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Physician Service Fee Schedule-Affordable Care Act(ACA) Taxonomy Defined Rates Pricing Specialty 01E Fee Schedule Updated On: 6/26/2020

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Physician Service Fee Schedule-Affordable Care Act(ACA) Taxonomy Defined Rates Pricing Specialty 01E Fee Schedule Updated On: 6/26/2020 NC Medicaid Physician Services Fee Schedule (See Affordable Care Act (ACA) Tab for Applicable ACA Defined Taxonomy Rates) Provider Specialty 001 Fee Schedule Updated on: 6/26/2020 ***The Agency's fee schedule rates below were set as of January 1, 2014 unless otherwise noted*** Rate changes after January 1, 2014 are based on the January 1st RVU of the year in which the service was initally established. The inclusion of a rate on this table does not guarantee that a service is covered. Please refer to the Medicaid Billing Guide and the Medicaid and Health Choice Clinical Policies on the DHB Web Site. Providers should always bill their usual and customary charges. Please use the monthly NC Medicaid Bulletins for additions, changes and deletion to this schedule. Medicaid Maximum Allowable NON-FACILITY Effective FEE END DATE PROCEDURE CODE MODIFIER PROCEDURE DESCRIPTION FACILITY RATE RATE Date of Rate 01967 ANESTH/ANALG VAG DELIVERY $ 220.11 $ 220.11 3/1/2020 12/31/9999 01996 HOSP MANAGE CONT DRUG ADMIN $ 40.88 $ 40.88 3/1/2020 12/31/9999 10004 FNA BX W/O IMG GDN EA ADDL $ 38.83 $ 46.10 3/1/2020 12/31/9999 10005 FNA BX W/US GDN 1ST LES $ 65.75 $ 110.89 3/1/2020 12/31/9999 10006 FNA BX W/US GDN EA ADDL $ 44.80 $ 53.29 3/1/2020 12/31/9999 10007 FNA BX W/FLUOR GDN 1ST LES $ 84.41 $ 247.72 3/1/2020 12/31/9999 10008 FNA BX W/FLUOR GDN EA ADDL $ 55.05 $ 139.88 3/1/2020 12/31/9999 10009 FNA BX W/CT GDN 1ST LES $ 102.46 $ 404.53 3/1/2020 12/31/9999 10010 FNA BX W/CT GDN EA ADDL $ 74.89 $ 244.25 3/1/2020 12/31/9999 10011 FNA BX W/MR GDN 1ST LES $ 54.57 $ 108.33 3/1/2020 12/31/9999 10012 FNA BX W/MR GDN EA ADDL $ 54.57 $ 108.33 3/1/2020 12/31/9999 10021 FNA BX W/O IMG GDN 1ST LES $ 54.98 $ 105.50 3/1/2020 12/31/9999 10030 GUIDE CATHET FLUID DRAINAGE $ 132.37 $ 645.99 3/1/2020 12/31/9999 10035 PERQ DEV SOFT TISS 1ST IMAG $ 78.18 $ 459.69 3/1/2020 12/31/9999 10036 PERQ DEV SOFT TISS ADD IMAG $ 39.36 $ 398.32 3/1/2020 12/31/9999 10040 ACNE SURGERY $ 66.71 $ 75.81 3/1/2020 12/31/9999 10060 DRAINAGE OF SKIN ABSCESS $ 70.76 $ 81.63 3/1/2020 12/31/9999 10061 DRAINAGE OF SKIN ABSCESS $ 126.15 $ 140.54 3/1/2020 12/31/9999 10080 DRAINAGE OF PILONIDAL CYST $ 72.31 $ 120.49 3/1/2020 12/31/9999 10081 DRAINAGE OF PILONIDAL CYST $ 126.75 $ 190.20 3/1/2020 12/31/9999 10120 REMOVE FOREIGN BODY $ 69.38 $ 99.65 3/1/2020 12/31/9999 10121 REMOVE FOREIGN BODY $ 142.05 $ 194.34 3/1/2020 12/31/9999 10140 DRAINAGE OF HEMATOMA/FLUID $ 90.65 $ 114.73 3/1/2020 12/31/9999 10160 PUNCTURE DRAINAGE OF LESION $ 73.00 $ 93.25 3/1/2020 12/31/9999 10180 COMPLEX DRAINAGE WOUND $ 133.77 $ 172.25 3/1/2020 12/31/9999 11000 DEBRIDE INFECTED SKIN $ 25.75 $ 40.44 3/1/2020 12/31/9999 11001 DEBRIDE INFECTED SKIN ADD-ON $ 12.98 $ 17.09 3/1/2020 12/31/9999 11004 DEBRIDE GENITALIA & PERINEUM $ 461.03 $ 461.03 3/1/2020 12/31/9999 11005 DEBRIDE ABDOM WALL $ 601.67 $ 601.67 3/1/2020 12/31/9999 11006 DEBRIDE GENIT/PER/ABDOM WALL $ 569.27 $ 569.27 3/1/2020 12/31/9999 11008 REMOVE MESH FROM ABD WALL $ 216.89 $ 216.89 3/1/2020 12/31/9999 11010 DEBRIDE SKIN AT FX SITE $ 219.49 $ 347.56 3/1/2020 12/31/9999 11011 DEBRIDE SKIN MUSC AT FX SITE $ 236.70 $ 387.67 3/1/2020 12/31/9999 11012 DEB SKIN BONE AT FX SITE $ 342.57 $ 529.69 3/1/2020 12/31/9999 11042 DEB SUBQ TISSUE 20 SQ CM/< $ 36.83 $ 55.92 3/1/2020 12/31/9999 11043 DEB MUSC/FASCIA 20 SQ CM/< $ 179.07 $ 204.04 3/1/2020 12/31/9999 11044 DEB BONE 20 SQ CM/< $ 246.38 $ 278.71 3/1/2020 12/31/9999 11045 DEB SUBQ TISSUE ADD-ON $ 14.92 $ 25.78 3/1/2020 12/31/9999 11046 DEB MUSC/FASCIA ADD-ON $ 31.77 $ 44.92 3/1/2020 12/31/9999 11047 DEB BONE ADD-ON $ 55.20 $ 73.77 3/1/2020 12/31/9999 11055 TRIM SKIN LESION $ 18.49 $ 36.11 3/1/2020 12/31/9999 11056 TRIM SKIN LESIONS 2 TO 4 $ 26.07 $ 44.29 3/1/2020 12/31/9999 11057 TRIM SKIN LESIONS OVER 4 $ 33.85 $ 53.53 3/1/2020 12/31/9999 11102 TANGNTL BX SKIN SINGLE LES $ 35.33 $ 85.63 3/1/2020 12/31/9999 11103 TANGNTL BX SKIN EA SEP/ADDL $ 20.46 $ 46.22 3/1/2020 12/31/9999 11104 PUNCH BX SKIN SINGLE LESION $ 44.34 $ 107.67 3/1/2020 12/31/9999 11105 PUNCH BX SKIN EA SEP/ADDL $ 24.18 $ 52.96 3/1/2020 12/31/9999 11106 INCAL BX SKN SINGLE LES $ 53.91 $ 130.26 3/1/2020 12/31/9999 11107 INCAL BX SKN EA SEP/ADDL $ 28.85 $ 62.49 3/1/2020 12/31/9999 11200 REMOVAL OF SKIN TAGS <W/15 $ 51.44 $ 60.56 3/1/2020 12/31/9999 11201 REMOVE SKIN TAGS ADD-ON $ 13.13 $ 14.31 3/1/2020 12/31/9999 11300 SHAVE SKIN LESION 0.5 CM/< $ 23.26 $ 50.00 3/1/2020 12/31/9999 11301 SHAVE SKIN LESION 0.6-1.0 CM $ 39.55 $ 68.92 3/1/2020 12/31/9999 11302 SHAVE SKIN LESION 1.1-2.0 CM $ 49.05 $ 82.53 3/1/2020 12/31/9999 11303 SHAVE SKIN LESION >2.0 CM $ 57.53 $ 96.89 3/1/2020 12/31/9999 11305 SHAVE SKIN LESION 0.5 CM/< $ 29.44 $ 51.77 3/1/2020 12/31/9999 11306 SHAVE SKIN LESION 0.6-1.0 CM $ 44.60 $ 71.62 3/1/2020 12/31/9999 11307 SHAVE SKIN LESION 1.1-2.0 CM $ 52.58 $ 84.61 3/1/2020 12/31/9999 11308 SHAVE SKIN LESION >2.0 CM $ 63.26 $ 95.28 3/1/2020 12/31/9999 11310 SHAVE SKIN LESION 0.5 CM/< $ 33.68 $ 62.46 3/1/2020 12/31/9999 11311 SHAVE SKIN LESION 0.6-1.0 CM $ 49.34 $ 79.59 3/1/2020 12/31/9999 11312 SHAVE SKIN LESION 1.1-2.0 CM $ 56.65 $ 91.90 3/1/2020 12/31/9999 11313 SHAVE SKIN LESION >2.0 CM $ 75.79 $ 115.15 3/1/2020 12/31/9999 11400 EXC TR-EXT B9+MARG 0.5 CM< $ 56.16 $ 84.95 3/1/2020 12/31/9999 11401 EXC TR-EXT B9+MARG 0.6-1 CM $ 74.90 $ 104.86 3/1/2020 12/31/9999 11402 EXC TR-EXT B9+MARG 1.1-2 CM $ 82.96 $ 117.03 3/1/2020 12/31/9999 11403 EXC TR-EXT B9+MARG 2.1-3CM $ 105.55 $ 134.94 3/1/2020 12/31/9999 11404 EXC TR-EXT B9+MARG 3.1-4 CM $ 117.58 $ 153.70 3/1/2020 12/31/9999 11406 EXC TR-EXT B9+MARG >4.0 CM $ 176.27 $ 217.69 3/1/2020 12/31/9999 11420 EXC H-F-NK-SP B9+MARG 0.5/< $ 60.89 $ 86.14 3/1/2020 12/31/9999 11421 EXC H-F-NK-SP B9+MARG 0.6-1 $ 82.41 $ 112.10 3/1/2020 12/31/9999 11422 EXC H-F-NK-SP B9+MARG 1.1-2 $ 99.38 $ 125.23 3/1/2020 12/31/9999 11423 EXC H-F-NK-SP B9+MARG 2.1-3 $ 116.08 $ 146.04 3/1/2020 12/31/9999 11424 EXC H-F-NK-SP B9+MARG 3.1-4 $ 133.94 $ 168.61 3/1/2020 12/31/9999 11426 EXC H-F-NK-SP B9+MARG >4 CM $ 205.00 $ 242.60 3/1/2020 12/31/9999 11440 EXC FACE-MM B9+MARG 0.5 CM/< $ 72.78 $ 94.22 3/1/2020 12/31/9999 11441 EXC FACE-MM B9+MARG 0.6-1 CM $ 95.78 $ 119.87 3/1/2020 12/31/9999 11442 EXC FACE-MM B9+MARG 1.1-2 CM $ 106.94 $ 135.15 3/1/2020 12/31/9999 11443 EXC FACE-MM B9+MARG 2.1-3 CM $ 132.43 $ 162.68 3/1/2020 12/31/9999 11444 EXC FACE-MM B9+MARG 3.1-4 CM $ 170.13 $ 205.67 3/1/2020 12/31/9999 11446 EXC FACE-MM B9+MARG >4 CM $ 241.16 $ 280.82 3/1/2020 12/31/9999 11450 REMOVAL SWEAT GLAND LESION $ 175.30 $ 256.07 3/1/2020 12/31/9999 11451 REMOVAL SWEAT GLAND LESION $ 231.95 $ 335.34 3/1/2020 12/31/9999 11462 REMOVAL SWEAT GLAND LESION $ 168.50 $ 252.50 3/1/2020 12/31/9999 11463 REMOVAL SWEAT GLAND LESION $ 236.54 $ 344.65 3/1/2020 12/31/9999 11470 REMOVAL SWEAT GLAND LESION $ 199.78 $ 281.43 3/1/2020 12/31/9999 11471 REMOVAL SWEAT GLAND LESION $ 251.67 $ 354.20 3/1/2020 12/31/9999 11600 EXC TR-EXT MAL+MARG 0.5 CM/< $ 84.80 $ 131.21 3/1/2020 12/31/9999 11601 EXC TR-EXT MAL+MARG 0.6-1 CM $ 109.75 $ 162.33 3/1/2020 12/31/9999 11602 EXC TR-EXT MAL+MARG 1.1-2 CM $ 120.79 $ 178.37 3/1/2020 12/31/9999 11603 EXC TR-EXT MAL+MARG 2.1-3 CM $ 143.78 $ 203.11 3/1/2020 12/31/9999 11604 EXC TR-EXT MAL+MARG 3.1-4 CM $ 158.04 $ 224.43 3/1/2020 12/31/9999 11606 EXC TR-EXT MAL+MARG >4 CM $ 234.70 $ 316.93 3/1/2020 12/31/9999 11620 EXC H-F-NK-SP MAL+MARG 0.5/< $ 86.08 $ 133.96 3/1/2020 12/31/9999 11621 EXC S/N/H/F/G MAL+MRG 0.6-1 $ 110.94 $ 163.81 3/1/2020 12/31/9999 11622 EXC S/N/H/F/G MAL+MRG 1.1-2 $ 128.00 $ 185.57 3/1/2020 12/31/9999 11623 EXC S/N/H/F/G MAL+MRG 2.1-3 $ 157.90 $ 217.23 3/1/2020 12/31/9999 11624 EXC S/N/H/F/G MAL+MRG 3.1-4 $ 179.61 $ 244.53 3/1/2020 12/31/9999 11626 EXC S/N/H/F/G MAL+MRG >4 CM $ 224.95 $ 298.10 3/1/2020 12/31/9999 11640 EXC F/E/E/N/L MAL+MRG 0.5CM< $ 90.68 $ 140.03 3/1/2020 12/31/9999 11641 EXC F/E/E/N/L MAL+MRG 0.6-1 $ 118.42 $ 172.47 3/1/2020 12/31/9999 11642 EXC F/E/E/N/L MAL+MRG 1.1-2 $ 139.79 $ 199.12 3/1/2020 12/31/9999 11643 EXC F/E/E/N/L MAL+MRG 2.1-3 $ 174.81 $ 234.75 3/1/2020 12/31/9999 11644 EXC F/E/E/N/L MAL+MRG 3.1-4 $ 218.00 $ 289.97 3/1/2020 12/31/9999 11646 EXC F/E/E/N/L MAL+MRG >4 CM $ 307.02 $ 383.10 3/1/2020 12/31/9999 11719 TRIM NAIL(S) ANY NUMBER $ 7.27 $ 15.79 3/1/2020 12/31/9999 11720 DEBRIDE NAIL 1-5 $ 13.61 $ 23.30 3/1/2020 12/31/9999 11721 DEBRIDE NAIL 6 OR MORE $ 23.26 $ 33.54 3/1/2020 12/31/9999 11730 REMOVAL OF NAIL PLATE $ 47.15 $ 73.88 3/1/2020 12/31/9999 11732 REMOVE NAIL PLATE ADD-ON $ 24.51 $ 34.48 3/1/2020 12/31/9999 11740 DRAIN BLOOD FROM UNDER NAIL $ 24.30 $ 33.42 3/1/2020 12/31/9999 11750 REMOVAL OF NAIL BED $ 134.11 $ 159.96 3/1/2020 12/31/9999 11755 BIOPSY NAIL UNIT $ 66.74 $ 99.34 3/1/2020 12/31/9999 11760 REPAIR OF NAIL BED $ 99.69 $ 148.45 3/1/2020 12/31/9999 11762 RECONSTRUCTION OF NAIL BED $ 154.00 $ 200.71 3/1/2020 12/31/9999 11765 EXCISION OF NAIL FOLD TOE $ 51.18 $ 94.08 3/1/2020 12/31/9999 11770 REMOVE PILONIDAL CYST SIMPLE $ 135.10 $ 191.50 3/1/2020 12/31/9999 11771 REMOVE PILONIDAL CYST EXTEN $ 312.90 $ 393.98 3/1/2020 12/31/9999 11772 REMOVE PILONIDAL CYST COMPL $ 407.61 $ 478.11 3/1/2020 12/31/9999 11900 INJECT SKIN LESIONS </W 7 $ 24.27 $ 41.88 3/1/2020 12/31/9999 11901 INJECT SKIN LESIONS >7 $ 37.76 $ 53.33 3/1/2020 12/31/9999 11920 CORRECT SKIN COLOR 6.0 CM/< $ 94.99 $ 160.65 3/1/2020 12/31/9999 11921 CORRECT SKN COLOR 6.1-20.0CM $ 104.74 $ 154.08 3/1/2020 12/31/9999 11950 TX CONTOUR DEFECTS 1 CC/< $ 39.63 $ 56.67 3/1/2020 12/31/9999 11951 TX CONTOUR DEFECTS 1.1-5.0CC $ 55.27 $ 75.85 3/1/2020 12/31/9999 11952 TX CONTOUR DEFECTS 5.1-10CC $ 79.80
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