Appendix Exhbit 1 Physicians' And ASC Fee Schedules
AppendixExhbit 1Physicians' and ASC Fee SchedulesCPT*HCPCSMODDESCRIPTION*Current Procedural Terminology (CPT) is copyright 2010 American Medical Association(AMA). All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein.Applicable FARS/DFARS restrictions apply to government use. CPT is a trademark of theAmerican Medical Association.ANESTHESIA BASE UNITSAnes0232TNJX PLATELET PLASMAG0283ELECTRICAL STIMULATION, (UNATTENDED), TO ONE OR MORE AREAS,G0289ARTHRO, LOOSE BODY CHONDRO10060DRAIN SKIN ABSCESS10061DRAIN SKIN ABSCESS10120REMOVE FOREIGN BODY10121REMOVE FOREIGN BODY10140DRAIN HEMATOMA/FLUID10160PUNCTURE DRAIN LESION10180COMPLEX DRAIN WOUND11000DEBRIDE INFECTED SKIN11001DEBRIDE INFECTED SKIN, ADDED11010DEBRIDE SKIN, FX11011DEBRIDE SKIN/MUSCLE, FX11012DEBRIDE SKIN/MUSCLE/BONE, FX11042DEBRIDE SKIN/TISSUE11043DEBRIDE TISSUE/MUSCLE11044DEBRIDE TISSUE/MUSCLE/BONE11045DEBRIDE SUBQ TISSUE ADD-ON11046DEBRIDE MUSCLE/FASCIA ADD-ON11047DEBRIDE BONE ADD-ON11055TRIM SKIN LESION11056TRIM SKIN LESIONS, 2 TO 411057TRIM SKIN LESIONS, OVER 411100BIOPSY SKIN LESION11101BIOPSY SKIN, ADDED11200REMOVE SKIN TAGS11300SHAVE SKIN LESION11301SHAVE SKIN LESION11302SHAVE SKIN LESION11305SHAVE SKIN LESION11306SHAVE SKIN LESION11310SHAVE SKIN LESION11311SHAVE SKIN LESION11400EXCISE TRT-EXT BENIGN MARG 0.5 CM11401EXCISE TRT-EXT BENIGN MARG 0.6-1 CM11402EXCISE TRT-EXT BENIGN MARG 1.1-2 CM11403EXCISE TRT-EXT BENIGN MARG 2.1-3 CM11404EXCISE TRT-EXT BENIGN MARG 3.1-4 CM11406EXCISE TRT-EXT BENIGN MARG 4.0 CM11420EXCISE H-F-NECK-SP BENIGN MARG 0.5 11421EXCISE H-F-NECK-SP BENIGN MARG 0.6-111422EXCISE H-F-NECK-SP BENIGN MARG 1.1-211423EXCISE H-F-NECK-SP BENIGN MARG 2.1-311424EXCISE H-F-NECK-SP BENIGN MARG 3.1-411426EXCISE H-F-NECK-SP BENIGN MARG 4 CM11440EXCISE FACE-MM BENIGN MARG 0.5 CM11441EXCISE FACE-MM BENIGN MARG 0.6-1 CM11442EXCISE FACE-MM BENIGN MARG 1.1-2 CM11443EXCISE FACE-MM BENIGN MARG 2.1-3 CM11444EXCISE FACE-MM BENIGN MARG 3.1-4 CM11719TRIM NAIL(S)11720DEBRIDE NAIL, 1-511721DEBRIDE NAIL, 6 OR MORE11730REMOVE NAIL PLATE11732REMOVE NAIL PLATE, ADDED11740DRAIN BLOOD UNDER NAIL11750REMOVE NAIL BED11752REMOVE NAIL BED/FINGER TIP11760REPAIR NAIL BED11762RECONSTRUCT NAIL BED11765EXCISE NAIL FOLD, TOE11900INJECTION INTO SKIN LESIONS11901ADDED SKIN LESIONS INJECTION11950THERAPY FOR CONTOUR DEFECTS11951THERAPY FOR CONTOUR DEFECTS11960INSERT TISSUE 3409.09209.9986.02108.02107.85153.191,374.88ASC FeesNorthASC 1.522,736.03PaymentIndicator(Seebottom forcodes)XX, N1
AppendixExhbit 1Physicians' and ASC Fee 120151211513015170151711517515220MODPhysicians' 61,178.97DESCRIPTIONINSERT DRUG IMPLANT DEVICEREMOVE DRUG IMPLANT DEVICEREPAIR SUPERFICIAL WOUND(S)REPAIR SUPERFICIAL WOUND(S)REPAIR SUPERFICIAL WOUND(S)REPAIR SUPERFICIAL WOUND(S)REPAIR SUPERFICIAL WOUND(S)REPAIR SUPERFICIAL WOUND(S)REPAIR SUPERFICIAL WOUND(S)REPAIR SUPERFICIAL WOUND(S)REPAIR SUPERFICIAL WOUND(S)REPAIR SUPERFICIAL WOUND(S)REPAIR SUPERFICIAL WOUND(S)REPAIR SUPERFICIAL WOUND(S)CLOSE SPLIT WOUNDCLOSE SPLIT WOUNDINTERMED WOUND REPAIR S/TRT/EXTINTERMED WOUND REPAIR S/TRT/EXTINTERMED WOUND REPAIR S/TRT/EXTINTERMED WOUND REPAIR S/TRT/EXTINTERMED WOUND REPAIR S/TRT/EXTINTERMED WOUND REPAIR S/TRT/EXTINTERMED WOUND REPAIR N-HF/GENITALINTERMED WOUND REPAIR N-HG/GENITALINTERMED WOUND REPAIR N-HG/GENITALINTERMED WOUND REPAIR N-HG/GENITALINTERMED WOUND REPAIR N-HG/GENITALINTERMED WOUND REPAIR N-HG/GENITALINTERMED WOUND REPAIR FACE/MMINTERMED WOUND REPAIR FACE/MMINTERMED WOUND REPAIR FACE/MMINTERMED WOUND REPAIR FACE/MMINTERMED WOUND REPAIR FACE/MMINTERMED WOUND REPAIR FACE/MMINTERMED WOUND REPAIR FACE/MMREPAIR WOUND OR LESIONREPAIR WOUND OR LESIONREPAIR WOUND/LESION, ADDEDREPAIR WOUND OR LESIONREPAIR WOUND OR LESIONREPAIR WOUND/LESION, ADDEDREPAIR WOUND OR LESIONREPAIR WOUND OR LESIONREPAIR WOUND/LESION, ADDEDREPAIR WOUND OR LESIONREPAIR WOUND OR LESIONREPAIR WOUND OR LESIONREPAIR WOUND/LESION, ADDEDLATE CLOSE WOUNDSKIN TISSUE REARRANGEMENTSKIN TISSUE REARRANGEMENTSKIN TISSUE REARRANGEMENTSKIN TISSUE REARRANGEMENTSKIN TISSUE REARRANGEMENTSKIN TISSUE REARRANGEMENTSKIN TISSUE REARRANGEMENTSKIN TISSUE REARRANGEMENTSKIN TISSUE REARRANGEMENTSKIN TISSUE REARRANGE ADDEDWOUND PREP, TRUNK/ARM/LEGWOUND PREP, ADDED 100 CMWOUND PREP, F/N/HF/GWOUND PREP, F/N/HF/G, ADDED CMSKIN PINCH GRAFTSKIN SPLIT GRAFT, TRUNK/ARM/LEGSKIN SPLIT GRAFT T/A/L, ADDEDSKIN SPLIT A-GRAFT FAC/NECK/HF/GSKIN SPLIT A-GRAFT F/N/HF/G ADDEDDERM AUTOGRAFT, TRUNK/ARM/LEGACELLULAR GRAFT TRUNK/ARMS/LEGSACELLULAR GRAFT T/ARM/LEG, ADDEDACELLULAR GRAFT, F/N/HF/GSKIN FULL GRAFT SCALP/ARM/LEG2ASC SC Fees bottom 032,113.44570.03388.26570.032,113.44
AppendixExhbit 1Physicians' and ASC Fee 103205202052520526205502055120552MODPhysicians' N FULL GRAFT, ADDEDSKIN FULL GRAFT FACE/GENITAL/HFSKIN FULL GRAFT, ADDEDSKIN FULL GRAFT EEN & LIPSAPPLY ACELLULAR ALLOGRAFT T/ARM/LEGAPPLY ACELLULAR GRAFT T/A/L, ADDEDAPPLY CULT SKIN SUBSTITUTEAPPLY CULT SKIN SUB, ADDEDAPPLY CULT DERM SUB F/N/HF/GAPPLY CULT DERM F/HF/G ADDEDAPPLY ACELLULAR XENOGRAFTAPPLY ACELLULAR XENOGRAFT ADDEDFORM SKIN PEDICLE FLAPFORM SKIN PEDICLE FLAPFORM SKIN PEDICLE FLAPFORM SKIN PEDICLE FLAPSKIN GRAFTMUSCLE-SKIN GRAFT, HEAD/NECKMUSCLE-SKIN GRAFT, TRUNKMUSCLE-SKIN GRAFT, ARMMUSCLE-SKIN GRAFT, LEGFREE MYO/SKIN FLAP MICROVASCDERMA-FAT-FASCIA GRAFTABRASION TREAT SKINABRASION TREAT SKINABRASION TREAT SKINABRASION, LESION, SINGABRASION, LESIONS, ADDEDREVISE UPPER EYELIDEXCISE SKIN ABDEXCISE EXCESSIVE SKIN TISSUEREMOVE SUTURESDRESSING CHANGE NOT FOR BURNREMOVE HIP PRESSURE SOREREMOVE HIP PRESSURE SOREREMOVE HIP PRESSURE SOREREMOVE HIP PRESSURE SOREREMOVE HIP PRESSURE SOREREMOVE THIGH PRESSURE SOREREMOVE THIGH PRESSURE SOREREMOVE THIGH PRESSURE SOREREMOVE THIGH PRESSURE SOREREMOVE THIGH PRESSURE SOREREMOVE THIGH PRESSURE SOREINITIAL TREAT BURN(S)DRESS/DEBRIDE P-THICK BURN, SDRESS/DEBRIDE P-THICK BURN, MDRESS/DEBRIDE P-THICK BURN, LDESTROY PREMALIG LESIONDESTROY PREMALIG LES, 2-14DESTROY PREMALIG LESIONS 15 DESTROY SKIN LESIONSDESTROY SKIN LESIONSDESTROY SKIN LESIONSDESTROY B9 LESION, 1-14DSTRJ B9 SK TGS/CUTAN VASC 15/ CHEM CAUT GRANLTJ TISS PROUD FLESH SINUS/FSTLDESTROY SKIN LESIONSDESTROY SKIN LESIONSDRAIN BREAST LESIONREMOVE BREAST LESIONEXCISE BREAST LESIONPLACE NEEDLE WIRE, BREASTEXPLORE WOUND, NECKEXPLORE WOUND, CHESTEXPLORE WOUND, ABDOMENEXPLORE WOUND, EXTREMITYREMOVE FOREIGN BODYREMOVE FOREIGN BODYTHERAPEUTIC INJECTION, CARP TUNNELINJECT TENDON SHEATH/LIGAMENTINJECT TENDON ORIGIN/INSERTINJECT TRIGGER POINT, 1/2 MUSCLE3ASC ,972.49ASC 42.35PaymentIndicator(Seebottom forcodes)XX, .86369.362,934.54117.3688.2991.5387.21
AppendixExhbit 1Physicians' and ASC Fee 406214072140821450214512145221453MODPhysicians' 4298.60680.98652.96724.98694.28DESCRIPTIONINJECT TRIGGER POINTS, / 3DRAIN/INJ, JOINT/BURSADRAIN/INJ, JOINT/BURSADRAIN/INJ, JOINT/BURSAASPIRATE/INJECT GANGLION CYSTTREAT BONE CYSTINSERT & REMOVE BONE PINAPPLY PELVIS BRACEAPPLY THIGH BRACEREMOVE FIXATION DEVICEREMOVE SUPPORT IMPLANTREMOVE SUPPORT IMPLANTAPPLY BONE FIXATION DEVICEAPPLY BONE FIXATION DEVICEADJUST BONE FIXATION DEVICEREMOVE BONE FIXATION DEVICECOMP MULTIPLANE EXT FIXATIONCOMP EXT FIXATE STRUT CHANGEREMOVE BONE FOR GRAFTREMOVE BONE FOR GRAFTREMOVE CARTILAGE FOR GRAFTREMOVE CARTILAGE FOR GRAFTREMOVE FASCIA FOR GRAFTREMOVE FASCIA FOR GRAFTREMOVE TENDON FOR GRAFTREMOVE TISSUE FOR GRAFTSP BONE ALLOGRAFT STRUCT, ADDEDFLUID PRESSURE, MUSCLEFIBULA BONE GRAFT, MICROVASCELECTRICAL BONE STIMULATIONELECTRICAL BONE STIMULATIONUS BONE STIMULATIONCOMPUTER-ASSIST DIR MS PXREMOVE JAW JOINT CARTILAGEREMOVE CORONOID PROCESSMANIPULATE TMJ W/ANESTHPREPARE FACE/ORAL PROSTHESISINTERDENTAL FIXATIONINJECTION, JAW JOINT X-RAYREDUCE FACIAL BONESFACE BONE GRAFTRECONSTRUCT JAW JOINTRECONSTRUCT JAW JOINTRECONSTRUCT JAW JOINTRECONSTRUCT LOWER JAWRECONSTRUCT JAWRECONSTRUCT JAWRECONSTRUCT LOWER JAW BONERECONSTRUCT JAWRECONSTRUCT JAWTREAT NOSE FXTREAT NOSE FXTREAT NOSE FXTREAT NOSE FXTREAT NOSE FXTREAT NOSE FXTREAT CHEEK BONE FXTREAT CHEEK BONE FXTREAT CHEEK BONE FXTREAT CHEEK BONE FXTREAT EYE SOCKET FXTREAT EYE SOCKET FXTREAT EYE SOCKET FXTREAT EYE SOCKET FXTREAT EYE SOCKET FXTREAT EYE SOCKET FXTREAT EYE SOCKET FXTREAT EYE SOCKET FXTREAT EYE SOCKET FXTREAT LOWER JAW FXTREAT LOWER JAW FXTREAT LOWER JAW FXTREAT LOWER JAW .951,360.70ASC SC ottom forcodes)XX, N1XX, N1X, N1
AppendixExhbit 1Physicians' and ASC Fee 505245152451624530245352454524546MODPhysicians' ONTREAT LOWER JAW FXTREAT LOWER JAW FXTREAT LOWER JAW FXTREAT LOWER JAW FXTREAT LOWER JAW FXTREAT RIB FXTREAT STERNUM FXTREAT STERNUM FXTREAT SPINE PROCESS FXTREAT SPINE FXTREAT SPINE FXMANIPULATE SPINEPERCUT VERTEBROPLASTY THORACICPERCUT VERTEBROPLASTY LUMBARPERCUT VERTEBROPLASTY ADDEDNECK SPINE FUSIONADDED SPINAL FUSIONINSERT SPINE FIXATION DEVICEAPPLY SPINE PROSTH DEVICEPARTIAL REMOVE COLLAR BONEREMOVE COLLAR BONEREMOVE SHOULDER BONE, PARTREMOVE SHOULDER FOREIGN BODYREMOVE SHOULDER FOREIGN BODYINJECTION FOR SHOULDER X-RAYTX SHO AREA 1 TDNTX SHO AREA MLT TDN THRU SM INCOPEN REPAIR OF ROTATOR CUFF, RECENTOPEN REPAIR OF ROTATOR CUFF, OLDCORACOACROMIAL LIGM RLS -ACROMPRECONSTRUCTION ROTATOR CUFF, OLDTENODIS LONG TDN BICEPSRESCJ/TRNSPLJ LONG TDN BICEPSRECONSTRUCT SHOULDER JOINTRECONSTRUCT SHOULDER JOINTREVISE COLLAR BONEREVISE COLLAR BONETREAT CLAVICLE FXTREAT CLAVICLE FXTREAT CLAVICLE FXTREAT CLAVICLE DISLOCATIONTREAT CLAVICLE DISLOCATIONTREAT CLAVICLE DISLOCATIONTREAT CLAVICLE DISLOCATIONTREAT CLAVICLE DISLOCATIONTREAT CLAVICLE DISLOCATIONTREAT CLAVICLE DISLOCATIONTREAT SHOULDER BLADE FXTREAT HUMERUS FXTREAT HUMERUS FXTREAT HUMERUS FXTREAT HUMERUS FXTREAT HUMERUS FXTREAT HUMERUS FXTREAT HUMERUS FXTREAT SHOULDER DISLOCATIONTREAT SHOULDER DISLOCATIONFIXATE SHOULDERINJECTION FOR ELBOW X-RAYMANIPULATE ELBOW W/ANESTHARM TENDON LENGTHENINGREPAIR BICEPS TENDONREPAIR ARM TENDON/MUSCLEREPAIR RUPTURED TENDONREPAIR ELBOW LAT LIGAMENT W/TISSTREAT HUMERUS FXTREAT HUMERUS FXTREAT HUMERUS FXTREAT HUMERUS FXTREAT HUMERUS FXTREAT HUMERUS FXTREAT HUMERUS FXTREAT HUMERUS .741,399.911,583.95ASC FeesNorth3,421.415,961.755,961.755,961.75ASC 04,3
Appendix Exhbit 1 Physicians' and ASC Fee Schedules Anes ANESTHESIA BASE UNITS 86.47 84.36 0232T NJX PLATELET PLASMA 63.95 89.55 82.44 X G0283 ELECTRICAL STIMULATION, (UNATTENDED), TO ONE OR MORE AREAS, 20.14 19.26
Issue of orders 69 : Publication of misleading information 69 : Attending Committees, etc. 69 : Responsibility 69-71 : APPENDICES : Appendix I : 72-74 Appendix II : 75 Appendix III : 76 Appendix IV-A : 77-78 Appendix IV-B : 79 Appendix VI : 79-80 Appendix VII : 80 Appendix VIII-A : 80-81 Appendix VIII-B : 81-82 Appendix IX : 82-83 Appendix X .
Appendix G Children's Response Log 45 Appendix H Teacher's Journal 46 Appendix I Thought Tree 47 Appendix J Venn Diagram 48 Appendix K Mind Map 49. Appendix L WEB. 50. Appendix M Time Line. 51. Appendix N KWL. 52. Appendix 0 Life Cycle. 53. Appendix P Parent Social Studies Survey (Form B) 54
Appendix H Forklift Operator Daily Checklist Appendix I Office Safety Inspection Appendix J Refusal of Workers Compensation Appendix K Warehouse/Yard Inspection Checklist Appendix L Incident Investigation Report Appendix M Incident Investigation Tips Appendix N Employee Disciplinary Warning Notice Appendix O Hazardous Substance List
Appendix 1 - School Food and Beverage Policy 66 Appendix 2 - Trans Fat Standards (O.Reg. 200/08) 83 Appendix 3 - Calculating Trans Fat 84 Appendix 4 - A-Z Food and Beverage List 86 Appendix 5 - Cafeteria Food Service Provider Checklist 92 Appendix 6 - Caterer Checklist 93 Appendix 7 - School Event Menu Ideas 94
Appendix#10 Pre-Job Briefing and Post-Job Review Attendance Form Appendix#11 Safety Task Assignment (STA) Appendix#12 Physiological Monitoring for Heat Stress Appendix#13 Weekly Hour Usage Report Appendix#14 Project - Training Matrix A or B Appendix#15 Excavation Trench Inspection Form Appendix#16 Inbound Equipment Inspection Form
Appendix E: DD Form 577 for Appointing a Certifying Officer 57 Appendix F: Sample GPC Appointment Letters 58 Appendix G: Formal Reporting Requirements 66 Appendix H: Semi-Annual Surveillance Report Template 70 Appendix I: GPC Thresholds 73 Appendix J: Glossary – Sections I and II 75 Chapter 1: The Government Purchase Card Program 1-1. Purpose a.
Port Side. Appendix D . Appendix D . Page D-3. Changed to below 280 PSI and above 350 PSI. Appendix D . Page D-4. Changed to any fuel leak. Appendix E . Appendix E . Page E-3. Line item 10.C, added will not close completely. Appendix E . Page E-4. Line item 12.A, added grade 5 or better mounting . bolts. Appendix E . Page E-4.
Adopted by the Council of The American Society of Mechanical Engineers, 1914; latest edition 2019. The American Society of Mechanical Engineers Two Park Avenue, New York, NY 10016-5990
