No-fault reimbursement schedules for hospital: A) Inpatient services rendered on and after 1-1-86 and B) Inpatient services rendered on and after 1-1-87.

October 2, 1989 SUBJECT: INSURANCE Circular Letter No. 14 (1989) WITHDRAWN TO: AUTOMOBILE SELF-INSURERS AND INSURERS LICENSED TO WRITE AUTOMOBILE INSURANCE IN NEW YORK STATE RE: NO-FAULT REIMBURSMENT SCHEDULES FOR HOSPITAL (A) INPATIENT SERVICES RENDERED ON AND AFTER JANUARY 1, 1986; AND (B) INPATIENT SERVICES RENDERED ON AND AFTER JANUARY 1, 1987 Pursuant to Regulation No. 83, 11 NYCRR 68.2; the no-fault rate schedules' for reimbursing hospital services provided under § 5102(a)(1) of the Insurance Law shall be those established, for workers' compensation by the Chair of the Workers' Compensation Board (WCB). These rates have now been established for hospital inpatient services in conformity with Chapter 767 of the Laws of 1977, as amended and § 2807-a of the Public Health Law; as amended. Attached are two rate schedules duly established by the WCB Chair: the first revised per diem schedule to. reimburse hospitals for inpatient services rendered during the period January 1, 1986' through December 31, 1986. the second per diem schedule to reimburse hospitals for inpatient services, rendered during the period January 1, 1987 through December 31, 1987. Please note that the Health Department has determined that inpatient hospital admissions prior to January 1, 1988 shall be reimbursed on a per diem basis, rather than by the Diagnosis-Related Group (DRG) approach, effective January 1, 1988 for inpatient reimbursement as discussed in Circular Letters Number 11 and 18 (1988). Very truly yours, [SIGNATURE] James P. Corcoran Superintendent of Insurance TO: Medical Fee Schedule Users Subject: Amendments to September 1986 Medical Fee Schedule Attached are amendments to the September 1986 Workers' Compensation Board Schedule of Medical Fees. The amendments to the Medical Fee. Schedule, which include changes in Dollar Conversion Factors, apply to Medical, Physical Therapy and Occupational Therapy services rendered on or after September 1, 1989. For services rendered prior to September 1, 1989, please refer to previously issued material. NOTE: Effective 1-1-89, the fees listed in this schedule are applicable to services rendered under the Volunteer Ambulance Workers' Benefit Law. Barbara Patton, Chairwoman Conversion Factors This schedule is divided into seven sections, each containing a coded listing of procedures pertinent to the section, with unit values assigned on a relativity basis to each section therein. The relativity within any one section is applicable to that particular section only. Familiarize yourself with the instructions preceding each section. In submitting reports and bills, list the 5 digit code(s) that identifies the service(s) performed (it is not necessary to describe the service if the 5 digit code is enumerated). Billing: The unit values reflect relativity, not fees. To determine the fee for a procedure, it is necessary to multiply the unit value of each procedure by the dollar conversion factor applicable to the particular section in effect on the date the service was rendered. The Chairman has established four regions within New York State based on the difference in cost of maintaining a medical practice in different localities of the State. The Chairman has defined each such region by use of the U.S. Postal Service Zip Codes for the State of New York, based upon the relative cost factors which are compatible with that region. The fees payable for medical care and treatment shall be determined by the Region in which the services were rendered. Regional Conversion Factors - effective September 1, 1986 SECTIONS REGION 1 REGION 2 REGION 3 REGION 4 Medicine $ 4.88 $ 5.11 $ 5.85 $ 6.36 Physical Therapy 4.30 4.51 5.16 5.61 Anesthesia 16.74 17.52 20.05 21.81 Surgery 123.66 129.42 148.12 161.00 Radiology 31.35 32.82 37.55 40.82 Pathology .76 .80 .91 1.00 Regional Conversion Factors - effective September 1, 1987 SECTIONS REGION 1 REGION 2 REGION 3 REGION 4 Medicine $ 5.10 $ 5.35 $ 6.12 $ 6.65 Physical Therapy 4.61 4.83 5.53 6.01 Anesthesia 17.51 18.33 20.97 22.81 Surgery 129.35 135.37 154.93 168.41 Radiology 32.79 3433 39.28 42.70 Pathology .79 .84 .95 1.05 Regional Conversion Factors - effective September 1, 1988 SECTIONS REGION 1 REGION 2 REGION 3 REGION 4 Medicine $ 5.39 $ 5.65 $ 6.46 $ 7.02 Physical Therapy 4.82 5.05 5.78 6.29 Occupational Therapy 4.82 5.05 5.78 6.29 Anesthesia 18.49 19.36 22.14 24.09 Surgery 136.59 142.95 163.61 177.84 Radiology 34.63 36.25 41.48 45.09 Pathology .83 .89 1.00 1.11 Regional Conversion Factors - effective September 1, 1989 SECTIONS REGION 1 REGION 2 REGION 3 Medicine, $ 5.71 $ 5.98 $ 6.84 Physical Therapy 5.10 5.35 6.12 Occupational Therapy 5.10 5.35 6.12 Anesthesia 19.58 20.50 23.45 Surgery 144.65 151.38 173.26 Radiology 36.67 38.39 43.93 Pathology .88 .94 1.06 POSTAL ZIP CODES INCLUDED IN EACH REGION Region I Region II Region IV From, Thru From Thru From Thru 12007 12099 12180 12183 10001 10099 12106 12177 12201 12257 10301 10314 12184 12199 12301 12345 10401 10475 12401 12498 12501 12594 11001 11050 12701 12792 12601 12614 11101 11111 12801 12887 13201 13260 11201 11252 12901 12998 13440 11301 11390 13020 13094 13501 13503 11401 11460 13101 13167 13901 13905 11501 11598 13301 13368 14201 14265 11601 11697 13401 13439 14601 14692 11701 11798 13441 13495 11801 11819 13601 13698 13730 13797 13801 13865 From Thru 14001 14098 10501 10598 14101 14174 10601 10650 14301 14305 10701 10710 14410 14489 10801 10805 14501 14592 10901 10998 14701 14788 11901 11980 14801 14898 14901 14905 NUMERICAL LIST OF POSTAL ZIP CODES From Thru Region From Thru Region 10001 10099 IV 12601 12614 II 10301 10314 IV 12701 12792 I 10401 10475 IV 12801 12887 I 10501 10598 III 12901 12998 I 10601 10650 III 13020 13094 I 10701 10710 III 13101 13176 I 10801 10805 III 13201 13260 II 10901 10998 III 13301 13368 I 11001 11050 IV 13401 13439 I 11101 11111 IV 13440 II 11201 11252 IV 13441 13495 I 11301 11390 IV 13501 13503 II 11401 11460 IV 13601 13698 I 11501 11598 IV 13730 13797 I 11601 11697 IV 13801 13865 I 11701 11798 IV 13901 13905 II 11801 11819 IV 14001 14098 I 11901 11980 III 14101 14174 I 12007 12099 I 14201 14265 II 12106 12177 I 14301 14305 I 12180 12183 II 14410 14489 I 12184 12199 I 14501 14592 I 12201 12257 II 14601 14692 II 12301 12345 II 14701 14788 I 12401 12498 I 14801 14898 I 12501 12594 II 14901 14905 I Medicine The relative values listed in this section have been determined on an entirely different basis than those in other sections. A conversion factor applicable to this section is not applicable to any other section. The unit values listed in this section reflect the relativity of charges for procedures within this section only. The fee for a particular procedure or service in this section is determined by multiplying the listed "unit value" by the current dollar "conversion factor" applicable to this section, subject to the Ground Rules, Instructions and Definitions of the Schedule. Medicine Ground Rules General information and Instructions GENERAL : Visits, examinations, consultations and similar services as listed in this section reflect the wide variations in time and skills required in the diagnosis and treatment of illness or injury. The listed relativities apply only when these services are performed by or under the responsible and direct supervision of a physician unless otherwise stated. Specialists rendering services outside their field of specialization as designated by Workers' Compensation Board Coding may charge only general practitioner fees. A specialist shall be paid a specialist's fee only if the injuries sustained or the services rendered are within the scope of his specialty and the services of specialists are indicated or required. (See page 6 for specialist coding and scope restrictions.) Fees indicated for examinations or visits by specialists are payable only to specialists with "C" ratings. Physicians with specialty ratings such as "IM,S" etc., (without the "C" prefix) shall be paid three-quarters of the fee indicated as payable to a specialist with a "C" rating for an office, home or hospital call, but in no event shall the fee for a physician with such a specialty rating be less than the fee payable to a general practitioner for the same service. (See also comprehensive level of service, page 4.) If a patient is referred by a physician to a specialist for an opinion on diagnosis, prognosis, necessity and type of treatment, and such written opinion is sent to the referring physician, the insurance carrier, and the Workers' Compensation Board, a fee shall be payable for such opinion and examination in accordance with the level of service (see definitions), regardless of whether or not the specialist subsequently operates upon or treats the patient. See Ground Rule 20 below. If a patient consults a specialist directly (non-referred case) and a complete examination is necessary for diagnosis, prognosis, necessity and type of treatment, and the specialist submits a report thereon to the Workers' Compensation Board and to the insurance carrier, in addition to or on the regular C-4/C-48 form, a specialist's fee is payable in accordance with the level of service (see definitions), regardless of whether or not the specialist subsequently operates upon or treats the patient. A fee is payable to a specialist, in accordance with the level of service, for the examination of a patient who seeks the care of a physician either directly or by referral from another physician, in instances of elective surgery or when it is incumbent upon the specialist to examine the patient in order to make a proper diagnosis, prognosis and to decide on the necessity and type of treatment to be rendered. This fee is in addition to the unit fee prescribed for the operation or treatment subsequently rendered by the specialist except that where the therapeutic procedure or treatment is of a minor character and the fee for the procedure or treatment is in excess of the fee for the office visit, the greater fee (not both fees) is payable. Similarly, if the fee for the minor procedure or treatment is less than the fee for the office visit, the fee for the office visit alone is payable. Where a physician renders treatment in the EMERGENCY ROOM of a hospital as an individual or as a member of a group under contract with the hospital, including those physicians who are hospital salaried or employed, all such services shall be paid at the general practice rates. Where a physician enters into an agreement to cover the emergency room of a hospital on a fee-for-service basis, and is not under contract or salaried by the hospital, such physician shall be paid the fees of a general practitioner for the services rendered under the appropriate office visit category. The above applies to all physicians regardless of specialty coding except for those physicians coded C-EM (Board Certified in Emergency Medicine) or EM (Board-eligible). C-EM's or EM's practicing under a fee-for-service agreement with a hospital shall be paid fees as set forth in the Specialist Fees section, office visits (see page 17). However, C-EM or EM remuneration shall not be at a level of reimbursement above the intermediate level with the exception of treatment of a substantiated life or limb threatening situation when the comprehensive level of service may be applicable. Consultation fees do not apply to C-EMs. Unit Value 90620 A comprehensive consultation involves an in-depth evaluation of a patient with a problem requiring the development and documentation of medical data (the chief complaints, present illness, family history, past medical history, personal history, system review and physical examination, review of all diagnostic tests and procedures that have previously been done), the establishment or verification of a plan for further investigative and/or therapeutic management and the preparation of a report. For example: A young person with fever, arthritis, and anemia; or a comprehensive psychiatric consultation that may include a detailed present illness history, past history, a mental status examination, exchange of information with primary physician or nursing personnel or family members and other informants, and preparation of a report with recommendations; or a neurological evaluation for possible intracranial pathology; or the in-depth evaluation for spinal cord pathology or a chronic back disorder 22.0 SUBSEQUENT CONSULTATIONS Unit Value 90640 Brief consultative follow-up visit 3.5 90641 Limited consultative follow-up visit 6.0 90642 Intermediate consultative follow-up visit and evaluation 8.5 Immunization and Therapeutic Injections (For allergy testing, see 95000) (For skin testing of bacterial, viral, fungal extracts see 86400-86585) These injections are usually given in conjunction with a medical service. The unit value for the appropriate medical service will be added to the unit values for the type of injection administered. The cost of the medication or material injected is also additional in accordance with Ground Rule 13; specify material. Unit Value 90745 Injection, subcutaneous. No additional other than the cost of the specified injectant. 0.0 90746 Intramuscular or deep structures 0.83 90747 Intravenous 3.42 90798 Intravenous therapy for severe or intractable allergic disease in physician's office or institution (eg. theophyllines, corticosteroids, antihistamines) 90799 Unlisted therapeutic injection BR Psychiatric Services Medical services may be described as coded and listed in other segments in the Medicine Section as appropriate. For initial office or hospital visit see 90010-90020; for subsequent office or hospital visit see 90040-90060; for consultations see 90600-90642. For diagnostic services performed in hospital emergency rooms, Hospital care by the attending physician in treating a psychiatric inpatient may be initial or subsequent in nature, and may include exchanges with nursing and ancillary personnel. Hospital care services involve a variety of responsibilities unique to the medical management of inpatients, such as physician hospital orders, interpretation of laboratory or other medical diagnostic studies and observations, review of activity therapy reports, supervision of nursing and ancillary personnel, and the programming of all hospital resources for diagnosis and treatment. Some patients receive hospital care services only and others receive hospital care services and other procedures. If other procedures such as electroconvulsive therapy or medical psychotherapy are rendered, these should be listed separately. Unit Value Basic Anes 90803 Psychotherapy, adult or child (verbal and/or play therapy, with or without drug management), 45-50 minutes, office 16.0 90805 home 17.5 90806 25 minutes, office 9.7 90808 home 10.0 90811 15 minutes, office 6.4 90813 home 7.3 90815 Group therapy (maximum 8 persons per group), per person; per session, 45-50 minutes, office 6.4 90817 90 minutes, office 3.2 90821 Group therapy (maximum 16 persons per group), per person, per session, 45-50 minutes, office 4.8 90823 90 minutes, office 90835 Narcosynthesis for psychiatric diagnostic and therapeutic purposes, e.g. sodium amobarbital (Amytal) interview 20.5 90836 Convulsive therapy, in-patient 14.0 3.0 90838 out-patient 14.0 3.0 90840 Psychologic testing, psychometric and/ or projective tests, with written report, given by or under supervision of physician, per hour (identify test(s) used) 18.5 90860 Marathon therapy BR 90870 Crisis intervention BR 90875 Hypnotherapy, 45-50 minutes 16.0 90876 25 minutes 9.7 90877 15 minutes 6.4 90880 Sleep therapy, drug induced BR 90885 electrically induced BR 90899 Unlisted psychiatric procedure BR Biofeedback Administration of biofeedback treatment is limited to qualified physicians. Those wishing to administer such treatments to patients covered by the provisions of the Workers' Compensation Law for the conditions listed below should submit evidence of their training and experience to the insurance carrier to expedite processing. Biofeedback treatments may be administered only for the following conditions: (a) Idiopathic Raynaud's disease (b) Temporomandibular Joint Dysfunction (c) Myofascial Pain Dysfunction Syndrome (MPD) (d) Tension headaches (e) Migraine headaches (f) Tinnitus (g) Torticollis (h) Neuromuscular re-education as result of neurological damage in CVA or spinal cord injury (i) Inflammatory and/or musculoskeletal disorders usually related to the accepted condition. Up to twelve Biofeedback treatments in a ninety day period may be allowed for the above conditions when the following is presented and authorization granted: (a) An evaluation report documenting: (i) The basis for the claimant's condition; (ii) The condition's relationship to the industrial injury or illness; (iii) An evaluation of the claimant's current functional measurable modalities (i.e., range of motion, up time, walking tolerance, medication intake, etc.); (iv) An outline of the proposed treatment program; (v) An outline of the expected restoration goals. (b) No further Biofeedback treatments will be authorized or paid for without substantiation of evidence of improvement in measurable, functional modalities (i.e., range of motion, up time, walking tolerance, medication intake, etc.). The need for additional treatments will be determined on a case by case review in accordance with Workers' Compensation Board practices. The fees include interpretations and reports of the treatments. When more than one of the treatments are performed on the same day, the maximum payment will be limited to 8.0 units. Unit Value 90900 Biofeedback training by electromyogram application - separate procedure (one-half hour) 5.0 90901 Biofeedback training, by electromyogram application, including office visit (one-hour) 8.0 90902 In conduction disorder-separate procedure (one-half hour) 5.0 90903 In conduction disorder, including office visit (one hour) 8.0 90904 Regulation of blood pressure-separate procedure (one-half hour) 5.0 90905 Regulation of blood pressure, including office visit (one hour) 8.0 90906 Regulation of skin temperature or peripheral blood flow-separate procedure (one-half hour) 5.0 90907 Regulation of skin temperature or peripheral blood flow, including office visit (one hour) 8.0 90908 By electroencephalogram application - separate procedure (one-half hour) 5.0 90909 By electroencephalogram application, including office visit (one hour) 8.0 90910 By electro-oculogram application - separate procedure (one-half. hour) 5.0 90911 By electro-oculogram application, including office visit (one hour) 8.0 MONITORING SERVICES (For fetal monitoring during labor, see 59050) The following values are for physician's services only and do not include charges for use of equipment or supplies where such charges are justified. The values apply only when the physician is engaged solely and is continuously present in the monitoring process. Unit Value 90919 Assembly and operation of pump with oxygenator or heat exchanger (with or without ECG and/or pressure monitoring), per hour 19.0 90920 Monitoring ECG, pressures, etc., in intrathoracic or other critical surgery, per hour (independent procedure) 16.0 Dialysis The following descriptors apply only when these services are under the direct supervision of a physician and reflect only the professional component. Supplies, materials, and services of other personnel should be identified separately. If hemodialysis for acute renal failure exceeds six weeks, a further report is required. Detention time may be allowed in addition for highly complicated or unusual or extended hemodialysis if substantiated by report. If other significant, identifiable services are provided in addition to the appropriate hemodialysis procedure, list the appropriate visit for that service. Peritoneal Dialysis Unit Value 90962 Acute renal failure and/or intoxication, including cannula insertion and institution of treatment program, per dialysis 80.0 90963 excluding cannula and/or catheter insertion, per dialysis 30.0 90964 Chronic renal failure, cannula and/or catheter insertion, per dialysis 80.0 90965 excluding cannula and/or catheter insertions with dialysis through a permanent indwelling peritoneal catheter, per dialysis 30.0 Hemodialysis (Each of the following code numbers (90970- 90981) is for a single therapeutic hemodialysis treatment.) Unit Value 90970 Acute renal failure and/or intoxication, initial hemodialysis 130.0 90971 second hemodialysis 80.0 90972 third hemodialysis 80.0 90973 fourth hemodialysis through end of second week, per treatment 40.0 90974 third through end of sixth week, per treatment.  (For cannula declotting, see 36860-36861) 20.0 90980 Chronic renal failure, initial stabilization through sixth treatment, per treatment 80.0 90981 seventh stabilization through end of first month of chronic hemodialysis therapy, per treatment 30.0 90982 Hemodialysis service for a hospitalized chronic renal failure patient who is hospitalized because of an inter-current illness or for a problem related or unrelated to chronic renal failure 30.0 90983 Hemodialysis treatment per month, two treatments per week 120.0 90984 three treatments per week 180.0 PHYSICAL THERAPY The procedure codes listed in this section apply only to services rendered by a self-employed duly licensed and registered physical therapist (PT) unless otherwise stated. Physicians rendering physical therapy should utilize the appropriate codes in the Medicine Section. The relative values listed in this section have been determined on an entirely different basis than those in other sections. A conversion factor applicable to this Section is not applicable to any other section. The unit values listed in this section reflect the relativity for procedures within this section only. The fee for a particular procedure or service in this section is determined by multiplying the listed "unit value" by the current dollar "conversion factor" applicable to this section, subject to the Ground Rules, Instructions and Definitions of the Schedule. Physical Therapists are advised to familiarize themselves with the appropriate Ground Rules listed in the Medicine and Surgery Sections of this Schedule. PHYSICAL THERAPY The fees for physical therapy services listed below are payable only when the services are rendered by a self-employed duly licensed and registered physical therapist (PT) unless otherwise stated. Referral of patients by a physician for the treatment by a PT must be made by means of a referral which may be directive, indicating treatment plan and duration of such treatment. The Physical Therapist shall be responsible for obtaining initial authorization and reauthorization from the carrier after the twelfth physical therapy treatment or after 45 days, whichever comes first, unless previous authorization was for a longer period of time or number of treatments. The physical therapist shall submit PT-4 reports as required by regulation. PT's employed by physicians (i.e. not self-employed) may not bill separately from the physician-employer although the latter's billing must indicate the manner of service as delineated above. When physical therapy is rendered in a hospital department, the hospital shall be entitled to the listed values whether or not the head of the department is C-PMR or PMR coded. When physical therapists who are self-employed render physical therapy during the after care periods for fractures, dislocations or other post-operative procedures, fees for such treatments shall be in addition to those payable to the referring physician or physician for the after care period, notwithstanding that one or more physicians are also treating the same patient during said after-care period. The referring physician or the physical therapist must inform the employer or carrier of the need for such additional therapy and obtain authorization for such from the employer or carrier. If such authorization is refused, a determination by the Workers' Compensation Board shall be requested. The refusal of such requested authorization shall be appealable in accordance with the Workers' Compensation Law. When it is necessary to render physical therapy in a patient's home, add 50% to the listed unit value. An explanation justifying the need for home therapy rather than in an office or out-patient hospital setting shall be submitted along with the bill. When multiple services or procedures (different code numbers) are rendered or performed on one day, the payments will be limited to the greatest allowable fee plus one-half of the lesser fee(s) up to a maximum of twice the highest fee. ELECTROMYOGRAPHY: Unit Value (See codes 95860-95869 and addendum thereto). T95860 Electromyography, one extremity and related paraspinal areas 12.0 T95861 two extremities and related paraspinal areas 21.6 T95863 three extremities and related paraspinal areas 26.4 195864 four extremities and related paraspinal areas 31.2 T95867 cranial nerve supplied muscles, unilateral 15.6 T95868 bilateral 23.4 T95869 Limited study of specific muscles, e.g., external anal sphincter, thoracic spinal muscles, etc 12.0 MODALITIES Codes 97000 through 97201 apply whether treatment is rendered to one or more areas on any one day. List Modalities used. Unit Value T97000 Office visit with one or more of the following modalities initial 30 minutes 3.0 a. Hot or cold packs b. Traction, mechanical c. Electrical stimulation d. Vasopneumatic devices e. Paraffin bath f. Microwave g. Whirlpool h. Diathermy i. Infrared j. Ultraviolet k. Other (identify) T97001 maximum additional 1.1 PHYSICAL THERAPY (T97100-T97799) PROCEDURES Physical therapist is required to be in constant attendance Unit Value T97100 Office visit with one or more of the following procedures, initial 30 minutes 3.8 a. Therapeutic exercises b. Neuromuscular re-education c. Functional activities d. Gait training e. Electrical stimulation (manual) f. lontophoresis g. Traction, manual h. Massage i. Contrast baths j. Isokinetic or Isometric exercises (eg. Cybex) k. Ultrasound l. Laser m. Other (identify) T97101 maximum additional 1.8 T97200 Office visit including combination of any modality (ies) and procedures(s) initial 30 minutes 4.7 T97201 maximum additional 1.7 T97220 Hubbard tank, initial 30 minutes 5.4 T97221 each additional 15 minutes (maximum allowance, one hour) 1.1 197240 Pool therapy or Hubbard tank with therapeutic exercises initial 30 minutes 6.6 T97241 each additional 15 minutes (maximum allowance, one hour) 1.4 T97500 Orthotics training (dynamic bracing, splinting 4.5 etc) initial 30 minutes T97501 each additional 15 minutes (maximum allowance, one hour) 0.9 197520 Prosthetic training, initial 30 minutes 4.5 allowance, one hour) T97521 each additional 15 minutes (maximum allowance, one hour) 1.7 197540 Activities of daily with adequate report to be submitted (initial and separate procedure) 4.5 T97541 each additional 15 minutes (maximum allowance, one hour) 1.3 (For subsequent ADL training, use code T97100) (For muscle testing, manual or electrical, joint range of motion, electromyography or nerve velocity determination, use 95842 et seq) T97700 Office visit, including one of the following tests or measurements, with adequate report a. Orthotic "check-out" b. Prosthetic "check-out" c. Activities of daily living "check-out" initial 30 minutes 6.8 T97101 each additional 15 minutes 1.9 197702 maximum allowance 9.8 machine) initial testing 7.3 T97752 Muscle testing, torque curves during isometric and isokinetic exercise (eg. by use of Cybex T97753 subsequent retesting 5.3 (applicable only after suitable period of therapy T97799 Unlisted physical therapy service or procedure. BR OCCUPATIONAL THERAPY The procedure codes listed in this section apply only to services rendered by a self-employed duly licensed and registered Occupational Therapist (OT). Physicians rendering occupational therapy should utilize the appropriate codes in the Medicine Section. The relative values listed in this section have been determined on an entirely different basis than those in other sections. A conversion factor applicable to this Section is not applicable to any other section. The fee for a particular procedure or service in this section is determined by multiplying the listed "unit value" by the current dollar "conversion factor" applicable to this section, subject to the Ground Rules, Instructions and Definitions of the Schedule. Occupational Therapists are advised to familiarize themselves with the appropriate Ground Rules listed in the Medicine and Surgery Sections of this Schedule. AUDITORY SYSTEM EXTERNAL EAR (For diagnostic services, such as audiometric, vestibular and speech tests, see 92551 et seq) Unit Value Follow-up Days Basic Anes: *69000 Drainage, external ear, abscess or hematoma *0.25 0 4 *69020 Drainage, external auditory canal, abscess *0.25 0 4 69350 Otoscopy, under general EXCISION 69100 Biopsy, external ear 0.45 0 4 69105 Biopsy, external auditory canal 0.45 0 4 69110 Excision, external ear, 1.9 30 4 partial 69120 complete amputation 5.1 90 4 (For reconstructive of ear, see 15100 et seq., bone and cartilage grafts) 69140 Excision, exostosis(es), external auditory canal 7.7 90 4 69145 Excision, soft tissue lesion, external auditory canal 0.35 30 4 69150 Radical excision, external auditory canal lesion, without neck dissection 14.4 90 4 69155 with neck dissection 19.2 90 6 (for resection of temporal bone, see 69535) (For skin grafts and flaps, see 15000 et seq.) REMOVAL, FOREIGN BODY *69200 Removal, foreign body from external auditory canal, without general anesthesia *0.25 0 69205 with general anesthesia 1.3 7 4 one or both ears (separate procedure) 0.25 0 4 REPAIR (For suture of wound or injury of external ear, see 12011-14062) Unit Follow-up Basic Value Days Anes: 69300 Otoplasty for protruding ear, with or without size reduction, unilateral 5.8 90 4 69301 bilateral 8.3 90 4 69320 Reconstruction, external auditory canal for congenital atresia, single stage BR 4 (For combination with middle ear reconstruction, see 69631 or 69641) (For other reconstructive procedures with grafts [skin, cartilage, bone], see 13150- 15730, 21230-21235) OTHER PROCEDURES 69350 Otoscopy, under general anesthesia 1.3 7 4 69399 Unlisted Procedure on external ear BR 4 MIDDLE EAR INTRODUCTION 69400 Eustachian tube inflation, transnasal, with catheterization 0.2 0 4 69401 without catheterization 0.2 0 4 INCISION *69420 Myringotomy, including aspiration and/or eustachian tube inflation *0.35 0 4 *69424 Ventilating tube removal when originally inserted by another physician, unlateral *0.35 0 4 *69425 bilateral *0.45 0 4 *69433 Tympanostomy (requiring insertion of ventilating tube) local or topical, anesthesia, unilateral *0.65 0 4 *69434 bilateral *0.9 0 4 69436 general anesthesia, unilateral 2.3 15 4 69437 bilateral 3.2 15 4 69440 Middle ear exploration through post auricular or ear canal incision 6.4 30 5 (For atticotomy, see 69601 et seq) EXCISION 69501 Transmastoid antrotomy 6.4 90 5 69502 Mastoidectomy, complete 10.0 90 5 69505 modified radical 13.0 90 5 69511 radical 13.0 90 6 (For skin graft, see 15100 et seq.) 69530 Petrous apicectomy including radical mastoidectomy 20.8 90 5 An error occurred in the processing of a table at this point in the document. Please refer to the table in the online document. Basic Anes: 69535 5 69540 4 69550 4 69552 5 69554 5 REPAIR 69601 5 69603 5 69604 5 69605 5 *69610 4 69620 4 69631 5 69632 5 69635 5 69636 5 69637 5 69641 5 69642 5 69643 5 69644 5 69645 5 69646 5 69650 5 69666 5 69667 5 69670 5 69675 5 OTHER PROCEDURE 69700 4 69720 9 69740 5 69745 5 69799 5 INNER EAR INCISION 69801 5 RADIOLOGY Including Nuclear. Medicine and Diagnostic Ultrasound GROUND RULES 1. GENERAL: Listed values for radiology procedures apply only when these services are performed by or under the supervision of a physician, with CR ratings. The listed values for Nuclear Medicine also apply to those physicians with C-NUM ratings. Fees for physicians with R ratings shall be three-fourths of fees indicated. Fees payable to qualified specialists (C-rated but other than C-R) for items listed in this section, and within the scope of their specialty, shall be two-thirds of the indicated fees, except that full fees are payable to those physicians who are certified by the American. Board of Neurological Surgery or the American Board of Psychiatry and Neurology as Neurologists, who perform and interpret CT scans for neurological diagnoses. Fees for all other physicians, including those for items outside the scope of their coding, shall be one-half of the indicated values. Consultations and referrals for diagnostic and therapeutic radiology are to be done only by specialists, with CR & R ratings. Physicians qualified as general practitioners with the GP ratings, treating patients under their general medical care are permitted to take x-rays, but radiology requiring the use of ingestion or injection of foreign substance, shall be limited to qualified specialists within their specialty and physicians with the R ratings. 2. DUPLICATION OF X-RAYS: Every attempt should be made to minimize the number of x-rays taken. The attending doctor or any other person or institution having possession of x-rays which pertain to the patient that are deemed to be needed for diagnostic or treatment purposes should make these x-rays available upon request. No payments shall be made for additional x-rays when recent x-rays are available except when supported by adequate information regarding the need to re-x-ray. The use of photographic media and/or imaging is not reported separately but is considered to be a component of the basic procedure, and shall not merit any additional payment. 3. MULTIPLE DIAGNOSTIC X-RAY PROCEDURES: The following adjustments apply: a. For two contiguous parts, the charge shall be the greater fee plus 50% of the lesser fee. b. For two remote parts, the charge shall be the greater fee plus 75% of the lesser fee. c. For three or more parts, whether contiguous or remote, the charge shall be the greatest fee plus 75% of the total of the lesser fees. d. Where more than one part is included in a single line item, it shall be charged for as a single line item. Any additional item examined shall be considered under paragraph a, b, or c above, whichever pertains. e. No charge shall be made for comparative x-rays except when such x-rays are specifically authorized by the carrier or the chairman. Comparative x-rays specifically authorized shall be subject to fees for contiguous and remote parts as provided in this formula (3a-3d). f. X-Rays of different areas taken on different but proximate dates and related to the injury or problem necessitating the first x-ray studies, and which could have reasonably been performed at one time, shall be subject to rules a through e above. 4. XERORADIOGRAPHY: Imaging performed by this process shall have the identical values listed for conventional x-ray procedures of the same area and views. 5. MULTIPLE SERVICES OTHER THAN DIAGNOSTIC RADIOLOGY: When multiple or bilateral procedures or services are provided at the same session, the highest fee procedure will be reported as listed. The other procedure (s) will be billed for in accordance with Surgery ground rule 5. 6. UNIT VALUES: The total unit value includes professional services plus expenses of personnel, materials, including usual contrast media and drugs, space, equipment and other facilities. Values for injection procedures include all usual pre and post-injection car specifically related to the injection procedure, necessary local anesthesia, placement of needle or catheter, and injection of contrast media. Supplies and materials provided by the physician (e.g. sterile trays, radioisotopes, etc.) over and above those usually included with or necessitated by the services rendered may be charged for separately; in these instances, list items individually on bill. See Medicine ground rule 13. The total unit value includes the professional component (see PC unit value below) plus the technical component (TC). This value is applicable in any situation in which a single charge is made to include both professional, services and the technical cost of providing that service. Identification of a procedure by its 5-digit code without modifier -26 or -27 indicates that the charge includes both the "professional" and "technical" components. The PC unit value (professional component unit value) represents the value of the professional radiological services of the physician. This includes examination of the patient, when indicated, performance and/or supervision of the procedure, interpretation and written report of the examination including images, and consultation with the referring physician. This component is applicable in any situation in which the physician submits a charge for these professional services only. It does not include the cost of personnel, materials, space, equipment or other facilities. To identify a charge for professional component, use the 5-digit procedure code followed by modifier -26. (See modifier -26 and rule 15 for use of modifiers.) When this section of the Schedule is used in connection with a "conversion factor" to establish fees, it must be emphasized that the conversion factor cannot be applied to both the TOTAL UNIT VALUE and the PROFESSIONAL COMPONENT UNIT VALUE. Physicians who determine their fees by application of conversion factors to the unit values in this section must determine a separate factor for TOTAL UNIT VALUE and for PC UNIT VALUE. The technical component includes the charges for personnel, materials, including usual contrast media and drugs, film or xerograph, space, equipment and other facilities but excludes the cost of radioisotopes. No unit values are listed for the technical component of radiology procedures, since these are institutional charges not billed separately by physicians. To identify a charge for the technical component, use the 5-digit procedure code followed by modifier -27. (See modifier -27 and Rule 15 for use of modifiers). The total cost of a procedure(s) (PC plus TC) cannot exceed the total unit value cost of the procedure(s). Fees are for a competent diagnosis by image, expert interpretation and opinion. Size and number of films are not relevant except as indicated by minimum number listed for respective procedures. 7. NECESSITY OF SERVICES OR PROCEDURES: When a patient is referred to radiologists or other specialists for services covered in the Radiology Section, they shall evaluate the patient's problem and determine the service(s) or procedure(s) medically necessary. Such evaluations and necessary consultation with the referring physician(s) is an integral part of the professional component unit value and does not merit any additional charges. 8. REPORTS AND CUSTODY OF X-RAYS AND OTHER RECORDED IMAGES: C48 and C4 reports are not acceptable. A written report of the findings must be submitted in quadruplicate; mail one to the district office of the Workers' Compensation Board, one to the attending physician and retain one for your records; the fourth to accompany bill to insurance carrier, if known, or to the employer. Films or other recorded images shall be preserved for at least six years (but in no case shall they be destroyed without a report of the findings of such images being filed, as a permanent record). They (or satisfactory reproductions) shall be made available to the attending physician, insurance carrier or self-insured employer. When requested, carriers and self-insured employers shall return original films to the physician within 20 days of their receipt. When a carrier or self-insured employer requests x-rays and satisfactory reproductions are furnished in lieu of the original films, a fee of four dollars ($ 4.00) may be charged for the first sheet of duplicating film and two dollars ($ 2.00) for each additional sheet of film. These reproductions are not returnable to the physician. Copies of images produced by copiers (e.g. Xerox) shall not merit any additional payment and shall not be returnable to the physician; such copies should accompany the bill submitted for the particular, imaging procedure. (The use of photographic media and/or imaging is not reported separately but is considered to be a component of the basic procedure.) In cases where the patient transfers from one physician to another the former treating physician will promptly forward all images or copies of such to the new attending physician. 9. MATERIALS SUPPLIED BY PHYSICIAN: Supplies and materials provided by the physician (e.g., sterile trays, drugs, etc.) over and above those usually included with the office visit or other services rendered may be charged for separately. (List drugs, trays, materials or supplies provided.) Radiopharmaceutical or other radionuclide material cost: Listed values in this section do not include these costs. List the name and dosage of radiopharmaceutical material and cost (See Medicine ground rule 13.) 10. INJECTION PROCEDURES: Values for injection procedures include all usual pre-and post-injection care specifically related to the injection procedure, necessary local anesthesia, placement of needle or catheter and injection of contrast media. Vascular injection procedures are listed in the cardiovascular section, under procedure codes 36000-36299. Other injection procedures are listed in appropriate sections. 11. "BR" (BY REPORT) ITEMS: "BR" in the value column (s) indicates that the value of that service is to be determined by report because the service is too unusual, variable or new to be assigned a unit value (s). Submit a special report describing medical appropriateness of the service. Pertinent information-should include an adequate definition or description of the nature, extent, and need for the procedure and the time, effort, and equipment necessary to provide the service. Additional items which may be helpful might include: Complexity of symptoms, final diagnosis, pertinent physical findings, diagnostic and therapeutic procedures, concurrent problems, and follow-up care. 12. UNLISTED SERVICE OR PROCEDURE: A service or procedure may be provided that is not listed in this Fee Schedule. When reporting such a service, the appropriate "Unlisted Procedure" code may be used to indicate the service, identifying it by report ("BR"). See 11. above. 13. SUBSECTION INFORMATION: Several of the subheadings or subsections have special needs or instructions unique to that section. Where these are indicated, e.g. "Therapeutic Radiology," special "NOTES" will be presented preceding those procedural terminology listings, referring to that subsection specifically. If there is an "Unlisted Procedure" code number (see item 12) for the individual subsection it will be shown. Those subsections with "NOTES" are as follows. Subsection Code Numbers Diagnostic Ultrasound 76500-76999 Therapeutic Radiology 77261-77999 Nuclear Medicine 78000-79999 14. MISCELLANEOUS: a.) Emergency services rendered between 10 p.m. and 8 a.m. in response to requests received during those hours or on Sundays or legal holidays, provided such services are not otherwise reimbursed, may warrant an additional payment of one-third of the applicable fee. Submit report (See 11 above and Medicine ground rules 7 & 8). b.) Values for office, home and hospital visits, consultation and other medical services, anesthesia, surgical and laboratory procedures are listed in the sections entitled "Medicine," "Anesthesia," "Surgery," and "Pathology." 15. UNIT VALUE MODIFIERS: -26 Professional Component: When the professional component unit value only is applicable, identify by adding this modifier (-26) to the usual procedure number(s). Charges shall be in accordance with the "PC Unit Value" for that procedure(s). -27 Technical Component: When the professional component is charged for separately from the total unit value, the technical component will also be charged for separately. The technical component unit value will be the total value, less the professional component value. Identify by adding this modifier (-27) to the usual procedure(s) code number(s). See item 6 above for correct conversion factor applicable to -26 and -27. 16. CT SCAN RECONSTRUCTION: (effective September 1, 1989) An additional fee up to a maximum of $ 100 may be permitted for CT scan reconstruction. This additional fee shall be payable only when the reconstruction is requested by the primary care physician. The request must follow a review of the regular CT scan film and only if there is a specifically stated need for clarification via reconstruction. The fee for reconstruction must be submitted on a separate bill with a separate report and a copy of the primary care physician's request. 17. MAGNETIC RESONANCE IMAGING: (effective September 1, 1989) The fees for Magnetic Resonance Imaging shall be as follows: Professional component: 4 Radiology units for an MRI of any one part of the body Technical component: see chart below Region I Region II Region III Region IV Technical component $ 611 $ 635 $ 654 $ 670 The fees payable for an MRI study include both standard and axial views. The provisions of Radiology Ground Rules 1 and 3 apply to Magnetic Resonance Imaging. DIAGNOSTIC RADIOLOGY HEAD AND NECK PC Unit Value Total Unit Value 70002 Pneumoencephalography, supervision and interpretation only 3.3 9.0 70003 complete procedure (For injection procedure for pneumoencephalography, see 61053, 62286) 9.0 15.0 70010 Myelography, posterior fossa, supervision and interpretation only 3.0 7.5 70011 complete procedure (For injection procedure only for myelography, see 61052) 5.5 10.0 70015 Cisternography, positive contrast supervision and interpretation only 3.0 7.5 70016 complete procedure (For injection procedure only for cisternography, see 61053) 5.5 10.0 70020 Ventriculography, air contrast, supervision and interpretation only 3.0 7.5 70021 positive contrast, supervision and interpretation only (For injection procedure only for ventriculography, see 61025, 61120) 3.0 7.5 70022 Stereotactic localization, head 4.0 9.0 70030 Eye, for foreign body detection 0.8 2.0 70040 for localization of foreign body (70030 not included) 1.5 3.0 70050 combined 70030 and 70040 2.0 4.0 70100 Mandible, partial, less than four views 0.6 1.5 70110 complete, minimum of four views 0.8 2.0 70120 Mastoids, less than three views per side 0.7 1.7 70130 complete, minimum of three views per side 1.0 2.5 70131 Internal auditory complete 1.0 2.5 70140 Facial bones, less than three views 0.6 1.5 70150 complete, minimum of three views 0.8 2.0 70160 Nasal bones, complete, minimum of three views 0.6 1.5 70170 Dacryocystography, (nasolacrimal duct), supervision and interpretation only 0.8 2.0 70171 complete procedure (For injection procedure only for dacryocystography, see 68850) 2.3 3.5 70190 Optic foramina 0.6 1.5 70200 Orbits, complete, minimum of four views 0.8 2.0 70210 Sinuses, paranasal, less than three views 0.6 1.5 70220 complete, minimum of three views, without contrast studies 0.8 2.0 70230 with contrast studies, in addition to 70220, supervision and interpretation only 0.9 2.5 70231 with contrast studies, in addition to 70220, complete procedure 4.8 6.0 70240 Sella turcica 0.7 1.7 70250 Skull, less than four views, with or without stereo 0.6 1.5 70260 complete, minimum of four views, with or without stereo 1.2 3.0 70300 Teeth, single view 0.2 0.5 70310 partial examination, less than full mouth 0.4 1.0 70320 complete full mouth 0.8 2.0 70328 Temporomandibular joint, open and closed mouth, unilateral 0.6 1.5 70330 bilateral 1.0 2.5 70332 Temporomandibular joint arthrotomography (includes a contrast arthrogram and appropriate laminographic studies); supervision and interpretation only 2.0 4.5 70333 complete procedure (For injection procedure only for arthrotomography, see 21116) 4.0 6.5 70350 Cephalogram, orthodontic 0.4 1.0 70355 Orthopantogram 0.4 1.0 70360 Neck, soft tissue 0.4 1.0 70370 pharynx or larynx, including fluoroscopy and/or magnification technique 1.0 2.5 70373 Laryngography, contrast, supervision and interpretation only 1.2 3.0 70374 complete procedure (For injection procedure only for laryngography, see 31708) 3.0 4.5 70380 Radiologic examination, salivary gland for calculus 0.6 1.5 70390 Sialography, supervision and interpretation only 0.8 2.0 70391 complete procedure 2.3 3.5 (For injection procedure only for sialography, see 42550) 70400 Orbitography, all or positive contrast, supervision and interpretation only 1.8 4.5 (For injection procedure only for orbitography, see 67510) 70401 complete procedure 5.7 9.0 70450 Computerized axial tomography, head, without contrast material 4.0 8.5 70460 with contrast material(s) 4.0 10.5 70470 without intravenous contrast material, followed by contrast material(s) and further sections 5.0 12.0 70480 Computerized axial tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear, without contrast material 4.0 8.5 PC Unit Value Total Unit Value 75718 by serialography, complete procedure. 10.5 16.5 75722 Angiography, renal, unilateral, selective, supervision and interpretation only 3.0 12.0 75723 complete procedure 9.6 18.0 75724 Angiography, renal, bilateral, selective (including flush aortogram), supervision and interpretation only 4.5 13.5 75725 complete procedure 13.2 21.0 75726 Angiography, visceral, selective or subselective, supervision and interpretation only 3.9 13.5 75727 selective (including flush aortogram), complete procedure 11.1 21.0 75728 subselective, complete procedure 13.2 22.5 (For selective angiography, additional visceral vessels, studied after basic examination, see 75772, 75773) 75731 Angiography, adrenal, unilateral, selective, supervision and interpretation only 3.3 12.0 75732 complete procedure 11.1 19.5 75733 Angiography, adrenal, bilateral selective, supervision and interpretation only 4.8 13.5 75734 complete procedure 15.0 22.5 75736 Angiography, pelvic, selective or supraselective, supervision and interpretation only 3.0 9.0 75737 selective; complete procedure 7.5 13.5 75738 supraselective, complete procedure 9.6 15.0 75741 Angiography, pulmonary, unilateral, selective, supervision and interpretation only 3.0 9.0 75742 complete procedure 9.6 15.0 75743 Angiography, pulmonary, bilateral, selective, supervision and interpretation only 4.5 10.5 75744 complete procedure 11.1 18.0 75746 Angiography, pulmonary, by nonselective catheter or venous injection, supervision and interpretation only 3.0 9.0 75747 catheter, nonselective, complete procedure 9.0 15.0 75748 venous injection, complete procedure 5.7 12.0 75750 Angiography, coronary, root injection, supervision and interpretation only 3.9 12.0 75751 complete procedure 9.6 16.5 75752 Angiography, coronary, unilateral selective injection, including left ventricular and supravalvular angiogram and pressure recording, supervision and interpretation only 3.9 15.0 75753 complete procedure 15.0 27.0 75754 Angiography, coronary, bilateral selective injection, including left ventricular and supravalvular angiogram and pressure recording, supervision and interpretation only 5.7 21.0 75755 complete procedure 18.9 34.5 75756 Angiography, internal mammary, supervision and interpretation only 1.8 9.0 75757 complete procedure 9.6 16.5 75762 Angiography, coronary bypass, unilateral selective injection, supervision and interpretation only 3.9 15.0 75764 complete procedure 15.0 27.0 75766 Angiography, coronary bypass, multiple selective injection, supervision and interpretation only 5.7 21.0 75767 complete procedure 18.9 34.5 75772 Angiography, visceral, selective, additional vessels studied after basic examination, supervision and interpretation only 3.5 10.5 75773 complete procedure 8.5 10.5 VEINS AND LYMPHATICS For injection procedure only for venous system, see 36400-36510) For injection procedure only for lymphatic system, see 38790-38794) PC Unit Value Total Unit Value 75801 Lymphangiography, extremity only, unilateral, supervision and interpretation only 1.8 7.5 75802 complete procedure 7.5 13.5 75803 Lymphangiography, extremity only, bilateral, supervision and interpretation only 3.0 9.0 75804 complete procedure 9.6 15.0 75805 Lymphangiography, pelvic/abdominal, unilateral, supervision and interpretation only 2.4 7.5 75806 complete procedure 7.5 13.5 75807 Lymphangiography, pelvic/abdominal, bilateral, supervision and interpretation only 3.3 9.0 75808 complete procedure 10.2 15.0 75810 Splenoportography, supervision and interpretation only 1.8 7.5 75811 complete procedure 7.5 13.5 75820 Venography, extremity, unilateral, supervision and interpretation only 1.5 4.5 75821 complete procedure 3.9 6.5 75822 Venography, extremity, bilateral, supervision and interpretation only 1.2 6.0 75823 complete procedure 5.7 9.0 75825 Venography, caval, inferior with serialography, supervision and interpretation only 1.8 6.0 75826 complete procedure 5.7 9.0 75827 Venography, caval, superior, with serialography, supervision and interpretation only 1.8 6.0 75828 complete procedure 5.7 9.0 75831 Venography, renal, unilateral, selective, supervision and interpretation only 2.7 6.5 75832 complete procedure 6.3 10.5 75833 Venography, renal, bilateral, selective,  supervision and interpretation only 4.2 7.5 75834 complete procedure 9.6 13.5 75840 Venography, adrenal, unilateral, selective, supervision and interpretation only 2.7 6.5 75841 complete procedure 7.5 12.0 75842 bilateral, selective, supervision and interpretation only 4.2 7.5 75843 complete procedure 13.2 18.0 75845 Venography, azygos, selective or nonselective, supervision and interpretation only 2.4 6.0 PC Unit Value Total Unit Value 75846 selective, complete procedure 7.5 12.0 75847 non-selective, complete procedure 6.3 10.5 75850 Venography, intraosseous, supervision and interpretation only 2.4 6.0 75851 complete procedure 5.7 9.0 75860 Venography, sinus or jugular, catheter, supervision and interpretation only 3.9 9.0 75861 complete procedure 9.6 14.5 75870 Venography, superior sagittal sinus, supervision and interpretation only 3.0 7.5 75871 direct puncture, complete procedure 7.5 12.0 75880 Venography, orbital, supervision and interpretation only 1.8 6.0 75881 complete procedure 5.7 10.0 75885 Percutaneous transhepatic photography with hemodynamic evaluation, supervision and interpretation only 3.0 8.5 75886 complete procedure 10.5 15.0 75887 Percutaneous transhepatic portography without hemodynamic evaluation, supervision and interpretation only 2.9 8.4 75888 complete procedure 10.0 14.5 75889 Hepatic venography, wedged or free, with hemodynamic evaluation, supervision and interpretation only 3.5 10.4 75890 complete procedure 8.5 10.5 75891 Hepatic venograph, wedged or free without hemodynamic evaluation, supervision and interpretation only 3.4 10.3 75892 complete procedure 8.4 10.4 75893 Venous sampling through catheter without angiography (eg. for parathyroid hormone, renin) 10.0 15.0 Transcatheter Therapy and Biopsy PC Unit Value Total Unit Value 75894 Transcatheter therapy, embolization, including angiography, supervision and interpretation only 3.5 18.4 75895 complete procedure 10.5 15.0 75896 Transcatheter therapy, infusion, including angiography, supervision and interpretation only 3.5 10.4 75897 complete procedure 10.5 15.0 75898 Angiogram through existing catheter for follow-up study for transcatheter therapy, embolization or infusion 3.5 10.5 75950 Transcatheter, intravascular occlusion, temporary; supervision and interpretation only 3.5 10.4 75951 complete procedure 10.5 15.0 75955 Transcatheter intravascular occlusion, permanent, supervision and interpretation only 3.5 10.5 75956 complete procedure 10.5 15.0 75961 Transcatheter retrieval, percutaneous, of fractured venous or arterial catheter 10.0 12.0 75970 Transcatheter biopsy, supervision and interpretation only 3.0 7.5 75971 complete procedure (For transcatheter renal and ureteral biopsy, see 52007, 52107) (For percutaneous needle biopsy of pancreas, see 48102; of retroperitoneal lymph node or mass, see 49180) 9.5 12.5 75972 Percutaneous transluminal angioplasty, unilateral, supervision and interpretation only 6.5 13.5 75973 complete procedure 30.0 37.0 75974 Percutaneous transluminal angioplasty, bilateral, single catheter, supervision and interpretation only 8.5 15.0 75975 complete procedure 35.0 38.0 75976 Percutaneous transluminal angioplasty, bilateral, dual catheters, supervision and interpretation only 8.5 15.0 75977 complete procedure 35.0 38.0 75980 Percutaneous transhepatic biliary drainage with contrast monitoring, supervision and interpretation only 3.0 7.5 75981 complete procedure 30.0 37.5 75982 Percutaneous placement of drainage catheter for combined internal and external biliary drainage or of a drainage stent for internal biliary drainage in patients with an inoperable mechanical biliary obstruction, supervision and interpretation only 4.5 9.5 75983 complete procedure 30.0 37.5 75985 Change of percutaneous drainage catheter with contrast monitoring (ie. biliary tract, urinary tract) complete procedure (For injection procedure only for percutaneous biliary drainage, see 47510) 3.0 7.5 75990 Drainage of abscess, percutaneous, with radiologic guidance (ie. fluoroscopy, ultrasound or computerized tomography) with or without placement of indwelling catheter 8.5 15.0 (75990 is neither organ nor area specific. For drainage of abscess performed without radiology or fluoroscopy, see under specific anatomic site.) Miscellaneous (For arthrography of shoulder, see 73040, 73041; elbow, see 73085, 73086; wrist, see 73115, 73116; hip, see 73525, 73526, knee, see 73580, 73581; ankle, see 73615, 73616) PC Unit Value Total Unit Value 76000 Fluoroscopy, (separate procedure) other than 71034 1.3 0 76020 Bone age studies 0.6 1.5 76040 Bone length studies (orthoroentgenogram, scanogram) 1.0 2.5 76061 Radiologic examination, osseous survey, limited (eg. for metastases) 2.0 4.5 76062 complete (axial and appendicular skeleton) BR BR 76065 infant 0.8 2.0 76080 Radiologic examination, fistula or sinus tract study, supervision and interpretation only 1.0 2.5 76081 complete procedure 2.5 4.0 PC Unit Value Total Unit Value 76086 Mammary ductogram or galactogram, unilateral, supervision and interpretation only 1.0 2.5 76087 complete procedure 1.5 3.5 76088 Mammary ductogram or galactogram, bilateral, supervision and interpretation only 1.0 2.5 76089 complete procedure (For injection procedure only for mammary ductogram or galactogram, see 19030) 1.5 3.5 76090 Mammography, unilateral 1.0 2.5 76091 bilateral 1.5 3.5 76094 Radiologic examination, localization of breast nodule or calcification before operation, with marker and confirmation of its position with appropriate imaging 2.4 4.0 76100 Radiologic examination, single plane body section (eg. tomography, planigraphy, body section radiography) (Separate procedure) 2.0 2.8 76120 Cineradiography, except where specifically included 1.1 2.8 76125 Cineradiography, to complement routine examination 0.6 1.5 76400 Magnetic Resonance: bone marrow blood supply See page 159 76499 Unlisted diagnostic, radiologic procedure BR BR Diagnostic Ultrasound NOTES: A-mode implies a one-dimensional ultrasonic measurement procedure. M-mode implies a one-dimensional ultrasonic measurement procedure with movement of the trace to record amplitude and velocity of moving echo-producing structures. B-scan implies a two-dimensional ultrasonic scanning procedure with a two-dimensional display. Real-time scan implies a two-dimensional ultrasonic scanning procedure with display of both two-dimensional structure and motion with time. Head and Neck PC Unit Value Total Unit Value 76500 Echoencephalography, A-mode, diencephalic midline 1.0 2.0 76505 complete (diencephalic midline and ventricular size) 1.5 3.0 76506 Echoencephalography, B-mode, (gray scale) complete (for determination of ventricular size, delineation of cerebral contents and detection of fluid, masses or other intracranial abnormalities), including A-mode encephalography as secondary component where indicated BR BR 76511 Echography, ophthalmic, spectral analysis with amplitude quantitation, A-mode 1.9 3.8 76512 contract B-scan 1.9 3.8 76515 tomography with or without A or M-mode 2.8 5.6 76516 Echography, ophthalmic, ultrasonic biometry, A-mode 1.3 2.6 76517 B-scan 2.8 5.6 76529 Ophthalmic ultrasonic, foreign body localization BR BR 76530 Echography, thyroid, A-mode 1.0 2.0 76535 B-scan 1.5 3.0 76550 Carotid imaging 1.5 3.0 (For Doppler, see 76900) CHEST PC Unit Value Total Unit Value 76601 Echography, chest, A-mode 1.2 2.5 76604 B-scan (includes mediastinum) 1.5 3.0 76620 Echocardiography, M-mode complete 1.5 4.0 76625 limited (eg. follow-up or limited studies) 1.0 2.0 76627 Echocardiography, real-time scan, complete (includes 76620) 4.0 5.6 76628 limited 3.2 4.5 (For echocardiography as a cardiovascular procedure, see 76620- 76625) 76640 Echography, breast, A-mode 1.2 2.5 76645 B-scan 2.5 5.0 ABDOMEN AND RETROPERITONEUM PC Unit Value Total Unit Value 76700 Echography, abdominal, B-scan, complete 3.0 6.0 76705 limited (eg. follow-up or limited studies) 2.0 4.0 76770 Echography, retroperitoneal (eg. renal, aorta, nodes), B-scan, complete 2.5 5.0 76775 limited 1.8 3.5 PELVIS PC Unit Value Total Unit Value 76805 Echography, pelvic, B-scan (eg. real- time) in obstetrics, gynecology or transplants, complete 2.0 4.0 76815 limited (fetal growth rate, heart beat, anomalies, placental location) 1.5 3.0 GENITALIA PC Unit Value Total Unit Value 76870 Echography, scrotum and contents 2.0 4.0 EXTREMITIES PC Unit Value Total Unit Value 76880 Echography, extremity, B-scan 1.5 3.0 VASCULAR STUDIES PC Unit Value Total Unit Value 76900 Peripheral flow study (Doppler), arterial only 1.5 3.0 76910 venous only 1.5 3.0 76920 arterial and venous 2.3 4.5 76925 Peripheral imaging, B-scan, Doppler or real-time scan 1.5 3.0 Magnetic Resonance Imaging abdomen 74181 bone marrow blood supply 76400 brain, including brain stem 70551 chest 71550 lower extremity 73720 myocardium 75552 orbit, face and neck 70540 pelvis 72196 spinal canal and contents; cervical 72141 spinal canal and contents; lumbar 72144 spinal canal and contents; thoracic 72143 upper extremity 73220