OUTPATIENT LIMITATION FOR MEDICAL/SURGICAL FACILITY FEE

Subpart 1. No facility fee. Procedures whose codes are listed in subpart 2b are predominantly performed in office settings and, therefore, no additional facility fees are payable when the procedure is performed by the employee's treating health care provider, unless it is an emergency or medically necessary to perform the procedure in a nonoffice setting or after normal office hours. This part does not preclude payment of a facility fee where the employee is treated by emergency room or urgent care staff. Subp. 1a. Payment of facility fee. Except where the facility fee is precluded from payment in subpart 1, fees for ambulatory surgical center and hospital outpatient surgical center are paid in accordance with part 5221.0500 , subpart 2. A. Services and supplies included in facility fee. The services in subitems (1) to (8) are included in the facility fee. There may be no separate payment for these services and supplies: (1) nursing, technician, and related services; (2) use of the facilities where the surgical procedures are performed; (3) drugs, biologicals, surgical dressings, supplies, splints, casts, appliances, and equipment directly related to the provision of surgical procedures; (4) diagnostic or therapeutic services or items directly related to the provision of a surgical procedure; (5) administrative, record keeping, and housekeeping items and services; (6) materials for anesthesia; (7) intraocular lenses (IOLs); and (8) supervision of the services of an anesthetist by the operating surgeon. B. Services and supplies in subitems (1) to (7) are paid separately from the facility fee: (1) physician services; (2) laboratory, X-ray, or diagnostic procedures, other than those directly related to performance of the surgical procedure; (3) prosthetic devices, except IOLs; (4) ambulance services; (5) leg, arm, back, and neck braces and artificial limbs; (6) durable medical equipment for use in the patient's home or take-home supplies; and (7) anesthetist services. Subp. 2a. [Repealed, 25 SR 1142] Subp. 2b. Procedure codes subject to limitation. A. Surgery: Integumentary system: CPT/HCPCS Procedure Code CPT/HCPCS Description 10040 Acne surgery 10060 Drainage of skin abscess 10061 Drainage of skin abscess 10080 Drainage of pilonidal cyst 10081 Drainage of pilonidal cyst 10120 Remove foreign body 10121 Remove foreign body 10140 Drainage of hematoma/fluid 10160 Puncture drainage of lesion 11000 Surgical cleansing of skin 11001 Additional cleansing of skin 11200 Removal of skin tags 11201 Removal of added skin tags 11300 Shave skin lesion 11301 Shave skin lesion 11302 Shave skin lesion 11303 Shave skin lesion 11305 Shave skin lesion 11306 Shave skin lesion 11307 Shave skin lesion 11308 Shave skin lesion 11310 Shave skin lesion 11311 Shave skin lesion 11312 Shave skin lesion 11313 Shave skin lesion 11400 Removal of skin lesion 11401 Removal of skin lesion 11402 Removal of skin lesion 11403 Removal of skin lesion 11420 Removal of skin lesion 11421 Removal of skin lesion 11422 Removal of skin lesion 11423 Removal of skin lesion 11440 Removal of skin lesion 11441 Removal of skin lesion 11442 Removal of skin lesion 11443 Removal of skin lesion 11600 Removal of skin lesion 11601 Removal of skin lesion 11602 Removal of skin lesion 11603 Removal of skin lesion 11620 Removal of skin lesion 11621 Removal of skin lesion 11622 Removal of skin lesion 11623 Removal of skin lesion 11640 Removal of skin lesion 11641 Removal of skin lesion 11642 Removal of skin lesion 11643 Removal of skin lesion 11730 Removal of nail plate 11732 Remove additional nail plate 11740 Drain blood from under nail 11750 Removal of nail bed 11760 Reconstruction of nail bed 11762 Reconstruction of nail bed 11765 Excision of nail fold, toe 11900 Injection into skin lesions 11901 Added skin lesion injections 12031 Layer closure of wound(s) 12032 Layer closure of wound(s) 12041 Layer closure of wound(s) 12042 Layer closure of wound(s) 12051 Layer closure of wound(s) 12052 Layer closure of wound(s) 15780 Abrasion treatment of skin 15781 Abrasion treatment of skin 15782 Abrasion treatment of skin 15783 Abrasion treatment of skin 15786 Abrasion treatment of lesion 15787 Abrasion, added skin lesions 15851 Removal of sutures 16000 Initial treatment of burn(s) 16020 Treatment of burn(s) 16025 Treatment of burn(s) 17000 Destroy benign/premal lesion 17106 Destruction of skin lesions 17107 Destruction of skin lesions 17110 Destruction of skin lesions 17250 Chemical cautery, tissue 17260 Destruction of skin lesions 17261 Destruction of skin lesions 17262 Destruction of skin lesions 17263 Destruction of skin lesions 17264 Destruction of skin lesions 17266 Destruction of skin lesions 17270 Destruction of skin lesions 17271 Destruction of skin lesions 17272 Destruction of skin lesions 17273 Destruction of skin lesions 17274 Destruction of skin lesions 17276 Destruction of skin lesions 17280 Destruction of skin lesions 17281 Destruction of skin lesions 17282 Destruction of skin lesions 17283 Destruction of skin lesions 17284 Destruction of skin lesions 17286 Destruction of skin lesions 17340 Cryotherapy of skin 17360 Skin peel therapy 19000 Drainage of breast lesion 19001 Drain added breast lesion B. Surgery: Musculoskeletal system: CPT/HCPCS Procedure Code CPT/HCPCS Description 20500 Injection of sinus tract 20520 Removal of foreign body 20550 Inject tendon/ligament/cyst 20600 Drain/inject joint/bursa 20605 Drain/inject joint/bursa 20610 Drain/inject joint/bursa 20615 Treatment of bone cyst 20974 Electrical bone stimulation 21029 Contour of face bone lesion 21030 Removal of face bone lesion 21031 Remove exostosis, mandible 21032 Remove exostosis, maxilla 21079 Prepare face/oral prosthesis 21080 Prepare face/oral prosthesis 21081 Prepare face/oral prosthesis 21082 Prepare face/oral prosthesis 21083 Prepare face/oral prosthesis 21084 Prepare face/oral prosthesis 21085 Prepare face/oral prosthesis 21086 Prepare face/oral prosthesis 21087 Prepare face/oral prosthesis 21088 Prepare face/oral prosthesis 21089 Prepare face/oral prosthesis 21110 Interdental fixation 23031 Drain shoulder bursa 24200 Removal of arm foreign body 24650 Treat radius fracture 25500 Treat fracture of radius 25530 Treat fracture of ulna 25600 Treat fracture radius/ulna 25622 Treat wrist bone fracture 25630 Treat wrist bone fracture 25650 Repair wrist bone fracture 26010 Drainage of finger abscess 26600 Treat metacarpal fracture 26720 Treat finger fracture, each 26725 Treat finger fracture, each 26740 Treat finger fracture, each 28001 Drainage of bursa of foot 28010 Incision of toe tendon 28011 Incision of toe tendons 28022 Exploration of a foot joint 28024 Exploration of a toe joint 28052 Biopsy of foot joint lining 28108 Removal of toe lesions 28124 Partial removal of toe 28126 Partial removal of toe 28153 Partial removal of toe 28160 Partial removal of toe 28190 Removal of foot foreign body 28220 Release of foot tendon 28230 Incision of foot tendon(s) 28232 Incision of toe tendon 28234 Incision of foot tendon 28270 Release of foot contracture 28272 Release of toe joint, each 28430 Treatment of ankle fracture 28450 Treat midfoot fracture, each 28455 Treat midfoot fracture, each 28470 Treat metatarsal fracture 28475 Treat metatarsal fracture 28490 Treat big toe fracture 28495 Treat big toe fracture 28510 Treatment of toe fracture 28515 Treatment of toe fracture 28530 Treat sesamoid bone fracture 28540 Treat foot dislocation 28570 Treat foot dislocation 28600 Treat foot dislocation 28630 Treat toe dislocation 29015 Application of body cast 29035 Application of body cast 29049 Application of shoulder cast 29065 Application of long arm cast 29075 Application of forearm cast 29085 Apply hand/wrist cast 29105 Apply long arm splint 29125 Apply forearm splint 29126 Apply forearm splint 29130 Application of finger splint 29131 Application of finger splint 29200 Strapping of chest 29260 Strapping of elbow or wrist 29280 Strapping of hand or finger 29345 Application of long leg cast 29355 Application of long leg cast 29358 Apply long leg cast brace 29365 Application of long leg cast 29405 Apply short leg cast 29425 Apply short leg cast 29435 Apply short leg cast 29440 Addition of walker to cast 29450 Application of leg cast 29515 Application lower leg splint 29520 Strapping of hip 29530 Strapping of knee 29540 Strapping of ankle 29550 Strapping of toes 29580 Application of paste boot 29700 Removal/revision of cast 29705 Removal/revision of cast 29710 Removal/revision of cast 29720 Repair of body cast 29730 Windowing of cast 29740 Wedging of cast 29750 Wedging of clubfoot cast 29850 Knee arthroscopy/surgery C. Surgery: Respiratory, cardiovascular, hemic and lymphatic systems: CPT/HCPCS Procedure Code CPT/HCPCS Description 30000 Drainage of nose lesion 30020 Drainage of nose lesion 30100 Intranasal biopsy 30110 Removal of nose polyp(s) 30200 Injection treatment of nose 30210 Nasal sinus therapy 30220 Insert nasal septal button 30300 Remove nasal foreign body 30901 Control of nosebleed 31000 Irrigation maxillary sinus 31002 Irrigation sphenoid sinus 31505 Diagnostic laryngoscopy 31575 Diagnostic laryngoscopy 31579 Diagnostic laryngoscopy 36000 Place needle in vein 36400 Drawing blood 36405 Drawing blood 36406 Drawing blood 36410 Drawing blood 36430 Blood transfusion service 36450 Exchange transfusion service 36470 Injection therapy of vein 36471 Injection therapy of veins 36510 Insertion of catheter, vein D. Surgery: Digestive system: CPT/HCPCS Procedure Code CPT/HCPCS Description 40490 Biopsy of lip 40800 Drainage of mouth lesion 40804 Removal foreign body, mouth 40808 Biopsy of mouth lesion 40810 Excision of mouth lesion 40812 Excise/repair mouth lesion 41100 Biopsy of tongue 41108 Biopsy of floor of mouth 41825 Excision of gum lesion 41826 Excision of gum lesion 42100 Biopsy roof of mouth 42330 Removal of salivary stone 42400 Biopsy of salivary gland 42650 Dilation of salivary duct 42660 Dilation of salivary duct 42800 Biopsy of throat 45300 Proctosigmoidoscopy 45303 Proctosigmoidoscopy 45330 Sigmoidoscopy, diagnostic 45520 Treatment of rectal prolapse 46083 Incise external hemorrhoid 46221 Ligation of hemorrhoid(s) 46230 Removal of anal tabs 46320 Removal of hemorrhoid clot 46500 Injection into hemorrhoids 46600 Diagnostic anoscopy 46604 Anoscopy and dilation 46606 Anoscopy and biopsy 46614 Anoscopy, control bleeding 46615 Anoscopy 46900 Destruction, anal lesion(s) 46910 Destruction, anal lesion(s) 46916 Cryosurgery, anal lesion(s) 46917 Laser surgery, anal lesion(s) 46940 Treatment of anal fissure 46942 Treatment of anal fissure 46945 Ligation of hemorrhoids 46946 Ligation of hemorrhoids E. Surgery: Urinary, male genital, female genital, maternity care and delivery systems: CPT/HCPCS Procedure Code CPT/HCPCS Description 51700 Irrigation of bladder 51705 Change of bladder tube 51720 Treatment of bladder lesion 52265 Cystoscopy and treatment 53270 Removal of urethra gland 53600 Dilate urethra stricture 53601 Dilate urethra stricture 53620 Dilate urethra stricture 53621 Dilate urethra stricture 53660 Dilation of urethra 53661 Dilation of urethra 54050 Destruction, penis lesion(s) 54055 Destruction, penis lesion(s) 54056 Cryosurgery, penis lesion(s) 54200 Treatment of penis lesion 54230 Prepare penis study 54235 Penile injection 55000 Drainage of hydrocele 55250 Removal of sperm duct(s) 56420 Drainage of gland abscess 56501 Destruction, vulva lesion(s) 56606 Biopsy of vulva/perineum 57061 Destruction, vagina lesion(s) 57100 Biopsy of vagina 57150 Treat vagina infection 57160 Insertion of pessary 57170 Fitting of diaphragm/cap 57452 Examination of vagina 57454 Vagina examination and biopsy 57460 LEEP procedure 57500 Biopsy of cervix 57505 Endocervical curettage 57510 Cauterization of cervix 57511 Cryocautery of cervix 58100 Biopsy of uterus lining 58301 Remove intrauterine device 59200 Insert cervical dilator 59300 Episiotomy or vaginal repair 59425 Antepartum care only 59426 Antepartum care only 59430 Care after delivery F. Surgery: Endocrine, nervous, eye and ocular adnexa, and auditory systems: CPT/HCPCS Procedure Code CPT/HCPCS Description 60100 Biopsy of thyroid 61001 Remove cranial cavity fluid 64400 Injection for nerve block 64405 Injection for nerve block 64408 Injection for nerve block 64418 Injection for nerve block 64435 Injection for nerve block 64445 Injection for nerve block 64450 Injection for nerve block 64505 Injection for nerve block 64553 Implant neuroelectrodes 64555 Implant neuroelectrodes 64612 Destroy nerve, face muscle 65205 Remove foreign body from eye 65210 Remove foreign body from eye 65220 Remove foreign body from eye 65222 Remove foreign body from eye 65286 Repair of eye wound 65430 Corneal smear 65435 Curette/treat cornea 65436 Curette/treat cornea 65600 Revision of cornea 65772 Correction of astigmatism 65855 Laser surgery of eye 65860 Incise inner eye adhesions 66761 Revision of iris 66770 Removal of inner eye lesion 67145 Treatment of retina 67210 Treatment of retinal lesion 67228 Treatment of retinal lesion 67345 Destroy nerve of eye muscle 67505 Inject/treat eye socket 67515 Inject/treat eye socket 67700 Drainage of eyelid abscess 67710 Incision of eyelid 67800 Remove eyelid lesion 67801 Remove eyelid lesions 67805 Remove eyelid lesions 67810 Biopsy of eyelid 67820 Revise eyelashes 67825 Revise eyelashes 67840 Remove eyelid lesion 67850 Treat eyelid lesion 67915 Repair eyelid defect 67922 Repair eyelid defect 67930 Repair eyelid wound 67938 Remove eyelid foreign body 68020 Incise/drain eyelid lining 68040 Treatment of eyelid lesions 68100 Biopsy of eyelid lining 68110 Remove eyelid lining lesion 68135 Remove eyelid lining lesion 68200 Treat eyelid by injection 68400 Incise/drain tear gland 68420 Incise/drain tear sac 68440 Incise tear duct opening 68530 Clearance of tear duct 68705 Revise tear duct opening 68760 Close tear duct opening 68761 Close tear duct opening 68770 Close tear system fistula 68840 Explore/irrigate tear ducts 69000 Drain external ear lesion 69005 Drain external ear lesion 69020 Drain outer ear canal lesion 69100 Biopsy of external ear 69105 Biopsy of external ear canal 69200 Clear outer ear canal 69210 Remove impacted ear wax 69220 Clean out mastoid cavity 69222 Clean out mastoid cavity 69420 Incision of eardrum 69433 Create eardrum opening 69540 Remove ear lesion 69610 Repair of eardrum G. Medicine, evaluation and management services: CPT/HCPCS Procedure Code CPT/HCPCS Description 92002 Eye exam, new patient 92004 Eye exam, new patient 92012 Eye exam, established patient 92014 Eye exam and treatment 92019 Eye exam and treatment 92020 Special eye evaluation 92100 Serial tonometry exam(s) 92230 Eye exam with photos 92260 Ophthalmoscopy/dynamometry 92287 Internal eye photography 92311 Contact lens fitting 92312 Contact lens fitting 92313 Contact lens fitting 92315 Prescription of contact lens 92316 Prescription of contact lens 92317 Prescription of contact lens 92352 Special spectacles fitting 92353 Special spectacles fitting 92354 Special spectacles fitting 92371 Repair and adjust spectacles 92504 Ear microscopy examination 92507 Speech/hearing therapy 92508 Speech/hearing therapy 92511 Nasopharyngoscopy 92512 Nasal function studies 92516 Facial nerve function test 92520 Laryngeal function studies 92565 Stenger test, pure tone 92571 Filtered speech hearing test 92575 Sensorineural acuity test 92576 Synthetic sentence test 92577 Stenger test, speech 92582 Conditioning play audiometry 93797 Cardiac rehab 93798 Cardiac rehab/monitor 95056 Photosensitivity tests 95065 Nose allergy test 95144 Antigen therapy services 95145 Antigen therapy services 95146 Antigen therapy services 95147 Antigen therapy services 95148 Antigen therapy services 95149 Antigen therapy services 95165 Antigen therapy services 95170 Antigen therapy services 95180 Rapid desensitization 95851 Range of motion measurements 95852 Range of motion measurements 95857 Tensilon test 96405 Intralesional chemotherapy administration 96406 Intralesional chemotherapy administration 96450 Chemotherapy, into central nervous system 96542 Chemotherapy injection 98940 Chiropractor manip of spine 98941 Chiropractor manip of spine 98942 Chiropractor manip of spine 98943 Chiropractor manip extra spinal 99202 Office/outpatient visit, new 99203 Office/outpatient visit, new 99204 Office/outpatient visit, new 99205 Office/outpatient visit, new 99211 Office/outpatient visit, established 99212 Office/outpatient visit, established 99213 Office/outpatient visit, established 99214 Office/outpatient visit, established 99215 Office/outpatient visit, established 99242 Office consultation 99243 Office consultation 99244 Office consultation 99245 Office consultation