NEW YORK STATE MEDICAID PROGRAM PHYSICIAN FEE SCHEDULE Physician Fee Schedule Table of Contents A. GENERAL INFORMATION.........................................................................................3 B. CONDITIONS FOR PAYMENT...................................................................................5 C. PHYSICIAN SERVICES PROVIDED IN HOSPITALS ...............................................5 D. MMIS MODIFIERS......................................................................................................5 E. MEDICINE: General Information and Rules ....................................................................................10 MMIS Modifiers: Medicine..............................................................................................20 Evaluation and Management Services..........................................................................22 Laboratory Services Performed in a Physician's Office ..............................................104 Immunization Injections ..............................................................................................105 Hydration, Therapeutic, Prophylactic And Diagnostic Injections And Infusions ...... ...108 Drugs Administered by Other than Oral Methods........................................................110 Chemotherapy Administration .....................................................................................118 Chemotherapy Drugs...................................................................................................119 Psychiatry....................................................................................................................122 Dialysis Procedures ....................................................................................................126 Gastroenterology.........................................................................................................128 Ophthalmology ................ ...........................................................................................129 Otorhinolaryngologic Services ....................................................................................135 Cardiovascular .................. .........................................................................................138 Non-Invasive Vascular Diagnostic Studies .................................................................148 Pulmonary................... ...............................................................................................150 Allergy and Clinical Immunology ................................................................................152 Neurology and Neuromuscular Procedures ...............................................................153 Central Nervous System Assessments/Tests..............................................................160 Photodynamic Therapy................................................................................................160 Dermatalogical Procedures ........................................................................................161 Osteopathic Manipulative Treatment ..........................................................................161 Special Services .........................................................................................................161 Moderate (Conscious) Sedation..................................................................................162 F. ANESTHESIA: General Information and Rules ..................................................................................163 Calculation of Total Anesthesia Values ......................................................................165 Version 2006-1 (4/1/06) Page 1 of 529 Physician Fee Schedule G. SURGERY: General Information and Rules ..................................................................................166 General........................................................................................................................172 Integumentary System ...............................................................................................172 Musculoskeletal System .............................................................................................198 Respiratory System ....................................................................................................277 Cardiovascular System ..............................................................................................291 Hemic and Lymphatic Systems ..................................................................................331 Mediastinum and Diaphragm .....................................................................................334 Digestive System .......................................................................................................336 Urinary System ...........................................................................................................382 Male Genital System ..................................................................................................401 Female Genital System ..............................................................................................411 Maternity Care and Delivery .......................................................................................424 Endocrine System ......................................................................................................428 Nervous System .........................................................................................................430 Eye and Ocular Adnexa .............................................................................................461 Auditory Systems .......................................................................................................478 H. RADIOLOGY: General Instructions ............................................................................................... ...484 General Information and Rules................................................................ ............... ...485 MMIS Modifiers: Radiology........................................................................................ 486 Diagnostic Radiology ............................................................................................. ...488 Diagnostic Ultrasound ............................................................................................ ...509 Radiation Oncology ................................................................................................ ...514 Nuclear Medicine ........................................................................................................519 Positron Emission Tomography ..................................................................................527 I. APPENDIX A: Physician Specialty ................................................................................................ ...528 Version 2006-1 (4/1/06) Page 2 of 529 Physician Fee Schedule GENERAL INFORMATION This Medical Fee Schedule applies to Medicine, Surgery, Anesthesia and Radiology Services. Underlined procedure codes require Prior Approval before services are rendered. 1. OSTEOPATHIC PHYSICIANS: The Medical Fee Schedule for physicians is applicable to services provided by osteopathic physicians. 2. MULTIPLE CALLS: If an individual patient is seen on more than one occasion during a single day, the fee for each visit may be allowed. 3. CHARGES FOR DIAGNOSTIC PROCEDURES: Charges for special diagnostic procedures which are not considered to be a routine part of an attending physician's or consultant's examination (eg, pregnancy test, diagnostic X-ray, lumbar puncture) are reimbursable in addition to the usual physician's visit fee. 4. REFERRAL: A referral is the transfer of the total or specific care of a patient from one physician to another and does not constitute a consultation. Initial evaluation and subsequent services are designated as listed in LEVELS OF E/M SERVICE. 5. CONSULTATION: Consultation is to be distinguished from referral. REFERRAL is the transfer of the patient from one physician to another for definitive treatment. CONSULTATION is advice and opinion from an accredited physician specialist called in by the attending practitioner in regard to the further management of the patient by the attending practitioner. Consultation fees are applicable only when examinations are provided by an accredited physician specialist within the scope of his specialty upon request of the authorizing agency or of the attending practitioner who is treating the medical problem for which consultation is required.The attending practitioner must certify that he requested such consultation and that it was incident and necessary to his further care of the patient. When the consultant physician assumes responsibility for a portion of patient management, he will be rendering concurrent care (use appropriate level of Evaluation and Management codes). If he has had the case transferred or referred to him, he should then use the appropriate codes for services rendered (eg, visits, procedures)on and subsequent to the date of transfer. 6. PROCEDURE NOT INCLUDED: Each public agency may determine, on an individual basis, fees for services or procedures not included in the Medical Fee Schedule. The value and appropriateness of services not specifically listed in this fee schedule will be determined "By Report". Claims for these services will be manually reviewed by medical professional staff. The MMIS procedure codes to be utilized when