Section 533.4 - Medicine.

EXPLANATION--matter in braces { } is superscript material

533.4 Medicine. (a) Conversion factor. The conversion factor for the services and procedures listed in subdivision (g) of this section shall be $5.

(b) Services and values. For the numbered and described items of services or procedures set forth in subdivision (g) of this section, the maximum reimbursable fee shall be computed on the basis of the respective assigned value multiplied by the conversion factor of $5.

(c) Clinic services. (1) Maximum reimbursable allowances established for payment to a physician for clinic services (items 9023, 9024, 9032, 9033, 9026, 9027, 9030, 9031) shall not apply when the physician receives any form of compensation from the facility for providing such services.

(2) Clinic fees (items 9023, 9024, 9032, 9033, 9026, 9027, 9030, 9031) shall be prorated according to the number of medical assistance patients treated as a percentage of the total number of patients seen during a clinic session.

(d) Hospital visits. (1) Hospital visit fees shall not apply to preoperative consultations or follow-up visits as designated in accordance with the surgical fees listed in section 533.5 of this Part.

(2) Reimbursement for hospital visits shall only be made for care provided in accordance with the provisions of Part 505 of this Subchapter.

(e) Newborn care. Newborn care (fee codes 9035 and 9038) is in addition to any appropriate fee for maternity care.

(f) Psychiatric services by a private practicing physician require prior approval of the local professional director when more than 15 visits within a continuous six-month period are required to complete the course of treatment.

(g) Maximum reimbursable medical fee schedule.

GENERAL PRACTITIONER

(or Specialist Providing Service in Nonspecialist Area)

OFFICE VISITS

Unit or Dollar

Value 9000 First visit, new patient or new illness, history,

examination and treatment $ 7.80 9001 Subsequent visit, including treatment $ 6.00 9002 Complete physical examination with special report $12.00

HOME VISITS 9010 First visit, new patient or new illness, history,

examination and treatment 1.6 9011 Subsequent visit, including treatment 1.4 9012 Complete physical examination with special report 2.25 9018 Home visit each additional member of same

household 1.0

HOSPITAL VISITS 9020 First visit, new patient or new illness, history,

examination and treatment 1.3 9021 Subsequent visit, including treatment 1.0 9022 Complete physical examination with special report 2.0

NURSING HOME VISITS 9003 First visit, new patient or new illness, history,

examination and treatment 1.6 9005 Subsequent visit, including treatment 1.4 9014 Complete physical examination with special report 2.25 9019 Visit, each additional patient, same nursing home,

same session 1.0

CLINIC VISITS, NONSPECIALIST 9023 One-hour session 3.0 9024 Two-hour session 5.0 9032 Three-hour session 7.0 9033 Each additional hour (per hour) 1.4

OSTEOPATHIC PHYSICIAN 9041 Osteopathic manipulation, where indicated,

additional .2

SPECIALIST PROCEDURES

CONSULTATION BY SPECIALIST 9028G Initial consultation (office) $24.00 9029G Subsequent consultation when required to complete

diagnosis (office) $18.00 9028J Initial consultation (other than office) 4.0 9029J Subsequent consultation when required to complete

diagnosis (other than office) 3.0

INTERNIST

Office Visits

Comprehensive diagnostic history, physical examination and treatment, including screening test for anemia and urinary glucose and albumin, taking of blood specimens, and furnishing of reports when requested. 9002B Up to 45 minutes $15.00 9002M 46 minutes to one hour $20.00 9002E More than one hour $25.00 9004 Follow-up visit, routine $7.50 9006 Follow-up visit, prolonged (over 20 minutes) $10.00

Home Visits 9012B Initial home visit, routine, new patient or new

illness, history and examination 3.0 9012M Initial home visit, complete diagnostic history

and physical examination, established patient or minor chronic illness, including initiation of diagnostic and treatment programs 4.0 9021E Initial home visit, complete diagnostic history

and physical examination, new patient or major illness, including initiation of diagnostic and treatment programs 5.0 9015 Examination or evaluation, routine 2.0

Hospital Visits 9020B Initial hospital visit, brief history and physical

examination, including initiation of diagnostic and treatment programs and preparation of hospital records 3.0 9021M Initial hospital visit, complete diagnostic history

and physical examination, established patient or minor chronic illness, including initiation of diagnostic and treatment programs and preparation of hospital records 4.0 9022E Initial hospital visit, complete diagnostic history

and physical examination, new patient or major illness, including initiation of diagnostic and treatment programs and preparation of hospital records 5.0 9025 Examination or evaluation, routine follow-up 1.5

PEDIATRICIAN

Office, Home and Hospital Visits 9007F Comprehensive diagnostic history and physical

examination, new patient or new illness, office $12.00 9007R Comprehensive diagnostic history and physical

examination, new patient or new illness, home 2.0 9007H Comprehensive diagnostic history and physical

examination, new patient or new illness, hospital 2.0 9009F Routine office visit, including treatment $7.20 9009H Routine hospital visit, including treatment 1.2 9013 Routine home visit, including treatment 1.8 9018P Each additional child at home 1.0 9037 Pediatrician in attendance at problem

deliveries 5.0 9038 Total newborn care in hospital, including

physical examinations of the baby and discussion with the mother during the hospital stay (total fee for minimum 3-day stay) 4.0
OTOLARYNGOLOGIST

Office Visits 9042 Complete diagnosis, history, physical

examination, new patient or new illness $12.00 9043 Routine visit and treatment $7.20

Hospital Visits 9044 Initial visit 2.0 9045 Follow-up visit, including treatment 1.2

UROLOGIST

Office Visits 9078 Complete diagnosis, history, physical

examination, new patient or new illness $12.00 9079 Routine visit, including treatment $7.20

Hospital Visits 9080 Initial visit 2.0 9081 Follow-up visit, including treatment 1.2

DERMATOLOGIST Office Visits 9065 Comprehensive diagnosis, history, physical

examination, new patient or new illness $12.00 9066 Routine visit, including treatment $7.30

Hospital Visits 9067 Initial visit 2.0 9068 Follow-up visit, including treatment 1.2

SURGEON (excluding neurosurgeon)

Office Visits 9074 Complete diagnosis, history, physical

examination, new patient or new illness $12.00 9075 Routine visit, including treatment $7.20

Hospital Visits 9076 Initial visit 2.0 9077 Follow-up visit, including treatment 1.2

PSYCHIATRIST 9082 Complete diagnosis, history, physical

examination, new patient or new illness, office $12.00 9083 Routine visit, including treatment, office $7.20 9084 Initial visit, hospital 2.0 9085 Follow-up visit, including treatment,

hospital 1.2

FAMILY PRACTITIONER

Office Visits

Comprehensive diagnostic history and physical

examination--new patient or new illness 9660 Child up to and including 16 years $12.00 9661 Persons over 16 years $12.50

Routine Office Visit, including treatment 9662 Child up to and including 16 years $7.20 9663 Persons over 16 years $7.50

Home Visits

Comprehensive diagnostic history and physical

examination--new patient or new illness 9666 Child up to and including 16 years 2.0 9667 Persons over 16 years 2.5

Routine home visit including treatment 9668 Child up to and including 16 years 1.8 9669 Persons over 16 years 2.0 9670 Each additional person at home 1.0

Hospital Visits

Initial Visit 9671 Child up to and including 16 years 2.0 9672 Persons over 16 years 2.5

Follow-up visit, including treatment 9673 Child up to and including 16 years 1.2 9674 Persons over 16 years 1.5

ORTHOPEDIST

Office Visits 9086 Complete diagnosis, physical examination,

history, new patient or new illness $12.00 9087 Routine visit, including treatment $7.20

Home Visits 9088 Home visit, including treatment 1.8

Hospital Visits 9089 Initial visit 2.0 9090 Follow-up visit, including treatment 1.2

OBSTETRICIAN-GYNECOLOGIST

Office Visits 9091 Pelvic examination, breast examination, Pap smear

exclusive of laboratory charge, or new illness $12.00 9092 Follow-up visit $7.20

Hospital Visits 9093 Initial visit 2.0 9094 Follow-up visit, including treatment 1.2

NEUROLOGIST AND NEUROSURGEON

Office Visits

Comprehensive diagnostic history, physical examination and treatment 9500 Up to 45 minutes $15.00 9501 46 minutes to one hour $20.00 9502 More than one hour $25.00 9503 Follow-up visit, routine $7.50 9504 Follow-up visit, prolonged (over

20 minutes) $10.00

Home Visits 9505 Initial home visit, routine, new patient

or new illness, history and examination 3.0 9506 Initial home visit, complete diagnostic

history and physical examination, established patient, including initiation of diagnostic and treatment programs 4.0 9507 Initial home visit, complete diagnostic history

and physical examination, new patient, including initiation of diagnostic and treatment programs 5.0 9508 Examination or evaluation, routine follow-up 2.0

Hospital Visits 9509 Initial hospital visit, brief history

and physical examination, including initiation of diagnostic and treatment programs and preparation of hospital records 3.0 9510 Initial hospital visit, complete diagnostic

history and physical examination, established patient, including initiation of diagnostic and treatment programs and preparation of hospital records 4.0 9511 Initial hospital visit, complete diagnostic

history and physical examination, new patient, including initiation of diagnostic and treatment programs and preparation of hospital records 5.0 9512 Examination or evaluation, routine follow-up 1.5

CLINIC VISITS, SPECIALISTS 9026 One-hour session 4.0 9027 Two-hour session 7.0 9030 Three-hour session 10.0 9031 Each additional hour (per hour) 2.0

CHAP (Child Health Assurance Program)

The following composite fee codes for use in the Medicaid program, effective April 1, 1974, include: office visit, 9040; immunization, 9998; average cost of materials, L112; hemoglobin or hematocrit; and L557 urinalysis for CHAP when performed by a pediatrician, internist, obstetrician-gynecologist, general practitioner or other specialist. 9008P Pediatrician $21.20 9008B Internist $21.20 9008Y Obstetrician-Gynecologist $21.20 9008G General Practitioner or other specialist $21.20

No provider shall be paid such a composite fee more than once annually per patient.

{1} In addition to the above composite fee codes, optional tests, when indicated and when performed in accordance with criteria outlined in Item 44 of the State Medical Handbook, are eligible for additional payment on a fee-for-service basis at fees established in applicable fee schedules; e.g., 9340--audiometric hearing screening, etc.

For completion of the Child Health Care Status Report, effective Sept. 27, 1974: 9008R Child Health Care Status Report (once per patient

per period of eligibility) $5.00

PSYCHIATRIC TREATMENT 9050G Psychotherapy, office, verbal, drug augmented

or other methods, one hour (office) $30.00 9051G Comprehensive psychiatric examination with written

report (office) $30.00 9053G Group (maximum eight persons per group) one and

one half hours, per person (office) $9.00 9050J Psychotherapy, hospital or home, verbal, drug

augmented or other methods, one hour 5.0 9051J Comprehensive psychiatric examination with written

report (other than office) 5.0 9053J Group (maximum eight persons per group) one

and one half hours, per person (other than office) 1.5 9055 Electroshock, (per treatment), subconvulsive 4.0 9056 convulsive 5.0

for anesthetist 3.0+T 9057 Insulin shock (per treatment), subcoma 4.0 9058 coma 6.0 9059 Metrazol convulsive shock (per treatment) 5.0 9060 Psychometric testing (one hour) with written report 5.0 9061G Initial routine office visit to include general

history, physical and treatment $12.00 9062G Routine follow-up visit $7.20 9061J Initial routine visit to include general history,

physical and treatment (other than office) 2.0 9062J Routine follow-up visit (other than office) 1.2 9064 Inpatient care, prolonged (chronic case) by report

FAMILY PLANNING VISITS

Office Visits 9160 Family planning visit, specialist in

obstetrics-gynecology, initial visit $12.00 9161 Follow-up visit $7.20 9165 Family planning visit, nonspecialist,

initial visit $7.80 9166 Follow-up visit $6.00

OTHER SERVICES

In calculating fees please refer to general instructions, rules 10, 11, 12 9035 Total newborn care in hospital provided

by a physician other than a pediatrician, including physical examinations of the baby and discussions with the mother during the hospital stay (total fee for minimum 3-day stay) 3.0 9040 Immunization(s), per visit (plus cost of

materials) 0.4 9049 Theraputic injectable material used for each

injection may be charged at acquisition cost rounded to the nearest one-dollar amount, (effective 3/15/78). 9070 Mileage, per mile, one way, beyond 10 mile radius

of point of origin (office or home) 0.1 9071 Night emergency: additional fee for service

rendered between hours of 10 p.m. and 8 a.m. 1.0 9072 Intensive care, minimum of one hour 5.0 9073 each additional half hour 2.5 9998 cost of materials by report

SPECIFIC DIAGNOSTIC AND THERAPEUTIC PROCEDURES

Listed values may be added to other significant services rendered at the same visit. Values for items 9101 to 9227 include laboratory procedure(s), interpretation and physicians' services (except surgical and anesthesia services as listed in the section on Surgery), unless otherwise stated. For other similar services, see appropriate sections. 9101 Electrocardiogram with interpretation and

report 3.0 9102 tracing only, without interpretation and

report 1.5 9103 interpretation and report only 1.5 9104 with exercise test 5.0 9105 tracing only without interpretation and report 2.5 9106 interpretation and report only 2.5 9107 single lead (for rhythm) with interpretation 1.0

Continuous EKG Monitoring

(e.g., Holter Monitor) 9109 Up to 12 hours 9.0 9110 Over 12 to 16 hours 10.0 9111 Over 16 hours 12.0 9112 Phonocardiogram with interpretation

and report 4.0 9113 with indirect carotid artery tracing or

similar study 5.0 9115 Vectorcardiogram (VCG), with or without EKG,

interpretation and report 5.0 9116 when part of other diagnostic studies 4.0 9120 Venous pressure determination 1.0 9121 Circulation time, per test (not

to exceed 2.0 units) 1.0

(For radioisotope tests, see 7836.) 9123 Recording of direct arterial pressure tracings

(independent procedure) 4.0

(Recording of intracardiac pressures with evaluation and interpretation included as part of items 2330-2335.) 9126 Cardiac output (Fick) (independent procedure) (excluding

cardiac catheterization--see 2330-2335) 5.0

(For radioisotope methods, see 7835.) 9127 Dye dilution studies, indicator dye curves 1.0 9128 cardiac output, initial (independent procedure) 5.0 9129 subsequent, same study period, each (independent

procedure) 2.5

(When dye dilution studies are part of right heart catheterization, maximum units allowed will be 18; when part of combined right and left heart catheterization, maximum units allowed will be 22.) 9140 Screening throat culture 0.75 9190 Peripheral vascular disease studies by report 9192 Plethysmography by report 9193 Temperature gradient studies by report 9194 Thermogram by report

NONSURGICAL OPERATING ROOM SERVICES 9195 Operation of pump with oxygenator or heart exchanger,

per hour pump time 6.0 9196 Monitoring E.K.G., pressures, etc., in intrathoracic or

other critical surgery, per hour 5.0

PULMONARY 9201 Spirometry, complete (respirometer) including graphic

record, total and timed vital capacity and maximal breathing capacity, with written report 3.0 9203 Branchospirometry; expired gas analysis, (independent

procedure) (for insertion of tube see 2126) 5.0 9206 Bronchospasm evaluation; spirometry as in 9201 before

and after bronchodilator (aerosol or parenteral) 5.0 9215 Vital capacity, total 0.6 9216 total and timed 1.0 9220 Maximal breathing capacity 2.0 9221 Maximal expiratory flow rate measurement or equivalent

(independent procedure) 1.0 9224 Residual air (helium method) including equilibration

time, initial 3.0 9225 subsequent 2.0 9228 Residual air (open circuit method) including alveolar

nitrogen, initial 6.0 9229 subsequent 4.0 9235 Nitrogen washout curve (continuous) by report 9268 Oxygen uptake, expired gas analysis rest and

exercise (direct) 5.0 9269 rest (indirect) 1.5 9272 Carbon monoxide diffusing capacity by report 9275 Pulmonary compliance by report 9277 Carbon dioxide, expired gas determination by

infrared analyzer by report

ALLERGY TESTING AND TREATMENT

The following values are based on the type and number of tests performed, and must include observation and interpretation of the tests by a physician. In routine office practice, the following items may be added to fee code items 9004 or 9009F. 9300 Scratch or puncture tests, up to 60 tests,

per 10 tests (minimum-1.0 unit) 1.0 9301 in excess of first 60 tests, per 20 tests 1.0 9302 Intradermal tests, up to total of 60 tests,

per 10 tests (minimum-1.0 unit) 1.5 9303 in excess of first 60 tests, per 20 tests 1.5 9304 Patch tests, each (minimum-1.0 unit) 0.2 9305 Direct opththalmic tests, each (minimum-1.0 unit) 0.4 9306 Direct nasal tests, each (minimum-1.0 unit) 0.4 9307 Passive transfer tests (including cost of recipient)

per 10 tests (minimum-10.0 units) 3.0 9308 Maximum allowable for allergy testing; reserved for

allergic conditions necessitating unusually extensive testing 22.0 9550 Antigens-treatment sets prepared by allergist for

administration by or under the supervision of another physician; solutions of increasing concentration, e.g., ragweed, dust, feathers, four vials 4.0 9551 five vials 5.0 9552 one vial or one refill 2.0 9553 Injection(s) of antigens prepared by allergists

for own patients allow maximum of 0.5 unit plus immunization fee (code 9040) 0.5

MISCELLANEOUS 9320 Skin test with bacterial, viral or fungal extracts

(includes reading test), e.g., brucella, tuberculln, histoplasma, coccidioidin, Frel, etc. each 1.0 9321 Tine test, includes injection and reading 0.375 9323 Exclusion test for pheochromocytoma, e.g.,

regitine, benzodiozane, histamine, each 2.0 9330 Electroencephalogram, awake, asleep (natural or

induced) and activation 7.0 9331 at surgery by report 9332 Electroencephalogram, interpretation

and report only 1.5 9333 Electroencephalogram, tracing only,

without interpretation and report 5.0 9340 Audiometric hearing screening, pure tone

(air only) 1.0 9341 air and bone, with or without masking 2.0 9342 Air, bone and speech audiometry (includes reception

and discrimination tests) 3.0 9343 Vestibular function test 3.0 9350 Muscle testing, manual or electrical, with

report, one extremity 1.5 9351 four extremities and trunk 4.0 9354 Range of motion measurements and report, two

extremities 1.0 9358 Electromyography, one extremity and related

areas of the back 7.0 9362 Nerve velocity determination, each nerve

(independent procedure) 3.0

(For vision testing see 5400-5411.) 9400 Phlebotomy, therapeutic (independent

procedure) 2.0 9404 Intermittent positive pressure treatment, initial

or subsequent 0.6 9412 Chemotherapy for malignant disease by report 9413 Perfusion for malignant disease by report 9415 Desensitization, e.g., horse serum by report 9417 Gastric lavage, treatment, e.g., ingested

poisons, etc. 8v. 9420 Cardioversion 10.0 9420a Cardioversion, anesthesia fee 3.0+T

Professional Dialysis Fees for Physician in Personal

Attendance* 9405 Peritoneal dialysis (hospital) 15.0 9407 Patient's first hemodialysis 20.0 9408 See item 9405 above 9410 Home hemodialysis 3.0

(This fee is applicable when physician participates in a training session in the home. In all other instances, the regular home visit fee will apply.) ---------------

FOOTNOTE: *For corresponding surgical procedures see codes 2590-2592.

 

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