OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering...

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OHIO PART B 2017 Enrollment Package (Includes Fee Schedule) © 2017 Copyright, CGS Administrators, LLC. MEDICARE PARTICIPATING PROVIDER PROGRAM

Transcript of OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering...

Page 1: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

OHIO PART B

2017 Enrollment Package(Includes Fee Schedule)

© 2017 Copyright, CGS Administrators, LLC.

MEDICARE

PARTICIPATING

PROVIDER PROGRAM

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We wish to emphasize the importance and advantages of being a Medicare participating (PAR) provider, and we are pleased that the favorable trend of participation continued into 2016 with a participation rate of 97.2 percent. As you plan for 2017 and become familiar with the coming changes, we hope that you will continue to be a PAR provider or, if you are non-participating (Non-PAR), will consider becoming a PAR provider.

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Quality Payment Program, which replaces the flawed Sustainable Growth Rate (SGR), will equip clinicians with the tools and flexibility to provide high-quality, patient-centered care. With clinicians as partners, the Administration is building a system that delivers better care, one in which clinicians work together and have a full understanding of patients’ needs, Medicare pays for what works and spends taxpayer money more wisely, and patients are in the center of their care, resulting in a healthier country. The Quality Payment Program policy will reform Medicare payments for more than 600,000 clinicians across the country, and is a major step in improving care across the entire health care delivery system. To be successful in the long run, the Quality Payment Program must account for diversity in care delivery, giving clinicians options that work for them and their patients. Additional information about the Quality Payment Program can be found below in this announcement.

WHY BECOME A PARTICIPATING MEDICARE PROVIDER

All physicians, practitioners and suppliers – regardless of their Medicare participation status – must make their calendar year (CY) 2017 Medicare participation decision by December 31, 2016. Providers who want to maintain their current PAR status or Non-PAR status do not need to take any action during the upcoming annual participation enrollment period. To sign a participation agreement is to agree to accept assignment for all covered services that you provide to Medicare patients in CY 2017. The overwhelming majority of physicians, practitioners and suppliers have chosen to participate in Medicare. During CY 2016, 97.2 percent of all physicians and practitioners are billing under Medicare participation agreements.

If you participate and bill for services paid under the Medicare physician fee schedule (MPFS), your Medicare fee schedule amounts are 5 percent higher than if you do not participate. Your Medicare Administrative Contractor (MAC) publishes an electronic directory of providers that choose to participate.

WHAT TO DO

If you choose to be a PAR physician in CY 2017:

• Do nothing if you are currently participating, or

• If you are not currently a Medicare participant, complete the available blank agreement (https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS460.pdf) and mail it (or a copy) to each MAC to which you submit Part B claims. (On the form show thename(s) and identification number(s) under which you bill.)

If you decide not to participate in CY 2017:

• Do nothing if you are currently not participating, or

• If you are currently a participant, write to each MAC to which you submit claims, advising ofthe termination of your participation in the participating physician program effective January1, 2017. This written notice must be postmarked prior to January 1, 2017.

ANNOUNCEMENTAbout Medicare Participation for Calendar Year 2017

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ANNOUNCEMENT: About Medicare Participation for Calendar Year 2017

We hope you will decide to be a Medicare participant in CY 2017. Please call 1.866.276.9558 if you have any questions or need further information on participation.

The Medicare Learning Network® (MLN) offers many products on how providers and suppliers can enroll in the Medicare Program. The products include specific information for physicians and other Part B suppliers; ordering/referring providers; institutional providers; and Durable Medical Equipment, Prosthetics, Orthotics and Supplies suppliers as well as information on the electronic Medicare enrollment system, Provider Enrollment, Chain and Ownership System (PECOS). Refer to “Medicare Provider-Supplier Enrollment National Educational Products” (https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/Downloads/Medicare_Provider-Supplier_Enrollment_National_Education_Products.pdf) for a list of all MLN provider-supplier products.

How Medicare is Getting Better for Doctors and Beneficiaries

Starting in 2017, Medicare will implement an important set of changes to improve how Medicare pays for primary care, care coordination, and mental health care. Clinicians will be compensated for spending more time with their patients, serving their patients’ needs outside of the office visit, and better coordinating care. These changes will deliver improved health outcomes that matter to the patient. With these changes, Medicare continues to move toward a health care system that encourages teams of clinicians to work together and collaborate in order to provide more personalized care for their patients. For more information about these new codes and other changes for 2017 see here (https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-11-02.html).

In addition, Medicare is laying the groundwork to expand access to the Medicare Diabetes Prevention Program (MDPP) model starting in 2018. The model has shown clear short-term benefits to the health of beneficiaries and the Medicare program from these commonsense improvements. For the long term, we know that fewer people with diabetes also saves patients and Medicare money because they use fewer expensive prescription drugs and have fewer hospital visits. And most importantly, by preventing diabetes, patients and families across the country can avoid suffering from a debilitating disease. That’s why we are expanding the model to make it available to all eligible Medicare beneficiaries.

In the Diabetes Prevention Program Model, Medicare beneficiaries at high risk for developing diabetes are provided strategies to increase their physical activity, control their weight and decrease their risk of type 2 diabetes. These interventions have been shown to lead to a 5 percent reduction in weight and will save Medicare an estimated $2,650 for each person enrolled over a 15-month period, more than enough to cover the cost of the program.

New Data Reporting Requirement for the Clinical Laboratory Fee Schedule:

On June 23, 2016, CMS released the “Medicare Clinical Diagnostic Laboratory Tests Payment System” final rule (https://www.federalregister.gov/articles/2016/06/23/2016-14531/medicare-program-medicare-clinical-diagnostic-laboratory-tests-payment-system), requiring laboratories performing clinical diagnostic laboratory tests to report the amounts paid by private payors for tests on the Clinical Laboratory Fee Schedule (CLFS). For the system’s first year, laboratories, including physician offices laboratories, are required to collect HCPCS laboratory codes, associated private payor rates, and volume data from the period of January 1, 2016 through June 30, 2016 and report it to CMS by March 31, 2017, if they:

• Have more than $12,500 in Medicare revenues from laboratory services on the CLFS during the data collection period and

• Receive more than 50 percent of their Medicare revenues from laboratory and physician services during the data collection period.

CMS will use this data to set CLFS payment rates effective January 1, 2018. For more information, visit the CLFS PAMA Regulations (https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/PAMA-Regulations.html) web page.

New Payment and Care Delivery Model Tests at the CMS Innovation Center:

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ANNOUNCEMENT: About Medicare Participation for Calendar Year 2017

Physicians can directly participate in health care transformation through the efforts of the CMS Innovation Center which is charged with identifying, testing, and evaluating innovative payment and service delivery models that show promise of providing better access to quality care at lower costs for beneficiaries of Medicare, Medicaid and the Children’s Health Insurance Program (CHIP). The CMS Innovation Center offers opportunities for innovators working in the field to share ideas, contribute to the discussion of improvements in health care, and participate in model tests.

As of September 30, 2015 more than 61,000 providers in all 50 states, the District of Columbia, and Puerto Rico are currently participating in over 25 Innovation Center payment and service delivery model tests, serving an estimated 4.7 million beneficiaries of Medicare, Medicaid, and CHIP. Participants include states, organizations, and a broad array of health care professionals, as well as other stakeholders in the health care community. Millions of other Americans are benefiting from CMS Innovation Center quality improvement initiatives and the engagement of other payers in model tests.

The broad engagement of providers across the country in alternative payment and service delivery models is leading to improvement. Medicare per capita spending growth rates have reached historic lows, and hospital readmission rates have declined meaningfully. All alternative payment models and payment reforms that seek to deliver better care at lower cost share a common pathway for success. Providers, payers, and others in the health care system must make fundamental changes in their day-to-day operations that improve quality and reduce the cost of health care.

This work aligns with the goals the Department of Health and Human Services (HHS) set in January of 2015 of tying 30 percent of traditional, or fee-for-service (FFS), Medicare payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and tying 50 percent of payments to these models by the end of 2018. In March of 2016, President Obama announced that HHS had met its 30 percent target 11 months ahead of schedule. HHS also set a goal of tying 85 percent of all traditional Medicare payments to quality or value by 2016 and 90 percent by 2018 through programs such as physician value-based payment modifier (VM).

We encourage providers to join the Health Care Payment Learning and Action Network (http://innovation.cms.gov/initiatives/Health-Care-Payment-Learning-and-Action-Network/) that brings together private payers, providers, employers, state partners, consumer groups, individual consumers, and many others to accelerate the transition to alternative payment models. If you would like to join the Network, please complete the online form (http://innovationgov.force.com/hcplan).

We also encourage you to visit the CMS Innovation Center website (https://innovation.cms.gov/) for further information and for announcements of new opportunities including large scale transformation of clinical practices to accomplish our aims of better care and better health at lower costs.

Medicare Shared Savings Program:

Currently, over 400 ACOs participate in the Medicare Shared Savings Program (Shared Savings Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers serve, it may share in the savings it achieves for the Medicare program. In performance year 2015, we shared more than $645 million in savings with 119 ACOs. ACOs that reported quality in both 2014 and 2015 improved on 84 percent of the quality measures that were reported in both years. The average quality performance improved by over 15 percent between 2014 and 2015 for four measures: screening for risk of future falls, depression screening and follow-up, blood pressure screening and follow-up, and providing pneumonia vaccinations. Over 91 percent of ACOs in a second or third performance year during 2015 increased their overall quality performance score through Quality Improvement Reward points in at least one of four quality measure domains.

When a Shared Savings Program ACO successfully reports required quality measures through the Physician Quality Reporting System (PQRS) Group Practice Reporting Option (GPRO) web interface, eligible professionals (EPs), (i.e. physicians and other practitioners) that bill under the Tax Identification Number (TIN) of an ACO participant will be deemed eligible to

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avoid the PQRS payment adjustment, will have their Clinical Quality Measure (CQM) reporting requirements satisfied for the Medicare Electronic Health Record (EHR) Incentive Program if they extract the data necessary for the ACO to satisfy the quality reporting requirements from certified EHR technology and the EPs meet all other requirements of the Medicare EHR Incentive Program; and will avoid the automatic downward adjustment under the Value-Based Payment Modifier (Value Modifier) and may be eligible for upward adjustments under the Value Modifier based on the ACO’s quality performance. For more information on how to access Quality and Resource Use Reports (QRURs), please refer to the QRUR section of this letter.

We encourage you to consider joining or forming an ACO under the Shared Savings Program. We also encourage physicians and other practitioners to collaborate with ACOs in your area so that together they can achieve the goals of the Shared Savings Program including successful reporting and performance on quality measures.

Please visit the Shared Savings Program web page (http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/) for more information about the program including how to apply, join or learn about ACOs in your area.

Moving From a Patchwork of Quality Programs:

On December 31, 2018, three CMS quality programs: the Physician Quality Reporting System, the Medicare EHR Incentive Program and the Value-Based Payment Modifier program will end. The Quality Payment Program, which is a part of the bipartisan MACRA legislation, will transition the way clinicians are paid- from a system where payments are based on volume to payments based on quality- with the ultimate goal in mind of better care, smarter spending, and healthier beneficiaries.

To wrap-up reporting for the existing programs, clinicians should be aware of the following 2017 updates:

• There is still time to successfully report quality measures for 2016 to avoid the 2018 negative 2% PQRS payment adjustment. The 2016 reporting period ends December 31, 2016 with submission beginning January 1, 2017.

• All 2016 quality data reported under PQRS, including Qualified Clinical Data Registries (QCDR) and Consumer Assessment of Healthcare Providers and Systems (CAHPS) for PQRS data, are available for public reporting on Physician Compare in late 2017. Learn more about public reporting by visiting the Physician Compare Initiative page (https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/physician-compare-initiative/) or contacting the Physician Compare support team at [email protected].

Introducing the Quality Payment Program:

In April 2015, an overwhelmingly bipartisan Congress passed MACRA. MACRA ended the SGR and its potential payment cliffs, and created a new, streamlined Medicare payment system that supports and rewards quality care for clinicians. CMS named this new payment system the Quality Payment Program and created a website (https://qpp.cms.gov/) to help clinicians learn about this new program.

Who’s in the Quality Payment Program?

You’re a part of the Quality Payment Program if you bill Medicare more than $30,000 a year and provide care for more than 100 Medicare patients a year. In addition, you must be a physician, physician assistant, nurse practitioner, clinical nurse specialist, or a certified registered nurse anesthetist to be in the program. If it is your first year participating in Medicare, then you’re not in the Quality Payment Program. CMS will be providing additional support to help you determine your eligibility soon.

When does the Quality Payment Program start?

The first performance year of the Quality Payment Program begins in 2017 and it will affect payments starting in 2019. The Quality Payment Program replaces PQRS, the EHR Incentive

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Program (also known as Medicare Meaningful Use), and the Value-based Payment Modifier. You will no longer need to submit information for PQRS and the Medicare EHR Incentive Program after 2016. Beginning January 1, 2017, clinicians may participate in the Quality Payment Program through one of two tracks:

• Advanced Alternative Payment Models (APMs), which are care organizations or approaches that let practices earn more for taking on some risk related to their patients’ outcomes. You may earn a 5% incentive payment by going further in improving patient care and taking on risk through an Advanced APM. To qualify for the 5% incentive payment, you must receive at least 25% of Medicare covered professional services or see at least 20% of your Medicare patients through an Advanced APM in 2017. Examples of Advanced APMs include Medicare Shared Savings Program Track 2 and 3. A full list of Advanced APMs is available here (https://qpp.cms.gov/learn/apms).

• The Merit-based Incentive Payment System (MIPS), which gives you the opportunity to be paid more for better care and investments that support patients. In the first year, you may earn as much as a 4% payment adjustment for participating in MIPS by submitting evidence-based and practice-specific quality data. If you do not submit any information to MIPS and do not qualify for the 5% incentive payment through an Advanced APM, then you will receive a 4% negative payment adjustment in 2019. You must submit 2017 information by March 31, 2018 to earn the positive payment adjustment. Learn more about MIPS and the information available to submit here (https://qpp.cms.gov/measures/performance).

If you belong to a practice with 15 or fewer clinicians, then you will soon be eligible to receive free, on-the-ground help from a local organization. We’re listening and want your input on how to improve the Quality Payment Program. Email us at [email protected] or call 1.866.288.8292 weekdays from 8 a.m. to 8 p.m. ET. Together, we’re moving towards a modern Medicare that supports better patient care through smarter spending for a healthier America.

Availability of the 2015 Annual and Supplemental Quality and Resource Use Reports (QRURs):

We encourage all groups and solo practitioners nationwide to access their 2015 Annual QRUR which were made available in September 2016, to learn about their 2017 Value Modifier payment adjustment and performance on quality and cost measures. These QRURs are also available for groups and solo practitioners that participated in the Shared Savings Program, the Pioneer ACO Model, or the Comprehensive Primary Care initiative in 2015. The 2015 Annual QRURs show how groups and solo practitioners, as identified by their Medicare-enrolled TIN, performed in 2015 on the quality and cost measures used to calculate the 2017 Value Modifier. For physicians in TINs who are subject to the 2017 Value Modifier, the QRUR shows how the Value Modifier will apply to physician payments under the MPFS for physicians who bill under the TIN in 2017. Detailed information about the Annual QRURs is available on the 2015 QRUR and 2017 Value Modifier website (https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/2015-QRUR.html).

In October 2016, CMS made available the 2015 Supplemental QRURs. These QRURs are confidential feedback reports provided to group practices with cost information on the management of their Medicare (FFS) patients based on 23 episodes of care (“episodes”) that include 9 major acute condition episode types and 14 major procedural episode types. The Supplemental QRURs are for informational purposes only and complement the per capita cost and quality information provided in the Annual QRURs. Information contained in the Supplemental QRURs is not used in the Value Modifier Program and does not impact payment. Detailed information about the Supplemental QRURs is available on the Supplemental QRUR website (https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Episode-Costs-and-Medicare-Episode-Grouper.html).

The Annual and Supplemental QRURs are available here and can be accessed by an authorized representative of the TIN using an Enterprise Identity Management (EIDM) account with the correct role. Please see the How to Obtain a QRUR (https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Obtain-2013-QRUR.html) website for instructions on how to set up an EIDM account and access your TIN’s QRURs.

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ANNOUNCEMENT: About Medicare Participation for Calendar Year 2017

Medicare and Medicaid EHR Incentive Programs:

In 2016, EPs will use EHR technology certified to the 2014 Edition or if available may use EHR technology certified to the 2015 edition or a combination of both to meet the objectives and measures of meaningful use as modified in a recent final rule1, which includes alternate exclusions for EPs scheduled to be in Stage 1. We are proposing EPs will have a 90-day EHR reporting period within CY 2016 and attest between January 3through February 28, 2017. For more information about the EHR Incentive Programs, including the 2016 definition of meaningful use, visit the EHR Incentive Programs website (http://www.cms.gov/EHRIncentivePrograms).

In order to align programs and reduce the burden on physicians and other eligible professionals, physicians may submit CQM data for both the Medicare EHR Incentive Program and the PQRS program electronically.

Physicians who fail to demonstrate meaningful use for the applicable EHR reporting period may be subject to a payment adjustment to their Medicare claims. In 2017, the result will be payment of 97% of the MPFS amount. Physicians must successfully demonstrate meaningful use every year to avoid the Medicare payment adjustments. Successful demonstration of meaningful use for an EHR reporting period in 2016 will enable physicians to avoid the payment adjustment in 2018. Physicians also have the option of filing a significant hardship exception application by July 1, 2017. Don’t wait until the last minute to meet meaningful use or file a hardship exception!

For more information on CMS Quality Programs:

PQRS web page (https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html)

Medicare EHR Incentive Program web page (https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/ehrincentiveprograms/)

Value-Based Payment Modifier web page (https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/ValueBasedPaymentModifier.html)

Social Security Number Removal Initiative (SSNRI):

The MACRA (https://www.congress.gov/bill/114th-congress/house-bill/2/text), requires CMS to remove Social Security Numbers (SSNs) from all Medicare cards by April 2019. A new Medicare Beneficiary Identifier (MBI) will replace the SSN-based Health Insurance Claim Number (HICN) on the new Medicare cards for Medicare transactions, such as claims, eligibility status, and claim status. Look at your practice management systems and business processes and determine what changes you need to make to use the new MBI. You’ll need to make those changes and test them by April 2018, before we send out new Medicare cards. If you use vendors to bill Medicare, you should contact them to find out about their MBI practice management system changes. Visit our SSNRI web page (https://www.cms.gov/Medicare/SSNRI/Index.html) for more information

Information Related to Medicare Prescription Drug (Part D) Coverage:

Prescriber Enrollment in Medicare

Physicians and EPs who write prescriptions for Part D drugs should be enrolled in Medicare in an approved status or have a valid record of opting out of Medicare. Any physicians and EPs not in compliance with these requirements should enroll now. The current enforcement date of the prescriber enrollment requirement is February 1, 2017. While CMS is committed to the implementation of the prescriber enrollment requirements, CMS also recognizes the need to minimize the impact on the beneficiary population and ensure beneficiaries have access to the care they need. To strike this balance, CMS will implement a multifaceted, phased approach which will align full enforcement of the Part D prescriber enrollment requirements with other ongoing CMS initiatives. Full enforcement of the Part D prescriber enrollment requirement is January 1, 2019.

1 Medicare and Medicaid Programs; Electronic Health Record Incentive Program—Stage 3 and Modifications to Meaningful Use in 2015 Through 2017; Final Rule, 80 Fed. Reg. 62,762 (Oct. 16, 2015).

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Providers may enroll by completing an Internet-based PECOS application or they may complete and submit a CMS-855O application (allows the physician to enroll in Medicare to order and certify services and items, and to prescribe Part D drugs; however, this option does not confer billing privileges). Providers who wish to opt-out of Medicare may submit an opt-out affidavit to their MAC.

If you are unsure if you are compliant with this requirement, please review the prescriber enrollment file located here (https://data.cms.gov/dataset/Medicare-Individual-Provider-List/u8u9-2upx). The file identifies those providers who are currently in compliance with the prescriber enrollment requirements.

As part of the enrollment process, provider credentials and eligibility are verified.

• If you haven’t enrolled, please do so and encourage your colleagues who are not enrolled in Medicare to enroll now. The options available for enrolling or opting out of Medicare are identified above. Please visit the prescriber enrollment website (https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/Prescriber-Enrollment-Information.html) to obtain additional information.

• Interns, residents, and fellows who are prescribers of Part D drugs may enroll in Medicare to prescribe if the state licenses these prescribers. Licensure can include a provisional license or similarly- regulated credential. Otherwise, un-licensed interns, residents, and fellows must specify the teaching physician as the authorized prescriber on the prescription. Licensed residents have the option to either enroll or use the teaching physician on claims.

• Pharmacists need not enroll or opt out for their prescriptions to be covered under Part D. More information is available by visiting Part D Prescriber Enrollment website (https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/Prescriber-Enrollment-Information.html).

NPPES Taxonomy

Please check your data in the National Plan and Provider Enumeration System (NPPES) and confirm that it still correctly reflects you as a health care provider. There is increased focus on the National Provider Identifier (NPI) as a health care provider identifier for program integrity purposes. Incorrect taxonomy data in NPPES may lead to unnecessary inquiries about your credentials as it may appear to Medicare oversight authorities that you may not be lawfully prescribing Part D drugs. Comprehensive information about how the NPI rule pertains to prescribers may be obtained here (https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/NationalProvIdentStand/Downloads/NPI-Requirements-for-Prescribers.pdf).

Prescription Drug Abuse

Prescription drug abuse is the nation’s fastest growing drug problem. Additional prescriber awareness and engagement are crucial to addressing this problem. CMS has implemented an approach to help Medicare prescription drug plans identify and manage the most egregious cases of opioid overutilization, which often involves multiple prescribers and pharmacies who are not aware of each other. If you are contacted by a prescription drug plan about the opioid use of one of your patients, please take the time to provide your feedback and expertise to help assure the safe use of these products.

Prescriber Identifiers in Research

You should be aware that CMS now allows researchers to request the release of unencrypted prescriber identifiers contained in Medicare Part D data. This change in policy now gives researchers the ability to conduct important research that involves identified prescribers, which will increase the positive contributions researchers make to the evaluation and function of the Part D program. This access supports CMS’s growing role as a value-based purchaser of health care, and is only granted pursuant to CMS’s policies and procedures for release of such data to researchers.

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Serving Qualified Medicare Beneficiaries (QMBs):

Many Medicare beneficiaries with limited incomes and resources are also covered by their state’s QMB program. This means that the state Medicaid agency is responsible for these beneficiaries’ Medicare cost sharing. We encourage all Medicare physicians and other practitioners to serve individuals eligible for the QMB program.

We also remind all Medicare physicians and other practitioners that they may not bill their QMB patients for Medicare cost sharing, including deductibles, coinsurance, and copayments. These rules apply to all QMB patients, including those enrolled in a Medicare Advantage (Part C) plan. Under federal law, Medicare payment plus any Medicaid payment are considered payment in full for services rendered to a beneficiary participating in the QMB program. Physicians and other practitioners may want to refresh their understanding of how their state handles QMB cost sharing claims. In most states, claims submitted to Medicare are crossed over automatically to the state Medicaid agency. States may require providers to register with their State payment system in order to receive cost sharing payments. Providers can also query their state’s Medicaid eligibility verification system to identify QMBs.

Providers should make sure their billing software and administrative staff exempt QMB individuals from Medicare cost-sharing billing and related collection efforts. If they become aware of improper billing of QMBs, providers should refund any erroneous charges and recall any past or existing bills (including referrals to collection agencies) as appropriate. More information on billing procedures for QMBs is available here (http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1128.pdf).

Revalidation:

CMS has met the requirements established in section 6401(a) of the Affordable Care Act (ACA) and has mailed revalidation letters to all 1.6 million providers and suppliers by the March 23, 2015 deadline. CMS is resuming regular revalidation cycles every 3 years for Durable Medical Equipment (DME) suppliers and every 5 years for all other providers and suppliers.

CMS has implemented several revalidation processing improvements to include establishing due dates by which a provider or supplier must revalidate. Revalidation due dates will fall on the last day of the month (i.e.: June 30, 2016, July 31, 2016, August 30, 2016) and are posted to https://data.cms.gov/revalidation. Providers and suppliers are expected to submit their revalidation application by this date. Generally, this due date will remain with you throughout subsequent revalidation cycles.

In addition to the posted lists, providers and suppliers will still receive email or mailed revalidation notices from their MACs when they are due to revalidate. Providers can revalidate their enrollment information using the Internet-based PECOS (https://pecos.cms.hhs.gov/pecos/login.do) or the CMS-855 paper application (http://www.cms.gov/CMSForms/CMSForms/list.asp). CMS encourages all practitioners to respond timely to revalidation requests received by their MAC. Failure to submit a complete revalidation application, including all supporting documents, may result in deactivation of your Medicare billing privileges.

For more information on the revalidation process please refer to the Revalidations website (https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/Revalidations.html) and this MLN Matters Special Edition Article (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1605.pdf).

The Medicare Learning Network® (MLN):

The MLN offers free educational materials for health care professionals on CMS programs, policies, and initiatives. Visit the MLN homepage (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNGenInfo/Index.html) for information on:

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Publications & Multimedia

• MLN Publications (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications.html) offer current information on many topics such as billing, policy initiatives,and program updates.

• MLN Matters® Articles (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index.html) explain national Medicare policy in an easy-to-understand format andfocus on coverage, billing, and payment rules for specific provider types.

• Multimedia (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Multimedia.html) offers videos, podcasts, and graphics that help explain the Medicare Program.Videos are also available on the YouTube MLN playlist (https://www.youtube.com/playlist?list=PLaV7m2-zFKpihHxb4AiWNjbsIUUKCGljK).

Events & Training

• National Provider Calls & Events (https://www.cms.gov/Outreach-and-Education/Outreach/NPC/National-Provider-Calls-and-Events.html) are conference calls and webcast presentations explainingnew policies and changes to the Medicare Program and typically include Question & Answersessions for participants.

• Web-Based Training Courses (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/WebBasedTraining.html) offer self-paced training on many topics such as coding, fraudand abuse, Medicare payment policy, and provider compliance. CMS provides continuingeducation credit for most courses.

Newsletter

• MLN Connects® Provider eNews (https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Provider-Partnership-Email-Archive.html) is a weekly email newsletter for health care professionalscontaining CMS program and policy news, announcements, upcoming events, claim, pricer,and code information, and MLN updates.

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We offer many ways to earn continuing education credit. Visit the Earn credit (https://www.cms.gov/Outreach-and-Education/Learn/Earn-Credit/Earn-credit-page.html) page for more details.

CMS is accredited to provide continuing education credit by the International Association for Continuing Education and Training (IACET) (http://iacet.org/) and the Accreditation Council for Continuing Medical Education (ACCME) (http://www.accme.org/). Click here to see CMS’ Accreditation Statements (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/ACCME-IACET-Accreditation-Statements.pdf). In addition, many professional associations offer continuing education credit to complete training activities designed for health care professionals including physicians, nurses, billers, coders, and other clinicians. You can find a broad range of courses that focus on Medicare updates, meeting professional development goals, and state license renewal requirements. The Medicare Learning Network®, MLN Connects®, and MLN Matters® are registered trademarks of the U.S. Department of Health & Human Services (HHS).

CY 2017 payment rates are available here: http://www.cgsmedicare.com/partb/fees/index.html For further information you can contact CGS at: 1.866.876.9558

Page 11: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 11Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

ANES 21.77 20.68 23.78 23.07 23.31 22.61 G0101 37.38 35.51 40.84 39.61 40.02 38.81 # G0101 27.83 26.44 30.41 29.50 29.80 28.91 G0102 18.98 18.03 20.73 20.11 20.32 19.71 # G0102 8.77 8.33 9.58 9.29 9.38 9.11 G0104 158.98 151.03 173.68 168.48 170.21 165.11 # G0104 56.85 54.01 62.11 60.25 60.87 59.04 G0105 306.43 291.11 334.78 324.74 328.08 318.24 # G0105 189.47 180.00 207.00 200.79 202.86 196.78 G0105 53 153.03 145.38 167.19 162.17 163.84 158.93 # G0105 53 95.05 90.30 103.85 100.73 101.76 98.72 G0106 200.38 190.36 218.91 212.35 214.53 208.10 G0106 TC 151.58 144.00 165.60 160.63 162.29 157.42 G0106 26 48.80 46.36 53.31 51.72 52.24 50.68 G0108 52.54 49.91 57.40 55.67 56.25 54.56 G0109 14.27 13.56 15.59 15.12 15.28 14.82 G0117 52.12 49.51 56.94 55.22 55.80 54.12 G0118 40.72 38.68 44.48 43.15 43.60 42.29 G0120 204.32 194.10 223.22 216.52 218.75 212.19 G0120 TC 151.58 144.00 165.60 160.63 162.29 157.42 G0120 26 52.74 50.10 57.62 55.89 56.47 54.77 G0121 307.14 291.78 335.55 325.48 328.83 318.98 # G0121 190.19 180.68 207.78 201.55 203.63 197.51 G0121 53 153.39 145.72 167.58 162.55 164.23 159.30 # G0121 53 95.41 90.64 104.24 101.11 102.15 99.08 G0124 31.60 30.02 34.52 33.49 33.83 32.82 G0127 21.94 20.84 23.97 23.24 23.48 22.78 # G0127 7.78 7.39 8.50 8.25 8.33 8.08 G0128 7.28 6.92 7.96 7.72 7.80 7.57 G0130 32.66 31.03 35.68 34.62 34.97 33.93 G0130 TC 21.44 20.37 23.43 22.72 22.95 22.26 G0130 26 11.22 10.66 12.26 11.89 12.02 11.65 G0141 31.60 30.02 34.52 33.49 33.83 32.82 G0166 129.14 122.68 141.08 136.85 138.26 134.11 G0168 97.04 92.19 106.02 102.83 103.90 100.77 # G0168 27.86 26.47 30.44 29.53 29.83 28.95 G0179 39.96 37.96 43.65 42.34 42.78 41.49 G0180 52.19 49.58 57.02 55.30 55.88 54.20 G0181 105.92 100.62 115.71 112.24 113.40 110.00 G0182 106.55 101.22 116.40 112.91 114.08 110.65 G0202 129.22 122.76 141.17 136.94 138.35 134.21 G0202 TC 92.28 87.67 100.82 97.80 98.81 95.84 G0202 26 36.95 35.10 40.37 39.16 39.56 38.38 G0204 160.30 152.29 175.13 169.88 171.63 166.49 G0204 TC 111.72 106.13 122.05 118.39 119.61 116.02 G0204 26 48.58 46.15 53.07 51.49 52.01 50.45 G0206 126.43 120.11 138.13 133.99 135.37 131.31 G0206 TC 87.34 82.97 95.42 92.55 93.51 90.70 G0206 26 39.10 37.15 42.72 41.45 41.87 40.62

Page 12: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 12Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

G0237 9.25 8.79 10.11 9.81 9.90 9.61 G0238 9.58 9.10 10.47 10.15 10.26 9.95 G0239 12.22 11.61 13.35 12.95 13.09 12.68 G0245 64.04 60.84 69.97 67.86 68.56 66.50 # G0245 42.96 40.81 46.93 45.53 45.99 44.62 G0246 36.99 35.14 40.41 39.20 39.61 38.42 # G0246 21.51 20.43 23.49 22.79 23.02 22.33 G0247 69.10 65.65 75.50 73.23 73.99 71.77 # G0247 23.30 22.14 25.46 24.70 24.96 24.21 G0248 101.86 96.77 111.29 107.95 109.05 105.79 G0249 102.16 97.05 111.61 108.26 109.38 106.10 G0250 9.12 8.66 9.96 9.66 9.76 9.46 G0268 51.48 48.91 56.25 54.56 55.12 53.46 # G0268 34.01 32.31 37.16 36.04 36.41 35.32 G0270 29.39 27.92 32.11 31.14 31.46 30.52 # G0270 27.08 25.73 29.59 28.70 29.00 28.13 G0271 15.59 14.81 17.03 16.53 16.69 16.19 # G0271 14.93 14.18 16.31 15.81 15.99 15.50 G0276 400.53 380.50 437.58 424.45 428.82 415.97 G0277 45.85 43.56 50.09 48.59 49.09 47.62 G0278 14.09 13.39 15.40 14.94 15.09 14.64 G0279 53.58 50.90 58.54 56.78 57.36 55.64 G0279 TC 23.39 22.22 25.55 24.78 25.05 24.29 G0279 26 30.19 28.68 32.98 31.99 32.33 31.35 G0281 13.41 12.74 14.65 14.21 14.36 13.93 G0283 13.41 12.74 14.65 14.21 14.36 13.93 G0288 33.87 32.18 37.01 35.89 36.27 35.18 G0289 88.58 84.15 96.77 93.87 94.84 92.00 G0296 27.97 26.57 30.56 29.64 29.95 29.04 # G0296 26.33 25.01 28.76 27.90 28.19 27.34 G0297 238.35 226.43 260.39 252.59 255.19 247.54 G0297 TC 187.82 178.43 205.19 199.04 201.09 195.06 G0297 26 50.53 48.00 55.20 53.54 54.10 52.47 G0329 9.43 8.96 10.30 9.99 10.10 9.80 G0339 3,176.51 3,017.68 3,470.33 3,366.22 3,400.93 3,298.90 G0340 2,334.07 2,217.37 2,549.98 2,473.48 2,498.97 2,424.00 G0341 1,952.25 1,854.64 2,132.84 2,068.85 2,090.18 2,027.47 # G0341 377.77 358.88 412.71 400.33 404.46 392.32 G0342 704.31 669.09 769.45 746.37 754.07 731.45 G0343 1,283.51 1,219.33 1,402.23 1,360.16 1,374.18 1,332.97 G0364 12.03 11.43 13.14 12.75 12.88 12.50 # G0364 8.74 8.30 9.55 9.26 9.35 9.07 C G0365 115.83 110.04 126.55 122.75 124.02 120.30 C G0365 TC 103.48 98.31 113.06 109.66 110.79 107.47 G0365 26 12.35 11.73 13.49 13.09 13.23 12.82 G0372 8.77 8.33 9.58 9.29 9.38 9.11 G0396 35.33 33.56 38.59 37.43 37.82 36.69 # G0396 33.36 31.69 36.44 35.35 35.72 34.65 G0397 69.62 66.14 76.06 73.78 74.54 72.31

Page 13: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 13Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# G0397 67.64 64.26 73.90 71.68 72.42 70.24 G0398 248.81 236.37 271.83 263.67 266.39 258.39 G0398 TC 149.28 141.82 163.09 158.21 159.83 155.04 G0398 26 99.53 94.55 108.73 105.47 106.56 103.36 G0399 191.41 181.84 209.12 202.84 204.93 198.78 G0399 TC 114.84 109.10 125.47 121.70 122.96 119.27 G0399 26 76.58 72.75 83.66 81.16 82.00 79.53 G0400 172.28 163.67 188.22 182.57 184.46 178.92 G0400 TC 103.36 98.19 112.92 109.53 110.66 107.34 G0400 26 68.91 65.46 75.28 73.03 73.77 71.56 G0402 162.43 154.31 177.46 172.13 173.90 168.69 # G0402 126.19 119.88 137.86 133.72 135.10 131.04 G0403 16.37 15.55 17.88 17.34 17.53 17.00 G0404 7.94 7.54 8.67 8.41 8.50 8.23 G0405 8.44 8.02 9.22 8.95 9.04 8.76 G0406 38.26 36.35 41.80 40.55 40.96 39.73 G0407 71.20 67.64 77.79 75.45 76.23 73.95 G0408 102.41 97.29 111.88 108.53 109.64 106.35 G0409 10.24 9.73 11.19 10.86 10.97 10.64 G0412 719.98 683.98 786.58 762.98 770.85 747.72 G0413 1,068.89 1,015.45 1,167.77 1,132.74 1,144.41 1,110.08 G0414 978.36 929.44 1,068.86 1,036.79 1,047.48 1,016.06 G0415 1,373.31 1,304.64 1,500.34 1,455.33 1,470.33 1,426.22 G0416 461.61 438.53 504.31 489.18 494.22 479.39 G0416 TC 279.80 265.81 305.68 296.52 299.56 290.58 G0416 26 181.82 172.73 198.64 192.68 194.67 188.83 G0420 107.76 102.37 117.73 114.20 115.37 111.91 G0421 24.95 23.70 27.26 26.44 26.71 25.91 G0422 106.29 100.98 116.13 112.64 113.80 110.39 G0423 106.29 100.98 116.13 112.64 113.80 110.39 G0424 28.56 27.13 31.20 30.27 30.58 29.66 # G0424 13.73 13.04 15.00 14.55 14.70 14.26 G0425 98.61 93.68 107.73 104.50 105.58 102.41 G0426 134.00 127.30 146.40 142.00 143.46 139.16 G0427 199.55 189.57 218.01 211.46 213.65 207.23 G0429 96.54 91.71 105.47 102.30 103.36 100.26 # G0429 71.51 67.93 78.12 75.77 76.56 74.26 G0438 167.05 158.70 182.51 177.03 178.86 173.49 G0439 112.77 107.13 123.20 119.51 120.74 117.12 G0442 17.36 16.49 18.96 18.40 18.58 18.03 # G0442 9.45 8.98 10.33 10.02 10.12 9.82 G0443 25.46 24.19 27.82 26.98 27.27 26.44 # G0443 23.49 22.32 25.67 24.90 25.15 24.40 G0444 17.36 16.49 18.96 18.40 18.58 18.03 # G0444 9.45 8.98 10.33 10.02 10.12 9.82 G0445 26.45 25.13 28.90 28.04 28.32 27.47 # G0445 23.49 22.32 25.67 24.90 25.15 24.40 G0446 25.46 24.19 27.82 26.98 27.27 26.44 # G0446 23.49 22.32 25.67 24.90 25.15 24.40

Page 14: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 14Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

G0447 25.46 24.19 27.82 26.98 27.27 26.44 # G0447 23.49 22.32 25.67 24.90 25.15 24.40 G0451 8.92 8.47 9.74 9.45 9.55 9.27 G0452 26 18.25 17.34 19.94 19.34 19.54 18.95 G0453 32.55 30.92 35.56 34.49 34.85 33.80 G0454 9.12 8.66 9.96 9.66 9.76 9.46 G0455 124.33 118.11 135.83 131.76 133.11 129.12 # G0455 73.92 70.22 80.75 78.33 79.14 76.76 G0459 41.13 39.07 44.93 43.59 44.03 42.71 G0460 166.79 158.45 182.22 176.76 178.57 173.22 G0473 12.57 11.94 13.73 13.32 13.46 13.05 # G0473 11.58 11.00 12.65 12.27 12.40 12.03 G0500 54.71 51.97 59.77 57.97 58.57 56.81 # G0500 5.62 5.34 6.14 5.96 6.01 5.84 G0502 136.45 129.63 149.07 144.60 146.10 141.71 # G0502 88.02 83.62 96.16 93.28 94.24 91.41 G0503 120.76 114.72 131.93 127.97 129.29 125.41 # G0503 79.25 75.29 86.58 83.98 84.85 82.31 G0504 63.18 60.02 69.02 66.95 67.64 65.62 # G0504 42.42 40.30 46.35 44.95 45.41 44.06 G0505 229.47 218.00 250.70 243.18 245.69 238.31 # G0505 174.12 165.41 190.22 184.52 186.42 180.83 G0506 61.38 58.31 67.06 65.04 65.71 63.74 # G0506 45.23 42.97 49.42 47.93 48.43 46.98 G0507 45.73 43.44 49.96 48.46 48.96 47.50 # G0507 31.56 29.98 34.48 33.44 33.79 32.78 G0508 197.38 187.51 215.64 209.16 211.32 204.98 G0509 190.35 180.83 207.95 201.72 203.79 197.69 G6001 50.22 47.71 54.87 53.22 53.77 52.15 G6001 TC 20.46 19.44 22.36 21.69 21.91 21.25 G6001 26 29.77 28.28 32.52 31.54 31.87 30.91 G6002 72.07 68.47 78.74 76.38 77.17 74.85 G6002 TC 51.75 49.16 56.53 54.84 55.41 53.75 G6002 26 20.31 19.29 22.18 21.52 21.74 21.09 G6003 177.61 168.73 194.04 188.22 190.16 184.46 G6004 134.78 128.04 147.25 142.83 144.30 139.98 G6005 134.45 127.73 146.89 142.49 143.96 139.63 G6006 134.45 127.73 146.89 142.49 143.96 139.63 G6007 277.43 263.56 303.09 294.00 297.03 288.12 G6008 185.51 176.23 202.66 196.58 198.62 192.65 G6009 184.86 175.62 201.96 195.90 197.93 191.98 G6010 184.20 174.99 201.24 195.20 197.21 191.30 G6011 268.87 255.43 293.74 284.94 287.87 279.23 G6012 245.48 233.21 268.19 260.14 262.83 254.94 G6013 245.80 233.51 268.54 260.48 263.17 255.27 G6014 246.13 233.82 268.89 260.83 263.51 255.61 G6015 321.34 305.27 351.06 340.53 344.03 333.72 G6016 320.26 304.25 349.89 339.39 342.90 332.60 G9157 97.24 92.38 106.24 103.05 104.11 100.99

Page 15: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 15Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

G9187 42.13 40.02 46.02 44.64 45.10 43.75 G9481 19.02 18.07 20.78 20.16 20.37 19.76 G9482 36.24 34.43 39.59 38.41 38.80 37.64 G9483 56.34 53.52 61.55 59.70 60.32 58.50 G9484 95.10 90.35 103.90 100.79 101.82 98.77 G9485 124.16 117.95 135.64 131.57 132.93 128.94 G9486 18.66 17.73 20.39 19.78 19.99 19.39 G9487 37.32 35.45 40.77 39.55 39.95 38.76 G9488 57.42 54.55 62.73 60.85 61.48 59.63 G9489 81.10 77.05 88.61 85.95 86.84 84.24 G9490 42.13 40.02 46.02 44.64 45.10 43.75 G9685 200.98 190.93 219.57 212.98 215.18 208.73 G9686 77.84 73.95 85.04 82.49 83.34 80.85 P3001 31.60 30.02 34.52 33.49 33.83 32.82 Q0035 19.67 18.69 21.49 20.85 21.07 20.44 Q0035 TC 10.90 10.36 11.91 11.56 11.67 11.33 Q0035 26 8.77 8.33 9.58 9.29 9.38 9.11 Q0091 43.05 40.90 47.04 45.62 46.09 44.71 # Q0091 19.65 18.67 21.47 20.83 21.05 20.41 Q0092 23.42 22.25 25.59 24.82 25.08 24.32 R0070 138.32 131.40 151.11 146.58 148.09 143.65 R0075 138.32 131.40 151.11 146.58 148.09 143.65 0100T 2,727.07 2,590.72 2,979.33 2,889.95 2,919.75 2,832.15 0159T 22.11 21.00 24.15 23.43 23.67 22.95 0159T TC 18.82 17.88 20.56 19.94 20.15 19.54 0159T 26 3.29 3.13 3.60 3.50 3.53 3.43 0191T 1,125.67 1,069.39 1,229.80 1,192.91 1,205.20 1,169.04 0249T 385.89 366.60 421.59 408.94 413.16 400.76 0295T 87.95 83.55 96.08 93.20 94.16 91.33 0296T 25.35 24.08 27.69 26.86 27.14 26.32 0297T 35.69 33.91 39.00 37.82 38.21 37.06 0298T 26.91 25.56 29.39 28.51 28.81 27.93 0308T 827.64 786.26 904.20 877.07 886.11 859.53 0387T 743.17 706.01 811.91 787.55 795.67 771.80 0389T 48.24 45.83 52.70 51.13 51.65 50.11 0395T 1,758.75 1,670.81 1,921.43 1,863.79 1,883.00 1,826.52 10021 118.55 112.62 129.51 125.63 126.93 123.12 # 10021 70.12 66.61 76.60 74.30 75.07 72.82 10022 135.90 129.11 148.48 144.03 145.51 141.15 # 10022 66.05 62.75 72.16 70.00 70.73 68.60 10030 662.28 629.17 723.55 701.83 709.08 687.79 # 10030 157.22 149.36 171.76 166.61 168.33 163.28 10035 508.10 482.70 555.11 538.45 544.01 527.69 # 10035 90.34 85.82 98.69 95.74 96.72 93.83 10036 437.38 415.51 477.84 463.50 468.28 454.23 # 10036 44.99 42.74 49.15 47.68 48.17 46.72 10040 99.27 94.31 108.46 105.20 106.28 103.10 # 10040 87.41 83.04 95.50 92.63 93.59 90.78 10060 113.68 108.00 124.20 120.47 121.72 118.06

Page 16: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 16Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 10060 95.56 90.78 104.40 101.27 102.30 99.25 10061 201.14 191.08 219.74 213.15 215.35 208.89 # 10061 177.09 168.24 193.48 187.67 189.61 183.92 10080 171.48 162.91 187.35 181.72 183.60 178.09 # 10080 100.97 95.92 110.31 107.00 108.10 104.86 10081 259.75 246.76 283.77 275.26 278.09 269.76 # 10081 168.16 159.75 183.71 178.20 180.04 174.64 10120 146.32 139.00 159.85 155.05 156.65 151.95 # 10120 101.19 96.13 110.55 107.24 108.34 105.10 10121 265.22 251.96 289.75 281.06 283.96 275.44 # 10121 184.17 174.96 201.20 195.17 197.18 191.27 10140 157.77 149.88 172.36 167.19 168.91 163.84 # 10140 116.59 110.76 127.37 123.56 124.82 121.08 10160 125.38 119.11 136.98 132.87 134.24 130.21 # 10160 94.42 89.70 103.16 100.06 101.10 98.06 10180 238.84 226.90 260.94 253.10 255.71 248.04 # 10180 176.90 168.06 193.27 187.47 189.41 183.72 11000 52.65 50.02 57.52 55.80 56.37 54.68 # 11000 28.93 27.48 31.60 30.66 30.97 30.05 11001 21.07 20.02 23.02 22.33 22.56 21.88 # 11001 14.48 13.76 15.82 15.35 15.50 15.04 11004 589.80 560.31 644.36 625.03 631.47 612.52 11005 798.09 758.19 871.92 845.76 854.48 828.84 11006 718.36 682.44 784.81 761.27 769.11 746.04 11008 280.61 266.58 306.57 297.37 300.44 291.42 11010 488.20 463.79 533.36 517.36 522.69 507.01 # 11010 284.93 270.68 311.28 301.94 305.06 295.91 11011 520.50 494.48 568.65 551.60 557.28 540.57 # 11011 302.40 287.28 330.37 320.46 323.76 314.05 11012 690.72 656.18 754.61 731.96 739.52 717.32 # 11012 429.46 407.99 469.19 455.11 459.80 446.02 11042 112.04 106.44 122.41 118.74 119.96 116.37 # 11042 61.64 58.56 67.34 65.32 66.00 64.01 11043 222.57 211.44 243.16 235.87 238.29 231.15 # 11043 156.68 148.85 171.18 166.04 167.75 162.71 11044 308.52 293.09 337.05 326.95 330.31 320.40 # 11044 233.07 221.42 254.63 247.00 249.54 242.05 11045 39.89 37.90 43.59 42.27 42.71 41.42 # 11045 26.38 25.06 28.82 27.96 28.24 27.39 11046 72.41 68.79 79.11 76.74 77.52 75.21 # 11046 56.93 54.08 62.19 60.33 60.95 59.12 11047 123.24 117.08 134.64 130.61 131.95 128.00 # 11047 101.17 96.11 110.53 107.21 108.32 105.08 11055 45.57 43.29 49.78 48.29 48.78 47.32 # 11055 16.24 15.43 17.74 17.22 17.39 16.87 11056 55.92 53.12 61.09 59.26 59.87 58.08 # 11056 22.97 21.82 25.09 24.35 24.59 23.86 11057 62.98 59.83 68.80 66.75 67.42 65.41 # 11057 30.03 28.53 32.81 31.82 32.15 31.19

Page 17: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 17Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

11100 99.23 94.27 108.41 105.16 106.24 103.05 # 11100 49.16 46.70 53.71 52.10 52.64 51.05 11101 32.02 30.42 34.98 33.94 34.28 33.26 # 11101 25.10 23.85 27.43 26.60 26.88 26.07 11200 85.43 81.16 93.33 90.54 91.47 88.73 # 11200 72.25 68.64 78.94 76.57 77.36 75.04 11201 18.76 17.82 20.49 19.88 20.08 19.48 # 11201 16.78 15.94 18.33 17.78 17.96 17.42 11300 93.59 88.91 102.25 99.18 100.20 97.20 # 11300 35.60 33.82 38.89 37.73 38.11 36.97 11301 115.67 109.89 126.37 122.58 123.84 120.13 # 11301 54.06 51.36 59.06 57.29 57.88 56.14 11302 136.30 129.49 148.91 144.45 145.94 141.57 # 11302 63.49 60.32 69.37 67.29 67.98 65.94 11303 150.81 143.27 164.76 159.82 161.46 156.62 # 11303 75.04 71.29 81.98 79.52 80.34 77.94 11305 95.14 90.38 103.94 100.82 101.86 98.81 # 11305 39.79 37.80 43.47 42.17 42.60 41.33 11306 117.80 111.91 128.70 124.83 126.12 122.34 # 11306 52.56 49.93 57.42 55.69 56.27 54.58 11307 138.72 131.78 151.55 147.00 148.51 144.06 # 11307 67.55 64.17 73.80 71.58 72.32 70.15 11308 146.04 138.74 159.55 154.77 156.37 151.67 # 11308 74.55 70.82 81.44 79.01 79.81 77.43 11310 109.42 103.95 119.54 115.95 117.15 113.63 # 11310 47.81 45.42 52.23 50.67 51.19 49.66 11311 107.45 102.08 117.39 113.87 115.05 111.60 # 11311 65.94 62.64 72.04 69.87 70.60 68.47 11312 154.94 147.19 169.27 164.19 165.89 160.90 # 11312 78.84 74.90 86.14 83.55 84.41 81.88 11313 180.28 171.27 196.96 191.05 193.02 187.23 # 11313 101.21 96.15 110.57 107.26 108.36 105.11 11400 119.00 113.05 130.01 126.11 127.41 123.59 # 11400 79.13 75.17 86.45 83.85 84.72 82.17 11401 143.68 136.50 156.98 152.27 153.84 149.22 # 11401 102.50 97.38 111.99 108.63 109.74 106.46 11402 160.11 152.10 174.92 169.67 171.42 166.28 # 11402 112.67 107.04 123.10 119.40 120.64 117.01 11403 185.90 176.61 203.10 197.01 199.04 193.06 # 11403 145.71 138.42 159.18 154.41 156.00 151.32 11404 211.28 200.72 230.83 223.91 226.22 219.43 # 11404 160.87 152.83 175.75 170.49 172.24 167.08 11406 306.27 290.96 334.60 324.56 327.91 318.08 # 11406 245.98 233.68 268.73 260.67 263.36 255.46 11420 117.70 111.82 128.59 124.74 126.02 122.25 # 11420 80.47 76.45 87.92 85.28 86.16 83.58 11421 151.19 143.63 165.17 160.22 161.87 157.01 # 11421 109.02 103.57 119.11 115.53 116.73 113.22 11422 169.74 161.25 185.44 179.87 181.73 176.27

Page 18: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 18Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 11422 133.83 127.14 146.21 141.83 143.29 138.99 11423 195.47 185.70 213.56 207.15 209.29 203.01 # 11423 155.28 147.52 169.65 164.55 166.26 161.26 11424 227.28 215.92 248.31 240.86 243.34 236.04 # 11424 178.85 169.91 195.40 189.53 191.49 185.74 11426 326.84 310.50 357.08 346.37 349.93 339.45 # 11426 274.46 260.74 299.85 290.86 293.86 285.04 11440 128.99 122.54 140.92 136.69 138.10 133.95 # 11440 100.33 95.31 109.61 106.32 107.41 104.19 11441 161.96 153.86 176.94 171.63 173.40 168.20 # 11441 128.69 122.26 140.60 136.38 137.78 133.65 11442 181.60 172.52 198.40 192.44 194.43 188.59 # 11442 143.05 135.90 156.29 151.59 153.16 148.56 11443 217.50 206.63 237.62 230.49 232.88 225.88 # 11443 176.32 167.50 192.63 186.85 188.77 183.11 11444 274.44 260.72 299.83 290.84 293.84 285.02 # 11444 225.68 214.40 246.56 239.17 241.63 234.38 11446 382.39 363.27 417.76 405.23 409.40 397.12 # 11446 324.74 308.50 354.78 344.14 347.68 337.26 11450 368.64 350.21 402.74 390.66 394.69 382.85 # 11450 250.37 237.85 273.53 265.32 268.05 260.02 11451 470.72 447.18 514.26 498.82 503.98 488.84 # 11451 323.45 307.28 353.37 342.77 346.30 335.92 11462 359.56 341.58 392.82 381.03 384.96 373.41 # 11462 238.97 227.02 261.07 253.24 255.85 248.18 11463 476.45 452.63 520.52 504.91 510.12 494.81 # 11463 324.90 308.66 354.96 344.31 347.86 337.42 11470 398.62 378.69 435.49 422.43 426.79 413.98 # 11470 278.37 264.45 304.12 295.00 298.03 289.10 11471 495.08 470.33 540.88 524.65 530.06 514.17 # 11471 347.81 330.42 379.98 368.59 372.38 361.22 11600 185.35 176.08 202.49 196.42 198.44 192.49 # 11600 118.47 112.55 129.43 125.55 126.85 123.04 11601 221.14 210.08 241.59 234.35 236.76 229.66 # 11601 148.33 140.91 162.05 157.18 158.80 154.04 11602 239.94 227.94 262.13 254.27 256.89 249.18 # 11602 162.84 154.70 177.91 172.57 174.35 169.12 11603 275.12 261.36 300.56 291.55 294.55 285.72 # 11603 195.72 185.93 213.82 207.40 209.54 203.25 11604 306.04 290.74 334.35 324.32 327.67 317.84 # 11604 215.76 204.97 235.72 228.64 231.00 224.07 11606 439.76 417.77 480.44 466.03 470.82 456.71 # 11606 321.81 305.72 351.58 341.03 344.55 334.21 11620 187.08 177.73 204.39 198.26 200.31 194.29 # 11620 119.88 113.89 130.97 127.04 128.35 124.50 11621 222.52 211.39 243.10 235.81 238.23 231.09 # 11621 149.38 141.91 163.20 158.30 159.93 155.14 11622 248.34 235.92 271.31 263.17 265.88 257.90 # 11622 171.25 162.69 187.09 181.48 183.36 177.85

Page 19: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 19Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

11623 292.26 277.65 319.30 309.72 312.92 303.52 # 11623 212.21 201.60 231.84 224.88 227.21 220.39 11624 330.32 313.80 360.87 350.05 353.65 343.05 # 11624 241.04 228.99 263.34 255.44 258.07 250.33 11626 398.42 378.50 435.28 422.22 426.57 413.78 # 11626 295.96 281.16 323.33 313.64 316.87 307.37 11640 193.10 183.45 210.97 204.64 206.75 200.55 # 11640 123.92 117.72 135.38 131.32 132.68 128.70 11641 230.06 218.56 251.34 243.80 246.32 238.92 # 11641 155.60 147.82 169.99 164.90 166.59 161.60 11642 263.24 250.08 287.59 278.97 281.84 273.39 # 11642 183.84 174.65 200.85 194.82 196.83 190.92 11643 311.44 295.87 340.25 330.04 333.44 323.44 # 11643 230.72 219.18 252.06 244.49 247.02 239.60 11644 384.10 364.90 419.64 407.04 411.24 398.90 # 11644 285.59 271.31 312.01 302.65 305.76 296.60 11646 504.43 479.21 551.09 534.55 540.07 523.86 # 11646 397.69 377.81 434.48 421.45 425.79 413.02 11719 13.71 13.02 14.97 14.52 14.67 14.24 # 11719 7.78 7.39 8.50 8.25 8.33 8.08 11720 30.98 29.43 33.84 32.83 33.17 32.18 # 11720 14.84 14.10 16.22 15.73 15.89 15.42 11721 43.55 41.37 47.58 46.15 46.62 45.23 # 11721 25.10 23.85 27.43 26.60 26.88 26.07 11730 101.17 96.11 110.53 107.21 108.32 105.08 # 11730 55.71 52.92 60.86 59.03 59.64 57.85 11732 30.86 29.32 33.72 32.71 33.04 32.05 # 11732 18.01 17.11 19.68 19.09 19.29 18.71 11740 47.30 44.94 51.68 50.13 50.65 49.13 # 11740 31.82 30.23 34.76 33.72 34.07 33.04 11750 147.98 140.58 161.67 156.81 158.44 153.67 # 11750 111.74 106.15 122.07 118.42 119.63 116.05 11755 128.35 121.93 140.22 136.01 137.41 133.29 # 11755 77.29 73.43 84.44 81.91 82.75 80.28 11760 181.61 172.53 198.41 192.45 194.44 188.60 # 11760 113.41 107.74 123.90 120.19 121.43 117.78 11762 269.68 256.20 294.63 285.79 288.74 280.07 # 11762 181.71 172.62 198.51 192.56 194.55 188.70 11765 160.02 152.02 174.82 169.58 171.33 166.19 # 11765 92.48 87.86 101.04 98.00 99.02 96.05 11770 268.77 255.33 293.63 284.82 287.75 279.13 # 11770 184.43 175.21 201.49 195.44 197.47 191.53 11771 558.86 530.92 610.56 592.24 598.35 580.39 # 11771 432.35 410.73 472.34 458.17 462.90 449.01 11772 677.05 643.20 739.68 717.49 724.89 703.13 # 11772 570.30 541.79 623.06 604.37 610.59 592.28 11900 53.79 51.10 58.77 57.01 57.59 55.87 # 11900 31.39 29.82 34.29 33.27 33.60 32.60 11901 68.24 64.83 74.55 72.32 73.06 70.87

Page 20: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 20Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 11901 48.80 46.36 53.31 51.72 52.24 50.68 11920 164.62 156.39 179.85 174.46 176.25 170.97 # 11920 113.23 107.57 123.71 119.99 121.23 117.59 11921 191.41 181.84 209.12 202.84 204.93 198.78 # 11921 133.42 126.75 145.76 141.39 142.85 138.56 11922 59.00 56.05 64.46 62.53 63.17 61.27 # 11922 30.01 28.51 32.79 31.80 32.13 31.17 11950 75.69 71.91 82.70 80.21 81.04 78.61 # 11950 53.29 50.63 58.22 56.48 57.06 55.35 11951 97.65 92.77 106.69 103.49 104.55 101.42 # 11951 72.94 69.29 79.68 77.29 78.09 75.75 11952 122.33 116.21 133.64 129.63 130.97 127.04 # 11952 94.32 89.60 103.04 99.95 100.98 97.95 11954 154.27 146.56 168.54 163.48 165.17 160.22 # 11954 115.40 109.63 126.07 122.29 123.56 119.84 11960 937.67 890.79 1,024.41 993.68 1,003.92 973.81 11970 604.08 573.88 659.96 640.16 646.76 627.36 11971 450.86 428.32 492.57 477.79 482.71 468.23 # 11971 311.83 296.24 340.68 330.45 333.87 323.84 11976 139.28 132.32 152.17 147.60 149.12 144.65 # 11976 94.80 90.06 103.57 100.46 101.50 98.45 11980 91.55 86.97 100.02 97.01 98.01 95.07 # 11980 56.96 54.11 62.23 60.36 60.98 59.16 11981 137.22 130.36 149.91 145.42 146.91 142.51 # 11981 83.85 79.66 91.61 88.86 89.78 87.08 11982 156.04 148.24 170.48 165.36 167.07 162.05 # 11982 101.68 96.60 111.09 107.76 108.87 105.60 11983 222.53 211.40 243.11 235.82 238.25 231.10 # 11983 177.73 168.84 194.17 188.34 190.28 184.56 12001 86.47 82.15 94.47 91.64 92.59 89.82 # 12001 44.63 42.40 48.76 47.30 47.78 46.36 12002 105.26 100.00 115.00 111.55 112.70 109.32 # 12002 59.14 56.18 64.61 62.66 63.32 61.41 12004 124.08 117.88 135.56 131.49 132.85 128.86 # 12004 74.01 70.31 80.86 78.43 79.24 76.87 12005 157.17 149.31 171.71 166.55 168.27 163.22 # 12005 96.55 91.72 105.48 102.32 103.37 100.27 12006 185.96 176.66 203.16 197.06 199.10 193.12 # 12006 118.75 112.81 129.73 125.84 127.13 123.33 12007 214.41 203.69 234.24 227.22 229.56 222.67 # 12007 148.52 141.09 162.25 157.39 159.01 154.24 12011 105.72 100.43 115.49 112.03 113.18 109.79 # 12011 55.64 52.86 60.79 58.96 59.57 57.78 12013 110.50 104.98 120.73 117.10 118.31 114.76 # 12013 58.77 55.83 64.20 62.28 62.92 61.04 12014 129.80 123.31 141.81 137.55 138.97 134.80 # 12014 75.76 71.97 82.77 80.28 81.11 78.67 12015 157.53 149.65 172.10 166.93 168.66 163.60 # 12015 95.59 90.81 104.43 101.30 102.34 99.28

Page 21: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 21Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

12016 199.75 189.76 218.22 211.68 213.85 207.45 # 12016 130.23 123.72 142.28 138.01 139.44 135.25 12017 158.41 150.49 173.06 167.88 169.60 164.52 12018 179.26 170.30 195.85 189.97 191.92 186.17 12020 271.30 257.74 296.40 287.51 290.48 281.76 # 12020 187.29 177.93 204.62 198.48 200.53 194.51 12021 158.31 150.39 172.95 167.76 169.49 164.40 # 12021 136.24 129.43 148.84 144.38 145.87 141.50 12031 228.84 217.40 250.01 242.51 245.01 237.66 # 12031 152.08 144.48 166.15 161.17 162.83 157.95 12032 292.18 277.57 319.21 309.63 312.82 303.44 # 12032 193.68 184.00 211.60 205.25 207.37 201.15 12034 302.04 286.94 329.98 320.08 323.38 313.67 # 12034 207.15 196.79 226.31 219.52 221.78 215.13 12035 368.19 349.78 402.25 390.18 394.20 382.38 # 12035 239.70 227.72 261.88 254.02 256.65 248.94 12036 408.72 388.28 446.52 433.12 437.59 424.47 # 12036 279.24 265.28 305.07 295.92 298.97 290.00 12037 468.20 444.79 511.51 496.17 501.27 486.24 # 12037 329.50 313.03 359.98 349.19 352.79 342.21 12041 228.81 217.37 249.98 242.48 244.97 237.62 # 12041 150.07 142.57 163.96 159.03 160.68 155.85 12042 279.92 265.92 305.81 296.63 299.69 290.70 # 12042 200.19 190.18 218.71 212.14 214.34 207.90 12044 346.50 329.18 378.56 367.20 370.99 359.85 # 12044 214.72 203.98 234.58 227.54 229.89 222.99 12045 387.37 368.00 423.20 410.50 414.74 402.29 # 12045 268.44 255.02 293.27 284.48 287.41 278.78 12046 460.24 437.23 502.81 487.73 492.76 477.97 # 12046 308.69 293.26 337.25 327.13 330.50 320.59 12047 529.77 503.28 578.77 561.41 567.19 550.18 # 12047 367.35 348.98 401.33 389.29 393.30 381.50 12051 249.04 236.59 272.08 263.91 266.64 258.64 # 12051 170.63 162.10 186.42 180.83 182.69 177.22 12052 284.79 270.55 311.13 301.79 304.91 295.76 # 12052 203.75 193.56 222.59 215.91 218.14 211.60 12053 333.59 316.91 364.45 353.51 357.16 346.44 # 12053 217.62 206.74 237.75 230.62 233.00 226.01 12054 348.55 331.12 380.79 369.37 373.18 361.99 # 12054 223.02 211.87 243.65 236.34 238.77 231.61 12055 451.45 428.88 493.21 478.41 483.35 468.84 # 12055 304.84 289.60 333.04 323.05 326.38 316.58 12056 476.21 452.40 520.26 504.65 509.85 494.56 # 12056 342.12 325.01 373.76 362.55 366.29 355.29 12057 529.59 503.11 578.58 561.22 567.01 550.00 # 12057 392.86 373.22 429.20 416.32 420.62 408.00 13100 323.15 306.99 353.04 342.45 345.98 335.59 # 13100 206.19 195.88 225.26 218.50 220.75 214.13 13101 382.15 363.04 417.50 404.97 409.15 396.88

Page 22: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 22Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 13101 253.00 240.35 276.40 268.11 270.87 262.75 13102 117.92 112.02 128.82 124.96 126.25 122.46 # 13102 75.09 71.34 82.04 79.58 80.40 77.99 13120 338.41 321.49 369.71 358.63 362.32 351.45 # 13120 235.62 223.84 257.42 249.69 252.26 244.70 13121 413.15 392.49 451.36 437.83 442.34 429.08 # 13121 268.19 254.78 293.00 284.21 287.13 278.53 13122 129.80 123.31 141.81 137.55 138.97 134.80 # 13122 86.64 82.31 94.66 91.82 92.76 89.98 13131 373.36 354.69 407.89 395.66 399.74 387.75 # 13131 250.80 238.26 274.00 265.78 268.51 260.46 13132 461.89 438.80 504.62 489.49 494.52 479.70 # 13132 316.27 300.46 345.53 335.17 338.62 328.46 13133 175.13 166.37 191.33 185.59 187.50 181.87 # 13133 132.96 126.31 145.26 140.90 142.35 138.08 13151 410.04 389.54 447.97 434.53 439.01 425.83 # 13151 288.47 274.05 315.16 305.70 308.86 299.59 13152 492.46 467.84 538.02 521.87 527.25 511.43 # 13152 350.13 332.62 382.51 371.04 374.87 363.62 13153 190.30 180.79 207.91 201.68 203.75 197.64 # 13153 143.19 136.03 156.43 151.74 153.31 148.71 13160 802.10 762.00 876.30 850.01 858.77 833.01 14000 605.08 574.83 661.05 641.23 647.83 628.41 # 14000 498.01 473.11 544.08 527.76 533.20 517.20 14001 783.13 743.97 855.57 829.90 838.45 813.30 # 14001 652.99 620.34 713.39 691.99 699.12 678.16 14020 677.61 643.73 740.29 718.08 725.49 703.72 # 14020 563.28 535.12 615.39 596.93 603.08 584.99 14021 850.44 807.92 929.11 901.23 910.52 883.21 # 14021 715.36 679.59 781.53 758.08 765.90 742.92 14040 743.65 706.47 812.44 788.07 796.19 772.31 # 14040 629.00 597.55 687.18 666.56 673.44 653.23 14041 922.55 876.42 1,007.88 977.65 987.72 958.10 # 14041 776.60 737.77 848.44 822.99 831.46 806.53 14060 760.24 722.23 830.56 805.64 813.96 789.53 # 14060 670.29 636.78 732.30 710.33 717.65 696.13 14061 991.97 942.37 1,083.73 1,051.22 1,062.05 1,030.19 # 14061 830.53 789.00 907.35 880.13 889.20 862.52 14301 1,055.01 1,002.26 1,152.60 1,118.02 1,129.54 1,095.66 # 14301 881.39 837.32 962.92 934.03 943.66 915.35 14302 223.75 212.56 244.44 237.11 239.56 232.37 14350 685.58 651.30 749.00 726.52 734.01 711.99 15002 338.11 321.20 369.38 358.29 362.00 351.13 # 15002 228.40 216.98 249.53 242.04 244.54 237.20 15003 73.62 69.94 80.43 78.02 78.82 76.45 # 15003 46.28 43.97 50.57 49.05 49.55 48.07 15004 390.56 371.03 426.68 413.89 418.15 405.61 # 15004 271.63 258.05 296.76 287.86 290.82 282.10 15005 122.84 116.70 134.21 130.18 131.53 127.58

Page 23: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 23Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 15005 92.53 87.90 101.09 98.05 99.06 96.08 15040 244.89 232.65 267.55 259.52 262.20 254.33 # 15040 128.26 121.85 140.13 135.92 137.32 133.20 15050 544.11 516.90 594.44 576.60 582.54 565.06 # 15050 438.35 416.43 478.89 464.53 469.32 455.24 15100 840.15 798.14 917.86 890.33 899.51 872.53 # 15100 712.65 677.02 778.57 755.22 763.00 740.12 15101 180.39 171.37 197.08 191.16 193.13 187.35 # 15101 111.86 106.27 122.21 118.54 119.76 116.17 15110 784.58 745.35 857.15 831.44 840.01 814.81 # 15110 691.02 656.47 754.94 732.30 739.84 717.65 15111 115.69 109.91 126.40 122.60 123.87 120.15 # 15111 105.14 99.88 114.86 111.41 112.56 109.18 15115 791.11 751.55 864.28 838.35 847.00 821.58 # 15115 697.55 662.67 762.07 739.21 746.83 724.42 15116 162.74 154.60 177.79 172.45 174.24 169.00 # 15116 149.56 142.08 163.39 158.49 160.13 155.32 15120 833.12 791.46 910.18 882.88 891.97 865.23 # 15120 695.73 660.94 760.08 737.28 744.88 722.53 15121 202.72 192.58 221.47 214.82 217.04 210.52 # 15121 133.86 127.17 146.25 141.85 143.32 139.01 15130 652.68 620.05 713.06 691.67 698.80 677.83 # 15130 556.14 528.33 607.58 589.35 595.42 577.56 15131 90.26 85.75 98.61 95.66 96.65 93.75 # 15131 83.34 79.17 91.05 88.31 89.23 86.54 15135 825.57 784.29 901.93 874.87 883.89 857.37 # 15135 731.02 694.47 798.64 774.69 782.67 759.20 15136 86.67 82.34 94.69 91.85 92.79 90.01 # 15136 81.73 77.64 89.29 86.61 87.50 84.87 15150 677.59 643.71 740.27 718.06 725.47 703.70 # 15150 625.20 593.94 683.03 662.54 669.37 649.29 15151 121.13 115.07 132.33 128.36 129.69 125.80 # 15151 112.56 106.93 122.97 119.28 120.51 116.90 15152 148.46 141.04 162.20 157.33 158.95 154.18 # 15152 140.23 133.22 153.20 148.60 150.14 145.64 15155 709.12 673.66 774.71 751.47 759.22 736.44 # 15155 660.36 627.34 721.44 699.80 707.01 685.80 15156 163.82 155.63 178.97 173.60 175.40 170.13 # 15156 155.91 148.11 170.33 165.22 166.92 161.92 15157 183.79 174.60 200.79 194.76 196.78 190.87 # 15157 172.59 163.96 188.55 182.90 184.78 179.24 15200 811.74 771.15 886.82 860.22 869.09 843.02 # 15200 669.41 635.94 731.33 709.39 716.70 695.20 15201 141.64 134.56 154.74 150.10 151.65 147.10 # 15201 79.37 75.40 86.71 84.11 84.97 82.43 15220 751.14 713.58 820.62 796.00 804.21 780.08 # 15220 611.45 580.88 668.01 647.97 654.65 635.01 15221 131.94 125.34 144.14 139.82 141.25 137.02 # 15221 72.31 68.69 78.99 76.62 77.42 75.10

Page 24: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 24Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

15240 911.79 866.20 996.13 966.24 976.21 946.92 # 15240 796.15 756.34 869.79 843.70 852.39 826.83 15241 179.34 170.37 195.93 190.05 192.00 186.24 # 15241 112.46 106.84 122.87 119.17 120.41 116.79 15260 990.34 940.82 1,081.94 1,049.49 1,060.30 1,028.50 # 15260 855.59 812.81 934.73 906.69 916.03 888.56 15261 209.18 198.72 228.53 221.67 223.96 217.24 # 15261 140.98 133.93 154.02 149.40 150.94 146.41 15271 136.15 129.34 148.74 144.28 145.76 141.39 # 15271 85.41 81.14 93.31 90.52 91.45 88.71 15272 26.48 25.16 28.93 28.07 28.36 27.51 # 15272 17.59 16.71 19.22 18.64 18.84 18.27 15273 293.55 278.87 320.70 311.08 314.28 304.85 # 15273 205.58 195.30 224.60 217.86 220.10 213.50 15274 70.06 66.56 76.54 74.24 75.01 72.76 # 15274 46.67 44.34 50.99 49.46 49.97 48.47 15275 145.27 138.01 158.71 153.95 155.54 150.87 # 15275 96.84 92.00 105.80 102.63 103.68 100.58 15276 34.26 32.55 37.43 36.31 36.69 35.58 # 15276 25.70 24.42 28.08 27.24 27.52 26.70 15277 320.47 304.45 350.12 339.62 343.11 332.82 # 15277 230.53 219.00 251.85 244.29 246.81 239.41 15278 83.91 79.71 91.67 88.92 89.84 87.14 # 15278 58.54 55.61 63.95 62.03 62.68 60.79 15570 893.30 848.64 975.94 946.66 956.42 927.73 # 15570 732.86 696.22 800.65 776.63 784.65 761.09 15572 870.65 827.12 951.19 922.66 932.17 904.20 # 15572 743.81 706.62 812.61 788.23 796.36 772.47 15574 892.75 848.11 975.33 946.07 955.82 927.15 # 15574 762.61 724.48 833.15 808.16 816.49 792.01 15576 788.29 748.88 861.21 835.37 843.99 818.66 # 15576 667.71 634.32 729.47 707.58 714.87 693.43 15600 308.06 292.66 336.56 326.46 329.83 319.93 # 15600 201.97 191.87 220.65 214.03 216.23 209.75 15610 342.05 324.95 373.69 362.48 366.22 355.24 # 15610 237.61 225.73 259.59 251.80 254.40 246.77 15620 421.97 400.87 461.00 447.17 451.78 438.22 # 15620 319.84 303.85 349.43 338.94 342.44 332.17 15630 443.81 421.62 484.86 470.32 475.17 460.91 # 15630 341.68 324.60 373.29 362.09 365.83 354.84 15650 490.07 465.57 535.41 519.34 524.70 508.96 # 15650 379.04 360.09 414.10 401.68 405.82 393.65 15731 1,106.36 1,051.04 1,208.70 1,172.44 1,184.52 1,148.99 # 15731 1,002.58 952.45 1,095.32 1,062.46 1,073.41 1,041.21 15732 1,260.12 1,197.11 1,376.68 1,335.38 1,349.15 1,308.68 # 15732 1,109.88 1,054.39 1,212.55 1,176.17 1,188.30 1,152.65 15734 1,484.92 1,410.67 1,622.27 1,573.60 1,589.83 1,542.13 # 15734 1,320.19 1,254.18 1,442.31 1,399.03 1,413.47 1,371.05 15736 1,300.92 1,235.87 1,421.25 1,378.61 1,392.82 1,351.03

Page 25: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 25Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 15736 1,138.82 1,081.88 1,244.16 1,206.83 1,219.28 1,182.69 15738 1,383.95 1,314.75 1,511.96 1,466.61 1,481.73 1,437.27 # 15738 1,231.74 1,170.15 1,345.67 1,305.31 1,318.76 1,279.20 15740 996.46 946.64 1,088.64 1,055.98 1,066.87 1,034.86 # 15740 849.52 807.04 928.10 900.25 909.54 882.25 15750 913.35 867.68 997.83 967.90 977.88 948.54 15756 2,327.41 2,211.04 2,542.70 2,466.42 2,491.84 2,417.09 15757 2,296.69 2,181.86 2,509.14 2,433.86 2,458.95 2,385.18 15758 2,302.27 2,187.16 2,515.23 2,439.78 2,464.93 2,390.99 15760 834.17 792.46 911.33 883.99 893.10 866.32 # 15760 705.36 670.09 770.60 747.49 755.19 732.54 15770 662.84 629.70 724.16 702.43 709.68 688.38 15775 295.21 280.45 322.52 312.85 316.07 306.59 # 15775 224.71 213.47 245.49 238.13 240.58 233.37 15776 474.85 451.11 518.78 503.22 508.40 493.15 # 15776 351.30 333.74 383.80 372.29 376.13 364.85 15777 217.94 207.04 238.10 230.95 233.34 226.33 15780 837.01 795.16 914.43 887.01 896.15 869.26 # 15780 641.97 609.87 701.35 680.31 687.32 666.70 15781 537.10 510.25 586.79 569.18 575.06 557.80 # 15781 426.40 405.08 465.84 451.87 456.53 442.83 15782 612.40 581.78 669.05 648.98 655.66 636.00 # 15782 437.13 415.27 477.56 463.23 468.00 453.96 15783 462.30 439.19 505.07 489.91 494.97 480.11 # 15783 364.78 346.54 398.52 386.56 390.55 378.83 15786 236.12 224.31 257.96 250.22 252.79 245.21 # 15786 135.64 128.86 148.19 143.74 145.22 140.86 15787 47.15 44.79 51.51 49.97 50.47 48.97 # 15787 17.17 16.31 18.76 18.19 18.38 17.83 15788 436.31 414.49 476.66 462.37 467.13 453.12 # 15788 238.63 226.70 260.71 252.89 255.50 247.83 15789 538.32 511.40 588.11 570.47 576.35 559.06 # 15789 418.06 397.16 456.73 443.04 447.60 434.18 15792 414.57 393.84 452.92 439.32 443.85 430.54 # 15792 248.86 236.42 271.88 263.73 266.44 258.45 15793 476.62 452.79 520.71 505.09 510.29 494.99 # 15793 361.64 343.56 395.09 383.24 387.19 375.58 15819 786.12 746.81 858.83 833.07 841.65 816.41 15820 568.73 540.29 621.33 602.69 608.90 590.64 # 15820 514.37 488.65 561.95 545.09 550.71 534.19 15821 589.07 559.62 643.56 624.25 630.69 611.77 # 15821 531.75 505.16 580.93 563.51 569.32 552.24 15822 431.46 409.89 471.37 457.23 461.94 448.09 # 15822 381.05 362.00 416.30 403.81 407.97 395.74 15823 588.67 559.24 643.13 623.83 630.27 611.35 # 15823 530.68 504.15 579.77 562.38 568.18 551.14 15830 1,172.06 1,113.46 1,280.48 1,242.07 1,254.87 1,217.23 15832 910.00 864.50 994.18 964.36 974.29 945.07 15833 849.15 806.69 927.69 899.86 909.14 881.87

Page 26: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 26Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

15834 881.71 837.62 963.26 934.36 944.00 915.68 15835 909.35 863.88 993.46 963.65 973.59 944.38 15836 781.72 742.63 854.02 828.40 836.95 811.83 15837 835.70 793.92 913.01 885.62 894.75 867.91 # 15837 706.56 671.23 771.91 748.75 756.48 733.78 15838 564.73 536.49 616.96 598.46 604.62 586.49 15839 864.72 821.48 944.70 916.37 925.81 898.04 # 15839 733.60 696.92 801.46 777.41 785.43 761.86 15840 1,000.75 950.71 1,093.32 1,060.52 1,071.46 1,039.31 15841 1,593.58 1,513.90 1,740.99 1,688.75 1,706.16 1,654.98 15842 2,448.50 2,326.08 2,674.99 2,594.75 2,621.49 2,542.85 15845 988.25 938.84 1,079.67 1,047.27 1,058.07 1,026.33 15847 655.82 623.03 716.48 694.99 702.16 681.09 15851 95.04 90.29 103.83 100.72 101.75 98.70 # 15851 45.95 43.65 50.20 48.69 49.20 47.71 15852 47.41 45.04 51.80 50.24 50.76 49.24 15860 111.19 105.63 121.47 117.83 119.05 115.47 15920 616.28 585.47 673.29 653.10 659.82 640.03 15922 774.97 736.22 846.65 821.25 829.73 804.83 15931 686.83 652.49 750.36 727.86 735.36 713.30 15933 840.94 798.89 918.72 891.16 900.35 873.33 15934 930.75 884.21 1,016.84 986.33 996.51 966.61 15935 1,099.36 1,044.39 1,201.05 1,165.02 1,177.03 1,141.72 15936 889.10 844.65 971.35 942.21 951.92 923.36 15937 1,029.23 977.77 1,124.44 1,090.71 1,101.94 1,068.89 15940 698.03 663.13 762.60 739.73 747.35 724.94 15941 892.37 847.75 974.91 945.67 955.42 926.75 15944 884.46 840.24 966.28 937.28 946.96 918.54 15945 976.92 928.07 1,067.28 1,035.26 1,045.94 1,014.56 15946 1,632.34 1,550.72 1,783.33 1,729.83 1,747.67 1,695.24 15950 588.02 558.62 642.41 623.14 629.57 610.67 15951 860.58 817.55 940.18 911.97 921.38 893.73 15952 891.56 846.98 974.03 944.81 954.55 925.91 15953 987.94 938.54 1,079.32 1,046.94 1,057.74 1,026.00 15956 1,145.93 1,088.63 1,251.92 1,214.37 1,226.89 1,190.08 15958 1,167.74 1,109.35 1,275.75 1,237.48 1,250.23 1,212.73 16000 67.51 64.13 73.75 71.54 72.28 70.12 # 16000 46.43 44.11 50.73 49.21 49.71 48.22 16020 78.79 74.85 86.08 83.49 84.35 81.82 # 16020 53.42 50.75 58.36 56.61 57.20 55.49 16025 143.89 136.70 157.21 152.49 154.07 149.44 # 16025 111.27 105.71 121.57 117.92 119.14 115.56 16030 181.09 172.04 197.85 191.91 193.89 188.07 # 16030 133.98 127.28 146.37 141.98 143.44 139.14 16035 196.93 187.08 215.14 208.69 210.84 204.52 16036 82.62 78.49 90.26 87.56 88.46 85.81 17000 64.30 61.09 70.25 68.15 68.85 66.78 # 17000 52.11 49.50 56.93 55.22 55.79 54.12 17003 5.42 5.15 5.92 5.75 5.81 5.64

Page 27: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 27Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 17003 2.45 2.33 2.68 2.60 2.62 2.54 17004 144.93 137.68 158.33 153.58 155.17 150.51 # 17004 98.81 93.87 107.95 104.71 105.79 102.61 17106 333.59 316.91 364.45 353.51 357.16 346.44 # 17106 274.62 260.89 300.02 291.02 294.02 285.20 17107 421.64 400.56 460.64 446.82 451.43 437.89 # 17107 343.55 326.37 375.33 364.07 367.82 356.79 17108 628.89 597.45 687.07 666.46 673.33 653.13 # 17108 526.43 500.11 575.13 557.88 563.63 546.72 17110 105.77 100.48 115.55 112.09 113.24 109.85 # 17110 68.21 64.80 74.52 72.29 73.03 70.84 17111 126.12 119.81 137.78 133.65 135.02 130.99 # 17111 84.28 80.07 92.08 89.32 90.24 87.54 17250 75.47 71.70 82.46 79.98 80.81 78.38 # 17250 36.60 34.77 39.99 38.79 39.18 38.02 17260 91.86 87.27 100.36 97.35 98.35 95.40 # 17260 69.78 66.29 76.23 73.95 74.70 72.46 17261 137.84 130.95 150.59 146.07 147.58 143.15 # 17261 90.73 86.19 99.12 96.14 97.14 94.22 17262 168.88 160.44 184.51 178.97 180.81 175.40 # 17262 115.83 110.04 126.55 122.75 124.02 120.30 17263 184.74 175.50 201.83 195.78 197.79 191.87 # 17263 128.40 121.98 140.28 136.07 137.47 133.34 17264 197.43 187.56 215.69 209.22 211.38 205.03 # 17264 136.81 129.97 149.47 144.98 146.48 142.08 17266 225.46 214.19 246.32 238.92 241.40 234.14 # 17266 161.22 153.16 176.13 170.86 172.62 167.44 17270 145.29 138.03 158.73 153.97 155.56 150.89 # 17270 99.50 94.53 108.71 105.44 106.54 103.34 17271 157.71 149.82 172.29 167.13 168.84 163.78 # 17271 110.27 104.76 120.47 116.86 118.06 114.53 17272 180.07 171.07 196.73 190.83 192.80 187.01 # 17272 127.02 120.67 138.77 134.61 136.00 131.92 17273 201.43 191.36 220.06 213.46 215.66 209.20 # 17273 144.11 136.90 157.44 152.71 154.28 149.65 17274 238.84 226.90 260.94 253.10 255.71 248.04 # 17274 176.57 167.74 192.90 187.12 189.05 183.38 17276 276.42 262.60 301.99 292.93 295.95 287.07 # 17276 211.18 200.62 230.71 223.79 226.10 219.32 17280 135.90 129.11 148.48 144.03 145.51 141.15 # 17280 90.43 85.91 98.80 95.83 96.82 93.91 17281 172.34 163.72 188.28 182.63 184.52 178.97 # 17281 124.57 118.34 136.09 132.01 133.37 129.36 17282 198.11 188.20 216.43 209.93 212.11 205.74 # 17282 143.42 136.25 156.69 151.98 153.56 148.95 17283 238.02 226.12 260.04 252.24 254.84 247.19 # 17283 179.71 170.72 196.33 190.44 192.41 186.63 17284 272.34 258.72 297.53 288.60 291.58 282.83 # 17284 210.08 199.58 229.52 222.63 224.93 218.18

Page 28: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 28Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

17286 350.52 332.99 382.94 371.45 375.28 364.02 # 17286 282.32 268.20 308.43 299.17 302.27 293.19 17311 640.00 608.00 699.20 678.22 685.22 664.65 # 17311 381.38 362.31 416.66 404.16 408.32 396.07 17312 374.89 356.15 409.57 397.29 401.38 389.34 # 17312 202.91 192.76 221.67 215.03 217.24 210.73 17313 597.30 567.44 652.56 632.98 639.50 620.32 # 17313 341.97 324.87 373.60 362.39 366.13 355.14 17314 359.24 341.28 392.47 380.70 384.62 373.08 # 17314 188.25 178.84 205.67 199.49 201.55 195.50 17315 78.05 74.15 85.27 82.72 83.57 81.06 # 17315 53.67 50.99 58.64 56.88 57.47 55.74 17340 50.96 48.41 55.67 54.00 54.56 52.92 # 17340 48.65 46.22 53.15 51.55 52.10 50.52 17360 125.16 118.90 136.74 132.63 134.00 129.97 # 17360 98.14 93.23 107.21 103.99 105.08 101.91 19000 108.22 102.81 118.23 114.69 115.86 112.40 # 19000 44.30 42.09 48.40 46.95 47.44 46.01 19001 26.75 25.41 29.22 28.35 28.64 27.78 # 19001 22.14 21.03 24.18 23.46 23.70 22.99 19020 456.53 433.70 498.76 483.79 488.78 474.12 # 19020 303.01 287.86 331.04 321.10 324.42 314.69 19030 159.43 151.46 174.18 168.96 170.69 165.58 # 19030 79.04 75.09 86.35 83.77 84.63 82.09 19081 657.81 624.92 718.66 697.10 704.28 683.16 # 19081 171.86 163.27 187.76 182.13 184.00 178.48 19082 539.46 512.49 589.36 571.69 577.58 560.26 # 19082 86.45 82.13 94.45 91.62 92.56 89.79 19083 637.73 605.84 696.72 675.81 682.78 662.30 # 19083 161.66 153.58 176.62 171.32 173.09 167.89 19084 518.32 492.40 566.26 549.27 554.93 538.29 # 19084 80.47 76.45 87.92 85.28 86.16 83.58 19085 965.24 916.98 1,054.53 1,022.89 1,033.44 1,002.43 # 19085 188.71 179.27 206.16 199.97 202.03 195.97 19086 768.55 730.12 839.64 814.45 822.85 798.17 # 19086 93.82 89.13 102.50 99.43 100.45 97.44 19100 145.59 138.31 159.06 154.28 155.87 151.20 # 19100 71.13 67.57 77.71 75.37 76.15 73.86 19101 331.20 314.64 361.84 350.98 354.60 343.97 # 19101 221.16 210.10 241.62 234.37 236.79 229.68 19105 2,204.35 2,094.13 2,408.25 2,336.01 2,360.09 2,289.28 # 19105 202.57 192.44 221.31 214.67 216.88 210.38 19110 471.07 447.52 514.65 499.20 504.36 489.22 # 19110 339.95 322.95 371.39 360.25 363.96 353.04 19112 444.76 422.52 485.90 471.32 476.18 461.89 # 19112 309.35 293.88 337.96 327.82 331.20 321.26 19120 485.67 461.39 530.60 514.68 519.98 504.39 # 19120 412.86 392.22 451.05 437.52 442.04 428.77 19125 538.95 512.00 588.80 571.14 577.02 559.72

Page 29: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 29Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 19125 458.89 435.95 501.34 486.30 491.31 476.57 19126 164.81 156.57 180.06 174.65 176.46 171.15 19260 1,204.89 1,144.65 1,316.35 1,276.86 1,290.02 1,251.32 19271 1,621.45 1,540.38 1,771.44 1,718.30 1,736.01 1,683.93 19272 1,777.64 1,688.76 1,942.07 1,883.82 1,903.23 1,846.14 19281 231.10 219.55 252.48 244.90 247.43 240.01 # 19281 102.94 97.79 112.46 109.09 110.20 106.90 19282 159.04 151.09 173.75 168.54 170.28 165.17 # 19282 51.63 49.05 56.41 54.72 55.28 53.62 19283 260.18 247.17 284.25 275.71 278.56 270.20 # 19283 104.02 98.82 113.64 110.24 111.37 108.03 19284 194.05 184.35 212.00 205.64 207.76 201.53 # 19284 52.38 49.76 57.22 55.51 56.07 54.40 19285 488.81 464.37 534.03 518.01 523.34 507.64 # 19285 88.19 83.78 96.35 93.46 94.42 91.59 19286 424.14 402.93 463.37 449.47 454.10 440.47 # 19286 44.27 42.06 48.37 46.92 47.40 45.98 19287 817.02 776.17 892.60 865.81 874.75 848.49 # 19287 131.75 125.16 143.93 139.62 141.06 136.83 19288 654.77 622.03 715.33 693.88 701.03 680.00 # 19288 65.70 62.42 71.78 69.63 70.35 68.24 19296 3,701.41 3,516.34 4,043.79 3,922.48 3,962.91 3,844.02 # 19296 213.76 203.07 233.53 226.53 228.86 222.00 19297 96.85 92.01 105.81 102.64 103.70 100.59 19298 935.80 889.01 1,022.36 991.69 1,001.91 971.85 # 19298 318.07 302.17 347.50 337.07 340.55 330.33 19300 510.67 485.14 557.91 541.18 546.76 530.36 # 19300 409.52 389.04 447.40 433.98 438.45 425.29 19301 655.12 622.36 715.71 694.24 701.40 680.36 19302 904.15 858.94 987.78 958.15 968.02 938.99 19303 1,015.91 965.11 1,109.88 1,076.58 1,087.68 1,055.06 19304 574.69 545.96 627.85 609.02 615.30 596.84 19305 1,134.58 1,077.85 1,239.53 1,202.34 1,214.73 1,178.29 19306 1,190.65 1,131.12 1,300.79 1,261.77 1,274.78 1,236.54 19307 1,200.86 1,140.82 1,311.94 1,272.59 1,285.70 1,247.14 19316 768.56 730.13 839.65 814.46 822.86 798.18 19318 1,100.45 1,045.43 1,202.24 1,166.18 1,178.20 1,142.86 19324 492.26 467.65 537.80 521.66 527.05 511.23 19325 637.40 605.53 696.36 675.46 682.43 661.95 19328 490.87 466.33 536.28 520.19 525.55 509.78 19330 629.44 597.97 687.67 667.03 673.91 653.69 19340 999.24 949.28 1,091.67 1,058.92 1,069.83 1,037.74 19342 917.03 871.18 1,001.86 971.80 981.82 952.36 19350 806.56 766.23 881.16 854.73 863.55 837.64 # 19350 669.18 635.72 731.08 709.15 716.46 694.97 19355 687.53 653.15 751.12 728.59 736.10 714.02 # 19355 570.90 542.36 623.71 605.00 611.24 592.91 19357 1,489.17 1,414.71 1,626.92 1,578.11 1,594.38 1,546.54 19361 1,575.67 1,496.89 1,721.42 1,669.78 1,686.99 1,636.38

Page 30: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 30Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

19364 2,764.26 2,626.05 3,019.96 2,929.36 2,959.56 2,870.77 19366 1,415.18 1,344.42 1,546.08 1,499.70 1,515.16 1,469.71 19367 1,789.44 1,699.97 1,954.97 1,896.32 1,915.87 1,858.39 19368 2,208.54 2,098.11 2,412.83 2,340.45 2,364.57 2,293.64 19369 2,030.79 1,929.25 2,218.64 2,152.08 2,174.27 2,109.03 19370 681.27 647.21 744.29 721.96 729.41 707.51 19371 779.17 740.21 851.24 825.70 834.22 809.19 19380 768.52 730.09 839.60 814.42 822.81 798.13 19396 281.57 267.49 307.61 298.39 301.46 292.42 # 19396 146.16 138.85 159.68 154.88 156.48 151.79 20005 304.75 289.51 332.94 322.94 326.28 316.48 # 20005 234.25 222.54 255.92 248.24 250.80 243.27 20100 613.62 582.94 670.38 650.27 656.97 637.26 20101 430.16 408.65 469.95 455.85 460.55 446.73 # 20101 209.75 199.26 229.15 222.27 224.56 217.82 20102 470.60 447.07 514.13 498.71 503.85 488.74 # 20102 256.12 243.31 279.81 271.41 274.21 265.98 20103 565.32 537.05 617.61 599.08 605.26 587.10 # 20103 348.87 331.43 381.14 369.71 373.52 362.32 20150 948.22 900.81 1,035.93 1,004.86 1,015.21 984.76 20200 199.75 189.76 218.22 211.68 213.85 207.45 # 20200 96.30 91.49 105.21 102.06 103.11 100.03 20205 280.25 266.24 306.18 296.99 300.06 291.05 # 20205 157.36 149.49 171.91 166.76 168.48 163.43 20206 223.28 212.12 243.94 236.62 239.06 231.89 # 20206 59.54 56.56 65.04 63.09 63.74 61.82 20220 161.21 153.15 176.12 170.84 172.60 167.43 # 20220 72.58 68.95 79.29 76.91 77.71 75.37 20225 493.98 469.28 539.67 523.48 528.87 513.02 # 20225 109.18 103.72 119.28 115.70 116.90 113.39 20240 154.05 146.35 168.30 163.25 164.93 159.99 20245 356.94 339.09 389.95 378.26 382.16 370.69 20250 388.28 368.87 424.20 411.47 415.71 403.24 20251 425.23 403.97 464.57 450.63 455.27 441.61 20500 100.65 95.62 109.96 106.66 107.77 104.54 # 20500 83.19 79.03 90.88 88.16 89.07 86.40 20501 112.81 107.17 123.25 119.54 120.78 117.15 # 20501 38.68 36.75 42.26 41.00 41.42 40.18 20520 197.46 187.59 215.73 209.25 211.42 205.07 # 20520 144.75 137.51 158.14 153.39 154.97 150.32 20525 460.67 437.64 503.29 488.19 493.22 478.42 # 20525 246.85 234.51 269.69 261.59 264.29 256.36 20526 75.71 71.92 82.71 80.22 81.05 78.61 # 20526 57.92 55.02 63.27 61.38 62.01 60.15 20527 82.54 78.41 90.17 87.47 88.37 85.72 # 20527 66.72 63.38 72.89 70.70 71.43 69.29 20550 51.89 49.30 56.70 54.99 55.56 53.89 # 20550 39.70 37.72 43.38 42.08 42.52 41.24 20551 59.11 56.15 64.57 62.64 63.28 61.39

Page 31: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 31Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 20551 42.63 40.50 46.58 45.18 45.64 44.28 20552 53.87 51.18 58.86 57.09 57.68 55.95 # 20552 38.06 36.16 41.58 40.34 40.76 39.54 20553 62.07 58.97 67.82 65.78 66.46 64.47 # 20553 43.29 41.13 47.30 45.89 46.36 44.97 20555 329.41 312.94 359.88 349.08 352.68 342.10 20600 46.95 44.60 51.29 49.75 50.27 48.75 # 20600 35.75 33.96 39.05 37.88 38.27 37.12 20604 70.78 67.24 77.33 75.00 75.79 73.51 # 20604 47.06 44.71 51.42 49.88 50.39 48.88 20605 49.35 46.88 53.91 52.29 52.83 51.24 # 20605 37.49 35.62 40.96 39.73 40.15 38.94 20606 78.41 74.49 85.66 83.10 83.95 81.43 # 20606 53.37 50.70 58.31 56.56 57.14 55.43 20610 59.34 56.37 64.83 62.88 63.53 61.63 # 20610 46.49 44.17 50.80 49.27 49.78 48.28 20611 89.03 84.58 97.27 94.35 95.32 92.46 # 20611 62.02 58.92 67.76 65.72 66.40 64.41 20612 58.99 56.04 64.45 62.51 63.16 61.26 # 20612 41.86 39.77 45.74 44.37 44.82 43.48 20615 234.10 222.40 255.76 248.09 250.64 243.13 # 20615 160.96 152.91 175.85 170.57 172.33 167.15 20650 203.67 193.49 222.51 215.84 218.06 211.53 # 20650 156.88 149.04 171.40 166.26 167.97 162.93 20660 250.73 238.19 273.92 265.70 268.44 260.38 20661 500.25 475.24 546.53 530.13 535.60 519.52 20662 430.80 409.26 470.65 456.53 461.23 447.40 20663 448.84 426.40 490.36 475.65 480.55 466.14 20664 876.55 832.72 957.63 928.90 938.48 910.33 20665 103.79 98.60 113.39 109.99 111.12 107.79 # 20665 89.95 85.45 98.27 95.32 96.30 93.41 20670 361.24 343.18 394.66 382.81 386.77 375.15 # 20670 145.11 137.85 158.53 153.77 155.35 150.70 20680 600.95 570.90 656.54 636.84 643.40 624.09 # 20680 421.07 400.02 460.02 446.22 450.82 437.30 20690 594.81 565.07 649.83 630.34 636.84 617.73 20692 1,116.63 1,060.80 1,219.92 1,183.33 1,195.52 1,159.66 20693 440.77 418.73 481.54 467.10 471.91 457.76 20694 414.14 393.43 452.44 438.87 443.39 430.10 # 20694 334.41 317.69 365.34 354.38 358.04 347.30 20696 1,206.97 1,146.62 1,318.61 1,279.05 1,292.24 1,253.48 20697 1,967.94 1,869.54 2,149.97 2,085.47 2,106.97 2,043.76 20802 2,775.00 2,636.25 3,031.69 2,940.73 2,971.06 2,881.92 20805 3,148.36 2,990.94 3,439.58 3,336.39 3,370.79 3,269.67 20808 4,014.38 3,813.66 4,385.71 4,254.14 4,298.00 4,169.06 20816 2,111.90 2,006.31 2,307.26 2,238.04 2,261.11 2,193.28 20822 1,793.66 1,703.98 1,959.58 1,900.79 1,920.39 1,862.77 20824 1,963.75 1,865.56 2,145.39 2,081.03 2,102.49 2,039.41 20827 1,838.27 1,746.36 2,008.31 1,948.07 1,968.14 1,909.10

Page 32: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 32Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

20838 2,703.35 2,568.18 2,953.41 2,864.80 2,894.34 2,807.51 20900 401.14 381.08 438.24 425.10 429.48 416.60 # 20900 190.28 180.77 207.89 201.65 203.72 197.62 20902 287.48 273.11 314.08 304.66 307.80 298.56 20910 446.64 424.31 487.96 473.32 478.19 463.85 20912 472.79 449.15 516.52 501.03 506.20 491.02 20920 391.57 371.99 427.79 414.95 419.23 406.65 20922 580.79 551.75 634.51 615.48 621.83 603.18 # 20922 487.89 463.50 533.03 517.04 522.36 506.70 20924 503.25 478.09 549.80 533.31 538.81 522.65 20926 420.18 399.17 459.05 445.27 449.87 436.37 20931 115.49 109.72 126.18 122.39 123.66 119.95 20937 171.77 163.18 187.66 182.02 183.91 178.38 20938 190.19 180.68 207.78 201.55 203.63 197.51 20950 239.91 227.91 262.10 254.23 256.85 249.15 # 20950 90.67 86.14 99.06 96.09 97.08 94.17 20955 2,517.15 2,391.29 2,749.98 2,667.48 2,694.98 2,614.13 20956 2,673.23 2,539.57 2,920.51 2,832.89 2,862.10 2,776.23 20957 2,295.70 2,180.92 2,508.06 2,432.81 2,457.90 2,384.16 20962 2,169.77 2,061.28 2,370.47 2,299.36 2,323.06 2,253.37 20969 2,777.43 2,638.56 3,034.34 2,943.31 2,973.66 2,884.44 20970 2,893.07 2,748.42 3,160.68 3,065.87 3,097.47 3,004.55 20972 2,438.37 2,316.45 2,663.92 2,584.00 2,610.64 2,532.32 20973 2,504.11 2,378.90 2,735.74 2,653.66 2,681.02 2,600.59 20974 74.71 70.97 81.62 79.17 79.98 77.58 # 20974 50.33 47.81 54.98 53.34 53.88 52.27 20975 179.57 170.59 196.18 190.29 192.26 186.48 20979 50.82 48.28 55.52 53.85 54.41 52.77 # 20979 32.70 31.07 35.73 34.66 35.02 33.97 20982 1,616.82 1,535.98 1,766.38 1,713.39 1,731.05 1,679.12 # 20982 374.10 355.40 408.71 396.45 400.53 388.53 20983 5,901.48 5,606.41 6,447.37 6,253.95 6,318.42 6,128.88 # 20983 374.82 356.08 409.49 397.21 401.30 389.26 20985 149.16 141.70 162.96 158.07 159.70 154.91 21010 755.14 717.38 824.99 800.24 808.48 784.23 21011 337.55 320.67 368.77 357.71 361.40 350.55 # 21011 255.84 243.05 279.51 271.12 273.92 265.70 21012 336.90 320.06 368.07 357.03 360.71 349.89 21013 506.97 481.62 553.86 537.25 542.79 526.50 # 21013 398.91 378.96 435.80 422.73 427.09 414.28 21014 519.01 493.06 567.02 550.01 555.68 539.01 21015 704.70 669.47 769.89 746.80 754.49 731.86 21016 1,020.82 969.78 1,115.25 1,081.79 1,092.94 1,060.16 21025 880.06 836.06 961.47 932.63 942.24 913.97 # 21025 751.24 713.68 820.73 796.11 804.32 780.18 21026 605.91 575.61 661.95 642.09 648.72 629.25 # 21026 495.55 470.77 541.39 525.15 530.55 514.65 21029 756.51 718.68 826.48 801.69 809.96 785.66 # 21029 635.93 604.13 694.75 673.91 680.86 660.43

Page 33: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 33Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

21030 509.70 484.22 556.85 540.14 545.72 529.35 # 21030 415.48 394.71 453.92 440.30 444.84 431.49 21031 386.92 367.57 422.71 410.02 414.25 401.82 # 21031 293.69 279.01 320.86 311.24 314.44 305.01 21032 391.32 371.75 427.51 414.69 418.97 406.40 # 21032 289.85 275.36 316.66 307.17 310.33 301.02 21034 1,307.04 1,241.69 1,427.94 1,385.11 1,399.39 1,357.40 # 21034 1,161.75 1,103.66 1,269.21 1,231.13 1,243.83 1,206.51 21040 513.00 487.35 560.45 543.64 549.24 532.77 # 21040 415.81 395.02 454.27 440.65 445.19 431.84 21044 874.89 831.15 955.82 927.15 936.71 908.62 21045 1,226.53 1,165.20 1,339.98 1,299.78 1,313.19 1,273.79 21046 1,114.81 1,059.07 1,217.93 1,181.40 1,193.57 1,157.76 21047 1,321.54 1,255.46 1,443.78 1,400.47 1,414.90 1,372.46 21048 1,144.24 1,087.03 1,250.08 1,212.58 1,225.08 1,188.33 21049 1,210.76 1,150.22 1,322.75 1,283.07 1,296.30 1,257.41 21050 830.97 789.42 907.83 880.60 889.67 862.99 21060 799.53 759.55 873.48 847.27 856.01 830.32 21070 605.74 575.45 661.77 641.92 648.53 629.08 21073 389.10 369.65 425.10 412.34 416.60 404.10 # 21073 256.00 243.20 279.68 271.29 274.09 265.86 21076 990.69 941.16 1,082.33 1,049.87 1,060.69 1,028.87 # 21076 839.14 797.18 916.76 889.25 898.43 871.46 21077 2,501.49 2,376.42 2,732.88 2,650.90 2,678.22 2,597.88 # 21077 2,125.25 2,018.99 2,321.84 2,252.18 2,275.40 2,207.14 21079 1,684.34 1,600.12 1,840.14 1,784.94 1,803.34 1,749.24 # 21079 1,415.83 1,345.04 1,546.80 1,500.39 1,515.86 1,470.39 21080 1,891.63 1,797.05 2,066.61 2,004.61 2,025.28 1,964.52 # 21080 1,577.33 1,498.46 1,723.23 1,671.54 1,688.76 1,638.11 21081 1,743.85 1,656.66 1,905.16 1,848.00 1,867.06 1,811.04 # 21081 1,450.30 1,377.79 1,584.46 1,536.93 1,552.76 1,506.19 21082 1,641.73 1,559.64 1,793.59 1,739.78 1,757.72 1,704.98 # 21082 1,350.49 1,282.97 1,475.42 1,431.15 1,445.91 1,402.53 21083 1,564.53 1,486.30 1,709.25 1,657.97 1,675.06 1,624.81 # 21083 1,256.82 1,193.98 1,373.08 1,331.88 1,345.62 1,305.25 21084 1,795.00 1,705.25 1,961.04 1,902.20 1,921.82 1,864.16 # 21084 1,456.64 1,383.81 1,591.38 1,543.65 1,559.55 1,512.77 21085 751.37 713.80 820.87 796.25 804.45 780.32 # 21085 572.48 543.86 625.44 606.67 612.93 594.54 21086 1,858.63 1,765.70 2,030.56 1,969.64 1,989.95 1,930.25 # 21086 1,573.65 1,494.97 1,719.22 1,667.64 1,684.83 1,634.29 21087 1,849.26 1,756.80 2,020.32 1,959.72 1,979.91 1,920.52 # 21087 1,562.63 1,484.50 1,707.18 1,655.97 1,673.03 1,622.85 21100 803.21 763.05 877.51 851.18 859.96 834.16 # 21100 400.95 380.90 438.04 424.89 429.27 416.39 21110 783.26 744.10 855.72 830.05 838.60 813.44 # 21110 661.03 627.98 722.18 700.51 707.73 686.50 21116 140.75 133.71 153.77 149.16 150.70 146.18 # 21116 44.87 42.63 49.02 47.55 48.05 46.60

Page 34: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 34Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

21120 584.39 555.17 638.45 619.29 625.68 606.90 # 21120 470.07 446.57 513.56 498.15 503.29 488.19 21121 790.78 751.24 863.93 838.01 846.65 821.25 # 21121 667.23 633.87 728.95 707.08 714.37 692.93 21122 655.03 622.28 715.62 694.15 701.30 680.27 21123 897.88 852.99 980.94 951.51 961.32 932.48 21125 3,051.28 2,898.72 3,333.53 3,233.52 3,266.86 3,168.85 # 21125 735.85 699.06 803.92 779.80 787.84 764.21 21127 4,168.40 3,959.98 4,553.98 4,417.36 4,462.90 4,329.01 # 21127 890.62 846.09 973.00 943.82 953.55 924.95 21137 693.59 658.91 757.75 735.01 742.59 720.31 21138 916.95 871.10 1,001.77 971.72 981.73 952.28 21139 1,079.27 1,025.31 1,179.11 1,143.73 1,155.52 1,120.86 21141 1,360.04 1,292.04 1,485.85 1,441.27 1,456.13 1,412.44 21142 1,439.87 1,367.88 1,573.06 1,525.87 1,541.60 1,495.35 21143 1,466.56 1,393.23 1,602.21 1,554.14 1,570.18 1,523.06 21145 1,605.44 1,525.17 1,753.95 1,701.32 1,718.87 1,667.29 21146 1,672.46 1,588.84 1,827.17 1,772.35 1,790.62 1,736.90 21147 1,688.79 1,604.35 1,845.00 1,789.65 1,808.10 1,753.87 21150 1,740.92 1,653.87 1,901.95 1,844.89 1,863.91 1,808.00 21151 2,013.79 1,913.10 2,200.07 2,134.07 2,156.07 2,091.39 21154 1,895.04 1,800.29 2,070.33 2,008.22 2,028.92 1,968.05 21155 2,104.48 1,999.26 2,299.15 2,230.17 2,253.16 2,185.56 21159 2,639.91 2,507.91 2,884.10 2,797.57 2,826.41 2,741.62 21160 2,743.40 2,606.23 2,997.16 2,907.25 2,937.23 2,849.10 21172 2,074.75 1,971.01 2,266.66 2,198.66 2,221.33 2,154.69 21175 2,116.00 2,010.20 2,311.73 2,242.37 2,265.50 2,197.52 21179 1,372.53 1,303.90 1,499.49 1,454.50 1,469.49 1,425.40 21180 1,602.31 1,522.19 1,750.52 1,698.00 1,715.51 1,664.04 21181 737.69 700.81 805.93 781.76 789.81 766.12 21182 1,992.16 1,892.55 2,176.43 2,111.14 2,132.91 2,068.91 21183 2,231.31 2,119.74 2,437.70 2,364.57 2,388.95 2,317.28 21184 2,753.52 2,615.84 3,008.22 2,917.96 2,948.05 2,859.60 21188 1,629.56 1,548.08 1,780.29 1,726.89 1,744.69 1,692.35 21193 1,184.47 1,125.25 1,294.04 1,255.21 1,268.16 1,230.11 21194 1,482.74 1,408.60 1,619.89 1,571.29 1,587.49 1,539.86 21195 1,317.94 1,252.04 1,439.85 1,396.65 1,411.05 1,368.72 21196 1,485.26 1,411.00 1,622.65 1,573.97 1,590.20 1,542.50 21198 1,165.96 1,107.66 1,273.81 1,235.59 1,248.34 1,210.88 21199 1,017.36 966.49 1,111.46 1,078.13 1,089.23 1,056.56 21206 1,212.21 1,151.60 1,324.34 1,284.61 1,297.86 1,258.92 21208 1,781.40 1,692.33 1,946.18 1,887.79 1,907.25 1,850.04 # 21208 839.48 797.51 917.14 889.62 898.79 871.83 21209 795.88 756.09 869.50 843.42 852.12 826.55 # 21209 614.02 583.32 670.82 650.69 657.40 637.68 21210 2,188.23 2,078.82 2,390.64 2,318.93 2,342.83 2,272.55 # 21210 867.10 823.75 947.31 918.90 928.37 900.52 21215 3,827.46 3,636.09 4,181.50 4,056.06 4,097.88 3,974.94 # 21215 902.52 857.39 986.00 956.42 966.28 937.30

Page 35: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 35Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

21230 744.89 707.65 813.80 789.38 797.53 773.59 21235 708.59 673.16 774.13 750.92 758.66 735.90 # 21235 561.99 533.89 613.97 595.55 601.69 583.64 21240 1,123.57 1,067.39 1,227.50 1,190.68 1,202.95 1,166.86 21242 1,033.16 981.50 1,128.73 1,094.87 1,106.15 1,072.97 21243 1,715.73 1,629.94 1,874.43 1,818.20 1,836.94 1,781.83 21244 1,057.74 1,004.85 1,155.58 1,120.91 1,132.46 1,098.49 21245 1,086.18 1,031.87 1,186.65 1,151.05 1,162.91 1,128.02 # 21245 881.26 837.20 962.78 933.89 943.53 915.22 21246 886.25 841.94 968.23 939.18 948.87 920.40 21247 1,539.65 1,462.67 1,682.07 1,631.61 1,648.43 1,598.97 21248 1,099.30 1,044.34 1,200.99 1,164.96 1,176.97 1,141.66 # 21248 909.53 864.05 993.66 963.85 973.79 944.58 21249 1,503.20 1,428.04 1,642.25 1,592.98 1,609.40 1,561.13 # 21249 1,288.39 1,223.97 1,407.57 1,365.34 1,379.41 1,338.04 21255 1,379.69 1,310.71 1,507.32 1,462.10 1,477.18 1,432.85 21256 1,197.89 1,138.00 1,308.70 1,269.44 1,282.53 1,244.05 21260 1,245.51 1,183.23 1,360.71 1,319.89 1,333.51 1,293.50 21261 2,117.49 2,011.62 2,313.36 2,243.96 2,267.10 2,199.08 21263 1,954.06 1,856.36 2,134.81 2,070.77 2,092.11 2,029.36 21267 1,569.53 1,491.05 1,714.71 1,663.27 1,680.41 1,630.00 21268 1,743.88 1,656.69 1,905.19 1,848.04 1,867.09 1,811.08 21270 948.00 900.60 1,035.69 1,004.62 1,014.98 984.53 # 21270 721.99 685.89 788.77 765.11 773.00 749.80 21275 836.06 794.26 913.40 885.99 895.13 868.27 21280 558.66 530.73 610.34 592.03 598.14 580.19 21282 372.14 353.53 406.56 394.36 398.43 386.47 21295 181.86 172.77 198.69 192.73 194.71 188.88 21296 436.19 414.38 476.54 462.24 467.00 453.00 21310 126.15 119.84 137.82 133.68 135.06 131.01 # 21310 27.64 26.26 30.20 29.29 29.59 28.70 21315 265.12 251.86 289.64 280.95 283.84 275.32 # 21315 149.16 141.70 162.96 158.07 159.70 154.91 21320 246.52 234.19 269.32 261.23 263.94 256.01 # 21320 133.85 127.16 146.23 141.85 143.31 139.01 21325 461.29 438.23 503.96 488.84 493.89 479.07 21330 560.33 532.31 612.16 593.79 599.91 581.91 21335 713.68 678.00 779.70 756.31 764.11 741.19 21336 632.00 600.40 690.46 669.75 676.65 656.35 21337 391.71 372.12 427.94 415.10 419.38 406.80 # 21337 290.57 276.04 317.45 307.92 311.10 301.76 21338 734.77 698.03 802.73 778.65 786.68 763.08 21339 830.77 789.23 907.61 880.38 889.47 862.78 21340 794.64 754.91 868.15 842.10 850.78 825.25 21343 1,201.77 1,141.68 1,312.93 1,273.54 1,286.68 1,248.07 21344 1,391.60 1,322.02 1,520.32 1,474.71 1,489.92 1,445.22 21345 791.03 751.48 864.20 838.28 846.92 821.51 # 21345 643.44 611.27 702.96 681.87 688.90 668.23 21346 895.83 851.04 978.70 949.34 959.12 930.35

Page 36: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 36Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

21347 1,125.36 1,069.09 1,229.45 1,192.57 1,204.87 1,168.72 21348 1,200.05 1,140.05 1,311.06 1,271.73 1,284.84 1,246.29 21355 439.41 417.44 480.06 465.66 470.45 456.34 # 21355 331.35 314.78 362.00 351.14 354.75 344.11 21356 489.88 465.39 535.20 519.14 524.49 508.76 # 21356 374.57 355.84 409.22 396.93 401.03 389.00 21360 536.01 509.21 585.59 568.02 573.88 556.66 21365 1,113.27 1,057.61 1,216.25 1,179.76 1,191.93 1,156.16 21366 1,136.91 1,080.06 1,242.07 1,204.81 1,217.23 1,180.72 21385 673.21 639.55 735.48 713.41 720.77 699.14 21386 691.46 656.89 755.42 732.76 740.31 718.11 21387 704.39 669.17 769.55 746.45 754.16 731.53 21390 790.16 750.65 863.25 837.35 845.99 820.61 21395 1,010.68 960.15 1,104.17 1,071.05 1,082.09 1,049.63 21400 186.31 176.99 203.54 197.43 199.47 193.49 # 21400 152.71 145.07 166.83 161.83 163.50 158.60 21401 470.85 447.31 514.41 498.97 504.11 488.99 # 21401 300.85 285.81 328.68 318.83 322.10 312.46 21406 566.80 538.46 619.23 600.66 606.84 588.64 21407 641.92 609.82 701.29 680.26 687.26 666.66 21408 889.93 845.43 972.24 943.08 952.80 924.22 21421 820.94 779.89 896.87 869.96 878.93 852.56 # 21421 683.55 649.37 746.78 724.37 731.84 709.88 21422 672.23 638.62 734.41 712.38 719.73 698.13 21423 786.48 747.16 859.23 833.46 842.05 816.80 21431 722.20 686.09 789.00 765.34 773.23 750.03 21432 675.67 641.89 738.17 716.02 723.41 701.71 21433 1,741.85 1,654.76 1,902.97 1,845.89 1,864.91 1,808.97 21435 1,275.09 1,211.34 1,393.04 1,351.25 1,365.18 1,324.23 21436 1,906.40 1,811.08 2,082.74 2,020.26 2,041.09 1,979.86 21440 559.70 531.72 611.48 593.14 599.25 581.27 # 21440 457.57 434.69 499.89 484.90 489.90 475.20 21445 749.25 711.79 818.56 794.01 802.18 778.12 # 21445 615.16 584.40 672.06 651.90 658.62 638.86 21450 597.78 567.89 653.07 633.48 640.01 620.80 # 21450 482.14 458.03 526.73 510.93 516.20 500.71 21451 797.48 757.61 871.25 845.11 853.83 828.21 # 21451 661.42 628.35 722.60 700.93 708.15 686.91 21452 547.79 520.40 598.46 580.51 586.49 568.89 # 21452 327.38 311.01 357.66 346.93 350.51 340.00 21453 887.18 842.82 969.24 940.17 949.85 921.37 # 21453 764.29 726.08 834.99 809.95 818.29 793.74 21454 573.54 544.86 626.59 607.79 614.05 595.63 21461 2,052.33 1,949.71 2,242.17 2,174.90 2,197.33 2,131.41 # 21461 924.59 878.36 1,010.11 979.81 989.91 960.22 21462 2,186.03 2,076.73 2,388.24 2,316.59 2,340.48 2,270.26 # 21462 1,033.59 981.91 1,129.20 1,095.32 1,106.61 1,073.41 21465 938.86 891.92 1,025.71 994.93 1,005.19 975.04 21470 1,207.79 1,147.40 1,319.51 1,279.93 1,293.12 1,254.33

Page 37: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 37Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

21480 94.63 89.90 103.39 100.28 101.32 98.28 # 21480 32.37 30.75 35.36 34.30 34.66 33.61 21485 677.92 644.02 740.62 718.41 725.81 704.04 # 21485 570.84 542.30 623.65 604.93 611.17 592.84 21490 916.82 870.98 1,001.63 971.58 981.59 952.14 21497 716.92 681.07 783.23 759.74 767.57 744.54 # 21497 599.31 569.34 654.74 635.10 641.64 622.39 21501 439.28 417.32 479.92 465.52 470.32 456.21 # 21501 317.38 301.51 346.74 336.33 339.80 329.60 21502 508.44 483.02 555.47 538.81 544.36 528.03 21510 446.09 423.79 487.36 472.74 477.61 463.29 21550 253.90 241.21 277.39 269.07 271.85 263.68 # 21550 156.71 148.87 171.20 166.06 167.77 162.74 21552 446.64 424.31 487.96 473.32 478.19 463.85 21554 733.70 697.02 801.57 777.53 785.54 761.98 21555 404.39 384.17 441.80 428.54 432.96 419.97 # 21555 303.90 288.71 332.02 322.06 325.38 315.62 21556 528.19 501.78 577.05 559.74 565.50 548.55 21557 962.13 914.02 1,051.12 1,019.59 1,030.10 999.20 21558 1,354.63 1,286.90 1,479.94 1,435.53 1,450.33 1,406.82 21600 552.70 525.07 603.83 585.72 591.76 574.00 21610 1,189.76 1,130.27 1,299.81 1,260.81 1,273.81 1,235.59 21615 630.40 598.88 688.71 668.05 674.94 654.68 21616 762.85 724.71 833.42 808.42 816.75 792.25 21620 504.39 479.17 551.05 534.51 540.03 523.81 21627 538.08 511.18 587.86 570.22 576.10 558.81 21630 1,221.07 1,160.02 1,334.02 1,294.00 1,307.34 1,268.13 21632 1,206.19 1,145.88 1,317.76 1,278.23 1,291.40 1,252.66 21685 993.22 943.56 1,085.09 1,052.54 1,063.39 1,031.49 21700 373.75 355.06 408.32 396.07 400.15 388.15 21705 560.76 532.72 612.63 594.25 600.38 582.37 21720 493.16 468.50 538.78 522.62 528.00 512.16 21725 537.08 510.23 586.76 569.16 575.03 557.77 21740 1,042.17 990.06 1,138.57 1,104.41 1,115.80 1,082.32 21742 729.41 692.94 796.88 772.97 780.94 757.52 21743 805.92 765.62 880.46 854.05 862.86 836.97 21750 691.43 656.86 755.39 732.72 740.28 718.07 21811 617.74 586.85 674.88 654.63 661.38 641.54 21812 741.49 704.42 810.08 785.78 793.88 770.06 21813 977.08 928.23 1,067.46 1,035.44 1,046.12 1,014.73 21820 136.48 129.66 149.11 144.64 146.13 141.74 # 21820 139.78 132.79 152.71 148.13 149.65 145.16 21825 539.90 512.91 589.85 572.15 578.05 560.71 21920 248.96 236.51 271.99 263.82 266.55 258.54 # 21920 159.02 151.07 173.73 168.52 170.26 165.15 21925 439.86 417.87 480.55 466.13 470.94 456.80 # 21925 354.86 337.12 387.69 376.06 379.94 368.54 21930 462.96 439.81 505.78 490.61 495.66 480.80 # 21930 363.79 345.60 397.44 385.51 389.49 377.81

Page 38: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 38Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

21931 471.23 447.67 514.82 499.38 504.53 489.39 21932 664.32 631.10 725.77 704.00 711.25 689.92 21933 741.47 704.40 810.06 785.76 793.86 770.04 21935 1,034.97 983.22 1,130.70 1,096.78 1,108.09 1,074.85 21936 1,425.21 1,353.95 1,557.04 1,510.33 1,525.90 1,480.12 22010 955.97 908.17 1,044.40 1,013.06 1,023.51 992.80 22015 941.46 894.39 1,028.55 997.69 1,007.98 977.74 22100 922.36 876.24 1,007.68 977.44 987.53 957.89 22101 851.61 809.03 930.38 902.47 911.78 884.42 22102 781.72 742.63 854.02 828.40 836.95 811.83 22103 143.05 135.90 156.29 151.59 153.16 148.56 22110 1,050.28 997.77 1,147.44 1,113.02 1,124.48 1,090.75 22112 1,109.06 1,053.61 1,211.65 1,175.30 1,187.42 1,151.79 22114 991.51 941.93 1,083.22 1,050.72 1,061.55 1,029.71 22116 144.54 137.31 157.91 153.17 154.74 150.11 22206 2,485.16 2,360.90 2,715.04 2,633.58 2,660.73 2,580.91 22207 2,436.33 2,314.51 2,661.69 2,581.83 2,608.45 2,530.20 22208 596.51 566.68 651.68 632.13 638.65 619.49 22210 1,807.26 1,716.90 1,974.44 1,915.20 1,934.94 1,876.89 22212 1,496.64 1,421.81 1,635.08 1,586.03 1,602.38 1,554.32 22214 1,500.44 1,425.42 1,639.23 1,590.06 1,606.45 1,558.26 22216 372.37 353.75 406.81 394.61 398.68 386.72 22220 1,613.97 1,533.27 1,763.26 1,710.36 1,727.99 1,676.15 22222 1,512.18 1,436.57 1,652.06 1,602.49 1,619.02 1,570.44 22224 1,595.15 1,515.39 1,742.70 1,690.42 1,707.84 1,656.61 22226 370.66 352.13 404.95 392.81 396.85 384.95 22310 304.38 289.16 332.53 322.56 325.89 316.11 # 22310 281.65 267.57 307.71 298.47 301.55 292.50 22315 873.63 829.95 954.44 925.81 935.35 907.29 # 22315 770.18 731.67 841.42 816.18 824.60 799.86 22318 1,666.26 1,582.95 1,820.39 1,765.78 1,783.98 1,730.46 22319 1,860.03 1,767.03 2,032.08 1,971.12 1,991.44 1,931.70 22325 1,451.35 1,378.78 1,585.60 1,538.03 1,553.88 1,507.27 22326 1,509.26 1,433.80 1,648.87 1,599.41 1,615.89 1,567.42 22327 1,516.16 1,440.35 1,656.40 1,606.71 1,623.27 1,574.58 22328 290.24 275.73 317.09 307.58 310.75 301.43 22505 132.46 125.84 144.72 140.37 141.82 137.56 22510 1,599.77 1,519.78 1,747.75 1,695.32 1,712.79 1,661.42 # 22510 442.06 419.96 482.95 468.46 473.29 459.09 22511 1,583.48 1,504.31 1,729.96 1,678.06 1,695.35 1,644.50 # 22511 414.57 393.84 452.92 439.32 443.85 430.54 22512 908.93 863.48 993.00 963.22 973.14 943.95 # 22512 213.44 202.77 233.19 226.19 228.52 221.67 22513 6,740.63 6,403.60 7,364.14 7,143.21 7,216.86 7,000.35 # 22513 528.03 501.63 576.87 559.57 565.34 548.38 22514 6,699.40 6,364.43 7,319.09 7,099.53 7,172.71 6,957.53 # 22514 491.09 466.54 536.52 520.42 525.79 510.01 22515 4,085.27 3,881.01 4,463.16 4,329.27 4,373.90 4,242.68 # 22515 229.62 218.14 250.86 243.34 245.85 238.48

Page 39: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 39Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

22532 1,798.97 1,709.02 1,965.37 1,906.41 1,926.07 1,868.29 22533 1,676.11 1,592.30 1,831.15 1,776.21 1,794.52 1,740.69 22534 369.64 351.16 403.83 391.72 395.76 383.89 22548 1,985.03 1,885.78 2,168.65 2,103.59 2,125.27 2,061.52 22551 1,740.07 1,653.07 1,901.03 1,844.00 1,863.01 1,807.12 22552 409.95 389.45 447.87 434.44 438.91 425.74 22554 1,269.71 1,206.22 1,387.15 1,345.53 1,359.42 1,318.62 22556 1,692.18 1,607.57 1,848.71 1,793.24 1,811.73 1,757.37 22558 1,557.48 1,479.61 1,701.55 1,650.50 1,667.52 1,617.50 22585 337.30 320.44 368.51 357.45 361.13 350.30 22586 1,934.49 1,837.77 2,113.44 2,050.04 2,071.16 2,009.04 22590 1,602.95 1,522.80 1,751.22 1,698.69 1,716.19 1,664.72 22595 1,528.53 1,452.10 1,669.92 1,619.82 1,636.52 1,587.43 22600 1,303.78 1,238.59 1,424.38 1,381.64 1,395.89 1,354.01 22610 1,275.34 1,211.57 1,393.31 1,351.50 1,365.44 1,324.48 22612 1,608.03 1,527.63 1,756.77 1,704.07 1,721.64 1,669.98 22614 402.42 382.30 439.65 426.45 430.85 417.92 22630 1,594.09 1,514.39 1,741.55 1,689.30 1,706.72 1,655.52 22632 331.01 314.46 361.63 350.78 354.40 343.77 22633 1,883.08 1,788.93 2,057.27 1,995.55 2,016.12 1,955.63 22634 510.50 484.98 557.73 540.99 546.57 530.17 22800 1,363.46 1,295.29 1,489.58 1,444.89 1,459.79 1,416.00 22802 2,127.89 2,021.50 2,324.73 2,254.99 2,278.23 2,209.89 22804 2,462.42 2,339.30 2,690.20 2,609.49 2,636.39 2,557.30 22808 1,874.66 1,780.93 2,048.07 1,986.63 2,007.11 1,946.89 22810 2,079.92 1,975.92 2,272.31 2,204.14 2,226.86 2,160.06 22812 2,215.96 2,105.16 2,420.93 2,348.31 2,372.52 2,301.35 22818 2,218.55 2,107.62 2,423.76 2,351.05 2,375.29 2,304.03 22819 2,775.67 2,636.89 3,032.42 2,941.45 2,971.77 2,882.61 22830 819.25 778.29 895.03 868.18 877.13 850.82 22840 780.92 741.87 853.15 827.55 836.08 811.00 22842 784.09 744.89 856.62 830.92 839.49 814.30 22843 838.74 796.80 916.32 888.84 897.99 871.06 22844 1,011.51 960.93 1,105.07 1,071.92 1,082.97 1,050.48 22845 751.77 714.18 821.31 796.66 804.89 780.74 22846 780.51 741.48 852.70 827.13 835.65 810.59 22847 853.20 810.54 932.12 904.15 913.48 886.08 22848 368.81 350.37 402.93 390.84 394.86 383.02 22849 1,315.76 1,249.97 1,437.47 1,394.34 1,408.72 1,366.45 22850 728.18 691.77 795.54 771.67 779.62 756.24 22852 696.69 661.86 761.14 738.30 745.91 723.53 22853 268.17 254.76 292.97 284.19 287.11 278.51 22854 347.14 329.78 379.25 367.87 371.66 360.51 22855 1,121.10 1,065.05 1,224.81 1,188.07 1,200.31 1,164.31 22856 1,661.11 1,578.05 1,814.76 1,760.32 1,778.46 1,725.12 22857 1,790.38 1,700.86 1,955.99 1,897.30 1,916.87 1,859.35 22858 513.58 487.90 561.09 544.25 549.86 533.36 22859 347.14 329.78 379.25 367.87 371.66 360.51 22861 1,999.85 1,899.86 2,184.84 2,119.29 2,141.14 2,076.90

Page 40: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 40Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

22862 2,152.56 2,044.93 2,351.67 2,281.12 2,304.63 2,235.50 22864 2,108.69 2,003.26 2,303.75 2,234.63 2,257.67 2,189.95 22865 2,062.47 1,959.35 2,253.25 2,185.66 2,208.18 2,141.94 22867 992.74 943.10 1,084.57 1,052.03 1,062.88 1,030.99 22868 250.55 238.02 273.72 265.51 268.25 260.20 22869 543.64 516.46 593.93 576.12 582.05 564.59 22870 145.95 138.65 159.45 154.66 156.26 151.57 22900 565.95 537.65 618.30 599.75 605.94 587.75 22901 669.99 636.49 731.96 710.01 717.32 695.81 22902 428.73 407.29 468.38 454.33 459.01 445.25 # 22902 329.23 312.77 359.69 348.90 352.49 341.92 22903 439.87 417.88 480.56 466.14 470.95 456.81 22904 1,059.33 1,006.36 1,157.31 1,122.60 1,134.16 1,100.15 22905 1,344.77 1,277.53 1,469.16 1,425.08 1,439.78 1,396.58 23000 561.30 533.24 613.23 594.83 600.97 582.94 # 23000 364.61 346.38 398.34 386.39 390.37 378.66 23020 685.19 650.93 748.57 726.11 733.60 711.59 23030 428.35 406.93 467.97 453.93 458.61 444.85 # 23030 254.73 241.99 278.29 269.94 272.72 264.55 23031 409.47 389.00 447.35 433.93 438.40 425.25 # 23031 217.40 206.53 237.51 230.38 232.76 225.77 23035 675.29 641.53 737.76 715.62 723.01 701.30 23040 712.96 677.31 778.91 755.54 763.32 740.43 23044 563.86 535.67 616.02 597.54 603.70 585.59 23065 212.41 201.79 232.06 225.10 227.41 220.60 # 23065 166.94 158.59 182.38 176.90 178.73 173.36 23066 539.74 512.75 589.66 571.98 577.88 560.53 # 23066 353.27 335.61 385.95 374.37 378.24 366.88 23071 419.24 398.28 458.02 444.28 448.86 435.39 23073 695.42 660.65 759.75 736.95 744.56 722.21 23075 456.15 433.34 498.34 483.39 488.37 473.72 # 23075 324.37 308.15 354.37 343.75 347.29 336.87 23076 537.81 510.92 587.56 569.93 575.81 558.53 23077 1,149.72 1,092.23 1,256.06 1,218.38 1,230.95 1,194.01 23078 1,444.57 1,372.34 1,578.19 1,530.85 1,546.62 1,500.23 23100 493.72 469.03 539.38 523.20 528.60 512.74 23101 442.60 420.47 483.54 469.04 473.87 459.66 23105 631.61 600.03 690.03 669.33 676.23 655.95 23106 476.33 452.51 520.39 504.77 509.98 494.67 23107 656.77 623.93 717.52 695.99 703.17 682.08 23120 578.14 549.23 631.61 612.66 618.99 600.42 23125 691.37 656.80 755.32 732.67 740.21 718.01 23130 603.68 573.50 659.53 639.75 646.33 626.95 23140 534.93 508.18 584.41 566.87 572.72 555.53 23145 682.64 648.51 745.79 723.41 730.87 708.94 23146 610.29 579.78 666.75 646.75 653.41 633.81 23150 653.84 621.15 714.32 692.90 700.04 679.04 23155 785.63 746.35 858.30 832.55 841.13 815.90 23156 665.29 632.03 726.83 705.03 712.30 690.93

Page 41: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 41Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

23170 555.62 527.84 607.02 588.80 594.87 577.02 23172 549.90 522.41 600.77 582.75 588.75 571.10 23174 753.42 715.75 823.11 798.42 806.66 782.45 23180 657.86 624.97 718.72 697.15 704.34 683.22 23182 652.33 619.71 712.67 691.29 698.42 677.47 23184 727.93 691.53 795.26 771.40 779.36 755.96 23190 566.77 538.43 619.19 600.62 606.81 588.60 23195 751.58 714.00 821.10 796.47 804.68 780.54 23200 1,514.38 1,438.66 1,654.46 1,604.83 1,621.37 1,572.73 23210 1,774.80 1,686.06 1,938.97 1,880.80 1,900.19 1,843.19 23220 1,956.47 1,858.65 2,137.45 2,073.32 2,094.70 2,031.85 23330 238.85 226.91 260.95 253.12 255.73 248.06 # 23330 152.53 144.90 166.64 161.63 163.30 158.40 23333 447.39 425.02 488.77 474.11 479.00 464.62 23334 1,075.98 1,022.18 1,175.51 1,140.24 1,152.00 1,117.43 23335 1,282.60 1,218.47 1,401.24 1,359.21 1,373.22 1,332.02 23350 125.10 118.85 136.68 132.57 133.94 129.92 # 23350 51.63 49.05 56.41 54.72 55.28 53.62 23395 1,279.98 1,215.98 1,398.38 1,356.43 1,370.41 1,329.30 23397 1,142.44 1,085.32 1,248.12 1,210.67 1,223.15 1,186.46 23400 942.64 895.51 1,029.84 998.94 1,009.24 978.96 23405 618.94 587.99 676.19 655.90 662.66 642.78 23406 766.76 728.42 837.68 812.56 820.93 796.31 23410 818.21 777.30 893.90 867.08 876.01 849.74 23412 848.37 805.95 926.84 899.04 908.30 881.05 23415 692.53 657.90 756.59 733.88 741.45 719.21 23420 965.48 917.21 1,054.79 1,023.14 1,033.70 1,002.69 23430 741.00 703.95 809.54 785.25 793.35 769.55 23440 751.57 713.99 821.09 796.46 804.67 780.53 23450 948.54 901.11 1,036.28 1,005.19 1,015.55 985.09 23455 994.61 944.88 1,086.61 1,054.01 1,064.88 1,032.93 23460 1,086.53 1,032.20 1,187.03 1,151.41 1,163.29 1,128.39 23462 1,056.29 1,003.48 1,154.00 1,119.39 1,130.92 1,097.00 23465 1,110.65 1,055.12 1,213.39 1,176.99 1,189.12 1,153.45 23466 1,115.95 1,060.15 1,219.17 1,182.60 1,194.79 1,158.95 23470 1,202.63 1,142.50 1,313.88 1,274.46 1,287.60 1,248.98 23472 1,460.52 1,387.49 1,595.61 1,547.75 1,563.70 1,516.79 23473 1,632.05 1,550.45 1,783.02 1,729.53 1,747.36 1,694.94 23474 1,763.66 1,675.48 1,926.80 1,869.00 1,888.27 1,831.63 23480 817.33 776.46 892.93 866.15 875.07 848.83 23485 951.44 903.87 1,039.45 1,008.26 1,018.66 988.10 23490 838.18 796.27 915.71 888.24 897.39 870.47 23491 1,009.58 959.10 1,102.97 1,069.88 1,080.91 1,048.48 23500 212.20 201.59 231.83 224.87 227.19 220.37 # 23500 215.50 204.73 235.44 228.38 230.74 223.81 23505 342.13 325.02 373.77 362.56 366.30 355.30 # 23505 324.01 307.81 353.98 343.37 346.90 336.50 23515 715.69 679.91 781.90 758.44 766.26 743.27 23520 222.52 211.39 243.10 235.81 238.23 231.09

Page 42: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 42Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 23520 225.82 214.53 246.71 239.30 241.78 234.52 23525 362.71 344.57 396.26 384.36 388.33 376.68 # 23525 337.02 320.17 368.20 357.14 360.84 350.00 23530 565.84 537.55 618.18 599.63 605.82 587.64 23532 614.74 584.00 671.60 651.45 658.17 638.42 23540 217.94 207.04 238.10 230.95 233.34 226.33 # 23540 221.24 210.18 241.71 234.45 236.88 229.76 23545 326.96 310.61 357.20 346.48 350.06 339.55 # 23545 298.95 284.00 326.60 316.80 320.07 310.47 23550 555.82 528.03 607.23 589.02 595.09 577.24 23552 650.31 617.79 710.46 689.15 696.24 675.36 23570 225.67 214.39 246.55 239.15 241.62 234.37 # 23570 232.59 220.96 254.10 246.48 249.02 241.55 23575 388.85 369.41 424.82 412.08 416.32 403.83 # 23575 365.79 347.50 399.63 387.64 391.63 379.89 23585 978.64 929.71 1,069.17 1,037.09 1,047.79 1,016.35 23600 316.19 300.38 345.44 335.08 338.53 328.37 # 23600 298.73 283.79 326.36 316.57 319.83 310.24 23605 452.21 429.60 494.04 479.22 484.16 469.64 # 23605 415.97 395.17 454.45 440.81 445.36 431.99 23615 880.66 836.63 962.12 933.26 942.89 914.60 23616 1,242.64 1,180.51 1,357.59 1,316.85 1,330.44 1,290.52 23620 260.91 247.86 285.04 276.48 279.34 270.95 # 23620 249.05 236.60 272.09 263.93 266.65 258.65 23625 368.44 350.02 402.52 390.45 394.47 382.64 # 23625 344.06 326.86 375.89 364.61 368.37 357.32 23630 775.02 736.27 846.71 821.31 829.77 804.89 23650 305.83 290.54 334.12 324.09 327.44 317.61 # 23650 282.11 268.00 308.20 298.95 302.04 292.97 23655 394.54 374.81 431.03 418.11 422.41 409.75 23660 576.41 547.59 629.73 610.83 617.14 598.62 23665 415.58 394.80 454.02 440.40 444.94 431.60 # 23665 388.23 368.82 424.14 411.42 415.66 403.19 23670 871.95 828.35 952.60 924.03 933.55 905.54 23675 537.51 510.63 587.22 569.61 575.48 558.21 # 23675 492.38 467.76 537.92 521.79 527.16 511.36 23680 923.19 877.03 1,008.58 978.33 988.41 958.77 23700 194.53 184.80 212.52 206.15 208.27 202.02 23800 1,015.39 964.62 1,109.31 1,076.03 1,087.13 1,054.52 23802 1,277.35 1,213.48 1,395.50 1,353.64 1,367.59 1,326.57 23900 1,391.68 1,322.10 1,520.42 1,474.81 1,490.01 1,445.31 23920 1,103.21 1,048.05 1,205.26 1,169.10 1,181.15 1,145.72 23921 459.74 436.75 502.26 487.20 492.22 477.46 23930 344.04 326.84 375.87 364.58 368.35 357.29 # 23930 215.55 204.77 235.49 228.42 230.77 223.86 23931 275.54 261.76 301.02 292.00 295.00 286.15 # 23931 157.27 149.41 171.82 166.67 168.38 163.33 23935 500.37 475.35 546.65 530.25 535.72 519.65 24000 472.65 449.02 516.37 500.88 506.05 490.87

Page 43: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 43Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

24006 707.12 671.76 772.52 749.35 757.07 734.37 24065 248.09 235.69 271.04 262.91 265.63 257.66 # 24065 166.39 158.07 181.78 176.33 178.15 172.80 24066 606.54 576.21 662.64 642.76 649.39 629.90 # 24066 412.82 392.18 451.01 437.47 441.99 428.72 24071 405.24 384.98 442.73 429.44 433.87 420.85 24073 693.39 658.72 757.53 734.80 742.38 720.11 24075 476.31 452.49 520.36 504.76 509.96 494.66 # 24075 327.72 311.33 358.03 347.29 350.87 340.34 24076 540.57 513.54 590.57 572.85 578.76 561.40 24077 1,040.18 988.17 1,136.40 1,102.30 1,113.67 1,080.25 24079 1,336.14 1,269.33 1,459.73 1,415.94 1,430.53 1,387.62 24100 408.75 388.31 446.56 433.16 437.62 424.50 24101 492.22 467.61 537.75 521.62 527.00 511.19 24102 611.35 580.78 667.90 647.86 654.53 634.90 24105 343.42 326.25 375.19 363.93 367.69 356.65 24110 577.25 548.39 630.65 611.73 618.03 599.50 24115 720.99 684.94 787.68 764.05 771.93 748.77 24116 860.64 817.61 940.25 912.04 921.45 893.80 24120 523.28 497.12 571.69 554.54 560.26 543.46 24125 608.53 578.10 664.82 644.87 651.52 631.97 24126 638.17 606.26 697.20 676.28 683.25 662.76 24130 501.89 476.80 548.32 531.88 537.35 521.24 24134 743.80 706.61 812.60 788.22 796.35 772.46 24136 590.81 561.27 645.46 626.09 632.55 613.57 24138 666.80 633.46 728.48 706.63 713.91 692.50 24140 698.75 663.81 763.38 740.49 748.11 725.67 24145 580.32 551.30 634.00 614.97 621.31 602.67 24147 616.02 585.22 673.00 652.81 659.55 639.76 24149 1,169.15 1,110.69 1,277.29 1,238.98 1,251.75 1,214.19 24150 1,563.22 1,485.06 1,707.82 1,656.59 1,673.66 1,623.46 24152 1,338.14 1,271.23 1,461.91 1,418.05 1,432.68 1,389.69 24155 851.91 809.31 930.71 902.78 912.09 884.73 24160 1,266.83 1,203.49 1,384.01 1,342.50 1,356.33 1,315.65 24164 726.89 690.55 794.13 770.30 778.25 754.89 24200 200.22 190.21 218.74 212.18 214.37 207.93 # 24200 137.95 131.05 150.71 146.19 147.69 143.27 24201 531.62 505.04 580.80 563.37 569.18 552.10 # 24201 359.32 341.35 392.55 380.78 384.70 373.16 24220 152.82 145.18 166.96 161.94 163.62 158.70 # 24220 69.47 66.00 75.90 73.62 74.38 72.15 24300 405.55 385.27 443.06 429.77 434.19 421.18 24301 745.60 708.32 814.57 790.13 798.27 774.33 24305 570.91 542.36 623.71 605.00 611.24 592.91 24310 463.25 440.09 506.10 490.92 495.98 481.10 24320 761.17 723.11 831.58 806.63 814.95 790.50 24330 712.15 676.54 778.02 754.68 762.46 739.59 24331 772.19 733.58 843.62 818.31 826.75 801.94 24332 607.18 576.82 663.34 643.45 650.07 630.58

Page 44: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 44Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

24340 607.50 577.13 663.70 643.79 650.43 630.91 24341 738.65 701.72 806.98 782.77 790.84 767.12 24342 771.65 733.07 843.03 817.74 826.17 801.39 24343 700.49 665.47 765.29 742.34 749.98 727.49 24344 1,087.05 1,032.70 1,187.61 1,151.98 1,163.86 1,128.94 24345 697.16 662.30 761.65 738.79 746.41 724.02 24346 1,094.14 1,039.43 1,195.34 1,159.49 1,171.44 1,136.30 24357 416.44 395.62 454.96 441.31 445.87 432.49 24358 516.40 490.58 564.17 547.24 552.89 536.29 24359 654.65 621.92 715.21 693.75 700.90 679.87 24360 897.07 852.22 980.05 950.65 960.46 931.64 24361 1,000.76 950.72 1,093.33 1,060.53 1,071.47 1,039.32 24362 1,058.90 1,005.96 1,156.85 1,122.15 1,133.72 1,099.70 24363 1,459.19 1,386.23 1,594.16 1,546.34 1,562.29 1,515.41 24365 634.29 602.58 692.97 672.18 679.11 658.73 24366 676.48 642.66 739.06 716.89 724.28 702.55 24370 1,555.25 1,477.49 1,699.11 1,648.15 1,665.13 1,615.19 24371 1,790.42 1,700.90 1,956.04 1,897.35 1,916.91 1,859.40 24400 814.62 773.89 889.97 863.27 872.17 846.01 24410 1,056.32 1,003.50 1,154.03 1,119.41 1,130.94 1,097.02 24420 981.29 932.23 1,072.06 1,039.90 1,050.63 1,019.10 24430 1,056.02 1,003.22 1,153.70 1,119.09 1,130.63 1,096.71 24435 1,072.25 1,018.64 1,171.44 1,136.29 1,148.01 1,113.57 24470 666.47 633.15 728.12 706.28 713.56 692.16 24495 534.40 507.68 583.83 566.32 572.16 554.99 24498 861.49 818.42 941.18 912.95 922.36 894.69 24500 347.58 330.20 379.73 368.33 372.14 360.96 # 24500 317.93 302.03 347.33 336.92 340.39 330.18 24505 486.99 462.64 532.04 516.07 521.40 505.75 # 24505 442.51 420.38 483.44 468.94 473.77 459.55 24515 872.46 828.84 953.17 924.57 934.10 906.07 24516 856.94 814.09 936.20 908.12 917.48 889.96 24530 369.34 350.87 403.50 391.39 395.43 383.56 # 24530 336.06 319.26 367.15 356.13 359.80 349.01 24535 601.76 571.67 657.42 637.70 644.28 624.94 # 24535 558.60 530.67 610.27 591.96 598.07 580.13 24538 739.28 702.32 807.67 783.44 791.51 767.77 24545 926.45 880.13 1,012.15 981.79 991.91 962.16 24546 1,037.39 985.52 1,133.35 1,099.34 1,110.68 1,077.35 24560 310.39 294.87 339.10 328.92 332.32 322.35 # 24560 279.75 265.76 305.62 296.46 299.51 290.52 24565 519.09 493.14 567.11 550.10 555.77 539.10 # 24565 478.90 454.96 523.20 507.51 512.74 497.35 24566 710.75 675.21 776.49 753.19 760.97 738.13 24575 728.27 691.86 795.64 771.77 779.72 756.33 24576 328.86 312.42 359.28 348.51 352.10 341.54 # 24576 296.90 282.06 324.37 314.64 317.88 308.35 24577 532.49 505.87 581.75 564.29 570.11 553.01 # 24577 490.98 466.43 536.39 520.31 525.67 509.90

Page 45: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 45Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

24579 830.82 789.28 907.67 880.44 889.51 862.83 24582 800.53 760.50 874.58 848.34 857.08 831.38 24586 1,080.82 1,026.78 1,180.80 1,145.38 1,157.18 1,122.47 24587 1,082.99 1,028.84 1,183.17 1,147.67 1,159.50 1,124.71 24600 355.83 338.04 388.75 377.09 380.97 369.54 # 24600 327.49 311.12 357.79 347.06 350.64 340.11 24605 461.96 438.86 504.69 489.54 494.59 479.76 24615 708.16 672.75 773.66 750.46 758.20 735.45 24620 542.22 515.11 592.38 574.61 580.53 563.12 24635 667.08 633.73 728.79 706.93 714.22 692.79 24640 113.85 108.16 124.38 120.66 121.90 118.24 # 24640 84.86 80.62 92.71 89.93 90.86 88.14 24650 252.78 240.14 276.16 267.88 270.64 262.52 # 24650 233.01 221.36 254.56 246.93 249.47 241.99 24655 424.48 403.26 463.75 449.83 454.47 440.84 # 24655 388.24 368.83 424.15 411.44 415.67 403.20 24665 646.00 613.70 705.76 684.58 691.64 670.89 24666 728.05 691.65 795.40 771.54 779.49 756.10 24670 281.44 267.37 307.48 298.25 301.32 292.28 # 24670 255.42 242.65 279.05 270.68 273.47 265.26 24675 440.78 418.74 481.55 467.11 471.93 457.77 # 24675 404.21 384.00 441.60 428.35 432.77 419.78 24685 647.10 614.75 706.96 685.76 692.83 672.04 24800 826.11 784.80 902.52 875.45 884.47 857.93 24802 982.99 933.84 1,073.92 1,041.69 1,052.43 1,020.86 24900 727.75 691.36 795.06 771.21 779.16 755.79 24920 717.52 681.64 783.89 760.37 768.21 745.17 24925 517.85 491.96 565.75 548.78 554.44 537.81 24930 757.24 719.38 827.29 802.47 810.74 786.42 24931 803.94 763.74 878.30 851.95 860.74 834.91 24935 980.20 931.19 1,070.87 1,038.74 1,049.46 1,017.97 25000 329.00 312.55 359.43 348.65 352.25 341.68 25001 336.69 319.86 367.84 356.80 360.48 349.66 25020 562.12 534.01 614.11 595.69 601.83 583.77 25023 1,086.32 1,032.00 1,186.80 1,151.20 1,163.06 1,128.17 25024 771.17 732.61 842.50 817.22 825.65 800.88 25025 1,223.79 1,162.60 1,336.99 1,296.88 1,310.25 1,270.95 25028 512.17 486.56 559.54 542.75 548.35 531.90 25031 357.31 339.44 390.36 378.65 382.55 371.07 25035 576.95 548.10 630.32 611.41 617.71 599.18 25040 557.14 529.28 608.67 590.41 596.49 578.60 25065 244.77 232.53 267.41 259.38 262.06 254.20 # 25065 161.42 153.35 176.35 171.06 172.82 167.65 25066 354.35 336.63 387.12 375.51 379.39 368.00 25071 424.31 403.09 463.55 449.65 454.28 440.66 25073 530.17 503.66 579.21 561.83 567.63 550.60 25075 462.37 439.25 505.14 489.98 495.04 480.18 # 25075 313.13 297.47 342.09 331.83 335.25 325.20 25076 513.13 487.47 560.59 543.78 549.38 532.90

Page 46: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 46Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

25077 889.64 845.16 971.93 942.78 952.50 923.92 25078 1,169.41 1,110.94 1,277.58 1,239.25 1,252.03 1,214.47 25085 442.32 420.20 483.23 468.73 473.57 459.36 25100 331.94 315.34 362.64 351.76 355.38 344.72 25101 397.33 377.46 434.08 421.06 425.40 412.64 25105 475.51 451.73 519.49 503.91 509.11 493.83 25107 608.19 577.78 664.45 644.52 651.15 631.63 25109 532.02 505.42 581.23 563.80 569.61 552.52 25110 336.01 319.21 367.09 356.07 359.75 348.96 25111 314.15 298.44 343.21 332.91 336.34 326.26 25112 381.01 361.96 416.25 403.77 407.93 395.69 25115 752.27 714.66 821.86 797.20 805.43 781.26 25116 592.48 562.86 647.29 627.87 634.34 615.31 25118 375.12 356.36 409.81 397.52 401.61 389.57 25119 487.06 462.71 532.12 516.15 521.48 505.83 25120 490.91 466.36 536.31 520.23 525.58 509.82 25125 582.21 553.10 636.07 616.99 623.35 604.65 25126 583.94 554.74 637.95 618.82 625.20 606.44 25130 438.80 416.86 479.39 465.00 469.80 455.70 25135 552.18 524.57 603.26 585.15 591.19 573.45 25136 478.65 454.72 522.93 507.24 512.47 497.10 25145 511.73 486.14 559.06 542.29 547.88 531.45 25150 558.94 530.99 610.64 592.32 598.43 580.47 25151 576.90 548.06 630.27 611.36 617.67 599.14 25170 1,483.03 1,408.88 1,620.21 1,571.60 1,587.81 1,540.17 25210 480.69 456.66 525.16 509.40 514.66 499.22 25215 611.70 581.12 668.29 648.24 654.93 635.28 25230 426.55 405.22 466.00 452.02 456.69 442.98 25240 421.89 400.80 460.92 447.10 451.70 438.15 25246 155.90 148.11 170.33 165.22 166.92 161.92 # 25246 76.17 72.36 83.21 80.72 81.55 79.11 25248 407.14 386.78 444.80 431.46 435.90 422.83 25250 524.71 498.47 573.24 556.05 561.78 544.93 25251 714.80 679.06 780.92 757.49 765.30 742.35 25259 404.87 384.63 442.32 429.05 433.48 420.47 25260 621.95 590.85 679.48 659.09 665.88 645.91 25263 617.41 586.54 674.52 654.28 661.03 641.19 25265 742.97 705.82 811.69 787.35 795.46 771.60 25270 483.26 459.10 527.97 512.13 517.41 501.88 25272 546.83 519.49 597.41 579.50 585.47 567.90 25274 655.77 622.98 716.43 694.93 702.10 681.03 25275 663.94 630.74 725.35 703.59 710.85 689.52 25280 557.27 529.41 608.82 590.56 596.64 578.75 25290 430.32 408.80 470.12 456.02 460.71 446.90 25295 518.23 492.32 566.17 549.18 554.84 538.20 25300 673.96 640.26 736.30 714.21 721.57 699.92 25301 637.39 605.52 696.35 675.45 682.42 661.94 25310 612.78 582.14 669.46 649.38 656.08 636.40 25312 712.16 676.55 778.03 754.69 762.47 739.60

Page 47: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 47Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

25315 767.52 729.14 838.51 813.36 821.74 797.09 25316 907.48 862.11 991.43 961.69 971.60 942.46 25320 976.60 927.77 1,066.94 1,034.93 1,045.59 1,014.23 25332 836.71 794.87 914.10 886.67 895.82 868.94 25335 940.29 893.28 1,027.27 996.45 1,006.72 976.52 25337 883.19 839.03 964.88 935.94 945.59 917.22 25350 667.67 634.29 729.43 707.55 714.84 693.39 25355 757.00 719.15 827.02 802.22 810.49 786.17 25360 647.53 615.15 707.42 686.21 693.28 672.49 25365 912.36 866.74 996.75 966.85 976.82 947.52 25370 1,003.32 953.15 1,096.12 1,063.24 1,074.20 1,041.98 25375 950.97 903.42 1,038.93 1,007.77 1,018.15 987.61 25390 765.56 727.28 836.37 811.28 819.64 795.05 25391 993.99 944.29 1,085.93 1,053.35 1,064.21 1,032.29 25392 1,017.04 966.19 1,111.12 1,077.78 1,088.90 1,056.23 25393 1,117.98 1,062.08 1,221.39 1,184.75 1,196.97 1,161.06 25394 778.33 739.41 850.32 824.81 833.31 808.32 25400 798.97 759.02 872.87 846.69 855.42 829.76 25405 1,034.10 982.40 1,129.76 1,095.87 1,107.16 1,073.95 25415 965.28 917.02 1,054.57 1,022.94 1,033.48 1,002.48 25420 1,161.18 1,103.12 1,268.59 1,230.53 1,243.22 1,205.92 25425 960.70 912.67 1,049.57 1,018.08 1,028.58 997.72 25426 1,092.03 1,037.43 1,193.04 1,157.26 1,169.18 1,134.11 25430 726.55 690.22 793.75 769.94 777.88 754.54 25431 781.98 742.88 854.31 828.68 837.22 812.11 25440 764.48 726.26 835.20 810.14 818.49 793.94 25441 930.08 883.58 1,016.12 985.63 995.80 965.92 25442 800.49 760.47 874.54 848.31 857.05 831.35 25443 770.96 732.41 842.27 817.01 825.42 800.66 25444 813.32 772.65 888.55 861.89 870.78 844.65 25445 717.51 681.63 783.87 760.36 768.20 745.15 25446 1,171.22 1,112.66 1,279.56 1,241.17 1,253.97 1,216.34 25447 821.78 780.69 897.79 870.86 879.84 853.44 25449 1,029.53 978.05 1,124.76 1,091.02 1,102.26 1,069.20 25450 516.13 490.32 563.87 546.95 552.59 536.02 25455 720.62 684.59 787.28 763.66 771.54 748.39 25490 714.75 679.01 780.86 757.44 765.24 742.29 25491 735.99 699.19 804.07 779.94 787.99 764.35 25492 901.38 856.31 984.76 955.21 965.06 936.11 25500 264.92 251.67 289.42 280.74 283.64 275.13 # 25500 244.16 231.95 266.74 258.74 261.41 253.56 25505 487.62 463.24 532.73 516.74 522.08 506.40 # 25505 448.74 426.30 490.25 475.54 480.44 466.03 25515 662.74 629.60 724.04 702.32 709.56 688.28 25520 553.72 526.03 604.93 586.79 592.84 575.06 # 25520 527.04 500.69 575.79 558.52 564.28 547.35 25525 779.25 740.29 851.33 825.79 834.30 809.28 25526 946.49 899.17 1,034.05 1,003.02 1,013.37 982.96 25530 252.90 240.26 276.30 268.01 270.77 262.65

Page 48: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 48Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 25530 230.17 218.66 251.46 243.92 246.43 239.04 25535 476.63 452.80 520.72 505.10 510.30 495.01 # 25535 443.35 421.18 484.36 469.82 474.67 460.43 25545 616.56 585.73 673.59 653.38 660.12 640.32 25560 268.84 255.40 293.71 284.90 287.83 279.21 # 25560 244.46 232.24 267.08 259.06 261.74 253.87 25565 505.53 480.25 552.29 535.72 541.25 525.00 # 25565 459.41 436.44 501.91 486.85 491.87 477.11 25574 668.10 634.70 729.91 708.01 715.31 693.85 25575 895.81 851.02 978.67 949.31 959.10 930.33 25600 316.69 300.86 345.99 335.60 339.07 328.89 # 25600 300.22 285.21 327.99 318.15 321.44 311.79 25605 531.65 505.07 580.83 563.41 569.22 552.14 # 25605 502.00 476.90 548.44 531.98 537.46 521.34 25606 655.28 622.52 715.90 694.42 701.58 680.52 25607 727.98 691.58 795.32 771.45 779.41 756.02 25608 817.91 777.01 893.56 866.76 875.69 849.42 25609 1,041.24 989.18 1,137.56 1,103.43 1,114.81 1,081.36 25622 294.59 279.86 321.84 312.18 315.40 305.93 # 25622 269.88 256.39 294.85 286.01 288.95 280.29 25624 463.90 440.71 506.82 491.61 496.69 481.78 # 25624 425.03 403.78 464.35 450.42 455.06 441.42 25628 714.98 679.23 781.11 757.68 765.50 742.52 25630 296.43 281.61 323.85 314.13 317.38 307.86 # 25630 273.69 260.01 299.01 290.04 293.03 284.25 25635 409.63 389.15 447.52 434.10 438.58 425.42 # 25635 369.11 350.65 403.25 391.15 395.19 383.33 25645 558.52 530.59 610.18 591.87 597.98 580.04 25650 309.89 294.40 338.56 328.41 331.79 321.84 # 25650 291.77 277.18 318.76 309.19 312.39 303.00 25651 475.40 451.63 519.37 503.79 508.99 493.72 25652 617.35 586.48 674.45 654.22 660.96 641.14 25660 403.46 383.29 440.78 427.56 431.96 419.00 25670 600.50 570.48 656.05 636.38 642.93 623.65 25671 523.18 497.02 571.57 554.43 560.14 543.34 25675 421.48 400.41 460.47 446.66 451.26 437.72 # 25675 385.89 366.60 421.59 408.94 413.16 400.76 25676 622.31 591.19 679.87 659.47 666.28 646.28 25680 472.66 449.03 516.38 500.89 506.06 490.88 25685 729.08 692.63 796.52 772.63 780.60 757.17 25690 464.63 441.40 507.61 492.38 497.46 482.54 25695 628.31 596.89 686.42 665.83 672.69 652.51 25800 727.15 690.79 794.41 770.58 778.52 755.17 25805 841.36 799.29 919.18 891.61 900.80 873.77 25810 862.73 819.59 942.53 914.25 923.68 895.97 25820 606.64 576.31 662.76 642.87 649.50 630.02 25825 749.10 711.65 818.40 793.85 802.03 777.96 25830 927.61 881.23 1,013.41 983.01 993.15 963.34 25900 703.45 668.28 768.52 745.46 753.15 730.56

Page 49: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 49Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

25905 698.14 663.23 762.71 739.83 747.47 725.03 25907 603.82 573.63 659.67 639.88 646.48 627.08 25909 678.36 644.44 741.11 718.88 726.28 704.50 25915 1,019.15 968.19 1,113.42 1,080.01 1,091.15 1,058.41 25920 689.88 655.39 753.70 731.09 738.62 716.47 25922 506.55 481.22 553.40 536.80 542.34 526.06 25924 658.54 625.61 719.45 697.87 705.07 683.91 25927 792.16 752.55 865.43 839.47 848.13 822.68 25929 567.58 539.20 620.08 601.47 607.68 589.44 25931 712.20 676.59 778.08 754.73 762.52 739.63 26010 252.77 240.13 276.15 267.87 270.63 262.51 # 26010 134.50 127.78 146.95 142.54 144.00 139.69 26011 372.44 353.82 406.89 394.69 398.75 386.80 # 26011 182.01 172.91 198.85 192.88 194.87 189.03 26020 425.88 404.59 465.28 451.32 455.98 442.29 26025 415.64 394.86 454.09 440.46 445.00 431.65 26030 486.54 462.21 531.54 515.59 520.92 505.28 26034 531.86 505.27 581.06 563.63 569.43 552.36 26035 849.98 807.48 928.60 900.75 910.03 882.73 26037 560.37 532.35 612.20 593.84 599.96 581.96 26040 305.53 290.25 333.79 323.77 327.12 317.30 26045 461.56 438.48 504.25 489.13 494.17 479.34 26055 533.06 506.41 582.37 564.90 570.72 553.61 # 26055 302.77 287.63 330.77 320.85 324.16 314.43 26060 255.11 242.35 278.70 270.34 273.13 264.94 26070 310.27 294.76 338.97 328.81 332.19 322.23 26075 327.19 310.83 357.45 346.74 350.30 339.80 26080 382.88 363.74 418.30 405.75 409.94 397.64 26100 318.60 302.67 348.07 337.63 341.11 330.88 26105 327.78 311.39 358.10 347.36 350.93 340.41 26110 315.79 300.00 345.00 334.65 338.10 327.96 26111 413.55 392.87 451.80 438.24 442.76 429.48 26113 543.33 516.16 593.58 575.78 581.72 564.27 26115 486.22 461.91 531.20 515.26 520.57 504.95 # 26115 327.42 311.05 357.71 346.98 350.55 340.04 26116 520.89 494.85 569.08 552.00 557.69 540.96 26117 741.66 704.58 810.27 785.96 794.06 770.24 26118 1,050.64 998.11 1,147.83 1,113.40 1,124.87 1,091.13 26121 590.61 561.08 645.24 625.89 632.34 613.38 26123 826.23 784.92 902.66 875.58 884.60 858.06 26125 276.91 263.06 302.52 293.45 296.47 287.58 26130 455.61 432.83 497.75 482.83 487.80 473.17 26135 543.21 516.05 593.46 575.66 581.59 564.14 26140 497.41 472.54 543.42 527.11 532.55 516.57 26145 506.26 480.95 553.09 536.50 542.03 525.77 26160 549.44 521.97 600.27 582.26 588.26 570.61 # 26160 326.73 310.39 356.95 346.24 349.81 339.32 26170 399.42 379.45 436.37 423.28 427.64 414.82 26180 435.51 413.73 475.79 461.52 466.28 452.28

Page 50: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 50Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

26185 534.73 507.99 584.19 566.66 572.50 555.34 26200 442.98 420.83 483.95 469.44 474.27 460.06 26205 590.97 561.42 645.63 626.27 632.72 613.74 26210 435.24 413.48 475.50 461.24 465.99 452.02 26215 553.01 525.36 604.16 586.04 592.08 574.32 26230 493.48 468.81 539.13 522.96 528.34 512.51 26235 486.09 461.79 531.06 515.13 520.43 504.83 26236 434.42 412.70 474.61 460.37 465.12 451.16 26250 1,074.03 1,020.33 1,173.38 1,138.18 1,149.91 1,115.42 26260 800.46 760.44 874.51 848.27 857.01 831.31 26262 623.81 592.62 681.51 661.07 667.89 647.84 26320 340.68 323.65 372.20 361.03 364.76 353.81 26340 323.07 306.92 352.96 342.37 345.90 335.52 26341 95.75 90.96 104.60 101.46 102.51 99.44 # 26341 74.01 70.31 80.86 78.43 79.24 76.87 26350 682.81 648.67 745.97 723.59 731.06 709.12 26352 770.98 732.43 842.29 817.03 825.45 800.69 26356 781.66 742.58 853.97 828.35 836.89 811.77 26357 876.31 832.49 957.36 928.65 938.22 910.08 26358 964.75 916.51 1,053.99 1,022.36 1,032.91 1,001.91 26370 729.67 693.19 797.17 773.25 781.23 757.78 26372 832.53 790.90 909.54 882.25 891.34 864.60 26373 804.16 763.95 878.54 852.18 860.97 835.14 26390 813.22 772.56 888.44 861.79 870.68 844.55 26392 941.22 894.16 1,028.28 997.44 1,007.72 977.49 26410 540.76 513.72 590.78 573.06 578.97 561.59 26412 665.98 632.68 727.58 705.76 713.03 691.64 26415 659.59 626.61 720.60 698.98 706.19 685.00 26416 839.05 797.10 916.67 889.17 898.33 871.39 26418 551.24 523.68 602.23 584.17 590.19 572.48 26420 679.92 645.92 742.81 720.52 727.95 706.11 26426 494.39 469.67 540.12 523.92 529.32 513.44 26428 713.00 677.35 778.95 755.58 763.37 740.47 26432 477.01 453.16 521.13 505.51 510.72 495.40 26433 507.55 482.17 554.50 537.86 543.41 527.10 26434 622.60 591.47 680.19 659.79 666.59 646.60 26437 599.00 569.05 654.41 634.78 641.32 622.08 26440 592.11 562.50 646.88 627.47 633.94 614.93 26442 932.60 885.97 1,018.87 988.30 998.49 968.53 26445 549.80 522.31 600.66 582.64 588.64 570.99 26449 685.05 650.80 748.42 725.97 733.45 711.45 26450 389.70 370.22 425.75 412.98 417.24 404.72 26455 387.25 367.89 423.07 410.38 414.61 402.17 26460 378.09 359.19 413.07 400.67 404.81 392.66 26471 591.28 561.72 645.98 626.60 633.06 614.07 26474 576.83 547.99 630.19 611.28 617.58 599.06 26476 554.60 526.87 605.90 587.72 593.78 575.97 26477 559.15 531.19 610.87 592.54 598.66 580.69 26478 595.91 566.11 651.03 631.50 638.01 618.87

Page 51: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 51Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

26479 590.45 560.93 645.07 625.72 632.17 613.20 26480 721.47 685.40 788.21 764.57 772.44 749.27 26483 810.85 770.31 885.86 859.28 868.14 842.10 26485 776.48 737.66 848.31 822.86 831.35 806.40 26489 902.75 857.61 986.25 956.66 966.53 937.53 26490 772.69 734.06 844.17 818.85 827.29 802.47 26492 858.48 815.56 937.89 909.75 919.14 891.56 26494 756.87 719.03 826.88 802.08 810.35 786.04 26496 831.89 790.30 908.85 881.58 890.66 863.95 26497 842.37 800.25 920.29 892.68 901.89 874.83 26498 1,108.23 1,052.82 1,210.74 1,174.43 1,186.52 1,150.94 26499 794.94 755.19 868.47 842.41 851.10 825.56 26500 601.08 571.03 656.68 636.99 643.55 624.24 26502 685.66 651.38 749.09 726.62 734.10 712.08 26508 606.77 576.43 662.89 643.01 649.64 630.15 26510 571.44 542.87 624.30 605.57 611.81 593.46 26516 675.86 642.07 738.38 716.23 723.61 701.90 26517 759.44 721.47 829.69 804.80 813.10 788.70 26518 799.10 759.15 873.02 846.84 855.57 829.90 26520 622.57 591.44 680.16 659.76 666.55 646.56 26525 622.96 591.81 680.58 660.17 666.97 646.97 26530 531.22 504.66 580.36 562.95 568.76 551.69 26531 616.88 586.04 673.95 653.73 660.47 640.65 26535 416.79 395.95 455.34 441.68 446.23 432.85 26536 679.77 645.78 742.65 720.37 727.79 705.96 26540 633.31 601.64 691.89 671.13 678.05 657.71 26541 775.81 737.02 847.57 822.15 830.62 805.70 26542 654.25 621.54 714.77 693.32 700.48 679.45 26545 680.62 646.59 743.58 721.27 728.71 706.85 26546 964.34 916.12 1,053.54 1,021.94 1,032.47 1,001.50 26548 733.06 696.41 800.87 776.85 784.85 761.31 26550 1,609.05 1,528.60 1,757.89 1,705.15 1,722.73 1,671.05 26551 3,321.46 3,155.39 3,628.70 3,519.84 3,556.12 3,449.45 26553 2,828.03 2,686.63 3,089.62 2,996.93 3,027.84 2,937.00 26554 3,313.18 3,147.52 3,619.65 3,511.05 3,547.26 3,440.83 26555 1,259.83 1,196.84 1,376.37 1,335.07 1,348.84 1,308.37 26556 3,393.16 3,223.50 3,707.03 3,595.82 3,632.88 3,523.90 26560 559.40 531.43 611.14 592.81 598.92 580.96 26561 906.13 860.82 989.94 960.25 970.14 941.05 26562 1,303.43 1,238.26 1,424.00 1,381.28 1,395.51 1,353.65 26565 653.21 620.55 713.63 692.22 699.36 678.37 26567 654.82 622.08 715.39 693.93 701.09 680.05 26568 869.75 826.26 950.20 921.69 931.19 903.26 26580 1,468.69 1,395.26 1,604.55 1,556.41 1,572.45 1,525.28 26587 998.15 948.24 1,090.48 1,057.76 1,068.67 1,036.60 26590 1,297.80 1,232.91 1,417.85 1,375.31 1,389.49 1,347.80 26591 414.92 394.17 453.30 439.69 444.23 430.89 26593 576.48 547.66 629.81 610.91 617.22 598.70 26596 737.14 700.28 805.32 781.16 789.21 765.53

Page 52: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 52Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

26600 284.06 269.86 310.34 301.02 304.13 295.00 # 26600 267.91 254.51 292.69 283.90 286.83 278.22 26605 310.98 295.43 339.74 329.56 332.95 322.97 # 26605 284.95 270.70 311.31 301.97 305.08 295.93 26607 447.39 425.02 488.77 474.11 479.00 464.62 26608 467.36 443.99 510.59 495.27 500.38 485.37 26615 567.92 539.52 620.45 601.83 608.04 589.79 26641 365.28 347.02 399.07 387.10 391.09 379.36 # 26641 334.64 317.91 365.60 354.63 358.28 347.53 26645 416.39 395.57 454.91 441.26 445.81 432.43 # 26645 384.10 364.90 419.64 407.04 411.24 398.90 26650 467.70 444.32 510.97 495.64 500.74 485.73 26665 619.71 588.72 677.03 656.72 663.49 643.59 26670 330.58 314.05 361.16 350.32 353.94 343.32 # 26670 301.59 286.51 329.49 319.60 322.90 313.20 26675 439.85 417.86 480.54 466.12 470.93 456.79 # 26675 406.25 385.94 443.83 430.51 434.95 421.90 26676 490.11 465.60 535.44 519.37 524.73 508.99 26685 567.62 539.24 620.13 601.52 607.73 589.49 26686 617.97 587.07 675.13 654.88 661.63 641.78 26700 315.40 299.63 344.57 334.24 337.69 327.55 # 26700 297.28 282.42 324.78 315.04 318.29 308.74 26705 402.21 382.10 439.42 426.24 430.63 417.71 # 26705 370.26 351.75 404.51 392.38 396.43 384.54 26706 432.60 410.97 472.62 458.44 463.16 449.27 26715 564.09 535.89 616.27 597.78 603.95 585.82 26720 191.15 181.59 208.83 202.56 204.65 198.51 # 26720 178.30 169.39 194.80 188.96 190.90 185.17 26725 326.62 310.29 356.83 346.13 349.69 339.20 # 26725 296.31 281.49 323.71 314.01 317.24 307.73 26727 460.69 437.66 503.31 488.21 493.25 478.45 26735 588.56 559.13 643.00 623.71 630.14 611.24 26740 222.63 211.50 243.23 235.93 238.36 231.22 # 26740 209.78 199.29 229.18 222.31 224.60 217.86 26742 359.71 341.72 392.98 381.19 385.12 373.57 # 26742 327.75 311.36 358.06 347.32 350.90 340.38 26746 735.13 698.37 803.13 779.03 787.06 763.45 26750 177.73 168.84 194.17 188.34 190.28 184.56 # 26750 178.39 169.47 194.89 189.05 190.99 185.27 26755 304.26 289.05 332.41 322.44 325.76 315.99 # 26755 266.71 253.37 291.38 282.64 285.55 276.98 26756 407.95 387.55 445.68 432.31 436.77 423.66 26765 492.14 467.53 537.66 521.53 526.91 511.09 26770 267.53 254.15 292.27 283.51 286.43 277.84 # 26770 248.75 236.31 271.76 263.60 266.32 258.34 26775 371.55 352.97 405.92 393.74 397.80 385.86 # 26775 338.27 321.36 369.56 358.48 362.17 351.31 26776 433.82 412.13 473.95 459.74 464.47 450.54 26785 539.23 512.27 589.11 571.44 577.32 560.00

Page 53: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 53Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

26820 743.93 706.73 812.74 788.36 796.49 772.59 26841 699.60 664.62 764.31 741.38 749.03 726.56 26842 758.22 720.31 828.36 803.51 811.79 787.44 26843 712.23 676.62 778.11 754.77 762.55 739.67 26844 795.79 756.00 869.40 843.32 852.01 826.45 26850 667.09 633.74 728.80 706.94 714.23 692.81 26852 770.07 731.57 841.31 816.06 824.48 799.74 26860 540.79 513.75 590.81 573.09 579.00 561.63 26861 104.56 99.33 114.23 110.80 111.94 108.58 26862 700.84 665.80 765.67 742.70 750.35 727.85 26863 233.44 221.77 255.04 247.39 249.93 242.44 26910 698.33 663.41 762.92 740.04 747.66 725.24 26951 627.32 595.95 685.34 664.78 671.63 651.49 26952 621.10 590.05 678.56 658.20 664.99 645.04 26990 620.56 589.53 677.96 657.62 664.40 644.46 26991 689.58 655.10 753.37 730.77 738.30 716.15 # 26991 519.58 493.60 567.64 550.61 556.29 539.59 26992 955.04 907.29 1,043.38 1,012.08 1,022.51 991.84 27000 404.20 383.99 441.59 428.34 432.76 419.77 27001 537.42 510.55 587.13 569.51 575.39 558.13 27003 579.31 550.34 632.89 613.90 620.23 601.62 27005 720.22 684.21 786.84 763.23 771.11 747.97 27006 730.07 693.57 797.61 773.67 781.66 758.20 27025 908.90 863.46 992.98 963.19 973.12 943.93 27027 885.53 841.25 967.44 938.41 948.09 919.64 27030 935.19 888.43 1,021.69 991.05 1,001.26 971.22 27033 971.76 923.17 1,061.65 1,029.79 1,040.42 1,009.19 27035 1,061.93 1,008.83 1,160.15 1,125.36 1,136.95 1,102.85 27036 1,008.97 958.52 1,102.30 1,069.22 1,080.25 1,047.83 27040 333.49 316.82 364.34 353.42 357.05 346.35 # 27040 199.07 189.12 217.49 210.97 213.14 206.75 27041 691.52 656.94 755.48 732.81 740.37 718.16 27043 471.56 447.98 515.18 499.72 504.87 489.73 27045 749.87 712.38 819.24 794.66 802.85 778.77 27047 457.50 434.63 499.82 484.83 489.83 475.13 # 27047 360.97 342.92 394.36 382.52 386.47 374.88 27048 611.50 580.93 668.07 648.03 654.71 635.06 27049 1,340.64 1,273.61 1,464.65 1,420.71 1,435.36 1,392.29 27050 381.63 362.55 416.93 404.42 408.60 396.34 27052 574.74 546.00 627.90 609.06 615.34 596.88 27054 679.75 645.76 742.62 720.35 727.77 705.94 27057 1,011.88 961.29 1,105.48 1,072.32 1,083.37 1,050.87 27059 1,828.06 1,736.66 1,997.16 1,937.24 1,957.22 1,898.50 27060 458.25 435.34 500.64 485.62 490.62 475.90 27062 450.90 428.36 492.61 477.84 482.76 468.28 27065 511.40 485.83 558.70 541.95 547.53 531.10 27066 809.30 768.84 884.17 857.64 866.48 840.48 27067 1,021.74 970.65 1,116.25 1,082.76 1,093.93 1,061.11 27070 847.37 805.00 925.75 897.98 907.24 880.01

Page 54: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 54Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

27071 910.45 864.93 994.67 964.83 974.77 945.53 27075 2,100.52 1,995.49 2,294.81 2,225.97 2,248.92 2,181.46 27076 2,544.63 2,417.40 2,780.01 2,696.61 2,724.41 2,642.68 27077 2,838.56 2,696.63 3,101.12 3,008.09 3,039.11 2,947.93 27078 2,072.24 1,968.63 2,263.92 2,196.01 2,218.65 2,152.09 27080 508.70 483.27 555.76 539.09 544.64 528.30 27086 267.33 253.96 292.05 283.29 286.21 277.62 # 27086 158.61 150.68 173.28 168.08 169.82 164.73 27087 615.72 584.93 672.67 652.49 659.21 639.43 27090 826.49 785.17 902.95 875.85 884.89 858.34 27091 1,602.32 1,522.20 1,750.53 1,698.01 1,715.52 1,664.05 27093 179.50 170.53 196.11 190.22 192.19 186.42 # 27093 70.78 67.24 77.33 75.00 75.79 73.51 27095 232.65 221.02 254.17 246.55 249.09 241.62 # 27095 84.07 79.87 91.85 89.09 90.01 87.31 27096 153.62 145.94 167.83 162.79 164.47 159.54 # 27096 83.77 79.58 91.52 88.77 89.69 87.00 27097 673.48 639.81 735.78 713.71 721.06 699.44 27098 635.68 603.90 694.49 673.65 680.59 660.17 27100 813.61 772.93 888.87 862.20 871.09 844.96 27105 863.92 820.72 943.83 915.52 924.96 897.21 27110 967.58 919.20 1,057.08 1,025.36 1,035.94 1,004.86 27111 899.87 854.88 983.11 953.61 963.45 934.55 27120 1,296.10 1,231.30 1,416.00 1,373.51 1,387.67 1,346.04 27122 1,101.01 1,045.96 1,202.85 1,166.77 1,178.80 1,143.43 27125 1,134.93 1,078.18 1,239.91 1,202.70 1,215.11 1,178.65 27130 1,361.20 1,293.14 1,487.11 1,442.50 1,457.37 1,413.65 27132 1,682.08 1,597.98 1,837.68 1,782.55 1,800.92 1,746.90 27134 1,929.10 1,832.65 2,107.55 2,044.32 2,065.40 2,003.44 27137 1,480.21 1,406.20 1,617.13 1,568.61 1,584.79 1,537.24 27138 1,538.04 1,461.14 1,680.31 1,629.91 1,646.71 1,597.30 27140 890.45 845.93 972.82 943.63 953.36 924.76 27146 1,275.37 1,211.60 1,393.34 1,351.54 1,365.48 1,324.51 27147 1,464.57 1,391.34 1,600.04 1,552.04 1,568.04 1,521.00 27151 1,599.03 1,519.08 1,746.94 1,694.54 1,712.01 1,660.65 27156 1,700.83 1,615.79 1,858.16 1,802.42 1,820.99 1,766.37 27158 1,407.41 1,337.04 1,537.60 1,491.47 1,506.85 1,461.64 27161 1,214.82 1,154.08 1,327.19 1,287.38 1,300.65 1,261.63 27165 1,374.53 1,305.80 1,501.67 1,456.62 1,471.63 1,427.50 27170 1,178.45 1,119.53 1,287.46 1,248.83 1,261.71 1,223.85 27175 653.56 620.88 714.01 692.59 699.73 678.74 27176 916.78 870.94 1,001.58 971.53 981.55 952.10 27177 1,114.81 1,059.07 1,217.93 1,181.40 1,193.57 1,157.76 27178 802.43 762.31 876.66 850.36 859.12 833.35 27179 953.63 905.95 1,041.84 1,010.59 1,021.00 990.37 27181 1,280.76 1,216.72 1,399.23 1,357.25 1,371.25 1,330.11 27185 714.66 678.93 780.77 757.34 765.15 742.20 27187 990.35 940.83 1,081.95 1,049.50 1,060.31 1,028.51 27197 115.48 109.71 126.17 122.38 123.65 119.93

Page 55: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 55Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

27198 297.49 282.62 325.01 315.26 318.52 308.96 27200 177.00 168.15 193.37 187.58 189.51 183.83 # 27200 183.92 174.72 200.93 194.90 196.91 191.00 27202 552.01 524.41 603.07 584.98 591.01 573.29 27220 524.44 498.22 572.95 555.76 561.50 544.64 # 27220 520.49 494.47 568.64 551.59 557.27 540.56 27222 973.38 924.71 1,063.42 1,031.52 1,042.15 1,010.88 27226 1,057.97 1,005.07 1,155.83 1,121.16 1,132.72 1,098.73 27227 1,668.55 1,585.12 1,822.89 1,768.21 1,786.43 1,732.84 27228 1,897.79 1,802.90 2,073.34 2,011.13 2,031.87 1,970.90 27230 468.42 445.00 511.75 496.40 501.52 486.47 # 27230 465.45 442.18 508.51 493.25 498.34 483.38 27232 750.04 712.54 819.42 794.83 803.03 778.94 27235 908.78 863.34 992.84 963.06 972.98 943.79 27236 1,197.91 1,138.01 1,308.71 1,269.45 1,282.54 1,244.06 27238 454.73 431.99 496.79 481.88 486.85 472.25 27240 956.59 908.76 1,045.07 1,013.73 1,024.17 993.45 27244 1,233.24 1,171.58 1,347.32 1,306.89 1,320.37 1,280.76 27245 1,233.24 1,171.58 1,347.32 1,306.89 1,320.37 1,280.76 27246 379.68 360.70 414.81 402.36 406.51 394.31 # 27246 381.66 362.58 416.97 404.46 408.63 396.37 27248 741.91 704.81 810.53 786.22 794.32 770.50 27250 183.95 174.75 200.96 194.94 196.95 191.04 27252 756.27 718.46 826.23 801.45 809.70 785.42 27253 941.30 894.24 1,028.38 997.52 1,007.81 977.57 27254 1,270.12 1,206.61 1,387.60 1,345.97 1,359.85 1,319.05 27256 295.60 280.82 322.94 313.26 316.48 306.99 # 27256 236.30 224.49 258.16 250.42 253.00 245.41 27257 342.21 325.10 373.87 362.65 366.39 355.40 27258 1,110.22 1,054.71 1,212.92 1,176.53 1,188.66 1,153.00 27259 1,559.22 1,481.26 1,703.45 1,652.34 1,669.37 1,619.29 27265 392.76 373.12 429.09 416.22 420.51 407.89 27266 576.97 548.12 630.34 611.43 617.73 599.21 27267 427.71 406.32 467.27 453.25 457.92 444.19 27268 526.17 499.86 574.84 557.59 563.34 546.43 27269 1,247.60 1,185.22 1,363.00 1,322.11 1,335.75 1,295.67 27275 180.05 171.05 196.71 190.81 192.77 186.99 27279 690.39 655.87 754.25 731.62 739.16 716.99 27280 1,372.44 1,303.82 1,499.39 1,454.42 1,469.40 1,425.33 27282 812.17 771.56 887.29 860.67 869.55 843.46 27284 1,489.02 1,414.57 1,626.76 1,577.95 1,594.22 1,546.39 27286 1,628.48 1,547.06 1,779.12 1,725.75 1,743.54 1,691.24 27290 1,615.53 1,534.75 1,764.96 1,712.02 1,729.67 1,677.78 27295 1,271.79 1,208.20 1,389.43 1,347.74 1,361.65 1,320.79 27301 656.31 623.49 717.01 695.51 702.67 681.59 # 27301 498.83 473.89 544.97 528.62 534.07 518.05 27303 636.24 604.43 695.09 674.25 681.19 660.76 27305 474.89 451.15 518.82 503.26 508.45 493.20 27306 347.93 330.53 380.11 368.70 372.51 361.33

Page 56: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 56Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

27307 423.25 402.09 462.40 448.53 453.16 439.56 27310 726.72 690.38 793.94 770.12 778.06 754.72 27323 262.72 249.58 287.02 278.40 281.28 272.84 # 27323 177.06 168.21 193.44 187.63 189.58 183.89 27324 394.33 374.61 430.80 417.88 422.19 409.52 27325 509.89 484.40 557.06 540.35 545.92 529.54 27326 494.71 469.97 540.47 524.25 529.66 513.76 27327 445.69 423.41 486.92 472.32 477.18 462.88 # 27327 311.27 295.71 340.07 329.87 333.27 323.27 27328 620.64 589.61 678.05 657.71 664.49 644.55 27329 1,043.53 991.35 1,140.05 1,105.85 1,117.25 1,083.74 27330 406.73 386.39 444.35 431.02 435.46 422.40 27331 469.57 446.09 513.00 497.62 502.75 487.67 27332 636.40 604.58 695.27 674.41 681.36 660.92 27333 580.87 551.83 634.60 615.57 621.91 603.26 27334 678.67 644.74 741.45 719.21 726.63 704.82 27335 758.16 720.25 828.29 803.44 811.73 787.37 27337 417.60 396.72 456.23 442.54 447.11 433.69 27339 754.96 717.21 824.79 800.04 808.30 784.05 27340 365.79 347.50 399.63 387.64 391.63 379.89 27345 474.42 450.70 518.31 502.76 507.94 492.71 27347 523.16 497.00 571.55 554.40 560.12 543.32 27350 645.86 613.57 705.61 684.43 691.50 670.75 27355 598.07 568.17 653.40 633.79 640.33 621.12 27356 730.49 693.97 798.07 774.12 782.10 758.64 27357 809.60 769.12 884.49 857.96 866.80 840.80 27358 282.91 268.76 309.07 299.81 302.89 293.81 27360 844.12 801.91 922.20 894.53 903.75 876.63 27364 1,570.03 1,491.53 1,715.26 1,663.80 1,680.96 1,630.52 27365 2,075.29 1,971.53 2,267.26 2,199.24 2,221.92 2,155.25 27370 147.12 139.76 160.72 155.91 157.50 152.79 # 27370 51.25 48.69 55.99 54.31 54.88 53.23 27372 584.94 555.69 639.04 619.87 626.27 607.48 # 27372 398.13 378.22 434.95 421.90 426.26 413.46 27380 586.25 556.94 640.48 621.26 627.67 608.84 27381 792.92 753.27 866.26 840.27 848.93 823.47 27385 566.31 537.99 618.69 600.13 606.31 588.12 27386 821.80 780.71 897.82 870.88 879.87 853.46 27390 436.32 414.50 476.68 462.38 467.14 453.13 27391 566.75 538.41 619.17 600.60 606.79 588.58 27392 696.02 661.22 760.40 737.59 745.20 722.83 27393 504.84 479.60 551.54 534.99 540.51 524.30 27394 630.85 599.31 689.21 668.53 675.42 655.16 27395 875.83 832.04 956.85 928.14 937.71 909.58 27396 608.03 577.63 664.27 644.35 650.99 631.45 27397 901.45 856.38 984.84 955.29 965.14 936.19 27400 680.42 646.40 743.36 721.06 728.49 706.64 27403 635.19 603.43 693.94 673.13 680.06 659.66 27405 669.37 635.90 731.29 709.34 716.66 695.15

Page 57: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 57Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

27407 770.99 732.44 842.31 817.04 825.46 800.70 27409 963.72 915.53 1,052.86 1,021.27 1,031.80 1,000.85 27412 1,658.50 1,575.58 1,811.92 1,757.56 1,775.68 1,722.40 27415 1,375.97 1,307.17 1,503.25 1,458.14 1,473.18 1,428.98 27416 980.82 931.78 1,071.55 1,039.40 1,050.11 1,018.61 27418 820.75 779.71 896.67 869.77 878.74 852.37 27420 738.74 701.80 807.07 782.86 790.92 767.21 27422 738.60 701.67 806.92 782.71 790.79 767.06 27424 744.90 707.66 813.81 789.39 797.54 773.61 27425 441.73 419.64 482.59 468.11 472.94 458.75 27427 707.06 671.71 772.47 749.29 757.02 734.31 27428 1,107.52 1,052.14 1,209.96 1,173.67 1,185.77 1,150.20 27429 1,238.07 1,176.17 1,352.60 1,312.01 1,325.55 1,285.77 27430 734.74 698.00 802.70 778.62 786.65 763.05 27435 801.18 761.12 875.29 849.03 857.79 832.05 27437 657.90 625.01 718.76 697.20 704.39 683.25 27438 836.99 795.14 914.41 886.98 896.13 869.24 27440 792.44 752.82 865.74 839.78 848.42 822.99 27441 822.63 781.50 898.73 871.77 880.75 854.34 27442 867.38 824.01 947.61 919.18 928.66 900.80 27443 810.87 770.33 885.88 859.30 868.16 842.12 27445 1,255.31 1,192.54 1,371.42 1,330.27 1,343.99 1,303.66 27446 1,162.37 1,104.25 1,269.89 1,231.79 1,244.50 1,207.16 27447 1,360.51 1,292.48 1,486.35 1,441.77 1,456.62 1,412.94 27448 768.72 730.28 839.82 814.63 823.02 798.33 27450 1,012.07 961.47 1,105.69 1,072.52 1,083.58 1,051.08 27454 1,300.08 1,235.08 1,420.34 1,377.73 1,391.94 1,350.18 27455 938.92 891.97 1,025.77 994.99 1,005.25 975.10 27457 945.33 898.06 1,032.77 1,001.79 1,012.12 981.76 27465 1,235.50 1,173.73 1,349.79 1,309.30 1,322.80 1,283.11 27466 1,174.73 1,115.99 1,283.39 1,244.89 1,257.72 1,219.99 27468 1,346.95 1,279.60 1,471.54 1,427.39 1,442.11 1,398.85 27470 1,175.45 1,116.68 1,284.18 1,245.66 1,258.50 1,220.75 27472 1,264.03 1,200.83 1,380.95 1,339.53 1,353.33 1,312.74 27475 657.90 625.01 718.76 697.20 704.39 683.25 27477 730.36 693.84 797.92 773.97 781.95 758.49 27479 919.94 873.94 1,005.03 974.88 984.93 955.39 27485 663.13 629.97 724.47 702.73 709.98 688.68 27486 1,410.38 1,339.86 1,540.84 1,494.61 1,510.02 1,464.72 27487 1,766.44 1,678.12 1,929.84 1,871.95 1,891.24 1,834.50 27488 1,201.06 1,141.01 1,312.16 1,272.80 1,285.92 1,247.34 27495 1,125.98 1,069.68 1,230.13 1,193.23 1,205.53 1,169.37 27496 531.69 505.11 580.88 563.45 569.26 552.18 27497 574.18 545.47 627.29 608.48 614.74 596.31 27498 645.70 613.42 705.43 684.27 691.32 670.59 27499 686.52 652.19 750.02 727.51 735.02 712.97 27500 510.97 485.42 558.23 541.49 547.07 530.66 # 27500 475.06 451.31 519.01 503.44 508.62 493.36 27501 498.14 473.23 544.21 527.88 533.34 517.33

Page 58: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 58Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 27501 494.19 469.48 539.90 523.71 529.10 513.23 27502 759.04 721.09 829.25 804.38 812.67 788.29 27503 796.71 756.87 870.40 844.28 852.99 827.40 27506 1,339.20 1,272.24 1,463.08 1,419.18 1,433.82 1,390.80 27507 974.04 925.34 1,064.14 1,032.22 1,042.85 1,011.57 27508 515.81 490.02 563.52 546.62 552.25 535.68 # 27508 486.81 462.47 531.84 515.89 521.20 505.57 27509 635.02 603.27 693.76 672.95 679.88 659.49 27510 679.63 645.65 742.50 720.22 727.65 705.81 27511 1,000.02 950.02 1,092.52 1,059.75 1,070.67 1,038.55 27513 1,246.20 1,183.89 1,361.47 1,320.63 1,334.24 1,294.21 27514 969.21 920.75 1,058.86 1,027.10 1,037.69 1,006.56 27516 496.79 471.95 542.74 526.46 531.89 515.92 # 27516 467.80 444.41 511.07 495.74 500.85 485.83 27517 637.13 605.27 696.06 675.18 682.13 661.68 27519 893.91 849.21 976.59 947.29 957.06 928.35 27520 313.35 297.68 342.33 332.06 335.49 325.43 # 27520 287.32 272.95 313.89 304.47 307.61 298.38 27524 748.41 710.99 817.64 793.11 801.29 777.25 27530 292.26 277.65 319.30 309.72 312.92 303.52 # 27530 272.16 258.55 297.33 288.41 291.39 282.64 27532 606.43 576.11 662.53 642.65 649.28 629.80 # 27532 571.50 542.93 624.37 605.64 611.88 593.53 27535 898.85 853.91 982.00 952.53 962.35 933.48 27536 1,189.90 1,130.41 1,299.97 1,260.98 1,273.97 1,235.76 27538 465.62 442.34 508.69 493.43 498.51 483.56 # 27538 437.62 415.74 478.10 463.76 468.54 454.48 27540 808.31 767.89 883.07 856.58 865.41 839.44 27550 497.76 472.87 543.80 527.48 532.92 516.94 # 27550 463.50 440.33 506.38 491.19 496.25 481.37 27552 621.12 590.06 678.57 658.21 665.00 645.05 27556 864.41 821.19 944.37 916.03 925.49 897.71 27557 1,025.32 974.05 1,120.16 1,086.55 1,097.76 1,064.82 27558 1,201.51 1,141.43 1,312.64 1,273.27 1,286.39 1,247.81 27560 351.03 333.48 383.50 372.00 375.83 364.56 # 27560 325.33 309.06 355.42 344.76 348.31 337.86 27562 468.89 445.45 512.27 496.90 502.02 486.97 27566 887.40 843.03 969.48 940.40 950.10 921.60 27570 149.00 141.55 162.78 157.90 159.53 154.73 27580 1,437.46 1,365.59 1,570.43 1,523.31 1,539.02 1,492.85 27590 813.15 772.49 888.36 861.72 870.60 844.48 27591 965.77 917.48 1,055.10 1,023.45 1,034.00 1,002.98 27592 691.02 656.47 754.94 732.30 739.84 717.65 27594 506.51 481.18 553.36 536.75 542.29 526.02 27596 729.09 692.64 796.54 772.64 780.61 757.18 27598 722.78 686.64 789.64 765.95 773.85 750.63 27600 408.05 387.65 445.80 432.42 436.89 423.78 27601 444.38 422.16 485.48 470.93 475.78 461.51 27602 492.94 468.29 538.53 522.38 527.76 511.93

Page 59: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 59Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

27603 515.84 490.05 563.56 546.65 552.29 535.72 # 27603 385.04 365.79 420.66 408.04 412.24 399.88 27604 477.26 453.40 521.41 505.77 510.98 495.65 # 27604 340.53 323.50 372.03 360.87 364.58 353.65 27605 332.00 315.40 362.71 351.83 355.45 344.79 # 27605 184.74 175.50 201.83 195.78 197.79 191.87 27606 281.14 267.08 307.14 297.93 301.00 291.97 27607 605.50 575.23 661.51 641.67 648.29 628.83 27610 646.35 614.03 706.13 684.95 692.01 671.26 27612 560.09 532.09 611.90 593.55 599.67 581.68 27613 244.94 232.69 267.59 259.57 262.25 254.38 # 27613 161.59 153.51 176.54 171.24 173.01 167.81 27614 566.04 537.74 618.40 599.85 606.04 587.86 # 27614 404.28 384.07 441.68 428.43 432.85 419.87 27615 1,026.66 975.33 1,121.63 1,087.98 1,099.19 1,066.22 27616 1,275.46 1,211.69 1,393.44 1,351.64 1,365.58 1,324.60 27618 438.23 416.32 478.77 464.40 469.19 455.11 # 27618 306.12 290.81 334.43 324.40 327.74 317.92 27619 466.30 442.99 509.44 494.16 499.25 484.28 27620 450.92 428.37 492.63 477.85 482.77 468.29 27625 576.92 548.07 630.28 611.37 617.68 599.15 27626 603.16 573.00 658.95 639.18 645.77 626.39 27630 543.49 516.32 593.77 575.95 581.89 564.43 # 27630 361.30 343.24 394.73 382.88 386.84 375.22 27632 412.64 392.01 450.81 437.29 441.80 428.55 27634 685.70 651.42 749.13 726.66 734.15 712.13 27635 581.64 552.56 635.44 616.38 622.74 604.05 27637 757.90 720.01 828.01 803.17 811.45 787.11 27638 759.94 721.94 830.23 805.32 813.63 789.21 27640 832.79 791.15 909.82 882.53 891.63 864.88 27641 665.93 632.63 727.52 705.70 712.98 691.59 27645 1,782.60 1,693.47 1,947.49 1,889.07 1,908.54 1,851.29 27646 1,491.24 1,416.68 1,629.18 1,580.31 1,596.60 1,548.71 27647 1,035.95 984.15 1,131.77 1,097.82 1,109.14 1,075.87 27648 158.38 150.46 173.03 167.84 169.57 164.48 # 27648 53.28 50.62 58.21 56.47 57.05 55.34 27650 653.88 621.19 714.37 692.93 700.09 679.08 27652 683.87 649.68 747.13 724.72 732.19 710.23 27654 705.35 670.08 770.59 747.48 755.18 732.53 27656 601.05 571.00 656.65 636.95 643.52 624.21 # 27656 385.59 366.31 421.26 408.62 412.83 400.44 27658 369.68 351.20 403.88 391.76 395.81 383.93 27659 475.94 452.14 519.96 504.37 509.57 494.28 27664 358.65 340.72 391.83 380.08 384.00 372.47 27665 406.85 386.51 444.49 431.15 435.60 422.52 27675 487.97 463.57 533.11 517.11 522.45 506.77 27676 603.98 573.78 659.85 640.06 646.65 627.26 27680 426.29 404.98 465.73 451.75 456.41 442.72 27681 542.18 515.07 592.33 574.56 580.49 563.07

Page 60: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 60Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

27685 648.85 616.41 708.87 687.61 694.69 673.85 # 27685 461.06 438.01 503.71 488.60 493.64 478.83 27686 555.81 528.02 607.22 589.01 595.08 577.23 27687 450.82 428.28 492.52 477.74 482.67 468.19 27690 629.88 598.39 688.15 667.51 674.38 654.15 27691 743.93 706.73 812.74 788.36 796.49 772.59 27692 106.26 100.95 116.09 112.61 113.77 110.35 27695 473.89 450.20 517.73 502.19 507.38 492.15 27696 551.21 523.65 602.20 584.13 590.16 572.45 27698 639.00 607.05 698.11 677.17 684.15 663.62 27700 608.50 578.08 664.79 644.85 651.50 631.96 27702 963.44 915.27 1,052.56 1,020.98 1,031.50 1,000.56 27703 1,110.06 1,054.56 1,212.74 1,176.36 1,188.49 1,152.83 27704 571.02 542.47 623.84 605.13 611.36 593.03 27705 755.63 717.85 825.53 800.76 809.01 784.74 27707 394.51 374.78 431.00 418.07 422.37 409.71 27709 1,173.16 1,114.50 1,281.68 1,243.23 1,256.04 1,218.37 27712 1,106.13 1,050.82 1,208.44 1,172.20 1,184.27 1,148.75 27715 1,051.54 998.96 1,148.80 1,114.34 1,125.83 1,092.05 27720 871.94 828.34 952.59 924.01 933.54 905.53 27722 888.34 843.92 970.51 941.39 951.10 922.56 27724 1,268.00 1,204.60 1,385.29 1,343.73 1,357.59 1,316.85 27725 1,192.05 1,132.45 1,302.32 1,263.25 1,276.27 1,237.99 27726 963.45 915.28 1,052.57 1,020.99 1,031.52 1,000.57 27727 896.45 851.63 979.37 949.99 959.79 930.99 27730 550.78 523.24 601.73 583.67 589.70 572.00 27732 368.76 350.32 402.87 390.78 394.81 382.96 27734 652.28 619.67 712.62 691.24 698.37 677.42 27740 689.37 654.90 753.14 730.54 738.07 715.93 27742 750.15 712.64 819.54 794.95 803.15 779.04 27745 752.68 715.05 822.31 797.64 805.86 781.69 27750 336.92 320.07 368.08 357.04 360.72 349.90 # 27750 310.24 294.73 338.94 328.77 332.17 322.20 27752 526.70 500.37 575.43 558.16 563.91 547.00 # 27752 488.48 464.06 533.67 517.66 523.00 507.31 27756 571.39 542.82 624.24 605.52 611.75 593.41 27758 888.49 844.07 970.68 941.56 951.27 922.74 27759 998.03 948.13 1,090.35 1,057.64 1,068.55 1,036.50 27760 322.98 306.83 352.85 342.27 345.79 335.43 # 27760 295.97 281.17 323.35 313.64 316.88 307.37 27762 460.55 437.52 503.15 488.05 493.09 478.29 # 27762 421.67 400.59 460.68 446.86 451.47 437.92 27766 603.53 573.35 659.35 639.57 646.16 626.78 27767 272.04 258.44 297.21 288.29 291.26 282.53 # 27767 273.69 260.01 299.01 290.04 293.03 284.25 27768 431.26 409.70 471.16 457.02 461.74 447.88 27769 719.88 683.89 786.47 762.88 770.74 747.62 27780 296.74 281.90 324.19 314.46 317.70 308.17 # 27780 271.37 257.80 296.47 287.58 290.54 281.83

Page 61: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 61Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

27781 416.63 395.80 455.17 441.52 446.06 432.69 # 27781 387.97 368.57 423.86 411.14 415.38 402.91 27784 710.66 675.13 776.40 753.11 760.87 738.05 27786 306.58 291.25 334.94 324.89 328.24 318.39 # 27786 278.91 264.96 304.70 295.56 298.61 289.65 27788 411.03 390.48 449.05 435.59 440.07 426.87 # 27788 377.10 358.25 411.99 399.63 403.75 391.63 27792 648.01 615.61 707.95 686.71 693.80 672.98 27808 323.80 307.61 353.75 343.14 346.68 336.27 # 27808 292.17 277.56 319.19 309.61 312.81 303.43 27810 455.85 433.06 498.02 483.08 488.06 473.42 # 27810 415.66 394.88 454.11 440.48 445.03 431.68 27814 767.59 729.21 838.59 813.43 821.82 797.16 27816 312.36 296.74 341.25 331.02 334.43 324.39 # 27816 281.72 267.63 307.77 298.54 301.62 292.57 27818 473.53 449.85 517.33 501.80 506.98 491.76 # 27818 427.08 405.73 466.59 452.59 457.26 443.54 27822 851.98 809.38 930.79 902.87 912.17 884.81 27823 967.91 919.51 1,057.44 1,025.71 1,036.29 1,005.19 27824 305.99 290.69 334.29 324.27 327.61 317.78 # 27824 297.76 282.87 325.30 315.54 318.79 309.22 27825 535.57 508.79 585.11 567.56 573.40 556.21 # 27825 488.79 464.35 534.00 517.98 523.32 507.62 27826 843.64 801.46 921.68 894.03 903.24 876.15 27827 1,093.29 1,038.63 1,194.42 1,158.59 1,170.54 1,135.42 27828 1,310.35 1,244.83 1,431.55 1,388.61 1,402.92 1,360.84 27829 688.95 654.50 752.68 730.10 737.62 715.50 27830 367.76 349.37 401.78 389.72 393.74 381.93 # 27830 344.04 326.84 375.87 364.58 368.35 357.29 27831 372.63 354.00 407.10 394.89 398.96 386.99 27832 752.52 714.89 822.12 797.46 805.68 781.51 27840 361.76 343.67 395.22 383.36 387.32 375.69 27842 488.05 463.65 533.20 517.20 522.54 506.86 27846 725.24 688.98 792.33 768.56 776.48 753.18 27848 804.22 764.01 878.61 852.25 861.04 835.21 27860 171.55 162.97 187.42 181.79 183.67 178.16 27870 1,029.71 978.22 1,124.95 1,091.20 1,102.46 1,069.37 27871 681.18 647.12 744.19 721.87 729.31 707.43 27880 931.47 884.90 1,017.64 987.10 997.28 967.36 27881 874.62 830.89 955.52 926.85 936.41 908.32 27882 608.41 577.99 664.69 644.75 651.39 631.86 27884 580.33 551.31 634.01 614.99 621.32 602.68 27886 663.20 630.04 724.55 702.81 710.06 688.76 27888 690.99 656.44 754.91 732.26 739.81 717.62 27889 657.66 624.78 718.50 696.95 704.12 683.01 27892 554.53 526.80 605.82 587.65 593.70 575.90 27893 601.49 571.42 657.13 637.42 643.99 624.67 27894 858.64 815.71 938.07 909.93 919.31 891.73 28001 271.07 257.52 296.15 287.26 290.23 281.51

Page 62: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 62Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 28001 169.27 160.81 184.93 179.39 181.23 175.80 28002 435.55 413.77 475.84 461.56 466.31 452.33 # 28002 318.26 302.35 347.70 337.27 340.75 330.52 28003 694.43 659.71 758.67 735.91 743.50 721.19 # 28003 560.67 532.64 612.54 594.16 600.29 582.28 28005 576.94 548.09 630.30 611.40 617.70 599.17 28008 426.13 404.82 465.54 451.58 456.23 442.55 # 28008 293.03 278.38 320.14 310.53 313.73 304.32 28010 228.86 217.42 250.03 242.54 245.03 237.68 # 28010 207.11 196.75 226.26 219.48 221.74 215.08 28011 317.52 301.64 346.89 336.48 339.95 329.75 # 28011 285.23 270.97 311.62 302.27 305.38 296.22 28020 530.43 503.91 579.50 562.11 567.90 550.86 # 28020 360.43 342.41 393.77 381.96 385.89 374.33 28022 477.15 453.29 521.28 505.64 510.85 495.54 # 28022 322.31 306.19 352.12 341.55 345.08 334.72 28024 451.08 428.53 492.81 478.02 482.95 468.46 # 28024 302.50 287.38 330.49 320.57 323.87 314.16 28035 518.54 492.61 566.50 549.50 555.17 538.51 # 28035 354.14 336.43 386.89 375.29 379.16 367.78 28039 500.14 475.13 546.40 530.01 535.47 519.41 # 28039 349.58 332.10 381.92 370.46 374.28 363.06 28041 456.88 434.04 499.15 484.17 489.16 474.49 28043 394.21 374.50 430.68 417.76 422.06 409.40 # 28043 262.43 249.31 286.71 278.10 280.97 272.54 28045 489.88 465.39 535.20 519.14 524.49 508.76 # 28045 347.88 330.49 380.06 368.67 372.46 361.30 28046 731.68 695.10 799.37 775.39 783.38 759.89 28047 1,069.71 1,016.22 1,168.65 1,133.59 1,145.29 1,110.92 28050 466.06 442.76 509.17 493.90 498.99 484.02 # 28050 307.92 292.52 336.40 326.30 329.67 319.78 28052 434.96 413.21 475.19 460.93 465.69 451.71 # 28052 282.09 267.99 308.19 298.94 302.02 292.96 28054 377.32 358.45 412.22 399.86 403.97 391.86 # 28054 239.28 227.32 261.42 253.58 256.19 248.50 28055 377.43 358.56 412.34 399.97 404.10 391.97 28060 509.31 483.84 556.42 539.72 545.28 528.92 # 28060 355.46 337.69 388.34 376.69 380.58 369.16 28062 579.78 550.79 633.41 614.41 620.74 602.12 # 28062 408.13 387.72 445.88 432.50 436.97 423.86 28070 528.21 501.80 577.07 559.76 565.52 548.57 # 28070 357.22 339.36 390.26 378.56 382.46 370.99 28072 500.18 475.17 546.45 530.05 535.52 519.44 # 28072 331.83 315.24 362.53 351.65 355.28 344.61 28080 515.79 490.00 563.50 546.60 552.23 535.66 # 28080 364.24 346.03 397.93 386.00 389.98 378.28 28086 535.35 508.58 584.87 567.32 573.17 555.97 # 28086 357.77 339.88 390.86 379.13 383.04 371.55 28088 437.66 415.78 478.15 463.81 468.58 454.53

Page 63: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 63Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 28088 280.51 266.48 306.45 297.26 300.32 291.32 28090 462.10 439.00 504.85 489.70 494.75 479.91 # 28090 306.93 291.58 335.32 325.25 328.61 318.75 28092 416.09 395.29 454.58 440.94 445.49 432.12 # 28092 267.83 254.44 292.61 283.83 286.75 278.15 28100 596.25 566.44 651.41 631.87 638.38 619.23 # 28100 410.76 390.22 448.75 435.29 439.78 426.58 28102 601.16 571.10 656.77 637.07 643.63 624.32 28103 397.32 377.45 434.07 421.05 425.39 412.63 28104 519.59 493.61 567.65 550.62 556.30 539.60 # 28104 352.55 334.92 385.16 373.60 377.45 366.13 28106 429.66 408.18 469.41 455.32 460.02 446.21 28107 510.29 484.78 557.50 540.78 546.34 529.97 # 28107 349.52 332.04 381.85 370.39 374.21 362.99 28108 432.47 410.85 472.48 458.30 463.02 449.13 # 28108 287.18 272.82 313.74 304.34 307.46 298.25 28110 454.73 431.99 496.79 481.88 486.85 472.25 # 28110 288.35 273.93 315.02 305.57 308.72 299.46 28111 485.93 461.63 530.87 514.95 520.26 504.64 # 28111 326.15 309.84 356.32 345.62 349.19 338.71 28112 480.90 456.86 525.39 509.62 514.88 499.43 # 28112 312.22 296.61 341.10 330.87 334.28 324.25 28113 582.35 553.23 636.21 617.12 623.50 604.79 # 28113 422.89 401.75 462.01 448.16 452.78 439.20 28114 1,061.92 1,008.82 1,160.14 1,125.34 1,136.94 1,102.84 # 28114 835.25 793.49 912.51 885.14 894.26 867.45 28116 752.10 714.50 821.68 797.03 805.24 781.09 # 28116 572.88 544.24 625.88 607.10 613.36 594.95 28118 582.85 553.71 636.77 617.67 624.04 605.31 # 28118 410.21 389.70 448.16 434.71 439.20 426.02 28119 517.63 491.75 565.51 548.55 554.21 537.58 # 28119 360.15 342.14 393.46 381.66 385.60 374.03 28120 666.63 633.30 728.30 706.45 713.72 692.31 # 28120 495.31 470.54 541.12 524.88 530.30 514.38 28122 591.83 562.24 646.58 627.18 633.65 614.63 # 28122 439.29 417.33 479.93 465.53 470.33 456.22 28124 470.20 446.69 513.69 498.28 503.42 488.31 # 28124 329.19 312.73 359.64 348.85 352.45 341.87 28126 388.54 369.11 424.48 411.75 415.99 403.51 # 28126 247.53 235.15 270.42 262.32 265.02 257.07 28130 641.35 609.28 700.67 679.65 686.65 666.06 28140 590.18 560.67 644.77 625.43 631.88 612.92 # 28140 440.28 418.27 481.01 466.58 471.39 457.25 28150 419.47 398.50 458.28 444.53 449.11 435.64 # 28150 279.45 265.48 305.30 296.15 299.20 290.23 28153 403.21 383.05 440.51 427.29 431.70 418.75 # 28153 261.87 248.78 286.10 277.52 280.37 271.96 28160 412.07 391.47 450.19 436.69 441.19 427.96 # 28160 267.44 254.07 292.18 283.42 286.34 277.75

Page 64: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 64Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

28171 855.76 812.97 934.92 906.87 916.22 888.73 28173 765.57 727.29 836.38 811.29 819.65 795.06 28175 490.94 466.39 536.35 520.26 525.62 509.85 28190 250.90 238.36 274.11 265.89 268.63 260.58 # 28190 133.28 126.62 145.61 141.24 142.70 138.41 28192 461.46 438.39 504.15 489.03 494.06 479.25 # 28192 312.55 296.92 341.46 331.21 334.63 324.59 28193 524.56 498.33 573.08 555.89 561.61 544.77 # 28193 369.06 350.61 403.20 391.10 395.14 383.28 28200 482.87 458.73 527.54 511.72 516.99 501.48 # 28200 320.78 304.74 350.45 339.94 343.45 333.14 28202 587.21 557.85 641.53 622.28 628.69 609.83 # 28202 424.79 403.55 464.08 450.16 454.80 441.15 28208 468.66 445.23 512.01 496.65 501.78 486.71 # 28208 312.17 296.56 341.04 330.81 334.22 324.20 28210 576.24 547.43 629.54 610.66 616.95 598.45 # 28210 414.48 393.76 452.82 439.24 443.76 430.46 28220 445.15 422.89 486.32 471.73 476.59 462.30 # 28220 302.16 287.05 330.11 320.21 323.51 313.80 28222 501.24 476.18 547.61 531.17 536.66 520.55 # 28222 349.69 332.21 382.04 370.58 374.41 363.17 28225 405.54 385.26 443.05 429.76 434.18 421.16 # 28225 259.92 246.92 283.96 275.44 278.28 269.93 28226 481.22 457.16 525.73 509.97 515.22 499.77 # 28226 315.17 299.41 344.32 333.99 337.43 327.31 28230 428.72 407.28 468.37 454.32 459.00 445.23 # 28230 283.10 268.95 309.29 300.01 303.11 294.01 28232 380.19 361.18 415.36 402.89 407.05 394.83 # 28232 241.82 229.73 264.19 256.27 258.91 251.14 28234 400.11 380.10 437.12 424.01 428.38 415.53 # 28234 261.41 248.34 285.59 277.02 279.88 271.48 28238 663.25 630.09 724.60 702.87 710.11 688.82 # 28238 486.99 462.64 532.04 516.07 521.40 505.75 28240 444.71 422.47 485.84 471.27 476.12 461.84 # 28240 295.46 280.69 322.79 313.11 316.34 306.84 28250 569.82 541.33 622.53 603.85 610.08 591.78 # 28250 402.13 382.02 439.32 426.14 430.54 417.62 28260 686.08 651.78 749.55 727.06 734.55 712.53 # 28260 515.09 489.34 562.74 545.86 551.48 534.95 28261 995.41 945.64 1,087.49 1,054.86 1,065.74 1,033.76 # 28261 793.78 754.09 867.20 841.19 849.86 824.37 28262 1,456.56 1,383.73 1,591.29 1,543.55 1,559.47 1,512.69 # 28262 1,184.10 1,124.90 1,293.64 1,254.82 1,267.76 1,229.73 28264 867.35 823.98 947.58 919.15 928.63 900.76 # 28264 673.63 639.95 735.94 713.86 721.22 699.59 28270 484.72 460.48 529.55 513.67 518.96 503.40 # 28270 333.17 316.51 363.99 353.06 356.71 346.00 28272 387.96 368.56 423.84 411.13 415.37 402.90 # 28272 253.54 240.86 276.99 268.67 271.45 263.30

Page 65: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 65Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

28280 508.81 483.37 555.88 539.20 544.76 528.41 # 28280 348.69 331.26 380.95 369.52 373.32 362.12 28285 527.39 501.02 576.17 558.89 564.65 547.71 # 28285 376.50 357.68 411.33 398.99 403.11 391.01 28286 443.80 421.61 484.85 470.30 475.16 460.90 # 28286 298.18 283.27 325.76 315.99 319.24 309.66 28288 594.09 564.39 649.05 629.58 636.07 616.99 # 28288 426.40 405.08 465.84 451.87 456.53 442.83 28289 733.52 696.84 801.37 777.32 785.34 761.77 # 28289 463.36 440.19 506.22 491.03 496.10 481.21 28291 722.29 686.18 789.11 765.43 773.33 750.12 # 28291 481.78 457.69 526.34 510.55 515.82 500.34 28292 734.84 698.10 802.82 778.73 786.76 763.16 # 28292 482.48 458.36 527.11 511.30 516.57 501.08 28295 920.17 874.16 1,005.28 975.13 985.18 955.63 # 28295 535.37 508.60 584.89 567.34 573.19 555.99 28296 893.78 849.09 976.45 947.16 956.93 928.22 # 28296 514.90 489.16 562.53 545.66 551.29 534.75 28297 1,027.00 975.65 1,122.00 1,088.34 1,099.56 1,066.57 # 28297 602.00 571.90 657.69 637.95 644.53 625.20 28298 833.92 792.22 911.05 883.72 892.84 866.04 # 28298 495.24 470.48 541.05 524.83 530.23 514.33 28299 983.05 933.90 1,073.99 1,041.76 1,052.50 1,020.92 # 28299 579.46 550.49 633.06 614.08 620.40 601.80 28300 650.01 617.51 710.14 688.83 695.93 675.05 28302 712.83 677.19 778.77 755.40 763.20 740.29 28304 818.73 777.79 894.46 867.63 876.56 850.28 # 28304 607.88 577.49 664.11 644.20 650.83 631.32 28305 667.29 633.93 729.02 707.15 714.44 693.00 28306 604.96 574.71 660.92 641.09 647.70 628.27 # 28306 403.00 382.85 440.28 427.06 431.47 418.52 28307 656.05 623.25 716.74 695.23 702.41 681.33 # 28307 439.59 417.61 480.25 465.84 470.65 456.53 28308 557.80 529.91 609.40 591.11 597.21 579.29 # 28308 375.93 357.13 410.70 398.38 402.49 390.41 28309 901.59 856.51 984.99 955.43 965.29 936.32 28310 539.85 512.86 589.79 572.09 577.99 560.65 # 28310 358.32 340.40 391.46 379.72 383.63 372.13 28312 499.50 474.53 545.71 529.33 534.80 518.74 # 28312 317.64 301.76 347.02 336.62 340.08 329.89 28313 518.42 492.50 566.38 549.39 555.05 538.41 # 28313 356.00 338.20 388.93 377.26 381.16 369.71 28315 475.67 451.89 519.67 504.08 509.28 493.99 # 28315 325.44 309.17 355.55 344.87 348.44 337.97 28320 611.53 580.95 668.09 648.05 654.73 635.09 28322 776.58 737.75 848.41 822.96 831.45 806.51 # 28322 575.61 546.83 628.85 609.99 616.27 597.79 28340 573.32 544.65 626.35 607.56 613.82 595.40 # 28340 414.52 393.79 452.86 439.28 443.80 430.49

Page 66: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 66Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

28341 666.56 633.23 728.21 706.36 713.66 692.24 # 28341 493.92 469.22 539.60 523.41 528.82 512.95 28344 545.94 518.64 596.44 578.54 584.51 566.97 # 28344 353.21 335.55 385.88 374.30 378.17 366.82 28345 524.74 498.50 573.28 556.08 561.81 544.96 # 28345 370.88 352.34 405.19 393.04 397.08 385.17 28360 923.53 877.35 1,008.95 978.68 988.77 959.11 28400 241.73 229.64 264.09 256.16 258.81 251.05 # 28400 221.63 210.55 242.13 234.86 237.29 230.17 28405 386.24 366.93 421.97 409.31 413.53 401.12 # 28405 352.30 334.69 384.89 373.35 377.20 365.88 28406 514.47 488.75 562.06 545.20 550.83 534.30 28415 1,120.03 1,064.03 1,223.63 1,186.93 1,199.16 1,163.19 28420 1,267.91 1,204.51 1,385.19 1,343.63 1,357.48 1,316.75 28430 229.91 218.41 251.17 243.64 246.15 238.76 # 28430 205.20 194.94 224.18 217.45 219.70 213.11 28435 315.06 299.31 344.21 333.88 337.32 327.20 # 28435 283.10 268.95 309.29 300.01 303.11 294.01 28436 437.93 416.03 478.43 464.08 468.87 454.80 28445 1,062.40 1,009.28 1,160.67 1,125.85 1,137.45 1,103.33 28446 1,206.39 1,146.07 1,317.98 1,278.44 1,291.62 1,252.88 28450 210.06 199.56 229.49 222.61 224.91 218.16 # 28450 187.99 178.59 205.38 199.21 201.27 195.24 28455 281.75 267.66 307.81 298.57 301.66 292.61 # 28455 254.41 241.69 277.94 269.61 272.39 264.21 28456 307.22 291.86 335.64 325.57 328.92 319.06 28465 624.56 593.33 682.33 661.86 668.68 648.62 28470 212.73 202.09 232.40 225.43 227.76 220.93 # 28470 199.22 189.26 217.65 211.12 213.29 206.90 28475 250.74 238.20 273.93 265.71 268.46 260.39 # 28475 224.05 212.85 244.78 237.43 239.88 232.68 28476 345.06 327.81 376.98 365.68 369.44 358.36 28485 537.18 510.32 586.87 569.26 575.13 557.88 28490 140.93 133.88 153.96 149.34 150.88 146.35 # 28490 121.83 115.74 133.10 129.11 130.44 126.52 28495 173.49 164.82 189.54 183.86 185.75 180.18 # 28495 147.13 139.77 160.74 155.92 157.52 152.80 28496 432.75 411.11 472.78 458.60 463.32 449.42 # 28496 233.75 222.06 255.37 247.71 250.26 242.75 28505 660.39 627.37 721.48 699.83 707.04 685.84 # 28505 499.29 474.33 545.48 529.12 534.57 518.54 28510 120.45 114.43 131.59 127.65 128.96 125.10 # 28510 117.15 111.29 127.98 124.14 125.42 121.66 28515 157.60 149.72 172.18 167.01 168.74 163.68 # 28515 139.80 132.81 152.73 148.15 149.67 145.19 28525 554.40 526.68 605.68 587.51 593.57 575.76 # 28525 394.28 374.57 430.76 417.83 422.14 409.47 28530 112.28 106.67 122.67 118.99 120.22 116.61 # 28530 100.09 95.09 109.35 106.08 107.17 103.96

Page 67: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 67Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

28531 334.25 317.54 365.17 354.21 357.87 347.13 # 28531 180.72 171.68 197.43 191.51 193.49 187.68 28540 188.74 179.30 206.20 200.01 202.07 196.01 # 28540 171.28 162.72 187.13 181.52 183.39 177.88 28545 288.24 273.83 314.90 305.46 308.60 299.36 # 28545 256.94 244.09 280.70 272.29 275.09 266.83 28546 544.54 517.31 594.91 577.06 583.00 565.51 # 28546 325.45 309.18 355.56 344.89 348.45 337.99 28555 867.03 823.68 947.23 918.82 928.29 900.44 # 28555 665.41 632.14 726.96 705.16 712.43 691.06 28570 175.56 166.78 191.80 186.05 187.96 182.32 # 28570 149.53 142.05 163.36 158.46 160.09 155.28 28575 346.59 329.26 378.65 367.29 371.07 359.94 # 28575 314.96 299.21 344.09 333.76 337.21 327.09 28576 389.43 369.96 425.45 412.69 416.94 404.43 28585 856.33 813.51 935.54 907.47 916.83 889.32 # 28585 677.44 643.57 740.11 717.90 725.31 703.54 28600 215.64 204.86 235.59 228.52 230.87 223.95 # 28600 185.98 176.68 203.18 197.09 199.12 193.14 28605 318.89 302.95 348.39 337.94 341.42 331.18 # 28605 287.92 273.52 314.55 305.11 308.26 299.00 28606 392.37 372.75 428.66 415.81 420.10 407.49 28615 798.31 758.39 872.15 845.99 854.70 829.07 28630 156.05 148.25 170.49 165.37 167.08 162.06 # 28630 110.92 105.37 121.18 117.54 118.75 115.20 28635 172.75 164.11 188.73 183.07 184.95 179.41 # 28635 131.57 124.99 143.74 139.43 140.86 136.64 28636 341.24 324.18 372.81 361.62 365.36 354.38 # 28636 222.31 211.19 242.87 235.58 238.02 230.86 28645 648.21 615.80 708.17 686.93 694.00 673.19 # 28645 483.81 459.62 528.56 512.70 517.99 502.45 28660 114.63 108.90 125.24 121.47 122.73 119.05 # 28660 88.60 84.17 96.80 93.89 94.86 92.01 28665 153.35 145.68 167.53 162.51 164.19 159.25 # 28665 131.27 124.71 143.42 139.12 140.55 136.33 28666 184.50 175.28 201.57 195.52 197.54 191.61 28675 574.07 545.37 627.18 608.36 614.63 596.19 # 28675 409.01 388.56 446.84 433.44 437.91 424.76 28705 1,251.72 1,189.13 1,367.50 1,326.48 1,340.15 1,299.95 28715 936.26 889.45 1,022.87 992.19 1,002.41 972.34 28725 775.91 737.11 847.68 822.25 830.73 805.81 28730 730.64 694.11 798.23 774.28 782.26 758.79 28735 783.83 744.64 856.34 830.65 839.21 814.03 28737 696.95 662.10 761.42 738.58 746.19 723.81 28740 835.12 793.36 912.36 884.99 894.11 867.30 # 28740 621.63 590.55 679.13 658.75 665.55 645.58 28750 799.17 759.21 873.09 846.89 855.63 829.96 # 28750 587.32 557.95 641.64 622.39 628.81 609.95 28755 499.49 474.52 545.70 529.32 534.78 518.73

Page 68: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 68Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 28755 329.16 312.70 359.61 348.82 352.42 341.84 28760 785.52 746.24 858.18 832.43 841.02 815.78 # 28760 580.60 551.57 634.31 615.27 621.62 602.97 28800 542.42 515.30 592.60 574.82 580.74 563.32 28805 738.45 701.53 806.76 782.55 790.63 766.90 28810 432.91 411.26 472.95 458.76 463.48 449.58 28820 555.69 527.91 607.10 588.88 594.95 577.10 # 28820 394.59 374.86 431.09 418.15 422.46 409.79 28825 530.42 503.90 579.49 562.10 567.89 550.85 # 28825 369.97 351.47 404.19 392.07 396.11 384.23 28890 318.77 302.83 348.25 337.81 341.29 331.06 # 28890 224.87 213.63 245.67 238.30 240.76 233.54 29000 291.86 277.27 318.86 309.29 312.48 303.11 # 29000 180.84 171.80 197.57 191.65 193.61 187.82 29010 212.76 202.12 232.44 225.47 227.79 220.96 # 29010 137.97 131.07 150.73 146.21 147.72 143.29 29015 259.13 246.17 283.10 274.60 277.44 269.10 # 29015 168.53 160.10 184.12 178.60 180.44 175.02 29035 247.09 234.74 269.95 261.86 264.56 256.62 # 29035 142.98 135.83 156.20 151.52 153.08 148.49 29040 219.91 208.91 240.25 233.04 235.44 228.38 # 29040 145.45 138.18 158.91 154.13 155.73 151.05 29044 242.52 230.39 264.95 257.00 259.65 251.86 # 29044 152.58 144.95 166.69 161.69 163.36 158.46 29046 254.16 241.45 277.67 269.34 272.11 263.96 # 29046 164.87 156.63 180.12 174.72 176.53 171.22 29049 72.18 68.57 78.86 76.49 77.28 74.96 # 29049 56.37 53.55 61.58 59.73 60.35 58.54 29055 213.18 202.52 232.90 225.91 228.24 221.39 # 29055 136.75 129.91 149.40 144.91 146.41 142.01 29058 120.28 114.27 131.41 127.47 128.78 124.91 # 29058 93.59 88.91 102.25 99.18 100.20 97.20 29065 93.27 88.61 101.90 98.84 99.87 96.86 # 29065 67.57 64.19 73.82 71.60 72.35 70.16 29075 84.35 80.13 92.15 89.39 90.31 87.61 # 29075 61.62 58.54 67.32 65.30 65.98 63.99 29085 92.94 88.29 101.53 98.49 99.50 96.52 # 29085 67.24 63.88 73.46 71.25 71.99 69.83 29086 73.55 69.87 80.35 77.94 78.74 76.37 # 29086 49.17 46.71 53.72 52.11 52.65 51.06 29105 85.63 81.35 93.55 90.75 91.68 88.93 # 29105 59.28 56.32 64.77 62.82 63.47 61.57 29125 62.30 59.19 68.07 66.02 66.71 64.70 # 29125 38.90 36.96 42.50 41.23 41.65 40.40 29126 73.43 69.76 80.22 77.82 78.61 76.27 # 29126 47.73 45.34 52.14 50.58 51.09 49.57 29130 40.22 38.21 43.94 42.62 43.07 41.77 # 29130 28.69 27.26 31.35 30.41 30.72 29.80 29131 49.59 47.11 54.18 52.56 53.10 51.51

Page 69: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 69Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 29131 33.12 31.46 36.18 35.10 35.45 34.40 29200 29.21 27.75 31.91 30.96 31.28 30.34 # 29200 18.34 17.42 20.03 19.44 19.63 19.04 29240 27.89 26.50 30.48 29.57 29.87 28.98 # 29240 18.34 17.42 20.03 19.44 19.63 19.04 29260 28.28 26.87 30.90 29.97 30.28 29.37 # 29260 19.71 18.72 21.53 20.88 21.10 20.47 29280 28.25 26.84 30.87 29.93 30.25 29.34 # 29280 19.68 18.70 21.51 20.86 21.08 20.45 29305 238.12 226.21 260.14 252.33 254.94 247.28 # 29305 157.40 149.53 171.96 166.80 168.52 163.46 29325 265.08 251.83 289.60 280.92 283.81 275.30 # 29325 176.79 167.95 193.14 187.35 189.28 183.60 29345 133.36 126.69 145.69 141.32 142.78 138.49 # 29345 100.75 95.71 110.07 106.77 107.87 104.63 29355 138.09 131.19 150.87 146.34 147.86 143.42 # 29355 106.46 101.14 116.31 112.83 113.99 110.57 29358 156.27 148.46 170.73 165.61 167.31 162.30 # 29358 103.56 98.38 113.14 109.74 110.87 107.55 29365 119.75 113.76 130.82 126.90 128.20 124.36 # 29365 87.14 82.78 95.20 92.35 93.29 90.49 29405 79.80 75.81 87.18 84.57 85.43 82.88 # 29405 59.70 56.72 65.23 63.27 63.93 62.01 29425 76.44 72.62 83.51 81.01 81.85 79.38 # 29425 56.35 53.53 61.56 59.71 60.33 58.51 29435 114.75 109.01 125.36 121.60 122.85 119.17 # 29435 83.12 78.96 90.80 88.08 88.99 86.32 29440 42.98 40.83 46.95 45.55 46.01 44.64 # 29440 29.14 27.68 31.83 30.88 31.20 30.26 29445 132.33 125.71 144.57 140.23 141.68 137.43 # 29445 104.33 99.11 113.98 110.56 111.70 108.35 29450 143.07 135.92 156.31 151.62 153.18 148.58 # 29450 114.08 108.38 124.64 120.90 122.14 118.48 29505 81.03 76.98 88.53 85.87 86.76 84.16 # 29505 49.40 46.93 53.97 52.35 52.89 51.30 29515 70.28 66.77 76.79 74.49 75.24 72.99 # 29515 49.52 47.04 54.10 52.47 53.02 51.43 29520 30.53 29.00 33.35 32.35 32.68 31.71 # 29520 18.67 17.74 20.40 19.79 20.00 19.40 29530 27.89 26.50 30.48 29.57 29.87 28.98 # 29530 18.34 17.42 20.03 19.44 19.63 19.04 29540 25.61 24.33 27.98 27.14 27.42 26.60 # 29540 18.37 17.45 20.07 19.47 19.67 19.08 29550 18.58 17.65 20.30 19.69 19.90 19.30 # 29550 11.67 11.09 12.75 12.37 12.50 12.12 29580 50.91 48.36 55.61 53.95 54.50 52.87 # 29580 35.43 33.66 38.71 37.55 37.94 36.80 29581 59.08 56.13 64.55 62.62 63.26 61.36 # 29581 12.95 12.30 14.15 13.72 13.86 13.44

Page 70: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 70Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

29582 66.95 63.60 73.14 70.94 71.68 69.53 # 29582 15.88 15.09 17.35 16.84 17.01 16.50 29583 41.95 39.85 45.83 44.45 44.91 43.56 # 29583 11.31 10.74 12.35 11.98 12.11 11.74 29584 66.95 63.60 73.14 70.94 71.68 69.53 # 29584 15.88 15.09 17.35 16.84 17.01 16.50 29700 61.24 58.18 66.91 64.89 65.57 63.60 # 29700 33.90 32.21 37.04 35.93 36.31 35.21 29705 65.54 62.26 71.60 69.45 70.16 68.06 # 29705 47.42 45.05 51.81 50.26 50.77 49.25 29710 119.38 113.41 130.42 126.51 127.81 123.98 # 29710 83.80 79.61 91.55 88.80 89.72 87.03 29720 82.47 78.35 90.10 87.40 88.30 85.65 # 29720 44.58 42.35 48.70 47.24 47.73 46.30 29730 63.18 60.02 69.02 66.95 67.64 65.62 # 29730 45.06 42.81 49.23 47.76 48.24 46.81 29740 97.86 92.97 106.92 103.71 104.78 101.64 # 29740 70.84 67.30 77.40 75.07 75.84 73.57 29750 89.33 84.86 97.59 94.66 95.63 92.76 # 29750 69.23 65.77 75.64 73.37 74.12 71.90 29800 523.99 497.79 572.46 555.29 561.00 544.18 29804 641.94 609.84 701.32 680.27 687.29 666.67 29805 468.04 444.64 511.34 496.00 501.11 486.07 29806 1,060.90 1,007.86 1,159.04 1,124.26 1,135.86 1,101.78 29807 1,034.22 982.51 1,129.89 1,095.98 1,107.29 1,074.07 29819 582.30 553.19 636.17 617.08 623.45 604.74 29820 530.57 504.04 579.65 562.26 568.05 551.01 29821 579.65 550.67 633.27 614.27 620.61 601.99 29822 562.77 534.63 614.82 596.38 602.53 584.45 29823 614.09 583.39 670.90 650.77 657.48 637.76 29824 661.67 628.59 722.88 701.19 708.42 687.17 29825 572.97 544.32 625.97 607.19 613.44 595.04 29826 178.57 169.64 195.09 189.23 191.19 185.45 29827 1,053.53 1,000.85 1,150.98 1,116.44 1,127.95 1,094.11 29828 908.39 862.97 992.42 962.64 972.57 943.39 29830 452.84 430.20 494.73 479.88 484.84 470.28 29834 482.97 458.82 527.64 511.82 517.09 501.58 29835 496.97 472.12 542.94 526.65 532.08 516.12 29836 567.32 538.95 619.79 601.20 607.40 589.17 29837 518.63 492.70 566.61 549.61 555.28 538.61 29838 583.53 554.35 637.50 618.38 624.75 606.02 29840 445.73 423.44 486.96 472.35 477.22 462.91 29843 480.34 456.32 524.77 509.02 514.27 498.85 29844 491.12 466.56 536.54 520.44 525.81 510.04 29845 570.92 542.37 623.73 605.02 611.25 592.92 29846 515.62 489.84 563.32 546.41 552.05 535.49 29847 538.31 511.39 588.10 570.46 576.33 559.05 29848 505.94 480.64 552.74 536.15 541.68 525.44 29850 603.71 573.52 659.55 639.76 646.36 626.96

Page 71: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 71Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

29851 902.04 856.94 985.48 955.91 965.77 936.80 29855 779.05 740.10 851.12 825.59 834.10 809.07 29856 991.66 942.08 1,083.39 1,050.89 1,061.73 1,029.87 29860 657.30 624.44 718.11 696.57 703.74 682.64 29861 718.16 682.25 784.59 761.05 768.90 745.82 29862 802.02 761.92 876.21 849.92 858.68 832.92 29863 801.81 761.72 875.98 849.70 858.46 832.70 29866 1,034.69 982.96 1,130.40 1,096.49 1,107.80 1,074.56 29867 1,280.75 1,216.71 1,399.22 1,357.24 1,371.24 1,330.10 29868 1,653.48 1,570.81 1,806.43 1,752.24 1,770.30 1,717.20 29870 567.50 539.13 620.00 601.40 607.60 589.38 # 29870 407.72 387.33 445.43 432.07 436.52 423.43 29871 511.24 485.68 558.53 541.78 547.37 530.94 29873 517.20 491.34 565.04 548.09 553.74 537.13 29874 534.24 507.53 583.66 566.15 571.99 554.82 29875 491.49 466.92 536.96 520.85 526.22 510.43 29876 654.67 621.94 715.23 693.77 700.93 679.89 29877 617.88 586.99 675.04 654.79 661.54 641.69 29879 659.19 626.23 720.16 698.56 705.77 684.58 29880 558.67 530.74 610.35 592.04 598.15 580.20 29881 537.31 510.44 587.01 569.40 575.26 558.01 29882 699.13 664.17 763.80 740.88 748.52 726.06 29883 842.74 800.60 920.69 893.07 902.28 875.21 29884 610.08 579.58 666.52 646.52 653.19 633.59 29885 744.14 706.93 812.97 788.58 796.71 772.81 29886 631.93 600.33 690.38 669.67 676.57 656.27 29887 736.21 699.40 804.31 780.18 788.22 764.58 29888 985.17 935.91 1,076.30 1,044.00 1,054.77 1,023.12 29889 1,221.37 1,160.30 1,334.35 1,294.31 1,307.65 1,268.43 29891 669.33 635.86 731.24 709.30 716.61 695.11 29892 647.10 614.75 706.96 685.76 692.83 672.04 29893 600.44 570.42 655.98 636.31 642.86 623.58 # 29893 424.84 403.60 464.14 450.21 454.86 441.21 29894 495.57 470.79 541.41 525.17 530.58 514.67 29895 475.88 452.09 519.90 504.31 509.51 494.22 29897 501.61 476.53 548.01 531.56 537.05 520.94 29898 562.91 534.76 614.97 596.53 602.67 584.60 29899 1,038.60 986.67 1,134.67 1,100.63 1,111.98 1,078.62 29900 416.12 395.31 454.61 440.97 445.51 432.15 29901 520.74 494.70 568.91 551.84 557.53 540.80 29902 483.79 459.60 528.54 512.68 517.97 502.42 29904 625.46 594.19 683.32 662.81 669.66 649.55 29905 676.25 642.44 738.81 716.65 724.03 702.32 29906 688.90 654.46 752.63 730.05 737.58 715.45 29907 873.47 829.80 954.27 925.65 935.18 907.13 29914 992.30 942.69 1,084.09 1,051.57 1,062.42 1,030.54 29915 1,010.73 960.19 1,104.22 1,071.09 1,082.14 1,049.66 29916 1,011.72 961.13 1,105.30 1,072.15 1,083.20 1,050.70 30000 218.45 207.53 238.66 231.50 233.89 226.86

Page 72: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 72Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 30000 115.33 109.56 125.99 122.21 123.48 119.76 30020 221.42 210.35 241.90 234.65 237.06 229.95 # 30020 116.32 110.50 127.08 123.27 124.53 120.81 30100 134.27 127.56 146.69 142.29 143.76 139.45 # 30100 67.72 64.33 73.98 71.76 72.50 70.32 30110 220.12 209.11 240.48 233.27 235.67 228.60 # 30110 127.54 121.16 139.33 135.16 136.55 132.46 30115 417.85 396.96 456.50 442.81 447.37 433.95 30117 825.71 784.42 902.08 875.02 884.04 857.52 # 30117 328.89 312.45 359.32 348.54 352.13 341.57 30118 753.03 715.38 822.69 798.01 806.23 782.05 30120 507.22 481.86 554.14 537.51 543.05 526.76 # 30120 431.77 410.18 471.71 457.55 462.28 448.40 30124 277.62 263.74 303.30 294.20 297.24 288.32 30125 590.84 561.30 645.50 626.13 632.58 613.61 30130 367.12 348.76 401.07 389.05 393.05 381.26 30140 422.52 401.39 461.60 447.75 452.36 438.79 30150 751.26 713.70 820.76 796.13 804.34 780.21 30160 755.52 717.74 825.40 800.64 808.90 784.63 30200 107.71 102.32 117.67 114.14 115.31 111.86 # 30200 58.29 55.38 63.69 61.78 62.41 60.55 30210 143.15 135.99 156.39 151.70 153.26 148.66 # 30210 97.03 92.18 106.01 102.82 103.89 100.76 30220 287.03 272.68 313.58 304.18 307.31 298.09 # 30220 122.31 116.19 133.62 129.61 130.95 127.02 30300 169.66 161.18 185.36 179.79 181.65 176.19 # 30300 102.78 97.64 112.29 108.92 110.04 106.74 30310 199.46 189.49 217.91 211.38 213.56 207.15 30320 437.31 415.44 477.76 463.43 468.20 454.16 30400 979.73 930.74 1,070.35 1,038.24 1,048.95 1,017.47 30410 1,145.73 1,088.44 1,251.71 1,214.16 1,226.67 1,189.87 30420 1,337.25 1,270.39 1,460.95 1,417.12 1,431.73 1,388.77 30430 826.95 785.60 903.44 876.33 885.37 858.81 30435 1,219.55 1,158.57 1,332.36 1,292.38 1,305.71 1,266.53 30450 1,460.39 1,387.37 1,595.48 1,547.61 1,563.56 1,516.67 30460 799.47 759.50 873.43 847.23 855.96 830.29 30462 1,387.77 1,318.38 1,516.14 1,470.65 1,485.81 1,441.24 30465 957.89 910.00 1,046.50 1,015.11 1,025.57 994.81 30520 605.03 574.78 661.00 641.17 647.77 628.35 30540 673.02 639.37 735.28 713.22 720.57 698.96 30545 868.37 824.95 948.69 920.23 929.72 901.83 30560 253.81 241.12 277.29 268.97 271.75 263.59 # 30560 132.57 125.94 144.83 140.48 141.93 137.68 30580 637.97 606.07 696.98 676.07 683.04 662.55 # 30580 507.18 481.82 554.09 537.48 543.01 526.72 30600 553.42 525.75 604.61 586.48 592.53 574.75 # 30600 421.97 400.87 461.00 447.17 451.78 438.22 30620 603.97 573.77 659.84 640.04 646.63 627.24 30630 605.31 575.04 661.30 641.46 648.07 628.62

Page 73: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 73Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

30801 216.95 206.10 237.02 229.91 232.28 225.31 # 30801 131.29 124.73 143.44 139.14 140.58 136.36 30802 277.48 263.61 303.15 294.06 297.09 288.18 # 30802 184.57 175.34 201.64 195.59 197.60 191.68 30901 92.66 88.03 101.23 98.20 99.21 96.23 # 30901 57.40 54.53 62.71 60.82 61.46 59.60 30903 211.41 200.84 230.97 224.03 226.34 219.55 # 30903 81.28 77.22 88.80 86.14 87.03 84.41 30905 259.96 246.96 284.00 275.48 278.32 269.97 # 30905 107.10 101.75 117.01 113.51 114.68 111.24 30906 332.41 315.79 363.16 352.27 355.89 345.22 # 30906 137.70 130.82 150.44 145.94 147.43 143.01 30915 562.29 534.18 614.31 595.87 602.03 583.96 30920 819.60 778.62 895.41 868.55 877.51 851.17 30930 119.36 113.39 130.40 126.49 127.79 123.96 31000 175.67 166.89 191.92 186.16 188.08 182.44 # 31000 103.19 98.03 112.73 109.35 110.48 107.17 31002 184.34 175.12 201.39 195.35 197.36 191.44 31020 463.35 440.18 506.21 491.02 496.09 481.19 # 31020 347.05 329.70 379.16 367.78 371.58 360.42 31030 665.38 632.11 726.93 705.12 712.39 691.02 # 31030 515.48 489.71 563.17 546.27 551.91 535.35 31032 559.55 531.57 611.31 592.96 599.08 581.11 31040 746.30 708.99 815.34 790.88 799.03 775.07 31050 469.70 446.22 513.15 497.75 502.90 487.80 31051 626.91 595.56 684.89 664.34 671.20 651.06 31070 423.97 402.77 463.19 449.29 453.92 440.31 31075 765.64 727.36 836.46 811.37 819.73 795.14 31080 1,020.73 969.69 1,115.14 1,081.69 1,092.85 1,060.06 31081 1,459.01 1,386.06 1,593.97 1,546.15 1,562.09 1,515.23 31084 1,162.53 1,104.40 1,270.06 1,231.96 1,244.66 1,207.32 31085 1,559.31 1,481.34 1,703.54 1,652.44 1,669.47 1,619.38 31086 1,108.53 1,053.10 1,211.07 1,174.74 1,186.85 1,151.24 31087 1,069.38 1,015.91 1,168.30 1,133.24 1,144.93 1,110.58 31090 994.24 944.53 1,086.21 1,053.62 1,064.49 1,032.55 31200 551.47 523.90 602.49 584.41 590.43 572.72 31201 720.12 684.11 786.73 763.13 770.99 747.87 31205 875.58 831.80 956.57 927.88 937.43 909.32 31225 1,850.27 1,757.76 2,021.42 1,960.78 1,980.99 1,921.57 31230 2,040.89 1,938.85 2,229.68 2,162.78 2,185.08 2,119.53 31231 198.71 188.77 217.09 210.58 212.74 206.37 # 31231 64.95 61.70 70.96 68.83 69.54 67.45 31233 251.77 239.18 275.06 266.80 269.56 261.46 # 31233 136.13 129.32 148.72 144.26 145.74 141.37 31235 287.87 273.48 314.50 305.07 308.21 298.97 # 31235 161.03 152.98 175.93 170.65 172.41 167.23 31237 249.89 237.40 273.01 264.82 267.55 259.52 # 31237 160.61 152.58 175.47 170.20 171.96 166.80 31238 250.03 237.53 273.16 264.96 267.70 259.66

Page 74: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 74Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 31238 168.33 159.91 183.90 178.38 180.22 174.81 31239 608.52 578.09 664.80 644.86 651.51 631.97 31240 160.34 152.32 175.17 169.91 171.66 166.52 31254 273.24 259.58 298.52 289.56 292.55 283.76 31255 400.56 380.53 437.61 424.48 428.86 415.99 31256 197.52 187.64 215.79 209.31 211.47 205.13 31267 317.45 301.58 346.82 336.41 339.88 329.68 31276 505.42 480.15 552.17 535.61 541.13 524.91 31287 231.89 220.30 253.35 245.74 248.27 240.83 31288 269.05 255.60 293.94 285.12 288.06 279.42 31290 1,151.64 1,094.06 1,258.17 1,220.43 1,233.01 1,196.02 31291 1,229.23 1,167.77 1,342.94 1,302.65 1,316.07 1,276.60 31292 994.38 944.66 1,086.36 1,053.77 1,064.64 1,032.69 31293 1,081.16 1,027.10 1,181.17 1,145.73 1,157.54 1,122.81 31294 1,251.48 1,188.91 1,367.25 1,326.23 1,339.90 1,299.71 31295 1,897.20 1,802.34 2,072.69 2,010.51 2,031.23 1,970.30 # 31295 163.60 155.42 178.73 173.37 175.16 169.90 31296 1,937.06 1,840.21 2,116.24 2,052.75 2,073.92 2,011.70 # 31296 196.20 186.39 214.35 207.92 210.06 203.76 31297 1,899.96 1,804.96 2,075.70 2,013.43 2,034.19 1,973.16 # 31297 160.42 152.40 175.26 170.00 171.75 166.60 31300 1,282.77 1,218.63 1,401.42 1,359.38 1,373.40 1,332.19 31320 548.69 521.26 599.45 581.46 587.45 569.84 31360 2,091.58 1,987.00 2,285.05 2,216.50 2,239.35 2,172.17 31365 2,586.00 2,456.70 2,825.21 2,740.45 2,768.71 2,685.64 31367 2,206.33 2,096.01 2,410.41 2,338.10 2,362.20 2,291.34 31368 2,456.62 2,333.79 2,683.86 2,603.35 2,630.18 2,551.28 31370 2,073.91 1,970.21 2,265.74 2,197.77 2,220.43 2,153.81 31375 1,966.01 1,867.71 2,147.87 2,083.43 2,104.91 2,041.77 31380 1,938.76 1,841.82 2,118.09 2,054.56 2,075.73 2,013.47 31382 2,134.67 2,027.94 2,332.13 2,262.17 2,285.49 2,216.92 31390 2,880.46 2,736.44 3,146.91 3,052.50 3,083.97 2,991.45 31395 3,041.74 2,889.65 3,323.10 3,223.40 3,256.64 3,158.94 31400 966.33 918.01 1,055.71 1,024.04 1,034.60 1,003.56 31420 820.60 779.57 896.51 869.61 878.58 852.22 31500 143.96 136.76 157.27 152.56 154.12 149.51 31502 35.42 33.65 38.70 37.54 37.93 36.79 31505 79.12 75.16 86.43 83.85 84.71 82.17 # 31505 48.48 46.06 52.97 51.38 51.91 50.36 31510 205.13 194.87 224.10 217.37 219.62 213.03 # 31510 121.77 115.68 133.03 129.04 130.38 126.47 31511 205.59 195.31 224.61 217.87 220.11 213.51 # 31511 130.15 123.64 142.19 137.92 139.35 135.16 31512 200.33 190.31 218.86 212.29 214.48 208.05 # 31512 130.15 123.64 142.19 137.92 139.35 135.16 31513 132.28 125.67 144.52 140.19 141.63 137.38 31515 176.15 167.34 192.44 186.67 188.59 182.93 # 31515 104.33 99.11 113.98 110.56 111.70 108.35 31520 157.20 149.34 171.74 166.59 168.30 163.25

Page 75: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 75Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

31525 246.05 233.75 268.81 260.75 263.44 255.54 # 31525 160.72 152.68 175.58 170.32 172.07 166.91 31526 157.88 149.99 172.49 167.31 169.04 163.97 31527 195.84 186.05 213.96 207.54 209.68 203.39 31528 145.35 138.08 158.79 154.03 155.62 150.95 31529 162.55 154.42 177.58 172.26 174.03 168.81 31530 199.49 189.52 217.95 211.40 213.59 207.17 31531 213.32 202.65 233.05 226.06 228.39 221.54 31535 190.52 180.99 208.14 201.89 203.98 197.86 31536 212.24 201.63 231.87 224.92 227.24 220.42 31540 243.83 231.64 266.39 258.39 261.06 253.23 31541 265.91 252.61 290.50 281.78 284.69 276.15 31545 365.41 347.14 399.21 387.24 391.23 379.50 31546 555.85 528.06 607.27 589.05 595.13 577.28 31551 1,413.89 1,343.20 1,544.68 1,498.34 1,513.79 1,468.37 31552 1,425.36 1,354.09 1,557.20 1,510.49 1,526.06 1,480.28 31553 1,552.94 1,475.29 1,696.58 1,645.68 1,662.65 1,612.77 31554 1,631.36 1,549.79 1,782.26 1,728.80 1,746.61 1,694.21 31560 315.72 299.93 344.92 334.57 338.02 327.88 31561 345.96 328.66 377.96 366.62 370.40 359.28 31570 330.70 314.17 361.30 350.45 354.07 343.45 # 31570 231.21 219.65 252.60 245.02 247.55 240.12 31571 251.88 239.29 275.18 266.93 269.68 261.59 31572 476.29 452.48 520.35 504.75 509.94 494.65 # 31572 181.76 172.67 198.57 192.61 194.60 188.76 31573 256.25 243.44 279.96 271.56 274.36 266.13 # 31573 149.84 142.35 163.70 158.79 160.43 155.62 31574 968.87 920.43 1,058.49 1,026.74 1,037.32 1,006.20 # 31574 149.84 142.35 163.70 158.79 160.43 155.62 31575 109.56 104.08 119.69 116.10 117.30 113.78 # 31575 67.06 63.71 73.27 71.07 71.81 69.64 31576 254.40 241.68 277.93 269.59 272.38 264.20 # 31576 119.32 113.35 130.35 126.44 127.74 123.91 31577 264.32 251.10 288.77 280.11 282.99 274.51 # 31577 134.85 128.11 147.33 142.91 144.38 140.05 31578 290.51 275.98 317.38 307.86 311.03 301.70 # 31578 149.84 142.35 163.70 158.79 160.43 155.62 31579 172.34 163.72 188.28 182.63 184.52 178.97 # 31579 119.62 113.64 130.69 126.76 128.08 124.23 31580 1,226.31 1,164.99 1,339.74 1,299.55 1,312.94 1,273.56 31584 1,365.36 1,297.09 1,491.65 1,446.91 1,461.82 1,417.97 31587 1,148.29 1,090.88 1,254.51 1,216.87 1,229.42 1,192.54 31590 848.91 806.46 927.43 899.61 908.88 881.61 31591 1,028.72 977.28 1,123.87 1,090.15 1,101.39 1,068.35 31592 1,674.62 1,590.89 1,829.52 1,774.63 1,792.93 1,739.15 31595 743.31 706.14 812.06 787.70 795.82 771.95 31600 402.58 382.45 439.82 426.63 431.02 418.09 31601 215.02 204.27 234.91 227.86 230.21 223.31 31603 226.42 215.10 247.37 239.95 242.42 235.15

Page 76: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 76Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

31605 187.64 178.26 205.00 198.85 200.89 194.87 31610 703.56 668.38 768.64 745.58 753.26 730.66 31611 524.89 498.65 573.45 556.24 561.98 545.12 31612 81.20 77.14 88.71 86.05 86.94 84.33 # 31612 48.91 46.46 53.43 51.83 52.36 50.80 31613 443.11 420.95 484.09 469.57 474.41 460.17 31614 738.50 701.58 806.82 782.61 790.68 766.96 31615 163.95 155.75 179.11 173.74 175.54 170.27 # 31615 115.19 109.43 125.84 122.07 123.33 119.63 31622 234.27 222.56 255.94 248.26 250.83 243.29 # 31622 133.78 127.09 146.15 141.77 143.23 138.93 31623 262.06 248.96 286.30 277.71 280.58 272.16 # 31623 135.88 129.09 148.45 144.00 145.49 141.13 31624 245.62 233.34 268.34 260.29 262.97 255.08 # 31624 137.56 130.68 150.28 145.77 147.28 142.85 31625 320.65 304.62 350.31 339.80 343.31 333.01 # 31625 159.21 151.25 173.94 168.72 170.46 165.35 31626 800.85 760.81 874.93 848.69 857.43 831.71 # 31626 202.55 192.42 221.28 214.65 216.86 210.36 31627 1,312.80 1,247.16 1,434.23 1,391.21 1,405.55 1,363.39 # 31627 99.40 94.43 108.59 105.34 106.42 103.24 31628 340.72 323.68 372.23 361.07 364.79 353.84 # 31628 178.96 170.01 195.51 189.65 191.60 185.85 31629 419.23 398.27 458.01 444.27 448.85 435.38 # 31629 190.59 181.06 208.22 201.97 204.06 197.94 31630 203.01 192.86 221.79 215.13 217.35 210.83 31631 233.04 221.39 254.60 246.96 249.50 242.03 31632 63.88 60.69 69.79 67.70 68.40 66.34 # 31632 50.05 47.55 54.68 53.04 53.59 51.98 31633 79.65 75.67 87.02 84.41 85.28 82.72 # 31633 64.50 61.28 70.47 68.36 69.06 66.99 31634 1,688.60 1,604.17 1,844.80 1,789.45 1,807.90 1,753.66 # 31634 197.14 187.28 215.37 208.91 211.06 204.73 31635 273.33 259.66 298.61 289.65 292.64 283.85 # 31635 178.12 169.21 194.59 188.75 190.70 184.98 31636 223.97 212.77 244.69 237.35 239.79 232.60 31637 75.50 71.73 82.49 80.02 80.85 78.42 31638 255.29 242.53 278.91 270.54 273.33 265.13 31640 256.70 243.87 280.45 272.03 274.84 266.59 31641 261.85 248.76 286.07 277.50 280.35 271.94 31643 179.83 170.84 196.47 190.57 192.53 186.76 31645 248.18 235.77 271.14 263.01 265.71 257.75 # 31645 151.32 143.75 165.31 160.36 162.01 157.15 31646 223.04 211.89 243.67 236.36 238.80 231.63 # 31646 129.15 122.69 141.09 136.86 138.28 134.12 31647 214.55 203.82 234.39 227.37 229.70 222.82 31648 196.09 186.29 214.23 207.81 209.94 203.65 31649 70.87 67.33 77.43 75.11 75.88 73.60 31651 75.86 72.07 82.88 80.40 81.22 78.79

Page 77: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 77Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

31652 787.89 748.50 860.78 834.96 843.56 818.26 # 31652 225.83 214.54 246.72 239.32 241.79 234.53 31653 834.64 792.91 911.85 884.49 893.61 866.80 # 31653 250.18 237.67 273.32 265.12 267.86 259.82 31654 122.77 116.63 134.12 130.10 131.45 127.50 # 31654 69.07 65.62 75.46 73.20 73.96 71.74 31660 199.15 189.19 217.57 211.04 213.22 206.82 31661 210.15 199.64 229.59 222.70 225.00 218.25 31717 250.17 237.66 273.31 265.11 267.85 259.81 # 31717 109.49 104.02 119.62 116.04 117.23 113.71 31720 52.86 50.22 57.75 56.02 56.60 54.90 31725 79.63 75.65 87.00 84.39 85.26 82.70 31730 1,165.34 1,107.07 1,273.13 1,234.94 1,247.67 1,210.24 # 31730 152.25 144.64 166.34 161.35 163.01 158.11 31750 1,375.36 1,306.59 1,502.58 1,457.50 1,472.53 1,428.35 31755 1,733.22 1,646.56 1,893.54 1,836.73 1,855.67 1,800.00 31760 1,411.18 1,340.62 1,541.71 1,495.46 1,510.88 1,465.55 31766 1,815.28 1,724.52 1,983.20 1,923.70 1,943.53 1,885.22 31770 1,358.46 1,290.54 1,484.12 1,439.59 1,454.44 1,410.80 31775 1,295.63 1,230.85 1,415.48 1,373.01 1,387.16 1,345.55 31780 1,185.15 1,125.89 1,294.77 1,255.93 1,268.88 1,230.81 31781 1,414.65 1,343.92 1,545.51 1,499.14 1,514.60 1,469.16 31785 1,086.39 1,032.07 1,186.88 1,151.28 1,163.14 1,128.25 31786 1,508.21 1,432.80 1,647.72 1,598.29 1,614.76 1,566.32 31800 719.39 683.42 785.93 762.36 770.21 747.11 31805 828.00 786.60 904.59 877.45 886.50 859.90 31820 421.88 400.79 460.91 447.09 451.69 438.14 # 31820 324.03 307.83 354.00 343.39 346.92 336.52 31825 586.49 557.17 640.75 621.52 627.93 609.09 # 31825 475.13 451.37 519.08 503.50 508.69 493.43 31830 430.18 408.67 469.97 455.87 460.58 446.75 # 31830 339.25 322.29 370.63 359.51 363.22 352.33 32035 729.60 693.12 797.09 773.18 781.15 757.71 32036 780.23 741.22 852.40 826.83 835.36 810.29 32096 818.28 777.37 893.98 867.16 876.09 849.82 32097 816.18 775.37 891.68 864.93 873.84 847.63 32098 773.68 735.00 845.25 819.89 828.35 803.49 32100 822.92 781.77 899.04 872.07 881.05 854.62 32110 1,486.37 1,412.05 1,623.86 1,575.14 1,591.38 1,543.65 32120 882.83 838.69 964.49 935.56 945.21 916.85 32124 939.45 892.48 1,026.35 995.57 1,005.82 975.66 32140 1,000.28 950.27 1,092.81 1,060.02 1,070.95 1,038.82 32141 1,551.55 1,473.97 1,695.07 1,644.21 1,661.16 1,611.33 32150 1,018.78 967.84 1,113.02 1,079.62 1,090.75 1,058.02 32151 1,016.36 965.54 1,110.37 1,077.06 1,088.16 1,055.52 32160 800.48 760.46 874.53 848.30 857.04 831.34 32200 1,142.31 1,085.19 1,247.97 1,210.52 1,223.01 1,186.32 32215 806.29 765.98 880.88 854.45 863.26 837.36 32220 1,605.02 1,524.77 1,753.49 1,700.88 1,718.41 1,666.87

Page 78: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 78Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

32225 1,006.87 956.53 1,100.01 1,067.00 1,078.01 1,045.66 32310 926.08 879.78 1,011.75 981.40 991.51 961.77 32320 1,621.12 1,540.06 1,771.07 1,717.94 1,735.65 1,683.58 32400 147.31 139.94 160.93 156.10 157.71 152.98 # 32400 88.67 84.24 96.88 93.97 94.94 92.09 32405 368.77 350.33 402.88 390.79 394.82 382.97 # 32405 92.36 87.74 100.90 97.88 98.89 95.92 32440 1,590.18 1,510.67 1,737.27 1,685.15 1,702.53 1,651.45 32442 3,140.79 2,983.75 3,431.31 3,328.38 3,362.69 3,261.81 32445 3,616.95 3,436.10 3,951.52 3,832.97 3,872.49 3,756.31 32480 1,502.92 1,427.77 1,641.94 1,592.68 1,609.09 1,560.83 32482 1,607.21 1,526.85 1,755.88 1,703.20 1,720.76 1,669.13 32484 1,460.87 1,387.83 1,596.00 1,548.13 1,564.08 1,517.17 32486 2,399.33 2,279.36 2,621.26 2,542.63 2,568.84 2,491.77 32488 2,447.31 2,324.94 2,673.68 2,593.47 2,620.21 2,541.60 32491 1,495.41 1,420.64 1,633.74 1,584.72 1,601.06 1,553.03 32501 250.80 238.26 274.00 265.78 268.51 260.46 32503 1,838.83 1,746.89 2,008.92 1,948.65 1,968.74 1,909.68 32504 2,113.41 2,007.74 2,308.90 2,239.64 2,262.73 2,194.84 32505 944.73 897.49 1,032.11 1,001.16 1,011.47 981.13 32506 160.38 152.36 175.21 169.96 171.71 166.55 32507 160.38 152.36 175.21 169.96 171.71 166.55 32540 1,764.56 1,676.33 1,927.78 1,869.95 1,889.22 1,832.55 32550 679.39 645.42 742.23 719.97 727.39 705.57 # 32550 212.54 201.91 232.20 225.23 227.55 220.72 32551 160.66 152.63 175.52 170.26 172.02 166.85 32552 182.50 173.38 199.39 193.41 195.40 189.54 # 32552 159.44 151.47 174.19 168.97 170.71 165.59 32553 500.29 475.28 546.57 530.17 535.64 519.57 # 32553 184.34 175.12 201.39 195.35 197.36 191.44 32554 195.02 185.27 213.06 206.67 208.79 202.54 # 32554 91.24 86.68 99.68 96.69 97.69 94.76 32555 278.71 264.77 304.49 295.35 298.39 289.44 # 32555 114.31 108.59 124.88 121.13 122.38 118.70 32556 525.75 499.46 574.38 557.15 562.89 546.01 # 32556 125.46 119.19 137.07 132.95 134.33 130.30 32557 488.34 463.92 533.51 517.50 522.84 507.15 # 32557 155.92 148.12 170.34 165.23 166.93 161.93 32560 233.57 221.89 255.17 247.51 250.07 242.57 # 32560 79.72 75.73 87.09 84.48 85.35 82.79 32561 91.53 86.95 99.99 96.99 97.99 95.05 # 32561 69.79 66.30 76.25 73.96 74.72 72.47 32562 82.20 78.09 89.80 87.11 88.01 85.38 # 32562 62.76 59.62 68.56 66.50 67.19 65.17 32601 314.27 298.56 343.34 333.04 336.48 326.38 32604 493.40 468.73 539.04 522.87 528.26 512.42 32606 472.08 448.48 515.75 500.28 505.44 490.28 32607 314.30 298.59 343.38 333.07 336.51 326.42 32608 386.02 366.72 421.73 409.08 413.30 400.90

Page 79: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 79Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

32609 263.45 250.28 287.82 279.19 282.06 273.60 32650 672.84 639.20 735.08 713.02 720.38 698.76 32651 1,112.21 1,056.60 1,215.09 1,178.64 1,190.79 1,155.06 32652 1,690.20 1,605.69 1,846.54 1,791.15 1,809.62 1,755.33 32653 1,074.94 1,021.19 1,174.37 1,139.13 1,150.89 1,116.35 32654 1,203.21 1,143.05 1,314.51 1,275.07 1,288.22 1,249.57 32655 969.59 921.11 1,059.28 1,027.50 1,038.09 1,006.95 32656 811.19 770.63 886.22 859.64 868.50 842.44 32658 722.37 686.25 789.19 765.51 773.41 750.20 32659 740.24 703.23 808.71 784.45 792.55 768.76 32661 810.45 769.93 885.42 858.85 867.71 841.67 32662 904.75 859.51 988.44 958.78 968.67 939.61 32663 1,425.25 1,353.99 1,557.09 1,510.38 1,525.95 1,480.17 32664 856.41 813.59 935.63 907.56 916.92 889.41 32665 1,254.88 1,192.14 1,370.96 1,329.84 1,343.55 1,303.24 32666 882.64 838.51 964.29 935.35 945.00 916.64 32667 161.07 153.02 175.97 170.69 172.45 167.28 32668 161.07 153.02 175.97 170.69 172.45 167.28 32669 1,368.63 1,300.20 1,495.23 1,450.37 1,465.33 1,421.37 32670 1,632.08 1,550.48 1,783.05 1,729.57 1,747.39 1,694.97 32671 1,810.82 1,720.28 1,978.32 1,918.97 1,938.75 1,880.60 32672 1,551.50 1,473.93 1,695.02 1,644.17 1,661.12 1,611.29 32673 1,236.66 1,174.83 1,351.05 1,310.53 1,324.03 1,284.32 32674 221.46 210.39 241.95 234.69 237.11 230.00 32701 219.25 208.29 239.53 232.35 234.74 227.70 32800 957.78 909.89 1,046.37 1,014.98 1,025.44 994.68 32810 904.75 859.51 988.44 958.78 968.67 939.61 32815 2,842.81 2,700.67 3,105.77 3,012.60 3,043.66 2,952.35 32820 1,422.99 1,351.84 1,554.62 1,507.97 1,523.52 1,477.81 32851 3,366.56 3,198.23 3,677.96 3,567.62 3,604.41 3,496.26 32852 3,679.64 3,495.66 4,020.01 3,899.41 3,939.61 3,821.42 32853 4,699.89 4,464.90 5,134.64 4,980.59 5,031.94 4,880.98 32854 4,990.55 4,741.02 5,452.17 5,288.61 5,343.13 5,182.83 32855 204.08 193.88 222.96 216.27 218.50 211.95 32856 306.10 290.80 334.42 324.39 327.73 317.91 32900 1,427.33 1,355.96 1,559.35 1,512.57 1,528.17 1,482.32 32905 1,365.98 1,297.68 1,492.33 1,447.56 1,462.49 1,418.62 32906 1,685.84 1,601.55 1,841.78 1,786.53 1,804.95 1,750.79 32940 1,258.23 1,195.32 1,374.62 1,333.38 1,347.12 1,306.71 32960 126.43 120.11 138.13 133.99 135.37 131.31 # 32960 94.15 89.44 102.86 99.77 100.80 97.77 32997 348.62 331.19 380.87 369.44 373.26 362.05 32998 1,828.60 1,737.17 1,997.75 1,937.81 1,957.79 1,899.05 # 32998 288.05 273.65 314.70 305.26 308.41 299.15 33010 109.57 104.09 119.70 116.12 117.31 113.79 33011 110.61 105.08 120.84 117.22 118.43 114.87 33015 518.45 492.53 566.41 549.41 555.08 538.43 33020 893.58 848.90 976.24 946.94 956.71 928.00 33025 811.12 770.56 886.14 859.56 868.42 842.36

Page 80: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 80Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

33030 2,044.14 1,941.93 2,233.22 2,166.22 2,188.55 2,122.90 33031 2,523.16 2,397.00 2,756.55 2,673.85 2,701.42 2,620.38 33050 1,013.39 962.72 1,107.13 1,073.92 1,084.99 1,052.43 33120 2,144.90 2,037.66 2,343.31 2,273.01 2,296.45 2,227.55 33130 1,407.21 1,336.85 1,537.38 1,491.25 1,506.63 1,461.43 33140 1,610.82 1,530.28 1,759.82 1,707.03 1,724.62 1,672.88 33141 135.31 128.54 147.82 143.38 144.87 140.52 33202 788.81 749.37 861.78 835.92 844.54 819.20 33203 819.60 778.62 895.41 868.55 877.51 851.17 33206 456.68 433.85 498.93 483.95 488.95 474.27 33207 487.78 463.39 532.90 516.91 522.24 506.58 33208 529.60 503.12 578.59 561.23 567.02 550.01 33210 169.39 160.92 185.06 179.50 181.36 175.92 33211 173.34 164.67 189.37 183.69 185.59 180.02 33212 323.80 307.61 353.75 343.14 346.68 336.27 33213 338.96 322.01 370.31 359.20 362.91 352.02 33214 483.61 459.43 528.34 512.50 517.78 502.25 33215 314.61 298.88 343.71 333.40 336.84 326.73 33216 373.80 355.11 408.38 396.13 400.21 388.21 33217 366.73 348.39 400.65 388.63 392.63 380.86 33218 392.68 373.05 429.01 416.14 420.43 407.81 33220 393.25 373.59 429.63 416.74 421.04 408.40 33221 364.67 346.44 398.41 386.46 390.44 378.73 33222 338.39 321.47 369.69 358.60 362.30 351.43 33223 412.17 391.56 450.29 436.78 441.29 428.04 33224 527.50 501.13 576.30 559.02 564.78 547.84 33225 481.15 457.09 525.65 509.89 515.14 499.69 33226 507.40 482.03 554.33 537.71 543.25 526.95 33227 341.51 324.43 373.09 361.91 365.63 354.67 33228 357.30 339.44 390.36 378.65 382.55 371.07 33229 378.40 359.48 413.40 401.01 405.13 392.99 33230 387.63 368.25 423.49 410.78 415.02 402.57 33231 407.38 387.01 445.06 431.71 436.16 423.07 33233 230.42 218.90 251.74 244.18 246.70 239.29 33234 491.21 466.65 536.65 520.55 525.92 510.14 33235 644.96 612.71 704.62 683.48 690.53 669.81 33236 794.35 754.63 867.82 841.79 850.47 824.95 33237 849.30 806.84 927.87 900.02 909.31 882.03 33238 946.06 898.76 1,033.57 1,002.57 1,012.90 982.51 33240 369.83 351.34 404.04 391.92 395.96 384.08 33241 216.23 205.42 236.23 229.15 231.51 224.56 33243 1,392.89 1,323.25 1,521.74 1,476.08 1,491.31 1,446.56 33244 872.04 828.44 952.71 924.13 933.65 905.65 33249 930.57 884.04 1,016.65 986.15 996.31 966.43 33250 1,480.60 1,406.57 1,617.56 1,569.03 1,585.21 1,537.64 33251 1,656.92 1,574.07 1,810.18 1,755.88 1,773.98 1,720.76 33254 1,390.29 1,320.78 1,518.90 1,473.33 1,488.51 1,443.87 33255 1,676.17 1,592.36 1,831.21 1,776.28 1,794.59 1,740.76 33256 1,983.57 1,884.39 2,167.05 2,102.04 2,123.71 2,060.00

Page 81: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 81Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

33257 590.44 560.92 645.06 625.70 632.16 613.19 33258 664.15 630.94 725.58 703.81 711.07 689.74 33259 857.40 814.53 936.71 908.60 917.98 890.43 33261 1,656.59 1,573.76 1,809.82 1,755.53 1,773.62 1,720.42 33262 377.14 358.28 412.02 399.66 403.78 391.67 33263 392.96 373.31 429.31 416.43 420.72 408.10 33264 409.74 389.25 447.64 434.21 438.69 425.52 33265 1,382.65 1,313.52 1,510.55 1,465.23 1,480.34 1,435.92 33266 1,884.03 1,789.83 2,058.30 1,996.56 2,017.13 1,956.63 33270 597.33 567.46 652.58 633.01 639.53 620.34 33271 498.98 474.03 545.13 528.78 534.23 518.20 33272 352.91 335.26 385.55 373.98 377.83 366.51 33273 412.62 391.99 450.79 437.26 441.77 428.52 33282 226.85 215.51 247.84 240.40 242.88 235.59 33284 199.06 189.11 217.48 210.96 213.13 206.74 33300 2,505.16 2,379.90 2,736.89 2,654.78 2,682.15 2,601.68 33305 4,199.97 3,989.97 4,588.47 4,450.81 4,496.70 4,361.79 33310 1,199.50 1,139.53 1,310.46 1,271.14 1,284.25 1,245.71 33315 1,954.31 1,856.59 2,135.08 2,071.02 2,092.38 2,029.60 33320 1,081.77 1,027.68 1,181.83 1,146.38 1,158.20 1,123.45 33321 1,211.85 1,151.26 1,323.95 1,284.23 1,297.46 1,258.55 33322 1,414.22 1,343.51 1,545.04 1,498.68 1,514.14 1,468.71 33330 1,457.07 1,384.22 1,591.85 1,544.09 1,560.02 1,513.22 33335 1,915.04 1,819.29 2,092.18 2,029.42 2,050.34 1,988.83 33340 815.16 774.40 890.56 863.85 872.75 846.57 33361 1,395.14 1,325.38 1,524.19 1,478.46 1,493.70 1,448.90 33362 1,522.74 1,446.60 1,663.59 1,613.68 1,630.32 1,581.41 33363 1,601.35 1,521.28 1,749.47 1,696.99 1,714.48 1,663.05 33364 1,662.16 1,579.05 1,815.91 1,761.43 1,779.59 1,726.21 33365 1,828.88 1,737.44 1,998.06 1,938.12 1,958.09 1,899.35 33366 1,978.37 1,879.45 2,161.37 2,096.53 2,118.14 2,054.60 33367 642.51 610.38 701.94 680.88 687.90 667.26 33368 767.97 729.57 839.01 813.83 822.23 797.56 33369 1,015.74 964.95 1,109.69 1,076.40 1,087.50 1,054.87 33390 1,948.46 1,851.04 2,128.70 2,064.84 2,086.12 2,023.54 33391 2,308.88 2,193.44 2,522.46 2,446.79 2,472.01 2,397.85 33404 1,790.04 1,700.54 1,955.62 1,896.95 1,916.51 1,859.01 33405 2,318.12 2,202.21 2,532.54 2,456.56 2,481.90 2,407.43 33406 2,942.03 2,794.93 3,214.17 3,117.74 3,149.88 3,055.39 33410 2,598.96 2,469.01 2,839.36 2,754.18 2,782.57 2,699.10 33411 3,433.07 3,261.42 3,750.63 3,638.12 3,675.62 3,565.36 33412 3,247.63 3,085.25 3,548.04 3,441.59 3,477.08 3,372.77 33413 3,305.93 3,140.63 3,611.72 3,503.37 3,539.49 3,433.30 33414 2,208.96 2,098.51 2,413.29 2,340.88 2,365.02 2,294.07 33415 2,077.96 1,974.06 2,270.17 2,202.07 2,224.77 2,158.02 33416 2,072.74 1,969.10 2,264.47 2,196.53 2,219.18 2,152.60 33417 1,707.00 1,621.65 1,864.90 1,808.95 1,827.60 1,772.77 33418 1,842.45 1,750.33 2,012.88 1,952.49 1,972.62 1,913.44 33419 436.62 414.79 477.01 462.70 467.46 453.45

Page 82: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 82Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

33420 1,490.42 1,415.90 1,628.29 1,579.43 1,595.72 1,547.84 33422 1,704.95 1,619.70 1,862.66 1,806.78 1,825.41 1,770.64 33425 2,791.08 2,651.53 3,049.26 2,957.78 2,988.28 2,898.62 33426 2,433.17 2,311.51 2,658.24 2,578.48 2,605.07 2,526.92 33427 2,500.00 2,375.00 2,731.25 2,649.31 2,676.63 2,596.33 33430 2,858.42 2,715.50 3,122.83 3,029.15 3,060.37 2,968.56 33460 2,483.45 2,359.28 2,713.17 2,631.78 2,658.90 2,579.14 33463 3,160.64 3,002.61 3,453.00 3,349.41 3,383.94 3,282.42 33464 2,495.38 2,370.61 2,726.20 2,644.41 2,671.68 2,591.53 33465 2,820.85 2,679.81 3,081.78 2,989.33 3,020.14 2,929.54 33468 2,519.13 2,393.17 2,752.15 2,669.58 2,697.11 2,616.18 33470 1,320.57 1,254.54 1,442.72 1,399.44 1,413.87 1,371.44 33471 1,411.07 1,340.52 1,541.60 1,495.35 1,510.77 1,465.43 33474 2,234.77 2,123.03 2,441.48 2,368.24 2,392.66 2,320.87 33475 2,382.25 2,263.14 2,602.61 2,524.54 2,550.56 2,474.05 33476 1,556.61 1,478.78 1,700.60 1,649.58 1,666.58 1,616.59 33477 1,338.12 1,271.21 1,461.89 1,418.03 1,432.66 1,389.67 33478 1,608.89 1,528.45 1,757.72 1,704.99 1,722.56 1,670.89 33496 1,707.82 1,622.43 1,865.79 1,809.82 1,828.48 1,773.62 33500 1,595.32 1,515.55 1,742.88 1,690.59 1,708.03 1,656.78 33501 1,135.24 1,078.48 1,240.25 1,203.05 1,215.45 1,178.99 33502 1,303.60 1,238.42 1,424.18 1,381.46 1,395.70 1,353.83 33503 1,353.75 1,286.06 1,478.97 1,434.60 1,449.39 1,405.91 33504 1,498.91 1,423.96 1,637.55 1,588.43 1,604.80 1,556.66 33505 2,122.41 2,016.29 2,318.73 2,249.17 2,272.35 2,204.18 33506 2,111.52 2,005.94 2,306.83 2,237.62 2,260.69 2,192.87 33507 1,770.19 1,681.68 1,933.93 1,875.91 1,895.26 1,838.40 33508 16.60 15.77 18.14 17.60 17.77 17.24 33510 1,973.03 1,874.38 2,155.54 2,090.87 2,112.42 2,049.06 33511 2,168.75 2,060.31 2,369.36 2,298.28 2,321.97 2,252.31 33512 2,466.03 2,342.73 2,694.14 2,613.32 2,640.26 2,561.05 33513 2,538.95 2,412.00 2,773.80 2,690.59 2,718.32 2,636.78 33514 2,681.83 2,547.74 2,929.90 2,842.01 2,871.31 2,785.16 33516 2,807.42 2,667.05 3,067.11 2,975.10 3,005.77 2,915.60 33517 192.53 182.90 210.34 204.02 206.13 199.94 33518 422.90 401.76 462.02 448.17 452.78 439.21 33519 559.26 531.30 611.00 592.66 598.77 580.81 33521 670.95 637.40 733.01 711.02 718.35 696.80 33522 752.90 715.26 822.55 797.87 806.09 781.91 33523 853.34 810.67 932.27 904.30 913.63 886.21 33530 540.21 513.20 590.18 572.47 578.38 561.02 33533 1,907.68 1,812.30 2,084.15 2,021.62 2,042.46 1,981.19 33534 2,245.44 2,133.17 2,453.15 2,379.55 2,404.09 2,331.96 33535 2,507.43 2,382.06 2,739.37 2,657.19 2,684.58 2,604.05 33536 2,703.32 2,568.15 2,953.37 2,864.78 2,894.31 2,807.48 33542 2,683.11 2,548.95 2,931.29 2,843.35 2,872.67 2,786.48 33545 3,168.40 3,009.98 3,461.48 3,357.63 3,392.25 3,290.48 33548 3,031.49 2,879.92 3,311.91 3,212.55 3,245.67 3,148.30 33572 236.35 224.53 258.21 250.46 253.05 245.44

Page 83: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 83Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

33600 1,759.31 1,671.34 1,922.04 1,864.38 1,883.60 1,827.10 33602 1,707.36 1,621.99 1,865.29 1,809.33 1,827.98 1,773.14 33606 1,821.07 1,730.02 1,989.52 1,929.84 1,949.73 1,891.24 33608 1,843.39 1,751.22 2,013.90 1,953.48 1,973.63 1,914.42 33610 1,818.29 1,727.38 1,986.49 1,926.89 1,946.75 1,888.36 33611 2,004.73 1,904.49 2,190.16 2,124.46 2,146.36 2,081.97 33612 2,058.45 1,955.53 2,248.86 2,181.39 2,203.88 2,137.76 33615 2,047.75 1,945.36 2,237.16 2,170.05 2,192.42 2,126.65 33617 2,219.46 2,108.49 2,424.76 2,352.03 2,376.27 2,304.99 33619 2,794.92 2,655.17 3,053.45 2,961.84 2,992.38 2,902.60 33620 1,695.27 1,610.51 1,852.09 1,796.52 1,815.05 1,760.59 33621 952.21 904.60 1,040.29 1,009.08 1,019.49 988.90 33622 3,729.23 3,542.77 4,074.19 3,951.96 3,992.70 3,872.92 33641 1,682.87 1,598.73 1,838.54 1,783.39 1,801.77 1,747.71 33645 1,776.43 1,687.61 1,940.75 1,882.53 1,901.94 1,844.88 33647 1,866.58 1,773.25 2,039.24 1,978.06 1,998.46 1,938.50 33660 1,803.35 1,713.18 1,970.16 1,911.05 1,930.76 1,872.82 33665 2,015.30 1,914.54 2,201.72 2,135.67 2,157.69 2,092.95 33670 2,030.35 1,928.83 2,218.15 2,151.62 2,173.79 2,108.58 33675 2,026.21 1,924.90 2,213.64 2,147.22 2,169.36 2,104.28 33676 2,187.33 2,077.96 2,389.65 2,317.96 2,341.86 2,271.61 33677 2,272.82 2,159.18 2,483.06 2,408.56 2,433.40 2,360.39 33681 1,882.62 1,788.49 2,056.76 1,995.07 2,015.63 1,955.16 33684 1,940.42 1,843.40 2,119.91 2,056.32 2,077.51 2,015.19 33688 2,040.97 1,938.92 2,229.76 2,162.86 2,185.16 2,119.61 33690 1,224.70 1,163.47 1,337.99 1,297.86 1,311.23 1,271.90 33692 2,120.84 2,014.80 2,317.02 2,247.51 2,270.68 2,202.56 33694 2,004.73 1,904.49 2,190.16 2,124.46 2,146.36 2,081.97 33697 2,112.14 2,006.53 2,307.51 2,238.28 2,261.36 2,193.51 33702 1,582.76 1,503.62 1,729.16 1,677.29 1,694.58 1,643.74 33710 2,108.25 2,002.84 2,303.27 2,234.16 2,257.20 2,189.49 33720 1,583.81 1,504.62 1,730.31 1,678.40 1,695.71 1,644.83 33722 1,667.35 1,583.98 1,821.58 1,766.93 1,785.15 1,731.59 33724 1,579.23 1,500.27 1,725.31 1,673.55 1,690.80 1,640.07 33726 2,089.44 1,984.97 2,282.72 2,214.23 2,237.06 2,169.95 33730 2,057.22 1,954.36 2,247.51 2,180.09 2,202.56 2,136.49 33732 1,686.87 1,602.53 1,842.91 1,787.62 1,806.05 1,751.86 33735 1,323.64 1,257.46 1,446.08 1,402.70 1,417.16 1,374.65 33736 1,437.75 1,365.86 1,570.74 1,523.61 1,539.32 1,493.14 33737 1,326.59 1,260.26 1,449.30 1,405.82 1,420.31 1,377.70 33750 1,350.71 1,283.17 1,475.65 1,431.37 1,446.14 1,402.75 33755 1,400.52 1,330.49 1,530.06 1,484.17 1,499.46 1,454.49 33762 1,372.19 1,303.58 1,499.12 1,454.14 1,469.14 1,425.06 33764 1,345.18 1,277.92 1,469.61 1,425.52 1,440.21 1,397.01 33766 1,427.80 1,356.41 1,559.87 1,513.08 1,528.67 1,482.82 33767 1,457.80 1,384.91 1,592.65 1,544.86 1,560.79 1,513.96 33768 456.04 433.24 498.23 483.28 488.27 473.62 33770 2,293.86 2,179.17 2,506.05 2,430.86 2,455.93 2,382.24 33771 2,366.74 2,248.40 2,585.66 2,508.09 2,533.94 2,457.93

Page 84: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 84Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

33774 1,842.53 1,750.40 2,012.96 1,952.57 1,972.70 1,913.52 33775 1,989.11 1,889.65 2,173.10 2,107.90 2,129.64 2,065.75 33776 2,101.26 1,996.20 2,295.63 2,226.76 2,249.72 2,182.22 33777 1,941.01 1,843.96 2,120.55 2,056.94 2,078.14 2,015.80 33778 2,412.32 2,291.70 2,635.46 2,556.39 2,582.75 2,505.26 33779 2,524.09 2,397.89 2,757.57 2,674.84 2,702.42 2,621.34 33780 2,568.69 2,440.26 2,806.30 2,722.11 2,750.17 2,667.67 33781 2,513.13 2,387.47 2,745.59 2,663.23 2,690.68 2,609.96 33782 3,322.93 3,156.78 3,630.30 3,521.39 3,557.69 3,450.97 33783 3,591.13 3,411.57 3,923.31 3,805.60 3,844.84 3,729.50 33786 2,463.15 2,339.99 2,690.99 2,610.26 2,637.17 2,558.05 33788 1,647.00 1,564.65 1,799.35 1,745.37 1,763.36 1,710.46 33800 1,010.92 960.37 1,104.43 1,071.29 1,082.33 1,049.87 33802 1,106.48 1,051.16 1,208.83 1,172.57 1,184.66 1,149.13 33803 1,177.74 1,118.85 1,286.68 1,248.07 1,260.94 1,223.11 33813 1,319.93 1,253.93 1,442.02 1,398.76 1,413.18 1,370.78 33814 1,558.25 1,480.34 1,702.39 1,651.32 1,668.34 1,618.29 33820 990.66 941.13 1,082.30 1,049.84 1,060.66 1,028.84 33822 1,089.90 1,035.41 1,190.72 1,155.00 1,166.91 1,131.90 33824 1,204.79 1,144.55 1,316.23 1,276.74 1,289.91 1,251.21 33840 1,318.52 1,252.59 1,440.48 1,397.26 1,411.67 1,369.32 33845 1,362.85 1,294.71 1,488.92 1,444.25 1,459.14 1,415.36 33851 1,355.46 1,287.69 1,480.84 1,436.42 1,451.23 1,407.69 33852 1,431.18 1,359.62 1,563.56 1,516.65 1,532.29 1,486.32 33853 1,877.66 1,783.78 2,051.35 1,989.81 2,010.32 1,950.01 33860 3,287.54 3,123.16 3,591.63 3,483.89 3,519.81 3,414.21 33863 3,227.18 3,065.82 3,525.69 3,419.93 3,455.18 3,351.53 33864 3,306.30 3,140.99 3,612.14 3,503.77 3,539.90 3,433.69 33870 2,583.69 2,454.51 2,822.69 2,738.00 2,766.23 2,683.24 33875 2,806.13 2,665.82 3,065.69 2,973.73 3,004.38 2,914.25 33877 3,734.19 3,547.48 4,079.60 3,957.22 3,998.01 3,878.08 33880 1,853.80 1,761.11 2,025.28 1,964.52 1,984.77 1,925.23 33881 1,592.09 1,512.49 1,739.36 1,687.19 1,704.58 1,653.45 33883 1,153.96 1,096.26 1,260.70 1,222.88 1,235.48 1,198.42 33884 426.42 405.10 465.87 451.89 456.55 442.85 33886 993.15 943.49 1,085.01 1,052.47 1,063.31 1,031.42 33889 815.53 774.75 890.96 864.24 873.15 846.95 33891 1,014.90 964.16 1,108.78 1,075.53 1,086.61 1,054.02 33910 2,695.65 2,560.87 2,945.00 2,856.65 2,886.10 2,799.51 33915 1,306.18 1,240.87 1,427.00 1,384.19 1,398.46 1,356.51 33916 4,302.98 4,087.83 4,701.00 4,559.98 4,606.98 4,468.79 33917 1,490.42 1,415.90 1,628.29 1,579.43 1,595.72 1,547.84 33920 1,949.98 1,852.48 2,130.35 2,066.45 2,087.74 2,025.12 33922 1,420.92 1,349.87 1,552.35 1,505.78 1,521.30 1,475.66 33924 295.03 280.28 322.32 312.65 315.87 306.39 33925 1,764.90 1,676.66 1,928.16 1,870.31 1,889.60 1,832.90 33926 2,620.48 2,489.46 2,862.88 2,777.00 2,805.62 2,721.45 33933 204.08 193.88 222.96 216.27 218.50 211.95 33935 5,091.08 4,836.53 5,562.01 5,395.14 5,450.77 5,287.24

Page 85: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 85Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

33944 204.08 193.88 222.96 216.27 218.50 211.95 33945 4,975.46 4,726.69 5,435.69 5,272.62 5,326.98 5,167.17 33946 316.61 300.78 345.90 335.52 338.97 328.81 33947 351.61 334.03 384.13 372.61 376.45 365.16 33948 244.77 232.53 267.41 259.38 262.06 254.20 33949 239.92 227.92 262.11 254.24 256.86 249.16 33951 437.69 415.81 478.18 463.84 468.61 454.56 33952 439.78 417.79 480.46 466.05 470.84 456.72 33953 488.99 464.54 534.22 518.19 523.54 507.83 33954 491.43 466.86 536.89 520.78 526.15 510.36 33955 856.61 813.78 935.85 907.78 917.13 889.62 33956 857.27 814.41 936.57 908.48 917.84 890.31 33957 190.62 181.09 208.25 202.01 204.09 197.97 33958 186.48 177.16 203.73 197.63 199.66 193.67 33959 241.60 229.52 263.95 256.02 258.67 250.91 33962 242.73 230.59 265.18 257.22 259.88 252.08 33963 483.37 459.20 528.08 512.23 517.52 501.99 33964 495.26 470.50 541.08 524.85 530.25 514.35 33965 190.62 181.09 208.25 202.01 204.09 197.97 33966 243.95 231.75 266.51 258.52 261.19 253.35 33967 266.51 253.18 291.16 282.42 285.34 276.77 33968 34.55 32.82 37.74 36.62 36.98 35.88 33969 283.82 269.63 310.07 300.77 303.88 294.76 33970 364.94 346.69 398.69 386.73 390.72 378.99 33971 722.42 686.30 789.25 765.57 773.46 750.26 33973 529.30 502.84 578.27 560.91 566.70 549.70 33974 908.61 863.18 992.66 962.87 972.81 943.61 33975 1,346.93 1,279.58 1,471.52 1,427.37 1,442.09 1,398.83 33976 1,643.13 1,560.97 1,795.12 1,741.26 1,759.21 1,706.44 33977 1,156.15 1,098.34 1,263.09 1,225.20 1,237.83 1,200.69 33978 1,370.91 1,302.36 1,497.71 1,452.78 1,467.76 1,423.72 33979 2,009.05 1,908.60 2,194.89 2,129.04 2,150.99 2,086.46 33980 1,832.81 1,741.17 2,002.35 1,942.27 1,962.30 1,903.42 33981 853.37 810.70 932.31 904.34 913.66 886.25 33982 2,016.65 1,915.82 2,203.19 2,137.10 2,159.13 2,094.36 33983 2,384.24 2,265.03 2,604.78 2,526.64 2,552.69 2,476.11 33984 294.83 280.09 322.10 312.44 315.66 306.20 33985 532.01 505.41 581.22 563.79 569.60 552.52 33986 538.00 511.10 587.77 570.14 576.01 558.73 33987 216.28 205.47 236.29 229.21 231.56 224.62 33988 807.07 766.72 881.73 855.28 864.10 838.18 33989 511.17 485.61 558.45 541.70 547.29 530.86 33990 437.37 415.50 477.83 463.50 468.27 454.23 33991 640.50 608.48 699.75 678.76 685.76 665.19 33992 205.91 195.61 224.95 218.20 220.46 213.84 33993 179.74 170.75 196.36 190.47 192.44 186.67 34001 997.96 948.06 1,090.27 1,057.56 1,068.47 1,036.41 34051 917.30 871.44 1,002.16 972.10 982.11 952.65 34101 617.66 586.78 674.80 654.56 661.30 641.47

Page 86: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 86Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

34111 617.27 586.41 674.37 654.14 660.88 641.06 34151 1,448.66 1,376.23 1,582.66 1,535.18 1,551.02 1,504.48 34201 1,065.31 1,012.04 1,163.85 1,128.93 1,140.57 1,106.36 34203 985.64 936.36 1,076.81 1,044.51 1,055.27 1,023.62 34401 1,499.81 1,424.82 1,638.54 1,589.39 1,605.77 1,557.61 34421 747.51 710.13 816.65 792.15 800.32 776.31 34451 1,674.95 1,591.20 1,829.88 1,774.98 1,793.29 1,739.48 34471 1,125.48 1,069.21 1,229.59 1,192.70 1,205.00 1,168.85 34490 625.93 594.63 683.82 663.31 670.15 650.04 34501 924.33 878.11 1,009.83 979.54 989.63 959.94 34502 1,578.93 1,499.98 1,724.98 1,673.23 1,690.48 1,639.76 34510 1,221.40 1,160.33 1,334.38 1,294.35 1,307.69 1,268.46 34520 1,083.33 1,029.16 1,183.53 1,148.03 1,159.87 1,125.07 34530 981.41 932.34 1,072.19 1,040.03 1,050.74 1,019.22 34800 1,166.83 1,108.49 1,274.76 1,236.53 1,249.27 1,211.80 34802 1,288.12 1,223.71 1,407.27 1,365.05 1,379.13 1,337.75 34803 1,336.42 1,269.60 1,460.04 1,416.24 1,430.84 1,387.91 34804 1,290.33 1,225.81 1,409.68 1,367.40 1,381.48 1,340.05 34805 1,232.66 1,171.03 1,346.68 1,306.29 1,319.75 1,280.16 34806 103.66 98.48 113.25 109.86 110.99 107.66 34808 215.26 204.50 235.18 228.13 230.47 223.56 34812 349.85 332.36 382.21 370.75 374.57 363.33 34813 245.25 232.99 267.94 259.90 262.58 254.70 34820 507.26 481.90 554.19 537.56 543.10 526.80 34825 716.86 681.02 783.17 759.68 767.51 744.49 34826 213.10 202.45 232.82 225.84 228.16 221.32 34830 1,864.65 1,771.42 2,037.13 1,976.02 1,996.39 1,936.50 34831 1,975.31 1,876.54 2,158.02 2,093.28 2,114.86 2,051.42 34832 1,961.56 1,863.48 2,143.00 2,078.72 2,100.14 2,037.14 34833 629.96 598.46 688.23 667.59 674.46 654.24 34834 281.84 267.75 307.91 298.68 301.76 292.71 34841 1,205.43 1,145.16 1,316.93 1,277.43 1,290.60 1,251.88 34842 1,458.69 1,385.76 1,593.62 1,545.82 1,561.75 1,514.91 34843 1,427.12 1,355.76 1,559.12 1,512.35 1,527.94 1,482.11 34844 1,474.66 1,400.93 1,611.07 1,562.74 1,578.85 1,531.48 34845 1,205.43 1,145.16 1,316.93 1,277.43 1,290.60 1,251.88 34846 1,458.69 1,385.76 1,593.62 1,545.82 1,561.75 1,514.91 34847 1,427.12 1,355.76 1,559.12 1,512.35 1,527.94 1,482.11 34848 1,474.66 1,400.93 1,611.07 1,562.74 1,578.85 1,531.48 34900 921.91 875.81 1,007.18 976.97 987.03 957.43 35001 1,151.30 1,093.74 1,257.80 1,220.07 1,232.65 1,195.67 35002 1,183.99 1,124.79 1,293.51 1,254.71 1,267.63 1,229.61 35005 1,154.79 1,097.05 1,261.61 1,223.76 1,236.38 1,199.29 35011 1,038.12 986.21 1,134.14 1,100.11 1,111.46 1,078.11 35013 1,293.30 1,228.64 1,412.94 1,370.55 1,384.68 1,343.13 35021 1,270.94 1,207.39 1,388.50 1,346.85 1,360.73 1,319.91 35022 1,465.99 1,392.69 1,601.59 1,553.55 1,569.57 1,522.47 35045 1,017.81 966.92 1,111.96 1,078.60 1,089.72 1,057.02 35081 1,804.89 1,714.65 1,971.85 1,912.69 1,932.41 1,874.44

Page 87: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 87Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

35082 2,271.80 2,158.21 2,481.94 2,407.48 2,432.31 2,359.33 35091 1,858.28 1,765.37 2,030.18 1,969.27 1,989.57 1,929.88 35092 2,699.31 2,564.34 2,948.99 2,860.52 2,890.01 2,803.31 35102 1,951.65 1,854.07 2,132.18 2,068.22 2,089.54 2,026.85 35103 2,330.36 2,213.84 2,545.92 2,469.53 2,494.99 2,420.14 35111 1,374.57 1,305.84 1,501.72 1,456.66 1,471.68 1,427.53 35112 1,938.65 1,841.72 2,117.98 2,054.44 2,075.62 2,013.35 35121 1,708.33 1,622.91 1,866.35 1,810.35 1,829.02 1,774.15 35122 2,220.46 2,109.44 2,425.86 2,353.08 2,377.34 2,306.03 35131 1,437.16 1,365.30 1,570.10 1,522.99 1,538.69 1,492.53 35132 1,695.09 1,610.34 1,851.89 1,796.33 1,814.85 1,760.41 35141 1,143.56 1,086.38 1,249.34 1,211.86 1,224.35 1,187.62 35142 1,368.73 1,300.29 1,495.33 1,450.47 1,465.42 1,421.46 35151 1,284.46 1,220.24 1,403.28 1,361.17 1,375.22 1,333.95 35152 1,441.78 1,369.69 1,575.14 1,527.89 1,543.65 1,497.33 35180 969.82 921.33 1,059.53 1,027.74 1,038.34 1,007.19 35182 1,829.59 1,738.11 1,998.83 1,938.87 1,958.85 1,900.09 35184 1,149.12 1,091.66 1,255.41 1,217.75 1,230.30 1,193.39 35188 1,090.06 1,035.56 1,190.89 1,155.16 1,167.08 1,132.06 35189 1,641.19 1,559.13 1,793.00 1,739.21 1,757.14 1,704.43 35190 781.88 742.79 854.21 828.59 837.12 812.02 35201 970.75 922.21 1,060.54 1,028.72 1,039.34 1,008.15 35206 798.99 759.04 872.90 846.71 855.44 829.77 35207 756.38 718.56 826.34 801.55 809.82 785.52 35211 1,407.76 1,337.37 1,537.98 1,491.84 1,507.21 1,462.01 35216 2,094.36 1,989.64 2,288.09 2,219.44 2,242.33 2,175.05 35221 1,500.61 1,425.58 1,639.42 1,590.23 1,606.63 1,558.42 35226 859.05 816.10 938.52 910.36 919.75 892.16 35231 1,259.87 1,196.88 1,376.41 1,335.12 1,348.88 1,308.41 35236 1,012.98 962.33 1,106.68 1,073.48 1,084.54 1,052.01 35241 1,408.32 1,337.90 1,538.59 1,492.42 1,507.81 1,462.57 35246 1,611.07 1,530.52 1,760.10 1,707.29 1,724.90 1,673.15 35251 1,765.10 1,676.85 1,928.38 1,870.52 1,889.81 1,833.11 35256 1,051.78 999.19 1,149.07 1,114.59 1,126.09 1,092.30 35261 1,093.59 1,038.91 1,194.75 1,158.90 1,170.85 1,135.73 35266 893.63 848.95 976.29 947.00 956.77 928.06 35271 1,416.36 1,345.54 1,547.37 1,500.95 1,516.42 1,470.93 35276 1,496.47 1,421.65 1,634.90 1,585.85 1,602.20 1,554.13 35281 1,665.04 1,581.79 1,819.06 1,764.49 1,782.67 1,729.20 35286 962.42 914.30 1,051.45 1,019.90 1,030.41 999.50 35301 1,169.99 1,111.49 1,278.21 1,239.87 1,252.65 1,215.08 35302 1,163.24 1,105.08 1,270.84 1,232.72 1,245.43 1,208.06 35303 1,283.42 1,219.25 1,402.14 1,360.07 1,374.10 1,332.87 35304 1,332.44 1,265.82 1,455.69 1,412.03 1,426.58 1,383.78 35305 1,274.11 1,210.40 1,391.96 1,350.20 1,364.12 1,323.20 35306 462.88 439.74 505.70 490.53 495.59 480.72 35311 1,601.84 1,521.75 1,750.01 1,697.52 1,715.02 1,663.57 35321 919.81 873.82 1,004.89 974.75 984.79 955.26 35331 1,501.68 1,426.60 1,640.59 1,591.37 1,607.78 1,559.54

Page 88: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 88Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

35341 1,418.07 1,347.17 1,549.25 1,502.76 1,518.26 1,472.71 35351 1,324.23 1,258.02 1,446.72 1,403.32 1,417.79 1,375.25 35355 1,070.56 1,017.03 1,169.58 1,134.50 1,146.19 1,111.81 35361 1,580.38 1,501.36 1,726.56 1,674.77 1,692.03 1,641.27 35363 1,820.89 1,729.85 1,989.33 1,929.64 1,949.54 1,891.05 35371 846.26 803.95 924.54 896.80 906.05 878.86 35372 1,014.86 964.12 1,108.74 1,075.48 1,086.57 1,053.98 35390 165.67 157.39 181.00 175.57 177.38 172.06 35400 154.81 147.07 169.13 164.06 165.75 160.78 35500 331.60 315.02 362.27 351.41 355.03 344.38 35501 1,552.68 1,475.05 1,696.31 1,645.42 1,662.38 1,612.51 35506 1,323.55 1,257.37 1,445.98 1,402.60 1,417.05 1,374.55 35508 1,385.46 1,316.19 1,513.62 1,468.21 1,483.35 1,438.85 35509 1,464.77 1,391.53 1,600.26 1,552.25 1,568.26 1,521.20 35510 1,273.54 1,209.86 1,391.34 1,349.59 1,363.51 1,322.60 35511 1,256.76 1,193.92 1,373.01 1,331.82 1,345.55 1,305.18 35512 1,412.39 1,341.77 1,543.04 1,496.75 1,512.17 1,466.81 35515 1,483.97 1,409.77 1,621.24 1,572.60 1,588.81 1,541.15 35516 1,263.96 1,200.76 1,380.87 1,339.45 1,353.25 1,312.67 35518 1,202.05 1,141.95 1,313.24 1,273.84 1,286.98 1,248.37 35521 1,269.93 1,206.43 1,387.39 1,345.78 1,359.65 1,318.87 35522 1,252.39 1,189.77 1,368.24 1,327.19 1,340.87 1,300.65 35523 1,323.31 1,257.14 1,445.71 1,402.34 1,416.80 1,374.30 35525 1,187.78 1,128.39 1,297.65 1,258.72 1,271.69 1,233.55 35526 1,742.57 1,655.44 1,903.76 1,846.65 1,865.68 1,809.71 35531 2,100.04 1,995.04 2,294.30 2,225.47 2,248.41 2,180.96 35533 1,553.94 1,476.24 1,697.68 1,646.74 1,663.73 1,613.81 35535 1,988.42 1,889.00 2,172.35 2,107.18 2,128.90 2,065.03 35536 1,779.04 1,690.09 1,943.60 1,885.30 1,904.73 1,847.59 35537 2,445.63 2,323.35 2,671.85 2,591.70 2,618.41 2,539.87 35538 2,440.96 2,318.91 2,666.75 2,586.74 2,613.41 2,535.00 35539 2,311.81 2,196.22 2,525.65 2,449.88 2,475.15 2,400.88 35540 2,652.06 2,519.46 2,897.38 2,810.46 2,839.43 2,754.25 35556 1,450.20 1,377.69 1,584.34 1,536.81 1,552.66 1,506.07 35558 1,274.12 1,210.41 1,391.97 1,350.22 1,364.13 1,323.21 35560 1,772.56 1,683.93 1,936.52 1,878.42 1,897.79 1,840.85 35563 1,540.80 1,463.76 1,683.32 1,632.83 1,649.65 1,600.17 35565 1,377.53 1,308.65 1,504.95 1,459.80 1,474.85 1,430.60 35566 1,732.32 1,645.70 1,892.56 1,835.78 1,854.71 1,799.06 35570 1,564.71 1,486.47 1,709.44 1,658.16 1,675.25 1,625.00 35571 1,375.62 1,306.84 1,502.87 1,457.77 1,472.81 1,428.62 35572 358.68 340.75 391.86 380.11 384.03 372.51 35583 1,499.96 1,424.96 1,638.70 1,589.54 1,605.93 1,557.76 35585 1,739.65 1,652.67 1,900.57 1,843.55 1,862.56 1,806.68 35587 1,418.67 1,347.74 1,549.90 1,503.41 1,518.91 1,473.33 35600 262.49 249.37 286.78 278.17 281.04 272.61 35601 1,451.64 1,379.06 1,585.92 1,538.34 1,554.20 1,507.58 35606 1,215.99 1,155.19 1,328.47 1,288.61 1,301.90 1,262.84 35612 1,101.85 1,046.76 1,203.77 1,167.66 1,179.69 1,144.31

Page 89: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 89Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

35616 1,147.27 1,089.91 1,253.40 1,215.79 1,228.33 1,191.48 35621 1,138.73 1,081.79 1,244.06 1,206.74 1,219.17 1,182.60 35623 1,370.38 1,301.86 1,497.14 1,452.22 1,467.19 1,423.17 35626 1,623.65 1,542.47 1,773.84 1,720.63 1,738.36 1,686.22 35631 1,921.42 1,825.35 2,099.15 2,036.18 2,057.17 1,995.46 35632 1,874.06 1,780.36 2,047.41 1,985.99 2,006.46 1,946.27 35633 2,079.10 1,975.15 2,271.42 2,203.29 2,226.00 2,159.22 35634 1,867.77 1,774.38 2,040.54 1,979.32 1,999.72 1,939.74 35636 1,683.08 1,598.93 1,838.77 1,783.60 1,801.99 1,747.93 35637 1,797.20 1,707.34 1,963.44 1,904.54 1,924.17 1,866.45 35638 1,826.60 1,735.27 1,995.56 1,935.69 1,955.64 1,896.98 35642 1,127.64 1,071.26 1,231.95 1,194.99 1,207.30 1,171.09 35645 1,073.71 1,020.02 1,173.02 1,137.83 1,149.56 1,115.07 35646 1,779.09 1,690.14 1,943.66 1,885.36 1,904.79 1,847.65 35647 1,610.52 1,529.99 1,759.49 1,706.70 1,724.30 1,672.57 35650 1,124.72 1,068.48 1,228.75 1,191.89 1,204.18 1,168.06 35654 1,420.58 1,349.55 1,551.98 1,505.42 1,520.94 1,475.31 35656 1,122.18 1,066.07 1,225.98 1,189.20 1,201.46 1,165.42 35661 1,123.75 1,067.56 1,227.69 1,190.86 1,203.14 1,167.04 35663 1,294.52 1,229.79 1,414.26 1,371.84 1,385.97 1,344.40 35665 1,214.45 1,153.73 1,326.79 1,286.99 1,300.26 1,261.25 35666 1,308.60 1,243.17 1,429.65 1,386.75 1,401.06 1,359.01 35671 1,153.49 1,095.82 1,260.19 1,222.39 1,234.99 1,197.94 35681 83.54 79.36 91.26 88.53 89.44 86.76 35682 367.55 349.17 401.55 389.49 393.52 381.71 35683 425.20 403.94 464.53 450.59 455.24 441.58 35685 206.64 196.31 225.76 218.98 221.24 214.60 35686 166.85 158.51 182.29 176.81 178.64 173.28 35691 973.19 924.53 1,063.21 1,031.31 1,041.95 1,010.68 35693 862.34 819.22 942.10 913.84 923.27 895.56 35694 1,024.12 972.91 1,118.85 1,085.28 1,096.47 1,063.58 35695 1,079.38 1,025.41 1,179.22 1,143.85 1,155.64 1,120.97 35697 153.46 145.79 167.66 162.63 164.30 159.38 35700 158.70 150.77 173.39 168.19 169.91 164.83 35701 574.60 545.87 627.75 608.91 615.19 596.74 35721 469.28 445.82 512.69 497.32 502.44 487.37 35741 524.68 498.45 573.22 556.03 561.75 544.90 35761 396.40 376.58 433.07 420.07 424.41 411.67 35800 729.27 692.81 796.73 772.83 780.79 757.38 35820 2,059.75 1,956.76 2,250.27 2,182.77 2,205.26 2,139.12 35840 1,216.99 1,156.14 1,329.56 1,289.68 1,302.97 1,263.88 35860 864.47 821.25 944.44 916.10 925.55 897.78 35870 1,290.16 1,225.65 1,409.50 1,367.21 1,381.31 1,339.87 35875 614.02 583.32 670.82 650.69 657.40 637.68 35876 979.42 930.45 1,070.02 1,037.92 1,048.62 1,017.16 35879 953.87 906.18 1,042.11 1,010.84 1,021.27 990.62 35881 1,055.42 1,002.65 1,153.05 1,118.46 1,129.99 1,096.09 35883 1,251.46 1,188.89 1,367.22 1,326.20 1,339.88 1,299.68 35884 1,285.32 1,221.05 1,404.21 1,362.08 1,376.12 1,334.84

Page 90: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 90Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

35901 507.57 482.19 554.52 537.88 543.43 527.13 35903 577.69 548.81 631.13 612.20 618.50 599.96 35905 1,830.05 1,738.55 1,999.33 1,939.35 1,959.35 1,900.56 35907 1,982.28 1,883.17 2,165.65 2,100.67 2,122.34 2,058.66 36002 158.13 150.22 172.75 167.57 169.30 164.22 # 36002 108.38 102.96 118.40 114.85 116.04 112.55 36005 304.69 289.46 332.88 322.90 326.22 316.43 # 36005 49.36 46.89 53.92 52.30 52.84 51.26 36010 459.15 436.19 501.62 486.57 491.59 476.84 # 36010 112.56 106.93 122.97 119.28 120.51 116.90 36011 783.52 744.34 855.99 830.31 838.87 813.71 # 36011 161.17 153.11 176.08 170.80 172.56 167.38 36012 808.44 768.02 883.22 856.73 865.56 839.59 # 36012 178.19 169.28 194.67 188.83 190.77 185.06 36013 727.22 690.86 794.49 770.65 778.60 755.24 # 36013 126.29 119.98 137.98 133.84 135.22 131.16 36014 755.31 717.54 825.17 800.41 808.67 784.40 # 36014 154.71 146.97 169.02 163.94 165.63 160.67 36015 816.00 775.20 891.48 864.73 873.66 847.44 # 36015 175.53 166.75 191.76 186.01 187.93 182.30 36100 457.85 434.96 500.20 485.20 490.20 475.49 # 36100 158.04 150.14 172.66 167.49 169.21 164.14 36120 399.40 379.43 436.34 423.26 427.62 414.79 # 36120 103.88 98.69 113.49 110.09 111.23 107.89 36140 401.22 381.16 438.33 425.19 429.57 416.69 # 36140 92.84 88.20 101.43 98.38 99.41 96.42 36160 467.19 443.83 510.40 495.10 500.19 485.20 # 36160 126.86 120.52 138.60 134.44 135.83 131.74 36200 534.69 507.96 584.15 566.63 572.47 555.30 # 36200 144.62 137.39 158.00 153.26 154.84 150.19 36215 1,064.72 1,011.48 1,163.20 1,128.31 1,139.94 1,105.75 # 36215 240.08 228.08 262.29 254.43 257.05 249.34 36216 1,102.93 1,047.78 1,204.95 1,168.80 1,180.84 1,145.42 # 36216 278.63 264.70 304.41 295.27 298.32 289.36 36217 1,797.06 1,707.21 1,963.29 1,904.39 1,924.03 1,866.30 # 36217 331.63 315.05 362.31 351.44 355.06 344.41 36218 177.12 168.26 193.50 187.69 189.62 183.94 # 36218 53.24 50.58 58.17 56.42 57.01 55.29 36221 976.18 927.37 1,066.48 1,034.48 1,045.14 1,013.79 # 36221 207.55 197.17 226.75 219.94 222.21 215.54 36222 1,144.04 1,086.84 1,249.87 1,212.36 1,224.87 1,188.12 # 36222 289.75 275.26 316.55 307.05 310.21 300.91 36223 1,401.04 1,330.99 1,530.64 1,484.72 1,500.03 1,455.03 # 36223 319.76 303.77 349.34 338.86 342.34 332.09 36224 1,780.89 1,691.85 1,945.63 1,887.25 1,906.71 1,849.51 # 36224 362.90 344.76 396.47 384.58 388.54 376.89 36225 1,348.81 1,281.37 1,473.58 1,429.37 1,444.10 1,400.78 # 36225 318.59 302.66 348.06 337.62 341.10 330.87 36226 1,689.75 1,605.26 1,846.05 1,790.67 1,809.12 1,754.85

Page 91: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 91Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 36226 358.08 340.18 391.21 379.47 383.39 371.88 36227 244.81 232.57 267.46 259.43 262.11 254.24 # 36227 118.96 113.01 129.96 126.06 127.36 123.54 36228 1,209.49 1,149.02 1,321.37 1,281.73 1,294.95 1,256.10 # 36228 243.52 231.34 266.04 258.06 260.72 252.90 36245 1,231.68 1,170.10 1,345.62 1,305.25 1,318.71 1,279.15 # 36245 245.94 233.64 268.69 260.62 263.32 255.42 36246 786.55 747.22 859.30 833.52 842.12 816.85 # 36246 263.37 250.20 287.73 279.09 281.98 273.52 36247 1,419.38 1,348.41 1,550.67 1,504.15 1,519.66 1,474.07 # 36247 313.06 297.41 342.02 331.76 335.18 325.13 36248 145.95 138.65 159.45 154.66 156.26 151.57 # 36248 50.40 47.88 55.06 53.41 53.96 52.34 36251 1,300.05 1,235.05 1,420.31 1,377.70 1,391.90 1,350.15 # 36251 272.80 259.16 298.03 289.10 292.08 283.31 36252 1,413.13 1,342.47 1,543.84 1,497.53 1,512.96 1,467.58 # 36252 371.72 353.13 406.10 393.92 397.98 386.04 36253 2,081.42 1,977.35 2,273.95 2,205.73 2,228.47 2,161.62 # 36253 371.53 352.95 405.89 393.71 397.77 385.84 36254 2,026.80 1,925.46 2,214.28 2,147.86 2,169.99 2,104.90 # 36254 434.20 412.49 474.36 460.14 464.88 450.94 36260 645.28 613.02 704.97 683.82 690.87 670.15 36261 329.88 313.39 360.40 349.59 353.19 342.60 36262 300.05 285.05 327.81 317.98 321.25 311.62 36400 26.60 25.27 29.06 28.19 28.47 27.62 # 36400 18.37 17.45 20.07 19.47 19.67 19.08 36405 25.08 23.83 27.40 26.59 26.85 26.06 # 36405 16.51 15.68 18.03 17.49 17.68 17.15 36406 18.05 17.15 19.72 19.14 19.33 18.76 # 36406 9.15 8.69 9.99 9.69 9.80 9.50 36410 16.40 15.58 17.92 17.38 17.56 17.03 # 36410 9.48 9.01 10.36 10.05 10.15 9.86 36420 54.83 52.09 59.90 58.11 58.71 56.95 36425 40.74 38.70 44.51 43.17 43.62 42.31 36430 32.67 31.04 35.70 34.63 34.98 33.94 36440 55.16 52.40 60.26 58.45 59.05 57.28 36450 189.52 180.04 207.05 200.84 202.91 196.82 36455 130.78 124.24 142.88 138.59 140.02 135.82 36456 108.44 103.02 118.47 114.92 116.10 112.62 36460 349.38 331.91 381.70 370.24 374.06 362.84 36470 141.86 134.77 154.99 150.34 151.88 147.34 # 36470 82.89 78.75 90.56 87.85 88.76 86.09 36471 169.47 161.00 185.15 179.60 181.45 176.01 # 36471 101.27 96.21 110.64 107.32 108.43 105.17 36473 1,409.49 1,339.02 1,539.87 1,493.68 1,509.08 1,463.80 # 36473 176.99 168.14 193.36 187.57 189.50 183.82 36474 261.95 248.85 286.18 277.59 280.45 272.03 # 36474 88.66 84.23 96.86 93.96 94.93 92.08 36475 1,437.71 1,365.82 1,570.69 1,523.58 1,539.28 1,493.10

Page 92: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 92Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 36475 287.57 273.19 314.17 304.74 307.89 298.64 36476 285.84 271.55 312.28 302.91 306.04 296.85 # 36476 140.22 133.21 153.19 148.59 150.13 145.62 36478 1,142.02 1,084.92 1,247.66 1,210.23 1,222.70 1,186.02 # 36478 285.75 271.46 312.18 302.82 305.93 296.76 36479 299.56 284.58 327.27 317.45 320.72 311.10 # 36479 140.76 133.72 153.78 149.17 150.71 146.19 36481 1,853.96 1,761.26 2,025.45 1,964.68 1,984.93 1,925.39 # 36481 344.05 326.85 375.88 364.60 368.36 357.31 36500 186.66 177.33 203.93 197.81 199.85 193.86 36510 84.99 80.74 92.85 90.07 91.00 88.26 # 36510 56.99 54.14 62.26 60.40 61.02 59.19 36511 94.12 89.41 102.82 99.74 100.76 97.75 36512 95.08 90.33 103.88 100.76 101.80 98.75 36513 98.10 93.20 107.18 103.96 105.04 101.88 36514 511.00 485.45 558.27 541.52 547.10 530.69 # 36514 94.24 89.53 102.96 99.87 100.90 97.87 36515 1,950.16 1,852.65 2,130.55 2,066.63 2,087.94 2,025.30 # 36515 90.04 85.54 98.37 95.42 96.40 93.51 36516 1,967.05 1,868.70 2,149.01 2,084.54 2,106.03 2,042.85 # 36516 71.01 67.46 77.58 75.26 76.03 73.75 36522 1,331.99 1,265.39 1,455.20 1,411.54 1,426.09 1,383.31 # 36522 102.45 97.33 111.93 108.57 109.69 106.40 36555 199.78 189.79 218.26 211.72 213.89 207.48 # 36555 108.85 103.41 118.92 115.36 116.54 113.05 36556 226.96 215.61 247.95 240.51 243.00 235.70 # 36556 122.85 116.71 134.22 130.19 131.54 127.59 36557 877.77 833.88 958.96 930.19 939.78 911.58 # 36557 316.71 300.87 346.00 335.62 339.08 328.90 36558 685.76 651.47 749.19 726.72 734.21 712.18 # 36558 266.69 253.36 291.36 282.62 285.53 276.97 36560 960.34 912.32 1,049.17 1,017.69 1,028.18 997.34 # 36560 344.91 327.66 376.81 365.50 369.28 358.19 36561 1,038.93 986.98 1,135.03 1,100.98 1,112.33 1,078.95 # 36561 344.43 327.21 376.29 365.00 368.77 357.70 36563 1,173.07 1,114.42 1,281.58 1,243.14 1,255.95 1,218.28 # 36563 373.80 355.11 408.38 396.13 400.21 388.21 36565 850.61 808.08 929.29 901.42 910.71 883.38 # 36565 340.28 323.27 371.76 360.61 364.32 353.40 36566 5,078.40 4,824.48 5,548.15 5,381.71 5,437.19 5,274.08 # 36566 379.01 360.06 414.07 401.65 405.79 393.61 36568 236.99 225.14 258.91 251.15 253.74 246.12 # 36568 86.43 82.11 94.43 91.60 92.54 89.77 36569 239.74 227.75 261.91 254.06 256.68 248.98 # 36569 93.13 88.47 101.74 98.69 99.71 96.72 36570 1,173.57 1,114.89 1,282.12 1,243.66 1,256.48 1,218.78 # 36570 319.61 303.63 349.17 338.70 342.19 331.92 36571 1,154.10 1,096.40 1,260.86 1,223.04 1,235.64 1,198.58 # 36571 313.65 297.97 342.67 332.38 335.81 325.74

Page 93: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 93Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

36575 157.41 149.54 171.97 166.81 168.53 163.47 # 36575 35.51 33.73 38.79 37.63 38.02 36.88 36576 305.62 290.34 333.89 323.87 327.21 317.40 # 36576 186.36 177.04 203.60 197.49 199.53 193.55 36578 431.25 409.69 471.14 457.01 461.73 447.87 # 36578 204.92 194.67 223.87 217.15 219.40 212.81 36580 204.27 194.06 223.17 216.48 218.71 212.15 # 36580 67.88 64.49 74.16 71.94 72.68 70.51 36581 669.23 635.77 731.14 709.21 716.51 695.03 # 36581 185.58 176.30 202.75 196.66 198.69 192.73 36582 960.70 912.67 1,049.57 1,018.08 1,028.58 997.72 # 36582 295.52 280.74 322.85 313.17 316.40 306.90 36583 1,186.22 1,126.91 1,295.95 1,257.07 1,270.03 1,231.93 # 36583 327.32 310.95 357.59 346.86 350.44 339.93 36584 195.27 185.51 213.34 206.93 209.07 202.79 # 36584 67.11 63.75 73.31 71.12 71.85 69.69 36585 1,022.27 971.16 1,116.83 1,083.33 1,094.50 1,061.67 # 36585 276.71 262.87 302.30 293.23 296.25 287.36 36589 162.16 154.05 177.16 171.84 173.62 168.41 # 36589 138.43 131.51 151.24 146.69 148.21 143.76 36590 219.96 208.96 240.30 233.09 235.50 228.44 # 36590 192.94 183.29 210.78 204.46 206.56 200.36 36591 22.10 21.00 24.15 23.43 23.67 22.95 36592 24.74 23.50 27.03 26.22 26.48 25.69 36593 29.38 27.91 32.10 31.13 31.45 30.51 36595 559.23 531.27 610.96 592.63 598.74 580.77 # 36595 186.94 177.59 204.23 198.10 200.15 194.13 36596 125.69 119.41 137.32 133.20 134.57 130.54 # 36596 44.97 42.72 49.13 47.66 48.15 46.70 36597 122.84 116.70 134.21 130.18 131.53 127.58 # 36597 62.22 59.11 67.98 65.94 66.62 64.62 36598 106.16 100.85 115.98 112.49 113.65 110.24 # 36598 37.63 35.75 41.11 39.88 40.30 39.09 36600 30.32 28.80 33.12 32.13 32.45 31.49 # 36600 15.50 14.73 16.94 16.43 16.61 16.10 36620 52.11 49.50 56.93 55.22 55.79 54.12 36625 106.69 101.36 116.56 113.07 114.23 110.80 36640 115.70 109.92 126.41 122.61 123.88 120.16 36660 74.85 71.11 81.78 79.33 80.14 77.74 36680 59.73 56.74 65.25 63.30 63.95 62.03 36800 125.79 119.50 137.43 133.31 134.68 130.64 36810 219.93 208.93 240.27 233.06 235.46 228.40 36815 141.21 134.15 154.27 149.65 151.19 146.66 36818 714.24 678.53 780.31 756.90 764.70 741.76 36819 755.05 717.30 824.90 800.15 808.39 784.14 36820 753.60 715.92 823.31 798.61 806.84 782.63 36821 683.78 649.59 747.03 724.62 732.09 710.13 36823 1,409.15 1,338.69 1,539.49 1,493.31 1,508.71 1,463.44 36825 822.20 781.09 898.25 871.31 880.29 853.89

Page 94: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 94Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

36830 687.88 653.49 751.51 728.97 736.48 714.39 36831 635.09 603.34 693.84 673.03 679.96 659.57 36832 779.18 740.22 851.25 825.71 834.23 809.20 36833 836.19 794.38 913.54 886.13 895.26 868.41 36835 498.46 473.54 544.57 528.23 533.68 517.66 36838 1,183.97 1,124.77 1,293.49 1,254.68 1,267.61 1,229.59 36860 202.47 192.35 221.20 214.57 216.78 210.28 # 36860 111.87 106.28 122.22 118.55 119.77 116.18 36861 137.89 131.00 150.65 146.13 147.64 143.21 36901 542.73 515.59 592.93 575.14 581.07 563.64 # 36901 148.37 140.95 162.09 157.23 158.85 154.09 36902 1,148.18 1,090.77 1,254.39 1,216.76 1,229.29 1,192.42 # 36902 221.08 210.03 241.53 234.29 236.70 229.61 36903 5,218.86 4,957.92 5,701.61 5,530.56 5,587.57 5,419.95 # 36903 302.68 287.55 330.68 320.76 324.07 314.34 36904 1,675.92 1,592.12 1,830.94 1,776.01 1,794.32 1,740.49 # 36904 348.54 331.11 380.78 369.36 373.16 361.97 36905 2,144.09 2,036.89 2,342.42 2,272.15 2,295.57 2,226.70 # 36905 437.49 415.62 477.96 463.62 468.41 454.35 36906 6,338.03 6,021.13 6,924.30 6,716.58 6,785.82 6,582.24 # 36906 510.57 485.04 557.80 541.06 546.64 530.24 36907 686.84 652.50 750.38 727.87 735.37 713.31 # 36907 127.42 121.05 139.21 135.03 136.42 132.33 36908 2,511.39 2,385.82 2,743.69 2,661.39 2,688.82 2,608.17 # 36908 191.02 181.47 208.69 202.43 204.52 198.39 36909 1,834.49 1,742.77 2,004.19 1,944.06 1,964.10 1,905.18 # 36909 181.27 172.21 198.04 192.10 194.09 188.26 37140 2,357.05 2,239.20 2,575.08 2,497.82 2,523.58 2,447.87 37145 2,190.36 2,080.84 2,392.97 2,321.17 2,345.10 2,274.75 37160 2,250.34 2,137.82 2,458.49 2,384.74 2,409.32 2,337.05 37180 2,165.18 2,056.92 2,365.46 2,294.49 2,318.15 2,248.61 37181 2,191.75 2,082.16 2,394.48 2,322.66 2,346.60 2,276.21 37182 847.88 805.49 926.31 898.53 907.79 880.56 37183 5,448.63 5,176.20 5,952.63 5,774.05 5,833.58 5,658.56 # 37183 387.49 368.12 423.34 410.64 414.87 402.43 37184 2,104.41 1,999.19 2,299.07 2,230.09 2,253.09 2,185.49 # 37184 463.05 439.90 505.89 490.71 495.77 480.90 37185 670.57 637.04 732.60 710.62 717.95 696.41 # 37185 173.75 165.06 189.82 184.13 186.02 180.45 37186 1,264.96 1,201.71 1,381.97 1,340.51 1,354.33 1,313.70 # 37186 255.17 242.41 278.77 270.41 273.19 265.01 37187 1,866.20 1,772.89 2,038.82 1,977.66 1,998.04 1,938.11 # 37187 404.39 384.17 441.80 428.54 432.96 419.97 37188 1,588.53 1,509.10 1,735.47 1,683.40 1,700.76 1,649.73 # 37188 286.51 272.18 313.01 303.61 306.75 297.54 37191 2,409.82 2,289.33 2,632.73 2,553.75 2,580.07 2,502.68 # 37191 231.77 220.18 253.21 245.61 248.15 240.70 37192 1,517.41 1,441.54 1,657.77 1,608.03 1,624.62 1,575.87 # 37192 371.22 352.66 405.56 393.39 397.45 385.53

Page 95: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 95Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

37193 1,451.31 1,378.74 1,585.55 1,537.99 1,553.85 1,507.22 # 37193 361.80 343.71 395.27 383.41 387.37 375.74 37195 132.26 125.65 144.50 140.16 141.61 137.36 37197 1,366.73 1,298.39 1,493.15 1,448.36 1,463.28 1,419.39 # 37197 311.15 295.59 339.93 329.73 333.13 323.14 37200 224.42 213.20 245.18 237.82 240.28 233.06 37211 397.64 377.76 434.42 421.39 425.73 412.97 37212 346.71 329.37 378.78 367.41 371.20 360.07 37213 240.95 228.90 263.24 255.33 257.97 250.23 37214 126.68 120.35 138.40 134.25 135.63 131.57 37215 1,022.58 971.45 1,117.17 1,083.66 1,094.82 1,061.98 37217 1,131.25 1,074.69 1,235.89 1,198.82 1,211.18 1,174.84 37218 837.02 795.17 914.45 887.01 896.16 869.26 37220 2,886.51 2,742.18 3,153.51 3,058.90 3,090.44 2,997.72 # 37220 416.23 395.42 454.73 441.09 445.64 432.27 37221 4,273.13 4,059.47 4,668.39 4,528.34 4,575.02 4,437.78 # 37221 514.34 488.62 561.91 545.05 550.68 534.15 37222 815.53 774.75 890.96 864.24 873.15 846.95 # 37222 193.85 184.16 211.78 205.44 207.55 201.33 37223 2,393.15 2,273.49 2,614.51 2,536.08 2,562.22 2,485.36 # 37223 222.02 210.92 242.56 235.28 237.71 230.58 37224 3,497.87 3,322.98 3,821.43 3,706.78 3,745.00 3,632.64 # 37224 459.94 436.94 502.48 487.40 492.43 477.65 37225 10,197.84 9,687.95 11,141.14 10,806.91 10,918.32 10,590.76 # 37225 627.74 596.35 685.80 665.23 672.08 651.92 37226 8,358.26 7,940.35 9,131.40 8,857.46 8,948.77 8,680.32 # 37226 542.19 515.08 592.34 574.57 580.50 563.09 37227 13,808.68 13,118.25 15,085.99 14,633.41 14,784.27 14,340.74 # 37227 756.86 719.02 826.87 802.07 810.34 786.03 37228 5,003.41 4,753.24 5,466.23 5,302.24 5,356.91 5,196.19 # 37228 563.96 535.76 616.12 597.64 603.80 585.70 37229 10,060.74 9,557.70 10,991.36 10,661.62 10,771.53 10,448.38 # 37229 734.10 697.40 802.01 777.95 785.97 762.39 37230 7,697.73 7,312.84 8,409.77 8,157.47 8,241.57 7,994.32 # 37230 724.74 688.50 791.78 768.03 775.94 752.66 37231 12,438.76 11,816.82 13,589.34 13,181.67 13,317.55 12,918.03 # 37231 786.48 747.16 859.23 833.46 842.05 816.80 37232 1,122.15 1,066.04 1,225.95 1,189.17 1,201.43 1,165.39 # 37232 209.88 199.39 229.30 222.42 224.71 217.97 37233 1,362.33 1,294.21 1,488.34 1,443.69 1,458.58 1,414.81 # 37233 341.01 323.96 372.55 361.38 365.10 354.15 37234 3,644.32 3,462.10 3,981.42 3,861.98 3,901.79 3,784.74 # 37234 295.04 280.29 322.33 312.66 315.88 306.41 37235 3,921.77 3,725.68 4,284.53 4,156.00 4,198.85 4,072.87 # 37235 409.42 388.95 447.29 433.87 438.35 425.19 37236 3,718.30 3,532.39 4,062.25 3,940.38 3,981.00 3,861.57 # 37236 456.00 433.20 498.18 483.23 488.22 473.57 37237 2,268.17 2,154.76 2,477.97 2,403.64 2,428.41 2,355.57 # 37237 220.92 209.87 241.35 234.11 236.52 229.43

Page 96: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 96Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

37238 3,866.85 3,673.51 4,224.54 4,097.80 4,140.05 4,015.83 # 37238 309.03 293.58 337.62 327.49 330.87 320.93 37239 1,878.84 1,784.90 2,052.64 1,991.05 2,011.58 1,951.23 # 37239 156.11 148.30 170.55 165.43 167.13 162.12 37241 4,452.58 4,229.95 4,864.44 4,718.51 4,767.15 4,624.14 # 37241 455.93 433.13 498.10 483.16 488.14 473.50 37242 6,967.42 6,619.05 7,611.91 7,383.55 7,459.67 7,235.88 # 37242 495.54 470.76 541.37 525.14 530.54 514.64 37243 9,049.54 8,597.06 9,886.62 9,590.02 9,688.89 9,398.23 # 37243 584.11 554.90 638.14 618.99 625.37 606.61 37244 6,329.49 6,013.02 6,914.97 6,707.52 6,776.67 6,573.38 # 37244 687.52 653.14 751.11 728.58 736.09 714.01 37246 2,020.61 1,919.58 2,207.52 2,141.29 2,163.37 2,098.46 # 37246 363.10 344.95 396.69 384.79 388.76 377.10 37247 819.88 778.89 895.72 868.85 877.81 851.47 # 37247 180.07 171.07 196.73 190.83 192.80 187.01 37248 1,403.72 1,333.53 1,533.56 1,487.55 1,502.89 1,457.80 # 37248 312.22 296.61 341.10 330.87 334.28 324.25 37249 602.92 572.77 658.69 638.93 645.51 626.15 # 37249 153.21 145.55 167.38 162.36 164.04 159.11 37252 1,292.99 1,228.34 1,412.59 1,370.21 1,384.34 1,342.81 # 37252 95.08 90.33 103.88 100.76 101.80 98.75 37253 198.92 188.97 217.32 210.80 212.97 206.57 # 37253 76.69 72.86 83.79 81.27 82.11 79.65 37500 663.88 630.69 725.29 703.54 710.79 689.46 37565 744.20 706.99 813.04 788.65 796.78 772.87 37600 723.60 687.42 790.53 766.82 774.72 751.48 37605 809.23 768.77 884.09 857.57 866.40 840.42 37606 528.77 502.33 577.68 560.35 566.12 549.14 37607 383.64 364.46 419.13 406.56 410.75 398.43 37609 302.02 286.92 329.96 320.06 323.36 313.65 # 37609 208.12 197.71 227.37 220.55 222.82 216.13 37615 511.43 485.86 558.74 541.97 547.56 531.13 37616 1,122.12 1,066.01 1,225.91 1,189.13 1,201.39 1,165.35 37617 1,369.50 1,301.03 1,496.18 1,451.30 1,466.26 1,422.27 37618 388.69 369.26 424.65 411.91 416.15 403.67 37619 1,689.20 1,604.74 1,845.45 1,790.09 1,808.55 1,754.29 37650 475.22 451.46 519.18 503.61 508.79 493.53 37660 1,324.66 1,258.43 1,447.19 1,403.78 1,418.25 1,375.71 37700 251.97 239.37 275.28 267.02 269.77 261.68 37718 442.19 420.08 483.09 468.60 473.43 459.23 37722 487.48 463.11 532.58 516.60 521.93 506.28 37735 600.77 570.73 656.34 636.65 643.22 623.92 37760 628.58 597.15 686.72 666.13 672.99 652.81 37761 560.29 532.28 612.12 593.76 599.87 581.88 37765 642.71 610.57 702.16 681.09 688.11 667.47 # 37765 458.54 435.61 500.95 485.92 490.94 476.20 37766 764.89 726.65 835.65 810.58 818.94 794.36 # 37766 560.63 532.60 612.49 594.11 600.24 582.23

Page 97: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 97Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

37780 255.04 242.29 278.63 270.27 273.06 264.87 37785 350.20 332.69 382.59 371.12 374.95 363.70 # 37785 265.53 252.25 290.09 281.38 284.29 275.76 37788 1,278.98 1,215.03 1,397.28 1,355.37 1,369.34 1,328.26 37790 491.39 466.82 536.84 520.74 526.10 510.32 38100 1,171.72 1,113.13 1,280.10 1,241.70 1,254.50 1,216.87 38101 1,172.87 1,114.23 1,281.36 1,242.92 1,255.74 1,218.06 38102 268.28 254.87 293.10 284.30 287.24 278.62 38115 1,289.85 1,225.36 1,409.16 1,366.89 1,380.98 1,339.55 38120 1,065.72 1,012.43 1,164.29 1,129.37 1,141.01 1,106.78 38200 137.56 130.68 150.28 145.77 147.28 142.85 38205 83.77 79.58 91.52 88.77 89.69 87.00 38206 83.77 79.58 91.52 88.77 89.69 87.00 38220 160.77 152.73 175.64 170.37 172.13 166.97 # 38220 62.26 59.15 68.02 65.99 66.67 64.66 38221 161.44 153.37 176.38 171.09 172.85 167.66 # 38221 75.13 71.37 82.08 79.61 80.43 78.03 38230 200.24 190.23 218.76 212.20 214.39 207.95 38232 197.75 187.86 216.04 209.55 211.72 205.37 38240 225.36 214.09 246.20 238.82 241.28 234.05 38241 168.51 160.08 184.09 178.57 180.41 175.00 38242 119.26 113.30 130.30 126.39 127.68 123.86 38243 119.32 113.35 130.35 126.44 127.74 123.91 38300 263.28 250.12 287.64 279.01 281.89 273.44 # 38300 180.59 171.56 197.29 191.37 193.35 187.54 38305 459.13 436.17 501.60 486.54 491.57 476.81 38308 449.19 426.73 490.74 476.02 480.93 466.50 38380 561.04 532.99 612.94 594.55 600.68 582.66 38381 815.31 774.54 890.72 864.00 872.91 846.71 38382 678.24 644.33 740.98 718.75 726.16 704.38 38500 326.34 310.02 356.52 345.83 349.39 338.92 # 38500 255.50 242.73 279.14 270.77 273.56 265.35 38505 121.95 115.85 133.23 129.23 130.56 126.64 # 38505 71.54 67.96 78.15 75.81 76.59 74.29 38510 513.52 487.84 561.02 544.18 549.79 533.30 # 38510 422.92 401.77 462.04 448.18 452.79 439.22 38520 465.83 442.54 508.92 493.65 498.74 483.77 38525 439.18 417.22 479.80 465.41 470.21 456.10 38530 556.61 528.78 608.10 589.86 595.93 578.06 38542 519.59 493.61 567.65 550.62 556.30 539.60 38550 505.77 480.48 552.55 535.98 541.50 525.26 38555 1,023.47 972.30 1,118.15 1,084.60 1,095.78 1,062.91 38562 709.96 674.46 775.63 752.36 760.12 737.32 38564 707.71 672.32 773.17 749.97 757.70 734.98 38570 509.46 483.99 556.59 539.89 545.46 529.09 38571 677.02 643.17 739.65 717.45 724.86 703.10 38572 950.26 902.75 1,038.16 1,007.02 1,017.41 986.88 38700 807.41 767.04 882.10 855.63 864.46 838.52 38720 1,350.66 1,283.13 1,475.60 1,431.34 1,446.09 1,402.71

Page 98: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 98Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

38724 1,459.22 1,386.26 1,594.20 1,546.37 1,562.31 1,515.45 38740 700.10 665.10 764.87 741.92 749.57 727.09 38745 885.83 841.54 967.77 938.73 948.42 919.95 38746 220.77 209.73 241.19 233.96 236.37 229.28 38747 272.95 259.30 298.20 289.25 292.23 283.46 38760 851.93 809.33 930.73 902.81 912.11 884.75 38765 1,312.48 1,246.86 1,433.89 1,390.87 1,405.21 1,363.05 38770 817.78 776.89 893.42 866.62 875.55 849.29 38780 1,038.39 986.47 1,134.44 1,100.41 1,111.75 1,078.40 38790 83.51 79.33 91.23 88.49 89.40 86.72 38792 39.62 37.64 43.29 41.99 42.42 41.15 38794 300.07 285.07 327.83 318.00 321.28 311.64 38900 141.21 134.15 154.27 149.65 151.19 146.66 39000 499.88 474.89 546.12 529.74 535.20 519.14 39010 798.73 758.79 872.61 846.43 855.15 829.51 39200 886.26 841.95 968.24 939.19 948.88 920.41 39220 1,152.69 1,095.06 1,259.32 1,221.54 1,234.13 1,197.12 39401 316.90 301.06 346.22 335.83 339.30 329.12 39402 414.41 393.69 452.74 439.16 443.69 430.38 39501 859.36 816.39 938.85 910.69 920.07 892.47 39503 6,056.52 5,753.69 6,616.74 6,418.24 6,484.41 6,289.88 39540 881.23 837.17 962.75 933.86 943.49 915.18 39541 957.46 909.59 1,046.03 1,014.65 1,025.11 994.35 39545 898.24 853.33 981.33 951.89 961.70 932.86 39560 808.42 768.00 883.20 856.70 865.54 839.57 39561 1,257.68 1,194.80 1,374.02 1,332.80 1,346.54 1,306.15 40490 125.65 119.37 137.28 133.16 134.53 130.49 # 40490 74.26 70.55 81.13 78.69 79.51 77.12 40500 493.53 468.85 539.18 523.00 528.39 512.53 # 40500 361.75 343.66 395.21 383.35 387.31 375.68 40510 474.34 450.62 518.21 502.67 507.85 492.61 # 40510 356.07 338.27 389.01 377.34 381.23 369.79 40520 479.19 455.23 523.51 507.81 513.05 497.65 # 40520 357.62 339.74 390.70 378.98 382.89 371.40 40525 551.09 523.54 602.07 584.00 590.03 572.32 40527 624.74 593.50 682.53 662.06 668.87 648.82 40530 526.56 500.23 575.26 558.00 563.76 546.85 # 40530 401.36 381.29 438.48 425.33 429.71 416.82 40650 427.24 405.88 466.76 452.76 457.42 443.70 # 40650 297.10 282.25 324.59 314.85 318.10 308.55 40652 479.91 455.91 524.30 508.56 513.81 498.40 # 40652 352.08 334.48 384.65 373.12 376.96 365.65 40654 560.01 532.01 611.81 593.46 599.58 581.59 # 40654 425.27 404.01 464.61 450.67 455.32 441.66 40700 1,010.70 960.17 1,104.20 1,071.06 1,082.12 1,049.64 40701 1,199.12 1,139.16 1,310.03 1,270.74 1,283.84 1,245.32 40702 906.86 861.52 990.75 961.02 970.93 941.80 40720 1,000.40 950.38 1,092.94 1,060.15 1,071.08 1,038.94 40761 977.34 928.47 1,067.74 1,035.71 1,046.39 1,015.00

Page 99: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 99Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

40800 207.15 196.79 226.31 219.52 221.78 215.13 # 40800 131.04 124.49 143.16 138.87 140.30 136.09 40801 309.81 294.32 338.47 328.31 331.69 321.75 # 40801 223.50 212.33 244.18 236.85 239.29 232.12 40804 179.29 170.33 195.88 190.00 191.96 186.21 # 40804 113.40 107.73 123.89 120.18 121.42 117.77 40805 316.96 301.11 346.28 335.89 339.35 329.18 # 40805 233.94 222.24 255.58 247.91 250.47 242.95 40806 100.58 95.55 109.88 106.58 107.69 104.45 # 40806 32.71 31.07 35.73 34.66 35.02 33.97 40808 181.02 171.97 197.77 191.83 193.81 187.99 # 40808 107.55 102.17 117.50 113.97 115.15 111.69 40810 201.30 191.24 219.93 213.33 215.53 209.06 # 40810 127.17 120.81 138.93 134.77 136.15 132.08 40812 284.19 269.98 310.48 301.16 304.27 295.14 # 40812 198.54 188.61 216.90 210.39 212.57 206.18 40814 381.37 362.30 416.65 404.14 408.31 396.06 # 40814 306.25 290.94 334.58 324.54 327.89 318.06 40816 397.65 377.77 434.44 421.41 425.74 412.98 # 40816 317.59 301.71 346.97 336.56 340.03 329.83 40818 353.33 335.66 386.01 374.43 378.29 366.94 # 40818 272.28 258.67 297.47 288.55 291.53 282.77 40819 311.02 295.47 339.79 329.60 332.99 323.01 # 40819 239.86 227.87 262.05 254.18 256.81 249.10 40820 257.91 245.01 281.76 273.31 276.13 267.85 # 40820 170.60 162.07 186.38 180.79 182.65 177.18 40830 261.77 248.68 285.98 277.40 280.27 271.86 # 40830 165.90 157.61 181.25 175.81 177.63 172.29 40831 330.94 314.39 361.55 350.70 354.32 343.69 # 40831 225.51 214.23 246.36 238.97 241.44 234.19 40840 801.06 761.01 875.16 848.91 857.66 831.93 # 40840 630.73 599.19 689.07 668.39 675.29 655.03 40842 810.27 769.76 885.22 858.67 867.51 841.50 # 40842 653.78 621.09 714.25 692.83 699.97 678.97 40843 1,077.73 1,023.84 1,177.42 1,142.09 1,153.86 1,119.25 # 40843 862.92 819.77 942.74 914.46 923.88 896.17 40844 1,283.74 1,219.55 1,402.48 1,360.40 1,374.43 1,333.20 # 40844 1,058.39 1,005.47 1,156.29 1,121.61 1,133.16 1,099.17 40845 1,453.77 1,381.08 1,588.24 1,540.60 1,556.48 1,509.79 # 40845 1,235.34 1,173.57 1,349.61 1,309.11 1,322.62 1,282.93 41000 159.10 151.15 173.82 168.61 170.35 165.24 # 41000 112.32 106.70 122.71 119.03 120.26 116.64 41005 220.20 209.19 240.57 233.35 235.76 228.68 # 41005 124.00 117.80 135.47 131.41 132.76 128.78 41006 381.11 362.05 416.36 403.87 408.03 395.80 # 41006 271.40 257.83 296.50 287.62 290.57 281.87 41007 375.34 356.57 410.06 397.75 401.86 389.79 # 41007 262.99 249.84 287.32 278.69 281.57 273.11 41008 375.89 357.10 410.67 398.35 402.45 390.38

Page 100: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 100Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 41008 272.77 259.13 298.00 289.06 292.04 283.28 41009 399.15 379.19 436.07 422.98 427.35 414.52 # 41009 296.03 281.23 323.41 313.71 316.95 307.43 41010 193.83 184.14 211.76 205.41 207.53 201.31 # 41010 106.19 100.88 116.01 112.53 113.69 110.27 41015 449.20 426.74 490.75 476.03 480.94 466.51 # 41015 352.34 334.72 384.93 373.38 377.23 365.92 41016 436.67 414.84 477.07 462.75 467.52 453.49 # 41016 353.65 335.97 386.37 374.77 378.64 367.28 41017 441.94 419.84 482.82 468.33 473.16 458.97 # 41017 355.96 338.16 388.88 377.22 381.11 369.68 41018 502.80 477.66 549.31 532.83 538.33 522.17 # 41018 416.15 395.34 454.64 441.00 445.54 432.18 41019 477.37 453.50 521.53 505.89 511.09 495.77 41100 164.58 156.35 179.80 174.41 176.20 170.92 # 41100 107.91 102.51 117.89 114.34 115.53 112.06 41105 167.75 159.36 183.26 177.77 179.60 174.21 # 41105 112.40 106.78 122.80 119.12 120.34 116.74 41108 144.74 137.50 158.13 153.39 154.96 150.32 # 41108 90.71 86.17 99.10 96.12 97.12 94.20 41110 206.89 196.55 226.03 219.25 221.51 214.87 # 41110 131.11 124.55 143.23 138.93 140.37 136.15 41112 329.54 313.06 360.02 349.22 352.82 342.24 # 41112 253.44 240.77 276.89 268.58 271.34 263.21 41113 361.41 343.34 394.84 383.00 386.94 375.34 # 41113 281.02 266.97 307.02 297.80 300.87 291.85 41114 639.11 607.15 698.22 677.28 684.26 663.73 41115 239.94 227.94 262.13 254.27 256.89 249.18 # 41115 144.73 137.49 158.11 153.38 154.95 150.31 41116 324.50 308.28 354.52 343.88 347.43 337.01 # 41116 220.06 209.06 240.42 233.21 235.61 228.54 41120 1,070.40 1,016.88 1,169.41 1,134.33 1,146.02 1,111.64 41130 1,324.06 1,257.86 1,446.54 1,403.14 1,417.61 1,375.08 41135 2,192.22 2,082.61 2,395.00 2,323.15 2,347.10 2,276.69 41140 2,204.54 2,094.31 2,408.46 2,336.20 2,360.28 2,289.48 41145 2,790.09 2,650.59 3,048.18 2,956.73 2,987.22 2,897.60 41150 2,216.96 2,106.11 2,422.03 2,349.37 2,373.59 2,302.38 41153 2,414.27 2,293.56 2,637.59 2,558.46 2,584.84 2,507.30 41155 3,049.23 2,896.77 3,331.29 3,231.35 3,264.65 3,166.72 41250 260.57 247.54 284.67 276.13 278.98 270.61 # 41250 153.49 145.82 167.69 162.67 164.34 159.41 41251 280.69 266.66 306.66 297.46 300.53 291.51 # 41251 181.53 172.45 198.32 192.37 194.35 188.52 41252 312.04 296.44 340.91 330.68 334.09 324.07 # 41252 212.87 202.23 232.56 225.58 227.92 221.08 41500 443.29 421.13 484.30 469.78 474.62 460.38 41510 417.95 397.05 456.61 442.91 447.48 434.06 41512 654.61 621.88 715.16 693.70 700.86 679.83 41520 346.43 329.11 378.48 367.13 370.91 359.79

Page 101: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 101Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 41520 257.48 244.61 281.30 272.86 275.68 267.40 41530 937.86 890.97 1,024.62 993.88 1,004.12 974.00 # 41530 370.20 351.69 404.44 392.31 396.36 384.47 41800 267.14 253.78 291.85 283.10 286.01 277.44 # 41800 146.23 138.92 159.76 154.96 156.56 151.87 41805 240.17 228.16 262.38 254.52 257.14 249.42 # 41805 168.68 160.25 184.29 178.76 180.61 175.18 41806 347.93 330.53 380.11 368.70 372.51 361.33 # 41806 259.64 246.66 283.66 275.15 277.99 269.64 41822 308.75 293.31 337.31 327.19 330.56 320.64 # 41822 186.85 177.51 204.14 198.01 200.05 194.05 41823 451.79 429.20 493.58 478.77 483.71 469.19 # 41823 335.17 318.41 366.17 355.19 358.85 348.08 41825 207.43 197.06 226.62 219.82 222.09 215.43 # 41825 122.43 116.31 133.76 129.74 131.08 127.14 41826 310.70 295.17 339.45 329.26 332.66 322.67 # 41826 214.17 203.46 233.98 226.96 229.30 222.42 41827 436.43 414.61 476.80 462.50 467.27 453.25 # 41827 310.90 295.36 339.66 329.48 332.87 322.89 41828 305.68 290.40 333.96 323.94 327.28 317.47 # 41828 217.71 206.82 237.84 230.71 233.08 226.10 41830 388.71 369.27 424.66 411.92 416.16 403.68 # 41830 285.92 271.62 312.36 302.99 306.12 296.93 41872 370.32 351.80 404.57 392.44 396.47 384.59 # 41872 263.91 250.71 288.32 279.67 282.56 274.08 41874 374.68 355.95 409.34 397.06 401.15 389.11 # 41874 259.70 246.72 283.73 275.22 278.06 269.71 42000 156.20 148.39 170.65 165.53 167.23 162.22 # 42000 104.15 98.94 113.78 110.37 111.50 108.16 42100 147.60 140.22 161.25 156.41 158.03 153.28 # 42100 109.38 103.91 119.50 115.91 117.10 113.59 42104 210.98 200.43 230.49 223.58 225.88 219.11 # 42104 139.16 132.20 152.03 147.46 148.99 144.52 42106 269.26 255.80 294.17 285.35 288.28 279.65 # 42106 179.65 170.67 196.27 190.38 192.35 186.58 42107 455.61 432.83 497.75 482.83 487.80 473.17 # 42107 347.55 330.17 379.70 368.30 372.11 360.93 42120 1,011.80 961.21 1,105.39 1,072.23 1,083.29 1,050.78 42140 244.92 232.67 267.57 259.54 262.22 254.36 # 42140 153.00 145.35 167.15 162.14 163.81 158.90 42145 702.34 667.22 767.30 744.28 751.96 729.40 42160 227.00 215.65 248.00 240.56 243.04 235.75 # 42160 146.94 139.59 160.53 155.71 157.32 152.59 42180 239.50 227.53 261.66 253.81 256.43 248.73 # 42180 183.16 174.00 200.10 194.10 196.10 190.21 42182 316.75 300.91 346.05 335.66 339.12 328.95 # 42182 256.79 243.95 280.54 272.12 274.93 266.69 42200 853.93 811.23 932.91 904.92 914.26 886.82 42205 914.58 868.85 999.18 969.20 979.19 949.81

Page 102: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 102Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

42210 1,041.69 989.61 1,138.05 1,103.91 1,115.29 1,081.83 42215 721.45 685.38 788.19 764.54 772.42 749.25 42220 527.45 501.08 576.24 558.96 564.72 547.78 42225 863.72 820.53 943.61 915.30 924.74 896.99 42226 898.54 853.61 981.65 952.20 962.02 933.16 42227 846.33 804.01 924.61 896.87 906.12 878.93 42235 721.41 685.34 788.14 764.50 772.37 749.20 42260 833.25 791.59 910.33 883.02 892.12 865.35 # 42260 699.82 664.83 764.55 741.62 749.26 726.79 42280 161.63 153.55 176.58 171.28 173.05 167.85 # 42280 111.88 106.29 122.23 118.57 119.78 116.20 42281 200.72 190.68 219.28 212.70 214.90 208.45 # 42281 150.31 142.79 164.21 159.29 160.92 156.10 42300 204.67 194.44 223.61 216.90 219.13 212.57 # 42300 151.96 144.36 166.01 161.03 162.69 157.81 42305 432.82 411.18 472.86 458.67 463.40 449.49 42310 157.95 150.05 172.56 167.38 169.11 164.04 # 42310 123.35 117.18 134.76 130.71 132.07 128.10 42320 242.96 230.81 265.43 257.47 260.12 252.32 # 42320 174.10 165.40 190.21 184.51 186.40 180.81 42330 227.69 216.31 248.76 241.29 243.78 236.46 # 42330 164.76 156.52 180.00 174.59 176.40 171.10 42335 365.99 347.69 399.84 387.85 391.85 380.09 # 42335 256.94 244.09 280.70 272.29 275.09 266.83 42340 457.34 434.47 499.64 484.66 489.65 474.96 # 42340 337.09 320.24 368.28 357.22 360.92 350.08 42400 102.05 96.95 111.49 108.15 109.26 105.98 # 42400 54.94 52.19 60.02 58.21 58.82 57.05 42405 294.26 279.55 321.48 311.83 315.05 305.60 # 42405 226.72 215.38 247.69 240.26 242.73 235.45 42408 445.93 423.63 487.17 472.56 477.43 463.11 # 42408 327.00 310.65 357.25 346.53 350.11 339.60 42409 325.41 309.14 355.51 344.85 348.40 337.95 # 42409 221.30 210.24 241.78 234.52 236.95 229.83 42410 623.27 592.11 680.93 660.50 667.31 647.29 42415 1,061.03 1,007.98 1,159.18 1,124.40 1,135.99 1,101.92 42420 1,191.55 1,131.97 1,301.77 1,262.71 1,275.73 1,237.46 42425 839.24 797.28 916.87 889.36 898.53 871.57 42426 1,359.39 1,291.42 1,485.13 1,440.58 1,455.43 1,411.77 42440 411.78 391.19 449.87 436.37 440.88 427.64 42450 445.21 422.95 486.39 471.80 476.66 462.36 # 42450 357.24 339.38 390.29 378.58 382.48 371.01 42500 426.39 405.07 465.83 451.86 456.52 442.82 # 42500 340.73 323.69 372.24 361.08 364.80 353.86 42505 547.39 520.02 598.02 580.08 586.06 568.48 # 42505 451.85 429.26 493.65 478.84 483.77 469.26 42507 498.42 473.50 544.53 528.20 533.63 517.63 42509 841.75 799.66 919.61 892.02 901.22 874.18 42510 642.02 609.92 701.41 680.36 687.38 666.76

Page 103: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 103Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

42550 131.50 124.93 143.67 139.36 140.79 136.57 # 42550 64.29 61.08 70.24 68.14 68.84 66.78 42600 462.87 439.73 505.69 490.52 495.58 480.71 # 42600 342.95 325.80 374.67 363.43 367.17 356.17 42650 81.66 77.58 89.22 86.54 87.43 84.81 # 42650 58.59 55.66 64.01 62.09 62.73 60.85 42660 126.21 119.90 137.89 133.75 135.13 131.07 # 42660 89.97 85.47 98.29 95.35 96.32 93.44 42665 308.02 292.62 336.51 326.42 329.79 319.88 # 42665 206.88 196.54 226.02 219.24 221.50 214.85 42700 184.84 175.60 201.94 195.88 197.90 191.96 # 42700 134.43 127.71 146.87 142.46 143.93 139.61 42720 451.16 428.60 492.89 478.10 483.03 468.54 # 42720 393.83 374.14 430.26 417.36 421.66 409.01 42725 823.12 781.96 899.25 872.28 881.27 854.83 42800 154.75 147.01 169.06 163.99 165.68 160.71 # 42800 111.26 105.70 121.56 117.91 119.13 115.55 42804 188.85 179.41 206.32 200.13 202.19 196.13 # 42804 111.75 106.16 122.08 118.43 119.65 116.06 42806 212.72 202.08 232.39 225.42 227.75 220.92 # 42806 130.69 124.16 142.78 138.51 139.93 135.73 42808 222.71 211.57 243.31 236.00 238.44 231.29 # 42808 162.09 153.99 177.09 171.78 173.55 168.34 42809 196.03 186.23 214.16 207.74 209.89 203.58 # 42809 122.56 116.43 133.89 129.88 131.22 127.28 42810 377.40 358.53 412.31 399.94 404.06 391.93 # 42810 285.81 271.52 312.25 302.88 306.00 296.82 42815 555.74 527.95 607.14 588.93 595.00 577.15 42820 288.27 273.86 314.94 305.49 308.64 299.38 42821 300.63 285.60 328.44 318.58 321.87 312.21 42825 260.55 247.52 284.65 276.10 278.96 270.58 42826 250.46 237.94 273.63 265.42 268.16 260.11 42830 205.59 195.31 224.61 217.87 220.11 213.51 42831 221.93 210.83 242.45 235.19 237.60 230.48 42835 180.60 171.57 197.31 191.38 193.36 187.55 42836 239.60 227.62 261.76 253.91 256.53 248.83 42842 1,011.72 961.13 1,105.30 1,072.15 1,083.20 1,050.70 42844 1,395.03 1,325.28 1,524.07 1,478.35 1,493.59 1,448.78 42845 2,253.28 2,140.62 2,461.71 2,387.86 2,412.48 2,340.10 42860 186.29 176.98 203.53 197.42 199.46 193.48 42870 588.80 559.36 643.26 623.97 630.40 611.49 42890 1,440.77 1,368.73 1,574.04 1,526.82 1,542.56 1,496.29 42892 1,904.64 1,809.41 2,080.82 2,018.40 2,039.20 1,978.03 42894 2,396.44 2,276.62 2,618.11 2,539.57 2,565.75 2,488.77 42900 339.30 322.34 370.69 359.57 363.27 352.38 42950 810.95 770.40 885.96 859.38 868.24 842.19 42953 972.60 923.97 1,062.57 1,030.69 1,041.31 1,010.08 42955 756.45 718.63 826.42 801.63 809.90 785.60 42960 169.79 161.30 185.50 179.93 181.78 176.33

Page 104: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 104Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

42961 420.67 399.64 459.59 445.80 450.40 436.89 42962 519.10 493.15 567.12 550.11 555.78 539.11 42970 408.21 387.80 445.97 432.60 437.05 423.95 42971 459.85 436.86 502.39 487.31 492.34 477.57 42972 511.16 485.60 558.44 541.68 547.27 530.85 43020 537.15 510.29 586.83 569.23 575.09 557.84 43030 519.30 493.34 567.34 550.32 555.99 539.32 43045 1,321.45 1,255.38 1,443.69 1,400.38 1,414.81 1,372.38 43100 623.07 591.92 680.71 660.28 667.09 647.08 43101 1,079.94 1,025.94 1,179.83 1,144.43 1,156.23 1,121.55 43107 2,603.84 2,473.65 2,844.70 2,759.36 2,787.81 2,704.17 43108 4,760.05 4,522.05 5,200.36 5,044.35 5,096.35 4,943.46 43112 2,753.95 2,616.25 3,008.69 2,918.42 2,948.52 2,860.05 43113 4,462.48 4,239.36 4,875.26 4,729.01 4,777.76 4,634.43 43116 5,328.84 5,062.40 5,821.76 5,647.11 5,705.32 5,534.17 43117 2,517.42 2,391.55 2,750.28 2,667.77 2,695.28 2,614.41 43118 3,864.17 3,670.96 4,221.60 4,094.95 4,137.17 4,013.05 43121 2,914.92 2,769.17 3,184.55 3,089.00 3,120.86 3,027.23 43122 2,609.12 2,478.66 2,850.46 2,764.95 2,793.45 2,709.64 43123 4,799.92 4,559.92 5,243.91 5,086.59 5,139.03 4,984.86 43124 3,922.16 3,726.05 4,284.96 4,156.41 4,199.26 4,073.28 43130 789.73 750.24 862.78 836.89 845.53 820.16 43135 1,511.41 1,435.84 1,651.22 1,601.67 1,618.19 1,569.64 43180 552.19 524.58 603.27 585.17 591.20 573.46 43191 155.67 147.89 170.07 164.97 166.67 161.67 43192 171.44 162.87 187.30 181.68 183.55 178.04 43193 171.17 162.61 187.00 181.39 183.26 177.77 43194 196.84 187.00 215.05 208.60 210.75 204.42 43195 186.93 177.58 204.22 198.09 200.13 194.13 43196 199.64 189.66 218.11 211.57 213.75 207.33 43197 182.09 172.99 198.94 192.97 194.96 189.11 # 43197 84.57 80.34 92.39 89.62 90.54 87.83 43198 202.20 192.09 220.90 214.28 216.49 209.99 # 43198 101.05 96.00 110.40 107.09 108.19 104.95 43200 207.44 197.07 226.63 219.83 222.10 215.44 # 43200 89.16 84.70 97.41 94.48 95.46 92.60 43201 212.69 202.06 232.37 225.40 227.72 220.89 # 43201 105.28 100.02 115.02 111.57 112.72 109.34 43202 293.11 278.45 320.22 310.62 313.81 304.41 # 43202 105.64 100.36 115.41 111.95 113.10 109.71 43204 139.18 132.22 152.05 147.49 149.02 144.54 43205 144.81 137.57 158.21 153.46 155.04 150.39 43206 256.68 243.85 280.43 272.01 274.82 266.57 # 43206 136.76 129.92 149.41 144.92 146.42 142.03 43210 442.75 420.61 483.70 469.19 474.03 459.80 43211 242.27 230.16 264.68 256.75 259.39 251.61 43212 195.59 185.81 213.68 207.28 209.40 203.14 43213 1,091.53 1,036.95 1,192.49 1,156.72 1,168.64 1,133.58 # 43213 265.57 252.29 290.13 281.43 284.33 275.80

Page 105: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 105Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

43214 197.55 187.67 215.82 209.35 211.51 205.16 43215 345.35 328.08 377.29 365.98 369.75 358.66 # 43215 145.37 138.10 158.82 154.05 155.64 150.97 43216 341.05 324.00 372.60 361.42 365.15 354.19 # 43216 137.78 130.89 150.52 146.00 147.51 143.08 43217 364.95 346.70 398.71 386.75 390.74 379.01 # 43217 164.97 156.72 180.23 174.82 176.63 171.33 43220 1,008.28 957.87 1,101.55 1,068.50 1,079.52 1,047.13 # 43220 120.72 114.68 131.88 127.93 129.25 125.37 43226 304.75 289.51 332.94 322.94 326.28 316.48 # 43226 133.76 127.07 146.13 141.75 143.21 138.91 43227 596.73 566.89 651.92 632.36 638.88 619.71 # 43227 169.43 160.96 185.10 179.55 181.40 175.96 43229 615.56 584.78 672.50 652.33 659.04 639.29 # 43229 202.75 192.61 221.50 214.85 217.07 210.55 43231 322.90 306.76 352.77 342.19 345.71 335.35 # 43231 164.10 155.90 179.29 173.90 175.70 170.43 43232 388.36 368.94 424.28 411.55 415.79 403.32 # 43232 203.20 193.04 222.00 215.34 217.56 211.04 43233 234.07 222.37 255.73 248.06 250.61 243.10 43235 246.84 234.50 269.68 261.59 264.28 256.36 # 43235 125.93 119.63 137.57 133.45 134.83 130.78 43236 315.65 299.87 344.85 334.50 337.95 327.81 # 43236 142.02 134.92 155.16 150.50 152.05 147.49 43237 200.93 190.88 219.51 212.92 215.12 208.67 43238 239.49 227.52 261.65 253.79 256.42 248.72 43239 328.53 312.10 358.92 348.15 351.74 341.19 # 43239 142.38 135.26 155.55 150.88 152.43 147.87 43240 404.27 384.06 441.67 428.42 432.84 419.85 43241 146.39 139.07 159.93 155.14 156.73 152.03 43242 270.31 256.79 295.31 286.45 289.40 280.73 43243 243.83 231.64 266.39 258.39 261.06 253.23 43244 252.45 239.83 275.80 267.54 270.28 262.19 43245 526.66 500.33 575.38 558.12 563.87 546.95 # 43245 180.40 171.38 197.09 191.18 193.14 187.36 43246 205.80 195.51 224.84 218.09 220.34 213.73 43247 337.88 320.99 369.14 358.06 361.76 350.90 # 43247 181.72 172.63 198.52 192.57 194.56 188.72 43248 337.48 320.61 368.70 357.64 361.33 350.49 # 43248 170.44 161.92 186.21 180.62 182.48 177.01 43249 958.40 910.48 1,047.05 1,015.65 1,026.11 995.34 # 43249 157.82 149.93 172.42 167.24 168.97 163.90 43250 381.71 362.62 417.01 404.50 408.68 396.42 # 43250 174.81 166.07 190.98 185.25 187.16 181.55 43251 423.37 402.20 462.53 448.65 453.28 439.68 # 43251 201.32 191.25 219.94 213.34 215.54 209.07 43252 292.58 277.95 319.64 310.05 313.25 303.85 # 43252 172.98 164.33 188.98 183.31 185.20 179.64 43253 270.31 256.79 295.31 286.45 289.40 280.73

Page 106: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 106Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

43254 278.41 264.49 304.16 295.04 298.08 289.14 43255 633.17 601.51 691.74 670.98 677.90 657.56 # 43255 206.52 196.19 225.62 218.85 221.11 214.46 43257 238.95 227.00 261.05 253.22 255.83 248.16 43259 232.46 220.84 253.97 246.34 248.88 241.42 43260 331.66 315.08 362.34 351.47 355.10 344.45 43261 348.48 331.06 380.72 369.30 373.11 361.92 43262 367.77 349.38 401.79 389.74 393.75 381.94 43263 368.49 350.07 402.58 390.51 394.53 382.70 43264 374.77 356.03 409.43 397.15 401.25 389.21 43265 446.30 423.99 487.59 472.96 477.84 463.50 43266 224.68 213.45 245.47 238.11 240.56 233.35 43270 636.65 604.82 695.54 674.68 681.63 661.19 # 43270 231.08 219.53 252.46 244.88 247.41 239.98 43273 123.40 117.23 134.81 130.77 132.12 128.16 43274 476.79 452.95 520.89 505.26 510.47 495.16 43275 387.76 368.37 423.63 410.92 415.15 402.70 43276 496.41 471.59 542.33 526.06 531.48 515.53 43277 389.85 370.36 425.91 413.14 417.39 404.88 43278 445.94 423.64 487.19 472.57 477.45 463.12 43279 1,313.20 1,247.54 1,434.67 1,391.63 1,405.98 1,363.80 43280 1,097.78 1,042.89 1,199.32 1,163.34 1,175.33 1,140.08 43281 1,571.65 1,493.07 1,717.03 1,665.52 1,682.69 1,632.21 43282 1,768.53 1,680.10 1,932.12 1,874.16 1,893.48 1,836.68 43283 162.57 154.44 177.61 172.28 174.05 168.83 43284 655.84 623.05 716.51 695.01 702.18 681.11 43285 664.32 631.10 725.77 704.00 711.25 689.92 43300 620.11 589.10 677.47 657.14 663.92 644.00 43305 1,098.52 1,043.59 1,200.13 1,164.12 1,176.13 1,140.83 43310 1,504.56 1,429.33 1,643.73 1,594.42 1,610.85 1,562.53 43312 1,642.97 1,560.82 1,794.94 1,741.10 1,759.04 1,706.28 43313 2,750.89 2,613.35 3,005.35 2,915.19 2,945.24 2,856.89 43314 3,036.88 2,885.04 3,317.80 3,218.26 3,251.44 3,153.90 43320 1,407.81 1,337.42 1,538.03 1,491.90 1,507.27 1,462.05 43325 1,357.44 1,289.57 1,483.01 1,438.51 1,453.35 1,409.74 43327 831.15 789.59 908.03 880.79 889.87 863.17 43328 1,149.62 1,092.14 1,255.96 1,218.29 1,230.85 1,193.92 43330 1,356.22 1,288.41 1,481.67 1,437.22 1,452.04 1,408.47 43331 1,361.97 1,293.87 1,487.95 1,443.31 1,458.19 1,414.44 43332 1,180.07 1,121.07 1,289.23 1,250.56 1,263.45 1,225.54 43333 1,288.38 1,223.96 1,407.55 1,365.33 1,379.40 1,338.03 43334 1,276.33 1,212.51 1,394.39 1,352.55 1,366.50 1,325.50 43335 1,370.06 1,301.56 1,496.79 1,451.89 1,466.86 1,422.85 43336 1,534.69 1,457.96 1,676.65 1,626.35 1,643.12 1,593.83 43337 1,654.02 1,571.32 1,807.02 1,752.81 1,770.87 1,717.76 43338 119.37 113.40 130.41 126.50 127.80 123.97 43340 1,390.43 1,320.91 1,519.05 1,473.47 1,488.66 1,444.00 43341 1,430.18 1,358.67 1,562.47 1,515.60 1,531.23 1,485.28 43351 1,396.54 1,326.71 1,525.72 1,479.95 1,495.21 1,450.35

Page 107: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 107Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

43352 1,087.53 1,033.15 1,188.12 1,152.48 1,164.36 1,129.44 43360 2,402.65 2,282.52 2,624.90 2,546.15 2,572.40 2,495.22 43361 2,629.69 2,498.21 2,872.94 2,786.75 2,815.49 2,731.01 43400 1,506.57 1,431.24 1,645.93 1,596.55 1,613.01 1,564.61 43401 1,496.83 1,421.99 1,635.29 1,586.23 1,602.58 1,554.50 43405 1,550.00 1,472.50 1,693.38 1,642.58 1,659.51 1,609.72 43410 1,063.23 1,010.07 1,161.58 1,126.74 1,138.35 1,104.20 43415 2,619.00 2,488.05 2,861.26 2,775.42 2,804.03 2,719.91 43420 1,024.71 973.47 1,119.49 1,085.91 1,097.10 1,064.19 43425 1,483.33 1,409.16 1,620.53 1,571.92 1,588.13 1,540.48 43450 151.20 143.64 165.19 160.23 161.89 157.02 # 43450 81.02 76.97 88.52 85.86 86.74 84.15 43453 853.69 811.01 932.66 904.68 914.01 886.59 # 43453 87.70 83.32 95.82 92.94 93.90 91.08 43460 218.82 207.88 239.06 231.89 234.28 227.25 43496 2,245.38 2,133.11 2,453.08 2,379.49 2,404.02 2,331.90 43500 795.86 756.07 869.48 843.40 852.09 826.53 43501 1,367.19 1,298.83 1,493.65 1,448.85 1,463.78 1,419.87 43502 1,530.34 1,453.82 1,671.89 1,621.74 1,638.45 1,589.31 43510 938.06 891.16 1,024.83 994.09 1,004.34 974.21 43520 696.13 661.32 760.52 737.70 745.30 722.95 43605 851.81 809.22 930.60 902.68 912.00 884.63 43610 994.11 944.40 1,086.06 1,053.48 1,064.34 1,032.41 43611 1,240.81 1,178.77 1,355.59 1,314.92 1,328.47 1,288.62 43620 2,002.47 1,902.35 2,187.70 2,122.07 2,143.95 2,079.63 43621 2,311.00 2,195.45 2,524.77 2,449.03 2,474.27 2,400.05 43622 2,336.05 2,219.25 2,552.14 2,475.57 2,501.10 2,426.06 43631 1,473.53 1,399.85 1,609.83 1,561.53 1,577.63 1,530.29 43632 2,068.51 1,965.08 2,259.84 2,192.05 2,214.65 2,148.21 43633 1,955.86 1,858.07 2,136.78 2,072.68 2,094.05 2,031.22 43634 2,157.65 2,049.77 2,357.24 2,286.52 2,310.09 2,240.79 43635 115.55 109.77 126.24 122.45 123.71 120.00 43640 1,195.98 1,136.18 1,306.61 1,267.40 1,280.48 1,242.06 43641 1,210.03 1,149.53 1,321.96 1,282.30 1,295.52 1,256.65 43644 1,761.36 1,673.29 1,924.28 1,866.55 1,885.79 1,829.22 43645 1,877.39 1,783.52 2,051.05 1,989.51 2,010.03 1,949.72 43647 297.38 282.51 324.89 315.13 318.39 308.83 43648 297.38 282.51 324.89 315.13 318.39 308.83 43651 659.25 626.29 720.23 698.63 705.82 684.65 43652 773.96 735.26 845.55 820.18 828.63 803.78 43653 576.71 547.87 630.05 611.14 617.45 598.92 43752 41.49 39.42 45.33 43.98 44.42 43.10 43753 22.25 21.14 24.31 23.59 23.83 23.12 43754 116.18 110.37 126.93 123.12 124.38 120.66 # 43754 35.13 33.37 38.38 37.23 37.61 36.48 43755 132.35 125.73 144.59 140.25 141.70 137.45 # 43755 60.53 57.50 66.13 64.15 64.80 62.86 43756 191.67 182.09 209.40 203.12 205.22 199.07 # 43756 50.99 48.44 55.71 54.04 54.59 52.96

Page 108: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 108Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

43757 276.31 262.49 301.86 292.81 295.83 286.96 # 43757 78.30 74.39 85.55 82.98 83.84 81.33 43760 460.97 437.92 503.61 488.50 493.53 478.72 # 43760 47.83 45.44 52.26 50.69 51.21 49.68 43761 117.25 111.39 128.10 124.26 125.53 121.77 # 43761 104.73 99.49 114.41 110.99 112.13 108.77 43770 1,133.79 1,077.10 1,238.67 1,201.51 1,213.89 1,177.47 43771 1,288.59 1,224.16 1,407.78 1,365.56 1,379.63 1,338.24 43772 960.29 912.28 1,049.12 1,017.65 1,028.13 997.29 43773 1,291.49 1,226.92 1,410.96 1,368.63 1,382.74 1,341.26 43774 971.98 923.38 1,061.89 1,030.03 1,040.65 1,009.44 43775 1,125.90 1,069.61 1,230.05 1,193.15 1,205.45 1,169.29 43800 943.43 896.26 1,030.70 999.78 1,010.08 979.78 43810 1,029.29 977.83 1,124.50 1,090.78 1,102.01 1,068.96 43820 1,362.23 1,294.12 1,488.24 1,443.60 1,458.48 1,414.72 43825 1,312.22 1,246.61 1,433.60 1,390.59 1,404.93 1,362.78 43830 705.33 670.06 770.57 747.45 755.16 732.50 43831 565.93 537.63 618.27 599.73 605.91 587.73 43832 1,051.88 999.29 1,149.18 1,114.71 1,126.20 1,092.41 43840 1,379.76 1,310.77 1,507.39 1,462.17 1,477.23 1,432.92 43843 1,289.34 1,224.87 1,408.60 1,366.34 1,380.43 1,339.01 43845 1,993.83 1,894.14 2,178.26 2,112.92 2,134.70 2,070.66 43846 1,644.84 1,562.60 1,796.99 1,743.08 1,761.05 1,708.22 43847 1,803.32 1,713.15 1,970.12 1,911.02 1,930.72 1,872.80 43848 1,954.93 1,857.18 2,135.76 2,071.68 2,093.05 2,030.24 43850 1,640.54 1,558.51 1,792.29 1,738.51 1,756.44 1,703.75 43855 1,693.86 1,609.17 1,850.55 1,795.02 1,813.54 1,759.12 43860 1,662.46 1,579.34 1,816.24 1,761.75 1,779.91 1,726.52 43865 1,721.78 1,635.69 1,881.04 1,824.61 1,843.43 1,788.12 43870 719.28 683.32 785.82 762.24 770.10 746.99 43880 1,625.49 1,544.22 1,775.85 1,722.57 1,740.34 1,688.12 43881 597.78 567.89 653.07 633.48 640.01 620.80 43882 597.78 567.89 653.07 633.48 640.01 620.80 43886 361.50 343.43 394.94 383.10 387.04 375.44 43887 326.42 310.10 356.62 345.92 349.49 339.00 43888 459.49 436.52 502.00 486.93 491.96 477.19 44005 1,112.08 1,056.48 1,214.95 1,178.51 1,190.65 1,154.93 44010 874.46 830.74 955.35 926.69 936.25 908.16 44015 145.91 138.61 159.40 154.62 156.22 151.52 44020 987.38 938.01 1,078.71 1,046.35 1,057.14 1,025.42 44021 988.07 938.67 1,079.47 1,047.09 1,057.89 1,026.15 44025 997.44 947.57 1,089.71 1,057.01 1,067.91 1,035.87 44050 947.95 900.55 1,035.63 1,004.56 1,014.92 984.47 44055 1,515.99 1,440.19 1,656.22 1,606.53 1,623.10 1,574.40 44100 111.17 105.61 121.45 117.81 119.03 115.45 44110 863.58 820.40 943.46 915.16 924.59 896.85 44111 995.41 945.64 1,087.49 1,054.86 1,065.74 1,033.76 44120 1,243.40 1,181.23 1,358.41 1,317.66 1,331.25 1,291.30 44121 247.94 235.54 270.87 262.74 265.45 257.49

Page 109: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 109Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

44125 1,199.29 1,139.33 1,310.23 1,270.92 1,284.02 1,245.51 44126 2,477.81 2,353.92 2,707.01 2,625.80 2,652.87 2,573.27 44127 2,819.26 2,678.30 3,080.05 2,987.64 3,018.44 2,927.89 44128 250.55 238.02 273.72 265.51 268.25 260.20 44130 1,333.49 1,266.82 1,456.84 1,413.14 1,427.70 1,384.88 44139 124.31 118.09 135.80 131.73 133.09 129.10 44140 1,362.30 1,294.19 1,488.32 1,443.66 1,458.56 1,414.79 44141 1,851.88 1,759.29 2,023.18 1,962.49 1,982.72 1,923.24 44143 1,690.39 1,605.87 1,846.75 1,791.34 1,809.81 1,755.52 44144 1,797.76 1,707.87 1,964.05 1,905.12 1,924.77 1,867.03 44145 1,686.23 1,601.92 1,842.21 1,786.94 1,805.36 1,751.20 44146 2,152.87 2,045.23 2,352.01 2,281.45 2,304.98 2,235.82 44147 1,976.97 1,878.12 2,159.84 2,095.05 2,116.64 2,053.14 44150 1,893.31 1,798.64 2,068.44 2,006.38 2,027.07 1,966.26 44151 2,163.77 2,055.58 2,363.92 2,293.00 2,316.64 2,247.13 44155 2,112.80 2,007.16 2,308.23 2,238.99 2,262.07 2,194.21 44156 2,301.36 2,186.29 2,514.23 2,438.81 2,463.94 2,390.03 44157 2,188.67 2,079.24 2,391.13 2,319.39 2,343.31 2,273.00 44158 2,267.17 2,153.81 2,476.88 2,402.58 2,427.34 2,354.53 44160 1,260.77 1,197.73 1,377.39 1,336.07 1,349.85 1,309.34 44180 932.34 885.72 1,018.58 988.02 998.21 968.27 44186 659.03 626.08 719.99 698.40 705.59 684.42 44187 1,116.22 1,060.41 1,219.47 1,182.89 1,195.08 1,159.23 44188 1,238.56 1,176.63 1,353.12 1,312.53 1,326.07 1,286.28 44202 1,407.62 1,337.24 1,537.83 1,491.69 1,507.08 1,461.86 44203 246.81 234.47 269.64 261.56 264.25 256.32 44204 1,564.13 1,485.92 1,708.81 1,657.54 1,674.63 1,624.39 44205 1,360.15 1,292.14 1,485.96 1,441.39 1,456.25 1,412.56 44206 1,779.92 1,690.92 1,944.56 1,886.22 1,905.67 1,848.50 44207 1,852.41 1,759.79 2,023.76 1,963.05 1,983.28 1,923.79 44208 2,019.12 1,918.16 2,205.88 2,139.71 2,161.77 2,096.92 44210 1,807.19 1,716.83 1,974.35 1,915.13 1,934.86 1,876.82 44211 2,218.04 2,107.14 2,423.21 2,350.52 2,374.75 2,303.51 44212 2,076.41 1,972.59 2,268.48 2,200.42 2,223.11 2,156.41 44213 192.91 183.26 210.75 204.42 206.53 200.33 44227 1,695.41 1,610.64 1,852.24 1,796.67 1,815.19 1,760.73 44300 852.66 810.03 931.53 903.59 912.90 885.52 44310 1,059.55 1,006.57 1,157.56 1,122.83 1,134.41 1,100.37 44312 596.06 566.26 651.20 631.66 638.17 619.02 44314 1,016.56 965.73 1,110.59 1,077.27 1,088.38 1,055.72 44316 1,439.69 1,367.71 1,572.87 1,525.68 1,541.41 1,495.17 44320 1,218.56 1,157.63 1,331.27 1,291.34 1,304.65 1,265.51 44322 997.41 947.54 1,089.67 1,056.98 1,067.88 1,035.84 44340 627.58 596.20 685.63 665.06 671.92 651.75 44345 1,065.59 1,012.31 1,164.16 1,129.23 1,140.87 1,106.65 44346 1,199.66 1,139.68 1,310.63 1,271.31 1,284.42 1,245.89 44360 147.62 140.24 161.28 156.43 158.06 153.31 44361 163.03 154.88 178.11 172.76 174.55 169.31 44363 197.13 187.27 215.36 208.90 211.05 204.72

Page 110: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 110Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

44364 210.02 199.52 229.45 222.56 224.86 218.11 44365 185.11 175.85 202.23 196.16 198.18 192.23 44366 246.82 234.48 269.65 261.57 264.26 256.34 44369 253.13 240.47 276.54 268.25 271.01 262.88 44370 273.96 260.26 299.30 290.32 293.31 284.51 44372 247.35 234.98 270.23 262.12 264.82 256.88 44373 197.54 187.66 215.81 209.33 211.50 205.15 44376 292.56 277.93 319.62 310.03 313.23 303.83 44377 308.27 292.86 336.79 326.68 330.05 320.15 44378 396.16 376.35 432.80 419.82 424.14 411.42 44379 421.75 400.66 460.76 446.94 451.55 438.00 44380 160.03 152.03 174.83 169.59 171.34 166.20 # 44380 57.24 54.38 62.54 60.66 61.28 59.46 44381 878.67 834.74 959.95 931.16 940.76 912.54 # 44381 86.65 82.32 94.67 91.83 92.77 89.99 44382 248.67 236.24 271.68 263.52 266.25 258.26 # 44382 74.71 70.97 81.62 79.17 79.98 77.58 44384 156.94 149.09 171.45 166.31 168.03 162.99 44385 182.59 173.46 199.48 193.50 195.49 189.62 # 44385 73.54 69.86 80.34 77.92 78.73 76.36 44386 271.89 258.30 297.05 288.13 291.10 282.37 # 44386 91.01 86.46 99.43 96.45 97.44 94.52 44388 279.74 265.75 305.61 296.45 299.51 290.51 # 44388 160.48 152.46 175.33 170.07 171.82 166.67 44388 53 138.97 132.02 151.82 147.27 148.79 144.33 # 44388 53 79.34 75.37 86.68 84.08 84.94 82.40 44389 364.66 346.43 398.39 386.45 390.43 378.72 # 44389 176.54 167.71 192.87 187.08 189.01 183.34 44390 363.27 345.11 396.88 384.97 388.94 377.27 # 44390 216.67 205.84 236.72 229.61 231.98 225.02 44391 661.44 628.37 722.63 700.95 708.17 686.93 # 44391 236.77 224.93 258.67 250.91 253.49 245.89 44392 340.07 323.07 371.53 360.39 364.10 353.18 # 44392 203.67 193.49 222.51 215.84 218.06 211.53 44394 392.09 372.49 428.36 415.52 419.80 407.20 # 44394 231.98 220.38 253.44 245.84 248.37 240.91 44401 2,982.69 2,833.56 3,258.59 3,160.83 3,193.42 3,097.62 # 44401 249.18 236.72 272.23 264.06 266.79 258.78 44402 267.70 254.32 292.47 283.69 286.61 278.02 44403 312.18 296.57 341.06 330.82 334.24 324.21 44404 347.12 329.76 379.22 367.85 371.63 360.49 # 44404 176.46 167.64 192.79 187.00 188.93 183.26 44405 514.86 489.12 562.49 545.62 551.24 534.70 # 44405 188.03 178.63 205.42 199.26 201.32 195.27 44406 236.08 224.28 257.92 250.18 252.76 245.18 44407 283.08 268.93 309.27 299.99 303.08 293.99 44408 238.17 226.26 260.20 252.39 254.99 247.34 44500 19.68 18.70 21.51 20.86 21.08 20.45 44602 1,437.95 1,366.05 1,570.96 1,523.83 1,539.54 1,493.36

Page 111: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 111Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

44603 1,650.41 1,567.89 1,803.07 1,748.98 1,767.01 1,713.99 44604 1,076.14 1,022.33 1,175.68 1,140.41 1,152.16 1,117.60 44605 1,323.86 1,257.67 1,446.32 1,402.93 1,417.40 1,374.87 44615 1,090.40 1,035.88 1,191.26 1,155.52 1,167.43 1,132.41 44620 880.31 836.29 961.73 932.88 942.49 914.23 44625 1,032.24 980.63 1,127.72 1,093.89 1,105.17 1,072.02 44626 1,631.97 1,550.37 1,782.93 1,729.44 1,747.26 1,694.85 44640 1,426.50 1,355.18 1,558.46 1,511.70 1,527.29 1,481.46 44650 1,471.73 1,398.14 1,607.86 1,559.63 1,575.71 1,528.44 44660 1,359.80 1,291.81 1,485.58 1,441.02 1,455.87 1,412.20 44661 1,578.05 1,499.15 1,724.02 1,672.31 1,689.55 1,638.87 44680 1,083.82 1,029.63 1,184.07 1,148.55 1,160.40 1,125.59 44700 1,032.40 980.78 1,127.90 1,094.06 1,105.33 1,072.18 44701 172.18 163.57 188.11 182.46 184.35 178.81 44720 307.74 292.35 336.20 326.12 329.48 319.60 44721 393.85 374.16 430.28 417.38 421.68 409.03 44800 773.12 734.46 844.63 819.29 827.74 802.91 44820 847.25 804.89 925.62 897.85 907.11 879.90 44850 758.86 720.92 829.06 804.18 812.48 788.10 44900 776.68 737.85 848.53 823.07 831.55 806.61 44950 650.84 618.30 711.05 689.71 696.82 675.92 44955 85.88 81.59 93.83 91.01 91.95 89.19 44960 886.77 842.43 968.79 939.73 949.42 920.94 44970 606.83 576.49 662.96 643.08 649.70 630.22 45000 424.81 403.57 464.11 450.18 454.83 441.17 45005 266.18 252.87 290.80 282.07 284.98 276.43 # 45005 160.75 152.71 175.62 170.35 172.11 166.95 45020 575.74 546.95 628.99 610.12 616.41 597.92 45100 298.78 283.84 326.42 316.62 319.88 310.28 45108 365.42 347.15 399.22 387.25 391.24 379.51 45110 1,871.61 1,778.03 2,044.73 1,983.39 2,003.84 1,943.73 45111 1,100.98 1,045.93 1,202.82 1,166.73 1,178.76 1,143.40 45112 1,908.44 1,813.02 2,084.97 2,022.42 2,043.27 1,981.98 45113 1,960.54 1,862.51 2,141.89 2,077.62 2,099.05 2,036.08 45114 1,835.40 1,743.63 2,005.17 1,945.02 1,965.07 1,906.11 45116 1,643.79 1,561.60 1,795.84 1,741.96 1,759.93 1,707.13 45119 1,974.90 1,876.16 2,157.58 2,092.86 2,114.44 2,051.00 45120 1,610.92 1,530.37 1,759.93 1,707.13 1,724.72 1,672.99 45121 1,684.33 1,600.11 1,840.13 1,784.93 1,803.33 1,749.23 45123 1,134.39 1,077.67 1,239.32 1,202.14 1,214.54 1,178.09 45126 2,834.64 2,692.91 3,096.85 3,003.94 3,034.91 2,943.86 45130 1,103.16 1,048.00 1,205.20 1,169.04 1,181.10 1,145.66 45135 1,385.10 1,315.85 1,513.23 1,467.83 1,482.96 1,438.47 45136 1,935.95 1,839.15 2,115.02 2,051.58 2,072.73 2,010.55 45150 362.40 344.28 395.92 384.04 388.00 376.36 45160 1,033.27 981.61 1,128.85 1,094.98 1,106.28 1,073.09 45171 600.52 570.49 656.06 636.39 642.94 623.66 45172 813.02 772.37 888.23 861.58 870.46 844.35 45190 698.11 663.20 762.68 739.80 747.43 724.99

Page 112: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 112Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

45300 118.37 112.45 129.32 125.44 126.73 122.94 # 45300 54.46 51.74 59.50 57.72 58.32 56.57 45303 848.62 806.19 927.12 899.30 908.58 881.31 # 45303 87.90 83.51 96.04 93.15 94.12 91.29 45305 137.75 130.86 150.49 145.97 147.48 143.05 # 45305 74.17 70.46 81.03 78.60 79.41 77.03 45307 161.71 153.62 176.66 171.36 173.13 167.93 # 45307 98.79 93.85 107.93 104.68 105.77 102.59 45308 154.63 146.90 168.94 163.86 165.55 160.59 # 45308 85.11 80.85 92.98 90.18 91.11 88.38 45309 161.27 153.21 176.19 170.90 172.67 167.49 # 45309 90.77 86.23 99.16 96.19 97.19 94.27 45315 175.78 166.99 192.04 186.28 188.20 182.55 # 45315 106.92 101.57 116.81 113.30 114.47 111.03 45317 177.81 168.92 194.26 188.43 190.37 184.66 # 45317 113.90 108.21 124.44 120.70 121.96 118.29 45320 172.45 163.83 188.40 182.76 184.63 179.10 # 45320 105.90 100.61 115.70 112.23 113.39 109.99 45321 103.01 97.86 112.54 109.16 110.29 106.97 45327 115.07 109.32 125.72 121.95 123.20 119.51 45330 158.98 151.03 173.68 168.48 170.21 165.11 # 45330 56.85 54.01 62.11 60.25 60.87 59.04 45331 243.31 231.14 265.81 257.84 260.50 252.69 # 45331 73.31 69.64 80.09 77.68 78.49 76.13 45332 240.84 228.80 263.12 255.23 257.85 250.13 # 45332 107.74 102.35 117.70 114.17 115.35 111.88 45333 279.70 265.72 305.58 296.41 299.47 290.49 # 45333 96.19 91.38 105.09 101.94 102.98 99.90 45334 521.26 495.20 569.48 552.39 558.10 541.34 # 45334 120.63 114.60 131.79 127.83 129.16 125.28 45335 221.93 210.83 242.45 235.19 237.60 230.48 # 45335 67.74 64.35 74.00 71.78 72.52 70.35 45337 118.77 112.83 129.75 125.87 127.16 123.35 45338 258.25 245.34 282.14 273.68 276.49 268.20 # 45338 123.50 117.33 134.93 130.88 132.23 128.26 45340 407.13 386.77 444.79 431.45 435.88 422.82 # 45340 79.32 75.35 86.65 84.05 84.92 82.37 45341 126.95 120.60 138.69 134.53 135.92 131.84 45342 174.27 165.56 190.39 184.68 186.59 180.99 45346 2,860.51 2,717.48 3,125.10 3,031.35 3,062.60 2,970.73 # 45346 164.88 156.64 180.14 174.73 176.54 171.24 45347 158.63 150.70 173.31 168.11 169.84 164.75 45349 203.80 193.61 222.65 215.97 218.20 211.65 45350 495.52 470.74 541.35 525.11 530.53 514.61 # 45350 103.13 97.97 112.67 109.28 110.41 107.10 45378 307.14 291.78 335.55 325.48 328.83 318.98 # 45378 190.19 180.68 207.78 201.55 203.63 197.51 45378 53 154.11 146.40 168.36 163.31 164.99 160.05 # 45378 53 95.80 91.01 104.66 101.52 102.57 99.49

Page 113: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 113Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

45379 396.51 376.68 433.18 420.19 424.52 411.78 # 45379 245.95 233.65 268.70 260.64 263.33 255.43 45380 390.75 371.21 426.89 414.08 418.36 405.80 # 45380 206.25 195.94 225.33 218.57 220.82 214.20 45381 373.92 355.22 408.50 396.24 400.34 388.32 # 45381 206.22 195.91 225.30 218.53 220.79 214.16 45382 689.20 654.74 752.95 730.37 737.90 715.76 # 45382 266.51 253.18 291.16 282.42 285.34 276.77 45384 434.17 412.46 474.33 460.10 464.84 450.90 # 45384 234.85 223.11 256.58 248.88 251.45 243.90 45385 413.54 392.86 451.79 438.23 442.75 429.47 # 45385 261.66 248.58 285.87 277.29 280.15 271.75 45386 559.54 531.56 611.29 592.95 599.07 581.10 # 45386 217.89 207.00 238.05 230.91 233.29 226.29 45388 3,013.12 2,862.46 3,291.83 3,193.08 3,225.99 3,129.22 # 45388 278.62 264.69 304.39 295.26 298.31 289.36 45389 298.51 283.58 326.12 316.33 319.60 310.01 45390 341.98 324.88 373.61 362.40 366.14 355.15 45391 265.10 251.85 289.63 280.93 283.83 275.31 45392 312.79 297.15 341.72 331.48 334.89 324.85 45393 260.51 247.48 284.60 276.07 278.91 270.55 45395 2,003.49 1,903.32 2,188.82 2,123.15 2,145.04 2,080.70 45397 2,182.45 2,073.33 2,384.33 2,312.80 2,336.64 2,266.55 45398 642.95 610.80 702.42 681.35 688.37 667.72 # 45398 241.34 229.27 263.66 255.75 258.38 250.63 45400 1,155.51 1,097.73 1,262.39 1,224.52 1,237.15 1,200.03 45402 1,543.36 1,466.19 1,686.12 1,635.53 1,652.40 1,602.82 45500 522.77 496.63 571.12 553.99 559.71 542.92 45505 592.57 562.94 647.38 627.96 634.43 615.40 45520 147.44 140.07 161.08 156.25 157.86 153.12 # 45520 40.37 38.35 44.10 42.78 43.22 41.93 45540 1,071.79 1,018.20 1,170.93 1,135.80 1,147.52 1,113.09 45541 952.23 904.62 1,040.31 1,009.10 1,019.51 988.92 45550 1,482.04 1,407.94 1,619.13 1,570.56 1,586.75 1,539.15 45560 692.45 657.83 756.50 733.82 741.37 719.14 45562 1,135.60 1,078.82 1,240.64 1,203.43 1,215.83 1,179.36 45563 1,660.98 1,577.93 1,814.62 1,760.18 1,778.33 1,724.98 45800 1,219.08 1,158.13 1,331.85 1,291.90 1,305.22 1,266.06 45805 1,449.69 1,377.21 1,583.79 1,536.27 1,552.12 1,505.55 45820 1,142.97 1,085.82 1,248.69 1,211.24 1,223.72 1,187.02 45825 1,446.38 1,374.06 1,580.17 1,532.77 1,548.57 1,502.11 45900 203.25 193.09 222.05 215.40 217.61 211.08 45905 168.64 160.21 184.24 178.71 180.56 175.13 45910 193.98 184.28 211.92 205.56 207.68 201.46 45915 323.14 306.98 353.03 342.44 345.97 335.58 # 45915 226.28 214.97 247.22 239.80 242.27 235.00 45990 109.08 103.63 119.17 115.60 116.79 113.29 46020 271.42 257.85 296.53 287.63 290.59 281.88 # 46020 232.87 221.23 254.41 246.78 249.33 241.85

Page 114: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 114Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

46030 135.50 128.73 148.04 143.60 145.08 140.73 # 46030 90.37 85.85 98.73 95.76 96.75 93.84 46040 524.12 497.91 572.60 555.42 561.14 544.31 # 46040 412.43 391.81 450.58 437.07 441.57 428.33 46045 433.93 412.23 474.06 459.84 464.59 450.64 46050 193.76 184.07 211.68 205.33 207.45 201.23 # 46050 96.90 92.06 105.87 102.70 103.75 100.64 46060 474.64 450.91 518.55 502.99 508.17 492.92 46070 224.45 213.23 245.21 237.85 240.32 233.09 46080 242.84 230.70 265.31 257.35 260.00 252.20 # 46080 160.81 152.77 175.69 170.42 172.17 167.01 46083 171.01 162.46 186.83 181.23 183.09 177.61 # 46083 106.11 100.80 115.92 112.45 113.60 110.19 46200 432.90 411.26 472.95 458.76 463.48 449.58 # 46200 321.54 305.46 351.28 340.75 344.25 333.93 46220 199.33 189.36 217.76 211.23 213.41 207.01 # 46220 118.28 112.37 129.23 125.35 126.64 122.84 46221 260.39 247.37 284.48 275.94 278.78 270.42 # 46221 188.56 179.13 206.00 199.82 201.88 195.82 46230 266.41 253.09 291.05 282.33 285.23 276.68 # 46230 173.18 164.52 189.20 183.52 185.41 179.85 46250 451.18 428.62 492.91 478.12 483.06 468.56 # 46250 314.13 298.42 343.18 332.89 336.32 326.23 46255 494.86 470.12 540.64 524.42 529.83 513.94 # 46255 353.52 335.84 386.22 374.62 378.49 367.13 46257 419.90 398.91 458.75 444.98 449.57 436.08 46258 463.80 440.61 506.70 491.50 496.57 481.67 46260 475.42 451.65 519.40 503.82 509.01 493.74 46261 523.13 496.97 571.52 554.37 560.08 543.28 46262 553.31 525.64 604.49 586.35 592.40 574.62 46270 496.45 471.63 542.37 526.10 531.53 515.58 # 46270 389.04 369.59 425.03 412.28 416.53 404.03 46275 526.52 500.19 575.22 557.96 563.72 546.80 # 46275 411.54 390.96 449.60 436.11 440.61 427.40 46280 467.55 444.17 510.80 495.47 500.58 485.55 46285 523.47 497.30 571.90 554.74 560.45 543.64 # 46285 411.13 390.57 449.16 435.68 440.17 426.96 46288 549.96 522.46 600.83 582.81 588.81 571.15 46320 178.66 169.73 195.19 189.34 191.29 185.55 # 46320 111.13 105.57 121.41 117.76 118.98 115.40 46500 181.44 172.37 198.23 192.28 194.26 188.44 # 46500 121.81 115.72 133.08 129.09 130.42 126.51 46505 279.85 265.86 305.74 296.56 299.62 290.63 # 46505 237.35 225.48 259.30 251.53 254.12 246.50 46600 84.90 80.66 92.76 89.98 90.91 88.18 # 46600 40.76 38.72 44.53 43.19 43.64 42.33 46601 133.27 126.61 145.60 141.23 142.69 138.40 # 46601 94.73 89.99 103.49 100.38 101.42 98.37 46604 585.35 556.08 639.49 620.31 626.70 607.90

Page 115: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 115Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 46604 67.11 63.75 73.31 71.12 71.85 69.69 46606 216.28 205.47 236.29 229.21 231.56 224.62 # 46606 76.59 72.76 83.67 81.17 82.00 79.55 46607 188.07 178.67 205.47 199.31 201.37 195.32 # 46607 128.44 122.02 140.32 136.11 137.52 133.39 46608 224.78 213.54 245.57 238.20 240.66 233.44 # 46608 84.43 80.21 92.24 89.47 90.40 87.68 46610 218.34 207.42 238.53 231.38 233.76 226.76 # 46610 82.27 78.16 89.88 87.19 88.09 85.45 46611 170.18 161.67 185.92 180.34 182.21 176.73 # 46611 82.22 78.11 89.83 87.14 88.03 85.39 46612 239.20 227.24 261.33 253.48 256.11 248.41 # 46612 92.92 88.27 101.51 98.46 99.48 96.50 46614 123.99 117.79 135.46 131.40 132.74 128.77 # 46614 65.02 61.77 71.04 68.91 69.61 67.53 46615 139.98 132.98 152.93 148.34 149.87 145.37 # 46615 93.52 88.84 102.17 99.10 100.12 97.12 46700 655.80 623.01 716.46 694.97 702.13 681.06 46705 500.21 475.20 546.48 530.08 535.56 519.48 46706 174.91 166.16 191.08 185.36 187.27 181.65 46707 470.23 446.72 513.73 498.32 503.46 488.35 46710 1,050.33 997.81 1,147.48 1,113.06 1,124.53 1,090.80 46712 2,137.77 2,030.88 2,335.51 2,265.44 2,288.80 2,220.13 46715 542.75 515.61 592.95 575.16 581.10 563.66 46716 1,112.14 1,056.53 1,215.01 1,178.55 1,190.71 1,154.98 46730 1,835.90 1,744.11 2,005.73 1,945.56 1,965.61 1,906.64 46735 2,128.65 2,022.22 2,325.55 2,255.78 2,279.05 2,210.67 46740 2,048.80 1,946.36 2,238.31 2,171.17 2,193.54 2,127.74 46742 2,730.40 2,593.88 2,982.96 2,893.47 2,923.30 2,835.60 46744 3,579.31 3,400.34 3,910.39 3,793.08 3,832.18 3,717.21 46746 3,631.47 3,449.90 3,967.39 3,848.36 3,888.04 3,771.39 46748 4,016.25 3,815.44 4,387.76 4,256.13 4,300.00 4,171.00 46750 758.19 720.28 828.32 803.47 811.75 787.41 46751 597.37 567.50 652.63 633.05 639.57 620.39 46753 579.42 550.45 633.02 614.03 620.36 601.75 46754 287.20 272.84 313.77 304.35 307.49 298.26 # 46754 224.93 213.68 245.73 238.36 240.82 233.59 46760 1,111.69 1,056.11 1,214.53 1,178.09 1,190.24 1,154.53 46761 929.54 883.06 1,015.52 985.06 995.21 965.36 46762 918.54 872.61 1,003.50 973.39 983.43 953.93 46900 234.09 222.39 255.75 248.08 250.63 243.12 # 46900 136.57 129.74 149.20 144.73 146.22 141.83 46910 247.71 235.32 270.62 262.50 265.20 257.24 # 46910 133.39 126.72 145.73 141.36 142.82 138.53 46916 222.83 211.69 243.44 236.14 238.58 231.41 # 46916 142.44 135.32 155.62 150.95 152.50 147.92 46917 433.35 411.68 473.43 459.23 463.97 450.04 # 46917 132.23 125.62 144.46 140.13 141.58 137.32 46922 257.74 244.85 281.58 273.13 275.94 267.66

Page 116: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 116Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 46922 135.19 128.43 147.69 143.27 144.74 140.40 46924 510.05 484.55 557.23 540.51 546.09 529.70 # 46924 183.89 174.70 200.91 194.88 196.89 190.98 46930 198.77 188.83 217.15 210.65 212.81 206.44 # 46930 144.41 137.19 157.77 153.03 154.62 149.97 46940 223.13 211.97 243.77 236.45 238.89 231.73 # 46940 147.02 139.67 160.62 155.80 157.41 152.69 46942 210.30 199.79 229.76 222.87 225.16 218.41 # 46942 131.89 125.30 144.10 139.77 141.21 136.98 46945 298.61 283.68 326.23 316.45 319.71 310.12 # 46945 221.84 210.75 242.36 235.09 237.52 230.39 46946 304.30 289.09 332.45 322.48 325.81 316.03 # 46946 222.59 211.46 243.18 235.89 238.31 231.17 46947 382.89 363.75 418.31 405.77 409.95 397.65 47000 291.92 277.32 318.92 309.35 312.54 303.16 # 47000 91.28 86.72 99.73 96.74 97.74 94.81 47001 106.73 101.39 116.60 113.10 114.26 110.84 47010 1,220.58 1,159.55 1,333.48 1,293.47 1,306.81 1,267.60 47015 1,175.72 1,116.93 1,284.47 1,245.93 1,258.78 1,221.01 47100 851.25 808.69 929.99 902.09 911.40 884.05 47120 2,366.44 2,248.12 2,585.34 2,507.78 2,533.63 2,457.63 47122 3,490.80 3,316.26 3,813.70 3,699.29 3,737.42 3,625.29 47125 3,128.56 2,972.13 3,417.95 3,315.42 3,349.59 3,249.11 47130 3,362.05 3,193.95 3,673.04 3,562.85 3,599.58 3,491.60 47135 5,450.82 5,178.28 5,955.02 5,776.37 5,835.92 5,660.84 47140 3,390.03 3,220.53 3,703.61 3,592.50 3,629.54 3,520.64 47141 4,336.71 4,119.87 4,737.85 4,595.71 4,643.09 4,503.79 47142 4,760.82 4,522.78 5,201.20 5,045.17 5,097.17 4,944.26 47143 334.61 317.88 365.56 354.59 358.25 347.50 47144 334.61 317.88 365.56 354.59 358.25 347.50 47145 334.61 317.88 365.56 354.59 358.25 347.50 47146 337.82 320.93 369.07 358.00 361.69 350.83 47147 392.05 372.45 428.32 415.47 419.75 407.16 47300 1,145.86 1,088.57 1,251.86 1,214.30 1,226.82 1,190.01 47350 1,386.74 1,317.40 1,515.01 1,469.56 1,484.71 1,440.17 47360 1,880.31 1,786.29 2,054.23 1,992.61 2,013.14 1,952.76 47361 3,087.86 2,933.47 3,373.49 3,272.29 3,306.02 3,206.84 47362 1,470.35 1,396.83 1,606.35 1,558.17 1,574.22 1,527.00 47370 1,266.42 1,203.10 1,383.57 1,342.06 1,355.90 1,315.22 47371 1,258.59 1,195.66 1,375.01 1,333.76 1,347.51 1,307.08 47380 1,462.65 1,389.52 1,597.95 1,550.00 1,565.99 1,519.00 47381 1,401.68 1,331.60 1,531.34 1,485.40 1,500.72 1,455.69 47382 4,566.68 4,338.35 4,989.10 4,839.43 4,889.32 4,742.65 # 47382 766.71 728.37 837.63 812.50 820.87 796.25 47383 6,379.40 6,060.43 6,969.49 6,760.41 6,830.10 6,625.21 # 47383 462.00 438.90 504.74 489.59 494.64 479.80 47400 2,168.14 2,059.73 2,368.69 2,297.63 2,321.32 2,251.68 47420 1,358.82 1,290.88 1,484.51 1,439.97 1,454.82 1,411.18 47425 1,325.77 1,259.48 1,448.40 1,404.96 1,419.43 1,376.86

Page 117: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 117Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

47460 1,274.64 1,210.91 1,392.55 1,350.77 1,364.69 1,323.75 47480 883.45 839.28 965.17 936.22 945.86 917.49 47490 330.52 313.99 361.09 350.26 353.87 343.25 47531 296.73 281.89 324.17 314.44 317.69 308.15 # 47531 72.04 68.44 78.71 76.35 77.13 74.82 47532 763.90 725.71 834.57 809.53 817.88 793.34 # 47532 218.98 208.03 239.23 232.06 234.45 227.41 47533 1,174.37 1,115.65 1,283.00 1,244.51 1,257.34 1,219.62 # 47533 274.95 261.20 300.38 291.36 294.38 285.53 47534 1,402.11 1,332.00 1,531.80 1,485.85 1,501.16 1,456.13 # 47534 383.09 363.94 418.53 405.97 410.16 397.85 47535 963.13 914.97 1,052.22 1,020.65 1,031.17 1,000.24 # 47535 203.73 193.54 222.57 215.89 218.12 211.58 47536 653.43 620.76 713.87 692.46 699.59 678.62 # 47536 136.18 129.37 148.78 144.31 145.80 141.43 47537 348.52 331.09 380.75 369.33 373.14 361.95 # 47537 98.79 93.85 107.93 104.68 105.77 102.59 47538 4,046.78 3,844.44 4,421.11 4,288.48 4,332.68 4,202.71 # 47538 242.53 230.40 264.96 257.01 259.66 251.87 47539 4,489.84 4,265.35 4,905.15 4,758.00 4,807.05 4,662.84 # 47539 440.14 418.13 480.85 466.43 471.24 457.10 47540 4,602.17 4,372.06 5,027.87 4,877.04 4,927.31 4,779.49 # 47540 455.94 433.14 498.11 483.17 488.15 473.51 47541 1,118.82 1,062.88 1,222.31 1,185.64 1,197.86 1,161.93 # 47541 342.95 325.80 374.67 363.43 367.17 356.17 47542 440.70 418.67 481.47 467.03 471.85 457.69 # 47542 139.91 132.91 152.85 148.26 149.79 145.29 47543 549.84 522.35 600.70 582.68 588.69 571.03 # 47543 163.71 155.52 178.85 173.48 175.27 170.00 47544 1,027.44 976.07 1,122.48 1,088.81 1,100.03 1,067.03 # 47544 165.90 157.61 181.25 175.81 177.63 172.29 47550 169.42 160.95 185.09 179.54 181.39 175.95 47552 315.56 299.78 344.75 334.41 337.85 327.72 47553 314.52 298.79 343.61 333.30 336.73 326.63 47554 483.46 459.29 528.18 512.34 517.62 502.09 47555 373.36 354.69 407.89 395.66 399.74 387.75 47556 425.63 404.35 465.00 451.05 455.70 442.04 47562 664.92 631.67 726.42 704.63 711.90 690.54 47563 722.62 686.49 789.46 765.79 773.67 750.47 47564 1,126.84 1,070.50 1,231.08 1,194.15 1,206.45 1,170.26 47570 786.42 747.10 859.17 833.39 841.98 816.73 47600 1,081.33 1,027.26 1,181.35 1,145.91 1,157.72 1,122.99 47605 1,138.76 1,081.82 1,244.09 1,206.78 1,219.21 1,182.64 47610 1,273.15 1,209.49 1,390.91 1,349.19 1,363.10 1,322.21 47612 1,286.13 1,221.82 1,405.09 1,362.95 1,376.99 1,335.69 47620 1,391.01 1,321.46 1,519.68 1,474.09 1,489.28 1,444.61 47700 1,050.91 998.36 1,148.11 1,113.67 1,125.15 1,091.40 47701 1,732.11 1,645.50 1,892.33 1,835.56 1,854.48 1,798.85 47711 1,579.42 1,500.45 1,725.52 1,673.76 1,691.01 1,640.28

Page 118: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 118Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

47712 2,026.31 1,924.99 2,213.74 2,147.33 2,169.46 2,104.39 47715 1,342.98 1,275.83 1,467.20 1,423.19 1,437.86 1,394.73 47720 1,155.14 1,097.38 1,261.99 1,224.13 1,236.74 1,199.65 47721 1,369.02 1,300.57 1,495.66 1,450.78 1,465.74 1,421.77 47740 1,324.17 1,257.96 1,446.65 1,403.25 1,417.72 1,375.19 47741 1,472.04 1,398.44 1,608.21 1,559.96 1,576.04 1,528.76 47760 2,290.65 2,176.12 2,502.54 2,427.47 2,452.49 2,378.91 47765 3,093.44 2,938.77 3,379.59 3,278.20 3,311.99 3,212.64 47780 2,516.24 2,390.43 2,748.99 2,666.53 2,694.01 2,613.20 47785 3,300.85 3,135.81 3,606.18 3,498.00 3,534.05 3,428.05 47800 1,599.51 1,519.53 1,747.46 1,695.03 1,712.51 1,661.13 47801 1,014.65 963.92 1,108.51 1,075.25 1,086.34 1,053.75 47802 1,545.12 1,467.86 1,688.04 1,637.39 1,654.28 1,604.64 47900 1,390.71 1,321.17 1,519.35 1,473.76 1,488.96 1,444.29 48000 1,896.45 1,801.63 2,071.87 2,009.72 2,030.44 1,969.52 48001 2,353.73 2,236.04 2,571.45 2,494.30 2,520.02 2,444.42 48020 1,176.49 1,117.67 1,285.32 1,246.76 1,259.62 1,221.83 48100 901.06 856.01 984.41 954.88 964.72 935.78 48102 514.84 489.10 562.47 545.59 551.22 534.68 # 48102 246.00 233.70 268.76 260.69 263.38 255.48 48105 2,898.68 2,753.75 3,166.81 3,071.81 3,103.48 3,010.38 48120 1,122.89 1,066.75 1,226.76 1,189.96 1,202.23 1,166.17 48140 1,588.26 1,508.85 1,735.18 1,683.12 1,700.47 1,649.46 48145 1,648.62 1,566.19 1,801.12 1,747.08 1,765.10 1,712.14 48146 1,898.62 1,803.69 2,074.24 2,012.02 2,032.76 1,971.78 48148 1,260.69 1,197.66 1,377.31 1,335.99 1,349.77 1,309.28 48150 3,166.90 3,008.56 3,459.84 3,356.05 3,390.65 3,288.92 48152 2,933.37 2,786.70 3,204.71 3,108.57 3,140.62 3,046.40 48153 3,149.21 2,991.75 3,440.51 3,337.30 3,371.71 3,270.55 48154 2,932.56 2,785.93 3,203.82 3,107.70 3,139.74 3,045.55 48155 1,841.70 1,749.62 2,012.06 1,951.70 1,971.82 1,912.67 48400 109.00 103.55 119.08 115.51 116.70 113.19 48500 1,143.06 1,085.91 1,248.80 1,211.33 1,223.82 1,187.10 48510 1,101.48 1,046.41 1,203.37 1,167.27 1,179.30 1,143.93 48520 1,107.52 1,052.14 1,209.96 1,173.67 1,185.77 1,150.20 48540 1,331.44 1,264.87 1,454.60 1,410.96 1,425.51 1,382.74 48545 1,364.27 1,296.06 1,490.47 1,445.76 1,460.66 1,416.85 48547 1,813.15 1,722.49 1,980.86 1,921.44 1,941.25 1,883.01 48548 1,683.56 1,599.38 1,839.29 1,784.11 1,802.50 1,748.43 48551 208.11 197.70 227.36 220.54 222.81 216.12 48552 239.89 227.90 262.09 254.22 256.84 249.14 48554 2,570.06 2,441.56 2,807.79 2,723.56 2,751.64 2,669.08 48556 1,279.45 1,215.48 1,397.80 1,355.87 1,369.85 1,328.76 49000 779.43 740.46 851.53 825.99 834.50 809.47 49002 1,061.08 1,008.03 1,159.23 1,124.46 1,136.05 1,101.96 49010 948.89 901.45 1,036.67 1,005.57 1,015.93 985.46 49020 1,614.46 1,533.74 1,763.80 1,710.89 1,728.53 1,676.68 49040 1,012.19 961.58 1,105.82 1,072.64 1,083.70 1,051.19 49060 1,113.95 1,058.25 1,216.99 1,180.48 1,192.65 1,156.87

Page 119: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 119Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

49062 748.76 711.32 818.02 793.48 801.65 777.61 49082 184.66 175.43 201.74 195.70 197.71 191.79 # 49082 74.95 71.20 81.88 79.42 80.25 77.83 49083 281.84 267.75 307.91 298.68 301.76 292.71 # 49083 110.19 104.68 120.38 116.77 117.98 114.44 49084 110.92 105.37 121.18 117.54 118.75 115.20 49180 158.40 150.48 173.05 167.87 169.59 164.51 # 49180 87.23 82.87 95.30 92.44 93.39 90.59 49185 922.79 876.65 1,008.15 977.90 987.99 958.34 # 49185 124.18 117.97 135.67 131.59 132.95 128.96 49203 1,214.66 1,153.93 1,327.02 1,287.21 1,300.48 1,261.46 49204 1,556.78 1,478.94 1,700.78 1,649.76 1,666.76 1,616.76 49205 1,788.60 1,699.17 1,954.05 1,895.42 1,914.97 1,857.51 49215 2,253.41 2,140.74 2,461.85 2,388.00 2,412.62 2,340.24 49220 984.67 935.44 1,075.76 1,043.49 1,054.24 1,022.61 49250 593.21 563.55 648.08 628.64 635.12 616.07 49255 799.03 759.08 872.94 846.76 855.49 829.82 49320 328.17 311.76 358.52 347.77 351.35 340.81 49321 347.82 330.43 379.99 368.60 372.39 361.23 49322 372.59 353.96 407.05 394.84 398.91 386.94 49323 642.54 610.41 701.97 680.92 687.93 667.30 49324 393.70 374.02 430.12 417.22 421.52 408.87 49325 420.23 399.22 459.10 445.33 449.93 436.43 49326 193.56 183.88 211.46 205.11 207.23 201.01 49327 133.86 127.17 146.25 141.85 143.32 139.01 49400 133.01 126.36 145.31 140.96 142.40 138.14 # 49400 95.13 90.37 103.93 100.81 101.84 98.80 49402 866.89 823.55 947.08 918.67 928.14 900.29 49405 767.58 729.20 838.58 813.42 821.81 797.15 # 49405 202.89 192.75 221.66 215.02 217.24 210.71 49406 767.91 729.51 838.94 813.76 822.16 797.49 # 49406 202.89 192.75 221.66 215.02 217.24 210.71 49407 626.79 595.45 684.77 664.23 671.07 650.95 # 49407 215.96 205.16 235.93 228.86 231.22 224.28 49411 462.77 439.63 505.57 490.41 495.47 480.60 # 49411 187.67 178.29 205.03 198.88 200.93 194.90 49412 84.11 79.90 91.89 89.13 90.05 87.34 49418 1,287.85 1,223.46 1,406.98 1,364.77 1,378.84 1,337.47 # 49418 208.87 198.43 228.19 221.35 223.63 216.92 49419 448.65 426.22 490.15 475.44 480.36 465.93 49421 234.87 223.13 256.60 248.91 251.47 243.93 49422 385.01 365.76 420.62 408.01 412.21 399.84 49423 515.66 489.88 563.36 546.46 552.09 535.53 # 49423 73.20 69.54 79.97 77.57 78.37 76.02 49424 138.84 131.90 151.69 147.13 148.65 144.19 # 49424 39.01 37.06 42.62 41.34 41.77 40.51 49425 729.51 693.03 796.98 773.08 781.05 757.62 49426 619.27 588.31 676.56 656.26 663.02 643.14 49427 46.79 44.45 51.12 49.59 50.09 48.60

Page 120: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 120Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

49428 464.09 440.89 507.02 491.81 496.88 481.98 49429 465.64 442.36 508.71 493.45 498.54 483.59 49435 122.48 116.36 133.81 129.80 131.13 127.20 49436 187.47 178.10 204.82 198.67 200.72 194.70 49440 919.31 873.34 1,004.34 974.21 984.25 954.73 # 49440 211.30 200.74 230.85 223.93 226.24 219.45 49441 1,038.20 986.29 1,134.23 1,100.21 1,111.54 1,078.21 # 49441 246.84 234.50 269.68 261.59 264.28 256.36 49442 863.32 820.15 943.17 914.88 924.31 896.59 # 49442 211.98 201.38 231.59 224.64 226.95 220.14 49446 880.91 836.86 962.39 933.51 943.14 914.85 # 49446 153.13 145.47 167.29 162.28 163.94 159.03 49450 626.73 595.39 684.70 664.16 671.00 650.88 # 49450 68.30 64.89 74.62 72.38 73.13 70.93 49451 685.94 651.64 749.39 726.90 734.40 712.37 # 49451 92.59 87.96 101.15 98.12 99.13 96.15 49452 849.92 807.42 928.53 900.68 909.96 882.67 # 49452 142.57 135.44 155.76 151.09 152.64 148.06 49460 691.35 656.78 755.30 732.64 740.19 717.99 # 49460 48.91 46.46 53.43 51.83 52.36 50.80 49465 155.50 147.73 169.89 164.80 166.50 161.49 # 49465 31.62 30.04 34.55 33.51 33.86 32.84 49491 791.91 752.31 865.16 839.20 847.85 822.42 49492 968.85 920.41 1,058.47 1,026.72 1,037.30 1,006.18 49495 380.79 361.75 416.01 403.54 407.70 395.46 49496 547.01 519.66 597.61 579.68 585.66 568.09 49500 395.39 375.62 431.96 419.00 423.33 410.62 49501 611.00 580.45 667.52 647.50 654.17 634.55 49505 524.37 498.15 572.87 555.69 561.42 544.58 49507 590.06 560.56 644.64 625.30 631.75 612.80 49520 638.15 606.24 697.18 676.26 683.24 662.73 49521 724.27 688.06 791.27 767.53 775.45 752.18 49525 577.94 549.04 631.40 612.46 618.77 600.21 49540 680.39 646.37 743.33 721.03 728.46 706.61 49550 580.48 551.46 634.18 615.16 621.49 602.85 49553 636.57 604.74 695.45 674.59 681.55 661.10 49555 603.33 573.16 659.13 639.37 645.96 626.58 49557 732.38 695.76 800.12 776.12 784.12 760.60 49560 746.17 708.86 815.19 790.73 798.88 774.92 49561 942.27 895.16 1,029.43 998.56 1,008.85 978.58 49565 776.74 737.90 848.59 823.12 831.61 806.66 49566 950.68 903.15 1,038.62 1,007.47 1,017.85 987.32 49568 273.31 259.64 298.59 289.63 292.62 283.83 49570 418.24 397.33 456.93 443.22 447.79 434.36 49572 519.79 493.80 567.87 550.84 556.51 539.82 49580 327.64 311.26 357.95 347.21 350.78 340.26 49582 463.74 440.55 506.63 491.43 496.50 481.60 49585 447.22 424.86 488.59 473.93 478.81 464.45 49587 477.68 453.80 521.87 506.22 511.43 496.10

Page 121: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 121Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

49590 577.52 548.64 630.94 612.01 618.32 599.77 49600 664.20 630.99 725.64 703.87 711.13 689.79 49605 5,041.92 4,789.82 5,508.29 5,343.05 5,398.12 5,236.19 49606 1,151.23 1,093.67 1,257.72 1,219.99 1,232.57 1,195.59 49610 657.04 624.19 717.82 696.28 703.47 682.35 49611 564.57 536.34 616.79 598.29 604.45 586.33 49650 430.59 409.06 470.42 456.31 461.01 447.18 49651 560.16 532.15 611.97 593.62 599.74 581.75 49652 751.83 714.24 821.38 796.73 804.95 780.79 49653 938.41 891.49 1,025.21 994.46 1,004.71 974.58 49654 856.04 813.24 935.23 907.17 916.53 889.02 49655 1,044.77 992.53 1,141.41 1,107.16 1,118.58 1,085.03 49656 929.29 882.83 1,015.25 984.80 994.95 965.10 49657 1,339.94 1,272.94 1,463.88 1,419.96 1,434.60 1,391.57 49900 820.48 779.46 896.38 869.49 878.45 852.10 49904 1,432.76 1,361.12 1,565.29 1,518.33 1,533.99 1,487.96 49905 361.31 343.24 394.73 382.88 386.84 375.22 50010 746.06 708.76 815.07 790.63 798.77 774.81 50020 1,025.14 973.88 1,119.96 1,086.36 1,097.56 1,064.64 50040 935.82 889.03 1,022.38 991.71 1,001.94 971.88 50045 949.97 902.47 1,037.84 1,006.71 1,017.08 986.57 50060 1,154.53 1,096.80 1,261.32 1,223.49 1,236.09 1,199.01 50065 1,223.96 1,162.76 1,337.17 1,297.06 1,310.43 1,271.12 50070 1,252.40 1,189.78 1,368.25 1,327.20 1,340.88 1,300.66 50075 1,477.89 1,404.00 1,614.60 1,566.16 1,582.31 1,534.84 50080 878.98 835.03 960.28 931.48 941.08 912.85 50081 1,291.73 1,227.14 1,411.21 1,368.88 1,382.99 1,341.50 50100 1,107.67 1,052.29 1,210.13 1,173.83 1,185.93 1,150.36 50120 974.70 925.97 1,064.87 1,032.92 1,043.57 1,012.26 50125 1,036.98 985.13 1,132.90 1,098.92 1,110.24 1,076.94 50130 1,043.82 991.63 1,140.37 1,106.16 1,117.57 1,084.04 50135 1,134.97 1,078.22 1,239.95 1,202.75 1,215.16 1,178.69 50200 508.81 483.37 555.88 539.20 544.76 528.41 # 50200 131.25 124.69 143.39 139.09 140.53 136.31 50205 762.24 724.13 832.75 807.77 816.10 791.61 50220 1,058.64 1,005.71 1,156.57 1,121.87 1,133.44 1,099.43 50225 1,215.93 1,155.13 1,328.40 1,288.55 1,301.83 1,262.78 50230 1,299.24 1,234.28 1,419.42 1,376.84 1,391.03 1,349.31 50234 1,317.95 1,252.05 1,439.86 1,396.66 1,411.06 1,368.73 50236 1,485.05 1,410.80 1,622.42 1,573.75 1,589.97 1,542.28 50240 1,339.06 1,272.11 1,462.93 1,419.04 1,433.67 1,390.66 50250 1,223.85 1,162.66 1,337.06 1,296.95 1,310.32 1,271.00 50280 969.14 920.68 1,058.78 1,027.02 1,037.61 1,006.48 50290 907.68 862.30 991.65 961.89 971.81 942.66 50320 1,513.59 1,437.91 1,653.60 1,603.99 1,620.52 1,571.90 50323 193.86 184.17 211.80 205.44 207.56 201.33 50325 193.86 184.17 211.80 205.44 207.56 201.33 50327 221.92 210.82 242.44 235.18 237.59 230.47 50328 194.43 184.71 212.42 206.05 208.17 201.93

Page 122: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 122Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

50329 183.45 174.28 200.42 194.41 196.41 190.52 50340 951.77 904.18 1,039.81 1,008.61 1,019.02 988.44 50360 2,449.97 2,327.47 2,676.59 2,596.30 2,623.06 2,544.38 50365 2,888.94 2,744.49 3,156.16 3,061.48 3,093.04 3,000.26 50370 1,213.03 1,152.38 1,325.24 1,285.48 1,298.73 1,259.77 50380 1,938.80 1,841.86 2,118.14 2,054.59 2,075.77 2,013.50 50382 1,054.97 1,002.22 1,152.55 1,117.97 1,129.51 1,095.62 # 50382 263.28 250.12 287.64 279.01 281.89 273.44 50384 829.98 788.48 906.75 879.55 888.62 861.96 # 50384 237.61 225.73 259.59 251.80 254.40 246.77 50385 1,024.33 973.11 1,119.08 1,085.51 1,096.70 1,063.80 # 50385 223.09 211.94 243.73 236.42 238.86 231.69 50386 654.38 621.66 714.91 693.46 700.61 679.59 # 50386 166.46 158.14 181.86 176.41 178.23 172.88 50387 464.19 440.98 507.13 491.91 496.98 482.08 # 50387 86.63 82.30 94.65 91.80 92.75 89.96 50389 281.59 267.51 307.64 298.40 301.48 292.43 # 50389 55.25 52.49 60.36 58.56 59.16 57.39 50390 98.18 93.27 107.26 104.04 105.11 101.96 50391 121.30 115.24 132.53 128.55 129.88 125.97 # 50391 99.56 94.58 108.77 105.50 106.59 103.40 50395 180.85 171.81 197.58 191.66 193.63 187.83 50396 118.36 112.44 129.31 125.43 126.72 122.92 50400 1,172.60 1,113.97 1,281.07 1,242.63 1,255.44 1,217.78 50405 1,415.87 1,345.08 1,546.84 1,500.44 1,515.91 1,470.44 50430 436.57 414.74 476.95 462.65 467.42 453.39 # 50430 156.20 148.39 170.65 165.53 167.23 162.22 50431 156.07 148.27 170.51 165.39 167.10 162.08 # 50431 66.78 63.44 72.96 70.77 71.50 69.36 50432 735.29 698.53 803.31 779.21 787.24 763.62 # 50432 211.12 200.56 230.64 223.72 226.03 219.25 50433 1,004.54 954.31 1,097.46 1,064.53 1,075.50 1,043.25 # 50433 263.59 250.41 287.97 279.34 282.21 273.75 50434 787.90 748.51 860.79 834.96 843.57 818.26 # 50434 199.16 189.20 217.58 211.05 213.23 206.83 50435 446.97 424.62 488.31 473.66 478.55 464.19 # 50435 102.35 97.23 111.81 108.46 109.58 106.28 50500 1,172.54 1,113.91 1,281.00 1,242.56 1,255.37 1,217.71 50520 1,042.29 990.18 1,138.71 1,104.54 1,115.94 1,082.45 50525 1,603.18 1,523.02 1,751.47 1,698.93 1,716.44 1,664.95 50526 1,500.34 1,425.32 1,639.12 1,589.94 1,606.33 1,558.15 50540 1,153.11 1,095.45 1,259.77 1,221.98 1,234.57 1,197.54 50541 929.79 883.30 1,015.80 985.32 995.47 965.61 50542 1,179.69 1,120.71 1,288.82 1,250.15 1,263.05 1,225.15 50543 1,505.84 1,430.55 1,645.13 1,595.77 1,612.23 1,563.86 50544 1,263.37 1,200.20 1,380.23 1,338.82 1,352.63 1,312.05 50545 1,358.27 1,290.36 1,483.91 1,439.40 1,454.23 1,410.61 50546 1,217.53 1,156.65 1,330.15 1,290.24 1,303.55 1,264.44 50547 1,627.07 1,545.72 1,777.58 1,724.25 1,742.03 1,689.76

Page 123: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 123Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

50548 1,366.49 1,298.17 1,492.90 1,448.10 1,463.04 1,419.15 50551 359.57 341.59 392.83 381.04 384.97 373.42 # 50551 299.28 284.32 326.97 317.16 320.42 310.81 50553 383.18 364.02 418.62 406.07 410.25 397.95 # 50553 317.95 302.05 347.36 336.94 340.41 330.20 50555 411.99 391.39 450.10 436.60 441.09 427.87 # 50555 346.76 329.42 378.83 367.47 371.25 360.12 50557 419.56 398.58 458.37 444.61 449.20 435.72 # 50557 352.02 334.42 384.58 373.05 376.89 365.59 50561 475.09 451.34 519.04 503.47 508.66 493.40 # 50561 400.63 380.60 437.69 424.56 428.94 416.07 50562 589.36 559.89 643.87 624.55 630.99 612.06 50570 502.01 476.91 548.45 531.99 537.48 521.35 50572 541.41 514.34 591.49 573.75 579.66 562.27 50574 575.54 546.76 628.77 609.91 616.19 597.71 50575 727.93 691.53 795.26 771.40 779.36 755.96 50576 574.14 545.43 627.24 608.43 614.70 596.26 50580 618.83 587.89 676.07 655.79 662.55 642.68 50590 712.22 676.61 778.10 754.76 762.54 739.66 # 50590 571.87 543.28 624.77 606.03 612.27 593.91 50592 1,174.07 1,115.37 1,282.68 1,244.20 1,257.02 1,219.31 # 50592 352.07 334.47 384.64 373.11 376.95 365.64 50593 4,257.00 4,044.15 4,650.77 4,511.25 4,557.76 4,421.03 # 50593 472.18 448.57 515.86 500.38 505.54 490.37 50600 953.04 905.39 1,041.20 1,009.96 1,020.37 989.77 50605 997.64 947.76 1,089.92 1,057.23 1,068.12 1,036.08 50606 668.49 635.07 730.33 708.42 715.73 694.26 # 50606 159.80 151.81 174.58 169.35 171.09 165.96 50610 978.04 929.14 1,068.51 1,036.46 1,047.14 1,015.73 50620 912.37 866.75 996.76 966.86 976.83 947.53 50630 907.25 861.89 991.17 961.43 971.35 942.21 50650 1,047.34 994.97 1,144.22 1,109.89 1,121.33 1,087.69 50660 1,172.30 1,113.69 1,280.74 1,242.32 1,255.13 1,217.47 50684 102.29 97.18 111.76 108.40 109.53 106.23 # 50684 50.57 48.04 55.25 53.59 54.14 52.52 50686 142.98 135.83 156.20 151.52 153.08 148.49 # 50686 90.27 85.76 98.62 95.67 96.65 93.76 50688 79.30 75.34 86.64 84.04 84.90 82.36 50690 96.64 91.81 105.58 102.42 103.47 100.37 # 50690 70.94 67.39 77.50 75.18 75.95 73.67 50693 936.14 889.33 1,022.73 992.05 1,002.27 972.21 # 50693 209.03 198.58 228.37 221.51 223.80 217.09 50694 1,030.56 979.03 1,125.88 1,092.11 1,103.37 1,070.27 # 50694 273.79 260.10 299.12 290.15 293.14 284.34 50695 1,266.45 1,203.13 1,383.60 1,342.10 1,355.93 1,315.26 # 50695 351.21 333.65 383.70 372.19 376.03 364.75 50700 933.43 886.76 1,019.77 989.18 999.37 969.40 50705 1,823.10 1,731.95 1,991.74 1,931.99 1,951.91 1,893.35 # 50705 203.81 193.62 222.66 215.98 218.21 211.66

Page 124: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 124Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

50706 945.67 898.39 1,033.15 1,002.16 1,012.48 982.11 # 50706 192.20 182.59 209.98 203.68 205.78 199.61 50715 1,235.64 1,173.86 1,349.94 1,309.44 1,322.94 1,283.25 50722 1,059.89 1,006.90 1,157.94 1,123.19 1,134.77 1,100.73 50725 1,139.75 1,082.76 1,245.17 1,207.82 1,220.27 1,183.66 50727 511.34 485.77 558.64 541.88 547.46 531.05 50728 703.90 668.71 769.02 745.95 753.64 731.03 50740 1,228.98 1,167.53 1,342.66 1,302.38 1,315.81 1,276.33 50750 1,160.88 1,102.84 1,268.27 1,230.21 1,242.90 1,205.61 50760 1,138.72 1,081.78 1,244.05 1,206.73 1,219.16 1,182.59 50770 1,188.77 1,129.33 1,298.73 1,259.77 1,272.75 1,234.57 50780 1,120.86 1,064.82 1,224.54 1,187.81 1,200.05 1,164.05 50782 1,207.15 1,146.79 1,318.81 1,279.25 1,292.43 1,253.66 50783 1,146.24 1,088.93 1,252.27 1,214.70 1,227.22 1,190.40 50785 1,227.76 1,166.37 1,341.33 1,301.09 1,314.50 1,275.06 50800 932.48 885.86 1,018.74 988.17 998.36 968.40 50810 1,382.07 1,312.97 1,509.92 1,464.62 1,479.72 1,435.33 50815 1,239.78 1,177.79 1,354.46 1,313.83 1,327.36 1,287.55 50820 1,331.06 1,264.51 1,454.19 1,410.56 1,425.10 1,382.35 50825 1,680.26 1,596.25 1,835.69 1,780.61 1,798.98 1,745.00 50830 1,843.29 1,751.13 2,013.80 1,953.39 1,973.53 1,914.32 50840 1,245.10 1,182.85 1,360.28 1,319.46 1,333.07 1,293.07 50845 1,263.40 1,200.23 1,380.26 1,338.85 1,352.66 1,312.08 50860 962.81 914.67 1,051.87 1,020.31 1,030.84 999.91 50900 867.61 824.23 947.86 919.43 928.91 901.04 50920 923.76 877.57 1,009.21 978.93 989.02 959.35 50930 1,115.02 1,059.27 1,218.16 1,181.61 1,193.79 1,157.98 50940 891.74 847.15 974.22 945.00 954.74 926.11 50945 988.96 939.51 1,080.44 1,048.02 1,058.83 1,027.05 50947 1,406.20 1,335.89 1,536.27 1,490.18 1,505.55 1,460.37 50948 1,293.56 1,228.88 1,413.21 1,370.81 1,384.95 1,343.40 50951 375.52 356.74 410.25 397.95 402.05 389.99 # 50951 311.61 296.03 340.43 330.22 333.63 323.62 50953 396.88 377.04 433.60 420.59 424.93 412.18 # 50953 330.99 314.44 361.61 350.76 354.37 343.75 50955 425.24 403.98 464.58 450.64 455.29 441.62 # 50955 358.36 340.44 391.51 379.76 383.67 372.17 50957 429.34 407.87 469.05 454.97 459.67 445.88 # 50957 360.82 342.78 394.20 382.38 386.31 374.73 50961 386.77 367.43 422.54 409.87 414.09 401.67 # 50961 322.52 306.39 352.35 341.78 345.30 334.95 50970 376.76 357.92 411.61 399.26 403.37 391.28 50972 364.08 345.88 397.76 385.83 389.80 378.11 50974 481.25 457.19 525.77 509.99 515.26 499.79 50976 474.55 450.82 518.44 502.90 508.07 492.83 50980 361.98 343.88 395.46 383.59 387.55 375.92 51020 471.22 447.66 514.81 499.36 504.52 489.38 51030 472.56 448.93 516.27 500.78 505.94 490.76 51040 289.79 275.30 316.60 307.10 310.26 300.96

Page 125: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 125Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

51045 490.80 466.26 536.20 520.11 525.47 509.70 51050 474.74 451.00 518.65 503.09 508.28 493.03 51060 582.83 553.69 636.74 617.64 624.01 605.29 51065 583.03 553.88 636.96 617.85 624.22 605.49 51080 412.03 391.43 450.14 436.64 441.14 427.92 51100 60.54 57.51 66.14 64.15 64.81 62.86 # 51100 39.79 37.80 43.47 42.17 42.60 41.33 51101 119.29 113.33 130.33 126.42 127.72 123.89 # 51101 52.74 50.10 57.62 55.89 56.47 54.77 51102 222.28 211.17 242.85 235.55 237.99 230.84 # 51102 146.50 139.18 160.06 155.25 156.86 152.15 51500 643.34 611.17 702.85 681.75 688.79 668.12 51520 600.09 570.09 655.60 635.94 642.49 623.22 51525 868.18 824.77 948.49 920.03 929.51 901.63 51530 804.52 764.29 878.93 852.56 861.35 835.51 51535 788.37 748.95 861.29 835.45 844.07 818.74 51550 975.81 927.02 1,066.07 1,034.09 1,044.75 1,013.41 51555 1,283.28 1,219.12 1,401.99 1,359.93 1,373.95 1,332.74 51565 1,316.08 1,250.28 1,437.82 1,394.69 1,409.06 1,366.79 51570 1,498.19 1,423.28 1,636.77 1,587.67 1,604.03 1,555.92 51575 1,846.62 1,754.29 2,017.43 1,956.91 1,977.08 1,917.77 51580 1,948.31 1,850.89 2,128.52 2,064.66 2,085.95 2,023.37 51585 2,144.58 2,037.35 2,342.95 2,272.66 2,296.09 2,227.22 51590 1,960.68 1,862.65 2,142.05 2,077.79 2,099.21 2,036.22 51595 2,219.12 2,108.16 2,424.38 2,351.66 2,375.90 2,304.62 51596 2,386.30 2,266.99 2,607.04 2,528.83 2,554.90 2,478.25 51597 2,323.21 2,207.05 2,538.11 2,461.97 2,487.35 2,412.72 51600 174.80 166.06 190.97 185.24 187.15 181.54 # 51600 44.99 42.74 49.15 47.68 48.17 46.72 51605 38.66 36.73 42.24 40.97 41.40 40.16 51610 103.54 98.36 113.11 109.72 110.85 107.53 # 51610 64.66 61.43 70.64 68.53 69.23 67.16 51700 70.14 66.63 76.62 74.32 75.10 72.84 # 51700 36.20 34.39 39.55 38.36 38.76 37.59 51701 46.12 43.81 50.38 48.88 49.37 47.90 # 51701 26.03 24.73 28.44 27.59 27.88 27.04 51702 60.62 57.59 66.23 64.24 64.91 62.95 # 51702 26.03 24.73 28.44 27.59 27.88 27.04 51703 122.08 115.98 133.38 129.38 130.71 126.79 # 51703 77.93 74.03 85.13 82.58 83.43 80.93 51705 88.27 83.86 96.44 93.54 94.51 91.67 # 51705 52.36 49.74 57.20 55.49 56.06 54.38 51710 125.32 119.05 136.91 132.80 134.17 130.15 # 51710 80.51 76.48 87.95 85.32 86.19 83.62 51715 285.98 271.68 312.43 303.06 306.19 297.00 # 51715 202.30 192.19 221.02 214.38 216.60 210.09 51720 85.52 81.24 93.43 90.62 91.56 88.80 # 51720 64.10 60.90 70.04 67.93 68.63 66.57 51725 180.12 171.11 196.78 190.88 192.84 187.06

Page 126: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 126Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

51725 TC 102.82 97.68 112.33 108.96 110.09 106.79 51725 26 77.30 73.44 84.46 81.93 82.77 80.29 51726 252.26 239.65 275.60 267.33 270.09 261.98 51726 TC 165.78 157.49 181.11 175.69 177.49 172.17 51726 26 86.49 82.17 94.50 91.66 92.61 89.83 51727 298.36 283.44 325.96 316.18 319.44 309.86 51727 TC 189.83 180.34 207.39 201.17 203.24 197.14 51727 26 108.54 103.11 118.58 115.02 116.21 112.72 51728 301.63 286.55 329.53 319.64 322.94 313.25 51728 TC 195.43 185.66 213.51 207.10 209.24 202.96 51728 26 106.20 100.89 116.02 112.54 113.70 110.29 51729 326.64 310.31 356.86 346.15 349.72 339.23 51729 TC 198.39 188.47 216.74 210.24 212.41 206.03 51729 26 128.25 121.84 140.12 135.91 137.31 133.19 51736 15.05 14.30 16.45 15.95 16.11 15.63 51736 TC 6.62 6.29 7.23 7.02 7.08 6.88 51736 26 8.44 8.02 9.22 8.95 9.04 8.76 51741 15.38 14.61 16.80 16.30 16.47 15.97 51741 TC 6.95 6.60 7.59 7.36 7.44 7.21 51741 26 8.44 8.02 9.22 8.95 9.04 8.76 51784 67.31 63.94 73.53 71.32 72.06 69.90 51784 TC 29.35 27.88 32.06 31.10 31.42 30.48 51784 26 37.96 36.06 41.47 40.23 40.64 39.42 51785 253.48 240.81 276.93 268.63 271.39 263.26 51785 TC 163.14 154.98 178.23 172.88 174.66 169.42 51785 26 90.34 85.82 98.69 95.74 96.72 93.83 51792 201.56 191.48 220.20 213.60 215.80 209.33 51792 TC 145.68 138.40 159.16 154.39 155.97 151.31 51792 26 55.88 53.09 61.05 59.23 59.83 58.04 51797 107.33 101.96 117.25 113.74 114.91 111.46 51797 TC 66.55 63.22 72.70 70.52 71.25 69.10 51797 26 40.77 38.73 44.54 43.21 43.65 42.34 51798 18.18 17.27 19.86 19.26 19.46 18.88 51800 1,057.22 1,004.36 1,155.01 1,120.36 1,131.91 1,097.96 51820 1,186.14 1,126.83 1,295.85 1,256.98 1,269.93 1,231.85 51840 660.93 627.88 722.06 700.40 707.62 686.39 51841 789.20 749.74 862.20 836.34 844.96 819.62 51845 587.99 558.59 642.38 623.10 629.53 610.64 51860 752.23 714.62 821.81 797.16 805.38 781.22 51865 904.82 859.58 988.52 958.86 968.75 939.68 51880 470.87 447.33 514.43 499.00 504.14 489.01 51900 846.35 804.03 924.63 896.90 906.14 878.96 51920 789.74 750.25 862.79 836.90 845.54 820.17 51925 1,039.63 987.65 1,135.80 1,101.72 1,113.09 1,079.69 51940 1,676.00 1,592.20 1,831.03 1,776.09 1,794.41 1,740.57 51960 1,402.46 1,332.34 1,532.19 1,486.23 1,501.54 1,456.50 51980 719.60 683.62 786.16 762.58 770.44 747.33 51990 758.45 720.53 828.61 803.75 812.04 787.67 51992 847.24 804.88 925.61 897.84 907.10 879.89

Page 127: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 127Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

52000 159.18 151.22 173.90 168.68 170.43 165.31 # 52000 101.86 96.77 111.29 107.95 109.05 105.79 52001 368.99 350.54 403.12 391.02 395.06 383.20 # 52001 291.89 277.30 318.90 309.33 312.51 303.14 52005 257.49 244.62 281.31 272.87 275.69 267.41 # 52005 134.93 128.18 147.41 142.98 144.46 140.12 52007 425.98 404.68 465.38 451.42 456.08 442.39 # 52007 168.02 159.62 183.56 178.05 179.89 174.49 52010 354.82 337.08 387.64 376.02 379.89 368.49 # 52010 168.02 159.62 183.56 178.05 179.89 174.49 52204 354.40 336.68 387.18 375.57 379.44 368.06 # 52204 143.54 136.36 156.81 152.11 153.67 149.06 52214 629.83 598.34 688.09 667.45 674.33 654.10 # 52214 179.79 170.80 196.42 190.53 192.49 186.73 52224 660.94 627.89 722.07 700.41 707.63 686.40 # 52224 207.94 197.54 227.17 220.35 222.63 215.95 52234 250.01 237.51 273.14 264.94 267.67 259.64 52235 293.21 278.55 320.33 310.72 313.93 304.51 52240 398.42 378.50 435.28 422.22 426.57 413.78 52250 242.98 230.83 265.45 257.50 260.14 252.34 52260 213.43 202.76 233.17 226.18 228.51 221.66 52265 352.25 334.64 384.84 373.29 377.14 365.83 # 52265 164.46 156.24 179.68 174.28 176.09 170.80 52270 345.03 327.78 376.95 365.64 369.40 358.33 # 52270 184.59 175.36 201.66 195.62 197.63 191.71 52275 466.01 442.71 509.12 493.84 498.94 483.97 # 52275 252.52 239.89 275.87 267.59 270.35 262.25 52276 269.01 255.56 293.89 285.07 288.02 279.37 52277 328.48 312.06 358.87 348.11 351.69 341.15 52281 265.31 252.04 289.85 281.15 284.05 275.53 # 52281 154.29 146.58 168.57 163.51 165.20 160.24 52282 342.15 325.04 373.80 362.58 366.32 355.33 52283 273.46 259.79 298.76 289.80 292.78 284.00 # 52283 204.27 194.06 223.17 216.48 218.71 212.15 52285 275.35 261.58 300.82 291.79 294.80 285.96 # 52285 198.59 188.66 216.96 210.45 212.62 206.24 52287 303.02 287.87 331.05 321.11 324.43 314.70 # 52287 171.90 163.31 187.81 182.17 184.05 178.53 52290 247.56 235.18 270.46 262.34 265.05 257.09 52300 284.83 270.59 311.18 301.84 304.96 295.80 52301 294.70 279.97 321.97 312.31 315.53 306.06 52305 283.54 269.36 309.76 300.47 303.57 294.46 52310 238.17 226.26 260.20 252.39 254.99 247.34 # 52310 153.83 146.14 168.06 163.02 164.70 159.76 52315 405.75 385.46 443.28 429.99 434.41 421.38 # 52315 278.91 264.96 304.70 295.56 298.61 289.65 52317 776.36 737.54 848.17 822.72 831.21 806.27 # 52317 353.33 335.66 386.01 374.43 378.29 366.94 52318 481.64 457.56 526.19 510.40 515.67 500.19

Page 128: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 128Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

52320 250.91 238.36 274.11 265.89 268.63 260.58 52325 326.50 310.18 356.71 346.00 349.58 339.08 52327 266.99 253.64 291.69 282.93 285.86 277.28 52330 480.64 456.61 525.10 509.35 514.60 499.16 # 52330 268.14 254.73 292.94 284.15 287.09 278.47 52332 467.84 444.45 511.12 495.79 500.89 485.88 # 52332 157.81 149.92 172.41 167.23 168.96 163.89 52334 259.52 246.54 283.52 275.01 277.85 269.51 52341 288.63 274.20 315.33 305.87 309.03 299.75 52342 314.33 298.61 343.40 333.10 336.54 326.44 52343 349.51 332.03 381.83 370.38 374.20 362.97 52344 375.54 356.76 410.27 397.97 402.06 390.01 52345 400.87 380.83 437.95 424.82 429.19 416.32 52346 453.64 430.96 495.60 480.73 485.69 471.12 52351 307.72 292.33 336.18 326.09 329.45 319.57 52352 359.71 341.72 392.98 381.19 385.12 373.57 52353 398.42 378.50 435.28 422.22 426.57 413.78 52354 424.09 402.89 463.32 449.42 454.05 440.43 52355 475.48 451.71 519.47 503.88 509.08 493.81 52356 422.77 401.63 461.87 448.02 452.64 439.06 52400 483.68 459.50 528.43 512.58 517.86 502.33 52402 271.90 258.31 297.06 288.14 291.11 282.38 52441 1,175.05 1,116.30 1,283.75 1,245.23 1,258.07 1,220.32 # 52441 230.82 219.28 252.17 244.61 247.12 239.72 52442 891.80 847.21 974.29 945.06 954.81 926.15 # 52442 61.56 58.48 67.25 65.24 65.91 63.94 52450 472.14 448.53 515.81 500.33 505.49 490.33 52500 490.45 465.93 535.82 519.74 525.10 509.35 52601 854.69 811.96 933.75 905.74 915.08 887.63 52630 401.89 381.80 439.07 425.90 430.28 417.38 52640 315.11 299.35 344.25 333.93 337.36 327.24 52647 1,706.91 1,621.56 1,864.79 1,808.85 1,827.50 1,772.67 # 52647 652.65 620.02 713.02 691.63 698.76 677.80 52648 1,758.11 1,670.20 1,920.73 1,863.10 1,882.32 1,825.84 # 52648 695.93 661.13 760.30 737.50 745.10 722.74 52649 830.65 789.12 907.49 880.27 889.34 862.66 52700 444.81 422.57 485.96 471.37 476.24 461.94 53000 147.96 140.56 161.64 156.79 158.41 153.65 53010 294.59 279.86 321.84 312.18 315.40 305.93 53020 98.37 93.45 107.47 104.25 105.32 102.17 53025 71.96 68.36 78.61 76.26 77.04 74.73 53040 394.65 374.92 431.16 418.22 422.53 409.86 53060 182.44 173.32 199.32 193.34 195.33 189.47 # 53060 164.98 156.73 180.24 174.83 176.64 171.34 53080 421.88 400.79 460.91 447.09 451.69 438.14 53085 663.78 630.59 725.18 703.42 710.68 689.36 53200 156.45 148.63 170.92 165.80 167.51 162.48 # 53200 144.26 137.05 157.61 152.88 154.46 149.82 53210 785.52 746.24 858.18 832.43 841.02 815.78

Page 129: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 129Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

53215 939.02 892.07 1,025.88 995.11 1,005.36 975.20 53220 460.37 437.35 502.95 487.86 492.89 478.11 53230 610.35 579.83 666.80 646.81 653.46 633.87 53235 639.24 607.28 698.37 677.42 684.40 663.87 53240 427.02 405.67 466.52 452.53 457.19 443.47 53250 410.16 389.65 448.10 434.65 439.14 425.96 53260 200.03 190.03 218.53 211.98 214.16 207.74 # 53260 180.59 171.56 197.29 191.37 193.35 187.54 53265 216.29 205.48 236.30 229.22 231.58 224.63 # 53265 186.97 177.62 204.26 198.13 200.18 194.17 53270 205.33 195.06 224.32 217.59 219.83 213.24 # 53270 185.23 175.97 202.37 196.29 198.32 192.37 53275 265.35 252.08 289.89 281.20 284.10 275.57 53400 807.50 767.13 882.20 855.74 864.56 838.63 53405 887.51 843.13 969.60 940.52 950.21 921.70 53410 988.12 938.71 1,079.52 1,047.13 1,057.93 1,026.19 53415 1,143.26 1,086.10 1,249.02 1,211.55 1,224.04 1,187.32 53420 850.11 807.60 928.74 900.88 910.17 882.86 53425 947.24 899.88 1,034.86 1,003.81 1,014.16 983.73 53430 976.93 928.08 1,067.29 1,035.28 1,045.95 1,014.58 53431 1,167.52 1,109.14 1,275.51 1,237.25 1,250.00 1,212.50 53440 759.83 721.84 830.12 805.21 813.51 789.11 53442 788.28 748.87 861.20 835.36 843.97 818.65 53444 800.42 760.40 874.46 848.23 856.97 831.27 53445 758.69 720.76 828.87 804.01 812.29 787.93 53446 646.46 614.14 706.26 685.08 692.14 671.38 53447 815.57 774.79 891.01 864.28 873.18 847.00 53448 1,296.76 1,231.92 1,416.71 1,374.20 1,388.37 1,346.72 53449 615.97 585.17 672.95 652.75 659.49 639.70 53450 410.51 389.98 448.48 435.02 439.51 426.32 53460 460.82 437.78 503.45 488.35 493.37 478.58 53500 754.22 716.51 823.99 799.26 807.51 783.28 53502 489.51 465.03 534.78 518.74 524.09 508.37 53505 488.85 464.41 534.07 518.05 523.39 507.69 53510 636.04 604.24 694.88 674.03 680.98 660.55 53515 797.76 757.87 871.55 845.40 854.12 828.49 53520 559.70 531.72 611.48 593.14 599.25 581.27 53600 82.35 78.23 89.96 87.26 88.17 85.51 # 53600 64.56 61.33 70.53 68.41 69.12 67.05 53601 79.64 75.66 87.01 84.40 85.27 82.71 # 53601 54.27 51.56 59.29 57.51 58.11 56.36 53605 65.78 62.49 71.86 69.71 70.43 68.32 53620 115.00 109.25 125.64 121.87 123.13 119.43 # 53620 88.64 84.21 96.84 93.93 94.91 92.06 53621 107.20 101.84 117.12 113.60 114.77 111.32 # 53621 73.27 69.61 80.05 77.65 78.45 76.10 53660 68.54 65.11 74.88 72.63 73.38 71.19 # 53660 42.19 40.08 46.09 44.71 45.17 43.82 53661 67.58 64.20 73.83 71.61 72.36 70.17

Page 130: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 130Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 53661 40.90 38.86 44.69 43.34 43.79 42.48 53665 39.40 37.43 43.04 41.76 42.18 40.92 53850 1,975.05 1,876.30 2,157.75 2,093.01 2,114.59 2,051.15 # 53850 609.77 579.28 666.17 646.19 652.84 633.26 53852 1,827.28 1,735.92 1,996.31 1,936.42 1,956.38 1,897.68 # 53852 627.40 596.03 685.43 664.87 671.73 651.58 53855 733.12 696.46 800.93 776.91 784.91 761.37 # 53855 84.09 79.89 91.87 89.11 90.03 87.33 53860 1,479.74 1,405.75 1,616.61 1,568.12 1,584.29 1,536.76 # 53860 227.14 215.78 248.15 240.71 243.18 235.89 54000 144.56 137.33 157.93 153.19 154.77 150.13 # 54000 107.99 102.59 117.98 114.44 115.62 112.15 54001 181.27 172.21 198.04 192.10 194.09 188.26 # 54001 139.10 132.15 151.97 147.42 148.94 144.47 54015 310.44 294.92 339.16 328.98 332.37 322.40 54050 129.16 122.70 141.11 136.87 138.29 134.14 # 54050 104.78 99.54 114.47 111.03 112.18 108.81 54055 115.83 110.04 126.55 122.75 124.02 120.30 # 54055 92.11 87.50 100.63 97.61 98.61 95.66 54056 137.75 130.86 150.49 145.97 147.48 143.05 # 54056 109.42 103.95 119.54 115.95 117.15 113.63 54057 132.39 125.77 144.64 140.30 141.74 137.49 # 54057 94.50 89.78 103.25 100.15 101.18 98.15 54060 175.51 166.73 191.74 185.99 187.91 182.28 # 54060 130.37 123.85 142.43 138.15 139.58 135.39 54065 214.14 203.43 233.94 226.93 229.26 222.39 # 54065 172.30 163.69 188.24 182.60 184.48 178.94 54100 192.79 183.15 210.62 204.31 206.41 200.23 # 54100 126.24 119.93 137.92 133.78 135.16 131.10 54105 260.98 247.93 285.12 276.56 279.42 271.03 # 54105 214.20 203.49 234.01 227.00 229.33 222.46 54110 631.07 599.52 689.45 668.76 675.66 655.39 54111 815.11 774.35 890.50 863.79 872.69 846.52 54112 947.94 900.54 1,035.62 1,004.55 1,014.91 984.46 54115 453.98 431.28 495.97 481.09 486.05 471.47 # 54115 428.94 407.49 468.61 454.56 459.24 445.46 54120 637.21 605.35 696.15 675.27 682.23 661.77 54125 822.56 781.43 898.64 871.69 880.67 854.25 54130 1,207.25 1,146.89 1,318.92 1,279.35 1,292.54 1,253.76 54135 1,531.67 1,455.09 1,673.35 1,623.16 1,639.89 1,590.69 54150 151.88 144.29 165.93 160.95 162.61 157.73 # 54150 99.50 94.53 108.71 105.44 106.54 103.34 54160 215.16 204.40 235.06 228.01 230.36 223.45 # 54160 145.31 138.04 158.75 153.99 155.57 150.90 54161 198.01 188.11 216.33 209.84 212.00 205.64 54162 253.00 240.35 276.40 268.11 270.87 262.75 # 54162 199.63 189.65 218.10 211.55 213.74 207.32 54163 218.76 207.82 238.99 231.83 234.21 227.19 54164 193.43 183.76 211.32 204.99 207.09 200.89

Page 131: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 131Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

54200 104.43 99.21 114.09 110.66 111.81 108.46 # 54200 83.01 78.86 90.69 87.96 88.87 86.20 54205 535.32 508.55 584.83 567.28 573.14 555.93 54220 200.73 190.69 219.29 212.72 214.91 208.46 # 54220 135.82 129.03 148.38 143.93 145.42 141.06 54230 95.64 90.86 104.49 101.35 102.40 99.33 # 54230 80.15 76.14 87.56 84.94 85.81 83.24 54231 139.11 132.15 151.97 147.42 148.94 144.47 # 54231 117.70 111.82 128.59 124.74 126.02 122.25 54235 89.21 84.75 97.46 94.54 95.52 92.66 # 54235 73.73 70.04 80.55 78.13 78.94 76.57 54240 102.73 97.59 112.23 108.86 109.99 106.69 54240 TC 32.65 31.02 35.67 34.60 34.96 33.91 54240 26 70.09 66.59 76.58 74.28 75.05 72.80 54250 121.74 115.65 133.00 129.01 130.34 126.43 54250 TC 10.24 9.73 11.19 10.86 10.97 10.64 54250 26 111.49 105.92 121.81 118.15 119.37 115.79 54300 648.07 615.67 708.02 686.78 693.86 673.05 54304 755.20 717.44 825.06 800.31 808.55 784.30 54308 721.51 685.43 788.24 764.60 772.48 749.31 54312 862.85 819.71 942.67 914.39 923.82 896.10 54316 1,053.23 1,000.57 1,150.66 1,116.13 1,127.64 1,093.81 54318 716.94 681.09 783.25 759.76 767.59 744.57 54322 781.20 742.14 853.46 827.86 836.40 811.30 54324 977.65 928.77 1,068.09 1,036.05 1,046.72 1,015.32 54326 955.63 907.85 1,044.03 1,012.70 1,023.14 992.45 54328 964.95 916.70 1,054.21 1,022.58 1,033.13 1,002.13 54332 1,067.95 1,014.55 1,166.73 1,131.73 1,143.40 1,109.09 54336 1,202.56 1,142.43 1,313.79 1,274.38 1,287.52 1,248.90 54340 569.70 541.22 622.40 603.73 609.96 591.65 54344 958.09 910.19 1,046.72 1,015.31 1,025.79 995.00 54348 1,025.13 973.87 1,119.95 1,086.35 1,097.55 1,064.62 54352 1,434.10 1,362.40 1,566.76 1,519.76 1,535.42 1,489.37 54360 727.67 691.29 794.98 771.13 779.08 755.71 54380 807.01 766.66 881.66 855.21 864.03 838.11 54385 978.65 929.72 1,069.18 1,037.10 1,047.80 1,016.36 54390 1,255.41 1,192.64 1,371.54 1,330.39 1,344.11 1,303.78 54400 533.33 506.66 582.66 565.18 571.01 553.87 54401 656.74 623.90 717.49 695.96 703.13 682.04 54405 816.67 775.84 892.22 865.44 874.37 848.14 54406 737.25 700.39 805.45 781.29 789.34 765.66 54408 797.59 757.71 871.37 845.23 853.94 828.32 54410 867.27 823.91 947.50 919.07 928.54 900.69 54411 1,036.42 984.60 1,132.29 1,098.32 1,109.65 1,076.35 54415 531.79 505.20 580.98 563.55 569.37 552.28 54416 715.14 679.38 781.29 757.85 765.66 742.69 54417 907.83 862.44 991.81 962.06 971.97 942.82 54420 709.87 674.38 775.54 752.27 760.02 737.23 54430 644.30 612.09 703.90 682.79 689.83 669.14

Page 132: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 132Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

54435 418.89 397.95 457.64 443.91 448.49 435.03 54437 682.82 648.68 745.98 723.60 731.07 709.14 54438 1,363.63 1,295.45 1,489.77 1,445.08 1,459.97 1,416.18 54450 69.90 66.41 76.37 74.08 74.84 72.60 # 54450 58.69 55.76 64.12 62.20 62.84 60.96 54500 75.43 71.66 82.41 79.94 80.76 78.34 54505 211.09 200.54 230.62 223.70 226.01 219.22 54512 544.64 517.41 595.02 577.17 583.12 565.63 54520 327.87 311.48 358.20 347.46 351.04 340.52 54522 596.49 566.67 651.67 632.12 638.64 619.48 54530 508.04 482.64 555.04 538.38 543.94 527.62 54535 758.63 720.70 828.81 803.94 812.23 787.87 54550 499.38 474.41 545.57 529.21 534.66 518.63 54560 724.00 687.80 790.97 767.25 775.15 751.90 54600 457.95 435.05 500.31 485.30 490.30 475.59 54620 302.33 287.21 330.29 320.38 323.69 313.97 54640 480.10 456.10 524.52 508.78 514.03 498.61 54650 732.75 696.11 800.53 776.51 784.52 760.99 54660 364.74 346.50 398.48 386.53 390.51 378.80 54670 411.53 390.95 449.59 436.10 440.60 427.39 54680 810.07 769.57 885.01 858.45 867.31 841.28 54690 667.02 633.67 728.72 706.86 714.15 692.73 54692 807.64 767.26 882.35 855.88 864.70 838.76 54700 214.77 204.03 234.63 227.60 229.94 223.04 54800 134.63 127.90 147.09 142.67 144.14 139.82 54830 374.19 355.48 408.80 396.54 400.63 388.61 54840 322.63 306.50 352.48 341.91 345.43 335.06 54860 421.01 399.96 459.95 446.15 450.75 437.23 54861 569.63 541.15 622.32 603.66 609.88 591.58 54865 360.16 342.15 393.47 381.67 385.61 374.04 54900 844.03 801.83 922.10 894.45 903.66 876.55 54901 1,067.16 1,013.80 1,165.87 1,130.90 1,142.55 1,108.28 55000 115.07 109.32 125.72 121.95 123.20 119.51 # 55000 85.75 81.46 93.68 90.87 91.80 89.06 55040 339.48 322.51 370.89 359.75 363.47 352.56 55041 513.30 487.64 560.79 543.96 549.57 533.08 55060 382.27 363.16 417.63 405.11 409.29 397.00 55100 211.06 200.51 230.59 223.66 225.98 219.19 # 55100 165.59 157.31 180.91 175.48 177.28 171.97 55110 389.80 370.31 425.86 413.08 417.34 404.82 55120 361.18 343.12 394.59 382.75 386.70 375.10 55150 494.61 469.88 540.36 524.15 529.55 513.66 55175 365.51 347.23 399.31 387.33 391.33 379.58 55180 692.95 658.30 757.05 734.33 741.90 719.65 55200 422.71 401.57 461.81 447.95 452.57 438.99 # 55200 275.12 261.36 300.56 291.55 294.55 285.72 55250 374.11 355.40 408.71 396.45 400.53 388.53 # 55250 227.83 216.44 248.91 241.44 243.93 236.61 55300 190.33 180.81 207.93 201.70 203.77 197.66

Page 133: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 133Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

55400 502.19 477.08 548.64 532.19 537.67 521.54 55450 360.30 342.29 393.63 381.82 385.76 374.19 # 55450 263.43 250.26 287.80 279.16 282.04 273.59 55500 397.22 377.36 433.96 420.95 425.28 412.53 55520 454.89 432.15 496.97 482.07 487.04 472.43 55530 353.24 335.58 385.92 374.34 378.20 366.85 55535 432.61 410.98 472.63 458.45 463.17 449.28 55540 555.34 527.57 606.71 588.50 594.57 576.74 55550 431.03 409.48 470.90 456.78 461.48 447.65 55600 423.82 402.63 463.02 449.13 453.77 440.15 55605 548.47 521.05 599.21 581.23 587.22 569.61 55650 725.37 689.10 792.47 768.69 776.62 753.32 55680 365.62 347.34 399.44 387.46 391.45 379.71 55700 240.77 228.73 263.04 255.15 257.78 250.04 # 55700 133.04 126.39 145.35 140.99 142.44 138.17 55705 268.43 255.01 293.26 284.46 287.40 278.77 55706 374.63 355.90 409.29 397.00 401.10 389.07 55720 455.16 432.40 497.26 482.34 487.31 472.70 55725 657.85 624.96 718.70 697.14 704.33 683.20 55801 1,108.92 1,053.47 1,211.49 1,175.15 1,187.26 1,151.64 55810 1,326.93 1,260.58 1,449.67 1,406.17 1,420.68 1,378.05 55812 1,675.65 1,591.87 1,830.65 1,775.73 1,794.03 1,740.21 55815 1,792.83 1,703.19 1,958.67 1,899.90 1,919.50 1,861.91 55821 883.02 838.87 964.70 935.76 945.40 917.04 55831 955.53 907.75 1,043.91 1,012.60 1,023.04 992.35 55840 1,185.65 1,126.37 1,295.33 1,256.47 1,269.42 1,231.34 55842 1,185.32 1,126.05 1,294.96 1,256.11 1,269.06 1,230.98 55845 1,380.61 1,311.58 1,508.32 1,463.06 1,478.15 1,433.81 55860 884.64 840.41 966.47 937.48 947.14 918.74 55862 1,133.57 1,076.89 1,238.42 1,201.27 1,213.65 1,177.24 55865 1,350.25 1,282.74 1,475.15 1,430.90 1,445.65 1,402.28 55866 1,462.60 1,389.47 1,597.89 1,549.96 1,565.93 1,518.95 55870 174.48 165.76 190.62 184.91 186.81 181.21 # 55870 144.17 136.96 157.50 152.78 154.35 149.72 55873 6,650.71 6,318.17 7,265.90 7,047.91 7,120.58 6,906.96 # 55873 771.53 732.95 842.89 817.60 826.03 801.25 55875 769.48 731.01 840.66 815.44 823.85 799.14 55876 133.44 126.77 145.79 141.42 142.86 138.59 # 55876 101.49 96.42 110.88 107.56 108.66 105.41 55920 452.32 429.70 494.16 479.33 484.28 469.74 56405 107.40 102.03 117.33 113.82 114.99 111.54 # 56405 106.74 101.40 116.61 113.11 114.28 110.85 56420 118.09 112.19 129.02 125.14 126.44 122.64 # 56420 90.42 85.90 98.79 95.82 96.81 93.90 56440 180.54 171.51 197.24 191.31 193.29 187.48 56441 141.39 134.32 154.47 149.83 151.37 146.83 # 56441 136.78 129.94 149.43 144.95 146.44 142.05 56442 47.04 44.69 51.39 49.85 50.37 48.85 56501 127.79 121.40 139.61 135.42 136.82 132.71

Page 134: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 134Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 56501 113.29 107.63 123.77 120.06 121.30 117.66 56515 222.84 211.70 243.46 236.15 238.59 231.43 # 56515 199.78 189.79 218.26 211.72 213.89 207.48 56605 80.74 76.70 88.21 85.56 86.45 83.85 # 56605 60.64 57.61 66.25 64.26 64.93 62.97 56606 37.43 35.56 40.89 39.66 40.08 38.87 # 56606 30.18 28.67 32.97 31.98 32.32 31.34 56620 517.69 491.81 565.58 548.62 554.27 537.65 56625 632.09 600.49 690.56 669.85 676.75 656.45 56630 934.08 887.38 1,020.49 989.87 1,000.07 970.07 56631 1,190.61 1,131.08 1,300.74 1,261.72 1,274.73 1,236.49 56632 1,387.69 1,318.31 1,516.06 1,470.57 1,485.73 1,441.16 56633 1,220.46 1,159.44 1,333.36 1,293.36 1,306.69 1,267.50 56634 1,307.80 1,242.41 1,428.77 1,385.91 1,400.19 1,358.20 56637 1,526.80 1,450.46 1,668.03 1,617.99 1,634.67 1,585.63 56640 1,537.61 1,460.73 1,679.84 1,629.45 1,646.25 1,596.86 56700 185.33 176.06 202.47 196.40 198.42 192.46 56740 299.07 284.12 326.74 316.94 320.21 310.60 56800 239.03 227.08 261.14 253.31 255.92 248.24 56805 1,258.46 1,195.54 1,374.87 1,333.62 1,347.37 1,306.95 56810 258.32 245.40 282.21 273.75 276.56 268.27 56820 110.54 105.01 120.76 117.14 118.35 114.79 # 56820 87.15 82.79 95.21 92.36 93.30 90.51 56821 145.61 138.33 159.08 154.31 155.89 151.23 # 56821 116.29 110.48 127.05 123.25 124.51 120.78 57000 182.84 173.70 199.76 193.76 195.76 189.89 57010 429.69 408.21 469.44 455.35 460.06 446.25 57020 91.56 86.98 100.03 97.03 98.03 95.08 # 57020 80.68 76.65 88.15 85.50 86.39 83.79 57022 170.36 161.84 186.12 180.53 182.39 176.92 57023 306.94 291.59 335.33 325.27 328.62 318.76 57061 110.41 104.89 120.62 117.00 118.21 114.67 # 57061 96.57 91.74 105.50 102.34 103.40 100.29 57065 192.20 182.59 209.98 203.68 205.78 199.61 # 57065 173.09 164.44 189.11 183.44 185.32 179.77 57100 88.10 83.70 96.26 93.37 94.33 91.51 # 57100 67.67 64.29 73.93 71.71 72.45 70.28 57105 133.71 127.02 146.07 141.69 143.15 138.86 # 57105 124.81 118.57 136.36 132.26 133.63 129.62 57106 491.20 466.64 536.64 520.54 525.91 510.13 57107 1,459.83 1,386.84 1,594.87 1,547.01 1,562.97 1,516.08 57109 1,770.61 1,682.08 1,934.39 1,876.36 1,895.71 1,838.84 57110 887.73 843.34 969.84 940.75 950.44 921.93 57111 1,617.88 1,536.99 1,767.54 1,714.51 1,732.19 1,680.22 57112 1,813.03 1,722.38 1,980.74 1,921.32 1,941.12 1,882.90 57120 503.58 478.40 550.16 533.66 539.15 522.99 57130 173.47 164.80 189.52 183.84 185.73 180.16 # 57130 156.67 148.84 171.17 166.03 167.74 162.70 57135 188.88 179.44 206.36 200.17 202.23 196.17

Page 135: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 135Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 57135 171.74 163.15 187.62 182.00 183.87 178.35 57150 43.96 41.76 48.02 46.59 47.06 45.66 # 57150 29.14 27.68 31.83 30.88 31.20 30.26 57155 358.47 340.55 391.63 379.88 383.80 372.28 # 57155 279.40 265.43 305.24 296.09 299.14 290.17 57156 194.64 184.91 212.65 206.26 208.39 202.14 # 57156 147.20 139.84 160.82 155.99 157.60 152.87 57160 74.40 70.68 81.28 78.84 79.66 77.27 # 57160 47.06 44.71 51.42 49.88 50.39 48.88 57170 59.99 56.99 65.54 63.57 64.23 62.30 # 57170 48.79 46.35 53.30 51.70 52.23 50.67 57180 136.50 129.68 149.13 144.66 146.15 141.76 # 57180 104.22 99.01 113.86 110.45 111.58 108.24 57200 298.86 283.92 326.51 316.71 319.98 310.37 57210 362.49 344.37 396.03 384.15 388.10 376.46 57220 315.47 299.70 344.66 334.32 337.77 327.64 57230 390.37 370.85 426.48 413.68 417.94 405.41 57240 667.33 633.96 729.05 707.18 714.47 693.04 57250 671.02 637.47 733.09 711.10 718.43 696.88 57260 827.26 785.90 903.79 876.67 885.71 859.13 57265 907.02 861.67 990.92 961.19 971.11 941.97 57267 256.85 244.01 280.61 272.19 275.00 266.75 57268 478.70 454.77 522.99 507.30 512.52 497.16 57270 797.70 757.82 871.49 845.35 854.06 828.45 57280 950.24 902.73 1,038.14 1,007.00 1,017.38 986.86 57282 495.31 470.54 541.12 524.88 530.30 514.38 57283 683.79 649.60 747.04 724.63 732.10 710.14 57284 812.09 771.49 887.21 860.60 869.47 843.39 57285 668.97 635.52 730.85 708.92 716.23 694.74 57287 676.97 643.12 739.59 717.40 724.80 703.05 57288 712.82 677.18 778.76 755.39 763.19 740.28 57289 734.95 698.20 802.93 778.84 786.88 763.27 57291 522.85 496.71 571.22 554.08 559.80 543.00 57292 812.67 772.04 887.85 861.21 870.09 843.99 57295 473.39 449.72 517.18 501.66 506.84 491.64 57296 933.13 886.47 1,019.44 988.86 999.05 969.08 57300 559.89 531.90 611.69 593.33 599.45 581.46 57305 938.73 891.79 1,025.56 994.80 1,005.04 974.90 57307 1,057.79 1,004.90 1,155.64 1,120.96 1,132.52 1,098.55 57308 632.77 601.13 691.30 670.57 677.48 657.16 57310 463.19 440.03 506.03 490.85 495.91 481.03 57311 526.16 499.85 574.83 557.58 563.33 546.42 57320 531.58 505.00 580.75 563.33 569.14 552.06 57330 754.80 717.06 824.62 799.88 808.13 783.89 57335 1,241.57 1,179.49 1,356.41 1,315.73 1,329.29 1,289.41 57400 134.45 127.73 146.89 142.49 143.96 139.63 57410 107.32 101.95 117.24 113.72 114.90 111.45 57415 158.43 150.51 173.09 167.89 169.63 164.53 57420 116.13 110.32 126.87 123.06 124.33 120.60

Page 136: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 136Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 57420 92.41 87.79 100.96 97.93 98.93 95.98 57421 155.03 147.28 169.37 164.29 165.98 161.00 # 57421 124.72 118.48 136.25 132.17 133.53 129.52 57423 907.49 862.12 991.44 961.70 971.61 942.46 57425 966.34 918.02 1,055.72 1,024.05 1,034.61 1,003.57 57426 836.68 794.85 914.08 886.65 895.79 868.92 57452 107.13 101.77 117.04 113.53 114.69 111.26 # 57452 91.97 87.37 100.48 97.46 98.46 95.52 57454 150.66 143.13 164.60 159.67 161.31 156.47 # 57454 135.50 128.73 148.04 143.60 145.08 140.73 57455 140.01 133.01 152.96 148.37 149.90 145.41 # 57455 111.02 105.47 121.29 117.66 118.86 115.30 57456 131.97 125.37 144.18 139.85 141.29 137.06 # 57456 103.30 98.14 112.86 109.48 110.61 107.30 57460 272.88 259.24 298.13 289.18 292.17 283.39 # 57460 162.19 154.08 177.19 171.88 173.65 168.44 57461 309.83 294.34 338.49 328.34 331.72 321.77 # 57461 187.93 178.53 205.31 199.15 201.20 195.17 57500 123.23 117.07 134.63 130.59 131.94 127.98 # 57500 75.46 71.69 82.44 79.97 80.80 78.37 57505 99.51 94.53 108.71 105.44 106.54 103.34 # 57505 90.61 86.08 98.99 96.03 97.01 94.10 57510 128.82 122.38 140.74 136.52 137.92 133.79 # 57510 114.65 108.92 125.26 121.50 122.75 119.07 57511 141.81 134.72 154.93 150.28 151.83 147.28 # 57511 130.28 123.77 142.34 138.07 139.48 135.31 57513 142.29 135.18 155.46 150.79 152.35 147.78 # 57513 132.41 125.79 144.66 140.32 141.76 137.52 57520 302.12 287.01 330.06 320.16 323.46 313.75 # 57520 273.12 259.46 298.38 289.43 292.41 283.65 57522 258.60 245.67 282.52 274.05 276.87 268.56 # 57522 240.48 228.46 262.73 254.85 257.47 249.76 57530 343.79 326.60 375.59 364.32 368.08 357.03 57531 1,852.97 1,760.32 2,024.37 1,963.64 1,983.88 1,924.36 57540 839.95 797.95 917.64 890.11 899.29 872.31 57545 831.14 789.58 908.02 880.77 889.86 863.16 57550 400.29 380.28 437.32 424.20 428.57 415.71 57555 597.01 567.16 652.23 632.67 639.19 620.02 57556 559.74 531.75 611.51 593.17 599.29 581.30 57558 121.61 115.53 132.86 128.87 130.20 126.29 # 57558 111.73 106.14 122.06 118.40 119.62 116.04 57700 308.03 292.63 336.52 326.43 329.80 319.90 57720 303.14 287.98 331.18 321.24 324.55 314.81 57800 59.22 56.26 64.70 62.76 63.40 61.50 # 57800 48.35 45.93 52.82 51.23 51.76 50.21 58100 107.19 101.83 117.10 113.60 114.76 111.32 # 58100 87.42 83.05 95.51 92.64 93.60 90.79 58110 47.33 44.96 51.70 50.15 50.67 49.15 # 58110 41.07 39.02 44.87 43.53 43.98 42.65

Page 137: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 137Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

58120 253.78 241.09 277.25 268.94 271.71 263.56 # 58120 217.54 206.66 237.66 230.53 232.91 225.92 58140 914.52 868.79 999.11 969.14 979.12 949.76 58145 543.64 516.46 593.93 576.12 582.05 564.59 58146 1,147.24 1,089.88 1,253.36 1,215.76 1,228.29 1,191.45 58150 1,014.43 963.71 1,108.27 1,075.02 1,086.11 1,053.52 58152 1,243.31 1,181.14 1,358.31 1,317.57 1,331.15 1,291.22 58180 959.07 911.12 1,047.79 1,016.36 1,026.84 996.03 58200 1,380.72 1,311.68 1,508.43 1,463.18 1,478.27 1,433.91 58210 1,862.23 1,769.12 2,034.49 1,973.46 1,993.80 1,933.99 58240 2,932.48 2,785.86 3,203.74 3,107.62 3,139.66 3,045.46 58260 819.46 778.49 895.26 868.41 877.36 851.05 58262 915.04 869.29 999.68 969.69 979.69 950.30 58263 982.11 933.00 1,072.95 1,040.76 1,051.49 1,019.95 58267 1,041.62 989.54 1,137.97 1,103.83 1,115.21 1,081.75 58270 875.73 831.94 956.73 928.03 937.60 909.47 58275 977.33 928.46 1,067.73 1,035.70 1,046.37 1,014.99 58280 1,041.98 989.88 1,138.36 1,104.21 1,115.59 1,082.13 58285 1,436.48 1,364.66 1,569.36 1,522.28 1,537.98 1,491.84 58290 1,143.47 1,086.30 1,249.25 1,211.77 1,224.26 1,187.54 58291 1,233.70 1,172.02 1,347.82 1,307.39 1,320.87 1,281.24 58292 1,301.13 1,236.07 1,421.48 1,378.84 1,393.05 1,351.26 58293 1,354.50 1,286.78 1,479.80 1,435.41 1,450.20 1,406.70 58294 1,207.02 1,146.67 1,318.67 1,279.11 1,292.30 1,253.52 58301 92.80 88.16 101.38 98.35 99.36 96.38 # 58301 67.76 64.37 74.03 71.81 72.54 70.37 58321 74.85 71.11 81.78 79.33 80.14 77.74 # 58321 48.82 46.38 53.34 51.74 52.27 50.70 58322 83.67 79.49 91.41 88.68 89.59 86.91 # 58322 58.63 55.70 64.06 62.13 62.78 60.89 58323 14.90 14.16 16.28 15.80 15.96 15.49 # 58323 11.94 11.34 13.04 12.65 12.78 12.40 58340 114.24 108.53 124.81 121.06 122.31 118.63 # 58340 57.57 54.69 62.89 61.01 61.64 59.79 58345 275.34 261.57 300.81 291.78 294.79 285.95 58346 452.58 429.95 494.44 479.61 484.55 470.02 58350 93.77 89.08 102.44 99.37 100.40 97.38 # 58350 77.30 73.44 84.46 81.93 82.77 80.29 58353 947.84 900.45 1,035.52 1,004.46 1,014.81 984.37 # 58353 216.77 205.93 236.82 229.71 232.08 225.12 58356 1,773.79 1,685.10 1,937.87 1,879.73 1,899.11 1,842.14 # 58356 344.60 327.37 376.48 365.18 368.94 357.88 58400 435.99 414.19 476.32 462.02 466.80 452.78 58410 801.26 761.20 875.38 849.11 857.88 832.13 58520 834.81 793.07 912.03 884.67 893.79 866.97 58540 894.25 849.54 976.97 947.66 957.43 928.71 58541 711.49 675.92 777.31 753.99 761.76 738.91 58542 813.32 772.65 888.55 861.89 870.78 844.65 58543 821.07 780.02 897.02 870.11 879.08 852.71

Page 138: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 138Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

58544 896.15 851.34 979.04 949.67 959.46 930.67 58545 899.47 854.50 982.68 953.20 963.02 934.13 58546 1,115.08 1,059.33 1,218.23 1,181.68 1,193.86 1,158.05 58548 1,917.70 1,821.82 2,095.09 2,032.25 2,053.19 1,991.60 58550 875.05 831.30 956.00 927.31 936.87 908.76 58552 982.59 933.46 1,073.48 1,041.28 1,052.01 1,020.45 58553 1,131.56 1,074.98 1,236.23 1,199.14 1,211.50 1,175.16 58554 1,322.09 1,255.99 1,444.39 1,401.06 1,415.50 1,373.03 58555 259.12 246.16 283.08 274.60 277.43 269.10 # 58555 153.69 146.01 167.91 162.87 164.55 159.62 58558 1,282.53 1,218.40 1,401.16 1,359.13 1,373.13 1,331.94 # 58558 235.18 223.42 256.93 249.23 251.79 244.25 58559 289.95 275.45 316.77 307.27 310.43 301.13 58560 317.69 301.81 347.08 336.67 340.14 329.94 58561 434.17 412.46 474.33 460.10 464.84 450.90 58562 330.79 314.25 361.39 350.54 354.17 343.53 # 58562 231.96 220.36 253.41 245.81 248.34 240.90 58563 1,496.27 1,421.46 1,634.68 1,585.64 1,601.98 1,553.93 # 58563 272.33 258.71 297.52 288.59 291.57 282.82 58565 1,774.80 1,686.06 1,938.97 1,880.80 1,900.19 1,843.19 # 58565 429.29 407.83 469.00 454.94 459.62 445.84 58570 775.00 736.25 846.69 821.28 829.76 804.86 58571 896.29 851.48 979.20 949.83 959.62 930.83 58572 1,016.89 966.05 1,110.96 1,077.63 1,088.74 1,056.08 58573 1,216.47 1,155.65 1,329.00 1,289.13 1,302.42 1,263.34 58600 358.57 340.64 391.74 379.98 383.90 372.38 58605 324.73 308.49 354.76 344.13 347.67 337.25 58611 76.91 73.06 84.02 81.50 82.34 79.87 58615 246.09 233.79 268.86 260.80 263.48 255.58 58660 670.63 637.10 732.67 710.69 718.01 696.47 58661 648.27 615.86 708.24 686.99 694.07 673.24 58662 707.10 671.75 772.51 749.34 757.07 734.36 58670 360.42 342.40 393.76 381.95 385.88 374.31 58671 359.37 341.40 392.61 380.83 384.76 373.22 58672 728.29 691.88 795.66 771.79 779.75 756.36 58673 792.70 753.07 866.03 840.05 848.71 823.25 58674 811.53 770.95 886.59 859.99 868.86 842.79 58700 776.07 737.27 847.86 822.42 830.90 805.98 58720 736.21 699.40 804.31 780.18 788.22 764.58 58740 880.62 836.59 962.08 933.21 942.84 914.55 58750 959.20 911.24 1,047.93 1,016.49 1,026.97 996.15 58752 902.19 857.08 985.64 956.08 965.93 936.95 58760 801.15 761.09 875.25 849.00 857.75 832.01 58770 868.68 825.25 949.04 920.56 930.06 902.15 58800 311.08 295.53 339.86 329.66 333.06 323.07 # 58800 292.96 278.31 320.06 310.45 313.65 304.24 58805 400.31 380.29 437.33 424.21 428.58 415.73 58820 322.34 306.22 352.15 341.58 345.12 334.75 58822 691.72 657.13 755.70 733.03 740.59 718.37

Page 139: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 139Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

58825 753.08 715.43 822.74 798.07 806.29 782.10 58900 408.50 388.08 446.29 432.91 437.37 424.25 58920 753.17 715.51 822.84 798.15 806.38 782.18 58925 743.91 706.71 812.72 788.34 796.47 772.57 58940 523.88 497.69 572.34 555.17 560.90 544.07 58943 1,179.57 1,120.59 1,288.68 1,250.02 1,262.91 1,225.01 58950 1,136.00 1,079.20 1,241.08 1,203.84 1,216.26 1,179.76 58951 1,466.33 1,393.01 1,601.96 1,553.90 1,569.92 1,522.83 58952 1,659.20 1,576.24 1,812.68 1,758.29 1,776.43 1,723.13 58953 2,054.04 1,951.34 2,244.04 2,176.72 2,199.16 2,133.18 58954 2,232.03 2,120.43 2,438.49 2,365.34 2,389.72 2,318.03 58956 1,392.79 1,323.15 1,521.62 1,475.98 1,491.19 1,446.46 58957 1,602.30 1,522.19 1,750.52 1,698.00 1,715.51 1,664.04 58958 1,767.97 1,679.57 1,931.51 1,873.56 1,892.88 1,836.09 58960 974.00 925.30 1,064.10 1,032.17 1,042.81 1,011.53 58970 219.80 208.81 240.13 232.93 235.32 228.28 # 58970 199.04 189.09 217.45 210.93 213.11 206.71 58976 249.30 236.84 272.37 264.19 266.92 258.91 # 58976 217.68 206.80 237.82 230.69 233.06 226.08 59000 123.39 117.22 134.80 130.76 132.11 128.14 # 59000 82.21 78.10 89.82 87.12 88.02 85.38 59001 182.69 173.56 199.59 193.60 195.60 189.73 59012 206.73 196.39 225.85 219.08 221.33 214.69 59015 156.06 148.26 170.50 165.38 167.08 162.07 # 59015 134.97 128.22 147.45 143.03 144.51 140.16 59020 69.29 65.83 75.70 73.44 74.19 71.97 59020 TC 31.66 30.08 34.59 33.56 33.90 32.89 59020 26 37.63 35.75 41.11 39.88 40.30 39.09 59025 47.40 45.03 51.78 50.23 50.75 49.23 59025 TC 17.16 16.30 18.75 18.18 18.37 17.81 59025 26 30.24 28.73 33.04 32.05 32.38 31.41 59030 101.48 96.41 110.87 107.55 108.65 105.40 59050 48.85 46.41 53.37 51.77 52.30 50.74 59051 43.25 41.09 47.25 45.84 46.31 44.92 59070 397.82 377.93 434.62 421.58 425.93 413.15 # 59070 310.52 294.99 339.24 329.06 332.45 322.48 59072 473.44 449.77 517.24 501.72 506.89 491.68 59074 383.13 363.97 418.57 406.01 410.19 397.89 # 59074 305.71 290.42 333.98 323.97 327.30 317.49 59076 473.44 449.77 517.24 501.72 506.89 491.68 59100 790.70 751.17 863.85 837.92 846.57 821.17 59120 799.23 759.27 873.16 846.96 855.69 830.02 59121 801.53 761.45 875.67 849.40 858.15 832.42 59130 941.18 894.12 1,028.24 997.40 1,007.68 977.44 59135 834.45 792.73 911.64 884.29 893.41 866.61 59136 891.02 846.47 973.44 944.24 953.97 925.36 59140 370.92 352.37 405.23 393.07 397.12 385.20 59150 775.60 736.82 847.34 821.93 830.39 805.49 59151 756.85 719.01 826.86 802.06 810.32 786.01

Page 140: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 140Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

59160 202.86 192.72 221.63 214.98 217.20 210.68 # 59160 175.19 166.43 191.39 185.66 187.57 181.94 59200 70.75 67.21 77.29 74.97 75.75 73.47 # 59200 45.71 43.42 49.93 48.44 48.93 47.47 59300 190.97 181.42 208.63 202.38 204.46 198.33 # 59300 149.79 142.30 163.65 158.73 160.37 155.56 59320 155.08 147.33 169.43 164.35 166.04 161.06 59325 246.91 234.56 269.74 261.65 264.35 256.42 59350 280.24 266.23 306.16 296.98 300.05 291.04 59400 2,102.97 1,997.82 2,297.49 2,228.57 2,251.54 2,184.00 59409 829.04 787.59 905.73 878.55 887.62 860.98 59410 1,057.20 1,004.34 1,154.99 1,120.34 1,131.89 1,097.94 59412 104.76 99.52 114.45 111.01 112.16 108.79 59414 93.92 89.22 102.60 99.52 100.56 97.53 59425 453.80 431.11 495.78 480.91 485.86 471.29 # 59425 362.54 344.41 396.07 384.19 388.15 376.51 59426 811.82 771.23 886.91 860.30 869.18 843.10 # 59426 639.84 607.85 699.03 678.05 685.04 664.49 59430 183.87 174.68 200.88 194.86 196.87 190.96 # 59430 141.70 134.62 154.81 150.17 151.72 147.17 59510 2,335.57 2,218.79 2,551.61 2,475.06 2,500.57 2,425.57 59514 934.71 887.97 1,021.17 990.53 1,000.74 970.72 59515 1,284.43 1,220.21 1,403.24 1,361.14 1,375.18 1,333.92 59525 495.98 471.18 541.86 525.60 531.02 515.09 59610 2,215.35 2,104.58 2,420.27 2,347.66 2,371.86 2,300.70 59612 936.05 889.25 1,022.64 991.96 1,002.19 972.12 59614 1,162.95 1,104.80 1,270.52 1,232.41 1,245.11 1,207.76 59618 2,367.42 2,249.05 2,586.41 2,508.82 2,534.68 2,458.64 59620 955.23 907.47 1,043.59 1,012.29 1,022.72 992.05 59622 1,308.13 1,242.72 1,429.13 1,386.26 1,400.55 1,358.53 59812 318.46 302.54 347.92 337.48 340.96 330.73 # 59812 297.71 282.82 325.24 315.49 318.73 309.18 59820 377.26 358.40 412.16 399.80 403.91 391.81 # 59820 356.50 338.68 389.48 377.80 381.70 370.24 59821 381.08 362.03 416.33 403.85 408.01 395.77 # 59821 358.01 340.11 391.13 379.40 383.31 371.81 59830 440.08 418.08 480.79 466.37 471.18 457.04 59840 216.62 205.79 236.66 229.56 231.92 224.97 # 59840 208.38 197.96 227.65 220.82 223.10 216.41 59841 384.56 365.33 420.13 407.53 411.72 399.37 # 59841 364.80 346.56 398.54 386.58 390.57 378.86 59850 383.83 364.64 419.34 406.76 410.95 398.62 59851 401.38 381.31 438.51 425.35 429.73 416.84 59852 503.02 477.87 549.55 533.06 538.56 522.40 59855 419.40 398.43 458.19 444.45 449.03 435.56 59856 493.93 469.23 539.61 523.42 528.83 512.96 59857 519.67 493.69 567.74 550.71 556.39 539.70 59866 217.51 206.63 237.62 230.49 232.88 225.88 59870 472.97 449.32 516.72 501.22 506.38 491.19

Page 141: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 141Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

59871 136.03 129.23 148.61 144.15 145.65 141.27 60000 155.54 147.76 169.92 164.83 166.52 161.53 # 60000 140.71 133.67 153.72 149.11 150.65 146.13 60100 111.11 105.55 121.38 117.74 118.96 115.38 # 60100 80.14 76.13 87.55 84.93 85.80 83.23 60200 660.92 627.87 722.05 700.38 707.61 686.38 60210 710.52 674.99 776.24 752.95 760.71 737.90 60212 1,015.45 964.68 1,109.38 1,076.10 1,087.20 1,054.58 60220 708.35 672.93 773.87 750.65 758.39 735.64 60225 934.70 887.97 1,021.17 990.53 1,000.74 970.72 60240 925.21 878.95 1,010.79 980.47 990.58 960.86 60252 1,331.76 1,265.17 1,454.95 1,411.29 1,425.85 1,383.07 60254 1,681.42 1,597.35 1,836.95 1,781.84 1,800.21 1,746.21 60260 1,101.03 1,045.98 1,202.88 1,166.79 1,178.82 1,143.46 60270 1,382.72 1,313.58 1,510.62 1,465.30 1,480.41 1,435.99 60271 1,065.58 1,012.30 1,164.15 1,129.22 1,140.86 1,106.63 60280 438.97 417.02 479.57 465.19 469.98 455.88 60281 589.19 559.73 643.69 624.38 630.82 611.89 60300 113.87 108.18 124.41 120.67 121.92 118.25 # 60300 50.62 48.09 55.30 53.65 54.20 52.58 60500 972.12 923.51 1,062.04 1,030.17 1,040.80 1,009.56 60502 1,298.73 1,233.79 1,418.86 1,376.30 1,390.48 1,348.77 60505 1,395.66 1,325.88 1,524.76 1,479.02 1,494.26 1,449.44 60512 247.29 234.93 270.17 262.06 264.76 256.82 60520 1,054.85 1,002.11 1,152.43 1,117.86 1,129.38 1,095.50 60521 1,138.15 1,081.24 1,243.43 1,206.12 1,218.56 1,181.99 60522 1,383.73 1,314.54 1,511.72 1,466.37 1,481.49 1,437.04 60540 1,077.16 1,023.30 1,176.80 1,141.49 1,153.25 1,118.66 60545 1,233.86 1,172.17 1,348.00 1,307.55 1,321.04 1,281.40 60600 1,413.37 1,342.70 1,544.11 1,497.78 1,513.23 1,467.83 60605 1,952.03 1,854.43 2,132.59 2,068.62 2,089.94 2,027.24 60650 1,210.21 1,149.70 1,322.16 1,282.49 1,295.72 1,256.85 61000 114.63 108.90 125.24 121.47 122.73 119.05 61001 84.61 80.38 92.44 89.67 90.59 87.87 61020 102.50 97.38 111.99 108.63 109.74 106.46 61026 105.28 100.02 115.02 111.57 112.72 109.34 61050 86.61 82.28 94.62 91.78 92.72 89.94 61055 123.22 117.06 134.62 130.58 131.93 127.97 61070 57.77 54.88 63.11 61.21 61.85 60.00 61105 447.54 425.16 488.93 474.27 479.16 464.78 61107 325.82 309.53 355.96 345.28 348.84 338.38 61108 919.56 873.58 1,004.62 974.48 984.53 954.98 61120 759.01 721.06 829.22 804.34 812.64 788.26 61140 1,288.24 1,223.83 1,407.40 1,365.19 1,379.25 1,337.89 61150 1,387.90 1,318.51 1,516.29 1,470.79 1,485.96 1,441.38 61151 1,019.89 968.90 1,114.24 1,080.80 1,091.95 1,059.18 61154 1,295.92 1,231.12 1,415.79 1,373.32 1,387.48 1,345.86 61156 1,277.09 1,213.24 1,395.23 1,353.37 1,367.33 1,326.30 61210 383.49 364.32 418.97 406.40 410.58 398.27

Page 142: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 142Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

61215 513.80 488.11 561.33 544.49 550.10 533.60 61250 842.63 800.50 920.58 892.96 902.16 875.10 61253 818.25 777.34 893.94 867.12 876.06 849.78 61304 1,675.70 1,591.92 1,830.71 1,775.78 1,794.09 1,740.27 61305 2,070.71 1,967.17 2,262.25 2,194.37 2,217.00 2,150.49 61312 2,135.04 2,028.29 2,332.53 2,262.56 2,285.88 2,217.30 61313 2,031.57 1,929.99 2,219.49 2,152.90 2,175.10 2,109.85 61314 1,872.66 1,779.03 2,045.88 1,984.51 2,004.97 1,944.82 61315 2,124.00 2,017.80 2,320.47 2,250.86 2,274.06 2,205.84 61316 92.09 87.49 100.61 97.60 98.60 95.65 61320 1,949.03 1,851.58 2,129.32 2,065.43 2,086.73 2,024.13 61321 2,169.61 2,061.13 2,370.30 2,299.20 2,322.90 2,253.21 61322 2,442.18 2,320.07 2,668.08 2,588.04 2,614.72 2,536.28 61323 2,476.19 2,352.38 2,705.24 2,624.08 2,651.13 2,571.60 61330 1,799.72 1,709.73 1,966.19 1,907.21 1,926.87 1,869.06 61332 1,719.22 1,633.26 1,878.25 1,821.90 1,840.68 1,785.46 61333 1,814.78 1,724.04 1,982.65 1,923.17 1,942.99 1,884.70 61340 1,486.83 1,412.49 1,624.36 1,575.64 1,591.88 1,544.13 61343 2,251.72 2,139.13 2,460.00 2,386.20 2,410.80 2,338.48 61345 2,087.76 1,983.37 2,280.88 2,212.45 2,235.26 2,168.20 61450 1,983.43 1,884.26 2,166.90 2,101.89 2,123.56 2,059.86 61458 2,061.89 1,958.80 2,252.62 2,185.05 2,207.56 2,141.35 61460 2,114.50 2,008.78 2,310.10 2,240.80 2,263.89 2,195.98 61480 2,001.70 1,901.62 2,186.86 2,121.26 2,143.13 2,078.83 61500 1,340.38 1,273.36 1,464.36 1,420.43 1,435.07 1,392.03 61501 1,162.54 1,104.41 1,270.07 1,231.97 1,244.67 1,207.33 61510 2,236.19 2,124.38 2,443.04 2,369.75 2,394.17 2,322.36 61512 2,616.11 2,485.30 2,858.10 2,772.35 2,800.93 2,716.91 61514 1,949.32 1,851.85 2,129.63 2,065.73 2,087.03 2,024.41 61516 1,903.14 1,807.98 2,079.18 2,016.80 2,037.59 1,976.47 61517 90.69 86.16 99.08 96.12 97.11 94.20 61518 2,827.98 2,686.58 3,089.57 2,996.88 3,027.78 2,936.94 61519 3,022.00 2,870.90 3,301.54 3,202.49 3,235.50 3,138.43 61520 3,866.27 3,672.96 4,223.90 4,097.19 4,139.43 4,015.24 61521 3,267.21 3,103.85 3,569.43 3,462.34 3,498.04 3,393.10 61522 2,255.67 2,142.89 2,464.32 2,390.39 2,415.03 2,342.58 61524 2,138.61 2,031.68 2,336.43 2,266.34 2,289.71 2,221.02 61526 3,775.32 3,586.55 4,124.53 4,000.79 4,042.04 3,920.78 61530 3,150.34 2,992.82 3,441.74 3,338.50 3,372.90 3,271.73 61531 1,228.67 1,167.24 1,342.33 1,302.05 1,315.49 1,276.02 61533 1,550.78 1,473.24 1,694.23 1,643.40 1,660.35 1,610.53 61534 1,692.22 1,607.61 1,848.75 1,793.29 1,811.78 1,757.42 61535 1,004.09 953.89 1,096.97 1,064.06 1,075.03 1,042.77 61536 2,630.79 2,499.25 2,874.14 2,787.91 2,816.66 2,732.15 61537 2,547.46 2,420.09 2,783.10 2,699.61 2,727.44 2,645.62 61538 2,746.55 2,609.22 3,000.60 2,910.58 2,940.60 2,852.37 61539 2,436.72 2,314.88 2,662.11 2,582.24 2,608.87 2,530.60 61540 2,219.70 2,108.72 2,425.03 2,352.28 2,376.53 2,305.23 61541 2,216.31 2,105.49 2,421.31 2,348.68 2,372.89 2,301.70

Page 143: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 143Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

61543 2,144.02 2,036.82 2,342.34 2,272.08 2,295.49 2,226.64 61544 1,961.63 1,863.55 2,143.08 2,078.79 2,100.22 2,037.21 61545 3,288.64 3,124.21 3,592.84 3,485.05 3,520.99 3,415.35 61546 2,368.68 2,250.25 2,587.79 2,510.15 2,536.04 2,459.95 61548 1,609.12 1,528.66 1,757.96 1,705.22 1,722.80 1,671.11 61550 1,212.43 1,151.81 1,324.58 1,284.85 1,298.09 1,259.15 61552 1,173.75 1,115.06 1,282.32 1,243.85 1,256.67 1,218.98 61556 1,584.97 1,505.72 1,731.58 1,679.63 1,696.95 1,646.04 61557 1,727.74 1,641.35 1,887.55 1,830.93 1,849.80 1,794.31 61558 1,932.68 1,836.05 2,111.46 2,048.12 2,069.23 2,007.15 61559 2,335.64 2,218.86 2,551.69 2,475.13 2,500.65 2,425.63 61563 2,024.35 1,923.13 2,211.60 2,145.26 2,167.37 2,102.35 61564 2,341.51 2,224.43 2,558.09 2,481.36 2,506.93 2,431.73 61566 2,318.76 2,202.82 2,533.24 2,457.25 2,482.57 2,408.11 61567 2,440.73 2,318.69 2,666.49 2,586.50 2,613.17 2,534.77 61570 1,886.00 1,791.70 2,060.46 1,998.64 2,019.25 1,958.67 61571 2,049.35 1,946.88 2,238.91 2,171.74 2,194.13 2,128.31 61575 2,553.67 2,425.99 2,789.89 2,706.19 2,734.09 2,652.07 61576 3,439.18 3,267.22 3,757.30 3,644.58 3,682.16 3,571.69 61580 2,477.64 2,353.76 2,706.82 2,625.62 2,652.68 2,573.11 61581 2,649.31 2,516.84 2,894.37 2,807.53 2,836.48 2,751.38 61582 3,032.66 2,881.03 3,313.18 3,213.79 3,246.92 3,149.52 61583 2,937.16 2,790.30 3,208.85 3,112.58 3,144.66 3,050.33 61584 2,883.36 2,739.19 3,150.07 3,055.56 3,087.07 2,994.45 61585 3,221.56 3,060.48 3,519.55 3,413.97 3,449.16 3,345.70 61586 2,390.72 2,271.18 2,611.86 2,533.50 2,559.62 2,482.83 61590 3,063.30 2,910.14 3,346.66 3,246.27 3,279.73 3,181.34 61591 3,105.01 2,949.76 3,392.22 3,290.46 3,324.37 3,224.65 61592 3,227.05 3,065.70 3,525.56 3,419.79 3,455.05 3,351.40 61595 2,359.64 2,241.66 2,577.91 2,500.57 2,526.35 2,450.56 61596 2,452.46 2,329.84 2,679.32 2,598.93 2,625.73 2,546.95 61597 2,904.73 2,759.49 3,173.41 3,078.22 3,109.95 3,016.66 61598 2,839.54 2,697.56 3,102.19 3,009.12 3,040.15 2,948.95 61600 2,131.27 2,024.71 2,328.42 2,258.57 2,281.85 2,213.39 61601 2,424.60 2,303.37 2,648.88 2,569.41 2,595.90 2,518.02 61605 2,168.60 2,060.17 2,369.20 2,298.11 2,321.82 2,252.15 61606 3,006.93 2,856.58 3,285.07 3,186.51 3,219.37 3,122.78 61607 2,728.89 2,592.45 2,981.32 2,891.88 2,921.69 2,834.05 61608 3,313.42 3,147.75 3,619.91 3,511.32 3,547.52 3,441.09 61610 1,686.34 1,602.02 1,842.32 1,787.05 1,805.48 1,751.31 61611 395.35 375.58 431.92 418.96 423.28 410.57 61612 1,230.11 1,168.60 1,343.89 1,303.57 1,317.01 1,277.50 61613 3,279.35 3,115.38 3,582.69 3,475.21 3,511.03 3,405.70 61615 2,492.95 2,368.30 2,723.55 2,641.84 2,669.07 2,589.01 61616 3,380.71 3,211.67 3,693.42 3,582.62 3,619.56 3,510.96 61618 1,316.13 1,250.32 1,437.87 1,394.73 1,409.11 1,366.83 61619 1,455.82 1,383.03 1,590.48 1,542.77 1,558.68 1,511.92 61623 584.37 555.15 638.42 619.28 625.66 606.89 61624 1,176.05 1,117.25 1,284.84 1,246.29 1,259.15 1,221.37

Page 144: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 144Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

61626 881.07 837.02 962.57 933.70 943.32 915.02 61630 1,372.88 1,304.24 1,499.88 1,454.88 1,469.88 1,425.78 61635 1,465.26 1,392.00 1,600.80 1,552.78 1,568.78 1,521.73 61645 803.42 763.25 877.74 851.40 860.19 834.37 61650 548.99 521.54 599.77 581.77 587.78 570.14 61651 233.40 221.73 254.99 247.34 249.90 242.40 61680 2,318.62 2,202.69 2,533.09 2,457.10 2,482.44 2,407.96 61682 4,291.27 4,076.71 4,688.22 4,547.57 4,594.46 4,456.62 61684 2,938.31 2,791.39 3,210.10 3,113.80 3,145.89 3,051.53 61686 4,652.67 4,420.04 5,083.05 4,930.56 4,981.39 4,831.94 61690 2,234.89 2,123.15 2,441.62 2,368.38 2,392.79 2,321.01 61692 3,771.57 3,582.99 4,120.44 3,996.83 4,038.03 3,916.89 61697 4,342.21 4,125.10 4,743.87 4,601.55 4,648.99 4,509.52 61698 4,786.98 4,547.63 5,229.77 5,072.88 5,125.18 4,971.43 61700 3,505.34 3,330.07 3,829.58 3,714.70 3,752.99 3,640.41 61702 4,131.00 3,924.45 4,513.12 4,377.73 4,422.85 4,290.18 61703 1,259.10 1,196.15 1,375.57 1,334.31 1,348.06 1,307.62 61705 2,689.08 2,554.63 2,937.82 2,849.69 2,879.07 2,792.69 61708 2,381.01 2,261.96 2,601.25 2,523.22 2,549.23 2,472.75 61710 2,190.05 2,080.55 2,392.63 2,320.85 2,344.78 2,274.44 61711 2,681.41 2,547.34 2,929.44 2,841.56 2,870.85 2,784.73 61720 1,305.19 1,239.93 1,425.92 1,383.14 1,397.40 1,355.48 61735 1,635.79 1,554.00 1,787.10 1,733.49 1,751.36 1,698.81 61750 1,443.17 1,371.01 1,576.66 1,529.36 1,545.13 1,498.77 61751 1,412.65 1,342.02 1,543.32 1,497.02 1,512.46 1,467.08 61760 1,620.55 1,539.52 1,770.45 1,717.33 1,735.04 1,682.98 61770 1,673.21 1,589.55 1,827.98 1,773.14 1,791.42 1,737.67 61781 244.61 232.38 267.24 259.22 261.89 254.04 61782 177.82 168.93 194.27 188.44 190.38 184.67 61783 239.86 227.87 262.05 254.18 256.81 249.10 61790 896.87 852.03 979.83 950.44 960.24 931.43 61791 1,119.07 1,063.12 1,222.59 1,185.91 1,198.14 1,162.20 61796 1,040.25 988.24 1,136.48 1,102.38 1,113.75 1,080.33 61797 229.20 217.74 250.40 242.89 245.40 238.04 61798 1,419.31 1,348.34 1,550.59 1,504.07 1,519.58 1,473.99 61799 317.05 301.20 346.38 335.98 339.46 329.27 61800 159.17 151.21 173.89 168.67 170.42 165.30 61850 1,007.08 956.73 1,100.24 1,067.23 1,078.24 1,045.89 61860 1,589.84 1,510.35 1,736.90 1,684.80 1,702.16 1,651.10 61863 1,538.25 1,461.34 1,680.54 1,630.13 1,646.93 1,597.52 61864 295.61 280.83 322.95 313.27 316.49 307.00 61867 2,343.21 2,226.05 2,559.96 2,483.16 2,508.76 2,433.49 61868 519.13 493.17 567.15 550.13 555.81 539.12 61870 1,052.29 999.68 1,149.63 1,115.14 1,126.64 1,092.85 61880 574.93 546.18 628.11 609.26 615.55 597.07 61885 518.20 492.29 566.13 549.15 554.81 538.17 61886 852.02 809.42 930.83 902.91 912.21 884.86 61888 402.83 382.69 440.09 426.89 431.30 418.36 62000 977.71 928.82 1,068.14 1,036.10 1,046.78 1,015.38

Page 145: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 145Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

62005 1,288.01 1,223.61 1,407.15 1,364.94 1,379.01 1,337.63 62010 1,566.58 1,488.25 1,711.49 1,660.14 1,677.26 1,626.94 62100 1,618.58 1,537.65 1,768.30 1,715.25 1,732.94 1,680.94 62115 1,322.80 1,256.66 1,445.16 1,401.80 1,416.26 1,373.77 62117 2,024.02 1,922.82 2,211.24 2,144.91 2,167.01 2,102.02 62120 1,661.29 1,578.23 1,814.96 1,760.51 1,778.67 1,725.30 62121 1,606.49 1,526.17 1,755.10 1,702.44 1,720.00 1,668.39 62140 1,053.47 1,000.80 1,150.92 1,116.40 1,127.90 1,094.06 62141 1,163.61 1,105.43 1,271.24 1,233.11 1,245.82 1,208.44 62142 902.90 857.76 986.42 956.83 966.69 937.70 62143 1,062.65 1,009.52 1,160.95 1,126.11 1,137.73 1,103.60 62145 1,448.06 1,375.66 1,582.01 1,534.55 1,550.37 1,503.86 62146 1,224.09 1,162.89 1,337.32 1,297.20 1,310.57 1,271.26 62147 1,454.13 1,381.42 1,588.63 1,540.98 1,556.86 1,510.16 62148 131.46 124.89 143.62 139.31 140.75 136.53 62160 197.89 188.00 216.20 209.71 211.88 205.52 62161 1,551.54 1,473.96 1,695.05 1,644.20 1,661.15 1,611.32 62162 1,936.78 1,839.94 2,115.93 2,052.45 2,073.61 2,011.41 62163 1,255.21 1,192.45 1,371.32 1,330.18 1,343.89 1,303.58 62164 2,129.80 2,023.31 2,326.81 2,257.00 2,280.27 2,211.86 62165 1,567.41 1,489.04 1,712.40 1,661.03 1,678.15 1,627.80 62180 1,647.27 1,564.91 1,799.65 1,745.65 1,763.65 1,710.74 62190 731.23 694.67 798.87 774.90 782.90 759.40 62192 997.32 947.45 1,089.57 1,056.88 1,067.78 1,035.75 62194 448.10 425.70 489.56 474.87 479.77 465.37 62200 1,385.74 1,316.45 1,513.92 1,468.50 1,483.64 1,439.13 62201 1,228.60 1,167.17 1,342.25 1,301.97 1,315.40 1,275.94 62220 1,053.91 1,001.21 1,151.39 1,116.85 1,128.37 1,094.51 62223 1,062.86 1,009.72 1,161.18 1,126.34 1,137.96 1,103.82 62225 511.63 486.05 558.96 542.19 547.78 531.35 62230 856.87 814.03 936.13 908.05 917.41 889.89 62252 84.07 79.87 91.85 89.09 90.01 87.31 62252 TC 35.94 34.14 39.26 38.09 38.48 37.33 62252 26 48.13 45.72 52.58 51.00 51.53 49.98 62256 607.15 576.79 663.31 643.41 650.04 630.55 62258 1,142.42 1,085.30 1,248.10 1,210.65 1,223.13 1,186.44 62263 581.89 552.80 635.72 616.65 623.00 604.33 # 62263 322.27 306.16 352.08 341.53 345.05 334.70 62264 406.17 385.86 443.74 430.42 434.86 421.81 # 62264 238.80 226.86 260.89 253.06 255.67 248.00 62267 243.20 231.04 265.70 257.73 260.38 252.57 # 62267 161.16 153.10 176.07 170.79 172.55 167.37 62268 261.48 248.41 285.67 277.10 279.96 271.56 62269 270.74 257.20 295.78 286.90 289.87 281.16 62270 153.17 145.51 167.34 162.31 163.99 159.07 # 62270 78.71 74.77 85.99 83.41 84.26 81.74 62272 193.95 184.25 211.89 205.53 207.66 201.42 # 62272 84.90 80.66 92.76 89.98 90.91 88.18 62273 168.31 159.89 183.87 178.35 180.19 174.79

Page 146: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 146Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 62273 114.28 108.57 124.86 121.11 122.36 118.68 62280 291.07 276.52 318.00 308.45 311.64 302.29 # 62280 160.61 152.58 175.47 170.20 171.96 166.80 62281 235.13 223.37 256.88 249.17 251.74 244.19 # 62281 157.37 149.50 171.93 166.77 168.49 163.44 62282 285.40 271.13 311.80 302.45 305.57 296.40 # 62282 146.37 139.05 159.91 155.11 156.71 152.01 62284 180.36 171.34 197.04 191.13 193.10 187.31 # 62284 88.44 84.02 96.62 93.73 94.69 91.85 62287 573.49 544.82 626.54 607.75 614.01 595.60 62290 317.99 302.09 347.40 336.98 340.46 330.25 # 62290 171.38 162.81 187.23 181.62 183.48 177.99 62291 319.25 303.29 348.78 338.32 341.80 331.56 # 62291 170.01 161.51 185.74 180.16 182.02 176.56 62292 576.48 547.66 629.81 610.91 617.22 598.70 62294 970.85 922.31 1,060.66 1,028.84 1,039.44 1,008.26 62302 234.68 222.95 256.39 248.70 251.26 243.72 # 62302 124.31 118.09 135.80 131.73 133.09 129.10 62303 241.59 229.51 263.94 256.01 258.66 250.90 # 62303 125.30 119.04 136.90 132.79 134.16 130.13 62304 231.56 219.98 252.98 245.39 247.92 240.48 # 62304 121.85 115.76 133.12 129.13 130.46 126.55 62305 251.65 239.07 274.93 266.69 269.43 261.35 # 62305 127.45 121.08 139.24 135.07 136.46 132.37 62320 162.43 154.31 177.46 172.13 173.90 168.69 # 62320 102.80 97.66 112.31 108.94 110.07 106.77 62321 239.03 227.08 261.14 253.31 255.92 248.24 # 62321 110.87 105.33 121.13 117.50 118.70 115.15 62322 151.03 143.48 165.00 160.06 161.70 156.86 # 62322 88.44 84.02 96.62 93.73 94.69 91.85 62323 234.19 222.48 255.85 248.18 250.73 243.21 # 62323 101.09 96.04 110.45 107.13 108.24 105.00 62324 142.98 135.83 156.20 151.52 153.08 148.49 # 62324 94.55 89.82 103.29 100.20 101.22 98.20 62325 213.53 202.85 233.28 226.27 228.61 221.74 # 62325 108.76 103.32 118.82 115.25 116.44 112.95 62326 149.49 142.02 163.32 158.42 160.06 155.25 # 62326 92.50 87.88 101.06 98.03 99.04 96.07 62327 216.45 205.63 236.47 229.38 231.75 224.79 # 62327 98.51 93.58 107.62 104.39 105.47 102.29 62350 400.63 380.60 437.69 424.56 428.94 416.07 62351 865.87 822.58 945.97 917.59 927.05 899.23 62355 266.94 253.59 291.63 282.88 285.80 277.22 62360 309.29 293.83 337.90 327.77 331.14 321.22 62361 424.36 403.14 463.61 449.71 454.34 440.71 62362 386.00 366.70 421.71 409.06 413.28 400.88 62365 297.63 282.75 325.16 315.41 318.67 309.10 62367 40.10 38.10 43.82 42.50 42.94 41.65 # 62367 25.61 24.33 27.98 27.14 27.42 26.60

Page 147: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 147Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

62368 54.89 52.15 59.97 58.18 58.78 57.02 # 62368 35.45 33.68 38.73 37.57 37.96 36.82 62369 112.87 107.23 123.31 119.61 120.85 117.22 # 62369 35.78 33.99 39.09 37.92 38.31 37.16 62370 119.84 113.85 130.93 126.99 128.31 124.45 # 62370 46.70 44.37 51.03 49.50 50.00 48.51 63001 1,263.77 1,200.58 1,380.67 1,339.24 1,353.06 1,312.46 63003 1,261.92 1,198.82 1,378.64 1,337.29 1,351.07 1,310.54 63005 1,199.53 1,139.55 1,310.48 1,271.16 1,284.27 1,245.74 63011 1,104.22 1,049.01 1,206.36 1,170.17 1,182.23 1,146.77 63012 1,208.38 1,147.96 1,320.15 1,280.55 1,293.75 1,254.94 63015 1,509.98 1,434.48 1,649.65 1,600.17 1,616.66 1,568.16 63016 1,553.67 1,475.99 1,697.39 1,646.47 1,663.44 1,613.54 63017 1,277.18 1,213.32 1,395.32 1,353.46 1,367.41 1,326.39 63020 1,176.63 1,117.80 1,285.47 1,246.91 1,259.76 1,221.97 63030 979.69 930.71 1,070.32 1,038.21 1,048.92 1,017.44 63035 196.80 186.96 215.00 208.55 210.70 204.38 63040 1,415.00 1,344.25 1,545.89 1,499.51 1,514.98 1,469.52 63042 1,311.83 1,246.24 1,433.18 1,390.18 1,404.52 1,362.37 63043 268.06 254.66 292.86 284.07 287.01 278.39 63044 268.06 254.66 292.86 284.07 287.01 278.39 63045 1,309.01 1,243.56 1,430.09 1,387.19 1,401.49 1,359.45 63046 1,238.67 1,176.74 1,353.25 1,312.66 1,326.19 1,286.40 63047 1,115.14 1,059.38 1,218.29 1,181.74 1,193.92 1,158.11 63048 217.20 206.34 237.29 230.17 232.54 225.57 63050 1,526.92 1,450.57 1,668.16 1,618.11 1,634.79 1,585.75 63051 1,737.45 1,650.58 1,898.17 1,841.22 1,860.21 1,804.40 63055 1,661.56 1,578.48 1,815.25 1,760.80 1,778.95 1,725.59 63056 1,507.46 1,432.09 1,646.90 1,597.50 1,613.97 1,565.55 63057 328.77 312.33 359.18 348.40 351.99 341.44 63064 1,807.78 1,717.39 1,975.00 1,915.75 1,935.50 1,877.43 63066 213.65 202.97 233.42 226.41 228.75 221.88 63075 1,374.85 1,306.11 1,502.03 1,456.97 1,471.99 1,427.83 63076 254.80 242.06 278.37 270.02 272.80 264.62 63077 1,515.96 1,440.16 1,656.18 1,606.50 1,623.06 1,574.37 63078 198.87 188.93 217.27 210.75 212.92 206.53 63081 1,786.71 1,697.37 1,951.98 1,893.42 1,912.93 1,855.55 63082 273.73 260.04 299.05 290.08 293.07 284.28 63085 1,950.86 1,853.32 2,131.32 2,067.38 2,088.69 2,026.04 63086 195.90 186.11 214.03 207.61 209.75 203.46 63087 2,457.34 2,334.47 2,684.64 2,604.11 2,630.95 2,552.02 63088 267.09 253.74 291.80 283.05 285.97 277.39 63090 1,984.96 1,885.71 2,168.57 2,103.51 2,125.20 2,061.44 63091 181.64 172.56 198.44 192.49 194.48 188.63 63101 2,358.78 2,240.84 2,576.97 2,499.65 2,525.42 2,449.66 63102 2,310.70 2,195.17 2,524.45 2,448.71 2,473.96 2,399.73 63103 300.72 285.68 328.53 318.68 321.97 312.31 63170 1,637.51 1,555.63 1,788.97 1,735.30 1,753.20 1,700.60 63172 1,441.85 1,369.76 1,575.22 1,527.97 1,543.71 1,497.42

Page 148: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 148Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

63173 1,748.22 1,660.81 1,909.93 1,852.64 1,871.73 1,815.59 63180 1,362.64 1,294.51 1,488.69 1,444.02 1,458.91 1,415.14 63182 1,677.92 1,594.02 1,833.12 1,778.13 1,796.46 1,742.57 63185 1,156.12 1,098.31 1,263.06 1,225.16 1,237.79 1,200.66 63190 1,296.54 1,231.71 1,416.47 1,373.97 1,388.14 1,346.49 63191 1,283.28 1,219.12 1,401.99 1,359.93 1,373.95 1,332.74 63194 1,418.60 1,347.67 1,549.82 1,503.33 1,518.83 1,473.27 63195 1,282.66 1,218.53 1,401.31 1,359.27 1,373.28 1,332.08 63196 1,429.82 1,358.33 1,562.08 1,515.22 1,530.83 1,484.91 63197 1,428.18 1,356.77 1,560.29 1,513.48 1,529.07 1,483.21 63198 1,685.15 1,600.89 1,841.02 1,785.79 1,804.20 1,750.07 63199 1,768.46 1,680.04 1,932.05 1,874.09 1,893.41 1,836.61 63200 1,570.10 1,491.60 1,715.34 1,663.88 1,681.04 1,630.60 63250 3,070.11 2,916.60 3,354.09 3,253.47 3,287.01 3,188.40 63251 3,106.87 2,951.53 3,394.26 3,292.43 3,326.38 3,226.58 63252 3,117.56 2,961.68 3,405.93 3,303.75 3,337.82 3,237.68 63265 1,703.08 1,617.93 1,860.62 1,804.80 1,823.41 1,768.70 63266 1,755.48 1,667.71 1,917.87 1,860.33 1,879.51 1,823.13 63267 1,391.39 1,321.82 1,520.09 1,474.50 1,489.69 1,445.01 63268 1,421.19 1,350.13 1,552.65 1,506.07 1,521.60 1,475.96 63270 2,131.43 2,024.86 2,328.59 2,258.73 2,282.01 2,213.55 63271 2,111.89 2,006.30 2,307.25 2,238.03 2,261.10 2,193.27 63272 1,928.38 1,831.96 2,106.75 2,043.55 2,064.62 2,002.68 63273 1,873.67 1,779.99 2,046.99 1,985.58 2,006.05 1,945.87 63275 1,837.08 1,745.23 2,007.01 1,946.80 1,966.88 1,907.86 63276 1,826.82 1,735.48 1,995.80 1,935.93 1,955.89 1,897.21 63277 1,578.49 1,499.57 1,724.51 1,672.77 1,690.02 1,639.31 63278 1,615.59 1,534.81 1,765.03 1,712.09 1,729.73 1,677.84 63280 2,159.77 2,051.78 2,359.55 2,288.76 2,312.35 2,242.99 63281 2,143.28 2,036.12 2,341.54 2,271.30 2,294.71 2,225.87 63282 2,014.55 1,913.82 2,200.89 2,134.87 2,156.87 2,092.17 63283 1,932.47 1,835.85 2,111.23 2,047.89 2,069.00 2,006.92 63285 2,701.39 2,566.32 2,951.27 2,862.73 2,892.24 2,805.47 63286 2,630.76 2,499.22 2,874.10 2,787.88 2,816.63 2,732.12 63287 2,835.33 2,693.56 3,097.59 3,004.66 3,035.64 2,944.58 63290 2,868.93 2,725.48 3,134.30 3,040.28 3,071.62 2,979.48 63295 345.20 327.94 377.13 365.82 369.59 358.50 63300 1,871.65 1,778.07 2,044.78 1,983.44 2,003.89 1,943.78 63301 2,121.32 2,015.25 2,317.54 2,248.01 2,271.19 2,203.04 63302 2,207.41 2,097.04 2,411.60 2,339.25 2,363.37 2,292.47 63303 2,311.35 2,195.78 2,525.15 2,449.40 2,474.64 2,400.41 63304 2,376.55 2,257.72 2,596.38 2,518.49 2,544.46 2,468.12 63305 2,466.11 2,342.80 2,694.22 2,613.40 2,640.33 2,561.13 63306 2,121.47 2,015.40 2,317.71 2,248.18 2,271.35 2,203.22 63307 2,215.89 2,105.10 2,420.87 2,348.24 2,372.45 2,301.28 63308 332.65 316.02 363.42 352.52 356.16 345.47 63600 897.94 853.04 981.00 951.57 961.38 932.54 63610 455.60 432.82 497.74 482.82 487.78 473.16 63615 1,272.66 1,209.03 1,390.38 1,348.67 1,362.58 1,321.70

Page 149: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 149Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

63620 1,147.42 1,090.05 1,253.56 1,215.95 1,228.49 1,191.63 63621 260.35 247.33 284.43 275.90 278.74 270.38 63650 1,249.92 1,187.42 1,365.53 1,324.57 1,338.22 1,298.07 # 63650 412.44 391.82 450.59 437.08 441.58 428.34 63655 836.35 794.53 913.71 886.29 895.44 868.57 63661 562.11 534.00 614.10 595.68 601.82 583.76 # 63661 322.60 306.47 352.44 341.87 345.39 335.03 63662 844.61 802.38 922.74 895.06 904.28 877.15 63663 760.59 722.56 830.94 806.01 814.33 789.89 # 63663 451.56 428.98 493.33 478.53 483.46 468.96 63664 872.58 828.95 953.29 924.69 934.23 906.20 63685 365.78 347.49 399.61 387.63 391.62 379.88 63688 371.79 353.20 406.18 393.99 398.06 386.11 63700 1,161.60 1,103.52 1,269.05 1,230.97 1,243.67 1,206.35 63702 1,291.61 1,227.03 1,411.08 1,368.75 1,382.86 1,341.38 63704 1,470.12 1,396.61 1,606.10 1,557.92 1,573.98 1,526.76 63706 1,768.28 1,679.87 1,931.85 1,873.89 1,893.21 1,836.41 63707 930.64 884.11 1,016.73 986.23 996.39 966.51 63709 1,114.79 1,059.05 1,217.91 1,181.37 1,193.55 1,157.74 63710 1,095.38 1,040.61 1,196.70 1,160.80 1,172.77 1,137.58 63740 949.16 901.70 1,036.96 1,005.85 1,016.22 985.73 63741 684.58 650.35 747.90 725.47 732.94 710.95 63744 670.16 636.65 732.15 710.18 717.51 695.98 63746 610.23 579.72 666.68 646.68 653.35 633.74 64400 123.53 117.35 134.95 130.90 132.25 128.28 # 64400 71.47 67.90 78.09 75.74 76.52 74.22 64402 130.05 123.55 142.08 137.82 139.24 135.06 # 64402 80.96 76.91 88.45 85.79 86.68 84.08 64405 97.54 92.66 106.56 103.36 104.43 101.29 # 64405 62.95 59.80 68.77 66.71 67.39 65.38 64408 116.06 110.26 126.80 122.99 124.26 120.53 # 64408 86.74 82.40 94.76 91.92 92.86 90.08 64410 131.51 124.93 143.67 139.36 140.79 136.57 # 64410 76.17 72.36 83.21 80.72 81.55 79.11 64413 123.97 117.77 135.44 131.38 132.72 128.75 # 64413 81.47 77.40 89.01 86.34 87.23 84.62 64415 114.08 108.38 124.64 120.90 122.14 118.48 # 64415 65.98 62.68 72.08 69.92 70.64 68.52 64416 80.19 76.18 87.61 84.97 85.86 83.27 64417 124.18 117.97 135.67 131.59 132.95 128.96 # 64417 70.81 67.27 77.36 75.04 75.81 73.54 64418 140.03 133.03 152.98 148.40 149.93 145.43 # 64418 76.44 72.62 83.51 81.01 81.85 79.38 64420 107.57 102.19 117.52 113.99 115.17 111.71 # 64420 67.71 64.32 73.97 71.75 72.48 70.31 64421 145.37 138.10 158.82 154.05 155.64 150.97 # 64421 92.00 87.40 100.51 97.50 98.50 95.54 64425 128.86 122.42 140.78 136.56 137.97 133.84 # 64425 93.94 89.24 102.63 99.54 100.58 97.55

Page 150: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 150Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

64430 133.19 126.53 145.51 141.14 142.60 138.32 # 64430 81.47 77.40 89.01 86.34 87.23 84.62 64435 131.27 124.71 143.42 139.12 140.55 136.33 # 64435 83.17 79.01 90.86 88.14 89.04 86.38 64445 131.30 124.74 143.45 139.15 140.59 136.37 # 64445 72.99 69.34 79.74 77.35 78.14 75.80 64446 80.19 76.18 87.61 84.97 85.86 83.27 64447 116.12 110.31 126.86 123.05 124.32 120.59 # 64447 67.36 63.99 73.59 71.38 72.12 69.95 64448 72.38 68.76 79.07 76.71 77.49 75.18 64449 84.89 80.65 92.75 89.96 90.90 88.17 64450 77.20 73.34 84.34 81.81 82.65 80.18 # 64450 45.24 42.98 49.43 47.94 48.44 46.99 64455 47.19 44.83 51.55 50.01 50.52 49.01 # 64455 35.33 33.56 38.59 37.43 37.82 36.69 64461 144.35 137.13 157.70 152.97 154.55 149.91 # 64461 88.01 83.61 96.15 93.27 94.23 91.40 64462 82.30 78.19 89.92 87.22 88.12 85.47 # 64462 55.28 52.52 60.40 58.58 59.19 57.41 64463 161.65 153.57 176.61 171.30 173.08 167.88 # 64463 90.81 86.27 99.21 96.23 97.22 94.31 64479 226.41 215.09 247.35 239.94 242.41 235.14 # 64479 132.19 125.58 144.42 140.08 141.53 137.28 64480 108.98 103.53 119.06 115.48 116.68 113.17 # 64480 63.84 60.65 69.75 67.65 68.36 66.30 64483 209.30 198.84 228.67 221.80 224.09 217.36 # 64483 111.78 106.19 122.12 118.45 119.68 116.08 64484 84.88 80.64 92.74 89.95 90.88 88.16 # 64484 52.26 49.65 57.10 55.38 55.96 54.28 64486 117.81 111.92 128.71 124.84 126.13 122.35 # 64486 63.12 59.96 68.95 66.88 67.57 65.55 64487 130.56 124.03 142.63 138.36 139.78 135.59 # 64487 68.62 65.19 74.97 72.71 73.47 71.27 64488 135.61 128.83 148.15 143.72 145.19 140.84 # 64488 74.99 71.24 81.93 79.47 80.29 77.88 64489 172.41 163.79 188.36 182.71 184.59 179.06 # 64489 80.16 76.15 87.57 84.95 85.82 83.25 64490 182.08 172.98 198.93 192.96 194.95 189.09 # 64490 106.31 100.99 116.14 112.65 113.82 110.40 64491 91.01 86.46 99.43 96.45 97.44 94.52 # 64491 60.70 57.67 66.32 64.33 65.00 63.04 64492 91.34 86.77 99.79 96.80 97.78 94.86 # 64492 61.36 58.29 67.03 65.02 65.69 63.72 64493 164.64 156.41 179.87 174.48 176.27 170.99 # 64493 90.51 85.98 98.88 95.91 96.90 93.99 64494 83.59 79.41 91.32 88.58 89.49 86.81 # 64494 52.29 49.68 57.13 55.42 55.99 54.31 64495 83.92 79.72 91.68 88.93 89.85 87.15 # 64495 52.95 50.30 57.85 56.11 56.68 54.98

Page 151: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 151Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

64505 103.66 98.48 113.25 109.86 110.99 107.66 # 64505 87.52 83.14 95.61 92.75 93.70 90.90 64508 60.07 57.07 65.63 63.66 64.32 62.39 # 64508 71.60 68.02 78.22 75.88 76.66 74.36 64510 122.16 116.05 133.46 129.46 130.79 126.87 # 64510 73.07 69.42 79.83 77.44 78.23 75.89 64517 180.59 171.56 197.29 191.37 193.35 187.54 # 64517 124.26 118.05 135.76 131.69 133.04 129.05 64520 177.29 168.43 193.69 187.89 189.82 184.13 # 64520 80.76 76.72 88.23 85.58 86.47 83.87 64530 181.29 172.23 198.06 192.12 194.11 188.28 # 64530 91.35 86.78 99.80 96.81 97.80 94.88 64550 15.38 14.61 16.80 16.30 16.47 15.97 # 64550 8.80 8.36 9.61 9.33 9.42 9.14 64553 197.65 187.77 215.94 209.46 211.61 205.28 # 64553 150.87 143.33 164.83 159.88 161.53 156.69 64555 204.87 194.63 223.82 217.11 219.35 212.76 # 64555 151.83 144.24 165.88 160.90 162.56 157.68 64561 789.40 749.93 862.42 836.54 845.17 819.81 # 64561 305.76 290.47 334.04 324.02 327.36 317.54 64565 187.23 177.87 204.55 198.41 200.46 194.44 # 64565 132.87 126.23 145.16 140.81 142.27 137.99 64566 120.87 114.83 132.05 128.10 129.41 125.53 # 64566 30.60 29.07 33.43 32.43 32.76 31.79 64568 656.34 623.52 717.05 695.53 702.71 681.62 64569 791.25 751.69 864.44 838.51 847.16 821.74 64570 661.91 628.81 723.13 701.44 708.66 687.41 64575 319.41 303.44 348.96 338.49 341.98 331.72 64580 301.51 286.43 329.39 319.52 322.81 313.12 64581 670.64 637.11 732.68 710.70 718.03 696.49 64585 236.93 225.08 258.84 251.08 253.67 246.05 # 64585 142.70 135.57 155.91 151.23 152.79 148.20 64590 257.18 244.32 280.97 272.54 275.34 267.09 # 64590 160.65 152.62 175.51 170.25 172.01 166.84 64595 236.53 224.70 258.41 250.65 253.24 245.64 # 64595 125.50 119.23 137.11 133.00 134.38 130.34 64600 380.49 361.47 415.69 403.22 407.38 395.16 # 64600 221.04 209.99 241.49 234.24 236.66 229.56 64605 590.34 560.82 644.94 625.60 632.04 613.09 # 64605 347.53 330.15 379.67 368.29 372.08 360.93 64610 731.26 694.70 798.91 774.94 782.93 759.44 # 64610 497.67 472.79 543.71 527.40 532.83 516.86 64611 115.22 109.46 125.88 122.11 123.36 119.67 # 64611 102.04 96.94 111.48 108.13 109.25 105.97 64612 127.88 121.49 139.71 135.53 136.92 132.81 # 64612 115.36 109.59 126.03 122.25 123.51 119.80 64615 144.36 137.14 157.71 152.98 154.56 149.93 # 64615 126.57 120.24 138.28 134.12 135.52 131.45 64616 126.27 119.96 137.95 133.81 135.19 131.13

Page 152: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 152Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 64616 110.78 105.24 121.03 117.39 118.61 115.05 64617 175.61 166.83 191.85 186.10 188.01 182.38 # 64617 119.27 113.31 130.31 126.40 127.70 123.87 64620 200.29 190.28 218.82 212.26 214.44 208.01 # 64620 170.97 162.42 186.78 181.18 183.05 177.56 64630 227.07 215.72 248.08 240.64 243.12 235.83 # 64630 191.49 181.92 209.21 202.93 205.02 198.87 64632 83.91 79.71 91.67 88.92 89.84 87.14 # 64632 68.76 65.32 75.12 72.86 73.61 71.40 64633 403.27 383.11 440.58 427.36 431.77 418.82 # 64633 225.36 214.09 246.20 238.82 241.28 234.05 64634 179.48 170.51 196.09 190.20 192.17 186.39 # 64634 68.78 65.34 75.14 72.89 73.63 71.43 64635 398.78 378.84 435.67 422.59 426.95 414.14 # 64635 222.19 211.08 242.74 235.46 237.89 230.76 64636 163.13 154.97 178.22 172.87 174.65 169.41 # 64636 60.01 57.01 65.56 63.60 64.25 62.32 64640 127.46 121.09 139.25 135.08 136.47 132.38 # 64640 91.55 86.97 100.02 97.01 98.01 95.07 64642 139.75 132.76 152.67 148.10 149.62 145.13 # 64642 109.77 104.28 119.92 116.32 117.52 114.00 64643 91.62 87.04 100.10 97.09 98.10 95.15 # 64643 73.17 69.51 79.94 77.53 78.34 75.98 64644 160.43 152.41 175.27 170.02 171.76 166.61 # 64644 119.91 113.91 131.00 127.06 128.37 124.52 64645 113.11 107.45 123.57 119.86 121.10 117.47 # 64645 84.78 80.54 92.62 89.84 90.77 88.04 64646 146.93 139.58 160.52 155.70 157.31 152.58 # 64646 117.60 111.72 128.48 124.63 125.91 122.13 64647 175.26 166.50 191.48 185.74 187.65 182.02 # 64647 139.35 132.38 152.24 147.67 149.19 144.72 64650 75.25 71.49 82.21 79.75 80.57 78.15 # 64650 42.63 40.50 46.58 45.18 45.64 44.28 64653 91.88 87.29 100.38 97.37 98.37 95.43 # 64653 54.65 51.92 59.71 57.91 58.51 56.75 64680 294.91 280.16 322.18 312.52 315.74 306.27 # 64680 164.45 156.23 179.66 174.27 176.08 170.79 64681 505.93 480.63 552.72 536.14 541.67 525.42 # 64681 272.35 258.73 297.54 288.62 291.59 282.84 64702 494.01 469.31 539.71 523.51 528.91 513.05 64704 317.04 301.19 346.37 335.97 339.45 329.26 64708 493.66 468.98 539.33 523.15 528.54 512.68 64712 578.57 549.64 632.09 613.12 619.45 600.86 64713 769.37 730.90 840.54 815.32 823.72 799.01 64714 708.43 673.01 773.96 750.74 758.48 735.72 64716 528.29 501.88 577.16 559.84 565.62 548.64 64718 585.00 555.75 639.11 619.94 626.34 607.55 64719 395.63 375.85 432.23 419.26 423.58 410.87 64721 422.77 401.63 461.87 448.02 452.64 439.06

Page 153: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 153Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 64721 420.46 399.44 459.36 445.58 450.17 436.67 64722 360.37 342.35 393.70 381.89 385.83 374.26 64726 271.61 258.03 296.73 287.83 290.80 282.07 64727 187.30 177.94 204.63 198.49 200.54 194.52 64732 372.59 353.96 407.05 394.84 398.91 386.94 64734 502.68 477.55 549.18 532.70 538.20 522.05 64736 385.87 366.58 421.57 408.92 413.14 400.74 64738 457.67 434.79 500.01 485.01 490.00 475.32 64740 448.41 425.99 489.89 475.19 480.09 465.69 64742 453.25 430.59 495.18 480.32 485.28 470.72 64744 490.79 466.25 536.19 520.10 525.47 509.69 64746 426.19 404.88 465.61 451.64 456.30 442.61 64755 887.57 843.19 969.67 940.57 950.28 921.76 64760 497.75 472.86 543.79 527.47 532.91 516.93 64763 480.74 456.70 525.21 509.45 514.71 499.26 64766 564.80 536.56 617.04 598.53 604.70 586.56 64771 597.26 567.40 652.51 632.94 639.46 620.28 64772 562.08 533.98 614.08 595.65 601.80 583.74 64774 412.51 391.88 450.66 437.14 441.65 428.40 64776 386.12 366.81 421.83 409.18 413.39 400.99 64778 144.51 137.28 157.87 153.13 154.71 150.08 64782 453.44 430.77 495.39 480.53 485.47 470.91 64783 223.82 212.63 244.52 237.19 239.64 232.45 64784 727.95 691.55 795.28 771.42 779.38 755.99 64786 1,086.76 1,032.42 1,187.28 1,151.67 1,163.54 1,128.63 64787 246.21 233.90 268.99 260.91 263.60 255.69 64788 396.42 376.60 433.09 420.10 424.43 411.69 64790 849.49 807.02 928.07 900.23 909.51 882.22 64792 1,084.31 1,030.09 1,184.60 1,149.07 1,160.91 1,126.09 64795 196.01 186.21 214.14 207.71 209.86 203.56 64802 646.01 613.71 705.77 684.60 691.66 670.90 64804 908.34 862.92 992.36 962.58 972.51 943.33 64809 915.02 869.27 999.66 969.67 979.66 950.28 64818 577.91 549.01 631.36 612.42 618.73 600.17 64820 707.64 672.26 773.10 749.90 757.63 734.91 64821 685.43 651.16 748.83 726.37 733.86 711.85 64822 685.08 650.83 748.45 726.01 733.48 711.48 64823 785.80 746.51 858.49 832.73 841.32 816.07 64831 681.75 647.66 744.81 722.46 729.92 708.02 64832 341.72 324.63 373.32 362.12 365.86 354.88 64834 744.44 707.22 813.30 788.90 797.04 773.12 64835 805.23 764.97 879.72 853.32 862.12 836.26 64836 821.90 780.81 897.93 871.00 879.97 853.58 64837 385.20 365.94 420.83 408.20 412.41 400.04 64840 974.08 925.38 1,064.19 1,032.26 1,042.90 1,011.62 64856 1,014.44 963.72 1,108.28 1,075.03 1,086.12 1,053.53 64857 1,057.17 1,004.31 1,154.96 1,120.31 1,131.85 1,097.91 64858 1,175.62 1,116.84 1,284.37 1,245.83 1,258.68 1,220.91 64859 253.94 241.24 277.43 269.10 271.88 263.72

Page 154: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 154Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

64861 1,259.56 1,196.58 1,376.07 1,334.78 1,348.55 1,308.09 64862 1,402.12 1,332.01 1,531.81 1,485.86 1,501.18 1,456.14 64864 880.63 836.60 962.09 933.23 942.85 914.56 64865 1,112.43 1,056.81 1,215.33 1,178.88 1,191.02 1,155.30 64866 1,141.77 1,084.68 1,247.38 1,209.96 1,222.44 1,185.77 64868 1,031.85 980.26 1,127.30 1,093.48 1,104.75 1,071.60 64872 118.68 112.75 129.66 125.78 127.08 123.26 64874 166.87 158.53 182.31 176.84 178.66 173.29 64876 179.94 170.94 196.58 190.68 192.65 186.86 64885 1,139.38 1,082.41 1,244.77 1,207.43 1,219.87 1,183.28 64886 1,305.18 1,239.92 1,425.91 1,383.13 1,397.39 1,355.47 64890 1,091.76 1,037.17 1,192.75 1,156.96 1,168.89 1,133.82 64891 1,155.49 1,097.72 1,262.38 1,224.51 1,237.14 1,200.01 64892 1,047.33 994.96 1,144.20 1,109.88 1,121.32 1,087.68 64893 1,139.87 1,082.88 1,245.31 1,207.95 1,220.40 1,183.79 64895 1,348.50 1,281.08 1,473.24 1,429.05 1,443.78 1,400.47 64896 1,443.31 1,371.14 1,576.81 1,529.51 1,545.28 1,498.92 64897 1,289.31 1,224.84 1,408.57 1,366.30 1,380.39 1,338.98 64898 1,494.10 1,419.40 1,632.31 1,583.34 1,599.66 1,551.67 64901 564.60 536.37 616.83 598.32 604.49 586.35 64902 660.80 627.76 721.92 700.27 707.48 686.26 64905 1,034.58 982.85 1,130.28 1,096.36 1,107.67 1,074.43 64907 1,331.97 1,265.37 1,455.18 1,411.52 1,426.07 1,383.29 64910 818.50 777.58 894.22 867.39 876.33 850.05 64911 1,013.92 963.22 1,107.70 1,074.47 1,085.55 1,052.97 65091 615.99 585.19 672.97 652.77 659.51 639.72 65093 608.04 577.64 664.29 644.36 651.00 631.47 65101 714.83 679.09 780.95 757.53 765.34 742.38 65103 746.12 708.81 815.13 790.68 798.82 774.87 65105 822.67 781.54 898.77 871.80 880.80 854.37 65110 1,192.76 1,133.12 1,303.09 1,264.00 1,277.03 1,238.72 65112 1,386.04 1,316.74 1,514.25 1,468.83 1,483.97 1,439.46 65114 1,444.35 1,372.13 1,577.95 1,530.62 1,546.39 1,500.00 65125 431.21 409.65 471.10 456.96 461.68 447.82 # 65125 280.32 266.30 306.25 297.06 300.12 291.11 65130 708.20 672.79 773.71 750.50 758.23 735.49 65135 719.33 683.36 785.86 762.29 770.14 747.04 65140 781.97 742.87 854.30 828.67 837.21 812.10 65150 559.67 531.69 611.44 593.10 599.22 581.24 65155 819.64 778.66 895.46 868.60 877.55 851.22 65175 636.50 604.68 695.38 674.52 681.48 661.03 65205 54.59 51.86 59.64 57.85 58.44 56.68 # 65205 43.39 41.22 47.40 45.98 46.46 45.06 65210 66.53 63.20 72.68 70.50 71.23 69.08 # 65210 52.37 49.75 57.21 55.50 56.07 54.38 65220 56.68 53.85 61.93 60.06 60.69 58.87 # 65220 42.19 40.08 46.09 44.71 45.17 43.82 65222 64.88 61.64 70.89 68.76 69.47 67.38 # 65222 51.38 48.81 56.13 54.45 55.00 53.36

Page 155: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 155Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

65235 691.00 656.45 754.92 732.27 739.82 717.62 65260 936.31 889.49 1,022.91 992.23 1,002.46 972.38 65265 1,054.66 1,001.93 1,152.22 1,117.65 1,129.17 1,095.29 65270 253.24 240.58 276.67 268.36 271.14 262.99 # 65270 137.27 130.41 149.97 145.48 146.97 142.57 65272 482.42 458.30 527.05 511.23 516.50 501.01 # 65272 342.40 325.28 374.07 362.85 366.59 355.59 65273 372.52 353.89 406.97 394.76 398.83 386.86 65275 558.15 530.24 609.78 591.48 597.59 579.65 # 65275 451.08 428.53 492.81 478.02 482.95 468.46 65280 655.99 623.19 716.67 695.16 702.34 681.26 65285 1,083.92 1,029.72 1,184.18 1,148.65 1,160.50 1,125.68 65286 676.53 642.70 739.11 716.93 724.33 702.59 # 65286 483.80 459.61 528.55 512.69 517.98 502.44 65290 480.32 456.30 524.75 509.00 514.25 498.82 65400 657.22 624.36 718.01 696.47 703.65 682.55 # 65400 587.04 557.69 641.34 622.10 628.52 609.66 65410 137.75 130.86 150.49 145.97 147.48 143.05 # 65410 102.49 97.37 111.98 108.62 109.73 106.44 65420 494.44 469.72 540.18 523.97 529.38 513.50 # 65420 366.28 347.97 400.17 388.16 392.16 380.40 65426 626.28 594.97 684.22 663.69 670.53 650.42 # 65426 466.16 442.85 509.28 493.99 499.09 484.12 65430 111.03 105.48 121.30 117.67 118.88 115.31 # 65430 101.48 96.41 110.87 107.55 108.65 105.40 65435 77.34 73.47 84.49 81.96 82.80 80.32 # 65435 68.11 64.70 74.41 72.17 72.92 70.73 65436 376.62 357.79 411.46 399.12 403.22 391.14 # 65436 362.45 344.33 395.98 384.10 388.06 376.42 65450 314.04 298.34 343.09 332.80 336.23 326.14 # 65450 311.07 295.52 339.85 329.65 333.05 323.06 65600 380.91 361.86 416.14 403.65 407.81 395.58 # 65600 334.78 318.04 365.75 354.78 358.43 347.68 65710 1,077.74 1,023.85 1,177.43 1,142.10 1,153.88 1,119.26 65730 1,197.40 1,137.53 1,308.16 1,268.91 1,282.00 1,243.53 65750 1,205.40 1,145.13 1,316.90 1,277.40 1,290.56 1,251.84 65755 1,199.11 1,139.15 1,310.02 1,270.73 1,283.83 1,245.31 65756 1,159.75 1,101.76 1,267.02 1,229.02 1,241.68 1,204.44 65757 127.52 121.14 139.31 135.14 136.53 132.43 65770 1,371.46 1,302.89 1,498.32 1,453.37 1,468.35 1,424.30 65772 436.77 414.93 477.17 462.85 467.62 453.59 # 65772 395.59 375.81 432.18 419.22 423.53 410.84 65775 536.40 509.58 586.02 568.43 574.30 557.06 65778 1,325.23 1,258.97 1,447.82 1,404.38 1,418.86 1,376.30 # 65778 56.82 53.98 62.08 60.21 60.84 59.01 65779 1,127.05 1,070.70 1,231.31 1,194.37 1,206.68 1,170.48 # 65779 150.21 142.70 164.11 159.18 160.83 156.00 65780 646.99 614.64 706.84 685.63 692.70 671.92 65781 1,302.54 1,237.41 1,423.02 1,380.33 1,394.56 1,352.72

Page 156: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 156Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

65782 1,123.33 1,067.16 1,227.23 1,190.42 1,202.69 1,166.62 65785 1,987.82 1,888.43 2,171.69 2,106.55 2,128.26 2,064.41 # 65785 381.05 362.00 416.30 403.81 407.97 395.74 65800 115.85 110.06 126.57 122.77 124.04 120.31 # 65800 90.48 85.96 98.85 95.89 96.88 93.97 65810 452.90 430.26 494.80 479.95 484.90 470.35 65815 612.62 581.99 669.29 649.21 655.90 636.23 # 65815 465.02 441.77 508.04 492.80 497.87 482.94 65820 726.23 689.92 793.41 769.60 777.54 754.22 65850 819.68 778.70 895.51 868.64 877.60 851.26 65855 237.45 225.58 259.42 251.63 254.23 246.59 # 65855 203.85 193.66 222.71 216.03 218.26 211.70 65860 298.94 283.99 326.59 316.79 320.06 310.45 # 65860 248.20 235.79 271.16 263.03 265.73 257.77 65865 459.68 436.70 502.21 487.14 492.17 477.40 65870 575.16 546.40 628.36 609.51 615.79 597.32 65875 613.05 582.40 669.76 649.67 656.36 636.67 65880 645.76 613.47 705.49 684.33 691.38 670.65 65900 938.85 891.91 1,025.70 994.92 1,005.18 975.03 65920 767.17 728.81 838.13 812.99 821.36 796.73 65930 621.47 590.40 678.96 658.59 665.38 645.43 66020 178.80 169.86 195.34 189.47 191.43 185.68 # 66020 127.73 121.34 139.54 135.36 136.75 132.65 66030 158.60 150.67 173.27 168.07 169.81 164.71 # 66030 107.54 102.16 117.48 113.97 115.14 111.69 66130 673.73 640.04 736.05 713.97 721.33 699.68 # 66130 556.77 528.93 608.27 590.02 596.10 578.22 66150 851.24 808.68 929.98 902.08 911.39 884.04 66155 850.55 808.02 929.22 901.35 910.64 883.32 66160 960.87 912.83 1,049.75 1,018.27 1,028.76 997.90 66170 1,065.61 1,012.33 1,164.18 1,129.25 1,140.89 1,106.67 66172 1,158.37 1,100.45 1,265.52 1,227.56 1,240.21 1,203.00 66174 925.77 879.48 1,011.40 981.07 991.17 961.45 66175 969.97 921.47 1,059.69 1,027.90 1,038.50 1,007.34 66179 1,050.30 997.79 1,147.46 1,113.04 1,124.50 1,090.78 66180 1,109.13 1,053.67 1,211.72 1,175.37 1,187.49 1,151.86 66183 1,002.97 952.82 1,095.74 1,062.88 1,073.82 1,041.62 66184 762.91 724.76 833.47 808.47 816.80 792.30 66185 821.41 780.34 897.39 870.47 879.44 853.06 66220 692.36 657.74 756.40 733.71 741.28 719.04 66225 910.24 864.73 994.44 964.61 974.56 945.31 66250 719.87 683.88 786.46 762.86 770.73 747.60 # 66250 542.95 515.80 593.17 575.38 581.30 563.87 66500 342.53 325.40 374.21 362.99 366.72 355.73 66505 377.85 358.96 412.80 400.42 404.55 392.41 66600 808.77 768.33 883.58 857.07 865.90 839.93 66605 1,031.24 979.68 1,126.63 1,092.83 1,104.10 1,070.97 66625 417.35 396.48 455.95 442.28 446.83 433.44 66630 554.71 526.97 606.02 587.83 593.89 576.08

Page 157: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 157Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

66635 559.62 531.64 611.39 593.04 599.16 581.19 66680 503.82 478.63 550.42 533.91 539.42 523.23 66682 618.11 587.20 675.28 655.02 661.78 641.92 66700 435.93 414.13 476.25 461.97 466.73 452.73 # 66700 383.55 364.37 419.03 406.46 410.64 398.33 66710 426.05 404.75 465.46 451.50 456.16 442.47 # 66710 383.22 364.06 418.67 406.11 410.30 397.99 66711 625.27 594.01 683.11 662.62 669.45 649.37 66720 443.95 421.75 485.01 470.47 475.32 461.06 # 66720 397.17 377.31 433.91 420.89 425.22 412.47 66740 423.41 402.24 462.58 448.70 453.33 439.73 # 66740 383.22 364.06 418.67 406.11 410.30 397.99 66761 285.22 270.96 311.60 302.25 305.37 296.21 # 66761 229.88 218.39 251.15 243.62 246.12 238.74 66762 459.76 436.77 502.29 487.22 492.23 477.48 # 66762 415.28 394.52 453.70 440.08 444.62 431.28 66770 511.56 485.98 558.88 542.11 547.70 531.27 # 66770 471.36 447.79 514.96 499.51 504.65 489.52 66820 380.32 361.30 415.50 403.03 407.18 394.97 66821 318.18 302.27 347.61 337.18 340.65 330.44 # 66821 301.04 285.99 328.89 319.02 322.31 312.64 66825 737.43 700.56 805.64 781.47 789.53 765.84 66830 696.01 661.21 760.39 737.58 745.19 722.82 66840 679.31 645.34 742.14 719.88 727.29 705.48 66850 773.55 734.87 845.10 819.74 828.20 803.34 66852 824.36 783.14 900.61 873.60 882.60 856.13 66920 736.32 699.50 804.43 780.30 788.34 764.69 66930 835.19 793.43 912.44 885.07 894.19 867.38 66940 763.08 724.93 833.67 808.66 816.99 792.49 66982 777.50 738.63 849.42 823.94 832.44 807.46 66983 725.02 688.77 792.09 768.33 776.24 752.96 66984 624.48 593.26 682.25 661.78 668.60 648.54 66985 750.31 712.79 819.71 795.12 803.31 779.22 66986 887.32 842.95 969.39 940.31 950.00 921.51 66990 89.43 84.96 97.70 94.77 95.75 92.87 67005 459.73 436.74 502.25 487.19 492.21 477.45 67010 528.97 502.52 577.90 560.56 566.34 549.34 67015 564.15 535.94 616.33 597.84 604.00 585.88 67025 702.29 667.18 767.26 744.23 751.92 729.35 # 67025 616.30 585.49 673.31 653.12 659.85 640.06 67027 832.61 790.98 909.63 882.34 891.43 864.70 67028 99.77 94.78 109.00 105.73 106.81 103.62 # 67028 98.45 93.53 107.56 104.33 105.41 102.25 67030 516.11 490.30 563.85 546.93 552.56 535.99 67031 376.52 357.69 411.34 399.00 403.12 391.02 # 67031 347.20 329.84 379.32 367.93 371.73 360.57 67036 879.66 835.68 961.03 932.20 941.82 913.56 67039 943.36 896.19 1,030.62 999.70 1,010.01 979.70 67040 1,020.59 969.56 1,114.99 1,081.54 1,092.70 1,059.91

Page 158: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 158Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

67041 1,127.50 1,071.13 1,231.80 1,194.85 1,207.17 1,170.95 67042 1,128.49 1,072.07 1,232.88 1,195.90 1,208.22 1,171.98 67043 1,192.16 1,132.55 1,302.43 1,263.36 1,276.39 1,238.09 67101 316.76 300.92 346.06 335.67 339.14 328.96 # 67101 276.90 263.06 302.52 293.45 296.47 287.58 67105 287.45 273.08 314.04 304.62 307.76 298.53 # 67105 267.68 254.30 292.45 283.67 286.59 278.00 67107 1,108.68 1,053.25 1,211.24 1,174.90 1,187.02 1,151.40 67108 1,176.15 1,117.34 1,284.94 1,246.39 1,259.24 1,221.46 67110 850.03 807.53 928.66 900.80 910.09 882.77 # 67110 791.39 751.82 864.59 838.66 847.30 821.88 67113 1,312.20 1,246.59 1,433.58 1,390.57 1,404.91 1,362.76 67115 486.16 461.85 531.13 515.19 520.50 504.88 67120 635.20 603.44 693.96 673.14 680.08 659.67 # 67120 543.61 516.43 593.89 576.08 582.02 564.56 67121 886.96 842.61 969.00 939.93 949.62 921.13 67141 507.66 482.28 554.62 537.98 543.52 527.22 # 67141 475.05 451.30 519.00 503.42 508.61 493.35 67145 511.16 485.60 558.44 541.68 547.27 530.85 # 67145 485.13 460.87 530.00 514.10 519.40 503.82 67208 583.56 554.38 637.54 618.41 624.78 606.05 # 67208 564.45 536.23 616.66 598.16 604.34 586.20 67210 503.70 478.52 550.30 533.78 539.29 523.11 # 67210 487.56 463.18 532.66 516.67 522.01 506.33 67218 1,357.31 1,289.44 1,482.86 1,438.37 1,453.20 1,409.60 67220 518.19 492.28 566.12 549.14 554.79 538.15 # 67220 487.56 463.18 532.66 516.67 522.01 506.33 67221 278.40 264.48 304.15 295.03 298.07 289.13 # 67221 210.86 200.32 230.37 223.46 225.76 218.98 67225 29.14 27.68 31.83 30.88 31.20 30.26 # 67225 27.83 26.44 30.41 29.50 29.80 28.91 67227 281.51 267.43 307.54 298.32 301.39 292.35 # 67227 251.20 238.64 274.44 266.20 268.95 260.88 67228 331.78 315.19 362.47 351.59 355.22 344.56 # 67228 301.14 286.08 328.99 319.13 322.41 312.74 67229 1,140.59 1,083.56 1,246.09 1,208.71 1,221.17 1,184.53 67250 758.72 720.78 828.90 804.03 812.31 787.96 67255 664.60 631.37 726.08 704.29 711.55 690.21 67311 582.63 553.50 636.53 617.44 623.79 605.08 67312 694.95 660.20 759.23 736.45 744.05 721.72 67314 655.68 622.90 716.34 694.84 702.01 680.95 67316 782.99 743.84 855.42 829.75 838.30 813.15 67318 687.67 653.29 751.28 728.74 736.25 714.17 67320 319.17 303.21 348.69 338.23 341.72 331.46 67331 303.16 288.00 331.20 321.26 324.58 314.84 67332 328.89 312.45 359.32 348.54 352.13 341.57 67334 298.61 283.68 326.23 316.45 319.71 310.12 67335 147.21 139.85 160.83 156.00 157.61 152.88 67340 354.98 337.23 387.81 376.18 380.06 368.66

Page 159: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 159Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

67343 637.60 605.72 696.58 675.68 682.65 662.17 67345 236.33 224.51 258.19 250.44 253.02 245.42 # 67345 214.26 203.55 234.08 227.06 229.40 222.51 67346 190.59 181.06 208.22 201.97 204.06 197.94 67400 902.87 857.73 986.39 956.80 966.67 937.66 67405 768.35 729.93 839.42 814.23 822.63 797.95 67412 826.24 784.93 902.67 875.59 884.61 858.07 67413 829.36 787.89 906.07 878.89 887.95 861.32 67414 1,295.63 1,230.85 1,415.48 1,373.01 1,387.16 1,345.55 67415 104.07 98.87 113.70 110.29 111.42 108.08 67420 1,581.35 1,502.28 1,727.62 1,675.79 1,693.06 1,642.28 67430 1,202.33 1,142.21 1,313.54 1,274.13 1,287.28 1,248.65 67440 1,171.55 1,112.97 1,279.92 1,241.52 1,254.32 1,216.69 67445 1,369.92 1,301.42 1,496.63 1,451.74 1,466.70 1,422.70 67450 1,215.24 1,154.48 1,327.65 1,287.83 1,301.10 1,262.07 67500 77.70 73.82 84.89 82.35 83.19 80.71 # 67500 71.77 68.18 78.41 76.05 76.84 74.53 67505 86.69 82.36 94.71 91.87 92.82 90.03 # 67505 79.77 75.78 87.15 84.54 85.40 82.85 67515 95.01 90.26 103.80 100.68 101.72 98.67 # 67515 88.09 83.69 96.24 93.36 94.32 91.49 67550 937.03 890.18 1,023.71 992.99 1,003.24 973.13 67560 960.37 912.35 1,049.20 1,017.73 1,028.22 997.37 67570 1,137.06 1,080.21 1,242.24 1,204.97 1,217.40 1,180.87 67700 253.51 240.83 276.95 268.65 271.41 263.28 # 67700 113.16 107.50 123.63 119.92 121.15 117.52 67710 210.61 200.08 230.09 223.19 225.49 218.73 # 67710 93.98 89.28 102.67 99.59 100.61 97.60 67715 226.50 215.18 247.46 240.03 242.51 235.23 # 67715 105.26 100.00 115.00 111.55 112.70 109.32 67800 122.39 116.27 133.71 129.70 131.03 127.10 # 67800 101.30 96.24 110.68 107.35 108.47 105.20 67801 156.92 149.07 171.43 166.29 168.00 162.97 # 67801 130.56 124.03 142.63 138.36 139.78 135.59 67805 194.64 184.91 212.65 206.26 208.39 202.14 # 67805 161.03 152.98 175.93 170.65 172.41 167.23 67808 358.57 340.64 391.74 379.98 383.90 372.38 67810 164.35 156.13 179.55 174.17 175.96 170.68 # 67810 71.78 68.19 78.42 76.06 76.85 74.54 67820 48.99 46.54 53.52 51.91 52.45 50.88 # 67820 51.95 49.35 56.75 55.05 55.61 53.95 67825 124.09 117.89 135.57 131.50 132.86 128.87 # 67825 117.83 111.94 128.73 124.87 126.16 122.37 67830 252.29 239.68 275.63 267.36 270.12 262.02 # 67830 134.35 127.63 146.77 142.37 143.84 139.52 67835 428.17 406.76 467.77 453.74 458.41 444.67 67840 262.28 249.17 286.55 277.94 280.82 272.39 # 67840 154.54 146.81 168.83 163.77 165.45 160.49 67850 205.98 195.68 225.03 218.28 220.54 213.91

Page 160: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 160Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 67850 133.17 126.51 145.49 141.12 142.58 138.30 67875 163.75 155.56 178.89 173.52 175.32 170.05 # 67875 95.55 90.77 104.39 101.26 102.29 99.23 67880 441.20 419.14 482.01 467.56 472.37 458.21 # 67880 358.84 340.90 392.04 380.27 384.19 372.67 67882 544.18 516.97 594.52 576.68 582.62 565.14 # 67882 460.17 437.16 502.73 487.66 492.68 477.91 67900 618.46 587.54 675.67 655.40 662.16 642.29 # 67900 498.54 473.61 544.65 528.31 533.76 517.74 67901 728.82 692.38 796.24 772.35 780.31 756.91 # 67901 563.43 535.26 615.55 597.08 603.23 585.14 67902 706.97 671.62 772.36 749.19 756.92 734.21 67903 573.47 544.80 626.52 607.73 613.99 595.57 # 67903 472.99 449.34 516.74 501.24 506.40 491.21 67904 707.59 672.21 773.04 749.85 757.59 734.85 # 67904 584.05 554.85 638.08 618.93 625.31 606.56 67906 496.93 472.08 542.89 526.61 532.04 516.07 67908 476.00 452.20 520.03 504.42 509.63 494.34 # 67908 413.07 392.42 451.28 437.75 442.26 429.00 67909 517.19 491.33 565.03 548.08 553.73 537.12 # 67909 427.90 406.51 467.49 453.46 458.14 444.38 67911 549.57 522.09 600.40 582.39 588.40 570.75 67912 839.28 797.32 916.92 889.41 898.58 871.62 # 67912 478.85 454.91 523.15 507.45 512.68 497.29 67914 448.77 426.33 490.28 475.57 480.47 466.06 # 67914 317.97 302.07 347.38 336.96 340.43 330.22 67915 277.88 263.99 303.59 294.48 297.52 288.59 # 67915 190.91 181.36 208.56 202.31 204.39 198.26 67916 568.59 540.16 621.18 602.55 608.76 590.50 # 67916 420.66 399.63 459.57 445.79 450.39 436.87 67917 579.86 550.87 633.50 614.49 620.83 602.20 # 67917 447.08 424.73 488.44 473.79 478.68 464.31 67921 438.60 416.67 479.17 464.80 469.59 455.50 # 67921 300.89 285.85 328.73 318.86 322.15 312.48 67922 275.58 261.80 301.07 292.04 295.04 286.20 # 67922 190.91 181.36 208.56 202.31 204.39 198.26 67923 567.51 539.13 620.00 601.40 607.60 589.38 # 67923 419.92 398.92 458.76 444.99 449.58 436.09 67924 605.20 574.94 661.18 641.34 647.96 628.52 # 67924 447.06 424.71 488.42 473.77 478.65 464.29 67930 350.93 333.38 383.39 371.89 375.72 364.45 # 67930 236.60 224.77 258.49 250.73 253.31 245.72 67935 574.19 545.48 627.30 608.49 614.76 596.32 # 67935 434.50 412.78 474.70 460.46 465.20 451.25 67938 230.66 219.13 252.00 244.44 246.96 239.56 # 67938 113.04 107.39 123.50 119.80 121.03 117.40 67950 552.47 524.85 603.58 585.47 591.50 573.76 # 67950 452.65 430.02 494.52 479.69 484.63 470.10 67961 553.59 525.91 604.80 586.65 592.70 574.92

Page 161: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 161Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 67961 443.88 421.69 484.94 470.40 475.25 460.99 67966 744.35 707.13 813.20 788.81 796.94 773.03 # 67966 643.20 611.04 702.70 681.62 688.64 667.99 67971 708.05 672.65 773.55 750.34 758.08 735.33 67973 911.98 866.38 996.34 966.45 976.41 947.12 67974 909.52 864.04 993.65 963.84 973.77 944.56 67975 669.42 635.95 731.34 709.40 716.71 695.21 68020 115.83 110.04 126.55 122.75 124.02 120.30 # 68020 107.59 102.21 117.54 114.01 115.20 111.73 68040 60.30 57.29 65.88 63.91 64.56 62.63 # 68040 49.76 47.27 54.36 52.73 53.27 51.67 68100 162.07 153.97 177.07 171.75 173.52 168.31 # 68100 95.52 90.74 104.35 101.22 102.27 99.20 68110 215.27 204.51 235.19 228.13 230.48 223.56 # 68110 144.44 137.22 157.80 153.07 154.65 150.01 68115 296.88 282.04 324.35 314.62 317.86 308.33 # 68115 179.59 170.61 196.20 190.31 192.28 186.51 68130 517.19 491.33 565.03 548.08 553.73 537.12 # 68130 400.89 380.85 437.98 424.83 429.21 416.33 68135 151.92 144.32 165.97 160.99 162.64 157.77 # 68135 146.98 139.63 160.57 155.76 157.37 152.64 68200 40.10 38.10 43.82 42.50 42.94 41.65 # 68200 34.17 32.46 37.33 36.21 36.58 35.49 68320 695.07 660.32 759.37 736.59 744.18 721.86 # 68320 524.74 498.50 573.28 556.08 561.81 544.96 68325 642.74 610.60 702.19 681.12 688.15 667.49 68326 630.18 598.67 688.47 667.82 674.71 654.47 68328 692.50 657.88 756.56 733.86 741.43 719.19 68330 580.65 551.62 634.36 615.33 621.68 603.03 # 68330 449.19 426.73 490.74 476.02 480.93 466.50 68335 632.60 600.97 691.12 670.38 677.29 656.97 68340 522.38 496.26 570.70 553.58 559.28 542.50 # 68340 388.62 369.19 424.57 411.83 416.08 403.59 68360 511.55 485.97 558.87 542.10 547.69 531.25 # 68360 401.51 381.43 438.64 425.49 429.87 416.98 68362 640.62 608.59 699.88 678.88 685.88 665.30 68371 401.85 381.76 439.02 425.86 430.24 417.34 68400 269.07 255.62 293.96 285.14 288.09 279.44 # 68400 128.72 122.28 140.62 136.40 137.80 133.68 68420 305.63 290.35 333.90 323.89 327.22 317.41 # 68420 164.95 156.70 180.21 174.80 176.61 171.30 68440 98.00 93.10 107.07 103.86 104.93 101.78 # 68440 95.37 90.60 104.19 101.06 102.11 99.04 68500 954.43 906.71 1,042.72 1,011.44 1,021.87 991.21 68505 945.52 898.24 1,032.98 1,001.98 1,012.32 981.94 68510 428.35 406.93 467.97 453.93 458.61 444.85 # 68510 287.68 273.30 314.30 304.87 308.00 298.77 68520 669.27 635.81 731.18 709.25 716.55 695.07 68525 261.75 248.66 285.96 277.38 280.24 271.84

Page 162: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 162Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

68530 409.03 388.58 446.87 433.46 437.93 424.79 # 68530 252.87 240.23 276.26 267.97 270.74 262.61 68540 906.20 860.89 990.02 960.32 970.22 941.11 68550 1,088.63 1,034.20 1,189.33 1,153.65 1,165.55 1,130.58 68700 589.24 559.78 643.75 624.44 630.87 611.95 68705 226.75 215.41 247.72 240.29 242.77 235.49 # 68705 162.18 154.07 177.18 171.87 173.64 168.43 68720 738.54 701.61 806.85 782.64 790.72 766.99 68745 740.85 703.81 809.38 785.11 793.19 769.41 68750 766.65 728.32 837.57 812.44 820.81 796.19 68760 192.75 183.11 210.58 204.26 206.37 200.18 # 68760 142.01 134.91 155.15 150.49 152.04 147.48 68761 141.80 134.71 154.92 150.27 151.82 147.27 # 68761 115.44 109.67 126.12 122.34 123.60 119.89 68770 614.64 583.91 671.50 651.35 658.06 638.32 68801 84.92 80.67 92.77 89.99 90.92 88.19 # 68801 76.36 72.54 83.42 80.91 81.75 79.29 68810 151.46 143.89 165.47 160.51 162.16 157.30 # 68810 124.12 117.91 135.60 131.53 132.88 128.89 68811 133.03 126.38 145.34 140.98 142.43 138.16 68815 377.88 358.99 412.84 400.45 404.58 392.45 # 68815 215.79 205.00 235.75 228.68 231.04 224.10 68816 606.26 575.95 662.34 642.47 649.09 629.63 # 68816 159.18 151.22 173.90 168.68 170.43 165.31 68840 123.02 116.87 134.40 130.36 131.71 127.75 # 68840 112.81 107.17 123.25 119.54 120.78 117.15 68850 60.21 57.20 65.78 63.80 64.47 62.53 # 68850 55.60 52.82 60.74 58.93 59.52 57.75 69000 180.24 171.23 196.91 191.00 192.98 187.19 # 69000 116.98 111.13 127.80 123.97 125.25 121.49 69005 208.23 197.82 227.49 220.67 222.94 216.26 # 69005 154.86 147.12 169.19 164.12 165.81 160.84 69020 221.93 210.83 242.45 235.19 237.60 230.48 # 69020 138.90 131.96 151.75 147.20 148.72 144.26 69100 96.93 92.08 105.89 102.72 103.78 100.66 # 69100 49.16 46.70 53.71 52.10 52.64 51.05 69105 133.65 126.97 146.02 141.63 143.09 138.81 # 69105 62.81 59.67 68.62 66.56 67.25 65.23 69110 441.63 419.55 482.48 468.00 472.83 458.64 # 69110 317.75 301.86 347.14 336.72 340.19 329.98 69120 395.98 376.18 432.61 419.62 423.96 411.23 69140 850.67 808.14 929.36 901.49 910.78 883.45 69145 379.39 360.42 414.48 402.05 406.19 394.01 # 69145 243.65 231.47 266.19 258.21 260.87 253.05 69150 1,033.13 981.47 1,128.69 1,094.83 1,106.12 1,072.94 69155 1,650.51 1,567.98 1,803.18 1,749.08 1,767.11 1,714.10 69200 79.98 75.98 87.38 84.76 85.63 83.06 # 69200 47.36 44.99 51.74 50.19 50.70 49.19 69205 99.60 94.62 108.81 105.55 106.64 103.43

Page 163: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 163Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

69209 11.89 11.30 13.00 12.60 12.73 12.35 69210 47.79 45.40 52.21 50.65 51.16 49.63 # 69210 32.97 31.32 36.02 34.94 35.29 34.24 69220 87.13 82.77 95.19 92.33 93.28 90.48 # 69220 51.55 48.97 56.32 54.63 55.19 53.53 69222 209.80 199.31 229.21 222.33 224.62 217.88 # 69222 133.37 126.70 145.71 141.34 142.80 138.51 69300 577.81 548.92 631.26 612.32 618.63 600.07 # 69300 455.91 433.11 498.08 483.14 488.12 473.48 69310 1,063.64 1,010.46 1,162.03 1,127.17 1,138.79 1,104.63 69320 1,492.05 1,417.45 1,630.07 1,581.17 1,597.47 1,549.54 69420 183.21 174.05 200.16 194.15 196.16 190.27 # 69420 117.98 112.08 128.89 125.03 126.32 122.53 69421 146.01 138.71 159.52 154.73 156.33 151.64 69424 121.78 115.69 133.04 129.05 130.39 126.48 # 69424 61.49 58.42 67.18 65.17 65.84 63.87 69433 194.40 184.68 212.38 206.01 208.14 201.89 # 69433 129.82 123.33 141.83 137.57 138.99 134.83 69436 157.65 149.77 172.24 167.07 168.79 163.73 69440 673.96 640.26 736.30 714.21 721.57 699.92 69450 531.77 505.18 580.96 563.52 569.34 552.25 69501 721.82 685.73 788.59 764.93 772.82 749.64 69502 962.30 914.19 1,051.32 1,019.77 1,030.30 999.37 69505 1,177.26 1,118.40 1,286.16 1,247.58 1,260.43 1,222.62 69511 1,207.80 1,147.41 1,319.52 1,279.94 1,293.13 1,254.34 69530 1,642.95 1,560.80 1,794.92 1,741.08 1,759.02 1,706.26 69535 2,668.99 2,535.54 2,915.87 2,828.39 2,857.55 2,771.82 69540 199.24 189.28 217.67 211.14 213.31 206.92 # 69540 123.47 117.30 134.90 130.85 132.19 128.23 69550 1,016.91 966.06 1,110.97 1,077.64 1,088.75 1,056.09 69552 1,534.99 1,458.24 1,676.98 1,626.66 1,643.44 1,594.13 69554 2,498.20 2,373.29 2,729.28 2,647.40 2,674.69 2,594.46 69601 1,030.60 979.07 1,125.93 1,092.16 1,103.41 1,070.32 69602 1,075.65 1,021.87 1,175.15 1,139.89 1,151.64 1,117.10 69603 1,241.22 1,179.16 1,356.03 1,315.36 1,328.92 1,289.05 69604 1,095.40 1,040.63 1,196.72 1,160.82 1,172.79 1,137.60 69605 1,646.87 1,564.53 1,799.21 1,745.23 1,763.23 1,710.33 69610 375.14 356.38 409.84 397.54 401.64 389.60 # 69610 289.81 275.32 316.62 307.12 310.28 300.98 69620 669.28 635.82 731.19 709.26 716.57 695.08 # 69620 480.17 456.16 524.58 508.85 514.10 498.67 69631 866.00 822.70 946.11 917.72 927.19 899.37 69632 1,058.61 1,005.68 1,156.53 1,121.84 1,133.41 1,099.40 69633 1,025.25 973.99 1,120.09 1,086.49 1,097.69 1,064.75 69635 1,210.11 1,149.60 1,322.04 1,282.38 1,295.60 1,256.73 69636 1,350.89 1,283.35 1,475.85 1,431.58 1,446.33 1,402.94 69637 1,371.47 1,302.90 1,498.34 1,453.38 1,468.37 1,424.31 69641 1,024.14 972.93 1,118.87 1,085.30 1,096.49 1,063.60 69642 1,315.50 1,249.73 1,437.19 1,394.08 1,408.45 1,366.20

Page 164: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 164Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

69643 1,205.22 1,144.96 1,316.70 1,277.20 1,290.37 1,251.66 69644 1,449.88 1,377.39 1,584.00 1,536.48 1,552.32 1,505.75 69645 1,424.45 1,353.23 1,556.21 1,509.52 1,525.10 1,479.34 69646 1,514.95 1,439.20 1,655.08 1,605.42 1,621.98 1,573.32 69650 793.47 753.80 866.87 840.87 849.53 824.06 69660 913.53 867.85 998.03 968.08 978.06 948.72 69661 1,189.42 1,129.95 1,299.44 1,260.46 1,273.45 1,235.25 69662 1,147.38 1,090.01 1,253.51 1,215.91 1,228.44 1,191.58 69666 798.68 758.75 872.56 846.39 855.12 829.46 69667 798.74 758.80 872.62 846.45 855.16 829.52 69670 934.30 887.59 1,020.73 990.10 1,000.32 970.30 69676 814.69 773.96 890.05 863.35 872.25 846.09 69700 681.82 647.73 744.89 722.55 730.00 708.09 69711 847.46 805.09 925.85 898.08 907.34 880.12 69714 1,065.04 1,011.79 1,163.56 1,128.66 1,140.28 1,106.08 69715 1,368.77 1,300.33 1,495.38 1,450.52 1,465.47 1,421.50 69717 1,120.80 1,064.76 1,224.47 1,187.74 1,199.98 1,163.98 69718 1,330.63 1,264.10 1,453.72 1,410.11 1,424.64 1,381.91 69720 1,199.21 1,139.25 1,310.14 1,270.83 1,283.94 1,245.42 69725 1,866.99 1,773.64 2,039.69 1,978.49 1,998.90 1,938.92 69740 1,183.53 1,124.35 1,293.00 1,254.21 1,267.14 1,229.13 69745 1,160.87 1,102.83 1,268.25 1,230.21 1,242.89 1,205.61 69801 190.11 180.60 207.69 201.46 203.54 197.43 # 69801 126.20 119.89 137.87 133.73 135.11 131.05 69805 1,043.37 991.20 1,139.88 1,105.68 1,117.09 1,083.56 69806 933.61 886.93 1,019.97 989.37 999.57 969.58 69820 823.06 781.91 899.20 872.22 881.21 854.77 69840 887.06 842.71 969.12 940.04 949.74 921.24 69905 901.66 856.58 985.07 955.51 965.37 936.40 69910 1,012.18 961.57 1,105.81 1,072.63 1,083.69 1,051.18 69915 1,577.98 1,499.08 1,723.94 1,672.23 1,689.47 1,638.78 69930 1,214.31 1,153.59 1,326.63 1,286.83 1,300.10 1,261.09 69950 1,810.90 1,720.36 1,978.41 1,919.06 1,938.84 1,880.69 69955 1,959.73 1,861.74 2,141.00 2,076.77 2,098.19 2,035.24 69960 1,916.47 1,820.65 2,093.75 2,030.93 2,051.88 1,990.32 69970 2,131.77 2,025.18 2,328.96 2,259.08 2,282.38 2,213.90 69990 225.98 214.68 246.88 239.48 241.95 234.69 70010 66.59 63.26 72.75 70.56 71.29 69.15 70015 148.90 141.46 162.68 157.80 159.42 154.65 70015 TC 86.02 81.72 93.98 91.16 92.10 89.33 70015 26 62.88 59.74 68.70 66.64 67.33 65.31 70030 26.26 24.95 28.69 27.83 28.12 27.28 70030 TC 17.82 16.93 19.47 18.88 19.08 18.50 70030 26 8.44 8.02 9.22 8.95 9.04 8.76 70100 31.23 29.67 34.12 33.10 33.44 32.43 70100 TC 22.10 21.00 24.15 23.43 23.67 22.95 70100 26 9.12 8.66 9.96 9.66 9.76 9.46 70110 36.05 34.25 39.39 38.20 38.61 37.44 70110 TC 23.42 22.25 25.59 24.82 25.08 24.32

Page 165: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 165Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

70110 26 12.63 12.00 13.80 13.39 13.52 13.12 70120 31.89 30.30 34.85 33.80 34.14 33.12 70120 TC 22.76 21.62 24.86 24.12 24.37 23.63 70120 26 9.12 8.66 9.96 9.66 9.76 9.46 70130 51.82 49.23 56.61 54.91 55.49 53.82 70130 TC 34.62 32.89 37.82 36.69 37.06 35.95 70130 26 17.20 16.34 18.79 18.23 18.41 17.86 70134 49.16 46.70 53.71 52.10 52.64 51.05 70134 TC 31.66 30.08 34.59 33.56 33.90 32.89 70134 26 17.50 16.63 19.12 18.55 18.75 18.18 70140 28.29 26.88 30.91 29.98 30.29 29.38 70140 TC 17.82 16.93 19.47 18.88 19.08 18.50 70140 26 10.47 9.95 11.44 11.10 11.21 10.88 70150 39.37 37.40 43.01 41.72 42.15 40.88 70150 TC 26.06 24.76 28.47 27.62 27.90 27.07 70150 26 13.31 12.64 14.54 14.10 14.25 13.81 70160 30.87 29.33 33.73 32.72 33.05 32.06 70160 TC 22.10 21.00 24.15 23.43 23.67 22.95 70160 26 8.77 8.33 9.58 9.29 9.38 9.11 70170 195.39 185.62 213.46 207.06 209.20 202.92 70170 TC 180.28 171.27 196.96 191.05 193.02 187.23 70170 26 15.11 14.35 16.50 16.01 16.17 15.69 70190 33.62 31.94 36.73 35.63 36.00 34.91 70190 TC 22.43 21.31 24.51 23.77 24.01 23.30 70190 26 11.19 10.63 12.22 11.86 11.98 11.62 70200 40.09 38.09 43.80 42.49 42.93 41.64 70200 TC 26.06 24.76 28.47 27.62 27.90 27.07 70200 26 14.03 13.33 15.33 14.87 15.02 14.57 70210 28.23 26.82 30.84 29.92 30.22 29.33 70210 TC 19.47 18.50 21.28 20.64 20.85 20.23 70210 26 8.77 8.33 9.58 9.29 9.38 9.11 70220 35.72 33.93 39.02 37.85 38.24 37.09 70220 TC 23.09 21.94 25.23 24.47 24.73 23.98 70220 26 12.63 12.00 13.80 13.39 13.52 13.12 70240 28.62 27.19 31.27 30.33 30.65 29.72 70240 TC 18.81 17.87 20.55 19.93 20.14 19.53 70240 26 9.81 9.32 10.72 10.40 10.50 10.19 70250 34.37 32.65 37.55 36.42 36.80 35.70 70250 TC 21.77 20.68 23.78 23.07 23.31 22.61 70250 26 12.60 11.97 13.77 13.35 13.49 13.09 70260 43.59 41.41 47.62 46.20 46.67 45.28 70260 TC 26.06 24.76 28.47 27.62 27.90 27.07 70260 26 17.53 16.65 19.15 18.57 18.77 18.20 70300 14.19 13.48 15.50 15.04 15.19 14.74 70300 TC 8.27 7.86 9.04 8.76 8.86 8.59 70300 26 5.92 5.62 6.46 6.27 6.34 6.14 70310 34.13 32.42 37.28 36.17 36.54 35.44 70310 TC 26.06 24.76 28.47 27.62 27.90 27.07 70310 26 8.08 7.68 8.83 8.57 8.66 8.40

Page 166: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 166Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

70320 50.15 47.64 54.79 53.14 53.69 52.08 70320 TC 37.92 36.02 41.42 40.18 40.60 39.38 70320 26 12.24 11.63 13.37 12.97 13.11 12.71 70328 28.92 27.47 31.59 30.65 30.96 30.04 70328 TC 19.80 18.81 21.63 20.99 21.19 20.57 70328 26 9.12 8.66 9.96 9.66 9.76 9.46 70330 45.57 43.29 49.78 48.29 48.78 47.32 70330 TC 32.97 31.32 36.02 34.94 35.29 34.24 70330 26 12.60 11.97 13.77 13.35 13.49 13.09 70332 76.16 72.35 83.20 80.71 81.54 79.10 70332 TC 45.49 43.22 49.70 48.21 48.71 47.24 70332 26 30.67 29.14 33.51 32.51 32.84 31.86 C 70336 281.39 267.32 307.42 298.20 301.27 292.23 C 70336 TC 207.62 197.24 226.83 220.02 222.30 215.61 70336 26 73.77 70.08 80.59 78.18 78.98 76.61 70350 19.04 18.09 20.80 20.18 20.39 19.78 70350 TC 8.92 8.47 9.74 9.45 9.55 9.27 70350 26 10.11 9.60 11.04 10.71 10.82 10.49 70355 20.11 19.10 21.97 21.31 21.53 20.88 70355 TC 8.92 8.47 9.74 9.45 9.55 9.27 70355 26 11.19 10.63 12.22 11.86 11.98 11.62 70360 26.59 25.26 29.05 28.18 28.46 27.61 70360 TC 18.15 17.24 19.83 19.23 19.44 18.85 70360 26 8.44 8.02 9.22 8.95 9.04 8.76 70370 72.52 68.89 79.22 76.84 77.64 75.30 70370 TC 56.37 53.55 61.58 59.73 60.35 58.54 70370 26 16.15 15.34 17.64 17.11 17.28 16.77 70371 86.30 81.99 94.29 91.46 92.40 89.63 70371 TC 44.51 42.28 48.62 47.16 47.64 46.22 70371 26 41.79 39.70 45.66 44.29 44.75 43.40 70380 33.83 32.14 36.96 35.86 36.23 35.14 70380 TC 24.74 23.50 27.03 26.22 26.48 25.69 70380 26 9.10 8.65 9.95 9.65 9.75 9.45 70390 88.18 83.77 96.34 93.45 94.40 91.57 70390 TC 69.22 65.76 75.62 73.36 74.11 71.89 70390 26 18.97 18.02 20.72 20.10 20.31 19.70 70450 110.74 105.20 120.98 117.35 118.57 115.00 70450 TC 67.90 64.51 74.19 71.96 72.70 70.52 70450 26 42.84 40.70 46.81 45.40 45.87 44.49 70460 154.42 146.70 168.71 163.65 165.34 160.37 70460 TC 97.88 92.99 106.94 103.73 104.80 101.66 70460 26 56.54 53.71 61.77 59.92 60.54 58.72 70470 182.54 173.41 199.42 193.44 195.43 189.58 70470 TC 118.63 112.70 129.61 125.72 127.02 123.20 70470 26 63.90 60.71 69.82 67.72 68.43 66.37 C 70480 167.74 159.35 183.25 177.76 179.58 174.20 C 70480 TC 103.48 98.31 113.06 109.66 110.79 107.47 70480 26 64.26 61.05 70.21 68.10 68.80 66.75 70481 260.64 247.61 284.75 276.21 279.06 270.69

Page 167: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 167Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

70481 TC 191.44 181.87 209.15 202.87 204.96 198.81 70481 26 69.20 65.74 75.60 73.34 74.09 71.86 70482 284.27 270.06 310.57 301.25 304.36 295.23 70482 TC 211.90 201.31 231.51 224.56 226.87 220.06 70482 26 72.37 68.75 79.06 76.69 77.49 75.16 70486 132.15 125.54 144.37 140.04 141.48 137.23 70486 TC 89.31 84.84 97.57 94.63 95.61 92.74 70486 26 42.84 40.70 46.81 45.40 45.87 44.49 70487 159.36 151.39 174.10 168.88 170.61 165.50 70487 TC 102.82 97.68 112.33 108.96 110.09 106.79 70487 26 56.54 53.71 61.77 59.92 60.54 58.72 70488 194.07 184.37 212.03 205.67 207.78 201.55 70488 TC 130.49 123.97 142.57 138.29 139.71 135.53 70488 26 63.57 60.39 69.45 67.37 68.06 66.02 C 70490 167.74 159.35 183.25 177.76 179.58 174.20 C 70490 TC 103.48 98.31 113.06 109.66 110.79 107.47 70490 26 64.26 61.05 70.21 68.10 68.80 66.75 70491 223.41 212.24 244.08 236.75 239.20 232.01 70491 TC 153.89 146.20 168.13 163.08 164.77 159.82 70491 26 69.53 66.05 75.96 73.68 74.44 72.21 70492 262.82 249.68 287.13 278.52 281.39 272.95 70492 TC 190.13 180.62 207.71 201.48 203.56 197.46 70492 26 72.70 69.07 79.43 77.05 77.84 75.51 70496 278.29 264.38 304.04 294.92 297.95 289.02 70496 TC 190.49 180.97 208.12 201.87 203.95 197.83 70496 26 87.81 83.42 95.93 93.06 94.01 91.20 70498 277.63 263.75 303.31 294.22 297.25 288.33 70498 TC 189.83 180.34 207.39 201.17 203.24 197.14 70498 26 87.81 83.42 95.93 93.06 94.01 91.20 C 70540 275.05 261.30 300.50 291.48 294.48 285.65 C 70540 TC 207.59 197.21 226.79 219.98 222.26 215.58 70540 26 67.46 64.09 73.70 71.50 72.23 70.07 70542 320.71 304.67 350.37 339.86 343.37 333.06 70542 TC 239.24 227.28 261.37 253.53 256.14 248.46 70542 26 81.46 77.39 89.00 86.33 87.22 84.61 70543 394.18 374.47 430.64 417.73 422.03 409.38 70543 TC 286.69 272.36 313.21 303.82 306.95 297.75 70543 26 107.49 102.12 117.44 113.92 115.09 111.64 C 70544 267.66 254.28 292.42 283.65 286.57 277.98 C 70544 TC 207.26 196.90 226.44 219.64 221.90 215.25 70544 26 60.40 57.38 65.99 64.01 64.66 62.73 C 70545 303.60 288.42 331.68 321.74 325.05 315.30 C 70545 TC 243.53 231.35 266.05 258.07 260.73 252.91 70545 26 60.07 57.07 65.63 63.66 64.32 62.39 C 70546 482.04 457.94 526.63 510.83 516.10 500.62 C 70546 TC 391.78 372.19 428.02 415.17 419.46 406.87 70546 26 90.26 85.75 98.61 95.66 96.65 93.75 C 70547 267.66 254.28 292.42 283.65 286.57 277.98 C 70547 TC 207.26 196.90 226.44 219.64 221.90 215.25

Page 168: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 168Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

70547 26 60.40 57.38 65.99 64.01 64.66 62.73 C 70548 303.57 288.39 331.65 321.70 325.01 315.27 C 70548 TC 243.17 231.01 265.66 257.69 260.35 252.54 70548 26 60.40 57.38 65.99 64.01 64.66 62.73 C 70549 482.04 457.94 526.63 510.83 516.10 500.62 C 70549 TC 391.78 372.19 428.02 415.17 419.46 406.87 70549 26 90.26 85.75 98.61 95.66 96.65 93.75 70551 219.42 208.45 239.72 232.53 234.92 227.88 70551 TC 145.32 138.05 158.76 154.00 155.58 150.91 70551 26 74.10 70.40 80.96 78.53 79.34 76.96 70552 303.42 288.25 331.49 321.54 324.86 315.11 70552 TC 213.88 203.19 233.67 226.65 229.00 222.12 70552 26 89.54 85.06 97.82 94.89 95.86 92.99 70553 358.38 340.46 391.53 379.79 383.70 372.20 70553 TC 243.53 231.35 266.05 258.07 260.73 252.91 70553 26 114.85 109.11 125.48 121.72 122.97 119.28 70554 424.70 403.47 463.99 450.08 454.71 441.07 70554 TC 318.31 302.39 347.75 337.32 340.79 330.57 70554 26 106.38 101.06 116.22 112.73 113.90 110.48 70555 640.40 608.38 699.64 678.65 685.64 665.08 70555 TC 514.93 489.18 562.56 545.68 551.31 534.76 70555 26 125.47 119.20 137.08 132.96 134.34 130.31 70557 26 147.10 139.75 160.71 155.89 157.50 152.78 70558 26 160.50 152.48 175.35 170.10 171.84 166.69 70559 26 162.57 154.44 177.61 172.28 174.05 168.83 71010 21.67 20.59 23.68 22.97 23.21 22.51 71010 TC 12.55 11.92 13.71 13.29 13.43 13.03 71010 26 9.12 8.66 9.96 9.66 9.76 9.46 71015 26.37 25.05 28.81 27.95 28.23 27.38 71015 TC 15.51 14.73 16.94 16.43 16.61 16.10 71015 26 10.86 10.32 11.87 11.51 11.63 11.28 71020 26.73 25.39 29.20 28.32 28.61 27.76 71020 TC 15.84 15.05 17.31 16.79 16.96 16.46 71020 26 10.89 10.35 11.90 11.55 11.66 11.32 71021 32.48 30.86 35.49 34.42 34.78 33.73 71021 TC 18.81 17.87 20.55 19.93 20.14 19.53 71021 26 13.67 12.99 14.94 14.49 14.64 14.20 71022 39.52 37.54 43.17 41.87 42.31 41.03 71022 TC 23.09 21.94 25.23 24.47 24.73 23.98 71022 26 16.43 15.61 17.95 17.41 17.60 17.07 71023 60.18 57.17 65.75 63.77 64.43 62.49 71023 TC 41.21 39.15 45.02 43.68 44.13 42.80 71023 26 18.97 18.02 20.72 20.10 20.31 19.70 71030 39.88 37.89 43.57 42.26 42.70 41.42 71030 TC 24.08 22.88 26.31 25.52 25.78 25.01 71030 26 15.80 15.01 17.26 16.74 16.92 16.41 71034 78.23 74.32 85.47 82.90 83.75 81.25 71034 TC 55.05 52.30 60.15 58.34 58.94 57.18 71034 26 23.19 22.03 25.33 24.58 24.83 24.08

Page 169: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 169Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

71035 30.90 29.36 33.76 32.75 33.09 32.10 71035 TC 21.77 20.68 23.78 23.07 23.31 22.61 71035 26 9.12 8.66 9.96 9.66 9.76 9.46 71100 31.35 29.78 34.25 33.22 33.56 32.56 71100 TC 20.13 19.12 21.99 21.33 21.55 20.91 71100 26 11.22 10.66 12.26 11.89 12.02 11.65 71101 34.82 33.08 38.04 36.90 37.28 36.17 71101 TC 21.11 20.05 23.06 22.37 22.60 21.92 71101 26 13.70 13.02 14.97 14.52 14.67 14.24 71110 35.78 33.99 39.09 37.92 38.31 37.16 71110 TC 22.10 21.00 24.15 23.43 23.67 22.95 71110 26 13.67 12.99 14.94 14.49 14.64 14.20 71111 45.84 43.55 50.08 48.58 49.08 47.61 71111 TC 29.35 27.88 32.06 31.10 31.42 30.48 71111 26 16.48 15.66 18.01 17.47 17.65 17.12 71120 27.99 26.59 30.58 29.66 29.97 29.06 71120 TC 17.82 16.93 19.47 18.88 19.08 18.50 71120 26 10.17 9.66 11.11 10.78 10.89 10.56 71130 33.98 32.28 37.12 36.01 36.37 35.28 71130 TC 22.76 21.62 24.86 24.12 24.37 23.63 71130 26 11.22 10.66 12.26 11.89 12.02 11.65 C 71250 154.76 147.02 169.07 164.00 165.69 160.72 C 71250 TC 103.48 98.31 113.06 109.66 110.79 107.47 71250 26 51.28 48.72 56.03 54.35 54.91 53.26 71260 217.37 206.50 237.48 230.36 232.73 225.75 71260 TC 154.87 147.13 169.20 164.13 165.82 160.85 71260 26 62.50 59.38 68.29 66.24 66.92 64.92 71270 259.98 246.98 284.03 275.51 278.35 270.00 71270 TC 190.79 181.25 208.44 202.18 204.27 198.13 71270 26 69.20 65.74 75.60 73.34 74.09 71.86 71275 285.09 270.84 311.47 302.12 305.23 296.08 71275 TC 193.78 184.09 211.70 205.36 207.47 201.25 71275 26 91.31 86.74 99.75 96.76 97.76 94.83 C 71550 280.31 266.29 306.23 297.05 300.10 291.10 C 71550 TC 207.26 196.90 226.44 219.64 221.90 215.25 71550 26 73.06 69.41 79.82 77.43 78.22 75.88 71551 434.72 412.98 474.93 460.68 465.43 451.47 71551 TC 347.97 330.57 380.16 368.75 372.55 361.38 71551 26 86.76 82.42 94.78 91.94 92.89 90.10 C 71552 505.26 480.00 552.00 535.44 540.96 524.73 C 71552 TC 391.81 372.22 428.05 415.21 419.50 406.90 71552 26 113.44 107.77 123.94 120.22 121.45 117.82 71555 375.96 357.16 410.73 398.42 402.52 390.45 71555 TC 286.36 272.04 312.85 303.46 306.59 297.39 71555 26 89.60 85.12 97.89 94.96 95.93 93.06 72020 20.93 19.88 22.86 22.17 22.40 21.72 72020 TC 13.21 12.55 14.43 14.00 14.15 13.72 72020 26 7.72 7.33 8.43 8.18 8.26 8.02 72040 31.35 29.78 34.25 33.22 33.56 32.56

Page 170: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 170Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

72040 TC 20.13 19.12 21.99 21.33 21.55 20.91 72040 26 11.22 10.66 12.26 11.89 12.02 11.65 72050 43.17 41.01 47.16 45.75 46.22 44.83 72050 TC 27.37 26.00 29.90 29.00 29.30 28.43 72050 26 15.80 15.01 17.26 16.74 16.92 16.41 72052 53.20 50.54 58.12 56.37 56.96 55.25 72052 TC 34.95 33.20 38.18 37.03 37.42 36.29 72052 26 18.25 17.34 19.94 19.34 19.54 18.95 72070 32.33 30.71 35.32 34.26 34.62 33.57 72070 TC 21.11 20.05 23.06 22.37 22.60 21.92 72070 26 11.22 10.66 12.26 11.89 12.02 11.65 72072 32.66 31.03 35.68 34.62 34.97 33.93 72072 TC 21.77 20.68 23.78 23.07 23.31 22.61 72072 26 10.89 10.35 11.90 11.55 11.66 11.32 72074 36.95 35.10 40.37 39.16 39.56 38.38 72074 TC 26.06 24.76 28.47 27.62 27.90 27.07 72074 26 10.89 10.35 11.90 11.55 11.66 11.32 72080 29.04 27.59 31.73 30.77 31.10 30.15 72080 TC 18.15 17.24 19.83 19.23 19.44 18.85 72080 26 10.89 10.35 11.90 11.55 11.66 11.32 72081 37.09 35.24 40.53 39.31 39.72 38.53 72081 TC 23.75 22.56 25.94 25.16 25.43 24.66 72081 26 13.34 12.67 14.57 14.13 14.28 13.85 72082 58.98 56.03 64.43 62.50 63.15 61.25 72082 TC 42.86 40.72 46.83 45.43 45.90 44.52 72082 26 16.13 15.32 17.62 17.09 17.26 16.74 72083 64.04 60.84 69.97 67.86 68.56 66.50 72083 TC 46.48 44.16 50.78 49.27 49.77 48.28 72083 26 17.56 16.68 19.18 18.61 18.80 18.24 72084 76.08 72.28 83.12 80.63 81.45 79.02 72084 TC 55.71 52.92 60.86 59.03 59.64 57.85 72084 26 20.37 19.35 22.25 21.59 21.80 21.15 72100 33.32 31.65 36.40 35.31 35.67 34.60 72100 TC 22.10 21.00 24.15 23.43 23.67 22.95 72100 26 11.22 10.66 12.26 11.89 12.02 11.65 72110 46.46 44.14 50.76 49.24 49.75 48.25 72110 TC 30.67 29.14 33.51 32.51 32.84 31.86 72110 26 15.80 15.01 17.26 16.74 16.92 16.41 72114 58.68 55.75 64.11 62.19 62.84 60.95 72114 TC 42.20 40.09 46.10 44.72 45.18 43.83 72114 26 16.48 15.66 18.01 17.47 17.65 17.12 72120 38.26 36.35 41.80 40.55 40.96 39.73 72120 TC 27.04 25.69 29.54 28.66 28.96 28.08 72120 26 11.22 10.66 12.26 11.89 12.02 11.65 C 72125 157.21 149.35 171.75 166.60 168.31 163.27 C 72125 TC 103.48 98.31 113.06 109.66 110.79 107.47 72125 26 53.73 51.04 58.70 56.94 57.52 55.80 72126 216.32 205.50 236.33 229.24 231.60 224.65 72126 TC 155.20 147.44 169.56 164.47 166.16 161.18

Page 171: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 171Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

72126 26 61.12 58.06 66.77 64.77 65.44 63.47 72127 255.02 242.27 278.61 270.25 273.03 264.85 72127 TC 191.44 181.87 209.15 202.87 204.96 198.81 72127 26 63.57 60.39 69.45 67.37 68.06 66.02 C 72128 153.71 146.02 167.92 162.89 164.57 159.63 C 72128 TC 103.48 98.31 113.06 109.66 110.79 107.47 72128 26 50.23 47.72 54.88 53.23 53.79 52.16 72129 217.31 206.44 237.41 230.29 232.66 225.69 72129 TC 155.86 148.07 170.28 165.17 166.88 161.87 72129 26 61.45 58.38 67.14 65.12 65.79 63.83 72130 256.01 243.21 279.69 271.30 274.10 265.87 72130 TC 192.43 182.81 210.23 203.93 206.02 199.85 72130 26 63.57 60.39 69.45 67.37 68.06 66.02 C 72131 153.71 146.02 167.92 162.89 164.57 159.63 C 72131 TC 103.48 98.31 113.06 109.66 110.79 107.47 72131 26 50.23 47.72 54.88 53.23 53.79 52.16 72132 215.99 205.19 235.97 228.88 231.25 224.31 72132 TC 154.87 147.13 169.20 164.13 165.82 160.85 72132 26 61.12 58.06 66.77 64.77 65.44 63.47 72133 254.69 241.96 278.25 269.91 272.69 264.51 72133 TC 191.11 181.55 208.78 202.52 204.61 198.47 72133 26 63.57 60.39 69.45 67.37 68.06 66.02 72141 213.52 202.84 233.27 226.26 228.60 221.74 72141 TC 139.06 132.11 151.93 147.37 148.89 144.43 72141 26 74.46 70.74 81.35 78.91 79.73 77.34 72142 308.03 292.63 336.52 326.43 329.80 319.90 72142 TC 218.49 207.57 238.71 231.54 233.93 226.91 72142 26 89.54 85.06 97.82 94.89 95.86 92.99 72146 213.85 203.16 233.63 226.63 228.97 222.10 72146 TC 139.39 132.42 152.28 147.72 149.24 144.76 72146 26 74.46 70.74 81.35 78.91 79.73 77.34 72147 306.05 290.75 334.36 324.33 327.68 317.85 72147 TC 216.51 205.68 236.53 229.44 231.81 224.85 72147 26 89.54 85.06 97.82 94.89 95.86 92.99 72148 212.86 202.22 232.55 225.57 227.91 221.06 72148 TC 138.07 131.17 150.85 146.31 147.83 143.39 72148 26 74.79 71.05 81.71 79.26 80.07 77.67 72149 304.76 289.52 332.95 322.95 326.29 316.49 72149 TC 214.86 204.12 234.74 227.70 230.05 223.15 72149 26 89.90 85.41 98.22 95.28 96.26 93.37 72156 360.68 342.65 394.05 382.23 386.17 374.58 72156 TC 245.83 233.54 268.57 260.51 263.20 255.30 72156 26 114.85 109.11 125.48 121.72 122.97 119.28 72157 361.34 343.27 394.76 382.92 386.86 375.26 72157 TC 246.49 234.17 269.30 261.21 263.91 255.99 72157 26 114.85 109.11 125.48 121.72 122.97 119.28 72158 359.37 341.40 392.61 380.83 384.76 373.22 72158 TC 244.19 231.98 266.78 258.77 261.44 253.60 72158 26 115.18 109.42 125.83 122.06 123.31 119.62

Page 172: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 172Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

72159 392.76 373.12 429.09 416.22 420.51 407.89 72159 TC 302.17 287.06 330.12 320.22 323.52 313.81 72159 26 90.59 86.06 98.97 96.00 96.99 94.08 72170 30.21 28.70 33.01 32.02 32.35 31.37 72170 TC 21.44 20.37 23.43 22.72 22.95 22.26 72170 26 8.77 8.33 9.58 9.29 9.38 9.11 72190 35.93 34.13 39.25 38.08 38.47 37.32 72190 TC 25.07 23.82 27.39 26.58 26.84 26.05 72190 26 10.86 10.32 11.87 11.51 11.63 11.28 72191 290.36 275.84 317.22 307.69 310.87 301.54 72191 TC 199.71 189.72 218.18 211.63 213.82 207.40 72191 26 90.65 86.12 99.04 96.07 97.06 94.15 72192 139.48 132.51 152.39 147.81 149.34 144.85 72192 TC 84.70 80.47 92.54 89.77 90.69 87.98 72192 26 54.78 52.04 59.85 58.05 58.65 56.89 72193 213.84 203.15 233.62 226.62 228.95 222.09 72193 TC 155.53 147.75 169.91 164.82 166.52 161.52 72193 26 58.31 55.39 63.70 61.79 62.42 60.56 72194 245.65 233.37 268.38 260.33 263.01 255.12 72194 TC 184.53 175.30 201.60 195.55 197.56 191.64 72194 26 61.12 58.06 66.77 64.77 65.44 63.47 C 72195 280.64 266.61 306.60 297.40 300.47 291.46 C 72195 TC 207.26 196.90 226.44 219.64 221.90 215.25 72195 26 73.39 69.72 80.18 77.77 78.58 76.22 72196 387.28 367.92 423.11 410.41 414.64 402.20 72196 TC 300.19 285.18 327.96 318.11 321.40 311.75 72196 26 87.09 82.74 95.15 92.30 93.25 90.45 72197 477.22 453.36 521.36 505.72 510.93 495.60 72197 TC 363.78 345.59 397.43 385.50 389.48 377.80 72197 26 113.44 107.77 123.94 120.22 121.45 117.82 72198 378.92 359.97 413.97 401.55 405.69 393.52 72198 TC 289.32 274.85 316.08 306.59 309.75 300.46 72198 26 89.60 85.12 97.89 94.96 95.93 93.06 72200 26.92 25.57 29.41 28.52 28.82 27.95 72200 TC 18.15 17.24 19.83 19.23 19.44 18.85 72200 26 8.77 8.33 9.58 9.29 9.38 9.11 72202 31.26 29.70 34.16 33.13 33.48 32.46 72202 TC 21.77 20.68 23.78 23.07 23.31 22.61 72202 26 9.48 9.01 10.36 10.05 10.15 9.86 72220 26.59 25.26 29.05 28.18 28.46 27.61 72220 TC 17.82 16.93 19.47 18.88 19.08 18.50 72220 26 8.77 8.33 9.58 9.29 9.38 9.11 72240 94.44 89.72 103.18 100.08 101.12 98.08 72240 TC 49.12 46.66 53.66 52.05 52.59 51.00 72240 26 45.32 43.05 49.51 48.02 48.52 47.06 72255 94.80 90.06 103.57 100.46 101.50 98.45 72255 TC 48.13 45.72 52.58 51.00 51.53 49.98 72255 26 46.67 44.34 50.99 49.46 49.97 48.47 72265 88.61 84.18 96.81 93.90 94.88 92.02

Page 173: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 173Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

72265 TC 47.14 44.78 51.50 49.96 50.46 48.96 72265 26 41.46 39.39 45.30 43.94 44.39 43.07 72270 122.78 116.64 134.14 130.11 131.46 127.51 72270 TC 55.71 52.92 60.86 59.03 59.64 57.85 72270 26 67.07 63.72 73.28 71.08 71.82 69.66 72275 109.79 104.30 119.95 116.35 117.54 114.02 72275 TC 70.86 67.32 77.42 75.10 75.87 73.59 72275 26 38.92 36.97 42.52 41.24 41.66 40.41 72285 108.74 103.30 118.80 115.23 116.41 112.93 72285 TC 48.46 46.04 52.95 51.36 51.89 50.34 72285 26 60.28 57.27 65.86 63.88 64.54 62.61 72295 93.58 88.90 102.24 99.16 100.19 97.19 72295 TC 50.44 47.92 55.11 53.45 54.00 52.38 72295 26 43.14 40.98 47.13 45.71 46.18 44.80 73000 26.23 24.92 28.66 27.80 28.08 27.24 73000 TC 17.82 16.93 19.47 18.88 19.08 18.50 73000 26 8.41 7.99 9.19 8.91 9.00 8.74 73010 28.56 27.13 31.20 30.27 30.58 29.66 73010 TC 19.47 18.50 21.28 20.64 20.85 20.23 73010 26 9.10 8.65 9.95 9.65 9.75 9.45 73020 21.91 20.81 23.93 23.22 23.45 22.76 73020 TC 13.87 13.18 15.16 14.70 14.86 14.40 73020 26 8.05 7.65 8.80 8.53 8.63 8.36 73030 27.60 26.22 30.15 29.24 29.56 28.66 73030 TC 18.15 17.24 19.83 19.23 19.44 18.85 73030 26 9.45 8.98 10.33 10.02 10.12 9.82 73040 94.61 89.88 103.36 100.26 101.29 98.26 73040 TC 67.24 63.88 73.46 71.25 71.99 69.83 73040 26 27.37 26.00 29.90 29.00 29.30 28.43 73050 33.59 31.91 36.70 35.59 35.96 34.88 73050 TC 23.09 21.94 25.23 24.47 24.73 23.98 73050 26 10.50 9.98 11.48 11.13 11.25 10.91 73060 27.54 26.16 30.08 29.19 29.49 28.60 73060 TC 19.14 18.18 20.91 20.27 20.49 19.87 73060 26 8.41 7.99 9.19 8.91 9.00 8.74 73070 25.87 24.58 28.27 27.42 27.70 26.86 73070 TC 17.82 16.93 19.47 18.88 19.08 18.50 73070 26 8.05 7.65 8.80 8.53 8.63 8.36 73080 29.55 28.07 32.28 31.31 31.64 30.69 73080 TC 20.78 19.74 22.70 22.02 22.25 21.59 73080 26 8.77 8.33 9.58 9.29 9.38 9.11 73085 90.69 86.16 99.08 96.12 97.11 94.20 73085 TC 61.97 58.87 67.70 65.67 66.34 64.35 73085 26 28.72 27.28 31.37 30.43 30.74 29.82 73090 24.58 23.35 26.85 26.05 26.31 25.53 73090 TC 16.17 15.36 17.66 17.14 17.31 16.79 73090 26 8.41 7.99 9.19 8.91 9.00 8.74 73092 26.23 24.92 28.66 27.80 28.08 27.24 73092 TC 18.15 17.24 19.83 19.23 19.44 18.85

Page 174: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 174Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

73092 26 8.08 7.68 8.83 8.57 8.66 8.40 73100 27.54 26.16 30.08 29.19 29.49 28.60 73100 TC 19.14 18.18 20.91 20.27 20.49 19.87 73100 26 8.41 7.99 9.19 8.91 9.00 8.74 73110 33.50 31.83 36.60 35.51 35.87 34.80 73110 TC 24.74 23.50 27.03 26.22 26.48 25.69 73110 26 8.77 8.33 9.58 9.29 9.38 9.11 73115 100.57 95.54 109.87 106.57 107.67 104.44 73115 TC 72.18 68.57 78.86 76.49 77.28 74.96 73115 26 28.39 26.97 31.02 30.08 30.39 29.49 73120 24.91 23.66 27.21 26.39 26.67 25.86 73120 TC 16.50 15.68 18.03 17.49 17.68 17.15 73120 26 8.41 7.99 9.19 8.91 9.00 8.74 73130 29.22 27.76 31.92 30.97 31.28 30.35 73130 TC 20.46 19.44 22.36 21.69 21.91 21.25 73130 26 8.77 8.33 9.58 9.29 9.38 9.11 73140 29.76 28.27 32.51 31.53 31.86 30.90 73140 TC 22.76 21.62 24.86 24.12 24.37 23.63 73140 26 7.00 6.65 7.65 7.42 7.50 7.27 C 73200 153.71 146.02 167.92 162.89 164.57 159.63 C 73200 TC 103.48 98.31 113.06 109.66 110.79 107.47 73200 26 50.23 47.72 54.88 53.23 53.79 52.16 73201 210.55 200.02 230.02 223.12 225.42 218.66 73201 TC 152.24 144.63 166.32 161.33 163.00 158.10 73201 26 58.31 55.39 63.70 61.79 62.42 60.56 73202 261.46 248.39 285.65 277.08 279.93 271.54 73202 TC 200.34 190.32 218.87 212.30 214.49 208.06 73202 26 61.12 58.06 66.77 64.77 65.44 63.47 73206 311.08 295.53 339.86 329.66 333.06 323.07 73206 TC 221.12 210.06 241.57 234.32 236.74 229.63 73206 26 89.96 85.46 98.28 95.34 96.31 93.43 C 73218 275.74 261.95 301.24 292.20 295.22 286.36 C 73218 TC 207.62 197.24 226.83 220.02 222.30 215.61 73218 26 68.12 64.71 74.42 72.19 72.93 70.74 73219 378.69 359.76 413.72 401.32 405.44 393.29 73219 TC 297.23 282.37 324.73 314.99 318.23 308.68 73219 26 81.46 77.39 89.00 86.33 87.22 84.61 73220 471.60 448.02 515.22 499.77 504.92 489.77 73220 TC 363.78 345.59 397.43 385.50 389.48 377.80 73220 26 107.82 102.43 117.79 114.26 115.44 111.98 73221 225.00 213.75 245.81 238.44 240.90 233.67 73221 TC 156.55 148.72 171.03 165.90 167.61 162.58 73221 26 68.45 65.03 74.78 72.54 73.29 71.09 73222 356.62 338.79 389.61 377.92 381.81 370.37 73222 TC 275.16 261.40 300.61 291.59 294.60 285.76 73222 26 81.46 77.39 89.00 86.33 87.22 84.61 73223 443.93 421.73 484.99 470.44 475.30 461.04 73223 TC 335.78 318.99 366.84 355.83 359.50 348.71 73223 26 108.15 102.74 118.15 114.61 115.79 112.32

Page 175: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 175Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

73225 385.63 366.35 421.30 408.66 412.87 400.49 73225 TC 299.54 284.56 327.24 317.42 320.70 311.08 73225 26 86.10 81.80 94.07 91.25 92.18 89.42 73501 28.26 26.85 30.88 29.95 30.26 29.35 73501 TC 18.81 17.87 20.55 19.93 20.14 19.53 73501 26 9.45 8.98 10.33 10.02 10.12 9.82 73502 39.25 37.29 42.88 41.60 42.02 40.77 73502 TC 28.03 26.63 30.62 29.70 30.02 29.11 73502 26 11.22 10.66 12.26 11.89 12.02 11.65 73503 48.98 46.53 53.51 51.90 52.44 50.86 73503 TC 34.62 32.89 37.82 36.69 37.06 35.95 73503 26 14.36 13.64 15.69 15.21 15.38 14.92 73521 37.60 35.72 41.08 39.85 40.26 39.05 73521 TC 26.06 24.76 28.47 27.62 27.90 27.07 73521 26 11.55 10.97 12.62 12.24 12.36 11.99 73522 46.41 44.09 50.70 49.19 49.69 48.20 73522 TC 31.33 29.76 34.22 33.20 33.53 32.53 73522 26 15.08 14.33 16.48 15.99 16.15 15.66 73523 53.71 51.02 58.67 56.91 57.50 55.78 73523 TC 37.59 35.71 41.07 39.84 40.25 39.04 73523 26 16.13 15.32 17.62 17.09 17.26 16.74 73525 96.29 91.48 105.20 102.05 103.10 100.02 73525 TC 67.57 64.19 73.82 71.60 72.35 70.16 73525 26 28.72 27.28 31.37 30.43 30.74 29.82 73551 26.56 25.23 29.01 28.14 28.44 27.58 73551 TC 18.15 17.24 19.83 19.23 19.44 18.85 73551 26 8.41 7.99 9.19 8.91 9.00 8.74 73552 30.90 29.36 33.76 32.75 33.09 32.10 73552 TC 21.44 20.37 23.43 22.72 22.95 22.26 73552 26 9.45 8.98 10.33 10.02 10.12 9.82 73560 29.19 27.73 31.89 30.94 31.26 30.31 73560 TC 20.78 19.74 22.70 22.02 22.25 21.59 73560 26 8.41 7.99 9.19 8.91 9.00 8.74 73562 33.86 32.17 37.00 35.88 36.26 35.17 73562 TC 24.41 23.19 26.67 25.86 26.14 25.35 73562 26 9.45 8.98 10.33 10.02 10.12 9.82 73564 37.60 35.72 41.08 39.85 40.26 39.05 73564 TC 26.39 25.07 28.83 27.97 28.26 27.40 73564 26 11.22 10.66 12.26 11.89 12.02 11.65 73565 33.80 32.11 36.93 35.82 36.19 35.11 73565 TC 25.07 23.82 27.39 26.58 26.84 26.05 73565 26 8.74 8.30 9.55 9.26 9.35 9.07 73580 107.49 102.12 117.44 113.92 115.09 111.64 73580 TC 79.43 75.46 86.78 84.18 85.04 82.50 73580 26 28.06 26.66 30.66 29.74 30.05 29.14 73590 27.22 25.86 29.74 28.84 29.14 28.27 73590 TC 18.81 17.87 20.55 19.93 20.14 19.53 73590 26 8.41 7.99 9.19 8.91 9.00 8.74 73592 26.23 24.92 28.66 27.80 28.08 27.24

Page 176: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 176Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

73592 TC 18.15 17.24 19.83 19.23 19.44 18.85 73592 26 8.08 7.68 8.83 8.57 8.66 8.40 73600 28.20 26.79 30.81 29.89 30.19 29.29 73600 TC 19.80 18.81 21.63 20.99 21.19 20.57 73600 26 8.41 7.99 9.19 8.91 9.00 8.74 73610 29.88 28.39 32.65 31.67 31.99 31.04 73610 TC 21.11 20.05 23.06 22.37 22.60 21.92 73610 26 8.77 8.33 9.58 9.29 9.38 9.11 73615 99.55 94.57 108.76 105.49 106.58 103.39 73615 TC 71.19 67.63 77.77 75.44 76.22 73.93 73615 26 28.36 26.94 30.98 30.05 30.36 29.45 73620 24.58 23.35 26.85 26.05 26.31 25.53 73620 TC 16.83 15.99 18.39 17.84 18.02 17.48 73620 26 7.75 7.36 8.46 8.21 8.29 8.05 73630 27.57 26.19 30.12 29.21 29.52 28.62 73630 TC 19.14 18.18 20.91 20.27 20.49 19.87 73630 26 8.44 8.02 9.22 8.95 9.04 8.76 73650 25.57 24.29 27.93 27.09 27.37 26.55 73650 TC 17.49 16.62 19.11 18.54 18.73 18.17 73650 26 8.08 7.68 8.83 8.57 8.66 8.40 73660 26.47 25.15 28.92 28.06 28.35 27.50 73660 TC 19.80 18.81 21.63 20.99 21.19 20.57 73660 26 6.67 6.34 7.29 7.07 7.14 6.93 C 73700 153.71 146.02 167.92 162.89 164.57 159.63 C 73700 TC 103.48 98.31 113.06 109.66 110.79 107.47 73700 26 50.23 47.72 54.88 53.23 53.79 52.16 73701 213.84 203.15 233.62 226.62 228.95 222.09 73701 TC 155.53 147.75 169.91 164.82 166.52 161.52 73701 26 58.31 55.39 63.70 61.79 62.42 60.56 73702 258.49 245.57 282.41 273.93 276.76 268.46 73702 TC 197.37 187.50 215.63 209.16 211.31 204.98 73702 26 61.12 58.06 66.77 64.77 65.44 63.47 73706 336.77 319.93 367.92 356.88 360.56 349.74 73706 TC 241.91 229.81 264.28 256.36 258.99 251.23 73706 26 94.86 90.12 103.64 100.53 101.57 98.52 C 73718 275.41 261.64 300.89 291.86 294.87 286.02 C 73718 TC 207.62 197.24 226.83 220.02 222.30 215.61 73718 26 67.79 64.40 74.06 71.84 72.58 70.40 C 73719 324.99 308.74 355.05 344.40 347.96 337.51 C 73719 TC 243.53 231.35 266.05 258.07 260.73 252.91 73719 26 81.46 77.39 89.00 86.33 87.22 84.61 73720 473.91 450.21 517.74 502.21 507.39 492.17 73720 TC 366.09 347.79 399.96 387.96 391.95 380.20 73720 26 107.82 102.43 117.79 114.26 115.44 111.98 73721 224.67 213.44 245.46 238.10 240.55 233.34 73721 TC 156.55 148.72 171.03 165.90 167.61 162.58 73721 26 68.12 64.71 74.42 72.19 72.93 70.74 73722 359.58 341.60 392.84 381.05 384.99 373.43 73722 TC 278.12 264.21 303.84 294.72 297.77 288.82

Page 177: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 177Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

73722 26 81.46 77.39 89.00 86.33 87.22 84.61 73723 444.25 422.04 485.35 470.79 475.64 461.37 73723 TC 336.44 319.62 367.56 356.53 360.21 349.40 73723 26 107.82 102.43 117.79 114.26 115.44 111.98 73725 378.98 360.03 414.03 401.61 405.75 393.59 73725 TC 288.66 274.23 315.36 305.90 309.06 299.78 73725 26 90.32 85.80 98.67 95.71 96.69 93.81 74000 22.66 21.53 24.76 24.01 24.27 23.53 74000 TC 13.54 12.86 14.79 14.34 14.49 14.05 74000 26 9.12 8.66 9.96 9.66 9.76 9.46 74010 33.35 31.68 36.43 35.34 35.71 34.64 74010 TC 21.77 20.68 23.78 23.07 23.31 22.61 74010 26 11.58 11.00 12.65 12.27 12.40 12.03 74020 35.80 34.01 39.11 37.94 38.33 37.18 74020 TC 22.10 21.00 24.15 23.43 23.67 22.95 74020 26 13.70 13.02 14.97 14.52 14.67 14.24 74022 42.54 40.41 46.47 45.08 45.54 44.18 74022 TC 26.39 25.07 28.83 27.97 28.26 27.40 74022 26 16.15 15.34 17.64 17.11 17.28 16.77 74150 143.10 135.95 156.34 151.65 153.21 148.61 74150 TC 83.38 79.21 91.09 88.35 89.27 86.58 74150 26 59.71 56.72 65.23 63.27 63.93 62.01 74160 218.78 207.84 239.02 231.84 234.23 227.21 74160 TC 154.87 147.13 169.20 164.13 165.82 160.85 74160 26 63.90 60.71 69.82 67.72 68.43 66.37 74170 248.51 236.08 271.49 263.35 266.06 258.08 74170 TC 178.27 169.36 194.76 188.92 190.87 185.14 74170 26 70.24 66.73 76.74 74.44 75.21 72.96 C 74174 353.50 335.83 386.20 374.62 378.48 367.13 C 74174 TC 243.53 231.35 266.05 258.07 260.73 252.91 74174 26 109.97 104.47 120.14 116.54 117.74 114.21 74175 291.35 276.78 318.30 308.75 311.93 302.58 74175 TC 200.70 190.67 219.27 212.69 214.89 208.44 74175 26 90.65 86.12 99.04 96.07 97.06 94.15 74176 192.57 182.94 210.38 204.07 206.17 199.99 74176 TC 105.13 99.87 114.85 111.40 112.55 109.17 74176 26 87.45 83.08 95.54 92.68 93.63 90.83 74177 295.27 280.51 322.59 312.90 316.14 306.65 74177 TC 203.96 193.76 222.82 216.14 218.36 211.82 74177 26 91.31 86.74 99.75 96.76 97.76 94.83 74178 335.09 318.34 366.09 355.11 358.77 348.00 74178 TC 234.30 222.59 255.98 248.30 250.86 243.33 74178 26 100.79 95.75 110.11 106.81 107.92 104.67 C 74181 280.67 266.64 306.64 297.44 300.51 291.49 C 74181 TC 207.62 197.24 226.83 220.02 222.30 215.61 74181 26 73.06 69.41 79.82 77.43 78.22 75.88 74182 428.13 406.72 467.73 453.70 458.38 444.62 74182 TC 341.05 324.00 372.60 361.42 365.15 354.19 74182 26 87.09 82.74 95.15 92.30 93.25 90.45

Page 178: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 178Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

74183 478.21 454.30 522.45 506.77 511.99 496.64 74183 TC 364.77 346.53 398.51 386.55 390.54 378.82 74183 26 113.44 107.77 123.94 120.22 121.45 117.82 74185 380.57 361.54 415.77 403.29 407.46 395.23 74185 TC 290.97 276.42 317.88 308.35 311.52 302.19 74185 26 89.60 85.12 97.89 94.96 95.93 93.06 74190 203.75 193.56 222.59 215.91 218.14 211.60 74190 TC 180.18 171.17 196.85 190.93 192.91 187.12 74190 26 23.57 22.39 25.75 24.98 25.23 24.48 74210 73.30 69.64 80.09 77.68 78.49 76.13 74210 TC 55.05 52.30 60.15 58.34 58.94 57.18 74210 26 18.25 17.34 19.94 19.34 19.54 18.95 74220 83.51 79.33 91.23 88.49 89.40 86.72 74220 TC 60.32 57.30 65.90 63.92 64.57 62.64 74220 26 23.19 22.03 25.33 24.58 24.83 24.08 74230 120.61 114.58 131.77 127.81 129.13 125.26 74230 TC 93.92 89.22 102.60 99.52 100.56 97.53 74230 26 26.69 25.36 29.16 28.29 28.58 27.73 74235 128.48 122.06 140.37 136.16 137.56 133.43 74235 TC 66.82 63.48 73.00 70.82 71.54 69.40 74235 26 61.66 58.58 67.37 65.34 66.02 64.03 74240 106.94 101.59 116.83 113.32 114.49 111.06 74240 TC 72.18 68.57 78.86 76.49 77.28 74.96 74240 26 34.76 33.02 37.97 36.83 37.21 36.10 74241 111.56 105.98 121.88 118.22 119.44 115.85 74241 TC 76.79 72.95 83.89 81.37 82.21 79.74 74241 26 34.76 33.02 37.97 36.83 37.21 36.10 74245 161.98 153.88 176.96 171.65 173.42 168.21 74245 TC 116.33 110.51 127.09 123.27 124.55 120.81 74245 26 45.65 43.37 49.88 48.38 48.88 47.41 74246 120.12 114.11 131.23 127.29 128.60 124.75 74246 TC 85.36 81.09 93.25 90.46 91.39 88.65 74246 26 34.76 33.02 37.97 36.83 37.21 36.10 74247 133.63 126.95 145.99 141.61 143.07 138.78 74247 TC 98.87 93.93 108.02 104.78 105.86 102.68 74247 26 34.76 33.02 37.97 36.83 37.21 36.10 74249 173.51 164.83 189.55 183.87 185.76 180.19 74249 TC 127.86 121.47 139.69 135.50 136.90 132.79 74249 26 45.65 43.37 49.88 48.38 48.88 47.41 74250 98.03 93.13 107.10 103.89 104.96 101.81 74250 TC 74.16 70.45 81.02 78.59 79.40 77.02 74250 26 23.87 22.68 26.08 25.30 25.56 24.79 C 74251 138.57 131.64 151.39 146.84 148.36 143.91 C 74251 TC 103.81 98.62 113.41 110.01 111.15 107.81 74251 26 34.76 33.02 37.97 36.83 37.21 36.10 C 74260 129.09 122.64 141.04 136.80 138.22 134.07 C 74260 TC 103.81 98.62 113.41 110.01 111.15 107.81 74260 26 25.28 24.02 27.62 26.80 27.07 26.25 C 74261 224.28 213.07 245.03 237.68 240.13 232.93

Page 179: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 179Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

C 74261 TC 103.48 98.31 113.06 109.66 110.79 107.47 74261 26 120.80 114.76 131.97 128.02 129.33 125.45 C 74262 368.88 350.44 403.01 390.92 394.94 383.10 C 74262 TC 243.17 231.01 265.66 257.69 260.35 252.54 74262 26 125.71 119.42 137.33 133.22 134.58 130.55 C 74270 138.24 131.33 151.03 146.50 148.01 143.57 C 74270 TC 103.48 98.31 113.06 109.66 110.79 107.47 74270 26 34.76 33.02 37.97 36.83 37.21 36.10 C 74280 153.35 145.68 167.53 162.51 164.19 159.25 C 74280 TC 103.48 98.31 113.06 109.66 110.79 107.47 74280 26 49.87 47.38 54.49 52.85 53.39 51.80 74283 200.70 190.67 219.27 212.69 214.89 208.44 74283 TC 97.55 92.67 106.57 103.37 104.44 101.30 74283 26 103.15 97.99 112.69 109.31 110.43 107.12 74290 66.26 62.95 72.39 70.22 70.94 68.82 74290 TC 50.11 47.60 54.74 53.10 53.65 52.04 74290 26 16.15 15.34 17.64 17.11 17.28 16.77 74300 121.45 115.38 132.69 128.71 130.03 126.13 74300 TC 103.17 98.01 112.71 109.33 110.46 107.15 74300 26 18.28 17.37 19.98 19.38 19.57 18.99 74301 113.73 108.04 124.25 120.52 121.76 118.11 74301 TC 103.17 98.01 112.71 109.33 110.46 107.15 74301 26 10.56 10.03 11.53 11.19 11.30 10.97 74328 26 35.78 33.99 39.09 37.92 38.31 37.16 74329 26 35.78 33.99 39.09 37.92 38.31 37.16 74330 26 45.62 43.34 49.84 48.35 48.84 47.38 74340 105.60 100.32 115.37 111.91 113.06 109.66 74340 TC 78.56 74.63 85.82 83.25 84.11 81.58 74340 26 27.04 25.69 29.54 28.66 28.96 28.08 74355 141.62 134.54 154.72 150.08 151.63 147.07 74355 TC 103.36 98.19 112.92 109.53 110.66 107.34 74355 26 38.26 36.35 41.80 40.55 40.96 39.73 74360 94.99 90.24 103.78 100.66 101.71 98.65 74360 TC 66.90 63.56 73.09 70.90 71.63 69.48 74360 26 28.09 26.69 30.69 29.77 30.08 29.18 74363 264.68 251.45 289.17 280.50 283.38 274.88 74363 TC 221.75 210.66 242.26 234.99 237.42 230.29 74363 26 42.93 40.78 46.90 45.49 45.95 44.59 74400 104.02 98.82 113.64 110.24 111.37 108.03 74400 TC 79.43 75.46 86.78 84.18 85.04 82.50 74400 26 24.59 23.36 26.86 26.06 26.32 25.54 74410 102.70 97.57 112.21 108.84 109.96 106.66 74410 TC 78.11 74.20 85.33 82.77 83.63 81.11 74410 26 24.59 23.36 26.86 26.06 26.32 25.54 74415 128.40 121.98 140.28 136.07 137.47 133.34 74415 TC 103.81 98.62 113.41 110.01 111.15 107.81 74415 26 24.59 23.36 26.86 26.06 26.32 25.54 74420 164.71 156.47 179.94 174.55 176.34 171.05 74420 TC 147.15 139.79 160.76 155.94 157.54 152.82

Page 180: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 180Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

74420 26 17.56 16.68 19.18 18.61 18.80 18.24 74425 164.74 156.50 179.98 174.58 176.38 171.09 74425 TC 147.15 139.79 160.76 155.94 157.54 152.82 74425 26 17.59 16.71 19.22 18.64 18.84 18.27 74430 36.28 34.47 39.64 38.46 38.85 37.69 74430 TC 20.13 19.12 21.99 21.33 21.55 20.91 74430 26 16.15 15.34 17.64 17.11 17.28 16.77 74440 76.65 72.82 83.74 81.24 82.06 79.61 74440 TC 58.01 55.11 63.38 61.48 62.11 60.25 74440 26 18.64 17.71 20.37 19.76 19.96 19.37 C 74445 157.69 149.81 172.28 167.12 168.83 163.77 C 74445 TC 103.48 98.31 113.06 109.66 110.79 107.47 74445 26 54.21 51.50 59.23 57.45 58.04 56.30 74450 163.71 155.52 178.85 173.48 175.27 170.00 74450 TC 147.20 139.84 160.82 155.99 157.60 152.87 74450 26 16.51 15.68 18.03 17.49 17.68 17.15 74455 77.16 73.30 84.30 81.77 82.60 80.13 74455 TC 60.65 57.62 66.26 64.27 64.94 62.99 74455 26 16.51 15.68 18.03 17.49 17.68 17.15 74470 129.66 123.18 141.66 137.40 138.83 134.65 74470 TC 103.27 98.11 112.83 109.45 110.57 107.26 74470 26 26.39 25.07 28.83 27.97 28.26 27.40 74485 87.01 82.66 95.06 92.21 93.16 90.37 74485 TC 60.98 57.93 66.62 64.62 65.29 63.33 74485 26 26.03 24.73 28.44 27.59 27.88 27.04 74710 35.35 33.58 38.62 37.46 37.85 36.71 74710 TC 18.15 17.24 19.83 19.23 19.44 18.85 74710 26 17.20 16.34 18.79 18.23 18.41 17.86 C 74712 254.44 241.72 277.98 269.64 272.42 264.25 C 74712 TC 103.48 98.31 113.06 109.66 110.79 107.47 74712 26 150.96 143.41 164.92 159.98 161.62 156.78 74713 222.55 211.42 243.13 235.84 238.27 231.13 74713 TC 129.51 123.03 141.48 137.24 138.66 134.49 74713 26 93.04 88.39 101.65 98.60 99.61 96.63 74740 70.72 67.18 77.26 74.93 75.72 73.44 74740 TC 51.75 49.16 56.53 54.84 55.41 53.75 74740 26 18.97 18.02 20.72 20.10 20.31 19.70 74742 210.73 200.19 230.22 223.31 225.62 218.85 74742 TC 180.18 171.17 196.85 190.93 192.91 187.12 74742 26 30.55 29.02 33.37 32.37 32.71 31.73 74775 178.41 169.49 194.91 189.07 191.02 185.29 74775 TC 147.15 139.79 160.76 155.94 157.54 152.82 74775 26 31.26 29.70 34.16 33.13 33.48 32.46 75557 305.09 289.84 333.32 323.31 326.65 316.85 75557 TC 189.14 179.68 206.63 200.43 202.50 196.42 75557 26 115.96 110.16 126.68 122.89 124.15 120.43 C 75559 350.68 333.15 383.12 371.63 375.46 364.21 C 75559 TC 207.59 197.21 226.79 219.98 222.26 215.58 75559 26 143.09 135.94 156.33 151.64 153.20 148.60

Page 181: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 181Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

75561 403.41 383.24 440.73 427.50 431.92 418.96 75561 TC 275.16 261.40 300.61 291.59 294.60 285.76 75561 26 128.25 121.84 140.12 135.91 137.31 133.19 75563 480.36 456.34 524.79 509.05 514.29 498.87 75563 TC 333.47 316.80 364.32 353.40 357.03 346.32 75563 26 146.89 139.55 160.48 155.66 157.27 152.55 75565 51.83 49.24 56.63 54.92 55.50 53.82 75565 TC 39.53 37.55 43.18 41.88 42.32 41.04 75565 26 12.30 11.69 13.44 13.04 13.18 12.78 C 75571 83.86 79.67 91.62 88.87 89.79 87.09 C 75571 TC 55.05 52.30 60.15 58.34 58.94 57.18 75571 26 28.81 27.37 31.48 30.53 30.84 29.92 75572 269.37 255.90 294.29 285.45 288.40 279.75 75572 TC 182.58 173.45 199.47 193.49 195.48 189.62 75572 26 86.79 82.45 94.82 91.98 92.92 90.14 C 75573 369.69 351.21 403.89 391.77 395.82 383.94 C 75573 TC 243.20 231.04 265.70 257.73 260.38 252.57 75573 26 126.49 120.17 138.20 134.04 135.44 131.36 C 75574 362.33 344.21 395.84 383.96 387.93 376.28 C 75574 TC 243.56 231.38 266.09 258.11 260.76 252.94 75574 26 118.77 112.83 129.75 125.87 127.16 123.35 75600 185.45 176.18 202.61 196.52 198.56 192.59 75600 TC 161.13 153.07 176.03 170.75 172.51 167.34 75600 26 24.32 23.10 26.57 25.77 26.04 25.25 75605 132.16 125.55 144.38 140.05 141.50 137.24 75605 TC 76.13 72.32 83.17 80.67 81.50 79.06 75605 26 56.03 53.23 61.21 59.37 60.00 58.19 75625 131.59 125.01 143.76 139.45 140.89 136.65 75625 TC 75.48 71.71 82.47 79.99 80.82 78.40 75625 26 56.12 53.31 61.31 59.47 60.08 58.28 75630 164.26 156.05 179.46 174.08 175.87 170.59 75630 TC 76.13 72.32 83.17 80.67 81.50 79.06 75630 26 88.13 83.72 96.28 93.39 94.36 91.53 C 75635 362.71 344.57 396.26 384.36 388.33 376.68 C 75635 TC 243.23 231.07 265.73 257.76 260.42 252.61 75635 26 119.49 113.52 130.55 126.63 127.94 124.10 75658 161.17 153.11 176.08 170.80 172.56 167.38 75658 TC 96.59 91.76 105.52 102.36 103.41 100.31 75658 26 64.58 61.35 70.55 68.44 69.14 67.07 75705 237.67 225.79 259.66 251.87 254.46 246.84 75705 TC 122.62 116.49 133.96 129.95 131.28 127.35 75705 26 115.05 109.30 125.70 121.92 123.18 119.49 75710 154.68 146.95 168.99 163.92 165.61 160.64 75710 TC 98.24 93.33 107.33 104.11 105.18 102.03 75710 26 56.45 53.63 61.67 59.82 60.44 58.63 75716 177.94 169.04 194.40 188.57 190.51 184.79 75716 TC 113.75 108.06 124.27 120.54 121.79 118.13 75716 26 64.19 60.98 70.13 68.02 68.72 66.67 75726 142.65 135.52 155.85 151.17 152.73 148.14

Page 182: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 182Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

75726 TC 87.01 82.66 95.06 92.21 93.16 90.37 75726 26 55.64 52.86 60.79 58.96 59.57 57.78 75731 163.40 155.23 178.51 173.16 174.95 169.69 75731 TC 106.14 100.83 115.95 112.48 113.63 110.23 75731 26 57.26 54.40 62.56 60.69 61.31 59.47 75733 177.08 168.23 193.46 187.66 189.60 183.91 75733 TC 113.42 107.75 123.91 120.20 121.44 117.79 75733 26 63.66 60.48 69.55 67.47 68.16 66.13 75736 152.62 144.99 166.74 161.74 163.40 158.50 75736 TC 97.25 92.39 106.25 103.06 104.12 101.00 75736 26 55.37 52.60 60.49 58.67 59.28 57.50 75741 144.47 137.25 157.84 153.10 154.69 150.04 75741 TC 80.75 76.71 88.22 85.57 86.46 83.86 75741 26 63.72 60.53 69.61 67.52 68.22 66.17 75743 162.39 154.27 177.41 172.09 173.86 168.65 75743 TC 81.73 77.64 89.29 86.61 87.50 84.87 75743 26 80.65 76.62 88.11 85.47 86.35 83.75 75746 146.24 138.93 159.77 154.97 156.57 151.87 75746 TC 89.97 85.47 98.29 95.35 96.32 93.44 75746 26 56.27 53.46 61.48 59.64 60.25 58.44 75756 161.99 153.89 176.97 171.66 173.43 168.22 75756 TC 104.83 99.59 114.53 111.09 112.24 108.87 75756 26 57.16 54.30 62.45 60.57 61.19 59.36 75774 81.56 77.48 89.10 86.43 87.32 84.71 75774 TC 63.94 60.74 69.85 67.76 68.46 66.40 75774 26 17.62 16.74 19.25 18.68 18.87 18.31 75801 224.84 213.60 245.64 238.27 240.73 233.51 75801 TC 180.12 171.11 196.78 190.88 192.84 187.06 75801 26 44.72 42.48 48.85 47.39 47.87 46.45 75803 240.79 228.75 263.06 255.17 257.81 250.07 75803 TC 180.12 171.11 196.78 190.88 192.84 187.06 75803 26 60.67 57.64 66.29 64.30 64.96 63.01 75805 220.87 209.83 241.30 234.07 236.47 229.39 75805 TC 180.12 171.11 196.78 190.88 192.84 187.06 75805 26 40.75 38.71 44.52 43.18 43.63 42.32 75807 239.12 227.16 261.23 253.40 256.01 248.33 75807 TC 180.12 171.11 196.78 190.88 192.84 187.06 75807 26 59.00 56.05 64.46 62.53 63.17 61.27 75809 93.42 88.75 102.06 99.00 100.03 97.03 75809 TC 69.54 66.06 75.97 73.69 74.45 72.22 75809 26 23.87 22.68 26.08 25.30 25.56 24.79 75810 636.17 604.36 695.01 674.16 681.11 660.69 75810 TC 578.61 549.68 632.13 613.17 619.49 600.91 75810 26 57.56 54.68 62.88 61.00 61.63 59.78 75820 109.67 104.19 119.82 116.22 117.43 113.90 75820 TC 74.82 71.08 81.74 79.29 80.11 77.71 75820 26 34.85 33.11 38.08 36.94 37.32 36.20 75822 130.91 124.36 143.01 138.72 140.15 135.95 75822 TC 78.44 74.52 85.70 83.12 83.98 81.45

Page 183: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 183Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

75822 26 52.47 49.85 57.33 55.60 56.18 54.49 75825 129.94 123.44 141.96 137.70 139.12 134.95 75825 TC 73.50 69.83 80.30 77.90 78.69 76.35 75825 26 56.45 53.63 61.67 59.82 60.44 58.63 75827 132.61 125.98 144.88 140.53 141.98 137.72 75827 TC 76.13 72.32 83.17 80.67 81.50 79.06 75827 26 56.48 53.66 61.71 59.86 60.48 58.66 75831 134.14 127.43 146.54 142.15 143.61 139.31 75831 TC 78.77 74.83 86.05 83.48 84.33 81.81 75831 26 55.37 52.60 60.49 58.67 59.28 57.50 75833 158.49 150.57 173.16 167.96 169.69 164.60 75833 TC 85.72 81.43 93.64 90.84 91.77 89.02 75833 26 72.78 69.14 79.51 77.13 77.92 75.59 75840 142.59 135.46 155.78 151.11 152.66 148.09 75840 TC 85.03 80.78 92.90 90.11 91.03 88.31 75840 26 57.56 54.68 62.88 61.00 61.63 59.78 75842 171.77 163.18 187.66 182.02 183.91 178.38 75842 TC 98.57 93.64 107.69 104.45 105.54 102.36 75842 26 73.20 69.54 79.97 77.57 78.37 76.02 75860 137.41 130.54 150.12 145.61 147.12 142.70 75860 TC 81.41 77.34 88.94 86.27 87.16 84.55 75860 26 56.00 53.20 61.18 59.34 59.96 58.16 75870 142.62 135.49 155.81 151.14 152.70 148.12 75870 TC 85.03 80.78 92.90 90.11 91.03 88.31 75870 26 57.59 54.71 62.92 61.03 61.66 59.81 75872 148.25 140.84 161.97 157.10 158.72 153.96 75872 TC 91.29 86.73 99.74 96.75 97.75 94.82 75872 26 56.96 54.11 62.23 60.36 60.98 59.16 75880 138.87 131.93 151.72 147.17 148.68 144.22 75880 TC 103.15 97.99 112.69 109.31 110.43 107.12 75880 26 35.72 33.93 39.02 37.85 38.24 37.09 75885 150.12 142.61 164.00 159.08 160.72 155.89 75885 TC 81.73 77.64 89.29 86.61 87.50 84.87 75885 26 68.39 64.97 74.72 72.47 73.22 71.02 75887 151.77 144.18 165.81 160.83 162.50 157.61 75887 TC 82.72 78.58 90.37 87.65 88.56 85.91 75887 26 69.04 65.59 75.43 73.16 73.92 71.70 75889 137.35 130.48 150.05 145.56 147.05 142.65 75889 TC 82.39 78.27 90.01 87.31 88.21 85.56 75889 26 54.95 52.20 60.03 58.22 58.83 57.06 75891 138.99 132.04 151.85 147.29 148.81 144.35 75891 TC 83.05 78.90 90.74 88.01 88.92 86.25 75891 26 55.94 53.14 61.11 59.28 59.89 58.10 75893 112.40 106.78 122.80 119.12 120.34 116.74 75893 TC 85.36 81.09 93.25 90.46 91.39 88.65 75893 26 27.04 25.69 29.54 28.66 28.96 28.08 75894 581.57 552.49 635.36 616.31 622.66 603.98 75894 TC 513.31 487.64 560.79 543.96 549.57 533.08 75894 26 68.26 64.85 74.58 72.34 73.08 70.89

Page 184: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 184Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

75898 190.26 180.75 207.86 201.63 203.71 197.59 75898 TC 103.72 98.53 113.31 109.91 111.04 107.71 75898 26 86.54 82.21 94.54 91.70 92.66 89.87 75901 166.29 157.98 181.68 176.23 178.04 172.71 75901 TC 142.68 135.55 155.88 151.20 152.77 148.18 75901 26 23.60 22.42 25.78 25.01 25.27 24.52 75902 68.47 65.05 74.81 72.57 73.31 71.12 75902 TC 49.45 46.98 54.03 52.41 52.95 51.36 75902 26 19.03 18.08 20.79 20.17 20.38 19.77 75952 275.49 261.72 300.98 291.95 294.96 286.11 75952 26 224.99 213.74 245.80 238.43 240.89 233.66 75953 275.49 261.72 300.98 291.95 294.96 286.11 75953 26 68.29 64.88 74.61 72.37 73.12 70.92 75954 26 114.26 108.55 124.83 121.08 122.34 118.66 75956 26 350.73 333.19 383.17 371.67 375.51 364.24 75957 26 301.17 286.11 329.03 319.16 322.45 312.78 75958 26 200.64 190.61 219.20 212.62 214.82 208.37 75959 26 171.76 163.17 187.65 182.01 183.90 178.37 75970 422.30 401.19 461.37 447.52 452.15 438.58 75970 TC 382.15 363.04 417.50 404.97 409.15 396.88 75970 26 40.15 38.14 43.86 42.55 42.99 41.70 75984 100.77 95.73 110.09 106.79 107.89 104.65 75984 TC 65.92 62.62 72.01 69.85 70.58 68.46 75984 26 34.85 33.11 38.08 36.94 37.32 36.20 75989 116.41 110.59 127.18 123.36 124.64 120.89 75989 TC 58.01 55.11 63.38 61.48 62.11 60.25 75989 26 58.40 55.48 63.80 61.89 62.53 60.65 76000 44.73 42.49 48.86 47.40 47.89 46.46 76000 TC 35.94 34.14 39.26 38.09 38.48 37.33 76000 26 8.79 8.35 9.60 9.32 9.41 9.13 76001 TC 42.24 40.13 46.15 44.77 45.23 43.87 76001 26 36.50 34.68 39.88 38.69 39.09 37.92 76010 24.97 23.72 27.28 26.46 26.74 25.93 76010 TC 15.84 15.05 17.31 16.79 16.96 16.46 76010 26 9.12 8.66 9.96 9.66 9.76 9.46 76080 53.10 50.45 58.02 56.28 56.86 55.15 76080 TC 26.72 25.38 29.19 28.31 28.60 27.75 76080 26 26.39 25.07 28.83 27.97 28.26 27.40 76098 16.01 15.21 17.49 16.96 17.15 16.63 76098 TC 7.94 7.54 8.67 8.41 8.50 8.23 76098 26 8.08 7.68 8.83 8.57 8.66 8.40 76100 87.21 82.85 95.28 92.41 93.37 90.56 76100 TC 55.71 52.92 60.86 59.03 59.64 57.85 76100 26 31.50 29.93 34.42 33.38 33.73 32.72 76101 124.53 118.30 136.05 131.96 133.32 129.33 76101 TC 89.64 85.16 97.93 95.00 95.98 93.10 76101 26 34.89 33.15 38.12 36.98 37.36 36.25 C 76102 136.57 129.74 149.20 144.73 146.22 141.83 C 76102 TC 103.51 98.33 113.08 109.69 110.81 107.49

Page 185: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 185Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

76102 26 33.06 31.41 36.12 35.04 35.40 34.34 C 76120 74.35 70.63 81.22 78.79 79.60 77.21 C 76120 TC 55.05 52.30 60.15 58.34 58.94 57.18 76120 26 19.30 18.34 21.09 20.46 20.67 20.04 76125 57.53 54.65 62.85 60.96 61.59 59.74 76125 TC 43.14 40.98 47.13 45.71 46.18 44.80 76125 26 14.39 13.67 15.72 15.25 15.41 14.94 76376 22.39 21.27 24.46 23.72 23.97 23.25 76376 TC 12.55 11.92 13.71 13.29 13.43 13.03 76376 26 9.84 9.35 10.75 10.43 10.53 10.22 76377 69.05 65.60 75.44 73.17 73.93 71.71 76377 TC 29.02 27.57 31.71 30.75 31.07 30.14 76377 26 40.03 38.03 43.73 42.42 42.86 41.57 C 76380 104.23 99.02 113.87 110.46 111.60 108.25 C 76380 TC 55.05 52.30 60.15 58.34 58.94 57.18 76380 26 49.18 46.72 53.73 52.12 52.66 51.07 76506 112.73 107.09 123.15 119.46 120.69 117.07 76506 TC 80.42 76.40 87.86 85.23 86.10 83.52 76506 26 32.31 30.69 35.29 34.24 34.59 33.55 76510 162.79 154.65 177.85 172.51 174.29 169.06 76510 TC 75.15 71.39 82.10 79.64 80.45 78.05 76510 26 87.64 83.26 95.75 92.87 93.83 91.01 76511 97.71 92.82 106.74 103.55 104.60 101.48 76511 TC 45.16 42.90 49.34 47.85 48.35 46.90 76511 26 52.54 49.91 57.40 55.67 56.25 54.56 76512 89.14 84.68 97.38 94.46 95.44 92.58 76512 TC 36.93 35.08 40.34 39.13 39.54 38.35 76512 26 52.21 49.60 57.04 55.33 55.90 54.22 76513 90.62 86.09 99.00 96.04 97.03 94.12 76513 TC 55.38 52.61 60.50 58.68 59.29 57.51 76513 26 35.25 33.49 38.51 37.36 37.74 36.62 76514 14.73 13.99 16.09 15.61 15.77 15.30 76514 TC 4.97 4.72 5.43 5.27 5.32 5.16 76514 26 9.75 9.26 10.65 10.33 10.43 10.12 76516 74.79 71.05 81.71 79.26 80.07 77.67 76516 TC 44.18 41.97 48.27 46.82 47.30 45.89 76516 26 30.61 29.08 33.44 32.44 32.78 31.80 76519 80.39 76.37 87.83 85.19 86.07 83.49 76519 TC 49.45 46.98 54.03 52.41 52.95 51.36 76519 26 30.94 29.39 33.80 32.79 33.12 32.13 76529 75.20 71.44 82.16 79.70 80.51 78.10 76529 TC 43.52 41.34 47.54 46.12 46.59 45.20 76529 26 31.69 30.11 34.63 33.59 33.94 32.92 76536 110.81 105.27 121.06 117.43 118.63 115.08 76536 TC 82.72 78.58 90.37 87.65 88.56 85.91 76536 26 28.09 26.69 30.69 29.77 30.08 29.18 76604 84.43 80.21 92.24 89.47 90.40 87.68 76604 TC 57.35 54.48 62.65 60.78 61.40 59.56 76604 26 27.07 25.72 29.58 28.69 28.99 28.12

Page 186: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 186Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

76641 102.78 97.64 112.29 108.92 110.04 106.74 76641 TC 66.25 62.94 72.38 70.21 70.93 68.80 76641 26 36.53 34.70 39.91 38.71 39.11 37.94 76642 84.84 80.60 92.69 89.91 90.84 88.11 76642 TC 50.77 48.23 55.46 53.80 54.36 52.72 76642 26 34.07 32.37 37.23 36.11 36.48 35.39 76700 117.18 111.32 128.02 124.18 125.45 121.69 76700 TC 76.79 72.95 83.89 81.37 82.21 79.74 76700 26 40.39 38.37 44.13 42.80 43.24 41.95 76705 87.51 83.13 95.60 92.74 93.69 90.88 76705 TC 58.01 55.11 63.38 61.48 62.11 60.25 76705 26 29.50 28.03 32.23 31.27 31.59 30.65 76706 89.37 84.90 97.64 94.70 95.68 92.81 76706 TC 61.64 58.56 67.34 65.32 66.00 64.01 76706 26 27.73 26.34 30.29 29.38 29.68 28.80 76770 108.41 102.99 118.44 114.89 116.07 112.59 76770 TC 71.52 67.94 78.13 75.79 76.57 74.27 76770 26 36.89 35.05 40.31 39.10 39.50 38.32 76775 56.51 53.68 61.73 59.88 60.50 58.68 76775 TC 27.70 26.32 30.27 29.36 29.66 28.77 76775 26 28.81 27.37 31.48 30.53 30.84 29.92 76776 149.32 141.85 163.13 158.23 159.86 155.07 76776 TC 111.39 105.82 121.69 118.05 119.26 115.69 76776 26 37.93 36.03 41.43 40.19 40.61 39.39 C 76800 115.18 109.42 125.83 122.06 123.31 119.62 C 76800 TC 55.05 52.30 60.15 58.34 58.94 57.18 76800 26 60.13 57.12 65.69 63.72 64.38 62.45 76801 119.09 113.14 130.11 126.21 127.51 123.69 76801 TC 68.89 65.45 75.27 73.01 73.76 71.55 76801 26 50.20 47.69 54.84 53.20 53.75 52.13 76802 63.24 60.08 69.09 67.02 67.71 65.68 76802 TC 20.76 19.72 22.68 22.00 22.23 21.56 76802 26 42.48 40.36 46.41 45.02 45.48 44.13 76805 136.91 130.06 149.57 145.08 146.58 142.19 76805 TC 86.35 82.03 94.33 91.51 92.45 89.68 76805 26 50.56 48.03 55.23 53.58 54.13 52.51 76810 90.72 86.18 99.11 96.13 97.13 94.21 76810 TC 40.52 38.49 44.26 42.94 43.38 42.08 76810 26 50.20 47.69 54.84 53.20 53.75 52.13 76811 178.75 169.81 195.28 189.43 191.37 185.64 76811 TC 80.12 76.11 87.53 84.90 85.78 83.20 76811 26 98.63 93.70 107.76 104.52 105.60 102.43 76812 199.12 189.16 217.53 211.01 213.19 206.79 76812 TC 106.11 100.80 115.92 112.45 113.60 110.19 76812 26 93.01 88.36 101.61 98.57 99.58 96.60 76813 118.77 112.83 129.75 125.87 127.16 123.35 76813 TC 57.35 54.48 62.65 60.78 61.40 59.56 76813 26 61.42 58.35 67.10 65.09 65.76 63.79 76814 79.64 75.66 87.01 84.40 85.27 82.71

Page 187: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 187Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

76814 TC 28.03 26.63 30.62 29.70 30.02 29.11 76814 26 51.61 49.03 56.38 54.69 55.26 53.60 76815 81.79 77.70 89.36 86.68 87.57 84.94 76815 TC 48.79 46.35 53.30 51.70 52.23 50.67 76815 26 33.00 31.35 36.05 34.97 35.33 34.27 76816 111.78 106.19 122.12 118.45 119.68 116.08 76816 TC 67.57 64.19 73.82 71.60 72.35 70.16 76816 26 44.22 42.01 48.31 46.86 47.35 45.93 76817 93.97 89.27 102.66 99.58 100.60 97.59 76817 TC 55.71 52.92 60.86 59.03 59.64 57.85 76817 26 38.26 36.35 41.80 40.55 40.96 39.73 76818 119.71 113.72 130.78 126.86 128.17 124.32 76818 TC 64.96 61.71 70.97 68.84 69.55 67.46 76818 26 54.75 52.01 59.81 58.02 58.62 56.86 76819 87.47 83.10 95.57 92.70 93.66 90.85 76819 TC 47.80 45.41 52.22 50.66 51.18 49.65 76819 26 39.67 37.69 43.34 42.04 42.48 41.20 76820 47.08 44.73 51.44 49.90 50.42 48.90 76820 TC 21.11 20.05 23.06 22.37 22.60 21.92 76820 26 25.97 24.67 28.37 27.52 27.81 26.97 76821 89.90 85.41 98.22 95.28 96.26 93.37 76821 TC 53.40 50.73 58.34 56.59 57.18 55.46 76821 26 36.50 34.68 39.88 38.69 39.09 37.92 76825 266.52 253.19 291.17 282.43 285.35 276.78 76825 TC 182.25 173.14 199.11 193.14 195.13 189.28 76825 26 84.28 80.07 92.08 89.32 90.24 87.54 76826 156.12 148.31 170.56 165.44 167.14 162.13 76826 TC 114.68 108.95 125.29 121.53 122.79 119.11 76826 26 41.43 39.36 45.26 43.91 44.36 43.03 76827 72.99 69.34 79.74 77.35 78.14 75.80 76827 TC 43.85 41.66 47.91 46.47 46.95 45.54 76827 26 29.14 27.68 31.83 30.88 31.20 30.26 76828 52.53 49.90 57.39 55.66 56.24 54.54 76828 TC 23.75 22.56 25.94 25.16 25.43 24.66 76828 26 28.78 27.34 31.44 30.50 30.81 29.89 76830 116.83 110.99 127.64 123.81 125.09 121.34 76830 TC 82.06 77.96 89.65 86.96 87.86 85.23 76830 26 34.76 33.02 37.97 36.83 37.21 36.10 76831 114.64 108.91 125.25 121.49 122.74 119.06 76831 TC 77.78 73.89 84.97 82.42 83.27 80.78 76831 26 36.86 35.02 40.27 39.07 39.47 38.28 76856 105.63 100.35 115.40 111.94 113.09 109.70 76856 TC 70.86 67.32 77.42 75.10 75.87 73.59 76856 26 34.76 33.02 37.97 36.83 37.21 36.10 76857 46.72 44.38 51.04 49.51 50.01 48.52 76857 TC 21.77 20.68 23.78 23.07 23.31 22.61 76857 26 24.95 23.70 27.26 26.44 26.71 25.91 76870 65.94 62.64 72.04 69.87 70.60 68.47 76870 TC 33.63 31.95 36.74 35.64 36.01 34.93

Page 188: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 188Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

76870 26 32.31 30.69 35.29 34.24 34.59 33.55 76872 91.07 86.52 99.50 96.51 97.51 94.58 76872 TC 57.68 54.80 63.02 61.13 61.76 59.92 76872 26 33.39 31.72 36.48 35.39 35.75 34.67 76873 164.88 156.64 180.14 174.73 176.54 171.24 76873 TC 87.01 82.66 95.06 92.21 93.16 90.37 76873 26 77.88 73.99 85.09 82.54 83.39 80.88 76881 112.67 107.04 123.10 119.40 120.64 117.01 76881 TC 81.08 77.03 88.58 85.93 86.81 84.21 76881 26 31.59 30.01 34.51 33.48 33.82 32.81 76882 35.16 33.40 38.41 37.26 37.64 36.51 76882 TC 10.57 10.04 11.55 11.20 11.32 10.98 76882 26 24.59 23.36 26.86 26.06 26.32 25.54 C 76885 92.27 87.66 100.81 97.78 98.80 95.83 C 76885 TC 55.05 52.30 60.15 58.34 58.94 57.18 76885 26 37.22 35.36 40.66 39.45 39.85 38.65 C 76886 84.96 80.71 92.82 90.03 90.97 88.23 C 76886 TC 55.05 52.30 60.15 58.34 58.94 57.18 76886 26 29.92 28.42 32.68 31.71 32.03 31.07 76930 26 33.03 31.38 36.09 35.01 35.36 34.30 76932 160.78 152.74 175.65 170.38 172.14 166.98 76932 TC 128.08 121.68 139.93 135.73 137.14 133.02 76932 26 32.70 31.07 35.73 34.66 35.02 33.97 76936 261.61 248.53 285.81 277.23 280.09 271.69 76936 TC 163.14 154.98 178.23 172.88 174.66 169.42 76936 26 98.47 93.55 107.58 104.35 105.43 102.27 76937 30.26 28.75 33.06 32.07 32.41 31.43 76937 TC 15.81 15.02 17.27 16.76 16.93 16.42 76937 26 14.45 13.73 15.79 15.32 15.48 15.01 76940 176.30 167.49 192.61 186.84 188.76 183.10 76940 TC 72.50 68.88 79.21 76.83 77.63 75.29 76940 26 103.80 98.61 113.40 110.00 111.14 107.80 76941 137.18 130.32 149.87 145.37 146.87 142.46 76941 TC 72.50 68.88 79.21 76.83 77.63 75.29 76941 26 64.68 61.45 70.67 68.55 69.25 67.18 76942 58.43 55.51 63.84 61.92 62.56 60.67 76942 TC 26.06 24.76 28.47 27.62 27.90 27.07 76942 26 32.37 30.75 35.36 34.30 34.66 33.61 76945 107.95 102.55 117.93 114.39 115.58 112.10 76945 TC 72.86 69.22 79.60 77.21 78.02 75.67 76945 26 35.09 33.34 38.34 37.19 37.57 36.44 76946 31.87 30.28 34.82 33.78 34.12 33.10 76946 TC 12.22 11.61 13.35 12.95 13.09 12.68 76946 26 19.66 18.68 21.48 20.84 21.06 20.42 76948 69.00 65.55 75.38 73.12 73.88 71.66 76948 TC 35.28 33.52 38.55 37.39 37.78 36.64 76948 26 33.72 32.03 36.83 35.73 36.10 35.02 76965 89.12 84.66 97.36 94.44 95.42 92.55 76965 TC 22.43 21.31 24.51 23.77 24.01 23.30

Page 189: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 189Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

76965 26 66.69 63.36 72.86 70.68 71.40 69.26 C 76970 74.40 70.68 81.28 78.84 79.66 77.27 C 76970 TC 55.05 52.30 60.15 58.34 58.94 57.18 76970 26 19.36 18.39 21.15 20.52 20.72 20.10 76975 137.03 130.18 149.71 145.21 146.72 142.30 76975 TC 94.94 90.19 103.72 100.60 101.65 98.59 76975 26 42.09 39.99 45.99 44.61 45.07 43.71 76977 7.12 6.76 7.77 7.54 7.61 7.39 76977 TC 4.31 4.09 4.70 4.57 4.61 4.47 76977 26 2.81 2.67 3.07 2.98 3.01 2.92 76998 159.24 151.28 173.97 168.75 170.49 165.38 76998 TC 95.44 90.67 104.27 101.14 102.19 99.12 76998 26 63.80 60.61 69.70 67.61 68.31 66.25 77001 79.65 75.67 87.02 84.41 85.28 82.72 77001 TC 60.65 57.62 66.26 64.27 64.94 62.99 77001 26 19.00 18.05 20.76 20.14 20.34 19.73 77002 88.38 83.96 96.55 93.66 94.62 91.78 77002 TC 60.32 57.30 65.90 63.92 64.57 62.64 77002 26 28.06 26.66 30.66 29.74 30.05 29.14 77003 89.52 85.04 97.80 94.86 95.84 92.97 77003 TC 59.66 56.68 65.18 63.23 63.88 61.96 77003 26 29.86 28.37 32.63 31.65 31.97 31.02 77011 212.37 201.75 232.01 225.06 227.38 220.56 77011 TC 149.60 142.12 163.44 158.54 160.17 155.37 77011 26 62.77 59.63 68.57 66.52 67.21 65.18 77012 119.29 113.33 130.33 126.42 127.72 123.89 77012 TC 61.97 58.87 67.70 65.67 66.34 64.35 77012 26 57.32 54.45 62.62 60.74 61.36 59.52 77013 489.68 465.20 534.98 518.93 524.29 508.55 77013 TC 294.75 280.01 322.01 312.35 315.57 306.11 77013 26 194.93 185.18 212.96 206.56 208.70 202.43 77014 113.02 107.37 123.48 119.77 121.00 117.38 77014 TC 69.22 65.76 75.62 73.36 74.11 71.89 77014 26 43.80 41.61 47.85 46.41 46.90 45.48 77021 376.99 358.14 411.86 399.51 403.63 391.52 77021 TC 302.47 287.35 330.45 320.54 323.84 314.13 77021 26 74.52 70.79 81.41 78.97 79.78 77.40 77022 490.11 465.60 535.44 519.37 524.73 508.99 77022 TC 276.95 263.10 302.57 293.49 296.52 287.63 77022 26 213.16 202.50 232.88 225.89 228.22 221.38 77053 55.84 53.05 61.01 59.18 59.79 57.99 77053 TC 37.59 35.71 41.07 39.84 40.25 39.04 77053 26 18.25 17.34 19.94 19.34 19.54 18.95 77054 73.59 69.91 80.40 77.98 78.79 76.42 77054 TC 50.77 48.23 55.46 53.80 54.36 52.72 77054 26 22.83 21.69 24.94 24.20 24.45 23.71 C 77058 473.64 449.96 517.45 501.93 507.10 491.89 C 77058 TC 391.81 372.22 428.05 415.21 419.50 406.90 77058 26 81.82 77.73 89.39 86.71 87.61 84.97

Page 190: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 190Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

C 77059 473.64 449.96 517.45 501.93 507.10 491.89 C 77059 TC 391.81 372.22 428.05 415.21 419.50 406.90 77059 26 81.82 77.73 89.39 86.71 87.61 84.97 77063 53.58 50.90 58.54 56.78 57.36 55.64 77063 TC 23.39 22.22 25.55 24.78 25.05 24.29 77063 26 30.19 28.68 32.98 31.99 32.33 31.35 77071 46.55 44.22 50.85 49.32 49.84 48.33 77072 22.03 20.93 24.07 23.35 23.59 22.87 77072 TC 12.55 11.92 13.71 13.29 13.43 13.03 77072 26 9.48 9.01 10.36 10.05 10.15 9.86 77073 34.16 32.45 37.32 36.20 36.57 35.48 77073 TC 19.80 18.81 21.63 20.99 21.19 20.57 77073 26 14.36 13.64 15.69 15.21 15.38 14.92 77074 61.40 58.33 67.08 65.07 65.73 63.77 77074 TC 38.58 36.65 42.15 40.88 41.31 40.07 77074 26 22.83 21.69 24.94 24.20 24.45 23.71 77075 82.75 78.61 90.40 87.69 88.60 85.94 77075 TC 55.71 52.92 60.86 59.03 59.64 57.85 77075 26 27.04 25.69 29.54 28.66 28.96 28.08 77076 92.15 87.54 100.67 97.65 98.66 95.69 77076 TC 57.03 54.18 62.31 60.43 61.07 59.23 77076 26 35.12 33.36 38.36 37.21 37.59 36.47 77077 35.59 33.81 38.88 37.72 38.10 36.96 77077 TC 19.47 18.50 21.28 20.64 20.85 20.23 77077 26 16.13 15.32 17.62 17.09 17.26 16.74 C 77078 67.34 63.97 73.57 71.36 72.09 69.93 C 77078 TC 55.05 52.30 60.15 58.34 58.94 57.18 77078 26 12.30 11.69 13.44 13.04 13.18 12.78 77080 38.86 36.92 42.46 41.18 41.61 40.35 77080 TC 28.69 27.26 31.35 30.41 30.72 29.80 77080 26 10.17 9.66 11.11 10.78 10.89 10.56 77081 26.73 25.39 29.20 28.32 28.61 27.76 77081 TC 15.84 15.05 17.31 16.79 16.96 16.46 77081 26 10.89 10.35 11.90 11.55 11.66 11.32 77084 368.09 349.69 402.14 390.08 394.11 382.28 77084 TC 287.35 272.98 313.93 304.51 307.65 298.41 77084 26 80.75 76.71 88.22 85.57 86.46 83.86 77085 53.02 50.37 57.93 56.19 56.76 55.06 77085 TC 37.59 35.71 41.07 39.84 40.25 39.04 77085 26 15.44 14.67 16.87 16.36 16.54 16.04 77086 33.50 31.83 36.60 35.51 35.87 34.80 77086 TC 24.74 23.50 27.03 26.22 26.48 25.69 77086 26 8.77 8.33 9.58 9.29 9.38 9.11 77261 75.52 71.74 82.50 80.03 80.86 78.43 77262 112.37 106.75 122.76 119.08 120.31 116.70 77263 165.08 156.83 180.35 174.95 176.74 171.45 77280 258.17 245.26 282.05 273.59 276.40 268.11 77280 TC 222.08 210.98 242.63 235.35 237.77 230.64 77280 26 36.08 34.28 39.42 38.24 38.63 37.48

Page 191: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 191Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

77285 411.10 390.55 449.13 435.65 440.15 426.94 77285 TC 356.83 338.99 389.84 378.14 382.04 370.58 77285 26 54.27 51.56 59.29 57.51 58.11 56.36 77290 487.15 462.79 532.21 516.25 521.56 505.92 77290 TC 406.58 386.25 444.19 430.86 435.31 422.25 77290 26 80.57 76.54 88.02 85.38 86.26 83.67 77293 442.08 419.98 482.98 468.49 473.32 459.11 77293 TC 338.74 321.80 370.07 358.97 362.66 351.80 77293 26 103.34 98.17 112.90 109.50 110.64 107.32 77295 471.90 448.31 515.56 500.09 505.24 490.08 77295 TC 251.52 238.94 274.78 266.54 269.28 261.20 77295 26 220.38 209.36 240.76 233.54 235.95 228.87 77300 64.21 61.00 70.15 68.05 68.75 66.69 77300 TC 31.99 30.39 34.95 33.90 34.25 33.22 77300 26 32.22 30.61 35.20 34.14 34.50 33.47 77301 1,851.72 1,759.13 2,023.00 1,962.31 1,982.54 1,923.06 77301 TC 1,440.76 1,368.72 1,574.03 1,526.81 1,542.55 1,496.28 77301 26 410.96 390.41 448.97 435.51 439.99 426.80 77306 144.04 136.84 157.37 152.64 154.22 149.59 77306 TC 71.88 68.29 78.53 76.18 76.96 74.66 77306 26 72.16 68.55 78.83 76.46 77.26 74.93 77307 279.13 265.17 304.95 295.79 298.85 289.88 77307 TC 129.89 123.40 141.91 137.66 139.07 134.91 77307 26 149.23 141.77 163.04 158.15 159.77 154.99 77316 180.64 171.61 197.35 191.43 193.41 187.60 77316 TC 108.48 103.06 118.52 114.97 116.15 112.67 77316 26 72.16 68.55 78.83 76.46 77.26 74.93 77317 235.37 223.60 257.14 249.42 252.00 244.43 77317 TC 141.12 134.06 154.17 149.55 151.09 146.56 77317 26 94.24 89.53 102.96 99.87 100.90 97.87 77318 340.82 323.78 372.35 361.18 364.90 353.96 77318 TC 191.59 182.01 209.31 203.03 205.13 198.97 77318 26 149.23 141.77 163.04 158.15 159.77 154.99 77321 89.92 85.42 98.23 95.29 96.27 93.38 77321 TC 40.88 38.84 44.67 43.32 43.77 42.46 77321 26 49.04 46.59 53.58 51.97 52.51 50.93 77331 62.67 59.54 68.47 66.41 67.10 65.09 77331 TC 17.82 16.93 19.47 18.88 19.08 18.50 77331 26 44.85 42.61 49.00 47.53 48.02 46.58 77332 64.34 61.12 70.29 68.18 68.89 66.82 77332 TC 40.88 38.84 44.67 43.32 43.77 42.46 77332 26 23.46 22.29 25.63 24.86 25.12 24.37 77333 92.59 87.96 101.15 98.12 99.13 96.15 77333 TC 54.06 51.36 59.06 57.29 57.88 56.14 77333 26 38.53 36.60 42.09 40.83 41.25 40.01 77334 125.79 119.50 137.43 133.31 134.68 130.64 77334 TC 66.58 63.25 72.74 70.55 71.29 69.14 77334 26 59.21 56.25 64.69 62.74 63.40 61.49 77336 74.33 70.61 81.20 78.76 79.58 77.19

Page 192: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 192Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

77338 487.74 463.35 532.85 516.87 522.19 506.53 77338 TC 267.37 254.00 292.10 283.34 286.26 277.67 77338 26 220.38 209.36 240.76 233.54 235.95 228.87 77370 114.34 108.62 124.91 121.16 122.42 118.74 77371 6,951.22 6,603.66 7,594.21 7,366.38 7,442.33 7,219.06 77372 1,003.67 953.49 1,096.51 1,063.62 1,074.58 1,042.35 77373 1,273.94 1,210.24 1,391.78 1,350.02 1,363.95 1,323.02 77401 23.09 21.94 25.23 24.47 24.73 23.98 77417 10.24 9.73 11.19 10.86 10.97 10.64 77427 184.24 175.03 201.28 195.25 197.26 191.34 77431 101.25 96.19 110.62 107.30 108.41 105.14 77432 416.06 395.26 454.55 440.91 445.45 432.09 77435 626.80 595.46 684.78 664.24 671.08 650.96 77469 318.52 302.59 347.98 337.54 341.02 330.79 77470 141.01 133.96 154.05 149.43 150.97 146.44 77470 TC 36.27 34.46 39.63 38.44 38.84 37.67 77470 26 104.74 99.50 114.43 111.00 112.14 108.78 77520 961.54 913.46 1,050.48 1,018.97 1,029.47 998.59 77600 391.29 371.73 427.49 414.67 418.95 406.38 77600 TC 322.00 305.90 351.79 341.23 344.75 334.41 77600 26 69.29 65.83 75.70 73.44 74.19 71.97 77605 734.23 697.52 802.15 778.08 786.11 762.52 77605 TC 632.68 601.05 691.21 670.47 677.38 657.06 77605 26 101.56 96.48 110.95 107.63 108.73 105.48 77610 807.66 767.28 882.37 855.90 864.72 838.78 77610 TC 738.76 701.82 807.09 782.89 790.95 767.22 77610 26 68.89 65.45 75.27 73.01 73.76 71.55 77615 962.99 914.84 1,052.07 1,020.50 1,031.02 1,000.09 77615 TC 868.38 824.96 948.70 920.24 929.73 901.84 77615 26 94.60 89.87 103.35 100.25 101.28 98.24 77620 437.53 415.65 478.00 463.66 468.44 454.39 77620 TC 350.99 333.44 383.46 371.96 375.79 364.52 77620 26 86.54 82.21 94.54 91.70 92.66 89.87 77750 363.35 345.18 396.96 385.04 389.02 377.34 77750 TC 106.20 100.89 116.02 112.54 113.70 110.29 77750 26 257.15 244.29 280.93 272.50 275.31 267.05 77761 377.73 358.84 412.67 400.28 404.41 392.28 77761 TC 181.02 171.97 197.77 191.83 193.81 187.99 77761 26 196.71 186.87 214.90 208.45 210.60 204.27 77762 505.98 480.68 552.78 536.20 541.73 525.47 77762 TC 209.38 198.91 228.75 221.88 224.17 217.44 77762 26 296.60 281.77 324.04 314.32 317.55 308.03 77763 714.40 678.68 780.48 757.07 764.88 741.92 77763 TC 268.77 255.33 293.63 284.82 287.75 279.13 77763 26 445.63 423.35 486.85 472.25 477.11 462.81 77767 213.52 202.84 233.27 226.26 228.60 221.74 77767 TC 159.22 151.26 173.95 168.73 170.46 165.36 77767 26 54.30 51.59 59.33 57.55 58.14 56.40 77768 334.23 317.52 365.15 354.19 357.85 347.10

Page 193: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 193Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

77768 TC 262.06 248.96 286.30 277.71 280.58 272.16 77768 26 72.16 68.55 78.83 76.46 77.26 74.93 77770 305.89 290.60 334.19 324.16 327.51 317.68 77770 TC 205.70 195.42 224.73 217.99 220.24 213.64 77770 26 100.20 95.19 109.47 106.18 107.28 104.05 77771 570.28 541.77 623.04 604.35 610.57 592.26 77771 TC 374.80 356.06 409.47 397.19 401.28 389.24 77771 26 195.49 185.72 213.58 207.17 209.31 203.03 77772 870.21 826.70 950.71 922.19 931.70 903.74 77772 TC 593.04 563.39 647.90 628.46 634.94 615.89 77772 26 277.16 263.30 302.80 293.71 296.73 287.83 77778 795.23 755.47 868.79 842.73 851.41 825.87 77778 TC 344.60 327.37 376.48 365.18 368.94 357.88 77778 26 450.63 428.10 492.32 477.55 482.47 467.99 77789 114.56 108.83 125.15 121.41 122.65 118.98 77789 TC 55.71 52.92 60.86 59.03 59.64 57.85 77789 26 58.85 55.91 64.30 62.36 63.01 61.12 77790 13.87 13.18 15.16 14.70 14.86 14.40 78012 78.07 74.17 85.30 82.73 83.59 81.08 78012 TC 68.59 65.16 74.93 72.69 73.44 71.24 78012 26 9.48 9.01 10.36 10.05 10.15 9.86 78013 185.40 176.13 202.55 196.48 198.50 192.54 78013 TC 167.12 158.76 182.57 177.10 178.92 173.56 78013 26 18.28 17.37 19.98 19.38 19.57 18.99 78014 234.57 222.84 256.27 248.57 251.14 243.60 78014 TC 209.62 199.14 229.01 222.15 224.43 217.71 78014 26 24.95 23.70 27.26 26.44 26.71 25.91 78015 215.99 205.19 235.97 228.88 231.25 224.31 78015 TC 182.94 173.79 199.86 193.87 195.86 189.99 78015 26 33.06 31.41 36.12 35.04 35.40 34.34 78016 276.34 262.52 301.90 292.84 295.86 286.98 78016 TC 241.61 229.53 263.96 256.04 258.68 250.92 78016 26 34.73 32.99 37.94 36.80 37.18 36.06 78018 304.55 289.32 332.72 322.74 326.06 316.28 78018 TC 263.02 249.87 287.35 278.73 281.60 273.15 78018 26 41.52 39.44 45.36 44.00 44.45 43.11 78020 81.94 77.84 89.52 86.83 87.72 85.09 78020 TC 54.09 51.39 59.10 57.33 57.91 56.18 78020 26 27.85 26.46 30.43 29.52 29.82 28.93 78070 291.82 277.23 318.81 309.25 312.44 303.06 78070 TC 252.45 239.83 275.80 267.54 270.28 262.19 78070 26 39.37 37.40 43.01 41.72 42.15 40.88 78071 348.11 330.70 380.31 368.90 372.70 361.51 78071 TC 289.38 274.91 316.15 306.66 309.82 300.53 78071 26 58.73 55.79 64.16 62.24 62.87 61.00 78072 402.03 381.93 439.22 426.04 430.43 417.52 78072 TC 325.29 309.03 355.38 344.72 348.28 337.82 78072 26 76.73 72.89 83.82 81.31 82.14 79.68 78075 430.41 408.89 470.22 456.11 460.82 446.99

Page 194: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 194Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

78075 TC 393.52 373.84 429.92 417.01 421.31 408.68 78075 26 36.89 35.05 40.31 39.10 39.50 38.32 78102 165.86 157.57 181.21 175.77 177.58 172.25 78102 TC 139.12 132.16 151.98 147.43 148.95 144.49 78102 26 26.74 25.40 29.21 28.34 28.62 27.77 78103 213.89 203.20 233.68 226.67 229.01 222.13 78103 TC 178.32 169.40 194.81 188.97 190.91 185.18 78103 26 35.57 33.79 38.86 37.70 38.08 36.94 78104 238.78 226.84 260.87 253.03 255.65 247.97 78104 TC 200.40 190.38 218.94 212.37 214.56 208.13 78104 26 38.38 36.46 41.93 40.68 41.09 39.86 78110 96.88 92.04 105.85 102.67 103.73 100.61 78110 TC 87.06 82.71 95.12 92.26 93.22 90.42 78110 26 9.81 9.32 10.72 10.40 10.50 10.19 78111 92.35 87.73 100.89 97.87 98.88 95.91 78111 TC 81.46 77.39 89.00 86.33 87.22 84.61 78111 26 10.89 10.35 11.90 11.55 11.66 11.32 78120 91.06 86.51 99.49 96.50 97.50 94.56 78120 TC 79.49 75.52 86.85 84.24 85.11 82.56 78120 26 11.58 11.00 12.65 12.27 12.40 12.03 78121 101.21 96.15 110.57 107.26 108.36 105.11 78121 TC 85.42 81.15 93.32 90.53 91.46 88.72 78121 26 15.80 15.01 17.26 16.74 16.92 16.41 78122 94.05 89.35 102.75 99.67 100.69 97.68 78122 TC 72.90 69.26 79.65 77.26 78.05 75.72 78122 26 21.15 20.09 23.10 22.41 22.64 21.97 78130 163.07 154.92 178.16 172.81 174.59 169.35 78130 TC 132.89 126.25 145.19 140.83 142.29 138.01 78130 26 30.19 28.68 32.98 31.99 32.33 31.35 C 78135 338.16 321.25 369.44 358.35 362.05 351.19 C 78135 TC 305.85 290.56 334.14 324.12 327.46 317.63 78135 26 32.31 30.69 35.29 34.24 34.59 33.55 78140 135.07 128.32 147.57 143.14 144.61 140.28 78140 TC 104.53 99.30 114.20 110.77 111.91 108.55 78140 26 30.55 29.02 33.37 32.37 32.71 31.73 78185 204.93 194.68 223.88 217.17 219.41 212.82 78185 TC 184.91 175.66 202.01 195.95 197.97 192.03 78185 26 20.01 19.01 21.86 21.21 21.42 20.78 78190 382.29 363.18 417.66 405.12 409.31 397.01 78190 TC 328.26 311.85 358.63 347.86 351.45 340.91 78190 26 54.03 51.33 59.03 57.26 57.85 56.11 78191 163.07 154.92 178.16 172.81 174.59 169.35 78191 TC 132.89 126.25 145.19 140.83 142.29 138.01 78191 26 30.19 28.68 32.98 31.99 32.33 31.35 78195 347.15 329.79 379.26 367.89 371.67 360.53 78195 TC 288.06 273.66 314.71 305.27 308.42 299.16 78195 26 59.08 56.13 64.55 62.62 63.26 61.36 78201 183.30 174.14 200.26 194.26 196.26 190.37 78201 TC 162.18 154.07 177.18 171.87 173.64 168.43

Page 195: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 195Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

78201 26 21.12 20.06 23.07 22.38 22.61 21.93 78202 194.38 184.66 212.36 205.99 208.12 201.87 78202 TC 170.75 162.21 186.54 180.94 182.82 177.32 78202 26 23.63 22.45 25.82 25.05 25.30 24.54 78205 205.54 195.26 224.55 217.81 220.05 213.45 78205 TC 171.73 163.14 187.61 181.99 183.86 178.35 78205 26 33.80 32.11 36.93 35.82 36.19 35.11 78206 332.87 316.23 363.66 352.75 356.40 345.70 78206 TC 286.09 271.79 312.56 303.19 306.30 297.13 78206 26 46.79 44.45 51.12 49.59 50.09 48.60 78215 188.75 179.31 206.21 200.02 202.08 196.02 78215 TC 164.49 156.27 179.71 174.32 176.11 170.83 78215 26 24.26 23.05 26.51 25.71 25.98 25.20 78216 123.75 117.56 135.19 131.13 132.49 128.51 78216 TC 96.29 91.48 105.20 102.05 103.10 100.02 78216 26 27.46 26.09 30.00 29.11 29.41 28.52 78226 321.33 305.26 351.05 340.52 344.02 333.71 78226 TC 284.77 270.53 311.11 301.77 304.89 295.73 78226 26 36.56 34.73 39.94 38.74 39.15 37.97 78227 435.52 413.74 475.80 461.53 466.29 452.30 78227 TC 390.88 371.34 427.04 414.23 418.50 405.95 78227 26 44.64 42.41 48.77 47.31 47.79 46.37 78230 169.85 161.36 185.56 180.00 181.85 176.40 78230 TC 147.03 139.68 160.63 155.81 157.42 152.70 78230 26 22.83 21.69 24.94 24.20 24.45 23.71 78231 125.58 119.30 137.20 133.08 134.45 130.42 78231 TC 99.58 94.60 108.79 105.52 106.62 103.41 78231 26 26.00 24.70 28.41 27.55 27.84 27.00 78232 97.70 92.82 106.74 103.55 104.60 101.48 78232 TC 77.84 73.95 85.04 82.49 83.34 80.85 78232 26 19.86 18.87 21.70 21.05 21.26 20.62 78258 219.16 208.20 239.43 232.24 234.65 227.60 78258 TC 182.28 173.17 199.15 193.17 195.17 189.30 78258 26 36.89 35.05 40.31 39.10 39.50 38.32 78261 238.76 226.82 260.84 253.02 255.62 247.96 78261 TC 205.01 194.76 223.97 217.26 219.49 212.91 78261 26 33.75 32.06 36.87 35.77 36.13 35.05 78262 235.76 223.97 257.57 249.84 252.41 244.85 78262 TC 202.70 192.57 221.46 214.81 217.03 210.51 78262 26 33.06 31.41 36.12 35.04 35.40 34.34 78264 326.74 310.40 356.96 346.25 349.82 339.33 78264 TC 287.73 273.34 314.34 304.91 308.05 298.82 78264 26 39.01 37.06 42.62 41.34 41.77 40.51 C 78265 354.71 336.97 387.52 375.89 379.76 368.37 C 78265 TC 306.21 290.90 334.54 324.50 327.84 318.01 78265 26 48.49 46.07 52.98 51.39 51.92 50.37 C 78266 447.61 425.23 489.01 474.34 479.24 464.85 C 78266 TC 394.18 374.47 430.64 417.73 422.03 409.38 78266 26 53.43 50.76 58.37 56.63 57.20 55.50

Page 196: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 196Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

78270 98.22 93.31 107.31 104.09 105.16 102.01 78270 TC 87.72 83.33 95.83 92.95 93.91 91.09 78270 26 10.50 9.98 11.48 11.13 11.25 10.91 78271 87.02 82.67 95.07 92.22 93.17 90.38 78271 TC 76.85 73.01 83.96 81.44 82.28 79.81 78271 26 10.17 9.66 11.11 10.78 10.89 10.56 78272 95.14 90.38 103.94 100.82 101.86 98.81 78272 TC 81.79 77.70 89.36 86.68 87.57 84.94 78272 26 13.34 12.67 14.57 14.13 14.28 13.85 78278 338.89 321.95 370.24 359.13 362.84 351.95 78278 TC 290.04 275.54 316.87 307.36 310.53 301.21 78278 26 48.85 46.41 53.37 51.77 52.30 50.74 78282 241.13 229.07 263.43 255.53 258.16 250.42 78282 TC 222.16 211.05 242.71 235.43 237.85 230.72 78282 26 18.97 18.02 20.72 20.10 20.31 19.70 78290 322.14 306.03 351.93 341.38 344.90 334.55 78290 TC 288.39 273.97 315.07 305.61 308.76 299.51 78290 26 33.75 32.06 36.87 35.77 36.13 35.05 78291 249.26 236.80 272.32 264.16 266.87 258.88 78291 TC 206.33 196.01 225.41 218.65 220.90 214.28 78291 26 42.93 40.78 46.90 45.49 45.95 44.59 78300 176.64 167.81 192.98 187.20 189.12 183.45 78300 TC 145.38 138.11 158.83 154.07 155.65 150.98 78300 26 31.26 29.70 34.16 33.13 33.48 32.46 78305 226.05 214.75 246.96 239.56 242.03 234.76 78305 TC 184.58 175.35 201.65 195.60 197.62 191.69 78305 26 41.46 39.39 45.30 43.94 44.39 43.07 78306 244.89 232.65 267.55 259.52 262.20 254.33 78306 TC 202.70 192.57 221.46 214.81 217.03 210.51 78306 26 42.18 40.07 46.08 44.70 45.16 43.80 78315 336.68 319.85 367.83 356.79 360.47 349.66 78315 TC 286.42 272.10 312.92 303.53 306.66 297.46 78315 26 50.26 47.75 54.91 53.27 53.82 52.20 78320 223.04 211.89 243.67 236.36 238.80 231.63 78320 TC 172.39 163.77 188.34 182.69 184.56 179.03 78320 26 50.65 48.12 55.34 53.68 54.23 52.61 78414 88.06 83.66 96.21 93.32 94.29 91.46 78414 TC 65.92 62.62 72.01 69.85 70.58 68.46 78414 26 22.14 21.03 24.18 23.46 23.70 22.99 78428 176.75 167.91 193.10 187.30 189.23 183.55 78428 TC 139.12 132.16 151.98 147.43 148.95 144.49 78428 26 37.63 35.75 41.11 39.88 40.30 39.09 78445 176.56 167.73 192.89 187.11 189.04 183.37 78445 TC 152.30 144.69 166.39 161.40 163.07 158.17 78445 26 24.26 23.05 26.51 25.71 25.98 25.20 78451 331.17 314.61 361.80 350.95 354.57 343.93 78451 TC 264.01 250.81 288.43 279.78 282.66 274.18 78451 26 67.16 63.80 73.37 71.17 71.90 69.75 78452 459.11 436.15 501.57 486.53 491.54 476.80

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CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 197Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

78452 TC 380.37 361.35 415.55 403.09 407.24 395.03 78452 26 78.74 74.80 86.02 83.44 84.30 81.78 78453 295.43 280.66 322.76 313.08 316.31 306.82 78453 TC 245.89 233.60 268.64 260.58 263.27 255.37 78453 26 49.54 47.06 54.12 52.50 53.04 51.45 78454 424.68 403.45 463.97 450.05 454.69 441.05 78454 TC 357.94 340.04 391.05 379.32 383.23 371.73 78454 26 66.74 63.40 72.91 70.73 71.45 69.31 78456 310.89 295.35 339.65 329.46 332.86 322.87 78456 TC 262.04 248.94 286.28 277.69 280.55 272.14 78456 26 48.85 46.41 53.37 51.77 52.30 50.74 78457 171.45 162.88 187.31 181.69 183.56 178.05 78457 TC 134.18 127.47 146.59 142.20 143.66 139.36 78457 26 37.28 35.42 40.73 39.51 39.92 38.72 78458 199.90 189.91 218.40 211.84 214.03 207.61 78458 TC 154.60 146.87 168.90 163.83 165.52 160.55 78458 26 45.29 43.03 49.48 48.00 48.50 47.05 78459 795.91 756.11 869.53 843.44 852.14 826.57 78459 TC 725.10 688.85 792.18 768.41 776.33 753.04 78459 26 70.81 67.27 77.36 75.04 75.81 73.54 78466 190.33 180.81 207.93 201.70 203.77 197.66 78466 TC 155.26 147.50 169.63 164.54 166.23 161.25 78466 26 35.06 33.31 38.31 37.16 37.54 36.41 78468 189.33 179.86 206.84 200.63 202.70 196.62 78468 TC 150.32 142.80 164.22 159.30 160.93 156.11 78468 26 39.01 37.06 42.62 41.34 41.77 40.51 78469 221.31 210.24 241.78 234.52 236.95 229.83 78469 TC 176.35 167.53 192.66 186.88 188.81 183.14 78469 26 44.97 42.72 49.13 47.66 48.15 46.70 78472 223.19 212.03 243.83 236.52 238.96 231.79 78472 TC 175.03 166.28 191.22 185.48 187.39 181.77 78472 26 48.17 45.76 52.62 51.05 51.57 50.03 78473 282.02 267.92 308.11 298.86 301.94 292.88 78473 TC 210.97 200.42 230.48 223.57 225.87 219.10 78473 26 71.05 67.50 77.63 75.30 76.07 73.80 78481 170.75 162.21 186.54 180.94 182.82 177.32 78481 TC 122.95 116.80 134.32 130.30 131.63 127.68 78481 26 47.81 45.42 52.23 50.67 51.19 49.66 78483 237.19 225.33 259.13 251.36 253.94 246.33 78483 TC 165.80 157.51 181.14 175.70 177.51 172.18 78483 26 71.38 67.81 77.98 75.65 76.42 74.13 78491 796.57 756.74 870.25 844.15 852.85 827.26 78491 TC 725.10 688.85 792.18 768.41 776.33 753.04 78491 26 71.47 67.90 78.09 75.74 76.52 74.22 78492 814.82 774.08 890.19 863.49 872.39 846.22 78492 TC 725.10 688.85 792.18 768.41 776.33 753.04 78492 26 89.72 85.23 98.01 95.07 96.06 93.17 78494 219.20 208.24 239.48 232.29 234.69 227.64 78494 TC 161.19 153.13 176.10 170.82 172.58 167.41

Page 198: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 198Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

78494 26 58.01 55.11 63.38 61.48 62.11 60.25 78496 43.40 41.23 47.41 45.99 46.47 45.07 78496 TC 19.14 18.18 20.91 20.27 20.49 19.87 78496 26 24.26 23.05 26.51 25.71 25.98 25.20 78579 180.78 171.74 197.50 191.58 193.56 187.75 78579 TC 156.88 149.04 171.40 166.26 167.97 162.93 78579 26 23.90 22.71 26.12 25.33 25.60 24.83 78580 232.67 221.04 254.20 246.57 249.11 241.64 78580 TC 196.11 186.30 214.25 207.82 209.96 203.67 78580 26 36.56 34.73 39.94 38.74 39.15 37.97 78582 325.98 309.68 356.13 345.45 349.01 338.54 78582 TC 272.91 259.26 298.15 289.20 292.18 283.42 78582 26 53.07 50.42 57.98 56.25 56.82 55.12 78597 196.73 186.89 214.92 208.47 210.62 204.30 78597 TC 161.16 153.10 176.07 170.79 172.55 167.37 78597 26 35.57 33.79 38.86 37.70 38.08 36.94 78598 297.60 282.72 325.13 315.38 318.63 309.07 78598 TC 256.11 243.30 279.80 271.40 274.19 265.97 78598 26 41.49 39.42 45.33 43.98 44.42 43.10 78600 180.04 171.04 196.70 190.80 192.76 186.98 78600 TC 157.57 149.69 172.14 166.98 168.71 163.65 78600 26 22.47 21.35 24.55 23.82 24.06 23.35 78601 208.58 198.15 227.87 221.04 223.32 216.63 78601 TC 183.60 174.42 200.58 194.57 196.57 190.68 78601 26 24.98 23.73 27.29 26.47 26.75 25.94 78605 194.80 185.06 212.82 206.44 208.56 202.31 78605 TC 168.11 159.70 183.66 178.15 179.99 174.58 78605 26 26.69 25.36 29.16 28.29 28.58 27.73 78606 320.01 304.01 349.61 339.12 342.62 332.34 78606 TC 288.72 274.28 315.42 305.96 309.11 299.84 78606 26 31.29 29.73 34.19 33.17 33.51 32.50 78607 342.59 325.46 374.28 363.06 366.79 355.80 78607 TC 283.12 268.96 309.30 300.02 303.12 294.02 78607 26 59.47 56.50 64.98 63.03 63.68 61.77 78608 919.78 873.79 1,004.86 974.72 984.76 955.22 78608 TC 847.95 805.55 926.38 898.59 907.86 880.61 78608 26 71.83 68.24 78.48 76.12 76.91 74.60 78610 169.71 161.22 185.40 179.84 181.70 176.24 78610 TC 154.60 146.87 168.90 163.83 165.52 160.55 78610 26 15.11 14.35 16.50 16.01 16.17 15.69 78630 328.73 312.29 359.13 348.36 351.95 341.39 78630 TC 294.98 280.23 322.26 312.59 315.82 306.34 78630 26 33.75 32.06 36.87 35.77 36.13 35.05 78635 331.82 315.23 362.51 351.64 355.27 344.60 78635 TC 300.58 285.55 328.38 318.53 321.82 312.16 78635 26 31.23 29.67 34.12 33.10 33.44 32.43 78645 314.54 298.81 343.63 333.33 336.75 326.66 78645 TC 286.74 272.40 313.26 303.86 306.99 297.79 78645 26 27.79 26.40 30.36 29.45 29.75 28.87

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CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 199Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

78647 344.26 327.05 376.11 364.83 368.59 357.54 78647 TC 298.61 283.68 326.23 316.45 319.71 310.12 78647 26 45.65 43.37 49.88 48.38 48.88 47.41 78650 321.24 305.18 350.96 340.42 343.94 333.62 78650 TC 291.36 276.79 318.31 308.76 311.94 302.59 78650 26 29.89 28.40 32.66 31.68 32.00 31.05 78660 174.70 165.97 190.87 185.14 187.05 181.44 78660 TC 148.34 140.92 162.06 157.19 158.82 154.05 78660 26 26.36 25.04 28.80 27.93 28.22 27.37 78700 166.53 158.20 181.93 176.47 178.30 172.94 78700 TC 144.39 137.17 157.75 153.01 154.59 149.95 78700 26 22.14 21.03 24.18 23.46 23.70 22.99 78701 205.19 194.93 224.17 217.44 219.68 213.10 78701 TC 181.62 172.54 198.42 192.46 194.45 188.61 78701 26 23.57 22.39 25.75 24.98 25.23 24.48 78707 227.09 215.74 248.10 240.66 243.14 235.84 78707 TC 180.30 171.29 196.98 191.07 193.04 187.25 78707 26 46.79 44.45 51.12 49.59 50.09 48.60 78708 172.86 164.22 188.85 183.18 185.08 179.52 78708 TC 113.45 107.78 123.95 120.23 121.46 117.83 78708 26 59.41 56.44 64.91 62.96 63.61 61.71 78709 355.67 337.89 388.57 376.91 380.80 369.38 78709 TC 287.07 272.72 313.63 304.22 307.36 298.14 78709 26 68.60 65.17 74.95 72.69 73.45 71.24 78710 195.51 185.73 213.59 207.18 209.32 203.04 78710 TC 164.82 156.58 180.07 174.66 176.47 171.17 78710 26 30.69 29.16 33.53 32.53 32.87 31.88 78725 103.73 98.54 113.32 109.92 111.06 107.72 78725 TC 85.42 81.15 93.32 90.53 91.46 88.72 78725 26 18.31 17.39 20.00 19.40 19.60 19.01 78730 68.34 64.92 74.66 72.42 73.16 70.97 78730 TC 60.98 57.93 66.62 64.62 65.29 63.33 78730 26 7.36 6.99 8.04 7.80 7.88 7.64 78740 212.68 202.05 232.36 225.39 227.71 220.88 78740 TC 185.24 175.98 202.38 196.31 198.33 192.38 78740 26 27.43 26.06 29.97 29.07 29.37 28.49 78761 207.87 197.48 227.10 220.29 222.56 215.89 78761 TC 172.06 163.46 187.98 182.34 184.22 178.70 78761 26 35.81 34.02 39.12 37.95 38.34 37.19 78800 187.69 178.31 205.06 198.90 200.95 194.93 78800 TC 153.94 146.24 168.18 163.13 164.82 159.86 78800 26 33.74 32.05 36.86 35.75 36.12 35.04 78801 255.64 242.86 279.29 270.91 273.70 265.49 78801 TC 215.55 204.77 235.49 228.42 230.77 223.86 78801 26 40.09 38.09 43.80 42.49 42.93 41.64 78802 314.76 299.02 343.87 333.56 337.00 326.89 78802 TC 272.91 259.26 298.15 289.20 292.18 283.42 78802 26 41.85 39.76 45.72 44.36 44.80 43.47 78803 332.60 315.97 363.37 352.46 356.10 345.41

Page 200: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 200Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

78803 TC 280.49 266.47 306.44 297.25 300.31 291.31 78803 26 52.11 49.50 56.93 55.22 55.79 54.12 78804 549.08 521.63 599.87 581.88 587.88 570.24 78804 TC 497.03 472.18 543.01 526.71 532.15 516.18 78804 26 52.05 49.45 56.87 55.17 55.73 54.06 78805 178.61 169.68 195.13 189.28 191.23 185.50 78805 TC 142.74 135.60 155.94 151.26 152.82 148.24 78805 26 35.87 34.08 39.19 38.02 38.41 37.26 78806 323.99 307.79 353.96 343.34 346.87 336.48 78806 TC 282.13 268.02 308.22 298.98 302.06 293.00 78806 26 41.85 39.76 45.72 44.36 44.80 43.47 78807 333.26 316.60 364.09 353.17 356.81 346.10 78807 TC 281.14 267.08 307.14 297.93 301.00 291.97 78807 26 52.11 49.50 56.93 55.22 55.79 54.12 78808 42.79 40.65 46.75 45.34 45.82 44.44 78811 924.87 878.63 1,010.42 980.11 990.22 960.50 78811 TC 847.95 805.55 926.38 898.59 907.86 880.61 78811 26 76.92 73.07 84.03 81.51 82.35 79.88 78812 941.86 894.77 1,028.99 998.12 1,008.40 978.16 78812 TC 847.95 805.55 926.38 898.59 907.86 880.61 78812 26 93.91 89.21 102.59 99.51 100.54 97.52 78813 945.72 898.43 1,033.19 1,002.20 1,012.53 982.16 78813 TC 847.95 805.55 926.38 898.59 907.86 880.61 78813 26 97.77 92.88 106.81 103.60 104.67 101.53 78814 1,050.51 997.98 1,147.68 1,113.25 1,124.72 1,090.98 78814 TC 941.88 894.79 1,029.01 998.14 1,008.42 978.18 78814 26 108.63 103.20 118.68 115.12 116.31 112.82 78815 1,061.43 1,008.36 1,159.61 1,124.83 1,136.42 1,102.33 78815 TC 941.88 894.79 1,029.01 998.14 1,008.42 978.18 78815 26 119.55 113.57 130.61 126.68 128.00 124.15 78816 1,062.92 1,009.77 1,161.24 1,126.40 1,138.01 1,103.87 78816 TC 941.88 894.79 1,029.01 998.14 1,008.42 978.18 78816 26 121.04 114.99 132.24 128.27 129.59 125.71 79005 134.08 127.38 146.49 142.09 143.55 139.25 79005 TC 46.18 43.87 50.45 48.93 49.44 47.96 79005 26 87.89 83.50 96.03 93.15 94.10 91.29 79101 140.78 133.74 153.80 149.19 150.73 146.21 79101 TC 44.84 42.60 48.99 47.52 48.01 46.56 79101 26 95.94 91.14 104.81 101.67 102.72 99.64 79200 137.48 130.61 150.20 145.69 147.20 142.78 79200 TC 51.12 48.56 55.84 54.17 54.73 53.08 79200 26 86.36 82.04 94.35 91.52 92.46 89.69 79300 26 80.39 76.37 87.83 85.19 86.07 83.49 79403 187.21 177.85 204.53 198.39 200.43 194.42 79403 TC 77.18 73.32 84.32 81.79 82.63 80.16 79403 26 110.03 104.53 120.21 116.60 117.81 114.26 79440 144.85 137.61 158.25 153.50 155.09 150.43 79440 TC 47.47 45.10 51.87 50.31 50.83 49.31 79440 26 97.38 92.51 106.39 103.19 104.26 101.13

Page 201: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 201Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

79445 26 115.47 109.70 126.16 122.37 123.64 119.92 80500 22.89 21.75 25.01 24.27 24.52 23.78 # 80500 19.93 18.93 21.77 21.11 21.33 20.69 80502 72.97 69.32 79.72 77.33 78.12 75.79 # 80502 70.34 66.82 76.84 74.54 75.30 73.05 83020 26 18.25 17.34 19.94 19.34 19.54 18.95 84165 26 18.25 17.34 19.94 19.34 19.54 18.95 84166 26 18.25 17.34 19.94 19.34 19.54 18.95 84181 26 18.25 17.34 19.94 19.34 19.54 18.95 84182 26 18.25 17.34 19.94 19.34 19.54 18.95 85060 24.77 23.53 27.06 26.24 26.52 25.71 85097 87.58 83.20 95.68 92.81 93.77 90.95 # 85097 50.02 47.52 54.65 53.00 53.56 51.95 85390 26 18.25 17.34 19.94 19.34 19.54 18.95 85396 20.59 19.56 22.49 21.82 22.05 21.38 85576 26 18.25 17.34 19.94 19.34 19.54 18.95 86077 55.62 52.84 60.77 58.94 59.55 57.76 # 86077 52.00 49.40 56.81 55.11 55.67 54.00 86078 55.62 52.84 60.77 58.94 59.55 57.76 # 86078 51.67 49.09 56.45 54.76 55.33 53.67 86079 55.30 52.54 60.42 58.60 59.21 57.43 # 86079 51.67 49.09 56.45 54.76 55.33 53.67 86153 26 34.38 32.66 37.56 36.43 36.81 35.71 86255 26 18.25 17.34 19.94 19.34 19.54 18.95 86256 26 18.25 17.34 19.94 19.34 19.54 18.95 86320 26 18.25 17.34 19.94 19.34 19.54 18.95 86325 26 18.25 17.34 19.94 19.34 19.54 18.95 86327 26 20.70 19.67 22.62 21.94 22.17 21.51 86334 26 18.25 17.34 19.94 19.34 19.54 18.95 86335 26 18.25 17.34 19.94 19.34 19.54 18.95 86486 4.64 4.41 5.07 4.92 4.97 4.82 86490 67.90 64.51 74.19 71.96 72.70 70.52 86510 5.63 5.35 6.15 5.97 6.03 5.85 86580 7.61 7.23 8.31 8.06 8.15 7.90 87164 26 18.25 17.34 19.94 19.34 19.54 18.95 87207 26 18.25 17.34 19.94 19.34 19.54 18.95 88104 70.89 67.35 77.45 75.13 75.90 73.62 88104 TC 41.54 39.46 45.38 44.02 44.47 43.14 88104 26 29.35 27.88 32.06 31.10 31.42 30.48 88106 60.78 57.74 66.40 64.41 65.08 63.12 88106 TC 40.88 38.84 44.67 43.32 43.77 42.46 88106 26 19.90 18.91 21.75 21.09 21.31 20.67 88108 59.67 56.69 65.19 63.24 63.89 61.97 88108 TC 36.60 34.77 39.99 38.79 39.18 38.02 88108 26 23.07 21.92 25.21 24.45 24.70 23.95 88112 64.96 61.71 70.97 68.84 69.55 67.46 88112 TC 36.60 34.77 39.99 38.79 39.18 38.02 88112 26 28.36 26.94 30.98 30.05 30.36 29.45 88120 592.09 562.49 646.86 627.46 633.93 614.92

Page 202: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 202Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

88120 TC 532.79 506.15 582.07 564.62 570.43 553.32 88120 26 59.30 56.34 64.79 62.85 63.49 61.59 88121 511.38 485.81 558.68 541.93 547.50 531.09 88121 TC 460.61 437.58 503.22 488.12 493.15 478.35 88121 26 50.77 48.23 55.46 53.80 54.36 52.72 88125 20.26 19.25 22.14 21.47 21.70 21.05 88125 TC 7.28 6.92 7.96 7.72 7.80 7.57 88125 26 12.98 12.33 14.18 13.75 13.89 13.48 88141 31.60 30.02 34.52 33.49 33.83 32.82 88160 69.07 65.62 75.46 73.20 73.96 71.74 88160 TC 42.53 40.40 46.46 45.07 45.53 44.17 88160 26 26.54 25.21 28.99 28.12 28.42 27.55 88161 62.48 59.36 68.26 66.22 66.90 64.89 88161 TC 36.93 35.08 40.34 39.13 39.54 38.35 88161 26 25.55 24.27 27.91 27.07 27.35 26.53 88162 95.26 90.50 104.08 100.96 101.99 98.93 88162 TC 55.41 52.64 60.54 58.72 59.33 57.55 88162 26 39.85 37.86 43.54 42.23 42.67 41.39 88172 55.49 52.72 60.63 58.81 59.42 57.64 88172 TC 18.48 17.56 20.19 19.58 19.79 19.19 88172 26 37.01 35.16 40.43 39.23 39.63 38.44 88173 147.22 139.86 160.84 156.01 157.62 152.89 88173 TC 74.85 71.11 81.78 79.33 80.14 77.74 88173 26 72.38 68.76 79.07 76.71 77.49 75.18 88177 29.60 28.12 32.34 31.37 31.69 30.74 88177 TC 6.92 6.57 7.56 7.33 7.41 7.18 88177 26 22.68 21.55 24.78 24.04 24.29 23.55 88182 113.74 108.05 124.26 120.53 121.77 118.12 88182 TC 75.86 72.07 82.88 80.40 81.22 78.79 88182 26 37.88 35.99 41.39 40.15 40.56 39.34 88184 56.70 53.87 61.95 60.09 60.71 58.89 88185 34.59 32.86 37.79 36.65 37.03 35.91 88187 56.65 53.82 61.89 60.04 60.65 58.85 88188 72.89 69.25 79.64 77.25 78.05 75.70 88189 90.24 85.73 98.59 95.63 96.62 93.73 88291 31.90 30.31 34.86 33.81 34.16 33.13 88300 15.45 14.68 16.88 16.38 16.55 16.05 88300 TC 10.90 10.36 11.91 11.56 11.67 11.33 88300 26 4.55 4.32 4.97 4.82 4.86 4.73 88302 29.10 27.65 31.80 30.84 31.17 30.22 88302 TC 21.77 20.68 23.78 23.07 23.31 22.61 88302 26 7.33 6.96 8.00 7.76 7.84 7.61 88304 38.92 36.97 42.52 41.24 41.66 40.41 88304 TC 27.04 25.69 29.54 28.66 28.96 28.08 88304 26 11.88 11.29 12.98 12.59 12.72 12.34 88305 66.21 62.90 72.34 70.16 70.89 68.76 88305 TC 27.37 26.00 29.90 29.00 29.30 28.43 88305 26 38.84 36.90 42.44 41.16 41.58 40.33 88307 252.61 239.98 275.98 267.70 270.46 262.34

Page 203: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 203Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

88307 TC 167.09 158.74 182.55 177.08 178.91 173.54 88307 26 85.51 81.23 93.41 90.61 91.55 88.79 88309 388.40 368.98 424.33 411.60 415.84 403.36 88309 TC 237.30 225.44 259.26 251.48 254.07 246.46 88309 26 151.10 143.55 165.08 160.13 161.78 156.93 88311 21.52 20.44 23.51 22.80 23.03 22.34 88311 TC 8.59 8.16 9.38 9.11 9.20 8.92 88311 26 12.93 12.28 14.12 13.70 13.83 13.42 88312 93.24 88.58 101.87 98.81 99.83 96.83 88312 TC 65.59 62.31 71.66 69.51 70.22 68.11 88312 26 27.65 26.27 30.21 29.30 29.60 28.72 88313 65.67 62.39 71.75 69.60 70.31 68.21 88313 TC 53.40 50.73 58.34 56.59 57.18 55.46 88313 26 12.27 11.66 13.41 13.01 13.14 12.74 88314 74.19 70.48 81.05 78.63 79.43 77.05 88314 TC 51.42 48.85 56.18 54.49 55.05 53.39 88314 26 22.77 21.63 24.87 24.13 24.38 23.64 88319 84.31 80.09 92.10 89.34 90.26 87.56 88319 TC 57.03 54.18 62.31 60.43 61.07 59.23 88319 26 27.29 25.93 29.82 28.92 29.22 28.35 88321 101.23 96.17 110.60 107.27 108.39 105.12 # 88321 86.08 81.78 94.05 91.23 92.16 89.40 88323 126.38 120.06 138.07 133.93 135.31 131.25 88323 TC 37.92 36.02 41.42 40.18 40.60 39.38 88323 26 88.47 84.05 96.66 93.76 94.73 91.89 88325 184.40 175.18 201.46 195.41 197.43 191.50 # 88325 154.09 146.39 168.35 163.30 164.98 160.03 88329 50.85 48.31 55.56 53.89 54.44 52.81 # 88329 37.01 35.16 40.43 39.23 39.63 38.44 88331 94.22 89.51 102.94 99.84 100.88 97.84 88331 TC 30.01 28.51 32.79 31.80 32.13 31.17 88331 26 64.21 61.00 70.15 68.05 68.75 66.69 88332 50.88 48.34 55.59 53.92 54.48 52.84 88332 TC 19.14 18.18 20.91 20.27 20.49 19.87 88332 26 31.75 30.16 34.68 33.65 33.99 32.97 88333 91.28 86.72 99.73 96.74 97.74 94.81 88333 TC 26.72 25.38 29.19 28.31 28.60 27.75 88333 26 64.57 61.34 70.54 68.43 69.13 67.06 88334 57.58 54.70 62.91 61.02 61.65 59.80 88334 TC 18.15 17.24 19.83 19.23 19.44 18.85 88334 26 39.44 37.47 43.09 41.80 42.23 40.96 88341 86.35 82.03 94.33 91.51 92.45 89.68 88341 TC 57.33 54.46 62.63 60.75 61.38 59.54 88341 26 29.02 27.57 31.71 30.75 31.07 30.14 88342 101.64 96.56 111.04 107.71 108.82 105.56 88342 TC 65.26 62.00 71.30 69.16 69.87 67.78 88342 26 36.38 34.56 39.74 38.55 38.95 37.78 88344 162.80 154.66 177.86 172.52 174.31 169.07 88344 TC 122.92 116.77 134.29 130.26 131.59 127.65

Page 204: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 204Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

88344 26 39.88 37.89 43.57 42.26 42.70 41.42 88346 90.20 85.69 98.54 95.59 96.58 93.68 88346 TC 53.07 50.42 57.98 56.25 56.82 55.12 88346 26 37.13 35.27 40.56 39.34 39.74 38.56 88348 327.22 310.86 357.49 346.76 350.34 339.83 88348 TC 249.55 237.07 272.63 264.45 267.18 259.16 88348 26 77.67 73.79 84.86 82.32 83.16 80.67 88350 69.96 66.46 76.43 74.14 74.90 72.66 88350 TC 40.52 38.49 44.26 42.94 43.38 42.08 88350 26 29.44 27.97 32.17 31.20 31.52 30.58 88355 138.27 131.36 151.06 146.53 148.04 143.60 88355 TC 55.05 52.30 60.15 58.34 58.94 57.18 88355 26 83.23 79.07 90.93 88.21 89.11 86.45 88356 203.15 192.99 221.94 215.28 217.50 210.98 88356 TC 80.15 76.14 87.56 84.94 85.81 83.24 88356 26 123.01 116.86 134.39 130.35 131.70 127.74 88358 86.24 81.93 94.22 91.39 92.33 89.56 88358 TC 39.56 37.58 43.22 41.92 42.35 41.08 88358 26 46.67 44.34 50.99 49.46 49.97 48.47 88360 133.79 127.10 146.17 141.78 143.24 138.94 88360 TC 77.78 73.89 84.97 82.42 83.27 80.78 88360 26 56.01 53.21 61.19 59.35 59.97 58.17 88361 147.56 140.18 161.21 156.37 157.99 153.24 88361 TC 87.99 83.59 96.13 93.24 94.21 91.38 88361 26 59.57 56.59 65.08 63.12 63.78 61.86 88362 222.08 210.98 242.63 235.35 237.77 230.64 88362 TC 110.43 104.91 120.65 117.02 118.23 114.68 88362 26 111.66 106.08 121.99 118.34 119.55 115.97 88363 23.22 22.06 25.37 24.61 24.86 24.12 # 88363 19.93 18.93 21.77 21.11 21.33 20.69 88364 124.38 118.16 135.88 131.81 133.17 129.18 88364 TC 88.65 84.22 96.85 93.94 94.92 92.07 88364 26 35.72 33.93 39.02 37.85 38.24 37.09 88365 167.74 159.35 183.25 177.76 179.58 174.20 88365 TC 122.59 116.46 133.93 129.92 131.25 127.32 88365 26 45.15 42.89 49.32 47.84 48.33 46.89 88366 242.62 230.49 265.06 257.12 259.76 251.98 88366 TC 179.25 170.29 195.83 189.96 191.91 186.16 88366 26 63.37 60.20 69.23 67.15 67.85 65.80 88367 100.71 95.67 110.02 106.72 107.82 104.58 88367 TC 65.26 62.00 71.30 69.16 69.87 67.78 88367 26 35.45 33.68 38.73 37.57 37.96 36.82 88368 111.37 105.80 121.67 118.02 119.23 115.67 88368 TC 69.87 66.38 76.34 74.05 74.81 72.57 88368 26 41.49 39.42 45.33 43.98 44.42 43.10 88369 101.61 96.53 111.01 107.67 108.79 105.52 88369 TC 68.89 65.45 75.27 73.01 73.76 71.55 88369 26 32.73 31.09 35.75 34.68 35.04 33.99 88371 26 18.25 17.34 19.94 19.34 19.54 18.95

Page 205: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 205Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

88372 26 18.25 17.34 19.94 19.34 19.54 18.95 88373 75.21 71.45 82.17 79.71 80.52 78.11 88373 TC 47.11 44.75 51.46 49.92 50.44 48.92 88373 26 28.09 26.69 30.69 29.77 30.08 29.18 88374 318.12 302.21 347.54 337.11 340.60 330.37 88374 TC 272.82 259.18 298.06 289.11 292.10 283.33 88374 26 45.30 43.04 49.50 48.01 48.51 47.06 88375 45.98 43.68 50.23 48.73 49.23 47.75 88377 380.81 361.77 416.04 403.56 407.71 395.49 88377 TC 315.35 299.58 344.52 334.18 337.63 327.50 88377 26 65.46 62.19 71.52 69.37 70.09 67.98 88380 130.64 124.11 142.73 138.45 139.87 135.68 88380 TC 74.52 70.79 81.41 78.97 79.78 77.40 88380 26 56.13 53.32 61.32 59.48 60.09 58.29 88381 114.65 108.92 125.26 121.50 122.75 119.07 88381 TC 89.01 84.56 97.24 94.32 95.30 92.44 88381 26 25.64 24.36 28.01 27.17 27.45 26.63 88387 37.49 35.62 40.96 39.73 40.15 38.94 88387 TC 6.95 6.60 7.59 7.36 7.44 7.21 88387 26 30.55 29.02 33.37 32.37 32.71 31.73 88388 33.67 31.99 36.79 35.68 36.05 34.97 88388 TC 9.25 8.79 10.11 9.81 9.90 9.61 88388 26 24.42 23.20 26.68 25.88 26.15 25.36 89049 252.85 240.21 276.24 267.95 270.72 262.59 # 89049 66.05 62.75 72.16 70.00 70.73 68.60 89060 26 18.25 17.34 19.94 19.34 19.54 18.95 89220 15.18 14.42 16.58 16.09 16.25 15.77 89230 3.98 3.78 4.35 4.22 4.26 4.14 90460 24.25 23.04 26.50 25.70 25.97 25.19 90461 12.33 11.71 13.47 13.06 13.20 12.80 90471 24.25 23.04 26.50 25.70 25.97 25.19 90472 12.33 11.71 13.47 13.06 13.20 12.80 90473 24.25 23.04 26.50 25.70 25.97 25.19 90474 12.33 11.71 13.47 13.06 13.20 12.80 90785 13.85 13.16 15.13 14.69 14.84 14.39 90791 130.39 123.87 142.45 138.17 139.60 135.41 # 90791 126.44 120.12 138.14 134.00 135.38 131.32 90792 146.07 138.77 159.59 154.80 156.39 151.71 # 90792 142.11 135.00 155.25 150.59 152.15 147.58 90832 63.53 60.35 69.40 67.32 68.01 65.98 # 90832 62.87 59.73 68.69 66.63 67.32 65.30 90833 65.90 62.61 72.00 69.84 70.56 68.45 # 90833 65.24 61.98 71.28 69.14 69.85 67.76 90834 84.50 80.28 92.32 89.55 90.47 87.76 # 90834 83.84 79.65 91.60 88.85 89.77 87.07 90836 83.25 79.09 90.95 88.23 89.14 86.47 # 90836 82.59 78.46 90.23 87.53 88.42 85.78 90837 126.76 120.42 138.48 134.33 135.71 131.64 # 90837 126.11 119.80 137.77 133.64 135.01 130.97

Page 206: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 206Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

90838 109.81 104.32 119.97 116.37 117.56 114.05 # 90838 109.15 103.69 119.24 115.67 116.86 113.36 90839 132.42 125.80 144.67 140.33 141.77 137.53 # 90839 131.43 124.86 143.59 139.28 140.71 136.49 90840 63.20 60.04 69.05 66.98 67.67 65.64 # 90840 62.87 59.73 68.69 66.63 67.32 65.30 90845 90.75 86.21 99.14 96.16 97.16 94.24 # 90845 90.42 85.90 98.79 95.82 96.81 93.90 90846 102.21 97.10 111.67 108.32 109.43 106.16 # 90846 101.55 96.47 110.94 107.62 108.72 105.47 90847 106.13 100.82 115.94 112.47 113.62 110.22 # 90847 105.47 100.20 115.23 111.77 112.93 109.54 90849 34.11 32.40 37.26 36.14 36.51 35.42 # 90849 30.82 29.28 33.67 32.66 32.99 32.00 90853 25.52 24.24 27.88 27.04 27.32 26.50 # 90853 25.19 23.93 27.52 26.69 26.97 26.16 90865 163.85 155.66 179.01 173.64 175.43 170.17 # 90865 127.94 121.54 139.77 135.57 136.98 132.86 90867 187.89 178.50 205.28 199.12 201.17 195.14 # 90867 113.76 108.07 124.28 120.55 121.80 118.14 90868 173.30 164.64 189.34 183.66 185.55 179.99 # 90868 23.66 22.48 25.85 25.08 25.33 24.58 90869 169.17 160.71 184.82 179.27 181.13 175.69 # 90869 95.03 90.28 103.82 100.71 101.74 98.69 90870 171.72 163.13 187.60 181.98 183.85 178.34 # 90870 110.44 104.92 120.66 117.04 118.24 114.69 90880 100.57 95.54 109.87 106.57 107.67 104.44 # 90880 93.00 88.35 101.60 98.56 99.57 96.59 90901 35.53 33.75 38.81 37.65 38.04 36.90 # 90901 19.38 18.41 21.17 20.54 20.75 20.13 90911 81.53 77.45 89.07 86.40 87.29 84.67 # 90911 44.31 42.09 48.40 46.95 47.44 46.01 90935 71.80 68.21 78.44 76.08 76.88 74.57 90937 103.42 98.25 112.99 109.60 110.73 107.40 90945 84.58 80.35 92.40 89.63 90.55 87.84 90947 123.16 117.00 134.55 130.51 131.86 127.90 90951 935.04 888.29 1,021.53 990.89 1,001.10 971.07 90952 460.47 437.45 503.07 487.98 493.01 478.22 90953 396.22 376.41 432.87 419.89 424.21 411.49 90954 807.96 767.56 882.69 856.21 865.04 839.09 90955 453.46 430.79 495.41 480.55 485.50 470.94 90956 314.44 298.72 343.53 333.22 336.66 326.55 90957 637.98 606.08 696.99 676.09 683.05 662.56 90958 431.20 409.64 471.09 456.95 461.67 447.81 90959 292.54 277.91 319.60 310.01 313.20 303.81 90960 279.68 265.70 305.56 296.39 299.45 290.47 90961 234.66 222.93 256.37 248.68 251.24 243.71 90962 180.45 171.43 197.14 191.23 193.20 187.40 90963 539.61 512.63 589.52 571.84 577.74 560.41

Page 207: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 207Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

90964 471.65 448.07 515.28 499.82 504.98 489.83 90965 448.79 426.35 490.30 475.59 480.49 466.08 90966 233.97 222.27 255.61 247.94 250.49 242.98 90967 17.89 17.00 19.55 18.96 19.16 18.58 90968 15.44 14.67 16.87 16.36 16.54 16.04 90969 15.08 14.33 16.48 15.99 16.15 15.66 90970 7.69 7.31 8.41 8.15 8.23 7.99 90997 89.45 84.98 97.73 94.79 95.77 92.90 91010 167.77 159.38 183.29 177.79 179.62 174.24 91010 TC 100.84 95.80 110.17 106.87 107.96 104.73 91010 26 66.93 63.58 73.12 70.92 71.66 69.51 91013 22.30 21.19 24.37 23.63 23.89 23.16 91013 TC 12.85 12.21 14.04 13.62 13.77 13.34 91013 26 9.45 8.98 10.33 10.02 10.12 9.82 91020 221.25 210.19 241.72 234.46 236.89 229.77 91020 TC 146.67 139.34 160.24 155.43 157.03 152.33 91020 26 74.59 70.86 81.49 79.04 79.86 77.46 91022 160.60 152.57 175.46 170.19 171.95 166.78 91022 TC 85.69 81.41 93.62 90.82 91.75 89.00 91022 26 74.92 71.17 81.85 79.38 80.21 77.80 91030 127.69 121.31 139.51 135.32 136.71 132.62 91030 TC 81.08 77.03 88.58 85.93 86.81 84.21 91030 26 46.61 44.28 50.92 49.39 49.90 48.40 91034 178.03 169.13 194.50 188.67 190.61 184.90 91034 TC 127.20 120.84 138.97 134.79 136.18 132.10 91034 26 50.83 48.29 55.53 53.87 54.42 52.79 91035 451.47 428.90 493.24 478.43 483.37 468.87 91035 TC 367.70 349.32 401.72 389.67 393.68 381.87 91035 26 83.77 79.58 91.52 88.77 89.69 87.00 91037 151.94 144.34 165.99 161.01 162.67 157.79 91037 TC 101.50 96.43 110.89 107.57 108.68 105.42 91037 26 50.44 47.92 55.11 53.45 54.00 52.38 91038 420.21 399.20 459.08 445.30 449.90 436.40 91038 TC 362.76 344.62 396.31 384.42 388.39 376.73 91038 26 57.44 54.57 62.76 60.87 61.50 59.65 91040 399.67 379.69 436.64 423.55 427.92 415.07 91040 TC 349.58 332.10 381.92 370.46 374.28 363.06 91040 26 50.08 47.58 54.72 53.07 53.62 52.01 91065 70.16 66.65 76.65 74.35 75.12 72.86 91065 TC 59.99 56.99 65.54 63.57 64.23 62.30 91065 26 10.17 9.66 11.11 10.78 10.89 10.56 C 91110 794.09 754.39 867.55 841.52 850.20 824.69 C 91110 TC 642.47 610.35 701.90 680.85 687.86 667.23 91110 26 151.62 144.04 165.65 160.68 162.33 157.47 C 91111 694.65 659.92 758.91 736.14 743.73 721.42 C 91111 TC 642.47 610.35 701.90 680.85 687.86 667.23 91111 26 52.18 49.57 57.01 55.29 55.87 54.19 91112 1,006.41 956.09 1,099.50 1,066.52 1,077.52 1,045.19 91112 TC 897.14 852.28 980.12 950.72 960.51 931.71

Page 208: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 208Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

91112 26 109.26 103.80 119.37 115.79 116.98 113.48 91117 139.16 132.20 152.03 147.46 148.99 144.52 91120 398.77 378.83 435.65 422.59 426.94 414.14 91120 TC 348.60 331.17 380.85 369.41 373.23 362.03 91120 26 50.17 47.66 54.81 53.16 53.72 52.11 91122 218.80 207.86 239.04 231.86 234.26 227.23 91122 TC 127.89 121.50 139.73 135.54 136.93 132.83 91122 26 90.92 86.37 99.33 96.35 97.34 94.42 91132 138.67 131.74 151.50 146.96 148.48 144.01 91132 TC 111.72 106.13 122.05 118.39 119.61 116.02 91132 26 26.96 25.61 29.45 28.57 28.87 27.99 91133 161.85 153.76 176.82 171.52 173.28 168.10 91133 TC 127.20 120.84 138.97 134.79 136.18 132.10 91133 26 34.65 32.92 37.86 36.72 37.10 35.98 91200 36.76 34.92 40.16 38.95 39.35 38.17 91200 TC 23.09 21.94 25.23 24.47 24.73 23.98 91200 26 13.67 12.99 14.94 14.49 14.64 14.20 92002 78.12 74.21 85.34 82.78 83.64 81.12 # 92002 47.48 45.11 51.88 50.32 50.84 49.31 92004 143.93 136.73 157.24 152.52 154.10 149.48 # 92004 98.80 93.86 107.94 104.70 105.78 102.60 92012 82.22 78.11 89.83 87.14 88.03 85.39 # 92012 52.24 49.63 57.07 55.36 55.94 54.26 92014 119.33 113.36 130.36 126.45 127.75 123.92 # 92014 79.14 75.18 86.46 83.86 84.73 82.18 92018 143.38 136.21 156.64 151.94 153.51 148.90 92019 71.57 67.99 78.19 75.84 76.62 74.32 92020 26.16 24.85 28.58 27.72 28.00 27.16 # 92020 20.89 19.85 22.83 22.14 22.37 21.70 92025 36.34 34.52 39.70 38.50 38.90 37.73 92025 TC 16.50 15.68 18.03 17.49 17.68 17.15 92025 26 19.84 18.85 21.68 21.02 21.24 20.60 92060 62.71 59.57 68.51 66.45 67.14 65.11 92060 TC 24.74 23.50 27.03 26.22 26.48 25.69 92060 26 37.97 36.07 41.48 40.24 40.65 39.43 92065 51.55 48.97 56.32 54.63 55.19 53.53 92065 TC 33.63 31.95 36.74 35.64 36.01 34.93 92065 26 17.92 17.02 19.57 18.99 19.18 18.61 92071 37.11 35.25 40.54 39.32 39.73 38.54 # 92071 33.15 31.49 36.21 35.13 35.49 34.43 92072 130.87 124.33 142.98 138.69 140.12 135.92 # 92072 101.87 96.78 111.30 107.96 109.07 105.80 92081 32.57 30.94 35.58 34.51 34.87 33.82 92081 TC 16.50 15.68 18.03 17.49 17.68 17.15 92081 26 16.07 15.27 17.56 17.03 17.20 16.69 92082 46.37 44.05 50.66 49.14 49.65 48.16 92082 TC 24.74 23.50 27.03 26.22 26.48 25.69 92082 26 21.63 20.55 23.63 22.92 23.16 22.46 92083 61.49 58.42 67.18 65.17 65.84 63.87

Page 209: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 209Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

92083 TC 33.96 32.26 37.10 35.98 36.35 35.26 92083 26 27.53 26.15 30.07 29.18 29.47 28.59 92100 76.31 72.49 83.36 80.87 81.70 79.25 # 92100 33.81 32.12 36.94 35.83 36.20 35.12 92132 29.93 28.43 32.69 31.72 32.04 31.08 92132 TC 13.54 12.86 14.79 14.34 14.49 14.05 92132 26 16.40 15.58 17.92 17.38 17.56 17.03 92133 36.16 34.35 39.50 38.32 38.71 37.55 92133 TC 13.87 13.18 15.16 14.70 14.86 14.40 92133 26 22.29 21.18 24.36 23.62 23.87 23.15 92134 39.60 37.62 43.26 41.96 42.40 41.12 92134 TC 14.20 13.49 15.51 15.05 15.20 14.75 92134 26 25.40 24.13 27.75 26.92 27.20 26.38 92136 85.33 81.06 93.22 90.42 91.36 88.62 92136 TC 54.39 51.67 59.42 57.64 58.24 56.49 92136 26 30.94 29.39 33.80 32.79 33.12 32.13 92145 17.36 16.49 18.96 18.40 18.58 18.03 92145 TC 7.61 7.23 8.31 8.06 8.15 7.90 92145 26 9.75 9.26 10.65 10.33 10.43 10.12 92225 26.19 24.88 28.61 27.75 28.04 27.20 # 92225 21.24 20.18 23.21 22.51 22.75 22.06 92226 24.06 22.86 26.29 25.50 25.76 24.99 # 92226 18.79 17.85 20.53 19.91 20.11 19.50 92227 13.54 12.86 14.79 14.34 14.49 14.05 92228 33.43 31.76 36.52 35.43 35.79 34.72 92228 TC 12.55 11.92 13.71 13.29 13.43 13.03 92228 26 20.89 19.85 22.83 22.14 22.37 21.70 92230 55.55 52.77 60.69 58.87 59.47 57.70 # 92230 32.49 30.87 35.50 34.43 34.79 33.74 92235 81.99 77.89 89.57 86.88 87.78 85.15 92235 TC 39.23 37.27 42.86 41.57 42.00 40.74 92235 26 42.76 40.62 46.71 45.31 45.78 44.40 92240 195.83 186.04 213.95 207.53 209.67 203.38 92240 TC 149.93 142.43 163.79 158.88 160.52 155.71 92240 26 45.90 43.61 50.15 48.65 49.15 47.67 92242 213.74 203.05 233.51 226.50 228.84 221.97 92242 TC 159.16 151.20 173.88 168.66 170.41 165.29 92242 26 54.58 51.85 59.63 57.83 58.43 56.67 92250 62.51 59.38 68.29 66.24 66.92 64.92 92250 TC 40.88 38.84 44.67 43.32 43.77 42.46 92250 26 21.63 20.55 23.63 22.92 23.16 22.46 92260 17.75 16.86 19.39 18.80 19.00 18.42 # 92260 10.83 10.29 11.83 11.48 11.59 11.25 92265 81.84 77.75 89.41 86.73 87.63 85.00 92265 TC 35.94 34.14 39.26 38.09 38.48 37.33 92265 26 45.90 43.61 50.15 48.65 49.15 47.67 92270 87.80 83.41 95.92 93.05 94.00 91.18 92270 TC 47.14 44.78 51.50 49.96 50.46 48.96 92270 26 40.66 38.63 44.42 43.09 43.54 42.23

Page 210: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 210Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

92275 141.43 134.36 154.51 149.88 151.42 146.88 92275 TC 87.69 83.31 95.81 92.93 93.89 91.07 92275 26 53.74 51.05 58.71 56.95 57.53 55.81 92283 52.61 49.98 57.48 55.75 56.33 54.64 92283 TC 43.19 41.03 47.18 45.77 46.24 44.85 92283 26 9.42 8.95 10.29 9.98 10.09 9.79 92284 59.08 56.13 64.55 62.62 63.26 61.36 92284 TC 46.48 44.16 50.78 49.27 49.77 48.28 92284 26 12.60 11.97 13.77 13.35 13.49 13.09 92285 19.64 18.66 21.46 20.82 21.03 20.40 92285 TC 16.50 15.68 18.03 17.49 17.68 17.15 92285 26 3.14 2.98 3.43 3.32 3.36 3.25 92286 37.15 35.29 40.58 39.36 39.77 38.58 92286 TC 15.18 14.42 16.58 16.09 16.25 15.77 92286 26 21.96 20.86 23.99 23.26 23.51 22.80 92287 130.63 124.10 142.72 138.44 139.86 135.67 92287 TC 84.40 80.18 92.21 89.44 90.37 87.64 92287 26 46.23 43.92 50.51 48.99 49.50 48.01 92311 97.19 92.33 106.18 102.99 104.05 100.94 # 92311 55.35 52.58 60.47 58.65 59.26 57.48 92312 113.20 107.54 123.67 119.96 121.20 117.55 # 92312 64.12 60.91 70.05 67.94 68.64 66.59 92313 92.41 87.79 100.96 97.93 98.93 95.98 # 92313 46.94 44.59 51.28 49.74 50.26 48.75 92315 70.24 66.73 76.74 74.44 75.21 72.96 # 92315 22.14 21.03 24.18 23.46 23.70 22.99 92316 88.38 83.96 96.55 93.66 94.62 91.78 # 92316 33.03 31.38 36.09 35.01 35.36 34.30 92317 71.92 68.32 78.57 76.21 76.99 74.68 # 92317 22.83 21.69 24.94 24.20 24.45 23.71 92325 39.23 37.27 42.86 41.57 42.00 40.74 92326 32.65 31.02 35.67 34.60 34.96 33.91 92502 95.01 90.26 103.80 100.68 101.72 98.67 92504 28.23 26.82 30.84 29.92 30.22 29.33 # 92504 9.45 8.98 10.33 10.02 10.12 9.82 92507 77.44 73.57 84.61 82.06 82.92 80.42 92508 22.42 21.30 24.50 23.76 24.00 23.29 92511 104.70 99.47 114.39 110.96 112.10 108.74 # 92511 37.49 35.62 40.96 39.73 40.15 38.94 92512 58.07 55.17 63.45 61.54 62.18 60.31 # 92512 28.42 27.00 31.05 30.12 30.43 29.52 92516 66.26 62.95 72.39 70.22 70.94 68.82 # 92516 22.77 21.63 24.87 24.13 24.38 23.64 92520 73.19 69.53 79.96 77.56 78.36 76.00 # 92520 40.90 38.86 44.69 43.34 43.79 42.48 92521 108.83 103.39 118.90 115.33 116.52 113.02 92522 90.28 85.77 98.64 95.68 96.66 93.77 92523 192.03 182.43 209.79 203.50 205.60 199.43 92524 87.31 82.94 95.38 92.52 93.47 90.67

Page 211: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 211Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

92526 84.15 79.94 91.93 89.17 90.09 87.39 92537 39.41 37.44 43.06 41.77 42.19 40.93 92537 TC 7.94 7.54 8.67 8.41 8.50 8.23 92537 26 31.48 29.91 34.40 33.36 33.71 32.69 92538 20.05 19.05 21.91 21.25 21.47 20.83 92538 TC 4.31 4.09 4.70 4.57 4.61 4.47 92538 26 15.74 14.95 17.19 16.68 16.85 16.34 92540 99.80 94.81 109.03 105.77 106.85 103.65 92540 TC 20.78 19.74 22.70 22.02 22.25 21.59 92540 26 79.02 75.07 86.33 83.74 84.61 82.06 92541 24.30 23.09 26.55 25.76 26.02 25.24 92541 TC 3.32 3.15 3.62 3.52 3.55 3.45 92541 26 20.97 19.92 22.91 22.22 22.45 21.77 92542 27.53 26.15 30.07 29.18 29.47 28.59 92542 TC 2.66 2.53 2.91 2.82 2.85 2.76 92542 26 24.86 23.62 27.16 26.35 26.62 25.82 92544 16.67 15.84 18.22 17.66 17.85 17.31 92544 TC 2.34 2.22 2.55 2.47 2.51 2.43 92544 26 14.33 13.61 15.65 15.18 15.34 14.88 92545 14.96 14.21 16.34 15.85 16.02 15.53 92545 TC 2.01 1.91 2.20 2.13 2.15 2.08 92545 26 12.95 12.30 14.15 13.72 13.86 13.44 92546 96.48 91.66 105.41 102.25 103.30 100.20 92546 TC 81.76 77.67 89.32 86.64 87.54 84.90 92546 26 14.72 13.98 16.08 15.59 15.76 15.28 92547 5.60 5.32 6.12 5.93 5.99 5.82 92548 94.14 89.43 102.84 99.76 100.79 97.77 92548 TC 68.23 64.82 74.54 72.31 73.05 70.86 92548 26 25.91 24.61 28.30 27.45 27.74 26.90 92550 20.86 19.82 22.79 22.11 22.33 21.68 92552 29.35 27.88 32.06 31.10 31.42 30.48 92553 34.95 33.20 38.18 37.03 37.42 36.29 92555 21.77 20.68 23.78 23.07 23.31 22.61 92556 35.28 33.52 38.55 37.39 37.78 36.64 92557 37.10 35.25 40.54 39.32 39.73 38.54 # 92557 32.49 30.87 35.50 34.43 34.79 33.74 92561 35.97 34.17 39.30 38.11 38.51 37.35 92562 43.19 41.03 47.18 45.77 46.24 44.85 92563 28.69 27.26 31.35 30.41 30.72 29.80 92564 25.40 24.13 27.75 26.92 27.20 26.38 92565 14.53 13.80 15.87 15.40 15.55 15.09 92567 14.13 13.42 15.43 14.97 15.12 14.67 # 92567 10.83 10.29 11.83 11.48 11.59 11.25 92568 15.74 14.95 17.19 16.68 16.85 16.34 # 92568 15.41 14.64 16.84 16.33 16.50 16.01 92570 31.69 30.11 34.63 33.59 33.94 32.92 # 92570 29.71 28.22 32.45 31.48 31.81 30.84 92571 25.40 24.13 27.75 26.92 27.20 26.38 92572 29.38 27.91 32.10 31.13 31.45 30.51

Page 212: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 212Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

92575 54.42 51.70 59.46 57.67 58.27 56.52 92576 33.96 32.26 37.10 35.98 36.35 35.26 92577 14.20 13.49 15.51 15.05 15.20 14.75 92579 44.65 42.42 48.78 47.32 47.81 46.38 # 92579 38.06 36.16 41.58 40.34 40.76 39.54 92582 62.33 59.21 68.09 66.04 66.73 64.72 92583 46.81 44.47 51.14 49.61 50.12 48.62 92584 68.59 65.16 74.93 72.69 73.44 71.24 92585 127.77 121.38 139.59 135.40 136.79 132.70 92585 TC 101.20 96.14 110.56 107.25 108.35 105.10 92585 26 26.57 25.24 29.03 28.15 28.45 27.59 92586 80.45 76.43 87.89 85.26 86.14 83.56 92587 21.19 20.13 23.15 22.46 22.69 22.01 92587 TC 2.99 2.84 3.27 3.16 3.20 3.11 92587 26 18.19 17.28 19.87 19.27 19.47 18.88 92588 32.67 31.04 35.70 34.63 34.98 33.94 92588 TC 3.65 3.47 3.99 3.88 3.91 3.80 92588 26 29.02 27.57 31.71 30.75 31.07 30.14 92596 38.60 36.67 42.17 40.91 41.33 40.09 92597 71.45 67.88 78.06 75.72 76.50 74.20 92601 145.13 137.87 158.55 153.79 155.38 150.72 # 92601 120.75 114.71 131.92 127.96 129.28 125.40 92602 81.15 77.09 88.65 86.00 86.88 84.27 # 92602 66.00 62.70 72.11 69.94 70.67 68.54 92603 148.55 141.12 162.29 157.42 159.05 154.27 # 92603 121.21 115.15 132.42 128.46 129.78 125.89 92604 87.84 83.45 95.97 93.09 94.05 91.23 # 92604 67.41 64.04 73.65 71.44 72.17 70.01 92607 124.61 118.38 136.14 132.05 133.41 129.41 92608 51.57 48.99 56.34 54.65 55.21 53.56 92609 107.35 101.98 117.28 113.76 114.93 111.48 92610 84.06 79.86 91.84 89.08 90.00 87.30 # 92610 72.20 68.59 78.88 76.51 77.30 74.98 92611 85.22 80.96 93.10 90.31 91.24 88.50 92612 178.91 169.96 195.45 189.59 191.54 185.79 # 92612 68.21 64.80 74.52 72.29 73.03 70.84 92613 38.17 36.26 41.70 40.45 40.86 39.64 92614 138.72 131.78 151.55 147.00 148.51 144.06 # 92614 66.90 63.56 73.09 70.90 71.63 69.48 92615 33.27 31.61 36.35 35.26 35.63 34.56 92616 198.94 188.99 217.34 210.82 212.99 206.60 # 92616 100.44 95.42 109.73 106.44 107.54 104.32 92617 41.68 39.60 45.54 44.17 44.63 43.29 92620 92.88 88.24 101.48 98.43 99.45 96.46 # 92620 82.01 77.91 89.60 86.91 87.80 85.17 92621 21.81 20.72 23.83 23.12 23.36 22.66 # 92621 18.85 17.91 20.60 19.98 20.18 19.57 92625 69.42 65.95 75.84 73.57 74.32 72.09 # 92625 62.17 59.06 67.92 65.88 66.56 64.56

Page 213: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 213Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

92626 88.28 83.87 96.45 93.55 94.52 91.68 # 92626 75.76 71.97 82.77 80.28 81.11 78.67 92627 21.76 20.67 23.77 23.06 23.30 22.60 # 92627 17.80 16.91 19.45 18.86 19.06 18.48 92640 109.49 104.02 119.62 116.04 117.23 113.71 # 92640 95.00 90.25 103.79 100.67 101.72 98.66 92920 545.83 518.54 596.32 578.43 584.40 566.86 92924 651.57 618.99 711.84 690.48 697.60 676.67 92928 607.54 577.16 663.73 643.83 650.46 630.95 92933 681.54 647.46 744.58 722.25 729.69 707.80 92937 607.18 576.82 663.34 643.45 650.07 630.58 92941 682.94 648.79 746.11 723.73 731.18 709.25 92943 682.23 648.12 745.34 722.98 730.43 708.53 92950 296.48 281.66 323.91 314.19 317.43 307.91 # 92950 189.08 179.63 206.57 200.38 202.45 196.37 92953 1.05 1.00 1.15 1.12 1.13 1.09 92960 154.22 146.51 168.49 163.43 165.12 160.16 # 92960 109.74 104.25 119.89 116.29 117.50 113.97 92961 253.73 241.04 277.20 268.88 271.65 263.50 92970 188.23 178.82 205.64 199.48 201.53 195.49 92971 102.93 97.78 112.45 109.08 110.19 106.89 92973 181.47 172.40 198.26 192.31 194.29 188.47 92974 166.37 158.05 181.76 176.31 178.12 172.78 92975 386.91 367.56 422.69 410.01 414.24 401.81 92977 64.84 61.60 70.84 68.71 69.43 67.34 92978 278.50 264.58 304.27 295.14 298.18 289.24 92978 TC 180.57 171.54 197.27 191.35 193.33 187.52 92978 26 97.93 93.03 106.98 103.78 104.85 101.71 92979 169.79 161.30 185.50 179.93 181.78 176.33 92979 TC 91.24 86.68 99.68 96.69 97.69 94.76 92979 26 78.55 74.62 85.81 83.24 84.10 81.57 92986 1,346.03 1,278.73 1,470.54 1,426.43 1,441.13 1,397.89 92987 1,389.25 1,319.79 1,517.76 1,472.23 1,487.40 1,442.79 92990 1,106.88 1,051.54 1,209.27 1,172.99 1,185.09 1,149.53 92997 662.87 629.73 724.19 702.47 709.71 688.41 92998 327.64 311.26 357.95 347.21 350.78 340.26 93000 16.37 15.55 17.88 17.34 17.53 17.00 93005 7.94 7.54 8.67 8.41 8.50 8.23 93010 8.44 8.02 9.22 8.95 9.04 8.76 93015 73.49 69.82 80.29 77.89 78.68 76.34 93016 22.14 21.03 24.18 23.46 23.70 22.99 93017 36.60 34.77 39.99 38.79 39.18 38.02 93018 14.75 14.01 16.11 15.63 15.79 15.32 93024 107.73 102.34 117.69 114.16 115.33 111.87 93024 TC 50.79 48.25 55.49 53.82 54.38 52.74 93024 26 56.93 54.08 62.19 60.33 60.95 59.12 93025 153.87 146.18 168.11 163.06 164.75 159.79 93025 TC 116.99 111.14 127.81 123.98 125.26 121.50 93025 26 36.89 35.05 40.31 39.10 39.50 38.32

Page 214: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 214Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

93040 12.36 11.74 13.50 13.10 13.24 12.83 93041 5.30 5.04 5.80 5.62 5.68 5.51 93042 7.06 6.71 7.72 7.49 7.57 7.34 93050 17.03 16.18 18.61 18.04 18.24 17.69 93050 TC 8.27 7.86 9.04 8.76 8.86 8.59 93050 26 8.77 8.33 9.58 9.29 9.38 9.11 93224 86.65 82.32 94.67 91.83 92.77 89.99 93225 24.74 23.50 27.03 26.22 26.48 25.69 93226 35.28 33.52 38.55 37.39 37.78 36.64 93227 26.63 25.30 29.10 28.22 28.51 27.66 93228 26.00 24.70 28.41 27.55 27.84 27.00 93229 669.30 635.84 731.22 709.27 716.59 695.08 93260 63.24 60.08 69.09 67.02 67.71 65.68 93260 TC 19.80 18.81 21.63 20.99 21.19 20.57 93260 26 43.44 41.27 47.46 46.03 46.51 45.11 93261 57.97 55.07 63.33 61.43 62.07 60.20 93261 TC 19.80 18.81 21.63 20.99 21.19 20.57 93261 26 38.18 36.27 41.71 40.46 40.87 39.65 93268 191.41 181.84 209.12 202.84 204.93 198.78 93270 8.59 8.16 9.38 9.11 9.20 8.92 93271 157.51 149.63 172.07 166.91 168.64 163.58 93272 25.31 24.04 27.65 26.82 27.09 26.28 93278 29.13 27.67 31.82 30.87 31.19 30.25 93278 TC 16.83 15.99 18.39 17.84 18.02 17.48 93278 26 12.30 11.69 13.44 13.04 13.18 12.78 93279 48.78 46.34 53.29 51.69 52.22 50.66 93279 TC 16.50 15.68 18.03 17.49 17.68 17.15 93279 26 32.28 30.67 35.27 34.21 34.57 33.53 93280 56.74 53.90 61.99 60.12 60.74 58.91 93280 TC 18.48 17.56 20.19 19.58 19.79 19.19 93280 26 38.26 36.35 41.80 40.55 40.96 39.73 93281 66.68 63.35 72.85 70.67 71.39 69.25 93281 TC 21.77 20.68 23.78 23.07 23.31 22.61 93281 26 44.91 42.66 49.06 47.59 48.08 46.63 93282 61.59 58.51 67.29 65.26 65.94 63.96 93282 TC 19.14 18.18 20.91 20.27 20.49 19.87 93282 26 42.45 40.33 46.38 44.99 45.45 44.09 93283 79.63 75.65 87.00 84.39 85.26 82.70 93283 TC 22.10 21.00 24.15 23.43 23.67 22.95 93283 26 57.53 54.65 62.85 60.96 61.59 59.74 93284 88.19 83.78 96.35 93.46 94.42 91.59 93284 TC 25.40 24.13 27.75 26.92 27.20 26.38 93284 26 62.80 59.66 68.61 66.55 67.24 65.22 93285 40.82 38.78 44.60 43.26 43.70 42.40 93285 TC 14.85 14.11 16.23 15.74 15.90 15.43 93285 26 25.97 24.67 28.37 27.52 27.81 26.97 93286 26.31 24.99 28.74 27.88 28.16 27.32 93286 TC 11.23 10.67 12.27 11.90 12.03 11.66 93286 26 15.08 14.33 16.48 15.99 16.15 15.66

Page 215: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 215Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

93287 35.68 33.90 38.99 37.81 38.20 37.05 93287 TC 12.55 11.92 13.71 13.29 13.43 13.03 93287 26 23.13 21.97 25.27 24.51 24.76 24.01 93288 36.28 34.47 39.64 38.46 38.85 37.69 93288 TC 14.85 14.11 16.23 15.74 15.90 15.43 93288 26 21.42 20.35 23.40 22.70 22.93 22.25 93289 64.10 60.90 70.04 67.93 68.63 66.57 93289 TC 18.48 17.56 20.19 19.58 19.79 19.19 93289 26 45.62 43.34 49.84 48.35 48.84 47.38 93290 30.67 29.14 33.51 32.51 32.84 31.86 93290 TC 8.92 8.47 9.74 9.45 9.55 9.27 93290 26 21.75 20.66 23.76 23.05 23.29 22.59 93291 35.62 33.84 38.92 37.74 38.13 36.98 93291 TC 13.87 13.18 15.16 14.70 14.86 14.40 93291 26 21.75 20.66 23.76 23.05 23.29 22.59 93292 31.66 30.08 34.59 33.56 33.90 32.89 93292 TC 10.24 9.73 11.19 10.86 10.97 10.64 93292 26 21.42 20.35 23.40 22.70 22.93 22.25 93293 51.08 48.53 55.81 54.13 54.69 53.05 93293 TC 35.28 33.52 38.55 37.39 37.78 36.64 93293 26 15.80 15.01 17.26 16.74 16.92 16.41 93294 33.66 31.98 36.78 35.67 36.04 34.96 93295 67.31 63.94 73.53 71.32 72.06 69.90 93296 24.41 23.19 26.67 25.86 26.14 25.35 93297 26.33 25.01 28.76 27.90 28.19 27.34 93298 26.66 25.33 29.13 28.26 28.54 27.69 93299 28.41 26.99 31.04 30.11 30.42 29.51 93303 224.44 213.22 245.20 237.84 240.30 233.08 93303 TC 160.83 152.79 175.71 170.44 172.19 167.04 93303 26 63.60 60.42 69.48 67.40 68.09 66.06 93304 146.96 139.61 160.55 155.73 157.34 152.62 93304 TC 110.40 104.88 120.61 116.99 118.20 114.66 93304 26 36.56 34.73 39.94 38.74 39.15 37.97 93306 216.53 205.70 236.56 229.46 231.83 224.87 93306 TC 152.93 145.28 167.07 162.06 163.73 158.82 93306 26 63.60 60.42 69.48 67.40 68.09 66.06 93307 123.73 117.54 135.17 131.11 132.47 128.49 93307 TC 78.77 74.83 86.05 83.48 84.33 81.81 93307 26 44.97 42.72 49.13 47.66 48.15 46.70 93308 117.95 112.05 128.86 124.99 126.28 122.50 93308 TC 92.28 87.67 100.82 97.80 98.81 95.84 93308 26 25.67 24.39 28.05 27.21 27.49 26.67 93312 236.39 224.57 258.26 250.50 253.09 245.49 93312 TC 126.90 120.56 138.64 134.48 135.87 131.79 93312 26 109.49 104.02 119.62 116.04 117.23 113.71 93313 11.70 11.12 12.79 12.41 12.54 12.16 93314 226.38 215.06 247.32 239.90 242.37 235.11 93314 TC 134.81 128.07 147.28 142.86 144.34 140.01 93314 26 91.57 86.99 100.04 97.04 98.04 95.09

Page 216: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 216Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

93315 509.86 484.37 557.03 540.32 545.88 529.51 93315 TC 380.74 361.70 415.96 403.48 407.64 395.40 93315 26 129.12 122.66 141.06 136.83 138.24 134.09 93316 27.28 25.92 29.81 28.91 29.21 28.34 93317 26 93.57 88.89 102.22 99.15 100.18 97.18 93318 486.04 461.74 531.00 515.07 520.39 504.77 93318 TC 380.74 361.70 415.96 403.48 407.64 395.40 93318 26 105.30 100.04 115.05 111.60 112.75 109.37 93320 51.55 48.97 56.32 54.63 55.19 53.53 93320 TC 33.28 31.62 36.36 35.27 35.64 34.57 93320 26 18.28 17.37 19.98 19.38 19.57 18.99 93321 25.84 24.55 28.23 27.38 27.67 26.83 93321 TC 18.45 17.53 20.16 19.55 19.76 19.16 93321 26 7.39 7.02 8.07 7.83 7.91 7.67 93325 23.93 22.73 26.14 25.36 25.62 24.85 93325 TC 20.76 19.72 22.68 22.00 22.23 21.56 93325 26 3.17 3.01 3.46 3.36 3.39 3.29 93350 228.53 217.10 249.67 242.18 244.67 237.34 93350 TC 157.54 149.66 172.11 166.95 168.67 163.61 93350 26 70.99 67.44 77.56 75.23 76.00 73.73 93351 257.78 244.89 281.62 273.17 275.99 267.71 93351 TC 172.72 164.08 188.69 183.03 184.92 179.38 93351 26 85.05 80.80 92.92 90.14 91.06 88.33 93352 32.25 30.64 35.24 34.18 34.53 33.50 93355 227.80 216.41 248.87 241.41 243.89 236.58 93451 685.10 650.85 748.48 726.02 733.50 711.49 93451 TC 551.24 523.68 602.23 584.17 590.19 572.48 93451 26 133.86 127.17 146.25 141.85 143.32 139.01 93452 785.72 746.43 858.39 832.65 841.23 815.99 93452 TC 542.05 514.95 592.19 574.43 580.35 562.94 93452 26 243.67 231.49 266.21 258.23 260.89 253.07 93453 1,020.78 969.74 1,115.20 1,081.75 1,092.90 1,060.12 93453 TC 694.61 659.88 758.86 736.09 743.68 721.37 93453 26 326.17 309.86 356.34 345.64 349.21 338.73 93454 797.54 757.66 871.31 845.17 853.89 828.26 93454 TC 550.61 523.08 601.54 583.50 589.51 571.83 93454 26 246.93 234.58 269.77 261.67 264.37 256.44 93455 932.30 885.69 1,018.54 987.99 998.18 968.23 93455 TC 644.84 612.60 704.49 683.35 690.40 669.69 93455 26 287.46 273.09 314.05 304.64 307.77 298.54 93456 1,008.90 958.46 1,102.23 1,069.17 1,080.18 1,047.79 93456 TC 688.00 653.60 751.64 729.09 736.61 714.51 93456 26 320.90 304.86 350.59 340.07 343.57 333.27 93457 1,143.02 1,085.87 1,248.75 1,211.28 1,223.77 1,187.05 93457 TC 781.59 742.51 853.89 828.26 836.81 811.70 93457 26 361.43 343.36 394.86 383.02 386.96 375.36 93458 961.11 913.05 1,050.01 1,018.51 1,029.01 998.14 93458 TC 656.40 623.58 717.12 695.60 702.78 681.69 93458 26 304.72 289.48 332.90 322.92 326.24 316.46

Page 217: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 217Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

93459 1,065.89 1,012.60 1,164.49 1,129.55 1,141.20 1,106.97 93459 TC 720.64 684.61 787.30 763.68 771.56 748.41 93459 26 345.25 327.99 377.19 365.87 369.64 358.56 93460 1,149.58 1,092.10 1,255.92 1,218.24 1,230.80 1,193.87 93460 TC 763.14 724.98 833.73 808.71 817.05 792.55 93460 26 386.44 367.12 422.19 409.53 413.75 401.34 93461 1,314.65 1,248.92 1,436.26 1,393.17 1,407.53 1,365.30 93461 TC 887.35 842.98 969.43 940.34 950.04 921.54 93461 26 427.30 405.94 466.83 452.82 457.49 443.76 93462 214.09 203.39 233.90 226.88 229.22 222.34 93463 99.17 94.21 108.34 105.09 106.18 102.98 93464 243.40 231.23 265.91 257.93 260.60 252.77 93464 TC 155.86 148.07 170.28 165.17 166.88 161.87 93464 26 87.54 83.16 95.63 92.77 93.73 90.92 93503 130.86 124.32 142.97 138.68 140.10 135.91 93505 668.18 634.77 729.99 708.09 715.38 693.93 93505 TC 444.17 421.96 485.25 470.70 475.55 461.28 93505 26 224.01 212.81 244.73 237.39 239.83 232.65 93530 887.56 843.18 969.66 940.56 950.27 921.75 93530 TC 676.01 642.21 738.54 716.38 723.78 702.05 93530 26 211.55 200.97 231.12 224.18 226.49 219.70 93531 2,370.69 2,252.16 2,589.98 2,512.29 2,538.19 2,462.05 93531 TC 1,933.11 1,836.45 2,111.92 2,048.56 2,069.68 2,007.59 93531 26 437.58 415.70 478.06 463.71 468.50 454.45 93532 26 545.30 518.04 595.75 577.88 583.83 566.32 93533 26 364.30 346.09 398.00 386.07 390.05 378.35 93561 34.85 33.11 38.08 36.94 37.32 36.20 93561 TC 21.84 20.75 23.86 23.15 23.39 22.69 93561 26 13.01 12.36 14.21 13.79 13.93 13.51 93562 14.61 13.88 15.96 15.48 15.64 15.17 93562 TC 13.56 12.88 14.81 14.36 14.51 14.08 93562 26 1.05 1.00 1.15 1.12 1.13 1.09 93563 59.88 56.89 65.42 63.46 64.11 62.19 93564 63.05 59.90 68.89 66.82 67.51 65.48 93565 46.48 44.16 50.78 49.27 49.77 48.28 93566 153.98 146.28 168.22 163.17 164.85 159.91 # 93566 47.56 45.18 51.96 50.39 50.92 49.38 93567 130.99 124.44 143.11 138.82 140.24 136.05 # 93567 53.90 51.21 58.89 57.12 57.72 55.98 93568 138.22 131.31 151.01 146.48 147.98 143.54 # 93568 48.61 46.18 53.11 51.51 52.05 50.47 93571 278.50 264.58 304.27 295.14 298.18 289.24 93571 TC 180.57 171.54 197.27 191.35 193.33 187.52 93571 26 97.93 93.03 106.98 103.78 104.85 101.71 93572 169.87 161.38 185.59 180.02 181.87 176.42 93572 TC 91.32 86.75 99.76 96.77 97.77 94.84 93572 26 78.55 74.62 85.81 83.24 84.10 81.57 93580 1,002.33 952.21 1,095.04 1,062.19 1,073.15 1,040.95 93581 1,376.17 1,307.36 1,503.46 1,458.36 1,473.39 1,429.20

Page 218: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 218Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

93582 671.44 637.87 733.55 711.54 718.88 697.31 93583 761.02 722.97 831.42 806.47 814.79 790.34 93590 1,221.76 1,160.67 1,334.77 1,294.73 1,308.08 1,268.83 93591 1,013.90 963.21 1,107.69 1,074.46 1,085.54 1,052.96 93592 447.06 424.71 488.42 473.77 478.65 464.29 93600 199.66 189.68 218.13 211.59 213.77 207.36 93600 TC 78.51 74.58 85.77 83.19 84.05 81.52 93600 26 121.15 115.09 132.35 128.39 129.71 125.82 93602 162.82 154.68 177.88 172.55 174.33 169.10 93602 TC 44.33 42.11 48.43 46.98 47.46 46.03 93602 26 118.49 112.57 129.46 125.57 126.87 123.06 93603 185.72 176.43 202.89 196.81 198.84 192.88 93603 TC 67.23 63.87 73.45 71.24 71.98 69.82 93603 26 118.49 112.57 129.46 125.57 126.87 123.06 93609 392.74 373.10 429.07 416.20 420.49 407.87 93609 TC 108.92 103.47 118.99 115.43 116.61 113.11 93609 26 283.82 269.63 310.07 300.77 303.88 294.76 93610 222.27 211.16 242.83 235.55 237.98 230.84 93610 TC 54.49 51.77 59.54 57.75 58.34 56.60 93610 26 167.78 159.39 183.30 177.80 179.63 174.25 93612 231.03 219.48 252.40 244.84 247.35 239.94 93612 TC 64.62 61.39 70.60 68.48 69.18 67.11 93612 26 166.41 158.09 181.80 176.35 178.17 172.82 93613 406.76 386.42 444.38 431.05 435.49 422.43 93615 51.26 48.70 56.01 54.33 54.89 53.25 93615 TC 12.75 12.11 13.93 13.51 13.65 13.25 93615 26 38.51 36.58 42.07 40.80 41.23 39.99 93616 26 53.90 51.21 58.89 57.12 57.72 55.98 93618 384.41 365.19 419.97 407.36 411.57 399.22 93618 TC 158.11 150.20 172.73 167.54 169.28 164.20 93618 26 226.30 214.99 247.24 239.82 242.29 235.03 93619 706.75 671.41 772.12 748.96 756.68 733.98 93619 TC 307.58 292.20 336.03 325.94 329.31 319.42 93619 26 399.17 379.21 436.09 423.00 427.37 414.54 93620 988.84 939.40 1,080.31 1,047.90 1,058.70 1,026.95 93620 26 641.83 609.74 701.20 680.17 687.18 666.56 93621 26 120.10 114.10 131.22 127.28 128.59 124.74 93622 26 176.01 167.21 192.29 186.52 188.45 182.79 93623 242.57 230.44 265.01 257.06 259.70 251.92 93623 TC 79.63 75.65 87.00 84.39 85.26 82.70 93623 26 162.94 154.79 178.01 172.67 174.44 169.22 93624 327.33 310.96 357.60 346.87 350.45 339.94 93624 TC 79.63 75.65 87.00 84.39 85.26 82.70 93624 26 247.70 235.32 270.62 262.50 265.20 257.24 93631 26 406.74 386.40 444.36 431.03 435.47 422.41 93640 372.22 353.61 406.65 394.45 398.52 386.56 93640 TC 189.06 179.61 206.55 200.35 202.42 196.35 93640 26 183.16 174.00 200.10 194.10 196.10 190.21 93641 580.71 551.67 634.42 615.39 621.74 603.08

Page 219: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 219Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

93641 TC 261.23 248.17 285.40 276.83 279.69 271.30 93641 26 319.48 303.51 349.04 338.56 342.06 331.79 93642 338.96 322.01 370.31 359.20 362.91 352.02 93642 TC 76.16 72.35 83.20 80.71 81.54 79.10 93642 26 262.79 249.65 287.10 278.48 281.36 272.92 93644 212.90 202.26 232.60 225.62 227.94 221.11 93644 TC 54.06 51.36 59.06 57.29 57.88 56.14 93644 26 158.84 150.90 173.54 168.33 170.06 164.96 93650 603.99 573.79 659.86 640.07 646.66 627.27 93653 855.52 812.74 934.65 906.61 915.96 888.48 93654 1,145.74 1,088.45 1,251.72 1,214.17 1,226.68 1,189.88 93655 435.99 414.19 476.32 462.02 466.80 452.78 93656 1,149.42 1,091.95 1,255.74 1,218.07 1,230.63 1,193.71 93657 435.00 413.25 475.24 460.98 465.74 451.75 93660 153.42 145.75 167.61 162.59 164.27 159.33 93660 TC 59.36 56.39 64.85 62.91 63.55 61.65 93660 26 94.06 89.36 102.76 99.68 100.71 97.69 93662 298.47 283.55 326.08 316.30 319.56 309.97 93662 TC 155.19 147.43 169.54 164.46 166.15 161.17 93662 26 143.28 136.12 156.54 151.85 153.41 148.81 93701 22.76 21.62 24.86 24.12 24.37 23.63 93702 115.04 109.29 125.68 121.91 123.17 119.47 93724 268.27 254.86 293.09 284.29 287.22 278.61 93724 TC 26.06 24.76 28.47 27.62 27.90 27.07 93724 26 242.21 230.10 264.62 256.68 259.33 251.55 93745 75.60 71.82 82.59 80.12 80.94 78.52 93745 TC 28.50 27.08 31.14 30.21 30.52 29.60 93745 26 47.07 44.72 51.43 49.89 50.40 48.89 93750 55.02 52.27 60.11 58.31 58.90 57.14 # 93750 46.46 44.14 50.76 49.24 49.75 48.25 93784 51.28 48.72 56.03 54.35 54.91 53.26 93786 27.70 26.32 30.27 29.36 29.66 28.77 93788 4.97 4.72 5.43 5.27 5.32 5.16 93790 18.61 17.68 20.33 19.72 19.93 19.33 93797 15.71 14.92 17.16 16.64 16.81 16.31 # 93797 8.80 8.36 9.61 9.33 9.42 9.14 93798 24.27 23.06 26.52 25.73 25.99 25.21 # 93798 14.06 13.36 15.36 14.90 15.05 14.61 93880 191.40 181.83 209.10 202.84 204.92 198.78 93880 TC 151.28 143.72 165.28 160.32 161.98 157.11 93880 26 40.12 38.11 43.83 42.52 42.95 41.66 93882 121.96 115.86 133.24 129.24 130.57 126.65 93882 TC 96.56 91.73 105.49 102.33 103.39 100.28 93882 26 25.40 24.13 27.75 26.92 27.20 26.38 C 93886 254.62 241.89 278.17 269.82 272.61 264.43 C 93886 TC 207.62 197.24 226.83 220.02 222.30 215.61 93886 26 47.00 44.65 51.35 49.81 50.32 48.81 C 93888 129.48 123.01 141.46 137.22 138.63 134.47 C 93888 TC 103.48 98.31 113.06 109.66 110.79 107.47

Page 220: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 220Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

93888 26 26.00 24.70 28.41 27.55 27.84 27.00 C 93890 258.84 245.90 282.79 274.30 277.13 268.81 C 93890 TC 207.62 197.24 226.83 220.02 222.30 215.61 93890 26 51.22 48.66 55.96 54.28 54.84 53.20 C 93892 163.46 155.29 178.58 173.22 175.01 169.76 C 93892 TC 103.48 98.31 113.06 109.66 110.79 107.47 93892 26 59.98 56.98 65.53 63.56 64.22 62.28 C 93893 163.07 154.92 178.16 172.81 174.59 169.35 C 93893 TC 103.48 98.31 113.06 109.66 110.79 107.47 93893 26 59.60 56.62 65.11 63.16 63.81 61.89 93922 83.55 79.37 91.28 88.54 89.45 86.77 93922 TC 70.86 67.32 77.42 75.10 75.87 73.59 93922 26 12.68 12.05 13.86 13.44 13.58 13.18 93923 130.02 123.52 142.05 137.78 139.21 135.02 93923 TC 107.46 102.09 117.40 113.88 115.06 111.61 93923 26 22.55 21.42 24.63 23.90 24.14 23.41 93924 161.79 153.70 176.76 171.45 173.22 168.03 93924 TC 136.78 129.94 149.43 144.95 146.44 142.05 93924 26 25.01 23.76 27.32 26.51 26.77 25.98 93925 244.08 231.88 266.66 258.66 261.33 253.48 93925 TC 204.65 194.42 223.58 216.88 219.11 212.54 93925 26 39.43 37.46 43.08 41.79 42.22 40.95 C 93926 127.86 121.47 139.69 135.50 136.90 132.79 C 93926 TC 103.51 98.33 113.08 109.69 110.81 107.49 93926 26 24.35 23.13 26.60 25.81 26.07 25.29 93930 196.70 186.87 214.90 208.45 210.60 204.27 93930 TC 156.55 148.72 171.03 165.90 167.61 162.58 93930 26 40.15 38.14 43.86 42.55 42.99 41.70 93931 121.57 115.49 132.81 128.83 130.16 126.26 93931 TC 96.89 92.05 105.86 102.68 103.74 100.63 93931 26 24.68 23.45 26.97 26.16 26.43 25.65 93970 186.13 176.82 203.34 197.25 199.27 193.30 93970 TC 151.28 143.72 165.28 160.32 161.98 157.11 93970 26 34.85 33.11 38.08 36.94 37.32 36.20 93971 113.46 107.79 123.96 120.24 121.47 117.84 93971 TC 91.29 86.73 99.74 96.75 97.75 94.82 93971 26 22.17 21.06 24.22 23.49 23.74 23.02 C 93975 265.35 252.08 289.89 281.20 284.10 275.57 C 93975 TC 207.29 196.93 226.47 219.67 221.94 215.28 93975 26 58.07 55.17 63.45 61.54 62.18 60.31 C 93976 143.54 136.36 156.81 152.11 153.67 149.06 C 93976 TC 103.48 98.31 113.06 109.66 110.79 107.47 93976 26 40.06 38.06 43.77 42.46 42.90 41.61 93978 180.58 171.55 197.28 191.36 193.34 187.53 93978 TC 140.74 133.70 153.76 149.14 150.68 146.17 93978 26 39.84 37.85 43.53 42.22 42.65 41.38 93979 113.36 107.69 123.84 120.13 121.37 117.73 93979 TC 88.32 83.90 96.49 93.59 94.55 91.71 93979 26 25.04 23.79 27.36 26.54 26.81 26.01

Page 221: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 221Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

93980 117.19 111.33 128.03 124.19 125.47 121.70 93980 TC 55.71 52.92 60.86 59.03 59.64 57.85 93980 26 61.48 58.41 67.17 65.16 65.83 63.86 93981 70.30 66.79 76.81 74.51 75.27 73.01 93981 TC 48.13 45.72 52.58 51.00 51.53 49.98 93981 26 22.17 21.06 24.22 23.49 23.74 23.02 93982 42.18 40.07 46.08 44.70 45.16 43.80 C 93990 128.27 121.86 140.14 135.93 137.33 133.22 C 93990 TC 103.51 98.33 113.08 109.69 110.81 107.49 93990 26 24.77 23.53 27.06 26.24 26.52 25.71 94002 92.97 88.32 101.57 98.52 99.53 96.55 94003 66.95 63.60 73.14 70.94 71.68 69.53 94004 49.30 46.84 53.87 52.24 52.79 51.20 94010 33.83 32.14 36.96 35.86 36.23 35.14 94010 TC 25.40 24.13 27.75 26.92 27.20 26.38 94010 26 8.44 8.02 9.22 8.95 9.04 8.76 94011 91.46 86.89 99.92 96.92 97.92 94.98 94012 147.25 139.89 160.87 156.04 157.65 152.93 94013 20.07 19.07 21.93 21.28 21.49 20.85 94014 54.33 51.61 59.35 57.57 58.17 56.42 94015 29.02 27.57 31.71 30.75 31.07 30.14 94016 25.31 24.04 27.65 26.82 27.09 26.28 94060 57.52 54.64 62.84 60.95 61.58 59.73 94060 TC 44.51 42.28 48.62 47.16 47.64 46.22 94060 26 13.01 12.36 14.21 13.79 13.93 13.51 94070 57.89 55.00 63.25 61.35 61.99 60.12 94070 TC 29.02 27.57 31.71 30.75 31.07 30.14 94070 26 28.87 27.43 31.54 30.60 30.91 29.99 94200 24.43 23.21 26.69 25.89 26.16 25.37 94200 TC 18.81 17.87 20.55 19.93 20.14 19.53 94200 26 5.62 5.34 6.14 5.96 6.01 5.84 94250 25.09 23.84 27.42 26.59 26.86 26.06 94250 TC 19.47 18.50 21.28 20.64 20.85 20.23 94250 26 5.62 5.34 6.14 5.96 6.01 5.84 94375 37.87 35.98 41.38 40.14 40.55 39.33 94375 TC 23.09 21.94 25.23 24.47 24.73 23.98 94375 26 14.78 14.04 16.15 15.66 15.82 15.35 94400 54.31 51.59 59.33 57.55 58.14 56.40 94400 TC 34.62 32.89 37.82 36.69 37.06 35.95 94400 26 19.68 18.70 21.51 20.86 21.08 20.45 94450 65.84 62.55 71.93 69.77 70.50 68.38 94450 TC 45.82 43.53 50.06 48.55 49.06 47.59 94450 26 20.01 19.01 21.86 21.21 21.42 20.78 94452 54.67 51.94 59.73 57.94 58.54 56.78 94452 TC 40.22 38.21 43.94 42.62 43.07 41.77 94452 26 14.45 13.73 15.79 15.32 15.48 15.01 94453 75.72 71.93 82.72 80.24 81.06 78.63 94453 TC 56.70 53.87 61.95 60.09 60.71 58.89 94453 26 19.03 18.08 20.79 20.17 20.38 19.77

Page 222: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 222Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

94610 56.03 53.23 61.21 59.37 60.00 58.19 94620 54.38 51.66 59.41 57.63 58.22 56.48 94620 TC 23.75 22.56 25.94 25.16 25.43 24.66 94620 26 30.63 29.10 33.47 32.46 32.80 31.82 94621 155.96 148.16 170.38 165.28 166.98 161.98 94621 TC 87.04 82.69 95.09 92.24 93.20 90.40 94621 26 68.93 65.48 75.30 73.05 73.80 71.59 94640 17.16 16.30 18.75 18.18 18.37 17.81 94642 12.75 12.11 13.93 13.51 13.65 13.25 94644 41.21 39.15 45.02 43.68 44.13 42.80 94645 13.54 12.86 14.79 14.34 14.49 14.05 94660 61.71 58.62 67.41 65.39 66.07 64.08 # 94660 38.32 36.40 41.86 40.61 41.02 39.79 94662 35.39 33.62 38.66 37.50 37.89 36.75 94664 16.17 15.36 17.66 17.14 17.31 16.79 94667 24.77 23.53 27.06 26.24 26.52 25.71 94668 27.37 26.00 29.90 29.00 29.30 28.43 94669 30.70 29.17 33.55 32.53 32.88 31.88 94680 53.87 51.18 58.86 57.09 57.68 55.95 94680 TC 41.21 39.15 45.02 43.68 44.13 42.80 94680 26 12.65 12.02 13.82 13.41 13.55 13.14 94681 51.05 48.50 55.78 54.11 54.66 53.03 94681 TC 40.88 38.84 44.67 43.32 43.77 42.46 94681 26 10.17 9.66 11.11 10.78 10.89 10.56 94690 48.04 45.64 52.49 50.91 51.44 49.89 94690 TC 44.18 41.97 48.27 46.82 47.30 45.89 94690 26 3.86 3.67 4.22 4.09 4.14 4.01 94726 49.91 47.41 54.52 52.89 53.43 51.83 94726 TC 37.59 35.71 41.07 39.84 40.25 39.04 94726 26 12.33 11.71 13.47 13.06 13.20 12.80 94727 40.03 38.03 43.73 42.42 42.86 41.57 94727 TC 27.70 26.32 30.27 29.36 29.66 28.77 94727 26 12.33 11.71 13.47 13.06 13.20 12.80 94728 37.72 35.83 41.20 39.97 40.38 39.17 94728 TC 25.07 23.82 27.39 26.58 26.84 26.05 94728 26 12.65 12.02 13.82 13.41 13.55 13.14 94729 51.35 48.78 56.10 54.42 54.97 53.33 94729 TC 42.20 40.09 46.10 44.72 45.18 43.83 94729 26 9.15 8.69 9.99 9.69 9.80 9.50 94750 74.20 70.49 81.06 78.64 79.44 77.06 94750 TC 63.29 60.13 69.15 67.08 67.77 65.73 94750 26 10.92 10.37 11.93 11.57 11.68 11.34 94760 2.99 2.84 3.27 3.16 3.20 3.11 94761 4.31 4.09 4.70 4.57 4.61 4.47 94762 22.76 21.62 24.86 24.12 24.37 23.63 94770 7.39 7.02 8.07 7.83 7.91 7.67 94780 56.85 54.01 62.11 60.25 60.87 59.04 # 94780 24.56 23.33 26.83 26.02 26.29 25.51 94781 21.94 20.84 23.97 23.24 23.48 22.78

Page 223: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 223Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 94781 8.77 8.33 9.58 9.29 9.38 9.11 95004 6.32 6.00 6.90 6.69 6.76 6.56 95012 17.82 16.93 19.47 18.88 19.08 18.50 95017 7.48 7.11 8.18 7.94 8.02 7.77 # 95017 3.53 3.35 3.85 3.74 3.77 3.67 95018 19.55 18.57 21.36 20.71 20.93 20.30 # 95018 7.03 6.68 7.68 7.45 7.53 7.30 95024 7.31 6.94 7.98 7.74 7.82 7.59 # 95024 1.05 1.00 1.15 1.12 1.13 1.09 95027 4.34 4.12 4.74 4.60 4.65 4.51 95028 12.55 11.92 13.71 13.29 13.43 13.03 95044 5.30 5.04 5.80 5.62 5.68 5.51 95052 6.29 5.98 6.88 6.67 6.74 6.53 95056 41.21 39.15 45.02 43.68 44.13 42.80 95060 32.97 31.32 36.02 34.94 35.29 34.24 95065 23.42 22.25 25.59 24.82 25.08 24.32 95070 28.72 27.28 31.37 30.43 30.74 29.82 95071 33.99 32.29 37.13 36.02 36.39 35.29 95076 112.65 107.02 123.07 119.38 120.61 116.99 # 95076 73.12 69.46 79.88 77.49 78.28 75.93 95079 81.30 77.24 88.83 86.16 87.06 84.43 # 95079 66.80 63.46 72.98 70.79 71.52 69.38 95115 8.27 7.86 9.04 8.76 8.86 8.59 95117 9.58 9.10 10.47 10.15 10.26 9.95 95144 12.40 11.78 13.55 13.14 13.27 12.88 # 95144 3.17 3.01 3.46 3.36 3.39 3.29 95145 23.60 22.42 25.78 25.01 25.27 24.52 # 95145 3.17 3.01 3.46 3.36 3.39 3.29 95146 43.04 40.89 47.02 45.61 46.08 44.70 # 95146 3.17 3.01 3.46 3.36 3.39 3.29 95147 45.67 43.39 49.90 48.40 48.90 47.44 # 95147 3.17 3.01 3.46 3.36 3.39 3.29 95148 64.45 61.23 70.41 68.30 69.01 66.93 # 95148 3.17 3.01 3.46 3.36 3.39 3.29 95149 85.21 80.95 93.09 90.30 91.23 88.49 # 95149 3.17 3.01 3.46 3.36 3.39 3.29 95165 12.40 11.78 13.55 13.14 13.27 12.88 # 95165 3.17 3.01 3.46 3.36 3.39 3.29 95170 9.10 8.65 9.95 9.65 9.75 9.45 # 95170 3.17 3.01 3.46 3.36 3.39 3.29 95180 130.35 123.83 142.40 138.14 139.55 135.38 # 95180 100.70 95.67 110.02 106.72 107.82 104.58 95250 146.73 139.39 160.30 155.49 157.09 152.39 95251 43.50 41.33 47.53 46.10 46.58 45.18 95782 958.98 911.03 1,047.68 1,016.26 1,026.73 995.93 95782 TC 832.71 791.07 909.73 882.44 891.54 864.79 95782 26 126.28 119.97 137.97 133.83 135.21 131.15 95783 1,089.44 1,034.97 1,190.22 1,154.51 1,166.41 1,131.42 95783 TC 946.40 899.08 1,033.94 1,002.93 1,013.27 982.87

Page 224: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 224Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

95783 26 143.04 135.89 156.27 151.58 153.15 148.55 95800 169.31 160.84 184.97 179.41 181.26 175.82 95800 TC 117.32 111.45 128.17 124.33 125.60 121.84 95800 26 52.00 49.40 56.81 55.11 55.67 54.00 95801 87.76 83.37 95.88 93.00 93.96 91.14 95801 TC 38.58 36.65 42.15 40.88 41.31 40.07 95801 26 49.18 46.72 53.73 52.12 52.66 51.07 95803 133.92 127.22 146.30 141.91 143.38 139.07 95803 TC 90.30 85.79 98.66 95.70 96.68 93.79 95803 26 43.62 41.44 47.66 46.23 46.70 45.31 95805 402.20 382.09 439.40 426.22 430.62 417.70 95805 TC 343.17 326.01 374.91 363.66 367.41 356.40 95805 26 59.03 56.08 64.49 62.56 63.20 61.31 95806 161.66 153.58 176.62 171.32 173.09 167.89 95806 TC 100.51 95.48 109.80 106.51 107.61 104.39 95806 26 61.15 58.09 66.80 64.80 65.47 63.50 95807 437.05 415.20 477.48 463.15 467.94 453.89 95807 TC 374.80 356.06 409.47 397.19 401.28 389.24 95807 26 62.26 59.15 68.02 65.99 66.67 64.66 95808 601.25 571.19 656.87 637.16 643.74 624.42 95808 TC 513.20 487.54 560.67 543.85 549.46 532.97 95808 26 88.05 83.65 96.20 93.31 94.28 91.45 95810 587.46 558.09 641.80 622.55 628.97 610.10 95810 TC 465.79 442.50 508.88 493.61 498.70 483.75 95810 26 121.67 115.59 132.93 128.94 130.27 126.36 95811 617.13 586.27 674.21 653.98 660.72 640.91 95811 TC 490.52 465.99 535.89 519.81 525.17 509.42 95811 26 126.61 120.28 138.32 134.17 135.55 131.49 95812 304.87 289.63 333.07 323.08 326.42 316.62 95812 TC 247.48 235.11 270.38 262.27 264.97 257.03 95812 26 57.38 54.51 62.69 60.80 61.43 59.58 95813 385.01 365.76 420.62 408.01 412.21 399.84 95813 TC 298.25 283.34 325.84 316.07 319.32 309.74 95813 26 86.76 82.42 94.78 91.94 92.89 90.10 95816 339.82 322.83 371.25 360.12 363.83 352.92 95816 TC 282.43 268.31 308.56 299.30 302.38 293.31 95816 26 57.38 54.51 62.69 60.80 61.43 59.58 95819 390.25 370.74 426.35 413.56 417.83 405.29 95819 TC 332.54 315.91 363.30 352.39 356.03 345.35 95819 26 57.71 54.82 63.04 61.16 61.78 59.94 95822 352.67 335.04 385.30 373.74 377.59 366.26 95822 TC 294.95 280.20 322.23 312.56 315.79 306.30 95822 26 57.71 54.82 63.04 61.16 61.78 59.94 95824 26 39.19 37.23 42.81 41.53 41.96 40.70 95827 622.07 590.97 679.62 659.23 666.02 646.05 95827 TC 565.34 537.07 617.63 599.10 605.28 587.12 95827 26 56.72 53.88 61.96 60.10 60.72 58.89 95829 1,803.26 1,713.10 1,970.07 1,910.97 1,930.67 1,872.75 95829 TC 1,467.25 1,393.89 1,602.97 1,554.88 1,570.91 1,523.78

Page 225: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 225Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

95829 26 336.01 319.21 367.09 356.07 359.75 348.96 95830 209.64 199.16 229.03 222.17 224.46 217.73 # 95830 91.37 86.80 99.82 96.83 97.82 94.90 95831 30.26 28.75 33.06 32.07 32.41 31.43 # 95831 15.77 14.98 17.23 16.71 16.88 16.38 95832 29.99 28.49 32.76 31.79 32.11 31.15 # 95832 16.81 15.97 18.37 17.81 18.00 17.46 95833 36.03 34.23 39.36 38.18 38.58 37.42 # 95833 21.54 20.46 23.53 22.83 23.06 22.37 95834 50.64 48.11 55.33 53.67 54.22 52.60 # 95834 31.20 29.64 34.09 33.06 33.41 32.41 95851 17.30 16.44 18.91 18.34 18.53 17.97 # 95851 7.75 7.36 8.46 8.21 8.29 8.05 95852 14.85 14.11 16.23 15.74 15.90 15.43 # 95852 5.62 5.34 6.14 5.96 6.01 5.84 95857 52.08 49.48 56.90 55.20 55.76 54.10 # 95857 29.68 28.20 32.43 31.45 31.79 30.82 95860 116.96 111.11 127.78 123.95 125.22 121.46 95860 TC 65.59 62.31 71.66 69.51 70.22 68.11 95860 26 51.37 48.80 56.12 54.44 54.99 53.35 95861 166.92 158.57 182.36 176.88 178.71 173.34 95861 TC 84.37 80.15 92.17 89.41 90.33 87.63 95861 26 82.55 78.42 90.18 87.48 88.38 85.73 95863 209.40 198.93 228.77 221.90 224.19 217.47 95863 TC 109.74 104.25 119.89 116.29 117.50 113.97 95863 26 99.66 94.68 108.88 105.62 106.71 103.50 95864 235.18 223.42 256.93 249.23 251.79 244.25 95864 TC 128.19 121.78 140.05 135.85 137.24 133.14 95864 26 106.99 101.64 116.89 113.38 114.55 111.11 95865 141.67 134.59 154.78 150.13 151.69 147.13 95865 TC 57.35 54.48 62.65 60.78 61.40 59.56 95865 26 84.31 80.09 92.10 89.34 90.26 87.56 95866 130.39 123.87 142.45 138.17 139.60 135.41 95866 TC 62.96 59.81 68.78 66.72 67.40 65.39 95866 26 67.44 64.07 73.68 71.47 72.21 70.05 95867 92.74 88.10 101.32 98.28 99.29 96.31 95867 TC 51.10 48.55 55.83 54.15 54.72 53.07 95867 26 41.65 39.57 45.51 44.14 44.60 43.25 95868 129.23 122.77 141.19 136.95 138.36 134.22 95868 TC 65.92 62.62 72.01 69.85 70.58 68.46 95868 26 63.31 60.14 69.16 67.09 67.78 65.75 95869 86.51 82.18 94.51 91.67 92.62 89.84 95869 TC 66.58 63.25 72.74 70.55 71.29 69.14 95869 26 19.93 18.93 21.77 21.11 21.33 20.69 95870 87.49 83.12 95.59 92.72 93.68 90.87 95870 TC 67.57 64.19 73.82 71.60 72.35 70.16 95870 26 19.93 18.93 21.77 21.11 21.33 20.69 95872 192.84 183.20 210.68 204.36 206.47 200.27 95872 TC 39.23 37.27 42.86 41.57 42.00 40.74

Page 226: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 226Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

95872 26 153.60 145.92 167.81 162.77 164.45 159.52 95873 69.32 65.85 75.73 73.45 74.21 71.98 95873 TC 49.42 46.95 53.99 52.37 52.91 51.32 95873 26 19.90 18.91 21.75 21.09 21.31 20.67 95874 70.00 66.50 76.48 74.19 74.95 72.70 95874 TC 50.08 47.58 54.72 53.07 53.62 52.01 95874 26 19.93 18.93 21.77 21.11 21.33 20.69 95875 112.82 107.18 123.26 119.55 120.80 117.16 95875 TC 54.06 51.36 59.06 57.29 57.88 56.14 95875 26 58.76 55.82 64.19 62.27 62.91 61.03 95885 55.78 52.99 60.94 59.11 59.72 57.93 95885 TC 36.90 35.06 40.32 39.11 39.51 38.33 95885 26 18.88 17.94 20.63 20.01 20.22 19.61 95886 87.65 83.27 95.76 92.89 93.84 91.02 95886 TC 41.51 39.43 45.34 43.99 44.44 43.11 95886 26 46.14 43.83 50.40 48.90 49.39 47.92 95887 77.32 73.45 84.47 81.94 82.78 80.30 95887 TC 39.53 37.55 43.18 41.88 42.32 41.04 95887 26 37.79 35.90 41.29 40.04 40.46 39.24 95905 66.76 63.42 72.93 70.75 71.47 69.33 95905 TC 63.94 60.74 69.85 67.76 68.46 66.40 95905 26 2.81 2.67 3.07 2.98 3.01 2.92 95907 94.05 89.35 102.75 99.67 100.69 97.68 95907 TC 40.55 38.52 44.30 42.96 43.41 42.10 95907 26 53.50 50.83 58.45 56.71 57.28 55.57 95908 120.84 114.80 132.02 128.06 129.38 125.50 95908 TC 53.73 51.04 58.70 56.94 57.52 55.80 95908 26 67.11 63.75 73.31 71.12 71.85 69.69 95909 144.01 136.81 157.33 152.62 154.18 149.57 95909 TC 63.61 60.43 69.49 67.41 68.10 66.07 95909 26 80.39 76.37 87.83 85.19 86.07 83.49 95910 190.37 180.85 207.98 201.73 203.81 197.70 95910 TC 83.05 78.90 90.74 88.01 88.92 86.25 95910 26 107.32 101.95 117.24 113.72 114.90 111.45 95911 227.15 215.79 248.16 240.72 243.19 235.90 95911 TC 93.27 88.61 101.90 98.84 99.87 96.86 95911 26 133.89 127.20 146.28 141.89 143.36 139.05 95912 251.45 238.88 274.71 266.47 269.22 261.14 95912 TC 92.94 88.29 101.53 98.49 99.50 96.52 95912 26 158.51 150.58 173.17 167.97 169.71 164.61 95913 289.09 274.64 315.84 306.36 309.52 300.23 95913 TC 101.50 96.43 110.89 107.57 108.68 105.42 95913 26 187.59 178.21 204.94 198.79 200.85 194.81 95921 82.19 78.08 89.79 87.10 88.00 85.36 95921 TC 36.93 35.08 40.34 39.13 39.54 38.35 95921 26 45.26 43.00 49.45 47.97 48.46 47.01 95922 96.21 91.40 105.11 101.96 103.01 99.92 95922 TC 47.80 45.41 52.22 50.66 51.18 49.65 95922 26 48.41 45.99 52.89 51.30 51.83 50.28

Page 227: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 227Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

95923 134.28 127.57 146.71 142.30 143.77 139.46 95923 TC 88.32 83.90 96.49 93.59 94.55 91.71 95923 26 45.95 43.65 50.20 48.69 49.20 47.71 95924 147.77 140.38 161.44 156.60 158.21 153.47 95924 TC 58.01 55.11 63.38 61.48 62.11 60.25 95924 26 89.75 85.26 98.05 95.11 96.08 93.21 95925 130.88 124.34 142.99 138.70 140.13 135.93 95925 TC 103.18 98.02 112.72 109.34 110.47 107.16 95925 26 27.70 26.32 30.27 29.36 29.66 28.77 95926 126.93 120.58 138.67 134.50 135.90 131.81 95926 TC 99.55 94.57 108.76 105.49 106.58 103.39 95926 26 27.37 26.00 29.90 29.00 29.30 28.43 95927 130.22 123.71 142.27 138.00 139.43 135.24 95927 TC 102.85 97.71 112.37 109.00 110.12 106.81 95927 26 27.37 26.00 29.90 29.00 29.30 28.43 95928 203.67 193.49 222.51 215.84 218.06 211.53 95928 TC 123.58 117.40 135.01 130.96 132.31 128.34 95928 26 80.09 76.09 87.50 84.88 85.76 83.18 95929 209.57 199.09 228.95 222.09 224.38 217.65 95929 TC 129.18 122.72 141.13 136.90 138.31 134.16 95929 26 80.39 76.37 87.83 85.19 86.07 83.49 95930 121.70 115.62 132.96 128.97 130.31 126.40 95930 TC 103.18 98.02 112.72 109.34 110.47 107.16 95930 26 18.52 17.59 20.23 19.62 19.83 19.23 95933 73.35 69.68 80.13 77.73 78.53 76.18 95933 TC 41.87 39.78 45.75 44.38 44.83 43.49 95933 26 31.47 29.90 34.39 33.35 33.70 32.68 95937 78.46 74.54 85.72 83.15 84.01 81.48 95937 TC 44.18 41.97 48.27 46.82 47.30 45.89 95937 26 34.29 32.58 37.47 36.34 36.72 35.62 95938 322.01 305.91 351.80 341.24 344.76 334.42 95938 TC 275.84 262.05 301.36 292.32 295.33 286.48 95938 26 46.16 43.85 50.43 48.91 49.42 47.93 95939 477.55 453.67 521.72 506.07 511.29 495.95 95939 TC 357.91 340.01 391.01 379.28 383.19 371.69 95939 26 119.65 113.67 130.72 126.80 128.11 124.26 95940 32.55 30.92 35.56 34.49 34.85 33.80 95943 142.75 135.61 155.95 151.27 152.84 148.25 95943 TC 53.43 50.76 58.37 56.63 57.20 55.50 95943 26 89.31 84.84 97.57 94.63 95.61 92.74 95950 315.44 299.67 344.62 334.28 337.73 327.60 95950 TC 235.65 223.87 257.45 249.72 252.30 244.73 95950 26 79.79 75.80 87.17 84.56 85.42 82.87 95951 1,565.18 1,486.92 1,709.96 1,658.66 1,675.76 1,625.48 95951 TC 1,246.13 1,183.82 1,361.39 1,320.56 1,334.16 1,294.14 95951 26 319.05 303.10 348.57 338.11 341.60 331.35 95953 405.02 384.77 442.49 429.21 433.63 420.64 95953 TC 241.25 229.19 263.57 255.66 258.30 250.54 95953 26 163.77 155.58 178.92 173.55 175.34 170.07

Page 228: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 228Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

95954 429.83 408.34 469.59 455.50 460.20 446.40 95954 TC 304.24 289.03 332.38 322.41 325.74 315.96 95954 26 125.59 119.31 137.21 133.09 134.46 130.43 95955 202.47 192.35 221.20 214.57 216.78 210.28 95955 TC 148.94 141.49 162.71 157.84 159.46 154.69 95955 26 53.52 50.84 58.47 56.71 57.29 55.57 95956 1,529.60 1,453.12 1,671.09 1,620.96 1,637.67 1,588.54 95956 TC 1,338.81 1,271.87 1,462.65 1,418.77 1,433.39 1,390.40 95956 26 190.79 181.25 208.44 202.18 204.27 198.13 95957 290.89 276.35 317.80 308.27 311.44 302.11 95957 TC 186.23 176.92 203.46 197.35 199.39 193.41 95957 26 104.65 99.42 114.33 110.91 112.04 108.69 95958 554.77 527.03 606.08 587.90 593.96 576.15 95958 TC 328.94 312.49 359.36 348.59 352.18 341.62 95958 26 225.82 214.53 246.71 239.30 241.78 234.52 95961 295.55 280.77 322.89 313.20 316.42 306.94 95961 TC 133.13 126.47 145.44 141.08 142.53 138.26 95961 26 162.42 154.30 177.45 172.12 173.89 168.68 95962 254.96 242.21 278.54 270.18 272.98 264.78 95962 TC 81.73 77.64 89.29 86.61 87.50 84.87 95962 26 173.23 164.57 189.26 183.57 185.47 179.91 95965 26 420.44 399.42 459.33 445.56 450.14 436.64 95966 26 210.69 200.16 230.18 223.28 225.58 218.82 95967 26 184.78 175.54 201.87 195.81 197.83 191.89 95970 65.03 61.78 71.05 68.92 69.62 67.54 # 95970 24.17 22.96 26.40 25.61 25.88 25.09 95971 49.61 47.13 54.20 52.58 53.12 51.53 # 95971 40.72 38.68 44.48 43.15 43.60 42.29 95972 56.95 54.10 62.22 60.35 60.97 59.14 # 95972 41.79 39.70 45.66 44.29 44.75 43.40 95974 204.08 193.88 222.96 216.27 218.50 211.95 # 95974 164.22 156.01 179.41 174.03 175.82 170.55 95975 109.88 104.39 120.05 116.45 117.65 114.11 # 95975 92.75 88.11 101.33 98.29 99.30 96.32 95978 244.60 232.37 267.23 259.21 261.88 254.02 # 95978 192.22 182.61 210.00 203.70 205.80 199.63 95979 106.41 101.09 116.25 112.77 113.93 110.52 # 95979 89.60 85.12 97.89 94.96 95.93 93.06 95980 46.34 44.02 50.62 49.11 49.61 48.13 95981 30.98 29.43 33.84 32.83 33.17 32.18 # 95981 17.80 16.91 19.45 18.86 19.06 18.48 95982 51.59 49.01 56.36 54.67 55.23 53.58 # 95982 36.44 34.62 39.81 38.62 39.02 37.85 95990 84.43 80.21 92.24 89.47 90.40 87.68 95991 113.47 107.80 123.97 120.26 121.49 117.85 # 95991 39.67 37.69 43.34 42.04 42.48 41.20 95992 42.52 40.39 46.45 45.06 45.52 44.16 # 95992 37.25 35.39 40.70 39.48 39.88 38.69 96000 94.93 90.18 103.71 100.59 101.64 98.58

Page 229: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 229Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

96001 121.70 115.62 132.96 128.97 130.31 126.40 96002 21.72 20.63 23.72 23.01 23.25 22.55 96003 16.60 15.77 18.14 17.60 17.77 17.24 96004 116.50 110.68 127.28 123.46 124.74 120.99 96020 26 161.36 153.29 176.28 170.99 172.75 167.58 96101 79.81 75.82 87.19 84.58 85.45 82.89 # 96101 79.15 75.19 86.47 83.87 84.74 82.19 96102 59.21 56.25 64.69 62.74 63.40 61.49 # 96102 23.63 22.45 25.82 25.05 25.30 24.54 96103 27.31 25.94 29.83 28.93 29.23 28.36 # 96103 26.33 25.01 28.76 27.90 28.19 27.34 96105 105.51 100.23 115.26 111.80 112.96 109.57 96111 130.29 123.78 142.35 138.08 139.50 135.32 # 96111 124.69 118.46 136.23 132.15 133.50 129.50 96116 91.39 86.82 99.84 96.85 97.84 94.92 # 96116 86.12 81.81 94.08 91.26 92.20 89.44 96118 96.28 91.47 105.19 102.04 103.09 100.00 # 96118 78.82 74.88 86.11 83.52 84.39 81.86 96119 75.48 71.71 82.47 79.99 80.82 78.40 # 96119 23.75 22.56 25.94 25.16 25.43 24.66 96120 46.42 44.10 50.72 49.20 49.70 48.21 # 96120 26.00 24.70 28.41 27.55 27.84 27.00 96125 113.27 107.61 123.75 120.04 121.28 117.63 96127 5.30 5.04 5.80 5.62 5.68 5.51 96150 21.63 20.55 23.63 22.92 23.16 22.46 # 96150 21.30 20.24 23.28 22.57 22.82 22.13 96151 20.91 19.86 22.84 22.15 22.38 21.70 # 96151 20.58 19.55 22.48 21.80 22.03 21.37 96152 19.86 18.87 21.70 21.05 21.26 20.62 # 96152 19.53 18.55 21.33 20.69 20.91 20.27 96153 4.61 4.38 5.04 4.89 4.93 4.80 # 96153 4.28 4.07 4.68 4.54 4.59 4.45 96154 19.50 18.53 21.31 20.67 20.88 20.25 # 96154 19.17 18.21 20.94 20.31 20.53 19.91 96160 4.28 4.07 4.68 4.54 4.59 4.45 96161 4.28 4.07 4.68 4.54 4.59 4.45 96360 54.29 51.58 59.32 57.53 58.13 56.38 96361 14.46 13.74 15.80 15.33 15.49 15.02 96365 64.98 61.73 70.99 68.86 69.58 67.48 96366 18.02 17.12 19.69 19.10 19.30 18.72 96367 29.28 27.82 31.99 31.04 31.35 30.42 96368 19.64 18.66 21.46 20.82 21.03 20.40 96369 166.42 158.10 181.82 176.36 178.18 172.83 96370 14.73 13.99 16.09 15.61 15.77 15.30 96371 63.59 60.41 69.47 67.39 68.08 66.04 96372 24.25 23.04 26.50 25.70 25.97 25.19 96373 18.32 17.40 20.01 19.41 19.61 19.02 96374 54.02 51.32 59.02 57.25 57.83 56.10 96375 21.08 20.03 23.03 22.34 22.57 21.90

Page 230: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 230Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

96401 69.95 66.45 76.42 74.13 74.89 72.65 96402 30.93 29.38 33.79 32.78 33.11 32.12 96405 77.72 73.83 84.90 82.36 83.20 80.72 # 96405 29.95 28.45 32.72 31.74 32.06 31.11 96406 113.86 108.17 124.40 120.66 121.91 118.24 # 96406 45.99 43.69 50.24 48.74 49.24 47.76 96409 104.03 98.83 113.65 110.25 111.38 108.04 96411 58.69 55.76 64.12 62.20 62.84 60.96 96413 129.22 122.76 141.17 136.94 138.35 134.21 96415 26.97 25.62 29.46 28.58 28.88 28.00 96416 130.30 123.79 142.36 138.09 139.51 135.33 96417 61.35 58.28 67.02 65.01 65.68 63.71 96420 99.54 94.56 108.74 105.48 106.57 103.37 96422 172.77 164.13 188.75 183.09 184.98 179.43 96423 70.49 66.97 77.02 74.70 75.47 73.21 96425 171.18 162.62 187.01 181.40 183.28 177.78 96440 732.77 696.13 800.55 776.54 784.54 761.01 # 96440 125.91 119.61 137.55 133.42 134.80 130.76 96446 190.65 181.12 208.29 202.04 204.13 198.01 # 96446 28.89 27.45 31.57 30.62 30.94 30.02 96450 173.86 165.17 189.95 184.24 186.15 180.56 # 96450 80.63 76.60 88.09 85.45 86.33 83.73 96521 130.96 124.41 143.07 138.78 140.21 136.01 96522 106.94 101.59 116.83 113.32 114.49 111.06 96523 23.21 22.05 25.36 24.60 24.85 24.10 96542 118.02 112.12 128.94 125.07 126.36 122.57 # 96542 41.92 39.82 45.79 44.42 44.87 43.54 96567 125.91 119.61 137.55 133.42 134.80 130.76 96570 57.49 54.62 62.81 60.93 61.56 59.71 96571 26.44 25.12 28.89 28.03 28.31 27.46 96900 19.47 18.50 21.28 20.64 20.85 20.23 96904 58.37 55.45 63.77 61.86 62.49 60.62 96910 66.25 62.94 72.38 70.21 70.93 68.80 96912 85.03 80.78 92.90 90.11 91.03 88.31 96913 120.67 114.64 131.84 127.88 129.20 125.33 96920 148.85 141.41 162.62 157.75 159.37 154.59 # 96920 66.81 63.47 72.99 70.81 71.53 69.39 96921 164.15 155.94 179.33 173.95 175.74 170.46 # 96921 75.52 71.74 82.50 80.03 80.86 78.43 96922 227.57 216.19 248.62 241.16 243.65 236.34 # 96922 121.15 115.09 132.35 128.39 129.71 125.82 96931 151.29 143.73 165.29 160.33 161.99 157.12 C 96932 26.39 25.07 28.83 27.97 28.26 27.40 96933 44.87 42.63 49.02 47.55 48.05 46.60 96934 79.02 75.07 86.33 83.74 84.61 82.06 96935 32.32 30.70 35.31 34.25 34.60 33.56 96936 42.78 40.64 46.74 45.33 45.80 44.42 97012 15.92 15.12 17.39 16.87 17.04 16.54 97016 18.68 17.75 20.41 19.80 20.01 19.41

Page 231: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 231Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

97018 10.42 9.90 11.39 11.04 11.16 10.82 97022 22.60 21.47 24.69 23.95 24.20 23.47 97024 6.47 6.15 7.07 6.87 6.93 6.73 97026 5.81 5.52 6.35 6.15 6.22 6.03 97028 7.18 6.82 7.84 7.61 7.68 7.46 97032 18.56 17.63 20.27 19.67 19.87 19.27 97033 21.22 20.16 23.18 22.49 22.72 22.05 97034 17.45 16.58 19.07 18.49 18.69 18.12 97035 12.51 11.88 13.66 13.25 13.39 12.98 97036 31.49 29.92 34.41 33.37 33.72 32.71 97110 31.69 30.11 34.63 33.59 33.94 32.92 97112 33.01 31.36 36.06 34.98 35.34 34.28 97113 41.52 39.44 45.36 44.00 44.45 43.11 97116 27.56 26.18 30.11 29.20 29.51 28.61 97124 25.44 24.17 27.80 26.96 27.24 26.42 97140 29.30 27.84 32.02 31.05 31.37 30.43 97150 17.03 16.18 18.61 18.04 18.24 17.69 97161 78.94 74.99 86.24 83.65 84.51 81.98 97162 78.94 74.99 86.24 83.65 84.51 81.98 97163 78.94 74.99 86.24 83.65 84.51 81.98 97164 53.48 50.81 58.43 56.68 57.26 55.55 97165 76.63 72.80 83.72 81.21 82.04 79.59 97166 76.63 72.80 83.72 81.21 82.04 79.59 97167 76.63 72.80 83.72 81.21 82.04 79.59 97168 50.48 47.96 55.15 53.50 54.05 52.43 97530 33.94 32.24 37.08 35.96 36.34 35.24 97532 26.03 24.73 28.44 27.59 27.88 27.04 # 97532 21.42 20.35 23.40 22.70 22.93 22.25 97533 28.67 27.24 31.33 30.38 30.71 29.77 97535 34.00 32.30 37.15 36.03 36.40 35.31 97537 29.72 28.23 32.46 31.49 31.82 30.85 97542 30.05 28.55 32.83 31.84 32.18 31.21 97597 71.73 68.14 78.36 76.02 76.80 74.50 # 97597 23.30 22.14 25.46 24.70 24.96 24.21 97598 23.80 22.61 26.00 25.22 25.48 24.71 # 97598 10.95 10.40 11.96 11.60 11.72 11.37 97605 40.22 38.21 43.94 42.62 43.07 41.77 # 97605 25.07 23.82 27.39 26.58 26.84 26.05 97606 47.29 44.93 51.67 50.12 50.63 49.12 # 97606 27.19 25.83 29.70 28.82 29.11 28.24 97607 42.86 40.72 46.83 45.43 45.90 44.52 # 97607 27.88 26.49 30.46 29.56 29.85 28.97 97608 50.73 48.19 55.42 53.75 54.31 52.68 # 97608 30.73 29.19 33.57 32.56 32.90 31.90 97610 112.75 107.11 123.18 119.49 120.72 117.09 # 97610 15.88 15.09 17.35 16.84 17.01 16.50 97750 32.02 30.42 34.98 33.94 34.28 33.26 97755 35.16 33.40 38.41 37.26 37.64 36.51 97760 36.96 35.11 40.38 39.17 39.57 38.39

Page 232: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 232Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

97761 32.35 30.73 35.34 34.28 34.64 33.59 97762 45.57 43.29 49.78 48.29 48.78 47.32 97802 33.90 32.21 37.04 35.93 36.31 35.21 # 97802 31.93 30.33 34.88 33.83 34.18 33.15 97803 29.39 27.92 32.11 31.14 31.46 30.52 # 97803 27.08 25.73 29.59 28.70 29.00 28.13 97804 15.59 14.81 17.03 16.53 16.69 16.19 # 97804 14.93 14.18 16.31 15.81 15.99 15.50 98925 30.76 29.22 33.60 32.59 32.94 31.94 # 98925 23.84 22.65 26.05 25.27 25.53 24.76 98926 44.71 42.47 48.84 47.38 47.86 46.44 # 98926 35.81 34.02 39.12 37.95 38.34 37.19 98927 58.65 55.72 64.08 62.16 62.80 60.92 # 98927 47.45 45.08 51.84 50.29 50.81 49.29 98928 71.60 68.02 78.22 75.88 76.66 74.36 # 98928 59.41 56.44 64.91 62.96 63.61 61.71 98929 85.55 81.27 93.46 90.65 91.59 88.84 # 98929 72.04 68.44 78.71 76.35 77.13 74.82 98940 27.77 26.38 30.34 29.43 29.73 28.84 # 98940 22.50 21.38 24.59 23.85 24.09 23.38 98941 40.04 38.04 43.75 42.44 42.87 41.58 # 98941 34.43 32.71 37.62 36.49 36.87 35.77 98942 52.33 49.71 57.17 55.45 56.03 54.35 # 98942 46.73 44.39 51.05 49.52 50.03 48.53 99151 73.44 69.77 80.24 77.83 78.63 76.28 # 99151 23.69 22.51 25.89 25.10 25.37 24.60 99152 48.57 46.14 53.06 51.47 52.00 50.44 # 99152 12.32 11.70 13.46 13.05 13.19 12.79 99153 10.24 9.73 11.19 10.86 10.97 10.64 99155 92.73 88.09 101.30 98.27 99.28 96.30 99156 76.13 72.32 83.17 80.67 81.50 79.06 99157 57.70 54.82 63.04 61.16 61.78 59.94 99170 159.33 151.36 174.06 168.84 170.58 165.46 # 99170 87.83 83.44 95.96 93.08 94.04 91.22 99175 14.85 14.11 16.23 15.74 15.90 15.43 99183 110.39 104.87 120.60 116.98 118.19 114.64 99184 213.28 202.62 233.01 226.02 228.36 221.50 99195 93.41 88.74 102.05 98.99 100.02 97.01 99201 42.41 40.29 46.33 44.94 45.40 44.05 # 99201 26.60 25.27 29.06 28.19 28.47 27.62 99202 72.49 68.87 79.20 76.82 77.61 75.28 # 99202 50.08 47.58 54.72 53.07 53.62 52.01 99203 105.10 99.85 114.83 111.38 112.53 109.15 # 99203 76.11 72.30 83.15 80.65 81.48 79.04 99204 160.33 152.31 175.16 169.90 171.65 166.51 # 99204 128.70 122.27 140.61 136.39 137.79 133.66 99205 202.25 192.14 220.96 214.34 216.55 210.05 # 99205 167.65 159.27 183.16 177.66 179.49 174.11 99211 19.34 18.37 21.13 20.49 20.70 20.08

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CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 233Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 99211 9.12 8.66 9.96 9.66 9.76 9.46 99212 42.05 39.95 45.94 44.56 45.02 43.68 # 99212 25.25 23.99 27.59 26.76 27.04 26.22 99213 70.93 67.38 77.49 75.16 75.93 73.66 # 99213 50.50 47.98 55.18 53.52 54.07 52.45 99214 104.53 99.30 114.20 110.77 111.91 108.55 # 99214 77.84 73.95 85.04 82.49 83.34 80.85 99215 141.06 134.01 154.11 149.49 151.03 146.50 # 99215 110.10 104.60 120.29 116.68 117.89 114.34 99217 71.90 68.31 78.56 76.20 76.98 74.67 99218 98.99 94.04 108.15 104.90 105.98 102.81 99219 134.69 127.96 147.15 142.74 144.21 139.89 99220 184.14 174.93 201.17 195.13 197.14 191.23 99221 100.76 95.72 110.08 106.78 107.88 104.64 99222 135.79 129.00 148.35 143.90 145.38 141.02 99223 200.98 190.93 219.57 212.98 215.18 208.73 99224 39.64 37.66 43.31 42.01 42.45 41.17 99225 72.22 68.61 78.90 76.53 77.33 75.00 99226 104.11 98.90 113.74 110.32 111.46 108.11 99231 38.98 37.03 42.58 41.31 41.73 40.48 99232 71.56 67.98 78.18 75.83 76.61 74.31 99233 103.48 98.31 113.06 109.66 110.79 107.47 99234 132.32 125.70 144.56 140.22 141.67 137.41 99235 167.68 159.30 183.20 177.70 179.53 174.14 99236 216.15 205.34 236.14 229.06 231.41 224.48 99238 71.54 67.96 78.15 75.81 76.59 74.29 99239 106.10 100.80 115.92 112.45 113.60 110.19 99281 21.21 20.15 23.17 22.48 22.71 22.03 99282 41.37 39.30 45.20 43.84 44.29 42.96 99283 61.95 58.85 67.68 65.64 66.32 64.33 99284 117.58 111.70 128.46 124.60 125.89 122.11 99285 173.63 164.95 189.69 184.00 185.90 180.32 99291 269.71 256.22 294.65 285.81 288.77 280.09 # 99291 222.59 211.46 243.18 235.89 238.31 231.17 99292 121.52 115.44 132.76 128.78 130.10 126.20 # 99292 111.64 106.06 121.97 118.31 119.53 115.94 99304 90.15 85.64 98.49 95.53 96.52 93.62 99305 128.59 122.16 140.48 136.28 137.68 133.55 99306 164.73 156.49 179.96 174.57 176.36 171.07 99307 43.89 41.70 47.96 46.52 47.00 45.59 99308 67.89 64.50 74.18 71.96 72.69 70.52 99309 89.85 85.36 98.16 95.22 96.20 93.31 99310 133.89 127.20 146.28 141.89 143.36 139.05 99315 72.20 68.59 78.88 76.51 77.30 74.98 99316 104.48 99.26 114.15 110.72 111.86 108.50 99318 94.96 90.21 103.74 100.63 101.67 98.61 99324 54.57 51.84 59.62 57.82 58.42 56.66 99325 79.55 75.57 86.91 84.30 85.17 82.60 99326 138.04 131.14 150.81 146.29 147.80 143.37

Page 234: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 234Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

99327 183.79 174.60 200.79 194.76 196.78 190.87 99328 215.44 204.67 235.37 228.31 230.67 223.74 99334 59.36 56.39 64.85 62.91 63.55 61.65 99335 93.68 89.00 102.35 99.28 100.30 97.29 99336 133.23 126.57 145.56 141.19 142.65 138.36 99337 190.79 181.25 208.44 202.18 204.27 198.13 99341 54.24 51.53 59.26 57.48 58.08 56.33 99342 78.56 74.63 85.82 83.25 84.11 81.58 99343 129.18 122.72 141.13 136.90 138.31 134.16 99344 180.62 171.59 197.33 191.41 193.38 187.58 99345 218.79 207.85 239.03 231.85 234.24 227.22 99347 54.54 51.81 59.58 57.80 58.39 56.64 99348 83.32 79.15 91.02 88.30 89.21 86.53 99349 126.92 120.57 138.66 134.49 135.88 131.80 99350 176.04 167.24 192.33 186.55 188.49 182.83 99354 127.90 121.51 139.74 135.54 136.94 132.83 # 99354 120.99 114.94 132.18 128.21 129.54 125.65 99355 96.49 91.67 105.42 102.26 103.32 100.21 # 99355 89.90 85.41 98.22 95.28 96.26 93.37 99356 91.01 86.46 99.43 96.45 97.44 94.52 99357 91.01 86.46 99.43 96.45 97.44 94.52 99358 110.72 105.18 120.96 117.32 118.54 114.98 99359 53.22 50.56 58.14 56.40 56.98 55.27 99406 14.27 13.56 15.59 15.12 15.28 14.82 # 99406 12.30 11.69 13.44 13.04 13.18 12.78 99407 27.61 26.23 30.16 29.26 29.57 28.67 # 99407 25.64 24.36 28.01 27.17 27.45 26.63 99415 8.27 7.86 9.04 8.76 8.86 8.59 99416 4.28 4.07 4.68 4.54 4.59 4.45 99460 99.24 94.28 108.42 105.17 106.25 103.06 99461 90.59 86.06 98.97 96.00 96.99 94.08 # 99461 62.91 59.76 68.72 66.67 67.34 65.33 99462 44.13 41.92 48.21 46.76 47.24 45.83 99463 118.03 112.13 128.95 125.09 126.37 122.58 99464 76.50 72.68 83.58 81.08 81.91 79.45 99465 151.47 143.90 165.49 160.52 162.17 157.31 99466 241.99 229.89 264.37 256.44 259.08 251.31 99467 121.46 115.39 132.70 128.72 130.04 126.14 99468 985.45 936.18 1,076.61 1,044.30 1,055.08 1,023.42 99469 397.34 377.47 434.09 421.07 425.41 412.65 99471 856.87 814.03 936.13 908.05 917.41 889.89 99472 409.61 389.13 447.50 434.08 438.55 425.40 99475 572.95 544.30 625.95 607.17 613.42 595.02 99476 342.30 325.19 373.97 362.74 366.49 355.49 99477 351.34 333.77 383.84 372.32 376.15 364.87 99478 139.35 132.38 152.24 147.67 149.19 144.72 99479 124.12 117.91 135.60 131.53 132.88 128.89 99480 119.87 113.88 130.96 127.03 128.34 124.49 99487 89.11 84.65 97.35 94.43 95.40 92.54

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CGS PART B Ohio - 2017 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM.*** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM.**** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2016 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 235Originated November 10, 2016 | Revised February 9, 2017

© 2017 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 99487 51.55 48.97 56.32 54.63 55.19 53.53 99489 44.72 42.48 48.85 47.39 47.87 46.45 # 99489 25.94 24.64 28.34 27.49 27.77 26.93 99490 41.12 39.06 44.92 43.57 44.02 42.70 # 99490 31.89 30.30 34.85 33.80 34.14 33.12 99495 158.47 150.55 173.13 167.93 169.67 164.58 # 99495 109.38 103.91 119.50 115.91 117.10 113.59 99496 224.33 213.11 245.08 237.73 240.18 232.98 # 99496 158.44 150.52 173.10 167.90 169.64 164.54 99497 80.78 76.74 88.25 85.61 86.49 83.89 # 99497 76.17 72.36 83.21 80.72 81.55 79.11 99498 70.90 67.36 77.46 75.14 75.91 73.63

Page 236: OHIO PART B - CGS Medicare · 2017-02-16 · Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers

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