MCCPP Fee Schedule 2022 - Dphhs.mt.gov

Cytopathology with automated screening and re-screening under physician supervision.88175 26.61Evaluation of fine needle aspirate, immediate cytohistologic study to determine adequacy of specimen(s), each separateadditional evaluation episode, same site. (Use with 88172) (global)88177 29.30Evaluation of fine needle aspirate, immediate cytohistologic study to determine adequacy of specimen(s), each separateadditional evaluation episode, same site. (Use with 88172) (technical)88177/TC 7.33Evaluation of fine needle aspirate, immediate cytohistologic study to determine adequacy of specimen(s), each separateadditional evaluation episode, same site. (Use with 88172) (professional)88177-26 21.97Surgical pathology/biopsy lab. Breast or Cervical specimens only (global)88305 71.51Surgical pathology/biopsy lab. Breast or Cervical specimens only (technical)88305/TC 33.84Surgical pathology/biopsy lab. Breast or Cervical specimens only (professional)88305-26 37.68Surgical pathology. Level V. Breast or Cervical specimens only (global)88307 290.25Surgical pathology. Level V. Breast or Cervical specimens only (technical)88307/TC 206.88Surgical pathology. Level V. Breast or Cervical pecimens only (professional)88307-26 83.36Surgical pathology. Level VI. Breast or Cervical pecimens only (global)88309 441.67Surgical pathology. Level VI. Breast or Cervical pecimens only (technical)88309/TC 294.81Surgical pathology. Level VI. Breast or Cervical pecimens only (professional)88309-26 146.86Consultation, comprehensive, with review of records and specimens, with report on referred material.88325 166.68Pathology consultation during surgery88329 59.29First tissue block with frozen sections, single specimen (global)88331 104.66First tissue block with frozen sections, single specimen (technical)88331/TC 42.21First tissue block with frozen sections, single specimen (professional)88331-26 62.44Each additional tissue block with frozen sections (global)88332 55.12Each additional tissue block with frozen sections (technical)88332/TC 24.07Each additional tissue block with frozen sections (professional)88332-26 31.05Pathology: Immunohistochemistry or immunocytochemistry, per specimen, each additional single antibody stainprocedure (global)88341 93.85Pathology: Immunohistochemistry or immunocytochemistry, per specimen, each additional single antibody stainprocedure (technical)88341/TC 65.25Pathology: Immunohistochemistry or immunocytochemistry, per specimen, each additional single antibody stainprocedure (professional)88341-26 28.60Pathology:Immunohistochemistry or immunocytochemistry, per specimen, initial single antibody stain procedure (global)88342Pathology:Immunohistochemistry or immunocytochemistry, per specimen, initial single antibody stain procedure(technical)88342/TC 70.82Pathology:Immunohistochemistry or immunocytochemistry, per specimen, initial single antibody stain procedure(professional)88342-26 35.23Morphometric analysis, tumor immunohistochemistry, quantitative or semiquantitative, per specimen, each singleantibody stain procedure; manual (global)88360Morphometric analysis, tumor immunohistochemistry, quantitative or semiquantitative, per specimen, each singleantibody stain procedure; manual (technical)88360/TC 82.69Morphometric analysis, tumor immunohistochemistry, quantitative or semiquantitative, per specimen, each singleantibody stain procedure; manual (professional)88360-26 42.21Morphometric analysis, tumor immunohistochemistry, quantitative or semiquantitative, per specimen, each singleantibody stain procedure; using computer assisted technology (global)88361Morphometric analysis, tumor immunohistochemistry, quantitative or semiquantitative, per specimen, each singleantibody stain procedure; using computer assisted technology (technical)Morphometric analysis, tumor immunohistochemistry, quantitative or semiquantitative, per specimen, each singleantibody stain procedure; using computer assisted technology (professional)6/17/2021 106.06 124.90 124.2088361/TC 80.2588361-26 43.96Page 4 of 9

In situ hybridization (e.g. FISH) per specimen, each additional single probe stain procedure (global)88364 144.44In situ hybridization (e.g. FISH) per specimen, each additional single probe stain procedure (technical)88364/TC 109.56In situ hybridization (e.g. FISH) per specimen, each additional single probe stain procedure (professional)88364-26 34.89In situ hybridization (e.g. FISH) per specimen, initial single probe stain procedure (global)88365 185.95In situ hybridization (e.g. FISH) per specimen, initial single probe stain procedure (technical)88365/TC 142.00In situ hybridization (e.g. FISH) per specimen, initial single probe stain procedure (professional)88365-26 43.95In situ hybridization (e.g. FISH) per specimen, each multiplex probe stain procedure (global)88366 293.42In situ hybridization (e.g. FISH) per specimen, each multiplex probe stain procedure (technical)88366/TC 230.98In situ hybridization (e.g. FISH) per specimen, each multiplex probe stain procedure (professional)Morphometric analysis, in situ hybridization, computer-assisted, per specimen, initial single probe stain procedure(global)Morphometric analysis, in situ hybridization, computer-assisted, per specimen, initial single probe stain procedure(technical)Morphometric analysis, in situ hybridization, computer-assisted, per specimen, initial single probe stain procedure(professional)88366-26 62.44Morphometric analysis, in situ hybridization, manual, per specimen, initial single probe stain procedure (global)88368Morphometric analysis, in situ hybridization, manual, per specimen, initial single probe stain procedure (technical)88368/TC 95.59Morphometric analysis, in situ hybridization, manual, per specimen, initial single probe stain procedure (professional)88368-26 41.51Morphometric analysis, in situ hybridization, manual, per specimen, each additional probe stain procedure (global)88369Morphometric analysis, in situ hybridization, manual, per specimen, each additional probe stain procedure (technical)88369/TC 85.83Morphometric analysis, in situ hybridization, manual, per specimen, each additional probe stain procedure (professional)Morphometric analysis, in situ hybridization, computer-assisted, per specimen, each additional probe stain procedure(global)88369-26 32.4488373 73.2788373/TC 47.11Morphometric analysis, in situ hybridization, computer-assisted, per specimen, each additional probe stain procedure(technical)Morphometric analysis, in situ hybridization, computer-assisted, per specimen, each additional probe stain procedure(professional)88367 115.8388367/TC 81.9988367-26 33.8488373-26 137.11 118.27 26.16Morphometric analysis, in situ hybridization, computer-assisted, per specimen, each multiplex stain procedure (global)88374 352.40Morphometric analysis, in situ hybridization, computer-assisted, per specimen, each multiplex stain procedure (technical)88374/TC 308.45Morphometric analysis, in situ hybridization, computer-assisted, per specimen, each multiplex stain procedure(professional)88374-26 43.96Morphometric analysis, in situ hybridization, manual, per specimen, each multiplex stain procedure (global)88377 424.62Morphometric analysis, in situ hybridization, manual, per specimen, each multiplex stain procedure (technical)88377/TC 360.08Morphometric analysis, in situ hybridization, manual, per specimen, each multiplex stain procedure (professional)88377-26 64.546/17/2021Page 5 of 9

BREAST SURGERIESAnesthesia, anterior trunk (baseline 3 units@ 15 minutes each)00400 21.53Fine needle aspiration, without imaging guidance, each additional lesion. (Use with 10021)10004 52.25Fine needle aspiration, without imaging guidance, each additional lesion. (Use with 10021) Physicians Fee if performedin facility10004-26 43.53Fine needle aspiration biopsy, including ultrasound guidance, first lesion.10005Fine needle aspiration biopsy, including ultrasound guidance, first lesion. Physician fee if performed in facility10005-26 73.50Fine needle aspiration biopsy, including ultrasound guidance, each additional lesion.10006 61.68Fine needle aspiration biopsy, including ultrasound guidance, each additional lesion. Physician fee if performed in facility.10006-26 51.21Fine needle aspiration biopsy, including fluoroscopic guidance, first lesion10007Fine needle aspiration biopsy, including fluoroscopic guidance, first lesion. Physician fee if performed in facility.10007-26Fine needle aspiration biopsy, including fluoroscopic guidance, each additional lesion.10008Fine needle aspiration biopsy, including fluoroscopic guidance, each additional lesion. Physician fee if performed infacility.10008-26Fine needle aspiration biopsy, including CT guidance, first lesion10009 485.19Fine needle aspiration biopsy, including CT guidance, first lesion. Physician fee if performed in facility.10009-26 113.23Fine needle aspiration biopsy, including CT guidance, each additional lesion.10010 286.70Fine needle aspiration biopsy, including CT guidance, each additional lesion. Physician fee if performed in facility.10010-26Fine needle aspiration biopsy, including MR guidance, first lesion10011 485.19Fine needle aspiration biopsy, including MR guidance, first lesion. Physician fee if performed in facility.10011-26 113.23Fine needle aspiration biopsy, including MR guidance, each additional lesion10012 286.70Fine needle aspiration biopsy, including MR guidance, each additional lesion. Physician fee if performed in facility.10012-26Fine needle aspiration, without imaging guidance, first lesion10021Fine needle aspiration, without imaging guidance, first lesion. Physicians Fee if performed in facility10021-26Puncture aspiration of cyst of breast19000Puncture aspiration of cyst of breast, Physician fee if performed in facility19000-26 43.88Puncture aspiration of cyst of breast, each additional19001 27.53Puncture aspiration of cyst of breast, each additional, Physician fee if performed in facility19001-26 21.59Breast biopsy, with placement of localization device and imaging of biopsy specimen, percutaneous; stereotacticguidance; first lesion19081 588.39Breast biopsy, with placement of localization device and imaging of biopsy specimen, percutaneous; stereotacticguidance; first lesion. Physician Fee if performed in facility.19081-26 167.236/17/2021 139.10 315.98 93.01 167.75 59.23 82.23 82.23 105.26 56.07 110.52Page 6 of 9

Breast biopsy, with placement of localization device and imaging of biopsy specimen, percutaneous; stereotacticguidance; each additional lesion19082Breast biopsy, with placement of localization device and imaging of biopsy specimen, percutaneous; stereotacticguidance; each additional lesion. Physician Fee if performed in facility.19082-26Breast biopsy, with placement of localization device and imaging of biopsy specimen, percutaneous; ultrasoundguidance; first lesion19083 589.09Breast biopsy, with placement of localization device and imaging of biopsy specimen, percutaneous; ultrasoundguidance; first lesion. Physician Fee if performed in facility.19083-26 158.16Breast biopsy, with placement of localization device and imaging of biopsy specimen, percutaneous; ultrasoundguidance; each additional lesion.19084 462.91Breast biopsy, with placement of localization device and imaging of biopsy specimen, percutaneous; ultrasoundguidance; each additional lesion. Physician Fee if performed in facility.19084-26Breast biopsy, with placement of localization device and imaging of biopsy specimen, percutaneous; magnetic resonanceguidance; first lesion.19085 905.24Breast biopsy, with placement of localization device and imaging of biopsy specimen, percutaneous; magnetic resonanceguidance; first lesion. Physician Fee if performed in facility.19085-26 183.30Breast biopsy, with placement of localization device and imaging of biopsy specimen, percutaneous; magnetic resonanceguidance; each additional lesion.19086 717.28Breast biopsy, with placement of localization device and imaging of biopsy specimen, percutaneous; magnetic resonanceguidance; each additional lesion. Physician Fee if performed in facility.19086-26Biopsy of breast, percutaneous, needle core, not using imaging guidance19100Biopsy of breast, percutaneous, needle core, not using imaging guidance, Physician fee if performed in facility19100-26Biopsy of breast, open, incisional19101 353.92Biopsy of breast, open, incisional, Physician fee if performed in facility19101-26 229.70Nipple Exploration, with or without excision of a solitary lactiferous duct or a papilloma lactiferous duct19110 517.64Nipple Exploration, with or without excision of a solitary lactiferous duct or a papilloma lactiferous duct, Physician fee ifperformed in facility19110-26 361.66Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolarlesion, open, one or more lesions.19120 533.43Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolarlesion, open, one or more lesions, Physician fee if performed in facility19120-26 428.05Excision of breast lesion identified by preoperative placement of radiological marker, single lesion.19125 588.04Excision of breast lesion identified by preoperative placement of radiological marker, single lesion, Physician fee ifperformed in facility19125-26 473.94Excision of breast lesion separately identified by preoperative placement of radiological marker, each additional lesion.19126 164.82Placement of breast localization device, percutaneous; mammographic guidance; first lesion.19281 252.506/17/2021 471.28 83.96 78.74 91.65 163.06 71.29Page 7 of 9

Placement of breast localization device, percutaneous; mammographic guidance; first lesion. Physician Fee if performedin facility.19281-26 100.36Placement of breast localization device, percutaneous; mammographic guidance; each additional lesion.19282 180.33Placement of breast localization device, percutaneous; mammographic guidance; each additional lesion.Physician Fee ifperformed in facility.19282-26 50.52Placement of breast localization device, percutaneous; stereotactic guidance; first lesion.Placement of breast localization device, percutaneous; stereotactic guidance; first lesion. Physician Fee if performed infacility.19283 278.9819283-26 101.73Placement of breast localization device, percutaneous; stereotactic guidance; each additional lesion.Placement of breast localization device, percutaneous; stereotactic guidance; each additional lesion. Physician Fee ifperformed in facility.19284 213.09Placement of breast localization device, percutaneous; ultrasound guidance; first lesion19285Placement of breast localization device, percutaneous; ultrasound guidance; first lesion. Physician Fee if performed infacility.19285-26Breast biopsy, with placement of localization device and imaging of biopsy specimen, percutaneous; magnetic resonanceguidance; each additional lesion.19286Breast biopsy, with placement of localization device and imaging of biopsy specimen, percutaneous; magnetic resonanceguidance; each additional lesion. Physician Fee if performed in facility.19286-26Placement of breast localization device, percutaneous; magnetic resonance guidance; first lesion19287 759.80Placement of breast localization device, percutaneous; magnetic resonance guidance; first lesion. Physician Fee ifperformed in facility.19287-26 128.24Placement of breast localization device, percutaneous; magnetic resonance guidance; each additional lesion19288 600.42Placement of breast localization device, percutaneous; magnetic resonance guidance; each additional lesion.PhysicianFee if performed in facility.19288-2619284-26 51.89 442.32 86.07 373.63 43.54 64.46CERVICAL SURGERIESColposcopy of the cervix including upper/adjacent vagina.Facility fee.57452Colposcopy of the cervix including upper/adjacent vagina, Physician fee if performed in facilityColposcopy with biopsy(s) of the cervix and endocervical curettage.Facility fee.Colposcopy with biopsy(s) of the cervix and endocervical curettage,Physician fee if performed in facility57452-26 127.87 92.6357454 172.4257454-26 136.83Colposcopy with biopsy(s) of the cervix. Facility fee.57455 164.10Colposcopy with biopsy(s) of the cervix, Physician fee if performed in facility57455-26 111.41Colposcopy with endocervical curettage. Facility fee.57456 154.00Colposcopy with endocervical curettage, Physician fee if performed in facility57456-26 103.41Colposcopy with Loop Electrode biopsy(s) of the cervix. Facility fee.57460 330.43Colposcopy with Loop Electrode biopsy(s) of the cervix, Physician fee if performed in facility57460-26 163.64Colposcopy with Loop Electrode conization of the cervix57461 367.69Colposcopy with Loop Electrode conization of the cervix, Physician fee if performed in facility57461-26 188.69Biopsy of cervix, single or multiple, or local excision of lesion, with or without fulguration.57500 158.606/17/2021Page 8 of 9

Biopsy of cervix, single or multiple, or local excision of lesion, with or without fulguration. Physician fee if performed infacility57500-26Endocervical Curettage57505 150.93Endocervical Curettage, Physician fee if performed in facility57505-26 109.06Conization of cervix, with or without fulguration, with or without dilation and curettage, with or without repair, cold knifeor laser57520 358.54Conization of cervix, with or without fulguration, with or without dilation and curettage, with or without repair, cold knifeor laser, Physician fee if performed in facility57520-26 300.61Conization of cervix, with or without fulguration, with or without dilation and curettage, with or without repair, loopelectrode excision57522 308.33Conization of cervix, with or without fulguration, with or without dilation and curettage, with or without repair, loopelectrode excision, Physician fee if performed in facility57522-26 260.53Endometrial Biopsy58100 104.87Endometrial Biopsy, Physician fee if performed in facility58100-26 65.44Endometrial sampling (biopsy) performed in conjunction with colposcopy58110 51.89Endometrial sampling (biopsy) performed in conjunction with colposcopy. Physician fee if performed in facility58110-26 41.77 76.60PRIOR APPROVAL CODESUltrasound, transvaginal. Non obstetric (global)76830 125.67Ultrasound, transvaginal. Non obstetric (technical)76830/TC 89.97Ultrasound, transvaginal. Non obstetric (professional)76830-26 35.70Biopsy of vaginal mucosa, simple57100Biopsy of vaginal mucosa, simple. Physician Fee if performed in facility57100-26Biopsy of vaginal mucosa, extensive, requiring suture57105 167.53Biopsy of vaginal mucosa, extensive, requiring suture. Physician Fee if performed in facility57105-26 144.79Colposcopy of entire vagina, with cervix if present.57420 133.14Colposcopy of entire vagina, with cervix if present. Physician Fee if performed in facilityColposcopy of entire vagina, with cervix if present, with biopsy of vagina/cervix57420-2657421 97.41 179.24Colposcopy of entire vagina, with cervix if present, with biopsy of vagina/cervix. Physician Feeif performed in facility57421-26 131.96Anesthesia, Vaginal Procedures00940 101.58 70.55 22.17 Surgical facility reimbursement is paid for outpatient surgery only. Claim lines containing allowable codes willbe paid at the MCCP rate. Reimbursement for the remaining claim lines that are related to allowableprocedures will be calculated at the current Montana Medicaid statewide outpatient cost to charge ratio (CCR).The CCR for FY2021 is 50%. Per instruction from the CDC, codes 99385-99387 are to be reimbursed at or below the 99203 rate, and codes99395-33937 are to be reimbursed at or below the 99213 rate. Colorectal screening services are not covered by the MCCP after 6/29/2015 due to the end of the federalgrant. In order for a claim to be paid, it must be received within 365 days of the date of service. These rates may be subject to change if Medicare Participating rates change during the year.6/17/2021Page 9 of 9

Specimen Handling 99000 43.93 New Patient, straightforward decision making; 15-29 minutes 99202 73.90 New Patient, straightforward decision making; 15-29 minutes. Facility Fee 99202/TC 49.82 New Patient, low level decision making; 30-44 minutes 99203 113.63 New Patient, low level decision making; 30-44 minutes Facility Fee 99203/TC 84.32