Attachment 4 Agency Proposed Incentive Program Included .

Attachment 4Agency Proposed Incentive Program Included ServicesPrimary Care Codes Applicable to Enrollees Under Age escription of CPT CodePhysician office supplies for reimbursement ofpermanent implantsExtended family planning services-new patient(treatment of STI)Office or Other Outpatient Services, New Patient99202Office or Other Outpatient Services, New Patient99203Office or Other Outpatient Services, New Patient99204Office or Other Outpatient Services, New Patient99205Office or Other Outpatient Services, New Patient99211Office or Other Outpatient Services, EstablishedPatientFamily Planning Supply Visit99201Office Visits992119921299217Office or Other Outpatient Services, EstablishedPatientOffice or Other Outpatient Services, EstablishedPatientOffice or Other Outpatient Services, EstablishedPatientOffice or Other Outpatient Services, EstablishedPatientHospital Observation Care Discharge Services99218Initial Observation Care99219Initial Observation Care99220Initial Observation Care99221Hospital Inpatient Services, Initial Hospital Care99222Hospital Inpatient Services, Initial Hospital Care99223Hospital Inpatient Services, Initial Hospital Care99224Subsequent Observation Care99225Subsequent Observation Care99226Subsequent Observation Care99231Hospital Inpatient Services, Subsequent Hospital Care99232Hospital Inpatient Services, Subsequent Hospital Care99233Hospital Inpatient Services, Subsequent Hospital Care99234Observation or Inpatient Care Services (IncludingAdmission and Discharge Services)99235Observation or Inpatient Care Services (Including99236Admission and Discharge Services)99238Hospital Discharge Services99239Hospital Discharge Services992139921499215Hospital CareFPPage 1 of 12

Attachment 4Agency Proposed Incentive Program Included ServicesConsultationsEmergencyRoomCritical CareNursingHome99241Office Consultations99242Office Consultations99243Office Consultations99244Office Consultations99245Office Consultations99251Inpatient Consultations99252Inpatient Consultations99253Inpatient Consultations99254Inpatient Consultations99255Inpatient Consultations99281Emergency Department Services99282Emergency Department Services99283Emergency Department Services99284Emergency Department Services99285Emergency Department Services99291Critical Care Services99292Critical Care Services99304Initial Nursing Facility Care99305Initial Nursing Facility Care99306Initial Nursing Facility Care99307Subsequent Nursing Facility Care99308Subsequent Nursing Facility Care99309Subsequent Nursing Facility Care99310Subsequent Nursing Facility Care99315Nursing Facility Discharge Services99318Other Nursing Facility Services99324Domiciliary, Rest Home or Custodial Care Services,New PatientDomiciliary, Rest Home or Custodial Care Services,New PatientDomiciliary, Rest Home or Custodial Care Services,New PatientDomiciliary, Rest Home or Custodial Care Services,New PatientDomiciliary, Rest Home or Custodial Care Services,New PatientDomiciliary, Rest Home or Custodial Care Services,Established PatientDomiciliary, Rest Home or Custodial Care Services,Established PatientDomiciliary, Rest Home or Custodial Care Services,Established 99336Page 2 of 12

Attachment 4Agency Proposed Incentive Program Included Services9933799341Domiciliary, Rest Home or Custodial Care Services,Established PatientDomiciliary, Rest Home or Home Care Plan OversightServicesDomiciliary, Rest Home or Home Care Plan OversightServicesHome Services, New Patient99342Home Services, New Patient99343Home Services, New Patient99344Home Services, New Patient99345Home Services, New Patient99347Home Services, Established Patient99348Home Services, Established Patient99349Home Services, Established Patient99350Home Services, Established Patient99354Prolonged Services, With Direct Patient Contact99355Prolonged Services, With Direct Patient Contact99356Prolonged Services, With Direct Patient Contact99357Prolonged Services, With Direct Patient Contact99360Physician Standby Services99381Initial comprehensive preventive medicine evaluationandmanagement of an infant, age under 1 yearInitial comprehensive preventive medicine evaluationandmanagement of early childhood, age 1 through 4 yearsInitial comprehensive preventive medicine evaluationandmanagement of late childhood, age 5 through 11 yearsInitial comprehensive preventive medicine evaluationandmanagement of an adolescent, age 12 through 17yearsFamily Planning New Visit9933999340HomeServicesProlongedServicesPhys. New Patient Screenings age 21–39 years99385EP99385FPInitial comprehensive preventive medicine evaluationandmanagement of an 18 through 20 year oldFamily Planning New Visit99386FPFamily Planning New Visit99386New Patient Screenings age 40–64 years99387New Patient Screenings age 65 years and olderPage 3 of 12

Attachment 4Agency Proposed Incentive Program Included itical CareEstablished Patient Screenings age 21–39 years99395EP99395FPPeriodic comprehensive preventive medicinereevaluationand management of an 18 through 20 year oldFamily Planning Established Visit99396FPFamily Planning Established Visit99396Established Patient Screenings age 40–64 years99397Established Patient Screenings age 65 years and older99401Preventive Medicine Services, Individual Counseling99402Preventive Medicine Services, Individual Counseling99403NewbornCarePeriodic comprehensive preventive medicinereevaluationand management of an infant, age under 1 yearPeriodic comprehensive preventive medicinereevaluationand management of early childhood, age 1 through 4yearsPeriodic comprehensive preventive medicinereevaluationand management of late childhood, age 5 through 11yearsPeriodic comprehensive preventive medicinereevaluationand management of an adolescent, age 12 through 17yearsFamily Planning Established VisitFPFamily Planning Counseling Visit99406Smoking and tobacco cessation99407Smoking and tobacco cessation99460Newborn Care99461Newborn Care99462Newborn Care99463Newborn Care99464Attendance and Delivery99465Attendance and Delivery99468Inpatient Neonatal and Pediatric Critical Care99469Inpatient Neonatal and Pediatric Critical Care99471Inpatient Neonatal and Pediatric Critical Care99472Inpatient Neonatal and Pediatric Critical Care99475Inpatient Neonatal and Pediatric Critical Care99476Inpatient Neonatal and Pediatric Critical Care99477Initial and Continuing Intensive Care ServicesPage 4 of 12

Attachment 4Agency Proposed Incentive Program Included ServicesChronic CareManagement99478Initial and Continuing Intensive Care Services99479Initial and Continuing Intensive Care Services99480Initial and Continuing Intensive Care Services99490Chronic Care Management ServicesVaccine Administration CodesExplanationCurrently UsedCode90460 9046190471Vaccines 9047290473 90474ModifierDescription of CPT CodeImmunization administration through 18 years of agevia any route of administration with counseling byphysician or other qualified health care professionalfirst or only component of each vaccine or toxoidadministeredEach additional vaccine/toxoid component (listseparately in addition to code for primary procedure)Immunization administration (includes percutaneous,intradermal, subcutaneous, or intramuscularinjections) one vaccine single or combinationvaccine/toxoidEach additional vaccine (single or combinationvaccine/toxoid). List separately in addition to code forprimary procedure.Immunization administration by intranasal or oralroute one vaccine single or combinationvaccine/toxoid.Each additional vaccine single or combinationvaccine/toxoid. List separately in addition to code forprimary procedure.Page 5 of 12

Attachment 4Agency Proposed Incentive Program Included ServicesOB CodesCategory of ServicePrenatal/Antepartumand Postpartum VisitsAntepartum and FetalInvasive ServicesCurrently UsedCodeH1000 & H1001CPT Code Equivalent594255942659430Description of CPT CodeAntepartum care only; 4-6 visitsAntepartum care only; 7 or more visitsPostpartum care only (separate procedure)59000Amniocentesis; diagnostic59001Amniocentesis therapeutic amniotic fluid reduction (includes ultrasound is (intrauterine), any methodChorionic villus sampling, any methodFetal contraction stress testFetal non-stress testAmniocentesis, therapeutic amniotic fluid reductionFetal scalp blood samplingFetal monitoring during labor by consulting physician (i.e., non-attending physician) withwritten report; supervision and aternal Excision59120Fetal monitoring during labor by consulting physician (i.e., non-attending physician) withwritten report; interpretation onlyTransabdominal amnioinfusion, including ultrasound guidanceFetal umbilical cord occlusion, including ultrasound guidanceFetal fluid drainage (e.g. vesicocentesis, thoracocentesis, paracentesis), includingultrasound guidanceFetal shunt placement, including ultrasound guidanceHysterotomy, abdominal (e.g. for hydatiform mole, abortion)Surgical treatment of ectopic pregnancy; tubal or ovarian, requiring salpingectomyand/or oophorectomy, abdominal or vaginal approachPage 6 of 12

Attachment 4Agency Proposed Incentive Program Included Services591215913059135591365914059150Surgical treatment of ectopic pregnancy; tubal or ovarian, without salpingectomy and/oroophorectomy, abdominal or vaginal approachSurgical treatment of ectopic pregnancy; abdominal pregnancySurgical treatment of ectopic pregnancy; interstitial, uterine pregnancy requiring totalhysterectomySurgical treatment of ectopic pregnancy; interstitial, uterine pregnancy with partialresection of uterusSurgical treatment of ectopic pregnancy; cervical, with evacuationLaparoscopic treatment of ectopic pregnancy; without salpingectomy and/oroophorectomy59151Laparoscopic treatment of ectopic pregnancy; with salpingectomy and/or oophorectomy59160Curettage, postpartumIntroduction59200Insertion of cervical dilator (e.g., laminaria, prostaglandin) (separate procedure)Repair59300593205932559350Episiotomy or vaginal repair, by other than attendingCerclage of cervix, during pregnancy; vaginalCerclage of cervix, during pregnancy; abdominalHysterorrhaphy of ruptured uterus59400Vaginal Delivery59409 TC59410 26594095940959410594125941459510Cesarean Delivery5951459515Routine obstetric care including antepartum care, vaginal delivery (with or withoutepisiotomy, and/or forceps) and postpartum careVaginal delivery only (with or without episiotomy and/or forceps);Delivery services reimbursement provided to the birth centerVaginal delivery only (with or without episiotomy and/or forceps); including postpartumcareExternal cephalic version, with or without tocolysisDelivery of placenta (separate procedure)Routine obstetric care including antepartum care, cesarean delivery (with or withoutepisiotomy, and/or forceps) and postpartum careCesarean delivery only;Cesarean delivery only; including postpartum carePage 7 of 12