MEDICAL FEE SCHEDULE MAINE WORKERS' …...applies to all medical, surgical and hospital services,...

MEDICAL FEE SCHEDULE

MAINE WORKERS' COMPENSATION BOARD

90-351

CHAPTER 5

BOARD RULES

WITH APPENDICES I - IV

MAINE WORKERS' COMPENSATION BOARD

OFFICE OF MEDICAL/REHABILITATION SERVICES 27 STATE HOUSE STATION

AUGUSTA, MAINE 04333-0027

EFFECTIVE: JANUARY 1, 2016

90-351 WORKERS' COMPENSATION BOARD

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CHAPTER 5 MEDICAL FEES; REIMBURSEMENT LEVELS; REPORTING REQUIREMENTS

This chapter outlines billing procedures and reimbursement levels for health care providers who treat injured employees. It also describes the dispute resolution process when there is a dispute regarding reimbursement and/or appropriateness of care. Finally, this chapter sets standards for health care reporting.

SECTION 1. GENERAL PROVISIONS

1.01 APPLICATION

1. This chapter is promulgated pursuant to 39-A M.R.S.A. §§ 208 and 209-A. It applies to all medical, surgical and hospital services, nursing, medicines, and mechanical, surgical aids provided for treatment of a claimed work-related injury or disease on or after the effective date of this chapter, regardless of the employee's date of injury or illness. Treatment does not include expenses related to nurse case management services or to examinations performed pursuant to 39-A M.R.S.A. §§ 207 and 312.

1.02 PAYMENT CALCULATION

1. Pursuant to Title 39-A M.R.S.A. §209-A, the medical fee schedule must be consistent with the most current medical coding and billing systems, including the federal Centers for Medicare and Medicaid Services resource-based relative value scale, severity-diagnosis related group system, ambulatory payment classification system and healthcare common procedure coding system; the International Statistical Classification of Diseases and Related Health Problems report issued by the World Health Organization and the current procedural terminology codes used by the American Medical Association.

2. Payment is based on the fees in effect on the date of service.

1.03 DEFINITIONS

1. Acute Care Hospital: A health care facility with a General Acute Care Hospital Primary Taxonomy in the NPI Registry at https://nppes.cms.hhs.gov/NPPES.

2. Ambulatory Payment Classification System (APC): Medicare’s grouping methodology for determining payment for outpatient services. Medicare assigns procedure codes to APC groups which are then given relative weights.

3. Ambulatory Surgical Center (ASC): A health care facility with an Ambulatory Surgical Clinic/Center Primary Taxonomy in the NPI Registry at https://nppes.cms.hhs.gov/NPPES.

https://nppes.cms.hhs.gov/NPPEShttps://nppes.cms.hhs.gov/NPPES


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4. Bill: A request by a health care provider that is submitted to an employer/insurer for payment of medical, surgical and hospital services, nursing, medicines, and mechanical, surgical aids provided for treatment of a work-related injury or disease.

5. Board: The Maine Workers' Compensation Board pursuant to 39-A M.R.S.A. §151.

6. Critical Access Hospital: A health care facility with a Critical Access Hospital Primary Taxonomy in the NPI Registry at https://nppes.cms.hhs.gov/NPPES.

7. Follow-up Days (FUD): The number of days of care following a surgical procedure that are included in the procedure’s maximum allowable payment but does not include care for complications, exacerbations, recurrence, or other diseases or injuries.

8. Health Care Provider: An individual, group of individuals, or facility licensed, registered, or certified and practicing within the scope of the health care provider’s license, registration or certification. This paragraph shall not be construed as enlarging the scope and/or limitations of practice of any health care provider.

9. Health Care Records: includes office notes, surgical/operative notes, progress notes, diagnostic test results and any other information necessary to support the services rendered.

10. Implantable: An object or device that is made to replace and act as a missing biological structure that is surgically implanted, embedded, inserted, or otherwise applied. The term also includes any related equipment necessary to operate, program, and recharge the implantable.

11. Incidental Surgery: A surgery which is performed on the same patient, on the same day, by the same health care provider but is not related to the diagnosis.

12. Inpatient Services: Services rendered to a person who is formally admitted to a hospital and whose length of stay exceeds 23 hours.

13. Maximum Allowable Payment (MAP): The sum of all fees for medical, surgical and hospital services, nursing, medicines, and mechanical, surgical aids established by the Board pursuant to this chapter.

14. Medicare Severity-Diagnosis Related Group (MS-DRG): Medicare’s grouping methodology for determining payment for inpatient services. Medicare assigns services to an MS-DRG based on patient demographics, diagnosis codes, and procedure codes which is then given a relative weight.

15. Modifier: A code adopted by the Centers for Medicare & Medicaid Services that provides the means to report or indicate that a service or procedure that has been performed has been altered by some specific circumstance but not changed in its definition or code.

16. Outpatient Services: Services provided to a patient who is not admitted for inpatient or residential care (includes observation services).

https://nppes.cms.hhs.gov/NPPES


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17. Procedure Code: A code adopted by the Centers for Medicare & Medicaid Services that is divided into two principal subsystems, referred to as level I and level II of the Healthcare Common Procedure Coding System (HCPCS). Level I is comprised of Current Procedural Terminology (CPT®), a numeric coding system maintained by the American Medical Association (AMA). Level II is a standardized coding system that is used primarily to identify products, supplies, and services not included in the CPT® codes. The CPT® manual is published by and may be purchased from the AMA, PO Box 930876, Atlanta, GA 31193-0876.

18. Specialty Hospital: A health care facility with a Long Term Care Hospital, Psychiatric Hospital, or Rehabilitation Hospital Primary Taxonomy in the NPI Registry at https://nppes.cms.hhs.gov/NPPES.

19. Usual and Customary Charge: The charge on the price list for the medical, surgical and hospital services, nursing, medicines, and mechanical, surgical aids that is maintained by the health care provider.

1.04 LEGAL DISCLAIMERS

1. This chapter includes data that is proprietary to the AMA, therefore, certain restrictions apply. These restrictions are established by the AMA and are set out below:

A. The five character codes included in this chapter are obtained from the Current Procedural Terminology (CPT®), Copyright by the AMA. CPT® is developed by the AMA as a listing of descriptive terms and five character identifying codes and modifiers for reporting medical services and procedures.

B. The responsibility for the content of this chapter is with the Board and no endorsement by the AMA is intended or should be implied. The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in this chapter.

C. No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT®. Any use of CPT® outside of this chapter should refer to the most current CPT® which contains the complete and most current listing of codes and descriptive terms.

1.05 AUTHORIZATION

1. Nothing in the Act or these rules requires the authorization of medical, surgical and hospital services, nursing, medicines, and mechanical, surgical aids provided pursuant to 39-A M.R.S.A. § 206.

2. An employer/insurer is not permitted to require pre-authorization of medical, surgical and hospital services, nursing, medicines, and mechanical, surgical aids provided pursuant to 39-A M.R.S.A. § 206 as a condition of payment.

https://nppes.cms.hhs.gov/NPPES


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1.06 BILLING PROCEDURES

1. Bills must specify the billing entity’s tax identification number, the license number, registration number, certificate number, or National Provider Identifier of the health care provider, the employer, the date of injury/occurrence, the date of service, the work-related injury or disease treated, the appropriate procedure code(s) for the work-related injury or disease treated, and the charges for each procedure code. Bills properly submitted on standardized claim forms prescribed by the Centers for Medicare & Medicaid are sufficient to comply with this requirement. Uncoded bills may be returned for coding.

2. In the event a patient fails to keep a scheduled appointment, health care providers are not to bill for any services that would have been provided nor will there be any reimbursement for such scheduled services.

3. A bill must be accompanied by health care records to substantiate the services rendered. Fees for copies of health care records are outlined below.

1.07 REIMBURSEMENT

1. The injured employee is not liable for payment of any medical, surgical and hospital services, nursing, medicines, and mechanical, surgical aids provided pursuant to 39-A M.R.S.A. § 206. Except as provided by 39-A M.R.S.A. §206(2)(B), health care providers may charge the patient directly only for the treatment of conditions that are unrelated to the compensable injury or disease. See 39-A M.R.S.A. §206(13).

2. An employer/insurer is not liable for charges for medical, surgical and hospital services, nursing, medicines, and mechanical, surgical aids provided pursuant to 39-A M.R.S.A. § 206 in excess of the maximum allowable payment under this chapter.

3. The employer/insurer must pay the health care provider's usual and customary charge or the maximum allowable payment under this chapter, whichever is less, within 30 days of receipt of a properly coded bill unless the bill or previous bills from the same health care provider have been controverted or denied.

4. Changes to bills are not allowed. When there is a dispute whether the provision of medical, surgical and hospital services, nursing, medicines, and mechanical, surgical aids is reasonable and proper under §206 of the Act, the employer/insurer must pay the undisputed amounts, if any, and file a notice of controversy. A copy of the notice of controversy must be sent to the health care provider from whom the bill originated. A health care provider, employee or other interested party is entitled to file a petition for payment of medical and related services for determination of any dispute regarding the provision of medical services.


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5. When there is a dispute whether a request for medical, surgical and hospital services, nursing, medicines, and mechanical, surgical aids is reasonable and proper under §206 of the Act, the employer/insurer must file a notice of controversy. A copy of the notice of controversy must be sent to the originator of the request. A health care provider, employee, or other interested party is entitled to file a petition for payment of medical and related services for determination of any dispute regarding the request for medical, surgical and hospital services, nursing, medicines, and mechanical, surgical aids.

6. Payment of a medical bill is not an admission by the employer/insurer as to the reasonableness of subsequent medical bills.

7. Nothing in this chapter precludes payment agreements to promote the quality of care and/or the reduction of health care costs.

A. A written payment agreement directly between a health care provider and an employer/insurer supersedes the maximum allowable payment otherwise available under this chapter.

B. A written payment agreement between a health care provider and an entity other than the employer/insurer seeking to invoke its terms supersedes the maximum allowable payment otherwise available under this chapter only if the employer/insurer was a named beneficiary of the payment agreement at the time the health care provider signed the payment agreement.

C. An employee retains the right to select health care providers for the treatment of an injury or disease for which compensation is claimed regardless of any such payment agreement.

8. Payment to out-of-state health care providers who treat injured employees pursuant to 39-A M.R.S.A. § 206 are subject to this chapter.

9. Modifiers which affect reimbursement are as follows:

-22 Increased Procedural Services: pay 150% of the maximum allowable payment under this chapter. -50 Bilateral Procedure: pay 150% of the maximum allowable payment under this chapter for both procedures combined. -51 Multiple Procedures: the total reimbursement for all services is the maximum allowable payment under this chapter for the primary procedure in addition to 50% for the secondary procedure, 25% for the tertiary procedure and 10% for each lesser procedure thereafter. -52 Reduced Services: pay 50% of the maximum allowable payment under this chapter if the procedure was discontinued after 1) the employee was prepared for the procedure and 2) the employee was taken to the room where the procedure was to be performed. Pay 100% of the maximum allowable payment if the procedure was discontinued after 1) the employee received anesthesia or 2) the procedure was started (e.g. scope inserted, intubation started, incision made).


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-53 Discontinued Procedure: pay 25% of the maximum allowable payment under this chapter. -54 Surgical Care Only: pay the intra-operative percentage of the maximum allowable payment under this chapter. -55 Post-operative Management Only: pay the post-operative percentage of the maximum allowable payment under this chapter. -56 Pre-operative Management Only: pay the pre-operative percentage of the maximum allowable payment under this chapter. -59 Distinct Procedural Service: pay 100% of the maximum allowable payment under this chapter (not subject to multiple procedure discounting). -62 Two Surgeons: pay each surgeon 75% of the maximum allowable payment under this chapter. -66 Surgical Team: pay 100% of the maximum allowable payment under this chapter for the surgical procedure and 25% of the maximum allowable payment under this chapter for the surgical procedure for each additional surgeon in the same specialty as the primary surgeon. If the surgeons are of two different specialties, each surgeon must be paid 100% of the maximum allowable payment under this chapter. -73 Discontinued Out-Patient Hospital/Ambulatory Surgery Center (ASC) Procedure Prior to the Administration of Anesthesia: pay 50% of the maximum allowable payment under this chapter. -80 Assistant Surgeon: pay 25% of the maximum allowable payment under this chapter. -81 Minimum Assistant Surgeon: pay 10% of the maximum allowable payment under this chapter. -82 Assistant Surgeon (when qualified resident surgeon not available): pay 25% of the maximum allowable payment under this chapter. -AD Surgical Anesthesia: Physician medically supervised more than 2 to 4 concurrent procedures: pay 50% of the maximum allowable payment under this chapter. -QK Surgical Anesthesia: Physician medically directed 2, 3, or 4 concurrent procedures: pay 50% of the maximum allowable payment under this chapter.


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-QX Surgical Anesthesia: CRNA was medically directed by a physician (2, 3, or 4 concurrent procedures): pay 50% of the maximum allowable payment under this chapter. -QY Surgical Anesthesia: Physician medically directed a CRNA in a single case: pay 50% of the maximum allowable payment under this chapter.

1.08 FEES FOR REPORTS/COPIES

1. Health care providers may charge for completing an initial diagnostic medical report (Form M-1) or other supplemental report. The charge is to be identified by billing CPT® Code 99080.

2. The maximum fee for completing an initial M-1 form or other supplemental report is: Each 10 minutes: $30.00

3. Health care providers may charge for copies of the health care records required to accompany the bill. The charge is to be identified by billing CPT® Code S9981 (units equal total number of pages). The maximum fee for copies is $5 for the first page and 45¢ for each additional page, up to a maximum of $250.00.

4. Health care providers must at the written request of the employer/insurer or the employer/insurer’s representative furnish copies of the health care records to the employer/insurer or the employer/insurer’s representative and to the employee’s representative (if none, to the employee) within 10 business days from receipt of a properly completed Form 220. An itemized invoice must accompany the copies sent to the employer/insurer. The maximum fee for copies is $5 for the first page and 45¢ for each additional page, up to a maximum of $250.00. The copying charge must be paid by the party requesting the records. Health care providers shall not require payment prior to responding to the request. Health care providers shall not charge a fee for postage/ shipping, sales tax, or a fee for researching a request that results in no records.

5. Health care providers must at the written request of the employee or the employee’s representative furnish copies of any written information (may include billing records) pertaining to a claimed workers’ compensation injury or disease regardless of whether the claimed injury or disease is denied by the employer/insurer. Copies must be furnished within 10 business days from receipt of the written request. An itemized invoice must accompany the copies. The maximum fee for copies is $5 for the first page and 45¢ for each additional page, up to a maximum of $250.00. The copying charge must be paid by the party requesting the records. Health care providers shall not require payment prior to responding to the request. Health care providers shall not charge a fee for postage/ shipping, sales tax, or a fee for researching a request that results in no records.


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1.09 FEES FOR MEDICAL TESTIMONY

1. Health care providers may charge for preparing to testify at depositions and hearings and for attendance at depositions and hearings for the purpose of giving testimony.

2. The maximum fee for preparing to testify at depositions and hearings is:

First 30 minutes: $180.00 Each additional 15 minutes: $90.00

3. The maximum fee for attendance at depositions and hearings for the purpose of giving testimony is:

First hour or any fraction thereof: $400.00 Each subsequent 15 minutes: $90.00

4. Travel time for attendance at depositions and hearings for the purpose of giving testimony is paid on a portal to portal basis when a deposition or hearing is more than ten miles from the health care provider’s home base. The maximum fee for portal-to-portal travel for the purpose of giving testimony is:

Each 60 minutes: $300.00

5. Health care providers may request advance payment of not more than $400.00 in order to schedule attendance at depositions and hearings. The advance payment will be applied against the total fees for medical testimony (preparation, travel, and attendance).

6. Health care providers will receive a maximum of $350.00 per canceled deposition when the cancellation occurs less than 24 hours prior to the scheduled start of the deposition. Health care providers will receive a maximum of $300.00 per canceled deposition when the cancellation takes place less than 48 but more than 24 hours prior to the scheduled start of the deposition. The party canceling the deposition is responsible for the fee.

1.10 EXPENSES

1. The employer/insurer must pay the employee’s travel-related expenses incurred for treatment (includes travel to the pharmacy) related to the claimed injury in accordance with Board Rules and Regulations Chapter 17.

2. The employer/insurer must pay the employee’s travel-related expenses within 30 days of receipt of a request for reimbursement.

3. The employer/insurer must reimburse the employee’s out-of-pocket costs for medicines and other non-travel-related expenses within 30 days of a request for reimbursement accompanied by receipts.

1.11 MEDICAL INFORMATION

1. Authorization from the employee for release of medical information by health care providers to the employee or the employee’s representative, employer or the employer’s representative, or insurer or insurer’s representative is not required if


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the information pertains to treatment of an injury or disease that is claimed to be compensable under this Act regardless of whether the claimed injury or disease is denied by the employer/insurer.

2. Nothing in the Act or these rules requires any personal or telephonic contact between any health care provider and a representative of the employer/insurer.

3. Health care providers must complete the M-1 form in accordance with Title 39-A M.R.S.A. §208.

4. Pursuant to Title 39-A M.R.S.A. §208, in the event that an employee changes or is referred to a different health care provider or facility, any health care provider or facility having health care records regarding the employee, including x rays, must forward all health care records relating to an injury or disease for which compensation is claimed to the next health care provider. When an employee is scheduled to be treated by a different health care provider or in a different facility, the employee must request to have the records transferred.

1.12 PERMANENT IMPAIRMENT RATINGS

1. Permanent impairment will be determined by the use of the American Medical Association’s Guides to the Evaluation of Permanent Impairment, 4th edition, copyright 1993.

2. Permanent Impairment examinations performed by the employee’s treating health care provider will have a maximum charge of $450.00.


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SECTION 2. PROFESSIONAL SERVICES


1. Pursuant to Title 39-A §209-A, the medical fee schedule for services rendered by individual health care providers must reflect the methodology underlying the federal Centers for Medicare and Medicaid Services resource-based relative value scale.

2. Fees for anesthesia services are calculated for procedure codes by multiplying the applicable conversion factor times the sum of the base unit (relative value unit (RVU) of the procedure code plus any modifying units) and time unit. The definition of the unit components are as outlined below. The conversion factor for anesthesia services is $50.00.

3. Fees for all other professional services are calculated for procedure codes by multiplying the applicable conversion factor times the non-facility total RVU. The conversion factor for all other professional services is $60.00.

4. Fees for professional services (excluding anesthesia) are as outlined in Appendix II. In the event of a dispute regarding the fee listed in Appendix II, the listed relative weight times the base rate controls.

2.02 ANESTHESIA GUIDELINES

1. Definition of the Unit Components

A. Base Unit: RVU of the five digit anesthesia procedure code (00100-01999) listed in Appendix II plus the unit value of the physical status modifier plus the unit values for any qualifying circumstances.

Physical Status Modifiers. Physical Status modifiers are represented by the initial letter ‘P’ followed by a single digit from 1 to 6 as defined in the following list:

UNIT VALUE

P1: A normal healthy patient 0 P2: A patient with mild systemic disease 0 P3: A patient with severe systemic disease 1 P4: A patient with severe systemic disease that is a constant threat to life 2 P5: A moribund patient who is not expected to survive without the operation 3 P6: A declared brain-dead patient whose organs are being Removed for donor purposes 0

Qualifying Circumstances. More than one qualifying circumstance may be selected. Many anesthesia services are provided under particularly difficult circumstances, depending on factors such as the extraordinary condition of patient, notable operative conditions, and/or unusual risk factors. This section includes a list of important qualifying circumstances that significantly affect the


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character of the anesthesia service provided. These procedures would not be reported alone, but would be reported as additional procedure numbers qualifying as an anesthesia procedure or service.

UNIT VALUE

99100: Anesthesia for patient of extreme age, under one year and over seventy 1 99116: Anesthesia complicated by utilization of total body hypothermia 5 99135: Anesthesia complicated by utilization of controlled hypotension 5 99140: Anesthesia complicated by emergency conditions (an emergency is defined as existing when delay in treatment of the patient would lead to a significant increase in the threat to life or body part) 2

B. Time Unit: Health care providers must bill time units only. One time unit is allowed for each 15 minute time interval, or significant fraction thereof (7.5 minutes or more) of anesthesia time. If anesthesia time extends beyond three hours, one time unit for each 10 minute time interval, or significant fraction thereof (5 minutes or more) is allowed after the first three hours. Documentation of actual anesthesia time is required, such as a copy of the anesthesia record.

2. Calculation Examples

A. In a procedure with a RVU of 3 (no modifiers) requiring one hour of anesthesia time, the total units are determined as follows:

Base Unit 3.0 units Time Unit + 4.0 units Total Units = 7.0 units

B. In a procedure with a RVU of 10, modifying units of 1 and qualifying circumstances of 2, requiring four hours and thirty minutes of anesthesia time, the total units are determined as follows:

Base Unit 13.0 units Time Unit (First three hours) + 12.0 units Time Unit (Subsequent 90 minutes) + 9.0 units

Total Units = 34.0 units

C. In both cases, the maximum allowable payment is determined by multiplying the total units by the conversion factor.

Total Units X Conversion Factor = Maximum Allowable Payment

CONVERSION FACTOR = $50.00


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2.03 SURGICAL GUIDELINES

1. For surgical procedures that usually mandate a variety of attendant services, the reimbursement allowances are based on a global reimbursement concept. Global reimbursement covers the performance of the basic service and the normal range of care required before and after surgery. The normal range of post-surgical care is indicated under “FUD” in Appendix II. The maximum allowable payment for a surgical procedure includes all of the following:

A. Any visit that has as its principal function the determination that the surgical procedure is needed.

B. All visits which occur after the need for surgery is determined and are related to or preparatory to the surgery.

C. Surgery.

D. Post-surgical care including removal of sutures.

2. The following four exceptions to the global reimbursement policy may warrant additional reimbursement for services provided before surgery:

A. When a pre-operative visit is the initial visit and prolonged detention or

evaluation is necessary to prepare the patient or to establish the need for a particular type of surgery.

B. When the pre-operative visit is a consultation.

C. When pre-operative services are provided that are usually not part of the preparation for a particular surgical procedure. For example, bronchoscopy prior to chest surgery.

D. When a procedure would normally be performed in the office, but circumstances mandate hospitalization.

3. Additional charges and reimbursement may be warranted for additional services rendered to treat complications, exacerbation, recurrence, or other diseases and injuries. Under such circumstances, additional reimbursement may be requested.

4. An incidental surgery will not be paid under the Workers' Compensation system.

2.04 DURABLE MEDICAL EQUIPMENT, PROSTHETICS, ORTHOTICS, AND SUPPLIES

1. The employer/insurer must pay for all durable medical equipment, prosthetics, orthotics, and supplies that are ordered and approved by the treating health care provider.

2. Fees for durable medical equipment, prosthetics, orthotics, and supplies are as outlined in Appendix II.


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SECTION 3. INPATIENT FACILITY FEES

3.01 BILLING

Bills for inpatient services must be submitted on a CMS Uniform Billing (UB-04) form. Health care providers are not required to provide the MS-DRG. Inpatient bills without the MS-DRG do not constitute uncoded bills.

3.02 ACUTE CARE HOSPITALS

The base rate for inpatient services at acute care hospitals shall be as follows:

1. On the effective date of this chapter, the base rate shall be $9,021.06.

2. On April 1, 2016, the base rate shall be $9,119.12.


3.03 CRITICAL ACCESS HOSPITALS

The base rate for inpatient services at critical access hospitals shall be as follows:

1. On the effective date of this chapter, the base rate shall be $10,525.95.



3.04 RESERVED 3.05 PAYMENT CALCULATION

Pursuant to Title 39-A §209-A, the medical fee schedule for services rendered by health care facilities must reflect the methodology and categories set forth in the federal Centers for Medicare and Medicaid Services severity-diagnosis related group system for inpatient services. Inpatient fees are calculated by multiplying the base rate times the MS-DRG weight. In the event of a dispute regarding the fee listed in Appendix III, the listed relative weight times the base rate controls. For inpatient services that take place during two different calendar years, payment is calculated based on the discharge date.

3.06 OUTLIER PAYMENTS

The threshold for outlier payments is $75,000.00 plus the fee established in Appendix III. If the outlier threshold is met, the outlier payment is the charges above the threshold multiplied by 75%.

3.07 IMPLANTABLES

Where an implantable exceeds $10,000.00 in cost, an acute care or critical access hospital may seek additional reimbursement. Reimbursement is set at the actual amount paid plus


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$500.00. Handling and freight charges must be included in the hospital's invoiced cost and are not to be reimbursed separately. When a hospital seeks additional reimbursement pursuant to this chapter, the implantable charge is excluded from any calculation for an outlier payment.

3.08 SERVICES INCLUDED

All services provided during an uninterrupted patient encounter leading to an inpatient admittance must be included in the inpatient stay. Services do not include costs related to transportation of a patient to obtain medical care.

3.09 FACILITY TRANSFERS

The following applies to facility transfers when a patient is transferred for continuation of medical treatment between two hospitals:

1. A hospital transferring a patient is paid as follows: The MS-DRG reimbursement amount is divided by the number of days duration listed for the DRG; the resultant per diem amount is then multiplied by two for the first day of stay at the transferring hospital; the per diem amount is multiplied by one for each subsequent day of stay at the transferring hospital; and the amounts for each day of stay at the transferring hospital are totaled. If the result is greater than the MS-DRG reimbursement amount, the transferring hospital is paid the MS-DRG reimbursement amount. Associated outliers and add-ons are then added to the payment.

2. A hospital discharging a patient is paid the full MS-DRG payment plus any appropriate outliers and add-ons.

3. Facility transfers do not include costs related to transportation of a patient to obtain medical care.

3.10 OTHER INPATIENT FACILITY FEES

Inpatient services provided at specialty hospitals must be paid at 75% of the provider’s usual and customary charge.

3.11 PROFESSIONAL SERVICES

Individual health care providers who furnish professional services in an inpatient setting must be reimbursed using the fees set forth in Appendix II. The individual health care provider’s charges are excluded from any calculation of outlier payments.


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SECTION 4. OUTPATIENT FACILITY FEES

4.01 BILLING

Bills for hospital outpatient and ambulatory surgical services must be submitted on a UB-04 form. Outpatient hospital facility services performed on the same day for the same patient must be reported on a single UB-04 form.

4.02 ACUTE CARE HOSPITALS

The base rate for outpatient services at acute care hospitals shall be as follows:

1. On the effective date of this chapter, the base rate shall be $120.14.

2. On April 1, 2016, the base rate shall be $131.86.


4.03 CRITICAL ACCESS HOSPITALS

The base rate for outpatient services at critical access hospitals shall be as follows:




4.04 AMBULATORY SURGICAL CENTERS

The base rate for surgical services at ambulatory surgical centers shall be:





Pursuant to Title 39-A §209-A, the medical fee schedule for services rendered by health care facilities must reflect the methodology and categories set forth in the federal Centers for Medicare and Medicaid Services ambulatory payment classification system for outpatient services. Fees for procedure codes are calculated by multiplying the base rate times the APC weight. In the event of a dispute regarding the fee listed in Appendix IV, the listed relative weight times the base rate controls.

1. For procedure codes with no CPT®/HCPCS code or for procedure codes with a status indicator of N, there is no separate payment.

2. If the ACH Fee, CAH Fee or ASC Fee listed in Appendix IV is $0.00 for a procedure code with a status indicator other than N, then payment must be


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calculated at 75% of the health care provider’s usual and customary charge.

3. When two or more procedure codes with a status indicator of T are billed on the same date of service, the highest weighted code is paid at 100% of the fee listed in Appendix IV and subsequent T status code procedures are paid at 50% of the fee listed in Appendix IV. Add-on codes are not subject to discounting.

4. When one or more procedure codes with a status indicator of N are billed without other outpatient services (i.e. non-patient referred specimens or the facility collects the specimen and furnishes only the outpatient labs on a given date of service, etc.), payment must be 75% of the provider’s usual and customary charges.

4.06 OUTLIER PAYMENTS

The threshold for outlier payments is $2,500.00 per procedure code plus the fee listed in Appendix IV. If the outlier threshold is met, the outlier payment is the charges above the threshold multiplied by 75%.

4.07 IMPLANTABLES

Where an implantable exceeds $250.00 in cost, hospitals or ambulatory surgical centers may seek additional reimbursement (regardless of the status indicator). Reimbursement is set at the actual amount paid plus 20% or the actual amount paid plus $500.00, whichever is less. Handling and freight charges must be included in the facility's invoiced cost and are not to be reimbursed separately.

4.08 SERVICES INCLUDED

Outpatient services include observation in an outpatient status.

4.09 TRANSFERS

The following applies to facility transfers when a patient is transferred for continuation of medical treatment between two facilities:

1. A hospital or ambulatory surgical center transferring a patient is paid the maximum allowable payment established in this section.

2. A hospital discharging a patient is paid the full MS-DRG payment plus any appropriate outliers and add-ons per Section 3.

3. Facility transfers do not include costs related to transportation of a patient to obtain medical care.

4.10 OTHER OUTPATIENT FACILITY FEES

Outpatient services provided by institutional health care providers other than hospitals and ambulatory surgical centers (e.g. clinical medical laboratories, free standing outpatient facilities, etc.) must be paid at 75% of the provider’s usual and customary charge.


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4.11 PROFESSIONAL SERVICES

Individual health care providers who furnish professional services in an outpatient setting must be reimbursed using the maximum fees set forth in Appendix II. The individual health care provider’s charges are excluded from any calculation of outlier payments.

STATUTORY AUTHORITY: 39-A M.R.S. §§ 152(2) and 209 EFFECTIVE DATE: January 15, 1993 (EMERGENCY) EFFECTIVE DATE OF PERMANENT RULE: April 17, 1993 REPEALED AND REPLACED: April 4, 1994 EFFECTIVE DATE (ELECTRONIC CONVERSION): April 28, 1996 AMENDED: January 1, 1997 - agency asserts § 16 as effective retroactively to April 4, 1994. July 1, 1997 - changed address in § 9 (4), replaced Appendix III. May 1, 1999 - updated CPT® copyright year, replaced Appendices I, II, & III. NON-SUBSTANTIVE CORRECTIONS: October 25, 1999 - minor formatting; date corrections from paper filing in 4.1 - 4.4. AMENDED: July 1, 2001 July 1, 2002 - refiled June 13, 2002 to include some codes missing from the previous filing. September 24, 2002 - filing 2002-349 affecting § 7 sub-§ 2. NON-SUBSTANTIVE CORRECTIONS: January 8, 2003 - character spacing only in §§ 1-19. AMENDED: November 5, 2006 - filing 2006-458

December 11, 2011 – filing 2011 - (repeal Rule and Apps. I-III and replace with new Rule and Apps. I-V) October 1, 2015 – filing 2015-173


- 19 -

CHAPTER 5

APPENDIX I


PRACTITIONER’S REPORT (FORM M-1)


- 20 -

M-1 DIAGNOSTIC MEDICAL REPORT MAINE WORKERS' COMPENSATION BOARD

EMPLOYER NAME: EMPLOYER MAILING ADDRESS:

INSURER NAME: INSURER MAILING ADDRESS:

CLAIM NUMBER (IF KNOWN): THIRD PARTY ADMIN. NAME (IF APPL.): THIRD PARTY ADMIN. MAILING ADDRESS (IF APPL.):

EMPLOYEE NAME:

SSN (last 4 digits only): XXX-XX-

DOB: DATE OF INJURY:

PATIENT COMPLAINTS:

DATE OF THIS EXAMINATION : ________________________________________ INITIAL PROGRESS FINAL

ICD-9 ICD-10 DIAGNOSIS:_____________________________________________________________________________________________________

IN MY OPINION, THIS DIAGNOSIS IS WORK RELATED NOT WORK RELATED NOT YET IDENTIFIED AS TO CAUSE HAVE DIAGNOSTIC TESTS BEEN PERFORMED? YES NO IF YES, LIST: ________________________________________________________ TREATMENT TO CONTINUE? YES IF YES, DATE TO BE SEEN AGAIN:__________________ NO IF NO, PATIENT AT MMI? YES NO ESTIMATED LENGTH OF TREATMENT ___________________ DAYS WEEKS MONTHS TREATMENT PLAN (CHECK ALL THAT APPLY): REST MEDICATION EXERCISE

MEDICAL REFERRALS: THERAPY (LIST):_________________ SURGERY (LIST):_______________ OTHER(LIST):_________________

OFFICE PROCEDURES: CAST STRAPPING OTHER (LIST): _________________________________________________________ _____________________________________________________________________________________________________________________________ DOES TREATMENT PLAN INCLUDE MEDICATION THAT WOULD PREVENT THE PATIENT FROM DRIVING AND/OR WORKING SAFELY? YES NO

IF YES, LIST MEDICATIONS: _______________________________________________________________________________________________________ WORK CAPACITY: REGULAR DUTY NO WORK CAPACITY IF CHECKED, ESTIMATED DATE OF RETURN : ____________________________

MODIFIED WORK (DESCRIBE RESTRICTIONS BELOW) IF CHECKED, ESTIMATED LENGTH OF RESTRICTIONS? ____________________________ BODY PARTS: RIGHT LEFT UPPER LOWER ACTIVITY/USE OF: NEVER MINIMAL MODERATE NORMAL

HEAD LIFT/CARRY > LBS NECK THORAX WALKING BACK FLANK STANDING SPINE STAIR CLIMBING ABDOMEN SITTING SHOULDER STOOP/BEND HUMERUS KNEEL/CRAWL FOREARM WRIST PUSH/PULL HAND FINGERS VIBRATORY TOOLS PELVIS HIP REPETITIVE ACTIVITIES FEMUR KNEE KEYBOARD USE LEG ANKLE FOOT TOES OTHER_____________

PERMANENT IMPAIRMENT EXPECTED? YES NO IF YES, PERMANENT IMPAIRMENT RATING ______ % OR NOT YET AVAILABLE __________________________________________________________________ __________________________________________________________________________ SIGNATURE OF HEALTH CARE PROVIDER PRINT NAME

ADDRESS _______________________________________ TELEPHONE #___________________________________________

M-1 (Effective 10/1/2015)


- 21 -

DUTIES OF HEALTH CARE PROVIDERS

Pursuant to 39-A M.R.S.A. §208(2), duties of health care providers are as follows:

• Except for claims for medical benefits only, within 5 business days from the completion of a medical examination or within 5 business days from the date notice of injury is given to the employer, whichever is later, the health care provider treating the employee shall forward to the employer and the employee a diagnostic medical report, on forms prescribed by the board, for the injury for which compensation is being claimed. The report must include the employee's work capacity, likely duration of incapacity, return to work suitability and treatment required. The board may assess penalties up to $500 per violation on health care providers who fail to comply with the 5-day requirement of this subsection.

• If ongoing medical treatment is being provided, every 30 days the employee's health care provider shall forward to the employer and the employee a diagnostic medical report on forms prescribed by the board. An employer may request, at any time, medical information concerning the condition of the employee for which compensation is sought. The health care provider shall respond within 10 business days from receipt of the request.

• A health care provider shall submit to the employer and the employee a final report of treatment within 5 working days of the termination of treatment, except that only an initial report must be submitted if the provider treated the employee on a single occasion.

• Upon the request of the employee and in the event that an employee changes or is referred to a different health care provider or facility, any health care provider or facility having medical records regarding the employee, including x rays, shall forward all medical records relating to an injury or disease for which compensation is claimed to the next health care provider. When an employee is scheduled to be treated by a different health care provider or in a different facility, the employee shall request to have the records transferred.

• A health care provider may not charge the insurer or self-insurer an amount in excess of the fees prescribed in section 209-A for the submission of reports prescribed by this section and for the submission of any additional records.

• An insurer or self-insurer may withhold payment of fees for the submission of any required reports of treatment to any provider who fails to submit the reports on the forms prescribed by the board and within the time limits provided. The insurer or self-insurer is not required to file a notice of controversy under these circumstances, but must notify the provider that payment is being withheld due to the failure to use prescribed forms or to submit the reports in a timely fashion. In the case of dispute, any interested party may petition the board to resolve the dispute.

Other reminders:

• Except for the header information, the remainder of the M-1 form must be completed by the health care provider. This information is vital to the administration of the claim and the employee’s return to work.

• The M-1 form is not submitted to the board.

• Pursuant to Board Rules Chapter 5, a health care provider may charge a fee for completing the initial M-1.

• The attachment of narratives is optional; however, an employer/insurer may request, at any time (for a fee), medical information concerning the condition of the employee for which compensation is sought. The health care provider shall respond within 10 business days from receipt of the request. Pursuant to 39-A M.R.S.A. §208(1) a medical release is not necessary if the information pertains to an injury claimed to be compensable under the Act (whether or not the claim is controverted/denied).

CHAPTER 5

APPENDIX II


PROFESSIONAL SERVICES

Professional Services - Anesthesia Maine Workers' Compensation BoardMedical Fee Schedule

Appendix II

CPT Codes, Copyright 2015, American Medical Association 1

Code Base Unit00100 500102 600103 500104 400120 500124 400126 400140 500142 400144 600145 600147 400148 400160 500162 700164 400170 500172 600174 600176 700190 500192 700210 1100211 1000212 500214 900215 900216 1500218 1300220 1000222 600300 500320 600322 300326 700350 1000352 500400 300402 500404 500406 1300410 400450 500452 600454 300470 600472 1000474 1300500 1500520 600522 400524 400528 800529 11


Appendix II


Code Base Unit00530 400532 400534 700537 700539 1800540 1200542 1500541 1500546 1500548 1700550 1000560 1500561 2500562 2000563 2500566 2500567 1800580 2000600 1000604 1300620 1000622 1300625 1300626 1500630 800632 700634 1000635 400640 300670 1300700 400702 400730 500740 500750 400752 600754 700756 700770 1500790 700792 1300794 800796 3000797 1100800 400802 500810 500820 500830 400832 600834 500836 600840 600842 4


Appendix II


Code Base Unit00844 700846 800848 800851 600860 600862 700864 800865 700866 1000868 1000870 500872 700873 500880 1500882 1000902 500904 700906 400908 600910 300912 500914 500916 500918 500920 300921 300922 600924 400926 400928 600930 400932 400934 600936 800938 400940 300942 400944 600948 400950 500952 401112 501120 601130 301140 1501150 1001160 401170 801173 1201180 301190 401200 401202 401210 6


Appendix II


Code Base Unit01212 1001214 801215 1001220 401230 601232 501234 801250 401260 301270 801272 401274 601320 401340 401360 501380 301382 301390 301392 401400 401402 701404 501420 301430 301432 601440 801442 801444 801462 301464 301470 301472 501474 501480 301482 401484 401486 701490 301500 801502 601520 301522 501610 501620 401622 401630 501634 901636 1501638 1001650 601652 1001654 801656 1001670 4


Appendix II


Code Base Unit01680 301682 401710 301712 501714 501716 501730 301732 301740 401742 501744 501756 601758 501760 701770 601772 601780 301782 401810 301820 301829 301830 301832 601840 601842 601844 601850 301852 401860 301916 501920 701922 701924 501925 701926 801930 501931 701932 601933 701935 501936 501951 301952 501953 101958 501960 501961 701962 801963 801965 401966 401967 501968 201969 5


Appendix II


Code Base Unit01990 701991 301992 501996 301999 0

Professional Services - Other Maine Workers' Compensation BoardMedical Fee Schedule

Appendix II


Code ModNon-Facility Total RVU

Global Days

Pre-Operative

Intra-operative

Post-operative Fee

10021 3.50 XXX 0.00 0.00 0.00 $210.0010022 3.99 XXX 0.00 0.00 0.00 $239.4010030 22.15 XXX 0.00 0.00 0.00 $1,329.0010035 15.18 000 0.00 0.00 0.00 $910.8010036 13.19 ZZZ 0.00 0.00 0.00 $791.4010040 2.89 010 0.10 0.80 0.10 $173.4010060 3.32 010 0.10 0.80 0.10 $199.2010061 5.85 010 0.10 0.80 0.10 $351.0010080 5.07 010 0.10 0.80 0.10 $304.2010081 7.60 010 0.10 0.80 0.10 $456.0010120 4.30 010 0.10 0.80 0.10 $258.0010121 7.81 010 0.10 0.80 0.10 $468.6010140 4.61 010 0.10 0.80 0.10 $276.6010160 3.71 010 0.10 0.80 0.10 $222.6010180 7.02 010 0.10 0.80 0.10 $421.2011000 1.55 000 0.00 0.00 0.00 $93.0011001 0.61 ZZZ 0.00 0.00 0.00 $36.6011004 16.79 000 0.00 0.00 0.00 $1,007.4011005 22.74 000 0.00 0.00 0.00 $1,364.4011006 20.37 000 0.00 0.00 0.00 $1,222.2011008 8.00 ZZZ 0.00 0.00 0.00 $480.0011010 14.02 010 0.10 0.80 0.10 $841.2011011 15.24 000 0.00 0.00 0.00 $914.4011012 20.46 000 0.00 0.00 0.00 $1,227.6011042 3.31 000 0.00 0.00 0.00 $198.6011043 6.49 000 0.00 0.00 0.00 $389.4011044 8.98 000 0.00 0.00 0.00 $538.8011045 1.16 ZZZ 0.00 0.00 0.00 $69.6011046 2.09 ZZZ 0.00 0.00 0.00 $125.4011047 3.55 ZZZ 0.00 0.00 0.00 $213.0011055 1.35 000 0.00 0.00 0.00 $81.0011056 1.65 000 0.00 0.00 0.00 $99.0011057 1.86 000 0.00 0.00 0.00 $111.6011100 2.93 000 0.00 0.00 0.00 $175.8011101 0.93 ZZZ 0.00 0.00 0.00 $55.8011200 2.49 010 0.10 0.80 0.10 $149.4011201 0.54 ZZZ 0.00 0.00 0.00 $32.4011300 2.75 000 0.00 0.00 0.00 $165.0011301 3.38 000 0.00 0.00 0.00 $202.8011302 3.99 000 0.00 0.00 0.00 $239.4011303 4.41 000 0.00 0.00 0.00 $264.6011305 2.81 000 0.00 0.00 0.00 $168.6011306 3.45 000 0.00 0.00 0.00 $207.0011307 4.06 000 0.00 0.00 0.00 $243.6011308 4.27 000 0.00 0.00 0.00 $256.2011310 3.22 000 0.00 0.00 0.00 $193.2011311 3.17 000 0.00 0.00 0.00 $190.2011312 4.54 000 0.00 0.00 0.00 $272.4011313 5.27 000 0.00 0.00 0.00 $316.2011400 3.50 010 0.10 0.80 0.10 $210.0011401 4.21 010 0.10 0.80 0.10 $252.6011402 4.69 010 0.10 0.80 0.10 $281.4011403 5.42 010 0.10 0.80 0.10 $325.20


Appendix II



Global Days

Pre-Operative

Intra-operative

Post-operative Fee

11404 6.17 010 0.10 0.80 0.10 $370.2011406 8.92 010 0.10 0.80 0.10 $535.2011420 3.46 010 0.10 0.80 0.10 $207.6011421 4.43 010 0.10 0.80 0.10 $265.8011422 4.96 010 0.10 0.80 0.10 $297.6011423 5.72 010 0.10 0.80 0.10 $343.2011424 6.62 010 0.10 0.80 0.10 $397.2011426 9.51 010 0.10 0.80 0.10 $570.6011440 3.81 010 0.10 0.80 0.10 $228.6011441 4.75 010 0.10 0.80 0.10 $285.0011442 5.34 010 0.10 0.80 0.10 $320.4011443 6.37 010 0.10 0.80 0.10 $382.2011444 8.00 010 0.10 0.80 0.10 $480.0011446 11.14 010 0.10 0.80 0.10 $668.4011450 10.84 090 0.10 0.71 0.19 $650.4011451 13.87 090 0.10 0.71 0.19 $832.2011462 10.59 090 0.10 0.71 0.19 $635.4011463 14.04 090 0.10 0.71 0.19 $842.4011470 11.78 090 0.10 0.71 0.19 $706.8011471 14.59 090 0.10 0.71 0.19 $875.4011600 5.43 010 0.10 0.80 0.10 $325.8011601 6.46 010 0.10 0.80 0.10 $387.6011602 7.02 010 0.10 0.80 0.10 $421.2011603 8.04 010 0.10 0.80 0.10 $482.4011604 8.95 010 0.10 0.80 0.10 $537.0011606 12.85 010 0.10 0.80 0.10 $771.0011620 5.49 010 0.10 0.80 0.10 $329.4011621 6.51 010 0.10 0.80 0.10 $390.6011622 7.27 010 0.10 0.80 0.10 $436.2011623 8.55 010 0.10 0.80 0.10 $513.0011624 9.64 010 0.10 0.80 0.10 $578.4011626 11.66 010 0.10 0.80 0.10 $699.6011640 5.67 010 0.10 0.80 0.10 $340.2011641 6.74 010 0.10 0.80 0.10 $404.4011642 7.71 010 0.10 0.80 0.10 $462.6011643 9.10 010 0.10 0.80 0.10 $546.0011644 11.25 010 0.10 0.80 0.10 $675.0011646 14.74 010 0.10 0.80 0.10 $884.4011719 0.40 000 0.00 0.00 0.00 $24.0011720 0.91 000 0.00 0.00 0.00 $54.6011721 1.27 000 0.00 0.00 0.00 $76.2011730 2.81 000 0.00 0.00 0.00 $168.6011732 1.01 ZZZ 0.00 0.00 0.00 $60.6011740 1.41 000 0.00 0.00 0.00 $84.6011750 5.10 010 0.10 0.80 0.10 $306.0011752 9.20 010 0.10 0.80 0.10 $552.0011755 3.78 000 0.00 0.00 0.00 $226.8011760 5.54 010 0.10 0.80 0.10 $332.4011762 7.99 010 0.10 0.80 0.10 $479.4011765 4.74 010 0.10 0.80 0.10 $284.4011770 7.89 010 0.10 0.80 0.10 $473.4011771 16.34 090 0.10 0.71 0.19 $980.4011772 19.81 090 0.10 0.71 0.19 $1,188.60


Appendix II



Global Days

Pre-Operative

Intra-operative

Post-operative Fee

11900 1.57 000 0.00 0.00 0.00 $94.2011901 1.98 000 0.00 0.00 0.00 $118.8011920 4.87 000 0.00 0.00 0.00 $292.2011921 5.68 000 0.00 0.00 0.00 $340.8011922 1.76 ZZZ 0.00 0.00 0.00 $105.6011950 2.09 000 0.00 0.00 0.00 $125.4011951 2.77 000 0.00 0.00 0.00 $166.2011952 3.72 000 0.00 0.00 0.00 $223.2011954 4.52 000 0.00 0.00 0.00 $271.2011960 27.27 090 0.10 0.71 0.19 $1,636.2011970 17.66 090 0.10 0.71 0.19 $1,059.6011971 13.49 090 0.10 0.71 0.19 $809.4011976 4.05 000 0.00 0.00 0.00 $243.0011980 2.66 000 0.00 0.00 0.00 $159.6011981 4.00 XXX 0.00 0.00 0.00 $240.0011982 4.54 XXX 0.00 0.00 0.00 $272.4011983 6.31 XXX 0.00 0.00 0.00 $378.6012001 2.52 000 0.00 0.00 0.00 $151.2012002 3.07 000 0.00 0.00 0.00 $184.2012004 3.62 000 0.00 0.00 0.00 $217.2012005 4.57 000 0.00 0.00 0.00 $274.2012006 5.42 000 0.00 0.00 0.00 $325.2012007 6.34 000 0.00 0.00 0.00 $380.4012011 3.09 000 0.00 0.00 0.00 $185.4012013 3.23 000 0.00 0.00 0.00 $193.8012014 3.78 000 0.00 0.00 0.00 $226.8012015 4.58 000 0.00 0.00 0.00 $274.8012016 5.81 000 0.00 0.00 0.00 $348.6012017 4.41 000 0.00 0.00 0.00 $264.6012018 5.00 000 0.00 0.00 0.00 $300.0012020 8.25 010 0.10 0.80 0.10 $495.0012021 4.75 010 0.10 0.80 0.10 $285.0012031 6.72 010 0.10 0.80 0.10 $403.2012032 8.60 010 0.10 0.80 0.10 $516.0012034 8.85 010 0.10 0.80 0.10 $531.0012035 10.88 010 0.10 0.80 0.10 $652.8012036 12.02 010 0.10 0.80 0.10 $721.2012037 13.64 010 0.10 0.80 0.10 $818.4012041 6.72 010 0.10 0.80 0.10 $403.2012042 8.20 010 0.10 0.80 0.10 $492.0012044 10.20 010 0.10 0.80 0.10 $612.0012045 11.45 010 0.10 0.80 0.10 $687.0012046 13.60 010 0.10 0.80 0.10 $816.0012047 14.79 010 0.10 0.80 0.10 $887.4012051 7.34 010 0.10 0.80 0.10 $440.4012052 8.36 010 0.10 0.80 0.10 $501.6012053 9.81 010 0.10 0.80 0.10 $588.6012054 10.25 010 0.10 0.80 0.10 $615.0012055 13.32 010 0.10 0.80 0.10 $799.2012056 15.69 010 0.10 0.80 0.10 $941.4012057 16.09 010 0.10 0.80 0.10 $965.4013100 9.51 010 0.10 0.80 0.10 $570.6013101 11.25 010 0.10 0.80 0.10 $675.00


Appendix II



Global Days

Pre-Operative

Intra-operative

Post-operative Fee

13102 3.48 ZZZ 0.00 0.00 0.00 $208.8013120 9.96 010 0.10 0.80 0.10 $597.6013121 12.14 010 0.10 0.80 0.10 $728.4013122 3.80 ZZZ 0.00 0.00 0.00 $228.0013131 10.96 010 0.10 0.80 0.10 $657.6013132 13.55 010 0.10 0.80 0.10 $813.0013133 5.09 ZZZ 0.00 0.00 0.00 $305.4013151 12.02 010 0.10 0.80 0.10 $721.2013152 14.44 010 0.10 0.80 0.10 $866.4013153 5.54 ZZZ 0.00 0.00 0.00 $332.4013160 23.27 090 0.10 0.71 0.19 $1,396.2014000 17.80 090 0.10 0.71 0.19 $1,068.0014001 22.88 090 0.10 0.71 0.19 $1,372.8014020 19.91 090 0.10 0.71 0.19 $1,194.6014021 24.90 090 0.10 0.71 0.19 $1,494.0014040 21.78 090 0.10 0.71 0.19 $1,306.8014041 26.95 090 0.10 0.71 0.19 $1,617.0014060 22.21 090 0.10 0.71 0.19 $1,332.6014061 28.99 090 0.10 0.71 0.19 $1,739.4014301 30.88 090 0.10 0.71 0.19 $1,852.8014302 6.42 ZZZ 0.00 0.00 0.00 $385.2014350 20.01 090 0.10 0.71 0.19 $1,200.6015002 9.96 000 0.00 0.00 0.00 $597.6015003 2.17 ZZZ 0.00 0.00 0.00 $130.2015004 11.48 000 0.00 0.00 0.00 $688.8015005 3.58 ZZZ 0.00 0.00 0.00 $214.8015040 7.31 000 0.00 0.00 0.00 $438.6015050 16.04 090 0.10 0.71 0.19 $962.4015100 24.64 090 0.10 0.71 0.19 $1,478.4015101 5.33 ZZZ 0.00 0.00 0.00 $319.8015110 22.92 090 0.10 0.71 0.19 $1,375.2015111 3.33 ZZZ 0.00 0.00 0.00 $199.8015115 23.58 090 0.10 0.71 0.19 $1,414.8015116 4.40 ZZZ 0.00 0.00 0.00 $264.0015120 24.44 090 0.10 0.71 0.19 $1,466.4015121 5.97 ZZZ 0.00 0.00 0.00 $358.2015130 19.25 090 0.10 0.71 0.19 $1,155.0015131 2.88 ZZZ 0.00 0.00 0.00 $172.8015135 24.15 090 0.10 0.71 0.19 $1,449.0015136 2.74 ZZZ 0.00 0.00 0.00 $164.4015150 20.00 090 0.10 0.71 0.19 $1,200.0015151 3.52 ZZZ 0.00 0.00 0.00 $211.2015152 4.31 ZZZ 0.00 0.00 0.00 $258.6015155 20.65 090 0.10 0.71 0.19 $1,239.0015156 4.55 ZZZ 0.00 0.00 0.00 $273.0015157 5.00 ZZZ 0.00 0.00 0.00 $300.0015200 23.81 090 0.10 0.71 0.19 $1,428.6015201 4.24 ZZZ 0.00 0.00 0.00 $254.4015220 22.06 090 0.10 0.71 0.19 $1,323.6015221 3.91 ZZZ 0.00 0.00 0.00 $234.6015240 26.75 090 0.10 0.71 0.19 $1,605.0015241 5.30 ZZZ 0.00 0.00 0.00 $318.0015260 28.93 090 0.10 0.71 0.19 $1,735.80


Appendix II



Global Days

Pre-Operative

Intra-operative

Post-operative Fee

15261 6.17 ZZZ 0.00 0.00 0.00 $370.2015271 4.00 000 0.00 0.00 0.00 $240.0015272 0.77 ZZZ 0.00 0.00 0.00 $46.2015273 8.45 000 0.00 0.00 0.00 $507.0015274 2.04 ZZZ 0.00 0.00 0.00 $122.4015275 4.23 000 0.00 0.00 0.00 $253.8015276 0.99 ZZZ 0.00 0.00 0.00 $59.4015277 9.20 000 0.00 0.00 0.00 $552.0015278 2.44 ZZZ 0.00 0.00 0.00 $146.4015570 26.29 090 0.10 0.71 0.19 $1,577.4015572 25.50 090 0.10 0.71 0.19 $1,530.0015574 26.21 090 0.10 0.71 0.19 $1,572.6015576 23.10 090 0.10 0.71 0.19 $1,386.0015600 9.26 090 0.10 0.71 0.19 $555.6015610 10.19 090 0.10 0.71 0.19 $611.4015620 12.61 090 0.10 0.71 0.19 $756.6015630 13.12 090 0.10 0.71 0.19 $787.2015650 14.39 090 0.10 0.71 0.19 $863.4015731 32.41 090 0.10 0.71 0.19 $1,944.6015732 36.94 090 0.10 0.71 0.19 $2,216.4015734 43.31 090 0.10 0.71 0.19 $2,598.6015736 38.13 090 0.10 0.71 0.19 $2,287.8015738 40.42 090 0.10 0.71 0.19 $2,425.2015740 29.21 090 0.10 0.71 0.19 $1,752.6015750 26.63 090 0.10 0.71 0.19 $1,597.8015756 67.50 090 0.10 0.71 0.19 $4,050.0015757 66.52 090 0.10 0.71 0.19 $3,991.2015758 66.62 090 0.10 0.71 0.19 $3,997.2015760 24.49 090 0.10 0.71 0.19 $1,469.4015770 19.45 090 0.10 0.71 0.19 $1,167.0015775 8.56 000 0.00 0.00 0.00 $513.6015776 14.28 000 0.00 0.00 0.00 $856.8015777 6.22 ZZZ 0.00 0.00 0.00 $373.2015780 23.90 090 0.10 0.71 0.19 $1,434.0015781 15.92 090 0.10 0.71 0.19 $955.2015782 18.32 090 0.10 0.71 0.19 $1,099.2015783 13.14 090 0.10 0.71 0.19 $788.4015786 6.94 010 0.10 0.80 0.10 $416.4015787 1.39 ZZZ 0.00 0.00 0.00 $83.4015788 13.11 090 0.10 0.71 0.19 $786.6015789 15.67 090 0.10 0.71 0.19 $940.2015792 12.60 090 0.10 0.71 0.19 $756.0015793 14.03 090 0.10 0.71 0.19 $841.8015819 21.26 090 0.10 0.71 0.19 $1,275.6015820 16.01 090 0.10 0.71 0.19 $960.6015821 17.28 090 0.10 0.71 0.19 $1,036.8015822 12.67 090 0.10 0.71 0.19 $760.2015823 17.25 090 0.10 0.71 0.19 $1,035.0015830 33.99 090 0.10 0.71 0.19 $2,039.4015832 26.63 090 0.10 0.71 0.19 $1,597.8015833 24.99 090 0.10 0.71 0.19 $1,499.4015834 25.78 090 0.10 0.71 0.19 $1,546.8015835 26.93 090 0.10 0.71 0.19 $1,615.80


Appendix II



Global Days

Pre-Operative

Intra-operative

Post-operative Fee

15836 22.06 090 0.10 0.71 0.19 $1,323.6015837 23.13 090 0.10 0.71 0.19 $1,387.8015838 16.51 090 0.10 0.71 0.19 $990.6015839 25.35 090 0.10 0.71 0.19 $1,521.0015840 29.17 090 0.10 0.71 0.19 $1,750.2015841 46.80 090 0.10 0.71 0.19 $2,808.0015842 76.54 090 0.10 0.71 0.19 $4,592.4015845 28.86 090 0.10 0.71 0.19 $1,731.6015850 2.52 XXX 0.00 0.00 0.00 $151.2015851 2.80 000 0.00 0.00 0.00 $168.0015852 1.35 000 0.00 0.00 0.00 $81.0015860 3.21 000 0.00 0.00 0.00 $192.6015920 17.48 090 0.10 0.71 0.19 $1,048.8015922 22.65 090 0.10 0.71 0.19 $1,359.0015931 19.79 090 0.10 0.71 0.19 $1,187.4015933 24.51 090 0.10 0.71 0.19 $1,470.6015934 26.79 090 0.10 0.71 0.19 $1,607.4015935 31.57 090 0.10 0.71 0.19 $1,894.2015936 25.73 090 0.10 0.71 0.19 $1,543.8015937 29.91 090 0.10 0.71 0.19 $1,794.6015940 20.25 090 0.10 0.71 0.19 $1,215.0015941 25.97 090 0.10 0.71 0.19 $1,558.2015944 25.58 090 0.10 0.71 0.19 $1,534.8015945 28.18 090 0.10 0.71 0.19 $1,690.8015946 47.45 090 0.10 0.71 0.19 $2,847.0015950 17.03 090 0.10 0.71 0.19 $1,021.8015951 25.47 090 0.10 0.71 0.19 $1,528.2015952 25.99 090 0.10 0.71 0.19 $1,559.4015953 28.84 090 0.10 0.71 0.19 $1,730.4015956 33.28 090 0.10 0.71 0.19 $1,996.8015958 33.93 090 0.10 0.71 0.19 $2,035.8016000 1.95 000 0.00 0.00 0.00 $117.0016020 2.31 000 0.00 0.00 0.00 $138.6016025 4.20 000 0.00 0.00 0.00 $252.0016030 5.29 000 0.00 0.00 0.00 $317.4016035 5.61 000 0.00 0.00 0.00 $336.6016036 2.34 ZZZ 0.00 0.00 0.00 $140.4017000 1.89 010 0.10 0.80 0.10 $113.4017003 0.16 ZZZ 0.00 0.00 0.00 $9.6017004 4.26 010 0.10 0.80 0.10 $255.6017106 9.71 090 0.10 0.71 0.19 $582.6017107 12.35 090 0.10 0.71 0.19 $741.0017108 18.21 090 0.10 0.71 0.19 $1,092.6017110 3.14 010 0.10 0.80 0.10 $188.4017111 3.72 010 0.10 0.80 0.10 $223.2017250 2.25 000 0.00 0.00 0.00 $135.0017260 2.69 010 0.10 0.80 0.10 $161.4017261 4.07 010 0.10 0.80 0.10 $244.2017262 4.96 010 0.10 0.80 0.10 $297.6017263 5.42 010 0.10 0.80 0.10 $325.2017264 5.82 010 0.10 0.80 0.10 $349.2017266 6.59 010 0.10 0.80 0.10 $395.4017270 4.26 010 0.10 0.80 0.10 $255.60


Appendix II



Global Days

Pre-Operative

Intra-operative

Post-operative Fee

17271 4.62 010 0.10 0.80 0.10 $277.2017272 5.28 010 0.10 0.80 0.10 $316.8017273 5.89 010 0.10 0.80 0.10 $353.4017274 6.96 010 0.10 0.80 0.10 $417.6017276 8.07 010 0.10 0.80 0.10 $484.2017280 3.99 010 0.10 0.80 0.10 $239.4017281 5.04 010 0.10 0.80 0.10 $302.4017282 5.80 010 0.10 0.80 0.10 $348.0017283 6.94 010 0.10 0.80 0.10 $416.4017284 7.94 010 0.10 0.80 0.10 $476.4017286 10.19 010 0.10 0.80 0.10 $611.4017311 18.80 000 0.00 0.00 0.00 $1,128.0017312 11.02 ZZZ 0.00 0.00 0.00 $661.2017313 17.57 000 0.00 0.00 0.00 $1,054.2017314 10.58 ZZZ 0.00 0.00 0.00 $634.8017315 2.27 ZZZ 0.00 0.00 0.00 $136.2017340 1.46 010 0.10 0.80 0.10 $87.6017360 3.67 010 0.10 0.80 0.10 $220.2019000 3.21 000 0.00 0.00 0.00 $192.6019001 0.77 ZZZ 0.00 0.00 0.00 $46.2019020 13.45 090 0.10 0.71 0.19 $807.0019030 4.67 000 0.00 0.00 0.00 $280.2019081 19.67 000 0.00 0.00 0.00 $1,180.2019082 16.25 ZZZ 0.00 0.00 0.00 $975.0019083 19.03 000 0.00 0.00 0.00 $1,141.8019084 15.63 ZZZ 0.00 0.00 0.00 $937.8019085 29.21 000 0.00 0.00 0.00 $1,752.6019086 23.13 ZZZ 0.00 0.00 0.00 $1,387.8019100 4.28 000 0.00 0.00 0.00 $256.8019101 9.73 010 0.10 0.80 0.10 $583.8019105 60.59 000 0.00 0.00 0.00 $3,635.4019110 13.85 090 0.10 0.71 0.19 $831.0019112 12.98 090 0.10 0.71 0.19 $778.8019120 14.14 090 0.10 0.71 0.19 $848.4019125 15.68 090 0.10 0.71 0.19 $940.8019126 4.70 ZZZ 0.00 0.00 0.00 $282.0019260 34.84 090 0.10 0.71 0.19 $2,090.4019271 47.19 090 0.10 0.71 0.19 $2,831.4019272 51.52 090 0.10 0.71 0.19 $3,091.2019281 6.78 000 0.00 0.00 0.00 $406.8019282 4.75 ZZZ 0.00 0.00 0.00 $285.0019283 7.64 000 0.00 0.00 0.00 $458.4019284 5.76 ZZZ 0.00 0.00 0.00 $345.6019285 14.59 000 0.00 0.00 0.00 $875.4019286 12.81 ZZZ 0.00 0.00 0.00 $768.6019287 24.39 000 0.00 0.00 0.00 $1,463.4019288 19.66 ZZZ 0.00 0.00 0.00 $1,179.6019296 112.31 000 0.00 0.00 0.00 $6,738.6019297 2.75 ZZZ 0.00 0.00 0.00 $165.0019298 29.49 000 0.00 0.00 0.00 $1,769.4019300 14.98 090 0.10 0.71 0.19 $898.8019301 18.86 090 0.10 0.71 0.19 $1,131.6019302 25.94 090 0.10 0.71 0.19 $1,556.40


Appendix II



Global Days

Pre-Operative

Intra-operative

Post-operative Fee

19303 29.17 090 0.10 0.71 0.19 $1,750.2019304 16.53 090 0.10 0.71 0.19 $991.8019305 32.56 090 0.10 0.71 0.19 $1,953.6019306 34.62 090 0.10 0.71 0.19 $2,077.2019307 34.53 090 0.10 0.71 0.19 $2,071.8019316 22.25 090 0.10 0.71 0.19 $1,335.0019318 31.97 090 0.10 0.71 0.19 $1,918.2019324 14.10 090 0.10 0.71 0.19 $846.0019325 18.56 090 0.10 0.71 0.19 $1,113.6019328 14.38 090 0.10 0.71 0.19 $862.8019330 18.40 090 0.10 0.71 0.19 $1,104.0019340 29.14 090 0.10 0.71 0.19 $1,748.4019342 26.78 090 0.10 0.71 0.19 $1,606.8019350 23.78 090 0.10 0.71 0.19 $1,426.8019355 20.14 090 0.10 0.71 0.19 $1,208.4019357 43.68 090 0.10 0.71 0.19 $2,620.8019361 45.69 090 0.10 0.71 0.19 $2,741.4019364 80.13 090 0.10 0.71 0.19 $4,807.8019366 40.73 090 0.10 0.71 0.19 $2,443.8019367 51.95 090 0.10 0.71 0.19 $3,117.0019368 64.06 090 0.10 0.71 0.19 $3,843.6019369 59.29 090 0.10 0.71 0.19 $3,557.4019370 19.92 090 0.10 0.71 0.19 $1,195.2019371 22.76 090 0.10 0.71 0.19 $1,365.6019380 22.44 090 0.10 0.71 0.19 $1,346.4019396 7.97 000 0.00 0.00 0.00 $478.2020005 8.84 010 0.10 0.80 0.10 $530.4020100 17.59 010 0.10 0.80 0.10 $1,055.4020101 12.79 010 0.10 0.80 0.10 $767.4020102 14.04 010 0.10 0.80 0.10 $842.4020103 16.73 010 0.10 0.80 0.10 $1,003.8020150 26.14 090 0.10 0.69 0.21 $1,568.4020200 5.91 000 0.00 0.00 0.00 $354.6020205 8.26 000 0.00 0.00 0.00 $495.6020206 6.70 000 0.00 0.00 0.00 $402.0020220 4.78 000 0.00 0.00 0.00 $286.8020225 14.92 000 0.00 0.00 0.00 $895.2020240 4.48 010 0.10 0.80 0.10 $268.8020245 14.88 010 0.10 0.80 0.10 $892.8020250 11.33 010 0.10 0.80 0.10 $679.8020251 12.23 010 0.10 0.80 0.10 $733.8020500 2.96 010 0.10 0.80 0.10 $177.6020501 3.35 000 0.00 0.00 0.00 $201.0020520 5.80 010 0.10 0.80 0.10 $348.0020525 13.77 010 0.10 0.80 0.10 $826.2020526 2.21 000 0.00 0.00 0.00 $132.6020527 2.42 000 0.00 0.00 0.00 $145.2020550 1.68 000 0.00 0.00 0.00 $100.8020551 1.73 000 0.00 0.00 0.00 $103.8020552 1.57 000 0.00 0.00 0.00 $94.2020553 1.81 000 0.00 0.00 0.00 $108.6020555 9.43 000 0.00 0.00 0.00 $565.8020600 1.36 000 0.00 0.00 0.00 $81.60


Appendix II



Global Days

Pre-Operative

Intra-operative

Post-operative Fee

20604 2.06 000 0.00 0.00 0.00 $123.6020605 1.43 000 0.00 0.00 0.00 $85.8020606 2.28 000 0.00 0.00 0.00 $136.8020610 1.72 000 0.00 0.00 0.00 $103.2020611 2.61 000 0.00 0.00 0.00 $156.6020612 1.73 000 0.00 0.00 0.00 $103.8020615 6.98 010 0.10 0.80 0.10 $418.8020650 5.96 010 0.10 0.80 0.10 $357.6020660 7.14 000 0.00 0.00 0.00 $428.4020661 14.76 090 0.10 0.69 0.21 $885.6020662 12.39 090 0.10 0.69 0.21 $743.4020663 13.54 090 0.10 0.69 0.21 $812.4020664 25.56 090 0.10 0.69 0.21 $1,533.6020665 3.00 010 0.10 0.80 0.10 $180.0020670 10.89 010 0.10 0.80 0.10 $653.4020680 17.75 090 0.10 0.69 0.21 $1,065.0020690 17.20 090 0.10 0.69 0.21 $1,032.0020692 32.30 090 0.10 0.69 0.21 $1,938.0020693 12.80 090 0.10 0.69 0.21 $768.0020694 12.14 090 0.10 0.69 0.21 $728.4020696 34.73 090 0.10 0.69 0.21 $2,083.8020697 56.67 000 0.00 0.00 0.00 $3,400.2020802 69.36 090 0.10 0.69 0.21 $4,161.6020805 95.86 090 0.10 0.69 0.21 $5,751.6020808 116.77 090 0.10 0.69 0.21 $7,006.2020816 60.04 090 0.10 0.69 0.21 $3,602.4020822 52.20 090 0.10 0.69 0.21 $3,132.0020824 59.42 090 0.10 0.69 0.21 $3,565.2020827 53.00 090 0.10 0.69 0.21 $3,180.0020838 70.07 090 0.10 0.69 0.21 $4,204.2020900 11.94 000 0.00 0.00 0.00 $716.4020902 8.25 000 0.00 0.00 0.00 $495.0020910 11.82 090 0.10 0.69 0.21 $709.2020912 13.89 090 0.10 0.69 0.21 $833.4020920 11.31 090 0.10 0.69 0.21 $678.6020922 17.98 090 0.10 0.69 0.21 $1,078.8020924 14.51 090 0.10 0.69 0.21 $870.6020926 12.24 090 0.10 0.69 0.21 $734.4020931 3.30 ZZZ 0.00 0.00 0.00 $198.0020937 4.79 ZZZ 0.00 0.00 0.00 $287.4020938 5.30 ZZZ 0.00 0.00 0.00 $318.0020950 7.22 000 0.00 0.00 0.00 $433.2020955 72.79 090 0.10 0.69 0.21 $4,367.4020956 77.03 090 0.10 0.69 0.21 $4,621.8020957 71.07 090 0.10 0.69 0.21 $4,264.2020962 61.23 090 0.10 0.69 0.21 $3,673.8020969 80.33 090 0.10 0.69 0.21 $4,819.8020970 84.92 090 0.10 0.69 0.21 $5,095.2020972 67.99 090 0.10 0.69 0.21 $4,079.4020973 76.26 090 0.10 0.69 0.21 $4,575.6020974 2.19 000 0.00 0.00 0.00 $131.4020975 5.09 000 0.00 0.00 0.00 $305.4020979 1.49 000 0.00 0.00 0.00 $89.40


Appendix II



Global Days

Pre-Operative

Intra-operative

Post-operative Fee

20982 85.83 000 0.00 0.00 0.00 $5,149.8020983 207.53 000 0.00 0.00 0.00 $12,451.8020985 4.27 ZZZ 0.00 0.00 0.00 $256.2021010 21.46 090 0.10 0.69 0.21 $1,287.6021011 10.00 090 0.10 0.69 0.21 $600.0021012 9.78 090 0.10 0.69 0.21 $586.8021013 14.94 090 0.10 0.69 0.21 $896.4021014 15.08 090 0.10 0.69 0.21 $904.8021015 20.58 090 0.10 0.69 0.21 $1,234.8021016 29.70 090 0.10 0.69 0.21 $1,782.0021025 25.97 090 0.10 0.69 0.21 $1,558.2021026 17.98 090 0.10 0.69 0.21 $1,078.8021029 22.25 090 0.10 0.69 0.21 $1,335.0021030 15.10 090 0.10 0.69 0.21 $906.0021031 11.48 090 0.10 0.69 0.21 $688.8021032 11.67 090 0.10 0.69 0.21 $700.2021034 38.13 090 0.10 0.69 0.21 $2,287.8021040 15.22 090 0.10 0.69 0.21 $913.2021044 25.47 090 0.10 0.69 0.21 $1,528.2021045 35.75 090 0.10 0.69 0.21 $2,145.0021046 32.70 090 0.10 0.69 0.21 $1,962.0021047 38.57 090 0.10 0.69 0.21 $2,314.2021048 33.52 090 0.10 0.69 0.21 $2,011.2021049 35.16 090 0.10 0.69 0.21 $2,109.6021050 24.46 090 0.10 0.69 0.21 $1,467.6021060 23.16 090 0.10 0.69 0.21 $1,389.6021070 17.68 090 0.10 0.69 0.21 $1,060.8021073 11.23 090 0.10 0.69 0.21 $673.8021076 29.24 010 0.10 0.80 0.10 $1,754.4021077 73.31 090 0.10 0.69 0.21 $4,398.6021079 49.36 090 0.10 0.69 0.21 $2,961.6021080 55.39 090 0.10 0.69 0.21 $3,323.4021081 51.15 090 0.10 0.69 0.21 $3,069.0021082 48.34 090 0.10 0.69 0.21 $2,900.4021083 46.03 090 0.10 0.69 0.21 $2,761.8021084 52.95 090 0.10 0.69 0.21 $3,177.0021085 22.16 010 0.10 0.80 0.10 $1,329.6021086 54.53 090 0.10 0.69 0.21 $3,271.8021087 54.44 090 0.10 0.69 0.21 $3,266.4021100 29.78 090 0.10 0.69 0.21 $1,786.8021110 23.42 090 0.10 0.69 0.21 $1,405.2021116 4.16 000 0.00 0.00 0.00 $249.6021120 19.07 090 0.10 0.69 0.21 $1,144.2021121 23.63 090 0.10 0.69 0.21 $1,417.8021122 19.04 090 0.10 0.69 0.21 $1,142.4021123 27.43 090 0.10 0.69 0.21 $1,645.8021125 87.87 090 0.10 0.69 0.21 $5,272.2021127 128.02 090 0.10 0.69 0.21 $7,681.2021137 22.03 090 0.10 0.69 0.21 $1,321.8021138 25.76 090 0.10 0.69 0.21 $1,545.6021139 27.49 090 0.10 0.69 0.21 $1,649.4021141 39.14 090 0.10 0.69 0.21 $2,348.4021142 41.09 090 0.10 0.69 0.21 $2,465.40


Appendix II



Global Days

Pre-Operative

Intra-operative

Post-operative Fee

21143 41.29 090 0.10 0.69 0.21 $2,477.4021145 45.98 090 0.10 0.69 0.21 $2,758.8021146 44.86 090 0.10 0.69 0.21 $2,691.6021147 50.99 090 0.10 0.69 0.21 $3,059.4021150 48.71 090 0.10 0.69 0.21 $2,922.6021151 59.12 090 0.10 0.69 0.21 $3,547.2021154 60.72 090 0.10 0.69 0.21 $3,643.2021155 62.63 090 0.10 0.69 0.21 $3,757.8021159 72.45 090 0.10 0.69 0.21 $4,347.0021160 92.94 090 0.10 0.69 0.21 $5,576.4021172 52.39 090 0.10 0.69 0.21 $3,143.4021175 62.76 090 0.10 0.69 0.21 $3,765.6021179 41.96 090 0.10 0.69 0.21 $2,517.6021180 44.64 090 0.10 0.69 0.21 $2,678.4021181 21.54 090 0.10 0.69 0.21 $1,292.4021182 56.16 090 0.10 0.69 0.21 $3,369.6021183 67.52 090 0.10 0.69 0.21 $4,051.2021184 61.77 090 0.10 0.69 0.21 $3,706.2021188 46.84 090 0.10 0.69 0.21 $2,810.4021193 35.42 090 0.10 0.69 0.21 $2,125.2021194 41.73 090 0.10 0.69 0.21 $2,503.8021195 38.92 090 0.10 0.69 0.21 $2,335.2021196 43.35 090 0.10 0.69 0.21 $2,601.0021198 34.21 090 0.10 0.69 0.21 $2,052.6021199 31.25 090 0.10 0.69 0.21 $1,875.0021206 34.37 090 0.10 0.69 0.21 $2,062.2021208 54.85 090 0.10 0.69 0.21 $3,291.0021209 23.44 090 0.10 0.69 0.21 $1,406.4021210 66.41 090 0.10 0.69 0.21 $3,984.6021215 118.10 090 0.10 0.69 0.21 $7,086.0021230 20.61 090 0.10 0.69 0.21 $1,236.6021235 20.98 090 0.10 0.69 0.21 $1,258.8021240 32.77 090 0.10 0.69 0.21 $1,966.2021242 30.04 090 0.10 0.69 0.21 $1,802.4021243 49.69 090 0.10 0.69 0.21 $2,981.4021244 31.18 090 0.10 0.69 0.21 $1,870.8021245 32.05 090 0.10 0.69 0.21 $1,923.0021246 25.29 090 0.10 0.69 0.21 $1,517.4021247 45.10 090 0.10 0.69 0.21 $2,706.0021248 32.36 090 0.10 0.69 0.21 $1,941.6021249 44.31 090 0.10 0.69 0.21 $2,658.6021255 40.47 090 0.10 0.69 0.21 $2,428.2021256 34.77 090 0.10 0.69 0.21 $2,086.2021260 40.55 090 0.10 0.69 0.21 $2,433.0021261 60.90 090 0.10 0.69 0.21 $3,654.0021263 56.26 090 0.10 0.69 0.21 $3,375.6021267 45.22 090 0.10 0.69 0.21 $2,713.2021268 50.27 090 0.10 0.69 0.21 $3,016.2021270 27.69 090 0.10 0.69 0.21 $1,661.4021275 24.36 090 0.10 0.69 0.21 $1,461.6021280 16.28 090 0.10 0.69 0.21 $976.8021282 10.94 090 0.10 0.69 0.21 $656.4021295 5.17 090 0.10 0.69 0.21 $310.20


Appendix II



Global Days

Pre-Operative

Intra-operative

Post-operative Fee

21296 12.49 090 0.10 0.69 0.21 $749.4021310 3.75 000 0.00 0.00 0.00 $225.0021315 7.95 010 0.10 0.80 0.10 $477.0021320 7.38 010 0.10 0.80 0.10 $442.8021325 13.72 090 0.10 0.69 0.21 $823.2021330 16.41 090 0.10 0.69 0.21 $984.6021335 21.04 090 0.10 0.69 0.21 $1,262.4021336 18.64 090 0.10 0.69 0.21 $1,118.4021337 11.65 090 0.10 0.69 0.21 $699.0021338 20.96 090 0.10 0.69 0.21 $1,257.6021339 22.25 090 0.10 0.69 0.21 $1,335.0021340 21.83 090 0.10 0.69 0.21 $1,309.8021343 35.11 090 0.10 0.69 0.21 $2,106.6021344 40.36 090 0.10 0.69 0.21 $2,421.6021345 23.46 090 0.10 0.69 0.21 $1,407.6021346 26.27 090 0.10 0.69 0.21 $1,576.2021347 33.18 090 0.10 0.69 0.21 $1,990.8021348 35.21 090 0.10 0.69 0.21 $2,112.6021355 12.34 010 0.10 0.80 0.10 $740.4021356 14.52 010 0.10 0.80 0.10 $871.2021360 15.63 090 0.10 0.69 0.21 $937.8021365 32.35 090 0.10 0.69 0.21 $1,941.0021366 33.41 090 0.10 0.69 0.21 $2,004.6021385 19.71 090 0.10 0.69 0.21 $1,182.6021386 20.23 090 0.10 0.69 0.21 $1,213.8021387 20.59 090 0.10 0.69 0.21 $1,235.4021390 22.99 090 0.10 0.69 0.21 $1,379.4021395 29.20 090 0.10 0.69 0.21 $1,752.0021400 5.53 090 0.10 0.69 0.21 $331.8021401 12.72 090 0.10 0.69 0.21 $763.2021406 15.01 090 0.10 0.69 0.21 $900.6021407 18.71 090 0.10 0.69 0.21 $1,122.6021408 25.52 090 0.10 0.69 0.21 $1,531.2021421 21.93 090 0.10 0.69 0.21 $1,315.8021422 19.61 090 0.10 0.69 0.21 $1,176.6021423 23.90 090 0.10 0.69 0.21 $1,434.0021431 21.53 090 0.10 0.69 0.21 $1,291.8021432 18.98 090 0.10 0.69 0.21 $1,138.8021433 50.57 090 0.10 0.69 0.21 $3,034.2021435 36.52 090 0.10 0.69 0.21 $2,191.2021436 60.69 090 0.10 0.69 0.21 $3,641.4021440 16.80 090 0.10 0.69 0.21 $1,008.0021445 22.46 090 0.10 0.69 0.21 $1,347.6021450 17.83 090 0.10 0.69 0.21 $1,069.8021451 22.21 090 0.10 0.69 0.21 $1,332.6021452 17.28 090 0.10 0.69 0.21 $1,036.8021453 26.66 090 0.10 0.69 0.21 $1,599.6021454 17.37 090 0.10 0.69 0.21 $1,042.2021461 62.39 090 0.10 0.69 0.21 $3,743.4021462 66.11 090 0.10 0.69 0.21 $3,966.6021465 28.05 090 0.10 0.69 0.21 $1,683.0021470 35.16 090 0.10 0.69 0.21 $2,109.6021480 2.84 000 0.00 0.00 0.00 $170.40


Appendix II



Global Days

Pre-Operative

Intra-operative

Post-operative Fee

21485 20.43 090 0.10 0.69 0.21 $1,225.8021490 26.71 090 0.10 0.69 0.21 $1,602.6021495 20.42 090 0.10 0.69 0.21 $1,225.2021497 21.49 090 0.10 0.69 0.21 $1,289.4021501 13.02 090 0.10 0.69 0.21 $781.2021502 15.38 090 0.10 0.69 0.21 $922.8021510 13.01 090 0.10 0.69 0.21 $780.6021550 7.52 010 0.10 0.80 0.10 $451.2021552 12.91 090 0.10 0.69 0.21 $774.6021554 21.18 090 0.10 0.69 0.21 $1,270.8021555 11.91 090 0.10 0.69 0.21 $714.6021556 15.34 090 0.10 0.69 0.21 $920.4021557 27.79 090 0.10 0.69 0.21 $1,667.4021558 39.11 090 0.10 0.69 0.21 $2,346.6021600 16.10 090 0.10 0.69 0.21 $966.0021610 34.88 090 0.10 0.69 0.21 $2,092.8021615 17.83 090 0.10 0.69 0.21 $1,069.8021616 21.79 090 0.10 0.69 0.21 $1,307.4021620 14.58 090 0.10 0.69 0.21 $874.8021627 15.56 090 0.10 0.69 0.21 $933.6021630 34.98 090 0.10 0.69 0.21 $2,098.8021632 35.17 090 0.10 0.69 0.21 $2,110.2021685 29.05 090 0.10 0.76 0.14 $1,743.0021700 10.80 090 0.10 0.69 0.21 $648.0021705 16.01 090 0.10 0.69 0.21 $960.6021720 13.12 090 0.10 0.69 0.21 $787.2021725 15.34 090 0.10 0.69 0.21 $920.4021740 29.73 090 0.10 0.69 0.21 $1,783.8021750 19.81 090 0.10 0.69 0.21 $1,188.6021811 17.75 000 0.00 0.00 0.00 $1,065.0021812 21.29 000 0.00 0.00 0.00 $1,277.4021813 27.84 000 0.00 0.00 0.00 $1,670.4021820 4.01 090 0.10 0.69 0.21 $240.6021825 15.67 090 0.10 0.69 0.21 $940.2021920 7.36 010 0.10 0.80 0.10 $441.6021925 12.67 090 0.10 0.69 0.21 $760.2021930 13.57 090 0.10 0.69 0.21 $814.2021931 13.59 090 0.10 0.69 0.21 $815.4021932 19.15 090 0.10 0.69 0.21 $1,149.0021933 21.33 090 0.10 0.69 0.21 $1,279.8021935 29.75 090 0.10 0.69 0.21 $1,785.0021936 40.95 090 0.10 0.69 0.21 $2,457.0022010 27.73 090 0.10 0.69 0.21 $1,663.8022015 27.14 090 0.10 0.69 0.21 $1,628.4022100 25.45 090 0.10 0.69 0.21 $1,527.0022101 24.81 090 0.10 0.69 0.21 $1,488.6022102 22.77 090 0.10 0.69 0.21 $1,366.2022103 4.04 ZZZ 0.00 0.00 0.00 $242.4022110 30.35 090 0.10 0.69 0.21 $1,821.0022112 28.72 090 0.10 0.69 0.21 $1,723.2022114 28.84 090 0.10 0.69 0.21 $1,730.4022116 4.04 ZZZ 0.00 0.00 0.00 $242.4022206 70.89 090 0.10 0.69 0.21 $4,253.40


Appendix II



Global Days

Pre-Operative

Intra-operative

Post-operative Fee

22207 69.47 090 0.10 0.69 0.21 $4,168.2022208 16.53 ZZZ 0.00 0.00 0.00 $991.8022210 51.85 090 0.10 0.69 0.21 $3,111.0022212 42.87 090 0.10 0.69 0.21 $2,572.2022214 42.91 090 0.10 0.69 0.21 $2,574.6022216 10.39 ZZZ 0.00 0.00 0.00 $623.4022220 46.37 090 0.10 0.69 0.21 $2,782.2022222 45.23 090 0.10 0.69 0.21 $2,713.8022224 45.71 090 0.10 0.69 0.21 $2,742.6022226 10.33 ZZZ 0.00 0.00 0.00 $619.8022305 5.49 090 0.10 0.69 0.21 $329.4022310 8.87 090 0.10 0.69 0.21 $532.2022315 25.49 090 0.10 0.69 0.21 $1,529.4022318 47.91 090 0.10 0.69 0.21 $2,874.6022319 53.54 090 0.10 0.69 0.21 $3,212.4022325 41.47 090 0.10 0.69 0.21 $2,488.2022326 43.34 090 0.10 0.69 0.21 $2,600.4022327 43.73 090 0.10 0.69 0.21 $2,623.8022328 8.02 ZZZ 0.00 0.00 0.00 $481.2022505 3.70 010 0.10 0.80 0.10 $222.0022510 50.35 010 0.10 0.80 0.10 $3,021.0022511 49.85 010 0.10 0.80 0.10 $2,991.0022512 27.94 ZZZ 0.00 0.00 0.00 $1,676.4022513 209.45 010 0.10 0.80 0.10 $12,567.0022514 209.22 010 0.10 0.80 0.10 $12,553.2022515 126.77 ZZZ 0.00 0.00 0.00 $7,606.2022526 67.90 010 0.10 0.80 0.10 $4,074.0022527 56.34 ZZZ 0.00 0.00 0.00 $3,380.4022532 51.51 090 0.10 0.69 0.21 $3,090.6022533 47.83 090 0.10 0.69 0.21 $2,869.8022534 10.27 ZZZ 0.00 0.00 0.00 $616.2022548 58.11 090 0.10 0.69 0.21 $3,486.6022551 49.87 090 0.10 0.69 0.21 $2,992.2022552 11.35 ZZZ 0.00 0.00 0.00 $681.0022554 36.26 090 0.10 0.69 0.21 $2,175.6022556 48.53 090 0.10 0.69 0.21 $2,911.8022558 44.78 090 0.10 0.69 0.21 $2,686.8022585 9.44 ZZZ 0.00 0.00 0.00 $566.4022586 52.58 090 0.10 0.69 0.21 $3,154.8022590 46.14 090 0.10 0.69 0.21 $2,768.4022595 44.00 090 0.10 0.69 0.21 $2,640.0022600 37.46 090 0.10 0.69 0.21 $2,247.6022610 36.63 090 0.10 0.69 0.21 $2,197.8022612 46.12 090 0.10 0.69 0.21 $2,767.2022614 11.20 ZZZ 0.00 0.00 0.00 $672.0022630 45.51 090 0.10 0.69 0.21 $2,730.6022632 9.14 ZZZ 0.00 0.00 0.00 $548.4022633 53.69 090 0.10 0.69 0.21 $3,221.4022634 14.09 ZZZ 0.00 0.00 0.00 $845.4022800 39.07 090 0.10 0.69 0.21 $2,344.2022802 60.86 090 0.10 0.69 0.21 $3,651.6022804 70.48 090 0.10 0.69 0.21 $4,228.8022808 53.42 090 0.10 0.69 0.21 $3,205.20


Appendix II



Global Days

Pre-Operative

Intra-operative

Post-operative Fee

22810 58.89 090 0.10 0.69 0.21 $3,533.4022812 70.67 090 0.10 0.69 0.21 $4,240.2022818 63.21 090 0.11 0.76 0.13 $3,792.6022819 81.44 090 0.11 0.76 0.13 $4,886.4022830 23.49 090 0.10 0.69 0.21 $1,409.4022840 21.66 ZZZ 0.00 0.00 0.00 $1,299.6022842 21.76 ZZZ 0.00 0.00 0.00 $1,305.6022843 23.48 ZZZ 0.00 0.00 0.00 $1,408.8022844 28.42 ZZZ 0.00 0.00 0.00 $1,705.2022845 20.78 ZZZ 0.00 0.00 0.00 $1,246.8022846 21.55 ZZZ 0.00 0.00 0.00 $1,293.0022847 23.68 ZZZ 0.00 0.00 0.00 $1,420.8022848 10.34 ZZZ 0.00 0.00 0.00 $620.4022849 37.68 090 0.10 0.69 0.21 $2,260.8022850 20.95 090 0.10 0.69 0.21 $1,257.0022851 11.57 ZZZ 0.00 0.00 0.00 $694.2022852 20.09 090 0.10 0.69 0.21 $1,205.4022855 32.02 090 0.10 0.69 0.21 $1,921.2022856 47.13 090 0.10 0.69 0.21 $2,827.8022857 57.34 090 0.10 0.69 0.21 $3,440.4022858 14.76 ZZZ 0.00 0.00 0.00 $885.6022861 58.36 090 0.10 0.69 0.21 $3,501.6022862 58.06 090 0.10 0.71 0.19 $3,483.6022864 60.49 090 0.10 0.69 0.21 $3,629.4022865 59.64 090 0.10 0.71 0.19 $3,578.4022900 16.32 090 0.10 0.69 0.21 $979.2022901 19.22 090 0.10 0.69 0.21 $1,153.2022902 12.59 090 0.10 0.69 0.21 $755.4022903 12.69 090 0.10 0.69 0.21 $761.4022904 30.40 090 0.09 0.81 0.10 $1,824.0022905 38.54 090 0.09 0.81 0.10 $2,312.4023000 16.76 090 0.10 0.69 0.21 $1,005.6023020 19.74 090 0.10 0.69 0.21 $1,184.4023030 12.68 010 0.10 0.80 0.10 $760.8023031 12.21 010 0.10 0.80 0.10 $732.6023035 19.51 090 0.10 0.69 0.21 $1,170.6023040 20.76 090 0.10 0.69 0.21 $1,245.6023044 16.36 090 0.10 0.69 0.21 $981.6023065 6.19 010 0.10 0.80 0.10 $371.4023066 15.90 090 0.10 0.69 0.21 $954.0023071 12.12 090 0.10 0.80 0.10 $727.2023073 20.03 090 0.10 0.69 0.21 $1,201.8023075 13.39 090 0.10 0.80 0.10 $803.4023076 15.60 090 0.10 0.69 0.21 $936.0023077 33.22 090 0.10 0.69 0.21 $1,993.2023078 41.64 090 0.10 0.69 0.21 $2,498.4023100 14.37 090 0.10 0.69 0.21 $862.2023101 13.09 090 0.10 0.69 0.21 $785.4023105 18.33 090 0.10 0.69 0.21 $1,099.8023106 14.19 090 0.10 0.69 0.21 $851.4023107 18.98 090 0.10 0.69 0.21 $1,138.8023120 16.77 090 0.10 0.69 0.21 $1,006.2023125 20.49 090 0.10 0.69 0.21 $1,229.40


Appendix II



Global Days

Pre-Operative

Intra-operative

Post-operative Fee

23130 17.60 090 0.10 0.69 0.21 $1,056.0023140 15.35 090 0.10 0.69 0.21 $921.0023145 20.08 090 0.10 0.69 0.21 $1,204.8023146 17.89 090 0.10 0.69 0.21 $1,073.4023150 18.87 090 0.10 0.69 0.21 $1,132.2023155 22.93 090 0.10 0.69 0.21 $1,375.8023156 19.51 090 0.10 0.69 0.21 $1,170.6023170 16.08 090 0.10 0.69 0.21 $964.8023172 16.36 090 0.10 0.69 0.21 $981.6023174 21.66 090 0.10 0.69 0.21 $1,299.6023180 19.15 090 0.10 0.69 0.21 $1,149.0023182 18.63 090 0.10 0.69 0.21 $1,117.8023184 21.19 090 0.10 0.69 0.21 $1,271.4023190 16.34 090 0.10 0.69 0.21 $980.4023195 21.76 090 0.10 0.69 0.21 $1,305.6023200 43.12 090 0.10 0.69 0.21 $2,587.2023210 51.43 090 0.10 0.69 0.21 $3,085.8023220 56.16 090 0.10 0.69 0.21 $3,369.6023330 6.79 010 0.10 0.80 0.10 $407.4023333 13.09 090 0.10 0.69 0.21 $785.4023334 31.19 090 0.10 0.69 0.21 $1,871.4023335 37.11 090 0.10 0.69 0.21 $2,226.6023350 3.70 000 0.00 0.00 0.00 $222.0023395 37.04 090 0.10 0.69 0.21 $2,222.4023397 33.01 090 0.10 0.69 0.21 $1,980.6023400 28.11 090 0.10 0.69 0.21 $1,686.6023405 17.95 090 0.10 0.69 0.21 $1,077.0023406 22.09 090 0.10 0.69 0.21 $1,325.4023410 23.68 090 0.10 0.69 0.21 $1,420.8023412 24.53 090 0.10 0.69 0.21 $1,471.8023415 20.12 090 0.10 0.69 0.21 $1,207.2023420 27.92 090 0.10 0.69 0.21 $1,675.2023430 21.44 090 0.10 0.69 0.21 $1,286.4023440 21.73 090 0.10 0.69 0.21 $1,303.8023450 27.27 090 0.10 0.69 0.21 $1,636.2023455 28.84 090 0.10 0.69 0.21 $1,730.4023460 31.56 090 0.10 0.69 0.21 $1,893.6023462 30.61 090 0.10 0.69 0.21 $1,836.6023465 32.00 090 0.10 0.69 0.21 $1,920.0023466 32.18 090 0.10 0.69 0.21 $1,930.8023470 34.74 090 0.10 0.69 0.21 $2,084.4023472 42.03 090 0.10 0.69 0.21 $2,521.8023473 46.68 090 0.10 0.69 0.21 $2,800.8023474 50.45 090 0.10 0.69 0.21 $3,027.0023480 23.74 090 0.10 0.69 0.21 $1,424.4023485 27.54 090 0.10 0.69 0.21 $1,652.4023490 24.32 090 0.10 0.69 0.21 $1,459.2023491 29.30 090 0.10 0.69 0.21 $1,758.0023500 6.29 090 0.10 0.69 0.21 $377.4023505 10.15 090 0.10 0.69 0.21 $609.0023515 20.75 090 0.10 0.69 0.21 $1,245.0023520 6.41 090 0.10 0.69 0.21 $384.6023525 10.79 090 0.10 0.69 0.21 $647.40


Appendix II



Global Days

Pre-Operative

Intra-operative

Post-operative Fee

23530 15.85 090 0.10 0.69 0.21 $951.0023532 17.94 090 0.10 0.69 0.21 $1,076.4023540 6.49 090 0.10 0.69 0.21 $389.4023545 9.69 090 0.10 0.69 0.21 $581.4023550 16.16 090 0.10 0.69 0.21 $969.6023552 18.85 090 0.10 0.69 0.21 $1,131.0023570 6.65 090 0.10 0.69 0.21 $399.0023575 11.45 090 0.10 0.69 0.21 $687.0023585 28.31 090 0.10 0.69 0.21 $1,698.6023600 9.37 090 0.10 0.69 0.21 $562.2023605 13.35 090 0.10 0.69 0.21 $801.0023615 25.53 090 0.10 0.69 0.21 $1,531.8023616 35.87 090 0.10 0.69 0.21 $2,152.2023620 7.71 090 0.

MEDICAL FEE SCHEDULE MAINE WORKERS' …...applies to all medical, surgical and hospital services,...

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Transcript of MEDICAL FEE SCHEDULE MAINE WORKERS' …...applies to all medical, surgical and hospital services,...