Medicaid Fee Schedule without mods effective 01/01/2013 Procedure Medicaid fee code Description 2013 0001F HEART FAILURE ASSESSED $0.00 0001T ENDOVASCULAR REPAIR OF INFRARENAL ABDOMINAL AORTIC ANEURYSM OR DISSECTION; MODUL $0.00 0002F TOBACCO USE, SMOKING, ASSESSED $0.00 0002T ENDOVASCULAR REPAIR OF INFRARENAL ABDOMINAL AORTIC ANEURYSM OR DISSECTION; $0.00 00030 MILEAGE-LESS THAN 100 MILES-PER MILE $0.00 00031 MILEAGE-MORE THAN 99 MILES $0.00 0003F TOBACCO USE, NON-SMOKING, ASSESSED $0.00 0003T CERVICOGRAPHY $0.00 0004F TOBACCO USE CESSATION INTERVENTION, COUNSELING $0.00 0005F OSTEOARTHRITIS ASSESSED $0.00 0005T TRANSCATHETER PLACEMENT OF EXTRACRANIAL CEREBROVASCULAR ARTERY STENT(S), PERCUTA $0.00 0006F STATIN THERAPY, PRESCRIBED $0.00 0006T TRANSCATHETER PLACEMENT OF EXTRACRANIAL CEREBROVASCULAR ARTERY STENT(S), PERCUTA $0.00 0007F BETA-BLOCKER THERAPY, PRESCRIBED $0.00 0007T TRANSCATHETER PLACEMENT OF EXTRACRANIAL CEREBROVASCULAR ARTERY STENT(S), PERCUTA $0.00 0008F ACE INHIBITOR THERAPY, PRESCRIBED $0.00 0008T UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE $0.00 00090 IHS AMBULATORY SURGERY CENTER I $0.00 00091 IHS AMBULATORY SURGERY CENTER II $0.00 00092 IHS AMBULATORY SURGERY CENTER III $0.00 00093 IHS AMBULATORY SURGERY CENTER IV $0.00 00094 IHS AMBULATORY SURGERY CENTER V $0.00 00095 IHS AMBULATORY SURGERY CENTER VI $0.00 00096 IHS AMBULATORY SURGERY CENTER VII $0.00 00097 IHS AMBULATORY SURGERY CENTER VIII $0.00 00098 IHS AMBULATORY SURGERY CENTER IX $0.00 00099 IHS-OUTPATIENT REIMBURSEMENT RATE $0.00 0009F ANGINAL SYMPTOMS AND LEVEL OF ACTIVITY, ASSESSED $0.00 0009T ENDOMETRIAL CRYOABLATION WITH ULTRASONIC GUIDANCE $0.00 00100 ANESTHESIA FOR PROCEDURES ON SALIVARY GLANDS, INCLUDING BIOPSY $22.80 00102 ANESTHESIA FOR PROCEDURES INVOLVING PLASTIC REPAIR OF CLEFT LIP $22.80 Note: Any procedure code with payment of $0.00 is a non-covered service. Medicaid Fee Schedule without mods effective 01/01/2013 Procedure Medicaid fee code Description 2013 00103 ANESTHESIA FOR RECONSTRUCTIVE PROCEDURES OF EYELID (EG, BLEPHAROPLASTY, PTOSIS $22.80 00104 ANESTHESIA FOR ELECTROCONVULSIVE THERAPY $22.80 0010F ANGINAL SYMPTOMS AND LEVEL OF ACTIVITY, ASSESSED USING A STANDARDIZED INSTRUMENT $0.00 0010T TUBERCULOSIS TEST, CELL MEDIATED IMMUNITY MEASUREMENT OF GAMMA INTERFERON $0.00 0011F ORAL ANTIPLATELET THERAPY; PRESCRIBED (EG, ASPIRIN, CLOPIDOGREL/ PLAVIX, OR COMB $0.00 00120 ANESTHESIA FOR PROCEDURES ON EXTERNAL, MIDDLE, AND INNER EAR INCLUDING BIOPSY; $22.80 00124 ANESTHESIA FOR PROCEDURES ON EXTERNAL, MIDDLE, AND INNER EAR INCLUDING BIOPSY; $22.80 00126 ANESTHESIA FOR PROCEDURES ON EXTERNAL, MIDDLE, AND INNER EAR INCLUDING BIOPSY; $22.80 0012F COMMUNITY-ACQUIRED BACTERIAL PNEUMONIA ASSESSMENT (INCLUDES ALL OF THE FOLLOWING $0.00 0012T ARTHROSCOPY, KNEE, SURGICAL, IMPLANTATION OF OSTEOCHONDRAL GRAFT(S) FOR TREATMEN $0.00 0013T ARTHROSCOPY, KNEE, SURGICAL, IMPLANTATION OF OSTEOCHONDRAL GRAFT(S) FOR TREATMEN $0.00 00140 ANESTHESIA FOR PROCEDURES ON EYE; NOT OTHERWISE SPECIFIED $22.80 00142 ANESTHESIA FOR PROCEDURES ON EYE; LENS SURGERY $22.80 00144 ANESTHESIA FOR PROCEDURES ON EYE; CORNEAL TRANSPLANT $22.80 00145 ANESTHESIA FOR PROCEDURES ON EYE; VITREORETINAL SURGERY $22.80 00147 ANESTHESIA FOR PROCEDURES ON EYE; IRIDECTOMY $22.80 00148 ANESTHESIA FOR PROCEDURES ON EYE; OPHTHALMOSCOPY $22.80 0014F COMPREHENSIVE PREOPERATIVE ASSESSMENT PERFORMED FOR CATARACT SURGERY WITH INTRAO $0.00 0014T MENISCAL TRANSPLANTATION, MEDIAL OR LATERAL, KNEE (ANY METHOD) $0.00 0015F MELANOMA FOLLOW UP COMPLETED (INCLUDES ASSESSMENT OF ALL OF THE FOLLOWING COMPON $0.00 00160 ANESTHESIA FOR PROCEDURES ON NOSE AND ACCESSORY SINUSES; NOT OTHERWISE SPECIFIED $22.80 00162 ANESTHESIA FOR PROCEDURES ON NOSE AND ACCESSORY SINUSES; RADICAL SURGERY $22.80 00164 ANESTHESIA FOR PROCEDURES ON NOSE AND ACCESSORY SINUSES; BIOPSY, SOFT TISSUE $22.80 0016T DESTRUCTION OF LOCALIZED LESION OF CHOROID (EG, CHOROIDAL NEOVASCULARIZATION), $0.00 00170 ANESTHESIA FOR INTRAORAL PROCEDURES, INCLUDING BIOPSY; NOT OTHERWISE SPECIFIED $22.80 00172 ANESTHESIA FOR INTRAORAL PROCEDURES, INCLUDING BIOPSY; REPAIR OF CLEFT PALATE $22.80 00174 ANESTHESIA FOR INTRAORAL PROCEDURES, INCLUDING BIOPSY; EXCISION OF $22.80 00176 ANESTHESIA FOR INTRAORAL PROCEDURES, INCLUDING BIOPSY; RADICAL SURGERY $22.80 0017T DESTRUCTION OF MACULAR DRUSEN, PHOTOCOAGULATION $0.00 0018T DELIVERY OF HIGH POWER, FOCAL MAGNETIC PULSES FOR DIRECT STIMULATION TO $0.00 00190 ANESTHESIA FOR PROCEDURES ON FACIAL BONES OR SKULL; NOT OTHERWISE SPECIFIED $22.80 Note: Any procedure code with payment of $0.00 is a non-covered service. Medicaid Fee Schedule without mods effective 01/01/2013 Procedure Medicaid fee code Description 2013 00192 ANESTHESIA FOR PROCEDURES ON FACIAL BONES OR SKULL; RADICAL SURGERY (INCLUDING $22.80 0019T EXTRACORPOREAL SHOCK WAVE INVOLVING MUSCULOSKELETAL SYSTEM, NOT OTHERWISE SPECIF $0.00 0020T EXTRACORPOREAL SHOCK WAVE THERAPY; INVOLVING PLANTAR FASCIA $0.00 00210 ANESTHESIA FOR INTRACRANIAL PROCEDURES; NOT OTHERWISE SPECIFIED $22.80 00211 ANESTHESIA FOR INTRACRANIAL PROCEDURES; CRANIOTOMY OR CRANIECTOMY FOR EVACUATION $22.80 00212 ANESTHESIA FOR INTRACRANIAL PROCEDURES; SUBDURAL TAPS $22.80 00214 ANESTHESIA FOR INTRACRANIAL PROCEDURES; BURR HOLES, INCLUDING VENTRICULOGRAPHY $22.80 00215 ANESTHESIA FOR INTRACRANIAL PROCEDURES; CRANIOPLASTY OR ELEVATION OF DEPRESSED $22.80 00216 ANESTHESIA FOR INTRACRANIAL PROCEDURES; VASCULAR PROCEDURES $22.80 00218 ANESTHESIA FOR INTRACRANIAL PROCEDURES; PROCEDURES IN SITTING POSITION $22.80 0021T INSERTION OF TRANSCERVICAL OR TRANSVAGINAL FETAL OXIMETRY SENSOR $0.00 00220 ANESTHESIA FOR INTRACRANIAL PROCEDURES; CEREBROSPINAL FLUID SHUNTING PROCEDURES $22.80 00222 ANESTHESIA FOR INTRACRANIAL PROCEDURES; ELECTROCOAGULATION OF INTRACRANIAL NERVE $22.80 0023T INFECTIOUS AGENT DRUG SUSCEPTIBILITY PHENOTYPE PREDICTION USING GENOTYPIC $0.00 0024T NON-SURGICAL SEPTAL REDUCTION THERAPY (EG, ALCOHOL ABLATION), FOR HYPERTROPHIC $0.00 0025T DETERMINATION OF CORNEAL THICKNESS (EG, PACHYMETRY) WITH INTERPRETATION AND $0.00 0026T LIPOPROTEIN, DIRECT MEASUREMENT, INTERMEDIATE DENSITY LIPOPROTEINS (IDL) $0.00 0027T ENDOSCOPIC LYSIS OF EPIDURAL ADHESIONS WITH DIRECT VISUALIZATION USING $0.00 0028T DUAL ENERGY X-RAY ABSORPTIOMETRY (DEXA) BODY COMPOSITION STUDY, ONE OR MORE $0.00 0029T TREATMENT(S) FOR INCONTINENCE, PULSED MAGNETIC NEUROMODULATION, PER DAY $0.00 00300 ANESTHESIA FOR ALL PROCEDURES ON THE INTEGUMENTARY SYSTEM, MUSCLES AND NERVES OF $22.80 0030T ANTIPROTHROMBIN (PHOSPHOLIPID COFACTOR) ANTIBODY, EACH IG CLASS $0.00 0031T SPECULOSCOPY; $0.00 00320 ANESTHESIA FOR ALL PROCEDURES ON ESOPHAGUS, THYROID, LARYNX, TRACHEA AND $22.80 00322 ANESTHESIA FOR ALL PROCEDURES ON ESOPHAGUS, THYROID, LARYNX, TRACHEA AND $22.80 00326 ANESTHESIA FOR ALL PROCEDURES ON THE LARYNX AND TRACHEA IN CHILDREN LESS THAN 1 $22.80 0032T SPECULOSCOPY; WITH DIRECTED SAMPLING $0.00 0033T ENDOVASCULAR REPAIR OF DESCENDING THORACIC AORTIC ANEURYSM, PSEUDOANEURYSM OR $0.00 0034T ENDOVASCULAR REPAIR OF DESCENDING THORACIC AORTIC ANEURYSM, PSEUDOANEURYSM OR $0.00 00350 ANESTHESIA FOR PROCEDURES ON MAJOR VESSELS OF NECK; NOT OTHERWISE SPECIFIED $22.80 00352 ANESTHESIA FOR PROCEDURES ON MAJOR VESSELS OF NECK; SIMPLE LIGATION $22.80 Note: Any procedure code with payment of $0.00 is a non-covered service. Medicaid Fee Schedule without mods effective 01/01/2013 Procedure Medicaid fee code Description 2013 0035T PLACEMENT OF PROXIMAL OR DISTAL EXTENSION PROSTHESIS FOR ENDOVASCULAR REPAIR OF $0.00 0036T PLACEMENT OF PROXIMAL OR DISTAL EXTENSION PROSTHESIS FOR ENDOVASCULAR REPAIR OF $0.00 0037T OPEN SUBCLAVIAN TO CAROTID ARTERY TRANSPOSITION PERFORMED IN CONJUNCTION WITH $0.00 0038T ENDOVASCULAR REPAIR OF DESCENDING THORACIC AORTIC ANEURYSM, PSEUDOANEURYSM OR $0.00 0039T ENDOVASCULAR REPAIR OF DESCENDING THORACIC AORTIC ANEURYSM, PSEUDOANEURYSM OR $0.00 00400 ANESTHESIA FOR PROCEDURES ON THE INTEGUMENTARY SYSTEM ON THE EXTREMITIES, ANTERI $22.80 00402 ANESTHESIA FOR PROCEDURES ON THE INTEGUMENTARY SYSTEM ON THE EXTREMITIES, $22.80 00404 ANESTHESIA FOR PROCEDURES ON THE INTEGUMENTARY SYSTEM ON THE EXTREMITIES, $22.80 00406 ANESTHESIA FOR PROCEDURES ON THE INTEGUMENTARY SYSTEM ON THE EXTREMITIES, $22.80 0040T PLACEMENT OF PROXIMAL OR DISTAL EXTENSION PROSTHESIS FOR ENDOVASCULAR REPAIR OF $0.00 00410 ANESTHESIA FOR PROCEDURES ON THE INTEGUMENTARY SYSTEM ON THE EXTREMITIES, $22.80 0041T URINALYSIS INFECTIOUS AGENT DETECTION, SEMI-QUANTITATIVE ANALYSIS OF VOLATILE $0.00 00420 ANESTHESIA FOR PROCEDURES ON POSTERIOR INTEGUMENTARY SYSTEM OF CHEST, INCLUDING $22.80 0042T CEREBRAL PERFUSION ANALYSIS USING COMPUTED TOMOGRAPHY WITH CONTRAST $0.00 0043T CARBON MONOXIDE, EXPIRED GAS ANALYSIS (EG, ETCO/HEMOLYSIS BREATH TEST) $0.00 0044T WHOLE BODY INTEGUMENTARY PHOTOGRAPHY, AT REQUEST OF A PHYSICIAN, FOR MONITORING $0.00 00450 ANESTHESIA FOR PROCEDURES ON CLAVICLE AND SCAPULA; NOT OTHERWISE SPECIFIED $22.80 00452 ANESTHESIA FOR PROCEDURES ON CLAVICLE AND SCAPULA; RADICAL SURGERY $22.80 00454 ANESTHESIA FOR PROCEDURES ON CLAVICLE AND SCAPULA; BIOPSY OF CLAVICLE $22.80 0045T WHOLE BODY INTEGUMENTARY PHOTOGRAPHY, AT REQUEST OF A PHYSICIAN, FOR MONITORING $0.00 0046T CATHETER LAVAGE OF A MAMMARY DUCT(S) FOR COLLECTION OF CYTOLOGY SPECIMEN(S), IN $0.00 00470 ANESTHESIA FOR PARTIAL RIB RESECTION; NOT OTHERWISE SPECIFIED $22.80 00472 ANESTHESIA FOR PARTIAL RIB RESECTION; THORACOPLASTY (ANY TYPE) $22.80 00474 ANESTHESIA FOR PARTIAL RIB RESECTION; RADICAL PROCEDURES (EG, PECTUS EXCAVATUM) $22.80 0047T