia<br />
administered by the operating surgeon is included in the<br />
unit value for the surgical procedure.<br />
If the attending surgeon administers anesthesia, the value<br />
shall be the lesser of the basic unit value without benefit for<br />
time or 25 percent of the total dollar value of the surgery.<br />
(See modifier 47 for guidelines on reporting administration<br />
of anesthesia by the attending surgeon.)<br />
Major regional anesthesia administered by the surgeon, such<br />
as a spinal epidural or major peripheral nerve block, shall be<br />
reimbursed the basic anesthesia value only without benefit<br />
for time. (See modifier 47 for guidelines on reporting<br />
administration of anesthesia by the attending surgeon.)<br />
If the surgeon or attending physician administers a local or<br />
regional block for anesthesia during a procedure, the bill<br />
should so indicate with the use of a modifier NT for “no<br />
time.”<br />
Nerve Block<br />
For diagnostic or therapeutic nerve block, see 62310–62319<br />
and 64400–64530.<br />
For diagnostic or therapeutic nerve blocks performed by the<br />
surgeon, anesthesiologist, CRNA, or AA, only one<br />
reimbursement per procedure shall be allowed, regardless of<br />
the time required (e.g., see codes 62310–62319,<br />
64400–64530).<br />
CPT only © 2010 American Medical Association. All Rights Reserved. 31
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Moderate (Conscious) Sedation<br />
For reporting requirements and reimbursement guidelines<br />
related to moderate (conscious) sedation services, see<br />
Section IV: General Reimbursement Requirements, CPT<br />
Codes That Include Moderate (Conscious) Sedation.<br />
Field Avoidance<br />
Any procedure around the head, neck, or shoulder girdle<br />
that requires field avoidance or any procedure compromising<br />
the anesthesia administration (e.g., requiring a position other<br />
than supine or lithotomy) has a minimum basic value of 5.0<br />
units regardless of any lesser basic value assigned to such<br />
procedures. In this case, modifier 22 is required.<br />
Multiple Procedures<br />
Anesthesia reimbursement for multiple procedures is based<br />
on the procedure with the highest base value, plus modifying<br />
units (if appropriate), plus total time units for all combined<br />
surgical procedures.<br />
No additional base value shall be reimbursed for anesthesia<br />
rendered during additional surgical procedures (other than<br />
the primary procedure) performed on the same day during<br />
the same operative setting.<br />
Section VI: Anesthesia Services<br />
Adjunctive Services<br />
Adjunctive services provided during anesthesia and certain<br />
other circumstances may warrant an additional charge.<br />
Identify by using the appropriate unit value modifier.<br />
Cardiopulmonary Resuscitation<br />
For cardiopulmonary resuscitation (independent procedure),<br />
see 92950.<br />
Time Units<br />
<strong>The</strong> time value is computed by allowing one unit for each<br />
ten (10) minutes of anesthesia time during the duration of<br />
the service or significant portion thereof with a significant<br />
portion being defined as five (5) minutes or more. In<br />
instances where total time units are less than ten (10)<br />
minutes, but five (5) minutes or more for the entire<br />
procedure, then one (1) time unit would be paid. For<br />
anesthesia lasting a total of less than five minutes, only base<br />
units without time units will be used to calculate<br />
reimbursement by the fee schedule. (See Subsection A:<br />
Payment Ground Rules for Anesthesia Services, for<br />
additional information on reporting of time units.)<br />
32 CPT only © 2010 American Medical Association. All Rights Reserved.
Section VI: Anesthesia Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
00100–01999, 99100–99140 ANESTHESIA<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION BASE UNIT<br />
00100 ANESTHESIA SALIVARY GLANDS WITH BIOPSY 5<br />
00102 ANESTHESIA CLEFT LIP INVOLVING PLASTIC REPAIR 6<br />
00103 ANESTHESIA EYELID RECONSTRUCTIVE PROCEDURE 5<br />
00104 ANESTHESIA ELECTROCONVULSIVE THERAPY 4<br />
00120 ANESTHESIA EXTERNAL MIDDLE & INNER EAR W/BIOPSY 5<br />
00124 ANES EXTERNAL MIDDLE & INNER EAR W/BX OTOSCOPY 4<br />
00126 ANES XTRNL MID & INNER EAR W/BX TYMPANOTOMY 4<br />
00140 ANESTHESIA EYE NOT OTHERWISE SPECIFIED 5<br />
00142 ANESTHESIA EYE LENS SURGERY 4<br />
00144 ANESTHESIA EYE CORNEAL TRANSPLANT 6<br />
00145 ANESTHESIA EYE VITREORETINAL SURGERY 6<br />
00147 ANESTHESIA EYE IRIDECTOMY 4<br />
00148 ANESTHESIA EYE OPHTHALMOSCOPY 4<br />
00160 ANESTHESIA NOSE & ACCESSORY SINUSES 5<br />
00162 ANES NOSE & ACCESSORY SINUSES RADICAL SURGERY 7<br />
00164 ANES NOSE&ACCESSORY SINUSES BIOPSY SOFT TISSUE 4<br />
00170 ANESTHESIA INTRAORAL WITH BIOPSY 5<br />
00172 ANES INTRAORAL W/BIOPSY REPAIR CLEFT PALATE 6<br />
00174 ANES INTRAORAL W/BX EXC RETROPHARYNGEAL TUMOR 6<br />
00176 ANESTHESIA INTRAORAL W/BIOPSY RADICAL SURGERY 7<br />
00190 ANESTHESIA FACIAL BONES OR SKULL 5<br />
00192 ANES FACIAL BONES/SKULL RAD SURG W/PROGNATHISM 7<br />
00210 ANESTHESIA INTRACRANIAL PROCEDURE NOS 11<br />
00211 ANES INTRACRANIAL CRANIOTOMY/CRANIECTOMY HMTMA 10<br />
00212 ANESTHESIA INTRACRANIAL PROCEDURE SUBDURAL TAPS 5<br />
00214 ANES INTRACRANIAL BURR HOLES W/VENTRICULOGRAPHY 9<br />
00215 ANES ICRA CRNOP/ELEVATION DEPRS SKULL FX XDRL 9<br />
00216 ANESTHESIA INTRACRANIAL VASCULAR PROCEDURE 15<br />
00218 ANES INTRACRANIAL PROCEDURE IN SITTING POSITION 13<br />
00220 ANES INTRACRANIAL CEREBROSPINAL FLUID SHUNTING 10<br />
00222 ANES INTRACRANIAL ELECTROCOAGULATION ICRA NERVE 6<br />
00300 ANES INTEG MUSC&NRV HEAD NCK&POSTERIOR TRUNK 5<br />
00320 ANES ESOPH THYR LARX TRACH&LYMPHTC NECK 1YR/> 6<br />
00322 ANES ESOPH THYR LARX TRACH&LYMPHTC NCK BX THYR 3<br />
00326 ANESTHESIA LARYNX & TRACHEA CHILDREN
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VI: Anesthesia Services<br />
ANESTHESIA 00100–01999, 99100–99140<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION BASE UNIT<br />
00472 ANESTHESIA PARTIAL RIB RESECTION THORACOPLASTY 10<br />
00474 ANESTHESIA PARTIAL RIB RESECTION RADICAL 13<br />
00500 ANESTHESIA ESOPHAGUS 15<br />
00520 ANESTHESIA CLOSED CHEST W/BRONCHOSCOPY 6<br />
00522 ANESTHESIA CLOSED CHEST NEEDLE BIOPSY PLEURA 4<br />
00524 ANESTHESIA CLOSED CHEST PNEUMOCENTESIS 4<br />
00528 ANES CLSD CHEST MEDIASTSC&THRSC W/O 1 LUNG VNTJ 8<br />
00529 ANES CLOSED CHEST MEDIASTSC&THRSC W/1 LUNG VNTJ 11<br />
00530 ANES PERMANENT TRANSVENOUS PACEMAKER INSERTION 4<br />
00532 ANESTHESIA ACCESS CENTRAL VENOUS CIRCULATION 4<br />
00534 ANES TRANSVENOUS INSJ/REPLACEMENT PACING CVDFB 7<br />
00537 ANES CARDIAC ELECTROPHYSIOLOGIC W/RF ABLATION 7<br />
00539 ANESTHESIA TRACHEOBRONCHIAL RECONSTRUCTION 18<br />
00540 ANESTHESIA THRCM LUNG PLEURA DPHRM&MED THRSC 12<br />
00541 ANES THRCM LUNG PLEURA DPHRM&MED THRSC 1 LUNG 15<br />
00542 ANES THRCM LUNG PLEURA DPHRM&MED THRSC DCRTCTJ 15<br />
00546 ANES THRCM LNG PLEUR DPHRM&MED THRSC PULM RESCJ 15<br />
00548 ANES THRCM LNG PLEUR DPHRM&MED THRSC TRACH&BRNCH 17<br />
00550 ANESTHESIA FOR STERNAL DEBRIDEMENT 10<br />
00560 ANES HRT PRCRD SAC&GREAT VESSEL CH W/O PMP OXTJ 15<br />
00561 ANES HRT PRCRD SAC&GREAT VSL CH W/PMP OXTJ 20<br />
00563 ANES HRT PRCRD&GREAT VSL CH W/PUMP OXTJ HYPTHRM 25<br />
00566 ANES DIR CAB GRFG W/O PMP OXTJ 25<br />
00567 ANES DIRECT CAB GRAFTING W/ PUMP OXYGENATOR 18<br />
00580 ANES HEART TRANSPLANT/HEART/LUNG TRANSPLANT 20<br />
00600 ANESTHESIA CERVICAL SPINE & CORD 10<br />
00604 ANES CERVICAL SPINE&CORD W/PATIENT SITTING 13<br />
00620 ANESTHESIA THORACIC SPINE & CORD 10<br />
00622 ANES THORACIC SPINE&CORD THORACOLMBR SYMPTH 13<br />
00625 ANES THRC SPINE & CORD ANT APPR W/O 1 LUNG VNTJ 13<br />
00626 ANES THORACIC SPINE & C/D ANT APPR W/1 LNG VNTJ 15<br />
00630 ANESTHESIA LUMBAR REGION 8<br />
00632 ANESTHESIA LUMBAR REGION LUMBAR SYMPATHECTOMY 7<br />
00634 ANESTHESIA LUMBAR CHEMONUCLEOLYSIS 10<br />
00635 ANES DIAGNOSTIC/THERAPEUTIC LUMBAR PUNCTURE 4<br />
00640 ANES MNPJ SPINE/CLSD CRV THORACIC/LUMBAR SPINE 3<br />
00670 ANESTHESIA EXTENSIVE SPINE & SPINAL CORD 13<br />
00700 ANESTHESIA UPPER ANTERIOR ABDOMINAL WALL 4<br />
00702 ANES UPR ANT ABDL WALL PERCUTANEOUS LIVER BX 4<br />
00730 ANESTHESIA UPPER POSTERIOR ABDOMINAL WALL 5<br />
00740 ANES UPPER GI ENDOSCOPIC PROXIMAL TO DUODENUM 5<br />
00750 ANESTHESIA HERNIA REPAIR UPPER ABDOMEN 4<br />
00752 ANES HRNA RPR UPR ABD LMBR&VNT HRNAS&/WND DEHSN 6<br />
00754 ANES HERNIA REPAIR UPPER ABDOMEN OMPHALOCELE 7<br />
00756 ANES HRNA REPAIR UPR ABD TABDL RPR DIPHRG HRNA 7<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure<br />
34 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VI: Anesthesia Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
00100–01999, 99100–99140 ANESTHESIA<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION BASE UNIT<br />
00770 ANESTHESIA MAJOR ABDOMINAL BLOOD VESSELS 15<br />
00790 ANES INTRAPERITONEAL UPPER ABDOMEN W/LAPS 7<br />
00792 ANES IPR UPR ABD LAPS PRTL HPTC/MGMT LVR HEMRRG 13<br />
00794 ANES IPR UPPER ABD W/LAPS PNCRTECT PRTL/TOTAL 8<br />
00796 ANES IPR UPPER ABD W/LAPS LIVER TRANSPLANT 30<br />
00797 ANES IPR UPPER ABDOMEN LAPS GASTRIC RSTCV MO 11<br />
00800 ANESTHESIA LOWER ANTERIOR ABDOMINAL WALL 4<br />
00802 ANES LOWER ANT ABDOMINAL WALL PANNICULECTOMY 5<br />
00810 ANES LOWER INTESTINAL NDSC DISTAL DUODENUM 5<br />
00820 ANESTHESIA LOWER POSTERIOR ABDOMINAL WALL 5<br />
00830 ANESTHESIA HERNIA REPAIR LOWER ABDOMEN 4<br />
00832 ANES HRNA RPR LWR ABD VENTRAL&INCAL HRNAS 6<br />
00834 ANES HERNIA REPAIR LOWER ABDOMEN NOS
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VI: Anesthesia Services<br />
ANESTHESIA 00100–01999, 99100–99140<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION BASE UNIT<br />
00930 ANES ORCHIOPEXY UNI/BI INCL OPEN URETHRAL PX 4<br />
00932 ANES COMPLETE AMPUTATION PENIS INCL OPEN URTL 4<br />
00934 ANES RAD AMP PENIS W/BI INGUINAL NODE OPN URTL 6<br />
00936 ANES RAD AMP PNS W/BI INGUN&ILIAC INCL OPN URTL 8<br />
00938 ANES INSJ PENILE PROSTH PRNL INCL OPEN URTL 4<br />
00940 ANESTHESIA VAGINAL PROCEDURE INCL BIOPSY 3<br />
00942 ANES COLPTMY VAGNC COLPRPHY INCL BX W/OPN URTL 4<br />
00944 ANESTHESIA VAGINAL HYSTERECTOMY INCL BIOPSY 6<br />
00948 ANESTHESIA CERVICAL CERCLAGE INCLUDING BIOPSY 4<br />
00950 ANESTHESIA CULDOSCOPY INCLUDING BIOPSY 5<br />
00952 ANES HYSTEROSCOPY&/HYSTEROSALPINGOGRAPHY W/BX 4<br />
01112 ANES BONE MARROW ASPIR&/BX ANT/PST ILIAC CREST 5<br />
01120 ANESTHESIA ON BONY PELVIS 6<br />
01130 ANESTHESIA BODY CAST APPLICATION OR REVISION 3<br />
01140 ANESTHESIA INTERPELVIABDOMINAL AMPUTATION 15<br />
01150 ANES RADICAL TUMOR PELVIS XCP HINDQUARTER AMP 10<br />
01160 ANES CLOSED SYMPHYSIS PUBIS/SACROILIAC JOINT 4<br />
01170 ANES OPEN SYMPHYSIS PUBIS/SACROILIAC JOINT 8<br />
01173 ANES OPN RPR DISRPJ PELVIS/COLUMN FX ACETABULUM 12<br />
01180 ANESTHESIA OBTURATOR NEURECTOMY EXTRAPELVIC 3<br />
01190 ANESTHESIA OBTURATOR NEURECTOMY INTRAPELVIC 4<br />
01200 ANESTHESIA HIP JOINT 4<br />
01202 ANESTHESIA ARTHROSCOPY HIP JOINT 4<br />
01210 ANESTHESIA OPEN PX HIP JOINT 6<br />
01212 ANESTHESIA OPEN HIP JOINT DISARTICULATION 10<br />
01214 ANESTHESIA OPEN TOTAL HIP ARTHROPLASTY 8<br />
01215 ANESTHESIA OPEN REVISION TOTAL HIP ARTHROPLASTY 10<br />
01220 ANESTHESIA UPPER 2/3 FEMUR CLOSED PROCEDURES 4<br />
01230 ANESTHESIA UPPER 2/3 FEMUR OPEN PROCEDURES 6<br />
01232 ANESTHESIA UPPER 2/3 FEMUR AMPUTATION 5<br />
01234 ANES UPPER 2/3 FEMUR RADICAL RESCECTION 8<br />
01250 ANES NERVE MUSC TENDON FASCIA&BURSAE UPPER LEG 4<br />
01260 ANES VEINS OF UPPER LEG INCLUDING EXPLORATION 3<br />
01270 ANESTHESIA ARTERIES UPPER LEG INCL BYPASS GRAFT 8<br />
01272 ANES ART UPPER LEG W/BYPASS GRAFT FEM ART LIG 4<br />
01274 ANES ARTERIES UPPER LEG W/BYP GRF FEM ART EMBLC 6<br />
01320 ANES NERVE MUSC TENDON FSCA&BRS KNEE&/POP AREA 4<br />
01340 ANESTHESIA LOWER 1/3 FEMUR CLOSED PROCEDURES 4<br />
01360 ANESTHESIA LOWER 1/3 FEMUR OPEN PROCEDURES 5<br />
01380 ANESTHESIA KNEE JOINT CLOSED PROCEDURES 3<br />
01382 ANESTHESIA DIAGNOSTIC ARTHROSCOPIC KNEE JOINT 3<br />
01390 ANES UPPER ENDS TIBIA FIBULA&/PATELLA CLOSED 3<br />
01392 ANES UPPER ENDS TIBIA FIBULA&/PATELLA OPEN 4<br />
01400 ANES OPEN/SURGICAL ARTHROSCOPIC KNEE JOINT 4<br />
01402 ANESTHESIA ARTHROSCOPIC TOTAL KNEE ARTHROPLASTY 7<br />
01404 ANESTHESIA ARTHROSCOPIC KNEE DISARTICULATION 5<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure<br />
36 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VI: Anesthesia Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
00100–01999, 99100–99140 ANESTHESIA<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION BASE UNIT<br />
01420 ANES CAST APPLICATION REMOVAL/REPAIR KNEE JOINT 3<br />
01430 ANESTHESIA VEINS KNEE & POPLITEAL AREA 3<br />
01432 ANESTHESIA VEINS KNEE & POPLITEAL ARVEN FISTULA 6<br />
01440 ANESTHESIA ARTERIES OF KNEE & POPLITEAL AREA 8<br />
01442 ANES ART KNEE & POP/POP TEAEC +-PATCH GRAFT 8<br />
01444 ANES ART KNE&POP/POP EXC&GRF/RPR OCCLS/ARYSM 8<br />
01462 ANESTHESIA LOWER LEG ANKLE & FOOT CLOSED PX 3<br />
01464 ANESTHESIA ANKLE &/FOOT ARTHROSCOPIC PX 3<br />
01470 ANES NRV/MUS/TND/FASC LOWER LEG/ANKLE/FOOT 3<br />
01472 ANES RPR RUPTURED ACHILLES TENDON +-PATCH GRAFT 5<br />
01474 ANESTHESIA GASTROCNEMIUS RECESSION 5<br />
01480 ANESTHESIA BONES LOWER LEG/ANKLE/FOOT OPEN PX 3<br />
01482 ANES RADICAL RESECTION INCL BELOW KNEE AMP 4<br />
01484 ANES OSTEOTOMY/OSTEOPLASTY TIBIA&/FIBULA OPEN 4<br />
01486 ANESTHESIA TOTAL ANKLE REPLACEMENT OPEN 7<br />
01490 ANES LOWER LEG CAST APPLICATION REMOVAL/REPAIR 3<br />
01500 ANESTHESIA ARTERIES LOWER LEG W/BYPASS GRAFT 8<br />
01502 ANES ART LOWER LEG W/BYP GRAFT EMBLC DIR/W/CATH 6<br />
01520 ANESTHESIA VEINS OF LOWER LEG 3<br />
01522 ANES VEINS LOWER LEG VENOUS THRMBC DIR/W/CATH 5<br />
01610 ANES NERVE MUSCLE TENDON FSCA&BRS SHO&AXILLA 5<br />
01620 ANES CLOSED HUMRL H/N STRNCLAV JOINT&SHO JOINT 4<br />
01622 ANES SHOULDER JOINT DIAGNOSTIC ARTHROSCOPIC PX 4<br />
01630 ANES ARTHRS HUMERAL H/N STRNCLAV&SHOULDER JOINT 5<br />
01634 ANESTHESIA ARTHROSCOPIC SHOULDER DISARTICULATION 9<br />
01636 ANES ARTHRS INTERTHORACOSCAPULAR AMPUTATION 15<br />
01638 ANES ARTHROSCOPIC TOTAL SHOULDER REPLACEMENT 10<br />
01650 ANESTHESIA ARTERIES SHOULDER & AXILLA 6<br />
01652 ANESTHESIA AXILLARY-BRACHIAL ANEURYSM 10<br />
01654 ANES ARTERIES SHOULDER & AXILLA BYPASS GRAFT 8<br />
01656 ANESTHESIA AXILLARY-FEMORAL BYPASS GRAFT 10<br />
01670 ANESTHESIA VEINS SHOULDER & AXILLA 4<br />
01680 ANES SHOULDER CAST APPLICATION REMOVAL/REPAIR 3<br />
01682 ANES SHOULDER SPICA APPLICATION REMOVAL/REPAIR 4<br />
01710 ANES NRV MUSC TDN FSCA&BRS UPR ARM/ELBOW 3<br />
01712 ANESTHESIA TENOTOMY ELBOW TO SHOULDER OPEN 5<br />
01714 ANESTHESIA TENOPLASTY ELBOW TO SHOULDER 5<br />
01716 ANESTHESIA BICEPS TENODESIS RUPTURE LONG TENDON 5<br />
01730 ANESTHESIA HUMERUS & ELBOW CLOSED PX 3<br />
01732 ANESTHESIA ELBOW JOINT DIAGNOSTIC ARTHROSCOPIC 3<br />
01740 ANESTHESIA ELBOW OPEN/SURGICAL ARTHROSCOPIC 4<br />
01742 ANESTHESIA HUMERUS ARTHROSCOPIC OSTEOTOMY 5<br />
01744 ANES HUMERUS ARTHROSCOPIC REPAIR NON/MALUNION 5<br />
01756 ANESTHESIA ELBOW ARTHROSCOPIC RADICAL PX 6<br />
01758 ANES HUMERUS ARTHROSCOPIC EXCISION CYST/TUMOR 5<br />
01760 ANES ARTHROSCOPIC TOTAL ELBOW REPLACEMENT 7<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 37
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VI: Anesthesia Services<br />
ANESTHESIA 00100–01999, 99100–99140<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION BASE UNIT<br />
01770 ANESTHESIA ARTERIES UPPER ARM & ELBOW 6<br />
01772 ANESTHESIA ARTERIES UPPER ARM&ELBOW EMBOLECTOMY 6<br />
01780 ANESTHESIA VEINS UPPER ARM & ELBOW 3<br />
01782 ANESTHESIA VEINS UPPER ARM&ELBOW PHLEBORRHAPHY 4<br />
01810 ANES NERVE MUSCLE TDN FSCA&BRS F/ARM WRST&HAND 3<br />
01820 ANES RADIUS ULNA WRIST/HAND BONES CLOSED PX 3<br />
01829 ANESTHESIA WRIST DIAGNOSTIC ARTHROSCOPIC 3<br />
01830 ANES ARTHRS/ENDOSCOPIC DSTL RADIUS DSTL U/W/H 3<br />
01832 ANESTHESIA ARTHROSCOPIC TOTAL WRIST REPLACEMENT 6<br />
01840 ANESTHESIA ARTERIES FOREARM WRIST & HAND 6<br />
01842 ANES ARTERIES FOREARM WRIST&HAND EMBOLECTOMY 6<br />
01844 ANESTHESIA VASCULAR SHUNT/SHUNT REVISION 6<br />
01850 ANESTHESIA VEINS FOREARM WRIST & HAND 3<br />
01852 ANES VEINS FOREARM WRIST&HAND PHLEBORRHAPHY 4<br />
01860 ANES FOREARM WRIST/HAND CAST APPL RMVL/REPAIR 3<br />
01916 ANESTHESIA DIAGNOSTIC ARTERIOGRAPHY/VENOGRAPH 5<br />
01920 ANES C-CATHJ W/C ANGIOGRAPHY&VENTRICULOGRAPHY 7<br />
01922 ANES NON-INVASIVE IMAGING/RADIATION THERAPY 7<br />
01924 ANESTHESIA THER IVNTL RADIOLOGICAL ARTERIAL 5<br />
01925 ANESTHESIA CAROTID/CORONARY THER IVNTL RAD 7<br />
01926 ANES ICRA ICAR/AORTIC THER IVNTL RAD ARTL 8<br />
01930 ANESTHESIA VENOUS/LYMPHATIC NOS THER IVNTL RAD 5<br />
01931 ANESTHESIA INTRAHEPATIC/PORTAL THER IVNTL RAD 7<br />
01932 ANESTHESIA INTRATHORACIC/JUGULAR THER IVNTL RAD 6<br />
01933 ANES INTRACRANIAL THER IVNTL RAD VENS/LYMPHTC 7<br />
01935 ANESTHESIA PERQ IMAGE GUIDED SPINE DIAGNOSTIC 5<br />
01936 ANESTHESIA PERQ IMAGE GUIDED SPINE THERAPEUTIC 5<br />
01951 ANES 2/3 DGR BRN EXC/DBRDMT +-GRF 9 % TBSA 1<br />
01958 ANESTHESIA EXTERNAL CEPHALIC VERSION 5<br />
01960 ANESTHESIA VAGINAL DELIVERY ONLY 5<br />
01961 ANESTHESIA CESAREAN DELIVERY ONLY 7<br />
01962 ANES URGENT HYSTERECTOMY FOLLOWING DELIVERY 8<br />
01963 ANESTHESIA C HYST W/O ANY LABOR ANALG/ANES CARE 8<br />
01965 ANESTHESIA INCOMPLETE/MISSED ABORTION 4<br />
01966 ANESTHESIA INDUCED ABORTION 4<br />
01967 NEURAXIAL LABOR ANALG/ANES PLND VAG DLVR 5<br />
+ 01968 ANES C DLVR FLWG NEURAXIAL LABOR ANALG/ANES 2<br />
+ 01969 ANES C HYST FLWG NEURAXIAL LABOR ANALG/ANES 5<br />
01990 PHYSIOL SUPPORT HRVG ORGAN FROM BRN-DEAD PT 7<br />
01991 ANES DX/THER NRV BLK/NJX OTH/THN PRONE POS 3<br />
01992 ANES DX/THER NERVE BLOCK/INJECTION PRONE POS 5<br />
01996 DAILY HOSP MGMT EDRL/SARACH CONT DRUG ADMN 3<br />
01999 UNLISTED ANESTHESIA PROCEDURE BR<br />
+ 99100 ANESTHESIA EXTREME AGE PATIENT UNDER 1 YR&> 70 See Page 28<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure<br />
38 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VI: Anesthesia Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
00100–01999, 99100–99140 ANESTHESIA<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION BASE UNIT<br />
+ 99116 ANES COMP UTILIZATION TOT BDY HYPOTHMIA See Page 28<br />
+ 99135 ANES COMP UTILIZATION CTRLLED HYPOTENSION See Page 28<br />
+ 99140 ANES COMP EMER CONDITIONS SPEC See Page 28<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 39
Section VII: Surgical Services<br />
SUBSECTION A: PAYMENT GROUND RULES FOR<br />
SURGICAL SERVICES<br />
General Guidelines<br />
Listed values for all surgical procedures include the surgery,<br />
local infiltration, digital block or topical anesthesia when<br />
used. <strong>The</strong> normal uncomplicated follow-up care for the<br />
period is indicated in days in the column headed “FUD”<br />
(Follow-up Days).<br />
CPT Surgical Package Definition<br />
Inherent in the provision of any surgical procedure are<br />
certain components that may not be specifically identified in<br />
the code description, but are nonetheless included. <strong>The</strong>se<br />
services may include the following components:<br />
• Local anesthesia including topical, infiltration,<br />
metacarpal/metatarsal/digital block<br />
• One E/M service, other than the decision for surgery, on<br />
the date prior to, or date of the procedure and includes<br />
related history and physical<br />
• Postoperative services immediately following the<br />
procedure including discussion with the family and<br />
other physicians, dictation of operative report, writing<br />
operative summary and orders in the patient chart<br />
• Evaluation of the patient after transfer from the post<br />
anesthesia recovery area<br />
• Postoperative follow-up care associated with the<br />
procedure<br />
Unusual Service or Procedure<br />
Services that may necessitate skills and time of the physician<br />
over and above that usually required should be substantiated<br />
by report (see section IV).<br />
Unlisted Service or Procedure<br />
Some services performed are not described by any CPT code.<br />
<strong>The</strong>se services should be reported using an unlisted code<br />
and substantiated using a report. <strong>The</strong> unlisted services and<br />
accompanying codes are listed at the end of each Surgery<br />
subsection. Unlisted service or procedure codes must be<br />
selected from the appropriate subsection of the Surgery<br />
chapter. For these procedures a “BR” (by report) designation<br />
has been used in the fee schedule. Reimbursement for such<br />
procedures must be justified by report (see section IV).<br />
Surgical Assistants<br />
Certain circumstances may warrant the concurrent services<br />
of more than one surgeon. Should the services of an assistant<br />
surgeon be medically necessary, adding modifier 80 to the<br />
usual procedure number would identify the services.<br />
According to the Board, the total reimbursement for assistant<br />
surgeon services is at 20 percent of the primary surgeon’s fee.<br />
Other surgical assistants will be reimbursed as defined by the<br />
appropriate fee schedule arrangements (see appropriate<br />
category of service).<br />
If circumstances warrant the concurrent services of a surgeon<br />
and an assistant and it is medically necessary, those services<br />
may be performed by a physician extender (PE), in the<br />
categories set forth herein, in the place of the assistant<br />
surgeon, when medically appropriate. Fees for registered<br />
nurse first assistant (RNFA), nurse practitioner (NP), or<br />
physician assistant (PA) if utilized in the place of an assistant<br />
surgeon during surgical procedures are to be reimbursed at<br />
10 percent of the primary surgeon’s fee. In accordance with<br />
O.C.G.A. §33-24-59.9, the RNFA shall not be on the staff of<br />
a hospital or the treating physician. Should the services of a<br />
RNFA, NP, or PA be medically necessary, add modifier AS to<br />
the usual procedure number to identify the services and list<br />
on a separate line from surgeon’s fee on the CMS-1500 or a<br />
Uniform Billing 04 (UB-04) or electronic form.<br />
Separate Procedure Performed by Assistants<br />
Certain procedures are an inherent portion of a procedure or<br />
service and do not warrant a separate identification. If,<br />
however, such a procedure is performed independently of,<br />
and is not immediately related to other services, it may be<br />
listed as a “separate procedure.” Thus, when a procedure that<br />
is ordinarily a component of a larger procedure is performed<br />
alone for a specific purpose, it may be considered a separate<br />
procedure.<br />
Co-Surgeons<br />
When medically indicated during surgery, and when two<br />
different specialists are performing separate procedures for<br />
treatment of a common problem, each physician shall reduce<br />
CPT only © 2010 American Medical Association. All Rights Reserved. 41
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
the fee of their particular procedure by 25 percent and add<br />
modifier 62. Under such circumstances, the modifier shall<br />
be added to the procedure number used by each surgeon for<br />
reporting his/her services.<br />
Immediate Preoperative Visits and Other Services by the<br />
Surgeon<br />
Under most circumstances, including ordinary referrals, the<br />
immediate preoperative visit in the hospital or elsewhere<br />
necessary to examine the injured employee, complete the<br />
hospital records, and initiate the treatment program is<br />
included in the listed value for the surgical procedure. If a<br />
health care provider other than the physician performing the<br />
surgery performs the preoperative history and physical, then<br />
it shall be billed using modifier 56.<br />
Total reimbursement for preoperative and postoperative<br />
components should not exceed that defined by the listed<br />
value except under the following circumstances:<br />
A. When the preoperative visit is the initial visit (e.g., an<br />
emergency) and prolonged detention or evaluation is<br />
required to prepare the injured employee or to establish<br />
the need for and type of surgical procedure.<br />
1. Physicians shall not charge an emergency room visit<br />
in addition to a surgery resulting from that visit<br />
unless the requirements stipulated in (A) above are<br />
met.<br />
2. When a physician is called to the emergency room<br />
to observe and assume the care of an injured<br />
employee under the physician’s specialty, an<br />
additional consultation charge prior to surgery is<br />
not warranted since the hospital work-up is an<br />
integral part of the surgical procedure.<br />
B. When the preoperative visit is a consultation as defined<br />
in this schedule, use CPT codes 99241 through 99245.<br />
C. When procedures not usually part of the basic surgical<br />
procedure (e.g., bronchoscopy before chest surgery) are<br />
provided during the immediate preoperative period.<br />
D. When a procedure could normally be an office<br />
procedure, but under certain circumstances requires<br />
hospitalization (e.g., age or condition of injured<br />
employee). See modifier 22.<br />
E. Suture removal by the same physician or an associate<br />
will be included in the charge for the original procedure.<br />
Follow-Up Days<br />
<strong>The</strong> number of consecutive postoperative follow-up days<br />
allowed is listed in the column titled FUD adjacent to the<br />
MAR column for the specific surgical CPT code. <strong>The</strong> number<br />
of follow-up days allowed is the FUD for the primary<br />
procedure. For procedures in the fee schedule designating<br />
Section VII: Surgical Services<br />
follow-up days (FUD), the procedure shall include all<br />
charges for office and hospital visits during that period. If the<br />
length of follow-up care goes beyond the number of<br />
follow-up days indicated, the physician would be permitted<br />
to charge an evaluation and management code for<br />
subsequent encounters.<br />
When 000 is listed in the FUD column, services provided<br />
the day of the procedure are included in the fee schedule<br />
amount. When 010 is listed in the FUD column, services<br />
provided the day of and during the 10 day period following<br />
the surgical procedure are included in the fee schedule<br />
amount. When 090 is listed in the FUD column, services<br />
provided the day of and during the 90 day period following<br />
the surgical procedure are included in the fee schedule<br />
amount. When MMM appears in the FUD column, the code<br />
represents a maternity service and the normal follow-up<br />
concept does not apply. When XXX appears in the FUD<br />
column, the global surgery concept does not apply. When<br />
YYY appears in the FUD column, the service is too variable<br />
to assign a follow-up period and the follow-up days are to be<br />
determined by report. When ZZZ appears in the FUD<br />
column, the code is an add-on service and, therefore, is<br />
treated in the global period of the other procedure billed.<br />
To report a postoperative follow-up visit for documentation<br />
purposes only, use CPT code 99024.<br />
When an additional surgical procedure is carried out within<br />
the listed period of follow-up care for a previous surgery, the<br />
follow-up periods shall continue concurrently to their<br />
normal termination.<br />
Follow-Up Care For Diagnostic Procedures<br />
A diagnostic procedure is one in which the patient is still<br />
being diagnosed with consideration for possible treatment.<br />
Care related to recover from diagnostic procedures is<br />
included in the appropriate diagnostic procedure code.<br />
Ongoing care for the condition or symptoms that prompted<br />
the diagnostic procedure or other conditions is not included<br />
and may be listed separately.<br />
Follow-Up Care For <strong>The</strong>rapeutic Surgical Procedures<br />
A therapeutic procedure is one that provides a therapy or<br />
treatment for the patient’s condition. Such therapy may be<br />
surgical. If complications, exacerbations or the recurrence or<br />
presence of other conditions or injuries require additional<br />
services during the postoperative period of the original<br />
therapeutic surgical service, those services may be reported<br />
separately.<br />
Surgery and Follow-Up Care Provided by Different Physicians<br />
When one physician performs the surgical procedure and<br />
another physician provides the follow-up care, the value may<br />
be apportioned between the two physicians by agreement<br />
42 CPT only © 2010 American Medical Association. All Rights Reserved.
Section VII: Surgical Services<br />
and in accordance with medical ethics. (See modifier 54 or<br />
55.)<br />
Concurrent Services by More Than One Physician<br />
Charges for concurrent services of two or more physicians<br />
may be warranted under the following circumstances:<br />
A. Medical services are provided by the authorized treating<br />
physician who refers the injured employee to another<br />
physician (e.g., presurgical assessment).<br />
B. Identifiable medical services provided prior to or during<br />
the surgical procedure or in the postoperative period<br />
(e.g., diabetic management, operative monitoring of<br />
cardiac or brain conditions, management of<br />
postoperative electrolyte imbalance, prolonged injured<br />
employee or family counseling, psychological support).<br />
Failed Endoscopic Service<br />
When an endoscopic service is attempted and fails and<br />
another surgical service is necessary, only the successful<br />
service may be reported. For example, if a laparoscopic<br />
cholecystectomy is attempted and fails and an open<br />
cholecystectomy is performed, only the open<br />
cholecystectomy can be reported.<br />
Sequential Procedures<br />
An initial approach to a procedure may be followed at the<br />
same encounter by a second, usually more invasive<br />
approach. <strong>The</strong>re may be separate CPT codes describing each<br />
service. <strong>The</strong> second procedure is usually performed because<br />
the initial approach was unsuccessful in accomplishing the<br />
medically necessary service; these procedures are considered<br />
“sequential procedures.” Only the CPT code for one of the<br />
services, generally the more invasive service, should be<br />
reported. An example of this situation is a failed laparoscopic<br />
cholecystectomy, followed by an open cholecystectomy at<br />
the same session. Only the code for the successful<br />
procedure, in this case the open cholecystectomy, may be<br />
reported. This rule does not apply to planned multiple<br />
surgical procedures but they are subject to the modifier 51<br />
rule for multiple procedures.<br />
Incidental Procedures<br />
Incidental procedures, which are not customary, will not be<br />
reimbursed (e.g., an appendectomy during a<br />
cholecystectomy).<br />
Separate Procedure<br />
Certain procedures are an inherent portion of a procedure or<br />
service identified by the inclusion of the term “separate<br />
procedure.” When a procedure that is ordinarily a<br />
component of a larger procedure is performed at the same<br />
session, it should not be reported in addition to the code for<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
the total procedure or service of which it is considered an<br />
integral component.<br />
When a “separate procedure” is carried out as a separate<br />
entity not immediately related to other services, the<br />
indicated value for a separate procedure is applicable.<br />
<strong>The</strong>refore, when a procedure that is ordinarily a component<br />
of a larger procedure is performed alone for a specific<br />
purpose, it may be considered a separate procedure. (See<br />
modifier 59.)<br />
Surgical Destruction<br />
Destruction or ablation of tissue is considered an inherent<br />
portion of surgical procedures, and may be by any of the<br />
following methods used alone or in combination:<br />
electrosurgery, cryosurgery, laser, and chemical treatment.<br />
Unless specified by the CPT code description, destruction by<br />
any method does not change the selection of code to report<br />
the surgical service.<br />
Bilateral and Multiple Surgical Procedures<br />
Bilateral procedures require that modifier 50 be listed beside<br />
the surgery CPT code, thereby providing for supplemental<br />
reimbursement.<br />
Where multiple procedures are performed at the same<br />
operative site, the primary procedure is billed at 100 percent,<br />
and all other procedures are billed at 50 percent of the listed<br />
fee. Bilateral and secondary surgical procedures performed in<br />
separate areas will be billed at 100 percent of the listed fee.<br />
Where bilateral surgical procedures are performed through a<br />
common incision, the primary procedure will be billed at<br />
100 percent, and the second procedure on the opposite side<br />
will be billed at 50 percent of the primary procedure<br />
(example, bilateral spinal procedures).<br />
Multiple Surgeons<br />
When medically indicated during surgery, if two different<br />
specialists are performing separate procedures for treatment<br />
of a common problem, each physician shall reduce the fee of<br />
their particular procedure by 25 percent and add modifier<br />
62. <strong>The</strong> modifier shall be added to the procedure number<br />
used by each surgeon reporting the service.<br />
Postoperative Period<br />
<strong>The</strong> immediate postoperative period is the 48 hours<br />
immediately following completion of surgery.<br />
Subsection Information<br />
In the CPT book, several of the surgery subsections have<br />
definitions, guidelines, and instructions for reporting<br />
services contained in the subsection. This information<br />
generally follows the subsection heading. Adhere to the<br />
CPT only © 2010 American Medical Association. All Rights Reserved. 43
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
coding definitions, guidelines, and instructions contained in<br />
the CPT book unless otherwise instructed here.<br />
Wound Repair (Closure)<br />
Wound repair (closure) procedures may be accomplished by<br />
one or more of the following techniques: sutures, staples, or<br />
tissue adhesives. Wound closure or dressing may also<br />
include adhesive strips. When adhesive strips are the only<br />
method of closure, the service is reported using the<br />
appropriate E/M code.<br />
<strong>The</strong> repair of wounds may be classified as simple,<br />
intermediate, or complex:<br />
• Simple Repair: Surgical closure of a superficial wound,<br />
requiring single layer closure of the skin (epidermis,<br />
dermis, or subcutaneous tissue). Local anesthesia is<br />
included. Simple repair includes chemical or<br />
electrocauterization.<br />
• Intermediate Repair: Surgical closure of a wound<br />
requiring closure of one or more of the deeper<br />
subcutaneous tissue and non-muscle fascia layers in<br />
addition to suturing the skin. Simple wounds with<br />
heavy contamination that require extensive debridement<br />
may also be considered to require intermediate repair.<br />
• Complex Repair: Surgical closure of a wound requiring<br />
more than layered closure of the deeper subcutaneous<br />
tissue and fascia (i.e., debridement, scar excision,<br />
placement of stents or retention sutures, and sometimes<br />
site preparation or undermining that creates the defect<br />
requiring complex closure). Excision of benign or<br />
malignant lesions is not inherent in complex repairs.<br />
Surgical Injections<br />
Surgical injections delineated as per injection by CPT<br />
descriptor and nomenclature warrant additional<br />
reimbursement per injection and are subject to the multiple<br />
procedure rules within the same body area.<br />
Bone and Other Tissue Grafts<br />
When a separate incision is used to obtain grafts, they may<br />
be reported separately. If the code description includes<br />
obtaining the graft, a separate code may not be reported.<br />
Grafts include autogenous bone, cartilage, tendon, fascia lata<br />
grafts or other tissues.<br />
Grafting codes, 20900–20938, do not usually require<br />
co-surgeons and should not be reported with modifier 62.<br />
Plastic and metallic implant or nonautogenous graft<br />
materials supplied by the physician are to be valued at the<br />
cost to the facility. A wholesale vendor invoice must be<br />
included with the bill sent to the payor. Notice to the payor<br />
Section VII: Surgical Services<br />
shall be given in advance of this added charge for the graft,<br />
except in emergency/urgent care procedures.<br />
Carticel<br />
<strong>The</strong> carticel (cartilage growth process) may be billed by<br />
using CPT code 20999. A special report describing the<br />
physician’s use of carticel must accompany the billing of this<br />
code.<br />
Fractures<br />
Re-reduction of fractures and/or dislocations that are<br />
performed as a separate procedure by the physician may<br />
warrant an added charge for this secondary service.<br />
Casting and Strapping<br />
Application of Casts<br />
Casting and strapping codes are used to report replacement<br />
procedures during or after the period of follow-up care.<br />
<strong>The</strong>se codes can also be used when the cast application or<br />
strapping is an initial service performed to stabilize or<br />
protect a fracture, injury, or dislocation without a restorative<br />
treatment or procedure. A restorative treatment or procedure<br />
rendered by another physician following the application of<br />
the initial cast, splint, or strap may be reported with a<br />
treatment of fracture and/or dislocation code.<br />
A physician who applies the initial cast, strap, or splint and<br />
also assumes all the subsequent fracture, dislocation, or<br />
injury care cannot use the application of casts and strapping<br />
codes as an initial service. <strong>The</strong> first cast, splint, or strap<br />
application is included as part of the service of the treatment<br />
of the fracture and dislocation codes. Initial stabilization<br />
using a temporary cast, splint, or strap is inherent in the<br />
definitive treatment of the fracture or dislocation and not<br />
separately reported. Only when a significant or separate<br />
service is provided may an E/M code be reported with the<br />
application of a cast, splint, or strap. When an initial service<br />
consists of cast application or strapping in addition to<br />
evaluation and management, and definitive treatment will<br />
not be provided, the cast, splint, or strapping may be<br />
reported in addition to the appropriate E/M code.<br />
Vertebral Arthrodesis<br />
All arthrodesis procedures include vertebral graft<br />
preparations, such as discectomy necessary to accomplish<br />
the arthrodesis.<br />
Arthroscopic Surgery<br />
Arthroscopic surgery procedures include diagnostic exams,<br />
simple debridement or removal of foreign bodies in the<br />
global fees; therefore, only one fee will be allowed unless<br />
special circumstances warrant otherwise. Special<br />
circumstances may include multiple procedures involving<br />
different compartments or approaches for the same joint,<br />
44 CPT only © 2010 American Medical Association. All Rights Reserved.
Section VII: Surgical Services<br />
arthroscopically assisted open procedures, and<br />
reconstruction of multiple structures. In such cases multiple<br />
procedures may be reimbursed in accordance with CCI edits,<br />
however, operative notes must be sent for review.<br />
Microsurgery<br />
Code 69990 is used to report the use of a surgical<br />
microscope for microsurgery techniques. This code is an<br />
add-on code and should not be reported with modifier 51.<br />
Do not report the use of magnifying loupes or corrected<br />
vision separately. <strong>The</strong> descriptions of some codes specify the<br />
use of microsurgery. A list of these codes can be found with<br />
code 69990 in CPT 2011.<br />
Internal neurolysis requiring the use of an operating<br />
microscope is reported using CPT code 64727 and code<br />
69990 is not reported at the same surgical session.<br />
Microsurgery is allowed only in the case of surgery on nerves<br />
or blood vessels not explicitly excluded in CPT guidelines.<br />
For those operative surgical procedures requiring the use of<br />
the operative microscope, CPT code 69990 shall be used,<br />
and an additional fee of 25 percent of the billed procedure<br />
(not to exceed $358.93) will be allowed.<br />
SUBSECTION B: PAYMENT MODIFIERS FOR<br />
SURGICAL SERVICES<br />
A modifier indicates a service or procedure performed has<br />
been altered by some specific circumstance but has not<br />
changed its definition or code. <strong>The</strong> modifying circumstance<br />
shall be identified by the appropriate two-digit modifier<br />
following the procedure code. When two modifiers are<br />
applicable to a single code, indicate each modifier on the<br />
bill. If more than one modifier is used, place the “Multiple<br />
Modifiers” code 99 immediately after the procedure code.<br />
This indicates that one or more additional modifier codes<br />
will follow. Only certain modifiers in each of the categories<br />
(Evaluation and Management, Anesthesia, Surgery,<br />
Pathology/Laboratory, Radiology, General Medicine, and<br />
Physical Medicine) will be recognized for reimbursement<br />
purposes.<br />
<strong>The</strong> modifiers listed below may differ from those published<br />
by the American Medical Association. Providers submitting<br />
workers’ compensation billing shall use only the modifiers<br />
set out in the Medical Fee Guideline.<br />
<strong>The</strong> following modifiers will be recognized for<br />
reimbursement by the fee schedule for surgical service codes:<br />
22 Increased Procedural Services: When the work<br />
required to provide a service is substantially greater than<br />
typically required, it may be identified by adding<br />
modifier 22 to the usual procedure code.<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Documentation must support the substantial additional<br />
work and the reason for the additional work (i.e.,<br />
increased intensity, time, technical difficulty of<br />
procedure, severity of patient's condition, physical and<br />
mental effort required). Note: This modifier should not<br />
be appended to an E/M service.<br />
25 Significant, Separately Identifiable Evaluation and<br />
Management Service by the Same Physician on the<br />
Same Day of the Procedure or Other Service: Refer to<br />
E/M section.<br />
26 Professional Component: Certain procedures are a<br />
combination of a physician component and a technical<br />
component. When the physician component is reported<br />
separately, the service may be identified by adding<br />
modifier 26 to the usual procedure number.<br />
47 Anesthesia by Surgeon: Refer to Anesthesia section.<br />
50 Bilateral Procedure: Unless otherwise identified in the<br />
listings, bilateral procedures that are performed at the<br />
same session should be identified by adding modifier 50<br />
to the appropriate five-digit code. Unless otherwise<br />
indicated, the total reimbursed for the bilateral<br />
procedure is 150 percent of the fee schedule for<br />
unilateral surgery.<br />
51 Multiple Procedures: When multiple procedures,<br />
other than evaluation and management services,<br />
physical medicine and rehabilitation services, or<br />
provision of supplies (e.g., vaccines) are performed at<br />
the same session by the same provider, the primary<br />
procedure or service may be reported as listed. <strong>The</strong><br />
additional procedure(s) or service(s) may be identified<br />
by appending modifier 51 to the additional procedure<br />
or service code(s). Note: This modifier should not be<br />
appended to designated “add-on” codes (see Appendix<br />
D of the CPT book).<br />
When each procedure is clearly defined, the following<br />
values shall prevail:<br />
• 100 percent of the first or major procedure<br />
• 50 percent of all additional procedures<br />
52 Reduced Services: Under certain circumstances, a<br />
service or procedure is partially reduced or eliminated at<br />
the physician’s discretion. Under these circumstances,<br />
the service provided can be identified by its usual<br />
procedure number and the addition of modifier 52<br />
signifying that the service is reduced. This provides a<br />
means of reporting reduced services without disturbing<br />
the identification of the basic service. Note: For hospital<br />
outpatient reporting of a previously scheduled<br />
procedure/service that is partially reduced or cancelled<br />
as a result of extenuating circumstances or those that<br />
threaten the well-being of the patient prior to or after<br />
administration of anesthesia, see modifiers 73 and 74<br />
CPT only © 2010 American Medical Association. All Rights Reserved. 45
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
(see modifiers approved for ASC hospital outpatient<br />
use).<br />
53 Discontinued Procedure: Under certain circumstances,<br />
the physician may elect to terminate a surgical or<br />
diagnostic procedure. Due to extenuating circumstances<br />
or those that threaten the well-being of the patient, it<br />
may be necessary to indicate that a surgical or diagnostic<br />
procedure was started but discontinued. This<br />
circumstance may be reported by adding modifier 53 to<br />
the code reported by the physician for the discontinued<br />
procedure. Note: This modifier is not used to report the<br />
elective cancellation of a procedure prior to the patient’s<br />
anesthesia induction and/or surgical preparation in the<br />
operating suite. For outpatient hospital/ambulatory<br />
surgery center (ASC) reporting of a previously<br />
scheduled procedure/service that is partially reduced or<br />
cancelled as a result of extenuating circumstances or<br />
those that threaten the well-being of the patient prior to<br />
or after administration of anesthesia, see modifiers 73<br />
and 74 (see modifiers approved for ASC hospital<br />
outpatient use).<br />
54 Surgical Care Only: When one physician performs a<br />
surgical procedure and another provides preoperative<br />
and/or postoperative management, surgical services may<br />
be identified by adding modifier 54 to the usual<br />
procedure number. See Section VII: Surgical Services,<br />
Surgery and Follow-Up Care Provided by Different<br />
Medical Providers for full discussion of maximum<br />
allowable charges for all medical providers.<br />
55 Postoperative Management Only: When one<br />
physician performed the postoperative management and<br />
another physician performed the surgical procedure, the<br />
postoperative component may be identified by adding<br />
modifier 55 to the usual procedure number. <strong>The</strong><br />
maximum reimbursement for this modifier is 20 percent<br />
of the total value of the surgery.<br />
56 Preoperative Management Only: When one physician<br />
performed the preoperative care and evaluation and<br />
another physician performed the surgical procedure, the<br />
preoperative component may be identified by adding<br />
modifier 56 to the usual procedure number. <strong>The</strong><br />
maximum reimbursement for this modifier is 10 percent<br />
of the total value of the surgery.<br />
57 Decision for Surgery: An evaluation and management<br />
service that resulted in the initial decision to perform<br />
the surgery may be identified by adding modifier 57 to<br />
the appropriate level of E/M service.<br />
58 Staged or Related Procedure or Service by the Same<br />
Physician During the Postoperative Period: It may be<br />
necessary to indicate that the performance of a<br />
procedure or service during the postoperative period<br />
was: (a) planned or anticipated (staged); (b) more<br />
Section VII: Surgical Services<br />
extensive than the original procedure; or (c) for therapy<br />
following a surgical procedure. This circumstance may<br />
be reported by adding modifier 58 to the staged or<br />
related procedure. Note: For treatment of a problem that<br />
requires a return to the operating or procedure room<br />
(e.g., unanticipated clinical condition), see modifier 78.<br />
59 Distinct Procedural Service: Under certain<br />
circumstances, it may be necessary to indicate that a<br />
procedure or service was distinct or independent from<br />
other non-E/M services performed on the same day.<br />
Modifier 59 is used to identify procedures/services,<br />
other than E/M services, that are not normally reported<br />
together but are appropriate under the circumstances.<br />
Documentation must support a different session,<br />
different procedure or surgery, different site or organ<br />
system, separate incision or excision, separate lesion, or<br />
separate injury (or area of injury in extensive injuries)<br />
not ordinarily encountered or performed on the same<br />
day by the same individual. However, when another<br />
already established modifier is appropriate, it should be<br />
used rather than modifier 59. Only if no more<br />
descriptive modifier is available, and the use of modifier<br />
59 best explains the circumstances, should modifier 59<br />
be used. Note: Modifier 59 should not be appended to<br />
an E/M service. To report a separate and distinct E/M<br />
service with a non-E/M service performed on the same<br />
date, see modifier 25.<br />
62 Two Surgeons: When two surgeons work together as<br />
primary surgeons performing distinct part(s) of a<br />
procedure, each surgeon should report his/her distinct<br />
operative work by adding modifier 62 to the procedure<br />
code and any associated add-on code(s) for that<br />
procedure as long as both surgeons continue to work<br />
together as primary surgeons. Each surgeon should<br />
report the co-surgery once using the same procedure<br />
code. If additional procedure(s) (including add-on<br />
procedure(s) are performed during the same surgical<br />
session, separate code(s) may also be reported with<br />
modifier 62 added. Note: If a co-surgeon acts as an<br />
assistant in the performance of additional procedure(s)<br />
during the same surgical session, those services may be<br />
reported using separate procedure code(s) with modifier<br />
80 or modifier 82 added, as appropriate. <strong>The</strong><br />
reimbursement amount applicable for each co-surgeon<br />
is 75 percent of the surgical CPT code listed in the fee<br />
schedule.<br />
66 Surgical Team: Under some circumstances, highly<br />
complex procedures (requiring the concomitant services<br />
of several medical providers, often of different<br />
specialties, plus other highly skilled, specialty trained<br />
personnel, and various types of complex equipment) are<br />
carried out under the “surgical team” concept. Each<br />
participating physician may identify such circumstances<br />
46 CPT only © 2010 American Medical Association. All Rights Reserved.
Section VII: Surgical Services<br />
with the addition of modifier 66 to the basic procedure<br />
number used for reporting services.<br />
76 Repeat Procedure or Service by Same Physician or<br />
Other Qualified Health Care Professional: It may be<br />
necessary to indicate that a procedure or service was<br />
repeated by the same physician or other qualified health<br />
care professional subsequent to the original procedure<br />
or service. This circumstance may be reported by adding<br />
modifier 76 to the repeated procedure or service. Note:<br />
This modifier should not be appended to an E/M<br />
service.<br />
77 Repeat Procedure or Service by Another Physician or<br />
Other Qualified Health Care Professional: It may be<br />
necessary to indicate that a basic procedure or service<br />
was repeated by another physician or other qualified<br />
health care professional subsequent to the original<br />
procedure or service. This circumstance may be<br />
reported by adding modifier 77 to the repeated<br />
procedure or service. Note: This modifier should not be<br />
appended to an E/M service.<br />
78 Unplanned Return to the Operating Room/Procedure<br />
Room by the Same Physician or Other Qualified<br />
Health Care Professional Following Initial Procedure<br />
for a Related Procedure During the Postoperative<br />
Period: It may be necessary to indicate that another<br />
procedure was performed during the postoperative<br />
period of the initial procedure (unplanned procedure<br />
following initial procedure). When this procedure is<br />
related to the first and requires the use of the operating<br />
or procedure room, it may be reported by adding<br />
modifier 78 to the related procedure. (For repeat<br />
procedures, see modifier 76.)<br />
79 Unrelated Procedure or Service by the Same<br />
Physician during the Postoperative Period: <strong>The</strong><br />
physician may need to indicate that the performance of<br />
a procedure or service during the postoperative period<br />
was unrelated to the original procedure. This<br />
circumstance may be reported by using modifier 79.<br />
(For repeat procedures on the same day, see modifier<br />
76.)<br />
80 Assistant Surgeon: Surgical assistant services may be<br />
identified by adding modifier 80 to the usual procedure<br />
number(s). Assistant surgeon is defined to be a medical<br />
provider who is capable by background, training, and<br />
licensure of performing the surgery on a solo basis.<br />
<strong>The</strong>se services are valued at 20 percent of the listed<br />
value.<br />
81 Minimum Assistant Surgeon: Minimum surgical<br />
assistant services are identified by adding modifier 81 to<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
the usual procedure number. <strong>The</strong>se services are valued<br />
at 20 percent of the listed value.<br />
82 Assistant Surgeon (when qualified resident surgeon<br />
not available): <strong>The</strong> unavailability of a qualified resident<br />
surgeon is a prerequisite for use of modifier 82<br />
appended to the usual procedure code number(s).<br />
99 Multiple Modifiers: Under certain circumstances, two<br />
or more modifiers may be necessary to completely<br />
delineate a service. In such situations, modifier 99<br />
should be added to the basic procedure, and other<br />
applicable modifiers may be listed as part of the<br />
description of the service.<br />
AS Physician Assistant, Nurse Practitioner, Clinical<br />
Nurse Specialist Services, or Registered Nurse First<br />
Assistant (RNFA) for Assistant at Surgery: Report<br />
modifier AS when a physician assistant, nurse<br />
practitioner, clinical nurse specialist, or registered nurse<br />
first assistant, provides assistant at surgery services.<br />
Physician assistant, nurse practitioner, or clinical nurse<br />
specialist services for assistant at surgery are reimbursed<br />
at 10 percent of the listed value.<br />
LT Left Side: Used to identify procedures performed on the<br />
left side of the body.<br />
PE Physician Assistant or Nurse Practitioner (State<br />
Specific Modifier): Physician assistant, registered nurse<br />
first assistant, or nurse practitioner services are<br />
identified by adding modifier PE to the usual procedure<br />
number. A physician assistant must be properly licensed<br />
by the Composite Board of Medical Examiners in<br />
<strong>Georgia</strong> and/or licensed or certified in the state where<br />
services are provided. A nurse practitioner (NP) must be<br />
properly licensed by the <strong>Georgia</strong> Board of Nursing<br />
and/or licensed or certified in the state where services<br />
are provided. A registered nurse first assistant (RNFA)<br />
must be properly licensed by the Certification Board of<br />
Perioperative Nursing and/or licensed or certified in the<br />
state where services are provided. In accordance with<br />
O.C.G.A. §33-24-59.9, the RNFA shall not be on the<br />
staff of a hospital or the treating physician. Modifier PE<br />
will be at 85 percent of the MAR.<br />
RT Right Side: Used to identify procedures performed on<br />
the right side of the body.<br />
TC Technical Component Only: Certain procedures are a<br />
combination of a physician component and a technical<br />
component. When the technical component is reported<br />
separately, the service may be identified by adding<br />
modifier TC to the usual procedure number.<br />
CPT only © 2010 American Medical Association. All Rights Reserved. 47
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
10021 FINE NEEDLE ASPIRATION W/O IMAGING GUIDANCE 232.08 XXX<br />
10022 FINE NEEDLE ASPIRATION WITH IMAGING GUIDANCE 222.67 XXX<br />
10040 ACNE SURGERY 165.06 010<br />
10060 INCISION & DRAINAGE ABSCESS SIMPLE/SINGLE 177.25 010<br />
10061 INCISION&DRAINAGE ABSCESS COMPLICATED/MULTIPLE 295.78 010<br />
10080 INCISION & DRAINAGE PILONIDAL CYST SIMPLE 271.41 010<br />
10081 INCISION & DRAINAGE PILONIDAL CYST COMPLICATED 418.75 010<br />
10120 INCISION&REMOVAL FOREIGN BODY SUBQ TISS SMPL 218.79 010<br />
10121 INCISION&REMOVAL FOREIGN BODY SUBQ TISS COMP 424.84 010<br />
10140 I&D HEMATOMA SEROMA/FLUID COLLECTION 250.92 010<br />
10160 PUNCTURE ASPIRATION ABSCESS HEMATOMA BULLA/CYST 203.28 010<br />
10180 INCISION&DRAINAGE COMPLEX PO WOUND INFECTION 381.64 010<br />
11000 DBRDMT X10SV ECZMT/INFCT SKN UP 10% BDY SURF 84.75 000<br />
+ 11001 DBRDMT X10SV ECZMT/INFCT SKN EA 10% BDY SURF 34.34 ZZZ<br />
11004 DBRDMT SKN SUBQ T/M/F NECRO INFCTJ GENT&PR 953.82 000<br />
11005 DBRDMT SKN SUBQ T/M/F NECRO INFCTJ ABDL WALL 1278.40 000<br />
11006 DBRDMT SKN SUBQ T/M/F NECRO INFCTJ GENT/ABDL 1163.74 000<br />
+ 11008 REMOVAL PROSTHETIC MATRL ABDL WALL FOR INFECTION 449.21 ZZZ<br />
s 11010 DBRDMT W/RMVL FM FX&/DISLC SKN&SUBQ TISS 767.71 010<br />
s 11011 DBRDMT W/RMVL FM FX&/DISLC SKN SUBQ T/M/F MUSC 842.48 000<br />
s 11012 DBRDMT FX&/DISLC SUBQ T/M/F BONE 1130.51 000<br />
s 11042 DEBRIDEMENT SUBCUTANEOUS TISSUE 20 SQ CM/< 141.24 000<br />
s 11043 DEBRIDEMENT MUSCLE & FASCIA 20 SQ CM/< 310.74 000<br />
s 11044 DBRDMT BONE M&/F 20 SQ CM/< 474.14 000<br />
l + # 11045 DBRDMT SUBCUTANEOUS TISSUE EA ADDL 20 SQ CM 50.40 ZZZ<br />
l + # 11046 DBRDMT M&/F EA ADDL 20 SQ CM 87.52 ZZZ<br />
l + # 11047 DEBRIDEMENT BONE EA ADDL 20 SQ CM/< 144.01 ZZZ<br />
11055 PARING/CUTTING BENIGN HYPERKERATOTIC LESION 1 78.10 000<br />
11056 PARING/CUTTING BENIGN HYPERKERATOTIC LESION 2-4< 93.61 000<br />
11057 PARING/CUTTING BENIGN HYPERKERATOTIC LESION >4 110.78 000<br />
11100 BX SKIN SUBCUTANEOUS&/MUCOUS MEMBRANE 1 LESION 166.72 000<br />
+ 11101 BIOPSY SKN SUBQ&/MUC MEMB EA SPX ADDL LESION 53.17 ZZZ<br />
11200 REMOVAL SK TGS MLT FIBRQ TAGS ANY AREA UP&W/15< 136.26 010<br />
+ 11201 REMOVAL SK TGS MLT FIBRQ TAGS ANY AREA EA 10< 30.46 ZZZ<br />
11300 SHAVING SKIN LES 1 TRUNK/ARM/LEG DIAM 0.5CM/< 110.23 000<br />
11301 SHVG SKIN LES 1 TRUNK/ARM/LEG DIAM 0.6-1.0 CM 149.55 000<br />
11302 SHVG SKN LESION 1 TRUNK/ARM/LEG DIAM 1.1-2.0 CM 178.91 000<br />
11303 SHVG SKIN LESION 1 TRUNK/ARM/LEG DIAM >2.0 CM 211.04 000<br />
11305 SHAVING SKIN LESION 1 S/N/H/F/G DIAM 0.5 CM/< 110.23 000<br />
11306 SHAVING SKIN LESION 1 S/N/H/F/G DIAM 0.6-1.0 CM 152.88 000<br />
11307 SHAVING SKIN LESION 1 S/N/H/F/G DIAM 1.1-2.0 CM 181.13 000<br />
11308 SHAVING SKIN LESION 1 S/N/H/F/G DIAM >2.0 CM 200.51 000<br />
11310 SHAVING SKIN LESION 1 F/E/E/N/L/M DIAM 0.5 CM/< 136.26 000<br />
11311 SHVG SKIN LESION 1 F/E/E/N/L/M DIAM 0.6-1.0 CM 171.71 000<br />
11312 SHVG SKIN LESION 1 F/E/E/N/L/M DIAM 1.1-2.0 CM 199.96 000<br />
11313 SHAVING SKIN LESION 1 F/E/E/N/L/M DIAM >2.0 CM 248.15 000<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
48 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
11400 EXC B9 LES MRGN XCP SK TG T/A/L 0.5 CM/< 190.54 010<br />
11401 EXC B9 LES MRGN XCP SK TG T/A/L 0.6-1.0 CM 233.19 010<br />
11402 EXC B9 LES MRGN XCP SK TG T/A/L 1.1-2.0 CM 259.78 010<br />
11403 EXC B9 LES MRGN XCP SK TG T/A/L 2.1-3.0 CM 298.55 010<br />
11404 EXC B9 LES MRGN XCP SK TG T/A/L 3.1-4.0 CM 339.54 010<br />
11406 EXC B9 LES MRGN XCP SK TG T/A/L > 4.0 CM 484.11 010<br />
11420 EXC B9 LES MRGN XCP SK TG S/N/H/F/G 0.5 CM/< 189.99 010<br />
11421 EXC B9 LES MRGN XCP SK TG S/N/H/F/G 0.6-1.0CM 247.04 010<br />
11422 EXC B9 LES MRGN XCP SK TG S/N/H/F/G 1.1-2.0CM 275.29 010<br />
11423 EXC B9 LES MRGN XCP SK TG S/N/H/F/G 2.1-3.0CM 319.05 010<br />
11424 EXC B9 LES MRGN XCP SK TG S/N/H/F/G 3.1-4.0CM 366.68 010<br />
11426 EXC B9 LES MRGN XCP SK TG S/N/H/F/G > 4.0CM 524.54 010<br />
11440 EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 0.5CM/< 209.93 010<br />
11441 EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 0.6-1.0CM 264.21 010<br />
11442 EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 1.1-2.0CM 298.00 010<br />
11443 EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 2.1-3.0CM 355.05 010<br />
11444 EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 3.1-4.0CM 446.44 010<br />
11446 EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M > 4.0CM 614.83 010<br />
11450 EXCISION HIDRADENITIS AXILLARY SMPL/INTRM RPR 581.60 090<br />
11451 EXCISION HIDRADENITIS AXILLARY COMPLEX REPAIR 743.33 090<br />
11462 EXCISION HIDRADENITIS INGUINAL SMPL/INTRM RPR 571.07 090<br />
11463 EXCISION HIDRADENITIS INGUINAL COMPLEX REPAIR 758.84 090<br />
11470 EXCISION H/P/P/U SIMPLE/INTERMEDIATE REPAIR 635.88 090<br />
11471 EXCISION H/P/P/U COMPLEX REPAIR 786.54 090<br />
11600 EXCISION MAL LESION TRUNK/ARM/LEG 0.5 CM/< 296.89 010<br />
11601 EXCISION MAL LESION TRUNK/ARM/LEG 0.6-1.0 CM 361.14 010<br />
11602 EXCISION MAL LESION TRUNK/ARM/LEG 1.1-2.0 CM 394.93 010<br />
11603 EXCISION MAL LESION TRUNK/ARM/LEG 2.1-3.0 CM 448.66 010<br />
11604 EXCISION MAL LESION TRUNK/ARM/LEG 3.1-4.0 CM 497.40 010<br />
11606 EXCISION MALIGNANT LESION TRUNK/ARM/LEG >4.0 CM 704.56 010<br />
11620 EXCISION MALIGNANT LESION S/N/H/F/G 0.5 CM/< 302.43 010<br />
11621 EXCISION MALIGNANT LESION S/N/H/F/G 0.6-1.0 CM 363.91 010<br />
11622 EXCISION MALIGNANT LESION S/N/H/F/G 1.1-2.0 CM 409.89 010<br />
11623 EXCISION MALIGNANT LESION S/N/H/F/G 2.1-3.0 CM 479.12 010<br />
11624 EXCISION MALIGNANT LESION S/N/H/F/G 3.1-4.0 CM 538.39 010<br />
11626 EXCISION MALIGNANT LESION S/N/H/F/G > 4.0 CM 650.28 010<br />
11640 EXCISION MALIGNANT LESION F/E/E/N/L/M 0.5 CM/< 314.06 010<br />
11641 EXCISION MALIGNANT LES F/E/E/N/L/M 0.6-1.0 CM 379.98 010<br />
11642 EXCISION MALIGNANT LES F/E/E/N/L/M 1.1-2.0 CM 435.37 010<br />
11643 EXCISION MALIGNANT LES F/E/E/N/L/M 2.1-3.0 CM 512.91 010<br />
11644 EXCISION MALIGNANT LES F/E/E/N/L/M 3.1-4.0 CM 632.00 010<br />
11646 EXCISION MALIGNANT LESION F/E/E/N/L/M > 4.0 CM 827.53 010<br />
11719 TRIMMING NONDYSTROPHIC NAILS ANY NUMBER 34.34 000<br />
11720 DEBRIDEMENT NAIL ANY METHOD 1-5 49.85 000<br />
11721 DEBRIDEMENT NAIL ANY METHOD 6/> 68.13 000<br />
11730 AVULSION NAIL PLATE PARTIAL/COMPLETE SIMPLE 1 152.88 000<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 49
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
+ 11732 AVULSION NAIL PLATE PARTIAL/COMPLETE SMPL EA 69.79 ZZZ<br />
11740 EVACUATION SUBUNGUAL HEMATOMA 74.22 000<br />
11750 EXCISION NAIL MATRIX PERMANENT REMOVAL 345.63 010<br />
11752 EXC NAIL MATRIX PRM RMVL W/AMP TUFT DSTL PHALANX 498.51 010<br />
11755 BIOPSY NAIL UNIT SPX 211.04 000<br />
11760 REPAIR NAIL BED 342.86 010<br />
11762 RECONSTRUCTION NAIL BED W/GRAFT 431.49 010<br />
11765 WEDGE EXCISION SKIN NAIL FOLD 217.68 010<br />
11770 EXCISION PILONIDAL CYST/SINUS SIMPLE 424.84 010<br />
11771 EXCISION PILONIDAL CYST/SINUS EXTENSIVE 881.25 090<br />
11772 EXCISION PILONIDAL CYST/SINUS COMPLICATED 1056.29 090<br />
11900 INJECTION INTRALESIONAL UP TO & INCL 7 90.29 000<br />
11901 INJECTION INTRALESIONAL >7 114.10 000<br />
11920 TATTOOING INCL MICROPIGMENTATION 6.0 CM/< 283.60 000<br />
11921 TATTOOING INCL MICROPIGMENTATION 6.1-20.0 CM 326.80 000<br />
+ 11922 TATTOOING INCL MICROPIGMENTATION EA 20.0 CM 98.04 ZZZ<br />
11950 SUBCUTANEOUS INJECTION FILLING MATERIAL 1 CC/< 114.10 000<br />
11951 SUBCUTANEOUS INJECTION FILLING MATRL 1.1-5.0 CC 162.29 000<br />
11952 SUBCUTANEOUS INJECTION FILLING MATRL 5.1-10.0CC 208.82 000<br />
11954 SUBCUTANEOUS INJECTION FILLING MATRL > 10.0 CC 259.78 000<br />
11960 INSERTION TISSUE EXPANDER INCL SBSQ XPNSJ 1459.53 090<br />
11970 REPLACEMENT TISS EXPANDER PERMANENT PROSTHESIS 991.48 090<br />
11971 REMOVAL TISS EXPANDER W/O INSERTION PROSTHESIS 747.21 090<br />
11975 INSERTION IMPLANTABLE CONTRACEPTIVE CAPSULES 204.39 XXX<br />
11976 REMOVAL IMPLANTABLE CONTRACEPTIVE CAPSULES 234.85 000<br />
11977 RMVL W/RINSJ IMPLANTABLE CONTRACEPTIVE CAPSULES 359.48 XXX<br />
11980 SUBCUTANEOUS HORMONE PELLET IMPLANTATION 168.39 000<br />
11981 INSJ NON-BIODEGRADABLE DRUG DELIVERY IMPLANT 217.68 XXX<br />
11982 REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT 242.61 XXX<br />
11983 RMVL W/RINSJ NON-BIODEGRADABLE DRUG DLVR IMPLT 360.59 XXX<br />
12001 SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/< 155.65 000<br />
12002 SMPL REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.6-7.5CM 182.79 000<br />
12004 SIMPLE RPR SCALP/NECK/AX/GENIT/TRUNK 7.6-12.5CM 217.13 000<br />
12005 SMPL RPR SCALP/NECK/AX/GENIT/TRUNK 12.6-20.0CM 279.72 000<br />
12006 SMPL RPR SCALP/NECK/AX/GENIT/TRUNK 20.1-30.0CM 337.88 000<br />
12007 SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK >30.0CM 393.82 000<br />
12011 SIMPLE REPAIR F/E/E/N/L/M 2.5CM/< 186.66 000<br />
12013 SIMPLE REPAIR F/E/E/N/L/M 2.6CM-5.0CM 200.51 000<br />
12014 SIMPLE REPAIR F/E/E/N/L/M 5.1CM-7.5CM 237.62 000<br />
12015 SIMPLE REPAIR F/E/E/N/L/M 7.6CM-12.5CM 291.35 000<br />
12016 SIMPLE REPAIR F/E/E/N/L/M 12.6CM-20.0CM 364.47 000<br />
12017 SIMPLE REPAIR F/E/E/N/L/M 20.1CM-30.0CM 281.38 000<br />
12018 SIMPLE REPAIR F/E/E/N/L/M >30.0CM 333.45 000<br />
12020 TX SUPERFICIAL WOUND DEHISCENCE SIMPLE CLOSURE 432.04 010<br />
12021 TX SUPERFICIAL WOUND DEHISCENCE W/PACKING 257.01 010<br />
12031 REPAIR INTERMEDIATE S/A/T/E 2.5 CM/< 391.05 010<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
50 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
12032 REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM 492.42 010<br />
12034 REPAIR INTERMEDIATE S/A/T/E 7.6-12.5 CM 491.31 010<br />
12035 REPAIR INTERMEDIATE S/A/T/E 12.6-20.0CM 596.00 010<br />
12036 REPAIR INTERMEDIATE S/A/T/E 20.1-30.0 CM 651.39 010<br />
12037 REPAIR INTERMEDIATE S/A/T/E > 30.0 CM 730.04 010<br />
12041 REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.5CM/< 408.22 010<br />
12042 REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.6-7.5 CM 467.49 010<br />
12044 REPAIR INTERMEDIATE N/H/F/XTRNL GENT 7.6-12.5CM 553.90 010<br />
12045 REPAIR INTERMEDIATE N/H/F/XTRNL GENT 12.6-20 CM 593.78 010<br />
12046 RPR INTERMEDIATE N/H/F/XTRNL GENT 20.1-30.0 CM 704.56 010<br />
12047 REPAIR INTERMEDIATE N/H/F/XTRNL GENT >30.0 CM 764.94 010<br />
12051 REPAIR INTERMEDIATE F/E/E/N/L/M&/MUC 2.5 CM/< 432.04 010<br />
12052 REPAIR INTERMEDIATE F/E/E/N/L/M&/MUC 2.6-5.0 CM 492.97 010<br />
12053 REPAIR INTERMEDIATE F/E/E/N/L/M&/MUC 5.1-7.5 CM 544.48 010<br />
12054 REPAIR INTERMEDIATE F/E/E/N/L/M&/MUC 7.6-12.5 CM 577.72 010<br />
12055 REPAIR INTERMEDIATE F/E/E/N/L/M&/MUC 12.6-20.0CM 693.48 010<br />
12056 REPAIR INTERMEDIATE F/E/E/N/L/M&/MUC 20.1-30.0CM 827.53 010<br />
12057 REPAIR INTERMEDIATE F/E/E/N/L/M&/MUC > 30.0 CM 943.85 010<br />
13100 REPAIR COMPLEX TRUNK 1.1 CM-2.5 CM 504.60 010<br />
13101 REPAIR COMPLEX TRUNK 2.6 CM-7.5 CM 641.42 010<br />
+ 13102 REPAIR COMPLEX TRUNK EA 5 CM/< 174.48 ZZZ<br />
13120 REPAIR COMPLEX SCALP/ARM/LEG 1.1 CM-2.5 CM 525.10 010<br />
13121 REPAIR COMPLEX SCALP/ARM/LEG 2.6 CM-7.5 CM 715.08 010<br />
+ 13122 REPAIR COMPLEX SCALP/ARM/LEG EA 5 CM/< 192.76 ZZZ<br />
13131 REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 1.1 CM-2.5 CM 579.93 010<br />
13132 REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6 CM-7.5 CM 939.41 010<br />
+ 13133 REPAIR COMPLEX F/C/C/M/N/AX/G/H/F EA 5 CM/< 272.52 ZZZ<br />
13150 REPAIR COMPLEX EYELID/NOSE/EAR/LIP 1.0 CM/< 576.61 010<br />
13151 REPAIR COMPLEX EYELID/NOSE/EAR/LIP 1.1-2.5 CM 656.93 010<br />
13152 REPAIR COMPLEX EYELID/NOSE/EAR/LIP 2.6-7.5 CM 908.40 010<br />
+ 13153 REPAIR COMPLEX EYELID/NOSE/EAR/LIP EA 5 CM/< 299.11 ZZZ<br />
13160 SEC CLSR SURG WOUND/DEHSN EXTENSIVE/COMPLICATED 1311.64 090<br />
14000 ADJACENT TISSUE TRANSFER/REARGMT TRUNK 10 CM/< 1004.77 090<br />
14001 ATT/REARRANGEMENT TRUNK 10.1-30.0CM 1297.79 090<br />
14020 ATT/REARRANGEMENT SCALP/ARM/LEG 10 CM/< 1128.29 090<br />
14021 ATT/REARRANGEMENT SCALP/ARM/LEG 10.1-30.0 CM 1417.98 090<br />
14040 ATT/REARRANGEMENT F/C/C/M/N/AX/G/H/F 10 CM/< 1244.06 090<br />
14041 ATT/REARGMT F/C/C/M/N/AX/G/H/F 10.1-30.0CM 1542.06 090<br />
14060 ATT/REARGMT E/N/E/L DFCT 10 CM/< 1264.55 090<br />
14061 ATT/REARGMT EYELID/NOSE/EAR/LIP 10.1-30.0 CM 1655.05 090<br />
14301 ATT/R ANY AREA DEFECT 30.1-60SQCM 1786.88 090<br />
+ 14302 ATT/R ANY AREA DEFECT EA ADDL 30SQCM OR PART 382.19 ZZZ<br />
14350 FILLETED FINGER/TOE FLAP W/PREPJ RECIPIENT SITE 1173.16 090<br />
15002 PREP SITE TRUNK/ARM/LEG 1ST 100 SQ CM/1PCT 541.71 000<br />
+ 15003 PREP SITE T/A/L ADDL 100 SQ CM/1PCT 117.98 ZZZ<br />
15004 PREP SITE F/S/N/H/F/G/M/D GT 1ST 100 SQ CM/1PCT 636.99 000<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 51
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
+ 15005 PREP SITE F/S/N/H/F/G/M/D GT ADDL 100 SQ CM/1PCT 195.53 ZZZ<br />
15040 HARVEST SKIN TISSUE CLTR SKIN AGRFT 100 CM/< 407.67 000<br />
15050 PINCH GRAFT 1/MLT C> SM ULCER TIP/OTH AREA 2CM 899.53 090<br />
15100 SPLIT AGRFT T/A/L 1ST 100 CM/
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
+ 15366 TISS CLTR ALGC DRM F/S/N/H/F/G/M/D EA 100 CM 131.27 ZZZ<br />
15400 XENOGRAFT TEMP CLOSURE TRUNK/ARM/LEG 1ST 100CM 650.83 090<br />
+ 15401 XENOGRAFT TEMP CLOSURE TRUNK/ARM/LEG EA 100CM 146.78 ZZZ<br />
15420 XENOGRF TEMP CLOSURE F/S/N/H/F/G/M/D 1ST 100CM 706.78 090<br />
+ 15421 XENOGRAFT TEMP CLOSURE F/S/N/H/F/G/M/D EA 100CM 187.22 ZZZ<br />
15430 ACELLULAR XENOGRAFT IMPLANT 1ST 100 CM/1 PCT 870.18 090<br />
+ 15431 ACELLULAR XENOGRAFT IMPLANT EA 100 CM/1 PCT 386.07 ZZZ<br />
15570 FRMJ DIRECT/TUBED PEDICLE +-TRANSFER TRUNK 1440.14 090<br />
15572 FRMJ DIRECT/TUBED PEDICLE +-TR SCALP ARMS/LEGS 1403.58 090<br />
15574 FRMJ DIR/TUBED PEDCL +-TR FT/CH/CH/M/N/AX/G/H/F 1467.84 090<br />
15576 FRMJ DIRECT/TUBED PEDICLE +-TR E/N/E/L/NTRORAL 1303.88 090<br />
15600 DELAY FLAP/SECTIONING FLAP TRUNK 522.33 090<br />
15610 DELAY FLAP/SECTIONING FLAP SCALP ARMS/LEGS 548.36 090<br />
15620 DELAY FLAP/SECTIONING FLAP F/C/C/N/AX/G/H/F 705.11 090<br />
15630 DELAY FLAP/SCTJ FLAP EYELIDS NOSE EARS/LIPS 745.55 090<br />
15650 TRANSFER ANY PEDICLE FLAP ANY LOCATION 824.20 090<br />
15731 FOREHEAD FLAP W/ PRESERVATION VASCULAR PEDICLE 1850.58 090<br />
15732 MUSC MYOCUTANEOUS/FASCIOCUTANEOUS FLAP HEAD&NCK 2436.61 090<br />
15734 MUSC MYOCUTANEOUS/FASCIOCUTANEOUS FLAP TRUNK 2476.49 090<br />
15736 MUSC MYOCUTANEOUS/FASCIOCUTANEOUS FLAP UXTR 2179.04 090<br />
15738 MUSC MYOCUTANEOUS/FASCIOCUTANEOUS FLAP LXTR 2319.73 090<br />
15740 FLAP ISLAND PEDICLE 1660.59 090<br />
15750 FLAP NEUROVASCULAR PEDICLE 1493.31 090<br />
15756 FREE MUSCLE/MYOCUTANEOUS FLAP W/MVASC ANAST 3867.33 090<br />
15757 FREE SKIN FLAP W/MICROVASCULAR ANASTOMOSIS 3828.56 090<br />
15758 FREE FASCIAL FLAP W/MICROVASCULAR ANASTOMOSIS 3811.94 090<br />
15760 GRAFT COMPOSITE W/PRIMARY CLOSURE DONOR AREA 1378.10 090<br />
15770 GRAFT DERMA-FAT-FASCIA 1087.86 090<br />
15775 PUNCH GRAFT HAIR TRANSPLANT 1-15 PUNCH GRAFTS 465.28 000<br />
15776 PUNCH GRAFT HAIR TRANSPLANT >15 PUNCH GRAFTS 681.30 000<br />
15780 DERMABRASION TOTAL FACE 1327.14 090<br />
15781 DERMABRASION SEGMENTAL FACE 876.82 090<br />
15782 DERMABRASION REGIONAL OTHER THAN FACE 892.33 090<br />
15783 DERMABRASION SUPERFICIAL ANY SITE 785.98 090<br />
15786 ABRASION 1 LESION 389.39 010<br />
+ 15787 ABRASION EACH ADDITIONAL 4 LESIONS OR LESS 76.99 ZZZ<br />
15788 CHEMICAL PEEL FACIAL EPIDERMAL 721.18 090<br />
15789 CHEMICAL PEEL FACIAL DERMAL 905.07 090<br />
15792 CHEMICAL PEEL NONFACIAL EPIDERMAL 692.38 090<br />
15793 CHEMICAL PEEL NONFACIAL DERMAL 783.21 090<br />
15819 CERVICOPLASTY 1156.54 090<br />
15820 BLEPHAROPLASTY LOWER EYELID 903.96 090<br />
15821 BLEPHAROPLASTY LOWER EYELID HERNIATED FAT PAD 964.34 090<br />
15822 BLEPHAROPLASTY UPPER EYELID 700.68 090<br />
15823 BLEPHAROPLASTY UPPER EYELID W/EXCESSIVE SKIN 987.60 090<br />
15824 RHYTIDECTOMY FOREHEAD 1786.88 000<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 53
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
15825 RHYTIDECTOMY NECK W/PLATYSMAL TIGHTENING 2009.55 000<br />
15826 RHYTIDECTOMY GLABELLAR FROWN LINES 1451.77 000<br />
15828 RHYTIDECTOMY CHEEK CHIN&NECK 3796.43 000<br />
15829 RHYTIDECTOMY SMAS FLAP 4243.43 000<br />
15830 EXCISION SKIN ABD INFRAUMBILICAL PANNICULECTOMY 1897.66 090<br />
15832 EXCISION EXCESSIVE SKIN&SUBQ TISSUE THIGH 1502.18 090<br />
15833 EXCISION EXCESSIVE SKIN&SUBQ TISSUE LEG 1410.78 090<br />
15834 EXCISION EXCESSIVE SKIN&SUBQ TISSUE HIP 1420.20 090<br />
15835 EXCISION EXCESSIVE SKIN&SUBQ TISSUE BUTTOCK 1502.73 090<br />
15836 EXCISION EXCESSIVE SKIN&SUBQ TISSUE ARM 1173.16 090<br />
15837 EXC EXCESSIVE SKIN&SUBQ TISSUE FOREARM/HAND 1338.78 090<br />
15838 EXC EXCSV SKIN&SUBQ TISSUE SUBMENTAL FAT PAD 937.75 090<br />
15839 EXCISION EXCESSIVE SKIN&SUBQ TISSUE OTHER AREA 1392.50 090<br />
15840 GRAFT FACIAL NERVE PARALYSIS FREE FASCIAL GRAFT 1666.69 090<br />
15841 GRAFT FACIAL NERVE PARALYSIS FREE MUSCLE GRAFT 2752.33 090<br />
15842 GRF FACIAL NRV PALYSS FR MUSCLE FLAP MICROSURG 4129.32 090<br />
15845 GRF FACIAL NERVE PARALYSIS REGIONAL MUSCLE TR 1591.91 090<br />
+ 15847 EXCISION EXCESSIVE SKIN & SUBQ TISSUE ABDOMEN 781.55 YYY<br />
15850 REMOVAL SUTURES UNDER ANESTHESIA SAME SURGEON 139.03 XXX<br />
15851 REMOVAL SUTURES UNDER ANESTHESIA OTHER SURGEON 152.32 000<br />
15852 DRESSING CHANGE UNDER ANESTHESIA 76.44 000<br />
15860 IV INJECTION TEST VASCULAR FLOW FLAP/GRAFT 178.36 000<br />
15876 SUCTION ASSISTED LIPECTOMY HEAD&NECK BR 000<br />
15877 SUCTION ASSISTED LIPECTOMY TRUNK BR 000<br />
15878 SUCTION ASSISTED LIPECTOMY UPPER EXTREMITY BR 000<br />
15879 SUCTION ASSISTED LIPECTOMY LOWER EXTREMITY BR 000<br />
15920 EXC COCCYGEAL PR ULC W/COCCYGECTOMY W/PRIM SUTR 971.54 090<br />
15922 EXC COCCYGEAL PR ULC W/COCCYGECTOMY W/FLAP CLSR 1251.26 090<br />
15931 EXCISION SACRAL PRESSURE ULCER W/PRIMARY SUTURE 1087.31 090<br />
15933 EXC SACRAL PRESSURE ULC W/PRIM SUTR W/OSTECTOMY 1347.08 090<br />
15934 EXCISION SACRAL PRESSURE ULCER W/SKIN FLAP CLSR 1497.19 090<br />
15935 EXC SACRAL PR ULCER W/SKN FLAP CLSR W/OSTECTOMY 1772.48 090<br />
15936 EXC SAC PR ULC PREPJ MUSC/MYOQ FLAP/SKN GRF CLSR 1445.13 090<br />
15937 EXC SAC PR ULC PREPJ MUSC/MYOQ FLAP/SKN GRF OSTC 1691.06 090<br />
15940 EXC ISCHIAL PRESSURE ULCER W/PRIMARY SUTURE 1120.54 090<br />
15941 EXC ISCHIAL PR ULC W/PRIM SUTR W/OSTC ISCHIECT 1452.88 090<br />
15944 EXC ISCHIAL PRESSURE ULCER W/SKIN FLAP CLOSURE 1445.13 090<br />
15945 EXC ISCHIAL PR ULC W/SKN FLAP CLSR W/OSTECTOMY 1604.09 090<br />
15946 EXC ISCHIAL PR ULCER W/OSTC MUSC/MYOQ FLAP/SKIN 2667.03 090<br />
15950 EXC TROCHANTERIC PRESSURE ULCER W/PRIMARY SUTR 921.14 090<br />
15951 EXC TRCHNTRIC PR ULCER W/PRIM SUTR W/OSTECTOMY 1387.52 090<br />
15952 EXC TROCHANTERIC PR ULCER W/SKIN FLAP CLOSURE 1355.95 090<br />
15953 EXC TRCHNTRIC PR ULC W/SKN FLAP CLSR W/OSTECTOMY 1487.78 090<br />
15956 EXC TROCHANTERIC PR ULCER MUSC/MYOQ FLAP/SKIN 1874.40 090<br />
15958 EXC TRCHNTRIC PR ULC MUSC/MYOQ FLAP/SKIN W/OSTC 1912.62 090<br />
15999 UNLISTED PROCEDURE EXCISION PRESSURE ULCER BR YYY<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
54 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
16000 INITIAL TX 1ST DEGREE BURN LOCAL TX 109.67 000<br />
16020 DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ SMALL 132.38 000<br />
16025 DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ MEDIUM 237.62 000<br />
16030 DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ LARGE 285.81 000<br />
16035 ESCHAROTOMY FIRST INCISION 331.79 000<br />
+ 16036 ESCHAROTOMY EACH ADDITIONAL INCISION 134.04 ZZZ<br />
17000 DESTRUCTION PREMALIGNANT LESION 1ST 129.61 010<br />
+ 17003 DESTRUCTION PREMALIGNANT LESION 2-14 EA 11.63 ZZZ<br />
* 17004 DESTRUCTION PREMALIGNANT LESION 15/> 280.27 010<br />
17106 DESTRUCTION CUTANEOUS VASC PROLIFERATIVE 50.0CM 1024.72 090<br />
17110 DESTRUCTION BENIGN LESIONS UP TO 14 176.69 010<br />
17111 DESTRUCTION BENIGN LESIONS 15/> 210.48 010<br />
17250 CHEMICAL CAUTERIZATION GRANULATION TISSUE 121.86 000<br />
17260 DESTRUCTION MALIGNANT LESION T/A/L 0.5 CM/< 152.88 010<br />
17261 DESTRUCTION MAL LESION TRUNK/ARM/LEG 0.6-1.0 CM 230.98 010<br />
17262 DESTRUCTION MAL LESION TRUNK/ARM/LEG 1.1-2.0CM 280.27 010<br />
17263 DESTRUCTION MAL LESION TRUNK/ARM/LEG 2.1-3.0CM 308.52 010<br />
17264 DESTRUCTION MAL LESION TRUNK/ARM/LEG 3.1-4.0CM 330.68 010<br />
17266 DESTRUCTION MAL LESION TRUNK/ARM/LEG > 4.0 CM 374.99 010<br />
17270 DESTRUCTION MALIGNANT LESION S/N/H/F/G 0.5 CM/< 240.95 010<br />
17271 DESTRUCTION MALIGNANT LESION S/N/H/F/G 0.6-1.0CM 264.76 010<br />
17272 DESTRUCTION MALIGNANT LESION S/N/H/F/G 1.1-2.0CM 301.88 010<br />
17273 DESTRUCTION MALIGNANT LESION S/N/H/F/G 2.1-3.0CM 336.22 010<br />
17274 DESTRUCTION MALIGNANT LESION S/N/H/F/G 3.1-4.0CM 396.59 010<br />
17276 DSTRJ MAL LES S/N/H/F/G LES DIAM > 4.0 CM 459.18 010<br />
17280 DESTRUCTION MALIGNANT LESION F/E/E/N/L/M 0.5CM/< 225.99 010<br />
17281 DESTRUCTION MAL LESION F/E/E/N/L/M 0.6-1.0CM 286.37 010<br />
17282 DESTRUCTION MAL LESION F/E/E/N/L/M 1.1-2.0CM 331.79 010<br />
17283 DESTRUCTION MAL LESION F/E/E/N/L/M 2.1-3.0CM 398.81 010<br />
17284 DESTRUCTION MAL LESION F/E/E/N/L/M 3.1-4.0CM 462.51 010<br />
17286 DESTRUCTION MAL LESION F/E/E/N/L/M > 4.0 CM 585.47 010<br />
17311 MOHS MICROGRAPHIC H/N/H/F/G 1ST STAGE 5 BLOCKS 1088.97 000<br />
+ 17312 MOHS MICROGRAPHIC H/N/H/F/G EACH ADDL STAGE 649.72 ZZZ<br />
17313 MOHS TRUNK/ARM/LEG 1ST STAGE 5 BLOCKS 993.14 000<br />
+ 17314 MOHS TRUNK/ARM/LEG EA STAGE AFTER 1ST STAGE 602.64 ZZZ<br />
+ 17315 MOHS TRUNK/ARM/LEG EA ADDL BLOCK ANY STAGE 130.72 ZZZ<br />
17340 CRYOTHERAPY CO2 SLUSH LIQ N2 ACNE 80.32 010<br />
17360 CHEMICAL EXFOLIATION ACNE 213.81 010<br />
17380 ELECTROLYSIS EPILATION EA 30 MINUTES 123.52 000<br />
17999 UNLISTED PX SKIN MUC MEMBRANE &SUBQ TISSUE BR YYY<br />
19000 PUNCTURE ASPIRATION CYST BREAST 177.25 000<br />
+ 19001 PUNCTURE ASPIRATION BREAST EA ADDL CYST 43.20 ZZZ<br />
19020 MASTOTOMY W/EXPL/DRAINAGE ABSCESS DEEP 721.73 090<br />
19030 INJECTION MAMMARY DUCTOGRAM/GALACTOGRAM 263.10 000<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 55
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
19100 BX BREAST NEEDLE CORE W/O IMAGING GUIDANCE SPX 231.53 000<br />
19101 BIOPSY BREAST OPEN INCISIONAL 527.87 010<br />
19102 BIOPSY BREAST NEEDLE CORE W/IMAGING GUIDANCE 346.74 000<br />
19103 BREAST BIOPSY VACUUM ASSISTED/ROTATING DEVICE 891.23 000<br />
19105 ABLTJ CRYOSURGICAL W/ US GID EA FIBROADENOMA 3317.86 000<br />
19110 NIPPLE EXPLORATION 749.43 090<br />
19112 EXCISION LACTIFEROUS DUCT FISTULA 703.45 090<br />
19120 EXC CYST/ABERRANT BREAST TISSUE OPEN 1/> LES 763.83 090<br />
19125 EXC BRST LES PREOP PLMT RAD MARKER OPN 1 LES 848.02 090<br />
+ 19126 EXC BRST LES PREOP PLMT RAD MARKER OPN EA ADDL 261.44 ZZZ<br />
19260 EXCISION CHEST WALL TUMOR INCLUDING RIBS 1955.27 090<br />
19271 EXC CHEST TUMOR W/RCNSTJ W/O MEDSTNL LMPHADEC 2652.07 090<br />
19272 EXC CHEST TUMOR W/RCNSTJ W/MEDSTNL LMPHADEC 2936.78 090<br />
19290 PREOP PLACEMENT LOCALIZATION WIRE BREAST 259.78 000<br />
+ 19291 PREOP PLMT LOCALIZATION WIRE BREAST EA LESION 110.23 ZZZ<br />
+ 19295 IMG GID PLMT MTLC LOCLZJ CLIP PRQ BRST BX/ASPIR 147.34 ZZZ<br />
19296 PLMT EXPANDABLE CATH BRST FOLLOWING PRTL MAST 6437.43 000<br />
+ 19297 PLMT EXPANDABLE CATH BRST CONCURRENT PRTL MAST 152.88 ZZZ<br />
K 19298 PLMT RADTHX BRACHYTX BRST FOLLOWING PRTL MAST 1975.21 000<br />
19300 MASTECTOMY GYNECOMASTIA 810.36 090<br />
19301 MASTECTOMY PARTIAL 1025.27 090<br />
19302 MASTECTOMY PARTIAL W/AXILLARY LYMPHADENECTOMY 1414.11 090<br />
19303 MASTECTOMY SIMPLE COMPLETE 1587.48 090<br />
19304 MASTECTOMY SUBCUTANEOUS 902.86 090<br />
19305 MAST RAD W/PECTORAL MUSCLES AXILLARY LYMPH NODES 1793.53 090<br />
19306 MAST RAD W/PECTORAL MUSC AX INT MAM LYMPH NODES 1889.35 090<br />
19307 MAST MODF RAD W/AX LYMPH NOD W/WO PECT/ALIS MIN 1889.91 090<br />
19316 MASTOPEXY 1259.57 090<br />
19318 REDUCTION MAMMAPLASTY 1828.42 090<br />
19324 MAMMAPLASTY AUGMENTATION W/O PROSTHETIC IMPLANT 781.00 090<br />
19325 MAMMAPLASTY AUGMENTATION W/PROSTHETIC IMPLANT 1054.63 090<br />
19328 REMOVAL INTACT MAMMARY IMPLANT 804.26 090<br />
19330 REMOVAL MAMMARY IMPLANT MATERIAL 1027.48 090<br />
19340 IMMT INSJ BRST PROSTH FLWG MASTOPEXY MAST/RCNSTJ 1422.42 090<br />
19342 DLYD INSJ BRST PROSTH FLWG MASTOPEXY MAST/RCNSTJ 1509.93 090<br />
19350 NIPPLE/AREOLA RECONSTRUCTION 1353.73 090<br />
19355 CORRECTION INVERTED NIPPLES 1132.17 090<br />
19357 BRST RCNSTJ IMMT/DLYD W/TISS EXPANDER SBSQ XPNSJ 2413.90 090<br />
19361 BRST RCNSTJ W/LATSMS D/SI FLAP WO PRSTHC IMPL 2762.85 090<br />
19364 BREAST RECONSTRUCTION FREE FLAP 4563.58 090<br />
19366 BREAST RECONSTRUCTION OTHER TECHNIQUE 2251.60 090<br />
19367 BREAST RECONSTRUCTION TRAM FLAP 1 PEDICLE 2961.70 090<br />
19368 BREAST RECONSTRUCTION TRAM 1 PEDCL MVASC ANAST 3661.28 090<br />
19369 BREAST RECONSTRUCTION TRAM FLAP DOUBLE PEDICLE 3379.90 090<br />
19370 OPEN PERIPROSTHETIC CAPSULOTOMY BREAST 1119.43 090<br />
19371 PERIPROSTHETIC CAPSULECTOMY BREAST 1282.83 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
56 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
19380 REVISION RECONSTRUCTED BREAST 1261.23 090<br />
19396 PREPARATION MOULAGE CUSTOM BREAST IMPLANT 389.95 000<br />
19499 UNLISTED PROCEDURE BREAST BR YYY<br />
s 20005 I&D SOFT TISSUE ABSCESS SUBFASC 481.89 010<br />
20100 EXPLORATION PENETRATING WOUND SPX NECK 967.66 010<br />
20101 EXPLORATION PENETRATING WOUND SPX CHEST 644.19 010<br />
20102 EXPL PENETRATING WOUND SPX ABDOMEN/FLANK/BACK 759.95 010<br />
20103 EXPLORATION PENETRATING WOUND SPX EXTREMITY 913.94 010<br />
20150 EXCISION EPIPHYSEAL BAR 3088.86 090<br />
20200 BIOPSY MUSCLE SUPERFICIAL 611.79 000<br />
20205 BIOPSY MUSCLE DEEP 842.42 000<br />
20206 BIOPSY MUSCLE PERCUTANEOUS NEEDLE 776.22 000<br />
20220 BIOPSY BONE TROCAR/NEEDLE SUPERFICIAL 510.36 000<br />
20225 BIOPSY BONE TROCAR/NEEDLE DEEP 1913.32 000<br />
20240 BIOPSY BONE OPEN SUPERFICIAL 700.41 010<br />
20245 BIOPSY BONE OPEN DEEP 1968.84 010<br />
20250 BIOPSY VERTEBRAL BODY OPEN THORACIC 1184.08 010<br />
20251 BIOPSY VERTEBRAL BODY OPEN LUMBAR/CERVICAL 1294.05 010<br />
20500 INJECTION SINUS TRACT THERAPEUTIC SPX 176.69 010<br />
20501 INJECTION SINUS TRACT DIAGNOSTIC 200.51 000<br />
20520 REMOVAL FOREIGN BODY MUSCLE/TENDON SHEATH SIMPLE 311.85 010<br />
20525 RMVL FOREIGN BODY MUSCLE/TENDON SHEATH DEEP/COMP 755.52 010<br />
20526 INJECTION THERAPEUTIC CARPAL TUNNEL 120.20 000<br />
20550 INJECTION 1 TENDON SHEATH/LIGAMENT APONEUROSIS 91.39 000<br />
20551 INJECTION SINGLE TENDON ORIGIN/INSERTION 93.06 000<br />
20552 INJECTION SINGLE/MLT TRIGGER POINT 1/2 MUSCLES 85.30 000<br />
20553 INJECTION SINGLE/MLT TRIGGER POINT 3/> MUSCLES 96.38 000<br />
20555 PLACEMENT NEEDLES MUSCLE SUBSEQUENT RADIOELEMENT 536.73 000<br />
20600 ARTHROCENTESIS ASPIR&/INJECTION SMALL JT/BURSA 86.41 000<br />
20605 ARTHROCENTESIS ASPIR&/INJECTION INTERM JT/BURSA 94.16 000<br />
20610 ARTHROCENTESIS ASPIR&/INJECTION MAJOR JT/BURSA 125.18 000<br />
20612 ASPIRATION&/INJECTION GANGLION CYST ANY LOCATION 93.61 000<br />
20615 ASPIRATION&INJECTION TREATMENT BONE CYST 348.96 010<br />
20650 INSERTION WIRE/PIN W/APPL SKELETAL TRACTION SPX 608.59 010<br />
20660 APPLICATION CRANIAL TONG/STRTCTC FRAME W/REMOVAL 767.68 000<br />
20661 APPLICATION HALO CRANIAL INCLUDING REMOVAL 1520.40 090<br />
20662 APPLICATION HALO PELVIC INCLUDING REMOVAL 1343.17 090<br />
20663 APPLICATION HALO FEMORAL INCLUDING REMOVAL 1421.11 090<br />
s 20664 APPL HALO 6/> PINS THIN SKULL OSTEOLOGY 2540.06 090<br />
20665 REMOVAL TONG/HALO APPLIED BY ANOTHER PHYSICIAN 341.66 010<br />
20670 REMOVAL IMPLANT SUPERFICIAL SPX 1196.89 010<br />
20680 REMOVAL IMPLANT DEEP 1884.49 090<br />
20690 APPLICATION UNIPLANE EXTERNAL FIXATION SYSTEM 1792.67 090<br />
20692 APPLICATION MULTIPLANE EXTERNAL FIXATION SYSTEM 3368.59 090<br />
20693 ADJUSTMENT/REVJ XTRNL FIXATION SYSTEM REQ ANES 1417.91 090<br />
20694 REMOVAL EXTERNAL FIXATION SYSTEM UNDER ANES 1310.07 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 57
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
20696 XTRNL FIXJ W/STEREOTACTIC ADJUSTMENT 1ST&SUBQ 3357.92 090<br />
* 20697 XTRNL FIXJ W/STRTCTC ADJUSTMENT EXCHANGE STRUT 5261.63 000<br />
20802 REPLANTATION ARM COMPLETE AMPUTATION 3750.46 090<br />
20805 REPLANTATION FOREARM COMPLETE AMPUTATION 4640.02 090<br />
20808 REPLANTATION HAND COMPLETE AMPUTATION 6788.04 090<br />
20816 RPLJ DGT EXCEPT THMB MTCARPHLNGL JT COMPL AMP 3492.34 090<br />
20822 RPLJ DGT EXCLUDING THMB SUBLIMIS TDN COMPL AMP 3086.88 090<br />
20824 RPLJ THMB CARP/MTCRPL JT MP JT COMPL AMPUTATION 3531.67 090<br />
20827 RPLJ THUMB DISTAL TIP MP JOINT COMPL AMPUTATION 3205.42 090<br />
20838 REPLANTATION FOOT COMPLETE AMPUTATION 3850.16 090<br />
20900 BONE GRAFT ANY DONOR AREA MINOR/SMALL 1283.38 000<br />
20902 BONE GRAFT ANY DONOR AREA MAJOR/LARGE 1024.99 000<br />
20910 CARTILAGE GRAFT COSTOCHONDRAL 1320.74 090<br />
20912 CARTILAGE GRAFT NASAL SEPTUM 1528.95 090<br />
20920 FASCIA LATA GRAFT BY STRIPPER 1257.75 090<br />
20922 FASCIA LATA GRAFT INCISION & AREA EXPOSURE 1863.14 090<br />
20924 TENDON GRAFT FROM A DISTANCE 1572.72 090<br />
20926 TISSUE GRAFTS OTHER 1362.39 090<br />
s + 20930 ALLOGRAFT FOR SPINE SURGERY ONLY MORSELIZED 381.17 XXX<br />
s + 20931 ALLOGRAFT FOR SPINE SURGERY ONLY STRUCTURAL 358.75 ZZZ<br />
+ 20936 AUTOGRAFT SPINE SURGERY LOCAL FROM SAME INCISION 402.52 XXX<br />
+ 20937 AUTOGRAFT SPINE SURGERY MORSELIZED SEP INCISION 537.05 ZZZ<br />
+ 20938 AUTOGRAFT SPINE SURGERY BICORT/TRICORT SEP INC 589.37 ZZZ<br />
20950 MNTR INTERSTITIAL FLUID PRESSURE CMPRT SYNDROME 762.34 000<br />
20955 BONE GRAFT MICROVASCULAR ANASTOMOSIS FIBULA 8049.39 090<br />
20956 BONE GRAFT MICROVASCULAR ANAST ILIAC CREST 8319.52 090<br />
20957 BONE GRAFT MICROVASCULAR ANAST METATARSAL 8098.50 090<br />
20962 B1 GRF W/MVASC ANAST OTH/THN ILIAC CREST/METAR 8247.98 090<br />
20969 FREE OSTQ FLAP W/MVASC ANAST METAR/GREAT TOE 8876.86 090<br />
20970 FREE OSTQ FLAP W/MVASC ANASTOMOSIS ILIAC CREST 8885.40 090<br />
20972 FREE OSTQ FLAP W/MVASC ANASTOMOSIS METATARSAL 7216.58 090<br />
20973 FR OSTQ FLAP W/MVASC ANAST GRT TOE W/WEB SPACE 8438.03 090<br />
* 20974 ELECTRICAL STIMULATION BONE HEALING NONINVASIVE 215.68 000<br />
* 20975 ELECTRICAL STIMULATION BONE HEALING INVASIVE 555.20 000<br />
20979 LOW INTENSITY US STIMJ BONE HEALING NONINVASIVE 162.29 000<br />
K 20982 ABLATION BONE TUMOR RF PERCUTANEOUS CT GUIDANCE 11229.00 000<br />
+ 20985 CPTR-ASST SURGICAL NAVIGATION IMAGE-LESS 467.65 ZZZ<br />
20999 UNLISTED PROCEDURE MUSCSKELETAL SYSTEM GENERAL BR YYY<br />
21010 ARTHROTOMY TEMPOROMANDIBULAR JOINT 1175.38 090<br />
21011 EXCISION TUMOR SOFT TISS FACE/SCALP SUBQ < 2CM 535.62 090<br />
21012 EXCISION TUMOR SOFT TISS FACE/SCALP SUBQ 2+CM 564.42 090<br />
21013 EXC TUMOR SOFT TISS FACE&SCALP SUBFASCIAL < 2CM 827.53 090<br />
21014 EXC TUMOR SOFT TISS FACE&SCALP SUBFASCIAL 2+CM 870.73 090<br />
21015 RAD RESECTION TUMOR SOFT TISS FACE/SCALP < 2CM 1069.58 090<br />
21016 RAD RESECTION TUMOR SOFT TISS FACE/SCALP 2+CM 1727.06 090<br />
21025 EXCISION BONE MANDIBLE 1430.72 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
58 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
21026 EXCISION FACIAL BONE 975.97 090<br />
21029 REMOVAL CONTOURING BENIGN TUMOR FACIAL BONE 1244.61 090<br />
21030 EXC BENIGN TUMOR/CYST MAXL/ZYGOMA ENCL & CURTG 818.11 090<br />
21031 EXCISION TORUS MANDIBULARIS 615.94 090<br />
21032 EXCISION MAXILLARY TORUS PALATINUS 626.46 090<br />
21034 EXCISION MALIGNANT TUMOR MAXILLA/ZYGOMA 2162.43 090<br />
21040 EXCISION BENIGN TUMOR/CYST MANDIBLE ENCL&/CURTG 824.20 090<br />
21044 EXCISION MALIGNANT TUMOR MANDIBLE 1440.14 090<br />
21045 EXCISION MALIGNANT TUMOR MANDIBLE RADICAL 2006.78 090<br />
21046 EXC BENIGN TUMOR/CYST MNDBL INTRA-ORAL OSTEOT 1771.93 090<br />
21047 EXC B9 TUM/CST MNDBL XTR-ORAL OSTEOT&PRTL MNDBLC 2118.67 090<br />
21048 EXC BENIGN TUMOR/CYST MAXL INTRA-ORAL OSTEOT 1811.81 090<br />
21049 EXC B9 TUM/CST MAXL XTR-ORAL OSTEOT&PRTL MAXLCT 2031.71 090<br />
21050 CONDYLECTOMY TEMPOROMANDIBULAR JOINT SPX 1429.62 090<br />
21060 MENISCECTOMY PRTL/COMPL TEMPOROMANDIBULAR JT SPX 1332.68 090<br />
21070 CORONOIDECTOMY SPX 1015.85 090<br />
21073 MANIPULATION TMJ THERAPEUTIC REQUIRE ANESTHESIA 623.14 090<br />
21076 IMPRESSION&PREPARATION SURG OBTURATOR PROSTHESIS 1570.86 010<br />
21077 IMPRESSION & PREPARATION ORBITAL PROSTHESIS 3914.41 090<br />
21079 IMPRESSION&PREPARATION INTERIM OBTURATOR PROSTH 2658.17 090<br />
21080 IMPRESSION&PREPJ DEFINITIVE OBTURATOR PROSTHESIS 3001.58 090<br />
21081 IMPRESSION&PREPJ MANDIBULAR RESECTION PROSTHESIS 2754.54 090<br />
21082 IMPRESSION&PREPJ PALATAL AUGMENTATION PROSTHESIS 2583.94 090<br />
21083 IMPRESSION&PREPARATION PALATAL LIFT PROSTHESIS 2398.39 090<br />
21084 IMPRESSION&PREPARATION SPEECH AID PROSTHESIS 2829.88 090<br />
21085 IMPRESSION&PREPARATION ORAL SURGICAL SPLINT 1282.83 010<br />
21086 IMPRESSION&PREPARATION AURICULAR PROSTHESIS 2874.74 090<br />
21087 IMPRESSION&PREPARATION NASAL PROSTHESIS 2869.20 090<br />
21088 IMPRESSION&PREPARATION FACIAL PROSTHESIS BR 090<br />
21089 UNLISTED MAXILLOFACIAL PROSTHETIC PROCEDURE BR YYY<br />
21100 APPL HALO APPLIANCE MAXILLOFACIAL FIXATION SPX 1052.41 090<br />
21110 APPL INTERDENTAL FIXATION DEVICE NON-FX/DISLC 1245.17 090<br />
21116 INJECTION TEMPOROMANDIBULAR JOINT ARTHROGRAPHY 236.52 000<br />
21120 GENIOPLASTY AUGMENTATION 1032.47 090<br />
21121 GENIOPLASTY SLIDING OSTEOTOMY SINGLE PIECE 1240.74 090<br />
21122 GENIOPLASTY 2/> SLIDING OSTEOTOMIES 1132.17 090<br />
21123 GENIOP SLIDING AGMNTJ W/INTERPOSAL BONE GRAFTS 1415.21 090<br />
21125 AGMNTJ MNDBLR BODY/ANGLE PROSTHETIC MATERIAL 4921.96 090<br />
21127 AGMNTJ MNDBLR BDY/ANGL W/B1 GRF ONLAY/INTERPOSAL 6010.92 090<br />
21137 REDUCTION FOREHEAD CONTOURING ONLY 1169.28 090<br />
21138 RDCTJ FHD CNTRG&PROSTHETIC MATRL/BONE GRAFT 1444.57 090<br />
21139 RDCTJ FHD CNTRG&SETBACK ANT FRONTAL SINUS WALL 1603.54 090<br />
21141 RCNSTJ MIDFACE LEFORT I 1 PIECE W/O BONE GRAFT 2239.42 090<br />
21142 RCNSTJ MIDFACE LEFORT I 2 PIECES W/O BONE GRAFT 2257.70 090<br />
21143 RCNSTJ MIDFACE LEFORT I 3/>PIECE W/O BONE GRAFT 2392.85 090<br />
21145 RCNSTJ MIDFACE LEFORT I 1 PIECE W/BONE GRAFTS 2431.62 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 59
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
21146 RCNSTJ MIDFACE LEFORT I 2 PIECES W/BONE GRAFTS 2792.21 090<br />
21147 RCNSTJ MIDFACE LEFORT I 3/>PIECE W/BONE GRAFTS 2665.37 090<br />
21150 RCNSTJ MIDFACE LEFORT II ANTERIOR INTRUSION 2669.80 090<br />
21151 RCNSTJ MIDFACE LEFORT II W/BONE GRAFTS 3197.11 090<br />
21154 RCNSTJ MIDFACE LEFORT III W/O LEFORT I 3464.64 090<br />
21155 RCNSTJ MIDFACE LEFORT III W/LEFORT I 3529.45 090<br />
21159 RCNSTJ MIDFACE LEFORT III W/FHD W/O LEFORT I 4561.92 090<br />
21160 RCNSTJ MIDFACE LEFORT III W/FHD W/LEFORT I 4376.92 090<br />
21172 RCNSTJ SUPERIOR-LATERAL ORBITAL RIM&LOWER FHD 2911.85 090<br />
21175 RCNSTJ BIFRONTAL SUPERIOR-LAT ORB RIMS&LWR FHD 3914.41 090<br />
21179 RCNSTJ FOREHEAD&/SUPRAORB RIMS W/ALGRF/PROSTC 2489.78 090<br />
21180 RCNSTJ FOREHEAD&/SUPRAORBITAL RIMS W/AUTOGRAFT 2710.23 090<br />
21181 RCNSTJ CONTOURING BENIGN TUMOR CRNL BONES XTRC 1159.87 090<br />
21182 RCNSTJ ORBIT/FHD/NASETHMD EXC B9 TUM GRF 40 80 CM 4056.76 090<br />
21188 RCNSTJ MDFC OTH/THN LEFORT OSTEOT&BONE GRAFTS 2628.26 090<br />
21193 RCNSTJ MNDBLR RAMI HRZNTL/VER/C/L OSTEOT W/O GRF 2140.27 090<br />
21194 RCNSTJ MNDBLR RAMI HRZNTL/VER/C/L OSTEOT W/GRF 2278.19 090<br />
21195 RCNSTJ MNDBLR RAMI&/BODY SGTL SPLT W/O INT RGD 2190.67 090<br />
21196 RCNSTJ MNDBLR RAMI&/BDY SGTL SPLT W/INT RGD FIXJ 2397.28 090<br />
21198 OSTEOTOMY MANDIBLE SEGMENTAL 1893.78 090<br />
21199 OSTEOTOMY MANDIBLE SGMTL W/GENIOGLOSSUS ADVMNT 1668.90 090<br />
21206 OSTEOTOMY MAXILLA SEGMENTAL 1982.96 090<br />
21208 OSTEOPLASTY FACIAL BONES AUGMENTATION 2927.92 090<br />
21209 OSTEOPLASTY FACIAL BONES REDUCTION 1355.39 090<br />
21210 GRAFT BONE NASAL/MAXILLARY/MALAR AREAS 3501.76 090<br />
21215 GRAFT BONE MANDIBLE 6107.86 090<br />
21230 GRAFT RIB CRTLG AUTOGENOUS FACE/CHIN/NOSE/EAR 1268.43 090<br />
21235 GRAFT EAR CRTLG AUTOGENOUS NOSE/EAR 1185.90 090<br />
21240 ARTHRP TEMPOROMANDIBULAR JOINT +-AUTOGRAFT 1789.10 090<br />
21242 ARTHROPLASTY TEMPOROMANDIBULAR JT W/ALLOGRAFT 1641.21 090<br />
21243 ARTHRP TMPRMAND JOINT W/PROSTHETIC REPLACEMENT 2701.37 090<br />
21244 RCNSTJ MNDBL XTRORAL W/TRANSOSTEAL BONE PLATE 1726.51 090<br />
21245 RCNSTJ MNDBL/MAXL SUBPRIOSTEAL IMPLANT PARTIAL 1834.52 090<br />
21246 RCNSTJ MNDBL/MAXL SUBPRIOSTEAL IMPLANT COMPLETE 1364.81 090<br />
21247 RCNSTJ MNDBLR CONDYLE W/BONE CARTLG AUTOGRAFTS 2655.95 090<br />
21248 RCNSTJ MANDIBLE/MAXL ENDOSTEAL IMPLANT PARTIAL 1746.45 090<br />
21249 RCNSTJ MANDIBLE/MAXL ENDOSTEAL IMPLANT COMPLETE 2402.82 090<br />
21255 RCNSTJ ZYGMTC ARCH/GLENOID FOSSA W/BONE CARTLG 2248.83 090<br />
21256 RECONSTRUCTION ORBIT W/OSTEOTOMIES&BONE GRAFTS 1928.68 090<br />
21260 PERIORBITAL OSTEOTOMIES BONE GRAFTS EXTRACRANIAL 2161.87 090<br />
21261 PERIORBITAL OSTEOTOMIES W/BONE GRAFTS ICRA&XTRC 3600.35 090<br />
21263 PERIORBITAL OSTEOTOMIES W/BONE GRAFTS W/FOREHEAD 3074.15 090<br />
21267 ORBITAL REPOSITIONING W/BONE GRAFTS EXTRACRANIAL 2615.52 090<br />
21268 ORBITAL REPOSITIONING W/BONE GRAFTS ICRA&XTRC 2993.83 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
60 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
21270 MALAR AUGMENTATION PROSTHETIC MATERIAL 1538.18 090<br />
21275 SECONDARY REVISION ORBITOCRANIOFACIAL RCNSTJ 1364.81 090<br />
21280 MEDIAL CANTHOPEXY SPX 915.60 090<br />
21282 LATERAL CANTHOPEXY 602.64 090<br />
21295 REDUCTION MASSETER MUSCLE&BONE EXTRAORAL 286.92 090<br />
21296 REDUCTION MASSETER MUSCLE&BONE INTRAORAL 651.39 090<br />
21299 UNLISTED CRANIOFACIAL&MAXILLOFACIAL PROCEDURE BR YYY<br />
21310 CLOSED TREATMENT NASAL FRACTURE W/O MANIPULATION 181.13 000<br />
21315 CLOSED TX NASAL FRACTURE W/O STABILIZATION 437.03 010<br />
21320 CLOSED TREATMENT NASAL FRACTURE W/STABILIZATION 412.10 010<br />
21325 OPEN TREATMENT NASAL FRACTURE UNCOMPLICATED 768.26 090<br />
21330 OPEN TX NASAL FX COMP W/INT&/XTRNL SKELETAL FIXJ 927.23 090<br />
21335 OPEN TX NASAL FX W/CONCOMITANT OPTX FXD SEPTUM 1195.32 090<br />
21336 OPEN TX NASAL SEPTAL FRACTURE +-STABILIZATION 1056.29 090<br />
21337 CLOSED TX NASAL SEPTAL FRACTURE +-STABILIZATION 647.51 090<br />
21338 OPEN TX NASOETHMOID FX W/O EXTERNAL FIXATION 1216.92 090<br />
21339 OPEN TX NASOETHMOID FX W/EXTERNAL FIXATION 1311.08 090<br />
21340 PERCUTANEOUS TX NASOETHMOID COMPLEX FRACTURE 1268.43 090<br />
21343 OPEN TX DEPRESSED FRONTAL SINUS FRACTURE 1878.83 090<br />
21344 OPEN TX COMPLICATED FRONTAL SINUS FRACTURE 2724.63 090<br />
21345 CLOSED TX NASOMAXILLARY COMPLEX FRACTURE 1276.19 090<br />
21346 OPTX NASOMAX CPLX FX LEFT II TYPE W/WIRG&FIXJ 1517.13 090<br />
21347 OPTX NASOMAX CPLX FX LEFT II TYPE REQ MLT OPN 1797.41 090<br />
21348 OPTX NASOMAX CPLX FX LEFT II TYPE W/B1 GRFG 1892.68 090<br />
21355 PERCUTANEOUS TX MALAR AREA FRACTURE 721.18 010<br />
21356 OPEN TX DEPRESSED ZYGOMATIC ARCH FRACTURE 801.49 010<br />
21360 OPEN TX DEPRESSED MALAR FRACTURE 864.08 090<br />
21365 OPEN TX COMP FX MALAR W/INTERNAL FX&MULT SURG 1822.88 090<br />
21366 OPEN TX COMP FRACTURE MALAR AREA W/BONE GRAFT 2068.26 090<br />
21385 OPEN TX ORBITAL FLOOR BLOWOUT FX TRANSANTRAL 1137.16 090<br />
21386 OPEN TX ORBITAL FLOOR BLOWOUT FX PERIORBITAL 1086.20 090<br />
21387 OPEN TX ORBITAL FLOOR BLOWOUT FX COMBINED APPR 1222.46 090<br />
21390 OPTX ORB FLOOR BLWT FX PRI/BITAL APPR W/ALLPLSTC 1292.25 090<br />
21395 OPTX ORB FLOOR BLWT FX PRI/BITAL APPR W/B1 GRF 1587.48 090<br />
21400 CLSD TX FX ORBIT EXCEPT BLOWOUT W/O MANIPULATION 297.44 090<br />
21401 CLOSED TX FX ORBIT EXCEPT BLOWOUT W/MANIPULATION 768.26 090<br />
21406 OPEN TX FX ORBIT EXCEPT BLOWOUT W/O IMPLANT 895.10 090<br />
21407 OPEN TX FX ORBIT EXCEPT BLOWOUT W/IMPLANT 1056.84 090<br />
21408 OPEN TX FX ORBIT EXCEPT BLOWOUT W/BONE GRAFT 1473.37 090<br />
21421 CLOSED TX PALATAL/MAXILLARY FX W/FIXATION/SPLINT 1210.83 090<br />
21422 OPEN TREATMENT PALATAL/MAXILLARY FRACTURE 1079.55 090<br />
21423 OPEN TX PALATAL/MAXILLARY FX COMP MULTIPLE APPR 1339.88 090<br />
21431 CLOSED TX CRANIOFACIAL SEPARATION 1208.06 090<br />
21432 OPEN TX CRANIOFACIAL SEP W/WIRING&/INT FIXJ 1143.80 090<br />
21433 OPEN TX CRANIOFACIAL SEP COMPLICATED MLT APPR 2757.87 090<br />
21435 OPEN TX CRANIOFACIAL SEP COMP W/INT&/XTRNL FIXJ 2126.42 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 61
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
21436 OPTX CRANFCL SEP LEFT III TYP COMP INT FIXJ W/B1 3350.54 090<br />
21440 CLTX MANDIBULAR/MAXILLARY ALVEOLAR RIDGE FX SPX 894.55 090<br />
21445 OPTX MANDIBULAR/MAXILLARY ALVEOLAR RIDGE FX SPX 1221.35 090<br />
21450 CLOSED TX MANDIBULAR FRACTURE W/O MANIPULATION 937.75 090<br />
21451 CLOSED TX MANDIBULAR FRACTURE W/MANIPULATION 1216.36 090<br />
21452 PERCUTANEOUS TX MANDIBULAR FX W/EXTERNAL FIXJ 942.18 090<br />
21453 CLOSED TX MANDIBULAR FX W/INTERDENTAL FIXATION 1420.75 090<br />
21454 OPEN TX MANDIBULAR FX W/EXTERNAL FIXATION 903.96 090<br />
21461 OPEN TX MANDIBULAR FX W/O INTERDENTAL FIXATION 3280.75 090<br />
21462 OPEN TX MANDIBULAR FX W/INTERDENTAL FIXATION 3480.15 090<br />
21465 OPEN TX MANDIBULAR CONDYLAR FX 1549.26 090<br />
21470 OPTX COMP MANDIBULAR FX MLT APPR W/INT FIXATION 1968.01 090<br />
21480 CLOSED TX TEMPOROMANDIBULAR DISLOCATION 1ST/SBSQ 148.45 000<br />
21485 CLOSED TX TEMPOROMANDIBULAR DISLC COMP 1ST/SBSQ 1093.40 090<br />
21490 OPEN TREATMENT TEMPOROMANDIBULAR DISLOCATION 1519.35 090<br />
21495 OPEN TREATMENT HYOID FRACTURE 1142.70 090<br />
21497 INTERDENTAL WIRING OTHER THAN FRACTURE 1096.17 090<br />
21499 UNLISTED MUSCULOSKELETAL PROCEDURE HEAD BR YYY<br />
21501 I&D DEEP ABSC/HMTMA SOFT TISSUE NECK/THORAX 720.62 090<br />
21502 I&D DP ABSC/HMTMA SOFT TISS NCK/THORAX PRTL RIB 831.40 090<br />
21510 INCISION DEEP OPENING BONE CORTEX THORAX 765.49 090<br />
21550 BIOPSY SOFT TISSUE NECK/THORAX 415.43 010<br />
# 21552 EXC TUMOR SOFT TISSUE NECK/ANT THORAX SUBQ 3+CM 741.12 090<br />
# 21554 EXC TUMOR SOFT TISSUE NECK/THORAX SUBFASC 5+CM 1216.36 090<br />
21555 EXC TUMOR SOFT TISSUE NECK/ANT THORAX SUBQ
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
21805 OPEN TX RIB FRACTURE W/O FIXATION EACH 425.95 090<br />
21810 TX RIB FRACTURE EXTERNAL FIXATION FLAIL CHEST 846.36 090<br />
21820 CLOSED TREATMENT STERNUM FRACTURE 218.24 090<br />
21825 OPEN TX STERNUM FRACTURE +-SKELETAL FIXATION 922.24 090<br />
21899 UNLISTED PROCEDURE NECK/THORAX BR YYY<br />
21920 BIOPSY SOFT TISSUE BACK/FLANK SUPERFICIAL 415.98 010<br />
21925 BIOPSY SOFT TISSUE BACK/FLANK DEEP 692.38 090<br />
21930 EXCISION TUMOR SOFT TISSUE BACK/FLANK SUBQ
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
+ 22522 PERCUTANEOUS VERTEBROPLASTY EA ADDL THRC/LMBR 726.04 ZZZ<br />
22523 PERCUTANEOUS VERTEBRAL AUGMENTATION THORACIC 1844.99 010<br />
22524 PERCUTANEOUS VERTEBRAL AUGMENTATION LUMBAR 1773.45 010<br />
+ 22525 PERQ VERTEBRAL AUGMENTATION EA ADDL THRC/LMBR 828.54 ZZZ<br />
K 22526 PERQ INTRDSCL ELECTROTHRM ANNULOPLASTY 1 LVL 6568.49 010<br />
+ K 22527 PERQ INTRDSCL ELECTROTHRM ANNULOPLASTY ADDL LVL 5282.98 ZZZ<br />
22532 ARTHRODESIS LATERAL EXTRACAVITARY THORACIC 5585.14 090<br />
22533 ARTHRODESIS LATERAL EXTRACAVITARY LUMBAR 5261.63 090<br />
+ 22534 ARTHRODESIS LAT EXTRACAVITARY EA ADDL THRC/LMBR 1161.66 ZZZ<br />
22548 ARTHRD ANT TRANSORAL/XTRORAL C1-C2 +-EXC ODNTD 6090.16 090<br />
l 22551 ARTHRD ANT INTERBODY DECOMPRESS CERVICAL BELW C2 5460.22 090<br />
l + 22552 ARTHRD ANT INTERDY CERVCL BELW C2 EA ADDL NTRSPC 1272.70 ZZZ<br />
22554 ARTHRD ANT MIN DISCECT INTERBODY CERV BELW C2 3991.06 090<br />
22556 ARTHRD ANT MIN DISCECTOMY INTERBODY THORACIC 5234.93 090<br />
22558 ARTHRODESIS ANTERIOR INTERBODY LUMBAR 4837.75 090<br />
+ 22585 ARTHRODESIS ANTERIOR INTERBODY EA ADDL NTRSPC 1077.31 ZZZ<br />
22590 ARTHRODESIS POSTERIOR CRANIOCERVICAL 4923.16 090<br />
22595 ARTHRODESIS POSTERIOR ATLAS-AXIS C1-C2 4679.73 090<br />
22600 ARTHRODESIS PST/PSTLAT CERVICAL BELW C2 SGM 3996.40 090<br />
22610 ARTHRODESIS POSTERIOR/POSTEROLATERAL THORACIC 3915.26 090<br />
22612 ARTHRODESIS POSTERIOR/POSTEROLATERAL LUMBAR 5008.58 090<br />
+ 22614 ARTHRODESIS POSTERIOR/POSTEROLATERAL EA ADDL 1255.62 ZZZ<br />
22630 ARTHRODESIS POSTERIOR INTERBODY LUMBAR 4826.00 090<br />
+ 22632 ARTHRODESIS POSTERIOR INTERBODY EA ADDL 1023.92 ZZZ<br />
22800 ARTHRODESIS POSTERIOR SPINAL DFRM UP 6 VRT SEG 4238.77 090<br />
22802 ARTHRODESIS POSTERIOR SPINAL DFRM 7-12 VRT SEG 6637.89 090<br />
22804 ARTHRODESIS POSTERIOR SPINAL DFRM 13/> VRT SEG 7651.14 090<br />
22808 ARTHRODESIS ANTERIOR SPINAL DFRM 2-3 VRT SEG 5770.92 090<br />
22810 ARTHRODESIS ANTERIOR SPINAL DFRM 4-7 VRT SEG 6419.01 090<br />
22812 ARTHRODESIS POSTERIOR SPINAL DFRM 8/> VRT SEG 6938.98 090<br />
22818 KYPHECTOMY SINGLE OR TWO SEGMENTS 6861.04 090<br />
22819 KYPHECTOMY 3 OR MORE SEGMENTS 8573.63 090<br />
22830 EXPLORATION SPINAL FUSION 2526.18 090<br />
+ 22840 POSTERIOR NON-SEGMENTAL INSTRUMENTATION 2446.10 ZZZ<br />
+ 22841 INTERNAL SPINAL FIXATION WIRING SPINOUS PROCESS 1202.23 XXX<br />
+ 22842 POSTERIOR SEGMENTAL INSTRUMENTATION 3-6 VRT SEG 2450.37 ZZZ<br />
+ 22843 POSTERIOR SEGMENTAL INSTRUMENTATION 7-12 VRT SEG 2601.98 ZZZ<br />
+ 22844 POSTERIOR SEGMENTAL INSTRUMENTATION 13/> VRT SEG 3141.17 ZZZ<br />
+ 22845 ANTERIOR INSTRUMENTATION 2-3 VERTEBRAL SEGMENTS 2359.62 ZZZ<br />
+ 22846 ANTERIOR INSTRUMENTATION 4-7 VERTEBRAL SEGMENTS 2448.24 ZZZ<br />
+ 22847 ANTERIOR INSTRUMENTATION 8/> VERTEBRAL SEGMENTS 2798.44 ZZZ<br />
+ 22848 PELVIC FIXATION OTHER THAN SACRUM 1150.98 ZZZ<br />
22849 REINSERTION SPINAL FIXATION DEVICE 4089.29 090<br />
22850 REMOVAL POSTERIOR NONSEGMENTAL INSTRUMENTATION 2243.24 090<br />
s + 22851 APPLICATION INTERVERTEBRAL BIOMECHANICAL DEVICE 1309.00 ZZZ<br />
22852 REMOVAL POSTERIOR SEGMENTAL INSTRUMENTATION 2143.94 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
64 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
22855 REMOVAL ANTERIOR INSTRUMENTATION 3502.06 090<br />
22856 TOT DISC ARTHRP ART DISC ANT APPRO 1 NTRSPC CRV 5202.90 090<br />
22857 TOT DISC ARTHRP ART DISC ANT APPRO 1 NTRSPC LMBR 5272.30 090<br />
22861 REVJ RPLCMT DISC ARTHROPLASTY ANT 1 NTRSPC CRV 6347.48 090<br />
22862 REVJ RPLCMT DISC ARTHROPLASTY ANT 1 NTRSPC LMBR 6002.61 090<br />
22864 RMVL DISC ARTHROPLASTY ANT 1 INTERSPACE CERVICAL 5958.83 090<br />
22865 RMVL DISC ARTHROPLASTY ANT 1 INTERSPACE LUMBAR 6370.97 090<br />
22899 UNLISTED PROCEDURE SPINE BR YYY<br />
22900 EXC TUMOR SOFT TISSUE ABDL WALL SUBFASCIAL
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
23174 SEQUESTRECTOMY HUMERAL HEAD SURGERY NECK 2345.74 090<br />
23180 PARTIAL EXCISION BONE CLAVICLE 2107.64 090<br />
23182 PARTIAL EXCISION BONE SCAPULA 2059.59 090<br />
23184 PARTIAL EXCISION BONE PROXIMAL HUMERUS 2294.49 090<br />
23190 OSTECTOMY SCAPULA PARTIAL 1752.10 090<br />
23195 RESECTION HUMERAL HEAD 2340.40 090<br />
23200 RADICAL RESECTION TUMOR CLAVICLE 4418.14 090<br />
23210 RADICAL RESECTION TUMOR SCAPULA 5169.80 090<br />
23220 RADICAL RESECTION BONE TUMOR PROXIMAL HUMERUS 5707.92 090<br />
23330 REMOVAL FOREIGN BODY SHOULDER SUBCUTANEOUS 705.75 010<br />
23331 REMOVAL FOREIGN BODY SHOULDER DEEP 1826.83 090<br />
23332 REMOVAL FOREIGN BODY SHOULDER COMPLICATED 2747.19 090<br />
23350 INJECTION SHOULDER ARTHROGRAPHY/ CT/MRI ARTHG 465.52 000<br />
23395 MUSCLE TRANSFER SHOULDER/UPPER ARM SINGLE 4011.35 090<br />
23397 MUSCLE TRANSFER SHOULDER/UPPER ARM MULTIPLE 3575.73 090<br />
23400 SCAPULOPEXY 3035.47 090<br />
23405 TENOTOMY SHOULDER AREA 1 TENDON 1949.62 090<br />
23406 TENOTOMY SHOULDER MULTIPLE THRU SAME INCISION 2429.02 090<br />
23410 OPEN REPAIR OF ROTATOR CUFF ACUTE 2565.68 090<br />
23412 OPEN REPAIR OF ROTATOR CUFF CHRONIC 2669.25 090<br />
23415 CORACOACROMIAL LIGAMENT RELEASE +-ACROMIOPLASTY 2157.82 090<br />
23420 RECONSTRUCTION ROTATOR CUFF AVULSION CHRONIC 3028.00 090<br />
23430 TENODESIS LONG TENDON BICEPS 2307.30 090<br />
23440 RESECTION/TRANSPLANTATION LONG TENDON BICEPS 2355.35 090<br />
23450 CAPSULORRHAPHY ANTERIOR PUTTI-PLATT/MAGNUSON 2960.73 090<br />
23455 CAPSULORRHAPHY ANTERIOR W/LABRAL REPAIR 3145.44 090<br />
23460 CAPSULORRHAPHY ANTERIOR WITH BONE BLOCK 3416.64 090<br />
23462 CAPSULORRHAPHY ANTERIOR W/CORACOID PROCESS TR 3357.92 090<br />
23465 CAPSULORRHAPHY GLENOHUMERAL JT PST +-BONE BLK 3493.51 090<br />
23466 CAPSULORRHAPHY GLENOHUMRL JT MULTI-DIRIONAL INS 3489.24 090<br />
23470 ARTHROPLASTY GLENOHUMRL JT HEMIARTHROPLASTY 3792.47 090<br />
23472 ARTHROPLASTY GLENOHUMERAL JOINT TOTAL SHOULDER 4698.95 090<br />
23480 OSTEOTOMY CLAVICLE +-INTERNAL FIXATION 2555.01 090<br />
23485 OSTEOTOMY CLAV +-INT FIXJ W/B1 GRF NON/MAL 3001.30 090<br />
23490 PROPH TX +-METHYLMETHACRYLATE CLAVICLE 2721.57 090<br />
23491 PROPH TX +-METHYLMETHACRYLATE PROXIMAL HUMERUS 3166.80 090<br />
23500 CLSD TX CLAVICULAR FRACTURE W/O MANIPULATION 651.30 090<br />
23505 CLSD TX CLAVICULAR FRACTURE W/MANIPULATION 1058.09 090<br />
23515 OPEN TX CLAVICULAR FRACTURE INTERNAL FIXATION 2235.76 090<br />
23520 CLSD TX STERNOCLAVICULAR DISLC W/O MANIPULATION 684.40 090<br />
23525 CLOSED TX STERNOCLAVICULAR DISLC W/MANIPULATION 1121.09 090<br />
23530 OPEN TX STERNOCLAVICULAR DISLC ACUTE/CHRONIC 1724.34 090<br />
23532 OPTX STRNCLAV DISLC ACUTE/CHRONIC W/FASCIAL GRF 1928.27 090<br />
23540 CLSD TX ACROMIOCLAVICULAR DISLC W/O MANIPULATION 664.11 090<br />
23545 CLSD TX ACROMIOCLAVICULAR DISLC W/MANIPULATION 972.67 090<br />
23550 OPEN TX ACROMIOCLAVICULAR DISLC ACUTE/CHRONIC 1770.25 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
66 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
23552 OPTX ACROMCLAV DISLC ACUTE/CHRONIC W/FASCIAL GRF 2040.37 090<br />
23570 CLOSED TX SCAPULAR FRACTURE W/O MANIPULATION 692.94 090<br />
23575 CLTX SCAPULAR FX W/MANIPULATION +-SKEL TRACTION 1199.03 090<br />
23585 OPEN TX SCAPULAR FX W/INTERNAL FIXATION IF PFRMD 3034.40 090<br />
23600 CLTX PROXIMAL HUMERAL FRACTURE W/O MANIPULATION 972.67 090<br />
23605 CLTX PROX HUMRL FX W/MANIPULATION +-SKEL TRACJ 1413.63 090<br />
23615 OPEN TREATMENT PROXIMAL HUMERAL FRACTURE 2747.19 090<br />
23616 OPEN PROX HUMERAL FRACTURE PROSTHETIC RPLCMT 3923.80 090<br />
23620 CLTX GREATER HUMERAL TUBEROSITY FX W/O MNPJ 803.98 090<br />
23625 CLTX GRTER HUMERAL TUBEROSITY FX W/MANIPULATION 1149.91 090<br />
23630 OPEN TREATMENT GRTER HUMERAL TUBEROSITY FRACTURE 2400.19 090<br />
23650 CLSD TX SHOULDER DISLC W/MANIPULATION W/O ANES 905.41 090<br />
23655 CLSD TX SHOULDER DISLC W/MANIPULATION REQ ANES 1196.89 090<br />
23660 OPEN TX ACUTE SHOULDER DISLOCATION 1802.28 090<br />
23665 CLTX SHOULDER DISLC W/FX HUMERAL TUBRST W/MNPJ 1282.31 090<br />
23670 OPEN TX SHOULDER DISLC W/HUMERAL TUBEROSITY FX 2691.67 090<br />
23675 CLTX SHOULDER DISLC W/SURG/ANTMCL NCK FX W/MNPJ 1669.88 090<br />
23680 OPEN TX SHOULDER DISLOCATION W/NECK FRACTURE 2872.11 090<br />
23700 MNPJ W/ANES SHOULDER JOINT W/FIXATION APPARATUS 601.12 010<br />
23800 ARTHRODESIS GLENOHUMERAL JOINT 3205.24 090<br />
23802 ARTHRODESIS GLENOHUMERAL JT W/AUTOGENOUS GRAFT 3963.30 090<br />
23900 INTERTHORACOSCAPULAR AMPUTATION 4247.31 090<br />
23920 DISARTICULATION SHOULDER 3448.67 090<br />
23921 DISRTCJ SHOULDER SECONDARY CLSR/SCAR REVISION 1367.72 090<br />
23929 UNLISTED PROCEDURE SHOULDER BR YYY<br />
23930 I&D UPPER ARM/ELBOW DEEP ABSCESS/HEMATOMA 1087.99 010<br />
23931 INCISION&DRAINAGE UPPER ARM/ELBOW BURSA 860.57 010<br />
23935 INC DEEP W/OPENING BONE CORTEX HUMERUS/ELBOW 1554.57 090<br />
24000 ARTHRT ELBOW W/EXPLORATION DRAINAGE/REMOVAL FB 1470.22 090<br />
24006 ARTHRT ELBOW CAPSULAR EXCISION CAPSULAR RLS SPX 2208.00 090<br />
24065 BIOPSY SOFT TISSUE UPPER ARM/ELBOW SUPERFICIAL 787.96 010<br />
24066 BIOPSY SOFT TISSUE UPPER ARM/ELBOW AREA DEEP 1846.05 090<br />
# 24071 EXC TUMOR SOFT TISSUE UPPER ARM/ELBOW SUBQ 3+CM 1297.26 090<br />
# 24073 EXC TUMOR SOFT TISS UPPER ARM/ELBW SUBFASC 5+CM 2211.21 090<br />
24075 EXC TUMOR SOFT TISS UPPER ARM/ELBOW SUBQ
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
24125 EXC/CURTG BONE CST/B9 TUM H/N RDS/OLECRN W/AGRFT 1903.71 090<br />
24126 EXC/CURTG B1 CST/B9 TUM H/N RDS/OLECRN W/ALGRFT 2005.14 090<br />
24130 EXCISION RADIAL HEAD 1563.11 090<br />
24134 SEQUESTRECTOMY SHAFT/DISTAL HUMERUS 2329.72 090<br />
24136 SEQUESTRECTOMY RADIAL HEAD OR NECK 1901.57 090<br />
24138 SEQUESTRECTOMY OLECRANON PROCESS 2072.41 090<br />
24140 PARTIAL EXCISION BONE HUMERUS 2204.80 090<br />
24145 PARTIAL EXCISION BONE RADIAL HEAD/NECK 1854.59 090<br />
24147 PARTIAL EXCISION BONE OLECRANON PROCESS 1938.94 090<br />
24149 RAD RESCJ CAPSL TISS&HTRTPC BONE ELBW CONTRCT 3634.45 090<br />
24150 RADICAL RESECTION TUMOR SHAFT/DISTAL HUMERUS 4597.52 090<br />
24152 RADICAL RESECTION TUMOR RADIAL HEAD/NECK 3909.92 090<br />
24155 RESECTION ELBOW JOINT ARTHRECTOMY 2651.10 090<br />
24160 IMPLANT REMOVAL ELBOW JOINT 1875.95 090<br />
24164 IMPLANT REMOVAL RADIAL HEAD 1538.56 090<br />
24200 RMVL FOREIGN BODY UPPER ARM/ELBOW SUBCUTANEOUS 618.20 010<br />
24201 REMOVAL FOREIGN BODY UPPER ARM/ELBOW DEEP 1700.85 090<br />
24220 INJECTION ELBOW ARTHROGRAPHY 506.09 000<br />
24300 MANIPULATION ELBOW UNDER ANESTHESIA 1238.53 090<br />
24301 MUSCLE/TENDON TRANSFER UPPER ARM/ELBOW SINGLE 2336.13 090<br />
24305 TENDON LENGTHENING UPPER ARM/ELBOW EA TENDON 1792.67 090<br />
24310 TENOTOMY OPEN ELBOW TO SHOULDER EACH TENDON 1472.36 090<br />
24320 TENOPLASTY ELBOW TO SHOULDER SINGLE 2420.48 090<br />
24330 FLEXOR-PLASTY ELBOW 2227.22 090<br />
24331 FLEXOR-PLASTY ELBOW W/EXTENSOR ADVANCEMENT 2502.69 090<br />
24332 TENOLYSIS TRICEPS 1887.69 090<br />
24340 TENODESIS BICEPS TENDON ELBOW SPX 1900.51 090<br />
24341 REPAIR TENDON/MUSCLE UPPER ARM/ELBOW EA 2292.35 090<br />
24342 RINSJ RPTD BICEPS/TRICEPS TDN DSTL +-TDN GRF 2424.75 090<br />
24343 REPAIR LATERAL COLLATERAL LIGAMENT ELBOW 2179.18 090<br />
24344 RCNSTJ LAT COLTRL LIGM ELBOW W/TENDON GRAFT 3411.30 090<br />
24345 REPAIR MEDIAL COLLATERAL LIGAMENT ELBOW 2166.36 090<br />
24346 RCNSTJ MEDIAL COLTRL LIGM ELBW W/TDN GRF 3416.64 090<br />
24357 TENOTOMY ELBOW LATERAL/MEDIAL PERCUTANEOUS 1374.13 090<br />
24358 TNOT ELBOW LATERAL/MEDIAL DEBRIDE OPEN 1617.57 090<br />
24359 TNOT ELBOW LATERAL/MEDIAL DEBRIDE OPEN TDN RPR 2035.04 090<br />
24360 ARTHROPLASTY ELBOW W/MEMBRANE 2803.78 090<br />
24361 ARTHROPLASTY ELBOW W/DISTAL HUMRL PROSTC RPLCMT 3148.65 090<br />
24362 ARTHRP ELBOW W/IMPLT&FSCA LATA LIGAMENT RCNSTJ 3314.14 090<br />
24363 ARTHRP ELBOW W/DISTAL HUM&PROX UR PROSTC RPLCMT 4686.14 090<br />
24365 ARTHROPLASTY RADIAL HEAD 1984.85 090<br />
24366 ARTHROPLASTY RADIAL HEAD W/IMPLANT 2120.45 090<br />
24400 OSTEOTOMY HUMERUS +-INTERNAL FIXATION 2550.74 090<br />
24410 MLT OSTEOT W/RELIGNMT IMED ROD HUMERAL SHAFT 3279.97 090<br />
24420 OSTEOPLASTY HUMERUS 3084.59 090<br />
24430 REPAIR NON/MALUNION HUMERUS W/O GRAFT 3294.92 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
68 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
24435 REPAIR NON/MALUNION HUMERUS W/ILIAC/OTH AGRFT 3351.51 090<br />
24470 HEMIEPIPHYSEAL ARREST 2019.02 090<br />
24495 DECOMPRESSION FASCT F/ARM W/BRACH ART EXPL 2044.65 090<br />
24498 PROPHYLACTIC TX +-METHYLMETHACRYLATE HUMRL SHFT 2706.62 090<br />
24500 CLSD TX HUMERAL SHAFT FRACTURE W/O MANIPULATION 1061.29 090<br />
24505 CLTX HUMERAL SHFT FX W/MANIPULATION +-SKEL TRACJ 1517.20 090<br />
24515 OPTX HUMERAL SHFT FX W/PLATE/SCREWS +-CERCLAGE 2725.84 090<br />
24516 TX HUMERAL SHAFT FX W/INSJ IMED IMPLT +-CERCLAGE 2685.27 090<br />
24530 CLTX SPRCNDYLR/TRANSCNDYLR HUMERAL FX+-MNPJ 1137.10 090<br />
24535 CLTX SPRCNDYLR/TRANSCNDYLR HUMERAL FX W/MNPJ 1883.42 090<br />
24538 PRQ SKEL FIXJ SPRCNDYLR/TRANSCNDYLR HUMERAL FX 2307.30 090<br />
24545 OPEN TX HUMERAL SUPRACONDYLAR FRACTURE W/O XTN 2880.65 090<br />
24546 OPEN TX HUMERAL SUPRACONDYLAR FRACTURE W/XTN 3259.69 090<br />
24560 CLTX HUMERAL EPICONDYLAR FX MEDIAL/LAT W/O MNPJ 953.46 090<br />
24565 CLTX HUMERAL EPICONDYLAR FX MEDIAL/LAT W/MNPJ 1591.94 090<br />
24566 PRQ SKEL FIXJ HUMRL EPCNDYLR FX MEDIAL/LAT MNPJ 2206.94 090<br />
24575 OPEN TX HUMERAL EPICONDYLAR FRACTURE 2273.13 090<br />
24576 CLTX HUMERAL CONDYLAR FX MEDIAL/LAT W/O MNPJ 1011.11 090<br />
24577 CLTX HUMERAL CONDYLAR FX MEDIAL/LATERAL W/MNPJ 1647.46 090<br />
24579 OPEN TREATMENT HUMERAL CONDYLAR FRACTURE 2592.38 090<br />
24582 PRQ SKEL FIXJ HUMRL CNDYLR FX MEDIAL/LAT W/MNPJ 2472.79 090<br />
24586 OPTX PERIARTICULAR FRACTURE &/DISLOCATION ELBOW 3400.62 090<br />
24587 OPTX PRIARTICULAR FX&/DISLC ELBW W/IMPLT ARTHRP 3394.22 090<br />
24600 TREATMENT CLOSED ELBOW DISLOCATION W/O ANES 1090.12 090<br />
24605 TREATMENT CLOSED ELBOW DISLOCATION REQ ANES 1426.45 090<br />
24615 OPEN TX ACUTE/CHRONIC ELBOW DISLOCATION 2214.41 090<br />
24620 CLOSED TX MONTEGGIA FX DISLOCATION ELBOW W/MNPJ 1705.12 090<br />
24635 OPEN TX MONTEGGIA FRACTURE DISLOCATION ELBOW 2183.45 090<br />
24640 CLTX RDL HEAD SUBLXTJ CHLD NURSEMAID ELBW W/MNPJ 385.44 010<br />
24650 CLOSED TX RADIAL HEAD/NECK FX W/O MANIPULATION 775.15 090<br />
24655 CLOSED TX RADIAL HEAD/NECK FX W/MANIPULATION 1314.34 090<br />
24665 OPEN TX RADIAL HEAD/NECK FRACTURE 2012.61 090<br />
24666 OPEN TX RADIAL HEAD/NECK FRACTURE PROSTHETIC 2272.07 090<br />
24670 CLOSED TX ULNAR FRACTURE PROXIMAL END W/O MNPJ 866.97 090<br />
24675 CLOSED TX ULNAR FRACTURE PROXIMAL END W MNPJ 1384.81 090<br />
24685 OPEN TREATMENT ULNAR FRACTURE PROXIMAL END 2016.89 090<br />
24800 ARTHRODESIS ELBOW JOINT LOCAL 2533.65 090<br />
24802 ARTHRODESIS ELBOW JOINT W/AUTOGENOUS GRAFT 3120.89 090<br />
24900 AMPUTATION ARM THRU HUMERUS W/PRIMARY CLOSURE 2259.25 090<br />
24920 AMPUTATION ARM THRU HUMERUS OPEN CIRCULAR 2247.51 090<br />
24925 AMP ARM THRU HUMERUS SECONDARY CLSR/SCAR REVJ 1741.42 090<br />
24930 AMPUTATION ARM THRU HUMERUS RE-AMPUTATION 2382.04 090<br />
24931 AMPUTATION ARM THRU HUMERUS W/IMPLANT 2405.53 090<br />
24935 STUMP ELONGATION UPPER EXTREMITY 3013.05 090<br />
24940 CINEPLASTY UPPER EXTREMITY COMPLETE PROCEDURE 3253.28 090<br />
24999 UNLISTED PROCEDURE HUMERUS/ELBOW BR YYY<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 69
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
25000 INCISION EXTENSOR TENDON SHEATH WRIST 1059.16 090<br />
25001 INCISION FLEXOR TENDON SHEATH WRIST 1043.14 090<br />
25020 DCMPRN FASCT F/ARM&WRST FLXR/XTNSR W/O DBRDMT 1780.92 090<br />
25023 DCMPRN FASCT F/ARM&/WRST FLXR/XTNSR W/DBRDMT 3428.38 090<br />
25024 DCMPRN FASCT F/ARM&/WRST FLXR&XTNSR W/O DBRDMT 2416.21 090<br />
25025 DCMPRN FASCT F/ARM&/WRST FLXR&XTNSR DBRDMT NV 3785.00 090<br />
25028 I&D FOREARM&/WRIST DEEP ABSCESS/HEMATOMA 1597.28 090<br />
25031 INCISION & DRAINAGE FOREARM&/WRIST BURSA 1121.09 090<br />
25035 INCISION DEEP BONE CORTEX FOREARM&/WRIST 1910.12 090<br />
25040 ARTHRT RDCRPL/MIDCARPL JT W/EXPL DRG/RMVL FB 1755.30 090<br />
25065 BIOPSY SOFT TISSUE FOREARM&/WRIST SUPERFICIAL 784.76 010<br />
25066 BIOPSY SOFT TISSUE FOREARM&/WRIST DEEP 1138.17 090<br />
# 25071 EXC TUMOR SOFT TISS FOREARM AND/WRIST SUBQ 3+CM 1363.45 090<br />
# 25073 EXC TUMOR SFT TISS FOREARM&//WRIST SUBFASC 3+CM 1704.05 090<br />
25075 EXC TUMOR SOFT TISSUE FOREARM &/WRIST SUBQ
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
25248 EXPL W/REMOVAL DEEP FOREIGN BODY FOREARM/WRIST 1327.15 090<br />
25250 REMOVAL WRIST PROSTHESIS SPX 1632.51 090<br />
25251 REMOVAL WRIST PROSTH COMPLICATED W/TOTAL WRIST 2233.63 090<br />
25259 MANIPULATION WRIST UNDER ANESTHESIA 1246.01 090<br />
25260 RPR TDN/MUSC FLXR F/ARM&/WRST PRIM 1 EA TDN/MUSC 2042.51 090<br />
25263 RPR TDN/MUSC FLXR F/ARM&/WRST SEC 1 EA TDN/MUSC 2035.04 090<br />
25265 RPR TDN/MUSC FLXR F/ARM&/WRST SEC FR GRF EA 2419.41 090<br />
25270 RPR TDN/MUSC XTNSR F/ARM&/WRST PRIM 1 EA TDN 1616.50 090<br />
25272 RPR TDN/MUSC XTNSR F/ARM&/WRST SEC 1 EA TDN/MUSC 1815.09 090<br />
25274 RPR TDN/MUSC XTNSR F/ARM&/WRST SEC FR GRF EA TDN 2173.84 090<br />
25275 RPR TENDON SHEATH EXTENSOR F/ARM&/WRST W/GRAFT 2094.83 090<br />
25280 LNGTH/SHRT FLXR/XTNSR TDN F/ARM&/WRST 1 EA TDN 1840.71 090<br />
25290 TNOT FLXR/XTNSR TENDON FOREARM&/WRIST 1 EA 1500.12 090<br />
25295 TNOLS FLXR/XTNSR TENDON FOREARM&/WRIST 1 EA 1713.66 090<br />
25300 TENODESIS WRIST FLEXORS FINGERS 2132.20 090<br />
25301 TENODESIS WRIST EXTENSORS FINGERS 2008.34 090<br />
25310 TDN TRNSPLJ/TR FLXR/XTNSR F/ARM&/WRST 1 EA TDN 2006.21 090<br />
25312 TDN TRNSPLJ/TR FLXR/XTNSR F/ARM&/WRST 1/TDN GRF 2329.72 090<br />
25315 FLEXOR ORIGIN SLIDE FOREARM &/WRIST 2501.62 090<br />
25316 FLEXOR ORIGIN SLIDE F/ARM&/WRST TENDON TRANSFER 2835.81 090<br />
25320 CAPSL-RHPHY/RCNSTJ WRST OPN CARPL INS 3052.55 090<br />
25332 ARTHRP WRST +-INTERPOS +-XTRNL/INT FIXJ 2628.68 090<br />
25335 CENTRALIZATION WRST ULNA 2598.78 090<br />
25337 RCNSTJ STABLJ DSTL U/DSTL JT 2 SOFT TISS STABLJ 2766.41 090<br />
25350 OSTEOTOMY RADIUS DISTAL THIRD 2190.92 090<br />
25355 OSTEOTOMY RADIUS MIDDLE/PROXIMAL THIRD 2483.47 090<br />
25360 OSTEOTOMY ULNA 2131.13 090<br />
25365 OSTEOTOMY RADIUS & ULNA 2940.45 090<br />
25370 MLT OSTEOTOMIES W/RELIGNMT IMED ROD RADIUS/ULNA 3222.32 090<br />
25375 MLT OSTEOTOMIES W/RELIGNMT IMED ROD RADIUS&ULNA 2893.47 090<br />
25390 OSTEOPLASTY RADIUS/ULNA SHORTENING 2493.08 090<br />
25391 OSTEOPLASTY RADIUS/ULNA LENGTHENING W/AUTOGRAFT 3207.37 090<br />
25392 OSTEOPLASTY RADIUS & ULNA SHORTENING 3267.16 090<br />
25393 OSTEOPLASTY RADIUS&ULNA LENGTHENING W/AUTOGRAFT 3718.80 090<br />
25394 OSTEOPLASTY CARPAL BONE SHORTENING 2433.29 090<br />
25400 RPIR NONUNION/MALUNION RADIUS/ULNA W/O AUTOGRAFT 2608.39 090<br />
25405 RPR NONUNION/MALUNION RADIUS/ULNA W/AUTOGRAFT 3338.70 090<br />
25415 RPR NONUNION/MALUNION RADIUS&ULNA W/O AUTOGRAFT 3164.66 090<br />
25420 RPR NONUNION/MALUNION RADIUS&ULNA W/AUTOGRAFT 3764.71 090<br />
25425 REPAIR DEFECT W/AUTOGRAFT RADIUS/ULNA 3183.88 090<br />
25426 REPAIR DEFECT W/AUTOGRAFT RADIUS&ULNA 3504.19 090<br />
25430 INSERTION VASCULAR PEDICLE CARPAL BONE 2175.97 090<br />
25431 REPAIR NONUNION CARPAL BONE EACH BONE 2440.76 090<br />
25440 RPR NONUNION SCAPHOID CARPAL BONE +-RDL STYLODC 2398.05 090<br />
25441 ARTHROPLASTY W/PROSTHETIC RPLCMT DISTAL RADIUS 2885.99 090<br />
25442 ARTHROPLASTY W/PROSTHETIC RPLCMT DISTAL ULNA 2452.51 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 71
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
25443 ARTHROPLASTY W/PROSTHETIC RPLCMT SCAPHOID CARPAL 2431.15 090<br />
25444 ARTHROPLASTY W/PROSTHETIC REPLACEMENT LUNATE 2466.39 090<br />
25445 ARTHROPLASTY W/PROSTHETIC REPLACEMENT TRAPEZIUM 2238.97 090<br />
25446 ARTHRP W/PROSTC RPLCMT DSTL RDS&PRTL/CARPUS 3661.14 090<br />
25447 ARTHRP INTERPOS INTERCARPAL/METACARPAL JOINTS 2555.01 090<br />
25449 REVJ ARTHRP W/RMVL IMPLT WRST JT 3259.69 090<br />
25450 EPIPHYSL ARRST EPIPHYSIOD/STAPLING DSTL RDS/U 1755.30 090<br />
25455 EPIPHYSL ARRST EPIPHYSIOD/STAPLING DSTL RDS&U 1933.60 090<br />
25490 PROPH TX N/P/PLTWR +-MMA RDS 2187.72 090<br />
25491 PROPH TX N/P/PLTWR +-MMA U 2401.26 090<br />
25492 PROPH TX N/P/PLTWR +-MMA RDS&U 2906.28 090<br />
25500 CLOSED TX RADIAL SHAFT FRACTURE W/O MANIPULATION 798.64 090<br />
25505 CLOSED TX RADIAL SHAFT FRACTURE W/MANIPULATION 1519.34 090<br />
25515 OPEN TREATMENT RADIAL SHAFT FRACTURE 2066.00 090<br />
25520 CLTX RDL SHFT FX&CLTX DISLC DSTL RAD/ULN JT 1702.98 090<br />
25525 OPEN RDL SHAFT FX CLOSED RAD/ULN JT DISLOCATE 2452.51 090<br />
25526 OPEN RDL SHAFT FX OPEN RAD/ULN JT DISLOCATE 3021.59 090<br />
25530 CLOSED TX ULNAR SHAFT FRACTURE W/O MANIPULATION 774.08 090<br />
25535 CLOSED TX ULNAR SHAFT FRACTURE W/MANIPULATION 1478.76 090<br />
25545 OPEN TREATMENT OF ULNAR SHAFT FRACTURE 1926.13 090<br />
25560 CLOSED TX RADIAL&ULNAR SHAFT FRACTURES W/O MNPJ 811.45 090<br />
25565 CLOSED TX RADIAL&ULNAR SHAFT FRACTURES W/MNPJ 1586.60 090<br />
25574 OPEN TX RADIAL & ULNAR SHAFT FX FIXJ RADIUS/ULNA 2071.34 090<br />
25575 OPEN TX RDL& ULNAR SHAFT FX FIXJ RADIUS &ULNA 2786.70 090<br />
25600 CLTX DSTL RADIAL FX/EPIPHYSL SEP W/O MNPJ 873.38 090<br />
25605 CLTX DSTL RDL FX/EPIPHYSL SEP +-W/MNPJ 1894.10 090<br />
25606 PERQ SKEL FIXJ DISTAL RADIAL FX/EPIPHYSL SEP 2057.46 090<br />
25607 OPTX DSTL RADL X-ARTIC FX/EPIPHYSL SEP 2253.91 090<br />
25608 OPTX DSTL RADL I-ARTIC FX/EPIPHYSL SEP 2 FRAG 2532.58 090<br />
25609 OPTX DSTL RADL I-ARTIC FX/EPIPHYSL SEP 3 FRAG 3229.79 090<br />
25622 CLOSED TX CARPAL SCAPHOID FRACTURE W/O MNPJ 903.27 090<br />
25624 CLOSED TX CARPAL SCAPHOID FRACTURE W/MNPJ 1395.48 090<br />
25628 OPEN TX CARPAL SCAPHOID NAVICULAR FRACTURE 2228.29 090<br />
25630 CLTX CARPL B1 FX W/O MNPJ EA B1 915.02 090<br />
25635 CLTX CARPL B1 FX W/MNPJ EA B1 1353.84 090<br />
25645 OPEN TX CARPAL BONE FRACTURE OTH/THN SCAPHOID EA 1757.43 090<br />
25650 CLOSED TREATMENT ULNAR STYLOID FRACTURE 959.86 090<br />
25651 PRQ SKELETAL FIXATION ULNAR STYLOID FRACTURE 1483.04 090<br />
25652 OPEN TREATMENT ULNAR STYLOID FRACTURE 1919.72 090<br />
25660 CLTX RDCRPL/INTERCARPL DISLC 1+ B1S W/MNPJ 1233.19 090<br />
25670 OPEN TX RADIOCARPAL/INTERCARPAL DISLC 1+ BONES 1874.88 090<br />
25671 PRQ SKELETAL FIXJ DISTAL RADIOULNAR DISLOCATION 1627.17 090<br />
25675 CLOSED TX DISTAL RADIOULNAR DISLOCATION W/MNPJ 1309.00 090<br />
25676 OPEN TX DISTAL RADIOULNAR DISLC ACUTE/CHRONIC 1953.89 090<br />
25680 CLTX TRANS-SCAPHOPRILUNAR TYP FX DISLC W/MNPJ 1416.84 090<br />
25685 OPEN TX TRANS-SCAPHOPERILUNAR FRACTURE DISLC 2276.34 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
72 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
25690 CLOSED TX LUNATE DISLOCATION W/MANIPULATION 1455.28 090<br />
25695 OPEN TREATMENT LUNATE DISLOCATION 1962.43 090<br />
25800 ARTHRD WRST COMPL W/O B1 GRF 2290.22 090<br />
25805 ARTHRD WRST W/SLIDING GRF 2650.03 090<br />
25810 ARTHRD WRST W/ILIAC/OTH AGRFT 2702.35 090<br />
25820 ARTHRODESIS WRIST LIMITED W/O BONE GRAFT 1897.30 090<br />
25825 ARTHRODESIS WRIST LIMITED W/AUTOGRAFT 2342.53 090<br />
25830 ARTHRD DSTL RAD/ULN JT SGMTL RESCJ U +-B1 GRF 2950.06 090<br />
25900 AMPUTATION FOREARM THROUGH RADIUS & ULNA 2279.54 090<br />
25905 AMP FOREARM THRU RADIUS&ULNA OPEN CIRCULAR 2246.44 090<br />
25907 AMP F/ARM THRU RADIUS&ULNA SEC CLOSURE/SCAR REVJ 1965.64 090<br />
25909 AMP FOREARM THRU RADIUS&ULNA RE-AMPUTATION 2199.46 090<br />
25915 KRUKENBERG PROCEDURE 3541.56 090<br />
25920 DISARTICULATION THROUGH WRIST 2147.14 090<br />
25922 DISARTICULATION THRU WRIST SEC CLOSURE/SCAR REVJ 1600.48 090<br />
25924 DISARTICULATION THRU WRIST RE-AMPUTATION 1988.06 090<br />
25927 TRANSMETACARPAL AMPUTATION 2470.66 090<br />
25929 TRANSMETACARPAL AMPUTATION SEC CLOSURE/SCAR REVJ 1831.11 090<br />
25931 TRANSMETACARPAL AMPUTATION RE-AMPUTATION 2153.55 090<br />
25999 UNLISTED PROCEDURE FOREARM/WRIST BR YYY<br />
26010 DRAINAGE FINGER ABSCESS SIMPLE 779.42 010<br />
26011 DRAINAGE FINGER ABSCESS COMPLICATED 1180.88 010<br />
26020 DRAINAGE TENDON SHEATH DIGIT&/PALM EACH 1329.29 090<br />
26025 DRAINAGE OF PALMAR BURSA SINGLE BURSA 1289.78 090<br />
26030 DRAINAGE OF PALMAR BURSA MULTIPLE BURSA 1519.34 090<br />
26034 INCISION BONE CORTEX HAND/FINGER 1650.66 090<br />
26035 DECOMPRESSION FINGERS&/HAND INJECTION INJURY 2618.00 090<br />
26037 DECOMPRESSIVE FASCIOTOMY HAND 1768.11 090<br />
26040 FASCIOTOMY PALMAR PERCUTANEOUS 948.12 090<br />
26045 FASCIOTOMY PALMAR OPEN PARTIAL 1437.12 090<br />
26055 TENDON SHEATH INCISION 1717.93 090<br />
26060 TENOTOMY PERCUTANEOUS SINGLE EACH DIGIT 816.79 090<br />
26070 ARTHRT EXPL DRG/RMVL LOOSE/FB CARP/MTCRPL JT 936.37 090<br />
26075 ARTHRT EXPL DRG/RMVL LOOSE/FB MTCARPHLNGL JT EA 983.35 090<br />
26080 ARTHRT EXPL DRG/RMVL LOOSE/FB IPHAL JT EA 1187.28 090<br />
26100 ARTHROTOMY BIOPSY CARP/MTCRPL JOINT EACH 1008.98 090<br />
26105 ARTHROTOMY BIOPSY MTCARPHLNGL JOINT EACH 1023.92 090<br />
26110 ARTHROTOMY BIOPSY INTERPHALANGEAL JOINT EACH 980.15 090<br />
# 26111 EX TUM/VASC MALF SFT TISS HAND/FNGR SUBQ 1.5+CM 1331.42 090<br />
# 26113 EX TUM/VASC MAL SFT TIS HAND/FNGR SUBFSC 1.5+CM 1744.62 090<br />
26115 EXC TUM/VASC MAL SFT TISS HAND/FNGR SUBQ
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
+ 26125 FASCT PRTL PLMR 1 DGT PROX IPHAL JT +-Z-PLASTY 874.45 ZZZ<br />
26130 SYNOVECTOMY CARPOMETACARPAL JOINT 1413.63 090<br />
26135 SYNVCT MTCARPHLNGL JT W/INTRNSC RLS&XTNSR HOOD 1702.98 090<br />
26140 SYNVCT PROX IPHAL JT W/XTNSR RCNSTJ EA IPHAL JT 1556.71 090<br />
26145 SYNVCT TDN SHTH RAD FLXR TDN PALM&/FNGR EA TDN 1580.20 090<br />
26160 EXC LES TDN SHTH/JT CAPSL HAND/FNGR 1742.49 090<br />
26170 EXCISION TENDON PALM FLEXOR/EXTENSOR SINGLE EACH 1248.14 090<br />
26180 EXCISION TENDON FINGER FLEXOR/EXTENSOR EACH 1354.91 090<br />
26185 SESAMOIDECTOMY THUMB/FINGER SPX 1673.09 090<br />
26200 EXCISION/CURETTAGE CYST/TUMOR METACARPAL 1389.08 090<br />
26205 EXC/CURETTAGE CYST/TUMOR METACARPAL W/AUTOGRAFT 1866.34 090<br />
26210 EXCISION/CURETTAGE CYST/TUMOR PHALANX FINGER 1358.11 090<br />
26215 EXC/CURETTAGE CYST/TUMOR PHALANX FINGER W/AGRAFT 1732.88 090<br />
26230 PARTIAL EXCISION BONE METACARPAL 1542.83 090<br />
26235 PARTIAL EXCISION PROXIMAL/MIDDLE PHALANX FINGER 1525.74 090<br />
26236 PARTIAL EXCISION DISTAL PHALANX FINGER 1358.11 090<br />
26250 RADICAL RESECTION TUMOR METACARPAL 3079.25 090<br />
26260 RAD RESECTION TUMOR PROX/MIDDLE PHALANX FINGER 2413.00 090<br />
26262 RADICAL RESECTION TUMOR DISTAL PHALANX FINGER 1854.59 090<br />
26320 REMOVAL IMPLANT FROM FINGER/HAND 1064.50 090<br />
26340 MANIPULATION FINGER JOINT UNDER ANES EACH JOINT 1000.43 090<br />
26350 RPR/ADVMNT FLXR TDN N/Z/2 1/2 W/O FR GRF EA TDN 2184.51 090<br />
26352 RPR/ADVMNT FLXR TDN N/Z/2 2W/FR GRF EA TDN 2495.21 090<br />
26356 RPR/ADVMNT FLXR TDN ZONE 2 1W/O FR GRF EA TDN 3333.36 090<br />
26357 RPR/ADVMNT FLXR TDN ZONE 2 2W/O FR GRF EA TDN 2664.98 090<br />
26358 RPR/ADVMNT FLXR TDN ZONE 2 2W/FR GRF EA TDN 2846.49 090<br />
26370 RPR/ADVMNT TDN W/NTC SUPFCIS TDN PRIM EA TDN 2352.14 090<br />
26372 RPR/ADVMNT TDN W/NTC SUPFCIS TDN 2 W/FR GRF EA 2725.84 090<br />
26373 RPR/ADVMNT TDN W/NTC SUPFCIS TDN 2 W/O FR GRF EA 2604.12 090<br />
26390 EXC FLXR TDN W/IMPLTJ SYNTH ROD DLYD TDN GRF H/F 2562.48 090<br />
26392 RMVL SYNTH ROD&INSJ FLXR TDN GRF H/F EA ROD 2988.49 090<br />
26410 REPAIR EXTENSOR TENDON HAND W/O GRAFT EACH 1733.94 090<br />
26412 REPAIR EXTENSOR TENDON HAND W/GRAFT EACH 2102.30 090<br />
26415 EXC XTNSR TDN W/IMPLTJ SYNTH ROD DLYD GRF H/F EA 2145.01 090<br />
26416 RMVL SYNTH ROD&INSJ XTNSR TDN GRF H/F EA ROD 2576.36 090<br />
26418 REPAIR EXTENSOR TENDON FINGER W/O GRAFT EACH 1759.57 090<br />
26420 REPAIR EXTENSOR TENDON FINGER W/GRAFT EACH 2181.31 090<br />
26426 RPR XTNSR TDN CTR SLIP 2 TISS W/LAT BAND EA FNGR 1663.48 090<br />
26428 RPR XTNSR TDN CTR SLIP SEC W/FR GRF EA FNGR 2312.64 090<br />
26432 CLTX DSTL XTNSR TDN INSJ +-PRQ PINNING 1521.47 090<br />
26433 REPAIR EXTENSOR TENDON DISTAL INSERTION W/O GRF 1628.24 090<br />
26434 REPAIR EXTENSOR TENDON DISTAL INSERTION W/GRAFT 1969.91 090<br />
26437 REALIGNMENT EXTENSOR TENDON HAND EACH TENDON 1903.71 090<br />
26440 TENOLYSIS FLEXOR TENDON PALM/FINGER EACH TENDON 1906.91 090<br />
26442 TENOLYSIS FLEXOR TENDON PALM&FINGER EACH TENDON 2947.92 090<br />
26445 TENOLYSIS EXTENSOR TENDON HAND/FINGER EACH 1773.45 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
74 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
26449 TENOLYSIS CPLX XTNSR TENDON FINGER W/FOREARM EA 2268.86 090<br />
26450 TENOTOMY FLEXOR PALM OPEN EACH TENDON 1235.33 090<br />
26455 TENOTOMY FLEXOR FINGER OPEN EACH TENDON 1231.06 090<br />
26460 TENOTOMY EXTENSOR HAND/FINGER OPEN EACH TENDON 1197.96 090<br />
26471 TENODESIS PROXIMAL INTERPHALANGEAL JOINT EACH 1881.29 090<br />
26474 TENODESIS DISTAL JOINT EACH 1835.38 090<br />
26476 LENGTHENING TENDON EXTENSOR HAND/FINGER EACH 1796.94 090<br />
26477 SHORTENING TENDON EXTENSOR HAND/FINGER EACH 1783.06 090<br />
26478 LENGTHENING TENDON FLEXOR HAND/FINGER EACH 1913.32 090<br />
26479 SHORTENING TENDON FLEXOR HAND/FINGER EACH 1907.98 090<br />
26480 TR/TRNSPL TDN CARP/MTCRPL HAND W/O FR GRF EA TDN 2308.37 090<br />
26483 TENDON TRANSFER TRANSPLANT CARP/MTCRPL GRAFT 2595.58 090<br />
26485 TRANSFER/TRANSPLANT TENDON PALMAR W/O GRAFT EACH 2485.61 090<br />
26489 TRANSFER/TRANSPLANT TENDON PALMAR W/GRAFT EACH 2790.97 090<br />
26490 OPPONENSPLASTY SUPFCIS TDN TR TYP EA TDN 2439.69 090<br />
26492 OPPONENSPLASTY TDN TR W/GRF EA TDN 2702.35 090<br />
26494 OPPONENSPLASTY HYPOTHENAR MUSC TR 2448.24 090<br />
26496 OPPONENSPLASTY OTH METHS 2631.88 090<br />
26497 TR TDN RESTORE INTRNSC FUNCJ RING&SM FNGR 2656.44 090<br />
26498 TR TDN RESTORE INTRNSC FUNCJ ALL 4 FNGRS 3529.82 090<br />
26499 CORRECTION CLAW FINGER OTHER METHODS 2542.19 090<br />
26500 RCNSTJ TENDON PULLEY EACH W/LOCAL TISSUES SPX 1924.00 090<br />
26502 RCNSTJ TDN PULLEY EA TDN W/TDN/FSCAL GRF SPX 2191.99 090<br />
26508 RELEASE THENAR MUSCLE 1932.54 090<br />
26510 CROSS INTRINSIC TRANSFER EACH TENDON 1825.77 090<br />
26516 CAPSULODESIS MTCARPHLNGL JOINT SINGLE DIGIT 2148.21 090<br />
26517 CAPSULODESIS MTCARPHLNGL JOINT 2 DIGITS 2534.72 090<br />
26518 CAPSULODESIS MTCARPHLNGL JOINT 3/4 DIGITS 2578.50 090<br />
26520 CAPSULECTOMY/CAPSULOTOMY MTCARPHLNGL JOINT EACH 2001.94 090<br />
26525 CAPSULECTOMY/CAPSULOTOMY IPHAL JOINT EACH 2003.01 090<br />
26530 ARTHROPLASTY METACARPOPHALANGEAL JOINT EACH 1653.87 090<br />
26531 ARTHRP MTCARPHLNGL JT W/PROSTC IMPLT EA JT 1925.06 090<br />
26535 ARTHROPLASTY INTERPHALANGEAL JOINT EACH 1256.68 090<br />
26536 ARTHROPLASTY INTERPHALANGEAL JT W/PROSTHETIC EA 2120.45 090<br />
26540 RPR COLTRL LIGM MTCARPHLNGL/IPHAL JT 2021.16 090<br />
26541 RCNSTJ COLTRL LIGM MTCARPHLNGL 1 W/TDN/FSCAL GRF 2453.57 090<br />
26542 RCNSTJ COLTRL LIGM MTCARPHLNGL 1 W/LOCAL TISS 2091.62 090<br />
26545 RCNSTJ COLTRL LIGM IPHAL JT 1 W/GRF EA JT 2136.47 090<br />
26546 RPR NON-UNION MTCRPL/PHALANX 3025.86 090<br />
26548 RPR&RCNSTJ FINGER VOLAR PLATE INTERPHALANGEAL JT 2347.87 090<br />
26550 POLLICIZATION DIGIT 4867.64 090<br />
26551 TR TOE-TO-HAND W/MVASC ANAST GRT TOE WRP/ARND 9479.04 090<br />
26553 TR TOE-TO-HAND W/MVASC ANAST OTH/THN GRT TOE 1 9260.16 090<br />
26554 TR TOE-TO-HAND W/MVASC ANAST OTH/THN GRT TOE 2 10158.10 090<br />
26555 TR FNGR AXH POS W/O MVASC ANAST 4237.70 090<br />
26556 TRANSFER FREE TOE JOINT W/MVASC ANASTOMOSIS 8869.38 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 75
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
26560 REPAIR SYNDACTYLY EACH SPACE W/SKIN FLAPS 1787.33 090<br />
26561 REPAIR SYNDACTYLY EACH SPACE W/SKIN FLAPS&GRAFTS 2915.89 090<br />
26562 REPAIR SYNDACTYLY EACH SPACE COMPLEX 3894.97 090<br />
26565 OSTEOTOMY METACARPAL EACH 2084.15 090<br />
26567 OSTEOTOMY PHALANX FINGER EACH 2086.29 090<br />
26568 OSTEOPLASTY LENGTHENING METACARPAL/PHALANX 2754.67 090<br />
26580 REPAIR CLEFT HAND 4213.14 090<br />
26587 RCNSTJ POLYDACTYLOUS DGT SOFT TISS&B1 3210.57 090<br />
26590 REPAIR MACRODACTYLIA EACH DIGIT 3919.53 090<br />
26591 REPAIR INTRINSIC MUSCLES HAND EACH MUSCLE 1337.83 090<br />
26593 RELEASE INTRINSIC MUSCLES HAND EACH MUSCLE 1830.04 090<br />
26596 EXC CONSTRICTING RING FNGR W/MLT Z-PLASTIES 2300.89 090<br />
26600 CLTX MTCRPL FX 1 W/O MNPJ EA B1 861.63 090<br />
26605 CLTX MTCRPL FX 1 W/MNPJ EA B1 963.07 090<br />
26607 CLTX MTCRPL FX W/MNPJ W/XTRNL FIXJ EA B1 1376.27 090<br />
26608 PRQ SKEL FIXJ MTCRPL FX EA B1 1464.88 090<br />
26615 OPEN TX METACARPAL FRACTURE SINGLE EA BONE 1746.76 090<br />
26641 CLTX CARP/MTCRPL DISLC THMB W/MNPJ 1086.92 090<br />
26645 CLTX CARP/MTCRPL FX DISLC THMB W/MNPJ 1273.77 090<br />
26650 PRQ SKEL FIXATION CARP/MTCRPL FX DISLOCATE THUMB 1467.02 090<br />
26665 OPEN TX CARPOMETACARPAL FRACTURE DISLOCATE THUMB 1919.72 090<br />
26670 CLTX CARP/MTCRPL DISLC THMB MNPJ EA W/O ANES 992.96 090<br />
26675 CLTX CARP/MTCRPL DISLC THMB MNPJ EA JT REQ ANES 1355.98 090<br />
26676 PRQ SKEL FIXJ CARP/MTCRPL DISLC THMB MNPJ EA JT 1534.28 090<br />
26685 OPEN TX CARPOMETACARPAL DISLOCATE NOT THUMB 1764.91 090<br />
26686 OPTX CARP/MTCRPL DISLC THMB CPLX MLT/DLYD RDCTJ 1924.00 090<br />
26700 CLTX MTCARPHLNGL DISLC 1 W/MNPJ W/O ANES 949.19 090<br />
26705 CLTX MTCARPHLNGL DISLC 1 W/MNPJ REQ ANES 1249.21 090<br />
26706 PRQ SKEL FIXJ MTCARPHLNGL DISLC 1 W/MNPJ 1343.17 090<br />
26715 OPEN TREATMENT METACARPOPHALANGEAL DISLOCATION 1 1739.28 090<br />
26720 CLTX PHLNGL FX PROX/MIDDLE PX/F/T W/O MNPJ EA 584.03 090<br />
26725 CLTX PHLNGL FX PROX/MIDDLE PX/F/T W/MNPJ EA 1020.72 090<br />
26727 PRQ SKEL FIXJ PHLNGL SHFT FX PROX/MIDDLE PX/F/T 1442.46 090<br />
26735 OPEN TX PHALANGEAL SHAFT FRACTURE PROX/MIDDLE EA 1814.02 090<br />
26740 CLTX ARTICULAR FX INVG MTCARPHLNGL/IPHAL JT W/O 679.06 090<br />
26742 CLTX ARTICULAR FX INVG MTCARPHLNGL/IPHAL JT W/ 1110.41 090<br />
26746 OPEN TX ARTICULAR FRACTURE MCP/IP JOINT EA 2251.78 090<br />
26750 CLTX DSTL PHLNGL FX FNGR/THMB W/O MNPJ EA 543.46 090<br />
26755 CLTX DSTL PHLNGL FX FNGR/THMB W/MNPJ EA 939.58 090<br />
26756 PRQ SKEL FIXJ DSTL PHLNGL FX FNGR/THMB EA 1276.97 090<br />
26765 OPEN TX DISTAL PHALANGEAL FRACTURE EACH 1506.52 090<br />
26770 CLTX IPHAL JT DISLC 1 W/MNPJ W/O ANES 808.25 090<br />
26775 CLTX IPHAL JT DISLC 1 W/MNPJ REQ ANES 1147.78 090<br />
26776 PRQ SKEL FIXJ IPHAL JT DISLC 1 W/MNPJ 1354.91 090<br />
26785 OPEN TX INTERPHALANGEAL JOINT DISLOCATION 1 1643.19 090<br />
26820 FUSION OPPOSITION THUMB W/AUTOGENOUS GRAFT 2415.14 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
76 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
26841 ARTHRD CARP/MTCRPL JT THMB +-INT FIXJ 2237.90 090<br />
26842 ARTHRD CARP/MTCRPL JT THMB +-INT FIXJ W/AGRFT 2426.88 090<br />
26843 ARTHRD CARP/MTCRPL JT DGT OTHER THAN THUMB EACH 2259.25 090<br />
26844 ARTHRD CARP/MTCRPL JT DGT OTH/THN THMB W/AGRFT 2514.43 090<br />
26850 ARTHRD MTCARPHLNGL JT +-INT FIXJ 2125.79 090<br />
26852 ARTHRD MTCARPHLNGL JT +-INT FIXJ W/AGRFT 2439.69 090<br />
26860 ARTHRD IPHAL JT +-INT FIXJ 1720.06 090<br />
+ 26861 ARTHRD IPHAL JT +-INT FIXJ EA IPHAL JT 328.85 ZZZ<br />
26862 ARTHRD IPHAL JT +-INT FIXJ W/AGRFT 2224.02 090<br />
+ 26863 ARTHRD IPHAL JT +-INT FIXJ W/AGRFT EA JT 735.65 ZZZ<br />
26910 AMP MTCRPL W/FNGR/THMB 1 +-INTEROSS TR 2200.53 090<br />
26951 AMP F/TH 1/2 JT/PHALANX 1 W/NEURECT W/DIR CLSR 1963.50 090<br />
26952 AMP F/TH 1/2 JT/PHALANX 1 W/NEURECT LOCAL FLAP 1989.13 090<br />
26989 UNLIS PX HANDS/FNGRS BR YYY<br />
26990 I&D PELVIS/HIP JT AREA DP ABSC/HMTMA 1924.00 090<br />
26991 I&D PELVIS/HIP JT AREA INFCT BURSA 2163.16 090<br />
26992 INCISION BONE CORTEX PELVIS&/HIP JOINT 2992.76 090<br />
27000 TENOTOMY ADDUCTOR HIP PERCUTANEOUS SPX 1361.32 090<br />
27001 TENOTOMY ADDUCTOR HIP OPEN 1673.09 090<br />
27003 TX ADDUXOR SUBQ OPN W/OBTURATOR NEURECTOMY 1832.17 090<br />
27005 TENOTOMY HIP FLEXOR OPEN SPX 2260.32 090<br />
27006 TENOTOMY ABDUCTORS&/EXTENSOR HIP OPEN SPX 2290.22 090<br />
27025 FASCIOTOMY HIP/THIGH ANY TYPE 2827.27 090<br />
27027 DECOMPRESSION FASCIOTOMY PELVIC COMPARTMENT UNI 2594.51 090<br />
27030 ARTHROTOMY HIP W/DRAINAGE 2926.57 090<br />
27033 ARTHROTOMY HIP EXPLORATION/REMOVAL FOREIGN BODY 3046.15 090<br />
27035 DNRVTJ HIP JT INTRAPEL/XTRPEL INTRA-ARTCLR BRNCH 3574.66 090<br />
27036 CAPSLCTOMY/CAPSUL HIP W/RLS HIP FLXR MUSC 3137.97 090<br />
27040 BIOPSY SOFT TISSUE PELVIS&HIP AREA SUPERFICIAL 1045.28 010<br />
27041 BIOPSY SOFT TISSUE PELVIS&HIP DEEP/SUBFSCAL/IM 2110.84 090<br />
# 27043 EXCISION TUMOR SOFT TISSUE PELVIS&HIP SUBQ 3+CM 1492.64 090<br />
# 27045 EXC TUMOR SOFT TISSUE PELVIS & HIP SUBFASC 5+CM 2368.16 090<br />
27047 EXC TUMOR SOFT TISSUE PELVIS & HIP SUBQ
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
s 27071 PARTIAL EXCISION DEEP PELVIS 2833.68 090<br />
27075 RAD RESCT TUMOR WING OF ILIUM 1 PUBIC/ISCHIAL 6583.44 090<br />
27076 RAD RESCT TUMOR ILIUM ACETABULUM BOTH PUBIC 7535.83 090<br />
27077 RADICAL RESCTION TUMOR INNOMINATE BONE TOTAL 8833.08 090<br />
27078 RAD RESCT TUMOR ISCHIAL TUBEROSITY&GRT TRCHNTR 6018.62 090<br />
27080 COCCYGECTOMY PRIMARY 1566.32 090<br />
27086 RMVL FOREIGN BODY PELVIS/HIP SUBCUTANEOUS TISS 754.86 010<br />
27087 REMOVAL FOREIGN BODY PELVIS/HIP DEEP 1957.09 090<br />
27090 REMOVAL HIP PROSTHESIS SPX 2587.04 090<br />
27091 RMVL HIP PROSTH COMP W/TOT HIP PROSTH MMA 5013.92 090<br />
27093 INJECTION HIP ARTHROGRAPHY W/O ANESTHESIA 594.71 000<br />
27095 INJECTION HIP ARTHROGRAPHY W/ANESTHESIA 728.17 000<br />
27096 INJECTION SI JOINT ARTHROGRAPHY&/ANES/STEROID 579.76 000<br />
27097 RELEASE/RECESSION HAMSTRING PROXIMAL 2092.69 090<br />
27098 TRANSFER ADDUCTOR ISCHIUM 2068.13 090<br />
27100 TR XTRNL OBLQ MUSC TRCHNTR W/FSCAL/TDN XTN GRF 2562.48 090<br />
27105 TR PARASPI MUSC HIP FASC/TDN XTN GRF 2693.81 090<br />
27110 TRANSFER ILIOPSOAS GREATER TROCHANTER FEMUR 3004.51 090<br />
27111 TRANSFER ILIOPSOAS FEMORAL NECK 2733.31 090<br />
27120 ACETABULOPLASTY 4052.99 090<br />
27122 ACETABULOPLASTY RESECTION FEMORAL HEAD 3449.74 090<br />
27125 HEMIARTHROPLASTY HIP PARTIAL 3540.49 090<br />
27130 ARTHRP ACETBLR/PROX FEM PROSTC AGRFT/ALGRFT 4525.98 090<br />
27132 CONV PREVIOUS HIP TOT HIP ARTHRP +-AGRFT/ALGRFT 5284.05 090<br />
27134 REVJ TOT HIP ARTHRP BTH +-AGRFT/ALGRFT 6077.35 090<br />
27137 REVJ TOT HIP ARTHRP ACTBLR ONLY +-AGRFT/ALGRFT 4651.97 090<br />
27138 REVJ TOT HIP ARTHRP FEM ONLY +-ALGRFT 4840.95 090<br />
27140 OSTEOTOMY&TRANSFER GREATER TROCHANTER SPX 2796.31 090<br />
27146 OSTEOTOMY ILIAC ACETABULAR/INNOMINATE BONE 3996.40 090<br />
27147 OSTEOTOMY ILIAC ACETABULAR/INNOMINATE HIP RDCTJ 4608.19 090<br />
27151 OSTEOTOMY ILIAC ACETABULAR/INNOMINATE FEM OSTEOT 4891.13 090<br />
27156 OSTEOT ILIAC ACTBLR/INNOMINATE B1 OSTEOT RDCTJ 5378.00 090<br />
27158 OSTEOTOMY PELVIS BILATERAL 4364.76 090<br />
27161 OSTEOTOMY FEMORAL NECK SPX 3808.49 090<br />
27165 OSTEOT INTERTRCHNTRIC/SUBTRCHNTRIC W/INT/XTRNL 4299.63 090<br />
27170 B1 GRF FEM H/N INTERTRCHNTRIC/SUBTRCHNTRIC AREA 3695.31 090<br />
27175 TX SLP FEM EPIPHYSIS TRCJ W/O RDCTJ 2073.47 090<br />
27176 TX SLP FEM EPIPHYSIS 1/MLT PINNING SITU 2853.96 090<br />
27177 OPTX SLP FEM EPIPHYSIS 1/MLT PINNING/B1 GRF 3478.57 090<br />
27178 OPTX SLP FEM EPIPHYSIS CLSD MNPJ 1/MLT PINNING 2844.35 090<br />
27179 OPTX SLP FEM EPIPHYSIS OSTPL FEM NCK HEYMAN PX 3042.95 090<br />
27181 OPTX SLP FEM EPIPHYSIS OSTEOT&INT FIXJ 3493.51 090<br />
27185 EPIPHYSL ARRST EPIPHYSIOD/STAPLING TRCHNTR FEMUR 1871.68 090<br />
27187 PROPH TX N/P/PLTWR +-MMA FEM NCK&PROX FEMUR 3100.60 090<br />
27193 CLTX PEL RING FX DISLC DIAST/SUBLXTJ W/O MNPJ 1448.87 090<br />
27194 CLTX PEL RING FX DISLC DIAST/SUBLXTJ W/MNPJ ANES 2156.75 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
78 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
27200 CLOSED TREATMENT COCCYGEAL FRACTURE 538.12 090<br />
27202 OPEN TREATMENT COCCYGEAL FRACTURE 1870.61 090<br />
27215 OPTX ILIAC TUBRST AVLS/WING FX FIXJ IF PRFRMD 1980.58 090<br />
27216 PERQ SKELETAL FIXATION PST PELVIC BONE FX&/DISLC 2927.63 090<br />
27217 OPTX ANT PELVIC BONE FX&/DISLC INT FIXJ IF PFRMD 2763.21 090<br />
27218 OPTX POST PEL BONE FX&/DISLC INT FIXJ IF PFRMD 3783.93 090<br />
27220 CLTX ACETABULUM HIP/SOCKT FX W/O MNPJ 1630.38 090<br />
27222 CLTX ACETABULUM HIP/SOCKT FX MNPJ +-SKEL TRACJ 3048.28 090<br />
27226 OPTX PST/ANT ACTBLR WALL FX W/INT FIXJ 3281.04 090<br />
27227 OPTX ACTBLR FX INVG ANT/PST 1 COLUMN/FX W/INT 5237.07 090<br />
27228 OPTX ACTBLR FX INVG ANT&PST 2 COLUMNS FX W/INT 5979.12 090<br />
27230 CLTX FEM FX PROX END NCK W/O MNPJ 1453.14 090<br />
27232 CLTX FEM FX PROX END NCK W/MNPJ +-SKEL TRACJ 2394.85 090<br />
27235 PRQ SKEL FIXJ FEM FX PROX END NCK 2844.35 090<br />
27236 OPTX FEM FX PROX END NCK INT FIXJ/PROSTC RPLCMT 3740.15 090<br />
27238 CLTX INTER/PERI/SUBTROCHANTERIC FEM FX W/O MNPJ 1407.23 090<br />
27240 CLTX INTR/PERI/SBTRCHNTC FEM FX W/MNPJ 2979.95 090<br />
27244 TX INTER/PR/SUBTRCHNTRIC FEM FX SCREW IMPLT 3847.99 090<br />
27245 TX INTER/PR/SUBTRCHNTRIC FEM FX IMED IMPLTSCREW 3889.63 090<br />
27246 CLTX GRTER TRCHNTRIC FX W/O MNPJ 1181.94 090<br />
27248 OPEN TREATMENT GREATER TROCHANTERIC FRACTURE 2335.06 090<br />
27250 CLTX HIP DISLC TRAUMTC W/O ANES 642.76 000<br />
27252 CLTX HIP DISLC TRAUMTC REQ ANES 2354.28 090<br />
27253 OPTX HIP DISLC TRAUMTC W/O INT FIXJ 2945.78 090<br />
27254 OPTX HIP DISLC TRAUMTC W/ACTBLR WALL&FEM HEAD FX 3970.78 090<br />
27256 TX SPON HIP DISLC ABDCT SPLNT/TRCJ W/O ANES 902.21 010<br />
27257 TX SPON HIP DISLC ABDCT SPLNT/TRCJ W/MNPJ ANES 1041.01 010<br />
27258 OPTX SPON HIP DISLC RPLCMT FEM HEAD ACTBLM 3468.96 090<br />
27259 OPTX SPON HIP DISLC RPLCMT FEM HEAD ACTBLM SHRT 4864.44 090<br />
27265 CLTX POST HIP ARTHRP DISLC W/O ANES 1207.57 090<br />
27266 CLTX POST HIP ARTHRP DISLC REQ ANES 1800.14 090<br />
27267 CLOSED TX FEMORAL FRACTURE PROX HEAD W/O MNPJ 1316.47 090<br />
27268 CLOSED TX FEMORAL FRACTURE PROX HEAD W MNPJ 1630.38 090<br />
27269 OPEN TX FEMORAL FRACTURE PROXIMAL END HEAD 3836.25 090<br />
27275 MANIPULATION HIP JOINT GENERAL ANESTHESIA 549.87 010<br />
27280 ARTHRODESIS SACROILIAC JOINT W/OBTAINING GRAFT 3213.78 090<br />
27282 ARTHRODESIS SYMPHYSIS PUBIS W/OBTAINING GRAFT 2590.24 090<br />
27284 ARTHRODESIS HIP JOINT W/OBTAINING GRAFT 4976.55 090<br />
27286 ARTHRD HIP JT W/OBTG GRF W/SUBTRCHNTRIC OSTEOT 5208.24 090<br />
27290 INTERPELVIABDOMINAL AMPUTATION 5025.66 090<br />
27295 DISARTICULATION HIP 3983.59 090<br />
27299 UNLISTED PROCEDURE PELVIS/HIP JOINT BR YYY<br />
27301 I&D DP ABSC BURSA/HMTMA THI/KNE REGION 2047.85 090<br />
27303 INC DP W/OPNG B1 CORTEX FEMUR/KNE 1982.72 090<br />
27305 FASCIOTOMY ILIOTIBIAL OPEN 1465.95 090<br />
27306 TENOTOMY PRQ ADDUCTOR/HAMSTRING 1 TENDON SPX 1160.59 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 79
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
27307 TENOTOMY PRQ ADDUCTOR/HAMSTRING MULTIPLE TENDON 1462.75 090<br />
27310 ARTHRT KNE W/EXPL DRG/RMVL FB 2266.73 090<br />
27323 BIOPSY SOFT TISSUE THIGH/KNEE AREA SUPERFICIAL 832.81 010<br />
27324 BIOPSY SOFT TISSUE THIGH/KNEE AREA DEEP 1205.43 090<br />
27325 NEURECTOMY HAMSTRING MUSCLE 1683.76 090<br />
27326 NEURECTOMY POPLITEAL 1549.23 090<br />
27327 EXCISION TUMOR SOFT TISSUE THIGH/KNEE SUBQ
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
27409 RPR 1 TORN LIGM&/CAPSL KNE COLTRL&CRUCIATE LIGMS 3009.85 090<br />
27412 AUTOLOGOUS CHONDROCYTE IMPLANTATION KNEE 5169.80 090<br />
27415 OSTEOCHONDRAL ALLOGRAFT KNEE OPEN 4283.61 090<br />
27416 OSTEOCHONDRAL AUTOGRAFT KNEE OPEN MOSAICPLASTY 3037.61 090<br />
27418 ANTERIOR TIBIAL TUBERCLEPLASTY 2591.31 090<br />
27420 RCNSTJ DISLOCATING PATELLA 2320.11 090<br />
27422 RCNSTJ DISLC PATELLA W/XTNSR RELIGNMT&/MUSC RLS 2310.50 090<br />
27424 RCNSTJ DISLC PATELLA W/PATELLECTOMY 2313.71 090<br />
27425 LATERAL RETINACULAR RELEASE OPEN 1374.13 090<br />
27427 LIGAMENTOUS RECONSTRUCTION KNEE EXTRA-ARTICULAR 2229.36 090<br />
27428 LIGAMENTOUS RECONSTRUCTION KNEE INTRA-ARTICULAR 3463.62 090<br />
27429 LIGMOUS RCNSTJ AGMNTJ KNE INTRA-ARTICULAR XTR 3874.68 090<br />
27430 QUADRICEPSPLASTY 2299.83 090<br />
27435 CAPSULOTOMY POSTERIOR CAPSULAR RELEASE KNEE 2497.35 090<br />
27437 ARTHROPLASTY PATELLA W/O PROSTHESIS 2052.12 090<br />
27438 ARTHROPLASTY PATELLA W/PROSTHESIS 2618.00 090<br />
27440 ARTHROPLASTY KNEE TIBIAL PLATEAU 2438.63 090<br />
27441 ARTHRP KNEE TIBIAL PLATEAU DBRDMT&PRTL SYNVCT 2517.64 090<br />
27442 ARTHROPLASTY FEM CONDYLES/TIBIAL PLATEAU KNEE 2707.69 090<br />
27443 ARTHRP FEM CONDYLES/TIBL PLATU KNE DBRDMT&PRTL 2542.19 090<br />
27445 ARTHROPLASTY KNEE HINGE PROSTHESIS 3934.47 090<br />
27446 ARTHRP KNEE CONDYLE&PLATEAU MEDIAL/LAT CMPRT 3474.30 090<br />
27447 ARTHRP KNE CONDYLE&PLATU MEDIAL&LAT CMPRTS 4837.75 090<br />
27448 OSTEOTOMY FEMUR SHAFT/SUPRACONDYLAR W/O FIXATION 2552.87 090<br />
27450 OSTEOTOMY FEMUR SHAFT/SUPRACONDYLAR W/FIXATION 3174.27 090<br />
27454 OSTEOT MLT W/RELIGNMT IMED ROD FEM SHFT 4045.52 090<br />
27455 OSTEOT PROX TIBIA FIB EXC/OSTEOT BEFORE EPIPHYSL 2939.38 090<br />
27457 OSTEOT PROX TIBIA FIB EXC/OSTEOT AFTER EPIPHYSL 3017.32 090<br />
27465 OSTEOPLASTY FEMUR SHORTENING EXCLUDING 64876 3894.97 090<br />
27466 OSTEOPLASTY FEMUR LENGTHENING 3691.04 090<br />
27468 OSTPL FEMUR CMBN LNGTH&SHRT W/FEM SGM TR 4194.99 090<br />
27470 RPR NON/MAL FEMUR DSTL H/N W/O GRF 3692.11 090<br />
27472 RPR NON/MAL FEMUR DSTL H/N W/ILIAC/AUTOG B1 GRF 3972.91 090<br />
27475 ARREST EPIPHYSEAL DISTAL FEMUR 1909.05 090<br />
27477 ARREST EPIPHYSEAL TIBIA&FIBULA PROXIMAL 2278.47 090<br />
27479 ARRST EPIPHYSL CMBN DSTL FEMUR PROX TIBFIB 2699.15 090<br />
27485 ARRST HEMIEPIPHYSL DSTL FEMUR/PROX TIBIA/FIBULA 2085.22 090<br />
27486 REVJ TOT KNE ARTHRP +-ALGRFT 1 COMP 4423.48 090<br />
27487 REVJ TOT KNE ARTHRP FEM&ENTIRE TIBL COMP 5553.11 090<br />
27488 RMVL PROSTH TOT KNE PROSTH MMA +-INSJ SPACER 3761.51 090<br />
27495 PROPH TX N/P/PLTWR +-MMA FEMUR 3537.29 090<br />
27496 DCMPRN FASCT THI&/KNE 1 CMPRT 1626.11 090<br />
27497 DCMPRN FASCT THI&/KNE 1 DBRDMT NV MUSC&/NRV 1753.16 090<br />
27498 DCMPRN FASCT THI&/KNE MLT CMPRTS 1942.15 090<br />
27499 DCMPRN FASCT THI&/KNE MLT DBRDMT NV MUSC&/NRV 2111.91 090<br />
27500 CLOSED TX FEMORAL SHAFT FX W/O MANIPULATION 1585.53 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 81
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
27501 CLTX SPRCNDYLR/TRNSCNDYLR FEM FX W/O MNPJ 1554.57 090<br />
27502 CLTX FEM SHFT FX W/MNPJ +-SKN/SKEL TRACJ 2436.49 090<br />
27503 CLTX SPRCNDYLR/TRNSCNDYLR FEM FX W/MNPJ 2500.55 090<br />
27506 OPTX FEM SHFT FX W/INSJ IMED IMPLT +-SCREW 4188.59 090<br />
27507 OPTX FEM SHFT FX W/PLATE/SCREWS +-CERCLAGE 3062.16 090<br />
27508 CLTX FEM FX DSTL END MEDIAL/LAT CONDYLE W/O MNPJ 1603.69 090<br />
27509 PRQ SKEL FIXJ FEM FX DSTL END 1998.73 090<br />
27510 CLTX FEM FX DSTL END MEDIAL/LAT CONDYLE W/MNPJ 2155.69 090<br />
27511 OPEN TX FEMORAL SUPRACONDYLAR FRACTURE W/O XTN 3166.80 090<br />
27513 OPEN TX FEMORAL SUPRACONDYLAR FRACTURE W XTN 3957.96 090<br />
27514 OPEN TX FEMORAL FRACTURE DISTAL MED/LAT CONDYLE 3107.01 090<br />
27516 CLTX DSTL FEM EPIPHYSL SEP W/O MNPJ 1533.22 090<br />
27517 CLTX DSTL FEM EPIPHYSL SEP W/MNPJ +-SKN/SKEL 2121.52 090<br />
27519 OPEN TX DISTAL FEMORAL EPIPHYSEAL SEPARATION 2843.29 090<br />
27520 CLOSED TX PATELLAR FRACTURE W/O MANIPULATION 967.34 090<br />
27524 OPTX PATLLR FX W/INT FIXJ/PATLLC&SOFT TISS RPR 2343.60 090<br />
27530 CLTX TIBL FX PROX W/O MNPJ 1203.30 090<br />
27532 CLTX TIBL FX PROX +-MNPJ W/SKEL TRACJ 1894.10 090<br />
27535 OPEN TX TIBIAL FRACTURE PROXIMAL UNICONDYLAR 2841.15 090<br />
27536 OPTX TIBL FX PROX BICONDYLAR +-INT FIXJ 3728.41 090<br />
27538 CLTX INTERCONDYLAR SPI&/TUBRST FX KNE +-MNPJ 1434.99 090<br />
27540 OPEN TX INTERCONDYLAR SPINE/TUBRST FRACTURE KNEE 2549.67 090<br />
27550 CLOSED TX KNEE DISLOCATION W/O ANESTHESIA 1514.00 090<br />
27552 CLOSED TX KNEE DISLOCATION W/ANESTHESIA 1934.67 090<br />
27556 OPEN TX KNEE DISLOCATION W/O LIGAMENTOUS REPAIR 2796.31 090<br />
27557 OPEN TX KNEE DISLOCATION W LIGAMENTOUS REPAIR 3347.24 090<br />
27558 OPEN TX KNEE DISLOCATION W REPAIR/RECONSTRUCTION 3797.81 090<br />
27560 CLOSED TX PATELLAR DISLOCATION W/O ANESTHESIA 1142.44 090<br />
27562 CLOSED TX PATELLAR DISLOCATION W/ANESTHESIA 1461.68 090<br />
27566 OPTX PATELLAR DISLC +-PRTL/TOT PATELLECTOMY 2782.43 090<br />
27570 MANIPULATION KNEE JOINT UNDER GENERAL ANESTHESIA 460.18 010<br />
27580 ARTHRODESIS KNEE ANY TECHNIQUE 4515.30 090<br />
27590 AMPUTATION THIGH THROUGH FEMUR ANY LEVEL 2615.87 090<br />
27591 AMP THI THRU FEMUR LVL IMMT FITG TQ W/1ST CST 2857.17 090<br />
27592 AMPUTATION THIGH THRU FEMUR OPEN CIRCULAR 2220.82 090<br />
27594 AMP THIGH THRU FEMUR SEC CLOSURE/SCAR REVISION 1609.02 090<br />
27596 AMPUTATION THIGH THROUGH FEMUR RE-AMPUTATION 2320.11 090<br />
27598 DISARTICULATION KNEE 2352.14 090<br />
27599 UNLISTED PROCEDURE FEMUR/KNEE BR YYY<br />
27600 DCMPRN FASCT LEG ANT&/LAT CMPRTS ONLY 1320.74 090<br />
27601 DCMPRN FASCT LEG PST CMPRT ONLY 1396.55 090<br />
27602 DCMPRN FASCT LEG ANT&/LAT&PST CMPRT 1621.84 090<br />
27603 INCISION&DRAINAGE LEG/ANKLE ABSCESS/HEMATOMA 1645.33 090<br />
27604 INCISION&DRAINAGE LEG/ANKLE INFECTED BURSA 1439.26 090<br />
27605 TENOTOMY PRQ ACHILLES TENDON SPX LOCAL ANES 1071.97 010<br />
27606 TENOTOMY PRQ ACHILLES TENDON SPX GENERAL ANES 905.41 010<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
82 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
27607 INCISION LEG/ANKLE 1913.32 090<br />
27610 ARTHROTOMY ANKLE W/EXPL DRAINAGE/REMOVAL FB 2037.17 090<br />
27612 ARTHRT PST CAPSULAR RLS ANKLE +-ACHLL TDN LNGTH 1748.89 090<br />
27613 BIOPSY SOFT TISSUE LEG/ANKLE AREA SUPERFICIAL 777.29 010<br />
27614 BIOPSY SOFT TISSUE LEG/ANKLE AREA DEEP 1756.37 090<br />
27615 RAD RESECTION TUMOR SOFT TISSUE LEG/ANKLE
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
27702 ARTHROPLASTY ANKLE W/IMPLANT 3079.25 090<br />
27703 ARTHROPLASTY ANKLE REVISION TOTAL ANKLE 3567.19 090<br />
27704 REMOVAL ANKLE IMPLANT 1785.19 090<br />
27705 OSTEOTOMY TIBIA 2385.24 090<br />
27707 OSTEOTOMY FIBULA 1247.07 090<br />
27709 OSTEOTOMY TIBIA&FIBULA 3644.06 090<br />
27712 OSTEOT MLT W/RELIGNMT IMED ROD 3449.74 090<br />
27715 OSTEOPLASTY TIBIA&FIBULA LENGTHENING/SHORTENING 3322.68 090<br />
27720 REPAIR NONUNION/MALUNION TIBIA W/O GRAFT 2740.79 090<br />
27722 REPAIR NONUNION/MALUNION TIBIA W/SLIDING GRAFT 2760.00 090<br />
27724 RPR NON/MAL TIBIA W/ILIAC/OTH AGRFT 4003.88 090<br />
27725 RPR NON/MAL TIBIA SYNOSTOSIS W/FIBULA ANY METH 3797.81 090<br />
27726 REPAIR FIBULA NONUNION/MALUNION W INT FIXATION 2989.56 090<br />
27727 REPAIR CONGENITAL PSEUDARTHROSIS TIBIA 3143.31 090<br />
27730 ARREST EPIPHYSEAL OPEN DISTAL TIBIA 1810.82 090<br />
27732 ARREST EPIPHYSEAL OPEN DISTAL FIBULA 1322.88 090<br />
27734 ARREST EPIPHYSEAL OPEN DISTAL TIBIA&FIBULA 1838.58 090<br />
27740 ARRST EPIPHYSL ANY METH TIBFIB 1983.79 090<br />
27742 ARRST EPIPHYSL ANY METH TIBFIB&DSTL FEMUR 2218.68 090<br />
27745 PROPH TX N/P/PLTWR +-MMA TIBIA 2351.08 090<br />
27750 CLTX TIBL SHFT FX W/O MNPJ 1038.87 090<br />
27752 CLTX TIBL SHFT FX W/MNPJ +-SKEL TRACJ 1648.53 090<br />
27756 PRQ SKEL FIXJ TIBL SHFT FX 1776.65 090<br />
27758 OPTX TIBL SHFT FX W/PLATE/SCREWS +-CERCLAGE 2778.16 090<br />
27759 TX TIBL SHFT FX IMED IMPLT +-SCREWS&/CERCLAGE 3130.50 090<br />
27760 CLTX MEDIAL MALLS FX W/O MNPJ 1003.64 090<br />
27762 CLTX MEDIAL MALLS FX W/MNPJ +-SKN/SKEL TRACJ 1471.29 090<br />
27766 OPEN TREATMENT MEDIAL MALLEOLUS FRACTURE 1895.17 090<br />
27767 CLOSED TREATMENT PST MALLEOLUS FRACTURE W/O MNPJ 831.74 090<br />
27768 CLOSED TREATMENT PST MALLEOLUS FRACTURE W MNPJ 1309.00 090<br />
27769 OPEN TREATMENT POSTERIOR MALLEOLUS FRACTURE 2234.70 090<br />
27780 CLTX PROX FIBULA/SHFT FX W/O MNPJ 908.61 090<br />
27781 CLTX PROX FIBULA/SHFT FX W/MNPJ 1288.71 090<br />
27784 OPEN TREATMENT PROXIMAL FIBULA/SHAFT FRACTURE 2210.14 090<br />
27786 CLTX DSTL FIBULAR FX LAT MALLS W/O MNPJ 949.19 090<br />
27788 CLTX DSTL FIBULAR FX LAT MALLS W/MNPJ 1287.65 090<br />
27792 OPEN TX DISTAL FIBULAR FRACTURE LAT MALLEOLUS 2211.21 090<br />
27808 CLOSED TX BIMALLEOLAR ANKLE FRACTURE W/O MNPJ 999.37 090<br />
27810 CLOSED TX BIMALLEOLAR ANKLE FRACTURE W MNPJ 1440.33 090<br />
27814 OPEN TREATMENT BIMALLEOLAR ANKLE FRACTURE 2413.00 090<br />
27816 CLTX TRIMAL ANKLE FX W/O MNPJ 949.19 090<br />
27818 CLTX TRIMAL ANKLE FX W/MNPJ 1476.63 090<br />
27822 OPEN TX TRIMALLEOLAR ANKLE FX W/O FIXJ PST LIP 2640.42 090<br />
27823 OPEN TX TRIMALLEOLAR ANKLE FX W FIXJ PST LIP 3003.44 090<br />
27824 CLTX FX W8 BRG ARTCLR PRTN DSTL TIBIA W/O MNPJ 944.91 090<br />
27825 CLTX FX W8 BRG ARTCLR PRTN DSTL TIB W/SKEL TRACJ 1682.70 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
84 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
27826 OPEN TREATMENT FRACTURE DISTAL TIBIA FIBULA 2596.65 090<br />
27827 OPEN TREATMENT FRACTURE DISTAL TIBIA ONLY 3395.29 090<br />
27828 OPEN TREATMENT FRACTURE DISTAL TIBIA & FIBULA 4065.80 090<br />
27829 OPEN TX DISTAL TIBIOFIBULAR JOINT DISRUPTION 2106.57 090<br />
27830 CLTX PROX TIBFIB JT DISLC W/O ANES 1126.42 090<br />
27831 CLTX PROX TIBFIB JT DISLC REQ ANES 1202.23 090<br />
27832 OPEN TX PROX TIBFIB JOINT DISLOCATE EXC PROX FIB 2298.76 090<br />
27840 CLOSED TX ANKLE DISLOCATION W/O ANESTHESIA 1097.60 090<br />
27842 CLTX ANKLE DISLC REQ ANES +-PRQ SKEL FIXJ 1521.47 090<br />
27846 OPTX ANKLE DISLC W/O RPR/INT FIXJ 2294.49 090<br />
27848 OPTX ANKLE DISLC W/RPR/INT/XTRNL FIXJ 2580.63 090<br />
27860 MNPJ ANKLE UNDER GENERAL ANES 544.53 010<br />
27870 ARTHRODESIS ANKLE OPEN 3268.23 090<br />
27871 ARTHRODESIS TIBIOFIBULAR JOINT PROXIMAL/DISTAL 2163.16 090<br />
27880 AMPUTATION LEG THROUGH TIBIA&FIBULA 2959.66 090<br />
27881 AMP LEG THRU TIBFIB W/IMMT FITG TQ W/1ST CST 2801.64 090<br />
27882 AMPUTATION LEG THRU TIBIA&FIBULA OPEN CIRCULAR 1982.72 090<br />
27884 AMP LEG THRU TIBIA&FIBULA SEC CLOSURE/SCAR REVJ 1856.73 090<br />
27886 AMP LEG THRU TIBIA&FIBULA RE-AMPUTATION 2116.18 090<br />
27888 AMP ANKLE-MALLI TIBFIB W/PLSTC CLSR&RESCJ NRV 2179.18 090<br />
27889 ANKLE DISARTICULATION 2166.36 090<br />
27892 DCMPRN FASCT LEG ANT&/LAT W/DBRDMT MUSC&/NRV 1730.74 090<br />
27893 DCMPRN FASCT LEG PST W/DBRDMT MUSC&/NRV 1831.11 090<br />
27894 DCMPRN FASCT LEG ANT&/LAT&PST W/DBRDMT MUSC&/NRV 2702.35 090<br />
27899 UNLISTED PROCEDURE LEG/ANKLE BR YYY<br />
28001 INCISION&DRAINAGE BURSA FOOT 826.40 010<br />
28002 I&D BELW FSCA FOOT 1 BURSAL SPACE 1564.18 010<br />
28003 I&D BELW FSCA FOOT MLT AREAS 2083.08 090<br />
28005 INCISION BONE CORTEX FOOT 1867.41 090<br />
28008 FASCIOTOMY FOOT&/TOE 1306.86 090<br />
28010 TENOTOMY PERCUTANEOUS TOE SINGLE TENDON 716.43 090<br />
28011 TENOTOMY PERCUTANEOUS TOE MULTIPLE TENDON 1018.59 090<br />
28020 ARTHRT W/EXPL DRG/RMVL LOOSE/FB NTRTRSL/TARS JT 1598.35 090<br />
28022 ARTHRT W/EXPL DRG/RMVL LOOSE/FB MTTARPHLNGL JT 1446.73 090<br />
28024 ARTHRT W/EXPL DRG/RMVL LOOSE/FB IPHAL JT 1366.66 090<br />
28035 RELEASE TARSAL TUNNEL 1584.47 090<br />
# 28039 EXCISION TUMOR SOFT TISSUE FOOT/TOE SUBQ 1.5+CM 1526.81 090<br />
# 28041 EXC TUMOR SOFT TISSUE FOOT/TOE SUBFASC 1.5+CM 1401.89 090<br />
28043 EXCISION TUMOR SOFT TISSUE FOOT/TOE SUBQ
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
28060 FASCIECTOMY PLANTAR FASCIA PARTIAL SPX 1553.50 090<br />
28062 FASCIOTOMY PLANTAR FASCIA RADICAL SPX 1790.53 090<br />
28070 SYNVCT INTERTARSAL/TARSOMETATARSAL JT EA SPX 1579.13 090<br />
28072 SYNOVECTOMY METATARSOPHALANGEAL JOINT EACH 1550.30 090<br />
28080 EXCISION INTERDIGITAL MORTON NEUROMA SINGLE EACH 1544.96 090<br />
28086 SYNOVECTOMY TENDON SHEATH FOOT FLEXOR 1645.33 090<br />
28088 SYNOVECTOMY TENDON SHEATH FOOT EXTENSOR 1443.53 090<br />
28090 EXC LESION TENDON SHEATH/CAPSULE W/SYNVCT FOOT 1409.36 090<br />
28092 EXC LESION TENDON SHEATH/CAPSULE W/SYNVCT TOE EA 1281.24 090<br />
28100 EXCISION/CURETTAGE CYST/TUMOR TALUS/CALCANEUS 1805.48 090<br />
28102 EXC/CURTG CST/B9 TUM TALUS/CLCNS W/ILIAC/AGRFT 1741.42 090<br />
28103 EXC/CURETTAGE CYST/TUMOR TALUS/CALCANEUS ALGRFT 1288.71 090<br />
28104 EXC/CURTG CST/B9 TUM TARSAL/METAR 1543.89 090<br />
28106 EXC/CURTG CST/B9 TUM TARSAL/METAR W/ILIAC/AGRFT 1383.74 090<br />
28107 EXC/CURTG CST/B9 TUM TARSAL/METAR W/ALGRFT 1625.04 090<br />
28108 EXC/CURTG CST/B9 TUM PHALANGES FOOT 1309.00 090<br />
28110 OSTECTOMY PRTL 5TH METAR HEAD SPX 1381.60 090<br />
28111 OSTECTOMY COMPLETE 1ST METATARSAL HEAD 1551.37 090<br />
28112 OSTECTOMY COMPLETE OTHER METATARSAL HEAD 2/3/4 1486.24 090<br />
28113 OSTECTOMY COMPLETE 5TH METATARSAL HEAD 1795.87 090<br />
28114 OSTC COMPL ALL METAR HEADS W/PRTL PROX PHALANGC 3256.49 090<br />
28116 OSTECTOMY TARSAL COALITION 2284.88 090<br />
28118 OSTECTOMY CALCANEUS 1781.99 090<br />
28119 OSTECTOMY CALCANEUS SPUR +-PLNTAR FSCAL RLS 1576.99 090<br />
28120 PRTL EXC B1 TALUS/CALCANEUS 2156.75 090<br />
28122 PRTL EXC B1 TARSAL/METAR B1 XCP TALUS/CALCANEUS 2001.94 090<br />
28124 PRTL EXC B1 PHALANX TOE 1439.26 090<br />
28126 RESECTION PARTIAL/COMPLETE PHALANGEAL BASE EACH 1181.94 090<br />
28130 TALECTOMY ASTRAGALECTOMY 2164.23 090<br />
28140 METATARSECTOMY 1879.15 090<br />
28150 PHALANGECTOMY TOE EA TOE 1311.14 090<br />
28153 RESECTION CONDYLE DISTAL END PHALANX EACH TOE 1237.46 090<br />
28160 HEMIPHALANGC/IPHAL JT EXC TOE 1265.22 090<br />
28171 RAD RESCJ TUMOR TARSAL EXCEPT TALUS/CALCANEUS 2638.29 090<br />
28173 RADICAL RESECTION TUMOR METATARSAL 2389.51 090<br />
28175 RADICAL RESECTION TUMOR PHALANX OR TOE 1504.39 090<br />
28190 REMOVAL FOREIGN BODY FOOT SUBCUTANEOUS 761.27 010<br />
28192 REMOVAL FOREIGN BODY FOOT DEEP 1429.65 090<br />
28193 REMOVAL FOREIGN BODY FOOT COMPLICATED 1621.84 090<br />
28200 RPR TDN FLXR FOOT 1/2 W/O FR GRF EA TDN 1433.92 090<br />
28202 RPR TDN FLXR FOOT SEC W/FR GRF EA TDN 1820.43 090<br />
28208 RPR TDN XTNSR FOOT 1/2 EA TDN 1400.82 090<br />
28210 RPR TDN XTNSR FOOT SEC W/FR GRF EA TDN 1742.49 090<br />
28220 TENOLYSIS FLEXOR FOOT SINGLE TENDON 1353.84 090<br />
28222 TENOLYSIS FLEXOR FOOT MULTIPLE TENDONS 1550.30 090<br />
28225 TENOLYSIS EXTENSOR FOOT SINGLE TENDON 1194.76 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
86 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
28226 TENOLYSIS EXTENSOR FOOT MULTIPLE TENDON 1423.24 090<br />
28230 TX OPN TDN FLXR FOOT 1/MLT TDN SPX 1301.53 090<br />
28232 TX OPN TDN FLXR TOE 1 TDN SPX 1174.47 090<br />
28234 TENOTOMY OPEN EXTENSOR FOOT/TOE EACH TENDON 1232.13 090<br />
28238 RCNSTJ PST TIBL TDN W/EXC ACCESSORY TARSL NAVCLR 2056.39 090<br />
28240 TENOTOMY LENGTHENING/RLS ABDUCTOR HALLUCIS MUSC 1334.63 090<br />
28250 DIVISION PLANTAR FASCIA&MUSCLE SPX 1728.61 090<br />
28260 CAPSULOTOMY MIDFOOT MEDIAL RELEASE ONLY SPX 2104.44 090<br />
28261 CAPSULOTOMY MIDFOOT W/TENDON LENGTHENING 2947.92 090<br />
28262 CAPSUL MIDFOOT W/PST TALOTIBL CAPSUL&TDN LNGTH 4253.72 090<br />
28264 CAPSULOTOMY MIDTARSAL 2782.43 090<br />
28270 CAPSUL MTTARPHLNGL JT +-TENORRHAPHY EA JT SPX 1475.56 090<br />
28272 CAPSUL IPHAL JT EA JT SPX 1185.15 090<br />
28280 SYNDACTYLIZATION TOES 1583.40 090<br />
28285 CORRECTION HAMMERTOE 1418.97 090<br />
28286 CORRECTION COCK-UP 5TH TOE W/PLASTIC CLOSURE 1374.13 090<br />
28288 OSTC PRTL EXOSTC/CONDYLC METAR HEAD 1824.70 090<br />
28289 HALLUX RGDUS CORRJ W/CHEILC 2240.03 090<br />
28290 CORRJ HALLUX VALGUS +-SESMDC SMPL EXOSTECTOMY 1764.91 090<br />
28292 KELLER/MCBRIDE/MAYO PROCEDURE 2392.72 090<br />
28293 CORRJ HALLUX VALGUS +-SESMDC RESCJ JT W/IMPLT 3163.60 090<br />
28294 CORRJ HALLUX VALGUS +-SESMDC W/TDN TRNSPLS 2229.36 090<br />
28296 CORRJ HALLUX VALGUS +-SESMDC W/METAR OSTEOT 2186.65 090<br />
28297 CORRJ HALLUX VALGUS +-SESMDC LAPIDUS-TYP PX 2509.10 090<br />
28298 CORRJ HALLUX VALGUS +-SESMDC PHALANX OSTEOT 2181.31 090<br />
28299 CORRJ HALLUX VALGUS +-SESMDC 2 OSTEOT 2743.99 090<br />
28300 OSTEOTOMY CALCANEUS +-INTERNAL FIXATION 2077.74 090<br />
28302 OSTEOTOMY TALUS 2171.70 090<br />
28304 OSTEOTOMY TARSAL BONES OTH/THN CALCANEUS/TALUS 2440.76 090<br />
28305 OSTEOT TARSAL OTH/THN CALCANEUS/TALUS W/AGRFT 2058.53 090<br />
28306 OSTEOT +-LNGTH SHRT/CORRJ 1ST METAR 1859.93 090<br />
28307 OSTEOT +-LNGTH SHRT/CORRJ 1ST METAR XCP 1ST TOE 2155.69 090<br />
28308 OSTEOT +-LNGTH SHRT/CORRJ METAR XCP 1ST EA 1682.70 090<br />
28309 OSTEOT +-LNGTH SHRT/ANGULAR CORRJ METAR MLT 2799.51 090<br />
28310 OSTEOT SHRT CORRJ PROX PHALANX 1ST TOE 1630.38 090<br />
28312 OSTEOT SHRT CORRJ OTH PHALANGES ANY TOE 1510.80 090<br />
28313 RCNSTJ ANGULAR DFRM TOE SOFT TISS PX ONLY 1595.14 090<br />
28315 SESAMOIDECTOMY FIRST TOE SPX 1436.06 090<br />
28320 REPAIR NONUNION/MALUNION TARSAL BONES 1932.54 090<br />
28322 RPR NON/MAL METAR +-B1 GRF 2386.31 090<br />
28340 RCNSTJ TOE MACRODACTYLY SOFT TISSUE RESECTION 1800.14 090<br />
28341 RCNSTJ TOE MACRODACTYLY REQUIRING BONE RESECTION 2078.81 090<br />
28344 RECONSTRUCTION TOE POLYDACTYLY 1368.79 090<br />
28345 RCNSTJ TOE SYNDACTYLY +-SKN GRF EA WEB 1647.46 090<br />
28360 RECONSTRUCTION CLEFT FOOT 3268.23 090<br />
28400 CLOSED TX CALCANEAL FRACTURE W/O MANIPULATION 749.53 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 87
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
28405 CLOSED TX CALCANEAL FRACTURE W/MANIPULATION 1196.89 090<br />
28406 PRQ SKEL FIXJ CALCANEAL FX W/MNPJ 1630.38 090<br />
28415 OPEN TREATMENT CALCANEAL FRACTURE 3523.41 090<br />
28420 OPEN TREATMENT CALCANEAL FRACTURE W BONE GRAFT 3852.26 090<br />
28430 CLOSED TX TALUS FRACTURE W/O MANIPULATION 705.75 090<br />
28435 CLOSED TX TALUS FRACTURE W/ MANIPULATION 1043.14 090<br />
28436 PRQ SKELETAL FIXATION TALUS FRACTURE W/MNPJ 1358.11 090<br />
28445 OPEN TREATMENT TALUS FRACTURE 3326.95 090<br />
28446 OPEN OSTEOCHONDRAL AUTOGRAFT TALUS 3787.13 090<br />
28450 TX TARSAL B1 FX XCP TALUS&CALCN W/O MNPJ 649.16 090<br />
28455 TX TARSAL B1 FX XCP TALUS&CALCN W/MNPJ 892.60 090<br />
28456 PRQ SKEL FIXJ TARSL FX XCP TALUS&CALCNS W/MNPJ 933.17 090<br />
28465 OPEN TX TARSAL FRACTURE XCP TALUS &CALCANEUS EA 1902.64 090<br />
28470 CLOSED TX METATARSAL FRACTURE W/O MANIPULATION 641.69 090<br />
28475 CLTX METAR FX W/MNPJ 787.96 090<br />
28476 PRQ SKEL FIXJ METAR FX W/MNPJ 1060.23 090<br />
28485 OPEN TREATMENT METATARSAL FRACTURE EACH 1651.73 090<br />
28490 CLTX FX GRT TOE PHLX/PHLG W/O MNPJ 426.01 090<br />
28495 CLTX FX GRT TOE PHLX/PHLG W/MNPJ 531.71 090<br />
28496 PRQ SKEL FIXJ FX GRT TOE PHLX/PHLG W/MNPJ 1309.00 090<br />
28505 OPEN TX FRACTURE GREAT TOE/PHALANX/PHALANGES 2041.44 090<br />
28510 CLTX FX PHLX/PHLG OTH/THN GRT TOE W/O MNPJ 365.15 090<br />
28515 CLTX FX PHLX/PHLG OTH/THN GRT TOE W/MNPJ 479.40 090<br />
28525 OPEN TX FRACTURE PHALANX/PHALANGES NOT GREAT TOE 1731.81 090<br />
28530 CLOSED TREATMENT SESAMOID FRACTURE 347.00 090<br />
28531 OPEN TX SESAMOID FRACTURE +-INTERNAL FIXATION 1109.34 090<br />
28540 CLTX TARSAL DISLC OTH/THN TALOTARSAL W/O ANES 612.86 090<br />
28545 CLTX TARSAL DISLC OTH/THN TALOTARSAL W/ANES 832.81 090<br />
28546 PRQ SKEL FIXJ TARSL DISLC XCP TALOTARSAL W/MNPJ 1602.62 090<br />
28555 OPEN TREATMENT TARSAL BONE DISLOCATION 2679.93 090<br />
28570 CLOSED TX TALOTARSAL JOINT DISLC W/O ANES 503.95 090<br />
28575 CLOSED TX TALOTARSAL JOINT DISLOCATION W/ANES 1068.77 090<br />
28576 PRQ SKEL FIXJ TALOTARSAL JT DISLC W/MNPJ 1167.00 090<br />
28585 OPEN TREATMENT TALOTARSAL JOINT DISLOCATION 2823.00 090<br />
28600 CLOSED TX TARSOMETATARSAL DISLOCATION W/O ANES 657.70 090<br />
28605 CLOSED TX TARSOMETATARSAL DISLOCATION W/ANES 860.57 090<br />
28606 PRQ SKEL FIXJ TARS JT DISLC W/MNPJ 1211.84 090<br />
28615 OPEN TREATMENT TARSOMETATARSAL JOINT DISLOCATION 2452.51 090<br />
28630 CLTX METATARSOPHLNGL JT DISLC W/O ANES 461.25 010<br />
28635 CLTX METATARSOPHLNGL JT DISLC REQ ANES 541.32 010<br />
28636 PRQ SKEL FIXJ METATARSOPHLNGL JT DISLC W/MNPJ 836.01 010<br />
28645 OPEN TX METATARSOPHALANGEAL JOINT DISLOCATION 1943.21 090<br />
28660 CLTX IPHAL JT DISLC W/O ANES 339.53 010<br />
28665 CLTX IPHAL JT DISLC REQ ANES 475.13 010<br />
28666 PRQ SKEL FIXJ IPHAL JT DISLC W/MNPJ 635.28 010<br />
28675 OPEN TREATMENT INTERPHALANGEAL JOINT DISLOCATION 1770.25 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
88 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
28705 ARTHRODESIS PANTALAR 4077.55 090<br />
28715 ARTHRODESIS TRIPLE 3049.35 090<br />
28725 ARTHRODESIS SUBTALAR 2484.54 090<br />
28730 ARTHRD MIDTARSL/TARS MLT/TRANSVRS 2636.15 090<br />
28735 ARTHRD MIDTARSL/TARS MLT/TRANSVRS W/OSTEOT 2489.88 090<br />
28737 ARTHRD W/TDN LNGTH&ADVMNT TARSL NVCLR-CUNEIFORM 2140.74 090<br />
28740 ARTHRODESIS MIDTARSOMETATARSAL SINGLE JOINT 2621.20 090<br />
28750 ARTHRODESIS GREAT TOE METATARSOPHALANGEAL JOINT 2548.60 090<br />
28755 ARTHRODESIS GREAT TOE INTERPHALANGEAL JOINT 1526.81 090<br />
28760 ARTHRD W/XTNSR HALLUCIS LONGUS TR 1ST METAR NCK 2415.14 090<br />
28800 AMPUTATION FOOT MIDTARSAL 1769.18 090<br />
28805 AMPUTATION FOOT TRANSMETARSAL 2389.51 090<br />
28810 AMPUTATION METATARSAL W/TOE SINGLE 1394.42 090<br />
28820 AMPUTATION TOE METATARSOPHALANGEAL JOINT 1617.57 090<br />
28825 AMPUTATION TOE INTERPHALANGEAL JOINT 1784.13 090<br />
28890 ESWT HI NRG PFRMD PHYS W/US GDN INVG PLNTAR FSCA 1050.62 090<br />
28899 UNLISTED PROCEDURE FOOT/TOES BR YYY<br />
29000 APPLICATION HALO TYPE BODY CAST 893.66 000<br />
29010 APPLICATION RISSER JACKET LOCALIZER BODY ONLY 863.77 000<br />
29015 APPLICATION RISSER JACKET LOCALIZER BODY W/HEAD 727.10 000<br />
29020 APPLICATION TURNBUCKLE JACKET BODY ONLY 651.30 000<br />
29025 APPLICATION TURNBUCKLE JACKET BODY W/HEAD 766.61 000<br />
29035 APPLICATION BODY CAST SHOULDER HIPS 754.86 000<br />
29040 APPLICATION BODY CAST SHOULDER HIPS HEAD MINERVA 722.83 000<br />
29044 APPLICATION BODY CAST SHOULDER HIPS W/ONE THIGH 832.81 000<br />
29046 APPLICATION BODY CAST SHOULDER HIPS BOTH THIGHS 822.13 000<br />
29049 APPLICATION CAST FIGURE-OF-8 282.94 000<br />
29055 APPLICATION CAST SHOULDER SPICA 652.36 000<br />
29058 APPLICATION CAST PLASTER VELPEAU 311.77 000<br />
29065 APPLICATION CAST SHOULDER HAND LONG ARM 287.21 000<br />
29075 APPLICATION CAST ELBOW FINGER SHORT ARM 267.99 000<br />
29085 APPLICATION CAST HAND&LOWER FOREARM GAUNTLET 284.01 000<br />
29086 APPLICATION CAST FINGER 225.28 000<br />
29105 APPLICATION LONG ARM SPLINT SHOULDER HAND 260.52 000<br />
29125 APPLICATION SHORT ARM SPLINT FOREARM-HAND STATIC 208.20 000<br />
29126 APPLICATION SHORT ARM SPLINT DYNAMIC 237.03 000<br />
29130 APPLICATION FINGER SPLINT STATIC 122.79 000<br />
29131 APPLICATION FINGER SPLINT DYNAMIC 155.88 000<br />
29200 STRAPPING THORAX 161.22 000<br />
29240 STRAPPING SHOULDER 174.04 000<br />
29260 STRAPPING ELBOW/WRIST 155.88 000<br />
29280 STRAPPING HAND/FINGER 151.61 000<br />
29305 APPLICATION HIP SPICA CAST 1 LEG 729.24 000<br />
29325 APPL HIP SPICA CAST ONE&ONE-HALF SPICA/BOTH LEGS 810.38 000<br />
29345 APPLICATION LONG LEG CAST THIGH-TOE 411.06 000<br />
29355 APPLICATION LONG LEG CAST WALKER/AMBULATORY TYPE 427.08 000<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 89
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
29358 APPLICATION LONG LEG CAST BRACE 475.13 000<br />
29365 APPLICATION CYLINDER CAST THIGH ANKLE 370.49 000<br />
29405 APPLICATION SHORT LEG CAST BELOW KNEE-TOE 267.99 000<br />
29425 APPLICATION SHORT LEG CAST WALKING/AMBULATORY 286.14 000<br />
29435 APPLICATION PATELLAR TENDON BEARING CAST 359.81 000<br />
29440 ADDING WALKER PREVIOUSLY APPLIED CAST 147.34 000<br />
29445 APPLICATION RIGID TOTAL CONTACT LEG CAST 431.35 000<br />
29450 APPL CLUBFOOT CAST MOLDING/MNPJ LONG/SHORT LEG 446.30 000<br />
29505 APPLICATION LONG LEG SPLINT THIGH ANKLE/TOES 233.83 000<br />
29515 APPLICATION SHORT LEG SPLINT CALF FOOT 217.81 000<br />
29520 STRAPPING HIP 150.55 000<br />
29530 STRAPPING KNEE 158.02 000<br />
29540 STRAPPING ANKLE &/FOOT 103.57 000<br />
29550 STRAPPING TOES 83.28 000<br />
29580 STRAPPING UNNA BOOT 160.16 000<br />
29581 APPL MLT-LAYER VENOUS WOUND COMPRESS BELOW KNEE 288.28 000<br />
29590 DENIS-BROWNE SPLINT STRAPPING 162.29 000<br />
29700 REMOVAL/BIVALVING GAUNTLET BOOT/BODY CAST 198.59 000<br />
29705 REMOVAL/BIVALVING FULL ARM/FULL LEG CAST 202.86 000<br />
29710 RMVL/BIVALV SHO/HIP SPICA MINERVA/RISSER JACKET 370.49 000<br />
29715 REMOVAL/BIVALVING TURNBUCKLE JACKET 260.52 000<br />
29720 REPAIR SPICA BODY CAST/JACKET 246.64 000<br />
29730 WINDOWING CAST 196.46 000<br />
29740 WEDGING CAST EXCEPT CLUBFOOT CASTS 276.53 000<br />
29750 WEDGING CLUBFOOT CAST 311.77 000<br />
29799 UNLISTED PROCEDURE CASTING/STRAPPING BR YYY<br />
29800 ARTHRS TMPRMAND JT DX +-SYNVAL BX SPX 1629.31 090<br />
29804 ARTHROSCOPY TEMPOROMANDIBULAR JOINT SURGICAL 2037.17 090<br />
29805 ARTHROSCOPY SHOULDER DX +-SYNOVIAL BIOPSY SPX 1460.61 090<br />
29806 ARTHROSCOPY SHOULDER SURGICAL CAPSULORRHAPHY 3318.41 090<br />
29807 ARTHROSCOPY SHOULDER SURGICAL REPAIR SLAP LESION 3238.33 090<br />
29819 ARTHROSCOPY SHOULDER SURGICAL REMOVAL LOOSE/FB 1824.70 090<br />
29820 ARTHROSCOPY SHOULDER SURG SYNOVECTOMY PARTIAL 1679.49 090<br />
29821 ARTHROSCOPY SHOULDER SURG SYNOVECTOMY COMPLETE 1838.58 090<br />
29822 ARTHROSCOPY SHOULDER SURG DEBRIDEMENT LIMITED 1787.33 090<br />
29823 ARTHROSCOPY SHOULDER SURG DEBRIDEMENT EXTENSIVE 1950.69 090<br />
29824 ARTHROSCOPY SHOULDER DISTAL CLAVICULECTOMY 2098.03 090<br />
29825 ARTHROSCOPY SHOULDER LYSIS&RESCJ ADHESION +-MNPJ 1820.43 090<br />
29826 SHOULDER SCOPE BONE SHAVING 2079.88 090<br />
29827 ARTHROSCOPY SHOULDER ROTATOR CUFF REPAIR 3379.27 090<br />
29828 ARTHROSCOPY SHOULDER BICEPS TENODESIS 2865.71 090<br />
29830 ARTHROSCOPY ELBOW DIAGNOSTIC +-SYNOVIAL BX SPX 1410.43 090<br />
29834 ARTHROSCOPY ELBOW SURGICAL W/REMOVAL LOOSE/FB 1528.95 090<br />
29835 ARTHROSCOPY ELBOW SURGICAL SYNOVECTOMY PARTIAL 1572.72 090<br />
29836 ARTHROSCOPY ELBOW SURGICAL SYNOVECTOMY COMPLETE 1814.02 090<br />
29837 ARTHROSCOPY ELBOW SURGICAL DEBRIDEMENT LIMITED 1645.33 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
90 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
29838 ARTHROSCOPY ELBOW SURGICAL DEBRIDEMENT EXTENSIVE 1840.71 090<br />
29840 ARTHROSCOPY WRIST DIAGNOSTIC +-SYNOVIAL BX SPX 1397.62 090<br />
29843 ARTHROSCOPY WRIST INFECTION LAVAGE&DRAINAGE 1496.92 090<br />
29844 ARTHROSCOPY WRIST SURGICAL SYNOVECTOMY PARTIAL 1543.89 090<br />
29845 ARTHROSCOPY WRIST SURGICAL SYNOVECTOMY COMPLETE 1783.06 090<br />
29846 ARTHRS WRST EXC&/RPR TRIANG FIBROCART&/JT DBRDMT 1619.70 090<br />
29847 ARTHRS WRST SURG INT FIXJ F/FX/INS 1689.10 090<br />
29848 NDSC WRST SURG W/RLS TRANSVRS CARPL LIGM 1571.65 090<br />
29850 ARTHRS AID TX SPI&/FX KNE W/O FIXJ 1862.07 090<br />
29851 ARTHRS AID TX SPI&/FX KNE W/FIXJ 2913.75 090<br />
29855 ARTHRS AID TIBIAL FRACTURE PROXIMAL UNICONDYLAR 2451.44 090<br />
29856 ARTHRS AID TIBIAL FX PROX UNICONDYLAR BICONDYLAR 3124.09 090<br />
29860 ARTHROSCOPY HIP DIAGNOSTIC +-SYNOVIAL BIOPSY SPX 2057.46 090<br />
29861 ARTHROSCOPY HIP SURGICAL W/REMOVAL LOOSE/FB 2264.59 090<br />
29862 ARTHRS HIP DEBRIDEMENT/SHAVING ARTICULAR CRTLG 2541.13 090<br />
29863 ARTHROSCOPY HIP SURGICAL W/SYNOVECTOMY 2533.65 090<br />
29866 ARTHROSCOPY KNEE OSTEOCHONDRAL AGRFT MOSAICPLAST 3272.50 090<br />
29867 ARTHROSCOPY KNEE OSTEOCHONDRAL ALLOGRAFT 3983.59 090<br />
29868 ARTHROSCOPY KNEE MENISCAL TRNSPLJ MED/LAT 5249.88 090<br />
29870 ARTHROSCOPY KNEE DIAGNOSTIC +-SYNOVIAL BX SPX 1815.09 090<br />
29871 ARTHROSCOPY KNEE INFECTION LAVAGE & DRAINAGE 1593.01 090<br />
29873 ARTHROSCOPY KNEE LATERAL RELEASE 1612.23 090<br />
29874 ARTHROSCOPY KNEE REMOVAL LOOSE/FOREIGN BODY 1675.22 090<br />
29875 ARTHROSCOPY KNEE SYNOVECTOMY LIMITED SPX 1539.62 090<br />
29876 ARTHROSCOPY KNEE SYNOVECTOMY 2/>COMPARTMENTS 2040.37 090<br />
29877 ARTHRS KNEE DEBRIDEMENT/SHAVING ARTCLR CRTLG 1932.54 090<br />
29879 ARTHRS KNEE ABRASION ARTHRP/MLT DRLG/MICROFX 2062.80 090<br />
29880 ARTHRS KNEE W/MENISCECTOMY MED&LAT W/SHAVING 2150.35 090<br />
29881 ARTHRS KNE SURG W/MENISCECTOMY MED/LAT W/SHVG 2009.41 090<br />
29882 ARTHROSCOPY KNEE W/MENISCUS RPR MEDIAL/LATERAL 2172.77 090<br />
29883 ARTHROSCOPY KNEE W/MENISCUS RPR MEDIAL&LATERAL 2623.34 090<br />
29884 ARTHROSCOPY KNEE W/LYSIS ADHESIONS+-MNPJ SPX 1927.20 090<br />
29885 ARTHRS KNE DRLG OSTEO DISS GRFG 2335.06 090<br />
29886 ARTHRS KNE DRLG OSTEO DISS LES 1970.97 090<br />
29887 ARTHRS KNE DRLG OSTEO DISS LES INT FIXJ 2320.11 090<br />
29888 ARTHRS AIDED ANT CRUCIATE LIGM RPR/AGMNTJ/RCNSTJ 3096.33 090<br />
29889 ARTHRS AIDED PST CRUCIATE LIGM RPR/AGMNTJ/RCNSTJ 3810.62 090<br />
29891 ARTHRS ANKLE EXC OSTCHNDRL DFCT W/DRLG DFCT 2156.75 090<br />
29892 ARTHRS AID RPR LES/TALAR DOME FX/TIBL PLAFOND FX 2077.74 090<br />
29893 ENDOSCOPIC PLANTAR FASCIOTOMY 1837.51 090<br />
29894 ARTHROSCOPY ANKLE W/REMOVAL LOOSE/FOREIGN BODY 1609.02 090<br />
29895 ARTHROSCOPY ANKLE SURGICAL SYNOVECTOMY PARTIAL 1538.56 090<br />
29897 ARTHROSCOPY ANKLE SURGICAL DEBRIDEMENT LIMITED 1612.23 090<br />
29898 ARTHROSCOPY ANKLE SURGICAL DEBRIDEMENT EXTENSIVE 1791.60 090<br />
29899 ARTHROSCOPY ANKLE SURGICAL W/ANKLE ARTHRODESIS 3277.84 090<br />
29900 ARTHROSCOPY METACARPOPHALANGEAL SYNOVIAL BIOPSY 1400.82 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 91
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
29901 ARTHRS METACARPOPHALANGEAL JOINT DEBRIDEMENT 1606.89 090<br />
29902 ARTHRS MTCARPHLNGL JT W/RDCTJ UR COLTRL LIGM 1705.12 090<br />
29904 ARTHRS SUBTALAR JOINT REMOVE LOOSE/FOREIGN BODY 1963.50 090<br />
29905 ARTHROSCOPY SUBTALAR JOINT WITH SYNOVECTOMY 2122.59 090<br />
29906 ARTHROSCOPY SUBTALAR JOINT WITH DEBRIDEMENT 2233.63 090<br />
29907 ARTHROSCOPY SUBTALAR JOINT SUBTALAR ARTHRODESIS 2708.75 090<br />
l # 29914 ARTHROSCOPY HIP W/FEMOROPLASTY 3237.27 090<br />
l # 29915 ARTHROSCOPY HIP W/ACETABULOPLASTY 3298.13 090<br />
l # 29916 ARTHROSCOPY HIP W/LABRAL REPAIR 3298.13 090<br />
29999 UNLISTED PROCEDURE ARTHROSCOPY BR YYY<br />
30000 DRAINAGE ABSCESS/HEMATOMA NASAL INT APPROACH 373.33 010<br />
30020 DRAINAGE ABSCESS/HEMATOMA NASAL SEPTUM 369.45 010<br />
30100 BIOPSY INTRANASAL 227.65 000<br />
30110 EXCISION NASAL POLYP SIMPLE 369.45 010<br />
30115 EXCISION NASAL POLYP EXTENSIVE 699.02 090<br />
30117 EXCISION/DESTRUCTION INTRANASAL LESION INT APPR 1380.32 090<br />
30118 EXCISION/DESTRUCTION INTRANASAL LESION XTRNL 1252.37 090<br />
30120 EXCISION/SURGICAL PLANING SKIN NOSE RHINOPHYMA 841.93 090<br />
30124 EXCISION DERMOID CYST NOSE SIMPLE SUBCUTANEOUS 444.23 090<br />
30125 EXC DERMOID CYST NOSE COMPLEX UNDER BONE/CRTLG 995.91 090<br />
30130 EXCISION INFERIOR TURBINATE PARTIAL/COMPLETE 613.72 090<br />
30140 SUBMUCOUS RESCJ INFERIOR TURBINATE PRTL/COMPL 707.33 090<br />
30150 RHINECTOMY PARTIAL 1271.20 090<br />
30160 RHINECTOMY TOTAL 1275.08 090<br />
30200 INJECTION TURBINATE THERAPEUTIC 182.79 000<br />
30210 DISPLACEMENT THERAPY PROETZ TYPE 240.95 010<br />
30220 INSERTION NASAL SEPTAL PROSTHESIS BUTTON 481.89 010<br />
30300 REMOVAL FOREIGN BODY INTRANASAL OFFICE PROCEDURE 367.79 010<br />
30310 REMOVAL FOREIGN BODY INTRANASAL GENERAL ANES 333.45 010<br />
30320 RMVL FOREIGN BODY INTRANASAL LATERAL RHINOTOMY 735.03 090<br />
30400 RHINP PRIM LAT&ALAR CRTLGS&/ELVTN NSL TIP 1666.69 090<br />
30410 RHINP PRIM COMPLETE XTRNL PARTS 1960.25 090<br />
30420 RHINOPLASTY PRIMARY W/MAJOR SEPTAL REPAIR 2243.30 090<br />
30430 RHINOPLASTY SECONDARY MINOR REVISION 1477.25 090<br />
30435 RHINOPLASTY SECONDARY INTERMEDIATE REVISION 1963.02 090<br />
30450 RHINOPLASTY SECONDARY MAJOR REVISION 2502.52 090<br />
30460 RHINP DFRM W/COLUM LNGTH TIP ONLY 1250.15 090<br />
30462 RHINP DFRM COLUM LNGTH TIP SEPTUM OSTEOT 2550.16 090<br />
30465 REPAIR NASAL VESTIBULAR STENOSIS 1602.43 090<br />
30520 SEPTOP/SBMCSL RESCJ 1003.67 090<br />
30540 REPAIR CHOANAL ATRESIA INTRANASAL 1107.25 090<br />
30545 REPAIR CHOANAL ATRESIA TRANSPALATINE 1413.00 090<br />
30560 LYSIS INTRANASAL SYNECHIA 436.47 010<br />
30580 REPAIR FISTULA OROMAXILLARY 1021.39 090<br />
30600 REPAIR FISTULA ORONASAL 932.21 090<br />
30620 SEPTAL/OTHER INTRANASAL DERMATOPLASTY 1008.65 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
92 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
30630 REPAIR NASAL SEPTAL PERFORATIONS 1018.62 090<br />
30801 ABLTJ SOF TISS INF TURBS UNI/BI SUPFC 365.57 010<br />
30802 ABLTJ SOF TISS INF TURBS UNI/BI SUPFC INTRAMURAL 469.15 010<br />
30901 CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE 156.20 000<br />
30903 CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX 319.60 000<br />
30905 CTRL NSL HEMRRG PST PST NSL PACKS&/CAUT 1ST 396.59 000<br />
30906 CTRL NSL HEMRRG PST PST NSL PACKS&/CAUT SBSQ 449.21 000<br />
30915 LIGATION ARTERIES ETHMOIDAL 941.63 090<br />
30920 LIGATION ARTERIES INT MAXILLARY TRANSANTRAL 1358.72 090<br />
30930 FRACTURE NASAL INFERIOR TURBINATE THERAPEUTIC 199.96 010<br />
30999 UNLISTED PROCEDURE NOSE BR YYY<br />
31000 LAVAGE CANNULATION MAXILLARY SINUS 290.80 010<br />
31002 LAVAGE CANNULATION SPHENOID SINUS 326.25 010<br />
31020 SINUSOTOMY MAXILLARY ANTROTOMY INTRANASAL 778.78 090<br />
31030 SINUSOTOMY MAXILLARY RAD W/O RMVL ANTROCH POLYPS 1116.11 090<br />
31032 SINUSOT MAX ANTRT RAD W/RMVL ANTROCH POLYPS 928.34 090<br />
31040 PTERYGOMAXILLARY FOSSA SURGERY ANY APPROACH 1220.24 090<br />
31050 SINUSOTOMY SPHENOID +-BIOPSY 794.29 090<br />
31051 SINUSOT SPHENOID W/MUCOSAL STRIPPING/RMVL POLYP 1047.98 090<br />
31070 SINUSOTOMY FRONTAL EXTERNAL SIMPLE 711.76 090<br />
31075 SINUSOTOMY FRONTAL TRANSORBITAL UNILATERAL 1276.19 090<br />
31080 SINUSOTOMY FRNT OBLITERATIVE W/O FLAP BROW INC 1661.70 090<br />
31081 SINUSOT FRNT OBLIT W/O OSTPL FLAP CORONAL INC 2247.73 090<br />
31084 SINUSOT FRNT OBLIT W/OSTPL FLAP BROW INC 1904.31 090<br />
31085 SINUSOT FRNT OBLIT W/OSTPL FLAP CORONAL INC 2180.15 090<br />
31086 SINUSOT FRNT NONOBLIT W/OSTPL FLAP BROW INC 1827.87 090<br />
31087 SINUSOT FRNT NONOBLIT W/OSTPL FLAP CORONAL INC 1777.47 090<br />
31090 SINUSOT UNI 3/> PARANSL SINUSES 1652.84 090<br />
31200 ETHMOIDECTOMY INTRANASAL ANTERIOR 887.35 090<br />
31201 ETHMOIDECTOMY INTRANASAL TOTAL 1193.65 090<br />
31205 ETHMOIDECTOMY EXTRANASAL TOTAL 1427.95 090<br />
31225 MAXILLECTOMY W/O ORBITAL EXENTERATION 3035.37 090<br />
31230 MAXILLECTOMY W/ORBITAL EXENTERATION 3387.10 090<br />
31231 NASAL ENDOSCOPY DIAGNOSTIC UNI/BI SPX 309.63 000<br />
31233 NSL/SINUS NDSC DX MAX SINUSC 432.60 000<br />
31235 NSL/SINUS NDSC DX SPHENOID SINUSOSCOPY 490.20 000<br />
31237 NSL/SINUS NDSC SURG W/BX POLYPC/DBRDMT SPX 530.64 000<br />
31238 NSL/SINUS NDSC SURG W/CTRL NSL HEMRRG 546.15 000<br />
31239 NSL/SINUS NDSC SURG W/DACRYOCSTORHINOSTOMY 1102.26 010<br />
31240 NSL/SINUS NDSC SURG W/CONCHA BULLOSA RESCJ 267.53 000<br />
31254 NASAL/SINUS ENDOSCOPY W/ETHMOIDECTOMY PARTIAL 455.86 000<br />
31255 NASAL/SINUS ENDOSCOPY W/ETHMOIDECTOMY TOTAL 668.00 000<br />
31256 NASAL/SINUS ENDOSCOPY W/MAXILLARY ANTROSTOMY 329.57 000<br />
31267 NSL/SINUS NDSC MAX ANTROST W/RMVL TISS MAX SINUS 529.53 000<br />
31276 NSL/SINUS NDSC W/FRNT SINUS EXPL 843.04 000<br />
31287 NASAL/SINUS ENDOSCOPY W/SPHENOIDECTOMY 387.18 000<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 93
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
31288 NSL/SINUS NDSC SPHENDT RMVL TISS SPHENOID SINUS 449.77 000<br />
31290 NSL/SINUS NDSC RPR CEREBSP FLU LEAK ETHMOID 1919.26 010<br />
31291 NSL/SINUS NDSC RPR CEREBSP FLU LEAK SPHENOID 2035.03 010<br />
31292 NSL/SINUS NDSC SURG W/MEDIAL/INF ORB WALL DCMPRN 1651.73 010<br />
31293 NSL/SINUS NDSC MEDIAL ORB&INF ORB WALL DCMPRN 1799.62 010<br />
31294 NSL/SINUS NDSC SURG W/OPTIC NRV DCMPRN 2062.17 010<br />
l 31295 NSL/SINUS NDSC SURG W/DILAT MAXILLARY SINUS 3313.98 000<br />
l 31296 NSL/SINUS NDSC SURG W/DILAT FRONTAL SINUS 6204.79 000<br />
l 31297 NSL/SINUS NDSC SURG W/DILAT SPHENOID SINUS 6146.63 000<br />
31299 UNLISTED PROCEDURE ACCESSORY SINUSES BR YYY<br />
31300 LRYNGOT W/RMVL TUM/LARYNGOCELE CORDECTOMY 2066.05 090<br />
31320 LARYNGOTOMY THYROTOMY LARYNGOFISSURE DX 1064.60 090<br />
31360 LARGTOM TOT W/O RAD NCK DSJ 3364.39 090<br />
31365 LARGTOM TOT W/RAD NCK DSJ 4177.51 090<br />
31367 LARGTOM STOT SUPRAGLOTTIC W/O RAD NCK DSJ 3592.04 090<br />
31368 LARGTOM STOT SUPRAGLOTTIC W/RAD NCK DSJ 3989.19 090<br />
31370 PRTL LARGTOM HEMILARGTOM HRZNTL 3374.36 090<br />
31375 PRTL LARGTOM HEMILARGTOM LATER> 3199.33 090<br />
31380 PRTL LARGTOM HEMILARGTOM ANTER> 3151.14 090<br />
31382 PRTL LARGTOM HEMILARGTOM ANTERO-LATERO-VER 3458.00 090<br />
31390 PHARYNGOLARGTOM W/RAD NCK DSJ W/O RCNSTJ 4643.34 090<br />
31395 PHARYNGOLARGTOM W/RAD NCK DSJ W/RCNSTJ 4902.02 090<br />
31400 ARYTENOIDECTOMY/ARYTENOIDOPEXY XTRNL APPR 1637.88 090<br />
31420 EPIGLOTTIDECTOMY 1370.35 090<br />
* 31500 INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE 179.46 000<br />
31502 TRACHEOTOMY TUBE CHANGE PRIOR TO FISTULA TRACT 57.61 000<br />
31505 LARYNGOSCOPY INDIRECT DIAGNOSTIC SPX 135.15 000<br />
31510 LARYNGOSCOPY INDIRECT W/BIOPSY 345.08 000<br />
31511 LARYNGOSCOPY INDIRECT W/REMOVAL FOREIGN BODY 344.53 000<br />
31512 LARYNGOSCOPY INDIRECT W/REMOVAL LESION 341.20 000<br />
31513 LARYNGOSCOPY INDIRECT W/VOCAL CORD INJECTION 219.90 000<br />
31515 LARYNGOSCOPY +-TRACHEOSCOPY ASPIRATION 340.09 000<br />
31520 LARYNGOSCOPY +-TRACHEOSCOPY DIAGNOSTIC NEWBORN 259.23 000<br />
31525 LARYNGOSCOPY +-TRACHEOSCOPY DX EXCEPT NEWBORN 410.44 000<br />
31526 LARYNGOSCOPY +-TRACHEOSCOPY MICROSCOPE/TELESCOPE 263.66 000<br />
31527 LARYNGOSCOPY +-TRACHEOSCOPY INSERTION OBTURATOR 324.59 000<br />
31528 LARYNGOSCOPY +-TRACHEOSCOPY W/DILATION INITIAL 241.50 000<br />
31529 LARYNGOSCOPY +-TRACHEOSCOPY DILATION SUBSEQUENT 270.30 000<br />
31530 LARYNGOSCOPY W/FOREIGN BODY REMOVAL 330.68 000<br />
31531 LARYNGOSCOPY F BODY RMVL MICROSCOPE/TELESCOPE 355.60 000<br />
31535 LARYNGOSCOPY DIRECT OPERATIVE W/BIOPSY 317.38 000<br />
31536 LARYNGOSCOPY W/BIOPSY MICROSCOPE/TELESCOPE 353.94 000<br />
31540 LARGSC EXC TUM&/STRIPPING CORDS/EPIGL 406.56 000<br />
31541 LARGSC EXC TUM&/STRPG CORDS/EPIGL MCRSCP/TLSCP 444.23 000<br />
31545 LARGSC MCRSCP/TLSCP RMVL LES VOCAL C/D FLAP 607.63 000<br />
31546 LARGSC MCRSCP/TLSCP RMVL LES VOCAL C/D GRF 920.58 000<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
94 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
31560 LARYNGOSCOPY DIRECT OPERATIVE W/ARYTENOIDECTOMY 526.21 000<br />
31561 LARGSC ARYTENOIDECTOMY MICROSCOPE/TELESCOPE 575.50 000<br />
31570 LARYNGOSCOPE INJECTION VOCAL CORD THERAPEUTIC 563.32 000<br />
31571 LARGSC W/NJX VOCAL CORD THER W/MCRSCP/TLSCP 418.75 000<br />
31575 LARYNGOSCOPY FLEXIBLE FIBEROPTIC DIAGNOSTIC 187.77 000<br />
31576 LARYNGOSCOPY FLEXIBLE FIBEROPTIC W/BIOPSY 367.79 000<br />
31577 LARYNGOSCOPY FLX FIBEROPTIC RMVL FOREIGN BODY 397.15 000<br />
31578 LARYNGOSCOPY FLEXIBLE FIBEROPTIC REMOVAL LESION 460.84 000<br />
31579 LARYNGOSCOPY FLX/RGD FIBOPT W/STROBOSCOPY 352.83 XXX<br />
31580 LARYNGOPLASTY LARYN WEB 2 STG W/KEEL INSJ&RMVL 1988.50 090<br />
31582 LARYNGP LARYN STENOSIS GRF/CORE MOLD W/TRACHT 3120.12 090<br />
31584 LARYNGOPLASTY W/OPN RDCTJ FX 2478.15 090<br />
31587 LARYNGOPLASTY CRICOID SPLIT 1639.54 090<br />
31588 LARYNGOPLASTY NOT OTHERWISE SPECIFIED 1871.07 090<br />
31590 LARYNGEAL REINNERVATION NEUROMUSCULAR PEDICLE 1458.42 090<br />
31595 SECTION RECURRENT LARYNGEAL NERVE THER UNI SPX 1253.48 090<br />
31599 UNLISTED PROCEDURE LARYNX BR YYY<br />
31600 TRACHEOSTOMY PLANNED SPX 657.48 000<br />
31601 TRACHEOSTOMY PLANNED UNDER 2 YEARS SPX 433.15 000<br />
31603 TRACHEOSTOMY EMERGENCY PROCEDURE TRANSTRACHEAL 370.56 000<br />
31605 TRACHEOSTOMY EMERGENCY CRICOTHYROID MEMBRANE 302.43 000<br />
31610 TRACHEOSTOMY FENESTRATION W/SKIN FLAPS 1165.41 090<br />
31611 CONSTJ TRACHEOESOPHGL FSTL&INSJ SP PROSTH 879.59 090<br />
31612 TRACHEAL PNXR PRQ W/TRANSTRACHEAL ASPIR&/NJX 132.38 000<br />
31613 TRACHEOSTOMA REVJ SMPL W/O FLAP ROTATION 733.36 090<br />
31614 TRACHEOSTOMA REVJ CPLX W/FLAP ROTATION 1224.67 090<br />
K 31615 TRACHEOBRNCHSC THRU EST TRACHS INC 298.55 000<br />
+ K 31620 ENDOBRNCL US BRONCHOSCOPIC DX/THER IVNTJ 453.09 ZZZ<br />
K 31622 BRNCHSC INCL FLUOR GID DX W/CELL WASHG SPX 511.80 000<br />
K 31623 BRNCHSC BRUSHING/PROTECTED BRUSHINGS 548.91 000<br />
K 31624 BRNCHSC W/BRNCL ALVEOLAR LAVAGE 512.91 000<br />
K 31625 BRNCHSC BRNCL/ENDOBRNCL BX 1+ SITS 551.13 000<br />
K 31626 BRNCHSC W/PLMT FIDUCIAL MARKERS 1/MLT 721.73 000<br />
+ K 31627 BRNCHSC W/CPTR-ASST IMAGE-GUIDED NAVIGATION 2072.69 ZZZ<br />
K 31628 BRNCHSC W/TRANSBRNCL LUNG BX 1 LOBE 645.29 000<br />
K 31629 BRNCHSC NDL BX TRACHEA MAIN STEM&/BRONCHUSI 1003.11 000<br />
31630 BRNCHSC W/TRACHEAL/BRNCL DILAT/CLSD RDCTJ FX 335.11 000<br />
31631 BRNCHSC W/PLACEMENT TRACHEAL STENT 382.19 000<br />
+ 31632 BRNCHSC W/TRANSBRNCL LUNG BX EA LOBE 116.32 ZZZ<br />
+ 31633 BRNCHSC W/TRANSBRNCL NDL ASPIR BX EA LOBE 142.35 ZZZ<br />
l K 31634 BRONCHOSCOPY BALLOON OCCLUSION 2940.66 000<br />
K 31635 BRNCHSC W/REMOVAL FOREIGN BODY 565.53 000<br />
31636 BRNCHSC W/PLACEMENT BRNCL STENT 1ST BRONCHUS 370.01 000<br />
+ 31637 BRNCHSC EA MAJOR BRONCHUS STENTED 126.29 ZZZ<br />
31638 BRNCHSC REVJ TRACHEAL/BRNCL STENT INS PREV SESS 423.18 000<br />
31640 BRNCHSC W/EXCISION TUMOR 427.06 000<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 95
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
31641 BRNCHSC W/DSTRJ TUM RELIEF STENOSIS OTH/THN EXC 425.95 000<br />
31643 BRNCHSC W/PLMT CATH INTRCV RADIOELMNT APPL 286.92 000<br />
K 31645 BRNCHSC W/THER ASPIR TRACHEOBRNCL TREE 1ST 494.08 000<br />
K 31646 BRNCHSC W/THER ASPIR TRACHEOBRNCL TREE SBSQ 450.32 000<br />
K 31656 BRNCHSC W/NJX CONTRAST SGMTL BRONCHOG 500.73 000<br />
31715 TRANSTRACHEAL INJECTION BRONCHOGRAPHY 87.52 000<br />
31717 CATHETERIZATION W/BRONCHIAL BRUSH BIOPSY 465.28 000<br />
31720 CATHETER ASPIRATION NASOTRACHEAL SPX 84.19 000<br />
K 31725 CATH ASPIR TRACHEOBRNCL FIBERSCOPE BEDSIDE SPX 155.65 000<br />
31730 TTRACH INTRO NDL WIRE DIL/STENT/TUBE O2 THER 1659.48 000<br />
31750 TRACHEOPLASTY CERVICAL 2228.89 090<br />
31755 TRACHEOPLASTY TRACHEOPHARYNGEAL FSTLJ EA STG 2816.58 090<br />
31760 TRACHEOPLASTY INTRATHORACIC 2309.76 090<br />
31766 CARINAL RECONSTRUCTION 2992.17 090<br />
31770 BRONCHOPLASTY GRAFT REPAIR 2239.97 090<br />
31775 BRONCHOPLASTY EXCISION STENOSIS & ANASTOMOSIS 2293.70 090<br />
31780 EXCISION TRACHEAL STENOSIS&ANASTOMOSIS CERVICAL 1980.75 090<br />
31781 EXC TRACHEAL STENOSIS&ANAST CERVICOTHORACIC 2369.58 090<br />
31785 EXCISION TRACHEAL TUMOR/CARCINOMA CERVICAL 1788.54 090<br />
31786 EXCISION TRACHEAL TUMOR/CARCINOMA THORACIC 2457.10 090<br />
31800 SUTURE TRACHEAL WOUND/INJURY CERVICAL 1144.91 090<br />
31805 SUTURE TRACHEAL WOUND/INJURY INTRATHORACIC 1369.79 090<br />
31820 SURG CLSR TRACHS/FSTL W/O PLSTC RPR 708.99 090<br />
31825 SURG CLSR TRACHS/FSTL W/PLSTC RPR 986.50 090<br />
31830 REVISION TRACHEOSTOMY SCAR 716.19 090<br />
31899 UNLISTED PROCEDURE TRACHEA BRONCHI BR YYY<br />
32035 THORACOSTOMY W/RIB RESECTION EMPYEMA 1198.64 090<br />
32036 THORACOSTOMY OPEN FLAP DRAINAGE EMPYEMA 1295.02 090<br />
32095 THORACOTOMY LIMITED BIOPSY LUNG/PLEURA 1055.18 090<br />
32100 THORACOTOMY WITH EXPLORATION 1606.86 090<br />
32110 THORCOM MAJOR CTRL TRAUMTC HEMRRG&/RPR LNG TEAR 2441.04 090<br />
32120 THORACOTOMY MAJOR POSTOPERATIVE COMPLICATIONS 1465.62 090<br />
32124 THORACOTOMY MAJOR OPN INTRAPLEURAL PNEUMONOLYSIS 1555.91 090<br />
32140 THORCOM W/ REMOVAL OF CYST 1658.38 090<br />
32141 THORACOTOMY W/EXCISION BULLAE 2563.45 090<br />
32150 THORCOM MAJOR W/RMVL INTRAPLEURAL FB/FIBRIN DEP 1676.10 090<br />
32151 THORCOM MAJOR W/RMVL IPUL FB 1695.49 090<br />
32160 THORACOTOMY MAJOR W/CARDIAC MASSAGE 1298.90 090<br />
32200 PNEUMONOSTOMY W/OPEN DRAINAGE ABSCESS/CYST 1894.34 090<br />
K 32201 PNEUMONOSTOMY PERCUTANEOUS DRAINAGE ABSCESS/CYST 1506.61 000<br />
32215 PLEURAL SCARIFICATION REPEAT PNEUMOTHORAX 1341.55 090<br />
32220 DECORTICATION PULMONARY TOTAL SPX 2674.78 090<br />
32225 DECORTICATION PULMONARY PARTIAL SPX 1671.67 090<br />
32310 PLEURECTOMY PARIETAL SPX 1538.18 090<br />
32320 DECORTICATION & PARIETAL PLEURECTOMY 2684.75 090<br />
32400 BIOPSY PLEURA PERCUTANEOUS NEEDLE 244.82 000<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
96 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
32402 BIOPSY PLEURA OPEN 946.62 090<br />
32405 BIOPSY LUNG/MEDIASTINUM PERCUTANEOUS NEEDLE 161.74 000<br />
32420 PNEUMOCENTESIS PUNCTURE LUNG ASPIRATION 182.23 000<br />
32421 THORACENTESIS PUNCTURE PLEURAL CAVITY ASPIRATION 253.13 000<br />
32422 THORACENTESIS WITH INSERTION TUBE WATER SEAL 320.71 000<br />
32440 REMOVAL OF LUNG 2650.41 090<br />
32442 REMOVAL LUNG PNEUMONECTOMY EXTRAPLEURAL 4620.63 090<br />
32445 REMOVAL LUNG TOTAL PNEUMONECTOMY EXTRAPLEURAL 5874.11 090<br />
32480 RMVL LNG OTH/THN PNUMEC 1 LOBE LOBEC 2507.51 090<br />
32482 RMVL LNG OTH/THN PNUMEC 2 LOBES BILOBEC 2680.32 090<br />
32484 RMVL LNG OTH/THN PNUMEC 1 SGM SGMECTOMY 2430.51 090<br />
32486 RMVL LNG XCP PNUMEC SLEEVE LOBECTOMY 3965.37 090<br />
32488 RMVL LNG OTH/THN PNUMEC COMPLETION PNUMEC 4022.42 090<br />
32491 RMVL LNG OTH/THN PNUMEC EXC-PLCTJ EMPHY LNG 2498.64 090<br />
32500 RMVL LNG OTH/THN TOT PNUMEC WEDGE RESCJ 1/MLT 2431.07 090<br />
+ 32501 RESCJ&BRONCHOPLASTY PFRMD TM LOBEC/SGMECTOMY 417.09 ZZZ<br />
32503 RESCJ APICAL LNG TUM W/O CH WALL RCNSTJ 3055.87 090<br />
32504 RESCJ APICAL LNG TUM W/CH WALL RCNSTJ 3474.61 090<br />
32540 EXTRAPLEURAL ENUCLEATION EMPYEMA EMPYEMECTOMY 2886.37 090<br />
K 32550 INSERTION INDWELLING TUNNELED PLEURAL CATHETER 1298.34 000<br />
K 32551 TUBE THORACOSTOMY INCLUDES WATER SEAL 285.26 000<br />
32552 RMVL NDWELLG TUN PLEURAL CATH W/CUFF 307.41 010<br />
K 32553 PLMT NTRSTL DEV RADJ THX GID PRQ INTRATHRC 1/MLT 1010.87 000<br />
32560 INSTLJ VIA CHEST TUBE/CATH AGENT FOR PLEURODESIS 424.84 000<br />
32561 INSTLJ VIA CH TUBE/CATH AGENT FBRNLYSIS 1ST DAY 157.31 000<br />
32562 INSTLJ CH TUBE/CATH AGENT FBRNLYSIS SBSQ DAY 140.69 000<br />
32601 THORSC DX LUNGS/PLEURAL SPACE/MED/PERICAR W/O BX 521.22 000<br />
32602 THORACOSCOPY DX LUNGS&PLEURAL SPACE W/BX SPX 564.42 000<br />
32603 THORACOSCOPY DX PERICARDIAL SAC W/O BIOPSY SPX 736.69 000<br />
32604 THORACOSCOPY DX PERICARDIAL SAC W/BIOPSY SPX 817.56 000<br />
32605 THORACOSCOPY DX MEDIASTINAL SPACE W/O BIOPSY SPX 649.72 000<br />
32606 THORACOSCOPY DX MEDIASTINAL SPACE W/BIOPSY SPX 783.21 000<br />
32650 THORACOSCOPY W/PLEURODESIS 1121.65 090<br />
32651 THORACOSCOPY W/PARTIAL PULMONARY DECORTICATION 1824.55 090<br />
32652 THRSC TOT PULM DCRTCTJ INTRAPLEURAL PNEUMONOLSS 2770.61 090<br />
32653 THORACOSCOPY RMVL INTRAPLEURAL FB/FIBRIN DEPOSIT 1758.08 090<br />
32654 THORACOSCOPY CONTROL TRAUMATIC HEMORRHAGE 1963.02 090<br />
32655 THORACOSCOPY W/EXCISION BULLAE 1599.66 090<br />
32656 THORACOSCOPY W/PARIETAL PLEURECTOMY 1342.65 090<br />
32657 THRSC W/WEDGE RESCJ LNG 1/MLT 1324.93 090<br />
32658 THRSC W/RMVL CLOT/FB FROM PRCRD SAC 1206.39 090<br />
32659 THRSC CRTJ PRCRD WINDOW/PRTL RESCJ PRCRD SAC 1236.30 090<br />
32660 THORACOSCOPY W/TOTAL PERICARDIECTOMY 1766.39 090<br />
32661 THRSC W/EXC PRCRD CST TUM/MASS 1348.19 090<br />
32662 THRSC W/EXC MEDSTNL CST TUM/MASS 1511.04 090<br />
32663 THORACOSCOPY W/LOBECTOMY TOTAL/SGMTL 2360.72 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 97
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
32664 THORACOSCOPY W/THORACIC SYMPATHECTOMY 1426.85 090<br />
32665 THORACOSCOPY W/ESOPHAGOMYOTOMY HELLER TYPE 2040.01 090<br />
32800 REPAIR LUNG HERNIA THROUGH CHEST WALL 1573.63 090<br />
32810 CLSR CH WALL FLWG OPN FLAP DRG EMPYEMA 1512.70 090<br />
32815 OPEN CLOSURE MAJOR BRONCHIAL FISTULA 4667.72 090<br />
32820 MAJOR RECONSTRUCTION CHEST WALL POSTTRAUMATIC 2252.16 090<br />
32850 DONOR PNEUMONECTOMY FROM CADAVER DONOR BR XXX<br />
32851 LUNG TRANSPLANT 1 W/O CARDIOPULMONARY BYPASS 4355.87 090<br />
32852 LUNG TRANSPLANT 1 W/CARDIOPULMONARY BYPASS 4819.48 090<br />
32853 LUNG TRANSPLANT 2 W/O CARDIOPULMONARY BYPASS 5180.63 090<br />
32854 LUNG TRANSPLANT 2 W/CARDIOPULMONARY BYPASS 5667.50 090<br />
32855 BKBENCH STANDARD PREPJ CDVR DON LNG ALGRFT UNI BR XXX<br />
32856 BKBENCH STANDARD PREPJ CDVR DON LNG ALGRFT BI BR XXX<br />
32900 RESECTION RIBS EXTRAPLEURAL ALL STAGES 2325.83 090<br />
32905 THORACOPLASTY SCHEDE TYPE/EXTRAPLEURAL 2249.94 090<br />
32906 THORACOP SCHEDE TYP/XTRPLEURAL CLSR BRNCPLR FSTL 2786.67 090<br />
32940 PNEUMONOLSS XTRPRIOSTEAL W/FILLING/PACKING PX 2073.80 090<br />
32960 PNEUMOTHORAX THER INTRAPLEURAL NJX AIR 230.98 000<br />
32997 TOTAL LUNG LAVAGE UNILATERAL 585.47 000<br />
32998 ABLATION PULMONARY TUMOR PERQ RF UNI 4707.60 000<br />
32999 UNLISTED PROCEDURE LUNGS & PLEURA BR YYY<br />
K 33010 PERICARDIOCENTESIS INITIAL 206.05 000<br />
K 33011 PERICARDIOCENTESIS SUBSEQUENT 206.05 000<br />
33015 TUBE PERICARDIOSTOMY 875.72 090<br />
33020 PERICARDIOTOMY REMOVAL CLOT/FOREIGN BODY PRIMARY 1478.91 090<br />
33025 CRTJ PERICARDIAL WINDOW/PRTL RESECJ W/DRG/BX 1353.73 090<br />
33030 PRICARDIECTOMY STOT/COMPL W/O CARD BYP 2180.70 090<br />
33031 PRICARDIECTOMY STOT/COMPL W/CARD BYP 2428.30 090<br />
33050 RESECJ PERICARDIAL CYST/TUMOR 1691.61 090<br />
33120 EXC INTRACARDIAC TUMOR RESCJ CARDIOPULMONARY BYP 2639.33 090<br />
33130 RESECTION EXTERNAL CARDIAC TUMOR 2350.20 090<br />
33140 TRANSMYOCRD LASER REVSC THORCOM SPX 2703.59 090<br />
+ 33141 TRANSMYOCRD LASER REVSC PFRMD TM OTH OPN CAR PX 234.85 ZZZ<br />
33202 INSERTION EPICARDIAL ELECTRODE OPEN 1316.07 090<br />
33203 INSERTION EPICARDIAL ELECTRODE ENDOSCOPIC 1380.87 090<br />
K 33206 INSJ/RPLCMT PRM PM W/TRANSVNS ELTRD ATR 787.09 090<br />
K 33207 INSJ/RPLCMT PRM PM W/TRANSVNS ELTRD VENTR 838.60 090<br />
K 33208 INSJ/RPLCMT PRM PM W/TRANSVNS ELTRD ATR&VENTR 905.63 090<br />
K 33210 INSJ/RPLCMT TEMP TRANSVNS 1CHMBR ELTRD/PM CATH 310.74 000<br />
K 33211 INSJ/RPLCMT TEMP TRANSVNS 2CHMBR PACG ELTRDS SPX 315.72 000<br />
K 33212 INSJ/RPLCMT PM PLS GEN ONLY 1CHMBR ATR/VENTR 583.26 090<br />
K 33213 INSJ/RPLCMT PM PLS GEN ONLY 2CHMBR 665.23 090<br />
K 33214 UPG PM SYS CONV 1CHMBR SYS 2CHMBR SYS 830.30 090<br />
33215 RPSG PREV IMPLTED PM/CVDFB R ATR/R VENTR ELTRD 526.76 090<br />
K 33216 INSJ 1 TRANSVNS ELTRD PERM PACEMAKER OR CVDFB 650.28 090<br />
K 33217 INSJ 2 TRANSVNS ELTRD PERM PACEMAKER OR CVDFB 646.40 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
98 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
K 33218 RPR 1 ELTRD 1CHMBR PRM PM/1CHMBR CVDFB 677.97 090<br />
K 33220 RPR 2 ELTRDS 2 CHMBR PRM PM/2CHMBR CVDFB 683.51 090<br />
K 33222 REVISION/RELOCATION SKIN POCKET PACEMAKER 596.55 090<br />
K 33223 REVJ SKN POCKET FOR CARDIOVERTER-DEFIBRILLATOR 716.19 090<br />
33224 INSJ ELTRD CAR VEN SYS ATTCH PM/CVDFB PLS GEN 877.38 000<br />
+ 33225 INSJ ELTRD CAR VEN SYS TM INSJ CVDFB/PM PLS GEN 790.97 ZZZ<br />
33226 RPSG PREV IMPLTED CAR VEN SYS L VENTR ELTRD 844.70 000<br />
K 33233 REMOVAL PERMANENT PACEMAKER PULSE GENERATOR 412.10 090<br />
K 33234 RMVL TRANSVNS PM ELTRD 1 LEAD SYS ATR/VENTR 840.27 090<br />
K 33235 RMVL TRANSVNS PM ELTRD DUAL LEAD SYS 1096.72 090<br />
33236 RMVL PRM EPICAR PM&ELTRDS THORCOM 1 LEAD SYS 1332.68 090<br />
33237 RMVL PRM EPICAR PM&ELTRDS THORCOM DUAL LEAD SYS 1427.40 090<br />
33238 RMVL PRM TRANSVNS ELTRD THORCOM 1587.48 090<br />
K 33240 INSJ 1/2CHMBR PACG CVDFB PLS GEN 800.39 090<br />
K 33241 SUBQ RMVL 1/2CHMBR PACG CVDFB PLS GEN 388.28 090<br />
33243 RMVL 1/2CHMBR PACG CVDFB ELTRD THORCOM 2334.69 090<br />
K 33244 RMVL 1/2CHMBR PACG CVDFB ELTRD TRANSVNS XTRJ 1476.70 090<br />
K 33249 INSJ/RPSG LEAD 1/2CHMBR CVDFB&INSJ PLS GEN 1569.20 090<br />
33250 ABLTJ ARRHYTGNIC FOC/PTHWY TRC&/FOC 2507.51 090<br />
33251 ABLTJ ARRHYTGNIC FOC/PTHWY TRC&/FOC CARD BYP 2780.58 090<br />
33254 ABLATION & RCNSTJ ATRIA LMTD 2330.81 090<br />
33255 ABLATION & RCNSTJ ATRIA X10SV W/O BYPASS 2828.21 090<br />
33256 ABLATION & RCNSTJ ATRIA X10SV W/BYPASS 3361.62 090<br />
+ 33257 ATRIA ABLATE & RCNSTJ W OTHER PROCEDURE LIMITED 993.70 ZZZ<br />
+ 33258 ATRIA ABLTJ &RCNSTJ W OTHER PX EXTENSIVE W/O BYP 1117.77 ZZZ<br />
+ 33259 ATRIA ABLATE &RCNSTJ W OTHER PX EXTENSIVE W BYP 1443.46 ZZZ<br />
33261 OPRATIVE ABLTJ VENTR ARRHYTGNIC FOC W/CARD BYP 2769.50 090<br />
33265 NDSC ABLATION & RCNSTJ ATRIA LMTD W/O BYPASS 2303.12 090<br />
33266 NDSC ABLATION & RCNSTJ ATRIA X10SV W/O BYPASS 3148.92 090<br />
33282 IMPLANTATION PT-ACTIVATED CARDIAC EVENT RECORDER 558.89 090<br />
33284 RMVL IMPLANTABLE PT-ACTIVATED CAR EVENT RECORDER 402.13 090<br />
33300 REPAIR CARDIAC WOUND W/O BYPASS 4112.15 090<br />
33305 REPAIR CARDIAC WOUND W/CARDIOPULMONARY BYPASS 6915.44 090<br />
33310 CARDIOT EXPL W/RMVL FB ATR/VENTR THRMB W/O BYP 1969.67 090<br />
33315 CARDIOT EXPL RMVL FB ATR/VENTR THRMB CARD BYP 2525.78 090<br />
33320 SUTR RPR AORTA/GRT VSL W/O SHUNT/CARD BYP 1806.82 090<br />
33321 SUTR RPR AORTA/GRT VSL W/SHUNT BYP 2019.52 090<br />
33322 SUTR RPR AORTA/GRT VSL W/CARD BYP 2374.02 090<br />
33330 INSJ GRF AORTA/GRT VSL W/O SHUNT/CARD BYP 2428.30 090<br />
33332 INSJ GRF AORTA/GRT VSL W/SHUNT BYP 2382.32 090<br />
33335 INSJ GRF AORTA/GRT VSL W/CARD BYP 3215.39 090<br />
33400 VLVP AORTIC VALVE OPN W/CARD BYP 3905.55 090<br />
33401 VLVP AORTIC VALVE OPN W/INFL OCCLUSION 2445.47 090<br />
33403 VLVP AORTIC VALVE W/TRANSVENTR DILAT W/CARD BYP 2555.69 090<br />
33404 CONSTRUCTION APICAL-AORTIC CONDUIT 3001.58 090<br />
33405 RPLCMT A-VALVE PROSTC XCP HOMOGRF/STENT< VALVE 3926.60 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 99
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
33406 RPLCMT A-VALVE ALGRFT VALVE FRHAND 4919.19 090<br />
33410 RPLCMT A-VALVE STENT< TISS VALVE 4353.65 090<br />
s 33411 RPLCMT AORTIC VALVE ANNULUS ENLGMENT NONC SINUS 5731.20 090<br />
33412 RPLCMT A-VALVE KONNO PROCEDURE 4221.83 090<br />
33413 RPLCMT A-VALVE ROSS PX 5531.80 090<br />
33414 RPR VENTR O/F TRC OBSTRCJ PATCH ENLGMENT O/F TRC 3711.68 090<br />
33415 RESCJ/INC SUBVALVULAR TISSUE 3443.04 090<br />
33416 VENTRICULOMYOTOMY-MYECTOMY 3465.75 090<br />
33417 AORTOPLASTY SUPRAVALVULAR STENOSIS 2852.59 090<br />
33420 VALVOTOMY MITRAL VALVE CLOSED HEART 2380.11 090<br />
33422 VALVOTOMY MITRAL VALVE OPN HRT W/CARD BYP 2885.82 090<br />
33425 VLVP MITRAL VALVE W/CARD BYP 4629.50 090<br />
33426 VLVP MITRAL VALVE W/CARD BYP W/PROSTC RING 4092.77 090<br />
33427 VLVP MITRAL VALVE W/CARD BYP RAD RCNSTJ +-RING 4213.52 090<br />
33430 REPLACEMENT MITRAL VALVE W/CARDIOPULMONARY BYP 4792.90 090<br />
33460 VALVECTOMY TRICUSPID VALVE W/CARDIOPULMONARY BYP 4121.57 090<br />
33463 VALVULOPLASTY TRICUSPID VALVE W/O RING INSERTION 5243.22 090<br />
33464 VALVULOPLASTY TRICUSPID VALVE W/RING INSERTION 4166.44 090<br />
33465 REPLACEMENT TRICUSPID VALVE W/CARD BYPASS 4683.22 090<br />
33468 TRICUSPID VALVE RPSG&PLCTJ EBSTEIN ANOMALY 3188.80 090<br />
33470 VALVOTOMY PULMONARY VALVE CLSD HEART TRANSVENTR 2143.59 090<br />
33471 VALVOTOMY PULM VALVE CLSD HRT VIA P-ART 2067.71 090<br />
33472 VALVOTOMY PULM VALVE OPN HRT W/INFL OCCLUSION 2023.40 090<br />
33474 VALVOTOMY PULM VALVE OPN HRT W/CARD BYP 3618.63 090<br />
33475 REPLACEMENT PULMONARY VALVE 3994.73 090<br />
33476 R VENTR RESCJ INFUND STEN +-COMMISSUROTOMY 2577.30 090<br />
33478 O/F TRC AGMNTJ +-COMMISSUROTOMY/INFUND RESCJ 2683.65 090<br />
33496 RPR NON-STRUCTURAL PROSTC VALVE DYSF CARD BYP 2849.26 090<br />
33500 RPR C ARVEN/ARTERIOCAR CHAMBER FSTL W/CARD BYP 2694.72 090<br />
33501 RPR C ARVEN/ARTERIOCAR CHAMBER FSTL W/O CARD BYP 1911.51 090<br />
33502 RPR ANOM C ART FROM P-ART ORIGIN LIG 2170.73 090<br />
33503 RPR ANOM C ART FROM P-ART ORIGIN GRF 2267.11 090<br />
33504 RPR ANOM C ART FROM P-ART ORIGIN GRF W/CARD BYP 2487.56 090<br />
33505 RPR ANOM C ART W/CONSTJ INTRAP-ART TUNNEL 3525.57 090<br />
33506 RPR ANOM C ART FROM P-ART TO AORTA 3696.17 090<br />
33507 RPR ANOM AORTIC ORIGIN C ART UNROOFING/TLCJ 2936.22 090<br />
+ 33508 NDSC SURG W/VID-ASSTD HARVEST VEIN CAB 27.70 ZZZ<br />
33510 CORONARY ARTERY BYPASS 1 CORONARY VENOUS GRAFT 3343.34 090<br />
33511 CORONARY ARTERY BYPASS 2 CORONARY VENOUS GRAFTS 3662.94 090<br />
33512 CORONARY ARTERY BYPASS 3 CORONARY VENOUS GRAFTS 4154.80 090<br />
33513 CORONARY ARTERY BYPASS 4 CORONARY VENOUS GRAFTS 4257.83 090<br />
33514 CORONARY ARTERY BYPASS 5 CORONARY VENOUS GRAFTS 4507.08 090<br />
33516 CORONARY ARTERY BYPASS 6/+ CORONARY VENOUS GRAFT 4697.63 090<br />
+ 33517 CORONARY ARTERY BYP W VEIN &ARTERY GRAFT 1 VEIN 321.26 ZZZ<br />
+ 33518 CORONARY ARTERY BYP W VEIN &ARTERY GRAFT 2 VEIN 704.56 ZZZ<br />
+ 33519 CORONARY ARTERY BYP W VEIN &ARTERY GRAFT 3 VEIN 933.88 ZZZ<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
100 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
+ 33521 CORONARY ARTERY BYP W VEIN &ARTERY GRAFT 4 VEIN 1124.97 ZZZ<br />
+ 33522 CORONARY ARTERY BYP W VEIN &ARTERY GRAFT 5 VEIN 1266.77 ZZZ<br />
+ 33523 CORONARY ARTERY BYP W VEIN &ARTERY GRAFT 6 VEIN 1437.92 ZZZ<br />
+ 33530 ROPRTJ CAB/VALVE PX > 1 MO AFTER ORIGINAL OPERJ 897.32 ZZZ<br />
33533 CAB W/ARTL GRF 1 ARTL GRF 3234.78 090<br />
33534 CAB W/ARTL GRF 2 C ARTL GRFS 3795.32 090<br />
33535 CAB W/ARTL GRF 3 C ARTL GRFS 4227.36 090<br />
33536 CAB W/ARTL GRF 4/> C ARTL GRFS 4546.97 090<br />
33542 MYOCARDIAL RESECTION 4468.87 090<br />
33545 RPR POSTINFRCJ VENTR SEPTAL DFCT 5252.08 090<br />
33548 SURG VENTR RSTRJ PX W/PROSTC PATCH PFRMD 5096.43 090<br />
+ 33572 C ENDARTERCOMY OPN ANY METH 399.36 ZZZ<br />
33600 CLSR ATRIOVENTRICULAR VALVE SUTURE/PATCH 2899.67 090<br />
33602 CLSR SEMILUNAR VALVE AORTIC/PULM SUTR/PATCH 2763.96 090<br />
33606 ANAST P-ART AORTA DAMUS-KAYE-STANSEL PX 3030.39 090<br />
33608 RPR CAR ANOMAL XCP PULM ATRESIA VENTR SEPTL DFCT 3064.17 090<br />
33610 RPR CAR ANOMAL SURG ENLGMENT VENTR SEPTL DFCT 3002.69 090<br />
33611 RPR 2 OUTLET R VNTRC W/INTRAVENTR TUNNEL RPR 3351.65 090<br />
33612 RPR 2 OUTLET R VNTRC RPR R VENTR O/F TRC OBSTRCJ 3363.83 090<br />
33615 RPR CAR ANOMAL CLSR SEPTL DFCT SMPL FONTAN PX 3409.81 090<br />
33617 RPR CPLX CAR ANOMAL MODF FONTAN PX 3654.63 090<br />
33619 RPR 1 VNTRC W/O/F OBSTRCJ&AORTIC ARCH HYPOPLASIA 4642.24 090<br />
l 33620 APPLICATION RIGHT & LEFT PULMONARY ARTERY BANDS 2819.35 090<br />
l 33621 TTHRC CATHETER INSERT FOR STENT PLACEMENT 1513.81 090<br />
l 33622 RECONSTRUCTION COMPLEX CARDIAC ANOMALY 5936.70 090<br />
33641 RPR ATR SEPTAL DFCT SECUNDUM W/CARD BYP +-PATCH 2791.66 090<br />
33645 DIR/PATCH CLSR SINUS VENOSUS +-ANOM PULM VEN DRG 2705.80 090<br />
33647 RPR ATR&VENTR SEPTAL DFCT DIR/PATCH CLSR 2892.47 090<br />
33660 RPR INCOMPL/PRTL AV CANAL +-AV VALVE RPR 3176.62 090<br />
33665 RPR INTRM/TRANSJ AV CANAL +-AV VALVE RPR 3286.84 090<br />
33670 RPR COMPL AV CANAL +-PROSTC VALVE 3392.64 090<br />
33675 CLOSURE MULTIPLE VENTRICULAR SEPTAL DEFECTS 3374.91 090<br />
33676 CLOSURE MULTIPLE VSD W/RESECTION 3196.00 090<br />
33677 CLOSURE MULTIPLE VSD W/REMOVAL ARTERY BAND 3155.57 090<br />
33681 CLSR 1 VENTR SEPTAL DFCT +- PATCH 3135.07 090<br />
33684 CLSR V-SEPTL DFCT W/PULM VLVT/INFUND RESCJ 3242.53 090<br />
33688 CLSR V-SEPTL DFCT W/RMVL P-ART BAND +-GUSSET 3213.17 090<br />
33690 BANDING PULMONARY ARTERY 2072.14 090<br />
33692 COMPL RPR TETRALOGY FALLOT W/O PULM ATRESIA 2751.22 090<br />
33694 COMPL RPR T-FALLOT W/O PULM ATRESIA TANULR PATCH 3359.40 090<br />
33697 COMPL RPR T-FALLOT W/PULM ATRESIA 3561.02 090<br />
33702 RPR SINUS VALSALVA FISTULA 2634.90 090<br />
33710 RPR SINUS VALSALVA FSTL W/RPR V-SEPTL DFCT 3022.08 090<br />
33720 RPR SINUS VALSALVA ANEURYSM 2622.72 090<br />
33722 CLOSURE AORTICO-LEFT VENTRICULAR TUNNEL 2826.55 090<br />
33724 REPAIR ISOLATED PARTIAL PULM VENOUS RETURN 2634.90 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 101
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
33726 REPAIR PULMONARY VENOUS STENOSIS 3597.03 090<br />
33730 COMPL RPR ANOM VEN RETURN 3385.44 090<br />
33732 RPR C TRIATM/SUPVALVR RING RESCJ L ATR MEMB 2818.24 090<br />
33735 ATR SEPTECT/SEPTOST CLSD HRT 2198.43 090<br />
33736 ATR SEPTECT/SEPTOST OPN HRT W/CARD BYP 2395.62 090<br />
33737 ATR SEPTECT/SEPTOST OPN HRT W/INFL OCCLUSION 2195.11 090<br />
33750 SHUNT SUBCLA P-ART 2342.44 090<br />
33755 SHUNT ASCENDING AORTA P-ART 2187.91 090<br />
33762 SHUNT DESCENDING AORTA P-ART 2016.20 090<br />
33764 SHUNT CTR W/PROSTC GRF 2202.86 090<br />
33766 SHUNT SUPRIOR V/C P-ART FLO 1 LNG 2284.84 090<br />
33767 SHUNT SUPRIOR V/C P-ART FLO BTH LNGS 2419.44 090<br />
+ 33768 ANAST CAVOPULM 2ND SUPRIOR V/C 662.46 ZZZ<br />
33770 RPR TGA W/O SURG ENLGMNT V-SEPTL DFCT 3600.90 090<br />
33771 RPR TGA ENLGMNT V-SEPTL DFCT 3430.86 090<br />
33774 RPR TGA ATR BAFFLE W/CARD BYP 3076.91 090<br />
33775 RPR TGA ATR BAFFLE W/RMVL PULM BAND 2922.93 090<br />
33776 RPR TGA ATR BAFFLE W/CLSR V-SEPTL DFCT 3086.88 090<br />
33777 RPR TGA ATR BAFFLE RPR SBPULMC OBSTRCJ 2846.49 090<br />
33778 RPR TGA AORTIC P-ART RCNSTJ 3707.81 090<br />
33779 RPR TGA AORTIC P-ART RCNSTJ W/RMVL PULM BAND 3677.90 090<br />
33780 RPR TGA AORTIC P-ART RCNSTJ W/CLSR V-SEPTL DFCT 3772.06 090<br />
33781 RPR TGA AORTIC P-ART RCNSTJ RPR SBPULMC OBSTRCJ 3645.77 090<br />
33782 A-ROOT TLCJ VSD PULM STNS RPR W/O C OST RIMPLTJ 5438.19 090<br />
33783 A-ROOT TLCJ VSD PULM STNS RPR W/ RIMPLTJ C OSTIA 5877.43 090<br />
33786 TOTAL REPAIR TRUNCUS ARTERIOSUS 3496.22 090<br />
33788 REIMPLANTATION ANOMALOUS PULMONARY ARTERY 2360.17 090<br />
33800 AORTIC SSP TRACHEAL DCMPRN SPX 1671.67 090<br />
33802 DIVISION ABERRANT VESSEL VASCULAR RING 1882.15 090<br />
33803 DIVISION ABERRANT VESSEL W/REANASTOMOSIS 1948.07 090<br />
33813 OBLTRJ AORTOPULM SEPTAL DFCT W/O CARD BYP 2181.81 090<br />
33814 OBLTRJ AORTOPULM SEPTAL DFCT W/CARD BYP 2599.45 090<br />
33820 REPAIR PATENT DUCTUS ARTERIOSUS LIGATION 1663.36 090<br />
33822 RPR PATENT DUXUS ARTERIOSUS DIV UNDER 18 YR 1608.53 090<br />
33824 RPR PATENT DUXUS ARTERIOSUS DIV 18 YR&OLDER 2023.40 090<br />
33840 EXC COARCJ AORTA +-PDA W/DIR ANAST 2148.02 090<br />
33845 EXC COARCTATION AORTA +-PDA W/GRF 2308.66 090<br />
33851 EXC COARCJ AORTA W/L SUBCLA ART/PROSTC AS GUSSET 2357.95 090<br />
33852 RPR HYPOPLSTC A-ARCH W/AGRFT/PROSTC 2377.34 090<br />
33853 RPR HYPOPLSTC A-ARCH AGRFT/PROSTC CARD BYP 3177.17 090<br />
s 33860 ASCENDING AORTA GRF W/CARD BYP & VALVE SSP 5470.87 090<br />
s 33863 AS-AORT GRF W/CARD BYP & AORTIC ROOT RPLCMT 5394.43 090<br />
s 33864 ASCENDING AORTA GRF VALVE SPARE ROOT REMODEL 5522.38 090<br />
33870 TRANSVERSE ARCH GRAFT W/CARDIOPULMONARY BYPASS 4316.54 090<br />
33875 DESCENDING THORACIC AORTA GRAFT +-BYPASS 3401.50 090<br />
33877 RPR THORACOAAA W/GRF +-CARD BYP 6179.31 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
102 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
33880 EVASC RPR DTA COVERAGE ART ORIGIN 1ST ENDOPROSTH 3136.18 090<br />
33881 EVASC RPR DTA EXP COVERAGE W/O ART ORIGIN 2698.05 090<br />
33883 PLMT PROX XTN PROSTH EVASC RPR DTA 1ST XTN 1955.82 090<br />
+ 33884 PLMT PROX XTN PROSTH EVASC RPR DTA EA PROX XTN 712.87 ZZZ<br />
33886 PLMT DSTL XTN PROSTH DLYD AFTER EVASC RPR DTA 1697.70 090<br />
33889 OPN SUBCLA CRTD ART TRPOS NCK INC ULAT 1395.27 000<br />
33891 BYP GRF W/DTA RPR NCK INC 1723.18 000<br />
33910 PULMONARY ARTERY EMBOLECTOMY W/CARD BYPASS 2864.77 090<br />
33915 PULMONARY ARTERY EMBOLECTOMY W/O CARD BYPASS 2314.75 090<br />
33916 PULM ENDARTERCOMY +-EMBOLECTOMY W/CARD BYP 2794.43 090<br />
33917 RPR P-ART STENOSIS RCNSTJ W/PATCH/GRF 2510.27 090<br />
33920 RPR PULM ATRESIA W/CONSTJ/RPLCMT CONDUIT 3105.72 090<br />
33922 TRANSECTION PULMONARY ARTERY W/CARD BYPASS 2365.15 090<br />
+ 33924 LIG&TKDN SYSIC-TO-P-ART SHUNT W/CGEN HRT PX 485.22 ZZZ<br />
33925 RPR P-ART ARBORIZJ ANOMAL UNIFCLIZJ W/O CARD BYP 2947.86 090<br />
33926 RPR P-ART ARBORIZJ ANOMAL UNIFCLIZJ W/CARD BYP 4309.90 090<br />
33930 DONOR CARDIECTOMY-PNEUMONECTOMY BR XXX<br />
33933 BKBENCH PREPJ CDVR DON HRT/LNG ALGRFT BR XXX<br />
33935 HRT-LNG TRNSPL W/RCP CARDIECTOMY-PNUMEC 5912.88 090<br />
33940 DONOR CARDIECTOMY BR XXX<br />
33944 BKBENCH STANDARD PREPJ CDVR DON HRT ALGRFT BR XXX<br />
33945 HEART TRANSPLANT +-RECIPIENT CARDIECTOMY 8189.97 090<br />
33960 PROLNG XTRCORP CRCJ 1ST 24 HR 1674.44 000<br />
+ 33961 PROLNG XTRCORP CRCJ EA 24 HR 925.01 ZZZ<br />
33967 INSERTION INTRA-AORTIC BALLOON ASSIST DEV PRQ 457.52 000<br />
33968 REMOVAL INTRA-AORTIC BALLOON ASSIST DEVICE PRQ 58.71 000<br />
33970 INSJ I-AORT BALO ASSIST DEV THRU FEM ART OPN 617.60 000<br />
33971 RMVL I-AORT BALO ASSIST DEV W/RPR FEM ART +-GRF 1218.03 090<br />
33973 INSJ I-AORT BALO ASSIST DEV THRU AS-AORT 896.21 000<br />
33974 RMVL I-AORT BALO DEV FROM AS-AORT RPR AS-AORT 1536.52 090<br />
33975 INSJ VENTR ASSIST DEV XTRCORP 1 VNTRC 1880.49 XXX<br />
33976 INSJ VENTR ASSIST DEV XTRCORP BIVENTR 2086.54 XXX<br />
33977 REMOVAL VENTR ASSIST DEVICE XTRCORP 1 VENTRICLE 2051.09 090<br />
33978 REMOVAL VENTR ASSIST DEVICE XTRCORP BIVENTR 2279.85 090<br />
33979 INSJ VENTR ASSIST DEV IMPLTABLE ICORP 1 VNTRC 4112.15 XXX<br />
33980 RMVL VENTR ASSIST DEV IMPLTABLE ICORP 1 VNTRC 6175.99 090<br />
33981 RPLCMT XTRCORP VAD 1/BIVENTR PUMP 1/EA PUMP BR XXX<br />
33982 RPLCMT VAD PMP IMPLTBL ICORP 1 VNTR W/O CARD BYP BR XXX<br />
33983 RPLCMT VAD PMP IMPLTBL ICORP 1 VNTR W/CARD BYP BR XXX<br />
33999 UNLISTED CARDIAC SURGERY BR YYY<br />
34001 EMBLC/THRMBC CATH CRTD SUBCLA/INNOMINATE ART 1692.16 090<br />
34051 EMBLC/THRMBC INNOMINATE SUBCLA ART 1683.86 090<br />
34101 EMBLC/THRMBC AX BRACH INNOMINATE SUBCLA ART 1056.84 090<br />
34111 EMBLC/THRMBC +-CATH RDL/UR ART ARM INC 1056.29 090<br />
34151 EMBLC/THRMBC RNL CELIAC MESENTERY A-ILIAC ART 2441.04 090<br />
34201 EMBLC/THRMBC FEMPOP A-ILIAC ART 1790.20 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 103
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
34203 EMBLC/THRMBC POP-TIBIO-PRONEAL ART LEG INC 1688.29 090<br />
34401 THRMBC DIR/W/CATH V/C ILIAC VEIN ABDL INC 2552.37 090<br />
34421 THRMBC DIR/W/CATH V/C ILIAC FEMPOP VEIN LEG INC 1285.05 090<br />
34451 THRMBC DIR/W/CATH V/C ILIAC FEMPOP VEIN ABDL&LEG 2585.05 090<br />
34471 THRMBC DIR/W/CATH SUBCLA VEIN NCK INC 1995.15 090<br />
34490 THRMBC DIR/W/CATH AX&SUBCLA VEIN ARM INC 1067.92 090<br />
34501 VALVULOPLASTY FEMORAL VEIN 1611.30 090<br />
34502 RECONSTRUCTION VENA CAVA ANY METHOD 2626.04 090<br />
34510 VENOUS VALVE TRANSPOSITION ANY VEIN DONOR 1925.36 090<br />
34520 CROSS-OVER VEIN GRAFT VENOUS SYSTEM 1776.91 090<br />
34530 SAPHENOPOPLITEAL VEIN ANASTOMOSIS 1664.47 090<br />
34800 EVASC RPR AAA W/AORTO-AORTIC TUBE PROSTH 1973.55 090<br />
34802 EVASC RPR AAA W/MDLR BFRC PROSTH 1 LIMB 2181.26 090<br />
34803 EVASC RPR AAA W/MDLR BFRC PROSTH 2 LIMBS 2253.82 090<br />
34804 EVASC RPR AAA W/UNIBDY BFRC PROSTH 2183.47 090<br />
34805 EVASC RPR AAA AORTO-UNIILIAC/AORTO-UNIFEM PROSTH 2076.02 090<br />
+ 34806 TCAT PLACEMENT PHYSIOLOGIC SENSOR ANEURYSMAL SAC 180.02 ZZZ<br />
+ 34808 EVASC PLMT ILIAC ART OCCLUSION DEV 357.82 ZZZ<br />
34812 OPN FEM ART EXPOS DLVR EVASC PROSTH UNI 588.24 000<br />
+ 34813 PLMT FEM-FEM PROSTC GRF EVASC AORTIC ARYSM RPR 415.43 ZZZ<br />
34820 ILIAC ART EXPOS PROSTH/ILIAC OCCLS EVASC UNI 848.02 000<br />
34825 PLMT XTN PROSTH EVASC RPR ARYSM/DSJ 1ST VSL 1223.57 090<br />
+ 34826 PLMT XTN PROSTH EVASC RPR ARYSM/DSJ EA VSL 358.93 ZZZ<br />
34830 OPN RPR ARYSM RPR ARTL TRAUMA TUBE PROSTH 3159.45 090<br />
34831 OPN RPR ARYSM RPR ARTL TRMA AORTOBIILIAC PROSTH 3371.04 090<br />
34832 OPN RPR ARYSM RPR ARTL TRMA AORTO-BIFEM PROSTH 3397.07 090<br />
34833 ILIAC ART EXPOS W/CRTJ CONDUIT UNI 1066.26 000<br />
34834 BRACH ART EXPOS DPLMNT AORTIC/ILIAC PROSTH UNI 481.89 000<br />
s 34900 EVASC RPR ILIAC ART ILIO-ILIAC PROSTHESIS 1570.86 090<br />
35001 DIR RPR ARYSM/&GRF INSJ CRTD SUBCLA ART 1973.55 090<br />
35002 DIR RPR ARYSM&GRF INSJ RPTD ARYSM CRTD SUBCLA 2021.74 090<br />
35005 DIR RPR ARYSM&GRF INSJ VRT ART 1917.05 090<br />
35011 DIR RPR ARYSM&GRF INSJ AX-BRACH ART 1740.35 090<br />
35013 DIR RPR ARYSM&GRF INSJ AX-BRACH ART 2177.93 090<br />
35021 DIR RPR ARYSM&GRF INSJ INNOMINATE SUBCLA ART 2066.05 090<br />
35022 DIR RPR ARYSM&GRF RPTD ARYSM INNOM SUBCLA ART 2421.10 090<br />
35045 DIR RPR ARYSM&GRF INSJ RDL/UR ART 1706.57 090<br />
35081 DIR RPR ARYSM&GRF INSJ ABDL AORTA 3070.82 090<br />
35082 DIR RPR ARYSM&GRF INSJ RPTD ARYSM ABDL AORTA 3829.66 090<br />
35091 DIR RPR ARYSM&GRF INSJ ABDL AORTA VISC VSL 3166.09 090<br />
35092 DIR RPR ARYSM&GRF RPTD ARYSM ABDL AORTA VISC VSL 4563.03 090<br />
35102 DIR RPR ARYSM&GRF INSJ ABDL AORTA ILIAC VSL 3316.75 090<br />
35103 DIR RPR ARYSM&GRF RPTD ARYSM ABDL AORTA ILIAC 3928.81 090<br />
35111 DIR RPR ARYSM&GRF INSJ SPLENIC ART 2487.01 090<br />
35112 DIR RPR ARYSM&GRF INSJ RPTD ARYSM SPLENIC ART 3052.54 090<br />
35121 DIR RPR ARYSM&GRF INSJ HEPATC CELIAC RNL/MSN ART 2887.48 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
104 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
35122 DIR RPR ARYSM&GRF RPTD ARYSM HEPATC CEL RNL/MSN 3349.43 090<br />
35131 DIR RPR ARYSM&GRF INSJ ILIAC ART 2444.36 090<br />
35132 DIR RPR ARYSM&GRF INSJ RPTD ARYSM ILIAC ART 2912.41 090<br />
35141 DIR RPR ARYSM&GRF INSJ COMMON FEM ART 1943.64 090<br />
35142 DIR RPR ARYSM&GRF INSJ RPTD ARYSM COMMON FEM ART 2328.04 090<br />
35151 DIR RPR ARYSM&GRF INSJ POP ART 2194.00 090<br />
35152 DIR RPR ARYSM&GRF INSJ RPTD ARYSM POP ART 2513.04 090<br />
35180 REPAIR CONGENITAL ARTERIOVENOUS FISTULA HEAD&NCK 1593.02 090<br />
35182 RPR CONGENITAL ARTERIOVENOUS FISTULA THORAX&ABD 2959.49 090<br />
35184 RPR CONGENITAL ARTERIOVENOUS FISTULA EXTREMITIES 1766.94 090<br />
35188 RPR/TRAUMTC ARVEN FSTL HEAD&NCK 1423.52 090<br />
35189 RPR/TRAUMTC ARVEN FSTL THORAX&ABD 2889.70 090<br />
35190 RPR/TRAUMTC ARVEN FSTL XTR 1303.33 090<br />
35201 REPAIR BLOOD VESSEL DIRECT NECK 1625.70 090<br />
35206 REPAIR BLOOD VESSEL DIRECT UPPER EXTREMITY 1334.90 090<br />
35207 REPAIR BLOOD VESSEL DIRECT HAND FINGER 1221.90 090<br />
35211 RPR BLOOD VESSEL DIRECT INTRATHORACIC W/BYPASS 2367.92 090<br />
35216 RPR BLOOD VESSEL DIRECT INTRATHORACIC W/O BYPASS 3443.60 090<br />
35221 RPR BLOOD VESSEL DIRECT INTRA-ABDOMINAL 2446.58 090<br />
35226 RPR BLOOD VESSEL DIRECT LOWER EXTREMITY 1461.19 090<br />
35231 REPAIR BLOOD VESSEL W/VEIN GRAFT NECK 2020.07 090<br />
35236 REPAIR BLOOD VESSEL W/VEIN GRAFT UPPER EXTREMITY 1696.60 090<br />
35241 RPR BLOOD VESSEL VEIN GRAFT INTRATHORACIC W/BYP 2493.10 090<br />
35246 RPR BLOOD VESSEL VEIN GRF INTRATHORACIC W/O BYP 2600.01 090<br />
35251 REPAIR BLOOD VESSEL VEIN GRAFT INTRA-ABDOMINAL 2898.00 090<br />
35256 REPAIR BLOOD VESSEL VEIN GRAFT LOWER EXTREMITY 1778.02 090<br />
35261 REPAIR BLOOD VESSEL W/GRAFT OTHER/THAN VEIN NECK 1827.87 090<br />
35266 RPR BLOOD VSL GRF OTH/THN VEIN UPPER EXTREMITY 1502.18 090<br />
35271 RPR BLOOD VSL GRF OTH/THN VEIN INTRATHRC W/BYP 2379.55 090<br />
35276 RPR BLOOD VSL GRF OTH/THN VEIN INTRATHRC W/O BYP 2471.50 090<br />
35281 RPR BLVSL W/GRF OTH/THN VEIN INTRA-ABDL 2777.25 090<br />
35286 RPR BLVSL W/GRF OTH/THN VEIN LXTR 1640.65 090<br />
35301 TEAEC W/PATCH GRF CRTD VRT SUBCLA NCK INC 1840.06 090<br />
35302 TEAEC W/GRAFT SUPERFICIAL FEMORAL ART 1962.47 090<br />
35303 TEAEC W/GRAFT POPLITEAL ART 2164.64 090<br />
35304 TEAEC W/GRAFT TIBIOPERONEAL TRUNK ART 2241.63 090<br />
35305 TEAEC W/GRAFT TIBIAL/PERONEAL ART 1ST VESSEL 2159.66 090<br />
+ 35306 TEAEC W/GRAFT EA ADDL TIBIAL/PERONEAL ART 827.53 ZZZ<br />
35311 TEAEC +-PATCH GRF SUBCLA INNOMINATE THRC INC 2644.87 090<br />
35321 TEAEC +-PATCH GRF AX-BRACH 1562.00 090<br />
35331 TEAEC +-PATCH GRF ABDL AORTA 2571.76 090<br />
35341 TEAEC +-PATCH GRF MESENTERIC CELIAC/RNL 2404.48 090<br />
35351 TEAEC +-PATCH GRF ILIAC 2254.93 090<br />
35355 TEAEC +-PATCH GRF ILIOFEM 1828.98 090<br />
35361 TEAEC +-PATCH GRF CMBN AORTOILIAC 2731.83 090<br />
35363 TEAEC +-PATCH GRF CMBN AORTOILIOFEM 3018.20 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 105
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
35371 TEAEC +-PATCH GRF COMMON FEM 1444.02 090<br />
35372 TEAEC +-PATCH GRF DP PROFUNDA FEM 1725.95 090<br />
+ 35390 ROPRTJ CRTD TEAEC > 1 MO AFTER ORIGINAL OPRATION 279.17 ZZZ<br />
+ 35400 ANGIOSCOPY NON-C VSL/GRFS THER IVNTJ 261.99 ZZZ<br />
35450 TRLUML BALO ANGIOP OPN RNL/OTH VISC ART 897.87 000<br />
35452 TRLUML BALO ANGIOP OPN AORTIC 624.80 000<br />
35458 TRLUML BALO ANGIOP OPN BRCH/CPHLC TRNK/BRNCH EA 853.01 000<br />
35460 TRLUML BALO ANGIOP OPN VEN 543.93 000<br />
s K 35471 TRLUML BALO ANGIOP PRQ RNL/VISC ART 4816.71 000<br />
K 35472 TRLUML BALO ANGIOP PRQ AORTIC 3487.91 000<br />
K 35475 TRLUML BALO ANGIOP PRQ BRCH/CPHLC TRNK/BRNCH EA 3785.35 000<br />
K 35476 TRLUML BALO ANGIOP PRQ VEN 2860.34 000<br />
+ 35500 HARVEST UXTR VEIN 1 SGM LXTR/CAB PX 562.21 ZZZ<br />
35501 BYP W/VEIN COMMON-IPSILATERAL CRTD 2751.78 090<br />
35506 BYP W/VEIN CAROTID-SUBCLA/ SUBCLA CAROTID 2345.77 090<br />
35508 BYP W/VEIN CRTD-VRT 2477.04 090<br />
35509 BYP W/VEIN CAROTID-CONTRALATERAL CAROTID 2613.30 090<br />
35510 BYP W/VEIN CRTD-BRACH 2215.05 090<br />
35511 BYP W/VEIN SUBCLA-SUBCLA 2165.75 090<br />
35512 BYP W/VEIN SUBCLA-BRACH 2165.75 090<br />
35515 BYP W/VEIN SUBCLA-VRT 2349.09 090<br />
35516 BYP W/VEIN SUBCLA-AX 2159.10 090<br />
35518 BYP W/VEIN AX-AX 2067.15 090<br />
35521 BYP W/VEIN AX-FEM 2326.93 090<br />
35522 BYP W/VEIN AX-BRACH 2150.79 090<br />
35523 BYPASS GRAFT WITH VEIN BRACHIAL-ULNAR/-RADIAL 2257.14 090<br />
35525 BYP W/VEIN BRACH-BRACH 2004.56 090<br />
s 35526 BYPASS W/VEIN AORTOSUBCLAV/CAROTID/INNOMINATE 2891.36 090<br />
35531 BYP W/VEIN AORTOCELIAC/AORTOMESENTERIC 3549.95 090<br />
35533 BYP W/VEIN AX-FEM-FEM 2859.23 090<br />
35535 BYPASS GRAFT WITH VEIN HEPATORENAL 3089.65 090<br />
35536 BYP W/VEIN SPLENORNL 3021.52 090<br />
35537 BYP W/VEIN AORTOILIAC 3934.35 090<br />
35538 BYP W/VEIN AORTOBI-ILIAC 4410.15 090<br />
35539 BYP W/VEIN AORTOFEMORAL 3907.76 090<br />
35540 BYP W/VEIN AORTOBIFEMORAL 4464.99 090<br />
35548 BYP W/VEIN AORTOILIOFEM UNI 2079.34 090<br />
35549 BYP W/VEIN AORTOILIOFEM BI 2404.48 090<br />
35551 BYP W/VEIN AORTOFEMPOP 2653.73 090<br />
35556 BYP W/VEIN FEMPOP 2456.55 090<br />
35558 BYP W/VEIN FEM-FEM 2167.41 090<br />
35560 BYP W/VEIN AORTORNL 3064.73 090<br />
35563 BYP W/VEIN ILIOILIAC 2366.26 090<br />
35565 BYP W/VEIN ILIOFEM 2322.50 090<br />
35566 BYP FEM-ANT TIBL PST TIBL PRONEAL ART/OTH DSTL 2943.98 090<br />
35570 BYP TIBL-TIBL/PRONEAL-TIBL/TIBL/PRONEAL TRK-TIBL 2396.73 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
106 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
35571 BYP W/VEIN POP-TIBL-PRONEAL ART/OTH DSTL VSL 2351.86 090<br />
+ 35572 HARVEST FEMPOP VEIN 1 SGM VASC RCNSTJ PX 605.97 ZZZ<br />
35583 IN-SITU VEIN BYP FEMPOP 2540.74 090<br />
35585 IN-SITU FEM-ANT TIBL PST TIBL/PRONEAL ART 2954.50 090<br />
35587 IN-SITU VEIN BYP POP-TIBL PRONEAL 2432.73 090<br />
+ 35600 HARVEST UPPER EXTREMITY ART 1 SEGMENT FOR CABG 446.44 ZZZ<br />
35601 BYP OTH/THN VEIN COMMON-IPSILATERAL CRTD 2559.57 090<br />
35606 BYP OTH/THN VEIN CRTD-SUBCLA 2072.14 090<br />
35612 BYP OTH/THN VEIN SUBCLA-SUBCLA 1584.71 090<br />
35616 BYP OTH/THN VEIN SUBCLA-AX 2057.18 090<br />
35621 BYP OTH/THN VEIN AX-FEM 1940.31 090<br />
35623 BYP OTH/THN VEIN AX-POP/-TIBL 2489.23 090<br />
s 35626 BYPASS NOT VEIN AORTOSUBCLA/CAROTID/INNOMINATE 2731.83 090<br />
35631 BYP OTH/THN VEIN AORTOCELIAC AORTOMSN AORTORNL 3253.61 090<br />
35632 BYPASS GRAFT W/OTHER THAN VEIN ILIO-CELIAC 2934.01 090<br />
35633 BYPASS GRAFT W/OTHER THAN VEIN ILIO-MESENTERIC 3205.97 090<br />
35634 BYPASS GRAFT W/OTHER THAN VEIN ILIORENAL 2900.77 090<br />
35636 BYP OTH/THN VEIN SPLENORNL 3019.31 090<br />
35637 BYP OTH/THN VEIN AORTOILIAC 3014.88 090<br />
35638 BYP OTH/THN VEIN AORTOBI-ILIAC 3081.90 090<br />
35642 BYP OTH/THN VEIN CRTD-VRT 1900.43 090<br />
35645 BYP OTH/THN VEIN SUBCLA-VRT 1812.36 090<br />
35646 BYP OTH/THN VEIN AORTOBIFEM 3021.52 090<br />
35647 BYP OTH/THN VEIN AORTOFEM 2744.02 090<br />
35650 BYP OTH/THN VEIN AX-AX 1878.83 090<br />
35651 BYP OTH/THN VEIN AORTOFEMPOP 2350.20 090<br />
35654 BYP OTH/THN VEIN AX-FEM-FEM 2419.44 090<br />
35656 BYP OTH/THN VEIN FEMPOP 1905.97 090<br />
35661 BYP OTH/THN VEIN FEM-FEM 1914.28 090<br />
35663 BYP OTH/THN VEIN ILIOILIAC 2206.74 090<br />
35665 BYP OTH/THN VEIN ILIOFEM 2070.48 090<br />
35666 BYP OTH/THN VEIN FEM-ANT TIBL PST TIBL/PRONEAL 2238.86 090<br />
35671 BYP OTH/THN VEIN POP-TIBL/-PRONEAL ART 1972.44 090<br />
+ 35681 BYP COMPOSIT PROSTC&VEIN 140.14 ZZZ<br />
+ 35682 BYP AUTOG COMPOSIT 2 SEG VEINS FROM 2 LOCATIONS 623.69 ZZZ<br />
+ 35683 BYP AUTOG COMPOSIT 3/> SEG FROM 2/> LOCATIONS 730.59 ZZZ<br />
+ 35685 PLMT VEIN PATCH/CUFF DSTL ANAST BYP CONDUIT 351.17 ZZZ<br />
+ 35686 CRTJ DSTL ARVEN FSTL LXTR BYP SURG NON-HEMO 291.35 ZZZ<br />
35691 TRPOS&/RIMPLTJ VRT CRTD ART 1701.58 090<br />
35693 TRPOS&/RIMPLTJ VRT SUBCLA ART 1507.72 090<br />
35694 TRPOS&/RIMPLTJ SUBCLA CRTD ART 1796.30 090<br />
35695 TRPOS&/RIMPLTJ CRTD SUBCLA ART 1839.50 090<br />
+ 35697 RIMPLTJ VISC ART INFRARNL AORTIC PROSTH EA ART 261.44 ZZZ<br />
+ 35700 ROPRTJ > 1 MO AFTER ORIGINAL OPRATION 269.20 ZZZ<br />
35701 EXPL N/FLWD SURG RPR +-LSS ART CRTD ART 949.38 090<br />
35721 EXPL N/FLWD SURG RPR +-LSS ART FEM ART 790.97 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 107
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
35741 EXPL N/FLWD SURG RPR +-LSS ART POP ART 876.82 090<br />
35761 EXPL N/FLWD SURG RPR +-LSS ART OTH VSL 657.48 090<br />
35800 EXPL PO HEMRRG THROMBOSIS/INFCTJ NCK 839.16 090<br />
35820 EXPL PO HEMRRG THROMBOSIS/INFCTJ CH 3388.76 090<br />
35840 EXPL PO HEMRRG THROMBOSIS/INFCTJ ABD 1095.06 090<br />
35860 EXPL PO HEMRRG THROMBOSIS/INFCTJ XTR 707.88 090<br />
35870 RPR GRF-ENTERIC FSTL 2357.95 090<br />
35875 THRMBC ARTL/VEN GRF OTH/THN HEMO GRF/FSTL 1043.55 090<br />
35876 THRMBC ARTL/VEN GRF XCP HEMO GRF/FSTL W/REVJ GRF 1661.15 090<br />
35879 REVJ LXTR ARTL BYP OPN VEIN PATCH ANGIOP 1632.34 090<br />
35881 REVJ LXTR ARTL BYP OPN W/SGMTL VEIN INTERPOS 1807.38 090<br />
35883 REVISION FEMORAL ANAST OPEN NONAUTOG GRAFT 2115.90 090<br />
35884 REVISION FEMORAL ANAST OPEN W/AUTOG GRAFT 2201.75 090<br />
35901 EXC INFCT GRF NCK 880.15 090<br />
35903 EXC INFCT GRF XTR 989.27 090<br />
35905 EXC INFCT GRF THORAX 3013.77 090<br />
35907 EXC INFCT GRF ABD 3374.91 090<br />
36000 INTRO NDL/INTRACATH VEIN 40.99 XXX<br />
36002 NJX PX PRQ TX XTR PSEUDOARYSM 274.73 000<br />
36005 NJX PX XTR VNGRPH W/INTRO NDL/INTRACATH 569.41 000<br />
36010 INTRO CATH SUPRIOR/IVC 925.57 XXX<br />
36011 SLCTV CATH PLMT VEN SYS 1ST ORDER BRANCH 1517.69 XXX<br />
36012 SLCTV CATH PLMT VEN SYS 2ND ORDER/> SLCTV BRANCH 1471.71 XXX<br />
36013 INTRO CATH R HRT/MAIN P-ART 1339.88 XXX<br />
36014 SLCTV CATH PLMT L/R P-ART 1404.69 XXX<br />
36015 SLCTV CATH PLMT SGMTL/SUBSGMTL P-ART 1526.55 XXX<br />
36100 INTRO NDL/INTRACATH CRTD/VRT ART 876.82 XXX<br />
36120 INTRO NDL/INTRACATH RTRGR BRACH ART 744.44 XXX<br />
36140 INTRO NDL/INTRACATH XTR ART 794.85 XXX<br />
K 36147 INTRO NDL/CATH AV SHUNT IST ACCESS W/ RAD EVAL 1347.64 XXX<br />
+ K 36148 INTRO NDL/CATH AV SHUNT ADDL ACCESS THER IVNTJ 424.84 ZZZ<br />
36160 INTRO NDL/INTRACATH AORTIC TRANSLMBR 860.76 XXX<br />
36200 INTRO CATH AORTA 1075.67 XXX<br />
36215 SLCTV CATHJ EA 1ST ORD THRC/BRCH/CPHLC BRNCH 1910.40 XXX<br />
36216 SLCTV CATHJ 1ST 2ND ORD THRC/BRCH/CPHLC BRNCH 2102.05 XXX<br />
36217 SLCTV CATHJ 3RD+ ORD SLCTV THRC/BRCH/CPHLC BRNCH 3432.52 XXX<br />
+ 36218 SLCTV CATHJ EA 2ND+ ORD THRC/BRCH/CPHLC BRNCH 317.94 ZZZ<br />
36245 SLCTV CATHJ EA 1ST ORD ABDL PEL/LXTR ART BRNCH 2015.64 XXX<br />
36246 SLCTV CATHJ 2ND ORDER ABDL PEL/LXTR ART BRNCH 2036.14 XXX<br />
36247 SLCTV CATHJ 3RD+ ORD SLCTV ABDL PEL/LXTR BRNCH 3200.99 XXX<br />
+ 36248 SLCTV CATHJ EA 2ND+ ORD ABDL PEL/LXTR ART BRNCH 266.98 ZZZ<br />
36260 INSJ IMPLTABLE IA NFS PMP 1027.48 090<br />
36261 REVJ IMPLTED IA NFS PMP 639.75 090<br />
36262 RMVL IMPLTED IA NFS PMP 482.45 090<br />
36299 UNLIS PX VASC NJX BR YYY<br />
36400 VNPNXR
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
36405 VNPNXR 65.36 XXX<br />
36430 TRANSFUSION BLD/BLD COMPONENTS 57.05 XXX<br />
36440 PUSH TRANSFUSION BLD 2 YR/UNDER 93.61 XXX<br />
36450 EXCHNG TRANSFUSION BLD NB 186.66 XXX<br />
36455 EXCHNG TRANSFUSION BLD OTH/THN NB 197.19 XXX<br />
36460 TRANSFUSION INTRAUTERINE FTL 592.12 XXX<br />
36468 1/MLT NJXS SCLRSG SLNS SPIDER VEINS LIMB/TRNK BR 000<br />
36469 1/MLT NJXS SCLRSG SLNS SPIDER VEINS FACE BR 000<br />
36470 NJX SCLRSG SLN 1 VEIN 235.96 010<br />
36471 NJX SCLRSG SLN MLT VEINS SM LEG 290.24 010<br />
36475 ENDOVEN ABLTJ INCMPTNT VEIN XTR RF 1ST VEIN 3016.54 000<br />
+ 36476 ENDOVEN ABLTJ INCMPTNT VEIN XTR RF 2ND+ VEINS 659.14 ZZZ<br />
36478 ENDOVEN ABLTJ INCMPTNT VEIN XTR LASER 1ST VEIN 2384.54 000<br />
+ 36479 ENDOVEN ABLTJ INCMPTNT VEIN XTR LASER 2ND+ VEINS 678.53 ZZZ<br />
K 36481 PRQ PORTAL VEIN CATHETERIZATION ANY METHOD 2068.26 000<br />
36500 VEN CATHJ SLCTV ORGAN BLD SAMPLING 305.75 000<br />
36510 CATHJ UMBILICAL VEIN DX/THER NB 173.92 000<br />
36511 THER APHERESIS WHITE BLD CELLS 156.75 000<br />
36512 THER APHERESIS RED BLD CELLS 151.77 000<br />
36513 THER APHERESIS PLTLTS 165.62 000<br />
36514 THER APHERESIS PLSM PHERESIS 849.68 000<br />
36515 THER APHERESIS W/XTRCORP IMMUNODSPTJ&PLSM RENFS 3165.54 000<br />
36516 THER APHRS XTRCORP SLCTV ADSRPJ/FILTRJ&RENFS 3498.99 000<br />
36522 PHOTOPHERESIS XTRCORP 2226.12 000<br />
K 36555 INSJ NON-TUN CTR CVC UNDER 5 YR 441.46 000<br />
36556 INSJ NON-TUN CTR CVC AGE 5 YR/> 384.41 000<br />
K 36557 INSJ TUN CTR CVC W/O SUBQ PORT/PMP UNDER 5 YR 1540.95 010<br />
K 36558 INSJ TUN CTR CVC W/O SUBQ PORT/PMP AGE 5 YR/> 1326.59 010<br />
K 36560 INSJ TUN CTR CTR VAD W/SUBQ PORT UNDER 5 YR 2076.02 010<br />
K 36561 INSJ TUN CTR CTR VAD W/SUBQ PORT AGE 5 YR/> 1943.64 010<br />
K 36563 INSJ TUN CTR CTR VAD W/SUBQ PMP 2066.60 010<br />
K 36565 INSJ TUN VAD REQ 2 CATH 2 SITS W/O SUBQ PORT/PMP 1651.18 010<br />
K 36566 INSJ TUN VAD REQ 2 CATH 2 SITS W/SUBQ PORT 7343.05 010<br />
K 36568 INSJ PRPH CVC W/O SUBQ PORT/PMP UNDER 5 YR 489.09 000<br />
36569 INSJ PRPH CVC W/O SUBQ PORT/PMP AGE 5 YR/> 423.73 000<br />
K 36570 INSJ PRPH CTR VAD W/SUBQ PORT UNDER 5 YR 1850.58 010<br />
K 36571 INSJ PRPH CTR VAD W/SUBQ PORT AGE 5 YR/> 2090.42 010<br />
36575 RPR TUN/NON-TUN CTR VAD CATH W/O SUBQ PORT/PMP 266.43 000<br />
K 36576 RPR CTR VAD W/SUBQ PORT/PMP CTR/PRPH INSJ SIT 615.94 010<br />
K 36578 RPLCMT CATH CTR VAD SUBQ PORT/PMP 841.93 010<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 109
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
36580 RPLCMT COMPL NON-TUN CVC W/O SUBQ PORT/PMP 367.24 000<br />
K 36581 RPLCMT COMPL TUN CVC W/O SUBQ PORT/PMP 1259.57 010<br />
K 36582 RPLCMT COMPL TUN CTR VAD W/SUBQ PORT 1810.70 010<br />
K 36583 RPLCMT COMPL TUN CTR VAD W/SUBQ PMP 2018.41 010<br />
36584 RPLCMT COMPL PRPH CVC W/O SUBQ PORT/PMP 352.28 000<br />
K 36585 RPLCMT COMPL PRPH CTR VAD W/SUBQ PORT 1819.56 010<br />
36589 RMVL TUN CVC W/O SUBQ PORT/PMP 276.95 010<br />
K 36590 RMVL TUN CTR VAD W/SUBQ PORT/PMP CTR/PRPH INSJ 470.82 010<br />
36591 COLLECT BLOOD FROM IMPLANT VENOUS ACCESS DEVICE 37.67 XXX<br />
36592 COLLECT BLOOD FROM CATHETER VENOUS NOS 42.10 XXX<br />
36593 DECLOT BY THROMBOLYTIC AGENT IMPLANT DEVICE/CATH 47.08 XXX<br />
36595 MCHNL RMVL PRICATH OBSTR CV DEV VIA VEN ACCESS 969.33 000<br />
36596 MCHNL RMVL INTRAL OBSTR CV DEV THRU DEV LUMEN 223.22 000<br />
36597 RPSG PREVIOUSLY PLACED CVC UNDER FLUOR GDN 206.60 000<br />
36598 CNTRST NJX RAD EVAL CTR VAD FLUOR IMG&REPRT 186.11 000<br />
36600 ARTL PNXR W/DRAWAL BLD DX 50.40 XXX<br />
* 36620 ARTL CATHJ/CANNULJ MNTR/TRANSFUSION SPX PRQ 83.09 000<br />
36625 ARTL CATHJ/CANNULJ MNTR/TRANSFUSION SPX CUTDOWN 178.91 000<br />
36640 ARTL CATHJ PROLNG NFS THER CHEMOTX CUTDOWN 211.04 000<br />
36660 CATHETERIZATION UMBILICAL NEWBORN ART DX/THERAPY 125.74 000<br />
36680 PLMT NDL INTRAOSS NFS 99.15 000<br />
36800 INSJ CANNULA HEMO OTH PURPOSE SPX VEIN VEIN 268.64 000<br />
36810 INSJ CANNULA HEMO OTH PURPOSE SPX ARVEN XTRNL 356.16 000<br />
36815 INSJ CANNULA HEMO OTH SPX ARVEN XTRNL REVJ/CLSR 254.79 000<br />
36818 ARVEN ANAST OPN UPR ARM CEPHALIC VEIN TRPOS 1152.11 090<br />
36819 ARVEN ANAST OPN UPR ARM BASILIC VEIN TRPOS 1372.01 090<br />
36820 ARVEN ANAST OPN F/ARM VEIN TRPOS 1381.98 090<br />
36821 ARTERIOVENOUS ANASTOMOSIS OPEN DIRECT 1177.04 090<br />
36822 INSJ CANNULA PROLNG XC-CIRCJ ECMO SPX 645.29 090<br />
36823 INSJ CNULA ISLTD XC-CIRCJ REG CHEMOTX XTR RMVL 2210.06 090<br />
36825 CRTJ ARVEN FSTL XCP DIR ARVEN ANAST AUTOG GRF 1396.94 090<br />
36830 CRTJ ARVEN FSTL XCP DIR ARVEN ANAST NONAUTOG GRF 1131.06 090<br />
36831 THRMBC OPN ARVEN FSTL W/O REVJ DIAL GRF 785.43 090<br />
36832 REVJ OPN ARVEN FSTL W/O THRMBC DIAL GRF 998.13 090<br />
36833 REVJ OPN ARVEN FSTL W/THRMBC DIAL GRF 1128.29 090<br />
36835 INSJ THOMAS SHUNT SPX 819.77 090<br />
36838 DSTL REVSC&INTERVAL LIG UXTR HEMO ACCESS 2002.35 090<br />
36860 XTRNL CANNULA DECLTNG SPX W/O BALO CATH 331.23 000<br />
36861 XTRNL CANNULA DECLTNG SPX W/BALO CATH 255.90 000<br />
K 36870 THRMBC PRQ ARVEN FSTL AUTOG/NONAUTOG GRF 3081.90 090<br />
37140 VEN ANAST OPN PORTOCAVAL 2408.91 090<br />
37145 VEN ANAST OPN RENOPORTAL 2527.45 090<br />
37160 VEN ANAST OPN CAVAL-MESENTERIC 2226.68 090<br />
37180 VEN ANAST OPN SPLENORNL PROX 2488.12 090<br />
37181 VEN ANAST OPN SPLENORNL DSTL 2685.86 090<br />
37182 INSJ TRANSVNS INTRAHEPATC PORTOSYSIC SHUNT 1434.60 000<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
110 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
K 37183 REVJ TRANSVNS INTRAHEPATIC PORTOSYSTEMIC SHUNT 8880.12 000<br />
K 37184 PRIM PRQ TRLUML MCHNL THRMBC 1ST VSL 3942.11 000<br />
+ K 37185 PRIM PRQ TRLUML MCHNL THRMBC SBSQ VSL 1301.67 ZZZ<br />
+ K 37186 SEC PRQ TRLUML THRMBC 2565.11 ZZZ<br />
K 37187 PRQ TRLUML MCHNL THRMBC VEIN 3752.12 000<br />
K 37188 PRQ TRLUML MCHNL THRMBC VEIN REPEAT TX 3164.43 000<br />
37195 THROMBOLSS CERE IV NFS 1506.61 XXX<br />
37200 TCAT BX 379.98 000<br />
37201 TCAT THER NFS THROMBOLSS OTH/THN C 470.82 000<br />
37202 TCAT THER NFS OTH/THN THROMBOLSS ANY TYP 572.73 000<br />
K 37203 TCAT RETRIEVAL PRQ IV FB 2218.92 000<br />
37204 TCAT OCCLS/EMBOLJ PRQ NON-CNS NON-HEAD/NCK 1531.53 000<br />
s 37205 TCAT PLMT IV STENT PERCUTANEOUS 1ST VESSEL 7090.47 000<br />
s + 37206 TCAT PLMT IV STENT PERCUTANEOUS EACH ADDL VESSEL 4263.92 ZZZ<br />
s 37207 TCAT PLMT IV STENT OPEN 1ST VESSEL 741.67 000<br />
s + 37208 TCAT PLMT IV STENT OPEN EACH ADDL VESSEL 358.37 ZZZ<br />
37209 EXCHNG PREV PLACED IV CATH THROMBOLYTIC THER 193.31 000<br />
K 37210 UTERINE FIBROID EMBOLIZATION PERQ W/RAD GID 5896.27 000<br />
K 37215 TCAT IV STENT CRV CRTD ART EMBOLIC PROTECJ 1902.09 090<br />
K 37216 TCAT IV STENT CRV CRTD ART W/O EMBOLIC PROTECJ 1677.21 090<br />
l K 37220 REVASCULARIZATION ILIAC ARTERY ANGIOP 1ST VSL 5170.66 000<br />
l K 37221 REVSC OPN/PRQ ILIAC ART W/STNT PLMT & ANGIOP UNI 7639.94 000<br />
l + K 37222 REVASCULARIZATION ILIAC ART ANGIOP EA IPSI VSL 1491.10 ZZZ<br />
l + K 37223 REVSC OPN/PRQ ILIAC ART W/STNT & ANGIOP IPSI VSL 4207.42 ZZZ<br />
l K 37224 REVSC OPN/PRG FEM/POP W/ANGIOPLASTY UNI 6211.99 000<br />
l K 37225 REVSC OPN/PRQ FEM/POP W/ATHRC/ANGIOP SM VSL 17537.03 000<br />
l K 37226 REVSC OPN/PRQ FEM/POP W/STNT/ANGIOP SM VSL 14678.90 000<br />
l K 37227 REVSC OPN/PRQ FEM/POP W/STNT/ATHRC/ANGIOP SM VSL 23708.58 000<br />
l K 37228 REVSC OPN/PRQ TIB/PERO W/ANGIOPLASTY UNI 8842.46 000<br />
l K 37229 REVSC OPN/PRQ TIB/PERO W/ATHRC/ANGIOP SM VSL 17387.47 000<br />
l K 37230 REVSC OPN/PRQ TIB/PERO W/STNT/ANGIOP SM VSL 13660.84 000<br />
l K 37231 REVSC OPN/PRQ TIB/PERO W/STNT/ATHR/ANGIOP SM VSL 21918.93 000<br />
l + K 37232 REVSC OPN/PRQ TIB/PERO W/ANGIOPLASTY UNI EA VSL 1986.29 ZZZ<br />
l + K 37233 REVSC OPN/PRQ TIB/PERO W/ATHRC/ANGIOP UNI EA VSL 2427.74 ZZZ<br />
l + K 37234 REVSC OPN/PRQ TIB/PERO W/STNT/ANGIOP UNI EA VSL 6323.88 ZZZ<br />
l + K 37235 REVSC OPN/PRQ TIB/PERO W/STNT/ATHR/ANGIOP EA VSL 6756.47 ZZZ<br />
+ 37250 IV US NON-C VSL DX EVAL&/THER IVNTJ 1ST VSL 187.77 ZZZ<br />
+ 37251 IV US NON-C VSL DX EVAL&/THER IVNTJ EA VSL 140.14 ZZZ<br />
37500 VASC NDSC SEPS 1188.12 090<br />
37501 UNLIS VASC NDSC PX BR YYY<br />
37565 LIG INT JUG VEIN 1206.39 090<br />
37600 LIG XTRNL CRTD ART 1210.27 090<br />
37605 LIG INT/COMMON CRTD ART 1386.41 090<br />
37606 LIG INT/COMMON CRTD ART W/GRADUAL OCCLS 861.31 090<br />
37607 LIG/BANDING ANGIOACCESS ARVEN FSTL 644.19 090<br />
37609 LIG/BX TEMPORAL ART 504.05 010<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 111
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
37615 LIG MAJOR ART NCK 859.10 090<br />
37616 LIG MAJOR ART CH 1843.93 090<br />
37617 LIG MAJOR ART ABD 2207.85 090<br />
37618 LIG MAJOR ART XTR 650.28 090<br />
37620 INTERRUPJ IVC SUTR LIG PLCTJ CLIP XTRVASC IV 1096.17 090<br />
37650 LIG FEM VEIN 835.84 090<br />
37660 LIG COMMON ILIAC VEIN 2112.02 090<br />
37700 LIG&DIV LONG SAPH VEIN SAPHFEM JUNCT/INTERRUPJ 430.38 090<br />
37718 LIG DIV&STRIPPING SHORT SAPHENOUS VEIN 743.89 090<br />
37722 LIG DIV&STRIP LONG SAPH SAPHFEM JUNCT KNE/BELW 828.08 090<br />
37735 LIG&DIV&COMPL STRIP LONG/SHORT SAPH RAD EXC 1075.67 090<br />
37760 LIG PRFRATR VEIN SUBFSCAL RAD INCL SKN GRF 1 LEG 1095.61 090<br />
37761 LIG PRFRATR VEIN SUBFSCAL OPEN INCL US GID 1 LEG 956.59 090<br />
37765 STAB PHLEBT VARICOSE VEINS 1 XTR 10-20 STAB INCS 1103.37 090<br />
37766 STAB PHLEBT VARICOSE VEINS 1 XTR > 20 INCS 1314.40 090<br />
37780 LIG&DIV SHORT SAPH VEIN SAPHENOPOP JUNCT SPX 443.67 090<br />
37785 LIG DIV&/EXC VARICOSE VEIN CLUSTER 1 LEG 598.21 090<br />
37788 PEN REVSC ART +-VEIN GRF 2325.83 090<br />
37790 PEN VEN OCCLUSIVE PX 803.71 090<br />
37799 UNLIS PX VASC SURG BR YYY<br />
38100 SPLENC TOT SPX 1842.27 090<br />
38101 SPLENC PRTL SPX 1856.67 090<br />
+ 38102 SPLENC TOT EN BLOC X10SV DS CONJUNCT W/OTH PX 425.95 ZZZ<br />
38115 RPR RPTD SPLEEN SPLENORRHAPHY +-PRTL SPLENC 2033.92 090<br />
38120 LAPS SURG SPLENC 1687.18 090<br />
38129 UNLIS LAPS PX SPLEEN BR YYY<br />
38200 NJX PX SPLENOPORTOGRAPY 245.93 000<br />
38204 MGMT RCP HEMATOP PROGENITOR CELL DON SEARCH&CELL 165.62 XXX<br />
38205 BLD-DRV HEMATOP PROGEN CELL HRVG TRNSPLJ ALGNC 130.17 000<br />
38206 BLD-DRV HEMATOP PROGEN CELL HRVG TRNSPLJ AUTOL 131.83 000<br />
38207 TRNSPL PREPJ HEMATOP PROGEN CELLS CRYOPRSRV&STRG 77.55 XXX<br />
38208 TRNSPL PREPJ HEMATOP PROGEN THAW PREV HRV 49.30 XXX<br />
38209 TRNSPL PREPJ HEMATOP PROGEN THAW PREV HRV WASHG 21.05 XXX<br />
38210 TRNSPL PREPJ HEMATOP PROGEN DEPLJ IN HRV T-CELL 137.92 XXX<br />
38211 TRNSPL PREPJ HEMATOP PROGEN TUM CELL DEPLJ 125.18 XXX<br />
38212 TRNSPL PREPJ HEMATOP PROGEN RED BLD CELL RMVL 81.98 XXX<br />
38213 TRNSPL PREPJ HEMATOP PROGEN PLTLT DEPLJ 21.05 XXX<br />
38214 TRNSPL PREPJ HEMATOP PROGEN PLSM VOL DEPLJ 70.90 XXX<br />
38215 TRNSPL PREPJ HEMATOP PROGEN CONCENTRATION PLSM 81.98 XXX<br />
38220 MARROW ASPIRATION ONLY 246.49 XXX<br />
38221 MARROW BX NDL/TROCAR 266.43 XXX<br />
38230 MARROW HRVG TRNSPLJ 559.44 010<br />
38240 MARROW/BLD-DRV PRPH STEM CELL TRNSPLJ ALLOGENEIC 204.39 XXX<br />
38241 MARROW/BLD-DRV PRPH STEM CELL TRNSPLJ AUTOL 203.84 XXX<br />
38242 MARROW/BLD-DRV PRPH STEM CELL TRNSPLJ ALGC DON 155.65 000<br />
38300 DRG LYMPH NODE ABSC/LYMPHADENITIS SMPL 443.67 010<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
112 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
38305 DRG LYMPH NODE ABSC/LYMPHADENITIS X10SV 746.66 090<br />
38308 LYMPHANGIOTOMY/OTH OPRATIONS LYMPHATIC CHANNELS 724.50 090<br />
38380 SUTR&/LIG THRC DUX CRV APPR 931.66 090<br />
38381 SUTR&/LIG THRC DUX THRC APPR 1345.42 090<br />
38382 SUTR&/LIG THRC DUX ABDL APPR 1098.94 090<br />
38500 BX/EXC LYMPH NODE OPN SUPFC 522.33 010<br />
38505 BX/EXC LYMPH NODE NDL SUPFC 204.94 000<br />
38510 BX/EXC LYMPH NODE OPN DP CRV NODE 836.94 010<br />
38520 BX/EXC LYMPH NODE OPN DP CRV NODE W/EXC FAT PAD 753.86 090<br />
38525 BX/EXC LYMPH NODE OPN DP AX NODE 691.27 090<br />
38530 BX/EXC LYMPH NODE OPN INT MAM NODE 882.92 090<br />
38542 DSJ DP JUG NODE 846.36 090<br />
38550 EXC CSTIC HYGROMA AX/CRV W/O DP NEUROVASC DSJ 798.17 090<br />
38555 EXC CSTIC HYGROMA AX/CRV W/DP NEUROVASC DSJ 1625.70 090<br />
38562 LMTD LMPHADEC STAGING SPX PEL&PARA-AORTIC 1133.28 090<br />
38564 LMTD LMPHADEC STAGING SPX RPR AORTIC&/SPLENIC 1138.26 090<br />
38570 LAPS SURG RPR LYMPH NODE BX 1/MLT 878.49 010<br />
38571 LAPS SURG BI TOT PEL LMPHADEC 1329.91 010<br />
38572 LAPS BI TOT PEL LMPHADEC&PRI-AORTIC LYMPH BX 1/+ 1537.63 010<br />
38589 UNLIS LAPS PX LYMPHATIC SYS BR YYY<br />
38700 SUPRAHYOID LMPHADEC 1313.85 090<br />
38720 CRV LMPHADEC COMPL 2194.55 090<br />
38724 CRV LMPHADEC MODF RAD NCK DSJ 2375.12 090<br />
38740 AX LMPHADEC SUPFC 1100.60 090<br />
38745 AX LMPHADEC COMPL 1398.04 090<br />
+ 38746 THORCOM THRC W/MEDSTNL & REGIONAL LMPHADEC 436.47 ZZZ<br />
+ 38747 ABDL LMPHADEC REG CELIAC GSTR PORTAL PRIPNCRTC 434.26 ZZZ<br />
38760 INGUINOFEM LMPHADEC SUPFC W/CLOQUETS NODE SPX 1359.27 090<br />
38765 INGUINOFEM LMPHADEC SUPFC W/PEL LMPHADEC 2089.86 090<br />
38770 PEL LMPHADEC W/XTRNL ILIAC HYPOGSTR&OBTURATOR 1323.27 090<br />
38780 RPR TABDL LMPHADEC X10SV W/PEL AORTIC&RNL 1693.27 090<br />
38790 NJX PX LYMPHANGRPH 137.37 000<br />
38792 INJECTION FOR IDENTIFICATION OF SENTINEL NODE 65.91 000<br />
38794 CANNULATION THRC DUX 488.54 090<br />
l + 38900 INTRAOP SENTINEL LYMPH ID W/DYE NJX 223.78 ZZZ<br />
38999 UNLIS PX HEMIC/LYMPHATIC SYS BR YYY<br />
39000 MEDIAST W/EXPL DRG RMVL FB/BX CRV APPR 825.86 090<br />
39010 MEDIAST W/EXPL DRG RMVL FB/BX TTHRC APPR 1339.33 090<br />
39200 RESECJ MEDIASTINAL CYST 1482.79 090<br />
39220 RESECJ MEDIASTINAL TUMOR 1913.72 090<br />
39400 MEDIASTINOSCOPY W/BX WHEN PERFORMED 848.57 010<br />
39499 UNLIS PX MED BR YYY<br />
39501 RPR LAC DPHRM ANY APPR 1380.87 090<br />
39503 RPR NEONATAL DIPHRG HRNA +-CH TUBE INSJ 9856.65 090<br />
39540 RPR DIPHRG HRNA OTH/THN NEONATAL TRAUMTC AQT 1415.77 090<br />
39541 RPR DIPHRG HRNA OTH/THN NEONATAL TRAUMTC CHRNC 1534.30 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 113
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
39545 IMBRCJ OF DIAPHRAGM 1490.54 090<br />
39560 RESCJ DPHRM SMPL RPR 1295.02 090<br />
39561 RESCJ DPHRM CPLX RPR 2035.58 090<br />
39599 UNLIS PX DPHRM BR YYY<br />
40490 BX LIP 210.48 000<br />
40500 VERMILIONECTOMY LIP SHV W/MUCOSAL ADVMNT 819.22 090<br />
40510 EXC LIP TRANSVRS WEDGE EXC W/PRIM CLSR 783.77 090<br />
40520 EXC LIP V-EXC W/PRIM DIR LINR CLSR 800.94 090<br />
40525 EXC LIP FULL THKNS RCNSTJ W/LOCAL FLAP 913.38 090<br />
40527 EXC LIP FULL THKNS RCNSTJ W/CROSS LIP FLAP 1045.21 090<br />
40530 RESCJ LIP > ONE-4TH W/O RCNSTJ 884.02 090<br />
40650 RPR LIP FULL THKNS VERMILION ONLY 675.20 090<br />
40652 RPR LIP FULL THKNS UP HALF VER H8 787.09 090<br />
40654 RPR LIP FULL THKNS > ONE-HALF VER H8/CPLX 926.67 090<br />
40700 PLSTC RPR CL LIP/NSL DFRM PRIM PRTL/COMPL UNI 1578.62 090<br />
40701 PLSTC RPR CL LIP/NSL DFRM PRIM BI 1 STG PX 1825.65 090<br />
40702 PLSTC RPR CL LIP/NSL DFRM PRIM BI 1 2 STGS 1353.73 090<br />
40720 PLSTC RPR CL LIP/NSL DFRM SEC RECRTJ DFCT&RECLSR 1616.28 090<br />
40761 PLSTC RPR CL LIP/NSL DFRM W/CROSS LIP PEDCL FLAP 1796.85 090<br />
40799 UNLIS PX LIPS BR YYY<br />
40800 DRG ABSC CST HMTMA VESTIBULE MOUTH SMPL 332.34 010<br />
40801 DRG ABSC CST HMTMA VESTIBULE MOUTH COMP 501.83 010<br />
40804 RMVL EMBEDDED FB VESTIBULE MOUTH SMPL 340.65 010<br />
40805 RMVL EMBEDDED FB VESTIBULE MOUTH COMP 520.67 010<br />
40806 INC LABIAL FRENUM FREXOMY 170.60 000<br />
40808 BX VESTIBULE MOUTH 297.44 010<br />
40810 EXC LES MUCOSA&SBMCSL VESTIBULE MOUTH W/O RPR 330.12 010<br />
40812 EXC LES MUCOSA&SBMCSL VESTIBULE SMPL RPR 458.63 010<br />
40814 EXC LES MUCOSA&SBMCSL VESTIBULE CPLX RPR 617.60 090<br />
40816 EXC LES MUCOSA&SBMCSL VESTIBULE CPLX EXC MUSC 649.72 090<br />
40818 EXC MUCOSA VESTIBULE MOUTH AS DON GRF 570.52 090<br />
40819 EXC FRENUM LABIAL/BUCCAL 491.31 090<br />
40820 DSTRJ LES/SCAR VESTIBULE MOUTH PHYSICAL METHS 427.61 010<br />
40830 CLSR LAC VESTIBULE MOUTH 2.5 CM/< 398.25 010<br />
40831 CLSR LAC VESTIBULE MOUTH > 2.5 CM/CPLX 529.53 010<br />
40840 VESTIBULOPLASTY ANT 1351.52 090<br />
40842 VESTIBULOPLASTY PST UNI 1295.57 090<br />
40843 VESTIBULOPLASTY PST BI 1730.94 090<br />
40844 VESTIBULOPLASTY ENTIRE ARCH 2274.31 090<br />
40845 VESTIBULOPLASTY CPLX W/RIDGE XTN MUSC RPSG 2389.52 090<br />
40899 UNLIS PX VESTIBULE MOUTH BR YYY<br />
41000 INTRAORAL I&D TONGUE/FLOOR LNGL 260.89 010<br />
41005 INTRAORAL I&D TONGUE/FLOOR SUBLNGL SUPFC 360.59 010<br />
41006 INTRAORAL I&D TONGUE/FLOOR SUBLNGL DP SPRMLHYD 581.60 090<br />
41007 INTRAORAL I&D TONGUE/FLOOR SUBMENTAL SPACE 580.49 090<br />
41008 INTRAORAL I&D TONGUE/FLOOR SUBMNDBLR SPACE 600.98 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
114 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
41009 INTRAORAL I&D TONGUE/FLOOR MASTICATOR SPACE 639.75 090<br />
41010 INC LNGL FRENUM FREXOMY 332.34 010<br />
41015 XTRORAL I&D ABSC CST/HMTMA FLOOR MOUTH SUBLNGL 701.79 090<br />
41016 XTRORAL I&D ABSC CST/HMTMA FLOOR MOUTH SUBMENTAL 701.79 090<br />
41017 XTRORAL I&D ABSC CST/HMTMA FLOOR MOUTH SUBMNDBLR 707.88 090<br />
41018 XTRORAL I&D FLOOR MASTICATOR SPACE 800.39 090<br />
41019 PLACEMENT NEEDLE HEAD/NECK RADIOELEMENT APPLICAT 766.04 000<br />
41100 BX TONGUE ANT 2-3RD 273.63 010<br />
41105 BX TONGUE PST ONE-3RD 276.40 010<br />
41108 BX FLOOR MOUTH 238.18 010<br />
41110 EXC LES TONGUE W/O CLSR 343.97 010<br />
41112 EXC LES TONGUE W/CLSR ANT 2-3RD 537.84 090<br />
41113 EXC LES TONGUE W/CLSR PST ONE-3RD 586.58 090<br />
41114 EXC LES TONGUE W/CLSR W/LOCAL TONGUE FLAP 1046.32 090<br />
41115 EXC LNGL FRENUM FRENECTOMY 394.38 010<br />
41116 EXC LES FLOOR MOUTH 531.74 090<br />
41120 GLSSC < ONE-HALF TONGUE 1729.83 090<br />
41130 GLSSC HEMIGLSSC 2140.27 090<br />
41135 GLSSC PRTL W/UNI RAD NCK DSJ 3541.64 090<br />
41140 GLSSC COMPL/TOT +-TRACHS W/O RAD NCK DSJ 3609.21 090<br />
41145 GLSSC COMPL/TOT +-TRACHS W/UNI RAD NCK DSJ 4544.20 090<br />
41150 GLSSC COMPOSIT W/RESCJ FLOOR&MNDBLR RESCJ 3597.58 090<br />
41153 GLSSC COMPOSIT RESCJ FLOOR SUPRAHYOID NCK DSJ 3909.43 090<br />
41155 GLSSC COMPOSIT RESCJ FLR MNDBLR RESCJ&RAD NCK 4885.95 090<br />
41250 RPR LAC 2.5 CM/< FLOOR MOUTH&/ANT 2-3RD TONGUE 388.84 010<br />
41251 RPR LAC 2.5 CM/< PST ONE-3RD TONGUE 407.12 010<br />
41252 RPR LAC TONGUE FLOOR MOUTH > 2.6 CM/CPLX 505.16 010<br />
41500 FIXJ TONGUE MCHNL OTH/THN SUTR 738.35 090<br />
41510 SUTR TONGUE LIP MICROGNATHIA 623.14 090<br />
41512 TONGUE BASE SUSPENSION PERMANENT SUTURE TQ 1018.62 090<br />
41520 FRENOPLASTY SURG REVJ FRENUM EG W/Z-PLASTY 561.10 090<br />
41530 SUBMUCOSAL ABLTJ TONGUE RF 1/> SITES PR SESSION 5253.74 010<br />
41599 UNLIS PX TONGUE FLOOR MOUTH BR YYY<br />
41800 DRG ABSC CST HMTMA FROM DENTOALVEOLAR STRUXS 396.04 010<br />
41805 RMVL EMBEDDED FB FROM DENTALVLR STRUXS SOFT TISS 388.28 010<br />
41806 RMVL EMBEDDED FB FROM DENTOALVEOLAR STRUXS B1 577.16 010<br />
41820 GINGIVECTOMY EXC GINGIVA EA QUADRANT 407.12 000<br />
41821 OPRCULECTOMY EXC PRICORONAL TISS 91.95 000<br />
41822 EXC FIBROUS TUBEROSITIES DENTOALVEOLAR STRUXS 463.06 010<br />
41823 EXC OSS TUBEROSITIES DENTOALVEOLAR STRUXS 687.39 090<br />
41825 EXC LES/TUM XCP LISTED ABOVE DENTALVLR 336.77 010<br />
41826 EXC LES/TUM XCP LISTED ABOVE DENTALVLR SMPL RPR 483.00 010<br />
41827 EXC LES/TUM XCP LISTED ABOVE DENTALVLR CPLX RPR 699.02 090<br />
41828 EXC HYPRPLSTC ALVEOLAR MUCOSA EA QUADRANT SPEC 487.43 010<br />
41830 ALVEOLECTOMY W/CURTG OSTEITIS/SEQUESTRECTOMY 624.25 010<br />
41850 DSTRJ LES XCP EXC DENTOALVEOLAR STRUXS 203.28 000<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 115
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
41870 PDONTAL MUCOSAL GRFG 508.48 000<br />
41872 GINGIVOPLASTY EA QUADRANT SPEC 596.55 090<br />
41874 ALVEOLOPLASTY EA QUADRANT SPEC 591.57 090<br />
41899 UNLIS PX DENTOALVEOLAR STRUXS BR YYY<br />
42000 DRG ABSC PALATE UVULA 254.24 010<br />
42100 BX PALATE UVULA 243.16 010<br />
42104 EXC LES PALATE UVULA W/O CLSR 345.08 010<br />
42106 EXC LES PALATE UVULA W/SMPL PRIM CLSR 433.70 010<br />
42107 EXC LES PALATE UVULA W/LOCAL FLAP CLSR 743.89 090<br />
42120 RESCJ PALATE/X10SV RESCJ LES 1628.47 090<br />
42140 UVULECTOMY EXC UVULA 413.21 090<br />
42145 PALATOPHARYNGOPLASTY 1164.85 090<br />
42160 DSTRJ LES PALATE/UVULA THERMAL CRYO/CHEM 384.41 010<br />
42180 RPR LAC PALATE UP 2 CM 381.08 010<br />
42182 RPR LAC PALATE > 2 CM/CPLX 530.08 010<br />
42200 PALATOP CL PALATE SOFT&/HARD PALATE ONLY 1429.62 090<br />
42205 PALATOP W/CLSR ALVEOLAR RIDGE SOFT TISS 1565.88 090<br />
42210 PALATOP CLSR ALVEOLAR RIDGE GRF ALVEOLAR RIDGE 1732.60 090<br />
42215 PALATOP CL PALATE MAJOR REVJ 1182.02 090<br />
42220 PALATOP CL PALATE SEC LNGTH PX 863.53 090<br />
42225 PALATOP CL PALATE ATTACHMENT PHARYNGEAL FLAP 1502.73 090<br />
42226 LNGTH PALATE&PHARYNGEAL FLAP 1506.05 090<br />
42227 LNGTH PALATE W/ISLAND FLAP 1438.48 090<br />
42235 RPR ANT PALATE W/VOMER FLAP 1219.13 090<br />
42260 RPR NASOLABIAL FSTL 1342.65 090<br />
42280 MAX IMPRESJ PALATAL PROSTH 265.32 010<br />
42281 INSJ PIN-RETAINED PALATAL PROSTH 334.00 010<br />
42299 UNLIS PX PALATE UVULA BR YYY<br />
42300 DRG ABSC PRTD SMPL 341.76 010<br />
42305 DRG ABSC PRTD COMP 711.76 090<br />
42310 DRG ABSC SUBMAX/SUBLNGL INTRAORAL 265.32 010<br />
42320 DRG ABSC SUBMAX XTRNL 409.33 010<br />
42330 SIALOT SUBMNDBLR SUBLNGL/PRTD UNCOMP INTRAORAL 379.98 010<br />
42335 SIALOLITHOTOMY SUBMNDBLR SUBMAX COMP INTRAORAL 608.74 090<br />
42340 SIALOLITHOTOMY PRTD XTRORAL/COMP INTRAORAL 758.29 090<br />
42400 BX SALIVARY GLND NDL 175.59 000<br />
42405 BX SALIVARY GLND INCAL 489.09 010<br />
42408 EXC SUBLNGL SALIVARY CST RANULA 744.44 090<br />
42409 MARSUPIALIZATION SUBLNGL SALIVARY CST RANULA 543.93 090<br />
42410 EXC PRTD TUM/PRTD GLND LAT LOBE W/O NRV DSJ 1029.70 090<br />
42415 EXC PRTD TUM/PRTD GLND LAT DSJ&PRSRV FACIAL NRV 1842.83 090<br />
42420 EXC PRTD TUM/PRTD GLND TOT DSJ&PRSRV FACIAL NRV 2110.91 090<br />
42425 EXC PRTD TUM/PRTD GLND TOT EN BLOC RMVL 1393.06 090<br />
42426 EXC PRTD TUM/PRTD GLND TOT W/UNI RAD NCK DSJ 2252.71 090<br />
42440 EXC SUBMNDBLR SUBMAX GLND 773.24 090<br />
42450 EXC SUBLNGL GLND 741.67 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
116 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
42500 PLSTC RPR SALIVARY DUX SIALODOCHOPLASTY PRIM 708.44 090<br />
42505 PLSTC RPR SALIVARY DUX SIALODOCHOPLASTY SEC/COMP 910.61 090<br />
42507 PRTD DUX DVRJ BI 851.90 090<br />
42508 PRTD DUX DVRJ BI W/EXC 1 SUBMNDBLR GLND 1167.62 090<br />
42509 PRTD DUX DVRJ BI W/EXC BTH SUBMNDBLR GLNDS 1357.06 090<br />
42510 PAROTID DUCT DVRJ BILATERAL WITH LIG BOTH DUCTS 1044.66 090<br />
42550 NJX SIALOGRAPY 227.10 000<br />
42600 CLSR SALIVARY FSTL 792.08 090<br />
42650 DILAT SALIVARY DUX 136.26 000<br />
42660 DILAT&CATHJ SALIVARY DUX +-NJX 173.92 000<br />
42665 LIG SALIVARY DUX INTRAORAL 511.80 090<br />
42699 UNLIS PX SALIVARY GLNDS/DUXS BR YYY<br />
42700 I&D ABSC PRITONSILLAR 309.63 010<br />
42720 I&D ABSC RTRPHRNGL/PARAPHARYNGEAL INTRAORAL 749.98 010<br />
42725 I&D ABSC RTRPHRNGL/PARAPHARYNGEAL XTRNL APPR 1343.21 090<br />
42800 BX OROPHARYNX 260.33 010<br />
42802 BX HYPOPHARYNX 388.84 010<br />
42804 BX NASOPHARYNX VISIBLE LES SMPL 327.35 010<br />
42806 BX NASOPHARYNX SURV UNKNOWN PRIM LES 367.79 010<br />
42808 EXC/DSTRJ LES PHARYNX ANY METH 373.88 010<br />
42809 RMVL FB FROM PHARYNX 279.17 010<br />
42810 EXC BRANCHIAL CL CST CONFINED SKN&SUBQ TISS 636.43 090<br />
42815 EXC BRANCHIAL CL CST EXTG BELW SUBQ TISS&/PHRNX 921.69 090<br />
42820 TONSILLECTOMY&ADENOIDECTOMY UNDER AGE 12 482.45 090<br />
42821 TONSILLECTOMY&ADENOIDECTOMY AGE 12/> 502.39 090<br />
42825 TONSILLECTOMY 1/2 UNDER AGE 12 435.37 090<br />
42826 TONSILLECTOMY 1/2 AGE 12/> 418.19 090<br />
42830 ADENOIDECTOMY PRIM UNDER AGE 12 343.97 090<br />
42831 ADENOIDECTOMY PRIM AGE 12/> 370.56 090<br />
42835 ADENOIDECTOMY SEC UNDER AGE 12 295.78 090<br />
42836 ADENOIDECTOMY SEC AGE 12/> 401.02 090<br />
42842 RAD RESCJ TONSIL W/O CLSR 1631.79 090<br />
42844 RAD RESCJ TONSIL CLSR W/LOCAL FLAP 2258.80 090<br />
42845 RAD RESCJ TONSIL CLSR W/OTH FLAP 3671.25 090<br />
42860 EXC TONSIL TAGS 312.40 090<br />
42870 EXC/DSTRJ LNGL TONSIL ANY METH SPX 955.48 090<br />
42890 LMTD PHARYNGECTOMY 2320.29 090<br />
42892 RESCJ LAT PHRNGL WALL/PYRIFORM SINUS DIR CLSR 3061.96 090<br />
42894 RESCJ PHRNGL WALL CLSR W/FLP OR FLP W/MVASC ANAS 3882.29 090<br />
42900 SUTR PHARYNX WND/INJ 565.53 010<br />
42950 PHARYNGOPLASTY PLSTC/RCNSTV OPRATION PHARYNX 1312.19 090<br />
42953 PHARYNGOESOPHGL RPR 1594.68 090<br />
42955 PHARYNGOSTOMY FSTLJ PHARYNX XTRNL <strong>FEE</strong>DING 1236.86 090<br />
42960 CTRL OROPHARYNGEAL HEMRRG 1/2 SMPL 280.83 010<br />
42961 CTRL OROPHARYNGEAL HEMRRG 1/2 COMP REQ HOSPITJ 697.91 090<br />
42962 CTRL OROPHARYNGEAL HEMRRG 1/2 W/SEC SURG IVNTJ 860.76 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 117
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
42970 CTRL NASPHRYNGL HEMRRG 1/2 SMPL W/PST NSL PACKS 653.05 090<br />
42971 CTRL NASPHRYNGL HEMRRG 1/2 COMP REQ HOSPIZATION 759.40 090<br />
42972 CTRL NASPHRYNGL HEMRRG 1/2 W/SEC SURG IVNTJ 850.24 090<br />
42999 UNLIS PX PHARYNX ADENOIDS/TONSILS BR YYY<br />
43020 ESOPHAGOTOMY CRV APPR W/RMVL FB 880.15 090<br />
43030 CRICOPHARYNGEAL MYOTOMY 864.08 090<br />
43045 ESOPHAGOTOMY THRC APPR W/RMVL FB 2180.15 090<br />
43100 EXC LES ESOPH W/PRIM RPR CRV APPR 1034.69 090<br />
43101 EXC LES ESOPH W/PRIM RPR THRC/ABDL APPR 1686.07 090<br />
43107 TOT ESPHG W/O THORCOM PHRNGSTRSTY/EGST 4217.39 090<br />
43108 TOT ESPHG W/O THORCOM COLON NTRPSTJ/INT RCNSTJ 7498.70 090<br />
43112 TOT ESPHG W/THORCOM W/PHRNGSTRSTY/EGST 4473.85 090<br />
43113 TOT ESPHG W/THORCOM W/COLON NTRPSTJ/INT RCNSTJ 7399.55 090<br />
43116 PRTL ESPHG CRV W/FR INTSTINAL GRF 8436.45 090<br />
43117 PRTL ESPHG DSTL THORCOM ABDL INC EGST 4102.74 090<br />
43118 PRTL ESPHG DSTL THORCOM ABDL INC NTRPSTJ/RCNSTJ 6125.58 090<br />
43121 PRTL ESPHG DSTL THORCOM ONLY THRC EGST 4755.79 090<br />
43122 PRTL ESPHG THORACOABDL/ABDL APPR EGST 4174.74 090<br />
43123 PRTL ESPHG THORACOABDL/ABDL APPR NTRPSTJ/RCNSTJ 7565.72 090<br />
43124 TOT/PRTL ESPHG W/O RCNSTJ W/CRV ESOPHAGOSTOMY 6504.45 090<br />
43130 DIVERTICULECTOMY HYPOPHARYNX/ESOPH CRV APPR 1305.54 090<br />
43135 DIVERTICULECTOMY HYPOPHARYNX/ESOPH THRC APPR 2479.81 090<br />
K 43200 ESPHGSC RGD/FLX DX +-COLLJ SPEC BR/WA SPX 353.94 000<br />
K 43201 ESPHGSC RGD/FLX DIRED SBMCSL NJX ANY SBST 483.55 000<br />
K 43202 ESPHGSC RGD/FLX W/BX 1/MLT 463.06 000<br />
K 43204 ESPHGSC RGD/FLX W/NJX SCLEROSIS ESOPHGL VARC 369.45 000<br />
K 43205 ESPHGSC RGD/FLX W/BAND LIG ESOPHGL VARC 372.77 000<br />
K 43215 ESPHGSC RGD/FLX W/RMVL FB 256.46 000<br />
K 43216 ESPHGSC RGD/FLX RMVL TUM HOT BX FORCEPS/CAUT 339.54 000<br />
K 43217 ESPHGSC RGD/FLX W/RMVL TUM SNARE TQ 619.81 000<br />
K 43219 ESPHGSC RGD/FLX W/INSJ PLSTC TUBE/STENT 285.26 000<br />
K 43220 ESPHGSC RGD/FLX W/BALO DILAT < 30 MM DIAM 211.04 000<br />
K 43226 ESPHGSC RGD/FLX W/INSJ GD WIRE DILAT 235.41 000<br />
K 43227 ESPHGSC RGD/FLX W/CTRL BLD 349.51 000<br />
K 43228 ESPHGSC RGD/FLX ABLTJ TUM XCP HOT BX/CAUT/SNARE 371.11 000<br />
K 43231 ESPHGSC RGD/FLX W/NDSC US XM 316.83 000<br />
K 43232 ESPHGSC RGD/FLX W/TNDSC US-GID FINE NDL ASPIR/BX 436.47 000<br />
K 43234 UPPER STOMACH-INTESTINE SCOPE SIMPLE 458.63 000<br />
K 43235 UPPER STOMACH-INTESTINE SCOPE FOR DIAGNOSIS 485.77 000<br />
K 43236 STOMACH-INTESTINE SCOPE INJECT INTESTINE WALL 602.09 000<br />
K 43237 UPR GI NDSC NDSC US XM LMTD ESOPH 392.16 000<br />
K 43238 UPR GI NDSC TNDSC US FINE NDL ASPIR/BX ESOPH 489.09 000<br />
K 43239 UPPER STOMACH-INTESTINE SCOPE FOR BIOPSY 562.76 000<br />
K 43240 UPR GI NDSC TRANSMURAL DRG PSEUDOCST 660.25 000<br />
K 43241 UPR GI NDSC TNDSC INTRAL TUBE/CATH PLMT 258.67 000<br />
K 43242 STOMACH-INTESTINE SCOPE ULTRASOUND GUIDED BIOPSY 705.11 000<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
118 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
K 43243 UPR GI NDSC NJX SCLEROSIS ESOPHGL&/GSTR VARC 445.34 000<br />
K 43244 UPR GI NDSC BAND LIG ESOPHGL&/GSTR VARC 491.86 000<br />
K 43245 UPR GI NDSC DILAT GSTR OUTLET FOR OBSTRCJ 312.95 000<br />
K 43246 UPR GI NDSC DIRED PLMT PRQ GASTROSTOMY TUBE 418.75 000<br />
K 43247 STOMACH-INTESTINE SCOPE FOR FOREIGN BODY REMOVAL 333.45 000<br />
K 43248 UPR GI NDSC INSJ GD WIRE DILAT ESOPH > GD WIRE 313.51 000<br />
K 43249 UPR GI NDSC BALO DILAT ESOPH < 30 MM DIAM 289.14 000<br />
K 43250 UPR GI NDSC RMVL LES HOT BX/BIPOLAR CAUT 314.06 000<br />
K 43251 UPR GI NDSC RMVL TUM POLYP/OTH LES SNARE TQ 362.80 000<br />
K 43255 UPR GI NDSC CTRL BLD ANY METH 470.26 000<br />
K 43256 UPR GI NDSC TNDSC STENT PLMT W/PREDILAT 424.29 000<br />
K 43257 UPR GI NDSC DLVR THERMAL NRG SPHNCTR/CARDIA 529.53 000<br />
K 43258 UPR GI NDSC ABLTJ LES X RMVL FORCEPS/CAUT/SNARE 444.23 000<br />
K 43259 STOMACH-INTESTINE SCOPE WITH ULTRASOUND EXAM 505.71 000<br />
K 43260 ERCP DX COLLJ SPEC BR/WA SPX 577.16 000<br />
K 43261 ERCP W/BX 1/MLT 606.52 000<br />
K 43262 ERCP W/SPHNCTROTOMY/PAPILLOTOMY 712.87 000<br />
K 43263 ERCP W/PRESS MEAS SPHNCTR ODDI 702.90 000<br />
K 43264 ERCP W/RMVL ST1/CALCULI BILIARY&/PNCRTC DUXS 855.78 000<br />
K 43265 ERCP W/DSTRJ LITHOTRP ST1/CALCULI ANY METH 959.91 000<br />
K 43267 ERCP W/INSJ NASOBILIARY/NASOPNCRTC DRG TUBE 710.10 000<br />
K 43268 ERCP W/INSJ TUBE/STENT BILE/PNCRTC DUX 722.29 000<br />
K 43269 ERCP W/RTRGR RMVL FB&/CHNG TUBE/STENT 789.86 000<br />
K 43271 ERCP W/BALO DILAT AMPULLA BILIARY&/PNCRTC DUX 712.32 000<br />
K 43272 ERCP W/ABLTJ LES X RMVL FORCEPS/CAUT/SNARE 712.87 000<br />
+ K 43273 ENDOSCOPIC PAPILLA CANNULATION BILE PANCREATIC 213.25 ZZZ<br />
43279 LAPS ESOPHAGOMYOTOMY W/FUNDOPLASTY IF PERFORMED 2092.08 090<br />
43280 LAPS SURG ESOPG/GSTR FUNDOPLASTY 1743.12 090<br />
43281 LAPS RPR PARAESPHGL HRNA INCL FUNDPLSTY W/O MESH 2567.88 090<br />
43282 LAPS RPR PARAESPHGL HRNA INCL FUNDPLSTY W/MESH 2885.27 090<br />
l + 43283 LAPS ESOPHAGEAL LENGTHENING ADDL 267.53 ZZZ<br />
43289 UNLIS LAPS PX ESOPH BR YYY<br />
43300 ESPHGP CRV APPR W/O RPR TRACHEOESOPHGL FSTL 1018.07 090<br />
43305 ESPHGP CRV APPR W/RPR TRACHEOESOPHGL FSTL 1818.45 090<br />
43310 ESPHGP THRC APPR W/O RPR TRACHEOESOPHGL FSTL 2502.52 090<br />
43312 ESPHGP THRC APPR W/RPR TRACHEOESOPHGL FSTL 2729.62 090<br />
43313 ESPHGP CGEN DFCT THRC APPR W/O RPR FSTL 4618.42 090<br />
43314 ESPHGP CGEN DFCT THRC APPR W/RPR FSTL 4712.58 090<br />
43320 EGST+-VAGOTOMY&PYLOROPLASTY TABDL/TTHRC APPR 2260.47 090<br />
43325 ESOPG/GSTR FUNDOPLASTY W/FUNDIC PATCH 2159.10 090<br />
l 43327 ESOPG/GSTR FUNDOPLASTY W/LAPT 1346.53 090<br />
l 43328 ESOPG/GSTR FUNDOPLASTY W/THORCOM 1977.98 090<br />
43330 ESOPHAGOMYOTOMY HELLER TYP ABDL APPR 2126.98 090<br />
43331 ESOPHAGOMYOTOMY HELLER TYP THRC APPR 2261.02 090<br />
l 43332 RPR PARAESOPH HIATAL HERNIA W/LAPT W/O MESH 1928.68 090<br />
l 43333 LAPT RPR PARAESOPH HIATAL HERNIA W/ MESH 2094.30 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 119
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
l 43334 RPR PARAESOPH HIATAL HERNIA W/THORCOM W/O MESH 2117.01 090<br />
l 43335 RPR PARAESOPH HIATAL HERNIA W/THORCOM W/MESH 2280.96 090<br />
l 43336 RPR PARAESOPH HIATAL HERNIA THORCOABDOM W/O MESH 2499.20 090<br />
l 43337 RPR PARAESOPH HIATAL HERNIA THORCOABDOM W/MESH 2727.96 090<br />
l + 43338 ESOPHAGUS LENGTHENING 222.11 ZZZ<br />
43340 ESOPHAGOJEJUNOSTOMY W/O TOT GSTRCT ABDL APPR 2218.92 090<br />
43341 ESOPHAGOJEJUNOSTOMY W/O TOT GSTRCT THRC APPR 2438.27 090<br />
43350 ESOPHAGOSTOMY FSTLJ ESOPH XTRNL ABDL APPR 1995.15 090<br />
43351 ESOPHAGOSTOMY FSTLJ ESOPH XTRNL THRC APPR 2181.81 090<br />
43352 ESOPHAGOSTOMY FSTLJ ESOPH XTRNL CRV APPR 1785.77 090<br />
43360 GI RCNSTJ PREV ESPHG/EXCLUSION W/STOMACH 3792.00 090<br />
43361 GI RCNSTJ PREV ESPHG/EXCLUSION W/COLON SM INT 4223.49 090<br />
43400 LIG DIR ESOPHGL VARC 2491.44 090<br />
43401 TRNSXJ ESOPH W/RPR ESOPHGL VARC 2463.19 090<br />
43405 LIG/STAPLING G-ESOP JUNCT PRE-ESOPHGL PRF8J 2466.52 090<br />
43410 SUTR ESOPHGL WND/INJ CRV APPR 1709.34 090<br />
43415 SUTR ESOPHGL WND/INJ TTHRC/TABDL APPR 2833.75 090<br />
43420 CLSR ESOPHAGOSTOMY/FSTL CRV APPR 1668.90 090<br />
43425 CLSR ESOPHAGOSTOMY/FSTL TTHRC/TABDL APPR 2480.92 090<br />
43450 OPENING OF ESOPHAGUS 257.01 000<br />
K 43453 DILAT ESOPH > GD WIRE 483.55 000<br />
K 43456 DILAT ESOPH BALO/DILATOR RTRGR 978.74 000<br />
K 43458 DILAT ESOPH BALO 30 MM DIAM/LGR ACHALASIA 634.22 000<br />
43460 ESOPG/GSTR TAMPONADE W/BALO SENGSTAKEN TYP 367.79 000<br />
43496 FR JEJUNUM TR W/MVASC ANAST BR 090<br />
43499 UNLIS PX ESOPH BR YYY<br />
43500 GSTRT W/EXPL/FB RMVL 1258.46 090<br />
43501 GSTRT W/SUTR RPR BLD ULCER 2156.33 090<br />
43502 GSTRT W/SUTR RPR PRE-ESOPG/GSTR LAC 2441.59 090<br />
43510 GSTRT W/ESOPHGL DILAT&INSJ PRM INTRAL TUBE 1531.53 090<br />
43520 PYLOROMYOTOMY CUTTING PYLORIC MUSC 1124.97 090<br />
s 43605 BX STOMACH LAPT 1344.32 090<br />
43610 EXC LOCAL ULCER/B9 TUM STOMACH 1572.52 090<br />
43611 EXC LOCAL MAL TUM STOMACH 1958.04 090<br />
43620 GSTRCT TOT W/ESOPHAGONTRSTM 3171.63 090<br />
43621 GSTRCT TOT W/ROUX-EN-Y RCNSTJ 3643.00 090<br />
43622 GSTRCT TOT W/FRMJ INTSTINAL POUCH ANY TYP 3694.51 090<br />
43631 GSTRCT PRTL DSTL W/GASTRODUODENOSTOMY 2330.26 090<br />
43632 GSTRCT PRTL DSTL W/GASTROJEJUNOSTOMY 3241.42 090<br />
43633 GSTRCT PRTL DSTL W/ROUX-EN-Y RCNSTJ 3071.38 090<br />
43634 GSTRCT PRTL DSTL W/FRMJ INTSTINAL POUCH 3397.62 090<br />
+ 43635 VAGOTOMY PFRMD W/PRTL DSTL GSTRCT 181.68 ZZZ<br />
43640 VGTMY W/PYPS +-GASTROSTOMY TRUNCAL/SLCTV 1887.14 090<br />
43641 VGTMY W/PYPS +-GASTROSTOMY PARIETAL CELL 1914.28 090<br />
43644 LAPS GSTR RSTCV PX W/BYP ROUX-EN-Y
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
43647 LAPS IMPLTJ/RPLCMT GASTRIC NSTIM ELTRD ANTRUM BR YYY<br />
43648 LAPS REVISION/RMVL GASTRIC NSTIM ELTRD ANTRUM BR YYY<br />
43651 LAPS SURG TRNSXJ VAGUS NRV TRUNCAL 1042.44 090<br />
43652 LAPS SURG TRNSXJ VAGUS NRV SLCTV/HILY SLCTV 1219.69 090<br />
43653 LAPS SURG GASTROSTOMY W/O CONSTJ GSTR TUBE SPX 905.63 090<br />
43659 UNLIS LAPS PX STOMACH BR YYY<br />
43752 NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDN 67.58 000<br />
l 43753 GASTRIC TUBE PLMT W/ASPIR & LAVAGE 33.79 000<br />
l 43754 GASTRIC TUBE DX PLMT W/ASPIR 1 SPECIMEN 128.50 000<br />
l 43755 GASTRIC TUBE DX PLMT W/ASPIR MULT SPECIMENS 196.08 000<br />
l 43756 DUODENAL TUBE DX PLMT W/IMG GID 1 SPECIMEN 355.60 000<br />
l 43757 DUODENAL TUBE DX PLMT W/IMG GID MULT SPECIMEN 457.52 000<br />
43760 CHANGE GASTROSTOMY TUBE PERCUTANEOUS W/O GUIDE 658.59 000<br />
43761 REPOS NASO/ORO GASTRIC <strong>FEE</strong>DING TUBE THRU DUO 196.63 000<br />
43770 LAPS GASTRIC RESTRICTIVE PROCEDURE PLACE DEVICE 1789.10 090<br />
43771 LAPS GASTRIC RESTRICTIVE PX REVISION DEVICE 2038.91 090<br />
43772 LAPS GASTRIC RESTRICTIVE PX REMOVE DEVICE 1535.96 090<br />
43773 LAPS GASTRIC RESTRICTIVE PX REMOVE&RPLCMT DEVICE 2038.91 090<br />
43774 LAPS GASTRIC RESTRICTIVE PX REMOVE DEVICE &PORT 1540.40 090<br />
43775 LAPS GSTRC RSTRICTIV PX LONGITUDINAL GASTRECTOMY 2118.11 XXX<br />
43800 PYLOROPLASTY 1492.21 090<br />
43810 GASTRODUODENOSTOMY 1624.03 090<br />
43820 GASTROJEJUNOSTOMY W/O VAGOTOMY 2135.28 090<br />
43825 GASTROJEJUNOSTOMY W/VAGOTOMY ANY TYP 2092.08 090<br />
43830 GASTROSTOMY OPN W/O CONSTJ GSTR TUBE SPX 1114.45 090<br />
43831 GASTROSTOMY OPN NEONATAL <strong>FEE</strong>DING 942.18 090<br />
43832 GASTROSTOMY OPN W/CONSTJ GSTR TUBE 1692.16 090<br />
43840 GASTRORRHAPHY SUTR PRF8 DUOL/GSTR ULCER WND/INJ 2164.09 090<br />
43842 GSTR RSTCV W/O BYP VER-BANDED GSTP 1868.86 090<br />
43843 GSTR RSTCV W/O BYP OTH/THN VER-BANDED GSTP 2042.23 090<br />
43845 GSTR RSTCV W/PRTL GSTRCT 50-100 CM 3141.17 090<br />
43846 GSTR RSTCV W/BYP W/SHORT LIMB 150 CM/< 2618.29 090<br />
43847 GSTR RSTCV W/BYP W/SM INT RCNSTJ LIMIT ABSRPJ 2874.74 090<br />
43848 REVISION OPEN GASTRIC RESTRICTIVE PX NOT DEVICE 3099.62 090<br />
43850 REVJ GASTRODUOL ANAST W/RCNSTJ W/O VAGOTOMY 2603.33 090<br />
43855 REVJ GASTRODUOL ANAST W/RCNSTJ W/VGTMY 2709.12 090<br />
43860 REVJ GSTR/JJ ANAST W/RCNSTJ W/O VGTMY 2626.04 090<br />
43865 REVJ GSTR/JJ ANAST W/RCNSTJ W/VGTMY 2739.59 090<br />
43870 CLSR GASTROSTOMY SURG 1136.05 090<br />
43880 CLSR GASTROCOLIC FSTL 2563.45 090<br />
43881 IMPLTJ/RPLCMT GASTRIC NSTIM ELTRD ANTRUM OPEN BR YYY<br />
43882 REVISION/RMVL GASTRIC NSTIM ELTRD ANTRUM OPEN BR YYY<br />
43886 GSTR RSTCV PX OPN REVJ SUBQ PORT COMPONENT ONLY 567.19 090<br />
43887 GSTR RSTCV PX OPN RMVL SUBQ PORT COMPONENT ONLY 514.57 090<br />
43888 GSTR RSTCV OPN RMVL&RPLCMT SUBQ PORT 726.72 090<br />
43999 UNLIS PX STOMACH BR YYY<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 121
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
44005 ENTEROLSS FRING INTSTINAL ADHESION SPX 1755.31 090<br />
44010 DUODEXOMY EXPL BX/FB RMVL 1388.07 090<br />
+ 44015 TUBE/NDL CATH JEJUNOSTOMY ANY METH 233.19 ZZZ<br />
44020 ENTEROTOMY SM INT OTH/THN DUO EXPL BX/FB RMVL 1558.67 090<br />
44021 ENTEROTOMY SM INT OTH/THN DUO DCMPRN 1575.29 090<br />
44025 COLOTOMY EXPL BX/FB RMVL 1583.60 090<br />
44050 RDCTJ VOLVULUS INTUSSUSCEPTION INT HRNA LAPT 1497.19 090<br />
44055 CORRJ MALROTATION BANDS&/RDCTJ VOLVULUS 2400.60 090<br />
44100 BX INT CAPSL TUBE PRORAL 1+ SPECS 188.88 000<br />
44110 EXC 1+ < SM/LG INT 1 ENTEROTOMY 1359.82 090<br />
44111 EXC 1+ < SM/LG INT MLT ENTEROTOMIES 1579.72 090<br />
44120 ENTRC RESCJ SM INT 1 RESCJ&ANAST 1960.81 090<br />
+ 44121 ENTRC RESCJ SM INT EA RESCJ&ANAST 392.72 ZZZ<br />
44125 ENTRC RESCJ SM INT W/NTRSTM 1894.89 090<br />
44126 ENTRC RESCJ ATRESIA RESCJ&ANAST W/O TAPRING 3945.98 090<br />
44127 ENTRC RESCJ ATRESIA RESCJ&ANAST SGM W/TAPRING 4570.78 090<br />
+ 44128 ENTRC RESCJ ATRESIA EA RESCJ&ANAST 394.93 ZZZ<br />
44130 ENTERONTRSTM ANAST INT +-CUTAN NTRSTM SPX 2090.97 090<br />
44132 DON ENTRC OPN FROM CDVR DON BR XXX<br />
44133 DON ENTRC OPN PRTL FROM LIV DON BR XXX<br />
44135 INTSTINAL ALTRNSPLJ FROM CDVR DON BR XXX<br />
44136 INTSTINAL ALTRNSPLJ FROM LIV DON BR XXX<br />
44137 RMVL TRNSPLED INTSTINAL ALGRFT COMPL BR XXX<br />
+ 44139 MOBLJ SPLENIC FLXR PFRMD CONJUNCT W/PRTL COLCT 196.63 ZZZ<br />
44140 COLCT PRTL W/ANAST 2153.01 090<br />
44141 COLCT PRTL W/SKN LVL CECOSTOMY/CLST 2907.98 090<br />
44143 COLCT PRTL W/END CLST&CLSR DSTL SGM 2671.46 090<br />
44144 COLCT PRTL W/RESCJ W/CLST/ILEOST&MUCOFSTL 2832.09 090<br />
44145 COLCT PRTL W/COLOPXTSTMY LW PEL ANAST 2670.91 090<br />
44146 COLCT PRTL W/COLOPXTSTMY LW PEL ANAST W/CLST 3385.99 090<br />
44147 COLCT PRTL ABDL&TRANSANAL APPR 3097.41 090<br />
44150 COLCT TOT ABDL W/O PRCTECT W/ILEOST/ILEOPXTS 2987.74 090<br />
44151 COLCT TOT ABDL W/O PRCTECT W/CONTINENT ILEOST 3426.43 090<br />
44155 COLCT TOT ABDL W/PRCTECT W/ILEOST 3323.95 090<br />
44156 COLCT TOT ABDL W/PRCTECT W/CONTINENT ILEOST 3687.31 090<br />
44157 COLCT TTL ABD W/PRCTECT ILEOANAL ANAST 3486.25 090<br />
44158 COLCT TTL ABD W/PRCTECT ILEOANAL ANAST & RSVR 3568.78 090<br />
44160 COLCT PRTL W/RMVL TERMINAL ILE W/ILEOCLST 1991.27 090<br />
44180 LAPS ENTEROLSS FRING INTSTINAL ADHESION SPX 1478.36 090<br />
44186 LAPS JEJUNOSTOMY 1048.53 090<br />
44187 LAPS ILEOST/JEJUNOSTOMY NON-TUBE 1765.83 090<br />
44188 LAPS CLST/SKN LVL CECOSTOMY 1959.14 090<br />
44202 LAPS ENTRC RESCJ SM INT 1 RESCJ&ANAST 2228.34 090<br />
+ 44203 LAPS EA SM INT RESCJ&ANAST 393.27 ZZZ<br />
44204 LAPS COLCT PRTL W/ANAST 2477.59 090<br />
44205 LAPS COLCT PRTL W/RMVL TERMINAL ILE 2156.89 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
122 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
44206 LAPS COLCT PRTL W/END CLST&CLSR DSTL SGM 2826.00 090<br />
44207 LAPS COLCT PRTL W/COLOPXTSTMY LW ANAST 2945.64 090<br />
44208 LAPS COLCT PRTL W/COLOPXTSTMY LW ANAST W/CLST 3200.43 090<br />
44210 LAPS COLCT TOT W/O PRCTECT W/ILEOST/ILEOPXTS 2882.50 090<br />
44211 LAPS COLCT TTL ABD W/PRCTECT ILEOANAL ANAST&RSVR 3595.92 090<br />
44212 LAPS COLCT ABDL W/PRCTECT W/ILEOST 3305.12 090<br />
+ 44213 LAPS MOBLJ SPLENIC FLXR PFRMD W/PRTL COLCT 306.86 ZZZ<br />
44227 LAPS CLSR NTRSTM LG/SM INT W/RESCJ&ANAST 2688.63 090<br />
44238 UNLIS LAPS PX INT XCP RECTUM BR YYY<br />
44300 PLACEMENT ENTEROSTOMY/CECOSTOMY TUBE OPEN 1351.52 090<br />
44310 ILEOST/JEJUNOSTOMY NON-TUBE 1675.55 090<br />
44312 REVJ ILEOST SMPL RLS SUPFC SCAR SPX 951.60 090<br />
44314 REVJ ILEOST COMP RCNSTJ IN-DEPTH SPX 1620.16 090<br />
44316 CONTINENT ILEOST KOCK PX SPX 2259.91 090<br />
44320 CLST/SKN LVL CECOSTOMY 1925.36 090<br />
44322 CLST/SKN LVL CECOSTOMY W/MLT BXS SPX 1572.52 090<br />
44340 REVJ CLST SMPL RLS SUPFC SCAR SPX 987.05 090<br />
44345 REVJ CLST COMP RCNSTJ IN-DEPTH SPX 1685.52 090<br />
44346 REVJ CLST W/RPR PARACLST HRNA SPX 1893.23 090<br />
K 44360 SCOPE OF UPPER SMALL INTESTINE 261.99 000<br />
K 44361 SCOPE OF UPPER SMALL INTESTINE WITH BIOPSY 288.03 000<br />
K 44363 ENTEROSCOPY > 2ND PRTN X ILE RMVL FB 343.42 000<br />
K 44364 ENTEROSCOPY > 2ND PRTN X ILE RMVL LES SNARE 367.79 000<br />
K 44365 ENTEROSCOPY > 2ND PRTN X ILE RMVL LES CAUT 328.46 000<br />
K 44366 ENTEROSCOPY > 2ND PRTN X ILE CTRL BLD 432.60 000<br />
K 44369 ENTEROSCOPY > 2ND PRTN X ILE ABLTJ LES 442.01 000<br />
K 44370 ENTEROSCOPY > 2ND PRTN X ILE TNDSC STENT PLMT 477.46 000<br />
K 44372 ENTEROSCOPY > 2ND PRTN X ILE W/PLMT PRQ TUBE 424.84 000<br />
K 44373 ENTEROSCOPY > 2ND PRTN X ILE CONV GSTRST TUBE 341.76 000<br />
K 44376 ENTEROSCOPY > 2ND PRTN W/ILE +-COLLJ SPEC SPX 505.71 000<br />
K 44377 ENTEROSCOPY > 2ND PRTN W/ILE W/BX 1/MLT 535.07 000<br />
K 44378 ENTEROSCOPY > 2ND PRTN ILE CTRL BLD 686.84 000<br />
K 44379 ENTEROSCOPY > 2ND PRTN W/ILE W/STENT PLMT 727.82 000<br />
K 44380 ILESC THRU STOMA DX +-COLLJ SPEC BR/WA SPX 113.00 000<br />
K 44382 ILESC THRU STOMA W/BX 1/MLT 137.37 000<br />
K 44383 ILESC THRU STOMA W/TNDSC STENT PLMT 279.72 000<br />
K 44385 NDSC EVAL INTSTINAL POUCH DX +-COLLJ SPEC SPX 412.66 000<br />
K 44386 NDSC EVAL INTSTINAL POUCH W/BX 1/MLT 568.30 000<br />
K 44388 SCOPE OF COLON THRU OSTOMY FOR DIAGNOSIS 568.86 000<br />
K 44389 SCOPE OF COLON WITH BIOPSY THRU OSTOMY 651.39 000<br />
K 44390 COLSC THRU STOMA W/RMVL FB 757.18 000<br />
K 44391 COLSC THRU STOMA CTRL BLD 829.74 000<br />
K 44392 COLSC THRU STOMA RMVL LES CAUT 714.53 000<br />
K 44393 COLSC THRU STOMA ABLTJ LES 827.53 000<br />
K 44394 COLSC THRU STOMA W/RMVL TUM POLYP/OTH LES SNARE 824.20 000<br />
K 44397 COLSC THRU STOMA W/TNDSC STENT PLMT 457.52 000<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 123
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
* K 44500 INTRO LONG GI TUBE SPX 40.43 000<br />
44602 ENTERORRHAPHY 1 PRF8J 2252.71 090<br />
44603 ENTERORRHAPHY MLT PRF8J 2584.50 090<br />
44604 SUTR LG INT 1/MLT PRF8J W/O CLST 1698.81 090<br />
44605 SUTR LG INT 1/MLT PRF8J W/CLST 2101.50 090<br />
44615 INTSTINAL STRICTUROPLASTY+-DILAT OBSTRCJ 1730.38 090<br />
44620 CLSR NTRSTM LG/SM INT 1388.07 090<br />
44625 CLSR NTRSTM LG/SM RESCJ&ANAST OTH/THN CLRCT 1636.22 090<br />
44626 CLSR NTRSTM LG/SM RESCJ&CLRCT ANAST 2586.16 090<br />
44640 CLSR INTSTINAL CUTAN FSTL 2258.25 090<br />
44650 CLSR ENTEROENTERIC/ENTEROCOLIC FSTL 2338.01 090<br />
44660 CLSR ENTEROVES FSTL W/O INTSTINAL/BLDR RESCJ 2195.66 090<br />
44661 CLSR ENTEROVES FSTL W/INT&/BLDR RESCJ 2516.92 090<br />
44680 INTSTINAL PLCTJ SPX 1719.86 090<br />
44700 EXCLUSION SM INT FROM PELVIS MESH/PROSTH/TISS 1632.90 090<br />
+ 44701 INTRAOP COLONIC LVG 271.41 ZZZ<br />
44715 BKBENCH ALGRFT INT FASHIONING ART&VEIN BR XXX<br />
44720 BKBENCH RCNSTJ INT ALGRFT VEN ANAST EA 413.76 XXX<br />
44721 BKBENCH RCNSTJ INT ALGRFT ARTL ANAST EA 626.46 XXX<br />
44799 UNLIS PX INT BR YYY<br />
44800 EXC MECKEL'S DIVERTICULUM/OMPHALOMESENTERIC DUCT 1219.69 090<br />
44820 EXC LES MESENTERY SPX 1346.53 090<br />
44850 SUTR MESENTERY SPX 1196.42 090<br />
44899 UNLISTED PX MECKEL'S DIVERTICULUM & MESENTERY BR YYY<br />
44900 I&D APPENDICEAL ABSC OPN 1235.20 090<br />
K 44901 I&D APPENDICEAL ABSC PRQ 1537.63 000<br />
44950 APPENDEC 1029.70 090<br />
+ 44955 APPENDEC INDICATED PURPOSE OTH MAJOR PX X SPX 136.26 ZZZ<br />
44960 APPENDEC RPTD APPENDIX ABSC/PRITONITIS 1399.15 090<br />
44970 LAPS SURG APPENDEC 955.48 090<br />
44979 UNLIS LAPS PX APPENDIX BR YYY<br />
45000 TRANSRCT DRG PEL ABSC 670.77 090<br />
45005 I&D SBMCSL ABSC RECTUM 413.21 010<br />
45020 I&D DP SUPRALEVATOR PELVIRCT/RETRORCT ABSC 895.66 090<br />
45100 BX ANRCT WALL ANAL APPR 469.15 090<br />
45108 ANRCT MYOMECTOMY 578.27 090<br />
45110 PRCTECT COMPL CMBN ABDOMINOPRNL W/CLST 2967.80 090<br />
45111 PRCTECT PRTL RESCJ RECTUM TABDL APPR 1747.00 090<br />
45112 PRCTECT CMBN ABDOMINOPRNL PULL-THRU PX 3035.37 090<br />
45113 PRCTECT PRTL W/MUCOSEC ILEOANAL ANAST RSVR 3174.40 090<br />
45114 PRCTECT PRTL W/ANAST ABDL&TRANSSAC APPR 2901.88 090<br />
45116 PRCTECT PRTL W/ANAST TRANSSAC APPR ONLY 2514.71 090<br />
45119 PRCTECT CMBN PULL-THRU W/RSVR W/NTRSTM 3126.77 090<br />
45120 PRCTECT COMPL W/PULL-THRU PX&ANAST 2541.29 090<br />
45121 PRCTECT COMPL W/STOT/TOT COLCT W/MLT BXS 2776.15 090<br />
45123 PRCTECT PRTL W/O ANAST PRNL APPR 1780.79 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
124 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
45126 PEL EXNTJ CLRCT MAL 4676.58 090<br />
45130 EXC RCT PROCIDENTIA W/ANAST PRNL APPR 1738.69 090<br />
45135 EXC RCT PROCIDENTIA W/ANAST ABDL&PRNL APPR 2183.47 090<br />
45136 EXC ILEOANAL RSVR W/ILEOST 2898.56 090<br />
45150 DIV STRIX RECTUM 631.45 090<br />
45160 EXC RCT TUM PROCTOTOMY TRANSSAC/TRANSCOCCYGEAL 1613.51 090<br />
45171 EXC RCT TUM NOT INCL MUSCULARIS PROPRIA 978.74 090<br />
45172 EXC RCT TUM INCL MUSCULARIS PROPRIA 1336.01 090<br />
45190 DSTRJ RCT TUM TRANSANAL APPR 1090.63 090<br />
45300 PROCTOSGMDSC RGD DX +-COLLJ SPEC BR/WA SPX 185.00 000<br />
K 45303 PROCTOSGMDSC RGD W/DILAT 1431.28 000<br />
K 45305 PROCTOSGMDSC RGD W/BX 1/MLT 296.89 000<br />
K 45307 PROCTOSGMDSC RGD W/RMVL FB 333.45 000<br />
K 45308 PROCTOSGMDSC RGD RMVL 1 LES CAUT 313.51 000<br />
K 45309 PROCTOSGMDSC RGD RMVL 1 LES SNARE TQ 334.00 000<br />
K 45315 PROCTOSGMDSC RGD RMVL MLT TUM < CAUT/SNARE 370.01 000<br />
K 45317 PROCTOSGMDSC RGD CTRL BLD 356.71 000<br />
K 45320 PROCTOSGMDSC RGD ABLTJ LES 346.74 000<br />
K 45321 PROCTOSGMDSC RGD DCMPRN VOLVULUS 174.48 000<br />
K 45327 PROCTOSGMDSC RGD TNDSC STENT PLMT 206.60 000<br />
45330 SCOPE OF SIGMOID COLON ONLY FOR DIAGNOSIS 224.33 000<br />
45331 SCOPE OF SIGMOID COLON ONLY WITH BIOPSY 279.72 000<br />
K 45332 SGMDSC FLX RMVL FB 466.94 000<br />
K 45333 SGMDSC FLX RMVL LES CAUT 471.92 000<br />
K 45334 SGMDSC FLX CTRL BLD 271.96 000<br />
K 45335 SGMDSC FLX DIRED SBMCSL NJX ANY SBST 412.10 000<br />
K 45337 SGMDSC FLX DCMPRN VOLVULUS ANY METH 235.41 000<br />
K 45338 SGMDSC FLX RMVL TUM POLYP/OTH LES SNARE TQ 517.34 000<br />
K 45339 SGMDSC FLX ABLTJ LES 545.59 000<br />
K 45340 SGMDSC FLX DILAT BALO 1/MORE STRIXS 741.12 000<br />
K 45341 SGMDSC FLX NDSC US XM 260.89 000<br />
K 45342 SGMDSC FLX TNDSC US GID NDL ASPIR/BX 398.25 000<br />
K 45345 SGMDSC FLX TNDSC STENT PLMT 289.69 000<br />
K 45355 COLSC RGD/FLX TABDL VIA COLOTOMY 1/MLT 336.77 000<br />
K 45378 SCOPE OF COLON FOR DIAGNOSIS 645.29 000<br />
K 45379 COLSC FLX PROX SPLENIC FLXR RMVL FB 823.10 000<br />
K 45380 SCOPE OF COLON WITH BIOPSY 771.03 000<br />
K 45381 COLSC FLX PROX SPLENIC FLXR SBMCSL NJX 750.53 000<br />
K 45382 COLSC FLX PROX SPLENIC FLXR CTRL BLD 1009.76 000<br />
K 45383 COLSC FLX PROX SPLENIC FLXR ABLTJ LES 926.12 000<br />
K 45384 COLSC FLX PROX SPLENIC FLXR RMVL LES CAUT 763.27 000<br />
K 45385 COLSC FLX PROX SPLENIC FLXR RMVL LES SNARE TQ 869.07 000<br />
K 45386 COLSC FLX PROX SPLENIC FLXR DILAT BALO 1+ STRIXS 1077.89 000<br />
K 45387 COLSC FLX PROX SPLENIC FLXR TNDSC STENT PLMT 573.29 000<br />
K 45391 COLSC FLX PROX SPLENIC FLXR NDSC US XM 491.86 000<br />
K 45392 COLSC FLX PROX SPLENIC FLXR US GID NDL ASPIR/BX 632.00 000<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 125
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
45395 LAPS PRCTECT COMPL CMBN ABDOMINOPRNL W/CLST 3192.68 090<br />
45397 LAPS PRCTECT CMBN PULL-THRU CRTJ RSVR 3443.60 090<br />
45400 LAPS PROCTOPEXY FOR PROLAPSE 1848.36 090<br />
45402 LAPS PROCTOPEXY FOR PROLAPSE SIGMOID RESCJ 2459.32 090<br />
45499 UNLIS LAPS PX RECTUM BR YYY<br />
45500 PROCTOPLASTY STENOSIS 823.10 090<br />
45505 PROCTOPLASTY PROLAPSE MUC MEMB 922.24 090<br />
45520 PRIRCT NJX SCLRSG SLN PROLAPSE 223.78 000<br />
45540 PROCTOPEXY ABDL APPR 1693.27 090<br />
45541 PROCTOPEXY PRNL APPR 1475.04 090<br />
45550 PROCTOPEXY W/SIGMOID RESCJ ABDL APPR 2343.55 090<br />
45560 RPR RECTOCELE SPX 1132.73 090<br />
45562 EXPL RPR&PRESAC DRG RCT INJ 1785.22 090<br />
45563 EXPL RPR&PRESAC DRG RCT INJ W/CLST 2617.18 090<br />
45800 CLSR RECTOVESICAL FSTL 1949.17 090<br />
45805 CLSR RECTOVESICAL FSTL W/CLST 2322.50 090<br />
45820 CLSR RECTOURTL FSTL 1884.92 090<br />
45825 CLSR RECTOURTL FSTL W/CLST 2328.04 090<br />
45900 RDCTJ PROCIDENTIA SPX UNDER ANES 319.60 010<br />
45905 DILAT ANAL SPHNCTR SPX UNDER ANES OTH/THN LOCAL 268.09 010<br />
45910 DILAT RCT STRIX SPX UNDER ANES OTH/THN LOCAL 313.51 010<br />
45915 RMVL FECAL IMPACTION/FB SPX UNDER ANES 506.26 010<br />
45990 ANRCT XM SURG REQ ANES GENERAL SPI/EDRL DX 173.37 000<br />
45999 UNLIS PX RECTUM BR YYY<br />
46020 PLMT SETON 421.52 010<br />
46030 RMVL ANAL SETON OTH MARKER 212.14 010<br />
46040 I&D ISCHIORCT&/PRIRCT ABSC SPX 816.45 090<br />
46045 I&D INTRAMURAL IM/ABSC TRANSANAL ANES 674.10 090<br />
46050 I&D PRIANAL ABSC SUPFC 300.21 010<br />
46060 I&D ISCHIORCT/INTRAMURAL ABSC +-SETON 738.35 090<br />
46070 INC ANAL SEPTUM INFT 358.37 090<br />
46080 SPHNCTROTOMY ANAL DIV SPHNCTR SPX 381.08 010<br />
46083 INC THROMBOSED HEMORRHOID XTRNL 276.95 010<br />
46200 FISSURECTOMY INCL SPHINCTEROTOMY WHEN PERFORMED 659.69 090<br />
# 46220 EXCISION SINGLE EXTERNAL PAPILLA OR TAG ANUS 313.51 010<br />
46221 HEMORRHOIDECTOMY INTERNAL RUBBER BAND LIGATIONS 408.22 010<br />
46230 EXCISION MULTIPLE EXTERNAL PAPILLAE/TAGS ANUS 419.86 010<br />
46250 HEMORRHOIDECTOMY XTRNL 2+ COLUMN/GROUP 705.67 090<br />
46255 HEMORRHOIDECTOMY NTRNL & XTRNL 1 COLUMN/GROUP 776.57 090<br />
46257 HRHC SMPL W/FISSURECTOMY 656.93 090<br />
46258 HRHC 1 COL/GRP W/FSTULECTMY INCL FSSRECTOMY 731.70 090<br />
46260 HEMORRHOIDECTOMY INT & XTRNL 2+ COLUMN/GROUP 741.67 090<br />
46261 HRHC CPLX/X10SV W/FISSURECTOMY 829.19 090<br />
46262 HRHC 2+ COL/GRP W/FSTULECTMY INCL FSSRECTMY 865.75 090<br />
46270 SURG TX ANAL FSTL SUBQ 772.69 090<br />
46275 SURG TX ANAL FISTULA INTERSPHINCTERIC 814.23 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
126 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
46280 TX ANAL FSTL TRANS/SUPRA/XTRASPHNCTRC INCL SETON 727.82 090<br />
46285 SURG TX ANAL FSTL 2ND STG 799.83 090<br />
46288 CLSR ANAL FSTL W/RCT ADVMNT FLAP 854.11 090<br />
# 46320 EXC THROMBOSED HEMORRHOID XTRNL 279.17 010<br />
46500 NJX SCLRSG SLN HEMORRHOIDS 351.73 010<br />
46505 CHEMODNRVTJ INT ANAL SPHNCTR 445.34 010<br />
46600 ANOSC DX +-COLLJ SPEC BR/WA SPX 134.04 000<br />
46604 ANOSC DILAT 890.12 000<br />
46606 ANOSC BX 1/MLT 346.19 000<br />
46608 ANOSC RMVL FB 357.27 000<br />
46610 ANOSC RMVL 1 LES CAUT 351.17 000<br />
46611 ANOSC RMVL 1 TUM POLYP/OTH LES SNARE TQ 274.18 000<br />
46612 ANOSC RMVL MLT TUMS CAUT/SNARE 414.32 000<br />
46614 ANOSC CTRL BLD 200.51 000<br />
46615 ANOSC ABLTJ LES 229.87 000<br />
46700 ANOPLASTY PLSTC OPRATION STRIX ADLT 1024.16 090<br />
46705 ANOPLASTY PLSTC OPRATION STRIX INFT 772.14 090<br />
46706 RPR ANAL FSTL W/FIBRIN GLUE 265.87 010<br />
46707 REPAIR ANORECTAL FISTULA PLUG 763.83 090<br />
46710 RPR ILEOANAL POUCH FSTL/POUCH ADVMNT TPRNL APPR 1749.22 090<br />
46712 RPR ILEOANAL POUCH FSTL/POUCH ADVMNT CMBN APPR 3265.24 090<br />
46715 RPR LW IMPRF8 ANUS W/ANOPRNL FSTL CUT-BK 774.91 090<br />
46716 RPR LW IMPRF8 ANUS W/TRPOS FSTL 1840.61 090<br />
46730 RPR HI IMPRF8 ANUS W/O FSTL PRNL/SACROPRNL APPR 2838.74 090<br />
46735 RPR HI IMPRF8 ANUS W/O FSTL CMBN APPR 3291.27 090<br />
46740 RPR HI IMPRF8 ANUS W/FSTL PRNL/SACROPRNL APPR 3397.07 090<br />
46742 RPR HI IMPRF8 ANUS W/FSTL TABDL&SACROPRNL 3965.37 090<br />
46744 RPR CLOACAL ANOMAL SACROPRNL 5418.25 090<br />
46746 RPR CLOACAL ANOMAL CMBN ABDL&SACROPRNL 5739.51 090<br />
46748 RPR CLOACAL ANOMAL CMBN ABDL&SACROPRNL W/GRF 6099.55 090<br />
46750 SPHNCTROP ANAL INCONT/PROLAPSE ADLT 1216.36 090<br />
46751 SPHNCTROP ANAL INCONT/PROLAPSE CHLD 983.73 090<br />
46753 GRF THIERSCH RCT INCONT&/PROLAPSE 923.91 090<br />
46754 RMVL THIERSCH WIRE/SUTR ANAL CANAL 459.18 010<br />
46760 SPHNCTROP ANAL MUSC TRNSPL 1719.86 090<br />
46761 SPHNCTROP ANAL LEVATOR MUSC IMBRCJ 1484.45 090<br />
46762 SPHNCTROP ANAL IMPLTJ ARTIF SPHNCTR 1460.08 090<br />
46900 DSTRJ LES ANUS SMPL CHEM 368.90 010<br />
46910 DSTRJ LES ANUS SMPL ELTRDSICCATION 383.85 010<br />
46916 DSTRJ LES ANUS SMPL CRYOSURG 370.56 010<br />
46917 DSTRJ LES ANUS SMPL LASER SURG 724.50 010<br />
46922 DSTRJ LES ANUS SMPL SURG EXC 405.45 010<br />
46924 DSTRJ LES ANUS X10SV 827.53 010<br />
46930 DESTRUCTION INTERNAL HEMORRHOID THERMAL ENERGY 331.79 090<br />
46940 CURTG/CAUT ANAL FISSURE W/DILAT SPHNCTR SPX 1ST 348.40 010<br />
46942 CURTG/CAUT ANAL FISSURE W/DILAT SPHNCTR SPX SBSQ 325.69 010<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 127
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
# 46945 HRHC NTRNL LIG OTH THAN RBBR BAND 1 COL/GRP 460.84 090<br />
# 46946 HRHC NTRNL LIG OTH THAN RBBR BAND 2+ COL/GRP 480.23 090<br />
# 46947 HEMORRHOIDOPEXY STAPLING 602.09 090<br />
46999 UNLIS PX ANUS BR YYY<br />
47000 BX LVR NDL PRQ 562.21 000<br />
+ 47001 BX LVR NDL DONE PURPOSE TM OTH MAJOR PX 167.83 ZZZ<br />
47010 HEPATOTOMY OPN DRG ABSC/CST 1/2 STGS 1920.37 090<br />
K 47011 HEPATOTOMY PRQ DRG ABSC/CST 1/2 STGS 309.08 000<br />
47015 LAPT W/ASPIR&/NJX HEPATC PARASITIC CST/ABSCES 1848.36 090<br />
47100 BX LVR WEDGE 1342.65 090<br />
47120 HPTC RESCJ LVR PRTL LOBEC 3734.39 090<br />
47122 HPTC RESCJ LVR TRISGMECTOMY 5520.17 090<br />
47125 HPTC RESCJ LVR TOT L LOBEC 4942.45 090<br />
47130 HPTC RESCJ LVR TOT R LOBEC 5305.81 090<br />
47133 DON HPTC FROM CDVR DON BR XXX<br />
47135 LVR ALTRNSPLJ ORTHOTOPIC PRTL/WHL DON ANY AGE 7863.72 090<br />
47136 LVR ALTRNSPLJ HTRTPC PRTL/WHL DON ANY AGE 6677.26 090<br />
47140 DON HPTC LIV DON L LAT SGM ONLY II&III 5708.49 090<br />
47141 DON HPTC LIV DON TOT L LOBEC II III&IV 6208.67 090<br />
47142 DON HPTC LIV DON TOT R LOBEC V VI VII&VIII 7536.92 090<br />
47143 BKBENCH PREPJ CDVR WHL LVR GRF W/O TRISGM/LOBE BR XXX<br />
47144 BKBENCH PREPJ CDVR WHL LVR GRF I&IV VIII BR 090<br />
47145 BKBENCH PREPJ CDVR DON WHL LVR GRF I&V VIII BR XXX<br />
47146 BKBENCH RCNSTJ LVR GRF VEN ANAST EA 534.51 XXX<br />
47147 BKBENCH RCNSTJ LVR GRF ARTL ANAST EA 623.14 XXX<br />
47300 MARSUPIALIZATION CST/ABSC LVR 1808.48 090<br />
47350 MGMT LVR HEMRRG SMPL SUTR LVR WND/INJ 2195.66 090<br />
47360 MGMT LVR HEMRRG CPLX SUTR WND/INJ 3002.69 090<br />
47361 MGMT LVR HEMRRG EXPL WND DBRDMT COAGJ/SUTR 4853.27 090<br />
47362 MGMT LVR HEMRRG RE-EXPL WND RMVL PACKING 2302.01 090<br />
47370 LAPS SURG ABLTJ 1+ LVR TUM RF 1987.39 090<br />
47371 LAPS SURG ABLTJ 1+ LVR TUM CRYOSURG 2026.72 090<br />
47379 UNLIS LAPAROSCOPIC PX LVR BR YYY<br />
47380 ABLTJ OPN 1+ LVR TUM RF 2315.86 090<br />
47381 ABLTJ OPN 1+ LVR TUM CRYOSURG 2310.87 090<br />
K 47382 ABLTJ 1+ LVR TUM PRQ RF 7550.21 010<br />
47399 UNLIS PX LVR BR YYY<br />
47400 HEPATCOTOMY/HEPATCOSTOMY W/EXPL DRG/RMVL ST1 3454.12 090<br />
47420 CHOLEDOCHOT/OST W/O SPHNCTROTOMY/SPHNCTROP 2148.58 090<br />
47425 CHOLEDOCHOT/OST W/SPHNCTROTOMY/SPHNCTROP 2180.70 090<br />
47460 TRANSDUOL SPHNCTROTOMY/SPHNCTROP +-XTRJ ST1 SPX 2046.11 090<br />
s 47480 CHOLECSTOT/CHOLECSTOST W/EXPL DRG/RMVL ST1 SPX 1384.20 090<br />
s 47490 CHOLECSTOST PRQ W/IMG GID 595.44 010<br />
47500 NJX PRQ TRANSHEPATC CHOLANGRPH 164.51 000<br />
47505 NJX CHOLANGRPH THRU AN CATH 63.14 000<br />
47510 INTRO PRQ TRANSHEPATC CATH BILIARY DRG 790.42 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
128 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
47511 INTRO PRQ TRANSHEPATC STENT BILIARY DRG 977.63 090<br />
K 47525 CHNG PRQ BILIARY DRG CATH 838.60 000<br />
47530 REVJ&/RINSJ TRANSHEPATC TUBE 2360.72 090<br />
+ 47550 BILIARY NDSC INTRAOP 269.20 ZZZ<br />
47552 BILIARY NDSC PRQ T-TUBE DX +-COLLJ SPEC SPX 530.64 000<br />
47553 BILIARY NDSC PRQ T-TUBE W/BX 1/MLT 531.19 000<br />
47554 BILIARY NDSC PRQ T-TUBE RMVL ST1 814.23 000<br />
47555 BILIARY NDSC PRQ T-TUBE DILAT STRIX W/O STENT 630.89 000<br />
47556 BILIARY NDSC PRQ T-TUBE DILAT STRIX W/STENT 715.08 000<br />
47560 LAPS SURG W/GID TRANSHEPATC CHOLANGRPH W/O BX 436.47 000<br />
47561 LAPS SURG W/GID TRANSHEPATC CHOLANGRPH W/BX 476.35 000<br />
47562 LAPS SURG CHOLECSTC 1192.55 090<br />
47563 LAPS SURG CHOLECSTC W/CHOLANGRPH 1208.61 090<br />
47564 LAPS SURG CHOLECSTC W/EXPL COMMON DUX 1385.86 090<br />
47570 LAPS SURG CHOLECSTONTRSTM 1239.63 090<br />
47579 UNLIS LAPS PX BILIARY TRC BR YYY<br />
47600 CHOLECSTC 1723.74 090<br />
47605 CHOLECSTC CHOLANGRPH 1570.86 090<br />
47610 CHOLECSTC EXPL DUX 2010.10 090<br />
47612 CHOLECSTC EXPL DUX CHOLEDOCHONTRSTM 2031.71 090<br />
47620 CHOLECSTC EXPL DUX SPHNCTROTOMY/SPHNCTROP 2207.85 090<br />
47630 BILIARY DUX STONE XTRJ PRQ VIA BASKET/SNARE 916.70 090<br />
47700 EXPL CGEN ATRESIA BILE DUXS 1679.42 090<br />
47701 PORTONTRSTM 2823.78 090<br />
47711 EXC BILE DUX TUM +-PRIM RPR XTRHEPATC 2498.09 090<br />
47712 EXC BILE DUX TUM +-PRIM RPR INTRAHEPATC 3202.10 090<br />
47715 EXC CHOLEDOCHAL CST 2118.11 090<br />
47720 CHOLECSTONTRSTM DIR 1827.32 090<br />
47721 CHOLECSTONTRSTM W/GASTRONTRSTM 2158.55 090<br />
47740 CHOLECSTONTRSTM ROUX-EN-Y 2088.20 090<br />
47741 CHOLECSTONTRSTM ROUX-EN-Y W/GASTRONTRSTM 2355.74 090<br />
47760 ANAST XTRHEPATC BILIARY DUXS&GI 3593.70 090<br />
47765 ANAST INTRAHEPATC DUXS&GI 4823.36 090<br />
47780 ANAST ROUX-EN-Y XTRHEPATC BILIARY DUXS&GI 3939.89 090<br />
47785 ANAST ROUX-EN-Y INTRAHEPATC BILIARY DUXS&GI 5166.23 090<br />
47800 RCNSTJ PLSTC BILIARY DUXS W/END-TO-END ANAST 2530.77 090<br />
47801 PLMT CHOLEDOCHAL STENT 1683.86 090<br />
47802 U-TUBE HEPATCONTRSTM 2436.61 090<br />
47900 SUTURE EXTRAHEPATIC BILE DUCT PRE-EXIST INJURY 2182.37 090<br />
47999 UNLIS PX BILIARY TRC BR YYY<br />
48000 PLACE DRAIN PERIPANCREATIC ACUTE PANCREATITIS 2977.21 090<br />
48001 PLACE DRAIN PERIPANCREATIC W/CHOLECYSTOSTOMY 3709.47 090<br />
48020 RMVL PNCRTC ST1 1881.04 090<br />
48100 BX PNCRS OPN 1419.09 090<br />
48102 BX PNCRS PRQ NDL 881.25 010<br />
48105 RESECJ/DBRDMT PANCREAS NECROTIZING PANCREATITIS 4579.09 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 129
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
48120 EXC LES PNCRS 1773.03 090<br />
48140 PNCRTECT DSTL STOT W/O PNCRTCOJEJUNOSTOMY 2505.29 090<br />
48145 PNCRTECT DSTL STOT W/PNCRTCOJEJUNOSTOMY 2610.53 090<br />
48146 PNCRTECT DSTL NR-TOT W/PRSRV DUO CHLD-TYP PX 2993.83 090<br />
48148 EXC AMPULLA VATER 1989.05 090<br />
48150 PNCRTECT PROX STOT W/PANCREATOJEJUNOSTOMY 4984.55 090<br />
48152 PNCRTECT WHIPPLE W/O PANCREATOJEJUNOSTOMY 4628.39 090<br />
48153 PNCRTECT W/PANCREATOJEJUNOSTOMY 4977.35 090<br />
48154 PNCRTECT PROX STOT W/O PANCREATOJEJUNOSTOMY 4643.90 090<br />
48155 PNCRTECT TOT 2899.11 090<br />
48160 PNCRTECT TOT/STOT W/TRNSPLJ PNCRS/ISLET 5018.33 XXX<br />
+ 48400 INJECTION INTRAOPERATIVE PANCREATOGRAPHY 171.71 ZZZ<br />
48500 MARSUPIALIZATION PNCRTC CST 1828.42 090<br />
48510 XTRNL DRG PSEUDOCST PNCRS OPN 1731.49 090<br />
K 48511 XTRNL DRG PSEUDOCST PNCRS PRQ 1535.96 000<br />
48520 INT ANAST PNCRTC CST GI TRC DIR 1751.43 090<br />
48540 INT ANAST PNCRTC CST GI TRC ROUX-EN-Y 2078.23 090<br />
48545 PANCREATORRHAPHY INJ 2143.04 090<br />
48547 DUOL EXCLUSION W/GASTROJEJUNOSTOMY PNCRTC INJ 2866.43 090<br />
48548 PANCREATICOJEJUNOSTOMY SIDE-TO-SIDE ANAST 2670.35 090<br />
48550 DONOR PANCREATECTOMY DUODENAL SGM TRANSPLANT BR XXX<br />
48551 BKBENCH PREPJ CDVR PNCRS ALGRFT BR XXX<br />
48552 BKBENCH RCNSTJ CDVR PNCRS ALGRFT VEN ANAST EA 383.85 XXX<br />
48554 TRNSPLJ PNCRTC ALGRFT 4056.21 090<br />
48556 RMVL TRNSPLED PNCRTC ALGRFT 2016.75 090<br />
48999 UNLIS PX PNCRS BR YYY<br />
49000 EXPL LAPT EXPL CELIOTOMY +-BX SPX 1237.41 090<br />
49002 REOPNG RECENT LAPT 1667.24 090<br />
49010 EXPL RPR AREA +-BX SPX 1528.76 090<br />
49020 DRG PRTL ABSC/LOCLZD PRITONITIS OPN 2552.93 090<br />
K 49021 DRG PRTL ABSC/LOCLZD PRITONITIS PRQ 1461.74 000<br />
49040 DRG SUBDIPHRG/SUBPHRENIC ABSC OPN 1605.76 090<br />
K 49041 DRG SUBDIPHRG/SUBPHRENIC ABSC PRQ 1506.61 000<br />
49060 DRG RPR ABSC OPN 1779.13 090<br />
K 49061 DRG RPR ABSC PRQ 1474.48 000<br />
49062 DRG XTRPRTL LYMPHOCELE PRTL CAVITY OPN 1203.62 090<br />
49080 PRITONEOCNTS ABDL PCNTS/PRTL LVG 1ST 266.43 000<br />
49081 PRITONEOCNTS ABDL PCNTS/PRTL LVG SBSQ 266.43 000<br />
49180 BX ABDL/RPR MASS PRQ NDL 267.53 000<br />
49203 EXCISION/DESTRUCTION OPEN ABDOMINAL TUMORS 5 CM 1925.36 090<br />
49204 EXC/DESTRUCTION OPEN ABDMNL TUMORS 5.1-10.0 CM 2452.12 090<br />
49205 EXC/DESTRUCTION OPEN ABDOMINAL TUMORS >10.0 CM 2814.37 090<br />
49215 EXC PRESAC/SACROCOCCYGEAL TUM 3547.18 090<br />
49220 STAGING LAPAROTOMY HODGKINS DISEASE/LYMPHOMA 1557.01 090<br />
49250 UMBILECTOMY OMPHALECTOMY EXC UMBILICUS SPX 932.21 090<br />
49255 OMNTC EPIPLOECTOMY RESCJ OMENTUM SPX 1264.00 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
130 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
49320 LAPS ABD PRTM&OMENTUM DX +-SPEC BR/WA SPX 526.76 010<br />
49321 LAPS SURG W/BX 1/MLT 557.78 010<br />
49322 LAPS SURG W/ASPIR CAVITY/CST 1/MLT 599.32 010<br />
49323 LAPS SURG W/DRG LYMPHOCELE PRTL CAVITY 1037.45 090<br />
s 49324 LAPS INSERTION TUNNELED INTRAPERITONEAL CATHETER 634.77 010<br />
49325 LAPS W/REVISION INTRAPERITONEAL CATHETER 679.64 010<br />
+ 49326 LAPS W/OMENTOPEXY 307.41 ZZZ<br />
l + 49327 LAPS W/INSERTION NTRSTL DEV W/IMG GID 1+ 215.47 ZZZ<br />
49329 UNLIS LAPS PX ABD PRTM&OMENTUM BR YYY<br />
49400 NJX AIR/CNTRST IN PRTL CAVITY SPX 257.01 000<br />
49402 REMOVAL PERITONEAL FOREIGN BODY FROM CAVITY 1372.01 090<br />
K 49411 INTERSTITIAL DEV PLMT RADIATION THERAPY 1/MLT 850.79 000<br />
l + 49412 PLMT INTRSTL DEV OPN W/IMG GID 1+ 134.60 ZZZ<br />
l K 49418 INSJ INTRAPERITONEAL CATHETER W/IMG GID 2476.49 000<br />
s 49419 INSERTION TUNNEL INTRAPERITONEAL CATH SUBQ PORT 713.98 090<br />
s 49421 INSERTION TUNNEL INTRAPERITONEAL CATH DIAL OPEN 439.24 000<br />
s 49422 REMOVAL TUNNELED INTRAPERITONEAL CATHETER 619.81 010<br />
49423 EXCHNG ABSC/CST DRG CATH RAD GID SPX 930.00 000<br />
49424 CNTRST NJX ASSMT ABSC/CST VIA DRG CATH/TUBE SPX 248.15 000<br />
49425 INSJ PRTL-VEN SHUNT 1222.46 090<br />
49426 REVJ PRTL-VEN SHUNT 1031.36 090<br />
49427 INJECT EVALUATE PREVIOUS PERITONEAL-VENOUS SHUNT 75.88 000<br />
49428 LIG PRTL-VEN SHUNT 702.35 010<br />
49429 RMVL PRTL-VEN SHUNT 738.90 010<br />
+ 49435 INSJ SUBQ EXTENSION INTRAPERITONEAL CATHETER 194.42 ZZZ<br />
49436 DELAYED CREATION EXIT SITE EMBEDDED CATHETER 299.11 010<br />
K 49440 INSERT GASTROSTOMY TUBE PERCUTANEOUS 1776.91 010<br />
K 49441 INSERT DUODENOSTOMY/JEJUNOSTOMY TUBE PERQ 1969.11 010<br />
K 49442 INSERT CECOSTOMY/OTHER COLONIC TUBE PERCUTANEOUS 1652.28 010<br />
K 49446 CONVERT GASTROSTOMY-GASTRO-JEJUNOSTOMY TUBE PERQ 1642.87 000<br />
49450 REPLACE GASTROSTOMY/CECOSTOMY TUBE PERCUTANEOUS 1171.50 000<br />
49451 REPLACE DUODENOSTOMY/JEJUNOSTOMY TUBE PERQ 1187.01 000<br />
49452 REPLACEMENT GASTRO-JEJUNOSTOMY TUBE PERCUTANEOUS 1475.59 000<br />
49460 OBSTRUCTIVE MATERIAL REMOVAL FROM GI TUBE 1292.80 000<br />
49465 CONTRAST INJECTION PERQ RADIOLOGIC EVAL GI TUBE 281.94 000<br />
49491 RPR 1ST INGUN HRNA PRETERM INFT RDC 1259.01 090<br />
49492 RPR 1ST INGUN HRNA PRETERM INFT NCRC8 1525.44 090<br />
49495 RPR 1ST INGUN HRNA FULL TERM INFT NCRC8 1016.96 090<br />
49520 RPR RECRT INGUN HRNA ANY AGE RDC 1007.54 090<br />
49521 RPR RECRT INGUN HRNA ANY AGE NCRC8 1223.57 090<br />
49525 RPR INGUN HRNA SLIDING ANY AGE 912.27 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 131
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
49540 RPR LMBR HRNA 1079.55 090<br />
49550 RPR 1ST FEM HRNA ANY AGE RDC 917.81 090<br />
49553 RPR 1ST FEM HRNA ANY AGE NCRC8 1005.88 090<br />
49555 RPR RECRT FEM HRNA RDC 953.26 090<br />
49557 RPR RECRT FEM HRNA NCRC8 1156.54 090<br />
49560 REPAIR FIRST ABDOMINAL WALL HERNIA 1178.70 090<br />
49561 RPR 1ST INCAL/VNT HRNA NCRC8 1488.88 090<br />
49565 RPR RECRT INCAL/VNT HRNA RDC 1227.44 090<br />
49566 RPR RECRT INCAL/VNT HRNA NCRC8 1504.95 090<br />
+ 49568 IMPLANT MESH OPN HERNIA RPR/DEBRIDEMENT CLOSURE 434.26 ZZZ<br />
49570 RPR EPIGSTR HRNA RDC SPX 658.03 090<br />
49572 RPR EPIGSTR HRNA NCRC8 816.45 090<br />
49580 RPR UMBILICAL HRNA < 5 YRS RDC 520.67 090<br />
49582 RPR UMBILICAL HRNA RDC 704.01 090<br />
49587 RPR UMBILICAL HRNA AGE 5 YRS/> NCRC8 832.51 090<br />
49590 RPR SPIGELIAN HRNA 911.17 090<br />
49600 RPR SM OMPHALOCELE W/PRIM CLSR 1171.50 090<br />
49605 RPR LG OMPHALOCELE/GASTROSCHISIS +-PROSTH 8014.38 090<br />
49606 RPR LG OMPHALOCELE/GASTROSCHISIS RMVL PROSTH 1817.90 090<br />
49610 RPR OMPHALOCELE GROSS TYP OPRATION 1ST STG 1100.05 090<br />
49611 RPR OMPHALOCELE GROSS TYP OPRATION 2ND STG 892.33 090<br />
49650 LAPS SURG RPR 1ST INGUN HRNA 678.53 090<br />
49651 LAPS SURG RPR RECRT INGUN HRNA 883.47 090<br />
49652 LAPS REPAIR HERNIA EXCEPT INCAL/INGUN REDUCIBLE 1172.61 090<br />
49653 LAP RPR HRNA XCPT INCAL/INGUN NCRC8/STRANGULATED 1469.50 090<br />
49654 LAPAROSCOPY REPAIR INCISIONAL HERNIA REDUCIBLE 1347.64 090<br />
49655 LAPS RPR INCISIONAL HERNIA NCRC8/STRANGULATED 1621.82 090<br />
49656 LAPS RPR RECURRENT INCISIONAL HERNIA REDUCIBLE 1352.62 090<br />
49657 LAPS RPR RECURRENT INCAL HRNA NCRC8/STRANGULATED 1945.30 090<br />
49659 UNLIS LAPS PX HRNAP HERNIORRHAPHY HERNIOTOMY BR YYY<br />
49900 SEC ABDOMINAL WALL SUTURE EVISCERATION/DEHSN 1303.33 090<br />
49904 OMENTAL FLAP XTR-ABDL 2375.12 090<br />
+ 49905 OMENTAL FLAP INTRA-ABDL 574.39 ZZZ<br />
49906 FR OMENTAL FLAP W/MVASC ANAST BR 090<br />
49999 UNLIS PX ABD PRTM&OMENTUM BR YYY<br />
50010 RNL EXPL X NECESSITATING OTH SPEC PX 1218.03 090<br />
50020 DRG PRIRNL/RNL ABSC OPN 1731.49 090<br />
K 50021 DRG PRIRNL/RNL ABSC PRQ 1544.27 000<br />
50040 NFROS NFROT W/DRG 1558.67 090<br />
50045 NFROT W/EXPL 1563.11 090<br />
50060 NEPHROLITHOTOMY RMVL ST1 1920.93 090<br />
50065 NEPHROLITHOTOMY SECONDARY FOR CALCULUS 2023.95 090<br />
50070 NEPHROLITHOTOMY COMP CGEN KDN ABNORMALITY 2003.46 090<br />
50075 NEPHROLITHOTOMY RMVL LG STAGHORN ST1 2461.53 090<br />
50080 PRQ NEPHROSTOLITHOTOMY/PYELOSTOLITHOTOMY UP 2 CM 1468.94 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
132 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
50081 PRQ NEPHROSTOLITHOTOMY/PYELOSTOLITHOTOMY > 2 CM 2156.33 090<br />
50100 TRNSXJ/RPSG ABERRANT RNL VSL SPX 1634.01 090<br />
50120 PLOT W/EXPL 1593.57 090<br />
50125 PLOT W/DRG PYELOSTOMY 1694.38 090<br />
50130 PLOT W/RMVL ST1 1743.12 090<br />
50135 PLOT COMP 1888.25 090<br />
K 50200 RNL BX PRQ TROCAR/NDL 943.85 000<br />
50205 RNL BX SURG EXPOS KDN 1212.49 090<br />
50220 NFRCT W/PRTL URTREC ANY OPN RIB RESCJ 1749.22 090<br />
50225 NFRCT W/PRTL URTREC ANY OPN RIB RESCJ COMP 2008.44 090<br />
50230 NFRCT W/PRTL URTREC ANY OPN RIB RESCJ RAD 2159.66 090<br />
50234 NFRCT W/TOT URTREC&BLDR CUFF THRU SM INC 2192.89 090<br />
50236 NFRCT TOT URTREC&BLDR CUFF THRU SEP INC 2473.72 090<br />
50240 NFRCT PRTL 2231.66 090<br />
s 50250 OPEN ABLATION RENAL MASS CRYOSURG ULTRASOUND 2059.95 090<br />
50280 EXC/UNROOFING CST KDN 1605.20 090<br />
50290 EXC PRINEPHRIC CST 1527.10 090<br />
50300 DON NFRCT FROM CDVR DON UNI/BI BR XXX<br />
50320 DON NFRCT OPN FROM LIV DON 2306.44 090<br />
50323 BKBENCH PREPJ CDVR RNL ALGRFT BR XXX<br />
50325 BKBENCH PREPJ LIV RNL ALGRFT OPN/LAPS BR XXX<br />
50327 BKBENCH RCNSTJ RNL ALGRFT VEN ANAST EA 353.39 XXX<br />
50328 BKBENCH RCNSTJ RNL ALGRFT ARTL ANAST EA 309.08 XXX<br />
50329 BKBENCH RCNSTJ ALGRFT URTRL ANAST EA 290.24 XXX<br />
50340 RCP NFRCT SPX 1501.62 090<br />
50360 RNL ALTRNSPLJ IMPLTJ GRF W/O RCP NFRCT 4099.97 090<br />
50365 RNL ALTRNSPLJ IMPLTJ GRF W/RCP NFRCT 4618.42 090<br />
50370 RMVL TRNSPLED RNL ALGRFT 1914.83 090<br />
50380 RNL AUTOTRNSPLJ RIMPLTJ KDN 3237.55 090<br />
K 50382 RMVL&RPLCMT INTLY DWELLING URTRL STENT 2088.76 000<br />
K 50384 RMVL INTLY DWELLING URTRL STENT 1744.79 000<br />
K 50385 REMOVE & REPLACE INT DWELL URETERAL STENT TRURL 2040.57 000<br />
K 50386 REMOVE INT DWELL URETERAL STENT TRANSURETHRAL 1329.91 000<br />
K 50387 RMVL&RPLCMT XTRNLLY ACCESSIBLE URTRL STENT 968.22 000<br />
50389 RMVL NFROS TUBE REQ FLUOR GID 538.39 000<br />
50390 ASPIR&/NJX RNL CST/PELVIS NDL PRQ 163.40 000<br />
50391 INSTLJ AGT RNL PELVIS&/URTR THRU TUBE 211.04 000<br />
50392 INTRO INTRACATH/CATH IN RNL PELVIS DRG&/NJX PRQ 301.32 000<br />
50393 INTRO URTRL CATH/STENT THRU PELVIS DRG&/NJX PRQ 366.68 000<br />
50394 NJX PX PLOG THRU TUBE/CATH 171.16 000<br />
50395 INTRO GD PELVIS&/URTR W/DILAT NFROS TRC 304.65 000<br />
50396 MANOMETRIC STDS THRU TUBE/NDWELLG URTRL CATH 196.08 000<br />
50398 CHNG NFROS/PYELOSTOMY TUBE 876.27 000<br />
50400 PLOP RNL PELVIS SMPL 1948.07 090<br />
50405 PLOP RNL PELVIS COMP 2350.20 090<br />
50500 NEPHRORRHAPHY SUTR KDN WND/INJ 2068.82 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 133
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
50520 CLSR NEPHROCUTAN/PYELOCUTAN FSTL 1738.14 090<br />
50525 CLSR NEPHROVISC FSTL W/VISC RPR ABDL APPR 2407.80 090<br />
50526 CLSR NEPHROVISC FSTL W/VISC RPR THRC APPR 2319.73 090<br />
50540 SYMPHYSIOTOMY HORSESHOE KDN +-PLOP UNI/BI 1914.83 090<br />
50541 LAPS ABLTJ RNL CSTS 1552.03 090<br />
s 50542 LAPS ABLTJ RNL MASS LES W/INTRAOP US 1970.22 090<br />
50543 LAPS PRTL NFRCT 2513.04 090<br />
50544 LAPS PLOP 2107.04 090<br />
50545 LAPS RADICAL NFRCT 2267.67 090<br />
50546 LAPS NFRCT W/PRTL URTREC 2023.40 090<br />
50547 LAPS DON NFRCT FROM LIV DON 2603.88 090<br />
50548 LAPS NFRCT W/TOT URTREC 2278.19 090<br />
50549 UNLIS LAPS PX RNL BR YYY<br />
50551 RNL NDSC NFROS/PYELOSTOMY 612.06 000<br />
50553 RNL NDSC NFROS/PYELOSTOMY URTRL CATHJ 650.28 000<br />
50555 RNL NDSC NFROS/PYELOSTOMY BX 699.02 000<br />
50557 RNL NDSC NFROS/PYELOSTOMY FULG&/INC +-BX 711.76 000<br />
50561 RNL NDSC NFROS/PYELOSTOMY RMVL FB/ST1 808.69 000<br />
50562 RNL NDSC NFROS/PYELOSTOMY RESCJ TUM 985.94 090<br />
50570 RNL NDSC NFROT/PLOT 833.07 000<br />
50572 RNL NDSC NFROT/PLOT W/URTRL CATHJ +-DILAT URTR 902.86 000<br />
50574 RNL NDSC NFROT/PLOT BX 959.91 000<br />
50575 RNL NDSC NFROT/PLOT W/ENDOPLOT 1211.93 000<br />
50576 RNL NDSC NFROT FULGURATION&/INC +-BX 956.59 000<br />
50580 RNL NDSC NFROT/PLOT W/RMVL FB/ST1 1028.04 000<br />
50590 LITHOTRP XTRCORP SHOCK WAVE 1442.36 090<br />
K 50592 ABLTJ 1+ RNL TUM PRQ UNI RF 5622.09 010<br />
K 50593 ABLATION RENAL TUMOR UNILATERAL PERQ CRYOTHERAPY 7734.66 010<br />
50600 URTROTOMY W/EXPL/DRG SPX 1576.95 090<br />
50605 URETEROTOMY INSERTION INDWELLING STENT ALL TYPES 1601.88 090<br />
50610 URTROLITHOTOMY UPPER ONE-THIRD URETER 1593.02 090<br />
50620 URTROLITHOTOMY MIDDLE ONE-THIRD URETER 1523.78 090<br />
50630 URTROLITHOTOMY LOWER ONE-THIRD URETER 1493.31 090<br />
50650 URTREC W/BLDR CUFF SPX 1744.23 090<br />
50660 URTREC TOT ECTOPIC URTR CMBN APPR 1922.03 090<br />
50684 NJX URTRG/URTROPLOG THRU URTROST/URTRL CATH 245.93 000<br />
50686 MANOMETRIC STDS THRU URTROST/NDWELLG URTRL CATH 240.95 000<br />
50688 CHNG URTROST TUBE/XTRNLLY ACCESSIBLE STENT ILEAL 134.04 010<br />
50690 NJX VISUALIZATION ILEAL CONDUIT&/URTROPLOG 163.95 000<br />
50700 URTROPLASTY PLSTC OPRATION URTR 1554.80 090<br />
50715 URTROLSS +-RPSG URTR RPR FIBROSIS 1934.22 090<br />
50722 URETEROLYSIS FOR OVARIAN VEIN SYNDROME 1718.20 090<br />
50725 URTROLSS RETROCAVAL URTR W/REANAST 1889.35 090<br />
50727 REVJ UR-CUTAN ANAST 849.13 090<br />
50728 REVJ UR-CUTAN ANAST RPR FSCAL DFCT&HRNA 1164.30 090<br />
50740 URTROPYELOSTOMY ANAST URTR&RNL PELVIS 1970.22 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
134 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
50750 URTROCALYCOSTOMY ANAST URTR RNL CALYX 1948.62 090<br />
50760 URTROURTROST 1879.38 090<br />
50770 TRANSURTROURTROST ANAST URTR CLAT URTR 1911.51 090<br />
50780 URTRONEOCSTOST ANAST 1 URTR BLDR 1853.90 090<br />
50782 URTRONEOCSTOST ANAST DUPLICATED URTR BLDR 1920.93 090<br />
50783 URTRONEOCSTOST W/X10SV URTRL TAILORING 1918.16 090<br />
50785 URTRONEOCSTOST W/VESICO-PSOAS HITCH/BLDR FLAP 2037.80 090<br />
50800 URTRONTRSTM DIR ANAST URTR INT 1556.46 090<br />
50810 URTROSIGMOIDOSTOMY CRTJ CLST INT ANAST 2189.57 090<br />
50815 URTROCOLON CONDUIT INT ANAST 2056.63 090<br />
50820 URTROILEAL CONDUIT W/INT ANAST 2210.06 090<br />
50825 CONTINENT DVRJ W/INT ANAST W/ANY SGM SM&/LG INT 2789.44 090<br />
50830 UR UNDVRJ 3017.65 090<br />
50840 RPLCMT ALL/PART URTR INT SGM W/INT ANAST 2071.03 090<br />
50845 CUTAN APPENDICO-VESICOSTOMY 2102.05 090<br />
50860 URTROST TRNSPLJ URTR SKN 1587.48 090<br />
50900 URTRORRHAPHY SUTR URTR SPX 1414.66 090<br />
50920 CLSR URTROCUTAN FSTL 1483.90 090<br />
50930 CLSR URTROVISC FSTL W/VISC RPR 1948.62 090<br />
50940 DELIG URTR 1487.78 090<br />
50945 LAPS URTROLITHOTOMY 1640.10 090<br />
50947 LAPS URTRONEOCSTOST W/CSTSC&URTRL STENT PLMT 2323.06 090<br />
50948 LAPS URTRONEOCSTOST W/O CSTSC&URTRL STENT PLMT 2155.78 090<br />
50949 UNLIS LAPS PX URTR BR YYY<br />
50951 NDSC THRU URTROST 639.75 000<br />
50953 NDSC URTROST W/URTRL CATHJ 676.87 000<br />
50955 NDSC THRU URTROST BX 736.69 000<br />
50957 NDSC THRU URTROST FULG&/INC +-BX 727.82 000<br />
50961 NDSC THRU URTROST RMVL FB/ST1 657.48 000<br />
50970 NDSC THRU URTROTOMY 628.12 000<br />
50972 NDSC THRU URTROTOMY URTRL CATHJ +-DILAT 606.52 000<br />
50974 NDSC THRU URTROTOMY BX 802.05 000<br />
50976 NDSC THRU URTROTOMY FULG&/INC +-BX 789.86 000<br />
50980 NDSC THRU URTROTOMY RMVL FB/ST1 603.75 000<br />
51020 CSTOTOMY/CSTOST FULG&/INSJ RADACT MATRL 789.31 090<br />
51030 CSTOTOMY/CSTOST CRYOSURG DSTRJ INTRAVESICAL LES 782.11 090<br />
51040 CSTOST CSTOTOMY W/DRG 489.09 090<br />
51045 CSTOTOMY W/INSJ URTRL CATH/STENT SPX 815.34 090<br />
51050 CSTOLITHOTOMY CSTOTOMY W/RMVL ST1 795.95 090<br />
51060 TRANSVESICAL URTROLITHOTOMY 979.85 090<br />
51065 CSTOTOMY W/ST1 BASKET XTRJ&/FRAGMENTATION 973.76 090<br />
51080 DRG PRIVESICAL/PREVESICAL SPACE ABSC 685.17 090<br />
51100 ASPIRATION BLADDER NEEDLE 104.13 000<br />
51101 ASPIRATION BLADDER TROCAR/INTRACATHETER 212.70 000<br />
51102 ASPIRATION BLADDER INSERT SUPRAPUBIC CATHETER 387.73 000<br />
51500 EXC URACHAL CST/SINUS +-UMBILICAL HRNA RPR 1090.63 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 135
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
51520 CYSTOTOMY SIMPLE EXCISION VESICAL NECK 991.48 090<br />
51525 CYSTOTOMY EXCISE BLADDER DIVERTICULUM 1/MULTIPLE 1449.00 090<br />
51530 CYSTOTOMY EXCISION BLADDER TUMOR 1318.84 090<br />
51535 CYSTOTOMY EXCISE/INCISE/REPAIR URETEROCELE 1301.67 090<br />
51550 CSTC PRTL SMPL 1620.16 090<br />
51555 CSTC PRTL COMP 2131.96 090<br />
51565 CSTC PRTL W/RIMPLTJ URTR IN BLDR URTRONEOCSTOST 2172.40 090<br />
51570 CSTC COMPL SPX 2484.80 090<br />
51575 CSTC COMPL W/BI PEL LMPHADEC 3072.48 090<br />
51580 CSTC COMPL W/TRNSPLJS 3200.43 090<br />
51585 CSTC COMPL W/TRNSPLJS W/LMPHADEC 3563.79 090<br />
51590 CSTC COMPL W/URTROILEAL CONDUIT/BLDR W/INT ANAST 3258.59 090<br />
51595 CSTC COMPL W/CONDUIT/SIGMOID BLDR PEL LMPHADEC 3695.62 090<br />
51596 CSTC COMPL W/CONTINENT DVRJ OPN NEOBLDR 3970.91 090<br />
51597 PEL EXNTJ COMPL MAL 3860.68 090<br />
51600 NJX CSTOGRAPY/VOIDING URETHROCSTOGRAPY 319.60 000<br />
51605 NJX&PLMT CHAIN C+&/URETHROCSTOGRAPY 64.25 000<br />
51610 NJX RTRGR URETHROCSTOGRAPY 183.34 000<br />
51700 BLDR IRRIGATION SMPL LVG&/INSTLJ 142.91 000<br />
51701 INSJ NON-NDWELLG BLDR CATH 97.49 000<br />
51702 INSJ TEMP NDWELLG BLDR CATH SMPL 125.74 000<br />
51703 INSJ TEMP NDWELLG BLDR CATH COMP 227.65 000<br />
51705 CHNG CSTOST TUBE SMPL 185.00 010<br />
51710 CHNG CSTOST TUBE COMP 257.56 010<br />
51715 NDSC NJX IMPLT MATRL URT&/BLDR NCK 489.65 000<br />
51720 BLDR INSTLJ ANTICARCINOGENIC AGT 188.33 000<br />
51725 SMPL CSTOMETROGRAM 343.97 000<br />
51725 26 SMPL CSTOMETROGRAM 126.84 000<br />
51725 TC SMPL CSTOMETROGRAM 217.13 000<br />
51726 BLADDER PRESSURE MEASUREMENT DURING FILLING 502.39 000<br />
51726 26 BLADDER PRESSURE MEASUREMENT DURING FILLING 144.57 000<br />
51726 TC BLADDER PRESSURE MEASUREMENT DURING FILLING 357.82 000<br />
51727 COMPLEX CYSTOMETROGRAM URETHRAL PRESS PROFILE 499.62 000<br />
51727 26 COMPLEX CYSTOMETROGRAM URETHRAL PRESS PROFILE 178.91 000<br />
51727 TC COMPLEX CYSTOMETROGRAM URETHRAL PRESS PROFILE 320.71 000<br />
51728 COMPLEX CYSTOMETROGRAM VOIDING PRESSURE STUDIES 494.63 000<br />
51728 26 COMPLEX CYSTOMETROGRAM VOIDING PRESSURE STUDIES 175.03 000<br />
51728 TC COMPLEX CYSTOMETROGRAM VOIDING PRESSURE STUDIES 319.60 000<br />
51729 COMPLX CYSTOMETRO W/VOID PRESS&URETHRAL PROFILE 541.71 000<br />
51729 26 COMPLX CYSTOMETRO W/VOID PRESS&URETHRAL PROFILE 211.04 000<br />
51729 TC COMPLX CYSTOMETRO W/VOID PRESS&URETHRAL PROFILE 330.67 000<br />
51736 SMPL UROFLOMETRY 57.61 XXX<br />
51736 26 SMPL UROFLOMETRY 19.94 XXX<br />
51736 TC SMPL UROFLOMETRY 37.67 XXX<br />
51741 CPLX UROFLOMETRY 70.35 XXX<br />
51741 26 CPLX UROFLOMETRY 27.14 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
136 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
51741 TC CPLX UROFLOMETRY 43.21 XXX<br />
51784 EMG STDS ANAL/URTL SPHNCTR OTH/THN NDL 335.66 000<br />
51784 26 EMG STDS ANAL/URTL SPHNCTR OTH/THN NDL 128.50 000<br />
51784 TC EMG STDS ANAL/URTL SPHNCTR OTH/THN NDL 207.16 000<br />
51785 NDL EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ 368.90 000<br />
51785 26 NDL EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ 129.06 000<br />
51785 TC NDL EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ 239.84 000<br />
51792 STIMULUS EVOKED RSPSE 379.98 000<br />
51792 26 STIMULUS EVOKED RSPSE 93.61 000<br />
51792 TC STIMULUS EVOKED RSPSE 286.37 000<br />
+ # 51797 VOID PRESSURE STUDIES INTRAABDOMINAL 220.45 ZZZ<br />
+ # 51797 26 VOID PRESSURE STUDIES INTRAABDOMINAL 68.68 ZZZ<br />
+ # 51797 TC VOID PRESSURE STUDIES INTRAABDOMINAL 151.77 ZZZ<br />
51798 MEAS POST-VOIDING RESIDUAL URINE&/BLDR CAP 32.13 XXX<br />
51800 CSTOPLASTY/CSTOURTP PLSTC ANY 1760.29 090<br />
51820 CSTOURTP W/UNI/BI URTRONEOCSTOST 1792.97 090<br />
51840 ANT VESICOURETHROPEXY/URETHROPEXY SMPL 1101.15 090<br />
51841 ANT VESICOURETHROPEXY/URETHROPEXY COMP 1310.53 090<br />
51845 ABDOMINO-VAG VESICAL NCK SSP +-NDSC CTRL 990.37 090<br />
51860 CSTORR SUTR BLDR WND INJ/RPT SMPL 1240.18 090<br />
51865 CSTORR SUTR BLDR WND INJ/RPT COMP 1501.07 090<br />
51880 CLSR CSTOST SPX 786.54 090<br />
51900 CLSR VESICOVAG FSTL ABDL APPR 1378.66 090<br />
51920 CLSR VESICOUTERINE FSTL 1267.32 090<br />
51925 CLSR VESICOUTERINE FSTL W/HYST 1761.40 090<br />
51940 CLSR EXSTROPHY BLDR 2720.76 090<br />
51960 ENTEROCSTOPLASTY W/INTSTINAL ANAST 2343.00 090<br />
51980 CUTAN VESICOSTOMY 1197.53 090<br />
51990 LAPAROSCOPY URETHRAL SUSPENSION STRESS INCONT 1261.23 090<br />
51992 LAPAROSCOPY SLING OPERATION STRESS INCONT 1411.89 090<br />
51999 UNLIS LAPS PX BLDR BR YYY<br />
52000 CYSTOURETHROSCOPY 348.40 000<br />
52001 CSTO W/IRRG&EVAC MLT OBSTRUCTING CLOTS 634.77 000<br />
52005 SCOPE BLADDER INSERT TUBE FOR INJECTION 476.91 000<br />
52007 CSTO W/URTRL CATHJ BRUSH BX URTR&/RNL PELVIS 855.78 000<br />
52010 CSTO W/EJACULATORY DUX CATHJ 660.25 000<br />
52204 CYSTOURETHROSCOPY WITH BIOPSY 691.82 000<br />
52214 SCOPE BLADDER DESTRUCTION OF LESIONS 1033.02 000<br />
52224 SCOPE BLADDER REMOVAL OF LESIONS SMALL 1234.64 000<br />
52234 SCOPE BLADDER REMOVAL OF TUMORS SMALL 416.53 000<br />
52235 SCOPE BLADDER REMOVAL OF TUMORS MEDIUM 488.54 000<br />
52240 SCOPE BLADDER W/ REMOVAL OF TUMORS LARGE 853.56 000<br />
52250 CSTO INSJ RADACT SBST +-BX/FULG 410.99 000<br />
52260 SCOPE BLADDER OPENING OF BLADDER 355.05 000<br />
52265 CYSTO BLADDER DILAT INTRSTL CYSTITIS LOCAL 675.20 000<br />
52270 CSTO INT URETHROTOMY FEMALE 647.51 000<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 137
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
52275 CSTO INT URETHROTOMY MALE 880.70 000<br />
52276 CSTO DIR VIS INT URETHROTOMY 449.77 000<br />
52277 CSTO RESCJ XTRNL SPHNCTR 550.58 000<br />
52281 CSTO CALIBRATION DILAT URTL STRIX/STENOSIS 478.57 000<br />
52282 CYSTOURETHROSCOPY INSERTION PERM URETHRAL STENT 569.96 000<br />
52283 CSTO STRD NJX IN STRIX 471.37 000<br />
52285 SCOPE BLADDER OPEN NARROWED FEMALE URETHRA 475.25 000<br />
52290 CSTO URTRL MEATOTOMY UNI/BI 413.76 000<br />
52300 CSTO ORTHOTOPIC URTROCELE UNI/BI 479.68 000<br />
52301 CSTO ECTOPIC URTROCELE UNI/BI 495.74 000<br />
52305 CSTO INC/RESCJ ORIFICE BLDR DIVERTICULUM 1/MLT 471.92 000<br />
52310 SCOPE BLADDER W/SIMPLE REMOVAL STONE & STENT 413.76 000<br />
52315 SCOPE BLADDER W/COMPLEX REMOVAL STONE & STENT 724.50 000<br />
52317 LITHOLAPAXY SMPL/SM < 2.5 CM 1499.96 000<br />
52318 LITHOLAPAXY COMP/LG > 2.5 CM 802.05 000<br />
52320 CSTO RMVL URTRL ST1 417.09 000<br />
52325 CSTO FRAGMENTATION URTRL ST1 542.82 000<br />
52327 CSTO W/SUBURTRIC NJX IMPLT MATRL 444.23 000<br />
52330 CSTO MNPJ W/O RMVL URTRL ST1 1098.38 000<br />
52332 SCOPE BLADDER & URETER INSERT STENT INTO URETER 817.00 000<br />
52334 CSTO INSJ URTRL GD WIRE PRQ NFROS RTRGR 434.81 000<br />
52341 CSTO W/TX URTRL STRIX 490.76 000<br />
52342 CSTO W/TX URTROPEL JUNCT STRIX 533.41 000<br />
52343 CSTO W/TX INTRA-RNL STRIX 593.78 000<br />
52344 CSTO W/URTROSCOPY W/TX URTRL STRIX 644.19 000<br />
52345 CSTO W/URTROSCOPY W/TX URTROPEL JUNCT STRIX 686.84 000<br />
52346 CSTO W/URTROSCOPY W/TX INTRA-RNL STRIX 775.46 000<br />
52351 CSTO W/URTROSCOPY&/PYELOSCOPY DX 531.19 000<br />
52352 SCOPE BLADDER & URETER REMOVE OR MOVE STONES 624.25 000<br />
52353 SCOPE BLADDER & URETER BREAK UP KIDNEY STONE 716.75 000<br />
52354 CSTO/PYELOSCOPY BX&/FULG PEL LES 663.57 000<br />
52355 CSTO/PYELOSCOPY RESCJ PEL TUM 790.42 000<br />
52400 CSTO INC FULG/RESCJ URTL VALVES/FOLDS 810.91 090<br />
52402 CSTO W/TRURL RESCJ/INC EJACULATORY DUXS 451.98 000<br />
52450 TRURL INC PRST8 790.97 090<br />
52500 SURGERY ON BLADDER NECK THROUGH URETHRA 822.54 090<br />
52601 TRURL ELECTROSURG RESCJ PRST8 CTRL BLD COMPL 1409.12 090<br />
52630 TRURL RESCJ RESIDUAL/REGROWTH OBSTR PRST8 TISSUE 747.77 090<br />
52640 OPENING OF POSTOPERATIVE BLADDER NECK NARROWING 500.73 090<br />
52647 LASER COAGULATION OF PROSTATE FOR URINE FLOW 3382.67 090<br />
52648 LASER VAPORIZATION OF PROSTATE FOR URINE FLOW 3465.20 090<br />
52649 LASER ENUCLEATION PROSTATE W MORCELLATION 1630.13 090<br />
52700 TRURL DRG PROSTATIC ABSC 736.13 090<br />
53000 URTT/URTS XTRNL SPX PENDULOUS URT 250.92 010<br />
53010 URTT/URTS XTRNL SPX PRNL URT XTRNL 495.74 090<br />
53020 MEATOTOMY CUTTING MEATUS SPX XCP INFT 163.95 000<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
138 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
53025 MEATOTOMY CUTTING MEATUS SPX INFT 111.33 000<br />
53040 DRG DP PRIURTL ABSC 660.25 090<br />
53060 DRG OF SKENE'S GLAND ABSC OR CYST 307.97 010<br />
53080 DRG PRNL UR XTRVASATION UNCOMP SPX 720.62 090<br />
53085 DRG PRNL UR XTRVASATION COMP 1077.34 090<br />
53200 BX URT 260.89 000<br />
53210 URETHRECTOMY TOT W/CSTOST FEMALE 1300.00 090<br />
53215 URETHRECTOMY TOT W/CSTOST MALE 1566.98 090<br />
53220 EXC/FULGURATION CARC URT 762.72 090<br />
53230 EXC URTL DIVERTICULUM SPX FEMALE 1023.61 090<br />
53235 EXC URTL DIVERTICULUM SPX MALE 1070.13 090<br />
53240 MARSUPIALIZATION URTL DIVERTICULUM MALE/FEMALE 718.41 090<br />
53250 EXC OF BULBOURTL GLAND 724.50 090<br />
53260 EXC/FULGURATION URTL POLYP DSTL URT 338.43 010<br />
53265 EXC/FULGURATION URTL CARUNCLE 370.01 010<br />
53270 EXC OR FULGURATION SKENE'S GLANDS 357.27 010<br />
53275 EXC/FULGURATION URTL PROLAPSE 444.23 010<br />
53400 URETHROPLASTY 1ST STG FISTULA/DIVERTICULUM/STRIX 1350.96 090<br />
53405 URTP 2ND STG W/UR DVRJ 1476.14 090<br />
53410 URTP ONE-STG RCNSTJ MALE ANT URT 1652.28 090<br />
53415 URTP TRANSPUBIC/PRNL 1 STG RCNSTJ/RPR URT 1904.86 090<br />
53420 URTP 2-STG RCNSTJ/RPR URT 1ST STG 1382.53 090<br />
53425 URTP 2-STG RCNSTJ/RPR URT 2ND STG 1584.71 090<br />
53430 URTP RCNSTJ FEMALE URT 1619.60 090<br />
53431 URTP W/TUBULARIZATION POST URT&/LWR BLDR 1944.19 090<br />
53440 SLING OPRATION CORRJ MALE UR INCONT 1486.67 090<br />
53442 RMVL/REVJ SLING MALE UR INCONT 1313.30 090<br />
53444 INSJ TANDEM CUFF 1339.33 090<br />
53445 INSJ NFLTBL URTL/BLDR NCK SPHNCTR 1483.34 090<br />
53446 RMVL NFLTBL URTL/BLDR NCK SPHNCTR 1086.20 090<br />
53447 RMVL&RPLCMT NFLTBL NCK SPHNCTR SM SESS 1368.13 090<br />
53448 RMVL&RPLCMT NFLTBL NCK SPHNCTR THRU INFCT FLD 2160.21 090<br />
53449 RPR NFLTBL URTL/BLDR NCK SPHNCTR 1033.58 090<br />
53450 URETHROMEATOPLASTY W/MUCOSAL ADVMNT 688.50 090<br />
53460 URETHROMEATOPLASTY W/PRTL EXC DSTL URTL SGM 771.03 090<br />
53500 URETHROLSS TRVG SEC OPN W/CSTO 1260.12 090<br />
53502 URTORR SUTR URTL WND/INJ FEMALE 815.89 090<br />
53505 URTORR SUTR URTL WND/INJ PEN 819.77 090<br />
53510 URTORR SUTR URTL WND/INJ PRNL 1064.60 090<br />
53515 URTORR SUTR URTL WND/INJ PROSTATOMEMBRANOUS 1338.22 090<br />
53520 CLSR URETHROSTOMY/URETHROQ FSTL MALE SPX 937.20 090<br />
53600 DILAT URTL STRIX DILATOR MALE 1ST 142.35 000<br />
53601 DILAT URTL STRIX DILATOR MALE SBSQ 138.48 000<br />
53605 DILAT URTL STRIX/VESICAL NCK DILATOR MALE ANES 108.56 000<br />
53620 DILAT URTL STRIX FILIFORM&FOLLWR MALE 1ST 202.17 000<br />
53621 DILAT URTL STRIX FILIFORM&FOLLWR MALE SBSQ 190.54 000<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 139
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
53660 DILAT FEMALE URT W/SUPPOSITORY&/INSTLJ 1ST 121.30 000<br />
53661 DILAT FEMALE URT W/SUPPOSITORY&/INSTLJ SBSQ 120.20 000<br />
53665 DILAT FEMALE URT GENERAL/CNDJ SPI ANES 64.81 000<br />
53850 TRURL DSTRJ PRST8 TISS MICROWAVE THERMOTH 3831.88 090<br />
53852 TRURL DSTRJ PRST8 TISS RF THERMOTH 3694.51 090<br />
53855 INSERT TEMP PROSTATIC URETH STENT W/MEASUREMENT 1166.51 000<br />
l 53860 TRURL RF FEMALE BLADDER NECK STRS URIN INCONT 2380.11 090<br />
53899 UNLIS PX UR SYS BR YYY<br />
54000 SLITTING PREPUCE DORSAL/LAT SPX NB 257.01 010<br />
54001 SLITTING PREPUCE DORSAL/LAT SPX XCP NB 319.05 010<br />
54015 I&D PNS DP 520.11 010<br />
54050 DSTRJ LES PNS SMPL CHEM 214.36 010<br />
54055 DSTRJ LES PNS SMPL ELTRDSICCATION 196.08 010<br />
54056 DSTRJ LES PNS SMPL CRYOSURG 229.87 010<br />
54057 DSTRJ LES PNS SMPL LASER SURG 230.42 010<br />
54060 DSTRJ LES PNS SMPL SURG EXC 307.97 010<br />
54065 DSTRJ LES PNS X10SV 360.59 010<br />
54100 BX PNS SPX 327.35 000<br />
54105 BX PNS DP STRUXS 456.41 010<br />
54110 EXC PEN PLAQUE 1051.30 090<br />
54111 EXC PEN PLAQUE GRF 5 CM LENGTH 1352.07 090<br />
54112 EXC PEN PLAQUE GRF > 5 CM LENGTH 1584.71 090<br />
54115 RMVL FB FROM DP PEN TISS 761.06 090<br />
54120 AMP PNS PRTL 1065.70 090<br />
54125 AMP PNS COMPL 1371.46 090<br />
54130 AMP PNS RAD W/BI INGUINOFEM LMPHADEC 2014.53 090<br />
54135 AMP PNS RAD BI PEL LMPHADEC 2555.14 090<br />
54150 CIRCUMCISION W/CLAMP/OTH DEV W/BLOCK 274.73 000<br />
54160 CIRCUMCISION NEONATE 381.64 010<br />
54161 CIRCUMCISION >28 DAYS 332.34 010<br />
54162 LSS/EXC PEN POST-CIRCUMCISION ADS 447.00 010<br />
54163 RPR INCOMPL CIRCUMCISION 368.90 010<br />
54164 FRENULOTOMY PNS 325.69 010<br />
54200 NJX PEYRONIE 183.89 010<br />
54205 NJX PEYRONIE EXPOS PLAQUE 901.75 090<br />
54220 IRRIGATION CORPORA CAVERNOSA PRIAPISM 350.06 000<br />
54230 INJECTION CORPORA CAVERNOSOGRAPY 162.85 000<br />
54231 DYNAMIC CAVERNOSOMETRY NJX VASOACTIVE DRUGS 236.52 000<br />
54235 NJX C/P/A CAVERNOSA W/PHARMACOLOGIC AGT 151.77 000<br />
54240 PEN PLETHYSMOGRAPY 166.17 000<br />
54240 26 PEN PLETHYSMOGRAPY 108.56 000<br />
54240 TC PEN PLETHYSMOGRAPY 57.61 000<br />
54250 NOCTURNAL PEN TUMESCENCE&/RGDITY TST 204.39 000<br />
54250 26 NOCTURNAL PEN TUMESCENCE&/RGDITY TST 185.00 000<br />
54250 TC NOCTURNAL PEN TUMESCENCE&/RGDITY TST 19.39 000<br />
54300 PNS STRAIGHTENING CHORDEE 1088.97 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
140 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
54304 PNS CORRJ CHORDEE 1ST STG HYPSPAD RPR 1272.86 090<br />
54308 URTP 2ND STG HYPSPAD RPR < 3 CM 1234.64 090<br />
54312 URTP 2ND STG HYPSPAD RPR > 3 CM 1414.11 090<br />
54316 URTP 2ND STG HYPSPAD RPR SKN GRF 1722.08 090<br />
54318 URTP 3RD STG HYPSPAD RPR RLS PNS 1207.50 090<br />
54322 1 STG DSTL HYPSPAD RPR W/SMPL MEATAL ADVMNT 1325.48 090<br />
54324 1 STG DSTL HYPSPAD RPR W/URTP SKN FLAPS 1645.08 090<br />
54326 1 STG DSTL HYPSPAD RPR URTP SKN FLAPS&MOBLJ 1572.52 090<br />
54328 1 STG DSTL HYPSPAD RPR W/X10SV DSJ 1583.05 090<br />
54332 1 STG PROX PEN/PENOSCROTAL HYPSPAD RPR 1717.64 090<br />
54336 1 STG PRNL HYPSPAD RPR REQ X10SV DSJ SKN GRF 1994.59 090<br />
54340 RPR HYPSPAD COMPLCTJS CLSR INC/EXC SMPL 955.48 090<br />
54344 RPR HYPSPAD COMPLCTJS MOBLJ FLAPS&URTP 1636.77 090<br />
54348 RPR HYPSPAD COMPLCTJS X10SV DSJ&URTP FLAP/GRF 1896.00 090<br />
54352 RPR HYPSPAD CRIPPLE REQ X10SV DSJ&EXC 2682.54 090<br />
54360 PLSTC PNS CORRECT ANGULATION 1223.01 090<br />
54380 PLSTC PNS EPSPAD DSTL SPHNCTR 1355.39 090<br />
54385 PLSTC PNS EPSPAD DSTL SPHNCTR W/INCONT 1661.15 090<br />
54390 PLSTC PNS EPSPAD DSTL SPHNCTR W/EXSTROPHY BLDR 2070.48 090<br />
54400 INSJ PEN PROSTH NON-NFLTBL SEMI-RGD 895.66 090<br />
54401 INSJ PEN PROSTH NFLTBL SELF-CONTAINED 1107.25 090<br />
54405 INSJ MULTI-COMPONENT NFLTBL PEN PROSTH 1366.47 090<br />
54406 RMVL NFLTBL PEN PROSTH W/O RPLCMT PROSTH 1232.43 090<br />
54408 RPR COMPONENT MULTI-COMPONENT NFLTBL PEN PROSTH 1333.24 090<br />
54410 RMVL&RPLCMT NFLTBL PEN PROSTH SM SESS 1453.43 090<br />
54411 RMVL&RPLCMT NFLTBL PEN PROSTH THRU INFCT FLD 1729.83 090<br />
54415 RMVL NON-NFLTBL/NFLTBL PEN PROSTH W/O RPLCMT 890.12 090<br />
54416 RMVL&RPLCMT NON-NFLTBL/NFLTBL PROSTH SM SESS 1196.98 090<br />
54417 RMVL&RPLCMT NON-NFLTBL/NFLTBL PEN INFCT SM SESS 1515.47 090<br />
54420 C/P/A CAVERNOSA-SAPHENOUS VEIN SHUNT UNI/BI 1193.10 090<br />
54430 C/P/A CAVERNOSA-CORPUS SPONGIOSUM SHUNT UNI/BI 1083.43 090<br />
54435 CORPORA CAVERNOSA-GLANS PENIS FSTLJ PRIAPISM 704.01 090<br />
54440 PLASTIC OPERATION PENIS INJURY 958.80 090<br />
54450 FORESKN MNPJ W/LSS PREPUTIAL ADS&STRETCHING 120.20 000<br />
54500 BX TSTIS NDL SPX 125.74 000<br />
54505 BX TSTIS INCAL SPX 356.16 010<br />
54512 EXC XTRPARENCHYMAL LES TSTIS 904.52 090<br />
54520 ORCHIECTOMY SMPL SCROTAL/INGUN APPR 550.02 090<br />
54522 ORCHIECTOMY PRTL 981.51 090<br />
54530 ORCHIECTOMY RAD TUM INGUN APPR 853.56 090<br />
54535 ORCHIECTOMY RAD TUM W/ABDL EXPL 1242.95 090<br />
54550 EXPL UNDESCENDED TSTIS INGUN/SCROTAL AREA 825.86 090<br />
54560 EXPL UNDESCENDED TSTIS W/ABDL EXPL 1134.94 090<br />
54600 RDCTJ TORSION TSTIS +-FIXJ CLAT TSTIS 762.72 090<br />
54620 FIXJ CLAT TSTIS SPX 507.37 010<br />
54640 ORCHIOPEXY INGUN APPR +-HRNA RPR 800.94 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 141
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
54650 ORCHIOPEXY ABDL APPR INTRA-ABDL TSTIS 1191.44 090<br />
54660 INSJ TSTICULAR PROSTH SPX 599.32 090<br />
54670 SUTR/RPR TSTICULAR INJ 681.30 090<br />
54680 TRNSPLJ TSTIS THI 1317.17 090<br />
54690 LAPAROSCOPY SURGICAL ORCHIECTOMY 1152.67 090<br />
54692 LAPAROSCOPY ORCHIOPEXY INTRA-ABDOMINAL TESTIS 1282.28 090<br />
54699 UNLIS LAPS PX TSTIS BR YYY<br />
54700 I&D EPIDIDYMIS TSTIS&/SCROTAL SPACE 358.37 010<br />
54800 BX EPIDIDYMIS NDL 247.59 000<br />
54830 EXC LOCAL LES EPIDIDYMIS 627.01 090<br />
54840 EXC SPRMATOCELE +-EPIDIDYMECTOMY 542.82 090<br />
54860 EPIDIDYMECTOMY UNI 705.67 090<br />
54861 EPIDIDYMECTOMY BI 952.15 090<br />
54865 EXPLORATION EPIDIDYMIS W/WO BIOPSY 602.64 090<br />
54900 EPIDIDYMOVASOSTOMY ANAST EPIDIDYMIS UNI 1285.60 090<br />
54901 EPIDIDYMOVASOSTOMY ANAST EPIDIDYMIS BI 1787.99 090<br />
55000 PNXR ASPIR HYDROCELE TUNICA VAGIS +-NJX MED 201.07 000<br />
55040 EXC HYDROCELE UNI 570.52 090<br />
55041 EXC HYDROCELE BI 858.55 090<br />
55060 RPR TUNICA VAGIS HYDROCELE BOTTLE TYP 640.31 090<br />
55100 DRG SCROTAL WALL ABSC 366.13 010<br />
55110 SCROTAL EXPL 653.05 090<br />
55120 RMVL FB SCROTUM 599.32 090<br />
55150 RESCJ SCROTUM 825.86 090<br />
55175 SCROTOPLASTY SMPL 613.17 090<br />
55180 SCROTOPLASTY COMP 1163.74 090<br />
55200 VASOTOMY CANNULIZATION +-INC VAS UNI/BI SPX 784.88 090<br />
55250 VASECT UNI/BI SPX W/PO SEMEN XM 700.13 090<br />
55300 VASOTOMY VASOGRAMS UNI/BI 307.97 000<br />
55400 VASOVASOSTOMY VASOVASORRHAPHY 843.59 090<br />
55450 LIG PRQ VAS DEFERENS UNI/BI SPX 625.35 010<br />
55500 EXC HYDROCELE SPRMATIC CORD UNI SPX 658.03 090<br />
55520 EXC LES SPRMATIC CORD SPX 720.07 090<br />
55530 EXC VARICOCELE/LIG SPRMATIC VEINS SPX 596.55 090<br />
55535 EXC VARICOCELE/LIG SPRMATIC VEINS ABDL 721.18 090<br />
55540 EXC VARICOCELE/LIG VEINS W/HRNA RPR 864.64 090<br />
55550 LAPS LIG SPRMATIC VEINS VARICOCELE 713.42 090<br />
55559 UNLIS LAPS SPRMATIC CORD BR YYY<br />
55600 VESICULOTOMY 711.21 090<br />
55605 VESICULOTOMY COMP 875.72 090<br />
55650 VESICULECTOMY ANY APPR 1202.52 090<br />
55680 EXC MULLERIAN DUX CST 573.84 090<br />
55700 PROSTATE NEEDLE BIOPSY ANY APPROACH 380.53 000<br />
55705 BX PRST8 INCAL ANY APPR 451.43 010<br />
55706 BX PROSTATE STRTCTC SATURATION SAMPLING IMG GID 630.89 010<br />
55720 PROSTATOTOMY XTRNL DRG ABSC SMPL 759.95 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
142 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
55725 PROSTATOTOMY XTRNL DRG ABSC COMP 994.80 090<br />
55801 PRST8ECT PRNL STOT 1836.18 090<br />
55810 PRST8ECT PRNL RAD 2220.59 090<br />
55812 PRST8ECT PRNL RAD LYMPH NODE BX 2714.11 090<br />
55815 PRST8ECT PRNL RAD BI PEL LMPHADEC 2976.66 090<br />
55821 PRST8ECT SUPRAPUBIC STOT 1/2 STGS 1475.59 090<br />
55831 PRST8ECT RETROPUBIC STOT 1595.79 090<br />
55840 PRST8ECT RETROPUBIC RAD +-NRV SPARING 2258.80 090<br />
55842 PRST8ECT RETROPUBIC RAD LYMPH NODE BX 2418.33 090<br />
55845 PRST8ECT RETROPUBIC RAD W/BI PEL LMPHADEC 2763.41 090<br />
55860 EXPOS PRST8 ANY APPR INSJ RADACT SBST 1475.59 090<br />
55862 EXPOS PRST8 INSJ RADACT NODE BX 1853.90 090<br />
55865 EXPOS PRST8 INSJ RADACT BI PEL LMPHADEC 2254.93 090<br />
s 55866 LAPS PRSTECT RETROPUBIC RAD W/NRV SPARING ROBOT 2925.15 090<br />
55870 ELECTROEJACULATION 295.78 000<br />
55873 CRYOSURG ABLATION PROSTATE US & MONITORING 10324.70 090<br />
55875 TPRNL PLMT NDL/CATHS INTO PRST8 RADJ INSJ 1285.05 090<br />
s 55876 PLACE INTERSTITIAL DEV RADIATION TX PROSTATE 1+ 229.87 000<br />
55899 UNLIS MALE GEN SYS BR YYY<br />
55920 PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL 732.26 000<br />
55970 INTERSEX SURG MALE FEMALE BR XXX<br />
55980 INTERSEX SURG FEMALE MALE BR XXX<br />
56405 I&D VULVA/PRNL ABSC 179.46 010<br />
56420 I&D OF BARTHOLIN'S GLAND ABSC 202.73 010<br />
56440 MARSUPIALIZATION BARTHOLIN'S GLAND CYST 301.32 010<br />
56441 LSS LABIAL ADS 240.39 010<br />
56442 HYMENOTOMY SIMPLE INCISION 79.21 000<br />
56501 DSTRJ LES VULVA SMPL 214.36 010<br />
56515 DSTRJ LES VULVA X10SV 367.24 010<br />
56605 BX VULVA/PR SPX 1 LES 135.71 000<br />
+ 56606 BX VULVA/PR SPX EA SEP ADDL LES 61.48 ZZZ<br />
56620 VULVECTOMY SMPL PRTL 821.43 090<br />
56625 VULVECTOMY SMPL COMPL 985.94 090<br />
56630 VULVECTOMY RAD PRTL 1448.45 090<br />
56631 VULVECTOMY RAD PRTL UNI INGUINOFEM LMPHADEC 1835.62 090<br />
56632 VULVECTOMY RAD PRTL BI INGUINOFEM LMPHADEC 2133.07 090<br />
56633 VULVECTOMY RAD COMPL 1882.71 090<br />
56634 VULVECTOMY RAD COMPL UNI INGUINOFEM LMPHADEC 1990.16 090<br />
56637 VULVECTOMY RAD COMPL BI INGUINOFEM LMPHADEC 2342.44 090<br />
56640 VULVECTOMY RAD COMPL ILIAC&PEL LMPHADEC 2309.76 090<br />
56700 PRTL HYMENECTOMY/REVJ HYMENAL RING 307.97 010<br />
56740 EXC BARTHOLIN'S GLAND OR CYST 489.09 010<br />
56800 PLSTC RPR INTROITUS 397.70 010<br />
56805 CLITOROPLASTY INTERSEX STATE 1886.03 090<br />
56810 PRINEOPLASTY RPR PR NONOBAL SPX 427.61 010<br />
56820 COLPOSCOPY VULVA 181.13 000<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 143
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
56821 COLPOSCOPY VULVA W/BX 240.95 000<br />
57000 COLPOTOMY W/EXPL 312.95 010<br />
57010 COLPOTOMY W/DRG PEL ABSC 713.42 090<br />
57020 COLPOCNTS SPX 154.54 000<br />
57022 I&D VAG HMTMA OBAL/POSTPARTUM 275.84 010<br />
57023 I&D VAG HMTMA NON-OBAL 512.36 010<br />
57061 DSTRJ VAG LES SMPL 186.66 010<br />
57065 DSTRJ VAG LES X10SV 314.06 010<br />
57100 BX VAG MUCOSA SMPL SPX 144.01 000<br />
57105 BX VAG MUCOSA X10SV REQ SUTR 221.56 010<br />
57106 VAGNC PRTL RMVL VAG WALL 788.20 090<br />
57107 VAGNC PRTL RMVL VAG WALL PARAVAG TISS 2306.99 090<br />
57109 VAGNC PRTL RMVL VAG WALL W/BI TOT PEL LMPHADEC 2636.56 090<br />
57110 VAGNC COMPL RMVL VAG WALL 1478.91 090<br />
57111 VAGNC COMPL RMVL VAG WALL PARAVAG TISS 2652.63 090<br />
57112 VAGNC COMPL RMVL VAG WALL TOT PEL LMPHADEC BX 2487.01 090<br />
57120 COLPOCLEISIS LE FORT TYP 841.37 090<br />
57130 EXC VAG SEPTUM 293.57 010<br />
57135 EXC VAG CST/TUM 315.17 010<br />
57150 IRRG VAG&/APPL MEDICAMENT DISEASE 78.10 000<br />
s K 57155 INSJ UTERINE TANDEM&/VAG OVOIDS 535.07 000<br />
l 57156 INSJ VAGINAL RADIATION DEVICE 244.27 000<br />
57160 FITG&INSJ PESSARY/OTH INTRAVAG SUPPORT DEV 125.74 000<br />
57170 DPHRM/CRV CAP FITG W/INSTRUCTIONS 106.35 000<br />
57180 INTRO ANY HEMOSTATIC AGT/PACK VAG HEMRRG SPX 231.53 010<br />
57200 COLPORRHAPHY SUTR INJ VAG 489.09 090<br />
57210 COLPOPRINEORRHAPHY SUTR INJ VAG&/PR 601.54 090<br />
57220 PLSTC URTL SPHNCTR VAG APPR 526.76 090<br />
57230 PLSTC RPR URETHROCELE 658.59 090<br />
57240 ANT COLPORRHAPHY RPR CSTOCELE +-RPR URETHROCELE 1096.17 090<br />
57250 POST COLPORRHAPHY RPR RECTOCELE +-PRINEORRHAPHY 1100.05 090<br />
57260 CMBN ANTEROPOST COLPORRHAPHY 1359.27 090<br />
57265 CMBN ANTEROPOST COLPORRHAPHY W/NTRCL RPR 1497.75 090<br />
+ 57267 INSJ MESH/PROSTH PEL FLOOR DFCT EA SIT 428.16 ZZZ<br />
57268 RPR NTRCL VAG APPR SPX 792.08 090<br />
57270 RPR NTRCL ABDL APPR SPX 1313.30 090<br />
57280 COLPOPEXY ABDL APPR 1576.95 090<br />
57282 COLPOPEXY VAG XTR-PRTL APPR 826.97 090<br />
57283 COLPOPEXY VAG INTRA-PRTL APPR 1138.26 090<br />
57284 PARAVAGINAL DEFECT REPAIR OPEN ABDOMINAL APPR 1355.39 090<br />
57285 PARAVAGINAL DEFECT REPAIR VAGINAL APPROACH 1116.11 090<br />
57287 RMVL/REVJ SLING STRESS INCONTINENCE 1132.17 090<br />
57288 SLING OPERATION STRESS INCONTINENCE 1174.82 090<br />
57289 PREYRA PX W/ANT COLPORRHAPHY 1203.62 090<br />
57291 CONSTJ ARTIF VAG W/O GRF 975.97 090<br />
57292 CONSTJ ARTIF VAG W/GRF 1355.95 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
144 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
57295 REVJ RMVL PROSTC VAG GRF VAG APPR 794.85 090<br />
57296 REVJ W/RMVL PROSTHETIC VAG GRF ABD APPRO 1566.98 090<br />
57300 CLSR RECTOVAG FSTL VAG/TRANSANAL APPR 899.53 090<br />
57305 CLSR RECTOVAG FSTL ABDL APPR 1499.41 090<br />
57307 CLSR RECTOVAG FSTL ABDL APPR W/CONCOMITANT CLST 1702.69 090<br />
57308 CLSR RECTOVAG FSTL TPRNL PRNL BDY RCNSTJ 1063.49 090<br />
57310 CLSR URETHROVAG FSTL 767.71 090<br />
57311 CLSR URETHROVAG FSTL W/BULBOCAVERNOSUS TRNSPL 874.05 090<br />
57320 CLSR VESICOVAG FSTL VAG APPR 887.90 090<br />
57330 CLSR VESICOVAG FSTL TRANSVESICAL&VAG APPR 1230.21 090<br />
57335 VAGINOPLASTY INTERSEX STATE 1920.93 090<br />
57400 DILATION VAGINA W/ANESTHESIA OTHER THAN LOCAL 221.01 000<br />
57410 PELVIC EXAMINATION W/ANESTHESIA OTHER THAN LOCAL 176.14 000<br />
57415 REMOVAL IMPACTED VAG FB SPX W/ANES OTH/THN LOCAL 262.55 010<br />
57420 COLPOSCOPY ENTIRE VAG W/CERVIX IF PRESENT 189.43 000<br />
57421 COLPOSCOPY ENTIRE VAG W/CERVIX BX 255.35 000<br />
57423 PARAVAGINAL DEFECT REPAIR LAPAROSCOPIC APPROACH 1519.35 090<br />
57425 LAPS SURG COLPOPEXY SSP VAG APEX 1599.11 090<br />
57426 REVISION PROSTHETIC VAGINAL GRAFT LAPAROSCOPIC 1386.41 090<br />
57452 COLPOSCOPY CERVIX UPR/ADJ VAG 177.80 000<br />
57454 COLPOSCOPY CERVIX BX CERVIX&ENDOCRV CURTG 252.02 000<br />
57455 COLPOSCOPY CERVIX VAG BX CERVIX 234.30 000<br />
57456 COLPOSCOPY CERVIX VAG ENDOCRV CURTG 221.56 000<br />
57460 COLPOSCOPY CERVIX VAG LOOP ELTRD BX CERVIX 476.91 000<br />
57461 COLPOSCOPY CERVIX VAG ELTRD CONIZATION CERVIX 536.73 000<br />
57500 BIOPSY CERVIX 1/MLT OR EXCISION OF LESION 213.25 000<br />
57505 ENDOCRV CURTG X DONE AS PART DILAT&CURTG 166.72 010<br />
57510 CAUT CERVIX ELECTRO/THERMAL 216.02 010<br />
57511 CAUT CERVIX CRYOCAUT 1ST/REPEAT 238.73 010<br />
57513 CAUT CERVIX LASER ABLTJ 235.96 010<br />
57520 CONIZATION CERVIX +-D&C RPR KNIFE/LASER 501.83 090<br />
57522 CONIZATION CERVIX +-D&C RPR ELTRD EXC 433.15 090<br />
57530 TRACHELECTOMY CERVICECTOMY AMP CERVIX SPX 565.53 090<br />
57531 RAD TRACHELECTOMY W/BI PEL LMPHADEC 2815.47 090<br />
57540 EXC CRV STUMP ABDL APPR 1281.72 090<br />
57545 EXC CRV STUMP ABDL APPR W/PEL FLOOR RPR 1352.62 090<br />
57550 EXC CRV STUMP VAG APPR 671.88 090<br />
57555 EXC CRV STUMP VAG APPR W/ANT&/POST RPR 987.60 090<br />
57556 EXC CRV STUMP VAG APPR W/RPR NTRCL 933.32 090<br />
57558 DILATION & CURETTAGE CERVICAL STUMP 205.50 010<br />
57700 CERCLAGE UTERINE CERVIX NONOBAL 510.70 090<br />
57720 TRACHELORRHAPHY PLSTC RPR UTERINE CERVIX VAG 505.16 090<br />
57800 DILAT CRV CANAL INSTRUMENTAL SPX 98.04 000<br />
58100 ENDOMETRIAL BX +-ENDOCRV BX W/O DILAT SPX 180.02 000<br />
+ 58110 ENDOMETRIAL BX CONJUNCT W/COLPOSCOPY 79.21 ZZZ<br />
58120 D&C DX&/THER 416.53 010<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 145
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
58140 MYOMECTOMY 1-4 250 GM ABDL 1509.38 090<br />
58145 MYOMECTOMY 1-4 250 GM/< VAG 893.99 090<br />
58146 MYOMECTOMY 5+ > 250 GM ABDL 1904.86 090<br />
58150 TAH +-RMVL TUBE +-RMVL OVARY 1635.11 090<br />
58152 TAH +-RMVL TUBE OVARY COLPO-URTCSTOPEXY 2052.75 090<br />
58180 SUPRACRV ABDL HYST +-RMVL TUBE OVARY 1571.97 090<br />
58200 TAH W/PRTL VAGNC PEL LYMPH NODE SAMPLING 2155.22 090<br />
58210 RAD ABDL HYST W/BI PEL LMPHADEC 2880.28 090<br />
58240 PEL EXNTJ GYNECOLOGIC MAL 4570.23 090<br />
58260 VAG HYST 250 GM/< 1361.49 090<br />
58262 VAG HYST 250 GM/< W/RMVL TUBE&/OVARY 1518.79 090<br />
58263 VAG HYST 250 GM/< W/RMVL TUBE OVARY W/RPR NTRCL 1634.01 090<br />
58267 VAG HYST 250 GM/< W/COLPO-URTCSTOPEXY 1738.14 090<br />
58270 VAG HYST 250 GM/< W/RPR NTRCL 1452.33 090<br />
58275 VAG HYST W/TOT/PRTL VAGNC 1620.16 090<br />
58280 VAG HYST W/TOT/PRTL VAGNC W/RPR NTRCL 1732.60 090<br />
58285 VAG HYST RAD SCHAUTA 2162.43 090<br />
58290 VAGINAL HYSTERECTOMY UTERUS > 250 GM 1898.22 090<br />
58291 VAG HYST > 250 GM RMVL TUBE&/OVARY 2058.85 090<br />
58292 VAG HYST > 250 GM RMVL TUBE&/OVARY W/RPR NTRCL 2169.63 090<br />
58293 VAG HYST > 250 GM COLPO-URTCSTOPEXY +-NDSC CTRL 2254.93 090<br />
58294 VAG HYST > 250 GM RPR NTRCL 2009.00 090<br />
58300 INSJ INTRAUTERINE DEV 117.43 XXX<br />
58301 RMVL INTRAUTERINE DEV 157.31 000<br />
58321 ARTIF INSEMINATION INTRA-CRV 121.86 000<br />
58322 ARTIF INSEMINATION INTRA-UTERINE 141.80 000<br />
58323 SPRM WASHG ARTIF INSEMINATION 28.80 000<br />
58340 CATHJ&INTRO SALINE NFS SHG/HSG 200.51 000<br />
58345 TRANSCRV INTRO FLP TUBE CATH +-HSG 460.84 010<br />
58346 INSJ HEYMAN CAPSLS CLINICAL BRACHYTX 715.64 090<br />
58350 CHROMOTUBATION OVIDUX MATRLS 158.97 010<br />
58353 ENDOMETRIAL ABLTJ THERMAL W/O HYSTEROSCOPIC GID 1761.40 010<br />
58356 ENDOMETRIAL CRYOABLTJ US CURTG 3263.58 010<br />
58400 UTERINE SSP SPX 726.16 090<br />
58410 UTERINE SSP PRESAC SYMPTH 1322.71 090<br />
58520 HYSTERORRHAPHY RPR RPTD 1327.14 090<br />
58540 HYSTEROPLASTY RPR UTERINE ANOMAL 1494.42 090<br />
58541 LAPS SUPRACRV HYST 250 G/< 1415.21 090<br />
58542 LAPS SUPRACRV HYST 250 G/< RMVL TUBE/OVARY 1580.83 090<br />
58543 LAPS SUPRACRV HYST >250 G 1607.97 090<br />
58544 LAPS SUPRACRV HYST >250 G RMVL TUBE/OVARY 1738.14 090<br />
58545 LAPS MYOMECTOMY EXC 1-4 250 GM/< 1472.82 090<br />
58546 LAPS MYOMECTOMY EXC 5+ > 250 GRAMS 1858.89 090<br />
58548 LAPS W/RAD HYST W/BILAT LMPHADEC RMVL TUBE/OVARY 2937.89 090<br />
58550 LAPS W/VAG HYST 250 GM/< 1453.43 090<br />
58552 LAPS W/VAG HYST 250 GM/< RMVL TUBE&/OVARY 1612.40 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
146 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
58553 LAPS W/VAG HYST > 250 GRAMS 1869.97 090<br />
58554 LAPS VAG HYST > 250 GM RMVL TUBE&/OVARY 2162.98 090<br />
58555 HYSTSC DX SPX 442.57 000<br />
58558 HYSTSC BX ENDOMETRIUM&/POLYPC +-D&C 587.13 000<br />
58559 HYSTSC LSS INTRAUTERINE ADS 566.64 000<br />
58560 HYSTSC DIV/RESCJ INTRAUTERINE SEPTUM 639.75 000<br />
58561 HYSTSC RMVL LEIOMYOMATA 904.52 000<br />
58562 HYSTSC RMVL IMPACTED FB 613.72 000<br />
58563 HYSTSC ENDOMETRIAL ABLTJ 2883.05 000<br />
58565 HYSTSC OCCLUSION PLMT PRM 3138.40 090<br />
58570 LAPAROSCOPY W TOTAL HYSTERECTOMY UTERUS 250 G/< 1521.56 090<br />
58571 LAPS TOTAL HYSTERECTOMY 250 G/250 G 1891.01 090<br />
58573 LAPAROSCOPY TOT HYSTERECTOMY >250 G W TUBE/OVARY 2158.55 090<br />
58578 UNLIS LAPS UTER BR YYY<br />
58579 UNLIS HYSTSC UTER BR YYY<br />
58600 LIG/TRNSXJ FLP TUBE ABDL/VAG APPR UNI/BI 599.32 090<br />
58605 LIG/TRNSXJ FLP TUBE ABDL/VAG POSTPARTUM SPX 541.71 090<br />
+ 58611 LIG/TRNSXJ FLP TUBE DONE TM C DLVR/SURG 127.95 ZZZ<br />
58615 OCCLUSION FLP TUBE DEV VAG/SUPRAPUBIC APPR 405.45 010<br />
58660 LAPS LSS ADS SPX 1105.58 090<br />
58661 LAPS RMVL ADNEXAL STRUXS 1058.50 010<br />
58662 LAPS FULG/EXC OVARY VISCERA/PRTL SURF 1159.87 090<br />
58670 LAPS FULG OVIDUXS 601.54 090<br />
58671 LAPS OCCLUSION OVIDUXS DEV 600.98 090<br />
58672 LAPS FIMBRIOPLASTY 1213.04 090<br />
58673 LAPS SALPINGOSTOMY 1319.39 090<br />
58679 UNLIS LAPS PX OVIDUX OVARY BR YYY<br />
58700 SALPINGECTOMY COMPL/PRTL UNI/BI SPX 1270.65 090<br />
58720 SALPINGO-OOPHORECTOMY COMPL/PRTL UNI/BI SPX 1184.79 090<br />
58740 LSS ADS 1439.59 090<br />
58750 TUBOTUBAL ANAST 1486.67 090<br />
58752 TUBOUTERINE IMPLTJ 1401.92 090<br />
58760 FIMBRIOPLASTY 1337.11 090<br />
58770 SALPINGOSTOMY 1391.95 090<br />
58800 DRG OVARIAN CST UNI/BI SPX VAG 526.21 090<br />
58805 DRG OVARIAN CST UNI/BI SPX ABDL 663.02 090<br />
58820 DRG OVARIAN ABSC VAG OPN 535.62 090<br />
58822 DRG OVARIAN ABSC ABDL 1189.22 090<br />
K 58823 DRG PEL ABSC TRVG/TRANSRCT PRQ 1488.33 000<br />
58825 TRPOS OVARY 1152.11 090<br />
58900 BX OVARY UNI/BI SPX 716.75 090<br />
58920 WEDGE RESCJ/BISCTJ OVARY UNI/BI 1149.90 090<br />
58925 OVARIAN CSTC UNI/BI 1213.59 090<br />
58940 OOPHORECTOMY PRTL/TOT UNI/BI 843.59 090<br />
58943 OOPHORECTOMY PRTL/TOT UNI/BI OVARIAN MAL 1851.69 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 147
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
58950 RESCJ PRIM PRTL MAL W/BSO&OMNTC 1769.16 090<br />
58951 RESCJ PRIM PRTL MAL W/BSO&OMNTC TAH&LMPHADEC 2273.21 090<br />
58952 RESCJ PRIM PRTL MAL W/BSO&OMNTC RAD DEBULKING 2565.66 090<br />
58953 BSO W/OMNTC TAH&RAD DSJ DEBULKING 3174.40 090<br />
58954 BSO W/OMNTC TAH DEBULKING W/LMPHADEC 3440.83 090<br />
58956 BSO TOT OMNTC TAH MAL 2169.63 090<br />
58957 RESECTION RECRT MAL W/OMENTECTOMY 2474.27 090<br />
58958 RESECTION RECRT MAL W/OMENTECTOMY PEL LMPHADEC 2720.20 090<br />
58960 LAPT STG/RESTG OVARIAN TUBAL/PRIM MAL 2ND LOOK 1521.56 090<br />
58970 FOLLICLE PNXR OOCYTE RETRIEVAL ANY METH 348.40 000<br />
58974 EMBRYO TR INTRAUTERINE 238.73 000<br />
58976 GAMETE ZYGOTE/EMBRYO INTRAFLP TR ANY METH 394.38 000<br />
58999 UNLIS PX FEMALE GEN SYS BR YYY<br />
59000 AMNIOCNTS DX 209.93 000<br />
59001 AMNIOCNTS THER AMNIOTIC FLU RDCTJ US GID 304.09 000<br />
59012 CORDOCNTS INTRAUTERINE 338.99 000<br />
59015 CHORNC VILLUS SAMPLING 258.12 000<br />
59020 FTL CONTRCJ STRS TST 113.00 000<br />
59020 26 FTL CONTRCJ STRS TST 60.93 000<br />
59020 TC FTL CONTRCJ STRS TST 52.07 000<br />
59025 FTL NON-STRS TST 76.99 000<br />
59025 26 FTL NON-STRS TST 48.74 000<br />
59025 TC FTL NON-STRS TST 28.25 000<br />
59030 FTL SCALP BLD SAMPLING 162.29 000<br />
59050 FTL MNTR LABOR PHYS WRTTN REPRT S&I 84.75 XXX<br />
59051 FTL MNTR LABOR PHYS WRTTN REPRT INTERPJ ONLY 70.35 XXX<br />
59070 TABDL AMNIONFS US GID 695.14 000<br />
59072 FTL UMBILICAL CORD OCCLUSION W/US GID 874.05 000<br />
59074 FTL FLU DRG US GID 681.85 000<br />
59076 FTL SHUNT PLMT US GID 864.64 000<br />
59100 HYSTOT ABDL 1379.76 090<br />
59120 TX ECTOPIC PREGNANCY REQ SO 1318.84 090<br />
59121 TX ECTOPIC PREGNANCY W/O SO 1320.50 090<br />
59130 TX ECTOPIC PREGNANCY ABDL PREGNANCY 1358.72 090<br />
59135 TX ECTOPIC PREGNANCY NTRSTL REQ TOT HYST 1358.16 090<br />
59136 TX ECTOPIC PREGNANCY NTRSTL PRTL RESCJ UTER 1457.86 090<br />
59140 TX ECTOPIC PREGNANCY CRV W/EVAC 587.69 090<br />
59150 LAPS TX ECTOPIC PREGNANCY W/O SO 1275.63 090<br />
59151 LAPS TX ECTOPIC PREGNANCY W/SO 1244.06 090<br />
59160 CURTG POSTPARTUM 346.19 010<br />
59200 INSJ CRV DILATOR SPX 120.75 000<br />
59300 EPISIOTOMY/VAG RPR OTH/THN ATTENDING PHYS 317.38 000<br />
59320 CERCLAGE CERVIX PREGNANCY VAG 253.13 000<br />
59325 CERCLAGE CERVIX PREGNANCY ABDL 356.16 000<br />
59350 HYSTERORRHAPHY RPTD UTER 465.83 000<br />
59400 OB CARE ANTEPARTUM VAG DLVR&POSTPARTUM 3101.84 MMM<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
148 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
59409 VAG DLVR ONLY 1218.58 MMM<br />
59410 VAG DLVR ONLY POSTPARTUM CARE 1544.83 MMM<br />
59412 XTRNL CEPHALIC VERSION +-TOCOLSS 157.31 MMM<br />
59414 DLVR PLACENTA SPX 138.48 MMM<br />
59425 ANTEPARTUM CARE ONLY 4-6 VSTS 690.16 MMM<br />
59426 ANTEPARTUM CARE ONLY 7+ VSTS 1233.54 MMM<br />
59430 POSTPARTUM CARE ONLY SPX 257.01 MMM<br />
59510 OB ANTEPARTUM CARE C DLVR&POSTPARTUM 3454.12 MMM<br />
59514 C DLVR ONLY 1383.09 MMM<br />
59515 C DLVR ONLY W/POSTPARTUM CARE 1871.63 MMM<br />
+ 59525 STOT/TOT HYST AFTER C DLVR 809.80 ZZZ<br />
59610 OB ANTEPARTUM VAG DLVR&POSTPARTUM AFTER C DLVR 3268.56 MMM<br />
59612 VAG DLVR AFTER C DLVR 1373.67 MMM<br />
59614 VAG DLVR AFTER C DLVR POSTPARTUM CARE 1691.06 MMM<br />
59618 ANTEPARTUM C DLVR&POSTPARTUM FA V AP C DLVER 3518.37 MMM<br />
59620 C DLVR ONLY FA V AP C DLVER 1440.69 MMM<br />
59622 C DLVR ONLY FA V AP C DLVER W/POSTPARTUM CARE 1939.76 MMM<br />
59812 TX INCOMPL AB ANY TRI COMPLD SURGLY 523.44 090<br />
59820 TX MISSED AB COMPLD SURGLY 1ST TRI 627.01 090<br />
59821 TX MISSED AB COMPLD SURGLY 2ND TRI 633.11 090<br />
59830 TX SEPTIC AB COMPLD SURGLY 723.95 090<br />
59840 INDUCED AB DILAT&CURTG 355.05 010<br />
59841 INDUCED AB DILAT&EVAC 631.45 010<br />
59850 INDUCED AB 1+ IAM NJXS DLVR FETUS 567.19 090<br />
59851 INDUCED AB 1+ IAM NJXS DLVR FETUS D&C&EVAC 660.80 090<br />
59852 INDUCED AB 1+ IAM NJXS DLVR FETUS HYSTOT 821.43 090<br />
59855 INDUCED AB 1+ VAG SUPP DLVR FETUS 689.05 090<br />
59856 INDUCED AB 1+ VAG SUPP DLVR FETUS D&C&/EVAC 810.36 090<br />
59857 INDUCED AB 1+ VAG SUPP DLVR FETUS HYSTOT 850.24 090<br />
59866 MULTIFTL PREGNANCY RDCTJ 351.73 000<br />
59870 UTERINE EVAC&CURTG HYDATIDIFORM MOLE 783.77 090<br />
59871 RMVL CERCLAGE SUTR UNDER ANES 222.67 000<br />
59897 UNLIS FTL INVASIVE W/US GID BR YYY<br />
59898 UNLIS LAPS MATERNITY CARE&DLVR BR YYY<br />
59899 UNLIS MATERNITY CARE&DLVR BR YYY<br />
60000 I&D THYROGLOSSAL DUX CST INFCT 264.76 010<br />
60100 BX THYR PRQ CORE NDL 182.79 000<br />
60200 EXC CST/ADENOMA THYR/TRNSXJ ISTHMUS 1072.35 090<br />
60210 PRTL THYR LOBEC UNI +-ISTHMUSECTOMY 1147.68 090<br />
60212 PRTL THYR LOBEC UNI W/CLAT STOT LOBEC 1647.85 090<br />
60220 TOT THYR LOBEC UNI +-ISTHMUSECTOMY 1252.92 090<br />
60225 TOT THYR LOBEC UNI W/CLAT STOT LOBEC 1507.16 090<br />
60240 TRDEC TOT/COMPL 1581.94 090<br />
60252 THYROIDECTOMY TOTAL/SUBTOTAL LMTD NECK DISSECT 2146.36 090<br />
60254 THYROIDECTOMY TOTAL/SUBTOTAL RAD NECK DISSECT 2753.44 090<br />
60260 TRDEC RMVL REMAINING TISS FLWG RMVL PRTN 1785.77 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 149
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
60270 TRDEC W/SUBSTERNAL THYR STERNAL SPLT/TTHRC 2253.82 090<br />
60271 TRDEC W/SUBSTERNAL THYR CRV APPR 1724.29 090<br />
60280 EXC THYROGLOSSAL DUX CST/SINUS 723.95 090<br />
60281 EXC THYROGLOSSAL DUX CST/SINUS RECRT 964.89 090<br />
60300 ASPIRATION AND/OR INJECTION THYROID CYST 180.57 000<br />
60500 PARATRDEC/EXPL PARATHYR 1653.39 090<br />
60502 PARATRDEC/EXPL PARATHYR RE-EXPL 2077.13 090<br />
60505 PARATRDEC/EXPL PARATHYR MEDSTNL STERNAL/TTHRC 2268.22 090<br />
+ 60512 PARATHYR AUTOTRNSPLJ 396.59 ZZZ<br />
60520 THYMECTOMY PRTL/TOT TRANSCRV APPR SPX 1687.73 090<br />
60521 THYMECTOMY PRTL/TOT W/O RAD MEDSTNL DSJ SPX 1901.54 090<br />
60522 THYMECTOMY PRTL/TOT RAD MEDSTNL DSJ SPX 2303.12 090<br />
60540 ADRNLECTOMY EXPL ADRNL TABDL LMBR/DORSAL SPX 1732.05 090<br />
60545 ADRNLECTOMY EXPL ADRNL SPX EXC ADJ TUM 1989.61 090<br />
60600 EXC CRTD BDY TUM W/O EXC CRTD ART 2372.91 090<br />
60605 EXC CRTD BDY TUM W/EXC CRTD ART 2926.81 090<br />
60650 LAPS ADRNLECTOMY PRTL/COMPL TABDL 1947.51 090<br />
60659 UNLIS LAPS ENDOC SYS BR YYY<br />
60699 UNLIS ENDOC SYS BR YYY<br />
61000 SDRL TAP THRU FONTANELLE/SUTR INFT UNI/BI 1ST 176.14 000<br />
61001 SDRL TAP THRU FONTANELLE/SUTR INFT UNI/BI SBSQ 187.22 000<br />
61020 VENTR PNXR PREVIOUS BURR HOLE W/O NJX 221.01 000<br />
61026 VENTR PNXR PREVIOUS BURR HOLE W/NJX 207.16 000<br />
61050 CISTERNAL/LAT CRV C1-C2 PNXR W/O NJX SPX 168.94 000<br />
61055 CISTERNAL/LAT CRV C1-C2 PNXR W/NJX 221.56 000<br />
61070 PNXR SHUNT TUBING/RSVR ASPIR/NJX 135.71 000<br />
61105 TDH SDRL/VENTR PNXR 733.92 090<br />
* 61107 TDH SDRL/VENTR PNXR IMPLTING VENTR CATH/DEV 522.33 000<br />
61108 TDH SDRL/VENTR PNXR EVAC&/DRG SDRL HMTMA 1456.20 090<br />
61120 BURR HOLE VENTR PNXR 1199.75 090<br />
61140 BURR HOLE/TREPHINE W/BX BRN/ICRA LES 2039.46 090<br />
61150 BURR HOLE/TREPHINE W/DRG BRN ABSC/CST 2196.77 090<br />
61151 BURR HOLE/TREPHINE W/SBSQ TAPPING ICRA ABSC/CST 1602.99 090<br />
61154 BURR HOLE W/EVAC&/DRG HMTMA XDRL/SDRL 2047.77 090<br />
61156 BURR HOLE W/ASPIR HMTMA/CST ICERE 2026.17 090<br />
61210 BURR HOLE IMPLANT VENTRICULAR CATH/OTHER DEVICE 609.84 000<br />
61215 INSJ SUBQ RSVR PMP/NFS SYS VENTR CATH 803.71 090<br />
61250 BURR HOLE/TREPHINE STTL EXPL N/FLWD OTH SURG 1391.40 090<br />
61253 BURR HOLE/TREPHINE ITTL UNI/BI 1371.46 090<br />
61304 CRNEC/CRX EXPL STTL 2669.24 090<br />
61305 CRNEC/CRX EXPL ITTL 3271.89 090<br />
61312 CRANIECTOMY HMTMA SUPRATENTORIAL EXTRA/SUBDURAL 3387.10 090<br />
61313 CRANIECTOMY HMTMA SUPRATENTORIAL INTRACEREBRAL 3222.04 090<br />
61314 CRANIECTOMY HMTMA INFRATENTORIAL EXTRA/SUBDURAL 2968.90 090<br />
61315 CRANIECTOMY HMTMA SUPRATENTORIAL INTRACEREBRAL 3371.59 090<br />
+ 61316 INC&SUBQ PLMT CRNL B1 GRF 144.57 ZZZ<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
150 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
61320 CRNEC/CRX DRG ICRA ABSC STTL 3101.84 090<br />
61321 CRNEC/CRX DRG ICRA ABSC ITTL 3452.46 090<br />
61322 CRNEC/CRX DCMPRIVE W/O LOBEC 3846.28 090<br />
61323 CRNEC/CRX DCMPRIVE W/LOBEC 3888.38 090<br />
61330 DCMPRN ORBIT ONLY TRANSCRNL 2873.08 090<br />
61332 EXPL ORBIT TRANSCRNL BX 3198.77 090<br />
61333 EXPL ORBIT TRANSCRNL RMVL LES 3335.59 090<br />
61334 EXPL ORBIT TRANSCRNL W/RMVL FB 2184.03 090<br />
61340 STPL CRNL DCMPRN 2340.78 090<br />
61343 CRNEC SOPL CRV LAM DCMPRN MEDULLA&SPI CORD 3582.63 090<br />
61345 OTH CRNL DCMPRN POST FOSSA 3325.62 090<br />
61440 CRX SCTJ TENTORIUM CEREBELLI SPX 3260.81 090<br />
61450 CRNEC STPL SCTJ COMPRESSION/DCMPRN GANGLION 3128.43 090<br />
61458 CRNEC SOPL EXPL/DCMPRN CRNL NRV 3273.55 090<br />
61460 CRNEC SOPL SCTJ 1+ CRNL NRV 3409.25 090<br />
61470 CRNEC SOPL MEDULLARY TRCOTOMY 3126.21 090<br />
61480 CRNEC SOPL MESENCEPHAL TRCOTOMY/PEDUNCULOTOMY 2477.59 090<br />
61490 CRX LOBOTOMY W/CINGULOTOMY 3091.32 090<br />
61500 CRNEC EXC TUM/OTH B1 LES SKL 2177.38 090<br />
61501 CRNEC OSTEOMYELITIS 1872.18 090<br />
61510 CRNEC TREPH B1 FLAP CRX EXC TUM STTL 3550.50 090<br />
61512 CRNEC TREPH B1 FLAP CRX EXC MENINGIOMA STTL 4164.22 090<br />
61514 CRNEC TREPH B1 FLAP CRX EXC BRN ABSC STTL 3097.41 090<br />
61516 CRNEC TREPH B1 FLAP CRX EXC CST STTL 3015.43 090<br />
+ 61517 IMPLTJ BRN INTRCV CHEMOTX AGT 144.01 ZZZ<br />
61518 CRNEC EXC TUM ITTL/PFOS MENINGIOMA 4496.56 090<br />
61519 CRNEC EXC TUM ITTL/PFOS MENINGIOMA 4821.15 090<br />
61520 CRNEC EXC TUM ITTL/PFOS CRBLOPNT ANGL TUM 6149.95 090<br />
61521 CRNEC EXC TUM ITTL/PFOS MIDLINE TUM BASE SKL 5201.12 090<br />
61522 CRNEC ITTL/PFOS EXC ABSC 3569.89 090<br />
61524 CRNEC ITTL/PFOS EXC/FENESTRATION CST 3386.54 090<br />
61526 CRNEC EXC CRBLOPNT ANGL TUM 5926.18 090<br />
61530 CRNEC EXC CRBLOPNT ANGL TUM MIDDLE/PFOS 5009.47 090<br />
61531 SDRL IMPLTJ STRIP ELTRDS SEIZURE MNTR 1977.42 090<br />
61533 CRX B1 FLAP IMPLTJ ELTRD RA SEIZURE MNTR 2477.04 090<br />
61534 CRX B1 FLAP EXC EPILEPTOGENIC FOC W/O ECOG 2673.68 090<br />
61535 CRX B1 FLAP RMVL ELTRD RA W/O EXC CERE TISS SPX 1612.96 090<br />
61536 CRX B1 FLAP EXC CERE FOC W/ECOG 4221.27 090<br />
61537 CRX B1 FLAP TEMPORAL LOBE W/O ECOG 4001.93 090<br />
61538 CRX B1 FLAP LOBEC TEMPORAL LOBE W/ECOG 4329.28 090<br />
61539 CRX B1 FLAP LOBEC OTH/THN TEMPORAL LOBE W/ECOG 3843.51 090<br />
61540 CRX B1 FLAP LOBEC OTH/THN TEMPORAL LOBE W/O ECOG 3564.35 090<br />
61541 CRX B1 FLAP TRNSXJ CORPUS CALLOSUM 3500.09 090<br />
61542 CRX B1 FLAP TOT HEMISPHERCOMY 3652.42 090<br />
61543 CRX B1 FLAP PRTL/STOT HEMISPHERCOMY 3522.80 090<br />
61544 CRX B1 FLAP EXC/COAGJ CHOROID PLEXUS 3010.45 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 151
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
61545 CRX B1 FLAP EXC CRANIOPHARYNGIOMA 5191.70 090<br />
61546 CRX HYPPHSEC/EXC PITUITARY TUM ICRA 3760.43 090<br />
61548 HYPPHSEC/EXC PITUITARY TUM TRANSNSL/SEPTAL 2545.17 090<br />
61550 CRNEC CRANIOSYNOSTOSIS 1 CRNL SUTR 1509.93 090<br />
61552 CRNEC CRANIOSYNOSTOSIS MLT CRNL SUTRS 1917.60 090<br />
61556 CRX CRANIOSYNOSTOSIS FRNT/PARIETAL B1 FLAP 2680.32 090<br />
61557 CRX CRANIOSYNOSTOSIS BIFRNT B1 FLAP 2739.04 090<br />
61558 X10SV CRNEC MLT SUTR CRANIOSYNOSTOSIS X W/B1 GRF 2890.25 090<br />
61559 X10SV CRNEC MLT SUTR CRANIOSYNOSTOSIS B1 AGRFT 3364.94 090<br />
61563 EXC B9 TUM CRNL B1 W/O OPTIC NRV DCMPRN 3230.34 090<br />
61564 EXC B9 TUM CRNL B1 W/OPTIC NRV DCMPRN 3929.92 090<br />
61566 CRX B1 FLAP SLCTV AMYGDALOHIPPOCAMPECTOMY 3677.34 090<br />
61567 CRX B1 FLAP MLT SUBPIAL TRNSXJS W/ECOG 4197.45 090<br />
61570 CRNEC/CRX EXC FB FROM BRN 3026.51 090<br />
61571 CRNEC/CRX TX PENTRG WND BRN 3243.64 090<br />
61575 TRANSORAL SB BX DCMPRN/EXC LES 4053.44 090<br />
61576 TRANSORAL SB BX DCMPRN/EXC LES SPLTTING TONGUE 5788.26 090<br />
61580 CRANFCL ACF XDRL W/O ORB EXNTJ 3999.71 090<br />
61581 CRANFCL ACF XDRL ORB EXNTJ 4409.04 090<br />
61582 CRANFCL ACF XDRL ELVTN LOBE 4838.87 090<br />
61583 CRANFCL ACF IDRL ELVTN/RESCJ LOBE 4693.19 090<br />
61584 OC ACF XDRL W/O ORB EXNTJ 4615.09 090<br />
61585 OC ACF XDRL W/ORB EXNTJ 5145.18 090<br />
61586 BICORONAL TRANSZYGMTC&/LEFT W/O B1 GRF 3794.77 090<br />
61590 ITPRL PRE-AUR MCF&MSB 5041.04 090<br />
61591 ITPRL POST-AUR MCF 5104.19 090<br />
61592 OC ZYGMTC MCF 5143.52 090<br />
61595 TRANSTEMPORAL PCF JUG FORAMEN/MSB 3861.79 090<br />
61596 TRANSCOCHLEAR PCF JUG FORAMEN/MSB 4098.31 090<br />
61597 TRANSCONDYLAR PCF JUG FORAMEN/MSB 4728.64 090<br />
61598 TRANSPETROSAL PCF CLIVUS/FORAMEN MAGNUM 4456.68 090<br />
61600 RESCJ/EXC LES BASE ACF XDRL 3485.69 090<br />
61601 RESCJ/EXC LES BASE ACF IDRL W/RPR 3854.04 090<br />
61605 RESCJ/EXC LES ITPRL FOSSA SPACE APEX XDRL 3599.80 090<br />
61606 RESCJ/EXC LES ITPRL FOSSA SPACE APEX IDRL W/RPR 4887.06 090<br />
61607 RESCJ/EXC LES PARASELLAR SINUS CLIVUS/MSB XDRL 4734.18 090<br />
61608 RESCJ/EXC LES PARASELLAR SINUS CLIVUS/MSB IDRL 5273.13 090<br />
+ 61609 TRNSXJ/LIG CRTD ART SINUS W/O RPR 989.27 ZZZ<br />
+ 61610 TRNSXJ/LIG CRTD ART SINUS W/RPR ANAST/GRF 3099.07 ZZZ<br />
+ 61611 TRNSXJ/LIG CRTD ART PETROUS CANAL W/O RPR 635.88 ZZZ<br />
+ 61612 TRNSXJ/LIG CRTD ART PETROUS CANAL RPR ANAST/GRF 2359.06 ZZZ<br />
61613 OBLTRJ CRTD ARYSM ARVEN CRTD-FSTL DSJ 5309.69 090<br />
61615 RESCJ/EXC LES BASE PCF VRT BODIES XDRL 3804.19 090<br />
61616 RESCJ/EXC LES BASE PCF FORAMEN VRT BODIES IDRL 5391.66 090<br />
61618 SEC RPR DURA CSF LEAK FR TISS GRF 2118.67 090<br />
61619 SEC RPR DURA CSF LEAK LOCAL/REGIONALIZED FLAP 2433.84 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
152 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
61623 EVASC TEMP BALO ARTL OCCLUSION 912.83 000<br />
61624 TCAT PRM OCCLUSION/EMBOLIZATION PRQ CNS 1827.32 000<br />
61626 TCAT PRM OCCLUSION/EMBOLIZATION PRQ NON-CNS 1429.62 000<br />
61630 BALO ANGIOP ICRA PRQ 2095.96 XXX<br />
61635 TCAT PLMT IV STENT ICRA W/BALO ANGIOP IF PFRMD 2264.90 XXX<br />
61640 BALO DILAT ICRA PRQ 1ST VSL 1020.28 000<br />
+ 61641 BALO DILAT ICRA PRQ EA VSL SM VASC FAM 358.93 ZZZ<br />
+ 61642 BALO DILAT ICRA PRQ EA VSL DIFF VASC FAM 716.75 ZZZ<br />
61680 SURG ICRA ARVEN MALFRMJ STTL SMPL 3690.64 090<br />
61682 SURG ICRA ARVEN MALFRMJ STTL CPLX 6877.22 090<br />
61684 SURG ICRA ARVEN MALFRMJ ITTL SMPL 4630.05 090<br />
61686 SURG ICRA ARVEN MALFRMJ ITTL CPLX 7389.58 090<br />
61690 SURG ICRA ARVEN MALFRMJ DURAL SMPL 3558.81 090<br />
61692 SURG ICRA ARVEN MALFRMJ DURAL CPLX 5990.98 090<br />
61697 SURG CPLX ICRA ARYSM ICRA APPR CRTD CRCJ 6897.16 090<br />
61698 CPLX ICRA ICRA VERTEBROBASILAR CRCJ 7541.35 090<br />
61700 SMPL ICRA ICRA APPR CRTD CRCJ 5610.45 090<br />
61702 SMPL ICRA ICRA VERTEBROBASILAR CRCJ 6555.96 090<br />
61703 ICRA CRV APPL OCCLUDING CLAMP CRV CRTD ART 2208.95 090<br />
61705 ARYSM VASC MALFRMJ/CRTD-OCCLUSION CRTD ART 4224.60 090<br />
61708 ARYSM VASC MALFRMJ/ICRA ELECTROTHROMBOSIS 3371.59 090<br />
61710 ARYSM VASC MALFRMJ IA EMBOLIZATION 3042.02 090<br />
61711 ANAST ARTL XTRC-ICRA ARTS 4256.72 090<br />
61720 CRTJ LES STRTCTC BURR GLOBUS PALLIDUS/THALAMUS 2020.63 090<br />
61735 CRTJ LES STRTCTC BURR SUBCORTICAL STRUX OTH/THN 2463.19 090<br />
61750 STRTCTC BX ASPIR/EXC BURR ICRA LES 2286.50 090<br />
61751 STRTCTC BX ASPIR/EXC BURR ICRA LES W/CT&/MRG 2230.56 090<br />
61760 STRTCTC IMPLTJ ELTRD CEREBRUM SEIZURE MNTR 2544.62 090<br />
61770 STRTCTC LOCLZJ INSJ CATH/PRB PLMT RADJ SRC 2602.22 090<br />
l + 61781 STRTCTC CPTR ASSTD PX IDRL CRNL 394.93 ZZZ<br />
l + 61782 STRTCTC CPTR ASSTD PX XDRL CRNL 324.03 ZZZ<br />
l + 61783 STRTCTC CPTR ASSTD PX SPINAL 394.93 ZZZ<br />
61790 CRTJ LES STRTCTC PRQ NULYT GASSERIAN 1400.81 090<br />
61791 CRTJ LES STRTCTC PRQ NULYT TRIGEMINAL TRC 1799.62 090<br />
61796 STEREOTACTIC RADIOSURGERY 1 SIMPLE CRANIAL LES 1576.40 090<br />
+ 61797 STRTCTC RADIOSURGERY EA ADDL CRANIAL LES SIMPLE 356.16 ZZZ<br />
61798 STEREOTACTIC RADIOSURGERY 1 COMPLEX CRANIAL LES 2105.37 090<br />
+ 61799 STRTCTC RADIOSURGERY EA ADDL CRANIAL LES COMPLEX 491.31 ZZZ<br />
+ 61800 APPL STRTCTC HEADFRAME STEREOTACTIC RADIOSURGERY 246.49 ZZZ<br />
61850 TDH/BURR IMPLTJ NSTIM ELTRD CORTICAL 1511.04 090<br />
61860 CRNEC/CRX IMPLTJ NSTIM ELTRD CERE CORTICAL 2550.71 090<br />
61863 STRTCTC IMPLTJ NSTIM ELTRD W/O MER 1ST RA 2438.82 090<br />
+ 61864 STRTCTC IMPLTJ NSTIM ELTRD W/O MER EA RA 471.37 ZZZ<br />
61867 STRTCTC IMPLTJ NSTIM ELTRD W/MER 1ST RA 3728.30 090<br />
+ 61868 STRTCTC IMPLTJ NSTIM ELTRDW/MER EA RA 830.30 ZZZ<br />
61870 CRNEC IMPLTJ NSTIM ELTRD CEREBELLAR CORTICAL 1928.13 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 153
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
61875 CRNEC IMPLTJ NSTIM ELTRD CEREBELLAR SUBCORTICAL 1668.35 090<br />
61880 REVJ/RMVL ICRA NSTIM ELTRDS 904.52 090<br />
61885 INSJ/RPLCMT CRNL NPGR 1 ELTRD RA 881.25 090<br />
61886 INSJ/RPLCMT CRNL NPGR 2+ ELTRD RA 1344.87 090<br />
61888 REVJ/RMVL CRNL NPGR 634.77 010<br />
62000 ELVTN DEPRS SKL FX SMPL XDRL 1606.31 090<br />
62005 ELVTN DEPRS SKL FX COMPOUND/COMMIND XDRL 2051.65 090<br />
62010 ELVTN DEPRS SKL FX W/RPR DURA&/DBRDMT BRN 2479.81 090<br />
62100 CRX RPR DURAL/CSF LEAK RHINORRHEA/OTORRHEA 2615.52 090<br />
62115 RDCTJ CRANIOMEGALIC SKL X W/B1 GRFS/CRNOP 1999.58 090<br />
62116 RDCTJ CRANIOMEGALIC SKL W/SMPL CRNOP 2886.93 090<br />
62117 RDCTJ CRANIOMEGALIC REQ CRX&RCNSTJ +-B1 GRF 2848.71 090<br />
62120 RPR ENCEPHALOCELE SKL VAULT W/CRNOP 2796.09 090<br />
62121 CRANIOTOMY FOR ENCEPHALOCELE REPAIR SKULL BASE 2770.05 090<br />
62140 CRANIOPLASTY SKULL DEFECT UP TO 5 CM DIAMETER 1691.06 090<br />
62141 CRANIOPLASTY SKULL DEFECT LARGER THAN 5 CM DIAM 1857.78 090<br />
62142 RMVL B1 FLAP/PROSTC PLATE SKL 1434.05 090<br />
62143 RPLCMT B1 FLAP/PROSTC PLATE SKL 1679.98 090<br />
62145 CRANIOPLASTY SKULL DEFECT REPARATIVE BRAIN SURG 2303.67 090<br />
62146 CRNOP W/AGRFT UP 5 CM DIAM 2012.32 090<br />
62147 CRNOP W/AGRFT > 5 CM DIAM 2373.46 090<br />
+ 62148 INCISE&RETRIEVAL SUBQ CRANIOPLASTY BONE GRAFT 208.27 ZZZ<br />
+ 62160 NUNDSC ICRA PLMT/RPLCMT VENTR CATH SHUNT SYS 315.17 ZZZ<br />
62161 NUNDSC ICRA DSJ ADS FENESTRATION SEPTUM CSTS 2465.96 090<br />
62162 NUNDSC ICRA FENESTRATION/EXC CST PLMT CATH DRG 3084.12 090<br />
62163 NUNDSC ICRA W/RETRIEVAL FB 1987.95 090<br />
62164 NUNDSC ICRA EXC TUM PLMT CATH DRG 3374.91 090<br />
62165 NUNDSC ICRA EXC PITUITARY TUM 2546.83 090<br />
62180 VENTRICULOCISTERNOSTOMY 2606.10 090<br />
62190 CRTJ SHUNT SARACH/SDRL-ATR-JUG-AUR 1489.44 090<br />
62192 CRTJ SHUNT SARACH/SDRL-PRTL-PLEURAL OTH 1578.06 090<br />
62194 RPLCMT/IRRG SARACH/SDRL CATH 636.43 010<br />
62200 VENTRICULOCISTERNOSTOMY 3RD VNTRC 2237.76 090<br />
62201 VENTRICULOCISTERNOSTOMY 3RD VNTRC NEURONDSC 1941.97 090<br />
62220 CRTJ SHUNT VENTRICULO-ATR-JUG-AUR 1646.19 090<br />
62223 CRTJ SHUNT VENTRICULO-PRTL-PLEURAL OTH 1702.69 090<br />
62225 RPLCMT/IRRIGATION VENTR CATH 827.53 090<br />
62230 RPLCMT/REVJ CSF SHUNT VALVE/CATH SHUNT SYS 1360.93 090<br />
62252 REPRGRMG PRGRBL CEREBSP SHUNT 149.55 XXX<br />
62252 26 REPRGRMG PRGRBL CEREBSP SHUNT 75.88 XXX<br />
62252 TC REPRGRMG PRGRBL CEREBSP SHUNT 73.67 XXX<br />
62256 RMVL COMPL CEREBSP FLU SHUNT SYS W/O RPLCMT 959.91 090<br />
62258 RMVL COMPL CSF SHUNT SYS W/RPLCMT 1821.78 090<br />
62263 PRQ LSS EDRL ADS SLN NJX/MCHNL LOCLZJ 2+ D 1155.44 010<br />
62264 PRQ LSS EDRL ADS SLN NJX/MCHNL LOCLZJ 1 D 672.43 010<br />
62267 PRQ ASPIR PULPOSUS/INTERVERTEBRAL DISC/PVRT TISS 402.13 000<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
154 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
62268 PRQ ASPIR SPI CORD CST/SYRINX 574.39 000<br />
62269 BX SPI CORD PRQ NDL 618.15 000<br />
62270 SPI PNXR LMBR DX 253.13 000<br />
62272 SPINAL PUNCTURE THER DRAIN CEREBROSPINAL FLUID 314.06 000<br />
62273 NJX EDRL BLD/CLOT PATCH 273.07 000<br />
62280 NJX/NFS NULYT SBST SBST SARACH 527.31 010<br />
62281 NJX/NFS NULYT SBST EDRL CRV/THRC 422.63 010<br />
62282 NJX/NFS NULYT SBST EDRL LMBR SAC 478.02 010<br />
62284 INJECTION PROCEDURE MYELOGRAPHY/CT SPINAL 348.40 000<br />
62287 DCMPRN PERQ NUCLEUS PULPOSUS 1/> LEVELS LUMBAR 895.66 090<br />
62290 NJX DISKOGRAPY EA LVL LMBR 541.16 000<br />
62291 NJX DISKOGRAPY EA LVL CRV/THRC 510.70 000<br />
62292 NJX CHEMONUCLEOLSS DISKOGRAPY 1+ LMBR 887.35 090<br />
62294 NJX ARTL OCCLUSION ARVEN MALFRMJ SPI 1118.88 090<br />
62310 NJX C+-DX/THER SBST EDRL/SARACH CRV/THRC 375.54 000<br />
62311 NJX C+-DX/THER SBST EDRL/SARACH LMBR SAC 322.37 000<br />
62318 NJX NFS/BOLUS DX/SBST EDRL/SARACH CRV/THRC 386.07 000<br />
62319 NJX NFS/BOLUS DX/SBST EDRL/SARACH LMBR SAC 307.97 000<br />
62350 IMPLTJ REVJ/RPSG ITHCL/EDRL CATH PMP W/O LAM 635.32 010<br />
62351 IMPLTJ REVJ/RPSG ITHCL/EDRL CATH W/LAM 1390.84 090<br />
62355 RMVL PREVIOUSLY IMPLTED ITHCL/EDRL CATH 479.68 010<br />
62360 IMPLTJ/RPLCMT ITHCL/EDRL DRUG NFS SUBQ RSVR 490.20 010<br />
62361 IMPLTJ/RPLCMT ITHCL/EDRL NFS NON-PRGRBL PMP 632.55 010<br />
62362 IMPLTJ/RPLCMT ITHCL/EDRL DRUG NFS PRGRBL PMP 663.02 010<br />
62365 RMVL SUBQ RSVR/PMP 528.42 010<br />
62367 ELEC ALYS PRGRBL PMP W/O REPRGRMG 65.36 XXX<br />
62368 ELEC ALYS PRGRBL PMP REPRGRMG 94.16 XXX<br />
63001 LAM W/O FACETEC FORAMOT/DSKC 1/2 VRT SEG CRV 3866.14 090<br />
63003 LAM W/O FFD 1/2 VRT SEG THRC 3883.22 090<br />
63005 LAM W/O FFD 1/2 VRT SEG LMBR 3686.77 090<br />
63011 LAM W/O FFD 1/2 VRT SEG SAC 3395.29 090<br />
63012 LAM W/RMVL ABNORMAL FACETS LMBR 3720.93 090<br />
63015 LAM W/O FFD > 2 VRT SEG CRV 4642.36 090<br />
63016 LAM W/O FFD > 2 VRT SEG THRC 4749.13 090<br />
63017 LAM W/O FFD > 2 VRT SEG LMBR 3902.44 090<br />
63020 LAMINOTOMY INCL OPN & NDSC 1 INTERSPACE CERVICAL 3649.40 090<br />
63030 LAMINOTOMY INCL OPEN & NDSC 1 INTERSPACE LUMBAR 3021.59 090<br />
+ 63035 LAMOT INCL OPEN&NDSC EA ADDL INTERSPACE CRV/LMBR 615.00 ZZZ<br />
63040 LAMOT PRTL FFD HRNA8 REEXPL 1 NTRSPC CRV 4404.26 090<br />
63042 LAMOT PRTL FFD HRNA8 REEXPL 1 NTRSPC LMBR 4075.41 090<br />
+ 63043 LAMOT PRTL FFD HRNA8 REEXPL 1 NTRSPC EA CRV 1853.53 ZZZ<br />
+ 63044 LAMOT W/PRTL FFD HRNA8 REEXPL 1 NTRSPC EA LMBR 1760.64 ZZZ<br />
63045 LAM FACETEC&FORAMOT 1 SGM CRV 3980.39 090<br />
63046 LAM FACETEC&FORAMOT 1 SGM THRC 3790.34 090<br />
63047 LAM FACETEC&FORAMOT 1 SGM LMBR 3441.20 090<br />
+ 63048 LAM FACETEC&FORAMOT 1 SGM EA CRV THRC/LMBR 680.12 ZZZ<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 155
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
63050 LAMOP CRV W/DCMPRN SPI CORD 2/MORE VRT SEG 4924.23 090<br />
63051 LAMOP CRV DCMPRN SPI CORD 2+ SEG RCNSTJ B1 5384.41 090<br />
63055 TRANSPEDICULAR DCMPRN SPI CORD 1 SGM THRC 5112.15 090<br />
63056 TRANSPEDICULAR DCMPRN SPI CORD 1 SGM LMBR 4645.56 090<br />
+ 63057 TRANSPEDICULAR DCMPRN 1 SGM EA THRC/LMBR 1028.20 ZZZ<br />
63064 COSTOVRT DCMPRN THRC 1 SGM 5554.18 090<br />
+ 63066 COSTOVRT DCMPRN THRC EA SGM 661.97 ZZZ<br />
63075 DSKC ANT DCMPRN CRV 1 NTRSPC 4316.71 090<br />
+ 63076 DSKC ANT DCMPRN CRV EA NTRSPC 799.71 ZZZ<br />
63077 DSKC ANT DCMPRN THRC 1 NTRSPC 4717.10 090<br />
+ 63078 DSKC ANT DCMPRN THRC EA NTRSPC 620.33 ZZZ<br />
63081 VCRPEC ANT DCMPRN CRV 1 SGM 5570.19 090<br />
+ 63082 VCRPEC ANT DCMPRN CRV EA SGM 859.50 ZZZ<br />
63085 VCRPEC TTHRC DCMPRN THRC 1 SGM 5975.92 090<br />
+ 63086 VCRPEC TTHRC DCMPRN THRC EA SGM 611.79 ZZZ<br />
63087 VCRPEC THORACOLMBR DCMPRN LWR THRC/LMBR 1 SGM 7537.96 090<br />
+ 63088 VCRPEC THORACOLMBR DCMPRN LWR THRC/LMBR EA SGM 827.47 ZZZ<br />
63090 VCRPEC TRANSPRTL/RPR DCMPRN THRC LMBR/SAC 1 SGM 6193.73 090<br />
+ 63091 VCRPEC TRANSPRTL/RPR DCMPRN THRC LMBR/SAC EA SGM 569.08 ZZZ<br />
63101 VCRPEC LAT XTRCAVITARY DCMPRN THRC 1 SGM 3786.46 090<br />
63102 VCRPEC LAT XTRCAVITARY DCMPRN LMBR 1 SGM 3656.29 090<br />
+ 63103 VCRPEC LAT XTRCAVITARY DCMPRN THRC/LMBR EA SGM 485.77 ZZZ<br />
63170 LAM W/MYELOTOMY CRV THRC/THORACOLMBR 4950.92 090<br />
63172 LAM W/DRG IMED CST/SYRINX SARACH SPACE 4407.47 090<br />
63173 LAM W/DRG IMED CST/SYRINX PRTL/PLEURAL SPACE 5415.37 090<br />
63180 LAM&SCTJ DENTATE LIGMS CRV 1/2 SEG 4571.89 090<br />
63182 LAM&SCTJ DENTATE LIGMS CRV > 2 SEG 4922.10 090<br />
63185 LAM W/RHIZOTOMY 1/2 SEG 3717.73 090<br />
63190 LAM W/RHIZOTOMY > 2 SEG 3976.11 090<br />
63191 LAM W/SCTJ SPI ACCESSORY NRV 3719.87 090<br />
63194 LAM CORDOTOMY SCTJ 1 TRC 1 STG CRV 4301.76 090<br />
63195 LAM CORDOTOMY SCTJ 1 TRC 1 STG THRC 4791.84 090<br />
63196 LAM CORDOTOMY SCTJ BTH TRCS 1 STG CRV 4516.37 090<br />
63197 LAM CORDOTOMY SCTJ BTH TRCS 1 STG THRC 5359.85 090<br />
63198 LAM CORDOTOMY SCTJ BTH TRCS 2 STGS CRV 4996.84 090<br />
63199 LAM CORDOTOMY SCTJ BTH TRCS 2 STGS THRC 5507.20 090<br />
63200 LAM RLS TETHERED SPI CORD LMBR 4767.28 090<br />
63250 LAM EXC/OCCLUSION AVM SPI CORD CRV 9333.83 090<br />
63251 LAM EXC/OCCLUSION AVM SPI CORD THRC 9560.19 090<br />
63252 LAM EXC/OCCLUSION AVM SPI CORD THORACOLMBR 9552.71 090<br />
63265 LAM EXC/EVAC ISPI LES OTH/THN NEO XDRL CRV 5232.80 090<br />
63266 LAM EXC/EVAC ISPI LES OTH/THN NEO XDRL THRC 5390.82 090<br />
63267 LAM EXC/EVAC ISPI LES OTH/THN NEO XDRL LMBR 4308.17 090<br />
63268 LAM EXC/EVAC ISPI LES OTH/THN NEO XDRL SAC 4517.44 090<br />
63270 LAM EXC ISPI LES OTH/THN NEO IDRL CRV 6510.83 090<br />
63271 LAM EXC ISPI LES OTH/THN NEO IDRL THRC 6505.50 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
156 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
63272 LAM EXC ISPI LES OTH/THN NEO IDRL LMBR 5978.05 090<br />
63273 LAM EXC ISPI LES OTH/THN NEO IDRL SAC 5784.80 090<br />
63275 LAM BX/EXC ISPI NEO XDRL CRV 5633.19 090<br />
63276 LAM BX/EXC ISPI NEO XDRL THRC 5601.15 090<br />
63277 LAM BX/EXC ISPI NEO XDRL LMBR 4865.51 090<br />
63278 LAM BX/EXC ISPI NEO XDRL SAC 4944.52 090<br />
63280 LAM BX/EXC ISPI NEO IDRL XMED CRV 6647.50 090<br />
63281 LAM BX/EXC ISPI NEO IDRL XMED THRC 6582.37 090<br />
63282 LAM BX/EXC ISPI NEO IDRL XMED LMBR 6200.13 090<br />
63283 LAM BX/EXC ISPI NEO IDRL SAC 5939.62 090<br />
63285 LAM BX/EXC ISPI NEO IDRL IMED CRV 8189.26 090<br />
63286 LAM BX/EXC ISPI NEO IDRL IMED THRC 8089.96 090<br />
63287 LAM BX/EXC ISPI NEO IDRL IMED THORACOLMBR 8630.22 090<br />
63290 LAM BX/EXC ISPI NEO XDRL-IDRL LES ANY LVL 8756.21 090<br />
+ 63295 OSTPL RCNSTJ DORSAL SPI ELMNTS FLWG ISPI PX 1052.75 ZZZ<br />
63300 VCRPEC LES 1 SGM XDRL CRV 5755.97 090<br />
63301 VCRPEC LES 1 SGM XDRL THRC TTHRC 6821.54 090<br />
63302 VCRPEC LES 1 SGM XDRL THRC THORACOLMBR 6747.86 090<br />
63303 VCRPEC LES 1 SGM XDRL LMBR/SAC TRANSPRTL/RPR 7169.61 090<br />
63304 VCRPEC LES 1 SGM IDRL CRV 7363.93 090<br />
63305 VCRPEC LES 1 SGM IDRL THRC TTHRC 7726.94 090<br />
63306 VCRPEC LES 1 SGM IDRL THRC THORACOLMBR 7211.25 090<br />
63307 VCRPEC LES 1 SGM IDRL LMBR/SAC TRANSPRTL/RPR 7526.22 090<br />
+ 63308 VCRPEC LES 1 SGM EA SGM 1027.13 ZZZ<br />
63600 CRTJ LES SPI CORD STRTCTC PRQ 2656.44 090<br />
63610 STRTCTC STIMJ SPI CORD PRQ SPX N/FLWD OTH SURG 1400.26 000<br />
63615 STRTCTC BX ASPIR/EXC LES SPI CORD 1979.08 090<br />
63620 STEREOTACTIC RADIOSURGERY 1 SPINAL LESION 1721.52 090<br />
+ 63621 STEREOTACTIC RADIOSURGERY EA ADDL SPINAL LESION 408.78 ZZZ<br />
63650 PRQ IMPLTJ NSTIM ELTRD RA EDRL 676.31 010<br />
63655 LAM IMPLTJ NSTIM ELTRDS PLATE/PADDLE EDRL 1394.72 090<br />
63661 RMVL SPINAL NSTIM ELTRD PRQ ARRAY INCL FLUOR 974.31 010<br />
63662 RMVL SPINAL NSTIM ELTRD PLATE/PADDLE INCL FLUOR 1168.18 090<br />
63663 REVJ INCL RPLCMT NSTIM ELTRD PRQ RA INCL FLUOR 1391.95 010<br />
63664 REVJ INCL RPLCMT NSTIM ELTRD PLT/PDLE INCL FLUOR 1214.70 090<br />
63685 INSJ/RPLCMT SPI NPGR DIR/INDUXIVE COUPLING 646.40 010<br />
63688 REVJ/RMVL IMPLTED SPI NPGR 584.36 010<br />
63700 RPR MENINGOCELE < 5 CM DIAM 2078.79 090<br />
63702 RPR MENINGOCELE > 5 CM DIAM 2302.56 090<br />
63704 RPR MYELOMENINGOCELE < 5 CM DIAM 2622.72 090<br />
63706 RPR MYELOMENINGOCELE > 5 CM DIAM 2962.81 090<br />
63707 RPR DURAL/CEREBSP FLU LEAK X REQ LAM 1469.50 090<br />
63709 RPR DURAL/CSF LEAK/PSEUDOMENINGOCELE W/LAM 1783.56 090<br />
63710 DURAL GRF SPI 1791.31 090<br />
63740 CRTJ SHUNT LMBR SARACH-PRTL-PLEURAL/OTH W/LAM 1522.67 090<br />
63741 CRTJ SHUNT LMBR SARACH-PRTL-PLEURAL PRQ X LAM 995.91 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 157
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
63744 RPLCMT IRRIGATION/REVJ LUMBOSARACH SHUNT 1072.35 090<br />
63746 RMVL ENTIRE LUMBOSARACH SHUNT SYS W/O RPLCMT 948.83 090<br />
64400 NJX ANES TRIGEMINAL NRV ANY DIV/BRANCH 183.89 000<br />
64402 NJX ANES FACIAL NRV 183.34 000<br />
64405 NJX ANES GRTER OCCIPITAL NRV 183.34 000<br />
64408 NJX ANES VAGUS NRV 199.96 000<br />
64410 NJX ANES PHRENIC NRV 241.50 000<br />
64412 NJX ANES SPI ACCESSORY NRV 243.16 000<br />
64413 NJX ANES CRV PLEXUS 193.31 000<br />
64415 SINGLE NERVE BLOCK INJECTION ARM NERVE 199.40 000<br />
64416 INJECTION ANES BRACHIAL PLEXUS CONT NFS CATH 132.38 000<br />
64417 NJX ANES AX NRV 209.37 000<br />
64418 NJX ANES SUPRASCAPULAR NRV 223.22 000<br />
64420 NJX ANES INTERCOSTAL NRV 1 221.56 000<br />
64421 MULTIPLE NERVE BLOCK INJECTIONS RIB NERVES 318.49 000<br />
64425 NJX ANES ILIOINGUN ILIOHYPOGSTR NRV 212.70 000<br />
64430 NJX ANES PUDENDAL NRV 232.64 000<br />
64435 NJX ANES PARACRV NRV 229.87 000<br />
64445 NJX ANES SCIATIC NRV 1 217.68 000<br />
64446 INJECTION ANES SCIATIC NERVE CONT INFUSION CATH 134.60 000<br />
64447 NJX ANES FEM NRV 1 193.87 000<br />
64448 INJECTION ANES FEMORAL NERVE CONT INFUSION CATH 119.64 000<br />
64449 INJECTION ANES LUMBAR PLEXUS POST CONT NFS CATH 136.81 000<br />
64450 NJX ANES OTH PRPH NRV/BRANCH 166.72 000<br />
64455 NJX ANES&/STEROID PLANTAR COMMON DIGITAL NERVE 79.76 000<br />
s 64479 NJX ANES&/STRD W/IMG TFRML EDRL CRV/THRC 1 LVL 432.60 000<br />
s + 64480 NJX ANES&/STRD W/IMG TFRML EDRL CRV/THRC EA LVL 206.05 ZZZ<br />
s 64483 NJX ANES&/STRD W/IMG TFRML EDRL LMBR/SAC 1 LVL 391.61 000<br />
s + 64484 NJX ANES&/STRD W/IMG TFRML EDRL LMBR/SAC EA LVL 173.37 ZZZ<br />
64490 NJX DX/THER AGT PVRT FACET JT CRV/THRC 1 LEVEL 320.15 000<br />
+ 64491 NJX DX/THER AGT PVRT FACET JT CRV/THRC 2ND LEVEL 158.42 ZZZ<br />
+ 64492 NJX DX/THER AGT PVRT FACET JT CRV/THRC 3+ LEVEL 160.08 ZZZ<br />
64493 NJX DX/THER AGT PVRT FACET JT LMBR/SAC 1 LEVEL 285.26 000<br />
+ 64494 NJX DX/THER AGT PVRT FACET JT LMBR/SAC 2ND LEVEL 142.91 ZZZ<br />
+ 64495 NJX DX/THER AGT PVRT FACET JT LMBR/SAC 3+ LEVEL 145.12 ZZZ<br />
64505 NJX ANES SPHENOPALATINE GANGLION 159.52 000<br />
64508 NJX ANES CRTD SINUS SPX 170.05 000<br />
64510 NJX ANES STELLATE GANGLION CRV SYMPATHETIC 219.90 000<br />
64517 NJX ANES SUPRIOR HYPOGSTR PLEXUS 282.49 000<br />
64520 NJX ANES LMBR/THRC PVRT SYMPATHETIC 311.29 000<br />
64530 NJX ANES CELIAC PLEXUS +-RAD MNTR 315.17 000<br />
64550 APPL SURF TC NSTIM 25.48 000<br />
64553 PRQ IMPLTJ NSTIM ELTRDS CRNL NRV 335.66 010<br />
64555 PRQ IMPLTJ NSTIM ELTRDS PRPH NRV 327.91 010<br />
64560 PRQ IMPLTJ NSTIM ELTRDS AUTONOMIC NRV 373.33 010<br />
64561 PRQ IMPLTJ NSTIM ELTRDS SAC NRV 1590.80 010<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
158 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
64565 PRQ IMPLTJ NSTIM ELTRDS NEUROMUSCULAR 286.92 010<br />
l 64566 POST TIB NEUROSTIMULATION PRQ NEEDLE ELECTRODE 210.48 000<br />
l 64568 INC IMPLTJ CRNL NRV NSTIM ELTRDS & PULSE GENER 1046.32 090<br />
l 64569 REVISION/REPLMT NSTIM CRNL ELTRDS 1033.02 090<br />
l 64570 REMOVAL CRNL NRV NSTIM ELTRDS & PULSE GENERATOR 909.50 090<br />
s 64575 INC IMPLTJ PERIPH NRV NSTIM ELTRDS 466.94 090<br />
64577 INC IMPLTJ NSTIM ELTRDS AUTONOMIC NRV 547.25 090<br />
64580 INC IMPLTJ NSTIM ELTRDS NEUROMUSCULAR 491.86 090<br />
64581 INC IMPLTJ NSTIM ELTRDS SAC NRV 1152.11 090<br />
64585 REVJ/RMVL PRPH NSTIM ELTRDS 475.25 010<br />
64590 INSERTION/RPLCMT PERIPHERAL/GASTRIC NPGR 466.38 010<br />
64595 REVISION/RMVL PERIPHERAL/GASTRIC NPGR 462.51 010<br />
64600 DSTRJ TRIGEMINAL NRV SUPRAORB INFRAORB BRANCH 668.56 010<br />
64605 DSTRJ NULYT TRIGEMINAL NRV 2/3 DIV 1054.63 010<br />
64610 DSTRJ NULYT TRIGEMINAL NRV 2/3 DIV RAD MNTR 1186.45 010<br />
l 64611 CHEMODENERV PAROTID&SUBMANDIBL SALIVARY GLNDS BI 163.40 010<br />
64612 CHEMODNRVTJ MUSC MUSC INNERVATED FACIAL NRV 279.17 010<br />
64613 CHEMODNRVTJ MUSC NCK MUSC 267.53 010<br />
64614 CHEMODNRVTJ MUSC XTR&/TRNK MUSC 285.26 010<br />
64620 DSTRJ NULYT INTERCOSTAL NRV 389.39 010<br />
64622 DSTRJ NULYT PVRT FACET JT NRV LMBR/SAC 1 LVL 546.15 010<br />
+ 64623 DSTRJ NULYT PVRT FACET JT NRV LMBR/SAC EA LVL 203.84 ZZZ<br />
64626 DSTRJ NULYT PVRT FACET JT NRV CRV/THRC 1 LVL 649.72 010<br />
+ 64627 DSTRJ NULYT PVRT FACET JT NRV CRV/THRC EA LVL 278.61 ZZZ<br />
64630 DSTRJ NULYT PUDENDAL NRV 367.24 010<br />
64632 DSTRJ NEUROLYTIC PLANTAR COMMON DIGITAL NERVE 138.48 010<br />
64640 DSTRJ NULYT OTH PRPH NRV/BRANCH 355.05 010<br />
64650 CHEMODNRVTJ ECCRINE GLNDS BTH AX 149.55 000<br />
64653 CHEMODNRVTJ ECCRINE GLNDS OTH AREA PR D 178.91 000<br />
64680 DSTRJ NULYT +-RAD MNTR CELIAC PLEXUS 511.25 010<br />
64681 DSTRJ NULYT +-RAD MNTR SUPRIOR HYPOGSTR PLEXUS 608.74 010<br />
64702 NEURP DGTAL 1/BTH SM DGT 1504.39 090<br />
64704 NEURP NRV HAND/FOOT 1010.04 090<br />
s 64708 NEURP MAJOR PRPH NRV ARM/LEG OPN OTH/THN SPEC 1507.59 090<br />
s 64712 NEURP MAJOR PRPH NRV OPN ARM/LEG SCIATIC NRV 1717.93 090<br />
s 64713 NEURP MAJOR PRPH NRV OPN ARM/LEG BRACH PLEXUS 2376.70 090<br />
s 64714 NEURP MAJOR PRPH NRV OPN ARM/LEG LMBR PLEXUS 2101.23 090<br />
64716 NEURP&/TRPOS CRNL NRV 1663.48 090<br />
64718 NEURP&/TRPOS UR NRV ELBW 1815.09 090<br />
64719 NEURP&/TRPOS UR NRV WRST 1229.99 090<br />
64721 NEURP&/TRPOS MEDIAN NRV CARPL TUNNEL 1315.41 090<br />
64722 DCMPRN UNSPECIFIED NRV 1073.04 090<br />
64726 DCMPRN PLNTAR DGTAL NRV 865.90 090<br />
+ 64727 INT NEUROLSS REQ MCRSCP 584.03 ZZZ<br />
64732 TRNSXJ/AVLSN SUPRAORB NRV 680.74 090<br />
64734 TRNSXJ/AVLSN INFRAORB NRV 687.39 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 159
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
64736 TRNSXJ/AVLSN MENTAL NRV 701.79 090<br />
64738 TRNSXJ/AVLSN INF ALVEOLAR NRV OSTEOM 839.71 090<br />
64740 TRNSXJ/AVLSN LNGL NRV 746.66 090<br />
64742 TRNSXJ/AVLSN FACIAL NRV DIFFIAL/COMPL 774.91 090<br />
64744 TRNSXJ/AVLSN GRTER OCCIPITAL NRV 748.32 090<br />
64746 TRNSXJ/AVLSN PHRENIC NRV 717.85 090<br />
64752 TRNSXJ/AVLSN VAGUS NRV TTHRC 839.16 090<br />
64755 TRNSXJ/AVLSN VAGUS NRV PROX STOMACH 1468.39 090<br />
64760 TRNSXJ/AVLSN VAGUS NRV ABDL 804.26 090<br />
64761 TRNSXJ/AVLSN PUDENDAL NRV 727.82 090<br />
64763 TRNSXJ/AVLSN OBTURATOR NRV XTRPEL 855.78 090<br />
64766 TRNSXJ/AVLSN OBTURATOR NRV INTRAPEL 958.80 090<br />
64771 TRNSXJ/AVLSN OTH CRNL NRV XDRL 915.04 090<br />
64772 TRNSXJ/AVLSN OTH SPI NRV XDRL 930.55 090<br />
64774 EXC NEUROMA CUTAN NRV SURGLY IDENTIFIABLE 670.22 090<br />
64776 EXC NEUROMA DGTAL NRV 1/BTH SM DGT 630.34 090<br />
+ 64778 EXC NEUROMA DGTAL NRV EA DGT 312.95 ZZZ<br />
64782 EXC NEUROMA HAND/FOOT XCP DGTAL NRV 731.15 090<br />
+ 64783 EXC NEUROMA HAND/FOOT EA NRV XCP SM DGT 356.16 ZZZ<br />
64784 EXC NEUROMA MAJOR PRPH NRV XCP SCIATIC 1182.02 090<br />
64786 EXC NEUROMA SCIATIC NRV 1745.34 090<br />
+ 64787 IMPLTJ NRV END IN B1/MUSC 399.92 ZZZ<br />
64788 EXC NEUROFIBROMA/NEUROLEMMOMA CUTAN NRV 640.31 090<br />
64790 EXC NEUROFIBROMA/NEUROLEMMOMA MAJOR PRPH NRV 1349.30 090<br />
64792 EXC NEUROFIBROMA/NEUROLEMMOMA X10SV 1843.38 090<br />
64795 BX NRV 322.37 000<br />
64802 SYMPTH CRV 999.79 090<br />
64804 SYMPTH CERVICOTHRC 1328.25 090<br />
64809 SYMPTH THORACOLMBR 1380.87 090<br />
64818 SYMPTH LMBR 1086.20 090<br />
64820 SYMPTH DGTAL ARTS EA DGT 1233.54 090<br />
64821 SYMPTH RDL ART 1115.00 090<br />
64822 SYMPTH UR ART 1106.69 090<br />
64823 SYMPTH SUPFC PLMR ARCH 1255.69 090<br />
64831 SUTR DGTAL NRV HAND/FOOT 1 NRV 1101.15 090<br />
+ 64832 SUTR DGTAL NRV HAND/FOOT EA DGTAL NRV 558.89 ZZZ<br />
64834 SUTURE 1 NERVE HAND/FOOT COMMON SENSORY NERVE 1203.62 090<br />
64835 SUTURE 1 NERVE MEDIAN MOTOR THENAR 1313.30 090<br />
64836 SUTURE 1 NERVE ULNAR MOTOR 1314.40 090<br />
+ 64837 SUTR EA NRV HAND/FOOT 588.24 ZZZ<br />
64840 SUTR POST TIBL NRV 1420.75 090<br />
64856 SUTR PRPH NRV ARM/LEG XCP SCIATIC W/TRPOS 1648.96 090<br />
64857 SUTR PRPH NRV ARM/LEG XCP SCIATIC W/O TRPOS 1716.54 090<br />
64858 SUTR SCIATIC NRV 1981.30 090<br />
+ 64859 SUTR EA MAJOR PRPH NRV 431.49 ZZZ<br />
64861 SUTR BRACH PLEXUS 2099.28 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
160 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
64862 SUTR LMBR PLEXUS 2388.97 090<br />
64864 SUTR FACIAL NRV XTRC 1408.01 090<br />
64865 SUTR FACIAL NRV ITPRL +-GRFG 1858.33 090<br />
64866 ANAST FACIAL-SPI ACCESSORY 1868.30 090<br />
64868 ANAST FACIAL-HYPOGLOSSAL 1694.93 090<br />
64870 ANAST FACIAL-PHRENIC 1773.59 090<br />
+ 64872 SUTR NRV REQ SEC/DLYD SUTR 188.88 ZZZ<br />
+ 64874 SUTR NRV REQ X10SV MOBLJ/TRPOS NRV 286.92 ZZZ<br />
+ 64876 SUTR NRV REQ SHRT B1 XTR 318.49 ZZZ<br />
64885 NRV GRF HEAD/NCK 4 CM 2137.50 090<br />
64890 NRV GRF 1 STRAND HAND/FOOT 4 CM 1915.39 090<br />
64892 NRV GRF 1 STRAND ARM/LEG 4 CM 1831.75 090<br />
64895 NRV GRF MLT STRANDS HAND/FOOT 4 CM 2506.95 090<br />
64897 NRV GRF MLT STRANDS ARM/LEG 4 CM 2245.51 090<br />
+ 64901 NRV GRF EA NRV 1 STRAND 1029.15 ZZZ<br />
+ 64902 NRV GRF EA NRV MLT STRANDS 1187.56 ZZZ<br />
64905 NRV PEDCL TR 1ST STG 1668.90 090<br />
64907 NRV PEDCL TR 2ND STG 1873.84 090<br />
64910 NERVE REPAIR W/CONDUIT EA NERVE 1330.47 090<br />
64911 NERVE REPAIR W/AUTOGENOUS VEIN GRAFT EA NERVE 1660.04 090<br />
64999 UNLIS PX NRVS SYS BR YYY<br />
65091 EVSC OC CNTS W/O IMPLT 1016.41 090<br />
65093 EVSC OC CNTS W/IMPLT 1006.99 090<br />
65101 ENCL EYE W/O IMPLT 1177.04 090<br />
65103 ENCL EYE IMPLT MUSC X ATTACHED IMPLT 1230.21 090<br />
65105 ENCL EYE IMPLT MUSC ATTACHED IMPLT 1357.61 090<br />
65110 EXNTJ ORBIT RMVL ORB CNTS ONLY 1905.42 090<br />
65112 EXNTJ ORBIT RMVL ORB CNTS W/THER RMVL B1 2225.57 090<br />
65114 EXNTJ ORBIT RMVL ORB CNTS W/MUSC/MYOQ FLAP 2332.47 090<br />
65125 MODIFICAJ OC IMPLT W/PLMT/RPLCMT PEGS SPX 713.98 090<br />
65130 INSJ OC IMPLT SEC AFTER EVSC SCLL SHELL 1167.07 090<br />
65135 INSJ OC IMPLT AFTER ENCL MUSC X ATTACHED 1185.90 090<br />
65140 INSJ OC IMPLT AFTER ENCL MUSC ATTACHED 1257.91 090<br />
65150 RINSJ OC IMPLT +-CJNCL GRF 880.70 090<br />
65155 RINSJ OC IMPLT RNFCMT&/ATTACHMENT MUSC 1357.61 090<br />
65175 RMVL OC IMPLT 1021.95 090<br />
65205 RMVL FB XTRNL EYE CJNCL SUPFC 87.52 000<br />
65210 RMVL FB XTRNL EYE EMBEDDED SCJNCL/SCLL NONPRF8 108.56 000<br />
65220 RMVL FB XTRNL EYE CRNL W/O SLIT LAMP 90.29 000<br />
65222 RMVL FB XTRNL EYE CRNL W/SLIT LAMP 119.64 000<br />
65235 RMVL FB IO FROM ANT CHAMBER EYE/LENS 1107.25 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 161
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
65260 RMVL FB IO FROM POST SGM MAG XTRJ ANT/POST ROUTE 1455.10 090<br />
65265 RMVL FB IO FROM POST SGM NONMAG XTRJ 1753.09 090<br />
65270 RPR LAC CJNC +-NONPRF8 LAC SCL DIR CLSR 411.55 010<br />
65272 RPR LAC CJNC MOBLJ&REARGMT W/O HOSPIZATION 758.84 090<br />
65273 RPR LAC CJNC MOBLJ&REARGMT W/HOSPIZATION 580.49 090<br />
65275 RPR LAC CRN NONPRF8 +-RMVL FB 885.13 090<br />
65280 RPR LAC CRN&/SCL PRF8 X INVG UVEAL TISS 1079.55 090<br />
65285 RPR LAC CRN&/SCL PRF8 W/REPOS/RESCJ UVEAL TISS 1663.92 090<br />
65286 RPR LAC APPL TISS GLUE WND CRN&/SCL 1092.29 090<br />
65290 RPR WND EO MUSCLE TENDON&/TENON'S CAPSULE 792.08 090<br />
65400 EXC LES CRN XCP PTERYGIUM 1054.07 090<br />
65410 BX CRN 228.76 000<br />
65420 EXC/TRPOS PTERYGIUM W/O GRF 796.51 090<br />
65426 EXC/TRPOS PTERYGIUM W/GRF 1010.31 090<br />
65430 CORNEA SCRAPING DIAGNOSTIC SMEAR &/CULTURE 181.13 000<br />
65435 RMVL CRNL EPITHE +-CHEMOCAUT 126.84 000<br />
65436 RMVL CRNL EPITHE W/APPL CHELATING AGT 614.83 090<br />
65450 DSTRJ LES CRN CRTX PC/THERMOCAUT 503.50 090<br />
65600 MLT PNXRS ANT CRN 612.06 090<br />
65710 KERATOPLASTY ANTERIOR LAMELLAR 1735.92 090<br />
65730 KERATOPLASTY PENTRG EXCEPT APHAKIA/PSEUDOPHAKIA 1927.02 090<br />
65750 KERATOPLASTY PENTRG APHK 1935.88 090<br />
65755 KERATOPLASTY PENTRG PSEUDOPHAKIA 1933.66 090<br />
65756 KERATOPLASTY ENDOTHELIAL 1802.39 090<br />
+ 65757 BACKBENCH PREPJ CORNEAL ENDOTHELIAL ALLOGRAFT BR ZZZ<br />
65760 KERATOMILEUSIS 1852.80 XXX<br />
65765 KERATOPHAKIA 2686.42 XXX<br />
65767 EPIKERATOPLASTY 2500.86 XXX<br />
65770 KERATOPROSTH 2460.42 090<br />
65771 RDL KERATOTOMY 1019.18 XXX<br />
65772 CRNL RELAXING INC CORRJ INDUCED ASTIGMATISM 699.02 090<br />
65775 CRNL WEDGE RESCJ CORRJ INDUCED ASTIGMATISM 838.05 090<br />
l 65778 PLACE AMNIOTIC MEMB OCULAR SURFACE SELF RETAIN 2045.55 010<br />
l 65779 PLACE AMNIOTIC MEMBRANE OCULAR SURFACE SUTURED 1850.58 010<br />
s 65780 OCULAR SURFACE RECONSTRUCTION AMNIOTIC MEMBRANE 1385.30 090<br />
65781 OCULAR SURFACE RECONSTRUCTION LIMBAL ALLOGRAFT 2038.91 090<br />
65782 OCCULAR SURFACE RECONSTRUCTION LIMBAL AUTOGRAFT 1867.75 090<br />
65800 PCNTS EYE SPX DX ASPIR AQUEOUS 234.85 000<br />
65805 PCNTS EYE SPX THER RLS AQUEOUS 260.89 000<br />
65810 PCNTS EYE SPX RMVL VTS&/DSCJ MEMB 738.35 090<br />
65815 PCNTS EYE SPX RMVL BLD 1002.56 090<br />
65820 GONIOTOMY 1137.16 090<br />
65850 TRABECULOTOMY AB EXTERNO 1347.08 090<br />
65855 TRABECULOPLASTY LASER SURG 1+ SESS 535.62 010<br />
65860 SEVERING ADS ANT SGM LASER TQ SPX 531.19 090<br />
65865 SEVERING ADS ANT SGM INCAL TQ SPX GONIOSYNECHIAE 718.96 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
162 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
65870 SEVERING ADS ANT SGM INCAL SPX ANT SYNECHIAE 939.97 090<br />
65875 SEVERING ADS ANT SGM INCAL SPX POST SYNECHIAE 984.83 090<br />
65880 SEVERING ADS ANT SGM INCAL SPX CORNEOVITREAL 1005.88 090<br />
65900 RMVL EPITHELIAL DOWNGROWTH ANT CHAMBER EYE 1466.73 090<br />
65920 RMVL IMPLTED MATRL ANT SGM EYE 1227.44 090<br />
65930 RMVL BLD CLOT ANT SGM EYE 1021.39 090<br />
66020 NJX ANT CHAMBER EYE SPX AIR/LIQ 282.49 010<br />
66030 NJX ANT CHAMBER EYE SPX MED 256.46 010<br />
66130 EXC LES SCL 1123.86 090<br />
66150 FSTLJ SCL GLC TREPH IRDEC 1323.27 090<br />
66155 FSTLJ SCL GLC THERMOCAUT IRDEC 1322.16 090<br />
66160 FSTLJ SCL GLC SCLERCOMY PUNCH/SCISSORS IRDEC 1496.08 090<br />
66165 FSTLJ SCL GLC IRIDENCLEISIS/IRIDOTASIS 1296.68 090<br />
66170 FSTLJ SCL GLC TRBEC AB EXTERNO 1863.87 090<br />
66172 FSTLJ SCL GLC TRBEC AB EXTERNO SCARRING 2348.54 090<br />
l 66174 TRLUML DILAT AQUEOUS CANAL W/O DEV/STNT 1601.32 090<br />
l 66175 TRLUML DILAT AQUEOUS CANAL W/DEV/STNT 1815.68 090<br />
66180 AQUEOUS SHUNT EO RSVR 1829.53 090<br />
66185 REVJ AQUEOUS SHUNT EO RSVR 1190.33 090<br />
66220 RPR SCLL STAPHYLOMA W/O GRF 1151.56 090<br />
66225 RPR SCLL STAPHYLOMA W/GRF 1503.84 090<br />
66250 REVJ/RPR OPRATIVE WND ANT SGM 1185.90 090<br />
66500 IRIDOTOMY STAB INC SPX XCP TRANSFIXION 535.62 090<br />
66505 IRIDOTOMY STAB INC SPX TRANSFIXION 587.13 090<br />
66600 IRDEC CRNLSCLRL/CRNL SCTJ RMVL LES 1255.69 090<br />
66605 IRDEC CRNLSCLRL/CRNL SCTJ CYCLECTOMY 1604.65 090<br />
66625 IRDEC CRNLSCLRL/CRNL SCTJ PRPH GLC SPX 670.77 090<br />
66630 IRDEC CRNLSCLRL/CRNL SCTJ SECTOR GLC SPX 901.75 090<br />
66635 IRDEC CRNLSCLRL/CRNL SCTJ OPTICAL SPX 871.28 090<br />
66680 RPR IRIS CILIARY BDY 831.40 090<br />
66682 SUTR IRIS CILIARY BDY SPX RETRIEVAL SUTR 1008.65 090<br />
66700 CILIARY BDY DSTRJ DTHRM 687.94 090<br />
66710 CILIARY BDY DSTRJ CYCLOPC TRANSSCLL 704.56 090<br />
66711 CILIARY BDY DSTRJ CYCLOPC NDSC 971.54 090<br />
K 66720 CILIARY BDY DSTRJ CRTX 727.82 090<br />
66740 CILIARY BDY DSTRJ CYCLODIAL 662.46 090<br />
s 66761 IRIDOTOMY/IRDEC LASER SURG PER SESSION 513.47 010<br />
66762 IRIDOPLASTY PC 1+ SESS 735.58 090<br />
66770 DSTRJ CST/LES IRIS/CILIARY BDY 797.62 090<br />
66820 DSCJ SEC MEMBRANOUS CTRC STAB INC 619.81 090<br />
66821 POST-CATARACT LASER SURGERY 512.91 090<br />
66825 RPSG IO LENS PROSTH REQ INC SPX 1183.13 090<br />
66830 RMVL SEC MEMBRANOUS CTRC CORNEO-SCLL SCTJ 1083.43 090<br />
66840 RMVL LENS MATRL ASPIR TQ 1+ STGS 1120.54 090<br />
66850 RMVL LENS MATRL PHACOFRAGMENTATION ASPIR 1243.51 090<br />
66852 RMVL LENS MATRL PARS PLNA APPR +-VTRC 1350.96 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 163
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
66920 RMVL LENS MATRL ICAPSL 1146.57 090<br />
66930 REMOVAL LENS MATRL INTRACAPSULAR DISLOCATED LENS 1303.33 090<br />
66940 RMVL LENS MATRL XCAPSL 1242.95 090<br />
66982 XCAPSL CTRC RMVL INSJ LENS PROSTH 1 STG 1681.64 090<br />
66983 ICAPSL CTRC XTRJ INSJ IO LENS PROSTH 1 STG 1136.05 090<br />
66984 CATARACT REMOVAL INSERTION OF LENS 1210.27 090<br />
66985 INSJ IO LENS PROSTH X W/CNCRNT RMVL 1199.19 090<br />
66986 EXCHNG IO LENS 1427.40 090<br />
+ 66990 USE OPH ENDOSCOPE 139.58 ZZZ<br />
66999 UNLIS ANT SGM EYE BR YYY<br />
67005 RMVL VTS ANT APPR PRTL RMVL 761.06 090<br />
67010 RMVL VTS ANT APPR STOT RMVL VTRC 849.68 090<br />
67015 ASPIR/RLS FLU PARS PLNA 907.29 090<br />
67025 NJX VTS SUB PARS PLNA/LIMBAL SPX 1148.23 090<br />
67027 IMPLTJ INTRAVITREAL DRUG DLVR SYS RMVL VTS 1361.49 090<br />
67028 INTRAVITREAL NJX PHARMACOLOGIC AGT SPX 209.37 000<br />
67030 DSCJ VTS STRANDS PARS PLNA 800.39 090<br />
67031 SEVERING VTS STRANDS LASER 1+ STGS 603.20 090<br />
67036 VTRC MCHNL PARS PLNA 1511.59 090<br />
67039 VTRC MCHNL PARS PLNA FOCAL ENDOLASER PC 1978.53 090<br />
67040 VTRC MCHNL PARS PLNA ENDOLASER PANRTA PC 2237.20 090<br />
67041 VITRECTOMY PARS PLANA REMOVE PRERETINAL MEMBRANE 2088.20 090<br />
67042 VITRECTOMY PARS PLANA REMOVE INT MEMB RETINA 2388.97 090<br />
67043 VITRECTOMY PARS PLANA REMOVE SUBRETINAL MEMBRANE 2559.57 090<br />
67101 RPR RTA DTCHMNT 1+ SESS CRTX/DTHRM +-DRG 1235.20 090<br />
67105 RPR RTA DTCHMNT 1+ SESS PC +-DRG SUBRTA 1123.31 090<br />
67107 RPR RTA DTCHMNT SCLL BUCKLING +-IMPLT 1947.51 090<br />
67108 RPR RTA DTCHMNT W/VTRC ANY METH 2532.43 090<br />
67110 RPR RTA DTCHMNT NJX AIR/OTH GAS 1350.41 090<br />
67112 RPR RTA DTCHMNT SCLL BUCKLING/VTRC PT 2089.31 090<br />
67113 RPR COMPLEX RETINA DETACH VITRECTOMY & MEMB PEEL 2750.11 090<br />
67115 RLS ENCIRCLING MATRL 773.24 090<br />
67120 RMVL IMPLTED MATRL POST SGM EO 1045.76 090<br />
67121 RMVL IMPLTED MATRL POST SGM IO 1451.77 090<br />
67141 PROPH RTA DTCHMNT W/O DRG 1+ SESS CRTX DTHRM 828.08 090<br />
67145 PROPH RTA DTCHMNT W/O DRG 1+ SESS 820.88 090<br />
67208 DSTRJ LOCLZD LES RETINA 1+ SESS CRTX DTHRM 908.40 090<br />
67210 DSTRJ LOCLZD LES RETINA 1+ SESS PC 1090.63 090<br />
67218 DSTRJ LES RETINA 1+ SESS RADJ IMPLTJ 2117.56 090<br />
67220 DSTRJ LES CHOROID PC 1+ SESS 1700.47 090<br />
67221 DSTRJ LES CHOROID PDT 458.08 000<br />
+ 67225 DSTRJ LES CHOROID PDT 2ND EYE 1 SESS 45.97 ZZZ<br />
67227 DESTRUCTION RETINOPATHY 1+ SESS DIATHERMY 925.57 090<br />
67228 EXTENSIVE RETINOPATHY 1+ SESS PHOTOCOAGULATION 1846.70 090<br />
67229 EXTENSIVE RETINOPATHY 1+ SESS PRETERM INFANT 1738.69 090<br />
67250 SCLL RNFCMT SPX W/O GRF 1240.74 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
164 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
67255 SCLL RNFCMT SPX W/GRF 1349.30 090<br />
67299 UNLIS POST SGM BR YYY<br />
67311 STRABISMUS RECESSION/RESCJ 1 HRZNTL MUSC 950.49 090<br />
67312 STRABISMUS RECESSION/RESCJ 2 HRZNTL MUSC 1149.90 090<br />
67314 STRABISMUS RECESSION/RESCJ 1 VER MUSC 1067.92 090<br />
67316 STRABISMUS RECESSION/RESCJ 2/MORE VER MUSC 1292.25 090<br />
67318 STRABISMUS ANY SUPRIOR OBLQ MUSC 1068.47 090<br />
+ 67320 TRPOS ANY EO MUSC 495.74 ZZZ<br />
+ 67331 STRABISMUS PREVIOUS EYE X INVOLVE EO MUSC 496.85 ZZZ<br />
+ 67332 STRABISMUS SCARRING EO MUSC/RSTCV MYOPATHY 540.05 ZZZ<br />
+ 67334 STRABISMUS POST FIXJ SUTR TQ +-MUSC RECESSION 463.61 ZZZ<br />
+ 67335 PLMT ADJUSTABLE SUTR STRABISMUS 243.16 ZZZ<br />
+ 67340 STRABISMUS EXPL&/RPR DETACHED EO MUSC 551.68 ZZZ<br />
67343 RLS X10SV SCAR TISS W/O DETACHING EO MUSC SPX 1049.64 090<br />
67345 CHEMODNRVTJ EO MUSC 388.84 010<br />
67346 BIOPSY EXTRAOCULAR MUSCLE 329.57 000<br />
67399 UNLIS OC MUSC BR YYY<br />
67400 ORBT W/O B1 FLAP EXPL +-BX 1487.78 090<br />
67405 ORBT W/O B1 FLAP DRG ONLY 1236.86 090<br />
67412 ORBT W/O B1 FLAP RMVL LES 1364.26 090<br />
67413 ORBT W/O B1 FLAP RMVL FB 1375.89 090<br />
67414 ORBT W/O B1 FLAP RMVL B1 DCMPRN 2068.82 090<br />
67415 FINE NDL ASPIR ORB CNTS 168.39 000<br />
67420 ORBT B1 FLAP/WINDOW LAT RMVL LES 2629.36 090<br />
67430 ORBT B1 FLAP/WINDOW LAT RMVL FB 1899.32 090<br />
67440 ORBT B1 FLAP/WINDOW LAT DRG 1883.81 090<br />
67445 ORBT B1 FLAP/WINDOW LAT RMVL B1 DCMPRN 2272.65 090<br />
67450 ORBT B1 FLAP/WINDOW LAT EXPL +-BX 1957.48 090<br />
67500 RETROBULBAR NJX MED SPX 131.83 000<br />
67505 RETROBULBAR NJX ALCOHOL 144.57 000<br />
67515 NJX MED/OTHER SBST TENON'S CAPSULE 154.54 000<br />
67550 ORB IMPLT INSJ 1552.03 090<br />
67560 ORB IMPLT RMVL/REVJ 1545.38 090<br />
67570 OPTIC NRV DCMPRN 1975.76 090<br />
67599 UNLIS ORBIT BR YYY<br />
67700 BLEPHAROTOMY DRG ABSC EYELID 412.66 010<br />
67710 SEVERING TARSORRHAPHY 348.96 010<br />
67715 CANTHOTOMY SPX 368.90 010<br />
67800 EXC CHALAZION 1 200.51 010<br />
67801 EXC CHALAZION MLT SM LID 259.23 010<br />
67805 EXC CHALAZION MLT DIFF LIDS 321.82 010<br />
67808 EXC CHALAZION ANES REQ HOSPIZATION 1/MLT 589.90 090<br />
67810 BX EYELID 346.74 000<br />
67820 CORRJ TRICHIASIS EPILATION FORCEPS ONLY 81.42 000<br />
67825 CORRJ TRICHIASIS EPILATION OTH/THN FORCEPS 204.94 010<br />
67830 CORRJ TRICHIASIS INC LID MRGN 417.09 010<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 165
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
67835 CORRJ TRICHIASIS INC LID MRGN W/FR MUC MEMB GRF 708.44 090<br />
67840 EXC LES EYELID W/O CLSR/W/SMPL DIR CLSR 432.04 010<br />
67850 DSTRJ LES LID MRGN CORRJ PTOSIS 855.22 090<br />
67911 CORRJ LID RETRCJ 897.87 090<br />
67912 CORRJ LAGOPHTHALMOS IMPLTJ UPR EYELID LID LOAD 1396.38 090<br />
67914 RPR ECTROPION SUTR 614.83 090<br />
67915 RPR ECTROPION THERMOCAUT 541.16 090<br />
67916 RPR ECTROPION EXC TARSAL WEDGE 851.34 090<br />
67917 RPR ECTROPION X10SV 932.77 090<br />
67921 RPR ENTROPION SUTR 588.80 090<br />
67922 RPR ENTROPION THERMOCAUT 522.88 090<br />
67923 RPR ENTROPION EXC TARSAL WEDGE 902.86 090<br />
67924 RPR ENTROPION X10SV 931.66 090<br />
67930 SUTR RECENT WND EYELID PRTL THKNS 582.15 010<br />
67935 SUTR RECENT WND EYELID FULL THKNS 950.49 090<br />
67938 RMVL EMBEDDED FB EYELID 376.65 010<br />
67950 CANTHOPLASTY 912.83 090<br />
67961 EXC&RPR EYELID < ONE-4TH LID MRGN 915.04 090<br />
67966 EXC&RPR EYELID > ONE-4TH LID MRGN 1224.67 090<br />
67971 RCNSTJ EYELID FULL THKNS < 2-3RD 1 STG 1177.59 090<br />
67973 RCNSTJ EYELID FULL THKNS TOT LWR 1 STG 1521.56 090<br />
67974 RCNSTJ EYELID FULL THKNS TOT UPR 1 STG 1517.13 090<br />
67975 RCNSTJ EYELID FULL THKNS 2ND STG 1113.34 090<br />
67999 UNLIS EYELIDS BR YYY<br />
68020 INC CJNC DRG CST 187.22 010<br />
68040 EXPRESSION CJNCL FOLLICLES 104.69 000<br />
68100 BX CJNC 264.76 000<br />
68110 EXC LES CJNC UP 1 CM 354.50 010<br />
68115 EXC LES CJNC > 1 CM 481.34 010<br />
68130 EXC LES CJNC W/ADJ SCL 819.22 090<br />
68135 DSTRJ LES CJNC 244.82 010<br />
68200 SCJNCL NJX 67.02 000<br />
68320 CJP CJNCL GRF/X10SV REARGMT 1142.70 090<br />
68325 CJP BUCCAL MUC MEMB GRF 1061.27 090<br />
68326 CJP RCNSTJ CUL-DE-SAC CJNCL GRF/REARGMT 1039.12 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
166 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
68328 CJP RCNSTJ CUL-DE-SAC BUCCAL MUC MEMB GRF 1149.34 090<br />
68330 RPR SYMBLEPHARON CJP W/O GRF 957.14 090<br />
68335 RPR SYMBLEPHARON FR GRF CJNC/BUCCAL MUC MEMB 1041.33 090<br />
68340 RPR SYMBLEPHARON DIV 860.76 090<br />
68360 CJNCL FLAP BRIDGE/PRTL SPX 840.27 090<br />
68362 CJNCL FLAP TOT 1056.29 090<br />
68371 HRVG CJNCL ALGRFT LIV DON 628.12 010<br />
68399 UNLIS CJNC BR YYY<br />
68400 INC DRG LACRIMAL GLND 440.35 010<br />
68420 INC DRG LACRIMAL SAC 494.63 010<br />
68440 SNIP INC LACRIMAL PUNCTUM 166.72 010<br />
68500 EXC LACRIMAL GLND XCP TUM TOT 1596.89 090<br />
68505 EXC LACRIMAL GLND XCP TUM PRTL 1570.31 090<br />
68510 BX LACRIMAL GLND 716.19 000<br />
68520 EXC LACRIMAL SAC 1074.57 090<br />
68525 BX LACRIMAL SAC 439.24 000<br />
68530 RMVL FB/DACRYOLITH LACRIMAL PSAGES 680.74 010<br />
68540 EXC LACRIMAL GLND TUM FRNT APPR 1452.88 090<br />
68550 EXC LACRIMAL GLND TUM INVG OSTEOM 1779.13 090<br />
68700 PLSTC RPR CANALICULI 972.09 090<br />
68705 CORRJ EVERTED PUNCTUM CAUT 374.99 010<br />
68720 DACRYOCSTORHINOSTOMY 1206.39 090<br />
68745 CONJUNCTIVORHINOSTOMY W/O TUBE 1226.33 090<br />
68750 CONJUNCTIVORHINOSTOMY INSJ TUBE/STENT 1266.77 090<br />
68760 CLSR LACRIMAL PUNCTUM THERMOCAUT LIG/LASER 317.94 010<br />
68761 CLSR LACRIMAL PUNCTUM PLUG EA 230.98 010<br />
68770 CLSR LACRIMAL FSTL SPX 987.60 090<br />
68801 DILAT LACRIMAL PUNCTUM +-IRRG 193.87 010<br />
68810 PROBE NASOLACRIMAL DUX +-IRRG 377.76 010<br />
68811 PROBE NASOLACRIMAL DUX +-IRRG ANES 330.68 010<br />
68815 PROBE NASOLACRIMAL DUX +-IRRG INSJ TUBE/STENT 698.47 010<br />
68816 PROBE NASOLACRIMAL DUCT WITH CATHETER DILATION 1103.92 010<br />
68840 PROBE LACRIMAL CANALICULI +-IRRG 200.51 010<br />
68850 NJX CNTRST MEDIUM DACRYOCSTOGRAPY 97.49 000<br />
68899 UNLIS LACRIMAL SYS BR YYY<br />
69000 DRG XTRNL EAR ABSC/HMTMA SMPL 297.44 010<br />
69005 DRG XTRNL EAR ABSC/HMTMA COMP 347.85 010<br />
69020 DRG XTRNL AUD CANAL ABSC 378.31 010<br />
69090 EAR PIERCING 50.96 XXX<br />
69100 BX XTRNL EAR 167.83 000<br />
69105 BX XTRNL AUD CANAL 228.76 000<br />
69110 EXC XTRNL EAR PRTL SMPL RPR 746.10 090<br />
69120 EXC XTRNL EAR COMPL AMP 659.69 090<br />
69140 EXC EXOSTOSIS XTRNL AUD CANAL 1436.26 090<br />
69145 EXC SOFT TISS LES XTRNL AUD CANAL 639.75 090<br />
69150 RAD EXC XTRNL AUD CANAL LES W/O NCK DSJ 1721.52 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 167
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VII: Surgical Services<br />
SURGERY 10021–69990<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
69155 RAD EXC XTRNL AUD CANAL LES NCK DSJ 2763.41 090<br />
69200 RMVL FB XTRNL AUD CANAL W/O ANES 199.40 000<br />
69205 RMVL FB XTRNL AUD CANAL ANES 166.72 010<br />
69210 RMVL IMPACTED CERUMEN SPX 1/BTH EARS 81.42 000<br />
69220 DBRDMT MSTDC CAVITY SMPL 224.33 000<br />
69222 DBRDMT MSTDC CAVITY CPLX 360.04 010<br />
K 69300 OTOPLASTY PROTRUDING EAR +-SIZE RDCTJ 1092.29 YYY<br />
69310 RCNSTJ XTRNL AUD CANAL SPX 1785.77 090<br />
69320 RCNSTJ XTRNL AUD CANAL CGEN ATRESIA 1 STG 2524.68 090<br />
69399 UNLIS XTRNL EAR BR YYY<br />
69400 EUSTACHIAN TUBE NFLTJ TRANSNSL CATHJ 236.52 000<br />
69401 EUSTACHIAN TUBE NFLTJ TRANSNSL W/O CATHJ 137.92 000<br />
69405 EUSTACHIAN TUBE CATHJ TRANSTYMPANIC 425.95 010<br />
69420 MRGT ASPIR&/EUSTACHIAN TUBE NFLTJ 312.95 010<br />
69421 MRGT ASPIR&/EUSTACHIAN TUBE NFLTJ ANES 247.59 010<br />
69424 VENTILATING TUBE RMVL ANES 209.93 000<br />
69433 TMPST LOCAL/TOPICAL ANES 326.25 010<br />
69436 TMPST ANES 267.53 010<br />
69440 MIDDLE EAR EXPL THRU POSTAUR/EAR CANAL INC 1129.96 090<br />
69450 TYMPANOLSS TRANSCANAL 890.67 090<br />
69501 TRANSMASTOID ANTRT 1204.18 090<br />
69502 MSTDC COMPL 1601.32 090<br />
69505 MSTDC MODF RAD 1981.85 090<br />
69511 MSTDC RAD 2033.37 090<br />
69530 PETROUS APICECTOMY RAD MSTDC 2728.51 090<br />
69535 RESCJ TEMPORAL B1 XTRNL 4422.89 090<br />
69540 EXC AURAL POLYP 341.76 010<br />
69550 EXC AURAL GLOMUS TUM TRANSCANAL 1714.32 090<br />
69552 EXC AURAL GLOMUS TUM TRANSMASTOID 2592.25 090<br />
69554 EXC AURAL GLOMUS TUM EXTND 4132.09 090<br />
69601 REVJ MSTDC RSLTG COMPL MSTDC 1724.29 090<br />
69602 REVJ MSTDC RSLTG MODF RAD MSTDC 1794.08 090<br />
69603 REVJ MSTDC RSLTG RAD MSTDC 2083.77 090<br />
69604 REVJ MSTDC RSLTG TMPP 1841.72 090<br />
69605 REVJ MSTDC W/APICECTOMY 2575.08 090<br />
69610 TYMPANIC MEMB RPR +-SIT PREPJ PRF8J PATCH 638.09 010<br />
69620 MYRINGOPLASTY 1136.05 090<br />
69631 TMPP W/O MSTDC 1ST/REVJ W/O OCR 1451.77 090<br />
69632 TMPP W/O MSTDC 1ST/REVJ OCR 1774.70 090<br />
69633 TMPP W/O MSTDC 1ST/REVJ PROSTH TORP 1712.66 090<br />
69635 TMPP ANTRT/MASTOIDOTOMY W/O OCR 2011.21 090<br />
69636 TMPP ANTRT/MASTOIDOTOMY OCR 2273.21 090<br />
69637 TMPP ANTRT/MASTOIDOTOMY PROSTH TORP 2266.56 090<br />
69641 TMPP MSTDC W/O OCR 1714.32 090<br />
69642 TMPP MSTDC OCR 2206.18 090<br />
69643 TMPP MSTDC NTC/RCNSTED WALL W/O OCR 2016.20 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
168 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VII: Surgical Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
10021–69990 SURGERY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
69644 TMPP MSTDC NTC/RCNSTED CANAL WALL OCR 2439.38 090<br />
69645 TMPP MSTDC RAD/COMPL W/O OCR 2394.51 090<br />
69646 TMPP MSTDC RAD/COMPL OCR 2540.19 090<br />
69650 STAPES MOBLJ 1314.96 090<br />
69660 STAPEDECTOMY/STAPEDOTOMY 1529.87 090<br />
69661 STAPEDECTOMY/STAPEDOTOMY W/FOOTPLATE DRILL OUT 1994.59 090<br />
69662 REVJ STAPEDECTOMY/STAPEDOTOMY 1910.40 090<br />
69666 RPR OVAL WINDOW FSTL 1329.36 090<br />
69667 RPR ROUND WINDOW FSTL 1331.58 090<br />
69670 MASTOID OBLTRJ SPX 1553.14 090<br />
69676 TYMPANIC NEURECTOMY 1369.24 090<br />
69700 CLSR POSTAUR FSTL MASTOID SPX 1135.50 090<br />
69710 IMPLTJ/RPLCMT EMGNT B1 CNDJ DEV TEMPORAL B1 BR XXX<br />
69711 RMVL/RPR EMGNT B1 CNDJ DEV TEMPORAL B1 1424.63 090<br />
69714 IMPLTJ OI IMPLT B1 W/O MSTDC 1776.36 090<br />
69715 IMPLTJ OI IMPLT B1 MSTDC 2200.64 090<br />
69717 RPLCMT OI IMPLT B1 W/O MSTDC 1878.27 090<br />
69718 RPLCMT OI IMPLT B1 MSTDC 2225.02 090<br />
69720 DCMPRN NRV ITPRL LAT GENICULATE 1935.88 090<br />
69725 DCMPRN NRV ITPRL MEDIAL GENICULATE 3113.47 090<br />
69740 SUTR NRV ITPRL +-GRF/DCMPRN LAT GENICULATE 1932.00 090<br />
69745 SUTR NRV ITPRL +-GRF/DCMPRN MEDIAL GENICULATE 2059.40 090<br />
69799 UNLIS MIDDLE EAR BR YYY<br />
s 69801 LABYRINTHOTOMY TRANSCANAL 329.02 000<br />
s 69802 LABYRINTHOTOMY MASTOIDECTOMY 1716.54 090<br />
69805 ENDOLYMPHATIC SAC W/O SHUNT 1741.46 090<br />
69806 ENDOLYMPHATIC SAC SHUNT 1560.89 090<br />
69820 FENESTRATION SEMICIRCULAR CANAL 1417.43 090<br />
69840 REVJ FENESTRATION OPRATION 1373.12 090<br />
69905 LABYRINTHECTOMY TRANSCANAL 1515.47 090<br />
69910 LABYRINTHECTOMY MSTDC 1684.96 090<br />
69915 VSTBLR NRV SCTJ TRANSLABYRINTHINE APPR 2548.49 090<br />
69930 COCHLEAR DEV IMPLTJ +-MSTDC 2034.47 090<br />
69949 UNLIS INNER EAR BR YYY<br />
69950 VSTBLR NRV SCTJ TRANSCRNL 3112.92 090<br />
69955 TOT FACIAL NRV DCMPRN&/RPR 3281.30 090<br />
69960 DCMPRN INT AUD CANAL 3191.57 090<br />
69970 RMVL TUM TEMPORAL B1 3558.25 090<br />
69979 UNLIS TEMPORAL B1 MIDDLE FOSSA BR YYY<br />
+ 69990 MICROSURG TQS REQ USE OPRATING MCRSCP 358.93 ZZZ<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 169
Section VIII: Diagnostic and<br />
<strong>The</strong>rapeutic Radiological<br />
Services<br />
SUBSECTION A: PAYMENT GROUND RULES FOR<br />
DIAGNOSTIC AND THERAPEUTIC RADIOLOGICAL<br />
SERVICES<br />
General Guidelines<br />
<strong>The</strong> maximum allowed rate (MAR) column for a radiological<br />
procedure includes the professional component (PC) and the<br />
technical component (TC). Under no circumstances shall the<br />
MAR for a procedure be more than the combined value of<br />
the TC and the PC. This value is applicable in any situation<br />
in which a single charge is made to include both professional<br />
services and the technical cost of providing that service.<br />
Identification of a procedure without modifier 26 indicates<br />
that the charge includes both the “professional” and the<br />
“technical” components.<br />
<strong>The</strong> PC fee amount represents the value of the professional<br />
radiological services of the physician. This component is<br />
applicable in any situation in which the physician submits a<br />
bill for these professional services only. It does not include<br />
the cost of personnel, materials, space, equipment, or other<br />
facilities. <strong>The</strong> PC fee amount includes:<br />
• Examination of the injured employee when indicated<br />
• Performance and/or supervision of the procedure<br />
• Interpretation and written report of the examination<br />
• Consultation with the authorized treating physician<br />
A written report, signed by the interpreting physician, is<br />
considered an integral part of a radiological procedure or<br />
interpretation and shall not be reimbursed separately.<br />
To identify a charge for the PC, use the five-digit CPT<br />
procedure code followed by modifier 26. If a “0” fee amount<br />
appears in the PC column, the procedure is assumed to be<br />
purely technical in nature and no PC charge will be allowed.<br />
<strong>The</strong> TC includes the charges for personnel, materials<br />
(including ionic contrast media and drugs), film or<br />
xerography or digital images, space, equipment, and other<br />
facility resources. <strong>The</strong> technical component maximum<br />
allowable reimbursement excludes radioisotope cost. To<br />
identify a charge for the TC only, use the procedure code<br />
followed by modifier TC.<br />
A complete examination includes all of the necessary views<br />
for optimal examination of the body part for the suspected<br />
condition. If the reimbursement of multiple single views<br />
exceeds the cost of a complete examination, reimbursement<br />
shall be based on the complete examination value.<br />
Definitions and items unique to radiology are listed below:<br />
• Noninvasive/interventional diagnostic imaging includes<br />
standard radiographs, single or multiple views, contrast<br />
studies, computerized tomography, and magnetic<br />
resonance imaging. In the event that radiographs have<br />
to be repeated in the course of a radiographic encounter<br />
due to substandard quality, only one unit of service for<br />
the code can be billed.<br />
• Interventional/invasive diagnostic imaging—When a<br />
contrast can be administered orally (upper GI) or<br />
rectally (barium enema), the administration is included<br />
as part of the procedure and no administration service is<br />
billed. When contrast material is parenterally<br />
administered, whether the timing of the injection has to<br />
correlate with the procedure or not (e.g., IVP, CT scans,<br />
gadolinium), the administration and the injection (e.g.,<br />
CPT codes 36000, 36406, 36410, and 96372–96374)<br />
are included in the contrast studies.<br />
Subject Listings<br />
Subject listings apply when radiological services are<br />
performed by or under the responsible supervision of a<br />
physician.<br />
CPT only © 2010 American Medical Association. All Rights Reserved. 171
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Supervision and Interpretation<br />
Radiology services containing an invasive component are<br />
reported by the radiologist for supervision of the procedure<br />
and the personnel involved with performing the<br />
examination, reading the film, and preparing the written<br />
report. <strong>The</strong> injection is administered and coded with the<br />
appropriate code outside the Radiology (70000 series)<br />
section and a code for the radiological portion of the<br />
procedure is designated as the supervision and interpretation<br />
portion. <strong>The</strong>se services may be performed by a single<br />
physician who reports both services or may be split between<br />
a radiologist and another physician.<br />
Radiation oncology services are not considered to be part of<br />
the supervision and interpretation procedures.<br />
Review of Diagnostic Studies<br />
No separate charge is warranted for prior studies reviewed in<br />
conjunction with a visit, consultation, record review, or<br />
other evaluation by the medical practitioner or other medical<br />
personnel; neither the professional component value<br />
modifier 26 nor the radiological consultation CPT code<br />
76140 is reimbursable. <strong>The</strong> review of diagnostic tests is<br />
included in the evaluation and management codes.<br />
Written Report(s)<br />
A written report, signed by the interpreting physician,<br />
should be considered an integral part of a radiological<br />
procedure or interpretation.<br />
Unbundling of “Entrance” Fees<br />
Unbundling of fees to free-standing diagnostic radiology<br />
centers will not be allowed. Any entrance fees billed in<br />
addition to the global or testing procedure code will not be<br />
reimbursed.<br />
Injection Procedure<br />
Fees include all usual pre- and postinjection care specifically<br />
related to the injection procedure, necessary local anesthesia,<br />
placement of needle or catheter, and injection of contrast<br />
media with or without auto power injection.<br />
Procedures that include “with contrast” are considered to be<br />
those intravascular, intra-articular, or intrathecal injections<br />
of contrast for imaging services. Contrasted studies include<br />
computed tomography (CT), computed tomographic<br />
angiography (CTA), magnetic resonance imaging (MRI), and<br />
magnetic resonance angiography (MRA). Administration of<br />
oral or rectal contrast media does not necessarily meet the<br />
guidelines of a contrasted study.<br />
Intra-articular joint injections are reported with the codes<br />
that identify the specific joint. Arthrography, when<br />
performed, is reported using the supervision and<br />
interpretation code for the specific joint. Specific imaging<br />
Section VIII: Diagnostic and <strong>The</strong>rapeutic Radiological Services<br />
modalities of CT or MRI should also be reported when<br />
performed whether the sole procedure or in combination<br />
with an arthrography. <strong>The</strong> appropriate code identifying<br />
multiple images should be used when non-contrasted and<br />
contrasted studies are performed at the same session.<br />
Intravascular or intrathecal injections are included in spinal<br />
CT, MRI, or MRA contrasted studies. Codes 61055 or 62284<br />
may also be used to report intrathecal injections. No separate<br />
reimbursement is made for intravascular (IV) injections.<br />
When introducing additional materials through the same<br />
puncture site, reimbursement shall be allowed for the<br />
materials only. Usual, customary, and reasonable charges<br />
will apply to such charges.<br />
Unusual Service or Procedure<br />
Services that may necessitate skills and time of the physician<br />
over and above that usually required should be substantiated<br />
by report (see section IV).<br />
Unlisted Service or Procedure<br />
Some services performed are not described by any CPT code.<br />
Unlisted services should be reported using an unlisted code<br />
and substantiated by report. <strong>The</strong> unlisted services and<br />
accompanying codes are listed at the end of each Radiology<br />
subsection. Unlisted service or procedure codes must be<br />
selected from the appropriate subsection of the Radiology<br />
chapter. For these procedures a “BR” (by report) designation<br />
has been used in the fee schedule. Reimbursement for such<br />
procedures must be justified by report (see section IV).<br />
SUBSECTION B: PAYMENT MODIFIERS FOR<br />
DIAGNOSTIC AND THERAPEUTIC RADIOLOGICAL<br />
SERVICES<br />
A modifier indicates a service or procedure performed has<br />
been altered by some specific circumstance but has not<br />
changed its definition or code. <strong>The</strong> modifying circumstance<br />
shall be identified by the appropriate modifier following the<br />
procedure code. When two modifiers are applicable to a<br />
single code, indicate each modifier on the bill. If more than<br />
one modifier is used, place the “Multiple Modifiers” code 99<br />
immediately after the procedure code. This indicates that<br />
one or more additional modifier codes will follow. Only<br />
certain modifiers in each of the categories (Evaluation and<br />
Management Services, Anesthesia, Surgery,<br />
Pathology/Laboratory, Radiology, General Medicine, and<br />
Physical Medicine) will be recognized for reimbursement<br />
purposes.<br />
<strong>The</strong> modifiers listed below may differ from those published<br />
by the American Medical Association. Medical providers<br />
submitting workers’ compensation billing shall use only the<br />
modifiers set out in the fee schedule.<br />
172 CPT only © 2010 American Medical Association. All Rights Reserved.
Section VIII: Diagnostic and <strong>The</strong>rapeutic Radiological Services<br />
<strong>The</strong> following modifiers will be recognized for<br />
reimbursement by the fee schedule for diagnostic and<br />
therapeutic radiology services codes:<br />
22 Increased Procedural Services: When the work<br />
required to provide a service is substantially greater than<br />
typically required, it may be identified by adding<br />
modifier 22 to the usual procedure code.<br />
Documentation must support the substantial additional<br />
work and the reason for the additional work (i.e.,<br />
increased intensity, time, technical difficulty of<br />
procedure, severity of patient's condition, physical and<br />
mental effort required). Note: This modifier should not<br />
be appended to an E/M service.<br />
26 Professional Component: Certain procedures are a<br />
combination of a physician component and a technical<br />
component. When the physician component is reported<br />
separately, the service may be identified by adding<br />
modifier 26 to the usual procedure number.<br />
50 Bilateral Procedure: Unless otherwise identified in the<br />
listings, bilateral procedures that are performed at the<br />
same session should be identified by adding modifier 50<br />
to the appropriate five-digit code. Unless otherwise<br />
indicated, the total reimbursed for the bilateral<br />
procedure is 150 percent of the fee schedule for<br />
unilateral surgery.<br />
52 Reduced Services: Under certain circumstances, a<br />
service or procedure is partially reduced or eliminated at<br />
the physician’s discretion. Under these circumstances,<br />
the service provided can be identified by its usual<br />
procedure number and the addition of modifier 52<br />
signifying that the service is reduced. This provides a<br />
means of reporting reduced services without disturbing<br />
the identification of the basic service. Note: For hospital<br />
outpatient reporting of a previously scheduled<br />
procedure/service that is partially reduced or cancelled<br />
as a result of extenuating circumstances or those that<br />
threaten the well-being of the patient prior to or after<br />
administration of anesthesia, see modifiers 73 and 74<br />
(see modifiers approved for ASC hospital outpatient<br />
use).<br />
53 Discontinued Procedure: Under certain circumstances,<br />
the physician may elect to terminate a surgical or<br />
diagnostic procedure. Due to extenuating circumstances<br />
or those that threaten the well-being of the patient, it<br />
may be necessary to indicate that a surgical or diagnostic<br />
procedure was started but discontinued. This<br />
circumstance may be reported by adding modifier 53 to<br />
the code reported by the physician for the discontinued<br />
procedure. Note: This modifier is not used to report the<br />
elective cancellation of a procedure prior to the patient’s<br />
anesthesia induction and/or surgical preparation in the<br />
operating suite. For outpatient hospital/ambulatory<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
surgery center (ASC) reporting of a previously<br />
scheduled procedure/service that is partially reduced or<br />
cancelled as a result of extenuating circumstances or<br />
those that threaten the well-being of the patient prior to<br />
or after administration of anesthesia, see modifiers 73<br />
and 74 (see modifiers approved for ASC hospital<br />
outpatient use).<br />
59 Distinct Procedural Service: Under certain<br />
circumstances, it may be necessary to indicate that a<br />
procedure or service was distinct or independent from<br />
other non-E/M services performed on the same day.<br />
Modifier 59 is used to identify procedures/services,<br />
other than E/M services, that are not normally reported<br />
together but are appropriate under the circumstances.<br />
Documentation must support a different session,<br />
different procedure or surgery, different site or organ<br />
system, separate incision or excision, separate lesion, or<br />
separate injury (or area of injury in extensive injuries)<br />
not ordinarily encountered or performed on the same<br />
day by the same individual. However, when another<br />
already established modifier is appropriate, it should be<br />
used rather than modifier 59. Only if no more<br />
descriptive modifier is available, and the use of modifier<br />
59 best explains the circumstances, should modifier 59<br />
be used. Note: Modifier 59 should not be appended to<br />
an E/M service. To report a separate and distinct E/M<br />
service with a non-E/M service performed on the same<br />
date, see modifier 25.<br />
76 Repeat Procedure or Service by Same Physician or<br />
Other Qualified Health Care Professional: It may be<br />
necessary to indicate that a procedure or service was<br />
repeated by the same physician or other qualified health<br />
care professional subsequent to the original procedure<br />
or service. This circumstance may be reported by adding<br />
modifier 76 to the repeated procedure or service. Note:<br />
This modifier should not be appended to an E/M<br />
service.<br />
77 Repeat Procedure or Service by Another Physician or<br />
Other Qualified Health Care Professional: It may be<br />
necessary to indicate that a basic procedure or service<br />
was repeated by another physician or other qualified<br />
health care professional subsequent to the original<br />
procedure or service. This circumstance may be<br />
reported by adding modifier 77 to the repeated<br />
procedure or service. Note: This modifier should not be<br />
appended to an E/M service.<br />
99 Multiple Modifiers: Under certain circumstances, two<br />
or more modifiers may be necessary to completely<br />
delineate a service. In such situations, modifier 99<br />
should be added to the basic procedure, and other<br />
applicable modifiers may be listed as part of the<br />
description of the service.<br />
CPT only © 2010 American Medical Association. All Rights Reserved. 173
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
LT Left Side: Used to identify procedures performed on the<br />
left side of the body.<br />
RT Right Side: Used to identify procedures performed on<br />
the right side of the body.<br />
TC Technical Component Only: Certain procedures are a<br />
combination of a physician component and a technical<br />
Section VIII: Diagnostic and <strong>The</strong>rapeutic Radiological Services<br />
component. When the technical component is reported<br />
separately, the service may be identified by adding<br />
modifier TC to the usual procedure number.<br />
174 CPT only © 2010 American Medical Association. All Rights Reserved.
Section VIII: Diagnostic and <strong>The</strong>rapeutic Radiological Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
70010–79999 RADIOLOGY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
70010 MYELOGRAPY POST FOSSA RS&I 312.22 XXX<br />
70010 26 MYELOGRAPY POST FOSSA RS&I 81.56 XXX<br />
70010 TC MYELOGRAPY POST FOSSA RS&I 230.66 XXX<br />
70015 CISTRNG POSITIVE CNTRST RS&I 359.18 XXX<br />
70015 26 CISTRNG POSITIVE CNTRST RS&I 144.99 XXX<br />
70015 TC CISTRNG POSITIVE CNTRST RS&I 214.19 XXX<br />
70030 RADEX EYE DETCJ FB 70.02 XXX<br />
70030 26 RADEX EYE DETCJ FB 20.60 XXX<br />
70030 TC RADEX EYE DETCJ FB 49.42 XXX<br />
70100 RADEX MNDBL PRTL < 4 VIEWS 80.73 XXX<br />
70100 26 RADEX MNDBL PRTL < 4 VIEWS 22.24 XXX<br />
70100 TC RADEX MNDBL PRTL < 4 VIEWS 58.49 XXX<br />
70110 RADEX MNDBL COMPL MINIMUM 4 VIEWS 96.38 XXX<br />
70110 26 RADEX MNDBL COMPL MINIMUM 4 VIEWS 29.66 XXX<br />
70110 TC RADEX MNDBL COMPL MINIMUM 4 VIEWS 66.72 XXX<br />
70120 RADEX MASTOIDS < 3 VIEWS PR SIDE 85.68 XXX<br />
70120 26 RADEX MASTOIDS < 3 VIEWS PR SIDE 22.24 XXX<br />
70120 TC RADEX MASTOIDS < 3 VIEWS PR SIDE 63.44 XXX<br />
70130 RADEX MASTOIDS COMPL MINIMUM 3 VIEWS PR SIDE 136.75 XXX<br />
70130 26 RADEX MASTOIDS COMPL MINIMUM 3 VIEWS PR SIDE 40.37 XXX<br />
70130 TC RADEX MASTOIDS COMPL MINIMUM 3 VIEWS PR SIDE 96.38 XXX<br />
70134 RADEX INT AUD MEATI COMPL 112.86 XXX<br />
70134 26 RADEX INT AUD MEATI COMPL 40.37 XXX<br />
70134 TC RADEX INT AUD MEATI COMPL 72.49 XXX<br />
70140 RADEX FACIAL B1S < 3 VIEWS 74.14 XXX<br />
70140 26 RADEX FACIAL B1S < 3 VIEWS 23.89 XXX<br />
70140 TC RADEX FACIAL B1S < 3 VIEWS 50.25 XXX<br />
70150 RADEX FACIAL B1S COMPL MINIMUM 3 VIEWS 104.62 XXX<br />
70150 26 RADEX FACIAL B1S COMPL MINIMUM 3 VIEWS 31.30 XXX<br />
70150 TC RADEX FACIAL B1S COMPL MINIMUM 3 VIEWS 73.32 XXX<br />
70160 RADEX NSL B1S COMPL MINIMUM 3 VIEWS 80.73 XXX<br />
70160 26 RADEX NSL B1S COMPL MINIMUM 3 VIEWS 20.60 XXX<br />
70160 TC RADEX NSL B1S COMPL MINIMUM 3 VIEWS 60.13 XXX<br />
70170 DACRYOCSTOGRAPY NASOLACRIMAL DUX RS&I 128.51 XXX<br />
70170 26 DACRYOCSTOGRAPY NASOLACRIMAL DUX RS&I 37.07 XXX<br />
70170 TC DACRYOCSTOGRAPY NASOLACRIMAL DUX RS&I 91.44 XXX<br />
70190 RADEX OPTIC FORAMINA 87.32 XXX<br />
70190 26 RADEX OPTIC FORAMINA 25.54 XXX<br />
70190 TC RADEX OPTIC FORAMINA 61.78 XXX<br />
70200 RADEX ORBITS COMPL MINIMUM 4 VIEWS 107.92 XXX<br />
70200 26 RADEX ORBITS COMPL MINIMUM 4 VIEWS 33.78 XXX<br />
70200 TC RADEX ORBITS COMPL MINIMUM 4 VIEWS 74.14 XXX<br />
70210 RADEX SINUSES PARANSL < 3 VIEWS 75.79 XXX<br />
70210 26 RADEX SINUSES PARANSL < 3 VIEWS 21.42 XXX<br />
70210 TC RADEX SINUSES PARANSL < 3 VIEWS 54.37 XXX<br />
70220 RADEX SINUSES PARANSL COMPL MINIMUM 3 VIEWS 94.74 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 175
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VIII: Diagnostic and <strong>The</strong>rapeutic Radiological Services<br />
RADIOLOGY 70010–79999<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
70220 26 RADEX SINUSES PARANSL COMPL MINIMUM 3 VIEWS 29.66 XXX<br />
70220 TC RADEX SINUSES PARANSL COMPL MINIMUM 3 VIEWS 65.08 XXX<br />
70240 RADEX SELLA TURCICA 72.49 XXX<br />
70240 26 RADEX SELLA TURCICA 23.07 XXX<br />
70240 TC RADEX SELLA TURCICA 49.42 XXX<br />
70250 RADEX SKL < 4 VIEWS 90.62 XXX<br />
70250 26 RADEX SKL < 4 VIEWS 29.66 XXX<br />
70250 TC RADEX SKL < 4 VIEWS 60.96 XXX<br />
70260 RADEX SKL COMPL MINIMUM 4 VIEWS 115.33 XXX<br />
70260 26 RADEX SKL COMPL MINIMUM 4 VIEWS 40.37 XXX<br />
70260 TC RADEX SKL COMPL MINIMUM 4 VIEWS 74.96 XXX<br />
70300 RADEX TEETH 1 VIEW 35.42 XXX<br />
70300 26 RADEX TEETH 1 VIEW 14.00 XXX<br />
70300 TC RADEX TEETH 1 VIEW 21.42 XXX<br />
70310 RADEX TEETH PRTL XM < FULL MOUTH 91.44 XXX<br />
70310 26 RADEX TEETH PRTL XM < FULL MOUTH 21.42 XXX<br />
70310 TC RADEX TEETH PRTL XM < FULL MOUTH 70.02 XXX<br />
70320 RADEX TEETH COMPL FULL MOUTH 122.75 XXX<br />
70320 26 RADEX TEETH COMPL FULL MOUTH 28.01 XXX<br />
70320 TC RADEX TEETH COMPL FULL MOUTH 94.74 XXX<br />
70328 RADEX TMPRMAND JT OPN&CLSD MOUTH UNI 75.79 XXX<br />
70328 26 RADEX TMPRMAND JT OPN&CLSD MOUTH UNI 22.24 XXX<br />
70328 TC RADEX TMPRMAND JT OPN&CLSD MOUTH UNI 53.55 XXX<br />
70330 RADEX TMPRMAND JT OPN&CLSD MOUTH BI 117.80 XXX<br />
70330 26 RADEX TMPRMAND JT OPN&CLSD MOUTH BI 29.66 XXX<br />
70330 TC RADEX TMPRMAND JT OPN&CLSD MOUTH BI 88.14 XXX<br />
70332 TMPRMAND JT ARTHG RS&I 208.42 XXX<br />
70332 26 TMPRMAND JT ARTHG RS&I 69.20 XXX<br />
70332 TC TMPRMAND JT ARTHG RS&I 139.22 XXX<br />
70336 MRI TMPRMAND JT 1097.30 XXX<br />
70336 26 MRI TMPRMAND JT 177.94 XXX<br />
70336 TC MRI TMPRMAND JT 919.36 XXX<br />
70350 CEPHALOGRAM ORTHODONTIC 51.90 XXX<br />
70350 26 CEPHALOGRAM ORTHODONTIC 23.07 XXX<br />
70350 TC CEPHALOGRAM ORTHODONTIC 28.83 XXX<br />
70355 ORTHOPANTOGRAM 52.72 XXX<br />
70355 26 ORTHOPANTOGRAM 25.54 XXX<br />
70355 TC ORTHOPANTOGRAM 27.18 XXX<br />
70360 RADEX NCK SOFT TISS 67.55 XXX<br />
70360 26 RADEX NCK SOFT TISS 20.60 XXX<br />
70360 TC RADEX NCK SOFT TISS 46.95 XXX<br />
70370 RADEX PHARYNX/LARX W/FLUOR&/MAGNIFICATION TQ 198.54 XXX<br />
70370 26 RADEX PHARYNX/LARX W/FLUOR&/MAGNIFICATION TQ 38.72 XXX<br />
70370 TC RADEX PHARYNX/LARX W/FLUOR&/MAGNIFICATION TQ 159.82 XXX<br />
70371 CPLX DYNAMIC PHARYNGEAL&SP EVAL C/V REC 229.84 XXX<br />
70371 26 CPLX DYNAMIC PHARYNGEAL&SP EVAL C/V REC 99.68 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure<br />
176 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VIII: Diagnostic and <strong>The</strong>rapeutic Radiological Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
70010–79999 RADIOLOGY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
70371 TC CPLX DYNAMIC PHARYNGEAL&SP EVAL C/V REC 130.16 XXX<br />
70373 LARYNGOGRAPY CNTRST RS&I 200.18 XXX<br />
70373 26 LARYNGOGRAPY CNTRST RS&I 51.08 XXX<br />
70373 TC LARYNGOGRAPY CNTRST RS&I 149.10 XXX<br />
70380 RADIOLOGIC EXAMINATION SALIVARY GLAND CALCULUS 96.38 XXX<br />
70380 26 RADIOLOGIC EXAMINATION SALIVARY GLAND CALCULUS 22.24 XXX<br />
70380 TC RADIOLOGIC EXAMINATION SALIVARY GLAND CALCULUS 74.14 XXX<br />
70390 SIALOGRAPY RS&I 247.96 XXX<br />
70390 26 SIALOGRAPY RS&I 46.96 XXX<br />
70390 TC SIALOGRAPY RS&I 201.00 XXX<br />
70450 CT HEAD/BRN C-MATRL 478.63 XXX<br />
70450 26 CT HEAD/BRN C-MATRL 102.15 XXX<br />
70450 TC CT HEAD/BRN C-MATRL 376.48 XXX<br />
70460 CT HEAD/BRN C+ MATRL 623.62 XXX<br />
70460 26 CT HEAD/BRN C+ MATRL 135.93 XXX<br />
70460 TC CT HEAD/BRN C+ MATRL 487.69 XXX<br />
70470 CT HEAD/BRN C-/C+ 754.60 XXX<br />
70470 26 CT HEAD/BRN C-/C+ 154.05 XXX<br />
70470 TC CT HEAD/BRN C-/C+ 600.55 XXX<br />
70480 CT ORBIT SELLA/POST FOSSA/EAR C-MATRL 766.13 XXX<br />
70480 26 CT ORBIT SELLA/POST FOSSA/EAR C-MATRL 154.87 XXX<br />
70480 TC CT ORBIT SELLA/POST FOSSA/EAR C-MATRL 611.26 XXX<br />
70481 CT ORBIT SELLA/POST FOSSA/EAR C+ MATRL 889.70 XXX<br />
70481 26 CT ORBIT SELLA/POST FOSSA/EAR C+ MATRL 167.23 XXX<br />
70481 TC CT ORBIT SELLA/POST FOSSA/EAR C+ MATRL 722.47 XXX<br />
70482 CT ORBIT SELLA/POST FOSSA/EAR C-/C+ 1004.21 XXX<br />
70482 26 CT ORBIT SELLA/POST FOSSA/EAR C-/C+ 174.65 XXX<br />
70482 TC CT ORBIT SELLA/POST FOSSA/EAR C-/C+ 829.56 XXX<br />
70486 CT MAXLFCL AREA C-MATRL 638.45 XXX<br />
70486 26 CT MAXLFCL AREA C-MATRL 137.57 XXX<br />
70486 TC CT MAXLFCL AREA C-MATRL 500.88 XXX<br />
70487 CT MAXLFCL AREA C+ MATRL 769.43 XXX<br />
70487 26 CT MAXLFCL AREA C+ MATRL 157.35 XXX<br />
70487 TC CT MAXLFCL AREA C+ MATRL 612.08 XXX<br />
70488 CT MAXLFCL AREA C-/C+ 935.01 XXX<br />
70488 26 CT MAXLFCL AREA C-/C+ 171.35 XXX<br />
70488 TC CT MAXLFCL AREA C-/C+ 763.66 XXX<br />
70490 CT SOFT TISS NCK C-MATRL 626.09 XXX<br />
70490 26 CT SOFT TISS NCK C-MATRL 154.87 XXX<br />
70490 TC CT SOFT TISS NCK C-MATRL 471.22 XXX<br />
70491 CT SOFT TISS NCK C+ MATRL 753.78 XXX<br />
70491 26 CT SOFT TISS NCK C+ MATRL 166.41 XXX<br />
70491 TC CT SOFT TISS NCK C+ MATRL 587.37 XXX<br />
70492 CT SOFT TISS NCK C-/C+ 910.30 XXX<br />
70492 26 CT SOFT TISS NCK C-/C+ 174.65 XXX<br />
70492 TC CT SOFT TISS NCK C-/C+ 735.65 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 177
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VIII: Diagnostic and <strong>The</strong>rapeutic Radiological Services<br />
RADIOLOGY 70010–79999<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
70496 CT ANGIOGRAPHY HEAD W/CONTRAST/NONCONTRAST 1445.77 XXX<br />
70496 26 CT ANGIOGRAPHY HEAD W/CONTRAST/NONCONTRAST 212.54 XXX<br />
70496 TC CT ANGIOGRAPHY HEAD W/CONTRAST/NONCONTRAST 1233.23 XXX<br />
70498 CT ANGIOGRAPHY NECK W/CONTRAST/NONCONTRAST 1470.48 XXX<br />
70498 26 CT ANGIOGRAPHY NECK W/CONTRAST/NONCONTRAST 212.54 XXX<br />
70498 TC CT ANGIOGRAPHY NECK W/CONTRAST/NONCONTRAST 1257.94 XXX<br />
70540 MRI ORBIT FACE &/NECK W/O CONTRAST 1216.75 XXX<br />
70540 26 MRI ORBIT FACE &/NECK W/O CONTRAST 163.11 XXX<br />
70540 TC MRI ORBIT FACE &/NECK W/O CONTRAST 1053.64 XXX<br />
70542 MRI ORBIT FACE&NCK C+ MATRL 1360.09 XXX<br />
70542 26 MRI ORBIT FACE&NCK C+ MATRL 196.06 XXX<br />
70542 TC MRI ORBIT FACE&NCK C+ MATRL 1164.03 XXX<br />
70543 MRI ORBIT FACE&NCK C-/C+ 1776.94 XXX<br />
70543 26 MRI ORBIT FACE&NCK C-/C+ 258.67 XXX<br />
70543 TC MRI ORBIT FACE&NCK C-/C+ 1518.27 XXX<br />
70544 MRA HEAD C-MATRL 1330.44 XXX<br />
70544 26 MRA HEAD C-MATRL 144.99 XXX<br />
70544 TC MRA HEAD C-MATRL 1185.45 XXX<br />
70545 MRA HEAD C+ MATRL 1322.20 XXX<br />
70545 26 MRA HEAD C+ MATRL 144.99 XXX<br />
70545 TC MRA HEAD C+ MATRL 1177.21 XXX<br />
70546 MRA HEAD C-/C+ 2082.57 XXX<br />
70546 26 MRA HEAD C-/C+ 218.31 XXX<br />
70546 TC MRA HEAD C-/C+ 1864.26 XXX<br />
70547 MRA NCK C-MATRL 1327.97 XXX<br />
70547 26 MRA NCK C-MATRL 144.99 XXX<br />
70547 TC MRA NCK C-MATRL 1182.98 XXX<br />
70548 MRA NCK C+ MATRL 1393.87 XXX<br />
70548 26 MRA NCK C+ MATRL 144.99 XXX<br />
70548 TC MRA NCK C+ MATRL 1248.88 XXX<br />
70549 MRA NCK C-/C+ 2083.39 XXX<br />
70549 26 MRA NCK C-/C+ 217.48 XXX<br />
70549 TC MRA NCK C-/C+ 1865.91 XXX<br />
70551 MRI BRN BRN STEM C-MATRL 1258.77 XXX<br />
70551 26 MRI BRN BRN STEM C-MATRL 178.76 XXX<br />
70551 TC MRI BRN BRN STEM C-MATRL 1080.01 XXX<br />
70552 MRI BRN BRN STEM C+ MATRL 1404.58 XXX<br />
70552 26 MRI BRN BRN STEM C+ MATRL 216.66 XXX<br />
70552 TC MRI BRN BRN STEM C+ MATRL 1187.92 XXX<br />
70553 MRI BRN BRN STEM C-/C+ 1764.58 XXX<br />
70553 26 MRI BRN BRN STEM C-/C+ 285.86 XXX<br />
70553 TC MRI BRN BRN STEM C-/C+ 1478.72 XXX<br />
70554 MRI BRAIN FUNCTIONAL W/O PHYSICIAN ADMNISTRATION 1388.10 XXX<br />
70554 26 MRI BRAIN FUNCTIONAL W/O PHYSICIAN ADMNISTRATION 257.03 XXX<br />
70554 TC MRI BRAIN FUNCTIONAL W/O PHYSICIAN ADMNISTRATION 1131.07 XXX<br />
70555 MRI BRAIN FUNCTIONAL W/PHYSICIAN ADMNISTRATION 1860.96 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure<br />
178 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VIII: Diagnostic and <strong>The</strong>rapeutic Radiological Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
70010–79999 RADIOLOGY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
70555 26 MRI BRAIN FUNCTIONAL W/PHYSICIAN ADMNISTRATION 316.34 XXX<br />
70555 TC MRI BRAIN FUNCTIONAL W/PHYSICIAN ADMNISTRATION 1544.62 XXX<br />
70557 MRI BRN OPN ICRA PX C-MATRL 4082.75 XXX<br />
70557 26 MRI BRN OPN ICRA PX C-MATRL 448.97 XXX<br />
70557 TC MRI BRN OPN ICRA PX C-MATRL 3633.78 XXX<br />
70558 MRI BRN OPN ICRA PX C+ MATRL 3617.31 XXX<br />
70558 26 MRI BRN OPN ICRA PX C+ MATRL 397.90 XXX<br />
70558 TC MRI BRN OPN ICRA PX C+ MATRL 3219.41 XXX<br />
70559 MRI BRN OPN ICRA PX C-/C+ 3654.38 XXX<br />
70559 26 MRI BRN OPN ICRA PX C-/C+ 402.01 XXX<br />
70559 TC MRI BRN OPN ICRA PX C-/C+ 3252.37 XXX<br />
71010 RADEX CH 1 VIEW FRNT 57.67 XXX<br />
71010 26 RADEX CH 1 VIEW FRNT 21.42 XXX<br />
71010 TC RADEX CH 1 VIEW FRNT 36.25 XXX<br />
71015 RADEX CH STEREO FRNT 73.32 XXX<br />
71015 26 RADEX CH STEREO FRNT 24.71 XXX<br />
71015 TC RADEX CH STEREO FRNT 48.61 XXX<br />
71020 RADEX CH 2 VIEWS FRNT&LAT 75.79 XXX<br />
71020 26 RADEX CH 2 VIEWS FRNT&LAT 26.36 XXX<br />
71020 TC RADEX CH 2 VIEWS FRNT&LAT 49.43 XXX<br />
71021 RADEX CH 2 VIEWS FRNT&LAT APICAL LORDOTIC PX 93.09 XXX<br />
71021 26 RADEX CH 2 VIEWS FRNT&LAT APICAL LORDOTIC PX 32.13 XXX<br />
71021 TC RADEX CH 2 VIEWS FRNT&LAT APICAL LORDOTIC PX 60.96 XXX<br />
71022 RADEX CH 2 VIEWS FRNT&LAT OBLQ PRJCJ 113.68 XXX<br />
71022 26 RADEX CH 2 VIEWS FRNT&LAT OBLQ PRJCJ 37.07 XXX<br />
71022 TC RADEX CH 2 VIEWS FRNT&LAT OBLQ PRJCJ 76.61 XXX<br />
71023 RADEX CH 2 VIEWS FRNT&LAT FLUOR 168.88 XXX<br />
71023 26 RADEX CH 2 VIEWS FRNT&LAT FLUOR 46.13 XXX<br />
71023 TC RADEX CH 2 VIEWS FRNT&LAT FLUOR 122.75 XXX<br />
71030 RADEX CH COMPL MINIMUM 4 VIEWS 112.86 XXX<br />
71030 26 RADEX CH COMPL MINIMUM 4 VIEWS 37.07 XXX<br />
71030 TC RADEX CH COMPL MINIMUM 4 VIEWS 75.79 XXX<br />
71034 RADEX CH COMPL MINIMUM 4 VIEWS W/FLUOR 216.66 XXX<br />
71034 26 RADEX CH COMPL MINIMUM 4 VIEWS W/FLUOR 56.84 XXX<br />
71034 TC RADEX CH COMPL MINIMUM 4 VIEWS W/FLUOR 159.82 XXX<br />
71035 RADEX CH SPEC VIEWS 86.50 XXX<br />
71035 26 RADEX CH SPEC VIEWS 22.24 XXX<br />
71035 TC RADEX CH SPEC VIEWS 64.26 XXX<br />
71040 BRONCHOGRAPY UNI RS&I 235.61 XXX<br />
71040 26 BRONCHOGRAPY UNI RS&I 67.55 XXX<br />
71040 TC BRONCHOGRAPY UNI RS&I 168.06 XXX<br />
71060 BRONCHOGRAPY BI RS&I 344.35 XXX<br />
71060 26 BRONCHOGRAPY BI RS&I 88.97 XXX<br />
71060 TC BRONCHOGRAPY BI RS&I 255.38 XXX<br />
71090 INSJ PM FLUOR&RADIOGRAPY RS&I 230.66 XXX<br />
71090 26 INSJ PM FLUOR&RADIOGRAPY RS&I 69.20 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 179
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VIII: Diagnostic and <strong>The</strong>rapeutic Radiological Services<br />
RADIOLOGY 70010–79999<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
71090 TC INSJ PM FLUOR&RADIOGRAPY RS&I 161.46 XXX<br />
71100 RADEX RIBS UNI 2 VIEWS 79.08 XXX<br />
71100 26 RADEX RIBS UNI 2 VIEWS 26.36 XXX<br />
71100 TC RADEX RIBS UNI 2 VIEWS 52.72 XXX<br />
71101 RADEX RIBS UNI W/POSTEROANT CH MINIMUM 3 VIEWS 96.38 XXX<br />
71101 26 RADEX RIBS UNI W/POSTEROANT CH MINIMUM 3 VIEWS 32.13 XXX<br />
71101 TC RADEX RIBS UNI W/POSTEROANT CH MINIMUM 3 VIEWS 64.25 XXX<br />
71110 RADEX RIBS BI 3 VIEWS 99.68 XXX<br />
71110 26 RADEX RIBS BI 3 VIEWS 32.13 XXX<br />
71110 TC RADEX RIBS BI 3 VIEWS 67.55 XXX<br />
71111 RADEX RIBS BI W/POSTEROANT CH MINIMUM 4 VIEWS 128.51 XXX<br />
71111 26 RADEX RIBS BI W/POSTEROANT CH MINIMUM 4 VIEWS 37.89 XXX<br />
71111 TC RADEX RIBS BI W/POSTEROANT CH MINIMUM 4 VIEWS 90.62 XXX<br />
71120 RADEX STERNUM MINIMUM 2 VIEWS 78.26 XXX<br />
71120 26 RADEX STERNUM MINIMUM 2 VIEWS 23.89 XXX<br />
71120 TC RADEX STERNUM MINIMUM 2 VIEWS 54.37 XXX<br />
71130 RADEX STRNCLAV JT/JTS MINIMUM 3 VIEWS 91.44 XXX<br />
71130 26 RADEX STRNCLAV JT/JTS MINIMUM 3 VIEWS 26.36 XXX<br />
71130 TC RADEX STRNCLAV JT/JTS MINIMUM 3 VIEWS 65.08 XXX<br />
71250 CT THORAX C-MATRL 610.44 XXX<br />
71250 26 CT THORAX C-MATRL 123.57 XXX<br />
71250 TC CT THORAX C-MATRL 486.87 XXX<br />
71260 CT THORAX C+ MATRL 757.07 XXX<br />
71260 26 CT THORAX C+ MATRL 150.76 XXX<br />
71260 TC CT THORAX C+ MATRL 606.31 XXX<br />
71270 CT THORAX C-/C+ 929.25 XXX<br />
71270 26 CT THORAX C-/C+ 166.41 XXX<br />
71270 TC CT THORAX C-/C+ 762.84 XXX<br />
71275 CT ANGIOGRAPHY CHEST W/CONTRAST/NONCONTRAST 1156.62 XXX<br />
71275 26 CT ANGIOGRAPHY CHEST W/CONTRAST/NONCONTRAST 233.14 XXX<br />
71275 TC CT ANGIOGRAPHY CHEST W/CONTRAST/NONCONTRAST 923.48 XXX<br />
71550 MRI CH C-MATRL 1374.92 XXX<br />
71550 26 MRI CH C-MATRL 175.47 XXX<br />
71550 TC MRI CH C-MATRL 1199.45 XXX<br />
71551 MRI CH C+ MATRL 1549.57 XXX<br />
71551 26 MRI CH C+ MATRL 208.42 XXX<br />
71551 TC MRI CH C+ MATRL 1341.15 XXX<br />
71552 MRI CH C-/C+ 2041.38 XXX<br />
71552 26 MRI CH C-/C+ 273.50 XXX<br />
71552 TC MRI CH C-/C+ 1767.88 XXX<br />
71555 MRA CH C+-MATRL 1350.21 XXX<br />
71555 26 MRA CH C+-MATRL 219.95 XXX<br />
71555 TC MRA CH C+-MATRL 1130.26 XXX<br />
72010 RADEX SPI ENTIRE SURV STD ANTEROPOST&LAT 181.24 XXX<br />
72010 26 RADEX SPI ENTIRE SURV STD ANTEROPOST&LAT 55.19 XXX<br />
72010 TC RADEX SPI ENTIRE SURV STD ANTEROPOST&LAT 126.05 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure<br />
180 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VIII: Diagnostic and <strong>The</strong>rapeutic Radiological Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
70010–79999 RADIOLOGY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
72020 RADEX SPI 1 VIEW SPEC LVL 58.49 XXX<br />
72020 26 RADEX SPI 1 VIEW SPEC LVL 18.95 XXX<br />
72020 TC RADEX SPI 1 VIEW SPEC LVL 39.54 XXX<br />
72040 RADEX SPI CRV 2/3 VIEWS 95.56 XXX<br />
72040 26 RADEX SPI CRV 2/3 VIEWS 28.83 XXX<br />
72040 TC RADEX SPI CRV 2/3 VIEWS 66.73 XXX<br />
72050 RADEX SPI CRV MINIMUM 4 VIEWS 129.34 XXX<br />
72050 26 RADEX SPI CRV MINIMUM 4 VIEWS 38.72 XXX<br />
72050 TC RADEX SPI CRV MINIMUM 4 VIEWS 90.62 XXX<br />
72052 RADEX SPI CRV COMPL W/OBLQ&FLEXION&/XTN STDS 163.94 XXX<br />
72052 26 RADEX SPI CRV COMPL W/OBLQ&FLEXION&/XTN STDS 44.49 XXX<br />
72052 TC RADEX SPI CRV COMPL W/OBLQ&FLEXION&/XTN STDS 119.45 XXX<br />
72069 RADEX SPI THORACOLMBR STANDING SCOLIOSIS 91.44 XXX<br />
72069 26 RADEX SPI THORACOLMBR STANDING SCOLIOSIS 28.83 XXX<br />
72069 TC RADEX SPI THORACOLMBR STANDING SCOLIOSIS 62.61 XXX<br />
72070 RADEX SPI THRC 2 VIEWS 83.20 XXX<br />
72070 26 RADEX SPI THRC 2 VIEWS 27.19 XXX<br />
72070 TC RADEX SPI THRC 2 VIEWS 56.01 XXX<br />
72072 RADEX SPI THRC 3 VIEWS 92.27 XXX<br />
72072 26 RADEX SPI THRC 3 VIEWS 26.36 XXX<br />
72072 TC RADEX SPI THRC 3 VIEWS 65.91 XXX<br />
72074 RADEX SPI THRC MINIMUM 4 VIEWS 108.74 XXX<br />
72074 26 RADEX SPI THRC MINIMUM 4 VIEWS 26.36 XXX<br />
72074 TC RADEX SPI THRC MINIMUM 4 VIEWS 82.38 XXX<br />
72080 RADEX SPI THORACOLMBR 2 VIEWS 89.79 XXX<br />
72080 26 RADEX SPI THORACOLMBR 2 VIEWS 28.83 XXX<br />
72080 TC RADEX SPI THORACOLMBR 2 VIEWS 60.96 XXX<br />
72090 RADEX SPI SCOLIOSIS STD W/SUP&ERC STDS 121.10 XXX<br />
72090 26 RADEX SPI SCOLIOSIS STD W/SUP&ERC STDS 37.07 XXX<br />
72090 TC RADEX SPI SCOLIOSIS STD W/SUP&ERC STDS 84.03 XXX<br />
72100 RADEX SPI LUMBOSAC 2/3 VIEWS 99.68 XXX<br />
72100 26 RADEX SPI LUMBOSAC 2/3 VIEWS 28.83 XXX<br />
72100 TC RADEX SPI LUMBOSAC 2/3 VIEWS 70.85 XXX<br />
72110 RADEX SPI LUMBOSAC MINIMUM 4 VIEWS 135.93 XXX<br />
72110 26 RADEX SPI LUMBOSAC MINIMUM 4 VIEWS 38.72 XXX<br />
72110 TC RADEX SPI LUMBOSAC MINIMUM 4 VIEWS 97.21 XXX<br />
72114 RADEX SPI LUMBOSAC COMPL W/BENDING VIEWS 182.06 XXX<br />
72114 26 RADEX SPI LUMBOSAC COMPL W/BENDING VIEWS 46.13 XXX<br />
72114 TC RADEX SPI LUMBOSAC COMPL W/BENDING VIEWS 135.93 XXX<br />
72120 RADEX SPI LUMBOSAC BENDING MINIMUM 4 VIEWS 126.04 XXX<br />
72120 26 RADEX SPI LUMBOSAC BENDING MINIMUM 4 VIEWS 28.83 XXX<br />
72120 TC RADEX SPI LUMBOSAC BENDING MINIMUM 4 VIEWS 97.21 XXX<br />
72125 CT CRV SPI C-MATRL 613.73 XXX<br />
72125 26 CT CRV SPI C-MATRL 123.57 XXX<br />
72125 TC CT CRV SPI C-MATRL 490.16 XXX<br />
72126 CT CRV SPI C+ MATRL 755.42 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 181
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VIII: Diagnostic and <strong>The</strong>rapeutic Radiological Services<br />
RADIOLOGY 70010–79999<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
72126 26 CT CRV SPI C+ MATRL 147.46 XXX<br />
72126 TC CT CRV SPI C+ MATRL 607.96 XXX<br />
72127 CT CRV SPI C-/C+ 915.24 XXX<br />
72127 26 CT CRV SPI C-/C+ 153.23 XXX<br />
72127 TC CT CRV SPI C-/C+ 762.01 XXX<br />
72128 CT THRC SPI C-MATRL 612.91 XXX<br />
72128 26 CT THRC SPI C-MATRL 123.57 XXX<br />
72128 TC CT THRC SPI C-MATRL 489.34 XXX<br />
72129 CT THRC SPI C+ MATRL 757.07 XXX<br />
72129 26 CT THRC SPI C+ MATRL 148.28 XXX<br />
72129 TC CT THRC SPI C+ MATRL 608.79 XXX<br />
72130 CT THRC SPI C-/C+ 916.07 XXX<br />
72130 26 CT THRC SPI C-/C+ 153.23 XXX<br />
72130 TC CT THRC SPI C-/C+ 762.84 XXX<br />
72131 CT LMBR SPI C-MATRL 611.26 XXX<br />
72131 26 CT LMBR SPI C-MATRL 123.57 XXX<br />
72131 TC CT LMBR SPI C-MATRL 487.69 XXX<br />
72132 CT LMBR SPI C+ MATRL 755.42 XXX<br />
72132 26 CT LMBR SPI C+ MATRL 148.28 XXX<br />
72132 TC CT LMBR SPI C+ MATRL 607.14 XXX<br />
72133 CT LMBR SPI C-/C+ 915.24 XXX<br />
72133 26 CT LMBR SPI C-/C+ 153.23 XXX<br />
72133 TC CT LMBR SPI C-/C+ 762.01 XXX<br />
72141 MRI SPI CANAL&CNTS CRV C-MATRL 1136.02 XXX<br />
72141 26 MRI SPI CANAL&CNTS CRV C-MATRL 194.42 XXX<br />
72141 TC MRI SPI CANAL&CNTS CRV C-MATRL 941.60 XXX<br />
72142 MRI SPI CANAL&CNTS CRV C+ MATRL 1421.06 XXX<br />
72142 26 MRI SPI CANAL&CNTS CRV C+ MATRL 232.31 XXX<br />
72142 TC MRI SPI CANAL&CNTS CRV C+ MATRL 1188.75 XXX<br />
72146 MRI SPI CANAL&CNTS THRC C-MATRL 1152.50 XXX<br />
72146 26 MRI SPI CANAL&CNTS THRC C-MATRL 194.42 XXX<br />
72146 TC MRI SPI CANAL&CNTS THRC C-MATRL 958.08 XXX<br />
72147 MRI SPI CANAL&CNTS THRC C+ MATRL 1281.83 XXX<br />
72147 26 MRI SPI CANAL&CNTS THRC C+ MATRL 233.14 XXX<br />
72147 TC MRI SPI CANAL&CNTS THRC C+ MATRL 1048.69 XXX<br />
72148 MRI SPI CANAL&CNTS LMBR C-MATRL 1136.84 XXX<br />
72148 26 MRI SPI CANAL&CNTS LMBR C-MATRL 180.41 XXX<br />
72148 TC MRI SPI CANAL&CNTS LMBR C-MATRL 956.43 XXX<br />
72149 MRI SPI CANAL&CNTS LMBR C+ MATRL 1397.99 XXX<br />
72149 26 MRI SPI CANAL&CNTS LMBR C+ MATRL 216.66 XXX<br />
72149 TC MRI SPI CANAL&CNTS LMBR C+ MATRL 1181.33 XXX<br />
72156 MRI SPI CANAL&CNTS C-/C+ CRV 1765.40 XXX<br />
72156 26 MRI SPI CANAL&CNTS C-/C+ CRV 312.22 XXX<br />
72156 TC MRI SPI CANAL&CNTS C-/C+ CRV 1453.18 XXX<br />
72157 MRI SPI CANAL&CNTS C-/C+ 1660.78 XXX<br />
72157 26 MRI SPI CANAL&CNTS C-/C+ 312.22 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure<br />
182 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VIII: Diagnostic and <strong>The</strong>rapeutic Radiological Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
70010–79999 RADIOLOGY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
72157 TC MRI SPI CANAL&CNTS C-/C+ 1348.56 XXX<br />
72158 MRI SPI CANAL&CNTS C-/C+ LMBR 1737.39 XXX<br />
72158 26 MRI SPI CANAL&CNTS C-/C+ LMBR 287.51 XXX<br />
72158 TC MRI SPI CANAL&CNTS C-/C+ LMBR 1449.88 XXX<br />
72159 MRA SPI CANAL&CNTS C+-MATRL 1491.90 XXX<br />
72159 26 MRA SPI CANAL&CNTS C+-MATRL 218.31 XXX<br />
72159 TC MRA SPI CANAL&CNTS C+-MATRL 1273.59 XXX<br />
72170 RADEX PELVIS 1/2 VIEWS 66.73 XXX<br />
72170 26 RADEX PELVIS 1/2 VIEWS 23.07 XXX<br />
72170 TC RADEX PELVIS 1/2 VIEWS 43.66 XXX<br />
72190 RADEX PELVIS COMPL MINIMUM 3 VIEWS 102.98 XXX<br />
72190 26 RADEX PELVIS COMPL MINIMUM 3 VIEWS 28.01 XXX<br />
72190 TC RADEX PELVIS COMPL MINIMUM 3 VIEWS 74.97 XXX<br />
72191 CT ANGIOGRAPHY PELVIS W/CONTRAST/NONCONTRAST 1108.83 XXX<br />
72191 26 CT ANGIOGRAPHY PELVIS W/CONTRAST/NONCONTRAST 220.78 XXX<br />
72191 TC CT ANGIOGRAPHY PELVIS W/CONTRAST/NONCONTRAST 888.05 XXX<br />
72192 CT PELVIS C-MATRL 591.49 XXX<br />
72192 26 CT PELVIS C-MATRL 130.98 XXX<br />
72192 TC CT PELVIS C-MATRL 460.51 XXX<br />
72193 CT PELVIS C+ MATRL 716.71 XXX<br />
72193 26 CT PELVIS C+ MATRL 140.87 XXX<br />
72193 TC CT PELVIS C+ MATRL 575.84 XXX<br />
72194 CT PELVIS C-/C+ 917.71 XXX<br />
72194 26 CT PELVIS C-/C+ 147.46 XXX<br />
72194 TC CT PELVIS C-/C+ 770.25 XXX<br />
72195 MRI PELVIS C-MATRL 1252.18 XXX<br />
72195 26 MRI PELVIS C-MATRL 177.94 XXX<br />
72195 TC MRI PELVIS C-MATRL 1074.24 XXX<br />
72196 MRI PELVIS C+ MATRL 1386.46 XXX<br />
72196 26 MRI PELVIS C+ MATRL 210.07 XXX<br />
72196 TC MRI PELVIS C+ MATRL 1176.39 XXX<br />
72197 MRI PELVIS C-/C+ 1806.59 XXX<br />
72197 26 MRI PELVIS C-/C+ 272.68 XXX<br />
72197 TC MRI PELVIS C-/C+ 1533.91 XXX<br />
72198 MRA PELVIS C+-MATRL 1344.44 XXX<br />
72198 26 MRA PELVIS C+-MATRL 217.48 XXX<br />
72198 TC MRA PELVIS C+-MATRL 1126.96 XXX<br />
72200 RADEX SI JTS < 3 VIEWS 72.49 XXX<br />
72200 26 RADEX SI JTS < 3 VIEWS 20.60 XXX<br />
72200 TC RADEX SI JTS < 3 VIEWS 51.89 XXX<br />
72202 RADEX SI JTS 3/MORE VIEWS 84.85 XXX<br />
72202 26 RADEX SI JTS 3/MORE VIEWS 23.07 XXX<br />
72202 TC RADEX SI JTS 3/MORE VIEWS 61.78 XXX<br />
72220 RADEX SACRUM&COCCYX MINIMUM 2 VIEWS 71.67 XXX<br />
72220 26 RADEX SACRUM&COCCYX MINIMUM 2 VIEWS 20.60 XXX<br />
72220 TC RADEX SACRUM&COCCYX MINIMUM 2 VIEWS 51.07 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 183
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VIII: Diagnostic and <strong>The</strong>rapeutic Radiological Services<br />
RADIOLOGY 70010–79999<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
72240 MYELOGRAPY CRV RS&I 352.59 XXX<br />
72240 26 MYELOGRAPY CRV RS&I 110.39 XXX<br />
72240 TC MYELOGRAPY CRV RS&I 242.20 XXX<br />
72255 MYELOGRAPY THRC RS&I 331.17 XXX<br />
72255 26 MYELOGRAPY THRC RS&I 108.74 XXX<br />
72255 TC MYELOGRAPY THRC RS&I 222.43 XXX<br />
72265 MYELOGRAPY LUMBOSAC RS&I 336.11 XXX<br />
72265 26 MYELOGRAPY LUMBOSAC RS&I 100.50 XXX<br />
72265 TC MYELOGRAPY LUMBOSAC RS&I 235.61 XXX<br />
72270 MYELOGRAPY 2/MORE REGIONS RS&I 523.11 XXX<br />
72270 26 MYELOGRAPY 2/MORE REGIONS RS&I 160.64 XXX<br />
72270 TC MYELOGRAPY 2/MORE REGIONS RS&I 362.47 XXX<br />
72275 EPIDUROGRAPY RS&I 271.85 XXX<br />
72275 26 EPIDUROGRAPY RS&I 92.27 XXX<br />
72275 TC EPIDUROGRAPY RS&I 179.58 XXX<br />
72285 DISKOGRAPY CRV/THRC RS&I 359.18 XXX<br />
72285 26 DISKOGRAPY CRV/THRC RS&I 141.69 XXX<br />
72285 TC DISKOGRAPY CRV/THRC RS&I 217.49 XXX<br />
72291 RAD S&I PERQ VRTPLS/SACRPLSTY PR VRT BODY FLUOR 766.13 XXX<br />
72291 26 RAD S&I PERQ VRTPLS/SACRPLSTY PR VRT BODY FLUOR 176.29 XXX<br />
72291 TC RAD S&I PERQ VRTPLS/SACRPLSTY PR VRT BODY FLUOR 589.84 XXX<br />
72292 RAD S&I PERQ VRTPLS/SACRPLSTY PER VRT BODY CT 788.38 XXX<br />
72292 26 RAD S&I PERQ VRTPLS/SACRPLSTY PER VRT BODY CT 181.24 XXX<br />
72292 TC RAD S&I PERQ VRTPLS/SACRPLSTY PER VRT BODY CT 607.14 XXX<br />
72295 DISKOGRAPY LMBR RS&I 316.34 XXX<br />
72295 26 DISKOGRAPY LMBR RS&I 102.15 XXX<br />
72295 TC DISKOGRAPY LMBR RS&I 214.19 XXX<br />
73000 RADEX CLAV COMPL 70.02 XXX<br />
73000 26 RADEX CLAV COMPL 19.77 XXX<br />
73000 TC RADEX CLAV COMPL 50.25 XXX<br />
73010 RADEX SCAPULA COMPL 74.97 XXX<br />
73010 26 RADEX SCAPULA COMPL 23.07 XXX<br />
73010 TC RADEX SCAPULA COMPL 51.90 XXX<br />
73020 RADEX SHO 1 VIEW 57.67 XXX<br />
73020 26 RADEX SHO 1 VIEW 18.12 XXX<br />
73020 TC RADEX SHO 1 VIEW 39.55 XXX<br />
73030 RADEX SHO COMPL MINIMUM 2 VIEWS 75.79 XXX<br />
73030 26 RADEX SHO COMPL MINIMUM 2 VIEWS 24.71 XXX<br />
73030 TC RADEX SHO COMPL MINIMUM 2 VIEWS 51.08 XXX<br />
73040 RADEX SHO ARTHG RS&I 262.79 XXX<br />
73040 26 RADEX SHO ARTHG RS&I 66.73 XXX<br />
73040 TC RADEX SHO ARTHG RS&I 196.06 XXX<br />
73050 RADEX ACROMCLAV JTS BI +-W8ED DISTRCJ 93.91 XXX<br />
73050 26 RADEX ACROMCLAV JTS BI +-W8ED DISTRCJ 27.19 XXX<br />
73050 TC RADEX ACROMCLAV JTS BI +-W8ED DISTRCJ 66.72 XXX<br />
73060 RADEX HUM MINIMUM 2 VIEWS 71.67 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure<br />
184 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VIII: Diagnostic and <strong>The</strong>rapeutic Radiological Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
70010–79999 RADIOLOGY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
73060 26 RADEX HUM MINIMUM 2 VIEWS 21.42 XXX<br />
73060 TC RADEX HUM MINIMUM 2 VIEWS 50.25 XXX<br />
73070 RADEX ELBW 2 VIEWS 69.20 XXX<br />
73070 26 RADEX ELBW 2 VIEWS 18.95 XXX<br />
73070 TC RADEX ELBW 2 VIEWS 50.25 XXX<br />
73080 RADEX ELBW COMPL MINIMUM 3 VIEWS 83.20 XXX<br />
73080 26 RADEX ELBW COMPL MINIMUM 3 VIEWS 20.60 XXX<br />
73080 TC RADEX ELBW COMPL MINIMUM 3 VIEWS 62.60 XXX<br />
73085 RADEX ELBW ARTHG RS&I 238.08 XXX<br />
73085 26 RADEX ELBW ARTHG RS&I 66.73 XXX<br />
73085 TC RADEX ELBW ARTHG RS&I 171.35 XXX<br />
73090 RADEX F/ARM 2 VIEWS 68.38 XXX<br />
73090 26 RADEX F/ARM 2 VIEWS 19.77 XXX<br />
73090 TC RADEX F/ARM 2 VIEWS 48.61 XXX<br />
73092 RADEX UXTR INFT MINIMUM 2 VIEWS 74.97 XXX<br />
73092 26 RADEX UXTR INFT MINIMUM 2 VIEWS 19.77 XXX<br />
73092 TC RADEX UXTR INFT MINIMUM 2 VIEWS 55.20 XXX<br />
73100 RADEX WRST 2 VIEWS 75.79 XXX<br />
73100 26 RADEX WRST 2 VIEWS 22.24 XXX<br />
73100 TC RADEX WRST 2 VIEWS 53.55 XXX<br />
73110 RADEX WRST COMPL MINIMUM 3 VIEWS 88.97 XXX<br />
73110 26 RADEX WRST COMPL MINIMUM 3 VIEWS 21.42 XXX<br />
73110 TC RADEX WRST COMPL MINIMUM 3 VIEWS 67.55 XXX<br />
73115 RADEX WRST ARTHG RS&I 266.09 XXX<br />
73115 26 RADEX WRST ARTHG RS&I 68.38 XXX<br />
73115 TC RADEX WRST ARTHG RS&I 197.71 XXX<br />
73120 RADEX HAND 2 VIEWS 67.55 XXX<br />
73120 26 RADEX HAND 2 VIEWS 19.77 XXX<br />
73120 TC RADEX HAND 2 VIEWS 47.78 XXX<br />
73130 RADEX HAND MINIMUM 3 VIEWS 78.26 XXX<br />
73130 26 RADEX HAND MINIMUM 3 VIEWS 20.60 XXX<br />
73130 TC RADEX HAND MINIMUM 3 VIEWS 57.66 XXX<br />
73140 RADEX FNGR MINIMUM 2 VIEWS 76.61 XXX<br />
73140 26 RADEX FNGR MINIMUM 2 VIEWS 16.48 XXX<br />
73140 TC RADEX FNGR MINIMUM 2 VIEWS 60.13 XXX<br />
73200 CT UXTR C-MATRL 597.26 XXX<br />
73200 26 CT UXTR C-MATRL 123.57 XXX<br />
73200 TC CT UXTR C-MATRL 473.69 XXX<br />
73201 CT UXTR C+ MATRL 729.06 XXX<br />
73201 26 CT UXTR C+ MATRL 140.87 XXX<br />
73201 TC CT UXTR C+ MATRL 588.19 XXX<br />
73202 CT UXTR C-/C+ 932.54 XXX<br />
73202 26 CT UXTR C-/C+ 147.46 XXX<br />
73202 TC CT UXTR C-/C+ 785.08 XXX<br />
73206 CT ANGIOGRAPHY UPPER EXTREMITY 1056.94 XXX<br />
73206 26 CT ANGIOGRAPHY UPPER EXTREMITY 218.31 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 185
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VIII: Diagnostic and <strong>The</strong>rapeutic Radiological Services<br />
RADIOLOGY 70010–79999<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
73206 TC CT ANGIOGRAPHY UPPER EXTREMITY 838.63 XXX<br />
73218 MRI UXTR OTH/THN JT C-MATRL 1259.59 XXX<br />
73218 26 MRI UXTR OTH/THN JT C-MATRL 163.11 XXX<br />
73218 TC MRI UXTR OTH/THN JT C-MATRL 1096.48 XXX<br />
73219 MRI UXTR OTH/THN JT C+ MATRL 1363.39 XXX<br />
73219 26 MRI UXTR OTH/THN JT C+ MATRL 196.89 XXX<br />
73219 TC MRI UXTR OTH/THN JT C+ MATRL 1166.50 XXX<br />
73220 MRI UXTR OTH/THN JT C-/C+ 1800.83 XXX<br />
73220 26 MRI UXTR OTH/THN JT C-/C+ 260.32 XXX<br />
73220 TC MRI UXTR OTH/THN JT C-/C+ 1540.51 XXX<br />
73221 MRI ANY JT UXTR C-MATRL 1187.10 XXX<br />
73221 26 MRI ANY JT UXTR C-MATRL 166.41 XXX<br />
73221 TC MRI ANY JT UXTR C-MATRL 1020.69 XXX<br />
73222 MRI ANY JT UXTR C+ MATRL 1293.37 XXX<br />
73222 26 MRI ANY JT UXTR C+ MATRL 196.89 XXX<br />
73222 TC MRI ANY JT UXTR C+ MATRL 1096.48 XXX<br />
73223 MRI ANY JT UXTR C-/C+ 1709.39 XXX<br />
73223 26 MRI ANY JT UXTR C-/C+ 259.50 XXX<br />
73223 TC MRI ANY JT UXTR C-/C+ 1449.89 XXX<br />
73225 MRA UXTR C+-MATRL 1468.01 XXX<br />
73225 26 MRA UXTR C+-MATRL 210.07 XXX<br />
73225 TC MRA UXTR C+-MATRL 1257.94 XXX<br />
73500 RADEX HIP UNI 1 VIEW 65.90 XXX<br />
73500 26 RADEX HIP UNI 1 VIEW 23.07 XXX<br />
73500 TC RADEX HIP UNI 1 VIEW 42.83 XXX<br />
73510 RADEX HIP UNI COMPL MINIMUM 2 VIEWS 94.74 XXX<br />
73510 26 RADEX HIP UNI COMPL MINIMUM 2 VIEWS 28.01 XXX<br />
73510 TC RADEX HIP UNI COMPL MINIMUM 2 VIEWS 66.73 XXX<br />
73520 RADEX HIPS BI 2 VIEWS ANTEROPOST PELVIS 99.68 XXX<br />
73520 26 RADEX HIPS BI 2 VIEWS ANTEROPOST PELVIS 32.95 XXX<br />
73520 TC RADEX HIPS BI 2 VIEWS ANTEROPOST PELVIS 66.73 XXX<br />
73525 RADEX HIP ARTHG RS&I 244.67 XXX<br />
73525 26 RADEX HIP ARTHG RS&I 68.38 XXX<br />
73525 TC RADEX HIP ARTHG RS&I 176.29 XXX<br />
73530 RADEX HIP OPRATIVE PX 84.03 XXX<br />
73530 26 RADEX HIP OPRATIVE PX 36.25 XXX<br />
73530 TC RADEX HIP OPRATIVE PX 47.78 XXX<br />
73540 RADEX PELVIS&HIPS INFT/CHLD MINIMUM 2 VIEWS 99.68 XXX<br />
73540 26 RADEX PELVIS&HIPS INFT/CHLD MINIMUM 2 VIEWS 26.36 XXX<br />
73540 TC RADEX PELVIS&HIPS INFT/CHLD MINIMUM 2 VIEWS 73.32 XXX<br />
73542 RAD XM SI JT ARTHG RS&I 201.01 XXX<br />
73542 26 RAD XM SI JT ARTHG RS&I 71.67 XXX<br />
73542 TC RAD XM SI JT ARTHG RS&I 129.34 XXX<br />
73550 RADEX FEMUR 2 VIEWS 70.02 XXX<br />
73550 26 RADEX FEMUR 2 VIEWS 22.24 XXX<br />
73550 TC RADEX FEMUR 2 VIEWS 47.78 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure<br />
186 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VIII: Diagnostic and <strong>The</strong>rapeutic Radiological Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
70010–79999 RADIOLOGY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
73560 RADEX KNE 1/2 VIEWS 74.97 XXX<br />
73560 26 RADEX KNE 1/2 VIEWS 23.07 XXX<br />
73560 TC RADEX KNE 1/2 VIEWS 51.90 XXX<br />
73562 RADEX KNE 3 VIEWS 89.79 XXX<br />
73562 26 RADEX KNE 3 VIEWS 24.71 XXX<br />
73562 TC RADEX KNE 3 VIEWS 65.08 XXX<br />
73564 RADEX KNE COMPL 4/MORE VIEWS 102.98 XXX<br />
73564 26 RADEX KNE COMPL 4/MORE VIEWS 28.83 XXX<br />
73564 TC RADEX KNE COMPL 4/MORE VIEWS 74.15 XXX<br />
73565 RADEX KNE BTH KNES STANDING ANTEROPOST 83.20 XXX<br />
73565 26 RADEX KNE BTH KNES STANDING ANTEROPOST 23.89 XXX<br />
73565 TC RADEX KNE BTH KNES STANDING ANTEROPOST 59.31 XXX<br />
73580 RADEX KNE ARTHG RS&I 321.28 XXX<br />
73580 26 RADEX KNE ARTHG RS&I 70.85 XXX<br />
73580 TC RADEX KNE ARTHG RS&I 250.43 XXX<br />
73590 RADEX TIBFIB 2 VIEWS 67.55 XXX<br />
73590 26 RADEX TIBFIB 2 VIEWS 20.60 XXX<br />
73590 TC RADEX TIBFIB 2 VIEWS 46.95 XXX<br />
73592 RADEX LXTR INFT MINIMUM 2 VIEWS 75.79 XXX<br />
73592 26 RADEX LXTR INFT MINIMUM 2 VIEWS 19.77 XXX<br />
73592 TC RADEX LXTR INFT MINIMUM 2 VIEWS 56.02 XXX<br />
73600 RADEX ANKLE 2 VIEWS 69.20 XXX<br />
73600 26 RADEX ANKLE 2 VIEWS 19.77 XXX<br />
73600 TC RADEX ANKLE 2 VIEWS 49.43 XXX<br />
73610 RADEX ANKLE COMPL MINIMUM 3 VIEWS 79.08 XXX<br />
73610 26 RADEX ANKLE COMPL MINIMUM 3 VIEWS 20.60 XXX<br />
73610 TC RADEX ANKLE COMPL MINIMUM 3 VIEWS 58.48 XXX<br />
73615 RADEX ANKLE ARTHG RS&I 253.73 XXX<br />
73615 26 RADEX ANKLE ARTHG RS&I 68.38 XXX<br />
73615 TC RADEX ANKLE ARTHG RS&I 185.35 XXX<br />
73620 RADEX FOOT 2 VIEWS 66.73 XXX<br />
73620 26 RADEX FOOT 2 VIEWS 18.95 XXX<br />
73620 TC RADEX FOOT 2 VIEWS 47.78 XXX<br />
73630 RADEX FOOT COMPL MINIMUM 3 VIEWS 77.44 XXX<br />
73630 26 RADEX FOOT COMPL MINIMUM 3 VIEWS 20.60 XXX<br />
73630 TC RADEX FOOT COMPL MINIMUM 3 VIEWS 56.84 XXX<br />
73650 RADEX CALCANEUS MINIMUM 2 VIEWS 68.38 XXX<br />
73650 26 RADEX CALCANEUS MINIMUM 2 VIEWS 19.77 XXX<br />
73650 TC RADEX CALCANEUS MINIMUM 2 VIEWS 48.61 XXX<br />
73660 RADEX TOE MINIMUM 2 VIEWS 71.67 XXX<br />
73660 26 RADEX TOE MINIMUM 2 VIEWS 15.65 XXX<br />
73660 TC RADEX TOE MINIMUM 2 VIEWS 56.02 XXX<br />
73700 CT LXTR C-MATRL 598.08 XXX<br />
73700 26 CT LXTR C-MATRL 123.57 XXX<br />
73700 TC CT LXTR C-MATRL 474.51 XXX<br />
73701 CT LXTR C+ MATRL 735.65 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 187
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VIII: Diagnostic and <strong>The</strong>rapeutic Radiological Services<br />
RADIOLOGY 70010–79999<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
73701 26 CT LXTR C+ MATRL 140.87 XXX<br />
73701 TC CT LXTR C+ MATRL 594.78 XXX<br />
73702 CT LXTR C-/C+ 937.48 XXX<br />
73702 26 CT LXTR C-/C+ 148.28 XXX<br />
73702 TC CT LXTR C-/C+ 789.20 XXX<br />
73706 CT ANGIOGRAPHY LOWER EXTREMITY 1163.21 XXX<br />
73706 26 CT ANGIOGRAPHY LOWER EXTREMITY 231.49 XXX<br />
73706 TC CT ANGIOGRAPHY LOWER EXTREMITY 931.72 XXX<br />
73718 MRI LXTR OTH/THN JT C-MATRL 1234.05 XXX<br />
73718 26 MRI LXTR OTH/THN JT C-MATRL 163.11 XXX<br />
73718 TC MRI LXTR OTH/THN JT C-MATRL 1070.94 XXX<br />
73719 MRI IMG LXTR OTH/THN JT C+ MATRL 1359.27 XXX<br />
73719 26 MRI IMG LXTR OTH/THN JT C+ MATRL 196.06 XXX<br />
73719 TC MRI IMG LXTR OTH/THN JT C+ MATRL 1163.21 XXX<br />
73720 MRI LXTR OTH/THN JT C-/C+ 1802.47 XXX<br />
73720 26 MRI LXTR OTH/THN JT C-/C+ 259.50 XXX<br />
73720 TC MRI LXTR OTH/THN JT C-/C+ 1542.97 XXX<br />
73721 MRI ANY JT LXTR C-MATRL 1209.34 XXX<br />
73721 26 MRI ANY JT LXTR C-MATRL 165.58 XXX<br />
73721 TC MRI ANY JT LXTR C-MATRL 1043.76 XXX<br />
73722 MRI ANY JT LXTR C+ MATRL 1314.78 XXX<br />
73722 26 MRI ANY JT LXTR C+ MATRL 198.54 XXX<br />
73722 TC MRI ANY JT LXTR C+ MATRL 1116.24 XXX<br />
73723 MRI ANY JT LXTR C-/C+ 1706.09 XXX<br />
73723 26 MRI ANY JT LXTR C-/C+ 259.50 XXX<br />
73723 TC MRI ANY JT LXTR C-/C+ 1446.59 XXX<br />
73725 MRA LXTR C+-MATRL 1347.74 XXX<br />
73725 26 MRA LXTR C+-MATRL 219.95 XXX<br />
73725 TC MRA LXTR C+-MATRL 1127.79 XXX<br />
74000 RADEX ABD 1 ANTEROPOST VIEW 60.96 XXX<br />
74000 26 RADEX ABD 1 ANTEROPOST VIEW 21.42 XXX<br />
74000 TC RADEX ABD 1 ANTEROPOST VIEW 39.54 XXX<br />
74010 RADEX ABD ANTEROPOST&ADDL OBLQ&CONE VIEWS 93.09 XXX<br />
74010 26 RADEX ABD ANTEROPOST&ADDL OBLQ&CONE VIEWS 27.19 XXX<br />
74010 TC RADEX ABD ANTEROPOST&ADDL OBLQ&CONE VIEWS 65.90 XXX<br />
74020 RADEX ABD COMPL W/DCBTS&/ERC VIEWS 98.03 XXX<br />
74020 26 RADEX ABD COMPL W/DCBTS&/ERC VIEWS 32.13 XXX<br />
74020 TC RADEX ABD COMPL W/DCBTS&/ERC VIEWS 65.90 XXX<br />
74022 RADEX ABD COMPL AQT ABD W/S/E/D VIEWS 1 VIEW CH 117.80 XXX<br />
74022 26 RADEX ABD COMPL AQT ABD W/S/E/D VIEWS 1 VIEW CH 37.89 XXX<br />
74022 TC RADEX ABD COMPL AQT ABD W/S/E/D VIEWS 1 VIEW CH 79.91 XXX<br />
74150 CT ABD C-MATRL 601.37 XXX<br />
74150 26 CT ABD C-MATRL 144.17 XXX<br />
74150 TC CT ABD C-MATRL 457.20 XXX<br />
74160 CT ABD C+ MATRL 813.09 XXX<br />
74160 26 CT ABD C+ MATRL 154.05 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure<br />
188 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VIII: Diagnostic and <strong>The</strong>rapeutic Radiological Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
70010–79999 RADIOLOGY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
74160 TC CT ABD C+ MATRL 659.04 XXX<br />
74170 CT ABD C-/C+ 1074.24 XXX<br />
74170 26 CT ABD C-/C+ 169.70 XXX<br />
74170 TC CT ABD C-/C+ 904.54 XXX<br />
74175 CT ANGIOGRAPHY ABDOMEN W/CONTRAST/NONCONTRAST 1177.21 XXX<br />
74175 26 CT ANGIOGRAPHY ABDOMEN W/CONTRAST/NONCONTRAST 231.49 XXX<br />
74175 TC CT ANGIOGRAPHY ABDOMEN W/CONTRAST/NONCONTRAST 945.72 XXX<br />
l 74176 CT ABD & PELVIS W/O CONTRAST 524.76 XXX<br />
l 74176 26 CT ABD & PELVIS W/O CONTRAST 205.13 XXX<br />
l 74176 TC CT ABD & PELVIS W/O CONTRAST 319.63 XXX<br />
l 74177 CT ABD & PELVIS W/CONTRAST 824.62 XXX<br />
l 74177 26 CT ABD & PELVIS W/CONTRAST 215.01 XXX<br />
l 74177 TC CT ABD & PELVIS W/CONTRAST 609.61 XXX<br />
l 74178 CT ABD & PELVIS W/O CONTRST 1+ BODY REGNS 1043.75 XXX<br />
l 74178 26 CT ABD & PELVIS W/O CONTRST 1+ BODY REGNS 238.08 XXX<br />
l 74178 TC CT ABD & PELVIS W/O CONTRST 1+ BODY REGNS 805.67 XXX<br />
74181 MRI ABD C-MATRL 1120.37 XXX<br />
74181 26 MRI ABD C-MATRL 176.29 XXX<br />
74181 TC MRI ABD C-MATRL 944.08 XXX<br />
74182 MRI ABD C+ MATRL 1515.79 XXX<br />
74182 26 MRI ABD C+ MATRL 209.25 XXX<br />
74182 TC MRI ABD C+ MATRL 1306.54 XXX<br />
74183 MRI ABD C-/C+ 1809.06 XXX<br />
74183 26 MRI ABD C-/C+ 271.85 XXX<br />
74183 TC MRI ABD C-/C+ 1537.21 XXX<br />
74185 MRA ABD C+-MATRL 1341.97 XXX<br />
74185 26 MRA ABD C+-MATRL 217.48 XXX<br />
74185 TC MRA ABD C+-MATRL 1124.49 XXX<br />
74190 PRITONEOGRAM RS&I 148.28 XXX<br />
74190 26 PRITONEOGRAM RS&I 59.31 XXX<br />
74190 TC PRITONEOGRAM RS&I 88.97 XXX<br />
74210 RADEX PHARYNX&/CRV ESOPH 191.12 XXX<br />
74210 26 RADEX PHARYNX&/CRV ESOPH 42.84 XXX<br />
74210 TC RADEX PHARYNX&/CRV ESOPH 148.28 XXX<br />
74220 RADEX ESOPH 219.95 XXX<br />
74220 26 RADEX ESOPH 56.02 XXX<br />
74220 TC RADEX ESOPH 163.93 XXX<br />
74230 SWLNG FUNCJ W/CINERADIOGRAPY/VIDRADIOGRAPY 223.25 XXX<br />
74230 26 SWLNG FUNCJ W/CINERADIOGRAPY/VIDRADIOGRAPY 64.26 XXX<br />
74230 TC SWLNG FUNCJ W/CINERADIOGRAPY/VIDRADIOGRAPY 158.99 XXX<br />
74235 RMVL FB ESOPHGL W/USE BALO CATH RS&I 452.27 XXX<br />
74235 26 RMVL FB ESOPHGL W/USE BALO CATH RS&I 158.17 XXX<br />
74235 TC RMVL FB ESOPHGL W/USE BALO CATH RS&I 294.10 XXX<br />
74240 RADEX GI TRC UPR +-DLYD FLMS W/O KUB 272.68 XXX<br />
74240 26 RADEX GI TRC UPR +-DLYD FLMS W/O KUB 84.03 XXX<br />
74240 TC RADEX GI TRC UPR +-DLYD FLMS W/O KUB 188.65 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 189
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VIII: Diagnostic and <strong>The</strong>rapeutic Radiological Services<br />
RADIOLOGY 70010–79999<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
74241 RADEX GI TRC UPR +-DLYD FLMS W/KUB 289.15 XXX<br />
74241 26 RADEX GI TRC UPR +-DLYD FLMS W/KUB 82.38 XXX<br />
74241 TC RADEX GI TRC UPR +-DLYD FLMS W/KUB 206.77 XXX<br />
74245 RADEX GI TRC UPR W/SM INT W/MLT SRL FLMS 431.67 XXX<br />
74245 26 RADEX GI TRC UPR W/SM INT W/MLT SRL FLMS 110.39 XXX<br />
74245 TC RADEX GI TRC UPR W/SM INT W/MLT SRL FLMS 321.28 XXX<br />
74246 RADEX GI UPR C+ +-GLUC/DLYD FLMS W/O KUB 309.75 XXX<br />
74246 26 RADEX GI UPR C+ +-GLUC/DLYD FLMS W/O KUB 84.03 XXX<br />
74246 TC RADEX GI UPR C+ +-GLUC/DLYD FLMS W/O KUB 225.72 XXX<br />
74247 RADEX GI UPR C+ +-GLUC +-DLYD FLMS W/KUB 344.35 XXX<br />
74247 26 RADEX GI UPR C+ +-GLUC +-DLYD FLMS W/KUB 84.03 XXX<br />
74247 TC RADEX GI UPR C+ +-GLUC +-DLYD FLMS W/KUB 260.32 XXX<br />
74249 RADEX GI UPR C+ +-GLUC W/SM INT FOLLW-THRU 465.45 XXX<br />
74249 26 RADEX GI UPR C+ +-GLUC W/SM INT FOLLW-THRU 110.39 XXX<br />
74249 TC RADEX GI UPR C+ +-GLUC W/SM INT FOLLW-THRU 355.06 XXX<br />
74250 RADEX SM INT W/MLT SRL FLMS 259.50 XXX<br />
74250 26 RADEX SM INT W/MLT SRL FLMS 56.84 XXX<br />
74250 TC RADEX SM INT W/MLT SRL FLMS 202.66 XXX<br />
74251 RADEX SM INT W/MLT SRL FLMS VIA ENTEROCLSS TUBE 891.35 XXX<br />
74251 26 RADEX SM INT W/MLT SRL FLMS VIA ENTEROCLSS TUBE 84.03 XXX<br />
74251 TC RADEX SM INT W/MLT SRL FLMS VIA ENTEROCLSS TUBE 807.32 XXX<br />
74260 DUODENOGRAPY HYPOTONIC 735.65 XXX<br />
74260 26 DUODENOGRAPY HYPOTONIC 60.14 XXX<br />
74260 TC DUODENOGRAPY HYPOTONIC 675.51 XXX<br />
74261 CT COLONOGRPHY DX IMAGE POSTPROCESS NO CONTRAST 1254.65 XXX<br />
74261 26 CT COLONOGRPHY DX IMAGE POSTPROCESS NO CONTRAST 281.74 XXX<br />
74261 TC CT COLONOGRPHY DX IMAGE POSTPROCESS NO CONTRAST 972.91 XXX<br />
74262 CT COLONOGRPHY DX IMAGE POSTPROCESS W/CONTRAST 1393.87 XXX<br />
74262 26 CT COLONOGRPHY DX IMAGE POSTPROCESS W/CONTRAST 294.92 XXX<br />
74262 TC CT COLONOGRPHY DX IMAGE POSTPROCESS W/CONTRAST 1098.95 XXX<br />
74263 CT COLONOGRAPHY SCREENING IMAGE POSTPROCESSING 1853.55 XXX<br />
74263 26 CT COLONOGRAPHY SCREENING IMAGE POSTPROCESSING 280.09 XXX<br />
74263 TC CT COLONOGRAPHY SCREENING IMAGE POSTPROCESSING 1573.46 XXX<br />
74270 RADEX COLON BARIUM ENEMA +-KUB 373.18 XXX<br />
74270 26 RADEX COLON BARIUM ENEMA +-KUB 84.03 XXX<br />
74270 TC RADEX COLON BARIUM ENEMA +-KUB 289.15 XXX<br />
74280 RADEX COLON C+ W/SPEC HI DNS BARIUM +-GLUC 517.35 XXX<br />
74280 26 RADEX COLON C+ W/SPEC HI DNS BARIUM +-GLUC 119.45 XXX<br />
74280 TC RADEX COLON C+ W/SPEC HI DNS BARIUM +-GLUC 397.90 XXX<br />
74283 THER ENEMA C+ RDCTJ INTUSSUSCEPTION/OBSTRCJ 499.22 XXX<br />
74283 26 THER ENEMA C+ RDCTJ INTUSSUSCEPTION/OBSTRCJ 239.73 XXX<br />
74283 TC THER ENEMA C+ RDCTJ INTUSSUSCEPTION/OBSTRCJ 259.49 XXX<br />
74290 CCG ORAL CNTRST 166.41 XXX<br />
74290 26 CCG ORAL CNTRST 37.89 XXX<br />
74290 TC CCG ORAL CNTRST 128.52 XXX<br />
74291 CCG ORAL CNTRST ADDL/REPEAT XM/MLT D XM 155.70 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure<br />
190 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VIII: Diagnostic and <strong>The</strong>rapeutic Radiological Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
70010–79999 RADIOLOGY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
74291 26 CCG ORAL CNTRST ADDL/REPEAT XM/MLT D XM 23.89 XXX<br />
74291 TC CCG ORAL CNTRST ADDL/REPEAT XM/MLT D XM 131.81 XXX<br />
74300 CHOLANGRPH&/PCG INTRAOP RS&I 126.87 XXX<br />
74300 26 CHOLANGRPH&/PCG INTRAOP RS&I 44.49 XXX<br />
74300 TC CHOLANGRPH&/PCG INTRAOP RS&I 82.38 XXX<br />
+ 74301 CHOLANGRPH&/PCG ADDL SET INTRAOP RS&I 77.44 ZZZ<br />
+ 74301 26 CHOLANGRPH&/PCG ADDL SET INTRAOP RS&I 27.19 ZZZ<br />
+ 74301 TC CHOLANGRPH&/PCG ADDL SET INTRAOP RS&I 50.25 ZZZ<br />
74305 CHOLANGRPH&/PCG THRU CATH RS&I 148.28 XXX<br />
74305 26 CHOLANGRPH&/PCG THRU CATH RS&I 51.90 XXX<br />
74305 TC CHOLANGRPH&/PCG THRU CATH RS&I 96.38 XXX<br />
74320 CHOLANGRPH PRQ TRANSHEPATC RS&I 263.62 XXX<br />
74320 26 CHOLANGRPH PRQ TRANSHEPATC RS&I 65.90 XXX<br />
74320 TC CHOLANGRPH PRQ TRANSHEPATC RS&I 197.72 XXX<br />
74327 PO BILIARY ST1 RMVL PRQ RS&I 336.11 XXX<br />
74327 26 PO BILIARY ST1 RMVL PRQ RS&I 91.44 XXX<br />
74327 TC PO BILIARY ST1 RMVL PRQ RS&I 244.67 XXX<br />
74328 NDSC CATHJ BILIARY DUX SYS RS&I 290.80 XXX<br />
74328 26 NDSC CATHJ BILIARY DUX SYS RS&I 87.32 XXX<br />
74328 TC NDSC CATHJ BILIARY DUX SYS RS&I 203.48 XXX<br />
74329 NDSC CATHJ PNCRTC DUX SYS RS&I 249.61 XXX<br />
74329 26 NDSC CATHJ PNCRTC DUX SYS RS&I 87.32 XXX<br />
74329 TC NDSC CATHJ PNCRTC DUX SYS RS&I 162.29 XXX<br />
74330 CMBN NDSC CATHJ BILIARY&PNCRTC DUX SYSS RS&I 415.20 XXX<br />
74330 26 CMBN NDSC CATHJ BILIARY&PNCRTC DUX SYSS RS&I 112.04 XXX<br />
74330 TC CMBN NDSC CATHJ BILIARY&PNCRTC DUX SYSS RS&I 303.16 XXX<br />
74340 INTRO LONG GI TUBE W/MLT FLUOR&FLMS RS&I 266.91 XXX<br />
74340 26 INTRO LONG GI TUBE W/MLT FLUOR&FLMS RS&I 66.73 XXX<br />
74340 TC INTRO LONG GI TUBE W/MLT FLUOR&FLMS RS&I 200.18 XXX<br />
74355 PRQ PLMT ENTEROCLSS TUBE RS&I 354.23 XXX<br />
74355 26 PRQ PLMT ENTEROCLSS TUBE RS&I 95.56 XXX<br />
74355 TC PRQ PLMT ENTEROCLSS TUBE RS&I 258.67 XXX<br />
74360 INTRAL DILAT STRIXS&/OBSTRCJS RS&I 294.92 XXX<br />
74360 26 INTRAL DILAT STRIXS&/OBSTRCJS RS&I 70.85 XXX<br />
74360 TC INTRAL DILAT STRIXS&/OBSTRCJS RS&I 224.07 XXX<br />
74363 PRQ TRANSHEPATC DILAT BILIARY DUX STRIX RS&I 313.04 XXX<br />
74363 26 PRQ TRANSHEPATC DILAT BILIARY DUX STRIX RS&I 109.57 XXX<br />
74363 TC PRQ TRANSHEPATC DILAT BILIARY DUX STRIX RS&I 203.47 XXX<br />
74400 UROGRAPY PLOG IV +-KUB +-TOMOG 272.68 XXX<br />
74400 26 UROGRAPY PLOG IV +-KUB +-TOMOG 59.31 XXX<br />
74400 TC UROGRAPY PLOG IV +-KUB +-TOMOG 213.37 XXX<br />
74410 UROGRAPY NFS DRIP TQ&/BOLUS TQ 280.92 XXX<br />
74410 26 UROGRAPY NFS DRIP TQ&/BOLUS TQ 60.14 XXX<br />
74410 TC UROGRAPY NFS DRIP TQ&/BOLUS TQ 220.78 XXX<br />
74415 UROGRAPY NFS DRIP TQ&/BOLUS TQ W/NEPHROTOMOG 331.99 XXX<br />
74415 26 UROGRAPY NFS DRIP TQ&/BOLUS TQ W/NEPHROTOMOG 59.31 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 191
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VIII: Diagnostic and <strong>The</strong>rapeutic Radiological Services<br />
RADIOLOGY 70010–79999<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
74415 TC UROGRAPY NFS DRIP TQ&/BOLUS TQ W/NEPHROTOMOG 272.68 XXX<br />
74420 X-RAY URINARY TRACT EXAM WITH CONTRAST MATERIAL 296.57 XXX<br />
74420 26 X-RAY URINARY TRACT EXAM WITH CONTRAST MATERIAL 44.49 XXX<br />
74420 TC X-RAY URINARY TRACT EXAM WITH CONTRAST MATERIAL 252.08 XXX<br />
74425 UROGRAPY ANTEGRADE RS&I 164.76 XXX<br />
74425 26 UROGRAPY ANTEGRADE RS&I 44.49 XXX<br />
74425 TC UROGRAPY ANTEGRADE RS&I 120.27 XXX<br />
74430 CSTOGRAPY MINIMUM 3 VIEWS RS&I 148.28 XXX<br />
74430 26 CSTOGRAPY MINIMUM 3 VIEWS RS&I 37.89 XXX<br />
74430 TC CSTOGRAPY MINIMUM 3 VIEWS RS&I 110.39 XXX<br />
74440 VASOGRAPY VESICULOGRAPY/EPIDIDYMOGRAPY RS&I 210.89 XXX<br />
74440 26 VASOGRAPY VESICULOGRAPY/EPIDIDYMOGRAPY RS&I 46.96 XXX<br />
74440 TC VASOGRAPY VESICULOGRAPY/EPIDIDYMOGRAPY RS&I 163.93 XXX<br />
74445 C/P/A CAVERNOSOGRAPY RS&I 251.26 XXX<br />
74445 26 C/P/A CAVERNOSOGRAPY RS&I 143.34 XXX<br />
74445 TC C/P/A CAVERNOSOGRAPY RS&I 107.92 XXX<br />
74450 URETHROCSTOGRAPY RTRGR RS&I 178.76 XXX<br />
74450 26 URETHROCSTOGRAPY RTRGR RS&I 41.19 XXX<br />
74450 TC URETHROCSTOGRAPY RTRGR RS&I 137.57 XXX<br />
74455 URETHROCSTOGRAPY VOIDING RS&I 218.31 XXX<br />
74455 26 URETHROCSTOGRAPY VOIDING RS&I 39.54 XXX<br />
74455 TC URETHROCSTOGRAPY VOIDING RS&I 178.77 XXX<br />
74470 RADEX RNL CST STD TRANSLMBR C+ RS&I 185.36 XXX<br />
74470 26 RADEX RNL CST STD TRANSLMBR C+ RS&I 66.73 XXX<br />
74470 TC RADEX RNL CST STD TRANSLMBR C+ RS&I 118.63 XXX<br />
74475 INTRO CATH IN RNL PELVIS DRG&/NJX PRQ RS&I 272.68 XXX<br />
74475 26 INTRO CATH IN RNL PELVIS DRG&/NJX PRQ RS&I 65.90 XXX<br />
74475 TC INTRO CATH IN RNL PELVIS DRG&/NJX PRQ RS&I 206.78 XXX<br />
74480 INTRO URTRL CATH/STENT PRQ RS&I 273.50 XXX<br />
74480 26 INTRO URTRL CATH/STENT PRQ RS&I 65.90 XXX<br />
74480 TC INTRO URTRL CATH/STENT PRQ RS&I 207.60 XXX<br />
74485 DILAT NFROS URTRS/URT RS&I 269.38 XXX<br />
74485 26 DILAT NFROS URTRS/URT RS&I 65.90 XXX<br />
74485 TC DILAT NFROS URTRS/URT RS&I 203.48 XXX<br />
74710 PELVIMETRY +-PLACENTAL LOCLZJ 96.38 XXX<br />
74710 26 PELVIMETRY +-PLACENTAL LOCLZJ 40.37 XXX<br />
74710 TC PELVIMETRY +-PLACENTAL LOCLZJ 56.01 XXX<br />
74740 HSG RS&I 192.77 XXX<br />
74740 26 HSG RS&I 45.31 XXX<br />
74740 TC HSG RS&I 147.46 XXX<br />
74742 TRANSCRV CATHJ FLP TUBE RS&I 214.19 XXX<br />
74742 26 TRANSCRV CATHJ FLP TUBE RS&I 74.97 XXX<br />
74742 TC TRANSCRV CATHJ FLP TUBE RS&I 139.22 XXX<br />
74775 PRINEOGRAM 212.54 XXX<br />
74775 26 PRINEOGRAM 76.61 XXX<br />
74775 TC PRINEOGRAM 135.93 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure<br />
192 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VIII: Diagnostic and <strong>The</strong>rapeutic Radiological Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
70010–79999 RADIOLOGY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
75557 CARDIAC MRI MORPHOLOGY & FUNCTION W/O CONTRAST 1089.06 XXX<br />
75557 26 CARDIAC MRI MORPHOLOGY & FUNCTION W/O CONTRAST 288.33 XXX<br />
75557 TC CARDIAC MRI MORPHOLOGY & FUNCTION W/O CONTRAST 800.73 XXX<br />
75559 CARDIAC MRI W/O CONTRAST W STRESS IMAGING 1575.11 XXX<br />
75559 26 CARDIAC MRI W/O CONTRAST W STRESS IMAGING 366.59 XXX<br />
75559 TC CARDIAC MRI W/O CONTRAST W STRESS IMAGING 1208.52 XXX<br />
75561 CARDIAC MRI W/W/O CONTRAST & FURTHER SEQ 1474.60 XXX<br />
75561 26 CARDIAC MRI W/W/O CONTRAST & FURTHER SEQ 319.63 XXX<br />
75561 TC CARDIAC MRI W/W/O CONTRAST & FURTHER SEQ 1154.97 XXX<br />
75563 CARDIAC MRI W/W/O CONTRAST W STRESS 1795.06 XXX<br />
75563 26 CARDIAC MRI W/W/O CONTRAST W STRESS 376.48 XXX<br />
75563 TC CARDIAC MRI W/W/O CONTRAST W STRESS 1418.58 XXX<br />
+ 75565 CARDIAC MRI FOR VELOCITY FLOW MAPPING 180.41 ZZZ<br />
+ 75565 26 CARDIAC MRI FOR VELOCITY FLOW MAPPING 30.48 ZZZ<br />
+ 75565 TC CARDIAC MRI FOR VELOCITY FLOW MAPPING 149.93 ZZZ<br />
75571 CT HEART NO CONTRAST QUANT EVAL CORONRY CALCIUM 259.50 XXX<br />
75571 26 CT HEART NO CONTRAST QUANT EVAL CORONRY CALCIUM 66.73 XXX<br />
75571 TC CT HEART NO CONTRAST QUANT EVAL CORONRY CALCIUM 192.77 XXX<br />
75572 CT HEART CONTRAST EVAL CARDIAC STRUCTURE&MORPH 710.94 XXX<br />
75572 26 CT HEART CONTRAST EVAL CARDIAC STRUCTURE&MORPH 203.48 XXX<br />
75572 TC CT HEART CONTRAST EVAL CARDIAC STRUCTURE&MORPH 507.46 XXX<br />
75573 CT HRT CONTRST CARDIAC STRUCT&MORPH CONG HRT DX 967.14 XXX<br />
75573 26 CT HRT CONTRST CARDIAC STRUCT&MORPH CONG HRT DX 298.22 XXX<br />
75573 TC CT HRT CONTRST CARDIAC STRUCT&MORPH CONG HRT DX 668.92 XXX<br />
75574 CTA HRT CORNRY ART/BYPASS GRFTS CONTRST 3D POST 1080.83 XXX<br />
75574 26 CTA HRT CORNRY ART/BYPASS GRFTS CONTRST 3D POST 280.09 XXX<br />
75574 TC CTA HRT CORNRY ART/BYPASS GRFTS CONTRST 3D POST 800.74 XXX<br />
75600 AORTOGRAPY THRC W/O SRLOGRAPY RS&I 657.39 XXX<br />
75600 26 AORTOGRAPY THRC W/O SRLOGRAPY RS&I 61.79 XXX<br />
75600 TC AORTOGRAPY THRC W/O SRLOGRAPY RS&I 595.60 XXX<br />
75605 AORTOGRAPY THRC SRLOGRAPY RS&I 523.11 XXX<br />
75605 26 AORTOGRAPY THRC SRLOGRAPY RS&I 140.87 XXX<br />
75605 TC AORTOGRAPY THRC SRLOGRAPY RS&I 382.24 XXX<br />
75625 AORTOGRAPY ABDL SRLOGRAPY RS&I 523.94 XXX<br />
75625 26 AORTOGRAPY ABDL SRLOGRAPY RS&I 140.87 XXX<br />
75625 TC AORTOGRAPY ABDL SRLOGRAPY RS&I 383.07 XXX<br />
75630 AORTOGRAPY ABDL BI ILIOFEM LXTR CATH RS&I 610.44 XXX<br />
75630 26 AORTOGRAPY ABDL BI ILIOFEM LXTR CATH RS&I 218.31 XXX<br />
75630 TC AORTOGRAPY ABDL BI ILIOFEM LXTR CATH RS&I 392.13 XXX<br />
75635 CTA AA&BI ILIOFEM LXTR RS&I C-/C+ POST-PXESSING 1318.90 XXX<br />
75635 26 CTA AA&BI ILIOFEM LXTR RS&I C-/C+ POST-PXESSING 292.45 XXX<br />
75635 TC CTA AA&BI ILIOFEM LXTR RS&I C-/C+ POST-PXESSING 1026.45 XXX<br />
75650 ANGRPH CERVICOCERE CATH W/VSL ORIGIN RS&I 568.42 XXX<br />
75650 26 ANGRPH CERVICOCERE CATH W/VSL ORIGIN RS&I 182.88 XXX<br />
75650 TC ANGRPH CERVICOCERE CATH W/VSL ORIGIN RS&I 385.54 XXX<br />
75658 ANGRPH BRACH RTRGR RS&I 582.43 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 193
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VIII: Diagnostic and <strong>The</strong>rapeutic Radiological Services<br />
RADIOLOGY 70010–79999<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
75658 26 ANGRPH BRACH RTRGR RS&I 156.52 XXX<br />
75658 TC ANGRPH BRACH RTRGR RS&I 425.91 XXX<br />
75660 ANGRPH XTRNL CRTD UNI SLCTV RS&I 590.66 XXX<br />
75660 26 ANGRPH XTRNL CRTD UNI SLCTV RS&I 158.17 XXX<br />
75660 TC ANGRPH XTRNL CRTD UNI SLCTV RS&I 432.49 XXX<br />
75662 ANGRPH XTRNL CRTD BI SLCTV RS&I 702.70 XXX<br />
75662 26 ANGRPH XTRNL CRTD BI SLCTV RS&I 205.13 XXX<br />
75662 TC ANGRPH XTRNL CRTD BI SLCTV RS&I 497.57 XXX<br />
75665 ANGRPH CRTD CERE UNI RS&I 616.20 XXX<br />
75665 26 ANGRPH CRTD CERE UNI RS&I 163.94 XXX<br />
75665 TC ANGRPH CRTD CERE UNI RS&I 452.26 XXX<br />
75671 ANGRPH CRTD CERE BI RS&I 718.35 XXX<br />
75671 26 ANGRPH CRTD CERE BI RS&I 204.30 XXX<br />
75671 TC ANGRPH CRTD CERE BI RS&I 514.05 XXX<br />
75676 ANGRPH CRTD CRV UNI RS&I 591.49 XXX<br />
75676 26 ANGRPH CRTD CRV UNI RS&I 163.11 XXX<br />
75676 TC ANGRPH CRTD CRV UNI RS&I 428.38 XXX<br />
75680 ANGRPH CRTD CRV BI RS&I 669.75 XXX<br />
75680 26 ANGRPH CRTD CRV BI RS&I 204.30 XXX<br />
75680 TC ANGRPH CRTD CRV BI RS&I 465.45 XXX<br />
75685 ANGRPH VRT CRV&/ICRA RS&I 593.96 XXX<br />
75685 26 ANGRPH VRT CRV&/ICRA RS&I 161.46 XXX<br />
75685 TC ANGRPH VRT CRV&/ICRA RS&I 432.50 XXX<br />
75705 ANGRPH SPI SLCTV RS&I 691.99 XXX<br />
75705 26 ANGRPH SPI SLCTV RS&I 262.79 XXX<br />
75705 TC ANGRPH SPI SLCTV RS&I 429.20 XXX<br />
75710 ANGRPH XTR UNI RS&I 567.60 XXX<br />
75710 26 ANGRPH XTR UNI RS&I 136.75 XXX<br />
75710 TC ANGRPH XTR UNI RS&I 430.85 XXX<br />
75716 ANGRPH XTR BI RS&I 656.57 XXX<br />
75716 26 ANGRPH XTR BI RS&I 160.64 XXX<br />
75716 TC ANGRPH XTR BI RS&I 495.93 XXX<br />
75722 ANGRPH RNL UNI SLCTV W/FLUSH AORTOGRAM RS&I 550.30 XXX<br />
75722 26 ANGRPH RNL UNI SLCTV W/FLUSH AORTOGRAM RS&I 140.87 XXX<br />
75722 TC ANGRPH RNL UNI SLCTV W/FLUSH AORTOGRAM RS&I 409.43 XXX<br />
75724 ANGRPH RNL BI SLCTV W/FLUSH AORTOGRAM RS&I 652.45 XXX<br />
75724 26 ANGRPH RNL BI SLCTV W/FLUSH AORTOGRAM RS&I 186.18 XXX<br />
75724 TC ANGRPH RNL BI SLCTV W/FLUSH AORTOGRAM RS&I 466.27 XXX<br />
75726 ANGRPH VISC SLCTV/SUPRASLCTV RS&I 563.48 XXX<br />
75726 26 ANGRPH VISC SLCTV/SUPRASLCTV RS&I 139.22 XXX<br />
75726 TC ANGRPH VISC SLCTV/SUPRASLCTV RS&I 424.26 XXX<br />
75731 ANGRPH ADRNL UNI SLCTV RS&I 571.72 XXX<br />
75731 26 ANGRPH ADRNL UNI SLCTV RS&I 140.87 XXX<br />
75731 TC ANGRPH ADRNL UNI SLCTV RS&I 430.85 XXX<br />
75733 ANGRPH ADRNL BI SLCTV RS&I 658.22 XXX<br />
75733 26 ANGRPH ADRNL BI SLCTV RS&I 163.94 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure<br />
194 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VIII: Diagnostic and <strong>The</strong>rapeutic Radiological Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
70010–79999 RADIOLOGY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
75733 TC ANGRPH ADRNL BI SLCTV RS&I 494.28 XXX<br />
75736 ANGRPH PEL SLCTV/SUPRASLCTV RS&I 561.01 XXX<br />
75736 26 ANGRPH PEL SLCTV/SUPRASLCTV RS&I 137.57 XXX<br />
75736 TC ANGRPH PEL SLCTV/SUPRASLCTV RS&I 423.44 XXX<br />
75741 ANGRPH PULM UNI SLCTV RS&I 533.00 XXX<br />
75741 26 ANGRPH PULM UNI SLCTV RS&I 159.82 XXX<br />
75741 TC ANGRPH PULM UNI SLCTV RS&I 373.18 XXX<br />
75743 ANGRPH PULM BI SLCTV RS&I 596.43 XXX<br />
75743 26 ANGRPH PULM BI SLCTV RS&I 202.65 XXX<br />
75743 TC ANGRPH PULM BI SLCTV RS&I 393.78 XXX<br />
75746 ANGRPH PULM NONSLCTV CATH/VEN NJX RS&I 545.36 XXX<br />
75746 26 ANGRPH PULM NONSLCTV CATH/VEN NJX RS&I 139.22 XXX<br />
75746 TC ANGRPH PULM NONSLCTV CATH/VEN NJX RS&I 406.14 XXX<br />
75756 ANGRPH INT MAM RS&I 588.19 XXX<br />
75756 26 ANGRPH INT MAM RS&I 156.52 XXX<br />
75756 TC ANGRPH INT MAM RS&I 431.67 XXX<br />
+ 75774 ANGRPH SLCTV EA VSL STUDIED AFTER BASIC XM RS&I 387.19 ZZZ<br />
+ 75774 26 ANGRPH SLCTV EA VSL STUDIED AFTER BASIC XM RS&I 44.49 ZZZ<br />
+ 75774 TC ANGRPH SLCTV EA VSL STUDIED AFTER BASIC XM RS&I 342.70 ZZZ<br />
75791 ANGIOGRPHY AV SHUNT COMPLETE EVAL FLUOR S&I 795.79 XXX<br />
75791 26 ANGIOGRPHY AV SHUNT COMPLETE EVAL FLUOR S&I 200.18 XXX<br />
75791 TC ANGIOGRPHY AV SHUNT COMPLETE EVAL FLUOR S&I 595.61 XXX<br />
75801 LYMPHANGRPH XTR ONLY UNI RS&I 639.27 XXX<br />
75801 26 LYMPHANGRPH XTR ONLY UNI RS&I 108.74 XXX<br />
75801 TC LYMPHANGRPH XTR ONLY UNI RS&I 530.53 XXX<br />
75803 LYMPHANGRPH XTR ONLY BI RS&I 659.04 XXX<br />
75803 26 LYMPHANGRPH XTR ONLY BI RS&I 144.99 XXX<br />
75803 TC LYMPHANGRPH XTR ONLY BI RS&I 514.05 XXX<br />
75805 LYMPHANGRPH PEL/ABDL UNI RS&I 669.75 XXX<br />
75805 26 LYMPHANGRPH PEL/ABDL UNI RS&I 100.50 XXX<br />
75805 TC LYMPHANGRPH PEL/ABDL UNI RS&I 569.25 XXX<br />
75807 LYMPHANGRPH PEL/ABDL BI RS&I 729.06 XXX<br />
75807 26 LYMPHANGRPH PEL/ABDL BI RS&I 145.81 XXX<br />
75807 TC LYMPHANGRPH PEL/ABDL BI RS&I 583.25 XXX<br />
75809 SHUNTOGRAM NDWELLG NONVASC SHUNT RS&I 238.08 XXX<br />
75809 26 SHUNTOGRAM NDWELLG NONVASC SHUNT RS&I 57.67 XXX<br />
75809 TC SHUNTOGRAM NDWELLG NONVASC SHUNT RS&I 180.41 XXX<br />
75810 SPLENOPORTOGRAPY RS&I 1295.84 XXX<br />
75810 26 SPLENOPORTOGRAPY RS&I 142.52 XXX<br />
75810 TC SPLENOPORTOGRAPY RS&I 1153.32 XXX<br />
75820 VNGRPH XTR UNI RS&I 305.63 XXX<br />
75820 26 VNGRPH XTR UNI RS&I 85.68 XXX<br />
75820 TC VNGRPH XTR UNI RS&I 219.95 XXX<br />
75822 VNGRPH XTR BI RS&I 374.83 XXX<br />
75822 26 VNGRPH XTR BI RS&I 128.51 XXX<br />
75822 TC VNGRPH XTR BI RS&I 246.32 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 195
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VIII: Diagnostic and <strong>The</strong>rapeutic Radiological Services<br />
RADIOLOGY 70010–79999<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
75825 VNGRPH CAVAL INF SRLOGRAPY RS&I 501.69 XXX<br />
75825 26 VNGRPH CAVAL INF SRLOGRAPY RS&I 137.57 XXX<br />
75825 TC VNGRPH CAVAL INF SRLOGRAPY RS&I 364.12 XXX<br />
75827 VNGRPH CAVAL SUPRIOR SRLOGRAPY RS&I 507.46 XXX<br />
75827 26 VNGRPH CAVAL SUPRIOR SRLOGRAPY RS&I 135.93 XXX<br />
75827 TC VNGRPH CAVAL SUPRIOR SRLOGRAPY RS&I 371.53 XXX<br />
75831 VNGRPH RNL UNI SLCTV RS&I 523.94 XXX<br />
75831 26 VNGRPH RNL UNI SLCTV RS&I 151.58 XXX<br />
75831 TC VNGRPH RNL UNI SLCTV RS&I 372.36 XXX<br />
75833 VNGRPH RNL BI SLCTV RS&I 588.19 XXX<br />
75833 26 VNGRPH RNL BI SLCTV RS&I 176.29 XXX<br />
75833 TC VNGRPH RNL BI SLCTV RS&I 411.90 XXX<br />
75840 VNGRPH ADRNL UNI SLCTV RS&I 514.05 XXX<br />
75840 26 VNGRPH ADRNL UNI SLCTV RS&I 149.11 XXX<br />
75840 TC VNGRPH ADRNL UNI SLCTV RS&I 364.94 XXX<br />
75842 VNGRPH ADRNL BI SLCTV RS&I 589.84 XXX<br />
75842 26 VNGRPH ADRNL BI SLCTV RS&I 180.41 XXX<br />
75842 TC VNGRPH ADRNL BI SLCTV RS&I 409.43 XXX<br />
75860 VNGRPH VEN SINUS/JUG CATH RS&I 518.17 XXX<br />
75860 26 VNGRPH VEN SINUS/JUG CATH RS&I 141.69 XXX<br />
75860 TC VNGRPH VEN SINUS/JUG CATH RS&I 376.48 XXX<br />
75870 VNGRPH SUPRIOR SGTL SINUS RS&I 511.58 XXX<br />
75870 26 VNGRPH SUPRIOR SGTL SINUS RS&I 138.40 XXX<br />
75870 TC VNGRPH SUPRIOR SGTL SINUS RS&I 373.18 XXX<br />
75872 VNGRPH EDRL RS&I 690.34 XXX<br />
75872 26 VNGRPH EDRL RS&I 148.28 XXX<br />
75872 TC VNGRPH EDRL RS&I 542.06 XXX<br />
75880 VNGRPH ORB RS&I 417.67 XXX<br />
75880 26 VNGRPH ORB RS&I 87.32 XXX<br />
75880 TC VNGRPH ORB RS&I 330.35 XXX<br />
75885 PRQ TRANSHEPATC PORTOGRAPY HEMODYN EVAL RS&I 547.00 XXX<br />
75885 26 PRQ TRANSHEPATC PORTOGRAPY HEMODYN EVAL RS&I 174.65 XXX<br />
75885 TC PRQ TRANSHEPATC PORTOGRAPY HEMODYN EVAL RS&I 372.35 XXX<br />
75887 PRQ TRANSHEPATC PORTOGRAPY W/O HEMODYN EVAL RS&I 551.12 XXX<br />
75887 26 PRQ TRANSHEPATC PORTOGRAPY W/O HEMODYN EVAL RS&I 173.00 XXX<br />
75887 TC PRQ TRANSHEPATC PORTOGRAPY W/O HEMODYN EVAL RS&I 378.12 XXX<br />
75889 HEPATC VNGRPH WDG/FR HEMODYN EVAL RS&I 510.76 XXX<br />
75889 26 HEPATC VNGRPH WDG/FR HEMODYN EVAL RS&I 138.40 XXX<br />
75889 TC HEPATC VNGRPH WDG/FR HEMODYN EVAL RS&I 372.36 XXX<br />
75891 HEPATC VNGRPH WDG/FR W/O HEMODYN EVAL RS&I 511.58 XXX<br />
75891 26 HEPATC VNGRPH WDG/FR W/O HEMODYN EVAL RS&I 138.40 XXX<br />
75891 TC HEPATC VNGRPH WDG/FR W/O HEMODYN EVAL RS&I 373.18 XXX<br />
75893 VEN SAMPLING THRU CATH +-ANGRPH RS&I 433.32 XXX<br />
75893 26 VEN SAMPLING THRU CATH +-ANGRPH RS&I 63.43 XXX<br />
75893 TC VEN SAMPLING THRU CATH +-ANGRPH RS&I 369.89 XXX<br />
75894 TCAT THER EMBOLIZATION ANY METH RS&I 2365.95 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure<br />
196 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VIII: Diagnostic and <strong>The</strong>rapeutic Radiological Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
70010–79999 RADIOLOGY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
75894 26 TCAT THER EMBOLIZATION ANY METH RS&I 165.58 XXX<br />
75894 TC TCAT THER EMBOLIZATION ANY METH RS&I 2200.37 XXX<br />
75896 TCAT THER NFS ANY METH RS&I 2090.80 XXX<br />
75896 26 TCAT THER NFS ANY METH RS&I 167.23 XXX<br />
75896 TC TCAT THER NFS ANY METH RS&I 1923.57 XXX<br />
75898 ANGRPH CATH F-UP STD TCAT THER EMBOLIZATION/NFS 314.69 XXX<br />
75898 26 ANGRPH CATH F-UP STD TCAT THER EMBOLIZATION/NFS 210.89 XXX<br />
75898 TC ANGRPH CATH F-UP STD TCAT THER EMBOLIZATION/NFS 103.80 XXX<br />
75900 EXCHNG CATH THROMBOLYTIC THER C+ MNTR RS&I 406.13 XXX<br />
75900 26 EXCHNG CATH THROMBOLYTIC THER C+ MNTR RS&I 60.96 XXX<br />
75900 TC EXCHNG CATH THROMBOLYTIC THER C+ MNTR RS&I 345.17 XXX<br />
75901 MCHNL RMVL PRICATH OBSTR MATRL RS&I 406.96 XXX<br />
75901 26 MCHNL RMVL PRICATH OBSTR MATRL RS&I 59.31 XXX<br />
75901 TC MCHNL RMVL PRICATH OBSTR MATRL RS&I 347.65 XXX<br />
75902 MCHNL RMVL INTRAL OBSTR MATRL RS&I 187.83 XXX<br />
75902 26 MCHNL RMVL INTRAL OBSTR MATRL RS&I 47.78 XXX<br />
75902 TC MCHNL RMVL INTRAL OBSTR MATRL RS&I 140.05 XXX<br />
75940 PRQ PLMT IVC FILTER RS&I 1351.03 XXX<br />
75940 26 PRQ PLMT IVC FILTER RS&I 67.55 XXX<br />
75940 TC PRQ PLMT IVC FILTER RS&I 1283.48 XXX<br />
75945 IV US RS&I 1ST VSL 457.21 XXX<br />
75945 26 IV US RS&I 1ST VSL 50.25 XXX<br />
75945 TC IV US RS&I 1ST VSL 406.96 XXX<br />
+ 75946 IV US RS&I EA NON-C VSL 464.62 ZZZ<br />
+ 75946 26 IV US RS&I EA NON-C VSL 51.08 ZZZ<br />
+ 75946 TC IV US RS&I EA NON-C VSL 413.54 ZZZ<br />
75952 EVASC RPR INFRARNL AAA/DSJ RS&I 575.84 XXX<br />
75952 26 EVASC RPR INFRARNL AAA/DSJ RS&I 575.84 XXX<br />
75952 TC EVASC RPR INFRARNL AAA/DSJ RS&I 0.00 XXX<br />
75953 PLMT XTN PROSTH EVASC RPR INFRARNL RS&I 175.47 XXX<br />
75953 26 PLMT XTN PROSTH EVASC RPR INFRARNL RS&I 175.47 XXX<br />
75953 TC PLMT XTN PROSTH EVASC RPR INFRARNL RS&I 0.00 XXX<br />
s 75954 EVASC RPR ILIAC ART W/ILIO-ILIAC PROSTH RS&I 287.51 XXX<br />
s 75954 26 EVASC RPR ILIAC ART W/ILIO-ILIAC PROSTH RS&I 287.51 XXX<br />
s 75954 TC EVASC RPR ILIAC ART W/ILIO-ILIAC PROSTH RS&I 0.00 XXX<br />
75956 EVASC RPR DTA COVERAGE L SUBCLA ORIGIN RS&I 904.53 XXX<br />
75956 26 EVASC RPR DTA COVERAGE L SUBCLA ORIGIN RS&I 904.53 XXX<br />
75956 TC EVASC RPR DTA COVERAGE L SUBCLA ORIGIN RS&I 0.00 XXX<br />
75957 EVASC RPR DTA X COVERAGE L SUBCLA ORIGIN RS&I 773.55 XXX<br />
75957 26 EVASC RPR DTA X COVERAGE L SUBCLA ORIGIN RS&I 773.55 XXX<br />
75957 TC EVASC RPR DTA X COVERAGE L SUBCLA ORIGIN RS&I 0.00 XXX<br />
75958 PLMT PROX XTN PROSTH EVASC RPR DTA RS&I 514.05 XXX<br />
75958 26 PLMT PROX XTN PROSTH EVASC RPR DTA RS&I 514.05 XXX<br />
75958 TC PLMT PROX XTN PROSTH EVASC RPR DTA RS&I 0.00 XXX<br />
75959 PLMT DSTL XTN PROSTH AFTER EVASC RPR DTA RS&I 454.74 XXX<br />
75959 26 PLMT DSTL XTN PROSTH AFTER EVASC RPR DTA RS&I 454.74 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 197
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VIII: Diagnostic and <strong>The</strong>rapeutic Radiological Services<br />
RADIOLOGY 70010–79999<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
75959 TC PLMT DSTL XTN PROSTH AFTER EVASC RPR DTA RS&I 0.00 XXX<br />
s 75960 TCAT IV STNT ILIA/LOW EXT ART PRQ/OPN RSI EA VSL 471.21 XXX<br />
s 75960 26 TCAT IV STNT ILIA/LOW EXT ART PRQ/OPN RSI EA VSL 99.68 XXX<br />
s 75960 TC TCAT IV STNT ILIA/LOW EXT ART PRQ/OPN RSI EA VSL 371.53 XXX<br />
75961 TCAT RETRIEVAL PRQ IV FB RS&I 897.94 XXX<br />
75961 26 TCAT RETRIEVAL PRQ IV FB RS&I 514.05 XXX<br />
75961 TC TCAT RETRIEVAL PRQ IV FB RS&I 383.89 XXX<br />
s 75962 TRANSLUMINAL BALLOON ANGIOP PERIPHERAL ART RSI 516.52 XXX<br />
s 75962 26 TRANSLUMINAL BALLOON ANGIOP PERIPHERAL ART RSI 65.08 XXX<br />
s 75962 TC TRANSLUMINAL BALLOON ANGIOP PERIPHERAL ART RSI 451.44 XXX<br />
s + 75964 TRLUML BALOON ANGIOP PERIPHER EA ADDL ARTERY RSI 322.11 ZZZ<br />
s + 75964 26 TRLUML BALOON ANGIOP PERIPHER EA ADDL ARTERY RSI 44.49 ZZZ<br />
s + 75964 TC TRLUML BALOON ANGIOP PERIPHER EA ADDL ARTERY RSI 277.62 ZZZ<br />
75966 TRLUML BALO ANGIOP RNL/OTH VISC ART RS&I 621.15 XXX<br />
75966 26 TRLUML BALO ANGIOP RNL/OTH VISC ART RS&I 161.46 XXX<br />
75966 TC TRLUML BALO ANGIOP RNL/OTH VISC ART RS&I 459.69 XXX<br />
+ 75968 TRLUML BALO ANGIOP EA VISC ART RS&I 315.52 ZZZ<br />
+ 75968 26 TRLUML BALO ANGIOP EA VISC ART RS&I 43.66 ZZZ<br />
+ 75968 TC TRLUML BALO ANGIOP EA VISC ART RS&I 271.86 ZZZ<br />
75970 TCAT BX RS&I 1144.26 XXX<br />
75970 26 TCAT BX RS&I 102.98 XXX<br />
75970 TC TCAT BX RS&I 1041.28 XXX<br />
75978 TRLUML BALO ANGIOP VEN RS&I 517.35 XXX<br />
75978 26 TRLUML BALO ANGIOP VEN RS&I 64.26 XXX<br />
75978 TC TRLUML BALO ANGIOP VEN RS&I 453.09 XXX<br />
75980 PRQ TRANSHEPATC BILIARY DRG C+ MNTR RS&I 684.58 XXX<br />
75980 26 PRQ TRANSHEPATC BILIARY DRG C+ MNTR RS&I 177.94 XXX<br />
75980 TC PRQ TRANSHEPATC BILIARY DRG C+ MNTR RS&I 506.64 XXX<br />
75982 PRQ BILIARY DRG/DRG STENT RS&I 773.55 XXX<br />
75982 26 PRQ BILIARY DRG/DRG STENT RS&I 177.94 XXX<br />
75982 TC PRQ BILIARY DRG/DRG STENT RS&I 595.61 XXX<br />
75984 CHNG PRQ TUBE/DRAINAGE CATH W CONTRAST RS&I 280.09 XXX<br />
75984 26 CHNG PRQ TUBE/DRAINAGE CATH W CONTRAST RS&I 87.32 XXX<br />
75984 TC CHNG PRQ TUBE/DRAINAGE CATH W CONTRAST RS&I 192.77 XXX<br />
75989 RAD GID PRQ DRG W/PLMT CATH RS&I 330.34 XXX<br />
75989 26 RAD GID PRQ DRG W/PLMT CATH RS&I 142.52 XXX<br />
75989 TC RAD GID PRQ DRG W/PLMT CATH RS&I 187.82 XXX<br />
76000 FLUOR SPX 1 HR ASSISTING NON-RAD PHYS 259.50 XXX<br />
76010 RADEX FROM NOSE RECTUM FB 1 VIEW CHLD 67.55 XXX<br />
76010 26 RADEX FROM NOSE RECTUM FB 1 VIEW CHLD 22.24 XXX<br />
76010 TC RADEX FROM NOSE RECTUM FB 1 VIEW CHLD 45.31 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure<br />
198 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VIII: Diagnostic and <strong>The</strong>rapeutic Radiological Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
70010–79999 RADIOLOGY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
76080 RAD XM ABSC/FSTL/SINUS TRC RAD S&I 152.40 XXX<br />
76080 26 RAD XM ABSC/FSTL/SINUS TRC RAD S&I 65.90 XXX<br />
76080 TC RAD XM ABSC/FSTL/SINUS TRC RAD S&I 86.50 XXX<br />
76098 RAD XM SURG SPEC 46.96 XXX<br />
76098 26 RAD XM SURG SPEC 19.77 XXX<br />
76098 TC RAD XM SURG SPEC 27.19 XXX<br />
76100 RADEX 1 PLNE BDY SCTJ OTH/THN UROGRAPY 299.04 XXX<br />
76100 26 RADEX 1 PLNE BDY SCTJ OTH/THN UROGRAPY 74.97 XXX<br />
76100 TC RADEX 1 PLNE BDY SCTJ OTH/THN UROGRAPY 224.07 XXX<br />
76101 RADEX CPLX MOTION BDY SCTJ OTH/THN UROGRAPY UNI 430.02 XXX<br />
76101 26 RADEX CPLX MOTION BDY SCTJ OTH/THN UROGRAPY UNI 81.56 XXX<br />
76101 TC RADEX CPLX MOTION BDY SCTJ OTH/THN UROGRAPY UNI 348.46 XXX<br />
76102 RADEX CPLX MOTION BDY SCTJ OTH/THN UROGRAPY BI 577.48 XXX<br />
76102 26 RADEX CPLX MOTION BDY SCTJ OTH/THN UROGRAPY BI 83.20 XXX<br />
76102 TC RADEX CPLX MOTION BDY SCTJ OTH/THN UROGRAPY BI 494.28 XXX<br />
76120 CINERADIOGRAPY/VIDRADIOGRAPY XCPT WHERE SPEC 187.00 XXX<br />
76120 26 CINERADIOGRAPY/VIDRADIOGRAPY XCPT WHERE SPEC 46.13 XXX<br />
76120 TC CINERADIOGRAPY/VIDRADIOGRAPY XCPT WHERE SPEC 140.87 XXX<br />
+ 76125 CINERADIOGRAPY/VIDRADIOGRAPY ROUTINE XM 114.51 ZZZ<br />
+ 76125 26 CINERADIOGRAPY/VIDRADIOGRAPY ROUTINE XM 35.42 ZZZ<br />
+ 76125 TC CINERADIOGRAPY/VIDRADIOGRAPY ROUTINE XM 79.09 ZZZ<br />
76140 CONSLTJ X-RAY XM MADE ELSEWHERE WRTTN REPRT BR XXX<br />
76376 3D RNDR I&R CT MRI US/OTH X REQ POSTPCX 174.65 XXX<br />
76376 26 3D RNDR I&R CT MRI US/OTH X REQ POSTPCX 24.71 XXX<br />
76376 TC 3D RNDR I&R CT MRI US/OTH X REQ POSTPCX 149.94 XXX<br />
76377 3D RNDR I&R CT MRI US/OTH REQ POSTPCX 227.37 XXX<br />
76377 26 3D RNDR I&R CT MRI US/OTH REQ POSTPCX 95.56 XXX<br />
76377 TC 3D RNDR I&R CT MRI US/OTH REQ POSTPCX 131.81 XXX<br />
76380 CT LMTD/LOCLZD F-UP STD 461.33 XXX<br />
76380 26 CT LMTD/LOCLZD F-UP STD 117.80 XXX<br />
76380 TC CT LMTD/LOCLZD F-UP STD 343.53 XXX<br />
76390 MRI SPECTROSCOPY 1150.02 XXX<br />
76390 26 MRI SPECTROSCOPY 168.06 XXX<br />
76390 TC MRI SPECTROSCOPY 981.96 XXX<br />
76496 UNLIS FLUOR PX BR XXX<br />
76497 UNLIS CT PX BR XXX<br />
76498 UNLIS MRI PX BR XXX<br />
76499 UNLIS DX RADIOGRAPIC PX BR XXX<br />
76506 ECHOENCEPHALOGRAPY REAL TIME IMAGING 294.10 XXX<br />
76506 26 ECHOENCEPHALOGRAPY REAL TIME IMAGING 76.61 XXX<br />
76506 TC ECHOENCEPHALOGRAPY REAL TIME IMAGING 217.49 XXX<br />
76510 OPH US DX B-SCAN&QUAN A-SCAN SM PT ENCTR 406.13 XXX<br />
76510 26 OPH US DX B-SCAN&QUAN A-SCAN SM PT ENCTR 225.72 XXX<br />
76510 TC OPH US DX B-SCAN&QUAN A-SCAN SM PT ENCTR 180.41 XXX<br />
76511 OPH US DX QUAN A-SCAN ONLY 241.37 XXX<br />
76511 26 OPH US DX QUAN A-SCAN ONLY 123.57 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 199
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VIII: Diagnostic and <strong>The</strong>rapeutic Radiological Services<br />
RADIOLOGY 70010–79999<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
76511 TC OPH US DX QUAN A-SCAN ONLY 117.80 XXX<br />
76512 OPH US DX B-SCAN +-A-SCAN 224.07 XXX<br />
76512 26 OPH US DX B-SCAN +-A-SCAN 126.04 XXX<br />
76512 TC OPH US DX B-SCAN +-A-SCAN 98.03 XXX<br />
76513 OPH US DX ANT SGM US IMMERSION B-SCAN/HR BIOM 213.36 XXX<br />
76513 26 OPH US DX ANT SGM US IMMERSION B-SCAN/HR BIOM 82.38 XXX<br />
76513 TC OPH US DX ANT SGM US IMMERSION B-SCAN/HR BIOM 130.98 XXX<br />
76514 OPH US DX CRNL PACHYMETRY UNI/BI 33.78 XXX<br />
76514 26 OPH US DX CRNL PACHYMETRY UNI/BI 23.07 XXX<br />
76514 TC OPH US DX CRNL PACHYMETRY UNI/BI 10.71 XXX<br />
76516 OPH BMTRY US ECHOGRAPY A-SCAN 174.65 XXX<br />
76516 26 OPH BMTRY US ECHOGRAPY A-SCAN 70.85 XXX<br />
76516 TC OPH BMTRY US ECHOGRAPY A-SCAN 103.80 XXX<br />
76519 OPH BMTRY US ECHOGRAPY A-SCAN IO LENS PWR CAL 189.47 XXX<br />
76519 26 OPH BMTRY US ECHOGRAPY A-SCAN IO LENS PWR CAL 73.32 XXX<br />
76519 TC OPH BMTRY US ECHOGRAPY A-SCAN IO LENS PWR CAL 116.15 XXX<br />
76529 OPH ULTRASONIC FB LOCLZJ 178.76 XXX<br />
76529 26 OPH ULTRASONIC FB LOCLZJ 77.44 XXX<br />
76529 TC OPH ULTRASONIC FB LOCLZJ 101.32 XXX<br />
76536 US SOFT TISS HEAD&NCK R-T IMG 288.33 XXX<br />
76536 26 US SOFT TISS HEAD&NCK R-T IMG 67.55 XXX<br />
76536 TC US SOFT TISS HEAD&NCK R-T IMG 220.78 XXX<br />
76604 US CHEST R-T W/IMAGE DOCUMENTATION 214.19 XXX<br />
76604 26 US CHEST R-T W/IMAGE DOCUMENTATION 65.90 XXX<br />
76604 TC US CHEST R-T W/IMAGE DOCUMENTATION 148.29 XXX<br />
76645 US BREAST R-T W/IMAGE DOCUMENTATION 233.96 XXX<br />
76645 26 US BREAST R-T W/IMAGE DOCUMENTATION 65.90 XXX<br />
76645 TC US BREAST R-T W/IMAGE DOCUMENTATION 168.06 XXX<br />
76700 US ABDOMINAL R-T W/IMAGE DOCUMENTATION 342.70 XXX<br />
76700 26 US ABDOMINAL R-T W/IMAGE DOCUMENTATION 97.21 XXX<br />
76700 TC US ABDOMINAL R-T W/IMAGE DOCUMENTATION 245.49 XXX<br />
76705 ULTRASOUND ABDOMINAL R-T W/IMAGE LIMITED 260.32 XXX<br />
76705 26 ULTRASOUND ABDOMINAL R-T W/IMAGE LIMITED 70.85 XXX<br />
76705 TC ULTRASOUND ABDOMINAL R-T W/IMAGE LIMITED 189.47 XXX<br />
76770 US RETROPERITONEAL R-T W/IMAGE COMPL 325.40 XXX<br />
76770 26 US RETROPERITONEAL R-T W/IMAGE COMPL 88.97 XXX<br />
76770 TC US RETROPERITONEAL R-T W/IMAGE COMPL 236.43 XXX<br />
76775 US RPR B-SCAN&/R-T IMG LMTD 271.85 XXX<br />
76775 26 US RPR B-SCAN&/R-T IMG LMTD 70.85 XXX<br />
76775 TC US RPR B-SCAN&/R-T IMG LMTD 201.00 XXX<br />
76776 US TRNSPL KDN R-T IMG +- DUPLEX DOP STD 369.06 XXX<br />
76776 26 US TRNSPL KDN R-T IMG +- DUPLEX DOP STD 91.44 XXX<br />
76776 TC US TRNSPL KDN R-T IMG +- DUPLEX DOP STD 277.62 XXX<br />
76800 US SPI CANAL&CNTS 324.58 XXX<br />
76800 26 US SPI CANAL&CNTS 133.46 XXX<br />
76800 TC US SPI CANAL&CNTS 191.12 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure<br />
200 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VIII: Diagnostic and <strong>The</strong>rapeutic Radiological Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
70010–79999 RADIOLOGY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
76801 US PG UTER IMG F&MAT 14 WK TABDL 1/1ST GESTATION 317.16 XXX<br />
76801 26 US PG UTER IMG F&MAT 14 WK TABDL 1/1ST GESTATION 118.63 XXX<br />
76801 TC US PG UTER IMG F&MAT 14 WK TABDL 1/1ST GESTATION 198.53 XXX<br />
+ 76802 US PG UTER F&MAT 14 WK TABDL EA GESTATION 170.53 ZZZ<br />
+ 76802 26 US PG UTER F&MAT 14 WK TABDL EA GESTATION 99.68 ZZZ<br />
+ 76802 TC US PG UTER F&MAT 14 WK TABDL EA GESTATION 70.85 ZZZ<br />
76805 US PG UTER F&MAT AFTER 1ST TRI 1/1ST GESTATION 363.30 XXX<br />
76805 26 US PG UTER F&MAT AFTER 1ST TRI 1/1ST GESTATION 118.63 XXX<br />
76805 TC US PG UTER F&MAT AFTER 1ST TRI 1/1ST GESTATION 244.67 XXX<br />
+ 76810 US PG UTER F&MAT AFTER 1ST TRI ABDL EA GESTATION 238.08 ZZZ<br />
+ 76810 26 US PG UTER F&MAT AFTER 1ST TRI ABDL EA GESTATION 116.98 ZZZ<br />
+ 76810 TC US PG UTER F&MAT AFTER 1ST TRI ABDL EA GESTATION 121.10 ZZZ<br />
76811 US PG UTER F&MAT DETAILED FTL XM 1ST GESTATION 470.39 XXX<br />
76811 26 US PG UTER F&MAT DETAILED FTL XM 1ST GESTATION 227.37 XXX<br />
76811 TC US PG UTER F&MAT DETAILED FTL XM 1ST GESTATION 243.02 XXX<br />
+ 76812 US PG UTER F&MAT DETAILED FTL ANTMC XM EA 498.40 ZZZ<br />
+ 76812 26 US PG UTER F&MAT DETAILED FTL ANTMC XM EA 212.54 ZZZ<br />
+ 76812 TC US PG UTER F&MAT DETAILED FTL ANTMC XM EA 285.86 ZZZ<br />
76813 US FETAL NUCHAL TRANSLUCENCY 1ST GESTATION 308.93 XXX<br />
76813 26 US FETAL NUCHAL TRANSLUCENCY 1ST GESTATION 140.87 XXX<br />
76813 TC US FETAL NUCHAL TRANSLUCENCY 1ST GESTATION 168.06 XXX<br />
+ 76814 US FETAL NUCHAL TRANSLUCENCY EA ADDL GESTATION 196.89 XXX<br />
+ 76814 26 US FETAL NUCHAL TRANSLUCENCY EA ADDL GESTATION 117.80 XXX<br />
+ 76814 TC US FETAL NUCHAL TRANSLUCENCY EA ADDL GESTATION 79.09 XXX<br />
76815 US PG UTER R-T IMG LMTD 1+ FETUSES 222.43 XXX<br />
76815 26 US PG UTER R-T IMG LMTD 1+ FETUSES 76.61 XXX<br />
76815 TC US PG UTER R-T IMG LMTD 1+ FETUSES 145.82 XXX<br />
76816 US PG UTER R-T IMG F-UP TABDL APPR PR FETUS 285.03 XXX<br />
76816 26 US PG UTER R-T IMG F-UP TABDL APPR PR FETUS 102.15 XXX<br />
76816 TC US PG UTER R-T IMG F-UP TABDL APPR PR FETUS 182.88 XXX<br />
76817 US PG UTER R-T IMG TRVG 252.08 XXX<br />
76817 26 US PG UTER R-T IMG TRVG 89.79 XXX<br />
76817 TC US PG UTER R-T IMG TRVG 162.29 XXX<br />
76818 FTL BIOPHYSICAL PROFILE NON-STRS TSTG 298.22 XXX<br />
76818 26 FTL BIOPHYSICAL PROFILE NON-STRS TSTG 126.04 XXX<br />
76818 TC FTL BIOPHYSICAL PROFILE NON-STRS TSTG 172.18 XXX<br />
76819 FTL BIOPHYSICAL PROFILE W/O NON-STRS TSTG 224.07 XXX<br />
76819 26 FTL BIOPHYSICAL PROFILE W/O NON-STRS TSTG 93.09 XXX<br />
76819 TC FTL BIOPHYSICAL PROFILE W/O NON-STRS TSTG 130.98 XXX<br />
76820 DOP VELOCIMETRY FTL UMBILICAL ART 113.68 XXX<br />
76820 26 DOP VELOCIMETRY FTL UMBILICAL ART 59.31 XXX<br />
76820 TC DOP VELOCIMETRY FTL UMBILICAL ART 54.37 XXX<br />
76821 DOP VELOCIMETRY FTL MIDDLE CERE ART 237.25 XXX<br />
76821 26 DOP VELOCIMETRY FTL MIDDLE CERE ART 84.85 XXX<br />
76821 TC DOP VELOCIMETRY FTL MIDDLE CERE ART 152.40 XXX<br />
76825 ECHO FTL CV SYS R-T REC 528.88 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 201
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VIII: Diagnostic and <strong>The</strong>rapeutic Radiological Services<br />
RADIOLOGY 70010–79999<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
76825 26 ECHO FTL CV SYS R-T REC 198.54 XXX<br />
76825 TC ECHO FTL CV SYS R-T REC 330.34 XXX<br />
76826 ECHO FTL CV SYS R-T REC REPEAT STD 304.81 XXX<br />
76826 26 ECHO FTL CV SYS R-T REC REPEAT STD 98.86 XXX<br />
76826 TC ECHO FTL CV SYS R-T REC REPEAT STD 205.95 XXX<br />
76827 DOP ECHO FTL SPECTRAL DISPLAY COMPL 161.46 XXX<br />
76827 26 DOP ECHO FTL SPECTRAL DISPLAY COMPL 68.38 XXX<br />
76827 TC DOP ECHO FTL SPECTRAL DISPLAY COMPL 93.08 XXX<br />
76828 DOP ECHO FTL PLSD SPECTRAL DISPLAY REPEAT STD 118.63 XXX<br />
76828 26 DOP ECHO FTL PLSD SPECTRAL DISPLAY REPEAT STD 66.73 XXX<br />
76828 TC DOP ECHO FTL PLSD SPECTRAL DISPLAY REPEAT STD 51.90 XXX<br />
76830 US TRVG 304.81 XXX<br />
76830 26 US TRVG 83.20 XXX<br />
76830 TC US TRVG 221.61 XXX<br />
76831 SALINE NFS SHG SIS COL FLO DOP PFRMD 305.63 XXX<br />
76831 26 SALINE NFS SHG SIS COL FLO DOP PFRMD 86.50 XXX<br />
76831 TC SALINE NFS SHG SIS COL FLO DOP PFRMD 219.13 XXX<br />
76856 US PELVIC NONOB REAL-TIME IMG COMPLETE 303.98 XXX<br />
76856 26 US PELVIC NONOB REAL-TIME IMG COMPLETE 83.20 XXX<br />
76856 TC US PELVIC NONOB REAL-TIME IMG COMPLETE 220.78 XXX<br />
76857 US PEL NONOB B-SCAN&/R-T IMG LMTD/F-UP+C97 247.14 XXX<br />
76857 26 US PEL NONOB B-SCAN&/R-T IMG LMTD/F-UP+C97 47.78 XXX<br />
76857 TC US PEL NONOB B-SCAN&/R-T IMG LMTD/F-UP+C97 199.36 XXX<br />
76870 US SCROTUM&CNTS 302.33 XXX<br />
76870 26 US SCROTUM&CNTS 78.26 XXX<br />
76870 TC US SCROTUM&CNTS 224.07 XXX<br />
76872 US TRANSRCT 342.70 XXX<br />
76872 26 US TRANSRCT 85.68 XXX<br />
76872 TC US TRANSRCT 257.02 XXX<br />
76873 US TRANSRCT PRST8 VOL STD BRACHYTX PLNNING SPX 434.14 XXX<br />
76873 26 US TRANSRCT PRST8 VOL STD BRACHYTX PLNNING SPX 189.47 XXX<br />
76873 TC US TRANSRCT PRST8 VOL STD BRACHYTX PLNNING SPX 244.67 XXX<br />
l 76881 US EXTREMITY NON-VASC REAL-TIME IMG COMPL 279.27 XXX<br />
l 76881 26 US EXTREMITY NON-VASC REAL-TIME IMG COMPL 70.02 XXX<br />
l 76881 TC US EXTREMITY NON-VASC REAL-TIME IMG COMPL 209.25 XXX<br />
l 76882 US EXTREMITY NON-VASC REAL-TIME IMG LMTD 73.32 XXX<br />
l 76882 26 US EXTREMITY NON-VASC REAL-TIME IMG LMTD 48.60 XXX<br />
l 76882 TC US EXTREMITY NON-VASC REAL-TIME IMG LMTD 24.72 XXX<br />
76885 US INFT HIPS R-T IMG DYNAMIC REQ PHYS MNPJ 354.23 XXX<br />
76885 26 US INFT HIPS R-T IMG DYNAMIC REQ PHYS MNPJ 89.79 XXX<br />
76885 TC US INFT HIPS R-T IMG DYNAMIC REQ PHYS MNPJ 264.44 XXX<br />
76886 US INFT HIPS R-T IMG LMTD STATIC X PHYS MNPJ 280.92 XXX<br />
76886 26 US INFT HIPS R-T IMG LMTD STATIC X PHYS MNPJ 74.97 XXX<br />
76886 TC US INFT HIPS R-T IMG LMTD STATIC X PHYS MNPJ 205.95 XXX<br />
76930 US PRICARDIOCNTS IMG S&I 220.78 XXX<br />
76930 26 US PRICARDIOCNTS IMG S&I 82.38 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure<br />
202 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VIII: Diagnostic and <strong>The</strong>rapeutic Radiological Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
70010–79999 RADIOLOGY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
76930 TC US PRICARDIOCNTS IMG S&I 138.40 XXX<br />
76932 US ENDOMYOCRD BX IMG S&I 231.49 XXX<br />
76932 26 US ENDOMYOCRD BX IMG S&I 85.68 XXX<br />
76932 TC US ENDOMYOCRD BX IMG S&I 145.81 XXX<br />
76936 US CMPRN RPR ARTL PSEUDOARYSM/ARVEN FSTL 756.25 XXX<br />
76936 26 US CMPRN RPR ARTL PSEUDOARYSM/ARVEN FSTL 248.79 XXX<br />
76936 TC US CMPRN RPR ARTL PSEUDOARYSM/ARVEN FSTL 507.46 XXX<br />
+ 76937 US VASC ACCESS SITS VSL PATENCY NDL ENTRY 84.85 ZZZ<br />
+ 76937 26 US VASC ACCESS SITS VSL PATENCY NDL ENTRY 37.07 ZZZ<br />
+ 76937 TC US VASC ACCESS SITS VSL PATENCY NDL ENTRY 47.78 ZZZ<br />
76940 US &MNTR PARENCHYMAL TISSUE ABLATION 413.55 XXX<br />
76940 26 US &MNTR PARENCHYMAL TISSUE ABLATION 256.20 XXX<br />
76940 TC US &MNTR PARENCHYMAL TISSUE ABLATION 157.35 XXX<br />
76941 US INTRAUTERINE FTL TFUJ/CORDOCNTS IMG S&I 309.75 XXX<br />
76941 26 US INTRAUTERINE FTL TFUJ/CORDOCNTS IMG S&I 167.23 XXX<br />
76941 TC US INTRAUTERINE FTL TFUJ/CORDOCNTS IMG S&I 142.52 XXX<br />
76942 US NDL PLMT IMG S&I 480.28 XXX<br />
76942 26 US NDL PLMT IMG S&I 81.56 XXX<br />
76942 TC US NDL PLMT IMG S&I 398.72 XXX<br />
76945 US CHORNC VILLUS SAMPLING IMG S&I 229.02 XXX<br />
76945 26 US CHORNC VILLUS SAMPLING IMG S&I 82.38 XXX<br />
76945 TC US CHORNC VILLUS SAMPLING IMG S&I 146.64 XXX<br />
76946 US AMNIOCNTS IMG S&I 92.27 XXX<br />
76946 26 US AMNIOCNTS IMG S&I 45.31 XXX<br />
76946 TC US AMNIOCNTS IMG S&I 46.96 XXX<br />
76948 US ASPIR OVA IMG S&I 93.91 XXX<br />
76948 26 US ASPIR OVA IMG S&I 46.96 XXX<br />
76948 TC US ASPIR OVA IMG S&I 46.95 XXX<br />
76950 US PLMT RADJ THER FLDS 168.06 XXX<br />
76950 26 US PLMT RADJ THER FLDS 70.85 XXX<br />
76950 TC US PLMT RADJ THER FLDS 97.21 XXX<br />
76965 US NTRSTL RADIOELMNT APPL 287.51 XXX<br />
76965 26 US NTRSTL RADIOELMNT APPL 165.58 XXX<br />
76965 TC US NTRSTL RADIOELMNT APPL 121.93 XXX<br />
76970 US STD F-UP SPEC 233.96 XXX<br />
76970 26 US STD F-UP SPEC 49.43 XXX<br />
76970 TC US STD F-UP SPEC 184.53 XXX<br />
76975 GI NDSC US S&I 257.03 XXX<br />
76975 26 GI NDSC US S&I 105.45 XXX<br />
76975 TC GI NDSC US S&I 151.58 XXX<br />
76977 US B1 DNS MEAS&INTERPJ PRPH SIT ANY METH 25.54 XXX<br />
76977 26 US B1 DNS MEAS&INTERPJ PRPH SIT ANY METH 6.59 XXX<br />
76977 TC US B1 DNS MEAS&INTERPJ PRPH SIT ANY METH 18.95 XXX<br />
76998 ULTRASONIC GUIDANCE INTRAOPERATIVE 158.99 XXX<br />
76998 26 ULTRASONIC GUIDANCE INTRAOPERATIVE 158.99 XXX<br />
76998 TC ULTRASONIC GUIDANCE INTRAOPERATIVE 0.00 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 203
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VIII: Diagnostic and <strong>The</strong>rapeutic Radiological Services<br />
RADIOLOGY 70010–79999<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
76999 UNLIS US PX BR XXX<br />
+ 77001 FLUOR GID CTR VAD PLMT RPLCMT/RMVL 278.44 ZZZ<br />
+ 77001 26 FLUOR GID CTR VAD PLMT RPLCMT/RMVL 46.96 ZZZ<br />
+ 77001 TC FLUOR GID CTR VAD PLMT RPLCMT/RMVL 231.48 ZZZ<br />
77002 FLUOROSCOPIC GUIDANCE NEEDLE PLACEMENT 183.71 XXX<br />
77002 26 FLUOROSCOPIC GUIDANCE NEEDLE PLACEMENT 66.73 XXX<br />
77002 TC FLUOROSCOPIC GUIDANCE NEEDLE PLACEMENT 116.98 XXX<br />
s 77003 FLUOR GID & LOCLZJ NDL/CATH SPI DX/THER NJX 151.58 XXX<br />
s 77003 26 FLUOR GID & LOCLZJ NDL/CATH SPI DX/THER NJX 71.67 XXX<br />
s 77003 TC FLUOR GID & LOCLZJ NDL/CATH SPI DX/THER NJX 79.91 XXX<br />
77011 CT GUIDANCE STEREOTACTIC LOCALIZATION 1173.09 XXX<br />
77011 26 CT GUIDANCE STEREOTACTIC LOCALIZATION 147.46 XXX<br />
77011 TC CT GUIDANCE STEREOTACTIC LOCALIZATION 1025.63 XXX<br />
77012 CT GUIDANCE NEEDLE PLACEMENT 397.07 XXX<br />
77012 26 CT GUIDANCE NEEDLE PLACEMENT 138.40 XXX<br />
77012 TC CT GUIDANCE NEEDLE PLACEMENT 258.67 XXX<br />
77013 CT GUIDANCE &MONITORING VISC TISS ABLATION 1374.92 XXX<br />
77013 26 CT GUIDANCE &MONITORING VISC TISS ABLATION 495.10 XXX<br />
77013 TC CT GUIDANCE &MONITORING VISC TISS ABLATION 879.82 XXX<br />
77014 CT GUIDANCE RADIATION THERAPY FLDS PLACEMENT 465.45 XXX<br />
77014 26 CT GUIDANCE RADIATION THERAPY FLDS PLACEMENT 102.98 XXX<br />
77014 TC CT GUIDANCE RADIATION THERAPY FLDS PLACEMENT 362.47 XXX<br />
77021 MR GUIDANCE NEEDLE PLACEMENT 1053.64 XXX<br />
77021 26 MR GUIDANCE NEEDLE PLACEMENT 184.53 XXX<br />
77021 TC MR GUIDANCE NEEDLE PLACEMENT 869.11 XXX<br />
77022 MR GUIDANCE &MONITORING TISSUE ABLATION 1687.14 XXX<br />
77022 26 MR GUIDANCE &MONITORING TISSUE ABLATION 523.11 XXX<br />
77022 TC MR GUIDANCE &MONITORING TISSUE ABLATION 1164.03 XXX<br />
77031 STRTCTC LOCLZJ GID BREAST BX/NEEDLE PLACEMENT 392.13 XXX<br />
77031 26 STRTCTC LOCLZJ GID BREAST BX/NEEDLE PLACEMENT 194.42 XXX<br />
77031 TC STRTCTC LOCLZJ GID BREAST BX/NEEDLE PLACEMENT 197.71 XXX<br />
77032 MAMMOGRAPHIC GID NEEDLE PLACEMENTT BREAST 135.93 XXX<br />
77032 26 MAMMOGRAPHIC GID NEEDLE PLACEMENTT BREAST 67.55 XXX<br />
77032 TC MAMMOGRAPHIC GID NEEDLE PLACEMENTT BREAST 68.38 XXX<br />
+ 77051 COMPUTER-AIDED DETECTION DX MAMMOGRAPHY 28.01 ZZZ<br />
+ 77051 26 COMPUTER-AIDED DETECTION DX MAMMOGRAPHY 7.41 ZZZ<br />
+ 77051 TC COMPUTER-AIDED DETECTION DX MAMMOGRAPHY 20.60 ZZZ<br />
+ 77052 COMPUTER-AIDED DETECTION SCREENING MAMMOGRAPHY 28.01 ZZZ<br />
+ 77052 26 COMPUTER-AIDED DETECTION SCREENING MAMMOGRAPHY 7.41 ZZZ<br />
+ 77052 TC COMPUTER-AIDED DETECTION SCREENING MAMMOGRAPHY 20.60 ZZZ<br />
77053 MAMMARY DUCTOGRAM OR GALACTOGRAM SINGLE 164.76 XXX<br />
77053 26 MAMMARY DUCTOGRAM OR GALACTOGRAM SINGLE 42.84 XXX<br />
77053 TC MAMMARY DUCTOGRAM OR GALACTOGRAM SINGLE 121.92 XXX<br />
77054 MAMMARY DUCTOGRAM OR GALACTOGRAM MULTIPLE 223.25 XXX<br />
77054 26 MAMMARY DUCTOGRAM OR GALACTOGRAM MULTIPLE 55.19 XXX<br />
77054 TC MAMMARY DUCTOGRAM OR GALACTOGRAM MULTIPLE 168.06 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure<br />
204 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VIII: Diagnostic and <strong>The</strong>rapeutic Radiological Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
70010–79999 RADIOLOGY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
77055 MAMMOGRAPHY UNILATERAL 210.07 XXX<br />
77055 26 MAMMOGRAPHY UNILATERAL 84.85 XXX<br />
77055 TC MAMMOGRAPHY UNILATERAL 125.22 XXX<br />
77056 MAMMOGRAPHY BILATERAL 268.56 XXX<br />
77056 26 MAMMOGRAPHY BILATERAL 105.45 XXX<br />
77056 TC MAMMOGRAPHY BILATERAL 163.11 XXX<br />
77057 SCREENING MAMMOGRAPHY BILATERAL 196.89 XXX<br />
77057 26 SCREENING MAMMOGRAPHY BILATERAL 84.85 XXX<br />
77057 TC SCREENING MAMMOGRAPHY BILATERAL 112.04 XXX<br />
77058 MRI BREAST UNILATERAL 1839.55 XXX<br />
77058 26 MRI BREAST UNILATERAL 197.71 XXX<br />
77058 TC MRI BREAST UNILATERAL 1641.84 XXX<br />
77059 MRI BREAST BILATERAL 1908.74 XXX<br />
77059 26 MRI BREAST BILATERAL 197.71 XXX<br />
77059 TC MRI BREAST BILATERAL 1711.03 XXX<br />
77071 MANUAL APPL STRESS PFRMD PHYS JOINT RADIOGRAPHY 113.68 XXX<br />
77072 BONE AGE STUDIES 57.67 XXX<br />
77072 26 BONE AGE STUDIES 23.07 XXX<br />
77072 TC BONE AGE STUDIES 34.60 XXX<br />
77073 BONE LENGTH STUDIES 95.56 XXX<br />
77073 26 BONE LENGTH STUDIES 36.25 XXX<br />
77073 TC BONE LENGTH STUDIES 59.31 XXX<br />
77074 RADIOLOGIC EXAMINATION OSSEOUS SURVEY LIMITED 170.53 XXX<br />
77074 26 RADIOLOGIC EXAMINATION OSSEOUS SURVEY LIMITED 55.19 XXX<br />
77074 TC RADIOLOGIC EXAMINATION OSSEOUS SURVEY LIMITED 115.34 XXX<br />
77075 RADIOLOGIC EXAMINATION OSSEOUS SURVEY COMPL 250.44 XXX<br />
77075 26 RADIOLOGIC EXAMINATION OSSEOUS SURVEY COMPL 65.08 XXX<br />
77075 TC RADIOLOGIC EXAMINATION OSSEOUS SURVEY COMPL 185.36 XXX<br />
77076 RADIOLOGIC EXAMINATION OSSEOUS SURVEY INFANT 244.67 XXX<br />
77076 26 RADIOLOGIC EXAMINATION OSSEOUS SURVEY INFANT 83.20 XXX<br />
77076 TC RADIOLOGIC EXAMINATION OSSEOUS SURVEY INFANT 161.47 XXX<br />
77077 JOINT SURVEY SINGLE VIEW 2 OR MORE JOINTS 102.98 XXX<br />
77077 26 JOINT SURVEY SINGLE VIEW 2 OR MORE JOINTS 40.37 XXX<br />
77077 TC JOINT SURVEY SINGLE VIEW 2 OR MORE JOINTS 62.61 XXX<br />
77078 CT BONE MINERAL DENSITY STUDY 1+ SITS AXIAL SKEL 383.07 XXX<br />
77078 26 CT BONE MINERAL DENSITY STUDY 1+ SITS AXIAL SKEL 29.66 XXX<br />
77078 TC CT BONE MINERAL DENSITY STUDY 1+ SITS AXIAL SKEL 353.41 XXX<br />
77079 CT BONE MINERAL DENSITY STUDY 1+ SITS APPND 123.57 XXX<br />
77079 26 CT BONE MINERAL DENSITY STUDY 1+ SITS APPND 26.36 XXX<br />
77079 TC CT BONE MINERAL DENSITY STUDY 1+ SITS APPND 97.21 XXX<br />
77080 DXA BONE DENSITY STUDY 1+ SITS AXIAL SKEL 236.43 XXX<br />
77080 26 DXA BONE DENSITY STUDY 1+ SITS AXIAL SKEL 26.36 XXX<br />
77080 TC DXA BONE DENSITY STUDY 1+ SITS AXIAL SKEL 210.07 XXX<br />
77081 DXA BONE DENSITY STUDY 1+ SITS APPENDICULAR SKEL 70.02 XXX<br />
77081 26 DXA BONE DENSITY STUDY 1+ SITS APPENDICULAR SKEL 23.89 XXX<br />
77081 TC DXA BONE DENSITY STUDY 1+ SITS APPENDICULAR SKEL 46.13 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 205
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VIII: Diagnostic and <strong>The</strong>rapeutic Radiological Services<br />
RADIOLOGY 70010–79999<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
77082 DXA BONE DENSITY STUDY VERTEBRAL FRACTURE 67.55 XXX<br />
77082 26 DXA BONE DENSITY STUDY VERTEBRAL FRACTURE 15.65 XXX<br />
77082 TC DXA BONE DENSITY STUDY VERTEBRAL FRACTURE 51.90 XXX<br />
77083 RADIOGRAPHIC ABSORPTIOMETRY 1+ SITS 60.96 XXX<br />
77083 26 RADIOGRAPHIC ABSORPTIOMETRY 1+ SITS 23.89 XXX<br />
77083 TC RADIOGRAPHIC ABSORPTIOMETRY 1+ SITS 37.07 XXX<br />
77084 BONE MARROW BLOOD SUPPLY 1284.30 XXX<br />
77084 26 BONE MARROW BLOOD SUPPLY 195.24 XXX<br />
77084 TC BONE MARROW BLOOD SUPPLY 1089.06 XXX<br />
77261 THER RAD TX PLNNING SMPL 175.47 XXX<br />
77262 THER RAD TX PLNNING INTRM 264.44 XXX<br />
77263 THER RAD TX PLNNING CPLX 392.13 XXX<br />
77280 THER RAD SIMULAJ-AIDED FLD SETTING SMPL 458.03 XXX<br />
77280 26 THER RAD SIMULAJ-AIDED FLD SETTING SMPL 84.85 XXX<br />
77280 TC THER RAD SIMULAJ-AIDED FLD SETTING SMPL 373.18 XXX<br />
77285 THER RAD SIMULAJ-AIDED FLD SETTING INTRM 803.21 XXX<br />
77285 26 THER RAD SIMULAJ-AIDED FLD SETTING INTRM 127.69 XXX<br />
77285 TC THER RAD SIMULAJ-AIDED FLD SETTING INTRM 675.52 XXX<br />
77290 THER RAD SIMULAJ-AIDED FLD SETTING CPLX 1285.13 XXX<br />
77290 26 THER RAD SIMULAJ-AIDED FLD SETTING CPLX 189.47 XXX<br />
77290 TC THER RAD SIMULAJ-AIDED FLD SETTING CPLX 1095.66 XXX<br />
77295 THER RAD SIMULAJ-AIDED FLD SETTING 3-DIMENSIONAL 1369.16 XXX<br />
77295 26 THER RAD SIMULAJ-AIDED FLD SETTING 3-DIMENSIONAL 556.07 XXX<br />
77295 TC THER RAD SIMULAJ-AIDED FLD SETTING 3-DIMENSIONAL 813.09 XXX<br />
77299 UNLIS PX THER RAD CLINICAL TX PLNNING BR XXX<br />
77300 BASIC RADJ DOSIM CAL 169.70 XXX<br />
77300 26 BASIC RADJ DOSIM CAL 75.79 XXX<br />
77300 TC BASIC RADJ DOSIM CAL 93.91 XXX<br />
77301 NTSTY MODUL RADTHX PLN DOSE-VOL HISTOS 5063.07 XXX<br />
77301 26 NTSTY MODUL RADTHX PLN DOSE-VOL HISTOS 973.73 XXX<br />
77301 TC NTSTY MODUL RADTHX PLN DOSE-VOL HISTOS 4089.34 XXX<br />
77305 TELETHX ISODOSE PLN SMPL 161.46 XXX<br />
77305 26 TELETHX ISODOSE PLN SMPL 84.85 XXX<br />
77305 TC TELETHX ISODOSE PLN SMPL 76.61 XXX<br />
77310 TELETHX ISODOSE PLN INTRM 228.19 XXX<br />
77310 26 TELETHX ISODOSE PLN INTRM 127.69 XXX<br />
77310 TC TELETHX ISODOSE PLN INTRM 100.50 XXX<br />
77315 TELETHX ISODOSE PLN CPLX 346.00 XXX<br />
77315 26 TELETHX ISODOSE PLN CPLX 189.47 XXX<br />
77315 TC TELETHX ISODOSE PLN CPLX 156.53 XXX<br />
77321 SPEC TELETHX PORT PLN PARTS HEMIBDY TOT BDY 259.50 XXX<br />
77321 26 SPEC TELETHX PORT PLN PARTS HEMIBDY TOT BDY 114.51 XXX<br />
77321 TC SPEC TELETHX PORT PLN PARTS HEMIBDY TOT BDY 144.99 XXX<br />
77326 BRACHYTX ISODOSE PLN SMPL 351.76 XXX<br />
77326 26 BRACHYTX ISODOSE PLN SMPL 112.04 XXX<br />
77326 TC BRACHYTX ISODOSE PLN SMPL 239.72 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure<br />
206 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VIII: Diagnostic and <strong>The</strong>rapeutic Radiological Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
70010–79999 RADIOLOGY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
77327 BRACHYTX ISODOSE PLN INTRM 498.40 XXX<br />
77327 26 BRACHYTX ISODOSE PLN INTRM 168.88 XXX<br />
77327 TC BRACHYTX ISODOSE PLN INTRM 329.52 XXX<br />
77328 BRACHYTX ISODOSE PLN CPLX 673.04 XXX<br />
77328 26 BRACHYTX ISODOSE PLN CPLX 253.73 XXX<br />
77328 TC BRACHYTX ISODOSE PLN CPLX 419.31 XXX<br />
77331 SPEC DOSIM ONLY PRESCRIBED TREATING PHYS 153.23 XXX<br />
77331 26 SPEC DOSIM ONLY PRESCRIBED TREATING PHYS 106.27 XXX<br />
77331 TC SPEC DOSIM ONLY PRESCRIBED TREATING PHYS 46.96 XXX<br />
77332 TX DEV DESIGN&CONSTJ SMPL SMPL BLK SMPL BOLUS 191.12 XXX<br />
77332 26 TX DEV DESIGN&CONSTJ SMPL SMPL BLK SMPL BOLUS 65.90 XXX<br />
77332 TC TX DEV DESIGN&CONSTJ SMPL SMPL BLK SMPL BOLUS 125.22 XXX<br />
77333 TX DEV DESIGN&CONSTJ INTRM 144.99 XXX<br />
77333 26 TX DEV DESIGN&CONSTJ INTRM 102.15 XXX<br />
77333 TC TX DEV DESIGN&CONSTJ INTRM 42.84 XXX<br />
77334 TX DEV DESIGN&CONSTJ CPLX 372.36 XXX<br />
77334 26 TX DEV DESIGN&CONSTJ CPLX 149.93 XXX<br />
77334 TC TX DEV DESIGN&CONSTJ CPLX 222.43 XXX<br />
77336 CONTINUING <strong>MEDICAL</strong> PHYSICS CONSLTJ PR WK 126.87 XXX<br />
77338 MLC IMRT DESIGN & CONSTRUCTION PER IMRT PLAN 1162.38 XXX<br />
77338 26 MLC IMRT DESIGN & CONSTRUCTION PER IMRT PLAN 528.06 XXX<br />
77338 TC MLC IMRT DESIGN & CONSTRUCTION PER IMRT PLAN 634.32 XXX<br />
77370 SPEC <strong>MEDICAL</strong> RADJ PHYSICS CONSLTJ 282.56 XXX<br />
K 77371 RADIATION DELIVERY STEREOTACTIC CRANIAL COBALT 3413.83 XXX<br />
77372 RADIATION DELIVERY STEREOTACTIC CRANIAL LINEAR 2065.27 XXX<br />
77373 STEREOTACTIC BODY RADIATION DELIVERY 3856.21 XXX<br />
77399 UNLIS <strong>MEDICAL</strong> RADJ DOSIM TX DEV SPEC SVCS BR XXX<br />
77401 RADJ DLVR SUPFC&/ORTHO VOLTAGE 61.79 XXX<br />
77402 RADJ DLVR 1 AREA 1/PRLL OPSD PORTS SMPL PORTS 1 MLT BLKS PORTS 1 MLT BLKS 6-1MEV 432.50 XXX<br />
77409 RADJ DLVR 2 AREAS 3/>PORTS 1 MLT BLKS 11-19MEV 481.10 XXX<br />
77411 RADJ DLVR 2 AREAS 3/> PORTS 1 TX AREA 20 MEV/< 478.63 XXX<br />
77412 RADJ DLVR 3/> AREAS CUSTOM BLKING AREAS CUSTOM BLKING 6-10MEV 568.42 XXX<br />
77414 RADJ DLVR 3/> AREAS CUSTOM BLKING 11-19MEV 635.97 XXX<br />
77416 RADJ DLVR 3/> AREAS CUSTOM BLKING 20MEV/< 639.27 XXX<br />
77417 THER RAD PORT FLM 36.25 XXX<br />
77418 NTSTY MODUL DLVR 1/MLT FLDS/ARCS PR TX SESSION 1260.41 XXX<br />
77421 STRSC X-RAY GDN LOCLZJ TARGET VOL DLVR RADJ THER 266.91 XXX<br />
77421 26 STRSC X-RAY GDN LOCLZJ TARGET VOL DLVR RADJ THER 46.96 XXX<br />
77421 TC STRSC X-RAY GDN LOCLZJ TARGET VOL DLVR RADJ THER 219.95 XXX<br />
77422 HI NRG NEUTRON RADJ TX DLVR 1 TX AREA 482.75 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 207
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VIII: Diagnostic and <strong>The</strong>rapeutic Radiological Services<br />
RADIOLOGY 70010–79999<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
77423 HI NRG NEUTRON RADJ TX DLVR 1/> ISOCENTER 613.73 XXX<br />
77427 RADJ TX MGMT 5 TXS 437.44 XXX<br />
77431 RADJ THER MGMT COMPL 1/2 FXJS ONLY 239.73 XXX<br />
77432 STERETCTC RADIATION TX MANAGEMENT CRANIAL LESION 991.03 XXX<br />
77435 STEREOTACTIC BODY RADIATION MANAGEMENT 1641.83 XXX<br />
77470 SPEC TX PX 490.16 XXX<br />
77470 26 SPEC TX PX 254.55 XXX<br />
77470 TC SPEC TX PX 235.61 XXX<br />
77499 UNLIS THER RAD TX MGMT BR XXX<br />
77520 PROTON TX DLVR SMPL W/O COMPENSATION BR XXX<br />
77522 PROTON TX DLVR SMPL COMPENSATION BR XXX<br />
77523 PROTON TX DLVR INTRM BR XXX<br />
77525 PROTON TX DLVR CPLX BR XXX<br />
K 77600 HYPRTHM XTRNLLY GEN SUPFC 988.56 XXX<br />
K 77600 26 HYPRTHM XTRNLLY GEN SUPFC 189.47 XXX<br />
K 77600 TC HYPRTHM XTRNLLY GEN SUPFC 799.09 XXX<br />
K 77605 HYPRTHM XTRNLLY GEN DP 2258.86 XXX<br />
K 77605 26 HYPRTHM XTRNLLY GEN DP 271.03 XXX<br />
K 77605 TC HYPRTHM XTRNLLY GEN DP 1987.83 XXX<br />
K 77610 HYPRTHM GEN NTRSTL PRB 5/FEWER 2057.03 XXX<br />
K 77610 26 HYPRTHM GEN NTRSTL PRB 5/FEWER 186.18 XXX<br />
K 77610 TC HYPRTHM GEN NTRSTL PRB 5/FEWER 1870.85 XXX<br />
K 77615 HYPRTHM GEN NTRSTL PRB > 5 2358.54 XXX<br />
K 77615 26 HYPRTHM GEN NTRSTL PRB > 5 253.73 XXX<br />
K 77615 TC HYPRTHM GEN NTRSTL PRB > 5 2104.81 XXX<br />
77620 HYPRTHM GEN INTRCV PRB 1166.50 XXX<br />
77620 26 HYPRTHM GEN INTRCV PRB 182.88 XXX<br />
77620 TC HYPRTHM GEN INTRCV PRB 983.62 XXX<br />
77750 NFS/INSTLJ RADIOELMNT SLN 3 MO F-UP CARE 855.10 090<br />
77750 26 NFS/INSTLJ RADIOELMNT SLN 3 MO F-UP CARE 608.79 090<br />
77750 TC NFS/INSTLJ RADIOELMNT SLN 3 MO F-UP CARE 246.31 090<br />
77761 INTRCV RADJ SRC APPL SMPL 893.00 090<br />
77761 26 INTRCV RADJ SRC APPL SMPL 466.27 090<br />
77761 TC INTRCV RADJ SRC APPL SMPL 426.73 090<br />
77762 INTRCV RADJ SRC APPL INTRM 1200.28 090<br />
77762 26 INTRCV RADJ SRC APPL INTRM 701.05 090<br />
77762 TC INTRCV RADJ SRC APPL INTRM 499.23 090<br />
77763 INTRCV RADJ SRC APPL CPLX 1698.68 090<br />
77763 26 INTRCV RADJ SRC APPL CPLX 1052.82 090<br />
77763 TC INTRCV RADJ SRC APPL CPLX 645.86 090<br />
77776 NTRSTL RADJ SRC APPL SMPL 1023.16 090<br />
77776 26 NTRSTL RADJ SRC APPL SMPL 577.48 090<br />
77776 TC NTRSTL RADJ SRC APPL SMPL 445.68 090<br />
77777 NTRSTL RADJ SRC APPL INTRM 1417.76 090<br />
77777 26 NTRSTL RADJ SRC APPL INTRM 930.89 090<br />
77777 TC NTRSTL RADJ SRC APPL INTRM 486.87 090<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure<br />
208 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VIII: Diagnostic and <strong>The</strong>rapeutic Radiological Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
70010–79999 RADIOLOGY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
77778 NTRSTL RADJ SRC APPL CPLX 2041.38 090<br />
77778 26 NTRSTL RADJ SRC APPL CPLX 1378.22 090<br />
77778 TC NTRSTL RADJ SRC APPL CPLX 663.16 090<br />
77785 REMOTE AFTLD RADIONUCLIDE BRACHYTX 1 CHANNEL 533.00 XXX<br />
77785 26 REMOTE AFTLD RADIONUCLIDE BRACHYTX 1 CHANNEL 173.00 XXX<br />
77785 TC REMOTE AFTLD RADIONUCLIDE BRACHYTX 1 CHANNEL 360.00 XXX<br />
77786 REMOTE AFTLD RADIONUCLIDE BRACHYTX 2-12 CHANNEL 1384.81 XXX<br />
77786 26 REMOTE AFTLD RADIONUCLIDE BRACHYTX 2-12 CHANNEL 392.13 XXX<br />
77786 TC REMOTE AFTLD RADIONUCLIDE BRACHYTX 2-12 CHANNEL 992.68 XXX<br />
77787 REMOTE AFTLD RADIONUCLIDE BRACHYTX > 12 CHANNEL 2208.61 XXX<br />
77787 26 REMOTE AFTLD RADIONUCLIDE BRACHYTX > 12 CHANNEL 599.73 XXX<br />
77787 TC REMOTE AFTLD RADIONUCLIDE BRACHYTX > 12 CHANNEL 1608.88 XXX<br />
77789 SURF APPL RADJ SRC 269.38 000<br />
77789 26 SURF APPL RADJ SRC 139.22 000<br />
77789 TC SURF APPL RADJ SRC 130.16 000<br />
77790 SUPVJ HANDLING LOADING RADJ SRC 220.78 XXX<br />
77790 26 SUPVJ HANDLING LOADING RADJ SRC 126.87 XXX<br />
77790 TC SUPVJ HANDLING LOADING RADJ SRC 93.91 XXX<br />
77799 UNLIS CLINICAL BRACHYTX BR XXX<br />
78000 THYR UPTK 1 DETER 174.65 XXX<br />
78000 26 THYR UPTK 1 DETER 23.07 XXX<br />
78000 TC THYR UPTK 1 DETER 151.58 XXX<br />
78001 THYR UPTK MLT DETERS 224.07 XXX<br />
78001 26 THYR UPTK MLT DETERS 31.30 XXX<br />
78001 TC THYR UPTK MLT DETERS 192.77 XXX<br />
78003 THYR UPTK STIMJ SUPRJ/DSCHRG X 1ST UPTK STD 194.42 XXX<br />
78003 26 THYR UPTK STIMJ SUPRJ/DSCHRG X 1ST UPTK STD 39.54 XXX<br />
78003 TC THYR UPTK STIMJ SUPRJ/DSCHRG X 1ST UPTK STD 154.88 XXX<br />
78006 THYR IMG UPTK 1 DETER 571.72 XXX<br />
78006 26 THYR IMG UPTK 1 DETER 59.31 XXX<br />
78006 TC THYR IMG UPTK 1 DETER 512.41 XXX<br />
78007 THYR IMG UPTK MLT DETERS 473.69 XXX<br />
78007 26 THYR IMG UPTK MLT DETERS 60.14 XXX<br />
78007 TC THYR IMG UPTK MLT DETERS 413.55 XXX<br />
78010 THYR IMG ONLY 394.60 XXX<br />
78010 26 THYR IMG ONLY 45.31 XXX<br />
78010 TC THYR IMG ONLY 349.29 XXX<br />
78011 THYR IMG VASC FLO 435.79 XXX<br />
78011 26 THYR IMG VASC FLO 55.19 XXX<br />
78011 TC THYR IMG VASC FLO 380.60 XXX<br />
78015 THYR CARC METASTASES IMG LMTD AREA 522.29 XXX<br />
78015 26 THYR CARC METASTASES IMG LMTD AREA 79.91 XXX<br />
78015 TC THYR CARC METASTASES IMG LMTD AREA 442.38 XXX<br />
78016 THYR CARC METASTASES IMG ADDL STD 738.95 XXX<br />
78016 26 THYR CARC METASTASES IMG ADDL STD 91.44 XXX<br />
78016 TC THYR CARC METASTASES IMG ADDL STD 647.51 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 209
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VIII: Diagnostic and <strong>The</strong>rapeutic Radiological Services<br />
RADIOLOGY 70010–79999<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
78018 THYR CARC METASTASES IMG WHBDY 772.72 XXX<br />
78018 26 THYR CARC METASTASES IMG WHBDY 101.33 XXX<br />
78018 TC THYR CARC METASTASES IMG WHBDY 671.39 XXX<br />
+ 78020 THYR CARC METASTASES UPTK 209.25 ZZZ<br />
+ 78020 26 THYR CARC METASTASES UPTK 70.02 ZZZ<br />
+ 78020 TC THYR CARC METASTASES UPTK 139.23 ZZZ<br />
78070 PARATHYR IMG 402.01 XXX<br />
78070 26 PARATHYR IMG 98.03 XXX<br />
78070 TC PARATHYR IMG 303.98 XXX<br />
78075 ADRNL IMG CORTEX&/MEDULLA 1033.05 XXX<br />
78075 26 ADRNL IMG CORTEX&/MEDULLA 87.32 XXX<br />
78075 TC ADRNL IMG CORTEX&/MEDULLA 945.73 XXX<br />
78099 UNLIS ENDOC PX DX NUC MED BR XXX<br />
78102 B1 MARROW IMG LMTD AREA 403.66 XXX<br />
78102 26 B1 MARROW IMG LMTD AREA 65.08 XXX<br />
78102 TC B1 MARROW IMG LMTD AREA 338.58 XXX<br />
78103 B1 MARROW IMG MLT AREAS 532.17 XXX<br />
78103 26 B1 MARROW IMG MLT AREAS 88.15 XXX<br />
78103 TC B1 MARROW IMG MLT AREAS 444.02 XXX<br />
78104 B1 MARROW IMG WHBDY 604.67 XXX<br />
78104 26 B1 MARROW IMG WHBDY 94.74 XXX<br />
78104 TC B1 MARROW IMG WHBDY 509.93 XXX<br />
78110 PLSM VOL RP VOL-DIL TQ SPX 1 SAMPLING 201.01 XXX<br />
78110 26 PLSM VOL RP VOL-DIL TQ SPX 1 SAMPLING 23.07 XXX<br />
78110 TC PLSM VOL RP VOL-DIL TQ SPX 1 SAMPLING 177.94 XXX<br />
78111 PLSM VOL RP VOL-DIL TQ SPX MLT SAMPLINGS 212.54 XXX<br />
78111 26 PLSM VOL RP VOL-DIL TQ SPX MLT SAMPLINGS 25.54 XXX<br />
78111 TC PLSM VOL RP VOL-DIL TQ SPX MLT SAMPLINGS 187.00 XXX<br />
78120 RBC VOL DETER SPX 1 SAMPLING 213.36 XXX<br />
78120 26 RBC VOL DETER SPX 1 SAMPLING 28.01 XXX<br />
78120 TC RBC VOL DETER SPX 1 SAMPLING 185.35 XXX<br />
78121 RBC VOL DETER SPX MLT SAMPLINGS 244.67 XXX<br />
78121 26 RBC VOL DETER SPX MLT SAMPLINGS 37.89 XXX<br />
78121 TC RBC VOL DETER SPX MLT SAMPLINGS 206.78 XXX<br />
78122 WHL BLD VOL DETER RP VOL-DIL TQ 272.68 XXX<br />
78122 26 WHL BLD VOL DETER RP VOL-DIL TQ 51.90 XXX<br />
78122 TC WHL BLD VOL DETER RP VOL-DIL TQ 220.78 XXX<br />
78130 RBC SURV STD 376.48 XXX<br />
78130 26 RBC SURV STD 74.97 XXX<br />
78130 TC RBC SURV STD 301.51 XXX<br />
78135 RBC SURV STD DIFFIAL ORGAN/TISS KIN 832.86 XXX<br />
78135 26 RBC SURV STD DIFFIAL ORGAN/TISS KIN 78.26 XXX<br />
78135 TC RBC SURV STD DIFFIAL ORGAN/TISS KIN 754.60 XXX<br />
78140 LBLD RBC SQSJ DIFFIAL ORGAN/TISS 337.76 XXX<br />
78140 26 LBLD RBC SQSJ DIFFIAL ORGAN/TISS 74.14 XXX<br />
78140 TC LBLD RBC SQSJ DIFFIAL ORGAN/TISS 263.62 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure<br />
210 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VIII: Diagnostic and <strong>The</strong>rapeutic Radiological Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
70010–79999 RADIOLOGY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
78185 SPLEEN IMG ONLY +-VASC FLO 487.69 XXX<br />
78185 26 SPLEEN IMG ONLY +-VASC FLO 47.78 XXX<br />
78185 TC SPLEEN IMG ONLY +-VASC FLO 439.91 XXX<br />
78190 KIN STD PLTLT SURV +-DIFFIAL ORGAN/TISS LOCLZJ 917.71 XXX<br />
78190 26 KIN STD PLTLT SURV +-DIFFIAL ORGAN/TISS LOCLZJ 129.34 XXX<br />
78190 TC KIN STD PLTLT SURV +-DIFFIAL ORGAN/TISS LOCLZJ 788.37 XXX<br />
78191 PLTLT SURV STD 430.02 XXX<br />
78191 26 PLTLT SURV STD 74.14 XXX<br />
78191 TC PLTLT SURV STD 355.88 XXX<br />
78195 LYMPHATICS&LYMPH NOD IMG 855.10 XXX<br />
78195 26 LYMPHATICS&LYMPH NOD IMG 144.17 XXX<br />
78195 TC LYMPHATICS&LYMPH NOD IMG 710.93 XXX<br />
78199 UNLIS HEMATOP RET/ENDO&LYMPHATIC DX NUC MED BR XXX<br />
78201 LVR IMG STATIC ONLY 450.62 XXX<br />
78201 26 LVR IMG STATIC ONLY 52.72 XXX<br />
78201 TC LVR IMG STATIC ONLY 397.90 XXX<br />
78202 LVR IMG VASC FLO 490.98 XXX<br />
78202 26 LVR IMG VASC FLO 57.67 XXX<br />
78202 TC LVR IMG VASC FLO 433.31 XXX<br />
78205 LVR IMG SPECT 551.95 XXX<br />
78205 26 LVR IMG SPECT 84.85 XXX<br />
78205 TC LVR IMG SPECT 467.10 XXX<br />
78206 LVR IMG SPECT VASC FLO 843.57 XXX<br />
78206 26 LVR IMG SPECT VASC FLO 113.68 XXX<br />
78206 TC LVR IMG SPECT VASC FLO 729.89 XXX<br />
78215 LVR&SPLEEN IMG STATIC ONLY 466.27 XXX<br />
78215 26 LVR&SPLEEN IMG STATIC ONLY 59.31 XXX<br />
78215 TC LVR&SPLEEN IMG STATIC ONLY 406.96 XXX<br />
78216 LVR&SPLEEN IMG VASC FLO 317.16 XXX<br />
78216 26 LVR&SPLEEN IMG VASC FLO 67.55 XXX<br />
78216 TC LVR&SPLEEN IMG VASC FLO 249.61 XXX<br />
78220 LVR FUNCJ STD HEPATBL AGT SRL IMAGES 331.17 XXX<br />
78220 26 LVR FUNCJ STD HEPATBL AGT SRL IMAGES 56.84 XXX<br />
78220 TC LVR FUNCJ STD HEPATBL AGT SRL IMAGES 274.33 XXX<br />
78223 HEPATBL DUX SYS IMG GLBLDR 802.38 XXX<br />
78223 26 HEPATBL DUX SYS IMG GLBLDR 100.50 XXX<br />
78223 TC HEPATBL DUX SYS IMG GLBLDR 701.88 XXX<br />
78230 SALIVARY GLND IMG 402.84 XXX<br />
78230 26 SALIVARY GLND IMG 54.37 XXX<br />
78230 TC SALIVARY GLND IMG 348.47 XXX<br />
78231 SALIVARY GLND IMG SRL IMAGES 312.22 XXX<br />
78231 26 SALIVARY GLND IMG SRL IMAGES 60.96 XXX<br />
78231 TC SALIVARY GLND IMG SRL IMAGES 251.26 XXX<br />
78232 SALIVARY GLND FUNCJ STD 285.03 XXX<br />
78232 26 SALIVARY GLND FUNCJ STD 53.55 XXX<br />
78232 TC SALIVARY GLND FUNCJ STD 231.48 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 211
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VIII: Diagnostic and <strong>The</strong>rapeutic Radiological Services<br />
RADIOLOGY 70010–79999<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
78258 ESOPHGL MOTILITY 553.59 XXX<br />
78258 26 ESOPHGL MOTILITY 88.97 XXX<br />
78258 TC ESOPHGL MOTILITY 464.62 XXX<br />
78261 GSTR MUCOSA IMG 606.32 XXX<br />
78261 26 GSTR MUCOSA IMG 84.03 XXX<br />
78261 TC GSTR MUCOSA IMG 522.29 XXX<br />
78262 G-ESOP RFLX STD 593.96 XXX<br />
78262 26 G-ESOP RFLX STD 79.08 XXX<br />
78262 TC G-ESOP RFLX STD 514.88 XXX<br />
78264 GSTR EMPTYING STD 692.82 XXX<br />
78264 26 GSTR EMPTYING STD 93.09 XXX<br />
78264 TC GSTR EMPTYING STD 599.73 XXX<br />
78267 UREA BRTH TST C-14 ISOTOPIC ACQUISJ ALYS 27.19 XXX<br />
78268 UREA BRTH TST C-14 ISOTOPIC ALYS 229.84 XXX<br />
78270 VIT B-12 ABSRPJ STD W/O INTRNSC FACTOR 196.89 XXX<br />
78270 26 VIT B-12 ABSRPJ STD W/O INTRNSC FACTOR 23.89 XXX<br />
78270 TC VIT B-12 ABSRPJ STD W/O INTRNSC FACTOR 173.00 XXX<br />
78271 VIT B-12 ABSRPJ STD INTRNSC FACTOR 207.60 XXX<br />
78271 26 VIT B-12 ABSRPJ STD INTRNSC FACTOR 23.89 XXX<br />
78271 TC VIT B-12 ABSRPJ STD INTRNSC FACTOR 183.71 XXX<br />
78272 VIT B-12 ABSRPJ STD CMBN W/&W/O INTRNSC FACTOR 220.78 XXX<br />
78272 26 VIT B-12 ABSRPJ STD CMBN W/&W/O INTRNSC FACTOR 31.30 XXX<br />
78272 TC VIT B-12 ABSRPJ STD CMBN W/&W/O INTRNSC FACTOR 189.48 XXX<br />
78278 AQT GI BLD LOSS IMG 837.80 XXX<br />
78278 26 AQT GI BLD LOSS IMG 118.63 XXX<br />
78278 TC AQT GI BLD LOSS IMG 719.17 XXX<br />
78282 GI PROTEIN LOSS 187.83 XXX<br />
78282 26 GI PROTEIN LOSS 46.96 XXX<br />
78282 TC GI PROTEIN LOSS 140.87 XXX<br />
78290 INT IMG 779.31 XXX<br />
78290 26 INT IMG 82.38 XXX<br />
78290 TC INT IMG 696.93 XXX<br />
78291 PRTL-VEN SHUNT PATENCY TST 612.91 XXX<br />
78291 26 PRTL-VEN SHUNT PATENCY TST 105.45 XXX<br />
78291 TC PRTL-VEN SHUNT PATENCY TST 507.46 XXX<br />
78299 UNLIS GI PX DX NUC MED BR XXX<br />
78300 B1&/JT IMG LMTD AREA 427.55 XXX<br />
78300 26 B1&/JT IMG LMTD AREA 74.97 XXX<br />
78300 TC B1&/JT IMG LMTD AREA 352.58 XXX<br />
78305 B1&/JT IMG MLT AREAS 564.30 XXX<br />
78305 26 B1&/JT IMG MLT AREAS 98.86 XXX<br />
78305 TC B1&/JT IMG MLT AREAS 465.44 XXX<br />
78306 B1&/JT IMG WHBDY 614.55 XXX<br />
78306 26 B1&/JT IMG WHBDY 102.98 XXX<br />
78306 TC B1&/JT IMG WHBDY 511.57 XXX<br />
78315 B1&/JT IMG 3 PHASE STD 836.98 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure<br />
212 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VIII: Diagnostic and <strong>The</strong>rapeutic Radiological Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
70010–79999 RADIOLOGY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
78315 26 B1&/JT IMG 3 PHASE STD 121.92 XXX<br />
78315 TC B1&/JT IMG 3 PHASE STD 715.06 XXX<br />
78320 B1&/JT IMG TOMOG SPECT 592.31 XXX<br />
78320 26 B1&/JT IMG TOMOG SPECT 123.57 XXX<br />
78320 TC B1&/JT IMG TOMOG SPECT 468.74 XXX<br />
78350 B1 DNS STD 1+ SITS 1 PHTN ABSRPTM 79.91 XXX<br />
78350 26 B1 DNS STD 1+ SITS 1 PHTN ABSRPTM 26.36 XXX<br />
78350 TC B1 DNS STD 1+ SITS 1 PHTN ABSRPTM 53.55 XXX<br />
78351 B1 DNS STD 1+ SITS DUAL PHTN ABSRPTM 1+ SITS 36.25 XXX<br />
78351 26 B1 DNS STD 1+ SITS DUAL PHTN ABSRPTM 1+ SITS 10.71 XXX<br />
78351 TC B1 DNS STD 1+ SITS DUAL PHTN ABSRPTM 1+ SITS 25.54 XXX<br />
78399 UNLIS MUSCSKEL PX DX NUC MED BR XXX<br />
78414 DETER CTR C-V HEMODYN NON-IMG +-RX 1/MLT 181.24 XXX<br />
78414 26 DETER CTR C-V HEMODYN NON-IMG +-RX 1/MLT 54.37 XXX<br />
78414 TC DETER CTR C-V HEMODYN NON-IMG +-RX 1/MLT 126.87 XXX<br />
78428 CAR SHUNT DETCJ 470.39 XXX<br />
78428 26 CAR SHUNT DETCJ 95.56 XXX<br />
78428 TC CAR SHUNT DETCJ 374.83 XXX<br />
78445 NON-CAR VASC FLO IMG 415.20 XXX<br />
78445 26 NON-CAR VASC FLO IMG 56.84 XXX<br />
78445 TC NON-CAR VASC FLO IMG 358.36 XXX<br />
78451 MYOCARDIAL SPECT SINGLE STUDY AT REST OR STRESS 827.10 XXX<br />
78451 26 MYOCARDIAL SPECT SINGLE STUDY AT REST OR STRESS 159.82 XXX<br />
78451 TC MYOCARDIAL SPECT SINGLE STUDY AT REST OR STRESS 667.28 XXX<br />
78452 MYOCARDIAL SPECT MULTIPLE STUDIES 1158.26 XXX<br />
78452 26 MYOCARDIAL SPECT MULTIPLE STUDIES 188.65 XXX<br />
78452 TC MYOCARDIAL SPECT MULTIPLE STUDIES 969.61 XXX<br />
78453 MYOCARDIAL PERFUSION PLANAR 1 STUDY REST/STRESS 710.94 XXX<br />
78453 26 MYOCARDIAL PERFUSION PLANAR 1 STUDY REST/STRESS 116.98 XXX<br />
78453 TC MYOCARDIAL PERFUSION PLANAR 1 STUDY REST/STRESS 593.96 XXX<br />
78454 MYOCARDIAL PERFUSION PLANAR MULTIPLE STUDIES 1026.45 XXX<br />
78454 26 MYOCARDIAL PERFUSION PLANAR MULTIPLE STUDIES 155.70 XXX<br />
78454 TC MYOCARDIAL PERFUSION PLANAR MULTIPLE STUDIES 870.75 XXX<br />
78456 AQT VEN THROMBOSIS IMG PEPTIDE 858.40 XXX<br />
78456 26 AQT VEN THROMBOSIS IMG PEPTIDE 123.57 XXX<br />
78456 TC AQT VEN THROMBOSIS IMG PEPTIDE 734.83 XXX<br />
78457 VEN THROMBOSIS IMG VENOGRAM UNI 473.69 XXX<br />
78457 26 VEN THROMBOSIS IMG VENOGRAM UNI 92.27 XXX<br />
78457 TC VEN THROMBOSIS IMG VENOGRAM UNI 381.42 XXX<br />
78458 VEN THROMBOSIS IMG VENOGRAM BI 476.16 XXX<br />
78458 26 VEN THROMBOSIS IMG VENOGRAM BI 103.80 XXX<br />
78458 TC VEN THROMBOSIS IMG VENOGRAM BI 372.36 XXX<br />
78459 MYOCRD IMG P+ EMIJ TOMOG METAB EVAL 1075.88 XXX<br />
78459 26 MYOCRD IMG P+ EMIJ TOMOG METAB EVAL 182.88 XXX<br />
78459 TC MYOCRD IMG P+ EMIJ TOMOG METAB EVAL 893.00 XXX<br />
78466 MYOCRD IMG INFARCT AVID PLNR QUAL/QUAN 438.26 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 213
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VIII: Diagnostic and <strong>The</strong>rapeutic Radiological Services<br />
RADIOLOGY 70010–79999<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
78466 26 MYOCRD IMG INFARCT AVID PLNR QUAL/QUAN 84.85 XXX<br />
78466 TC MYOCRD IMG INFARCT AVID PLNR QUAL/QUAN 353.41 XXX<br />
78468 MYOCRD IMG INFARCT AVID PLNR EJEC FXJ 1ST PS TQ 531.35 XXX<br />
78468 26 MYOCRD IMG INFARCT AVID PLNR EJEC FXJ 1ST PS TQ 99.68 XXX<br />
78468 TC MYOCRD IMG INFARCT AVID PLNR EJEC FXJ 1ST PS TQ 431.67 XXX<br />
78469 MYOCRD IMG INFARCT AVID PLNR TOMOG SPECT +-QUAN 625.26 XXX<br />
78469 26 MYOCRD IMG INFARCT AVID PLNR TOMOG SPECT +-QUAN 115.33 XXX<br />
78469 TC MYOCRD IMG INFARCT AVID PLNR TOMOG SPECT +-QUAN 509.93 XXX<br />
78472 CARD BPI GTD =BRM PLNR 1 STD REST/STRS 611.26 XXX<br />
78472 26 CARD BPI GTD =BRM PLNR 1 STD REST/STRS 119.45 XXX<br />
78472 TC CARD BPI GTD =BRM PLNR 1 STD REST/STRS 491.81 XXX<br />
78473 CARD BPI GTD =BRM MLT STD WALL MOTION STD 807.32 XXX<br />
78473 26 CARD BPI GTD =BRM MLT STD WALL MOTION STD 180.41 XXX<br />
78473 TC CARD BPI GTD =BRM MLT STD WALL MOTION STD 626.91 XXX<br />
78481 CARD BPI PLNR 1ST PS 1 STD PLUS EJEC FXJ 509.93 XXX<br />
78481 26 CARD BPI PLNR 1ST PS 1 STD PLUS EJEC FXJ 122.75 XXX<br />
78481 TC CARD BPI PLNR 1ST PS 1 STD PLUS EJEC FXJ 387.18 XXX<br />
78483 CARD BPI PLNR 1ST PS MLT STD PLUS EJEC FXJ 707.64 XXX<br />
78483 26 CARD BPI PLNR 1ST PS MLT STD PLUS EJEC FXJ 185.36 XXX<br />
78483 TC CARD BPI PLNR 1ST PS MLT STD PLUS EJEC FXJ 522.28 XXX<br />
78491 MYOCRD IMG P+ EMIJ TOMOG PRFUJ 1 STD 1158.26 XXX<br />
78491 26 MYOCRD IMG P+ EMIJ TOMOG PRFUJ 1 STD 185.36 XXX<br />
78491 TC MYOCRD IMG P+ EMIJ TOMOG PRFUJ 1 STD 972.90 XXX<br />
78492 MYOCRD IMG P+ EMIJ TOMOG PRFUJ MLT STD 1467.19 XXX<br />
78492 26 MYOCRD IMG P+ EMIJ TOMOG PRFUJ MLT STD 234.78 XXX<br />
78492 TC MYOCRD IMG P+ EMIJ TOMOG PRFUJ MLT STD 1232.41 XXX<br />
78494 CARD BPI GTD =BRM SPECT REST WALL MOTION 650.80 XXX<br />
78494 26 CARD BPI GTD =BRM SPECT REST WALL MOTION 146.64 XXX<br />
78494 TC CARD BPI GTD =BRM SPECT REST WALL MOTION 504.16 XXX<br />
+ 78496 CARD BPI GTD =BRM 1 STD REST R VENTR EJEC FXJ 196.06 ZZZ<br />
+ 78496 26 CARD BPI GTD =BRM 1 STD REST R VENTR EJEC FXJ 60.96 ZZZ<br />
+ 78496 TC CARD BPI GTD =BRM 1 STD REST R VENTR EJEC FXJ 135.10 ZZZ<br />
78499 UNLIS CV DX NUC MED BR XXX<br />
78580 PULM PI PART 515.70 XXX<br />
78580 26 PULM PI PART 88.15 XXX<br />
78580 TC PULM PI PART 427.55 XXX<br />
78584 PULM PI PART VNTJ 1 BRTH 370.71 XXX<br />
78584 26 PULM PI PART VNTJ 1 BRTH 119.45 XXX<br />
78584 TC PULM PI PART VNTJ 1 BRTH 251.26 XXX<br />
78585 PULM PI PART VNTJ RBRTHING&WSHOT +-1 BRTH 856.75 XXX<br />
78585 26 PULM PI PART VNTJ RBRTHING&WSHOT +-1 BRTH 130.16 XXX<br />
78585 TC PULM PI PART VNTJ RBRTHING&WSHOT +-1 BRTH 726.59 XXX<br />
78586 PULM VI AERSL 1 PROJECTION 403.66 XXX<br />
78586 26 PULM VI AERSL 1 PROJECTION 46.96 XXX<br />
78586 TC PULM VI AERSL 1 PROJECTION 356.70 XXX<br />
78587 PULM VI AERSL MLT PRJCJ 505.81 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure<br />
214 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VIII: Diagnostic and <strong>The</strong>rapeutic Radiological Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
70010–79999 RADIOLOGY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
78587 26 PULM VI AERSL MLT PRJCJ 58.49 XXX<br />
78587 TC PULM VI AERSL MLT PRJCJ 447.32 XXX<br />
78588 PULM PI PART VNTJ IMG AERSL 1/MLT PRJCJ 830.39 XXX<br />
78588 26 PULM PI PART VNTJ IMG AERSL 1/MLT PRJCJ 130.16 XXX<br />
78588 TC PULM PI PART VNTJ IMG AERSL 1/MLT PRJCJ 700.23 XXX<br />
78591 PULM VI GASEOUS 1 PRJCJ 408.60 XXX<br />
78591 26 PULM VI GASEOUS 1 PRJCJ 47.78 XXX<br />
78591 TC PULM VI GASEOUS 1 PRJCJ 360.82 XXX<br />
78593 PULM VI GASEOUS RBRTHING&WSHOT 1 PRJCJ 475.33 XXX<br />
78593 26 PULM VI GASEOUS RBRTHING&WSHOT 1 PRJCJ 59.31 XXX<br />
78593 TC PULM VI GASEOUS RBRTHING&WSHOT 1 PRJCJ 416.02 XXX<br />
78594 PULM VI GASEOUS RBRTHING&WSHOT MLT PRJCJ 525.58 XXX<br />
78594 26 PULM VI GASEOUS RBRTHING&WSHOT MLT PRJCJ 62.61 XXX<br />
78594 TC PULM VI GASEOUS RBRTHING&WSHOT MLT PRJCJ 462.97 XXX<br />
78596 PULM QUAN DIFFIAL FUNCJ VNTJ/PRFUJ STD 903.71 XXX<br />
78596 26 PULM QUAN DIFFIAL FUNCJ VNTJ/PRFUJ STD 147.46 XXX<br />
78596 TC PULM QUAN DIFFIAL FUNCJ VNTJ/PRFUJ STD 756.25 XXX<br />
78599 UNLIS RESPIR PX DX NUC MED BR XXX<br />
78600 BRAIN IMAGING
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VIII: Diagnostic and <strong>The</strong>rapeutic Radiological Services<br />
RADIOLOGY 70010–79999<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
78635 26 CEREBSP FLU FLO IMG X INTRO MATRL VENTRG 72.49 XXX<br />
78635 TC CEREBSP FLU FLO IMG X INTRO MATRL VENTRG 705.18 XXX<br />
78645 CEREBSP FLU FLO IMG X INTRO MATRL SHUNT EVAL 766.96 XXX<br />
78645 26 CEREBSP FLU FLO IMG X INTRO MATRL SHUNT EVAL 68.38 XXX<br />
78645 TC CEREBSP FLU FLO IMG X INTRO MATRL SHUNT EVAL 698.58 XXX<br />
78647 CEREBSP FLU FLO IMG X INTRO MATRL TOMOG SPECT 842.75 XXX<br />
78647 26 CEREBSP FLU FLO IMG X INTRO MATRL TOMOG SPECT 106.27 XXX<br />
78647 TC CEREBSP FLU FLO IMG X INTRO MATRL TOMOG SPECT 736.48 XXX<br />
78650 CEREBSP FLU LEAKAGE DETCJ&LOCLZJ 799.09 XXX<br />
78650 26 CEREBSP FLU LEAKAGE DETCJ&LOCLZJ 73.32 XXX<br />
78650 TC CEREBSP FLU LEAKAGE DETCJ&LOCLZJ 725.77 XXX<br />
78660 RP DACRYOCSTOGRAPY 429.20 XXX<br />
78660 26 RP DACRYOCSTOGRAPY 65.08 XXX<br />
78660 TC RP DACRYOCSTOGRAPY 364.12 XXX<br />
78699 UNLIS NRVS SYS PX DX NUC MED BR XXX<br />
78700 KIDNEY IMAGING MORPHOLOGY 427.55 XXX<br />
78700 26 KIDNEY IMAGING MORPHOLOGY 55.19 XXX<br />
78700 TC KIDNEY IMAGING MORPHOLOGY 372.36 XXX<br />
78701 KDN IMG VASC FLO 516.52 XXX<br />
78701 26 KDN IMG VASC FLO 59.31 XXX<br />
78701 TC KDN IMG VASC FLO 457.21 XXX<br />
78707 KIDNEY IMG MORPHOLOGY VASCULAR FLOW 1 W/O RX 576.66 XXX<br />
78707 26 KIDNEY IMG MORPHOLOGY VASCULAR FLOW 1 W/O RX 113.68 XXX<br />
78707 TC KIDNEY IMG MORPHOLOGY VASCULAR FLOW 1 W/O RX 462.98 XXX<br />
78708 KIDNEY IMG MORPHOLOGY VASCULAR FLOW 1 W RX 438.26 XXX<br />
78708 26 KIDNEY IMG MORPHOLOGY VASCULAR FLOW 1 W RX 144.17 XXX<br />
78708 TC KIDNEY IMG MORPHOLOGY VASCULAR FLOW 1 W RX 294.09 XXX<br />
78709 KIDNEY IMG MORPHOLOGY VASCULAR FLOW MULTIPLE 888.88 XXX<br />
78709 26 KIDNEY IMG MORPHOLOGY VASCULAR FLOW MULTIPLE 168.06 XXX<br />
78709 TC KIDNEY IMG MORPHOLOGY VASCULAR FLOW MULTIPLE 720.82 XXX<br />
78710 KIDNEY IMAGING MORPHOLOGY TOMOGRAPHIC 539.59 XXX<br />
78710 26 KIDNEY IMAGING MORPHOLOGY TOMOGRAPHIC 75.79 XXX<br />
78710 TC KIDNEY IMAGING MORPHOLOGY TOMOGRAPHIC 463.80 XXX<br />
78725 KDN FUNCJ STD NON-IMG RADIOISOTOPIC STD 248.79 XXX<br />
78725 26 KDN FUNCJ STD NON-IMG RADIOISOTOPIC STD 44.49 XXX<br />
78725 TC KDN FUNCJ STD NON-IMG RADIOISOTOPIC STD 204.30 XXX<br />
+ 78730 URINARY BLADDER RESIDUAL STUDY 181.24 ZZZ<br />
+ 78730 26 URINARY BLADDER RESIDUAL STUDY 19.77 ZZZ<br />
+ 78730 TC URINARY BLADDER RESIDUAL STUDY 161.47 ZZZ<br />
78740 URTRL RFLX STD RP VOIDING CSTOGRAM 537.12 XXX<br />
78740 26 URTRL RFLX STD RP VOIDING CSTOGRAM 70.02 XXX<br />
78740 TC URTRL RFLX STD RP VOIDING CSTOGRAM 467.10 XXX<br />
78761 TESTICULAR IMAGING WITH VASCULAR FLOW 515.70 XXX<br />
78761 26 TESTICULAR IMAGING WITH VASCULAR FLOW 86.50 XXX<br />
78761 TC TESTICULAR IMAGING WITH VASCULAR FLOW 429.20 XXX<br />
78799 UNLIS GENITOUR DX NUC MED BR XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure<br />
216 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section VIII: Diagnostic and <strong>The</strong>rapeutic Radiological Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
70010–79999 RADIOLOGY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
78800 RP LOCLZJ TUM/DSTRBJ AGT LMTD AREA 453.91 XXX<br />
78800 26 RP LOCLZJ TUM/DSTRBJ AGT LMTD AREA 79.08 XXX<br />
78800 TC RP LOCLZJ TUM/DSTRBJ AGT LMTD AREA 374.83 XXX<br />
78801 RP LOCLZJ TUM/DSTRBJ AGT MLT AREAS 612.91 XXX<br />
78801 26 RP LOCLZJ TUM/DSTRBJ AGT MLT AREAS 94.74 XXX<br />
78801 TC RP LOCLZJ TUM/DSTRBJ AGT MLT AREAS 518.17 XXX<br />
78802 RP LOCLZJ TUM/DSTRBJ AGT WHBDY 1 D IMG 792.50 XXX<br />
78802 26 RP LOCLZJ TUM/DSTRBJ AGT WHBDY 1 D IMG 102.15 XXX<br />
78802 TC RP LOCLZJ TUM/DSTRBJ AGT WHBDY 1 D IMG 690.35 XXX<br />
78803 RP LOCLZJ TUM/DSTRBJ AGT TOMOG SPECT 851.81 XXX<br />
78803 26 RP LOCLZJ TUM/DSTRBJ AGT TOMOG SPECT 128.51 XXX<br />
78803 TC RP LOCLZJ TUM/DSTRBJ AGT TOMOG SPECT 723.30 XXX<br />
78804 RP LOCLZJ TUM/DSTRBJ AGT WHBDY REQ 2/> D IMG 1407.87 XXX<br />
78804 26 RP LOCLZJ TUM/DSTRBJ AGT WHBDY REQ 2/> D IMG 126.87 XXX<br />
78804 TC RP LOCLZJ TUM/DSTRBJ AGT WHBDY REQ 2/> D IMG 1281.00 XXX<br />
78805 RP LOCLZJ INFLAMMATORY PROCESS LMTD AREA 447.32 XXX<br />
78805 26 RP LOCLZJ INFLAMMATORY PROCESS LMTD AREA 87.32 XXX<br />
78805 TC RP LOCLZJ INFLAMMATORY PROCESS LMTD AREA 360.00 XXX<br />
78806 RP LOCLZJ INFLAMMATORY PROCESS WHBDY 820.50 XXX<br />
78806 26 RP LOCLZJ INFLAMMATORY PROCESS WHBDY 102.15 XXX<br />
78806 TC RP LOCLZJ INFLAMMATORY PROCESS WHBDY 718.35 XXX<br />
78807 RP LOCLZJ INFLAMMATORY PROCESS TOMOG SPECT 850.16 XXX<br />
78807 26 RP LOCLZJ INFLAMMATORY PROCESS TOMOG SPECT 126.87 XXX<br />
78807 TC RP LOCLZJ INFLAMMATORY PROCESS TOMOG SPECT 723.29 XXX<br />
78808 NJX RP LOCLZJ NON-IMG PROBE STUDY INTRAVENOUS 104.62 XXX<br />
78811 PET IMAGING LIMITED AREA CHEST HEAD/NECK 1613.00 XXX<br />
78811 26 PET IMAGING LIMITED AREA CHEST HEAD/NECK 193.59 XXX<br />
78811 TC PET IMAGING LIMITED AREA CHEST HEAD/NECK 1419.41 XXX<br />
78812 PET IMAGING SKULL BASE TO MID-THIGH 1970.53 XXX<br />
78812 26 PET IMAGING SKULL BASE TO MID-THIGH 236.43 XXX<br />
78812 TC PET IMAGING SKULL BASE TO MID-THIGH 1734.10 XXX<br />
78813 PET IMAGING WHOLE BODY 2059.50 XXX<br />
78813 26 PET IMAGING WHOLE BODY 247.14 XXX<br />
78813 TC PET IMAGING WHOLE BODY 1812.36 XXX<br />
78814 PET IMAGING CT FOR ATTENUATION LIMITED AREA 2244.86 XXX<br />
78814 26 PET IMAGING CT FOR ATTENUATION LIMITED AREA 269.38 XXX<br />
78814 TC PET IMAGING CT FOR ATTENUATION LIMITED AREA 1975.48 XXX<br />
78815 PET IMAGING CT ATTENUATION SKULL BASE MID-THIGH 2498.59 XXX<br />
78815 26 PET IMAGING CT ATTENUATION SKULL BASE MID-THIGH 299.86 XXX<br />
78815 TC PET IMAGING CT ATTENUATION SKULL BASE MID-THIGH 2198.73 XXX<br />
78816 PET IMAGING FOR CT ATTENUATION WHOLE BODY 2539.78 XXX<br />
78816 26 PET IMAGING FOR CT ATTENUATION WHOLE BODY 304.81 XXX<br />
78816 TC PET IMAGING FOR CT ATTENUATION WHOLE BODY 2234.97 XXX<br />
78999 UNLIS MISC DX NUC MED BR XXX<br />
79005 RP THER ORAL ADMN 346.00 XXX<br />
79005 26 RP THER ORAL ADMN 213.36 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 217
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section VIII: Diagnostic and <strong>The</strong>rapeutic Radiological Services<br />
RADIOLOGY 70010–79999<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
79005 TC RP THER ORAL ADMN 132.64 XXX<br />
79101 RP THER IV ADMN 391.31 XXX<br />
79101 26 RP THER IV ADMN 247.14 XXX<br />
79101 TC RP THER IV ADMN 144.17 XXX<br />
79200 RP THER INTRCV ADMN 406.13 XXX<br />
79200 26 RP THER INTRCV ADMN 242.20 XXX<br />
79200 TC RP THER INTRCV ADMN 163.93 XXX<br />
79300 RP THER NTRSTL RADACT COL ADMN 329.52 XXX<br />
79300 26 RP THER NTRSTL RADACT COL ADMN 197.71 XXX<br />
79300 TC RP THER NTRSTL RADACT COL ADMN 131.81 XXX<br />
79403 RP THER RADIOLBLD MONOCLONAL ANTB IV NFS 494.28 XXX<br />
79403 26 RP THER RADIOLBLD MONOCLONAL ANTB IV NFS 271.03 XXX<br />
79403 TC RP THER RADIOLBLD MONOCLONAL ANTB IV NFS 223.25 XXX<br />
79440 RP THER INTRA-ARTICULAR ADMN 381.42 XXX<br />
79440 26 RP THER INTRA-ARTICULAR ADMN 243.84 XXX<br />
79440 TC RP THER INTRA-ARTICULAR ADMN 137.58 XXX<br />
79445 RP THER IA PART ADMN 531.35 XXX<br />
79445 26 RP THER IA PART ADMN 291.63 XXX<br />
79445 TC RP THER IA PART ADMN 239.72 XXX<br />
79999 RP THER UNLIS PX BR XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure<br />
218 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section IX: Pathology and<br />
Laboratory Services<br />
SUBSECTION A: PAYMENT GROUND RULES FOR<br />
PATHOLOGY AND LABORATORY SERVICES<br />
General Guidelines<br />
Physicians should include CPT codes for specific<br />
performance of diagnostic tests/studies for which specific<br />
CPT codes are available. Items used by all physicians in<br />
reporting their services are presented in the introduction.<br />
Definitions and explanations unique to pathology and<br />
laboratory are included below.<br />
Services in Pathology and Laboratory<br />
Services are those provided by the pathologist or by the<br />
technologists under responsible supervision of a physician.<br />
<strong>The</strong> fees listed in this section include recording of the<br />
specimen, performance of the test, and reporting of the<br />
result. <strong>The</strong> fees do not include specimen collection,<br />
specimen transfer, or individual patient administrative<br />
services.<br />
Review of Diagnostic Studies<br />
<strong>The</strong> medical practitioner or other medical personnel warrant<br />
no separate charge for the review of prior studies in<br />
conjunction with a visit, consultation, record review, or<br />
other evaluation. Neither the professional component<br />
modifier 26 nor the pathology consultation CPT codes<br />
80500 and 80502 are reimbursable under this circumstance.<br />
<strong>The</strong> review of diagnostic tests is included in the evaluation<br />
and management (E/M) codes.<br />
Referral Laboratory Tests<br />
<strong>The</strong> laboratory tests and services listed in this section when<br />
performed by other than the billing physician shall be billed<br />
at the value charged by the referral (outside) laboratory<br />
under the applicable procedure number with the<br />
appropriate modifier 90; the name of the referral laboratory<br />
and the charge made by that laboratory should also be<br />
identified.<br />
Collection and Handling Procedures<br />
Fees assigned to each test represent only the cost of<br />
performing the individual test, whether it is manual or<br />
automated (mechanized). <strong>The</strong> collection, handling, and<br />
patient administrative services have been assigned separate<br />
fees and separate code numbers.<br />
A. Report a collection, handling, and patient administrative<br />
service separately, where applicable. For venipuncture,<br />
see CPT code 36415. For collection of capillary blood<br />
specimen, see CPT code 36416. For collection of blood<br />
specimen from a completely implantable venous access<br />
device, see CPT code 36591. For handling, see CPT<br />
codes 99000 and 99001.<br />
B. Only the physician or laboratory drawing the blood or<br />
obtaining the specimen is entitled to a collection and<br />
handling fee.<br />
C. Relative value units for specimen collection, handling,<br />
and patient administrative service are assigned in<br />
relation to the complexity of the process.<br />
D. Although there is no billing for the test itself, the<br />
physician or laboratory performing the service can<br />
report a collection and handling charge. <strong>The</strong> test<br />
ordered and the name of the testing facility should be<br />
indicated.<br />
E. When collection and handling are performed at the<br />
testing facility (laboratory), the laboratory may include<br />
separate charges for these services.<br />
Professional Component<br />
<strong>The</strong> maximum allowable reimbursement (MAR) includes the<br />
professional component (PC) plus the technical component<br />
(TC). This value is applicable in any situation in which a<br />
single charge is made to include both professional services<br />
and the technical cost of providing that service.<br />
Identification of a procedure by the five-digit CPT code<br />
without modifier 26 indicates that the charge includes both<br />
the professional and technical components.<br />
CPT only © 2010 American Medical Association. All Rights Reserved. 219
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
<strong>The</strong> professional component percentage represents the value<br />
of the professional pathology services of the physician. This<br />
includes: examination of the injured employee, when<br />
indicated, performance and/or supervision of the procedure,<br />
interpretation, and written report of the laboratory<br />
procedure, and consultation with the authorized treating<br />
physician. This component is applicable in any situation in<br />
which the physician submits a bill for these professional<br />
services only. It does not include the cost of personnel,<br />
materials, space, equipment, or other facilities. To identify<br />
the charge for the professional component, use the five-digit<br />
CPT code followed by modifier 26.<br />
<strong>The</strong> technical component includes the charges for personnel,<br />
materials, space, equipment, and other facilities, and should<br />
be reported using modifier TC. In no instance will the sum<br />
of the charges for the professional and technical components<br />
of a service be greater than the value of the total service<br />
listed.<br />
Separate or Multiple Procedures<br />
It is appropriate to designate multiple services rendered at<br />
the same session by separate entries.<br />
Unusual Service or Procedure<br />
Services that may necessitate skills and time of the physician<br />
over and above that usually required should be substantiated<br />
by report (see section IV).<br />
Procedures Listed without Specified Unit Values<br />
Fees are not shown for some procedures listed in the<br />
schedule that are rarely provided, unusual, variable, new, or<br />
unlisted services. <strong>The</strong> unlisted services and accompanying<br />
codes are listed at the end of each Pathology/Laboratory<br />
subsection. Unlisted service or procedure codes must be<br />
selected from the appropriate subsection of the<br />
Pathology/Laboratory chapter. For these procedures a “BR”<br />
(by report) designation has been used in the fee schedule.<br />
Reimbursement for such procedures must be justified by<br />
report (see section IV).<br />
Indices or Ratios<br />
Tests that produce an index or ratio based on mathematical<br />
calculations from two or more other results may not be<br />
billed as a separate, independent test (e.g., A/G ratio, free<br />
thyroxin index).<br />
Panel Tests<br />
When billing for panel tests (CPT codes 80047–80076) use<br />
the code number corresponding to the appropriate panel<br />
test. <strong>The</strong>se tests shall not be reimbursed separately. Any tests<br />
in addition to a particular panel or a second panel of tests<br />
shall be billed separately.<br />
Section IX: Pathology and Laboratory Services<br />
Consultations<br />
A clinical pathology study is a service that includes a written<br />
report rendered by the pathologist in response to a request<br />
from an authorized treating physician in relation to a test<br />
result(s) requiring additional medical interpretive judgment.<br />
Reporting on a test result(s) without medical interpretation<br />
is not considered a clinical pathology consultation and shall<br />
not be reimbursed as such.<br />
SUBSECTION B: PAYMENT MODIFIERS FOR<br />
PATHOLOGY AND LABORATORY SERVICES<br />
A modifier indicates a service or procedure performed has<br />
been altered by some specific circumstance but has not<br />
changed its definition or code. <strong>The</strong> modifying circumstance<br />
shall be identified by the appropriate two-digit modifier<br />
following the procedure code. When two modifiers are<br />
applicable to a single code, indicate each modifier on the<br />
bill. If more than one modifier is used, place the “Multiple<br />
Modifiers” code 99 immediately after the procedure code.<br />
This indicates that one or more additional modifier codes<br />
will follow. Only certain modifiers in each of the categories<br />
(Evaluation and Management, Anesthesia, Surgery,<br />
Pathology/Laboratory, Radiology, General Medicine, and<br />
Physical Medicine) will be recognized for reimbursement<br />
purposes.<br />
<strong>The</strong> modifiers listed below may differ from those published<br />
by the American Medical Association. Providers submitting<br />
workers’ compensation billing shall use only the modifiers<br />
set out in the Medical Fee Guideline.<br />
<strong>The</strong> following modifiers will be recognized for<br />
reimbursement by the fee schedule for surgical service codes:<br />
22 Increased Procedural Services: When the work<br />
required to provide a service is substantially greater than<br />
typically required, it may be identified by adding<br />
modifier 22 to the usual procedure code.<br />
Documentation must support the substantial additional<br />
work and the reason for the additional work (i.e.,<br />
increased intensity, time, technical difficulty of<br />
procedure, severity of patient's condition, physical and<br />
mental effort required). Note: This modifier should not<br />
be appended to an E/M service.<br />
26 Professional Component: Certain procedures are a<br />
combination of a physician component and a technical<br />
component. When the physician component is reported<br />
separately, the service may be identified by adding<br />
modifier 26 to the usual procedure number.<br />
53 Discontinued Procedure: Under certain circumstances,<br />
the physician may elect to terminate a surgical or<br />
diagnostic procedure. Due to extenuating circumstances<br />
or those that threaten the well-being of the patient, it<br />
220 CPT only © 2010 American Medical Association. All Rights Reserved.
Section IX: Pathology and Laboratory Services<br />
may be necessary to indicate that a surgical or diagnostic<br />
procedure was started but discontinued. This<br />
circumstance may be reported by adding modifier 53 to<br />
the code reported by the physician for the discontinued<br />
procedure. Note: This modifier is not used to report the<br />
elective cancellation of a procedure prior to the patient’s<br />
anesthesia induction and/or surgical preparation in the<br />
operating suite. For outpatient hospital/ambulatory<br />
surgery center (ASC) reporting of a previously<br />
scheduled procedure/service that is partially reduced or<br />
cancelled as a result of extenuating circumstances or<br />
those that threaten the well-being of the patient prior to<br />
or after administration of anesthesia, see modifiers 73<br />
and 74 (see modifiers approved for ASC hospital<br />
outpatient use).<br />
59 Distinct Procedural Service: Under certain<br />
circumstances, it may be necessary to indicate that a<br />
procedure or service was distinct or independent from<br />
other non-E/M services performed on the same day.<br />
Modifier 59 is used to identify procedures/services,<br />
other than E/M services, that are not normally reported<br />
together but are appropriate under the circumstances.<br />
Documentation must support a different session,<br />
different procedure or surgery, different site or organ<br />
system, separate incision or excision, separate lesion, or<br />
separate injury (or area of injury in extensive injuries)<br />
not ordinarily encountered or performed on the same<br />
day by the same individual. However, when another<br />
already established modifier is appropriate, it should be<br />
used rather than modifier 59. Only if no more<br />
descriptive modifier is available, and the use of modifier<br />
59 best explains the circumstances, should modifier 59<br />
be used. Note: Modifier 59 should not be appended to<br />
an E/M service. To report a separate and distinct E/M<br />
service with a non-E/M service performed on the same<br />
date, see modifier 25.<br />
90 Reference (Outside) Laboratory: When laboratory<br />
procedures are performed by a party other than the<br />
treating or reporting physician, the procedure may be<br />
identified by adding modifier 90 to the usual procedure<br />
number.<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
91 Repeat Clinical Diagnostic Laboratory Test: In the<br />
course of treatment of the patient, it may be necessary to<br />
repeat the same laboratory test on the same day to<br />
obtain subsequent (multiple) test results. Under these<br />
circumstances, the laboratory test performed can be<br />
identified by its usual procedure number and the<br />
addition of modifier 91. Note: This modifier may not be<br />
used when tests are rerun to confirm initial results; due<br />
to testing problems with specimens or equipment; or for<br />
any other reason when a normal, one-time, reportable<br />
result is all that is required. This modifier may not be<br />
used when other code(s) describe a series of test results<br />
(e.g., glucose tolerance tests, evocative/suppression<br />
testing). This modifier may only be used for laboratory<br />
test(s) performed more than once on the same day on<br />
the same patient.<br />
92 Alternative Laboratory Platform Testing: When<br />
laboratory testing is being performed using a kit or<br />
transportable instrument that wholly or in part consists<br />
of a single use, disposable analytical chamber, the<br />
service may be identified by adding modifier 92 to the<br />
usual laboratory procedure code (HIV testing<br />
86701–86703). <strong>The</strong> test does not require permanent<br />
dedicated space; hence by its design it may be hand<br />
carried or transported to the vicinity of the patient for<br />
immediate testing at that site, although location of the<br />
testing is not in itself determinative of the use of this<br />
modifier.<br />
99 Multiple Modifiers: Under certain circumstances, two<br />
or more modifiers may be necessary to completely<br />
delineate a service. In such situations, modifier 99<br />
should be added to the basic procedure, and other<br />
applicable modifiers may be listed as part of the<br />
description of the service.<br />
TC Technical Component Only: Certain procedures are a<br />
combination of a physician component and a technical<br />
component. When the technical component is reported<br />
separately, the service may be identified by adding<br />
modifier TC to the usual procedure number.<br />
CPT only © 2010 American Medical Association. All Rights Reserved. 221
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section IX: Pathology and Laboratory Services<br />
PATHOLOGY AND LABORATORY 80047–89398<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
80047 BASIC METABOLIC PANEL CALCIUM IONIZED 15.99 XXX<br />
80048 BASIC METABOLIC PANEL CALCIUM TOTAL 15.99 XXX<br />
80050 GENERAL HLTH PANEL 54.36 XXX<br />
80051 ELECTROLYTE PANEL 13.25 XXX<br />
80053 COMPRE METAB PANEL 20.10 XXX<br />
80055 OB PANEL 79.48 XXX<br />
80061 LIPID PANEL 31.52 XXX<br />
80069 RNL FUNCJ PANEL 16.44 XXX<br />
80074 AQT HEP PANEL 89.08 XXX<br />
80076 HEPATC FUNCJ PANEL 15.53 XXX<br />
80100 DRUG SCR QUAL MLT DRUG CLASSES CHROM EA PX 27.41 XXX<br />
80101 DRUG SCR QUAL 1 DRUG CLASS METH EA DRUG CLASS 37.46 XXX<br />
80102 DRUG CONFIRMATION EA PX 25.12 XXX<br />
80103 TISS PREPJ DRUG ALYS 32.89 XXX<br />
l # 80104 DRUG SCRN QUAL 1+ CLASS NONCHROMOTOGRAPHIC EA 47.51 XXX<br />
80150 AMIKACIN 28.32 XXX<br />
80152 AMITRIPTYLINE 33.80 XXX<br />
80154 BENZODIAZEPINES 35.17 XXX<br />
80156 CARBAMAZEPINE TOT 27.41 XXX<br />
80157 CARBAMAZEPINE FR 25.12 XXX<br />
80158 CYCLOSPORINE 34.26 XXX<br />
80160 DESIPRAMINE 32.43 XXX<br />
80162 DIGOXIN 25.12 XXX<br />
80164 DIPROPYLACETIC ACID 25.58 XXX<br />
80166 DOXEPIN 29.24 XXX<br />
80168 ETHOSUXIMIDE 31.06 XXX<br />
80170 GENTAMICIN 31.06 XXX<br />
80172 GOLD 30.61 XXX<br />
80173 HALOPRIDOL 27.41 XXX<br />
80174 IMIPRAMINE 32.43 XXX<br />
80176 LIDOCAINE 27.86 XXX<br />
80178 LITHIUM 12.33 XXX<br />
80182 NORTRIPTYLINE 25.58 XXX<br />
80184 PHENOBARBITAL 21.47 XXX<br />
80185 PHENYTOIN TOT 25.12 XXX<br />
80186 PHENYTOIN FR 26.04 XXX<br />
80188 PRIMIDONE 31.52 XXX<br />
80190 PROCAINAMIDE 31.52 XXX<br />
80192 PROCAINAMIDE METABOLITES 31.52 XXX<br />
80194 QUINIDINE 27.41 XXX<br />
80195 SIROLIMUS 26.04 XXX<br />
80196 SALICYLATE 13.25 XXX<br />
80197 TACROLIMUS 26.04 XXX<br />
80198 THEOPHYLLINE 26.95 XXX<br />
80200 TOBRAMYCIN 30.61 XXX<br />
80201 TOPIRAMATE 22.38 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
222 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section IX: Pathology and Laboratory Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
80047–89398 PATHOLOGY AND LABORATORY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
80202 VANCOMYCIN 25.58 XXX<br />
80299 QUAN DRUG NES 26.04 XXX<br />
80400 ACTH STIMJ PANEL ADRNL INSUFFICIENCY 93.19 XXX<br />
80402 ACTH STIMJ PANEL 21 HYDROXYLASE DEFNCY 151.66 XXX<br />
80406 ACTH STIMJ PANEL 3 BETA-HYDROXYDEHYD DEFNCY 159.42 XXX<br />
80408 ALDOSTERONE SUPRJ EVAL PANEL 173.58 XXX<br />
80410 CALCITONIN STIMJ PANEL 143.89 XXX<br />
80412 CORTICOTROPIC RELEASING HORM STIMJ PANEL 446.29 XXX<br />
80414 CHORNC GONAD STIMJ PANEL TSTOSTERONE RSPSE 74.46 XXX<br />
80415 CHORNC GONAD STIMJ PANEL ESTRADIOL RSPSE 74.46 XXX<br />
80416 RNL VEIN RENIN STIMJ PANEL 222.00 XXX<br />
80417 PRPH VEIN RENIN STIMJ PANEL 95.01 XXX<br />
80418 CMBN RAPID ANT PITUITARY EVAL PANEL 991.26 XXX<br />
80420 DXMETHASONE SUPRJ PANEL 48 HR 123.79 XXX<br />
80422 GLUC TOLERANCE PANEL INSULINOMA 84.05 XXX<br />
80424 GLUC TOLERANCE PANEL PHEOCHROMOCYTOMA 84.05 XXX<br />
80426 GONAD RELEASING HORM STIMJ PANEL 232.97 XXX<br />
80428 GROWTH HORM STIMJ PANEL 128.82 XXX<br />
80430 GROWTH HORM SUPRJ PANEL GLUC ADMN 128.82 XXX<br />
80432 INSULIN-INDUCED C-PEPTIDE SUPRJ PANEL 252.61 XXX<br />
80434 INSULIN TOLERANCE PANEL ACTH INSUFFICIENCY 158.51 XXX<br />
80435 INSULIN TOLERANCE PANEL GROWTH HORM DEFNCY 168.56 XXX<br />
80436 METYRAPONE PANEL 163.53 XXX<br />
80438 TRH STIMJ PANEL 1 HR 94.10 XXX<br />
80439 TRH STIMJ PANEL 2 HR 99.13 XXX<br />
80440 TRH STIMJ PANEL HYPRPROLACTINEMIA 99.13 XXX<br />
80500 CLIN PATH CONSLTJ LIMITED 27.86 XXX<br />
80502 CLIN PATH CONSLTJ COMPRE 85.88 XXX<br />
81000 URNLS DIP STICK/TABLET RGNT NON-AUTO MIC 5.94 XXX<br />
81001 URNLS DIP STICK/TABLET RGNT AUTO MIC 5.94 XXX<br />
81002 URNLS DIP STICK/TABLET RGNT NON-AUTO W/O MIC 5.02 XXX<br />
81003 URNLS DIP STICK/TABLET RGNT AUTO W/O MIC 4.11 XXX<br />
81005 URNLS QUAL/SEMIQUAN XCPT IAS 4.11 XXX<br />
81007 URNLS BACTERIURIA SCR XCPT CULTURE/DIPSTICK 5.02 XXX<br />
81015 URNLS MCRSCP ONLY 5.94 XXX<br />
81020 URNLS 2/3 GLASS TST 6.85 XXX<br />
81025 URINE PREGNANCY TST VIS COLOR CMPRSN METHS 11.88 XXX<br />
81050 VOL MEAS TMD COLLJ EA 5.48 XXX<br />
81099 UNLIS URNLS BR XXX<br />
82000 ACETALDEHYDE BLD 23.30 XXX<br />
82003 ACETAMINOPHEN 38.37 XXX<br />
82009 ACETONE/OTH KETONE BODIES SERUM QUAL 8.68 XXX<br />
82010 ACETONE/OTH KETONE BODIES SERUM QUAN 15.53 XXX<br />
82013 ACETYLCHOLINESTERASE 21.01 XXX<br />
82016 ACYLCARNITINES QUAL EA SPEC 26.04 XXX<br />
82017 ACYLCARNITINES QUAN EA SPEC 31.98 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 223
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section IX: Pathology and Laboratory Services<br />
PATHOLOGY AND LABORATORY 80047–89398<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
82024 ADRENOCORTICOTROPIC HORM 73.09 XXX<br />
82030 ADENOSINE 5-MONOPHOSPHATE CYCLIC 48.88 XXX<br />
82040 ALBUMIN SERUM PLASMA/WHOLE BLOOD 9.14 XXX<br />
82042 ALBUMIN URINE/OTH SRC QUAN EA SPEC 9.59 XXX<br />
82043 ALBUMIN URINE MICROALBUMIN QUAN 10.96 XXX<br />
82044 ALBUMIN URINE MICROALBUMIN SEMIQUAN 8.68 XXX<br />
82045 ALBUMIN ISCHEMIA MODF 64.41 XXX<br />
82055 ALCOHOL ANY SPEC XCPT BRTH 20.56 XXX<br />
82075 ALCOHOL BRTH 22.84 XXX<br />
82085 ALDOLASE 18.27 XXX<br />
82088 ALDOSTERONE 77.20 XXX<br />
82101 ALKALOIDS URINE QUAN 56.64 XXX<br />
82103 ALPHA-1-ANTITRYPSIN TOT 25.58 XXX<br />
82104 ALPHA-1-ANTITRYPSIN PHEXYP 27.41 XXX<br />
82105 ALPHA-FETOPROTEIN SERUM 31.52 XXX<br />
82106 ALPHA-FETOPROTEIN AMNIOTIC FLU 31.52 XXX<br />
82107 AFP-L3 FRACTION ISOFORM & TOTAL AFP W/RATIO 121.97 XXX<br />
82108 ALUMINUM 48.42 XXX<br />
82120 AMINES VAG FLU QUAL 7.31 XXX<br />
82127 AMINO ACIDS 1 QUAL EA SPEC 26.04 XXX<br />
82128 AMINO ACIDS MLT QUAL EA SPEC 26.04 XXX<br />
82131 AMINO ACIDS 1 QUAN EA SPEC 31.98 XXX<br />
82135 AMINOLEVULINIC ACID DELTA 31.06 XXX<br />
82136 AMINO ACIDS 2-5 AMINO ACIDS QUAN EA SPEC 31.98 XXX<br />
82139 AMINO ACIDS 6/> AMINO ACIDS QUAN EA SPEC 31.98 XXX<br />
82140 AMMONIA 27.41 XXX<br />
82143 AMNIOTIC FLU SCAN 12.79 XXX<br />
82145 AMPHETAMINE/METHAMPHETAMINE 29.24 XXX<br />
82150 AMYLASE 12.33 XXX<br />
82154 ANDROSTANEDIOL GLUCURONIDE 54.36 XXX<br />
82157 ANDROSTENEDIONE 55.27 XXX<br />
82160 ANDROSTERONE 47.51 XXX<br />
82163 ANGIOTENSIN II 38.83 XXX<br />
82164 ANGIOTENSIN I-CONVERTING ENZYME 27.41 XXX<br />
82172 APOLIPOPROTEIN EA 29.24 XXX<br />
82175 ARSENIC 36.09 XXX<br />
82180 ASCORBIC ACID BLD 18.73 XXX<br />
82190 ATOMIC ABSRPJ SPECTROSCOPY EA ANAL 28.32 XXX<br />
82205 BARBITURATES NES 21.47 XXX<br />
82232 BETA-2 MICROGLOBULIN 30.61 XXX<br />
82239 BILE ACIDS TOT 32.43 XXX<br />
82240 BILE ACIDS CHOLYLGLYCINE 50.25 XXX<br />
82247 BILIRUBIN TOT 9.59 XXX<br />
82248 BILIRUBIN DIR 9.59 XXX<br />
82252 BILIRUBIN FECES QUAL 8.68 XXX<br />
82261 BIOTINIDASE EA SPEC 31.98 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
224 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section IX: Pathology and Laboratory Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
80047–89398 PATHOLOGY AND LABORATORY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
82270 BLD OCLT PROXIDASE ACTV QUAL FECES 1 DETER 5.94 XXX<br />
82271 BLD OCLT PROXIDASE ACTV QUAL OTH SRCS 5.94 XXX<br />
82272 BLOOD OCCULT PEROXIDASE ACTV QUAL FECES 1-3 SPEC 5.94 XXX<br />
82274 BLD OCLT FECAL HGB DETER IA QUAL FECES 1-3 30.15 XXX<br />
82286 BRADYKININ 13.25 XXX<br />
82300 CADMIUM 43.85 XXX<br />
82306 25 HYDROXY INCLUDES FRACTIONS IF PERFORMED 56.19 XXX<br />
82308 CALCITONIN 50.70 XXX<br />
82310 CALCIUM TOT 9.59 XXX<br />
82330 CALCIUM IONIZED 26.04 XXX<br />
82331 CALCIUM AFTER CALCIUM NFS TST 9.59 XXX<br />
82340 CALCIUM URINE QUAN TMD SPEC 11.42 XXX<br />
82355 ST1 QUAL ALYS 21.93 XXX<br />
82360 ST1 QUAN ALYS CHEM 24.21 XXX<br />
82365 ST1 INFRARED SPECTROSCOPY 24.21 XXX<br />
82370 ST1 X-RAY DIFFXJ 23.75 XXX<br />
82373 CARBOHYDRATE DEFICIENT TRRIN 34.26 XXX<br />
82374 CARBON DIOXIDE 9.14 XXX<br />
82375 CARBOXYHEMOGLOBIN QUANTITATIVE 23.30 XXX<br />
82376 CARBOXYHEMOGLOBIN QUALITATIVE 11.42 XXX<br />
82378 CARCINOEMBRYONIC AG 36.09 XXX<br />
82379 CARNITINE QUAN EA SPEC 31.98 XXX<br />
82380 CAROTENE 17.36 XXX<br />
82382 CATECHOLAMINES TOT URINE 32.43 XXX<br />
82383 CATECHOLAMINES BLD 47.51 XXX<br />
82384 CATECHOLAMINES FXJATED 47.96 XXX<br />
82387 CATHEPSIN-D 39.28 XXX<br />
82390 CERULOPLASMIN 20.56 XXX<br />
82397 CHEMILUMINESCENT ASSAY 26.95 XXX<br />
82415 CHLORAMPHENICOL 23.75 XXX<br />
82435 CHLORIDE BLD 8.68 XXX<br />
82436 CHLORIDE URINE 9.59 XXX<br />
82438 CHLORIDE OTH SRC 9.14 XXX<br />
82441 CHLORINATED HYDROCARBONS SCR 11.42 XXX<br />
82465 CHOLESTEROL SERUM/WHL BLD TOT 8.22 XXX<br />
82480 CHOLINESTERASE SERUM 15.07 XXX<br />
82482 CHOLINESTERASE RBC 14.62 XXX<br />
82485 CHONDROITIN B SULFATE QUAN 39.28 XXX<br />
82486 CHROM QUAL COLUMN ANAL NES 34.26 XXX<br />
82487 CHROM QUAL PAPR 1-DIMENSIONAL ANAL NES 30.15 XXX<br />
82488 CHROM QUAL PAPR 2-DIMENSIONAL ANAL NES 40.66 XXX<br />
82489 CHROM QUAL THIN LYR ANAL NES 35.17 XXX<br />
82491 CHROM QUAN COLUMN 1 ANAL NES 34.26 XXX<br />
82492 CHROM QUAN COLUMN MLT ANALS 34.26 XXX<br />
82495 CHROMIUM 38.37 XXX<br />
82507 CITRATE 52.53 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 225
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section IX: Pathology and Laboratory Services<br />
PATHOLOGY AND LABORATORY 80047–89398<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
82520 COCAINE/METABOLITE 28.78 XXX<br />
82523 COLLAGEN CROSS LINKS ANY METH 35.17 XXX<br />
82525 COPPR 23.30 XXX<br />
82528 CORTICOSTERONE 42.48 XXX<br />
82530 CORTISOL FR 31.52 XXX<br />
82533 CORTISOL TOT 31.06 XXX<br />
82540 CREATINE 8.68 XXX<br />
82541 COL-CHR/MS QUAL 1 STATIONARY&MOBILE PHASE 34.26 XXX<br />
82542 COL-CHR/MS QUAN 1 STATIONARY&MOBILE PHASE 34.26 XXX<br />
82543 COL-CHR/MS STABLE ISOTOPE DIL 1 ANAL 34.26 XXX<br />
82544 COL-CHR/MS STABLE ISOTOPE DIL MLT ANALS 34.26 XXX<br />
82550 CREATINE KINASE TOT 12.33 XXX<br />
82552 CREATINE KINASE ISOENZYMES 25.58 XXX<br />
82553 CREATINE KINASE MB FXJ ONLY 21.93 XXX<br />
82554 CREATINE KINASE ISOFORMS 22.38 XXX<br />
82565 CREATININE BLD 9.59 XXX<br />
82570 CREATININE OTH SRC 9.59 XXX<br />
82575 CREATININE CLEARANCE 17.82 XXX<br />
82585 CRYOFIBRN 16.44 XXX<br />
82595 CRYOGLOBULIN QUAL/SEMI-QUAN 12.33 XXX<br />
82600 CYANIDE 36.54 XXX<br />
82607 CYANOCOBALAMIN 28.32 XXX<br />
82608 CYANOCOBALAMIN UNSAT BNDNG CAP 26.95 XXX<br />
82610 CYSTATIN C 25.58 XXX<br />
82615 CSTINE&HOMOCSTINE URINE QUAL 15.53 XXX<br />
82626 DEHYDROEPIANDROSTERONE 47.96 XXX<br />
82627 DEHYDROEPIANDROSTERONE-SULFATE 42.03 XXX<br />
82633 DESOXYCORTICOSTERONE 11- 58.47 XXX<br />
82634 DEOXYCORTISOL 11- 55.27 XXX<br />
82638 DIBUCAINE NUMBER 23.30 XXX<br />
82646 DIHYDROCODEINONE 39.28 XXX<br />
82649 DIHYDROMORPHINONE 48.42 XXX<br />
82651 DIHYDROTSTOSTERONE 48.88 XXX<br />
# 82652 1 25 DIHYDROXY INCLUDES FRACTIONS IF PERFORMED 72.63 XXX<br />
82654 DIMETHADIONE 26.04 XXX<br />
82656 ELASTASE PNCRTC FECAL QUAL/SEMI-QUAN 21.93 XXX<br />
82657 NZM ACTV CELLS/TISS NONRADACT SUBSTRATE EA 34.26 XXX<br />
82658 NZM ACTV CELLS/TISS RADACT SUBSTRATE EA 34.26 XXX<br />
82664 ELECTROP TQ NES 64.87 XXX<br />
82666 EPIANDROSTERONE 40.66 XXX<br />
82668 ERYTHROPOIETIN 35.63 XXX<br />
82670 ESTRADIOL 52.99 XXX<br />
82671 STRGNS FXJATED 61.21 XXX<br />
82672 STRGNS TOT 41.11 XXX<br />
82677 ESTRIOL 45.68 XXX<br />
82679 ESTRONE 47.05 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
226 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section IX: Pathology and Laboratory Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
80047–89398 PATHOLOGY AND LABORATORY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
82690 ETHCHLORVYNOL 32.89 XXX<br />
82693 ETHYLENE GLYCOL 28.32 XXX<br />
82696 ETIOCHOLANOLONE 44.77 XXX<br />
82705 FAT/LIPIDS FECES QUAL 9.59 XXX<br />
82710 FAT/LIPIDS FECES QUAN 31.98 XXX<br />
82715 FAT DIFFIAL FECES QUAN 32.43 XXX<br />
82725 FATTY ACIDS NONESTERIFIED 25.12 XXX<br />
82726 VERY LONG CHAIN FATTY ACIDS 34.26 XXX<br />
82728 FERRITIN 25.58 XXX<br />
82731 FTL FIBRONECTIN CERVICOVAG SECRETIONS SEMI-QUAN 121.97 XXX<br />
82735 FLUORIDE 35.17 XXX<br />
82742 FLURAZEPAM 37.46 XXX<br />
82746 FOLIC ACID SERUM 27.86 XXX<br />
82747 FOLIC ACID RBC 32.89 XXX<br />
82757 FRUCTOSE SEMEN 32.89 XXX<br />
82759 GALACTOKINASE RBC 40.66 XXX<br />
82760 GALACTOSE 21.01 XXX<br />
82775 GALACTOSE-1-PHOSPHATE URIDYL TRASE QUAN 39.74 XXX<br />
82776 GALACTOSE-1-PHOSPHATE URIDYL TRASE SCR 15.99 XXX<br />
82784 GAMMAGLOBULIN IGA IGD IGG IGM EACH 17.82 XXX<br />
82785 GAMMAGLOBULIN IGE 31.06 XXX<br />
82787 GAMMAGLOBULIN IMMUNOGLOBULIN SUBCLASSES 15.07 XXX<br />
82800 GASES BLD PH ONLY 15.99 XXX<br />
82803 BLOOD GASES ANY COMBINATION PH PCO2 PO2 CO2 HCO3 36.54 XXX<br />
82805 GASES BLD PH DIR MEAS XCPT PLS OXIMTRY 53.90 XXX<br />
82810 GASES BLD O2 SATURATION ONLY DIR MEAS 16.44 XXX<br />
82820 HGB-O2 AFFINITY PO2 50% SATURATION OXYGEN 18.73 XXX<br />
l 82930 GASTRIC ACID ANALYIS W/PH EA SPECIMEN 10.51 XXX<br />
82938 GASTRIN AFTER SECRETIN STIMJ 33.35 XXX<br />
82941 GASTRIN 33.35 XXX<br />
82943 GLUC 26.95 XXX<br />
82945 GLUC BDY FLU OTH/THN BLD 7.31 XXX<br />
82946 GLUC TOLERANCE TST 28.32 XXX<br />
82947 GLUC QUAN BLD 7.31 XXX<br />
82948 GLUC BLD RGNT STRIP 5.94 XXX<br />
82950 GLUC POST GLUC DOSE GLUC 9.14 XXX<br />
82951 GLUC TOLERANCE TST GTT 3 SPEC GLUC 24.21 XXX<br />
s + 82952 GLUCOSE TOLERANCE EA ADDL BEYOND 3 SPECIMENS 7.31 XXX<br />
82953 GLUC TOLBUTAMIDE TOLERANCE TST 28.78 XXX<br />
82955 GLUC-6-PHOSPHATE DEHYD QUAN 18.27 XXX<br />
82960 GLUC-6-PHOSPHATE DEHYD SCR 11.42 XXX<br />
82962 GLUC BLD GLUC MNTR DEV CLEARED FDA SPEC HOME USE 4.57 XXX<br />
82963 GLUCOSIDASE BETA 40.66 XXX<br />
82965 GLUTAMATE DEHYD 14.62 XXX<br />
82975 GLUTAMINE 30.15 XXX<br />
82977 GLUTAMYLTRASE GAMMA 13.70 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 227
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section IX: Pathology and Laboratory Services<br />
PATHOLOGY AND LABORATORY 80047–89398<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
82978 GLUTATHIONE 26.95 XXX<br />
82979 GLUTATHIONE REDUXASE RBC 13.25 XXX<br />
82980 GLUTETHIMIDE 34.72 XXX<br />
82985 GLYCATED PROTEIN 28.32 XXX<br />
83001 GONAD FOLLICLE STIMULATING HORM 35.17 XXX<br />
83002 GONAD LTNZNG HORM 35.17 XXX<br />
83003 GROWTH HORM HUMAN 31.52 XXX<br />
83008 GUANOSINE MONOPHOSPHATE CYCLIC 31.98 XXX<br />
83009 HPYLORI BLD NON-RADACT ISOTOPE 127.45 XXX<br />
83010 HAPTOGLOBIN QUAN 23.75 XXX<br />
83012 HAPTOGLOBIN PHEXYP 32.43 XXX<br />
83013 HPYLORI BRTH NON-RADACT ISOTOPE 127.45 XXX<br />
83014 HPYLORI DRUG ADMN 15.07 XXX<br />
83015 HEAVY METAL SCR 35.63 XXX<br />
83018 HEAVY METAL QUAN EA 41.57 XXX<br />
83020 HGB FXJ&QUAN ELECTROPHORESIS 50.25 XXX<br />
83020 26 HGB FXJ&QUAN ELECTROPHORESIS 26.04 XXX<br />
83020 TC HGB FXJ&QUAN ELECTROPHORESIS 24.21 XXX<br />
83021 HGB FXJ&QUAN CHROM 34.26 XXX<br />
83026 HGB COPPR SULFATE METH NON-AUTO 4.57 XXX<br />
83030 HGB F CHEM 15.53 XXX<br />
83033 HGB F QUAL 11.42 XXX<br />
83036 HGB GLYCOSYLATED 18.27 XXX<br />
83037 HGB GLYCOSYLATED DEV CLEARED FDA HOME USE 18.27 XXX<br />
83045 HGB METHGB QUAL 9.59 XXX<br />
83050 HGB METHGB QUAN 13.70 XXX<br />
83051 HGB PLSM 13.70 XXX<br />
83055 HGB SULFHGB QUAL 9.14 XXX<br />
83060 HGB SULFHGB QUAN 15.53 XXX<br />
83065 HGB THERMOLABILE 13.25 XXX<br />
83068 HGB UNSTABLE SCR 15.99 XXX<br />
83069 HGB URINE 7.31 XXX<br />
83070 HEMOSIDERIN QUAL 9.14 XXX<br />
83071 HEMOSIDERIN QUAN 12.79 XXX<br />
83080 B-HEXOSAMINIDASE EA ASSAY 31.98 XXX<br />
83088 HISTAM 55.73 XXX<br />
83090 HOMOCSTEINE 31.98 XXX<br />
83150 HOMOVANILLIC ACID 36.54 XXX<br />
83491 HYDROXYCORTICOSTRDS 17 33.35 XXX<br />
83497 HYDROXYINDOLACETIC ACID 5 24.21 XXX<br />
83498 HYDROXYPROGST 17-D 51.62 XXX<br />
83499 HYDROXYPROGST 20- 47.51 XXX<br />
83500 HYDROXYPROLINE FR 42.94 XXX<br />
83505 HYDROXYPROLINE TOT 46.14 XXX<br />
83516 IMMUNOASSAY ANALYTE QUAL/SEMIQUAL MULTIPLE STEP 21.93 XXX<br />
83518 IMMUNOASSAY ANALYTE QUAL/SEMIQUAL SINGLE STEP 15.99 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
228 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section IX: Pathology and Laboratory Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
80047–89398 PATHOLOGY AND LABORATORY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
83519 IMMUNOASSAY ANALYTE QUANT RADIOIMMUNOASSAY 25.58 XXX<br />
83520 IMMUNOASSAY ANALYTE QUANTITATIVE NOS 24.67 XXX<br />
83525 INSULIN TOT 21.47 XXX<br />
83527 INSULIN FR 24.67 XXX<br />
83528 INTRNSC FACTOR 30.15 XXX<br />
83540 IRON 12.33 XXX<br />
83550 IRON BNDNG CAP 16.44 XXX<br />
83570 ISOCITRIC DEHYD 16.90 XXX<br />
83582 KETOGENIC STRDS FXJ 26.95 XXX<br />
83586 KETOSTRDS 17 TOT 24.21 XXX<br />
83593 KETOSTRDS 17-FXJ 49.79 XXX<br />
83605 LACTATE 20.10 XXX<br />
83615 LACTATE DEHYD 11.42 XXX<br />
83625 LACTATE DEHYD ISOENZYMES SEP&QUAN 24.21 XXX<br />
83630 LACTOFERRIN FECAL QUAL 37.00 XXX<br />
83631 LACTOFERRIN FECAL QUAN 37.00 XXX<br />
83632 LACTOGEN HPL HUMAN CHORNC SOMAT 38.37 XXX<br />
83633 LACTOSE URINE QUAL 10.51 XXX<br />
83634 LACTOSE URINE QUAN 21.93 XXX<br />
83655 LEAD 22.84 XXX<br />
83661 FTL LNG MATRT ASSMT L/S RATIO 41.57 XXX<br />
83662 FTL LNG MATRT ASSMT FOAM STABILITY TST 35.63 XXX<br />
83663 FTL LNG MATRT ASSMT FLUORESCENCE POLARIZATION 35.63 XXX<br />
83664 FTL LNG MATRT ASSMT LAMELLAR BDY DNS 35.63 XXX<br />
83670 LEUCINE AMINOPEPTIDASE LAP 17.36 XXX<br />
83690 LIPASE 13.25 XXX<br />
83695 LIPOPROTEIN A 24.67 XXX<br />
83698 LIPOPROTEIN-ASSOCIATED PHOSPHOLIPASE A2 64.41 XXX<br />
83700 LIPOPROTEIN BLD ELECTROP SEP&QUAN 21.47 XXX<br />
83701 LIPOPROTEIN BLD HR SUBCLASSES 47.05 XXX<br />
83704 LIPOPROTEIN BLD QUAN NUMBERS&SUBCLASSES 59.84 XXX<br />
83718 LIPOPROTEIN DIR MEAS HI DNS CHOLESTEROL 15.53 XXX<br />
83719 LIPOPROTEIN DIR MEAS VLDL CHOLESTEROL 21.93 XXX<br />
83721 LIPOPROTEIN DIR MEAS LDL CHOLESTEROL 17.82 XXX<br />
83727 LTNZNG RELEASING FACTOR 32.43 XXX<br />
83735 MAGNESIUM 12.79 XXX<br />
83775 MALATE DEHYD 14.16 XXX<br />
83785 MANGANESE 46.59 XXX<br />
83788 MASS SPECT&TANDEM MASS SPECT ANAL QUAL EA SPEC 34.26 XXX<br />
83789 MASS SPECT&TANDEM MASS SPECT ANAL QUAN EA SPEC 34.26 XXX<br />
83805 MEPROBAMATE 33.35 XXX<br />
83825 MERCURY QUAN 30.61 XXX<br />
83835 METANEPHRINES 31.98 XXX<br />
83840 METHADONE 31.06 XXX<br />
83857 METHEMALBUMIN 20.56 XXX<br />
83858 METHSUXIMIDE 27.86 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 229
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section IX: Pathology and Laboratory Services<br />
PATHOLOGY AND LABORATORY 80047–89398<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
l 83861 MICROFLUID ANALYSIS TEAR OSMOLARITY 31.52 XXX<br />
83864 MUCOPOLYSACS ACID QUAN 37.46 XXX<br />
83866 MUCOPOLYSACS ACID SCR 18.73 XXX<br />
83872 MUCIN SYNVAL FLU ROPES TST 10.96 XXX<br />
83873 MYELIN BASIC PROTEIN CEREBSP FLU 32.43 XXX<br />
83874 MYOGLOBIN 24.21 XXX<br />
83876 MYELOPEROXIDASE MPO 64.41 XXX<br />
83880 NATRIURETIC PEPTIDE 64.41 XXX<br />
83883 NEPHELOMETRY EA ANAL NES 25.58 XXX<br />
83885 NICKEL 46.14 XXX<br />
83887 NICOTINE 44.77 XXX<br />
83890 MOLEC DIAG ISOL/XTRJ EA NUCLEIC ACID TYPE 7.77 XXX<br />
83891 MOLEC ISOL/XTRJ HP NUCLEIC ACID EA TYPE 7.77 XXX<br />
83892 MOLEC ENZYMATIC DIGESTION EA ENZYME TX 7.77 XXX<br />
83893 MOLEC DOT/SLOT BLOT EA NUCLEIC ACID PREPJ 7.77 XXX<br />
83894 MOLEC SEP GEL ELECTROPHORESIS EACH PREPJ 7.77 XXX<br />
83896 MOLEC NUCLEIC ACID PRB EA 7.77 XXX<br />
83897 MOLEC NUCLEIC ACID TR EA NUCLEIC ACID PREPJ 7.77 XXX<br />
83898 MOLECULAR DX AMPLIFICATION TARGET EA SEQUENCE 31.52 XXX<br />
83900 MOLECULAR DX AMP TARGET MULTIPLEX 1ST 2 SEQ 63.50 XXX<br />
+ 83901 MOLECULAR DX AMP TARGET MULTIPLEX EA ADDL SEQ 31.52 XXX<br />
83902 MOLEC REVERSE TRANSCRIPTION 26.95 XXX<br />
83903 MOLEC MUTATION SCANNING PROPERTIES 1 SGM EACH 31.52 XXX<br />
83904 MOLEC MUTATION ID SEQUENCING 1 SGM EA SGM 31.52 XXX<br />
83905 MOLEC MUTATION ALLELE TRANSCRIPTION 1 SGM EA 31.52 XXX<br />
83906 MOLEC MUTATION ALLELE SPEC TRANSLATION 1 SGM EA 31.52 XXX<br />
83907 MOLEC LSS CELLS PRIOR NUCLEIC ACID XTRJ 25.12 XXX<br />
83908 MOLECULAR DX AMPLIFICATION SIGNAL EA SEQUENCE 31.52 XXX<br />
83909 MOLEC SEP&ID HR TQ 31.52 XXX<br />
83912 MOLEC DX I&R 32.43 XXX<br />
83912 26 MOLEC DX I&R 24.67 XXX<br />
83912 TC MOLEC DX I&R 7.76 XXX<br />
83913 MOLECULAR DIAGNOSTICS RNA STABILIZATION 25.12 XXX<br />
83914 MUTATION ID ENZYMATIC LIG/PRIMER XTN 1 SGM EA 31.52 XXX<br />
83915 NUCLEOTIDASE 5'- 21.01 XXX<br />
83916 OLIGOCLONAL IMMUNE 37.91 XXX<br />
83918 ORGANIC ACIDS TOT QUAN EA SPEC 31.06 XXX<br />
83919 ORGANIC ACIDS QUAL EA SPEC 31.06 XXX<br />
83921 ORGANIC ACID 1 QUAN 31.06 XXX<br />
83925 OPIATE(S) DRUG AND METABOLITES EACH PROCEDURE 37.00 XXX<br />
83930 OSMOLALITY BLD 12.33 XXX<br />
83935 OSMOLALITY URINE 12.79 XXX<br />
83937 OSTEOCALCIN 56.64 XXX<br />
83945 OXALATE 24.21 XXX<br />
83950 ONCOPROTEIN HER-2/NEU 121.97 XXX<br />
83951 ONCOPROTEIN DES-GAMMA-CARBOXY-PROTHROMBIN DCP 121.97 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
230 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section IX: Pathology and Laboratory Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
80047–89398 PATHOLOGY AND LABORATORY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
83970 PARATHORM 78.11 XXX<br />
83986 PH BODY FLUID NOS 6.85 XXX<br />
83987 PH EXHALED BREATH CONDENSATE 30.15 XXX<br />
83992 PHENCYCLIDINE 27.86 XXX<br />
83993 CALPROTECTIN FECAL 37.00 XXX<br />
84022 PHEXHIAZINE 29.69 XXX<br />
84030 PHENYLALA9 BLD 10.51 XXX<br />
84035 PHENYLKETONES QUAL 6.85 XXX<br />
84060 PHOSPHATASE ACID TOT 14.16 XXX<br />
84061 PHOSPHATASE ACID FORENSIC XM 15.07 XXX<br />
84066 PHOSPHATASE ACID PROSTATIC 18.27 XXX<br />
84075 PHOSPHATASE ALKALINE 9.59 XXX<br />
84078 PHOSPHATASE ALKALINE HEAT STABLE TOT X W/ 13.70 XXX<br />
84080 PHOSPHATASE ALKALINE ISOENZYMES 27.86 XXX<br />
84081 PHOSPHATIDYLGLYCEROL 31.06 XXX<br />
84085 PHOSPHOGLUCONATE 6-DEHYD RBC 12.79 XXX<br />
84087 PHOSPHOHEXOSE ISOMERASE 19.64 XXX<br />
84100 PHOSPHORUS INORGANIC 9.14 XXX<br />
84105 PHOSPHORUS INORGANIC URINE 9.59 XXX<br />
84106 PORPHOBILINOGEN URINE QUAL 8.22 XXX<br />
84110 PORPHOBILINOGEN URINE QUAN 15.99 XXX<br />
l 84112 PLACENTAL ALPHA MICROGLOBULIN C/V QUAL 121.97 XXX<br />
84119 PORPHYRINS URINE QUAL 16.44 XXX<br />
84120 PORPHYRINS URINE QUAN&FXJ 27.86 XXX<br />
84126 PORPHYRINS FECES QUAN 48.42 XXX<br />
84127 PORPHYRINS FECES QUAL 21.93 XXX<br />
84132 POTASSIUM SERUM PLASMA/WHOLE BLOOD 8.68 XXX<br />
84133 POTASSIUM URINE 8.22 XXX<br />
84134 PREALBUMIN 27.41 XXX<br />
84135 PREGNANEDIOL 36.09 XXX<br />
84138 PREGNANETRIOL 35.63 XXX<br />
84140 PREGNENOLONE 39.28 XXX<br />
84143 17-HYDROXYPREGNENOLONE 43.40 XXX<br />
84144 PROGST 39.28 XXX<br />
84145 PROCALCITONIN (PCT) 50.70 XXX<br />
84146 PROLACTIN 36.54 XXX<br />
84150 PROSTAGLNDIN EA 47.05 XXX<br />
84152 PRST8 SPEC AG CPLXED DIR MEAS 34.72 XXX<br />
84153 PRST8 SPEC AG TOT 34.72 XXX<br />
84154 PRST8 SPEC AG FR 34.72 XXX<br />
84155 PROTEIN XCPT REFRACTOMETRY SERUM PLASMA/WHL BLD 6.85 XXX<br />
84156 PROTEIN TOT XCPT REFRACTOMETRY URINE 6.85 XXX<br />
84157 PROTEIN TOT XCPT REFRACTOMETRY OTH SRC 6.85 XXX<br />
84160 PROTEIN TOT REFRACTOMETRY ANY SRC 9.59 XXX<br />
84163 PREGNANCY-ASSOCIATED PLSM PROTEIN-A 28.32 XXX<br />
84165 PROTEIN ELECTROP FXJ&QUAN SERUM 46.14 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 231
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section IX: Pathology and Laboratory Services<br />
PATHOLOGY AND LABORATORY 80047–89398<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
84165 26 PROTEIN ELECTROP FXJ&QUAN SERUM 25.58 XXX<br />
84165 TC PROTEIN ELECTROP FXJ&QUAN SERUM 20.56 XXX<br />
84166 PROTEIN ELECTROP FXJ&QUAN OTH FLUS CONCENTRATION 59.38 XXX<br />
84166 26 PROTEIN ELECTROP FXJ&QUAN OTH FLUS CONCENTRATION 25.58 XXX<br />
84166 TC PROTEIN ELECTROP FXJ&QUAN OTH FLUS CONCENTRATION 33.80 XXX<br />
84181 PROTEIN WSTRN BLOT I&R BLD/OTH FLU 58.47 XXX<br />
84181 26 PROTEIN WSTRN BLOT I&R BLD/OTH FLU 26.04 XXX<br />
84181 TC PROTEIN WSTRN BLOT I&R BLD/OTH FLU 32.43 XXX<br />
84182 PROTEIN WSTRN BLOT BLD/OTH FLU IMMUNOLOGICAL 59.84 XXX<br />
84182 26 PROTEIN WSTRN BLOT BLD/OTH FLU IMMUNOLOGICAL 25.58 XXX<br />
84182 TC PROTEIN WSTRN BLOT BLD/OTH FLU IMMUNOLOGICAL 34.26 XXX<br />
84202 PROTOPORPHYRIN RBC QUAN 26.95 XXX<br />
84203 PROTOPORPHYRIN RBC SCR 16.44 XXX<br />
84206 PROINSULIN 33.80 XXX<br />
84207 PYRIDOXAL PHOSPHATE 52.99 XXX<br />
84210 PYRUVATE 20.56 XXX<br />
84220 PYRUVATE KINASE 17.82 XXX<br />
84228 QUININE 21.93 XXX<br />
84233 RCPTR ASSAY STRGN 121.97 XXX<br />
84234 RCPTR ASSAY PROGST 122.88 XXX<br />
84235 RCPTR ASSAY ENDOC OTH/THN STRGN/PROGST 99.13 XXX<br />
84238 RCPTR ASSAY NON-ENDOC SPEC RCPTR 68.98 XXX<br />
84244 RENIN 41.57 XXX<br />
84252 RIBOFLAVIN 38.37 XXX<br />
84255 SELENIUM 48.42 XXX<br />
84260 SEROTONIN 58.47 XXX<br />
84270 SEX HORM BNDNG GLOBULIN 41.11 XXX<br />
84275 SIALIC ACID 25.58 XXX<br />
84285 SILICA 44.77 XXX<br />
84295 SODIUM SERUM PLASMA OR WHOLE BLOOD 9.14 XXX<br />
84300 SODIUM URINE 9.14 XXX<br />
84302 SODIUM OTH SRC 9.14 XXX<br />
84305 SOMATOMEDIN 40.20 XXX<br />
84307 SOMATOSTATIN 34.72 XXX<br />
84311 SPECTROPHOTOMETRY ANAL NES 13.25 XXX<br />
84315 SPEC GRAVITY XCPT URINE 4.57 XXX<br />
84375 SUGARS CHROMATOGRAPIC TLC/PAPR CHROM 37.00 XXX<br />
84376 SUGARS MONO DI&OLIGOS 1 QUAL EA SPEC 10.51 XXX<br />
84377 SUGARS MONO DI&OLIGOS MLT QUAL EA SPEC 10.51 XXX<br />
84378 SUGARS MONO DI&OLIGOS 1 QUAN EA SPEC 21.93 XXX<br />
84379 SUGARS MONO DI&OLIGOS MLT QUAN EA SPEC 21.93 XXX<br />
84392 SULFATE URINE 9.14 XXX<br />
84402 TSTOSTERONE FR 47.96 XXX<br />
84403 TSTOSTERONE TOT 48.88 XXX<br />
84425 THIAMINE 40.20 XXX<br />
84430 THIOCYANATE 21.93 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
232 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section IX: Pathology and Laboratory Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
80047–89398 PATHOLOGY AND LABORATORY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
84431 THROMBOXANE METABOLITE W/WO THROMBOXANE URINE 31.98 XXX<br />
84432 THYROGLOBULIN 30.61 XXX<br />
84436 THYROXINE TOT 12.79 XXX<br />
84437 THYROXINE REQ ELUTION 12.33 XXX<br />
84439 THYROXINE FR 16.90 XXX<br />
84442 THYROXINE BNDNG GLOBULIN 27.86 XXX<br />
84443 THYR STIMULATING HORM 31.98 XXX<br />
84445 THYR STIMULATING IGS 96.38 XXX<br />
84446 TOCOPHEROL ALPHA 26.95 XXX<br />
84449 TRANSCORTIN 34.26 XXX<br />
84450 TRANSFERASE ASPARTATE AMINO 9.59 XXX<br />
84460 TRANSFERASE ALANINE AMINO 10.05 XXX<br />
84466 TRANSFERRIN 24.21 XXX<br />
84478 TRIGLYCERIDES 10.96 XXX<br />
84479 THYR HORM UPTK/THYR HORM BNDNG RATIO 12.33 XXX<br />
84480 TRIIODOTHYRO9 T3 TOT 26.95 XXX<br />
84481 TRIIODOTHYRO9 T3 FR 31.98 XXX<br />
84482 TRIIODOTHYRO9 T3 REVERSE 29.69 XXX<br />
84484 TROPONIN QUAN 18.73 XXX<br />
84485 TRYPSIN DUOL FLU 14.16 XXX<br />
84488 TRYPSIN FECES QUAL 13.70 XXX<br />
84490 TRYPSIN FECES QUAN 24-HR COLLJ 14.62 XXX<br />
84510 TYROSINE 19.64 XXX<br />
84512 TROPONIN QUAL 14.62 XXX<br />
84520 UREA N QUAN 7.31 XXX<br />
84525 UREA N SEMIQUAN 7.31 XXX<br />
84540 UREA N URINE 9.14 XXX<br />
84545 UREA N CLEARANCE 12.33 XXX<br />
84550 URIC ACID BLD 8.68 XXX<br />
84560 URIC ACID OTH SRC 9.14 XXX<br />
84577 UROBILINOGEN FECES QUAN 23.75 XXX<br />
84578 UROBILINOGEN URINE QUAL 5.94 XXX<br />
84580 UROBILINOGEN URINE QUAN TMD SPEC 13.25 XXX<br />
84583 UROBILINOGEN URINE SEMIQUAN 9.59 XXX<br />
84585 VANILLYLMANDELIC ACID URINE 29.24 XXX<br />
84586 VASOACTIVE INTSTINAL PEPTIDE 66.69 XXX<br />
84588 VASOPRESSIN 64.41 XXX<br />
84590 VIT 21.93 XXX<br />
84591 VIT NOS 21.93 XXX<br />
84597 VIT K 26.04 XXX<br />
84600 VOLATILES 30.61 XXX<br />
84620 XYLOSE ABSRPJ TST BLD&/URINE 22.38 XXX<br />
84630 ZINC 21.47 XXX<br />
84681 C-PEPTIDE 39.28 XXX<br />
84702 GONAD CHORNC QUAN 28.32 XXX<br />
84703 GONAD CHORNC QUAL 14.16 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 233
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section IX: Pathology and Laboratory Services<br />
PATHOLOGY AND LABORATORY 80047–89398<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
84704 GONADOTROPIN CHORIONIC HCG FREE BETA CHAIN 28.32 XXX<br />
84830 OVUL TSTS VIS COLOR CMPRSN METHS 19.19 XXX<br />
84999 UNLIS CHEMISTRY BR XXX<br />
85002 BLEEDING TM 8.68 XXX<br />
85004 BLD# AUTO DIFFIAL WBC CNT 12.33 XXX<br />
85007 BLD# BLD SMR MCRSCP XM MNL DIFFIAL WBC CNT 6.40 XXX<br />
85008 BLD# BLD SMR MCRSCP XM W/O MNL DIFFIAL WBC CNT 6.40 XXX<br />
85009 BLD# MNL DIFFIAL WBC CNT BUFFY COAT 6.85 XXX<br />
85013 BLD# SPUN MICROHEMATOCRIT 4.57 XXX<br />
85014 BLD# HEMATOCRIT 4.57 XXX<br />
85018 BLD# HGB 4.57 XXX<br />
85025 BLD# COMPL AUTO HHRWP&AUTO DIFFIAL 14.62 XXX<br />
85027 BLD# COMPL AUTO HHRWP 12.33 XXX<br />
85032 BLD# MNL C-CNT RBC WBC/PLTLT EA 8.22 XXX<br />
85041 BLD# RED BLD CELL AUTO 5.48 XXX<br />
85044 BLD# RETICULOCYTE MNL 8.22 XXX<br />
85045 BLD# RETICULOCYTE AUTO 7.77 XXX<br />
85046 BLD# RETICULOCYTES AUTO 1+ CELL MEAS 10.51 XXX<br />
85048 BLD# WBC AUTO 5.02 XXX<br />
85049 BLD# PLTLT AUTO 8.68 XXX<br />
85055 RETICULATED PLTLT ASSAY 50.70 XXX<br />
85060 BLD SMR PRPH INTERPJ PHYS WRTTN REPRT 31.06 XXX<br />
85097 B1 MARROW SMR INTERPJ 115.11 XXX<br />
85130 CHROMOGENIC SUBSTRATE ASSAY 22.38 XXX<br />
85170 CLOT RETRCJ 6.85 XXX<br />
85175 CLOT LSS TM WHL BLD DIL 8.68 XXX<br />
85210 CLTNG FACTOR II PROTHROMBIN SPEC 24.67 XXX<br />
85220 CLTNG FACTOR V ACG/PROACCELERIN LABILE FACTOR 33.35 XXX<br />
85230 CLTNG FACTOR VII PROCONVERTIN STABLE FACTOR 33.80 XXX<br />
85240 CLTNG FACTOR VIII AHG 1 STG 33.80 XXX<br />
85244 CLTNG FACTOR VIII RELATED AG 38.83 XXX<br />
85245 CLTNG FACTOR VIII VW FACTOR RISTOCETIN COFACTOR 43.40 XXX<br />
85246 CLTNG FACTOR VIII VW FACTOR AG 43.40 XXX<br />
85247 CLTNG FACTOR VIII MULTMTRIC ALYS 43.40 XXX<br />
85250 CLTNG FACTOR IX PTC/CHRISTMAS 36.09 XXX<br />
85260 CLTNG FACTOR X STUART-PROWER 33.80 XXX<br />
85270 CLTNG FACTOR XI PTA 33.80 XXX<br />
85280 CLTNG FACTOR XII HAGEMAN 36.54 XXX<br />
85290 CLTNG FACTOR XIII FIBRIN STABILIZING 31.06 XXX<br />
85291 CLTNG FACTOR XIII FIBRIN STABILIZING SCR SOLUB 16.90 XXX<br />
85292 CLTNG PREKALLIKREIN ASSAY FLETCHER FACTOR ASSAY 35.63 XXX<br />
85293 CLTNG HI MOLEC WEIGHT KININOGEN ASSAY 35.63 XXX<br />
85300 CLTNG NHBTORS ANTITHROMBIN III ACTV 22.38 XXX<br />
85301 CLTNG NHBTORS ANTITHROMBIN III AG ASSAY 20.56 XXX<br />
85302 CLTNG NHBTORS PROTEIN C AG 22.84 XXX<br />
85303 CLTNG NHBTORS PROTEIN C ACTV 26.04 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
234 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section IX: Pathology and Laboratory Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
80047–89398 PATHOLOGY AND LABORATORY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
85305 CLTNG NHBTORS PROTEIN S TOT 21.93 XXX<br />
85306 CLTNG NHBTORS PROTEIN S FR 28.78 XXX<br />
85307 ACTIVATED PROTEIN C APC RESISTANCE ASSAY 28.78 XXX<br />
85335 FACTOR NHBTOR TST 24.21 XXX<br />
85337 THROMBOMODULIN 19.64 XXX<br />
85345 COAGJ TM LEE&WHITE 8.22 XXX<br />
85347 COAGJ TM ACTIVATED 8.22 XXX<br />
85348 COAGJ TM OTH METHS 6.85 XXX<br />
85360 EUGLOBULIN LSS 15.99 XXX<br />
85362 FIBRIN DGRADJ SPLT PRODUXS AGGLUJ SLIDE SEMIQUAN 13.25 XXX<br />
85366 FIBRIN DGRADJ SPLT PRODUXS PARACOAGJ 16.44 XXX<br />
85370 FIBRIN DGRADJ SPLT PRODUXS QUAN 21.47 XXX<br />
85378 FIBRIN DGRADJ PRODUXS D-DIMER QUAL/SEMIQUAN 13.70 XXX<br />
85379 FIBRIN DGRADJ PRODUXS D-DIMER QUAN 19.19 XXX<br />
85380 FIBRIN DGRADJ PRODUXS D-DIMER ULTRSENS 19.19 XXX<br />
85384 FIBRN ACTV 15.99 XXX<br />
85385 FIBRN AG 15.99 XXX<br />
85390 FIBRINOLYSINS/COAGULOPATHY SCR I&R 36.09 XXX<br />
85390 26 FIBRINOLYSINS/COAGULOPATHY SCR I&R 26.49 XXX<br />
85390 TC FIBRINOLYSINS/COAGULOPATHY SCR I&R 9.60 XXX<br />
85396 COAGJ/FBRNLYS ASSAY WHL BLD USE ADDITIVE PR D 25.58 XXX<br />
85397 COAGJ&FIBRINOLYSIS FUNCTIONAL ACTV NOS EA ANAL 43.40 XXX<br />
85400 FBRNLYC FACTORS&NHBTORS PLASMIN 16.90 XXX<br />
85410 FBRNLYC FACTORS&NHBTORS ALPHA-2 ANTIPLASMIN 14.62 XXX<br />
85415 FBRNLYC FACTORS&NHBTORS PLSMNG ACTIVATOR 32.43 XXX<br />
85420 FBRNLYC FACTORS&NHBTORS PLSMNG XCPT AGIC ASSAY 12.33 XXX<br />
85421 FBRNLYC FACTORS&NHBTORS PLSMNG AGIC ASSAY 19.19 XXX<br />
85441 HEINZ BODIES DIR 7.77 XXX<br />
85445 HEINZ BODIES INDUCED ACETYL PHENYLHYDRAZINE 12.79 XXX<br />
85460 HGB/RBCS FTL F&MAT HEMRRG DIFFIAL LSS 14.62 XXX<br />
85461 HGB/RBCS FTL F&MAT HEMRRG ROSETTE 12.33 XXX<br />
85475 HEMOLYSIN ACID 16.90 XXX<br />
85520 HEPARIN ASSAY 24.67 XXX<br />
85525 HEPARIN NEUTRALIZATION 22.38 XXX<br />
85530 HEPARIN-PROTAMINE TOLERANCE TST 26.95 XXX<br />
85536 IRON STAIN PRPH BLD 12.33 XXX<br />
85540 WBC ALKALINE PHOSPHATASE CNT 16.44 XXX<br />
85547 MCHNL FRAGILITY RBC 16.44 XXX<br />
85549 MURAMIDASE 35.63 XXX<br />
85555 OSMOTIC FRAGILITY RBC UNINCUBATED 12.79 XXX<br />
85557 OSMOTIC FRAGILITY RBC INCUBATED 25.12 XXX<br />
85576 PLTLT AGGREGATION EA AGT 66.69 XXX<br />
85576 26 PLTLT AGGREGATION EA AGT 26.04 XXX<br />
85576 TC PLTLT AGGREGATION EA AGT 40.65 XXX<br />
s 85597 PHOSPHOLIPID NEUTRALIZATION PLATELET 33.80 XXX<br />
l 85598 PHOSPHOLIPID NEUTRALIZATION HEXAGONAL 33.80 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 235
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section IX: Pathology and Laboratory Services<br />
PATHOLOGY AND LABORATORY 80047–89398<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
85610 PROTHROMBIN TM 7.31 XXX<br />
85611 PROTHROMBIN TM SUBJ PLSM FXJS EA 7.31 XXX<br />
85612 RUSSELL VIPR VENOM TM UNDILD 18.27 XXX<br />
85613 RUSSELL VIPR VENOM TM DILD 18.27 XXX<br />
85635 REPTILASE TST 18.73 XXX<br />
85651 SEDIMENTATION RATE RBC NON-AUTO 6.85 XXX<br />
85652 SEDIMENTATION RATE RBC AUTO 5.02 XXX<br />
85660 SICKLING RBC RDCTJ 10.51 XXX<br />
85670 THROMBIN TM PLSM 10.96 XXX<br />
85675 THROMBIN TM TITER 12.79 XXX<br />
85705 THROMBOPLASTIN NHBTION TISS 18.27 XXX<br />
85730 THROMBOPLASTIN TM PRTL PLSM/WHL BLD 11.42 XXX<br />
85732 THROMBOPLASTIN TM PRTL SUBJ PLSM FXJS EA 12.33 XXX<br />
85810 VISCOSITY 21.93 XXX<br />
85999 UNLIS HEMATOLOGY&COAGJ BR XXX<br />
86000 AGGLUTININS FEBRILE EA AG 13.25 XXX<br />
86001 ALLG SPEC IGG QUAN/SEMIQUAN EA ALLG 10.05 XXX<br />
86003 ALLG SPEC IGE QUAN/SEMIQUAN EA ALLG 10.05 XXX<br />
86005 ALLG SPEC IGE QUAL MULTIALLG SCR 15.07 XXX<br />
86021 ANTB ID WBC ANTIBODIES 28.32 XXX<br />
86022 ANTB ID PLTLT ANTIBODIES 34.72 XXX<br />
86023 ANTB ID PLTLT ASSOCIATED IG ASSAY 23.75 XXX<br />
86038 ANA 22.84 XXX<br />
86039 ANA TITER 21.01 XXX<br />
86060 ANTISTREPTOLYSIN 0 TITER 13.70 XXX<br />
86063 ANTISTREPTOLYSIN 0 SCR 10.96 XXX<br />
86077 BLD BANK PHYS SVCS DIFFC CROSS MATCH&/EVAL REPRT 68.52 XXX<br />
86078 BLD BANK PHYS SVCS INVSTGJ TFUJ RXN REPRT 68.98 XXX<br />
86079 BLD BANK PHYS SVCS AUTHJ DEVIJ STANDARD REPRT 68.98 XXX<br />
86140 C-REACTIVE PROTEIN 9.59 XXX<br />
86141 C-REACTIVE PROTEIN HI SENSITIVITY 24.67 XXX<br />
86146 BETA 2 GLYCOPROTEIN I ANTB EA 47.96 XXX<br />
86147 CARDIOLIPIN ANTB EA IG CLASS 47.96 XXX<br />
86148 ANTI-PHOSPHATIDYLSERINE ANTB 30.61 XXX<br />
86155 CHEMOTAXIS ASSAY SPEC METH 30.15 XXX<br />
86156 COLD AGGLUTININ SCR 12.79 XXX<br />
86157 COLD AGGLUTININ TITER 15.07 XXX<br />
86160 COMPLEMENT AG EA COMPONENT 22.84 XXX<br />
86161 COMPLEMENT FUNCJAL ACTV EA COMPONENT 22.84 XXX<br />
86162 COMPLEMENT TOT HEMOLYTIC 38.37 XXX<br />
86171 COMPLEMENT FIXJ TSTS EA AG 18.73 XXX<br />
86185 CNTERIMMUNOELECTROPHORESIS EA AG 16.90 XXX<br />
86200 CYCLIC CITRULLINATED PEPTIDE ANTB 24.67 XXX<br />
86215 DEOXYRIBONUCLEASE ANTB 25.12 XXX<br />
86225 DNA ANTB NATIVE/2 STRANDED 26.04 XXX<br />
86226 DNA ANTB 1 STRANDED 22.84 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
236 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section IX: Pathology and Laboratory Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
80047–89398 PATHOLOGY AND LABORATORY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
86235 XTRCABLE NUC AG ANTB ANY METH EA ANTB 33.80 XXX<br />
86243 FC RCPTR 38.83 XXX<br />
86255 FLUORESCENT NONNFCT AGT ANTB SCR EA ANTB 48.88 XXX<br />
86255 26 FLUORESCENT NONNFCT AGT ANTB SCR EA ANTB 26.04 XXX<br />
86255 TC FLUORESCENT NONNFCT AGT ANTB SCR EA ANTB 22.84 XXX<br />
86256 FLUORESCENT NONNFCT AGT ANTB TITER EA ANTB 47.96 XXX<br />
86256 26 FLUORESCENT NONNFCT AGT ANTB TITER EA ANTB 25.12 XXX<br />
86256 TC FLUORESCENT NONNFCT AGT ANTB TITER EA ANTB 22.84 XXX<br />
86277 GROWTH HORM HUMAN ANTB 29.69 XXX<br />
86280 HEMAGGLUJ NHBTION TST 15.53 XXX<br />
86294 IA TUMOR ANTIGEN QUAL/SEMIQUANTITATIVE 37.00 XXX<br />
86300 IA TUM AG QUAN CA 15-3 39.28 XXX<br />
86301 IA TUM AG QUAN CA 19-9 39.28 XXX<br />
86304 IA TUM AG QUAN CA 125 39.28 XXX<br />
86305 HUMAN EPIDIDYMIS PROTEIN 4 (HE4) 39.28 XXX<br />
86308 HTROPHL ANTIBODIES SCR 9.59 XXX<br />
86309 HTROPHL ANTIBODIES TITER 12.33 XXX<br />
86310 HTROPHL ANTIBODIES TIT AFTER ABSRPJ 14.16 XXX<br />
86316 IA TUM AG OTH AG QUAN EA 39.28 XXX<br />
86317 IA NFCT AGT ANTB QUAN NOS 28.32 XXX<br />
86318 IA NFCT AGT ANTB QUAL/SEMIQUAN 1 STEP METH 24.67 XXX<br />
86320 IMMUNOELECTROPHORESIS SERUM 67.61 XXX<br />
86320 26 IMMUNOELECTROPHORESIS SERUM 25.12 XXX<br />
86320 TC IMMUNOELECTROPHORESIS SERUM 42.49 XXX<br />
86325 IMMUNOELECTROPHORESIS OTH FLUS CONCENTRATION 67.15 XXX<br />
86325 26 IMMUNOELECTROPHORESIS OTH FLUS CONCENTRATION 24.67 XXX<br />
86325 TC IMMUNOELECTROPHORESIS OTH FLUS CONCENTRATION 42.48 XXX<br />
86327 IMMUNOELECTROPHORESIS CROSSED 72.63 XXX<br />
86327 26 IMMUNOELECTROPHORESIS CROSSED 29.69 XXX<br />
86327 TC IMMUNOELECTROPHORESIS CROSSED 42.94 XXX<br />
86329 IMMUNODIFFUSION NES 26.49 XXX<br />
86331 IMMUNODIFFUSION GEL DIFFUSION QUAL EA AG/ANTB 22.84 XXX<br />
86332 IMMUNE CPLX ASSAY 46.14 XXX<br />
86334 IMMUNOFIXJ ELECTROPHORESIS SERUM 68.52 XXX<br />
86334 26 IMMUNOFIXJ ELECTROPHORESIS SERUM 26.04 XXX<br />
86334 TC IMMUNOFIXJ ELECTROPHORESIS SERUM 42.48 XXX<br />
86335 IMMUNOFIXJ ELECTROPHORESIS OTH FLU 81.31 XXX<br />
86335 26 IMMUNOFIXJ ELECTROPHORESIS OTH FLU 25.58 XXX<br />
86335 TC IMMUNOFIXJ ELECTROPHORESIS OTH FLU 55.73 XXX<br />
86336 INHIBIN 29.69 XXX<br />
86337 INSULIN ANTIBODIES 40.66 XXX<br />
86340 INTRNSC FACTOR ANTIBODIES 28.32 XXX<br />
86341 ISLET CELL ANTB 37.46 XXX<br />
86343 WBC HISTAM RLS TST 23.75 XXX<br />
86344 WBC PHAGOCYTOSIS 15.07 XXX<br />
86352 CELLULAR FUNCTION ASSAY STIMUL&DETECT BIOMARKER 257.18 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 237
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section IX: Pathology and Laboratory Services<br />
PATHOLOGY AND LABORATORY 80047–89398<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
86353 LYMPHOCYTE TR MITOGEN/AG INDUCED BLASTOGENESIS 92.73 XXX<br />
86355 B CELLS TOT CNT 71.26 XXX<br />
86356 MONONUCLEAR CELL ANTIGEN QUANTITATIVE NOS EA 50.70 XXX<br />
86357 NATURAL KILLER CELLS TOT CNT 71.26 XXX<br />
86359 T CELLS TOT CNT 71.26 XXX<br />
86360 T CELLS ABSOLUTE CD4&CD8 CNT RATIO 89.08 XXX<br />
86361 T CELLS ABSOLUTE CD4 CNT 50.70 XXX<br />
86367 STEM CELLS TOT CNT 71.26 XXX<br />
86376 MICROSOMAL ANTIBODIES EA 27.41 XXX<br />
86378 MIGRATION NHBTORY FACTOR TST MIF 37.46 XXX<br />
86382 NEUTRALIZATION TST VIRAL 31.98 XXX<br />
86384 NITROBLUE TETRAZOLIUM DYE TST NTD 21.47 XXX<br />
86403 PART AGGLUJ SCR EA ANTB 19.19 XXX<br />
86406 PART AGGLUJ TITER EA ANTB 20.10 XXX<br />
86430 RHEUMATOID FACTOR QUAL 10.51 XXX<br />
86431 RHEUMATOID FACTOR QUAN 10.51 XXX<br />
s 86480 TB CELL MEDIATED ANTIGN RESPNSE GAMMA INTERFER 117.40 XXX<br />
l 86481 TB ANTIGEN RESPONSE GAMMA INTERFERON T-CELL SUSP 117.40 XXX<br />
86485 SKN TST CANDIDA 17.82 XXX<br />
86486 SKIN TEST UNLISTED ANTIGEN EACH 6.85 XXX<br />
86490 SKN TST COCCIDIOIDOMYCOSIS 9.14 XXX<br />
86510 SKN TST HISTOPLASMOSIS 8.68 XXX<br />
86580 SKN TST TUBERCULOSIS ID 10.05 XXX<br />
86590 STREPTOKINASE ANTB 21.01 XXX<br />
86592 SYPHILIS TEST NON TREPONEMAL ANTIBODY QUAL 8.22 XXX<br />
86593 SYPHILIS TST QUAN 8.22 XXX<br />
86602 ANTB ACTINOMYCES 19.19 XXX<br />
86603 ANTB ADENOVIRUS 24.21 XXX<br />
86606 ANTB ASPRGILLUS 28.32 XXX<br />
86609 ANTB BACTERIUM NES 24.21 XXX<br />
86611 ANTB BARTONELLA 19.19 XXX<br />
86612 ANTB BLASTOMYCES 24.21 XXX<br />
86615 ANTB BORDETELLA 25.12 XXX<br />
86617 ANTB BORRELIA BURGDORFERI CONFIRMATORY TST 29.24 XXX<br />
86618 ANTB BORRELIA BURGDORFERI LYME DISEASE 32.43 XXX<br />
86619 ANTB BORRELIA RELAPSING FEVER 25.12 XXX<br />
86622 ANTB BRUCELLA 16.90 XXX<br />
86625 ANTB CAMPYLOBACTER 24.67 XXX<br />
86628 ANTB CANDIDA 22.84 XXX<br />
86631 ANTB CHLAMYDIA 22.38 XXX<br />
86632 ANTB CHLAMYDIA IGM 24.21 XXX<br />
86635 ANTB COCCIDIOIDES 21.93 XXX<br />
86638 ANTB COXIELLA BRNETII Q FEVER 22.84 XXX<br />
86641 ANTB CRYPTOCOCCUS 27.41 XXX<br />
86644 ANTB CMV CMV 27.41 XXX<br />
86645 ANTB CMV CMV IGM 31.98 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
238 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section IX: Pathology and Laboratory Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
80047–89398 PATHOLOGY AND LABORATORY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
86648 ANTB DIPHTHERIA 28.78 XXX<br />
86651 ANTB ENCEPHALITIS CALIFORNIA LA CROSSE 25.12 XXX<br />
86652 ANTB ENCEPHALITIS EASTERN EQUINE 25.12 XXX<br />
86653 ANTB ENCEPHALITIS ST. LOUIS 25.12 XXX<br />
86654 ANTB ENCEPHALITIS WSTRN EQUINE 25.12 XXX<br />
86658 ANTB ENTEROVIRUS 24.67 XXX<br />
86663 ANTB EPSTEIN-BARR EB VIRUS EARLY AG EA 24.67 XXX<br />
86664 ANTB EPSTEIN-BARR EB VIRUS NUC AG EBNA 28.78 XXX<br />
86665 ANTB EPSTEIN-BARR EB VIRUS VIRAL CAPSID VCA 34.26 XXX<br />
86666 ANTB EHRLICHIA 19.19 XXX<br />
86668 ANTB FRANCISELLA TULARENSIS 19.64 XXX<br />
86671 ANTB FUNGUS NES 23.30 XXX<br />
86674 ANTB GIARDIA LAMBLIA 27.86 XXX<br />
86677 ANTB HELICOBACTER PYLORI 27.41 XXX<br />
86682 ANTB HELMINTH NES 24.67 XXX<br />
86684 ANTB HAEMOPHILUS INF 30.15 XXX<br />
86687 ANTB HTLV-I 15.99 XXX<br />
86688 ANTB HTLV-II 26.49 XXX<br />
86689 ANTB HTLV/HIV ANTB CONFIRMATORY TST 36.54 XXX<br />
86692 ANTB HEP DELTA AGT 32.43 XXX<br />
86694 ANTB HERPES SMPLX NON-SPEC TYP TST 27.41 XXX<br />
86695 ANTB HERPES SMPLX TYP 1 25.12 XXX<br />
86696 ANTB HERPES SMPLX TYP 2 36.54 XXX<br />
86698 ANTB HISTOPLSM 23.75 XXX<br />
86701 ANTB HIV-1 16.90 XXX<br />
86702 ANTB HIV-2 25.58 XXX<br />
86703 ANTB HIV-1&HIV-2 1 ASSAY 26.04 XXX<br />
86704 HEP B CORE ANTB HBCAB TOT 22.84 XXX<br />
86705 HEP B CORE ANTB HBCAB IGM ANTB 22.38 XXX<br />
86706 HEP B SURF ANTB HBSAB 20.56 XXX<br />
86707 HEP BE ANTB HBEAB 21.93 XXX<br />
86708 HEP ANTB HAAB TOT 23.30 XXX<br />
86709 HEP ANTB HAAB IGM ANTB 21.47 XXX<br />
86710 ANTB INF VIRUS 25.58 XXX<br />
86713 ANTB LEGIONELLA 28.78 XXX<br />
86717 ANTB LEISHMANIA 23.30 XXX<br />
86720 ANTB LEPTOSPIRA 25.12 XXX<br />
86723 ANTB LISTERIA MONOCYTOGENES 25.12 XXX<br />
86727 ANTB LYMPHOCYTIC CHORIOMENINGITIS 24.21 XXX<br />
86729 ANTB LYMPHOGRANULOMA VENEREUM 22.38 XXX<br />
86732 ANTB MUCORMYCOSIS 25.12 XXX<br />
86735 ANTB MUMPS 24.67 XXX<br />
86738 ANTB MYCOPLSM 25.12 XXX<br />
86741 ANTB NEISSERIA MENINGITIDIS 25.12 XXX<br />
86744 ANTB NOCARDIA 25.12 XXX<br />
86747 ANTB PARVOVIRUS 28.32 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 239
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section IX: Pathology and Laboratory Services<br />
PATHOLOGY AND LABORATORY 80047–89398<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
86750 ANTB PLASMODIUM MALARIA 25.12 XXX<br />
86753 ANTB PROTOZOA NES 23.30 XXX<br />
86756 ANTB RSV 24.21 XXX<br />
86757 ANTB RICKETTSIA 36.54 XXX<br />
86759 ANTB ROTAVIRUS 25.12 XXX<br />
86762 ANTB RUBELLA 27.41 XXX<br />
86765 ANTB RUBEOLA 24.21 XXX<br />
86768 ANTB SALMONELLA 25.12 XXX<br />
86771 ANTB SHIGELLA 25.12 XXX<br />
86774 ANTB TETANUS 27.86 XXX<br />
86777 ANTB TOXOPLSM 27.41 XXX<br />
86778 ANTB TOXOPLSM IGM 27.41 XXX<br />
86780 ANTIBODY TREPONEMA PALLIDUM 25.12 XXX<br />
86784 ANTB TRICHINELLA 23.75 XXX<br />
86787 ANTB VARICELLA-ZOSTER 24.21 XXX<br />
86788 ANTIBODY WEST NILE VIRUS IGM 31.98 XXX<br />
86789 ANTIBODY WEST NILE VIRUS 27.41 XXX<br />
86790 ANTB VIRUS NES 24.21 XXX<br />
86793 ANTB YERSINIA 25.12 XXX<br />
86800 THYROGLOBULIN ANTB 30.15 XXX<br />
86803 HEP C ANTB 26.95 XXX<br />
86804 HEP C ANTB CONFIRMATORY TST 29.24 XXX<br />
86805 LPHOCYTOTOXICITY ASSAY VIS CROSSMATCH TITRJ 99.13 XXX<br />
86806 LPHOCYTOTOXICITY ASSAY VIS CROSSMATCH W/O TITRJ 89.99 XXX<br />
86807 SERUM SCR % REACTIVE ANTB STANDARD METH 74.92 XXX<br />
86808 SERUM SCR % REACTIVE ANTB PRA QUICK METH 56.19 XXX<br />
86812 HLA TYPING B/C 1 AG 48.88 XXX<br />
86813 HLA TYPING B/C MLT AGS 109.63 XXX<br />
86816 HLA TYPING DR/DQ 1 AG 52.53 XXX<br />
86817 HLA TYPING DR/DQ MLT AGS 121.97 XXX<br />
86821 HLA TYPING LYMPHOCYTE CULTURE MIXED 106.89 XXX<br />
86822 HLA TYPING LYMPHOCYTE CULTURE PRIMED 68.98 XXX<br />
86825 HLA CROSSMATCH NONCYTOTOXIC 1ST SERUM/DILUTION 152.11 XXX<br />
+ 86826 HLA CROSSMATCH NONCYTOTOXIC EA+ SERUM/DILUTION 50.70 XXX<br />
86849 UNLIS IMMUNOLOGY BR XXX<br />
86850 ANTB SCR RBC EA SERUM TQ 21.93 XXX<br />
86860 ANTB ELUTION EA ELUTION 28.32 XXX<br />
86870 ANTB ID RBC ANTIBODIES EA PANEL EA SERUM TQ 38.83 XXX<br />
86880 ANTIHUMAN GLOBULIN DIR EA ANTISERUM 10.05 XXX<br />
86885 ANTIHUMAN GLOBULIN INDIR QUAL EA REAGENT CELL 10.96 XXX<br />
86886 ANTIHUMAN GLOBULIN INDIRECT EA ANTIBODY TITER 9.59 XXX<br />
86890 AUTOL BLD/COMPONENT COLLJ STORAGE PREDEPOSITED 89.53 XXX<br />
86891 AUTOL BLD/COMPONENT COLLJ STORAGE SALVAGE 126.08 XXX<br />
86900 BLD TYPING ABO 5.48 XXX<br />
86901 BLD TYPING RH D 5.48 XXX<br />
l 86902 BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA 7.31 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
240 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section IX: Pathology and Laboratory Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
80047–89398 PATHOLOGY AND LABORATORY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
86904 BLD TYPING AG SCR UNIT PT SERUM SCR 17.82 XXX<br />
86905 BLD TYPING RBC AGS OTH/THN ABO/RH D EA 7.31 XXX<br />
86906 BLD TYPING RH PHEXYPING COMPL 14.62 XXX<br />
86910 BLD TYPING PATERNITY PR INDIV ABO RH&MN 23.30 XXX<br />
86911 BLD TYPING PATERNITY PR INDIV EA AG SYS 20.10 XXX<br />
86920 COMPATIBILITY EA UNIT IMMT SPIN 31.52 XXX<br />
86921 COMPATIBILITY EA UNIT INCUBATION 28.32 XXX<br />
86922 COMPATIBILITY EA UNIT ANTIGLOBULIN 33.80 XXX<br />
86923 COMPATIBILITY EA UNIT ELEC 25.12 XXX<br />
86927 FRSH FROZEN PLSM THAWING EA UNIT 17.82 XXX<br />
86930 FROZEN BLD EA UNIT FRZING PREPJ 105.06 XXX<br />
86931 FROZEN BLD EA UNIT THAWING 79.03 XXX<br />
86932 FROZEN BLD EA UNIT FRZING PREPJ&THAWING 89.53 XXX<br />
86940 HEMOLYSINS&AGGLUTININS AUTO SCR EA 15.53 XXX<br />
86941 HEMOLYSINS&AGGLUTININS INCUBATED 22.84 XXX<br />
86945 IRRADJ BLD PRODUX EA UNIT 26.49 XXX<br />
86950 WBC TRANSFUSION 68.52 XXX<br />
86960 VOL RDCTJ BLD/BLD PRODUX EA UNIT 29.24 XXX<br />
86965 PLING PLTLTS/OTH BLD PRODUXS 29.24 XXX<br />
86970 PRTX RBC ANTB CHEM AGT/DRUGS 26.49 XXX<br />
86971 PRTX RBC ANTB INCUBATION NZM EA 21.01 XXX<br />
86972 PRTX RBC ANTB DNS GRADIENT SEP 37.00 XXX<br />
86975 PRTX SRM INCUBATION DRUGS EA 28.32 XXX<br />
86976 PRTX SRM ANTB ID DIL 31.52 XXX<br />
86977 PRTX SRM ANTB ID INCUBATION NHBTORS EA 31.52 XXX<br />
86978 PRTX SRM ANTB ID DIFFIAL RBC ABSRPJ 31.52 XXX<br />
86985 SPLTTING BLD/BLD PRODUXS EA UNIT 23.30 XXX<br />
86999 UNLIS TRANSFUSION MED BR XXX<br />
87001 ANIMAL INOCULATION SM ANIMAL OBS 25.12 XXX<br />
87003 ANIMAL INOCULATION SM ANIMAL OBS&DSJ 31.98 XXX<br />
87015 CONCENTRATION NFCT AGT 12.79 XXX<br />
87040 CUL BACT BLD AERC ISOL 19.64 XXX<br />
87045 CUL BACT STL AERC ISOL SALMONELLA&SHIGELLA 17.82 XXX<br />
87046 CUL BACT STL AERC ADDL PATHOGENS&ID EA 17.82 XXX<br />
87070 CUL BACT XCPT URINE BLD/STL AERC ISOL 16.44 XXX<br />
87071 CUL BACT QUAN AERC ISOL XCPT UR BLD/STOOL 17.82 XXX<br />
87073 CUL BACT QUAN ANAERC ISOL XCPT UR BLD/STOOL 17.82 XXX<br />
87075 CUL BACT BLD ANAERC ISOL 17.82 XXX<br />
87076 CUL BACT ANAERC ADDL METHS DEFINITIVE EA ISOL 15.07 XXX<br />
87077 CUL BACT AERC ADDL METHS DEFINITIVE EA ISOL 15.07 XXX<br />
87081 CUL PRSMPTV PTHGNC ORGANISMS SCR 12.33 XXX<br />
87084 CUL PRSMPTV PTHGNC ORGANISMS SCR DNS CHART 16.44 XXX<br />
87086 CUL BACT QUAN COLONY CNT URINE 15.07 XXX<br />
87088 CULTURE BCT ISOL&PRSMPTV ID ISOLATE EA URINE 15.53 XXX<br />
87101 CUL FNGI MOLD/YEAST PRSMPTV ID SKN HAIR/NAIL 14.62 XXX<br />
87102 CUL FNGI MOLD/YEAST PRSMPTV ID OTH XCPT BLD 15.99 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 241
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section IX: Pathology and Laboratory Services<br />
PATHOLOGY AND LABORATORY 80047–89398<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
87103 CUL FNGI MOLD/YEAST ISOL PRSMPTV ID ISOL BLD 16.90 XXX<br />
87106 CUL FNGI DEFINITIVE ID EA ORGANISM YEAST 19.64 XXX<br />
87107 CUL FNGI DEFINITIVE ID EA ORGANISM MOLD 19.64 XXX<br />
87109 CUL MYCOPLSM ANY SRC 29.24 XXX<br />
87110 CUL CHLAMYDIA ANY SRC 37.00 XXX<br />
87116 CUL TUBERCLE/OTH ACID-FAST BACILLI ANY ISOL 20.56 XXX<br />
87118 CUL MYCOBACTERIAL DEFINITIVE ID EA ISOL 20.56 XXX<br />
87140 CULTYP IMFLUOR METH EA ANTISERUM 10.51 XXX<br />
87143 CULTYP GAS LIQ CHROM/HI PRESS LIQ CHROM 23.75 XXX<br />
87147 CULTYP IMMUNOLOGIC OTH/THN IMFLUOR PR ANTISERUM 9.59 XXX<br />
87149 CULTYP NUC ACID DIR PRB CULT/ISOLATE EA ORGNISM 37.91 XXX<br />
87150 CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM 66.24 XXX<br />
87152 CULTYP ID PLS FLD GEL TYP 10.05 XXX<br />
87153 CULTYP NUCLEIC ACID SEQUENCING METH EA ISOLATE 218.35 XXX<br />
87158 CULTYP OTH METHS 10.05 XXX<br />
87164 DARK FLD XM ANY SRC SPEC COLLJ 46.59 XXX<br />
87164 26 DARK FLD XM ANY SRC SPEC COLLJ 26.04 XXX<br />
87164 TC DARK FLD XM ANY SRC SPEC COLLJ 20.55 XXX<br />
87166 DARK FLD XM ANY SRC W/O COLLJ 21.47 XXX<br />
87168 MACROSCOPIC XM ARTHROPOD 8.22 XXX<br />
87169 MACROSCOPIC XM PARASIT 8.22 XXX<br />
87172 PINWORM XM 8.22 XXX<br />
87176 HOMOGENIZATION TISS CUL 10.96 XXX<br />
87177 OVA&PARASITS DIR SMRS CONCENTRATION&ID 16.90 XXX<br />
87181 SC STD ANTMCRB AGT AGAR DIL METH PR AGT 9.14 XXX<br />
87184 SC STD ANTMCRB AGT DISK METH PR PLATE 13.25 XXX<br />
87185 SC STD ANTMCRB AGT ENZYME DETCJ PR NZM 9.14 XXX<br />
87186 SC ANTMCRB MICRODIL/AGAR EA MULTI-ANTMCRB PLATE 16.44 XXX<br />
+ 87187 SC ANTMCRB MICRODIL/AGAR DIL MLC EA PLATE 19.64 XXX<br />
87188 SC STD ANTMCRB AGT MACROBROTH DIL METH EA AGT 12.33 XXX<br />
87190 SC ANTMCRB MYCOBACTERIA PROPRTN EA AGT 10.51 XXX<br />
87197 SERUM BACTERICIDAL TITER 28.32 XXX<br />
87205 SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL 8.22 XXX<br />
87206 SMR PRIM SRC FLUORESCENT&/AFS BCT FNGI PARASITS 10.05 XXX<br />
87207 SMR PRIM SRC SPEC STAIN BODIES/PARASITS 37.46 XXX<br />
87207 26 SMR PRIM SRC SPEC STAIN BODIES/PARASITS 26.04 XXX<br />
87207 TC SMR PRIM SRC SPEC STAIN BODIES/PARASITS 11.42 XXX<br />
87209 SMR PRIM SRC CPLX SPEC STAIN OVA&PARASITS 33.80 XXX<br />
87210 SMR PRIM SRC WET MOUNT NFCT AGT 8.22 XXX<br />
87220 TISS KOH SLIDE SAMPS SKN/HR/NLS FNGI/ECTOPARASIT 8.22 XXX<br />
87230 TOXIN/ANTITOXIN ASSAY TISS CUL 37.46 XXX<br />
87250 VIRUS INOCULATION EGGS/SM ANIMAL OBS&DSJ 37.00 XXX<br />
87252 VIRUS TISS CUL INOCULATION CYTOPATHIC EFFECT 49.33 XXX<br />
87253 VIRUS TISS CUL ADDL STD/ID EA ISOLATE 38.37 XXX<br />
87254 VIRUS CENTRIFUGE ENHNCD ID IMFLUOR STAIN EA 37.00 XXX<br />
87255 VIRUS ID NON-IMMUNOLOGIC OTH/THN CYTOPATHIC 63.95 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
242 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section IX: Pathology and Laboratory Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
80047–89398 PATHOLOGY AND LABORATORY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
87260 IAADI ADENOVIRUS 22.84 XXX<br />
87265 IAADI BORDETELLA PRTUSSIS/PARAPRTUSSIS 22.84 XXX<br />
87267 IAADI ENTEROVIRUS DIR FLUORESCENT ANTB 22.84 XXX<br />
87269 IAADI GIARDIA 22.84 XXX<br />
87270 IAADI CHLAMYDIA TRACHOMATIS 22.84 XXX<br />
87271 IAADICMV DIR FLUORESCENT ANTB 22.84 XXX<br />
87272 IAADI CRYPTOSPORIDIUM 22.84 XXX<br />
87273 IAADI HERPES SMPLX VIRUS TYP 2 22.84 XXX<br />
87274 IAADI HERPES SMPLX VIRUS TYP 1 22.84 XXX<br />
87275 IAADI INF B VIRUS 22.84 XXX<br />
87276 IAADI INF VIRUS 22.84 XXX<br />
87277 IAADI LEGIONELLA MICDADEI 22.84 XXX<br />
87278 IAADI LEGIONELLA PNEUMOPHILA 22.84 XXX<br />
87279 IAADI PARAINF VIRUS EA TYP 22.84 XXX<br />
87280 IAADI RSV 22.84 XXX<br />
87281 IAADI PNEUMOCSTIS CARINII 22.84 XXX<br />
87283 IAADI RUBEOLA 22.84 XXX<br />
87285 IAADI TREPONEMA PALLIDUM 22.84 XXX<br />
87290 IAADI VARICELLA ZOSTER VIRUS 22.84 XXX<br />
87299 IAADI NOS EA ORGANISM 22.84 XXX<br />
87300 IAADI POLYV MLT ORGANISMS EA POLYV ANTISERUM 22.84 XXX<br />
87301 IAAD EIA ADENOVIRUS ENTERIC TYP 40/41 22.84 XXX<br />
87305 IAAD EIA QUAL/SEMIQUAN MULTIPLE STEP ASPERGILLUS 22.84 XXX<br />
87320 IAAD EIA CHLAMYDIA TRACHOMATIS 22.84 XXX<br />
87324 IAAD EIA CLOSTRIDIUM DIFFICILE TOXIN 22.84 XXX<br />
87327 IAAD EIA CRYPTOCOCCUS NEOFORMANS 22.84 XXX<br />
87328 IAAD EIA CRYPTOSPORIDIUM 22.84 XXX<br />
87329 IAAD EIA GIARDIA 22.84 XXX<br />
87332 IAAD EIA CMV 22.84 XXX<br />
87335 IAAD EIA ESCHERICHIA COLI 0157 22.84 XXX<br />
87336 IAAD EIA ENTAMOEBA HISTOLYTICA DISPAR GRP 22.84 XXX<br />
87337 IAAD EIA ENTAMOEBA HISTOLYTICA GRP 22.84 XXX<br />
87338 IAAD EIA HPYLORI STOOL 27.41 XXX<br />
87339 IAAD EIA HPYLORI 22.84 XXX<br />
87340 IAAD EIA HEP B SURF AG 19.64 XXX<br />
87341 IAAD EIA HEP B SURF AG NEUTRALIZATION 19.64 XXX<br />
87350 IAAD EIA HEP BE AG 21.93 XXX<br />
87380 IAAD EIA HEP DELTA AGT 31.06 XXX<br />
87385 IAAD EIA HISTOPLSM CAPSULATUM 22.84 XXX<br />
87390 IAAD EIA HIV-1 33.35 XXX<br />
87391 IAAD EIA HIV-2 33.35 XXX<br />
87400 IAAD EIA INF/B EA 22.84 XXX<br />
87420 IAAD EIA RSV 22.84 XXX<br />
87425 IAAD EIA ROTAVIRUS 22.84 XXX<br />
87427 IAAD EIA SHIGA-LIKE TOXIN 22.84 XXX<br />
87430 IAAD EIA STREPTOCOCCUS GRP 22.84 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 243
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section IX: Pathology and Laboratory Services<br />
PATHOLOGY AND LABORATORY 80047–89398<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
87449 IAAD EIA NOS EA ORGANISM 22.84 XXX<br />
87450 IAAD EIA NOS EA ORGANISM 18.27 XXX<br />
87451 IAAD EIA POLYV MLT ORGANISMS EA POLYV ANTISERUM 18.27 XXX<br />
87470 IADNA BARTONELLA DIR PRB 37.91 XXX<br />
87471 IADNA BARTONELLA AMP PRB 66.24 XXX<br />
87472 IADNA BARTONELLA QUAN 80.85 XXX<br />
87475 IADNA BORRELIA BURGDORFERI DIR PRB 37.91 XXX<br />
87476 IADNA BORRELIA BURGDORFERI AMP PRB 66.24 XXX<br />
87477 IADNA BORRELIA BURGDORFERI QUAN 80.85 XXX<br />
87480 IADNA CANDIDA SPECIES DIR PRB 37.91 XXX<br />
87481 IADNA CANDIDA SPECIES AMP PRB 66.24 XXX<br />
87482 IADNA CANDIDA SPECIES QUAN 79.03 XXX<br />
87485 IADNA CHLAMYDIA PNEUMONIAE DIR PRB 37.91 XXX<br />
87486 IADNA CHLAMYDIA PNEUMONIAE AMP PRB 66.24 XXX<br />
87487 IADNA CHLAMYDIA PNEUMONIAE QUAN 80.85 XXX<br />
87490 IADNA CHLAMYDIA TRACHOMATIS DIR PRB 37.91 XXX<br />
87491 IADNA CHLAMYDIA TRACHOMATIS AMP PRB 66.24 XXX<br />
87492 IADNA CHLAMYDIA TRACHOMATIS QUAN 66.24 XXX<br />
87493 INF AGENT DET NUC ACID CLOSTRIDIUM AMP PROBE 66.24 XXX<br />
87495 IADNA CMV DIR PRB 37.91 XXX<br />
87496 IADNA CMV AMP PRB 66.24 XXX<br />
87497 IADNA CMV QUAN 80.85 XXX<br />
87498 IADNA ENTEROVIRUS AMPLIFIED PROBE TECHNIQUE 66.24 XXX<br />
87500 INFECTIOUS AGENT DNA/RNA VANCOMYCIN RESISTANCE 66.24 XXX<br />
l 87501 INFECTIOUS AGENT DNA/RNA INFLUENZA EA TYPE 97.30 XXX<br />
l 87502 INFECTIOUS AGENT DNA/RNA INFLUENZA 1ST 2 TYPES 160.79 XXX<br />
l + 87503 NFCT AGENT DNA/RNA INFLUENZA 1+ TYPES EA ADDL 39.28 XXX<br />
87510 IADNA GARDNERELLA VAGIS DIR PRB 37.91 XXX<br />
87511 IADNA GARDNERELLA VAGIS AMP PRB 66.24 XXX<br />
87512 IADNA GARDNERELLA VAGIS QUAN 79.03 XXX<br />
87515 IADNA HEP B VIRUS DIR PRB 37.91 XXX<br />
87516 IADNA HEP B VIRUS AMP PRB 66.24 XXX<br />
87517 IADNA HEP B VIRUS QUAN 80.85 XXX<br />
87520 IADNA HEP C DIR PRB 37.91 XXX<br />
87521 IADNA HEP C AMP PRB 66.24 XXX<br />
87522 IADNA HEP C QUAN 80.85 XXX<br />
87525 IADNA HEP G DIR PRB 37.91 XXX<br />
87526 IADNA HEP G AMP PRB 66.24 XXX<br />
87527 IADNA HEP G QUAN 79.03 XXX<br />
87528 IADNA HERPES SMPLX VIRUS DIR PRB 37.91 XXX<br />
87529 IADNA HERPES SMPLX VIRUS AMP PRB 66.24 XXX<br />
87530 IADNA HERPES SMPLX VIRUS QUAN 80.85 XXX<br />
87531 IADNA HERPES VIRUS-6 DIR PRB 37.91 XXX<br />
87532 IADNA HERPES VIRUS-6 AMP PRB 66.24 XXX<br />
87533 IADNA HERPES VIRUS-6 QUAN 79.03 XXX<br />
87534 IADNA HIV-1 DIR PRB 37.91 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
244 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section IX: Pathology and Laboratory Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
80047–89398 PATHOLOGY AND LABORATORY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
87535 IADNA HIV-1 AMP PRB 66.24 XXX<br />
87536 IADNA HIV-1 QUAN 160.79 XXX<br />
87537 IADNA HIV-2 DIR PRB 37.91 XXX<br />
87538 IADNA HIV-2 AMP PRB 66.24 XXX<br />
87539 IADNA HIV-2 QUAN 80.85 XXX<br />
87540 IADNA LEGIONELLA PNEUMOPHILA DIR PRB 37.91 XXX<br />
87541 IADNA LEGIONELLA PNEUMOPHILA AMP PRB 66.24 XXX<br />
87542 IADNA LEGIONELLA PNEUMOPHILA QUAN 79.03 XXX<br />
87550 IADNA MYCOBACTERIA SPECIES DIR PRB 37.91 XXX<br />
87551 IADNA MYCOBACTERIA SPECIES AMP PRB 66.24 XXX<br />
87552 IADNA MYCOBACTERIA SPECIES QUAN 80.85 XXX<br />
87555 IADNA MYCOBACTERIA TUBERCULOSIS DIR PRB 37.91 XXX<br />
87556 IADNA MYCOBACTERIA TUBERCULOSIS AMP PRB 66.24 XXX<br />
87557 IADNA MYCOBACTERIA TUBERCULOSIS QUAN 80.85 XXX<br />
87560 IADNA MYCOBACTERIA AVIUM-INTRACLRE DIR PRB 37.91 XXX<br />
87561 IADNA MYCOBACTERIA AVIUM-INTRACLRE AMP PRB 66.24 XXX<br />
87562 IADNA MYCOBACTERIA AVIUM-INTRACLRE QUAN 80.85 XXX<br />
87580 IADNA MYCOPLSM PNEUMONIAE DIR PRB 37.91 XXX<br />
87581 IADNA MYCOPLSM PNEUMONIAE AMP PRB 66.24 XXX<br />
87582 IADNA MYCOPLSM PNEUMONIAE QUAN 79.03 XXX<br />
87590 IADNA NEISSERIA GONORRHOEAE DIR PRB 37.91 XXX<br />
87591 IADNA NEISSERIA GONORRHOEAE AMP PRB 66.24 XXX<br />
87592 IADNA NEISSERIA GONORRHOEAE QUAN 80.85 XXX<br />
87620 IADNA PAPLMVIRUS HUMAN DIR PRB 37.91 XXX<br />
87621 IADNA PAPLMVIRUS HUMAN AMP PRB 66.24 XXX<br />
87622 IADNA PAPLMVIRUS HUMAN QUAN 79.03 XXX<br />
87640 IADNA S. AUREUS AMP PRB TQ 66.24 XXX<br />
87641 IADNA S. AUREUS METHICILLIN RESISTANT AMP PRB TQ 66.24 XXX<br />
87650 IADNA STREPTOCOCCUS GRP DIR PRB 37.91 XXX<br />
87651 IADNA STREPTOCOCCUS GRP AMP PRB 66.24 XXX<br />
87652 IADNA STREPTOCOCCUS GRP QUAN 79.03 XXX<br />
87653 IADNA STREPTOCOCCUS GROUP B AMPLIFIED PROBE TQ 66.24 XXX<br />
87660 IADNA TRICHOMONAS VAGIS DIR PRB 37.91 XXX<br />
87797 IADNA NOS DIR PRB EA ORGANISM 37.91 XXX<br />
87798 IADNA NOS AMP PRB EA ORGANISM 66.24 XXX<br />
87799 IADNA NOS QUAN EA ORGANISM 80.85 XXX<br />
87800 IADNA MLT ORGANISMS DIR PRB 75.83 XXX<br />
87801 IADNA MLT ORGANISMS AMP PRB 132.93 XXX<br />
87802 IAADIADOO STREPTOCOCCUS GRP B 22.84 XXX<br />
87803 IAADIADOO CLOSTRIDIUM DIFFICILE TOXIN 22.84 XXX<br />
87804 IAADIADOO INF 22.84 XXX<br />
87807 IAADIADOO RSV 22.84 XXX<br />
87808 IAADIADOO TRICHOMONAS VAGINALIS 22.84 XXX<br />
87809 INFECTIOUS AGENT IMMUNOASSAY OPTICAL ADENOVIRUS 22.84 XXX<br />
87810 CHLAMYDIA TRACHOMATIS 22.84 XXX<br />
87850 IAADIADOO NEISSERIA GONORRHOEAE 22.84 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 245
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section IX: Pathology and Laboratory Services<br />
PATHOLOGY AND LABORATORY 80047–89398<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
87880 IAADIADOO STREPTOCOCCUS GRP 22.84 XXX<br />
87899 IAADIADOO NOS 22.84 XXX<br />
87900 NFCT AGT DRUG SC PHEXYP PREDICT 246.67 XXX<br />
s 87901 NFCT AGT GEXYP HIV 1 REV TRANSCRIP&PROTEAS REGNS 486.95 XXX<br />
87902 NFCT AGT GEXYP HEP C VIRUS 486.95 XXX<br />
87903 NFCT AGT PHEXYP RESISTANCE TISS CUL HIV 1 1-10 924.56 XXX<br />
+ 87904 NFCT AGT PHEXYP RESISTANCE TISS CUL HIV 1 EA 1-5 49.33 XXX<br />
87905 INFECTIOUS AGENT ENZYMATIC ACTV OTH/THN VIRUS 23.30 XXX<br />
l # 87906 NFCT GEXYP DNA/RNA HIV 1 OTHER REGION 243.47 XXX<br />
87999 UNLIS MICROBIOLOGY BR XXX<br />
88000 NECROPSY GROSS XM W/O CNS 261.29 XXX<br />
88005 NECROPSY GROSS XM BRN 305.14 XXX<br />
88007 NECROPSY GROSS XM BRN&SPI CORD 319.76 XXX<br />
88012 NECROPSY GROSS XM INFT BRN 261.29 XXX<br />
88014 NECROPSY GROSS XM STILLBORN/NB BRN 239.82 XXX<br />
88016 NECROPSY GROSS XM MACERATED STILLBORN 333.92 XXX<br />
88020 NECROPSY GROSS&MCRSCP W/O CNS 450.40 XXX<br />
88025 NECROPSY GROSS&MCRSCP BRN 435.79 XXX<br />
88027 NECROPSY GROSS&MCRSCP BRN&SPI CORD 465.02 XXX<br />
88028 NECROPSY GROSS&MCRSCP INFT BRN 261.29 XXX<br />
88029 NECROPSY GROSS&MCRSCP STILLBORN/NB BRN 261.29 XXX<br />
88036 NECROPSY LMTD GROSS&/MCRSCP REGIONAL 130.64 XXX<br />
88037 NECROPSY LMTD GROSS&/MCRSCP 1 ORGAN 116.03 XXX<br />
88040 NECROPSY FORENSIC XM 726.31 XXX<br />
88045 NECROPSY CORONER'S CALL 72.63 XXX<br />
88099 UNLIS NECROPSY BR XXX<br />
88104 CYTP FLU WASHGS/BRUSHINGS XCPT C/V SMRS INTERPJ 87.71 XXX<br />
88104 26 CYTP FLU WASHGS/BRUSHINGS XCPT C/V SMRS INTERPJ 37.00 XXX<br />
88104 TC CYTP FLU WASHGS/BRUSHINGS XCPT C/V SMRS INTERPJ 50.71 XXX<br />
88106 CYTP FLU BR/WA XCPT C/V FILTER METH ONLY INTERPJ 107.35 XXX<br />
88106 26 CYTP FLU BR/WA XCPT C/V FILTER METH ONLY INTERPJ 36.54 XXX<br />
88106 TC CYTP FLU BR/WA XCPT C/V FILTER METH ONLY INTERPJ 70.81 XXX<br />
88107 CYTP FLU BR/WA XCPT C/V SMRS&FILTER INTERPJ 134.76 XXX<br />
88107 26 CYTP FLU BR/WA XCPT C/V SMRS&FILTER INTERPJ 51.16 XXX<br />
88107 TC CYTP FLU BR/WA XCPT C/V SMRS&FILTER INTERPJ 83.60 XXX<br />
88108 CYTP CONCENTRATION SMRS&INTERPJ 101.41 XXX<br />
88108 26 CYTP CONCENTRATION SMRS&INTERPJ 36.54 XXX<br />
88108 TC CYTP CONCENTRATION SMRS&INTERPJ 64.87 XXX<br />
88112 CYTP SLCTV CELL ENHANCEMENT INTERPJ XCPT C/V 137.95 XXX<br />
88112 26 CYTP SLCTV CELL ENHANCEMENT INTERPJ XCPT C/V 75.83 XXX<br />
88112 TC CYTP SLCTV CELL ENHANCEMENT INTERPJ XCPT C/V 62.12 XXX<br />
l 88120 CYTP INSITU HYBRID URINE SPEC 3-5 PROBES EA MNL 613.48 XXX<br />
l 88120 26 CYTP INSITU HYBRID URINE SPEC 3-5 PROBES EA MNL 70.35 XXX<br />
l 88120 TC CYTP INSITU HYBRID URINE SPEC 3-5 PROBES EA MNL 543.13 XXX<br />
l 88121 CYTP INSITU HYBRID URNE SPEC 3-5 PROBES CPTR EA 518.01 XXX<br />
l 88121 26 CYTP INSITU HYBRID URNE SPEC 3-5 PROBES CPTR EA 62.58 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
246 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section IX: Pathology and Laboratory Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
80047–89398 PATHOLOGY AND LABORATORY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
l 88121 TC CYTP INSITU HYBRID URNE SPEC 3-5 PROBES CPTR EA 455.43 XXX<br />
88125 CYTP FORENSIC 29.69 XXX<br />
88125 26 CYTP FORENSIC 17.82 XXX<br />
88125 TC CYTP FORENSIC 11.87 XXX<br />
88130 SEX CHROMATIN ID BARR BODIES 28.32 XXX<br />
88140 SEX CHROMATIN ID PRPH BLD SMR 15.07 XXX<br />
88141 CYTP C/V REQ INTERPJ PHYS 38.83 XXX<br />
88142 CYTP C/V FLU AUTO THIN MNL PHYS 38.37 XXX<br />
88143 CYTP C/V FLU AUTO THIN MNL SCR&RESCR PHYS 38.37 XXX<br />
88147 CYTP SMRS C/V SCR AUTO SYS PHYS 21.47 XXX<br />
88148 CYTP SMRS C/V SCR AUTO SYS MNL RESCR PHYS 28.78 XXX<br />
88150 CYTP SLIDES C/V MNL SCR UNDER PHYS 20.10 XXX<br />
88152 CYTP SLIDES C/V MNL SCR&CPTR RESCR PHYS 20.10 XXX<br />
88153 CYTP SLIDES C/V MNL SCR&RESCR PHYS 20.10 XXX<br />
88154 CYTP SLIDES C/V MNL SCR&CPTR-RESCR CELL S&R PHYS 20.10 XXX<br />
+ 88155 CYTP SLIDES C/V DEFINITIVE HORMONAL EVAL 11.42 XXX<br />
88160 CYTP SMRS ANY OTH SRC SCR&INTERPJ 73.09 XXX<br />
88160 26 CYTP SMRS ANY OTH SRC SCR&INTERPJ 32.89 XXX<br />
88160 TC CYTP SMRS ANY OTH SRC SCR&INTERPJ 40.20 XXX<br />
88161 CYTP SMRS ANY OTH SRC PREPJ SCR&INTERPJ 73.09 XXX<br />
88161 26 CYTP SMRS ANY OTH SRC PREPJ SCR&INTERPJ 31.98 XXX<br />
88161 TC CYTP SMRS ANY OTH SRC PREPJ SCR&INTERPJ 41.11 XXX<br />
88162 CYTP SMRS ANY OTH SRC EXTND STD > 5 SLIDES 105.06 XXX<br />
88162 26 CYTP SMRS ANY OTH SRC EXTND STD > 5 SLIDES 49.79 XXX<br />
88162 TC CYTP SMRS ANY OTH SRC EXTND STD > 5 SLIDES 55.27 XXX<br />
88164 CYTP SLIDES C/V MNL SCR PHYS 20.10 XXX<br />
88165 CYTP SLIDES C/V MNL SCR&RESCR PHYS 20.10 XXX<br />
88166 CYTP SLIDES C/V MNL SCR&CPTR RESCR PHYS 20.10 XXX<br />
88167 CYTP SLIDES C/V MNL SCR&CPTR RESCR CELL S&R PHYS 20.10 XXX<br />
s 88172 CYTP FINE NDL ASPIRATE IMMT CYTOHIST STD DX 1ST 68.06 XXX<br />
s 88172 26 CYTP FINE NDL ASPIRATE IMMT CYTOHIST STD DX 1ST 40.20 XXX<br />
s 88172 TC CYTP FINE NDL ASPIRATE IMMT CYTOHIST STD DX 1ST 27.86 XXX<br />
88173 CYTP FINE NDL ASPIRATE I&R 185.00 XXX<br />
88173 26 CYTP FINE NDL ASPIRATE I&R 91.82 XXX<br />
88173 TC CYTP FINE NDL ASPIRATE I&R 93.18 XXX<br />
88174 CYTP C/V AUTO THIN LYR PREPJ SCR SYS PHYS 40.20 XXX<br />
88175 CYTP C/V AUTO THIN LYR PREPJ SCR MNL RESCR PHYS 50.25 XXX<br />
l + # 88177 CYTP C/V AUTO THIN LYR PREPJ ADEQUACY EA EVAL 37.46 ZZZ<br />
l + # 88177 26 CYTP C/V AUTO THIN LYR PREPJ ADEQUACY EA EVAL 28.78 ZZZ<br />
l + # 88177 TC CYTP C/V AUTO THIN LYR PREPJ ADEQUACY EA EVAL 8.68 ZZZ<br />
88182 FLO CYTOMETRY CELL CYCLE/DNA ALYS 139.78 XXX<br />
88182 26 FLO CYTOMETRY CELL CYCLE/DNA ALYS 46.59 XXX<br />
88182 TC FLO CYTOMETRY CELL CYCLE/DNA ALYS 93.19 XXX<br />
88184 FLO CYTOMETRY CELL SURF MARKER TECHL ONLY 1ST 112.83 XXX<br />
+ 88185 FLO CYTOMETRY CELL SURF MARKER TECHL ONLY EA 67.61 ZZZ<br />
88187 FLO CYTOMETRY INTERPJ 2-8 MARKERS 90.90 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 247
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section IX: Pathology and Laboratory Services<br />
PATHOLOGY AND LABORATORY 80047–89398<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
88188 FLO CYTOMETRY INTERPJ 9-15 MARKERS 112.83 XXX<br />
88189 FLO CYTOMETRY INTERPJ 16/> MARKERS 138.87 XXX<br />
88199 UNLIS CYTP BR XXX<br />
88230 TISS CUL NON-NEO DISORDERS LYMPHOCYTE 220.63 XXX<br />
88233 TISS CUL NON-NEO DISORDERS SKN/OTH SOLID TISS BX 266.31 XXX<br />
88235 TISS CUL NON-NEO DISORDERS AMNIOTIC/CHORNC CELLS 278.65 XXX<br />
88237 TISS CUL NEO DISORDERS B1 MARROW BLD CELLS 238.91 XXX<br />
88239 TISS CUL NEO DISORDERS SOLID TUM 279.10 XXX<br />
88240 CRYOPRSRV FRZING&STORAGE CELLS EA CELL LINE 19.19 XXX<br />
88241 THAWING&XPNSJ FROZEN CELLS EA ALIQUOT 19.19 XXX<br />
88245 CHRMSM BRKG BASELINE SISTER 20-25 CLL 281.85 XXX<br />
88248 CHRMSM BRKG BASELINE BRKG 50-100 CLL 327.53 XXX<br />
88249 CHRMSM BRKG SYNDS SCORE 100 CLL 327.53 XXX<br />
88261 CHRMSM CNT 5 CLL 1KARYOTYP BANDING 334.38 XXX<br />
88262 CHRMSM CNT 15-20 CLL 2KARYOTYP BANDING 235.71 XXX<br />
88263 CHRMSM CNT 45 CLL MOSAICISM 2KARYOTYP 284.13 XXX<br />
88264 CHRMSM ANALYZE 20-25 CELLS 235.71 XXX<br />
88267 CHRMSM ALYS AMNIOTIC/VILLUS 15 CLL 1KARYOTYP 340.32 XXX<br />
88269 CHRMSM SITU AMNIOTIC CLL 6-12 COLONIES 1KARYOTYP 314.74 XXX<br />
88271 MOLEC CYTOGENETICS DNA PRB EA 40.66 XXX<br />
88272 MOLEC CYTG CHRMOML ISH 3-5 CLL 50.70 XXX<br />
88273 MOLEC CYTG CHRMOML ISH 10-30 CLL 60.75 XXX<br />
88274 MOLEC CYTG INTERPHASE ISH 25-99 CLL 65.78 XXX<br />
88275 MOLEC CYTG INTERPHASE ISH ANALYZE 100-300 CLL 75.83 XXX<br />
88280 CHRMSM ALYS ADDL KARYOTYP EA STD 47.51 XXX<br />
88283 CHRMSM ALYS ADDL SPECIZED BANDING 129.73 XXX<br />
88285 CHRMSM ALYS ADDL CELLS CNTED EA STD 36.09 XXX<br />
88289 CHRMSM ALYS ADDL HR STD 65.32 XXX<br />
88291 CYTOGENETICS&MOLEC CYTOGENETICS I&R 39.28 XXX<br />
88299 UNLIS CYTOGENETIC STD BR XXX<br />
88300 LVL I-SURG PATH GROSS XM ONLY 36.09 XXX<br />
88300 26 LVL I-SURG PATH GROSS XM ONLY 5.94 XXX<br />
88300 TC LVL I-SURG PATH GROSS XM ONLY 30.15 XXX<br />
88302 LVL II-SURG PATH GROSS&MCRSCP XM 71.72 XXX<br />
88302 26 LVL II-SURG PATH GROSS&MCRSCP XM 8.68 XXX<br />
88302 TC LVL II-SURG PATH GROSS&MCRSCP XM 63.04 XXX<br />
88304 LEVEL III-SURG PATH GROSS&MICROSCOPIC XM 84.05 XXX<br />
88304 26 LEVEL III-SURG PATH GROSS&MICROSCOPIC XM 14.62 XXX<br />
88304 TC LEVEL III-SURG PATH GROSS&MICROSCOPIC XM 69.43 XXX<br />
88305 LVL IV-SURG PATH GROSS&MCRSCP XM 142.52 XXX<br />
88305 26 LVL IV-SURG PATH GROSS&MCRSCP XM 48.88 XXX<br />
88305 TC LVL IV-SURG PATH GROSS&MCRSCP XM 93.64 XXX<br />
88307 LVL V-SURG PATH GROSS&MCRSCP XM 304.23 XXX<br />
88307 26 LVL V-SURG PATH GROSS&MCRSCP XM 106.89 XXX<br />
88307 TC LVL V-SURG PATH GROSS&MCRSCP XM 197.34 XXX<br />
88309 LVL VI-SURG PATH GROSS&MCRSCP XM 460.91 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
248 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section IX: Pathology and Laboratory Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
80047–89398 PATHOLOGY AND LABORATORY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
88309 26 LVL VI-SURG PATH GROSS&MCRSCP XM 186.83 XXX<br />
88309 TC LVL VI-SURG PATH GROSS&MCRSCP XM 274.08 XXX<br />
+ 88311 DECALCIFICATION PX 25.12 XXX<br />
+ 88311 26 DECALCIFICATION PX 15.99 XXX<br />
+ 88311 TC DECALCIFICATION PX 9.13 XXX<br />
88312 SPECIAL STAINS GROUP 1 MICROORGANISMS I&R EACH 143.44 XXX<br />
88312 26 SPECIAL STAINS GROUP 1 MICROORGANISMS I&R EACH 35.17 XXX<br />
88312 TC SPECIAL STAINS GROUP 1 MICROORGANISMS I&R EACH 108.27 XXX<br />
88313 SPECIAL STAINS GROUP II ALL OTHER I&R EACH 104.61 XXX<br />
88313 26 SPECIAL STAINS GROUP II ALL OTHER I&R EACH 15.53 XXX<br />
88313 TC SPECIAL STAINS GROUP II ALL OTHER I&R EACH 89.08 XXX<br />
+ 88314 SPECIAL STAINS HISTOCHEMICAL W/FROZEN SECTION 121.05 XXX<br />
+ 88314 26 SPECIAL STAINS HISTOCHEMICAL W/FROZEN SECTION 30.15 XXX<br />
+ 88314 TC SPECIAL STAINS HISTOCHEMICAL W/FROZEN SECTION 90.90 XXX<br />
88318 DETERMINATIVE HISTOCHEMISTRY ID CHEM COMPONENTS 156.68 XXX<br />
88318 26 DETERMINATIVE HISTOCHEMISTRY ID CHEM COMPONENTS 27.86 XXX<br />
88318 TC DETERMINATIVE HISTOCHEMISTRY ID CHEM COMPONENTS 128.82 XXX<br />
88319 DETERMINATIVE HCHEM/CCHEM ID NZM EA 196.88 XXX<br />
88319 26 DETERMINATIVE HCHEM/CCHEM ID NZM EA 35.63 XXX<br />
88319 TC DETERMINATIVE HCHEM/CCHEM ID NZM EA 161.25 XXX<br />
88321 CONSLTJ&REPRT SLIDES PREPARED ELSEWHERE 121.97 XXX<br />
88323 CONSLTJ&REPRT MATRL REQ PREPJ SLIDES 191.86 XXX<br />
88323 26 CONSLTJ&REPRT MATRL REQ PREPJ SLIDES 112.83 XXX<br />
88323 TC CONSLTJ&REPRT MATRL REQ PREPJ SLIDES 79.03 XXX<br />
88325 CONSLTJ COMPRE REVIEW REPRT REFERRED MATRL 268.14 XXX<br />
88329 PATH CONSLTJ SURG 69.89 XXX<br />
88331 PATH CONSLTJ SURG 1ST BLK FROZEN SCTJ 1 SPEC 122.88 XXX<br />
88331 26 PATH CONSLTJ SURG 1ST BLK FROZEN SCTJ 1 SPEC 79.94 XXX<br />
88331 TC PATH CONSLTJ SURG 1ST BLK FROZEN SCTJ 1 SPEC 42.94 XXX<br />
s + 88332 PATH CONSLTJ SURG EA BLK FROZEN SCTJ 54.36 XXX<br />
s + 88332 26 PATH CONSLTJ SURG EA BLK FROZEN SCTJ 39.28 XXX<br />
s + 88332 TC PATH CONSLTJ SURG EA BLK FROZEN SCTJ 15.08 XXX<br />
88333 PATH CONSLTJ SURG CYTOLOGIC XM 1ST SIT 127.90 XXX<br />
88333 26 PATH CONSLTJ SURG CYTOLOGIC XM 1ST SIT 80.85 XXX<br />
88333 TC PATH CONSLTJ SURG CYTOLOGIC XM 1ST SIT 47.05 XXX<br />
s + 88334 PATH CONSLTJ SURG CYTOL XM EA ADDL 79.03 XXX<br />
s + 88334 26 PATH CONSLTJ SURG CYTOL XM EA ADDL 49.33 XXX<br />
s + 88334 TC PATH CONSLTJ SURG CYTOL XM EA ADDL 29.70 XXX<br />
88342 IMCYTCHM TISS IMMUNOPROXIDASE EA ANTB 139.78 XXX<br />
88342 26 IMCYTCHM TISS IMMUNOPROXIDASE EA ANTB 55.27 XXX<br />
88342 TC IMCYTCHM TISS IMMUNOPROXIDASE EA ANTB 84.51 XXX<br />
88346 IMFLUOR STD EA ANTB DIR METH 137.04 XXX<br />
88346 26 IMFLUOR STD EA ANTB DIR METH 55.27 XXX<br />
88346 TC IMFLUOR STD EA ANTB DIR METH 81.77 XXX<br />
88347 IMFLUOR STD EA ANTB INDIR METH 103.69 XXX<br />
88347 26 IMFLUOR STD EA ANTB INDIR METH 51.16 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 249
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section IX: Pathology and Laboratory Services<br />
PATHOLOGY AND LABORATORY 80047–89398<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
88347 TC IMFLUOR STD EA ANTB INDIR METH 52.53 XXX<br />
88348 ELECTRON MIC DX 915.43 XXX<br />
88348 26 ELECTRON MIC DX 98.21 XXX<br />
88348 TC ELECTRON MIC DX 817.22 XXX<br />
88349 ELECTRON MIC SCANNING 482.84 XXX<br />
88349 26 ELECTRON MIC SCANNING 52.08 XXX<br />
88349 TC ELECTRON MIC SCANNING 430.76 XXX<br />
88355 M/PHMTRC ALYS SKEL MUSC 287.33 XXX<br />
88355 26 M/PHMTRC ALYS SKEL MUSC 112.37 XXX<br />
88355 TC M/PHMTRC ALYS SKEL MUSC 174.96 XXX<br />
88356 M/PHMTRC ALYS NRV 380.51 XXX<br />
88356 26 M/PHMTRC ALYS NRV 176.32 XXX<br />
88356 TC M/PHMTRC ALYS NRV 204.19 XXX<br />
88358 M/PHMTRC ALYS TUM 100.50 XXX<br />
88358 26 M/PHMTRC ALYS TUM 56.64 XXX<br />
88358 TC M/PHMTRC ALYS TUM 43.86 XXX<br />
88360 M/PHMTRC ALYS TUM IMHCHEM EA ANTB MNL 165.82 XXX<br />
88360 26 M/PHMTRC ALYS TUM IMHCHEM EA ANTB MNL 70.35 XXX<br />
88360 TC M/PHMTRC ALYS TUM IMHCHEM EA ANTB MNL 95.47 XXX<br />
88361 M/PHMTRC ALYS TUM IMHCHEM EA ANTB CPTR 203.73 XXX<br />
88361 26 M/PHMTRC ALYS TUM IMHCHEM EA ANTB CPTR 74.92 XXX<br />
88361 TC M/PHMTRC ALYS TUM IMHCHEM EA ANTB CPTR 128.81 XXX<br />
88362 NRV TEASING PREPJS 379.60 XXX<br />
88362 26 NRV TEASING PREPJS 143.89 XXX<br />
88362 TC NRV TEASING PREPJS 235.71 XXX<br />
l 88363 EXAM & SELECT ARCHIVE TISSUE MOLECULAR ANALYSIS 51.16 XXX<br />
88365 SITU HYBRIDIZATION EA PRB 222.46 XXX<br />
88365 26 SITU HYBRIDIZATION EA PRB 76.74 XXX<br />
88365 TC SITU HYBRIDIZATION EA PRB 145.72 XXX<br />
88367 M/PHMTRC ALYS ISH EA PRB CPTR-ASST TECHNOLOGY 344.43 XXX<br />
88367 26 M/PHMTRC ALYS ISH EA PRB CPTR-ASST TECHNOLOGY 81.77 XXX<br />
88367 TC M/PHMTRC ALYS ISH EA PRB CPTR-ASST TECHNOLOGY 262.66 XXX<br />
88368 M/PHMTRC ALYS ISH EA PRB MNL 295.55 XXX<br />
88368 26 M/PHMTRC ALYS ISH EA PRB MNL 83.59 XXX<br />
88368 TC M/PHMTRC ALYS ISH EA PRB MNL 211.96 XXX<br />
88371 PROTEIN ALYS WSTRN BLOT I&R 67.61 XXX<br />
88371 26 PROTEIN ALYS WSTRN BLOT I&R 25.58 XXX<br />
88371 TC PROTEIN ALYS WSTRN BLOT I&R 42.03 XXX<br />
88372 PROTEIN ALYS WSTRN BLOT I&R IMMUNOLOGICAL EA 68.98 XXX<br />
88372 26 PROTEIN ALYS WSTRN BLOT I&R IMMUNOLOGICAL EA 26.04 XXX<br />
88372 TC PROTEIN ALYS WSTRN BLOT I&R IMMUNOLOGICAL EA 42.94 XXX<br />
88380 MICRODISSECTION PREP IDENTIFIED TARGET LASER 235.25 XXX<br />
88380 26 MICRODISSECTION PREP IDENTIFIED TARGET LASER 97.30 XXX<br />
88380 TC MICRODISSECTION PREP IDENTIFIED TARGET LASER 137.95 XXX<br />
88381 MICRODISSECTION PREP IDENTIFIED TARGET MANUAL 247.59 XXX<br />
88381 26 MICRODISSECTION PREP IDENTIFIED TARGET MANUAL 71.72 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
250 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section IX: Pathology and Laboratory Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
80047–89398 PATHOLOGY AND LABORATORY<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
88381 TC MICRODISSECTION PREP IDENTIFIED TARGET MANUAL 175.87 XXX<br />
88384 RA-BASED EVAL MLT MOLEC PRBS 11 THRU 50 PRBS 469.13 XXX<br />
88384 26 RA-BASED EVAL MLT MOLEC PRBS 11 THRU 50 PRBS 51.62 XXX<br />
88384 TC RA-BASED EVAL MLT MOLEC PRBS 11 THRU 50 PRBS 417.51 XXX<br />
88385 RA-BASED EVAL MLT MOLEC PRBS 51 THRU 250 PRBS 771.99 XXX<br />
88385 26 RA-BASED EVAL MLT MOLEC PRBS 51 THRU 250 PRBS 88.16 XXX<br />
88385 TC RA-BASED EVAL MLT MOLEC PRBS 51 THRU 250 PRBS 683.83 XXX<br />
88386 RA-BASED EVAL MLT MOLEC PRBS 251 THRU 500 PRBS 861.07 XXX<br />
88386 26 RA-BASED EVAL MLT MOLEC PRBS 251 THRU 500 PRBS 116.03 XXX<br />
88386 TC RA-BASED EVAL MLT MOLEC PRBS 251 THRU 500 PRBS 745.04 XXX<br />
88387 MACRO EXAM DISSECT&PREP TISS NONMICRO STD EA 54.36 XXX<br />
88387 26 MACRO EXAM DISSECT&PREP TISS NONMICRO STD EA 42.48 XXX<br />
88387 TC MACRO EXAM DISSECT&PREP TISS NONMICRO STD EA 11.88 XXX<br />
+ 88388 MACR EXM DISS&PRP NONMICR IMPRNT/CONSLT/FRZ SEC 31.52 XXX<br />
+ 88388 26 MACR EXM DISS&PRP NONMICR IMPRNT/CONSLT/FRZ SEC 25.58 XXX<br />
+ 88388 TC MACR EXM DISS&PRP NONMICR IMPRNT/CONSLT/FRZ SEC 5.94 XXX<br />
88399 UNLIS SURG PATH PX BR XXX<br />
88720 BILIRUBIN TOTAL TRANSCUTANEOUS 9.59 XXX<br />
88738 HGB QUANTITATIVE TRANSCUTANEOUS 9.59 XXX<br />
88740 HEMOGLOBIN QUAN TC PER DAY CARBOXYHEMOGLOBIN 9.59 XXX<br />
88741 HEMOGLOBIN QUANTITATIVE TC PER DAY METHEMOGLOBIN 9.59 XXX<br />
l 88749 UNLISTED IN VIVO LAB SERVICE BR XXX<br />
89049 CAFFEINE HALOTHANE CONTRCURE 342.60 XXX<br />
89050 C-CNT MISC BDY FLUS XCPT BLD 9.14 XXX<br />
89051 C-CNT MISC BDY FLUS XCPT BLD DIFFIAL CNT 10.51 XXX<br />
89055 WBC ASSMT FECAL QUAL/SEMIQUAN 8.22 XXX<br />
89060 CRYSTAL ID LIGHT MIC ALYS TISSUE/ANY FLU 39.74 XXX<br />
89060 26 CRYSTAL ID LIGHT MIC ALYS TISSUE/ANY FLU 26.04 XXX<br />
89060 TC CRYSTAL ID LIGHT MIC ALYS TISSUE/ANY FLU 13.70 XXX<br />
89125 FAT STAIN FECES URINE/RESPIR SECRETIONS 8.22 XXX<br />
89160 MEAT FIBERS FECES 6.85 XXX<br />
89190 NSL SMR EOSINOPHILS 9.14 XXX<br />
89220 SPTM OBTG SPEC AERSL INDUCED SPX 21.47 XXX<br />
89230 SWEAT COLLJ IONTOPHORESIS 4.11 XXX<br />
89240 UNLIS MISC PATH BR XXX<br />
89250 CUL OOCYTE/EMBRYO < 4 D 1318.78 XXX<br />
89251 CUL OOCYTE/EMBRYO < 4 D CO-CULT OCYTE/EMBRY 1371.77 XXX<br />
89253 ASSTD EMBRYO HATCHING MICROTQS ANY METH BR XXX<br />
89254 OOCYTE ID FROM FOLLICULAR FLU BR XXX<br />
89255 PREPJ EMBRYO TR BR XXX<br />
89257 SPRM ID FROM ASPIR OTH/THN SEMINAL BR XXX<br />
89258 CRYOPRESERVATION EMBRYO(S) BR XXX<br />
89259 CRYOPRESERVATION SPERM BR XXX<br />
89260 SPRM ISOL SMPL PREP INSEMINATION/DX SEMEN ALYS BR XXX<br />
89261 SPRM ISOL CPLX PREP INSEMINATION/DX SEMEN ALYS BR XXX<br />
89264 SPRM ID FROM TSTIS TISS FRSH/CRYOPRSRVD BR XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
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<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section IX: Pathology and Laboratory Services<br />
PATHOLOGY AND LABORATORY 80047–89398<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
89268 INSEMINATION OOCYTES BR XXX<br />
89272 EXTND CUL OOCYTE/EMBRYO 4-7 D BR XXX<br />
89280 ASSTD FERTILIZATION MICROTQ 10 OOCYTES BR XXX<br />
89290 BX OOCYTE MICROTQ 5 EMBRY BR XXX<br />
89300 SEMEN ALYS PRESENCE&/MOTILITY SPRM HUHNER 16.90 XXX<br />
89310 SEMEN ALYS MOTILITY&CNT X W/HUHNER TST 16.44 XXX<br />
89320 SEMEN ANALYSIS VOLUME COUNT MOTILITY DIFFERENT 22.84 XXX<br />
89321 SEMEN ANALYSIS SPERM PRESENCE&/MOTILITY SPRM 22.84 XXX<br />
89322 SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA 29.24 XXX<br />
89325 SPRM ANTIBODIES 20.10 XXX<br />
89329 SPRM EVAL HAMSTER PENETRATION TST 39.74 XXX<br />
89330 SPRM EVAL CRV MUCUS PENETRATION 18.73 XXX<br />
89331 SPERM EVALUATION RETROGRADE EJACULATION URINE 37.00 XXX<br />
89335 CRYOPRSRV REPRDTVE TISS TSTICULAR BR XXX<br />
89342 STORAGE PR YR EMBRYO BR XXX<br />
89343 STORAGE PR YR SPRM/SEMEN BR XXX<br />
89344 STORAGE PR YR REPRDTVE TISS TSTICULAR/OVARIAN BR XXX<br />
89346 STORAGE PR YR OOCYTE BR XXX<br />
89352 THAWING CRYOPRSRVD EMBRYO BR XXX<br />
89353 THAWING CRYOPRSRVD SPRM/SEMEN EA ALIQUOT BR XXX<br />
89354 THAWING CRYOPRSRVD TSTICULAR/OVARIAN BR XXX<br />
89356 THAWING CRYOPRSRVD OOCYTES EA ALIQUOT BR XXX<br />
89398 UNLISTED REPRODUCTIVE MEDICINE LAB PROCEDURE BR XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
252 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section X: General Medicine<br />
Services<br />
SUBSECTION A: PAYMENT GROUND RULES FOR<br />
GENERAL MEDICINE SERVICES<br />
General Guidelines<br />
Some of the commonalties are repeated here for the<br />
convenience of those medical providers referring to this<br />
section on General Medicine. If no appropriate code is found<br />
for medical services performed by a provider, use the<br />
appropriate unlisted code (e.g., CPT code 99199), and<br />
adequately describe the service provided.<br />
Materials and supplies not usually considered part of the<br />
procedure may be separately reported with CPT code 99070<br />
(see Materials Supplied by the Health Care Provider in<br />
section IV).<br />
A physician office visit code may be charged in addition to<br />
the code for modalities/procedures only if the accompanying<br />
documentation clearly indicates that the physician actually<br />
examined the worker during the office visit.<br />
To report the administration of a vaccine/toxoid, the<br />
vaccine/toxoid product CPT codes 90476–90749 are<br />
reported in addition to an immunization administration CPT<br />
code(s) 90460–90474. Hydration services shall use CPT<br />
code(s) 96360, 96361 and will not include the cost of the<br />
prepackaged fluid and electrolytes, which will be billed and<br />
paid separately. A therapeutic, prophylactic or diagnostic<br />
injection shall use CPT code(s) 96365–96379 and will not<br />
include the cost of the drug, which will be billed and paid<br />
separately.<br />
Definitions<br />
<strong>The</strong> following services represent definitions and special<br />
billing considerations for general medicine services.<br />
Osteopathic, chiropractic, and physical therapist service<br />
reimbursements are explained in the Physical Medicine<br />
section. Evaluation and management (E/M) services are<br />
thoroughly explained in Evaluation and Management (E/M)<br />
section.<br />
Office Visits<br />
An evaluation and management code may be reported<br />
separately only if the injured employee requires a separate<br />
evaluation for treatment determination. (See Evaluation and<br />
Management section for further details on appropriate<br />
codes.) If the injured employee has a predetermined medical<br />
treatment plan by the authorized treating physician or<br />
referring physician, a separate E/M code for an office visit<br />
should not be charged and will not be reimbursed.<br />
Multiple Procedures<br />
It is appropriate to designate multiple procedures that are<br />
rendered on the same date by separate entries.<br />
Add-on Codes<br />
Some of the listed procedures are commonly carried out in<br />
addition to the primary procedure performed. Add-on<br />
procedures are not reported as stand-alone codes. All add-on<br />
codes are exempt from the multiple procedure concept, and<br />
as such, modifier 51 does not apply. <strong>The</strong>se additional or<br />
supplemental procedures, designated as add-on codes, can<br />
be readily identified by specific nomenclature in the CPT<br />
description which includes phrases such as “each additional”<br />
or “(List separately in addition to primary procedure).”<br />
Separate Procedure<br />
Certain procedures are an inherent portion of a procedure or<br />
service, and do not warrant a separate charge. When such a<br />
procedure is carried out as a separate entity not immediately<br />
related to other services, the indicated value for a separate<br />
procedure is applicable. <strong>The</strong>refore, when a procedure that is<br />
ordinarily a component of a larger procedure is performed<br />
alone for a specific purpose, it may be considered a separate<br />
procedure. It may be necessary to report a separate<br />
procedure with modifier 59 if it is a different session,<br />
encounter, procedure, surgery, site, separate incision, lesion,<br />
or separate injury.<br />
Interpretation<br />
In circumstances where an interpreter is required during<br />
face-to-face evaluation and management services, or physical<br />
CPT only © 2010 American Medical Association. All Rights Reserved. 253
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
medicine evaluations (97001–97004), provided to the<br />
injured worker by a physician or PE, whether interpretation<br />
is provided live, via telephone or video, add state-specific<br />
modifier TR to the E/M code. Reimbursement will be an<br />
additional 25 percent of the lesser of billed charges or<br />
maximum allowable rate of that code only. Prolonged service<br />
codes 99354–99357 may not be used in combination with<br />
this modifier. Additional reimbursement as outlined above<br />
does not apply to independent medical evaluations (IME).<br />
In circumstances where an interpreter is required for an<br />
injured worker, and the service is provided by telephone<br />
with a physician or qualified non-physician health care<br />
provider, use the appropriate CPT codes 99441–99443<br />
(physicians) and 98966–98968 (qualified non-physician<br />
health care providers), and append state-specific modifier<br />
TR. <strong>The</strong>se codes should be used in accordance with the<br />
guidelines and descriptions found in CPT 2011.<br />
Reimbursement will be an additional 25 percent of the lesser<br />
of billed charges or maximum allowable rate of that code<br />
only.<br />
Unusual Service or Procedure<br />
Services that may necessitate skills and time of the physician<br />
over and above that usually required should be substantiated<br />
by report (see section IV).<br />
Unlisted Service or Procedure<br />
Some services performed are not described by any CPT code.<br />
<strong>The</strong>se services should be reported using an unlisted code,<br />
substantiating it by report. <strong>The</strong> unlisted services and<br />
accompanying codes are listed at the end of each Medicine<br />
subsection. Unlisted service or procedure codes must be<br />
selected from the appropriate subsection of the Medicine<br />
chapter. For these procedures a “BR” (by report) designation<br />
has been used in the fee schedule. Reimbursement for such<br />
procedures must be justified by report (see section IV).<br />
SUBSECTION B: PAYMENT MODIFIERS FOR GENERAL<br />
MEDICINE SERVICES<br />
A modifier indicates a service or procedure performed has<br />
been altered by some specific circumstance but has not<br />
changed its definition or code. <strong>The</strong> modifying circumstance<br />
shall be identified by use of the appropriate modifier<br />
following the procedure code. When two modifiers are<br />
applicable to a single code, indicate each modifier on the<br />
bill. If more than one modifier is used, place the “Multiple<br />
Modifiers” code 99 immediately after the procedure code.<br />
This indicates that one or more additional modifier codes<br />
will follow. Only certain modifiers in each of the categories<br />
(Evaluation and Management, Anesthesia, Surgery,<br />
Pathology/Laboratory, Radiology, General Medicine, and<br />
Section X: General Medicine Services<br />
Physical Medicine) will be recognized for reimbursement<br />
purposes.<br />
<strong>The</strong> modifiers listed below may differ from those published<br />
by the American Medical Association. Providers submitting<br />
workers’ compensation billing shall use only the modifiers<br />
set out in the fee schedule.<br />
<strong>The</strong> following modifiers will be recognized for<br />
reimbursement by the fee schedule for general medicine<br />
codes:<br />
22 Increased Procedural Services: When the work<br />
required to provide a service is substantially greater than<br />
typically required, it may be identified by adding<br />
modifier 22 to the usual procedure code.<br />
Documentation must support the substantial additional<br />
work and the reason for the additional work (i.e.,<br />
increased intensity, time, technical difficulty of<br />
procedure, severity of patient's condition, physical and<br />
mental effort required). Note: This modifier should not<br />
be appended to an E/M service.<br />
26 Professional Component: Certain procedures are a<br />
combination of a physician component and a technical<br />
component. When the physician component is reported<br />
separately, the service may be identified by adding<br />
modifier 26 to the usual procedure number.<br />
50 Bilateral Procedure: Unless otherwise identified in the<br />
listings, bilateral procedures that are performed at the<br />
same session, should be identified by adding modifier<br />
50 to the appropriate five-digit code.<br />
52 Reduced Services: Under certain circumstances, a<br />
service or procedure is partially reduced or eliminated at<br />
the physician’s discretion. Under these circumstances,<br />
the service provided can be identified by its usual<br />
procedure number and the addition of modifier 52<br />
signifying that the service is reduced. This provides a<br />
means of reporting reduced services without disturbing<br />
the identification of the basic service. Note: For hospital<br />
outpatient reporting of a previously scheduled<br />
procedure/service that is partially reduced or cancelled<br />
as a result of extenuating circumstances or those that<br />
threaten the well-being of the patient prior to or after<br />
administration of anesthesia, see modifiers 73 and 74<br />
(see modifiers approved for ASC hospital outpatient<br />
use).<br />
53 Discontinued Procedure: Due to extenuating<br />
circumstances or those that threaten the well-being of<br />
the patient, it may be necessary to indicate that a<br />
surgical or diagnostic procedure was started but<br />
discontinued. This circumstance may be reported by<br />
adding modifier 53 to the code for the discontinued<br />
procedure. Note: This modifier is not used to report the<br />
254 CPT only © 2010 American Medical Association. All Rights Reserved.
Section X: General Medicine Services<br />
elective cancellation of a procedure before the patient’s<br />
anesthesia induction and/or surgical preparation in the<br />
operating suite. For outpatient hospital/ambulatory<br />
surgery center (ASC) reporting of a previously<br />
scheduled procedure/service that is partially reduced or<br />
cancelled as a result of extenuating circumstances or<br />
those that threaten the well-being of the patient prior to<br />
or after administration of anesthesia, see modifier 73<br />
and 74 (see modifiers approved for ASC hospital<br />
outpatient use).<br />
59 Distinct Procedural Service: Under certain<br />
circumstances, it may be necessary to indicate that a<br />
procedure or service was distinct or independent from<br />
other non-E/M services performed on the same day.<br />
Modifier 59 is used to identify procedures/services,<br />
other than E/M services, that are not normally reported<br />
together but are appropriate under the circumstances.<br />
Documentation must support a different session,<br />
different procedure or surgery, different site or organ<br />
system, separate incision or excision, separate lesion, or<br />
separate injury (or area of injury in extensive injuries)<br />
not ordinarily encountered or performed on the same<br />
day by the same individual. However, when another<br />
already established modifier is appropriate, it should be<br />
used rather than modifier 59. Only if no more<br />
descriptive modifier is available, and the use of modifier<br />
59 best explains the circumstances, should modifier 59<br />
be used. Note: Modifier 59 should not be appended to<br />
an E/M service. To report a separate and distinct E/M<br />
service with a non-E/M service performed on the same<br />
date, see modifier 25.<br />
76 Repeat Procedure or Service by Same Physician or<br />
Other Qualified Health Care Professional: It may be<br />
necessary to indicate that a procedure or service was<br />
repeated by the same physician or other qualified health<br />
care professional subsequent to the original procedure<br />
or service. This circumstance may be reported by adding<br />
modifier 76 to the repeated procedure or service. Note:<br />
This modifier should not be appended to an E/M<br />
service.<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
77 Repeat Procedure or Service by Another Physician or<br />
Other Qualified Health Care Professional: It may be<br />
necessary to indicate that a basic procedure or service<br />
was repeated by another physician or other qualified<br />
health care professional subsequent to the original<br />
procedure or service. This circumstance may be<br />
reported by adding modifier 77 to the repeated<br />
procedure/service. Note: This modifier should not be<br />
appended to an E/M service.<br />
99 Multiple Modifiers: Under certain circumstances, two<br />
or more modifiers may be necessary to completely<br />
delineate a service. In such situations modifier 99<br />
should be added to the basic procedure, and other<br />
applicable modifiers may be listed as part of the<br />
description of the service.<br />
LT Left Side: Used to identify procedures performed on the<br />
left side of the body.<br />
RT Right Side: Used to identify procedures performed on<br />
the right side of the body.<br />
TC Technical Component Only: Certain procedures are a<br />
combination of a physician component and a technical<br />
component. When the technical component is reported<br />
separately, the service may be identified by adding<br />
modifier TC to the usual procedure number.<br />
TR Interpretation: In circumstances where an interpreter is<br />
required during face-to-face evaluation and<br />
management services provided to the injured worker by<br />
a physician or PE, add state-specific modifier TR to the<br />
E/M code. Reimbursement will be an additional 25<br />
percent of the lesser of billed charges or maximum<br />
allowable rate of that code only. Prolonged service codes<br />
99353–99357 may not be used in combination with the<br />
TR modifier unless it is documented that the reason for<br />
the code is additional time required as a result of factors<br />
beyond the need for an interpreter. Additional<br />
reimbursement as outlined above does not apply to<br />
independent medical evaluations (IME).<br />
CPT only © 2010 American Medical Association. All Rights Reserved. 255
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section X: General Medicine Services<br />
MEDICINE 90281–96999, 97597–97606, 97802–97804, 98960–99091, 99143–99199, 99605–99607<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
90281 IMMUNE GLOBULIN IG HUMAN IM USE BR XXX<br />
90283 IMMUNE GLOBULIN IGIV HUMAN IV USE BR XXX<br />
90284 IMMUNE GLOBULIN HUMAN SUBQ INFUSION 100 MG EA BR XXX<br />
90287 BOTULINUM ANTITOXIN EQUINE ANY ROUTE BR XXX<br />
90288 BOTULISM IMMUNE GLOBULIN HUMAN INTRAVENOUS USE BR XXX<br />
90291 CYTOMEGALOVIRUS IMMUNE GLOBULIN HUMAN IV BR XXX<br />
90296 DIPHTHERIA ANTITOXIN EQUINE ANY ROUTE BR XXX<br />
90371 HEPATITIS B IMMUNE GLOBULIN HBIG HUMAN IM 189.43 XXX<br />
90375 RABIES IMMUNE GLOBULIN RIG HUMAN IM/SUBQ 261.99 XXX<br />
90376 RABIES IG HEAT-TREATED HUMAN IM/SUBQ 257.01 XXX<br />
90378 RESPIRATORY SYNCYTIAL VIRUS IG IM 50 MG E BR XXX<br />
90384 RHO(D) IMMUNE GLOBULIN HUMAN FULL-DOSE IM 135.15 XXX<br />
90385 RHO(D) IMMUNE GLOBULIN HUMAN MINI-DOSE IM 39.88 XXX<br />
90386 RHO(D) IMMUNE GLOBULIN HUMAN IV 144.57 XXX<br />
90389 TETANUS IMMUNE GLOBULIN TIG HUMAN IM 125.18 XXX<br />
90393 VACCINIA IMMUNE GLOBULIN HUMAN IM BR XXX<br />
90396 VARICELLA-ZOSTER IMMUNE GLOBULIN HUMAN IM 139.03 XXX<br />
90399 UNLISTED IMMUNE GLOBULIN BR XXX<br />
l 90460 IMADM THROUGH 18YR ANY ROUTE 1ST VAC/TOXOID 37.67 XXX<br />
l + 90461 IMADM THROUGH 18YR ANY ROUTE EA ADDL VAC/TOXOID 18.83 ZZZ<br />
l 90470 IMMUNE ADMIN H1N1 IM/NASAL INCL CNSL 33.23 XXX<br />
90471 IMADM PRQ ID SUBQ/IM NJXS 1 VACC 37.67 XXX<br />
+ 90472 IMADM PRQ ID SUBQ/IM NJXS EA VACC 18.83 ZZZ<br />
90473 IMADM INTRANSL/ORAL 1 VACC 37.67 XXX<br />
+ 90474 IMADM INTRANSL/ORAL EA VACC 18.83 ZZZ<br />
90476 ADENOVIRUS VACCINE TYPE 4 LIVE ORAL BR XXX<br />
90477 ADENOVIRUS VACCINE TYPE 7 LIVE FOR ORAL BR XXX<br />
90581 ANTHRAX VACCINE SUBCUTANEOUS USE 160.63 XXX<br />
90585 BACILLUS CALMETTE-GUERIN VACC FOR TB LIVE PERQ 186.66 XXX<br />
90586 BCG BLDR CANCER LIVE INTRAVESICAL 185.00 XXX<br />
90632 HEPATITIS A VACCINE ADULT FOR INTRAMUSCULAR USE 83.09 XXX<br />
90633 HEPATITIS A VACCINE PEDIATRIC 2 DOSE <strong>SCHEDULE</strong> IM 38.77 XXX<br />
90634 HEPATITIS A VACCINE PEDIATRIC 3 DOSE <strong>SCHEDULE</strong> IM 40.43 XXX<br />
90636 HEPATITIS A & B VACCINE HEPA-HEPB ADULT IM 105.79 XXX<br />
l 90644 MENINGOCOCCAL & HIB CONJ VACCINE 4 DOSE IM 31.02 XXX<br />
90645 HEMOPHILUS INFLUENZA B VACC HBOC CONJ 4 DOSE IM 31.02 XXX<br />
90646 HEMOPHILUS INFLUENZA B VACCINE PRP-D BOOSTER IM 31.02 XXX<br />
90647 HEMOPHILUS INFLUENZA B VACCINE PRP-OMP 3 DOSE IM 32.68 XXX<br />
90648 HEMOPHILUS INFLUENZA B VACCINE PRP-T 4 DOSE IM 31.02 XXX<br />
90649 HUMAN PAPILLOMA VIRUS VACCINE QUADRIV 3 DOSE IM 146.23 XXX<br />
s 90650 HUMAN PAPILLOMA VIRUS BIVALENT VACCINE 3 DOSE IM BR XXX<br />
90654 INFLUENZA VACCINE PRSV FREE ID USE BR XXX<br />
90655 INFLUENZA VIRUS VACC SPLIT PRSRV FREE 6-35 MO IM 24.37 XXX<br />
90656 INFLUENZA VIRUS VACC SPLIT PRSRV FR 3 YEARS + IM 22.71 XXX<br />
90657 INFLUENZA VIRUS VACCINE SPLIT VIRUS 6-35 MO IM 10.52 XXX<br />
90658 INFLUENZA VIRUS VACCINE SPLIT VIRUS 3 YEARS + IM 17.72 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
256 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section X: General Medicine Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
90281–96999, 97597–97606, 97802–97804, 98960–99091, 99143–99199, 99605–99607 MEDICINE<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
90660 INFLUENZA VIRUS VACCINE LIVE INTRANASAL 36.56 XXX<br />
90661 INFLUENZA VACCINE CELL CULT PRSRV FREE IM BR XXX<br />
s 90662 INFLUENZA VACCINE SPLT PRSRV FREE INC ANTIGEN IM 47.64 XXX<br />
s 90663 INFLUENZA VACCINE PANDEMIC FORMULATION H1N1 BR XXX<br />
l 90664 INFLUENZA VACCINE PANDEMIC LIVE INTRANASAL USE BR XXX<br />
# 90665 LYME DISEASE VACCINE ADULT IM BR XXX<br />
l 90666 INFLUENZA VACCINE PANDEMIC PRSV FREE IM USE BR XXX<br />
l 90667 INFLUENZA VACCINE PANDEMIC ADJUVANT IM USE BR XXX<br />
l 90668 INFLUENZA VACCINE PANDEMIC IM USE BR XXX<br />
90669 PNEUMOCOCCAL CONJ VACCINE 7 VALENT IM 155.65 XXX<br />
s 90670 PNEUMOCOCCAL CONJ VACCINE 13 VALENT IM 201.62 XXX<br />
90675 RABIES VACCINE INTRAMUSCULAR 316.83 XXX<br />
90676 RABIES VACCINE INTRADERMAL BR XXX<br />
90680 ROTAVIRUS VACCINE PENTAVALENT 3 DOSE LIVE ORAL 86.96 XXX<br />
90681 ROTAVIRUS VACC HUMAN ATTENUATED 2 DOSE LIVE ORAL 86.96 XXX<br />
90690 TYPHOID VACCINE LIVE ORAL 44.31 XXX<br />
90691 TYPHOID VACCINE VI CAPSULAR POLYSACCHARIDE IM 97.49 XXX<br />
90692 TYPHOID VACC H-P INACTIVATED SUBQ/INTRADERMAL BR XXX<br />
90693 TYPHOID VACCINE AKD SUBQ U.S. MILITARY BR XXX<br />
90696 DTAP-IPV INACTIVATED IF ADMIN PTS AGE 4-6 YRS IM BR XXX<br />
90698 DTAP-HIB-IPV VACCINE IM 86.96 XXX<br />
90700 DTAP VACCINE < 7 YR IM 28.80 XXX<br />
90701 DIPHTHERIA TETANUS TOXOID PERTUSSIS VACCINE IM 31.57 XXX<br />
90702 DIPHTHERIA TETANUS TOXOID ADSORBED < 7 YR IM 23.82 XXX<br />
90703 TETANUS TOXOID ADSORBED INTRAMUSCULAR 44.87 XXX<br />
90704 MUMPS VIRUS VACCINE LIVE SUBCUTANEOUS 29.91 XXX<br />
90705 MEASLES VIRUS VACCINE LIVE SUBCUTANEOUS 31.02 XXX<br />
90706 RUBELLA VIRUS VACCINE LIVE SUBCUTANEOUS 31.02 XXX<br />
90707 MEASLES MUMPS RUBELLA VIRUS VACCINE LIVE SUBQ 57.61 XXX<br />
90708 MEASLES & RUBELLA VIRUS VACCINE LIVE SUBQ BR XXX<br />
90710 MEASLES MUMPS RUBELLA VARICELLA VACC LIVE SUBQ 153.98 XXX<br />
90712 POLIOVIRUS VACCINE ANY LIVE ORAL BR XXX<br />
90713 POLIOVIRUS VACCINE INACTIVATED SUBQ/IM 32.68 XXX<br />
90714 TD TOXOIDS ADSORBED PRSRV FR 7 YR + IM 30.46 XXX<br />
90715 TDAP VACCINE 7 YR + IM 65.91 XXX<br />
90716 VARICELLA VIRUS VACCINE LIVE SUBQ 84.75 XXX<br />
90717 YELLOW FEVER VACCINE LIVE SUBQ 105.79 XXX<br />
90718 TETANUS & DIPHTHERIA TOXOIDS ADSORBED 7 YR + IM 38.77 XXX<br />
90719 DIPHTHERIA TOXOID INTRAMUSCULAR BR XXX<br />
90720 DTP-HIB VACCINE INTRAMUSCULAR BR XXX<br />
90721 DTAP-HIB VACCINE INTRAMUSCULAR BR XXX<br />
90723 DTAP-HEPB-IPV VACCINE INTRAMUSCULAR 84.75 XXX<br />
90725 CHOLERA VACCINE INJECTABLE BR XXX<br />
90727 PLAGUE VACCINE INTRAMUSCULAR BR XXX<br />
90732 PNEUMOCOCCAL POLYSAC VACCINE 23-V 2 YR + SUBQ/IM 80.87 XXX<br />
90733 MENINGOCOCCAL POLYSAC VACCINE SUBCUTANEOUS 168.39 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 257
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section X: General Medicine Services<br />
MEDICINE 90281–96999, 97597–97606, 97802–97804, 98960–99091, 99143–99199, 99605–99607<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
90734 MENINGOCOCCAL CONJ VACCINE TETRAVALENT IM 109.67 XXX<br />
90735 JAPANESE ENCEPHALITIS VIRUS VACCINE SUBCUTANEOUS 166.17 XXX<br />
90736 ZOSTER SHINGLES VACCINE LIVE SUBCUTANEOUS 185.00 XXX<br />
90738 JAPANESE ENCEPHALITIS VACCINE INACTIVATED IM 76.44 XXX<br />
90740 HEPATITIS B VACCINE DIALYSIS DOSAGE 3 DOSE IM 194.42 XXX<br />
90743 HEPATITIS B VACCINE ADOLESCENT 2 DOSE IM 39.33 XXX<br />
90744 HEPATITIS B VACCINE PEDIATRIC3 DOSE IM 39.33 XXX<br />
90746 HEPATITIS B VACCINE ADULT DOSAGE INTRAMUSCULAR 97.49 XXX<br />
90747 HEPATITIS B VACCINE DIALYSIS DOSAGE 4 DOSE IM 194.42 XXX<br />
90748 HEPB-HIB VACCINE INTRAMUSCULAR 64.81 XXX<br />
90749 UNLISTED VACCINE/TOXOID BR XXX<br />
90801 PSYC DX INTERVIEW XM 250.92 XXX<br />
90802 IA PSYC DX INTERVIEW XM W/PLAY 272.52 XXX<br />
90804 IPI-OB-M/S OFFICE 20-30 MIN 103.03 XXX<br />
90805 IPI-OB-M/S OFFICE 20-30 MIN <strong>MEDICAL</strong> E/M 117.43 XXX<br />
90806 IPI-OB-M/S OFFICE 45-50 MIN 138.48 XXX<br />
90807 IPI-OB-M/S OFFICE 45-50 MIN <strong>MEDICAL</strong> E/M 162.85 XXX<br />
90808 IPI-OB-M/S OFFICE 75-80 MIN 203.84 XXX<br />
90809 IPI-OB-M/S OFFICE 75-80 MIN <strong>MEDICAL</strong> E/M 228.76 XXX<br />
90810 INDIV PSYCTX IA 20-30 MIN 106.35 XXX<br />
90811 INDIV PSYCTX IA 20-30 MIN <strong>MEDICAL</strong> E/M 132.38 XXX<br />
90812 INDIV PSYCTX IA 45-50 MIN 151.77 XXX<br />
90813 INDIV PSYCTX IA 45-50 MIN <strong>MEDICAL</strong> E/M 176.69 XXX<br />
90814 INDIV PSYCTX IA 75-80 MIN 218.79 XXX<br />
90815 INDIV PSYCTX IA 75-80 MIN <strong>MEDICAL</strong> E/M 248.70 XXX<br />
90816 IPI-OB-M/S I/P 20-30 MIN 85.85 XXX<br />
90817 IPI-OB-M/S I/P 20-30 MIN <strong>MEDICAL</strong> E/M 103.58 XXX<br />
90818 IPI-OB-M/S I/P 45-50 MIN 127.40 XXX<br />
90819 IPI-OB-M/S I/P 45-50 MIN <strong>MEDICAL</strong> E/M 148.45 XXX<br />
90821 IPI-OB-M/S I/P 75-80 MIN 188.88 XXX<br />
90822 IPI-OB-M/S I/P 75-80 MIN <strong>MEDICAL</strong> E/M 213.25 XXX<br />
90823 INDIV PSYCTX IA I/P 20-30 MIN 93.61 XXX<br />
90824 INDIV PSYCTX IA I/P 20-30 MIN <strong>MEDICAL</strong> E/M 111.89 XXX<br />
90826 INDIV PSYCTX IA I/P 45-50 MIN 136.26 XXX<br />
90827 INDIV PSYCTX IA I/P 45-50 MIN <strong>MEDICAL</strong> E/M 155.09 XXX<br />
90828 INDIV PSYCTX IA I/P 75-80 MIN 196.63 XXX<br />
90829 INDIV PSYCTX IA I/P 75-80 MIN <strong>MEDICAL</strong> E/M 219.90 XXX<br />
90845 PSYCHOALYS 129.61 XXX<br />
90846 FAM PSYCTX W/O PT PRESENT 137.37 XXX<br />
90847 FAM PSYCTX W/PT PRESENT 171.16 XXX<br />
90849 MLT-FAM GRP PSYCTX 55.39 XXX<br />
90853 GRP PSYCTX 52.07 XXX<br />
90857 IA GRP PSYCTX 59.82 XXX<br />
90862 PHARMACOLOGIC MGMT MIN <strong>MEDICAL</strong> PSYCTX 94.16 XXX<br />
90865 NARCOSYNTHESIS PSYC DX&THER PURPOSES 257.01 XXX<br />
l 90867 TRANSCRANIAL MAG STIMJ TX PLANNING BR YYY<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
258 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section X: General Medicine Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
90281–96999, 97597–97606, 97802–97804, 98960–99091, 99143–99199, 99605–99607 MEDICINE<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
l 90868 TRANSCRANIAL MAG STIMJ TX DLVR & MGMT BR YYY<br />
90870 ELECTROCONVULSIVE THER 271.96 000<br />
90875 INDIV PSYCPHYSTX BFB TRAINJ 20-30 MIN 118.53 XXX<br />
90876 INDIV PSYCPHYSTX BFB TRAINJ 45-50 MIN 175.59 XXX<br />
90880 HYPXH 163.95 XXX<br />
90882 ENVIRONMENTAL IVNTJ MGMT PURPOSES PSYC PT 129.61 XXX<br />
90885 PSYC EVAL HOSP RECORDS DX PURPOSES 80.87 XXX<br />
90887 INTERPJ/EXPLNAJ RESULTS PSYC XMS FAM 141.80 XXX<br />
90889 PREPJ REPORT PSYC STATUS 109.12 XXX<br />
90899 UNLIS PSYC SVC/PX BR XXX<br />
90901 BFB TRAINJ ANY MODALITY 59.82 000<br />
90911 BFB TRAINJ PRNL MUSC 142.35 000<br />
90935 HEMO PX W/1 PHYS EVAL 121.86 000<br />
90937 HEMO REPEATED EVAL +-REVJ DIAL RX 173.92 000<br />
90940 HEMO ACCESS FLO STD 94.72 XXX<br />
90940 26 HEMO ACCESS FLO STD 37.67 XXX<br />
90940 TC HEMO ACCESS FLO STD 57.05 XXX<br />
90945 DIAL OTH/THN HEMO 1 PHYS EVAL 134.60 000<br />
90947 DIAL OTH/THN HEMO REPEATED PHYS EVALS 203.84 000<br />
90951 ESRD RELATED SVC MONTHLY VISITS 1557.57 XXX<br />
90952 ESRD RELATED SVC MONTHLY VISITS 1045.21 XXX<br />
90958 ESRD RELATED SVC MONTHLY 12-19 YR OLD 2/3 VISITS 707.88 XXX<br />
90959 ESRD RELATED SVC MONTHLY 12-19 YR OLD 1 VISIT 471.37 XXX<br />
90960 ESRD RELATED SVC MONTHLY 20&> YR OLD 4/> VISITS 464.72 XXX<br />
90961 ESRD RELATED SVC MONTHLY 20&> YR OLD 2/3 VISITS 382.19 XXX<br />
90962 ESRD RELATED SVC MONTHLY 20&> YR OLD 1 VISIT 285.81 XXX<br />
90963 ESRD SVC HOME DIALYSIS FULL MONTH
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section X: General Medicine Services<br />
MEDICINE 90281–96999, 97597–97606, 97802–97804, 98960–99091, 99143–99199, 99605–99607<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
l + 91013 ESOPHGL MOTILITY STD W/I&R STIM/PERFUSION 37.67 ZZZ<br />
l + 91013 26 ESOPHGL MOTILITY STD W/I&R STIM/PERFUSION 16.06 ZZZ<br />
l + 91013 TC ESOPHGL MOTILITY STD W/I&R STIM/PERFUSION 21.61 ZZZ<br />
91020 GSTR MOTILITY STD 386.62 000<br />
91020 26 GSTR MOTILITY STD 125.74 000<br />
91020 TC GSTR MOTILITY STD 260.88 000<br />
91022 DUOL MOTILITY STD 298.55 000<br />
91022 26 DUOL MOTILITY STD 127.40 000<br />
91022 TC DUOL MOTILITY STD 171.15 000<br />
91030 ESOPH ACID PRFJ TST ESOPHAGITIS 229.87 000<br />
91030 26 ESOPH ACID PRFJ TST ESOPHAGITIS 80.87 000<br />
91030 TC ESOPH ACID PRFJ TST ESOPHAGITIS 149.00 000<br />
91034 ESOPH G-ESOP RFLX NCATH ELTRD PLMT 322.37 000<br />
91034 26 ESOPH G-ESOP RFLX NCATH ELTRD PLMT 84.19 000<br />
91034 TC ESOPH G-ESOP RFLX NCATH ELTRD PLMT 238.18 000<br />
91035 ESOPH G-ESOP RFLX TLMTR ELTRD PLMT 793.18 000<br />
91035 26 ESOPH G-ESOP RFLX TLMTR ELTRD PLMT 139.03 000<br />
91035 TC ESOPH G-ESOP RFLX TLMTR ELTRD PLMT 654.15 000<br />
91037 ESOPHGL FUNCJ G-ESOP RFLX IMPD ELTRD PLMT 266.98 000<br />
91037 26 ESOPHGL FUNCJ G-ESOP RFLX IMPD ELTRD PLMT 86.96 000<br />
91037 TC ESOPHGL FUNCJ G-ESOP RFLX IMPD ELTRD PLMT 180.02 000<br />
91038 ESOPHGL FUNCJ G-ESOP RFLX IMPD ELTRD PROLNG 487.43 000<br />
91038 26 ESOPHGL FUNCJ G-ESOP RFLX IMPD ELTRD PROLNG 96.93 000<br />
91038 TC ESOPHGL FUNCJ G-ESOP RFLX IMPD ELTRD PROLNG 390.50 000<br />
91040 ESOPHGL BALO DISTENSION PROVOCATION STD 558.89 000<br />
91040 26 ESOPHGL BALO DISTENSION PROVOCATION STD 81.42 000<br />
91040 TC ESOPHGL BALO DISTENSION PROVOCATION STD 477.47 000<br />
91065 BRTH HYDROGEN TST 129.61 000<br />
91065 26 BRTH HYDROGEN TST 17.17 000<br />
91065 TC BRTH HYDROGEN TST 112.44 000<br />
91110 GI TRC IMG INTRAL ESOPH THRU ILE PHYS I&R 1499.96 XXX<br />
91110 26 GI TRC IMG INTRAL ESOPH THRU ILE PHYS I&R 321.26 XXX<br />
91110 TC GI TRC IMG INTRAL ESOPH THRU ILE PHYS I&R 1178.70 XXX<br />
91111 GASTROINTESTINAL TRACT IMAGING ESOPHAGUS 1200.86 XXX<br />
91111 26 GASTROINTESTINAL TRACT IMAGING ESOPHAGUS 88.62 XXX<br />
91111 TC GASTROINTESTINAL TRACT IMAGING ESOPHAGUS 1112.24 XXX<br />
l 91117 COLON MOTILITY STDY MIN 6 HR CONT RECORD W/I&R 232.08 000<br />
91120 RCT SENSATION TONE&COMPLIANCE 627.57 XXX<br />
91120 26 RCT SENSATION TONE&COMPLIANCE 81.42 XXX<br />
91120 TC RCT SENSATION TONE&COMPLIANCE 546.15 XXX<br />
91122 ANRCT MANO 372.77 000<br />
91122 26 ANRCT MANO 146.23 000<br />
91122 TC ANRCT MANO 226.54 000<br />
91132 EGG DX TC 230.42 XXX<br />
91132 26 EGG DX TC 45.97 XXX<br />
91132 TC EGG DX TC 184.45 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
260 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section X: General Medicine Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
90281–96999, 97597–97606, 97802–97804, 98960–99091, 99143–99199, 99605–99607 MEDICINE<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
91133 EGG DX TC PROVOCATIVE TSTG 281.38 XXX<br />
91133 26 EGG DX TC PROVOCATIVE TSTG 59.27 XXX<br />
91133 TC EGG DX TC PROVOCATIVE TSTG 222.11 XXX<br />
91299 UNLIS DX GASTROENTEROLOGY BR XXX<br />
92002 OPH <strong>MEDICAL</strong> XM&EVAL INTRM NEW PT 122.97 XXX<br />
92004 OPH <strong>MEDICAL</strong> XM&EVAL COMPRE NEW PT 1+ VST 228.21 XXX<br />
92012 OPH <strong>MEDICAL</strong> XM&EVAL INTRM EST PT 130.17 XXX<br />
92014 OPH <strong>MEDICAL</strong> XM&EVAL COMPRE EST PT 1+ VST 188.88 XXX<br />
92015 DETER REFRACTIVE STATE 43.76 XXX<br />
92018 OPH XM&EVAL ANES +-MNPJ GLOBE COMPL 225.99 XXX<br />
92019 OPH XM&EVAL ANES +-MNPJ GLOBE LMTD 109.12 XXX<br />
92020 GONIOSCOPY SPX 42.65 XXX<br />
92025 COMPUTERIZED CORNEAL TOPOGRAPHY UNI/BI 57.05 XXX<br />
92025 26 COMPUTERIZED CORNEAL TOPOGRAPHY UNI/BI 31.02 XXX<br />
92025 TC COMPUTERIZED CORNEAL TOPOGRAPHY UNI/BI 26.03 XXX<br />
92060 SENSIMOTR XM W/MLT MEAS OC DEVIJ W/I&R SPX 98.59 XXX<br />
92060 26 SENSIMOTR XM W/MLT MEAS OC DEVIJ W/I&R SPX 60.93 XXX<br />
92060 TC SENSIMOTR XM W/MLT MEAS OC DEVIJ W/I&R SPX 37.66 XXX<br />
92065 ORTHOPTIC&/PLEOPTIC TRAINJ 79.21 XXX<br />
92065 26 ORTHOPTIC&/PLEOPTIC TRAINJ 28.80 XXX<br />
92065 TC ORTHOPTIC&/PLEOPTIC TRAINJ 50.41 XXX<br />
92070 FITG C-LENS TX DISEASE SUPPLY LENS 109.12 XXX<br />
92081 VIS FLD XM UNI/BI I&R LMTD XM 79.21 XXX<br />
92081 26 VIS FLD XM UNI/BI I&R LMTD XM 27.14 XXX<br />
92081 TC VIS FLD XM UNI/BI I&R LMTD XM 52.07 XXX<br />
92082 VIS FLD XM UNI/BI I&R INTRM XM 110.23 XXX<br />
92082 26 VIS FLD XM UNI/BI I&R INTRM XM 36.00 XXX<br />
92082 TC VIS FLD XM UNI/BI I&R INTRM XM 74.23 XXX<br />
92083 VIS FLD XM UNI/BI I&R EXTND XM 137.37 XXX<br />
92083 26 VIS FLD XM UNI/BI I&R EXTND XM 44.87 XXX<br />
92083 TC VIS FLD XM UNI/BI I&R EXTND XM 92.50 XXX<br />
92100 SRL TNMTRY SPX MLT MEAS IO PRESS 147.89 XXX<br />
92120 TNGRPHY I&R REC INDENTAJ TNMTR SUCJ 120.75 XXX<br />
92130 TNGRPHY WATER PROVOCATION 134.04 XXX<br />
l 92132 CMPTR OPHTHALMIC DX IMG ANT SEGMT W/I&R UNI/BI 59.27 XXX<br />
l 92132 26 CMPTR OPHTHALMIC DX IMG ANT SEGMT W/I&R UNI/BI 34.34 XXX<br />
l 92132 TC CMPTR OPHTHALMIC DX IMG ANT SEGMT W/I&R UNI/BI 24.93 XXX<br />
l 92133 COMPUTERIZED OPHTHALMIC IMAGING OPTIC NERVE 72.56 XXX<br />
l 92133 26 COMPUTERIZED OPHTHALMIC IMAGING OPTIC NERVE 47.64 XXX<br />
l 92133 TC COMPUTERIZED OPHTHALMIC IMAGING OPTIC NERVE 24.92 XXX<br />
l 92134 COMPUTERIZED OPHTHALMIC IMAGING RETINA 72.56 XXX<br />
l 92134 26 COMPUTERIZED OPHTHALMIC IMAGING RETINA 47.64 XXX<br />
l 92134 TC COMPUTERIZED OPHTHALMIC IMAGING RETINA 24.92 XXX<br />
92136 OPH BMTRY PRTL COHER INTRFRMTRY IO LENS PWR CAL 135.15 XXX<br />
92136 26 OPH BMTRY PRTL COHER INTRFRMTRY IO LENS PWR CAL 48.19 XXX<br />
92136 TC OPH BMTRY PRTL COHER INTRFRMTRY IO LENS PWR CAL 86.96 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 261
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section X: General Medicine Services<br />
MEDICINE 90281–96999, 97597–97606, 97802–97804, 98960–99091, 99143–99199, 99605–99607<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
92140 PROVOCATIVE TSTS GLC I&R W/O TNGRPHY 95.82 XXX<br />
92225 OPSCPY EXTND RTA DRAWING I&R 1ST 41.54 XXX<br />
92226 OPSCPY EXTND RTA DRAWING I&R SBSQ 37.11 XXX<br />
l 92227 REMOTE IMG DX RETINL DIS W/ALYS & REPORT UNI/BI 18.83 XXX<br />
l 92228 REMOTE IMG MGT RETINL DIS W/I&R UNI/BI 48.74 XXX<br />
l 92228 26 REMOTE IMG MGT RETINL DIS W/I&R UNI/BI 28.25 XXX<br />
l 92228 TC REMOTE IMG MGT RETINL DIS W/I&R UNI/BI 20.49 XXX<br />
92230 FLUORESCEIN ANGIOSCOPY I&R 93.61 XXX<br />
92235 FLUORESCEIN ANGRPH I&R 212.70 XXX<br />
92235 26 FLUORESCEIN ANGRPH I&R 73.67 XXX<br />
92235 TC FLUORESCEIN ANGRPH I&R 139.03 XXX<br />
92240 INDOCYA9-GREEN ANGRPH I&R 388.28 XXX<br />
92240 26 INDOCYA9-GREEN ANGRPH I&R 99.15 XXX<br />
92240 TC INDOCYA9-GREEN ANGRPH I&R 289.13 XXX<br />
92250 FUNDUS PHTGRPHY I&R 119.64 XXX<br />
92250 26 FUNDUS PHTGRPHY I&R 37.67 XXX<br />
92250 TC FUNDUS PHTGRPHY I&R 81.97 XXX<br />
92260 OPHTHALMODYNAMOMETRY 28.80 XXX<br />
92265 NDL OCULOEMG 1+ EO MUSC 1/OU I&R 127.40 XXX<br />
92265 26 NDL OCULOEMG 1+ EO MUSC 1/OU I&R 69.79 XXX<br />
92265 TC NDL OCULOEMG 1+ EO MUSC 1/OU I&R 57.61 XXX<br />
92270 ELECTRO-OCULOGRAPY I&R 142.35 XXX<br />
92270 26 ELECTRO-OCULOGRAPY I&R 66.47 XXX<br />
92270 TC ELECTRO-OCULOGRAPY I&R 75.88 XXX<br />
92275 ELECTRORETINOGRAPY I&R 230.98 XXX<br />
92275 26 ELECTRORETINOGRAPY I&R 90.84 XXX<br />
92275 TC ELECTRORETINOGRAPY I&R 140.14 XXX<br />
92283 COLOR VIS XM EXTND ANOMALOSCOPE/EQUIV 79.21 XXX<br />
92283 26 COLOR VIS XM EXTND ANOMALOSCOPE/EQUIV 14.40 XXX<br />
92283 TC COLOR VIS XM EXTND ANOMALOSCOPE/EQUIV 64.81 XXX<br />
92284 DARK ADAPTATION XM I&R 96.38 XXX<br />
92284 26 DARK ADAPTATION XM I&R 19.39 XXX<br />
92284 TC DARK ADAPTATION XM I&R 76.99 XXX<br />
92285 XTRNL OC PHTGRPHY I&R PROGRESS 45.42 XXX<br />
92285 26 XTRNL OC PHTGRPHY I&R PROGRESS 6.65 XXX<br />
92285 TC XTRNL OC PHTGRPHY I&R PROGRESS 38.77 XXX<br />
92286 SPEC ANT SGM PHTGRPHY I&R SPECLR ENDOTHELIAL 193.31 XXX<br />
92286 26 SPEC ANT SGM PHTGRPHY I&R SPECLR ENDOTHELIAL 57.05 XXX<br />
92286 TC SPEC ANT SGM PHTGRPHY I&R SPECLR ENDOTHELIAL 136.26 XXX<br />
92287 SPEC ANT SGM PHTGRPHY I&R FLUORESCEIN ANGRPH 189.43 XXX<br />
92287 26 SPEC ANT SGM PHTGRPHY I&R FLUORESCEIN ANGRPH 49.30 XXX<br />
92287 TC SPEC ANT SGM PHTGRPHY I&R FLUORESCEIN ANGRPH 140.13 XXX<br />
92310 RX&FITG C-LENS SUPVJ CRNL LENS OU XCPT APHK 152.32 XXX<br />
92311 RX&FITG C-LENS SUPVJ CRNL LENS APHK 1O 156.75 XXX<br />
92312 RX&FITG C-LENS SUPVJ CRNL LENS APHK OU 177.80 XXX<br />
92313 RX&FITG C-LENS SUPVJ CRNLSCLRL LENS 153.98 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
262 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section X: General Medicine Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
90281–96999, 97597–97606, 97802–97804, 98960–99091, 99143–99199, 99605–99607 MEDICINE<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
92314 RX C-LENS SUPVJ&DIRION FITG TECH OU XCPT APHK 123.52 XXX<br />
92315 RX C-LENS SUPVJ FITG TECH CRNL APHK 1O 114.10 XXX<br />
92316 RX C-LENS SUPVJ FITG TECH CRNL APHK OU 152.88 XXX<br />
92317 RX C-LENS SUPVJ FITG TECH CRNLSCLRL 113.55 XXX<br />
92325 MODIFICAJ C-LENS SPX SUPVJ ADAPTATION 54.84 XXX<br />
92326 RPLCMT C-LENS 58.16 XXX<br />
92340 FITG SPECTLS XCPT APHK MONOFOCAL 57.61 XXX<br />
92341 FITG SPECTLS XCPT APHK BIFOCAL 65.91 XXX<br />
92342 FITG SPECTLS XCPT APHK MLTFCL 71.45 XXX<br />
92352 FITG SPECTL PROSTH APHK MONOFOCAL 65.36 XXX<br />
92353 FITG SPECTL PROSTH APHK MLTFCL 75.33 XXX<br />
92354 FITG SPECTL MOUNTED LW VIS AID 1 ELMNT 92.50 XXX<br />
92355 FITG SPECTL MOUNTED LW VIS AID TLSCP 64.81 XXX<br />
92358 PROSTH APHK TEMP DISPOSABLE/LOAN MATRLS 23.26 XXX<br />
92370 RPR&REFITG SPECTLS XCPT APHK 50.40 XXX<br />
92371 RPR&REFITG SPECTLS SPECTL PROSTH APHK 21.05 XXX<br />
92499 UNLIS OPH SVC BR XXX<br />
92502 OTOLARYNGOLOGIC XM ANES 157.86 000<br />
92504 BINOC MIC 49.30 XXX<br />
92506 EVAL SP LANG VOICE COMUNICAJ&/AUD 272.52 XXX<br />
92507 TX SP LANG COMUNICAJ PCX DISORDER INDIV 134.04 XXX<br />
92508 TX SP LANG COMUNICAJ PCX DISORDER 2/> 43.76 XXX<br />
92511 NASOPHARYNGOSCOPY W/ENDOSCOPE SPX 260.89 XXX<br />
92512 NSL FUNCJ STD 100.26 XXX<br />
92516 FACIAL NRV FUNCJ STD 110.78 XXX<br />
92520 LARYN FUNCJ STD 110.23 XXX<br />
92526 TX SWLNG DYSF&/ORAL FUNCJ <strong>FEE</strong>DING 153.43 XXX<br />
92531 SPON NYSTAGMUS GAZE 29.36 XXX<br />
92532 POSAL NYSTAGMUS TST 33.79 XXX<br />
92533 CALORIC VSTBLR TST EA IRRIGATION 48.74 XXX<br />
92534 OKN TST 36.56 XXX<br />
92540 VSTBLR FUNCJ NYSTAG FOVL&PERPH STIMJ OSCIL TRKG 158.42 XXX<br />
92540 26 VSTBLR FUNCJ NYSTAG FOVL&PERPH STIMJ OSCIL TRKG 127.95 XXX<br />
92540 TC VSTBLR FUNCJ NYSTAG FOVL&PERPH STIMJ OSCIL TRKG 30.47 XXX<br />
92541 SPON NYSTAGMUS TST 74.22 XXX<br />
92541 26 SPON NYSTAGMUS TST 33.23 XXX<br />
92541 TC SPON NYSTAGMUS TST 40.99 XXX<br />
92542 POSAL NYSTAGMUS TST 73.67 XXX<br />
92542 26 POSAL NYSTAGMUS TST 27.70 XXX<br />
92542 TC POSAL NYSTAGMUS TST 45.97 XXX<br />
92543 CALORIC VSTBLR TST EA IRRIGATION REC 36.56 XXX<br />
92543 26 CALORIC VSTBLR TST EA IRRIGATION REC 8.86 XXX<br />
92543 TC CALORIC VSTBLR TST EA IRRIGATION REC 27.70 XXX<br />
92544 OKN TST BIDIREC FOVEAL/PRPH STIMJ REC 60.38 XXX<br />
92544 26 OKN TST BIDIREC FOVEAL/PRPH STIMJ REC 21.60 XXX<br />
92544 TC OKN TST BIDIREC FOVEAL/PRPH STIMJ REC 38.78 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 263
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section X: General Medicine Services<br />
MEDICINE 90281–96999, 97597–97606, 97802–97804, 98960–99091, 99143–99199, 99605–99607<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
92545 OSCILLATING TRACKING TST W/REC 56.50 XXX<br />
92545 26 OSCILLATING TRACKING TST W/REC 19.39 XXX<br />
92545 TC OSCILLATING TRACKING TST W/REC 37.11 XXX<br />
92546 SINUSOIDAL VER AXIS ROTATIONAL TSTG 153.43 XXX<br />
92546 26 SINUSOIDAL VER AXIS ROTATIONAL TSTG 23.82 XXX<br />
92546 TC SINUSOIDAL VER AXIS ROTATIONAL TSTG 129.61 XXX<br />
+ 92547 USE VER ELTRDS 8.31 ZZZ<br />
+ 92547 26 USE VER ELTRDS 1.66 ZZZ<br />
+ 92547 TC USE VER ELTRDS 6.65 ZZZ<br />
92548 CPTRIZED DYNAMIC POSTUROGRAPY 166.72 XXX<br />
92548 26 CPTRIZED DYNAMIC POSTUROGRAPY 41.54 XXX<br />
92548 TC CPTRIZED DYNAMIC POSTUROGRAPY 125.18 XXX<br />
92550 TYMPANOMETRY AND REFLEX THRESHOLD MEASUREMENTS 33.79 XXX<br />
92551 SCR TST PURE TONE AIR ONLY 18.83 XXX<br />
92552 PURE TONE AUDIOMTRY AIR ONLY 41.54 XXX<br />
92553 PURE TONE AUDIOMTRY AIR&B1 52.62 XXX<br />
92555 SP AUDIOMTRY THRESHOLD 30.46 XXX<br />
92556 SP AUDIOMTRY THRESHOLD SP RECOGNIJ 47.08 XXX<br />
92557 COMPRE AUDIOMTRY THRESHOLD EVAL SP RECOGNIJ 65.91 XXX<br />
92559 AUDIOMETRIC TSTG GRPS 46.53 XXX<br />
92560 BEKESY AUDIOMTRY SCR 32.68 XXX<br />
92561 BEKESY AUDIOMTRY DX 53.17 XXX<br />
92562 LOUDNESS BALANCE BINAURAL/MONAURAL 51.51 XXX<br />
92563 TONE DECAY 40.43 XXX<br />
92564 SHORT INCREMENT SENSITIVITY INDEX 36.56 XXX<br />
92565 STENGER TST PURE TONE 21.05 XXX<br />
92567 TYMPANOMETRY 24.93 XXX<br />
92568 ACOUS RFLX THRESHOLD 27.14 XXX<br />
92570 ACOUSTIC IMMIT TEST TYMPANOM/ACOUST REFLX/DECAY 52.07 XXX<br />
92571 FILTERED SP 32.68 XXX<br />
92572 STAGGERED SPONDAIC WORD 51.51 XXX<br />
92575 SENSORINEURAL ACUITY LVL 80.32 XXX<br />
92576 SYNTH SENTENCE ID 43.20 XXX<br />
92577 STENGER SP 26.59 XXX<br />
92579 VIS RNFCMT AUDIOMTRY 70.90 XXX<br />
92582 CONDITIONING PLAY AUDIOMTRY 83.64 XXX<br />
92583 SELECT PICTURE AUDIOMTRY 58.16 XXX<br />
92584 ELECTROCOCHLEOGRAPY 108.56 XXX<br />
92585 AEP ERA&/TSTG CNS COMPRE 184.45 XXX<br />
92585 26 AEP ERA&/TSTG CNS COMPRE 41.54 XXX<br />
92585 TC AEP ERA&/TSTG CNS COMPRE 142.91 XXX<br />
92586 AEP ERA&/TSTG CNS LMTD 114.66 XXX<br />
92587 EVOKED OTOACOUS EMIJS LMTD 60.38 XXX<br />
92587 26 EVOKED OTOACOUS EMIJS LMTD 11.63 XXX<br />
92587 TC EVOKED OTOACOUS EMIJS LMTD 48.75 XXX<br />
92588 EVOKED OTOACOUS EMIJS COMPRE/DX EVAL 108.01 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
264 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section X: General Medicine Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
90281–96999, 97597–97606, 97802–97804, 98960–99091, 99143–99199, 99605–99607 MEDICINE<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
92588 26 EVOKED OTOACOUS EMIJS COMPRE/DX EVAL 30.46 XXX<br />
92588 TC EVOKED OTOACOUS EMIJS COMPRE/DX EVAL 77.55 XXX<br />
92590 HEARING AID XM&SELECTION MONAURAL 85.85 XXX<br />
92591 HEARING AID XM&SELECTION BINAURAL 108.56 XXX<br />
92592 HEARING AID CHECK MONAURAL 34.34 XXX<br />
92593 HEARING AID CHECK BINAURAL 56.50 XXX<br />
92594 ELECTROACOUS EVAL HEARING AID MONAURAL 32.68 XXX<br />
92595 ELECTROACOUS EVAL HEARING AID BINAURAL 69.79 XXX<br />
92596 EAR PROTECTOR ATTENUATION MEAS 64.81 XXX<br />
92597 EVAL&/FITG VOICE PROSTC DEV SUPPLEMENT O-SP 159.52 XXX<br />
92601 ALYS COCHLEAR IMPLT PT SBSQ REPRGRMG 137.37 XXX<br />
92605 EVAL RX N-SP-GENRATJ AUGMNT COMUNICAJ DEV BR XXX<br />
92606 THER SVC N-SP-GENRATJ DEV PRGRMG&MODIFICAJ 132.94 XXX<br />
92607 RX SP-GENRATJ AUGMNT&COMUNICAJ DEV 1ST HR 287.47 XXX<br />
+ 92608 RX SP-GENRATJ AUGMNT&COMUNICAJ DEV EA 30 MIN 85.30 ZZZ<br />
92609 THER SP-GENRATJ DEV PRGRMG&MODIFICAJ 188.88 XXX<br />
92610 EVAL ORAL&PHARYNGEAL SWLNG FUNCJ 171.16 XXX<br />
92611 MOTION FLUOR EVAL SWLNG FUNCJ C/V REC 185.00 XXX<br />
92612 FLX FIBOPT NDSC EVAL SWLNG C/V REC 271.96 XXX<br />
92613 FLX FIBOPT NDSC EVAL SWLNG C/V REC PHYS I&R 62.59 XXX<br />
92614 FLX FIBOPT NDSC EVAL LARYN SENS C/V REC 242.05 XXX<br />
92615 FLX FIBOPT NDSC EVAL LARYN SENS PHYS I&R 55.39 XXX<br />
92616 FLX FIBOPT NDSC EVAL SWLNG&LARYN SENS C/V REC 327.91 XXX<br />
92617 FLX FIBOPT NDSC EVAL SWLNG&LARYN SENS PHYS I&R 68.68 XXX<br />
92620 EVAL CTR AUD FUNCJ W/REPRT 1ST 60 MIN 134.60 XXX<br />
92621 EVAL CTR AUD FUNCJ W/REPRT EA 15 MIN 31.02 ZZZ<br />
92625 ASSMT TINNITUS 103.03 XXX<br />
92626 EVAL AUD RHAB STATUS 1ST HR 136.81 XXX<br />
+ 92627 EVAL AUD RHAB STATUS EA 15 MIN 33.23 ZZZ<br />
92630 AUD RHAB PRELNG HEARING LOSS BR XXX<br />
92633 AUD RHAB POST-LNGL HEARING LOSS BR XXX<br />
92640 ANALYSIS W/PRGRMG AUD BRAINSTEM IMPLANT PR HR 161.18 XXX<br />
92700 UNLIS OTORHINOLARYNGOLOGICAL SVC BR XXX<br />
92950 CARDIOPULM RESUSCITATION 458.08 000<br />
K 92953 TEMP TC PACG 18.28 000<br />
K 92960 CARDIOVERSION ELECTIVE ARRHYT XTRNL 392.72 000<br />
K 92961 CARDIOVERSION ELECTIVE ARRHYT INT SPX 415.43 000<br />
92970 CARDIOASSIST-METH CRC ASSIST INT 291.91 000<br />
92971 CARDIOASSIST-METH CRC ASSIST XTRNL 161.74 000<br />
+ K 92973 PRQ TRLUML C THRMBC 311.85 ZZZ<br />
+ K 92974 TCAT PLMT RADJ DLVR DEV SBSQ C IV BRACHYTX 285.81 ZZZ<br />
K 92975 THROMBOLSS C INTRAC NFS SLCTV C ANGRPH 689.05 000<br />
92977 THROMBOLSS C IV NFS 150.66 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 265
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section X: General Medicine Services<br />
MEDICINE 90281–96999, 97597–97606, 97802–97804, 98960–99091, 99143–99199, 99605–99607<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
+ K 92978 IV US C VSL DX&/THER 1ST VSL 446.44 ZZZ<br />
+ K 92978 26 IV US C VSL DX&/THER 1ST VSL 156.20 ZZZ<br />
+ K 92978 TC IV US C VSL DX&/THER 1ST VSL 290.24 ZZZ<br />
+ K 92979 IV US C VSL DX&/THER EA VSL 271.96 ZZZ<br />
+ K 92979 26 IV US C VSL DX&/THER EA VSL 125.18 ZZZ<br />
+ K 92979 TC IV US C VSL DX&/THER EA VSL 146.78 ZZZ<br />
K 92980 TCAT PLMT AN INTRAC STENT PRQ 1 VSL 1423.52 000<br />
+ K 92981 TCAT PLMT INTRAC STENT PRQ EA VSL 395.48 ZZZ<br />
K 92982 PRQ TRLUML C BALO ANGIOP 1 VSL 1054.63 000<br />
+ K 92984 PRQ TRLUML C BALO ANGIOP EA VSL 281.94 ZZZ<br />
K 92986 PRQ BALO VLVP AORTIC VALVE 2349.09 090<br />
K 92987 PRQ BALO VLVP MITRAL VALVE 2424.42 090<br />
92990 PRQ BALO VLVP PULM VALVE 1886.58 090<br />
92992 ATR SEPTECT/SEPTOST TRANSVNS BALO 1702.69 090<br />
92993 ATR SEPTECT/SEPTOST BLADE METH 1346.53 090<br />
K 92995 PRQ TRLUML C ATHRC 1 VSL 1161.53 000<br />
+ K 92996 PRQ TRLUML C ATHRC EA VSL 310.74 ZZZ<br />
92997 PRQ TRLUML P-ART BALO ANGIOP 1 VSL 1118.88 000<br />
+ 92998 PRQ TRLUML P-ART BALO ANGIOP EA VSL 562.76 ZZZ<br />
93000 ECG ROUTINE ECG W/LEAST 12 LDS W/I&R 32.13 XXX<br />
93005 ECG ROUTINE ECG W/LEAST 12 LDS TRCG ONLY W/O I&R 17.72 XXX<br />
93010 ECG ROUTINE ECG W/LEAST 12 LDS I&R ONLY 14.40 XXX<br />
93015 CV STRS TST XERS&/OR RX CONT ECG PHYS SI&R 150.66 XXX<br />
93016 CV STRS TST XERS&/OR RX CONT ECG PHYS SUPVJ 37.67 XXX<br />
93017 CV STRS TST XERS&/OR RX CONT ECG TRCG ONLY 88.07 XXX<br />
93018 CV STRS TST XERS&/OR RX CONT ECG I&R ONLY 24.93 XXX<br />
93024 ERGONOVINE PROVOCATION TST 190.54 XXX<br />
93024 26 ERGONOVINE PROVOCATION TST 98.04 XXX<br />
93024 TC ERGONOVINE PROVOCATION TST 92.50 XXX<br />
93025 MICROVOLT T-WAVE ASSESS VENTRICULAR ARRHYTHMIAS 314.62 XXX<br />
93025 26 MICROVOLT T-WAVE ASSESS VENTRICULAR ARRHYTHMIAS 63.70 XXX<br />
93025 TC MICROVOLT T-WAVE ASSESS VENTRICULAR ARRHYTHMIAS 250.92 XXX<br />
93040 RHYTHM ECG 1-3 LDS W/I&R 21.60 XXX<br />
93041 RHYTHM ECG 1-3 LDS TRCG ONLY W/O I&R 9.42 XXX<br />
93042 RHYTHM ECG 1-3 LDS I&R ONLY 12.19 XXX<br />
s 93224 XTRNL ECG UP TO 48 HR RECORD SCAN STOR W/PHY R&I 157.86 XXX<br />
s 93225 XTRNL ECG UP TO 48 HR RECORDING 45.97 XXX<br />
s 93226 EXTERNAL ECG SCANNING ANALYSIS REPORT 67.58 XXX<br />
s 93227 XTRNL ECG CONTINUOUS RHYTHM PHYS REVIEW&INTERPJ 44.31 XXX<br />
s 93228 XTRNL MOBILE CV TELEMETRY W/PHYS R&I W/REPORT 42.10 XXX<br />
s 93229 XTRNL MOBILE CV TELEMETRY W/TECHNICAL SUPPORT 1110.57 XXX<br />
s 93268 XTRNL PT ACTIV ECG TRANSMIS PHYS R&I 30 DAYS 408.78 XXX<br />
s 93270 XTRNL PT ACTIVATED ECG RECORD MONITOR 30 DAYS 24.93 XXX<br />
s 93271 XTRNL PT ACTIVATED ECG REC DWNLD 30 DAYS 341.76 XXX<br />
s 93272 XTRNL PT ACTIVTD ECG DWNLD 30 DAYS PHYS R&I 42.10 XXX<br />
93278 SAECG +-ECG 57.05 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
266 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section X: General Medicine Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
90281–96999, 97597–97606, 97802–97804, 98960–99091, 99143–99199, 99605–99607 MEDICINE<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
93278 26 SAECG +-ECG 20.49 XXX<br />
93278 TC SAECG +-ECG 36.56 XXX<br />
93279 PROGRAM EVAL IMPLANTABLE IN PRSN 1 LD PACEMAKER 85.85 XXX<br />
93279 26 PROGRAM EVAL IMPLANTABLE IN PRSN 1 LD PACEMAKER 55.94 XXX<br />
93279 TC PROGRAM EVAL IMPLANTABLE IN PRSN 1 LD PACEMAKER 29.91 XXX<br />
93280 PROGRAM EVAL IMPLANTABLE IN PERSN DUAL LD PACER 101.36 XXX<br />
93280 26 PROGRAM EVAL IMPLANTABLE IN PERSN DUAL LD PACER 66.47 XXX<br />
93280 TC PROGRAM EVAL IMPLANTABLE IN PERSN DUAL LD PACER 34.89 XXX<br />
93281 PROGRAM EVAL IMPLANTABLE IN PRSN MULTI LD PACER 117.98 XXX<br />
93281 26 PROGRAM EVAL IMPLANTABLE IN PRSN MULTI LD PACER 77.55 XXX<br />
93281 TC PROGRAM EVAL IMPLANTABLE IN PRSN MULTI LD PACER 40.43 XXX<br />
93282 PROGRAM EVAL IMPLANTABLE IN PERSN 1 LD CARD/DFB 108.56 XXX<br />
93282 26 PROGRAM EVAL IMPLANTABLE IN PERSN 1 LD CARD/DFB 72.56 XXX<br />
93282 TC PROGRAM EVAL IMPLANTABLE IN PERSN 1 LD CARD/DFB 36.00 XXX<br />
93283 PROGRM EVAL IMPLANTABLE IN PRSN DUAL L CARD/DFB 139.03 XXX<br />
93283 26 PROGRM EVAL IMPLANTABLE IN PRSN DUAL L CARD/DFB 97.49 XXX<br />
93283 TC PROGRM EVAL IMPLANTABLE IN PRSN DUAL L CARD/DFB 41.54 XXX<br />
93284 PROGRM EVAL IMPLANTABLE IN PRSN MLT LD CARD/DFB 154.54 XXX<br />
93284 26 PROGRM EVAL IMPLANTABLE IN PRSN MLT LD CARD/DFB 107.46 XXX<br />
93284 TC PROGRM EVAL IMPLANTABLE IN PRSN MLT LD CARD/DFB 47.08 XXX<br />
93285 PROGRAM EVAL IMPLANTABLE DEV IN PRSN ILR SYSTEM 72.01 XXX<br />
93285 26 PROGRAM EVAL IMPLANTABLE DEV IN PRSN ILR SYSTEM 44.31 XXX<br />
93285 TC PROGRAM EVAL IMPLANTABLE DEV IN PRSN ILR SYSTEM 27.70 XXX<br />
93286 PERI-PX EVAL&PROGRAM IN PRSN PACEMAKER SYSTEM 43.20 XXX<br />
93286 26 PERI-PX EVAL&PROGRAM IN PRSN PACEMAKER SYSTEM 23.82 XXX<br />
93286 TC PERI-PX EVAL&PROGRAM IN PRSN PACEMAKER SYSTEM 19.38 XXX<br />
93287 PERI-PX EVAL&PROGRAM CARDIOVERTER/DEFIBRILLATOR 56.50 XXX<br />
93287 26 PERI-PX EVAL&PROGRAM CARDIOVERTER/DEFIBRILLATOR 35.45 XXX<br />
93287 TC PERI-PX EVAL&PROGRAM CARDIOVERTER/DEFIBRILLATOR 21.05 XXX<br />
93288 INTERROGATION EVAL IN PERSON 1/DUAL/MLT LEAD PM 64.81 XXX<br />
93288 26 INTERROGATION EVAL IN PERSON 1/DUAL/MLT LEAD PM 36.56 XXX<br />
93288 TC INTERROGATION EVAL IN PERSON 1/DUAL/MLT LEAD PM 28.25 XXX<br />
93289 INTERROGATION EVAL F2F 1/DUAL/MLT LEADS CVDFB 111.33 XXX<br />
93289 26 INTERROGATION EVAL F2F 1/DUAL/MLT LEADS CVDFB 76.44 XXX<br />
93289 TC INTERROGATION EVAL F2F 1/DUAL/MLT LEADS CVDFB 34.89 XXX<br />
93290 INTERROGATION EVAL F2F IMPLANTABLE CV MNTR SYS 49.85 XXX<br />
93290 26 INTERROGATION EVAL F2F IMPLANTABLE CV MNTR SYS 33.79 XXX<br />
93290 TC INTERROGATION EVAL F2F IMPLANTABLE CV MNTR SYS 16.06 XXX<br />
93291 INTERROGATION EVALUATION IN PERSON ILR SYSTEM 62.04 XXX<br />
93291 26 INTERROGATION EVALUATION IN PERSON ILR SYSTEM 36.56 XXX<br />
93291 TC INTERROGATION EVALUATION IN PERSON ILR SYSTEM 25.48 XXX<br />
93292 INTERROGATION EVAL IN PERSON WR DEFIBRILLATOR 55.94 XXX<br />
93292 26 INTERROGATION EVAL IN PERSON WR DEFIBRILLATOR 36.56 XXX<br />
93292 TC INTERROGATION EVAL IN PERSON WR DEFIBRILLATOR 19.38 XXX<br />
93293 TRANSTELEPHONIC RHYTHM STRIP PACEMAKER EVAL 91.39 XXX<br />
93293 26 TRANSTELEPHONIC RHYTHM STRIP PACEMAKER EVAL 26.03 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 267
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section X: General Medicine Services<br />
MEDICINE 90281–96999, 97597–97606, 97802–97804, 98960–99091, 99143–99199, 99605–99607<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
93293 TC TRANSTELEPHONIC RHYTHM STRIP PACEMAKER EVAL 65.36 XXX<br />
93294 INTERROGATION EVAL REMOTE
Section X: General Medicine Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
90281–96999, 97597–97606, 97802–97804, 98960–99091, 99143–99199, 99605–99607 MEDICINE<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
+ 93325 26 DOP ECHO COLOR FLO VEL MAPG 6.09 ZZZ<br />
+ 93325 TC DOP ECHO COLOR FLO VEL MAPG 52.07 ZZZ<br />
93350 ECHO TTHRC R-T 2D -+M-MODE COMPLETE REST&STRS 342.86 XXX<br />
93350 26 ECHO TTHRC R-T 2D -+M-MODE COMPLETE REST&STRS 124.07 XXX<br />
93350 TC ECHO TTHRC R-T 2D -+M-MODE COMPLETE REST&STRS 218.79 XXX<br />
93351 ECHO TTHRC R-T 2D -+M-MODE REST&STRS CONT ECG 403.79 XXX<br />
93351 26 ECHO TTHRC R-T 2D -+M-MODE REST&STRS CONT ECG 149.55 XXX<br />
93351 TC ECHO TTHRC R-T 2D -+M-MODE REST&STRS CONT ECG 254.24 XXX<br />
+ 93352 USE OF ECHO CONTRAST AGENT DURING STRESS ECHO 59.27 ZZZ<br />
l K 93451 RIGHT HEART CATH O2 SATURATION & CARDIAC OUTPUT 1244.61 000<br />
l K 93451 26 RIGHT HEART CATH O2 SATURATION & CARDIAC OUTPUT 242.05 000<br />
l K 93451 TC RIGHT HEART CATH O2 SATURATION & CARDIAC OUTPUT 1002.56 000<br />
l K 93452 L HRT CATH W/NJX L VENTRICULOGRAPHY IMG S&I 1381.98 000<br />
l K 93452 26 L HRT CATH W/NJX L VENTRICULOGRAPHY IMG S&I 424.29 000<br />
l K 93452 TC L HRT CATH W/NJX L VENTRICULOGRAPHY IMG S&I 957.69 000<br />
l K 93453 R & L HRT CATH W/NJX L VENTRICULOG IMG S&I 1808.48 000<br />
l K 93453 26 R & L HRT CATH W/NJX L VENTRICULOG IMG S&I 556.12 000<br />
l K 93453 TC R & L HRT CATH W/NJX L VENTRICULOG IMG S&I 1252.36 000<br />
l K 93454 CATH PLMT & NJX CORONARY ART ANGIO IMG S&I 1425.18 000<br />
l K 93454 26 CATH PLMT & NJX CORONARY ART ANGIO IMG S&I 427.61 000<br />
l K 93454 TC CATH PLMT & NJX CORONARY ART ANGIO IMG S&I 997.57 000<br />
l K 93455 CATH PLMT & NJX CORONARY ART/GRFT ANGIO IMG S&I 1662.81 000<br />
l K 93455 26 CATH PLMT & NJX CORONARY ART/GRFT ANGIO IMG S&I 493.52 000<br />
l K 93455 TC CATH PLMT & NJX CORONARY ART/GRFT ANGIO IMG S&I 1169.29 000<br />
l K 93456 CATH PLMT R HRT & ARTS W/NJX & ANGIO IMG S&I 1783.56 000<br />
l K 93456 26 CATH PLMT R HRT & ARTS W/NJX & ANGIO IMG S&I 547.25 000<br />
l K 93456 TC CATH PLMT R HRT & ARTS W/NJX & ANGIO IMG S&I 1236.31 000<br />
l K 93457 CATH PLMT R HRT/ARTS/GRFTS W/NJX&ANGIO IMG S&I 2021.18 000<br />
l K 93457 26 CATH PLMT R HRT/ARTS/GRFTS W/NJX&ANGIO IMG S&I 613.72 000<br />
l K 93457 TC CATH PLMT R HRT/ARTS/GRFTS W/NJX&ANGIO IMG S&I 1407.46 000<br />
l K 93458 CATH PLMT L HRT & ARTS W/NJX & ANGIO IMG S&I 1719.86 000<br />
l K 93458 26 CATH PLMT L HRT & ARTS W/NJX & ANGIO IMG S&I 521.77 000<br />
l K 93458 TC CATH PLMT L HRT & ARTS W/NJX & ANGIO IMG S&I 1198.09 000<br />
l K 93459 CATH PLMT L HRT/ARTS/GRFTS WNJX & ANGIO IMG S&I 1899.32 000<br />
l K 93459 26 CATH PLMT L HRT/ARTS/GRFTS WNJX & ANGIO IMG S&I 587.13 000<br />
l K 93459 TC CATH PLMT L HRT/ARTS/GRFTS WNJX & ANGIO IMG S&I 1312.19 000<br />
l K 93460 R & L HRT CATH WINJX HRT ART& L VENTR IMG S&I 2032.81 000<br />
l K 93460 26 R & L HRT CATH WINJX HRT ART& L VENTR IMG S&I 654.16 000<br />
l K 93460 TC R & L HRT CATH WINJX HRT ART& L VENTR IMG S&I 1378.65 000<br />
l K 93461 R&L HRT CATH W/INJEC HRT ART/GRFT&L VENT IMG S&I 2329.15 000<br />
l K 93461 26 R&L HRT CATH W/INJEC HRT ART/GRFT&L VENT IMG S&I 721.73 000<br />
l K 93461 TC R&L HRT CATH W/INJEC HRT ART/GRFT&L VENT IMG S&I 1607.42 000<br />
l + K 93462 LEFT HEART CATH BY TRANSEPTAL PUNCTURE 332.34 ZZZ<br />
l + K 93463 MEDICATION ADMIN & HEMODYNAMIC MEASURMENT 176.14 ZZZ<br />
l + K 93464 PHYSIOLOGIC EXERCISE STUDY & HEMODYNAMIC MEASURE 410.99 ZZZ<br />
l + K 93464 26 PHYSIOLOGIC EXERCISE STUDY & HEMODYNAMIC MEASURE 155.09 ZZZ<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 269
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section X: General Medicine Services<br />
MEDICINE 90281–96999, 97597–97606, 97802–97804, 98960–99091, 99143–99199, 99605–99607<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
l + K 93464 TC PHYSIOLOGIC EXERCISE STUDY & HEMODYNAMIC MEASURE 255.90 ZZZ<br />
* 93503 INSERTION FLOW DIRECTED CATHETER FOR MONITORING 218.79 000<br />
K 93505 ENDOMYOCARDIAL BIOPSY 1307.76 000<br />
K 93505 26 ENDOMYOCARDIAL BIOPSY 407.67 000<br />
K 93505 TC ENDOMYOCARDIAL BIOPSY 900.09 000<br />
K 93530 R HRT CATHETERIZATION CONGENITAL CARDIAC ANOMALY 1529.87 000<br />
K 93530 26 R HRT CATHETERIZATION CONGENITAL CARDIAC ANOMALY 397.70 000<br />
K 93530 TC R HRT CATHETERIZATION CONGENITAL CARDIAC ANOMALY 1132.17 000<br />
93531 CMBN R HRT & RETROGRADE L HRT CATHJ CGEN ANOMALY 3128.43 000<br />
93531 26 CMBN R HRT & RETROGRADE L HRT CATHJ CGEN ANOMALY 782.11 000<br />
93531 TC CMBN R HRT & RETROGRADE L HRT CATHJ CGEN ANOMALY 2346.32 000<br />
93532 CMBN R HRT T-SEPTAL L HRT CATHJ NTC SEPTUM CGEN 3719.99 000<br />
93532 26 CMBN R HRT T-SEPTAL L HRT CATHJ NTC SEPTUM CGEN 930.00 000<br />
93532 TC CMBN R HRT T-SEPTAL L HRT CATHJ NTC SEPTUM CGEN 2789.99 000<br />
93533 CMBN R HRT T-SEPTAL L HRT CATHJ SEPTAL OPNG CGEN 3124.00 000<br />
93533 26 CMBN R HRT T-SEPTAL L HRT CATHJ SEPTAL OPNG CGEN 624.80 000<br />
93533 TC CMBN R HRT T-SEPTAL L HRT CATHJ SEPTAL OPNG CGEN 2499.20 000<br />
K 93561 INDIC DIL STD ARTL&/OR VEN CATHJ W/OUTP MEAS 74.78 000<br />
K 93561 26 INDIC DIL STD ARTL&/OR VEN CATHJ W/OUTP MEAS 40.43 000<br />
K 93561 TC INDIC DIL STD ARTL&/OR VEN CATHJ W/OUTP MEAS 34.35 000<br />
K 93562 INDIC DIL STD ARTL&/OR VEN CATHJ SBSQ OUTP MEAS 32.13 000<br />
K 93562 26 INDIC DIL STD ARTL&/OR VEN CATHJ SBSQ OUTP MEAS 12.19 000<br />
K 93562 TC INDIC DIL STD ARTL&/OR VEN CATHJ SBSQ OUTP MEAS 19.94 000<br />
l + K 93563 NJX SEL HRT ART CONGENITAL HRT CATH W/S&I 91.39 ZZZ<br />
l + K 93564 NJX SEL HRT ART/GRFT CONGENITAL HRT CATH W/S&I 93.06 ZZZ<br />
l + K 93565 NJX SEL L VENT/ATRIAL ANGIO HRT CATH W/S&I 70.35 ZZZ<br />
l + K 93566 NJX SEL R VENT/ATRIAL ANGIO HRT CATH W/S&I 275.84 ZZZ<br />
l + K 93567 NJX SUPRAVALV AORTOG HRT CATH W/S&I 227.65 ZZZ<br />
l + K 93568 NJX PULMONARY ANGIO HRT CATH W/S&I 249.26 ZZZ<br />
+ K 93571 IV DOP VEL&/OR PRESS C/FLO RSRV MEAS 1ST VSL 443.12 ZZZ<br />
+ K 93571 26 IV DOP VEL&/OR PRESS C/FLO RSRV MEAS 1ST VSL 155.09 ZZZ<br />
+ K 93571 TC IV DOP VEL&/OR PRESS C/FLO RSRV MEAS 1ST VSL 288.03 ZZZ<br />
+ K 93572 IV DOP VEL&/OR PRESS C/FLO RSRV MEAS ADDL VSL 264.21 ZZZ<br />
+ K 93572 26 IV DOP VEL&/OR PRESS C/FLO RSRV MEAS ADDL VSL 124.07 ZZZ<br />
+ K 93572 TC IV DOP VEL&/OR PRESS C/FLO RSRV MEAS ADDL VSL 140.14 ZZZ<br />
93580 PRQ TCAT CLSR CGEN INTRATRL COMUNICAJ W/IMPLT 1721.52 000<br />
93581 PRQ TCAT CLSR CGEN VENTR SEPTAL DFCT W/IMPLT 2284.28 000<br />
* 93600 BUNDLE OF HIS RECORDING 333.45 000<br />
* 93600 26 BUNDLE OF HIS RECORDING 199.96 000<br />
* 93600 TC BUNDLE OF HIS RECORDING 133.49 000<br />
* 93602 INTRA-ATRIAL RECORDING 276.95 000<br />
* 93602 26 INTRA-ATRIAL RECORDING 199.40 000<br />
* 93602 TC INTRA-ATRIAL RECORDING 77.55 000<br />
* 93603 R VENTRICULAR REC 316.28 000<br />
* 93603 26 R VENTRICULAR REC 199.40 000<br />
* 93603 TC R VENTRICULAR REC 116.88 000<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
270 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section X: General Medicine Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
90281–96999, 97597–97606, 97802–97804, 98960–99091, 99143–99199, 99605–99607 MEDICINE<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
+ K 93609 INTRA-VNTR MAPG TCHYCAR SIT W/CATH MNPJ 658.03 ZZZ<br />
+ K 93609 26 INTRA-VNTR MAPG TCHYCAR SIT W/CATH MNPJ 473.58 ZZZ<br />
+ K 93609 TC INTRA-VNTR MAPG TCHYCAR SIT W/CATH MNPJ 184.45 ZZZ<br />
* 93610 INTRA-ATRIAL PACING 378.31 000<br />
* 93610 26 INTRA-ATRIAL PACING 283.60 000<br />
* 93610 TC INTRA-ATRIAL PACING 94.71 000<br />
* 93612 INTRAVENTRICAL PACING 392.16 000<br />
* 93612 26 INTRAVENTRICAL PACING 282.49 000<br />
* 93612 TC INTRAVENTRICAL PACING 109.67 000<br />
+ K 93613 ICAR EPHYS 3-DIMENSIONAL MAPG 664.13 ZZZ<br />
+ K 93613 26 ICAR EPHYS 3-DIMENSIONAL MAPG 477.46 ZZZ<br />
+ K 93613 TC ICAR EPHYS 3-DIMENSIONAL MAPG 186.67 ZZZ<br />
* K 93615 ESOPHGL REC ATR EGRM +-VENTR EGRM 106.35 000<br />
* K 93615 26 ESOPHGL REC ATR EGRM +-VENTR EGRM 84.19 000<br />
* K 93615 TC ESOPHGL REC ATR EGRM +-VENTR EGRM 22.16 000<br />
* K 93616 ESOPHGL REC ATR EGRM +-VENTR EGRM W/PACG 146.78 000<br />
* K 93616 26 ESOPHGL REC ATR EGRM +-VENTR EGRM W/PACG 110.23 000<br />
* K 93616 TC ESOPHGL REC ATR EGRM +-VENTR EGRM W/PACG 36.55 000<br />
* K 93618 INDCTJ ARRHYT ELEC PACG 672.99 000<br />
* K 93618 26 INDCTJ ARRHYT ELEC PACG 403.79 000<br />
* K 93618 TC INDCTJ ARRHYT ELEC PACG 269.20 000<br />
K 93619 COMPRE ELECTROPHYSIOLOGIC W/O ARRHYT INDUCTION 1224.67 000<br />
K 93619 26 COMPRE ELECTROPHYSIOLOGIC W/O ARRHYT INDUCTION 697.91 000<br />
K 93619 TC COMPRE ELECTROPHYSIOLOGIC W/O ARRHYT INDUCTION 526.76 000<br />
K 93620 COMPRE ELECTROPHYSIOLOGIC ARRHYTHMIA INDUCTION 1468.39 000<br />
K 93620 26 COMPRE ELECTROPHYSIOLOGIC ARRHYTHMIA INDUCTION 1101.15 000<br />
K 93620 TC COMPRE ELECTROPHYSIOLOGIC ARRHYTHMIA INDUCTION 367.24 000<br />
+ K 93621 COMPRE ELECTROPHYSIOLOGIC W/L ATR PAC/REC 265.32 ZZZ<br />
+ K 93621 26 COMPRE ELECTROPHYSIOLOGIC W/L ATR PAC/REC 198.85 ZZZ<br />
+ K 93621 TC COMPRE ELECTROPHYSIOLOGIC W/L ATR PAC/REC 66.47 ZZZ<br />
+ K 93622 COMPRE ELECTROPHYSIOLOGIC W/L VENTR PAC/REC 389.95 ZZZ<br />
+ K 93622 26 COMPRE ELECTROPHYSIOLOGIC W/L VENTR PAC/REC 292.46 ZZZ<br />
+ K 93622 TC COMPRE ELECTROPHYSIOLOGIC W/L VENTR PAC/REC 97.49 ZZZ<br />
+ 93623 PROGRAMMED STIMJ&PACG AFTER IV DRUG NFS 361.14 ZZZ<br />
+ 93623 26 PROGRAMMED STIMJ&PACG AFTER IV DRUG NFS 270.86 ZZZ<br />
+ 93623 TC PROGRAMMED STIMJ&PACG AFTER IV DRUG NFS 90.28 ZZZ<br />
K 93624 ELECTROPHYSIOLOGIC FOLLOW-UP W/PAC/REC W/ARRHYT 588.24 000<br />
K 93624 26 ELECTROPHYSIOLOGIC FOLLOW-UP W/PAC/REC W/ARRHYT 458.63 000<br />
K 93624 TC ELECTROPHYSIOLOGIC FOLLOW-UP W/PAC/REC W/ARRHYT 129.61 000<br />
* 93631 INTRAOP EPICAR&ENDOCAR PACG&MAPG 921.14 000<br />
* 93631 26 INTRAOP EPICAR&ENDOCAR PACG&MAPG 690.71 000<br />
* 93631 TC INTRAOP EPICAR&ENDOCAR PACG&MAPG 230.43 000<br />
K 93640 EPHYS EVAL PACG CVDFB LDS INITIAL IMPLAN/REPLACE 832.51 000<br />
K 93640 26 EPHYS EVAL PACG CVDFB LDS INITIAL IMPLAN/REPLACE 332.89 000<br />
K 93640 TC EPHYS EVAL PACG CVDFB LDS INITIAL IMPLAN/REPLACE 499.62 000<br />
K 93641 EPHYS EVAL PACG CVDFB LDS W/TSTG OF PULSE GEN 1060.72 000<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 271
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section X: General Medicine Services<br />
MEDICINE 90281–96999, 97597–97606, 97802–97804, 98960–99091, 99143–99199, 99605–99607<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
K 93641 26 EPHYS EVAL PACG CVDFB LDS W/TSTG OF PULSE GEN 562.21 000<br />
K 93641 TC EPHYS EVAL PACG CVDFB LDS W/TSTG OF PULSE GEN 498.51 000<br />
K 93642 EPHYS EVAL PACG CVDFB PRGRMG/REPRGRMG PARAMETERS 697.36 000<br />
K 93642 26 EPHYS EVAL PACG CVDFB PRGRMG/REPRGRMG PARAMETERS 417.64 000<br />
K 93642 TC EPHYS EVAL PACG CVDFB PRGRMG/REPRGRMG PARAMETERS 279.72 000<br />
K 93650 ICAR CATHETER ABLATION ATRIOVENTR NODE FUNCTION 1011.98 000<br />
K 93651 ICAR CATH ABLTJ ARRHYTGNIC FOC SUPVENTR TCHYCAR 1540.95 000<br />
K 93652 ICAR CATH ABLATION ARRHYTGNIC FOC VENTR TCHYCAR 1677.21 000<br />
93660 CARDIOVASCULAR FUNCTION EVAL W/TILT TABLE W/MNTR 268.09 000<br />
93660 26 CARDIOVASCULAR FUNCTION EVAL W/TILT TABLE W/MNTR 160.63 000<br />
93660 TC CARDIOVASCULAR FUNCTION EVAL W/TILT TABLE W/MNTR 107.46 000<br />
+ 93662 ICE DURING THER/DX IVNTJ INCL IMG S&I 323.48 ZZZ<br />
+ 93662 26 ICE DURING THER/DX IVNTJ INCL IMG S&I 242.61 ZZZ<br />
+ 93662 TC ICE DURING THER/DX IVNTJ INCL IMG S&I 80.87 ZZZ<br />
93668 PRPH ARTL DISEASE RHAB PR SESS 30.46 XXX<br />
93701 BIOMPEDANCE-DERIVED PHYSIOLOGIC CV ANALYSIS 43.76 XXX<br />
93701 26 BIOMPEDANCE-DERIVED PHYSIOLOGIC CV ANALYSIS 11.63 XXX<br />
93701 TC BIOMPEDANCE-DERIVED PHYSIOLOGIC CV ANALYSIS 32.13 XXX<br />
93720 PLETHYSMOGRAPY TOT BDY W/I&R 79.76 XXX<br />
93720 26 PLETHYSMOGRAPY TOT BDY W/I&R 32.13 XXX<br />
93720 TC PLETHYSMOGRAPY TOT BDY W/I&R 47.63 XXX<br />
93721 PLETHYSMOGRAPY TOT BDY TRCG ONLY W/O I&R 66.47 XXX<br />
93722 PLETHYSMOGRAPY TOT BDY I&R ONLY 13.29 XXX<br />
93724 ELEC ALYS ANTITACHYCARDIA PM SYSTEM 489.65 000<br />
93724 26 ELEC ALYS ANTITACHYCARDIA PM SYSTEM 414.32 000<br />
93724 TC ELEC ALYS ANTITACHYCARDIA PM SYSTEM 75.33 000<br />
93740 TEMPRATURE GRADIENT STD 14.40 XXX<br />
93740 26 TEMPRATURE GRADIENT STD 11.63 XXX<br />
93740 TC TEMPRATURE GRADIENT STD 2.77 XXX<br />
93745 1ST SET-UP&PRGRMG BY PHYS OF WEARABLE CVDFB BR XXX<br />
93750 INTERROGATION VAD IN PRSON W/PHYSICIAN ANALYSIS 83.64 XXX<br />
93770 DETER VEN PRESS 14.40 XXX<br />
93770 26 DETER VEN PRESS 13.29 XXX<br />
93770 TC DETER VEN PRESS 1.11 XXX<br />
93784 AMBL BLD PRESS W/TAPE&/DISK 24+ HR ALYS I&R 101.36 XXX<br />
93786 AMBL BLD PRESS W/TAPE&/DISK 24+ HR + REC ONLY 50.96 XXX<br />
93788 AMBL BLD PRESS W/TAPE/DISK 24+ HR ALYS W/REPRT 19.39 XXX<br />
93790 AMBL BLD PRESS TAPE&/DISK 24+ HR PHYS REV W/I&R 31.02 XXX<br />
93797 OUTPATIENT CARDIAC REHAB W/O CONT ECG MONITOR 29.36 000<br />
93798 OUTPATIENT CARDIAC REHAB W/CONT ECG MONITORING 41.54 000<br />
93799 UNLIS CV SVC/PX BR XXX<br />
93875 N-INVAS PHYSIOLOGIC STD XTRC ART COMPL BI STD 172.26 XXX<br />
93875 26 N-INVAS PHYSIOLOGIC STD XTRC ART COMPL BI STD 17.72 XXX<br />
93875 TC N-INVAS PHYSIOLOGIC STD XTRC ART COMPL BI STD 154.54 XXX<br />
93880 DUP-SCAN XTRC ART COMPL BI STD 408.22 XXX<br />
93880 26 DUP-SCAN XTRC ART COMPL BI STD 49.30 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
272 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section X: General Medicine Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
90281–96999, 97597–97606, 97802–97804, 98960–99091, 99143–99199, 99605–99607 MEDICINE<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
93880 TC DUP-SCAN XTRC ART COMPL BI STD 358.92 XXX<br />
93882 DUP-SCAN XTRC ART UNI/LMTD STD 283.04 XXX<br />
93882 26 DUP-SCAN XTRC ART UNI/LMTD STD 33.23 XXX<br />
93882 TC DUP-SCAN XTRC ART UNI/LMTD STD 249.81 XXX<br />
93886 TCD STD ICRA ART COMPL STD 540.05 XXX<br />
93886 26 TCD STD ICRA ART COMPL STD 76.44 XXX<br />
93886 TC TCD STD ICRA ART COMPL STD 463.61 XXX<br />
93888 TCD STD ICRA ART LMTD STD 343.97 XXX<br />
93888 26 TCD STD ICRA ART LMTD STD 50.96 XXX<br />
93888 TC TCD STD ICRA ART LMTD STD 293.01 XXX<br />
93890 TCD STD ICRA ART VASOREACTV STD 441.46 XXX<br />
93890 26 TCD STD ICRA ART VASOREACTV STD 80.32 XXX<br />
93890 TC TCD STD ICRA ART VASOREACTV STD 361.14 XXX<br />
93892 TCD STD ICRA ART EMBOLI DETCJ W/O IV MBUBB NJX 520.67 XXX<br />
93892 26 TCD STD ICRA ART EMBOLI DETCJ W/O IV MBUBB NJX 93.06 XXX<br />
93892 TC TCD STD ICRA ART EMBOLI DETCJ W/O IV MBUBB NJX 427.61 XXX<br />
93893 TCD STD ICRA ART EMBOLI DETCJ W/IV MBUBB NJX 543.93 XXX<br />
93893 26 TCD STD ICRA ART EMBOLI DETCJ W/IV MBUBB NJX 93.61 XXX<br />
93893 TC TCD STD ICRA ART EMBOLI DETCJ W/IV MBUBB NJX 450.32 XXX<br />
s 93922 NON-INVAS PHYSIOLOGIC STD EXTREMITY ART 2 LEVEL 180.02 XXX<br />
s 93922 26 NON-INVAS PHYSIOLOGIC STD EXTREMITY ART 2 LEVEL 19.94 XXX<br />
s 93922 TC NON-INVAS PHYSIOLOGIC STD EXTREMITY ART 2 LEVEL 160.08 XXX<br />
s 93923 NON-INVASIVE PHYSIOLOGIC STUDY EXTREMITY 3 LEVLS 278.61 XXX<br />
s 93923 26 NON-INVASIVE PHYSIOLOGIC STUDY EXTREMITY 3 LEVLS 37.11 XXX<br />
s 93923 TC NON-INVASIVE PHYSIOLOGIC STUDY EXTREMITY 3 LEVLS 241.50 XXX<br />
s 93924 N-INVAS PHYSIOLOGIC STD LXTR ART COMPL BI 347.85 XXX<br />
s 93924 26 N-INVAS PHYSIOLOGIC STD LXTR ART COMPL BI 40.99 XXX<br />
s 93924 TC N-INVAS PHYSIOLOGIC STD LXTR ART COMPL BI 306.86 XXX<br />
93925 DUP-SCAN LXTR ART/ARTL BPGS COMPL BI STD 516.23 XXX<br />
93925 26 DUP-SCAN LXTR ART/ARTL BPGS COMPL BI STD 47.08 XXX<br />
93925 TC DUP-SCAN LXTR ART/ARTL BPGS COMPL BI STD 469.15 XXX<br />
93926 DUP-SCAN LXTR ART/ARTL BPGS UNI/LMTD STD 335.66 XXX<br />
93926 26 DUP-SCAN LXTR ART/ARTL BPGS UNI/LMTD STD 32.68 XXX<br />
93926 TC DUP-SCAN LXTR ART/ARTL BPGS UNI/LMTD STD 302.98 XXX<br />
93930 DUP-SCAN UXTR ART/ARTL BPGS COMPL BI STD 406.56 XXX<br />
93930 26 DUP-SCAN UXTR ART/ARTL BPGS COMPL BI STD 37.67 XXX<br />
93930 TC DUP-SCAN UXTR ART/ARTL BPGS COMPL BI STD 368.89 XXX<br />
93931 DUP-SCAN UXTR ART/ARTL BPGS UNI/LMTD STD 271.96 XXX<br />
93931 26 DUP-SCAN UXTR ART/ARTL BPGS UNI/LMTD STD 25.48 XXX<br />
93931 TC DUP-SCAN UXTR ART/ARTL BPGS UNI/LMTD STD 246.48 XXX<br />
93965 N-INVAS PHYSIOLOGIC STD XTR VEINS COMPL BI STD 206.60 XXX<br />
93965 26 N-INVAS PHYSIOLOGIC STD XTR VEINS COMPL BI STD 28.80 XXX<br />
93965 TC N-INVAS PHYSIOLOGIC STD XTR VEINS COMPL BI STD 177.80 XXX<br />
93970 DUP-SCAN XTR VEINS COMPL BI STD 420.96 XXX<br />
93970 26 DUP-SCAN XTR VEINS COMPL BI STD 56.50 XXX<br />
93970 TC DUP-SCAN XTR VEINS COMPL BI STD 364.46 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 273
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section X: General Medicine Services<br />
MEDICINE 90281–96999, 97597–97606, 97802–97804, 98960–99091, 99143–99199, 99605–99607<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
93971 DUP-SCAN XTR VEINS UNI/LMTD STD 276.40 XXX<br />
93971 26 DUP-SCAN XTR VEINS UNI/LMTD STD 37.11 XXX<br />
93971 TC DUP-SCAN XTR VEINS UNI/LMTD STD 239.29 XXX<br />
93975 DUP-SCAN ARTL FLO ABDL/PEL/SCROT&/RPR ORGN COMPL 619.81 XXX<br />
93975 26 DUP-SCAN ARTL FLO ABDL/PEL/SCROT&/RPR ORGN COMPL 147.89 XXX<br />
93975 TC DUP-SCAN ARTL FLO ABDL/PEL/SCROT&/RPR ORGN COMPL 471.92 XXX<br />
93976 DUP-SCAN ARTL FLO ABDL/PEL/SCROT&/RPR ORGN LMTD 355.05 XXX<br />
93976 26 DUP-SCAN ARTL FLO ABDL/PEL/SCROT&/RPR ORGN LMTD 99.15 XXX<br />
93976 TC DUP-SCAN ARTL FLO ABDL/PEL/SCROT&/RPR ORGN LMTD 255.90 XXX<br />
93978 DUP-SCAN AORTA IVC ILIAC VASCL/BPGS COMPL 396.04 XXX<br />
93978 26 DUP-SCAN AORTA IVC ILIAC VASCL/BPGS COMPL 54.28 XXX<br />
93978 TC DUP-SCAN AORTA IVC ILIAC VASCL/BPGS COMPL 341.76 XXX<br />
93979 DUP-SCAN AORTA IVC ILIAC VASCL/BPGS UNI/LMTD 274.18 XXX<br />
93979 26 DUP-SCAN AORTA IVC ILIAC VASCL/BPGS UNI/LMTD 36.00 XXX<br />
93979 TC DUP-SCAN AORTA IVC ILIAC VASCL/BPGS UNI/LMTD 238.18 XXX<br />
93980 DUP-SCAN ARTL INFL&VEN O/F PEN VSL COMPL 287.47 XXX<br />
93980 26 DUP-SCAN ARTL INFL&VEN O/F PEN VSL COMPL 103.03 XXX<br />
93980 TC DUP-SCAN ARTL INFL&VEN O/F PEN VSL COMPL 184.44 XXX<br />
93981 DUP-SCAN ARTL INFL&VEN O/F PEN VSL F-UP/LMTD STD 196.63 XXX<br />
93981 26 DUP-SCAN ARTL INFL&VEN O/F PEN VSL F-UP/LMTD STD 36.00 XXX<br />
93981 TC DUP-SCAN ARTL INFL&VEN O/F PEN VSL F-UP/LMTD STD 160.63 XXX<br />
93982 IMPLANT WIRELESS PRESS SENSOR STUDY ANEURYSM SAC 70.35 XXX<br />
93990 DUP-SCAN OF HEMODIALYSIS ACCESS 343.42 XXX<br />
93990 26 DUP-SCAN OF HEMODIALYSIS ACCESS 21.05 XXX<br />
93990 TC DUP-SCAN OF HEMODIALYSIS ACCESS 322.37 XXX<br />
94002 VENTILATION ASSIST & MGMT INPATIENT 1ST DAY 147.89 XXX<br />
94003 VENTILATION ASSIST & MGMT INPATIENT EA SBSQ DAY 106.35 XXX<br />
94004 VENTILATION ASSIST & MGMT NURSING FAC PR DAY 77.55 XXX<br />
94005 HOME VENTILATOR MGMT CARE OVERSIGHT 30 MIN/> 149.00 XXX<br />
94010 SPMTRY W/VC EXPIRATORY FLO +-MXML VOL VNTJ 57.61 XXX<br />
94010 26 SPMTRY W/VC EXPIRATORY FLO +-MXML VOL VNTJ 13.85 XXX<br />
94010 TC SPMTRY W/VC EXPIRATORY FLO +-MXML VOL VNTJ 43.76 XXX<br />
K 94011 MEAS SPIROMTRC FORCD EXPIRATORY FLO INFANT-2 YR 161.18 XXX<br />
K 94012 MEAS SPIRO FORCD EXP FLO PRE&POST BRONCH INF-2Y 248.70 XXX<br />
K 94013 MEAS LUNG VOLUMES INFANT OR CHILD THRU 2 YRS 50.96 XXX<br />
94014 PT-INITIATE SPIROMETRIC RECORDING&PHYS R&I 79.76 XXX<br />
94014 26 PT-INITIATE SPIROMETRIC RECORDING&PHYS R&I 32.13 XXX<br />
94014 TC PT-INITIATE SPIROMETRIC RECORDING&PHYS R&I 47.63 XXX<br />
94015 PATIENT-INITIATED SPIROMETRIC RECORDING 39.88 XXX<br />
94016 PATIENT-INITIATED SPIROMETRIC PHYS R&I ONLY 39.88 XXX<br />
94060 BRNCDILAT RSPSE SPMTRY PRE&POST-BRNCDILAT ADMN 99.15 XXX<br />
94060 26 BRNCDILAT RSPSE SPMTRY PRE&POST-BRNCDILAT ADMN 23.82 XXX<br />
94060 TC BRNCDILAT RSPSE SPMTRY PRE&POST-BRNCDILAT ADMN 75.33 XXX<br />
94070 BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT 97.49 XXX<br />
94070 26 BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT 46.53 XXX<br />
94070 TC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT 50.96 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
274 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section X: General Medicine Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
90281–96999, 97597–97606, 97802–97804, 98960–99091, 99143–99199, 99605–99607 MEDICINE<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
94150 VC TOT SPX 39.33 XXX<br />
94150 26 VC TOT SPX 6.09 XXX<br />
94150 TC VC TOT SPX 33.24 XXX<br />
94200 MAX BRTHING CAP MXML VOL VNTJ 39.33 XXX<br />
94200 26 MAX BRTHING CAP MXML VOL VNTJ 8.86 XXX<br />
94200 TC MAX BRTHING CAP MXML VOL VNTJ 30.47 XXX<br />
94240 FUNCTIONAL RESIDUAL CAPACITY OR RESIDUAL VOLUME 65.36 XXX<br />
94240 26 FUNCTIONAL RESIDUAL CAPACITY OR RESIDUAL VOLUME 19.94 XXX<br />
94240 TC FUNCTIONAL RESIDUAL CAPACITY OR RESIDUAL VOLUME 45.42 XXX<br />
94250 EXP GAS COLLJ QUAN 1 PX SPX 41.54 XXX<br />
94250 26 EXP GAS COLLJ QUAN 1 PX SPX 8.86 XXX<br />
94250 TC EXP GAS COLLJ QUAN 1 PX SPX 32.68 XXX<br />
94260 THRC GAS VOL 53.17 XXX<br />
94260 26 THRC GAS VOL 9.97 XXX<br />
94260 TC THRC GAS VOL 43.20 XXX<br />
94350 DETER MALDISTRIBJ OF INSPIRED GAS N WSHOT CURVE 56.50 XXX<br />
94350 26 DETER MALDISTRIBJ OF INSPIRED GAS N WSHOT CURVE 19.94 XXX<br />
94350 TC DETER MALDISTRIBJ OF INSPIRED GAS N WSHOT CURVE 36.56 XXX<br />
94360 DETER RESIST TO AIRFLO OSCILLATORY/PLETHYSMOGRAP 72.56 XXX<br />
94360 26 DETER RESIST TO AIRFLO OSCILLATORY/PLETHYSMOGRAP 19.94 XXX<br />
94360 TC DETER RESIST TO AIRFLO OSCILLATORY/PLETHYSMOGRAP 52.62 XXX<br />
94370 DETER AIRWY CLOSING VOL 1 BRTH TSTS 55.94 XXX<br />
94370 26 DETER AIRWY CLOSING VOL 1 BRTH TSTS 19.94 XXX<br />
94370 TC DETER AIRWY CLOSING VOL 1 BRTH TSTS 36.00 XXX<br />
94375 RESPIR FLO VOL LOOP 62.59 XXX<br />
94375 26 RESPIR FLO VOL LOOP 23.82 XXX<br />
94375 TC RESPIR FLO VOL LOOP 38.77 XXX<br />
94400 BRTHING RSPSE CO2 CO2 RSPSE CURVE 87.52 XXX<br />
94400 26 BRTHING RSPSE CO2 CO2 RSPSE CURVE 30.46 XXX<br />
94400 TC BRTHING RSPSE CO2 CO2 RSPSE CURVE 57.06 XXX<br />
94450 BRTHING RSPSE HYPOXIA HYPOXIA RSPSE CURVE 96.38 XXX<br />
94450 26 BRTHING RSPSE HYPOXIA HYPOXIA RSPSE CURVE 31.02 XXX<br />
94450 TC BRTHING RSPSE HYPOXIA HYPOXIA RSPSE CURVE 65.36 XXX<br />
94452 HAST W/PHYS I&R 93.61 XXX<br />
94452 26 HAST W/PHYS I&R 23.26 XXX<br />
94452 TC HAST W/PHYS I&R 70.35 XXX<br />
94453 HAST W/PHYS I&R W/SUPPL O2 TITRJ 126.84 XXX<br />
94453 26 HAST W/PHYS I&R W/SUPPL O2 TITRJ 30.46 XXX<br />
94453 TC HAST W/PHYS I&R W/SUPPL O2 TITRJ 96.38 XXX<br />
* 94610 INTRAPULMONARY SURFACTANT ADMINISTRATION 96.38 XXX<br />
94620 PULM STRS TSTG SMPL 103.58 XXX<br />
94620 26 PULM STRS TSTG SMPL 49.85 XXX<br />
94620 TC PULM STRS TSTG SMPL 53.73 XXX<br />
94621 PULM STRS TSTG CPLX 265.32 XXX<br />
94621 26 PULM STRS TSTG CPLX 111.89 XXX<br />
94621 TC PULM STRS TSTG CPLX 153.43 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 275
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section X: General Medicine Services<br />
MEDICINE 90281–96999, 97597–97606, 97802–97804, 98960–99091, 99143–99199, 99605–99607<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
94640 PRESSURIZED/NONPRESSURIZED INHALATION TREATMENT 26.03 XXX<br />
94642 PENTAMIDINE AERSL INHALATION PNEUMOCYSTIS/PROPH 69.24 XXX<br />
94644 CONTINUOUS INHALATION TREATMENT 1ST HR 65.36 XXX<br />
+ 94645 CONTINUOUS INHALATION TREATMENT EA ADDL HR 23.82 XXX<br />
94660 CPAP VNTJ CPAP INITIATION&MGMT 96.93 XXX<br />
94662 CNP VNTJ CNP INITIATION&MGMT 58.71 XXX<br />
94664 DEMO&/EVAL OF PT UTILIZ AERSL GEN/NEB/INHLR/IPPB 26.03 XXX<br />
94667 MNPJ CH WALL FACILITATE LNG FUNCJ 1 DEMO&/EVAL 36.56 XXX<br />
94668 MNPJ CH FACILITATE LNG FUNCJ SBSQ 35.45 XXX<br />
94680 O2 UPTK EXP GAS ALYS REST&XERS DIR SMPL 95.82 XXX<br />
94680 26 O2 UPTK EXP GAS ALYS REST&XERS DIR SMPL 20.49 XXX<br />
94680 TC O2 UPTK EXP GAS ALYS REST&XERS DIR SMPL 75.33 XXX<br />
94681 O2 UPTK EXP GAS ALYS W/CO2 OUTPUT % O2 XTRC 93.06 XXX<br />
94681 26 O2 UPTK EXP GAS ALYS W/CO2 OUTPUT % O2 XTRC 15.51 XXX<br />
94681 TC O2 UPTK EXP GAS ALYS W/CO2 OUTPUT % O2 XTRC 77.55 XXX<br />
94690 O2 UPTK EXP GAS ALYS REST INDIR SPX 84.19 XXX<br />
94690 26 O2 UPTK EXP GAS ALYS REST INDIR SPX 6.09 XXX<br />
94690 TC O2 UPTK EXP GAS ALYS REST INDIR SPX 78.10 XXX<br />
94720 CARBON MONOXIDE DIFFW/CAP 85.30 XXX<br />
94720 26 CARBON MONOXIDE DIFFW/CAP 19.94 XXX<br />
94720 TC CARBON MONOXIDE DIFFW/CAP 65.36 XXX<br />
94725 MEMB DIFFUSION CAP 97.49 XXX<br />
94725 26 MEMB DIFFUSION CAP 20.49 XXX<br />
94725 TC MEMB DIFFUSION CAP 77.00 XXX<br />
94750 PULM COMPLIANCE STD 126.84 XXX<br />
94750 26 PULM COMPLIANCE STD 17.72 XXX<br />
94750 TC PULM COMPLIANCE STD 109.12 XXX<br />
94760 NONINVASIVE EAR/PULSE OXIMETRY SINGLE DETER 4.43 XXX<br />
94761 NONINVASIVE EAR/PULSE OXIMETRY MULTIPLE DETER 7.20 XXX<br />
94762 NONINVASIVE EAR/PULSE OXIMETRY OVERNIGHT MONITOR 32.68 XXX<br />
94770 CARBON DIOXIDE EXP GAS DETER INFRARED ANALYZER 37.67 XXX<br />
94770 26 CARBON DIOXIDE EXP GAS DETER INFRARED ANALYZER 7.75 XXX<br />
94770 TC CARBON DIOXIDE EXP GAS DETER INFRARED ANALYZER 29.92 XXX<br />
94772 CIRCADIAN RESPIR PATTERN REC 12-24 HR INFT BR XXX<br />
94774 PED APNEA MONITOR ATTACHMENT PHYS I&R BR YYY<br />
94775 PED APNEA MONITOR ATTACHMENT BR YYY<br />
94776 PED APNEA MONITOR ANALYSES COMPUTER BR YYY<br />
94777 PED APNEA MONITOR PHYSICIAN REVIEW BR YYY<br />
94799 UNLIS PULM SVC/PX BR XXX<br />
95004 PERCUTANEOUS TESTS W/ALLERGENIC EXTRACTS 10.52 XXX<br />
95010 PERQ TSTS SEQL&INCRL RX/BIOLOGIC/VNM IMMT RXN 29.91 XXX<br />
95012 NITRIC OXIDE EXPIRED GAS DETERMINATION 33.79 XXX<br />
95015 IQ TSTS SEQL&INCRL RX/BIOLOGIC/VNM IMMT RXN 23.26 XXX<br />
95024 INTRACUTANEOUS TESTS W/ALLERGENIC EXTRACTS 12.19 XXX<br />
95027 INTRACUTANEOUS TESTS W/ALLERGENIC XTRCS AIRBORNE 7.75 XXX<br />
95028 IQ TSTS W/ALLGIC XTRCS DLYD TYP RXN W/READING 20.49 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
276 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section X: General Medicine Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
90281–96999, 97597–97606, 97802–97804, 98960–99091, 99143–99199, 99605–99607 MEDICINE<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
95044 PATCH/APPL TST SPEC NUMBER TSTS 9.97 XXX<br />
95052 PHOTO PATCH TST SPEC NUMBER TSTS 11.63 XXX<br />
95056 PHOTO TSTS 66.47 XXX<br />
95060 OPH MUC MEMB TSTS 46.53 XXX<br />
95065 DIR NSL MUC MEMB TST 39.88 XXX<br />
95070 INHLJ BRNCL CHALLENGE TSTG W/HISTAM/METHACHOL 62.04 XXX<br />
95071 INHLJ BRNCL CHALLENGE TSTG W/AGS/GASES 83.09 XXX<br />
95075 INGESTION CHALLENGE TEST 104.69 XXX<br />
95115 PROF SVCS ALLG IMMNTX X W/PRV ALLGIC XTRCS 1 NJX 16.62 XXX<br />
95117 PROF SVCS ALLG IMMNTX X W/PRV ALLGIC XTRCS NJXS 20.49 XXX<br />
95120 PROF SVCS ALLG IMMNTX W/PRV ALLGIC XTRC 1 NJX 19.94 XXX<br />
95125 PROF SVCS ALLG IMMNTX W/PRV ALLGIC XTRC 2/> NJXS 25.48 XXX<br />
95130 PROF SVCS ALLG IMMNTX W/PRV XTRC 1 STING INSECT 34.90 XXX<br />
95131 PROF SVCS ALLG IMMNTX W/PRV XTRC 2 STING INSECT 44.31 XXX<br />
95132 PROF SVCS ALLG IMMNTX W/PRV ALLGIC XTRC 3 INSECT 54.28 XXX<br />
95133 PROF SVCS ALLG IMMNTX W/PRV ALLGIC XTRC 4 INSECT 64.81 XXX<br />
95134 PROF SVCS ALLG IMMNTX W/PRV ALLGIC XTRC 5 INSECT 78.10 XXX<br />
95144 PREPJ& ANTIGEN PRV ALLERGEN IMMUNOTHERAPY 1 DOSE 20.49 XXX<br />
95145 PREPJ& ANTIGEN ALLERGEN IMMUNOTHERAPY 1 INSECT 31.02 XXX<br />
95146 PREPJ& ANTIGEN ALLERGEN IMMUNOTHERAPY 2 INSECTS 54.28 XXX<br />
95147 PREPJ& ANTIGEN ALLERGEN IMMUNOTHERAPY 3 INSECTS 50.96 XXX<br />
95148 PREPJ& ANTIGEN ALLERGEN IMMUNOTHERAPY 4 INSECTS 73.67 XXX<br />
95149 PREPJ& ANTIGEN ALLERGEN IMMUNOTHERAPY 5 INSECTS 98.04 XXX<br />
95165 PREPJ& ALLERGEN IMMUNOTHERAPY 1/MLT ANTIGEN 20.49 XXX<br />
95170 PREPJ& ANTIGEN ALLERGEN IMMUNOTHERAPY WHL INSECT 16.06 XXX<br />
95180 RAPID DESENSITIZATION PX EA HR 229.87 XXX<br />
95199 UNLIS ALL/CLINICAL IMMUNOLOGIC SVC/PX BR XXX<br />
95250 GLUC MNTR CONT REC FROM INTERSTITIAL TISS FLUID 241.50 XXX<br />
95251 GLUC MNTR CONT REC FROM NTRSTL TISS FLU I&R 68.13 XXX<br />
l # 95800 SLP STDY UNATND W/HRT RATE/O2 SAT/RESP/SLP TIME 335.11 XXX<br />
l # 95800 26 SLP STDY UNATND W/HRT RATE/O2 SAT/RESP/SLP TIME 94.72 XXX<br />
l # 95800 TC SLP STDY UNATND W/HRT RATE/O2 SAT/RESP/SLP TIME 240.39 XXX<br />
l # 95801 SLP STDY UNATND W/MIN HRT RATE/O2 SAT/RESP ANAL 157.86 XXX<br />
l # 95801 26 SLP STDY UNATND W/MIN HRT RATE/O2 SAT/RESP ANAL 83.64 XXX<br />
l # 95801 TC SLP STDY UNATND W/MIN HRT RATE/O2 SAT/RESP ANAL 74.22 XXX<br />
95803 ACTIGRAPHY TESTING RECORDING ANALYSIS I&R 264.76 XXX<br />
95803 26 ACTIGRAPHY TESTING RECORDING ANALYSIS I&R 76.44 XXX<br />
95803 TC ACTIGRAPHY TESTING RECORDING ANALYSIS I&R 188.32 XXX<br />
95805 MLT SLEEP LATENCY/MAINT OF WAKEFULNESS TSTG 669.11 XXX<br />
95805 26 MLT SLEEP LATENCY/MAINT OF WAKEFULNESS TSTG 100.81 XXX<br />
95805 TC MLT SLEEP LATENCY/MAINT OF WAKEFULNESS TSTG 568.30 XXX<br />
95806 SLEEP STD AIRFLOW HRT RATE&O2 SAT EFFORT UNATTN 296.89 XXX<br />
95806 26 SLEEP STD AIRFLOW HRT RATE&O2 SAT EFFORT UNATTN 102.47 XXX<br />
95806 TC SLEEP STD AIRFLOW HRT RATE&O2 SAT EFFORT UNATTN 194.42 XXX<br />
95807 SLEEP STD REC VNTJ RESPIR ECG/HRT RATE&O2 ATTN 766.04 XXX<br />
95807 26 SLEEP STD REC VNTJ RESPIR ECG/HRT RATE&O2 ATTN 103.03 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 277
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section X: General Medicine Services<br />
MEDICINE 90281–96999, 97597–97606, 97802–97804, 98960–99091, 99143–99199, 99605–99607<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
95807 TC SLEEP STD REC VNTJ RESPIR ECG/HRT RATE&O2 ATTN 663.01 XXX<br />
95808 POLYSM SLEEP STAGING 1-3 ADDL PARAM 1059.06 XXX<br />
95808 26 POLYSM SLEEP STAGING 1-3 ADDL PARAM 146.78 XXX<br />
95808 TC POLYSM SLEEP STAGING 1-3 ADDL PARAM 912.28 XXX<br />
95810 POLYSM SLEEP STAGING 4/> ADDL PARAM 1131.62 XXX<br />
95810 26 POLYSM SLEEP STAGING 4/> ADDL PARAM 204.39 XXX<br />
95810 TC POLYSM SLEEP STAGING 4/> ADDL PARAM 927.23 XXX<br />
95811 POLYSM SLEEP STAGING 4/> ADDL PARAM W/CPAP TX 1221.35 XXX<br />
95811 26 POLYSM SLEEP STAGING 4/> ADDL PARAM W/CPAP TX 213.81 XXX<br />
95811 TC POLYSM SLEEP STAGING 4/> ADDL PARAM W/CPAP TX 1007.54 XXX<br />
95812 EEG EXTND MNTR 41-60 MIN 513.47 XXX<br />
95812 26 EEG EXTND MNTR 41-60 MIN 88.07 XXX<br />
95812 TC EEG EXTND MNTR 41-60 MIN 425.40 XXX<br />
95813 EEG EXTND MNTR > 1 HR 578.83 XXX<br />
95813 26 EEG EXTND MNTR > 1 HR 140.69 XXX<br />
95813 TC EEG EXTND MNTR > 1 HR 438.14 XXX<br />
95816 EEG W/REC AWAKE&DROWSY 475.80 XXX<br />
95816 26 EEG W/REC AWAKE&DROWSY 89.18 XXX<br />
95816 TC EEG W/REC AWAKE&DROWSY 386.62 XXX<br />
95819 EEG W/REC AWAKE&ASLEEP 530.64 XXX<br />
95819 26 EEG W/REC AWAKE&ASLEEP 88.62 XXX<br />
95819 TC EEG W/REC AWAKE&ASLEEP 442.02 XXX<br />
95822 EEG REC COMA/SLEEP ONLY 496.29 XXX<br />
95822 26 EEG REC COMA/SLEEP ONLY 88.62 XXX<br />
95822 TC EEG REC COMA/SLEEP ONLY 407.67 XXX<br />
95824 EEG CERE DEATH EVAL ONLY 157.86 XXX<br />
95824 26 EEG CERE DEATH EVAL ONLY 61.48 XXX<br />
95824 TC EEG CERE DEATH EVAL ONLY 96.38 XXX<br />
95827 EEG ALL NIGHT REC 911.72 XXX<br />
95827 26 EEG ALL NIGHT REC 88.62 XXX<br />
95827 TC EEG ALL NIGHT REC 823.10 XXX<br />
95829 ELECTROCORTICOGRAM SURG SPX 2434.94 XXX<br />
95829 26 ELECTROCORTICOGRAM SURG SPX 504.05 XXX<br />
95829 TC ELECTROCORTICOGRAM SURG SPX 1930.89 XXX<br />
95830 INSERTION SPHENOIDAL ELECTRODES EEG RECORDING 310.74 XXX<br />
95831 MUSC TSTG MNL W/REPRT XTR EX HAND/TRNK 47.08 XXX<br />
95832 MUSC TSTG MNL W/REPRT HAND +-CMPRSN NML SIDE 45.42 XXX<br />
95833 MUSC TSTG MNL W/REPRT TOT EVAL BDY EX HANDS 59.82 XXX<br />
95834 MUSC TSTG MNL W/REPRT TOT EVAL BDY W/HANDS 75.33 XXX<br />
95851 ROM MEAS&REPRT EA XTR EX HAND/EA TRNK SCTJ SPINE 28.25 XXX<br />
95852 ROM MEAS&REPRT HAND +-CMPRSN NML SIDE 23.82 XXX<br />
s 95857 CHOLINESTERASE INHIBITOR CHALLENGE TEST 76.44 XXX<br />
95860 NDL EMG 1 XTR +-RELATED PARASPI AREAS 147.34 XXX<br />
95860 26 NDL EMG 1 XTR +-RELATED PARASPI AREAS 80.87 XXX<br />
95860 TC NDL EMG 1 XTR +-RELATED PARASPI AREAS 66.47 XXX<br />
95861 NDL EMG 2 XTR +-RELATED PARASPI AREAS 213.81 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
278 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section X: General Medicine Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
90281–96999, 97597–97606, 97802–97804, 98960–99091, 99143–99199, 99605–99607 MEDICINE<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
95861 26 NDL EMG 2 XTR +-RELATED PARASPI AREAS 129.06 XXX<br />
95861 TC NDL EMG 2 XTR +-RELATED PARASPI AREAS 84.75 XXX<br />
95863 NDL EMG 3 XTR +-RELATED PARASPI AREAS 258.12 XXX<br />
95863 26 NDL EMG 3 XTR +-RELATED PARASPI AREAS 155.09 XXX<br />
95863 TC NDL EMG 3 XTR +-RELATED PARASPI AREAS 103.03 XXX<br />
95864 NDL EMG 4 XTR +-RELATED PARASPI AREAS 283.60 XXX<br />
95864 26 NDL EMG 4 XTR +-RELATED PARASPI AREAS 165.62 XXX<br />
95864 TC NDL EMG 4 XTR +-RELATED PARASPI AREAS 117.98 XXX<br />
95865 NDL EMG LARX 194.97 XXX<br />
95865 26 NDL EMG LARX 132.38 XXX<br />
95865 TC NDL EMG LARX 62.59 XXX<br />
95866 NDL EMG HEMIDPHRM 168.94 XXX<br />
95866 26 NDL EMG HEMIDPHRM 104.13 XXX<br />
95866 TC NDL EMG HEMIDPHRM 64.81 XXX<br />
95867 NDL EMG CRNL NRV SUPPLIED MUSC UNI 130.72 XXX<br />
95867 26 NDL EMG CRNL NRV SUPPLIED MUSC UNI 66.47 XXX<br />
95867 TC NDL EMG CRNL NRV SUPPLIED MUSC UNI 64.25 XXX<br />
95868 NDL EMG CRNL NRV SUPPLIED MUSC BI 177.25 XXX<br />
95868 26 NDL EMG CRNL NRV SUPPLIED MUSC BI 98.04 XXX<br />
95868 TC NDL EMG CRNL NRV SUPPLIED MUSC BI 79.21 XXX<br />
95869 NDL EMG THRC PARASPI MUSC EXCLUDING T1/T12 95.27 XXX<br />
95869 26 NDL EMG THRC PARASPI MUSC EXCLUDING T1/T12 31.02 XXX<br />
95869 TC NDL EMG THRC PARASPI MUSC EXCLUDING T1/T12 64.25 XXX<br />
95870 NDL EMG LMTD STD MUSC 1 XTR/NON-LIMB UNI/BI 93.06 XXX<br />
95870 26 NDL EMG LMTD STD MUSC 1 XTR/NON-LIMB UNI/BI 30.46 XXX<br />
95870 TC NDL EMG LMTD STD MUSC 1 XTR/NON-LIMB UNI/BI 62.60 XXX<br />
95872 NDL EMG W/1 FIBER ELTRD QUAN MEAS JITTER 289.69 XXX<br />
95872 26 NDL EMG W/1 FIBER ELTRD QUAN MEAS JITTER 232.64 XXX<br />
95872 TC NDL EMG W/1 FIBER ELTRD QUAN MEAS JITTER 57.05 XXX<br />
+ 95873 ESTIM GDN CONJUNCT CHEMODNRVTJ 94.72 ZZZ<br />
+ 95873 26 ESTIM GDN CONJUNCT CHEMODNRVTJ 32.13 ZZZ<br />
+ 95873 TC ESTIM GDN CONJUNCT CHEMODNRVTJ 62.59 ZZZ<br />
+ 95874 NDL EMG GDN CONJUNCT CHEMODNRVTJ 90.29 ZZZ<br />
+ 95874 26 NDL EMG GDN CONJUNCT CHEMODNRVTJ 31.02 ZZZ<br />
+ 95874 TC NDL EMG GDN CONJUNCT CHEMODNRVTJ 59.27 ZZZ<br />
95875 ISCHEMIC LIMB XERS TST SPEC ACQUISJ METAB 171.16 XXX<br />
95875 26 ISCHEMIC LIMB XERS TST SPEC ACQUISJ METAB 90.84 XXX<br />
95875 TC ISCHEMIC LIMB XERS TST SPEC ACQUISJ METAB 80.32 XXX<br />
* 95900 NRV CNDJ AMPLT&STD EA NRV MOTOR W/O F-WAVE STD 98.04 XXX<br />
* 95900 26 NRV CNDJ AMPLT&STD EA NRV MOTOR W/O F-WAVE STD 34.90 XXX<br />
* 95900 TC NRV CNDJ AMPLT&STD EA NRV MOTOR W/O F-WAVE STD 63.14 XXX<br />
* 95903 NRV CNDJ AMPLT&STD EA NRV MOTOR W/F-WAVE STD 113.55 XXX<br />
* 95903 26 NRV CNDJ AMPLT&STD EA NRV MOTOR W/F-WAVE STD 49.85 XXX<br />
* 95903 TC NRV CNDJ AMPLT&STD EA NRV MOTOR W/F-WAVE STD 63.70 XXX<br />
* 95904 NRV CNDJ AMPLT&STD EA NRV SENS 86.41 XXX<br />
* 95904 26 NRV CNDJ AMPLT&STD EA NRV SENS 28.25 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 279
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section X: General Medicine Services<br />
MEDICINE 90281–96999, 97597–97606, 97802–97804, 98960–99091, 99143–99199, 99605–99607<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
* 95904 TC NRV CNDJ AMPLT&STD EA NRV SENS 58.16 XXX<br />
* 95905 MOTOR &/SENS NRV CNDJ PRECONF ELTRD ARRAY LIMB 137.37 XXX<br />
* 95905 26 MOTOR &/SENS NRV CNDJ PRECONF ELTRD ARRAY LIMB 4.99 XXX<br />
* 95905 TC MOTOR &/SENS NRV CNDJ PRECONF ELTRD ARRAY LIMB 132.38 XXX<br />
+ 95920 INTRAOP NEUROPHYSIOLOGY TSTG PR HR 258.12 ZZZ<br />
+ 95920 26 INTRAOP NEUROPHYSIOLOGY TSTG PR HR 173.92 ZZZ<br />
+ 95920 TC INTRAOP NEUROPHYSIOLOGY TSTG PR HR 84.20 ZZZ<br />
95921 TSTG ANS FUNCJ CARDIOVAGAL INNERVAJ PARASYMP 130.17 XXX<br />
95921 26 TSTG ANS FUNCJ CARDIOVAGAL INNERVAJ PARASYMP 72.56 XXX<br />
95921 TC TSTG ANS FUNCJ CARDIOVAGAL INNERVAJ PARASYMP 57.61 XXX<br />
95922 TSTG ANS FUNCJ VASOMOTOR ADRENERGIC INNERVAJ 160.63 XXX<br />
95922 26 TSTG ANS FUNCJ VASOMOTOR ADRENERGIC INNERVAJ 77.55 XXX<br />
95922 TC TSTG ANS FUNCJ VASOMOTOR ADRENERGIC INNERVAJ 83.08 XXX<br />
95923 TSTG ANS FUNCJ SUDOMOTOR 235.96 XXX<br />
95923 26 TSTG ANS FUNCJ SUDOMOTOR 74.22 XXX<br />
95923 TC TSTG ANS FUNCJ SUDOMOTOR 161.74 XXX<br />
95925 SHORT-LATENCY SOMATOSENS EP STD UPR LIMBS 255.35 XXX<br />
95925 26 SHORT-LATENCY SOMATOSENS EP STD UPR LIMBS 43.76 XXX<br />
95925 TC SHORT-LATENCY SOMATOSENS EP STD UPR LIMBS 211.59 XXX<br />
95926 SHORT-LATENCY SOMATOSENS EP STD LWR LIMBS 247.59 XXX<br />
95926 26 SHORT-LATENCY SOMATOSENS EP STD LWR LIMBS 44.87 XXX<br />
95926 TC SHORT-LATENCY SOMATOSENS EP STD LWR LIMBS 202.72 XXX<br />
95927 SHORT-LATENCY SOMATOSENS EP STD TRNK/HEAD 232.08 XXX<br />
95927 26 SHORT-LATENCY SOMATOSENS EP STD TRNK/HEAD 44.31 XXX<br />
95927 TC SHORT-LATENCY SOMATOSENS EP STD TRNK/HEAD 187.77 XXX<br />
95928 CTR MOTOR EP STD TRANSCRNL MOTOR STIMJ UPR LIMBS 381.08 XXX<br />
95928 26 CTR MOTOR EP STD TRANSCRNL MOTOR STIMJ UPR LIMBS 123.52 XXX<br />
95928 TC CTR MOTOR EP STD TRANSCRNL MOTOR STIMJ UPR LIMBS 257.56 XXX<br />
95929 CTR MOTOR EP STD TRANSCRNL MOTOR STIMJ LWR LIMBS 403.79 XXX<br />
95929 26 CTR MOTOR EP STD TRANSCRNL MOTOR STIMJ LWR LIMBS 124.07 XXX<br />
95929 TC CTR MOTOR EP STD TRANSCRNL MOTOR STIMJ LWR LIMBS 279.72 XXX<br />
95930 VISUAL EP TSTG CNS CHECKERBOARD/FLASH 217.13 XXX<br />
95930 26 VISUAL EP TSTG CNS CHECKERBOARD/FLASH 28.80 XXX<br />
95930 TC VISUAL EP TSTG CNS CHECKERBOARD/FLASH 188.33 XXX<br />
95933 MNTR SEIZURE CMPTR 16>CHAN EEG UNATND EA 24 HR 120.75 XXX<br />
95933 26 MNTR SEIZURE CMPTR 16>CHAN EEG UNATND EA 24 HR 49.30 XXX<br />
95933 TC MNTR SEIZURE CMPTR 16>CHAN EEG UNATND EA 24 HR 71.45 XXX<br />
95934 H-REFLEX AMPLT&LATENCY GASTRCN/SOLEUS MUSC 91.39 XXX<br />
95934 26 H-REFLEX AMPLT&LATENCY GASTRCN/SOLEUS MUSC 42.10 XXX<br />
95934 TC H-REFLEX AMPLT&LATENCY GASTRCN/SOLEUS MUSC 49.29 XXX<br />
95936 H-REFLEX AMPLT&LATENCY OTH/THN GASTRCN/SOLEUS 75.33 XXX<br />
95936 26 H-REFLEX AMPLT&LATENCY OTH/THN GASTRCN/SOLEUS 44.87 XXX<br />
95936 TC H-REFLEX AMPLT&LATENCY OTH/THN GASTRCN/SOLEUS 30.46 XXX<br />
95937 NEUROMUSCULAR JUNCT TSTG EA NRV ANY 1 METH 105.24 XXX<br />
95937 26 NEUROMUSCULAR JUNCT TSTG EA NRV ANY 1 METH 54.28 XXX<br />
95937 TC NEUROMUSCULAR JUNCT TSTG EA NRV ANY 1 METH 50.96 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
280 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section X: General Medicine Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
90281–96999, 97597–97606, 97802–97804, 98960–99091, 99143–99199, 99605–99607 MEDICINE<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
95950 MONITOR ID& LATERALIZATION SEIZURE FOCUS EEG 440.90 XXX<br />
95950 26 MONITOR ID& LATERALIZATION SEIZURE FOCUS EEG 124.07 XXX<br />
95950 TC MONITOR ID& LATERALIZATION SEIZURE FOCUS EEG 316.83 XXX<br />
95951 LOCALIZE CEREBRAL SEIZURE CABLE/RADIO EEG/VIDEO 1262.89 XXX<br />
95951 26 LOCALIZE CEREBRAL SEIZURE CABLE/RADIO EEG/VIDEO 505.16 XXX<br />
95951 TC LOCALIZE CEREBRAL SEIZURE CABLE/RADIO EEG/VIDEO 757.73 XXX<br />
s 95953 LOCALIZE CEREBRAL SEIZURE CPTR PORTABLE EEG 672.99 XXX<br />
s 95953 26 LOCALIZE CEREBRAL SEIZURE CPTR PORTABLE EEG 255.90 XXX<br />
s 95953 TC LOCALIZE CEREBRAL SEIZURE CPTR PORTABLE EEG 417.09 XXX<br />
95954 RX/PHYSICAL ACTIVAJ PHYS ATTN DURING EEG ACTIVAJ 505.71 XXX<br />
95954 26 RX/PHYSICAL ACTIVAJ PHYS ATTN DURING EEG ACTIVAJ 185.56 XXX<br />
95954 TC RX/PHYSICAL ACTIVAJ PHYS ATTN DURING EEG ACTIVAJ 320.15 XXX<br />
95955 EEG NONICRA SURG 273.63 XXX<br />
95955 26 EEG NONICRA SURG 81.98 XXX<br />
95955 TC EEG NONICRA SURG 191.65 XXX<br />
s 95956 MNTR SEIZURE CMPTR 16>CHAN EEG ATND EA 24 HR 1645.64 XXX<br />
s 95956 26 MNTR SEIZURE CMPTR 16>CHAN EEG ATND EA 24 HR 289.14 XXX<br />
s 95956 TC MNTR SEIZURE CMPTR 16>CHAN EEG ATND EA 24 HR 1356.50 XXX<br />
95957 DGTAL ALYS EEG 552.24 XXX<br />
95957 26 DGTAL ALYS EEG 163.40 XXX<br />
95957 TC DGTAL ALYS EEG 388.84 XXX<br />
95958 WADA ACTIVATION TEST HEMISPHERIC FUNCTION W/EEG 739.46 XXX<br />
95958 26 WADA ACTIVATION TEST HEMISPHERIC FUNCTION W/EEG 348.96 XXX<br />
95958 TC WADA ACTIVATION TEST HEMISPHERIC FUNCTION W/EEG 390.50 XXX<br />
95961 FUNCJAL CORT&SUBCORT MAPG ELTRDS 1 HR PHYS ATTN 409.33 XXX<br />
95961 26 FUNCJAL CORT&SUBCORT MAPG ELTRDS 1 HR PHYS ATTN 247.59 XXX<br />
95961 TC FUNCJAL CORT&SUBCORT MAPG ELTRDS 1 HR PHYS ATTN 161.74 XXX<br />
+ 95962 FUNCJAL CORT&SUBCORT MAPG ELTRDS EA HR PHYS ATTN 368.34 ZZZ<br />
+ 95962 26 FUNCJAL CORT&SUBCORT MAPG ELTRDS EA HR PHYS ATTN 264.76 ZZZ<br />
+ 95962 TC FUNCJAL CORT&SUBCORT MAPG ELTRDS EA HR PHYS ATTN 103.58 ZZZ<br />
95965 MAGNETOENCEPHALOGRAPHY SPON BRAIN ACTIVITY 3412.02 XXX<br />
95965 26 MAGNETOENCEPHALOGRAPHY SPON BRAIN ACTIVITY 682.40 XXX<br />
95965 TC MAGNETOENCEPHALOGRAPHY SPON BRAIN ACTIVITY 2729.62 XXX<br />
95966 MAGNETOENCEPHALOGRAPY EVOKED FIELDS 1 MODALITY 1703.24 XXX<br />
95966 26 MAGNETOENCEPHALOGRAPY EVOKED FIELDS 1 MODALITY 340.65 XXX<br />
95966 TC MAGNETOENCEPHALOGRAPY EVOKED FIELDS 1 MODALITY 1362.59 XXX<br />
+ 95967 MAGNETOENCEPHALOGRAPY EVOKED FIELDS EACH ADDL 1478.91 ZZZ<br />
+ 95967 26 MAGNETOENCEPHALOGRAPY EVOKED FIELDS EACH ADDL 295.78 ZZZ<br />
+ 95967 TC MAGNETOENCEPHALOGRAPY EVOKED FIELDS EACH ADDL 1183.13 ZZZ<br />
95970 ELEC ALYS NSTIM PLS GEN BRN/SC/PERPH W/O REPRGRM 95.82 XXX<br />
95971 ELEC ALYS NSTIM PLS GEN SMPL SC/PERPH W/PRGRMG 94.16 XXX<br />
95972 ELEC ALYS NSTIM PLS GEN CPLX SC/PERPH 1ST HR 173.37 XXX<br />
+ 95973 ELEC ALYS NSTIM PLS GEN CPLX SC/PERPH EA 30 MIN 97.49 ZZZ<br />
95974 ELEC ALYS NSTIM PLS GEN CPLX CRNL NRV 1ST HR 301.32 XXX<br />
+ 95975 ELEC ALYS NSTIM PLS GEN CPLX CRNL NRV EA 30 MIN 162.85 ZZZ<br />
95978 ELEC ALYS NSTIM PLS GEN CPLX DP BRN 1ST HR 365.02 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 281
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section X: General Medicine Services<br />
MEDICINE 90281–96999, 97597–97606, 97802–97804, 98960–99091, 99143–99199, 99605–99607<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
+ 95979 ELEC ALYS NSTIM PLS GEN CPLX DP BRN EA 30 MIN 159.52 ZZZ<br />
95980 ELEC ALYS NSTIM PLS GEN GASTRIC INTRAOP W/PRGRMG 73.67 XXX<br />
95981 ELEC ALYS NSTIM GEN GASTRIC SBSQ W/O REPRGRMG 49.85 XXX<br />
95982 ELEC ALYS NSTIM PLS GEN GASTRIC SBSQ W/REPRGRMG 77.55 XXX<br />
95990 REFILL&MAINTENANCE PUMP DRUG DLVR SPINAL/BRAIN 122.97 XXX<br />
95991 RFL&MAIN IMPLT PMP/RSVR RX DLVR SPI/BRN BY PHYS 171.71 XXX<br />
* 95992 CANALITH REPOSITIONING PROCEDURE 69.24 XXX<br />
95999 UNLIS NEUROLOGICAL/NEUROMUSCULAR DX PX BR XXX<br />
96000 COMPRE CPTR MTN ALYS VIDEO TAPING 3-D KINEMATICS 148.45 XXX<br />
96001 COMPRE CPTR MTN ALYS W/DYN PLNTR PRES MEAS WALKG 163.40 XXX<br />
96002 DYN SURF EMG WALKG/FUNCJAL ACTV 1-12 MUSC 34.34 XXX<br />
96003 DYN FINE WIRE EMG WALKG/FUNCJAL ACTV 1 MUSC 30.46 XXX<br />
96004 PHYS R&I CPTR MTN ALYS WALKG/FUNCJAL ACTV REPRT 181.68 XXX<br />
96020 TEST SELECTION & ADMN FUNCTIONAL BRAIN MAPPING BR XXX<br />
96040 <strong>MEDICAL</strong> GENETICS COUNSELING EA 30 MIN 73.11 XXX<br />
96101 PSYCHOLOGICAL TESTING PR HR F2F TIME W/PT 135.15 XXX<br />
96102 PSYCL TSTG PR HR ADMN BY TECH PR HR 108.56 XXX<br />
96103 PSYCL TSTG PR HR ADMN BY CPTR W/PROF I&R 91.39 XXX<br />
96105 ASSMT APHASIA W/I&R PR HR 173.92 XXX<br />
96110 DEVELOPMENTAL TSTG LMTD W/I&R 13.29 XXX<br />
96111 DEVELOPMENTAL TSTG EXTND W/I&R 204.39 XXX<br />
96116 NUBHVL STATUS XM PR HR F2F W/PT INTERPJ&PREPJ 148.45 XXX<br />
96118 NUROPSYC TESTING PR HR F2F W/PT + INTERPJ TIME 158.42 XXX<br />
96119 NUROPSYC TSTG WPROF I&R ADMN BY TECH PR HR 114.66 XXX<br />
96120 NUROPSYC TSTG ADMN BY CPTR W/PROF I&R 134.04 XXX<br />
96125 STANDARDIZED COGNITIVE PERFORMANCE TESTING 152.88 XXX<br />
96150 HLTH&BEHAVIOR ASSMT EA 15 MIN F2F W/PT 1ST ASSMT 34.34 XXX<br />
96151 HLTH&BEHAVIOR ASSMT EA 15 MIN F2F W/PT RE-ASSMT 33.23 XXX<br />
96152 HLTH&BEHAVIOR IVNTJ EA 15 MIN F2F INDIV 31.57 XXX<br />
96153 HLTH&BEHAVIOR IVNTJ EA 15 MIN F2F GRP 2/> PTS 7.75 XXX<br />
96154 HLTH&BEHAVIOR IVNTJ EA 15 MIN F2F FAM W/PT 31.02 XXX<br />
96155 HLTH&BEHAVIOR IVNTJ EA 15 MIN F2F FAM W/O PT 37.11 XXX<br />
96360 IV INFUSION HYDRATION INITIAL 31 MIN-1 HOUR 93.06 XXX<br />
+ 96361 IV INFUSION HYDRATION EACH ADDITIONAL HOUR 24.93 ZZZ<br />
96365 IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR 115.77 XXX<br />
+ 96366 IV INFUSION THERAPY PROPHYLAXIS/DX EA HOUR 35.45 ZZZ<br />
+ 96367 IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR 53.73 ZZZ<br />
+ 96368 IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS 31.57 ZZZ<br />
96369 SUBCUTANEOUS INFUSION INITIAL 1 HR W/PUMP SET-UP 278.61 XXX<br />
+ 96370 SUBCUTANEOUS INFUSION EACH ADDITIONAL HOUR 24.93 ZZZ<br />
+ 96371 SUBQ INFUSION ADDITIONAL PUMP INFUSION SITE 130.72 ZZZ<br />
96372 THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM 37.67 XXX<br />
96373 THERAPEUTIC PROPHYLACTIC/DX NJX INTRA-ARTERIAL 31.02 XXX<br />
96374 THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG 90.84 XXX<br />
+ 96375 THERAPEUTIC INJECTION IV PUSH EACH NEW DRUG 37.11 ZZZ<br />
+ 96376 THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC 22.71 ZZZ<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
282 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section X: General Medicine Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
90281–96999, 97597–97606, 97802–97804, 98960–99091, 99143–99199, 99605–99607 MEDICINE<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
96379 UNLISTED THERAPEUTIC PROPH/DX IV/IA NJX/NFS BR XXX<br />
96401 CHEMOTX ADMN SUBQ/IM NON-HORMONAL ANTI-NEO 118.53 XXX<br />
96402 CHEMOTX ADMN SUBQ/IM HORMONAL ANTI-NEO 57.05 XXX<br />
96405 CHEMOTX ADMN ILESN UP&W/7 < 140.14 000<br />
96406 CHEMOTX ADMN ILESN > 7 192.76 000<br />
96409 CHEMOTX ADMN IV PUSH TQ 1/1ST SBST/DRUG 183.89 XXX<br />
+ 96411 CHEMOTX ADMN IV PUSH TQ EA SBST/DRUG 103.03 ZZZ<br />
96413 CHEMOTX ADMN IV NFS TQ UP 1 HR 1/1ST SBST/DRUG 238.73 XXX<br />
+ 96415 CHEMOTHERAPY ADMN IV INFUSION TQ EA HR 50.96 ZZZ<br />
96416 CHEMOTX ADMN TQ INIT PROLNG CHEMOTX NFUS PMP 263.10 XXX<br />
+ 96417 CHEMOTX ADMN IV NFS TQ EA SEQL NFS TO 1 HR 117.98 ZZZ<br />
96420 CHEMOTX ADMN IA PUSH TQ 177.80 XXX<br />
96422 CHEMOTX ADMN IA NFS TQ UP 1 HR 285.81 XXX<br />
+ 96423 CHEMOTHERAPY ADMN INTRAARTERIAL INFUSION EA HR 130.17 ZZZ<br />
96425 CHEMOTX ADMN IA NFS > 8 HR PRTBLE IMPLTBL PMP 293.01 XXX<br />
96440 CHEMOTX ADMN PLEURAL CAVITY REQ&W/THORACNTS 1188.12 000<br />
l 96446 CHEMOTX ADMN PRTL CAVITY PORT/CATH 288.58 XXX<br />
96450 CHEMOTX ADMN CNS REQ&W/SPI PNXR 324.03 000<br />
96521 RFL/MAIN PORTABLE PMP 217.13 XXX<br />
96522 REFILL&MAINTENANCE PUMP DRUG DLVR SYSTEMIC 181.13 XXX<br />
96523 IRRIGATION IMPLANTED VAD FOR DRUG DLVR 41.54 XXX<br />
96542 CHEMOTX NJX SUBARACHND/INTRAVENTR RSVR 1+ AGENTS 207.16 XXX<br />
96549 UNLIS CHEMOTX PX BR XXX<br />
96567 PDT XTRNL APPL LIGHT DSTR LES SKN BY ACTIVJ RX 213.25 XXX<br />
+ 96570 PDT NDSC ABL ABNOR TISS VIA ACTIVJ RX 30 MIN 96.93 ZZZ<br />
+ 96571 PDT NDSC ABL ABNOR TISS VIA ACTIVJ RX A 15 MIN 44.31 ZZZ<br />
96900 ACTIXH ULTRAVIOLET LIGHT 33.79 XXX<br />
96902 MCRSCP XM HAIR PLUCK/CLIP FOR CNTS/STRUCT ABNORM 35.45 XXX<br />
96904 WHOLE BODY INTEGUMENTARY PHOTOGRAPHY 110.78 XXX<br />
96910 PHOTOCHEMOTX TAR&UVB/PETROLATUM/UVB 113.00 XXX<br />
96912 PHOTOCHEMOTX PSORALENS&ULTRAVIOLET PUVA 145.12 XXX<br />
96913 PHOTOCHEMOTHERAPY DERMATOSES 4-8 HRS SUPERVISION 201.62 XXX<br />
96920 LASER SKIN DISEASE PSORIASIS TOT AREA 500 SQ CM 407.12 000<br />
96999 UNLIS SPEC DERMATOLOGICAL SVC/PX BR XXX<br />
s 97597 DEBRIDEMENT OPEN WOUND 20 SQ CM< 104.64 000<br />
s + 97598 DEBRIDEMENT OPEN WOUND ADDL 20 SQ CM 35.05 ZZZ<br />
97602 RMVL DEVITAL TISS N-SLCTV DBRDMT W/O ANES 1 SESS 50.35 XXX<br />
97605 NEG PRESS WND THER 50 SQ CM 61.21 XXX<br />
97802 MED NUTR THER 1ST ASSMT&IVNTJ INDIV EA 15 MIN 46.40 XXX<br />
97803 MED NUTR THER RE-ASSMT&IVNTJ INDIV EA 15 MIN 40.48 XXX<br />
97804 MED NUTR THER GRP2/> INDIV EA 30 MIN 20.24 XXX<br />
98960 EDUCATION&TRAINING SELF-MGMT NONPHYS 1 PT 42.65 XXX<br />
98961 EDUCATION&TRAINING SELF-MGMT NONPHYS 2-4 PTS 20.49 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 283
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section X: General Medicine Services<br />
MEDICINE 90281–96999, 97597–97606, 97802–97804, 98960–99091, 99143–99199, 99605–99607<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
98962 EDUCATION&TRAINING SELF-MGMT NONPHYS 5-8 PTS 15.51 XXX<br />
98966 NONPHYSICIAN TELEPHONE ASSESSMENT 5-10 MIN 22.71 XXX<br />
98967 NONPHYSICIAN TELEPHONE ASSESSMENT 11-20 MIN 43.20 XXX<br />
98968 NONPHYSICIAN TELEPHONE ASSESSMENT 21-30 MIN 63.70 XXX<br />
98969 NONPHYSICIAN ONLINE ASSESSMENT AND MANAGEMENT 34.90 XXX<br />
99000 HANDLG&/OR CONVEY OF SPEC FOR TR OFFICE TO LAB 11.08 XXX<br />
99001 HANDLG&/OR CONVEY OF SPEC FOR TR FROM PT TO LAB 12.74 XXX<br />
99002 HANDLING CONVEY/ANY OTH SVC INVG DEV FIT BY PHYS 13.85 XXX<br />
99024 PO F-UP VST RELATED TO ORIGINAL PX BR XXX<br />
99026 HOSP MANDATED CALL SVC IN-HOSP EA HR BR XXX<br />
99027 HOSP MANDATED CALL SVC OUT-OF-HOSP EA HR BR XXX<br />
99050 SVCS PRV OFFICE OTH/THN REG SCHEDD HRS 36.00 XXX<br />
99051 SVC PRV OFFICE REG SCHEDD EVN WKEND/HOLIDAY HRS BR XXX<br />
99053 SVC PRV BTW 10 PM&8 AM AT 24-HR FAC BR XXX<br />
99056 SVC TYPICAL PRV OFFICE PRV OUT OFFICE REQUEST PT 34.34 XXX<br />
99058 SVC PRV EMER BASIS OFFICE DISRUPTS OFFICE SVCS 43.20 XXX<br />
99060 SVC PRV EMER OUT OFFICE DISRUPTS OFFICE SVC 47.64 XXX<br />
99070 SUPPLIES&MATERIALS PRV BY PHYS >&ABOVE BR XXX<br />
99071 EDUCATIONAL SUPPLIES PRV BY THE PHYS AT COST BR XXX<br />
99075 <strong>MEDICAL</strong> TSTIMONY See Page 14 XXX<br />
99078 PHYS EDUCATIONAL SVCS RENDERED PTS GRP SETTING BR XXX<br />
99080 SPEC REPORTS > USUAL MED COMUNICAJ/STAND RPRTG See Page 14 XXX<br />
99082 UNUSUAL TRAVEL BR XXX<br />
99090 ALYS CLINICAL DATA STORED CPTRS BR XXX<br />
99091 COLLJ&INTERPJ PHYSIO DATA DIG STRD/TRANS 30 MIN 90.84 XXX<br />
* 99143 M-SEDATJ BY SM PHYS PERFRMG SVC < 5 YR 103.58 XXX<br />
* 99144 M-SEDAJ BY SM PHYS PERFRMG SVC 5+ YR 85.85 XXX<br />
+ 99145 M-SEDAJ BY SM PHYS PERFRMG SVC EA 15 MIN 34.34 ZZZ<br />
99148 M-SEDATION BY PHYS OTH/THN HC PROF PERFRMG < 5 94.72 XXX<br />
99149 M-SEDATION BY PHYS OTH/THN HC PROF PERFRMG 5+ 77.55 XXX<br />
+ 99150 M-SEDAJ PHYS OTH/THN HC PROF PERFRMG EA 15 MIN 34.34 ZZZ<br />
99170 COLLJ/INT PHYSIO DATA DIG STRD/TRANS MINIM 30MIN 235.41 000<br />
99172 VSL FUNC SCRNG AUTO SEMI-AUTO BI QUAN DETERM 34.34 XXX<br />
99172 26 VSL FUNC SCRNG AUTO SEMI-AUTO BI QUAN DETERM 6.65 XXX<br />
99172 TC VSL FUNC SCRNG AUTO SEMI-AUTO BI QUAN DETERM 27.69 XXX<br />
99173 SCREENING 4.43 XXX<br />
99174 OCULAR PHOTOSCREENING INTERPRETATION BILATERAL 45.42 XXX<br />
99175 IPECAC/SIMILAR ADMN EMESIS&OBS STOMACH EMPTIED 39.88 XXX<br />
99183 PHYS ATTN&SUPVJ HYPRBARIC OXYGEN THER PR SESS 338.99 XXX<br />
99190 ASSEM/OPRATN PMP OXTJ/HEAT EXCHNGR EA HR 859.10 XXX<br />
99191 ASSEM/OPRATN PMP OXTJ/HEAT EXCHNGR 3/4 HR 600.98 XXX<br />
99192 ASSEM/OPRATN PMP OXTJ/HEAT EXCHNGR 1/2 HR 429.27 XXX<br />
99195 PHLEBOTOMY THER SPX 140.69 XXX<br />
99199 UNLIS SPEC SVC PX/REPRT BR XXX<br />
99605 MEDICATION THERAPY 1ST 15 MIN NEW PATIENT BR XXX<br />
99606 MEDICATION THERAPY F2F 1ST 15 MIN ESTABLISHED PT BR XXX<br />
+ 99607 MEDICATION THERAPY F2F EA ADDITIONAL 15 MIN BR XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure # Resequenced Code l New CPT Procedure s Revised CPT Procedure<br />
284 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section XI: Physical Medicine<br />
Services<br />
SUBSECTION A: PAYMENT GROUND RULES FOR<br />
PHYSICAL MEDICINE SERVICES<br />
General Guidelines<br />
Protocols used by physicians in reporting their services are<br />
generally described below. Some of the commonalties with<br />
other subsections may be repeated here. If no appropriate<br />
code is found for medical services performed by a medical<br />
provider, use the appropriate unlisted code (e.g., CPT code<br />
99199), and adequately describe the service provided.<br />
Chiropractic and physical therapy service reimbursements<br />
are explained in this section.<br />
Supplies and materials provided by the medical provider<br />
(e.g., sterile trays), over and above that usually provided<br />
during an office visit, or other services rendered, may be<br />
charged for separately and coded separately. A physician<br />
office visit code may be charged in addition to the code for<br />
modalities/procedures only if the accompanying<br />
documentation clearly indicates that the physician or<br />
medical provider actually examined the worker during the<br />
office visit.<br />
Interpretation<br />
In circumstances where an interpreter is required during<br />
face-to-face evaluation and management services, or physical<br />
medicine evaluations (97001–97004), provided to the<br />
injured worker by a physician or PE, whether interpretation<br />
is provided live, via telephone or video, add state-specific<br />
modifier TR to the E/M code. Reimbursement will be an<br />
additional 25 percent of the lesser of billed charges or<br />
maximum allowable rate of that code only. Prolonged service<br />
codes 99354–99357 may not be used in combination with<br />
this modifier. Additional reimbursement as outlined above<br />
does not apply to independent medical evaluations (IME).<br />
In circumstances where an interpreter is required for an<br />
injured worker, and the service is provided by telephone<br />
with a physician or qualified non-physician health care<br />
provider, use the appropriate CPT codes 99441–99443<br />
(physicians) and 98966–98968 (qualified non-physician<br />
health care providers), and append state-specific modifier<br />
TR. <strong>The</strong>se codes should be used in accordance with the<br />
guidelines and descriptions found in CPT 2011.<br />
Reimbursement will be an additional 25 percent of the lesser<br />
of billed charges or maximum allowable rate of that code<br />
only.<br />
Unusual Service or Procedure<br />
Services that may necessitate skills and time of the physician<br />
over and above that usually required should be substantiated<br />
by report (see section IV).<br />
Unlisted Service or Procedure<br />
Some services performed are not described by any CPT code.<br />
Unlisted services should be reported using an unlisted code<br />
and substantiated by report. <strong>The</strong> unlisted services and<br />
accompanying codes are listed at the end of each Physical<br />
Medicine subsection. Unlisted service or procedure codes<br />
must be selected from the appropriate subsection of the<br />
Physical Medicine chapter. For these procedures a “BR” (by<br />
report) designation has been used in the fee schedule.<br />
Reimbursement for such procedures must be justified by<br />
report (see section IV).<br />
Initial Evaluation and Re-evaluation by Physical<br />
<strong>The</strong>rapists or Occupational <strong>The</strong>rapists<br />
CPT code 97001 Physical therapy evaluation, is a<br />
one-time-only charge. If the patient changes treatment<br />
facilities, another one-time-only evaluation may be charged.<br />
CPT code 97002 Physical therapy re-evaluation, may be<br />
charged if the existing patient suffers a reoccurrence of the<br />
same medical condition at least one month after the date of<br />
the last visit for therapy or the existing patient sustains an<br />
additional injury and requires additional physical therapy.<br />
CPT code 97003 Occupational therapy evaluation, is a<br />
one-time-only charge. If the patient changes treatment<br />
facilities, a one-time-only evaluation may be charged. CPT<br />
code 97004 Occupational therapy re-evaluation, may be<br />
CPT only © 2010 American Medical Association. All Rights Reserved. 285
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
charged if the existing patient suffers a reoccurrence of the<br />
same medical condition at least one month after the date of<br />
the last visit for therapy or the existing patient sustains an<br />
additional injury and requires additional occupational<br />
therapy.<br />
Exam Visits to Occupational <strong>The</strong>rapists or Physical<br />
<strong>The</strong>rapists<br />
Services performed by a physical therapist and/or<br />
occupational therapist shall be under the prescription of the<br />
authorized treating physician detailing the type, frequency,<br />
and duration of therapy to be provided. Only physical<br />
therapists’ and/or occupational therapists’ procedures and<br />
services are billable, and there will be no reimbursement for<br />
office visits.<br />
Multiple Concurrent Physical Medicine Procedures<br />
and Modalities<br />
Multiple concurrent physical medicine procedures are<br />
subject to the following rules and limitations.<br />
• No more than four physical medicine procedures,<br />
modalities or time units will be reimbursed in one visit<br />
by each type of medical provider. No more than two of<br />
the four CPT code charges can be modality codes (CPT<br />
codes 97010–97039). <strong>The</strong> only exceptions to this are:<br />
1. If injured employee is diagnosed as “catastrophic.”<br />
2. CPT codes 97545 and 97546 (see Section IV:<br />
General Reimbursment Requirements, Physical<br />
Medicine Maximum Per Visit and/or Day for more<br />
details).<br />
3. State-specific code FCE01 must be used for billing<br />
functional capacity evaluation. <strong>The</strong> maximum<br />
allowable rate of reimbursement is $45.41 per each<br />
15 minutes (not to exceed $600.00 per FCE).<br />
4. CPT code 97750 must be used by physical/<br />
occupational therapists when billing for Physical<br />
Performance Test/Measurements that are required<br />
by the treating physician in preparing an<br />
impairment rating. No more than 4 time units per<br />
visit per day can be billed. Additional physical<br />
medicine treatment can be conducted on the same<br />
day, with reimbursement in accordance with<br />
Section XI: Physical Medicine Services. Modifier 59<br />
may be used when multiple procedures are<br />
performed on the same day.<br />
CPT code 99455 shall be used by the treating<br />
physician when performing an impairment rating.<br />
Under the guidelines above, Physical Performance<br />
Test/Measurement testing and FCE can be<br />
performed on the same day by<br />
Section XI: Physical Medicine Services<br />
physical/occupational therapists. Modifier 59 may<br />
be used when multiple procedures are performed<br />
on the same day.<br />
5. CPT code 97760, Management and training<br />
(including assessment and fitting when not<br />
otherwise reported) for orthotics, CPT code 97761,<br />
Prosthetic training, and CPT code 97762, Checkout<br />
for orthotic/prosthetic use, established patient. CPT<br />
code 97762 is used to checkout the<br />
orthotic/prosthetic for any medically necessary<br />
adjustments.<br />
6. By mutual agreement of all parties.<br />
• CPT code 97010 covers the application of one or more<br />
hot or cold packs and should be billed only once per<br />
treatment session. This code should not be used to bill<br />
the application of each individual pack.<br />
For additional information on reimbursement related to<br />
these exceptions, see Section IV: General Reimbursement<br />
Requirements.<br />
Manipulation Codes<br />
Special codes are designated for use by chiropractors and<br />
osteopaths to bill for manipulation services. When billing for<br />
manipulation services, licensed chiropractors may bill using<br />
CPT codes 98940–98943. Licensed osteopaths may bill<br />
using CPT codes 98925–98929. <strong>The</strong> chiropractic<br />
manipulative treatment codes include a premanipulation<br />
patient assessment. Additional evaluation and management<br />
(E/M) services may be reported separately using modifier 25,<br />
if the injured employee’s condition requires a significant,<br />
separately identifiable E/M service, which is above and<br />
beyond the usual preservice and postservice work associated<br />
with the procedure.<br />
Tests and Measurements<br />
Test and measurement codes are included in the value of an<br />
evaluation and management service when performed on the<br />
same day as test and measurement services (CPT codes<br />
97750–97755).<br />
Fabrication of Orthotics<br />
Orthotics must be billed separately for professional fitting<br />
and supplies. CPT code 97760 must be used for a medical<br />
provider or therapist to fabricate orthotics. Custom-made<br />
orthotics and prosthetics are exempt from the medical<br />
supplies reimbursement formula; however, usual, customary,<br />
and reasonable charges will apply or by agreement of the<br />
parties. Additional medical supplies may not exceed medical<br />
supplies reimbursement formula. Medical supplies shall be<br />
reported using CPT code 99070. (See Materials Supplied by<br />
the Health Care Provider in section IV.)<br />
286 CPT only © 2010 American Medical Association. All Rights Reserved.
Section XI: Physical Medicine Services<br />
TENS Units<br />
TENS units (transcutaneous electrical nerve stimulation)<br />
must be prescribed by the authorized treating physician.<br />
Rental equipment is subject to usual, customary, and<br />
reasonable charges or by agreement. Rental equipment is<br />
exempt from the reimbursement formula. <strong>The</strong> purchase of<br />
such units will be subject to durable/medical supplies<br />
reimbursement formula utilizing CPT code 99070. (See<br />
Materials Supplied by the Health Care Provider in section<br />
IV.)<br />
SUBSECTION B: PAYMENT MODIFIERS FOR<br />
PHYSICAL MEDICINE SERVICES<br />
A modifier indicates a service or procedure performed has<br />
been altered by some specific circumstance but has not<br />
changed its definition or code. <strong>The</strong> modifying circumstance<br />
shall be identified by the appropriate modifier following the<br />
procedure code. When two modifiers are applicable to a<br />
single code, indicate each modifier on the bill. If more than<br />
one modifier is used, place the “Multiple Modifiers” code 99<br />
immediately after the procedure code. This indicates that<br />
one or more additional modifier codes will follow. Only<br />
certain modifiers in each of the categories (Evaluation and<br />
Management, Anesthesia, Surgery, Pathology/Laboratory,<br />
Radiology, General Medicine, and Physical Medicine) will be<br />
recognized for reimbursement purposes.<br />
<strong>The</strong> modifiers listed below may differ from those published<br />
by the American Medical Association. Medical providers<br />
submitting workers’ compensation billing shall use only the<br />
modifiers set out in the fee schedule.<br />
Note: Modifier 21 has been deleted. To report prolonged<br />
physician services, see 99354–99357.<br />
<strong>The</strong> following modifiers will be recognized for<br />
reimbursement by the fee schedule for physical medicine<br />
services codes:<br />
22 Increased Procedural Services: When the work<br />
required to provide a service is substantially greater than<br />
typically required, it may be identified by adding<br />
modifier 22 to the usual procedure code.<br />
Documentation must support the substantial additional<br />
work and the reason for the additional work (i.e.,<br />
increased intensity, time, technical difficulty of<br />
procedure, severity of patient’s condition, physical and<br />
mental effort required). Note: This modifier should not<br />
be appended to an E/M service.<br />
24 Unrelated Evaluation and Management Service by<br />
the Same Physician during a Postoperative Period:<br />
<strong>The</strong> physician may need to indicate that an evaluation<br />
and management service was performed during a<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
postoperative period for a reason(s) unrelated to the<br />
original procedure. This circumstance may be reported<br />
by adding modifier 24 to the appropriate level of E/M<br />
service.<br />
26 Professional Component Only: Certain procedures are<br />
a combination of a physician component and a technical<br />
component. When the physician component is reported<br />
separately, the service may be identified by adding<br />
modifier 26 to the usual procedure number.<br />
52 Reduced Services: Under certain circumstances, a<br />
service or procedure is partially reduced or eliminated at<br />
the physician’s discretion. Under these circumstances,<br />
the service provided can be identified by its usual<br />
procedure number and the addition of modifier 52<br />
signifying that the service is reduced. This provides a<br />
means of reporting reduced services without disturbing<br />
the identification of the basic service. Note: For hospital<br />
outpatient reporting of a previously scheduled<br />
procedure/service that is partially reduced or cancelled<br />
as a result of extenuating circumstances or those that<br />
threaten the well-being of the patient prior to or after<br />
administration of anesthesia, see modifiers 73 and 74<br />
(see modifiers approved for ASC hospital outpatient<br />
use).<br />
53 Discontinued Procedure: Under certain circumstances,<br />
the physician may elect to end a surgical or diagnostic<br />
procedure. Due to extenuating circumstances or those<br />
that threaten the well-being of the patient, it may be<br />
necessary to indicate that a surgical or diagnostic<br />
procedure was started but discontinued. This<br />
circumstance may be reported by adding modifier 53 to<br />
the code for the discontinued procedure. Note: This<br />
modifier is not used to report the elective cancellation of<br />
a procedure before the patient’s anesthesia induction<br />
and/or surgical preparation in the operating suite. For<br />
outpatient hospital/ambulatory surgery center (ASC)<br />
reporting of a previously scheduled procedure/service<br />
that is partially reduced or cancelled as a result of<br />
extenuating circumstances or those that threaten the<br />
well-being of the patient prior to or after administration<br />
of anesthesia, see modifiers 73 and 74 (see modifiers<br />
approved for ASC hospital outpatient use).<br />
59 Distinct Procedural Service: Under certain<br />
circumstances, it may be necessary to indicate that a<br />
procedure or service was distinct or independent from<br />
other non-E/M services performed on the same day.<br />
Modifier 59 is used to identify procedures/services,<br />
other than E/M services, that are not normally reported<br />
together but are appropriate under the circumstances.<br />
Documentation must support a different session,<br />
different procedure or surgery, different site or organ<br />
system, separate incision or excision, separate lesion, or<br />
separate injury (or area of injury in extensive injuries)<br />
CPT only © 2010 American Medical Association. All Rights Reserved. 287
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
not ordinarily encountered or performed on the same<br />
day by the same individual. However, when another<br />
already established modifier is appropriate, it should be<br />
used rather than modifier 59. Only if no more<br />
descriptive modifier is available, and the use of modifier<br />
59 best explains the circumstances, should modifier 59<br />
be used. Note: Modifier 59 should not be appended to<br />
an E/M service. To report a separate and distinct E/M<br />
service with a non-E/M service performed on the same<br />
date, see modifier 25.<br />
99 Multiple Modifiers: Under certain circumstances, two<br />
or more modifiers may be necessary to completely<br />
delineate a service. In such situations modifier 99<br />
should be added to the basic procedure, and other<br />
applicable modifiers may be listed as part of the<br />
description of the service.<br />
Section XI: Physical Medicine Services<br />
TC Technical Component Only: Certain procedures are a<br />
combination of a physician component and a technical<br />
component. When the technical component is reported<br />
separately, the service may be identified by adding<br />
modifier TC to the usual procedure number.<br />
TR Interpretation: In circumstances where an interpreter is<br />
required during face-to-face evaluation and<br />
management services provided to the injured worker by<br />
a physician or PE, add state-specific modifier TR to the<br />
E/M code. Reimbursement will be an additional 25<br />
percent of the lesser of billed charges or maximum<br />
allowable rate of that code only. Prolonged service codes<br />
99353–99357 may not be used in combination with the<br />
TR modifier unless it is documented that the reason for<br />
the code is additional time required as a result of factors<br />
beyond the need for an interpreter. Additional<br />
reimbursement as outlined above does not apply to<br />
independent medical evaluations (IME).<br />
288 CPT only © 2010 American Medical Association. All Rights Reserved.
Section XI: Physical Medicine Services<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
97001–97546, 97750–97799, 97810–98943, FCE01 PHYSICAL MEDICINE<br />
Effective April 1, 2011<br />
Medical Fee Schedule<br />
CODE MOD DESCRIPTION MAR FUD<br />
97001 PHYSICAL THER EVAL 105.14 XXX<br />
97002 PHYSICAL THER RE-EVAL 58.24 XXX<br />
97003 OCCUPATIONAL THER EVAL 116.00 XXX<br />
97004 OCCUPATIONAL THER RE-EVAL 70.58 XXX<br />
97005 ATHLETIC TRAINJ EVAL 0.00 XXX<br />
97006 ATHLETIC TRAINJ RE-EVAL 0.00 XXX<br />
97010 APPL MODALITY 1+ AREAS HOT/COLD PACKS 7.90 XXX<br />
97012 APPL MODALITY 1+ AREAS TRCJ MCHNL 22.21 XXX<br />
97014 APPL MODALITY 1+ AREAS ELEC STIMJ UNATTN 21.22 XXX<br />
97016 APPL MODALITY 1+ AREAS VASOPNEUMATIC DEV 25.17 XXX<br />
97018 APPL MODALITY 1+ AREAS PARAFFIN BATH 13.82 XXX<br />
97022 APPL MODALITY 1+ AREAS WP 29.62 XXX<br />
97024 APPL MODALITY 1+ AREAS DTHRM 8.88 XXX<br />
97026 APPL MODALITY 1+ AREAS INFRARED 7.90 XXX<br />
97028 APPL MODALITY 1+ AREAS ULTRAVIOLET 9.87 XXX<br />
97032 APPL MODALITY 1+ AREAS ELEC STIMJ EA 15 MIN 25.67 XXX<br />
97033 APPL MODALITY 1+ AREAS IONTOPHORESIS EA 15 MIN 40.97 XXX<br />
97034 APPL MODALITY 1+ AREAS CNTRST BATHS EA 15 MIN 23.69 XXX<br />
97035 APPL MODALITY 1+ AREAS US EA 15 MIN 17.28 XXX<br />
97036 APPL MODALITY 1+ AREAS HUBBARD TANK EA 15 MIN 42.45 XXX<br />
97039 UNLIS MODALITY SPEC TYP&TM IF CONSTANT ATTN BR XXX<br />
97110 THER PX 1+ AREAS EA 15 MIN THER XERSS 42.94 XXX<br />
97112 THER PX 1+ AREAS EA 15 MIN NEUROMUSC REEDUCAJ 44.92 XXX<br />
97113 THER PX 1+ AREAS EA 15 MIN AQUATIC THER W/XERSS 56.27 XXX<br />
97116 THER PX 1+ AREAS EA 15 MIN GAIT TRAINJ W/STAIR 38.01 XXX<br />
97124 THER PX 1+ AREAS EA 15 MIN MASSAGE 35.05 XXX<br />
97139 UNLIS THER PX SPEC BR XXX<br />
97140 MNL THER TQS 1+ REGIONS EA 15 MIN 40.48 XXX<br />
97150 THER PX GRP 2/> INDIVS 27.64 XXX<br />
97530 THER ACTV DIR PT CONTACT BY PROVIDER EA 15 MIN 46.89 XXX<br />
97532 DEVELOPMENT OF COGNITIVE SKILLS EA 15 MIN 36.53 XXX<br />
97533 SENSORY INTEGRATIVE TQS EA 15 MIN 39.98 XXX<br />
97535 SELF-CARE/HOME MGMT TRAINING EA 15 MIN 46.89 XXX<br />
97537 COMMUNITY/WORK REINTEGRATION TRAINJ EA 15 MIN 40.97 XXX<br />
97542 WHEELCHAIR MGMT EA 15 MIN 41.46 XXX<br />
97545 WORK HARDENING/CONDITIONING 1ST 2 HR 182.14 XXX<br />
+ 97546 WORK HARDENING/CONDITIONING EA HR 72.56 ZZZ<br />
97750 PHYSICAL PERFORMANCE TST/MEAS W/RPRT 15 MIN 45.41 XXX<br />
97755 ASSTV TECHN ASSMT DIR CNTCT W/REPRT 15 MIN 49.85 XXX<br />
97760 ORTHOTIC MGMT&TRAINJ UXTR LXTR&/TRNK EA 15 MIN 50.84 XXX<br />
97761 PROSTC TRAINJ UPR&/LXTR EA 15 MIN 44.92 XXX<br />
97762 CHECKOUT ORTHOTIC/PROSTHETIC USE 58.74 XXX<br />
97799 UNLIS PHYSICAL MED/RHAB SVC/PX BR XXX<br />
97810 ACUP 1/> NDLS W/O ELEC STIMJ 1ST 15 MIN 51.83 XXX<br />
+ 97811 ACUP 1/> NDLS W/O ELEC STIMJ EA 15 MIN 39.49 ZZZ<br />
97813 ACUP 1/> NDLS W/ELEC STIMJ 1ST 15 MIN 55.78 XXX<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 289
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section XI: Physical Medicine Services<br />
PHYSICAL MEDICINE<br />
97001–97546, 97750–97799, 97810–98943, FCE01<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
+ 97814 ACUP 1/> NDLS W/ELEC STIMJ EA 15 MIN W/RE-INSJ 44.92 ZZZ<br />
98925 OSTEOPATHIC MANIPULATIVE TX 1-2 BDY REGIONS 43.93 000<br />
98926 OSTEOPATHIC MANIPULATIVE TX 3-4 BDY REGIONS 58.74 000<br />
98927 OSTEOPATHIC MANIPULATIVE TX 5-6 BDY REGIONS 76.51 000<br />
98928 OSTEOPATHIC MANIPULATIVE TX 7-8 BDY REGIONS 89.34 000<br />
98929 OSTEOPATHIC MANIPULATIVE TX 9-10 BDY REGIONS 103.16 000<br />
98940 CMT SPI 1-2 REGIONS 37.02 000<br />
98941 CMT SPI 3-4 REGIONS 51.33 000<br />
98942 CMT SPI 5 REGIONS 66.14 000<br />
98943 CMT XTRSPI 1+ REGIONS 35.05 XXX<br />
FCE01 FUNCTIONAL CAPACITY EVALUATION (GEORGIA SPECIFIC) See Page 286<br />
+ Add-on Procedure K Moderate Sedation * Modifier 51 Exempt Procedure l New CPT Procedure s Revised CPT Procedure<br />
290 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section XII: Home Health<br />
Services<br />
When home care is medically necessary for employees<br />
injured on the job, the authorized treating physician will set<br />
requirements for the level of care to be utilized.<br />
When four hours or more of care are provided, hourly rates,<br />
based upon the licensure below, will apply. <strong>The</strong> maximum<br />
allowable hourly rate for specific providers is as follows:<br />
Registered Nurse (RN)<br />
$49.02 per hour weekday<br />
$57.42 per hour weekend and holiday day<br />
Licensed Practical Nurse (LPN)<br />
$36.41 per hour weekday<br />
$42.01 per hour weekend and holiday day<br />
Certified Nurse Assistant/Personal Care Attendant<br />
(CNA/PCA)<br />
Non-credentialed Care, Including Family Members<br />
$10.13 per hour with a maximum of 12 hours per day<br />
When care is provided for less than four hours, the allowed<br />
rate will be per visit as indicated below:<br />
• $126.28 per visit Registered Nurse<br />
• $103.32 per visit Licensed Practical Nurse<br />
• $64.29 per visit Certified Nurse Assistant or Personal<br />
Care Attendant<br />
• Physical <strong>The</strong>rapist, Occupational <strong>The</strong>rapist and<br />
Speech-Language <strong>The</strong>rapist are reimbursed according to<br />
the fee schedule for CPT codes provided plus $34.44<br />
per visit.<br />
Note: Domestic services (e.g., lawn mowing services, home<br />
cleaning) are not included in this payment system.<br />
$24.11 per hour weekday<br />
$27.56 per hour weekend and holiday day<br />
CPT only © 2010 American Medical Association. All Rights Reserved. 291
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section XII: Home Health Services<br />
HOME HEALTH SERVICES 99500–99602<br />
Medical Fee Schedule Effective April 1, 2011<br />
CODE MOD DESCRIPTION MAR FUD<br />
99500 HOME VST PRENATAL MNTR&ASSMT BR XXX<br />
99501 HOME VST POSTNATAL ASSMT&F-UP CARE BR XXX<br />
99502 HOME VST NB CARE&ASSMT BR XXX<br />
99503 HOME VST RESPIR THER CARE BR XXX<br />
99504 HOME VST MCHNL VNTJ CARE BR XXX<br />
99505 HOME VST STOMA CARE&MAINT CLST&CSTOST BR XXX<br />
99506 HOME VST IM NJXS BR XXX<br />
99507 HOME VST CARE&MAINT CATH BR XXX<br />
99509 HOME VST ASSISTANCE DAILY LIV&PRSONAL CARE BR XXX<br />
99510 HOME VST INDIV FAM/MARRIAGE CNSL BR XXX<br />
99511 HOME VST FECAL IMPACTION MGMT&ENEMA ADMN BR XXX<br />
99512 HOME VST HEMO BR XXX<br />
99600 UNLIS HOME VST SVC/PX BR XXX<br />
99601 HOME NFS/SPECTY DRUG ADMN PR VST
Section XIII: Transportation<br />
SUBSECTION A: NON-EMERGENCY SERVICES<br />
<strong>The</strong> following are guidelines for reimbursement of<br />
non-emergency transportation. <strong>The</strong>se codes are <strong>Georgia</strong><br />
state-specific and should be used for workers’ compensation<br />
billing purposes.<br />
General Guidelines<br />
Codes and fees specify ambulatory and lift van<br />
reimbursements separately.<br />
Flat-rate, pick-up fees are not applicable.<br />
Additional gasoline surcharge fees are not reimbursable as<br />
they are included in fee schedule reimbursement.<br />
Very remote areas are considered 50 miles or more.<br />
Wait-time fees are reimbursed at the fee rates listed below. A<br />
cumulative total-day wait time of one hour or more can be<br />
charged. <strong>The</strong>re is no wait-time reimbursement for anything<br />
less than one hour for an entire day.<br />
Any transportation fees outside of this schedule should be<br />
negotiated between the payor and provider before services<br />
are rendered.<br />
Ambulatory:<br />
Code Description Maximum Allowable Rate<br />
TP010 Per-mile charge $2.15 per mile<br />
TP015 Wait-time charge first hour $26.10 first 60 minutes<br />
TP016 Wait-time charge additional time $6.53 each additional 15 minutes<br />
TP020 Minimum charge Only one minimum fee of $31.31 allowable for entire day. If mileage<br />
exceeds $31.31, use per-mile rate (TP010)<br />
TP025<br />
After hours, weekends, and<br />
holidays<br />
Regular working hours are considered to be Monday through Friday,<br />
6:00 a.m. to 6:00 p.m. Saturday and Sunday are considered to be<br />
weekend days. An additional charge not to exceed $26.10 per day may<br />
be billed if pick-up time is earlier than 6:00 a.m. or later than 6:00<br />
p.m. weekdays. An additional charge not to exceed $26.10 per day<br />
may be billed for pickup on weekend days and holidays.<br />
TP030 Wheelchair handling A $10.43 charge for each time a wheelchair is folded and loaded into a<br />
trunk or backseat, with a maximum daily charge of $41.75 may be<br />
billed.<br />
TP035 Hands-on passenger assistance If hands-on assistance is needed to move a patient in and out of the<br />
vehicle, a fee according to the degree of assistance that is required<br />
should be negotiated with the payor prior to travel.<br />
TP040 Additional fees – rural areas Negotiate fee prior.<br />
TP045<br />
Passenger pick-up fees when<br />
driver is leaving from and<br />
returning home<br />
No additional reimbursement unless it is a very remote area, and then<br />
reimbursement must be negotiated prior.<br />
TP046 Rush – less than 24 business hours $26.10<br />
TP047 Late cancellation – two business $31.31<br />
hours or less<br />
TP050 No-call/no-show charges A $52.18 charge may be billed; very remote areas (50 miles or more)<br />
may charge $78.28.<br />
CPT only © 2010 American Medical Association. All Rights Reserved. 293
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section XIII: Transportation<br />
Lift Vans:<br />
Code Description Maximum Allowable Rate<br />
TP100 Per-mile charge $3.08 per mile<br />
TP105 Wait-time charge first hour $41.75 first 60 minutes<br />
TP106 Wait-time charge additional time $10.70 each additional 15 minutes<br />
TP110 Loading and unloading of patient $41.75 per trip, not to exceed $83.50 per day<br />
TP115<br />
After hours, weekends, and<br />
holidays<br />
Regular working hours are considered to be Monday through Friday,<br />
6:00 a.m. to 6:00 p.m. Saturday and Sunday are considered to be<br />
weekend days. An additional charge not to exceed $26.10 per day may<br />
be billed if pick-up time is earlier than 6:00 a.m. or later than 6:00<br />
p.m. weekdays. An additional charge not to exceed $26.10 per day<br />
may be billed for pick-up on weekend days and holidays.<br />
TP120 Additional handling fees If stretcher transportation or other unusual handling is required, this<br />
should be identified and negotiated prior. Otherwise charges are<br />
included in loading fees.<br />
TP125 Additional fees – rural areas Negotiate fee prior.<br />
TP130 Passenger pick-up when driver is<br />
leaving from and returning home<br />
No additional reimbursement unless it is a very remote area, and then<br />
reimbursement must be negotiated prior.<br />
TP131 Rush – less than 24 business hours $26.10<br />
TP132 Late cancellation – two business $41.75<br />
hours or less<br />
TP135 No-call/no-show charges A $78.28 charge may be billed; $104.36 charge for very remote (50<br />
miles or more) areas.<br />
294 CPT only © 2010 American Medical Association. All Rights Reserved.
Section XIII: Transportation<br />
SUBSECTION B: AMBULANCE AND AIR SERVICES<br />
<strong>The</strong> following guidelines are for reimbursement of<br />
ambulance and air transportation. <strong>The</strong>se services are<br />
reported with HCPCS ambulance and air transportation<br />
codes. <strong>The</strong> table below indicates the HCPCS codes and their<br />
reimbursement for transportation services using the<br />
appropriate calculations for urban and rural base rate and<br />
mileage.<br />
For the purpose of determining the definition of rural<br />
mileage versus urban mileage, any county outside of the eight<br />
(8) counties listed below would be considered rural:<br />
Cherokee County<br />
Clayton County<br />
Cobb County<br />
Dekalb County<br />
Douglas County<br />
Fulton County<br />
Gwinnett County<br />
Paulding County<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Charges for services and mileage must be based on “loaded”<br />
mileage only, e.g., from the pickup of a patient to his/her<br />
arrival at the destination. Unloaded trips and mileage are not<br />
reimbursable.<br />
Any ambulance and air transportation fees outside of this<br />
schedule should be paid at usual, customary, and reasonable<br />
charges in compliance with O.C.G.A. §34-9-203(a), and<br />
reasonable charges shall be limited to such charges as prevail<br />
in the state of <strong>Georgia</strong> for similar treatment or services.<br />
Example fee calculation:<br />
Given a total mileage of 44 miles under A0425 for ground<br />
ambulance service in a rural area, multiply the rural mileage<br />
times total miles ($11.40 x 44 = $501.60) and add the value<br />
of rural base rate ($11.40) ($501.60 + $11.40) for a total of<br />
$513.00. If this service also required ambulance service,<br />
basic life support, emergency transport (BLS – emergency)<br />
(A0429), add $546.82 to the earlier calculation of $513.00,<br />
giving a new total of $1059.82 ($546.82 + $513.00).<br />
HCPCS CODE<br />
DESCRIPTION<br />
BASE RATE &<br />
URBAN MILEAGE<br />
RURAL BASE RATE<br />
& RURAL MILEAGE<br />
A0425 Ground mileage, per statute mile, and base rate $11.28 $11.40<br />
A0426 Ambulance service, advanced life support, non-emergency<br />
$406.15 $410.12<br />
transport, level 1 (ALS 1)<br />
A0427 Ambulance service, advanced life support, emergency<br />
$643.05 $649.36<br />
transport, level 1 (ALS 1 – emergency)<br />
A0428 Ambulance service, basic life support, non-emergency<br />
$338.45 $341.76<br />
transport (BLS)<br />
A0429 Ambulance service, basic life support, emergency transport<br />
$541.52 $546.82<br />
(BLS – emergency)<br />
A0430 Ambulance service, conventional air services, transport, one<br />
$3,982.18 $5,973.27<br />
way (fixed wing)<br />
A0431 Ambulance service, conventional air services, transport, one<br />
$4,629.87 $6,944.80<br />
way (rotary wing)<br />
A0432 Paramedic intercept (PI), rural area, transport furnished by a<br />
volunteer ambulance company which is prohibited by state<br />
law from billing third-party payers<br />
$592.28 $598.08<br />
A0433 Advanced life support, level 2 (ALS2) $930.74 $939.84<br />
A0434 Specialty care transport (SCT) $1,152.26 $1,163.56<br />
A0435 Fixed wing air mileage, per statute mile $11.60 $17.40<br />
A0436 Rotary wing air mileage, per statute mile $30.93 $46.40<br />
CPT only © 2010 American Medical Association. All Rights Reserved. 295
Section XIV: Inpatient <strong>Hospital</strong><br />
Payment Schedule<br />
INPATIENT REIMBURSEMENT METHODOLOGY<br />
Inpatient hospital maximum allowable reimbursement<br />
(MAR) totals are provided by MS-DRG in this schedule. As of<br />
the date of publication, the MS-DRG maximum allowable<br />
reimbursement is based upon the 2011 CMS relative weights<br />
multiplied by a base rate of $8,201.53. Any MS-DRGs<br />
outside of this schedule will be reimbursed at 62.23 percent<br />
of charge. Reimbursement will be effective for the date of<br />
discharge. MS-DRG MARs represent payment in full, unless<br />
the outlier payment is applicable or a contract between a<br />
payor/provider is negotiated.<br />
MS-DRGs 945 and 946 (Rehabilitation) are exempt from the<br />
<strong>Hospital</strong> Payment Fee Schedule. Reimbursements for<br />
inpatient rehabilitation should be negotiated by the facility<br />
and the payor, on a case-by-case basis, prior to services<br />
being rendered. If a payment rate has not been negotiated<br />
prior to services being rendered, the hospital will be<br />
reimbursed based on the MS-DRG payment schedule, which<br />
is calculated by multiplying the current relative weight of<br />
MS-DRG 945 or 946 and the current year’s <strong>Georgia</strong> Workers’<br />
Compensation base rate of $8,201.53, plus any applicable<br />
reimbursable outlier costs.<br />
IMPLANTS, DURABLE <strong>MEDICAL</strong> EQUIPMENT (DME),<br />
AND SUPPLIES<br />
Generally, durable medical equipment and supplies<br />
provided or administered in a hospital setting are not<br />
separately reimbursed since they are included in the<br />
payment reimbursement. However, surgical implantables are<br />
exempted from this rule.<br />
A provider shall submit a hard copy of the wholesale vendor<br />
invoice for the implantable(s) at the cost to the hospital,<br />
ambulatory surgery center, or other provider. In some cases,<br />
vendor invoices list multiple items; therefore, a copy of a<br />
multiple-item vendor invoice shall be acceptable. In this<br />
case, the payor shall calculate reimbursement for items used<br />
per procedure. Clarification of which implant is used for<br />
each procedure billed will facilitate reimbursement. Only the<br />
actual invoiced cost of the item(s) will be reimbursed. Tax,<br />
handling, and freight charges are included in the hospital’s<br />
invoiced cost and shall not be reimbursed. Implantable(s)<br />
are not subject to outlier reimbursement.<br />
PAYMENT FOR OUTLIERS<br />
Most MS-DRG payments will be at the base rate times the<br />
MS-DRG weight. However, to provide additional<br />
reimbursement where the <strong>Georgia</strong> Workers’ Compensation<br />
Board deems the MS-DRG payment inadequate to cover the<br />
costs incurred by the facility, the Board has established an<br />
outlier payment for high-cost cases. Implantables are not<br />
subject to outlier reimbursement.<br />
<strong>The</strong> outlier payment will be made according to the following<br />
formula:<br />
Outlier Charge = Total Billed Charges – MS-DRG Payment –<br />
implants if applicable – 40,000.00<br />
If Outlier Charge > 0, then Outlier Payment = 0.45 x Outlier<br />
Charge<br />
If Outlier Charge is 0, then Outlier Payment = 0<br />
CPT only © 2010 American Medical Association. All Rights Reserved. 297
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
Section XIV: Inpatient <strong>Hospital</strong> Payment Schedule<br />
Example for MS-DRG 460:<br />
Total Billed Charges<br />
MS-DRG<br />
Payment Outlier Charge Outlier Payment Total Payment<br />
Example A $100,000.00 $31,751.00 $28,249.00 $12,712.00 $44,463.00<br />
Example B $18,000.00 $31,751.00 0.00 0.00 $31,751.00<br />
Example C $45,000.00 $31,751.00 0, then Outlier Payment = 0.65 x Outlier<br />
Charge.<br />
If Outlier Charge is 0, then Outlier Payment = 0<br />
MS-DRG EXEMPT HOSPITALS<br />
<strong>The</strong> following freestanding rehabilitation or freestanding<br />
long-term acute care hospitals are exempt from the Inpatient<br />
<strong>Hospital</strong> Payment Schedule:<br />
• Shepherd Center<br />
• Roosevelt Warm Springs Institute<br />
• Walton Rehabilitation <strong>Hospital</strong><br />
• Central <strong>Georgia</strong> Rehabilitation <strong>Hospital</strong>, LLC (formerly<br />
HealthSouth Central <strong>Georgia</strong> Rehabilitation <strong>Hospital</strong>)<br />
• Kindred <strong>Hospital</strong> — Atlanta<br />
• Windy Hill <strong>Hospital</strong><br />
DISPUTED <strong>MEDICAL</strong> CHARGES<br />
Any hospital whose charges are disputed and any party<br />
disputing such charges must comply with the requirements<br />
of the law, Board Rules, and, if applicable, rules of the<br />
appropriate peer review committee before the Board will<br />
issue an order regarding payment of any disputed charges.<br />
Pursuant to Board Rule 203(c)(5), if there is no appropriate<br />
peer review committee for hospital charges, the party<br />
requesting review may request a mediation conference by<br />
filing Form WC-14 with the Board. If the dispute is not<br />
resolved through mediation, a hearing may be requested.<br />
298 CPT only © 2010 American Medical Association. All Rights Reserved.
Section XIV: Inpatient <strong>Hospital</strong> Payment Schedule<br />
Effective April 1, 2011<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
MS-DRG<br />
Inpatient <strong>Hospital</strong> Fee Schedule<br />
MS-DRG DESCRIPTION <strong>FEE</strong><br />
001 Heart Transplant or Implant of Heart Assist System with MCC 216061.93<br />
002 Heart Transplant or Implant of Heart Assist System without MCC 111644.97<br />
003 ECMO or Tracheostomy with Mechanical Ventilation 96+ Hours or Principal Diagnosis Except Face, Mouth 148643.71<br />
and Neck with Major O.R.<br />
004 Tracheostomy with Mechanical Ventilation 96+ Hours or Principal Diagnosis Except Face, Mouth and Neck 92187.66<br />
without Major O.R.<br />
005 Liver Transplant with MCC or Intestinal Transplant 83467.79<br />
006 Liver Transplant without MCC 39656.86<br />
007 Lung Transplant 76561.28<br />
008 Simultaneous Pancreas/Kidney Transplant 40705.83<br />
010 Pancreas Transplant 31027.21<br />
011 Tracheostomy for Face, Mouth, and Neck Diagnoses with MCC 39093.41<br />
012 Tracheostomy for Face, Mouth, and Neck Diagnoses with CC 25679.81<br />
013 Tracheostomy for Face, Mouth, and Neck Diagnoses without CC/MCC 15997.08<br />
014 Allogeneic Bone Marrow Transplant 95094.28<br />
015 Autologous Bone Marrow Transplant 48802.38<br />
020 Intracranial Vascular Procedures with Principal Diagnosis of Hemorrhage with MCC 67645.40<br />
021 Intracranial Vascular Procedures with Principal Diagnosis of Hemorrhage with CC 51576.14<br />
022 Intracranial Vascular Procedures with Principal Diagnosis of Hemorrhage without CC/MCC 34102.78<br />
023 Craniotomy with Major Device Implant/Acute Complex Central Nervous System Principal Diagnosis with 41731.85<br />
MCC or Chemo Implant<br />
024 Craniotomy with Major Device Implant/Acute Complex Central Nervous System Principal Diagnosis without 28665.99<br />
MCC<br />
025 Craniotomy and Endovascular Intracranial Procedures with MCC 39018.78<br />
026 Craniotomy and Endovascular Intracranial Procedures with CC 24461.06<br />
027 Craniotomy and Endovascular Intracranial Procedures without CC/MCC 17475.00<br />
028 Spinal Procedures with MCC 43918.37<br />
029 Spinal Procedures with CC or Spinal Neurostimulator 23572.02<br />
030 Spinal Procedures without CC/MCC 13477.57<br />
031 Ventricular Shunt Procedures with MCC 33840.33<br />
032 Ventricular Shunt Procedures with CC 15763.34<br />
033 Ventricular Shunt Procedures without CC/MCC 11175.40<br />
034 Carotid Artery Stent Procedure with MCC 28903.83<br />
035 Carotid Artery Stent Procedure with CC 17581.62<br />
036 Carotid Artery Stent Procedure without CC/MCC 13442.31<br />
037 Extracranial Procedures with MCC 25870.09<br />
038 Extracranial Procedures with CC 12681.21<br />
039 Extracranial Procedures without CC/MCC 8353.26<br />
040 Peripheral/Cranial Nerve and Other Nervous System Procedures with MCC 32275.48<br />
041 Peripheral/Cranial Nerve and Other Nervous System Procedures with CC or Peripheral Neurostimulator 17575.88<br />
042 Peripheral/Cranial Nerve and Other Nervous System Procedures without CC/MCC 13864.69<br />
052 Spinal Disorders and Injuries with CC/MCC 13211.84<br />
053 Spinal Disorders and Injuries without CC/MCC 6922.91<br />
054 Nervous System Neoplasms with MCC 12189.93<br />
055 Nervous System Neoplasms without MCC 8733.81<br />
056 Degenerative Nervous System Disorders with MCC 13735.92<br />
057 Degenerative Nervous System Disorders without MCC 7668.43<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 299
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
MS-DRG<br />
Section XIV: Inpatient <strong>Hospital</strong> Payment Schedule<br />
Inpatient <strong>Hospital</strong> Fee Schedule Effective April 1, 2011<br />
MS-DRG DESCRIPTION <strong>FEE</strong><br />
058 Multiple Sclerosis and Cerebellar Ataxia with MCC 13004.35<br />
059 Multiple Sclerosis and Cerebellar Ataxia with CC 8046.52<br />
060 Multiple Sclerosis and Cerebellar Ataxia without CC/MCC 6215.12<br />
061 Acute Ischemic Stroke with Use of Thrombolytic Agent with MCC 24250.28<br />
062 Acute Ischemic Stroke with Use of Thrombolytic Agent with CC 15975.76<br />
063 Acute Ischemic Stroke with Use of Thrombolytic Agent without CC/MCC 12508.15<br />
064 Intracranial Hemorrhage or Cerebral Infarction with MCC 15315.54<br />
065 Intracranial Hemorrhage or Cerebral Infarction with CC 9568.73<br />
066 Intracranial Hemorrhage or Cerebral Infarction without CC/MCC 6723.61<br />
067 Nonspecific Cerebrovascular Accident and Precerebral Occlusion without Infarction with MCC 11671.60<br />
068 Nonspecific Cerebrovascular Accident and Precerebral Occlusion without Infarction without MCC 7177.16<br />
069 Transient Ischemia 5996.14<br />
070 Nonspecific Cerebrovascular Disorders with MCC 15104.76<br />
071 Nonspecific Cerebrovascular Disorders with CC 9065.97<br />
072 Nonspecific Cerebrovascular Disorders without CC/MCC 6150.33<br />
073 Cranial and Peripheral Nerve Disorders with MCC 10585.71<br />
074 Cranial and Peripheral Nerve Disorders without MCC 7058.24<br />
075 Viral Meningitis with CC/MCC 13587.47<br />
076 Viral Meningitis without CC/MCC 7422.38<br />
077 Hypertensive Encephalopathy with MCC 14250.98<br />
078 Hypertensive Encephalopathy with CC 8327.83<br />
079 Hypertensive Encephalopathy without CC/MCC 6178.21<br />
080 Nontraumatic Stupor and Coma with MCC 9767.20<br />
081 Nontraumatic Stupor and Coma without MCC 6062.57<br />
082 Traumatic Stupor and Coma, Coma Greater Than One Hour with MCC 16509.68<br />
083 Traumatic Stupor and Coma, Coma Greater Than One Hour with CC 10878.51<br />
084 Traumatic Stupor and Coma, Coma Greater Than One Hour without CC/MCC 7347.75<br />
085 Traumatic Stupor and Coma, Coma Less Than One Hour with MCC 17570.14<br />
086 Traumatic Stupor and Coma, Coma Less Than One Hour with CC 9883.66<br />
087 Traumatic Stupor and Coma, Coma Less Than One Hour without CC/MCC 6502.99<br />
088 Concussion with MCC 12197.32<br />
089 Concussion with CC 7928.42<br />
090 Concussion without CC/MCC 5681.20<br />
091 Other Disorders of Nervous System with MCC 13383.26<br />
092 Other Disorders of Nervous System with CC 7712.72<br />
093 Other Disorders of Nervous System without CC/MCC 5599.18<br />
094 Bacterial and Tuberculous Infections of Nervous System with MCC 30156.21<br />
095 Bacterial and Tuberculous Infections of Nervous System with CC 19664.81<br />
096 Bacterial and Tuberculous Infections of Nervous System without CC/MCC 15785.48<br />
097 Nonbacterial Infections of Nervous System Except Viral Meningitis with MCC 26401.55<br />
098 Nonbacterial Infections of Nervous System Except Viral Meningitis with CC 15669.84<br />
099 Nonbacterial Infections of Nervous System Except Viral Meningitis without CC/MCC 9910.73<br />
100 Seizures with MCC 12390.05<br />
101 Seizures without MCC 6248.75<br />
102 Headaches with MCC 8437.73<br />
103 Headaches without MCC 5495.85<br />
300 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section XIV: Inpatient <strong>Hospital</strong> Payment Schedule<br />
Effective April 1, 2011<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
MS-DRG<br />
Inpatient <strong>Hospital</strong> Fee Schedule<br />
MS-DRG DESCRIPTION <strong>FEE</strong><br />
113 Orbital Procedures with CC/MCC 15017.82<br />
114 Orbital Procedures without CC/MCC 7372.36<br />
115 Extraocular Procedures Except Orbit 9910.73<br />
116 Intraocular Procedures with CC/MCC 10395.44<br />
117 Intraocular Procedures without CC/MCC 5991.22<br />
121 Acute Major Eye Infections with CC/MCC 7466.67<br />
122 Acute Major Eye Infections without CC/MCC 5349.04<br />
123 Neurological Eye Disorders 5859.17<br />
124 Other Disorders of the Eye with MCC 9762.28<br />
125 Other Disorders of the Eye without MCC 5625.43<br />
129 Major Head and Neck Procedures with CC/MCC or Major Device 18329.60<br />
130 Major Head and Neck Procedures without CC/MCC 10087.06<br />
131 Cranial/Facial Procedures with CC/MCC 17153.50<br />
132 Cranial/Facial Procedures without CC/MCC 10208.44<br />
133 Other Ear, Nose, Mouth and Throat O.R. Procedures with CC/MCC 13942.60<br />
134 Other Ear, Nose, Mouth and Throat O.R. Procedures without CC/MCC 6982.78<br />
135 Sinus and Mastoid Procedures with CC/MCC 15650.16<br />
136 Sinus and Mastoid Procedures without CC/MCC 7997.31<br />
137 Mouth Procedures with CC/MCC 10667.73<br />
138 Mouth Procedures without CC/MCC 6430.82<br />
139 Salivary Gland Procedures 7181.26<br />
146 Ear, Nose, Mouth and Throat Malignancy with MCC 17949.87<br />
147 Ear, Nose, Mouth and Throat Malignancy with CC 10180.56<br />
148 Ear, Nose, Mouth and Throat Malignancy without CC/MCC 6615.35<br />
149 Dysequilibrium 5239.96<br />
150 Epistaxis with MCC 10504.52<br />
151 Epistaxis without MCC 5243.24<br />
152 Otitis Media and Upper Respiratory Infection with MCC 7860.35<br />
153 Otitis Media and Upper Respiratory Infection without MCC 5158.76<br />
154 Other Ear, Nose, Mouth and Throat Diagnoses with MCC 11453.44<br />
155 Other Ear, Nose, Mouth and Throat Diagnoses with CC 7395.32<br />
156 Other Ear, Nose, Mouth and Throat Diagnoses without CC/MCC 5106.27<br />
157 Dental and Oral Diseases with MCC 12953.50<br />
158 Dental and Oral Diseases with CC 7403.52<br />
159 Dental and Oral Diseases without CC/MCC 4836.44<br />
163 Major Chest Procedures with MCC 41686.74<br />
164 Major Chest Procedures with CC 21517.53<br />
165 Major Chest Procedures without CC/MCC 14564.28<br />
166 Other Respiratory System O.R. Procedures with MCC 30659.78<br />
167 Other Respiratory System O.R. Procedures with CC 16868.09<br />
168 Other Respiratory System O.R. Procedures without CC/MCC 10668.55<br />
175 Pulmonary Embolism with MCC 13201.18<br />
176 Pulmonary Embolism without MCC 8780.56<br />
177 Respiratory Infections and Inflammations with MCC 16950.10<br />
178 Respiratory Infections and Inflammations with CC 12209.62<br />
179 Respiratory Infections and Inflammations without CC/MCC 8087.53<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 301
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
MS-DRG<br />
Section XIV: Inpatient <strong>Hospital</strong> Payment Schedule<br />
Inpatient <strong>Hospital</strong> Fee Schedule Effective April 1, 2011<br />
MS-DRG DESCRIPTION <strong>FEE</strong><br />
180 Respiratory Neoplasms with MCC 14238.68<br />
181 Respiratory Neoplasms with CC 9991.10<br />
182 Respiratory Neoplasms without CC/MCC 6639.96<br />
183 Major Chest Trauma with MCC 12254.73<br />
184 Major Chest Trauma with CC 8000.59<br />
185 Major Chest Trauma without CC/MCC 5579.50<br />
186 Pleural Effusion with MCC 12824.73<br />
187 Pleural Effusion with CC 9043.83<br />
188 Pleural Effusion without CC/MCC 6297.13<br />
189 Pulmonary Edema and Respiratory Failure 10505.34<br />
190 Chronic Obstructive Pulmonary Disease with MCC 9779.50<br />
191 Chronic Obstructive Pulmonary Disease with CC 7984.19<br />
192 Chronic Obstructive Pulmonary Disease without CC/MCC 5921.50<br />
193 Simple Pneumonia and Pleurisy with MCC 12134.98<br />
194 Simple Pneumonia and Pleurisy with CC 8326.19<br />
195 Simple Pneumonia and Pleurisy without CC/MCC 5819.81<br />
196 Interstitial Lung Disease with MCC 13173.30<br />
197 Interstitial Lung Disease with CC 9166.03<br />
198 Interstitial Lung Disease without CC/MCC 6727.72<br />
199 Pneumothorax with MCC 14676.64<br />
200 Pneumothorax with CC 8408.21<br />
201 Pneumothorax without CC/MCC 5913.30<br />
202 Bronchitis and Asthma with CC/MCC 6908.97<br />
203 Bronchitis and Asthma without CC/MCC 4987.35<br />
204 Respiratory Signs and Symptoms 5506.51<br />
205 Other Respiratory System Diagnoses with MCC 10639.02<br />
206 Other Respiratory System Diagnoses without MCC 6212.66<br />
207 Respiratory System Diagnosis with Ventilator Support 96+ Hours 42703.73<br />
208 Respiratory System Diagnosis with Ventilator Support
Section XIV: Inpatient <strong>Hospital</strong> Payment Schedule<br />
Effective April 1, 2011<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
MS-DRG<br />
Inpatient <strong>Hospital</strong> Fee Schedule<br />
MS-DRG DESCRIPTION <strong>FEE</strong><br />
230 Other Cardiothoracic Procedures without CC/MCC 29075.24<br />
231 Coronary Bypass with PTCA with MCC 64449.26<br />
232 Coronary Bypass with PTCA without MCC 47718.96<br />
233 Coronary Bypass with Cardiac Catheterization with MCC 59117.45<br />
234 Coronary Bypass with Cardiac Catheterization without MCC 39597.81<br />
235 Coronary Bypass without Cardiac Catheterization with MCC 48003.56<br />
236 Coronary Bypass without Cardiac Catheterization without MCC 30925.51<br />
237 Major Cardiovascular Procedures with MCC or Thoracic Aortic Aneurysm Repair 42568.40<br />
238 Major Cardiovascular Procedures without MCC 25285.32<br />
239 Amputation for Circulatory System Disorders Except Upper Limb and Toe with MCC 37353.05<br />
240 Amputation for Circulatory System Disorders Except Upper Limb and Toe with CC 21807.05<br />
241 Amputation for Circulatory System Disorders Except Upper Limb and Toe without CC/MCC 11999.66<br />
242 Permanent Cardiac Pacemaker Implant with MCC 30572.84<br />
243 Permanent Cardiac Pacemaker Implant with CC 21740.62<br />
244 Permanent Cardiac Pacemaker Implant without CC/MCC 16729.48<br />
245 AICD Generator Procedures 34845.02<br />
246 Percutaneous Cardiovascular Procedure with Drug-Eluting Stent with MCC or 4+ Vessels/Stents 26082.51<br />
247 Percutaneous Cardiovascular Procedure with Drug-Eluting Stent without MCC 16149.63<br />
248 Percutaneous Cardiovascular Procedure with Non Drug-Eluting Stent with MCC or 4+ Vessels/Stents 23987.83<br />
249 Percutaneous Cardiovascular Procedure with Non Drug-Eluting Stent without MCC 14542.95<br />
250 Percutaneous Cardiovascular Procedure without Coronary Artery Stent with MCC 23649.93<br />
251 Percutaneous Cardiovascular Procedure without Coronary Artery Stent without MCC 14756.19<br />
252 Other Vascular Procedures with MCC 24402.83<br />
253 Other Vascular Procedures with CC 19695.15<br />
254 Other Vascular Procedures without CC/MCC 13247.11<br />
255 Upper Limb and Toe Amputation for Circulatory System Disorders with MCC 20539.09<br />
256 Upper Limb and Toe Amputation for Circulatory System Disorders with CC 13097.02<br />
257 Upper Limb and Toe Amputation for Circulatory System Disorders without CC/MCC 7996.49<br />
258 Cardiac Pacemaker Device Replacement with MCC 23686.02<br />
259 Cardiac Pacemaker Device Replacement without MCC 15036.69<br />
260 Cardiac Pacemaker Revision Except Device Replacement with MCC 29115.43<br />
261 Cardiac Pacemaker Revision Except Device Replacement with CC 13507.10<br />
262 Cardiac Pacemaker Revision Except Device Replacement without CC/MCC 9223.44<br />
263 Vein Ligation and Stripping 14405.99<br />
264 Other Circulatory System O.R. Procedures 20753.97<br />
265 AICD Lead Procedures 18992.28<br />
280 Acute Myocardial Infarction, Discharged Alive with MCC 15175.29<br />
281 Acute Myocardial Infarction, Discharged Alive with CC 9769.66<br />
282 Acute Myocardial Infarction, Discharged Alive without CC/MCC 6613.71<br />
283 Acute Myocardial Infarction, Expired with MCC 14066.44<br />
284 Acute Myocardial Infarction, Expired with CC 7289.52<br />
285 Acute Myocardial Infarction, Expired without CC/MCC 4684.71<br />
286 Circulatory Disorders Except Acute Myocardial Infarction, with Cardiac Catheterization with MCC 16414.54<br />
287 Circulatory Disorders Except Acute Myocardial Infarction, with Cardiac Catheterization without MCC 8922.44<br />
288 Acute and Subacute Endocarditis with MCC 24110.04<br />
289 Acute and Subacute Endocarditis with CC 15166.27<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 303
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
MS-DRG<br />
Section XIV: Inpatient <strong>Hospital</strong> Payment Schedule<br />
Inpatient <strong>Hospital</strong> Fee Schedule Effective April 1, 2011<br />
MS-DRG DESCRIPTION <strong>FEE</strong><br />
290 Acute and Subacute Endocarditis without CC/MCC 10628.36<br />
291 Heart Failure and Shock with MCC 12255.55<br />
292 Heart Failure and Shock with CC 8449.22<br />
293 Heart Failure and Shock without CC/MCC 5620.51<br />
294 Deep Vein Thrombophlebitis with CC/MCC 8507.45<br />
295 Deep Vein Thrombophlebitis without CC/MCC 5251.44<br />
296 Cardiac Arrest, Unexplained with MCC 9589.23<br />
297 Cardiac Arrest, Unexplained with CC 5570.48<br />
298 Cardiac Arrest, Unexplained without CC/MCC 3688.23<br />
299 Peripheral Vascular Disorders with MCC 11541.19<br />
300 Peripheral Vascular Disorders with CC 8017.82<br />
301 Peripheral Vascular Disorders without CC/MCC 5425.31<br />
302 Atherosclerosis with MCC 8000.59<br />
303 Atherosclerosis without MCC 4781.49<br />
304 Hypertension with MCC 8417.23<br />
305 Hypertension without MCC 5034.10<br />
306 Cardiac Congenital and Valvular Disorders with MCC 12029.18<br />
307 Cardiac Congenital and Valvular Disorders without MCC 6539.90<br />
308 Cardiac Arrhythmia and Conduction Disorders with MCC 10119.87<br />
309 Cardiac Arrhythmia and Conduction Disorders with CC 6878.62<br />
310 Cardiac Arrhythmia and Conduction Disorders without CC/MCC 4682.25<br />
311 Angina Pectoris 4158.18<br />
312 Syncope and Collapse 5882.14<br />
313 Chest Pain 4510.02<br />
314 Other Circulatory System Diagnoses with MCC 14881.68<br />
315 Other Circulatory System Diagnoses with CC 7939.90<br />
316 Other Circulatory System Diagnoses without CC/MCC 5041.48<br />
326 Stomach, Esophageal and Duodenal Procedures with MCC 47685.34<br />
327 Stomach, Esophageal and Duodenal Procedures with CC 22333.59<br />
328 Stomach, Esophageal and Duodenal Procedures without CC/MCC 11726.55<br />
329 Major Small and Large Bowel Procedures with MCC 43309.82<br />
330 Major Small and Large Bowel Procedures with CC 21184.55<br />
331 Major Small and Large Bowel Procedures without CC/MCC 13341.43<br />
332 Rectal Resection with MCC 39888.14<br />
333 Rectal Resection with CC 20471.02<br />
334 Rectal Resection without CC/MCC 13105.22<br />
335 Peritoneal Adhesiolysis with MCC 35083.68<br />
336 Peritoneal Adhesiolysis with CC 19237.51<br />
337 Peritoneal Adhesiolysis without CC/MCC 12129.24<br />
338 Appendectomy with Complicated Principal Diagnosis with MCC 26339.21<br />
339 Appendectomy with Complicated Principal Diagnosis with CC 15303.23<br />
340 Appendectomy with Complicated Principal Diagnosis without CC/MCC 10164.16<br />
341 Appendectomy without Complicated Principal Diagnosis with MCC 18570.72<br />
342 Appendectomy without Complicated Principal Diagnosis with CC 10863.75<br />
343 Appendectomy without Complicated Principal Diagnosis without CC/MCC 7847.22<br />
344 Minor Small and Large Bowel Procedures with MCC 25905.35<br />
304 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section XIV: Inpatient <strong>Hospital</strong> Payment Schedule<br />
Effective April 1, 2011<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
MS-DRG<br />
Inpatient <strong>Hospital</strong> Fee Schedule<br />
MS-DRG DESCRIPTION <strong>FEE</strong><br />
345 Minor Small and Large Bowel Procedures with CC 13971.31<br />
346 Minor Small and Large Bowel Procedures without CC/MCC 9745.88<br />
347 Anal and Stomal Procedures with MCC 19833.76<br />
348 Anal and Stomal Procedures with CC 11240.20<br />
349 Anal and Stomal Procedures without CC/MCC 6545.64<br />
350 Inguinal and Femoral Hernia Procedures with MCC 20402.95<br />
351 Inguinal and Femoral Hernia Procedures with CC 11104.05<br />
352 Inguinal and Femoral Hernia Procedures without CC/MCC 7076.28<br />
353 Hernia Procedures Except Inguinal and Femoral with MCC 22562.41<br />
354 Hernia Procedures Except Inguinal and Femoral with CC 12731.24<br />
355 Hernia Procedures Except Inguinal and Femoral without CC/MCC 8471.36<br />
356 Other Digestive System O.R. Procedures with MCC 33046.42<br />
357 Other Digestive System O.R. Procedures with CC 17605.40<br />
358 Other Digestive System O.R. Procedures without CC/MCC 10670.19<br />
368 Major Esophageal Disorders with MCC 14416.65<br />
369 Major Esophageal Disorders with CC 8834.69<br />
370 Major Esophageal Disorders without CC/MCC 6188.87<br />
371 Major Gastrointestinal Disorders and Peritoneal Infections with MCC 17211.73<br />
372 Major Gastrointestinal Disorders and Peritoneal Infections with CC 10608.68<br />
373 Major Gastrointestinal Disorders and Peritoneal Infections without CC/MCC 7052.50<br />
374 Digestive Malignancy with MCC 16955.84<br />
375 Digestive Malignancy with CC 10498.78<br />
376 Digestive Malignancy without CC/MCC 6953.26<br />
377 GI Hemorrhage with MCC 14386.30<br />
378 GI Hemorrhage with CC 8426.25<br />
379 GI Hemorrhage without CC/MCC 5860.81<br />
380 Complicated Peptic Ulcer with MCC 16120.93<br />
381 Complicated Peptic Ulcer with CC 9191.45<br />
382 Complicated Peptic Ulcer without CC/MCC 6667.84<br />
383 Uncomplicated Peptic Ulcer with MCC 9827.07<br />
384 Uncomplicated Peptic Ulcer without MCC 6828.59<br />
385 Inflammatory Bowel Disease with MCC 15666.56<br />
386 Inflammatory Bowel Disease with CC 8558.30<br />
387 Inflammatory Bowel Disease without CC/MCC 6407.86<br />
388 GI Obstruction with MCC 13497.26<br />
389 GI Obstruction with CC 7663.51<br />
390 GI Obstruction without CC/MCC 5223.55<br />
391 Esophagitis, Gastroenteritis and Miscellaneous Digestive Disorders with MCC 9472.77<br />
392 Esophagitis, Gastroenteritis and Miscellaneous Digestive Disorders without MCC 5882.96<br />
393 Other Digestive System Diagnoses with MCC 13608.80<br />
394 Other Digestive System Diagnoses with CC 8151.50<br />
395 Other Digestive System Diagnoses without CC/MCC 5535.21<br />
405 Pancreas, Liver and Shunt Procedures with MCC 45717.79<br />
406 Pancreas, Liver and Shunt Procedures with CC 22792.87<br />
407 Pancreas, Liver and Shunt Procedures without CC/MCC 15308.16<br />
408 Biliary Tract Procedures Except Only Cholecystectomy with or without C.D.E. with MCC 32287.78<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 305
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
MS-DRG<br />
Section XIV: Inpatient <strong>Hospital</strong> Payment Schedule<br />
Inpatient <strong>Hospital</strong> Fee Schedule Effective April 1, 2011<br />
MS-DRG DESCRIPTION <strong>FEE</strong><br />
409 Biliary Tract Procedures Except Only Cholecystectomy with or without C.D.E. with CC 20401.31<br />
410 Biliary Tract Procedures Except Only Cholecystectomy with or without C.D.E. without CC/MCC 13215.95<br />
411 Cholecystectomy with C.D.E. with MCC 30196.39<br />
412 Cholecystectomy with C.D.E. with CC 20431.65<br />
413 Cholecystectomy with C.D.E. without CC/MCC 14090.23<br />
414 Cholecystectomy Except by Laparoscope without C.D.E. with MCC 30079.11<br />
415 Cholecystectomy Except by Laparoscope without C.D.E. with CC 17138.74<br />
416 Cholecystectomy Except by Laparoscope without C.D.E. without CC/MCC 10727.60<br />
417 Laparoscopic Cholecystectomy without C.D.E. with MCC 20527.61<br />
418 Laparoscopic Cholecystectomy without C.D.E. with CC 13939.32<br />
419 Laparoscopic Cholecystectomy without C.D.E. without CC/MCC 9594.15<br />
420 Hepatobiliary Diagnostic Procedures with MCC 29888.84<br />
421 Hepatobiliary Diagnostic Procedures with CC 15509.09<br />
422 Hepatobiliary Diagnostic Procedures without CC/MCC 10450.39<br />
423 Other Hepatobiliary or Pancreas O.R. Procedures with MCC 36559.96<br />
424 Other Hepatobiliary or Pancreas O.R. Procedures with CC 19958.42<br />
425 Other Hepatobiliary or Pancreas O.R. Procedures without CC/MCC 13346.35<br />
432 Cirrhosis and Alcoholic Hepatitis with MCC 13943.42<br />
433 Cirrhosis and Alcoholic Hepatitis with CC 7830.82<br />
434 Cirrhosis and Alcoholic Hepatitis without CC/MCC 5045.58<br />
435 Malignancy of Hepatobiliary System or Pancreas with MCC 14777.52<br />
436 Malignancy of Hepatobiliary System or Pancreas with CC 10018.17<br />
437 Malignancy of Hepatobiliary System or Pancreas without CC/MCC 7384.66<br />
438 Disorders of Pancreas Except Malignancy with MCC 15043.25<br />
439 Disorders of Pancreas Except Malignancy with CC 8274.52<br />
440 Disorders of Pancreas Except Malignancy without CC/MCC 5650.85<br />
441 Disorders of Liver Except Malignancy, Cirrhosis, Alcoholic Hepatitis with MCC 14961.23<br />
442 Disorders of Liver Except Malignancy, Cirrhosis, Alcoholic Hepatitis with CC 8084.25<br />
443 Disorders of Liver Except Malignancy, Cirrhosis, Alcoholic Hepatitis without CC/MCC 5425.31<br />
444 Disorders of the Biliary Tract with MCC 12782.90<br />
445 Disorders of the Biliary Tract with CC 8765.80<br />
446 Disorders of the Biliary Tract without CC/MCC 6078.15<br />
453 Combined Anterior/Posterior Spinal Fusion with MCC 84191.17<br />
454 Combined Anterior/Posterior Spinal Fusion with CC 59509.48<br />
455 Combined Anterior/Posterior Spinal Fusion without CC/MCC 44540.87<br />
456 Spinal Fusion Except Cervical with Spinal Curvature/Malignancy/Infection or 9+ Fusions with MCC 76179.91<br />
457 Spinal Fusion Except Cervical with Spinal Curvature/Malignancy/Infection or 9+ Fusions with CC 50869.17<br />
458 Spinal Fusion Except Cervical with Spinal Curvature/Malignancy/Infection or 9+ Fusions without CC/MCC 40498.33<br />
459 Spinal Fusion Except Cervical with MCC 53363.25<br />
460 Spinal Fusion Except Cervical without MCC 31750.58<br />
461 Bilateral or Multiple Major Joint Procedures of Lower Extremity with MCC 40503.26<br />
462 Bilateral or Multiple Major Joint Procedures of Lower Extremity without MCC 27413.61<br />
463 Wound Debridement and Skin Graft Except Hand, for Musculo-Connective Tissue Disorders with MCC 40993.71<br />
464 Wound Debridement and Skin Graft Except Hand, for Musculo-Connective Tissue Disorders with CC 23397.32<br />
465 Wound Debridement and Skin Graft Except Hand, for Musculo-Connective Tissue Disorders without<br />
14684.84<br />
CC/MCC<br />
466 Revision of Hip or Knee Replacement with MCC 40305.60<br />
306 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section XIV: Inpatient <strong>Hospital</strong> Payment Schedule<br />
Effective April 1, 2011<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
MS-DRG<br />
Inpatient <strong>Hospital</strong> Fee Schedule<br />
MS-DRG DESCRIPTION <strong>FEE</strong><br />
467 Revision of Hip or Knee Replacement with CC 26508.17<br />
468 Revision of Hip or Knee Replacement without CC/MCC 21100.90<br />
469 Major Joint Replacement or Reattachment of Lower Extremity with MCC 28478.99<br />
470 Major Joint Replacement or Reattachment of Lower Extremity without MCC 17255.20<br />
471 Cervical Spinal Fusion with MCC 38794.06<br />
472 Cervical Spinal Fusion with CC 22736.28<br />
473 Cervical Spinal Fusion without CC/MCC 17032.94<br />
474 Amputation for Musculoskeletal System and Connective Tissue Disorders with MCC 28627.44<br />
475 Amputation for Musculoskeletal System and Connective Tissue Disorders with CC 16070.08<br />
476 Amputation for Musculoskeletal System and Connective Tissue Disorders without CC/MCC 8135.92<br />
477 Biopsies of Musculoskeletal System and Connective Tissue with MCC 27299.61<br />
478 Biopsies of Musculoskeletal System and Connective Tissue with CC 18491.17<br />
479 Biopsies of Musculoskeletal System and Connective Tissue without CC/MCC 13423.44<br />
480 Hip and Femur Procedures Except Major Joint with MCC 25374.71<br />
481 Hip and Femur Procedures Except Major Joint with CC 15489.41<br />
482 Hip and Femur Procedures Except Major Joint without CC/MCC 12607.39<br />
483 Major Joint and Limb Reattachment Procedures of Upper Extremity with CC/MCC 19699.25<br />
484 Major Joint and Limb Reattachment Procedures of Upper Extremity without CC/MCC 16037.27<br />
485 Knee Procedures with Principal Diagnosis of Infection with MCC 26352.34<br />
486 Knee Procedures with Principal Diagnosis of Infection with CC 16681.09<br />
487 Knee Procedures with Principal Diagnosis of Infection without CC/MCC 12075.93<br />
488 Knee Procedures without Principal Diagnosis of Infection with CC/MCC 14120.57<br />
489 Knee Procedures without Principal Diagnosis of Infection without CC/MCC 9957.48<br />
490 Back and Neck Procedures Except Spinal Fusion with CC/MCC or Disc Device/Neurostimulator 14693.86<br />
491 Back and Neck Procedures Except Spinal Fusion without CC/MCC 8131.00<br />
492 Lower Extremity and Humerus Procedures Except Hip, Foot, Femur with MCC 25154.09<br />
493 Lower Extremity and Humerus Procedures Except Hip, Foot, Femur with CC 15188.41<br />
494 Lower Extremity and Humerus Procedures Except Hip, Foot, Femur without CC/MCC 10776.81<br />
495 Local Excision and Removal Internal Fixation Devices Except Hip and Femur with MCC 23524.45<br />
496 Local Excision and Removal Internal Fixation Devices Except Hip and Femur with CC 13292.22<br />
497 Local Excision and Removal Internal Fixation Devices Except Hip and Femur without CC/MCC 8833.05<br />
498 Local Excision and Removal Internal Fixation Devices of Hip and Femur with CC/MCC 16330.89<br />
499 Local Excision and Removal Internal Fixation Devices of Hip and Femur without CC/MCC 8133.46<br />
500 Soft Tissue Procedures with MCC 24840.79<br />
501 Soft Tissue Procedures with CC 12996.14<br />
502 Soft Tissue Procedures without CC/MCC 8451.68<br />
503 Foot Procedures with MCC 18706.87<br />
504 Foot Procedures with CC 12864.10<br />
505 Foot Procedures without CC/MCC 8833.05<br />
506 Major Thumb or Joint Procedures 9690.11<br />
507 Major Shoulder or Elbow Joint Procedures with CC/MCC 15345.88<br />
508 Major Shoulder or Elbow Joint Procedures without CC/MCC 11446.06<br />
509 Arthroscopy 10783.37<br />
510 Shoulder, Elbow or Forearm Procedure, Except Major Joint Procedure with MCC 17800.60<br />
511 Shoulder, Elbow or Forearm Procedure, Except Major Joint Procedure with CC 12048.05<br />
512 Shoulder, Elbow or Forearm Procedure, Except Major Joint Procedure without CC/MCC 8579.62<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 307
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
MS-DRG<br />
Section XIV: Inpatient <strong>Hospital</strong> Payment Schedule<br />
Inpatient <strong>Hospital</strong> Fee Schedule Effective April 1, 2011<br />
MS-DRG DESCRIPTION <strong>FEE</strong><br />
513 Hand or Wrist Procedures, Except Major Thumb or Joint Procedures with CC/MCC 10667.73<br />
514 Hand or Wrist Procedures, Except Major Thumb or Joint Procedures without CC/MCC 6732.64<br />
515 Other Musculoskeletal System and Connective Tissue O.R. Procedure with MCC 26157.96<br />
516 Other Musculoskeletal System and Connective Tissue O.R. Procedure with CC 15783.02<br />
517 Other Musculoskeletal System and Connective Tissue O.R. Procedure without CC/MCC 12135.80<br />
533 Fractures of Femur with MCC 12841.14<br />
534 Fractures of Femur without MCC 6233.98<br />
535 Fractures of Hip and Pelvis with MCC 11094.21<br />
536 Fractures of Hip and Pelvis without MCC 5897.72<br />
537 Sprains, Strains, and Dislocations of Hip, Pelvis and Thigh with CC/MCC 6786.77<br />
538 Sprains, Strains, and Dislocations of Hip, Pelvis and Thigh without CC/MCC 5009.49<br />
539 Osteomyelitis with MCC 16786.07<br />
540 Osteomyelitis with CC 10765.33<br />
541 Osteomyelitis without CC/MCC 7145.99<br />
542 Pathological Fractures and Musculoskeletal and Connective Tissue Malignancy with MCC 16010.21<br />
543 Pathological Fractures and Musculoskeletal and Connective Tissue Malignancy with CC 9511.31<br />
544 Pathological Fractures and Musculoskeletal and Connective Tissue Malignancy without CC/MCC 6376.69<br />
545 Connective Tissue Disorders with MCC 20886.84<br />
546 Connective Tissue Disorders with CC 9605.63<br />
547 Connective Tissue Disorders without CC/MCC 6026.48<br />
548 Septic Arthritis with MCC 16114.37<br />
549 Septic Arthritis with CC 9870.54<br />
550 Septic Arthritis without CC/MCC 6787.59<br />
551 Medical Back Problems with MCC 13448.87<br />
552 Medical Back Problems without MCC 6728.54<br />
553 Bone Diseases and Arthropathies with MCC 9312.84<br />
554 Bone Diseases and Arthropathies without MCC 5586.88<br />
555 Signs and Symptoms of Musculoskeletal System and Connective Tissue with MCC 8983.96<br />
556 Signs and Symptoms of Musculoskeletal System and Connective Tissue without MCC 5386.76<br />
557 Tendonitis, Myositis and Bursitis with MCC 13139.67<br />
558 Tendonitis, Myositis and Bursitis without MCC 7236.21<br />
559 Aftercare, Musculoskeletal System and Connective Tissue with MCC 14530.65<br />
560 Aftercare, Musculoskeletal System and Connective Tissue with CC 8219.57<br />
561 Aftercare, Musculoskeletal System and Connective Tissue without CC/MCC 5093.97<br />
562 Fractures, Sprains, Strains and Dislocations Except Femur, Hip, Pelvis and Thigh with MCC 11436.21<br />
563 Fractures, Sprains, Strains and Dislocations Except Femur, Hip, Pelvis and Thigh without MCC 5866.55<br />
564 Other Musculoskeletal System and Connective Tissue Diagnoses with MCC 12057.89<br />
565 Other Musculoskeletal System and Connective Tissue Diagnoses with CC 7459.29<br />
566 Other Musculoskeletal System and Connective Tissue Diagnoses without CC/MCC 5433.51<br />
573 Skin Graft and/or Debridement for Skin Ulcer or Cellulitis with MCC 26622.99<br />
574 Skin Graft and/or Debridement for Skin Ulcer or Cellulitis with CC 15316.36<br />
575 Skin Graft and/or Debridement for Skin Ulcer or Cellulitis without CC/MCC 8938.85<br />
576 Skin Graft and/or Debridement Except for Skin Ulcer or Cellulitis with MCC 32189.36<br />
577 Skin Graft and/or Debridement Except for Skin Ulcer or Cellulitis with CC 13971.31<br />
578 Skin Graft and/or Debridement Except for Skin Ulcer or Cellulitis without CC/MCC 8542.71<br />
579 Other Skin, Subcutaneous Tissue and Breast Procedures with MCC 24256.85<br />
308 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section XIV: Inpatient <strong>Hospital</strong> Payment Schedule<br />
Effective April 1, 2011<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
MS-DRG<br />
Inpatient <strong>Hospital</strong> Fee Schedule<br />
MS-DRG DESCRIPTION <strong>FEE</strong><br />
580 Other Skin, Subcutaneous Tissue and Breast Procedures with CC 12268.67<br />
581 Other Skin, Subcutaneous Tissue and Breast Procedures without CC/MCC 7564.27<br />
582 Mastectomy for Malignancy with CC/MCC 8666.56<br />
583 Mastectomy for Malignancy without CC/MCC 6933.57<br />
584 Breast Biopsy, Local Excision and Other Breast Procedures with CC/MCC 12427.78<br />
585 Breast Biopsy, Local Excision and Other Breast Procedures without CC/MCC 8538.61<br />
592 Skin Ulcers with MCC 14491.28<br />
593 Skin Ulcers with CC 8783.02<br />
594 Skin Ulcers without CC/MCC 6225.78<br />
595 Major Skin Disorders with MCC 15328.66<br />
596 Major Skin Disorders without MCC 7200.12<br />
597 Malignant Breast Disorders with MCC 12791.11<br />
598 Malignant Breast Disorders with CC 8702.64<br />
599 Malignant Breast Disorders without CC/MCC 5138.26<br />
600 Nonmalignant Breast Disorders with CC/MCC 7875.11<br />
601 Nonmalignant Breast Disorders without CC/MCC 5517.99<br />
602 Cellulitis with MCC 12095.62<br />
603 Cellulitis without MCC 6870.42<br />
604 Trauma to the Skin, Subcutaneous Tissue and Breast with MCC 10137.91<br />
605 Trauma to the Skin, Subcutaneous Tissue & Breast without MCC 5890.34<br />
606 Minor Skin Disorders with MCC 10729.24<br />
607 Minor Skin Disorders without MCC 5623.79<br />
614 Adrenal and Pituitary Procedures with CC/MCC 20138.04<br />
615 Adrenal and Pituitary Procedures without CC/MCC 11457.54<br />
616 Amputation of Lower Limb for Endocrine, Nutritional, and Metabolic Disorders with MCC 36852.75<br />
617 Amputation of Lower Limb for Endocrine, Nutritional, and Metabolic Disorders with CC 16407.98<br />
618 Amputation of Lower Limb for Endocrine, Nutritional, and Metabolic Disorders without CC/MCC 9846.76<br />
619 O.R. Procedures for Obesity with MCC 28880.87<br />
620 O.R. Procedures for Obesity with CC 15276.99<br />
621 O.R. Procedures for Obesity without CC/MCC 12094.80<br />
622 Skin Grafts and Wound Debridement for Endocrine, Nutritional and Metabolic Disorders with MCC 28021.35<br />
623 Skin Grafts and Wound Debridement for Endocrine, Nutritional and Metabolic Disorders with CC 15220.40<br />
624 Skin Grafts and Wound Debridement for Endocrine, Nutritional and Metabolic Disorders without CC/MCC 8301.59<br />
625 Thyroid, Parathyroid and Thyroglossal Procedures with MCC 18390.29<br />
626 Thyroid, Parathyroid and Thyroglossal Procedures with CC 9596.61<br />
627 Thyroid, Parathyroid and Thyroglossal Procedures without CC/MCC 6414.42<br />
628 Other Endocrine, Nutritional and Metabolic O.R. Procedures with MCC 27736.75<br />
629 Other Endocrine, Nutritional and Metabolic O.R. Procedures with CC 18576.47<br />
630 Other Endocrine, Nutritional and Metabolic O.R. Procedures without CC/MCC 11616.65<br />
637 Diabetes with MCC 11861.05<br />
638 Diabetes with CC 6812.19<br />
639 Diabetes without CC/MCC 4546.93<br />
640 Nutritional and Miscellaneous Metabolic Disorders with MCC 9349.74<br />
641 Nutritional and Miscellaneous Metabolic Disorders without MCC 5672.18<br />
642 Inborn Errors of Metabolism 8439.37<br />
643 Endocrine Disorders with MCC 14893.16<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 309
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
MS-DRG<br />
Section XIV: Inpatient <strong>Hospital</strong> Payment Schedule<br />
Inpatient <strong>Hospital</strong> Fee Schedule Effective April 1, 2011<br />
MS-DRG DESCRIPTION <strong>FEE</strong><br />
644 Endocrine Disorders with CC 8738.73<br />
645 Endocrine Disorders without CC/MCC 5903.46<br />
652 Kidney Transplant 24967.10<br />
653 Major Bladder Procedures with MCC 49971.10<br />
654 Major Bladder Procedures with CC 24648.88<br />
655 Major Bladder Procedures without CC/MCC 16047.93<br />
656 Kidney and Ureter Procedures for Neoplasm with MCC 29290.12<br />
657 Kidney and Ureter Procedures for Neoplasm with CC 16406.34<br />
658 Kidney and Ureter Procedures for Neoplasm without CC/MCC 11665.86<br />
659 Kidney and Ureter Procedures for Non-neoplasm with MCC 28695.51<br />
660 Kidney and Ureter Procedures for Non-neoplasm with CC 15607.51<br />
661 Kidney and Ureter Procedures for Non-neoplasm without CC/MCC 10367.55<br />
662 Minor Bladder Procedures with MCC 24734.17<br />
663 Minor Bladder Procedures with CC 12071.01<br />
664 Minor Bladder Procedures without CC/MCC 9082.37<br />
665 Prostatectomy with MCC 23499.84<br />
666 Prostatectomy with CC 13483.32<br />
667 Prostatectomy without CC/MCC 6494.79<br />
668 Transurethral Procedures with MCC 20647.35<br />
669 Transurethral Procedures with CC 10331.47<br />
670 Transurethral Procedures without CC/MCC 6372.59<br />
671 Urethral Procedures with CC/MCC 11810.20<br />
672 Urethral Procedures without CC/MCC 6466.91<br />
673 Other Kidney and Urinary Tract Procedures with MCC 23997.68<br />
674 Other Kidney and Urinary Tract Procedures with CC 17169.08<br />
675 Other Kidney and Urinary Tract Procedures without CC/MCC 10972.83<br />
682 Renal Failure with MCC 13456.25<br />
683 Renal Failure with CC 8400.83<br />
684 Renal Failure without CC/MCC 5402.35<br />
685 Admit for Renal Dialysis 7335.45<br />
686 Kidney and Urinary Tract Neoplasms with MCC 14957.95<br />
687 Kidney and Urinary Tract Neoplasms with CC 8888.82<br />
688 Kidney and Urinary Tract Neoplasms without CC/MCC 5313.77<br />
689 Kidney and Urinary Tract Infections with MCC 9993.56<br />
690 Kidney and Urinary Tract Infections without MCC 6449.68<br />
691 Urinary Stones with ESW Lithotripsy with CC/MCC 13250.39<br />
692 Urinary Stones with ESW Lithotripsy without CC/MCC 9174.23<br />
693 Urinary Stones without ESW Lithotripsy with MCC 11076.17<br />
694 Urinary Stones without ESW Lithotripsy without MCC 5819.81<br />
695 Kidney and Urinary Tract Signs and Symptoms with MCC 9909.09<br />
696 Kidney and Urinary Tract Signs and Symptoms without MCC 5404.81<br />
697 Urethral Stricture 6373.41<br />
698 Other Kidney and Urinary Tract Diagnoses with MCC 13202.82<br />
699 Other Kidney and Urinary Tract Diagnoses with CC 8200.71<br />
700 Other Kidney and Urinary Tract Diagnoses without CC/MCC 5541.77<br />
707 Major Male Pelvic Procedures with CC/MCC 14555.26<br />
310 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section XIV: Inpatient <strong>Hospital</strong> Payment Schedule<br />
Effective April 1, 2011<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
MS-DRG<br />
Inpatient <strong>Hospital</strong> Fee Schedule<br />
MS-DRG DESCRIPTION <strong>FEE</strong><br />
708 Major Male Pelvic Procedures without CC/MCC 10318.34<br />
709 Penis Procedures with CC/MCC 15279.45<br />
710 Penis Procedures without CC/MCC 10425.78<br />
711 Testes Procedures with CC/MCC 14466.68<br />
712 Testes Procedures without CC/MCC 6630.12<br />
713 Transurethral Prostatectomy with CC/MCC 9679.45<br />
714 Transurethral Prostatectomy without CC/MCC 5367.08<br />
715 Other Male Reproductive System O.R. Procedures for Malignancy with CC/MCC 14297.73<br />
716 Other Male Reproductive System O.R. Procedures for Malignancy without CC/MCC 8180.21<br />
717 Other Male Reproductive System O.R. Procedures Except Malignancy with CC/MCC 13235.63<br />
718 Other Male Reproductive System O.R. Procedures Except Malignancy without CC/MCC 6597.31<br />
722 Malignancy, Male Reproductive System with MCC 13853.20<br />
723 Malignancy, Male Reproductive System with CC 8357.36<br />
724 Malignancy, Male Reproductive System without CC/MCC 5093.97<br />
725 Benign Prostatic Hypertrophy with MCC 10450.39<br />
726 Benign Prostatic Hypertrophy without MCC 5751.73<br />
727 Inflammation of the Male Reproductive System with MCC 11200.83<br />
728 Inflammation of the Male Reproductive System without MCC 6243.00<br />
729 Other Male Reproductive System Diagnoses with CC/MCC 8112.95<br />
730 Other Male Reproductive System Diagnoses without CC/MCC 5260.46<br />
734 Pelvic Evisceration, Radical Hysterectomy and Radical Vulvectomy with CC/MCC 19982.21<br />
735 Pelvic Evisceration, Radical Hysterectomy and Radical Vulvectomy without CC/MCC 9582.67<br />
736 Uterine and Adnexa Procedures for Ovarian or Adnexal Malignancy with MCC 36039.98<br />
737 Uterine and Adnexa Procedures for Ovarian or Adnexal Malignancy with CC 16710.62<br />
738 Uterine and Adnexa Procedures for Ovarian or Adnexal Malignancy without CC/MCC 10107.57<br />
739 Uterine, Adnexa Procedures for Nonovarian/Adnexal Malignancy with MCC 28131.25<br />
740 Uterine, Adnexa Procedures for Nonovarian/Adnexal Malignancy with CC 12531.94<br />
741 Uterine, Adnexa Procedures for Nonovarian/Adnexal Malignancy without CC/MCC 9004.46<br />
742 Uterine and Adnexa Procedures for Nonmalignancy with CC/MCC 11386.18<br />
743 Uterine and Adnexa Procedures for Nonmalignancy without CC/MCC 7446.17<br />
744 D&C, Conization, Laparoscopy and Tubal Interruption with CC/MCC 12426.14<br />
745 D&C, Conization, Laparoscopy and Tubal Interruption without CC/MCC 6598.13<br />
746 Vagina, Cervix and Vulva Procedures with CC/MCC 10967.91<br />
747 Vagina, Cervix and Vulva Procedures without CC/MCC 7259.99<br />
748 Female Reproductive System Reconstructive Procedures 7519.98<br />
749 Other Female Reproductive System O.R. Procedures with CC/MCC 20729.37<br />
750 Other Female Reproductive System O.R. Procedures without CC/MCC 7683.19<br />
754 Malignancy, Female Reproductive System with MCC 16645.01<br />
755 Malignancy, Female Reproductive System with CC 9385.83<br />
756 Malignancy, Female Reproductive System without CC/MCC 5216.99<br />
757 Infections, Female Reproductive System with MCC 13585.83<br />
758 Infections, Female Reproductive System with CC 8991.34<br />
759 Infections, Female Reproductive System without CC/MCC 6042.89<br />
760 Menstrual and Other Female Reproductive System Disorders with CC/MCC 6879.44<br />
761 Menstrual and Other Female Reproductive System Disorders without CC/MCC 4280.38<br />
765 Cesarean Section with CC/MCC 9242.30<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 311
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
MS-DRG<br />
Section XIV: Inpatient <strong>Hospital</strong> Payment Schedule<br />
Inpatient <strong>Hospital</strong> Fee Schedule Effective April 1, 2011<br />
MS-DRG DESCRIPTION <strong>FEE</strong><br />
766 Cesarean Section without CC/MCC 6557.12<br />
767 Vaginal Delivery with Sterilization and/or D&C 7472.41<br />
768 Vaginal Delivery with O.R. Procedure Except Sterilization and/or D&C 14854.61<br />
769 Postpartum and Postabortion Diagnoses with O.R. Procedure 16920.58<br />
770 Abortion with D&C, Aspiration Curettage or Hysterotomy 5755.01<br />
774 Vaginal Delivery with Complicating Diagnoses 5616.41<br />
775 Vaginal Delivery without Complicating Diagnoses 4310.72<br />
776 Postpartum and Postabortion Diagnoses without O.R. Procedure 5341.66<br />
777 Ectopic Pregnancy 6074.05<br />
778 Threatened Abortion 4053.20<br />
779 Abortion without D&C 4355.83<br />
780 False Labor 1873.23<br />
781 Other Antepartum Diagnoses with Medical Complications 5584.42<br />
782 Other Antepartum Diagnoses without Medical Complications 3890.81<br />
789 Neonates, Died or Transferred to Another Acute Care Facility 12201.42<br />
790 Extreme Immaturity or Respiratory Distress Syndrome, Neonate 40235.07<br />
791 Prematurity with Major Problems 27479.23<br />
792 Prematurity without Major Problems 16580.21<br />
793 Full Term Neonate with Major Problems 28227.21<br />
794 Neonate with Other Significant Problems 9990.28<br />
795 Normal Newborn 1352.43<br />
799 Splenectomy with MCC 40543.44<br />
800 Splenectomy with CC 21220.64<br />
801 Splenectomy without CC/MCC 12782.90<br />
802 Other O.R. Procedures of the Blood and Blood-Forming Organs with MCC 29665.75<br />
803 Other O.R. Procedures of the Blood and Blood-Forming Organs with CC 15504.99<br />
804 Other O.R. Procedures of the Blood and Blood-Forming Organs without CC/MCC 8567.32<br />
808 Major Hematologic/Immunologic Diagnoses Except Sickle Cell Crisis and Coagulation with MCC 17616.07<br />
809 Major Hematologic/Immunologic Diagnoses Except Sickle Cell Crisis and Coagulation with CC 9801.65<br />
810 Major Hematologic/Immunologic Diagnoses Except Sickle Cell Crisis and Coagulation without CC/MCC 7570.01<br />
811 Red Blood Cell Disorders with MCC 10288.00<br />
812 Red Blood Cell Disorders without MCC 6525.96<br />
813 Coagulation Disorders 11787.24<br />
814 Reticuloendothelial and Immunity Disorders with MCC 13475.93<br />
815 Reticuloendothelial and Immunity Disorders with CC 8221.21<br />
816 Reticuloendothelial and Immunity Disorders without CC/MCC 5591.80<br />
820 Lymphoma and Leukemia with Major O.R. Procedure with MCC 46840.58<br />
821 Lymphoma and Leukemia with Major O.R. Procedure with CC 19682.03<br />
822 Lymphoma and Leukemia with Major O.R. Procedure without CC/MCC 10049.33<br />
823 Lymphoma and Nonacute Leukemia with Other O.R. Procedure with MCC 37431.78<br />
824 Lymphoma and Nonacute Leukemia with Other O.R. Procedure with CC 18908.63<br />
825 Lymphoma and Nonacute Leukemia with Other O.R. Procedure without CC/MCC 10184.66<br />
826 Myeloproliferative Disorders or Poorly Differentiated Neoplasms with Major O.R. Procedure with MCC 39913.57<br />
827 Myeloproliferative Disorders or Poorly Differentiated Neoplasms with Major O.R. Procedure with CC 17599.66<br />
828 Myeloproliferative Disorders or Poorly Differentiated Neoplasms with Major O.R. Procedure without<br />
11368.14<br />
CC/MCC<br />
829 Myeloproliferative Disorders or Poorly Differentiated Neoplasms with Other O.R. Procedure with CC/MCC 22220.41<br />
312 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section XIV: Inpatient <strong>Hospital</strong> Payment Schedule<br />
Effective April 1, 2011<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
MS-DRG<br />
Inpatient <strong>Hospital</strong> Fee Schedule<br />
MS-DRG DESCRIPTION <strong>FEE</strong><br />
830 Myeloproliferative Disorders or Poorly Differentiated Neoplasms with Other O.R. Procedure without CC/MCC 9002.00<br />
834 Acute Leukemia without Major O.R. Procedure with MCC 40414.68<br />
835 Acute Leukemia without Major O.R. Procedure with CC 19916.60<br />
836 Acute Leukemia without Major O.R. Procedure without CC/MCC 9338.26<br />
837 Chemotherapy with Acute Leukemia as Secondary Diagnosis or with High Dose Chemotherapy Agent with 54621.37<br />
MCC<br />
838 Chemotherapy with Acute Leukemia as Secondary Diagnosis with CC or High Dose Chemotherapy Agent 25775.77<br />
839 Chemotherapy with Acute Leukemia as Secondary Diagnosis without CC/MCC 10516.82<br />
840 Lymphoma and Nonacute Leukemia with MCC 24044.43<br />
841 Lymphoma and Nonacute Leukemia with CC 13430.83<br />
842 Lymphoma and Nonacute Leukemia without CC/MCC 8520.57<br />
843 Other Myeloproliferative Disorders or Poorly Differentiated Neoplasm Diagnoses with MCC 15060.47<br />
844 Other Myeloproliferative Disorders or Poorly Differentiated Neoplasm Diagnoses with CC 9792.63<br />
845 Other Myeloproliferative Disorders or Poorly Differentiated Neoplasm Diagnoses without CC/MCC 6585.01<br />
846 Chemotherapy without Acute Leukemia as Secondary Diagnosis with MCC 18011.38<br />
847 Chemotherapy without Acute Leukemia as Secondary Diagnosis with CC 8086.71<br />
848 Chemotherapy without Acute Leukemia as Secondary Diagnosis without CC/MCC 6625.20<br />
849 Radiotherapy 10356.07<br />
853 Infectious and Parasitic Diseases with O.R. Procedure with MCC 45302.79<br />
854 Infectious and Parasitic Diseases with O.R. Procedure with CC 22868.33<br />
855 Infectious and Parasitic Diseases with O.R. Procedure without CC/MCC 11315.65<br />
856 Postoperative or Posttraumatic Infections with O.R. Procedure with MCC 42070.57<br />
857 Postoperative or Posttraumatic Infections with O.R. Procedure with CC 17202.71<br />
858 Postoperative or Posttraumatic Infections with O.R. Procedure without CC/MCC 10703.00<br />
862 Postoperative and Posttraumatic Infections with MCC 16002.01<br />
863 Postoperative and Posttraumatic Infections without MCC 8029.30<br />
864 Fever 6787.59<br />
865 Viral Illness with MCC 12836.21<br />
866 Viral Illness without MCC 6119.98<br />
867 Other Infectious and Parasitic Diseases Diagnoses with MCC 20264.34<br />
868 Other Infectious and Parasitic Diseases Diagnoses with CC 9525.26<br />
869 Other Infectious and Parasitic Diseases Diagnoses without CC/MCC 5910.84<br />
870 Septicemia or Severe Sepsis with Mechanical Ventilation 96+ Hours 47819.02<br />
871 Septicemia or Severe Sepsis without Mechanical Ventilation 96+ Hours with MCC 15643.60<br />
872 Septicemia or Severe Sepsis without Mechanical Ventilation 96+ Hours without MCC 9468.67<br />
876 O.R. Procedure with Principal Diagnoses of Mental Illness 23081.57<br />
880 Acute Adjustment Reaction and Psychosocial Dysfunction 5052.96<br />
881 Depressive Neuroses 5066.91<br />
882 Neuroses Except Depressive 5147.28<br />
883 Disorders of Personality and Impulse Control 8770.72<br />
884 Organic Disturbances and Mental Retardation 7633.98<br />
885 Psychoses 7415.00<br />
886 Behavioral and Developmental Disorders 6481.67<br />
887 Other Mental Disorder Diagnoses 6469.37<br />
894 Alcohol/Drug Abuse or Dependence, Left Against Medical Advice 3341.30<br />
895 Alcohol/Drug Abuse or Dependence with Rehabilitation <strong>The</strong>rapy 8427.07<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 313
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
MS-DRG<br />
Section XIV: Inpatient <strong>Hospital</strong> Payment Schedule<br />
Inpatient <strong>Hospital</strong> Fee Schedule Effective April 1, 2011<br />
MS-DRG DESCRIPTION <strong>FEE</strong><br />
896 Alcohol/Drug Abuse or Dependence without Rehabilitation <strong>The</strong>rapy with MCC 11945.53<br />
897 Alcohol/Drug Abuse or Dependence without Rehabilitation <strong>The</strong>rapy without MCC 5341.66<br />
901 Wound Debridements for Injuries with MCC 32020.41<br />
902 Wound Debridements for Injuries with CC 14698.78<br />
903 Wound Debridements for Injuries without CC/MCC 8713.31<br />
904 Skin Grafts for Injuries with CC/MCC 24059.19<br />
905 Skin Grafts for Injuries without CC/MCC 9607.27<br />
906 Hand Procedures for Injuries 8493.50<br />
907 Other O.R. Procedures for Injuries with MCC 31385.62<br />
908 Other O.R. Procedures for Injuries with CC 15788.77<br />
909 Other O.R. Procedures for Injuries without CC/MCC 9476.05<br />
913 Traumatic Injury with MCC 11026.14<br />
914 Traumatic Injury without MCC 5736.15<br />
915 Allergic Reactions with MCC 11688.82<br />
916 Allergic Reactions without MCC 3991.68<br />
917 Poisoning and Toxic Effects of Drugs with MCC 12194.03<br />
918 Poisoning and Toxic Effects of Drugs without MCC 5141.54<br />
919 Complications of Treatment with MCC 13042.89<br />
920 Complications of Treatment with CC 8025.20<br />
921 Complications of Treatment without CC/MCC 5098.07<br />
922 Other Injury, Poisoning and Toxic Effect Diagnoses with MCC 11054.02<br />
923 Other Injury, Poisoning and Toxic Effect Diagnoses without MCC 5583.60<br />
927 Extensive Burns or Full Thickness Burns with Mechanical Ventilation 96+ Hours with Skin Graft 103873.20<br />
928 Full Thickness Burn with Skin Graft or Inhalation Injury with CC/MCC 39140.98<br />
929 Full Thickness Burn with Skin Graft or Inhalation Injury without CC/MCC 16859.89<br />
933 Extensive Burns or Full Thickness Burns with Mechanical Ventilation 96+ Hours without Skin Graft 18026.14<br />
934 Full Thickness Burn without Skin Graft or Inhalation Injury 11117.99<br />
935 Nonextensive Burns 20873.25<br />
939 O.R. Procedure with Diagnoses of Other Contact with Health Services with MCC 23540.03<br />
940 O.R. Procedure with Diagnoses of Other Contact with Health Services with CC 13776.11<br />
941 O.R. Procedure with Diagnoses of Other Contact with Health Services without CC/MCC 9396.49<br />
945 Rehabilitation with CC/MCC 10493.86<br />
946 Rehabilitation without CC/MCC 9245.58<br />
947 Signs and Symptoms with MCC 8982.32<br />
948 Signs and Symptoms without MCC 5630.35<br />
949 Aftercare with CC/MCC 8206.45<br />
950 Aftercare without CC/MCC 4133.57<br />
951 Other Factors Influencing Health Status 5407.27<br />
955 Craniotomy for Multiple Significant Trauma 45383.99<br />
956 Limb Reattachment, Hip and Femur Procedures for Multiple Significant Trauma 27642.44<br />
957 Other O.R. Procedures for Multiple Significant Trauma with MCC 51275.15<br />
958 Other O.R. Procedures for Multiple Significant Trauma with CC 30913.21<br />
959 Other O.R. Procedures for Multiple Significant Trauma without CC/MCC 19034.11<br />
963 Other Multiple Significant Trauma with MCC 23065.16<br />
964 Other Multiple Significant Trauma with CC 12221.10<br />
965 Other Multiple Significant Trauma without CC/MCC 7697.96<br />
314 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section XIV: Inpatient <strong>Hospital</strong> Payment Schedule<br />
Effective April 1, 2011<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
MS-DRG<br />
Inpatient <strong>Hospital</strong> Fee Schedule<br />
MS-DRG DESCRIPTION <strong>FEE</strong><br />
969 HIV with Extensive O.R. Procedure with MCC 45168.29<br />
970 HIV with Extensive O.R. Procedure without MCC 21943.19<br />
974 HIV with Major Related Condition with MCC 21200.13<br />
975 HIV with Major Related Condition with CC 11186.89<br />
976 HIV with Major Related Condition without CC/MCC 7360.87<br />
977 HIV with or without Other Related Condition 8600.12<br />
981 Extensive O.R. Procedure Unrelated to Principal Diagnosis with MCC 41527.63<br />
982 Extensive O.R. Procedure Unrelated to Principal Diagnosis with CC 24114.14<br />
983 Extensive O.R. Procedure Unrelated to Principal Diagnosis without CC/MCC 14571.66<br />
984 Prostatic O.R. Procedure Unrelated to Principal Diagnosis with MCC 27263.53<br />
985 Prostatic O.R. Procedure Unrelated to Principal Diagnosis with CC 17639.85<br />
986 Prostatic O.R. Procedure Unrelated to Principal Diagnosis without CC/MCC 9136.50<br />
987 Nonextensive O.R. Procedure Unrelated to Principal Diagnosis with MCC 28291.18<br />
988 Nonextensive O.R. Procedure Unrelated to Principal Diagnosis with CC 15368.85<br />
989 Nonextensive O.R. Procedure Unrelated to Principal Diagnosis without CC/MCC 8684.60<br />
998 Principal Diagnosis Invalid as Discharge Diagnosis NA<br />
999 Ungroupable NA<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 315
Section XV: Outpatient Surgery<br />
Payment Schedule<br />
SURGICAL SERVICES PROVIDED BY OUTPATIENT<br />
HOSPITAL AND AMBULATORY SURGERY CENTERS<br />
Payment for outpatient surgical services and associated<br />
goods rendered by a hospital or an ambulatory surgery<br />
center must be submitted on form Uniform Billing 04<br />
(UB-04). Claims not containing the required information,<br />
which is outlined below, may cause delay in payment.<br />
Payment shall be the lower of:<br />
1. Billed charges, or<br />
2. <strong>The</strong> fee set forth in the Outpatient Surgery Payment Fee<br />
Schedule for the procedure listed in locator Field 74 of<br />
UB-04 on the facility’s bill. This payment schedule is not<br />
all-inclusive. For any UB-04 for which a corresponding<br />
ICD-9-CM, volume 3 code listed in Field 74 of Form<br />
UB-04 does not exist in the above-referenced listing and<br />
schedule, payment shall be made at 62.23 percent of<br />
charges (excluding implants, which are reimbursed as<br />
discussed below).<br />
No additional payment shall be required even if other<br />
procedures are listed in Fields 74A-E (UB-04), except as<br />
follows: Facilities may receive additional payment in excess<br />
of the fee for the primary procedure listed in fields above if<br />
(1) the additional procedures are performed on a separate<br />
and distinct body part or system, and (2) the additional<br />
procedures would not normally be considered an integral<br />
part of a larger procedure or incidental to another procedure<br />
performed during the same session.<br />
In order to receive the additional payment, facilities must<br />
code the additional procedures in Field 74A-E (UB-04) of<br />
the bill, include a concise medical justification for the<br />
additional procedures in the “Remarks” section of the UB-04<br />
(Field 80), and provide an itemized bill and a copy of the<br />
operating room notes reflecting that the additional<br />
procedures meet the criteria listed above.<br />
When multiple procedures are performed that meet the<br />
above requirements and the procedures are included in the<br />
ICD-9-CM, volume 3 listing, payment shall be at the lower<br />
of:<br />
1. Billed charges, or<br />
2. Primary procedure: 100 percent of the amount specified<br />
in the ICD-9-CM, volume 3 listing<br />
Each additional procedure: 75 percent of the amount<br />
specified in the ICD-9-CM, volume 3 listing<br />
When multiple procedures are performed that meet the<br />
above requirements and the additional procedures are not<br />
included in the ICD-9-CM, volume 3 listing, payment shall<br />
be at the lower of:<br />
1. Billed charges, or<br />
2. Primary procedure: 100 percent of the amount specified<br />
in the ICD-9-CM, volume 3 listing<br />
Each additional procedure: 62.23 percent of the<br />
difference between the total charges and the listed<br />
amount for the primary procedure, calculated as<br />
follows:<br />
(Total charges – Primary procedure listed amount) x 62.23<br />
percent<br />
When multiple procedures are performed that meet the<br />
above requirements and neither the primary nor the<br />
additional procedures are included in the ICD-9-CM,<br />
volume 3 listing, payment shall be 62.23 percent of billed<br />
charges (excluding implants, which are reimbursed as<br />
discussed below).<br />
Multiple procedures, consisting of an endoscopic or<br />
arthroscopic procedure followed by an open procedure on<br />
the same body part or system, do not warrant separate<br />
reimbursement. <strong>The</strong> higher valued procedure, usually the<br />
open procedure, should be listed in Field 74 (UB-04) and<br />
will be reimbursed as the primary procedure. <strong>The</strong><br />
endoscopic or arthroscopic procedure is considered to be<br />
part of the larger procedure and will not be reimbursed<br />
separately.<br />
CPT only © 2010 American Medical Association. All Rights Reserved. 317
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
IMPLANTS, DME, AND SUPPLIES<br />
See Inpatient <strong>Hospital</strong> Payment Schedule for rules related to<br />
implants, DME, and supplies.<br />
NONSURGICAL RADIOLOGY SERVICES<br />
Radiology services, including discography, myelography,<br />
arthrography, and epidurography, not performed incident to<br />
surgical sessions shall be reimbursed at 10 percent above the<br />
technical component set forth in the fee schedule. <strong>The</strong><br />
reimbursement is based upon the CPT codes, as well as<br />
pharmaceuticals and supplies as appropriate, which are<br />
reported in Field 44 of Form UB-04 on the facility’s bill. Note<br />
that ICD-9-CM, volume 3 procedure codes are not valid to<br />
report these services. <strong>The</strong> technical component<br />
reimbursement for a procedure is the value of the total<br />
maximum allowable rate (MAR) column minus the<br />
professional column.<br />
Example for technical component only modifier TC<br />
calculation:<br />
MAR for CPT code 70010-TC for technical component is<br />
$230.66<br />
Maximum allowed rate = $230.66 + 10 percent ($23.07) =<br />
$253.73<br />
PHYSICAL THERAPY SERVICES<br />
Physical therapy services shall be reimbursed at the<br />
maximum allowable rate (MAR) set forth in the provider fee<br />
schedule. <strong>The</strong> reimbursement is based upon the CPT codes<br />
which are reported in Field 44 of Form UB-04 on the<br />
facility’s bill. Note that ICD-9-CM, volume 3 procedure<br />
codes are not valid to report these services. (See Section XI:<br />
Physical Medicine Services for guidelines.)<br />
MODIFIERS<br />
A modifier is the methodology used by the reporting<br />
physician to indicate or flag a service or procedure code<br />
regarding special circumstances affecting that service. <strong>The</strong><br />
service or procedure description is not affected.<br />
<strong>The</strong> modifiers listed below may differ from those published<br />
by the American Medical Association. Medical providers<br />
submitting workers’ compensation billing shall use only the<br />
modifiers set out in the fee schedule. All facilities that bill for<br />
Section XV: Outpatient Surgery Payment Schedule<br />
services on the UB-04 forms are required to include all<br />
appropriate CPT and HCPCS codes and applicable modifiers<br />
in Field 44.<br />
<strong>The</strong> following modifiers will be recognized for<br />
reimbursement by the fee schedule for outpatient surgery<br />
services reported on hospital outpatient facility and<br />
ambulatory surgery center claims:<br />
73 Discontinued Out-Patient <strong>Hospital</strong>/Ambulatory<br />
Surgery Center (ASC) Procedure Prior to the<br />
Administration of Anesthesia: Due to extenuating<br />
circumstances or those that threaten the well-being of<br />
the patient, the physician may cancel a surgical or<br />
diagnostic procedure subsequent to the patient’s surgical<br />
preparation (including sedation when provided, and<br />
being taken to the room where the procedure is to be<br />
performed), but prior to the administration of<br />
anesthesia (local, regional block(s), or general). Under<br />
these circumstances, the intended service that is<br />
prepared for but cancelled can be reported by its usual<br />
procedure number and the addition of modifier 73.<br />
Note: <strong>The</strong> elective cancellation of a service prior to the<br />
administration of anesthesia and/or surgical preparation<br />
of the patient should not be reported. For physician<br />
reporting of a discontinued procedure, see modifier 53.<br />
Reimbursement By Report.<br />
74 Discontinued Out-Patient <strong>Hospital</strong>/Ambulatory<br />
Surgery Center (ASC) Procedure After<br />
Administration of Anesthesia: Due to extenuating<br />
circumstances or those that threaten the well-being of<br />
the patient, the physician may terminate a surgical or<br />
diagnostic procedure after the administration of<br />
anesthesia (local, regional block(s), general) or after the<br />
procedure was started (incision made, intubation<br />
started, scope inserted, etc.). Under these<br />
circumstances, the procedure started but terminated can<br />
be reported by its usual procedure number and the<br />
addition of modifier 74. Note: <strong>The</strong> elective cancellation<br />
of a service prior to the administration of anesthesia<br />
and/or surgical preparation of the patient should not be<br />
reported. For physician reporting of a discontinued<br />
procedure, see modifier 53. Reimbursement By Report.<br />
OTHER BILLING AND PAYMENT REQUIREMENTS<br />
All facilities that bill for services on UB-04 forms are<br />
required to include all appropriate CPT and HCPCS codes in<br />
Field 44.<br />
318 CPT only © 2010 American Medical Association. All Rights Reserved.
Section XV: Outpatient Surgery Payment Schedule<br />
Effective April 1, 2011<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
ICD-9-CM<br />
Outpatient Surgery Fee Schedule<br />
ICD-9-CM DESCRIPTION<br />
03.01 REMOVAL OF FOREIGN BODY FROM SPINAL CANAL 9596.91<br />
03.09 OTHER EXPLORATION&DECOMPRESSION OF SPINAL CANAL 9885.70<br />
03.21 PERCUTANEOUS CHORDOTOMY 3153.37<br />
03.31 SPINAL TAP 961.09<br />
03.53 REPAIR OF VERTEBRAL FRACTURE 9331.50<br />
03.6 LYSIS OF ADHESIONS OF SPINAL CORD&NERVE ROOTS 3030.61<br />
03.8 INJECTION OF DESTRUCTIVE AGENT INTO SPINAL CANAL 2721.93<br />
03.90 INSRT SPINAL CANAL CATH-INFUS THERAP/PALLIATIVE 7996.25<br />
03.91 INJECTION ANESTHETIC INTO SPINAL CANAL ANALGESIA 1316.53<br />
03.92 INJECTION OF OTHER AGENT INTO SPINAL CANAL 989.16<br />
03.93 IMPL/REPLACEMENT SPINAL NEUROSTIMULATOR LEAD(S) 14885.26<br />
03.94 REMOVAL OF SPINAL NEUROSTIMULATOR LEAD(S) 2972.14<br />
03.95 SPINAL BLOOD PATCH 838.33<br />
03.96 PERCUTANEOUS DENERVATION OF FACET 2007.54<br />
03.97 REVISION OF SPINAL THECAL SHUNT 5761.89<br />
03.99 OTH OP SPINAL CORD&SPINAL CANAL STRUCTURES 4230.22<br />
04.02 DIVISION OF TRIGEMINAL NERVE 2064.83<br />
04.07 OTH EXCISION/AVULSION CRANIAL&PERIPHERAL NERVES 4075.88<br />
04.2 DESTRUCTION OF CRANIAL AND PERIPHERAL NERVES 2633.07<br />
04.3 SUTURE OF CRANIAL AND PERIPHERAL NERVES 6215.54<br />
04.43 RELEASE OF CARPAL TUNNEL 2997.87<br />
04.44 RELEASE OF TARSAL TUNNEL 3752.01<br />
04.49 OTH PERIPHERAL NERVE/GANG DECOMPRS/LYSIS ADHES 4862.76<br />
04.5 CRANIAL OR PERIPHERAL NERVE GRAFT 10604.77<br />
04.6 TRANSPOSITION OF CRANIAL AND PERIPHERAL NERVES 5381.90<br />
04.75 REV PREVIOUS REPAIR CRANIAL&PERIPHERAL NERVES 4916.54<br />
04.76 REPAIR OLD TRAUMATIC INJURY CRANIAL&PERIPH NERV 4372.87<br />
04.79 OTHER NEUROPLASTY 2464.70<br />
04.81 INJECTION ANESTHETIC INTO PERIPHERAL NERVE ANALG 1371.48<br />
04.92 IMPL/REPL PERIPHERAL NEUROSTIMULATOR LEAD(S) 17746.33<br />
05.29 OTHER SYMPATHECTOMY AND GANGLIONECTOMY 3407.09<br />
05.31 INJECTION ANESTHETIC IN SYMPATHETIC NERVE ANALG 1162.20<br />
05.39 OTHER INJECTION INTO SYMPATHETIC NERVE/GANGLION 3464.38<br />
06.11 CLOSED BIOPSY OF THYROID GLAND 726.08<br />
08.33 REPR BLEPHAROPTOSIS-RESECT/ADVANCE LEVATOR 5540.90<br />
08.43 REPAIR ENTROPION OR ECTROPION W/WEDGE RESECTION 6167.60<br />
08.44 REPAIR ENTROPION/ECTROPION W/LID RECONSTRUCTION 4130.83<br />
08.59 OTHER ADJUSTMENT OF LID POSITION 8550.46<br />
08.86 LOWER EYELID RHYTIDECTOMY 6186.31<br />
08.89 OTHER EYELID REPAIR 4858.08<br />
08.92 CRYOSURGICAL EPILATION OF EYELID 2898.48<br />
09.83 CONJUNCTIVORHINOSTOMY W/INSERTION TUBE OR STENT 3357.98<br />
11.51 SUTURE OF CORNEAL LACERATION 2738.29<br />
11.64 OTHER PENETRATING KERATOPLASTY 8626.46<br />
12.39 OTHER IRIDOPLASTY 16381.86<br />
12.81 SUTURE OF LACERATION OF SCLERA 11533.13<br />
MAR<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 319
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
ICD-9-CM<br />
Section XV: Outpatient Surgery Payment Schedule<br />
Outpatient Surgery Fee Schedule Effective April 1, 2011<br />
ICD-9-CM DESCRIPTION<br />
MAR<br />
12.84 EXCISION OR DESTRUCTION OF LESION OF SCLERA 1904.65<br />
13.19 OTHER INTRACAPSULAR EXTRACTION OF LENS 3942.59<br />
13.41 PHACOEMULSIFICATION AND ASPIRATION OF CATARACT 4267.63<br />
13.42 MECH PHACOFRAGATION&ASPIR CATARACT POST ROUTE 4212.68<br />
13.64 DISCISSION OF SECONDARY MEMBRANE 475.87<br />
13.70 INSERTION OF PSEUDOPHAKOS NOS 4120.31<br />
13.72 SEC INSERTION OF INTRAOCULAR LENS PROSTHESIS 2613.19<br />
13.8 REMOVAL OF IMPLANTED LENS 5019.43<br />
14.01 REMOVAL FB FROM POST SEGMENT EYE W/USE MAGNET 6168.78<br />
14.24 DESTRUC CHORIORETINAL LESION LASER PHOTOCOAGULAT 10603.61<br />
14.32 REPAIR OF RETINAL TEAR BY CRYOTHERAPY 4737.66<br />
14.39 OTHER REPAIR OF RETINAL TEAR 14657.27<br />
14.41 SCLERAL BUCKLING WITH IMPLANT 5357.34<br />
14.49 OTHER SCLERAL BUCKLING 8276.87<br />
14.74 OTHER MECHANICAL VITRECTOMY 6420.15<br />
15.13 RESECTION OF ONE EXTRAOCULAR MUSCLE 3858.40<br />
15.3 OP>=2 EXTRAOCCULAR MUSC W/TEMP DETACH-1/BOTH 3395.40<br />
15.7 REPAIR OF INJURY OF EXTRAOCULAR MUSCLE 6936.95<br />
16.72 REMOVAL OF ORBITAL IMPLANT 8825.23<br />
16.82 REPAIR OF RUPTURE OF EYEBALL 4839.38<br />
18.29 EXCISION/DESTRUCTION OTHER LESION EXTERNAL EAR 5187.80<br />
19.11 STAPEDECTOMY WITH INCUS REPLACEMENT 10912.27<br />
19.4 MYRINGOPLASTY 2360.64<br />
19.52 TYPE II TYMPANOPLASTY 2229.69<br />
19.53 TYPE III TYMPANOPLASTY 2468.22<br />
19.9 OTHER REPAIR OF MIDDLE EAR 6650.49<br />
20.1 REMOVAL OF TYMPANOSTOMY TUBE 1199.61<br />
20.49 OTHER MASTOIDECTOMY 2588.64<br />
21.32 LOCAL EXCISION OR DESTRUCTION OTHER LESION NOSE 7634.96<br />
21.5 SUBMUCOUS RESECTION OF NASAL SEPTUM 3657.30<br />
21.69 OTHER TURBINECTOMY 1792.40<br />
21.71 CLOSED REDUCTION OF NASAL FRACTURE 3156.88<br />
21.72 OPEN REDUCTION OF NASAL FRACTURE 4291.02<br />
21.84 REVISION RHINOPLASTY 5322.26<br />
21.86 LIMITED RHINOPLASTY 4190.46<br />
21.87 OTHER RHINOPLASTY 6081.08<br />
21.88 OTHER SEPTOPLASTY 4609.04<br />
21.89 OTHER REPAIR AND PLASTIC OPERATIONS ON NOSE 10373.27<br />
22.2 INTRANASAL ANTROTOMY 1705.89<br />
22.52 SPHENOIDOTOMY 8204.38<br />
22.63 ETHMOIDECTOMY 6657.51<br />
27.43 OTHER EXCISION OF LESION OR TISSUE OF LIP 2096.40<br />
30.09 OTHER EXCISION/DESTRUCTION LESION/TISSUE LARYNX 3322.91<br />
33.27 CLOSED ENDOSCOPIC BIOPSY OF LUNG 2140.83<br />
34.91 THORACENTESIS 496.92<br />
37.89 REVISION OR REMOVAL OF PACEMAKER DEVICE 5159.75<br />
320 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section XV: Outpatient Surgery Payment Schedule<br />
Effective April 1, 2011<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
ICD-9-CM<br />
Outpatient Surgery Fee Schedule<br />
ICD-9-CM DESCRIPTION<br />
MAR<br />
38.03 INCISION OF UPPER LIMB VESSELS 5021.77<br />
38.59 LIGATION&STRIPPING OF LOWER LIMB VARICOSE VEINS 4872.12<br />
38.63 OTHER EXCISION OF UPPER LIMB VESSELS 2732.45<br />
38.7 INTERRUPTION OF THE VENA CAVA 6829.38<br />
38.83 OTHER SURGICAL OCCLUSION OF UPPER LIMB VESSELS 3499.46<br />
38.89 OTHER SURGICAL OCCLUSION OF LOWER LIMB VEINS 7069.07<br />
38.91 ARTERIAL CATHETERIZATION 3539.21<br />
38.93 VENOUS CATHETERIZATION NOT ELSEWHERE CLASSIFIED 1638.07<br />
39.49 OTHER REVISION OF VASCULAR PROCEDURE 7611.59<br />
39.50 ANGIOPLASTY/ATHERECT OTH NON-CORONARY VESSEL(S) 12038.23<br />
40.19 OTHER DIAGNOSTIC PROCEDURES LYMPHATIC STRUCTURES 1519.97<br />
40.24 EXCISION OF INGUINAL LYMPH NODE 4305.04<br />
42.92 DILATION OF ESOPHAGUS 1601.82<br />
45.16 ESOPHAGOGASTRODUODENOSCOPY WITH CLOSED BIOPSY 1262.75<br />
45.25 CLOSED [ENDOSCOPIC] BIOPSY OF LARGE INTESTINE 1205.46<br />
46.85 DILATION OF INTESTINE 1308.35<br />
49.12 ANAL FISTULECTOMY 1877.76<br />
49.46 EXCISION OF HEMORRHOIDS 3188.45<br />
50.0 HEPATOTOMY 3685.36<br />
51.23 LAPAROSCOPIC CHOLECYSTECTOMY 5903.36<br />
53.00 UNILATERAL REPAIR OF INGUINAL HERNIA NOS 4710.77<br />
53.01 OTH & OPEN REPAIR OF DIRECT INGUINAL HERNIA 4641.78<br />
53.02 OTHER & OPEN REPAIR OF INDIRECT INGUINAL HERNIA 4764.54<br />
53.03 OTH & OPEN REP DIRECT ING HERNIA W/GRAFT/PROSTH 5090.76<br />
53.04 OTH & OPN REP INDIRECT ING HERNIA W/GRAFT/PROSTH 5492.96<br />
53.05 UNILAT REPAIR ING HERNIA W/GRAFT/PROSTHESIS NOS 5170.26<br />
53.11 OTH & OPEN BILATERAL REP DIRECT INGUINAL HERNIA 5167.92<br />
53.14 OTH & OPEN BILAT REP DIR ING HERNIA W/GRAFT/PROS 7233.92<br />
53.15 OTH & OPEN BILAT REP INDIR ING HERNIA W/GFT/PROS 6855.10<br />
53.16 OTH&OPEN BIL REP ING HERN 1 DIR&1 INDIR GFT/PROS 10870.18<br />
53.17 BILAT ING HERNIA REPAIR W/GRAFT/PROSTHESIS NOS 7045.68<br />
53.21 UNILAT REPAIR FEMORAL HERNIA W/GRAFT/PROSTHESIS 3691.21<br />
53.29 OTHER UNILATERAL FEMORAL HERNIORRHAPHY 2369.99<br />
53.41 OTH & OPEN REP UMBILICAL HERNIA W/GRAFT/PROSTH 6685.57<br />
53.49 OTHER OPEN UMBILICAL HERNIORRHAPHY 4057.18<br />
53.51 INCISIONAL HERNIA REPAIR 3024.76<br />
53.59 REPAIR OTHER HERNIA ANTERIOR ABDOMINAL WALL 3624.56<br />
53.61 OTH & OPEN INCISIONAL HERNIA REP W/GRAFT/PROSTH 5668.35<br />
53.69 OTH & OPEN REP OTH HERN ANT ABD WALL W/GFT/PROS 8518.89<br />
54.0 INCISION OF ABDOMINAL WALL 6124.34<br />
54.59 OTHER LYSIS OF PERITONEAL ADHESIONS 7104.15<br />
54.91 PERCUTANEOUS ABDOMINAL DRAINAGE 5039.31<br />
57.0 TRANSURETHRAL CLEARANCE OF BLADDER 6006.25<br />
58.1 URETHRAL MEATOTOMY 2537.19<br />
58.5 RELEASE OF URETHRAL STRICTURE 3715.76<br />
59.79 OTHER REPAIR OF URINARY STRESS INCONTINENCE 3363.83<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 321
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
ICD-9-CM<br />
Section XV: Outpatient Surgery Payment Schedule<br />
Outpatient Surgery Fee Schedule Effective April 1, 2011<br />
ICD-9-CM DESCRIPTION<br />
MAR<br />
61.2 EXCISION OF HYDROCELE 3547.40<br />
62.5 ORCHIOPEXY 2944.08<br />
63.3 EXC OTH LESION/TISSUE SPERMATIC CORD&EPIDIDYMIS 3806.96<br />
64.0 CIRCUMCISION 2240.21<br />
64.96 REMOVAL OF INTERNAL PROSTHESIS OF PENIS 3660.81<br />
64.97 INSERTION/REPLCMT INFLATABLE PENILE PROSTHESIS 23058.06<br />
64.98 OTHER OPERATIONS ON PENIS 6789.62<br />
68.23 ENDOMETRIAL ABLATION 4875.62<br />
69.09 OTHER DILATION AND CURETTAGE OF UTERUS 4167.08<br />
69.52 ASPIRATION CURETTAGE FOLLOWING DELIVERY/ABORTION 4681.53<br />
76.5 TEMPOROMANDIBULAR ARTHROPLASTY 6129.02<br />
76.64 OTHER ORTHOGNATHIC SURGERY ON MANDIBLE 8148.25<br />
76.65 SEGMENTAL OSTEOPLASTY OF MAXILLA 3829.18<br />
76.66 TOTAL OSTEOPLASTY OF MAXILLA 9911.43<br />
76.72 OPEN REDUCTION OF MALAR AND ZYGOMATIC FRACTURE 5497.65<br />
76.73 CLOSED REDUCTION OF MAXILLARY FRACTURE 7658.35<br />
76.74 OPEN REDUCTION OF MAXILLARY FRACTURE 5302.38<br />
76.76 OPEN REDUCTION OF MANDIBULAR FRACTURE 9600.41<br />
76.79 OTHER OPEN REDUCTION OF FACIAL FRACTURE 7551.95<br />
76.91 BONE GRAFT TO FACIAL BONE 6662.18<br />
76.97 REMOVAL INTERNAL FIXATION DEVICE FROM FCE BONE 4876.79<br />
76.99 OTHER OPERATIONS ON FACIAL BONES AND JOINTS 9525.59<br />
77.07 SEQUESTRECTOMY OF TIBIA AND FIBULA 4939.93<br />
77.13 OTHER INCISION OF RADIUS&ULNA WITHOUT DIVISION 4514.33<br />
77.15 OTHER INCISION OF FEMUR WITHOUT DIVISION 5697.58<br />
77.28 WEDGE OSTEOTOMY OF TARSALS AND METATARSALS 2926.54<br />
77.33 OTHER DIVISION OF RADIUS AND ULNA 7862.96<br />
77.34 OTHER DIVISION OF CARPALS AND METACARPALS 4963.31<br />
77.37 OTHER DIVISION OF TIBIA AND FIBULA 7658.35<br />
77.38 OTHER DIVISION OF TARSALS AND METATARSALS 19601.87<br />
77.49 BIOPSY OF OTHER BONE EXCEPT FACIAL BONES 30025.41<br />
77.53 OTHER BUNIONECTOMY WITH SOFT TISSUE CORRECTION 6321.94<br />
77.58 OTHER EXCISION FUSION AND REPAIR OF TOES 8268.68<br />
77.61 LOCAL EXCISION LESION/TISSUE SCAPULA CLAV&THORAX 3380.20<br />
77.63 LOCAL EXCISION LESION OR TISSUE RADIUS&ULNA 2890.29<br />
77.64 LOCAL EXCISION LESION/TISSUE CARPALS&METACARPALS 2156.03<br />
77.65 LOCAL EXCISION OF LESION OR TISSUE OF FEMUR 5865.95<br />
77.66 LOCAL EXCISION OF LESION OR TISSUE OF PATELLA 15580.94<br />
77.67 LOCAL EXCISION LESION OR TISSUE TIBIA&FIBULA 6456.40<br />
77.68 LOCAL EXCISION LESION/TISSUE TARSALS&METATARSALS 4426.64<br />
77.69 LOCAL EXCISION LESION/TISSUE OTH BONE NO FCE BNS 4103.94<br />
77.79 EXCISION OF OTHER BONE GRAFT EXCEPT FACIAL BONES 9713.83<br />
77.81 OTHER PARTIAL OSTECTOMY SCAPULA CLAVICLE&THORAX 6728.83<br />
77.82 OTHER PARTIAL OSTECTOMY OF HUMERUS 3669.00<br />
77.83 OTHER PARTIAL OSTECTOMY OF RADIUS AND ULNA 5436.85<br />
77.84 OTHER PARTIAL OSTECTOMY OF CARPALS&METACARPALS 8585.54<br />
322 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section XV: Outpatient Surgery Payment Schedule<br />
Effective April 1, 2011<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
ICD-9-CM<br />
Outpatient Surgery Fee Schedule<br />
ICD-9-CM DESCRIPTION<br />
MAR<br />
77.86 OTHER PARTIAL OSTECTOMY OF PATELLA 4276.99<br />
77.88 OTHER PARTIAL OSTECTOMY OF TARSALS&METATARSALS 3173.25<br />
77.89 OTH PARTIAL OSTECTOMY OTH BONE EXCEPT FACIAL BNS 2651.78<br />
77.94 TOTAL OSTECTOMY OF CARPALS AND METACARPALS 4709.59<br />
77.98 TOTAL OSTECTOMY OF TARSALS AND METATARSALS 3353.31<br />
77.99 TOTAL OSTECTOMY OTHER BONE EXCEPT FACIAL BONES 3976.50<br />
78.03 BONE GRAFT OF RADIUS AND ULNA 12086.17<br />
78.04 BONE GRAFT OF CARPALS AND METACARPALS 3656.14<br />
78.07 BONE GRAFT OF TIBIA AND FIBULA 10114.87<br />
78.09 BONE GRAFT OF OTHER BONE EXCEPT FACIAL BONES 7665.36<br />
78.13 APPLICATION OF EXTERNAL FIXATOR DEVC RADIUS&ULNA 3633.91<br />
78.17 APPLICATION EXTERNAL FIXATOR DEVC TIBIA&FIBULA 2196.95<br />
78.19 APPLICATION OF EXTERNAL FIXATOR DEVICE OTHER 4088.74<br />
78.23 LIMB SHORTENING PROCEDURES RADIUS AND ULNA 11434.91<br />
78.33 LIMB LENGTHENING PROCEDURES RADIUS AND ULNA 6272.83<br />
78.43 OTHER REPAIR OR PLASTIC OPERATIONS RADIUS&ULNA 5257.96<br />
78.47 OTHER REPAIR OR PLASTIC OPERATIONS TIBIA&FIBULA 12594.77<br />
78.49 OTH REPAIR/PLASTIC OP OTH BONE NO FCE BNS 2810.79<br />
78.51 INTRL FIX SCAPULA CLAV&THOR W/O FRACTURE RDUC 10034.19<br />
78.52 INTERNAL FIX HUMERUS WITHOUT FRACTURE REDUCTION 11325.01<br />
78.54 INTRL FIX CARPALS&MCS WITHOUT FRACTURE REDUCTION 5137.52<br />
78.55 INTERNAL FIXATION FEM WITHOUT FRACTURE REDUCTION 6084.59<br />
78.57 INTRL FIX TIBIA&FIB WITHOUT FRACTURE REDUCTION 7739.03<br />
78.58 INTRL FIX TARSALS&MTS WITHOUT FRACTURE REDUCTION 5557.27<br />
78.59 INTRL FIX OTH BONE NO FCE BNS W/O FRACTURE RDUC 10374.43<br />
78.61 REMOVAL IMPL DEVICE FROM SCAPULA CLAV&THORAX 5779.43<br />
78.62 REMOVAL OF IMPLANTED DEVICE FROM HUMERUS 5632.10<br />
78.63 REMOVAL OF IMPLANTED DEVICE FROM RADIUS AND ULNA 3476.07<br />
78.64 REMOVAL IMPL DEVICE FROM CARPALS&METACARPALS 3614.04<br />
78.65 REMOVAL OF IMPLANTED DEVICE FROM FEMUR 4648.79<br />
78.66 REMOVAL OF IMPLANTED DEVICE FROM PATELLA 3818.65<br />
78.67 REMOVAL OF IMPLANTED DEVICE FROM TIBIA&FIBULA 4383.38<br />
78.68 REMOVAL IMPLANTED DEVICE FROM TARSAL&METATARSALS 4009.24<br />
78.69 REMOVAL OF IMPLANTED DEVICE FROM OTHER BONE 4179.94<br />
78.75 OSTEOCLASIS OF FEMUR 5760.71<br />
78.77 OSTEOCLASIS OF TIBIA AND FIBULA 4351.82<br />
79.02 CLOS RDUC FRACTURE RADIUS&ULNA WITHOUT INTRL FIX 5302.38<br />
79.04 CLOS RDUC FRACTURE PHALANG HAND W/O INTRL FIX 3499.46<br />
79.06 CLOS RDUC FRACTURE TIBIA&FIB WITHOUT INTRL FIX 2428.45<br />
79.11 CLOS REDUCTION FRACTURE HUMERUS W/INTERNAL FIX 6596.71<br />
79.12 CLOS REDUCTION FRACTURE RADIUS&ULNA W/INTRL FIX 3965.98<br />
79.13 CLOS REDUCTION FRACTURE CARPALS&MCS W/INTRL FIX 2828.33<br />
79.14 CLOS REDUCTION FRACTURE PHALANG HAND W/INTRL FIX 2948.76<br />
79.16 CLOS REDUCTION FRACTURE TIBIA&FIB W/INTERNAL FIX 7687.58<br />
79.17 CLOS REDUCTION FRACTURE TARSALS&MTS W/INTRL FIX 5062.70<br />
79.21 OPEN REDUCTION FRACTURE HUM WITHOUT INTERNAL FIX 7802.16<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 323
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
ICD-9-CM<br />
Section XV: Outpatient Surgery Payment Schedule<br />
Outpatient Surgery Fee Schedule Effective April 1, 2011<br />
ICD-9-CM DESCRIPTION<br />
MAR<br />
79.22 OPEN RDUC FRACTURE RADIUS&ULNA WITHOUT INTRL FIX 9738.39<br />
79.24 OPEN RDUC FRACTURE PHALANG HAND W/O INTRL FIX 1991.17<br />
79.27 OPEN RDUC FRACTURE TARSALS&MTS WITHOUT INTRL FIX 3715.76<br />
79.29 OPN RED FX OTH SPEC BONE EXP FCE BNS W/O INT FIX 3810.46<br />
79.31 OPEN REDUCTION FRACTURE HUMERUS W/INTERNAL FIX 11017.50<br />
79.32 OPEN REDUCTION FRACTURE RADIUS&ULNA W/INTRL FIX 7175.47<br />
79.33 OPEN REDUCTION FRACTURE CARPALS&MCS W/INTRL FIX 4851.07<br />
79.34 OPEN REDUCTION FRACTURE PHALANG HAND W/INTRL FIX 4246.59<br />
79.35 OPEN REDUCTION FRACTURE FEM W/INTERNAL FIXATION 10776.65<br />
79.36 OPEN REDUCTION FRACTURE TIBIA&FIB W/INTERNAL FIX 6138.38<br />
79.37 OPEN REDUCTION FRACTURE TARSALS&MTS W/INTRL FIX 6779.11<br />
79.38 OPEN REDUCTION FRACTURE PHALANGES FT W/INTRL FIX 3968.31<br />
79.39 OPN RED FX OTH SPEC BONE EXP FACE BNS W/INT FIX 6438.87<br />
79.63 DEBRIDEMENT OPEN FRACTURE CARPALS&METACARPALS 2748.82<br />
79.64 DEBRIDEMENT OPEN FRACTURE PHALANGES HAND 3919.20<br />
79.66 DEBRIDEMENT OF OPEN FRACTURE OF TIBIA AND FIBULA 4948.11<br />
79.71 CLOSED REDUCTION OF DISLOCATION OF SHOULDER 3956.62<br />
79.72 CLOSED REDUCTION OF DISLOCATION OF ELBOW 1458.01<br />
79.74 CLOSED REDUCTION OF DISLOCATION OF HAND&FINGER 1883.60<br />
79.81 OPEN REDUCTION OF DISLOCATION OF SHOULDER 7043.35<br />
79.84 OPEN REDUCTION OF DISLOCATION OF HAND AND FINGER 5019.43<br />
79.87 OPEN REDUCTION OF DISLOCATION OF ANKLE 3038.78<br />
79.88 OPEN REDUCTION OF DISLOCATION OF FOOT AND TOE 12226.47<br />
80.04 ARTHRTMY REMVAL OF PROSTH W/O RPLCE HAND&FINGER 5367.86<br />
80.11 OTHER ARTHROTOMY OF SHOULDER 7352.02<br />
80.12 OTHER ARTHROTOMY OF ELBOW 5828.53<br />
80.13 OTHER ARTHROTOMY OF WRIST 1979.48<br />
80.14 OTHER ARTHROTOMY OF HAND AND FINGER 2029.75<br />
80.16 OTHER ARTHROTOMY OF KNEE 4787.93<br />
80.17 OTHER ARTHROTOMY OF ANKLE 6658.67<br />
80.21 ARTHROSCOPY OF SHOULDER 7117.01<br />
80.22 ARTHROSCOPY OF ELBOW 8490.83<br />
80.23 ARTHROSCOPY OF WRIST 4761.04<br />
80.26 ARTHROSCOPY OF KNEE 5211.18<br />
80.27 ARTHROSCOPY OF ANKLE 4073.54<br />
80.35 BIOPSY OF JOINT STRUCTURE OF HIP 558.88<br />
80.36 BIOPSY OF JOINT STRUCTURE OF KNEE 2977.98<br />
80.41 DIVISION JOINT CAPSULE LIGAMENT/CART SHOULDER 5899.85<br />
80.42 DIVISION JOINT CAPSULE LIGAMENT/CARTILAGE ELBOW 5384.23<br />
80.44 DIVISION JOINT CAPSULE LIGAMENT/CART HAND&FINGER 4928.23<br />
80.46 DIVISION JOINT CAPSULE LIGAMENT/CARTILAGE KNEE 4832.36<br />
80.47 DIVISION JOINT CAPSULE LIGAMENT/CARTILAGE ANKLE 5760.71<br />
80.48 DIVISION JOINT CAPSULE LIGAMENT/CART FOOT&TOE 3911.02<br />
80.51 EXCISION OF INTERVERTEBRAL DISC 8737.53<br />
80.59 OTHER DESTRUCTION OF INTERVERTEBRAL DISC 5372.54<br />
80.6 EXCISION OF SEMILUNAR CARTILAGE OF KNEE 4743.51<br />
324 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section XV: Outpatient Surgery Payment Schedule<br />
Effective April 1, 2011<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
ICD-9-CM<br />
Outpatient Surgery Fee Schedule<br />
ICD-9-CM DESCRIPTION<br />
MAR<br />
80.72 SYNOVECTOMY OF ELBOW 3921.54<br />
80.73 SYNOVECTOMY OF WRIST 5153.90<br />
80.74 SYNOVECTOMY OF HAND AND FINGER 3753.17<br />
80.76 SYNOVECTOMY OF KNEE 4745.84<br />
80.77 SYNOVECTOMY OF ANKLE 5153.90<br />
80.81 OTH LOCAL EXCISION/DESTRUC LESION SHOULDER JOINT 6872.64<br />
80.82 OTH LOCAL EXCISION/DESTRUC LESION ELBOW JOINT 5407.61<br />
80.83 OTH LOCAL EXCISION/DESTRUC LESION WRIST JOINT 5373.71<br />
80.84 OTH LOCAL EXC/DESTRUC LESION JOINT HAND&FINGER 3264.45<br />
80.85 OTH LOCAL EXCISION/DESTRUCTION LESION HIP JOINT 9830.75<br />
80.86 OTH LOCAL EXCISION/DESTRUCTION LESION KNEE JOINT 5436.85<br />
80.87 OTH LOCAL EXCISION/DESTRUCTION LESION ANK JOINT 4983.19<br />
80.88 OTH LOCAL EXCISION/DESTRUC LESION JOINT FOOT&TOE 8729.36<br />
80.91 OTHER EXCISION OF SHOULDER JOINT 5786.44<br />
80.92 OTHER EXCISION OF ELBOW JOINT 4424.30<br />
80.94 OTHER EXCISION OF JOINT OF HAND AND FINGER 4680.37<br />
81.02 OTH CERVICAL FUSION ANT COLUMN ANT TECHNIQUE 15644.08<br />
81.03 OTH CERVICAL FUSION POST COLUMN POST TECHNIQUE 13168.86<br />
81.06 LUMBAR LUMBOSACRAL FUSION ANT COLUMN ANT TECH 58194.12<br />
81.08 LUMBAR LUMBOSACRAL FUSION ANT COLUMN POST TECH 31472.90<br />
81.11 ANKLE FUSION 19826.35<br />
81.13 SUBTALAR FUSION 13027.38<br />
81.14 MIDTARSAL FUSION 11733.06<br />
81.16 METATARSOPHALANGEAL FUSION 8161.12<br />
81.25 CARPORADIAL FUSION 6678.54<br />
81.26 METACARPOCARPAL FUSION 7558.96<br />
81.27 METACARPOPHALANGEAL FUSION 2851.72<br />
81.28 INTERPHALANGEAL FUSION 5930.25<br />
81.29 ARTHRODESIS OF OTHER SPECIFIED JOINT 7401.12<br />
81.32 REFUSION OTH C-SPINE ANTERIOR COLUMN ANT TECH 18139.18<br />
81.33 REFUSION OTH C-SPINE POSTERIOR COLUMN POST TECH 10667.91<br />
81.40 REPAIR OF HIP NOT ELSEWHERE CLASSIFIED 11956.38<br />
81.43 TRIAD KNEE REPAIR 5732.65<br />
81.44 PATELLAR STABILIZATION 6969.68<br />
81.45 OTHER REPAIR OF THE CRUCIATE LIGAMENTS 10002.63<br />
81.46 OTHER REPAIR OF THE COLLATERAL LIGAMENTS 6610.73<br />
81.47 OTHER REPAIR OF KNEE 5909.20<br />
81.49 OTHER REPAIR OF ANKLE 6959.16<br />
81.71 ARTHPLSTY METACARPOPHALANGEAL&IP JOINT W/IMPLANT 11403.34<br />
81.72 ARTHPLSTY MCP&IP JOINT WITHOUT IMPLANT 3633.91<br />
81.74 ARTHRPLSTY CARPOCARPAL/CMC JOINT WITH IMPLANT 4883.81<br />
81.75 ARTHRPLSTY CARPOCARPAL/CMC JOINT WITHOUT IMPLANT 5180.78<br />
81.79 OTHER REPAIR OF HAND FINGERS AND WRIST 5758.38<br />
81.81 PARTIAL SHOULDER REPLACEMENT 13477.53<br />
81.82 REPAIR OF RECURRENT DISLOCATION OF SHOULDER 7681.74<br />
81.83 OTHER REPAIR OF SHOULDER 7571.82<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 325
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
ICD-9-CM<br />
Section XV: Outpatient Surgery Payment Schedule<br />
Outpatient Surgery Fee Schedule Effective April 1, 2011<br />
ICD-9-CM DESCRIPTION<br />
MAR<br />
81.84 TOTAL ELBOW REPLACEMENT 10311.29<br />
81.85 OTHER REPAIR OF ELBOW 8154.10<br />
81.91 ARTHROCENTESIS 1311.86<br />
81.92 INJ THERAPEUTIC SUBSTANCE IN JOINT/LIGAMENT 1058.14<br />
81.93 SUTURE OF CAPSULE OR LIGAMENT OF UPPER EXTREMITY 7443.21<br />
81.94 SUTURE OF CAPSULE OR LIGAMENT OF ANKLE AND FOOT 3285.50<br />
81.95 SUTURE CAPSULE OR LIGAMENT OTHER LOWER EXTREMITY 8245.29<br />
81.96 OTHER REPAIR OF JOINT 5764.22<br />
81.97 REVISION OF JOINT REPLACEMENT OF UPPER EXTREMITY 4613.72<br />
82.01 EXPLORATION OF TENDON SHEATH OF HAND 2628.39<br />
82.02 MYOTOMY OF HAND 3902.84<br />
82.09 OTHER INCISION OF SOFT TISSUE OF HAND 3118.30<br />
82.11 TENOTOMY OF HAND 3933.24<br />
82.19 OTHER DIVISION OF SOFT TISSUE OF HAND 8013.79<br />
82.21 EXCISION OF LESION OF TENDON SHEATH OF HAND 3020.08<br />
82.29 EXCISION OF OTHER LESION OF SOFT TISSUE OF HAND 1407.73<br />
82.33 OTHER TENONECTOMY OF HAND 2854.06<br />
82.35 OTHER FASCIECTOMY OF HAND 3356.81<br />
82.36 OTHER MYECTOMY OF HAND 6067.05<br />
82.42 DELAYED SUTURE OF FLEXOR TENDON OF HAND 5683.55<br />
82.43 DELAYED SUTURE OF OTHER TENDON OF HAND 2392.22<br />
82.44 OTHER SUTURE OF FLEXOR TENDON OF HAND 4971.50<br />
82.45 OTHER SUTURE OF OTHER TENDON OF HAND 3231.71<br />
82.56 OTHER HAND TENDON TRANSFER OR TRANSPLANTATION 3425.80<br />
82.57 OTHER HAND TENDON TRANSPOSITION 4134.34<br />
82.71 TENDON PULLEY RECONSTRUCTION ON HAND 6426.00<br />
82.79 PLASTIC OPERATION HAND W/OTHER GRAFT OR IMPLANT 7085.43<br />
82.84 REPAIR OF MALLET FINGER 2360.64<br />
82.85 OTHER TENODESIS OF HAND 5157.41<br />
82.86 OTHER TENOPLASTY OF HAND 3173.25<br />
82.91 LYSIS OF ADHESIONS OF HAND 4462.89<br />
83.01 EXPLORATION OF TENDON SHEATH 3960.13<br />
83.02 MYOTOMY 3898.16<br />
83.03 BURSOTOMY 4091.08<br />
83.09 OTHER INCISION OF SOFT TISSUE 3431.65<br />
83.13 OTHER TENOTOMY 5017.10<br />
83.14 FASCIOTOMY 3858.40<br />
83.19 OTHER DIVISION OF SOFT TISSUE 8625.29<br />
83.21 OPEN BIOPSY OF SOFT TISSUE 3499.46<br />
83.31 EXCISION OF LESION OF TENDON SHEATH 3939.08<br />
83.39 EXCISION OF LESION OF OTHER SOFT TISSUE 4676.86<br />
83.42 OTHER TENONECTOMY 4050.15<br />
83.44 OTHER FASCIECTOMY 2858.73<br />
83.45 OTHER MYECTOMY 1410.07<br />
83.5 BURSECTOMY 4558.77<br />
83.61 SUTURE OF TENDON SHEATH 5271.98<br />
326 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Section XV: Outpatient Surgery Payment Schedule<br />
Effective April 1, 2011<br />
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
ICD-9-CM<br />
Outpatient Surgery Fee Schedule<br />
ICD-9-CM DESCRIPTION<br />
MAR<br />
83.62 DELAYED SUTURE OF TENDON 4068.86<br />
83.63 ROTATOR CUFF REPAIR 7431.52<br />
83.64 OTHER SUTURE OF TENDON 5069.71<br />
83.65 OTHER SUTURE OF MUSCLE OR FASCIA 4488.62<br />
83.71 ADVANCEMENT OF TENDON 3948.44<br />
83.73 REATTACHMENT OF TENDON 4825.34<br />
83.75 TENDON TRANSFER OR TRANSPLANTATION 5570.14<br />
83.81 TENDON GRAFT 9536.11<br />
83.83 TENDON PULLEY RECONSTRUCT MUSCLE TENDON&FASCIA 4547.07<br />
83.85 OTHER CHANGE IN MUSCLE OR TENDON LENGTH 5240.42<br />
83.86 QUADRICEPSPLASTY 5557.27<br />
83.87 OTHER PLASTIC OPERATIONS ON MUSCLE 5422.81<br />
83.88 OTHER PLASTIC OPERATIONS ON TENDON 6297.39<br />
83.91 LYSIS OF ADHESIONS OF MUSCLE TENDON FASCIA&BURSA 5043.98<br />
83.98 INJ LOCLY ACTING TX SBSTNC IN OTH SFT TISSUE 354.28<br />
84.01 AMPUTATION AND DISARTICULATION OF FINGER 3705.24<br />
84.02 AMPUTATION AND DISARTICULATION OF THUMB 4312.06<br />
84.11 AMPUTATION OF TOE 3350.97<br />
84.22 FINGER REATTACHMENT 4372.87<br />
84.3 REVISION OF AMPUTATION STUMP 2973.31<br />
85.11 CLOSED BIOPSY OF BREAST 2140.83<br />
85.12 OPEN BIOPSY OF BREAST 2629.57<br />
85.21 LOCAL EXCISION OF LESION OF BREAST 2952.27<br />
86.01 ASPIRATION OF SKIN AND SUBCUTANEOUS TISSUE 3893.49<br />
86.02 INJECTION OR TATTOOING OF SKIN LESION OR DEFECT 4317.90<br />
86.04 OTH INCISION W/DRAINAGE SKIN&SUBCUTANEOUS TISSUE 2820.14<br />
86.05 INCI W/REMOVAL FB/DEVICE FROM SKIN & SUBQ TISSUE 2666.98<br />
86.06 INSERTION OF TOTALLY IMPLANTABLE INFUSION PUMP 19183.29<br />
86.11 CLOSED BIOPSY OF SKIN AND SUBCUTANEOUS TISSUE 285.29<br />
86.22 EXCISIONAL DEBRIDEMENT WOUND INFECTION OR BURN 1410.07<br />
86.23 REMOVAL OF NAIL NAILBED OR NAIL FOLD 2876.27<br />
86.24 CHEMOSURGERY OF SKIN 1419.42<br />
86.25 DERMABRASION 11282.91<br />
86.28 NONEXCISIONAL DEBRIDEMENT WOUND INFECTION/BURN 1211.31<br />
86.4 RADICAL EXCISION OF SKIN LESION 5330.45<br />
86.59 CLOSURE SKIN&SUBCUTANEOUS TISSUE OTHER SITES 2657.62<br />
86.61 FULL-THICKNESS SKIN GRAFT TO HAND 4810.14<br />
86.62 OTHER SKIN GRAFT TO HAND 4178.77<br />
86.63 FULL-THICKNESS SKIN GRAFT TO OTHER SITES 4446.52<br />
86.65 HETEROGRAFT TO SKIN 790.39<br />
86.66 HOMOGRAFT TO SKIN 3522.84<br />
86.67 DERMAL REGENERATIVE GRAFT 7689.92<br />
86.69 OTHER SKIN GRAFT TO OTHER SITES 4286.34<br />
86.71 CUTTING&PREPARATION OF PEDICLE GRAFTS OR FLAPS 3632.75<br />
86.72 ADVANCEMENT OF PEDICLE GRAFT 2414.43<br />
86.73 ATTACHMENT OF PEDICLE OR FLAP GRAFT TO HAND 4068.86<br />
Fee data © 2011 Ingenix CPT only © 2010 American Medical Association. All Rights Reserved. 327
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
ICD-9-CM<br />
Section XV: Outpatient Surgery Payment Schedule<br />
Outpatient Surgery Fee Schedule Effective April 1, 2011<br />
ICD-9-CM DESCRIPTION<br />
MAR<br />
86.74 ATTACHMENT PEDICLE OR FLAP GRAFT TO OTHER SITES 5648.47<br />
86.75 REVISION OF PEDICLE OR FLAP GRAFT 2218.00<br />
86.84 RELAXATION OF SCAR OR WEB CONTRACTURE OF SKIN 4841.72<br />
86.86 ONYCHOPLASTY 3576.62<br />
86.89 OTH REPAIR&RECONSTRUCT SKIN&SUBCUTANEOUS TISSUE 4136.68<br />
86.93 INSERTION OF TISSUE EXPANDER 7727.34<br />
328 CPT only © 2010 American Medical Association. All Rights Reserved. Fee data © 2011 Ingenix
Index<br />
A<br />
add-on 46<br />
procedures 8<br />
air transportation 295<br />
allografts 10<br />
ambulance transportation 295<br />
ambulatory surgery 317<br />
ambulatory surgery center 9, 21, 30, 46, 173, 221, 318<br />
anesthesia 27, 31, 318<br />
services 27, 28, 32<br />
values 27, 28<br />
appointed physician 14<br />
arthroscopic surgery 44<br />
ASC 46, 173<br />
ASC hospital 21, 30, 46, 173, 221, 254, 255, 287<br />
authorization to treat 7<br />
B<br />
base unit values 27<br />
bilateral procedures 45, 173<br />
bone and other tissue grafts 44<br />
broken or missed appointments 15<br />
by report 13, 42, 220, 318<br />
C<br />
carticel 44<br />
casting 44<br />
catastrophic injury 11<br />
CCI (see National Correct Coding Initiative) 7<br />
chiropractors 286<br />
clinical nurse specialist 10, 20, 22<br />
collection and handling procedures 219<br />
concurrent<br />
care 18<br />
services by more than one physician 43<br />
concurrent care 18<br />
confidentiality 7<br />
considerations for reimbursement 7<br />
consultations 17, 18, 20, 220<br />
conversion factor 5, 6, 27<br />
coordination of care 18<br />
co-surgeons 41<br />
counseling 18, 19, 43<br />
CPT 5, 7, 8, 9, 10, 11, 12, 14, 15, 17, 18, 20, 22, 30, 32, 41,<br />
42, 43, 44, 45, 171, 172, 219, 220, 285, 286, 291, 318<br />
critical care 20<br />
D<br />
deposition/testimony, physician 14<br />
drugs 10, 171<br />
durable medical equipment 8, 10<br />
E<br />
emergency room 17<br />
emergency room services 20<br />
exempt from modifier 51 codes 8<br />
F<br />
follow-up days 8, 41, 42<br />
fractures 44<br />
functional capacity 11, 12, 286<br />
H<br />
home care 291<br />
I<br />
impairment 12, 19, 286<br />
implants 10, 318<br />
independent medical exam 12<br />
inpatient hospital 6, 8, 20, 318<br />
instrumentation 10<br />
CPT only © 2010 American Medical Association. All Rights Reserved. 329
<strong>Georgia</strong> Workers’ Compensation Medical Fee Schedule<br />
interpreter 11, 18, 22, 253, 254, 255, 285, 288<br />
L<br />
late payment 15<br />
M<br />
manipulation codes 286<br />
medical records 14<br />
microsurgery 45<br />
missed appointments 15, 20<br />
moderate conscious sedation 5<br />
modifiers for<br />
anesthesia 30<br />
diagnostic and therapeutic radiological services 172<br />
pathology and laboratory services 220<br />
physical medicine services 287<br />
surgical services 45<br />
MS-DRG 8, 10, 13, 15<br />
multiple<br />
concurrent physical medicine procedures and modalities<br />
286<br />
procedures 9, 32, 43, 45, 220, 317<br />
surgeons 43<br />
N<br />
National Correct Coding Initiative (CCI) 7, 9, 45<br />
nature of presenting problem 19<br />
new & established patient 17<br />
new CPT codes 12<br />
no show/missed appointments 20<br />
nurse practitioner 10, 20, 22, 41, 47<br />
nursing facility services 20<br />
O<br />
occupational therapists 11, 285, 286<br />
on-call or substitute physician 17<br />
one-time-only 285<br />
orthotic 286<br />
orthotics 12, 286<br />
osteopaths 286<br />
outpatient hospital 9, 21, 30, 46, 173, 221, 317<br />
P<br />
panel tests 220<br />
peer review 13, 14<br />
physical therapy 285, 318<br />
physician<br />
extenders 10, 20<br />
testimony 14<br />
preauthorization 7<br />
professional component 5, 45, 171, 172, 173, 219, 220<br />
Q<br />
qualifying circumstances 5, 27, 28, 31<br />
R<br />
referral 219<br />
rental equipment 10<br />
S<br />
separate procedure 8, 41, 43<br />
separate procedure code(s) 46<br />
special report 13, 29, 44<br />
surgical<br />
assistants 41<br />
destruction 43<br />
package 41<br />
T<br />
Index<br />
technical component 5, 45, 47, 171, 173, 174, 219, 220,<br />
221<br />
TENS units 287<br />
time 8, 10, 12, 13, 14, 15, 17, 19, 27, 29, 31, 32, 220, 286<br />
time reporting 28<br />
transportation 16, 293<br />
air 295<br />
ambulance 295<br />
non-emergency 5, 293<br />
U<br />
unlisted service or procedure 12, 20, 41, 254<br />
urgent care facility 9<br />
W<br />
work hardening 11, 12<br />
wound repair 44<br />
330 CPT only © 2010 American Medical Association. All Rights Reserved.